Medi-Cal DHCS Carve Out Medication List

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1 Medi-Cal DHCS Carve Out Medication List The drugs shown below are non-capitated or carved-out of Managed Care Plans (MCPs). IE H P i s a man ag ed c a r e p l a n. T his means they are not reimbursed by MCPs except where indicated. They should be billed to Fee-For-Service (FFS) Medi-Cal for payment. Please note that this list is frequently updated b y M e di - Ca l with additions and deletions of drugs. If a Phar mac y requ ests a Prior Authori zation fo r an y car ve o ut medicati ons: 1. Infor m Phar mac y to bill Medi -Cal Fee -F or -Ser vice (FF S) 2. If a T reat ment Auth ori zation Re quest (T AR) is required, sub mit T AR t o Medi -Cal for r e view Psychiatric Drugs Brand ame Generic ame (/) Abilify Aripiprazole (Age 0-17) Artane Trihexyphenidyl Clozaril, FazaClo, Versacloz Clozapine (Age 0-17) Cogentin Benztropine Mesylate Emsam Selegiline (transdermal only) Eskalith, Lithobid Lithium Carbonate Lithium Citrate Lithium Citrate Fanapt Iloperidone (Age 0-17) Geodon Ziprasidone HCl (Age 0-17) Geodon Ziprasidone Mesylate Haloperidol Haloperidol (Age 0-17) Haldol Haloperidol Lactate (Age 0-17) Haldol Decanoate Haloperidol Decanoate Invega Paliperidone Invega Sustenna Paliperidone Palmitate Invega Trinza Paliperidone Palmitate Latuda Lurasidone Hydrochloride (Age 0-17) Loxitane Loxapine Succinate (Age 0-17) Marplan Isocarboxazid Mellaril (Brand not available) Thioridazine HCl (Age 0-17) Moban (Brand not available) Molindone HCl (Age 0-17) ardil Phenelzine Sulfate 1

2 Psychiatric Drugs Cont. Brand ame Generic ame (/) avane Thiothixene, HCl (Age 0-17) uplazid Pimavanserin Orap Pimozide Parnate Tranylcypromine Sulfate Prolixin Decanoate Fluphenazine Decanoate Prolixin Fluphenazine HCl (Age 0-17) Rexulti Brexpiprazole Risperdal Risperidone (Age 0-17) Risperdal Consta Risperidone Microspheres Saphris Asenapine (Age 0-17) Seroquel, Seroquel XR Quetiapine (Age 0-17) Stelazine Trifluoperazine HCl (Age 0-17) Symbyax Olanzapine/Fluoxetine HCl Symmetrel Amantadine HCl Thorazine (Brand not available) Chlorpromazine HCl (Age 0-17) Trilafon Perphenazine (Age 0-17) Vraylar Cariprazine Zyprexa Olanzapine (Age 0-17) Zyprexa Relprevv Olanzapine Pamoate Monohydrate AIDS (and Hep C) Drugs: Selected HIV AIDS treatment drugs that meet DHCS, Medi-Cal Managed Care Division definitions are noncapitated for all plans except HCPs 503 (Health Plan of San Mateo) and 506 (CalOPTIMA). Selected HIV AIDS drugs shown in Table 2 below are not carved out for AIDS Healthcare Foundation Health Care Plan 915 (AIDs Healthcare Centers). This means that adjudication and reimbursement of those drugs are the responsibility of that Plan. Brand ame Generic ame (/) Aptivus Tipranavir Atripla Efavirenz/Emtricitabine/Tenofovir Disoproxil Fumarate Combivir Zidovudine/Lamivudine 2

