Pharmacy Program Preferred Drug List Pharmacy Benefit Manager Specialty Drugs

Transcription

1 Pharmacy Program California Health & Wellness is committed to providing appropriate, high quality, and cost effective drug therapy to all California Health & Wellness members. California Health & Wellness works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. California Health & Wellness covers prescription medications and certain over-the-counter (OTC) medications when ordered by a licensed practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. Preferred List The California Health & Wellness Preferred List (PDL) is the list of covered drugs. The PDL applies to drugs members can receive at retail pharmacies. The California Health & Wellness PDL is continually evaluated by the California Health & Wellness Pharmacy and Therapeutics (P&T) Committee to promote the appropriate and cost-effective use of medications. The Committee is composed of the California Health & Wellness Medical Director, California Health & Wellness Pharmacy Director, and several California physicians, pharmacists, and other healthcare professionals. Pharmacy Benefit Manager California Health & Wellness works with US Script to process pharmacy claims for prescribed drugs. Some drugs on the California Health & Wellness PDL may require PA and US Script is responsible for administering this process. US Script is our Pharmacy Benefit Manager. Specialty s Certain medications are only covered when supplied by California Health & Wellness specialty pharmacy provider. AcariaHealth is the preferred specialty pharmacy provider of California Health & Wellness. All specialty drugs, such as biopharmaceuticals and injectables, require PA to be approved for payment by California Health & Wellness. The California Health & Wellness Medical Director and California Health & Wellness Pharmacy Director oversee the clinical review of these PA request. AcariaHealth provides the following services: A dedicated, multilingual team available 24 hours a day, 7 days a week to meet the unique needs of each patient Disease-specific product education and training Customized treatment programs and compliance monitoring Prior authorization support Timely delivery to your office or the patient s home, as requested

2 Dispensing s may be dispensed up to a maximum of thirty (30) days supply for each new prescription or refill. A total of 85% of the days supply must have elapsed before the prescription can be refilled for all drugs. Prior Authorizations Some medications listed on the California Health & Wellness PDL may require PA. The information should be submitted by the practitioner or pharmacist to US Script on the Medication Prior Authorization orm. This form should be faxed to US Script at This document can be found on the California Health & Wellness website. California Health & Wellness will cover the medication if it is determined that: 1. There is a medical reason the member needs the specific medication. 2. Depending on the medication, other medications on the PDL have not worked. Authorization requests are reviewed by a licensed clinical pharmacist using the criteria established by the California Health & Wellness P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, California Health & Wellness will notify the member and their practitioner of alternatives and provide information regarding the appeal process. Step Therapy Some medications listed on the California Health & Wellness PDL may require specific medications to be used before the member can receive the step therapy medication. If California Health & Wellness has a record that the required medication was tried first the step therapy medications are automatically covered. If California Health & Wellness does not have a record that the required medication was tried, the member s practitioner may be required to provide additional information. If authorization is not granted, California Health & Wellness will notify the member and their practitioner and provide information regarding the appeal process. Quantity California Health & Wellness may limit how much of a certain medication a member can get at one time. If the practitioner feels the member has a medical reason for getting a greater amount, a PA may be requested. If California Health & Wellness does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process.

3 Age Some medications on the California Health & Wellness PDL may have age limits. These are set for certain drugs based on DA approved labeling and for safety concerns and quality standards of care. Age limits align with current DA alerts for the appropriate use of pharmaceuticals. Medical Necessity Requests If the member requires a medication that does not appear on the PDL, the member s practitioner can make a medical necessity (MN) request for the medication. It is anticipated that such exceptions will be rare as the PDL medications are appropriate to treat the vast majority of medical conditions. or a MN request California Health & Wellness requires: Documentation of failure of at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications) for the same diagnosis (e.g. migraine, neuropathic pain, etc.); or Documented intolerance or contraindication to at least two PDL agents within the same therapeutic class (provided two agents exist in the therapeutic category with comparable labeled indications); or Documented clinical history or presentation where the patient is not a candidate for any of the PDL agents for the indication. These requests are reviewed by a licensed clinical pharmacist using the criteria established by the California Health & Wellness P&T Committee. If the request is approved, US Script notifies the practitioner by fax. If the clinical information provided does not meet the coverage criteria for the requested medication, California Health & Wellness will notify the member and their practitioner of alternatives and provide information regarding the appeal process. 72 Hour Emergency Supply Policy State and ederal law require that a pharmacy dispense a 72 hour (3 day) supply of medication to any member awaiting PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72 hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72 hour supply of medication, whether or not the PA request is ultimately approved or denied. The pharmacy must call US Script at for a prescription override to submit the 72 hour medication supply for payment. Exclusions The following drug categories are not part of the California Health & Wellness PDL and are not covered by the 72 hour emergency supply policy: s that are considered experimental Efficacy Study and Implementation (DESI) drugs

4 - s prescribed for infertility - s prescribed for erectile dysfunction - s prescribed for cosmetic purposes or hair growth Over-the-counter (OTC) cough and cold preparations Over-the-counter adult acetaminophen products - s carved-out of the California Health & Wellness contract with the DHCS (TARs/claims submitted to Medi-Cal ee-or-service directly) o Select HIV AIDS treatment drugs o Select alcohol and heroin detoxification and dependency treatment o Select psychiatric drugs Newly Approved Products California Health & Wellness reviews new drugs for safety and effectiveness before adding them to the PDL. During this period, access to these medications will be considered through the PA review process. If California Health & Wellness does not grant PA we will notify the member and their practitioner and provide information regarding the appeal process. Over-the-Counter Medications California Health & Wellness covers a variety of OTC medications. These medications can be found throughout the California Health & Wellness PDL. California Health & Wellness covers OTC products listed in the PDL if the member has a prescription from a licensed practitioner that meets all the legal requirements for a prescription. Generic s When generic drugs are available, the brand name drug will not be covered without California Health & Wellness authorization. Generic drugs have the same active ingredient and work the same as brand name drugs. If the member or their practitioner feels a brand name drug is medically necessary, the practitioner requests the drug using the PA process. We will cover the brand-name drug according to our clinical guidelines if there is a medical reason the member needs the particular brand-name drug. If California Health & Wellness does not grant authorization, we will notify the member and their practitioner and provide information regarding the appeal process. The provision is waived for the following products due to their narrow therapeutic index (NTI) as recognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine, Cyclosporine, Digoxin, Disopyramide, Ethosuximide, lecainide, L-Thyroxine, Lithium, Phenytoin, Procainamide, Theophylline, Thyroid, Valproic Acid, and Warfarin.

5 Efficacy Study and Implementation s DESI products and known related drug products are defined as less than effective by the ood and Administration because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. DESI products are not covered by California Health & Wellness. illing a Prescription A member can have prescriptions filled at a California Health & Wellness network pharmacy. If the member decides to have a prescription filled at a network pharmacy they can locate a pharmacy near them by contacting California Health & Wellness Member Services. At the pharmacy the member will need to provide the pharmacist with the prescription and their California Health & Wellness ID card. Copayments Copayments are not required for California Health & Wellness Medi-Cal members. Abbreviations The following notations and abbreviations may be found throughout the drug listing in the limitations and restrictions column. DS/DU: Days Supply per Dosage Unit Max Days Sply: Maximum Days Supply Max ills: Maximum ills (per a designated time period) Max Qty: Maximum Quantity (per claim or designated time period) Min DS: Minimum Days Supply PA: Prior Authorization Pkg Size: Package Size Contact Information California Health & Wellness Provider Services: US Script Prior Authorizations: ax: US Script Help Desk: AcariaHealth Prior Authorizations: ax: Provider Administered Prior Authorizations ax:

6 Tier N Description Preferred s Non-formulary Carve Out s Legend Description AL Age Limit is limited to specific age. PA QL Prior Authorization Quantity Limit Prior Authorization required before prescription can be filled. There is a limit on the amount of drug covered per prescription, or within a specific time frame. Rx/OTC Rx/OTC Product has both Rx and OTC National Codes. SP ST Specialty Step Therapy Specialty drugs are high-cost drugs used to treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia and may be limited to a specific pharmacy. Requires trial and failure of one or more preferred products prior to coverage.

