Medi-Cal Rx Contract Drugs List

1 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. December 1, 2021 Isosorbide Mononitrate Additional strength (30 mg) added.

2 December 1, 2021 Ketotifen Fumarate Added to CDL. December 1, 2021 Levofloxacin Restrictions removed. December 1, 2021 Medroxyprogesterone acetate Additional formulation (prefilled syringe) added to CDL. December 1, 2021 Phenazopyridine HCL Strength updated. December 1, 2021 Rifabutin Restrictions removed. December 1, 2021 Secnidazole Labeler restriction (27437) added. December 1, 2021 Tisotumab Vedotin-TFTV Added to CDL with diagnosis and prior authorization requirements. December 1, 2021 Triamcinolone Additional formulation (paste) added to CDL. December 1, 2021 Adalimumab Added to CDL with restrictions. January 1, 2022 Asciminib Added to CDL with restrictions. January 1, 2022 Atazanavir Sulfate Labeler restriction (00003) removed. January 1, 2022 Bictegravir/ Emtricitabine/Tenofovir Alafenamide Additional strength (30 mg/120 mg/15 mg) added.

3 January 1, 2022 DHCS (CDL) Contract Drugs List 3 02/01/2022 drug Name Description Effective Date Brigatinib Labeler restriction (76189) removed. January 1, 2022 Brinzolamide/ Brimonidine Tartrate Added to CDL with restrictions. January 1, 2022 Clindamycin Phosphate Additional formulation (gel) added. January 1, 2022 Clobazam Added to CDL with restrictions. January 1, 2022 Clobetasol Propionate Added to CDL (various formulations). January 1, 2022 Colchicine Capsules removed from CDL, and quantity limit restriction removed from tablets. January 1, 2022 Glecaprevir/ Pibrentasvir Restrictions updated. January 1, 2022 Infigratinib Prior authorization required. Labeler restriction (72730) removed. January 1, 2022 leuprolide acetate (Lupron depot -Ped ) Added to CDL with restrictions. January 1, 2022 Linezolid Added to CDL (various formulations).

4 January 1, 2022 Lovastatin Added to CDL. January 1, 2022 Midazolam Added to CDL with restrictions. January 1, 2022 Moxifloxacin HCl Additional formulation (IV) added, and restriction removed from tablets. January 1, 2022 Naloxegol Oxalate Labeler restriction (00310) removed. January 1, 2022 Naloxone HCL Additional strength (8 ml) added for intranasal spray with labeler restriction (59467). January 1, 2022 Norgestimate and Ethinyl Estradiol (Lo) Added to CDL with restrictions. January 1, 2022 Pancrelipase (Amylase/ Lipase/Protease) Additional labeler code (73562) added to labeler restriction. January 1, 2022 Panobinostat Labeler restriction updated. January 1, 2022 Peginterferon Alfa-2A Restrictions updated and pen injectors removed from CDL. January 1, 2022 Peginterferon Alfa-2B Removed from the CDL.

5 January 1, 2022 DHCS (CDL) Contract Drugs List 4 02/01/2022 drug Name Description Effective Date Ponatinib Additional strengths (10 mg & 30 mg) and labeler restriction (63020) added. January 1, 2022 Prasugrel Added to CDL. January 1, 2022 Ribavirin Duration of therapy restriction removed. January 1, 2022 Rifampin Additional formulation (vial) added. January 1, 2022 Secukinumab Added to CDL with restrictions. January 1, 2022 Sofosbuvir/Velpatasvir Additional formulation (pellet packets) added, and restrictions updated. January 1, 2022 Tenofovir Disoproxil Fumarate Restrictions updated. January 1, 2022 Bisacodyl EC Added to CDL. February 1, 2022 Butenafine HCl Labeler code restriction (00378) removed. February 1, 2022 Cinacalcet HCl Effective March 1, 2022: Labeler code restriction (55513) removed.

