2017 List of Covered Drugs (Formulary)

Transcription

1 Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 List of Covered s (Formulary) This drug list was updated on 12/01/201. If you have questions, please call Health Net Cal MediConnect at for Los Angeles County or for San Diego County (TTY: 71. A live person is here to talk with you Monday through Friday, 8:00 a.m. to 8:00 p.m. At other times including Saturday, Sunday and federal holidays you can leave a voic . We will return your call the following business day. The call is free. For more information, visit HPMS Approved Formulary File Submission ID: Version Number: 21 H3237_2017_0020 CMS Approved

2 This is a list of drugs that members can get in Health Net Cal MediConnect. Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. The List of Covered s and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or copayments may change on January 1 of each year. You can always check Health Net Cal MediConnect s up-to-date List of Covered s online at or by calling for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. Limitations, copays, and restrictions may apply. For more information, call Health Net Cal MediConnect Member Services or read the Health Net Cal MediConnect Member Handbook. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. You can get this information for free in other languages. Call for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. Puede obtener esta información de manera gratuita en otros idiomas. Llame al para el condado de Los Angeles o al para el condado de San Diego (TTY: 71, de lunes a viernes de 8.00 a.m. a 8.00 p.m. La llamada es gratuita.? If you have questions, please call Health Net Cal MediConnect at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. For more information, visit i

3 برای شما میتوانید این اطالعات را بهطور رایگان به زبانهای دیگر دریافت بخش لس آنجلس ساعت تماس از دوشنبه تا جمعه 08:00 صبح تا 08:00 شب کنید. با شماره یا ببرای بخش سن دیگو تماس بگیرید )کاربران :TTY 711 ( روزها و. تماسها رایگان است. ល កអ នកអ ចទទ លប នព ត ម នលន ជ ភ ស ដទទលទ តល យឥតគ តទល ស មទ រស ពទល លលខ សម រម ប ល នធ Los Angeles ឬលលខ សម រម ប ល នធ San Diego (TTY: 71 ព ទល ច នទ ដល ទល ស ម រក លម ង 8:00 ម រព ក ដល លម ង 8:00 យប ក រល ទ រស ពទគ ឥតគ តទល تستطيع الحصول على هذه المعلومات مجان ا بلغات أخرى. اتصل على الرقم لمقاطعة لوس أنجلوس أو الرقم لمقاطعة سان ديغو )الهاتف النصي: 711( من يوم اإلثنين إلى الجمعة من الساعة 8:00 صباح ا إلى 8:00 مساء. المكالمة مجانية. You can get this information for free in other formats, such as large print, braille, or audio. Call for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. If you would like Health Net Cal MediConnect to send you member materials on an ongoing basis in other formats, such as Braille or large print, or in a language other than English, please contact Member Services. Tell Member Services that you would like to place a standing request to get your materials in another format or language. ii

4 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered s. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered s? (We call the List of Covered s the List for short.) The drugs on the List are the drugs covered by Health Net Cal MediConnect. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. Health Net Cal MediConnect will cover all medically necessary drugs on the List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a Health Net Cal MediConnect network pharmacy. In some cases, you have to do something before you can get a drug (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Member Services at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. 2. Does the List ever change? Yes. Health Net Cal MediConnect may add or remove drugs on the List during the year. Generally, the List will only change if: a cheaper drug comes along that works as well as a drug on the List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Health Net Cal MediConnect before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page iv.)? If you have questions, please call Health Net Cal MediConnect at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. For more information, visit iii

5 We will tell you when a drug you are taking is removed from the List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the List changes. You can always check Health Net Cal MediConnect s up-to-date List online at You can also call Member Services to check the current List at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. 3. What happens when a cheaper drug comes along that works as well as a drug on the List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the List or when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is removed from the drug list. We will send you a letter that tells you about this change. We will also put these types of changes on our website at 4. What happens when we find out a drug is not safe? If the Food and Administration (FDA) says a drug you are taking is not safe, we will take it off the List right away. We will also send you a letter telling you that. If you get one of these letters, please call your doctor to talk about other drug options. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Health Net Cal MediConnect before you fill your prescription. If you don t get approval, Health Net Cal MediConnect may not cover the drug. Quantity limits: Sometimes Health Net Cal MediConnect limits the amount of a drug you can get. Step therapy: Sometimes Health Net Cal MediConnect requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. iv You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1 Index 1. You can also get more information by visiting our website at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

6 You can ask for an exception from these limits. Please see Question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Health Net Cal MediConnect member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to ask for an exception. Please see Question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered s on page 1 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some of the drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the coverage rules is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it in the Index that begins on page Index 1. To search by medical condition, find the section labeled List of drugs by medical condition on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, CARDIOVASCULAR AGES - MISC. s to Treat Heart and Circulation Conditions. That is where you will find drugs that treat heart conditions.? If you have questions, please call Health Net Cal MediConnect at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. For more information, visit v

7 9. What if the drug you want to take is not on the List? If you don t see your drug on the List, call Member Services at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. and ask about it. If you learn that Health Net Cal MediConnect will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new Health Net Cal MediConnect member and can t find your drug on the List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Health Net Cal MediConnect. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to ask for an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by Health Net Cal MediConnect, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to those on the List or ask for an exception. Level of Care Changes If your level of care changes, we will cover a transition supply of your drugs. A level of care change happens when you are released from a hospital. It also happens when you move to or from a long-term care facility. If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 30-day supply. If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 31-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 31-day supply. vi

8 11. Can you ask for an exception to cover your drug? Yes. You can ask Health Net Cal MediConnect to make an exception to cover a drug that is not on the List. You can also ask us to change the rules on your drug. For example, Health Net Cal MediConnect may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services. Member Services will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and their names are less commonly known. Generic drugs are approved by the Food and Administration (FDA). Health Net Cal MediConnect covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. Health Net Cal MediConnect covers some OTC drugs when they are written as prescriptions by your provider. You can read the Health Net Cal MediConnect List to see what OTC drugs are covered.? If you have questions, please call Health Net Cal MediConnect at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. For more information, visit vii