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8 Name ADHD/ANTI-NARLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL TABS (Use Amphetamine- Dextroamphetamine) ADDERALL XR CP24 (Use Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp24 5mg-5mg-5mg-5mg, 2.5mg-2.5mg-2.5mg- 2.5mg, 7.5mg-7.5mg- 7.5mg-7.5mg, 1.25mg- 1.25mg-1.25mg-1.25mg, 3.75mg-3.75mg-3.75mg- 3.75mg, 6.25mg-6.25mg- 6.25mg-6.25mg amphetaminedextroamphetamine tabs 5mg-5mg-5mg-5mg, 2.5mg-2.5mg-2.5mg- 2.5mg, 7.5mg-7.5mg- 7.5mg-7.5mg, 1.25mg- 1.25mg-1.25mg-1.25mg, 3.75mg-3.75mg-3.75mg- 3.75mg, 1.875mg mg-1.875mg mg, 3.125mg mg-3.125mg mg DEXEDRINE CP24 10 MG, 15 MG (Use Dextroamphetamine Sulfate) DEXEDRINE CP24 5 MG (Use Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 10 mg, 15 mg dextroamphetamine sulfate cp24 5 mg dextroamphetamine sulfate tabs 5 mg, 10 mg N N N N ; AL; At least 3 ; AL; At least 6 ; AL; At least 6 ; AL; At least 3 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 QL(3 ea daily); AL; At least 3 Name VYVANSE CAPS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG Analeptics caffeine citrate soln CA Health & Wellness Preferred List Update June 1, 2018 PA; QL(1 ea daily) QL(45 ml per Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps ST; AL; At least 6 clonidine hcl (adhd) tb12 guanfacine hcl (adhd) tb24 INTUNIV TB24 (Use Guanfacine HCl (ADHD)) KAPVAY TB12 (Use Clonidine HCl (ADHD)) STRATTERA CAPS (Use Atomoxetine HCl) Stimulants - Misc. NCERTA TBCR 18 MG, 27 MG, 54 MG (Use Methylphenidate HCl) NCERTA TBCR 36 MG (Use Methylphenidate HCl) dexmethylphenidate hcl tabs 5 mg, 10 mg, 2.5 mg OCALIN TABS (Use Dexmethylphenidate HCl) METADATE CD CPCR (Use Methylphenidate HCl) methylphenidate hcl cpcr 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg METHYLPHENIDATE HCL ER TB24 18 MG, 27 MG METHYLPHENIDATE HCL ER TB24 36 MG, 54 MG N N N N N N N ; AL; At least 6 ; AL; At least 6 ST; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 ; AL; At least 6 AL; At least 6 1

9 Name METHYLPHENIDATE HCL ER TBCR 18 MG methylphenidate hcl tabs 10 mg, 20 mg methylphenidate hcl tabs 5 mg methylphenidate hcl tbcr 10 mg, 36 mg methylphenidate hcl tbcr 18 mg, 27 mg, 54 mg methylphenidate hcl tbcr 20 mg RITALIN TABS 10 MG, 20 MG (Use Methylphenidate HCl) RITALIN TABS 5 MG (Use Methylphenidate HCl) ; AL; At least 6 QL(3 ea daily); AL; At least 3 QL(6 ea daily); AL; At least 3 N N ; AL; At least 6 ; AL; At least 6 AL; At least 6 QL(3 ea daily); AL; At least 3 QL(6 ea daily); AL; At least 3 AMINOGLYSIDES - s to Treat Bacterial Infections Aminoglycosides KITABIS PAK NEBU neomycin sulfate tabs paromomycin sulfate caps TOBI NEBU (Use Tobramycin) tobramycin nebu TOBRAMYCIN NEBU TOBRAMYCIN SULATE SOLN 10 MG/ML, 40 MG/ML tobramycin sulfate soln 40 mg/ml, 80 mg/2ml, 1.2 gm/30ml tobramycin sulfate solr 1.2 gm N PA PA PA PA Name ANALGESICS - ANTI-INLAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-TN-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT HUMIRA PEN PNKT HUMIRA PEN-CROHNS DISEASESTARTER PNKT HUMIRA PEN-PSORIASIS STARTER PNKT HUMIRA PSKT 20 MG/0.4ML, 40 MG/0.8ML Antirheumatic Antimetabolites RHEUMATREX TABS Gold Compounds RIDAURA CAPS Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL TABS (Use Ibuprofen) N ALEVE ARTHRITIS TABS (Use Naproxen Sodium) N ALEVE TABS (Use Naproxen Sodium) N ANAPROX DS TABS (Use Naproxen Sodium) N CELEBREX CAPS (Use Celecoxib) N PA; QL(2 ea daily) celecoxib caps PA; QL(2 ea daily) CHILDRENS ADVIL SUSP N (Use Ibuprofen) CHILDRENS MOTRIN N SUSP (Use Ibuprofen) DAYPRO TABS (Use Oxaprozin) N diclofenac potassium tabs diclofenac sodium tb24 or 100 mg CA Health & Wellness Preferred List Update June 1,

10 Name diclofenac sodium tbec or 25 mg, 50 mg, 75 mg EC-NAPROSYN TBEC (Use Naproxen) etodolac caps etodolac tabs etodolac tb24 ELDENE CAPS (Use Piroxicam) flurbiprofen tabs ibuprofen chew 100 mg ibuprofen susp 100 mg/5ml ibuprofen susp 40 mg/ml, 50 mg/1.25ml ibuprofen tabs 200 mg, 400 mg, 600 mg, 800 mg indomethacin caps indomethacin cpcr INANTS ADVIL SUSP (Use Ibuprofen) KETOPROEN CAPS 50 MG, 75 MG ketoprofen caps 50 mg, 75 mg KETOPROEN ER CP24 ketorolac tromethamine tabs or 10 mg LODINE TABS (Use Etodolac) meloxicam tabs MOBIC TABS 15 MG, 7.5 MG (Use Meloxicam) MOTRIN INANTS DROPS SUSP (Use Ibuprofen) nabumetone tabs N N N N N N AL; At least 17 Name NAPROSYN SUSP (Use Naproxen) NAPROSYN TABS (Use Naproxen) naproxen sodium tabs 220 mg, 275 mg, 550 mg naproxen susp 125 mg/5ml naproxen tabs 250 mg, 375 mg, 500 mg naproxen tbec 375 mg, 500 mg oxaprozin tabs piroxicam caps sulindac tabs TOLMETIN SODIUM CAPS TOLMETIN SODIUM TABS N N Pyrimidine Synthesis Inhibitors ARAVA TABS (Use N Leflunomide) leflunomide tabs Soluble Tumor Necrosis actor Receptor Agents ENBREL SOLR ENBREL SOSY ENBREL SURECLICK SOAJ ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Analgesic Combinations butalbital-acetaminophen tabs 325mg-50mg butalbital-acetaminophencaffeine caps 325mg- 50mg-40mg butalbital-acetaminophencaffeine tabs 325mg-50mg- 40mg CA Health & Wellness Preferred List Update June 1,

