SANTA CLARA FAMILY HEALTH PLAN
CAL MEDICONNECT PLAN
(PLAN DE MEDICARE-MEDICAID)
Listahan ng mga Sakop na Gamot
(Formulary)
2016
Walang Bayad: 1-877-723-4795
TTY: 1-800-735-2929
8 a.m. hanggang 8 p.m., 7 araw as isang linggo, kabilang ang mga pista opisyal.
Kung mayroon kang mga tanong, pakitawagan ang Santa Clara Family Health Plan.
Libre ang tawag. Para sa karagdagang impormasyon, bisitahin ang www.scfhp.com.
Formulary ID: 16510.000 Version Number: 10
Last Updated: 02/29/2016
H7890_11015T_Final_3 Accepted
SCFHP Cal MediConnect Plan (Medicare-Medicaid Plan) |
2016 Listahan ng mga Saklaw na Gamot (Formulary)
Ito ang listahan ng mga gamot na maaaring makuha ng mga miyembro sa Santa Clara Family
Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan).

Ang Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) ay
isang health plan na nakikipagkontrata sa Medicare at Medi-Cal upang makapagbigay
ng mga benepisyo ng kapwa programa sa mga nagpatala.

Ang Listahan ng mga Saklaw na Gamot at/o mga network ng parmasya at provider ay
maaaring magbago sa buong taon. Padadalhan ka namin ng abiso bago kami gumawa
ng pagbabago na makakaapekto sa iyo.

Maaaring magbago ang mga benepisyo sa Enero 1 ng bawat taon.

Maaaring palaging tingnan ang up-to-date na Listahan ng mga Saklaw na Gamot ng Cal
MediConnect ng Santa Clara Family Health Plan (SCFHP) sa online sa www.scfhp.com
o sa pagtawag sa Mga Serbisyo para sa Miyembro ng SCFHP sa 1-877-723-4795,
7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista opisyal. Ang mga
gumagamit ng TTY/TDD tumawag sa 1-800-735-2929.

Maaari mong makuha ang impormasyon na ito nang libre sa ibang format, tulad ng
malaking print, braille, o audio. Tumawag sa 1-877-723-4795. Libre ang tawag.

Maaaring lumapat ang mga limitasyon at paghihigpit. Para sa higit na impormasyon,
tawagan ang Mga Serbisyo para sa Miyembro ng SCFHP o basahin ang Handbook ng
Miyembro ng Member

You can get this information for free in other languages. Call 1-877-723-4795, 7 days a
week, 8 a.m. to 8 p.m., including holidays. TTY/TDD users call 1-800-735-2929. The call
is free.
Puede obtener esta información gratuita en otros idiomas. Llame al 1-877-723-4795, los
7 días de la semana, de 8:00 a. m. a 8:00 p. m., incluyendo feriados. Los usuarios de
TTY/TDD deben llamar al 1-800-735-2929. La llamada es gratuita.
Quý vị có thể nhận thông tin này miễn phí theo các ngôn ngữ khác. Gọi số
1-877-723-4795, 7 ngày một tuần, 8 giờ sáng đến 8 giờ tối kể cả các ngày nghỉ lễ.
Những người sử dụng TTY/TDD nên gọi số 1-800-735-2929. Cuộc gọi được miễn phí.
您可免费获得此信息的其他语言版本。请致电 1-877-723-4795，一周 7 天, 工作时间为
上午 8:00 至下午 8:00 (包含节假日)。TTY/TDD 使用者应拨打 1-800-735-2929。这是
免付费电话。
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Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
i
H7890_11015T_Final_3 Accepted
Makukuha mo nang libre ang impormasyong ito sa iba pang mga wika. Tumawag sa
1-877-723-4795, 7 araw sa isang linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga
pista opisyal. Ang mga gumagamit ng TTY/TDD ay dapat tumawag sa 1-800-735-2929.
Libre ang tawag.
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
ii
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
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Mga Madalas Itanong (Frequently Asked Questions (FAQ))
Humanap ng mga kasagutan dito sa mga katanungan na mayroon ka tungkol sa Listahan ng
mga Saklaw na Gamot. Maaari mong basahin ang lahat ng FAQ upang malaman ang iba pa, o
maghanap ng katanungan at sagot.
1. Anong mga may-resetang gamot ang nasa Listahan ng mga
Saklaw na Gamot? (Tinatawag namin ang Listahan ng mga Saklaw
na Gamot na “Listahan ng Gamot” para mas maikli.)
Ang mga gamot sa Listahan ng Gamot ay ang mga gamot na saklaw ng SCFHP Cal
MediConnect. Mabibili ang mga gamot sa mga botika sa loob ng aming network. Ang isang
botika ay nasa aming network kung may kasunduan kami sa kanila na makipagtulungan sa
amin at magbigay ng serbisyo sa iyo. Tinatawag namin ang mga botikang ito na “mga botika
sa network” (network pharmacies).
Sasaklawin ng SCFHP Cal MediConnect ang lahat ng medikal na kinakailangang gamot na
nasa Listahan ng Gamot kung:

sinasabi ng iyong doktor o ibang tagareseta na kailangan mo ang mga ito para gumaling
o manatiling malusog, at

pupunan mo ang inireseta sa isang parmasya ng network ng SCFHP.
Sa ilang kaso, kinakailangang may gawin ka muna bago ka makakakuha ng gamot (tingnan ang
tanong #5 sa ibaba).
Maaari mo ring makita ang isang up-to-date na listahan ng mga gamot na nasasaklawan namin
sa aming website sa www.scfhp.com o tawagan ang Mga Serbisyo para sa Miyembro sa
1-877-723-4795.
2. Nagbabago ba ang Listahan ng Gamot?
Oo. Maaaring magdagdag o mag-alis ng mga gamot ang SCFHP sa Listahan ng Gamot sa loob
ng isang taon. Sa pangkalahatan, magbabago lamang ang Listahan ng Gamot kung:
?

may dumating na mas murang gamot na singbisa ng gamot na nasa Listahan ng Gamot
ngayon, o

nalaman namin na hindi ligtas ang isang gamot.
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
iii
Maaari rin naming baguhin ang aming mga tuntunin tungkol sa mga gamot. Halimbawa,
maaari kaming:

Magpasyang humingi o hindi humingi ng paunang pag-apruba para sa isang gamot.
(Ang paunang pag-apruba ay pahintulot mula SCFHP bago ka makakuha ng gamot.)

Dagdagan o baguhin ang dami ng isang gamot na maaari mong makuha (tinatawag na
“mga limit sa bilang”).

Dagdagan o baguhin ang mga paghihigpit sa step therapy para sa isang gamot. (Ang
step therapy ay nangangahulugang dapat mong subukan ang isang gamot bago namin
sasaklawin ang isa pang gamot.)
(Para sa higit na impormasyon sa mga tuntunin ng mga gamot na ito, tingnan ang pahina v.)
Sasabihin namin sa iyo kapag tinanggal sa Listahan ng Gamot ang ginagamit mong gamot.
Sasabihin din namin sa iyo kapag binago namin ang aming mga tuntunin sa pagsasaklaw ng
isang gamot. Mga katanungan ‎3, ‎4, at ‎7 sa ibaba ay may karagdagang impormasyon sa kung
anong mangyayari kapag nagbago ang Listahan ng Gamot.

Maaari mong palaging tingnan ang up-to-date na Listahan ng Gamot ng SCFHP Cal
MediConnect sa online sa www.scfhp.com. Maaari mo rin tawagan ang Mga Serbisyo para
sa Miyembro para alamin ang kasalukuyang Listahan ng Gamot sa 1-877-723-4795.
3. Ano ang mangyayari kung may dumating na mas murang gamot
na singbisa ng gamot na nasa Listahan ng Gamot ngayon?
Kung gumagamit ka ng gamot na tinanggal dahil may dumating na mas mura na singbisang
gamot, sasabihin namin sa iyo. Sasabihin namin sa iyo nang hindi bababa sa 60 araw bago
namin alisin ito mula sa Listahan ng Gamot o kapag humingi ka ng refill. Pagkatapos ay maaari
kang makakuha ng 60-araw na supply ng gamot bago pa man ito alisin sa listahan ng gamot.
Makakatanggap ka ng sulat mula sa SCFHP nang hindi bababa sa 60 araw bago pa man
magkaroon ng bisa ang pagbabago. Mapo-post din ang impormasyon na ito sa www.scfhp.com.
4. Ano ang mangyayari kapag nalaman namin na hindi ligtas ang
isang gamot?
Kung sinasabi ng Food and Drug Administration (FDA) na hindi ligtas ang gamot na iniinom mo,
aalisin namin agad ito sa Listahan ng Gamot. Magpapadala rin kami ng sulat sa iyo na
nagsasabi sa iyo tungkol dito. Mangyaring makipag-ugnayan sa iyong nagreresetang provider
pagkatapos mong matanggap ang sulat.
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
iv
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
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5. Mayroon bang anumang paghihigpit o limit sa saklaw na gamot?
O mayroon bang anumang kinakailangang gawin upang makuha
ang ilang gamot?
Oo, may mga tuntunin sa pagsasaklaw ng ilang gamot o may mga limit sa dami ng maaari
mong makuha. Sa ilang kaso ikaw o ang iyong doktor o iba pang tagapagreseta ay dapat
gumawa ng isang bagay bago mo makuha ang gamot. Bilang halimbawa:

Paunang pag-apruba (o naunang pahintulot): Para sa ilang gamot, ikaw o ang iyong
doktor o ibang tagapagreseta ay dapat kumuha ng pag-apruba mula sa SCFHP bago
mo punan ang iyong inireseta Kung hindi ka nakakuha ng pag-apruba, maaaring hindi
saklawin ng SCFHP ang gamot.

Mga limit ng dami: Kung minsan ay nililimitahan ng SCFHP ang dami ng gamot na
maaari mong makuha.

Step therapy: Kung minsan hihingin sa iyo ng SCFHP na magsagawa ng step therapy
Nangangahulugan ito na susubok ka ng mga gamot sa isang tiyak na pagkakasunodsunod para sa iyong kondisyong medikal. Maaaring kailangan mong subukan ang isang
gamot bago namin sasaklawin ang isa pang gamot. Kung sa palagay ng iyong doktor ay
hindi mabisa sa iyo ang unang gamot, sasaklawin namin ang pangalawa.
Maaari mong malaman kung ang iyong gamot ay mayroong anumang karagdagang hinihini o
mga limit sa pamamagitan ng pagtingin sa mga table umpisa sa pahina 1. Maari ka rin
makakuha ng marami pang impormasyon sa pamamagitan ng pagbisita sa aming website sa
www.scfhp.com. Nag-post kami ng mga dokumento sa onlin na ipinapaliwanag ang aming
paunang pahintulot at mga paghihigpit sa step therapy. Maaari mo ring hilingin sa amin na
padalhan ka ng kopya.
Maaari kang humingi ng “eksepsiyon”. mula sa mga limit na ito. Mangyaring tingnan ang
Tanong 11 para sa karagdagang impormasyon tungkol sa mga eksepsiyon.

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Kung ikaw ay nasa isang nursing home o iba pang mga pasilidad sa pangmatagalang
pangangalaga at kailangan mo ng gamot na wala sa Listahan ng Gamot, o kung
nahihirapan kang kumuha ng kinakailangan mong gamot, maaari kaming makatulong.
Sasaklawin namin ang isang 31-day na emergency na supply ng kinakailangan mong gamot
(maliban na lang kung may iniresetang pang-ilang araw lamang), bagong miyembro ka man
o hindi ng SCFHP. Magbibigay ito sa iyo ng panahon upang sumangguni sa iyong doktor o
iba pang taga-reseta. Maaaring makatulong siya sa iyo na magpasya kung may katulad na
gamot na nasa Listahan ng Gamot ang maaari mong inumin o kung hihiling ba ng
eksepsiyon. Mangyaring tingnan ang Tanong ‎11 para sa karagdagang impormasyon tungkol
sa mga eksepsiyon.
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
v
6. Paano mo ba malalaman kung ang gusto mong gamot ay may mga
limitasyon o kung mayroon bang kinakailangang gawin upang
makakuha ng gamot?
Ang Listahan ng mga Saklaw na Gamot simula sa pahina 1 ay may hanay na may markang
“Mga kinakailangang aksiyon, paghihigpit, o limit sa paggamit.”
7. Ano ang mangyayari kapag binago namin ang aming mga tuntunin
sa kung paano namin sinasaklaw ang ilan sa mga gamot?
Halimbawa, kung idadagdag namin ang paunang pahintulot
(pag-apruba), mga limit sa bilang, at/o mga paghihigpit sa step
therapy para sa isang gamot.
Sasabihin namin sa iyo kung idadagdag namin ang paunang pag-apruba, mga limit sa bilang,
at/o mga paghihigpit sa step therapy para sa isang gamot. Sasabihin namin sa iyo nang hindi
bababa sa 60 araw bago idagdag ang paghihigpit o sa susunod na humingi ka na ng refill sa
botika. Pagkatapos, maaari kang makakuha ng 60-araw na supply ng gamot bago pa man
baguhin ang mga tuntunin sa pagsasaklaw. Nagbibigay ito sa iyo ng panahon upang makipagusap sa iyong doktor o iba pang taga-reseta tungkol sa kung ano ang susunod na gagawin.
8. Paano mo ba mahahanap ang isang gamot sa Listahan ng Gamot?
May dalawang paraan para mahanap ang gamot:

Maaari mong hanapin ayon sa alpabeto (kung alam mo kung paano baybayin ang
gamot), o

Maaari kang maghanap ayon sa kondisyong medikal.
Para maghanap nang nakaalpabeto, pumunta sa seksiyon na Listahang Alpabetiko (Indese).
Maaari mo itong mahanap sa pahina I-1.
Para maghanap ayon sa medikal na kundisyon, hanapin ang seksyon na may label na
“Listahan ng mga gamot ayon sa medikal na kundisyon” sa pahina 1. Ang mga gamot sa
seksyon na ito ay naka-grupo sa mga kategorya depende sa uri ng mga medikal na kundisyon
na ginagamot sila. Bilang halimbawa, kung mayroon kang kundisyon sa puso, dapat kang
mahanap sa kategorya na, Cardiovascular Agents. Doon mo mahahanap ang gamot na lunas
para sa mga kondisyon sa puso.
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
vi
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
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9. Paano kung wala sa Listahan ng Gamot ang gusto mong gamot?
Kung hindi mo makita ang iyong gamot sa Listahan ng Gamot, tawagan ang Mga Serbisyo para sa
Miyembro sa 1-877-723-4795 at magtanong tungkol dito. Kung malaman mong hindi sasaklawin
ng SCFHP Cal MediConnect ang gamot, maaari mong gawin ang isa sa mga bagay na ito:

Humingi ng lista ng mga gamot sa Mga Serbisyo para sa Miyembro tulad ng gamot na gusto
mong inumin. Pagkatapos ay ipakita ang lista sa iyong doktor o sa iba pang tagareseta. Maaari
siyang magreseta ng gamot mula sa Listahan ng Gamot tulad ng gusto mong inumin. O

Maaari mong hilingin sa planong pangkalusugan na gumawa ng eksepsiyon upang
masaklaw ang iyong gamot. Pakitingnan ang tanong 11 para sa karagdagang
impormasyon tungkol sa mga eksepsiyon.
10. Paano kung bagong miyembro ka ng SCFHP Cal MediConnect at
hindi mo mahanap ang iyong gamot sa Listahan ng Gamot o may
problema sa pagkuha ng iyong gamot?
Maaari kaming makatulong. Maaari naming saklawan ang 30-day na supply ng iyong gamot sa
unang 90 days na ikaw ay miyembro ng SCFHP Cal MediConnect. Magbibigay ito sa iyo ng
panahon upang sumangguni sa iyong doktor o iba pang taga-reseta. Maaaring makatulong siya
sa iyo na magpasya kung may katulad na gamot na nasa Listahan ng Gamot ang maaari mong
inumin o kung hihiling ba ng eksepsiyon.
Sasaklawan namin ang 30-day na supply ng iyong gamot kung:

umiinom ka ng gamot na wala sa aming Listahan ng Gamot, o

hindi ka pinahihintulutan ng mga tuntunin sa planong pangkalusugan na makuha ang
dami na inatas ng iyong tagareseta, o

nangangailangan ang gamot ng paunang pag-apruba ng SCFHP, o

umiinom ka ng gamot na bahagi ng isang paghihigpit sa step therapy.
Kung naninirahan ka sa isang nursing home o iba pang pasilidad sa pangmatagalang
pangangalaga, maaari mong i-refill ang reseta sa iyo nang hanggang 91 days. Maaari mong irefill ang gamot nang maraming beses sa panahon ng iyong unang 90 days sa plan. Nagbibigay
ito ng panahon sa iyong tagareseta na palitan ang iyong mga gamot ng mga nasa Listahan ng
Gamot o humingi ng eksepsiyon.
Kung lumilipat ka sa pagitan ng iba't ibang antas ng pangangalaga (halimbawa, pagpasok o
paglabas sa isang pasilidad sa pangmatagalang pangangalaga o ospital), sasaklawin ng
?
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
vii
SCFHP ang bagong 31-day na supply ng gamot sa paglipat para magamit mo sa iyong bagong
kapaligiran. Ito na ang titingin sa anumang paghihigpit na maaaring umiral.
11. Maaari ka bang humingi ng eksepsiyon upang masaklaw ang
iyong gamot?
Oo. Maaari mong hilingin sa SCFHP Cal MediConnect na magkaroon ng eksepsiyon upang
masaklaw ang isang gamot na wala sa Listahan ng Gamot.
Maaari mo ring hilingin sa amin na baguhin ang mga tuntunin sa iyong gamot.

Halimbawa, maaaring limitahan ng SCFHP Cal MediConnect ang dami ng gamot na
aming sasaklawin. Kung ang iyong gamot ay may limit, maaari mong hilingin sa amin
na baguhin ang limit at dagdagan ang nasasaklaw.

Iba pang mga halimbawa: Maaari mong hilingin sa amin na alisin na ang mga
paghihigpit sa step therapy o mga kinakailangan sa paunang pag-apruba.
12. Gaano katagal makakakuha ng eksepsiyon?
Una, dapat makatanggap kami ng pahayag mula sa iyong taga-reseta na sumusuporta sa iyong
kahilingan para sa isang eksepsiyon. Pagkatapos naming matanggap ang pahayag, magbibigay
kami ng desisyon patungkol sa iyong hiling na eksepsiyon sa loob ng 72 oras.
Kung sa tingin mo o ng iyong taga-reseta ay makasasama sa iyong kalusugan kung
maghihintay pa ng 72 oras para sa isang desisyon, maaari kang humiling ng pinabilis na
eksepsiyon. Ito ay mas mabilis na pagdedesisyon. Kung sinusuportahan ng iyong taga-reseta
ang iyong kahilingan, bibigyan ka namin ng desisyon sa loob 24 na oras pagkatanggap ng
suportang pahayag mula sa iyong tagareseta.
13. Paano ka ba makakahingi ng eksepsiyon?
Upang humingi ng eksepsiyon, tawagan ang Mga Serbisyo para sa Miyembro. Ang Mga
Serbisyo para sa Miyembro ay makikipagtulungan sa iyo at sa iyong tagareseta upang
matulungan ka sa paghingi ng eksepsiyon.
14. Ano ang mga generic na gamot?
Ang mga gamot na generic ay binubuo ng mga parehong sangkap tulad ng sa mga branded
na gamot. Karaniwan mas mura ang mga ito kaysa sa mga branded na gamot at ang mga
pangalan nila ay hindi masyadong kilala. Ang mga generic na gamot ay inaprubahan ng Food
and Drug Administration (FDA).
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
viii
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
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Sinasaklawan ng SCFHP Cal MediConnect ang parehong mga branded na gamot at mga
gamot na generic.
15. Ano ang mga gamot na OTC?
Ang ibig sabihin ng OTC ay “over-the-counter.” Saklaw ng SCFHP Cal MediConnect ang ilang
gamot na OTC kapag inireseta ito ng iyong provider.
Maaari mong basahin ang Listahan ng Gamot ng SCFHP Cal MediConnect upang makita kung
anong mga gamot na OTC ang saklaw.
16. Saklaw ba ng SCFHP Cal MediConnect ang mga produktong OTC
na hindi gamot?
Saklaw ng SCFHP Cal MediConnect ang ilang produktong OTC na hindi gamot kapag inireseta
ito ng iyong provider.
Maaari mong basahin ang Listahan ng Gamot ng SCFHP Cal MediConnect upang makita kung
anong mga produktong OTC na hindi gamot ang saklaw.
17. Ano ang iyong mga copay?
Maaari mong basahin ang Listahan ng Gamot ng SCFHP Cal MediConnect upang malaman
ang tungkol sa co-pay para sa bawat gamot.
Hindi magkakaroon ng mga co-pay ang mga miyembro ng SCFHP Cal MediConnect na
naninirahan sa mga nursing home o iba pang mga pasilidad sa pangmatagalang pangangalaga.
Hindi rin magkakaroon ng mga co-pay ang ilang miyembrong nakakatanggap ng
pangmatagalang pangangalaga sa komunidad.
Inililista ang mga copay ayon sa mga baitang. Ang mga baitang ay grupo ng mga gamot sa
SCFHP Cal MediConnect formulary.
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
Ang baitang 1 na mga gamot ay mayroong $0 na copay. Mga generic na gamot ang
mga ito.

Ang baitang 2 na mga gamot ay may $0 na copay. Mga gamot na branded ang mga ito.

Ang baitang 3 na mga gamot ay may $0 na copay. Mga may-resetang gamot na hindi
galing sa Medicare ang mga ito.

