I. INTRODUCTION 1. This Preferred Drug List (PDL) was updated as of 7/30/2015. It is subject to change without notice. If you choose to print out/photocopy the PDL, please refer to the CCHP website for the most up to date version before making prescribing decisions. You will need Acrobat Reader to download the PDL. You may wish to bookmark the URL below for both the CCHP PDL and the “Medication Prior Authorization Request” form: http://cchealth.org/health_plan/pdl.php 2. To search this PDL: in addition to referring to the Table of Contents and Index, use “Control F” or the binoculars icon, and type in the drug name. 3. For Prior Authorization forms please call 925-957-7260 (option 2). The Medication Prior Authorization form is also available from the website address listed in #1 above. The PDL is a listing of “Preferred” first line drugs. If you have clinical reasons to choose a second line agent, please provide complete clinical information to expedite the processing of your Medication Prior Authorization Request. 4. This is only a listing of preferred medications. Listing in the PDL is not a guarantee of payment. There are many different levels of coverage and members should refer to their “Evidence of Coverage” (EOC) for information about co-pays, and exclusions to coverage for their specific situation. Most Over The Counter (OTC) medication is not covered, except where specified. Medication Supplies and Devices are not included in this list. II. OVERVIEW 1. All CCHP members and recipients of County health programs are subject to the PDL protocols. 2. A PDA-enabled version is available at the ePocrates web site: http://www.epocrates.com (choose < ePocrates Rx Formulary >). Follow these instructions to add the CCHP formulary to your epocrates user profile: a. Go to www.epocrates.com. b. Click on "My Account" in the top right. c. Sign in with your Epocrates username and password, if needed. d. Click on "Edit Formularies." e. Follow the on screen instructions to select and download formularies or to remove formularies. i. For the ‘Select State’ filter, click California ii. For the ‘Select Category’ filter, click Health Plan iii. Choose the Contra Costa Healthplan formulary; click the ‘Add’ button iv. Click the "Done" button when you've finished. f. Update your device, and the formularies on your mobile device will be changed accordingly. g. If you have any questions about the installation or use of Epocrates, please contact Epocrates Customer Support at goldsupport@epocrates.com or at (800)230-2150. 1 January 2015 3. Urgent PAs are processed within 4 hours if the clinical information is complete. For an emergency medication during off hours pharmacists can give up to a 5 day supply (at their discretion) before receiving the PA approval. We will monitor Urgent PA requests to make sure they are appropriately urgent. 4. Routine PAs are processed as quickly as possible. The usual reason for a delay is lack of adequate clinical information. We will call, page or fax you if we receive a prescription for a non-preferred drug without adequate medical justification. If you do not provide medical necessity for a non-preferred drug or if we do not hear back from you within five business days, the Rx may be modified or denied. 5. C1 (Code 1) are non-preferred drugs with criteria that can be satisfied without a PA. Some criteria such as “tried and failed <drug name> Rx” can be written on the prescription. Other criteria, such as “under 12 years old”, can be identified by the pharmacist. 6. Basic Health Care (BHC) patients must use the following Walgreens pharmacies to fill their prescriptions: 24-hour Pharmacy Location Walgreens Store #4026 2900 North Main Street Walnut Creek, CA 94596 925-933-0307 (PHONE) 925-933-0559 (FAX) Pharmacy Locations (alpha by City) Walgreens Store #4724 3416 Deer Valley Road Antioch, CA 94531 Walgreen Store #13026 2700 Willow Pass Road Bay Point, CA 94565 Walgreens Store #6871 4520 Balfour Road Brentwood, CA 94513 Walgreens Store #9978 6570 Lone Tree Way Brentwood, CA 94513 Walgreens Store #2112 5437 Clayton Road Clayton, CA 94517 Walgreens Store #3164 1800 Concord Ave Concord, CA 94520 Walgreens Store #15003 1990 Monument Blvd Concord, CA 94520 Walgreens Store #3770 11565 San Pablo Ave El Cerrito, CA 94530 Walgreens Store #4049 3630 San Pablo Dam Road El Sobrante, CA 94803 925-978-8000 (PHONE) 925-978-4209 (FAX) 925-709-0317 (PHONE) 925-709-0527 (FAX) 925-513-4055 (PHONE) 925-516-9544 (FAX) 925-240-6043 (PHONE) 925-240-6134 (FAX) 925-672-1334 (PHONE) 925-672-0587 (FAX) 925-674-9477 (PHONE) 925-674-9258 (FAX) 925-689-7812 (PHONE) 925-246-9861 (FAX) 510-234-9300 (PHONE) 510-234-8986 (FAX) 510-758-1294 (PHONE) Walgreens Store #6101 3655 Alhambra Ave Martinez, CA 94553 Walgreens Store #11614 2750 Pinole Valley Road Pinole, CA 94564 Walgreens Store #7376 2901 Railroad Ave Pittsburg, CA 94565 Walgreens Store #5864 721 Gregory Lane Pleasant Hill, CA 94523 Walgreens Store #2506 1150 MacDonald Ave Richmond, CA 94801 Walgreens Store #2435 13751 San Pablo Ave San Pablo, CA 94806 Walgreens Store #4491 15650 San Pablo Ave San Pablo, CA 94806 Walgreen Store #13796 14280 San Pablo Ave San Pablo, CA 94806 925-372-0337 (PHONE) 925-372-6018 (FAX) 510-222-9422 (PHONE) 510-222-9428 (FAX) 925-439-8575 (PHONE) 925-439-1558 (FAX) 925-944-1592 (PHONE) 925-944-5976 (FAX) 510-236-5748 (PHONE) 510-236-5267 (FAX) 510-233-9467 (PHONE) 510-233-8467 (FAX) 510-243-1100 (PHONE) 510-243-0527 (FAX) 510-730-7000 (PHONE) 510-730-7006 (FAX) 510-758-6192 (FAX) Thank you for providing cost-effective high quality health care! 2 January 2015 CCHP pharmacy locations (alpha by City) Pharmacy RITE AID PHARMACY RITE AID PHARMACY RITE AID PHARMACY RITE AID PHARMACY WALGREENS WALGREENS CITY CENTER PHARMACY BRENTWOOD WALGREENS WALGREENS WALGREENS WALGREENS BACON EAST PHARMACY OAK GROVE PHARMACY RITE AID PHARMACY SYCAMORE MEDICAL PHARMACY WALGREENS WALGREENS DANVILLE SAN RAMON PHARMACY WALGREENS WALGREENS WALGREENS PARK PHARMACY WALGREENS RITE AID PHARMACY RITE AID PHARMACY WALGREENS RITE AID PHARMACY MEDICINE SHOPPE PHARMACY RITE AID PHARMACY WALGREENS WHITECROSS PROFESSIONAL PHCY CITY CENTER PHARMACY INC RITE AID PHARMACY WALGREENS MEDICAL ARTS PHARMACY RITE AID PHARMACY WALGREENS CENTRAL PHARMACY CIVIC CENTER PHARMACY WALGREENS BROOKVALE MEDICAL CENTER PHARM VALE ROAD PHARMACY WALGREENS WALGREENS WALGREENS RITE AID PHARMACY SAN RAMON CUSTOM CARE PHARMACY WALGREENS ADVANCE MEDICAL PHARMACY RIDGECREST PHARMACY RITE AID PHARMACY RITE AID PHARMACY SYCAMORE WEST PHARMACY WALGREENS WALGREENS Address 130 ALAMO PLAZA 20 EAST 18TH STREET 3353 DEER VALLEY ROAD 4100 LONE TREE WAY 3416 DEER VALLEY ROAD 2700 WILLOW PASS RD 50 EAGLE ROCK WAY STE C 2271 BALFOUR RD 4520 BALFOUR 6570 LONE TREE WAY 5437 CLAYTON RD 2425 EAST ST 785 OAK GROVE RD 1905 MONUMENT BOULEVARD 2485 HIGH SCHOOL AVENUE 1800 CONCORD AVE 1990 MONUMENT BLVD 905 SAN RAMON VALLEY BLVD 480 DIABLO RD 611 SAN RAMON VALLEY BLVD 11565 SAN PABLO AVE 3716 DAM RD 3630 SAN PABLO DAM RD 1560 SYCAMORE AVENUE 1165 ARNOLD DRIVE 3655 ALHAMBRA AVE 2555 MAIN STREET 282 VILLAGE SQUARE 27 ORINDA WAY 2750 PINOLE VALLEY RD 2160 APPIAN WAY 1270 E LELAND RD 580 BAILEY ROAD 2901 RAILROAD AVE 2100 MONUMENT BLVD 2140 CONTRA COSTA BOULEVARD 721 GREGORY LN 2300 MACDONALD AVE 2729 MACDONALD AVE 1150 MACDONALD 2101 VALE RD 2023 VALE RD 13751 SAN PABLO AVE 14280 SAN PABLO AVE 15650 SAN PABLO AVE 3207 CROW CANYON PLACE 124 MARKET PLACE 21001 SAN RAMON VALLEY 112 LA CASA VIA 1844 SAN MIGUEL DR 1526 PALOS VERDES MALL 1997 TICE VALLEY BOULEVARD 452 N WIGET LN 2900 N MAIN ST 2923 YGNACIO VALLEY RD 3 City ALAMO ANTIOCH ANTIOCH ANTIOCH ANTIOCH BAY POINT BRENTWOOD BRENTWOOD BRENTWOOD BRENTWOOD CLAYTON CONCORD CONCORD CONCORD CONCORD CONCORD CONCORD DANVILLE DANVILLE DANVILLE EL CERRITO EL SOBRANTE EL SOBRANTE HERCULES MARTINEZ MARTINEZ OAKLEY ORINDA ORINDA PINOLE PINOLE PITTSBURG PITTSBURG PITTSBURG PLEASANT HILL PLEASANT HILL PLEASANT HILL RICHMOND RICHMOND RICHMOND SAN PABLO SAN PABLO SAN PABLO SAN PABLO SAN PABLO SAN RAMON SAN RAMON SAN RAMON WALNUT CREEK WALNUT CREEK WALNUT CREEK WALNUT CREEK WALNUT CREEK WALNUT CREEK WALNUT CREEK State CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA CA ZIP 94507 94509 94509 94531 94509 94565 94513 94513 94513 94513 94517 94520 94518 94520 94520 94520 94520 94526 94526 94526 94530 94803 94803 94547 94553 94553 94561 94563 94563 94564 94564 94565 94565 94565 94523 94523 94523 94804 94804 94801 94806 94806 94806 94806 94806 94583 94583 94583 94598 94596 94596 94595 94598 94596 94598 Phone 925-820-1233 925-757-7161 925-757-3390 925-522-0150 925-978-7000 925-709-0317 925-240-9777 925-626-3491 925-516-8614 925-240-6043 925-672-1334 925-687-0565 925-681-1823 925-680-2845 925-682-5600 925-674-8789 925-689-7812 925-820-4603 925-855-8145 925-743-0160 510-234-9200 510-223-1321 510-758-1294 510-799-1252 925-372-0945 925-372-6398 925-625-7440 925-254-1211 925-253-1904 510-222-9422 510-724-2333 925-432-9770 925-458-0955 925-439-1054 925-685-0147 925-691-0164 925-944-0192 510-234-4381 510-234-5023 510-236-5830 510-235-4443 510-232-2377 510-233-9220 510-730-7000 510-243-0300 925-866-0505 925-830-0555 925-803-0890 925-939-6311 925-937-6800 925-939-8378 925-932-0568 925-979-9500 925-933-0117 925-256-7253 January 2015 Preferred Drug List (PDL) Table of Contents Page Number ANTINEOPLASTICS........................................................................................................................................... 9 ENDOCRINE SYSTEM MEDICATIONS .......................................................................................................... 10 Androgens ................................................................................................................................................. 10 Glucocorticoids ......................................................................................................................................... 10 Mineralocorticoids .................................................................................................................................... 10 Diabetic Medications ................................................................................................................................ 10 Medications to Treat Hypoglycemia ......................................................................................................... 11 Medications to Treat Of Osteoporosis ...................................................................................................... 11 Miscellaneous Bisphosphonates ............................................................................................................... 11 Estrogens................................................................................................................................................... 11 Estrogens/Progestin combinations ........................................................................................................... 12 Selective Estrogen Receptor Modulators .................................................................................................. 12 Oral Contraceptives .................................................................................................................................. 12 Non-Oral Contraceptives .......................................................................................................................... 12 OB/GYN Medications................................................................................................................................ 13 Oxytocics ................................................................................................................................................... 13 Progestins ................................................................................................................................................. 13 Estrogen/Androgen Combinations ............................................................................................................ 13 Gout Medications ...................................................................................................................................... 13 Thyroid Medications ................................................................................................................................. 13 Miscellaneous Endocrine Agents .............................................................................................................. 13 GASTROINTESTINAL MEDICATIONS ........................................................................................................... 13 4 January 2015 Ammonia Detoxicants ............................................................................................................................... 13 Antispasmodics ......................................................................................................................................... 13 Anti-Ulcer Medications ............................................................................................................................. 14 Antidiarrheal Preparations ....................................................................................................................... 14 Digestive Enzymes .................................................................................................................................... 14 Medications for Nausea & Vomiting ........................................................................................................ 14 Medications for Bowel Disease ................................................................................................................ 15 Miscellaneous Gastrointestinal Medications ............................................................................................ 15 GENITOURINARY TRACT MEDICATIONS ................................................................................................... 15 Gall Stone Stabilizing Agents.................................................................................................................... 15 Medications For The Urinary Tract ......................................................................................................... 15 Misc Medications: (Phosphodiesterase Inhibitors) .................................................................................. 16 HEART AND BLOOD PRESSURE MEDICATIONS ....................................................................................... 16 Angiotensin Converting Enzyme Inhibitors .............................................................................................. 16 Angiotensin II Receptor Blockers ............................................................................................................. 16 Angiotensin Converting Enzyme Inhibitor/Diuretic Combinations .......................................................... 16 Antiarrhythmics......................................................................................................................................... 17 Beta Blockers ............................................................................................................................................ 17 Calcium Channel Blockers ....................................................................................................................... 17 Carbonic Anhydrase Inhibitors................................................................................................................. 