ALAMEDA ALLIANCE FOR HEALTH MEDI CAL WRAP DRUG FORMULARY. November 2015

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1 ALAMEDA ALLIANCE FOR HEALTH MEDI CAL WRAP DRUG FORMULARY November 205 The Drug Formulary is a list of covered and preferred prescription drugs for members. The Alliance reviews the list at least four times a year and makes needed updates. This printable list may not reflect the latest updates. Members can search an up to date list on line at Or simply call the Alliance to confirm if a drug is covered. Medi Cal members, please call Member Services at (877) Medi Cal Wrap Drug Formulary The Medicare Part D Plan is the primary payor for prescription drugs. However, in limited circumstances, Medi Cal will provide an additional wrap around benefit for drugs not covered by the Part D Plan. The drugs covered by the Medi Cal Wrap are listed in this Drug Formulary. How to Use the Drug Formulary To find a drug on the list, search first for what the drug will treat. All drugs are then listed by their generic or brand names in alphabetical order. Any drug not found in this Formulary list is a Non Formulary drug. This Drug Formulary applies only to outpatient drugs prescribed to members. It does not apply to drugs used in inpatient settings. ALAMEDA ALLIANCE FOR HEALTH MEDI CAL WRAP Drug Formulary November 205 ii

2 Drug coverage requirements or limits There are some processes and limits that may apply to drugs in the formulary. Some are marked with a code on the list: Code Meaning Definition QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period ST Step Therapy Coverage may depend on previous use of another drug PA Prior Authorization Requires specific request process Quantity Limits: For certain drugs, the Alliance has a limit on the number of pills that will be covered. In general, a 30 day supply is covered. However, if a member requires a drug in excess of the limit, a doctor can submit a Prior Authorization Form. Step Therapy: In some cases, the Alliance requires members to first try certain drugs to treat a medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat a medical condition, we may not cover Drug B unless the member tries Drug A first. If Drug A does not work for the member, we will then cover Drug B. Doctors can request an exception by submitting a Prior Authorization Form. Generic Substitutions: The Alliance has a mandatory generic program. This program promotes the use of generic drugs over brand when medically appropriate. A doctor may write a prescription for a brand name drug and not a generic due to medical need. In these cases the doctor must submit a Prior Authorization Form. Prior Authorization Process: To prescribe drugs that are not in our Drug Formulary or exceed the plan quantity limits, a doctor can submit a Prior Authorization Form. The Alliance reviews these requests and asks for more details if needed. We will inform the doctor of our decision within 24 hours ( business day) for all requests. Therapeutic Interchange: The Alliance may, with a doctor s approval, change the drug that the doctor prescribed to a drug on the formulary that is the same in effectiveness and safety. ALAMEDA ALLIANCE FOR HEALTH MEDI CAL WRAP Drug Formulary November 205 ii

3 lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs Drug Tier Notes Antihistamine Drugs Ethanolamine Derivatives ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL CAPSULE ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL TABLET DIPHEDRYL ORAL LIQUID DIPHENHIST ORAL TABLET 50 MG diphenhydramine hcl oral capsule 50 mg diphenhydramine hcl oral tablet 25 mg Q-DRYL ORAL LIQUID First Generation Antihistamines ALLERGY (CHLORPHENIRAMINE) ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET EXTENDED RELEASE ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL CAPSULE ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL TABLET DIPHEDRYL ORAL LIQUID DIPHENHIST ORAL TABLET 50 MG diphenhydramine hcl oral capsule 50 mg diphenhydramine hcl oral tablet 25 mg Q-DRYL ORAL LIQUID Propylamine Derivatives ALLERGY (CHLORPHENIRAMINE) ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET EXTENDED RELEASE 2 PA 2 PA

4 AMBI 60PSE-4CPM Second Generation Antihistamines ALLERCLEAR D-24HR QL ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING 2 QL cetirizine oral tablet 0 mg QL fexofenadine oral tablet 80 mg, 60 mg 2 PA loratadine oral tablet QL LORATADINE-D ORAL TABLET EXTENDED RELEASE 2 HR Autonomic Drugs Alpha- And Beta-Adrenergic Agonists QL ALLERCLEAR D-24HR QL AMBI 60PSE-4CPM LORATADINE-D ORAL TABLET EXTENDED RELEASE 2 HR NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET pseudoephedrine hcl oral tablet 60 mg SUDAFED 2 HOUR Alpha-Adrenergic Agonists TUSSIN CF COUGH-COLD Antimuscarinics/Antispasmodics hyoscyamine sulfate oral tablet 2 hyoscyamine sulfate sublingual 2 Autonomic Drugs, Miscellaneous QL nicotine (polacrilex) buccal gum QL nicotine transdermal patch 24 hour 4 mg/24 hr, 2 mg/24 hr, 7 mg/24 hr Blood Formation,Coagulation & Thrombosis Iron Preparations CERTA PLUS COMPLETE MULTIVITAMIN ORAL TABLET QL