Ang baitang 4 na mga gamot ay may $0 na copay. Mga OTC na gamot na hindi galing
sa Medicare ang mga ito.
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
ix
Listahan ng mga Saklaw na Gamot
Ang listahan ng mga saklaw na gamot na nagsisimula sa susunod na pahina ay nagbibigay
sa iyo ng impormasyon tungkol sa mga gamot na saklaw ng SCFHP Cal MediConnect. Kung
nahihirapan kang hanapin ang iyong gamot sa listahan, pumunta sa Indeks na nagsisimula
sa pahina I-1.
Nakalista sa unang hanay ng chart ang pangalan ng gamot. ng mga branded na gamot ay
nakasulat sa malalaking titik (halimbawa, FLOVENT) at ang mga generic na gamot ay nakasulat
sa maliliit na titik na italics (hal., fluticasone propionate).
Ang impormasyon sa hanay na “Mga kinakailangang aksiyon, paghihigpit, o limit sa paggamit”
ang nagsasabi sa iyo kung may anumang tuntunin ang SCFHP sa pagsasaklaw ng iyong
gamot.
Tandaan: Ang asterisk (*) sa tabi ng gamot ay nangangahulugang ang gamot ay hindi “gamot
ng Part D.” Hindi ka hihilingan na magbayad ng copay para sa mga gamot na ito. Ang mga
gamot na ito ay mayroon ding iba't ibang tuntunin para sa mga pag-apela. Anh apela ay isang
pormal na paraan ng paghiling sa amin na suriin ang isang desisyong aming ginawa tungkol
sa iyong saklaw at upang baguhin ito kung sa tingin mo ay nagkamali kam. Halimbawa,
maaari naming ipasya na ang gusto mong gamot ay hindi saklaw o hindi na saklaw ng
Medicare o Medi-Cal. Kung ikaw o ang iyong doktor ay hindi sang-ayon sa aming desisyon,
maaari kang mag-apela. Kung mayroon kang katanungan, tumawag sa Mga Serbisyo para sa
Miyembro sa 1-877-723-4795. Maaari mo ring basahin ang Handbook ng Miyembro ng SCFHP
Cal MediConnect upang malaman kung paano iapela ang desisyon.
Listahan ng mga Gamot ayon sa Medikal na Kundisyon
Ang mga gamot sa seksyon na ito ay naka-grupo sa mga kategorya depende sa uri ng mga
medikal na kundisyon na ginagamot sila. Bilang halimbawa, kung mayroon kang kundisyon sa
puso, dapat kang mahanap sa kategorya na, Cardiovascular Agents. Doon mo mahahanap ang
gamot na lunas para sa mga kondisyon sa puso.
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
x
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
?
Listahan ng mga Simbolo at Daglat
Ang mga sumusunod na pagdaglat ay maaaring gamitin sa Listahan ng Gamot.
MGA DAGLAT NG MGA TALA NG NASASAKLAWAN
DAGLAT
PAGLALARAWAN
PALIWANAG
Mga Paghihigpit sa Utilization Management
PA
Paunang Pahintulot
(Prior Authorization)
Paunang Pahintulot
(Prior Authorization)
PA BvD
for Part B vs Part D
Determination
(Paunang Pahintulot
para sa Part B vs
Part D na
Pagpapasiya)
Paunang Pahintulot
(Prior Authorization)
for High Risk
Medications
PA-HRM
?
(Paghihigpit sa
Paunang Pahintulot
Para sa Mga Mas
Mapanganib na
Gamot)
Ikaw (o ang iyong doktor) ay kinakailangang
makakuha ng paunang pahintulot mula sa SCFHP Cal
MediConnect bago mo punan ang iyong reseta para
sa gamot na ito. Kapag walang paunang pag-apruba,
maaaring hindi saklawin ng SCFHP Cal MediConnect
ang gamot na ito.
Maaaring maging karapat-dapat ang gamot na ito
para sa pagbabayad sa ilalim ng Medicare Part B o
Part D. Ikaw (o ang iyong doktor) ay kinakailangang
makakuha ng paunang pahintulot mula sa SCFHP Cal
MediConnect upang malaman na saklaw ang gamot
na ito sa ilalim ng Medicare Part D bago mo punan
ang iyong reseta para sa gamot na ito. Kapag walang
paunang pag-apruba, maaaring hindi saklawin ng
SCFHP Cal MediConnect ang gamot na ito.
Itinuring ng CMS ang gamot na ito na posibleng
nakapipinsala at sa gayon ay isang Mas Mapanganib
na Gamot para sa mga benepisyaryo na 65 taong
gulang o mas matanda. Ang mga Miyembrong may
edad 65 taon o mas matanda pa ay kinakailangang
kumuha ng paunang pahintulot mula SCFHP Cal
MediConnect bago punan ang iyong reseta para sa
gamot na ito. Kung walang paunang pag-apruba,
maaaring hindi saklawin ng SCFHP Cal MediConnect
ang gamot na ito.
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
1
DAGLAT
PAGLALARAWAN
Prior Authorization
for New Starts Only
PA NSO
QL
ST
(Paunang Pahintulot
Para sa Mga
Kasisimula Lang)
Quantity Limit
(Limit sa Bilang)
Step Therapy
PALIWANAG
Kung ikaw ay isang bagong miyembro o kung ikaw ay
isang miyembrong nagre-renew at hindi pa nakagamit
dati ng gamot na ito, ikaw (o ang iyong doktor) ay
kinakailangang kumuha ng paunang pahintulot mula sa
SCFHP Cal MediConnect bago mo punan ang iyong
reseta para sa gamot na ito. Kapag walang paunang
pag-apruba, maaaring hindi saklawin ng SCFHP Cal
MediConnect ang gamot na ito.
Nililimitahan ng SCFHP Cal MediConnect ang dami
ng gamot na ito na nasasaklaw kada reseta o sa loob
ng partikular na panahon.
Bago pa man sasaklawin ng SCFHP Cal
MediConnect ang gamot na ito, dapat mo munang
subukan ang iba pang (mga) gamot upang gamutin
ang iyong kondisyong medikal. Maaari lamang
saklawin ang gamot na ito kung ang iba pang (mga)
gamot ay hindi tumatalab sa iyo.
Ang mga sumusunod na pagdaglat ay maaari ring gamitin sa Listahan ng Gamot.
IBA PANG MGA ESPESYAL NA KINAKAILANGAN PARA SA PAGSASAKLAW
DAGLAT
PAGLALARAWAN
PALIWANAG
*
Hindi isang Gamot
sa Part D
Ang gamot na ito ay isang gamot hindi na-Part D. Ito
ay saklaw ng Medi-Cal.
LA
Limited Access Drug
(Gamot na Limitado
ang Access)
Maaaring mabili lamang sa ilang botika ang
resetang ito. Para sa higit na impormasyon,
konsultahin ang Directory ng iyong Botika
o tawagan ang Mga Serbisyo para sa Miyembro sa
1-877-723-4795, 7 araw sa isang linggo, 8 a.m.
hanggang 8 p.m. , kabilang na ang mga bakasyon.
Ang mga gumagamit ng TTY/TDD tumawag sa
1-800-735-2929.
Kung mayroon kang mga katanungan, mangyaring tawagan ang Santa Clara Family Health
Plan sa 1-877-723-4795, 7 araw kada linggo, 8 a.m. hanggang 8 p.m., kabilang ang mga pista
opisyal. Ang mga gumagamit ng TTY/TDD tumawag sa 1-800-735-2929. Libre ang tawag.
2
Para sa higit na impormasyon, bisitahin ang www.scfhp.com.
?
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
Analgesics
Analgesics, Miscellaneous
acephen * 120 mg suppository outer
acephen * 325 mg suppository outer
acetaminophen * 120 mg suppos outer
acetaminophen * 160 mg/5 ml elx
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
acetaminophen * 80 mg/0.8 ml drp infants
(Acetaminophen)
$0 (Tier 4)
acetaminophen-codeine 120 mg-12 mg/5 ml
solution
acetaminophen-codeine oral solution 300
mg-30 mg /12.5 ml
acetaminophen-codeine oral tablet 300-15
mg, 300-30 mg
acetaminophen-codeine oral tablet 300-60
mg
buprenorphine hcl injection syringe
butalb-acetaminophen-caffeine oral
capsule 50-325-40 mg
butalbital-acetaminop-caf-cod
(Acetaminophen with
Codeine)
(Acetaminophen with
Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Buprenorphine HCl)
(Esgic)
$0 (Tier 1)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (2700 per 30 days)
$0 (Tier 1)
QL (2700 per 30 days)
$0 (Tier 1)
QL (360 per 30 days)
$0 (Tier 1)
QL (180 per 30 days)
(Fioricet with Codeine)
$0 (Tier 1)
butalbital-acetaminophen oral tablet 50325 mg
butalbital-acetaminophen-caff oral capsule
50-325-40 mg
butalbital-acetaminophen-caff oral tablet
50-325-40 mg
butalbital-aspirin-caffeine oral capsule
(Tencon)
$0 (Tier 1)
(Esgic)
$0 (Tier 1)
(Esgic)
$0 (Tier 1)
(Fiorinal)
$0 (Tier 1)
(Acetaminophen)
$0 (Tier 2)
$0 (Tier 4)
BUTRANS
child non-aspirin 160 mg/5 ml children's
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
QL (4 per 28 days)
PA; QL (240 per 30
days); AGE (Max 21
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
1
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
child pain & fever 160 mg/5 ml
a/f,gluten/f,cherry
(Infants' Tylenol)
$0 (Tier 4)
children's silapap * elixir
(Tylenol Sore Throat)
$0 (Tier 4)
codeine sulfate oral tablet
codeine-butalbital-asa-caffein oral capsule
30-50-325-40 mg
cvs child non-asa 80 mg tb chw
cvs non-aspirin jr tab chew
fentanyl
fentanyl citrate
(Codeine Sulfate)
(Fiorinal with Codeine
#3)
(Acetaminophen)
(Acetaminophen)
(Duragesic)
(Actiq)
$0 (Tier 1)
$0 (Tier 1)
feverall * 120 mg suppository children's,
outer
feverall * 325 mg suppository junior str,
outer
FEVERALL * 80 MG SUPPOSITORY
INFANT'S, OUTER
hydrocodone-acetaminophen oral solution
10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml,
7.5-325 mg/15 ml
hydrocodone-acetaminophen oral tablet
10-300 mg, 5-300 mg, 7.5-300 mg
(Acetaminophen)
$0 (Tier 4)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (240 per 30
days); AGE (Max 21
Years)
QL (180 per 30 days)
PA-HRM; QL (180 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA; QL (10 per 30 days)
PA; QL (120 per 30
days)
QL (30 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
$0 (Tier 4)
QL (30 per 30 days)
(Hycet)
$0 (Tier 1)
QL (2700 per 30 days)
(Norco)
$0 (Tier 1)
hydrocodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
hydrocodone-ibuprofen
hydromorphone (pf) injection solution 10
mg/ml
hydromorphone (pf) injection solution 4
mg/ml
hydromorphone injection solution
hydromorphone injection syringe 2 mg/ml
(Norco)
$0 (Tier 1)
(includes Vicodin,
Vicodin ES and Vicodin
HP); QL (390 per 30
days)
QL (360 per 30 days)
(Ibudone)
(Dilaudid-HP)
$0 (Tier 1)
$0 (Tier 1)
(Dilaudid)
$0 (Tier 1)
(Hydromorphone HCl)
(Hydromorphone HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
QL (150 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
2
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
hydromorphone oral liquid
hydromorphone oral tablet 2 mg, 4 mg
hydromorphone oral tablet 8 mg
LAZANDA
mapap 160 mg/5 ml elixir unboxed
(Dilaudid)
(Dilaudid)
(Dilaudid)
(Acetaminophen)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
mapap 160 mg/5 ml suspension
(Infants' Tylenol)
$0 (Tier 4)
mapap 325 mg tablet
mapap 500 mg capsule
mapap 500 mg tablet
mapap 80 mg tablet chew
methadone hcl oral tablet,soluble 40 mg
methadone injection
methadone oral solution
methadone oral tablet
morphine 10 mg/ml carpuject
morphine 2 mg/ml carpuject
morphine 4 mg/ml carpuject
morphine 8 mg/ml syringe
morphine concentrate oral solution
morphine concentrate oral syringe
morphine in dextrose 5 % injection pt
controlled analgesia syring 50 mg/25 ml (2
mg/ml)
morphine injection solution 15 mg/ml
morphine injection solution 8 mg/ml
morphine injection syringe 10 mg/ml
morphine intramuscular
morphine intravenous cartridge 15 mg/ml
morphine intravenous solution 25 mg/ml,
50 mg/ml
morphine intravenous syringe
morphine oral solution 10 mg/5 ml
(Tylenol)
(Acetaminophen)
(Tylenol)
(Acetaminophen)
(Diskets)
(Methadone HCl)
(Methadone HCl)
(Diskets)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine
Sulfate/D5W)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
QL (1200 per 30 days)
QL (180 per 30 days)
QL (240 per 30 days)
PA; QL (30 per 30 days)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (240 per 30
days); AGE (Max 21
Years)
QL (360 per 30 days)
QL (240 per 30 days)
QL (240 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (1800 per 30 days)
QL (360 per 30 days)
QL (200 per 30 days)
QL (700 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
3
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
morphine oral solution 20 mg/5 ml
MORPHINE ORAL TABLET
morphine oral tablet extended release 100
mg, 30 mg, 60 mg
morphine oral tablet extended release 15
mg, 200 mg
morphine rectal
nortemp * 80 mg/0.8 ml drop
NUCYNTA
NUCYNTA ER
oxycodone hcl-acetaminophen oral solution
5-325 mg/5 ml
oxycodone hcl-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
oxycodone hcl-aspirin
oxycodone oral concentrate
oxycodone oral solution
oxycodone oral tablet
oxycodone-acetaminophen oral tablet 10325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
oxycodone-acetaminophen oral tablet 10650 mg
oxycodone-acetaminophen oral tablet 7.5500 mg
oxycodone-aspirin
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15 MG,
20 MG, 30 MG, 40 MG, 60 MG
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet
oxymorphone oral tablet extended release
12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
(Morphine Sulfate)
(MS Contin)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
QL (300 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
(MS Contin)
$0 (Tier 1)
QL (180 per 30 days)
(Morphine Sulfate)
(Acetaminophen)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (181 per 30 days)
QL (60 per 30 days)
QL (1800 per 30 days)
$0 (Tier 1)
QL (360 per 30 days)
(Percodan)
(Oxycodone HCl)
(Oxycodone HCl)
(Roxicodone)
(Xolox)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (360 per 30 days)
QL (180 per 30 days)
QL (1300 per 30 days)
QL (180 per 30 days)
QL (360 per 30 days)
(Xolox)
$0 (Tier 1)
QL (180 per 30 days)
(Xolox)
$0 (Tier 1)
QL (240 per 30 days)
(Percodan)
$0 (Tier 1)
$0 (Tier 2)
QL (360 per 30 days)
QL (60 per 30 days)
$0 (Tier 2)
QL (120 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
QL (180 per 30 days)
QL (60 per 30 days)
(Oxycodone
HCl/Acetaminophen)
(Xolox)
(Opana)
(Opana ER)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
4
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
oxymorphone oral tablet extended release
12 hr 30 mg, 40 mg
pain relief * 500 mg capsule
pain reliever 500 mg caplet caplet, exstrength
pharbetol * 325 mg tablet regular strength
pharbetol * 500 mg caplet extra-str, caplet
pv non-aspirin 500 mg softgel ex-str,liq
filled
q-pap * 160 mg/5 ml solution a/f, cherry
(Opana ER)
$0 (Tier 1)
QL (120 per 30 days)
(Acetaminophen)
(Tylenol)
$0 (Tier 4)
$0 (Tier 4)
QL (240 per 30 days)
QL (240 per 30 days)
(Tylenol)
(Tylenol)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
QL (360 per 30 days)
QL (240 per 30 days)
QL (240 per 30 days)
(Tylenol Sore Throat)
$0 (Tier 4)
q-pap * 325 mg tablet
q-pap * 80 mg/0.8 ml drops
(Tylenol)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
q-pap ex-str 500 mg tablet aspirin free
silapap * infant's drops infant's
(Tylenol)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
sm pain rel jr str tab chew
sm pain reliever 80 mg tab children's
tactinal * 325 mg tablet
tactinal 500 mg tablet extra-strength
tramadol oral tablet
tramadol-acetaminophen
xylon 10
Nonsteroidal Anti-Inflammatory
Agents
advil * 100 mg tablet jr strength,coated
advil * 200 mg tablet
advil * jr str 100 mg tab chew tb chew,8
hour,grape
aspirin * 325 mg tablet
aspirin * 81 mg chewable tablet
(Acetaminophen)
(Acetaminophen)
(Tylenol)
(Tylenol)
(Ultram)
(Ultracet)
(Ibudone)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (240 per 30
days); AGE (Max 21
Years)
QL (360 per 30 days)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (240 per 30 days)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (30 per 30 days)
QL (30 per 30 days)
QL (360 per 30 days)
QL (240 per 30 days)
QL (240 per 30 days)
QL (240 per 30 days)
QL (150 per 30 days)
(Motrin Ib)
(Motrin Ib)
(Ibuprofen)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Ecotrin)
(Bayer Chewable
Aspirin)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
5
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
aspirin buffered 325 mg tab
aspirin * ec 325 mg tablet
aspirin * ec 650 mg tablet
aspirin * ec 81 mg tablet low dose
aspir-low * ec 81 mg tablet
bufferin * 325 mg tablet coated
CALDOLOR INTRAVENOUS RECON
SOLN 400 MG/4 ML (100 MG/ML)
celecoxib
children's advil * 100 mg/5 ml a/f (otc)
choline,magnesium salicylate
cvs ibuprofen * 200 mg softgel liquid
filled,softge
cvs naproxen sodium * 220 mg cap
liquidgel
diclofenac potassium
diclofenac sodium oral tablet extended
release 24 hr
diclofenac sodium oral tablet,delayed
release (dr/ec)
diclofenac sodium topical gel
diclofenac-misoprostol
diflunisal
ecotrin * ec 325 mg tablet saftey coated
ecpirin ec 325 mg tablet
etodolac
fenoprofen oral tablet
FLECTOR
flurbiprofen
gnp ibuprofen jr str 100 mg tb
ibuprofen * 100 mg/5 ml susp children's
(otc)
ibuprofen * 200 mg tablet
(Aspirin/Calcium
Carbonate/Mag)
(Ecotrin)
(Ecotrin)
(Ecotrin)
(Ecotrin)
(Aspirin/Calcium
Carbonate/Mag)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
(Celebrex)
(Children'S Motrin)
(Choline Sal/Mag
Salicylate)
(Advil)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
(Aleve)
$0 (Tier 4)
(Diclofenac Potassium)
(Voltaren-XR)
$0 (Tier 1)
$0 (Tier 1)
(Diclofenac Sodium)
$0 (Tier 1)
(Solaraze)
(Arthrotec 50)
(Diflunisal)
(Ecotrin)
(Ecotrin)
(Etodolac)
(Fenoprofen Calcium)
(Flurbiprofen)
(Ibuprofen)
(Children'S Motrin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Motrin Ib)
$0 (Tier 4)
QL (60 per 30 days)
$0 (Tier 4)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
6
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ibuprofen oral suspension 100 mg/5 ml
ibuprofen oral tablet 400 mg, 600 mg, 800
mg
indomethacin oral capsule 25 mg
(Ibuprofen)
(Ibuprofen)
$0 (Tier 1)
$0 (Tier 1)
(Indomethacin)
$0 (Tier 1)
indomethacin oral capsule 50 mg
(Indomethacin)
$0 (Tier 1)
indomethacin oral capsule, extended
release
indomethacin sodium
(Indomethacin)
$0 (Tier 1)
(Indomethacin
Sodium)
(Infants' Motrin)
$0 (Tier 1)
(Ketoprofen)
(Ketoprofen)
$0 (Tier 1)
$0 (Tier 1)
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
(Ec-Naprosyn)
$0 (Tier 1)
(Anaprox)
$0 (Tier 1)
(Feldene)
(Aspirin/Calcium
Carbonate/Mag)
(Salsalate)
(Motrin Ib)
$0 (Tier 1)
$0 (Tier 4)
infant ibuprofen 50 mg/1.25 ml d/f,a/f,nonstaining
ketoprofen oral capsule
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
ketorolac oral
mefenamic acid
meloxicam
nabumetone
naproxen oral suspension
naproxen oral tablet
naproxen oral tablet,delayed release
(dr/ec)
naproxen sodium oral tablet 275 mg, 550
mg
piroxicam
ra aspirin tri-buffered tb
salsalate
sm ibuprofen * ib 100 mg tablet junior
strength
sm naproxen sod 220 mg caplet gluten free, (Midol)
caplet
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (60 per
30 days)
PA-HRM
$0 (Tier 4)
QL (20 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
7
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
st. joseph aspirin 81 mg chew orange
(Bayer Chewable
Aspirin)
(Ecotrin)
$0 (Tier 4)
(Sulindac)
(Tolmetin Sodium)
(Advil)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
glydo
lidocaine (pf) injection solution 15 mg/ml
(1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)
lidocaine 2% viscous soln 2 %
lidocaine hcl injection solution 10 mg/ml (1
%), 20 mg/ml (2 %)
lidocaine hcl laryngotracheal
lidocaine hcl mucous membrane gel
lidocaine hcl mucous membrane jelly in
applicator
lidocaine hcl mucous membrane solution
lidocaine hcl urethral
lidocaine topical adhesive patch,medicated
lidocaine topical ointment
(Lidocaine HCl)
(Xylocaine-MPF)
$0 (Tier 1)
$0 (Tier 1)
(Xylocaine)
(Xylocaine)
$0 (Tier 1)
$0 (Tier 1)
(Xylocaine)
(Lidocaine HCl)
(Lidocaine HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Xylocaine)
(Lidocaine HCl)
(Lidoderm)
(Lidocaine)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
lidocaine-prilocaine topical cream
(EMLA)
$0 (Tier 1)
lidocaine-prilocaine topical kit
RELADOR PAK
(Relador Pak)
$0 (Tier 1)
$0 (Tier 1)
(Acamprosate
Calcium)
$0 (Tier 1)
st. joseph aspirin * ec 81 mg tb enteric
coated
sulindac oral
tolmetin
VOLTAREN TOPICAL
wal-profen * 200 mg softgel softgel
$0 (Tier 4)
Anesthetics
Local Anesthetics
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
PA
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
Anti-Addiction/Substance Abuse
Treatment Agents
Anti-Addiction/Substance Abuse
Treatment Agents
acamprosate
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
8
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
buprenorphine hcl sublingual
buprenorphine-naloxone
bupropion hcl sr 150 mg tablet f/c
CHANTIX
CHANTIX 1 MG CONT MONTH BOX 2
PACKS,F/C,OUTER
CHANTIX 1 MG CONT MONTH PAK
CHANTIX CONTINUING MONTH BOX
ORAL TABLET 1 MG
CHANTIX STARTING MONTH BOX
disulfiram
naloxone
naltrexone hcl
naltrexone oral
nicorelief * 2 mg gum
nicorelief * 4 mg gum
nicorette * 2 mg chewing gum white ice
mint
nicotine * 14 mg/24hr patch outer (otc)
nicotine 2 mg chewing gum sugar free
nicotine 2 mg lozenge mint, 3 quittube
nicotine * 21 mg/24hr patch step 1 (otc)
nicotine * 22 mg/24hr patch 1 week starter
kit
nicotine 4 mg chewing gum
nicotine 4 mg lozenge mint, 3 quittube
nicotine * 7 mg/24hr patch (otc)
NICOTROL
ZUBSOLV
(Subutex)
(Buprenorphine
HCl/Naloxone HCl)
(Zyban)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (90 per 30 days)
PA; QL (90 per 30 days)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
QL (168 per 84 days)
QL (168 per 84 days)
$0 (Tier 2)
$0 (Tier 2)
QL (56 per 28 days)
QL (56 per 28 days)
QL (53 per 28 days)
(Revia)
(Nicorette)
(Nicorette)
(Nicorette)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Nicoderm Cq)
(Nicorette)
(Nicorette)
(Nicoderm Cq)
(Nicoderm Cq)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
QL (224 per 365 days)
QL (3285 per 365 days)
QL (3285 per 365 days)
QL (224 per 365 days)
QL (224 per 365 days)
(Nicorette)
(Nicorette)
(Nicoderm Cq)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
QL (3285 per 365 days)
QL (3285 per 365 days)
QL (224 per 365 days)
QL (1008 per 90 days)
PA; QL (90 per 30 days)
(Xanax)
(Chlordiazepoxide
HCl)
$0 (Tier 1)
$0 (Tier 1)
QL (120 per 30 days)
QL (120 per 30 days)
(Antabuse)
(Naloxone HCl)
QL (3285 per 365 days)
QL (3285 per 365 days)
QL (3285 per 365 days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet
chlordiazepoxide hcl
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
9
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
clonazepam oral tablet 0.5 mg, 1 mg
clonazepam oral tablet 2 mg
clonazepam oral tablet,disintegrating 0.125
mg, 0.25 mg, 0.5 mg, 1 mg
clonazepam oral tablet,disintegrating 2 mg
clorazepate dipotassium oral tablet 15 mg
clorazepate dipotassium oral tablet 3.75
mg, 7.5 mg
diazepam injection solution
diazepam intensol
diazepam oral solution 5 mg/5 ml (1 mg/ml)
diazepam oral tablet
diazepam rectal
lorazepam oral tablet
ONFI ORAL SUSPENSION
(Klonopin)
(Klonopin)
(Clonazepam)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
QL (300 per 30 days)
QL (90 per 30 days)
(Clonazepam)
(Tranxene T-Tab)
(Tranxene T-Tab)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (300 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
(Diazepam)
(Diazepam)
(Diazepam)
(Valium)
(Diastat)
(Ativan)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (10 per 28 days)
QL (1200 per 30 days)
QL (1200 per 30 days)
QL (120 per 30 days)
ONFI ORAL TABLET 10 MG, 20 MG
$0 (Tier 2)
QL (90 per 30 days)
PA NSO; QL (480 per
30 days)
PA NSO; QL (60 per 30
days)
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 100 mg/50 ml,
60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml,
80 mg/50 ml, 90 mg/100 ml
gentamicin injection solution 40 mg/ml
gentamicin ped 20 mg/2 ml vial
25's,pedi,latex-free
gentamicin sulfate (pf) intravenous solution
80 mg/8 ml
neomycin
streptomycin intramuscular
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION DEVICE
tobramycin in 0.225 % nacl
(Gentamicin In Nacl,
Iso-Osm)
(Gentamicin Sulfate)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin Sulfate)
(Tobi)
$0 (Tier 2)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (224 per 28 days)
$0 (Tier 1)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
10
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
tobramycin in 0.9 % nacl
tobramycin sulfate injection solution
Antibacterials, Miscellaneous
bacitracin intramuscular
chloramphenicol sod succinate
clindamycin 75 mg/5 ml soln
clindamycin hcl
clindamycin in 5 % dextrose
clindamycin ph 9 g/60 ml vial bulk vial
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na)
CUBICIN
linezolid
methenamine hippurate
methenamine mandelate
metronidazole in nacl (iso-os)
(Tobramycin/Sodium
Chloride)
(Tobramycin Sulfate)
$0 (Tier 1)
(Bacitracin)
(Chloramphenicol Sod
Succ)
(Cleocin Palmitate)
(Cleocin HCl)
(Cleocin Phosphate In
D5w)
(Cleocin Phosphate)
(Cleocin Phosphate)
$0 (Tier 1)
$0 (Tier 1)
(Coly-Mycin M
Parenteral)
$0 (Tier 1)
(Zyvox)
(Hiprex)
(Methenamine
Mandelate)
(Metronidazole/Sodiu
m Chloride)
(Flagyl)
(Macrodantin)
metronidazole oral
nitrofurantoin macrocrystal oral capsule
100 mg, 25 mg
nitrofurantoin macrocrystal oral capsule 50 (Macrodantin)
mg
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; QL (120 per
30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (120 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
11
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
nitrofurantoin monohyd/m-cryst
(Macrobid)
$0 (Tier 1)
polymyxin b sulfate
SYNERCID
trimethoprim
vancomycin hcl 1g/200 ml bag
(Polymyxin B Sulfate)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Trimethoprim)
(Vancomycin
HCl/D5W)
(Vancomycin HCl)
vancomycin intravenous recon soln 1,000
mg, 10 gram, 750 mg
vancomycin intravenous recon soln 500 mg (Vancomycin
HCl/D5W)
vancomycin oral
(Vancocin HCl)
XIFAXAN ORAL TABLET 200 MG
XIFAXAN ORAL TABLET 550 MG
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION
Cephalosporins
cefaclor oral capsule
(Cefaclor)
cefaclor oral suspension for reconstitution (Cefaclor)
125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
cefadroxil oral capsule
(Cefadroxil)
cefadroxil oral suspension for
(Cefadroxil)
reconstitution 250 mg/5 ml, 500 mg/5 ml
cefadroxil oral tablet
(Cefadroxil)
CEFAZOLIN IN DEXTROSE (ISO-OS)
INTRAVENOUS PIGGYBACK 1
GRAM/50 ML
cefazolin in dextrose (iso-os) intravenous
(Cefazolin
piggyback 2 gram/50 ml
Sodium/Dextrose, Iso)
cefazolin injection recon soln 1 gram, 10
(Cefazolin Sodium)
gram, 100 gram, 300 g, 500 mg
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (120 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (9 per 30 days)
PA
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
12
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
cefdinir
cefditoren pivoxil
cefepime
CEFEPIME 2 GM INJECTION
CEFEPIME IN DEXTROSE 5 %
cefotaxime
cefoxitin
cefoxitin in dextrose, iso-osm intravenous
piggyback 2 gram/50 ml
cefpodoxime
cefprozil
ceftazidime injection recon soln 2 gram, 6
gram
ceftibuten
ceftriaxone 1 gm piggyback 50ml
galaxycontainer
ceftriaxone 1 gm vial 10's, fliptop,l/f
CEFTRIAXONE 2 GM PIGGYBACK
50ML GALAXYCONTAINER
ceftriaxone injection recon soln 10 gram,
250 mg, 500 mg
ceftriaxone intravenous recon soln 1 gram
CEFTRIAXONE INTRAVENOUS
RECON SOLN 2 GRAM
cefuroxime axetil oral tablet
cefuroxime sodium injection recon soln 1.5
gram, 750 mg
cefuroxime sodium intravenous
cephalexin oral capsule
cephalexin oral suspension for
reconstitution
cephalexin oral tablet
MEFOXIN IN DEXTROSE (ISO-OSM)
SUPRAX ORAL TABLET,CHEWABLE
(Cefdinir)
(Spectracef)
(Maxipime)
(Claforan)
(Cefoxitin Sodium)
(Cefoxitin
Sodium/Dextrose, Iso)
(Cefpodoxime
Proxetil)
(Cefprozil)
(Fortaz)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cedax)
(Ceftriaxone
Na/Dextrose, Iso)
(Rocephin)
$0 (Tier 1)
$0 (Tier 1)
(Rocephin)
$0 (Tier 1)
(Ceftriaxone
Na/Dextrose, Iso)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Ceftin)
(Zinacef)
$0 (Tier 1)
$0 (Tier 1)
(Zinacef)
(Keflex)
(Cephalexin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cephalexin)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
13
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
TEFLARO
Macrolides
azithromycin
clarithromycin oral suspension for
reconstitution
clarithromycin oral tablet
clarithromycin oral tablet extended release
24 hr
DIFICID
ERYTHROCIN
erythromycin base oral tablet,delayed
release (dr/ec) 250 mg, 500 mg
ERYTHROMYCIN BASE ORAL
TABLET,DELAYED RELEASE (DR/EC)
333 MG
erythromycin ethylsuccinate oral
suspension for reconstitution
erythromycin ethylsuccinate oral tablet
erythromycin oral capsule,delayed
release(dr/ec)
erythromycin oral tablet
erythromycin stearate oral tablet 250 mg
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1 gram
CAYSTON
imipenem-cilastatin
INVANZ
meropenem intravenous recon soln 500 mg
meropenem iv 1 gm vial 25's,latex-free
Penicillins
amoxicillin oral capsule
amoxicillin oral suspension for
reconstitution
$0 (Tier 2)
(Zithromax)
(Biaxin)
$0 (Tier 1)
$0 (Tier 1)
(Biaxin)
(Clarithromycin)
$0 (Tier 1)
$0 (Tier 1)
(Erythromycin Base)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
QL (20 per 10 days)
$0 (Tier 2)
(Eryped 200)
$0 (Tier 1)
(Erythromycin
Ethylsuccinate)
(Erythromycin Base)
$0 (Tier 1)
(Erythromycin Base)
(Erythromycin
Stearate)
$0 (Tier 1)
$0 (Tier 1)
(Azactam)
(Merrem)
(Merrem)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Amoxicillin)
(Amoxicillin)
$0 (Tier 1)
$0 (Tier 1)
(Primaxin)
$0 (Tier 1)
LA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
14
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
amoxicillin oral tablet
amoxicillin oral tablet,chewable 125 mg,
250 mg
amoxicillin-pot clavulanate oral suspension
for reconstitution
amoxicillin-pot clavulanate oral tablet
amoxicillin-pot clavulanate oral tablet
extended release 12 hr
amoxicillin-pot clavulanate oral
tablet,chewable
ampicillin
ampicillin 2 gm vial 10's, latex-free
ampicillin sodium injection recon soln 1
gram, 10 gram, 125 mg
ampicillin sodium intravenous recon soln 2
gram
ampicillin-sulbactam 1.5 gm vl p/f, latexfree
ampicillin-sulbactam injection recon soln
15 gram, 3 gram
ampicillin-sulbactam intravenous recon
soln 1.5 gram
BICILLIN C-R
BICILLIN L-A
dicloxacillin
nafcillin 2 gm vial sterile, latex-free
nafcillin injection recon soln 1 gram, 10
gram
nafcillin intravenous recon soln 2 gram
oxacillin 1 gm add-vantage vl add-vantage,
inner
oxacillin in dextrose(iso-osm)
oxacillin injection recon soln 10 gram
oxacillin intravenous recon soln 2 gram
(Amoxicillin)
(Amoxicillin)
$0 (Tier 1)
$0 (Tier 1)
(Augmentin)
$0 (Tier 1)
(Augmentin)
(Augmentin XR)
$0 (Tier 1)
$0 (Tier 1)
(Amoxicillin/Potassiu
m Clav)
(Ampicillin
Trihydrate)
(Ampicillin Sodium)
(Ampicillin Sodium)
$0 (Tier 1)
(Ampicillin Sodium)
$0 (Tier 1)
(Unasyn)
$0 (Tier 1)
(Unasyn)
$0 (Tier 1)
(Unasyn)
$0 (Tier 1)
(Dicloxacillin Sodium)
(Nafcillin Sodium)
(Nafcillin Sodium)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Nafcillin Sodium)
(Oxacillin Sodium)
$0 (Tier 1)
$0 (Tier 1)
(Oxacillin
Sodium/Dextrose, Iso)
(Oxacillin Sodium)
(Oxacillin Sodium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
15
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
penicillin g pot in dextrose
penicillin g potassium injection recon soln
20 million unit, 5 million unit
penicillin g procaine
penicillin gk 20 million unit
penicillin v potassium
piperacillin-tazobactam intravenous recon
soln 2.25 gram, 3.375 gram, 4.5 gram
piperacil-tazobact 40.5 gram p/f, pharmacy
bulk
Quinolones
ciprofloxacin
ciprofloxacin 200 mg/20 ml vl sdv,latexfree
ciprofloxacin hcl oral
ciprofloxacin in 5 % dextrose intravenous
piggyback 200 mg/100 ml
ciprofloxacin lactate intravenous solution
400 mg/40 ml
ciprofloxacn-d5w 400 mg/200 ml p/f,latex/f,
in d5w
levofloxacin in d5w intravenous piggyback
500 mg/100 ml
levofloxacin intravenous
levofloxacin oral
levofloxacin-d5w 750 mg/150 ml 24's,outer,
p/f
moxifloxacin
ofloxacin oral tablet 400 mg
Sulfonamides
sulfadiazine oral
sulfamethoxazole-trimethoprim intravenous
(Pen G Pot/DextroseWater)
(Penicillin G
Potassium)
(Penicillin G Procaine)
(Penicillin G
Potassium)
(Penicillin V
Potassium)
(Zosyn)
$0 (Tier 1)
(Zosyn)
$0 (Tier 1)
(Cipro)
(Ciprofloxacin Lactate)
$0 (Tier 1)
$0 (Tier 1)
(Cipro)
(Cipro I.V.)
$0 (Tier 1)
$0 (Tier 1)
(Ciprofloxacin Lactate)
$0 (Tier 1)
(Cipro I.V.)
$0 (Tier 1)
(Levaquin)
$0 (Tier 1)
(Levofloxacin)
(Levaquin)
(Levaquin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Avelox)
(Ofloxacin)
$0 (Tier 1)
$0 (Tier 1)
(Sulfadiazine)
(Sulfamethoxazole/Tri
methoprim)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
16
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
sulfamethoxazole-trimethoprim oral
suspension
sulfamethoxazole-trimethoprim oral tablet
sulfasalazine dr 500 mg tab
sulfasalazine oral tablet
sulfatrim
sulfazine
sulfazine ec
Tetracyclines
doxy 100 vial 10's, p/f 100 mg
doxycycline hyclate 100 mg cap
doxycycline hyclate 100 mg tab f/c
doxycycline hyclate intravenous
doxycycline hyclate oral capsule 100 mg
doxycycline hyclate oral capsule 50 mg
doxycycline hyclate oral tablet 100 mg, 50
mg
doxycycline hyclate oral tablet 20 mg
doxycycline mono 100 mg cap
doxycycline mono 100 mg tablet f/c
doxycycline mono 50 mg tablet
doxycycline monohydrate oral capsule 150
mg, 50 mg, 75 mg
doxycycline monohydrate oral suspension
for reconstitution
doxycycline monohydrate oral tablet 150
mg, 75 mg
minocycline oral capsule
minocycline oral tablet
tetracycline
TYGACIL
(Sulfamethoxazole/Tri
methoprim)
(Bactrim)
(Azulfidine)
(Azulfidine)
(Sulfamethoxazole/Tri
methoprim)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Azulfidine)
$0 (Tier 1)
$0 (Tier 1)
(Doxycycline Hyclate)
(Morgidox)
(Doryx)
(Doxycycline Hyclate)
(Adoxa)
(Morgidox)
(Avidoxy)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Doryx)
(Adoxa)
(Avidoxy)
(Avidoxy)
(Adoxa)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Vibramycin)
$0 (Tier 1)
(Avidoxy)
$0 (Tier 1)
(Minocin)
(Minocycline HCl)
(Tetracycline HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
Anticancer Agents
Anticancer Agents
ABRAXANE
$0 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
17
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ADCETRIS
adrucil 2,500 mg/50 ml vial outer, latexfree 2.5 gram/50 ml
AFINITOR DISPERZ
$0 (Tier 2)
(Fluorouracil)
$0 (Tier 1)
$0 (Tier 2)
AFINITOR ORAL TABLET 10 MG
$0 (Tier 2)
AFINITOR ORAL TABLET 2.5 MG, 5
MG, 7.5 MG
ALECENSA
$0 (Tier 2)
ALIMTA INTRAVENOUS RECON
SOLN 500 MG
anastrozole
AVASTIN
azacitidine
BELEODAQ
BENDEKA
bexarotene
$0 (Tier 2)
bicalutamide
bleomycin injection recon soln 30 unit
bleomycin sulfate 15 unit vial latex-free
BLINCYTO
$0 (Tier 2)
(Arimidex)
(Vidaza)
(Targretin)
(Casodex)
(Bleomycin Sulfate)
(Bleomycin Sulfate)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
BOSULIF ORAL TABLET 100 MG
$0 (Tier 2)
BOSULIF ORAL TABLET 500 MG
$0 (Tier 2)
CAPRELSA ORAL TABLET 100 MG
$0 (Tier 2)
CAPRELSA ORAL TABLET 300 MG
$0 (Tier 2)
COMETRIQ
$0 (Tier 2)
PA NSO; QL (4 per 21
days)
PA BvD
PA NSO; QL (112 per
28 days)
PA NSO; QL (56 per 28
days)
PA NSO; QL (28 per 28
days)
PA NSO; QL (240 per
30 days)
PA NSO
PA NSO
PA NSO
PA NSO; QL (420 per
30 days)
PA BvD
PA BvD
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (30 per 30
days)
PA NSO; QL (60 per 30
days)
PA NSO; QL (30 per 30
days)
PA NSO; QL (112 per
28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
18
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
COTELLIC
cyclophosphamide intravenous recon soln 2
gram
CYCLOPHOSPHAMIDE ORAL
CAPSULE
cyclophosphamide oral tablet
CYRAMZA
dactinomycin
DARZALEX
decitabine
doxorubicin hcl intravenous recon soln 10
mg
doxorubicin hcl peg-liposomal intravenous
suspension 2 mg/ml
doxorubicin, peg-liposomal
DROXIA
ELIGARD SUBCUTANEOUS SYRINGE
22.5 MG (3 MONTH)
ELIGARD SUBCUTANEOUS SYRINGE
30 MG (4 MONTH)
ELIGARD SUBCUTANEOUS SYRINGE
45 MG (6 MONTH)
ELIGARD SUBCUTANEOUS SYRINGE
7.5 MG (1 MONTH)
EMCYT
EMPLICITI
ERIVEDGE
ETOPOPHOS
etoposide intravenous
exemestane
FARESTON
FARYDAK
FASLODEX
floxuridine
$0 (Tier 2)
$0 (Tier 1)
PA NSO; LA; QL (63
per 28 days)
PA BvD
$0 (Tier 2)
PA BvD; ST
PA BvD; ST
PA NSO
(Dacogen)
(Doxorubicin HCl)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Doxil)
$0 (Tier 1)
PA BvD
(Doxil)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
QL (1 per 112 days)
$0 (Tier 2)
QL (1 per 168 days)
(Cyclophosphamide)
(Cyclophosphamide)
(Dactinomycin)
PA NSO; LA
PA BvD
QL (1 per 84 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Etoposide)
(Aromasin)
(Floxuridine)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
PA NSO
PA NSO; QL (30 per 30
days)
PA NSO
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
19
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
fluorouracil 5,000 mg/100 ml latex-free
fluorouracil intravenous solution 2.5
gram/50 ml, 500 mg/10 ml
flutamide
GAZYVA
GILOTRIF
(Fluorouracil)
(Fluorouracil)
$0 (Tier 1)
$0 (Tier 1)
(Flutamide)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
GLEEVEC ORAL TABLET 100 MG
$0 (Tier 2)
GLEEVEC ORAL TABLET 400 MG
$0 (Tier 2)
HERCEPTIN
HEXALEN
hydroxyurea
IBRANCE
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
(Hydrea)
ICLUSIG ORAL TABLET 15 MG
$0 (Tier 2)
ICLUSIG ORAL TABLET 45 MG
$0 (Tier 2)
ifosfamide 1 gm/20 ml vial sd polymer vial
ifosfamide intravenous recon soln 1 gram
ifosfamide-mesna
IMBRUVICA
IMLYGIC INJECTION SUSPENSION
10EXP6 (1 MILLION) PFU/ML
IMLYGIC INJECTION SUSPENSION
10EXP8 (100 MILLION) PFU/ML
INLYTA ORAL TABLET 1 MG
(Ifex)
(Ifex)
(Ifosfamide/Mesna)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
INLYTA ORAL TABLET 5 MG
$0 (Tier 2)
IRESSA
$0 (Tier 2)
IXEMPRA 15 MG KIT WITH DILUENT
$0 (Tier 2)
PA BvD
PA BvD
PA NSO
PA NSO; QL (30 per 30
days)
PA NSO; QL (90 per 30
days)
PA NSO; QL (60 per 30
days)
PA NSO
PA NSO; QL (21 per 28
days)
PA NSO; QL (60 per 30
days)
PA NSO; QL (30 per 30
days)
PA BvD
PA BvD
PA BvD
PA NSO
PA NSO; QL (4 per 365
days)
PA NSO; QL (8 per 28
days)
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per 30
days)
PA NSO; QL (60 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
20
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
IXEMPRA INTRAVENOUS RECON
SOLN 45 MG
JAKAFI
$0 (Tier 2)
KEYTRUDA 100 MG/4 ML VIAL
LATEX-FREE,P/F,INNER
KEYTRUDA INTRAVENOUS RECON
SOLN
KYPROLIS
$0 (Tier 2)
PA NSO; QL (60 per 30
days)
PA NSO
$0 (Tier 2)
PA NSO
$0 (Tier 2)
LENVIMA
letrozole
LEUKERAN
leuprolide subcutaneous kit
lomustine
LONSURF ORAL TABLET 15-6.14 MG
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA NSO; QL (6 per 28
days)
PA NSO
$0 (Tier 2)
(Femara)
(Leuprolide Acetate)
(Lomustine)
LONSURF ORAL TABLET 20-8.19 MG
$0 (Tier 2)
LUPRON DEPOT
LUPRON DEPOT (3 MONTH)
LUPRON DEPOT (4 MONTH)
LUPRON DEPOT (6 MONTH)
LYNPARZA
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
LYSODREN
MATULANE
megestrol oral tablet
MEKINIST ORAL TABLET 0.5 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
(Megestrol Acetate)
MEKINIST ORAL TABLET 2 MG
$0 (Tier 2)
mercaptopurine
(Mercaptopurine)
methotrexate 50 mg/2 ml vial latex-free, 5's, (Methotrexate Sodium)
mdv
$0 (Tier 1)
$0 (Tier 1)
PA NSO; QL (100 per
28 days)
PA NSO; QL (80 per 28
days)
QL (1 per 84 days)
QL (1 per 84 days)
QL (1 per 168 days)
PA NSO; QL (480 per
30 days)
PA NSO; QL (90 per 30
days)
PA NSO; QL (30 per 30
days)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
21
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
methotrexate sodium (pf) injection recon
soln
methotrexate sodium (pf) injection solution
methotrexate sodium oral
mitoxantrone
NEXAVAR
(Methotrexate
Sodium/PF)
(Methotrexate Sodium)
(Methotrexate Sodium)
(Mitoxantrone HCl)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA BvD
PA BvD; ST
NILANDRON
NINLARO
$0 (Tier 2)
$0 (Tier 2)
ODOMZO
ONCASPAR
OPDIVO INTRAVENOUS SOLUTION 40
MG/4 ML
POMALYST
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PORTRAZZA
$0 (Tier 2)
PROLEUKIN
PURIXAN
REVLIMID
RITUXAN
SOLTAMOX
SPRYCEL ORAL TABLET 100 MG, 140
MG, 50 MG, 70 MG, 80 MG
SPRYCEL ORAL TABLET 20 MG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
STIVARGA
$0 (Tier 2)
SUTENT
$0 (Tier 2)
SYLVANT
SYNRIBO
$0 (Tier 2)
$0 (Tier 2)
TABLOID
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA NSO; QL (120 per
30 days)
PA NSO; QL (3 per 28
days)
PA NSO; LA
PA NSO
PA NSO
PA NSO; QL (21 per 28
days)
PA NSO; QL (100 per
21 days)
PA NSO; LA
PA NSO
PA NSO; QL (30 per 30
days)
PA NSO; QL (60 per 30
days)
PA NSO; QL (84 per 28
days)
PA NSO; QL (30 per 30
days)
PA NSO
PA NSO; QL (28 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
22
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
TAFINLAR
$0 (Tier 2)
TAGRISSO
$0 (Tier 2)
tamoxifen
TARCEVA ORAL TABLET 100 MG, 25
MG
TARCEVA ORAL TABLET 150 MG
(Tamoxifen Citrate)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
TARGRETIN ORAL
$0 (Tier 2)
TARGRETIN TOPICAL
$0 (Tier 2)
TASIGNA
$0 (Tier 2)
TEMODAR INTRAVENOUS
thiotepa
(Thiotepa)
toposar
(Etoposide)
TREANDA 25 MG VIAL
TREANDA INTRAVENOUS RECON
SOLN 100 MG
TREANDA INTRAVENOUS SOLUTION
TRELSTAR 22.5 MG SYRINGE WITH
MIXJECT
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION
TRELSTAR INTRAMUSCULAR
SYRINGE 11.25 MG/2 ML
TRELSTAR INTRAMUSCULAR
SYRINGE 3.75 MG/2 ML
tretinoin (chemotherapy)
(Tretinoin)
TREXALL
TYKERB
UNITUXIN
VALSTAR
VELCADE
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
PA NSO; QL (120 per
30 days)
PA NSO; LA; QL (30
per 30 days)
PA NSO; QL (60 per 30
days)
PA NSO; QL (90 per 30
days)
PA NSO; QL (420 per
30 days)
PA NSO; QL (60 per 28
days)
PA NSO; QL (112 per
28 days)
PA NSO; (vial only)
$0 (Tier 2)
$0 (Tier 2)
QL (1 per 168 days)
$0 (Tier 2)
QL (1 per 168 days)
$0 (Tier 2)
QL (1 per 84 days)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(capsule: 10mg)
PA BvD; ST
PA NSO
PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
23
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
vinorelbine intravenous solution 50 mg/5
ml
VOTRIENT
(Navelbine)
$0 (Tier 1)
$0 (Tier 2)
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per 30
days)
PA NSO; QL (120 per
30 days)
PA NSO
XALKORI
$0 (Tier 2)
XTANDI
$0 (Tier 2)
YERVOY INTRAVENOUS SOLUTION
50 MG/10 ML (5 MG/ML)
YONDELIS
ZELBORAF
$0 (Tier 2)
ZOLADEX SUBCUTANEOUS IMPLANT
10.8 MG
ZOLADEX SUBCUTANEOUS IMPLANT
3.6 MG
ZOLINZA
ZYDELIG
$0 (Tier 2)
PA NSO
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
$0 (Tier 2)
QL (1 per 28 days)
ZYKADIA
$0 (Tier 2)
ZYTIGA
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA NSO; QL (60 per 30
days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4 mg/ml
atropine injection syringe 0.05 mg/ml, 0.1
mg/ml
propantheline
STIOLTO RESPIMAT
(Atropine Sulfate)
(Atropine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
(Propantheline
Bromide)
$0 (Tier 1)
$0 (Tier 2)
QL (4 per 28 days)
$0 (Tier 2)
$0 (Tier 2)
ST
ST
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
24
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
carbamazepine oral capsule, er multiphase
12 hr
carbamazepine oral suspension 100 mg/5
ml
carbamazepine oral tablet extended release
12 hr
carbamazepine oral tablet,chewable
CELONTIN ORAL CAPSULE 300 MG
DILANTIN
divalproex oral capsule, sprinkle
divalproex oral tablet extended release 24
hr
divalproex oral tablet,delayed release
(dr/ec)
ethosuximide
felbamate
fosphenytoin 500 mg pe/10 ml
10's,sdv,latex-free
fosphenytoin injection solution 100 mg pe/2
ml
FYCOMPA ORAL TABLET
gabapentin oral capsule
gabapentin oral solution 250 mg/5 ml
gabapentin oral tablet 600 mg, 800 mg
GABITRIL ORAL TABLET 12 MG, 16
MG
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
lamotrigine oral tablet
lamotrigine oral tablet extended release
24hr
lamotrigine oral tablet, chewable
dispersible
lamotrigine oral tablets,dose pack 25 mg
(35)
levetiracetam intravenous
(Carbatrol)
$0 (Tier 1)
(Tegretol)
$0 (Tier 1)
(Tegretol XR)
$0 (Tier 1)
(Carbamazepine)
(Depakote Sprinkle)
(Depakote ER)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Depakote)
$0 (Tier 1)
(Zarontin)
(Felbatol)
(Cerebyx)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cerebyx)
$0 (Tier 1)
(Neurontin)
(Neurontin)
(Neurontin)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
ST
$0 (Tier 2)
(Lamictal)
(Lamictal XR)
$0 (Tier 1)
$0 (Tier 1)
(Lamictal)
$0 (Tier 1)
(Lamictal (Blue))
$0 (Tier 1)
(Keppra)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
25
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
levetiracetam oral solution 100 mg/ml
levetiracetam oral tablet
levetiracetam oral tablet extended release
24 hr
LYRICA ORAL CAPSULE
LYRICA ORAL SOLUTION
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital oral elixir
phenobarbital oral tablet 100 mg, 15 mg,
16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection solution
phenytoin oral suspension 125 mg/5 ml
phenytoin oral tablet,chewable
phenytoin sodium
phenytoin sodium extended
POTIGA ORAL TABLET 200 MG, 300
MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone
SABRIL
tiagabine
topiramate
topiramate oral capsule, sprinkle
topiramate oral capsule,sprinkle,er 24hr
TROKENDI XR
valproate sodium
valproic acid
valproic acid (as sodium salt) oral solution
250 mg/5 ml
VIMPAT INTRAVENOUS
VIMPAT ORAL SOLUTION
(Keppra)
(Keppra)
(Keppra XR)
(Trileptal)
(Phenobarbital)
(Phenobarbital)
(Phenobarbital)
(Phenobarbital
Sodium)
(Dilantin-125)
(Dilantin)
(Phenytoin Sodium)
(Dilantin)
(Mysoline)
(Gabitril)
(Topamax)
(Topamax)
(Qudexy XR)
(Depacon)
(Depakene)
(Depakene)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
QL (900 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
QL (200 per 30 days)
QL (2 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (90 per 30 days)
ST
QL (1500 per 30 days)
QL (90 per 30 days)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (270 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
QL (200 per 5 days)
QL (1200 per 30 days)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
26
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
VIMPAT ORAL TABLET
zonisamide
(Zonegran)
$0 (Tier 2)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (200 per 30 days)
QL (60 per 30 days)
QL (360 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
$0 (Tier 2)
QL (30 per 30 days)
$0 (Tier 2)
$0 (Tier 1)
QL (60 per 30 days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet
donepezil oral tablet,disintegrating
EXELON TRANSDERMAL
galantamine oral capsule,ext rel. pellets 24
hr
galantamine oral solution
galantamine oral tablet
memantine oral solution
memantine oral tablet
memantine oral tablets,dose pack
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
NAMZARIC
rivastigmine tartrate
(Aricept)
(Donepezil HCl)
(Razadyne ER)
(Galantamine Hbr)
(Razadyne)
(Namenda)
(Namenda)
(Namenda)
(Exelon)
Antidepressants
Antidepressants
amitriptyline
amoxapine
BRINTELLIX
bupropion hcl oral tablet
bupropion hcl oral tablet extended release ,
150 mg
bupropion hcl oral tablet extended release
24 hr
citalopram oral solution
citalopram oral tablet
clomipramine
desipramine oral
(Amitriptyline HCl)
(Amoxapine)
(Wellbutrin)
(Wellbutrin SR)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Wellbutrin XL)
$0 (Tier 1)
