I. INTRODUCTION
1. This Preferred Drug List (PDL) was updated as of 10/31/2010. It is subject to change without notice
and will be updated at least quarterly (the next update will be October 2010). If you choose to print out/photocopy the
PDL, please refer to the web site for the most up to date version before making prescribing decisions. You will need
Acrobat Reader to download the PDL.
You may wish to bookmark the URL below, for both the CCHP PDL and the “Medication Prior Authorization
Request” form:
http://cchealth.org/health_plan/pdl.php
2. To search this PDL: in addition to referring to the Table of Contents and Index, use “Control F” or the binoculars
icon, and type in the drug name.
3. For Prior Authorization forms please call 925-957-7260 (option 2). The Medication Prior Authorization form is
also available from the website address listed in #1 above.
The PDL is a listing of “Preferred” first line drugs. If you have clinical reasons to choose a second line
agent, please provide complete clinical information to expedite the processing of your "Medication Prior
Authorization Request."
4. Disclaimer: This is only a listing of preferred medications. Listing in the PDL is not a guarantee of
payment. There are many different levels of coverage and members should refer to their “Evidence of Coverage”
(EOC) for information about co-pays, and exclusions to coverage for their specific situation. Most Over the Counter
medication is not covered (except where specified). Medication Supplies and Devices are not included in this list.
II. OVERVIEW
1. All CCHP members and recipients of County health programs are subject to the PDL protocols.
2. A PDA-enabled version is available at the ePocrates web site:
http://www.epocrates.com (choose < ePocrates Rx Formulary >). The CCHP electronic formulary available from
this site is updated quarterly.
3. Urgent PAs are processed within 4 hours if the clinical information is complete. For an emergency medication
during off hours pharmacists can give up to a 5 day supply (at their discretion) before receiving the PA approval.
We will monitor “Urgent” requests to make sure they are appropriately urgent.
4. Routine PAs are processed as quickly as possible. The usual reason for a delay is lack of adequate clinical
information. We will call, page or fax you if we receive a prescription for a “Non-preferred drug” without adequate
explanation. If you do not provide “medical necessity” for a non-preferred agent, or if we do not hear back from
you within five business days, the Rx may be denied.
5. C1=Code 1 These are non-preferred drugs with criteria that can be satisfied without a PA. Some criteria such as
“tried and failed <name> Rx” can be written on the prescription. Other criteria, such as “under 12 years old” , can
be identified by the pharmacist.
6. If the patient is a member of the Basic Health Care(BHC) or Health Care Initiative(HCI) Groups, they must use
any of the following 12 Walgreens pharmacies to fill their prescriptions:
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Walgreens Store #4724
3416 Deer Valley Road
Antioch, CA 94531
Walgreens Store #6871
4520 Balfour
Brentwood, CA 94513
Walgreens Store #9978
6570 Lone Tree Way
Brentwood, CA 94513
Walgreens Store #3164
1800 Concord Ave
Concord, CA 94520
Walgreens Store #3770
11565 San Pablo Ave
El Cerrito, CA 94530
Walgreens Store #6101
3655 Alhambra Ave
Martinez, CA 94553
Walgreens Store #7376
2901 Railroad Ave
Pittsburg, CA 94565
Walgreens Store #5864
721 Gregory Lane
Pleasant Hill, CA 94523
Walgreens Store #2506
1150 MacDonald Ave
Richmond, CA 94801
Walgreens Store #11861
2455 San Pablo Ave Dam Rd
San Pablo, CA 94806
Walgreens Store #2435
13751 San Pablo Ave
San Pablo, CA 94806
Walgreens Store #4026
2900 Main Street
Walnut Creek, CA 94596
925-978-8000 (PHONE)
925-978-4209 (FAX)
925-513-4055 (PHONE)
925-516-9544 (FAX)
925-240-6043 (PHONE)
925-240-6134 (FAX)
925-674-9477 (PHONE)
925-674-9258 (FAX)
510-234-9300 (PHONE)
510-234-8986 (FAX)
925-372-0337 (PHONE)
925-372-6018 (FAX)
925-439-8575 (PHONE)
925-439-1558 (FAX)
925-944-1592 (PHONE)
925-944-5976 (FAX)
510-236-5748 (PHONE)
510-236-5267 (FAX)
510-235-0810 (PHONE)
510- - (FAX)
510-233-9467 (PHONE)
510-- (FAX)
925-933-0307 (PHONE)
925-933-0559(FAX)
7. Please note that our contracted Pharmacy Network consists of only Walgreens and Rite Aid with regards to
national pharmacy chains, no other chains are contracted. Some independent pharmacies that were already in
our network prior to July 1st, 2009 do remain. A complete list is available from CCHP upon request.
8. Thank you for your assistance in helping us to provide cost effective, high quality health care!
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Preferred Drug List (PDL)
Table of Contents
Page Number
ANTINEOPLASTICS........................................................................................................................................... 7
ENDOCRINE SYSTEM MEDICATIONS ............................................................................................................ 8

Androgens ................................................................................................................................................... 8

Glucocorticoids ........................................................................................................................................... 8

Mineralocorticoids ...................................................................................................................................... 8

Diabetic Medications .................................................................................................................................. 8

Medications to Treat Hypoglycemia ........................................................................................................... 9

Medications to Treat Of Osteoporosis ........................................................................................................ 9

Miscellaneous Bisphosphonates ................................................................................................................. 9

Estrogens..................................................................................................................................................... 9

Estrogens/Progestin combinations ............................................................................................................. 9

Selective Estrogen Receptor Modulators .................................................................................................. 10

Oral Contraceptives .................................................................................................................................. 10

Non-Oral Contraceptives .......................................................................................................................... 10

OB/GYN Medications................................................................................................................................ 10

Oxytocics ................................................................................................................................................... 10

Progestins ................................................................................................................................................. 10

Estrogen/Androgen Combinations ............................................................................................................ 10

Gout Medications ...................................................................................................................................... 10

Thyroid Medications ................................................................................................................................. 11

Miscellaneous Endocrine Agents .............................................................................................................. 11
GASTROINTESTINAL MEDICATIONS ........................................................................................................... 11

Ammonia Detoxicants ............................................................................................................................... 11

Antispasmodics ......................................................................................................................................... 11

Anti-Ulcer Medications ............................................................................................................................. 11

Antidiarrheal Preparations ....................................................................................................................... 12
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
Laxatives ................................................................................................................................................... 12

Digestive Enzymes .................................................................................................................................... 12

Medications for Nausea & Vomiting ........................................................................................................ 12

Medications for Bowel Disease ................................................................................................................ 12

Miscellaneous Gastrointestinal Medications ............................................................................................ 13
GENITOURINARY TRACT MEDICATIONS ................................................................................................... 13

Gall Stone Stabilizing Agents.................................................................................................................... 13

Medications For The Urinary Tract ......................................................................................................... 13

Misc Medications: (Phosphodiesterase Inhibitors) .................................................................................. 14
HEART AND BLOOD PRESSURE MEDICATIONS ....................................................................................... 14

Angiotensin Converting Enzyme Inhibitors .............................................................................................. 14

Angiotensin II Receptor Blockers ............................................................................................................. 14

Angiotensin Converting Enzyme Inhibitor/Diuretic Combinations .......................................................... 14

Antiarrhythmics......................................................................................................................................... 14

Beta Blockers ............................................................................................................................................ 15

Calcium Channel Blockers ....................................................................................................................... 15

Carbonic Anhydrase Inhibitors................................................................................................................. 15

Centrally Acting Antihypertensives........................................................................................................... 15

Choleserol Lowering Drugs ...................................................................................................................... 16

Diuretics .................................................................................................................................................... 16
MEDICATIONS AFFECTING THE BLOOD ................................................................................................... 16

Anticoagulants .......................................................................................................................................... 16

Hematopoetic ............................................................................................................................................ 17

Antiplatelets .............................................................................................................................................. 17

Misc. Cardiovascular Drugs ..................................................................................................................... 17

Medication For Angina ............................................................................................................................. 17

Vasopressor............................................................................................................................................... 17
MEDICATIONS FOR EYES, EAR, NOSE & THROAT .................................................................................... 17

Anti-Inflammatory Medications For The Eyes ......................................................................................... 17
GLAUCOMA MEDICATIONS.......................................................................................................................... 18

Beta Blockers ............................................................................................................................................ 18

Alpha-2 Adrenergic Agonist ..................................................................................................................... 18

Carbonic Anhydrase Inhibitors................................................................................................................. 18
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
Prostaglandins .......................................................................................................................................... 18
OPHTHALMIC MEDICATIONS ...................................................................................................................... 18

Other Treatments for Glaucoma ............................................................................................................... 18

Ophthalmic Anti-infectives........................................................................................................................ 18

Ophthalmic Anti-infective Combinations .................................................................................................. 18

Ophthalmic Anti-Allergic Medications ..................................................................................................... 19

Other Ophthalmic Medications................................................................................................................. 20

Medications For The Ear .......................................................................................................................... 20

Medications For The Nose ........................................................................................................................ 20

Nasal Antihistamine .................................................................................................................................. 20

Medications For The Throat And Mouth .................................................................................................. 20
MEDICATIONS THAT AFFECT THE NERVOUS SYSTEM ........................................................................... 21

Antianxiety Medications............................................................................................................................ 21

Anticonvulsants ......................................................................................................................................... 21

Antidepressants ......................................................................................................................................... 22

Anti-Mania ................................................................................................................................................ 22

Anti-Psychotic Medications ...................................................................................................................... 22
MISCELLANEOUS MEDICATIONS AFFECTING THE BRAIN .................................................................... 23

Parkinson’s Medications .......................................................................................................................... 23

Sedative/Hypnotics .................................................................................................................................... 23

Stimulants.................................................................................................................................................. 24
MEDICATIONS TO TREAT INFECTIONS ...................................................................................................... 24

Antibiotics ................................................................................................................................................. 24

Antimalarials............................................................................................................................................. 25

Anti-Parasitic Medications ....................................................................................................................... 25

Antituberculosis Medications.................................................................................................................... 25
ANTIRETROVIRALS......................................................................................................................................... 26

Anti-HIV Medications, CCR5 Co-Receptor Antagonists .......................................................................... 26

Anti-HIV Medications, Fusion Inhibitors ................................................................................................. 26

Anti-HIV Medications, Integrase Strand Transfer Inhibitors ................................................................... 26

Anti-HIV Medications, Non-Nucleoside Reverse Transcriptase Inhibitors.............................................. 26

Anti-HIV Medications, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors ............................ 26

Anti-HIV Medications, Protease Inhibitors .............................................................................................. 26
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
Misc. Antiviral Medications ...................................................................................................................... 27

Oral Antifungals........................................................................................................................................ 27

Other Oral Anti-Infective Medications ..................................................................................................... 27

Vaginal Anti-Infectives.............................................................................................................................. 27
IMMUNOLOGICAL AGENTS .......................................................................................................................... 27
ANALGESICS/PAIN/RHEUMATIC MEDICATIONS ...................................................................................... 28

Anti-Inflammatory Medications (NSAIDS) ............................................................................................... 28

Anti-Rheumatic Medications ..................................................................................................................... 28

Migraine Medications ............................................................................................................................... 28

Analgesics ................................................................................................................................................. 29

Opiate Antagonists .................................................................................................................................... 30

Skeletal Muscle Relaxants......................................................................................................................... 30
NUTRITION ...................................................................................................................................................... 30

Electrolytes ............................................................................................................................................... 30

Vitamins and Minerals .............................................................................................................................. 30

Phosphate Binding Medications ............................................................................................................... 31
RESPIRATORY DRUGS ................................................................................................................................... 31

Antihistamine/Decongestants .................................................................................................................... 31

Antihistamines ........................................................................................................................................... 31

Cough Medications ................................................................................................................................... 31

Medications For Asthma & Other Lung Disease ..................................................................................... 32

Mucolytic Agent ........................................................................................................................................ 33
SKIN MEDICATIONS (TOPICAL) ................................................................................................................... 33

Acne Medications ...................................................................................................................................... 33

Topical Antiparasitics/Anti-helmintic ....................................................................................................... 33

Other Topical Medications ....................................................................................................................... 33

Topical Immunomodulator........................................................................................................................ 34

Topical Antifungal .................................................................................................................................... 34

Topical Coricosteroids.............................................................................................................................. 34

Grade 1 (Very High Potency) ................................................................................................................... 34

Grade 2 (High Potency) ............................................................................................................................ 35

Grade 3 (Medium Potency) ....................................................................................................................... 35