5 ferrous gluconate oral tablet 324 mg (38 mg iron) ferrous sulfate oral solution ferrous sulfate oral tablet 325 mg (65 mg iron) ferrous sulfate oral tablet,delayed release (dr/ec) 325 mg (65 mg iron) MULTI-VIT WITH FLUORIDE & IRON AL PRENATABS RX AL PRENATAL 9 AL RIGHT STEP PRENATAL VITAMINS AL THERA-M ORAL TABLET, 9 MG IRON-400 MCG Platelet-Aggregation Inhibitors aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 8 mg LITE COAT ASPIRIN MIGRAINE FORMULA Thrombolytic Agents aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 8 mg LITE COAT ASPIRIN MIGRAINE FORMULA Cardiovascular Drugs Antilipemic Agents, Miscellaneous FISH OIL OMEGA QL FISH OIL ORAL CAPSULE 340-,000 MG, 360-,200 MG niacin oral capsule, extended release 500 mg niacin oral tablet 00 mg, 250 mg, 500 mg niacin oral tablet extended release,000 mg, 250 mg, 500 mg omega 3-dha-epa-fish oil oral capsule,000 mg (20 mg-80 mg) Central Nervous System Agents QL 2 QL 3

6 Amphetamine Derivatives phentermine oral capsule 5 mg, 30 mg 2 PA phentermine oral tablet 2 PA QSYMIA 2 PA Analgesics And Antipyretics, Misc. 8 HOUR PAIN RELIEVER ACEPHEN RECTAL SUPPOSITORY 325 MG acetaminophen oral elixir acetaminophen oral liquid 60 mg/5 ml MIGRAINE FORMULA PAIN RELIEF ORAL TABLET 500 MG PAIN RELIEF ORAL TABLET EXTENDED RELEASE PAIN RELIEVER ORAL TABLET 325 MG Anticonvulsants, Miscellaneous QSYMIA 2 PA Antimigraine Agents, Miscellaneous aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 8 mg LITE COAT ASPIRIN MIGRAINE FORMULA Other Nonsteroidal Anti-Inflam. Agents ibuprofen oral tablet 200 mg Respiratory And Cns Stimulants MIGRAINE FORMULA Salicylates aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 8 mg LITE COAT ASPIRIN MIGRAINE FORMULA Contraceptives (E.G. Foams, Devices) 4

7 Contraceptives (E.G. Foams, Devices) CONDOMS-PREM LUBRICATED GYNOL II VAGINAL CONTRACEPTIVE FOAM Devices Devices VORTEX HOLDING CHAMBER QL VORTEX HOLDING CHAMBER CHILD QL VORTEX HOLDING CHAMBER TODDLER QL VORTEX VHC FROG MASK-CHILD QL VORTEX VHC LADYBUG MASK-TODDLR QL Diagnostic Agents Ketones KETONE CARE QL Sugar DIASTIX Electrolytic, Caloric, And Water Balance Caloric Agents BOOST GLUCOSE CONTROL ORAL LIQUID GRAM-KCAL/ML 2 PA CAMINO PRO 5 PKU 2 PA CAMINO PRO RESTORE LITE 2 PA CAMINO-PRO RESTORE 2 PA COMPLEAT PEDIATRIC ORAL LIQUID 2 PA CRUCIAL 2 PA GLUCERNA.2 CAL 2 PA GLYTACTIN 5 PE BETTERMILK ORAL POWDER IN PACKET 3 GRAM-327 KCAL/00 GRAM NUTREN JUNIOR ORAL LIQUID GRAM-KCAL/ML 2 PA 2 PA PEPTAMEN AF 2 PA PERATIVE 2 PA 5

