H5172_Formulary2016 v12 Approved
A.CommuniCare Advantage Cal MediConnect Plan
(Medicare-Medicaid Plan)
offered by
Community Health Group
2016 List of Covered Drugs (Formulary)
This formulary was updated on 11/25/2016. For more recent information or other
questions, please contact CommuniCare Advantage Cal MediConnect Plan
Member Services, at 1-888-244-4430 or, for TTY users, 1-855-266-4584, twentyfour hours a day, seven days a week, or visit www.chgsd.com.
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CommuniCare Advantage Cal MediConnect Plan (MedicareMedicaid Plan) | 2016 List of Covered Drugs (Formulary)
This is a list of drugs that members can get in CommuniCare Advantage Cal MediConnect Plan.
 CommuniCare Advantage Cal MediConnect Plan is a health plan that contracts with both
Medicare and Medi-Cal to provide benefits of both programs to enrollees.
 The List of Covered Drugs and/or pharmacy and provider networks may change throughout
the year. We will send you a notice before we make a change that affects you.
 Benefits and/or co-payments may change on January 1 of each year.
 You can always check CommuniCare Advantage Cal MediConnect Plan’s up-to-date List of
Covered Drugs online at www.chgsd.com or by calling 1-888-244-4430.
 You can get this information for free in other formats, such as large print, braille, or audio. Call
1-888-244-4430. The call is free.
 Limitations, copays, and restrictions may apply. For more information, call CommuniCare
Advantage Cal MediConnect Plan Member Services or read the CommuniCare Advantage
Cal MediConnect Plan Member Handbook.
 Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please
contact the plan for more details.
 You can get this information for free in other languages. Call 1-888-244-4430. The call is free.
 Esta información está disponible en otros idiomas y es gratis. Llame al 1-888-244-4430. La
llamada es gratis.
 Bạn có thể nhận được thông tin này miễn phí bằng các ngôn ngữ khác. Gọi 1-888-244-4430.
Các cuộc gọi miễn phí.
 Maaari mong makuha ang impormasyong ito nang libre sa iba pang mga wika. Tumawag sa
1-888-244-4430. Ang tawag ay libre.
 ‫أخرى ل غات ف ي مجان ا ال م ع لومات هذه ع لى ال ح صول ي م ك نك‬. ‫ ا س تدعاء‬1-888-244-4430. ‫مجان ية ال م كال مة ف ي‬.
?
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888244-4430, twenty-four hours a day, seven days a week. The call is free. For more information,
visit www.chgsd.com.
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H5172_Formulary2016 v12 Approved
Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of
the FAQ to learn more, or look for a question and answer.
1.
What prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the Drug List are the drugs covered by CommuniCare Advantage Cal MediConnect
Plan. The drugs are available at pharmacies within our network. A pharmacy is in our network if
we have an agreement with them to work with us and provide you services. We refer to these
pharmacies as “network pharmacies.”
CommuniCare Advantage Cal MediConnect Plan will cover all medically necessary drugs on the
Drug List if:
 your doctor or other prescriber says you need them to get better or stay healthy, and
 you fill the prescription at a CommuniCare Advantage Cal MediConnect Plan network
pharmacy.
In some cases, you have to do something before you can get a drug (see question #5 below).
You can also see an up-to-date list of drugs that we cover on our website at www.chgsd.com or
call Member Services at 1-888-244-4430.
2.
Does the Drug List ever change?
Yes. CommuniCare Advantage Cal MediConnect Plan may add or remove drugs on the Drug List
during the year. Generally, the Drug List will only change if:
 a cheaper drug comes along that works as well as a drug on the Drug List now, or
 we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
 Decide to require or not require prior approval for a drug. (Prior approval is permission from
CommuniCare Advantage Cal MediConnect Plan before you can get a drug.)
 Add or change the amount of a drug you can get (called “quantity limits”).
 Add or change step therapy restrictions on a drug. (Step therapy means you must try one
drug before we will cover another drug.)
(For more information on these drug rules, see page iv and v).
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you
?
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888244-4430, twenty-four hours a day, seven days a week. The call is free. For more information,
visit www.chgsd.com.
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H5172_Formulary2016 v12 Approved
when we change our rules for covering a drug. Questions 3, 4, and 7 below have more
information on what happens when the Drug List changes.
 You can always check CommuniCare Advantage Cal MediConnect Plan’s up to date Drug List
online at www.chgsd.com. You can also call Member Services to check the current Drug List
at 1-888-244-4430.
3.
What happens when a cheaper drug comes along that works as
well as a drug on the Drug List now?
If you are taking a drug that is removed because a cheaper drug that works just as well comes
along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or
when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is
removed from the drug list. You will receive a Formulary Change Notice with your Monthly
Prescription Drug Summary. The Formulary Change Notice will tell you of the changes that will
occur at least 60 days from the date of the notice.
4.
What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it
off the Drug List right away. We will also send you a letter telling you that. If you receive a letter
telling you that a drug that you have been taking has been taken off the Drug List due to safety
reasons by the FDA, you should contact your doctor as soon as possible to discuss other drugs
that you may be able to take for your condition.
5.
Are there any restrictions or limits on drug coverage? Or are there
any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases
you or your doctor or other prescriber must do something before you can get the drug. For
example:
 Prior approval (or prior authorization): For some drugs, you or your doctor or other
prescriber must get approval from CommuniCare Advantage Cal MediConnect Plan before
you fill your prescription. If you don’t get approval, CommuniCare Advantage Cal
MediConnect Plan may not cover the drug.
 Quantity limits: Sometimes CommuniCare Advantage Cal MediConnect Plan limits the
amount of a drug you can get.
 Step therapy: Sometimes CommuniCare Advantage Cal MediConnect Plan requires you to
do step therapy. This means you will have to try drugs in a certain order for your medical
?
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888244-4430, twenty-four hours a day, seven days a week. The call is free. For more information,
visit www.chgsd.com.
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condition. You might have to try one drug before we will cover another drug. If your doctor
thinks the first drug doesn’t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables
starting on page one. You can also get more information by visiting our web site at
www.chgsd.com. We have posted online documents that explain our prior authorization and step
therapy restrictions. You may also ask us to send you a copy.
You can ask for an “exception” from these limits. Please see Question 11 for more information on
exceptions.

If you are in a nursing home or other long-term care facility and need a drug that is not on the
Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day
emergency supply of the drug you need (unless you have a prescription for fewer days),
whether or not you are a new CommuniCare Advantage Cal MediConnect Plan member. This
will give you time to talk to your doctor or other prescriber. He or she can help you decide if
there is a similar drug on the Drug List you can take instead or whether to request an
exception. Please see Question 11 for more information about exceptions.
6.
How will you know if the drug you want has limitations or if there
are required actions to take to get the drug?
The List of Covered Drugs beginning on page one has a column labeled “Necessary actions,
restrictions, or limits on use.”
7.
What happens if we change our rules on how we cover some of the
drugs? For example, if we add prior authorization (approval),
quantity limits, and/or step therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug.
We will tell you at least 60 days before the restriction is added or when you next ask your
pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the
coverage rules is made. This gives you time to talk to your doctor or other prescriber about what
to do next.
8.
How can you find a drug on the Drug List?
There are two ways to find a drug:
 You can search alphabetically (if you know how to spell the drug), or
 You can search by medical condition.
?
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888244-4430, twenty-four hours a day, seven days a week. The call is free. For more information,
visit www.chgsd.com.
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H5172_Formulary2016 v12 Approved
To search alphabetically, go to the Alphabetical Listing section. You can find it in the Index
beginning on page I-1.
To search by medical condition, find the section labeled “List of drugs by medical condition”
beginning on page one. The drugs in this section are grouped into categories depending on the
type of medical conditions they are used to treat. For example, if you have a heart condition, you
should look in the category, Cardiovascular Agents. That is where you will find drugs that treat
heart conditions.
9.
What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at 1-888-244-4430 and ask
about it. If you learn that CommuniCare Advantage Cal MediConnect Plan will not cover the drug,
you can do one of these things:
 Ask Member Services for a list of drugs like the one you want to take. Then show the list to
your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like
the one you want to take. Or
 You can ask the health plan to make an exception to cover your drug. Please see question
11 for more information about exceptions.
10. What if you are a new CommuniCare Advantage Cal MediConnect
Plan member and can’t find your drug on the Drug List or have a
problem getting your drug?
We can help. We may cover a temporary 31-day supply of your drug during the first 90 days you
are a member of CommuniCare Advantage Cal MediConnect Plan. This will give you time to talk
to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the
Drug List you can take instead or whether to request an exception.
We will cover a 31-day supply of your drug if:
 you are taking a drug that is not on our Drug List, or
 health plan rules do not let you get the amount ordered by your prescriber, or
 the drug requires prior approval by CommuniCare Advantage Cal MediConnect Plan, or
 you are taking a drug that is part of a step therapy restriction.
If you live in a nursing home or other long-term care facility, you may refill your prescription for as
long as 93 days. You may refill the drug multiple times during your first 90 days in the plan. This
gives your prescriber time to change your drugs to those on the Drug List or ask for an exception.
For level of care transitions, for example, when you are discharged from the hospital to a longterm care facility or home:
?
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888244-4430, twenty-four hours a day, seven days a week. The call is free. For more information,
visit www.chgsd.com.
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We will make coverage determinations and re-determinations as soon as your health condition
requires. You will be provided with an emergency supply of non- formulary drugs, including drugs
that are subject to certain restrictions, such as prior authorization or step therapy.
11. Can you ask for an exception to cover your drug?
Yes. You can ask CommuniCare Advantage Cal MediConnect Plan to make an exception to
cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
 For example, CommuniCare Advantage Cal MediConnect Plan may limit the amount of a
drug we will cover. If your drug has a limit, you can ask us to change the limit and cover
more.
 Other examples: You can ask us to drop step therapy restrictions or prior approval
requirements.
12. How long does it take to get an exception?
First, we must receive a statement from your prescriber supporting your request for an
exception. After we receive the statement, we will give you a decision on your exception request
within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a
decision, you can ask for an expedited exception. This is a faster decision. If your prescriber
supports your request, we will give you a decision within 24 hours of receiving your prescriber’s
supporting statement.
13. How can you ask for an exception?
To ask for an exception, call Member Services. Member Services will work with you and your
provider to help you ask for an exception.
14. What are generic drugs?
Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less
than the brand name drug and their names are less commonly known. Generic drugs are
approved by the Food and Drug Administration (FDA).
CommuniCare Advantage Cal MediConnect Plan covers both brand name drugs and generic
drugs.
?
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888244-4430, twenty-four hours a day, seven days a week. The call is free. For more information,
visit www.chgsd.com.
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15. What are OTC drugs?
OTC stands for “over-the-counter”. CommuniCare Advantage Cal MediConnect Plan covers some
OTC drugs when they are written as prescriptions by your provider.
You can read the CommuniCare Advantage Cal MediConnect Plan Drug List to see what OTC
drugs are covered.
16. Does CommuniCare Advantage Cal MediConnect Plan cover OTC
non-drug products?
CommuniCare Advantage Cal MediConnect Plan covers some OTC non-drug products when they
are written as prescriptions by your provider.
You can read the CommuniCare Advantage Cal MediConnect Plan Drug List to see what OTC
non-drug products are covered.
17. What is your co-pay?
You can read the CommuniCare Advantage Cal MediConnect Plan Drug List to learn about the
co-pay for each drug.
CommuniCare Advantage Cal MediConnect Plan members living in nursing homes or other longterm care facilities will have no co-pays. Some members getting long-term care in the community
will also have no co-pays.
Co-pays are listed by tiers. Tiers are groups of drugs with the same co-pay.
 Tier 1 drugs have the lowest co-pay. They are generic drugs. There is no cost sharing for
drugs in this tier.
 Tier 2 drugs have a medium co-pay. They are brand name drugs. The co-pay will be from
$0 to $7.40, depending on your level of Medi-Cal eligibility.
 Tier 3 drugs include non-Medicare brand and generic prescription drugs. These drugs are
traditionally not covered by Medicare but are covered by Medicaid. There is no cost-sharing
for drugs in this tier.
 Tier 4 includes non-Medicare brand and generic over-the-counter drugs. These drugs are
traditionally not covered by Medicare but are covered by Medicaid. There is no cost-sharing
for drugs in this tier.
?
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888244-4430, twenty-four hours a day, seven days a week. The call is free. For more information,
visit www.chgsd.com.
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H5172_Formulary2016 v12 Approved
List of Covered Drugs
The list of covered drugs that begins on page one gives you information about the drugs covered
by CommuniCare Advantage Cal MediConnect Plan. If you have trouble finding your drug in the
list, turn to the Index that begins on page I-1.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g.,
BYETTA) and generic drugs are listed in lower-case italics (e.g., metformin).
The information in the “Necessary actions, restrictions, or limits on use” column tells you if
CommuniCare Advantage Cal MediConnect Plan has any rules for covering your drug.
The information in the “Necessary actions, restrictions, or limits on use” column tells you if
CommuniCare Advantage Cal MediConnect Plan has any rules for covering your drug. You can
find information on what the symbols and abbreviations in this table mean by going to the table
below.
Note: The * next to a drug means the drug is not a “Part D drug.” You will not be required to pay a
copay for these drugs. These drugs also have different rules for appeals. An appeal is a formal
way of asking us to review a decision we made about your coverage and to change it if you think
we made a mistake. For example, we might decide that a drug that you want is not covered or is
no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you
can appeal. If you ever have a question, call Member Services at 1-888-244-4430. You can also
read the Member Handbook to learn how to appeal a decision.
?
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888244-4430, twenty-four hours a day, seven days a week. The call is free. For more information,
visit www.chgsd.com.
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The following Utilization Management abbreviations may be found within the body of this
document
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION
PA
PA BvD
PA-HRM
PA NSO
?
DESCRIPTION
EXPLANATION
Utilization Management Restrictions
You (or your physician) are required to get prior
authorization from CommuniCare Advantage
Cal MediConnect before you fill your
Prior Authorization
prescription for this drug. Without prior
Restriction
approval, CommuniCare Advantage Cal
MediConnect may not cover this drug.
Prior Authorization
Restriction
for
Part B vs Part D
Determination
Prior Authorization
Restriction for
High Risk Medications
Prior Authorization
Restriction for
New Starts Only
This drug may be eligible for payment under
Medicare Part B or Part D. You (or your
physician) are required to get prior authorization
from CommuniCare Advantage Cal
MediConnect to determine that this drug is
covered under Medicare Part D before you fill
your prescription for this drug. Without prior
approval, CommuniCare Advantage Cal
MediConnect may not cover this drug.
This drug has been deemed by CMS to be
potentially harmful and therefore, a High Risk
Medication for Medicare beneficiaries 65 years
or older. Members age 65 years or older are
required to get prior authorization from
CommuniCare Advantage Cal MediConnect
before you fill your prescription for this
drug. Without prior approval, CommuniCare
Advantage Cal MediConnect may not cover this
drug.
If you are a new member, you (or your
physician) are required to get prior authorization
from CommuniCare Advantage Cal
MediConnect before you fill your prescription for
this drug. Without prior approval, CommuniCare
Advantage Cal MediConnect may not cover this
drug.
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888-2444430, twenty-four hours a day, seven days a week. The call is free. For more information, visit
www.chgsd.com.
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H5172_Formulary2016 v12 Approved
ABBREVIATION
DESCRIPTION
QL
Quantity Limit
Restriction
ST
Step Therapy
Restriction
EXPLANATION
CommuniCare Advantage Cal MediConnect
limits the amount of this drug that is covered per
prescription, or within a specific time frame.
Before CommuniCare Advantage Cal
MediConnect will provide coverage for this drug,
you must first try another drug(s) to treat your
medical condition. This drug may only be
covered if the other drug(s) does not work for
you.
The following additional coverage note abbreviations may be found within the body of this
document
OTHER SPECIAL REQUIREMENTS FOR COVERAGE
ABBREVIATION
DESCRIPTION
*
Not a Part D Drug
LA
NM
?
EXPLANATION
This drug is a non-Part D drug covered
by Medicaid.
Limited Access Drug
This prescription may be available only
at certain pharmacies. For more
information consult your Pharmacy
Directory or call Member Services at 1888-244-4430 seven days a week,
twenty-four hours a day. TTY/TDD users
should call 1-855-266-4584.
Non-Mail Order Drug
You may be able to receive greater than
a 1-month supply of most of the drugs on
your formulary via mail order at a
reduced cost share. Drugs not available
via your mail order benefit are noted with
“NM” in the Necessary Actions,
Restrictions, or Limits on Use column of
your formulary.
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888-2444430, twenty-four hours a day, seven days a week. The call is free. For more information, visit
www.chgsd.com.
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List of Drugs by Medical Condition
The drugs in this section are grouped into categories depending on the type of medical conditions
they are used to treat. For example, if you have a heart condition, you should look in the category,
Cardiovascular Agents. That is where you will find drugs that treat heart conditions.
?
If you have questions, please call CommuniCare Advantage Cal MediConnect Plan at 1-888-2444430, twenty-four hours a day, seven days a week. The call is free. For more information, visit
www.chgsd.com.
xii
Table of Contents
Contents
of
Table
Analgesics ........................................................................................................................................................................................................................................................................................................ 3
Anesthetics ................................................................................................................................................................................................................................................................................................. 13
Anti-Addiction/Substance Abuse Treatment Agents ................................................................................................................................................................... 14
Antianxiety Agents ........................................................................................................................................................................................................................................................................ 15
Antibacterials ......................................................................................................................................................................................................................................................................................... 16
Anticancer Agents ........................................................................................................................................................................................................................................................................... 27
Anticholinergic Agents ............................................................................................................................................................................................................................................................. 37
Anticonvulsants .................................................................................................................................................................................................................................................................................. 38
Antidementia Agents .................................................................................................................................................................................................................................................................. 42
Antidepressants ................................................................................................................................................................................................................................................................................... 43
Antidiabetic Agents ...................................................................................................................................................................................................................................................................... 46
Antifungals ................................................................................................................................................................................................................................................................................................ 50
Antihistamines ...................................................................................................................................................................................................................................................................................... 54
Anti-Infectives (Skin And Mucous Membrane) .................................................................................................................................................................................. 61
Antimigraine Agents ................................................................................................................................................................................................................................................................... 61
Antimycobacterials ........................................................................................................................................................................................................................................................................ 62
Antinausea Agents ......................................................................................................................................................................................................................................................................... 63
Antiparasite Agents ...................................................................................................................................................................................................................................................................... 65
Antiparkinsonian Agents ...................................................................................................................................................................................................................................................... 66
Antipsychotic Agents ................................................................................................................................................................................................................................................................. 67
Antivirals (Systemic) ................................................................................................................................................................................................................................................................... 71
Blood Products/Modifiers/Volume Expanders ..................................................................................................................................................................................... 78
Caloric Agents ...................................................................................................................................................................................................................................................................................... 81
Cardiovascular Agents ............................................................................................................................................................................................................................................................. 86
Central Nervous System Agents ............................................................................................................................................................................................................................. 103
Contraceptives .................................................................................................................................................................................................................................................................................. 106
Cough And Cold Products ............................................................................................................................................................................................................................................. 114
Dental And Oral Agents .................................................................................................................................................................................................................................................... 116
Dermatological Agents ........................................................................................................................................................................................................................................................ 117
Devices ......................................................................................................................................................................................................................................................................................................... 126
Enzyme Replacement/Modifiers ............................................................................................................................................................................................................................ 152
Eye, Ear, Nose, Throat Agents ................................................................................................................................................................................................................................. 154
Gastrointestinal Agents ....................................................................................................................................................................................................................................................... 163
Genitourinary Agents ............................................................................................................................................................................................................................................................. 178
Heavy Metal Antagonists ................................................................................................................................................................................................................................................. 179
Hormonal Agents, Stimulant/Replacement/Modifying ....................................................................................................................................................... 180
Immunological Agents .......................................................................................................................................................................................................................................................... 186
Inflammatory Bowel Disease Agents ............................................................................................................................................................................................................... 195
Irrigating Solutions .................................................................................................................................................................................................................................................................... 196
Metabolic Bone Disease Agents .............................................................................................................................................................................................................................. 196
1
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Contents
of
Table
Miscellaneous Therapeutic Agents ..................................................................................................................................................................................................................... 198
Ophthalmic Agents .................................................................................................................................................................................................................................................................... 204
Replacement Preparations .............................................................................................................................................................................................................................................. 205
Respiratory Tract Agents ................................................................................................................................................................................................................................................. 215
Skeletal Muscle Relaxants ............................................................................................................................................................................................................................................... 219
Sleep Disorder Agents ........................................................................................................................................................................................................................................................... 220
Urine And Feces Contents .............................................................................................................................................................................................................................................. 222
Vasodilating Agents .................................................................................................................................................................................................................................................................. 222
Vitamins And Minerals ....................................................................................................................................................................................................................................................... 223
2