Grade 4 (Low Potency) ............................................................................................................................. 35
INDEX ............................................................................................................................................................... 36
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CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
ANTINEOPLASTICS
 Alkylating Agents
Melphalan
ALKERAN
Lomustine
CEENU
Cyclophosphamide
CYTOXAN
Altretamine
HEXALEN
Chlorambucil
LEUKERAN
Procarbazine
MATULANE
Busulfan
MYLERAN
Temozolomide
TEMODAR
PA
Lenalidomide
REVLIMID
PA
Thalidomide
THALOMID
PA
 Antiangiogenic Agents
 Antiestrogens/Modifiers
Estramustine
EMCYTt
Toremifene
FARESTON
 Antimetabolites
Hydroxyurea
DROXIA, HYDREA
Thioguanine
TABLOID
Capecitabine
XELODA
PA
 Other Antineoplastics
Metyrosine
DEMSER
Phenoxybenzamine
DIBENZYLINE
Mesna
MESNEX
Etoposide
ETOPOPHOS
Vorinostat
ZOLINZA
PA
 3 Generation Aromatase Inhibitors
rd
Anastrozole
ARIMIDEX
Exemestane
AROMASIN
Letrozole
FEMARA
 Molecular Target Inhibitors
Imatinib
GLEEVEC
PA
Gefitinib
IRESSA
PA
Sorafenib
NEXAVAR
PA
Dasatinib
SPRYCEL
PA
Sunitinib
SUTENT
PA
Erlotinib
TARCEVA
PA
Nilotinib
TASIGNA
PA
Lapatinib
TYKERB
PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
 Androgens
Testolactone
TESLAC
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
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CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
HORMONAL AGENTS, ADRENAL SUPPRESANT
Mitotane
LYSODREN
HORMONAL AGENTS; SUPPRESSANT
 Antiandrogens
Bicalutamide
CASODEX
Flutamide
FLUTAMIDE
Nilutamide
NILANDRON
IMMUNOLOGICAL AGENTS
 Immune Suppressants
Mycophenolate mofetil
CELLCEPT
Mycophenolic acid
MYFORTIC
Cyclosporine Modified
NEORAL , GENGRAF
Tacrolimus
PROGRAF
Sirolimus
RAPAMUNE
Cyclosporine non-modified
SANDIMMUNE
ENDOCRINE SYSTEM MEDICATIONS
 Androgens
Fluoxymesterone
ANDROXY
Methyltestosterone
ANDROID, TESTRED
Testosterone Cypionate (Injection)
DEPO-TESTOSTERONE (inj)
Testosterone Enanthate (Injection)
TESTOSTERONE (inj)
PA: Tried and failed OR contraindications to at least
one preferred alternative. Testosterone (Inj)
indicated for treatment of hypogonadism.
 Glucocorticoids
Dexamethasone
DECADRON
Hydrocortisone
CORTEF
Methylprednisolone
MEDROL
Prednisolone
DELTA-CORTEF
PRELONE
ORAPRED
ORASONE
Prednisolone syrup
Prednisone
 Mineralocorticoids
Fludrocortisone
FLORINEF
 Diabetic Medications
Acarbose
PRECOSE
Exenatide
BYETTA
Glimepiride
AMARYL
Glimepiride/Pioglitazone
DUETACT
Glipizide
GLUCOTROL
Glucose Monitor and diabetes test strips
TRUETRACK AND TRUETEST (OR
VARIOUS STORE BRANDED
TRUETRACK OR TRUETEST STRIPS)
Glyburide
DIABETA/MICRONASE
PA: Tried and failed OR contraindications to a
sulfonylurea or metformin. Claim processes at
the point of sale when PA criteria met.
PA: Pre-requisite therapy required.
PA: Tried and failed OR contraindications to a
sulfonylurea or Metformin and failure of Januvia
QL: Quanity Limit:150 test strips per 30 days.
Non-TrueTrack or TrueTest monitor and test
strips require patient try TrueTrack AND
TrueTest AND be on injectable insulin.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
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CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
Tolazamide
HUMULIN N, HUMULIN R, HUMULIN
QL: Quantity limits apply. Lantus and Levemir
50/50, HUMULIN 70/30, HUMALOG 50/50,
limited to 2 vials per month.
HUMALOG 75/25, LANTUS, LEVEMIR
GLUCOPHAGE
PA: Tried and failed OR contraindications to a
GLYSET
sulfonylurea or metformin.
PA: Tried and failed OR contraindications to a
STARLIX
sulfonylurea or metformin.
C1: Qty must = dose of self injection
PA: Tried and failed OR contraindications to a
ACTOS
sulfonylurea or Metformin and failure of Januvia
PA: Tried and failed OR contraindications to a
ACTOSPLUS MET
sulfonylurea or Metformin and failure of Januvia
PA: Tried and failed OR contraindications to a
PRANDIN
sulfonylurea or metformin.
PA: Tried and failed OR contraindications to a
AVANDIA
sulfonylurea or Metformin and failure of Januvia
PA: Tried and failed OR contraindications to a
AVANDRYL
sulfonylurea or Metformin and failure of Januvia
PA: Tried and failed OR contraindications to a
AVANDAMET
sulfonylurea or Metformin and failure of Januvia
PA: Tried and failed OR contraindications to a
JANUVIA
sulfonylurea or metformin. Claim processes at
the point of sale when PA criteria met.
PA: Tried and failed OR contraindications to a
JANUMET
sulfonylurea or metformin. Claim processes at
the point of sale when PA criteria met.
TOLINASE
Tolbutamide
ORINASE
Insulin
Metformin
Miglitol
Nateglinide
Needles & Syringes (Not including diabetic)
Pioglitazone
Pioglitazone/Metform
Repaglinide
Rosiglitazone
Rosiglitazone/Glimepiride
Rosiglitazone/Metformin
Sitagliptin
Sitagliptin/Metformin
 Medications to Treat Hypoglycemia
Glucagon HCl
GLUCAGON
 Medications to Treat Of Osteoporosis
Alendronate
FOSAMAX
Calcitonin-Salmon
MIACALCIN NASAL SPRAY
Raloxifene
EVISTA
Risedronate
ACTONEL
C1: Postmenopausal woman who has been on
estrogen for about 10 years OR any
postmenopausal woman with an increased risk
for breast cancer OR tried and failed or any
contraindictions/intolerance to estrogen
PA
 Miscellaneous Bisphosphonates
Etidronate Disodium
DIDRONEL
C1: Restricted to hypercalcemia of malignancy.
Choose other bisphosphonates for Paget’s
disease of the bone if not contraindicated.
 Estrogens
Conjugated Estrogens (Tablet, Vaginal Cream)
PREMARIN (TABLET, VAGINAL CREAM)
Esterified Estrogens
MENEST
ESTINYL, ESTRACE (Tablet, Vaginal
Cream)
Estradiol (Tablet, Vaginal Cream)
Estradiol (Vaginal Tablet).
VAGIFEM (VAGINAL TABLET)
Estradiol, transdermal
CLIMARA (TRANSDERMAL)
Estropipate
OGEN
 Estrogens/Progestin combinations
Conjugated Estrogens/Medroxy Progesterone
PREMPRO/PREMPHASE
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
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CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
 Selective Estrogen Receptor Modulators
Tamoxifen
NOLVADEX
 Oral Contraceptives
Ethinyl Estradiol/Desogestrel
CYCLESSA
Ethinyl Estradiol/Desogestrel
DESOGEN
Ethinyl Estradiol/Desogestrel
MIRCETTE
Ethinyl Estradiol/Drospirenone
YASMIN
Ethinyl Estradiol/Ethynodiol
DEMULEN 1/35
Ethinyl Estradiol/Ethynodiol
DEMULEN 1/50
Ethinyl Estradiol/Levonorgestrel
ALESSE
Ethinyl Estradiol/Levonorgestrel
NOREDETTE
Ethinyl Estradiol/Levonorgestrel
TRI-LEVLEN
Ethinyl Estradiol/Norethindrone
LOESTRIN FE 1/20
Ethinyl Estradiol/Norethindrone
LOESTRIN FE 1.5/30
Ethinyl Estradiol/Norethindrone
ORTHONOVUM 1/35
Ethinyl Estradiol/Norethindrone
ORTHO NOVUM 7/7/7
Ethinyl Estradiol/Norethindrone
ORTHO NOVUM 10/11
Ethinyl Estradiol/Norethindrone
OVCON 35
Ethinyl Estradiol/Norethindrone
OVCON 50
Ethinyl Estradiol/Norethindrone
TRI-NORINYL
Ethinyl Estradiol/Norgestimate
ORTHO CYCLEN
Ethinyl Estradiol/Norgestimate
ORTHO TRI-CYCLEN
Estradiol/Norgestrel
LO OVRAL
Ethinyl Estradiol/Norgestrel
OVRAL
Mestranol/Norethindrone
ORTHONOVUM 1/50
Norethindrone
MICRONOR
PA
 Non-Oral Contraceptives
Ethinyl Estradiol/Etonogestrel
Ethinyl Estradiol/Norelgestromin
NUVARING
ORTHO EVRA
 OB/GYN Medications
Prenatal Vitamins
PRENATAL, PRENATAL FORTE,
PRENAVITE, PRENATAL RX
Formulary for females > 13 years old < 45 years
old.
 Oxytocics
Methylergonorine
METHERGINE
 Progestins
Levonorgestrel
PLAN B
Medroxyprogesterone Acetate
PROVERA, DEPO-PROVERA
Norethindrone Acetate
AYGESTIN
 Estrogen/Androgen Combinations
Esterified Estrogens/ Methyltestosterone
ESTRATEST
 Gout Medications
Allopurinol
ZYLOPRIM
Colchicine
COLCHICINE
Colchicine/Probenecid
COL-PROBENECID
Probenecid
BENEMID
Quantity limits apply.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
10
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
 Thyroid Medications
Levothyroxine
SYNTHROID
Liothyronine
CYTOMEL
Liotrix
THYROLAR
Methimazole
TAPAZOLE
Propylthiouracil
PTU
Thyroid dessicated
ARMOUR THYROID
 Miscellaneous Endocrine Agents
Formulary: Tablets for patients 6 years of age and
older.
PA: Nasal Spray, Rhinal Tube, and Injection.
Desmopressin Acetate
DDAVP
Leuprolide
LUPRON DEPOT, LUPRON DEPOT PED
GASTROINTESTINAL MEDICATIONS
 Ammonia Detoxicants
Lactulose
CEPHULAC
 Antispasmodics
Belladonna Alkaloids/Phenobarbital
DONNATAL
Clinidium/Chlordiazepoxide
LIBRAX
Dicyclomine
BENTYL
Diphenoxylate/Atropine
LOMOTIL
Ergotamine/Belladonna/Phenobarbital
BELLERGAL-S
Hyoscyamine
LEVSIN
Hyoscyamine Sulfate CR
LEVSINEX
Metoclopramide
REGLAN
Paregoric
OPIUM
PEG Solution
COLYTE
Propantheline
PRO-BANTHINE
PA: Urology consult, approvable for one year for the
DIAGNOSIS of urinary incontinence when at
least one preferred alternative listed on the PDL
has been tried and failed.
 Anti-Ulcer Medications
Cimetidine
TAGAMET
Dexlansoprazole
DEXILANT
Esomeprazole
NEXIUM
Famotidine
PEPCID
Lansoprazole (OTC version)
PREVACID 24HR OTC
Lansoprazole
PREVACID
Misoprostol
CYTOTEC
Omeprazole Magnesium, Omeprazole OTC
PRILOSEC, PRILOSEC (OTC)
PA: Tried and failed OR contraindications to
preferred alternative Omeprazole and then
Prevacid 24HR OTC.
QL: QL: Quantlity limits apply
PA: Tried and failed OR contraindications to
preferred alternative Omeprazole and then
Prevacid 24HR OTC.
QL: Quantlity limits apply.
B:
OTC Chewables and OTC Tablets
A:
Rx formulary
PA: Tried and failed OR contraindications to
preferred alternative Omeprazole and then
Prevacid 24HR OTC.
Solutab is formulary for 9 and younger.
PA: Tried and failed OR contraindications to
preferred alternative Omeprazole and then
Prevacid 24HR OTC.
QL: Quantlity limits apply.
A:
(Packet for Oral Suspension is PA required)
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
11
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Omeprazole/Sodium Bicarbonate
ZEGERID OTC
Pantoprazole
PROTONIX
Rabeprazole
ACIPHEX
Ranitidine
ZANTAC
Sucralfate
CARAFATE
NOTES
PA: Tried and failed OR contraindications to
preferred alternative Omeprazole and then
Prevacid 24HR OTC.
PA: Tried and failed OR contraindications to
preferred alternative Omeprazole and then
Prevacid 24HR OTC.
40mg Oral Suspension formulary for <9 yo.
PA: QL: Quantlity limits apply.
Formulary for patients currently on Plavix.
PA: Tried and failed OR contraindications to
preferred alternative Omeprazole and then
Prevacid 24HR OTC.
QL: Quantity limits apply.
B: BA: Tablets only. Capsules are not covered
 Antidiarrheal Preparations
Diphenoxylate/Atropine
LOMOTIL
Paregoric
OPIUM
Loperamide (2 mg capsules)
IMODIUM
Covered: Prescription 2mg capsule only
 Laxatives
Polyethylene Glycol 3350 oral powder
GLYCOLAX, Miralax OTC
A: OTC formulation.
 Digestive Enzymes
Amylase/ Lipase/ Protease
CREON, ZENPEP, PANCREASE MT,
VIOKASE
Pancreatin
PANCREASE MT
Covered: Prescription strength only.
 Medications for Nausea & Vomiting
Aprepitant
Prevention of nausea/vomiting secondary to
chemotherapy in Cancer patients only
EMEND
Dolasetron
ANZEMET
Dronabinol
MARINOL
Granisetron
KYTRIL
Meclizine
ANTIVERT
Ondansetron
ZOFRAN, ZOFRAN ODT
PA: Restricted to treatment with emetogenic
chemotherapy or radiation therapy AND
documented trial and failure with therapeutic
doses or intolerance to ondansetron (Zofran).
QL: Quantity limits apply.
PA: Restricted to use in cancer patients or the
treatment of anorexia associated with weight
loss in patients with AIDs
PA: Restricted to treatment with emetogenic
chemotherapy or radiation therapy AND
documented trial and failure with therapeutic
doses or intolerance to ondansetron (Zofran).
QL: Quantity limits apply.
Covered: Rx only 25mg
M: OTC strength 12.5mg/25mg
QL: Quantity limit of #15/30 days apply.
Prochlorperazine
Promethazine
PHENERGAN
Trimethobenzamide
TIGAN
Phenergan suppositories
 Medications for Bowel Disease
Azathioprine
IMURAN
Hydrocortisone Acetate Rectal
CORTIFOAM
Hydrocortisone
ANUSOL-HC CREAM, SUPP.
PURINETHOL
Mercaptopurine (6M-P)
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
12
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
 Miscellaneous Gastrointestinal Medications
Aluminum Hydroxide Gel
Aluminum Hydroxide, Magnesium Hydroxide, and
Simethicone
Bisacodyl
AMPHOGEL
B
MYLANTA
B
DULCOLAX
B
Bismuth Subsalicylate
PEPTO-BISMOL
M
Calcium Carbonate/Magnesium Carbonate
MYLANTA
B
Docusate Sodium
COLACE
M
Hydrocortisone Retention Enema
CORTENEMA
Magnesium Citrate
CITRATE OF MAGNESIA
Mesalamine
ASACOL, PENTASA
Mesalamine Enema
CANASA (ENEMA)
Mesalamine Supp
ROWASA (SUPPOSITORY)
Olsalazine
DIPENTUM
PEG 3350 Solution
COLYTE
Sulfasalazine
AZULFIDINE
B
GENITOURINARY TRACT MEDICATIONS
 Gall Stone Stabilizing Agents
Ursodiol
ACTIGALL
 Medications For The Urinary Tract
Bethanechol
URECHOLINE
Doxazosin Mesylate
CARDURA
Methenamine/Methylene Blue Atropine
URISED
Finasteride
PROSCAR
Nitrofurantoin
FURADANTIN
Nitrofurantoin/Nitrofurantoin Macrocrystals
MACROBID
Nitrofurantoin Macrocrystals
MACRODANTIN
Oxybutynin IR
DITROPAN
Oxybutynin XL
DITROPAN XL
Phenazopyridine
PYRIDIUM
Pentosan
ELMIRON
Prazosin
MINIPRESS
Tamsulosin
FLOMAX
Terazosin
HYTRIN
Tolterodine
DETROL, DETROL LA
Trimethoprim
PA: Tried and failed, or any contraindications to other
alternatives.
PA: Tried and failed OR contraindications to at least
one preferred alternative. Treatment of
symptomatic BPH.
PA: Tried and failed immediate release (IR)
oxybutynin. Claim pays on-line contingent upon
trial of IR oxybutynin. PA required if criteria not
met.
PA: Tried and failed or contraindications to terazosin
or doxazosin. Claim pays on-line contingent
upon trial of preferred agents in past 365 days
claim history. PA required if criteria not met.
PA: Tried and failed immediate release (IR)
oxybutynin. Claim pays on-line contingent upon
trial of IR oxybutynin. PA required if criteria not
met.
TRIMPEX
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
13
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
 Misc Medications: (Phosphodiesterase Inhibitors)
*ED Medications are carved-out for Medi-Cal members & not covered for treatment of ED for BHC recipients
PA: Questionnaire/PA form must be completed.
Sildenafil
VIAGRA
(Form available on-line: www.CCHealth.org or
call CCHP (925) 313-6008. Limit: 3 tablets/30
days.
PA: Questionnaire/PA form must be completed.
Alprostadil
MUSE, CAVERJECT
(Form available on-line: www.CCHealth.org or
call CCHP (925) 313-6008.
HEART AND BLOOD PRESSURE MEDICATIONS
 Angiotensin Converting Enzyme Inhibitors
Benazepril
LOTENSIN
Captopril
CAPOTEN
Enalapril
VASOTEC
Lisinopril
ZESTRIL
 Angiotensin II Receptor Blockers
Losartan
COZAAR
Olmesartan
BENICAR
Ramipril
ALTACE
Telmisartan
MICARDIS
PA: Tried and failed or contraindications to formulary
Angiotensin converting enzyme inhibitors (i.e.
Lisinopril, Enalapril). Claim pays on-line when
PA criteria met.
PA: Tried and failed OR contraindications to
formulary angiotensin converting enzyme
inhibitors. Claim pays at point-of-sale when PA
criteria met.
Only capsules are formulary
PA: Tried and failed OR contraindications to
formulary angiotensin converting enzyme
inhibitors. Claim pays at point-of-sale when PA
criteria met.
 Angiotensin Converting Enzyme Inhibitor/Diuretic Combinations
Benazepril/HCTZ
LOTENSIN HCT
Lisinopril/HCTZ
ZESTORETIC, PRINIZIDE
 Angiotensin II Receptor Blocker/Diuretic Combinations
Losartan/HCTZ
HYZAAR
Olmesartan/HCTZ
BENICAR HCT
Telmisartan/HCTZ
MICARDIS HCT
PA: Tried and failed Or contraindications to preferred
alternatives. Claim pays on-line when PA
criteria met.
PA: Tried and failed OR contraindications to
formulary angiotensin converting enzyme
inhibitors. Claim pays at point-of-sale when PA
criteria met.
PA: Tried and failed OR contraindications to
formulary angiotensin converting enzyme
inhibitors. Claim pays at point-of-sale when PA
criteria met.
 Antiarrhythmics
Amiodarone
CORDARONE
Digoxin
LANOXIN
Disopyramide
NORPACE, NORPACE CR
TIKOSYN
Dofetilide
Flecainide
TAMBOCOR
Mexitiline
MEXITIL
Moricizine
ETHMOZINE
PRONESTYL
PRONESTYL-SR
RYTHMOL, RYTHMOL SR
Procainamide
Propafenone
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
14
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Quinidine Gluconate
QUINAGLUTE
Quinidine Sulfate
QUINIDINE SULFATE
Sotalol
BETAPACE
Sotalol AF
BETAPACE AF
NOTES
 Beta Blockers
Acebutolol
SECTRAL
Atenolol
TENORMIN
Bisoprolol
ZEBETA
Carvedilol
COREG
Labetalol
TRANDATE, NORMODYNE
Metoprolol Succinate
TOPROL XL
Metoprolol Tartrate
LOPRESSOR
Nadolol
CORGARD
Propranolol
INDERAL
Propanolol LA
INDERAL LA
Recommended for CHF only.
Tablets only
PA: Tried and failed OR contraindications to at least
one preferred alternative.
 Beta Blocker/Diuretic Combinations
Atenolol/Chlorthalidone
ZEBETA
Bisoprolol/HCTZ
ZIAC
Propanolol/HCTZ
INDERIDE
 Calcium Channel Blockers
Amlodipine
NORVASC
Diltiazem
CARDIZEM, CARTIA XT
Diltiazem CR
DILACOR XR, CARDIZEM CD
Diltiazem ER, Diltiazem SR
CARDIZEM LA, CARDIZEM SR, DILT XR
Felodipine
PLENDIL
Isradipine
DYNACIRC
Isradipine CR
DYNACIRC CR
Nicardipine
CARDENE
Nicardipine SR
CARDENE SR
Nifedipine
ADALAT, PROCARDIA
Verapamil
ADALAT CC, PROCARDIA XL,
AFEDITAB, NIFEDICAL XL, NiFEDIAC CC
CALAN
Verapamil SR
CALAN SR, ISOPTIN SR
Nifedipine SR, ER
PA: Required for Tiazac equivalent.
PA: Required for Dynacirc CR.
PA: Tried and failed OR contraindications to at least
one preferred alternative.
PA: Tried and failed OR contraindications to at least
one preferred alternative.
PA: Tried and failed OR contraindications to at least
one preferred alternative. Cardiovascular: Failed
long-acting calcium channel blocker.
 Carbonic Anhydrase Inhibitors
Acetazolamide
DIAMOX, DIAMOX SEQUELS
 Centrally Acting Antihypertensives
Clonidine
CATAPRES
Guanfacine
TENEX
Methyldopa
ALDOMET
Minoxidil tablets
LONITEN
Reserpine
SERPASIL
(Tablets or patches covered)
Topical solution is a plan exclusion.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
15
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
 Choleserol Lowering Drugs
PA: Subject to tablet splitting. Tried and failed OR
contraindications to at least two preferred
alternatives.
Atorvastatin
LIPITOR
Cholestyramine
QUESTRAN
Cholestyramine Light
QUESTRAN LIGHT
Colestipol
COLESTID
Fenofibrate
LOFIBRA
Fluvastatin
LESCOL
Gemfibrozil
LOPID
Niacin
NIACIN, NIASPAN
B: OTC formulations.
Nicotinic Acid SR
SLO-NIACIN
Lovastatin
MEVACOR
PA
PA: Tried and failed or contraindications to
simvastatin.
Pravastatin
PRAVACHOL
Rosuvastatin
CRESTOR
Simvastatin
Simvastatin/Niacin
Formulary if patient on a Statin. Otherwise PA
required.
PA: Tried and failed or contraindications to
pravastatin and simvastatin.
Subject to tablet splitting
ZOCOR
Simcor
PA
 Diuretics
Amiloride
MIDAMOR
Amiloride/HCTZ
MODURETIC
Bumetanide
BUMEX
Chlorthalidone
HYGROTON
Ethacrynic Acid
EDECRIN
Furosemide
LASIX
Hydrochlorothiazide
HYDRODIURIL
Indapamide
LOZOL
Metolazone
ZAROXOLYN
Spironolactone
ALDACTONE
Spironolactone/HCTZ
ALDACTAZIDE
Triamterene/HCTZ
DYAZIDE, MAXZIDE
Torsemide
DEMADEX
C1: Formulary if recent history of preferred diuretic
(past 120 days), otherwise prior authorization is
required.
MEDICATIONS AFFECTING THE BLOOD
 Anticoagulants
Enoxaparin
LOVENOX
Heparin Sodium
HEPARIN SODIUM
Warfarin
QL: #10 syringes per 5 days quantity limit applies.
Warfarin should be started concurrently with
Lovenox.
COUMADIN
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
16
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
 Hematopoetic
PA:

Anemia CRF

zidovudine-treated patients

chemotherapy-treated patients
Erythropoietin (Epoetin Alfa)
EPOGEN
Appropriate quantity approved for 3 months at a time
if patient has one of the above Diagnosis, and a)
Hemoglobin<10g/dL OR HCT<30% (or rolling 90 day
average HCT<36%) and b) Patient on iron or iron
studies labs are nml (i.e., has adequate iron stores)
Transferrin saturation should be at least 20%; ferritin
at least 100 ng/ml.
 Antiplatelets
Clopidogrel
PLAVIX
Dipyridamole
PERSANTINE
Dipyridamole/Aspirin
AGGRENOX
Ticlopidine
TICLID
Quantity limits apply.
 Misc. Cardiovascular Drugs
PA: Tried and failed OR contraindications to at least
one preferred alternative. Patient diagnosed with
T claudication.
Cilostazol
PLETAL
Pentoxifylline
TRENTAL
 Medication For Angina
Hydralazine
APRESOLINE
Isosorbide Dinitrate
ISORDIL TITRADOSE
Isosorbide Dinitrate SR
DILATRATE-SR, ISOCHRON
Isosorbide Mononitrate
IMDUR, ISMO, MONOKET
Nitroglycerin
NITROSTAT
Nitroglycerin (ointment)
NITROL-BID (Oinment)
Nitroglycerin (patch)
NITRO-DUR (Patch)
Nitroglycerin SR (Capsule)
NITRO-BID (Capsule)
 Vasodilators
Doxazosin
CARDURA
Hydralazine
APRESOLINE
Minoxidil
LONITEN
Prazosin
MINIPRESS
Terazosin
HYTRIN
 Vasopressor
Epinephrine
EPIPEN, EPIPEN JR
MEDICATIONS FOR EYES, EAR, NOSE & THROAT
 Anti-Inflammatory Medications For The Eyes
Dexamethasone
DECADRON,
Fluorometholone
FLAREX, FML LIQUIFILM, FLUR-OP, FML
FORTE
Ketorolac OPHTH
ACULAR, ACULAR LS, ACULAR PF,
Prednisolone acetate
ECONOPRED PLUS, PRED FORTE,
PRED-MILD,
Prednisolone sodium
AK-PRED, INFLAMASE FORTE,
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
17
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
GLAUCOMA MEDICATIONS
 Beta Blockers
Betaxolol
BETOPTIC, BETOPTIC S
Metipranolol
OPTIPRANOLOL
Levobunolol
AKBETA , BETAGAN
Timolol Hemihydrate
BETIMOL
Timolol Maleate
TIMOPTIC, TIMOPTIC XE
PA: Tried and failed OR contraindications to at least
one preferred alternative. Indicated for treatment
of ocular HTN and chronic open-angle glaucoma.
May be used as an add-on therapy.
PA: Tried and failed OR contraindications to at least
one preferred alternative.
 Alpha-2 Adrenergic Agonist
Brimonidine
ALPHAGAN P
PA: Tried and failed OR Contraindications to at
least one preferred alternative..
 Carbonic Anhydrase Inhibitors
Acetazolamide
DIAMOX, DIAMOX SEQUELS
Brinzolamide
AZOPT
Dorzolamide
Methazolamide
TRUSOPT
PA: Tried and failed OR contraindications to at least
one preferred alternative. Elevated IOP in
patients with ocular HTN or open-angle
glaucoma.
PA: Tried and failed OR contraindications to at least
one preferred alternative, Treatment of elevated
IOP.
NEPTAZANE
 Prostaglandins
Bimatoprost
LUMIGAN
Latanoprost
XALATAN
Travaprost
TRAVATAN, TRAVATAN Z
PA: Tried and failed OR contraindications to at least
one preferred alternative.
PA: Tried and failed OR contraindications to at least
one preferred alternative.
OPHTHALMIC MEDICATIONS
 Other Treatments for Glaucoma
Carbachol
ISOPTO-CARBACHOL
Dipivefrin
AKPRO, PROPINE,
Echothiophate Iodide
PHOSPHOLINE IODIDE
ISOPTO CARPINE,, PILOCAR, PILOPINE
HS
Pilocarpine
 Ophthalmic Anti-infectives
Bacitracin optthalmic
AK-TRACIN
Ciprofloxacin
CILOXAN
Erythromycin
ILOTYCIN OPHTH OINT
Gentamicin
GENOPTIC. GENOPTIC S.O.P.
Ofloxacin
OCUFLOX
Sulfacetamide
BLEPH 10, SODIUM SULAMYD
Tobramycin
TOBREX
Trifluridine
VIROPTIC
 Ophthalmic Anti-infective Combinations
Bacitracin/ Polymyxin B Sultate
POLYSPORIN OINTMENT
Gentamicin/Prednisolone
PRED-G, PRED-G SOP
Neomycin Sultate, Polymyxin B Sulfate, Bacitracin
Neomycin Sulfate/Polymyxin B Sulfate/Bacitracin/
Hydrocortisone
NEOSPORIN OPHTH OINT
CORTISPORIN OPHTH OINTMENT
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
18
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Neomycin Sulfate/Polymyxin B Sulfate/Gramicidin
Neomycin Sulfate, Polymyxin B Sulfate,
Dexamethasone
Neomycin Sulfate/Polymyxin B Sulfate/Prednisolone
NEOSPORIN OPHTH SOLUTION
Neomy, Polym, Bac
NEOSPORIN OPHTH OINT
Neo/Poly/Prednisolone
Neomycin Sulfate,Polymyxin B
Sulfate,Hydrocortizone
Polymyxin B Sulfate/TMP
POLY-PRED
Sulfacetamide/Prednisolone (ointment)
BLEPHAMIDE, BLEPHAMIDE S.O.P.
Tobramycin Sulfate/Dexamethasone
TOBRADEX
NOTES
MAXITROL OINTMENT & SUSP
POLY-PRED
CORTISPORIN OPHTH SUSP
POLYTRIM
 Ophthalmic Anti-Allergic Medications
Azelastine HCl
OPTIVAR
Cromolyn
CROLOM
Epinastine HCl
ELESTAT
Emedastine Difumarate
EMADINE
Ketotifen furmarate
ALAWAY OTC, ZADITOR OTC
Lodoxamide
ALOMIDE
Naphazoline HCl
NAPHCON
Naphazoline HCl/Pheniramine Maleate
NAPHCON A
Nedrocromil
ALOCRIL
Olopatadine
PATADAY
Olopatadine HCl
PATANOL
PA: Approvable for diagnosis of allergic conjunctivitis
if tried and failed OR contraindications to Alaway
OTC or Zaditor OTC AND THEN Pataday or
Patanol. For members without OTC coverage,
tried and failed OR contraindications to Crolom
AND THEN Pataday or Patanol.
QL: Quantity limit of 1 bottle/30 days.
Quantity limit of 1 bottle / 30days
PA: Approvable for diagnosis of allergic conjunctivitis
if tried and failed OR contraindications to Alaway
OTC or Zaditor OTC AND THEN Pataday or
Patanol. For members without OTC coverage,
tried and failed OR contraindications to Crolom
AND THEN Pataday or Patanol.
QL: Quantity limit of 1 bottle/30 days.
PA: Approvable for diagnosis of allergic conjunctivitis
if tried and failed OR contraindications to Alaway
OTC or Zaditor OTC AND THEN Pataday or
Patanol. For members without OTC coverage,
tried and failed OR contraindications to Crolom
AND THEN Pataday or Patanol.
QL: Quantity limit of 1 bottle/30 days.
B
QL: Quantity limit of 1 bottle / 30days
PA: Approvable for diagnosis vernal conjunctivitis,
vernal keratitis or vernal kerato-conjunctivitis.
QL: Quantity limit of 1 bottle / 30days
B
QL: Quantity limit of 1 bottle / 30days
B
QL: Quantity limit of 1 bottle / 30days
PA: Approvable for diagnosis of allergic conjunctivitis
if tried and failed OR contraindications to Alaway
OTC or Zaditor OTC AND THEN Pataday or
Patanol. For members without OTC coverage,
tried and failed OR contraindications to Crolom
AND THEN Pataday or Patanol.
QL: Quantity limit of 1 bottle/30 days.
PA: Approvable for diagnosis of allergic conjunctivitis
if tried and failed OR contraindication to Zaditor
OTC, Alaway OTC, or Crolom.
QL: Quantity limit of 1 bottle/30 days.
PA: Approvable for diagnosis vernal conjunctivitis,
vernal keratitis or vernal kerato-conjunctivitis.
Approvable for diagnosis of allergic conjunctivitis
if tried and failed or contraindication to Zaditor
OTC, Alaway (OTC), or Crolom.
Quantity limit of 1 bottle / 30days
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
19
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
Pemirolast
BRAND NAME
ALAMAST
NOTES
PA: Approvable for diagnosis of allergic conjunctivitis
if tried and failed OR contraindications to Alaway
OTC or Zaditor OTC AND THEN Pataday or
Patanol. For members without OTC coverage,
tried and failed OR contraindications to Crolom
AND THEN Pataday or Patanol.
QL: Quantity limit of 1 bottle/30 days.
 Other Ophthalmic Medications
Atropine
ISOPTOATROPINE
Cyclopentolate
CYCLOGYL
Homatropine
ISOPTOHOMATROPINE
Scopolamine
ISOPTOHYOSCINE
Sodium Chloride Ophthalmic
MURO-128
Tropicamide
MYDRIACYL
Tyloxapol with Benzalkonium Chloride
ENUCLENE
M
M
 Medications For The Ear
Acetic Acid/Aluminum Acetate
DOMEBORO
Acetic Acid/HC
VOSOL HC
Benzocaine/Antipyrine Otic
Neomycin Sulfate/Polymyxin B Sulfate/Buffers/
Hydrocortisone (Otic Suspension)
Neomycin Sulfate/Polymyxin B Sulfate/
Hydrocortisone (Otic Solution)
Neomycin Sulfate/Polymyxin B Sulfate/
Hydrocortisone (Otic Suspension)
Ofloxacin (OTIC)
AURALGAN
PEDIOTIC OTIC SUSPENSION
CORTISPORIN OTIC SOLN
CORTISPORIN OTIC SUSPENSION
FLOXIN
 Medications For The Nose
Beclomethasone Dipropionate Monohydrate
Nasal Inhaler 0.042%
BECONASE AQ
Budesonide Nasal Susp 32 Mcg/Act
RHINOCORT AQUA
Flunisolide Nasal Soln 0.025%
Flunisolide
Fluticasone Propionate
FLONASE
Ipratropium
ATROVENT NASAL SPRAY
Mometasone, Nasal
NASONEX
Triamcinolone Acetonide
NASACORT AQ
PA: Tried and failed OR contraindications to
fluticasone (Flonase) and flunisolide
0.025%.
PA: Tried and failed OR contraindications to
fluticasone (Flonase) AND flunisolide
0.025%.
QL: Quantity limits apply.
Brand Nasarel 29mcg is PA, only generic
flunisolide 25mcg is formulary.
QL: Quantity limits apply.
PA: 0.03%: Tried and failed OR contraindications to
preferred alternatives for patients >12 years old.
Diagnosis of non-allergic perennial rhinitis or
allergic rhinitis. 0.06% not approvable for
allergic rhinitis.
Formulary for patients 2-3 years of age.
PA: Patients 4 years of age and older: Documented
trial and failure OR intolerance to Flonase AND
Nasarel for at least 2 weeks (14 days) of
therapy for each agent: Approve x 1 year.
Continuation of therapy AND patient has tried
and failed Flonase AND Nasarel: Approve x 1
year.
PA: Tried and failed OR contraindications to Flonase
AND Nasarel.
QL: Quantity limits apply.
 Nasal Antihistamine
Azelastine Nasal Spray
ASTELIN
 Medications For The Throat And Mouth
Chlorhexidine Gluconate (for the mouth)
PERIDEX
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
20
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Lidocaine, viscous
VISCOUS XYLOCAINE
Cevimeline HCL
EVOXAC
Triamcinolone 0.1% in Orabarol
KENALOG in ORABASE
NOTES
MEDICATIONS THAT AFFECT THE NERVOUS SYSTEM
 Antianxiety Medications
Alprazolam
XANAX
Buspirone
BUSPAR, VANSPAR
Chlordiazepoxide
LIBRIUM
Clorazepate
TRANXENE SD, TRANXENE T
Diazepam
VALIUM
Lorazepam
ATIVAN
Oxazepam
SERAX
PA: Tried and failed OR contraindications to at least
one preferred alternative.
 Anticonvulsants
Clonazepam
CARBATROL, EQUETRO, TEGRETOL,
TEGRETOL XR
KLONOPIN, KLONOPIN WAFERS
Clorazepate
TRANXENE SD, TRANXENE T
Diazepam
Ethosuximide
VALIUM
DEPAKOTE, DEPAKOTE ER,
DEPAKOTE SPRINKLE
ZARONTIN
Felbamate
FELBATOL
Pregabalin
LYRICA
Gabapentin
NEURONTIN
Lamotrigine
LAMICTAL
Levetiracetam
KEPPRA
Mephenytoin
MESANTOIN
Methsuximide
CELONTIN KAPSEALS
Oxcarbazepine
TRILEPTAL
Phenobarbital
PHENOBARBITAL
Phenytoin
DILANTIN, PHENYTEK
Primidone
MYSOLINE
Rufinamide
BANZEL
Tiagabine
GABITRIL
Topiramate
TOPAMAX
Trimethadione
TRIDIONE
Valproic acid
DEPAKENE
Zonisamide
ZONEGRAN
Carbamazepine
Divalproex sodium
PA: Tried and failed OR contraindications to at least
one preferred alternative.
PA: Pre-requisite therapy required.
Consolidate dose. Doses >3,600mg subject to PA.
PA: Required for Oral Solution.
PA: Tried and failed OR contraindications to at least
one preferred alternative.
PA: Tried and failed OR contraindications to at least
one preferred alternative.
PA: Tried and failed OR contraindications to
preferred alternatives. Approvable for treatment
of seizure disorder, or if prescribed by
neurologist, psychiatrist or pain specialist.
PA: Tried and failed OR contraindications to at least
one preferred alternative.and a dx of LennoxGastaut syndrome.
QL: Quantity Limits apply. Sprinkle caps formulary
for 4yo or less.
PA: Tried and failed OR contraindications to at least
one preferred alternative. Used as an
anticonvulsant.
PA: Tried and failed OR Contraindications to
preferred alternatives.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
21
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
 Antidepressants
Amitriptyline
ELAVIL
Bupropion
WELLBUTRIN
Bupropion SR
WELLBUTRIN SR
Citalopram Hydrobromide
CELEXA
Clomipramine
ANAFRANIL
Desipramine
NORPRAMIN
Doxepin
SINEQUAN
Fluoxetine
PROZAC
Fluvoxamine
LUVOX
Imipramine
TOFRANIL
Imipramine
TOFRANIL PM
Mirtazapine
REMERON
Mirtazapine
REMERON SolTab
Nefazodone
SERZONE
Nortriptyline
PAMELOR
Paroxetine
PAXIL
Paroxetine
PAXIL CR
Protriptyline
Sertraline
VIVACTIL
ZOLOFT
Trazodone
DESYREL
Venlafaxine
EFFEXOR, EFFEXOR XR
Doses > 60mg subject to PA.
QL: Quantity limits apply.
For 40 mg dose, use two 20 mg capsules. 20mg
tablets are nonformulary.
PA: For Prozac weekly.
PA: Tried and failed OR contraindications to at least
one preferred alternative (i.e., contraindications
to Fluoxetine)
PA: Tried and failed OR Contraindications to Tofranil.
PA: Tried and failed OR contraindications to at
least one preferred alternative, including
Mirtazapine tabs.
PA: Required for Paxil CR.
Dosing above 60 mg/day, subject to PA.
PA: Tried and failed OR contraindications to at least
one preferred alternative, including Paxil.
PA: Tried and failed OR contraindications to at least
one preferred alternative.
C1: Must be prescribed by psychiatrist or
continuation of therapy originally initiated by
psychiatrist.
 Anti-Mania
*Medications are carved-out for Medi-Cal members
Lithium Carbonate
ESKALITH, LITHONATE
Lithium Carbonate Sustained Release
ESKALITH CR
Lithium Citrate
LITHIUM
 Anti-Psychotic Medications
*Anti-Psychotic Medications are carved-out for Medi-Cal members
Chlorpromazine
THORAZINE
Clozapine
Fluphenazine Hydrochloride, Fluphenazine
Decanoate, Enanthate
Haloperidol Decanoate, Lactate
CLOZARIL
Loxapine
LOXITANE
Molindone
MOBAN
Olanzapine
ZYPREXA, ZYPREXA ZYDIS
Perphenazine
TRILAFON
Pimozide
ORAP
PROLIXIN
HALDOL
PA: Tried and failed OR contraindications to at least
one preferred alternative. Indicated for treatment
of Psychosis.
PA: Tried and failed OR contraindications to at least
one preferred alternative.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
22
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
Quetiapine
BRAND NAME
NOTES
SEROQUEL, SEROQUEL XR
Risperidone
RISPERDAL, RISPERDAL M-TAB
Thioridazine
MELLARIL
Thiothixene
NAVANE
Trifluoperazine
STELAZINE
Ziprasidone
GEODON
PA: Tried and failed OR contraindications to at least
one preferred alternative.
ALCOHOL CESSATION MEDICATIONS
Disulfiram
ANTABUSE
SMOKING CESSATION MEDICATIONS
Bupropion Sustained Release
WELLBUTRIN SR
Bupropion Sustained Release
ZYBAN
Nicotine (Transdermal)
NICODERM (TRANSDERMAL)
Varenicline
CHANTIX
QL: 60 tablets/30 days. Maximum 3 consecutive fills
for 12 weeks. Maximum one treatment course
per year.
C1, A: Requires letter of certification from behavioral
modification smoking cessation program.
QL: Therapy lasting up to 12 weeks from the
dispensing date of the first prescription. 14
patches/14 days each fill. Maximum one
treatment course per year.
C1: Requires letter of certification from behavioral
modification smoking cessation program.
QL: Therapy lasting up to 12 weeks from the
dispensing date of the first prescription.
Maximum one treatment course per year.
MISCELLANEOUS MEDICATIONS AFFECTING THE BRAIN
 Alzheimer’s Medications
Donepezil
ARICEPT, ARICEPT ODT
C1: Indication: Mild, moderate, and severe dementia
of the Alzheimer’s type. Mild to Severe
Alzheimer’s Disease: MMSE score <26, or
Neuro-Psych testing. Updated MMSE required
every 12 months.
 Myasthenia Gravis Medications
Guanidine
GUANIDINE
Neostigmine
PROSTIGMIN
Pyridostigmine
MESTINON
 Parkinson’s Medications
Amantadine
SYMMETREL
Benztropine Mesylate
COGENTIN
Bromocriptine
PARLODEL
Carbidopa/levodopa
SINEMET
Carbidopa/levodopa CR
SINEMET CR
Levodopa
DOPAR
Ropinirole
REQUIP
Selegiline
ELDEPRYL
Trihexiphenidyl
ARTANE
 Sedative/Hypnotics
Chloral Hydrate
NOCTEC, SOMNOTE
Flurazepam
DALMANE
Hydroxyzine HCL
ATARAX
Hydroxyzine Pamoate
VISTARIL
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
23
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Ramelteon
ROZEREM
Temazepam
RESTORIL
Triazolam
HALCION
Zaleplon
SONATA
Zolpidem
AMBIEN
NOTES
PA: Tried and failed or contraindication to at least two
preferred alternatives. Claim pays at point of
sale when PA criteria are met.
PA Required for 7.5 mg & 22.5mg strengths.
PA: Tried and failed or contraindications to generic
zolpidem (Ambien). Claim pays on-line when
criteria met.
QL: Quantity limit of 30 tabs/month
 Stimulants
Amphetamine & dextroamphetamine mixture
Dextroamphetamine
ADDERALL,
ADDERALL XR
Formulary for patients <18 years old.
PA: Required for patients >18 years old or >1
capsule per day for Adderall XR.
DEXEDRINE
Formulary for patients <18 years old.
PA: Required for patients > 18 years old.
Formulary for patients <18 years old.
PA: Required for patients > 18 years old.
Methylphenidate
RITALIN
Methylphenidate Extended Release
RITALIN SR, METHADATE ER,
CONCERTA, RITALIN LA
Modafinil
PROVIGIL
Formulary for patients <18 years old.
PA: Required for patients >18 years old or >1
tablet per day for Concerta, Ritalin LA.
Concerta 36mg limit: 2 tablets per day.
PA: Tried and failed OR contraindications to at least
three preferred alternatives. Indicated for
treatment of narcolepsy.
MEDICATIONS TO TREAT INFECTIONS
 Antibiotics
Amoxicillin
AMOXIL, TRIMOX
Amoxicillin/potassium clavulanate
AUGMENTIN, AUGMENTIN ES,
AUGMENTIN XR
Ampicillin
PRINCIPEN
Azithromycin
ZITHROMAX
Cefaclor
CECLOR
Cefdinir
OMNICEF
Cefixime
SUPRAX
PA: Prescription from Emergency Room, treatment of
STD or continuation of therapy with a 3rd
generation cephalosporin IV to PO transition.
C1: Otitis Media (O.M.) in children < 8 y.o.
Cefpodoxime
VANTIN
QL: Limit 2 tabs per fill & 2 fills per 180 days.
Cefuroxime
CEFTIN
Cephalexin
KEFLEX
Ciprofloxacin
CIPRO
Clarithromycin
BIAXIN, BIAXIN XL
Clindamycin
CLEOCIN
Demeclocycline
DECLOMYCIN
QL: Limit duration of therapy to 14 days, & 2 fills/90
days
QL: 2 fills/90 days.
Formulary: Capsules & Suspension
PA: Chewable tablets & SR12H.
Formulary: 250mg & 500mg Capsules & Suspension.
PA: Tablets & 750mg Capsules.
Formulary: Tablets.
QL: Limit 14 days/fill & 2 fills/90 days.