8 PHENYLADE RTD PKU 0 2 PA PKU COOLER 0 2 PA PKU LOPHLEX 2 PA PULMOCARE 2 PA Replacement Preparations ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) CALCIO DEL MAR CALCIUM D ORAL TABLET 500 MG(,250MG) -200 UNIT CALCIUM 500 WITH D CALCIUM 600 CALCIUM D(3) ORAL TABLET 600 MG(,500MG) -200 UNIT, 600 MG(,500MG) UNIT calcium carbonate oral suspension calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (,250 mg) calcium carbonate-vitamin d3 oral tablet,chewable mg-unit calcium citrate-vitamin d3 oral tablet mgunit calcium gluconate oral tablet 45 mg (500 mg), 60 mg (648 mg) OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET MG-UNIT, 500 MG(,250MG) -200 UNIT PRENATABS RX AL RIGHT STEP PRENATAL VITAMINS AL RISACAL-D THERA-M ORAL TABLET 9 MG IRON-400 MCG Eye, Ear, Nose And Throat (Eent) Preps. Eent Drugs, Miscellaneous ALTACHLORE ARTIFICIAL TEARS (POLYVIN ALC) 6

9 BABY AYR SALINE SALINE MIST Vasoconstrictors EYE ALLERGY RELIEF Gastrointestinal Drugs Antacids And Adsorbents ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION MG/5 ML ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) calcium carbonate oral tablet 260 mg calcium (648 mg) GELUSIL ANTACID & ANTI-GAS ORAL TABLET,CHEWABLE GERI-MOX ANTACID-ANTIGAS magnesium oxide oral tablet 400 mg PINK BISMUTH ORAL TABLET PINK BISMUTH ORAL TABLET,CHEWABLE sodium bicarbonate oral tablet 650 mg SOOTHE REGULAR STRENGTH STOMACH RELIEF MAX STRENGTH Antidiarrhea Agents ANTI-DIARRHEAL (LOPERAMIDE) ORAL TABLET PINK BISMUTH ORAL TABLET PINK BISMUTH ORAL TABLET,CHEWABLE SOOTHE REGULAR STRENGTH STOMACH RELIEF MAX STRENGTH Antiflatulents ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION MG/5 ML GAS RELIEF ORAL CAPSULE 25 MG 7

10 GELUSIL ANTACID & ANTI-GAS ORAL TABLET,CHEWABLE GERI-MOX ANTACID-ANTIGAS Cathartics And Laxatives BISA-LAX COLACE ORAL CAPSULE 50 MG docusate sodium oral capsule 00 mg ENEMA DISPOSABLE FIBER SMOOTH KONSYL SUGAR-FREE ORAL POWDER IN PACKET LAXATIVE RECTAL magnesium citrate oral solution METAMUCIL (WITH SUGAR) ORAL POWDER IN PACKET MILK OF MAGNESIA REGULOID ORAL POWDER 2 SANI-SUPP (ADULT) SENNA LAX SENNA ORAL SYRUP 8.8 MG/5 ML sorbitol solution 70 % STOOL SOFTENER ORAL CAPSULE 250 MG STOOL SOFTENER ORAL LIQUID STOOL SOFTENER ORAL SYRUP Gi Drugs, Miscellaneous XENICAL 2 PA Miscellaneous Therapeutic Agents Cariostatic Agents MULTI-VIT WITH FLUORIDE & IRON AL MULTI-VITAMIN WITH FLUORIDE ORAL DROPS Other Miscellaneous Therapeutic Agents AL 8

11 ICAPS AREDS ORAL TABLET,DELAYED RELEASE (DR/EC) Respiratory Tract Agents Alpha And Beta Adrenergic Agonist(Respr) ALLERCLEAR D-24HR QL AMBI 60PSE-4CPM LORATADINE-D ORAL TABLET EXTENDED RELEASE 2 HR NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET pseudoephedrine hcl oral tablet 60 mg SUDAFED 2 HOUR Antitussives QL benzonatate oral capsule 00 mg, 200 mg QL codeine-guaifenesin promethazine-codeine QL promethazine-dm TUSSIN CF COUGH-COLD TUSSIN COUGH (DM ONLY) ORAL LIQUID TUSSIN DM MAX ORAL LIQUID MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN DM ORAL SYRUP 0-00 MG/5 ML ZONATUSS QL Expectorants ADULT TUSSIN CHEST CONGESTION codeine-guaifenesin guaifenesin oral liquid guaifenesin oral tablet 400 mg TUSSIN CF COUGH-COLD TUSSIN DM MAX ORAL LIQUID MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN DM ORAL SYRUP 0-00 MG/5 ML 9