11 Name butalbital-aspirin-caffeine caps ESGIC TABS (Use Butalbital-Acetaminophen- Caffeine) IORINAL CAPS (Use Butalbital-Aspirin-Caffeine) TENN TABS Analgesics Other acetaminophen elix or 160 mg/5ml, 80 mg/2.5ml acetaminophen liqd or 160 mg/5ml acetaminophen soln or 160 mg/5ml, 650 mg/20.3ml, 325 mg/10.15ml acetaminophen supp re 120 mg acetaminophen susp or 160 mg/5ml, 80 mg/0.8ml, 80 mg/2.5ml NORTEMP INANTS SUSP TYLENOL CHILDRENS SUSP (Use Acetaminophen) TYLENOL INANTS PAIN+EVER SUSP (Use Acetaminophen) TYLENOL INANTS SUSP (Use Acetaminophen) Salicylates aspirin buffered (cal carbmag carb-mag oxide) tabs aspirin chew or 81 mg ASPIRIN SUPP RE 300 MG, 600 MG aspirin supp re 300 mg, 600 mg aspirin tabs or 325 mg aspirin tbec or 81 mg, 324 mg, 325 mg, 500 mg N N N N N Name BUERIN TABS (Use Aspirin Buffered (Cal Carb- Mag Carb-Mag Oxide)) choline & mag salicylate liqd diflunisal tabs DISALCID TABS (Use Salsalate) ETRIN MAXIMUM STRENGTH TBEC (Use Aspirin) ETRIN REGULAR STRENGTH TBEC (Use Aspirin) salsalate tabs N N N N ANALGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists codeine sulfate tabs 15 mg, QL (2 ea daily) 30mg, 60mg DEMEROL TABS OR 50 QL(6 ea daily) MG, 100 MG (Use N Meperidine HCl) DILAUDID TABS 2 MG, 4 QL(8 ea daily) MG, 8 MG (Use N Hydromorphone HCl) DOLOPHINE TABS 10 MG N PA; QL(10 ea (Use Methadone HCl) daily) DOLOPHINE TABS 5 MG N PA; QL(4 ea (Use Methadone HCl) daily) DURAGESIC PT72 (Use N QL(0.34 ea entanyl) fentanyl pt72 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr HYDROMORPHONE HCL SUPP RE 3 MG hydromorphone hcl tabs or 2 mg, 4 mg, 8 mg MEPERIDINE HCL SOLN OR 50 MG/5ML meperidine hcl tabs or 50 mg, 100 mg daily) QL(0.34 ea daily) QL(12 ea per QL(8 ea daily) QL(500 ml per QL(6 ea daily) CA Health & Wellness Preferred List Update June 1,

12 Name methadone hcl tabs or 10 mg methadone hcl tabs or 5 mg morphine sulfate soln or 10 mg/5ml, 20 mg/5ml morphine sulfate soln or 20 mg/ml, 100 mg/5ml MORPHINE SULATE SUPP RE 5 MG, 10 MG, 20 MG, 30 MG MORPHINE SULATE TABS OR 15 MG, 30 MG morphine sulfate tbcr or 15 mg, 30 mg, 60 mg, 100 mg, 200 mg MS NTIN TBCR (Use Morphine Sulfate) oxycodone hcl caps 5 mg oxycodone hcl conc 100 mg/5ml OXYDONE HCL ER T12A oxycodone hcl soln 5 mg/5ml oxycodone hcl tabs 5 mg, 10 mg, 15 mg, 20 mg, 30 mg ROXIDONE TABS (Use Oxycodone HCl) tramadol hcl tabs 50 mg ULTRAM TABS (Use Tramadol HCl) Opioid Combinations acetaminophen w/ codeine soln 120mg/5ml-12mg/5ml acetaminophen w/ codeine tabs 300mg-15mg, 300mg- 30mg, 300mg-60mg butalbital-acetaminophencaffeine w/ codeine caps 325mg-50mg-40mg-30mg butalbital-aspirin-caffeine w/cod caps PA; QL(10 ea daily) PA; QL(4 ea daily) QL(500 ml per QL(240 ml per N N N QL(24 ea per QL(6 ea daily) QL(3 ea daily) QL(3 ea daily) QL(6 ea daily) QL(6 ml daily) PA; QL(2 ea daily) QL(6 ea daily) QL(6 ea daily) QL(8 ea daily) QL(8 ea daily) QL(30 ml daily) QL(6 ea daily) Name IORINAL/DEINE #3 CAPS (Use Butalbital- Aspirin-Caffeine w/cod) hydrocodoneacetaminophen soln 2.5mg/5ml-108mg/5ml, 5mg/10ml-217mg/10ml, 7.5mg/15ml-325mg/15ml hydrocodoneacetaminophen tabs 10mg- 325mg hydrocodoneacetaminophen tabs 5mg- 325mg hydrocodoneacetaminophen tabs 7.5mg-325mg NOR TABS 10MG- 325MG (Use Hydrocodone- Acetaminophen) NOR TABS 5MG- 325MG (Use Hydrocodone- Acetaminophen) NOR TABS 7.5MG- 325MG (Use Hydrocodone- Acetaminophen) oxycodone w/ acetaminophen tabs 5mg- 325mg, 10mg-325mg, 7.5mg-325mg oxycodone-aspirin tabs OXYDONE/ACETAMIN OPHEN SOLN PERCET TABS 5MG- 325MG, 10MG-325MG, 7.5MG-325MG (Use Oxycodone w/ Acetaminophen) tramadol-acetaminophen tabs TYLENOL/DEINE #3 TABS (Use Acetaminophen w/ Codeine) TYLENOL/DEINE #4 TABS (Use Acetaminophen w/ Codeine) N N N N N N N QL(180 ml daily) QL(6 ea daily) QL(12 ea daily) QL(8 ea daily) QL(6 ea daily) QL(12 ea daily) QL(8 ea daily) QL(6 ea daily) QL(6 ea daily) QL(30 ml daily) QL(6 ea daily) QL(6 ea daily) QL(6 ea daily) CA Health & Wellness Preferred List Update June 1,

13 Name ULTRACET TABS (Use Tramadol-Acetaminophen) Opioid Partial Agonists BELBUCA ILM BUNAVAIL ILM BUPRENEX SOLN (Use Buprenorphine HCl) buprenorphine hcl soln buprenorphine hcl subl buprenorphine hclnaloxone hcl dihydrate subl BUPRENORPHINE PTWK BUTRANS PTWK PROBUPHINE IMPLANT KIT IMPL SUBLOCADE SOSY SUBOXONE ILM ZUBSOLV SUBL N ANDROGENS-ANABOLIC - s to Regulate Hormones Androgens ANDRODERM PT24 ANDROXY TABS DEPO-TESTOSTERONE SOLN (Use Testosterone Cypionate) METHITEST TABS N QL(0.134 ml daily) testosterone cypionate soln QL(0.134 ml daily) ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Intrarectal Steroids RTENEMA ENEM (Use Hydrocortisone (Intrarectal)) N QL(420 ml per Name hydrocortisone (intrarectal) enem Rectal Combinations phenylephrine-shark liver oil-cocoa butter supp phenylephrine-shark liver oil-mineral oil-petrolatum oint Rectal Local Anesthetics pramoxine hcl (rectal) foam PROCTOOAM OAM (Use Pramoxine HCl (Rectal)) Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) hydrocortisone (rectal) crea 2.5 % ANTACIDS CA Health & Wellness Preferred List Update June 1, 2018 Antacid Combinations alum & mag hydroxsimethicone liqd 200mg/5ml-20mg/5ml- 200mg/5ml alum & mag hydroxsimethicone susp 200mg/5ml-20mg/5ml- 200mg/5ml, 200mg/5ml- 200mg/5ml-20mg/5ml- 20mg/5ml-200mg/5ml- 200mg/5ml Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR Antacids - Bicarbonate sodium bicarbonate (antacid) tabs Antacids - Calcium Salts calcium carbonate (antacid) chew 500 mg calcium carbonate (antacid) susp 1250 mg/5ml QL(420 ml per N N QL(60 gm per QL(30 gm per QL(30 gm per 6