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Analgesics
Analgesics, Miscellaneous
acephen 120 mg suppository outer 120 mg
*
acephen 325 mg suppository outer 325 mg
*
acetaminophen 120 mg suppos outer 120
mg *
acetaminophen 160 mg rapid tab 160 mg *
acetaminophen 160 mg/5 ml elx 160 mg/5
ml *
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
(Acetaminophen)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
acetaminophen 80 mg/0.8 ml drp infants
80 mg/0.8 ml *
(Acetaminophen)
$0 (Tier 4)
acetaminophen-codeine 120 mg-12 mg/5
ml solution 120-12 mg/5 ml
acetaminophen-codeine oral solution 300
mg-30 mg /12.5 ml
acetaminophen-codeine oral tablet 300-15
mg, 300-30 mg
acetaminophen-codeine oral tablet 300-60
mg
ALLZITAL ORAL TABLET 25-325
MG
ascomp with codeine oral capsule
30-50-325-40 mg
(Acetaminophen with
Codeine)
(Acetaminophen with
Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
$0 (Tier 1)
QL (30 per 30 days)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (2700 per 30 days)
$0 (Tier 1)
QL (2700 per 30 days)
$0 (Tier 1)
QL (360 per 30 days)
$0 (Tier 1)
QL (180 per 30 days)
$0 (Tier 1)
(Fiorinal with
Codeine #3)
BELBUCA BUCCAL FILM 150 MCG,
300 MCG, 450 MCG, 600 MCG, 75
MCG, 750 MCG, 900 MCG
buprenorphine hcl injection syringe 0.3
(Buprenorphine HCl)
mg/ml
$0 (Tier 1)
$0 - $7.40
(Tier 2)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
ST; QL (60 per 30
days)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
3
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
(Fiorinal with
Codeine #3)
$0 (Tier 1)
butalbital-acetaminop-caf-cod oral capsule (Fioricet with
50-300-40-30 mg, 50-325-40-30 mg
Codeine)
$0 (Tier 1)
butalbital compound w/codeine oral
capsule 30-50-325-40 mg
butalbital-acetaminophen oral tablet
50-325 mg
(Tencon)
$0 (Tier 1)
butalbital-acetaminophen-caff oral capsule (Esgic)
50-325-40 mg
$0 (Tier 1)
butalbital-acetaminophen-caff oral tablet
50-325-40 mg
(Esgic)
$0 (Tier 1)
butalbital-aspirin-caffeine oral capsule
50-325-40 mg
(Fiorinal)
$0 (Tier 1)
BUTRANS TRANSDERMAL PATCH
WEEKLY 10 MCG/HOUR, 15
MCG/HOUR, 20 MCG/HOUR, 5
MCG/HOUR, 7.5 MCG/HOUR
capacet oral capsule 50-325-40 mg
(Esgic)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
child non-aspirin 160 mg/5 ml children's
160 mg/5 ml *
(Acetaminophen)
$0 (Tier 4)
child pain-fever 160 mg/5 ml
a/f,gluten/f,cherry 160 mg/5 ml *
(Infants' Tylenol)
$0 (Tier 4)
child tactinal 80 mg tab chw 80 mg *
codeine sulfate oral tablet 15 mg, 30 mg,
60 mg
(Acetaminophen)
(Codeine Sulfate)
$0 (Tier 4)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
QL (4 per 28 days)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (240 per 30
days); AGE (Max 21
Years)
QL (30 per 30 days)
QL (180 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
4
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
cvs child non-asa 80 mg tb chw 80 mg *
cvs non-aspirin jr tab chew 160 mg *
endocet oral tablet 10-325 mg, 2.5-325
mg, 5-325 mg, 7.5-325 mg
endodan oral tablet 4.8355-325 mg
fentanyl citrate buccal lozenge on a handle
1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg,
600 mcg, 800 mcg
fentanyl transdermal patch 72 hour 100
mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5
mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75
mcg/hr, 87.5 mcg/hour
feverall 120 mg suppository children's,
outer 120 mg *
feverall 325 mg suppository junior str,
outer 325 mg *
FEVERALL 80 MG SUPPOSITORY
INFANT'S, OUTER 80 MG *
hydrocodone-acetaminophen oral solution
10-325 mg/15 ml(15 ml), 2.5-167 mg/5
ml, 7.5-325 mg/15 ml
hydrocodone-acetaminophen oral tablet
10-300 mg, 5-300 mg, 7.5-300 mg
(Acetaminophen)
(Acetaminophen)
(Xolox)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
QL (30 per 30 days)
QL (30 per 30 days)
QL (360 per 30 days)
(Percodan)
(Actiq)
$0 (Tier 1)
$0 (Tier 1)
QL (360 per 30 days)
PA; QL (120 per 30
days)
(Duragesic)
$0 (Tier 1)
QL (10 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (30 per 30 days)
$0 (Tier 4)
QL (30 per 30 days)
(Hycet)
$0 (Tier 1)
QL (2700 per 30 days)
(Norco)
$0 (Tier 1)
hydrocodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
hydrocodone-ibuprofen oral tablet 10-200
mg, 2.5-200 mg, 5-200 mg, 7.5-200 mg
hydromorphone (pf) injection solution 10
mg/ml
hydromorphone injection solution 2 mg/ml,
4 mg/ml
(Norco)
$0 (Tier 1)
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
QL (360 per 30 days)
(Ibudone)
$0 (Tier 1)
QL (150 per 30 days)
(Dilaudid-HP)
$0 (Tier 1)
(Hydromorphone
HCl)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
5
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
hydromorphone injection syringe 2 mg/ml
(Hydromorphone
HCl)
(Dilaudid)
(Dilaudid)
(Dilaudid)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
QL (1200 per 30 days)
QL (180 per 30 days)
QL (240 per 30 days)
QL (30 per 30 days)
$0 - $7.40
(Tier 2)
PA; QL (30 per 30
days)
(Norco)
(Norco)
(Norco)
(Tylenol Sore Throat)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
mapap 160 mg/5 ml suspension 160 mg/5
ml *
(Infants' Tylenol)
$0 (Tier 4)
mapap 325 mg tablet 325 mg *
mapap 500 mg capsule 500 mg *
mapap 500 mg tablet 500 mg *
mapap 80 mg tablet chew 80 mg *
margesic oral capsule 50-325-40 mg
(Tylenol)
(Acetaminophen)
(Tylenol)
(Acetaminophen)
(Esgic)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
QL (360 per 30 days)
QL (360 per 30 days)
QL (360 per 30 days)
PA; QL (240 per 30
days); AGE (Max 21
Years)
PA; QL (240 per 30
days); AGE (Max 21
Years)
QL (360 per 30 days)
QL (240 per 30 days)
QL (240 per 30 days)
QL (30 per 30 days)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
methadone injection solution 10 mg/ml
methadone oral solution 10 mg/5 ml, 5
mg/5 ml
methadone oral tablet 10 mg, 5 mg
(Methadone HCl)
(Methadone HCl)
$0 (Tier 1)
$0 (Tier 1)
QL (1800 per 30 days)
(Diskets)
$0 (Tier 1)
QL (360 per 30 days)
hydromorphone oral liquid 1 mg/ml
hydromorphone oral tablet 2 mg, 4 mg
hydromorphone oral tablet 8 mg
HYSINGLA ER ORAL
TABLET,ORAL ONLY,EXT.REL.24
HR 100 MG, 120 MG, 20 MG, 30 MG,
40 MG, 60 MG, 80 MG
LAZANDA NASAL
SPRAY,NON-AEROSOL 100
MCG/SPRAY, 300 MCG/SPRAY, 400
MCG/SPRAY
lorcet (hydrocodone) oral tablet 5-325 mg
lorcet hd oral tablet 10-325 mg
lorcet plus oral tablet 7.5-325 mg
mapap 160 mg/5 ml elixir 160 mg/5 ml *
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
6
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
methadose oral tablet,soluble 40 mg
morphine (pf) in 0.9 % nacl intravenous pt
controlled analgesia syring 50 mg/25 ml (2
mg/ml)
morphine 10 mg/ml carpuject 10 mg/ml
morphine 2 mg/ml carpuject outer, latex-f,
p/f 2 mg/ml
morphine 4 mg/ml carpuject
outer,latex-free,p/f 4 mg/ml
morphine 8 mg/ml syringe 8 mg/ml
morphine concentrate oral solution 100
mg/5 ml (20 mg/ml)
morphine in dextrose 5 % injection pt
controlled analgesia syring 100 mg/50 ml
(2 mg/ml), 50 mg/25 ml (2 mg/ml)
morphine injection solution 15 mg/ml, 8
mg/ml
morphine injection syringe 10 mg/ml
morphine intramuscular pen injector 10
mg/0.7 ml
morphine intravenous cartridge 15 mg/ml
morphine intravenous solution 25 mg/ml,
50 mg/ml
morphine intravenous syringe 10 mg/ml, 2
mg/ml, 4 mg/ml, 8 mg/ml
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml (4
mg/ml)
MORPHINE ORAL TABLET 15 MG,
30 MG
morphine oral tablet extended release 100
mg, 30 mg, 60 mg
morphine oral tablet extended release 15
mg, 200 mg
Necessary Actions,
Restrictions, or
Limits on Use
(Diskets)
(Morphine
Sulfate/0.9%
Nacl/PF)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
(Morphine Sulfate)
$0 (Tier 1)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
(Morphine
Sulfate/D5W)
$0 (Tier 1)
(Morphine Sulfate)
$0 (Tier 1)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
(Morphine Sulfate)
$0 (Tier 1)
(Morphine Sulfate)
(Morphine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
QL (700 per 30 days)
QL (300 per 30 days)
QL (180 per 30 days)
(MS Contin)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(MS Contin)
$0 (Tier 1)
QL (180 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
QL (200 per 30 days)
QL (120 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
7
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
morphine rectal suppository 10 mg, 20 mg, (Morphine Sulfate)
30 mg, 5 mg
nortemp 80 mg/0.8 ml drop 80 mg/0.8 ml * (Acetaminophen)
$0 (Tier 1)
NUCYNTA ER ORAL TABLET
EXTENDED RELEASE 12 HR 100
MG, 150 MG, 200 MG, 250 MG, 50 MG
NUCYNTA ORAL TABLET 100 MG,
50 MG, 75 MG
oxycodone oral concentrate 20 mg/ml
oxycodone oral solution 5 mg/5 ml
oxycodone oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
oxycodone oral tablet,oral only,ext.rel.12
hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60
mg
oxycodone oral tablet,oral only,ext.rel.12
hr 80 mg
oxycodone-acetaminophen oral solution
5-325 mg/5 ml
oxycodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
oxycodone-acetaminophen oral tablet
10-650 mg
oxycodone-acetaminophen oral tablet
7.5-500 mg
oxycodone-aspirin oral tablet 4.8355-325
mg
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15
MG, 20 MG, 30 MG, 40 MG, 60 MG
$0 - $7.40
(Tier 2)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (60 per 30 days)
QL (181 per 30 days)
(Oxycodone HCl)
(Oxycodone HCl)
(Roxicodone)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Oxycontin)
$0 (Tier 1)
QL (60 per 30 days)
(Oxycontin)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
QL (120 per 30 days)
$0 (Tier 1)
QL (360 per 30 days)
(Xolox)
$0 (Tier 1)
QL (180 per 30 days)
(Xolox)
$0 (Tier 1)
QL (240 per 30 days)
(Percodan)
$0 (Tier 1)
QL (360 per 30 days)
$0 - $7.40
(Tier 2)
QL (60 per 30 days)
(Oxycodone
HCl/Acetaminophen)
(Xolox)
QL (180 per 30 days)
QL (1300 per 30 days)
QL (180 per 30 days)
QL (1800 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
8
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet 10 mg, 5 mg
oxymorphone oral tablet extended release
12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
oxymorphone oral tablet extended release
12 hr 30 mg, 40 mg
pain relief 500 mg capsule 500 mg *
pharbetol 325 mg tablet regular strength
325 mg *
pharbetol 500 mg caplet extra-str, caplet
500 mg *
pv non-aspirin 500 mg softgel ex-str,liq
filled 500 mg *
q-pap 160 mg/5 ml solution a/f, cherry 160
mg/5 ml *
Necessary Actions,
Restrictions, or
Limits on Use
QL (120 per 30 days)
(Opana)
(Opana ER)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Opana ER)
$0 (Tier 1)
QL (120 per 30 days)
(Acetaminophen)
(Tylenol)
$0 (Tier 4)
$0 (Tier 4)
QL (240 per 30 days)
QL (360 per 30 days)
(Tylenol)
$0 (Tier 4)
QL (240 per 30 days)
(Acetaminophen)
$0 (Tier 4)
QL (240 per 30 days)
(Tylenol Sore Throat)
$0 (Tier 4)
(Tylenol)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
QL (180 per 30 days)
QL (60 per 30 days)
q-pap ex-str 500 mg tablet aspirin free 500 (Tylenol)
mg *
reprexain oral tablet 10-200 mg, 2.5-200
(Ibudone)
mg, 5-200 mg
roxicet oral solution 5-325 mg/5 ml
(Oxycodone
HCl/Acetaminophen)
silapap infant's drops infant 80 mg/0.8 ml (Acetaminophen)
*
$0 (Tier 4)
PA; QL (240 per 30
days); AGE (Max 21
Years)
QL (360 per 30 days)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (240 per 30 days)
$0 (Tier 1)
QL (150 per 30 days)
$0 (Tier 1)
QL (1800 per 30 days)
$0 (Tier 4)
sm pain rel jr str tab chew 160 mg *
sm pain reliever 80 mg tab children's 80
mg *
tactinal 325 mg tablet 325 mg *
(Acetaminophen)
(Acetaminophen)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (30 per 30
days); AGE (Max 21
Years)
QL (30 per 30 days)
QL (30 per 30 days)
(Tylenol)
$0 (Tier 4)
QL (360 per 30 days)
q-pap 325 mg tablet 325 mg *
q-pap 80 mg/0.8 ml drops 80 mg/0.8 ml *
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
9
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
tactinal 500 mg tablet extra-strength 500
mg *
tencon oral tablet 50-325 mg
(Tylenol)
$0 (Tier 4)
QL (240 per 30 days)
(Tencon)
$0 (Tier 1)
tramadol oral tablet 50 mg
tramadol-acetaminophen oral tablet
37.5-325 mg
vicodin es oral tablet 7.5-300 mg
(Ultram)
(Ultracet)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
QL (240 per 30 days)
QL (240 per 30 days)
(Norco)
$0 (Tier 1)
vicodin hp oral tablet 10-300 mg
(Norco)
$0 (Tier 1)
vicodin oral tablet 5-300 mg
(Norco)
$0 (Tier 1)
xylon 10 oral tablet 10-200 mg
zebutal oral capsule 50-325-40 mg
(Ibudone)
(Esgic)
$0 (Tier 1)
$0 (Tier 1)
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
QL (150 per 30 days)
PA-HRM; QL (180 per
30 days); AGE (Max
64 Years)
Nonsteroidal
Anti-Inflammatory Agents
ADVIL 100 MG TABLET JR
STRENGTH,COATED 100 MG *
ADVIL 200 MG TABLET 200 MG *
ADVIL JR STR 100 MG TAB CHEW
TB CHEW,8 HOUR,GRAPE 100 MG *
aspirin 325 mg tablet 325 mg *
(Ecotrin)
aspirin 81 mg chewable tablet 81 mg *
(Bayer Chewable
Aspirin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
10
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
aspirin buffered 325 mg tab 325 mg *
aspirin ec 325 mg tablet 325 mg *
aspirin ec 650 mg tablet 650 mg *
aspirin ec 81 mg tablet low dose 81 mg *
aspir-low ec 81 mg tablet 81 mg *
bufferin 325 mg tablet coated 325 mg *
CALDOLOR INTRAVENOUS
RECON SOLN 400 MG/4 ML (100
MG/ML)
celecoxib oral capsule 100 mg, 200 mg,
400 mg, 50 mg
CHILDREN'S ADVIL 100 MG/5 ML
A/F (OTC) 100 MG/5 ML *
choline,magnesium salicylate oral liquid
500 mg/5 ml
cvs ibuprofen 200 mg softgel liquid
filled,softge 200 mg *
cvs naproxen sodium 220 mg cap liquidgel
220 mg *
diclofenac potassium oral tablet 50 mg
diclofenac sodium oral tablet extended
release 24 hr 100 mg
diclofenac sodium oral tablet,delayed
release (dr/ec) 25 mg, 50 mg, 75 mg
diclofenac sodium topical gel 3 %
diclofenac-misoprostol oral
tablet,ir,delayed rel,biphasic 50-200
mg-mcg, 75-200 mg-mcg
diflunisal oral tablet 500 mg
ecotrin ec 325 mg tablet saftey coated 325
mg *
(Aspirin/Calcium
Carbonate/Mag)
(Ecotrin)
(Ecotrin)
(Ecotrin)
(Ecotrin)
(Aspirin/Calcium
Carbonate/Mag)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
(Celebrex)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 4)
(Choline Sal/Mag
Salicylate)
(Advil)
$0 (Tier 1)
(Aleve)
$0 (Tier 4)
(Diclofenac
Potassium)
(Voltaren-XR)
$0 (Tier 1)
(Diclofenac Sodium)
$0 (Tier 1)
(Voltaren)
(Arthrotec 50)
$0 (Tier 1)
$0 (Tier 1)
(Diflunisal)
(Ecotrin)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
11
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ecpirin ec 325 mg tablet 325 mg *
etodolac oral capsule 200 mg, 300 mg
etodolac oral tablet 400 mg, 500 mg
etodolac oral tablet extended release 24 hr
400 mg, 500 mg, 600 mg
fenoprofen oral capsule 200 mg
fenoprofen oral tablet 600 mg
FLECTOR TRANSDERMAL PATCH
12 HOUR 1.3 %
flurbiprofen oral tablet 100 mg, 50 mg
gnp ibuprofen jr str 100 mg tb 100 mg *
ibuprofen 100 mg/5 ml susp children's
(otc) 100 mg/5 ml *
ibuprofen 200 mg tablet 200 mg *
ibuprofen oral suspension 100 mg/5 ml
ibuprofen oral tablet 400 mg, 600 mg, 800
mg
indomethacin oral capsule 25 mg
indomethacin oral capsule 50 mg
indomethacin oral capsule, extended
release 75 mg
indomethacin sodium intravenous recon
soln 1 mg
infant ibuprofen 50 mg/1.25 ml
d/f,a/f,non-staining 50 mg/1.25 ml *
ketoprofen oral capsule 50 mg, 75 mg
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
ketorolac oral tablet 10 mg
mefenamic acid oral capsule 250 mg
meloxicam oral suspension 7.5 mg/5 ml
(Ecotrin)
(Etodolac)
(Etodolac)
(Etodolac)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Nalfon)
(Fenoprofen
Calcium)
$0 (Tier 1)
$0 (Tier 1)
(Flurbiprofen)
(Advil)
(Children'S Advil)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Advil)
(Ibuprofen)
(Ibuprofen)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Indomethacin)
(Indomethacin)
(Indomethacin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Indomethacin
Sodium)
(Infants' Motrin)
$0 (Tier 1)
(Ketoprofen)
(Ketoprofen)
$0 (Tier 1)
$0 (Tier 1)
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (240 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
$0 (Tier 4)
QL (20 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
12
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
meloxicam oral tablet 15 mg, 7.5 mg
nabumetone oral tablet 500 mg, 750 mg
naproxen oral suspension 125 mg/5 ml
naproxen oral tablet 250 mg, 375 mg, 500
mg
naproxen oral tablet,delayed release
(dr/ec) 375 mg, 500 mg
naproxen sodium oral tablet 275 mg, 550
mg
piroxicam oral capsule 10 mg, 20 mg
ra aspirin tri-buffered tb 325 mg *
sm ibuprofen ib 100 mg tablet junior
strength 100 mg *
sm naproxen sod 220 mg caplet gluten
free, caplet 220 mg *
st. joseph aspirin 81 mg chew orange 81
mg *
st. joseph aspirin ec 81 mg tb enteric
coated 81 mg *
sulindac oral tablet 150 mg, 200 mg
tolmetin oral capsule 400 mg
tolmetin oral tablet 200 mg, 600 mg
VOLTAREN TOPICAL GEL 1 %
wal-profen 200 mg softgel softgel 200 mg
*
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Ec-Naprosyn)
$0 (Tier 1)
(Anaprox)
$0 (Tier 1)
(Feldene)
(Aspirin/Calcium
Carbonate/Mag)
(Advil)
$0 (Tier 1)
$0 (Tier 4)
(Midol)
$0 (Tier 4)
(Bayer Chewable
Aspirin)
(Ecotrin)
$0 (Tier 4)
(Sulindac)
(Tolmetin Sodium)
(Tolmetin Sodium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Advil)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
Anesthetics
Local Anesthetics
glydo mucous membrane jelly in applicator (Lidocaine HCl)
2%
lidocaine (pf) injection solution 15 mg/ml (Xylocaine-MPF)
(1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5
%)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
13
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
lidocaine 2% viscous soln 2 %
lidocaine hcl injection solution 10 mg/ml
(1 %), 20 mg/ml (2 %)
lidocaine hcl mucous membrane gel 2 %
lidocaine hcl mucous membrane solution 2
%, 4 % (40 mg/ml)
lidocaine topical adhesive patch,medicated
5%
lidocaine topical ointment 5 %
lidocaine-prilocaine topical cream 2.5-2.5
%
(Xylocaine)
(Xylocaine)
$0 (Tier 1)
$0 (Tier 1)
(Lidocaine HCl)
(Xylocaine)
$0 (Tier 1)
$0 (Tier 1)
(Lidoderm)
$0 (Tier 1)
(Lidocaine)
(EMLA)
$0 (Tier 1)
$0 (Tier 1)
(Acamprosate
Calcium)
(Buprenorphine HCl)
$0 (Tier 1)
(Buprenorphine
HCl/Naloxone HCl)
(Zyban)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA
Anti-Addiction/Substance Abuse
Treatment Agents
Anti-Addiction/Substance
Abuse Treatment Agents
acamprosate oral tablet,delayed release
(dr/ec) 333 mg
buprenorphine hcl sublingual tablet 2 mg,
8 mg
buprenorphine-naloxone sublingual tablet
2-0.5 mg, 8-2 mg
bupropion hcl sr 150 mg tablet f/c 150 mg
CHANTIX CONTINUING MONTH
BOX ORAL TABLET 1 MG
CHANTIX ORAL TABLET 0.5 MG, 1
MG
CHANTIX STARTING MONTH BOX
ORAL TABLETS,DOSE PACK 0.5
MG (11)- 1 MG (42)
disulfiram oral tablet 250 mg, 500 mg
naloxone injection solution 0.4 mg/ml
naloxone injection syringe 0.4 mg/ml, 1
mg/ml
(Antabuse)
(Naloxone HCl)
(Naloxone HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
QL (168 per 84 days)
QL (168 per 84 days)
QL (53 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
14
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
naltrexone oral tablet 50 mg
NARCAN NASAL
SPRAY,NON-AEROSOL 4
MG/ACTUATION
nicorelief 2 mg gum 2 mg *
nicorelief 4 mg gum 4 mg *
nicorette 2 mg chewing gum white ice mint
2 mg *
nicotine 14 mg/24hr patch outer (otc) 14
mg/24 hr *
nicotine 2 mg chewing gum sugar free 2
mg *
nicotine 2 mg lozenge mint, 3 quittube 2
mg *
nicotine 21 mg/24hr patch step 1 (otc) 21
mg/24 hr *
nicotine 22 mg/24hr patch 1 week starter
kit 22 mg/24 hr *
nicotine 4 mg chewing gum 4 mg *
nicotine 4 mg lozenge mint, 3 quittube 4
mg *
nicotine 7 mg/24hr patch (otc) 7 mg/24 hr
*
NICOTROL INHALATION
CARTRIDGE 10 MG
ZUBSOLV SUBLINGUAL TABLET
1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG,
5.7-1.4 MG, 8.6-2.1 MG
(Revia)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 - $7.40
(Tier 2)
QL (4 per 30 days)
(Nicorette)
(Nicorette)
(Nicorette)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
QL (3285 per 365 days)
QL (3285 per 365 days)
QL (3285 per 365 days)
(Nicoderm Cq)
$0 (Tier 4)
QL (224 per 365 days)
(Nicorette)
$0 (Tier 4)
QL (3285 per 365 days)
(Nicorette)
$0 (Tier 4)
QL (3285 per 365 days)
(Nicoderm Cq)
$0 (Tier 4)
QL (224 per 365 days)
(Nicoderm Cq)
$0 (Tier 4)
QL (224 per 365 days)
(Nicorette)
(Nicorette)
$0 (Tier 4)
$0 (Tier 4)
QL (3285 per 365 days)
QL (3285 per 365 days)
(Nicoderm Cq)
$0 (Tier 4)
QL (224 per 365 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (1008 per 90 days)
$0 (Tier 1)
QL (120 per 30 days)
PA; QL (90 per 30
days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg
(Xanax)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
15
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
chlordiazepoxide hcl oral capsule 10 mg,
25 mg, 5 mg
clonazepam oral tablet 0.5 mg, 1 mg
clonazepam oral tablet 2 mg
clonazepam oral tablet,disintegrating
0.125 mg, 0.25 mg, 0.5 mg, 1 mg
clonazepam oral tablet,disintegrating 2 mg
clorazepate dipotassium oral tablet 15 mg
clorazepate dipotassium oral tablet 3.75
mg, 7.5 mg
diazepam injection syringe 5 mg/ml
diazepam intensol oral concentrate 5
mg/ml
diazepam oral solution 5 mg/5 ml (1
mg/ml)
diazepam oral tablet 10 mg, 2 mg, 5 mg
diazepam rectal kit 12.5-15-17.5-20 mg,
2.5 mg, 5-7.5-10 mg
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
ONFI ORAL SUSPENSION 2.5
MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
(Chlordiazepoxide
HCl)
(Klonopin)
(Klonopin)
(Clonazepam)
$0 (Tier 1)
QL (120 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
QL (300 per 30 days)
QL (90 per 30 days)
(Clonazepam)
(Tranxene T-Tab)
(Tranxene T-Tab)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (300 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
(Diazepam)
(Diazepam)
$0 (Tier 1)
$0 (Tier 1)
QL (10 per 28 days)
QL (1200 per 30 days)
(Diazepam)
$0 (Tier 1)
QL (1200 per 30 days)
(Valium)
(Diastat)
$0 (Tier 1)
$0 (Tier 1)
QL (120 per 30 days)
(Ativan)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
QL (90 per 30 days)
PA NSO; QL (480 per
30 days)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
PA BvD
Antibacterials
Aminoglycosides
BETHKIS INHALATION SOLUTION
FOR NEBULIZATION 300 MG/4 ML
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 100 mg/50 ml,
60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml,
80 mg/50 ml, 90 mg/100 ml
gentamicin injection solution 40 mg/ml
gentamicin ped 20 mg/2 ml vial latex-free,
sdv 20 mg/2 ml
(Gentamicin In Nacl,
Iso-Osm)
(Gentamicin Sulfate)
(Gentamicin
Sulfate/PF)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
16
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
gentamicin sulfate (pf) intravenous
solution 80 mg/8 ml
neomycin oral tablet 500 mg
streptomycin intramuscular recon soln 1
gram
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION
DEVICE 28 MG
tobramycin in 0.225 % nacl inhalation
solution for nebulization 300 mg/5 ml
tobramycin in 0.9 % nacl intravenous
piggyback 60 mg/50 ml, 80 mg/100 ml
tobramycin sulfate injection solution 10
mg/ml, 40 mg/ml
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin
Sulfate)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
QL (224 per 28 days)
(Tobi)
$0 (Tier 1)
PA BvD
(Tobramycin/Sodium
Chloride)
(Tobramycin Sulfate)
$0 (Tier 1)
(Bacitracin)
$0 (Tier 1)
(Chloramphenicol
Sod Succ)
(Cleocin Palmitate)
(Cleocin HCl)
$0 (Tier 1)
(Cleocin Phosphate
In D5w)
$0 (Tier 1)
(Cleocin Palmitate)
$0 (Tier 1)
(Cleocin Phosphate)
$0 (Tier 1)
(Cleocin Phosphate)
$0 (Tier 1)
(Coly-Mycin M
Parenteral)
$0 (Tier 1)
$0 (Tier 1)
Antibacterials, Miscellaneous
bacitracin intramuscular recon soln 50,000
unit
chloramphenicol sod succinate intravenous
recon soln 1 gram
clindamycin 75 mg/5 ml soln 75 mg/5 ml
clindamycin hcl oral capsule 150 mg, 300
mg, 75 mg
clindamycin in 5 % dextrose intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml,
900 mg/50 ml
clindamycin pediatric oral recon soln 75
mg/5 ml
clindamycin phosphate injection solution
150 mg/ml
clindamycin phosphate intravenous
solution 600 mg/4 ml
colistin (colistimethate na) injection recon
soln 150 mg
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
17
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
CUBICIN INTRAVENOUS RECON
SOLN 500 MG
daptomycin intravenous recon soln 500 mg
linezolid intravenous parenteral solution
600 mg/300 ml
linezolid oral suspension for reconstitution
100 mg/5 ml
linezolid oral tablet 600 mg
methenamine hippurate oral tablet 1 gram
metronidazole in nacl (iso-os) intravenous
piggyback 500 mg/100 ml
metronidazole oral capsule 375 mg
metronidazole oral tablet 250 mg, 500 mg
nitrofurantoin macrocrystal oral capsule
100 mg, 25 mg, 50 mg
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg
(Cubicin)
(Zyvox)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Zyvox)
$0 (Tier 1)
(Zyvox)
(Hiprex)
(Metronidazole/Sodiu
m Chloride)
(Flagyl)
(Flagyl)
(Macrodantin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Macrobid)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (120 per 30 days);
AGE (Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (120 per 30 days);
AGE (Max 64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
18
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
nitrofurantoin monohyd/m-cryst oral
capsule 100 mg (75/25)
(Macrobid)
$0 (Tier 1)
polymyxin b sulfate injection recon soln
500,000 unit
SYNERCID INTRAVENOUS RECON
SOLN 500 MG
trimethoprim oral tablet 100 mg
vancomycin hcl 1g/200 ml bag 1 gram/200
ml
vancomycin in 0.9% sodium cl intravenous
solution 1.5 gram/500 ml
vancomycin intravenous recon soln 1,000
mg, 10 gram, 750 mg
vancomycin intravenous recon soln 500 mg
(Polymyxin B Sulfate)
$0 (Tier 1)
vancomycin oral capsule 125 mg, 250 mg
XIFAXAN ORAL TABLET 200 MG
(Trimethoprim)
(Vancomycin Hcl In
Dextrose 5 %)
(Vancomycin/0.9 %
Sod Chloride)
(Vancomycin HCl)
(Vancomycin Hcl In
Dextrose 5 %)
(Vancocin HCl)
XIFAXAN ORAL TABLET 550 MG
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (120 per 30 days);
AGE (Max 64 Years)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; QL (9 per 30 days)
PA
Cephalosporins
cefaclor oral capsule 250 mg, 500 mg
cefaclor oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
cefadroxil oral capsule 500 mg
(Cefaclor)
(Cefaclor)
$0 (Tier 1)
$0 (Tier 1)
(Cefadroxil)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
19
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500 mg/5 ml
cefadroxil oral tablet 1 gram
cefazolin in dextrose (iso-os) intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
cefazolin injection recon soln 1 gram, 10
gram, 500 mg
cefdinir oral capsule 300 mg
cefdinir oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml
cefditoren pivoxil oral tablet 200 mg, 400
mg
CEFEPIME 2 GM INJECTION 2
GRAM/100 ML
CEFEPIME IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK 1
GRAM/50 ML, 2 GRAM/50 ML
cefepime injection recon soln 1 gram, 2
gram
cefotaxime injection recon soln 1 gram, 10
gram, 2 gram, 500 mg
cefoxitin in dextrose, iso-osm intravenous
piggyback 2 gram/50 ml
cefoxitin intravenous recon soln 1 gram,
10 gram, 2 gram
cefpodoxime oral suspension for
reconstitution 100 mg/5 ml, 50 mg/5 ml
cefpodoxime oral tablet 100 mg, 200 mg
(Cefadroxil)
$0 (Tier 1)
(Cefadroxil)
(Cefazolin
Sodium/Dextrose,
Iso)
(Cefazolin Sodium)
$0 (Tier 1)
$0 (Tier 1)
(Cefdinir)
(Cefdinir)
$0 (Tier 1)
$0 (Tier 1)
(Spectracef)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Maxipime)
$0 (Tier 1)
(Claforan)
$0 (Tier 1)
(Cefoxitin
Sodium/Dextrose,
Iso)
(Cefoxitin Sodium)
$0 (Tier 1)
(Cefpodoxime
Proxetil)
(Cefpodoxime
Proxetil)
cefprozil oral suspension for reconstitution (Cefprozil)
125 mg/5 ml, 250 mg/5 ml
cefprozil oral tablet 250 mg, 500 mg
(Cefprozil)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
20
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ceftazidime injection recon soln 2 gram, 6
gram
ceftibuten oral capsule 400 mg
ceftibuten oral suspension for
reconstitution 180 mg/5 ml
ceftriaxone 1 gm piggyback 50ml
galaxycontainer 1 gram/50 ml
ceftriaxone 1 gm vial 10's, fliptop,l/f 1
gram
ceftriaxone 2 gm piggyback 50ml
galaxycontainer 2 gram/50 ml
ceftriaxone injection recon soln 10 gram,
250 mg, 500 mg
ceftriaxone intravenous recon soln 1 gram,
2 gram
cefuroxime axetil oral tablet 250 mg, 500
mg
cefuroxime sodium injection recon soln 1.5
gram, 750 mg
cefuroxime sodium intravenous recon soln
7.5 gram
cephalexin oral capsule 250 mg, 500 mg,
750 mg
cephalexin oral suspension for
reconstitution 125 mg/5 ml, 250 mg/5 ml
cephalexin oral tablet 250 mg, 500 mg
MEFOXIN IN DEXTROSE
(ISO-OSM) INTRAVENOUS
PIGGYBACK 1 GRAM/50 ML, 2
GRAM/50 ML
SUPRAX ORAL
TABLET,CHEWABLE 100 MG, 200
MG
tazicef injection recon soln 2 gram, 6 gram
(Fortaz)
$0 (Tier 1)
(Cedax)
(Cedax)
$0 (Tier 1)
$0 (Tier 1)
(Ceftriaxone
Na/Dextrose, Iso)
(Rocephin)
$0 (Tier 1)
(Ceftriaxone
Na/Dextrose, Iso)
(Rocephin)
$0 (Tier 1)
(Ceftriaxone
Na/Dextrose, Iso)
(Ceftin)
$0 (Tier 1)
(Zinacef)
$0 (Tier 1)
(Zinacef)
$0 (Tier 1)
(Keflex)
$0 (Tier 1)
(Cephalexin)
$0 (Tier 1)
(Cephalexin)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
(Fortaz)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
21
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
TEFLARO INTRAVENOUS RECON
SOLN 400 MG, 600 MG
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
Macrolides
azithromycin intravenous recon soln 500
mg
azithromycin oral packet 1 gram
azithromycin oral suspension for
reconstitution 100 mg/5 ml, 200 mg/5 ml
azithromycin oral tablet 250 mg, 250 mg
(6 pack), 600 mg
azithromycin oral tablet 500 mg
clarithromycin oral suspension for
reconstitution 125 mg/5 ml, 250 mg/5 ml
clarithromycin oral tablet 250 mg, 500 mg
clarithromycin oral tablet extended release
24 hr 500 mg
DIFICID ORAL TABLET 200 MG
(Zithromax)
$0 (Tier 1)
(Zithromax)
(Zithromax)
$0 (Tier 1)
$0 (Tier 1)
(Zithromax)
$0 (Tier 1)
(Zithromax)
(Biaxin)
$0 (Tier 1)
$0 (Tier 1)
(Biaxin)
(Clarithromycin)
$0 (Tier 1)
$0 (Tier 1)
e.e.s. 400 oral tablet 400 mg
(Erythromycin
Ethylsuccinate)
(Eryped 200)
e.e.s. granules oral suspension for
reconstitution 200 mg/5 ml
ery-tab oral tablet,delayed release (dr/ec)
250 mg, 500 mg
ERY-TAB ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythrocin (as stearate) oral tablet 250
mg
ERYTHROCIN INTRAVENOUS
RECON SOLN 1,000 MG, 500 MG
erythromycin ethylsuccinate oral
suspension for reconstitution 200 mg/5 ml
(Erythromycin Base)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
QL (20 per 10 days)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
(Erythromycin
Stearate)
(Eryped 200)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
22
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
erythromycin ethylsuccinate oral tablet
400 mg
erythromycin oral capsule,delayed
release(dr/ec) 250 mg
erythromycin oral tablet 250 mg, 500 mg
(Erythromycin
Ethylsuccinate)
(Erythromycin Base)
$0 (Tier 1)
(Erythromycin Base)
$0 (Tier 1)
(Azactam)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1 gram
CAYSTON INHALATION
SOLUTION FOR NEBULIZATION 75
MG/ML
imipenem-cilastatin intravenous recon soln
250 mg, 500 mg
INVANZ INJECTION RECON SOLN
1 GRAM
meropenem intravenous recon soln 500 mg
meropenem iv 1 gm vial outer, latex-free 1
gram
(Primaxin)
$0 (Tier 1)
(Merrem)
(Merrem)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Amoxicillin)
(Amoxicillin)
$0 (Tier 1)
$0 (Tier 1)
(Amoxicillin)
(Amoxicillin)
$0 (Tier 1)
$0 (Tier 1)
(Augmentin)
$0 (Tier 1)
(Augmentin)
$0 (Tier 1)
LA
Penicillins
amoxicillin oral capsule 250 mg, 500 mg
amoxicillin oral suspension for
reconstitution 125 mg/5 ml, 200 mg/5 ml,
250 mg/5 ml, 400 mg/5 ml
amoxicillin oral tablet 500 mg, 875 mg
amoxicillin oral tablet,chewable 125 mg,
250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution 200-28.5
mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5
ml, 600-42.9 mg/5 ml
amoxicillin-pot clavulanate oral tablet
250-125 mg, 500-125 mg, 875-125 mg
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
23
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
amoxicillin-pot clavulanate oral tablet
extended release 12 hr 1,000-62.5 mg
amoxicillin-pot clavulanate oral
tablet,chewable 200-28.5 mg, 400-57 mg
ampicillin 2 gm vial 10's, latex-free 2 gram
ampicillin oral capsule 250 mg, 500 mg
(Augmentin XR)
$0 (Tier 1)
(Amoxicillin/Potassiu
m Clav)
(Ampicillin Sodium)
(Ampicillin
Trihydrate)
(Ampicillin
Trihydrate)
(Ampicillin Sodium)
$0 (Tier 1)
ampicillin oral suspension for
reconstitution 125 mg/5 ml, 250 mg/5 ml
ampicillin sodium injection recon soln 1
gram, 10 gram, 125 mg
ampicillin sodium intravenous recon soln 2 (Ampicillin Sodium)
gram
ampicillin-sulbactam injection recon soln
(Unasyn)
1.5 gram, 15 gram, 3 gram
BICILLIN C-R INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/ 2
ML(600K/600K), 1,200,000 UNIT/ 2
ML(900K/300K)
BICILLIN L-A INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/2 ML,
2,400,000 UNIT/4 ML, 600,000
UNIT/ML
dicloxacillin oral capsule 250 mg, 500 mg (Dicloxacillin
Sodium)
nafcillin 2 gm vial sterile, latex-free 2
(Nafcillin Sodium)
gram
nafcillin injection recon soln 1 gram, 10
(Nafcillin Sodium)
gram
nafcillin intravenous recon soln 2 gram
(Nafcillin Sodium)
oxacillin 1 gm add-vantage vl add-vantage, (Oxacillin Sodium)
inner 1 gram
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
24
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
oxacillin in dextrose(iso-osm) intravenous (Oxacillin
piggyback 1 gram/50 ml, 2 gram/50 ml
Sodium/Dextrose,
Iso)
oxacillin injection recon soln 10 gram
(Oxacillin Sodium)
oxacillin intravenous recon soln 2 gram
(Oxacillin Sodium)
penicillin g pot in dextrose intravenous
(Pen G
piggyback 1 million unit/50 ml, 2 million
Pot/Dextrose-Water)
unit/50 ml, 3 million unit/50 ml
penicillin g potassium injection recon soln (Penicillin G
5 million unit
Potassium)
penicillin g procaine intramuscular syringe (Penicillin G
1.2 million unit/2 ml, 600,000 unit/ml
Procaine)
penicillin gk 20 million unit 20 million unit (Penicillin G
Potassium)
penicillin v potassium oral recon soln 125 (Penicillin V
mg/5 ml, 250 mg/5 ml
Potassium)
penicillin v potassium oral tablet 250 mg, (Penicillin V
500 mg
Potassium)
pfizerpen-g injection recon soln 20 million (Penicillin G
unit
Potassium)
piperacillin-tazobactam intravenous recon (Zosyn)
soln 2.25 gram, 3.375 gram, 4.5 gram
piperacil-tazobact 40.5 gram p/f,
(Zosyn)
latex-free 40.5 gram
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Quinolones
ciprofloxacin hcl oral tablet 100 mg, 250
mg, 500 mg, 750 mg
ciprofloxacin in 5 % dextrose intravenous
piggyback 200 mg/100 ml
ciprofloxacin lactate intravenous solution
400 mg/40 ml
ciprofloxacin oral suspension,microcapsule
recon 250 mg/5 ml, 500 mg/5 ml
(Cipro)
$0 (Tier 1)
(Cipro I.V.)
$0 (Tier 1)
(Ciprofloxacin
Lactate)
(Cipro)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
25
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ciprofloxacn-d5w 400 mg/200 ml
p/f,latex/f, in d5w 400 mg/200 ml
levofloxacin in d5w intravenous piggyback
500 mg/100 ml, 750 mg/150 ml
levofloxacin intravenous solution 25 mg/ml
levofloxacin oral solution 250 mg/10 ml
levofloxacin oral tablet 250 mg, 500 mg,
750 mg
moxifloxacin oral tablet 400 mg
ofloxacin oral tablet 400 mg
(Cipro I.V.)