(Citalopram
Hydrobromide)
(Celexa)
(Anafranil)
(Norpramin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA NSO-HRM
ST
QL (30 per 30 days)
PA NSO-HRM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
27
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
doxepin oral
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
duloxetine oral capsule,delayed
release(dr/ec) 30 mg
duloxetine oral capsule,delayed
release(dr/ec) 40 mg
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine oral capsule
fluoxetine oral capsule,delayed
release(dr/ec)
fluoxetine oral solution
fluoxetine oral tablet 10 mg, 20 mg
fluvoxamine
imipramine hcl
imipramine pamoate
maprotiline
MARPLAN
mirtazapine
nefazodone
nortriptyline oral capsule
nortriptyline oral solution
olanzapine-fluoxetine
paroxetine hcl oral tablet
paroxetine hcl oral tablet extended release
24 hr
PAXIL ORAL SUSPENSION
perphenazine-amitriptyline
phenelzine
PRISTIQ
protriptyline
sertraline
SILENOR
(Doxepin HCl)
(Duloxetine)
$0 (Tier 1)
$0 (Tier 1)
(Duloxetine)
$0 (Tier 1)
(Duloxetine)
$0 (Tier 1)
(Lexapro)
(Prozac)
(Prozac Weekly)
(Fluoxetine HCl)
(Fluoxetine HCl)
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-Pm)
(Maprotiline HCl)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Nortriptyline HCl)
(Symbyax)
(Paxil)
(Paxil CR)
(Perphenazine/Amitrip
tyline HCl)
(Nardil)
(Protriptyline HCl)
(Zoloft)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA NSO-HRM
(Cymbalta); QL (60 per
30 days)
(Cymbalta); QL (30 per
30 days)
(Irenka); QL (30 per 30
days)
QL (30 per 30 days)
ST
PA NSO-HRM
PA NSO-HRM
PA NSO-HRM
ST; QL (30 per 30 days)
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
28
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
SURMONTIL
tranylcypromine
trazodone
trimipramine
venlafaxine oral capsule,extended release
24hr
venlafaxine oral tablet
venlafaxine oral tablet extended release
24hr 150 mg, 37.5 mg, 75 mg
VIIBRYD
(Parnate)
(Trazodone HCl)
(Trimipramine
Maleate)
(Effexor XR)
(Venlafaxine HCl)
(Venlafaxine HCl)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA NSO-HRM
PA NSO-HRM
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
acarbose
(Precose)
CYCLOSET
GLYXAMBI
INVOKAMET ORAL TABLET 150-1,000
MG, 150-500 MG, 50-1,000 MG
INVOKAMET ORAL TABLET 50-500
MG
INVOKANA ORAL TABLET 100 MG
INVOKANA ORAL TABLET 300 MG
JANUMET
JANUMET XR
JANUVIA
JARDIANCE
JENTADUETO
KORLYM
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended release 24
hr 500 mg
(Glucophage)
(Glucophage)
(Glucophage)
(Glucophage XR)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (90 per 30 days)
QL (180 per 30 days)
ST; QL (30 per 30 days)
ST; QL (60 per 30 days)
$0 (Tier 2)
ST; QL (120 per 30
days)
ST; QL (60 per 30 days)
ST; QL (30 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
ST; QL (30 per 30 days)
PA; QL (112 per 28
days)
QL (60 per 30 days)
QL (150 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
29
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
metformin oral tablet extended release 24
hr 750 mg
metformin oral tablet extended release 24hr
1,000 mg
nateglinide
pioglitazone
pioglitazone-glimepiride
pioglitazone-metformin
PRANDIMET
repaglinide
repaglinide-metformin
SYMLINPEN 120
(Glucophage XR)
$0 (Tier 1)
QL (90 per 30 days)
(Fortamet)
$0 (Tier 1)
QL (60 per 30 days)
(Starlix)
(Actos)
(Duetact)
(Actoplus Met)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (150 per 30 days)
QL (240 per 30 days)
QL (150 per 30 days)
PA; QL (10.8 per 28
days)
PA; QL (6 per 28 days)
ST; QL (60 per 30 days)
(Prandin)
(Prandimet)
SYMLINPEN 60
SYNJARDY
TRADJENTA
TRULICITY
VICTOZA 3-PAK
Insulins
HUMULIN R U-500 (CONCENTRATED)
LANTUS
LANTUS SOLOSTAR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG PENFILL
TOUJEO SOLOSTAR
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
(Amaryl)
glimepiride oral tablet 4 mg
(Amaryl)
glipizide oral tablet 10 mg
(Glucotrol)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (40 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (30 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
30
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
glipizide oral tablet 5 mg
glipizide oral tablet extended release 24hr
10 mg
glipizide oral tablet extended release 24hr
2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5-250 mg
(Glucotrol)
(Glucotrol XL)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
$0 (Tier 1)
QL (30 per 30 days)
(Glipizide/Metformin
HCl)
glipizide-metformin oral tablet 2.5-500 mg, (Glipizide/Metformin
5-500 mg
HCl)
glyburide micronized oral tablet 1.5 mg
(Glynase)
$0 (Tier 1)
QL (240 per 30 days)
$0 (Tier 1)
QL (120 per 30 days)
$0 (Tier 1)
glyburide micronized oral tablet 3 mg
(Glynase)
$0 (Tier 1)
glyburide micronized oral tablet 6 mg
(Glynase)
$0 (Tier 1)
glyburide oral tablet 1.25 mg
(Glyburide)
$0 (Tier 1)
glyburide oral tablet 2.5 mg
(Glyburide)
$0 (Tier 1)
glyburide oral tablet 5 mg
(Glyburide)
$0 (Tier 1)
glyburide-metformin oral tablet 1.25-250
mg
glyburide-metformin oral tablet 2.5-500
mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide
(Glucovance)
$0 (Tier 1)
(Glucovance)
$0 (Tier 1)
(Tolazamide)
(Tolazamide)
(Tolbutamide)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; QL (400 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (280 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (180 per 30 days)
Antifungals
Antifungals
ABELCET
aloe vesta 2% antifungal oint
AMBISOME
amphotericin b
anti-fungal 1% powder
athlete's foot * 2% powder
(Miconazole Nitrate)
(Amphotericin B)
(Tolnaftate)
(Lotrimin AF)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
31
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
baza antifungal * 2% cream 12's
CANCIDAS
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
ciclopirox-ure-camph-menth-euc
clotrim 1% vaginal cream
clotrimazole * 1% cream (otc)
clotrimazole * 1% solution (otc)
clotrimazole * insert
clotrimazole mucous membrane
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
clotrimazole-7 * cream
clotrimazole-betamethasone topical cream
clotrimazole-betamethasone topical lotion
critic-aid clear af * 2% oint 12's, w/
antifungal
cvs af * 1% spray powder
cvs anti-fungal * 2% powder
cvs antifungal * 25% liquid
cvs athlete's foot * powd spray
cvs miconazole 1 combo pack
cvs miconazole 3 combo pack 3pref applic
w/cream
cvs tioconazole * 1 6.5% ointmnt
dermafungal * 2% ointment
desenex * 2% powder
desenex 2% spray powder
econazole topical
elon dual defense * 25% solution
fluconazole
(Nuzole)
(Ciclodan)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox Olamine)
(Ciclodan)
(Gyne-Lotrimin)
(Lotrimin AF)
(Clotrimazole)
(Clotrimazole)
(Clotrimazole)
(Clotrimazole)
(Lotrimin)
(Gyne-Lotrimin)
(Lotrisone)
(Clotrimazole/Betamet
hasone Dip)
(Miconazole Nitrate)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Tinactin)
(Lotrimin AF)
(Undecylenic Acid)
(Lotrimin AF)
(Monistat 3)
(Miconazole Nitrate)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Tioconazole)
(Miconazole Nitrate)
(Lotrimin AF)
(Lotrimin AF)
(Econazole Nitrate)
(Undecylenic Acid)
(Diflucan)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
32
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
fluconazole in dextrose(iso-o) intravenous
piggyback 400 mg/200 ml
fluconazole-nacl 400 mg/200 ml latex-free,
outer
flucytosine
fungi cure * intensive 1% spray
FUNGI-NAIL * TINCTURE
fungoid-d * 1% cream
gnp miconazole 3 combo pack
griseofulvin microsize oral tablet
HONGO CURA ANTI-FUNGAL 25%
SPR
inzo antifungal * 2% cream
itraconazole
ketoconazole oral
ketoconazole topical cream
ketoconazole topical shampoo
lamisil af * defens 1% spray pwd
lamisil af * defense 1% powder
LAMISIL ANTIFUNGAL 1% SPRAY
FOR ATHLETES FOOT
LAMISIL AT * 1% CREAM ATHLETE'S
FOOT
LAMISIL AT * 1% GEL
micatin * 2% antifungal cream
miconazole 3 combo pack 3 sup,9gm crm
w/app 200 mg- 2 % (9 gram)
miconazole 7 * 100 mg vag supp
miconazole nitrate * 2% cream
miconazole nitrate * 2% cream
miconazole nitrate vaginal suppository 200
mg
micro-guard * 2% powder 12's,antifungal
MONISTAT 3 * COMBO PACK
monistat 7 * cream 7 applicators
myco nail a * 25% solution
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Clotrimazole)
(Tinactin)
(Miconazole Nitrate)
(Grifulvin V)
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Tinactin)
(Tolnaftate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Nuzole)
(Monistat 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Miconazole Nitrate)
(Miconazole Nitrate)
(Nuzole)
(Monistat 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
(Lotrimin AF)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Miconazole Nitrate)
(Undecylenic Acid)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
33
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
NIZORAL A-D * 1% SHAMPOO
NOXAFIL ORAL
NYSTATIN (BULK) POWDER 1
BILLION UNIT, 10 BILLION UNIT
nystatin oral suspension
nystatin oral tablet
nystatin topical
nystatin topical powder 100,000 unit/gram
nystatin-triamcinolone
podactin * 1% powder
qc 3 day vaginal * 4% cream
ra anti-fungal liquid
ra miconazole 3 kit 3pref app w/crm+6wip
remedy phytoplex antifungal * 2%
terbinafine 1% cream
terbinafine hcl oral
tolnaftate * 1% cream
tolnaftate * 1% solution
triple paste af * 2% ointment
vagistat-1 * 6.5% ointment
vagistat-3 * combo pack
voriconazole intravenous
voriconazole oral
zeasorb 2% powder athlete's foot
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 1)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin/Triamcin)
(Tolnaftate)
(Miconazole Nitrate)
(Undecylenic Acid)
(Miconazole/Skin
Cleanser No.17)
(Lotrimin AF)
(Desenex)
(Lamisil)
(Tinactin)
(Tolnaftate)
(Miconazole Nitrate)
(Tioconazole)
(Monistat 3)
(Vfend IV)
(Vfend)
(Lotrimin AF)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Dexbromphenir/Pseud
oephed Sulf)
(Triaminic Nighttime
Cold-Cough)
(Dexbrompheniramine
Maleate)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
Antihistamines
Antihistamines
12 hour relief * tablet
25dph-7.5peh liquid
ala-hist ir * 2 mg tablet
ALA-HIST PE * TABLET
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
34
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
ALLEGRA ALLERGY * 180 MG
TABLET
ALLEGRA ALLERGY * 60 MG TABLET
aller-chlor * 2 mg/5 ml syrup
(Chlorpheniramine
Maleate)
aller-chlor * 4 mg tablet
(Chlor-Trimeton)
allergy 4 mg tablet
(Chlor-Trimeton)
allerhist-1 * 1.34 mg tablet
(Clemastine Fumarate)
ambi 60pse-4cpm * tablet
(Chlorpheniramine/Pse
udoephed)
aprodine * tablet
(Triprolidine/Pseudoep
hedrine)
banophen * 25 mg capsule
(Benadryl)
banophen * 25 mg tablet
(Diphenhydramine
HCl)
banophen allergy * 12.5 mg/5 ml a/f
(Zzzquil)
BENADRYL ALLERGY * 12.5 MG/5 ML
A/F,CHILD'S,CHERRY
benadryl allergy * 25 mg ultratb ultratab
(Diphenhydramine
HCl)
cetirizine * hcl 1 mg/1 ml soln children, s/f, (Children'S Zyrtec)
grape (otc)
cetirizine * hcl 10 mg tablet indoor &
(Zyrtec)
outdoor
cetirizine * hcl 5 mg chew tab
(Zyrtec)
children's,outer,u-d
cetirizine * hcl 5 mg tablet indoor &
(Zyrtec)
outdoor
cetirizine oral solution 1 mg/ml
(Cetirizine HCl)
child allegra allergy 30 mg/5 ml suspension (Fexofenadine HCl)
child benadryl-d aller-sin liq
(Phenylephrine/Diphen
hydramine)
child dometuss-da * liquid
(Triaminic ColdAllergy Pe)
child triaminic cold & allergy
(Dimetapp)
child wal-tap cold-allergy * elx
(Dimetapp)
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
35
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
children's allegra allergy * oral tablet
child's aller-tec 1 mg/ml soln
child's wal-dryl 12.5 mg/5 ml
a/f,s/f,d/f,bubb gum
child's wal-zyr 10 mg chew tab
chlorpheniramine er 12 mg tab
clemastine * fum 1.34 mg tablet (otc)
cold-allergy-sinus *
compoz * 25 mg gelcap
CONEX * SOLUTION
conex * tablet
cvs allergy 25 mg tablet
cvs allergy relief 10 mg odt disintegrating
tabs
cvs child allergy 10 mg chw tb 24
hr,indoor/outdoor
cvs cold & cough nighttime liq
(Allegra Allergy)
(Children'S Zyrtec)
(Zzzquil)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA
(Zyrtec)
(Chlor-Trimeton
Allergy)
(Clemastine Fumarate)
(Triprolidine/Pseudoep
hedrine)
(Diphenhydramine
HCl)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA
$0 (Tier 4)
PA; AGE (Min 2 Years)
(Zyrtec)
$0 (Tier 4)
PA; AGE (Min 2 Years)
(Triaminic Nighttime
Cold-Cough)
(Cyproheptadine HCl)
(Clemastine Fumarate)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
PA
PA
$0 (Tier 4)
$0 (Tier 4)
PA
PA
(Dexbrompheniramine/
Pseudoephed)
(Diphenhydramine
HCl)
(Claritin)
cyproheptadine
dailyhist-1 * 1.34 mg tablet
DALLERGY 1-5 MG TABLET
dayhist allergy * 1.34 mg tablet 12 hr relief (Clemastine Fumarate)
dimaphen elixir a/f
(Dimetapp)
dimetapp cold & congest liquid
(Triaminic Nighttime
Cold-Cough)
diphenhist * 12.5 mg/5 ml soln
(Zzzquil)
diphenhist * 25 mg capsule
(Benadryl)
diphenhist * 25 mg captab captab
(Diphenhydramine
HCl)
diphenhydramine 25 mg capsule (otc)
(Benadryl)
diphenhydramine 50 mg capsule (otc)
(Benadryl)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
36
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
diphenhydramine 50 mg tablet
diphenhydramine hcl injection solution 50
mg/ml
ed chlorped drops
ed chlorped jr * syrup
ed-a-hist 4 mg-10 mg tablet 4-10 mg
entre-hist pse * liquid
eq allergy & sinus relief tab
fexofenadine * hcl 180 mg tablet
24hr,original str (otc)
fexofenadine * hcl 30 mg/5 ml
fexofenadine * hcl 60 mg tablet
indoor/outdoor (otc)
histex-pe syrup
hm z-sleep * 25 mg softgel
levocetirizine
lohist-d liquid
lohist-peb * liquid 12's, s/f, a/f, d/f
loratadine * 10 mg tablet
loratadine * allergy 5 mg/5 ml d/f, a/f, s/f
nasal decongestant *
nohist-lq * liquid
PEDIAVENT * 1 MG TABLET CHEW
PEDIAVENT * 2 MG/5 ML SYRUP
phenylephrine-pyrilamine 10-25
promethazine oral syrup
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
(Chlorpheniramine
Maleate)
(Chlorpheniramine
Maleate)
(Chlorpheniramine/Phe
nylephrine)
(Triprolidine/Pseudoep
hedrine)
(Phenylephrine/Diphen
hydramine)
(Allegra Allergy)
$0 (Tier 4)
PA
$0 (Tier 1)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
(Fexofenadine HCl)
(Allegra Allergy)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
(Phenylephrine/Triprol
idine)
(Benadryl)
(Xyzal)
(Chlorpheniramine/Pse
udoephed)
(Brovex Peb)
(Claritin)
(Children'S Claritin)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA-HRM
(Triaminic ColdAllergy Pe)
(Poly Hist Forte)
(Promethazine HCl)
PA; AGE (Min 2 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
37
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
pv nyt-time sleep * 25 mg caplet
pv sinus nighttime * tablet
pyrilamine-phenylephrine * susp
q-dryl * 12.5 mg/5 ml liquid a/f
q-tapp * elixir a/f,grape,unboxed
ra allergy plus sinus tablet
ritifed * syrup
RYMED TABLET
siladryl 12.5 mg/5 ml liquid
simply sleep * 25 mg caplet caplet
sm sinus and allergy tablet maximum
strength
sm triacting cold-allergy syr
sudogest sinus & allergy tab
TRIAMINIC NIGHTTIME COLDCOUGH CHILDREN'S, GRAPE
unisom 50 mg sleepgels softgel
vazobid-pd * suspension
v-r triacting orange * syrup
wal-act d cold & allergy tab
wal-dryl allergy * 25 mg capsule
wal-dryl allergy * 25 mg minitab minitab,
coated
wal-fex allergy * 180 mg tablet
(Diphenhydramine
HCl)
(Phenylephrine/Triprol
idine)
(Phenylephrine/Pyrila
mine)
(Zzzquil)
(Brompheniramin/Pseu
doephedrine)
(Phenylephrine/Diphen
hydramine)
(Triprolidine/Pseudoep
hedrine)
(Zzzquil)
(Diphenhydramine
HCl)
(Chlorpheniramine/Pse
udoephed)
(Chlorpheniramine/Pse
udoephed)
(Chlorpheniramine/Pse
udoephed)
(Benadryl)
(Brompheniramin/Phe
nylephrine)
(Chlorpheniramine/Pse
udoephed)
(Triprolidine/Pseudoep
hedrine)
(Benadryl)
(Diphenhydramine
HCl)
(Allegra Allergy)
$0 (Tier 4)
PA
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
PA
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA
PA
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
PA
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 4)
PA; AGE (Min 2 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
38
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
wal-fex allergy * 60 mg tablet
wal-finate * 4 mg tablet
wal-finate-d * tablet
(Allegra Allergy)
(Chlor-Trimeton)
(Chlorpheniramine/Pse
udoephed)
wal-itin * 10 mg odt non-drowsy
(Claritin)
wal-itin * 10 mg tablet non-drowsy
(Claritin)
wal-itin * 5 mg/5 ml syrup children's, grape (Children'S Claritin)
wal-phed pe sinus & allergy tb
(Chlorpheniramine/Phe
nylephrine)
wal-phed * sinus and allergy tab
(Chlorpheniramine/Pse
udoephed)
wal-sleep z * 25 mg softgel
(Benadryl)
wal-som 25 mg odt
(Unisom Sleepmelts)
wal-som 50 mg softgel softgel
(Benadryl)
wal-tap * elixir
(Dimetapp)
wal-zyr 10 mg tablet
(Zyrtec)
wal-zyr solution children's, a/f
(Children'S Zyrtec)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
Anti-Infectives (Skin And Mucous
Membrane)
Anti-Infectives (Skin And Mucous
Membrane)
AVC VAGINAL
clindamycin phosphate vaginal
metronidazole vaginal
terconazole vaginal cream
terconazole vaginal suppository
(Cleocin)
(Metrogel-Vaginal)
(Terazol 7)
(Terconazole)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection
dihydroergotamine nasal
ERGOMAR
naratriptan
rizatriptan oral tablet
rizatriptan oral tablet,disintegrating
sumatriptan
(D.H.E.45)
(Migranal)
(Amerge)
(Maxalt)
(Maxalt Mlt)
(Imitrex)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 28 days)
QL (8 per 28 days)
QL (40 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (12 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
39
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
sumatriptan 4 mg/0.5 ml inject latex-free
sumatriptan 4 mg/0.5 ml refill
sumatriptan 6 mg/0.5 ml refill latex-free
sumatriptan succinate oral
sumatriptan succinate subcutaneous
cartridge 4 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml (auto-injector)
sumatriptan succinate subcutaneous
solution
zolmitriptan oral tablet
zolmitriptan oral tablet,disintegrating
(Sumatriptan
Succinate)
(Imitrex)
(Imitrex)
(Imitrex)
(Sumatriptan
Succinate)
(Imitrex)
$0 (Tier 1)
QL (4 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (4 per 28 days)
QL (4 per 28 days)
QL (18 per 28 days)
QL (4 per 28 days)
$0 (Tier 1)
QL (4 per 28 days)
(Sumatriptan
Succinate)
(Imitrex)
$0 (Tier 1)
QL (4 per 28 days)
$0 (Tier 1)
QL (4 per 28 days)
(Zomig)
(Zomig Zmt)
$0 (Tier 1)
$0 (Tier 1)
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT
dapsone
ethambutol
isoniazid oral
PASER
PRIFTIN
pyrazinamide
rifabutin
rifampin intravenous
rifampin oral
RIFATER
SIRTURO
(Dapsone)
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
TRECATOR
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (188 per 168
days)
$0 (Tier 2)
Antinausea Agents
Antinausea Agents
AKYNZEO
cvs motion sickness * 50 mg tab
(Dimenhydrinate)
$0 (Tier 2)
$0 (Tier 4)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
40
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
dimenhydrinate injection solution
dramamine * 50 mg tablet
driminate * 50 mg tablet
dronabinol
EMEND INTRAVENOUS
EMEND ORAL CAPSULE 125 MG, 80
MG
EMEND ORAL CAPSULE 40 MG
EMEND ORAL CAPSULE,DOSE PACK
granisetron (pf) intravenous solution 100
mcg/ml
granisetron hcl intravenous solution 1
mg/ml (1 ml)
granisetron hcl oral
meclizine * 12.5 mg caplet caplet (otc)
meclizine * 25 mg tablet (otc)
meclizine oral tablet 12.5 mg, 25 mg
motion sickness 25 mg tablet
ondansetron
ondansetron hcl (pf)
ondansetron hcl oral
prochlorperazine
prochlorperazine edisylate injection
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate oral
promethazine hcl
promethazine oral tablet
promethazine rectal
TRANSDERM-SCOP
travel sickness 25 mg tab chew
wal-dram * 50 mg tablet
(Dimenhydrinate)
(Dimenhydrinate)
(Dimenhydrinate)
(Marinol)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Granisetron HCl/PF)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
(Granisetron HCl)
$0 (Tier 1)
(Granisetron HCl)
(Meclizine HCl)
(Meclizine HCl)
(Antivert)
(Meclizine HCl)
(Zofran Odt)
(Ondansetron HCl/PF)
(Zofran)
(Compazine)
(Prochlorperazine
Edisylate)
(Compazine)
(Phenergan)
(Promethazine HCl)
(Phenergan)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Bonine)
(Dimenhydrinate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
QL (2 per 28 days)
PA BvD
PA BvD
PA BvD
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA BvD
PA BvD
PA-HRM
PA-HRM
PA-HRM
QL (10 per 30 days)
PA; AGE (Min 2 Years)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
$0 (Tier 2)
$0 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
41
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
atovaquone
atovaquone-proguanil
chloroquine phosphate oral
COARTEM
DARAPRIM
hydroxychloroquine oral
ivermectin oral
mefloquine
NEBUPENT
paromomycin
PENTAM
pin-x * 144 mg/ml (50 mg/ml base) s/f,
caramel flavor
PRIMAQUINE
quinine sulfate
reese pinworm 144 mg/ml susp
(Mepron)
(Malarone)
(Chloroquine
Phosphate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Pyrantel Pamoate)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
(Qualaquin)
(Pyrantel Pamoate)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 4)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin Sulfate)
PA BvD
QL (90 per 30 days)
PA; QL (42 per 7 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
APOKYN
AZILECT
benztropine oral
bromocriptine
cabergoline
carbidopa
carbidopa-levodopa oral tablet
carbidopa-levodopa oral tablet extended
release
carbidopa-levodopa-entacapone
entacapone
NEUPRO
pramipexole oral tablet
ropinirole oral tablet
(Amantadine HCl)
(Benztropine
Mesylate)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
(Sinemet CR)
(Stalevo 50)
(Comtan)
(Mirapex)
(Requip)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
QL (60 per 30 days)
PA-HRM
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
ST; QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
42
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ropinirole oral tablet extended release 24
hr
selegiline hcl oral capsule
selegiline hcl oral tablet
trihexyphenidyl
(Requip XL)
$0 (Tier 1)
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM
$0 (Tier 2)
QL (90 per 30 days)
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON
300 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON
400 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING
aripiprazole oral solution
aripiprazole oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
aripiprazole oral tablet,disintegrating 10
mg
aripiprazole oral tablet,disintegrating 15
mg
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 441 MG/1.6 ML
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 662 MG/2.4 ML
$0 (Tier 2)
$0 (Tier 2)
QL (1 per 28 days)
$0 (Tier 2)
QL (1 per 28 days)
(Abilify)
(Abilify)
$0 (Tier 1)
$0 (Tier 1)
QL (900 per 30 days)
QL (30 per 30 days)
(Abilify)
(Abilify Discmelt)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
QL (90 per 30 days)
(Abilify Discmelt)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 2)
QL (1.6 per 28 days)
$0 (Tier 2)
QL (2.4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
43
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 882 MG/3.2 ML
chlorpromazine
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating
FANAPT ORAL TABLET
FANAPT ORAL TABLETS,DOSE PACK
fluphenazine decanoate
fluphenazine hcl
GEODON INTRAMUSCULAR
haloperidol
haloperidol decanoate intramuscular
solution 100 mg/ml
haloperidol decanoate intramuscular
solution 50 mg/ml
haloperidol lactate
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 1.5 MG, 3 MG, 9 MG
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 6 MG
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 156
MG/ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 234
MG/1.5 ML
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 39
MG/0.25 ML
(Chlorpromazine HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
(Haloperidol)
(Haloperidol
Decanoate)
(Haldol Decanoate 50)
(Haloperidol Lactate)
$0 (Tier 2)
QL (3.2 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
QL (270 per 30 days)
QL (135 per 30 days)
QL (90 per 30 days)
ST
ST; QL (60 per 30 days)
ST; QL (8 per 28 days)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
QL (6 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (30 per 30 days)
$0 (Tier 2)
QL (60 per 30 days)
$0 (Tier 2)
QL (0.75 per 28 days)
$0 (Tier 2)
QL (1 per 28 days)
$0 (Tier 2)
QL (1.5 per 28 days)
$0 (Tier 2)
QL (0.25 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
44
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 78
MG/0.5 ML
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 273 MG/0.875 ML
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 410 MG/1.315 ML
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 546 MG/1.75 ML
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 819 MG/2.625 ML
LATUDA
loxapine succinate
molindone oral tablet 10 mg
molindone oral tablet 25 mg
molindone oral tablet 5 mg
olanzapine intramuscular
olanzapine oral tablet
olanzapine oral tablet,disintegrating 10 mg,
15 mg, 5 mg
olanzapine oral tablet,disintegrating 20 mg
ORAP
paliperidone oral tablet extended release
24hr 1.5 mg, 3 mg, 9 mg
paliperidone oral tablet extended release
24hr 6 mg
perphenazine
pimozide
quetiapine
REXULTI ORAL TABLET 0.25 MG
REXULTI ORAL TABLET 0.5 MG
REXULTI ORAL TABLET 1 MG, 2 MG,
3 MG, 4 MG
RISPERDAL CONSTA
risperidone oral solution
risperidone oral tablet
(Loxapine Succinate)
(Moban)
(Moban)
(Moban)
(Zyprexa)
(Zyprexa)
(Zyprexa Zydis)
(Zyprexa Zydis)
$0 (Tier 2)
QL (0.5 per 28 days)
$0 (Tier 2)
QL (0.875 per 84 days)
$0 (Tier 2)
QL (1.315 per 84 days)
$0 (Tier 2)
QL (1.75 per 84 days)
$0 (Tier 2)
QL (2.625 per 84 days)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (240 per 30 days)
QL (270 per 30 days)
QL (120 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (31 per 30 days)
(Invega)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
(Invega)
$0 (Tier 1)
QL (60 per 30 days)
(Perphenazine)
(Orap)
(Seroquel)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (90 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
QL (4 per 28 days)
QL (480 per 30 days)
QL (60 per 30 days)
(Risperdal)
(Risperdal)
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
45
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
risperidone oral tablet,disintegrating 0.25
mg, 0.5 mg, 1 mg, 2 mg
risperidone oral tablet,disintegrating 3 mg,
4 mg
SAPHRIS (BLACK CHERRY)
thioridazine
thiothixene
trifluoperazine
VERSACLOZ
(Risperdal M-Tab)
$0 (Tier 1)
QL (60 per 30 days)
(Risperdal M-Tab)
$0 (Tier 1)
QL (120 per 30 days)
(Thioridazine HCl)
(Thiothixene)
(Trifluoperazine HCl)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
ST; QL (60 per 30 days)
PA NSO-HRM
ziprasidone hcl
ZYPREXA RELPREVV 405 MG VL KIT
W/ DILUENT, OUTER
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION 210 MG
(Geodon)
$0 (Tier 1)
$0 (Tier 2)
ST; QL (540 per 30
days)
QL (60 per 30 days)
$0 (Tier 2)
Antivirals (Systemic)
Antiretrovirals
abacavir
abacavir-lamivudine-zidovudine
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN ORAL CAPSULE 200 MG,
400 MG
didanosine
EDURANT
EMTRIVA
EPIVIR HBV ORAL SOLUTION
EPZICOM
EVOTAZ
FUZEON SUBCUTANEOUS RECON
SOLN
GENVOYA
INTELENCE
INVIRASE
(Ziagen)
(Trizivir)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Videx EC)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
46
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ISENTRESS
KALETRA
lamivudine
lamivudine-zidovudine
LEXIVA
nevirapine oral suspension
nevirapine oral tablet
nevirapine oral tablet extended release 24
hr
NORVIR
PREZCOBIX
PREZISTA
RESCRIPTOR
RETROVIR INTRAVENOUS
REYATAZ ORAL CAPSULE 150 MG,
200 MG, 300 MG
REYATAZ ORAL POWDER IN PACKET
SELZENTRY
stavudine
STRIBILD
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIDEX 2 GRAM PEDIATRIC
VIDEX 4 GM PEDIATRIC SOLN
VIRACEPT ORAL TABLET
VIRAMUNE XR ORAL TABLET
EXTENDED RELEASE 24 HR 100 MG
VIREAD
VITEKTA
ZIAGEN ORAL SOLUTION
zidovudine oral capsule
zidovudine oral syrup
zidovudine oral tablet
(Epivir)
(Combivir)
(Viramune)
(Viramune)
(Viramune XR)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Zerit)
(Retrovir)
(Retrovir)
(Zidovudine)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
47
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
Antivirals, Miscellaneous
foscarnet
RELENZA DISKHALER
rimantadine
SYNAGIS 100 MG/1 ML VIAL
SYNAGIS INTRAMUSCULAR
SOLUTION 50 MG/0.5 ML
TAMIFLU ORAL CAPSULE 30 MG
TAMIFLU ORAL CAPSULE 45 MG
TAMIFLU ORAL CAPSULE 75 MG
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION
Hcv Antivirals
DAKLINZA
HARVONI
OLYSIO
SOVALDI
TECHNIVIE
Interferons
INTRON A 10 MILLION UNIT/ML
INTRON A INJECTION RECON SOLN
INTRON A INJECTION SOLUTION 6
MILLION UNIT/ML
PEGASYS
PEGASYS PROCLICK
PEGINTRON
SYLATRON
Nucleosides And Nucleotides
acyclovir oral capsule
acyclovir oral suspension 200 mg/5 ml
acyclovir oral tablet
acyclovir sodium intravenous solution
adefovir
entecavir
famciclovir
(Foscavir)
(Flumadine)
(Zovirax)
(Zovirax)
(Zovirax)
(Acyclovir Sodium)
(Hepsera)
(Baraclude)
(Famvir)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (84 per 180 days)
QL (48 per 180 days)
QL (42 per 180 days)
QL (540 per 180 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (28 per 28 days)
PA; QL (30 per 30 days)
PA; QL (28 per 28 days)
PA; QL (28 per 28 days)
PA; QL (56 per 28 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA NSO
PA NSO
PA NSO
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA
PA
PA
PA NSO; QL (4 per 28
days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
48
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ganciclovir sodium
ribavirin oral capsule 200 mg
ribavirin oral tablet 200 mg, 400 mg, 600
mg
TYZEKA
valacyclovir
valganciclovir
VIRAZOLE
(Cytovene)
(Rebetol)
(Copegus)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
(Valtrex)
(Valcyte)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA BvD
(Lovenox)
(Lovenox)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
QL (36 per 30 days)
QL (36 per 30 days)
(Lovenox)
$0 (Tier 1)
QL (27.2 per 30 days)
(Lovenox)
$0 (Tier 1)
QL (34 per 30 days)
(Lovenox)
$0 (Tier 1)
QL (18 per 30 days)
(Lovenox)
$0 (Tier 1)
QL (13.6 per 30 days)
(Lovenox)
$0 (Tier 1)
QL (20.4 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (24 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (15 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (12 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (18 per 30 days)
Blood Products/Modifiers/Volume
Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
ELIQUIS
enoxaparin subcutaneous solution
enoxaparin subcutaneous syringe 100
mg/ml
enoxaparin subcutaneous syringe 120
mg/0.8 ml, 80 mg/0.8 ml
enoxaparin subcutaneous syringe 150
mg/ml
enoxaparin subcutaneous syringe 30
mg/0.3 ml
enoxaparin subcutaneous syringe 40
mg/0.4 ml
enoxaparin subcutaneous syringe 60
mg/0.6 ml
fondaparinux subcutaneous syringe 10
mg/0.8 ml
fondaparinux subcutaneous syringe 2.5
mg/0.5 ml
fondaparinux subcutaneous syringe 5
mg/0.4 ml
fondaparinux subcutaneous syringe 7.5
mg/0.6 ml
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
49
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml,
20,000 unit/500 ml (40 unit/ml), 25,000
unit/500 ml (50 unit/ml)
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250 ml(100
unit/ml)
heparin (porcine) in nacl (pf) intravenous
parenteral solution 1,000 unit/500 ml
heparin (porcine) injection solution 1,000
unit/ml, 20,000 unit/ml, 5,000 unit/ml
heparin (porcine) injection solution 10,000
unit/ml
heparin sodium,porcine-pf intravenous
syringe 10 unit/ml
heparin, porcine (pf) injection solution
5,000 unit/0.5 ml
heparin, porcine (pf) injection syringe
heparin, porcine (pf) intravenous syringe
heparin-0.45% nacl 25,000 units/250 ml
(100 units/ml) bag latex-free, inner
heparin-d5w 25,000 units/250 ml (100
units/ml) bag excel container
IPRIVASK
jantoven
PRADAXA
warfarin
XARELTO
Blood Formation Modifiers
CINRYZE
EPOGEN 10,000 UNITS/ML VIAL SDV,
P/F, OUTER
(Heparin
Sodium,Porcine/D5W)
$0 (Tier 1)
(Heparin Sod,Pork In
0.45% NaCl)
$0 (Tier 1)
(Heparin
Sodium,Porcine/Ns/PF
)
(Heparin
Sodium,Porcine)
(Heparin
Sodium,Porcine)
(Monoject Prefill
Advanced)
(Heparin
Sodium,Porcine/PF)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
(Heparin Sod,Pork In
0.45% NaCl)
(Heparin
Sodium,Porcine/D5W)
$0 (Tier 1)
(Coumadin)
(Coumadin)
$0 (Tier 1)
$0 (Tier 1)
PA BvD; (PA for ESRD
Only)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD; (PA for ESRD
Only)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
PA; QL (24 per 28 days)
$0 (Tier 2)
$0 (Tier 2)
PA
PA; QL (12 per 28 days)
ST; QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
50
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
EPOGEN INJECTION SOLUTION 2,000
UNIT/ML, 20,000 UNIT/2 ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
GRANIX
LEUKINE INJECTION RECON SOLN
MIRCERA
$0 (Tier 2)
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT 10,000 UNITS/ML VIAL 4'S,
MDV, OUTER
PROCRIT INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
PROCRIT INJECTION SOLUTION
40,000 UNIT/ML
PROMACTA
ZARXIO
Hematologic Agents,
Miscellaneous
aminocaproic acid oral
(Aminocaproic Acid)
anagrelide
(Agrylin)
protamine
(Protamine Sulfate)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (12 per 28 days)
$0 (Tier 2)
PA; QL (12 per 28 days)
$0 (Tier 2)
PA; QL (6 per 28 days)
$0 (Tier 2)
$0 (Tier 2)
PA; QL (30 per 30 days)
tranexamic acid intravenous
tranexamic acid oral
Platelet-Aggregation Inhibitors
AGGRENOX
aspirin-dipyridamole
BRILINTA
cilostazol
clopidogrel
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Tranexamic Acid)
(Lysteda)
(Aggrenox)
(Pletal)
(Plavix)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (12 per 28 days)
PA; QL (0.6 per 28
days)
PA BvD; (PA for ESRD
Only)
QL (30 per 30 days)
QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
51
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
EFFIENT
pentoxifylline
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN, HUMAN 25 %
ALBUMIN, HUMAN 5 %
ALBUMINAR 25 %
ALBUMINAR 5 %
ALBURX (HUMAN) 5 %
ALBUTEIN 25 %
ALBUTEIN 5 %
BUMINATE 25 %
BUMINATE 5 %
FLEXBUMIN 25 %
FLEXBUMIN 5 %
KEDBUMIN
PLASBUMIN 25 %
PLASBUMIN 5 %
(Pentoxifylline)
$0 (Tier 2)
$0 (Tier 1)
QL (30 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
AMINOSYN 10 %
AMINOSYN 3.5 %
AMINOSYN 7 %
AMINOSYN 7 % WITH
ELECTROLYTES
AMINOSYN 8.5 %
AMINOSYN 8.5 %-ELECTROLYTES
AMINOSYN II 10 %
AMINOSYN II 15 %
AMINOSYN II 7 %
AMINOSYN II 8.5 %
AMINOSYN II 8.5 %-ELECTROLYTES
AMINOSYN M 3.5 %
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
52
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
AMINOSYN-HBC 7%
AMINOSYN-PF 10 %
AMINOSYN-PF 7 % (SULFITE-FREE)
AMINOSYN-RF 5.2 %
CLINIMIX 5%/D15W SULFITE FREE
CLINIMIX 5%/D25W SULFITE-FREE
CLINIMIX 2.75%/D5W SULFIT FREE
CLINIMIX 4.25%/D10W SULF FREE
CLINIMIX 4.25%/D5W SULFIT FREE
CLINIMIX 4.25%-D20W SULF-FREE
CLINIMIX 4.25%-D25W SULF-FREE
CLINIMIX 5%-D20W(SULFITE-FREE)
CLINIMIX E 2.75%/D10W SUL FREE
CLINIMIX E 2.75%/D5W SULF FREE
CLINIMIX E 4.25%/D10W SUL FREE
CLINIMIX E 4.25%/D25W SUL FREE
CLINIMIX E 4.25%/D5W SULF FREE
CLINIMIX E 5%/D15W SULFIT FREE
CLINIMIX E 5%/D20W SULFIT FREE
CLINIMIX E 5%/D25W SULFIT FREE
CLINISOL SF 15 %
cvs glucose bits * tablet chew
cysteine (l-cysteine) intravenous solution
d10 %-0.9 % sodium chloride
dex4 glucose * 4 gm tablet chew grape
flavor
dex4 glucose bits * tablet chew
dextrose 10 % in water (d10w)
dextrose 2.5 % in water(d2.5w)
dextrose 20 % in water (d20w)
dextrose 25 % in water (d25w)
dextrose 40 % in water (d40w)
(Dextrose)
(Cysteine HCl)
(Dextrose)
(Dextrose)
(Dextrose 10 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
$0 (Tier 4)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
PA BvD
$0 (Tier 1)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
53
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
dextrose 5 % in ringers
dextrose 5 % in water (d5w) intravenous
parenteral solution
dextrose 50 % in water (d50w)
dextrose 70 % in water (d70w)
FREAMINE HBC 6.9 %
FREAMINE III 10 %
gluco burst * 40% gel
glucose * 4 gram tablet chew na/f, caffeine
free
glucose 40% gel tropical fruit
glutose 15 * gel 3 pak, outer, u-d
HEPATAMINE 8%
HEPATASOL 8 %
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN
LIPOSYN II
LIPOSYN III
NEPHRAMINE 5.4 %
NUTRILIPID
PERIKABIVEN
PREMASOL 10 %
PREMASOL 6 %
PROCALAMINE 3%
PROSOL 20 %
relion glucose liquid gluten-f,mixed berry
TRAVASOL 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
(Dextrose 5% In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
(Dextrose)
(Dextrose)
(Dextrose)
(Dextrose)
(Gluco Shot)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
PA BvD
PA BvD
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
54
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
clonidine hcl oral tablet
clonidine hcl-chlorthalidone
clonidine transdermal patch weekly 0.1
mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly 0.3
mg/24 hr
doxazosin
guanfacine oral tablet
midodrine
NORTHERA
phenylephrine hcl injection
prazosin oral
Angiotensin Ii Receptor
Antagonists
BENICAR
BENICAR HCT
candesartan
candesartan-hydrochlorothiazid
ENTRESTO
irbesartan
irbesartan-hydrochlorothiazide
losartan
losartan-hydrochlorothiazide
telmisartan
telmisartan-hydrochlorothiazid
TRIBENZOR
valsartan
valsartan-hydrochlorothiazide
Angiotensin-Converting Enzyme
Inhibitors
benazepril
benazepril-hydrochlorothiazide
captopril
(Catapres)
(Clonidine
HCl/Chlorthalidone)
(Catapres-Tts 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (4 per 28 days)
(Catapres-Tts 1)
$0 (Tier 1)
QL (8 per 28 days)
(Cardura)
(Tenex)
(Midodrine HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Vazculep)
(Minipress)
(Diovan)
(Diovan HCT)
(Lotensin)
(Lotensin HCT)
(Captopril)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Avapro)
(Avalide)
(Cozaar)
(Hyzaar)
(Micardis)
(Micardis HCT)
PA; QL (180 per 30
days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Atacand)
(Atacand HCT)
PA-HRM
PA; QL (60 per 30 days)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
55
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
captopril-hydrochlorothiazide
enalapril maleate
enalaprilat intravenous solution
enalapril-hydrochlorothiazide
fosinopril
fosinopril-hydrochlorothiazide
lisinopril
lisinopril-hydrochlorothiazide
moexipril
moexipril-hydrochlorothiazide
perindopril erbumine
quinapril
quinapril-hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmic Agents
amiodarone hcl oral tablet 100 mg, 200
mg, 400 mg
amiodarone oral
disopyramide phosphate oral capsule
flecainide
lidocaine (pf) intravenous syringe 50 mg/5
ml (1 %)
lidocaine in 5 % dextrose (pf) intravenous
parenteral solution 8 mg/ml (0.8 %)
mexiletine
MULTAQ
procainamide injection
propafenone oral capsule,extended release
12 hr
propafenone oral tablet
quinidine gluconate oral
quinidine sulfate
(Captopril/Hydrochlor
othiazide)
(Vasotec)
(Enalaprilat Dihydrate)
(Vaseretic)
(Fosinopril Sodium)
(Fosinopril/Hydrochlor
othiazide)
(Zestril)
(Zestoretic)
(Moexipril HCl)
(Moexipril/Hydrochlor
othiazide)
(Aceon)
(Accupril)
(Accuretic)
(Altace)
(Mavik)
$0 (Tier 1)
(Cordarone)
$0 (Tier 1)
(Cordarone)
(Norpace)
(Tambocor)
(Lidocaine HCl/PF)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Lidocaine
HCl/D5w/PF)
(Mexiletine HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Procainamide HCl)
(Rythmol SR)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Rythmol)
(Quinidine Gluconate)
(Quinidine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
56
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
TIKOSYN
Beta-Adrenergic Blocking Agents
acebutolol
atenolol
atenolol-chlorthalidone
betaxolol oral
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
BYSTOLIC
carvedilol
esmolol intravenous solution
labetalol intravenous solution
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate intravenous solution
metoprolol tartrate oral
nadolol
pindolol
propranolol intravenous
propranolol oral capsule,extended release
24 hr
propranolol oral solution
propranolol oral tablet
propranolol-hydrochlorothiazid
sotalol 120 mg tablet
sotalol hcl oral tablet 120 mg, 160 mg, 240
mg, 80 mg
sotalol oral tablet 160 mg, 240 mg, 80 mg
timolol maleate oral
Calcium-Channel Blocking Agents
cartia xt
diltiazem 24hr er 180 mg cap
$0 (Tier 2)
(Sectral)
(Tenormin)
(Tenoretic 50)
(Kerlone)
(Zebeta)
(Ziac)
(Coreg)
(Esmolol HCl)
(Labetalol HCl)
(Trandate)
(Toprol XL)
(Lopressor HCT)
(Lopressor)
(Lopressor)
(Corgard)
(Pindolol)
(Propranolol HCl)
(Inderal LA)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Propranolol HCl)
(Propranolol HCl)
(Propranolol/Hydrochl
orothiazid)
(Betapace)
(Betapace)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Betapace)
(Timolol Maleate)
$0 (Tier 1)
$0 (Tier 1)
(Cardizem CD)
(Cardizem CD)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
57
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
diltiazem 24hr er 360 mg cap once a day
dosage
diltiazem hcl intravenous
diltiazem hcl oral capsule, extended release
180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended release
12 hr
diltiazem hcl oral capsule,extended release
24hr 120 mg, 240 mg, 300 mg
diltiazem hcl oral tablet
diltiazem hcl oral tablet extended release
24 hr
dilt-xr
matzim la
taztia xt
verapamil intravenous syringe
verapamil oral capsule, 24 hr er pellet ct
verapamil oral capsule,ext rel. pellets 24 hr
verapamil oral tablet
verapamil oral tablet extended release
Cardiovascular Agents,
Miscellaneous
CORLANOR
DEMSER
digitek oral tablet 125 mcg
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
(Cardizem CD)
$0 (Tier 1)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
(Cardizem LA)
$0 (Tier 1)
$0 (Tier 1)
(Cardizem CD)
(Cardizem CD)
(Cardizem CD)
(Verapamil HCl)
(Verelan Pm)
(Verelan)
(Calan)
(Calan SR)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Lanoxin)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
digitek oral tablet 250 mcg
(Lanoxin)
$0 (Tier 1)
ST
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
PA-HRM; QL (30 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
58
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
digox 125 mcg tablet 125 mcg
(Lanoxin)
$0 (Tier 1)
digox 250 mcg tablet 250 mcg
(Lanoxin)
$0 (Tier 1)
digoxin 0.25 mg/ml syringe
digoxin injection solution
DIGOXIN ORAL SOLUTION 50
MCG/ML
digoxin oral tablet
(Digoxin)
(Digoxin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Lanoxin)
$0 (Tier 1)
dobutamine in d5w intravenous parenteral
solution 1,000 mg/250 ml (4,000 mcg/ml),
250 mg/250 ml (1 mg/ml), 500 mg/250 ml
(2,000 mcg/ml)
dobutamine intravenous solution 250 mg/20
ml (12.5 mg/ml)
dopamine in 5 % dextrose intravenous
solution 200 mg/250 ml (800 mcg/ml), 400
mg/250 ml (1,600 mcg/ml), 800 mg/250 ml
(3,200 mcg/ml)
dopamine intravenous solution 200 mg/5 ml
(40 mg/ml), 800 mg/10 ml (80 mg/ml), 800
mg/5 ml (160 mg/ml)
ephedrine sulfate injection solution
epinephrine hcl (pf) intravenous
(Dobutamine
HCl/D5W)
$0 (Tier 1)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
PA-HRM
PA-HRM
PA-HRM; QL (300 per
30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
PA BvD
(Dobutamine HCl)
$0 (Tier 1)
PA BvD
(Dopamine HCl/D5W)
$0 (Tier 1)
PA BvD
(Dopamine HCl)
$0 (Tier 1)
PA BvD
(Ephedrine Sulfate)
(Epinephrine HCl/PF)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
59
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
epinephrine injection auto-injector
epinephrine injection solution 1 mg/ml (1
ml)
epinephrine injection syringe 0.1 mg/ml
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethamolin
FIRAZYR
hydralazine
LANOXIN ORAL TABLET 187.5 MCG,
62.5 MCG
(Adrenaclick)
(Epinephrine)
$0 (Tier 1)
$0 (Tier 1)
(Epinephrine)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
milrinone
milrinone in 5 % dextrose intravenous
piggyback 40 mg/200 ml (200 mcg/ml)
norepinephrine bitartrate
papaverine injection solution
papaverine oral
RANEXA
Dihydropyridines
amlodipine
amlodipine-benazepril
amlodipine-valsartan
amlodipine-valsartan-hcthiazid
AZOR
CLEVIPREX INTRAVENOUS
EMULSION 50 MG/100 ML
felodipine
isradipine
nicardipine oral
nifedipine er 30 mg tablet f/c
nifedipine oral tablet extended release 24hr
30 mg
(Milrinone Lactate)
(Milrinone
Lactate/D5W)
(Levophed Bitartrate)
(Papaverine HCl)
(Papaverine HCl)
$0 (Tier 1)
$0 (Tier 1)
(Norvasc)
(Lotrel)
(Exforge)
(Exforge HCT)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
(Ethanolamine Oleate)
(Hydralazine HCl)
(Felodipine)
(Isradipine)
(Nicardipine HCl)
(Adalat CC)
(Adalat CC)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
PA BvD
PA BvD
PA BvD
PA
PA
ST
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
60
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
nifedipine oral tablet extended release 24hr
60 mg, 90 mg
nifedipine oral tablet extended release 30
mg, 60 mg
Diuretics
amiloride oral
amiloride-hydrochlorothiazide
bumetanide
chlorothiazide
chlorothiazide sodium
chlorthalidone oral tablet 25 mg, 50 mg
DYRENIUM
furosemide injection
furosemide oral solution 10 mg/ml, 40 mg/5
ml
furosemide oral tablet
hydrochlorothiazide oral capsule
hydrochlorothiazide oral tablet
indapamide
methyclothiazide
metolazone
torsemide oral
triamterene-hydrochlorothiazid oral
capsule
triamterene-hydrochlorothiazid oral tablet
Dyslipidemics
amlodipine-atorvastatin
atorvastatin
cholestyramine packet
cholestyramine-aspartame oral powder 4
gram
cholestyramine-aspartame oral powder in
packet 4 gram
colestipol hcl granules packet
colestipol oral granules
(Procardia XL)
$0 (Tier 1)
(Adalat CC)
$0 (Tier 1)
(Midamor)
(Amiloride/Hydrochlor
othiazide)
(Bumetanide)
(Chlorothiazide)
(Sodium Diuril)
(Chlorthalidone)
$0 (Tier 1)
$0 (Tier 1)
(Furosemide)
(Furosemide)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Lasix)
(Microzide)
(Hydrochlorothiazide)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
(Dyazide)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Maxzide)
$0 (Tier 1)
(Caduet)
(Lipitor)
(Questran)
(Cholestyramine/Aspar
tame)
