Just the Fax
A fax bulletin from Molina Healthcare of California (MHC)• May 30, 2014
MOLINA HEALTHCARE OF CALIFORNIA
DRUG FORMULARY UPDATE
Drug Efficacy Study Implementation (DESI) category 5 or 6 products1
DESI category 5 or 6 products will no longer be a reimbursable pharmacy benefit for Molina Healthcare
of California members, effective June 1, 2014.‡
DESI 5 or 6 products no longer covered:
1. Estrogens, conjugated with methyltestosterone
2. Estrogens, esterified with methyltestosterone
3. Belladonna alkaloids with phenobarbital
‡
DESI 5 = less than effective for all indications, 6 = withdrawn from the market
Formulary Alternative products that are available include:
1. conjugated estrogen, estradiol tablets, estradiol transdermal
2. esterified estrogen, estradiol tablets, estradiol transdermal
3. polyethylene glycol, lactulose, loperamide
Silver Nitrate products1
Silver nitrate products will no longer be a reimbursable pharmacy benefit for Molina Healthcare of
California members, effective June 1, 2014.
Silver Nitrate products no longer covered:
1. Silver nitrate 75% and potassium nitrate 25% topical applicator sticks
2. Silver nitrate topical solution 0.5%, 10%, 25%, 50%
Formulary Alternative products that are available include:
1. mupirocin ointment, bacitracin ointment, silver sulfadiazine, cadexomer iodine (PA required)
Reminder: Ista Pharmaceuticals products2
Ista Pharmaceuticals products are not a reimbursable pharmacy benefit for Molina Healthcare of
California members, effective February 1, 2014.
Ista Pharmaceuticals products no longer covered:
1. Bromday/Xibrom (bromfenac ophthalmic solution 0.09%)
2. Bepreve (bepotastine besilate ophthalmic solution 1.5%)
3. Istalol (timolol maleate ophthalmic solution 0.5%)
Formulary Alternative products that are available include:
1. flurbiprofen 0.03% and ketorolac 0.4% and 0.5% ophthalmic drops
2. ketotifen 0.025% ophthalmic drops
3. brimonidine 0.1% and 0.2%, brimonidine/timolol 0.2-0.5%, latanoprost 0.005%, betaxolol ophthalmic
drops (PA required)
References
1. Medi-Cal Pharmacy Bulletin 820. http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/ph201403r.asp
2. Medi-Cal Pharmacy Bulletin 815. http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/ph201401.asp
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