$0 (Tier 1)
(Levaquin)
$0 (Tier 1)
(Levofloxacin)
(Levaquin)
(Levaquin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Avelox)
(Ofloxacin)
$0 (Tier 1)
$0 (Tier 1)
(Sulfadiazine)
(Sulfamethoxazole/Tr
imethoprim)
(Sulfamethoxazole/Tr
imethoprim)
(Bactrim)
$0 (Tier 1)
$0 (Tier 1)
(Azulfidine)
(Azulfidine)
$0 (Tier 1)
$0 (Tier 1)
(Sulfamethoxazole/Tr
imethoprim)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
Sulfonamides
sulfadiazine oral tablet 500 mg
sulfamethoxazole-trimethoprim
intravenous solution 400-80 mg/5 ml
sulfamethoxazole-trimethoprim oral
suspension 200-40 mg/5 ml
sulfamethoxazole-trimethoprim oral tablet
400-80 mg, 800-160 mg
sulfasalazine oral tablet 500 mg
sulfasalazine oral tablet,delayed release
(dr/ec) 500 mg
sulfatrim oral suspension 200-40 mg/5 ml
$0 (Tier 1)
$0 (Tier 1)
Tetracyclines
(Doxycycline
Hyclate)
doxycycline hyclate 100 mg cap 100 mg
(Morgidox)
doxycycline hyclate 100 mg tab 100 mg
(Doryx)
doxycycline hyclate intravenous recon soln (Doxycycline
100 mg
Hyclate)
doxycycline hyclate oral capsule 100 mg
(Adoxa)
doxycycline hyclate oral capsule 50 mg
(Morgidox)
doxy-100 intravenous recon soln 100 mg
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
26
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
(Avidoxy)
$0 (Tier 1)
(Doryx)
(Adoxa)
(Avidoxy)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Avidoxy)
(Adoxa)
$0 (Tier 1)
$0 (Tier 1)
(Vibramycin)
$0 (Tier 1)
(Avidoxy)
$0 (Tier 1)
(Minocin)
$0 (Tier 1)
(Minocycline HCl)
$0 (Tier 1)
(Tetracycline HCl)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
ABRAXANE INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 100 MG
ADCETRIS INTRAVENOUS RECON
SOLN 50 MG
adriamycin intravenous recon soln 10 mg, (Doxorubicin HCl)
20 mg, 50 mg
adriamycin intravenous solution 10 mg/5
(Doxorubicin HCl)
ml
adrucil 2,500 mg/50 ml vial outer,
(Fluorouracil)
latex-free 2.5 gram/50 ml
$0 - $7.40
(Tier 2)
doxycycline hyclate oral tablet 100 mg, 50
mg
doxycycline hyclate oral tablet 20 mg
doxycycline mono 100 mg cap 100 mg
doxycycline mono 100 mg tablet f/c 100
mg
doxycycline mono 50 mg tablet 50 mg
doxycycline monohydrate oral capsule 150
mg, 50 mg, 75 mg
doxycycline monohydrate oral suspension
for reconstitution 25 mg/5 ml
doxycycline monohydrate oral tablet 150
mg, 75 mg
minocycline oral capsule 100 mg, 50 mg,
75 mg
minocycline oral tablet 100 mg, 50 mg, 75
mg
tetracycline oral capsule 250 mg, 500 mg
TYGACIL INTRAVENOUS RECON
SOLN 50 MG
Necessary Actions,
Restrictions, or
Limits on Use
Anticancer Agents
Anticancer Agents
$0 - $7.40
(Tier 2)
$0 (Tier 1)
PA NSO; QL (4 per 21
days)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
27
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
adrucil intravenous solution 500 mg/10 ml (Fluorouracil)
AFINITOR DISPERZ ORAL TABLET
FOR SUSPENSION 2 MG, 3 MG, 5
MG
AFINITOR ORAL TABLET 10 MG
AFINITOR ORAL TABLET 2.5 MG, 5
MG, 7.5 MG
ALECENSA ORAL CAPSULE 150
MG
ALIMTA INTRAVENOUS RECON
SOLN 500 MG
anastrozole oral tablet 1 mg
(Arimidex)
AVASTIN INTRAVENOUS
SOLUTION 25 MG/ML, 25 MG/ML
(16 ML)
azacitidine injection recon soln 100 mg
(Vidaza)
BELEODAQ INTRAVENOUS
RECON SOLN 500 MG
BENDEKA INTRAVENOUS
SOLUTION 25 MG/ML
bexarotene oral capsule 75 mg
(Targretin)
bicalutamide oral tablet 50 mg
(Casodex)
bleomycin injection recon soln 30 unit
(Bleomycin Sulfate)
bleomycin sulfate 15 unit vial latex-free 15 (Bleomycin Sulfate)
unit
BLINCYTO INTRAVENOUS KIT 35
MCG
BOSULIF ORAL TABLET 100 MG
BOSULIF ORAL TABLET 500 MG
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 - $7.40
(Tier 2)
PA BvD
PA NSO; QL (112 per
28 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
PA NSO; QL (56 per
28 days)
PA NSO; QL (28 per
28 days)
PA NSO; QL (240 per
30 days)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
PA NSO
PA NSO
PA NSO
PA NSO; QL (420 per
30 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (30 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
28
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (112 per
28 days)
(Cyclophosphamide)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
PA NSO; LA; QL (63
per 28 days)
PA BvD
PA BvD; ST
(Cyclophosphamide)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
PA NSO
Name of Drug
CABOMETYX ORAL TABLET 20
MG, 60 MG
CABOMETYX ORAL TABLET 40
MG
CAPRELSA ORAL TABLET 100 MG
CAPRELSA ORAL TABLET 300 MG
COMETRIQ ORAL CAPSULE 100
MG/DAY(80 MG X1-20 MG X1), 140
MG/DAY(80 MG X1-20 MG X3), 60
MG/DAY (20 MG X 3/DAY)
COTELLIC ORAL TABLET 20 MG
cyclophosphamide intravenous recon soln
1 gram, 2 gram, 500 mg
CYCLOPHOSPHAMIDE ORAL
CAPSULE 25 MG, 50 MG
cyclophosphamide oral tablet 25 mg, 50
mg
CYRAMZA INTRAVENOUS
SOLUTION 10 MG/ML, 10 MG/ML
(50 ML)
dactinomycin intravenous recon soln 0.5
mg
DARZALEX INTRAVENOUS
SOLUTION 20 MG/ML
decitabine intravenous recon soln 50 mg
doxorubicin, peg-liposomal intravenous
suspension 2 mg/ml
DROXIA ORAL CAPSULE 200 MG,
300 MG, 400 MG
(Dactinomycin)
$0 (Tier 1)
(Dacogen)
(Doxil)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA BvD; ST
PA NSO; LA
PA BvD
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
29
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ELIGARD (3 MONTH)
SUBCUTANEOUS SYRINGE 22.5
MG
ELIGARD (4 MONTH)
SUBCUTANEOUS SYRINGE 30 MG
ELIGARD (6 MONTH)
SUBCUTANEOUS SYRINGE 45 MG
ELIGARD SUBCUTANEOUS
SYRINGE 7.5 MG (1 MONTH)
EMCYT ORAL CAPSULE 140 MG
$0 - $7.40
(Tier 2)
QL (1 per 84 days)
QL (1 per 112 days)
(Floxuridine)
(Fluorouracil)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Fluorouracil)
$0 (Tier 1)
PA BvD
(Flutamide)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
PA NSO
EMPLICITI INTRAVENOUS RECON
SOLN 300 MG, 400 MG
ERIVEDGE ORAL CAPSULE 150 MG
ETOPOPHOS INTRAVENOUS
RECON SOLN 100 MG
etoposide intravenous solution 20 mg/ml
exemestane oral tablet 25 mg
FARESTON ORAL TABLET 60 MG
FARYDAK ORAL CAPSULE 10 MG,
15 MG, 20 MG
FASLODEX INTRAMUSCULAR
SYRINGE 250 MG/5 ML
floxuridine injection recon soln 0.5 gram
fluorouracil 5,000 mg/100 ml latex-free 5
gram/100 ml
fluorouracil intravenous solution 1
gram/20 ml, 2.5 gram/50 ml, 500 mg/10 ml
flutamide oral capsule 125 mg
GAZYVA INTRAVENOUS
SOLUTION 1,000 MG/40 ML
Necessary Actions,
Restrictions, or
Limits on Use
(Etoposide)
(Aromasin)
QL (1 per 168 days)
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
30
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
GILOTRIF ORAL TABLET 20 MG, 30
MG, 40 MG
GLEOSTINE ORAL CAPSULE 10
MG, 100 MG, 40 MG
HERCEPTIN INTRAVENOUS
RECON SOLN 440 MG
HEXALEN ORAL CAPSULE 50 MG
Necessary Actions,
Restrictions, or
Limits on Use
ifosfamide 1 gm/20 ml vial suv 1 gram/20
ml
ifosfamide intravenous recon soln 1 gram
ifosfamide-mesna intravenous kit 1-1
gram, 3,000-1,000 mg
imatinib oral tablet 100 mg
(Ifex)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Ifex)
(Ifosfamide/Mesna)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
(Gleevec)
$0 (Tier 1)
imatinib oral tablet 400 mg
(Gleevec)
$0 (Tier 1)
PA NSO; QL (90 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO
hydroxyurea oral capsule 500 mg
IBRANCE ORAL CAPSULE 100 MG,
125 MG, 75 MG
ICLUSIG ORAL TABLET 15 MG
(Hydrea)
ICLUSIG ORAL TABLET 45 MG
IMBRUVICA ORAL CAPSULE 140
MG
IMLYGIC INJECTION SUSPENSION
10EXP6 (1 MILLION) PFU/ML
IMLYGIC INJECTION SUSPENSION
10EXP8 (100 MILLION) PFU/ML
INLYTA ORAL TABLET 1 MG
INLYTA ORAL TABLET 5 MG
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO; QL (30 per
30 days)
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA NSO; QL (4 per
365 days)
PA NSO; QL (8 per 28
days)
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
31
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
IRESSA ORAL TABLET 250 MG
IXEMPRA 15 MG KIT WITH
DILUENT 15 MG
IXEMPRA INTRAVENOUS RECON
SOLN 45 MG
JAKAFI ORAL TABLET 10 MG, 15
MG, 20 MG, 25 MG, 5 MG
KEYTRUDA INTRAVENOUS
RECON SOLN 50 MG
KEYTRUDA INTRAVENOUS
SOLUTION 100 MG/4 ML (25
MG/ML)
KYPROLIS INTRAVENOUS RECON
SOLN 30 MG
KYPROLIS INTRAVENOUS RECON
SOLN 60 MG
LARTRUVO INTRAVENOUS
SOLUTION 10 MG/ML
LENVIMA ORAL CAPSULE 10
MG/DAY (10 MG X 1/DAY), 14
MG/DAY(10 MG X 1-4 MG X 1), 18
MG/DAY (10 MG X 1-4 MG X2), 20
MG/DAY (10 MG X 2), 24
MG/DAY(10 MG X 2-4 MG X 1), 8
MG/DAY (4 MG X 2)
letrozole oral tablet 2.5 mg
(Femara)
LEUKERAN ORAL TABLET 2 MG
leuprolide subcutaneous kit 1 mg/0.2 ml
lipodox 50 intravenous suspension 2 mg/ml
lipodox intravenous suspension 2 mg/ml
lomustine oral capsule 10 mg, 100 mg, 40
mg
(Leuprolide Acetate)
(Doxil)
(Doxil)
(Lomustine)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO; QL (60 per
30 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO; QL (12 per
28 days)
PA NSO; QL (6 per 28
days)
PA NSO; LA
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO
PA NSO
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
32
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
LONSURF ORAL TABLET 15-6.14
MG
LONSURF ORAL TABLET 20-8.19
MG
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
11.25 MG, 22.5 MG
LUPRON DEPOT (4 MONTH)
INTRAMUSCULAR SYRINGE KIT
30 MG
LUPRON DEPOT (6 MONTH)
INTRAMUSCULAR SYRINGE KIT
45 MG
LUPRON DEPOT
INTRAMUSCULAR SYRINGE KIT
3.75 MG, 7.5 MG
LYNPARZA ORAL CAPSULE 50 MG
(Megestrol Acetate)
MEKINIST ORAL TABLET 2 MG
mercaptopurine oral tablet 50 mg
methotrexate 50 mg/2 ml vial latex-free,
5's, mdv 25 mg/ml
methotrexate sodium (pf) injection recon
soln 1 gram
methotrexate sodium (pf) injection
solution 25 mg/ml
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO; QL (100 per
28 days)
PA NSO; QL (80 per
28 days)
QL (1 per 84 days)
$0 - $7.40
(Tier 2)
QL (1 per 84 days)
$0 - $7.40
(Tier 2)
QL (1 per 168 days)
$0 - $7.40
(Tier 2)
LYSODREN ORAL TABLET 500 MG
MATULANE ORAL CAPSULE 50
MG
megestrol oral tablet 20 mg, 40 mg
MEKINIST ORAL TABLET 0.5 MG
Necessary Actions,
Restrictions, or
Limits on Use
(Mercaptopurine)
(Methotrexate
Sodium)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA NSO; QL (480 per
30 days)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
PA NSO; QL (90 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
33
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
methotrexate sodium oral tablet 2.5 mg
mitoxantrone intravenous concentrate 2
mg/ml
NEXAVAR ORAL TABLET 200 MG
NILANDRON ORAL TABLET 150
MG
nilutamide oral tablet 150 mg
NINLARO ORAL CAPSULE 2.3 MG,
3 MG, 4 MG
ODOMZO ORAL CAPSULE 200 MG
(Methotrexate
Sodium)
(Mitoxantrone HCl)
(Nilandron)
ONCASPAR INJECTION SOLUTION
750 UNIT/ML
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
POMALYST ORAL CAPSULE 1 MG,
2 MG, 3 MG, 4 MG
PORTRAZZA INTRAVENOUS
SOLUTION 800 MG/50 ML (16
MG/ML)
PROLEUKIN INTRAVENOUS
RECON SOLN 22 MILLION UNIT
PURIXAN ORAL SUSPENSION 20
MG/ML
REVLIMID ORAL CAPSULE 10 MG,
15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG
RITUXAN INTRAVENOUS
CONCENTRATE 10 MG/ML
SOLTAMOX ORAL SOLUTION 10
MG/5 ML
SPRYCEL ORAL TABLET 100 MG,
140 MG, 50 MG, 70 MG, 80 MG
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; ST
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO; QL (120 per
30 days)
PA NSO; QL (3 per 28
days)
PA NSO; LA
PA NSO
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (100 per
21 days)
PA NSO; LA
PA NSO
PA NSO; QL (30 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
34
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
SPRYCEL ORAL TABLET 20 MG
STIVARGA ORAL TABLET 40 MG
SUTENT ORAL CAPSULE 12.5 MG,
25 MG, 37.5 MG, 50 MG
SYLVANT INTRAVENOUS RECON
SOLN 100 MG, 400 MG
SYNRIBO SUBCUTANEOUS RECON
SOLN 3.5 MG
TABLOID ORAL TABLET 40 MG
TAFINLAR ORAL CAPSULE 50 MG,
75 MG
TAGRISSO ORAL TABLET 40 MG,
80 MG
tamoxifen oral tablet 10 mg, 20 mg
(Tamoxifen Citrate)
TARCEVA ORAL TABLET 100 MG,
25 MG
TARCEVA ORAL TABLET 150 MG
TARGRETIN ORAL CAPSULE 75
MG
TARGRETIN TOPICAL GEL 1 %
TASIGNA ORAL CAPSULE 150 MG,
200 MG
TECENTRIQ INTRAVENOUS
SOLUTION 1,200 MG/20 ML (60
MG/ML)
TEMODAR INTRAVENOUS RECON
SOLN 100 MG
thiotepa injection recon soln 15 mg
(Thiotepa)
toposar intravenous solution 20 mg/ml
(Etoposide)
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO; QL (60 per
30 days)
PA NSO; QL (84 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA NSO; (vial only)
PA NSO; QL (28 per
28 days)
PA NSO; QL (120 per
30 days)
PA NSO; LA; QL (30
per 30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (420 per
30 days)
PA NSO; QL (60 per
28 days)
PA NSO; QL (112 per
28 days)
PA NSO; QL (20 per
21 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
35
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
TREANDA 25 MG VIAL 25 MG
TREANDA INTRAVENOUS RECON
SOLN 100 MG
TREANDA INTRAVENOUS
SOLUTION 180 MG/2 ML, 45 MG/0.5
ML
TRELSTAR 22.5 MG SYRINGE
OUTER 22.5 MG/2 ML
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 22.5 MG
TRELSTAR INTRAMUSCULAR
SYRINGE 11.25 MG/2 ML
TRELSTAR INTRAMUSCULAR
SYRINGE 3.75 MG/2 ML
tretinoin (chemotherapy) oral capsule 10 (Tretinoin)
mg
TREXALL ORAL TABLET 10 MG, 15
MG, 5 MG, 7.5 MG
TYKERB ORAL TABLET 250 MG
UNITUXIN INTRAVENOUS
SOLUTION 3.5 MG/ML
VALSTAR INTRAVESICAL
SOLUTION 40 MG/ML
VELCADE INJECTION RECON
SOLN 3.5 MG
VENCLEXTA ORAL TABLET 10 MG,
100 MG, 50 MG
VENCLEXTA STARTING PACK
ORAL TABLETS,DOSE PACK 10
MG-50 MG- 100 MG
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (1 per 168 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
QL (1 per 84 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD; ST
QL (1 per 168 days)
(capsule: 10mg)
PA NSO
PA NSO
PA NSO; LA
PA NSO; LA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
36
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
vinorelbine intravenous solution 50 mg/5
ml
VOTRIENT ORAL TABLET 200 MG
(Navelbine)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
XALKORI ORAL CAPSULE 200 MG,
250 MG
XTANDI ORAL CAPSULE 40 MG
YERVOY INTRAVENOUS
SOLUTION 50 MG/10 ML (5 MG/ML)
YONDELIS INTRAVENOUS RECON
SOLN 1 MG
ZELBORAF ORAL TABLET 240 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA ORAL CAPSULE 100 MG
ZYDELIG ORAL TABLET 100 MG,
150 MG
ZYKADIA ORAL CAPSULE 150 MG
ZYTIGA ORAL TABLET 250 MG
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
QL (1 per 28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodi
cs
atropine injection solution 0.4 mg/ml
atropine injection syringe 0.05 mg/ml, 0.1
mg/ml
(Atropine Sulfate)
(Atropine Sulfate)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
37
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
atropine intravenous syringe 0.8 mg/2 ml
(0.4 mg/ml)
propantheline oral tablet 15 mg
(Atropine Sulfate)
$0 (Tier 1)
(Propantheline
Bromide)
$0 (Tier 1)
STIOLTO RESPIMAT INHALATION
MIST 2.5-2.5 MCG/ACTUATION
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
QL (4 per 28 days)
ST
(Carbatrol)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Tegretol)
$0 (Tier 1)
(Tegretol)
(Tegretol XR)
$0 (Tier 1)
$0 (Tier 1)
(Carbamazepine)
$0 (Tier 1)
(Depakote Sprinkle)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
Anticonvulsants
Anticonvulsants
APTIOM ORAL TABLET 200 MG, 400
MG, 600 MG, 800 MG
BANZEL ORAL SUSPENSION 40
MG/ML
BANZEL ORAL TABLET 200 MG,
400 MG
BRIVIACT INTRAVENOUS
SOLUTION 50 MG/5 ML
BRIVIACT ORAL SOLUTION 10
MG/ML
BRIVIACT ORAL TABLET 10 MG,
100 MG, 25 MG, 50 MG, 75 MG
carbamazepine oral capsule, er multiphase
12 hr 100 mg, 200 mg, 300 mg
carbamazepine oral suspension 100 mg/5
ml
carbamazepine oral tablet 200 mg
carbamazepine oral tablet extended
release 12 hr 100 mg, 200 mg, 400 mg
carbamazepine oral tablet,chewable 100
mg
CELONTIN ORAL CAPSULE 300 MG
DILANTIN ORAL CAPSULE 30 MG
divalproex oral capsule, sprinkle 125 mg
ST
ST
QL (80 per 30 days)
QL (600 per 30 days)
QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
38
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
divalproex oral tablet extended release 24
hr 250 mg, 500 mg
divalproex oral tablet,delayed release
(dr/ec) 125 mg, 250 mg, 500 mg
epitol oral tablet 200 mg
ethosuximide oral capsule 250 mg
ethosuximide oral solution 250 mg/5 ml
felbamate oral suspension 600 mg/5 ml
felbamate oral tablet 400 mg, 600 mg
fosphenytoin 500 mg pe/10 ml
10's,sdv,latex-free 500 mg pe/10 ml
fosphenytoin injection solution 100 mg
pe/2 ml
FYCOMPA ORAL SUSPENSION 0.5
MG/ML
FYCOMPA ORAL TABLET 10 MG,
12 MG, 2 MG, 4 MG, 6 MG, 8 MG
gabapentin oral capsule 100 mg, 300 mg,
400 mg
gabapentin oral solution 250 mg/5 ml
gabapentin oral tablet 600 mg, 800 mg
GABITRIL ORAL TABLET 12 MG, 16
MG
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
lamotrigine oral tablet 100 mg, 150 mg,
200 mg, 25 mg
lamotrigine oral tablet extended release
24hr 100 mg, 200 mg, 25 mg, 250 mg, 300
mg, 50 mg
lamotrigine oral tablet, chewable
dispersible 25 mg, 5 mg
(Depakote ER)
$0 (Tier 1)
(Depakote)
$0 (Tier 1)
(Tegretol)
(Zarontin)
(Zarontin)
(Felbatol)
(Felbatol)
(Cerebyx)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cerebyx)
$0 (Tier 1)
(Neurontin)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Neurontin)
(Neurontin)
(Lamictal)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Lamictal XR)
$0 (Tier 1)
(Lamictal)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
ST
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
39
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
lamotrigine oral tablets,dose pack 25 mg
(35)
levetiracetam intravenous solution 500
mg/5 ml
levetiracetam oral solution 100 mg/ml
levetiracetam oral tablet 1,000 mg, 250
mg, 500 mg, 750 mg
levetiracetam oral tablet extended release
24 hr 500 mg, 750 mg
LYRICA ORAL CAPSULE 100 MG,
150 MG, 200 MG, 225 MG, 25 MG, 300
MG, 50 MG, 75 MG
LYRICA ORAL SOLUTION 20
MG/ML
oxcarbazepine oral suspension 300 mg/5
ml
oxcarbazepine oral tablet 150 mg, 300 mg,
600 mg
OXTELLAR XR ORAL TABLET
EXTENDED RELEASE 24 HR 150
MG, 300 MG, 600 MG
PEGANONE ORAL TABLET 250 MG
(Lamictal (Blue))
$0 (Tier 1)
(Keppra)
$0 (Tier 1)
(Keppra)
(Roweepra)
$0 (Tier 1)
$0 (Tier 1)
(Keppra XR)
$0 (Tier 1)
phenobarbital oral elixir 20 mg/5 ml (4
mg/ml)
phenobarbital oral tablet 100 mg, 15 mg,
16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2
mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection solution
130 mg/ml, 65 mg/ml
phenytoin oral suspension 125 mg/5 ml
phenytoin oral tablet,chewable 50 mg
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
QL (90 per 30 days)
QL (900 per 30 days)
(Trileptal)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Trileptal)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
ST
(Phenobarbital)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
QL (1500 per 30 days)
(Phenobarbital)
$0 (Tier 1)
QL (90 per 30 days)
(Phenobarbital)
(Phenobarbital
Sodium)
(Dilantin-125)
(Dilantin)
$0 (Tier 1)
$0 (Tier 1)
QL (200 per 30 days)
QL (2 per 30 days)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
40
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
phenytoin sodium extended oral capsule
(Dilantin)
100 mg, 200 mg, 300 mg
phenytoin sodium intravenous solution 50 (Phenytoin Sodium)
mg/ml
phenytoin sodium intravenous syringe 50
(Phenytoin Sodium)
mg/ml
POTIGA ORAL TABLET 200 MG, 300
MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone oral tablet 250 mg, 50 mg
(Mysoline)
ROWEEPRA ORAL TABLET 500 MG
SABRIL ORAL POWDER IN
PACKET 500 MG
SABRIL ORAL TABLET 500 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 1,000 MG
SPRITAM ORAL TABLET FOR
SUSPENSION 250 MG, 500 MG, 750
MG
tiagabine oral tablet 2 mg, 4 mg
topiragen oral tablet 100 mg, 200 mg, 25
mg, 50 mg
topiramate oral capsule, sprinkle 15 mg,
25 mg
topiramate oral capsule,sprinkle,er 24hr
100 mg, 150 mg, 200 mg, 25 mg, 50 mg
topiramate oral tablet 100 mg, 200 mg, 25
mg, 50 mg
TROKENDI XR ORAL
CAPSULE,EXTENDED RELEASE
24HR 100 MG, 200 MG, 25 MG, 50 MG
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Gabitril)
(Topamax)
$0 (Tier 1)
$0 (Tier 1)
(Topamax)
$0 (Tier 1)
(Qudexy XR)
$0 (Tier 1)
(Topamax)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
QL (90 per 30 days)
QL (270 per 30 days)
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
41
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
valproate sodium intravenous solution 500
mg/5 ml (100 mg/ml)
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
valproic acid oral capsule 250 mg
VIMPAT INTRAVENOUS
SOLUTION 200 MG/20 ML
VIMPAT ORAL SOLUTION 10
MG/ML
VIMPAT ORAL TABLET 100 MG, 150
MG, 200 MG, 50 MG
zonisamide oral capsule 100 mg, 25 mg, 50
mg
Necessary Actions,
Restrictions, or
Limits on Use
(Depacon)
$0 (Tier 1)
(Depakene)
$0 (Tier 1)
(Depakene)
(Zonegran)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Aricept)
(Donepezil HCl)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
QL (30 per 30 days)
(Razadyne ER)
$0 (Tier 1)
QL (30 per 30 days)
(Galantamine Hbr)
(Razadyne)
(Namenda)
(Namenda)
(Namenda)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
QL (200 per 30 days)
QL (60 per 30 days)
QL (360 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
$0 - $7.40
(Tier 2)
QL (30 per 30 days)
QL (200 per 5 days)
QL (1200 per 30 days)
QL (60 per 30 days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet 10 mg, 23 mg, 5 mg
donepezil oral tablet,disintegrating 10 mg,
5 mg
galantamine oral capsule,ext rel. pellets 24
hr 16 mg, 24 mg, 8 mg
galantamine oral solution 4 mg/ml
galantamine oral tablet 12 mg, 4 mg, 8 mg
memantine oral solution 2 mg/ml
memantine oral tablet 10 mg, 5 mg
memantine oral tablets,dose pack 5-10 mg
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK 7-14-21-28 MG
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR 14
MG, 21 MG, 28 MG, 7 MG
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
42
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
NAMZARIC ORAL
CAPSULE,SPRINKLE,ER 24HR 14-10
MG, 21-10 MG, 28-10 MG, 7-10 MG
rivastigmine tartrate oral capsule 1.5 mg, (Exelon)
3 mg, 4.5 mg, 6 mg
rivastigmine transdermal patch 24 hour
(Exelon)
13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24
hr
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 1)
QL (30 per 30 days)
(Amitriptyline HCl)
$0 (Tier 1)
PA NSO-HRM
(Amoxapine)
$0 (Tier 1)
(Wellbutrin SR)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Wellbutrin SR)
$0 (Tier 1)
(Wellbutrin)
(Wellbutrin SR)
$0 (Tier 1)
$0 (Tier 1)
(Wellbutrin XL)
$0 (Tier 1)
(Citalopram
Hydrobromide)
(Celexa)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
(Anafranil)
$0 (Tier 1)
PA NSO-HRM
(Norpramin)
$0 (Tier 1)
Antidepressants
Antidepressants
amitriptyline oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
amoxapine oral tablet 100 mg, 150 mg, 25
mg, 50 mg
BRINTELLIX ORAL TABLET 10 MG,
20 MG, 5 MG
buproban oral tablet extended release 150
mg
bupropion hcl (smoking deter) oral tablet
extended release 150 mg
bupropion hcl oral tablet 100 mg, 75 mg
bupropion hcl oral tablet extended release
100 mg, 150 mg, 200 mg
bupropion hcl oral tablet extended release
24 hr 150 mg, 300 mg
citalopram oral solution 10 mg/5 ml
citalopram oral tablet 10 mg, 20 mg, 40
mg
clomipramine oral capsule 25 mg, 50 mg,
75 mg
desipramine oral tablet 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75 mg
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
43
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
doxepin oral capsule 10 mg, 100 mg, 150
mg, 25 mg, 50 mg, 75 mg
doxepin oral concentrate 10 mg/ml
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
duloxetine oral capsule,delayed
release(dr/ec) 30 mg
duloxetine oral capsule,delayed
release(dr/ec) 40 mg
EMSAM TRANSDERMAL PATCH 24
HOUR 12 MG/24 HR, 6 MG/24 HR, 9
MG/24 HR
escitalopram oxalate oral solution 5 mg/5
ml
escitalopram oxalate oral tablet 10 mg, 20
mg, 5 mg
FETZIMA ORAL CAPSULE,EXT
REL 24HR DOSE PACK 20 MG (2)- 40
MG (26)
FETZIMA ORAL
CAPSULE,EXTENDED RELEASE 24
HR 120 MG, 20 MG, 40 MG, 80 MG
fluoxetine oral capsule 10 mg, 20 mg, 40
mg
fluoxetine oral capsule,delayed
release(dr/ec) 90 mg
fluoxetine oral solution 20 mg/5 ml (4
mg/ml)
fluoxetine oral tablet 10 mg, 20 mg
fluvoxamine oral capsule,extended release
24hr 100 mg, 150 mg
fluvoxamine oral tablet 100 mg, 25 mg, 50
mg
Necessary Actions,
Restrictions, or
Limits on Use
(Doxepin HCl)
$0 (Tier 1)
PA NSO-HRM
(Doxepin HCl)
(Duloxetine)
$0 (Tier 1)
$0 (Tier 1)
(Duloxetine)
$0 (Tier 1)
(Duloxetine)
$0 (Tier 1)
PA NSO-HRM
(Cymbalta); QL (60
per 30 days)
(Cymbalta); QL (30
per 30 days)
(Irenka); QL (30 per 30
days)
QL (30 per 30 days)
$0 - $7.40
(Tier 2)
(Lexapro)
$0 (Tier 1)
(Lexapro)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
ST
$0 - $7.40
(Tier 2)
ST
(Prozac)
$0 (Tier 1)
(Prozac Weekly)
$0 (Tier 1)
(Fluoxetine HCl)
$0 (Tier 1)
(Fluoxetine HCl)
(Fluvoxamine
Maleate)
(Fluvoxamine
Maleate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
44
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
imipramine hcl oral tablet 10 mg, 25 mg,
50 mg
imipramine pamoate oral capsule 100 mg,
125 mg, 150 mg, 75 mg
maprotiline oral tablet 25 mg, 50 mg, 75
mg
MARPLAN ORAL TABLET 10 MG
(Tofranil)
$0 (Tier 1)
PA NSO-HRM
(Tofranil-Pm)
$0 (Tier 1)
PA NSO-HRM
(Maprotiline HCl)
$0 (Tier 1)
mirtazapine oral tablet 15 mg, 30 mg, 45
mg, 7.5 mg
mirtazapine oral tablet,disintegrating 15
mg, 30 mg, 45 mg
nefazodone oral tablet 100 mg, 150 mg,
200 mg, 250 mg, 50 mg
nortriptyline oral capsule 10 mg, 25 mg,
50 mg, 75 mg
nortriptyline oral solution 10 mg/5 ml
olanzapine-fluoxetine oral capsule 12-25
mg, 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg
paroxetine hcl oral tablet 10 mg, 20 mg,
30 mg, 40 mg
paroxetine hcl oral tablet extended release
24 hr 12.5 mg, 25 mg, 37.5 mg
PAXIL ORAL SUSPENSION 10 MG/5
ML
perphenazine-amitriptyline oral tablet
2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50
mg
phenelzine oral tablet 15 mg
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24 HR 100
MG, 25 MG, 50 MG
protriptyline oral tablet 10 mg, 5 mg
sertraline oral concentrate 20 mg/ml
(Remeron)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Remeron)
$0 (Tier 1)
(Nefazodone HCl)
$0 (Tier 1)
(Pamelor)
$0 (Tier 1)
(Nortriptyline HCl)
(Symbyax)
$0 (Tier 1)
$0 (Tier 1)
(Paxil)
$0 (Tier 1)
(Paxil CR)
$0 (Tier 1)
(Perphenazine/Amitri
ptyline HCl)
(Nardil)
(Protriptyline HCl)
(Zoloft)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
PA NSO-HRM
$0 (Tier 1)
$0 - $7.40
(Tier 2)
ST; QL (30 per 30
days)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
45
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
sertraline oral tablet 100 mg, 25 mg, 50
mg
SILENOR ORAL TABLET 3 MG, 6
MG
SURMONTIL ORAL CAPSULE 100
MG, 25 MG, 50 MG
tranylcypromine oral tablet 10 mg
trazodone oral tablet 100 mg, 150 mg, 300
mg, 50 mg
trimipramine oral capsule 100 mg, 25 mg,
50 mg
TRINTELLIX ORAL TABLET 10 MG,
20 MG, 5 MG
venlafaxine oral capsule,extended release
24hr 150 mg, 37.5 mg, 75 mg
venlafaxine oral tablet 100 mg, 25 mg,
37.5 mg, 50 mg, 75 mg
venlafaxine oral tablet extended release
24hr 150 mg, 37.5 mg, 75 mg
VIIBRYD ORAL TABLET 10 MG, 20
MG, 40 MG
VIIBRYD ORAL TABLETS,DOSE
PACK 10 MG (7)- 20 MG (23), 10 MG
(7)-20 MG (7)-40 MG (16)
Necessary Actions,
Restrictions, or
Limits on Use
(Zoloft)
$0 (Tier 1)
QL (30 per 30 days)
(Parnate)
(Trazodone HCl)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA NSO-HRM
ST
(Effexor XR)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Venlafaxine HCl)
$0 (Tier 1)
(Venlafaxine HCl)
$0 (Tier 1)
(Trimipramine
Maleate)
PA NSO-HRM
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
acarbose oral tablet 100 mg, 25 mg, 50 mg (Precose)
CYCLOSET ORAL TABLET 0.8 MG
GLYXAMBI ORAL TABLET 10-5
MG, 25-5 MG
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (90 per 30 days)
QL (180 per 30 days)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
46
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 50-1,000
MG, 50-500 MG
INVOKAMET XR ORAL TABLET,
IR - ER, BIPHASIC 24HR 150-1,000
MG, 150-500 MG, 50-1,000 MG, 50-500
MG
INVOKANA ORAL TABLET 100 MG,
300 MG
JANUMET ORAL TABLET 50-1,000
MG, 50-500 MG
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG,
50-1,000 MG, 50-500 MG
JANUVIA ORAL TABLET 100 MG, 25
MG, 50 MG
JARDIANCE ORAL TABLET 10 MG,
25 MG
JENTADUETO ORAL TABLET
2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG
JENTADUETO XR ORAL TABLET,
IR - ER, BIPHASIC 24HR 2.5-1,000
MG, 5-1,000 MG
KORLYM ORAL TABLET 300 MG
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended release 24
hr 500 mg
metformin oral tablet extended release 24
hr 750 mg
metformin oral tablet extended release
24hr 1,000 mg
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
ST
$0 - $7.40
(Tier 2)
ST
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
ST
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
ST
(Glucophage)
(Glucophage)
(Glucophage)
(Glucophage XR)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (112 per 28
days)
QL (75 per 30 days)
QL (150 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
(Glucophage XR)
$0 (Tier 1)
QL (90 per 30 days)
(Fortamet)
$0 (Tier 1)
QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
47
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
metformin oral tablet extended release
24hr 500 mg
miglitol oral tablet 100 mg, 25 mg, 50 mg
nateglinide oral tablet 120 mg, 60 mg
pioglitazone oral tablet 15 mg, 30 mg, 45
mg
pioglitazone-glimepiride oral tablet 30-2
mg, 30-4 mg
pioglitazone-metformin oral tablet 15-500
mg, 15-850 mg
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
repaglinide-metformin oral tablet 1-500
