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Medi-Cal Rx Contract Drugs List - California

2022 California Department of Health Care Services. All rights reserved. Medi-Cal Rx Contract Drugs List February 1, 2022 DHCS (CDL) Contract Drugs List 2 02/01/2022 Revision History drug Name Description Effective Date Amikacin Sulfate Strengths updated. December 1, 2021 Amoxicillin Trihydrate Tablets added to CDL. December 1, 2021 Amoxicillin/ Clavulanate Potassium Restrictions removed. December 1, 2021 Chlorhexidine Gluconate Added to CDL. December 1, 2021 Ethionamide Strength updated. December 1, 2021 Finasteride Added to CDL. December 1, 2021 Hydromorphone Tablets (1 mg & 3 mg) removed. December 1, 2021 Ibuprofen Capsules and 300 mg formulations removed. December 1, 2021 Insulin Glargine-YFGN Added to CDL. December 1, 2021 Isoniazid Liquid strength updated.

Epinephrine Labeler code (49502) restriction removed. February 1, 2022 Erythromycin/Benzoyl ... Lidocaine/Prilocaine Added to CDL. February 1, 2022 ... Ozanimod Hydrochloride Added to CDL with restrictions. April 1, 2022 Pentoxifylline Restrictions removed. April 1, 2022 ...

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medi-calrx.dhcs.ca.gov

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medi-calrx.dhcs.ca.gov

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medi-calrx.dhcs.ca.gov

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medi-calrx.dhcs.ca.gov

Liquid * 160 mg/5 ml 60 ml 120 ml 240 ml 480 ml ml ml ml ml ml * Restricted to individuals younger than 21 years of age for the liquid and drops only. ... CALCIUM SUPPLEMENTS AND VITAMIN D ANALOGS Calcium Carbonate Tablets or capsules 650 mg 1250 mg ea ea Calcium Gluconate Tablets or wafers 325 mg 500 mg 650 mg 1 gm ea ea ea

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