(Questran)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Colestid)
(Colestid)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
61
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
colestipol oral tablet
CRESTOR
cvs fish oil * 1,200 mg softgel softgel, s/f
cvs niacin flush free * 500 mg
cvs omega-3 gummy fish child, brain
booster
endur-acin * sr 250 mg tablet
endur-acin * sr 500 mg tablet
eql fish oil 1,200 mg softgel sftgl,e/c,no
lactose
eql omega 3 fish oil * softgel
fenofibrate micronized
fenofibrate nanocrystallized
fenofibrate oral tablet
fenofibric acid
fenofibric acid (choline)
fish oil * 1,000 mg capsule
fish oil * 1,000 mg softgel
fish oil * 1,000 mg softgel s/f,na/f, yeast
free
fish oil * 1,000 mg softgel softgel, s/f, p/f
fish oil concentrate softgel softgel, exstrengh
fish oil dr 1,000 mg softgel
fish oil pearls * softgel
gemfibrozil oral
JUXTAPID
KYNAMRO
lovastatin
(Colestid)
(Omega-3 Fatty
Acids/Fish Oil)
(Niacin (Inositol
Niacinate))
(Omega-3 Fatty Acids)
(Slo-Niacin)
(Slo-Niacin)
(Omega-3 Fatty
Acids/Fish Oil)
(Omega-3 Fatty
Acids/Fish Oil)
(Lofibra)
(Tricor)
(Lofibra)
(Fibricor)
(Trilipix)
(Omega-3 Fatty
Acids/Fish Oil)
(Omega-3 Fatty Acids)
(Omega-3 Fatty
Acids/Fish Oil)
(Omega-3 Fatty
Acids/Fish Oil)
(Omega-3 Fatty
Acids/Fish Oil)
(Omega-3 Fatty
Acids/Fish Oil)
(Omega-3 Fatty
Acids/Fish Oil)
(Lopid)
(Mevacor)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
PA
PA; QL (4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
62
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
maxepa * capsule
niacin
niacin * 100 mg tablet
niacin * 125 mg capsule sa (otc)
niacin * 250 mg tablet
niacin * 250 mg tablet sa p/f,s/f
niacin * 400 mg capsule sa
niacin * 50 mg tablet
niacin * 500 mg capsule sa
niacin * 500 mg tablet
niacin * 750 mg tablet sa
niacin * er 1,000 mg tablet
niacin flush-free 500 mg cap s/f,p/f,na/f
niacin inositol 500 mg capsule
niacin oral tablet extended release 24 hr
niacin * sa 250 mg capsule (otc)
niacin * tr 500 mg caplet caplet
niacinamide * 500 mg tablet
omega 3 fish oil softgel
omega-3 acid ethyl esters
omega-3 fish oil 1,760 mg stgl
PRALUENT PEN
PRALUENT SYRINGE
pravastatin
prevalite packet outer 4 gram
pv fish oil 1,000 mg softgel softgel
ra fish oil * 1,000 mg softgel softgel,s/f,p/f
ra niacin 500 mg tablet no flush
(Omega-3 Fatty Acids)
(Niacin)
(Slo-Niacin)
(Niacin)
(Slo-Niacin)
(Slo-Niacin)
(Niacin)
(Slo-Niacin)
(Niacin)
(Slo-Niacin)
(Slo-Niacin)
(Slo-Niacin)
(Niacin (Inositol
Niacinate))
(Niacin (Inositol
Niacinate))
(Niaspan)
(Niacin)
(Slo-Niacin)
(Niacinamide)
(Omega-3 Fatty
Acids/Fish Oil)
(Lovaza)
(Omega-3 Fatty
Acids/Fish Oil)
(Pravachol)
(Cholestyramine/Aspar
tame)
(Omega-3 Fatty
Acids/Fish Oil)
(Omega-3 Fatty
Acids/Fish Oil)
(Niacin (Inositol
Niacinate))
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (2 per 28 days)
PA; QL (2 per 28 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
63
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
REPATHA SURECLICK
REPATHA SYRINGE
sea-omega 30 * capsule p/f,s/f,gluten free
simvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
simvastatin oral tablet 80 mg
sm fish oil * 1,200 mg softgel softgel,
gluten-free
SUPER TWIN EPA-DHA * 1,250 MG
VASCEPA
ZETIA
Renin-Angiotensin-Aldosterone
System Inhibitors
eplerenone
spironolactone
spironolacton-hydrochlorothiaz
Vasodilators
isosorbide dinitrate oral
isosorbide dinitrate sublingual
isosorbide mononitrate oral tablet
(Omega-3 Fatty
Acids/Fish Oil)
(Zocor)
(Zocor)
(Omega-3 Fatty
Acids/Fish Oil)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 4)
PA; QL (3 per 28 days)
PA; QL (3 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
QL (30 per 30 days)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
(Inspra)
(Aldactone)
(Aldactazide)
(Isochron)
(Isosorbide Dinitrate)
(Isosorbide
Mononitrate)
isosorbide mononitrate oral tablet extended (Imdur)
release 24 hr
minitran transdermal patch 24 hour 0.1
(Nitro-Dur)
mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour 0.4
(Nitro-Dur)
mg/hr
minoxidil oral
(Minoxidil)
NITRO-BID
nitroglycerin in 5 % dextrose intravenous
(Nitroglycerin/D5W)
solution 100 mg/250 ml (400 mcg/ml), 25
mg/250 ml (100 mcg/ml), 50 mg/250 ml
(200 mcg/ml)
nitroglycerin intravenous
(Nitroglycerin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
64
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
nitroglycerin transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
nitroglycerin transdermal patch 24 hour
0.4 mg/hr
NITROSTAT
PROGLYCEM
(Nitro-Dur)
$0 (Tier 1)
QL (30 per 30 days)
(Nitro-Dur)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 2)
$0 (Tier 2)
Central Nervous System Agents
Central Nervous System Agents
amphetamine salt combo
AMPYRA
caffeine citrated intravenous
caffeine citrated oral
caffeine-sodium benzoate
clonidine hcl oral tablet extended release
12 hr
dexmethylphenidate oral tablet
dextroamphetamine oral capsule, extended
release
dextroamphetamine oral tablet
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 5 mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 20 mg, 25
mg, 30 mg
flumazenil
guanfacine oral tablet extended release 24
hr
lithium carbonate oral capsule
lithium carbonate oral tablet
lithium carbonate oral tablet extended
release
lithium citrate oral solution 8 meq/5 ml
methylphenidate cd 20 mg cap
methylphenidate cd 40 mg cap
(Adderall)
(Cafcit)
(Cafcit)
(Caffeine/Sodium
Benzoate)
(Kapvay)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
PA; QL (60 per 30 days)
$0 (Tier 1)
(Focalin)
(Dexedrine)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
QL (120 per 30 days)
(Dexedrine)
(Adderall XR)
$0 (Tier 1)
$0 (Tier 1)
QL (180 per 30 days)
QL (30 per 30 days)
(Adderall XR)
$0 (Tier 1)
QL (60 per 30 days)
(Romazicon)
(Intuniv)
$0 (Tier 1)
$0 (Tier 1)
(Lithium Carbonate)
(Lithobid)
(Lithobid)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Lithium Citrate)
(Metadate Cd)
(Metadate Cd)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
65
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
methylphenidate oral capsule, er biphasic
30-70 10 mg, 50 mg, 60 mg
methylphenidate oral capsule, er biphasic
30-70 30 mg
methylphenidate oral capsule,er biphasic
50-50 20 mg, 40 mg
methylphenidate oral solution
methylphenidate oral tablet
methylphenidate oral tablet extended
release
methylphenidate oral tablet extended
release 24hr 18 mg, 27 mg, 54 mg
methylphenidate oral tablet extended
release 24hr 36 mg
NUEDEXTA
phentermine * 15 mg capsule
phentermine * 30 mg capsule pelletized
phentermine * 37.5 mg capsule
phentermine * 37.5 mg tablet
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
tetrabenazine
(Metadate Cd)
$0 (Tier 1)
QL (30 per 30 days)
(Metadate Cd)
$0 (Tier 1)
QL (60 per 30 days)
(Metadate Cd)
$0 (Tier 1)
QL (30 per 30 days)
(Methylin)
(Ritalin)
(Methylphenidate HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (900 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
(Concerta)
$0 (Tier 1)
QL (30 per 30 days)
(Concerta)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 2)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
QL (60 per 30 days)
PA; QL (30 per 30 days)
PA; QL (30 per 30 days)
PA; QL (30 per 30 days)
PA; QL (30 per 30 days)
(Adipex-P)
(Adipex-P)
(Adipex-P)
(Adipex-P)
(Rilutek)
(Xenazine)
XENAZINE
$0 (Tier 2)
QL (60 per 30 days)
PA; QL (112 per 28
days)
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
AIMSCO * LATEX CONDOM
ashlyna
bekyree (28)
blisovi 24 fe
blisovi fe 1.5/30 (28)
blisovi fe 1/20 (28)
CONDOMS LUBRICATED
(Seasonique)
(Mircette)
(Loestrin Fe)
(Loestrin Fe)
(Loestrin Fe)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
66
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
cyred
deblitane
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
desogestrel-ethinyl estradiol oral tablet
0.1/.125/.15-25 mg-mcg
drospirenone-ethinyl estradiol
econtra ez * 1.5 mg tablet inner
ELLA
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
fallback solo * 1.5 mg tablet inner
FANTASY * CONDOM
gildess 1/20 (21)
gildess 24 fe
gildess fe 1/20 (28)
GYNOL II * 3% GEL
juleber
junel fe 24
kimidess (28)
KIMONO CONDOMS
KIMONO MAXX CONDOM
KIMONO MICROTHIN AQUA LUBE
KIMONO MICROTHIN CONDOM
KIMONO MICROTHIN LARGE
CONDOM
KIMONO TEXTURED CONDOM
l norgest/e.estradiol-e.estrad
larin 24 fe
larin fe 1/20 (28)
levonor-eth estrad 0.15-0.03 outer
levonorgestrel * 1.5 mg tablet (otc)
levonorgestrel oral tablet 0.75 mg
levonorgestrel oral tablet 1.5 mg
(Desogen)
(Nor-Q-D)
(Mircette)
(Desogen)
(Desogen)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Yaz)
(Aftera)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Yaz)
(Demulen 1-50-21)
(Aftera)
(Loestrin)
(Loestrin Fe)
(Loestrin Fe)
(Desogen)
(Loestrin Fe)
(Mircette)
(Seasonique)
(Loestrin Fe)
(Loestrin Fe)
(Amethyst)
(Aftera)
(Plan B One-Step)
(Plan B One-Step)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
QL (6 per 365 days)
QL (6 per 365 days)
PA; QL (6 per 365 days)
QL (91 per 84 days)
QL (91 per 84 days)
PA; QL (6 per 365 days)
QL (12 per 365 days)
QL (6 per 365 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
67
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
levonorgestrel-ethin estradiol oral tablet
0.1-20 mg-mcg, 0.15-0.03 mg, 50-30
(6)/75-40 (5)/125-30(10)
levonorgestrel-ethin estradiol oral
tablets,dose pack,3 month 0.15-30 mg-mcg
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month
l-norgest-eth estr/ethin estra
my way 1.5 mg tablet (otc) 1.5 mg
next choice one dose 1.5 mg tb (otc) 1.5 mg
norelgestromin/ethin.estradiol
norethindrone
norethindrone (contraceptive)
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg, 1.5-30 mg-mcg
norethindrone-e.estradiol-iron oral tablet 1
mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg
(24)/75 mg (4), 1-20(5)/1-30(7) /1mg35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7)
norethindrone-ethinyl estrad oral tablet
0.4-35 mg-mcg, 0.5-35 mg-mcg, 0.5-35/135 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35
mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
opcicon one-step * 1.5 mg tablet
setlakin
tarina fe 1/20 (28)
tri-lo-estarylla
tri-lo-marzia
(Amethyst)
$0 (Tier 1)
(Levonorgestrel-Ethin
Estradiol)
(Amethyst)
$0 (Tier 1)
(Amethyst)
$0 (Tier 1)
QL (91 per 84 days)
(Seasonique)
(Aftera)
(Aftera)
(Ortho Evra)
(Nor-Q-D)
(Nor-Q-D)
(Loestrin)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (91 per 84 days)
PA; QL (6 per 365 days)
PA; QL (6 per 365 days)
QL (3 per 28 days)
(Loestrin Fe)
$0 (Tier 1)
(Modicon)
$0 (Tier 1)
(Norinyl 1+50)
(Ortho-Cyclen)
(Norgestrel-Ethinyl
Estradiol)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Aftera)
(Levonorgestrel-Ethin
Estradiol)
(Loestrin Fe)
(Ortho-Cyclen)
(Ortho-Cyclen)
QL (91 per 84 days)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 1)
ST; QL (1 per 28 days)
PA; QL (6 per 365 days)
QL (91 per 84 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
68
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
tri-lo-sprintec
TRUSTEX CONDOM
TRUSTEX CONDOM 12'S,EXTRA
STRENGTH
TRUSTEX LATEX CONDOM * 12'S
TRUSTEX-RIA CONDOM
12'S,W/SPERMICIDE
TRUSTEX-RIA CONDOM 48'S,NONLUBRICATED
VCF CONTRACEPTIVE FOAM
vienva
WIDE SEAL DIAPHRAGM 70MM
(Ortho-Cyclen)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Amethyst)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 3)
Cough And Cold Products
Cough And Cold Products
adult wal-tussin * liquid
benzonatate * 100 mg capsule
benzonatate * 150 mg capsule
benzonatate * 200 mg capsule
cheratussin ac * syrup (otc)
children's silfedrine * liq
childs sudafed 15 mg/5 ml liq nondrowsy,a/f,s/f
chl mucinex chest congest liq a/f
cvs child's chest congest liq
diabetic siltussin das-na * liq
diabetic tussin ex * liquid a/f,d/f,na/f,s/f
expectorant * 100 mg/5 ml syrup
liquituss gg * 200 mg/5 ml liq
mar-cof cg * liquid
(Robitussin MucusChest Congest)
(Zonatuss)
(Zonatuss)
(Zonatuss)
(M-Clear Wc)
(Pseudoephedrine HCl)
(Pseudoephedrine HCl)
$0 (Tier 4)
(Robitussin MucusChest Congest)
(Robitussin MucusChest Congest)
(Robitussin MucusChest Congest)
(Robitussin MucusChest Congest)
(Robitussin MucusChest Congest)
(Robitussin MucusChest Congest)
(M-Clear Wc)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
69
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
nasal-sinus decongest tab
ninjacof-xg * liquid
phenylhistine dh * liquid (otc)
promethazine vc-codeine syrup 6.25-5-10
mg/5 ml
promethazine-codeine * syrup
promethazine-dm * syrup
pseudoephed 30 mg/5 ml soln
pseudoephedrine 30 mg tablet
pseudoephedrine 60 mg tablet ex-str, non
drowsy (otc)
q-tussin * 100 mg/5 ml solution a/f, nondrowsy
relcof c * liquid
robafen * 100 mg/5 ml syrup
scot-tussin 100 mg/5 ml liq
siltussin sa * 100 mg/5 ml syr
sm adult nasal decongestant * lq
sudogest * 30 mg tablet boxed
sudogest * 60 mg tablet
suphedrin * liquid
trymine cg * liquid
valu-tapp decongestant * drop
virtussin ac * liquid
wal-phed * 30 mg tablet non-drowsy
zephrex-d * 30 mg tablet
(Sudafed 12-Hour)
(M-Clear Wc)
(P-Ephed
HCl/Cod/Chlorphenir)
(Promethazine/Phenyle
ph/Codeine)
(Promethazine
HCl/Codeine)
(Promethazine/Dextro
methorphan)
(Pseudoephedrine HCl)
(Sudafed 12-Hour)
(Sudafed 12-Hour)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 3)
PA; AGE (Min 2 Years)
$0 (Tier 3)
PA; AGE (Min 2 Years)
$0 (Tier 3)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
(Robitussin MucusChest Congest)
(M-Clear Wc)
(Robitussin MucusChest Congest)
(Robitussin MucusChest Congest)
(Robitussin MucusChest Congest)
(Pseudoephedrine HCl)
(Sudafed 12-Hour)
(Sudafed 12-Hour)
(Pseudoephedrine HCl)
(M-Clear Wc)
(Pseudoephedrine HCl)
(M-Clear Wc)
(Sudafed 12-Hour)
(Sudafed 12-Hour)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
PA; AGE (Min 2 Years)
Dental And Oral Agents
Dental And Oral Agents
cevimeline
(Evoxac)
chlorhexidine gluconate mucous membrane (Peridex)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
70
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
pilocarpine hcl oral
pv dry mouth * mouthwash a/f
triamcinolone acetonide
(Salagen)
(Saliva Substitute
Combo No.7)
(Triamcinolone
Acetonide)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acne & blackhead 2.5% gel
acne foaming 10% wash
acne medication * 5% gel
ACNE MEDICATION * 5% LOTION
acneclear gel
acyclovir topical
ALCOHOL PADS
ALCOHOL PREP PADS
ammonium lactate topical
ANACAINE
benzoyl peroxide * 10% gel aqueous (otc)
benzoyl peroxide * 2.5% gel (otc)
benzoyl peroxide * 5% gel aqueous (otc)
benzoyl peroxide * 5% wash (otc)
benzoyl peroxide * 6% cleanser (otc)
calamine * lotion
calcipotriene
calcipotriene scalp
calcipotriene topical cream
calcitriol topical
clearasil daily clear 10% crm
CONDYLOX TOPICAL GEL
COSENTYX
COSENTYX (150 MG/ML) 300 MG
DOSE-2 PENS
(Soriatane)
(Benzoyl Peroxide)
(Bp Wash)
(Benzoyl Peroxide)
(Benzoyl Peroxide)
(Zovirax)
(Lac-Hydrin)
(Benzoyl Peroxide)
(Benzoyl Peroxide)
(Benzoyl Peroxide)
(Bp Wash)
(Bp Wash)
(Calamine)
(Calcipotriene)
(Calcipotriene)
(Dovonex)
(Vectical)
(Benzoyl Peroxide)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (30 per 30 days)
PA
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
71
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
COSENTYX (150 MG/ML) 300 MG
DOSE-2 SYRINGES
COSENTYX PEN
cvs acne foaming face 10% wash
ELTA TAR * 2% OINTMENT
FLUOROPLEX
fluorouracil topical cream
fluorouracil topical solution
ichthammol * 20% ointment
imiquimod
isotretinoin oral capsule 10 mg, 20 mg, 30
mg, 40 mg
methoxsalen rapid
mg217 psoriasis * ointment
panoxyl * 10% acne foaming wash
panoxyl-4 * acne creamy wash
PANRETIN
persa-gel * 10% 12's,max-strength
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podofilox
podophyllum resin
potassium hydroxide
pub calamine lotion
pv acne pimple 10% gel
ra scalp itch-dandruff rel liq
SANTYL
TOLAK
VALCHLOR
ZOVIRAX TOPICAL CREAM
Dermatological Antibacterials
bacitracin * 500 unit/gm ointmnt
bacitracin-polymyxin ointment
$0 (Tier 2)
PA
PA
(Carac)
(Fluorouracil)
(Ichthammol)
(Aldara)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
(Isotretinoin)
$0 (Tier 1)
(Oxsoralen-Ultra)
(Coal Tar)
(Bp Wash)
(Bp Wash)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Bp Wash)
(Benzoyl Peroxide)
(Condylox)
(Podophyllum Resin)
(Potassium Hydroxide)
(Calamine/Zinc Oxide)
(Benzoyl Peroxide)
(Oil-Free Acne Wash)
(Bacitracin)
(Bacitracin/Polymyxin
B Sulfate)
PA NSO; QL (24 per 30
days)
QL (3 per 56 days)
QL (2 per 56 days)
QL (15 per 30 days)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
72
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
bacitraycin plus * 500 unit/gm
clindamycin phosphate topical gel
clindamycin phosphate topical lotion
clindamycin phosphate topical solution
clindamycin phosphate topical swab
cvs antibiotic plus cream
erythromycin base-ethanol
erythromycin with ethanol topical gel
erythromycin with ethanol topical solution
erythromycin with ethanol topical swab
gentamicin topical
metronidazole topical cream 0.75 %
metronidazole topical gel
metronidazole topical lotion
multi antibiotic plus * cream
mupirocin
mupirocin calcium
neomycin-polymyxin b gu
neosporin + pain relief * cream maximum
strength
polysporin * ointment (otc)
selenium sulfide topical lotion
selenium sulfide topical shampoo 2.25 %
silver nitrate applicators
silver nitrate topical
silver sulfadiazine
sulfacetamide sodium (acne)
(Bacitracin)
(Cleocin T)
(Cleocin T)
(Cleocin T)
(Cleocin T)
(Neomycin Su/Plymx
B Su/Pram)
(Erythromycin
Base/Ethanol)
(Emgel)
(Erythromycin
Base/Ethanol)
(Erythromycin
Base/Ethanol)
(Gentamicin Sulfate)
(Metrocream)
(Rosadan)
(Metrolotion)
(Neomycin Su/Plymx
B Su/Pram)
(Centany)
(Bactroban)
(Neosporin G.U.
Irrigant)
(Neomycin Su/Plymx
B Su/Pram)
(Bacitracin/Polymyxin
B Sulfate)
(Selenium Sulfide)
(Selenium Sulfide)
(Silver Nitrate
Applicator)
(Silver Nitrate)
(Silvadene)
(Klaron)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
73
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
Dermatological AntiInflammatory Agents
alclometasone
(Alclometasone
Dipropionate)
aquanil hc * 1% lotion
(Cortizone-10)
beta hc 1% lotion
(Cortizone-10)
betamethasone dipropionate
(Betamethasone
Dipropionate)
betamethasone valerate topical cream
(Betamethasone
Valerate)
betamethasone valerate topical foam
(Luxiq)
betamethasone valerate topical lotion
(Betamethasone
Valerate)
betamethasone valerate topical ointment
(Betamethasone
Valerate)
betamethasone, augmented topical cream
(Diprolene AF)
betamethasone, augmented topical gel
(Betamethasone
Dipropionate)
betamethasone, augmented topical lotion
(Diprolene)
betamethasone, augmented topical ointment (Diprolene)
clobetasol 0.05% cream
(Temovate)
clobetasol propionate scalp solution 0.05 % (Clobetasol
Propionate)
clobetasol scalp
(Clobetasol
Propionate)
clobetasol topical foam
(Olux)
clobetasol topical gel
(Clobetasol
Propionate)
clobetasol topical lotion
(Clobex)
clobetasol topical ointment
(Temovate)
clobetasol topical shampoo
(Clobex)
clobetasol-emollient topical cream
(Temovate)
clocortolone pivalate
(Cloderm)
cortaid * 1% cream 12 hr, anti-itch
(Hydrocortisone)
cortizone-10 * 1% creme maximum
(Hydrocortisone)
strength
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
74
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
CORTIZONE-10 * 1% LOTION
cortizone-10 * 1% ointment
cvs hydrocortisone 0.5% crm
dermarest eczema 1% lotion
desonide topical cream
desonide topical ointment
desoximetasone
ELIDEL
fluocinonide 0.05% cream
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-emollient base
fluticasone topical cream
fluticasone topical ointment
halobetasol propionate
hydro skin 1% lotion
hydrocortisone * 0.5% cream (otc)
hydrocortisone * 0.5% ointment
hydrocortisone 1% cream maximum
strength
hydrocortisone * 1% cream maximum
strength (otc)
hydrocortisone * 1% lotion (otc)
hydrocortisone * 1% ointment carton (otc)
hydrocortisone acet-aloe vera topical gel
hydrocortisone acetate-aloe *
hydrocortisone acetate-urea
hydrocortisone buty 0.1% cream
hydrocortisone butyrate topical ointment
(Hydrocortisone)
(Hydrocortisone
Acetate)
(Cortizone-10)
(Desowen)
(Desonide)
(Topicort)
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone
Propionate)
(Ultravate)
(Cortizone-10)
(Hydrocortisone)
(Hydrocortisone)
(Hydrocortisone
Acetate)
(Hydrocortisone)
(Cortizone-10)
(Hydrocortisone)
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Acetate/Urea)
(Hydrocortisone
Butyrate)
(Locoid)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
75
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
hydrocortisone butyrate topical solution
hydrocortisone butyr-emollient
(Locoid)
(Hydrocortisone
Butyrate)
hydrocortisone rectal cream 1 %
(Anusol-HC)
hydrocortisone rectal cream 2.5 %
(Hydrocortisone)
hydrocortisone rectal enema
(Cortenema)
hydrocortisone topical cream 1 %, 2.5 %
(Anusol-HC)
hydrocortisone topical lotion 2 %, 2.5 %
(Scalacort)
hydrocortisone topical ointment 1 %, 2.5 % (Hydrocortisone)
hydrocortisone valerate topical cream
(Hydrocortisone
Valerate)
hydrocortisone valerate topical ointment
(Westcort)
mometasone
(Elocon)
neosporin 1% anti-itch cream
(Hydrocortisone)
obagi nu-derm tolereen * lotion
(Cortizone-10)
prednicarbate
(Dermatop)
preparation h hc 1% cream
(Hydrocortisone)
recort plus * 1% cream
(Hydrocortisone)
tacrolimus topical
(Protopic)
triamcinolone acetonide
(Triamcinolone
Acetonide)
triamcinolone acetonide topical cream
(Triamcinolone
Acetonide)
triamcinolone acetonide topical lotion
(Triamcinolone
Acetonide)
triamcinolone acetonide topical ointment
(Triamcinolone
0.025 %, 0.1 %, 0.5 %
Acetonide)
Dermatological Retinoids
adapalene topical cream
(Differin)
adapalene topical gel 0.1 %
(Differin)
TAZORAC TOPICAL CREAM
tretinoin gel micro 0.04% tube
(Retin-A Micro)
tretinoin gel micro 0.1% tube
(Retin-A Micro)
tretinoin microspheres topical gel with
(Retin-A Micro)
pump
tretinoin topical
(Retin-A)
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA
PA
PA
$0 (Tier 1)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
76
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
Scabicides And Pediculicides
cvs lice killing * shampoo maximum
strength
cvs lice solution * kit
shamp/gel/spray/comb
cvs permethrin * 1% lotion
eql lice treatment * kit
household lice control * spry
lice egg remover * gel w/ nit comb
lice treatment * liquid
malathion
NIX 1% CREME RINSE LIQUID W/ NIT
COMB
permethrin topical cream
pv 0.5% bedding spray *
ra lice treatment * 1% crm rinse 2x59ml, 2
combs
rid lice killing * shampoo
rid pediculicides spray
sm lice treatment permethrin 2's
stop lice * 0.5% spray
v-r lice cream rinse *
(Piperonyl
Butoxide/Pyrethrins)
(Pip
Butox/Pyrethrins/Perm
eth)
(Nix)
(Piperonyl
Butoxide/Pyrethrins)
(Piperonyl
Butoxide/Pyrethrins)
(Piperonyl
Butoxide/Pyrethrins)
(Ovide)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
(Elimite)
(Permethrin)
(Nix)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Piperonyl
Butoxide/Pyrethrins)
(Permethrin)
(Nix)
(Permethrin)
(Nix)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Devices
Devices
1ST CHOICE SUPER THIN LANCETS
$0 (Tier 4)
1ST TIER COMFORTOUCH 28G LANCT
$0 (Tier 4)
1ST TIER COMFORTOUCH 30G LANCT
$0 (Tier 4)
ACCU-CHEK ACTIVE TEST * STRIP
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
77
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
ACCU-CHEK AVIVA PLUS TEST STRP
*
ACCU-CHEK AVIVA * TEST STRIPS
NOT FOR RETAIL SALE
ACCU-CHEK COMPACT PLUS STRIPS
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
ACCU-CHEK FASTCLIX * LANCETS
$0 (Tier 4)
ACCU-CHEK MULTICLIX LANCET *S
$0 (Tier 4)
ACCU-CHEK SAFE-T-PRO * 23G
LANCT
ACCU-CHEK SAFE-T-PRO PLUS * 23G
$0 (Tier 4)
ACCU-CHEK SMARTVIEW TEST
STRIP *
ACCU-CHEK SOFTCLIX LANCETS *
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
ACCUTREND GLUCOSE * TEST STRIP
ACE AEROSOL CLOUD ENHANCER *
ACTI-LANCE LITE 28G LANCETS
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
ACTI-LANCE SPECIAL 17G LANCETS
$0 (Tier 4)
ACTI-LANCE UNIVERS 23G LANCETS
$0 (Tier 4)
ACURA TEST STRIPS *
ADVANCED TRAVEL 28G LANCETS
28G,SINGLE-USE,STRL
ADVANCED TRAVEL 30G LANCETS
$0 (Tier 3)
$0 (Tier 4)
ADVOCATE 26G LANCETS 26
G,STERILE
ADVOCATE 26G LANCETS STERILE
$0 (Tier 4)
ADVOCATE 30G LANCETS TWIST TOP
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
78
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
ADVOCATE REDI-CODE * TEST STRIP
ADVOCATE REDI-CODE+ * TEST
STRIP NO CODING
ADVOCATE TEST STRIP
AEROCHAMBER MINI * 10'S, LATEXFREE
AEROCHAMBER MV * HOLD
CHAMBER
AEROCHAMBER PLUS FLOW-VU *
AEROCHAMBER PLUS FLOW-VU
MED
AEROCHAMBER PLUS FLOW-VU
MED WITH MASK
AEROCHAMBER PLUS WFLOWSIGNAL
AEROCHAMBER PLUS Z STAT
MEDIUM 10'S, W/MEDIUM MASK
AEROCHAMBER Z-STAT PLUS WFLOW
AEROTRACH HOLDING CHAMBER
AEROVENT PLUS * HOLDING
CHAMBER
AGAMATRIX AMP TEST STRIPS *
ALTERNATE SITE 26G LANCETS 26G,
STRL
ASSURE 4 TEST STRIPS
ASSURE HAEMOLANCE PLUS * 18G
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
ASSURE HAEMOLANCE PLUS * 21G
$0 (Tier 4)
ASSURE HAEMOLANCE PLUS * 25G
$0 (Tier 4)
ASSURE HAEMOLANCE PLUS * 28G
$0 (Tier 4)
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
$0 (Tier 1)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
79
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
ASSURE LANCE * 25G LANCETS
$0 (Tier 4)
ASSURE LANCE * 28G LANCETS
$0 (Tier 4)
ASSURE LANCE PLUS * 21G LANCETS
$0 (Tier 4)
ASSURE LANCE PLUS * 25G LANCETS
$0 (Tier 4)
ASSURE LANCE PLUS * 30G LANCETS
$0 (Tier 4)
ASSURE PLATINUM * TEST STRIPS
ASSURE PRISM MULTI TEST STRIPS
BD 3 ML SYRINGE 25GX1"
BD 3 ML SYRINGE 25GX1-1/2"
BD 3 ML SYRINGE WITH NEEDLE
BD BULK SYRINGE 3 ML
BD ECLIPSE LUER-LOK SYRINGE 1
ML 27 X 1/2"
BD ECLIPSE SYRINGE * 3 ML 25GX1"
BD INSULIN SYR 0.3 ML 31GX5/16
BD INSULIN SYR 0.5 ML 31GX5/16"
BD INSULIN SYR 1 ML 31GX5/16"
BD INTEGRA SYR 3 ML 25GX5/8"
BD INTEGRA SYRINGE * 3 ML 25GX1"
BD LANCETS * 33G
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
BD LUER-LOK SYR 3 ML 25GX5/8"
BD LUER-LOK SYRINGE * 3 ML LUERLOK TIP
BD MEDSAVER SYRINGE *
BD MICROTAINER 21G LANCETS
$0 (Tier 4)
$0 (Tier 4)
BD MICROTAINER 30G LANCETS
$0 (Tier 4)
BD SAFETYGLIDE TB 1 ML SYR
BD SYRINGE 3 ML
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
80
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
BD SYRINGE-SAFETY GLIDE
BD TB SYRINGE 21GX1"
BD TB SYRINGE 22GX1"
BD TB SYRINGE 25GX5/8"
BD TB SYRINGE 26GX3/8"
BD TB SYRINGE 27GX1/2"
BD TB SYRNGE 27GX1/2"
BD TUBERCULIN 1 ML SYRINGE
BD ULTRA-FINE 33G LANCETS
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
BD ULTRA-FINE II 30G LANCETS
$0 (Tier 4)
BD ULTRA-FINE PEN NDL 8MMX31G
SHORT
BG-STAR * GLUCOSE TEST STRIPS
BLOOD GLUCOSE TEST * STRIP NO
CODING
BLOOD GLUCOSE TEST * STRIPS
BLOOD LANCETS * 30G EASY TWIST
$0 (Tier 1)
BREATHERITE MDI SPACER
BREATHRITE VALVED MDI SPACER
BULLSEYE MINI SAFETY 21G
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
BULLSEYE MINI SAFETY 25G LANCT
$0 (Tier 4)
CAREONE THIN LANCET *
$0 (Tier 4)
CARESENS N TEST STRIPS * NO
CODING
CARESENS ULTRA THIN 30G LANCET
$0 (Tier 3)
CHOICEDM CLARUS * TEST STRIPS
CLEVER CHEK ULTRA THIN 30G
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 4)
QL (100 per 20 days)
PA; QL (100 per 20
days)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
81
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
CLEVER CHOICE MICRO TEST STRIP
*
CLEVER CHOICE PRO * TEST STRIP
CLEVER CHOICE TALK TEST *
STRIPS
CLEVER CHOICE TEST STRIPS *
AUTO-CODE
CLEVER CHOICE VOICE+ TST STRIP
AUTO-CODE
COAGUCHEK LANCETS *
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
COMFORT EZ SAFETY 21G LANCETS
$0 (Tier 4)
COMFORT EZ SAFETY 23G LANCETS
$0 (Tier 4)
COMFORT EZ SAFETY 28G LANCETS
$0 (Tier 4)
COMFORT LANCETS *
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
COMPACT SPACE CHAMBER PLUS *
CONTOUR NEXT STRIPS *
CONTOUR TEST STRIPS *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
CONTROL G3 * TEST STRIP
CONTROL TEST * STRIPS
CVS ADVANCED GLUCOSE TEST STR
CVS THIN 26G LANCETS *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
CVS ULTRA THIN 30G LANCETS
$0 (Tier 4)
DIATRUE PLUS TEST STRIP *
DROPLET 30G LANCETS
$0 (Tier 3)
$0 (Tier 4)
EASIVENT HOLDING CHAMBER *
RETAIL PACK
EASY CHECK TEST *
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
82
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
EASY COMFORT 30G LANCETS
30G,TWIST TOP,STRL
EASY GLUCO G2 * TEST STRIP
EASY PLUS * GLUCOSE TEST STRIP
EASY PLUS II TEST * STRIPS
EASY STEP * GLUCOSE TEST STRIPS
EASY TALK GLUCOSE TEST * STRIP
EASY TOUCH 28G LANCETS
28G,PULL TOP,STERILE
EASY TOUCH * GLUCOSE TEST
STRIPS
EASY TOUCH SAFETY 21G LANCETS
$0 (Tier 4)
EASY TOUCH SAFETY 23G LANCETS
$0 (Tier 4)
EASY TOUCH SAFETY 26G LANCETS
$0 (Tier 4)
EASY TOUCH * SYR 3 ML 25GX5/8"
EASY TOUCH * SYRINGE 3 ML
25GX1"
EASY TOUCH TWIST 28G LANCETS
$0 (Tier 4)
$0 (Tier 4)
EASY TOUCH TWIST 30G LANCETS
$0 (Tier 4)
EASY TOUCH TWIST 32G LANCETS
$0 (Tier 4)
EASY TOUCH TWIST 33G LANCETS
$0 (Tier 4)
EASY TRAK GLUCOSE TEST * STRIP
EASY TWIST & CAP 28G LANCETS
$0 (Tier 3)
$0 (Tier 4)
EASYGLUCO PLUS * TEST STRIPS
EASYGLUCO TEST * STRIPS
EASYMAX 15 * GLUCOSE TEST STRIP
EASYMAX * GLUCOSE TEST STRIPS
MEDICAL BENEFIT USE
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
83
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
ELEMENT COMPACT TEST STRIPS *
ELEMENT TEST STRIPS *
EMBRACE 30G LANCETS
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
EMBRACE EVO TEST STRIPS *
EMBRACE PRO TEST STRIPS *
EMBRACE TEST STRIPS
EVENCARE G2 * TEST STRIP
EVENCARE G3 TEST * STRIP
EVENCARE GLUCOSE TST STRIPS
EVENCARE MINI GLUCOSE TEST STR
*
EVOLUTION TEST STRIPS *
EXEL SYRINGE 25GX1" 3 ML
EXEL SYRINGE * 25GX5/8" 3 ML
EXEL SYRINGE 3 ML
EXEL TB WITH NEEDLE 25GX5/8"
EXEL TB WITH NEEDLE 26GX3/8"
EXEL TB WITH NEEDLE 26GX5/8"
EXEL TB WITH NEEDLE 27GX1/2"
EXEL TUBERCULIN SYRINGE * 1 ML
E-Z JECT LANCETS *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
EZ SMART 28G LANCETS
$0 (Tier 4)
EZ SMART PLUS TEST * STRIPS
EZ SMART TEST * STRIPS
E-Z SPACER *
E-ZJECT COLOR 32G LANCETS
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
E-ZJECT COLOR 33G LANCETS
$0 (Tier 4)
E-ZJECT SUPER THIN 30G LANCETS
SUPER THIN
E-ZJECT THIN LANCETS * 26 GAUGE
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
84
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
FIFTY50 GLUCOSE TEST STRIP
FIFTY50 SAFETY SEAL 30G LANCET
$0 (Tier 3)
$0 (Tier 4)
FIFTY50 SAFETY SEAL 32G LANCET
$0 (Tier 4)
FINE 30 UNIVERSAL 30G LANCETS
$0 (Tier 4)
FINGERSTIX LANCETS *
$0 (Tier 4)
FLEXICHAMBER *
FORA 30G LANCETS * TWIST
OFF,SINGLE USE
FORA BLOOD GLUCOSE TEST STRIP
FORA D10 * GLUCOSE TEST STRIPS
FORA D15G * GLUCOSE TEST STRIPS
FORA D20 * GLUCOSE TEST STRIPS
FORA D40-G31 TEST STRIPS *
FORA G20 * GLUCOSE TEST STRIPS
FORA G30A * GLUCOSE TEST STRIP
FORA GD50 TEST STRIPS *
FORA TN'G VOICE TEST STRIPS *
FORA V10 * GLUCOSE TEST STRIP
FORA V12 GLUCOSE * TEST STRIP
FORA V20 * GLUCOSE TEST STRIPS
FORA V30A * GLUCOSE TEST STRIP
FORACARE 30G LANCETS
$0 (Tier 3)
$0 (Tier 4)
FORACARE GD20 * TEST STRIPS
FORACARE GD40 * GLUCOSE STRIPS
FORTISCARE GLUCOSE TEST STRIPS
*
FREESTYLE 28G LANCETS
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
FREESTYLE INSULINX * TEST STRIP
NO CODE
FREESTYLE INSULINX TEST STRIPS *
$0 (Tier 3)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
85
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
FREESTYLE LITE TEST STRIP
FREESTYLE LITE TEST STRIPS
FREESTYLE PREC NEO TEST STRIPS
FREESTYLE TEST * STRIPS
FREESTYLE UNISTIK 2 * LANCETS
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
G-4 TEST * STRIPS
GE100 BLOOD GLUCOSE TEST STRIP
* 2 VIALS X 25 STRIPS
GENSTRIP GLUCOSE TEST STRIP
GENULTIMATE TEST * STRIP
$0 (Tier 3)
$0 (Tier 3)
GLUCO NAVII GLUCOSE TEST STRIP
GLUCOCARD 01 SENSOR PLUS *
STRIP
GLUCOCARD EXPRESSION * TEST
STRP
GLUCOCARD SHINE TEST STRIPS *
GLUCOCARD VITAL TEST STRIPS *
GLUCOCOM 28G LANCETS
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
GLUCOCOM 30G LANCETS
$0 (Tier 4)
GLUCOCOM 33G LANCETS
$0 (Tier 4)
GLUCOCOM GLUCOSE * TEST STRIP
GLUCOSOURCE * LANCETS
$0 (Tier 3)
$0 (Tier 4)
GMATE 30G LANCETS
$0 (Tier 4)
GMATE TEST STRIPS *
GNP UNIVERSAL 1 STANDARD 21G
$0 (Tier 3)
$0 (Tier 4)
GNP UNIVERSAL 1 SUPER THIN 30G
$0 (Tier 4)
HEALTHPRO GLUCOSE TEST STRIPS
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
86
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
HEALTHY ACCENTS UNILET 30G
$0 (Tier 4)
INCONTROL SUPER THIN 30G LANCT
$0 (Tier 4)
INCONTROL ULTRA THIN 28G LANCT
$0 (Tier 4)
INFINITY TEST STRIPS *
INJECT EASE 28G LANCETS
$0 (Tier 3)
$0 (Tier 4)
INJECT EASE 30G LANCETS
$0 (Tier 4)
INSPIRACHAMBER *
INSPIRACHAMBER WITH MASK-MED
*
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 0.3 ML 29, 1 ML 29 X 1/2", 1/2
ML 28 GAUGE
INVACARE 30G LANCETS
$0 (Tier 3)
$0 (Tier 3)
KINNEY BRAND 23G LANCETS
$0 (Tier 4)
KRO PREMIUM BLOOD GLUCOSE
TEST * NO CODING,PREMIUM
KRO UNIVERSAL 1 THIN 26G LANCT
$0 (Tier 3)
KROGER SUPER THIN LANCETS
$0 (Tier 4)
LANCETS THIN 23G
$0 (Tier 4)
LANCETS ULTRA THIN 26G
$0 (Tier 4)
LIBERTY TEST * STRIPS BLOOD
GLUCOSE
LITE TOUCH 30G LANCETS
$0 (Tier 3)
LITE TOUCH 33G LANCETS
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
87
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
LITEAIRE MDI CHAMBER *
LONGS THIN LANCETS 30G 30G
$0 (Tier 3)
$0 (Tier 4)
MAGELLAN TUBERCULIN SYR 1 ML
MAXIMA * TEST STRIP
MEDI-LANCE LANCETS *
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
MEDISENSE THIN 28G LANCETS
$0 (Tier 4)
MEDLANCE PLUS 21G LANCETS
UNIVERSAL, 1.8MM
MEDLANCE PLUS 30G LANCETS
SUPERLITE, 1.2MM
MEDLANCE PLUS LITE 25G LANCETS
STERILE, 1.5MM
MICRO THIN 33G LANCETS
UNIVERSAL 1
MICROCHAMBER * LATEX/F
MICRODOT TEST STRIPS
MICRODOT XTRA TEST STRIPS
MICROLET LANCET *S
$0 (Tier 4)
MICROSPACER * FOR AEROSOL
DEVICE LATEX/F
MONAGHAN Z STAT CHAMBER-MD
MSK *
MONOJECT 1 ML TB SYRN 25X5/8"
MONOJECT 3 ML SYRINGE
MONOJECT 3 ML SYRN 25GX1"
MONOJECT 3 ML SYRN 25GX5/8"
LUER-LOCK, SOFTPACK
MONOJECT 3 ML SYRN 27GX1.25"
LUER LOCK,SOFTPACK
MONOJECT LUER LOCK TB SYR 1 ML
MONOJECT SAFETY SYRINGE
MONOJECT SYR PHARM TRAY PK
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
88
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
MONOJECT SYRINGE * 3 ML SOFTPK,
REG LUER TIP
MONOJECT TB 1 ML SYRN 26X3/8"
MONOJECT TB * 1 ML SYRN 28GX1/2
MONOJECT TB SAFETY SYRINGE *
MONOJECT TB SYRN 27GX1/2"
MONOJECT TUBERCULIN SYR 1 ML
MONOJECT TUBERCULIN SYR 1 ML
REGULAR LUER TIP (OTC)
MONOLET 21G LANCETS
$0 (Tier 4)
MONOLET THIN 28G LANCETS
$0 (Tier 4)
MYGLUCOHEALTH 30G LANCETS
$0 (Tier 4)
MYGLUCOHEALTH * TEST STRIPS
NEUTEK 2TEK TEST STRIPS *
NOVA MAX GLUCOSE TEST * STRIP
NOVA SAFETY 23G LANCETS
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
NOVA SAFETY 28G LANCETS
$0 (Tier 4)
NOVA SUREFLEX THIN LANCETS
$0 (Tier 4)
ON CALL 30G LANCET
$0 (Tier 4)
ON CALL EXPRESS TEST STRIP *
ON CALL PLUS 30G LANCET
$0 (Tier 3)
$0 (Tier 4)
ON CALL PLUS TEST STRIP *
ON CALL VIVID TEST STRIP *
ONE TOUCH DELICA 33G LANCETS
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
ONETOUCH DELICA 30G LANCETS
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
89
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
ONETOUCH DELICA 33G LANCETS
$0 (Tier 4)
ONETOUCH FINEPOINT 25G LANCETS
$0 (Tier 4)
ONETOUCH ULTRA TEST * STRIPS
ONETOUCH ULTRASOFT LANCETS *
$0 (Tier 3)
$0 (Tier 4)
ONETOUCH VERIO * TEST STRIP
OPTICHAMBER ADULT MASK-LARGE
*
OPTICHAMBER DIAMOND VHC *
OPTIUM EZ * TEST STRIP
OPTIUM TEST * STRIP
OPTUMRX * TEST STRIP
PEN NEEDLE, DIABETIC NEEDLE 29
GAUGE X 1/2 "
PHARMACIST CHOICE 30G LANCETS
* ULTRA THIN
PHARMACIST CHOICE TEST STRIPS
PHARMACIST CHOICE * TEST STRIPS
POCKET CHAMBER *
PRECISION PCX PLUS TEST * STR
PRECISION PCX TEST * STRIPS
PRECISION POINT OF CARE STR
PRECISION Q-I-D TEST * STRIPS
PRECISION XTRA TEST * STRIPS
PREMIUM V10 * GLUCOSE TEST
STRIP
PRESSURE ACTIVATED 21G LANCETS
$0 (Tier 3)
$0 (Tier 3)
PRESSURE ACTIVATED 28G LANCETS
$0 (Tier 4)
PRIMEAIRE * CHAMBER
PROCHAMBER * HOLDING CHAMBER
PRODIGY NO CODING * TEST STRIPS
50 STRIPS
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
90
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
PRODIGY PRESSURE ACTIVATED 28G
$0 (Tier 4)
PRODIGY PRESSURE ACTIVE
LANCET 26G, 1.8MM DEPTH
PRODIGY SAFETY 26G LANCETS
$0 (Tier 4)
PRODIGY TWIST TOP 28G LANCET
$0 (Tier 4)
PUB 28G LANCETS *
$0 (Tier 4)
PUSH BUTTON SAFETY 28G LANCET
$0 (Tier 4)
PV TRUETRACK SMART SYS STRIPS
QC UNILET SUPER THIN 30G LANCT
$0 (Tier 3)
$0 (Tier 4)
QUINTET AC * GLUCOSE TEST
STRIPS
QUINTET GLUCOSE TEST STRIPS *
RA E-ZJECT 26G LANCETS
$0 (Tier 3)
RA E-ZJECT 28G LANCETS
$0 (Tier 4)
REFUAH PLUS * TEST STRIPS
RELIAMED 30G LANCETS
$0 (Tier 3)
$0 (Tier 4)
RELIAMED SAFETY 23G LANCETS
$0 (Tier 4)
RELIAMED SAFETY 28G LANCETS
LATEX-FREE
RELIAMED SAFETY SEAL 28G LANCT
$0 (Tier 4)
RELIAMED SAFETY SEAL 30G LANCT
$0 (Tier 4)
RELION CONFIRM-MICRO * TEST
STRP
RELION MICRO TEST STRIPS
RELION PRIME TEST STRIPS *
$0 (Tier 3)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
91
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
RELION THIN 26G LANCETS
$0 (Tier 4)
RELION ULTIMA TEST STRIPS *
RELION ULTRA THIN PLUS 33G
$0 (Tier 3)
$0 (Tier 4)
RELION ULTRA THIN PLUS LANCETS
*
REVEAL TEST STRIP *
RIGHTEST GL300 30G LANCETS
$0 (Tier 4)
RIGHTEST GS100 TEST STRIPS
RIGHTEST GS250S TEST STRIPS *
RIGHTEST GS260 TEST STRIPS *
RIGHTEST GS300 TEST STRIPS
RIGHTEST GS550 TEST STRIPS *
RITEFLO SPACER
SAFESNAP SYRINGE * 3 ML
SAFESNAP TUBERCULIN SYR 1 ML
SAFESNAP TUBERCULIN SYR 1 ML
27GX0.5",LATEX-FREE
SAFETY 21G LANCETS LATEX-FREE
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
SAFETY 28G LANCETS LATEX-FREE
$0 (Tier 4)
SAFETY LANCETS * 26G
$0 (Tier 4)
SAFETY SEAL 28G LANCETS
$0 (Tier 4)
SAFETY SEAL 30G LANCETS
$0 (Tier 4)
SAFETY SYRINGE W-SHIELD 3 ML
SAFETY-LET 30G LANCETS
$0 (Tier 4)
$0 (Tier 4)
SAFETY-LOK 3 ML SYRINGE
SAFETY-LOK 3 ML SYRINGE
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
92
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
SHOPKO ON-THE-GO 30G LANCETS
GENTLE
SHOPKO UNILET ULTRA THIN 28G
STERILE
SINGLE-LET * LANCETS
$0 (Tier 4)
SM COLOR LANCETS * 21G
$0 (Tier 4)
SM LANCETS * 21G
$0 (Tier 4)
SM THIN LANCETS * 26G
$0 (Tier 4)
SMART SENSE COLOR 33G LANCETS
$0 (Tier 4)
SMART SENSE STANDARD 21G
$0 (Tier 4)
SMART SENSE TEST STRIPS *
PREMIUM, NO CODE
SMART SENSE THIN 26G LANCETS
$0 (Tier 3)
SMARTEST LANCET *
$0 (Tier 4)
SMARTEST TEST * STRIPS
SOFT TOUCH LANCETS *
$0 (Tier 3)
$0 (Tier 4)
SOLUS V2 28G LANCETS
$0 (Tier 4)
SOLUS V2 30G TWIST LANCETS
$0 (Tier 4)
SOLUS V2 AUDIBLE TEST STRIPS
SPACE CHAMBER PLUS *
STERILANCE TL * TWIST 30G
LANCET
STERILANCE TL * TWIST 32G
LANCET
SUPER THIN 28G LANCETS STERILE
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
93
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
SUPER THIN 33G LANCETS
$0 (Tier 4)
SURE COMFORT 28G LANCETS
$0 (Tier 4)
SURE COMFORT 30G LANCETS
$0 (Tier 4)
SURE-LANCE * 26G LANCETS
$0 (Tier 4)
SURE-LANCE * FLAT LANCETS
$0 (Tier 4)
SURE-LANCE * THIN 28G LANCETS
$0 (Tier 4)
SURE-LANCE ULTRA THIN * 30G
$0 (Tier 4)
SURE-TEST EASYPLUS MINI * STRIP
SURE-TOUCH LANCET *
$0 (Tier 3)
$0 (Tier 4)
TD GOLD TEST STRIP *
TECHLITE 28G LANCETS
$0 (Tier 3)
$0 (Tier 4)
TECHLITE 30G LANCETS
$0 (Tier 4)
TELCARE TEST STRIPS *
TELCARE ULTRA THIN 30G LANCETS
$0 (Tier 3)
$0 (Tier 4)
TERUMO SURGUARD2 SYR 25G 3 ML
TERUMO SYRINGE * 3 ML
TEST N'GO GLUCOSE TEST STRIP
THIN LANCETS 28G
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
TOPCARE UNIVERSAL1 THIN
LANCET ULTRA THIN, 30G
TRUE METRIX GLUCOSE TEST STRIP
*
TRUEPLUS 26G LANCETS
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
94
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
TRUEPLUS 33G LANCETS
$0 (Tier 4)
TRUEPLUS SAFETY 28G LANCETS
28G, STERILE
TRUEPLUS SUPER THIN 28G LANCET
28G, STERILE
TRUEPLUS ULTRA THIN 30G LANCET
$0 (Tier 4)
TRUETEST GLUCOSE TEST STRIPS
TRUETEST GLUCOSE TEST STRIPS
HRI
TRUETRACK GLUCOSE TEST STRIPS
TUBERCULIN 1 ML SYRINGE SLIP TIP
DET.NEEDLE (OTC)
TUBERCULIN SYRINGE
TUBERCULIN SYRINGES
ULTILET 28G LANCETS
$0 (Tier 3)
$0 (Tier 3)
ULTILET 30G LANCETS
$0 (Tier 4)
ULTILET 33G LANCETS
$0 (Tier 4)
ULTILET BASIC 30G LANCETS
$0 (Tier 4)
ULTILET CLASSIC 26G LANCETS
$0 (Tier 4)
ULTILET CLASSIC 28G LANCETS
$0 (Tier 4)
ULTILET CLASSIC 30G LANCETS
$0 (Tier 4)
ULTILET CLASSIC 33G LANCETS
$0 (Tier 4)
ULTILET SAFETY 23G LANCETS
$0 (Tier 4)
ULTIMA TEST STRIPS *
ULTRA THIN 28G LANCETS ULTRA
THIN
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
95
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
ULTRA THIN 30G LANCETS STERILE
$0 (Tier 4)
ULTRA THIN 31G LANCETS
$0 (Tier 4)
ULTRA THIN 33G LANCETS
$0 (Tier 4)
ULTRALANCE 26G LANCETS
$0 (Tier 4)
ULTRALANCE 28G LANCETS
$0 (Tier 4)
ULTRA-THIN II 26G LANCET
$0 (Tier 4)
ULTRA-THIN II 28G LANCETS
$0 (Tier 4)
ULTRA-THIN II 30G LANCETS
$0 (Tier 4)
ULTRATLC LANCETS
$0 (Tier 4)
ULTRATRAK * TEST STRIP
ULTRATRAK ULTIMATE * TEST
STRIPS
UNILET COMFORTOUCH 26G
LANCETS
UNILET COMFORTOUCH LANCET *
$0 (Tier 3)
$0 (Tier 3)
UNILET EXCELITE II LANCET *
$0 (Tier 4)
UNILET EXCELITE LANCET *
$0 (Tier 4)
UNILET GP LANCET *
$0 (Tier 4)
UNILET LANCET * SUPERLITE
$0 (Tier 4)
UNILET MICRO THIN 33G LANCETS
$0 (Tier 4)
UNISTIK 3 COMFORT LANCET *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
96
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
UNISTIK 3 EXTRA 21G LANCETS
$0 (Tier 4)
UNISTIK 3 GENTLE * ON-THE-GO 30G
$0 (Tier 4)
UNISTIK 3 NORMAL 23G LANCETS
$0 (Tier 4)
UNISTIK 3 SAFETY 21G LANCETS
$0 (Tier 4)
UNISTIK CZT COMFORT 28G LANCET
$0 (Tier 4)
UNISTIK CZT NORMAL 23G LANCETS
$0 (Tier 4)
UNISTIK SAFETY * 28G LANCET
$0 (Tier 4)
UNISTIK SAFETY * 30G LANCETS
$0 (Tier 4)
UNISTRIP1 GLUCOSE TEST STRIP
UNIVERSAL 1 33G LANCETS FOR
MEIJER
UP & UP BLOOD GLUCOSE TST STRP
NO CODING
VANISHPOINT 25GX1" 3 ML SYRING
VGO 40 DISPOSABLE DEVICE
VORTEX HOLDING CHAMBER *
VORTEX VHC FROG CHILD MASK
WALGREENS ULTRA THIN LANCETS
$0 (Tier 3)
$0 (Tier 4)
WAVESENSE JAZZ * TEST STRIPS
WAVESENSE PRESTO * TEST STRIPS
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
CEREZYME INTRAVENOUS RECON
SOLN 400 UNIT
CREON
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
97
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ELAPRASE
ELITEK INTRAVENOUS RECON SOLN
1.5 MG
FABRAZYME INTRAVENOUS RECON
SOLN 35 MG
KANUMA
KRYSTEXXA
KUVAN ORAL TABLET,SOLUBLE
lipase-protease-amylase
(Lipase/Protease/Amyl
ase)
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
STRENSIQ
VIMIZIM
VPRIV
ZAVESCA
ZENPEP
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA
PA BvD
PA; LA
PA
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents,
Miscellaneous
advanced eye relief opth oint
AKTEN (PF)
alaway * 0.025% eye drops
altacaine
altamist * 0.65% nose spray
altazine * 0.05% eye drops
apraclonidine
artificial tears
artificial tears drops p/f, sterile
artificial tears * drops sterile, lubricant
artificial tears * eye drops
(Genteal Pm)
(Zaditor)
(Tetravisc)
(Little Remedies)
(Visine)
(Iopidine)
(Dextran
70/Hypromellose)
(Dextran
70/Hypromellose/PF)
(Visine)
(Tears Naturale)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
98
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
artificial tears * eye drops strl
artificial tears eye ointment
atropine ophthalmic drops
atropine ophthalmic ointment
atropine sulfate ophthalmic drops 1 %
ayr saline * 0.65% nose drops
ayr saline * 0.65% nose spray
azelastine nasal aerosol,spray
azelastine ophthalmic
bion tears eye drops
carteolol
cromolyn ophthalmic
cvs eye allergy relief * eye drp
cvs eye drops * dual action sterile
cvs eye wash * solution
cvs lubricant 0.5% eye drops sterile
cvs lubricant dry eye rlf 1%
cvs lubricant eye ointment
cvs lubricating eye drops dry eye soln
cvs maximum redness relief * drp
cvs natural tears drops
cvs redness relief drops original
cvs redness relief * eye drops sterile
cvs saline 3% nasal mist
CYCLOGYL OPHTHALMIC DROPS 0.5
%
cyclopentolate
CYSTARAN
(Tears Naturale)
(Genteal Pm)
(Isopto Atropine)
(Atropine Sulfate)
(Isopto Atropine)
(Sodium Chloride)
(Little Remedies)
(Astepro)
(Azelastine HCl)
(Dextran
70/Hypromellose/PF)
(Carteolol HCl)
(Cromolyn Sodium)
(Opcon-A)
(Visine Allergy Relief)
(Sodium/Potassium/So
d Chl)
(Refresh Tears)
(Carboxymethylcellulo
se Sodium)
(Petrolat,Wht/Min
Oil/Sod Chl)
(Refresh Optive)
(Advanced Eye Relief
Redness)
(Dextran
70/Hypromellose/PF)
(Naphazoline HCl/Peg
300)
(Clear Eyes Redness
Relief)
(Sodium Chloride)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Cyclogyl)
$0 (Tier 1)
$0 (Tier 2)
QL (30 per 25 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
99
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
deep sea 0.65% nose spray
dristan long lasting * mist
epinastine
eq gentle * 0.3% eye drops
eql nasal decngstnt nose drops
eye drops max relief,strl
for sty relief * eye ointment
GENTEAL GEL * DROPS
homatropine hbr
ipratropium bromide nasal spray,nonaerosol 0.03 %
ipratropium bromide nasal spray,nonaerosol 0.06 %
ketotifen fum 0.025% eye drops (otc)
LACRISERT
liquitears * 1.4 % drops
little remedies * stuffy nose kt w/ nasal
aspirator
lubricant 0.6% eye drops
lubricant eye drops * p/f, sterile
lubricant pm eye ointment p/f
lubricant redness eye drops redness
relief,strl
lubricant redness reliever * drp
lubrifresh pm * eye ointment
mucinex sinus-max * nasal spray full force
muro-128 2% eye drops
muro-128 5% eye drops
muro-128 5% eye ointment
naphazoline
nasal decongestant 0.05% spray
natural balance * tears drops
(Little Remedies)
(Oxymetazoline HCl)
(Elestat)
(Genteal Mild To
Moderate)
(Phenylephrine HCl)
(Visine Advanced)
(Genteal Pm)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
PA; AGE (Min 2 Years)
(Isopto Homatropine)
(Atrovent)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Atrovent)
$0 (Tier 1)
QL (15 per 10 days)
(Zaditor)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
(Polyvinyl Alcohol)
(Little Remedies)
(Propylene Glycol)
(Carboxymethylcellulo
se Sodium)
(Genteal Pm)
(Advanced Eye Relief
Redness)
(Tetrahydrozoline
HCl/Peg)
(Genteal Pm)
(Afrin)
(Sodium Chloride)
(Sodium Chloride)
(Sodium Chloride)
(Naphazoline HCl)
(Afrin)
(Genteal Mild To