mg, 2-500 mg
SYMLINPEN 120 SUBCUTANEOUS
PEN INJECTOR 2,700 MCG/2.7 ML
SYMLINPEN 60 SUBCUTANEOUS
PEN INJECTOR 1,500 MCG/1.5 ML
SYNJARDY ORAL TABLET
12.5-1,000 MG, 12.5-500 MG, 5-1,000
MG, 5-500 MG
TRADJENTA ORAL TABLET 5 MG
Necessary Actions,
Restrictions, or
Limits on Use
(Fortamet)
$0 (Tier 1)
QL (150 per 30 days)
(Glyset)
(Starlix)
(Actos)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
(Duetact)
$0 (Tier 1)
QL (30 per 30 days)
(Actoplus Met)
$0 (Tier 1)
QL (90 per 30 days)
(Prandin)
(Prandimet)
$0 (Tier 1)
$0 (Tier 1)
QL (240 per 30 days)
QL (150 per 30 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; QL (10.8 per 28
days)
PA; QL (6 per 28 days)
TRULICITY SUBCUTANEOUS PEN
INJECTOR 0.75 MG/0.5 ML, 1.5
MG/0.5 ML
VICTOZA
ST
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Insulins
HUMULIN R U-500 (CONC)
KWIKPEN SUBCUTANEOUS
INSULIN PEN 500 UNIT/ML (3 ML)
$0 - $7.40
(Tier 2)
QL (24 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
48
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS SOLUTION 500
UNIT/ML
LANTUS SOLOSTAR
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
LANTUS SUBCUTANEOUS
SOLUTION 100 UNIT/ML
NOVOLIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
NOVOLIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
NOVOLIN R INJECTION SOLUTION
100 UNIT/ML
NOVOLOG FLEXPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML
NOVOLOG MIX 70-30 FLEXPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (70-30)
NOVOLOG MIX 70-30
SUBCUTANEOUS SOLUTION 100
UNIT/ML (70-30)
NOVOLOG PENFILL
SUBCUTANEOUS CARTRIDGE 100
UNIT/ML
NOVOLOG SUBCUTANEOUS
SOLUTION 100 UNIT/ML
TOUJEO SOLOSTAR
SUBCUTANEOUS INSULIN PEN 300
UNIT/ML (1.5 ML)
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
QL (40 per 28 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
$0 - $7.40
(Tier 2)
QL (30 per 28 days)
$0 - $7.40
(Tier 2)
QL (40 per 28 days)
$0 - $7.40
(Tier 2)
QL (30 per 28 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (40 per 28 days)
$0 (Tier 1)
QL (30 per 30 days)
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
(Amaryl)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
49
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended release 24hr
10 mg
glipizide oral tablet extended release 24hr
2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5-250 mg
glipizide-metformin oral tablet 2.5-500
mg, 5-500 mg
glyburide micronized oral tablet 1.5 mg, 3
mg, 6 mg
glyburide oral tablet 1.25 mg, 2.5 mg, 5
mg
glyburide-metformin oral tablet 1.25-250
mg, 2.5-500 mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide oral tablet 500 mg
Necessary Actions,
Restrictions, or
Limits on Use
(Amaryl)
(Glucotrol)
(Glucotrol)
(Glucotrol XL)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
$0 (Tier 1)
QL (30 per 30 days)
(Glipizide/Metformin
HCl)
(Glipizide/Metformin
HCl)
(Glynase)
$0 (Tier 1)
QL (240 per 30 days)
$0 (Tier 1)
QL (120 per 30 days)
$0 (Tier 1)
(Glyburide)
$0 (Tier 1)
(Glucovance)
$0 (Tier 1)
(Tolazamide)
(Tolazamide)
(Tolbutamide)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (120 per 30 days)
QL (60 per 30 days)
QL (180 per 30 days)
PA BvD
(Miconazole Nitrate)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA BvD
Antifungals
Antifungals
ABELCET INTRAVENOUS
SUSPENSION 5 MG/ML
aloe vesta 2% antifungal oint 2 % *
AMBISOME INTRAVENOUS
SUSPENSION FOR
RECONSTITUTION 50 MG
amphotericin b injection recon soln 50 mg
anti-fungal 1% powder 1 % *
antifungal 2% cream 2 % *
athlete's foot 2% powder 2 % *
baza antifungal 2% cream 12's 2 % *
(Amphotericin B)
(Tolnaftate)
(Nuzole)
(Lotrimin AF)
(Nuzole)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
50
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
CANCIDAS INTRAVENOUS RECON
SOLN 50 MG, 70 MG
ciclopirox topical cream 0.77 %
ciclopirox topical gel 0.77 %
ciclopirox topical shampoo 1 %
ciclopirox topical solution 8 %
ciclopirox topical suspension 0.77 %
ciclopirox-ure-camph-menth-euc topical
solution 8 %
clotrim 1% vaginal cream 1 % *
clotrimazole 1% cream (otc) 1 % *
clotrimazole 1% solution (otc) 1 % *
clotrimazole insert 100 mg *
clotrimazole mucous membrane troche 10
mg
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
clotrimazole-7 cream 1 % *
clotrimazole-betamethasone topical cream
1-0.05 %
clotrimazole-betamethasone topical lotion
1-0.05 %
critic-aid clear af 2% oint 12's, w/
antifungal 2 % *
cvs af 1% spray powder 1 % *
cvs anti-fungal 2% powder 2 % *
cvs athlete's foot powd spray 2 % *
cvs miconazole 1 combo pack sftgl
insert/9gm crm 1,200-2 mg-% *
cvs miconazole 3 combo pack 3pref applic
w/cream 4 % (200 mg)- 2 % (9 gram) *
cvs tioconazole 1 6.5% ointmnt 6.5 % *
dermafungal 2% ointment 2 % *
(Loprox)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox Olamine)
(Ciclodan)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Gyne-Lotrimin)
(Lotrimin AF)
(Clotrimazole)
(Clotrimazole)
(Clotrimazole)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
(Clotrimazole)
(Clotrimazole)
(Gyne-Lotrimin)
(Lotrisone)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
(Clotrimazole/Betame
thasone Dip)
(Miconazole Nitrate)
$0 (Tier 1)
(Tinactin)
(Lotrimin AF)
(Lotrimin AF)
(Monistat 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Miconazole Nitrate)
$0 (Tier 4)
(Tioconazole)
(Miconazole Nitrate)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
51
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
desenex 2% powder 2 % *
desenex 2% spray powder 2 % *
econazole topical cream 1 %
elon dual defense 25% solution 25 % *
fluconazole in dextrose(iso-o) intravenous
piggyback 400 mg/200 ml
fluconazole in nacl (iso-osm) intravenous
piggyback 100 mg/50 ml, 200 mg/100 ml
fluconazole oral suspension for
reconstitution 10 mg/ml, 40 mg/ml
fluconazole oral tablet 100 mg, 150 mg,
200 mg, 50 mg
fluconazole-nacl 400 mg/200 ml
10's,latex-free, p/f 400 mg/200 ml
flucytosine oral capsule 250 mg, 500 mg
fungi cure intensive 1% spray 1 % *
FUNGI-NAIL TINCTURE *
fungoid-d 1% cream 1 % *
gnp miconazole 3 combo pack 4 % (200
mg)- 2 % (9 gram) *
griseofulvin microsize oral tablet 500 mg
HONGO CURA ANTI-FUNGAL 25%
SPR 25 % *
inzo antifungal 2% cream 2 % *
itraconazole oral capsule 100 mg
ketoconazole oral tablet 200 mg
ketoconazole topical cream 2 %
ketoconazole topical shampoo 2 %
lamisil af defens 1% spray pwd 1 % *
lamisil af defense 1% powder 1 % *
LAMISIL ANTIFUNGAL 1% SPRAY
FOR ATHLETES FOOT 1 % *
(Lotrimin AF)
(Lotrimin AF)
(Econazole Nitrate)
(Undecylenic Acid)
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Diflucan)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
(Diflucan)
$0 (Tier 1)
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Clotrimazole)
$0 (Tier 1)
(Tinactin)
(Miconazole Nitrate)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Grifulvin V)
$0 (Tier 1)
$0 (Tier 4)
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Tinactin)
(Tolnaftate)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
52
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
LAMISIL AT 1% CREAM
ATHLETE'S FOOT 1 % *
LAMISIL AT 1% GEL 1 % *
micatin 2% antifungal cream 2 % *
miconazole 3 combo pack 3 sup,9gm crm
w/app 200 mg- 2 % (9 gram) *
miconazole 7 100 mg vag supp 100 mg *
miconazole nitrate 2% cream 2 % *
miconazole-3 vaginal suppository 200 mg
micro-guard 2% powder 12's,antifungal 2
%*
MONISTAT 3 COMBO PACK 4 % (200
MG)- 2 % (9 GRAM) *
monistat 7 cream 7 applicators 2 % *
myco nail a 25% solution 25 % *
NIZORAL A-D 1% SHAMPOO 1 % *
NOXAFIL ORAL SUSPENSION 200
MG/5 ML (40 MG/ML)
NOXAFIL ORAL
TABLET,DELAYED RELEASE
(DR/EC) 100 MG
nyamyc topical powder 100,000 unit/gram
nystatin oral suspension 100,000 unit/ml
nystatin oral tablet 500,000 unit
nystatin topical cream 100,000 unit/gram
nystatin topical ointment 100,000
unit/gram
nystatin topical powder 100,000 unit/gram
nystatin-triamcinolone topical cream
100,000-0.1 unit/g-%
nystatin-triamcinolone topical ointment
100,000-0.1 unit/gram-%
nystop topical powder 100,000 unit/gram
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
(Nuzole)
(Monistat 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Miconazole Nitrate)
(Miconazole Nitrate)
(Miconazole Nitrate)
(Lotrimin AF)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Miconazole Nitrate)
(Undecylenic Acid)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
(Nystatin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Nystatin)
(Nystatin/Triamcin)
$0 (Tier 1)
$0 (Tier 1)
(Nystatin/Triamcin)
$0 (Tier 1)
(Nystatin)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
53
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
podactin 1% powder 1 % *
qc 3 day vaginal 4% cream 200 mg/5 gram
(4 %) *
ra anti-fungal liquid 12.5 % *
ra miconazole 3 kit 3pref app w/crm+6wip
4 % (200 mg)- 2 % (9 gram) *
remedy phytoplex antifungal 2% 2 % *
terbinafine 1% cream 1 % *
terbinafine hcl oral tablet 250 mg
tolnaftate 1% cream 1 % *
tolnaftate 1% solution 1 % *
triple paste af 2% ointment 2 % *
vagistat-1 6.5% ointment 6.5 % *
vagistat-3 combo pack 200 mg- 2 % (9
gram) *
voriconazole intravenous solution 200 mg
voriconazole oral suspension for
reconstitution 200 mg/5 ml (40 mg/ml)
voriconazole oral tablet 200 mg, 50 mg
zeasorb 2% powder athlete's foot 2 % *
(Tolnaftate)
(Miconazole Nitrate)
$0 (Tier 4)
$0 (Tier 4)
(Undecylenic Acid)
(Miconazole/Cleanser
17 On Wipe)
(Lotrimin AF)
(Lamisil At)
(Lamisil)
(Tinactin)
(Tolnaftate)
(Miconazole Nitrate)
(Tioconazole)
(Monistat 3)
$0 (Tier 4)
$0 (Tier 4)
(Vfend IV)
(Vfend)
$0 (Tier 1)
$0 (Tier 1)
(Vfend)
(Lotrimin AF)
$0 (Tier 1)
$0 (Tier 4)
(Dexbromphenir/Pseu
doephed Sulf)
(Triaminic Nighttime
Cold-Cough)
(Dexbrompheniramin
e Maleate)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Antihistamines
Antihistamines
12 hour relief tablet 6-120 mg *
25dph-7.5peh liquid 25-7.5 mg/5 ml *
ala-hist ir 2 mg tablet 2 mg *
$0 (Tier 4)
$0 (Tier 4)
ALA-HIST PE TABLET 2-10 MG *
$0 (Tier 4)
alavert 10 mg odt non-drowsy, mint 10 mg (Claritin)
*
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
54
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ALLEGRA ALLERGY 180 MG
TABLET 180 MG *
ALLEGRA ALLERGY 60 MG
TABLET 60 MG *
aller-chlor 2 mg/5 ml syrup 2 mg/5 ml *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA
$0 (Tier 4)
PA
(Diphenhydramine
HCl)
(Children'S Zyrtec)
$0 (Tier 4)
PA
$0 (Tier 4)
(Zyrtec)
$0 (Tier 4)
(Zyrtec)
$0 (Tier 4)
(Zyrtec)
$0 (Tier 4)
(Cetirizine HCl)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
$0 (Tier 4)
$0 (Tier 4)
aller-chlor 4 mg tablet 4 mg *
(Chlorpheniramine
Maleate)
(Chlor-Trimeton)
allergy 4 mg tablet 4 mg *
(Chlor-Trimeton)
$0 (Tier 4)
allerhist-1 1.34 mg tablet 1.34 mg *
(Clemastine
Fumarate)
(Chlorpheniramine/Ps
eudoephed)
(Triprolidine/Pseudoe
phedrine)
(Zzzquil)
(Diphenhydramine
HCl)
(Zzzquil)
$0 (Tier 4)
ambi 60pse-4cpm tablet 4-60 mg *
aprodine tablet 2.5-60 mg *
banophen 25 mg capsule 25 mg *
banophen 25 mg tablet 25 mg *
banophen allergy 12.5 mg/5 ml a/f 12.5
mg/5 ml *
benadryl allergy 25 mg ultratb ultratab 25
mg *
cetirizine hcl 1 mg/1 ml soln children, s/f,
grape (otc) 1 mg/ml *
cetirizine hcl 10 mg tablet indoor &
outdoor 10 mg *
cetirizine hcl 5 mg chew tab
children's,outer,u-d 5 mg *
cetirizine hcl 5 mg tablet indoor & outdoor
5 mg *
cetirizine oral solution 1 mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
55
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
child allegra allergy 30 mg/5 ml
suspension 30 mg/5 ml *
child benadryl-d aller-sin liq 12.5-5 mg/5
ml *
child dometuss-da liquid 1-2.5 mg/5 ml *
child triaminic cold & allergy 1-2.5 mg/5
ml *
child wal-tap cold-allergy elx 1-2.5 mg/5
ml *
child's aller-tec 1 mg/ml soln 1 mg/ml *
CHILD'S BENADRYL 12.5 MG/5 ML
12.5 MG/5 ML *
child's wal-dryl 12.5 mg/5 ml
a/f,s/f,d/f,bubb gum 12.5 mg/5 ml *
child's wal-zyr 10 mg chew tab 10 mg *
chlorpheniramine er 12 mg tab 12 mg *
cold-allergy-sinus oral tablet 2.5-60 mg *
compoz 25 mg gelcap 25 mg *
(Fexofenadine HCl)
$0 (Tier 4)
(Phenylephrine/Diphe
nhydramine)
(Triaminic
Cold-Allergy Pe)
(Dimetapp)
$0 (Tier 4)
(Dimetapp)
$0 (Tier 4)
(Children'S Zyrtec)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
(Zzzquil)
$0 (Tier 4)
PA
(Zyrtec)
$0 (Tier 4)
(Chlor-Trimeton
Allergy)
(Triprolidine/Pseudoe
phedrine)
(Diphenhydramine
HCl)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
CONEX SOLUTION 1-30 MG/5 ML *
conex tablet 2-60 mg *
cvs allergy 25 mg tablet 25 mg *
cvs child allergy 10 mg chw tb 24
hr,indoor/outdoor 10 mg *
cvs cold & cough nighttime liq 6.25-2.5
mg/5 ml *
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Dexbrompheniramin
e/Pseudoephed)
(Diphenhydramine
HCl)
(Zyrtec)
$0 (Tier 4)
(Triaminic Nighttime
Cold-Cough)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
56
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
cyproheptadine oral syrup 2 mg/5 ml
cyproheptadine oral tablet 4 mg
dailyhist-1 1.34 mg tablet 1.34 mg *
DALLERGY 1-5 MG TABLET 1-5 MG
*
dayhist allergy 1.34 mg tablet 12 hr relief
1.34 mg *
dimaphen elixir a/f, grape, gluten-f 1-2.5
mg/5 ml *
dimetapp cold & congest liquid 6.25-2.5
mg/5 ml *
diphenhist 12.5 mg/5 ml soln 12.5 mg/5 ml
*
diphenhist 25 mg capsule 25 mg *
diphenhist 25 mg captab captab 25 mg *
diphenhydramine 25 mg capsule (otc) 25
mg *
diphenhydramine 50 mg capsule (otc) 50
mg *
diphenhydramine 50 mg tablet 50 mg *
diphenhydramine hcl injection solution 50
mg/ml
ed chlorped drops 2 mg/ml *
ed chlorped jr syrup 2 mg/5 ml *
ed-a-hist 4 mg-10 mg tablet 4-10 mg *
(Cyproheptadine
HCl)
(Cyproheptadine
HCl)
(Clemastine
Fumarate)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Clemastine
Fumarate)
(Dimetapp)
$0 (Tier 4)
(Triaminic Nighttime
Cold-Cough)
(Zzzquil)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
(Zzzquil)
(Diphenhydramine
HCl)
(Zzzquil)
$0 (Tier 4)
$0 (Tier 4)
PA
PA
$0 (Tier 4)
PA
(Zzzquil)
$0 (Tier 4)
PA
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
(Chlorpheniramine
Maleate)
(Chlorpheniramine
Maleate)
(Chlorpheniramine/P
henylephrine)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
57
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
entre-hist pse liquid 0.938-10 mg/ml *
(Triprolidine/Pseudoe
phedrine)
(Phenylephrine/Diphe
nhydramine)
(Allegra Allergy)
$0 (Tier 4)
(Fexofenadine HCl)
$0 (Tier 4)
fexofenadine hcl 60 mg tablet
indoor/outdoor (otc) 60 mg *
glenmax peb liquid 4-10 mg/5 ml *
(Allegra Allergy)
$0 (Tier 4)
(Brovex Peb)
$0 (Tier 4)
histex-pe syrup 2.5-10 mg/5 ml *
(Phenylephrine/Tripr
olidine)
(Zzzquil)
(Xyzal)
(Xyzal)
(Chlorpheniramine/Ps
eudoephed)
(Claritin)
$0 (Tier 4)
(Children'S Claritin)
$0 (Tier 4)
(Triaminic
Cold-Allergy Pe)
$0 (Tier 4)
eq allergy & sinus relief tab 25-10 mg *
fexofenadine hcl 180 mg tablet
24hr,original str (otc) 180 mg *
fexofenadine hcl 30 mg/5 ml 30 mg/5 ml *
hm z-sleep 25 mg softgel 25 mg *
levocetirizine oral solution 2.5 mg/5 ml
levocetirizine oral tablet 5 mg
lohist-d liquid 2-30 mg/5 ml *
loratadine 10 mg tablet 10 mg *
loratadine allergy 5 mg/5 ml d/f, a/f, s/f 5
mg/5 ml *
nohist-lq liquid 4-10 mg/5 ml *
PEDIAVENT 1 MG TABLET CHEW 1
MG *
PEDIAVENT 2 MG/5 ML SYRUP 2
MG/5 ML *
phenylephrine-pyrilamine 10-25 25-10 mg (Poly Hist Forte)
*
promethazine oral syrup 6.25 mg/5 ml
(Promethazine HCl)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA-HRM; AGE (Max
64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
58
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
pv nyt-time sleep 25 mg caplet 25 mg *
pv sinus nighttime tablet 2.5-10 mg *
(Diphenhydramine
HCl)
(Phenylephrine/Tripr
olidine)
(Pyril D)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
PA
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
pyrilamine-phenylephrine susp 16-5 mg/5
ml *
q-dryl 12.5 mg/5 ml liquid a/f 12.5 mg/5 ml (Zzzquil)
*
q-tapp elixir a/f,grape,unboxed 1-15 mg/5 (Brovex Psb)
ml *
ra allergy plus sinus tablet 25-10 mg *
(Phenylephrine/Diphe
nhydramine)
ritifed syrup 1.25-30 mg/5 ml *
(Triprolidine/Pseudoe
phedrine)
RYMED TABLET 2-10 MG *
$0 (Tier 4)
siladryl 12.5 mg/5 ml liquid 12.5 mg/5 ml * (Zzzquil)
simply sleep 25 mg caplet caplet 25 mg *
(Diphenhydramine
HCl)
sm allergy relief 1.34 mg tab 1.34 mg *
(Clemastine
Fumarate)
sm sinus and allergy tablet maximum
(Chlorpheniramine/Ps
strength 4-60 mg *
eudoephed)
sudogest sinus & allergy tab 4-60 mg *
(Chlorpheniramine/Ps
eudoephed)
TRIAMINIC NIGHTTIME
COLD-COUGH CHILDREN'S,
GRAPE 6.25-2.5 MG/5 ML *
unisom 50 mg sleepgels softgel 50 mg *
(Zzzquil)
vazobid-pd suspension 6-10 mg/5 ml *
(Brompheniramine/P
henylephrine)
v-r triacting orange syrup 1-15 mg/5 ml * (Chlorpheniramine/Ps
eudoephed)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
59
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
wal-act d cold & allergy tab 2.5-60 mg *
$0 (Tier 4)
wal-dryl allergy 25 mg capsule 25 mg *
wal-dryl allergy 25 mg minitab minitab,
coated 25 mg *
wal-fex allergy 180 mg tablet 180 mg *
(Triprolidine/Pseudoe
phedrine)
(Zzzquil)
(Diphenhydramine
HCl)
(Allegra Allergy)
wal-fex allergy 60 mg tablet 60 mg *
(Allegra Allergy)
$0 (Tier 4)
wal-finate 4 mg tablet 4 mg *
(Chlor-Trimeton)
$0 (Tier 4)
wal-finate-d tablet 4-60 mg *
$0 (Tier 4)
wal-itin 10 mg odt non-drowsy 10 mg *
(Chlorpheniramine/Ps
eudoephed)
(Claritin)
wal-itin 10 mg tablet non-drowsy 10 mg *
(Claritin)
$0 (Tier 4)
wal-itin 5 mg/5 ml syrup children's, grape
5 mg/5 ml *
wal-phed pe sinus-allergy tab 4-10 mg *
(Children'S Claritin)
$0 (Tier 4)
$0 (Tier 4)
wal-sleep z 25 mg softgel 25 mg *
(Chlorpheniramine/P
henylephrine)
(Chlorpheniramine/Ps
eudoephed)
(Zzzquil)
wal-som 25 mg odt 25 mg *
(Unisom Sleepmelts)
$0 (Tier 4)
wal-som 50 mg softgel softgel 50 mg *
wal-tap elixir 1-2.5 mg/5 ml *
(Zzzquil)
(Dimetapp)
$0 (Tier 4)
$0 (Tier 4)
wal-zyr 10 mg tablet 10 mg *
(Zyrtec)
$0 (Tier 4)
wal-zyr solution children's, a/f 1 mg/ml *
(Children'S Zyrtec)
$0 (Tier 4)
wal-phed sinus and allergy tab 4-60 mg *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; AGE (Min 2
Years)
PA
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
60
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Anti-Infectives (Skin And Mucous
Membrane)
Anti-Infectives (Skin And
Mucous Membrane)
AVC VAGINAL VAGINAL CREAM
15 %
clindamycin phosphate vaginal cream 2 %
metronidazole vaginal gel 0.75 %
terconazole vaginal cream 0.4 %, 0.8 %
terconazole vaginal suppository 80 mg
(Cleocin)
(Metrogel-Vaginal)
(Terazol 7)
(Terconazole)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(D.H.E.45)
$0 (Tier 1)
QL (30 per 28 days)
(Migranal)
$0 (Tier 1)
QL (8 per 28 days)
QL (40 per 28 days)
(Amerge)
(Maxalt)
(Maxalt Mlt)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Sumatriptan
Succinate)
(Imitrex)
$0 (Tier 1)
QL (4 per 28 days)
$0 (Tier 1)
QL (12 per 28 days)
(Imitrex)
$0 (Tier 1)
QL (18 per 28 days)
(Sumatriptan
Succinate)
$0 (Tier 1)
QL (4 per 28 days)
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection solution 1
mg/ml
dihydroergotamine nasal
spray,non-aerosol 0.5 mg/pump act. (4
mg/ml)
ERGOMAR SUBLINGUAL TABLET
2 MG
naratriptan oral tablet 1 mg, 2.5 mg
rizatriptan oral tablet 10 mg, 5 mg
rizatriptan oral tablet,disintegrating 10
mg, 5 mg
sumatriptan 6 mg/0.5 ml syrng
p/f,dehp/f,pvc/f 6 mg/0.5 ml
sumatriptan nasal spray,non-aerosol 20
mg/actuation, 5 mg/actuation
sumatriptan succinate oral tablet 100 mg,
25 mg, 50 mg
sumatriptan succinate subcutaneous
cartridge 4 mg/0.5 ml
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
61
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
sumatriptan succinate subcutaneous
cartridge 6 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 4 mg/0.5 ml
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml, 6 mg/0.5 ml
(auto-injector)
sumatriptan succinate subcutaneous
solution 6 mg/0.5 ml
zolmitriptan oral tablet 2.5 mg, 5 mg
zolmitriptan oral tablet,disintegrating 2.5
mg, 5 mg
Necessary Actions,
Restrictions, or
Limits on Use
(Imitrex)
$0 (Tier 1)
QL (4 per 28 days)
(Sumatriptan
Succinate)
(Sumatriptan
Succinate)
$0 (Tier 1)
QL (4 per 28 days)
$0 (Tier 1)
QL (4 per 28 days)
(Imitrex)
$0 (Tier 1)
QL (4 per 28 days)
(Zomig)
(Zomig Zmt)
$0 (Tier 1)
$0 (Tier 1)
QL (12 per 28 days)
QL (12 per 28 days)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; QL (188 per 168
days)
Antimycobacterials
Antimycobacterials
CAPASTAT INJECTION RECON
SOLN 1 GRAM
dapsone oral tablet 100 mg, 25 mg
ethambutol oral tablet 100 mg, 400 mg
isoniazid oral solution 50 mg/5 ml
isoniazid oral tablet 100 mg, 300 mg
PASER ORAL GRANULES DR FOR
SUSP IN PACKET 4 GRAM
PRIFTIN ORAL TABLET 150 MG
pyrazinamide oral tablet 500 mg
rifabutin oral capsule 150 mg
rifampin intravenous recon soln 600 mg
rifampin oral capsule 150 mg, 300 mg
RIFATER ORAL TABLET 50-120-300
MG
SIRTURO ORAL TABLET 100 MG
(Dapsone)
(Myambutol)
(Isoniazid)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
62
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
TRECATOR ORAL TABLET 250 MG
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
Antinausea Agents
Antinausea Agents
AKYNZEO ORAL CAPSULE 300-0.5
MG
compro rectal suppository 25 mg
cvs motion sickness 50 mg tab 50 mg *
dimenhydrinate injection solution 50
mg/ml
dramamine 50 mg tablet 50 mg *
dramamine less drowsy 25 mg tb 25 mg *
(Compazine)
(Dimenhydrinate)
(Dimenhydrinate)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
(Dimenhydrinate)
(Meclizine HCl)
$0 (Tier 4)
$0 (Tier 4)
driminate 50 mg tablet 50 mg *
(Dimenhydrinate)
dronabinol oral capsule 10 mg, 2.5 mg, 5
(Marinol)
mg
EMEND INTRAVENOUS RECON
SOLN 150 MG
EMEND ORAL CAPSULE 125 MG, 80
MG
EMEND ORAL CAPSULE 40 MG
$0 (Tier 4)
$0 (Tier 1)
EMEND ORAL CAPSULE,DOSE
PACK 125 MG (1)- 80 MG (2)
EMEND ORAL SUSPENSION FOR
RECONSTITUTION 125 MG (25 MG/
ML FINAL CONC.)
granisetron (pf) intravenous solution 100
mcg/ml
granisetron hcl intravenous solution 1
mg/ml (1 ml)
granisetron hcl oral tablet 1 mg
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Granisetron
HCl/PF)
(Granisetron HCl)
$0 (Tier 1)
(Granisetron HCl)
$0 (Tier 1)
PA BvD
PA; AGE (Min 2
Years)
QL (2 per 28 days)
PA BvD
PA BvD
PA BvD
$0 (Tier 1)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
63
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
meclizine 12.5 mg caplet caplet (otc) 12.5 (Meclizine HCl)
mg *
meclizine 25 mg tablet (otc) 25 mg *
(Meclizine HCl)
$0 (Tier 4)
meclizine oral tablet 12.5 mg, 25 mg
motion sickness 25 mg tablet 25 mg *
(Meclizine HCl)
(Meclizine HCl)
$0 (Tier 1)
$0 (Tier 4)
ondansetron hcl (pf) injection solution 4
mg/2 ml
ondansetron hcl (pf) injection syringe 4
mg/2 ml
ondansetron hcl oral solution 4 mg/5 ml
ondansetron hcl oral tablet 24 mg, 4 mg, 8
mg
ondansetron oral tablet,disintegrating 4
mg, 8 mg
phenadoz rectal suppository 12.5 mg, 25
mg
prochlorperazine edisylate injection
solution 10 mg/2 ml (5 mg/ml)
prochlorperazine maleate oral tablet 10
mg, 5 mg
prochlorperazine rectal suppository 25 mg
promethazine oral tablet 12.5 mg, 25 mg,
50 mg
promethazine rectal suppository 12.5 mg,
25 mg, 50 mg
promethegan rectal suppository 12.5 mg,
25 mg, 50 mg
TRANSDERM-SCOP
TRANSDERMAL PATCH 3 DAY 1.5
MG (1 MG OVER 3 DAYS)
travel sickness 25 mg tab chew 25 mg *
(Ondansetron
HCl/PF)
(Ondansetron
HCl/PF)
(Zofran)
(Zofran)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
(Zofran Odt)
$0 (Tier 1)
PA BvD
(Phenergan)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
(Prochlorperazine
Edisylate)
(Compazine)
$0 (Tier 1)
(Compazine)
(Promethazine HCl)
$0 (Tier 1)
$0 (Tier 1)
(Phenergan)
$0 (Tier 1)
(Phenergan)
$0 (Tier 1)
$0 (Tier 4)
PA; AGE (Min 2
Years)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
(Bonine)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
$0 (Tier 4)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (10 per 30 days)
PA; AGE (Min 2
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
64
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
wal-dram 50 mg tablet 50 mg *
(Dimenhydrinate)
$0 (Tier 4)
(Mepron)
(Malarone)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
Antiparasite Agents
Antiparasite Agents
ALBENZA ORAL TABLET 200 MG
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
ALINIA ORAL TABLET 500 MG
atovaquone oral suspension 750 mg/5 ml
atovaquone-proguanil oral tablet 250-100
mg, 62.5-25 mg
chloroquine phosphate oral tablet 250 mg,
500 mg
COARTEM ORAL TABLET 20-120
MG
DARAPRIM ORAL TABLET 25 MG
EMVERM ORAL
TABLET,CHEWABLE 100 MG
hydroxychloroquine oral tablet 200 mg
ivermectin oral tablet 3 mg
mefloquine oral tablet 250 mg
NEBUPENT INHALATION RECON
SOLN 300 MG
paromomycin oral capsule 250 mg
(Chloroquine
Phosphate)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin
Sulfate)
PENTAM INJECTION RECON SOLN
300 MG
pin-x 144 mg/ml (50 mg/ml base) s/f,
(Pyrantel Pamoate)
caramel flavor 50 mg/ml *
PRIMAQUINE ORAL TABLET 26.3
MG
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
QL (6 per 21 days)
PA BvD
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
QL (90 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
65
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
quinine sulfate oral capsule 324 mg
reese's pinworm 144 mg/ml susp 50 mg/ml
*
(Qualaquin)
(Pyrantel Pamoate)
$0 (Tier 1)
$0 (Tier 4)
(Amantadine HCl)
(Amantadine HCl)
(Amantadine HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (42 per 7 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral capsule 100 mg
amantadine hcl oral solution 50 mg/5 ml
amantadine hcl oral tablet 100 mg
APOKYN SUBCUTANEOUS
CARTRIDGE 10 MG/ML
AZILECT ORAL TABLET 0.5 MG, 1
MG
benztropine oral tablet 0.5 mg, 1 mg, 2 mg
(Benztropine
Mesylate)
bromocriptine oral capsule 5 mg
(Parlodel)
bromocriptine oral tablet 2.5 mg
(Parlodel)
cabergoline oral tablet 0.5 mg
(Cabergoline)
carbidopa oral tablet 25 mg
(Lodosyn)
carbidopa-levodopa oral tablet 10-100 mg, (Sinemet CR)
25-100 mg, 25-250 mg
carbidopa-levodopa oral tablet extended
(Sinemet CR)
release 25-100 mg, 50-200 mg
carbidopa-levodopa-entacapone oral tablet (Stalevo 50)
12.5-50-200 mg, 18.75-75-200 mg,
25-100-200 mg, 31.25-125-200 mg,
37.5-150-200 mg, 50-200-200 mg
entacapone oral tablet 200 mg
(Comtan)
NEUPRO TRANSDERMAL PATCH
24 HOUR 1 MG/24 HOUR, 2 MG/24
HOUR, 3 MG/24 HOUR, 4 MG/24
HOUR, 6 MG/24 HOUR, 8 MG/24
HOUR
QL (60 per 30 days)
PA-HRM; AGE (Max
64 Years)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
66
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
pramipexole oral tablet 0.125 mg, 0.25
mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg
ropinirole oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg, 5 mg
ropinirole oral tablet extended release 24
hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg
selegiline hcl oral capsule 5 mg
selegiline hcl oral tablet 5 mg
trihexyphenidyl oral elixir 0.4 mg/ml
trihexyphenidyl oral tablet 2 mg, 5 mg
(Mirapex)
$0 (Tier 1)
(Requip)
$0 (Tier 1)
(Requip XL)
$0 (Tier 1)
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl
HCl)
(Trihexyphenidyl
HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
Antipsychotic Agents
Antipsychotic Agents
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 300 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 400 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 300 MG, 400 MG
aripiprazole oral solution 1 mg/ml
aripiprazole oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
aripiprazole oral tablet,disintegrating 10
mg
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (1 per 28 days)
$0 - $7.40
(Tier 2)
QL (1 per 28 days)
(Abilify)
(Abilify)
$0 (Tier 1)
$0 (Tier 1)
QL (900 per 30 days)
QL (30 per 30 days)
(Abilify)
(Abilify Discmelt)
$0 (Tier 1)
$0 (Tier 1)
QL (60 per 30 days)
QL (90 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
67
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
aripiprazole oral tablet,disintegrating 15
mg
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 441 MG/1.6 ML
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 662 MG/2.4 ML
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 882 MG/3.2 ML
chlorpromazine injection solution 25
mg/ml
chlorpromazine oral tablet 10 mg, 100 mg,
200 mg, 25 mg, 50 mg
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating 100
mg, 12.5 mg, 150 mg, 200 mg, 25 mg
FANAPT ORAL TABLET 1 MG, 10
MG, 12 MG, 2 MG, 4 MG, 6 MG, 8
MG
FANAPT ORAL TABLETS,DOSE
PACK 1MG(2)-2MG(2)4MG(2)-6MG(2)
fluphenazine decanoate injection solution
25 mg/ml
fluphenazine hcl injection solution 2.5
mg/ml
fluphenazine hcl oral concentrate 5 mg/ml
fluphenazine hcl oral elixir 2.5 mg/5 ml
fluphenazine hcl oral tablet 1 mg, 10 mg,
2.5 mg, 5 mg
(Abilify Discmelt)
(Chlorpromazine
HCl)
(Chlorpromazine
HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
QL (60 per 30 days)
$0 - $7.40
(Tier 2)
QL (1.6 per 28 days)
$0 - $7.40
(Tier 2)
QL (2.4 per 28 days)
$0 - $7.40
(Tier 2)
QL (3.2 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (270 per 30 days)
QL (135 per 30 days)
QL (90 per 30 days)
ST
$0 - $7.40
(Tier 2)
ST; QL (60 per 30
days)
$0 - $7.40
(Tier 2)
ST; QL (8 per 28 days)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
$0 (Tier 1)
(Fluphenazine HCl)
(Fluphenazine HCl)
(Fluphenazine HCl)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
68
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
GEODON INTRAMUSCULAR
RECON SOLN 20 MG/ML (FINAL
CONC.)