14 Name TUMS CHEW (Use Calcium Carbonate (Antacid)) TUMS LASTING EECTS CHEW (Use Calcium Carbonate (Antacid)) Antacids - Magnesium Salts magnesium oxide tabs N N ANTHELMINTICS - s to Treat Worm Infections Anthelmintics EMVERM CHEW pyrantel pamoate susp ANTI-INECTIVE AGENTS - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. LAGYL TABS 250 MG, 500 MG (Use N Metronidazole) metronidazole tabs or 250 mg, 500 mg trimethoprim tabs VANCIN HCL CAPS 125 MG (Use Vancomycin HCl) VANCIN HCL CAPS 250 MG (Use Vancomycin HCl) vancomycin hcl caps or 125 mg vancomycin hcl caps or 250 mg vancomycin hcl solr iv 500 mg, 1000 mg N N Anti-infective Misc. - Combinations BACTRIM DS TABS (Use Sulfamethoxazole- N Trimethoprim) BACTRIM TABS (Use Sulfamethoxazole- N Trimethoprim) QL(8 ea daily) QL(8 ea daily) QL(14 ea per Name sulfamethoxazoletrimethoprim susp or 40mg/5ml-200mg/5ml sulfamethoxazoletrimethoprim tabs or 80mg- 400mg, 160mg-800mg Antiprotozoal Agents atovaquone susp MEPRON SUSP (Use Atovaquone) Leprostatics dapsone tabs Lincosamides CLEOCIN CAPS OR 150 MG, 300 MG (Use Clindamycin HCl) CLEOCIN PEDIATRIC GRANULES SOLR (Use Clindamycin Palmitate Hydrochloride) clindamycin hcl caps 150 mg, 300 mg clindamycin palmitate hydrochloride solr Oxazolidinones SIVEXTRO TABS N N N PA; QL(10 ml daily) PA; QL(10 ml daily) QL(100 ml per QL(100 ml per PA; QL(6 ea per ANTIANGINAL AGENTS - s to Treat Chest Pain Nitrates ISORDIL TITRADOSE TABS 5 MG (Use N Isosorbide Dinitrate) ISOSORBIDE DINITRATE ER TBCR isosorbide dinitrate tabs isosorbide mononitrate tabs 10 mg, 20 mg isosorbide mononitrate tb24 30 mg, 60 mg, 120 mg NITRO-BID OINT CA Health & Wellness Preferred List Update June 1,

15 Name NITRO-DUR PT MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (Use Nitroglycerin) nitroglycerin cpcr or 9 mg, 2.5 mg, 6.5 mg nitroglycerin pt24 td 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin subl sl 0.3 mg, 0.4 mg, 0.6 mg NITROSTAT SUBL (Use Nitroglycerin) N N ANTIANXIETY AGENTS - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs 15 mg buspirone hcl tabs 30 mg, 7.5 mg buspirone hcl tabs 5 mg, 10 mg hydroxyzine hcl syrp hydroxyzine hcl tabs HYDROXYZINE PAMOATE CAPS 100 MG hydroxyzine pamoate caps 25 mg, 50 mg meprobamate tabs VISTARIL CAPS (Use Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs 0.25 mg, 0.5 mg, 1 mg, 2 mg ATIVAN TABS 0.5 MG, 2 MG (Use Lorazepam) ATIVAN TABS 1 MG (Use Lorazepam) chlordiazepoxide hcl caps clorazepate dipotassium tabs N N N QL(3 ea daily) QL(6 ea daily) QL(3 ea daily) QL(3 ea daily) Name DIAZEPAM SOLN OR 1 MG/ML diazepam tabs or 2 mg, 5 mg, 10 mg lorazepam tabs 0.5 mg, 2 mg lorazepam tabs 1 mg oxazepam caps 10 mg, 15 mg, 30 mg OXAZEPAM CAPS 30 MG QL(500 ml per QL(3 ea daily) TRANXENE T TABS (Use Clorazepate Dipotassium) N QL(3 ea daily) VALIUM TABS (Use Diazepam) N XANAX TABS (Use Alprazolam) N ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps NORPACE CAPS (Use Disopyramide Phosphate) NORPACE CR CP MG quinidine gluconate tbcr or 324 mg QUINIDINE SULATE TABS Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs propafenone hcl tabs 150 mg, 225 mg, 300 mg RYTHMOL TABS (Use Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs 200 mg N CA Health & Wellness Preferred List Update June 1,

16 Name dofetilide caps MULTAQ TABS TIKOSYN CAPS (Use Dofetilide) N ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu QL(240 ml per Bronchodilators - Anticholinergics ATROVENT HA AERS QL(26 gm per INCRUSE ELLIPTA AEPB QL(30 ea per ipratropium bromide soln TUDORZA PRESSAIR AEPB Leukotriene Modulators montelukast sodium chew montelukast sodium pack montelukast sodium tabs SINGULAIR CHEW (Use Montelukast Sodium) SINGULAIR PACK (Use Montelukast Sodium) SINGULAIR TABS (Use Montelukast Sodium) Steroid Inhalants AEROSPAN AERS budesonide (inhalation) susp LOVENT DISKUS AEPB 100 MCG/BLIST, 250 MCG/BLIST LOVENT DISKUS AEPB 50 MCG/BLIST N N N fill QL(8.9 gm per QL(4 ml daily); AL; At least 1 - Up to 8 QL(60 ea per 25 days Name LOVENT HA AERO PULMIRT LEXHALER AEPB PULMIRT SUSP (Use Budesonide (Inhalation)) Sympathomimetics ALBUTEROL SULATE ER TB12 albuterol sulfate nebu in 0.5 % albuterol sulfate nebu in 0.63 mg/3ml, %, 1.25 mg/3ml albuterol sulfate syrp or 2 mg/5ml albuterol sulfate tabs or 2 mg albuterol sulfate tabs or 4 mg albuterol sulfate tb12 or 4 mg, 8 mg BREO ELLIPTA AEPB 25MCG/INH-200MCG/INH MBIVENT RESPIMAT AERS DULERA AERO ipratropium-albuterol soln METAPROTERENOL SULATE SYRP 10 MG/5ML METAPROTERENOL SULATE TABS 10 MG, 20 MG PROAIR HA AERS SEREVENT DISKUS AEPB SYMBIRT AERO terbutaline sulfate tabs N fill QL(4 ml daily); AL; At least 1 - Up to 8 QL(2 ml daily) QL(100 ml per QL(150 ea per QL(200 ea per QL(60 ea per QL(4 gm per fill QL(13 gm per QL(12 ml daily) QL(30 ml daily) QL(17 gm per 30 days QL(11 gm per CA Health & Wellness Preferred List Update June 1,

17 Name VENTOLIN HA AERS VENTOLIN HA AERS VOSPIRE ER TB12 (Use Albuterol Sulfate) Xanthines ELIXOPHYLLIN ELIX THEO-24 CP24 theophylline soln 80 mg/15ml theophylline tb mg, 200 mg, 300 mg, 450 mg theophylline tb mg, 600 mg QL(36 gm per 30 days QL(16 gm per 30 days N ANTIAGULANTS - Blood Thinners Coumarin Anticoagulants UMADIN TABS (Use Warfarin Sodium) warfarin sodium tabs Direct actor Xa Inhibitors ELIQUIS STARTER PACK TABS ELIQUIS TABS XARELTO STARTER PACK TBPK XARELTO TABS 10 MG XARELTO TABS 15 MG XARELTO TABS 20 MG Heparins And Heparinoid-Like Agents enoxaparin sodium soln SP heparin sodium (porcine) soln LOVENOX SOLN (Use Enoxaparin Sodium) N QL(475 ml per QL(1 ea daily,35 ea per 180 days SP Name ANTINVULSANTS - s to Treat Seizures Anticonvulsants - Benzodiazepines clonazepam tabs 0.5 mg, 1 mg, 2 mg DIAZEPAM GEL RE 10 MG, 20 MG, 2.5 MG DIAZEPAM RECTAL GEL GEL KLONOPIN TABS (Use Clonazepam) Anticonvulsants - Misc. carbamazepine chew 100 mg carbamazepine susp 100 mg/5ml carbamazepine tabs 200 mg carbamazepine tb mg, 200 mg, 400 mg gabapentin caps 100 mg, 300 mg, 400 mg gabapentin soln 250 mg/5ml, 300 mg/6ml gabapentin tabs 600 mg gabapentin tabs 800 mg KEPPRA SOLN 100 MG/ML (Use Levetiracetam) KEPPRA TABS 1000 MG (Use Levetiracetam) KEPPRA TABS 250 MG, 750 MG (Use Levetiracetam) KEPPRA TABS 500 MG (Use Levetiracetam) KEPPRA XR TB24 (Use Levetiracetam) LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use Lamotrigine) N N N N N N N fill ; AL; At least 2 fill ; AL; At least 2 QL(9 ea daily) QL(6 ea daily) QL(30 ml daily) QL(6 ea daily) ST CA Health & Wellness Preferred List Update June 1,