3 AIDS (and Hep C) Drugs Cont. Brand ame Generic ame (/) Complera Emtricitabine/Rilpivirine/Tenofovir Disoproxil Fumarate Crixivan Indinavir Sulfate Descovy Emtricitabine/Tenofovir Alafenamide Edurant Rilpivirine Hydrochloride Emtriva Emtricitabine Epivir Lamivudine Epzicom Abacavir/Lamivudine Evotaz Atazanavir/Cobicistat Fortovase Saquinavir Fuzeon Enfuvirtide Genvoya Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir Alafenamide Intelence Etravirine Invirase Saquinavir Mesylate Isentress Raltegravir Potassium Kaletra Lopinavir/Ritonavir Lexiva Fosamprenavir Calcium orvir Ritonavir Odefsey Emtricitabine/Rilpivirine/ Tenofovir Alafenamide Prezcobix Darunavir/Cobicistat Prezista Darunavir Ethanolate Rescriptor Delavirdine Mesylate Reyataz Atazanavir Sulfate Selzentry Maraviroc Stribild Elvitegravir /Cobicistat/Emtricitabine/ Tenofovir Disoproxil Fumarate Sustiva Efavirenz Tivicay Dolutegravir Triumeq Abacavir Sulfate/Dolutegravir/ Trizivir Zidovudine/Lamivudine/ i di Abacavir Sulfate Truvada Tenofovir Disoproxil/ Emtricitabine Tybost Cobicistat 3

4 AIDS (and Hep C) Drugs Cont. Brand ame Generic ame (/) Vemlidy Tenofovir Alafenamide Viracept elfinavir Mesylate Viramune, Viramune XR evirapine Viread Tenofovir Disoproxil Fumarate Vitekta Elvitegravir Zerit, Zerit XR Stavudine Ziagen Abacavir Sulfate Alcohol, Heroin Detoxification, and Dependency Treatment Drugs: *ot all forms are FDA approved for the treatment of alcohol and heroin detoxification and dependency. The drug remains noncapitated regardless of the diagnosis for which it was used. Brand ame Generic ame (/) Belbuca* Buprenorphine HCl Buprenex, Probuphine, Subutex Buprenorphine HCl Butrans* Buprenorphine Transdermal Patch Campral Acamprosate Calcium Depade, ReVia altrexone (oral) arcan aloxone HCl Evzio aloxone 0.4 mg/0.4 ml auto injector Suboxone, Zubsolv, Bunavail Buprenorphine/aloxone HCl Probuphine Buprenorphine Implant Vivitrol altrexone Microsphere Injectable Suspension 4

5 Blood Factor Products [Effective July 1, 2017] DC/HCPCS Brand ame Generic ame (/) C9140 Factor VIII (antihemophilic factor, recombinant) (Afstyla), per IU Afstyla 250 IU Kit Antihem. FVIII, SI-CH, B-DM TRU Afstyla 500 IU Kit Antihem. FVIII, SI-CH, B-DM Afstyla 1000 IU Kit TRU Antihem. FVIII, SI-CH, B-DM TRU Afstyla 2000 IU Kit Antihem. FVIII, SI-CH, B-DM TRU Afstyla 3000 IU Kit Antihem. FVIII, SI-CH, B-DM TRU J7180 Factor XIII, anti-hemophilic factor Corifact Kit Factor XIII concentrate (Human) J7181 Factor XIII a-subunit, (recombinant), per iu Tretten Coagulation Factor XIII A-Subunit (Recombinant) J7182 Factor VIII (Antihemophilic Factor, Recombinant), (OVOEIGHT), per IU ovoeight 250 IU Kit Turotocog Alfa ovoeight 500 IU Kit Turotocog Alfa ovoeight 1000 IU Kit Turotocog Alfa ovoeight 1500 IU Kit Turotocog Alfa ovoeight 2000 IU Kit Turotocog Alfa ovoeight 3000 IU Kit Turotocog Alfa 5