haloperidol decanoate intramuscular
solution 100 mg/ml
haloperidol decanoate intramuscular
solution 50 mg/ml
haloperidol lactate injection solution 5
mg/ml
haloperidol lactate oral concentrate 2
mg/ml
haloperidol oral tablet 0.5 mg, 1 mg, 10
mg, 2 mg, 20 mg, 5 mg
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML, 156 MG/ML, 234 MG/1.5
ML, 39 MG/0.25 ML, 78 MG/0.5 ML
INVEGA TRINZA
INTRAMUSCULAR SYRINGE 273
MG/0.875 ML, 410 MG/1.315 ML, 546
MG/1.75 ML, 819 MG/2.625 ML
LATUDA ORAL TABLET 120 MG, 20
MG, 40 MG, 60 MG, 80 MG
loxapine succinate oral capsule 10 mg, 25
mg, 5 mg, 50 mg
molindone oral tablet 10 mg
molindone oral tablet 25 mg
molindone oral tablet 5 mg
NUPLAZID ORAL TABLET 17 MG
$0 - $7.40
(Tier 2)
(Haloperidol
Decanoate)
(Haldol Decanoate
50)
(Haloperidol Lactate)
$0 (Tier 1)
(Haloperidol Lactate)
$0 (Tier 1)
(Haloperidol)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Loxapine Succinate)
(Molindone HCl)
(Molindone HCl)
(Molindone HCl)
olanzapine intramuscular recon soln 10 mg (Zyprexa)
olanzapine oral tablet 10 mg, 15 mg, 2.5
(Zyprexa)
mg, 20 mg, 5 mg, 7.5 mg
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
QL (240 per 30 days)
QL (270 per 30 days)
QL (120 per 30 days)
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
69
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
olanzapine oral tablet,disintegrating 10
mg, 15 mg, 5 mg
olanzapine oral tablet,disintegrating 20
mg
paliperidone oral tablet extended release
24hr 1.5 mg, 3 mg, 9 mg
paliperidone oral tablet extended release
24hr 6 mg
perphenazine oral tablet 16 mg, 2 mg, 4
mg, 8 mg
pimozide oral tablet 1 mg, 2 mg
quetiapine oral tablet 100 mg, 200 mg, 25
mg, 300 mg, 400 mg, 50 mg
REXULTI ORAL TABLET 0.25 MG
(Zyprexa Zydis)
$0 (Tier 1)
QL (30 per 30 days)
(Zyprexa Zydis)
$0 (Tier 1)
QL (31 per 30 days)
(Invega)
$0 (Tier 1)
QL (30 per 30 days)
(Invega)
$0 (Tier 1)
QL (60 per 30 days)
(Perphenazine)
$0 (Tier 1)
(Orap)
(Seroquel)
$0 (Tier 1)
$0 (Tier 1)
QL (90 per 30 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (120 per 30 days)
(Risperdal)
(Risperdal)
$0 (Tier 1)
$0 (Tier 1)
QL (480 per 30 days)
QL (60 per 30 days)
(Risperdal M-Tab)
$0 (Tier 1)
QL (60 per 30 days)
(Risperdal M-Tab)
$0 (Tier 1)
QL (120 per 30 days)
$0 - $7.40
(Tier 2)
ST; QL (60 per 30
days)
REXULTI ORAL TABLET 0.5 MG
REXULTI ORAL TABLET 1 MG, 2
MG, 3 MG, 4 MG
RISPERDAL CONSTA
INTRAMUSCULAR SYRINGE 12.5
MG/2 ML, 25 MG/2 ML, 37.5 MG/2
ML, 50 MG/2 ML
risperidone oral solution 1 mg/ml
risperidone oral tablet 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
risperidone oral tablet,disintegrating 0.25
mg, 0.5 mg, 1 mg, 2 mg
risperidone oral tablet,disintegrating 3 mg,
4 mg
SAPHRIS (BLACK CHERRY)
SUBLINGUAL TABLET 10 MG, 2.5
MG, 5 MG
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (30 per 30 days)
QL (4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
70
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
thioridazine oral tablet 10 mg, 100 mg, 25
mg, 50 mg
thiothixene oral capsule 1 mg, 10 mg, 2
mg, 5 mg
trifluoperazine oral tablet 1 mg, 10 mg, 2
mg, 5 mg
VERSACLOZ ORAL SUSPENSION 50
MG/ML
VRAYLAR ORAL CAPSULE 1.5 MG,
3 MG, 4.5 MG, 6 MG
VRAYLAR ORAL CAPSULE,DOSE
PACK 1.5 MG (1)- 3 MG (6)
ziprasidone hcl oral capsule 20 mg, 40 mg,
60 mg, 80 mg
ZYPREXA RELPREVV 405 MG VL
KIT W/ DILUENT, OUTER 405 MG
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 210 MG
(Thioridazine HCl)
$0 (Tier 1)
(Thiothixene)
$0 (Tier 1)
(Trifluoperazine HCl)
$0 (Tier 1)
(Geodon)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO-HRM
ST; QL (540 per 30
days)
QL (30 per 30 days)
QL (7 per 30 days)
QL (60 per 30 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Antivirals (Systemic)
Antiretrovirals
abacavir oral tablet 300 mg
(Ziagen)
abacavir-lamivudine oral tablet 600-300
(Epzicom)
mg
abacavir-lamivudine-zidovudine oral tablet (Trizivir)
300-150-300 mg
APTIVUS ORAL CAPSULE 250 MG
APTIVUS ORAL SOLUTION 100
MG/ML
ATRIPLA ORAL TABLET 600-200-300
MG
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
71
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
COMPLERA ORAL TABLET
200-25-300 MG
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
DESCOVY ORAL TABLET 200-25
MG
didanosine oral capsule,delayed
release(dr/ec) 125 mg, 200 mg, 250 mg,
400 mg
EDURANT ORAL TABLET 25 MG
(Videx EC)
EMTRIVA ORAL CAPSULE 200 MG
EMTRIVA ORAL SOLUTION 10
MG/ML
EPIVIR HBV ORAL SOLUTION 25
MG/5 ML (5 MG/ML)
EPZICOM ORAL TABLET 600-300
MG
EVOTAZ ORAL TABLET 300-150 MG
FUZEON SUBCUTANEOUS RECON
SOLN 90 MG
GENVOYA ORAL TABLET
150-150-200-10 MG
INTELENCE ORAL TABLET 100
MG, 200 MG, 25 MG
INVIRASE ORAL CAPSULE 200 MG
INVIRASE ORAL TABLET 500 MG
ISENTRESS ORAL POWDER IN
PACKET 100 MG
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
72
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ISENTRESS ORAL TABLET 400 MG
ISENTRESS ORAL
TABLET,CHEWABLE 100 MG, 25
MG
KALETRA ORAL SOLUTION 400-100
MG/5 ML
KALETRA ORAL TABLET 100-25
MG, 200-50 MG
lamivudine oral solution 10 mg/ml
(Epivir)
lamivudine oral tablet 100 mg, 150 mg,
(Epivir)
300 mg
lamivudine-zidovudine oral tablet 150-300 (Combivir)
mg
LEXIVA ORAL SUSPENSION 50
MG/ML
LEXIVA ORAL TABLET 700 MG
nevirapine oral suspension 50 mg/5 ml
nevirapine oral tablet 200 mg
nevirapine oral tablet extended release 24
hr 100 mg, 400 mg
NORVIR ORAL CAPSULE 100 MG
(Viramune)
(Viramune)
(Viramune XR)
NORVIR ORAL SOLUTION 80
MG/ML
NORVIR ORAL TABLET 100 MG
ODEFSEY ORAL TABLET 200-25-25
MG
PREZCOBIX ORAL TABLET 800-150
MG-MG
PREZISTA ORAL SUSPENSION 100
MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
73
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
PREZISTA ORAL TABLET 150 MG,
400 MG, 600 MG, 75 MG, 800 MG
RESCRIPTOR ORAL TABLET 200
MG
RESCRIPTOR ORAL TABLET,
DISPERSIBLE 100 MG
RETROVIR INTRAVENOUS
SOLUTION 10 MG/ML
REYATAZ ORAL CAPSULE 150 MG,
200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET 50 MG
SELZENTRY ORAL TABLET 150
MG, 300 MG
stavudine oral capsule 15 mg, 20 mg, 30
(Zerit)
mg, 40 mg
stavudine oral recon soln 1 mg/ml
(Zerit)
STRIBILD ORAL TABLET
150-150-200-300 MG
SUSTIVA ORAL CAPSULE 200 MG,
50 MG
SUSTIVA ORAL TABLET 600 MG
TIVICAY ORAL TABLET 10 MG, 25
MG, 50 MG
TRIUMEQ ORAL TABLET 600-50-300
MG
TRUVADA ORAL TABLET 100-150
MG, 133-200 MG, 167-250 MG, 200-300
MG
VIDEX 2 GRAM PEDIATRIC ORAL
RECON SOLN 10 MG/ML (FINAL)
VIDEX 4 GM PEDIATRIC SOLN 10
MG/ML (FINAL)
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
74
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
VIRACEPT ORAL TABLET 250 MG,
625 MG
VIRAMUNE XR ORAL TABLET
EXTENDED RELEASE 24 HR 100
MG
VIREAD ORAL POWDER 40
MG/SCOOP (40 MG/GRAM)
VIREAD ORAL TABLET 150 MG, 200
MG, 250 MG, 300 MG
VITEKTA ORAL TABLET 150 MG, 85
MG
ZIAGEN ORAL SOLUTION 20
MG/ML
zidovudine oral capsule 100 mg
(Retrovir)
zidovudine oral syrup 10 mg/ml
(Retrovir)
zidovudine oral tablet 300 mg
(Zidovudine)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Antivirals, Miscellaneous
foscarnet intravenous solution 24 mg/ml
RELENZA DISKHALER
INHALATION BLISTER WITH
DEVICE 5 MG/ACTUATION
rimantadine oral tablet 100 mg
SYNAGIS 100 MG/1 ML VIAL 100
MG/ML
SYNAGIS INTRAMUSCULAR
SOLUTION 50 MG/0.5 ML
TAMIFLU ORAL CAPSULE 30 MG
(Foscavir)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
(Flumadine)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
TAMIFLU ORAL CAPSULE 45 MG
TAMIFLU ORAL CAPSULE 75 MG
PA BvD
QL (84 per 180 days)
QL (48 per 180 days)
QL (42 per 180 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
75
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION 6 MG/ML
$0 - $7.40
(Tier 2)
QL (540 per 180 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (56 per 28
days)
PA; QL (112 per 28
days)
$0 - $7.40
(Tier 2)
PA; QL (84 per 28
days)
$0 - $7.40
(Tier 2)
PA; QL (30 per 30
days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO
$0 - $7.40
(Tier 2)
PA NSO
Necessary Actions,
Restrictions, or
Limits on Use
Hcv Antivirals
DAKLINZA ORAL TABLET 30 MG,
60 MG, 90 MG
EPCLUSA ORAL TABLET 400-100
MG
HARVONI ORAL TABLET 90-400
MG
OLYSIO ORAL CAPSULE 150 MG
SOVALDI ORAL TABLET 400 MG
TECHNIVIE ORAL TABLET
12.5-75-50 MG
VIEKIRA PAK ORAL
TABLETS,DOSE PACK 12.5 MG-75
MG -50 MG/250 MG
VIEKIRA XR ORAL TABLET, IR ER, BIPHASIC 24HR 8.33 MG-50 MG33.33 MG-200 MG
ZEPATIER ORAL TABLET 50-100
MG
Interferons
INTRON A 25 MILLION UNIT/2.5
ML 10 MILLION UNIT/ML
INTRON A INJECTION RECON
SOLN 10 MILLION UNIT (1 ML)
INTRON A INJECTION RECON
SOLN 18 MILLION UNIT (1 ML), 50
MILLION UNIT (1 ML)
INTRON A INJECTION SOLUTION 6
MILLION UNIT/ML
PA NSO
PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
76
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
PEGASYS PROCLICK
SUBCUTANEOUS PEN INJECTOR
135 MCG/0.5 ML, 180 MCG/0.5 ML
PEGASYS SUBCUTANEOUS
SOLUTION 180 MCG/ML
PEGASYS SUBCUTANEOUS
SYRINGE 180 MCG/0.5 ML
PEGINTRON SUBCUTANEOUS KIT
120 MCG/0.5 ML, 150 MCG/0.5 ML, 50
MCG/0.5 ML, 80 MCG/0.5 ML
SYLATRON SUBCUTANEOUS KIT
200 MCG, 300 MCG, 600 MCG
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
PA NSO; QL (4 per 28
days)
PA BvD
PA
PA
Nucleosides And Nucleotides
acyclovir oral capsule 200 mg
acyclovir oral suspension 200 mg/5 ml
acyclovir oral tablet 400 mg, 800 mg
acyclovir sodium intravenous solution 50
mg/ml
adefovir oral tablet 10 mg
entecavir oral tablet 0.5 mg, 1 mg
famciclovir oral tablet 125 mg, 250 mg,
500 mg
ganciclovir sodium intravenous recon soln
500 mg
ribasphere oral capsule 200 mg
ribasphere oral tablet 200 mg, 400 mg,
600 mg
TYZEKA ORAL TABLET 600 MG
(Zovirax)
(Zovirax)
(Zovirax)
(Acyclovir Sodium)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Hepsera)
(Baraclude)
(Famvir)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cytovene)
$0 (Tier 1)
(Rebetol)
(Copegus)
$0 (Tier 1)
$0 (Tier 1)
valacyclovir oral tablet 1 gram, 500 mg
valganciclovir oral tablet 450 mg
VIRAZOLE INHALATION RECON
SOLN 6 GRAM
(Valtrex)
(Valcyte)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
77
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Blood Products/Modifiers/Volume
Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
INTRAVENOUS RECON SOLN 500
UNIT
ELIQUIS ORAL TABLET 2.5 MG, 5
MG
enoxaparin subcutaneous solution 300
mg/3 ml
enoxaparin subcutaneous syringe 100
mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30
mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80
mg/0.8 ml
fondaparinux subcutaneous syringe 10
mg/0.8 ml
fondaparinux subcutaneous syringe 2.5
mg/0.5 ml
fondaparinux subcutaneous syringe 5
mg/0.4 ml
fondaparinux subcutaneous syringe 7.5
mg/0.6 ml
heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml,
20,000 unit/500 ml (40 unit/ml), 25,000
unit/500 ml (50 unit/ml)
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250
ml(100 unit/ml)
heparin (porcine) in nacl (pf) intravenous
parenteral solution 1,000 unit/500 ml
$0 - $7.40
(Tier 2)
(Lovenox)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Lovenox)
$0 (Tier 1)
(Arixtra)
$0 (Tier 1)
QL (24 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (15 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (12 per 30 days)
(Arixtra)
$0 (Tier 1)
QL (18 per 30 days)
(Heparin
Sodium,Porcine/D5W
)
$0 (Tier 1)
(Heparin Sod,Pork In
0.45% NaCl)
$0 (Tier 1)
(Heparin
Sodium,Porcine/Ns/P
F)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
78
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
heparin (porcine) injection solution 1,000
unit/ml, 10,000 unit/ml, 20,000 unit/ml,
5,000 unit/ml
heparin, porcine (pf) injection solution
5,000 unit/0.5 ml
heparin, porcine (pf) injection syringe
5,000 unit/0.5 ml
heparin-0.45% nacl 25,000 units/250 ml
(100 units/ml) bag latex-free, inner
25,000 unit/250 ml
heparin-d5w 25,000 units/250 ml (100
units/ml) bag excel container 25,000
unit/250 ml(100 unit/ml)
IPRIVASK SUBCUTANEOUS
RECON SOLN 15 MG
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5
mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
PRADAXA ORAL CAPSULE 110 MG,
150 MG, 75 MG
warfarin oral tablet 1 mg, 10 mg, 2 mg,
2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg
XARELTO ORAL TABLET 10 MG, 15
MG, 20 MG
XARELTO ORAL TABLETS,DOSE
PACK 15 MG (42)- 20 MG (9)
(Heparin
Sodium,Porcine)
$0 (Tier 1)
(Heparin
Sodium,Porcine/PF)
(Heparin
Sodium,Porcine/PF)
(Heparin Sod,Pork In
0.45% NaCl)
$0 (Tier 1)
(Heparin
Sodium,Porcine/D5W
)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
PA; QL (24 per 28
days)
(Coumadin)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
ST; QL (60 per 30
days)
(Coumadin)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Blood Formation Modifiers
CINRYZE INTRAVENOUS RECON
SOLN 500 UNIT (5 ML)
EPOGEN 10,000 UNITS/ML VIAL
SDV, P/F, OUTER 10,000 UNIT/ML
EPOGEN INJECTION SOLUTION
2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
79
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
GRANIX SUBCUTANEOUS
SYRINGE 300 MCG/0.5 ML, 480
MCG/0.8 ML
LEUKINE INJECTION RECON
SOLN 250 MCG
MIRCERA INJECTION SYRINGE
100 MCG/0.3 ML, 200 MCG/0.3 ML, 50
MCG/0.3 ML, 75 MCG/0.3 ML
MOZOBIL SUBCUTANEOUS
SOLUTION 24 MG/1.2 ML (20
MG/ML)
NEULASTA SUBCUTANEOUS
SYRINGE 6 MG/0.6ML
NEULASTA SUBCUTANEOUS
SYRINGE, W/ WEARABLE
INJECTOR 6 MG/0.6 ML
NEUMEGA SUBCUTANEOUS
RECON SOLN 5 MG
NEUPOGEN INJECTION SOLUTION
300 MCG/ML, 480 MCG/1.6 ML
NEUPOGEN INJECTION SYRINGE
300 MCG/0.5 ML, 480 MCG/0.8 ML
PROCRIT 10,000 UNITS/ML VIAL
4'S, MDV, OUTER 20,000 UNIT/2 ML
PROCRIT INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
PROCRIT INJECTION SOLUTION
40,000 UNIT/ML
PROMACTA ORAL TABLET 12.5
MG, 25 MG, 50 MG, 75 MG
ZARXIO INJECTION SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; QL (0.6 per 28
days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; QL (12 per 28
days)
PA; QL (12 per 28
days)
PA; QL (6 per 28 days)
PA; QL (30 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
80
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Hematologic Agents,
Miscellaneous
aminocaproic acid oral solution 250 mg/ml
(25 %)
aminocaproic acid oral tablet 1,000 mg,
500 mg
anagrelide oral capsule 0.5 mg, 1 mg
protamine intravenous solution 10 mg/ml
tranexamic acid intravenous solution
1,000 mg/10 ml (100 mg/ml)
tranexamic acid oral tablet 650 mg
Necessary Actions,
Restrictions, or
Limits on Use
(Aminocaproic Acid)
$0 (Tier 1)
(Aminocaproic Acid)
$0 (Tier 1)
(Agrylin)
(Protamine Sulfate)
(Tranexamic Acid)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Lysteda)
$0 (Tier 1)
(Aggrenox)
$0 (Tier 1)
(Pletal)
(Plavix)
(Persantine)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 30 days)
(Pentoxifylline)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
QL (30 per 30 days)
Platelet-Aggregation
Inhibitors
aspirin-dipyridamole oral capsule, er
multiphase 12 hr 25-200 mg
BRILINTA ORAL TABLET 60 MG, 90
MG
cilostazol oral tablet 100 mg, 50 mg
clopidogrel oral tablet 300 mg, 75 mg
dipyridamole oral tablet 25 mg, 50 mg, 75
mg
EFFIENT ORAL TABLET 10 MG, 5
MG
pentoxifylline oral tablet extended release
400 mg
Caloric Agents
Caloric Agents
AMINO ACIDS 15 % INTRAVENOUS
PARENTERAL SOLUTION 15 %
AMINOSYN 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
AMINOSYN 3.5 % INTRAVENOUS
PARENTERAL SOLUTION 3.5 %
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
81
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
AMINOSYN 7 % INTRAVENOUS
PARENTERAL SOLUTION 7 %
AMINOSYN 7 % WITH
ELECTROLYTES INTRAVENOUS
PARENTERAL SOLUTION 7 %
AMINOSYN 8.5 % INTRAVENOUS
PARENTERAL SOLUTION 8.5 %
AMINOSYN 8.5 %-ELECTROLYTES
INTRAVENOUS PARENTERAL
SOLUTION 8.5 %
AMINOSYN II 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
AMINOSYN II 15 % INTRAVENOUS
PARENTERAL SOLUTION 15 %
AMINOSYN II 7 % INTRAVENOUS
PARENTERAL SOLUTION 7 %
AMINOSYN II 8.5 % INTRAVENOUS
PARENTERAL SOLUTION 8.5 %
AMINOSYN II 8.5
%-ELECTROLYTES INTRAVENOUS
PARENTERAL SOLUTION 8.5 %
AMINOSYN M 3.5 %
INTRAVENOUS PARENTERAL
SOLUTION 3.5 %
AMINOSYN-HBC 7%
INTRAVENOUS PARENTERAL
SOLUTION 7 %
AMINOSYN-PF 10 %
INTRAVENOUS PARENTERAL
SOLUTION 10 %
AMINOSYN-PF 7 %
(SULFITE-FREE) INTRAVENOUS
PARENTERAL SOLUTION 7 %
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
82
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
AMINOSYN-RF 5.2 %
INTRAVENOUS PARENTERAL
SOLUTION 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINIMIX 5%/D25W
SULFITE-FREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINIMIX 2.75%/D5W SULFIT FREE
INTRAVENOUS PARENTERAL
SOLUTION 2.75 %
CLINIMIX 4.25%/D10W SULF FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX 4.25%/D5W SULFIT FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX 4.25%-D20W SULF-FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX 4.25%-D25W SULF-FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX
5%-D20W(SULFITE-FREE)
INTRAVENOUS PARENTERAL
SOLUTION 5 %
CLINIMIX E 2.75%/D10W SUL FREE
INTRAVENOUS PARENTERAL
SOLUTION 2.75 %
CLINIMIX E 2.75%/D5W SULF FREE
INTRAVENOUS PARENTERAL
SOLUTION 2.75 %
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
83
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
CLINIMIX E 4.25%/D10W SUL FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX E 4.25%/D25W SUL FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX E 4.25%/D5W SULF FREE
INTRAVENOUS PARENTERAL
SOLUTION 4.25 %
CLINIMIX E 5%/D15W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINIMIX E 5%/D20W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINIMIX E 5%/D25W SULFIT
FREE INTRAVENOUS
PARENTERAL SOLUTION 5 %
CLINISOL SF 15 % INTRAVENOUS
PARENTERAL SOLUTION 15 %
cvs glucose bits tablet chew 1 gram *
cvs glucose liquid shot concord grape 15
gram/59 ml *
cysteine (l-cysteine) intravenous solution
50 mg/ml
dex4 glucose 4 gm tablet chew grape
flavor 4 gram *
dex4 glucose bits tablet chew 1 gram *
dextrose 10 % in water (d10w)
intravenous parenteral solution 10 %
dextrose 20 % in water (d20w)
intravenous parenteral solution 20 %
dextrose 25 % in water (d25w)
intravenous syringe
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
PA BvD
(Dextrose)
(Gluco Shot)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 4)
(Cysteine HCl)
$0 (Tier 1)
PA BvD
(Dextrose)
$0 (Tier 4)
(Dextrose)
(Dextrose 10 % in
Water)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
$0 (Tier 4)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
84
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
dextrose 40 % in water (d40w)
intravenous parenteral solution 40 %
dextrose 5 % in ringers intravenous
parenteral solution 5 %
dextrose 5 % in water (d5w) intravenous
parenteral solution
dextrose 50 % in water (d50w)
intravenous parenteral solution
dextrose 50 % in water (d50w)
intravenous syringe
dextrose 70 % in water (d70w)
intravenous parenteral solution
FREAMINE HBC 6.9 %
INTRAVENOUS PARENTERAL
SOLUTION 6.9 %
FREAMINE III 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
gluco burst 40% gel 40 % *
glucose 4 gram tablet chew na/f, caffeine
free 4 gram *
glucose 40% gel tropical fruit 40 % *
glutose 15 gel 3 pak, outer, u-d 40 % *
HEPATAMINE 8% INTRAVENOUS
PARENTERAL SOLUTION 8 %
HEPATASOL 8 % INTRAVENOUS
PARENTERAL SOLUTION 8 %
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN INTRAVENOUS
EMULSION 3.31-9.8-3.9 %
NEPHRAMINE 5.4 %
INTRAVENOUS PARENTERAL
SOLUTION 5.4 %
(Dextrose 40 % in
Water)
(Dextrose 5 % In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
(Dextrose)
(Dextrose)
(Dextrose)
(Dextrose)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 4)
PA BvD
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
85
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
NUTRILIPID INTRAVENOUS
EMULSION 20 %
PERIKABIVEN INTRAVENOUS
EMULSION 2.36-6.8-3.5 %
PREMASOL 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
PREMASOL 6 % INTRAVENOUS
PARENTERAL SOLUTION 6 %
PROCALAMINE 3% INTRAVENOUS
PARENTERAL SOLUTION 3 %
PROSOL 20 % INTRAVENOUS
PARENTERAL SOLUTION
smoflipid intravenous emulsion 20 %
(Fat
Emul/Soy/Mct/Oliv/F
ish Oil)
TRAVASOL 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
TROPHAMINE 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
TROPHAMINE 6% INTRAVENOUS
PARENTERAL SOLUTION 6 %
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet 0.1 mg, 0.2 mg,
0.3 mg
clonidine transdermal patch weekly 0.1
mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly 0.3
mg/24 hr
clorpres oral tablet 0.1-15 mg, 0.2-15 mg,
0.3-15 mg
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8
mg
(Catapres)
$0 (Tier 1)
(Catapres-Tts 1)
$0 (Tier 1)
QL (4 per 28 days)
(Catapres-Tts 1)
$0 (Tier 1)
QL (8 per 28 days)
(Clonidine
HCl/Chlorthalidone)
(Cardura)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
86
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
guanfacine oral tablet 1 mg, 2 mg
(Tenex)
$0 (Tier 1)
midodrine oral tablet 10 mg, 2.5 mg, 5 mg
NORTHERA ORAL CAPSULE 100
MG, 200 MG, 300 MG
phenylephrine hcl injection solution 10
mg/ml
prazosin oral capsule 1 mg, 2 mg, 5 mg
(Midodrine HCl)
(Vazculep)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Minipress)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; AGE (Max
64 Years)
PA; QL (180 per 30
days)
Angiotensin Ii Receptor
Antagonists
BENICAR HCT ORAL TABLET
20-12.5 MG, 40-12.5 MG, 40-25 MG
BENICAR ORAL TABLET 20 MG, 40
MG, 5 MG
candesartan oral tablet 16 mg, 32 mg, 4
mg, 8 mg
candesartan-hydrochlorothiazid oral tablet
16-12.5 mg, 32-12.5 mg, 32-25 mg
ENTRESTO ORAL TABLET 24-26
MG, 49-51 MG, 97-103 MG
irbesartan oral tablet 150 mg, 300 mg, 75
mg
irbesartan-hydrochlorothiazide oral tablet
150-12.5 mg, 300-12.5 mg
losartan oral tablet 100 mg, 25 mg, 50 mg
losartan-hydrochlorothiazide oral tablet
100-12.5 mg, 100-25 mg, 50-12.5 mg
telmisartan oral tablet 20 mg, 40 mg, 80
mg
telmisartan-hydrochlorothiazid oral tablet
40-12.5 mg, 80-12.5 mg, 80-25 mg
$0 (Tier 1)
$0 (Tier 1)
(Atacand)
$0 (Tier 1)
(Atacand HCT)
$0 (Tier 1)
(Avapro)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Avalide)
$0 (Tier 1)
(Cozaar)
(Hyzaar)
$0 (Tier 1)
$0 (Tier 1)
(Micardis)
$0 (Tier 1)
(Micardis HCT)
$0 (Tier 1)
PA; QL (60 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
87
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
TRIBENZOR ORAL TABLET
20-5-12.5 MG, 40-10-12.5 MG, 40-10-25
MG, 40-5-12.5 MG, 40-5-25 MG
valsartan oral tablet 160 mg, 320 mg, 40
mg, 80 mg
valsartan-hydrochlorothiazide oral tablet
160-12.5 mg, 160-25 mg, 320-12.5 mg,
320-25 mg, 80-12.5 mg
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
(Diovan)
$0 (Tier 1)
(Diovan HCT)
$0 (Tier 1)
(Lotensin)
$0 (Tier 1)
(Lotensin HCT)
$0 (Tier 1)
(Captopril)
$0 (Tier 1)
(Captopril/Hydrochlo
rothiazide)
(Vasotec)
$0 (Tier 1)
(Enalaprilat
Dihydrate)
(Vaseretic)
$0 (Tier 1)
(Fosinopril Sodium)
(Fosinopril/Hydrochl
orothiazide)
(Zestril)
$0 (Tier 1)
$0 (Tier 1)
(Zestoretic)
$0 (Tier 1)
(Moexipril HCl)
$0 (Tier 1)
Angiotensin-Converting
Enzyme Inhibitors
benazepril oral tablet 10 mg, 20 mg, 40
mg, 5 mg
benazepril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25
mg
captopril oral tablet 100 mg, 12.5 mg, 25
mg, 50 mg
captopril-hydrochlorothiazide oral tablet
25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg
enalapril maleate oral tablet 10 mg, 2.5
mg, 20 mg, 5 mg
enalaprilat intravenous solution 1.25
mg/ml
enalapril-hydrochlorothiazide oral tablet
10-25 mg, 5-12.5 mg
fosinopril oral tablet 10 mg, 20 mg, 40 mg
fosinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg,
30 mg, 40 mg, 5 mg
lisinopril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
moexipril oral tablet 15 mg, 7.5 mg
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
88
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
moexipril-hydrochlorothiazide oral tablet
15-12.5 mg, 15-25 mg, 7.5-12.5 mg
perindopril erbumine oral tablet 2 mg, 4
mg, 8 mg
quinapril oral tablet 10 mg, 20 mg, 40 mg,
5 mg
quinapril-hydrochlorothiazide oral tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg
ramipril oral capsule 1.25 mg, 10 mg, 2.5
mg, 5 mg
trandolapril oral tablet 1 mg, 2 mg, 4 mg
(Moexipril/Hydrochl
orothiazide)
(Aceon)
$0 (Tier 1)
(Accupril)
$0 (Tier 1)
(Accuretic)
$0 (Tier 1)
(Altace)
$0 (Tier 1)
(Mavik)
$0 (Tier 1)
(Cordarone)
$0 (Tier 1)
(Norpace)
$0 (Tier 1)
(Tikosyn)
$0 (Tier 1)
(Tambocor)
$0 (Tier 1)
(Lidocaine HCl/PF)
$0 (Tier 1)
(Lidocaine
HCl/D5w/PF)
(Mexiletine HCl)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
Antiarrhythmic Agents
amiodarone oral tablet 100 mg, 200 mg,
400 mg
disopyramide phosphate oral capsule 100
mg, 150 mg
dofetilide oral capsule 125 mcg, 250 mcg,
500 mcg
flecainide oral tablet 100 mg, 150 mg, 50
mg
lidocaine (pf) intravenous syringe 50 mg/5
ml (1 %)
lidocaine in 5 % dextrose (pf) intravenous
parenteral solution 8 mg/ml (0.8 %)
mexiletine oral capsule 150 mg, 200 mg,
250 mg
MULTAQ ORAL TABLET 400 MG
pacerone oral tablet 100 mg, 200 mg, 400 (Cordarone)
mg
procainamide injection solution 100
(Procainamide HCl)
mg/ml, 500 mg/ml
propafenone oral capsule,extended release (Rythmol SR)
12 hr 225 mg, 325 mg, 425 mg
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
89
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
propafenone oral tablet 150 mg, 225 mg,
300 mg
quinidine gluconate oral tablet extended
release 324 mg
quinidine sulfate oral tablet 200 mg, 300
mg
quinidine sulfate oral tablet extended
release 300 mg
(Rythmol)
$0 (Tier 1)
(Quinidine
Gluconate)
(Quinidine Sulfate)
$0 (Tier 1)
(Quinidine Sulfate)