Moderate)
QL (30 per 28 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
100
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
nature's tears drops
neo-synephrine 12 hour spray
ocean 0.65% nasal spray
olopatadine ophthalmic
opti-clear * 0.05% eye drops
PATADAY
phenylephrine hcl ophthalmic
proparacaine
proparacaine hcl ophthalmic drops 0.5 %
proparacaine-fluorescein sod
(Genteal Mild To
Moderate)
(Oxymetazoline HCl)
(Little Remedies)
(Patanol)
(Visine)
(Mydfrin)
(Proparacaine HCl)
(Proparacaine HCl)
(Proparacaine/Fluoresc
ein Sod)
puralube * ophthalmic ointment p/f, sterile, (Genteal Pm)
outer
pure & gentle eye drops lubricant
(Genteal Mild To
Moderate)
pv artificial tears
(Genteal Mild To
Moderate)
pv lubricant 1.4 % eye drops
(Polyvinyl Alcohol)
pv pure-gentle eye drops sterile
(Genteal Mild To
Moderate)
ra eye allergy relief * drops
(Opcon-A)
ra sterile eye drops *
(Advanced Eye Relief
Redness)
ra sterile eye drops *
(Naphazoline HCl/Peg
300)
redness lubricant eye drops regular, strl
(Naphazoline HCl/Peg
300)
redness relief * eye drops
(Clear Eyes Redness
Relief)
REFRESH TEARS * 0.5% EYE DROPS
retaine cmc * 0.5% eye drops
(Carboxymethylcellulo
se Sodium)
retaine hpmc * 0.3% eye drops
(Hypromellose/PF)
retaine pm * eye ointment
(Genteal Pm)
saline mist * 0.65% nose spry
(Little Remedies)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
ST
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
101
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
sea soft 0.65% nasal mist
sm eye wash * solution
sm nose drops *
sochlor * 5% eye drops
sodium chloride * 5% eye drop
sodium chloride * 5% eye oint
SYSTANE BALANCE * 0.6% EYE
DROP CLINICAL STRENGTH
systane nighttime * eye oint
tears again * 1.4 % drops
tears naturale free drops u-d,36x.9ml,p/f
tears naturale pm * eye oint
tetracaine hcl (pf) ophthalmic
vicks qlearquil 0.05% mist
vicks sinex 12 hour spray
VISINE MAX REDNESS RELIEF *
DROP
VISINE TOTALITY * EYE DROPS
visine-a * eye allergy drops
wal-zyr 0.025% eye drops
zyrtec itchy eye 0.025% drops
Eye, Ear, Nose, Throat AntiInfectives Agents
acetic acid otic
auraphene-b * 6.5% ear drops
auro 6.5% ear drops
bacitracin ophthalmic
bacitracin-polymyxin b ophthalmic
CIPRODEX
ciprofloxacin hcl ophthalmic
ciprofloxacin hcl otic
COLY-MYCIN S
debrox * 6.5% ear drops
(Little Remedies)
(Sodium/Potassium/So
d Chl)
(Phenylephrine HCl)
(Sodium Chloride)
(Sodium Chloride)
(Sodium Chloride)
$0 (Tier 4)
$0 (Tier 4)
(Genteal Pm)
(Polyvinyl Alcohol)
(Dextran
70/Hypromellose/PF)
(Genteal Pm)
(Tetracaine HCl/PF)
(Oxymetazoline HCl)
(Afrin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Opcon-A)
(Zaditor)
(Zaditor)
(Acetic Acid)
(Carbamide Peroxide)
(Carbamide Peroxide)
(Bacitracin)
(Bacitracin/Polymyxin
B Sulfate)
(Ciloxan)
(Cetraxal)
(Carbamide Peroxide)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2 Years)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
102
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ear drops 6.5%
erythromycin ophthalmic
gatifloxacin
gentamicin ophthalmic
gentamicin sulfate ophthalmic ointment 0.3
% (3 mg/gram)
levofloxacin ophthalmic
MOXEZA
murine ear wax removal system *
NATACYN
neomy sulf-bacitrac zn-poly-hc
neomycin-bacitracin-poly-hc
neomycin-bacitracin-polymyxin
neomycin-polymyxin b-dexameth
neomycin-polymyxin-gramicidin
neomycin-polymyxin-hc ophthalmic
neomycin-polymyxin-hc otic
drops,suspension
neomycin-polymyxin-hc otic solution
neo-polycin
ofloxacin ophthalmic
ofloxacin otic
polymyxin b sulf-trimethoprim
sulfacetamide sodium ophthalmic
sulfacetamide-prednisolone
TOBRADEX OPHTHALMIC
OINTMENT
TOBRADEX ST
tobramycin
(Carbamide Peroxide)
(Ilotycin)
(Zymaxid)
(Garamycin)
(Garamycin)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Levofloxacin)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 1)
(Carbamide Peroxide)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin)
(Maxitrol)
(Neosporin)
(Neomycin/Polymyxin
B Sulf/HC)
(Neomycin/Polymyxin
B Sulf/HC)
(Cortisporin)
(Neomycin
Su/Bacitra/Polymyxin)
(Ocuflox)
(Ocuflox)
(Polytrim)
(Sulfacetamide
Sodium)
(Sulfacetamide/Prednis
olone Sp)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Tobrex)
$0 (Tier 2)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
103
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
tobramycin-dexamethasone
trifluridine
VIGAMOX
ZIRGAN
ZYLET
Eye, Ear, Nose, Throat AntiInflammatory Agents
ALREX
bromfenac
CHILD NASACORT ALLERGY 24 HR
dexamethasone sodium phosphate
ophthalmic
diclofenac sodium ophthalmic
DUREZOL
FLONASE ALLERGY RLF 50 MCG SPR
120 METERED SPRAYS
flunisolide nasal spray,non-aerosol 25 mcg
(0.025 %)
fluorometholone
flurbiprofen sodium
fluticasone nasal
ILEVRO
ketorolac ophthalmic
LOTEMAX
NASACORT * ALLERGY 24HR SPRAY
MULTI-SYMP,60 SPRAYS
nasal allergy * 24hr spray
NEVANAC
prednisolone acetate
prednisolone sodium phosphate ophthalmic
PROLENSA
RESTASIS
(Tobradex)
(Viroptic)
(Bromfenac Sodium)
(Dexasol)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
(Diclofenac Sodium)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
(Flunisolide)
$0 (Tier 1)
(FML)
(Ocufen)
(Fluticasone
Propionate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Acular)
(Nasacort)
(Omnipred)
(Prednisolone Sod
Phosphate)
ST
QL (50 per 25 days)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
QL (60 per 30 days)
Gastrointestinal Agents
Antiflatulents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
104
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
bicarsim forte * 125 mg tablet
cvs gas relief 125 mg chew tab extra
strength
cvs gas relief * 125 mg softgel softgel
cvs gas relief * 80 mg tab chew
gas relief * 125 mg chew tablet max
str,lactose-free
gas relief * 80 mg tablet chew lactose-free
gas-x extra strength * softgel softgel, exstrength
gas-x ultra strength softgel
mi-acid gas 80 mg tab chew
mytab gas * 80 mg tablet chew
mytab gas max str 125 mg tab
simethicone * 180 mg softgel
simethicone * 40 mg/0.6 ml drop
v-r anti-gas 166 mg softgel
Antiulcer Agents And Acid
Suppressants
acid reducer 20 mg tablet maximum
strength
amoxicil-clarithromy-lansopraz
CARAFATE ORAL SUSPENSION
cimetidine hcl oral
cimetidine oral tablet 200 mg, 300 mg, 400
mg, 800 mg
cvs cimetidine * 200 mg tablet (otc)
esomeprazole sodium
famotidine (pf)
famotidine (pf)-nacl (iso-os)
famotidine 40 mg/4 ml vial 25's,outer
famotidine oral tablet 20 mg, 40 mg
gnp acid reducer 10 mg tablet
lansoprazole * dr 15 mg capsule na/f (otc)
(Simethicone)
(Gas-X)
$0 (Tier 4)
$0 (Tier 4)
(Phazyme)
(Gas-X)
(Gas-X)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Gas-X)
(Phazyme)
$0 (Tier 4)
$0 (Tier 4)
(Phazyme)
(Gas-X)
(Gas-X)
(Gas-X)
(Phazyme)
(Simethicone)
(Phazyme)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Pepcid Ac)
$0 (Tier 4)
(Prevpac)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Cimetidine HCl)
(Cimetidine)
(Tagamet Hb)
(Nexium I.V.)
(Famotidine)
(Famotidine In
Nacl,Iso-Osm/PF)
(Famotidine)
(Pepcid)
(Pepcid Ac)
(Prevacid 24hr)
(Rx Product Only)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Rx Product Only)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
105
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
lansoprazole oral capsule,delayed
release(dr/ec) 15 mg, 30 mg
misoprostol
NEXIUM 24HR * 22.3 MG CAPSULE
omeprazole * dr 20 mg tablet
omeprazole mag dr 20.6 mg cap two 14days course
omeprazole oral capsule,delayed
release(dr/ec)
pantoprazole oral
pub famotidine * 20 mg tablet max strength
(otc)
pv acid relief 200 mg tablet
ra omeprazole-bicarb 20-1,100 3x14 day
course (otc)
ranitidine 150 mg tablet maximum strength
(otc)
ranitidine 75 mg tablet s/f, sodium-free
ranitidine hcl 50 mg/2 ml vial sdv
ranitidine hcl injection solution 25 mg/ml
ranitidine hcl oral capsule
ranitidine hcl oral syrup
ranitidine hcl oral tablet 150 mg, 300 mg
sucralfate oral suspension
sucralfate oral tablet
wal-zan 75 * mg tablet
Gastrointestinal Agents, Other
acid gone antacid * liquid
acid gone tablet chew
ALKA-SELTZER GOLD * TAB EFF
almacone * liquid
almacone-2 * liquid
aluminum hydroxide gel *
(Prevacid)
$0 (Tier 1)
(Cytotec)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Omeprazole)
(Omeprazole
Magnesium)
(Prilosec)
$0 (Tier 1)
(Protonix)
(Pepcid Ac)
$0 (Tier 1)
$0 (Tier 4)
(Tagamet Hb)
(Zegerid Otc)
$0 (Tier 4)
$0 (Tier 4)
(Zantac)
$0 (Tier 4)
(Zantac)
(Zantac)
(Zantac)
(Ranitidine HCl)
(Ranitidine HCl)
(Zantac)
(Sucralfate)
(Carafate)
(Zantac)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Gaviscon)
(Gaviscon)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Aluminum
Hydroxide)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
106
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
aluminum hydroxide gel * sugar-free
AMITIZA
antacid 1000-200 mg tab chew
antacid 675-135 mg tab chew ex-str, asstd
fruit
antacid chewable tablet peppermint flavor
antacid plus x-stren susp
antacid ultra tablet chew
antacid xtra strength chew tab extrastrength
antacid-antigas liquid
anti-diarrheal 2 mg caplet caplet
bismatrol * 525 mg/15 ml susp
bismatrol * suspension
BUPHENYL ORAL TABLET
calci-chew * tablet
calcium 500 mg chewable tablet tab
chew,p/f
calcium antacid * 500 mg chw tab assorted
fruit
cal-gest 500 mg tablet chew
CARBAGLU
child soothe 400 mg tab chew
children pepto 400 mg tab chew bubble
gum, na/f
comfort gel max str susp max-str
cromolyn oral
cvs antacid supreme * liquid
cvs anti-diarrheal 2 mg sftgel softgel
cvs anti-diarrheal * suspension
cvs loperamide * 1 mg/7.5 ml liq mint
(Aluminum
Hydroxide)
(Rolaids)
(Rolaids)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
(Rolaids)
(Maalox Maximum
Strength)
(Tums)
(Tums)
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Imodium A-D)
(Pepto-Bismol)
(Pepto-Bismol)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Tums)
(Tums)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
(Tums)
$0 (Tier 4)
(Tums)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
(Tums)
(Tums)
(Maalox Maximum
Strength)
(Gastrocrom)
(Mylanta Supreme
Antacid)
(Loperamide HCl)
(Pepto-Bismol)
(Loperamide HCl)
QL (60 per 30 days)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
107
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
diamode * 2 mg tablet outer, f/c
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
diotame instydose * 524 mg/30 ml
diphenoxylate-atropine oral liquid
diphenoxylate-atropine oral tablet
flanax antacid * liquid
(Imodium A-D)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Bismuth
Subsalicylate)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
(Maalox Maximum
Strength)
FLEET PEDIA-LAX * TABLET CHEW
foaming antacid * liquid
(Gaviscon)
GATTEX 5 MG 30-VIAL KIT
GATTEX ONE-VIAL
GAVISCON ES TABLET CHEW EXTRA
STRENGTH
gelusil antacid & antigas liq
(Maalox Maximum
Strength)
gelusil tablet chewable cool mint
(Almacone)
glycopyrrolate injection
(Robinul)
glycopyrrolate oral
(Robinul)
heartburn antacid * chew tablet
(Gaviscon)
imodium a-d * 1 mg/7.5 ml liquid mint
(Loperamide HCl)
kaopectate 262 mg/15 ml susp vanilla
(Pepto-Bismol)
flavor
kaopectate extra strength liq peppermint
(Pepto-Bismol)
kionex 15 gm/60 ml suspension 15 gram/60 (Sodium Polystyrene
ml
Sulfonate)
lactulose oral solution 10 gram/15 ml
(Lactulose)
LINZESS
loperamide * 1 mg/5 ml liquid
(Loperamide HCl)
loperamide oral capsule
(Loperamide HCl)
LOTRONEX
maalox advanced * suspension regular
(Maalox Maximum
strength
Strength)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 4)
PA
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 4)
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
108
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
MAALOX MAXIMUM STRENGTH *
SUSP MINT, MAX STRENGTH
MAG-AL * LIQUID
MAGNESIUM 400 MG CAPS
magnesium 500 mg capsule s/f,na/f
magnesium oxide * 250 mg tablet
magnesium oxide * 400 mg tablet
magnesium oxide * 420 mg tablet
magnesium oxide * 500 mg tablet
p/f,s/f,lactose-free
MAGOX * 400 TABLET S/F, GLUTEN
FREE
masanti liquid
medi-first pep-t-med * tab chew
methscopolamine oral
metoclopramide hcl injection solution
metoclopramide hcl oral solution
metoclopramide hcl oral tablet
mi acid suspension
mi-acid * ds tablet
mintox maximum strength * susp max str,
lemon creme
mintox plus * tablet chewable
mintox * suspension mint creme
MOVANTIK
NUTRESTORE
phillips * 500 mg caplet
PHILLIPS' MOM TABLET CHEW
pink bismuth * tablet chew
pv anti-diarrheal+gas relief caplet
pv foaming antacid chew tablet ex-strength
$0 (Tier 4)
(Uromag)
(Magox 400)
(Magox 400)
(Magox 400)
(Magox 400)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Pepto-Bismol To-Go)
(Methscopolamine
Bromide)
(Metoclopramide HCl)
(Metoclopramide HCl)
(Reglan)
(Maalox Maximum
Strength)
(Rolaids)
(Maalox Maximum
Strength)
(Almacone)
(Maalox Maximum
Strength)
(Magox 400)
(Pepto-Bismol To-Go)
(Imodium MultiSymptom Relief)
(Gaviscon)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
QL (30 per 30 days)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
109
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
pv supreme antacid * suspension
(Mylanta Supreme
Antacid)
(Loperamide HCl)
(Uromag)
ra loperamide * 1 mg/7.5 ml susp mint
ra magnesium 500 mg capsule
RAVICTI
RELISTOR SUBCUTANEOUS
SOLUTION
RELISTOR SUBCUTANEOUS SYRINGE
ri-gel ii * suspension
(Maalox Maximum
Strength)
riginic * suspension
(Gaviscon)
ri-mox plus * suspension
(Maalox Maximum
Strength)
ri-mox * suspension
(Maalox Maximum
Strength)
sm foaming antacid * tablet chew
(Gaviscon)
sm stomach relief * caplet
(Bismuth
Subsalicylate)
sodium bicarb 325 mg tablet
(Sodium Bicarbonate)
sodium bicarb 650 mg tablet 10 gr
(Sodium Bicarbonate)
sodium polystyrene sulfonate oral powder
(Sodium Polystyrene
Sulfonate)
sodium polystyrene sulfonate oral
(Sodium Polystyrene
suspension 15 gram/60 ml
Sulfonate)
sodium polystyrene sulfonate rectal enema (Sodium Polystyrene
30 gram/120 ml
Sulfonate)
soothe 262 mg caplet caplet
(Bismuth
Subsalicylate)
soothe 262 mg/15 ml suspension s/f,cherry (Pepto-Bismol)
sps 15 gm/60 ml suspension 15 gram/60 ml (Sodium Polystyrene
Sulfonate)
ursodiol oral capsule
(Actigall)
ursodiol oral tablet
(Urso)
Laxatives
alophen * pills
(Dulcolax)
bisac-evac * 10 mg suppository
(Dulcolax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 4)
PA
PA; QL (28 per 28 days)
PA; QL (28 per 28 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
110
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
bisacodyl * 10 mg suppository
bisacodyl * ec 5 mg tablet
biscolax * 10 mg suppository
CASTOR OIL *
CEO-TWO * SUPPOSITORY
chocolated laxative regular strength
citroma * solution
CITRUCEL * 500 MG CAPLET
CITRUCEL * POWDER
colace * 100 mg capsule
COLACE CLEAR * 50 MG SOFTGEL
cvs castor oil * 67%
cvs child suppository *
cvs enema disposable *
cvs fiber 0.52 g capsule
cvs fiber therapy * 500 mg caplt soluble,
caplet
cvs glycerin suppository child size
cvs glycerin suppository laxative
cvs laxative 15 mg pills pills, chocolate
cvs magnesium citrate * soln
cvs natural daily fiber powder
cvs natural daily fiber * powder
cvs purelax * powder 14 once-daily doses
cvs purelax * powder packet 12 to-go
pouches
cvs senna laxative * 8.6 mg tab
cvs senna-extra * 17.2 mg tablet
cvs stool softener * 50 mg sftgl
cvs stool softener * 50 mg softgel
cvs stool softener * softgel softgel
cvs suppository
doc-q-lace * 100 mg softgel
docu * liquid 50 mg/5 ml
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Sennosides)
(Magnesium Citrate)
(Colace Clear)
(Castor Oil)
(Glycerin)
(Enema)
(Metamucil)
(Citrucel)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Glycerin)
(Glycerin)
(Sennosides)
(Magnesium Citrate)
(Metamucil)
(Natural Vegetable
Fiber)
(Gavilax)
(Miralax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Senokot)
(Senokot)
(Colace Clear)
(Colace Clear)
(Surfak)
(Glycerin)
(Colace Clear)
(Docusate Sodium)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
111
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
docusate sodium * 100 mg tablet crushable
docusate sodium * 250 mg softgel softgel
docusol * mini-enema outer
dok * 100 mg softgel softgel
dok * 100 mg tablet
dulcolax ss 100 mg softgel
enema disposable *
enema * ready to use latex-free
enemeez * mini enema 5cc tubes, outer
enemeez plus * mini enema outer
eq fiber therapy powder
(Docusate Sodium)
(Colace Clear)
(Docusate Sodium)
(Colace Clear)
(Docusate Sodium)
(Colace Clear)
(Enema)
(Enema)
(Docusate Sodium)
(Docusol Plus)
(Psyllium Seed (With
Sugar))
equalactin * 500 mg tab chew
(Calcium
Polycarbophil)
ex-lax chocolate chocolate
(Sennosides)
ex-lax pills
(Senokot)
fiber tablet unboxed
(Fibercon)
fiber therapy * powder
(Citrucel)
fiber-lax * captabs 500mg polycarbophil
(Fibercon)
fleet glycerin adult suppos
(Glycerin)
fleet pedia-lax stool softener *
(Docusate Sodium)
fleet pedia-lax suppositories
(Glycerin)
gentlelax * powder 30 once-daily doses
(Gavilax)
glycerin adult suppository
(Glycerin)
glycerin suppository
(Glycerin)
glycolax * powder 7 doses (otc)
(Gavilax)
healthylax * powder packet 14x17gm, outer (Miralax)
hydrocil instant * packet
(Psyllium Seed)
konsyl 520 mg capsule
(Metamucil)
konsyl fiber * 625 mg caplet caplet, s/f
(Fibercon)
konsyl psyllium fiber packet orange, gluten (Psyllium Husk (With
free
Sugar))
laxative 15 mg pills
(Senokot)
laxative 15 mg pills
(Senokot)
magic bullet 10 mg suppos
(Dulcolax)
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
112
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
magnesium citrate * solution lemon
MILK OF MAGNESIA
CONCENTRATED *
milk of magnesia * suspension
mineral oil * enema latex-free
mineral oil laxative *
MOVIPREP
natural fiber lax powder
oral saline laxative * liquid s/f, ginger
lemon
peg 3350-electrolytes
PEG 3350-GRX
peg 3350-na sulf,bicarb,cl-kcl
peg-electrolyte soln
perdiem overnight relief * tb
phillips' lax liqui-gels
PHILLIPS' MILK OF MAGNESIA
phosphate oral saline laxative s/f, ginger
lemon
polyethylene glycol 3350 oral powder
polyethylene glycol 3350 * powd 17 grams
pkts,outer (otc)
POLYETHYLENE GLYCOL 3350 *
POWD NF, PEG-75
polyethylene glycol 3350 * powd outer,s/f
(otc)
promolaxin * 100 mg tablet
pv enema *
pv fiber therapy powder
pv senna * 8.6 mg softgel
qc natural vegetable * powder 48 doses,
reg flavor
ra citrate of magnesia * soln
(Magnesium Citrate)
$0 (Tier 4)
$0 (Tier 4)
(Milk Of Magnesia)
(Mineral Oil Enema)
(Mineral Oil)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 4)
(Psyllium Seed (With
Sugar))
(Na Phos,M-B/Na
Phos,Di-Ba)
(Golytely)
(Golytely)
(Nulytely with Flavor
Packs)
(Senokot)
(Colace Clear)
(Na Phos,M-B/Na
Phos,Di-Ba)
(Polyethylene Glycol
3350)
(Miralax)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Miralax)
$0 (Tier 4)
(Docusate Sodium)
(Mineral Oil Enema)
(Methylcellulose)
(Sennosides)
(Psyllium Seed (With
Dextrose))
(Magnesium Citrate)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
113
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ra col-rite * 50 mg softgel
ra enema * twin pack 2 x 4.5oz, rtu
ra laxative 17.2 mg tablet
ra laxative peg 3350 * powder 14 oncedaily doses
reguloid * capsule
reguloid * powder orange
sani-supp adult suppository outer
sani-supp pediatric suppos outer
senexon * 8.8 mg/5 ml liquid
senexon * tablet
senna * 8.8 mg/5 ml syrup a/f, chocolate
senna-lax 8.6 mg tablet
silace * 50 mg/5 ml liquid
silace * 60 mg/15 ml syrup
sm castor oil *
sm clearlax * powder 14 once-daily doses
sm fiber laxative 500 mg cplt
sm fiber laxative capsule
sm fiber smooth * powder
sm glycerin pediatric suppo
sm laxative pediatric suppos
sm senna laxative * pills
smoothlax * powder packet 10 once-daily
doses
sodium chloride-nahco3-kcl-peg oral recon
soln 420 gram
wal-mucil 0.52 g capsule
Phosphate Binders
CALCIUM ACETATE * 668 MG
TABLET
calcium acetate oral capsule
calcium acetate oral tablet 667 mg
(Colace Clear)
(Enema)
(Senokot)
(Gavilax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Metamucil)
(Psyllium Seed (With
Sugar))
(Glycerin)
(Glycerin)
(Sennosides)
(Senokot)
(Sennosides)
(Senokot)
(Docusate Sodium)
(Docusate Sodium)
(Castor Oil)
(Gavilax)
(Citrucel)
(Metamucil)
(Psyllium Seed)
(Glycerin)
(Glycerin)
(Senokot)
(Miralax)
$0 (Tier 4)
$0 (Tier 4)
(Nulytely with Flavor
Packs)
(Metamucil)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Phoslo)
(Calcium Acetate)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
114
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
calcium carbonate-mag carb-fa
(Calcium
Carbonate/Mag
Carb/Fa)
PHOSLYRA
RENAGEL
RENVELA
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
Genitourinary Agents
Antispasmodics, Urinary
MYRBETRIQ
oxybutynin chloride oral tablet
oxybutynin chloride oral tablet extended
release 24hr
tolterodine oral capsule,extended release
24hr
tolterodine oral tablet
TOVIAZ
trospium
Genitourinary Agents,
Miscellaneous
alfuzosin
tamsulosin
terazosin
(Oxybutynin Chloride)
(Ditropan XL)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Detrol LA)
$0 (Tier 1)
(Detrol)
(Trospium Chloride)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
(Uroxatral)
(Flomax)
(Terazosin HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Desferal)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln 2 gram
DEPEN TITRATABS
EXJADE
FERRIPROX
sodium thiosulfate intravenous solution 1
gram/10 ml (100 mg/ml), 12.5 gram/50 ml
(250 mg/ml)
SYPRINE
(Sodium Thiosulfate)
PA BvD
$0 (Tier 2)
Hormonal Agents,
Stimulant/Replacement/Modifying
Androgens
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
115
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ANDRODERM
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25
GRAM (1.62 %)
ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/1.25 GRAM),
1.62 % (40.5 MG/2.5 GRAM)
danazol oral
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
testosterone transdermal gel
testosterone transdermal gel in metereddose pump 1.25 gram/ actuation (1 %)
testosterone transdermal gel in packet 1 %
(25 mg/2.5gram)
testosterone transdermal gel in packet 1 %
(50 mg/5 gram)
Estrogens And Antiestrogens
COMBIPATCH
$0 (Tier 2)
$0 (Tier 2)
PA; QL (30 per 30 days)
PA; QL (150 per 30
days)
$0 (Tier 2)
PA; QL (150 per 30
days)
(Danazol)
(Fluoxymesterone)
(Oxandrin)
(Depo-Testosterone)
(Testosterone
Enanthate)
(Testim)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Vogelxo)
$0 (Tier 1)
(Androgel)
$0 (Tier 1)
(Testim)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
DUAVEE
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch semiweekly
(Estrace)
(Vivelle-Dot)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
estradiol transdermal patch weekly
(Climara)
$0 (Tier 1)
estradiol valerate
estradiol/norethindrone acet
estradiol-norethindrone acet
estropipate
FEMRING
(Delestrogen)
(Activella)
(Activella)
(Estropipate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA
PA; QL (5 per 28 days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
PA-HRM; QL (8 per 28
days)
PA-HRM
PA-HRM
PA-HRM; QL (8 per 28
days)
PA-HRM; QL (4 per 28
days)
PA-HRM
PA-HRM
PA-HRM
QL (1 per 84 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
116
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
MENEST
PREMARIN INJECTION
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
raloxifene
(Evista)
VAGIFEM
Glucocorticoids/Mineralocorticoids
betamethasone acet,sod phos
(Celestone)
cortisone
(Cortisone Acetate)
dexamethasone oral elixir
(Dexamethasone)
dexamethasone oral tablet
(Dexamethasone)
dexamethasone sodium phosphate injection (Dexamethasone Sod
solution
Phosphate)
fludrocortisone
(Fludrocortisone
Acetate)
hydrocortisone oral
(Cortef)
hydrocortisone sod succinate
(Hydrocortisone Sod
Succinate)
methylprednisolone
(Medrol)
methylprednisolone acetate
(Depo-Medrol)
methylprednisolone sodium succ injection
(A-Methapred)
recon soln 125 mg, 40 mg
methylprednisolone sodium succ
(A-Methapred)
intravenous
prednisolone sodium phosphate oral
(Pediapred)
solution 15 mg/5 ml, 25 mg/5 ml (5 mg/ml),
5 mg base/5 ml (6.7 mg/5 ml)
prednisone oral
(Prednisone)
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML
triamcinolone acetonide injection
(Triamcinolone
Acetonide)
Pituitary
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (18 per 28 days)
PA BvD
PA BvD
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 2)
PA BvD
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
117
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
desmopressin injection
desmopressin nasal solution
desmopressin nasal spray,non-aerosol
(Desmopressin
Acetate)
(DDAVP)
(Desmopressin
Acetate)
(DDAVP)
desmopressin oral
GENOTROPIN
GENOTROPIN MINIQUICK
INCRELEX
LUPRON DEPOT-PED
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 30
MG
NORDITROPIN FLEXPRO
octreotide acet 50 mcg/ml syr outer,single- (Octreotide Acetate)
dose,10
octreotide acetate injection solution 1,000 (Sandostatin)
mcg/ml, 100 mcg/ml, 200 mcg/ml, 500
mcg/ml
octreotide acetate injection solution 50
(Octreotide Acetate)
mcg/ml
SAIZEN
SAIZEN CLICK.EASY
SANDOSTATIN LAR 10 MG KIT
SANDOSTATIN LAR 20 MG KIT
SANDOSTATIN LAR 30 MG KIT
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON
SEROSTIM SUBCUTANEOUS RECON
SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
SOMAVERT
SUPPRELIN LA
Progestins
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
QL (15 per 30 days)
QL (15 per 30 days)
PA
PA
QL (1 per 84 days)
PA
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA
PA
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (1 per 28 days)
QL (1 per 360 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
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118
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
DEPO-PROVERA INTRAMUSCULAR
SOLUTION
medroxyprogesterone intramuscular
medroxyprogesterone oral
MEGACE ES
megestrol oral suspension 400 mg/10 ml
(40 mg/ml), 625 mg/5 ml
norethindrone acetate
progesterone
progesterone micronized
Thyroid And Antithyroid Agents
levothyroxine intravenous
levothyroxine oral
liothyronine oral
methimazole oral tablet 10 mg, 5 mg
propylthiouracil
$0 (Tier 2)
QL (10 per 28 days)
QL (1 per 84 days)
(Megace Es)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
(Aygestin)
(Progesterone)
(Prometrium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Levothyroxine
Sodium)
(Levoxyl)
(Cytomel)
(Tapazole)
(Propylthiouracil)
$0 (Tier 1)
(Depo-Provera)
(Provera)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Immunological Agents
Immunological Agents
ARCALYST
ASTAGRAF XL
AUBAGIO
azathioprine
azathioprine sodium
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 6 GRAM
CELLCEPT INTRAVENOUS
CIMZIA
CIMZIA POWDER FOR RECONST
cyclosporine intravenous
cyclosporine modified
cyclosporine oral capsule
cyclosporine, modified
ENBREL
ENBREL SURECLICK
(Imuran)
(Azathioprine Sodium)
(Sandimmune)
(Neoral)
(Sandimmune)
(Neoral)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA BvD
PA; QL (28 per 28 days)
PA BvD
PA BvD
PA BvD
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
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119
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ENVARSUS XR
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAPLEX
HUMIRA
HUMIRA PEN
HUMIRA PEN CROHN'S-UC-HS START
HYPERRAB S/D (PF)
HYQVIA
ILARIS (PF)
IMOGAM RABIES-HT (PF)
KINERET
leflunomide
mycophenolate mofetil
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
ORENCIA (WITH MALTOSE)
PRIVIGEN
PROGRAF INTRAVENOUS
RAPAMUNE ORAL SOLUTION
RIDAURA
sirolimus
tacrolimus oral
TYSABRI
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Arava)
(Cellcept)
(Myfortic)
(Rapamune)
(Hecoria)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
ZORTRESS
$0 (Tier 2)
Vaccines
ACTHIB (PF)
ADACEL(TDAP
ADOLESN/ADULT)(PF)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA
PA BvD
PA
PA; QL (18.76 per 28
days)
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
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120
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
BCG (TICE STRAIN) VIAL
BCG VACCINE, LIVE (PF)
BEXSERO (PF)
BOOSTRIX TDAP
CERVARIX VACCINE (PF)
COMVAX (PF)
DAPTACEL (DTAP PEDIATRIC) (PF)
ENGERIX-B (PF) INTRAMUSCULAR
SYRINGE
ENGERIX-B 20 MCG/ML VIAL
10'S,ADULT,P/F,OUTER
ENGERIX-B PEDIATRIC (PF)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
GARDASIL (PF)
GARDASIL 9 (PF)
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML
HAVRIX (PF) INTRAMUSCULAR
SYRINGE
IMOVAX RABIES VACCINE (PF)
INFANRIX (DTAP) (PF)
INTRAMUSCULAR SUSPENSION
IPOL INJECTION SUSPENSION
IXIARO (PF)
KINRIX (PF)
MENACTRA (PF) INTRAMUSCULAR
SOLUTION
MENHIBRIX (PF)
MENOMUNE - A/C/Y/W-135 (PF)
MENVEO A-C-Y-W-135-DIP (PF)
MENVEO MENA COMPONENT (PF)
MENVEO MENCYW-135 COMPNT (PF)
M-M-R II (PF)
PEDIARIX (PF)
PEDVAX HIB (PF)
PENTACEL (PF)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
PA BvD
PA BvD; QL (3 per 365
days)
PA BvD; QL (3 per 365
days)
PA BvD; QL (3 per 365
days)
QL (1.5 per 365 days)
QL (1.5 per 365 days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (2 per 365 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
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121
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
PENTACEL ACTHIB COMPONENT (PF)
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
RECOMBIVAX HB (PF)
INTRAMUSCULAR SUSPENSION 10
MCG/ML, 40 MCG/ML
RECOMBIVAX HB (PF)
INTRAMUSCULAR SYRINGE
ROTARIX
ROTATEQ VACCINE
TENIVAC (PF) INTRAMUSCULAR
SYRINGE
TETANUS TOXOID,ADSORBED (PF)
TETANUS,DIPHTHERIA TOX PED(PF)
TETANUS-DIPHTHERIA TOXOIDS-TD
TRUMENBA
TWINRIX (PF)
TYPHIM VI
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 50 UNIT/ML
VAQTA (PF) INTRAMUSCULAR
SYRINGE
VAQTA 25 UNITS/0.5 ML VIAL SDV,
OUTER
VARIVAX (PF)
YF-VAX (PF)
ZOSTAVAX (PF)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (2 per 365 days)
PA BvD
PA BvD; QL (3 per 365
days)
PA BvD; QL (3 per 365
days)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (2 per 365 days)
QL (1 per 365 days)
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease
Agents
alosetron
APRISO
ASACOL HD
balsalazide
budesonide oral
(Alosetron HCl)
(Colazal)
(Entocort EC)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
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122
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
DELZICOL
DIPENTUM
$0 (Tier 2)
$0 (Tier 2)
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation
LACTATED RINGERS IRRIGATION
ringers irrigation
sodium chloride irrigation
sorbitol irrigation
sorbitol-mannitol
water for irrigation, sterile
(Acetic Acid)
(Ringers Solution)
(Sodium Chloride Irrig
Solution)
(Sorbitol Solution)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate oral solution
alendronate oral tablet 10 mg, 40 mg, 5 mg
alendronate oral tablet 35 mg, 70 mg
calcitonin (salmon)
calcitriol intravenous solution 1 mcg/ml
(Alendronate Sodium)
(Fosamax)
(Fosamax)
(Miacalcin)
(Calcitriol)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
calcitriol oral
(Rocaltrol)
$0 (Tier 1)
doxercalciferol intravenous
(Doxercalciferol)
$0 (Tier 1)
doxercalciferol oral
(Hectorol)
$0 (Tier 1)
FORTEO
$0 (Tier 2)
FORTICAL
ibandronate intravenous solution
(Ibandronate Sodium)
$0 (Tier 2)
$0 (Tier 1)
ibandronate intravenous syringe
(Boniva)
$0 (Tier 1)
QL (300 per 28 days)
QL (4 per 28 days)
QL (3.7 per 28 days)
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
PA; QL (2.4 per 28
days)
QL (3.7 per 28 days)
PA BvD; (PA for ESRD
Only); QL (3 per 84
days)
PA BvD; QL (3 per 84
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
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123
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ibandronate oral
MIACALCIN INJECTION
NATPARA
paricalcitol oral
PROLIA
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
ZEMPLAR INTRAVENOUS
(Boniva)
(Zemplar)
(Actonel)
(Actonel)
zoledronic acid intravenous solution
(Zometa)
zoledronic acid-mannitol-water intravenous (Zoledronic
piggyback 4 mg/100 ml
Acid/Mannitol and
Water)
zoledronic acid-mannitol-water intravenous (Reclast)
solution
ZOMETA INTRAVENOUS SOLUTION 4
MG/100 ML
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
QL (1 per 28 days)
PA BvD; (PA for ESRD
Only)
PA; QL (2 per 28 days)
PA BvD; (PA for ESRD
Only)
QL (1 per 180 days)
QL (1 per 28 days)
QL (30 per 28 days)
PA BvD; (PA for ESRD
Only)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (100 per 300 days)
$0 (Tier 2)
PA BvD
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS SOLUTION
200 MG/10 ML (20 MG/ML)
ACTEMRA SUBCUTANEOUS
ACTIMMUNE
allopurinol
(Zyloprim)
amifostine crystalline
(Amifostine
Crystalline)
anticoag citrate phos dextrose
(Citrate Phosphate
Dextros Soln)
AVONEX (WITH ALBUMIN)
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT
AVONEX INTRAMUSCULAR
SYRINGE KIT
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
ST
ST
$0 (Tier 2)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
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124
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
BENLYSTA INTRAVENOUS RECON
SOLN 120 MG
BETASERON SUBCUTANEOUS KIT
bethanechol chloride
buspirone
CERDELGA
colchicine oral tablet
colchicine-probenecid
COPAXONE SUBCUTANEOUS
SYRINGE
CYSTADANE
droperidol injection solution
dutasteride
dutasteride-tamsulosin
ELMIRON
ergoloid
EXTAVIA SUBCUTANEOUS KIT
finasteride oral tablet 5 mg
fomepizole
FUSILEV
GAUZE PAD TOPICAL BANDAGE 2 X
2"
GILENYA
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
(HUMAN)
gnp epsom salt * granules
guanidine
hydroxyzine hcl intramuscular
hydroxyzine hcl oral solution 10 mg/5 ml
hydroxyzine hcl oral tablet
hydroxyzine pamoate
JALYN
KEVEYIS
(Urecholine)
(Buspirone HCl)
(Colcrys)
(Colchicine/Probeneci
d)
$0 (Tier 2)
PA
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
ST
PA
$0 (Tier 2)
(Droperidol)
(Avodart)
(Jalyn)
(Ergoloid Mesylates)
(Proscar)
(Fomepizole)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
(Magnesium Sulfate)
(Guanidine HCl)
(Hydroxyzine HCl)
(Hydroxyzine HCl)
(Hydroxyzine HCl)
(Vistaril)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
QL (30 per 30 days)
ST
PA; QL (28 per 28 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (30 per 30 days)
PA NSO; QL (120 per
30 days)
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125
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
LEMTRADA
leucovorin calcium 200 mg vial sdv, p/f,
latex-free
leucovorin calcium injection recon soln 100
mg, 350 mg
leucovorin calcium oral
levocarnitine (with sugar)
levocarnitine oral tablet
licide spray *
(Leucovorin Calcium)
$0 (Tier 2)
$0 (Tier 1)
(Leucovorin Calcium)
$0 (Tier 1)
(Leucovorin Calcium)
(Levocarnitine (With
Sugar))
(Carnitor)
$0 (Tier 1)
$0 (Tier 1)
(Piperonyl
Butoxide/Pyrethrins)
(Mesnex)
$0 (Tier 4)
mesna
MESNEX ORAL
MESTINON ORAL SYRUP
MESTINON TIMESPAN
morrhuate sodium
(Sodium Morrhuate)
OTEZLA
OTEZLA STARTER
OTREXUP (PF)
PLEGRIDY SUBCUTANEOUS PEN
INJECTOR
PLEGRIDY SUBCUTANEOUS
SYRINGE 125 MCG/0.5 ML
PLEGRIDY SYRINGE STARTER PACK
POLYETHYLENE GLYCOL 3350 GRAN
probenecid
(Probenecid)
PROCYSBI
pyridostigmine bromide
(Mestinon)
RASUVO (PF)
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
REBIF TITRATION PACK
REMICADE
SENSIPAR
SIGNIFOR
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
PA; QL (60 per 30 days)
PA; QL (60 per 30 days)
ST
$0 (Tier 2)
ST
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
ST
PA
QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
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126
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
SIMPONI
SIMPONI ARIA
STELARA SUBCUTANEOUS SYRINGE
STERILE PADS 2" X 2"
SYNAREL
TECFIDERA ORAL
CAPSULE,DELAYED RELEASE(DR/EC)
120 MG
TECFIDERA ORAL
CAPSULE,DELAYED RELEASE(DR/EC)
120 MG (14)- 240 MG (46), 240 MG
THALOMID
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
PA
PA
PA
$0 (Tier 2)
PA; QL (60 per 30 days)
$0 (Tier 2)
TYBOST
ULORIC
XELJANZ
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
PA NSO; QL (60 per 30
days)
QL (30 per 30 days)
ST; QL (30 per 30 days)
PA; QL (60 per 30 days)
PA; QL (14 per 30 days)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended
release
acetazolamide oral tablet
acetazolamide sodium
ALPHAGAN P OPHTHALMIC DROPS
0.1 %
AZOPT
betaxolol ophthalmic
bimatoprost
brimonidine
COMBIGAN
dorzolamide
dorzolamide-timolol
latanoprost
levobunolol
LUMIGAN OPHTHALMIC DROPS 0.01
%
(Diamox Sequels)
$0 (Tier 1)
(Acetazolamide)
(Acetazolamide
Sodium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(Betaxolol HCl)
(Bimatoprost)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
(drops: 0.15%, 0.20%)
QL (2.5 per 25 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
127
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
methazolamide oral
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic drops 1 %, 2 %,
4%
SIMBRINZA
timolol maleate ophthalmic drops
timolol maleate ophthalmic gel forming
solution
TRAVATAN Z
travoprost (benzalkonium)
(Neptazane)
(Metipranolol)
(Isopto Carpine)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 1)
(Timoptic)
(Timoptic-Xe)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Travoprost
(Benzalkonium))
$0 (Tier 2)
$0 (Tier 1)
QL (2.5 per 25 days)
QL (2.5 per 25 days)
Replacement Preparations
Replacement Preparations
calci-mix * 1.25 gm capsule
calcitrate * 200 mg (950 mg) tab
cal-citrate * plus vitamin d tab
(Calcium Carbonate)
(Calcium Citrate)
(Calcium
Citrate/Vitamin D2)
calcium 500 + d * tablet p/f,na/f,no lactose (Caltrate 600 + D)
calcium 500 + vit d3 400 tab s/f,p/f,gluten-f (Caltrate 600 + D)
calcium 500+d tablet chew
(Calcium 600 + Vit D)
calcium 600 + vit d 200 tablet
(Caltrate 600 + D)
calcium 600 + vit d 400 softgl
(Calcium
Carbonate/Vitamin
D3)
calcium 600 + vit d 400 tablet
(Caltrate 600 + D)
calcium 600 + vit d tablet
(Caltrate 600 + D)
calcium 600+d softgel
(Calcium
Carbonate/Vitamin
D3)
calcium adult gummies
(Citracal + D3)
calcium carbonate * 648 mg tab
(Calcium Carbonate)
calcium chloride intravenous
(Calcium Chloride)
calcium citrate - vit d caplet caplet, coated (Citracal-Vitamin D)
calcium citrate malate with d
(Calcium Cit
Malate/Vitamin D3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
128
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
calcium citrate with d tablet p/f,s/f
calcium citrate-vit d3 caplet s/f, p/f
calcium cit-vit d 250-200 cplt s/f, p/f, caplet
calcium cit-vit d 250-200 tab p/f,coated,no
lact
calcium gluconate * 50 mg tablet
calcium gluconate * 500 mg tab
calcium gluconate * 648 mg tab
calcium gluconate * 650 mg tab
calcium gluconate intravenous
(Citracal-Vitamin D)
(Citracal-Vitamin D)
(Citracal-Vitamin D)
(Citracal-Vitamin D)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Calcium Gluconate)
(Calcium Gluconate)
(Calcium Gluconate)
(Calcium Gluconate)
(Calcium Gluconate)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
calcium gummies
calcium lactate * 10gr tablet
calcium lactate * 648 mg tablet
calcium with magnesium tab
calcium with vit d tablet
(Citracal + D3)
(Calcium Lactate)
(Calcium Lactate)
(Calcium/Magnesium)
(Calcium
Carbonate/Vitamin
D2)
(Calcium
Citrate/Vitamin D2)
(Caltrate 600 + D)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
calcium with vit d tablet caplet,s/f,na/f,p/f
calcium-vitamin d tablet
CALTRATE 600 + D * SOFT CHEW TAB
VANILLA CREME
CALTRATE 600 + D TABLET
calvite p&d tablet
(Calcium Phosphate
Dibas/Vit D3)
citracal + d maximum * caplet
(Citracal-Vitamin D)
citric acid-sodium citrate
(Citric Acid/Sodium
Citrate)
citrus calcium * + d tablet
(Citracal-Vitamin D)
citrus calcium *-vit d 200-250
(Citracal-Vitamin D)
cvs calcium + vit d3 gummies
(Citracal + D3)
cvs calcium + vitamin d3 sftgl absorbable (Calcium
Carbonate/Vitamin
D3)
cvs calcium 500 + vit d tablet oyster shell
(Caltrate 600 + D)
PA BvD; (PA for ESRD
Only)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
129
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
cvs calcium 600 + vit d tablet p/f,
s/f,gluten-free
cvs magnesium * 250 mg tablet
cvs pediatric electrolyte * soln
cvs pediatric electrolyte * soln a/f, p/f
d10 %-0.45 % sodium chloride
d2.5 %-0.45 % sodium chloride
d5 % and 0.9 % sodium chloride
d5 %-0.45 % sodium chloride
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
dextrose 10%-1/4ns iv soln 12's
dextrose 5 %-lactated ringers
(Caltrate 600 + D)
$0 (Tier 4)
(Magnesium)
(Pedialyte)
(Pedialyte)
(Dextrose 10 % and
0.45 % NaCl)
(Dextrose 2.5 % and
0.45 % NaCl)
(Dextrose 5 % and 0.9
% NaCl)
(Dextrose 5 %-0.45 %
NaCl)
(Dextrose 10 % and
0.2 % NaCl)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
(Dextrose 5%-Lactated
Ringers)
dextrose 5%-0.2 % sod chloride
(Dextrose 5 %-0.2 %
NaCl)
dextrose 5%-0.3 % sod.chloride
(Dextrose 5 % and 0.3
% NaCl)
dextrose with sodium chloride
(Dextrose 5 %-0.2 %
NaCl)
electrolyte-48 in d5w
(Electrolyte-48
Solution/D5W)
eql calcium 600 mg + d softgel
(Calcium
Carbonate/Vitamin
D3)
eql children's calcium gummies *
(Calcium Phos
Tribas/Vitamin D2)
gnp calcium 500 + vit d3 tab
(Caltrate 600 + D)
hm calcium citrate-vit d cplt caplet, gluten- (Citracal-Vitamin D)
free
HYPERLYTE CR
IONOSOL-B IN D5W
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
130
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
IONOSOL-MB IN D5W
ISOLYTE M IN 5 % DEXTROSE
ISOLYTE-H IN 5 % DEXTROSE
ISOLYTE-P IN 5 % DEXTROSE
ISOLYTE-S
klor-con 10
klor-con m10 tablet
klor-con m15
klor-con m20
klor-con sprinkle
liquid calcium 600-vit d3 sfgl
liquid calcium 600-vit d3 sfgl
softgel,p/f,gluten-f
liquid calcium with vitamin d * softgel, s/f,
p/f
mag delay dr 64 mg tablet
mag64 dr 64 mg tablet
magbid er * 84 mg tablet
mag-g * 500 mg tablet
magnesium * 200 mg tablet
salt,starch,s/f,p/f
magnesium * 250 mg tablet
MAGNESIUM CHLORIDE * 64 MG TAB
SLOW, E/C, W/CALCIUM
magnesium chloride injection
MAGNESIUM CITRATE * 100 MG TAB
magnesium gluc 500 mg tablet
magnesium sulf in 0.45% nacl
magnesium sulfate in d5w intravenous
piggyback 1 gram/100 ml, 4 gram/100 ml
(Potassium Chloride)
(Potassium Chloride)
(Potassium Chloride)
(Potassium Chloride)
(Potassium Chloride)
(Calcium
Carbonate/Vitamin
D3)
(Calcium
Carbonate/Vitamin
D3)
(Calcium
Carbonate/Vitamin
D3)
(Slow-Mag)
(Slow-Mag)
(Mag-Tab SR)
(Magonate)
(Magnesium)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Magnesium)
$0 (Tier 4)
$0 (Tier 4)
(Magnesium Chloride)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
(Magonate)
(Magnesium Sulf In
0.45% NaCl)
(Magnesium
Sulfate/D5W)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
131
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
magnesium sulfate in water
magnesium sulfate injection
MAGONATE * 27 MG TABLET
MAGONATE 54 MG/5 ML LIQUID
natural calcium * 500 mg tablet
NORMOSOL-M IN 5 % DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE
NUTRILYTE II
oralyte * electrolyte soln
oralyte * freezer pops
oysco 500+d tablet
oysco-500 * tablet
oyster shell calcium 500 * mg tb 500mg
elemental ca
oyster shell calcium tablet
oyster shell calcium-vit d tab
oyster shell calcium-vit d tab p/f,s/f,glutenfree
oystercal-d * 500 mg-400 unit tb
PEDIALYTE * SOLUTION
pediatric electrolyte * pwd pack natural
flavor
pediatric electrolyte * solution
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 % DEXTROSE
potassium acetate intravenous
potassium bicarb and chloride
potassium bicarb-citric acid
potassium bicarbonate-cit ac oral tablet,
effervescent 25 meq
(Magnesium Sulfate in
Water)
(Magnesium Sulfate)
$0 (Tier 1)
(Pedialyte)
(Pedialyte)
(Caltrate 600 + D)
(Calcium Carbonate)
(Calcium Carbonate)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Caltrate 600 + D)
(Caltrate 600 + D)
(Caltrate 600 + D)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Caltrate 600 + D)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Calcium Carbonate)
(Pedialyte)
(Pedialyte)
(K-Phos Neutral)
(Potassium Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
(Klor-Con-Ef)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
132
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
potassium chlorid-d5-0.45%nacl
potassium chloride in 0.9%nacl
intravenous parenteral solution 20 meq/l,
40 meq/l
potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 30 meq/l, 40
meq/l
potassium chloride in lr-d5 intravenous
parenteral solution 20 meq/l
potassium chloride intravenous piggyback
10 meq/100 ml, 20 meq/100 ml, 30 meq/100
ml, 40 meq/100 ml
potassium chloride intravenous solution
potassium chloride oral capsule, extended
release
potassium chloride oral liquid
potassium chloride oral packet
potassium chloride oral tablet extended
release 8 meq
potassium chloride oral tablet,er
particles/crystals 10 meq
potassium chloride oral tablet,er
particles/crystals 20 meq
potassium chloride-0.45 % nacl
potassium chloride-d5-0.2%nacl
potassium chloride-d5-0.3%nacl
intravenous parenteral solution 20 meq/l
potassium chloride-d5-0.9%nacl
potassium citrate
(Potassium
Chloride/D5-0.45nacl)
(Potassium Chloride In
0.9%NaCl)
$0 (Tier 1)
(Potassium Chloride In
D5w)
$0 (Tier 1)
(Potassium Chloride In
Lr-D5)
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride)
(Potassium Chloride)
$0 (Tier 1)
$0 (Tier 1)
(Potassium Chloride)
(Klor-Con)
(K-Tab ER)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(K-Tab ER)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride0.45% NaCl)
(Potassium
Chloride/D50.2%NaCl)
(Potassium
Chloride/D50.3%NaCl)
(Potassium
Chloride/D50.9%NaCl)
(Urocit-K)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
133
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
potassium citrate-citric acid oral packet
potassium cl 10 meq/50 ml sol
potassium cl 20 meq/50 ml sol
potassium cl er 10 meq tablet f/c
potassium phosphate m-/d-basic
ra pediatric electrolyte * soln a/f
ra pediatric freezer pops *
ringers intravenous
sm calcium 600 + vit d 800 tab
sm magnesium * 250 mg tablet
sm pediatric electrolyte * soln
sodium acetate intravenous
sodium bicarbonate intravenous solution 1
meq/ml (8.4 %)
sodium bicarbonate intravenous syringe
sodium chloride 0.45 % intravenous
parenteral solution
sodium chloride 0.9 % injection solution
sodium chloride 0.9 % intravenous