9 16. Does Health Net Cal MediConnect cover OTC non-drug products? Health Net Cal MediConnect covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the Health Net Cal MediConnect List to see what OTC non-drug products are covered. 17. What is your copay? You can read the Health Net Cal MediConnect List to learn about the copay for each drug. Health Net Cal MediConnect members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. s are groups of drugs with the same copay. 1 drugs have a low copay. They are generic drugs. The copay is from.00 to. This depends on your level of Medi-Cal coverage. 2 drugs have a higher copay. They are brand name drugs. The copay is from.00 to. This depends on your level of Medi-Cal coverage. 3 drugs have a.00 copay. They are prescription and OTC drugs that Medi-Cal covers. Abbreviation What this means How it works AL Age Limit This drug may need prior authorization if your age does not meet drug maker, FDA or clinical guidelines. B/D Medicare Part B vs. Part D This drug may need prior authorization to decide if it should be covered under Medicare Part B or Part D. This is a Medicare rule. Your doctor or other prescriber may need to give more facts to help us make this decision. GL Gender Limit This drug may only be safe for males or females. LA Limited Access This drug may be found at only one or a few pharmacies because: The FDA limits the drug to certain facilities, pharmacies or prescribers, or Certain drugs need special care, or patient training that cannot be given at a retail pharmacy. You should talk to your doctor, other prescriber, or pharmacist for details about getting limited access drugs. viii

10 Abbreviation What this means How it works Mail Order You can get this drug at Health Net Cal MediConnect s mail order pharmacy. Not Covered This drug is not covered on the List. You can ask for an exception for the drug to be covered. Not Part D This drug is not a Part D drug. You will not be required to pay a copay for these drugs. PA Prior Authorization This drug requires prior authorization. This means that you or your doctor must get approval from Health Net Cal MediConnect before you fill your prescription. If you don t get approval, we may not cover the drug. QL Quantity Limit This drug has a limit on the amount that Health Net Cal MediConnect will cover. RX/OTC Prescription and Over-the-Counter (OTC) This drug is made in both prescription form and OTC form. SL Safety Limit This drug has a maximum daily dose limit for safety supported by the FDA. This means that Health Net will not cover more than the maximum daily dose. For example, the FDA maximum daily dose of simvastatin is 80. Therefore, we will only cover up to two tablets per day for simvastatin 40. ST Step Therapy This drug requires step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second.? If you have questions, please call Health Net Cal MediConnect at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. For more information, visit ix

11 List of Covered s The List of Covered s that begins on page 1 gives you information about the drugs covered by Health Net Cal MediConnect. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., LIPITOR) and generic drugs are listed in lower-case italics (e.g., atorvastatin calcium). The information in the Necessary actions, restrictions, or limits on use column tells you if Health Net Cal MediConnect has any rules for covering your drug. Here are the meanings of the codes used in the Necessary actions, restrictions, or limits on use column: Note: The next to a drug means the drug is not a Part D drug. You will not be required to pay a copay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m.. You can also read the Member Handbook to learn how to appeal a decision. List of s by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, CARDIOVASCULAR AGES MISC. s to Treat Heart and Circulation Conditions. That is where you will find drugs that treat heart conditions. x

12 Non-Discrimination Notice Health Net Cal MediConnect complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net Cal MediConnect does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Net Cal MediConnect: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Health Net Cal MediConnect's Customer Contact Center at Los Angeles County: /San Diego County: (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. At other times including Saturday, Sunday and federal holidays you can leave a voic . We will return your call the following business day. The call is free. If you believe that Health Net Cal MediConnect has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net Cal MediConnect's Customer Contact Center 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 or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, (TDD: ). Complaint forms are available at If you have questions, please call Health Net Cal MediConnect at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. For more information, visit xi

13 Multi-language Interpreter Services English: ATTEION: If you speak English, language assistance services, free of charge, are available to you. Call (Los Angeles), (San Diego) (TTY: 71. Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (Los Angeles), (San Diego) (TTY: 71. Chinese Mandarin: 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 (Los Angeles), (San Diego) (TTY: 71. Chinese Cantonese: 注意 : 如果您說英文, 您可獲得免費的語言協助服務 請致電 (Los Angeles), (San Diego)( 聽障專線 :71 Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (Los Angeles), (San Diego) (TTY: 71. French: ATTEION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (Los Angeles), (San Diego) (TTY: 71. Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (Los Angeles), (San Diego) (TTY: 71. German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (Los Angeles), (San Diego) (TTY: 71. xii

14 Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (Los Angeles), (San Diego) (TTY: 71. 번으로전화해주십시오. Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (Los Angeles), (San Diego) (телетайп: 71. Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم - Diego), (San Angeles) (Los )رقم هاتف الصم والبكم: 711(. Hindi: ध य न द : यदद आप ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (Los Angeles), (San Diego) (TTY: 71. पर क ल कर. Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (Los Angeles), (San Diego) (TTY: 71. Portugués: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (Los Angeles), (San Diego) (TTY: 71. French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (Los Angeles), (San Diego) (TTY: 71. Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (Los Angeles), (San Diego) (TTY: 71.? If you have questions, please call Health Net Cal MediConnect at for Los Angeles County or for San Diego County (TTY: 71, Monday through Friday, 8:00 a.m. to 8:00 p.m. The call is free. For more information, visit xiii