6 DC/HCPCS Blood Factor cont. Brand ame Generic ame (/) J7183 Von Willebrand Factor/Coagulation Factor VIII Complex (Human) Wilate unit Kit AHF, Human/VWF, Human Wilate unit Kit AHF, Human/VWF, Human Wilate unit Kit AHF, Human/VWF, Human Wilate unit Kit AHF, Human/VWF, Human J7185 Factor VIII (antihemophilic factor, (recombinant), per IU (formerly Q2023) Xyntha 250 IU Vial Antihemophilic Factor, Rec Xyntha 250 IU Vial Antihemophilic Factor, Rec Xyntha 500 IU Vial Antihemophilic Factor, Rec Xyntha 500 IU Vial Antihemophilic Factor, Rec Xyntha 1000 IU Vial Antihemophilic Factor, Rec Xyntha 1000 IU Vial Antihemophilic Factor, Rec Xyntha 2000 IU Vial Antihemophilic Factor, Rec Xyntha 2000 IU Vial Antihemophilic Factor, Rec Xyntha 3000 IU Vial Antihemophilic Factor, Rec J7186 Antihemophilic factor VIII/von willebrand factor complex (human), per factor VIII IU Alphanate 250 IU Vial AHF, Human/VWF, Human Alphanate 500 IU Vial AHF, Human/VWF, Human Alphanate 1000 IU Vial AHF, Human/VWF, Human Alphanate 1500 IU Vial AHF, Human/VWF, Human Alphanate 2000 IU Vial AHF, Human/VWF, Human J7187 Von Willebrand Factor Complex, human Humate-P AHF/VWF 600 Rcof Kit AHF, Human/VWF, Human Humate-P AHF/VWF 1200 Rcof Kit AHF, Human/VWF, Human Humate-P AHF/VWF 2400 Rcof Kit AHF, Human/VWF, Human 6

7 DC/HCPCS Blood Factor cont. Brand ame Generic ame (/) J7188 Injection, factor viii (antihemophilic factor, recombinant), (obizur), per IU Obizur 500 Unit Vial Antihemophilic FVIII, Rec Porc Obizur 500 Unit Vial Antihemophilic FVIII, Rec Porc Obizur 500 Unit Vial Antihemophilic FVIII, Rec Porc J7189 Recombinant factor VIIa ovoseven RT 1 mg Vial Factor VIIA, Recomb (BHK Cells) ovoseven RT 2 mg Vial Factor VIIA, Recomb (BHK Cells) ovoseven RT 5 mg Vial Factor VIIA, Recomb (BHK Cells) ovoseven RT 8mg Vial Factor VIIA, Recomb (BHK Cells) J7190 Factor VIII (antihemophilic factor, human), per IU Koate-DVI 250 IU Kit Antihemophilic Factor, Human Koate-DVI 500 IU Kit Antihemophilic Factor, Human Koate-DVI 500 IU Kit Antihemophilic Factor, Human Koate-DVI 1000 IU Kit Antihemophilic Factor, Human Koate-DVI 1000 IU Kit Antihemophilic Factor, Human Koate-DVI 1000 IU Kit Antihemophilic Factor, Human Koate 1000 IU Kit Antihemophilic Factor, Human Monoclate-P 1000 IU Kit Antihemophilic Factor, Human Monoclate-P 1500 IU Kit Antihemophilic Factor, Human Hemofil-M 250 IU Vial Antihemophilic Factor, Human Hemofil-M 500 IU Vial Antihemophilic Factor, Human Hemofil-M 1000 IU Vial Antihemophilic Factor, Human Hemofil-M 1700 IU Vial Antihemophilic Factor, Human J7192 Factor VIII (antihemophilic factor, recombinant), per IU Kogenate FS 250 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 250 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 500 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 500 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 1000 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 1000 IU Vial Antihemophilic Factor, Human Rec 7