parenteral solution
sodium chloride 3 %
sodium chloride 5 %
sodium chloride intravenous
sodium citrate-citric acid
sodium lactate
sodium phosphate
sod-pot-k cit-sod cit-cit acid
TPN ELECTROLYTES
TPN ELECTROLYTES II IV SOLN
25'S,20ML/50ML FTV
(Potassium
Citrate/Citric Acid)
(Potassium Chloride)
(Potassium Chloride)
(K-Tab ER)
(Potassium Phos,MBasic-D-Basic)
(Pedialyte)
(Pedialyte)
(Ringers Solution)
(Caltrate 600 + D)
(Magnesium)
(Pedialyte)
(Sodium Acetate)
(Sodium Bicarbonate)
$0 (Tier 1)
(Sodium Bicarbonate)
(Sodium Chloride 0.45
%)
(0.9 % Sodium
Chloride)
(0.9 % Sodium
Chloride)
(Sodium Chloride 3 %)
(Sodium Chloride 5 %)
(Sodium Chloride)
(Citric Acid/Sodium
Citrate)
(Sodium Lactate)
(Sodium Phos,MBasic-D-Basic)
(Sod/Pot/K Cit/Sod
Cit/Cit Acid)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
134
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
Respiratory Tract Agents
Anti-Inflammatories, Inhaled
Corticosteroids
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA
DULERA
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50
MCG/ACTUATION
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 250
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 220
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 44
MCG/ACTUATION
QVAR
Antileukotrienes
montelukast
zafirlukast
Bronchodilators
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,
2.5 mg /3 ml (0.083 %), 5 mg/ml
albuterol sulfate oral syrup
albuterol sulfate oral tablet
albuterol sulfate oral tablet extended
release 12 hr
ATROVENT HFA
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
QL (60 per 30 days)
QL (12 per 28 days)
QL (60 per 30 days)
QL (13 per 28 days)
QL (60 per 30 days)
$0 (Tier 2)
QL (120 per 30 days)
$0 (Tier 2)
QL (12 per 28 days)
$0 (Tier 2)
QL (24 per 28 days)
$0 (Tier 2)
QL (21.2 per 28 days)
$0 (Tier 2)
QL (17.4 per 25 days)
(Singulair)
(Accolate)
$0 (Tier 1)
$0 (Tier 1)
(Albuterol Sulfate)
$0 (Tier 1)
(Albuterol Sulfate)
(Albuterol Sulfate)
(Vospire ER)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
PA BvD
QL (25.8 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
135
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
COMBIVENT RESPIMAT
metaproterenol oral
PROAIR HFA
PROAIR RESPICLICK
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA WITH HANDIHALER
STRIVERDI RESPIMAT
terbutaline oral
terbutaline subcutaneous
theophylline anhydrous oral tablet extended
release 12 hr 100 mg, 200 mg, 300 mg
theophylline in dextrose 5 % intravenous
parenteral solution 200 mg/100 ml, 200
mg/50 ml, 400 mg/250 ml, 400 mg/500 ml,
800 mg/250 ml
theophylline oral solution
(Metaproterenol
Sulfate)
(Terbutaline Sulfate)
(Terbutaline Sulfate)
(Theophylline
Anhydrous)
(Theophylline/D5W)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (8 per 30 days)
QL (60 per 30 days)
$0 (Tier 1)
(Theophylline
Anhydrous)
theophylline oral tablet extended release
(Theophylline
Anhydrous)
theophylline oral tablet extended release 12 (Theophylline
hr
Anhydrous)
TUDORZA PRESSAIR
VENTOLIN HFA
Respiratory Tract Agents, Other
acetylcysteine
(Acetadote)
acetylcysteine
(Acetadote)
cromolyn inhalation
(Cromolyn Sodium)
cromolyn * sodium nasal spray
(Nasalcrom)
DALIRESP
ESBRIET
$0 (Tier 1)
KALYDECO
NUCALA
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
QL (1 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 2)
$0 (Tier 2)
PA BvD
PA BvD
PA BvD
QL (30 per 30 days)
PA; QL (270 per 30
days)
PA; QL (60 per 30 days)
PA; LA; QL (1 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
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136
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
OFEV
ORKAMBI
PROLASTIN-C
sodium chloride * 0.9% inhal vl u-d, suv,
p/f (rx)
XOLAIR
$0 (Tier 2)
$0 (Tier 2)
(Pulmosal)
PA
PA; QL (120 per 30
days)
$0 (Tier 2)
$0 (Tier 4)
$0 (Tier 2)
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
carisoprodol
(Baclofen)
(Soma)
$0 (Tier 1)
$0 (Tier 1)
chlorzoxazone
cyclobenzaprine oral tablet 10 mg, 5 mg
dantrolene
dantrolene sodium
metaxall
metaxalone
methocarbamol oral
tizanidine
(Parafon Forte DSC)
(Fexmid)
(Dantrium)
(Dantrium)
(Skelaxin)
(Skelaxin)
(Robaxin)
(Zanaflex)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Sonata)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
PA-HRM; QL (120 per
30 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
Sleep Disorder Agents
Sleep Disorder Agents
BELSOMRA
HETLIOZ
NUVIGIL
ROZEREM
XYREM
zaleplon
QL (30 per 30 days)
PA
PA
LA
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (60
per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
137
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
zolpidem oral tablet
(Ambien)
$0 (Tier 1)
zolpidem oral tablet,ext release multiphase
(Ambien CR)
$0 (Tier 1)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (30
per 30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (30
per 30 days)
Urine And Feces Contents
Ketones
KETONE CARE * TEST STRIPS
KETONE TEST STRIPS
KETOSTIX * REAGENT STRIPS
Urine And Feces Contents
KETO-DIASTIX * REAGENT STRIPS
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Vasodilating Agents
Vasodilating Agents
ADCIRCA
ADEMPAS
epoprostenol (glycine)
LETAIRIS
OPSUMIT
ORENITRAM
REMODULIN
sildenafil intravenous
sildenafil oral
(Flolan)
(Revatio)
(Revatio)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (60 per 30 days)
PA; QL (90 per 30 days)
PA BvD
PA; QL (30 per 30 days)
PA; QL (30 per 30 days)
PA
PA BvD
PA; QL (37.5 per 1 day)
PA; QL (90 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
138
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
TRACLEER
$0 (Tier 2)
TYVASO
TYVASO REFILL KIT
TYVASO STARTER KIT
UPTRAVI ORAL TABLET 1,000 MCG,
1,200 MCG, 1,400 MCG, 1,600 MCG, 400
MCG, 600 MCG, 800 MCG
UPTRAVI ORAL TABLET 200 MCG
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
$0 (Tier 2)
UPTRAVI ORAL TABLETS,DOSE
PACK
$0 (Tier 2)
$0 (Tier 2)
PA; LA; QL (60 per 30
days)
PA BvD
PA BvD
PA BvD
PA; QL (60 per 30 days)
PA; QL (240 per 30
days)
PA; QL (200 per 365
days)
Vitamins And Minerals
Vitamins And Minerals
abaneu-sl * tablet sl
advanced am/pm combo pack 650-1000800 mg
AQUASOL A * 50,000 UNITS/ML VIAL
SDV, LATEX-FREE
ascorbic acid * 500 mg/ml vial
b-12 1,000 mcg sub tablet
b-12 2,500 mcg tab sl 2,500 mcg
b-12 500 mcg tablet 500 mcg
b-12 dots * 500 mcg tablet
bacmin caplet 27-1 mg
b-complex 100 injection 100-2-100-2-2
mg/ml
b-complex with c tablet
B-NATAL 25 MG THERAPOPS
b-plex plus *
calcidol * drops
(Cyanocobalamin/Mec
obalamin)
(Om3/Calcium/D3/Fa/Mv
Cmb 13)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
(Ascorbic Acid)
(Cyanocobalamin/Foli
c Acid)
(B-12)
(B-12)
(B-12)
(Multivit, Min
Cmb#20/Iron/Fa)
(Vitamins
B1,B2,B3,B5, and B6)
(Vita-Bee with C)
(Multivits,Therap WFe,Hematin)
(Drisdol)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
139
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
child ferrous sulfate * 15 mg/ml
corvita 150 tablet 150-1.25-120-10 mg
cvs b-12 1,000 mcg/15 ml liq
cvs children's vit d 400 unit
cvs daily multiple * tablet
cvs daily multiple * tablet for women
cvs iron 27 mg tablet
cvs men's multi-vit tablet
cvs prenatal gummy * vitamins
cvs prenatal vitamins tablet with minerals
cvs vitamin d3 1,000 unit sfgl softgel
cvs women's prenatal + dha *
cyanocobalamin 1,000 mcg/ml 25's
d3 dots * 2,000 unit tablet p/f
daily multiple * vitamin tab sugar coated
daily prenatal * combo pack
daily value * multivitamin tab s/f
daily vitamin formula * tablet
daily vitamin * tablet p/f,na/f
daily vite tablet s/f, p/f
daily vite tablet s/f,p/f
daily-vite * tablet
decara * 50,000 unit softgel
delta d3 * 400 unit tablet lactose free, s/f
dialyvite 3,000 tablet 3-70-15 mg-mcg-mg
dialyvite 800 with iron tab 29-800 mg-mcg
dialyvite tablet 100-1 mg
(Fer-In-Sol)
(Corvite 150)
(Cyanocobalamin
(Vitamin B-12))
(Vitamin D3)
(Multivitamin)
(Multivitamin)
(Fergon)
(Multivitamin)
(Pnv62/Fa/Om3/Dha/E
pa/Fish Oil)
(Prenatal Vit/Iron
Fumarate/Fa)
(Vitamin D)
(Pnv with
Ca,No.61/Iron/Fa/Dha)
(Cyanocobalamin
(Vitamin B-12))
(Vitamin D3)
(Multivitamin)
(One-A-Day Women'S
Prenatal Dha)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Vitamin D)
(Vitamin D3)
(Folic Acid/B
Cplx/C/Selen/Zinc)
(Fe Fumarate/Fa/Vit
Bcomp,C)
(Folic Acid/Vit
Bcomp,C)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
140
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
dialyvite with zinc tablet 1-100-300-50 mgmg-mcg-mg
DRISDOL * 8,000 UNITS/ML DROPS
d-vi-sol * 400 units/ml drop
eql one daily essential * tablet
eql prenatal vitamin tablet 28 mg iron- 800
mcg
ergocalciferol 8,000 units/ml
EXPECTA PRENATAL * COMBO PACK
ezfe forte * capsule
fabb tablet 2.2-25-1 mg
FEOSOL * 45 MG CAPLET
CPLT,NATURAL RELEASE
feosol * 65 mg tablet
ferocon capsule 110-0.5 mg
ferotrinsic *
ferretts * 325 mg tablet
FERRETTS IRON 18 MG TABLET CHW
ferrex 150 forte capsule outer, medical food
150-25-1 mg-mcg-mg
ferrex 150 forte plus capsule 150-60-25-1
mg-mg-mcg-mg
ferrex 28 tablet 151-200-1-0.8 mg
ferrocite plus tablet 106 mg iron- 1 mg
ferrocite * tablet
ferrogels forte softgel 460-60-0.01-1 mg
ferrous fumarate * 324 mg tab
ferrous gluconate * 240 mg tab
240mg=27mg elemental
ferrous gluconate * 324 mg tab
(Vit B Cplx
#11/Fa/C/Biot/Zn Ox)
(Just D)
(Multivitamin)
(Prenatal Vit
No.128/Iron/Fa)
(Drisdol)
(Pnv No.23-Iron Ps
Complex-Fa)
(Niva-Fol)
(Ferrous Sulfate)
(Fe Fumarate/Vit
C/B12-If/Fa)
(Ferrous Fumarate)
(Niferex-150 Forte)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
(Iron Aspgly and
Ps/C/B12/Fa/Ca/Suc)
(Iron Ag and
Fum/C/Fa/Mv
Cmb11/Ca-T)
(Iron/Fa/Vit
Bcomp,C/Minerals)
(Ferrous Fumarate)
(Iron Fumarate/Vit
C/Vit B12/Fa)
(Ferrous Fumarate)
(Fergon)
$0 (Tier 3)
(Fergon)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
141
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ferrous gluconate * 325 mg tab
p/f,s/f,gluten-free
ferrous sulf 220 mg/5 ml elix
ferrous sulf 300 mg/5 ml liq
ferrous sulfate * 325 mg tablet red
folbee plus cz tablet 5-1.5-25 mg
(Fergon)
(Ferrous Sulfate)
(Ferrous Sulfate)
(Ferrous Sulfate)
(Folic Acid/Vit
Bcomp,C/Cu/Znox)
folbee plus tablet 5 mg
(Folic Acid/Vit
Bcomp,C)
folbee tablet 2.5-25-1 mg
(Niva-Fol)
folbic tablet a/f,s/f,lactose free (rx) 2.5-25-2 (Niva-Fol)
mg
folic acid * 0.8 mg tablet
(Folic Acid)
folic acid * 1 mg tablet (rx)
(Folic Acid)
folic acid * 1,000 mcg tablet p/f,s/f (otc)
(Folic Acid)
folic acid 2.5 mg tablet
(Niva-Fol)
folic acid * 400 mcg tablet s/f,p/f,lactose(Folic Acid)
free
folic acid * 5 mg/ml vial latex-free
(Folic Acid)
folic acid-vit b6-vit b12 * tab
(Niva-Fol)
folivane-f capsule 125-1-40-3 mg
(Integra F)
folivane-plus capsule 125-1 mg
(Integra Plus)
folplex 2.2 tablet 2.2-25-0.5 mg
(Niva-Fol)
gnp one daily essential * tablet
(Multivitamin)
hematinic-folic acid tablet 324 mg (106 mg (Hemocyte-F)
iron)-1 mg
hematinic-vitamin-mineral tab 106 mg
(Iron/Fa/Vit
iron- 1 mg
Bcomp,C/Minerals)
hematogen fa softgel 200-250-0.01-1 mg
(Iron Fumarate/Vit
C/Vit B12/Fa)
hematogen forte softgel 460-60-0.01-1 mg (Iron Fumarate/Vit
C/Vit B12/Fa)
hematogen softgel 200 (66)-10-250 mg-mg- (Fe Fumarate/Vit
mcg-mg
C/B12/Stomc)
hemocyte * tablet u-u,blister pk
(Ferrous Fumarate)
hydroxocobalamin * 1,000 mcg/ml
(Hydroxocobalamin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; AGE (Max 46
Years)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
142
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ICAR * 15 MG/1.25 ML SUSPENSION
iferex 150 forte capsule 150-25-1 mg-mcgmg
iron 27 mg tablet
iron 28 mg tablet
kpn * tablet
liquid b12
l-methylfolate 7.5 mg tablet 7.5 mg
MEPHYTON * 5 MG TABLET
metafolbic tablet 6-5-50-1 mg
multigen caplet 70 mg-150 mg-10 mcg-2
mg-75 mg
(Niferex-150 Forte)
(Fergon)
(Fergon)
(Prenatal Vit WCa,Fe,Fa( Less Than 1
Mg))
(Cyanocobalamin
(Vitamin B-12))
(Levomefolate
Calcium)
(Cerefolin)
(Iron
Ag/C/B12/Ca/Suc.Aci
d/Stom)
multigen folic caplet 70-150-10-1-2 mg-mg- (Iron
mcg-mg-mg
Aspgly/C/B12/Fa/CaTh/Suc)
multigen plus caplet 151-60-10-1 mg-mg(Iron Fum and
mcg-mg
Ag/C/B12/Fa/Ca/Succ)
multiple vitamins * tablet one daily
(Multivitamin)
multi-vitamin daily tablet
(Multivitamin)
multivitamin *s men tablet
(Multivitamin)
multivitamin *s tablet
(Multivitamin)
multivit-fluor 0.5 mg tab chew chewable,
(Pedi M.Vit No.17
d/f, s/f 0.5 mg
with Fluoride)
myferon-150 forte capsule 150-25-1 mg(Niferex-150 Forte)
mcg-mg
NASCOBAL * 500 MCG NASAL SPRAY
nephplex rx tablet 1-60-300-12.5 mg-mg(Vit B Cmplx
mcg-mg
No3/Fa/C/Biot/Zinc)
nephron fa tablet
(Fe
Fumarate/Doss/Fa/Bco
mp,C)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
143
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
nephro-vite rx tablet 1-60-300 mg-mg-mcg
neurin-sl tablet sl 600-600 mcg
niacinamide * 100 mg tablet
niacinamide * er 500 mg tablet
once daily * tablet
ONE A DAY PRENATAL DHA PACK 30
LIQ GELS,30 TABS
one daily essential * tablet
one daily multivitamin * tab
one daily * tablet
one daily * tablet men's formula
one-a-day essential * tablet
ONE-A-DAY PRENATAL 1 DHA SFGL
optimal d3 * 50,000 units cap
PERFECT IRON * 25 MG TABLET
perry prenatal * capsule
pharmacist multi-vite tab
pnv prenatal plus multivit tab s/f, glutenfree 27 mg iron- 1 mg
poly-iron 150 forte capsule 150-25-1 mgmcg-mg
poly-vita with iron drops
polyvitamin w-iron drops
prenatal + dha * combo pack
prenatal 19 chewable tablet (otc) 29 mg
iron- 1 mg
PRENATAL DHA+COMPLETE
PRENATAL *
prenatal formula * tablet
(Vit B Cmplx 3/Fa/Vit
C/Biotin)
(Cyanocobalamin/Mec
obalamin)
(Niacinamide)
(Niacinamide)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Vitamin D)
(Pnv with Ca
No.36/Iron/Fa)
(Multivitamin)
(Pnv with
Ca,No.72/Iron/Fa)
(Niferex-150 Forte)
(Ped Multivit #46/Iron
Sulfate)
(Ped Multivit #46/Iron
Sulfate)
(Prenatal Vit #91/Fe
Fum/Fa/Dha)
(Pnv No.118/Iron
Fumarate/Fa)
(Prenatal)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 2)
PA
PA
PA
(All Rx Prenatal
Vitamins Covered)
$0 (Tier 3)
$0 (Tier 4)
PA; AGE (Max 4 Years)
$0 (Tier 4)
PA; AGE (Max 4 Years)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
144
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
prenatal formula tablet
prenatal gummies
prenatal multi + dha softgel
PRENATAL MULTI + DHA * SOFTGEL
P/F, GLUTEN-FREE
prenatal multivitamins * tablet
prenatal one daily * tablet
prenatal one * tablet
prenatal tablet
prenatal tablet
PRENATAL * TABLET
prenatal tablet (otc) 27-0.8 mg
prenatal vitamin tablet
prenatal vitamin tablet 27 mg iron- 800
mcg
prenatal vitamins oral tablet 27 mg iron- 1
mg
prenatal vitamins tablet
prenatal * vitamins tablet phosphorus free
prenatal-1 * capsule
PROFE FORTE * CAPSULE
pv prenatal formula * tablet
pyridoxine * 100 mg/ml vial
pyridoxine * 250 mg tablet
(Prenatal Vits #90/Iron
Fum/Fa)
(Pnv103/Fa/Omega3/D
ha/Fish Oil)
(Prenatal
No.40/Iron/Fa/Dha)
(Prenatal)
(Prenatal Vit
No.129/Iron/Fa)
(Prenatal Vit
#108/Iron/Fa)
(Prenatal
Vit#96/Ferrous
Fum/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Prenatal Vit
No.130/Iron/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Prenatal Vit
No.124/Iron/Fa)
(Pnv with
Ca,No.72/Iron/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Prenatal)
(Pnv No.25/Iron
Fumarate/Fa/Dha)
(Prenatal Vit
No.131/Iron/Fa)
(Pyridoxine HCl)
(Pyridoxine HCl)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 2)
$0 (Tier 4)
(All Rx Prenatal
Vitamins Covered)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 3)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
145
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
ra one daily prenatal * dha pack 30's tab &
30's cap
ra one daily * tablet p/f
ra prenatal tablet *
(One-A-Day Women'S
Prenatal Dha)
(Multivitamin)
(Prenatal Vit/Iron
Fumarate/Fa)
(Vitamin D3)
ra vitamin d3 * 1,000 unit tab
s/f,gluten/f,yeast/f
ra vitamin e * 400 unit softgel p/f,s/f,softgel (Vitamin E)
renal caps softgel 1 mg
(B Complex and C
No.20/Folic Acid)
rena-vite rx tablet 1-60-300 mg-mg-mcg
(Vit B Cmplx 3/Fa/Vit
C/Biotin)
reno caps softgel 1 mg
(B Complex and C
No.20/Folic Acid)
riboflavin 100 mg tablet
(Riboflavin)
riboflavin 50 mg tablet
(Riboflavin)
right step prenatal vit tab
(Prenatal Vit/Iron
Fumarate/Fa)
se-tan plus capsule 162-115.2-1 mg
(Tandem Plus)
siderol tablet
(Iron/Liver Ext/Vit
Bcomp,C/Min)
SIMILAC PRENATAL * COMBO PACK
sm multivitamin *s tablet
(Multivitamin)
sm one daily prenatal * combo pk
(One-A-Day Women'S
Prenatal Dha)
sm prenatal * vitamins tablet
(Prenatal)
sm vitamin d3 * 4,000 unit sftgl softgel,
(Vitamin D)
gluten-free
sodium fluoride oral tablet
(Pedi M.Vit No.17
with Fluoride)
strovite forte caplet 10-1 mg
(Multivit, Iron, Min
#5, Fa)
STROVITE ONE * CAPLET
STUART ONE * CAPSULE
super multivitamin * tablet
(Multivitamin)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 1)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
146
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
support-500 * softgel
tab-a-vite * tablet
taron forte capsule 150-60-25-1 mg-mgmcg-mg
thera-d * 2000 tablet
THERANATAL * CORE NUTRITION
TAB
THERANATAL ONE * SOFTGEL
THERANATAL OVAVITE * COMBO
PACK
THERANATAL PLUS * COMBO PACK
therapeutic vitamins/minerals *
thiamine 200 mg/2 ml vial 25's,mdv,outer
thiamine 250 mg tablet
thiamine 500 mg tablet
tl gard rx tablet 2.2-25-1 mg
tl-hem 150 caplet 150-1-50 mg
trigels-f forte softgel 460-60-0.01-1 mg
tri-vi-sol * drops
tri-vita * drops
tri-vitamin * drops
v-c forte capsule 1 mg
vic-forte capsule 1 mg
vinacal b * prenatal combo pack
vit d2 1.25 mg (50,000 unit) 50,000 unit
vit e nat'l blnd 1,000 unit cp
(B Complex with
Vitamin C)
(Multivitamin)
(Iron
Bg,Ps/Vitc/B12/Fa/Cal
cium)
(Vitamin D3)
(Multivitamins with
Min No.7/Fa)
(Thiamine HCl)
(Thiamine HCl)
(Thiamine HCl)
(Niva-Fol)
(Hemax)
(Iron Fumarate/Vit
C/Vit B12/Fa)
(Vit A Palmitate/Vit
C/Vit D3)
(Pedi Multivits A,C,
and D3 No.21)
(Pedi Multivits A,C,
and D3 No.21)
(Multivitamins with
Min No.7/Fa)
(Multivitamins with
Min No.7/Fa)
(Prenatal #48/Iron Cb
and Glu/Fa/B6)
(Drisdol)
(Vitamin E Mixed)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 3)
PA
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; AGE (Max 4 Years)
$0 (Tier 4)
PA; AGE (Max 4 Years)
$0 (Tier 4)
PA; AGE (Max 4 Years)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
147
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
Name of Drug
vitacel tablet
vitafol caplet 65-1 mg
vital-d rx tablet 1,750-60-1-12.5 unit-mgmg-mg
vitamin a * 10,000 units capsule soluble
vitamin b-1 * 100 mg tablet
vitamin b-1 * 50 mg tablet
vitamin b-12 1,000 mcg tablet 1,000 mcg
vitamin b-12 100 mcg tablet 100 mcg
vitamin b-12 250 mcg tablet 250 mcg
vitamin b12 500 mcg tablet 500 mcg
vitamin b-2 * 100 mg tablet s/f,p/f
vitamin b-2 * 25 mg tablet
vitamin b-2 * 50 mg tablet
vitamin b-6 * 100 mg tablet
vitamin b-6 * 25 mg tablet
vitamin b-6 * 250 mg tablet p/f
vitamin b-6 * 50 mg capsule
vitamin b-6 * 50 mg tablet
vitamin b-6 * sr 200 mg tablet
vitamin c * 1,000 mg tablet
vitamin c * 100 mg tablet
vitamin c * 250 mg tablet
vitamin c * 500 mg tablet
vitamin c * 500 mg tablet buffered
vitamin d 10,000 unit softgel softgel,p/f,s/f
vitamin d 2,000 unit softgel
VITAMIN D 400 UNIT SOFTGEL
SOFTGEL,P/F,S/F
vitamin d 400 unit tablet p/f,na/f,s/f
vitamin d 400 unit/ml drop a/f, s/f, fruit
VITAMIN D2 2,000 UNIT TABLET
(Biocel)
(Fe
Fumarate/Cal/E/Fa/Mu
ltivit)
(B Cmplx 4/Vit
D3/C/Fa/Zinc Ox)
(Vitamin A)
(Thiamine HCl)
(Thiamine HCl)
(B-12)
(B-12)
(B-12)
(B-12)
(Riboflavin)
(Riboflavin)
(Riboflavin)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Ascorbic Acid)
(Ascorbic Acid)
(Ascorbic Acid)
(Ascorbic Acid)
(Ascorbate Calcium)
(Vitamin D)
(Vitamin D)
$0 (Tier 3)
$0 (Tier 3)
(Ergocalciferol
(Vitamin D2))
(Just D)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
148
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
Name of Drug
vitamin d2 400 unit tablet s/f,l/f,y/f,gluten/f
(Ergocalciferol
(Vitamin D2))
vitamin d3 * 1,000 unit tablet s/f,p/f
(Vitamin D3)
vitamin d3 * 1,000 units softgel softgel, p/f, (Vitamin D)
s/f
vitamin d3 10,000 unit softgel softgel
(Vitamin D)
vitamin d-3 2,000 unit tablet s/f,p/f
(Vitamin D3)
vitamin d3 400 unit tab chew orange, p/f
(Vitamin D3)
vitamin d3 * 400 unit tablet s/f,p/f
(Vitamin D3)
vitamin d3 400 unit/5 ml liq
(Cholecalciferol
(Vitamin D3))
vitamin d3 5,000 unit capsule s/f, p/f
(Vitamin D)
vitamin d3 5,000 unit/ml drops a/f,
(Just D)
p/f,gluten-free
VITAMIN D3 LIQUID
vitamin e * 1,000 units capsule
(Vitamin E)
vitamin e 100 unit softgel softgel
(Vitamin E
(Dl,Tocopheryl Acet))
vitamin e * 200 unit capsule
(Vitamin E)
vitamin e 400 unit softgel softgel,s/f,p/f,na/f (Vitamin E
(Dl,Tocopheryl Acet))
vitamin k 100 mcg tablet p/f, gluten-free
(Phytonadione)
vitamin k-1 10 mg/ml ampul 25's,latex-free (Phytonadione)
10 mg/ml
vitamins for hair * tablet
(Multivitamin)
VITA-RESPA * TABLET
vp-vite rx * tablet
(Vit B Cmplx 3/Fa/Vit
C/Biotin)
wee care * 15 mg/1.25 ml susp
(Icar)
What the
Necessary Actions,
drug will
Restrictions, or Limits
cost you
on Use
(Tier level)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
149
SCFHP Cal MediConnect Formulary
Effective: March 01, 2016
Formulary ID: 16510.000, Version: 10
INDEX
1
12 hour relief .......................... 34
1ST TIER UNILET
COMFORTOUCH ............. 77
3
3 day vaginal .......................... 34
8
8-MOP .................................... 71
A
abacavir .................................. 46
abacavir-lamivudine-zidovudine
............................................ 46
abaneu-sl............................... 139
ABELCET .............................. 31
ABILIFY DISCMELT ........... 43
ABILIFY MAINTENA .......... 43
ABRAXANE .......................... 17
acamprosate .............................. 8
acarbose .................................. 29
ACCU-CHEK ACTIVE TEST
............................................ 77
ACCU-CHEK AVIVA ........... 78
ACCU-CHEK AVIVA PLUS
TEST STRP ........................ 78
ACCU-CHEK COMPACT
PLUS TEST........................ 78
ACCU-CHEK FASTCLIX .... 78
ACCU-CHEK MULTICLIX
LANCET ............................ 78
ACCU-CHEK SAFE-T-PRO . 78
ACCU-CHEK SAFE-T-PRO
PLUS .................................. 78
ACCU-CHEK SMARTVIEW
TEST STRIP ...................... 78
ACCU-CHEK SOFTCLIX
LANCETS .......................... 78
ACCUTREND GLUCOSE .... 78
ACE AEROSOL CLOUD
ENHANCER ..................... 78
acebutolol............................... 57
acephen .................................... 1
acetaminophen ......................... 1
acetaminophen-codeine ........... 1
acetazolamide ...................... 127
acetazolamide sodium.......... 127
acetic acid .................... 102, 123
acetylcysteine....................... 136
acid gone antacid ................. 106
acid gone antacid e.strength. 106
acid reducer (famotidine)..... 105
acid relief (cimetidine)......... 106
acitretin .................................. 71
acne & blackhead terminator . 71
acne foaming wash ................ 71
acne medication ............... 71, 72
ACNE MEDICATION .......... 71
acne-clear ............................... 71
ACTEMRA.......................... 124
ACTHIB (PF) ...................... 120
ACTI-LANCE LANCETS .... 78
ACTIMMUNE..................... 124
ACURA TEST STRIPS......... 78
acyclovir .......................... 48, 71
acyclovir sodium.................... 48
ADACEL(TDAP
ADOLESN/ADULT)(PF) 120
ADAGEN .............................. 97
adapalene ............................... 76
ADCETRIS ............................ 18
ADCIRCA ........................... 138
adefovir .................................. 48
ADEMPAS .......................... 138
adult nasal decongestant ........ 70
adult wal-tussin ...................... 69
ADVAIR DISKUS .............. 135
ADVAIR HFA ..................... 135
advanced eye relief (mo-wpet)
............................................ 98
ADVANCED GLUC METER
TEST STRIP ...................... 82
ADVANCED TRAVEL
LANCETS.......................... 78
advil.......................................... 5
ADVOCATE LANCET ......... 78
ADVOCATE REDI-CODE ... 79
ADVOCATE REDI-CODE+ . 79
ADVOCATE TEST STRIPS . 79
AEROCHAMBER MINI ....... 79
AEROCHAMBER MV ......... 79
AEROCHAMBER PLUS
FLOW-VU ......................... 79
AEROCHAMBER PLUS
FLOW-VU,M MSK ........... 79
AEROCHAMBER PLUS Z
STAT MD MSK ................ 79
AEROCHAMBER WITH
FLOWSIGNAL.................. 79
AEROCHAMBER Z-STAT
PLUS-FLW SG .................. 79
AEROTRACH PLUS ............ 79
AEROVENT PLUS ............... 79
af 32
AFINITOR ............................. 18
AFINITOR DISPERZ ............ 18
AGAMATRIX AMP TEST
STRIPS .............................. 79
AGGRENOX ......................... 51
AIMSCO ................................ 66
AKTEN (PF) .......................... 98
AKYNZEO ............................ 40
ala-hist ir ................................ 34
ALA-HIST PE ....................... 34
alaway .................................... 98
I-1
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
ALBENZA ............................. 41
ALBUKED-25 ....................... 52
ALBUKED-5 ......................... 52
ALBUMIN, HUMAN 25 % ... 52
ALBUMIN, HUMAN 5 % ..... 52
ALBUMINAR 25 % .............. 52
ALBUMINAR 5 % ................ 52
ALBURX (HUMAN) 5 % ..... 52
ALBUTEIN 25 %................... 52
ALBUTEIN 5 %..................... 52
albuterol sulfate .................... 135
alclometasone ......................... 74
ALCOHOL PADS.................. 71
ALCOHOL PREP PADS ....... 71
ALDURAZYME .................... 97
ALECENSA ........................... 18
alendronate ........................... 123
alfuzosin ............................... 115
ALIMTA ................................ 18
ALINIA .................................. 41
ALKA-SELTZER GOLD .... 106
ALLEGRA ALLERGY.......... 35
aller-chlor ............................... 35
allergy (chlorpheniramine) ..... 35
allergy (diphenhydramine) ..... 36
allergy and sinus relief ..... 37, 38
allergy relief (loratadine) ........ 36
allerhist-1................................ 35
allopurinol ............................ 124
almacone............................... 106
almacone-2 ........................... 106
aloe vesta antifungal (micon) . 31
alophen ................................. 110
alosetron ............................... 122
ALPHAGAN P ..................... 127
alprazolam ................................ 9
ALREX................................. 104
altacaine .................................. 98
altamist ................................... 98
altazine ................................... 98
ALTERNATE SITE LANCET
............................................ 79
aluminum hydroxide gel ..... 106,
107
amantadine hcl ....................... 42
ambi 60pse-4cpm ................... 35
AMBISOME .......................... 31
amifostine crystalline ........... 124
amiloride ................................ 61
amiloride-hydrochlorothiazide
........................................... 61
AMINO ACIDS 15 % ........... 52
aminocaproic acid .................. 51
AMINOSYN 10 % ................ 52
AMINOSYN 3.5 % ............... 52
AMINOSYN 7 % .................. 52
AMINOSYN 7 % WITH
ELECTROLYTES ............. 52
AMINOSYN 8.5 % ............... 52
AMINOSYN 8.5 %ELECTROLYTES ............. 52
AMINOSYN II 10 % ............. 52
AMINOSYN II 15 % ............. 52
AMINOSYN II 7 % ............... 52
AMINOSYN II 8.5 % ............ 52
AMINOSYN II 8.5 %ELECTROLYTES ............. 52
AMINOSYN M 3.5 % ........... 52
AMINOSYN-HBC 7% .......... 53
AMINOSYN-PF 10 %........... 53
AMINOSYN-PF 7 %
(SULFITE-FREE) ............. 53
AMINOSYN-RF 5.2 % ......... 53
amiodarone ............................ 56
amiodarone hcl ...................... 56
AMITIZA ............................ 107
amitriptyline........................... 27
amlodipine ............................. 60
amlodipine-atorvastatin ......... 61
amlodipine-benazepril ........... 60
amlodipine-valsartan ............. 60
amlodipine-valsartan-hcthiazid
........................................... 60
ammonium lactate.................. 71
amoxapine .............................. 27
amoxicil-clarithromy-lansopraz
.......................................... 105
amoxicillin ....................... 14, 15
amoxicillin-pot clavulanate .... 15
amphetamine salt combo........ 65
amphotericin b ....................... 31
ampicillin ............................... 15
ampicillin sodium................... 15
ampicillin-sulbactam .............. 15
AMPYRA .............................. 65
ANACAINE ........................... 71
anagrelide ............................... 51
anastrozole ............................. 18
ANDRODERM ............ 115, 116
ANDROGEL........................ 116
antacid (calcium carb-mag hyd)
.......................................... 107
antacid anti-gas .................... 107
antacid exst (ca carb-mag hyd)
.......................................... 107
antacid extra-strength ........... 107
antacid plus extra strength ... 107
antacid supreme ................... 107
antibiotic plus (pramoxine) .... 73
anticoag citrate phos dextrose
.......................................... 124
anti-diarrheal ........................ 107
anti-diarrheal (lope)-anti-gas 109
anti-diarrheal (loperamide) .. 107
antifungal ......................... 32, 34
anti-fungal .............................. 32
antifungal (tolnaftate)............. 31
anti-gas maximum strength .. 105
APOKYN ............................... 42
apraclonidine .......................... 98
APRISO ............................... 122
aprodine.................................. 35
APTIOM ................................ 24
APTIVUS ............................... 46
aquanil hc ............................... 74
AQUASOL A....................... 139
I-2
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
ARCALYST ......................... 119
aripiprazole ............................. 43
ARISTADA ...................... 43, 44
artificial tears .................... 98, 99
artificial tears (petro/min)....... 99
artificial tears (pf) ................... 98
artificial tears(hypromellose)101
ASACOL HD ....................... 122
ascorbic acid ......................... 139
ashlyna .................................... 66
aspirin ................................... 5, 6
aspirin, buffered ....................... 6
aspirin-dipyridamole .............. 51
aspir-low ................................... 6
ASSURE 4 STRIPS ............... 79
ASSURE HAEMOLANCE
PLUS .................................. 79
ASSURE ID INSULIN
SAFETY ............................. 79
ASSURE LANCE .................. 80
ASSURE LANCE PLUS ....... 80
ASSURE PLATINUM ........... 80
ASSURE PRISM MULTI
STRIP ................................. 80
ASTAGRAF XL .................. 119
atenolol ................................... 57
atenolol-chlorthalidone........... 57
athlete's foot ..................... 31, 32
atorvastatin ............................. 61
atovaquone ............................. 42
atovaquone-proguanil ............. 42
ATRIPLA ............................... 46
atropine ............................. 24, 99
atropine sulfate ....................... 99
ATROVENT HFA ............... 135
AUBAGIO ........................... 119
auraphene-b .......................... 102
auro eardrops ........................ 102
AVASTIN .............................. 18
AVC VAGINAL .................... 39
AVONEX ............................. 124
AVONEX (WITH ALBUMIN)
......................................... 124
ayr saline ................................ 99
azacitidine .............................. 18
azathioprine ......................... 119
azathioprine sodium ............. 119
azelastine ............................... 99
AZILECT............................... 42
azithromycin .......................... 14
AZOPT ................................ 127
AZOR .................................... 60
aztreonam............................... 14
B
b cmplx 4-vit d3-c-fa-zinc ox
......................................... 148
b complex and c no.20-folic acid
......................................... 146
b-12 dots .............................. 139
bacitracin ................. 11, 72, 102
bacitracin-polymyxin b .. 72, 102
bacitraycin plus ...................... 73
baclofen ............................... 137
balsalazide ........................... 122
banophen ................................ 35
banophen allergy.................... 35
BANZEL ............................... 24
baza antifungal ....................... 32
BCG VACCINE, LIVE (PF) 121
b-complex with vitamin c .... 139
BD BULK LUER-LOK NONSTERILE ........................... 80
BD ECLIPSE LUER-LOK .... 80
BD INSULIN PEN NEEDLE
UF SHORT ........................ 81
BD INSULIN SYRINGE
ULTRA-FINE .................... 80
BD INTEGRA SYRINGE ..... 80
BD LUER-LOK SYRINGE .. 80
BD MICROTAINER LANCET
........................................... 80
BD SAFETYGLIDE SYRINGE
........................................... 81
BD SAFETYGLIDE TB REG
BEVEL ............................... 80
BD SAFETY-LOK
DETACHABLE NEEDL ... 92
BD SAFETY-LOK WITH
LUER-LOK........................ 92
BD TUBERCULIN SLIP-TIP 81
BD TUBERCULIN SYRINGE
............................................ 81
BD ULTRA FINE LANCETS
............................................ 81
BD ULTRA-FINE II
LANCETS.......................... 81
bedding spray ......................... 77
bekyree (28) ........................... 66
BELEODAQ .......................... 18
BELSOMRA ........................ 137
benadryl allergy ..................... 35
BENADRYL ALLERGY ...... 35
benazepril ............................... 55
benazepril-hydrochlorothiazide
............................................ 55
BENDEKA ............................ 18
BENICAR .............................. 55
BENICAR HCT ..................... 55
BENLYSTA ......................... 125
benzonatate ............................ 69
benzoyl peroxide .................... 71
benztropine ............................. 42
beta-hc .................................... 74
betamethasone acet,sod phos 117
betamethasone dipropionate... 74
betamethasone valerate .......... 74
betamethasone, augmented .... 74
BETASERON ...................... 125
betaxolol......................... 57, 127
bethanechol chloride ............ 125
BETHKIS ............................... 10
bexarotene .............................. 18
BEXSERO (PF) ................... 121
BG-STAR .............................. 81
bicalutamide ........................... 18
I-3
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
bicarsim forte................ 104, 105
BICILLIN C-R ....................... 15
BICILLIN L-A ....................... 15
bimatoprost ........................... 127
bion tears (pf) ......................... 99
BIONIME RIGHTEST TEST
STRIPS ............................... 92
bisac-evac ............................. 110
bisacodyl............................... 111
biscolax................................. 111
bismatrol ............................... 107
bisoprolol fumarate ................ 57
bisoprolol-hydrochlorothiazide
............................................ 57
bleomycin ............................... 18
BLINCYTO ............................ 18
blisovi 24 fe ............................ 66
blisovi fe 1.5/30 (28) .............. 66
blisovi fe 1/20 (28) ................. 66
BLOOD GLUCOSE TEST ... 81,
87, 90, 97
B-NATAL THERAPOPS .... 139
BOOSTRIX TDAP .............. 121
BOSULIF ............................... 18
b-plex plus ............................ 139
BREATHERITE RIGID
SPACER-MASK ................ 81
BREATHERITE VALVED
MDI SPACER .................... 81
BREO ELLIPTA .................. 135
BRILINTA ............................. 51
brimonidine .......................... 127
BRINTELLIX ........................ 27
bromfenac ............................. 104
bromocriptine ......................... 42
budesonide............................ 122
bufferin ..................................... 6
BULLSEYE MINI SAFETY
LANCETS .......................... 81
bumetanide ............................. 61
BUMINATE 25 % ................. 52
BUMINATE 5 % ................... 52
BUPHENYL ........................ 107
buprenorphine hcl ................ 1, 9
buprenorphine-naloxone .......... 9
bupropion hcl ..................... 9, 27
buspirone ............................. 125
butalb-acetaminophen-caffeine 1
butalbital-acetaminop-caf-cod . 1
butalbital-acetaminophen......... 1
butalbital-acetaminophen-caff . 1
butalbital-aspirin-caffeine ........ 1
BUTRANS............................... 1
BYSTOLIC ............................ 57
C
cabergoline............................. 42
caffeine citrated ..................... 65
caffeine-sodium benzoate ...... 65
calamine ................................. 71
calamine-zinc oxide ............... 72
calci-chew ............................ 107
calcidol................................. 139
calci-mix .............................. 128
calcipotriene........................... 71
calcitonin (salmon) .............. 123
calcitrate............................... 128
cal-citrate ............................. 128
cal-citrate ............................. 128
cal-citrate ............................. 128
cal-citrate ............................. 128
calcitriol ......................... 71, 123
calcium 500 + d ................... 128
calcium 500 + d (d3)............ 129
calcium 500 with d .............. 128
calcium 600 + d(3)............... 128
calcium 600 with vitamin d3 131
calcium acetate .................... 114
CALCIUM ACETATE........ 114
calcium adult (calcium phos)128
calcium antacid .................... 107
calcium carbonate ........ 107, 128
calcium carbonate-mag carb-fa
......................................... 115
calcium carbonate-vitamin d2
.......................................... 129
calcium carbonate-vitamin d3
.................. 128, 129, 130, 134
calcium chloride ................... 128
calcium citrate malate-vit d3 128
calcium citrate-vitamin d2 ... 129
calcium citrate-vitamin d3 .. 128,
129, 130
calcium gluconate ................ 129
calcium lactate ..................... 129
calcium phosphate-vitamin d3
.......................................... 129
calcium-magnesium ............. 129
CALDOLOR ............................ 6
cal-gest antacid..................... 107
CALTRATE 600 + D .......... 129
CALTRATE WITH VITAMIN
D3 ..................................... 129
calvite p and d ...................... 129
CANCIDAS ........................... 32
candesartan ............................. 55
candesartan-hydrochlorothiazid
............................................ 55
CAPASTAT ........................... 40
CAPRELSA ........................... 18
captopril ................................. 55
captopril-hydrochlorothiazide 56
CARAFATE ........................ 105
CARBAGLU........................ 107
carbamazepine........................ 25
carbidopa ................................ 42
carbidopa-levodopa ................ 42
carbidopa-levodopa-entacapone
............................................ 42
CAREONE THIN LANCET . 81
CARESENS LANCETS ........ 81
CARESENS N TEST STRIPS
............................................ 81
CARIMUNE NF
NANOFILTERED ........... 119
carisoprodol.......................... 137
I-4
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
carteolol .................................. 99
cartia xt ................................... 57
carvedilol ................................ 57
castor oil ....................... 111, 114
CASTOR OIL ...................... 111
CAYSTON ............................. 14
cefaclor ................................... 12
cefadroxil................................ 12
cefazolin ................................. 12
cefazolin in dextrose (iso-os) . 12
CEFAZOLIN IN DEXTROSE
(ISO-OS) ............................ 12
cefdinir ................................... 13
cefditoren pivoxil ................... 13
cefepime ................................. 13
CEFEPIME IN DEXTROSE 5
%......................................... 13
CEFEPIME IN
DEXTROSE,ISO-OSM...... 13
cefotaxime .............................. 13
cefoxitin.................................. 13
cefoxitin in dextrose, iso-osm 13
cefpodoxime ........................... 13
cefprozil .................................. 13
ceftazidime ............................. 13
ceftibuten ................................ 13
ceftriaxone .............................. 13
CEFTRIAXONE .................... 13
ceftriaxone in dextrose,iso-os . 13
CEFTRIAXONE IN
DEXTROSE,ISO-OS ......... 13
cefuroxime axetil .................... 13
cefuroxime sodium ................. 13
celecoxib................................... 6
CELLCEPT INTRAVENOUS
.......................................... 119
CELONTIN ............................ 25
CEO-TWO ........................... 111
cephalexin............................... 13
CEPROTIN (BLUE BAR) ..... 49
CERDELGA......................... 125
CEREZYME .......................... 97
CERVARIX VACCINE (PF)
......................................... 121
cetirizine ................................ 35
cevimeline .............................. 70
CHANTIX ............................... 9
CHANTIX CONTINUING
MONTH BOX ..................... 9
CHANTIX CONTINUING
MONTH PAK...................... 9
CHANTIX STARTING
MONTH BOX ..................... 9
cheratussin ac ......................... 69
child allergy relf(cetirizine) ... 36
child dometuss-da .................. 35
child mucinex chest congestion
........................................... 69
child suppository.................. 111
child triaminic cold-allergy ... 35
child wal-tap cold-allergy ...... 35
children's advil ......................... 6
children's allegra allergy .. 35, 36
children's aller-tec .................. 36
children's calcium gummies 130
children's chest congestion .... 69
CHILDREN'S NASACORT 104
children's non-aspirin ........... 1, 2
children's pain reliever ............. 5
children's pain-fever relief ....... 2
children's pepto .................... 107
children's silapap ..................... 2
children's silfedrine ................ 69
children's soothe .................. 107
children's sudafed .................. 69
children's vitamin d.............. 140
children's wal-dryl allergy ..... 36
children's wal-zyr................... 36
child's benadryl-d allergy-sin 35
chloramphenicol sod succinate
........................................... 11
chlordiazepoxide hcl ................ 9
chlorhexidine gluconate ......... 70
chloroquine phosphate ........... 42
chlorothiazide ......................... 61
chlorothiazide sodium ............ 61
chlorpheniramine maleate ...... 36
chlorpromazine ...................... 44
chlorthalidone ........................ 61
chlorzoxazone ...................... 137
chocolate laxative................. 111
CHOICEDM CLARUS ......... 81
CHOLECALCIFEROL (VIT
D3)(BULK) ...................... 149
cholecalciferol (vitamin d3) 140,
148, 149
cholestyramine (with sugar) ... 61
cholestyramine-aspartame 61, 63
choline,magnesium salicylate .. 6
ciclopirox ............................... 32
ciclopirox-ure-camph-mentheuc ...................................... 32
cilostazol ................................ 51
cimetidine ............................. 105
cimetidine hcl ....................... 105
CIMZIA ............................... 119
CIMZIA POWDER FOR
RECONST ....................... 119
CINRYZE .............................. 50
CIPRODEX.......................... 102
ciprofloxacin .......................... 16
ciprofloxacin hcl ............ 16, 102
ciprofloxacin in 5 % dextrose 16
ciprofloxacin lactate ............... 16
citalopram .............................. 27
citracal + d maximum .......... 129
citrate of magnesia ............... 113
citric acid-sodium citrate...... 129
citroma ................................. 111
CITRUCEL .......................... 111
citrus calcium ....................... 129
clarithromycin ........................ 14
clearasil daily clear(benzoyl) . 71
clearlax ................................. 114
clemastine .............................. 36
CLEVER CHEK LANCETS . 81
I-5
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
CLEVER CHOICE MICRO
TEST STRIP ...................... 82
CLEVER CHOICE PRO ........ 82
CLEVER CHOICE TALK
TEST .................................. 82
CLEVER CHOICE TEST
STRIPS ............................... 82
CLEVER CHOICE VOICE+
TEST .................................. 82
CLEVIPREX .......................... 60
clindamycin hcl ...................... 11
clindamycin in 5 % dextrose .. 11
clindamycin palmitate hcl ...... 11
clindamycin phosphate .... 11, 39,
73
CLINIMIX 5%/D15W
SULFITE FREE ................. 53
CLINIMIX 5%/D25W
SULFITE-FREE ................. 53
CLINIMIX 2.75%/D5W
SULFIT FREE.................... 53
CLINIMIX 4.25%/D10W SULF
FREE .................................. 53
CLINIMIX 4.25%/D5W
SULFIT FREE.................... 53
CLINIMIX 4.25%-D20W
SULF-FREE ....................... 53
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 53
CLINIMIX 5%D20W(SULFITE-FREE) ... 53
CLINIMIX E 2.75%/D10W
SUL FREE.......................... 53
CLINIMIX E 2.75%/D5W
SULF FREE ....................... 53
CLINIMIX E 4.25%/D10W
SUL FREE.......................... 53
CLINIMIX E 4.25%/D25W
SUL FREE.......................... 53
CLINIMIX E 4.25%/D5W
SULF FREE ....................... 53
CLINIMIX E 5%/D15W
SULFIT FREE ................... 53
CLINIMIX E 5%/D20W
SULFIT FREE ................... 53
CLINIMIX E 5%/D25W
SULFIT FREE ................... 53
CLINISOL SF 15 % .............. 53
clobetasol ............................... 74
clobetasol propionate ............. 74
clobetasol-emollient............... 74
clocortolone pivalate.............. 74
clomipramine ......................... 27
clonazepam ............................ 10
clonidine ................................ 55
clonidine hcl .............. 54, 55, 65
clonidine hcl-chlorthalidone .. 55
clopidogrel ............................. 51
clorazepate dipotassium ......... 10
clotrimazole ........................... 32