15 Japanese: 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 (Los Angeles), (San Diego) (TTY: 71. まで お電話にてご連絡ください Farsi: توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رايگان برای شما فراهم با 71 (TTY: (San Diego), (Los Angeles) تماس بگیريد. می باشد. Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (Los Angeles), (San Diego) (TTY (հեռատիպ) 71: Cambodian: ប រយ ត ន បរ ស នជ អ នកន យ យ ភ ស ខ ម រ, បសវ ជ ន យខ នកភ ស ប យម នគ ត ឈ ន ល គ អ ចម នស រ រ រ បរ អ នក ច រ ទ រស ព ទ (Los Angeles), (San Diego) (TTY: 71. Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (Los Angeles), (San Diego) (TTY: 71. xiv

16 Name ADHD/AI-NARCOLEPSY/AI- OBESITY/ANOREXIAS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines ADDERALL XR CP24 (Amphetamine- Dextroamphetamine) amphetaminedextroamphetamine cp , , , , , DESOXYN TABS (Methamphetamine HCl) DEXEDRINE CP24 (Dextroamphetamine Sulfate) dextroamphetamine sulfate cp24 5, 15, 10 dextroamphetamine sulfate tabs 5, 10 methamphetamine hcl tabs amphetaminedextroamphetamine tabs , , , , , , Anorexiants Non-Amphetamine ADIPEX-P CAPS (Phentermine HCl) PA; PA; PA; ; Name ADIPEX-P TABS (Phentermine HCl) diethylpropion hcl tabs 25 DIETHYLPROPION HCL TABS 25 MG (Diethylpropion HCl) diethylpropion hcl tb24 75 LOMAIRA TABS phentermine hcl caps phentermine hcl tabs QSYMIA CP24 SUPRENZA TBDP 30 MG, 15 MG SUPRENZA TBDP 37.5 MG Anti-Obesity Agents ALLI CAPS BELVIQ XR TB24 XENICAL CAPS PA; ; PA; ; PA; ; PA; ; PA; ; PA; ; PA; ; PA; PA; ; ; PA; PA; ; PA; ; Attention-Deficit/Hyperactivity Disorder (ADHD) SL(10 ea daily); atomoxetine hcl caps Health Net Cal MediConnect List Updated 12/1/2017 1

17 Name atomoxetine hcl caps 100 atomoxetine hcl caps 18 atomoxetine hcl caps 25 atomoxetine hcl caps 40 atomoxetine hcl caps 60 atomoxetine hcl caps 80 clonidine hcl (adhd) tb12 guanfacine hcl (adhd) tb24 IUNIV TB24 (Guanfacine HCl (ADHD)) KAPVAY TB12 (Clonidine HCl (ADHD)) STRATTERA CAPS 10 MG (Atomoxetine HCl) STRATTERA CAPS 100 MG (Atomoxetine HCl) STRATTERA CAPS 18 MG (Atomoxetine HCl) SL(1 ea daily); SL(5.55 ea daily); SL(4 ea daily); SL(2.5 ea daily); SL(1.66 ea daily); SL(1.25 ea daily); yrs old; yrs old; SL(10 ea daily); SL(1 ea daily); SL(5.55 ea daily); Name STRATTERA CAPS 25 MG (Atomoxetine HCl) STRATTERA CAPS 40 MG (Atomoxetine HCl) STRATTERA CAPS 60 MG (Atomoxetine HCl) STRATTERA CAPS 80 MG (Atomoxetine HCl) Stimulants - Misc. CONCERTA TBCR dexmethylphenidate hcl cp24 15, 20, 10 dexmethylphenidate hcl tabs 10, 2.5, 5 FOCALIN TABS (Dexmethylphenidate HCl) FOCALIN XR CP24 10 MG, 15 MG, 20 MG (Dexmethylphenidate HCl) METADATE CD CPCR (Methylphenidate HCl) methylphenidate hcl cp24 or 20, 60, 40, 30 methylphenidate hcl cpcr or 10, 50, 60, 20, 40, 30 methylphenidate hcl tabs or 20, 5, 10 SL(4 ea daily); SL(2.5 ea daily); SL(1.66 ea daily); SL(1.25 ea daily); 2017 Health Net Cal MediConnect List Updated 12/1/2017 2

18 Name methylphenidate hcl tb24 or 36, 27 methylphenidate hcl tbcr or 54, 20, 36, 27, 18 modafinil tabs PROVIGIL TABS (Modafinil) RITALIN LA CP24 30 MG, 20 MG, 40 MG (Methylphenidate HCl) RITALIN LA CP24 60 MG RITALIN TABS (Methylphenidate HCl) Non-Osmotic Release PA; PA; ALLERGENIC EXTRACTS/BIOLOGICALS MISC Biologicals Misc ADAGEN SOLN LA AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln ij 1 gm/4ml, 500 /2ml BETHKIS NEBU gentamicin in saline soln 0.9%-1/ml B/D Name gentamicin sulfate soln ij 40 /ml KITABIS PAK NEBU neomycin sulfate tabs or paromomycin sulfate caps B/D TOBI NEBU (Tobramycin) B/D TOBI PODHALER CAPS tobramycin nebu in tobramycin sulfate soln ij 80 /2ml, 40 /ml, 1.2 gm/30ml tobramycin sulfate solr ij 1.2 gm B/D ANALGESICS - AI-ILAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-T-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC PA CROHNS DISEASE STARTER PACK PSKT PA HUMIRA PEN PNKT 2017 Health Net Cal MediConnect List Updated 12/1/2017 3