18 Centrally Acting Antihypertensives........................................................................................................... 18 Cholesterol Lowering Drugs..................................................................................................................... 18 Diuretics .................................................................................................................................................... 18 MEDICATIONS AFFECTING THE BLOOD ................................................................................................... 19 Anticoagulants .......................................................................................................................................... 19 Hematopoetic ............................................................................................................................................ 19 Antiplatelets .............................................................................................................................................. 19 Misc. Cardiovascular Drugs ..................................................................................................................... 19 Medication For Angina ............................................................................................................................. 19 Vasopressor............................................................................................................................................... 20 MEDICATIONS FOR EYES, EAR, NOSE & THROAT .................................................................................... 20 Anti-Inflammatory Medications For The Eyes ......................................................................................... 20 GLAUCOMA MEDICATIONS.......................................................................................................................... 20 5 January 2015 Beta Blockers ............................................................................................................................................ 20 Alpha-2 Adrenergic Agonist ..................................................................................................................... 20 Carbonic Anhydrase Inhibitors................................................................................................................. 20 Prostaglandins .......................................................................................................................................... 21 OPHTHALMIC MEDICATIONS ...................................................................................................................... 21 Other Treatments for Glaucoma ............................................................................................................... 21 Ophthalmic Anti-infectives........................................................................................................................ 21 Ophthalmic Anti-infective Combinations .................................................................................................. 21 Ophthalmic Anti-Allergic Medications ..................................................................................................... 21 Other Ophthalmic Medications................................................................................................................. 22 Medications For The Ear .......................................................................................................................... 22 Medications For The Nose ........................................................................................................................ 23 Medications For The Throat And Mouth .................................................................................................. 23 MEDICATIONS THAT AFFECT THE NERVOUS SYSTEM ........................................................................... 23 Antianxiety Medications............................................................................................................................ 23 Anticonvulsants ......................................................................................................................................... 23 Antidepressants ......................................................................................................................................... 24 Anti-Mania ................................................................................................................................................ 25 Anti-Psychotic Medications ...................................................................................................................... 25 MISCELLANEOUS MEDICATIONS AFFECTING THE BRAIN .................................................................... 25 Parkinson’s Medications .......................................................................................................................... 26 Sedative/Hypnotics .................................................................................................................................... 26 Stimulants.................................................................................................................................................. 26 MEDICATIONS TO TREAT INFECTIONS ...................................................................................................... 27 Antibiotics ................................................................................................................................................. 27 Bacterial Vaccines .................................................................................................................................... 28 Antimalarials............................................................................................................................................. 28 Anti-Parasitic Medications ....................................................................................................................... 28 Antituberculosis Medications.................................................................................................................... 28 ANTIRETROVIRALS......................................................................................................................................... 28 Anti-HIV Medications, CCR5 Co-Receptor Antagonists .......................................................................... 28 Anti-HIV Medications, Fusion Inhibitors ................................................................................................. 28 Anti-HIV Medications, Integrase Strand Transfer Inhibitors ................................................................... 28 6 January 2015 Anti-HIV Medications, Non-Nucleoside Reverse Transcriptase Inhibitors .............................................. 28 Anti-HIV Medications, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors and Single-Tablet Regimens ........................................................................................................................................................... 29 Anti-HIV Medications, Protease Inhibitors .............................................................................................. 29 Misc. Antiviral Medications ...................................................................................................................... 29 Oral Antifungals........................................................................................................................................ 29 Other Oral Anti-Infective Medications ..................................................................................................... 30 Vaginal Anti-Infectives.............................................................................................................................. 30 IMMUNOLOGICAL AGENTS .......................................................................................................................... 30 ANALGESICS/PAIN/RHEUMATIC MEDICATIONS ...................................................................................... 30 Anti-Inflammatory Medications (NSAIDS) ............................................................................................... 30 Anti-Rheumatic Medications ..................................................................................................................... 31 Migraine Medications ............................................................................................................................... 31 Analgesics ................................................................................................................................................. 32 Opiate Antagonists .................................................................................................................................... 33 Carved-out for Medi-Cal members ................................................................................................................... 33 Skeletal Muscle Relaxants......................................................................................................................... 33 NUTRITION ...................................................................................................................................................... 33 Electrolytes ............................................................................................................................................... 33 Vitamins and Minerals .............................................................................................................................. 33 Phosphate Binding Medications ............................................................................................................... 34 RESPIRATORY DRUGS ................................................................................................................................... 34 Antihistamine/Decongestants .................................................................................................................... 34 Antihistamines ........................................................................................................................................... 34 Cough Medications ................................................................................................................................... 35 Medications For Asthma & COPD ........................................................................................................... 35 Mucolytic Agent ........................................................................................................................................ 36 SKIN MEDICATIONS (TOPICAL) ................................................................................................................... 36 Acne Medications ...................................................................................................................................... 36 Topical Antiparasitics/Anti-helmintic ....................................................................................................... 36 Other Topical Medications ....................................................................................................................... 37 Topical Immunomodulator........................................................................................................................ 37 Topical Antifungal .................................................................................................................................... 38 Topical Coricosteroids.............................................................................................................................. 38 7 January 2015 Grade 1 (Very High Potency) ................................................................................................................... 38 Grade 2 (High Potency) ............................................................................................................................ 38 Grade 3 (Medium Potency) ....................................................................................................................... 38 Grade 4 (Low Potency) ............................................................................................................................. 39 INDEX ............................................................................................................................................................... 40 8 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES ANTINEOPLASTICS Alkylating Agents Melphalan ALKERAN PA Lomustine CEENU PA Cyclophosphamide CYTOXAN PA Altretamine HEXALEN PA Chlorambucil LEUKERAN PA Procarbazine MATULANE PA Busulfan MYLERAN PA Temozolomide TEMODAR PA Lenalidomide REVLIMID PA Thalidomide THALOMID PA Antiangiogenic Agents Antiestrogens/Modifiers Estramustine EMCYT Toremifene FARESTON Antimetabolites Hydroxyurea DROXIA, HYDREA Thioguanine TABLOID Capecitabine XELODA PA Ruxolitinib JAKAFI PA Metyrosine DEMSER Phenoxybenzamine DIBENZYLINE Mesna MESNEX Etoposide ETOPOPHOS Vorinostat ZOLINZA Other Antineoplastics PA PA rd 3 Generation Aromatase Inhibitors Anastrozole ARIMIDEX Exemestane AROMASIN Letrozole FEMARA Molecular Target Inhibitors Imatinib GLEEVEC PA Gefitinib IRESSA PA Sorafenib NEXAVAR PA Dasatinib SPRYCEL PA Sunitinib SUTENT PA Erlotinib TARCEVA PA Nilotinib TASIGNA PA Lapatinib TYKERB PA HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) Androgens BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 9 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME Testolactone BRAND NAME NOTES TESLAC HORMONAL AGENTS, ADRENAL SUPPRESANT Mitotane LYSODREN HORMONAL AGENTS; SUPPRESSANT Antiandrogens Abiraterone Acetate ZYTIGA Bicalutamide CASODEX Flutamide FLUTAMIDE Nilutamide NILANDRON PA IMMUNOLOGICAL AGENTS Immune Suppressants Mycophenolate mofetil Mycophenolic acid Cyclosporine Modified Tacrolimus Sirolimus Cyclosporine non-modified CELLCEPT MYFORTIC NEORAL , GENGRAF PROGRAF RAPAMUNE SANDIMMUNE ENDOCRINE SYSTEM MEDICATIONS Androgens Testosterone Cypionate (Injection) DEPO-TESTOSTERONE (inj) Testosterone Enanthate (Injection) TESTOSTERONE (inj) Testosterone Buccal STRIANT PA Glucocorticoids Dexamethasone DECADRON Hydrocortisone CORTEF Methylprednisolone MEDROL Prednisolone DELTA-CORTEF Prednisolone syrup PRELONE, ORAPRED Prednisone ORASONE Mineralocorticoids Fludrocortisone FLORINEF Diabetic Medications PA: Tried and failed OR contraindications to a sulfonylurea or metformin. Claim processes at the point of sale when PA criteria met. PA: Trial of metformin AND Januvia AND insulin AND Victoza Acarbose PRECOSE Exenatide BYETTA Glimepiride AMARYL Glimepiride/Pioglitazone DUETACT Glipizide Glucose Monitor GLUCOTROL TRUETRACK, TRUETEST Diabetic Test Strips TRUETRACK, TRUETEST Glyburide DIABETA/MICRONASE Insulin basal HUMULIN N, HUMULIN R, HUMULIN 50/50, HUMULIN 70/30 QL: 12 vials/30days Insulin lispro HUMALOG PA: Documented recent trial and failure to insulin glulisine (Apidra) PA: Consider separate glimepiride and pioglitazone QL: Quanity Limit:150 test strips per 30 days if insulin dependent or gestational diabetes. 100 strips per 90 days if non-insulin dependent. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 10 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Insulin aspart NOVOLOG PA: Documented recent trial and failure to insulin glulisine (Apidra) Insulin glulisine APIDRA QL: 3000 units monthly (3 vials or 2 boxes of pens) Insulin detemir LEVEMIR QL: 3000 units monthly (3 vials or 2 boxes of pens) Insulin glargine LANTUS QL: 3000 units monthly (3 vials or 2 boxes of pens) Liraglutide VICTOZA PA: Trial of metformin AND Januvia AND insulin Metformin GLUCOPHAGE Metformin ER GLUCOPHAGE XR Metformin/Glipizide METAGLIP PA: Tried and failed separate agents Metformin/Glyburide GLUCOVANCE PA: Tried and failed separate agents Metformin/Pioglitazone ACTOPLUS Miglitol GLYSET Nateglinide STARLIX PA: Tried and failed preferred alternatives PA: Tried and failed OR contraindications to a sulfonylurea or metformin. PA: Tried and failed OR contraindications to a sulfonylurea or metformin. C1: Qty must = dose of self injection Needles & Syringes Pioglitazone ACTOS Pioglitazone/Metformin ACTOSPLUS MET PA: Consider separate pioglitazone and metformin Pramlintide SYMLIN Repaglinide PRANDIN Sitagliptin JANUVIA Sitagliptin/Metformin JANUMET PA: Tried and failed preferred alternatives PA: Tried and failed OR contraindications to a sulfonylurea or metformin. PA: Tried and failed OR contraindications to a sulfonylurea or metformin. Claim processes at the point of sale when PA criteria met. PA: Tried and failed OR contraindications to a sulfonylurea or metformin. Claim processes at the point of sale when PA criteria met. Tolazamide TOLINASE Tolbutamide ORINASE Medications to Treat Hypoglycemia Glucagon HCl GLUCAGON Medications to Treat Of Osteoporosis Alendronate FOSAMAX Denosumab PROLIA Calcitonin-Salmon MIACALCIN NASAL SPRAY Ibandronate BONIVA Raloxifene EVISTA Risedronate ACTONEL Zolendronic Acid ZOMETA, RECLAST PA: Trial/failure OR contraindication to alendronate AND zolendronic acid PA QL: limit #1/30 days C1: Postmenopausal woman who has been on estrogen for 10 years OR any postmenopausal woman with an increased risk for breast cancer OR tried and failed or any contraindications/intolerance to estrogen PA PA: Tried and failed OR contraindications to at least one oral bisphosphonate Miscellaneous Bisphosphonates Etidronate Disodium C1: Restricted to hypercalcemia of malignancy. Choose other bisphosphonates for Paget’s disease of the bone if not contraindicated. DIDRONEL Estrogens Conjugated Estrogens (Tablet, Vaginal Cream) PREMARIN (TABLET, VAGINAL CREAM) Esterified Estrogens MENEST Estradiol acetate FEMRING PA: Tried and failed OR contraindications to at least one preferred alternative BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 11 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Estradiol ESTRING Estradiol (Tablet, Vaginal Cream) ESTINYL, ESTRACE (Tablet, Vaginal Cream) Estradiol (Vaginal Tablet). VAGIFEM (VAGINAL TABLET) Estradiol, transdermal CLIMARA (TRANSDERMAL) Estradiol, transdermal VIVELLE-DOT, ESTRADERM, ALORA Estrogen, conjugated PREMARIN Estrogen, conjugated synthetic CENESTIN Estropipate OGEN NOTES PA: Tried and failed OR contraindications to at least one preferred alternative ST: trial of Climara PA: Tried and failed OR contraindications to at least one preferred alternative PA: Tried and failed OR contraindications to at least one preferred alternative Estrogens/Progestin combinations Conjugated Estrogens/Medroxy Progesterone PREMPRO/PREMPHASE Estradiol/Levonorgestrel, transdermal CLIMARA-PRO Estradiol/Norethindrone, transdermal COMBIPATCH Ethinyl Estradiol/Norethindrone acetate FEMHRT Estradiol/Norgestimate PREFEST PA: Tried and failed OR contraindications to at least one preferred alternative ST: trial of Climara or Premphase or Prempro PA: Tried and failed OR contraindications to at least one preferred alternative PA: Tried and failed OR contraindications to at least one preferred alternative Selective Estrogen Receptor Modulators Tamoxifen NOLVADEX Oral Contraceptives Ethinyl Estradiol/Desogestrel VELIVET, CAZIANT Ethinyl Estradiol/Desogestrel DESOGEN Ethinyl Estradiol/Desogestrel MIRCETTE Ethinyl Estradiol/Drospirenone YASMIN Ethinyl Estradiol/Ethynodiol DEMULEN 1/35 Ethinyl Estradiol/Ethynodiol DEMULEN 1/50 Ethinyl Estradiol/Levonorgestrel ALESSE Ethinyl Estradiol/Levonorgestrel NOREDETTE Ethinyl Estradiol/Levonorgestrel TRI-LEVLEN Ethinyl Estradiol/Levonorgestrel SEASONALE Ethinyl Estradiol/Norethindrone LOESTRIN FE 1/20 Ethinyl Estradiol/Norethindrone LOESTRIN FE 1.5/30 Ethinyl Estradiol/Norethindrone ORTHONOVUM 1/35 Ethinyl Estradiol/Norethindrone ORTHO NOVUM 7/7/7 Ethinyl Estradiol/Norethindrone ORTHO NOVUM 10/11 Ethinyl Estradiol/Norethindrone OVCON 35 Ethinyl Estradiol/Norethindrone OVCON 50 Ethinyl Estradiol/Norethindrone TRI-NORINYL Ethinyl Estradiol/Norgestimate ORTHO CYCLEN Ethinyl Estradiol/Norgestimate ORTHO TRI-CYCLEN Estradiol/Norgestrel LO OVRAL Ethinyl Estradiol/Norgestrel OVRAL Mestranol/Norethindrone ORTHONOVUM 1/50 Norethindrone MICRONOR PA: Tried and failed OR contraindications to at least three preferred alternatives PA Non-Oral Contraceptives Ethinyl Estradiol/Etonogestrel NUVARING BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 12 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME Ethinyl Estradiol/Norelgestromin BRAND NAME NOTES ORTHO EVRA OB/GYN Medications Prenatal Vitamins PRENATAL, PRENATAL FORTE, PRENAVITE, PRENATAL RX Formulary for females > 13 years old < 45 years old. Oxytocics Methylergonorine METHERGINE Ulipristal ELLA QL: 1 tablet monthly; 6 fills per year Progestins Levonorgestrel NEXT CHOICE ONE-DOSE, PLAN B Medroxyprogesterone Acetate PROVERA, DEPO-PROVERA Norethindrone Acetate AYGESTIN Progesterone, oral micronized PROMETRIUM ST: trial of medroxyprogesterone Progesterone, transdermal PROGESTERONE TD PA: Tried and failed preferred alternatives Estrogen/Androgen Combinations Esterified Estrogens/ Methyltestosterone ESTRATEST Gout Medications Allopurinol ZYLOPRIM Colchicine COLCRYS Colchicine/Probenecid COL-PROBENECID Probenecid BENEMID QL: 15 tabs per dispense every 60 days PA: > 15 tabs requires concurrent allopurinol Thyroid Medications Levothyroxine SYNTHROID Liothyronine CYTOMEL Liotrix THYROLAR Methimazole TAPAZOLE Propylthiouracil PTU Thyroid dessicated ARMOUR THYROID, NATURE-THROID Miscellaneous Endocrine Agents Desmopressin Acetate DDAVP Teriparatide FORTEO Formulary: Tablets for patients 6 years of age and older. PA: Nasal Spray, Rhinal Tube, and Injection. PA: Tried and failed or contraindications to preferred alternatives. GASTROINTESTINAL MEDICATIONS Ammonia Detoxicants Lactulose CEPHULAC Antispasmodics Belladonna Alkaloids/Phenobarbital DONNATAL Clinidium/Chlordiazepoxide LIBRAX Darifenacin ENABLEX Dicyclomine BENTYL Diphenoxylate/Atropine LOMOTIL Ergotamine/Belladonna/Phenobarbital BELLERGAL-S Flavoxate URIPAS Hyoscyamine LEVSIN Hyoscyamine Sulfate CR LEVSINEX Metoclopramide REGLAN PA: Urology consult PA: Tried and failed OR contraindications to preferred alternatives BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 13 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES PEG Solution COLYTE Propantheline PRO-BANTHINE PA: Urology consult, approvable for one year for the DIAGNOSIS of urinary incontinence when at least one preferred alternative listed on the PDL has been tried and failed. Omeprazole Magnesium, Omeprazole OTC PRILOSEC, PRILOSEC (OTC) Only packet for oral suspension requires PA Pantoprazole PROTONIX Lansoprazole PREVACID Cimetidine TAGAMET Dexlansoprazole DEXILANT Esomeprazole NEXIUM Famotidine PEPCID Lansoprazole (OTC version) PREVACID 24HR OTC Misoprostol CYTOTEC Omeprazole/Sodium Bicarbonate ZEGERID OTC Rabeprazole ACIPHEX Ranitidine ZANTAC Sucralfate CARAFATE Anti-Ulcer Medications Solutab is formulary for 9 and younger or unable to take oral medications PA: PA: Trial/failure OR contraindication to omeprazole, pantoprazole, lansoprazole and rabeprazole PA: PA: Trial/failure OR contraindication to omeprazole, pantoprazole, lansoprazole and rabeprazole B: OTC Chewables and OTC Tablets A: Rx formulary PA: PA: Trial/failure OR contraindications to omeprazole, pantoprazole, lansoprazole and rabeprazole B: B A: Tablets only. Capsules are not covered Antidiarrheal Preparations Diphenoxylate/Atropine LOMOTIL Loperamide (2 mg capsules, 1mg/5mL liquid) IMODIUM Laxatives Linaclotide LINZESS Lubiprostone AMITIZA Polyethylene Glycol 3350 oral powder GLYCOLAX, Miralax OTC Sorbitol 70% solution SORBITOL PA: Tried and failed OR contraindications to preferred alternatives PA: Tried and failed OR contraindications to preferred alternatives A: OTC formulation. Digestive Enzymes Amylase/ Lipase/ Protease CREON, ZENPEP Medications for Nausea & Vomiting Aprepitant Prevention of nausea/vomiting secondary to chemotherapy in Cancer patients only EMEND Dolasetron ANZEMET Dronabinol MARINOL Granisetron KYTRIL Meclizine ANTIVERT PA: Restricted to treatment with emetogenic chemotherapy or radiation therapy AND documented trial and failure with therapeutic doses or intolerance to ondansetron (Zofran). QL: 5 tablets/30 days during chemotherapy PA: Restricted to use in cancer patients or the treatment of anorexia associated with weight loss in patients with AIDs PA: Restricted to treatment with emetogenic chemotherapy or radiation therapy AND documented trial and failure with therapeutic doses or intolerance to ondansetron (Zofran). QL: 12 tablets/30 days, not to exceed 3 months BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 14 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME Ondansetron BRAND NAME NOTES ZOFRAN, ZOFRAN ODT Prochlorperazine Promethazine PHENERGAN Trimethobenzamide TIGAN Phenergan suppositories Medications for Bowel Disease Azathioprine IMURAN Hydrocortisone Acetate Rectal CORTIFOAM Hydrocortisone ANUSOL-HC CREAM, SUPP. Mercaptopurine (6M-P) PURINETHOL Miscellaneous Gastrointestinal Medications Aluminum Hydroxide Gel Aluminum Hydroxide, Magnesium Hydroxide, and Simethicone Balsalazide AMPHOGEL B MYLANTA B Bisacodyl DULCOLAX B Bismuth Subsalicylate PEPTO-BISMOL M Calcium Carbonate/Magnesium Carbonate MYLANTA B Docusate Sodium COLACE M Hydrocortisone Retention Enema CORTENEMA Magnesium Citrate CITRATE OF MAGNESIA Mesalamine PENTASA, DELZICOL, ASACOL HD Mesalamine Enema CANASA (ENEMA) Mesalamine Supp ROWASA (SUPPOSITORY) Olsalazine DIPENTUM PEG 3350 Solution COLYTE Pilocarpine 5mg tablet SALAGEN Sennosides SENNA Sulfasalazine AZULFIDINE COLAZAL B M GENITOURINARY TRACT MEDICATIONS Gall Stone Stabilizing Agents Ursodiol ACTIGALL Medications For The Urinary Tract Alfuzosin ER UROXATRAL Bethanechol URECHOLINE Doxazosin Mesylate CARDURA Methenamine/Methylene Blue Atropine URISED Finasteride 5mg tablet PROSCAR Nitrofurantoin FURADANTIN Nitrofurantoin/Nitrofurantoin Macrocrystals MACROBID Nitrofurantoin Macrocrystals MACRODANTIN Oxybutynin IR DITROPAN Oxybutynin XL DITROPAN XL Oxybutynin, Transdermal OXYTROL Phenazopyridine PYRIDIUM PA: Tried and failed or contraindicated to alphaadrenergic antagonists 5mg, 10mg, 25mg formulary PA: 50mg strength only Propecia (finasteride 1mg) non-formulary PA: Tried and failed OR contraindications to at least one preferred alternative, including oxybutynin immediate release BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 15 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Pentosan ELMIRON Prazosin MINIPRESS Solifenacin VESICARE Tamsulosin FLOMAX Terazosin HYTRIN Tolterodine DETROL, DETROL LA Trimethoprim TRIMPEX NOTES PA: Tried and failed OR contraindications to oxybutynin immediate release PA: Tried and failed immediate release (IR) oxybutynin. Claim pays on-line contingent upon trial of IR oxybutynin. PA required if criteria not met. Misc Medications: (Phosphodiesterase Inhibitors) *ED Medications are carved-out for Medi-Cal members & not covered for treatment of ED for BHC recipients PA: Questionnaire/PA form must be completed. Sildenafil VIAGRA (Form available on-line: www.CCHealth.org or call CCHP (925) 313-6008. Limit: 3 tablets/30 days. PA Tadalafil CIALIS Vardenafil LEVITRA Alprostadil MUSE, CAVERJECT PA PA: Questionnaire/PA form must be completed. (Form available on-line: www.CCHealth.org or call CCHP (925) 313-6008. HEART AND BLOOD PRESSURE MEDICATIONS Angiotensin Converting Enzyme Inhibitors Benazepril LOTENSIN Captopril CAPOTEN Enalapril VASOTEC Enalapril/HCTZ VASARETIC Fosinopril MONOPRIL Lisinopril ZESTRIL , PRINIVIL Moexipril UNIVASC Perindopril ACEON Quinapril ACCUPRIL Ramipril ALTACE Trandolapril MAVIK PA: Tried and failed OR contraindications to preferred alternatives PA: Tried and failed OR contraindications to preferred alternatives PA: Tried and failed OR contraindications to Lisinopril or enalapril PA: Tried and failed OR contraindications to Lisinopril or enalapril PA: Tried and failed OR contraindications to Lisinopril or enalapril PA: Tried and failed OR contraindications to Lisinopril or enalapril Angiotensin II Receptor Blockers Losartan COZAAR Olmesartan BENICAR Telmisartan MICARDIS PA: Tried and failed OR contraindications to formulary angiotensin converting enzyme inhibitors or losartan.Claim pays at point-of-sale when PA criteria met. PA: Tried and failed OR contraindications to formulary angiotensin converting enzyme inhibitors or losartan. Claim pays at point-of-sale when PA criteria met. Angiotensin Converting Enzyme Inhibitor/Diuretic Combinations Benazepril/HCTZ LOTENSIN HCT Lisinopril/HCTZ ZESTORETIC, PRINZIDE Angiotensin II Receptor Blocker/Diuretic Combinations Losartan/HCTZ HYZAAR Olmesartan/HCTZ BENICAR HCT PA: Tried and failed OR contraindications to BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 16 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME Telmisartan/HCTZ BRAND NAME MICARDIS HCT NOTES formulary angiotensin converting enzyme inhibitors or losartan or losartan/HCTZ. Claim pays at point-of-sale when PA criteria met. PA: Tried and failed OR contraindications to formulary angiotensin converting enzyme inhibitors or losartan or losartan/HCTZ. Claim pays at point-of-sale when PA criteria met. Antiarrhythmics Amiodarone CORDARONE Digoxin LANOXIN Disopyramide NORPACE, NORPACE CR Dofetilide TIKOSYN Dronedarone MULTAQ Flecainide TAMBOCOR Mexitiline MEXITIL Procainamide PRONESTYL, PRONESTYL SR Propafenone RYTHMOL, RYTHMOL SR Quinidine Gluconate QUINAGLUTE Quinidine Sulfate QUINIDINE SULFATE Sotalol BETAPACE Sotalol AF BETAPACE AF PA: Prescribed by cardiologist Beta Blockers Acebutolol SECTRAL Atenolol TENORMIN Bisoprolol ZEBETA Carvedilol COREG Labetalol TRANDATE, NORMODYNE Metoprolol Succinate TOPROL XL Metoprolol Tartrate LOPRESSOR Nadolol CORGARD Pindolol VISKEN Propranolol INDERAL Propanolol LA INDERAL LA PA: Coreg CR PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Tried and failed OR contraindications to at least one preferred alternative. Beta Blocker/Diuretic Combinations Atenolol/Chlorthalidone TENORETIC Bisoprolol/HCTZ ZIAC Propanolol/HCTZ INDERIDE Calcium Channel Blockers Amlodipine NORVASC Amlodipine-Benazepril LOTREL Diltiazem CARDIZEM, CARTIA XT Diltiazem CR DILACOR XR, CARDIZEM CD Diltiazem ER, Diltiazem SR CARDIZEM LA, CARDIZEM SR, DILT XR Felodipine PLENDIL Isradipine DYNACIRC Isradipine CR DYNACIRC CR PA: : Tried and failed OR contraindications to the two products separately AND at least one preferred alternative PA: Required for Tiazac equivalent. PA: Tried and failed OR contraindications to at least one preferred alternative PA: Required for Dynacirc CR. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 17 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES PA: Tried and failed OR contraindications to at least one preferred alternative. Nicardipine CARDENE Nicardipine SR CARDENE SR Nifedipine ADALAT, PROCARDIA Nifedipine SR, ER ADALAT CC, PROCARDIA XL, AFEDITAB, NIFEDICAL XL, NIFEDIAC CC Nimodipine NIMOTOP PA: Tried and failed OR contraindications to at least one preferred alternative Nisoldipine SULAR PA: Tried and failed OR contraindications to at least one preferred alternative Verapamil CALAN Verapamil SR CALAN SR, ISOPTIN SR PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Nifedipine extended release (generic Adalat CC or Procardia XL) is on formulary. Prior authorization required for immediate release formulation. Carbonic Anhydrase Inhibitors Acetazolamide DIAMOX, DIAMOX SEQUELS Centrally Acting Antihypertensives Clonidine CATAPRES Guanfacine TENEX Guanfacine ER INTUNIV Methyldopa ALDOMET Minoxidil tablets LONITEN Reserpine SERPASIL PA: Tried and failed OR contraindications to preferred alternatives including guanfacine IR Topical solution is a plan exclusion. Cholesterol Lowering Drugs Lovastatin MEVACOR Pravastatin PRAVACHOL Simvastatin ZOCOR Atorvastatin LIPITOR Cholestyramine QUESTRAN Cholestyramine Light QUESTRAN LIGHT Colestipol COLESTID Ezetimibe ZETIA Fenofibrate LOFIBRA Fluvastatin LESCOL Gemfibrozil LOPID Niacin NIACIN B: OTC Niacin formulations. PA: Niaspan Niacin/Lovastatin ADVICOR PA: Tried and failed OR contraindications to at least one preferred alternative Nicotinic Acid SR SLO-NIACIN Simvastatin/Niacin SIMCOR Rosuvastatin CRESTOR ST: simvastatin or atorvastatin or lovastatin trial, or concurrent ritonavir therapy (due to interactions with other statins) PA: Tried and failed maximum doses of formulary statins Formulary if patient trialed any statin or gemfibrozil 54mg, 160mg tabs 67mg, 134mg, 200mg caps PA: Trial/failure OR contraindication to pravastatin, simvastatin, and atorvastatin PA PA: Tried and failed OR contraindications to at least one preferred alternative Diuretics Amiloride MIDAMOR BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 18 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Amiloride/HCTZ MODURETIC Bumetanide BUMEX Chlorthalidone HYGROTON Eplerenone INSPRA Furosemide LASIX Hydrochlorothiazide HYDRODIURIL Indapamide LOZOL Metolazone ZAROXOLYN Spironolactone ALDACTONE Spironolactone/HCTZ ALDACTAZIDE Triamterene DYRENIUM Triamterene/HCTZ DYAZIDE, MAXZIDE Torsemide DEMADEX NOTES PA: Tried and failed OR contraindications to Spironolactone PA MEDICATIONS AFFECTING THE BLOOD Anticoagulants PA Dabigatran PRADAXA Enoxaparin LOVENOX QL: 14 syringes twice per 6 months Rivaroxaban Warfarin XARELTO COUMADIN QL: 21 tablets of any strength per year Hematopoetic Erythropoietin (Epoetin Alfa) EPOGEN, PROCRIT Darbopoetin ARANESP PA: Anemia CRF zidovudine-treated patients chemotherapy-treated patients Appropriate quantity approved for 3 months at a time if patient has one of the above Diagnosis, and a) Hemoglobin<10g/dL OR HCT<30% (or rolling 90 day average HCT<36%) and b) Patient on iron or iron studies labs are nml (i.e., has adequate iron stores) Transferrin saturation should be at least 20%; ferritin at least 100 ng/ml. Antiplatelets Clopidogrel PLAVIX Dipyridamole PERSANTINE Dipyridamole/Aspirin AGGRENOX Aspirin BAYER, ST. JOSEPH Anagrelide AGRYLIN Ticagrelor BRILINTA Misc. Cardiovascular Drugs Cilostazol Pentoxifylline PA: Tried and failed or contraindications to preferred alternatives, including clopidogrel PLETAL TRENTAL Medication For Angina Hydralazine APRESOLINE Isosorbide Dinitrate ISORDIL TITRADOSE Isosorbide Dinitrate SR DILATRATE-SR, ISOCHRON Isosorbide Mononitrate IMDUR, ISMO, MONOKET Nitroglycerin NITROSTAT Nitroglycerin (ointment) NITROL-BID (Ointment) BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 19 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Nitroglycerin (patch) NITRO-DUR (Patch) Nitroglycerin SR (Capsule) NITRO-BID (Capsule) Ranolazine ER RANEXA NOTES PA: : Tried and failed OR contraindications to at least two preferred alternatives Vasodilators Ambrisentan LETAIRIS Bosentan TRACLEER Doxazosin CARDURA Hydralazine APRESOLINE Iloprost VENTAVIS Minoxidil LONITEN Prazosin MINIPRESS Terazosin HYTRIN Treprostinil TYVASO PA: : Tried and failed OR contraindications to at least one preferred alternative PA: : Tried and failed OR contraindications to at least one preferred alternative PA PA Vasopressor Epinephrine EPIPEN, EPIPEN JR MEDICATIONS FOR EYES, EAR, NOSE & THROAT Anti-Inflammatory Medications For The Eyes Dexamethasone DECADRON, Fluorometholone FLAREX, FML LIQUIFILM, FLUR-OP, FML FORTE Ketorolac OPHTH ACULAR, ACULAR LS, ACULAR PF, Prednisolone acetate ECONOPRED PLUS, PRED FORTE, PRED-MILD, Prednisolone sodium AK-PRED, INFLAMASE FORTE, GLAUCOMA MEDICATIONS Beta Blockers Betaxolol BETOPTIC, BETOPTIC S Metipranolol OPTIPRANOLOL Levobunolol AKBETA , BETAGAN Timolol Hemihydrate BETIMOL Timolol Maleate TIMOPTIC, TIMOPTIC XE PA: Tried and failed OR contraindications to at least one preferred alternative. Indicated for treatment of ocular HTN and chronic openangle glaucoma. May be used as an add-on therapy. Alpha-2 Adrenergic Agonist Brimonidine ALPHAGAN P Brimonidine Tartrate ALPHAGAN PA: Tried and failed OR Contraindications to at least one preferred alternative.. Carbonic Anhydrase Inhibitors Acetazolamide DIAMOX, DIAMOX SEQUELS Brinzolamide AZOPT Dorzolamide TRUSOPT Dorzolamide/timolol XE COSOPT XE Methazolamide NEPTAZANE PA: Tried and failed OR contraindications to at least one preferred alternative. Elevated IOP in patients with ocular HTN or open-angle glaucoma. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 20 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Prostaglandins PA: Tried and failed OR contraindications to at least one preferred alternative. Bimatoprost LUMIGAN Latanoprost XALATAN Travaprost TRAVATAN, TRAVATAN Z PA: Tried and failed OR contraindications to at least one preferred alternative. OPHTHALMIC MEDICATIONS Other Treatments for Glaucoma Carbachol ISOPTO-CARBACHOL Dipivefrin AKPRO, PROPINE, Echothiophate Iodide PHOSPHOLINE IODIDE Pilocarpine ISOPTO CARPINE, PILOCAR, PILOPINE HS Ophthalmic Anti-infectives Bacitracin optthalmic AK-TRACIN Ciprofloxacin CILOXAN Erythromycin ILOTYCIN OPHTH OINT Gatifloxacin ZYMAR Gentamicin GENOPTIC. GENOPTIC S.O.P. Moxifloxacin VIGAMOX Ofloxacin OCUFLOX Sulfacetamide BLEPH 10, SODIUM SULAMYD Tobramycin TOBREX Trifluridine VIROPTIC PA: Tried and failed OR contraindications to at least two preferred alternatives PA: Ophthalmologists exempt Ophthalmic Anti-infective Combinations Bacitracin/ Polymyxin B Sultate POLYSPORIN OINTMENT Gentamicin/Prednisolone Neomycin Sultate, Polymyxin B Sulfate, Bacitracin Neomycin Sulfate/Polymyxin B Sulfate/Bacitracin/ Hydrocortisone Neomycin Sulfate/Polymyxin B Sulfate/Gramicidin Neomycin Sulfate, Polymyxin B Sulfate, Dexamethasone Neomycin Sulfate/Polymyxin B Sulfate/Prednisolone Neomy, Polym, Bac PRED-G, PRED-G SOP Neo/Poly/Prednisolone Neomycin Sulfate,Polymyxin B Sulfate,Hydrocortizone Polymyxin B Sulfate/TMP POLY-PRED Sulfacetamide/Prednisolone (ointment) BLEPHAMIDE, BLEPHAMIDE S.O.P. Tobramycin Sulfate/Dexamethasone TOBRADEX NEOSPORIN OPHTH OINT CORTISPORIN OPHTH OINTMENT NEOSPORIN OPHTH SOLUTION MAXITROL OINTMENT & SUSP POLY-PRED NEOSPORIN OPHTH OINT CORTISPORIN OPHTH SUSP POLYTRIM Ophthalmic Anti-Allergic Medications Azelastine HCl OPTIVAR Cromolyn CROLOM Epinastine HCl PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindications to Alaway OTC or Zaditor OTC AND THEN Pataday or Patanol. For members without OTC coverage, tried and failed OR contraindications to Crolom AND THEN Pataday or Patanol. ELESTAT BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 21 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Emedastine Difumarate EMADINE Ketotifen furmarate ALAWAY OTC, ZADITOR OTC Lodoxamide ALOMIDE Naphazoline HCl NAPHCON Naphazoline HCl/Pheniramine Maleate NAPHCON A Nedrocromil ALOCRIL Olopatadine PATADAY Olopatadine HCl PATANOL Pemirolast ALAMAST NOTES QL: Quantity limit of 1 bottle/30 days. PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindications to Alaway OTC or Zaditor OTC AND THEN Pataday or Patanol. For members without OTC coverage, tried and failed OR contraindications to Crolom AND THEN Pataday or Patanol. QL: Quantity limit of 1 bottle/30 days. B PA: Approvable for diagnosis vernal conjunctivitis, vernal keratitis or vernal kerato-conjunctivitis. QL: Quantity limit of 1 bottle / 30days B QL: Quantity limit of 1 bottle / 30days B QL: Quantity limit of 1 bottle / 30days PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindications to Alaway OTC or Zaditor OTC AND THEN Pataday or Patanol. For members without OTC coverage, tried and failed OR contraindications to Crolom AND THEN Pataday or Patanol. QL: Quantity limit of 1 bottle/30 days. PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindication to Zaditor OTC, Alaway OTC, or Crolom. QL: Quantity limit of 1 bottle/30 days. PA: Approvable for diagnosis vernal conjunctivitis, vernal keratitis or vernal kerato-conjunctivitis. Approvable for diagnosis of allergic conjunctivitis if tried and failed or contraindication to Zaditor OTC, Alaway (OTC), or Crolom. QL: Quantity limit of 1 bottle / 30days PA: Approvable for diagnosis of allergic conjunctivitis if tried and failed OR contraindications to Alaway OTC or Zaditor OTC AND THEN Pataday or Patanol. For members without OTC coverage, tried and failed OR contraindications to Crolom AND THEN Pataday or Patanol. QL: Quantity limit of 1 bottle per 30 days. Other Ophthalmic Medications Atropine ISOPTOATROPINE Bevacizumab AVASTIN Cyclopentolate CYCLOGYL Homatropine ISOPTOHOMATROPINE QL: Quantity limit of 5mg per 30 days, for the treatment of diabetic macular edema. Scopolamine ISOPTOHYOSCINE Sodium Chloride Ophthalmic MURO-128 Tropicamide MYDRIACYL Tyloxapol with Benzalkonium Chloride ENUCLENE M M Medications For The Ear Acetic Acid/Aluminum Acetate DOMEBORO Acetic Acid/HC VOSOL HC Benzocaine/Antipyrine Otic AURALGAN Ciprofloxacin/dexamethasone CIPRODEX OTIC BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 22 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME Ciprofloxacin/hydrocortisone Neomycin Sulfate/Polymyxin B Sulfate/Buffers/ Hydrocortisone (Otic Suspension) Neomycin Sulfate/Polymyxin B Sulfate/ Hydrocortisone (Otic Solution) Neomycin Sulfate/Polymyxin B Sulfate/ Hydrocortisone (Otic Suspension) Ofloxacin (OTIC) BRAND NAME NOTES CIPRO HC PEDIOTIC OTIC SUSPENSION CORTISPORIN OTIC SOLN CORTISPORIN OTIC SUSPENSION FLOXIN Medications For The Nose Beclomethasone QNASL, BECONASE AQ Ciclesonide OMNARIS, ZETONNA Flunisolide Nasal Soln 0.025% NASAREL Fluticasone Propionate FLONASE Azelastine Nasal Spray ASTELIN Mometasone NASONEX Triamcinolone Acetonide NASACORT AQ (RX) Triamcinolone Acetonide NASACORT AQ (OTC) Ipratropium ATROVENT NASAL SPRAY PA: Tried and failed OR contraindications to Flonase AND Nasarel for 2 weeks therapy of each, followed by triamcinolone for 4 weeks of therapy PA: Tried and failed OR contraindications to Flonase AND Nasarel for 2 weeks therapy of each, followed by triamcinolone for 4 weeks of therapy PA: Tried and failed OR contraindications to Flonase AND Nasarel for 2 weeks therapy of each, followed by triamcinolone for 4 weeks of therapy PA: Tried and failed OR contraindications to Flonase AND Nasarel for 2 weeks therapy of each. Medications For The Throat And Mouth Chlorhexidine Gluconate (for the mouth) PERIDEX Lidocaine, viscous VISCOUS XYLOCAINE Cevimeline HCL EVOXAC Glycopyrrolate Solution CUVPOSA Triamcinolone 0.1% in Orabarol KENALOG in ORABASE PA MEDICATIONS THAT AFFECT THE NERVOUS SYSTEM Antianxiety Medications Alprazolam XANAX Buspirone BUSPAR, VANSPAR Chlordiazepoxide LIBRIUM Clorazepate TRANXENE SD, TRANXENE T Diazepam VALIUM Lorazepam ATIVAN Oxazepam SERAX PA: Tried and failed OR contraindications to at least one preferred alternative. Anticonvulsants Clonazepam CARBATROL, EQUETRO, TEGRETOL, TEGRETOL XR KLONOPIN, KLONOPIN WAFERS Clorazepate TRANXENE SD, TRANXENE T Diazepam VALIUM Divalproex sodium DEPAKOTE, DEPAKOTE ER, DEPAKOTE SPRINKLE Ethosuximide ZARONTIN Felbamate FELBATOL Pregabalin LYRICA Carbamazepine PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Pre-requisite therapy required. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 23 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Gabapentin NEURONTIN Lamotrigine LAMICTAL Levetiracetam KEPPRA Mephenytoin MESANTOIN Methosuximide CELONTIN KAPSEALS Oxcarbazepine TRILEPTAL Phenobarbital PHENOBARBITAL Phenytoin DILANTIN, PHENYTEK Primidone MYSOLINE Rufinamide BANZEL Tiagabine GABITRIL Topiramate TOPAMAX Trimethadione TRIDIONE Valproic acid DEPAKENE Zonisamide ZONEGRAN NOTES PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Tried and failed OR contraindications to at least one preferred alternative. PA: Tried and failed OR contraindications to at least one preferred alternative and a Dx of LennoxGastaut syndrome. PA: Tried and failed OR contraindications to at least one preferred alternative. Used as an anticonvulsant. Fibromyalgia Milnacipran Hydrochloride PA: Fibromyalgia Agent. Requires a trial and failure or contraindication to gabapentin for a minimum of 30 days of therapy in the last 120 days at a minimum dose of 1800mg daily. SAVELLA Antidepressants Amitriptyline ELAVIL Bupropion WELLBUTRIN Bupropion SR WELLBUTRIN SR Bupropion XL WELLBUTRIN XL Citalopram Hydrobromide CELEXA Clomipramine ANAFRANIL Desipramine NORPRAMIN Doxepin SINEQUAN Duloxetine CYMBALTA Escitalopram LEXAPRO Fluoxetine PROZAC Fluvoxamine LUVOX Imipramine TOFRANIL Imipramine TOFRANIL PM Maprotiline LUDIOMIL Mirtazapine REMERON Mirtazapine ODT REMERON SolTab Nefazodone SERZONE Nortriptyline PAMELOR Paroxetine PAXIL Paroxetine PAXIL CR ST: For insomnia must have tried and failed or contraindications to zolpidem or zaleplon PA: Tried and failed OR contraindications to preferred alternatives 20mg tablets are non-preferred, use 20mg capsule PA: For Prozac 90mg weekly tablet. PA: Tried and failed OR Contraindications to Tofranil. dfdPA: Tried and failed OR contraindications to at least one preferred alternative PA: Tried and failed OR contraindications to at least one preferred alternative, including Paxil. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 24 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Protriptyline Sertraline VIVACTIL ZOLOFT Trazodone DESYREL Venlafaxine tablets EFFEXOR Venlafaxine XR capsules EFFEXOR XR CAPSULES Venlafaxine XR tablets EFFEXOR XR TABLETS NOTES PA: Tried and failed OR contraindications to at least one preferred alternative. PA Anti-Mania *Medications are carved-out for Medi-Cal members Lithium Carbonate ESKALITH, LITHONATE Lithium Carbonate Sustained Release ESKALITH CR Lithium Citrate LITHIUM Anti-Psychotic Medications *Anti-Psychotic Medications are carved-out for Medi-Cal members Aripiprazole ABILIFY Asenapine SAPHRIS Chlorpromazine THORAZINE Clozapine Fluphenazine Hydrochloride, Fluphenazine Decanoate, Enanthate Haloperidol Decanoate, Lactate CLOZARIL Loxapine LOXITANE Molindone MOBAN Olanzapine ZYPREXA Olanzapine ODT ZYPREXA ZYDIS Perphenazine TRILAFON Pimozide ORAP Quetiapine SEROQUEL, SEROQUEL XR Risperidone RISPERDAL, RISPERDAL M-TAB Risperidone IM injection CONSTA Thioridazine MELLARIL Thiothixene NAVANE Trifluoperazine STELAZINE Ziprasidone GEODON PA : Tried and failed OR contraindications to at least three atypical antipsychotics PA: : Tried and failed OR contraindications to at least two atypical antipsychotics PROLIXIN HALDOL PA: Tried and failed OR contraindications to at least one preferred alternative. Indicated for treatment of Psychosis. PA PA ALCOHOL CESSATION MEDICATIONS Disulfiram ANTABUSE SMOKING CESSATION MEDICATIONS Bupropion Sustained Release WELLBUTRIN SR Nicotine (Transdermal) NICODERM CQ (TRANSDERMAL) Varenicline CHANTIX Nicotine Gum NICORETTE Nicotine Lozenges NICORETTE 150mg BID QL: 28 patches/28 days each fill Maximum six months treatment per year Maximum six months treatment per year QL: 340 pieces every 30 days Maximum six months treatment per year QL: 324 pieces every 30 days Maximum six months treatment per year MISCELLANEOUS MEDICATIONS AFFECTING THE BRAIN Alzheimer’s Medications Donepezil PA: 23mg tablet, consider 2x10mg tab ARICEPT BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 25 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Donepezil ODT ARICEPT ODT Galantamine RAZADYNE ER NOTES PA: Tried and failed OR contraindications to preferred alternatives Myasthenia Gravis Medications Guanidine GUANIDINE Neostigmine PROSTIGMIN Pyridostigmine MESTINON Multiple Sclerosis Medications Dalfampridine AMPYRA PA Dimethyl fumarate Tecfidera PA Fingolimod Gilenya PA Amantadine SYMMETREL Bill fee-for-service Medi-Cal for MCAL members Benztropine Mesylate COGENTIN Bill fee-for-service Medi-Cal for MCAL members Bromocriptine PARLODEL Carbidopa/levodopa SINEMET Carbidopa/levodopa CR SINEMET CR Levodopa DOPAR Ropinirole REQUIP Selegiline ELDEPRYL Trihexiphenidyl ARTANE Parkinson’s Medications On Formulary PA: Emsam formulation only Bill fee-for-service Medi-Cal for MCAL members Sedative/Hypnotics Flurazepam DALMANE Hydroxyzine HCL ATARAX Hydroxyzine Pamoate VISTARIL Eszopiclone LUNESTA Ramelteon ROZEREM Temazepam RESTORIL Triazolam HALCION Zaleplon SONATA ST: Trial and failure of zolpidem Zolpidem AMBIEN Zolpidem CR AMBIEN CR PA: Female new starts limited to 5mg QHS PA: Tried and failed at least 14-days of (1) zolpidem AND (2) zaleplon PA: Tried and failed at least 14-days of (1) zolpidem AND (2) zaleplon PA: Tried and failed at least 14-days of (1) zolpidem AND (2) zaleplon PA: 7.5 mg and 22.5mg capsules Stimulants Amphetamine & dextroamphetamine mixture ADDERALL, ADDERALL XR Formulary for patients <18 years old. PA: Required for patients >18 years old or >1 capsule per day for Adderall XR. Dexmethylphenidate FOCALIN PA: Tried and failed OR contraindications to at least two preferred alternatives Dextroamphetamine DEXEDRINE Formulary for patients <18 years old. PA: Required for patients > 18 years old. Lisdexamfetamine VYVANSE Methylphenidate RITALIN Methylphenidate Extended Release RITALIN SR, METHADATE ER, CONCERTA, RITALIN LA PA: Tried and failed OR contraindications to at least two preferred alternatives Formulary for patients <18 years old. PA: Required for patients > 18 years old. Formulary for patients <18 years old. PA: Required for patients >18 years old or >1 tablet per day for Concerta, Ritalin LA. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 26 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Methylphenidate, Transdermal DAYTRANA Modafinil PROVIGIL NOTES Concerta 36mg limit: 2 tablets per day. PA: Tried and failed OR contraindications to at least three preferred alternatives PA: Tried and failed OR contraindications to at least two preferred alternatives. Indicated for treatment of narcolepsy. MEDICATIONS TO TREAT INFECTIONS Antibiotics Amoxicillin Amoxicillin/Clarithromycin/Lansoprazole AMOXIL, TRIMOX AUGMENTIN, AUGMENTIN ES, AUGMENTIN XR PREVPAC Ampicillin PRINCIPEN Azithromycin ZITHROMAX Cefaclor CECLOR Cefdinir OMNICEF Cefixime SUPRAX C1: Otitis Media (O.M.) in children < 8 y.o. Cefpodoxime VANTIN QL: Limit 2 tabs per fill & 2 fills per 180 days. Cefuroxime CEFTIN Cephalexin KEFLEX Ciprofloxacin CIPRO Clarithromycin BIAXIN Clindamycin CLEOCIN Demeclocycline DECLOMYCIN Dicloxacillin DYNAPEN Doxycycline hyclate tab VIBRAMYCIN, DORYX Doxycycline monohydrate tab ADOXA Eryth Es,Sulf Oral Susp PEDIAZOLE Erythromycin Base ERY-TAB (Enteric Coated) Erythromycin Ethylsuccinate EES Erythromycin Stearate ERYTHROCIN Levofloxacin LEVAQUIN QL: 30 tablets per month Linezolid ZYVOX PA: Pre-requisite therapy required. Minocycline capsules MINOCIN Tablets non-formulary. Moxifloxacin AVELOX QL: 21 tabs twice per 12 months Neomycin MYCIFRADIN Ofloxacin FLOXIN Penicillin VK VEETIDS Rifaximin XIFAXAN Sulfadiazine SULFADIAZINE Sulfisoxazole GANTRISIN Tetracycline SUMYCIN Trimethoprim/ Sulfamethoxazole BACTRIM, BACTRIM DS, SEPTRA DS Vancomycin - oral VANCOCIN Amoxicillin/potassium clavulanate QL: Limit duration of therapy to 14 days, & 2 fills/90 days PA: Tried and failed separate agents QL: 2 fills/90 days. Formulary: Capsules & Suspension PA: Chewable tablets & SR12H. Formulary: 250mg & 500mg Capsules & Suspension. PA: Tablets & 750mg Capsules. Immediate-release tablets are formulary PA: Suspension & XR Tablets. Formulary: 250mg & 500mg tablets PA: Oral Suspension 125mg/5 mL and 250mg/5mL PA: Tried and failed OR contraindications to at least one preferred alternative. Used for treatment of SIADH. PA: Tried and failed OR contraindications to at least one preferred alternative. One dose for GYN indications is covered without PA. PA PA: Tried and failed OR contraindications to at BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 27 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES least one preferred alternative. Indicated for: Pseudomembranous colitis. Restricted to pts who have failed Metronidazole therapy. Bacterial Vaccines VIVOTIF BERNA QL: 4 capsules per dispensing Atovaquone/Proguanil MALARONE PA: Use for prophylaxis of malaria in regions where chloroquine resistance exists. Chloroquine ARALEN Mefloquine LARIAM Primaquine Phosphate PRIMAQUINE Pyrimethamine DARAPRIM Primethamine/ Sufadoxine FANSIDAR Quinine sultfate QUALAQUIN Typhoid Vaccine Antimalarials PA: For treatment of Malaria only Anti-Parasitic Medications Iodoquinol YODOXIN Metronidazole FLAGYL Antituberculosis Medications Ethambutol MYAMBUTOL Ethionamide TRECATOR-SC Pyrazinamide PYRAZINAMIDE Isoniazid INH Rif/INH RIFAMATE Rif/INH/PZA RIFATER Rifabutin MYCOBUTIN Rifampin RIFADIN ANTIRETROVIRALS All oral FDA-approved HIV agents are eligible for coverage. *The following HIV Medications are carved-out for Medi-Cal members (billed to State Medi-Cal): Abacavir/Lamivudine(Ziagen), Abacavir(Epzicom), Abacavir/Lamivudine/Zidovudine(Trizivir), Amprenavir(Agenerase), Atazanavir(Reyataz), Darunavir(Prezista), Delavirdine(Rescriptor), Dolutegravir (Tivicay), Efavirenz(Sustiva), Efavirenz/Emtricitabine/Tenofovir(Atripla), Saquinavir, Tenofovir/Emtricitabine, Darunavir/Cobicistat (Prezcobix), Abacavir/Lamivudine/Dolutegravir (Triumeq), Zidovudine/Lamivudine/Abacavir(Trizivir), Elvitegravir/Cobicistat/Emtricitabine/Tenofovir(Stribild), Emtricitabine (Emtriva), Cobicistat (Tybost), Elvitegravir (Vitekta), Etravirine, Rilpivirine, Emtricitabine/Tenofovir(Truvada), Enfuvirtide(Fuzeon), Fosamprenavir(Lexiva), Indinavir(Crixivan), Lamivudine(Epivir or 3TC), Tenofovir(Viread), Lamivudine/Zidovudine(Combivir), Lopinavir/Ritonavir(Kaletra), Maraviroc(Selzentry), Nelfinavir(Viracept), Nevirapine(Viramune), Raltegravir(Isentress), Ritonavir(Norvir), Saquinavir(Invirase), Stavudine(Zerit), Emtricitabine/Rilpivirine/Tenofovir, Atazanavir/Cobicistat (Evotaz), Tipranavir(Aptivus), Zidovudine/Lamivudine(Combivir). *Antiretroviral Medications are limited to a 30-day supply per fill. *Please note lamivudine is also available as brand name Epivir HBV, which is used for the treatment of hepatitis and not HIV. Anti-HIV Medications, CCR5 Co-Receptor Antagonists Maraviroc SELZENTRY PA: Pre-requisite therapy required FUZEON PA: Pre-requisite therapy required. Anti-HIV Medications, Fusion Inhibitors Enfuvirtide Anti-HIV Medications, Integrase Strand Transfer Inhibitors Dolutegravir TIVICAY Raltegravir ISENTRESS Anti-HIV Medications, Non-Nucleoside Reverse Transcriptase Inhibitors Delavirdine RESCRIPTOR Efavirenz SUSTIVA Etravirine INTELENCE PA: Pre-requisite therapy required BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 28 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Nevirapine VIRAMUNE Rilpivirine EDURANT NOTES Anti-HIV Medications, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors and Single-Tablet Regimens Abacavir ZIAGEN Abacavir/Lamivudine EPZICOM Abacavir/Zidovudine TRIZIVIR Abacavir/Lamivudine/Dolutegravir TRIUMEQ Atazanavir/Cobicistat EVOTAZ Darunavir/Cobicistat PREZCOBIX Didanosine VIDEX EC, VIDEX PEDIATRIC Efavirenz/Emtricitabine/Tenofovir ATRIPLA Elvitegravir/Cobicistat/Emtricitabine/Tenofovir STRIBILD Emtricitabine/Rilpivirine/Tenofovir COMPLERA Emtricitabine EMTRIVA Emtricitabine/Tenofovir TRUVADA Lamivudine EPIVIR Lamivudine/Zidovudine COMBIVIR Stavudine ZERIT Tenofovir VIREAD Zidovudine RETROVIR Anti-HIV Medications, Protease Inhibitors Atazanavir REYATAZ Darunavir PREZISTA Fosamprenavir LEXIVA Indinavir CRIXIVAN Lopinavir/Ritonavir KALETRA Nelfinavir VIRACEPT Ritonavir NORVIR Saquinavir INVIRASE Tipranavir APTIVUS Misc. Antiviral Medications PA: ointment and cream topical forms Acyclovir ZOVIRAX Valacyclovir VALTREX Docosanol ABREVA Oseltamvir TAMIFLU Zanamivir RELENZA QL: 2 grams per fill QL: Suspension - 120mL per 6 months. Capsules - 10 per 6 months. QL: 20 units (1 package) per 6 months. Zoster-vaccine, live attenuated ZOSTAVAX AL: must be 60 years old, 1 shot per lifetime Oral Antifungals Clotrimazole MYCELEX TROCHE Fluconazole DIFLUCAN Flucytosine ANCOBON Griseofulvin Microsize GRIFULVIN Griseofulvin GRISPEG BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 29 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES PA: Restricted to use in immunocompromised pts, treatment of documented Aspergillosis, tried and failure of amphotericin B, or tried and failure to a preferred antifungal. Itraconazole SPORANOX Nystatin MYCOSTATIN Terbinafine LAMISIL Voriconazole VFEND PA Atovaquone MEPRON PA: Diagnosis of PCP, failure of TMP/SMX. Dapsone DAPSONE Neomycin MYCIFARDIN, NEO-FRADIN Other Oral Anti-Infective Medications Vaginal Anti-Infectives Acetic Acid, vag ACID JELLY, VAG GEL Clindamycin Vaginal Cream CLEOCIN VAGINAL CREAM Clotrimazole GYNE-LOTRIMIN, GYNE-LOTRIMIN 3 Metronidazole METROGEL VAGINAL Miconazole Nitrate MONISTAT-7 Nystatin NYSTATIN Terconazole TERAZOL-3, TERAZOL-7 VAGINAL CREAM B B IMMUNOLOGICAL AGENTS PA: Required except when prescribed by exempt physicians. Subject to tablet splitting regardless of prescribing physician. PA: Tried and failed OR contraindications to preferred alternatives PA: Pre-requisite therapy required. PA: Tried and failed OR contraindications to at least one preferred alternative. GI consult (including CCRMC GI specialists), is mandatory. PA PA: Tried and failed OR contraindications to at least one preferred alternative. GI consult (including CCRMC GI specialists), is mandatory. Entecavir BARACLUDE Famciclovir FAMVIR Interferon Alfa-2B INTRON-A Pegylated Interferon Alfa-2A PEGASYS Lamivudine EPIVIR HBV Pegylated Interferon Alfa-2B PEG-INTRON Ribavirin COPEGUS , REBETOL Valganciclovir VALCYTE PA: Tried and failed OR contraindications to at least one preferred alternative. CMV retinitis/AID-Ophthamology consult required. ANALGESICS/PAIN/RHEUMATIC MEDICATIONS B Acetaminophen TYLENOL Aspirin BAYER Hyaluronic Acid HYALGAN, SUPARTZ, ORTHOVISC, MONOVISC PA: Tried and failed OR contraindications to preferred alternatives Celecoxib CELEBREX PA: Restricted to one of the following criteria: geriatrics (age>65) OR patients with history of GI bleed OR tried and failed 3 formulary NSAIDs from 3 different NSAID categories OR concurrent anticoagulant, antiplatelet or corticosteroid therapy Diclofenac CATAFLAM, VOLTAREN Etodolac LODINE, LODINE XL QL: Lodine limit #360/90 days, Lodine XL limit #90/90 days Fenoprofen NALFON PA: Tried and failed OR contraindications to Anti-Inflammatory Medications (NSAIDS) BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 30 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Flurbiprofen ANSAID Ibuprofen MOTRIN Indomethacin INDOCIN Ketorolac TORADOL Ketoprofen ORUDIS Meclofenamate MECLOMEN Meloxicam MOBIC Nabumetone RELAFEN Naproxen NAPROSYN Oxaprozin DAYPRO Piroxicam FELDENE Salsalate DISALCID Sulindac CLINORIL Tolmetin TOLECTIN NOTES preferred alternatives PA: Tried and failed OR contraindications to preferred alternatives Motrin Rx covered for all CCHP membership. B 100mg/5ml suspension only. PA: Tried and failed OR contraindications to at least one preferred alternative. Not to exceed 5 days. PA: Tried and failed OR contraindications to at least one preferred alternative. Tried and failed OR contraindications to at least one preferred alternative QL: Max #270/90 days PA: Tried and failed OR contraindications to at least one preferred alternative. Anti-Rheumatic Medications Auranofin RIDAURA Golimumab SIMPONI Hydroxychlorquine PLAQUENIL Leflunomide ARAVA Methotrexate METHOTREXATE, MTX Penicillamine CUPRIMIN, DEPEN PA:Tried and failed OR contraindications to preferred alternatives Migraine Medications Ergotamine/caffeine CAFERGOT Almotriptan AXERT Eletriptan RELPAX Frovatriptan FROVA Naratriptan AMERGE Rizatriptan MAXALT Sumatriptan IMITREX Zolmitriptan ZOMIG, ZOMIG-ZMT PA: Tried and failed OR contraindications to two preferred agents sumatriptan, rizatriptan, naratriptan QL: 12 tablets/month with each PA. PA: Tried and failed OR contraindications to two preferred agents sumatriptan, rizatriptan, naratriptan QL: 12 tablets/month with each PA. ST: 2.5mg is formulary after failure of sumatriptan and rizatriptan. Naraptriptan 1mg is nonformulary QL: 12 tablets/month with each PA. ST: 2.5mg is formulary after failure of sumatriptan and rizatriptan. Naraptriptan 1mg is nonformulary QL: 12 tablets/month with each PA. 5mg and 10mg tablets, not dissolving tabs PA: Maxalt-MLT Oral tablets covered. PA: nasal spray and injection PA: Tried and failed OR contraindications to two preferred agents sumatriptan, rizatriptan, naratriptan QL: 12 tablets/month with each PA. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 31 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Analgesics Diclofenac/Misoprostol ARTHROTEC Lidocaine LIDODERM Tramadol ULTRAM Tramadol/APAP ULTRACET PA: Tried and failed OR contraindications to preferred alternatives. Separate agents are formulary. PA: Tried and failed OR contraindications to preferred alternatives Narcotic Analgesics Maximum Acetaminophen daily dose = 4gm/day. Acetaminophen/codeine tabs TYLENOL #2, #3, #4 Acetaminophen/codeine Elixir TYLENOL w/CODEINE Acetaminophen/hydrocodone NORCO 325/5 Acetaminophen/hydrocodone NORCO 325/7.5 Acetaminophen/hydrocodone NORCO 325/10 Acetaminophen/hydrocodone VICODIN 500/5 Acetaminophen/hydrocodone VICODIN E.S. 750/7.5 PA Acetaminophen/hydrocodone LORCET 650/10 PA Acetaminophen/Hydrocodone LORCET PLUS 650/7.5 PA Acetaminophen/hydrocodone LORTAB 500/5 Acetaminophen/hydrocodone LORTAB 500/7.5 Acetaminophen/hydrocodone LORTAB 500/10 Acetaminophen/hydrocodone LORTAB ELIXIR 167/2.5 Butalbital/acetaminophen/caffeine ESGIC, ESGIC PLUS Butalbital/acetaminophen/caffeine FIORICET Butalbital/acetaminophen/caffeine/codeine FIORICET/ CODEINE Butalbital/aspirin/caffeine FIORINAL TABS Butalbital/aspirin/caffeine/codeine FIORINAL/CODEINE Codeine Tabs CODEINE SULFATE Codeine Tabs CODEINE PHOSPHATE Codeine/Aspirin EMPIRIN w/Codeine Dihydrocodeine/Aspirin/Caffeine Panlor DC, Panlor SS Fentanyl transdermal patch DURAGESIC (TRANSDERMAL PATCH) Hydromorphone DILAUDID Ibuprofen/hydrocodone VICOPROFEN Levorphanol LEVO-DROMORAN Meperidine DEMEROL PA: Tried and failed OR contraindications to at least one preferred alternative. Treatment of Tension headache/headache symptom complex. PA: Tried and failed OR contraindications to at least one preferred alternative. Treatment of migraine or tension headache. PA: Tried and failed or contraindications to Codeine Sulfate PA: : Tried and failed OR contraindications to at least one preferred alternative PA: Diagnosis of Terminal disease Tried and failed or contraindications to Methadone and Morphine SR. Limit: 1 patch every 3 days. PA: Tried and failed OR contraindications to at least one preferred alternative. Restricted to patients refractory to other pain management therapies. PA: Tried and failed OR contraindications to at least one preferred alternative. Restricted to patients refractory to other pain management therapies. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 32 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Methadone DOLOPHINE Morphine (Concentrate). ROXANOL(CONCENTRATE) Morphine (Solution & Tablet) MSIR (Solution & Tablet) Morphine (Suppositories) RMS (SUPPOSITORIES) Morphine SR MS CONTIN Oxycodone IR tablet OXY-IR, ROXICODONE PA: Consider morphine IR or hydromorphone Oxycodone SR OXYCONTIN PA: Tried and failed or contraindications to Methadone AND Morphine Sulfate. Oxycodone/acetaminophen 5/325 tablet PERCOCET 5/325 Oxycodone/acetaminophen 10/325 tablet PERCOCET 10/325 Oxycodone/acetaminophen 5/500 capsule TYLOX 5/500 Oxycodone/aspirin PERCODAN Pentazocine TALWIN Tapentadol NUCYNTA QL: 30 tablets per fill. PA: Tried and failed or contraindications to preferred alternatives. PA: Tried and failed OR contraindications to at least one preferred alternative. Restricted to pts refractory to other pain management therapies. PA: Tried and failed or contraindications to preferred alternatives. Opiate Antagonists Naltrexone REVIA Carved-out for Medi-Cal members Naloxone 1mg/ml Injector NALOXONE Carved-out for Medi-Cal members Skeletal Muscle Relaxants Baclofen LIORESAL Carisoprodol SOMA Chlorzoxazone PARAFON, PARAFON FORTE Cyclobenzaprine FLEXERIL Dantrolene Sodium DANTRIUM Diazepam VALIUM Metaxalone SKELAXIN Methocarbamol ROBAXIN Tizanidine ZANAFLEX QL: 30 tablets per month of 350mg PA: 250mg tablets PA: Tried and failed OR contraindications to at least one preferred alternative 2mg and 4mg tablets are formulary. Capsules are non-formulary. NUTRITION Electrolytes KCL (potassium chloride) GENERIC FORMULATIONS Potassium Iodide SSKI Potassium Acid Phosphate K-PHOS Vitamins and Minerals Calcitriol ROCALTROL Calcium Carbonate TITRALAC B Calcium Gluconate CALCIUM GLUCONATE M Calcium Lactate CALCIUM LACTATE M Electrolytes, Oral Maintenance PEDIALYTE Ergocalciferol (Vitamin D) VITAMIN D Ferrous Sulfate FEOSOL B B: OTC formulation A: Rx formulation B Ferrous Gluconate FERROUS GLUCONATE BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 33 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Folic Acid FOLIC ACID Covered: Prescription strength 1mg tablet only. Magnesium Oxide 400mg tablet MAG-OX 400 Iron Sucrose, Intravenous VENOFER Pyridoxine VITAMIN B-6 B PA: Labs indicating iron deficiency anemia; trial and failure of oral iron supplementation B Sodium Flouride (drops & tabs) LURIDE(DROPS&TABLETS) Vitamins A, D, C TRI-VI-SOL B Vitamins A, D, C with Iron TRI-VI-SOL w/IRON B Vitamin A, D, C, & Fluoride TRI-VI-FLOR Vitamin A, C, D, Fluoride, & Iron TRI-VI-FLOR w/IRON Vitamin B-12 CYANOCOBALAMIN Vitamin K MEPHYTON B Phosphate Binding Medications Calcium acetate PHOSLO Lanthanum FOSRENOL Sevelamer RENVELA TABLET, RENVELA PACKET PA: Tried and failed at least one preferred alternative PA: Maximum dose: 12,000mg/day. Maximum approvable quantity: Renagel 400mg tablets 30 per day. Renagel 800mg tablet 15 per day. Approvable if patient on dialysis AND tried and failed Phoslo (calcium acetate) or serum calcium >10mg/dL.or Ca*P > 55. Calcimimetic Cinacalcet PA: Tried and failed at least one phosphate binder SENSIPAR RESPIRATORY DRUGS Antihistamine/Decongestants Carbinoxamine/ Pseudoephdrine RONDEC, RONDEC DM Antihistamines Brompheniramine J-TAN PD, LODRANE, VAZOL B: available Rx only Brompheniramine/Phenylephrine DIMETAPP B Cetirizine ZYRTEC B Cetirizine/Pseudoephedrine ZYRTEC-D B Levocetirizine XYZAL B Chlorpheniramine CHLOR-TRIMETON, CHLORITON, CPM B: OTC formulations. Chlorpheniramine/Dextromethorphan SCOT-TUSSIN DM B Cyproheptadine PERIACTIN Desloratadine CLARINEX Doxylamine DOXYSOM Fexofenadine ALLEGRA Hydroxyzine HCl ATARAX Hydroxyzine Pamoate VISTARIL Loratadine CLARITIN B Loratadine and pseudoephedrine CLARITIN-D B Promethazine PHENERGAN Pseudoephedrine PEDIACARE, SUDAFED B Pseudoephedrine/Guaifenesin ROBITUSSIN PE B PA: Tried and failed OR contraindications to at least two preferred alternatives (i.e., OTC Claritin and OTC Zyrtec). B B PA: Tried and failed OR contraindications to at least two preferred alternatives (i.e., OTC Claritin and OTC Zyrtec). BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 34 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME Triprolidine BRAND NAME NOTES TRIPOHIST, ZYMINE, ZYMINE XR Cough Medications Carbinoxamine/Pseudoephdrine RONDEC Carbinoxamine/Pseudoephdrine/Dextromethorp RONDEC-DM han Dextromethorphan ROBITUSSIN MAXIMUM STRENGTH B Guaifenesin (Syrup) ROBITUSSIN (SYRUP) B Guaifenesin (Tablet) MUCINEX (TABLET) B Guaifenesin/Codeine ROBITUSSIN AC Guaifenesin/Dextromethorphan (Syrup) ROBITUSSIN DM (SYRUP) Guaifenesin/Dextromethorphan (Tablet) MUCINEX DM (TABLET) Guaifenesin/Dextromethorphan/Pseudoephedri ROBITUSSIN CF ne Guaifenesin/Pseudoephedrine (Tablet) MUCINEX D (TABLET) Hydrocodone/Chlorpheniramine TUSSIONEX Hydrocodone/Homatropine HYCODAN Promethazine/Dextromethorphan PHENERGAN w/DM Promethazine PHENERGAN Promethazine/Codeine PHENERGAN w/CODEINE Promethazine/Phenylephrine PHENERGAN VC Promethazine/Phenylephrine/Codeine PHENERGAN VC w/CODEINE B B B B QL: 240ml per dispensing Medications For Asthma & COPD Albuterol HFA MDI, Nebulization VENTOLIN HFA, VENTOLIN Albuterol Sulfate (Syrup) VENTOLIN (SYRUP) Albuterol Sulfate Tab VOSPIRE ER Albuterol-ipratropium (Inhaler) COMBIVENT, COMBIVENT RESPIMAT Ipratropium Bromide ATROVENT HFA Tiotropium Bromide SPIRIVA Albuterol-ipratropium, (Nebulization) DUONEB (NEBULIZATION) Aminophylline AMINOPHYLLINE Beclomethasone Dipropionate QVAR Fluticasone Propionate FLOVENT DISKUS, FLOVENT HFA Budesonide PULMICORT TURBUHALER PA: Tried and failed or contraindications to other formulary inhaled corticosteroids including. Budesonide Respules PULMICORT RESPULES Formulary for patients <8 years of age and younger if dosed within appropriate dosing guidelines as follows: 0.25mg/2mL once daily (BID requires PA) 0.5mg/2mL once or twice daily 1mg/2mL once daily PA: Required for patients 9 and older for Diagnosis of Asthma. Requires tried and failure of a formulary corticosteroid. Budesonide/Formoterl SYMBICORT Mometasone/formoterol DULERA Fluticasone Propionate/Salmeterol Xinafoate ADVAIR DISKUS, ADVAIR HFA Flunisolide AEROBID, AEROBID-M PA: Trial/failure or contraindications to Symbicort or Dulera. Formulary for 4 thru 11 years old. PA: Tried and failed or contraindications to other Formulary inhaled corticosteroids including BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 35 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME Formoterol FORADIL Levalbuterol Nebulizer XOPENEX, XOPENEX HFA Mometasone furoate ASMANEX Cromolyn INTAL Metaproterenol ALUPENT Montelukast Sodium SINGULAIR, SINGULAIR CHEW Nedocromil Sodium TILADE Omalizumab XOLAIR Pirbuterol MAXAIR AUTOHALER Salmetrol SEREVENT DISKUS Sodium Chloride for Inhalation SODIUM CHLORIDE FOR INHALATION Terbutaline BRETHINE Theophylline Elixir ELIXOPHYLLIN Theophyline SR THEO-DUR, UNIPHYL Theophylline SLO-PHYLLIN Triamcinolone AZMACORT Zafirlukast ACCOLATE Zileuton ZYFLOW CR NOTES Qvar. PA: Tried and failed or contraindication to at least one preferred alternative including Albuterol solution for nebulization. PA B PA: Tried and failed or contraindication to other formulary inhaled corticosteroids including Qvar. PA: Diagnosis: Asthma – Tried and failed preferred inhaled corticosteroids or insufficient control with inhaled corticosteroids. QL: #180/90days PA: Tried and failed OR contraindications to at least one preferred alternative in patients > 12 years old. Indication: Asthma. Mucolytic Agent Acetylcysteine MUCOMYST SKIN MEDICATIONS (TOPICAL) Acne Medications Adapalene /Benzoyl peroxide EPIDUO Benzoyl peroxide DESQUAM-E, DESQUAM-X Benzoyl peroxide/Clindamycin BENZACLIN Benzoyl peroxide/Erythromycin BENZAMYCIN Clindamycin CLEOCIN-T Erythromycin ERYCETTE, ERY-GEL, Erythromycin/Benzoyl peroxide BENZAMYCIN Metronidazole METROGEL Tretinoin RETIN-A, RETIN-A MICRO Isotretinoin ACCUTANE PA: Tried and failed or contraindicated to topical benzoyl peroxide alone and topical tretinoin alone Formulary: Only 2.5%, 5%, and 10% strengths for all dosage forms. PA: Tried and failed or contraindicated to the products separately PA: Tried and failed or contraindicated to the products separately C1: Treatment of acne rosacea Formulary for Individuals < 30 years old; PA required for patients > 30 years old. Formulary for CCRMC Dermatology regardless of age. PA: Tried and failed OR contraindications to at least one preferred alternative. Severe recalcitrant nodular acne. For Dermatologist only. Topical Antiparasitics/Anti-helmintic Crotamiton QL: 120g (2 tubes) per rolling 365 days EURAX BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 36 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Permethrin ELIMITE Permethrin NIX B: OTC formulation (1% topical liquid) Piperonyl Butoxide/Pyrethrins R & C, PYRINYL II, B Pyrantel Pamoate REESE'S PINWORM, PIN-X B Other Topical Medications Aluminum Chloride DRYSOL Aluminum Acetate ACID MANTLE B Bacitracin Ointment BACIGUENT(OINMENT) B Bacitracin/polymyxin B Sulfate POLYSPORIN Becaplermin REGRANEX B PA: Approvable for diabetic neuropathic ulcers in the lower extremities. It is not indicated in children under the age of 16 years. Refer these to professional services. Ulcer size must be submitted on PA form. QL: 15-gram tube per month x 12 weeks Capsaicin topical cream 0.025% or 0.075% ZOSTRIX, ZOSTRIX-HP Collagenase SANTYL Calamine Lotion CALAMINE LOTION Calcipotriene DOVONEX Coal Tar IONIL T Diclofenac 1% topical gel VOLTAREN 1% GEL Fluorouracil EFUDEX Gentamicin GARAMYCIN Imiquimod ALDARA QL: 1 package per 30 days. Mupirocin Papain/Urea/Chlorophyllin Copper Complex Sodium Papain/Urea BACTROBAN Ointment only. Cream is not covered. Podofilox Gel CONDYLOX Salicylic acid 6% lotion, cream & shampoo SALACYLIC ACID Selenium sulfide 2.5% EXSEL,SELSUN RX Silver Sulfadiazine SILVADENE, SSD Trioxsalen B PA: : Tried and failed OR contraindications to at least two preferred alternative M PA: Requires 2 oral NSAIDs and capsaicin or contraindications to use PANAFIL ACCUZYME QL: Gel-7gm x 4 weeks, Soln-8mL x 4 weeks. 2 units each solution, or gel. Treatment >4 weeks requires PA. PA: Tried and failed OR contraindications to at least one preferred alternative. Indicated for Vitiligo OR enhanced pigmentation. Per dermatologists only. TRISORALEN Topical Immunomodulator Pimecrolimus ELIDEL Tacrolimus PROTOPIC PA: Quantity limit of 1 large tube every 30 days. Age < 12 years approve x 3 months if written by a dermatologist AND patient has tried and failed OR contraindications to at least two (2) formulary topical corticosteroids. Age > 12 years approve x 3 months if written by a dermatologist AND patient has tried and failed OR contraindications to at least two (2) formulary medium or high potency topical corticosteroids. PA: Quantity limit of 1 large tube every 30 days. Age < 12 years approve x 3 months if written by a dermatologist AND patient has tried and failed OR contraindications to at least two (2) formulary topical corticosteroids. Age > 12 years approve x 3 months if written by a BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 37 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES dermatologist AND patient has tried and failed OR contraindications to at least two (2) formulary medium or high potency topical corticosteroids. Topical Antifungal B Clotrimazole LOTRIMIN AF Clotrimazole/Betamethasone LOTRISONE Econazole SPECTAZOLE Gentian Violet 1% GENTIAN VIOLET Ketoconazole 2% (cream & shampoo) NIZORAL (CREAM & SHAMPOO) Miconazole 2% cream MICATIN, MONISTAT-DERM Nystatin MYCOSTATIN Triamcinolone/Nystatin MYCOLOG II Sodium Thiosulfate/Salicylic Acid EXODERM, VERSICLEAR Sulconazole EXELDERM Tolnaftate TINACTIN B B Topical Coricosteroids Grade 1 (Very High Potency) Betamethasone dipropionate 0.05% cream, aug DIPROLENE AF CREAM Clobetasol propionate 0.05% cream, oint, soln TEMOVATE, TEMOVATE E Clobetasol propionate 0.05% scalp foam OLUX Diflorasone diacetate ointment 0.5% PSORCON E Halobetasol propionate 0.05% ULTRAVATE PA: Tried and failed OR contraindications to preferred alternatives. PA: no PA for RMC dermatology PA: Tried and failed OR contraindications to preferred alternatives. PA: Tried and failed OR contraindications to clobetasol. Claim pays on-line if criteria met. Grade 2 (High Potency) PA: Tried and failed OR contraindications to at least two preferred alternatives. Amcinonide 0.1% CYCLOCORT Betamethasone dipropionate 0.05-0.1% DIPROSONE Desoximetasone 0.05-0.25% TOPICORT Fluocinonide 0.05% LIDEX Halcinonide 0.1% HALOG Triamcinolone acetonide 0.5% ARISTOCORT, KENALOG PA: Tried and failed OR contraindications to at least two preferred alternatives. PA: Tried and failed OR contraindications to at least two preferred alternatives. Grade 3 (Medium Potency) Formulary: Cream PA: Foam formulation PA: Tried and failed OR contraindications to at least three preferred alternatives. PA: Tried and failed OR contraindications to at least two preferred alternatives. Betamethasone valerate VALISONE Clocortolone pivalate 0.1% CLODERM Desoximetasone 0.05% TOPICORT LP Fluocinolone acetonide 0.025-0.01% SYNALAR, DERMA-SMOOTHE/FS Fluticasone propionate 0.05% CUTIVATE Hydrocortisone Probutate 0.1% PANDEL Hydrocortisone Butyrate 0.1% LOCOID, LOCOID LIPOCREAM Hydrocortisone Valerate 0.2% WESTCORT Mometasone furoate 0.1% ELOCON Prednicarbate 0.1% DERMATOP Triamcinolone acetonide 0.025-0.1% ARISTOCORT, KENALOG Formulary: Cream and ointment PA: Lotion PA: Tried and failed OR contraindications to at least three preferred alternatives. PA: Tried and failed OR contraindications to at least three preferred alternatives. PA: Tried and failed OR contraindications to at least three preferred alternatives. PA: Tried and failed OR contraindications to at least three preferred alternatives. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 38 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST GENERIC NAME BRAND NAME NOTES Grade 4 (Low Potency) PA: Tried and failed OR contraindications to at least two formulary low potency alternatives. Alclometasone dipropionate 0.05% ACLOVATE Desonide 0.05% DESOWEN Fluocinolone Acetonide 0.01% DERMA-SMOOTHE/FS, SYNALAR Hydrocortisone 0.5-2.5% CORTAID, HYTONE B: OTC products covered for Medi-Cal & BHC only. BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE PA: NON-PREFERRED DRUG REQUIRING A PRIOR AUTHORIZATION REQUEST C1 (CODE 1 RESTRICTION): NON-PREFERRED DRUG REQUIRING CERTAIN CRITERIA WHICH COULD BE CITED ON THE PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY. Drugs that are not listed require Prior Authorization (PA) OTC Coverage: (M)=Medi-Cal; (B)=Basic Health Care and Medi-Cal; (A)=Commercial, Medi-Cal and Basic Health Care 39 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST Abacavir, 29 Abacavir/Lamivudine, 29 Abacavir/Lamivudine/Dolutegravir, 29 Abacavir/Zidovudine, 29 ABREVA, 30 Acarbose, 10 ACCOLATE, 37 ACCUTANE, 37 ACCUZYME, 38 Acebutolol, 17 Acetaminophen, 31 Acetaminophen/codeine Elixir, 32 Acetaminophen/codeine tabs, 32 Acetaminophen/hydrocodone, 32, 33 Acetazolamide Caps, 20 Acetic Acid 2%, 23 Acetic Acid, vag, 30 Acetic Acid/HC, 23 Acetylcysteine, 37 ACID MANTLE, 38 ACID-JELLY, 30 ACIPHEX, 14 ACLOVATE, 40 ACTONEL, 11 ACTOS, 11 ACTOSPLUS MET, 11 ACULAR, 20 Acyclovir, 30 ADALAT, 18 ADALAT CC, 18 ADDERALL, 27 ADDERALL XR, 27 ADOXA, 28 ADVAIR DISKUS, 37 ADVAIR HFA, 37 AEROBID, AEROBID-M, 37 AFEDITAB, 18 AGGRENOX, 19 AGRYLIN, 19 AKBETA, 20 AK-PRED, 20 AKPRO, 21 AK-TRACIN, 21 ALAMAST, 23 ALAWAY OTC,, 22 Albuterol HFA MDI, Nebulization, 36 Albuterol Sulfate (Syrup), 36 Albuterol Sulfate Tab, 36 Albuterol-ipratropium (Inhaler), 36 Albuterol-ipratropium, nebulizer, 36 Alclometasone dipropionate 0.05%, 40 ALDACTAZIDE, 19 ALDACTONE, 19 ALDARA, 38 ALDOMET, 18 Alendronate, 11 ALESSE, 12 Alfuzosin ER, 16 ALKERAN, 9 ALLEGRA, 35 INDEX Allopurinol, 13 Almotriptan, 32 ALOCRIL, 22 ALOMIDE, 22 ALPHAGAN P, 20 Alprazolam, 24 Alprostadil, 16 Altretamine, 9 Aluminum Acetate, 38 Aluminum Chloride Hexahydrate, 38 Aluminum Hydroxide Gel, 15 Aluminum Hydroxide, Magnesium Hydroxide, and Simethicone, 15 ALUPENT, 37 Amantadine, 26 AMARYL, 10 AMBIEN, 27 AMBIEN CR, 27 Amcinonide 0.1%, 39 AMERGE, 32 Amiloride, 19 Amiloride/HCTZ, 19 Aminophylline, 36 AMINOPHYLLINE, 36 Amiodarone, 17 Amitriptyline, 25 Amlodipine, 17 Amoxicillin, 27 Amoxicillin/potassium clavulanate, 27 AMOXIL, 27 Amphetamine & dextroamphetamine mixture, 27 AMPHOGEL, 15 Ampicillin, 27 Amylase/ Lipase/ Protease, 14 ANAFRANIL, 25 Anagrelide, 19 Anastrozole, 9 ANCOBON, 30 ANTABUSE, 26 Antihistamine with Antitussive, 35 Antihistamine with Nasal Decongestant, 35 ANTIVERT, 15 ANUSOL-HC CREAM, SUPP, 15 ANZEMET, 14 APIDRA, 11 Aprepitant, 14 APRESOLINE, 19, 20 APTIVUS, 30 ARALEN, 28 ARAVA, 32 ARICEPT, 26 ARICEPT ODT, 26 ARIMIDEX, 9 ARISTOCORT, 39, 40 ARMOUR THYROID, 13 AROMASIN, 9 ARTANE, 26 ARTHROTEC, 32 40 ASACOL HD, 15 ASMANEX, 37 Aspirin, 19, 31 ASTELIN, 23 ATARAX, 27, 35 Atazanavir, 30 Atazanavir/Cobicistat, 29 Atenolol, 17 Atenolol/Chlorthalidone, 17 ATIVAN, 24 Atorvastatin, 18 Atovaquone, 30 Atovaquone/Proguanil, 28 ATRIPLA, 29 Atropine, 23 ATROVENT HFA, 36 ATROVENT NASAL SPRAY, 23 AUGMENTIN, 27 AUGMENTIN ES, 27 AUGMENTIN XR, 27 AURALGAN, 23 Auranofin, 32 AVELOX, 28 AXERT, 32 AYGESTIN, 13 Azathioprine, 15 Azelastine HCl, 22 Azelastine Nasal Spray, 23 Azithromycin, 27 AZMACORT, 37 AZOPT, 20 AZULFIDINE, 15 BACIGUENT, 38 Bacitracin ophthalmic, 21 Bacitracin or Bacitracin Zinc Topical Ointment, 38 Bacitracin/ Polymyxin B Sultate, 21 Bacitracin/polymyxin, 38 Baclofen, 34 BACTRIM, 28 BACTRIM DS, 28 BACTROBAN, 38 Balsalazide, 15 BANZEL, 24 BARACLUDE, 31 BAYER, 19, 31 Becaplermin, 38 Beclomethasone Dipropionate, 36 Belladonna Alkaloids/Phenobarbital, 13 BELLERGAL-S, 14 Benazepril, 16 Benazepril/HCTZ, 16 BENEMID, 13 BENICAR, 16 BENICAR HCT, 17 BENTYL, 14 BENZAMYCIN, 37 Benzocaine/Antipyrine Otic, 23 Benzoyl peroxide gel, 37 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST Benztropine Mesylate, 26 BETAGAN, 20 Betamethasone dipropionate 0.05%, 39 Betamethasone dipropionate 0.050.1%, 39 Betamethasone valerate, 39 BETAPACE, 17 BETAPACE AF, 17 Betaxolol, 20 Bethanechol, 16 BETIMOL, 20 BETOPTIC, 20 BIAXIN, 27 Bicalutamide, 10 Bimatoprost, 21 Bisacodyl, 15 Bismuth Subsalicylate, 15 Bisoprolol/HCTZ, 17 BLEPH 10, 21 BLEPHAMIDE, 22 BLEPHAMIDE S.O.P, 22 BRETHINE, 37 Brimonidine, 20 Brinzolamide, 20 Bromocriptine, 26 BRONCHO SALINE, 37 Budesonide Respules, 36 Budesonide Turbuhaler, 36 Budesonide/Formoterl, 36 Bumetanide, 19 BUMEX, 19 Bupropion, 25 Bupropion SR, 25 Bupropion Sustained Release, 26 Bupropion XL, 25 BUSPAR, 24 Buspirone, 24 Busulfan, 9 Butalbital/acetaminophen/caffeine, 33 Butalbital/acetaminophen/caffeine/cod eine, 33 Butalbital/aspirin/caffeine, 33 Butalbital/aspirin/caffeine/codeine, 33 BYETTA, 10 CAFERGOT, 32 Calamine Lotion, 38 CALAMINE LOTION, 38 CALAN, 18 CALAN SR, 18 Calcitonin-Salmon, 11 Calcitriol, 34 Calcium acetate, 35 Calcium Carbonate, 34 Calcium Carbonate/Magnesium Carbonate, 15 Calcium Gluconate, 34 Calcium Lactate, 34 CANASA, 15 Capecitabine, 9 CAPOTEN, 16 Capsaicin topical cream 0.025% or 0.075%, 38 Captopril, 16 CARAFATE, 14 Carbachol, 21 Carbamazepine, 24 CARBATROL, 24 Carbidopa/levodopa, 26 Carbidopa/levodopa CR, 26 Carbinoxamine/ Pseudoephdrine, 35 CARDENE, 18 CARDENE SR, 18 CARDIZEM, 17 CARDIZEM CD, 18 CARDIZEM LA, 18 CARDIZEM SR, 18 CARDURA, 16, 20 Carisoprodol, 34 CARTIA XT, 17 Carvedilol, 17 CASODEX, 10 CATAFLAM, 31 CATAPRES, 18 CAVERJECT, 16 CECLOR, 27 CEENU, 9 Cefaclor, 27 Cefdinir, 27 Cefixime, 27 Cefpodoxime, 27 CEFTIN, 27 Cefuroxime, 27 CELEBREX, 31 Celecoxib, 31 CELEXA, 25 CELLCEPT, 10 CELONTIN KAPSEALS, 24 Cephalexin, 27 Cetirizine, 35 Cevimeline HCL, 24 CHANTIX, 26 Chlorambucil, 9 Chlordiazepoxide, 24 Chlorhexidine Gluconate, 23 CHLORITON, 35 Chloroquine, 28 Chlorpromazine, 25 Chlorthalidone, 19 CHLOR-TRIMETON, 35 Chlorzoxazone, 34 Cholestyramine, 18 Cilostazol, 19 CILOXAN, 21 Cimetidine, 14 CIPRO, 27 Cipro HC, 23 Ciprodex OTIC, 23 Ciprofloxacin, 21 Ciprofloxacin, 27 ciprofloxacin/dexamethasone, 23 ciprofloxacin/hydrocortisone, 23 Citalopram Hydrobromide, 25 41 CITRATE OF MAGNESIUM, 15 Clarithromycin, 27 CLARITIN, 35 CLARITIN-D, 35 CLEOCIN, 27, 30 CLEOCIN VAGINAL CREAM, 30 CLEOCIN-T, 37 CLIMARA, 12 Clindamycin, 27, 30, 37 Clindamycin Vaginal Cream, 30 Clinidium/Chlordiazepoxide, 13 CLINORIL, 31 Clobetasol propionate 0.05%, 39 Clocortolone pivalate 0.1%, 39 CLODERM, 39 Clomipramine, 25 Clonazepam, 24 Clonidine, 18 Clopidogrel, 19 Clorazepate, 24 Clotrimazole, 30, 31, 39 Clotrimazole/Betamethasone, 39 Clozapine, 25 CLOZARIL, 25 Coal Tar, 38 CODEINE PHOSPHATE, 33 CODEINE SULFATE, 33 Codeine Tabs, 33 Codeine/Aspirin, 33 Codeine/Guaifenesin, 36 CODEINE®, 33 COGENTIN, 26 COLAZAL, 15 Colchicine, 13 Colchicine/Probenecid, 13 COLCRYS, 13 COLESTID, 18 Colestipol, 18 Collagenase, 38 COL-PROBENECID, 13 COLYTE, 14, 15 COMBIPATCH, 12 COMBIVENT, 36 COMBIVENT RESPIMAT, 36 COMBIVIR, 30 COMPAZINE, 15 COMPLERA, 29 CONCERTA, 27 CONDYLOX, 38 Conjugated Estrogen vag, 11 Conjugated Estrogens/Medroxy Progesterone, 12 COPEGUS, 31 CORDARONE, 17 COREG, 17 CORGARD, 17 CORTAID, HYTONE, 40 CORTEF, 10 CORTENEMA, 15 CORTIFOAM, 15 CORTISPORIN OPHTH OINTMENT, 21 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST CORTISPORIN OPHTH SUSP, 22 CORTISPORIN OTIC SOLN, 23 CORTISPORIN OTIC SUSP, 23 COSOPT XE, 20 COUMADIN, 19 COZAAR, 16 CPM, 35 CREON, 14 CRIXIVAN, 30 CROLOM, 22 Cromolyn, 22, 37 Crotamiton, 38 CUPRIMIN, 32 CUTIVATE, 40 CYANOCOBALAMIN, 34 CYCLESSA, 12 Cyclobenzaprine, 34 CYCLOCORT, 39 CYCLOGYL, 23 Cyclopentolate, 23 Cyclophosphamide, 9 Cyclosporine Modified, 10 Cyclosporine non-modified, 10 Cyproheptadine, 35 CYTOMEL, 13 CYTOTEC, 14 CYTOXAN, 9 DALMANE, 26 DANTRIUM, 34 Dantrolene Sodium, 34 Dapsone, 30 DAPSONE, 30 DARAPRIM, 28 Darunavir, 30 Darunavir/Cobicistat, 29 Dasatinib, 9 DAYPRO, 31 DDAVP, 13 DECADRON, 10, 20 DECLOMYCIN, 27 Delavirdine, 29 DELZICOL, 15 DEMADEX, 19 Demeclocycline, 27 DEMEROL TABS, 33 DEMSER, 9 DEMULEN, 12 DEPAKENE, 24 DEPAKOTE, 24 DEPAKOTE ER, 24 DEPAKOTE SPRINKLE, 24 DEPEN, 32 DEPO-PROVERA, 13 DEPO-TESTOSTERONE (inj), 10 DERMA-SMOOTHE/FS, 40 DERMA-SMOOTHE/FS, SYNALAR, 40 DERMATOP, 40 Desipramine, 25 Desmopressin Acetate, 13 DESOGEN, 12 Desonide 0.05%, 40 DESOWEN, 40 Desoximetasone 0.05%, 40 Desoximetasone 0.25%, 39 DESQUAM-E, 37 DESQUAM-X, 37 DESYREL, 25 DETROL, 16 DETROL LA, 16 Dexamethasone, 10, 20 DEXEDRINE, 27 DEXILANT, 14 Dexlansoprazole, 14 Dextroamphetamine, 27 Dextromethorphan, 35 DIABETA/MICRONASE, 10 DIAMOX, 18, 20 DIAMOX SEQUELS, 18, 20 Diazepam, 24, 34 DIBENZYLINE, 9 Diclofenac, 31 Diclofenac 1% topical gel, 38 Diclofenac/Misoprostol, 32 Dicloxacillin, 27 Dicyclomine, 14 Didanosine, 29 DIDRONEL, 11 Diflorasone diacetate ointment 0.5%, 39 DIFLUCAN, 30 DIGEL, 15 Digoxin, 17 DILACOR XR, 18 DILANTIN, 24 DILATRATE, 19 DILATRATE SR, 19 DILAUDID, 33 DILT XR, 18 Diltiazem, 17 Diltiazem CR, 18 Diltiazem SR, Diltiazem ER, 18 DIMETAPP, 35 DIPENTUM, 15 Diphenoxylate/Atropine, 14 Dipivefrin, 21 DIPROLENE AF CREAM, 39 DIPROSONE, 39 Dipyridamole, 19 Dipyridamole/Aspirin, 19 DISALCID, 31 Disopyramide, 17 Disulfiram, 26 DITROPAN, 16 DITROPAN XL, 16 Divalproex sodium, 24 Docosanol, 30 Docusate Sodium, 15 Dofetilide, 17 Dolasetron, 14 DOLOPHINE, 33 Dolutegravir, 29 DOMEBORO, 23 Donepezil, 26 42 Donepezil ODT, 26 DONNATAL, 13 DOPAR, 26 DORYX, 27 Dorzolamide, 20 Doxazosin, 20 Doxazosin Mesylate, 16 Doxepin, 25 Doxycycline hyclate tab, 27 Doxycycline monohydrate tab, 28 Doxylamine, 35 DOXYSOM, 35 Dronabinol, 14 DROXIA, 9 DRYSOL, 38 DSS, 15 DUETACT, 10 DULCOLAX, 15 DULERA, 36 DUONEB, 36 DURAGESIC, 33 DYAZIDE, 19 DYNACIRC, 18 DYNACIRC CR, 18 DYNAPEN, 27 Echothiophate Iodide, 21 Econazole, 39 ECONOPRED PLUS, 20 EDURANT, 29 EES, 28 Efavirenz, 29 Efavirenz/Emtricitabine/Tenofovir, 29 EFFEXOR, EFFEXOR XR, 25 EFUDEX, 38 ELAVIL, 25 ELDEPRYL, 26 Electrolytes, Oral Maintenance, 34 Elestat, 22 Eletriptan, 32 ELIDEL, 38 ELIMITE, 38 ELLA, 13 ELMIRON, 16 ELOCON, 40 Elvitegravir/Cobicistat/Emtricitabine/Te nofovir, 29 EMADINE, 22 EMCYT, 9 Emedastine Difumarate, 22 EMEND, 14 EMPIRIN w/Codeine, 33 Emtricitabine, 29 Emtricitabine/Rilpivirine/Tenofovir, 29 Emtricitabine/Tenofovir, 30 EMTRIVA, 29 Enalapril, 16 Enfuvirtide, 29 Enoxaparin, 19 Entecavir, 31 ENUCLENE, 23 Epinastine HCl, 22 EPIPEN, 20 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST EPIPEN JR, 20 EPIVIR, 30 EPIVIR HBV, 31 EPOGEN, 19 EPZICOM, 29 EQUETRO, 24 Ergocalciferol (Vitamin D), 34 Ergotamine/Belladonna/Phenobarbital, 14 Ergotamine/caffeine, 32 Erlotinib, 9 ERYCETTE, 37 ERY-GEL, 37 ERY-TAB (Enteric Coated), 28 Eryth Es,Sulf Oral Susp, 28 ERYTHROCIN, 28 Erythromycin, 21, 37 Erythromycin Base, 28 Erythromycin Ethylsuccinate, 28 Erythromycin Stearate, 28 Erythromycin/Benzoyl peroxide, 37 Erythropoietin (Epoetin Alfa), 19 ESGIC, 33 ESGIC PLUS, 33 ESKALITH, 25 ESKALITH CR, 25 Esomeprazole, 14 Esterified Estrogens, 11 Esterified Estrogens/ Methyltestosterone, 13 ESTINYL, ESTRACE, 11, 12 Estradiol, 11, 12 Estradiol, transdermal, 12 Estradiol/Norethindrone, transdermal, 12 Estradiol/Norgestrel, 12 Estramustine, 9 ESTRATEST, 13 Estropipate, 12 Ethambutol, 28 Ethinyl Estradiol/Desogestrel, 12 Ethinyl Estradiol/Drospirenone, 12 Ethinyl Estradiol/Ethynodiol, 12 Ethinyl Estradiol/Etonogestrel, 13 Ethinyl Estradiol/Levonorgestrel, 12 Ethinyl Estradiol/Norelgestromin, 13 Ethinyl Estradiol/Norethindrone, 12 Ethinyl Estradiol/Norgestimate, 12 Ethinyl Estradiol/Norgestrel, 12 Ethionamide, 28 Ethosuximide, 24 Etidronate Disodium, 11 Etodolac, 31 ETOPOPHOS, 9 Etoposide, 9 Etravirine, 29 EURAX, 38 EVISTA, 11 EVOTAZ, 29 EVOXAC, 24 EXELDERM, 39 Exemestane, 9 Exenatide, 10 EXODERM, 39 EXSEL, 38 Famotidine, 14 FANSIDAR, 28 FARESTON, 9 Felbamate, 24 FELBATOL, 24 FELDENE, 31 Felodipine, 18 FEMARA, 9 Fenofibrate, 18 Fentanyl transdermal patch, 33 FEOSOL, 34 Ferrous Gluconate, 34 FERROUS GLUCONATE, 34 Ferrous Sulfate, 34 Fexofenadine, 35 Finasteride, 16 FIORICET, 33 FIORICET TABS, 33 FIORINAL TABS, 33 FIORINAL/CODEINE TABS, 33 FLAGYL, 28 FLAREX, 20 Flecainide, 17 FLEXERIL, 34 FLOMAX, 16 FLONASE, 23 FLORINEF, 10 FLOVENT DISKUS, 36 FLOVENT HFA, 36 FLOXIN, 23, 28 Fluconazole, 30 Flucytosine, 30 Fludrocortisone, 10 Flunisolide, 37 Flunisolide Nasal Soln 0.025%, 23 Fluocinolone Acetonide 0.01%, 40 Fluocinolone acetonide 0.025-0.01%, 40 Fluocinonide 0.01-0.05%, 39 Fluorometholone, 20 Fluorouracil, 38 Fluoxetine, 25 Fluphenazine Decanoate, Enanthate, 25 Fluphenazine Hydrochloride, 25 Flurazepam, 26 FLUR-OP, 20 Flutamide, 10 FLUTAMIDE, 10 Fluticasone Propionate, 36 Fluticasone propionate 0.05%, 40 Fluticasone Propionate Nasal Inhaler 50 Mcg/dose, 23 Fluticasone Propionate/Salmeterol Xinafoate, 37 Fluvastatin, 18 Fluvoxamine, 25 FML FORTE, 20 FML LIQUIFILM, 20 43 Folic Acid, 34 FOLIC ACID, 34 FORADIL, 37 Formoterol, 37 FOSAMAX, 11 Fosamprenavir, 30 FURADANTIN, 16 Furosemide, 19 FUZEON, 29 Gabapentin, 24 GABITRIL, 24 GANTRISIN, 28 GARAMYCIN, 38 Gefitinib, 9 Gemfibrozil, 18 GENERIC FORMULATIONS, 34 GENGRAF, 10 GENOPTIC, 21 GENOPTIC S.O.P., 21 Gentamicin, 21, 38 Gentamicin/Prednisolone, 21 GENTIAN VIOLET, 39 Gentian Violet 1%, 39 GEODON, 26 GLEEVEC, 9 Glimepiride, 10 Glimepiride/Pioglitazone, 10 Glipizide, 10 GLUCOPHAGE, 11 GLUCOPHAGE XR, 11 GLUCOTROL, 10 Glyburide, 10 GLYCOLAX, 14 GLYSET, 11 Granisetron, 15 GRIFULVIN, 30 Griseofulvin, 30 GRISPEG, 30 Guaifenesin, 35 Guaifenesin/Dextromethorphan (Syrup), 36 Guaifenesin/Dextromethorphan (Tablet), 36 Guanfacine, 18 Guanidine, 26 GUANIDINE, 26 GYNE-LOTRIMIN, 31 GYNE-LOTRIMIN 3, 31 Halcinonide 0.025-0.1%, 39 HALCION, 27 HALDOL, 25 Halobetasol propionate 0.05%, 39 HALOG, 39 Haloperidol Decanoate, Lactate, 25 HCTZ/Triamterene, 19 HEXALEN, 9 HIV agents, 29 Homatropine, 23 HUMALOG, 11 HUMULIN 50/50, 11 HUMULIN 70/30, 11 HUMULIN N, 11 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST HUMULIN R, 11 HYCODAN, 36 Hydralazine, 19, 20 HYDREA, 9 Hydrochlorothiazide, 19 Hydrocodone/Chlorpheniramine, 36 Hydrocodone/Homatropine, 36 Hydrocortisone, 10, 15, 40 Hydrocortisone 0.5-2.5%, 40 Hydrocortisone Acetate Rectal, 15 Hydrocortisone Butyrate 0.1%, 40 Hydrocortisone Probutate 0.1%, 40 Hydrocortisone Retention Enema, 15 Hydrocortisone Valerate 0.2%, 40 HYDRODIURIL, 19 Hydromorphone, 33 Hydroxychlorquine, 32 Hydroxyurea, 9 Hydroxyzine, 35 Hydroxyzine HCL, 27 Hydroxyzine Pamoate, 27, 35 HYGROTON, 19 Hyoscyamine, 14 Hyoscyamine Sulfate CR, 14 HYTRIN, 16, 20 HYZAAR, 17 Ibuprofen, 31 Ibuprofen/hydrocodone, 33 ILOTYCIN OPHTH OINT, 21 Imatinib, 9 IMDUR, 19 IMDUR/ ISMO/ MONOKET, 19 Imipramine, 25 Imiquimod, 38 IMITREX, 32 IMODIUM, 14 IMURAN, 15 Indapamide, 19 INDERAL, 17 INDERAL LA, 17 INDERIDE, 17 Indinavir, 30 INDOCIN, 31 Indomethacin, 31 INFLAMASE FORTE, 20 INH, 28 Insulin, 11 INTAL, 37 INTELENCE, 29 Interferon Alfa-2B, 31 INTRON-A, 31 INVIRASE, 30 Iodoquinol, 28 IONIL T, 38 Ipratropium, 23 Ipratropium Bromide, 36 IRESSA, 9 ISENTRESS, 29 ISMO, 19 Isoniazid, 28 ISOPTIN SR, 18 ISOPTO CARPINE,, 21 ISOPTOATROPINE, 23 ISOPTO-CARBACHOL, 21 ISOPTOHOMATROPINE, 23 ISOPTOHYOSCINE, 23 ISORDIL, 19 Isosorbide Dinitrate, 19 Isosorbide Dinitrate SR, 19 Isosorbide Mononitrate, 19 Isotretinoin, 37 Isradipine, 18 Itraconazole, 30 JANUMET, 11 JANUVIA, 11 J-TAN PD, 35 KALETRA, 30 KCL, 34 KEFLEX, 27 KENALOG, 39, 40 KENALOG in ORABASE, 24 KEPPRA, 24 Ketoconazole (cream & shampoo), 39 Ketorolac, 31 Ketorolac OPHTH, 20 Ketotifen furmarate, 22 KLONOPIN, 24 KLONOPIN WAFERS, 24 K-PHOS, 34 KYTRIL, 15 Labetalol, 17 LAMICTAL, 24 LAMISIL, 30 Lamivudine, 30, 31 Lamivudine/Zidovudine, 30 Lamotrigine, 24 LANOXIN, 17 Lansoprazole, 14 LANTUS, 11 Lapatinib, 9 LARIAM, 28 LASIX, 19 Latanoprost, 21 Leflunomide, 32 Lenalidomide, 9 LESCOL, 18 Letrozole, 9 LEUKERAN, 9 Leuprolide, 13 Levalbuterol Nebulizer, 37 LEVAQUIN, 28 LEVEMIR, 11 Levetiracetam, 24 Levobunolol, 20 Levocetirizine, 35 