$0 (Tier 1)
(Sectral)
(Tenormin)
(Tenoretic 50)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Betaxolol HCl)
(Zebeta)
$0 (Tier 1)
$0 (Tier 1)
(Ziac)
$0 (Tier 1)
(Coreg)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Brevibloc)
$0 (Tier 1)
(Labetalol HCl)
(Trandate)
$0 (Tier 1)
$0 (Tier 1)
(Toprol XL)
$0 (Tier 1)
(Lopressor HCT)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
Beta-Adrenergic Blocking
Agents
acebutolol oral capsule 200 mg, 400 mg
atenolol oral tablet 100 mg, 25 mg, 50 mg
atenolol-chlorthalidone oral tablet 100-25
mg, 50-25 mg
betaxolol oral tablet 10 mg, 20 mg
bisoprolol fumarate oral tablet 10 mg, 5
mg
bisoprolol-hydrochlorothiazide oral tablet
10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg
BYSTOLIC ORAL TABLET 10 MG,
2.5 MG, 20 MG, 5 MG
carvedilol oral tablet 12.5 mg, 25 mg,
3.125 mg, 6.25 mg
esmolol intravenous solution 100 mg/10 ml
(10 mg/ml)
labetalol intravenous solution 5 mg/ml
labetalol oral tablet 100 mg, 200 mg, 300
mg
metoprolol succinate oral tablet extended
release 24 hr 100 mg, 200 mg, 25 mg, 50
mg
metoprolol ta-hydrochlorothiaz oral tablet
100-25 mg, 100-50 mg, 50-25 mg
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
90
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
metoprolol tartrate intravenous solution 5
mg/5 ml
metoprolol tartrate intravenous syringe 5
mg/5 ml
metoprolol tartrate oral tablet 100 mg, 25
mg, 37.5 mg, 50 mg, 75 mg
nadolol oral tablet 20 mg, 40 mg, 80 mg
pindolol oral tablet 10 mg, 5 mg
propranolol intravenous solution 1 mg/ml
propranolol oral capsule,extended release
24 hr 120 mg, 160 mg, 60 mg, 80 mg
propranolol oral solution 20 mg/5 ml (4
mg/ml), 40 mg/5 ml (8 mg/ml)
propranolol oral tablet 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
propranolol-hydrochlorothiazid oral tablet
40-25 mg, 80-25 mg
sorine oral tablet 120 mg, 160 mg, 240 mg,
80 mg
sotalol 120 mg tablet 120 mg
sotalol af oral tablet 120 mg
sotalol oral tablet 160 mg, 240 mg, 80 mg
timolol maleate oral tablet 10 mg, 20 mg,
5 mg
(Metoprolol Tartrate)
$0 (Tier 1)
(Metoprolol Tartrate)
$0 (Tier 1)
(Lopressor)
$0 (Tier 1)
(Corgard)
(Pindolol)
(Propranolol HCl)
(Inderal LA)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Propranolol HCl)
$0 (Tier 1)
(Propranolol HCl)
$0 (Tier 1)
(Propranolol/Hydroc
hlorothiazid)
(Betapace)
$0 (Tier 1)
(Betapace)
(Betapace)
(Betapace)
(Timolol Maleate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
(Cardizem CD)
(Cardizem CD)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
Calcium-Channel Blocking
Agents
cartia xt oral capsule,extended release
24hr 120 mg, 180 mg, 240 mg, 300 mg
diltiazem 24hr er 180 mg cap 180 mg
diltiazem 24hr er 360 mg cap 360 mg
diltiazem hcl intravenous recon soln 100
mg
diltiazem hcl intravenous solution 5 mg/ml
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
91
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
diltiazem hcl oral capsule, extended
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended release
12 hr 120 mg, 60 mg, 90 mg
diltiazem hcl oral capsule,extended release
24hr 120 mg, 240 mg, 300 mg
diltiazem hcl oral tablet 120 mg, 30 mg, 60
mg, 90 mg
diltiazem hcl oral tablet extended release
24 hr 180 mg, 240 mg, 300 mg, 360 mg,
420 mg
dilt-xr oral capsule,ext release degradable
120 mg, 180 mg, 240 mg
matzim la oral tablet extended release 24
hr 180 mg, 240 mg, 300 mg, 360 mg, 420
mg
taztia xt oral capsule, extended release
120 mg, 180 mg, 240 mg, 300 mg, 360 mg
verapamil intravenous syringe 2.5 mg/ml
verapamil oral capsule, 24 hr er pellet ct
100 mg, 200 mg, 300 mg
verapamil oral capsule,ext rel. pellets 24
hr 120 mg, 180 mg, 240 mg, 360 mg
verapamil oral tablet 120 mg, 40 mg, 80
mg
verapamil oral tablet extended release 120
mg, 180 mg, 240 mg
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem LA)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Cardizem CD)
$0 (Tier 1)
(Verapamil HCl)
(Verelan Pm)
$0 (Tier 1)
$0 (Tier 1)
(Verelan)
$0 (Tier 1)
(Calan)
$0 (Tier 1)
(Calan SR)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
Cardiovascular Agents,
Miscellaneous
CORLANOR ORAL TABLET 5 MG,
7.5 MG
DEMSER ORAL CAPSULE 250 MG
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
92
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
digitek oral tablet 125 mcg
(Lanoxin)
$0 (Tier 1)
digitek oral tablet 250 mcg
(Lanoxin)
$0 (Tier 1)
digox 125 mcg tablet 125 mcg
(Lanoxin)
$0 (Tier 1)
digox 250 mcg tablet 250 mcg
(Lanoxin)
$0 (Tier 1)
digoxin 0.25 mg/ml syringe 250 mcg/ml
(Digoxin)
$0 (Tier 1)
digoxin injection solution 250 mcg/ml
(Digoxin)
$0 (Tier 1)
DIGOXIN ORAL SOLUTION 50
MCG/ML
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
(High Risk Med for
Ages 65 and Older and
Dose is Greater Than
125mcg Per Day); QL
(30 per 30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days); AGE (Max
64 Years)
(High Risk Med for
Ages 65 and Older and
Dose is Greater Than
125mcg Per Day); QL
(30 per 30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days); AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; QL (300 per
30 days); AGE (Max
64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
93
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
digoxin oral tablet 125 mcg
(Lanoxin)
$0 (Tier 1)
digoxin oral tablet 250 mcg
(Lanoxin)
$0 (Tier 1)
dobutamine in d5w intravenous parenteral
solution 1,000 mg/250 ml (4,000 mcg/ml),
250 mg/250 ml (1 mg/ml), 500 mg/250 ml
(2,000 mcg/ml)
dobutamine intravenous solution 250
mg/20 ml (12.5 mg/ml)
dopamine in 5 % dextrose intravenous
solution 200 mg/250 ml (800 mcg/ml), 400
mg/250 ml (1,600 mcg/ml), 800 mg/250
ml (3,200 mcg/ml)
dopamine intravenous solution 200 mg/5
ml (40 mg/ml), 400 mg/5 ml (80 mg/ml),
800 mg/10 ml (80 mg/ml), 800 mg/5 ml
(160 mg/ml)
ephedrine sulfate injection solution 50
mg/ml
epinephrine hcl (pf) intravenous solution 1
mg/ml (1 ml)
epinephrine injection auto-injector 0.15
mg/0.15 ml, 0.3 mg/0.3 ml
epinephrine injection solution 1 mg/ml (1
ml)
(Dobutamine
HCl/D5W)
$0 (Tier 1)
(High Risk Med for
Ages 65 and Older and
Dose is Greater Than
125mcg Per Day); QL
(30 per 30 days)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days); AGE (Max
64 Years)
PA BvD
(Dobutamine HCl)
$0 (Tier 1)
PA BvD
(Dopamine
HCl/D5W)
$0 (Tier 1)
PA BvD
(Dopamine HCl)
$0 (Tier 1)
PA BvD
(Ephedrine Sulfate)
$0 (Tier 1)
(Epinephrine
HCl/PF)
(Adrenaclick)
$0 (Tier 1)
(Epinephrine)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
94
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
epinephrine injection syringe 0.1 mg/ml
EPIPEN 2-PAK INJECTION
AUTO-INJECTOR 0.3 MG/0.3 ML
EPIPEN INJECTION
AUTO-INJECTOR 0.3 MG/0.3 ML
EPIPEN JR 2-PAK INJECTION
AUTO-INJECTOR 0.15 MG/0.3 ML
ethamolin intravenous solution 5 %
FIRAZYR SUBCUTANEOUS
SYRINGE 30 MG/3 ML
hydralazine injection solution 20 mg/ml
hydralazine oral tablet 10 mg, 100 mg, 25
mg, 50 mg
LANOXIN ORAL TABLET 187.5
MCG
(Epinephrine)
(Ethanolamine
Oleate)
(Hydralazine HCl)
(Hydralazine HCl)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
(Milrinone
Lactate/D5W)
$0 (Tier 1)
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days); AGE (Max
64 Years)
(High Risk Med for
Ages 65 and Older and
Dose is Greater Than
125mcg Per Day); QL
(30 per 30 days)
PA BvD
(Milrinone Lactate)
(Levophed Bitartrate)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
(Papaverine HCl)
$0 (Tier 1)
PA
LANOXIN ORAL TABLET 62.5 MCG
milrinone in 5 % dextrose intravenous
piggyback 20 mg/100 ml (200 mcg/ml), 40
mg/200 ml (200 mcg/ml)
milrinone intravenous solution 1 mg/ml
norepinephrine bitartrate intravenous
solution 1 mg/ml
papaverine injection solution 30 mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
95
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
papaverine oral capsule, extended release
150 mg
RANEXA ORAL TABLET
EXTENDED RELEASE 12 HR 1,000
MG, 500 MG
(Papaverine HCl)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA
$0 - $7.40
(Tier 2)
Dihydropyridines
afeditab cr oral tablet extended release 30
mg, 60 mg
amlodipine oral tablet 10 mg, 2.5 mg, 5
mg
amlodipine-benazepril oral capsule 10-20
mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20
mg, 5-40 mg
amlodipine-valsartan oral tablet 10-160
mg, 10-320 mg, 5-160 mg, 5-320 mg
amlodipine-valsartan-hcthiazid oral tablet
10-160-12.5 mg, 10-160-25 mg, 10-320-25
mg, 5-160-12.5 mg, 5-160-25 mg
AZOR ORAL TABLET 10-20 MG,
10-40 MG, 5-20 MG, 5-40 MG
CLEVIPREX INTRAVENOUS
EMULSION 50 MG/100 ML
felodipine oral tablet extended release 24
hr 10 mg, 2.5 mg, 5 mg
isradipine oral capsule 2.5 mg, 5 mg
nicardipine oral capsule 20 mg, 30 mg
nifedical xl oral tablet extended release
24hr 30 mg, 60 mg
nifedipine er 30 mg tablet f/c 30 mg
nifedipine oral tablet extended release
24hr 30 mg
nifedipine oral tablet extended release
24hr 60 mg, 90 mg
(Adalat CC)
$0 (Tier 1)
(Norvasc)
$0 (Tier 1)
(Lotrel)
$0 (Tier 1)
(Exforge)
$0 (Tier 1)
(Exforge HCT)
$0 (Tier 1)
$0 (Tier 1)
(Felodipine)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Isradipine)
(Nicardipine HCl)
(Procardia XL)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Adalat CC)
(Adalat CC)
$0 (Tier 1)
$0 (Tier 1)
(Procardia XL)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
96
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Diuretics
amiloride oral tablet 5 mg
amiloride-hydrochlorothiazide oral tablet
5-50 mg
bumetanide injection solution 0.25 mg/ml
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg
chlorothiazide oral tablet 250 mg, 500 mg
chlorothiazide sodium intravenous recon
soln 500 mg
chlorthalidone oral tablet 25 mg, 50 mg
DYRENIUM ORAL CAPSULE 100
MG, 50 MG
furosemide injection solution 10 mg/ml
furosemide injection syringe 10 mg/ml
furosemide oral solution 10 mg/ml, 40
mg/5 ml (8 mg/ml)
furosemide oral tablet 20 mg, 40 mg, 80
mg
hydrochlorothiazide oral capsule 12.5 mg
hydrochlorothiazide oral tablet 12.5 mg,
25 mg, 50 mg
indapamide oral tablet 1.25 mg, 2.5 mg
methyclothiazide oral tablet 5 mg
metolazone oral tablet 10 mg, 2.5 mg, 5
mg
torsemide oral tablet 10 mg, 100 mg, 20
mg, 5 mg
triamterene-hydrochlorothiazid oral
capsule 37.5-25 mg, 50-25 mg
triamterene-hydrochlorothiazid oral tablet
37.5-25 mg, 75-50 mg
(Amiloride HCl)
(Amiloride/Hydrochl
orothiazide)
(Bumetanide)
(Bumetanide)
(Chlorothiazide)
(Sodium Diuril)
$0 (Tier 1)
$0 (Tier 1)
(Chlorthalidone)
(Furosemide)
(Furosemide)
(Furosemide)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Lasix)
$0 (Tier 1)
(Microzide)
(Hydrochlorothiazide
)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
$0 (Tier 1)
$0 (Tier 1)
(Demadex)
$0 (Tier 1)
(Dyazide)
$0 (Tier 1)
(Maxzide)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
97
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
Dyslipidemics
amlodipine-atorvastatin oral tablet 10-10 (Caduet)
mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10
mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20
mg, 5-40 mg, 5-80 mg
atorvastatin oral tablet 10 mg, 20 mg, 40 (Lipitor)
mg, 80 mg
cholestyramine light oral powder 4 gram
(Cholestyramine/Asp
artame)
cholestyramine light oral powder in packet (Questran)
4 gram
cholestyramine packet 4 gram
(Questran)
colestipol hcl granules packet 5 gram
(Colestid)
colestipol oral granules 5 gram
(Colestid)
colestipol oral tablet 1 gram
(Colestid)
cvs fish oil 1,200 mg softgel softgel,
(Omega-3 Fatty
natural 360-1,200 mg *
Acids/Fish Oil)
cvs niacin flush free 500 mg 400 mg niacin (Niacin (Inositol
(500 mg) *
Niacinate))
cvs omega-3 gummy fish child, brain
(Omega-3 Fatty
booster 100 mg *
Acids)
endur-acin sr 250 mg tablet 250 mg *
(Slo-Niacin)
endur-acin sr 500 mg tablet 500 mg *
(Slo-Niacin)
eql omega 3 fish oil softgel 684-1,200 mg * (Omega-3 Fatty
Acids/Fish Oil)
fenofibrate micronized oral capsule 130
(Lofibra)
mg, 134 mg, 200 mg, 43 mg, 67 mg
fenofibrate nanocrystallized oral tablet
(Tricor)
145 mg, 48 mg
fenofibrate oral tablet 120 mg, 160 mg, 40 (Lofibra)
mg, 54 mg
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
98
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
fenofibric acid (choline) oral
(Trilipix)
capsule,delayed release(dr/ec) 135 mg, 45
mg
fenofibric acid oral tablet 105 mg, 35 mg
(Fibricor)
fish oil 1,000 mg capsule 340-1,000 mg *
(Omega-3 Fatty
Acids/Fish Oil)
fish oil 1,000 mg softgel 500 mg *
(Omega-3 Fatty
Acids)
fish oil 1,000 mg softgel s/f,na/f, yeast free (Omega-3 Fatty
300-1,000 mg *
Acids/Fish Oil)
fish oil 1,000 mg softgel softgel, s/f, na/f
(Omega-3 Fatty
340-1,000 mg *
Acids/Fish Oil)
fish oil 1,000 mg softgel softgel, s/f, p/f
(Omega-3 Fatty
300-1,000 mg *
Acids/Fish Oil)
fish oil 1,200 mg softgel s/f, gluten-free
(Omega-3 Fatty
360-1,200 mg *
Acids/Fish Oil)
fish oil 500 mg softgel 500-100 mg *
(Salmon Oil/Omega-3
Fatty Acids)
fish oil concentrate softgel softgel,
(Omega-3 Fatty
ex-strengh 435-880 mg *
Acids/Fish Oil)
fish oil dr 1,000 mg softgel 300-1,000 mg * (Omega-3 Fatty
Acids/Fish Oil)
fish oil dr 500 mg softgel 60-90-500 mg * (Omega-3 Fish Oil)
fish oil pearls softgel 150-400 mg, 180-400 (Omega-3 Fatty
mg, 300-400 mg *
Acids/Fish Oil)
gemfibrozil oral tablet 600 mg
(Lopid)
JUXTAPID ORAL CAPSULE 10 MG,
20 MG, 30 MG, 40 MG, 5 MG, 60 MG
KYNAMRO SUBCUTANEOUS
SYRINGE 200 MG/ML
LIVALO ORAL TABLET 1 MG, 2
MG, 4 MG
lovastatin oral tablet 10 mg, 20 mg, 40 mg (Mevacor)
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
PA
PA; QL (4 per 28 days)
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
99
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
maxepa capsule 500 mg *
niacin 100 mg tablet 100 mg *
niacin 125 mg capsule sa (otc) 125 mg *
niacin 250 mg tablet 250 mg *
niacin 250 mg tablet sa p/f,s/f 250 mg *
niacin 400 mg capsule sa 400 mg *
niacin 50 mg caplet 50 mg *
niacin 500 mg capsule sa 500 mg *
niacin 500 mg tablet 500 mg *
niacin 750 mg tablet sa 750 mg *
niacin er 1,000 mg tablet 1,000 mg *
niacin flush-free 500 mg cap s/f,p/f,na/f
400 mg niacin (500 mg) *
niacin inositol 500 mg capsule 400 mg
niacin (500 mg) *
niacin oral tablet extended release 24 hr
1,000 mg, 500 mg, 750 mg
niacin sa 250 mg capsule (otc) 250 mg *
niacin tr 500 mg caplet caplet 500 mg *
niacinamide 500 mg tablet 500 mg *
niacor oral tablet 500 mg
omega 3 fish oil softgel 684-1,200 mg *
(Omega-3 Fatty
Acids)
(Slo-Niacin)
(Niacin)
(Slo-Niacin)
(Slo-Niacin)
(Niacin)
(Slo-Niacin)
(Niacin)
(Slo-Niacin)
(Slo-Niacin)
(Slo-Niacin)
(Niacin (Inositol
Niacinate))
(Niacin (Inositol
Niacinate))
(Niaspan)
$0 (Tier 4)
(Niacin)
(Slo-Niacin)
(Niacinamide)
(Niacin)
(Omega-3 Fatty
Acids/Fish Oil)
(Lovaza)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
omega-3 acid ethyl esters oral capsule 1
gram
omega-3 fish oil 1,760 mg stgl 440-880 mg (Omega-3 Fatty
*
Acids/Fish Oil)
PRALUENT PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML, 75
MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
PA; QL (2 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
100
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
PRALUENT SYRINGE
SUBCUTANEOUS SYRINGE 150
MG/ML, 75 MG/ML
pravastatin oral tablet 10 mg, 20 mg, 40
mg, 80 mg
prevalite oral powder 4 gram
prevalite packet outer 4 gram
ra fish oil 1,000 mg softgel softgel,s/f,p/f
300-500 mg *
ra niacin 500 mg tablet no flush 500 mg *
REPATHA PUSHTRONEX
SUBCUTANEOUS WEARABLE
INJECTOR 420 MG/3.5 ML
REPATHA SURECLICK
SUBCUTANEOUS PEN INJECTOR
140 MG/ML
REPATHA SYRINGE
SUBCUTANEOUS SYRINGE 140
MG/ML
rosuvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
sea-omega 30 capsule p/f,s/f,gluten free
360-1,200 mg *
simvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
simvastatin oral tablet 80 mg
sm fish oil 1,200 mg softgel softgel,
gluten-free 360-1,200 mg *
SUPER TWIN EPA-DHA 1,250 MG
1,250 MG *
$0 - $7.40
(Tier 2)
(Pravachol)
$0 (Tier 1)
(Cholestyramine/Asp
artame)
(Cholestyramine/Asp
artame)
(Omega-3 Fatty
Acids/Fish Oil)
(Niacin (Inositol
Niacinate))
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (2 per 28 days)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
PA; QL (3.5 per 28
days)
$0 - $7.40
(Tier 2)
PA; QL (3 per 28 days)
$0 - $7.40
(Tier 2)
PA; QL (3 per 28 days)
(Crestor)
$0 (Tier 1)
(Omega-3 Fatty
Acids/Fish Oil)
(Zocor)
$0 (Tier 4)
(Zocor)
(Omega-3 Fatty
Acids/Fish Oil)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
QL (30 per 30 days)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
101
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
VASCEPA ORAL CAPSULE 0.5
GRAM, 1 GRAM
WELCHOL ORAL POWDER IN
PACKET 3.75 GRAM
WELCHOL ORAL TABLET 625 MG
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
ZETIA ORAL TABLET 10 MG
Renin-Angiotensin-Aldosteron
e System Inhibitors
eplerenone oral tablet 25 mg, 50 mg
(Inspra)
spironolactone oral tablet 100 mg, 25 mg, (Aldactone)
50 mg
spironolacton-hydrochlorothiaz oral tablet (Aldactazide)
25-25 mg
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Vasodilators
BIDIL ORAL TABLET 20-37.5 MG
isosorbide dinitrate oral tablet 10 mg, 20
mg, 30 mg, 5 mg
isosorbide dinitrate oral tablet extended
release 40 mg
isosorbide dinitrate sublingual tablet 2.5
mg, 5 mg
isosorbide mononitrate oral tablet 10 mg,
20 mg
isosorbide mononitrate oral tablet
extended release 24 hr 120 mg, 30 mg, 60
mg
minitran transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour 0.4
mg/hr
(Isochron)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Isochron)
$0 (Tier 1)
(Isosorbide Dinitrate)
$0 (Tier 1)
(Isosorbide
Mononitrate)
(Imdur)
$0 (Tier 1)
(Nitro-Dur)
$0 (Tier 1)
QL (30 per 30 days)
(Nitro-Dur)
$0 (Tier 1)
QL (60 per 30 days)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
102
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
minoxidil oral tablet 10 mg, 2.5 mg
NITRO-BID TRANSDERMAL
OINTMENT 2 %
nitroglycerin in 5 % dextrose intravenous
solution 100 mg/250 ml (400 mcg/ml), 25
mg/250 ml (100 mcg/ml), 50 mg/250 ml
(200 mcg/ml)
nitroglycerin intravenous solution 50
mg/10 ml (5 mg/ml)
nitroglycerin sublingual tablet 0.3 mg, 0.4
mg, 0.6 mg
nitroglycerin transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
nitroglycerin transdermal patch 24 hour
0.4 mg/hr
NITROSTAT SUBLINGUAL
TABLET 0.3 MG, 0.4 MG, 0.6 MG
PROGLYCEM ORAL SUSPENSION
50 MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
(Minoxidil)
$0 (Tier 1)
$0 (Tier 1)
(Nitroglycerin/D5W)
$0 (Tier 1)
(Nitroglycerin)
$0 (Tier 1)
(Nitrostat)
$0 (Tier 1)
(Nitro-Dur)
$0 (Tier 1)
QL (30 per 30 days)
(Nitro-Dur)
$0 (Tier 1)
QL (60 per 30 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Central Nervous System Agents
Central Nervous System
Agents
AMPYRA ORAL TABLET
EXTENDED RELEASE 12 HR 10 MG
caffeine citrated intravenous solution 60
mg/3 ml (20 mg/ml)
caffeine citrated oral solution 60 mg/3 ml
(20 mg/ml)
caffeine-sodium benzoate injection
solution 250 mg/ml (125 mg/ml caffeine)
clonidine hcl oral tablet extended release
12 hr 0.1 mg
(Cafcit)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Cafcit)
$0 (Tier 1)
(Caffeine/Sodium
Benzoate)
(Kapvay)
$0 (Tier 1)
PA; QL (60 per 30
days)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
103
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
dexmethylphenidate oral tablet 10 mg, 2.5
mg, 5 mg
dextroamphetamine oral capsule, extended
release 10 mg, 15 mg, 5 mg
dextroamphetamine oral tablet 10 mg, 5
mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 5 mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 20 mg, 25
mg, 30 mg
dextroamphetamine-amphetamine oral
tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30
mg, 5 mg, 7.5 mg
flumazenil intravenous solution 0.1 mg/ml
guanfacine oral tablet extended release 24
hr 1 mg, 2 mg, 3 mg, 4 mg
lithium carbonate oral capsule 150 mg,
300 mg, 600 mg
lithium carbonate oral tablet 300 mg
lithium carbonate oral tablet extended
release 300 mg, 450 mg
lithium citrate oral solution 8 meq/5 ml
lomaira 8 mg tablet 8 mg *
(Focalin)
$0 (Tier 1)
QL (60 per 30 days)
(Dexedrine)
$0 (Tier 1)
QL (120 per 30 days)
(Dexedrine)
$0 (Tier 1)
QL (180 per 30 days)
(Adderall XR)
$0 (Tier 1)
QL (30 per 30 days)
(Adderall XR)
$0 (Tier 1)
QL (60 per 30 days)
(Adderall)
$0 (Tier 1)
QL (60 per 30 days)
(Romazicon)
(Intuniv)
$0 (Tier 1)
$0 (Tier 1)
(Lithium Carbonate)
$0 (Tier 1)
(Lithobid)
(Lithobid)
$0 (Tier 1)
$0 (Tier 1)
(Lithium Citrate)
(Adipex-P)
$0 (Tier 1)
$0 (Tier 3)
methylphenidate cd 20 mg cap 20 mg
methylphenidate cd 40 mg cap 40 mg
methylphenidate oral capsule, er biphasic
30-70 10 mg, 50 mg, 60 mg
methylphenidate oral capsule, er biphasic
30-70 30 mg
methylphenidate oral capsule,er biphasic
50-50 20 mg, 40 mg
(Metadate Cd)
(Metadate Cd)
(Metadate Cd)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (90 per 30
days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Metadate Cd)
$0 (Tier 1)
QL (60 per 30 days)
(Metadate Cd)
$0 (Tier 1)
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
104
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
methylphenidate oral solution 10 mg/5 ml,
5 mg/5 ml
methylphenidate oral tablet 10 mg, 20 mg,
5 mg
methylphenidate oral tablet extended
release 10 mg, 20 mg
methylphenidate oral tablet extended
release 24hr 18 mg, 27 mg, 54 mg
methylphenidate oral tablet extended
release 24hr 36 mg
NUEDEXTA ORAL CAPSULE 20-10
MG
phentermine 15 mg capsule 15 mg *
(Methylin)
$0 (Tier 1)
QL (900 per 30 days)
(Ritalin)
$0 (Tier 1)
QL (90 per 30 days)
(Methylphenidate
HCl)
(Concerta)
$0 (Tier 1)
QL (90 per 30 days)
$0 (Tier 1)
QL (30 per 30 days)
(Concerta)
$0 (Tier 1)
QL (60 per 30 days)
QL (60 per 30 days)
(Adipex-P)
$0 - $7.40
(Tier 2)
$0 (Tier 3)
phentermine 30 mg capsule pelletized 30
mg *
phentermine 37.5 mg capsule 37.5 mg *
(Adipex-P)
$0 (Tier 3)
(Adipex-P)
$0 (Tier 3)
phentermine 37.5 mg tablet 37.5 mg *
(Adipex-P)
$0 (Tier 3)
QUILLIVANT XR ORAL
SUSPENSION,EXT REL
24HR,RECON 5 MG/ML (25 MG/5
ML)
riluzole oral tablet 50 mg
SAVELLA ORAL TABLET 100 MG,
12.5 MG, 25 MG, 50 MG
SAVELLA ORAL TABLETS,DOSE
PACK 12.5 MG (5)-25 MG(8)-50
MG(42)
STRATTERA ORAL CAPSULE 10
MG, 100 MG, 18 MG, 25 MG, 40 MG,
60 MG, 80 MG
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
$0 - $7.40
(Tier 2)
(Rilutek)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (60 per 30 days)
QL (60 per 30 days)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
105
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
tetrabenazine oral tablet 12.5 mg, 25 mg
Necessary Actions,
Restrictions, or
Limits on Use
(Xenazine)
$0 (Tier 1)
PA; QL (112 per 28
days)
(Amethyst)
(Modicon)
(Modicon)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Seasonique)
$0 (Tier 1)
QL (91 per 84 days)
(Seasonique)
$0 (Tier 1)
QL (91 per 84 days)
(Desogen)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
(Seasonique)
$0 (Tier 1)
(Amethyst)
(Amethyst)
(Mircette)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Modicon)
(Mircette)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Modicon)
(Nor-Q-D)
$0 (Tier 1)
$0 (Tier 1)
Contraceptives
Contraceptives
AIMSCO LATEX CONDOM *
altavera (28) oral tablet 0.15-0.03 mg
alyacen 1/35 (28) oral tablet 1-35 mg-mcg
alyacen 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
amethia lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
amethia oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
apri oral tablet 0.15-0.03 mg
aranelle (28) oral tablet 0.5/1/0.5-35
mg-mcg
ashlyna oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
aubra oral tablet 0.1-20 mg-mcg
aviane oral tablet 0.1-20 mg-mcg
azurette (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
balziva (28) oral tablet 0.4-35 mg-mcg
bekyree (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
blisovi 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
blisovi fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
briellyn oral tablet 0.4-35 mg-mcg
camila oral tablet 0.35 mg
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
106
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
camrese lo oral tablets,dose pack,3 month
0.10 mg-20 mcg (84)/10 mcg (7)
camrese oral tablets,dose pack,3 month
0.15 mg-30 mcg (84)/10 mcg (7)
caziant (28) oral tablet 0.1/.125/.15-25
mg-mcg
CONDOMS LUBRICATED *
cryselle (28) oral tablet 0.3-30 mg-mcg
cyclafem 1/35 (28) oral tablet 1-35
mg-mcg
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
cyred oral tablet 0.15-0.03 mg
dasetta 1/35 (28) oral tablet 1-35 mg-mcg
dasetta 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
daysee oral tablets,dose pack,3 month 0.15
mg-30 mcg (84)/10 mcg (7)
deblitane oral tablet 0.35 mg
delyla (28) oral tablet 0.1-20 mg-mcg
desog-e.estradiol/e.estradiol oral tablet
0.15-0.02 mgx21 /0.01 mg x 5
desogestrel-ethinyl estradiol oral tablet
0.15-0.03 mg
drospirenone-ethinyl estradiol oral tablet
3-0.02 mg, 3-0.03 mg
econtra ez 1.5 mg tablet inner 1.5 mg *
elinest oral tablet 0.3-30 mg-mcg
(Seasonique)
$0 (Tier 1)
QL (91 per 84 days)
(Seasonique)
$0 (Tier 1)
QL (91 per 84 days)
(Desogen)
$0 (Tier 1)
(Norgestrel-Ethinyl
Estradiol)
(Modicon)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Modicon)
$0 (Tier 1)
(Desogen)
(Modicon)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Seasonique)
$0 (Tier 1)
(Nor-Q-D)
(Amethyst)
(Mircette)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Desogen)
$0 (Tier 1)
(Yaz)
$0 (Tier 1)
(Aftera)
(Norgestrel-Ethinyl
Estradiol)
$0 (Tier 4)
$0 (Tier 1)