19 Name HUMIRA PEN-CROHNS DISEASESTARTER PNKT HUMIRA PEN-PSORIASIS STARTER PNKT HUMIRA PSKT SIMPONI ARIA SOLN SIMPONI SOAJ SIMPONI SOSY Antirheumatic - Enzyme Inhibitors PA XELJANZ TABS Antirheumatic Antimetabolites OTREXUP SOAJ RASUVO SOAJ 17.5 MG/0.35ML, 30 MG/0.6ML, 20 MG/0.4ML, 7.5 MG/0.15ML, 10 MG/0.2ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 12.5 MG/0.25ML, 15 MG/0.3ML Gold Compounds RIDAURA CAPS Interleukin-1 Blockers PA PA PA PA PA PA PA PA Name ARCALYST SOLR LA Interleukin-1 Receptor Antagonist (IL-1Ra) PA KINERET SOSY Interleukin-1beta Blockers ILARIS SOLN 150 MG/ML ILARIS SOLR 180 MG PA LA Interleukin-6 Receptor Inhibitors PA ACTEMRA SOLN PA ACTEMRA SOSY Nonsteroidal Anti-inflammatory Agents (NSAIDs) ADVIL CAPS (Ibuprofen) ; ADVIL MIGRAINE CAPS (Ibuprofen) ADVIL TABS (Ibuprofen) ALEVE CAPS (Naproxen Sodium) ANAPROX DS TABS (Naproxen Sodium) ARTHROTEC 50 TBEC (Diclofenac w/ Misoprostol) ARTHROTEC 75 TBEC (Diclofenac w/ Misoprostol) CELEBREX CAPS (Celecoxib) ; ; 2017 Health Net Cal MediConnect List Updated 12/1/2017 4

20 Name celecoxib caps CHILDRENS ADVIL SUSP (Ibuprofen) CHILDRENS TRIN SUSP (Ibuprofen) DAYPRO TABS (Oxaprozin) diclofenac potassium tabs diclofenac sodium tb24 or 100 diclofenac sodium tbec or 25, 75, 50 diclofenac w/ misoprostol tbec EC-NAPROSYN TBEC (Naproxen) etodolac caps 300, 200 etodolac tabs 400, 500 etodolac tb24 500, 400, 600 FELDENE CAPS (Piroxicam) flurbiprofen tabs or 50, 100 RX/OTC; ; RX/OTC; ; Name ibuprofen caps or 200 ibuprofen chew or 100 ibuprofen susp or 100 /5ml ibuprofen susp or 100 /5ml ibuprofen susp or 40 /ml, 50 /1.25ml ibuprofen tabs or 100 ibuprofen tabs or 200 ibuprofen tabs or 400 ibuprofen tabs or 600 ibuprofen tabs or 800 indomethacin caps or 50, 25 indomethacin cpcr or 75 IAS ADVIL SUSP (Ibuprofen) ketoprofen caps or 75, 50 ; ; RX/OTC; Over-thecounter;RX/OT C; ; ; SL(8 ea daily); SL(5.33 ea daily); SL(4 ea daily); yrs old; yrs old; 2017 Health Net Cal MediConnect List Updated 12/1/2017 5

21 Name ketorolac tromethamine soln ij 15 /ml, 30 /ml ketorolac tromethamine soln im 30 /ml, 60 /2ml mefenamic acid caps or meloxicam tabs or 15, 7.5 BIC TABS 7.5 MG, 15 MG (Meloxicam) TRIN IAS DROPS SUSP (Ibuprofen) nabumetone tabs NAPROSYN TABS 500 MG (Naproxen) naproxen sodium caps or 220 naproxen sodium tabs or 275, 550 naproxen tabs or 375, 250, 500 naproxen tbec or 500, 375 oxaprozin tabs yrs old; yrs old; Name piroxicam caps or 10, 20 PONSTEL CAPS (Mefenamic Acid) sulindac tabs or 200, 150 tolmetin sodium caps 400 tolmetin sodium tabs 200 Phosphodiesterase 4 (PDE4) Inhibitors PA OTEZLA TABS PA OTEZLA TBPK Pyrimidine Synthesis Inhibitors ARAVA TABS (Leflunomide) leflunomide tabs or 20, 10 Selective Costimulation Modulators PA ORENCIA CLICKJECT SOAJ PA ORENCIA SOLR PA ORENCIA SOSY 2017 Health Net Cal MediConnect List Updated 12/1/2017 6

22 Name Soluble Tumor Necrosis Factor Receptor Agents PA ENBREL SOLR PA ENBREL SOSY PA ENBREL SURECLICK SOAJ ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Analgesics Other acetaminophen chew or 160 acetaminophen chew or 80 acetaminophen liqd or 160 /5ml acetaminophen soln or 160 /5ml, 325 /10.15ml, 650 /20.3ml acetaminophen supp re 120 acetaminophen susp or 160 /5ml, 80 /2.5ml acetaminophen susp or 80 /0.8ml acetaminophen tbdp or 160 acetaminophen tbdp or 80 FEVERALL IAS SUPP ; ; ; ; ; ; Name TYLENOL CHILDRENS SUSP (Acetaminophen) TYLENOL IAS PAIN+FEVER SUSP (Acetaminophen) TYLENOL IAS SUSP (Acetaminophen) Salicylates aspirin buffered (cal carbmag carb-mag oxide) tabs aspirin supp re 300, 600 aspirin tabs or 325 aspirin tbec or 81, 325, 324 BUFFERIN LOW DOSE TABS BUFFERIN TABS (Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide)) diflunisal tabs ECOTRIN REGULAR STRENGTH TBEC (Aspirin) ; ; ; ; ; ; ; ; ANALGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists ACTIQ LPOP 1200 MCG, 800 MCG, 600 MCG, 1600 MCG, 400 MCG (Fentanyl Citrate) ACTIQ LPOP 200 MCG (Fentanyl Citrate) DEMEROL SOLN IJ 25 MG/ML (Meperidine HCl) PA; QL(4 ea daily); PA; QL(8 ea daily); yrs old 2017 Health Net Cal MediConnect List Updated 12/1/2017 7