12 First Generation Antihist.(Respir Tract) ALLERGY (CHLORPHENIRAMINE) ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET EXTENDED RELEASE ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL CAPSULE ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL TABLET AMBI 60PSE-4CPM DIPHEDRYL ORAL LIQUID DIPHENHIST ORAL TABLET 50 MG diphenhydramine hcl oral capsule 50 mg diphenhydramine hcl oral tablet 25 mg 0 2 PA promethazine-codeine QL promethazine-dm Q-DRYL ORAL LIQUID Second Generation Antihist(Respir Tract) ALLERCLEAR D-24HR QL ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING QL cetirizine oral tablet 0 mg QL fexofenadine oral tablet 80 mg, 60 mg 2 PA loratadine oral tablet QL LORATADINE-D ORAL TABLET EXTENDED RELEASE 2 HR Skin And Mucous Membrane Agents Antibacterials (Skin & Mucous Membrane) bacitracin topical bacitracin zinc bacitracin-polymyxin b topical packet DOUBLE ANTIBIOTIC (B.TRACN ZN) POLY BACITRACIN Anti-Inflammatory Agents (Skin & Mucous) ANUCORT-HC QL

13 AQUANIL HC CORTISONE (HYDROCORTISONE) TOPICAL LOTION hydrocortisone acetate topical cream 0.5 % QL hydrocortisone rectal cream QL hydrocortisone topical cream 0.5 % hydrocortisone topical lotion % hydrocortisone topical ointment 0.5 %, % Antipruritics And Local Anesthetics ANTI-ITCH(DIPHENHYD) WITH ZINC TOPICAL CREAM 2-0. % Azoles (Skin & Mucous Membrane) ANTIFUNGAL CREAM clotrimazole vaginal cream CLOTRIMAZOLE-3 miconazole nitrate vaginal cream miconazole nitrate vaginal kit,200-2 mg-% miconazole nitrate vaginal suppository MICONAZORB AF Basic Lotions And Liniments calamine Basic Ointments And Protectants zinc oxide topical ointment 20 % Keratolytic Agents benzoyl peroxide topical cleanser 0 %, 5 % benzoyl peroxide topical gel 0 %, 2.5 % TARGETED ACNE SPOT TREATMENT Keratoplastic Agents CUTAR Local Anti-Infectives, Miscellaneous INSTACLEAN Scabicides And Pediculicides LICE TREATMENT TOPICAL LIQUID %

14 Thiocarbamates (Skin & Mucous Membrane) MEDI-FIRST ANTI-FUNGAL tolnaftate topical cream Vitamins Multivitamin Preparations CERTA PLUS COMPLETE MULTIVITAMIN ORAL TABLET MULTI-VIT WITH FLUORIDE & IRON AL MULTI-VITAMIN WITH FLUORIDE ORAL DROPS POLY-VITAMIN 2 AL PRENATABS RX AL PRENATAL 9 AL RIGHT STEP PRENATAL VITAMINS AL SUPER THERA VITE M THERA THERA-M ORAL TABLET, 9 MG IRON-400 MCG THERAPEUTIC LIQUID VITAMINS & MINERALS Vitamin B Complex CERTA PLUS cyanocobalamin (vitamin b-2) injection folic acid oral tablet mg 2 PRENATABS RX AL PRENATAL 9 AL pyridoxine oral tablet 25 mg RIGHT STEP PRENATAL VITAMINS AL THERA-M ORAL TABLET 9 MG IRON-400 MCG VITAMIN B- ORAL TABLET 00 MG VITAMIN B-6 ORAL TABLET 00 MG, 50 MG

15 Vitamin D CALCIUM D ORAL TABLET 500 MG(,250MG) -200 UNIT CALCIUM 500 WITH D CALCIUM D(3) ORAL TABLET 600 MG(,500MG) -200 UNIT, 600 MG(,500MG) UNIT calcium carbonate-vitamin d3 oral tablet,chewable mg-unit calcium citrate-vitamin d3 oral tablet mgunit cholecalciferol (vitamin d3) oral capsule 5,000 unit cholecalciferol (vitamin d3) oral tablet,000 unit ergocalciferol (vitamin d2) oral capsule 2 ergocalciferol (vitamin d2) oral drops OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET MG-UNIT, 500 MG(,250MG) -200 UNIT RISACAL-D VITAMIN D3 ORAL CAPSULE 2,000 UNIT VITAMIN D3 ORAL TABLET 400 UNIT 3