QL (6 per 365 days)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
QL (6 per 365 days)
ELLA ORAL TABLET 30 MG
emoquette oral tablet 0.15-0.03 mg
Necessary Actions,
Restrictions, or
Limits on Use
(Desogen)
QL (91 per 84 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
107
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
enpresse oral tablet 50-30 (6)/75-40
(5)/125-30(10)
enskyce oral tablet 0.15-0.03 mg
errin oral tablet 0.35 mg
estarylla oral tablet 0.25-35 mg-mcg
fallback solo 1.5 mg tablet inner 1.5 mg *
falmina (28) oral tablet 0.1-20 mg-mcg
FANTASY CONDOM *
femynor oral tablet 0.25-35 mg-mcg
gianvi (28) oral tablet 3-0.02 mg
gildagia oral tablet 0.4-35 mg-mcg
gildess 1.5/30 (21) oral tablet 1.5-30
mg-mcg
gildess 1/20 (21) oral tablet 1-20 mg-mcg
gildess 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
gildess fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
gildess fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
GYNOL II 3% GEL 3 % *
heather oral tablet 0.35 mg
introvale oral tablets,dose pack,3 month
0.15 mg-30 mcg
jencycla oral tablet 0.35 mg
jolessa oral tablets,dose pack,3 month 0.15
mg-30 mcg
jolivette oral tablet 0.35 mg
juleber oral tablet 0.15-0.03 mg
junel 1.5/30 (21) oral tablet 1.5-30
mg-mcg
junel 1/20 (21) oral tablet 1-20 mg-mcg
(Amethyst)
$0 (Tier 1)
(Desogen)
(Nor-Q-D)
(Ortho-Cyclen)
(Aftera)
(Amethyst)
(Ortho-Cyclen)
(Yaz)
(Modicon)
(Loestrin)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Nor-Q-D)
(Levonorgestrel-Ethi
n Estradiol)
(Nor-Q-D)
(Levonorgestrel-Ethi
n Estradiol)
(Nor-Q-D)
(Desogen)
(Loestrin)
(Loestrin)
Necessary Actions,
Restrictions, or
Limits on Use
QL (6 per 365 days)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
QL (91 per 84 days)
$0 (Tier 1)
$0 (Tier 1)
QL (91 per 84 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
108
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
junel fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
junel fe 1/20 (28) oral tablet 1 mg-20 mcg
(21)/75 mg (7)
junel fe 24 oral tablet 1 mg-20 mcg
(24)/75 mg (4)
kariva (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
kelnor 1/35 (28) oral tablet 1-35 mg-mcg
kimidess (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
KIMONO CONDOMS *
KIMONO MAXX CONDOM *
KIMONO MICROTHIN AQUA LUBE
*
KIMONO MICROTHIN CONDOM *
KIMONO MICROTHIN LARGE
CONDOM *
KIMONO TEXTURED CONDOM *
kurvelo oral tablet 0.15-0.03 mg
l norgest/e.estradiol-e.estrad oral
tablets,dose pack,3 month 0.10 mg-20 mcg
(84)/10 mcg (7), 0.15 mg-30 mcg (84)/10
mcg (7)
larin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
larin 1/20 (21) oral tablet 1-20 mg-mcg
larin 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
larin fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
larin fe 1/20 (28) oral tablet 1 mg-20 mcg
(21)/75 mg (7)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Mircette)
$0 (Tier 1)
(Demulen 1-50-21)
(Mircette)
$0 (Tier 1)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Amethyst)
(Seasonique)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin)
$0 (Tier 1)
(Loestrin)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
QL (91 per 84 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
109
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
larissia oral tablet 0.1-20 mg-mcg
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg
lessina oral tablet 0.1-20 mg-mcg
levonest (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
levonor-eth estrad 0.15-0.03 outer
0.15-0.03 mg
levonorgestrel 1.5 mg tablet (otc) 1.5 mg
*
levonorgestrel oral tablet 0.75 mg
levonorgestrel oral tablet 1.5 mg
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month 0.15 mg-30 mcg
levonorg-eth estrad triphasic oral tablet
50-30 (6)/75-40 (5)/125-30(10)
levora-28 oral tablet 0.15-0.03 mg
lomedia 24 fe oral tablet 1 mg-20 mcg
(24)/75 mg (4)
loryna (28) oral tablet 3-0.02 mg
low-ogestrel (28) oral tablet 0.3-30
mg-mcg
lutera (28) oral tablet 0.1-20 mg-mcg
lyza oral tablet 0.35 mg
marlissa oral tablet 0.15-0.03 mg
microgestin 1.5/30 (21) oral tablet 1.5-30
mg-mcg
microgestin 1/20 (21) oral tablet 1-20
mg-mcg
microgestin fe 1.5/30 (28) oral tablet 1.5
mg-30 mcg (21)/75 mg (7)
Necessary Actions,
Restrictions, or
Limits on Use
(Amethyst)
(Modicon)
(Amethyst)
(Amethyst)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Amethyst)
$0 (Tier 1)
QL (91 per 84 days)
(Aftera)
$0 (Tier 4)
QL (6 per 365 days)
(Plan B One-Step)
(Plan B One-Step)
(Amethyst)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (12 per 365 days)
QL (6 per 365 days)
(Amethyst)
$0 (Tier 1)
QL (91 per 84 days)
(Amethyst)
$0 (Tier 1)
QL (91 per 84 days)
(Amethyst)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
(Amethyst)
(Nor-Q-D)
(Amethyst)
(Loestrin)
$0 (Tier 1)
$0 (Tier 1)
(Loestrin)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
110
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
microgestin fe 1/20 (28) oral tablet 1
mg-20 mcg (21)/75 mg (7)
mono-linyah oral tablet 0.25-35 mg-mcg
mononessa (28) oral tablet 0.25-35
mg-mcg
my way 1.5 mg tablet (otc) 1.5 mg *
myzilra oral tablet 50-30 (6)/75-40
(5)/125-30(10)
necon 0.5/35 (28) oral tablet 0.5-35
mg-mcg
necon 1/35 (28) oral tablet 1-35 mg-mcg
necon 1/50 (28) oral tablet 1-50 mg-mcg
necon 10/11 (28) oral tablet 0.5-35/1-35
mg-mcg/mg-mcg
necon 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
next choice one dose 1.5 mg tb (otc) 1.5
mg *
next choice one dose oral tablet 1.5 mg
nikki (28) oral tablet 3-0.02 mg
nora-be oral tablet 0.35 mg
norethindrone (contraceptive) oral tablet
0.35 mg
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg
norethindrone-e.estradiol-iron oral tablet 1
mg-20 mcg (24)/75 mg (4)
norg-ee 0.18-0.215-0.25/0.035 3x28 day
regimen 0.18/0.215/0.25 mg-35 mcg (28)
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-25 mcg, 0.25-35
mg-mcg
norlyroc oral tablet 0.35 mg
Necessary Actions,
Restrictions, or
Limits on Use
(Loestrin Fe)
$0 (Tier 1)
(Ortho-Cyclen)
(Ortho-Cyclen)
$0 (Tier 1)
$0 (Tier 1)
(Aftera)
(Amethyst)
$0 (Tier 4)
$0 (Tier 1)
(Modicon)
$0 (Tier 1)
(Modicon)
(Norinyl 1+50)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Modicon)
$0 (Tier 1)
(Aftera)
$0 (Tier 4)
QL (6 per 365 days)
(Plan B One-Step)
(Yaz)
(Nor-Q-D)
(Nor-Q-D)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (6 per 365 days)
(Loestrin)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Nor-Q-D)
$0 (Tier 1)
QL (6 per 365 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
111
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
nortrel 0.5/35 (28) oral tablet 0.5-35
mg-mcg
nortrel 1/35 (21) oral tablet 1-35 mg-mcg
nortrel 1/35 (28) oral tablet 1-35 mg-mcg
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1
mg- 35 mcg
NUVARING VAGINAL RING
0.12-0.015 MG/24 HR
ocella oral tablet 3-0.03 mg
ogestrel (28) oral tablet 0.5-50 mg-mcg
opcicon one-step 1.5 mg tablet 1.5 mg *
option 2 1.5 mg tablet 1.5 mg *
orsythia oral tablet 0.1-20 mg-mcg
philith oral tablet 0.4-35 mg-mcg
pimtrea (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
pirmella oral tablet 0.5/0.75/1 mg- 35 mcg,
1-35 mg-mcg
portia oral tablet 0.15-0.03 mg
previfem oral tablet 0.25-35 mg-mcg
quasense oral tablets,dose pack,3 month
0.15 mg-30 mcg
react 1.5 mg tablet 1.5 mg *
reclipsen (28) oral tablet 0.15-0.03 mg
setlakin oral tablets,dose pack,3 month
0.15 mg-30 mcg
sharobel oral tablet 0.35 mg
sprintec (28) oral tablet 0.25-35 mg-mcg
sronyx oral tablet 0.1-20 mg-mcg
syeda oral tablet 3-0.03 mg
tarina fe 1/20 (28) oral tablet 1 mg-20
mcg (21)/75 mg (7)
(Modicon)
$0 (Tier 1)
(Modicon)
(Modicon)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Yaz)
(Norgestrel-Ethinyl
Estradiol)
(Aftera)
(Aftera)
(Amethyst)
(Modicon)
(Mircette)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
ST; QL (1 per 28 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (6 per 365 days)
QL (6 per 365 days)
(Modicon)
$0 (Tier 1)
(Amethyst)
(Ortho-Cyclen)
(Levonorgestrel-Ethi
n Estradiol)
(Aftera)
(Desogen)
(Levonorgestrel-Ethi
n Estradiol)
(Nor-Q-D)
(Ortho-Cyclen)
(Amethyst)
(Yaz)
(Loestrin Fe)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
QL (91 per 84 days)
QL (6 per 365 days)
QL (91 per 84 days)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
112
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
tilia fe oral tablet 1-20(5)/1-30(7)
/1mg-35mcg (9)
tri-estarylla oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-legest fe oral tablet 1-20(5)/1-30(7)
/1mg-35mcg (9)
tri-linyah oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-lo-estarylla oral tablet 0.18/0.215/0.25
mg-25 mcg
tri-lo-marzia oral tablet 0.18/0.215/0.25
mg-25 mcg
tri-lo-sprintec oral tablet 0.18/0.215/0.25
mg-25 mcg
trinessa (28) oral tablet 0.18/0.215/0.25
mg-35 mcg (28)
tri-previfem (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
tri-sprintec (28) oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
trivora (28) oral tablet 50-30 (6)/75-40
(5)/125-30(10)
TRUSTEX CONDOM *
TRUSTEX CONDOM 12'S,EXTRA
STRENGTH *
TRUSTEX LATEX CONDOM 12'S *
TRUSTEX-RIA CONDOM
12'S,W/SPERMICIDE *
TRUSTEX-RIA CONDOM
48'S,NON-LUBRICATED *
vcf contraceptive foam 12.5 % *
velivet triphasic regimen (28) oral tablet
0.1/.125/.15-25 mg-mcg
vestura (28) oral tablet 3-0.02 mg
(Loestrin Fe)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Loestrin Fe)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Ortho-Cyclen)
$0 (Tier 1)
(Amethyst)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Nonoxynol 9)
(Desogen)
$0 (Tier 4)
$0 (Tier 1)
(Yaz)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
113
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
vienva oral tablet 0.1-20 mg-mcg
viorele (28) oral tablet 0.15-0.02 mgx21
/0.01 mg x 5
vyfemla (28) oral tablet 0.4-35 mg-mcg
wera (28) oral tablet 0.5-35 mg-mcg
WIDE SEAL DIAPHRAGM 70MM 70
MM *
xulane transdermal patch weekly 150-35
mcg/24 hr
zarah oral tablet 3-0.03 mg
zenchent (28) oral tablet 0.4-35 mg-mcg
zovia 1/35e (28) oral tablet 1-35 mg-mcg
zovia 1/50e (28) oral tablet 1-50 mg-mcg
(Amethyst)
(Mircette)
$0 (Tier 1)
$0 (Tier 1)
(Modicon)
(Modicon)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 3)
(Ortho Evra)
$0 (Tier 1)
(Yaz)
(Modicon)
(Demulen 1-50-21)
(Demulen 1-50-21)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
QL (3 per 28 days)
Cough And Cold Products
Cough And Cold Products
adult wal-tussin liquid 100 mg/5 ml *
(Robitussin
Mucus-Chest
Congest)
benzonatate 100 mg capsule 100 mg *
(Zonatuss)
benzonatate 150 mg capsule 150 mg *
(Zonatuss)
benzonatate 200 mg capsule 200 mg *
(Zonatuss)
cheratussin ac syrup (otc) 10-100 mg/5 ml (M-Clear Wc)
*
children's silfedrine liq 15 mg/5 ml *
(Pseudoephedrine
HCl)
childs sudafed 15 mg/5 ml liq
(Pseudoephedrine
non-drowsy,a/f,s/f 15 mg/5 ml *
HCl)
chl mucinex chest congest liq a/f 100 mg/5 (Robitussin
ml *
Mucus-Chest
Congest)
cvs child's chest congest liq 100 mg/5 ml * (Robitussin
Mucus-Chest
Congest)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
114
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
diabetic tussin ex liquid a/f,d/f,na/f,s/f 100 (Robitussin
mg/5 ml *
Mucus-Chest
Congest)
expectorant 100 mg/5 ml syrup 100 mg/5 (Robitussin
ml *
Mucus-Chest
Congest)
liquituss gg 200 mg/5 ml liq 200 mg/5 ml * (Robitussin
Mucus-Chest
Congest)
mar-cof cg liquid 7.5-225 mg/5 ml *
(M-Clear Wc)
nasal-sinus decongest tab 30 mg *
(Sudafed 12-Hour)
$0 (Tier 4)
ninjacof-xg liquid 8-200 mg/5 ml *
(M-Clear Wc)
phenylhistine dh liquid (otc) 2-30-10 mg/5 (P-Ephed
ml *
HCl/Cod/Chlorpheni
r)
promethazine vc-codeine syrup 6.25-5-10 (Promethazine/Pheny
mg/5 ml *
leph/Codeine)
promethazine-codeine syrup 6.25-10 mg/5 (Promethazine
ml *
HCl/Codeine)
promethazine-dm syrup 6.25-15 mg/5 ml * (Promethazine/Dextr
omethorphan)
pseudoephed 30 mg/5 ml soln 30 mg/5 ml * (Pseudoephedrine
HCl)
pseudoephedrine 30 mg tablet 30 mg *
(Sudafed 12-Hour)
$0 (Tier 3)
$0 (Tier 4)
pseudoephedrine 60 mg tablet ex-str, non
drowsy (otc) 60 mg *
q-tussin 100 mg/5 ml solution a/f,
non-drowsy 100 mg/5 ml *
relcof c liquid 6.3-100 mg/5 ml *
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
(Sudafed 12-Hour)
$0 (Tier 4)
(Robitussin
Mucus-Chest
Congest)
(M-Clear Wc)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
115
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
robafen 100 mg/5 ml syrup 100 mg/5 ml *
(Robitussin
Mucus-Chest
Congest)
scot-tussin 100 mg/5 ml liq 100 mg/5 ml * (Robitussin
Mucus-Chest
Congest)
siltussin sa 100 mg/5 ml syr 100 mg/5 ml * (Robitussin
Mucus-Chest
Congest)
sm adult nasal decongestant lq 15 mg/5 ml (Pseudoephedrine
*
HCl)
sudafed 30 mg tablet non-drowsy,max-str (Sudafed 12-Hour)
30 mg *
sudogest 30 mg tablet boxed 30 mg *
(Sudafed 12-Hour)
$0 (Tier 4)
sudogest 60 mg tablet 60 mg *
(Sudafed 12-Hour)
$0 (Tier 4)
(Pseudoephedrine
HCl)
trymine cg liquid 7.5-225 mg/5 ml *
(M-Clear Wc)
valu-tapp decongestant drop 7.5 mg/0.8 ml (Pseudoephedrine
*
HCl)
virtussin ac liquid 10-100 mg/5 ml *
(M-Clear Wc)
wal-phed 30 mg tablet non-drowsy 30 mg * (Sudafed 12-Hour)
$0 (Tier 4)
zephrex-d 30 mg tablet 30 mg *
(Sudafed 12-Hour)
$0 (Tier 4)
(Evoxac)
(Peridex)
$0 (Tier 1)
$0 (Tier 1)
suphedrin liquid 15 mg/5 ml *
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
PA; AGE (Min 2
Years)
Dental And Oral Agents
Dental And Oral Agents
cevimeline oral capsule 30 mg
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
116
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
dry mouth mouthwash a/f, mint flavor *
oralone dental paste 0.1 %
(Saliva Substitute
Combo No.7)
(Triamcinolone
Acetonide)
(Peridex)
periogard mucous membrane mouthwash
0.12 %
pilocarpine hcl oral tablet 5 mg, 7.5 mg
(Salagen)
triamcinolone acetonide dental paste 0.1 % (Triamcinolone
Acetonide)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Dermatological Agents
Dermatological Agents, Other
8-MOP ORAL CAPSULE 10 MG
acitretin oral capsule 10 mg, 17.5 mg, 25
mg
acne & blackhead 2.5% gel 2.5 % *
acne foaming 10% wash 10 % *
acne medication 5% gel 5 % *
ACNE MEDICATION 5% LOTION 5
%*
acneclear gel 10 % *
acyclovir topical ointment 5 %
ALCOHOL PADS TOPICAL PADS,
MEDICATED
ALCOHOL PREP PADS
ammonium lactate topical cream 12 %
ammonium lactate topical lotion 12 %
ANACAINE TOPICAL OINTMENT
10 %
benzoyl peroxide 10% gel aqueous (otc)
10 % *
benzoyl peroxide 2.5% gel (otc) 2.5 % *
benzoyl peroxide 3% cleanser (otc) 3 % *
(Soriatane)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Benzoyl Peroxide)
(Bp Wash)
(Benzoyl Peroxide)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Benzoyl Peroxide)
(Zovirax)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Benzoyl Peroxide)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
(Benzoyl Peroxide)
(Bp Wash)
$0 (Tier 4)
$0 (Tier 4)
(Lac-Hydrin)
(Lac-Hydrin)
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
117
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
benzoyl peroxide 5% gel aqueous (otc) 5
%*
benzoyl peroxide 5% wash (otc) 5 % *
benzoyl peroxide 6% cleanser (otc) 6 % *
benzoyl peroxide 9% cleanser (otc) 9 % *
calamine lotion 8-8 % *
(Benzoyl Peroxide)
$0 (Tier 4)
(Bp Wash)
(Bp Wash)
(Bp Wash)
(Calamine/Zinc
Oxide)
(Calcipotriene)
(Dovonex)
(Calcipotriene)
(Calcipotriene)
(Vectical)
(Benzoyl Peroxide)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
COSENTYX (150 MG/ML) 300 MG
DOSE-2 PENS 150 MG/ML
COSENTYX (150 MG/ML) 300 MG
DOSE-2 SYRINGES 150 MG/ML
COSENTYX PEN SUBCUTANEOUS
PEN INJECTOR 150 MG/ML
COSENTYX SUBCUTANEOUS
SYRINGE 150 MG/ML
cvs acne foaming face 10% wash 10 % *
cvs adv exfoliating 5% cleansr 5 % *
elta tar 2% ointment 2 % *
fluorouracil topical cream 0.5 %, 5 %
fluorouracil topical solution 2 %, 5 %
ichthammol 20% ointment 20 % *
imiquimod topical cream in packet 5 %
(Bp Wash)
(Bp Wash)
(Coal Tar)
(Carac)
(Fluorouracil)
(Ichthammol)
(Aldara)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
methoxsalen rapid oral capsule 10 mg
mg217 psoriasis ointment 2 % *
(Oxsoralen-Ultra)
(Coal Tar)
$0 (Tier 1)
$0 (Tier 4)
calcipotriene scalp solution 0.005 %
calcipotriene topical cream 0.005 %
calcipotriene topical ointment 0.005 %
calcitrene topical ointment 0.005 %
calcitriol topical ointment 3 mcg/gram
clearasil daily clear 10% crm 10 % *
CONDYLOX TOPICAL GEL 0.5 %
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
PA
PA
PA NSO; QL (24 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
118
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
panoxyl 10% acne foaming wash 10 % *
panoxyl-4 acne creamy wash 4 % *
PANRETIN TOPICAL GEL 0.1 %
(Bp Wash)
(Bp Wash)
persa-gel 10% 12's,max-strength 10 % *
PICATO TOPICAL GEL 0.015 %
(Benzoyl Peroxide)
PICATO TOPICAL GEL 0.05 %
podocon topical liquid 25 %
podofilox topical solution 0.5 %
potassium hydroxide topical solution 5 %
pub calamine lotion *
pv acne pimple 10% gel 10 % *
ra scalp itch-dandruff rel liq 3 % *
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM
TALTZ AUTOINJECTOR
SUBCUTANEOUS AUTO-INJECTOR
80 MG/ML
TALTZ SYRINGE SUBCUTANEOUS
SYRINGE 80 MG/ML
TOLAK TOPICAL CREAM 4 %
(Podophyllum Resin)
(Condylox)
(Potassium
Hydroxide)
(Calamine/Zinc
Oxide)
(Benzoyl Peroxide)
(Salicylic Acid)
VALCHLOR TOPICAL GEL 0.016 %
zenatane oral capsule 10 mg, 20 mg, 30
mg, 40 mg
ZOVIRAX TOPICAL CREAM 5 %
(Isotretinoin)
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
QL (3 per 56 days)
QL (2 per 56 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
PA
$0 - $7.40
(Tier 2)
QL (15 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
119
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Dermatological Antibacterials
bacitracin 500 unit/gm ointmnt 500
unit/gram *
bacitracin-polymyxin ointment 500-10,000
unit/gram *
bacitraycin plus 500 unit/gm 500
unit/gram *
clindamycin phosphate topical gel 1 %
clindamycin phosphate topical lotion 1 %
clindamycin phosphate topical solution 1
%
clindamycin phosphate topical swab 1 %
cvs antibiotic plus cream 3.5-10,000-10
mg-unit-mg/gram *
ery pads topical swab 2 %
(Bacitracin)
$0 (Tier 4)
(Bacitracin/Polymyxi
n B Sulfate)
(Bacitracin)
$0 (Tier 4)
(Cleocin T)
(Cleocin T)
(Cleocin T)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Cleocin T)
(Neomycin Su/Plymx
B Su/Pram)
(Erythromycin
Base/Ethanol)
erythromycin with ethanol topical gel 2 % (Erygel)
erythromycin with ethanol topical solution (Erythromycin
2%
Base/Ethanol)
erythromycin with ethanol topical swab 2 (Erythromycin
%
Base/Ethanol)
gentamicin topical cream 0.1 %
(Gentamicin Sulfate)
gentamicin topical ointment 0.1 %
(Gentamicin Sulfate)
metronidazole topical cream 0.75 %
(Metrocream)
metronidazole topical gel 0.75 %, 1 %
(Rosadan)
metronidazole topical lotion 0.75 %
(Metrolotion)
multi antibiotic plus cream 3.5-10,000-10 (Neomycin Su/Plymx
mg-unit-mg/gram *
B Su/Pram)
mupirocin calcium topical cream 2 %
(Bactroban)
mupirocin topical ointment 2 %
(Centany)
neomycin-polymyxin b gu irrigation
(Neosporin G.U.
solution 40 mg-200,000 unit/ml
Irrigant)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
120
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
neosporin + pain relief cream maximum
strength 3.5-10,000-10 mg-unit-mg/gram *
polysporin ointment (otc) 500-10,000
unit/gram *
rosadan topical cream 0.75 %
selenium sulfide topical lotion 2.5 %
selenium sulfide topical shampoo 2.25 %
silver nitrate topical ointment 10 %
silver nitrate topical solution 0.5 %, 10 %,
25 %, 50 %
silver sulfadiazine topical cream 1 %
ssd topical cream 1 %
sulfacetamide sodium (acne) topical
suspension 10 %
(Neomycin Su/Plymx
B Su/Pram)
(Bacitracin/Polymyxi
n B Sulfate)
(Metrocream)
(Selenium Sulfide)
(Selenium Sulfide)
(Silver Nitrate)
(Silver Nitrate)
$0 (Tier 4)
(Silvadene)
(Silvadene)
(Klaron)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Dermatological
Anti-Inflammatory Agents
(Anusol-HC)
(Scalacort)
(Alclometasone
Dipropionate)
alclometasone topical ointment 0.05 %
(Alclometasone
Dipropionate)
aquanil hc 1% lotion 1 % *
(Cortizone-10)
beta hc 1% lotion 1 % *
(Cortizone-10)
betamethasone dipropionate topical cream (Betamethasone
0.05 %
Dipropionate)
betamethasone dipropionate topical lotion (Betamethasone
0.05 %
Dipropionate)
betamethasone dipropionate topical
(Betamethasone
ointment 0.05 %
Dipropionate)
betamethasone valerate topical cream 0.1 (Betamethasone
%
Valerate)
ala-cort topical cream 1 %
ala-scalp topical lotion 2 %
alclometasone topical cream 0.05 %
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
121
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
betamethasone valerate topical foam 0.12
%
betamethasone valerate topical lotion 0.1
%
betamethasone valerate topical ointment
0.1 %
betamethasone, augmented topical cream
0.05 %
betamethasone, augmented topical gel
0.05 %
betamethasone, augmented topical lotion
0.05 %
betamethasone, augmented topical
ointment 0.05 %
clobetasol 0.05% cream 0.05 %
clobetasol scalp solution 0.05 %
(Luxiq)
$0 (Tier 1)
(Betamethasone
Valerate)
(Betamethasone
Valerate)
(Diprolene AF)
$0 (Tier 1)
(Betamethasone
Dipropionate)
(Diprolene)
$0 (Tier 1)
(Diprolene)
$0 (Tier 1)
(Temovate)
(Clobetasol
Propionate)
clobetasol topical foam 0.05 %
(Olux)
clobetasol topical gel 0.05 %
(Clobetasol
Propionate)
clobetasol topical lotion 0.05 %
(Clobex)
clobetasol topical ointment 0.05 %
(Temovate)
clobetasol topical shampoo 0.05 %
(Clobex)
clobetasol-emollient topical cream 0.05 % (Temovate)
clocortolone pivalate topical cream 0.1 % (Cloderm)
colocort rectal enema 100 mg/60 ml
(Cortenema)
cormax scalp solution 0.05 %
(Clobetasol
Propionate)
cortaid 1% cream 12 hr, anti-itch 1 % *
(Hydrocortisone)
cortizone-10 1% creme maximum strength (Hydrocortisone)
1%*
CORTIZONE-10 1% LOTION 1 % *
cortizone-10 1% ointment 1 % *
(Hydrocortisone)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
122
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
cvs hydrocortisone 0.5% crm 0.5 % *
dermarest eczema 1% lotion 1 % *
desonide topical cream 0.05 %
desonide topical ointment 0.05 %
desoximetasone topical cream 0.05 %,
0.25 %
desoximetasone topical gel 0.05 %
desoximetasone topical ointment 0.05 %,
0.25 %
ELIDEL TOPICAL CREAM 1 %
fluocinonide topical cream 0.05 %
fluocinonide topical gel 0.05 %
fluocinonide topical ointment 0.05 %
fluocinonide topical solution 0.05 %
fluticasone topical cream 0.05 %
fluticasone topical ointment 0.005 %
halobetasol propionate topical cream 0.05
%
halobetasol propionate topical ointment
0.05 %
hydro skin 1% lotion 1 % *
hydrocortisone 0.5% cream (otc) 0.5 % *
hydrocortisone 0.5% ointment 0.5 % *
hydrocortisone 1% cream maximum
strength (otc) 1 % *
hydrocortisone 1% cream maximum
strength 1 % *
hydrocortisone 1% lotion (otc) 1 % *
hydrocortisone 1% ointment carton (otc)
1%*
(Hydrocortisone
Acetate)
(Cortizone-10)
(Desowen)
(Desonide)
(Topicort)
$0 (Tier 4)
(Topicort)
(Topicort)
$0 (Tier 1)
$0 (Tier 1)
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Cutivate)
(Fluticasone
Propionate)
(Ultravate)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Ultravate)
$0 (Tier 1)
(Cortizone-10)
(Hydrocortisone)
(Hydrocortisone)
(Hydrocortisone)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Hydrocortisone
Acetate)
(Cortizone-10)
(Hydrocortisone)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
123
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
hydrocortisone acet-aloe vera topical gel 2 (Hydrocortisone
%
Acetate/Aloe V)
hydrocortisone buty 0.1% cream 0.1 %
(Hydrocortisone
Butyrate)
hydrocortisone butyrate topical ointment (Locoid)
0.1 %
hydrocortisone butyrate topical solution
(Locoid)
0.1 %
hydrocortisone butyr-emollient topical
(Hydrocortisone
cream 0.1 %
Butyrate)
hydrocortisone rectal enema 100 mg/60 ml (Cortenema)
hydrocortisone topical cream 1 %, 2.5 %
(Anusol-HC)
hydrocortisone topical lotion 2.5 %
(Scalacort)
hydrocortisone topical ointment 1 %, 2.5
(Hydrocortisone)
%
hydrocortisone valerate topical cream 0.2 (Hydrocortisone
%
Valerate)
hydrocortisone valerate topical ointment
(Westcort)
0.2 %
mometasone topical cream 0.1 %
(Elocon)
mometasone topical ointment 0.1 %
(Elocon)
mometasone topical solution 0.1 %
(Elocon)
neosporin 1% anti-itch cream 1 % *
(Hydrocortisone)
obagi nu-derm tolereen lotion 0.5 % *
(Cortizone-10)
ONFI ORAL TABLET 10 MG, 20 MG
prednicarbate topical cream 0.1 %
prednicarbate topical ointment 0.1 %
preparation h hc 1% cream 1 % *
procto-med hc topical cream with perineal
applicator 2.5 %
procto-pak topical cream with perineal
applicator 1 %
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Dermatop)
(Dermatop)
(Hydrocortisone)
(Hydrocortisone)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
(Hydrocortisone)
$0 (Tier 1)
PA NSO; QL (60 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
124
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
proctosol hc rectal cream 2.5 %
proctosol-hc 2.5% cream 2.5 %
proctozone-hc topical cream with perineal
applicator 2.5 %
recort plus 1% cream 1 % *
tacrolimus topical ointment 0.03 %, 0.1 %
triamcinolone acetonide topical cream
0.025 %, 0.1 %, 0.5 %
triamcinolone acetonide topical lotion
0.025 %, 0.1 %
triamcinolone acetonide topical ointment
0.025 %, 0.1 %, 0.5 %
trianex topical ointment 0.05 %
u-cort topical cream 1-10 %
Necessary Actions,
Restrictions, or
Limits on Use
(Hydrocortisone)
(Hydrocortisone)