23 Name DEMEROL SOLN IJ 50 MG/ML, 100 MG/ML (Meperidine HCl) DILAUDID LIQD OR 1 MG/ML (Hydromorphone HCl) DILAUDID SOLN IJ 2 MG/ML DILAUDID SOLN IJ 2 MG/ML (Hydromorphone HCl) DILAUDID TABS OR 2 MG (Hydromorphone HCl) DILAUDID TABS OR 4 MG (Hydromorphone HCl) DILAUDID TABS OR 8 MG (Hydromorphone HCl) DILAUDID-HP SOLN (Hydromorphone HCl) DOLOPHINE TABS 10 MG (Methadone HCl) DOLOPHINE TABS 5 MG (Methadone HCl) DURAGESIC PT MCG/HR (Fentanyl) DURAGESIC PT72 12 MCG/HR (Fentanyl) DURAGESIC PT72 25 MCG/HR (Fentanyl) DURAGESIC PT72 50 MCG/HR, 75 MCG/HR (Fentanyl) fentanyl citrate lpop bu 1600 mcg, 800 mcg, 600 mcg, 1200 mcg, 400 mcg fentanyl citrate lpop bu 200 mcg yrs old; QL(50 ml daily); Preservative Free QL(25 ea daily); QL(12.5 ea daily); QL(6.25 ea daily); QL(6.67 ea daily); QL(13.34 ea daily); QL(0.5 ea daily); Limit 43 patches per month;ql(1.44 ea daily); QL(0.94 ea daily); Limit 15 patches per month;ql(0.5 ea daily); PA; QL(4 ea daily); PA; QL(8 ea daily); Name fentanyl pt mcg/hr fentanyl pt72 12 mcg/hr fentanyl pt72 25 mcg/hr fentanyl pt72 75 mcg/hr, 50 mcg/hr hydromorphone hcl liqd or 1 /ml hydromorphone hcl soln ij 2 /ml hydromorphone hcl soln ij 500 /50ml, 50 /5ml, 10 /ml hydromorphone hcl tabs or 2 hydromorphone hcl tabs or 4 hydromorphone hcl tabs or 8 KADIAN CP24 10 MG (Morphine Sulfate) KADIAN CP MG (Morphine Sulfate) KADIAN CP24 20 MG (Morphine Sulfate) KADIAN CP24 30 MG (Morphine Sulfate) QL(0.5 ea daily); Limit 43 patches per month;ql(1.44 ea daily); QL(0.94 ea daily); Limit 15 patches per month;ql(0.5 ea daily); QL(50 ml daily); QL(25 ea daily); QL(12.5 ea daily); QL(6.25 ea daily); QL(20 ea daily); QL(2 ea daily); QL(10 ea daily); QL(6.67 ea daily); 2017 Health Net Cal MediConnect List Updated 12/1/2017 8

24 Name KADIAN CP24 50 MG (Morphine Sulfate) KADIAN CP24 60 MG (Morphine Sulfate) KADIAN CP24 80 MG (Morphine Sulfate) LAZANDA SOLN 100 MCG/ACT LAZANDA SOLN 300 MCG/ACT LAZANDA SOLN 400 MCG/ACT meperidine hcl soln ij 25 /ml meperidine hcl soln ij 50 /ml, 100 /ml methadone hcl conc or 10 /ml methadone hcl soln or 10 /5ml methadone hcl soln or 5 /5ml methadone hcl tabs or 10 methadone hcl tabs or 5 METHADOSE CONC (Methadone HCl) QL(4 ea daily); QL(3.34 ea daily); QL(2.5 ea daily); PA; QL(1 ea daily); PA; QL(0.5 ea daily); PA; QL(0.27 ea daily); yrs old yrs old; QL(6.67 ml daily); QL(33.34 ml daily); QL(66.67 ml daily); QL(6.67 ea daily); QL(13.34 ea daily); QL(6.67 ml daily); Name METHADOSE SUGAR- FREE CONC (Methadone HCl) morphine sulfate cp24 or 10 morphine sulfate cp24 or 100 morphine sulfate cp24 or 20 morphine sulfate cp24 or 30 morphine sulfate cp24 or 50 morphine sulfate cp24 or 60 morphine sulfate cp24 or 80 morphine sulfate soln ij 0.5 /ml morphine sulfate soln ij 1 /ml morphine sulfate soln or 10 /5ml morphine sulfate soln or 20 /5ml QL(6.67 ml daily); QL(20 ea daily); QL(2 ea daily); QL(10 ea daily); QL(6.67 ea daily); QL(4 ea daily); QL(3.34 ea daily); QL(2.5 ea daily); QL(100 ml daily); QL(50 ml daily); 2017 Health Net Cal MediConnect List Updated 12/1/2017 9

25 Name morphine sulfate soln or 20 /ml, 100 /5ml RPHINE SULFATE TABS OR 15 MG RPHINE SULFATE TABS OR 30 MG morphine sulfate tbcr or 100, 200 morphine sulfate tbcr or 15 morphine sulfate tbcr or 30 morphine sulfate tbcr or 60 MS COIN TBCR 100 MG, 200 MG (Morphine Sulfate) MS COIN TBCR 15 MG (Morphine Sulfate) MS COIN TBCR 30 MG (Morphine Sulfate) MS COIN TBCR 60 MG (Morphine Sulfate) OPANA TABS OR 10 MG (Oxymorphone HCl) OPANA TABS OR 5 MG (Oxymorphone HCl) oxycodone hcl caps or 5 QL(10 ml daily); QL(13.34 ea daily); QL(6.67 ea daily); QL(2 ea daily); QL(13.34 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(2 ea daily); QL(13.34 ea daily); QL(6.67 ea daily); QL(3.34 ea daily); QL(6.67 ea daily); QL(13.34 ea daily); QL(26.67 ea daily); Name oxycodone hcl conc or 100 /5ml oxycodone hcl tabs or 15 oxycodone hcl tabs or 30 oxycodone hcl tabs or 5 oxymorphone hcl tabs 10 oxymorphone hcl tabs 5 oxymorphone hcl tb12 15 oxymorphone hcl tb ROXICODONE TABS 15 MG (Oxycodone HCl) ROXICODONE TABS 30 MG (Oxycodone HCl) ROXICODONE TABS 5 MG (Oxycodone HCl) SUBSYS LIQD 100 MCG SUBSYS LIQD 1200 MCG QL(6.67 ml daily); QL(8.9 ea daily); QL(4.44 ea daily); QL(26.67 ea daily); QL(6.67 ea daily); QL(13.34 ea daily); QL(4.44 ea daily); QL(8.89 ea daily); QL(8.9 ea daily); QL(4.44 ea daily); QL(26.67 ea daily); PA; QL(16 ea daily); PA; QL(2 ea daily) 2017 Health Net Cal MediConnect List Updated 12/1/