18 Name LAMICTAL TABS (Use Lamotrigine) LAMICTAL XR TB24 25 MG, 50 MG, 100 MG, 200 MG, 250 MG, 300 MG (Use Lamotrigine) lamotrigine chew 5 mg, 25 mg lamotrigine tabs 25 mg, 100 mg, 150 mg, 200 mg lamotrigine tb24 25 mg, 50 mg, 100 mg, 200 mg, 250 mg, 300 mg levetiracetam soln 100 mg/ml, 500 mg/5ml levetiracetam tabs 1000 mg levetiracetam tabs 250 mg, 750 mg levetiracetam tabs 500 mg levetiracetam tb mg, 750 mg MYSOLINE TABS (Use Primidone) NEURONTIN CAPS 100 MG, 300 MG, 400 MG (Use Gabapentin) NEURONTIN SOLN 250 MG/5ML (Use Gabapentin) NEURONTIN TABS 600 MG (Use Gabapentin) NEURONTIN TABS 800 MG (Use Gabapentin) oxcarbazepine susp oxcarbazepine tabs primidone tabs TEGRETOL SUSP (Use Carbamazepine) TEGRETOL TABS (Use Carbamazepine) TEGRETOL-XR TB12 (Use Carbamazepine) N N N N N N N ST ST QL(30 ml daily) QL(6 ea daily) ST QL(9 ea daily) QL(6 ea daily) Name TOPAMAX SPRINKLE CPSP 15 MG (Use Topiramate) TOPAMAX SPRINKLE CPSP 25 MG (Use Topiramate) TOPAMAX TABS 100 MG (Use Topiramate) TOPAMAX TABS 200 MG (Use Topiramate) TOPAMAX TABS 25 MG, 50 MG (Use Topiramate) topiramate cpsp 15 mg topiramate cpsp 25 mg topiramate tabs 100 mg topiramate tabs 200 mg topiramate tabs 25 mg, 50 mg TRILEPTAL SUSP (Use Oxcarbazepine) TRILEPTAL TABS (Use Oxcarbazepine) ZONEGRAN CAPS (Use Zonisamide) zonisamide caps Carbamates felbamate susp felbamate tabs ELBATOL SUSP (Use elbamate) ELBATOL TABS (Use elbamate) GABA Modulators GABITRIL TABS (Use Tiagabine HCl) tiagabine hcl tabs Hydantoins QL(6 ea daily) N N N N N N N N N N N QL(8 ea daily) QL(6 ea daily) QL(6 ea daily) QL(8 ea daily) QL(6 ea daily) CA Health & Wellness Preferred List Update June 1,

19 Name DILANTIN CAPS 100 MG (Use Phenytoin Sodium Extended) DILANTIN CAPS 30 MG DILANTIN INATABS CHEW (Use Phenytoin) DILANTIN-125 SUSP (Use Phenytoin) phenytoin chew phenytoin sodium extended caps 100 mg phenytoin susp Succinimides ethosuximide caps ethosuximide soln ZARONTIN CAPS (Use Ethosuximide) ZARONTIN SOLN (Use Ethosuximide) Valproic Acid DEPAKENE CAPS (Use Valproic Acid) DEPAKENE SOLN (Use Valproate Sodium) DEPAKOTE ER TB24 (Use Divalproex Sodium) DEPAKOTE SPRINKLES CSDR (Use Divalproex Sodium) DEPAKOTE TBEC (Use Divalproex Sodium) divalproex sodium csdr divalproex sodium tb24 divalproex sodium tbec valproate sodium soln valproic acid caps N N N Name ANTIDEPRESSANTS - s to Treat Depression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 15 mg QL(3 ea daily) mirtazapine tabs 30 mg QL(1.5 ea mirtazapine tabs 45 mg, 7.5 mg mirtazapine tbdp 15 mg mirtazapine tbdp 30 mg mirtazapine tbdp 45 mg REMERON SOLTAB TBDP 15 MG (Use Mirtazapine) REMERON SOLTAB TBDP 30 MG (Use Mirtazapine) REMERON SOLTAB TBDP 45 MG (Use Mirtazapine) REMERON TABS 15 MG (Use Mirtazapine) REMERON TABS 30 MG (Use Mirtazapine) REMERON TABS 45 MG (Use Mirtazapine) Antidepressants - Misc. bupropion hcl tabs 75 mg, 100 mg bupropion hcl tb mg bupropion hcl tb mg bupropion hcl tb mg bupropion hcl tb mg bupropion hcl tb mg MAPROTILINE HCL TABS WELLBUTRIN SR TB MG (Use Bupropion HCl) N N N N N N N daily) QL(3 ea daily) QL(1.5 ea daily) QL(3 ea daily) QL(1.5 ea daily) QL(3 ea daily) QL(1.5 ea daily) QL(3 ea daily) QL(3 ea daily) QL(3 ea daily) CA Health & Wellness Preferred List Update June 1,

20 Name WELLBUTRIN SR TB MG (Use Bupropion HCl) WELLBUTRIN SR TB MG (Use Bupropion HCl) WELLBUTRIN TABS (Use Bupropion HCl) WELLBUTRIN XL TB MG (Use Bupropion HCl) WELLBUTRIN XL TB MG (Use Bupropion HCl) QL(3 ea daily) N N N N N Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 MARPLAN TABS NARDIL TABS (Use Phenelzine Sulfate) PARNATE TABS (Use Tranylcypromine Sulfate) phenelzine sulfate tabs QL(3 ea daily) QL(3 ea daily) tranylcypromine sulfate tabs Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG (Use Citalopram N Hydrobromide) CELEXA TABS 20 MG (Use Citalopram N Hydrobromide) CELEXA TABS 40 MG (Use Citalopram N Hydrobromide) citalopram hydrobromide QL(8 ml daily) soln 10 mg/5ml citalopram hydrobromide tabs 10 mg citalopram hydrobromide tabs 20 mg citalopram hydrobromide tabs 40 mg Name CA Health & Wellness Preferred List Update June 1, 2018 escitalopram oxalate tabs 10 mg escitalopram oxalate tabs 20 mg escitalopram oxalate tabs 5 mg fluoxetine hcl caps 10 mg, 20 mg fluoxetine hcl caps 40 mg fluoxetine hcl soln 20 mg/5ml fluoxetine hcl tabs 10 mg fluoxetine hcl tabs 20 mg fluvoxamine maleate tabs 100 mg fluvoxamine maleate tabs 25 mg, 50 mg LEXAPRO TABS 10 MG (Use Escitalopram Oxalate) LEXAPRO TABS 20 MG (Use Escitalopram Oxalate) LEXAPRO TABS 5 MG (Use Escitalopram Oxalate) paroxetine hcl tabs 10 mg paroxetine hcl tabs 20 mg paroxetine hcl tabs 30 mg, 40 mg paroxetine hcl tb24 25 mg, 12.5 mg, 37.5 mg PAXIL CR TB24 (Use Paroxetine HCl) PAXIL SUSP 10 MG/5ML PAXIL TABS 10 MG (Use Paroxetine HCl) PAXIL TABS 20 MG (Use Paroxetine HCl) PAXIL TABS 30 MG, 40 MG (Use Paroxetine HCl) N N N N N N N ; AL; At least 7 QL(20 ml daily); AL; At least 7 ; AL; At least 7 QL(3 ea daily) QL(6 ea daily) QL(3 ea daily) QL(40 ml daily) QL(6 ea daily) QL(3 ea daily) 13