PA: Suspension & XR Tablets.
PA: Tried and failed at least one preferred alternative
OR any contraindications to azithromycin. Claim
processes at the point-of-sale when PA criteria
met for treatment of H. pylori (current claim for a
PPI AND amoxicillin (or metronidazole).
Formulary: 150mg Capsules and Suspension for
children <12 years of age.
PA: Required for 300mg capsules (use two 150mg
capsules instead).
PA: Tried and failed OR contraindications to at least
one preferred alternative. Used for treatment of
SIADH.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
24
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
Dicloxacillin
DYNAPEN
Doxycycline
VIBRAMYCIN, VIBRATAB
Eryth Es,Sulf Oral Susp
PEDIAZOLE
Erythromycin Base
ERY-TAB (Enteric Coated)
Erythromycin Ethylsuccinate
EES
Erythromycin Stearate
ERYTHROCIN
Levofloxacin
LEVAQUIN
Linezolid
ZYVOX
Minocycline
DYNACIN, MINOCIN
Moxifloxacin
Neomycin
AVELOX
MYCIFRADIN
Ofloxacin
FLOXIN
Penicillin VK
VEETIDS
Sulfadiazine
SULFADIAZINE
Sulfisoxazole
GANTRISIN
Tetracycline
SUMYCIN
Trimethoprim/ Sulfamethoxazole
BACTRIM, BACTRIM DS, SEPTRA DS
Vancomycin - oral
VANCOCIN
PA: Tried and failed OR contraindications to at least
one preferred alternative. Indicated for:
Pseudomembraneous colitis. Restricted to pts
who have failed Metronidazole therapy.
Atovaquone/Proguanil
MALARONE
PA: Use for prophylaxis of malaria in regions where
chloroquine resistance exists.
Chloroquine
ARALEN
Mefloquine
LARIAM
Primaquine Phosphate
PRIMAQUINE
Pyrimethamine
DARAPRIM
Primethamine/ Sufadoxine
FANSIDAR
Quinine sultfate
QUALAQUIN
PA: Tried and failed or contraindications to preferred
alternatives.
PA: Pre-requisite therapy required.
Formulary for individuals< 30 years old.
QL: Limit 2 capsules/tablets per day.
Formulary: Limit 14 days/fill & 2 fills/90 days.
PA: Tried and failed OR contraindications to at
least one preferred alternative. One dose for
GYN indications is covered without PA.
 Antimalarials
PA: For treatment of Malaria only
 Anti-Parasitic Medications
Iodoquinol
YODOXIN
Mebendazole
VERMOX
Metronidazole
FLAGYL
 Antituberculosis Medications
Ethambutol
MYAMBUTOL
Ethionamide
TRECATOR-SC
Pyrazinamide
PYRAZINAMIDE
Isoniazid
INH
Rif/INH
RIFAMATE
Rif/INH/PZA
RIFATER
Rifabutin
MYCOBUTIN
Rifampin
RIFADIN
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
25
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
ANTIRETROVIRALS
All oral FDA approved HIV agents are eligible for coverage.
*The following HIV Medications are carved-out for Medi-Cal members (billed to State Medi-Cal):
Abacavir/Lamivudine(Ziagen), Abacavir(Epzicom), Abacavir/Lamivudine/Zidovudine(Trizivir), Amprenavir(Agenerase), Atazanavir(Reyataz),
Darunavir(Prezista), Delavirdine(Rescriptor), Efavirenz(Sustiva), Efavirenz/Emtricitabine/Tenofovir(Atripla), Emtricitabine (Emtriva),
Emtricitabine/Tenofovir(Truvada), Enfuvirtide(Fuzeon), Fosamprenavir(Lexiva), Indinavir(Crixivan), Lamivudine(Epivir or 3TC),
Lamivudine/Zidovudine(Combivir), Lopinavir/Ritonavir(Kaletra), Maraviroc(Selzentry), Nelfinavir(Viracept), Nevirapine(Viramune),
Raltegravir(Isentress), Ritonavir(Norvir), Saquinavir(Invirase), Stavudine(Zerit), Tenofovir/Emtricitabine(Truvada), Tenofovir(Viread),
Tipranavir(Aptivus), Zidovudine/Lamivudine(Combivir), Zidovudine/Lamivudine/Abacavir(Trizivir).
*Antiretroviral Medications are limited to a 30-day supply per fill.
*Please note lamivudine is also available as brand name Epivir HBV, which is used for the treatment of hepatitis and not HIV.
 Anti-HIV Medications, CCR5 Co-Receptor Antagonists
Maraviroc
SELZENTRY
PA: Pre-requisite therapy required
FUZEON
PA: Pre-requisite therapy required.
 Anti-HIV Medications, Fusion Inhibitors
Enfuvirtide
 Anti-HIV Medications, Integrase Strand Transfer Inhibitors
Raltegravir
ISENTRESS
PA: Pre-requisite therapy required.
 Anti-HIV Medications, Non-Nucleoside Reverse Transcriptase Inhibitors
Delavirdine
RESCRIPTOR
Efavirenz
SUSTIVA
Etravirine
INTELENCE
Nevirapine
VIRAMUNE
PA: Pre-requisite therapy required
 Anti-HIV Medications, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
Abacavir
ZIAGEN
Abacavir/Lamivudine
EPZICOM
Abacavir/Zidovudine
TRIZIVIR
Didanosine
VIDEX EC, VIDEX PEDIATRIC
Efavirenz/Emtricitabine/Tenofovir
ATRIPLA
Emtricitabine
EMTRIVA
Emtricitabine/Tenofovir
TRUVADA
Lamivudine
EPIVIR
Lamivudine/Zidovudine
COMBIVIR
Stavudine
ZERIT
Tenofovir
VIREAD
Zidovudine
RETROVIR
 Anti-HIV Medications, Protease Inhibitors
Atazanavir
REYATAZ
Darunavir
PREZISTA
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
26
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Fosamprenavir
LEXIVA
Indinavir
CRIXIVAN
Lopinavir/Ritonavir
KALETRA
Nelfinavir
VIRACEPT
Ritonavir
NORVIR
Saquinavir
INVIRASE
Tipranavir
APTIVUS
NOTES
 Misc. Antiviral Medications
Acyclovir
ZOVIRAX
PA:
Docosanol
Abreva
Famciclovir
FAMVIR
Oseltamvir
TAMIFLU
QL: 2 grams per fill
PA: Tried and failed OR contraindications to at least
one preferred alternative.
QL: Solution - 75mL per 6 months.
Capsules - 10 per 6 months.
Zanamivir
RELENZA
QL: 20 units (1 package) per 6 months.
 Oral Antifungals
Clotrimazole
MYCELEX TROCHE
Fluconazole
DIFLUCAN
Flucytosine
ANCOBON
Griseofulvin Microsize
GRIFULVIN
Griseofulvin
GRISPEG
Itraconazole
SPORANOX
Ketoconazole
NIZORAL
Nystatin
MYCOSTATIN
Terbinafine
LAMISIL
PA: Restricted to use in immunocompromised pts,
treatment of documented Aspergillosis, tried and
failure of amphotericin B, or tried and failure to a
preferred antifungal.
 Other Oral Anti-Infective Medications
Atovaquone
MEPRON
Dapsone
DAPSONE
Neomycin
MYCIFARDIN, NEO-FRADIN
PA: Diagnosis of PCP, failure of TMP/SMX.
 Vaginal Anti-Infectives
Acetic Acid, vag
ACID JELLY, VAG GEL
Clindamycin(Cream & Suppositories)
CLEOCIN CREAM & SUPPOSITORIES
Clotrimazole
GYNE-LOTRIMIN, GYNE-LOTRIMIN 3
Metronidazole
METROGEL VAGINAL
Miconazole Nitrate
MONISTAT-7
Nystatin
NYSTATIN
Terconazole
TERAZOL-3, 7
PA: Claim will pay at point-of-sale if contingent
therapy criteria are met, otherwise PA required.
B
B
Claim will pay at point of sale if contingent
therapy criteria are met, otherwise PA required.
IMMUNOLOGICAL AGENTS
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
27
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Entecavir
BARACLUDE
Interferon Alfa
INTRON-A, ROFERON-A
Pegylated Interferon Alfa-2A
PEGASYS, PEG-INTRON KIT
Lamivudine
EPIVIR HBV
Pegylated Interferon Alfa-2B
PEG-INTRON KIT, PEGASYS
Ribavirin
COPEGUS , REBETOL
Valganciclovir
VALCYTE
NOTES
PA: Required except when prescribed by exempt
physicians.
Subject to tablet splitting regardless of prescribing
physician.
PA: Pre-requisite therapy required.
PA: Tried and failed OR contraindications to at least
one preferred alternative. GI consult (including
CCRMC GI specialists), is mandatory.
PA
PA: Tried and failed OR contraindications to at least
one preferred alternative. GI consult (including
CCRMC GI specialists), is mandatory.
PA: Tried and failed OR contraindications to at least
one preferred alternative. CMV retinitis/AIDOphthamology consult required.
ANALGESICS/PAIN/RHEUMATIC MEDICATIONS
Acetaminophen
TYLENOL
B
Aspirin
BAYER
B
Celecoxib
CELEBREX
PA: Restricted to geriatrics (age>65) OR patients
with history of GI bleed OR tried and failed 3
formulary NSAIDs from 3 different NSAID
categories.
Diclofenac
CATAFLAM, VOLTAREN
Etodolac
LODINE, LODINE XL
Ibuprofen
MOTRIN
Indomethacin
INDOCIN
Ketorolac
TORADOL
Meloxicam
MOBIC
Nabumetone
RELAFEN
Naproxen
NAPROSYN
Oxaprozin
DAYPRO
Piroxicam
FELDENE
Salsalate
DISALCID
Sulindac
CLINORIL
Tolmetin
TOLECTIN
 Anti-Inflammatory Medications (NSAIDS)
B
Motrin Rx covered for all CCHP membership.
100mg/5ml suspension only.
PA: Tried and failed OR contraindications to at least
one preferred alternative. Not to exceed 5 days.
PA: Tried and failed OR contraindications to at least
one preferred alternative.
 Anti-Rheumatic Medications
Auranofin
RIDAURA
Hydroxychlorquine
PLAQUENIL
Leflunomide
ARAVA
Methotrexate
METHOTREXATE, MTX
Penicillamine
CUPRIMIN, DEPEN
 Migraine Medications
Ergotamine/caffeine
CAFERGOT
Almotriptan
AXERT
PA: Tried and failed OR contraindications to
preferred agent sumatriptan.
QL: 12 tablets/month with each PA.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
28
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
PA: Tried and failed OR contraindications to
preferred agent sumatriptan.
QL: 12 tablets/month with each PA.
Eletriptan
RELPAX
Naratriptan
AMERGE
Rizatriptan
MAXALT, MAXALT-MLT
Sumatriptan
IMITREX
Zolmitriptan
ZOMIG, ZOMIG-ZMT
PA: Tried and failed OR contraindications to at least
three preferred alternatives.
QL: 12 tablets/month with each PA.
PA: Tried and failed OR contraindications to
preferred agent sumatriptan.
QL: 12 tablets/month with each PA.
QL: Quantity limit on tablets of 12/month.
PA: Tried and failed OR contraindications to
preferred agent sumatriptan.
QL: 12 tablets/month with each PA.
 Analgesics
Diclofenac/Misoprostol
ARTHROTEC
Tramadol
ULTRAM
PA: Tried and failed OR contraindications to
preferred alternatives. Separate agents are
formulary.
QL: Limit: 120 tabs/30 days
 Narcotic Analgesics
Maximum Acetaminophen daily dose = 4gm/day.
Acetaminophen/codeine tabs
TYLENOL #2, #3, #4
Acetaminophen/codeine Elixir
TYLENOL w/CODEINE
Acetaminophen/hydrocodone
NORCO 325/5
Acetaminophen/hydrocodone
NORCO 325/7.5
Acetaminophen/hydrocodone
NORCO 325/10
Acetaminophen/hydrocodone
VICODIN 500/5
Acetaminophen/hydrocodone
VICODIN E.S. 750/7.5
Acetaminophen/hydrocodone
LORCET 650/10
Acetaminophen/Hydrocodone
LORCET PLUS 650/7.5
Acetaminophen/hydrocodone
LORTAB 500/5
Acetaminophen/hydrocodone
LORTAB 500/7.5
Acetaminophen/hydrocodone
LORTAB 500/10
Acetaminophen/hydrocodone
LORTAB ELIXIR 167/2.5
Butalbital/acetaminophen/caffeine
ESGIC, ESGIC PLUS
Butalbital/acetaminophen/caffeine
FIORICET
Butalbital/acetaminophen/caffeine/codeine
FIORICET/ CODEINE
Butalbital/aspirin/caffeine
FIORINAL TABS
Butalbital/aspirin/caffeine/codeine
FIORINAL/CODEINE
Codeine Tabs
CODEINE SULFATE
Codeine Tabs
CODEINE PHOSPHATE
Codeine/Aspirin
EMPIRIN w/Codeine
Fentanyl transdermal patch
DURAGESIC (TRANSDERMAL PATCH)
Hydromorphone
DILAUDID
PA: Tried and failed OR contraindications to at least
one preferred alternative. Treatment of Tension
headache/headache symptom complex.
PA: Tried and failed OR contraindications to at least
one preferred alternative. Treatment of migraine
or tension headache.
PA: Tried and failed or contraindications to Codeine
Sulfate
PA: Tried and failed or contraindications to
Methadone and Morphine SR.
Limit: 1 patch every 3 days.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
29
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
PA: Tried and failed OR contraindications to at least
one preferred alternative. Restricted to patients
refractory to other pain management therapies.
PA: Tried and failed OR contraindications to at least
one preferred alternative. Restricted to patients
refractory to other pain management therapies.
Levorphanol
LEVO-DROMORAN
Meperidine
DEMEROL
Methadone
DOLOPHINE
Morphine (Concentrate).
ROXANOL(CONCENTRATE)
Morphine (Solution & Tablet)
MSIR (SOLUTION & TABLET)
Morphine (Suppositories)
RMS (SUPPOSITORIES)
Morphine SR
MS CONTIN
Oxycodone
OXYCONTIN, ROXICODONE
Oxycodone/acetaminophen
PERCOCET 5/325
Oxycodone/acetaminophen
PERCOCET 5/500
Oxycodone/acetaminophen
TYLOX 5/500
Oxycodone/aspirin
PERCODAN
Pentazocine
TALWIN
Propoxyphene
DARVON
Quantity limit of 6 capsules per day apply.
Propoxyphene HCl-APAP
WYGESIC
Quantity limit of 6 tabs per day apply.
Propoxyphene napsylate/APAP
DARVOCET-N 100
Quantity limit of 6 tabs per day apply.
PA: Tried and failed or contraindications to
Methadone AND Morphine Sulfate.
For Percocet 10/325, use two 5/325 Percocet
tablets
PA: Tried and failed or contraindications to at
preferred alternatives.
PA: Tried and failed OR contraindications to at least
one preferred alternative. Restricted to pts
refractory to other pain management therapies.
 Opiate Antagonists
Naltrexone
REVIA
 Skeletal Muscle Relaxants
Baclofen
LIORESAL
Carisoprodol
SOMA
QL: Quantity limit of 30 tablets per month.
Cyclobenzaprine
FLEXERIL
QL: Quantity limit of 30 tablets per month.
Dantrolene Sodium
DANTRIUM
Diazepam
VALIUM
Tizanidine
ZANAFLEX
2mg and 4mg tablets are formulary. Capsules are
non-formulary. Quantity limits of 30 tabs per
month apply.
NUTRITION
 Electrolytes
KCL (potassium chloride)
GENERIC FORMULATIONS
Potassium Iodide
SSKI
Potassium Acid Phosphate
K-PHOS
 Vitamins and Minerals
Calcitriol
ROCALTROL
Calcium Carbonate
TITRALAC
B
Calcium Gluconate
CALCIUM GLUCONATE
M
Calcium Lactate
CALCIUM LACTATE
M
Electrolytes, Oral Maintenance
PEDIALYTE
Ergocalciferol (Vitamin D)
VITAMIN D
Ferrous Sulfate
FEOSOL
B
B-OTC formulation
A-Rx formulation
B
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
30
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
Folic Acid
FOLIC ACID
Covered: Prescription strength 1mg tablet only.
Pyridoxine
VITAMIN B-6
B
Sodium Flouride (drops & tabs)
LURIDE(DROPS&TABLETS)
Vitamins A, D, C
TRI-VI-SOL
B
Vitamins A, D, C with Iron
TRI-VI-SOL w/IRON
B
Vitamin A, D, C, & Fluoride
TRI-VI-FLOR
Vitamin A, C, D, Fluoride, & Iron
TRI-VI-FLOR w/IRON
Vitamin K
MEPHYTON
 Phosphate Binding Medications
Calcium acetate
Sevelamer
PHOS LO
RENAGEL
PA: Maximum dose: 12,000mg/day.
Maximum approvable quantity: Renagel 400mg
tablets 30 per day. Renagel 800mg tablet 15 per
day.
Approvable if patient on dialysis AND tried and
failed Phoslo (calcium acetate) or serum calcium
>10mg/dL.
RESPIRATORY DRUGS
 Antihistamine/Decongestants
Carbinoxamine/ Pseudoephdrine
RONDEC, RONDEC DM
 Antihistamines
Brompheniramine
J-TAN PD, LODRANE, VAZOL
B: available Rx only
Brompheniramine/Phenylephrine
DIMETAPP
B
Cetirizine
ZYRTEC
B
Cetirizine/Pseudoephedrine
ZYRTEC-D
B
Chlorpheniramine
CHLOR-TRIMETON, CHLORITON, CPM
B: OTC formulations.
Chlorpheniramine/Dextromethorphan
SCOT-TUSSIN DM
B
Cyproheptadine
PERIACTIN
Diphenhydramine
BENADRYL
Doxylamine
DOXYSOM
Fexofenadine
ALLEGRA
Hydroxyzine HCl
ATARAX
Hydroxyzine Pamoate
VISTARIL
Loratadine
CLARITIN
B
Loratadine and pseudoephedrine
CLARITIN-D
B
Promethazine
PHENERGAN
Pseudoephedrine
PEDIACARE, SUDAFED
B
Pseudoephedrine/Guaifenesin
ROBITUSSIN PE
B
Triprolidine
TRIPOHIST, ZYMINE, ZYMINE XR
B
PA: Tried and failed OR contraindications to at least
two preferred alternatives (i.e., OTC Claritin and OTC
Zyrtec).
 Cough Medications
Carbinoxamine/Pseudoephdrine
RONDEC
Carbinoxamine/Pseudoephdrine/Dextromethorphan
RONDEC-DM
Dextromethorphan
ROBITUSSIN MAXIMUM STRENGTH
B
Guaifenesin (Syrup)
ROBITUSSIN (SYRUP)
B
Guaifenesin (Tablet)
MUCINEX (TABLET)
B
Guaifenesin/Codeine
ROBITUSSIN AC
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
31
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Guaifenesin/Dextromethorphan (Syrup)
ROBITUSSIN DM (SYRUP)
B
NOTES
Guaifenesin/Dextromethorphan (Tablet)
MUCINEX DM (TABLET)
B
Guaifenesin/Dextromethorphan/Pseudoephedrine
ROBITUSSIN CF
B
Guaifenesin/Pseudoephedrine (Tablet)
MUCINEX D (TABLET)
B
Hydrocodone/Chlorpheniramine
TUSSIONEX
Hydrocodone/Homatropine
HYCODAN
Promethazine/Dextromethorphan
PHENERGAN w/DM
Promethazine
PHENERGAN
Promethazine/Codeine
PHENERGAN w/CODEINE
Promethazine/Phenylephrine
PHENERGAN VC
Promethazine/Phenylephrine/Codeine
PHENERGAN VC w/CODEINE
 Medications For Asthma & Other Lung Disease
Albuterol HFA MDI, Nebulization
VENTOLIN HFA,
Albuterol Sulfate (Syrup)
VENTOLIN (SYRUP)
Albuterol Sulfate Tab
VOSPIRE ER
Albuterol-ipratropium (Inhaler)
COMBIVENT (INHALER)
Albuterol-ipratropium, (Nebulization)
DUONEB(NEBULIZATION)
Aminophylline
AMINOPHYLLINE
Beclomethasone Dipropionate
QVAR
Budesonide
PULMICORT TURBUHALER
Budesonide Respules
PULMICORT RESPULES
Budesonide/Formoterl
SYMBICORT
Cromolyn
INTAL
Flunisolide
AEROBID, AEROBID-M
Fluticasone Propionate
FLOVENT DISKUS, FLOVENT HFA
Fluticasone Propionate/Salmeterol Xinafoate
ADVAIR DISKUS, ADVAIR HFA
Formoterol
FORADIL
Ipratropium Bromide
ATROVENT HFA
Levalbuterol Nebulizer
XOPENEX, , XOPENEX HFA
Mometasone furoate
ASMANEX
Metaproterenol
ALUPENT
Montelukast Sodium
SINGULAIR
Nedocromil Sodium
TILADE
Pirbuterol
MAXAIR AUTOHALER
PA: Tried and failed or contraindication to at least
one preferred alternative. Tried and failed
combivent inhaler.
PA: Tried and failed or contraindications to other
formulary inhaled corticosteroids including.
Formulary for patients <8 years of age and younger if
dosed within appropriate dosing guidelines as
follows:
 0.25mg/2mL once daily (BID requires PA)
 0.5mg/2mL once or twice daily
 1mg/2mL once daily
PA: Required for patients 9 and older for Diagnosis
of Asthma. Requires tried and failure of a
formulary corticosteroid.
QL: Quantity limits apply
PA: Tried and failed or contraindications to other
Formulary inhaled corticosteroids including
Qvar.
PA: Tried and failed or contraindication to at least
one preferred alternative including Albuterol
solution for nebulization.
PA: Diagnosis: Asthma – Tried and failed preferred
inhaled corticosteroids or insufficient control with
inhaled corticosteroids. Claim pays on-line when
PA criteria met. PA required if criteria not met.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
32
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Salmetrol
SEREVENT DISKUS
Sodium Chloride for Inhalation
SODIUM CHLORIDE FOR INHALATION
Terbutaline
BRETHINE
Theophylline Elixir
ELIXOPHYLLIN
Theophyline SR
THEO-DUR, UNIPHYL
Theophylline