26 Name SUBSYS LIQD 200 MCG SUBSYS LIQD 400 MCG, 600 MCG, 1600 MCG, 800 MCG tramadol hcl tabs or 50 tramadol hcl tb24 or 100 tramadol hcl tb24 or 200 tramadol hcl tb24 or 300 ULTRAM ER TB MG (Tramadol HCl) ULTRAM ER TB MG (Tramadol HCl) ULTRAM ER TB MG (Tramadol HCl) ULTRAM TABS (Tramadol HCl) ZOHYDRO ER C12A 10 MG ZOHYDRO ER C12A 15 MG ZOHYDRO ER C12A 20 MG ZOHYDRO ER C12A 30 MG PA; QL(8 ea daily); PA; QL(4 ea daily); SL(8 ea daily); SL(3 ea daily); SL(1.5 ea daily); SL(1 ea daily); SL(3 ea daily); SL(1.5 ea daily); SL(1 ea daily); SL(8 ea daily); PA; QL(16.8 ea daily); PA; QL(11.2 ea daily); PA; QL(8.4 ea daily); PA; QL(5.6 ea daily); Name ZOHYDRO ER C12A 40 MG ZOHYDRO ER C12A 50 MG Opioid Combinations acetaminophen w/ codeine soln 120/5ml-12/5ml acetaminophen w/ codeine tabs acetaminophen w/ codeine tabs acetaminophen w/ codeine tabs butalbital-aspirin-caffeine w/cod caps FIORINAL/CODEINE #3 CAPS (Butalbital-Aspirin- Caffeine w/cod) hydrocodoneacetaminophen soln 5/10ml-217/10ml, 7.5/15ml-325/15ml, 2.5/5ml-108/5ml hydrocodoneacetaminophen tabs , , hydrocodoneacetaminophen tabs , , PA; QL(4.2 ea daily); PA; QL(3.37 ea daily); SL(150 ml daily); SL(13.3 ea daily); SL(12 ea daily); SL(6 ea daily); yrs old; SL(6 ea daily); yrs old; SL(6 ea daily); Limit 5535mls per month;sl( ml daily); SL(13.3 ea daily); SL(12.3 ea daily); 2017 Health Net Cal MediConnect List Updated 12/1/

27 Name hydrocodone-ibuprofen tabs hydrocodone-ibuprofen tabs , 200-5, oxycodone w/ acetaminophen soln 5/5ml-325/5ml oxycodone w/ acetaminophen tabs , , 5-325, oxycodone-aspirin tabs tramadol-acetaminophen tabs ULTRACET TABS (Tramadol-Acetaminophen) VICOPROFEN TABS (Hydrocodone-Ibuprofen) Opioid Partial Agonists BUPRENEX SOLN (Buprenorphine HCl) buprenorphine hcl soln ij 0.3 /ml buprenorphine hcl subl sl 2 buprenorphine hcl subl sl 8 buprenorphine hclnaloxone hcl dihydrate subl Limit 1845mls per month;sl(61.5 ml daily) SL(12.3 ea daily); SL(8 ea daily); SL(8 ea daily); PA; QL(16 ea daily); PA; QL(4 ea daily); PA; QL(16 ea daily); Name buprenorphine hclnaloxone hcl dihydrate subl 8-2 butorphanol tartrate soln ij 2 /ml butorphanol tartrate soln na 10 /ml nalbuphine hcl soln ij 10 /ml, 20 /ml PA; QL(4 ea daily); Limit 210mls per month;ql(7 ml daily); ANDROGENS-ANABOLIC - s to Regulate Hormones Anabolic Steroids ANADROL-50 TABS OXANDRIN TABS (Oxandrolone) oxandrolone tabs or 2.5, 10 Androgens ANDRODERM PT24 ANDROGEL GEL 40.5 MG/2.5GM, MG/1.25GM ANDROGEL GEL 50 MG/5GM, 25 MG/2.5GM (Testosterone) ANDROGEL PUMP GEL 2017 Health Net Cal MediConnect List Updated 12/1/

28 Name LA AVEED SOLN danazol caps or 100, 50, 200 fluoxymesterone tabs or methyltestosterone caps or TESTIM GEL (Testosterone) testosterone cypionate soln testosterone enanthate soln im TESTOSTERONE GEL TD 1 %, 25 MG/2.5GM, 50 MG/5GM testosterone gel td 50 /5gm, 1 %, 25 /2.5gm TESTOSTERONE PUMP GEL VOGELXO GEL VOGELXO PUMP GEL ANORECTAL AGES - Rectal s to Treat Pain, Swelling and Itching Name Intrarectal Steroids CORTENEMA ENEM (Hydrocortisone (Intrarectal)) hydrocortisone (intrarectal) enem UCERIS FOAM RE 2 MG/ACT Rectal Steroids hydrocortisone (rectal) crea PROCTOCORT CREA 1 % (Hydrocortisone (Rectal)) Vasodilating Agents RECTIV OI AACIDS - Ulcer and Stomach Acid s Antacid Combinations alum & mag hydroxsimethicone chew alum & mag hydroxsimethicone liqd 200/5ml-20/5ml- 200/5ml, 400/5ml- 40/5ml-400/5ml alum & mag hydroxsimethicone susp 200/5ml-20/5ml- 200/5ml, 400/5ml- 40/5ml-400/5ml, 400/5ml-400/5ml- 40/5ml-40/5ml- 400/5ml-400/5ml, 200/5ml-200/5ml- 20/5ml-20/5ml- 200/5ml-200/5ml ; ; 2017 Health Net Cal MediConnect List Updated 12/1/