clotrimazole-7 ........................ 32
clotrimazole-betamethasone .. 32
clozapine ................................ 44
COAGUCHEK LANCETS ... 82
COARTEM ............................ 42
codeine sulfate ......................... 2
codeine-butalbital-asa-caffein . 2
colace ................................... 111
COLACE CLEAR ............... 111
colchicine ............................. 125
colchicine-probenecid .......... 125
cold and cough (diphenhydr-pe)
........................................... 36
cold-allergy-sinus .................. 36
colestipol .......................... 61, 62
colistin (colistimethate na)..... 11
COLOR LANCETS ............... 93
col-rite .................................. 114
COLY-MYCIN S ................ 102
COMBIGAN ....................... 127
COMBIPATCH ................... 116
COMBIVENT RESPIMAT . 136
COMETRIQ .......................... 18
COMFORT EZ LANCETS ... 82
comfort gel extra strength .... 107
COMFORT LANCETS ......... 82
COMPACT SPACE
CHAMBER PLUS ............. 82
COMPLERA .......................... 46
compoz ................................... 36
COMVAX (PF) .................... 121
CONDOMS-PREM
LUBRICATED .................. 66
CONDYLOX ......................... 71
conex ...................................... 36
CONEX .................................. 36
CONTOUR NEXT STRIPS .. 82
CONTOUR TEST STRIPS.... 82
CONTROL G3 ....................... 82
CONTROL TEST .................. 82
COPAXONE ........................ 125
CORLANOR.......................... 58
cortaid .................................... 74
cortisone ............................... 117
cortizone-10 ..................... 74, 75
CORTIZONE-10.................... 75
COSENTYX .......................... 71
COSENTYX (2 SYRINGES) 72
COSENTYX PEN .................. 72
COSENTYX PEN (2 PENS) . 71
COTELLIC ............................ 19
CREON .................................. 97
CRESTOR.............................. 62
critic-aid clear af .................... 32
CRIXIVAN ............................ 46
cromolyn ................ 99, 107, 136
CUBICIN ............................... 11
cyanocobalamin (vitamin b-12)
.......................... 139, 140, 148
cyanocobalamin-fa-pyridoxine
.......................... 141, 142, 147
cyanocobalamin-mecobalamin
.......................................... 144
cyclobenzaprine ................... 137
CYCLOGYL .......................... 99
I-6
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
cyclopentolate......................... 99
cyclophosphamide .................. 19
CYCLOPHOSPHAMIDE ...... 19
CYCLOSET ........................... 29
cyclosporine ......................... 119
cyclosporine modified .......... 119
cyclosporine, modified ......... 119
cyproheptadine ....................... 36
CYRAMZA ............................ 19
cyred ....................................... 67
CYSTADANE ...................... 125
CYSTARAN .......................... 99
cysteine (l-cysteine)................ 53
D
d10 %-0.45 % sodium chloride
.......................................... 130
d10 %-0.9 % sodium chloride 53
d2.5 %-0.45 % sodium chloride
.......................................... 130
d3 dots .................................. 140
d5 % and 0.9 % sodium chloride
.......................................... 130
d5 %-0.45 % sodium chloride
.......................................... 130
dactinomycin .......................... 19
daily fiber (psyllium-sucrose)
.......................................... 111
daily multiple........................ 140
daily multi-vitamin ............... 143
daily prenatal ........................ 140
daily value ............................ 140
daily vitamin ......................... 140
daily vitamin formula ........... 140
dailyhist-1 ............................... 36
daily-vite............................... 140
DAKLINZA ........................... 48
DALIRESP ........................... 136
DALLERGY
(DEXBROMPHENIRAMNPE) ...................................... 36
danazol ................................. 116
dantrolene ............................. 137
dantrolene sodium................ 137
dapsone .................................. 40
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 121
DARAPRIM .......................... 42
DARZALEX .......................... 19
dayhist allergy........................ 36
deblitane................................. 67
debrox .................................. 102
decara ................................... 140
decitabine ............................... 19
deep sea nasal ...................... 100
deferoxamine ....................... 115
delta d3 ................................ 140
DELZICOL .......................... 123
DEMSER ............................... 58
DEPEN TITRATABS ......... 115
DEPO-PROVERA ....... 118, 119
dermafungal ........................... 32
dermarest eczema (hydrocort) 75
desenex .................................. 32
desenex spray......................... 32
desipramine ............................ 27
desmopressin ............... 117, 118
desog-e.estradiol/e.estradiol .. 67
desogestrel-ethinyl estradiol .. 67
desonide ................................. 75
desoximetasone...................... 75
dex4 glucose .......................... 53
dex4 glucose bits ................... 53
dexamethasone..................... 117
dexamethasone sodium
phosphate ................. 104, 117
dexmethylphenidate ............... 65
dextroamphetamine ............... 65
dextroamphetamineamphetamine ...................... 65
dextrose.................................. 54
dextrose 10 % and 0.2 % nacl
......................................... 130
dextrose 10 % in water (d10w)
........................................... 53
dextrose 2.5 % in water(d2.5w)
............................................ 53
dextrose 20 % in water (d20w)
............................................ 53
dextrose 25 % in water (d25w)
............................................ 53
dextrose 40 % in water (d40w)
............................................ 53
dextrose 5 % in ringers .......... 54
dextrose 5 % in water (d5w) .. 54
dextrose 5 %-lactated ringers
.......................................... 130
dextrose 5%-0.2 % sod chloride
.......................................... 130
dextrose 5%-0.3 % sod.chloride
.......................................... 130
dextrose 50 % in water (d50w)
............................................ 54
dextrose 70 % in water (d70w)
............................................ 54
dextrose with sodium chloride
.......................................... 130
diabetic siltussin das-na ......... 69
diabetic tussin ex .................... 69
diamode ................................ 108
DIATRUE PLUS TEST STRIP
............................................ 82
diazepam ................................ 10
diazepam intensol................... 10
diclofenac potassium ................ 6
diclofenac sodium ............ 6, 104
diclofenac-misoprostol ............. 6
dicloxacillin............................ 15
dicyclomine .......................... 108
didanosine .............................. 46
DIFICID ................................. 14
diflunisal .................................. 6
digitek .................................... 58
digoxin ................................... 59
DIGOXIN .............................. 59
dihydroergotamine ................. 39
DILANTIN ............................ 25
I-7
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
diltiazem hcl ..................... 57, 58
dilt-xr ...................................... 58
dimaphen (pe) ......................... 36
dimenhydrinate ....................... 41
dimetapp cold-congestion ...... 36
diotame instydose ................. 108
DIPENTUM ......................... 123
diphenhist ............................... 36
diphenhydramine hcl ........ 36, 37
diphenhydramine-phenylephrine
............................................ 34
diphenoxylate-atropine ......... 108
disopyramide phosphate ......... 56
disulfiram ................................. 9
divalproex ............................... 25
dobutamine ............................. 59
dobutamine in d5w ................. 59
doc-q-lace ............................. 111
docu ...................................... 111
docusate sodium ................... 112
docusol ................................. 112
dok ........................................ 112
donepezil ................................ 27
dopamine ................................ 59
dopamine in 5 % dextrose ...... 59
dorzolamide .......................... 127
dorzolamide-timolol ............. 127
doxazosin................................ 55
doxepin ................................... 28
doxercalciferol ...................... 123
doxorubicin hcl....................... 19
doxorubicin hcl peg-liposomal
............................................ 19
doxorubicin, peg-liposomal .... 19
doxycycline hyclate ................ 17
doxycycline monohydrate ...... 17
dramamine .............................. 41
driminate................................. 41
DRISDOL............................. 141
dristan long lasting ............... 100
dronabinol............................... 41
droperidol ............................. 125
DROPLET LANCETS .......... 82
drospirenone-ethinyl estradiol 67
DROXIA ................................ 19
dry mouth ............................... 71
DUAVEE ............................. 116
dulcolax stool softener (dss) 112
DULERA ............................. 135
duloxetine .............................. 28
DUREZOL........................... 104
dutasteride ............................ 125
dutasteride-tamsulosin ......... 125
d-vi-sol ................................. 141
DYRENIUM .......................... 61
E
e.c. prin .................................... 6
ear drops (carbamide peroxide)
......................................... 103
EASIVENT HOLDING
CHAMBER ....................... 82
EASY CHECK TEST ............ 82
EASY COMFORT LANCETS
........................................... 83
EASY GLUCO G2 ................ 83
EASY PLUS .......................... 83
EASY PLUS II TEST ............ 83
EASY STEP .......................... 83
EASY TALK GLUCOSE TEST
........................................... 83
EASY TOUCH ...................... 83
EASY TOUCH LANCETS ... 83
EASY TOUCH SAFETY
LANCETS ......................... 83
EASY TOUCH TWIST
LANCETS ......................... 83
EASY TRAK GLUCOSE TEST
........................................... 83
EASY TWIST AND CAP
LANCETS ......................... 83
EASYGLUCO PLUS ............ 83
EASYGLUCO TEST ............ 83
EASYMAX ........................... 83
EASYMAX 15 ...................... 83
ECLIPSE SYRINGE ............. 80
econazole................................ 32
econtra ez ............................... 67
ecotrin ...................................... 6
ed chlorped jr ......................... 37
ed-chlorped ............................ 37
EDURANT ............................ 46
EFFIENT................................ 52
ELAPRASE ........................... 98
electrolyte-48 in d5w ........... 130
ELEMENT COMPACT TEST
STRIPS .............................. 84
ELEMENT TEST STRIPS .... 84
ELIDEL.................................. 75
ELIGARD .............................. 19
ELIQUIS ................................ 49
ELITEK.................................. 98
ELLA ..................................... 67
ELMIRON ........................... 125
elon dual defense.................... 32
ELTA TAR ............................ 72
EMBRACE BLOOD
GLUCOSE SYSTEM ........ 84
EMBRACE EVO TEST
STRIPS .............................. 84
EMBRACE LANCETS ......... 84
EMBRACE PRO TEST
STRIPS .............................. 84
EMCYT.................................. 19
EMEND ................................. 41
EMPLICITI ............................ 19
EMSAM ................................. 28
EMTRIVA ............................. 46
enalapril maleate .................... 56
enalaprilat ............................... 56
enalapril-hydrochlorothiazide 56
ENBREL .............................. 119
ENBREL SURECLICK ....... 119
endur-acin .............................. 62
enema ................... 112, 113, 114
enema disposable ......... 111, 112
enemeez................................ 112
I-8
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
enemeez plus ........................ 112
ENGERIX-B (PF) ................ 121
ENGERIX-B PEDIATRIC (PF)
.......................................... 121
enoxaparin .............................. 49
entacapone .............................. 42
entecavir ................................. 48
entre-hist pse .......................... 37
ENTRESTO ........................... 55
ENVARSUS XR .................. 120
ephedrine sulfate .................... 59
epinastine.............................. 100
epinephrine ............................. 60
epinephrine hcl (pf) ................ 59
EPIPEN 2-PAK ...................... 60
EPIPEN JR 2-PAK ................. 60
EPIVIR HBV.......................... 46
eplerenone .............................. 64
EPOGEN .......................... 50, 51
epoprostenol (glycine) .......... 138
epsom salt ............................. 125
EPZICOM .............................. 46
eq gentle ............................... 100
equalactin ............................. 112
ergocalciferol (vitamin d2) .. 141,
147, 148, 149
ERGOCALCIFEROL
(VITAMIN D2) ................ 148
ergoloid................................. 125
ERGOMAR ............................ 39
ERIVEDGE ............................ 19
ERYTHROCIN ...................... 14
erythromycin .................. 14, 103
erythromycin base .................. 14
ERYTHROMYCIN BASE .... 14
erythromycin base-ethanol ..... 73
erythromycin ethylsuccinate .. 14
erythromycin stearate ............. 14
erythromycin with ethanol ..... 73
ESBRIET .............................. 136
escitalopram oxalate ............... 28
esmolol ................................... 57
esomeprazole sodium .......... 105
ESTRACE ........................... 116
estradiol ............................... 116
estradiol valerate .................. 116
estradiol/norethindrone acet 116
estradiol-norethindrone acet 116
estropipate ............................ 116
ethambutol ............................. 40
ethamolin ............................... 60
ethinyl estradiol/drospirenone 67
ethosuximide .......................... 25
ethynodiol d-ethinyl estradiol 67
etodolac .................................... 6
ETOPOPHOS ........................ 19
etoposide ................................ 19
EVENCARE G2 .................... 84
EVENCARE G3 TEST ......... 84
EVENCARE MINI GLUCOSE
TEST STR ......................... 84
EVENCARE TEST ............... 84
EVOLUTION TEST STRIPS 84
EVOTAZ ............................... 46
EXEL SYRINGE ................... 84
EXELON ............................... 27
exemestane............................. 19
EXJADE .............................. 115
ex-lax (sennosides) .............. 112
EXPECTA PRENATAL ..... 141
expectorant............................. 69
EXTAVIA ........................... 125
eye allergy relief ............ 99, 101
eye drops ................................ 99
eye drops (with povidone) ... 100
eye wash ........................ 99, 102
E-Z JECT LANCETS ...... 84, 91
E-Z JECT THIN LANCETS . 91
EZ SMART LANCETS......... 84
EZ SMART PLUS TEST ...... 84
EZ SMART TEST ................. 84
E-Z SPACER ......................... 84
ezfe forte .............................. 141
F
FABRAZYME ....................... 98
fallback solo ........................... 67
famciclovir ............................. 48
famotidine .................... 105, 106
famotidine (pf) ..................... 105
famotidine (pf)-nacl (iso-os)105
FANAPT ................................ 44
FANTASY ............................. 67
FARESTON ........................... 19
FARYDAK ............................ 19
FASLODEX ........................... 19
fa-vit bcomp and c-se-min aa-zn
.......................................... 140
fe fumarate-doss-fa-bcomp and
c ........................................ 143
fe fumarate-fa-vit bcomp and c
.......................................... 140
fe fumarate-vit c-b12-if-fa ... 141
fe fumarate-vit c-b12-stomc. 142
felbamate ................................ 25
felodipine ............................... 60
FEMRING............................ 116
fenofibrate .............................. 62
fenofibrate micronized ........... 62
fenofibrate nanocrystallized ... 62
fenofibric acid ........................ 62
fenofibric acid (choline) ......... 62
fenoprofen ................................ 6
fentanyl .................................... 2
fentanyl citrate ......................... 2
feosol .................................... 141
FEOSOL .............................. 141
ferotrinsic ............................. 141
ferretts .................................. 141
FERRETTS CARBONYL
IRON ................................ 141
FERRIPROX........................ 115
ferrocite ................................ 141
ferrous fumarate ................... 141
ferrous fumarate-folic acid ... 142
ferrous gluconate .. 141, 142, 143
I-9
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
ferrous sulfate ............... 140, 142
FETZIMA............................... 28
feverall ...................................... 2
FEVERALL ............................. 2
fexofenadine ........................... 37
fiber (calcium polycarbophil)
.......................................... 112
fiber laxative (methylcellulo)
.......................................... 114
fiber laxative (psyllium husk)
.................................. 111, 114
fiber smooth.......................... 114
fiber therapy ................. 111, 112
fiber therapy (psyllium/sugar)
.......................................... 112
fiber therapy sugar free ........ 113
fiber-lax ................................ 112
FIFTY50 SAFETY SEAL
LANCETS .......................... 85
FIFTY50 TEST STRIP .......... 85
finasteride ............................. 125
FINE 30 UNIVERSAL
LANCETS .......................... 85
FINGERSTIX LANCETS ..... 85
FIRAZYR ............................... 60
FIRST CHOICE LANCETS
THIN .................................. 77
fish oil......................... 62, 63, 64
fish oil extra strength .............. 62
fish oil omega 3-6-9 ............... 62
fish oil pearls .......................... 62
flanax antacid ....................... 108
FLEBOGAMMA DIF .......... 120
flecainide ................................ 56
FLECTOR ................................ 6
fleet glycerin (adult) ............. 112
fleet glycerin (child) ............. 112
FLEXBUMIN 25 % ............... 52
FLEXBUMIN 5 % ................. 52
FLEXICHAMBER ................. 85
FLONASE ALLERGY RELIEF
.......................................... 104
FLOVENT DISKUS............ 135
FLOVENT HFA .................. 135
floxuridine ............................. 19
fluconazole............................. 32
fluconazole in dextrose(iso-o) 33
fluconazole in nacl (iso-osm) 33
flucytosine ............................. 33
fludrocortisone ..................... 117
flumazenil .............................. 65
flunisolide ............................ 104
fluocinonide ........................... 75
fluocinonide-emollient base .. 75
fluorometholone................... 104
FLUOROPLEX ..................... 72
fluorouracil ................ 18, 20, 72
fluoxetine ............................... 28
fluoxymesterone .................. 116
fluphenazine decanoate.......... 44
fluphenazine hcl ..................... 44
flurbiprofen .............................. 6
flurbiprofen sodium ............. 104
flutamide ................................ 20
fluticasone ...................... 75, 104
fluvoxamine ........................... 28
foaming acne face wash ......... 72
foaming antacid ........... 108, 110
foaming antacid extra strength
......................................... 109
folic acid .............................. 142
folic acid-vit b6-vit b12 ....... 142
folic acid-vitamin b comp w-c
......................... 140, 141, 142
fomepizole ........................... 125
fondaparinux .......................... 49
for sty relief ......................... 100
FORA D10 ............................. 85
FORA D15G .......................... 85
FORA D20 ............................. 85
FORA D40-G31 TEST STRIPS
........................................... 85
FORA G20 ............................. 85
FORA G30A .......................... 85
FORA GD50 TEST STRIPS . 85
FORA TEST STRIP .............. 85
FORA TN'G VOICE TEST
STRIPS .............................. 85
FORA V10 ............................. 85
FORA V12 GLUCOSE.......... 85
FORA V20 ............................. 85
FORA V30A .......................... 85
FORACARE GD20 ............... 85
FORACARE GD40 ............... 85
FORACARE LANCETS ....... 85
FORTEO .............................. 123
FORTICAL .......................... 123
FORTISCARE GLUCOSE
TEST STRIPS .................... 85
foscarnet ................................. 48
fosinopril ................................ 56
fosinopril-hydrochlorothiazide
............................................ 56
fosphenytoin ........................... 25
FREAMINE HBC 6.9 %........ 54
FREAMINE III 10 % ............. 54
FREESTYLE INSULINX ..... 85
FREESTYLE INSULINX TEST
STRIPS .............................. 85
FREESTYLE LANCETS ...... 85
FREESTYLE LITE STRIPS . 86
FREESTYLE PRECISION
NEO STRIPS ..................... 86
FREESTYLE TEST ............... 86
FREESTYLE UNISTIK 2 ..... 86
fungi cure ............................... 33
FUNGI-NAIL ........................ 33
fungoid-d ................................ 33
furosemide.............................. 61
FUSILEV ............................. 125
FUZEON ................................ 46
FYCOMPA ............................ 25
G
G-4 TEST ............................... 86
gabapentin .............................. 25
GABITRIL ............................. 25
I-10
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
galantamine ............................ 27
GAMASTAN S/D ................ 120
GAMMAGARD LIQUID .... 120
GAMMAPLEX .................... 120
ganciclovir sodium ................. 49
GARDASIL (PF).................. 121
GARDASIL 9 (PF)............... 121
gas relief ............................... 105
gas relief extra strength ........ 105
gas-x extra strength .............. 105
gas-x ultra-strength ............... 105
gatifloxacin ........................... 103
GATTEX 30-VIAL .............. 108
GATTEX ONE-VIAL .......... 108
GAUZE PAD ....................... 125
GAVISCON EXTRA
STRENGTH ..................... 108
GAZYVA ............................... 20
GE100 BLOOD GLUCOSE
TEST STRIP ...................... 86
gelusil antacid and anti-gas .. 108
gemfibrozil ............................. 62
GENOTROPIN .................... 118
GENOTROPIN MINIQUICK
.......................................... 118
GENSTRIP TEST STRIP ...... 86
gentamicin ................ 10, 73, 103
gentamicin in nacl (iso-osm) .. 10
gentamicin sulfate ................ 103
gentamicin sulfate (ped) (pf) .. 10
gentamicin sulfate (pf) ........... 10
GENTEAL GEL ................... 100
gentlelax ............................... 112
GENULTIMATE TEST ......... 86
GENVOYA ............................ 46
GEODON ............................... 44
gildess 1/20 (21) ..................... 67
gildess 24 fe............................ 67
gildess fe 1/20 (28) ................. 67
GILENYA ............................ 125
GILOTRIF .............................. 20
GLEEVEC .............................. 20
glimepiride ............................. 30
glipizide ........................... 30, 31
glipizide-metformin ............... 31
GLUCAGEN HYPOKIT ..... 125
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 125
gluco burst ............................. 54
GLUCO NAVII TEST STRIP86
GLUCOCARD 01 SENSOR
PLUS ................................. 86
GLUCOCARD EXPRESSION
........................................... 86
GLUCOCARD SHINE TEST
STRIPS .............................. 86
GLUCOCARD VITAL TEST
STRIPS .............................. 86
GLUCOCOM GLUCOSE ..... 86
GLUCOCOM LANCETS ..... 86
glucose ................................... 54
glucose bits ............................ 53
glucose gel ............................. 54
GLUCOSOURCE .................. 86
glutose 15 ............................... 54
glyburide ................................ 31
glyburide micronized ............. 31
glyburide-metformin .............. 31
glycerin (adult) ............ 111, 112
glycerin (child) ............ 111, 114
glycolax ............................... 112
glycopyrrolate ...................... 108
glydo ........................................ 8
GLYXAMBI .......................... 29
GM100 ................................... 92
GMATE LANCETS .............. 86
GMATE TEST STRIPS ........ 86
granisetron (pf) ...................... 41
granisetron hcl ....................... 41
GRANIX ................................ 51
griseofulvin microsize ........... 33
guanfacine ........................ 55, 65
guanidine ............................. 125
GYNOL II.............................. 67
H
halobetasol propionate ........... 75
haloperidol ............................. 44
haloperidol decanoate ............ 44
haloperidol lactate .................. 44
HARVONI ............................. 48
HAVRIX (PF) ...................... 121
HEALTHPRO TEST STRIPS 86
HEALTHY ACCENTS
UNILET LANCET ............ 87
healthylax ............................. 112
heartburn antacid .................. 108
hemocyte .............................. 142
heparin (porcine) .................... 50
heparin (porcine) in 5 % dex .. 50
heparin (porcine) in nacl (pf) . 50
heparin sodium,porcine-pf ..... 50
heparin(porcine) in 0.45% nacl
............................................ 50
heparin, porcine (pf)............... 50
HEPATAMINE 8% ............... 54
HEPATASOL 8 % ................. 54
HERCEPTIN.......................... 20
HETLIOZ ............................. 137
HEXALEN ............................. 20
histex pe ................................. 37
homatropine hbr ................... 100
HONGO CURA SPRAY ....... 33
household lice control ............ 77
HUMIRA ............................. 120
HUMIRA PEN ..................... 120
HUMIRA PEN CROHN'S-UCHS START ....................... 120
HUMULIN R U-500
(CONCENTRATED) ......... 30
hydralazine ............................. 60
hydrochlorothiazide ............... 61
hydrocil instant..................... 112
hydrocodone-acetaminophen ... 2
hydrocodone-ibuprofen ............ 2
hydrocortisone.......... 75, 76, 117
hydrocortisone acet-aloe vera 75
I-11
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
hydrocortisone acetate ............ 75
hydrocortisone acetate-aloe .... 75
hydrocortisone acetate-urea.... 75
hydrocortisone butyrate .... 75, 76
hydrocortisone butyr-emollient
............................................ 76
hydrocortisone sod succinate 117
hydrocortisone valerate .......... 76
hydromorphone .................... 2, 3
hydromorphone (pf) ................. 2
hydroskin ................................ 75
hydroxocobalamin ................ 142
hydroxychloroquine ............... 42
hydroxyurea ............................ 20
hydroxyzine hcl .................... 125
hydroxyzine pamoate ........... 125
HYPERLYTE CR ................ 130
HYPERRAB S/D (PF) ......... 120
HYQVIA .............................. 120
I
ibandronate ................... 123, 124
IBRANCE .............................. 20
ibuprofen .............................. 6, 7
ibuprofen jr strength ................. 6
ICAR .................................... 143
ichthammol ............................. 72
ICLUSIG ................................ 20
ifosfamide ............................... 20
ifosfamide-mesna ................... 20
ILARIS (PF) ......................... 120
ILEVRO ............................... 104
IMBRUVICA ......................... 20
imipenem-cilastatin ................ 14
imipramine hcl........................ 28
imipramine pamoate ............... 28
imiquimod .............................. 72
IMLYGIC ............................... 20
imodium a-d ......................... 108
IMOGAM RABIES-HT (PF)
.......................................... 120
IMOVAX RABIES VACCINE
(PF) ................................... 121
INCONTROL SUPER THIN
LANCETS ......................... 87
INCONTROL ULTRA THIN
LANCETS ......................... 87
INCRELEX ......................... 118
indapamide............................. 61
indomethacin ........................... 7
indomethacin sodium ............... 7
INFANRIX (DTAP) (PF) .... 121
infant's ibuprofen ..................... 7
INFINITY TEST STRIPS ..... 87
INJECT EASE LANCETS .... 87
INLYTA ................................ 20
INSPIRACHAMBER ............ 87
INSPIRACHAMBER WITH
MASK-MED ..................... 87
INSULIN SYRINGE-NEEDLE
U-100 ................................. 87
INTELENCE ......................... 46
INTRALIPID ......................... 54
INTRON A ............................ 48
INVACARE LANCETS........ 87
INVANZ ................................ 14
INVEGA ................................ 44
INVEGA SUSTENNA .... 44, 45
INVEGA TRINZA ................ 45
INVIRASE............................. 46
INVOKAMET ....................... 29
INVOKANA .......................... 29
inzo antifungal ....................... 33
IONOSOL-B IN D5W ......... 130
IONOSOL-MB IN D5W ..... 131
IPOL .................................... 121
ipratropium bromide ............ 100
IPRIVASK ............................. 50
irbesartan ............................... 55
irbesartan-hydrochlorothiazide
........................................... 55
IRESSA ................................. 20
iron ag and fum-c-fa-mv cmb11ca-t ................................... 141
iron ag-c-b12-ca-suc.acid-stom
.......................................... 143
iron aspgly and ps-c-b12-fa-casuc .................................... 141
iron aspgly-c-b12-fa-ca-th-suc
.......................................... 143
iron bg and ps-vit c-b12-fa-ca
thr ..................................... 147
iron fum and ag-c-b12-fa-casucc .................................. 143
iron fum and p-fa-vit b and c
no.9................................... 142
iron fum and polysac#1-fa-mv
no.18................................. 146
iron fum and ps cmp-fa-vit c-b3
.......................................... 142
iron fumarate-vit c-vit b12-fa
.......................... 141, 142, 147
iron high potency ................. 140
iron ps cmplx-vit b12-fa...... 141,
143, 144
iron pyrophos-b12-fa-niac-b-6
.......................................... 148
iron, carbonyl-fa-c-b-6-b12-zn
.......................................... 140
iron,carb-dss-b12if-fa-mv-mn
.......................................... 147
iron-fa-vitamin b comp w-c-min
.......................... 141, 142, 146
ISENTRESS ........................... 47
ISOLYTE M IN 5 %
DEXTROSE ..................... 131
ISOLYTE-H IN 5 %
DEXTROSE ..................... 131
ISOLYTE-P IN 5 %
DEXTROSE ..................... 131
ISOLYTE-S ......................... 131
isoniazid ................................. 40
isosorbide dinitrate ................. 64
isosorbide mononitrate ........... 64
isotretinoin ............................. 72
isradipine ................................ 60
I-12
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
itraconazole ............................ 33
ivermectin ............................... 42
IXEMPRA ........................ 20, 21
IXIARO (PF) ........................ 121
J
JAKAFI .................................. 21
JALYN ................................. 125
jantoven .................................. 50
JANUMET ............................. 29
JANUMET XR....................... 29
JANUVIA............................... 29
JARDIANCE .......................... 29
JENTADUETO ...................... 29
juleber ..................................... 67
junel fe 24 ............................... 67
JUXTAPID ............................. 62
K
KABIVEN .............................. 54
KALETRA ............................. 47
KALYDECO ........................ 136
KANUMA .............................. 98
kaopectate (bismuth subsalicy)
.......................................... 108
kaopectate ex str (bismuth ss)
.......................................... 108
KEDBUMIN .......................... 52
ketoconazole ........................... 33
KETO-DIASTIX .................. 138
KETONE CARE .................. 138
KETONE URINE TEST ...... 138
ketoprofen................................. 7
ketorolac ........................... 7, 104
KETOSTIX .......................... 138
ketotifen fumarate ................ 100
KEVEYIS ............................. 125
KEYTRUDA .......................... 21
kimidess (28) .......................... 67
KIMONO CONDOMS(NONLUBRICATED) ................. 67
KIMONO MAXX CONDOMS
............................................ 67
KIMONO MICROTHIN AQUA
LUBE CON ....................... 67
KIMONO MICROTHIN
CONDOMS ....................... 67
KIMONO MICROTHIN
LARGE CONDOMS ......... 67
KIMONO TEXTURED
CONDOMS ....................... 67
KINERET ............................ 120
KINNEY BRAND LANCETS
........................................... 87
KINRIX (PF) ....................... 121
klor-con 10 ........................... 131
klor-con m10........................ 131
klor-con m15........................ 131
klor-con m20........................ 131
klor-con sprinkle .................. 131
konsyl (sugar) ...................... 112
konsyl fiber .......................... 112
konsyl sugar-free ................. 112
KORLYM .............................. 29
kpn ....................................... 143
KRYSTEXXA ....................... 98
KUVAN ................................. 98
KYNAMRO........................... 62
KYPROLIS ............................ 21
L
l norgest/e.estradiol-e.estrad .. 67
labetalol ................................. 57
LACRISERT ....................... 100
LACTATED RINGERS ...... 123
lactulose ............................... 108
LAMICTAL........................... 25
LAMISIL (AEROSOL) ......... 33
lamisil af ................................ 33
LAMISIL AT ......................... 33
lamivudine ............................. 47
lamivudine-zidovudine .......... 47
lamotrigine ............................. 25
LANCETS .... 80, 81, 82, 84, 85,
90, 91, 93
LANCETS, SUPER THIN .... 87
LANCETS,THIN ....... 87, 88, 94
LANCETS,ULTRA THIN .... 87,
97
LANOXIN ............................. 60
lansoprazole ................. 105, 106
LANTUS ................................ 30
LANTUS SOLOSTAR .......... 30
larin 24 fe ............................... 67
larin fe 1/20 (28) .................... 67
latanoprost ............................ 127
LATUDA ............................... 45
laxative (glycerin-pediatric) . 114
laxative (sennosides) ... 111, 112,
114
laxative peg 3350 ................. 114
laxative pills regular ............. 112
LAZANDA .............................. 3
leflunomide .......................... 120
LEMTRADA ....................... 126
LENVIMA ............................. 21
LETAIRIS ............................ 138
letrozole.................................. 21
leucovorin calcium ............... 126
LEUKERAN .......................... 21
LEUKINE .............................. 51
leuprolide ............................... 21
levetiracetam .................... 25, 26
levobunolol .......................... 127
levocarnitine ......................... 126
levocarnitine (with sugar) .... 126
levocetirizine .......................... 37
levofloxacin.................... 16, 103
levofloxacin in d5w................ 16
levomefolate calcium ........... 143
levonorgestrel ................... 67, 68
levonorgestrel-ethin estradiol. 68
levonorgestrel-ethinyl estrad . 67,
68
levothyroxine ....................... 119
LEXIVA ................................. 47
LIBERTY TEST .................... 87
lice cream rinse ...................... 77
I-13
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
lice egg remover ..................... 77
lice killing............................... 77
lice solution ............................ 77
lice treatment .......................... 77
lice treatment (permethrin) ..... 77
licide spray ........................... 126
lidocaine ................................... 8
lidocaine (pf) ...................... 8, 56
lidocaine hcl ............................. 8
lidocaine in 5 % dextrose (pf) 56
lidocaine-prilocaine .................. 8
linezolid .................................. 11
LINZESS .............................. 108
liothyronine .......................... 119
lipase-protease-amylase ......... 98
LIPOSYN II ........................... 54
LIPOSYN III .......................... 54
liquid b 12............................. 143
liquid calcium with vitamin d
.......................................... 131
liquitears ............................... 100
liquituss gg ............................. 69
lisinopril ................................. 56
lisinopril-hydrochlorothiazide 56
LITE TOUCH LANCETS ..... 87
LITEAIRE MDI CHAMBER 88
lithium carbonate .................... 65
lithium citrate ......................... 65
little remedies ....................... 100
l-norgest-eth estr/ethin estra ... 68
lohist - d.................................. 37
lohist-peb ................................ 37
lomustine ................................ 21
LONSURF.............................. 21
loperamide ............ 107, 108, 110
loratadine ................................ 37
lorazepam ............................... 10
losartan ................................... 55
losartan-hydrochlorothiazide.. 55
LOTEMAX .......................... 104
LOTRONEX ........................ 108
lovastatin ................................ 62
loxapine succinate.................. 45
lubricant dry eye relief ........... 99
lubricant eye ........................ 100
lubricant eye (polyv alcohol) 101
lubricant eye (propyl glycol) 100
lubricant eye drops......... 99, 100
lubricant redness reliever ..... 100
lubricating drops .................... 99
lubrifresh pm........................ 100
LUMIGAN .......................... 127
LUPRON DEPOT ................. 21
LUPRON DEPOT (3 MONTH)
........................................... 21
LUPRON DEPOT (4 MONTH)
........................................... 21
LUPRON DEPOT (6 MONTH)
........................................... 21
LUPRON DEPOT-PED ...... 118
LUPRON DEPOT-PED (3
MONTH) ......................... 118
LYNPARZA .......................... 21
LYRICA ................................ 26
LYSODREN .......................... 21
M
maalox advanced ................. 108
MAALOX MAXIMUM
STRENGTH .................... 109
mag 64 ................................. 131
MAG-AL ............................. 109
magbid er ............................. 131
mag-delay ............................ 131
MAGELLAN SYRINGE ...... 88
mag-g ................................... 131
magnesium ........... 130, 131, 134
magnesium chloride ............. 131
MAGNESIUM CHLORIDE 131
magnesium citrate ........ 111, 113
MAGNESIUM CITRATE ... 131
magnesium gluconate .......... 131
magnesium oxide ......... 109, 110
MAGNESIUM OXIDE ....... 109
magnesium sulf in 0.45% nacl
.......................................... 131
magnesium sulfate ............... 132
magnesium sulfate in d5w ... 131
magnesium sulfate in water . 132
MAGONATE ....................... 132
MAGONATE (MAGNESIUM
CARB) ............................. 132
MAGOX .............................. 109
malathion................................ 77
mapap (acetaminophen) ........... 3
mapap extra strength ................ 3
maprotiline ............................. 28
mar-cof cg .............................. 69
MARPLAN ............................ 28
masanti double strength ....... 109
MATULANE ......................... 21
matzim la................................ 58
maxepa ................................... 63
MAXIMA .............................. 88
maximum redness relief ......... 99
meclizine ................................ 41
MEDI-LANCE LANCETS .... 88
MEDISENSE THIN LANCETS
............................................ 88
MEDLANCE PLUS LANCETS
............................................ 88
medroxyprogesterone ........... 119
MEDSAVER SYRINGE ....... 80
mefenamic acid ........................ 7
mefloquine ............................. 42
MEFOXIN IN DEXTROSE
(ISO-OSM) ........................ 13
MEGACE ES ....................... 119
megestrol ........................ 21, 119
MEKINIST ............................ 21
meloxicam ................................ 7
memantine .............................. 27
MENACTRA (PF) ............... 121
MENEST.............................. 117
MENHIBRIX (PF) ............... 121
I-14
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
MENOMUNE - A/C/Y/W-135
(PF) ................................... 121
men's multi-vitamin .............. 140
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 121
MENVEO MENA
COMPONENT (PF) ......... 121
MENVEO MENCYW-135
COMPNT (PF) ................. 121
MEPHYTON........................ 143
mercaptopurine ....................... 21
meropenem ............................. 14
mesna.................................... 126
MESNEX ............................. 126
MESTINON ......................... 126
MESTINON TIMESPAN .... 126
metaproterenol ...................... 136
metaxall ................................ 137
metaxalone ........................... 137
metformin ......................... 29, 30
methadone ................................ 3
methadone hcl .......................... 3
methazolamide ..................... 128
methenamine hippurate .......... 11
methenamine mandelate ......... 11
methimazole ......................... 119
methocarbamol ..................... 137
methotrexate sodium ........ 21, 22
methotrexate sodium (pf) ....... 22
methoxsalen rapid .................. 72
methscopolamine.................. 109
methyclothiazide .................... 61
methylphenidate ............... 65, 66
methylprednisolone .............. 117
methylprednisolone acetate .. 117
methylprednisolone sodium succ
.......................................... 117
metipranolol ......................... 128
metoclopramide hcl .............. 109
metolazone ............................. 61
metoprolol succinate .............. 57
metoprolol ta-hydrochlorothiaz
........................................... 57
metoprolol tartrate ................. 57
metronidazole ............ 11, 39, 73
metronidazole in nacl (iso-os) 11
mexiletine .............................. 56
mg217 psoriasis ..................... 72
MIACALCIN....................... 124
mi-acid ................................. 109
mi-acid gas relief ................. 105
micatin ................................... 33
miconazole 7 .......................... 33
miconazole nitrate............ 32, 33
miconazole-3 prefil,cream,wipe
........................................... 34
MICRO BLOOD GLUCOSE 91
MICRO THIN LANCETS..... 88
MICROCHAMBER .............. 88
MICRODOT BLOOD
GLUCOSE SYSTEM ........ 88
MICRODOT XTRA BLOOD
GLUCOSE ......................... 88
micro-guard ........................... 33
MICROLET LANCET .......... 88
MICROSPACER ................... 88
midodrine ............................... 55
milk of magnesia ................. 113
MILK OF MAGNESIA
CONCENTRATED ......... 113
milrinone................................ 60
milrinone in 5 % dextrose ...... 60
mineral oil ............................ 113
mineral oil laxative .............. 113
minitran .................................. 64
minocycline ........................... 17
minoxidil................................ 64
mintox .................................. 109
mintox maximum strength ... 109
mintox plus .......................... 109
MIRCERA ............................. 51
mirtazapine ............................ 28
misoprostol .......................... 106
mitoxantrone .......................... 22
M-M-R II (PF) ..................... 121
moexipril ................................ 56
moexipril-hydrochlorothiazide
............................................ 56
molindone .............................. 45
mometasone ........................... 76
MONAGHAN Z STAT
CHAMBER-MD MSK ...... 88
MONISTAT 3 ........................ 33
monistat 7 ............................... 33
MONOJECT LUER-LOCK TIP
............................................ 88
MONOJECT PHARMACY
TRAY LUER ..................... 88
MONOJECT SAFETY LUER
LOCK TIP .......................... 88
MONOJECT SAFETY
SYRINGES ........................ 92
MONOJECT SYRINGE .. 88, 89
MONOJECT TB .................... 89
MONOJECT TB LUER LOK 88
MONOJECT TB REGULAR
LUER TIP .......................... 89
MONOJECT TB SAFETY
SYRINGE .......................... 89
MONOJECT TUBERCULIN
SYRINGE .............. 88, 89, 95
MONOLET LANCETS ......... 89
MONOLET THIN LANCETS
............................................ 89
montelukast .......................... 135
morphine .............................. 3, 4
MORPHINE ............................. 4
morphine concentrate ............... 3
morphine in dextrose 5 % ........ 3
morrhuate sodium ................ 126
motion sickness ...................... 40
motion sickness (meclizine) ... 41
MOVANTIK ........................ 109
MOVIPREP ......................... 113
MOXEZA ............................ 103
I-15
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
moxifloxacin........................... 16
MOZOBIL .............................. 51
mucinex sinus-max ............... 100
MULTAQ ............................... 56
multi antibiotic plus................ 73
multiple vitamins .................. 143
multivit, iron, min #5, fa ...... 146