21 Name PROZAC CAPS 10 MG, 20 MG (Use luoxetine HCl) PROZAC CAPS 40 MG (Use luoxetine HCl) sertraline hcl conc 20 mg/ml sertraline hcl tabs 100 mg sertraline hcl tabs 25 mg, 50 mg ZOLOT NC 20 MG/ML (Use Sertraline HCl) ZOLOT TABS 100 MG (Use Sertraline HCl) ZOLOT TABS 25 MG, 50 MG (Use Sertraline HCl) Serotonin Modulators NEAZODONE HCL TABS 100 MG, 150 MG, 200 MG nefazodone hcl tabs 50 mg, 250 mg trazodone hcl tabs 300 mg trazodone hcl tabs 50 mg, 100 mg, 150 mg VIIBRYD TABS N N N N N ; AL; At least 7 QL(10 ml daily) QL(10 ml daily) PA; QL(1 ea daily) Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use Duloxetine HCl) duloxetine hcl cpep 20 mg, 30 mg, 60 mg EEXOR XR CP MG (Use Venlafaxine HCl) EEXOR XR CP MG (Use Venlafaxine HCl) EEXOR XR CP24 75 MG (Use Venlafaxine HCl) venlafaxine hcl cp mg venlafaxine hcl cp mg N N N N ; AL; At least 7 ; AL; At least 7 QL(5 ea daily) Name venlafaxine hcl cp24 75 mg VENLAAXINE HCL ER TB MG VENLAAXINE HCL ER TB24 75 MG, 150 MG, 37.5 MG (Use Venlafaxine HCl) venlafaxine hcl tabs 25 mg, 50 mg, 75 mg, 100 mg, 37.5 mg venlafaxine hcl tb24 75 mg, 150 mg, 225 mg, 37.5 mg Tricyclic Agents amitriptyline hcl tabs 10 mg amitriptyline hcl tabs 150 mg amitriptyline hcl tabs 25 mg, 100 mg amitriptyline hcl tabs 50 mg amitriptyline hcl tabs 75 mg AMOXAPINE TABS ANARANIL CAPS (Use Clomipramine HCl) clomipramine hcl caps desipramine hcl tabs 10 mg, 50 mg, 75 mg, 100 mg, 150 mg desipramine hcl tabs 25 mg doxepin hcl caps doxepin hcl conc ELAVIL TABS (Use Amitriptyline HCl) imipramine hcl tabs NORPRAMIN TABS 10 MG, 50 MG, 75 MG, 100 MG, 150 MG (Use Desipramine HCl) QL(5 ea daily) N N N N QL(20 ea per QL(100 ea per QL(150 ea per QL(200 ea per QL(400 ea per QL(150 ea per CA Health & Wellness Preferred List Update June 1,

22 Name NORPRAMIN TABS 25 MG (Use Desipramine HCl) nortriptyline hcl caps 10 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl soln 10 mg/5ml PAMELOR CAPS (Use Nortriptyline HCl) TORANIL TABS (Use Imipramine HCl) N N N QL(20 ml daily) ANTIDIABETICS - s to Regulate Blood Sugar Antidiabetic - Amylin Analogs SYMLINPEN 120 SOPN SYMLINPEN 60 SOPN Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl- Metformin HCl) ALOGLIPTIN/METORMIN HCL TABS ALOGLIPTIN/PIOGLITAZO NE TABS glipizide-metformin hcl tabs GLUVANCE TABS (Use Glyburide-Metformin) glyburide-metformin tabs JENTADUETO TABS pioglitazone hcl-metformin hcl tabs Biguanides GLUPHAGE TABS 1000 MG (Use Metformin HCl) GLUPHAGE TABS 500 MG (Use Metformin HCl) N N N N PA; QL(10.8 ml per 30 days PA; QL(6 ml per 30 days PA; QL(2 ea daily) PA; QL(1 ea daily) PA; QL(2 ea daily); AL; At least 18 QL(5 ea daily) Name GLUPHAGE TABS 850 MG (Use Metformin HCl) GLUPHAGE XR TB MG (Use Metformin HCl) GLUPHAGE XR TB MG (Use Metformin HCl) metformin hcl tabs 1000 mg metformin hcl tabs 500 mg metformin hcl tabs 850 mg metformin hcl tb mg metformin hcl tb mg Diabetic Other BD GLUSE CHEW CVS GLUSE CHEW 4 GM DEX4 QUICK DISSOLVE GLUSE CHEW GLUCAGEN HYPOKIT SOLR GLUCAGON EMERGENCY KIT KIT GLUSE CHEW 4 GM N QL(3 ea daily) N N QL(5 ea daily) QL(3 ea daily) fill GNP GLUSE CHEW 4 GM GNP QUICK DISSOLVE GLUSE CHEW LEADER QUICK DISSOLVE GLUSE CHEW SM GLUSE CHEW 4 GM WALGREENS GLUSE CHEW 4 GM Dipeptidyl Peptidase-4 (DPP-4) Inhibitors ALOGLIPTIN TABS PA; QL(1 ea daily) CA Health & Wellness Preferred List Update June 1,

23 Name TRADJENTA TABS PA; QL(1 ea daily); AL; At least 18 Incretin Mimetic Agents (GLP-1 Receptor PA; QL(4 ea BYDUREON PEN PEN per 30 days ; AL; At least 18 BYDUREON SRER PA; QL(4 ea per 28 days ; AL; At least 18 BYETTA SOPN 10 MCG/0.04ML PA; QL(2.4 ml per 30 days ; AL; At least 18 BYETTA SOPN 5 MCG/0.02ML VICTOZA SOPN Insulin Sensitizing Agents ACTOS TABS (Use Pioglitazone HCl) AVANDIA TABS pioglitazone hcl tabs Insulin ADMELOG SOLN ADMELOG SOLOSTAR SOPN APIDRA SOLN APIDRA SOLOSTAR SOPN BASAGLAR KWIKPEN SOPN IASP LEXTOUCH SOPN IASP SOLN N PA; QL(1.2 ml per 30 days ; AL; At least 18 PA; QL(1.8 ml daily) QL(40 ml per 30 days QL(30 ml per 30 days QL(30 ml per 30 days Limit 50mls per month;ql(1.67 ml daily) QL(30 ml per 30 days QL(30 ml per 30 days Name HUMALOG JUNIOR KWIKPEN SOPN HUMALOG KWIKPEN SOPN 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUPN HUMALOG MIX 50/50 SUSP HUMALOG MIX 75/25 KWIKPEN SUPN HUMALOG MIX 75/25 SUSP HUMALOG SOCT HUMALOG SOLN HUMULIN 70/30 KWIKPEN SUPN HUMULIN 70/30 SUSP HUMULIN N KWIKPEN SUPN HUMULIN N SUSP HUMULIN R SOLN NOVOLIN 70/30 RELION SUSP NOVOLIN 70/30 SUSP NOVOLIN N RELION SUSP NOVOLIN N SUSP NOVOLIN R RELION SOLN NOVOLIN R SOLN NOVOLOG LEXPEN SOPN NOVOLOG MIX 70/30 PREILLED LEXPEN SUPN NOVOLOG MIX 70/30 SUSP QL(30 ml per 30 days QL(30 ml per 30 days QL(30 ml per 30 days QL(40 ml per 30 days QL(30 ml per 30 days QL(40 ml per 30 days QL(30 ml per 30 days QL(40 ml per 30 days QL(40 ml per 30 days QL(40 ml per 30 days QL(40 ml per 30 days QL(40 ml per 30 days QL(40 ml per 30 days QL(40 ml per 30 days QL(40 ml per 30 days QL(40 ml per 30 days QL(40 ml per 30 days QL(30 ml per 30 days QL(30 ml per 30 days QL(40 ml per 30 days CA Health & Wellness Preferred List Update June 1,