29 Name aluminum hydroxide-mag trisil chew GELUSIL CHEW 200MG- 25MG-200MG (Alum & Mag Hydrox-Simethicone) HYVEE ADVANCED AACID MAXIMUM STRENGTH SUSP (Alum & Mag Hydrox- Simethicone) Antacids - Aluminum Salts ALUMINUM HYDROXIDE SUSP OR Antacids - Calcium Salts calcium carbonate (antacid) chew 750, 500 calcium carbonate (antacid) tabs 648 CALCIUM CARBONATE TABS OR 648 MG TUMS CHEW (Calcium Carbonate (Antacid)) TUMS CHEWY BITES CHEW (Calcium Carbonate (Antacid)) TUMS E-X 750 CHEW (Calcium Carbonate (Antacid)) TUMS EXTRA STRENGTH 750 CHEW (Calcium Carbonate (Antacid)) TUMS KIDS CHEW (Calcium Carbonate (Antacid)) TUMS LASTING EFFECTS CHEW (Calcium Carbonate (Antacid)) TUMS SOTHIES CHEW (Calcium Carbonate (Antacid)) ; ; ; ; ; ; ; ; ; ; ; AHELMIICS - s to Treat Worm Infections Name Anthelmintics ALBENZA TABS ivermectin tabs or pyrantel pamoate susp or STROMECTOL TABS (Ivermectin) AI-IECTIVE AGES - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. AZACTAM SOLR (Aztreonam) aztreonam solr LA CAYSTON SOLR colistimethate sodium solr ij COLY-MYCIN M SOLR (Colistimethate Sodium) FLAGYL CAPS 375 MG SL(10.6 ea (Metronidazole) daily); FLAGYL TABS 250 MG SL(16 ea daily); (Metronidazole) FLAGYL TABS 500 MG SL(8 ea daily); (Metronidazole) SL(10.6 ea metronidazole caps or 375 daily); 2017 Health Net Cal MediConnect List Updated 12/1/

30 Name metronidazole in nacl soln metronidazole tabs or 250 metronidazole tabs or 500 NEBUPE SOLR ORBACTIV SOLR PEAM 300 SOLR TINDAMAX TABS (Tinidazole) tinidazole tabs or 250, 500 trimethoprim tabs or VANCOCIN HCL CAPS (Vancomycin HCl) vancomycin hcl caps or 125, 250 VANCOMYCIN HCL IN DEXTROSE SOLN 500MG/100ML-5%, 1GM/200ML-5%, 5%- 750MG/150ML vancomycin hcl solr iv 500 SL(16 ea daily); SL(8 ea daily); B/D; PA; PA; Name vancomycin hcl solr iv 5000, 10 gm, 1000 XIFAXAN TABS Anti-infective Misc. - Combinations BACTRIM DS TABS (Sulfamethoxazole- Trimethoprim) BACTRIM TABS (Sulfamethoxazole- Trimethoprim) sulfamethoxazoletrimethoprim soln sulfamethoxazoletrimethoprim susp sulfamethoxazoletrimethoprim tabs Antiprotozoal Agents ALINIA TABS 500 MG atovaquone susp MEPRON SUSP (Atovaquone) Carbapenems imipenem-cilastatin solr INVANZ SOLR IJ 2017 Health Net Cal MediConnect List Updated 12/1/

31 Name meropenem solr MERREM SOLR (Meropenem) PRIMAXIN IV SOLR (Imipenem-Cilastatin) Chloramphenicols chloramphenicol sodium succinate solr Cyclic Lipopeptides CUBICIN RF SOLR (Daptomycin) CUBICIN SOLR (Daptomycin) daptomycin solr Glycylcyclines TIGECYCLINE SOLR TYGACIL SOLR Leprostatics dapsone tabs or 25, 100 Lincosamides CLEOCIN CAPS OR 300 MG, 75 MG, 150 MG (Clindamycin HCl) Name CLEOCIN IN D5W SOLN (Clindamycin Phosphate in D5W) CLEOCIN PHOSPHATE SOLN IJ 900 MG/6ML, 600 MG/4ML (Clindamycin Phosphate) CLEOCIN PHOSPHATE SOLN IV 600MG/50ML- 5%, 300MG/50ML-5%, 900MG/50ML-5% (Clindamycin Phosphate in D5W) clindamycin hcl caps or 75, 300, 150 clindamycin palmitate hydrochloride solr clindamycin phosphate in d5w soln clindamycin phosphate soln ij 600 /4ml, 900 /6ml clindamycin phosphate soln ij 9000 /60ml, 150 /ml clindamycin phosphate soln iv 600 /4ml LINCOCIN SOLN (Lincomycin HCl) lincomycin hcl soln ij Oxazolidinones 2017 Health Net Cal MediConnect List Updated 12/1/