8 Blood Factor cont. DC/HCPCS Brand ame Generic ame (/) Kogenate FS 2000 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 2000 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 3000 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 3000 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 250 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 500 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 1000 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 2000 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 3000 IU Vial Antihemophilic Factor, Human Rec Helixate FS 250 IU Vial Antihemophilic Factor, Human Rec Helixate FS 500 IU Vial Antihemophilic Factor, Human Rec Helixate FS 1000 IU Vial Antihemophilic Factor, Human Rec Helixate FS 2000 IU Vial Antihemophilic Factor, Human Rec Helixate FS 3000 IU Vial Antihemophilic Factor, Human Rec Recombinate IU Vial Antihemophilic Factor, Human Rec Recombinate IU Vial Antihemophilic Factor, Human Rec Recombinate IU Vial Antihemophilic Factor, Human Rec Recombinate IU Vial Antihemophilic Factor, Human Rec Recombinate IU Vial Antihemophilic Factor, Human Rec Advate 4000 IU Kit Antihemophilic Factor, Human Rec Advate 2000 IU Kit Antihemophilic Factor, Human Rec Advate 3000 IU Kit Antihemophilic Factor, Human Rec Advate 250 IU Kit Antihemophilic Factor, Human Rec Advate 500 IU Kit Antihemophilic Factor, Human Rec Advate 1000 IU Kit Antihemophilic Factor, Human Rec Advate 1500 IU Kit Antihemophilic Factor, Human Rec Advate 2000 IU Kit Antihemophilic Factor, Human Rec Advate 3000 IU Kit Antihemophilic Factor, Human Rec Advate 4000 IU Kit Antihemophilic Factor, Human Rec Kovaltry 250 IU Vial Antihemophilic Factor, Human Rec Kovaltry 500 IU Vial Antihemophilic Factor, Human Rec Kovaltry 1000 IU Vial Antihemophilic Factor, Human Rec Kovaltry 2000 IU Vial Antihemophilic Factor, Human Rec Kovaltry 3000 IU Vial Antihemophilic Factor, Human Rec Kogenate FS 2000 IU Vial Antihemophilic Factor, Human Rec J7193 Factor IX (antihemophilic factor purified, non-recombinant) per IU Mononine 1000 U vial Factor IX Alphanine SD 500 U Vial Factor IX 8

9 Blood Factor cont. DC/HCPCS Brand ame Generic ame (/) Alphanine SD 1000 U Vial Factor IX Alphanine SD 1500 U Vial Factor IX J7194 Factor IX, complex, per IU Bebulin IU Factor IX Complex Human Profilnine SD 500 U vial Factor IX Complex Human Profilnine SD 1000 U vial Factor IX Complex Human Profilnine SD 1500 U vial Factor IX Complex Human J7195 Factor IX (antihemophilic factor, recombinant) IU Benefix 250 IU Vial Factor IX Human Recombinant Benefix 500 IU Vial Factor IX Human Recombinant Benefix 1000 IU Vial Factor IX Human Recombinant Benefix 2000 IU Vial Factor IX Human Recombinant Benefix 3000 IU Vial Factor IX Human Recombinant Ixinity 500 IU Kit Factor IX Human Recombinant Ixinity 1000 IU Kit Factor IX Human Recombinant Ixinity 1500 IU Kit Factor IX Human Recombinant Ixinity 1000 U Vial -2 Vials Kit Factor IX Human Recombinant Ixinity 1500 U Vial -2 Vials Kit Factor IX Human Recombinant J7198 Anti-Inhibitor Feiba F Immuno 500 IU vial Anti-Inhibitor Coagulant Comp Feiba F Immuno 1000 IU vial Anti-Inhibitor Coagulant Comp Feiba F Immuno 2500 IU vial Anti-Inhibitor Coagulant Comp Feiba F Immuno 500 IU vial Anti-Inhibitor Coagulant Comp J7175 Factor X (Human), per IU Coagadex 250 Unit Vial Coagulation Factor X Coagadex 500 Unit Vial Coagulation Factor X J7179 Von willebrand factor (recombinant) (Vonvendi), per IU Vonvendi 650 IU Von Willebrand factor, recombinant Vonvendi 1300 IU Von Willebrand factor, recombinant 9