24 Name NOVOLOG SOLN Meglitinide Analogues nateglinide tabs QL(30 ml per 30 days QL(3 ea daily) STARLIX TABS (Use Nateglinide) N QL(3 ea daily) Sodium-Glucose Co-Transporter 2 (SGLT2) JARDIANCE TABS PA; QL(1 ea daily) Sulfonylureas AMARYL TABS 1 MG, 2 N MG (Use Glimepiride) AMARYL TABS 4 MG (Use Glimepiride) N glimepiride tabs 1 mg, 2 mg glimepiride tabs 4 mg glipizide tabs glipizide tb24 GLUTROL TABS (Use Glipizide) GLUTROL XL TB24 (Use Glipizide) glyburide micronized tabs N N glyburide tabs GLYNASE TABS (Use N Glyburide Micronized) ANTIDIARRHEAL/PROBIOTIC AGENTS - s to Treat Diarrhea Antidiarrheal/Probiotic Agents - Misc. bismuth subsalicylate chew 262 mg bismuth subsalicylate susp 262 mg/15ml, 525 mg/15ml, 525 mg/30ml, 527 mg/30ml PEPTO-BISMOL CHEW 262 MG (Use Bismuth N Subsalicylate) Name PEPTO-BISMOL INSTAOL CHEW (Use Bismuth Subsalicylate) PEPTO-BISMOL MAX STRENGTH SUSP (Use Bismuth Subsalicylate) PEPTO-BISMOL SUSP 262 MG/15ML (Use Bismuth Subsalicylate) PEPTO-BISMOL TO-GO CHEW (Use Bismuth Subsalicylate) Antiperistaltic Agents diphenoxylate w/ atropine tabs DIPHENOXYLATE/ATROP INE LIQD IMODIUM A-D CAPS 2 MG (Use Loperamide HCl) IMODIUM A-D TABS 2 MG (Use Loperamide HCl) LOMOTIL TABS (Use Diphenoxylate w/ Atropine) loperamide hcl caps 2 mg loperamide hcl liqd 1 mg/5ml loperamide hcl tabs 2 mg PAREGORIC TINC N N N N N N N ANTIDOTES AND SPECIIC ANTAGONISTS Antidotes - Chelating Agents CHEMET CAPS JADENU SPRINKLE PACK JADENU TABS Antidotes and Specific Antagonists VISTOGARD PACK Opioid Antagonists NALOXONE HCL SOCT 0.4 MG/ML PA CA Health & Wellness Preferred List Update June 1,

25 Name naloxone hcl soln 0.4 mg/ml, 4 mg/10ml NALOXONE HCL SOSY 2 MG/2ML naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR ANTIEMETICS - s to Treat Nausea and Vomiting 5-HT3 Receptor Antagonists ondansetron hcl soln 4 QL(50 ml per mg/5ml ondansetron hcl tabs 4 mg, 8 mg ondansetron tbdp ZORAN ODT TBDP (Use N Ondansetron) ZORAN SOLN 4 MG/5ML N (Use Ondansetron HCl) ZORAN TABS 4 MG, 8 MG (Use Ondansetron N HCl) Antiemetics - Anticholinergic dimenhydrinate tabs or 50 mg DRAMAMINE CHEW DRAMAMINE TABS (Use Dimenhydrinate) meclizine hcl chew 25 mg N QL(20 ea per 30 days QL(20 ea per 30 days QL(20 ea per 30 days QL(50 ml per QL(20 ea per 30 days meclizine hcl tabs 25 mg, 12.5 mg Substance P/Neurokinin 1 (NK1) Receptor aprepitant caps 1 rtl pack lmt aprepitant caps 40 mg, 125 mg aprepitant caps 80 mg per fill, fill QL(2 ea per fill Name EMEND CAPS 40 MG, 125 MG (Use Aprepitant) EMEND CAPS 80 MG (Use Aprepitant) EMEND TRIPACK CAPS (Use Aprepitant) N fill N QL(2 ea per fill N 1 rtl pack lmt per fill, ANTIUNGALS - s to Treat ungal Infections Antifungals GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs LAMISIL TABS 250 MG (Use Terbinafine HCl) nystatin tabs terbinafine hcl tabs N N Imidazole-Related Antifungals DILUCAN SUSR 10 MG/ML, 40 MG/ML (Use N luconazole) DILUCAN TABS 100 MG (Use luconazole) N DILUCAN TABS 150 MG (Use luconazole) N DILUCAN TABS 200 MG (Use luconazole) N DILUCAN TABS 50 MG (Use luconazole) N fluconazole susr 10 mg/ml, 40 mg/ml fluconazole tabs 100 mg fluconazole tabs 150 mg fluconazole tabs 200 mg fluconazole tabs 50 mg QL(6 ea daily) QL(70 ml per QL(2 ea per fill QL(7 ea per fill QL(70 ml per QL(2 ea per fill QL(7 ea per fill CA Health & Wellness Preferred List Update June 1,

26 Name itraconazole caps ketoconazole tabs SPORANOX CAPS 100 MG (Use Itraconazole) SPORANOX PULSEPAK CAPS (Use Itraconazole) PA; QL(1 ea daily) N N PA; QL(1 ea daily) PA; QL(1 ea daily) ANTIHISTAMINES - s to Treat Allergies Antihistamines - Alkylamines CHLOR-TRIMETON SYRP (Use Chlorpheniramine N Maleate) CHLOR-TRIMETON TABS (Use Chlorpheniramine N Maleate) chlorpheniramine maleate syrp 2 mg/5ml chlorpheniramine maleate tabs 4 mg Antihistamines - Ethanolamines ALER-DRYL TABS BENADRYL ALLERGY CAPS (Use Diphenhydramine HCl) BENADRYL ALLERGY CHILDRENS LIQD 12.5 MG/5ML (Use Diphenhydramine HCl) BENADRYL ALLERGY TABS (Use Diphenhydramine HCl) clemastine fumarate tabs 1.34 mg diphenhydramine hcl caps 25 mg diphenhydramine hcl caps 50 mg diphenhydramine hcl elix 12.5 mg/5ml diphenhydramine hcl liqd 25 mg/10ml, 50 mg/20ml, 12.5 mg/5ml N N N ; QL(240 ml per ; Name diphenhydramine hcl syrp 12.5 mg/5ml diphenhydramine hcl tabs 25 mg SILPHEN UGH SYRP TAVIST ALLERGY TABS N (Use Clemastine umarate) Antihistamines - Non-Sedating ALLEGRA ALLERGY TABS (Use exofenadine N HCl) cetirizine hcl chew 5 mg, 10 mg cetirizine hcl soln 1 mg/ml, 5 mg/5ml cetirizine hcl syrp 1 mg/ml, 5 mg/5ml cetirizine hcl tabs 5 mg, 10 mg CLARITIN ALLERGY CHILDRENS SYRP (Use Loratadine) CLARITIN REDITABS TBDP 10 MG (Use Loratadine) CLARITIN SYRP 5 MG/5ML (Use Loratadine) CLARITIN TABS 10 MG (Use Loratadine) fexofenadine hcl tabs 60 mg, 180 mg levocetirizine dihydrochloride tabs 5 mg loratadine soln 5 mg/5ml loratadine syrp 5 mg/5ml loratadine tabs 10 mg loratadine tbdp 10 mg XYZAL ALLERGY 24HR TABS (Use Levocetirizine Dihydrochloride) N N N N N QL(240 ml per ; QL(240 ml per ; CA Health & Wellness Preferred List Update June 1,

27 Name XYZAL TABS 5 MG (Use Levocetirizine Dihydrochloride) ZYRTEC ALLERGY TABS (Use Cetirizine HCl) ZYRTEC CHILDRENS ALLERGY SOLN (Use Cetirizine HCl) N N N Antihistamines - Phenothiazines promethazine hcl soln or 6.25 mg/5ml promethazine hcl supp re 25 mg, 50 mg, 12.5 mg promethazine hcl syrp or 6.25 mg/5ml promethazine hcl tabs or 25 mg, 50 mg, 12.5 mg Antihistamines - Piperidines cyproheptadine hcl syrp cyproheptadine hcl tabs QL(240 ml per ; QL(240 ml per ; AL; At least 2 QL(12 ea per ; AL; At least 2 QL(240 ml per ; AL; At least 2 AL; At least 2 ANTIHYPERLIPIDEMICS - s to Treat High Cholesterol Bile Acid Sequestrants cholestyramine light pack cholestyramine light powd cholestyramine pack cholestyramine powd LESTID LAVORED GRAN 5 GM (Use Colestipol HCl) LESTID GRAN 5 GM (Use Colestipol HCl) LESTID TABS 1 GM (Use Colestipol HCl) colestipol hcl gran 5 gm colestipol hcl tabs 1 gm N N N Name QUESTRAN LIGHT POWD (Use Cholestyramine Light) QUESTRAN PACK (Use Cholestyramine) QUESTRAN POWD (Use Cholestyramine) ibric Acid Derivatives fenofibrate micronized caps 134 mg, 200 mg fenofibrate micronized caps 67 mg fenofibrate tabs 160 mg fenofibrate tabs 54 mg gemfibrozil tabs LOIBRA CAPS 134 MG, 200 MG (Use enofibrate Micronized) LOIBRA CAPS 67 MG (Use enofibrate Micronized) LOIBRA TABS 160 MG (Use enofibrate) LOIBRA TABS 54 MG (Use enofibrate) LOPID TABS (Use Gemfibrozil) TRIGLIDE TABS N N N N N N N N HMG CoA Reductase Inhibitors atorvastatin calcium tabs CRESTOR TABS (Use Rosuvastatin Calcium) LIPITOR TABS (Use Atorvastatin Calcium) lovastatin tabs 10 mg, 20 mg lovastatin tabs 40 mg MEVAR TABS (Use Lovastatin) PRAVACHOL TABS (Use Pravastatin Sodium) N N N N QL(3 ea daily) QL(3 ea daily) ST CA Health & Wellness Preferred List Update June 1,