NOTES
B
SLO-PHYLLIN
Triamcinolone
AZMACORT
Zafirlukast
ACCOLATE
Zileuton
ZYFLOW CR
PA: Tried and failed or contraindication to other
formulary inhaled corticosteroids including
Qvar.
PA: Diagnosis: Asthma – Tried and failed preferred
inhaled corticosteroids or insufficient control
with inhaled corticosteroids.
PA: Tried and failed OR contraindications to at least
one preferred alternative in patients > 12 years
old. Indication: Asthma.
Mucolytic Agent
Acetylcysteine
MUCOMYST
SKIN MEDICATIONS (TOPICAL)
 Acne Medications
Formulary: Only 2.5%, 5%, and 10% strengths for all
dosage forms.
Benzoyl peroxide
DESQUAM-E, DESQUAM-X
Clindamycin
CLEOCIN-T
Erythromycin
ERYCETTE, ERY-GEL,
Erythromycin/Benzoyl peroxide
BENZAMYCIN
PA: Tried and failed or contraindication to
erythromycin or benzoyl peroxide as separate
agents.
Metronidazole
METROGEL
C1: Treatment of acne rosacea
Tretinoin
RETIN-A, RETIN-A MICRO
Isotretinoin
ACCUTANE
Formulary for Individuals < 30 years old; PA
required for patients > 30 years old. Formulary
for CCRMC Dermatology regardless of age.
PA: Tried and failed OR contraindications to at least
one preferred alternative. Severe recalcitrant
nodular acne. For Dermatologist only.
 Topical Antiparasitics/Anti-helmintic
Crotamiton
EURAX
Permethrin
Permethrin
ELIMITE
Piperonyl Butoxide/Pyrethrins
R & C, PYRINYL II,
B
Pyrantel Pamoate
REESE'S PINWORM
B
B: OTC formulation (1%)
NIX
 Other Topical Medications
Aluminum Chloride
DRYSOL
Aluminum Acetate
ACID MANTLE
BACIGUENT(OINMENT)
B
B
Bacitracin/polymyxin B Sulfate
POLYSPORIN
Becaplermin
REGRANEX
B
PA: Approvable for diabetic neuropathic ulcers in the
lower extremities. It is not indicated in children
under the age of 16 years. Refer these to
professional services. Ulcer size must be
submitted on PA form.
Collagenase
SANTYL
Calamine Lotion
CALAMINE LOTION
Bacitracin Ointment
B
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
33
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
Coal Tar
IONIL T
Fluorouracil
EFUDEX
Gentamicin
GARAMYCIN
Hydrocortisone; diiodohydroxyquinoline
VYTONE
Hydrocortisone/pramoxine
ZYPRAM
Imiquimod
ALDARA
QL: 1 package per 30 days.
Mupirocin
Papain/Urea/Chlorophyllin Copper Complex
Sodium
Papain/Urea
BACTROBAN
PANAFIL
Oinmtent only. Cream is not covered.
Podofilox Gel
CONDYLOX
Selenium sulfide 2.5%
EXSEL,SELSUN RX
Silver Sulfadiazine
SILVADENE
Trioxsalen
NOTES
M
ACCUZYME
TRISORALEN
QL: Gel-7gm x 4 weeks, Soln-8mL x 4 weeks. 2 units
each soln, or gel. Treatment >4 weeks requires
PA.
PA: Tried and failed OR contraindications to at least
one preferred alternative. Indicated for Vitiligo
OR enhanced pigmentation. Per dermatologists
only.
 Topical Immunomodulator
Pimecrolimus
ELIDEL
Tacrolimus
PROTOPIC
PA: Quantity limit of 1 large tube every 30 days.
Age < 12 years approve x 3 months if written by a
dermatologist AND patient has tried and failed
OR contraindications to at least two (2) formulary
topical corticosteroids. Age > 12 years approve x
3 months if written by a dermatologist AND
patient has tried and failed OR contraindications
to at least two (2) formulary medium or high
potency topical corticosteroids.
PA: Quantity limit of 1 large tube every 30 days.
Age < 12 years approve x 3 months if written by a
dermatologist AND patient has tried and failed
OR contraindications to at least two (2) formulary
topical corticosteroids. Age > 12 years approve x
3 months if written by a dermatologist AND
patient has tried and failed OR contraindications
to at least two (2) formulary medium or high
potency topical corticosteroids.
 Topical Antifungal
B
Clotrimazole
LOTRIMIN AF
Clotrimazole/Betamethasone
LOTRISONE
Econazole
SPECTAZOLE
Gentian Violet 1%
GENTIAN VIOLET
Ketoconazole (cream & shampoo)
NIZORAL (CREAM & SHAMPOO)
Miconazole Cr, 2%
MICATIN, MONISTAT-DERM
Nystatin
MYCOSTATIN
Triamcinolone/Nystatin
MYCOLOG II
Sodium Thiosulfate/Salicylic Acid
EXODERM, VERSICLEAR
Sulconazole
EXELDERM
Tolnaftate
TINACTIN
B
DIPROLENE, DIPROLENE AF
PA: Tried and failed OR contraindications to
PA: Tried and failed OR contraindications to at least
one preferred alternative. Claim processes at the
point of sale when PA criteria met.
B
 Topical Coricosteroids
 Grade 1 (Very High Potency)
Augmented Betamethasone dipropionate 0.05%
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
34
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
GENERIC NAME
BRAND NAME
NOTES
preferred alternatives.
Clobetasol propionate 0.05%
TEMOVATE, TEMOVATE E
Diflorasone diacetate ointment 0.5%
PSORCON E
Halobetasol propionate 0.05%
ULTRAVATE
PA: Tried and failed OR contraindications to
preferred alternatives.
PA: Tried and failed OR contraindications to
clobetasol. Claim pays on-line if criteria met.
 Grade 2 (High Potency)
Amcinonide 0.1%
CYCLOCORT
Betamethasone dipropionate 0.05-0.1%
DIPROSONE
Desoximetasone 0.05-0.25%
TOPICORT
Fluocinonide 0.05%
LIDEX
Halcinonide 0.1%
HALOG
Triamcinolone acetonide 0.5%
ARISTOCORT, KENALOG
PA: Tried and failed OR contraindications to at least
two preferred alternatives.
PA: Tried and failed OR contraindications to at least
two preferred alternatives.
PA: Tried and failed OR contraindications to at least
two preferred alternatives.
 Grade 3 (Medium Potency)
Betamethasone valerate
VALISONE
Clocortolone pivalate 0.1%
CLODERM
Desoximetasone 0.05%
TOPICORT LP
Fluocinolone acetonide 0.025-0.01%
SYNALAR, DERMA-SMOOTHE/FS
Flurandrenolide 0.05%
CORDRAN, CORDRAN SP
Fluticasone propionate 0.05%
CUTIVATE
Hydrocortisone Probutate 0.1%
PANDEL
Hydrocortisone Butyrate 0.1%
LOCOID, LOCOID LIPOCREAM
Hydrocortisone Valerate 0.2%
WESTCORT
Mometasone furoate
ELOCON
Prednicarbate 0.1%
DERMATOP
Triamcinolone acetonide 0.025-0.1%
ARISTOCORT, KENALOG
PA: Tried and failed OR contraindications to at least
two preferred alternatives.
PA: Tried and failed OR contraindications to at
least two preferred alternatives.
PA: Tried and failed OR contraindications to at least
three preferred alternatives.
PA: Tried and failed OR contraindications to at least
three preferred alternatives.
PA: Tried and failed OR contraindications to at least
three preferred alternatives.
PA: Tried and failed OR contraindications to at least
three preferred alternatives.
PA: Tried and failed OR contraindications to at least
three preferred alternatives.
PA: Tried and failed OR contraindications to at least
three preferred alternatives
PA: Tried and failed OR contraindications to at
least three preferred alternatives.
 Grade 4 (Low Potency)
Alclometasone dipropionate 0.05%
ACLOVATE
Desonide 0.05%
DESOWEN
Fluocinolone Acetonide 0.01%
DERMA-SMOOTHE/FS, SYNALAR
Hydrocortisone 0.5-2.5%
CORTAID, HYTONE
PA: Tried and failed OR contraindications to at least
two formulary low potency alternatives.
B: OTC products covered for Medi-Cal & BHC only.
BRANDS ARE LISTED FOR REFERENCE ONLY – GENERICS WILL BE USED WHENEVER AVAILABLE
PA: REFERRING TO A NON-PREFERRED DRUG, REQUIRING A PRIOR AUTHORIZATION REQUEST.
C1: CODE 1 RESTRICTION, REFERRING TO A NON-PREFERRED DRUG REQUIRING A CERTAIN CRITERIA WHICH COULD BE CITED ON THE
PRESCRIPTION OR COMMUNICATED TO THE PHARMACIST. A PHARMACIST COULD ALSO OBTAIN THIS INFORMATION. NO PA FORM IS NECESSARY
TO BE FILLED FOR THIS CONDITION.
Drugs that are not listed require Prior Authorization (PA)
OTC Coverage: M= MEDI-CAL; B= BOTH Basic Health Care (BHC) and MEDI-CAL; A= COMMERCIAL, MEDI-CAL and BASIC HEALTH CARE
35
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
INDEX
2A.......................................................................................................................................................................... 28
2B.......................................................................................................................................................................... 28
A1+++ Chloride Hexahydrate ........................................................................................................................... 33
Abacavir ............................................................................................................................................................... 26
Abacavir/Lamivudine ......................................................................................................................................... 26
Abacavir/Zidovudine .......................................................................................................................................... 26
ABREVA .............................................................................................................................................................. 27
Acarbose................................................................................................................................................................ 8
ACCOLATE ......................................................................................................................................................... 33
ACCUTANE......................................................................................................................................................... 33
ACCUZYME ........................................................................................................................................................ 34
Acebutolol ............................................................................................................................................................ 15
Acetaminophen ................................................................................................................................................... 28
Acetaminophen/codeine Elixir .......................................................................................................................... 29
Acetaminophen/codeine tabs ........................................................................................................................... 29
Acetaminophen/hydrocodone .......................................................................................................................... 29
Acetazolamide Caps .......................................................................................................................................... 18
Acetic Acid 2% .................................................................................................................................................... 20
Acetic Acid, vag .................................................................................................................................................. 27
Acetic Acid/HC .................................................................................................................................................... 20
Acetylcysteine ..................................................................................................................................................... 33
ACID MANTLE.................................................................................................................................................... 33
ACID-JELLY ........................................................................................................................................................ 27
ACIPHEX ............................................................................................................................................................. 12
ACLOVATE ......................................................................................................................................................... 35
ACTONEL.............................................................................................................................................................. 9
ACTOS ................................................................................................................................................................... 9
ACTOSPLUS MET ............................................................................................................................................... 9
ACULAR .............................................................................................................................................................. 17
Acyclovir............................................................................................................................................................... 27
ADALAT ............................................................................................................................................................... 15
ADALAT CC ........................................................................................................................................................ 15
ADDERALL ......................................................................................................................................................... 24
ADDERALL XR ................................................................................................................................................... 24
ADVAIR DISKUS................................................................................................................................................ 32
ADVAIR HFA....................................................................................................................................................... 32
AEROBID, AEROBID-M.................................................................................................................................... 32
AFEDITAB ........................................................................................................................................................... 15
AGGRENOX ....................................................................................................................................................... 17
AKBETA ............................................................................................................................................................... 18
AK-PRED ............................................................................................................................................................. 17
AKPRO................................................................................................................................................................. 18
AK-TRACIN ......................................................................................................................................................... 18
36
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
ALAMAST ............................................................................................................................................................ 20
ALAWAY OTC, ................................................................................................................................................... 19
Albuterol HFA MDI, Nebulization ..................................................................................................................... 32
Albuterol Sulfate (Syrup) ................................................................................................................................... 32
Albuterol Sulfate Tab ......................................................................................................................................... 32
Albuterol-ipratropium (Inhaler) ......................................................................................................................... 32
Albuterol-ipratropium, nebulizer ....................................................................................................................... 32
Alclometasone dipropionate 0.05% ................................................................................................................. 35
ALDACTAZIDE ................................................................................................................................................... 16
ALDACTONE ...................................................................................................................................................... 16
ALDARA............................................................................................................................................................... 34
ALDOMET ........................................................................................................................................................... 15
Alendronate ........................................................................................................................................................... 9
ALESSE ............................................................................................................................................................... 10
ALKERAN .............................................................................................................................................................. 7
ALLEGRA ............................................................................................................................................................ 31
Allopurinol ............................................................................................................................................................ 10
Almotriptan .......................................................................................................................................................... 28
ALOCRIL ............................................................................................................................................................. 19
ALOMIDE............................................................................................................................................................. 19
ALPHAGAN P ..................................................................................................................................................... 18
Alprazolam........................................................................................................................................................... 21
Alprostadil ............................................................................................................................................................ 14
ALTACE ............................................................................................................................................................... 14
Altretamine ............................................................................................................................................................ 7
Aluminum Acetate .............................................................................................................................................. 33
Aluminum Hydroxide Gel .................................................................................................................................. 13
Aluminum Hydroxide, Magnesium Hydroxide, and Simethicone................................................................ 13
ALUPENT ............................................................................................................................................................ 32
Amantadine ......................................................................................................................................................... 23
AMARYL ................................................................................................................................................................ 8
AMBIEN ............................................................................................................................................................... 24
Amcinonide 0.1% ............................................................................................................................................... 35
AMERGE ............................................................................................................................................................. 29
Amiloride .............................................................................................................................................................. 16
Amiloride/HCTZ .................................................................................................................................................. 16
Aminophylline ...................................................................................................................................................... 32
AMINOPHYLLINE .............................................................................................................................................. 32
Amiodarone ......................................................................................................................................................... 14
Amitriptyline ......................................................................................................................................................... 22
Amlodipine ........................................................................................................................................................... 15
Amoxicillin ............................................................................................................................................................ 24
Amoxicillin/potassium clavulanate ................................................................................................................... 24
AMOXIL ............................................................................................................................................................... 24
Amphetamine & dextroamphetamine mixture ............................................................................................... 24
AMPHOGEL ........................................................................................................................................................ 13
37
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Ampicillin.............................................................................................................................................................. 24
Amylase/ Lipase/ Protease ............................................................................................................................... 12
ANAFRANIL ........................................................................................................................................................ 22
Anastrozole ........................................................................................................................................................... 7
ANCOBON .......................................................................................................................................................... 27
ANDROID .............................................................................................................................................................. 8
ANDROXY ............................................................................................................................................................. 8
ANTABUSE ......................................................................................................................................................... 23
Antihistamine with Antitussive .......................................................................................................................... 31
Antihistamine with Nasal Decongestant ......................................................................................................... 31
ANTIVERT ........................................................................................................................................................... 12
ANUSOL-HC CREAM, SUPP ......................................................................................................................... 12
ANZEMET ........................................................................................................................................................... 12
Aprepitant ............................................................................................................................................................ 12
APRESOLINE ..................................................................................................................................................... 17
aptivus .................................................................................................................................................................. 27
ARALEN............................................................................................................................................................... 25
ARAVA ................................................................................................................................................................. 28
ARICEPT ............................................................................................................................................................. 23
ARICEPT ODT .................................................................................................................................................... 23
ARIMIDEX ............................................................................................................................................................. 7
ARISTOCORT .................................................................................................................................................... 35
ARMOUR THYROID .......................................................................................................................................... 11
AROMASIN ........................................................................................................................................................... 7
ARTANE .............................................................................................................................................................. 23
ARTHROTEC...................................................................................................................................................... 29
ASACOL .............................................................................................................................................................. 13
ASMANEX ........................................................................................................................................................... 32
Aspirin .................................................................................................................................................................. 28
ASTELIN .............................................................................................................................................................. 20
ATARAX......................................................................................................................................................... 23, 31
Atazanavir ............................................................................................................................................................ 26
Atenolol ................................................................................................................................................................ 15
Atenolol/Chlorthalidone ..................................................................................................................................... 15
ATIVAN ................................................................................................................................................................ 21
Atorvastatin ......................................................................................................................................................... 16
Atovaquone ......................................................................................................................................................... 27
Atovaquone/Proguanil ....................................................................................................................................... 25
atripla.................................................................................................................................................................... 26
Atropine................................................................................................................................................................ 20
ATROVENT HFA................................................................................................................................................ 32
ATROVENT NASAL SPRAY ............................................................................................................................ 20
AUGMENTIN....................................................................................................................................................... 24
AUGMENTIN ES ................................................................................................................................................ 24
AUGMENTIN XR ................................................................................................................................................ 24
AURALGAN......................................................................................................................................................... 20
38
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Auranofin ............................................................................................................................................................. 28
AVANDAMET ........................................................................................................................................................ 9
AVANDIA ............................................................................................................................................................... 9
AVANDRYL ........................................................................................................................................................... 9
AVELOX............................................................................................................................................................... 25
AXERT ................................................................................................................................................................. 28
AYGESTIN .......................................................................................................................................................... 10
Azathioprine ........................................................................................................................................................ 12
Azelastine HCl .................................................................................................................................................... 19
Azelastine Nasal Spray ..................................................................................................................................... 20
Azithromycin ........................................................................................................................................................ 24
AZMACORT ........................................................................................................................................................ 33
AZOPT ................................................................................................................................................................. 18
AZULFIDINE ....................................................................................................................................................... 13
BACIGUENT ....................................................................................................................................................... 33
Bacitracin ophthalmic ........................................................................................................................................ 18
Bacitracin or Bacitracin Zinc Topical Ointment.............................................................................................. 33
Bacitracin/ Polymyxin B Sultate ....................................................................................................................... 18
Bacitracin/polymyxin .......................................................................................................................................... 33
Baclofen ............................................................................................................................................................... 30
BACTRIM............................................................................................................................................................. 25
BACTRIM DS ...................................................................................................................................................... 25
BACTROBAN...................................................................................................................................................... 34
BANZEL ............................................................................................................................................................... 21
BAYER ................................................................................................................................................................. 28
Becaplermin ........................................................................................................................................................ 33
Beclomethasone Dipropionate ......................................................................................................................... 32
Beclomethasone Dipropionate Monohydrate Nasal Inhaler 0.042% ......................................................... 20
BECONASE AQ ................................................................................................................................................. 20
Belladonna Alkaloids/Phenobarbital................................................................................................................ 11
BELLERGAL-S ................................................................................................................................................... 11
BENADRYL ......................................................................................................................................................... 31
Benazepril............................................................................................................................................................ 14
Benazepril/HCTZ ................................................................................................................................................ 14
BENEMID ............................................................................................................................................................ 10
BENICAR ............................................................................................................................................................. 14
BENICAR HCT ................................................................................................................................................... 14
BENTYL ............................................................................................................................................................... 11
BENZAMYCIN .................................................................................................................................................... 33
Benzocaine/Antipyrine Otic .............................................................................................................................. 20
Benzoyl peroxide gel ......................................................................................................................................... 33
Benztropine Mesylate ........................................................................................................................................ 23
BETAGAN ........................................................................................................................................................... 18
Betamethasone dipropionate 0.05% ............................................................................................................... 34
Betamethasone dipropionate 0.05-0.1% ........................................................................................................ 35
Betamethasone valerate ................................................................................................................................... 35
39
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
BETAPACE ......................................................................................................................................................... 15
BETAPACE AF ................................................................................................................................................... 15
Betaxolol .............................................................................................................................................................. 18
Bethanechol ........................................................................................................................................................ 13
BETIMOL ............................................................................................................................................................. 18
BETOPTIC........................................................................................................................................................... 18
BIAXIN ................................................................................................................................................................. 24
BIAXIN XL ........................................................................................................................................................... 24
Bicalutamide.......................................................................................................................................................... 8
Bimatoprost ......................................................................................................................................................... 18
Bisacodyl ............................................................................................................................................................. 13
Bismuth Subsalicylate ....................................................................................................................................... 13
Bisoprolol/HCTZ ................................................................................................................................................. 15
BLEPH 10 ............................................................................................................................................................ 18
BLEPHAMIDE ..................................................................................................................................................... 19
BLEPHAMIDE S.O.P ......................................................................................................................................... 19
BRETHINE .......................................................................................................................................................... 33
Brimonidine ......................................................................................................................................................... 18
Brinzolamide ....................................................................................................................................................... 18
Bromocriptine ...................................................................................................................................................... 23
BRONCHO SALINE ........................................................................................................................................... 33
Budesonide Nasal Susp 32 Mcg/Act ............................................................................................................... 20
Budesonide Respules........................................................................................................................................ 32
Budesonide Turbuhaler ..................................................................................................................................... 32
Budesonide/Formoterl ....................................................................................................................................... 32
Bumetanide ......................................................................................................................................................... 16
BUMEX ................................................................................................................................................................ 16
Bupropion ............................................................................................................................................................ 22
Bupropion SR...................................................................................................................................................... 22
Bupropion Sustained Release.......................................................................................................................... 23
BUSPAR .............................................................................................................................................................. 21
Buspirone............................................................................................................................................................. 21
Busulfan ................................................................................................................................................................. 7
Butalbital/acetaminophen/caffeine .................................................................................................................. 29
Butalbital/acetaminophen/caffeine/codeine ................................................................................................... 29
Butalbital/aspirin/caffeine .................................................................................................................................. 29
Butalbital/aspirin/caffeine/codeine ................................................................................................................... 29
BYETTA ................................................................................................................................................................. 8
CAFERGOT ........................................................................................................................................................ 28
Calamine Lotion.................................................................................................................................................. 33
CALAMINE LOTION .......................................................................................................................................... 33
CALAN ................................................................................................................................................................. 15
CALAN SR........................................................................................................................................................... 15
Calcitonin-Salmon ................................................................................................................................................ 9
Calcitriol ............................................................................................................................................................... 30
Calcium acetate .................................................................................................................................................. 31
40
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Calcium Carbonate ............................................................................................................................................ 30
Calcium Carbonate/Magnesium Carbonate ................................................................................................... 13
Calcium Gluconate ............................................................................................................................................. 30
Calcium Lactate .................................................................................................................................................. 30
CANASA .............................................................................................................................................................. 13
Capecitabine ......................................................................................................................................................... 7
CAPOTEN ........................................................................................................................................................... 14
Captopril............................................................................................................................................................... 14
CARAFATE ......................................................................................................................................................... 12
Carbachol ............................................................................................................................................................ 18
Carbamazepine .................................................................................................................................................. 21
CARBATROL ...................................................................................................................................................... 21
Carbidopa/levodopa ........................................................................................................................................... 23
Carbidopa/levodopa CR .................................................................................................................................... 23
Carbinoxamine/ Pseudoephdrine .................................................................................................................... 31
CARDENE ........................................................................................................................................................... 15
CARDENE SR .................................................................................................................................................... 15
CARDIZEM.......................................................................................................................................................... 15
CARDIZEM CD ................................................................................................................................................... 15
CARDIZEM LA.................................................................................................................................................... 15
CARDIZEM SR ................................................................................................................................................... 15
CARDURA ..................................................................................................................................................... 13, 17
Carisoprodol ........................................................................................................................................................ 30
CARTIA XT .......................................................................................................................................................... 15
Carvedilol ............................................................................................................................................................. 15
CASODEX ............................................................................................................................................................. 8
CATAFLAM ......................................................................................................................................................... 28
CATAPRES ......................................................................................................................................................... 15
CAVERJECT ....................................................................................................................................................... 14
CECLOR .............................................................................................................................................................. 24
CEENU................................................................................................................................................................... 7
Cefaclor................................................................................................................................................................ 24
Cefdinir ................................................................................................................................................................. 24
Cefixime ............................................................................................................................................................... 24
Cefpodoxime ....................................................................................................................................................... 24
CEFTIN ................................................................................................................................................................ 24
Cefuroxime .......................................................................................................................................................... 24
CELEBREX ......................................................................................................................................................... 28
Celecoxib ............................................................................................................................................................. 28
CELEXA ............................................................................................................................................................... 22
CELLCEPT ............................................................................................................................................................ 8
CELONTIN KAPSEALS .................................................................................................................................... 21
Cephalexin........................................................................................................................................................... 24
Cetirizine .............................................................................................................................................................. 31
Cevimeline HCL.................................................................................................................................................. 21
CHANTIX ............................................................................................................................................................. 23
41
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Chloral Hydrate ................................................................................................................................................... 23
Chlorambucil ......................................................................................................................................................... 7
Chlordiazepoxide ................................................................................................................................................ 21
Chlorhexidine Gluconate ................................................................................................................................... 20
CHLORITON ....................................................................................................................................................... 31
Chloroquine ......................................................................................................................................................... 25
Chlorpromazine .................................................................................................................................................. 22
Chlorthalidone ..................................................................................................................................................... 16
CHLOR-TRIMETON .......................................................................................................................................... 31
Cholestyramine ................................................................................................................................................... 16
Cilostazol ............................................................................................................................................................. 17
CILOXAN ............................................................................................................................................................. 18
Cimetidine............................................................................................................................................................ 11
CIPRO .................................................................................................................................................................. 24
Ciprofloxacin ....................................................................................................................................................... 18
Ciprofloxacin ....................................................................................................................................................... 24
Citalopram Hydrobromide ................................................................................................................................. 22
CITRATE OF MAGNESIUM ............................................................................................................................. 13
Clarithromycin ..................................................................................................................................................... 24
CLARITIN ............................................................................................................................................................ 31
CLARITIN-D ........................................................................................................................................................ 31
CLEOCIN ....................................................................................................................................................... 24, 27
CLEOCIN-T ......................................................................................................................................................... 33
CLIMARA ............................................................................................................................................................... 9
Clindamycin ............................................................................................................................................. 24, 27, 33
Clinidium/Chlordiazepoxide .............................................................................................................................. 11
CLINORIL ............................................................................................................................................................ 28
Clobetasol propionate 0.05% ........................................................................................................................... 35
Clocortolone pivalate 0.1% ............................................................................................................................... 35
CLODERM........................................................................................................................................................... 35
Clomipramine ...................................................................................................................................................... 22
Clonazepam ........................................................................................................................................................ 21
Clonidine .............................................................................................................................................................. 15
Clopidogrel .......................................................................................................................................................... 17
Clorazepate ......................................................................................................................................................... 21
Clotrimazole .................................................................................................................................................. 27, 34
Clotrimazole/Betamethasone ........................................................................................................................... 34
Clozapine ............................................................................................................................................................. 22
CLOZARIL ........................................................................................................................................................... 22
Coal Tar ............................................................................................................................................................... 34
CODEINE PHOSPHATE................................................................................................................................... 29
CODEINE SULFATE ......................................................................................................................................... 29
Codeine Tabs...................................................................................................................................................... 29
Codeine/Aspirin .................................................................................................................................................. 29
Codeine/Guaifenesin ......................................................................................................................................... 31
CODEINE® ......................................................................................................................................................... 29
42
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
COGENTIN ......................................................................................................................................................... 23
Colchicine ............................................................................................................................................................ 10
COLCHICINE ...................................................................................................................................................... 10
Colchicine/Probenecid ....................................................................................................................................... 10
COLESTID........................................................................................................................................................... 16
Colestipol ............................................................................................................................................................. 16
Collagenase ........................................................................................................................................................ 33
COL-PROBENECID........................................................................................................................................... 10
COLYTE......................................................................................................................................................... 11, 13
COMBIVENT (INHALER) .................................................................................................................................. 32
combivir ................................................................................................................................................................ 26
COMPAZINE ....................................................................................................................................................... 12
CONCERTA ........................................................................................................................................................ 24
CONDYLOX ........................................................................................................................................................ 34
Conjugated Estrogen vag ................................................................................................................................... 9
Conjugated Estrogens/Medroxy Progesterone ............................................................................................... 9
COPEGUS........................................................................................................................................................... 28
CORDARONE..................................................................................................................................................... 14
CORDRAN .......................................................................................................................................................... 35
CORDRAN SP .................................................................................................................................................... 35
COREG ................................................................................................................................................................ 15
CORGARD .......................................................................................................................................................... 15
CORTAID, HYTONE.......................................................................................................................................... 35
CORTEF ................................................................................................................................................................ 8
CORTENEMA ..................................................................................................................................................... 13
CORTIFOAM....................................................................................................................................................... 12
CORTISPORIN OPHTH OINTMENT............................................................................................................. 18
CORTISPORIN OPHTH SUSP ........................................................................................................................ 19
CORTISPORIN OTIC SOLN ............................................................................................................................ 20
CORTISPORIN OTIC SUSP ............................................................................................................................ 20
COUMADIN ......................................................................................................................................................... 16
COZAAR .............................................................................................................................................................. 14
CPM...................................................................................................................................................................... 31
CREON ................................................................................................................................................................ 12
CRESTOR ........................................................................................................................................................... 16
crixivan ................................................................................................................................................................. 27
CROLOM ............................................................................................................................................................. 19
Cromolyn ....................................................................................................................................................... 19, 32
Crotamiton ........................................................................................................................................................... 33
CUPRIMIN ........................................................................................................................................................... 28
CUTIVATE ........................................................................................................................................................... 35
CYCLESSA ......................................................................................................................................................... 10
Cyclobenzaprine ................................................................................................................................................. 30
CYCLOCORT ..................................................................................................................................................... 35
CYCLOGYL ......................................................................................................................................................... 20
Cyclopentolate .................................................................................................................................................... 20
43
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Cyclophosphamide .............................................................................................................................................. 7
Cyclosporine Modified ......................................................................................................................................... 8
Cyclosporine non-modified ................................................................................................................................. 8
Cyproheptadine .................................................................................................................................................. 31
CYTOMEL ........................................................................................................................................................... 11
CYTOTEC ........................................................................................................................................................... 11
CYTOXAN ............................................................................................................................................................. 7
DALMANE ........................................................................................................................................................... 23
DANTRIUM ......................................................................................................................................................... 30
Dantrolene Sodium ............................................................................................................................................ 30
Dapsone............................................................................................................................................................... 27
DAPSONE ........................................................................................................................................................... 27
DARAPRIM ......................................................................................................................................................... 25
Darunavir ............................................................................................................................................................. 26
DARVOCET-N 100 ............................................................................................................................................ 30
DARVON ............................................................................................................................................................. 30
Dasatinib ................................................................................................................................................................ 7
DAYPRO .............................................................................................................................................................. 28
DDAVP ................................................................................................................................................................. 11
DECADRON.................................................................................................................................................... 8, 17
DECLOMYCIN .................................................................................................................................................... 24
Delavirdine........................................................................................................................................................... 26
DEMADEX ........................................................................................................................................................... 16
Demeclocycline................................................................................................................................................... 24
DEMEROL TABS ............................................................................................................................................... 30