Levodopa, 26 LEVO-DROMORAN, 33 Levofloxacin, 28 Levonorgestrel, 13 Levorphanol, 33 Levothyroxine, 13 LEVSIN, 14 LEVSINEX, 14 LEXIVA, 30 44 LIBRAX, 13 LIBRIUM, 24 LIDEX, 39 Lidocaine, 23 LIORESAL, 34 Liothyronine, 13 Liotrix, 13 LIPITOR, 18 Liraglutide, 11 Lisinopril, 16 Lisinopril/HCTZ, 16 LITHIUM, 25 Lithium Carbonate, 25 Lithium Carbonate Sustained Release, 25 Lithium Citrate, 25 LITHONATE, 25 LO OVRAL, 12 LOCOID, LOCOID LIPOCREAM, 40 LODINE, 31 LODINE XL, 31 Lodoxamide, 22 LODRANE, 35 LOESTRIN FE 1.5/30, 12 LOESTRIN FE 1/20, 12 LOFIBRA, 18 LOMOTIL, 14 Lomustine, 9 LONITEN, 18, 20 Loperamide (2 mg capsules), 14 LOPID, 18 Lopinavir/Ritonavir, 30 LOPRESSOR, 17 Loratadine, 35 Loratadine and pseudoephedrine, 35 Lorazepam, 24 LORCET 650/10, 32 LORTAB 500/10, 33 LORTAB 500/5, 32 LORTAB 500/7.5, 32 LORTAB ELIXIR 167/2.5, 33 Losartan, 16 Losartan/HCTZ, 17 LOTENSIN, 16 LOTENSIN HCT, 16 LOTRIMIN AF, 39 LOTRISONE, 39 Lovastatin, 18 LOVENOX, 19 Loxapine, 25 LOXITANE, 25 LOZOL, 19 LUMIGAN, 21 LUPRON DEPOT PED, 13 LURIDE, 34 LUVOX, 25 LYRICA, 24 LYSODREN, 10 MACROBID, 16 MACRODANTIN, 16 Magnesium Citrate, 15 Magnesium Oxide 400mg tablet, 34 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST MAG-OX 400, 34 MALARONE, 28 Maraviroc, 29 MARINOL, 14 MATULANE, 9 MAXAIR AUTOHALER, 37 MAXALT, 32 MAXALT-MLT, 32 MAXITROL OINTMENT & SUSP, 21 MAXZIDE, 19 Meclizine, 15 MEDROL, 10 Medroxyprogesterone Acetate, 13 Mefloquine, 28 MELLARIL, 26 Meloxicam, 31 Melphalan, 9 MENEST, 11 Meperidine, 33 Mephenytoin, 24 MEPHYTON, 35 MEPRON, 30 Mercaptopurine (6M-P), 15 Mesalamine, 15 Mesalamine Supp, 15 Mesalamine, Enema, 15 MESANTOIN, 24 Mesna, 9 MESNEX, 9 MESTINON, 26 Mestranol/Norethindrone, 12 Metaproterenol, 37 Metformin, 11 Metformin ER, 11 METHADATE ER, 27 Methadone, 33 Methazolamide, 21 Methenamine/Methylene Blue Atropine, 16 METHERGINE, 13 Methimazole, 13 Methocarbamol, 34 Methotrexate, 32 METHOTREXATE, 32 Methsuximide, 24 Methyldopa, 18 Methylergonorine, 13 Methylphenidate, 27 Methylphenidate Extended Release, 27 Methylprednisolone, 10 Metipranolol, 20 Metoclopramide, 14 Metolazone, 19 Metoprolol, 17 Metoprolol ER, 17 METROGEL, 37 Metronidazole, 28, 31, 37 METRONIDAZOLE VAG CRM, VAG TABS, 31 Metyrosine, 9 MEVACOR, 18 MEXITIL, 17 Mexitiline, 17 MIACALCIN NASAL SPRAY, 11 MICARDIS, 16 MICARDIS HCT, 17 MICATIN, 39 Miconazole Cr, 2%, 39 Miconazole Nitrate, 31 MICRONOR, 12 MIDAMOR, 19 Miglitol, 11 Milnacipran Hydrochloride, 25 MINIPRESS, 16, 20 MINOCIN, 28 Minocycline, 28 Minoxidil, 20 Minoxidil tablets, 18 MIRCETTE, 12 Mirtazapine, 25 Mirtazapine ODT, 25 Misoprostol, 14 Mitotane, 10 MOBAN, 25 MOBIC, 31 Modafinil, 27 MODURETIC, 19 Molindone, 25 Mometasone furoate, 37, 40 Mometasone/formoterol, 36 MONISTAT-7, 31 MONISTAT-DERM, 39 MONOKET, 19 Montelukast Sodium, 37 Morphine soln., 33 Morphine SR, 33 Morphine suppositories, 33 MOTRIN, 31 Moxifloxacin, 28 MS CONCENTRATE, 33 MS CONTIN, 33 MSIR, 33 MTX, 32 MUCINEX (TABLET), 35 MUCOMYST, 37 Mupirocin, 38 MURO-128, 23 MUSE, 16 MYAMBUTOL, 28 MYCELEX TROCHE, 30 MYCIFARDIN, 30 MYCOBUTIN, 29 MYCOLOG II, 39 Mycophenolate mofetil, 10 Mycophenolic acid, 10 MYCOSTATIN, 30, 39 MYDRIACYL, 23 MYFORTIC, 10 MYLANTA, 15 MYLERAN, 9 MYSOLINE, 24 NA Thiosulfate 25%, 39 Nabumetone, 31 45 Nadolol, 17 NALOXONE, 34 Naloxone 1mg/ml Injector, 34 Naltrexone, 34 Naphazoline HCl, 22 Naphazoline HCl and Pheniramine Maleate, 22 NAPHCON, 22 NAPHCON A, 22 NAPROSYN, 31 Naproxen, 31 Naratriptan, 32 NASACORT AQ, 23 NASACORT AQ (OTC), 23 NASAREL, 23 Nateglinide, 11 NATURE-THROID, 13 NAVANE, 26 Nedocromil Sodium, 37 Nedrocromil, 22 Needles & Syringes (Not including diabetic), 11 Nefazodone, 25 Nelfinavir, 30 Neo/Poly/Prednisolone, 22 NEO-FRADIN, 30 Neomy, Polym, Bac, 21 Neomy,Polym,HC Otic Susp, 23 Neomy,Polym,HC-Otic Soln, 23 Neomycin, 28, 30 NEOMYCIN, 28 Neomycin Sulfate, Polymyxin B Sulfate, Dexamethasone, 21 Neomycin Sulfate,Polymyxin B Sulfate,Hydrocortizone, 22 Neomycin Sulfate/Polymyxin B Sulfate/Bacitracin/ Hydrocortisone, 21 Neomycin Sulfate/Polymyxin B Sulfate/Gramicidin, 21 Neomycin Sulfate/Polymyxin B Sulfate/Prednisolone, 21 Neomycin Sultate, Polymyxin B Sulfate, Bacitracin, 21 NEORAL, 10 NEOSPORIN OPHTH OINT, 21 NEOSPORIN OPHTH SOLUTION, 21 Neostigmine, 26 NEPTAZANE, 21 NEURONTIN, 24 Nevirapine, 29 NEXAVAR, 9 NEXIUM, 14 NIACIN, 18 NIASPAN, 18 Nicardipine, 18 Nicardipine SR, 18 NICODERM, 26 Nicotine Transdermal, 26 Nicotinic Acid, 18 Nicotinic Acid SR, 18 NiFEDIAC CC, 18 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST NIFEDICAL XL, 18 Nifedipine, 18 Nifedipine SR, 18 NILANDRON, 10 Nilotinib, 9 Nilutamide, 10 NITRO-BID, 20 NITRO-DUR, 20 Nitrofurantoin, 16 Nitrofurantoin ER, 16 Nitrofurantoin Macrocrystals, 16 Nitroglycerin, 20 Nitroglycerin (ointment), 20 Nitroglycerin (patch), 20 Nitroglycerin SR, 20 NITROL, 20 NITROSTAT, 20 NIX, 38 NIZORAL, 39 NOLVADEX, 12 NORCO 325/10, 32 NORCO 325/5, 32 NORCO 325/7.5, 32 NOREDETTE, 12 Norethindro 1 mg, eth estradio 20 mg, 12 Norethindro 1.5 mg, eth estradio 30 mg, 12 Norethindrone, 12 Norethindrone Acetate, 13 NORMODYNE, 17 NORPACE, NORPACE CR, 17 NORPRAMIN, 25 Nortriptyline, 25 NORVASC, 17 NORVIR, 30 NOVOLOG, 11 NUVARING, 13 Nystatin, 30, 31, 39 NYSTATIN, 31 OCUFLOX, 21 Ofloxacin, 28 Ofloxacin (OTIC), 23 Ofloxacin 0.3% drop, 21 OGEN, 12 Olanzapine, 26 Olmesartan, 16 Olmesartan/HCTZ, 17 Olopatadine, 22 Olopatadine HCl, 22 Olsalazine, 15 OLUX, 39 Omeprazole Magnesium, 14 Omeprazole OTC, 14 Omeprazole/Sodium Bicarbonate, 14 OMNICEF, 27 Ondansetron, 15 OPTIPRANOLOL, 20 OPTIVAR, 22 ORAP, 26 ORAPRED, 10 ORASONE, 10 ORINASE, 11 ORTHO CYCLEN, 12 ORTHO EVRA, 13 ORTHO NOVUM 10/11, 12 ORTHO NOVUM 7/7/7, 12 ORTHO TRI-CYCLEN, 12 ORTHONOVUM 1/35, 12 ORTHONOVUM 1/50, 12 Oseltamvir, 30 OVCON 35, 12 OVCON 50, 12 OVRAL, 12 Oxaprozin, 31 Oxazepam, 24 Oxcarbazepine, 24 Oxybutynin, 16 Oxycodone, 33 Oxycodone/acetaminophen, 33 Oxycodone/aspirin, 33 OXYCONTIN, 33 PAMELOR, 25 PANAFIL, 38 PANCREASE, 14 PANDEL, 40 Pantoprazole, 14 Papain/Urea, 38 Papain/Urea/Chlorophyllin Copper Complex, 38 PARAFON, 34 PARAFON FORTE, 34 PARLODEL, 26 Paroxetine, 25 PATADAY, 22 PATANOL, 22 PAXIL, 25 PAXIL CR, 25 PEDIALYTE, 34 PEDIAZOLE, 28 PEDIOTIC OTIC SUSP, 23 PEG Solution, 14, 15 PEGASYS, 31 PEG-INTRON, 31 Pegylated Interferon Alfa-2A, 31 Pegylated Interferon Alfa-2B, 31 Pemirolast, 23 Penicillamine, 32 Penicillin VK, 28 PENTASA, 15 Pentazocine, 33 Pentosan, 16 Pentoxifylline, 19 PEPCID, 14 PEPTO-BISMOL, 15 PERCOCET 5/325, 33 PERCODAN, 33 PERIACTIN, 35 PERIDEX, 23 Permethrin, 38 Perphenazine, 26 PERSANTINE, 19 Phenazopyridine, 16 PHENERGAN, 15, 35, 36 46 PHENERGAN DM, 36 PHENERGAN VC, 36 PHENERGAN VC w/ CODEINE, 36 PHENERGAN w/ CODEINE, 36 Phenobarbital, 24 PHENOBARBITAL, 24 Phenoxybenzamine, 9 PHENYTEK, 24 Phenytoin, 24 PHOSLO, 35 PHOSPHOLINE IODIDE, 21 PILOCAR, 21 PILOCAR HS, 21 Pilocarpine 5mg tablet, 15 Pilocarpine HCl, 21 Pimecrolimus, 38 Pimozide, 26 PIN-X, 38 Pioglitazone, 11 Pioglitazone/Metformin, 11 Pirbuterol, 37 Piroxicam, 31 PLAN B, 13 PLAQUENIL, 32 PLAVIX, 19 PLENDIL, 18 PLETAL, 19 Podofilox Gel, 38 Polyethylene Glycol 3350 oral powder, 14 Polymyxin B Sulfate/TMP, 22 POLY-PRED, 21, 22 POLYSPORIN, 38 POLYSPORIN OINTMENT, 21 POLYTRIM, 22 Potassium Acid Phosphate, 34 potassium chloride, 34 Potassium Iodide, 34 PRANDIN, 11 PRAVACHOL, 18 Pravastatin, 18 Prazosin, 16, 20 PRECOSE, 10 PRED FORTE, 20 PRED-G, 21 PRED-G SOP, 21 PRED-MILD, 20 Prednicarbate 0.1%, 40 Prednisolone, 10 PREDNISOLONE, 10 Prednisolone acetate, 20 Prednisolone sodium, 20 Prednisolone syrup, 10 Prednisone, 10 Pregabalin, 24 PRELONE, 10 PREMARIN VAG, 11 PREMPRO/PREMPHASE, 12 PRENATAL, 13 PRENATAL FORTE, 13 PRENATAL RX, 13 Prenatal Vitamins, 13 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST PRENAVITE, 13 PREVACID, 14 PREVACID 24HR OTC, 14 PREZCOBIX, 29 PREZISTA, 30 PRILOSEC, 14 PRILOSEC (OTC), 14 PRIMAQUINE, 28 Primaquine Phosphate, 28 Primethamine/ Sufadoxine, 28 Primidone, 24 PRINCIPEN, 27 PRINIZIDE, 16 PRO-BANTHINE, 14 Probenecid, 13 Procainamide, 17 Procarbazine, 9 PROCARDIA, 18 PROCARDIA XL, 18 Prochlorperazine, 15 Progesterone, oral micronized, 13 PROGRAF, 10 PROLIXIN, 25 Promethazine, 15, 35, 36 Promethazine/ Dextromethorphan, 36 Promethazine/Codeine, 36 Promethazine/Phenylephrine, 36 Promethazine/Phenylephrine/ Codeine, 36 PROMETRIUM, 13 PRONESTYL, 17 PRONESTYL-SR, 17 Propafenone, 17 Propanolol LA, 17 Propanolol/HCTZ, 17 Propantheline, 14 PROPINE, 21 Propranolol, 17 Propylthiouracil, 13 PROSCAR, 16 PROSTIGMIN, 26 PROTONIX, 14 PROTOPIC, 39 Protriptyline, 25 PROVENTIL, VENTOLIN (SYRUP), 36 PROVERA, 13 PROVIGIL, 27 PROZAC, 25 Pseudoephedrine, 35 Pseudoephedrine with Guaifenesin, 35 PSORCON E, 39 PTU, 13 PULMICORT RESPULES, 36 PULMICORT TURBUHALER, 36 PURINETHOL, 15 Pyrantel Pamoate,Susp, 38 Pyrazinamide, 28 PYRAZINAMIDE, 28 Pyrethrins, Piperonyl Butoxide, Petroleum Distillate, 38 PYRIDIUM, 16 Pyridostigmine, 26 Pyridoxine, 34 Pyrimethamine, 28 PYRINYL II, 38 QUALAQUIN, 28 QUESTRAN, 18 Quetiapine Fumarate, 26 QUINAGLUTE, 17 Quinidine Gluconate, 17 Quinidine Sulfate, 17 QUINIDINE SULFATE, 17 Quinine, 28 QVAR, 36 R & C, 38 Rabeprazole, 14 Raloxifene, 11 Raltegravir, 29 Rameltoeon, 27 Ranitidine, 14 RAPAMUNE, 10 REBETOL, 31 REESE'S PINWORM MEDICATION, 38 REGLAN, 14 REGRANEX, 38 RELAFEN, 31 RELENZA, 30 RELPAX, 32 REMERON, 25 REMERON SolTab, 25 RENVELA, 35 Repaglinide, 11 REQUIP, 26 RESCRIPTOR, 29 Reserpine, 18 RESTORIL, 27 RETIN-A, 37 RETIN-A MICRO, 37 RETROVIR, 30 REVIA, 34 REVLIMID, 9 REYATAZ, 30 Ribavirin, 31 RIDAURA, 32 Rif/INH, 28 Rif/INH/PZA, 28 Rifabutin, 29 RIFADIN, 29 RIFAMATE, 28 Rifampin, 29 RIFATER, 28 Rilpivirine, 29 Risedronate, 11 RISPERDAL, 26 RISPERDAL M-TAB, 26 Risperidone, 26 RITALIN, 27 RITALIN LA, 27 RITALIN SR, 27 Ritonavir, 30 Rivaroxaban, 19 Rizatriptan, 32 RMS SUPPOSITORIES, 33 47 ROBAXIN, 34 ROBITUSSIN, 35 ROBITUSSIN AC, 36 ROBITUSSIN DM (SYRUP), 36 ROBITUSSIN DM (TABLET), 36 ROBITUSSIN MAXIMUM STRENGTH, 35 ROBITUSSIN PE, 35 ROBITUSSIN-CF, 36 ROCALTROL, 34 RONDEC, 35 RONDEC DM, 35 RONDEC, RONDEC DM, 35 Ropinirole, 26 ROWASA, 15 ROXICODONE, 33 ROZEREM, 27 Rufinamide, 24 RYTHMOL, 17 RYTHMOL SR, 17 SALACYLIC ACID, 38 SALAGEN, 15 Salicylic acid 6% lotion and cream, 38 Salmetrol, 37 Salsalate, 31 SANDIMMUNE, 10 SANTYL, 38 Saquinavir, 30 SAVELLA, 25 Scopolamine, 23 SCOT-TUSSIN DM, 35 SECTRAL, 17 Selegiline, 26 Selenium sulfide 2.5%, 38 SELSUN RX, 38 SELZENTRY, 29 SEPTRA DS, 28 SERAX, 24 SEREVENT DISKUS, 37 SEROQUEL, 26 SERPASIL, 18 Sertraline, 25 SERZONE, 25 Sevelamer, 35 Sildenafil, 16 SILVADENE, 38 Silver Sulfadiazine, 38 SIMCOR, 18 Simvastatin, 18 SINEMET, 26 SINEMET CR, 26 SINEQUAN, 25 SINGULAIR, 37 SINGULAIR CHEW, 37 Sirolimus, 10 Sitagliptin, 11 Sitagliptin/Metformin, 11 SLO-NIACIN, 18 SLO-PHYLLIN, 37 Sodium Chloride for Inhalation, 37 Sodium Chloride Ophthalmic, 23 Sodium Flouride (drops & tabs), 34 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST SODIUM SULAMYD, 21 SOMA, 34 SONATA, 27 Sorafenib, 9 SORBITOL, 14 Sorbitol 70% solution, 14 Sotalol, 17 Sotalol AF, 17 SPECTAZOLE, 39 SPIRIVA, 36 Spironolactone, 19 Spironolactone/HCTZ, 19 SPORANOX, 30 SPRYCEL, 9 SSKI, 34 ST. JOSEPH, 19 STARLIX, 11 Stavudine, 30 STELAZINE, 26 STRIBILD, 29 Sucralfate, 14 Sulconazole, 39 Sulfacetamide, 21 Sulfacetamide/Prednisolone (ointment), 22 Sulfadiazine, 28 SULFADIAZINE, 28 Sulfasalazine, 15 Sulfisoxazole, 28 Sulindac, 31 Sumatriptan, 32 SUMYCIN, 28 Sunitinib, 9 SUPRAX, 27 SUSTIVA, 29 SUTENT, 9 SYMBICORT, 36 SYMMETREL, 26 SYNALAR, 40 SYNTHROID, 13 TABLOID, 9 Tacrolimus, 10, 39 TAGAMET, 14 TALWIN, 33 TAMBOCOR, 17 TAMIFLU, 30 Tamoxifen, 12 Tamsulosin, 16 TAPAZOLE, 13 TARCEVA, 9 TASIGNA, 9 TEGRETOL, 24 TEGRETOL XR, 24 Telmisartan, 16 Telmisartan/HCTZ, 17 Temazepam, 27 TEMODAR, 9 TEMOVATE, 39 TEMOVATE E, 39 Temozolomide, 9 TENEX, 18 Tenofovir, 30 TENORMIN, 17 TERAZOL 3, 7, 31 Terazosin, 16, 20 Terbinafine, 30 Terbutaline, 37 Terconazole, 31 TESLAC, 9 Testolactone, 9 TESTOSTERONE (inj), 10 Testosterone Cypionate, 10 Testosterone Enanthate, 10 Tetracycline, 28 Thalidomide, 9 THALOMID, 9 THEO-DUR, 37 Theophyline SR Sprinkles, 37 Theophylline, 37 Theophylline Liquid, 37 Thioguanine, 9 Thioridazine, 26 Thiothixene, 26 THORAZINE, 25 Thyroid dessicated, 13 THYROLAR, 13 Tiagabine, 24 TIGAN, 15 TIKOSYN, 17 TILADE, 37 Timolol Hemihydrate, 20 Timolol Maleate, 20 TIMOPTIC, 20 TIMOPTIC XE, 20 TINACTIN, 39 Tiotropium Bromide, 36 Tipranavir, 30 TITRALAC, 34 TIVICAY, 29 Tizanidine, 34 TOBRADEX, 22 Tobramycin, 21 Tobramycin Sulfate/Dexamethasone, 22 TOBREX, 21 TOFRANIL, 25 TOFRANIL PM, 25 Tolazamide, 11 Tolbutamide, 11 TOLECTIN, 31 TOLINASE, 11 Tolmetin, 31 Tolnaftate, 39 Tolterodine, 16 TOPAMAX, 24 TOPICORT, 39 TOPICORT LP, 40 Topiramate, 24 TOPROL XL, 17 TORADOL, 31 Toremifene, 9 Torsemide, 19 Tramadol, 32 Tramadol/APAP, 32 48 TRANDATE, 17 TRANXENE SD, 24 TRANXENE T, 24 Travaprost, 21 TRAVATAN, 21 TRAVATAN Z, 21 Trazodone, 25 TRECATOR-SC, 28 TRENTAL, 19 Tretinoin, 37 Triamcinolone, 37 Triamcinolone 0.1% in Orabarol, 24 Triamcinolone Acetonide, 23 Triamcinolone acetonide 0.025-0.1%, 40 Triamcinolone acetonide 0.5%, 39 Triamcinolone Acetonide Nasal Inhal 55 Mcg/Act, 23 Triamcinolone/Nystatin, 39 Triazolam, 27 TRIDIONE, 24 Trifluoperazine, 26 Trifluridine, 21 Trihexiphenidyl, 26 TRILAFON, 26 TRILEPTAL, 24 TRI-LEVLEN, 12 Trimethadione, 24 Trimethobenzamide, 15 Trimethoprim, 16 Trimethoprim/ Sulfamethoxazole, 28 TRIMOX, 27 TRIMPEX, 16 TRI-NORINYL, 12 Trioxsalen, 38 TRIPOHIST, 35 Triprolidine, 35 TRISORALEN, 38 TRIUMEQ, 29 TRI-VI-FLOR, 34 TRI-VI-SOL, 34 TRI-VI-SOL & Fe, 34 TRIZIVIR, 29 Tropicamide, 23 TRUETEST, 10 TRUETEST STRIPS, 10 TRUETRACK, 10 TRUETRACK STRIPS, 10 TRUSOPT, 20 TRUVADA, 30 TUSSIONEX, 36 TYKERB, 9 TYLENOL, 31 TYLENOL #2, #3, #4, …, 32 TYLENOL ELIXIR, 32 TYLOX 5/500, 33 Tyloxapol with Benzalkonium Chloride, 23 Typhoid Vaccine, 28 Ulipristal, 13 ULTRACET, 32 ULTRAM, 32 January 2015 CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST ULTRAVATE, 39 UNIPHYL, 37 URECHOLINE, 16 URISED, 16 UROXATRAL, 16 VAG GEL, 30 Valacyclovir, 30 VALCYTE, 31 Valganciclovir, 31 VALISONE, 39 VALIUM, 24, 34 Valproic acid, 24 VALTREX, 30 VANCOCIN, 28 Vancomycin - oral, 28 VANSPAR, 24 VANTIN, 27 VASOTEC, 16 VAZOL, 35 VEETIDS, 28 Venlafaxine, 25 VENTOLIN HFA, 36 Verapamil, 18 Verapamil SR, 18 VERSICLEAR, 39 VIAGRA, 16 VIBRAMYCIN, 27 VICODIN 500/5, 32 VICODIN E.S. 750/7.5, 32 VICOPROFEN, 33 VICTOZA, 11 VIDEX EC, 29 VIDEX PEDIATRIC, 29 VIRACEPT, 30 VIRAMUNE, 29 VIREAD, 30 VIROPTIC, 21 VISCOUS XYLOCAINE, 23 VISTARIL, 27, 35 Vitamin A, D, C, & Fluoride, 34 Vitamin B-12, 34 VITAMIN B-6, 34 VITAMIN D, 34 Vitamin K, 35 Vitamins A, D, C, 34 Vitamins A, D, C with Iron, 34 VIVACTIL, 25 VIVELLE-DOT, 12 VIVOTIF BERNA, 28 VOLTAREN, 31 VOLTAREN 1% GEL, 38 Vorinostat, 9 VOSOL HC, 23 VOSPIRE ER, 36 WELLBUTRIN, 25 WELLBUTRIN SR, 25, 26 WELLBUTRIN XL, 25 WESTCORT, 40 XALATAN, 21 XANAX, 24 XARELTO, 19 XELODA, 9 XOPENEX, 37 XOPENEX HFA, 37 XYZAL, 35 YASMIN, 12 YODOXIN, 28 ZADITOR OTC, 22 Zafirlukast, 37 Zaleplon, 27 ZANAFLEX, 34 Zanamivir, 30 ZANTAC, 14 ZARONTIN, 24 49 ZAROXOLYN, 19 ZEGERID OTC, 14 ZENPEP, 14 ZERIT, 30 ZESTORETIC, 16 ZESTRIL, 16 ZIAC, 17 ZIAGEN, 29 Zidovudine, 30 Zileuton, 37 Ziprasidone, 26 ZITHROMAX, 27 ZOCOR, 18 ZOFRAN, 15 ZOLINZA, 9 Zolmitriptan, 32 ZOLOFT, 25 Zolpidem, 27 Zolpidem CR, 27 ZOMIG, 32 ZOMIG-ZMT, 32 ZONEGRAN, 24 Zonisamide, 24 ZOSTAVAX, 30 Zoster-vaccine, live attenuated, 30 ZOSTRIX, 38 ZOSTRIX-HP, 38 ZOVIRAX, 30 ZYFLOW CR, 37 ZYLOPRIM, 13 ZYMINE, 35 ZYMINE XR, 35 ZYPREXA, 26 ZYPREXA ZYDIS, 26 ZYRTEC, 35 ZYRTEC-D, 35 ZYVOX, 28 January 2015