10 DC/HCPCS J7200 Blood Factor cont. Brand ame Factor IX (antihemophilic factor, recombinant), Rixubis, per i.u. Generic ame (/) Rixubis rfix IU (250 IU) Factor IX Human Recombinant Rixubis rfix IU (500 IU) Factor IX Human Recombinant Rixubis rfix IU (1000 Factor IX Human Recombinant IU) Rixubis rfix IU Factor IX Human Recombinant Rixubis rfix IU Factor IX Human Recombinant J7201 Injection, factor IX, Fc fusion protein (recombinant), per IU (Alprolix ) Alprolix 250 IU Coagulation Factor IX, (Recombinant), Alprolix 500 IU Coagulation Factor IX, (Recombinant), Alprolix 1000 IU Coagulation Factor IX, (Recombinant), Alprolix 2000 IU Coagulation Factor IX, (Recombinant), Alprolix 3000 IU Coagulation Factor IX, (Recombinant), Alprolix 4000 IU Coagulation Factor IX, (Recombinant), J7202 Factor IX, albumin fusion protein, (recombinant), (Idelvion) per IU Idelvion 250 unit vial Factor IX Recom, Albumin Fusion Idelvion 500 unit vial Factor IX Recom, Albumin Fusion Idelvion 1000 unit vial Factor IX Recom, Albumin Fusion Idelvion 2000 unit vial Factor IX Recom, Albumin Fusion J7205 Injection, Factor VIII, Fc fusion protein (recombinant), per IU (formerly Q9775) Eloctate 250 IU Antihemophilic Factor (Recombinant), 10

11 Blood Factor cont. DC/HCPCS Brand ame Generic ame Eloctate 500 IU Antihemophilic Factor Eloctate 750 IU Antihemophilic Factor Eloctate 1000 IU Antihemophilic Factor Eloctate 1500 IU Antihemophilic Factor Eloctate 2000 IU Antihemophilic Factor Eloctate 3000 IU Antihemophilic Factor Eloctate 4000 IU Antihemophilic Factor Eloctate 5000 IU Antihemophilic Factor Eloctate 6000 IU Antihemophilic Factor (/) J7207 Factor VIII (Antiemophilic factor, recombinant) ylated per IU (formerly C9137) Adynovate 250 unit vial Antihemoph. FVIII, Full Length Adynovate 500 unit vial Antihemoph. FVIII, Full Length Adynovate 1000 unit vial Antihemoph. FVIII, Full Length Adynovate 2000 unit vial Antihemoph. FVIII, Full Length Adynovate 250 AQ BJIII HF Kit Antihemoph. FVIII, Full Length Adynovate 500 AQ BJIII HF Kit Antihemoph. FVIII, Full Length Adynovate 1000 AQ BJIII HF Kit Antihemoph. FVIII, Full Length Adynovate 2000 AQ BJIII HF Kit Antihemoph. FVIII, Full Length Adynovate 750 AQ BJIII HF Kit Antihemoph. FVIII, Full Length 11

12 Blood Factor cont. DC/HCPCS Brand ame Generic ame (/) Adynovate 1500 AQ BJIII HF Kit Antihemoph. FVIII, Full Length J7209 Factor VIII (antihemophilic factor, recombinant) (uwiq), per IU (formerly C uwiq 250 unit vial Antihemoph. FVIII, Hek B-Delete uwiq 250 unit vial Antihemoph. FVIII, Hek B-Delete uwiq 500 unit vial Antihemoph. FVIII, Hek B-Delete uwiq 500 unit vial Antihemoph. FVIII, Hek B-Delete uwiq 1000 unit vial Antihemoph. FVIII, Hek B-Delete uwiq 1000 unit vial Antihemoph. FVIII, Hek B-Delete uwiq 2000 unit vial Antihemoph. FVIII, Hek B-Delete uwiq 2000 unit vial Antihemoph. FVIII, Hek B-Delete 12

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