DEMSER ............................................................................................................................................................... 7
DEMULEN ........................................................................................................................................................... 10
DEPAKENE ......................................................................................................................................................... 21
DEPAKOTE ......................................................................................................................................................... 21
DEPAKOTE ER .................................................................................................................................................. 21
DEPAKOTE SPRINKLE .................................................................................................................................... 21
DEPEN ................................................................................................................................................................. 28
DEPO-PROVERA .............................................................................................................................................. 10
DEPO-TESTOSTERONE (inj) ........................................................................................................................... 8
DERMA-SMOOTHE/FS .................................................................................................................................... 35
DERMA-SMOOTHE/FS, SYNALAR ............................................................................................................... 35
DERMATOP ........................................................................................................................................................ 35
Desipramine ........................................................................................................................................................ 22
Desmopressin Acetate ...................................................................................................................................... 11
DESOGEN........................................................................................................................................................... 10
Desonide 0.05% ................................................................................................................................................. 35
DESOWEN .......................................................................................................................................................... 35
Desoximetasone 0.05% .................................................................................................................................... 35
Desoximetasone 0.25% .................................................................................................................................... 35
DESQUAM-E ...................................................................................................................................................... 33
DESQUAM-X ...................................................................................................................................................... 33
44
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
DESYREL ............................................................................................................................................................ 22
DETROL .............................................................................................................................................................. 13
DETROL LA ........................................................................................................................................................ 13
Dexamethasone ............................................................................................................................................. 8, 17
DEXEDRINE ....................................................................................................................................................... 24
DEXILANT ........................................................................................................................................................... 11
Dexlansoprazole ................................................................................................................................................. 11
Dextroamphetamine .......................................................................................................................................... 24
Dextromethorphan ............................................................................................................................................. 31
DIABETA/MICRONASE ...................................................................................................................................... 8
DIAMOX ......................................................................................................................................................... 15, 18
DIAMOX SEQUELS ..................................................................................................................................... 15, 18
Diazepam....................................................................................................................................................... 21, 30
DIBENZYLINE ...................................................................................................................................................... 7
Diclofenac ............................................................................................................................................................ 28
Diclofenac/Misoprostol ...................................................................................................................................... 29
Dicloxacillin .......................................................................................................................................................... 25
Dicyclomine ......................................................................................................................................................... 11
Didanosine........................................................................................................................................................... 26
DIDRONEL ............................................................................................................................................................ 9
Diflorasone diacetate ointment 0.5% .............................................................................................................. 35
DIFLUCAN........................................................................................................................................................... 27
DIGEL................................................................................................................................................................... 13
Digoxin ................................................................................................................................................................. 14
DILACOR XR ...................................................................................................................................................... 15
DILANTIN ............................................................................................................................................................ 21
DILATRATE......................................................................................................................................................... 17
DILATRATE SR .................................................................................................................................................. 17
DILAUDID ............................................................................................................................................................ 29
DILT XR ............................................................................................................................................................... 15
Diltiazem .............................................................................................................................................................. 15
Diltiazem CR ....................................................................................................................................................... 15
Diltiazem SR, Diltiazem ER .............................................................................................................................. 15
DIMETAPP .......................................................................................................................................................... 31
DIPENTUM.......................................................................................................................................................... 13
Diphenhydramine ............................................................................................................................................... 31
Diphenoxylate/Atropine ............................................................................................................................... 11, 12
Dipivefrin .............................................................................................................................................................. 18
DIPROLENE ....................................................................................................................................................... 34
DIPROLENE AF ................................................................................................................................................. 34
DIPROSONE....................................................................................................................................................... 35
Dipyridamole ....................................................................................................................................................... 17
Dipyridamole/Aspirin .......................................................................................................................................... 17
DISALCID ............................................................................................................................................................ 28
Disopyramide ...................................................................................................................................................... 14
Disulfiram ............................................................................................................................................................. 23
45
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
DITROPAN .......................................................................................................................................................... 13
DITROPAN XL .................................................................................................................................................... 13
Divalproex sodium .............................................................................................................................................. 21
Docosanol............................................................................................................................................................ 27
Docusate Sodium ............................................................................................................................................... 13
Dofetilide .............................................................................................................................................................. 14
Dolasetron ........................................................................................................................................................... 12
DOLOPHINE ....................................................................................................................................................... 30
DOMEBORO ....................................................................................................................................................... 20
Donepezil ............................................................................................................................................................. 23
DONNATAL ......................................................................................................................................................... 11
DOPAR ................................................................................................................................................................ 23
Dorzolamide ........................................................................................................................................................ 18
Doxazosin ............................................................................................................................................................ 17
Doxazosin Mesylate ........................................................................................................................................... 13
Doxepin ................................................................................................................................................................ 22
Doxycycline ......................................................................................................................................................... 25
Doxylamine.......................................................................................................................................................... 31
DOXYSOM .......................................................................................................................................................... 31
Dronabinol ........................................................................................................................................................... 12
DROXIA ................................................................................................................................................................. 7
DRYSOL .............................................................................................................................................................. 33
DSS ...................................................................................................................................................................... 13
DUETACT .............................................................................................................................................................. 8
DULCOLAX ......................................................................................................................................................... 13
DUONEB ............................................................................................................................................................. 32
DURAGESIC ....................................................................................................................................................... 29
DYAZIDE ............................................................................................................................................................. 16
DYNACIN............................................................................................................................................................. 25
DYNACIRC .......................................................................................................................................................... 15
DYNACIRC CR ................................................................................................................................................... 15
DYNAPEN ........................................................................................................................................................... 25
Echothiophate Iodide ......................................................................................................................................... 18
Econazole ............................................................................................................................................................ 34
ECONOPRED PLUS ......................................................................................................................................... 17
EDECRIN............................................................................................................................................................. 16
EES....................................................................................................................................................................... 25
Efavirenz .............................................................................................................................................................. 26
Efavirenz/Emtricitabine/Tenofovir .................................................................................................................... 26
EFFEXOR, EFFEXOR XR ................................................................................................................................ 22
EFUDEX .............................................................................................................................................................. 34
ELAVIL ................................................................................................................................................................. 22
ELDEPRYL.......................................................................................................................................................... 23
Electrolytes, Oral Maintenance ........................................................................................................................ 30
Elestat .................................................................................................................................................................. 19
Eletriptan.............................................................................................................................................................. 29
46
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
ELIDEL ................................................................................................................................................................. 34
ELIMITE ............................................................................................................................................................... 33
ELMIRON ............................................................................................................................................................ 13
ELOCON.............................................................................................................................................................. 35
EMADINE ............................................................................................................................................................ 19
EMCYT................................................................................................................................................................... 7
Emedastine Difumarate ..................................................................................................................................... 19
EMEND ................................................................................................................................................................ 12
EMPIRIN w/Codeine .......................................................................................................................................... 29
Emtricitabine ....................................................................................................................................................... 26
Emtricitabine/Tenofovir ...................................................................................................................................... 26
emtriva ................................................................................................................................................................. 26
Enalapril ............................................................................................................................................................... 14
Enfuvirtide ............................................................................................................................................................ 26
Enoxaparin .......................................................................................................................................................... 16
ENUCLENE ......................................................................................................................................................... 20
Epinastine HCl .................................................................................................................................................... 19
EPIPEN ................................................................................................................................................................ 17
EPIPEN JR .......................................................................................................................................................... 17
epivir ..................................................................................................................................................................... 26
EPIVIR HBV ........................................................................................................................................................ 28
EPOGEN ............................................................................................................................................................. 17
epzicom ................................................................................................................................................................ 26
EQUETRO ........................................................................................................................................................... 21
Ergocalciferol (Vitamin D) ................................................................................................................................. 30
Ergotamine/Belladonna/Phenobarbital ........................................................................................................... 11
Ergotamine/caffeine ........................................................................................................................................... 28
Erlotinib .................................................................................................................................................................. 7
ERYCETTE ......................................................................................................................................................... 33
ERY-GEL ............................................................................................................................................................. 33
ERY-TAB (Enteric Coated) ............................................................................................................................... 25
Eryth Es,Sulf Oral Susp .................................................................................................................................... 25
ERYTHROCIN .................................................................................................................................................... 25
Erythromycin ................................................................................................................................................. 18, 33
Erythromycin Base ............................................................................................................................................. 25
Erythromycin Ethylsuccinate ............................................................................................................................ 25
Erythromycin Stearate ....................................................................................................................................... 25
Erythromycin/Benzoyl peroxide ....................................................................................................................... 33
Erythropoietin (Epoetin Alfa)............................................................................................................................. 17
ESGIC .................................................................................................................................................................. 29
ESGIC PLUS....................................................................................................................................................... 29
ESKALITH ........................................................................................................................................................... 22
ESKALITH CR .................................................................................................................................................... 22
Esomeprazole ..................................................................................................................................................... 11
Esterified Estrogens ............................................................................................................................................. 9
Esterified Estrogens/ Methyltestosterone ....................................................................................................... 10
47
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
ESTINYL, ESTRACE ........................................................................................................................................... 9
Estradiol ................................................................................................................................................................. 9
Estradiol, transdermal.......................................................................................................................................... 9
Estradiol/Norgestrel ........................................................................................................................................... 10
Estramustine ......................................................................................................................................................... 7
ESTRATEST ....................................................................................................................................................... 10
Estropipate ............................................................................................................................................................ 9
Ethacrynic Acid ................................................................................................................................................... 16
Ethambutol .......................................................................................................................................................... 25
Ethinyl Estradiol/Desogestrel ........................................................................................................................... 10
Ethinyl Estradiol/Drospirenone ......................................................................................................................... 10
Ethinyl Estradiol/Ethynodiol .............................................................................................................................. 10
Ethinyl Estradiol/Etonogestrel .......................................................................................................................... 10
Ethinyl Estradiol/Levonorgestrel ...................................................................................................................... 10
Ethinyl Estradiol/Norelgestromin...................................................................................................................... 10
Ethinyl Estradiol/Norethindrone ....................................................................................................................... 10
Ethinyl Estradiol/Norgestimate ......................................................................................................................... 10
Ethinyl Estradiol/Norgestrel .............................................................................................................................. 10
Ethionamide ........................................................................................................................................................ 25
ETHMOZINE ....................................................................................................................................................... 14
Ethosuximide....................................................................................................................................................... 21
Etidronate Disodium ............................................................................................................................................ 9
Etodolac ............................................................................................................................................................... 28
ETOPOPHOS ....................................................................................................................................................... 7
Etoposide ............................................................................................................................................................... 7
Etravirine .............................................................................................................................................................. 26
EURAX ................................................................................................................................................................. 33
EVISTA .................................................................................................................................................................. 9
EVOXAC .............................................................................................................................................................. 21
EXELDERM......................................................................................................................................................... 34
Exemestane .......................................................................................................................................................... 7
Exenatide ............................................................................................................................................................... 8
EXODERM .......................................................................................................................................................... 34
EXSEL.................................................................................................................................................................. 34
Famciclovir .......................................................................................................................................................... 27
Famotidine ........................................................................................................................................................... 11
FAMVIR ............................................................................................................................................................... 27
FANSIDAR .......................................................................................................................................................... 25
FARESTON ........................................................................................................................................................... 7
Felbamate............................................................................................................................................................ 21
FELBATOL .......................................................................................................................................................... 21
FELDENE ............................................................................................................................................................ 28
Felodipine ............................................................................................................................................................ 15
FEMARA ................................................................................................................................................................ 7
Fenofibrate .......................................................................................................................................................... 16
Fentanyl transdermal patch .............................................................................................................................. 29
48
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
FEOSOL .............................................................................................................................................................. 30
Ferrous Sulfate ................................................................................................................................................... 30
Fexofenadine ...................................................................................................................................................... 31
Finasteride ........................................................................................................................................................... 13
FIORICET ............................................................................................................................................................ 29
FIORICET TABS ................................................................................................................................................ 29
FIORINAL TABS................................................................................................................................................. 29
FIORINAL/CODEINE TABS ............................................................................................................................. 29
FLAGYL ............................................................................................................................................................... 25
FLAREX ............................................................................................................................................................... 17
Flecainide ............................................................................................................................................................ 14
FLEXERIL............................................................................................................................................................ 30
FLOMAX .............................................................................................................................................................. 13
FLONASE ............................................................................................................................................................ 20
FLORINEF ............................................................................................................................................................. 8
FLOVENT DISKUS ............................................................................................................................................ 32
FLOVENT HFA ................................................................................................................................................... 32
FLOXIN .......................................................................................................................................................... 20, 25
Fluconazole ......................................................................................................................................................... 27
Flucytosine .......................................................................................................................................................... 27
Fludrocortisone ..................................................................................................................................................... 8
Flunisolide ........................................................................................................................................................... 32
Flunisolide Nasal Soln 0.025% ........................................................................................................................ 20
Fluocinolone Acetonide 0.01% ........................................................................................................................ 35
Fluocinolone acetonide 0.025-0.01%.............................................................................................................. 35
Fluocinonide 0.01-0.05% .................................................................................................................................. 35
Fluorometholone................................................................................................................................................. 17
Fluorouracil.......................................................................................................................................................... 34
Fluoxetine ............................................................................................................................................................ 22
Fluoxymesterone .................................................................................................................................................. 8
Fluphenazine Decanoate, Enanthate.............................................................................................................. 22
Fluphenazine Hydrochloride ............................................................................................................................. 22
Flurandrenolide 0.05% ...................................................................................................................................... 35
Flurazepam ......................................................................................................................................................... 23
FLUR-OP ............................................................................................................................................................. 17
Flutamide ............................................................................................................................................................... 8
FLUTAMIDE .......................................................................................................................................................... 8
Fluticasone Propionate...................................................................................................................................... 32
Fluticasone propionate 0.05%.......................................................................................................................... 35
Fluticasone Propionate Nasal Inhaler 50 Mcg/dose ..................................................................................... 20
Fluticasone Propionate/Salmeterol Xinafoate ............................................................................................... 32
Fluvastatin ........................................................................................................................................................... 16
Fluvoxamine ........................................................................................................................................................ 22
FML FORTE ........................................................................................................................................................ 17
FML LIQUIFILM .................................................................................................................................................. 17
Folic Acid ............................................................................................................................................................. 31
49
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
FOLIC ACID ........................................................................................................................................................ 31
FORADIL ............................................................................................................................................................. 32
Formoterol ........................................................................................................................................................... 32
FOSAMAX ............................................................................................................................................................. 9
Fosamprenavir .................................................................................................................................................... 27
FURADANTIN ..................................................................................................................................................... 13
Furosemide ......................................................................................................................................................... 16
FUZEON .............................................................................................................................................................. 26
Gabapentin .......................................................................................................................................................... 21
GABITRIL ............................................................................................................................................................ 21
GANTRISIN ......................................................................................................................................................... 25
GARAMYCIN ...................................................................................................................................................... 34
Gefitinib .................................................................................................................................................................. 7
Gemfibrozil .......................................................................................................................................................... 16
GENERIC FORMULATIONS ........................................................................................................................... 30
GENGRAF ............................................................................................................................................................. 8
GENOPTIC.......................................................................................................................................................... 18
GENOPTIC S.O.P. ............................................................................................................................................. 18
Gentamicin .................................................................................................................................................... 18, 34
Gentamicin/Prednisolone .................................................................................................................................. 18
GENTIAN VIOLET ............................................................................................................................................. 34
Gentian Violet 1% .............................................................................................................................................. 34
GEODON ............................................................................................................................................................. 23
GLEEVEC.............................................................................................................................................................. 7
Glilmepiride/Pioglitazone..................................................................................................................................... 8
Glimepirid............................................................................................................................................................... 9
Glimepiride ............................................................................................................................................................ 8
Glipizide ................................................................................................................................................................. 8
GLUCOPHAGE .................................................................................................................................................... 9
GLUCOTROL........................................................................................................................................................ 8
Glyburide ............................................................................................................................................................... 8
GLYCOLAX ......................................................................................................................................................... 12
GLYSET ................................................................................................................................................................. 9
Granisetron.......................................................................................................................................................... 12
GRIFULVIN ......................................................................................................................................................... 27
Griseofulvin ......................................................................................................................................................... 27
GRISPEG ............................................................................................................................................................ 27
Guaifenesin ......................................................................................................................................................... 31
Guaifenesin/Dextromethorphan (Syrup) ......................................................................................................... 32
Guaifenesin/Dextromethorphan (Tablet) ........................................................................................................ 32
Guanfacine .......................................................................................................................................................... 15
Guanidine ............................................................................................................................................................ 23
GUANIDINE ........................................................................................................................................................ 23
GYNE-LOTRIMIN ............................................................................................................................................... 27
GYNE-LOTRIMIN 3 ........................................................................................................................................... 27
Halcinonide 0.025-0.1% .................................................................................................................................... 35
50
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
HALCION ............................................................................................................................................................. 24
HALDOL............................................................................................................................................................... 22
Halobetasol propionate 0.05% ......................................................................................................................... 35
HALOG................................................................................................................................................................. 35
Haloperidol Decanoate, Lactate ...................................................................................................................... 22
HCTZ/Triamterene ............................................................................................................................................. 16
Heparin Sodium .................................................................................................................................................. 16
HEPARIN SODIUM............................................................................................................................................ 16
HEXALEN .............................................................................................................................................................. 7
HIV agents ........................................................................................................................................................... 26
Homatropine........................................................................................................................................................ 20
HUMALOG 50/50 ................................................................................................................................................. 9
HUMALOG 75/25 ................................................................................................................................................. 9
HUMULIN 50/50 ................................................................................................................................................... 9
HUMULIN 70/30 ................................................................................................................................................... 9
HUMULIN N .......................................................................................................................................................... 9
HUMULIN R .......................................................................................................................................................... 9
HYCODAN........................................................................................................................................................... 32
Hydralazine ......................................................................................................................................................... 17
HYDREA ................................................................................................................................................................ 7
Hydrochlorothiazide ........................................................................................................................................... 16
Hydrocodone/Chlorpheniramine ...................................................................................................................... 32
Hydrocodone/Homatropine ............................................................................................................................... 32
Hydrocortisone.............................................................................................................................. 8, 12, 13, 34, 35
Hydrocortisone 0.5-2.5% .................................................................................................................................. 35
Hydrocortisone Acetate Rectal ........................................................................................................................ 12
Hydrocortisone Butyrate 0.1% ......................................................................................................................... 35
Hydrocortisone diiodohydroxyquinoline .......................................................................................................... 34
Hydrocortisone Probutate 0.1% ....................................................................................................................... 35
Hydrocortisone Retention Enema.................................................................................................................... 13
Hydrocortisone Valerate 0.2% ......................................................................................................................... 35
Hydrocortisone/pramoxine ................................................................................................................................ 34
HYDRODIURIL ................................................................................................................................................... 16
Hydromorphone .................................................................................................................................................. 29
Hydroxychlorquine ............................................................................................................................................. 28
Hydroxyurea .......................................................................................................................................................... 7
Hydroxyzine......................................................................................................................................................... 31
Hydroxyzine HCL ............................................................................................................................................... 23
Hydroxyzine Pamoate ................................................................................................................................. 23, 31
HYGROTON ....................................................................................................................................................... 16
Hyoscyamine....................................................................................................................................................... 11
Hyoscyamine Sulfate CR .................................................................................................................................. 11
HYTRIN .......................................................................................................................................................... 13, 17
HYZAAR .............................................................................................................................................................. 14
Ibuprofen.............................................................................................................................................................. 28
ILOTYCIN OPHTH OINT .................................................................................................................................. 18
51
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Imatinib................................................................................................................................................................... 7
IMDUR ................................................................................................................................................................. 17
IMDUR/ ISMO/ MONOKET............................................................................................................................... 17
Imipramine ........................................................................................................................................................... 22
Imiquimod ............................................................................................................................................................ 34
IMITREX .............................................................................................................................................................. 29
IMODIUM ............................................................................................................................................................. 12
IMURAN ............................................................................................................................................................... 12
Indapamide.......................................................................................................................................................... 16
INDERAL ............................................................................................................................................................. 15
INDERAL LA ....................................................................................................................................................... 15
INDERIDE ........................................................................................................................................................... 15
Indinavir ............................................................................................................................................................... 27
INDOCIN.............................................................................................................................................................. 28
Indomethacin....................................................................................................................................................... 28
INFLAMASE FORTE ......................................................................................................................................... 17
INH........................................................................................................................................................................ 25
Insulin ..................................................................................................................................................................... 9
INTAL ................................................................................................................................................................... 32
INTELENCE ........................................................................................................................................................ 26
Interferon Alfa ..................................................................................................................................................... 28
INTRON-A ........................................................................................................................................................... 28
invirase ................................................................................................................................................................. 27
Iodoquinol ............................................................................................................................................................ 25
IONIL T................................................................................................................................................................. 34
Ipratropium .......................................................................................................................................................... 20
Ipratropium Bromide .......................................................................................................................................... 32
IRESSA .................................................................................................................................................................. 7
ISENTRESS ........................................................................................................................................................ 26
ISMO .................................................................................................................................................................... 17
Isoniazid ............................................................................................................................................................... 25
ISOPTIN SR ........................................................................................................................................................ 15
ISOPTO CARPINE, ........................................................................................................................................... 18
ISOPTOATROPINE ........................................................................................................................................... 20
ISOPTO-CARBACHOL ..................................................................................................................................... 18
ISOPTOHOMATROPINE .................................................................................................................................. 20
ISOPTOHYOSCINE........................................................................................................................................... 20
ISORDIL............................................................................................................................................................... 17
Isosorbide Dinitrate ............................................................................................................................................ 17
Isosorbide Dinitrate SR ..................................................................................................................................... 17
Isosorbide Mononitrate ...................................................................................................................................... 17
Isotretinoin ........................................................................................................................................................... 33
Isradipine ............................................................................................................................................................. 15
Itraconazole ......................................................................................................................................................... 27
JANUMET.............................................................................................................................................................. 9
JANUVIA................................................................................................................................................................ 9
52
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
J-TAN PD............................................................................................................................................................. 31
kaletra................................................................................................................................................................... 27
KCL ....................................................................................................................................................................... 30
KEFLEX ............................................................................................................................................................... 24
KENALOG ........................................................................................................................................................... 35
KENALOG in ORABASE................................................................................................................................... 21
KEPPRA .............................................................................................................................................................. 21
Ketoconazole ...................................................................................................................................................... 27
Ketoconazole (cream & shampoo) .................................................................................................................. 34
Ketorolac.............................................................................................................................................................. 28
Ketorolac OPHTH............................................................................................................................................... 17
Ketotifen furmarate ............................................................................................................................................ 19
KLONOPIN .......................................................................................................................................................... 21
KLONOPIN WAFERS........................................................................................................................................ 21
K-PHOS ............................................................................................................................................................... 30
KYTRIL................................................................................................................................................................. 12
Labetalol .............................................................................................................................................................. 15
LAMICTAL ........................................................................................................................................................... 21
LAMISIL ............................................................................................................................................................... 27
Lamivudine .................................................................................................................................................... 26, 28
Lamivudine/Zidovudine ..................................................................................................................................... 26
Lamotrigine .......................................................................................................................................................... 21
LANOXIN ............................................................................................................................................................. 14
Lansoprazole....................................................................................................................................................... 11
LANTUS ................................................................................................................................................................. 9
Lapatinib ................................................................................................................................................................ 7
LARIAM................................................................................................................................................................ 25
LASIX ................................................................................................................................................................... 16
Latanoprost ......................................................................................................................................................... 18
Leflunomide ......................................................................................................................................................... 28
Lenalidomide ......................................................................................................................................................... 7
LESCOL ............................................................................................................................................................... 16
Letrozole ................................................................................................................................................................ 7
LEUKERAN ........................................................................................................................................................... 7
Leuprolide ............................................................................................................................................................ 11
Levalbuterol Nebulizer ....................................................................................................................................... 32
LEVAQUIN .......................................................................................................................................................... 25
LEVEMIR ............................................................................................................................................................... 9
Levetiracetam ..................................................................................................................................................... 21
Levobunolol ......................................................................................................................................................... 18
Levodopa ............................................................................................................................................................. 23
LEVO-DROMORAN ........................................................................................................................................... 30
Levofloxacin ........................................................................................................................................................ 25
Levonorgestrel .................................................................................................................................................... 10
Levorphanol......................................................................................................................................................... 30