multivit, min cmb#20-iron-fa
.......................................... 139
multivitamin ................. 143, 146
multivitamins with min no.7-fa
.......................................... 147
mupirocin ............................... 73
mupirocin calcium .................. 73
murine ear wax removal system
.......................................... 103
muro 128 .............................. 100
myco nail a ............................. 33
mycophenolate mofetil ......... 120
mycophenolate sodium ......... 120
MYGLUCOHEALTH ............ 89
MYGLUCOHEALTH
LANCETS .......................... 89
MYOZYME ........................... 98
MYRBETRIQ ...................... 115
mytab gas.............................. 105
mytab gas maximum strength
.......................................... 105
N
nabumetone .............................. 7
nadolol .................................... 57
nafcillin................................... 15
NAGLAZYME....................... 98
naloxone ................................... 9
naltrexone ................................. 9
naltrexone hcl ........................... 9
NAMENDA XR ..................... 27
NAMZARIC........................... 27
naphazoline........................... 100
naproxen ................................... 7
naproxen sodium .................. 6, 7
naratriptan............................... 39
NASACORT ........................ 104
nasal allergy ......................... 104
nasal and sinus decongestant . 70
nasal decongestant ................. 37
nasal decongestant (oxymetazl)
......................................... 100
nasal decongestant (pe) ........ 100
NASCOBAL ........................ 143
NATACYN .......................... 103
nateglinide ............................. 30
NATPARA .......................... 124
natural balance ..................... 100
natural calcium .................... 132
natural daily fiber................. 111
natural fiber laxative therapy 113
natural tears (pf)..................... 99
natural vegetable .................. 113
nature's tears (hypromellose) 101
NEBUPENT .......................... 42
nefazodone ............................. 28
neomy sulf-bacitrac zn-poly-hc
......................................... 103
neomycin ............................... 10
neomycin-bacitracin-poly-hc103
neomycin-bacitracin-polymyxin
......................................... 103
neomycin-polymyxin b gu ..... 73
neomycin-polymyxin bdexameth .......................... 103
neomycin-polymyxingramicidin ........................ 103
neomycin-polymyxin-hc ...... 103
neo-polycin .......................... 103
neosporin + pain relief ........... 73
neosporin anti-itch ................. 76
neo-synephrine 12 h spr (oxym)
......................................... 101
NEPHRAMINE 5.4 % ........... 54
NEULASTA .......................... 51
NEUMEGA ........................... 51
NEUPOGEN .......................... 51
NEUPRO ............................... 42
NEUTEK 2TEK TEST STRIPS
............................................ 89
NEVANAC .......................... 104
nevirapine ............................... 47
NEXAVAR ............................ 22
NEXIUM 24HR ................... 106
niacin ...................................... 63
niacin (inositol niacinate) ....... 63
niacin flush free................ 62, 63
niacinamide .................... 63, 144
nicardipine.............................. 60
nicorelief .................................. 9
nicorette.................................... 9
nicotine..................................... 9
nicotine (polacrilex) ................. 9
NICOTROL ............................. 9
nifedipine ......................... 60, 61
nighttime relief eye ................ 99
NILANDRON ........................ 22
ninjacof-xg ............................. 70
NINLARO.............................. 22
NITRO-BID ........................... 64
nitrofurantoin macrocrystal .... 11
nitrofurantoin monohyd/m-cryst
............................................ 12
nitroglycerin ..................... 64, 65
nitroglycerin in 5 % dextrose . 64
NITROSTAT ......................... 65
NIX CREME RINSE ............. 77
NIZORAL A-D ...................... 34
nohist-lq ................................. 37
non-aspirin extra strength ........ 5
non-aspirin jr strength .............. 2
NORDITROPIN FLEXPRO 118
norelgestromin/ethin.estradiol 68
norepinephrine bitartrate ........ 60
norethindrone ......................... 68
norethindrone (contraceptive) 68
norethindrone acetate ........... 119
norethindrone ac-eth estradiol 68
norethindrone-e.estradiol-iron 68
norethindrone-ethinyl estrad .. 68
I-16
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
norethindrone-mestranol ........ 68
norgestimate-ethinyl estradiol 68
norgestrel-ethinyl estradiol..... 68
NORMOSOL-M IN 5 %
DEXTROSE ..................... 132
NORMOSOL-R PH 7.4 ....... 132
nortemp..................................... 4
NORTHERA .......................... 55
nortriptyline ............................ 28
NORVIR................................. 47
nose drops ............................. 102
NOVA MAX GLUCOSE TEST
............................................ 89
NOVA SAFETY LANCETS . 89
NOVA SUREFLEX LANCETS
............................................ 89
NOVOLIN 70/30.................... 30
NOVOLIN N .......................... 30
NOVOLIN R .......................... 30
NOVOLOG ............................ 30
NOVOLOG FLEXPEN.......... 30
NOVOLOG MIX 70-30 ......... 30
NOVOLOG MIX 70-30
FLEXPEN .......................... 30
NOVOLOG PENFILL ........... 30
NOXAFIL .............................. 34
NUCALA ............................. 136
NUCYNTA .............................. 4
NUCYNTA ER ........................ 4
NUEDEXTA .......................... 66
NULOJIX ............................. 120
NUTRESTORE .................... 109
NUTRILIPID ......................... 54
NUTRILYTE ....................... 132
NUTRILYTE II .................... 132
NUVARING........................... 68
NUVIGIL ............................. 137
nystatin ................................... 34
NYSTATIN (BULK) ............. 34
nystatin-triamcinolone ............ 34
nyt-time sleep ......................... 38
O
obagi nu-derm tolereen .......... 76
ocean nasal ........................... 101
OCTAGAM ......................... 120
octreotide acetate ................. 118
ODOMZO .............................. 22
OFEV ................................... 137
ofloxacin ........................ 16, 103
olanzapine .............................. 45
olanzapine-fluoxetine ............ 28
olopatadine........................... 101
OLYSIO................................. 48
om-3-ca carb-d3-fa-mv cmb 13
......................................... 139
omega 3 fish oil ..................... 62
omega-3 acid ethyl esters ...... 63
omega-3 fatty acids ................ 62
omega-3 fatty acids-fish oil .. 62,
63
omeprazole........................... 106
omeprazole magnesium ....... 106
omeprazole-sodium bicarbonate
......................................... 106
ON CALL EXPRESS TEST
STRIP ................................ 89
ON CALL LANCET ............. 89
ON CALL PLUS LANCET .. 89
ON CALL PLUS TEST STRIP
........................................... 89
ON CALL VIVID TEST STRIP
........................................... 89
ONCASPAR .......................... 22
once daily............................. 144
ondansetron ............................ 41
ondansetron hcl ...................... 41
ondansetron hcl (pf) ............... 41
ONE A DAY WOMEN'S
PRENATAL DHA ........... 144
one daily ...................... 144, 146
one daily essential 141, 142, 144
one daily multivitamin ......... 144
one daily prenatal................. 146
one-a-day essential ............... 144
ONE-A-DAY WOMEN'S
PRENATAL 1 .................. 144
one-per-day omega-3 ............. 63
ONETOUCH DELICA
LANCETS.................... 89, 90
ONETOUCH FINEPOINT
LANCETS.......................... 90
ONETOUCH ULTRA TEST . 90
ONETOUCH ULTRASOFT
LANCETS.......................... 90
ONETOUCH VERIO ............ 90
ONFI ...................................... 10
ON-THE-GO LANCETS....... 93
opcicon one-step .................... 68
OPDIVO ................................ 22
OPSUMIT ............................ 138
OPTICHAMBER ADULT
MASK-LARGE ................. 90
OPTICHAMBER DIAMOND
VHC ................................... 90
opti-clear .............................. 101
optimal d3 ............................ 144
OPTIUM EZ .......................... 90
OPTIUM TEST ...................... 90
OPTUMRX ............................ 90
oral saline laxative ............... 113
oralyte .................................. 132
ORAP ..................................... 45
ORENCIA ............................ 120
ORENCIA (WITH MALTOSE)
.......................................... 120
ORENITRAM ...................... 138
ORFADIN .............................. 98
ORKAMBI ........................... 137
OTEZLA .............................. 126
OTEZLA STARTER ........... 126
OTREXUP (PF) ................... 126
oxacillin.................................. 15
oxacillin in dextrose(iso-osm) 15
oxandrolone.......................... 116
oxcarbazepine ........................ 26
I-17
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
OXTELLAR XR .................... 26
oxybutynin chloride.............. 115
oxycodone ................................ 4
oxycodone hcl-acetaminophen . 4
oxycodone hcl-aspirin .............. 4
oxycodone-acetaminophen ....... 4
oxycodone-aspirin .................... 4
OXYCONTIN .......................... 4
oxymorphone........................ 4, 5
oysco 500/d .......................... 132
oysco-500 ............................. 132
oyster shell calcium 500 ....... 132
oyster shell calcium-vit d3 ... 132
oystercal-d ............................ 132
P
pain relief.................................. 5
pain reliever extra strength ....... 5
pain reliever jr strength ............ 5
paliperidone ............................ 45
panoxyl ................................... 72
panoxyl-4................................ 72
PANRETIN ............................ 72
pantoprazole ......................... 106
papaverine .............................. 60
paricalcitol ............................ 124
paromomycin .......................... 42
paroxetine hcl ......................... 28
PASER ................................... 40
PATADAY ........................... 101
PAXIL .................................... 28
pedi m.vit no.17 with fluoride
.......................................... 143
PEDIA-LAX......................... 108
pedia-lax stool softener ........ 112
PEDIALYTE ........................ 132
PEDIARIX (PF) ................... 121
pediatric electrolyte ..... 130, 132,
134
pediatric freezer pops ........... 134
PEDIAVENT ......................... 37
PEDVAX HIB (PF) .............. 121
peg 3350-electrolytes ........... 113
PEG 3350-GRX ................... 113
peg 3350-na sulf,bicarb,cl-kcl
......................................... 113
PEGANONE .......................... 26
PEGASYS ............................. 48
PEGASYS PROCLICK ......... 48
peg-electrolyte soln.............. 113
PEGINTRON......................... 48
PEN NEEDLE, DIABETIC .. 90
penicillin g pot in dextrose .... 16
penicillin g potassium ............ 16
penicillin g procaine .............. 16
penicillin v potassium ............ 16
PENTACEL (PF) ................. 121
PENTACEL ACTHIB
COMPONENT (PF) ........ 122
PENTAM ............................... 42
pentoxifylline ......................... 52
pep-t-med ............................. 109
perdiem overnight relief ...... 113
PERFECT IRON ................. 144
PERIKABIVEN..................... 54
perindopril erbumine ............. 56
permethrin .............................. 77
perphenazine .......................... 45
perphenazine-amitriptyline .... 28
perry prenatal ....................... 144
persa-gel................................. 72
pharbetol .................................. 5
PHARMACIST CHOICE...... 90
pharmacist favorite multi-vit 144
phenelzine .............................. 28
phenobarbital ......................... 26
phenobarbital sodium ............ 26
phentermine ........................... 66
phenylephrine hcl .......... 55, 101
phenylephrine-chlorpheniramine
........................................... 37
phenylhistine dh ..................... 70
phenytoin ............................... 26
phenytoin sodium .................. 26
phenytoin sodium extended ... 26
phillips.................................. 109
phillips liqui-gels ................. 113
PHILLIPS MILK OF
MAGNESIA ............ 109, 113
PHOSLYRA ........................ 115
phosphate laxative ................ 113
PHOSPHOLINE IODIDE ... 128
phosphorus #1 ...................... 132
phytonadione ........................ 149
phytonadione (vitamin k1) ... 149
PICATO ................................. 72
pilocarpine hcl ................ 71, 128
pimozide................................. 45
pindolol .................................. 57
pink bismuth......................... 109
pin-x ....................................... 42
pioglitazone ............................ 30
pioglitazone-glimepiride ........ 30
pioglitazone-metformin.......... 30
piperacillin-tazobactam .......... 16
piroxicam ................................. 7
PLASBUMIN 25 % ............... 52
PLASBUMIN 5 % ................. 52
PLASMA-LYTE 148 ........... 132
PLASMA-LYTE A .............. 132
PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 132
PLEGRIDY .......................... 126
POCKET CHAMBER ........... 90
podactin .................................. 34
podofilox ................................ 72
podophyllum resin ................. 72
polyethylene glycol 3350 ..... 113
POLYETHYLENE GLYCOL
3350.................................. 113
POLYETHYLENE GLYCOL
3350(BULK) .................... 126
polymyxin b sulfate................ 12
polymyxin b sulf-trimethoprim
.......................................... 103
polysporin .............................. 73
poly-vita (iron) ..................... 144
I-18
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
poly-vitamin with iron .......... 144
POMALYST .......................... 22
PORTRAZZA ........................ 22
potassium acetate.................. 132
potassium bicarb and chloride
.......................................... 132
potassium bicarb-citric acid . 132
potassium bicarbonate-cit ac 132
potassium chlorid-d5-0.45%nacl
.......................................... 133
potassium chloride........ 133, 134
potassium chloride in 0.9%nacl
.......................................... 133
potassium chloride in 5 % dex
.......................................... 133
potassium chloride in lr-d5 ... 133
potassium chloride-0.45 % nacl
.......................................... 133
potassium chloride-d5-0.2%nacl
.......................................... 133
potassium chloride-d5-0.3%nacl
.......................................... 133
potassium chloride-d5-0.9%nacl
.......................................... 133
potassium citrate ................... 133
potassium citrate-citric acid . 134
potassium hydroxide .............. 72
potassium phosphate m-/d-basic
.......................................... 134
POTIGA ................................. 26
PRADAXA............................. 50
PRALUENT PEN .................. 63
PRALUENT SYRINGE ......... 63
pramipexole ............................ 42
PRANDIMET......................... 30
pravastatin .............................. 63
prazosin .................................. 55
PRECISION PCX PLUS TEST
............................................ 90
PRECISION PCX TEST ........ 90
PRECISION POINT OF CARE
TEST .................................. 90
PRECISION Q-I-D TEST ..... 90
PRECISION XTRA TEST .... 90
prednicarbate ......................... 76
prednisolone acetate ............ 104
prednisolone sodium phosphate
................................. 104, 117
prednisone ............................ 117
PREMARIN......................... 117
PREMASOL 10 %................. 54
PREMASOL 6 %................... 54
PREMIUM V10 ..................... 90
PREMPHASE...................... 117
PREMPRO........................... 117
prenatal ........................ 145, 146
PRENATAL ........................ 145
prenatal + dha ...................... 144
PRENATAL
DHA+COMPLETE
PRENATAL .................... 144
prenatal formula ........... 144, 145
prenatal gummy ................... 140
PRENATAL MULTI + DHA
......................................... 145
prenatal multi +dha(algal oil)
......................................... 145
prenatal multivitamins ......... 145
prenatal one.......................... 145
prenatal one daily................. 145
prenatal tablet .............. 145, 146
prenatal vit no.90-iron fum-fa
......................................... 145
prenatal vit#96-ferrous fum-fa
......................................... 145
prenatal vitamin with minerals
................................. 140, 145
prenatal vitamins.. 141, 144, 145
prenatal vit-iron fumarate-fa 145
prenatal with dha-folic acid . 145
prenatal-1 ............................. 145
preparation h hydrocortisone . 76
PRESSURE ACTIVATED
LANCETS ......................... 90
PREZCOBIX ......................... 47
PREZISTA ............................. 47
PRIFTIN ................................ 40
PRIMAQUINE ...................... 42
PRIMEAIRE .......................... 90
primidone ............................... 26
PRISTIQ ................................ 28
PRIVIGEN ........................... 120
PROAIR HFA ...................... 136
PROAIR RESPICLICK ....... 136
probenecid ............................ 126
procainamide .......................... 56
PROCALAMINE 3% ............ 54
PROCHAMBER .................... 90
prochlorperazine .................... 41
prochlorperazine edisylate ..... 41
prochlorperazine maleate ....... 41
PROCRIT ............................... 51
PROCYSBI .......................... 126
PRODIGY LANCETS ........... 91
PRODIGY NO CODING ...... 90
PRODIGY TWIST TOP
LANCET ............................ 91
PROFE FORTE ................... 145
progesterone ......................... 119
progesterone micronized ...... 119
PROGLYCEM ....................... 65
PROGRAF ........................... 120
PROLASTIN-C.................... 137
PROLENSA ......................... 104
PROLEUKIN ......................... 22
PROLIA ............................... 124
PROMACTA ......................... 51
promethazine .................... 37, 41
promethazine hcl .................... 41
promethazine-codeine ............ 70
promethazine-dm ................... 70
promethazine-phenylephcodeine ............................... 70
promolaxin ........................... 113
propafenone............................ 56
propantheline.......................... 24
I-19
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
proparacaine ......................... 101
proparacaine hcl ................... 101
proparacaine-fluorescein sod 101
propranolol ............................. 57
propranolol-hydrochlorothiazid
............................................ 57
propylthiouracil .................... 119
PROQUAD (PF) .................. 122
PROSOL 20 % ....................... 54
protamine................................ 51
protriptyline ............................ 28
pseudoephedrine hcl ............... 70
PULMOZYME....................... 98
puralube ................................ 101
pure and gentle eye ............... 101
purelax .................................. 111
PURIXAN .............................. 22
PUSH BUTTON SAFETY
LANCETS .......................... 91
pyrazinamide .......................... 40
pyridostigmine bromide ....... 126
pyridoxine............................. 145
pyrilamine-phenylephrine 37, 38
Q
q-dryl ...................................... 38
q-pap ......................................... 5
q-pap extra strength .................. 5
q-tapp...................................... 38
q-tussin ................................... 70
QUADRACEL (PF) ............. 122
quetiapine ............................... 45
QUILLIVANT XR ................. 66
quinapril ................................. 56
quinapril-hydrochlorothiazide 56
quinidine gluconate ................ 56
quinidine sulfate ..................... 56
quinine sulfate ........................ 42
QUINTET AC ........................ 91
QUINTET GLUCOSE TEST
STRIPS ............................... 91
QVAR................................... 135
R
RABAVERT (PF)................ 122
raloxifene ............................. 117
ramipril .................................. 56
RANEXA............................... 60
ranitidine hcl ........................ 106
RAPAMUNE ....................... 120
RASUVO (PF) ..................... 126
RAVICTI ............................. 110
REBIF (WITH ALBUMIN) 126
REBIF REBIDOSE ............. 126
REBIF TITRATION PACK 126
RECOMBIVAX HB (PF) .... 122
recort plus .............................. 76
redness relief .................. 99, 101
redness reliever lubricant 99, 101
reese's pinworm medicine...... 42
REFRESH TEARS .............. 101
REFUAH PLUS .................... 91
reguloid ................................ 114
RELADOR PAK ..................... 8
relcof c ................................... 70
RELENZA DISKHALER ..... 48
RELIAMED LANCET .......... 91
RELIAMED SAFETY SEAL
LANCETS ......................... 91
RELION CONFIRM-MICRO 91
RELION PRIME TEST STRIPS
........................................... 91
RELION THIN LANCETS ... 92
RELION ULTRA THIN PLUS
LANCETS ......................... 92
RELISTOR .......................... 110
remedy phytoplex antifungal . 34
REMICADE ........................ 126
REMODULIN ..................... 138
RENAGEL........................... 115
RENVELA........................... 115
repaglinide ............................. 30
repaglinide-metformin ........... 30
REPATHA SURECLICK...... 64
REPATHA SYRINGE .......... 64
RESCRIPTOR ....................... 47
RESTASIS ........................... 104
retaine cmc ........................... 101
retaine hpmc ......................... 101
retaine pm............................. 101
RETROVIR............................ 47
REVEAL TEST STRIP ......... 92
REVLIMID ............................ 22
REXULTI .............................. 45
REYATAZ ............................. 47
ribavirin .................................. 49
riboflavin (vitamin b2) ......... 146
rid complete lice elim kit ....... 77
rid lice killing ......................... 77
RIDAURA ........................... 120
rifabutin .................................. 40
rifampin .................................. 40
RIFATER ............................... 40
ri-gel ii .................................. 110
right step prenatal vitamins .. 146
RIGHTEST GL300 LANCETS
............................................ 92
RIGHTEST GS250S TEST
STRIPS .............................. 92
RIGHTEST GS260 TEST
STRIPS .............................. 92
RIGHTEST GS550 TEST
STRIPS .............................. 92
riginic ................................... 110
riluzole ................................... 66
rimantadine ............................ 48
ri-mox ................................... 110
ri-mox plus ........................... 110
ringers .......................... 123, 134
risedronate ............................ 124
RISPERDAL CONSTA ......... 45
risperidone........................ 45, 46
RITEFLO AEROCHAMBER 92
ritifed ...................................... 38
RITUXAN.............................. 22
rivastigmine tartrate ............... 27
rizatriptan ............................... 39
I-20
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
robafen .................................... 70
ropinirole .......................... 42, 43
ROTARIX ............................ 122
ROTATEQ VACCINE ........ 122
ROZEREM ........................... 137
RYMED
(DEXCHLORPHENIRAMIN
E-PE) .................................. 38
S
SABRIL.................................. 26
SAFESNAP SYRINGE ......... 92
SAFETY LANCETS .............. 92
SAFETY SEAL LANCETS ... 92
SAFETY-LET LANCETS ..... 92
SAIZEN ................................ 118
SAIZEN CLICK.EASY ....... 118
saline mist............................. 101
saline nasal mist ..................... 99
salsalate .................................... 7
SANDOSTATIN LAR DEPOT
.......................................... 118
sani-supp (adult) ................... 114
sani-supp (infant).................. 114
SANTYL ................................ 72
SAPHRIS (BLACK CHERRY)
............................................ 46
SAVELLA .............................. 66
scalp itch-dandruff relief ........ 72
scot-tussin expectorant ........... 70
sea soft nasal mist ................. 102
sea-omega 30 .......................... 64
selegiline hcl ........................... 43
selenium sulfide...................... 73
SELZENTRY ......................... 47
senexon ................................. 114
senna ............................. 113, 114
senna lax ............................... 114
senna laxative ............... 111, 114
senna-extra ........................... 111
SENSIPAR ........................... 126
SEREVENT DISKUS .......... 136
SEROSTIM .......................... 118
sertraline ................................ 28
setlakin ................................... 68
SIGNIFOR ........................... 126
silace .................................... 114
siladryl sa ............................... 38
silapap ...................................... 5
sildenafil .............................. 138
SILENOR .............................. 28
siltussin sa .............................. 70
silver nitrate ........................... 73
silver nitrate applicators......... 73
silver sulfadiazine .................. 73
SIMBRINZA ....................... 128
simethicone .......................... 105
SIMILAC PRENATAL ....... 146
simply sleep ........................... 38
SIMPONI ............................. 127
SIMPONI ARIA .................. 127
simvastatin ............................. 64
SINGLE-LET ........................ 93
sinus and allergy(pseudoephed)
........................................... 38
sinus nighttime....................... 38
sirolimus .............................. 120
SIRTURO .............................. 40
SMART SENSE LANCETS . 93
SMART SENSE TEST STRIPS
........................................... 93
SMARTEST LANCET.......... 93
SMARTEST TEST ................ 93
smoothlax............................. 114
sochlor ................................. 102
sodium acetate ..................... 134
sodium bicarbonate ...... 110, 134
sodium chloride .. 102, 123, 134,
137
sodium chloride 0.45 % ....... 134
sodium chloride 0.9 % ......... 134
sodium chloride 3 % ............ 134
sodium chloride 5 % ............ 134
sodium chloride-nahco3-kcl-peg
......................................... 114
sodium citrate-citric acid...... 134
sodium fluoride .................... 146
sodium lactate ...................... 134
sodium phosphate................. 134
sodium polystyrene sulfonate
.................................. 108, 110
sodium thiosulfate ................ 115
sod-pot-k cit-sod cit-cit acid 134
SOFT TOUCH LANCETS .... 93
SOLTAMOX ......................... 22
SOLU-CORTEF (PF) .......... 117
SOLUS V2 LANCETS .......... 93
SOLUS V2 TEST STRIPS .... 93
SOMATULINE DEPOT ...... 118
SOMAVERT........................ 118
soothe (bismuth subsalicylate)
.......................................... 110
soothe regular strength ......... 110
sorbitol ................................. 123
sorbitol-mannitol .................. 123
sotalol ..................................... 57
sotalol hcl ............................... 57
SOVALDI .............................. 48
SPACE CHAMBER PLUS ... 93
SPIRIVA RESPIMAT ......... 136
SPIRIVA WITH
HANDIHALER ............... 136
spironolactone ........................ 64
spironolacton-hydrochlorothiaz
............................................ 64
SPRYCEL .............................. 22
st joseph aspirin........................ 8
st. joseph aspirin....................... 8
stavudine ................................ 47
STELARA............................ 127
STERILANCE TL ................. 93
sterile eye drops ................... 101
STERILE PADS .................. 127
STIOLTO RESPIMAT .......... 24
STIVARGA ........................... 22
stomach relief ....................... 110
stool softener ........................ 111
I-21
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
stop lice .................................. 77
STRATTERA ......................... 66
STRENSIQ ............................. 98
streptomycin ........................... 10
STRIBILD .............................. 47
STRIVERDI RESPIMAT .... 136
STROVITE ONE ................. 146
STUART ONE ..................... 146
sucralfate .............................. 106
sudogest .................................. 70
sudogest sinus and allergy ...... 38
sulfacetamide sodium ........... 103
sulfacetamide sodium (acne) .. 73
sulfacetamide-prednisolone.. 103
sulfadiazine............................. 16
sulfamethoxazole-trimethoprim
...................................... 16, 17
sulfasalazine ........................... 17
sulfatrim ................................. 17
sulfazine ................................. 17
sulfazine ec ............................. 17
sulindac..................................... 8
sumatriptan ............................. 39
sumatriptan succinate ............. 40
super multivitamin................ 146
SUPER THIN LANCETS 93, 94
SUPER TWIN EPA-DHA ..... 64
suphedrin ................................ 70
support-500........................... 147
suppository adult .................. 111
SUPPRELIN LA .................. 118
SUPRAX ................................ 13
supreme antacid .................... 110
SURE COMFORT LANCETS
............................................ 94
SURE-LANCE ....................... 94
SURE-LANCE ULTRA THIN
............................................ 94
SURE-TEST EASYPLUS MINI
............................................ 94
SURE-TOUCH LANCET ...... 94
SURGUARD2 SAFETY ........ 94
SURMONTIL ........................ 29
SUSTIVA .............................. 47
SUTENT ................................ 22
SYLATRON .......................... 48
SYLVANT............................. 22
SYMLINPEN 120 ................. 30
SYMLINPEN 60 ................... 30
SYNAGIS .............................. 48
SYNAREL ........................... 127
SYNERCID ........................... 12
SYNJARDY .......................... 30
SYNRIBO .............................. 22
SYPRINE............................. 115
SYRINGE (DISPOSABLE) . 80,
84
SYRINGE 3CC/25GX1 ......... 84
SYSTANE BALANCE ....... 102
systane nighttime ................. 102
T
tab-a-vite .............................. 147
TABLOID .............................. 22
tacrolimus ...................... 76, 120
tactinal ..................................... 5
tactinal extra strength............... 5
TAFINLAR ........................... 23
TAGRISSO ............................ 23
TAMIFLU ............................. 48
tamoxifen ............................... 23
tamsulosin ............................ 115
TARCEVA ............................ 23
TARGRETIN......................... 23
tarina fe 1/20 (28) .................. 68
TASIGNA .............................. 23
TAZORAC ............................ 76
taztia xt .................................. 58
TD GOLD TEST STRIP ....... 94
tears again ............................ 102
tears naturale free (pf).......... 102
tears naturale pm .................. 102
TECFIDERA ....................... 127
TECHLITE LANCETS ......... 94
TECHNIVIE .......................... 48
TEFLARO.............................. 14
TELCARE LANCETS........... 94
TELCARE TEST STRIPS ..... 94
telmisartan .............................. 55
telmisartan-hydrochlorothiazid
............................................ 55
TEMODAR ............................ 23
TENIVAC (PF) .................... 122
terazosin ............................... 115
terbinafine hcl ........................ 34
terbutaline ............................ 136
terconazole ............................. 39
TERUMO SYRINGE ............ 94
TEST N'GO TEST ................. 94
testosterone .......................... 116
testosterone cypionate .......... 116
testosterone enanthate .......... 116
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 122
TETANUS,DIPHTHERIA TOX
PED(PF) ........................... 122
TETANUS-DIPHTHERIA
TOXOIDS-TD ................. 122
tetrabenazine .......................... 66
tetracaine hcl (pf) ................. 102
tetracycline ............................. 17
THALOMID ........................ 127
the magic bullet .................... 112
theophylline.......................... 136
theophylline anhydrous ........ 136
theophylline in dextrose 5 % 136
thera-d .................................. 147
THERANATAL ................... 147
THERANATAL ONE ......... 147
THERANATAL OVAVITE 147
THERANATAL PLUS ........ 147
therapeutic vitamins/minerals
.......................................... 147
thiamine hcl (vitamin b1) ..... 147
THIN LANCETS ................... 93
thioridazine ............................ 46
I-22
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
thiotepa ................................... 23
thiothixene .............................. 46
tiagabine ................................. 26
TICE BCG ............................ 121
TIKOSYN .............................. 57
timolol maleate ............... 57, 128
tioconazole ............................. 32
TIVICAY ............................... 47
tizanidine .............................. 137
TOBI PODHALER ................ 10
TOBRADEX ........................ 103
TOBRADEX ST .................. 103
tobramycin ............................ 103
tobramycin in 0.225 % nacl ... 10
tobramycin in 0.9 % nacl........ 11
tobramycin sulfate .................. 11
tobramycin-dexamethasone.. 104
TOLAK .................................. 72
tolazamide .............................. 31
tolbutamide ............................. 31
tolmetin..................................... 8
tolnaftate ................................. 34
tolterodine............................. 115
TOPCARE UNIVERSAL1
LANCET ............................ 94
topiramate ............................... 26
toposar .................................... 23
torsemide ................................ 61
TOUJEO SOLOSTAR ........... 30
TOVIAZ ............................... 115
TPN ELECTROLYTES ....... 134
TPN ELECTROLYTES II ... 134
TRACLEER ......................... 139
TRADJENTA ......................... 30
tramadol .................................... 5
tramadol-acetaminophen .......... 5
trandolapril ............................. 56
tranexamic acid ...................... 51
TRANSDERM-SCOP ............ 41
tranylcypromine ..................... 29
TRAVASOL 10 % ................. 54
TRAVATAN Z .................... 128
travel sickness (meclizine)..... 41
travoprost (benzalkonium) ... 128
trazodone ............................... 29
TREANDA ............................ 23
TRECATOR .......................... 40
TRELSTAR ........................... 23
tretinoin .................................. 76
tretinoin (chemotherapy) ....... 23
tretinoin microspheres ........... 76
TREXALL ............................. 23
triacting orange ...................... 38
triamcinolone acetonide .. 71, 76,
117
TRIAMINIC COLD AND
COUGHNT(PE) ................ 38
triamterene-hydrochlorothiazid
........................................... 61
TRIBENZOR ......................... 55
tri-buffered aspirin ................... 7
trifluoperazine ........................ 46
trifluridine ............................ 104
trihexyphenidyl ...................... 43
tri-lo-estarylla ........................ 68
tri-lo-marzia ........................... 68
tri-lo-sprintec ......................... 69
trimethoprim .......................... 12
trimipramine .......................... 29
triple paste af ......................... 34
TRIUMEQ ............................. 47
tri-vi-sol ............................... 147
tri-vita .................................. 147
tri-vitamin ............................ 147
TROKENDI XR .................... 26
TROPHAMINE 10 % ............ 54
TROPHAMINE 6% ............... 54
trospium ............................... 115
TRUE METRIX GLUCOSE
TEST STRIP ...................... 94
TRUEPLUS LANCETS .. 94, 95
TRUETEST TEST STRIPS... 95
TRUETRACK SMART
SYSTEM ........................... 91
TRUETRACK TEST ............. 95
TRULICITY .......................... 30
TRUMENBA ....................... 122
TRUSTEX LATEX CONDOM
............................................ 69
TRUSTEX LUBRICATED
CONDOMS........................ 69
TRUSTEX NON-LUB
CONDOMS........................ 69
TRUSTEX-RIA
LUB/SPERMICIDE ........... 69
TRUSTEX-RIA NON-LUB
CONDOMS........................ 69
TRUVADA ............................ 47
trymine cg .............................. 70
TUBERCULIN SYR
1CC/26GX5/8 .................... 84
TUBERCULIN SYRINGE ... 84,
95
TUBERCULIN-ALLERGY
SYRINGES ........................ 84
TUDORZA PRESSAIR ....... 136
TWINRIX (PF) .................... 122
TYBOST .............................. 127
TYGACIL .............................. 17
TYKERB................................ 23
TYPHIM VI ......................... 122
TYSABRI ............................ 120
TYVASO ............................. 139
TYVASO REFILL KIT ....... 139
TYVASO STARTER KIT ... 139
TYZEKA................................ 49
U
ULORIC ............................... 127
ULTILET BASIC LANCETS 95
ULTILET CLASSIC
LANCETS.......................... 95
ULTILET LANCETS ............ 95
ULTILET SAFETY LANCETS
............................................ 95
ULTIMA TEST STRIPS . 92, 95
ultra strength antacid ............ 107
I-23
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
ULTRA THIN II LANCETS . 96
ULTRA THIN LANCETS .... 82,
95, 96
ULTRA THIN PLUS
LANCETS .......................... 92
ULTRA TLC LANCETS ....... 96
ULTRALANCE LANCETS .. 96
ULTRA-THIN II LANCETS . 96
ULTRATRAK ........................ 96
ULTRATRAK ULTIMATE .. 96
UNILET COMFORTOUCH
LANCET ............................ 96
UNILET EXCELITE II
LANCET ............................ 96
UNILET EXCELITE LANCET
............................................ 96
UNILET GP LANCET........... 96
UNILET LANCET ........... 93, 96
UNILET SUPER THIN
LANCETS .......................... 91
unisom sleepgels .................... 38
UNISTIK 3 COMFORT
LANCET ............................ 96
UNISTIK 3 EXTRA LANCET
............................................ 97
UNISTIK 3 GENTLE ............ 97
UNISTIK 3 LANCETS .......... 97
UNISTIK 3 NORMAL
LANCET ............................ 97
UNISTIK CZT LANCET....... 97
UNISTIK SAFETY ................ 97
UNISTRIP1 TEST STRIP ..... 97
UNITUXIN ............................ 23
UNIVERSAL 1 LANCETS .. 86,
87, 97
UPTRAVI............................. 139
ursodiol ................................. 110
V
VAGIFEM ............................ 117
VAGINAL CONTRACEPTIVE
FOAM ................................ 69
vagistat-1 ................................ 34
vagistat-3 ............................... 34
valacyclovir ........................... 49
VALCHLOR ......................... 72
valganciclovir ........................ 49
valproate sodium.................... 26
valproic acid .......................... 26
valproic acid (as sodium salt) 26
valsartan ................................. 55
valsartan-hydrochlorothiazide 55
VALSTAR ............................. 23
valu-tapp decongestant .......... 70
vancomycin ............................ 12
vancomycin in d5w ................ 12
VANISHPOINT SYRINGE .. 97
VAQTA (PF) ....................... 122
VARIVAX (PF) ................... 122
VASCEPA ............................. 64
vazobid-pd ............................. 38
VELCADE............................. 23
venlafaxine............................. 29
VENTOLIN HFA ................ 136
verapamil ............................... 58
VERSACLOZ ........................ 46
VGO 40.................................. 97
vicks qlearquil(oxymetazoline)
......................................... 102
vicks sinex 12-hour.............. 102
VICTOZA 3-PAK ................. 30
VIDEX 2 GRAM PEDIATRIC
........................................... 47
VIDEX 4 GRAM PEDIATRIC
........................................... 47
vienva..................................... 69
VIGAMOX .......................... 104
VIIBRYD............................... 29
VIMIZIM ............................... 98
VIMPAT .......................... 26, 27
vinacal b ............................... 147
vinorelbine ............................. 24
VIRACEPT ............................ 47
VIRAMUNE XR ................... 47
VIRAZOLE ........................... 49
VIREAD ................................ 47
virtussin ac ............................. 70
VISINE MAX REDNESS
RELIEF ............................ 102
VISINE TOTALITY ............ 102
visine-a ................................. 102
vit b cmplx 3-fa-vit c-biotin 144,
146
vit b cmplx no3-fa-c-biot-zinc
.......................................... 143
vit b12-lmefolate ca-vit b6-b2
.......................................... 143
vitacel (with lutein) .............. 148
vitamin a............................... 148
vitamin b-1 ........................... 148
vitamin b12-folic acid .......... 139
vitamin b-2 ........................... 148
vitamin b-6 ........................... 148
vitamin c............................... 148
vitamin d3 ............ 146, 148, 149
VITAMIN D3 ...................... 148
vitamin e....................... 146, 149
vitamin e (dl, acetate) ........... 149
vitamin e natural blend......... 147
vitamins b1,b2,b3,b5, and b6139
vitamins for hair ................... 149
VITA-RESPA ...................... 149
VITEKTA .............................. 47
VOLTAREN ............................ 8
voriconazole ........................... 34
VORTEX HOLDING
CHAMBER ........................ 97
VORTEX VHC FROG MASKCHILD ............................... 97
VOTRIENT............................ 24
VPRIV.................................... 98
vp-vite rx .............................. 149
W
wal-act d cold and allergy ...... 38
wal-dram ................................ 41
wal-dryl allergy ...................... 38
wal-fex allergy ................. 38, 39
I-24
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
wal-finate ................................ 39
wal-finate-d ............................ 39
wal-itin ................................... 39
wal-mucil fiber ..................... 114
wal-phed ........................... 39, 70
wal-phed pe sinus and allergy 39
wal-profen ................................ 8
wal-sleep z .............................. 39
wal-som (diphenhydramine) .. 39
wal-tap .................................... 39
wal-zan 75 ............................ 106
wal-zyr (cetirizine) ................. 39
wal-zyr (ketotifen) ................ 102
warfarin .................................. 50
water for irrigation, sterile.... 123
WAVESENSE JAZZ ............. 97
WAVESENSE PRESTO ........ 97
wee care ................................ 149
WIDE-SEAL DIAPHRAGM 70
............................................ 69
women's prenatal + dha ........ 140
X
XALKORI .............................. 24
XARELTO ............................. 50
XELJANZ ............................ 127
XENAZINE ........................... 66
XIFAXAN ............................. 12
XOLAIR .............................. 137
XTANDI ................................ 24
xylon 10 ................................... 5
XYREM ............................... 137
Y
YERVOY............................... 24
YF-VAX (PF) ...................... 122
YONDELIS ........................... 24
Z
zafirlukast ............................ 135
zaleplon ................................ 137
ZARXIO ................................ 51
ZAVESCA ............................. 98
zeasorb (miconazole) ............. 34
ZELBORAF........................... 24
ZEMPLAR........................... 124
ZENPEP................................. 98
zephrex-d ............................... 70
ZETIA .................................... 64
ZIAGEN ................................ 47
zidovudine ............................. 47
ziprasidone hcl ....................... 46
ZIRGAN .............................. 104
ZOLADEX ............................. 24
zoledronic acid ..................... 124
zoledronic acid-mannitol-water
.......................................... 124
ZOLINZA .............................. 24
zolmitriptan ............................ 40
zolpidem............................... 138
ZOMETA ............................. 124
zonisamide ............................. 27
ZORTRESS.......................... 120
ZOSTAVAX (PF) ................ 122
ZOVIRAX.............................. 72
z-sleep .................................... 37
ZUBSOLV ............................... 9
ZYDELIG .............................. 24
ZYKADIA ............................. 24
ZYLET ................................. 104
ZYPREXA RELPREVV ....... 46
zyrtec itchy eye drops (keto) 102
ZYTIGA ................................. 24
ZYVOX.................................. 12
I-25
SCFHP Cal MediConnect Formulary
Formulary ID: 16510.000, Version: 10
Effective: March 01, 2016
Punong-tanggapan
210 E Hacienda Ave
Campbell, CA 95008-6617
1-877-723-4795 - Walang Bayad
1-800-735-2929 - TTY
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Formulary ID: 16510.000, Version Number: 10
Last Updated: 02/29/2016
© 2016, Santa Clara Family Health Plan. All rights reserved.
SH7015A
H7890_11015T_Final_3 Accepted