6 February 1, 2022 Clindamycin/Benzoyl Peroxide Added to CDL. February 1, 2022 Clotrimazole/ Betamethasone Dipropionate Added to CDL. February 1, 2022 Colesevelam HCl Effective March 1, 2022: Labeler code restriction (65597) removed from tablets. Labeler code restriction (65597) added to suspension . February 1, 2022 Dasiglucagon HCl Added to CDL with restrictions. (Policy effective January 1, 2022.) February 1, 2022 Diazepam Solution added to CDL with restrictions. February 1, 2022 Doxycycline Monohydrate Capsules & tablets added to CDL. February 1, 2022 DHCS (CDL) Contract Drugs List 5 02/01/2022 drug Name Description Effective Date Epinephrine Labeler code (49502) restriction removed. February 1, 2022 Erythromycin/Benzoyl Peroxide Added to CDL. February 1, 2022 Estrogens, conjugated and Medroxyprogesterone acetate Minimum dispensing restriction removed.

7 February 1, 2022 Ethinyl Estradiol/ Drospirenone Added to CDL with restrictions. February 1, 2022 Heparin Additional formulation (vials) added to CDL. February 1, 2022 Ketorolac Tromethamine Labeler code exclusion (00023) removed from % solution. February 1, 2022 Levonorgestrel and Ethinyl Estradiol Additional strength ( mg) added to CDL with restrictions. February 1, 2022 Levonorgestrel and Ethinyl Estradiol/Ethinyl Estradiol Added to CDL with restrictions. February 1, 2022 Lidocaine/Prilocaine Added to CDL. February 1, 2022 Lorazepam Oral concentration added to CDL with restrictions. February 1, 2022 Mesalamine Added to CDL with restrictions. February 1, 2022 Molnupiravir Effective 12/23/2021: Added to CDL with quantity limit restriction. February 1, 2022 Nirmatrelvir/Ritonavir Effective 12/22/2021: Added to CDL with quantity limit restriction.

8 February 1, 2022 Norethindrone/Ethinyl Estradiol/Iron Added to CDL with restrictions. February 1, 2022 Oxcarbazepine suspension added to CDL. February 1, 2022 Oxybutynin Chloride Extended-release tablets & syrup added to CDL. February 1, 2022 Sodium Chloride Inhalation vials added to CDL. February 1, 2022 DHCS (CDL) Contract Drugs List 6 02/01/2022 drug Name Description Effective Date Tobramycin with Dexamethasone Additional labeler restriction (00078) added. February 1, 2022 DHCS (CDL) Contract Drugs List 7 02/01/2022 General Provisions 1. Provisions of coverage are contained in the California Code of Regulations (CCR), Title 22, Sections 51313, , and 2. Code I Drugs marked with a symbol (*) require authorization in accordance with Section 51003 unless used under the conditions specified in the Contract Drugs List, and are subject to the prescription documentation requirements in CCR, Title 22, Section 51476(c).

9 See CCR, Title 22, Section (b). 3. Drugs marked with a symbol (+) have a frequency of billing requirement. See CCR, Title 22, Section 51513(b)(3). Full payment ( drug ingredient cost plus a professional fee component) to a pharmacy is limited to a maximum of three claims for the same drug and strength dispensed to the same beneficiary within any 75-day period. The fourth claim from any provider, and subsequent claims for the same drug and strength dispensed to the same beneficiary within any 75-day period will be paid at the drug ingredient cost only. Exceptions are with the initial prescription, when authorization is obtained for more frequent billing, or when Drugs are dispensed in a quantity of 180 or more tablets or capsules. 4. Drugs marked with a symbol ( ) have a unit price based on the package size determined by the Director to be the size most frequently purchased by providers.

10 See CCR, Title 22, Section 51513(a)(2). A complete listing of these Drugs is found in the Reimbursement section of this manual. 5. Drugs that have been end dated are subject to Prior Authorization unless the criteria for continuing care has been met. For information about continuing care, refer to the Medi-Cal Rx Provider Manual. Legend Drugs Legend Drugs that are listed in the Contract Drugs List of this manual are covered by the Medi-Cal program. Legend Drugs not listed may be covered subject to authorization from a Medi-Cal consultant. DHCS (CDL) Contract Drugs List 8 02/01/2022 Non-Legend Over-the-Counter Drugs Non-legend Over-the-Counter (OTC) Drugs that are listed in the Contract Drugs List are covered by the Medi-Cal program. OTC Drugs not listed, and not otherwise excluded, may be covered subject to authorization from a Medi-Cal consultant.