32 Name linezolid soln iv 600 /300ml LINEZOLID SOLN IV 600MG/300ML-0.9% linezolid susr or 100 /5ml linezolid tabs or 600 SIVEXTRO SOLR IV SIVEXTRO TABS OR ZYVOX SOLN IV 200 MG/100ML ZYVOX SOLN IV 600 MG/300ML (Linezolid) ZYVOX SUSR OR 100 MG/5ML (Linezolid) ZYVOX TABS OR 600 MG (Linezolid) Polymyxins polymyxin b sulfate solr ij Streptogramins Name SYNERCID SOLR AIANGINAL AGES - s to Treat Chest Pain Antianginals-Other RANEXA TB12 Nitrates ISORDIL TITRADOSE TABS 5 MG (Isosorbide Dinitrate) isosorbide dinitrate tabs isosorbide dinitrate tbcr isosorbide mononitrate tabs 10, 20 isosorbide mononitrate tb24 60, 120, 30 NITRO-DUR PT MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.1 MG/HR (Nitroglycerin) NITROGLYCERIN LINGUAL AERS nitroglycerin pt24 td 0.6 /hr, 0.4 /hr, 0.2 /hr, 0.1 /hr nitroglycerin soln tl 0.4 /spray PA; 2017 Health Net Cal MediConnect List Updated 12/1/

33 Name nitroglycerin subl sl 0.4, 0.6, 0.3 NITROLINGUAL PUMPSPRAY SOLN (Nitroglycerin) NITROMIST AERS NITROSTAT SUBL (Nitroglycerin) AIANXIETY AGES - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs or 10, 15, 7.5, 5, 30 hydroxyzine hcl soln im 50 /ml hydroxyzine hcl syrp or 10 /5ml hydroxyzine hcl tabs or 10, 25, 50 hydroxyzine pamoate caps or 50, 25 VISTARIL CAPS (Hydroxyzine Pamoate) Benzodiazepines alprazolam tabs or 0.25, 2, 0.5, 1 yrs old; yrs old; yrs old; yrs old; yrs old; Name ATIVAN SOLN IJ 2 MG/ML (Lorazepam) ATIVAN SOLN IJ 4 MG/ML (Lorazepam) ATIVAN TABS OR 1 MG, 2 MG, 0.5 MG (Lorazepam) alprazolam tb24 or 1, 3, 0.5, 2 alprazolam tbdp or 0.5, 0.25, 2, 1 clorazepate dipotassium tabs diazepam conc or 5 /ml diazepam soln or 1 /ml diazepam tabs or 2, 5, 10 lorazepam conc or 2 /ml lorazepam soln ij 2 /ml, 20 /10ml lorazepam soln ij 4 /ml lorazepam tabs or 2, 0.5, Health Net Cal MediConnect List Updated 12/1/

34 Name oxazepam caps TRANXENE T TABS (Clorazepate Dipotassium) VALIUM TABS (Diazepam) XANAX TABS (Alprazolam) XANAX XR TB24 (Alprazolam) AIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps NORPACE CAPS (Disopyramide Phosphate) quinidine gluconate tbcr or 324 quinidine sulfate tabs Antiarrhythmics Type I-B mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs 100 flecainide acetate tabs 150 flecainide acetate tabs 50 yrs old; yrs old; SL(4 ea daily); SL(2.66 ea daily); SL(8 ea daily); Name propafenone hcl cp12 propafenone hcl tabs RYTHL SR CP12 (Propafenone HCl) RYTHL TABS (Propafenone HCl) Antiarrhythmics Type III amiodarone hcl tabs or 200, 400, 100 CORDARONE TABS (Amiodarone HCl) dofetilide caps MULTAQ TABS TIKOSYN CAPS (Dofetilide) AIASTHMATIC AND BRONCHODILATOR AGES - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu in B/D; Antiasthmatic - Monoclonal Antibodies PA; LA CINQAIR SOLN PA; LA NUCALA SOLR 2017 Health Net Cal MediConnect List Updated 12/1/

35 Name XOLAIR SOLR Bronchodilators - Anticholinergics ATROVE HFA AERS ipratropium bromide soln in SPIRIVA HANDIHALER CAPS SPIRIVA RESPIMAT AERS TUDORZA PRESSAIR AEPB TUDORZA PRESSAIR AEPB Leukotriene Modulators ACCOLATE TABS (Zafirlukast) montelukast sodium chew 4, 5 montelukast sodium tabs 10 SINGULAIR CHEW 4 MG, 5 MG (Montelukast Sodium) SINGULAIR TABS 10 MG (Montelukast Sodium) PA; LA Limit 2 inhalers per month;ql(0.86 gm daily); B/D; QL(1 ea daily); Limit 1 inhaler per month (60 actuations);sl( 0.14 gm daily); Limit 2 inhalers per month (30 actuations);ql( 0.07 ea daily); Limit 1 inhaler per month (60 actuations);ql( 0.04 ea daily); Name zafirlukast tabs Selective Phosphodiesterase 4 (PDE4) Inhibitors QL(1 ea daily); DALIRESP TABS Steroid Inhalants AEROSPAN AERS AEROSPAN AERS budesonide (inhalation) susp 0.5 /2ml, 0.25 /2ml FLOVE DISKUS AEPB 100 MCG/BLIST FLOVE DISKUS AEPB 250 MCG/BLIST FLOVE DISKUS AEPB 50 MCG/BLIST FLOVE HFA AERO 220 MCG/ACT, 110 MCG/ACT FLOVE HFA AERO 44 MCG/ACT PULMICORT SUSP 0.25 MG/2ML, 0.5 MG/2ML (Budesonide (Inhalation)) Limit 2 inhalers per month (120 actuations);sl( 0.6 gm daily); Limit 4 inhalers per month (institutional pack);sl(0.68 gm daily); B/D; SL(20 ea daily); SL(8 ea daily); SL(40 ea daily); Limit 2 inhalers per month;ql(0.8 gm daily); Limit 1 inhaler per month;ql(0.36 gm daily); B/D; 2017 Health Net Cal MediConnect List Updated 12/1/