Levothyroxine ...................................................................................................................................................... 11
53
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
LEVSIN ................................................................................................................................................................ 11
LEVSINEX ........................................................................................................................................................... 11
lexiva .................................................................................................................................................................... 27
LIBRAX ................................................................................................................................................................ 11
LIBRIUM .............................................................................................................................................................. 21
LIDEX ................................................................................................................................................................... 35
Lidocaine ............................................................................................................................................................. 21
LIORESAL ........................................................................................................................................................... 30
Liothyronine ......................................................................................................................................................... 11
Liotrix .................................................................................................................................................................... 11
LIPITOR ............................................................................................................................................................... 16
Lisinopril ............................................................................................................................................................... 14
Lisinopril/HCTZ ................................................................................................................................................... 14
LITHIUM............................................................................................................................................................... 22
Lithium Carbonate .............................................................................................................................................. 22
Lithium Carbonate Sustained Release ........................................................................................................... 22
Lithium Citrate ..................................................................................................................................................... 22
LITHONATE ........................................................................................................................................................ 22
LO OVRAL........................................................................................................................................................... 10
LOCOID, LOCOID LIPOCREAM .................................................................................................................... 35
LODINE................................................................................................................................................................ 28
LODINE XL.......................................................................................................................................................... 28
Lodoxamide ......................................................................................................................................................... 19
LODRANE ........................................................................................................................................................... 31
LOESTRIN FE 1.5/30 ........................................................................................................................................ 10
LOESTRIN FE 1/20 ........................................................................................................................................... 10
LOFIBRA ............................................................................................................................................................. 16
LOMOTIL ....................................................................................................................................................... 11, 12
Lomustine .............................................................................................................................................................. 7
LONITEN ....................................................................................................................................................... 15, 17
Loperamide (2 mg capsules) ............................................................................................................................ 12
LOPID................................................................................................................................................................... 16
Lopinavir/Ritonavir ............................................................................................................................................. 27
LOPRESSOR...................................................................................................................................................... 15
Loratadine............................................................................................................................................................ 31
Loratadine and pseudoephedrine .................................................................................................................... 31
Lorazepam........................................................................................................................................................... 21
LORCET 650/10 ................................................................................................................................................. 29
LORTAB 500/10 ................................................................................................................................................. 29
LORTAB 500/5 ................................................................................................................................................... 29
LORTAB 500/7.5 ................................................................................................................................................ 29
LORTAB ELIXIR 167/2.5 .................................................................................................................................. 29
Losartan ............................................................................................................................................................... 14
Losartan/HCTZ ................................................................................................................................................... 14
LOTENSIN........................................................................................................................................................... 14
LOTENSIN HCT ................................................................................................................................................. 14
54
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
LOTRIMIN AF ..................................................................................................................................................... 34
LOTRISONE ....................................................................................................................................................... 34
Lovastatin ............................................................................................................................................................ 16
LOVENOX ........................................................................................................................................................... 16
Loxapine .............................................................................................................................................................. 22
LOXITANE ........................................................................................................................................................... 22
LOZOL ................................................................................................................................................................. 16
LUMIGAN ............................................................................................................................................................ 18
LUPRON DEPOT ............................................................................................................................................... 11
LUPRON DEPOT PED...................................................................................................................................... 11
LURIDE ................................................................................................................................................................ 31
LUVOX ................................................................................................................................................................. 22
LYRICA ................................................................................................................................................................ 21
LYSODREN........................................................................................................................................................... 8
MACROBID ......................................................................................................................................................... 13
MACRODANTIN ................................................................................................................................................. 13
Magnesium Citrate ............................................................................................................................................. 13
MALARONE ........................................................................................................................................................ 25
Maraviroc ............................................................................................................................................................. 26
MARINOL ............................................................................................................................................................ 12
MATULANE ........................................................................................................................................................... 7
MAXAIR AUTOHALER...................................................................................................................................... 32
MAXALT............................................................................................................................................................... 29
MAXALT-MLT ..................................................................................................................................................... 29
MAXITROL OINTMENT & SUSP .................................................................................................................... 19
MAXZIDE ............................................................................................................................................................. 16
Mebendazole....................................................................................................................................................... 25
Meclizine .............................................................................................................................................................. 12
MEDROL ............................................................................................................................................................... 8
Medroxyprogesterone Acetate ......................................................................................................................... 10
Mefloquine ........................................................................................................................................................... 25
MELLARIL ........................................................................................................................................................... 23
Meloxicam ........................................................................................................................................................... 28
Melphalan .............................................................................................................................................................. 7
MENEST ................................................................................................................................................................ 9
Meperidine ........................................................................................................................................................... 30
Mephenytoin........................................................................................................................................................ 21
MEPHYTON ........................................................................................................................................................ 31
MEPRON ............................................................................................................................................................. 27
Mercaptopurine (6M-P) ..................................................................................................................................... 12
Mesalamine ......................................................................................................................................................... 13
Mesalamine Supp .............................................................................................................................................. 13
Mesalamine, Enema .......................................................................................................................................... 13
MESANTOIN ....................................................................................................................................................... 21
Mesna..................................................................................................................................................................... 7
MESNEX................................................................................................................................................................ 7
55
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
MESTINON ......................................................................................................................................................... 23
Mestranol/Norethindrone................................................................................................................................... 10
Metaproterenol.................................................................................................................................................... 32
Metformin ............................................................................................................................................................... 9
METHADATE ER ............................................................................................................................................... 24
Methadone........................................................................................................................................................... 30
Methazolamide ................................................................................................................................................... 18
Methenamine/Methylene Blue Atropine .......................................................................................................... 13
METHERGINE .................................................................................................................................................... 10
Methimazole ........................................................................................................................................................ 11
Methotrexate ....................................................................................................................................................... 28
METHOTREXATE.............................................................................................................................................. 28
Methsuximide ...................................................................................................................................................... 21
Methyldopa .......................................................................................................................................................... 15
Methylergonorine................................................................................................................................................ 10
Methylphenidate ................................................................................................................................................. 24
Methylphenidate Extended Release ............................................................................................................... 24
Methylprednisolone .............................................................................................................................................. 8
Methyltestosterone ............................................................................................................................................... 8
Metipranolol ......................................................................................................................................................... 18
Metoclopramide .................................................................................................................................................. 11
Metolazone .......................................................................................................................................................... 16
Metoprolol ............................................................................................................................................................ 15
Metoprolol ER ..................................................................................................................................................... 15
METROGEL ........................................................................................................................................................ 33
Metronidazole ......................................................................................................................................... 25, 27, 33
METRONIDAZOLE VAG CRM, VAG TABS .................................................................................................. 27
Metyrosine ............................................................................................................................................................. 7
MEVACOR .......................................................................................................................................................... 16
MEXITIL ............................................................................................................................................................... 14
Mexitiline .............................................................................................................................................................. 14
MIACALCIN NASAL SPRAY .............................................................................................................................. 9
MICARDIS ........................................................................................................................................................... 14
MICARDIS HCT .................................................................................................................................................. 14
MICATIN .............................................................................................................................................................. 34
Miconazole Cr, 2% ............................................................................................................................................. 34
Miconazole Nitrate ............................................................................................................................................. 27
MICRONOR ........................................................................................................................................................ 10
MIDAMOR ........................................................................................................................................................... 16
Miglitol .................................................................................................................................................................... 9
MINIPRESS................................................................................................................................................... 13, 17
MINOCIN ............................................................................................................................................................. 25
Minocycline .......................................................................................................................................................... 25
Minoxidil ............................................................................................................................................................... 17
Minoxidil tablets .................................................................................................................................................. 15
MIRCETTE .......................................................................................................................................................... 10
56
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Mirtazapine .......................................................................................................................................................... 22
Misoprostol .......................................................................................................................................................... 11
Mitotane ................................................................................................................................................................. 8
MOBAN ................................................................................................................................................................ 22
MOBIC ................................................................................................................................................................. 28
Modafinil............................................................................................................................................................... 24
MODURETIC ...................................................................................................................................................... 16
Molindone ............................................................................................................................................................ 22
Mometasone furoate .................................................................................................................................... 32, 35
Mometasone, Nasal ........................................................................................................................................... 20
MONISTAT-7 ...................................................................................................................................................... 27
MONISTAT-DERM ............................................................................................................................................. 34
MONOKET .......................................................................................................................................................... 17
Montelukast Sodium .......................................................................................................................................... 32
Moricizine............................................................................................................................................................. 14
Morphine soln. .................................................................................................................................................... 30
Morphine SR ....................................................................................................................................................... 30
Morphine suppositories ..................................................................................................................................... 30
MOTRIN ............................................................................................................................................................... 28
Moxifloxacin......................................................................................................................................................... 25
MS CONCENTRATE ......................................................................................................................................... 30
MS CONTIN ........................................................................................................................................................ 30
MSIR..................................................................................................................................................................... 30
MTX ...................................................................................................................................................................... 28
MUCINEX (TABLET) ......................................................................................................................................... 31
MUCOMYST ....................................................................................................................................................... 33
Mupirocin ............................................................................................................................................................. 34
MURO-128 .......................................................................................................................................................... 20
MUSE ................................................................................................................................................................... 14
MYAMBUTOL ..................................................................................................................................................... 25
MYCELEX TROCHE ......................................................................................................................................... 27
MYCIFARDIN ...................................................................................................................................................... 27
MYCOBUTIN....................................................................................................................................................... 25
MYCOLOG II ....................................................................................................................................................... 34
Mycophenolate mofetil ........................................................................................................................................ 8
Mycophenolic acid................................................................................................................................................ 8
MYCOSTATIN .............................................................................................................................................. 27, 34
MYDRIACYL ....................................................................................................................................................... 20
MYFORTIC ............................................................................................................................................................ 8
MYLANTA............................................................................................................................................................ 13
MYLERAN ............................................................................................................................................................. 7
MYSOLINE .......................................................................................................................................................... 21
NA Thiosulfate 25% ........................................................................................................................................... 34
Nabumetone........................................................................................................................................................ 28
Nadolol ................................................................................................................................................................. 15
Naltrexone ........................................................................................................................................................... 30
57
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Naphazoline HCl................................................................................................................................................. 19
Naphazoline HCl and Pheniramine Maleate .................................................................................................. 19
NAPHCON........................................................................................................................................................... 19
NAPHCON A ....................................................................................................................................................... 19
NAPROSYN ........................................................................................................................................................ 28
Naproxen ............................................................................................................................................................. 28
Naratriptan ........................................................................................................................................................... 29
NASACORT AQ ................................................................................................................................................. 20
NASAREL ............................................................................................................................................................ 20
NASONEX ..................................................................................................................................................... 20, 31
Nateglinide............................................................................................................................................................. 9
NAVANE .............................................................................................................................................................. 23
Nedocromil Sodium............................................................................................................................................ 32
Nedrocromil ......................................................................................................................................................... 19
Needles & Syringes (Not including diabetic).................................................................................................... 9
Nefazodone ......................................................................................................................................................... 22
Nelfinavir .............................................................................................................................................................. 27
Neo/Poly/Prednisolone ...................................................................................................................................... 19
NEO-FRADIN...................................................................................................................................................... 27
Neomy, Polym, Bac ........................................................................................................................................... 19
Neomy,Polym,HC Otic Susp ............................................................................................................................ 20
Neomy,Polym,HC-Otic Soln ............................................................................................................................. 20
Neomycin ....................................................................................................................................................... 25, 27
NEOMYCIN ......................................................................................................................................................... 25
Neomycin Sulfate, Polymyxin B Sulfate, Dexamethasone .......................................................................... 19
Neomycin Sulfate,Polymyxin B Sulfate,Hydrocortizone .............................................................................. 19
Neomycin Sulfate/Polymyxin B Sulfate/Bacitracin/ Hydrocortisone ........................................................... 18
Neomycin Sulfate/Polymyxin B Sulfate/Gramicidin ...................................................................................... 19
Neomycin Sulfate/Polymyxin B Sulfate/Prednisolone .................................................................................. 19
Neomycin Sultate, Polymyxin B Sulfate, Bacitracin ...................................................................................... 18
NEORAL ................................................................................................................................................................ 8
NEOSPORIN OPHTH OINT ....................................................................................................................... 18, 19
NEOSPORIN OPHTH SOLUTION .................................................................................................................. 19
Neostigmine ........................................................................................................................................................ 23
NEPTAZANE....................................................................................................................................................... 18
NEURONTIN ....................................................................................................................................................... 21
Nevirapine ........................................................................................................................................................... 26
NEXAVAR ............................................................................................................................................................. 7
NEXIUM ............................................................................................................................................................... 11
NIACIN ................................................................................................................................................................. 16
NIASPAN ............................................................................................................................................................. 16
Nicardipine........................................................................................................................................................... 15
Nicardipine SR .................................................................................................................................................... 15
NICODERM ......................................................................................................................................................... 23
Nicotine Transdermal......................................................................................................................................... 23
Nicotinic Acid....................................................................................................................................................... 16
58
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Nicotinic Acid SR ................................................................................................................................................ 16
NiFEDIAC CC ..................................................................................................................................................... 15
NIFEDICAL XL.................................................................................................................................................... 15
Nifedipine ............................................................................................................................................................. 15
Nifedipine SR ...................................................................................................................................................... 15
NILANDRON ......................................................................................................................................................... 8
Nilotinib .................................................................................................................................................................. 7
Nilutamide.............................................................................................................................................................. 8
NITRO-BID .......................................................................................................................................................... 17
NITRO-DUR ........................................................................................................................................................ 17
Nitrofurantoin....................................................................................................................................................... 13
Nitrofurantoin ER ................................................................................................................................................ 13
Nitrofurantoin Macrocrystals ............................................................................................................................. 13
Nitroglycerin ........................................................................................................................................................ 17
Nitroglycerin (ointment) ..................................................................................................................................... 17
Nitroglycerin (patch) ........................................................................................................................................... 17
Nitroglycerin SR .................................................................................................................................................. 17
NITROL ................................................................................................................................................................ 17
NITROSTAT ........................................................................................................................................................ 17
NIX ........................................................................................................................................................................ 33
NIZORAL ....................................................................................................................................................... 27, 34
NOCTEC.............................................................................................................................................................. 23
NOLVADEX ......................................................................................................................................................... 10
NORCO 325/10 .................................................................................................................................................. 29
NORCO 325/5..................................................................................................................................................... 29
NORCO 325/7.5 ................................................................................................................................................. 29
NOREDETTE ...................................................................................................................................................... 10
Norethindro 1 mg, eth estradio 20 mg ............................................................................................................ 10
Norethindro 1.5 mg, eth estradio 30 mg ......................................................................................................... 10
Norethindrone ..................................................................................................................................................... 10
Norethindrone Acetate ...................................................................................................................................... 10
NORMODYNE .................................................................................................................................................... 15
NORPACE, NORPACE CR .............................................................................................................................. 14
NORPRAMIN ...................................................................................................................................................... 22
Nortriptyline ......................................................................................................................................................... 22
NORVASC ........................................................................................................................................................... 15
norvir..................................................................................................................................................................... 27
NUVARING ......................................................................................................................................................... 10
Nystatin .......................................................................................................................................................... 27, 34
NYSTATIN ........................................................................................................................................................... 27
OCUFLOX ........................................................................................................................................................... 18
Ofloxacin .............................................................................................................................................................. 25
Ofloxacin (OTIC)................................................................................................................................................. 20
Ofloxacin 0.3% drop .......................................................................................................................................... 18
OGEN ..................................................................................................................................................................... 9
Olanzapine .......................................................................................................................................................... 22
59
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Olmesartan .......................................................................................................................................................... 14
Olmesartan/HCTZ .............................................................................................................................................. 14
Olopatadine ......................................................................................................................................................... 19
Olopatadine HCl ................................................................................................................................................. 19
Olsalazine ............................................................................................................................................................ 13
Omeprazole Magnesium ................................................................................................................................... 11
Omeprazole OTC ............................................................................................................................................... 11
Omeprazole/Sodium Bicarbonate.................................................................................................................... 12
OMNICEF ............................................................................................................................................................ 24
Ondansetron ....................................................................................................................................................... 12
OPIUM ........................................................................................................................................................... 11, 12
OPTIPRANOLOL ............................................................................................................................................... 18
OPTIVAR ............................................................................................................................................................. 19
ORAP ................................................................................................................................................................... 22
ORAPRED ............................................................................................................................................................. 8
ORASONE............................................................................................................................................................. 8
ORINASE............................................................................................................................................................... 9
ORTHO CYCLEN ............................................................................................................................................... 10
ORTHO EVRA .................................................................................................................................................... 10
ORTHO NOVUM 10/11 ..................................................................................................................................... 10
ORTHO NOVUM 7/7/7 ...................................................................................................................................... 10
ORTHO TRI-CYCLEN ....................................................................................................................................... 10
ORTHONOVUM 1/35 ........................................................................................................................................ 10
ORTHONOVUM 1/50 ........................................................................................................................................ 10
Oseltamvir ........................................................................................................................................................... 27
OVCON 35 .......................................................................................................................................................... 10
OVCON 50 .......................................................................................................................................................... 10
OVRAL ................................................................................................................................................................. 10
Oxaprozin ............................................................................................................................................................ 28
Oxazepam ........................................................................................................................................................... 21
Oxcarbazepine .................................................................................................................................................... 21
Oxybutynin........................................................................................................................................................... 13
Oxycodone .......................................................................................................................................................... 30
Oxycodone/acetaminophen .............................................................................................................................. 30
Oxycodone/aspirin ............................................................................................................................................. 30
OXYCONTIN ....................................................................................................................................................... 30
PAMELOR ........................................................................................................................................................... 22
PANAFIL .............................................................................................................................................................. 34
PANCREASE ...................................................................................................................................................... 12
PANCREASE MT ............................................................................................................................................... 12
Pancreatin ........................................................................................................................................................... 12
PANDEL............................................................................................................................................................... 35
Pantoprazole ....................................................................................................................................................... 12
Papain/Urea ........................................................................................................................................................ 34
Papain/Urea/Chlorophyllin Copper Complex ................................................................................................. 34
Paregoric ....................................................................................................................................................... 11, 12
60
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
PARLODEL ......................................................................................................................................................... 23
Paroxetine ........................................................................................................................................................... 22
PATADAY ............................................................................................................................................................ 19
PATANOL ............................................................................................................................................................ 19
PAXIL ................................................................................................................................................................... 22
PAXIL CR ............................................................................................................................................................ 22
PEDIALYTE......................................................................................................................................................... 30
PEDIAZOLE ........................................................................................................................................................ 25
PEDIOTIC OTIC SUSP ..................................................................................................................................... 20
PEG Solution................................................................................................................................................. 11, 13
PEGASYS ........................................................................................................................................................... 28
PEG-INTRON KIT .............................................................................................................................................. 28
Pegylated Interferon Alfa-2A ............................................................................................................................ 28
Pegylated Interferon Alfa-2B ............................................................................................................................ 28
Pemirolast............................................................................................................................................................ 20
Penicillamine ....................................................................................................................................................... 28
Penicillin VK ........................................................................................................................................................ 25
PENTASA ............................................................................................................................................................ 13
Pentazocine......................................................................................................................................................... 30
Pentosan.............................................................................................................................................................. 13
Pentoxifylline ....................................................................................................................................................... 17
PEPCID................................................................................................................................................................ 11
PEPTO-BISMOL................................................................................................................................................. 13
PERCOCET 5/325 ............................................................................................................................................. 30
PERCOCET 5/500 ............................................................................................................................................. 30
PERCODAN ........................................................................................................................................................ 30
PERIACTIN ......................................................................................................................................................... 31
PERIDEX ............................................................................................................................................................. 20
Permethrin ........................................................................................................................................................... 33
Perphenazine ...................................................................................................................................................... 22
PERSANTINE ..................................................................................................................................................... 17
Phenazopyridine ................................................................................................................................................. 13
PHENERGAN ......................................................................................................................................... 12, 31, 32
PHENERGAN DM .............................................................................................................................................. 32
PHENERGAN VC............................................................................................................................................... 32
PHENERGAN VC w/ CODEINE ...................................................................................................................... 32
PHENERGAN w/ CODEINE ............................................................................................................................. 32
Phenobarbital ...................................................................................................................................................... 21
PHENOBARBITAL ............................................................................................................................................. 21
Phenoxybenzamine ............................................................................................................................................. 7
PHENYTEK ......................................................................................................................................................... 21
Phenytoin ............................................................................................................................................................. 21
PHOS LO ............................................................................................................................................................. 31
PHOSPHOLINE IODIDE ................................................................................................................................... 18
PILOCAR ............................................................................................................................................................. 18
PILOCAR HS ...................................................................................................................................................... 18
61
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Pilocarpine HCl ................................................................................................................................................... 18
Pimecrolimus....................................................................................................................................................... 34
Pimozide .............................................................................................................................................................. 22
Pioglitazone ........................................................................................................................................................... 9
Pioglitazone/Metform ........................................................................................................................................... 9
Pirbuterol ............................................................................................................................................................. 32
Piroxicam ............................................................................................................................................................. 28
PLAN B ................................................................................................................................................................ 10
PLAQUENIL ........................................................................................................................................................ 28
PLAVIX................................................................................................................................................................. 17
PLENDIL .............................................................................................................................................................. 15
PLETAL................................................................................................................................................................ 17
Podofilox Gel ....................................................................................................................................................... 34
Polyethylene Glycol 3350 oral powder ........................................................................................................... 12
Polymyxin B Sulfate/TMP ................................................................................................................................. 19
POLY-PRED ....................................................................................................................................................... 19
POLYSPORIN..................................................................................................................................................... 33
POLYSPORIN OINTMENT............................................................................................................................... 18
POLYTRIM .......................................................................................................................................................... 19
Potassium Acid Phosphate ............................................................................................................................... 30
potassium chloride ............................................................................................................................................. 30
Potassium Iodide ................................................................................................................................................ 30
PRANDIN............................................................................................................................................................... 9
PRAVACHOL ...................................................................................................................................................... 16
Pravastatin........................................................................................................................................................... 16
Prazosin ......................................................................................................................................................... 13, 17
PRECOSE ............................................................................................................................................................. 8
PRED FORTE ..................................................................................................................................................... 17
PRED-G ............................................................................................................................................................... 18
PRED-G SOP ..................................................................................................................................................... 18
PRED-MILD......................................................................................................................................................... 17
Prednicarbate 0.1% ........................................................................................................................................... 35
Prednisolone ......................................................................................................................................................... 8
PREDNISOLONE ................................................................................................................................................. 8
Prednisolone acetate ......................................................................................................................................... 17
Prednisolone sodium ......................................................................................................................................... 17
Prednisolone syrup .............................................................................................................................................. 8
Prednisone ............................................................................................................................................................ 8
Pregabalin ........................................................................................................................................................... 21
PRELONE ............................................................................................................................................................. 8
PREMARIN VAG .................................................................................................................................................. 9
PREMPRO/PREMPHASE .................................................................................................................................. 9
PRENATAL ......................................................................................................................................................... 10
PRENATAL FORTE ........................................................................................................................................... 10
PRENATAL RX ................................................................................................................................................... 10
Prenatal Vitamins ............................................................................................................................................... 10
62
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
PRENAVITE ........................................................................................................................................................ 10
PREVACID .......................................................................................................................................................... 11
PREVACID 24HR OTC ..................................................................................................................................... 11
prezista................................................................................................................................................................. 26
PRILOSEC .......................................................................................................................................................... 11
PRILOSEC (OTC) .............................................................................................................................................. 11
PRIMAQUINE ..................................................................................................................................................... 25
Primaquine Phosphate ...................................................................................................................................... 25
Primethamine/ Sufadoxine ................................................................................................................................ 25
Primidone............................................................................................................................................................. 21
PRINCIPEN ......................................................................................................................................................... 24
PRINIZIDE ........................................................................................................................................................... 14
PRO-BANTHINE ................................................................................................................................................ 11
Probenecid .......................................................................................................................................................... 10
Procainamide ...................................................................................................................................................... 14
Procarbazine ......................................................................................................................................................... 7
PROCARDIA ....................................................................................................................................................... 15
PROCARDIA XL ................................................................................................................................................. 15
Prochlorperazine ................................................................................................................................................ 12
PROGRAF ............................................................................................................................................................. 8
PROLIXIN ............................................................................................................................................................ 22