28 Name pravastatin sodium tabs rosuvastatin calcium tabs ST simvastatin tabs 5 mg, 10 mg, 20 mg, 40 mg simvastatin tabs 80 mg PA ZOR TABS 5 MG, 10 MG, 20 MG, 40 MG (Use N Simvastatin) ZOR TABS 80 MG (Use Simvastatin) N PA Nicotinic Acid Derivatives niacin (antihyperlipidemic) tbcr NIAR TABS NIASPAN TBCR (Use Niacin (Antihyperlipidemic)) N ANTIHYPERTENSIVES - s to Treat High Blood Pressure ACE Inhibitors ACCUPRIL TABS (Use Quinapril HCl) N ALTACE CAPS (Use Ramipril) N benazepril hcl tabs 40 mg benazepril hcl tabs 5 mg, 10 mg, 20 mg captopril tabs QL(3 ea daily) enalapril maleate tabs EPANED SOLR PA fosinopril sodium tabs lisinopril tabs LOTENSIN TABS 20 MG (Use Benazepril HCl) LOTENSIN TABS 40 MG (Use Benazepril HCl) MAVIK TABS (Use Trandolapril) N N N Name PRINIVIL TABS (Use Lisinopril) quinapril hcl tabs ramipril caps trandolapril tabs 1 mg, 2 mg trandolapril tabs 4 mg N VASOTEC TABS (Use Enalapril Maleate) N ZESTRIL TABS (Use Lisinopril) N Angiotensin II Receptor Antagonists ATACAND TABS (Use Candesartan Cilexetil) N AVAPRO TABS (Use Irbesartan) N BENICAR TABS (Use Olmesartan Medoxomil) N ST candesartan cilexetil tabs ZAAR TABS (Use Losartan Potassium) DIOVAN TABS (Use Valsartan) irbesartan tabs losartan potassium tabs MICARDIS TABS (Use Telmisartan) olmesartan medoxomil tabs telmisartan tabs valsartan tabs CA Health & Wellness Preferred List Update June 1, 2018 N N N Antiadrenergic Antihypertensives CARDURA TABS (Use Doxazosin Mesylate) N CATAPRES TABS (Use Clonidine HCl) N clonidine hcl tabs or 0.1 mg, 0.2 mg, 0.3 mg ST 21

29 Name doxazosin mesylate tabs guanfacine hcl tabs methyldopa tabs MINIPRESS CAPS (Use Prazosin HCl) prazosin hcl caps TENEX TABS (Use Guanfacine HCl) terazosin hcl caps N N Antihypertensive Combinations ACCURETIC TABS 10MG- 12.5MG (Use Quinapril- N Hydrochlorothiazide) ACCURETIC TABS 20MG- 12.5MG (Use Quinapril- N Hydrochlorothiazide) ACCURETIC TABS 20MG- 25MG (Use Quinapril- N Hydrochlorothiazide) amlodipine besylatebenazepril hcl caps amlodipine besylateolmesartan medoxomil tabs amlodipine besylatevalsartan tabs amlodipine-valsartanhydrochlorothiazide tabs ATACAND HCT TABS (Use Candesartan Cilexetil- N Hydrochlorothiazide) atenolol & chlorthalidone tabs AVALIDE TABS (Use Irbesartan- N Hydrochlorothiazide) AZOR TABS (Use Amlodipine Besylate- N Olmesartan Medoxomil) benazepril & hydrochlorothiazide tabs QL(3 ea daily) ST ST ST ST Name BENICAR HCT TABS (Use Olmesartan Medoxomil- Hydrochlorothiazide) bisoprolol & hydrochlorothiazide tabs 2.5mg-6.25mg bisoprolol & hydrochlorothiazide tabs 5mg-6.25mg, 10mg- 6.25mg candesartan cilexetilhydrochlorothiazide tabs CAPTOPRIL/HYDROCHL OROTHIAZIDE TABS DIOVAN HCT TABS (Use Valsartan- Hydrochlorothiazide) enalapril maleate & hydrochlorothiazide tabs EXORGE HCT TABS (Use Amlodipine-Valsartan- Hydrochlorothiazide) fosinopril sodium & hydrochlorothiazide tabs HYZAAR TABS (Use Losartan Potassium & Hydrochlorothiazide) EXORGE TABS (Use Amlodipine Besylate- Valsartan) irbesartanhydrochlorothiazide tabs lisinopril & hydrochlorothiazide tabs LOPRESSOR HCT TABS (Use Metoprolol & Hydrochlorothiazide) losartan potassium & hydrochlorothiazide tabs LOTENSIN HCT TABS (Use Benazepril & Hydrochlorothiazide) LOTREL CAPS (Use Amlodipine Besylate- Benazepril HCl) metoprolol & hydrochlorothiazide tabs ST N N N N N N N N ST ST CA Health & Wellness Preferred List Update June 1,

30 Name METOPROLOL SUCCINATE ER/HYDROCHLOROTHIA ZIDE TB24 METOPROLOL/HYDROCH LOROTHIAZIDE TABS MICARDIS HCT TABS (Use Telmisartan- Hydrochlorothiazide) olmesartan medoxomilamlodipinehydrochlorothiazide tabs olmesartan medoxomilhydrochlorothiazide tabs PROPRANOLOL/HYDROC HLOROTHIAZIDE TABS quinaprilhydrochlorothiazide tabs 10mg-12.5mg quinaprilhydrochlorothiazide tabs 20mg-12.5mg quinaprilhydrochlorothiazide tabs 20mg-25mg TARKA TBCR (Use Trandolapril-Verapamil HCl) telmisartan-amlodipine tabs telmisartanhydrochlorothiazide tabs TENORETIC 100 TABS (Use Atenolol & Chlorthalidone) TENORETIC 50 TABS (Use Atenolol & Chlorthalidone) trandolapril-verapamil hcl tbcr TRANDOLAPRIL/VERAPA MIL HCL ER TBCR TRIBENZOR TABS (Use Olmesartan Medoxomil- Amlodipine- Hydrochlorothiazide) N N N N N ST ST QL(3 ea daily) ST Name TWYNSTA TABS (Use Telmisartan-Amlodipine) valsartanhydrochlorothiazide tabs VASERETIC TABS (Use Enalapril Maleate & Hydrochlorothiazide) ZESTORETIC TABS (Use Lisinopril & Hydrochlorothiazide) ZIAC TABS 2.5MG- 6.25MG (Use Bisoprolol & Hydrochlorothiazide) ZIAC TABS 5MG-6.25MG, 10MG-6.25MG (Use Bisoprolol & Hydrochlorothiazide) Vasodilators hydralazine hcl tabs or 10 mg, 25 mg, 50 mg, 100 mg minoxidil tabs N N N N N ANTIMALARIALS - s to Treat Malaria (Parasitic Infections) Antimalarial Combinations ARTEM TABS Antimalarials CHLOROQUINE PHOSPHATE TABS 250 MG chloroquine phosphate tabs 500 mg hydroxychloroquine sulfate tabs mefloquine hcl tabs MELOQUINE HCL TABS PLAQUENIL TABS (Use Hydroxychloroquine Sulfate) N QL(24 ea per QL(8 ea per 56 days ANTIMYASTHENIC/CHOLINERGIC AGENTS Antimyasthenic/Cholinergic Agents CA Health & Wellness Preferred List Update June 1,