Promethazine .......................................................................................................................................... 12, 31, 32
Promethazine/ Dextromethorphan .................................................................................................................. 32
Promethazine/Codeine ...................................................................................................................................... 32
Promethazine/Phenylephrine ........................................................................................................................... 32
Promethazine/Phenylephrine/ Codeine .......................................................................................................... 32
PRONESTYL ...................................................................................................................................................... 14
PRONESTYL-SR ............................................................................................................................................... 14
Propafenone........................................................................................................................................................ 14
Propanolol LA ..................................................................................................................................................... 15
Propanolol/HCTZ................................................................................................................................................ 15
Propantheline ...................................................................................................................................................... 11
PROPINE............................................................................................................................................................. 18
Propoxyphene ..................................................................................................................................................... 30
Propoxyphene HCl-APAP ................................................................................................................................. 30
Propoxyphene napsylate/apap ........................................................................................................................ 30
Propranolol .......................................................................................................................................................... 15
Propylthiouracil ................................................................................................................................................... 11
PROSCAR ........................................................................................................................................................... 13
PROSTIGMIN ..................................................................................................................................................... 23
PROTONIX.......................................................................................................................................................... 12
PROTOPIC.......................................................................................................................................................... 34
Protriptyline ......................................................................................................................................................... 22
PROVENTIL, VENTOLIN (SYRUP) ................................................................................................................ 32
PROVERA ........................................................................................................................................................... 10
PROVIGIL............................................................................................................................................................ 24
63
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
PROZAC .............................................................................................................................................................. 22
Pseudoephedrine ............................................................................................................................................... 31
Pseudoephedrine with Guaifenesin ................................................................................................................ 31
PSORCON E....................................................................................................................................................... 35
PTU....................................................................................................................................................................... 11
PULMICORT RESPULES................................................................................................................................. 32
PULMICORT TURBUHALER ........................................................................................................................... 32
PURINETHOL ..................................................................................................................................................... 12
Pyrantel Pamoate,Susp .................................................................................................................................... 33
Pyrazinamide ...................................................................................................................................................... 25
PYRAZINAMIDE................................................................................................................................................. 25
Pyrethrins, Piperonyl Butoxide, Petroleum Distillate .................................................................................... 33
PYRIDIUM ........................................................................................................................................................... 13
Pyridostigmine .................................................................................................................................................... 23
Pyridoxine ............................................................................................................................................................ 31
Pyrimethamine .................................................................................................................................................... 25
PYRINYL II .......................................................................................................................................................... 33
QUALAQUIN ....................................................................................................................................................... 25
QUESTRAN ........................................................................................................................................................ 16
Quetiapine Fumarate ......................................................................................................................................... 23
QUINAGLUTE..................................................................................................................................................... 15
Quinidine Gluconate .......................................................................................................................................... 15
Quinidine Sulfate ................................................................................................................................................ 15
QUINIDINE SULFATE ....................................................................................................................................... 15
Quinine ................................................................................................................................................................. 25
QVAR ................................................................................................................................................................... 32
R & C .................................................................................................................................................................... 33
Rabeprazole ........................................................................................................................................................ 12
Raloxifene.............................................................................................................................................................. 9
Raltegravir ........................................................................................................................................................... 26
Rameltoeon ......................................................................................................................................................... 24
Ramipril ................................................................................................................................................................ 14
Ranitidine ............................................................................................................................................................. 12
RAPAMUNE .......................................................................................................................................................... 8
REBETOL ............................................................................................................................................................ 28
REESE'S PINWORM MEDICATION .............................................................................................................. 33
REGLAN .............................................................................................................................................................. 11
REGRANEX ........................................................................................................................................................ 33
RELAFEN ............................................................................................................................................................ 28
RELENZA ............................................................................................................................................................ 27
RELPAX ............................................................................................................................................................... 29
REMERON .......................................................................................................................................................... 22
REMERON SolTab ............................................................................................................................................ 22
RENAGEL ........................................................................................................................................................... 31
Repaglinide ........................................................................................................................................................... 9
REQUIP ............................................................................................................................................................... 23
64
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
rescriptor .............................................................................................................................................................. 26
Reserpine ............................................................................................................................................................ 15
RESTORIL........................................................................................................................................................... 24
RETIN-A............................................................................................................................................................... 33
RETIN-A MICRO ................................................................................................................................................ 33
retrovir .................................................................................................................................................................. 26
REVIA................................................................................................................................................................... 30
REVLIMID.............................................................................................................................................................. 7
reyataz ................................................................................................................................................................. 26
RHINOCORT AQUA .......................................................................................................................................... 20
Ribavirin ............................................................................................................................................................... 28
RIDAURA............................................................................................................................................................. 28
Rif/INH.................................................................................................................................................................. 25
Rif/INH/PZA ......................................................................................................................................................... 25
Rifabutin ............................................................................................................................................................... 25
RIFADIN............................................................................................................................................................... 25
RIFAMATE .......................................................................................................................................................... 25
Rifampin ............................................................................................................................................................... 25
RIFATER ............................................................................................................................................................. 25
Risedronate ........................................................................................................................................................... 9
RISPERDAL ........................................................................................................................................................ 23
RISPERDAL M-TAB .......................................................................................................................................... 23
Risperidone ......................................................................................................................................................... 23
RITALIN ............................................................................................................................................................... 24
RITALIN LA ......................................................................................................................................................... 24
RITALIN SR......................................................................................................................................................... 24
Ritonavir ............................................................................................................................................................... 27
Rizatriptan ........................................................................................................................................................... 29
RMS SUPPOSITORIES .................................................................................................................................... 30
ROBITUSSIN ...................................................................................................................................................... 31
ROBITUSSIN AC ............................................................................................................................................... 31
ROBITUSSIN DM (SYRUP) ............................................................................................................................. 32
ROBITUSSIN DM (TABLET) ............................................................................................................................ 32
ROBITUSSIN MAXIMUM STRENGTH........................................................................................................... 31
ROBITUSSIN PE................................................................................................................................................ 31
ROBITUSSIN-CF ............................................................................................................................................... 32
ROCALTROL ...................................................................................................................................................... 30
ROFERON-A....................................................................................................................................................... 28
RONDEC ............................................................................................................................................................. 31
RONDEC DM ...................................................................................................................................................... 31
RONDEC, RONDEC DM .................................................................................................................................. 31
Ropinirole............................................................................................................................................................. 23
Rosiglitazone......................................................................................................................................................... 9
Rosuvastatin ....................................................................................................................................................... 16
ROWASA ............................................................................................................................................................. 13
ROXICODONE ................................................................................................................................................... 30
65
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
ROZEREM........................................................................................................................................................... 24
Rufinamide .......................................................................................................................................................... 21
RYTHMOL ........................................................................................................................................................... 14
RYTHMOL SR .................................................................................................................................................... 14
Salmetrol.............................................................................................................................................................. 33
Salsalate .............................................................................................................................................................. 28
SANDIMMUNE ..................................................................................................................................................... 8
SANTYL ............................................................................................................................................................... 33
Saquinavir ............................................................................................................................................................ 27
Scopolamine ....................................................................................................................................................... 20
SCOT-TUSSIN DM ............................................................................................................................................ 31
SECTRAL ............................................................................................................................................................ 15
Selegiline ............................................................................................................................................................. 23
Selenium sulfide 2.5% ....................................................................................................................................... 34
SELSUN RX ........................................................................................................................................................ 34
SELZENTRY ....................................................................................................................................................... 26
SEPTRA DS ........................................................................................................................................................ 25
SERAX ................................................................................................................................................................. 21
SEREVENT DISKUS ......................................................................................................................................... 33
SEROQUEL ........................................................................................................................................................ 23
SERPASIL ........................................................................................................................................................... 15
Sertraline ............................................................................................................................................................. 22
SERZONE ........................................................................................................................................................... 22
Sevelamer ........................................................................................................................................................... 31
Sildenafil .............................................................................................................................................................. 14
SILVADENE ........................................................................................................................................................ 34
Silver Sulfadiazine .............................................................................................................................................. 34
SIMCOR............................................................................................................................................................... 16
Simvastatin .......................................................................................................................................................... 16
SINEMET ............................................................................................................................................................. 23
SINEMET CR ...................................................................................................................................................... 23
SINEQUAN.......................................................................................................................................................... 22
SINGULAIR ......................................................................................................................................................... 32
Sirolimus ................................................................................................................................................................ 8
Sitagliptin ............................................................................................................................................................... 9
Sitagliptin/Metformin ............................................................................................................................................ 9
SLO-NIACIN........................................................................................................................................................ 16
SLO-PHYLLIN..................................................................................................................................................... 33
Sodium Chloride for Inhalation ......................................................................................................................... 33
Sodium Chloride Ophthalmic............................................................................................................................ 20
Sodium Flouride (drops & tabs) ....................................................................................................................... 31
SODIUM SULAMYD .......................................................................................................................................... 18
SOMA ................................................................................................................................................................... 30
SOMNOTE .......................................................................................................................................................... 23
SONATA .............................................................................................................................................................. 24
Sorafenib ............................................................................................................................................................... 7
66
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Sotalol .................................................................................................................................................................. 15
Sotalol AF ............................................................................................................................................................ 15
SPECTAZOLE .................................................................................................................................................... 34
Spironolactone .................................................................................................................................................... 16
Spironolactone/HCTZ ........................................................................................................................................ 16
SPORANOX ........................................................................................................................................................ 27
SPRYCEL .............................................................................................................................................................. 7
SSKI ..................................................................................................................................................................... 30
STARLIX ................................................................................................................................................................ 9
Stavudine ............................................................................................................................................................. 26
STELAZINE ......................................................................................................................................................... 23
Sucralfate............................................................................................................................................................. 12
Sulconazole ......................................................................................................................................................... 34
Sulfacetamide ..................................................................................................................................................... 18
Sulfacetamide/Prednisolone (ointment).......................................................................................................... 19
Sulfadiazine ......................................................................................................................................................... 25
SULFADIAZINE .................................................................................................................................................. 25
Sulfasalazine ....................................................................................................................................................... 13
Sulfisoxazole ....................................................................................................................................................... 25
Sulindac ............................................................................................................................................................... 28
Sumatriptan ......................................................................................................................................................... 29
SUMYCIN ............................................................................................................................................................ 25
Sunitinib ................................................................................................................................................................. 7
SUPRAX .............................................................................................................................................................. 24
sustiva .................................................................................................................................................................. 26
SUTENT................................................................................................................................................................. 7
SYMBICORT ....................................................................................................................................................... 32
SYMMETREL...................................................................................................................................................... 23
SYNALAR ............................................................................................................................................................ 35
SYNTHROID ....................................................................................................................................................... 11
TABLOID ............................................................................................................................................................... 7
Tacrolimus ....................................................................................................................................................... 8, 34
TAGAMET ........................................................................................................................................................... 11
TALWIN ............................................................................................................................................................... 30
TAMBOCOR ....................................................................................................................................................... 14
TAMIFLU ............................................................................................................................................................. 27
Tamoxifen ............................................................................................................................................................ 10
Tamsulosin .......................................................................................................................................................... 13
TAPAZOLE.......................................................................................................................................................... 11
TARCEVA.............................................................................................................................................................. 7
TASIGNA ............................................................................................................................................................... 7
TEGRETOL ......................................................................................................................................................... 21
TEGRETOL XR .................................................................................................................................................. 21
Telmisartan.......................................................................................................................................................... 14
Telmisartan/HCTZ .............................................................................................................................................. 14
Temazepam ........................................................................................................................................................ 24
67
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
TEMODAR............................................................................................................................................................. 7
TEMOVATE......................................................................................................................................................... 35
TEMOVATE E ..................................................................................................................................................... 35
Temozolomide ...................................................................................................................................................... 7
TENEX ................................................................................................................................................................. 15
Tenofovir .............................................................................................................................................................. 26
TENORMIN ......................................................................................................................................................... 15
TERAZOL 3, 7 .................................................................................................................................................... 27
Terazosin ....................................................................................................................................................... 13, 17
Terbinafine........................................................................................................................................................... 27
Terbutaline........................................................................................................................................................... 33
Terconazole......................................................................................................................................................... 27
TESLAC ................................................................................................................................................................. 7
Testolactone.......................................................................................................................................................... 7
TESTOSTERONE (inj) ........................................................................................................................................ 8
Testosterone Cypionate ...................................................................................................................................... 8
Testosterone Enanthate ...................................................................................................................................... 8
TESTRED .............................................................................................................................................................. 8
Tetracycline ......................................................................................................................................................... 25
Thalidomide ........................................................................................................................................................... 7
THALOMID ............................................................................................................................................................ 7
THEO-DUR ......................................................................................................................................................... 33
Theophyline SR Sprinkles ................................................................................................................................ 33
Theophylline ........................................................................................................................................................ 33
Theophylline Liquid ............................................................................................................................................ 33
Thioguanine........................................................................................................................................................... 7
Thioridazine ......................................................................................................................................................... 23
Thiothixene .......................................................................................................................................................... 23
THORAZINE ....................................................................................................................................................... 22
Thyroid dessicated ............................................................................................................................................. 11
THYROLAR ......................................................................................................................................................... 11
Tiagabine ............................................................................................................................................................. 21
TICLID .................................................................................................................................................................. 17
Ticlopidine ........................................................................................................................................................... 17
TIGAN .................................................................................................................................................................. 12
TIKOSYN ............................................................................................................................................................. 14
TILADE................................................................................................................................................................. 32
Timolol Hemihydrate .......................................................................................................................................... 18
Timolol Maleate .................................................................................................................................................. 18
TIMOPTIC ........................................................................................................................................................... 18
TIMOPTIC XE ..................................................................................................................................................... 18
TINACTIN ............................................................................................................................................................ 34
Tipranavir ............................................................................................................................................................. 27
TITRALAC ........................................................................................................................................................... 30
Tizanidine ............................................................................................................................................................ 30
TOBRADEX......................................................................................................................................................... 19
68
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Tobramycin.......................................................................................................................................................... 18
Tobramycin Sulfate/Dexamethasone .............................................................................................................. 19
TOBREX .............................................................................................................................................................. 18
TOFRANIL ........................................................................................................................................................... 22
TOFRANIL PM.................................................................................................................................................... 22
Tolazamide ............................................................................................................................................................ 9
Tolbutamide........................................................................................................................................................... 9
TOLECTIN ........................................................................................................................................................... 28
TOLINASE ............................................................................................................................................................. 9
Tolmetin ............................................................................................................................................................... 28
Tolnaftate ............................................................................................................................................................. 34
Tolterodine........................................................................................................................................................... 13
TOPAMAX ........................................................................................................................................................... 21
TOPICORT .......................................................................................................................................................... 35
TOPICORT LP .................................................................................................................................................... 35
Topiramate .......................................................................................................................................................... 21
TOPROL XL ........................................................................................................................................................ 15
TORADOL ........................................................................................................................................................... 28
Toremifene ............................................................................................................................................................ 7
Torsemide............................................................................................................................................................ 16
Tramadol.............................................................................................................................................................. 29
TRANDATE ......................................................................................................................................................... 15
TRANXENE SD .................................................................................................................................................. 21
TRANXENE T ..................................................................................................................................................... 21
Travaprost ........................................................................................................................................................... 18
TRAVATAN ......................................................................................................................................................... 18
TRAVATAN Z...................................................................................................................................................... 18
Trazodone ........................................................................................................................................................... 22
TRECATOR-SC.................................................................................................................................................. 25
TRENTAL ............................................................................................................................................................ 17
Tretinoin ............................................................................................................................................................... 33
Triamcinolone ..................................................................................................................................................... 33
Triamcinolone 0.1% in Orabarol ...................................................................................................................... 21
Triamcinolone acetonide 0.025-0.1% ............................................................................................................. 35
Triamcinolone acetonide 0.5% ......................................................................................................................... 35
Triamcinolone Acetonide Nasal Inhal 55 Mcg/Act ........................................................................................ 20
Triamcinolone/Nystatin ...................................................................................................................................... 34
Triazolam ............................................................................................................................................................. 24
TRIDIONE ........................................................................................................................................................... 21
Trifluoperazine .................................................................................................................................................... 23
Trifluridine ............................................................................................................................................................ 18
Trihexiphenidyl .................................................................................................................................................... 23
TRILAFON ........................................................................................................................................................... 22
TRILEPTAL ......................................................................................................................................................... 21
TRI-LEVLEN ....................................................................................................................................................... 10
Trimethadione ..................................................................................................................................................... 21
69
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Trimethobenzamide ........................................................................................................................................... 12
Trimethoprim ....................................................................................................................................................... 13
Trimethoprim/ Sulfamethoxazole ..................................................................................................................... 25
TRIMOX ............................................................................................................................................................... 24
TRIMPEX ............................................................................................................................................................. 13
TRI-NORINYL ..................................................................................................................................................... 10
Trioxsalen ............................................................................................................................................................ 34
TRIPOHIST ......................................................................................................................................................... 31
Triprolidine ........................................................................................................................................................... 31
TRISORALEN ..................................................................................................................................................... 34
TRI-VI-FLOR ....................................................................................................................................................... 31
TRI-VI-SOL.......................................................................................................................................................... 31
TRI-VI-SOL & Fe ................................................................................................................................................ 31
trizivir .................................................................................................................................................................... 26
Tropicamide......................................................................................................................................................... 20
TRUETEST ........................................................................................................................................................... 8
TRUETEST STRIPS ............................................................................................................................................ 8
TRUETRACK ........................................................................................................................................................ 8
TRUETRACK STRIPS......................................................................................................................................... 8
TRUSOPT ........................................................................................................................................................... 18
truvada ................................................................................................................................................................. 26
TUSSIONEX ....................................................................................................................................................... 32
TYKERB................................................................................................................................................................. 7
TYLENOL ............................................................................................................................................................ 28
TYLENOL #2, #3, #4, … ................................................................................................................................... 29
TYLENOL ELIXIR............................................................................................................................................... 29
TYLOX 5/500 ...................................................................................................................................................... 30
Tyloxapol with Benzalkonium Chloride ........................................................................................................... 20
ULTRAM .............................................................................................................................................................. 29
ULTRAVATE ....................................................................................................................................................... 35
UNIPHYL ............................................................................................................................................................. 33
URECHOLINE .................................................................................................................................................... 13
URISED ............................................................................................................................................................... 13
VAG GEL ............................................................................................................................................................. 27
VALCYTE ............................................................................................................................................................ 28
Valganciclovir ...................................................................................................................................................... 28
VALISONE........................................................................................................................................................... 35
VALIUM.......................................................................................................................................................... 21, 30
Valproic acid........................................................................................................................................................ 21
VANCOCIN ......................................................................................................................................................... 25
Vancomycin - oral............................................................................................................................................... 25
VANSPAR ........................................................................................................................................................... 21
VANTIN ................................................................................................................................................................ 24
VASOTEC ........................................................................................................................................................... 14
VAZOL ................................................................................................................................................................. 31
VEETIDS ............................................................................................................................................................. 25
70
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
Venlafaxine .......................................................................................................................................................... 22
VENTOLIN HFA ................................................................................................................................................. 32
Verapamil............................................................................................................................................................. 15
Verapamil SR ...................................................................................................................................................... 15
VERMOX ............................................................................................................................................................. 25
VERSICLEAR ..................................................................................................................................................... 34
VIAGRA ............................................................................................................................................................... 14
VIBRAMYCIN ...................................................................................................................................................... 25
VIBRATAB ........................................................................................................................................................... 25
VICODIN 500/5 ................................................................................................................................................... 29
VICODIN E.S. 750/7.5 ....................................................................................................................................... 29
VIDEX EC ............................................................................................................................................................ 26
VIDEX PEDIATRIC ............................................................................................................................................ 26
VIOKASE ............................................................................................................................................................. 12
viracept................................................................................................................................................................. 27
viramune .............................................................................................................................................................. 26
viread.................................................................................................................................................................... 26
VIROPTIC............................................................................................................................................................ 18
VISCOUS XYLOCAINE .................................................................................................................................... 21
VISTARIL ....................................................................................................................................................... 23, 31
Vitamin A, D, C, & Fluoride ............................................................................................................................... 31
VITAMIN B-6 ....................................................................................................................................................... 31
VITAMIN D .......................................................................................................................................................... 30
Vitamin K ............................................................................................................................................................. 31
Vitamins A, D, C ................................................................................................................................................. 31
Vitamins A, D, C with Iron ................................................................................................................................. 31
VIVACTIL ............................................................................................................................................................. 22
VOLTAREN ......................................................................................................................................................... 28
Vorinostat............................................................................................................................................................... 7
VOSOL HC .......................................................................................................................................................... 20
VOSPIRE ER ...................................................................................................................................................... 32
VYTONE .............................................................................................................................................................. 34
WELLBUTRIN ..................................................................................................................................................... 22
WELLBUTRIN SR ........................................................................................................................................ 22, 23
WESTCORT ........................................................................................................................................................ 35
WYGESIC............................................................................................................................................................ 30
XALATAN ............................................................................................................................................................ 18
XANAX ................................................................................................................................................................. 21
XELODA ................................................................................................................................................................ 7
XOPENEX ........................................................................................................................................................... 32
XOPENEX HFA .................................................................................................................................................. 32
YASMIN ............................................................................................................................................................... 10
YODOXIN ............................................................................................................................................................ 25
ZADITOR OTC ................................................................................................................................................... 19
Zafirlukast ............................................................................................................................................................ 33
Zaleplon ............................................................................................................................................................... 24
71
10/31/10cchp.pdl
CONTRA COSTA HEALTH PLAN PREFERRED DRUG LIST
ZANAFLEX .......................................................................................................................................................... 30
Zanamivir ............................................................................................................................................................. 27
ZANTAC............................................................................................................................................................... 12
ZARONTIN .......................................................................................................................................................... 21
ZAROXOLYN ...................................................................................................................................................... 16
ZEGERID OTC ................................................................................................................................................... 12
ZENPEP............................................................................................................................................................... 12
zerit ....................................................................................................................................................................... 26
ZESTORETIC ..................................................................................................................................................... 14
ZESTRIL .............................................................................................................................................................. 14
ZIAC ..................................................................................................................................................................... 15
ziagen ................................................................................................................................................................... 26
Zidovudine ........................................................................................................................................................... 26
Zileuton ................................................................................................................................................................ 33
Ziprasidone.......................................................................................................................................................... 23
ZITHROMAX ....................................................................................................................................................... 24
ZOCOR ................................................................................................................................................................ 16
ZOFRAN .............................................................................................................................................................. 12
ZOLINZA................................................................................................................................................................ 7
Zolmitriptan.......................................................................................................................................................... 29
ZOLOFT ............................................................................................................................................................... 22
Zolpidem .............................................................................................................................................................. 24
ZOMIG ................................................................................................................................................................. 29
ZOMIG-ZMT ........................................................................................................................................................ 29
ZONEGRAN ........................................................................................................................................................ 21
Zonisamide .......................................................................................................................................................... 21
ZOVIRAX ............................................................................................................................................................. 27
ZYBAN ................................................................................................................................................................. 23
ZYFLOW CR ....................................................................................................................................................... 33
ZYLOPRIM .......................................................................................................................................................... 10
ZYMINE ............................................................................................................................................................... 31
ZYMINE XR ......................................................................................................................................................... 31
ZYPRAM .............................................................................................................................................................. 34
ZYPREXA ............................................................................................................................................................ 22
ZYPREXA ZYDIS ............................................................................................................................................... 22
ZYRTEC............................................................................................................................................................... 31
ZYRTEC-D .......................................................................................................................................................... 31
ZYVOX ................................................................................................................................................................. 25
72
10/31/10cchp.pdl