(Hydrocortisone)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Hydrocortisone)
(Protopic)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Hydrocortisone
Acetate/Urea)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Differin)
(Differin)
(Retin-A Micro)
(Retin-A Micro)
(Retin-A Micro)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA
PA
PA
(Retin-A)
$0 (Tier 1)
PA
(Retin-A)
$0 (Tier 1)
PA
(Permethrin)
(Permethrin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Dermatological Retinoids
adapalene topical cream 0.1 %
adapalene topical gel 0.1 %
TAZORAC TOPICAL CREAM 0.05 %,
0.1 %
tretinoin gel micro 0.04% tube 0.04 %
tretinoin gel micro 0.1% tube 0.1 %
tretinoin microspheres topical gel with
pump 0.04 %, 0.1 %
tretinoin topical cream 0.025 %, 0.05 %,
0.1 %
tretinoin topical gel 0.01 %, 0.025 %, 0.05
%
Scabicides And Pediculicides
bedding 0.5% spray 0.5 % *
cvs lice bedding spray 0.5 % *
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
125
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
cvs lice killing shampoo maximum
strength 0.33-4 % *
cvs lice solution kit shamp/gel/spray/comb
4-0.33-0.5 % *
cvs permethrin 1% lotion 1 % *
eql lice treatment kit 0.33-4 % *
lice treatment liquid *
malathion topical lotion 0.5 %
NIX 1% CREME RINSE LIQUID W/
NIT COMB 1 % *
permethrin topical cream 5 %
ra lice treatment 1% crm rinse 2x59ml, 2
combs 1 % *
rid lice killing shampoo 0.33-4 % *
rid pediculicides spray 0.5 % *
sm lice treatment permethrin 2's 1 % *
stop lice 0.5% spray 0.5 % *
v-r lice cream rinse 1 % *
(Piperonyl
Butoxide/Pyrethrins)
(Pip
Butox/Pyrethrins/Per
meth)
(Nix)
(Piperonyl
Butoxide/Pyrethrins)
(Piperonyl
Butoxide/Pyrethrins)
(Ovide)
$0 (Tier 4)
(Elimite)
(Nix)
$0 (Tier 1)
$0 (Tier 4)
(Piperonyl
Butoxide/Pyrethrins)
(Permethrin)
(Nix)
(Permethrin)
(Nix)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Devices
Devices
1ST CHOICE SUPER THIN
LANCETS *
1ST TIER COMFORTOUCH 28G
LANCT 28 GAUGE *
1ST TIER COMFORTOUCH 30G
LANCT 30 GAUGE *
ACCU-CHEK ACTIVE TEST STRIP *
ACCU-CHEK AVIVA PLUS TEST
STRP *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
126
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
ACCU-CHEK AVIVA TEST STRIPS
NOT FOR RETAIL SALE *
ACCU-CHEK COMPACT PLUS
STRIPS *
ACCU-CHEK FASTCLIX LANCETS
*
ACCU-CHEK MULTICLIX
LANCETS *
ACCU-CHEK SAFE-T-PRO 23G
LANCT 23 GAUGE *
ACCU-CHEK SAFE-T-PRO PLUS
23G 23 GAUGE *
ACCU-CHEK SMARTVIEW TEST
STRIP *
ACCU-CHEK SOFTCLIX LANCETS
*
ACCUTREND GLUCOSE TEST
STRIP *
ACE AEROSOL CLOUD
ENHANCER *
ACTI-LANCE LITE 28G LANCETS 28
GAUGE *
ACTI-LANCE SPECIAL 17G
LANCETS 17 GAUGE *
ACTI-LANCE UNIVERS 23G
LANCETS 23 GAUGE *
ACURA TEST STRIPS *
ADVANCED TRAVEL 28G
LANCETS 28G,SINGLE-USE,STRL
28 GAUGE *
ADVANCED TRAVEL 30G
LANCETS 30 GAUGE *
ADVOCATE 26G LANCETS 26
G,STERILE 26 GAUGE *
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
127
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
ADVOCATE 26G LANCETS
STERILE 26 GAUGE *
ADVOCATE 30G LANCETS TWIST
TOP 30 GAUGE *
ADVOCATE REDI-CODE TEST
STRIP *
ADVOCATE REDI-CODE+ TEST
STRIP NO CODING *
ADVOCATE TEST STRIP *
AEROCHAMBER MINI 10'S,
LATEX-FREE *
AEROCHAMBER MV HOLD
CHAMBER *
AEROCHAMBER PLUS FLOW-VU *
AEROCHAMBER PLUS FLOW-VU
MED *
AEROCHAMBER PLUS FLOW-VU
MED WITH MASK *
AEROCHAMBER PLUS
W-FLOWSIGNAL *
AEROCHAMBER PLUS Z STAT
MEDIUM 10'S, W/MEDIUM MASK *
AEROCHAMBER Z-STAT PLUS
W-FLOW *
AEROTRACH HOLDING
CHAMBER *
AEROVENT PLUS HOLDING
CHAMBER *
AGAMATRIX AMP TEST STRIPS *
ALTERNATE SITE 26G LANCETS
RECAPPABLE 26 GAUGE *
ASSURE 4 TEST STRIPS *
ASSURE HAEMOLANCE PLUS 18G
18 GAUGE *
What the
drug will
cost you
(Tier level)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
128
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
ASSURE HAEMOLANCE PLUS 21G
21 GAUGE *
ASSURE HAEMOLANCE PLUS 25G
25 GAUGE *
ASSURE HAEMOLANCE PLUS 28G
28 GAUGE *
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
ASSURE LANCE 25G LANCETS 25
GAUGE *
ASSURE LANCE 28G LANCETS 28
GAUGE *
ASSURE LANCE PLUS 21G
LANCETS 21 GAUGE *
ASSURE LANCE PLUS 25G
LANCETS 25 GAUGE *
ASSURE LANCE PLUS 30G
LANCETS 30 GAUGE *
ASSURE PLATINUM TEST STRIPS *
ASSURE PRISM MULTI TEST
STRIPS *
BD 3 ML SYRINGE 25GX1" 3 ML 25
GAUGE X 1" *
BD 3 ML SYRINGE 25GX1-1/2" 3 ML
25 X 1 1/2 " *
BD 3 ML SYRINGE WITH NEEDLE 3
ML 24 X 1", 3 ML 26 X 5/8" *
BD BULK SYRINGE 3 ML 3 ML *
BD ECLIPSE SYRINGE 3 ML 25GX1"
3 ML 25 GAUGE X 1" *
BD INSULIN SYR 0.3 ML 31GX5/16
0.3 ML 31 GAUGE X 5/16
BD INSULIN SYR 0.5 ML 31GX5/16"
0.5 ML 31 GAUGE X 5/16
What the
drug will
cost you
(Tier level)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
129
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
BD INSULIN SYR 1 ML 31GX5/16" 1
ML 31 GAUGE X 5/16
BD INTEGRA SYR 3 ML 25GX5/8" 3
ML 25 GAUGE X 5/8" *
BD INTEGRA SYRINGE 3 ML
25GX1" 3 ML 25 GAUGE X 1" *
BD LANCETS 33G 33 GAUGE *
$0 (Tier 1)
BD LUER-LOK SYR 3 ML 25GX5/8" 3
ML 25 X 5/8" *
BD LUER-LOK SYRINGE 3 ML
LUER-LOK TIP 3 ML *
BD MEDSAVER SYRINGE 3 ML 25
GAUGE X 1", 3 ML 25 X 5/8" *
BD MICROTAINER 21G LANCETS
21 GAUGE *
BD MICROTAINER 30G LANCETS
30 GAUGE *
BD SAFETYGLIDE TB 1 ML SYR 1
ML 27 X 1/2" *
BD SYRINGE 3 ML 3 ML *
BD SYRINGE-SAFETY GLIDE 3 ML
25 X 5/8" *
BD TB SYRINGE 21GX1" 1 ML 21
GAUGE X 1" *
BD TB SYRINGE 22GX1" 1 ML 22 X
1" *
BD TB SYRINGE 25GX5/8" 1 ML 25
GAUGE X 5/8" *
BD TB SYRINGE 26GX3/8" 1 ML 26 X
3/8" *
BD TB SYRINGE 27GX1/2" 1 ML 27 X
1/2" *
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
130
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
BD TB SYRNGE 27GX1/2" 1/2 ML 27
X 1/2 " *
BD TUBERCULIN 1 ML SYRINGE 1
ML *
BD ULTRA-FINE 33G LANCETS 33
GAUGE *
BD ULTRA-FINE II 30G LANCETS
30 GAUGE *
BD ULTRA-FINE PEN NDL
8MMX31G SHORT 31 GAUGE X
5/16"
BG-STAR GLUCOSE TEST STRIPS *
BLOOD GLUCOSE TEST STRIP NO
CODING *
BLOOD GLUCOSE TEST STRIPS *
BLOOD LANCETS 30G EASY TWIST
30 GAUGE *
BREATHERITE MDI SPACER *
BREATHRITE VALVED MDI
SPACER *
BULLSEYE MINI SAFETY 21G 21
GAUGE *
BULLSEYE MINI SAFETY 25G
LANCT 25 GAUGE *
CAREONE THIN LANCET *
$0 (Tier 4)
CARESENS N TEST STRIPS NO
CODING *
CARESENS ULTRA THIN 30G
LANCET 30 GAUGE *
CHOICEDM CLARUS TEST STRIPS
*
CLEVER CHEK ULTRA THIN 30G
30 GAUGE *
$0 (Tier 3)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 1)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 4)
QL (100 per 20 days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
131
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
CLEVER CHOICE CHAMBER-LRG
MASK *
CLEVER CHOICE MICRO TEST
STRIP *
CLEVER CHOICE PRO TEST STRIP
*
CLEVER CHOICE TALK TEST
STRIPS *
CLEVER CHOICE TEST STRIPS
AUTO-CODE *
CLEVER CHOICE VOICE+ TST
STRIP AUTO-CODE *
COAGUCHEK LANCETS *
$0 (Tier 3)
COMFORT EZ SAFETY 21G
LANCETS 21 GAUGE *
COMFORT EZ SAFETY 23G
LANCETS 23 GAUGE *
COMFORT EZ SAFETY 28G
LANCETS 28 GAUGE *
COMFORT LANCETS *
$0 (Tier 4)
COMPACT SPACE CHAMBER *
COMPACT SPACE CHAMBER PLUS
*
CONTOUR NEXT STRIPS *
CONTOUR TEST STRIPS *
$0 (Tier 3)
$0 (Tier 3)
CONTROL AST TEST STRIP *
CONTROL G3 TEST STRIP *
CONTROL TEST STRIPS *
COOL GLUCOSE TEST STRIP *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
132
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
CVS ADVANCED GLUCOSE TEST
STR *
CVS THIN 26G LANCETS 26 GAUGE
*
CVS ULTRA THIN 30G LANCETS 30
GAUGE *
DIATRUE PLUS TEST STRIP *
DROPLET 30G LANCETS 30 GAUGE
*
EASIVENT HOLDING CHAMBER
RETAIL PACK *
EASY COMFORT 30G LANCETS
30G,TWIST TOP,STRL 30 GAUGE *
EASY GLUCO G2 TEST STRIP *
EASY PLUS GLUCOSE TEST STRIP
*
EASY PLUS II TEST STRIPS *
EASY STEP GLUCOSE TEST STRIPS
*
EASY TALK GLUCOSE TEST STRIP
*
EASY TOUCH 28G LANCETS
28G,PULL TOP,STERILE 28 GAUGE
*
EASY TOUCH FLIPLOK 3 ML
25GX5/8 3 ML 25 GAUGE X 5/8" *
EASY TOUCH GLUCOSE TEST
STRIP *
EASY TOUCH SAFETY 21G
LANCETS 21 GAUGE *
EASY TOUCH SAFETY 23G
LANCETS 23 GAUGE *
EASY TOUCH SAFETY 26G
LANCETS 26 GAUGE *
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
133
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
EASY TOUCH SHEATH 3 ML
25GX5/8 3 ML 25 GAUGE X 5/8" *
EASY TOUCH SYR 3 ML 25GX5/8" 3
ML 25 X 5/8" *
EASY TOUCH SYRINGE 3 ML
25GX1" 3 ML 25 GAUGE X 1" *
EASY TOUCH TWIST 28G LANCETS
28 GAUGE *
EASY TOUCH TWIST 30G LANCETS
30 GAUGE *
EASY TOUCH TWIST 32G LANCETS
32 GAUGE *
EASY TOUCH TWIST 33G LANCETS
33 GAUGE *
EASY TRAK GLUCOSE TEST STRIP
*
EASY TWIST & CAP 28G LANCETS
28 GAUGE *
EASYGLUCO PLUS TEST STRIPS *
EASYGLUCO TEST STRIPS *
EASYMAX 15 GLUCOSE TEST
STRIP *
EASYMAX GLUCOSE TEST STRIPS
MEDICAL BENEFIT USE *
ELEMENT COMPACT TEST STRIPS
*
ELEMENT TEST STRIPS *
EMBRACE 30G LANCETS 30
GAUGE *
EMBRACE EVO TEST STRIPS *
EMBRACE PRO TEST STRIPS *
EMBRACE TEST STRIPS *
EVENCARE G2 TEST STRIP *
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 4)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
134
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
EVENCARE G3 TEST STRIP *
EVENCARE GLUCOSE TST STRIPS
*
EVENCARE MINI GLUCOSE TEST
STR *
EVOLUTION TEST STRIPS *
EXEL 3 ML SYRN 27G X 1 1/4" 3 ML
27 GAUGE X 1 1/4" *
EXEL SYRINGE 25GX1" 3 ML 3 ML
25 GAUGE X 1" *
EXEL SYRINGE 25GX5/8" 3 ML 3 ML
25 X 5/8" *
EXEL SYRINGE 3 ML 3 ML *
EXEL TB WITH NEEDLE 25GX5/8" 1
ML 25 GAUGE X 5/8" *
EXEL TB WITH NEEDLE 26GX3/8" 1
ML 26 X 3/8" *
EXEL TB WITH NEEDLE 26GX5/8" 1
ML 26 GAUGE X 5/8" *
EXEL TB WITH NEEDLE 27GX1/2" 1
ML 27 X 1/2" *
EXEL TUBERCULIN SYRINGE 1
ML 1 ML *
E-Z JECT LANCETS *
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 4)
QL (100 per 20 days)
EZ SMART 28G LANCETS 28
GAUGE *
EZ SMART PLUS TEST STRIPS *
EZ SMART TEST STRIPS *
E-Z SPACER *
E-ZJECT COLOR 32G LANCETS 32
GAUGE *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
135
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
E-ZJECT COLOR 33G LANCETS 33
GAUGE *
E-ZJECT SUPER THIN 30G
LANCETS SUPER THIN 30 GAUGE *
FIFTY50 GLUCOSE TEST STRIP *
FIFTY50 SAFETY SEAL 30G
LANCET 30 GAUGE *
FIFTY50 SAFETY SEAL 32G
LANCET 32 GAUGE *
FINE 30 UNIVERSAL 30G LANCETS
30 GAUGE *
FINGERSTIX LANCETS *
$0 (Tier 4)
FLEXICHAMBER *
FORA 30G LANCETS TWIST
OFF,SINGLE USE 30 GAUGE *
FORA BLOOD GLUCOSE TEST
STRIP *
FORA D10 GLUCOSE TEST STRIPS *
FORA D15G GLUCOSE TEST
STRIPS *
FORA D20 GLUCOSE TEST STRIPS *
FORA D40-G31 TEST STRIPS *
FORA G20 GLUCOSE TEST STRIPS *
FORA G30A GLUCOSE TEST STRIP
*
FORA GD50 TEST STRIPS *
FORA TN'G VOICE TEST STRIPS *
FORA V10 GLUCOSE TEST STRIP *
FORA V12 GLUCOSE TEST STRIP *
FORA V20 GLUCOSE TEST STRIPS *
FORA V30A GLUCOSE TEST STRIP
*
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
136
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
FORACARE 30G LANCETS 30
GAUGE *
FORACARE GD20 TEST STRIPS *
FORACARE GD40 GLUCOSE
STRIPS *
FORTISCARE GLUCOSE TEST
STRIPS *
FREESTYLE 28G LANCETS 28
GAUGE *
FREESTYLE INSULINX TEST STRIP
NO CODE *
FREESTYLE INSULINX TEST
STRIPS *
FREESTYLE LITE TEST STRIP *
FREESTYLE LITE TEST STRIPS *
FREESTYLE PREC NEO TEST
STRIPS *
FREESTYLE TEST STRIPS *
FREESTYLE UNISTIK 2 LANCETS *
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 4)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
G-4 TEST STRIPS *
GE100 BLOOD GLUCOSE TEST
STRIP 2 VIALS X 25 STRIPS *
GENSTRIP GLUCOSE TEST STRIP *
GENULTIMATE TEST STRIP *
$0 (Tier 3)
$0 (Tier 3)
GLUCO NAVII GLUCOSE TEST
STRIP *
GLUCOCARD 01 SENSOR PLUS
STRIP *
GLUCOCARD EXPRESSION TEST
STRP *
$0 (Tier 3)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
137
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
GLUCOCARD SHINE TEST STRIPS
*
GLUCOCARD VITAL SENSOR
STRIP *
GLUCOCARD VITAL TEST STRIPS
*
GLUCOCOM 28G LANCETS 28
GAUGE *
GLUCOCOM 30G LANCETS 30
GAUGE *
GLUCOCOM 33G LANCETS 33
GAUGE *
GLUCOCOM GLUCOSE TEST STRIP
*
GLUCOSOURCE LANCETS *
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
GMATE 30G LANCETS 30 GAUGE *
$0 (Tier 4)
GMATE TEST STRIPS *
GNP UNIVERSAL 1 STANDARD
21G 21 GAUGE *
GNP UNIVERSAL 1 SUPER THIN
30G 30 GAUGE *
HEALTHPRO GLUCOSE TEST
STRIPS *
HEALTHY ACCENTS UNILET 30G
30 GAUGE *
INCONTROL SUPER THIN 30G
LANCT 30 GAUGE *
INCONTROL ULTRA THIN 28G
LANCT 28 GAUGE *
INFINITY TEST STRIPS *
INJECT EASE 28G LANCETS 28
GAUGE *
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
138
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
INJECT EASE 30G LANCETS 30
GAUGE *
INSPIRACHAMBER *
INSPIRACHAMBER WITH
MASK-MED *
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 0.3 ML 29 GAUGE, 1 ML
29 GAUGE X 1/2", 1/2 ML 28 GAUGE
INVACARE 30G LANCETS 30
GAUGE *
KINNEY BRAND 23G LANCETS 23
GAUGE *
KRO PREMIUM BLOOD GLUCOSE
TEST NO CODING,PREMIUM *
KRO UNIVERSAL 1 THIN 26G
LANCT 26 GAUGE *
KROGER SUPER THIN LANCETS *
$0 (Tier 4)
LANCETS THIN 23G 23 GAUGE *
$0 (Tier 4)
LANCETS ULTRA THIN 26G 26
GAUGE *
LIBERTY TEST STRIPS BLOOD
GLUCOSE *
LITE TOUCH 30G LANCETS 30
GAUGE *
LITE TOUCH 33G LANCETS 33
GAUGE *
LITEAIRE MDI CHAMBER *
LONGS THIN LANCETS 30G 30G *
$0 (Tier 4)
MAGELLAN TUBERCULIN SYR 1
ML 1 ML 27 GAUGE X 1/2" *
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
139
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
MAJOR COMFORT *
$0 (Tier 4)
MAXIMA TEST STRIP *
MEDI-LANCE LANCETS *
$0 (Tier 3)
$0 (Tier 4)
MEDISENSE THIN 28G LANCETS 28
GAUGE *
MEDLANCE PLUS 21G LANCETS
UNIVERSAL, 1.8MM 21 GAUGE *
MEDLANCE PLUS 30G LANCETS
SUPERLITE, 1.2MM 30 GAUGE *
MEDLANCE PLUS LITE 25G
LANCETS STERILE, 1.5MM 25
GAUGE *
MICRO THIN 33G LANCETS
UNIVERSAL 1 33 GAUGE *
MICROCHAMBER LATEX/F *
MICRODOT TEST STRIPS *
MICRODOT XTRA TEST STRIPS *
MICROLET LANCETS *
$0 (Tier 4)
MICROSPACER FOR AEROSOL
DEVICE LATEX/F *
MONAGHAN Z STAT
CHAMBER-MD MSK *
MONOJECT 1 ML TB SYRN 25X5/8"
1 ML 25 GAUGE X 5/8" *
MONOJECT 3 ML SYRINGE 3 ML *
MONOJECT 3 ML SYRN 25GX1" 3
ML 25 GAUGE X 1" *
MONOJECT 3 ML SYRN 25GX5/8"
LUER-LOCK, SOFTPACK 3 ML 25 X
5/8" *
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
140
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
MONOJECT 3 ML SYRN 27GX1.25"
LUER LOCK,SOFTPACK 3 ML 27
GAUGE X 1 1/4" *
MONOJECT LUER LOCK TB SYR 1
ML 1 ML *
MONOJECT PHARMACY TRAY 40'S
(OTC) 1 ML *
MONOJECT PHARMACY TRAY
LATEX-FREE (RX) 1 ML *
MONOJECT SAFETY SYRINGE 3
ML *
MONOJECT SYR PHARM TRAY PK
3 ML *
MONOJECT SYRINGE 3 ML
SOFTPK, REG LUER TIP 3 ML *
MONOJECT TB 1 ML SYRN 26X3/8"
1 ML 26 X 3/8" *
MONOJECT TB 1 ML SYRN 28GX1/2
1 ML 28 GAUGE X 1/2" *
MONOJECT TB SAFETY SYRINGE 1
ML 28 GAUGE X 1/2" *
MONOJECT TB SYRN 27GX1/2" 1
ML 27 X 1/2" *
MONOJECT TUBERCULIN SYR 1
ML REGULAR LUER TIP (OTC) 1
ML *
MONOLET 21G LANCETS 21
GAUGE *
MONOLET THIN 28G LANCETS 28
GAUGE *
MYGLUCOHEALTH 30G LANCETS
30 GAUGE *
MYGLUCOHEALTH TEST STRIPS *
NEUTEK 2TEK TEST STRIPS *
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
141
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
NOVA MAX GLUCOSE TEST STRIP
*
NOVA SAFETY 23G LANCETS 23
GAUGE *
NOVA SAFETY 28G LANCETS 28
GAUGE *
NOVA SUREFLEX THIN LANCETS
*
ON CALL 30G LANCET 30 GAUGE *
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
ON CALL EXPRESS TEST STRIP *
ON CALL PLUS 30G LANCET 30
GAUGE *
ON CALL PLUS TEST STRIP *
ON CALL VIVID TEST STRIP *
ONE TOUCH DELICA 33G
LANCETS 33 GAUGE *
ONETOUCH DELICA 30G LANCETS
30 GAUGE *
ONETOUCH DELICA 33G LANCETS
33 GAUGE *
ONETOUCH FINEPOINT 25G
LANCETS 25 GAUGE *
ONETOUCH ULTRA TEST STRIPS *
ONETOUCH ULTRASOFT
LANCETS *
ONETOUCH VERIO TEST STRIP *
OPTICHAMBER ADULT
MASK-LARGE *
OPTICHAMBER DIAMOND VHC *
OPTIUM EZ TEST STRIP *
OPTIUM TEST STRIP *
OPTUMRX TEST STRIP *
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
142
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
PEN NEEDLE, DIABETIC NEEDLE
29 GAUGE X 1/2"
PHARMACIST CHOICE 30G
LANCETS ULTRA THIN 30 GAUGE
*
PHARMACIST CHOICE TEST
STRIPS *
PHARMACIST CHOICE TEST
STRIPS *
POCKET CHAMBER *
PRECISION PCX PLUS TEST STR *
PRECISION PCX TEST STRIPS *
PRECISION POINT OF CARE STR *
PRECISION Q-I-D TEST STRIPS *
PRECISION XTRA TEST STRIPS *
PREMIUM V10 GLUCOSE TEST
STRIP *
PRESSURE ACTIVATED 21G
LANCETS 21 GAUGE *
PRESSURE ACTIVATED 28G
LANCETS 28 GAUGE *
PRIMEAIRE CHAMBER *
PRO COMFORT 30G LANCETS 30
GAUGE *
PROCHAMBER HOLDING
CHAMBER *
PRODIGY NO CODING TEST
STRIPS 50 STRIPS *
PRODIGY PRESSURE ACTIVATED
28G 28 GAUGE *
PRODIGY SAFETY 26G LANCETS
26 GAUGE *
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 4)
PA; QL (100 per 20
days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
143
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
PRODIGY TWIST TOP 28G LANCET
28 GAUGE *
PUB 28G LANCETS 28 GAUGE *
$0 (Tier 4)
PUSH BUTTON SAFETY 21G
LANCET 21 GAUGE *
PUSH BUTTON SAFETY 28G
LANCET 28 GAUGE *
PV TRUETRACK SMART SYS
STRIPS *
QC UNILET SUPER THIN 30G
LANCT 30 GAUGE *
QUINTET AC GLUCOSE TEST
STRIPS *
QUINTET GLUCOSE TEST STRIPS *
RA E-ZJECT 26G LANCETS 26
GAUGE *
RA E-ZJECT 28G LANCETS 28
GAUGE *
REFUAH PLUS TEST STRIPS *
RELIAMED 30G LANCETS 30
GAUGE *
RELIAMED SAFETY 23G LANCETS
23 GAUGE *
RELIAMED SAFETY 28G LANCETS
LATEX-FREE 28 GAUGE *
RELIAMED SAFETY SEAL 28G
LANCT 28 GAUGE *
RELIAMED SAFETY SEAL 30G
LANCT 30 GAUGE *
RELION CONFIRM-MICRO TEST
STRP *
RELION MICRO TEST STRIPS *
RELION PRIME TEST STRIPS *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
$0 (Tier 3)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
144
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
RELION THIN 26G LANCETS 26
GAUGE *
RELION ULTIMA TEST STRIPS *
RELION ULTRA THIN PLUS 33G 33
GAUGE *
RELION ULTRA THIN PLUS
LANCETS *
REVEAL TEST STRIP *
RIGHTEST GL300 30G LANCETS 30
GAUGE *
RIGHTEST GS100 TEST STRIPS *
RIGHTEST GS250S TEST STRIPS *
RIGHTEST GS260 TEST STRIPS *
RIGHTEST GS300 TEST STRIPS *
RIGHTEST GS550 TEST STRIPS *
RITEFLO SPACER *
SAFESNAP SYRINGE 3 ML 3 ML 25
GAUGE X 5/8", 3 ML 25 X 1" *
SAFESNAP TUBERCULIN SYR 1
ML 1 ML 25 GAUGE X 5/8" *
SAFESNAP TUBERCULIN SYR 1
ML 27GX0.5",LATEX-FREE 1 ML 27
GAUGE X 1/2" *
SAFETY 21G LANCETS
LATEX-FREE 21 GAUGE *
SAFETY 28G LANCETS
LATEX-FREE 28 GAUGE *
SAFETY LANCETS 26G 26 GAUGE *
$0 (Tier 4)
SAFETY SEAL 28G LANCETS 28
GAUGE *
SAFETY SEAL 30G LANCETS 30
GAUGE *
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
145
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
SAFETY SYRINGE W-SHIELD 3 ML
3 ML 25 GAUGE X 5/8" *
SAFETY-LET 30G LANCETS 30
GAUGE *
SAFETY-LOK 3 ML SYRINGE 3 ML
*
SAFETY-LOK 3 ML SYRINGE 3 ML
25 GAUGE X 5/8" *
SB LANCETS THIN 28G 28 GAUGE *
$0 (Tier 4)
SHOPKO ON-THE-GO 30G
LANCETS GENTLE 30 GAUGE *
SHOPKO UNILET ULTRA THIN 28G
STERILE 28 GAUGE *
SINGLE-LET LANCETS *
$0 (Tier 4)
SM COLOR LANCETS 21G 21
GAUGE *
SM LANCETS 21G 21 GAUGE *
$0 (Tier 4)
SM THIN LANCETS 26G 26 GAUGE
*
SMART SENSE COLOR 33G
LANCETS 33 GAUGE *
SMART SENSE STANDARD 21G 21
GAUGE *
SMART SENSE TEST STRIPS
PREMIUM, NO CODE *
SMART SENSE THIN 26G LANCETS
26 GAUGE *
SMARTEST LANCET *
$0 (Tier 4)
SMARTEST TEST STRIPS *
$0 (Tier 3)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
146
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
SOFT TOUCH LANCETS *
$0 (Tier 4)
SOLUS V2 28G LANCETS 28 GAUGE
*
SOLUS V2 30G TWIST LANCETS 30
GAUGE *
SOLUS V2 AUDIBLE TEST STRIPS *
SPACE CHAMBER PLUS *
STERILANCE TL TWIST 30G
LANCET 30 GAUGE *
STERILANCE TL TWIST 32G
LANCET 32 GAUGE *
SUPER THIN 28G LANCETS
STERILE 28 GAUGE *
SUPER THIN 33G LANCETS 33
GAUGE *
SURE COMFORT 18G LANCETS 18
GAUGE *
SURE COMFORT 21G LANCETS 21
GAUGE *
SURE COMFORT 23G LANCETS 23
GAUGE *
SURE COMFORT 28G LANCETS 28
GAUGE *
SURE COMFORT 30G LANCETS 30
GAUGE *
SURE-LANCE 26G LANCETS 26
GAUGE *
SURE-LANCE FLAT LANCETS *
$0 (Tier 4)
SURE-LANCE THIN 28G LANCETS
28 GAUGE *
SURE-LANCE ULTRA THIN 30G 30
GAUGE *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
147
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
SURE-TEST EASYPLUS MINI STRIP
*
SURE-TOUCH LANCET *
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
TD GOLD TEST STRIP *
TECHLITE 28G LANCETS 28
GAUGE *
TECHLITE 30G LANCETS 30
GAUGE *
TELCARE TEST STRIPS *
TELCARE ULTRA THIN 30G
LANCETS 30 GAUGE *
TERUMO SURGUARD2 SYR 25G 3
ML 3 ML 25 GAUGE X 1", 3 ML 25
GAUGE X 5/8" *
TERUMO SYRINGE 3 ML 3 ML 25
GAUGE X 1", 3 ML 25 X 5/8" *
TEST N'GO GLUCOSE TEST STRIP *
THIN LANCETS 28G 28 GAUGE *
$0 (Tier 3)
$0 (Tier 4)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
TOPCARE UNIVERSAL1 33G
LANCETS 33 GAUGE *
TOPCARE UNIVERSAL1 THIN
LANCET ULTRA THIN, 30G *
TRUE METRIX GLUCOSE TEST
STRIP *
TRUEPLUS 26G LANCETS 26
GAUGE *
TRUEPLUS 33G LANCETS 33
GAUGE *
TRUEPLUS SAFETY 28G LANCETS
28G, STERILE 28 GAUGE *
TRUEPLUS SUPER THIN 28G
LANCET 28G, STERILE 28 GAUGE *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
148
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
TRUEPLUS ULTRA THIN 30G
LANCET 30 GAUGE *
TRUETEST GLUCOSE TEST STRIPS
*
TRUETEST GLUCOSE TEST STRIPS
HRI *
TRUETRACK GLUCOSE TEST
STRIPS *
TUBERCULIN 1 ML SYRINGE SLIP
TIP DET.NEEDLE (OTC) 1 ML 25
GAUGE X 1" *
TUBERCULIN SYRINGE 1 ML 28
GAUGE X 1/2" *
TUBERCULIN SYRINGES 1/2 ML 28
X 1/2" *
ULTILET 28G LANCETS 28 GAUGE
*
ULTILET 30G LANCETS 30 GAUGE
*
ULTILET 33G LANCETS 33 GAUGE
*
ULTILET BASIC 30G LANCETS 30
GAUGE *
ULTILET CLASSIC 26G LANCETS *
$0 (Tier 4)
ULTILET CLASSIC 28G LANCETS 28
GAUGE *
ULTILET CLASSIC 30G LANCETS 30
GAUGE *
ULTILET CLASSIC 33G LANCETS 33
GAUGE *
ULTILET SAFETY 23G LANCETS 23
GAUGE *
ULTIMA TEST STRIPS *
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 3)
PA; QL (100 per 20
days)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 3)
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
149
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
ULTRA THIN 28G LANCETS
ULTRA THIN 28 GAUGE *
ULTRA THIN 30G LANCETS
STERILE 30 GAUGE *
ULTRA THIN 31G LANCETS 31
GAUGE *
ULTRA THIN 33G LANCETS 33
GAUGE *
ULTRALANCE 26G LANCETS 26
GAUGE *
ULTRALANCE 28G LANCETS 28
GAUGE *
ULTRA-THIN II 26G LANCET 26
GAUGE *
ULTRA-THIN II 28G LANCETS 28
GAUGE *
ULTRA-THIN II 30G LANCETS 30
GAUGE *
ULTRATLC LANCETS *
$0 (Tier 4)
ULTRATRAK TEST STRIP *
ULTRATRAK ULTIMATE TEST
STRIPS *
UNILET COMFORTOUCH 26G
LANCETS 26 GAUGE *
UNILET COMFORTOUCH LANCET
*
UNILET EXCELITE II LANCET *
$0 (Tier 3)
$0 (Tier 3)
UNILET EXCELITE LANCET *
$0 (Tier 4)
UNILET GP LANCET *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
150
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
UNILET LANCET SUPERLITE *
$0 (Tier 4)
UNILET MICRO THIN 33G
LANCETS 33 GAUGE *
UNISTIK 3 COMFORT LANCET *
$0 (Tier 4)
UNISTIK 3 EXTRA 21G LANCETS 21
GAUGE *
UNISTIK 3 GENTLE ON-THE-GO
30G 30 GAUGE *
UNISTIK 3 NORMAL 23G LANCETS
23 GAUGE *
UNISTIK 3 SAFETY 21G LANCETS
21 GAUGE *
UNISTIK CZT COMFORT 28G
LANCET 28 GAUGE *
UNISTIK CZT NORMAL 23G
LANCETS 23 GAUGE *
UNISTIK SAFETY 28G LANCET 28
GAUGE *
UNISTIK SAFETY 30G LANCETS 30
GAUGE *
UNISTIK TOUCH 21G LANCETS 21
GAUGE *
UNISTIK TOUCH 23G LANCETS 23
GAUGE *
UNISTIK TOUCH 28G LANCETS 28
GAUGE *
UNISTIK TOUCH 30G LANCETS 30
GAUGE *
UNISTRIP1 GLUCOSE TEST STRIP *
UNIVERSAL 1 33G LANCETS FOR
MEIJER 33 GAUGE *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
PA; QL (100 per 20
days)
QL (100 per 20 days)
PA; QL (100 per 20
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
151
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
UP & UP BLOOD GLUCOSE TST
STRP NO CODING *
VANISHPOINT 25GX1" 3 ML
SYRING 3 ML 25 GAUGE X 1" *
VANISHPOINT 25GX5/8" 3 ML SYR 3
ML 25 X 5/8" *
VGO 40 DISPOSABLE DEVICE
VORTEX HOLDING CHAMBER *
VORTEX VHC FROG CHILD MASK
*
WALGREENS ULTRA THIN
LANCETS *
WAVESENSE JAZZ TEST STRIPS *
WAVESENSE PRESTO TEST STRIPS
*
What the
drug will
cost you
(Tier level)
$0 (Tier 3)
Necessary Actions,
Restrictions, or
Limits on Use
QL (100 per 20 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
PA; QL (100 per 20
days)
QL (100 per 20 days)
QL (100 per 20 days)
Enzyme Replacement/Modifiers
Enzyme
Replacement/Modifiers
ADAGEN INTRAMUSCULAR
SOLUTION 250 UNIT/ML
ALDURAZYME INTRAVENOUS
SOLUTION 2.9 MG/5 ML
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000
-60,000 UNIT, 24,000-76,000 -120,000
UNIT, 3,000-9,500- 15,000 UNIT,
36,000-114,000- 180,000 UNIT,
6,000-19,000 -30,000 UNIT
ELAPRASE INTRAVENOUS
SOLUTION 6 MG/3 ML
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
152
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
ELITEK INTRAVENOUS RECON
SOLN 1.5 MG, 7.5 MG
FABRAZYME INTRAVENOUS
RECON SOLN 35 MG
KANUMA INTRAVENOUS
SOLUTION 2 MG/ML
KRYSTEXXA INTRAVENOUS
SOLUTION 8 MG/ML
KUVAN ORAL TABLET,SOLUBLE
100 MG
MYOZYME INTRAVENOUS RECON
SOLN 50 MG
NAGLAZYME INTRAVENOUS
SOLUTION 5 MG/5 ML
ORFADIN ORAL CAPSULE 10 MG, 2
MG, 20 MG, 5 MG
pancrelipase 5000 oral capsule,delayed
(Zenpep)
release(dr/ec) 5,000-17,000 -27,000 unit
PULMOZYME INHALATION
SOLUTION 1 MG/ML
STRENSIQ SUBCUTANEOUS
SOLUTION 100 MG/ML, 40 MG/ML
VIMIZIM INTRAVENOUS
SOLUTION 5 MG/5 ML (1 MG/ML)
VPRIV INTRAVENOUS RECON
SOLN 400 UNIT
ZAVESCA ORAL CAPSULE 100 MG
What the
drug will
cost you
(Tier level)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA BvD
PA; LA
PA
QL (90 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
153
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ZENPEP ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000
-55,000 UNIT, 15,000-51,000 -82,000
UNIT, 20,000-68,000 -109,000 UNIT,
25,000-85,000- 136,000 UNIT,
3,000-10,000- 16,000 UNIT,
40,000-136,000- 218,000 UNIT,
5,000-17,000 -27,000 UNIT
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat
Agents, Miscellaneous
advanced eye relief opth oint 80-20 % *
AKTEN (PF) OPHTHALMIC GEL 3.5
%
alaway 0.025% eye drops 0.025 % (0.035
%) *
alcaine ophthalmic drops 0.5 %
altacaine ophthalmic drops 0.5 %
altamist 0.65% nose spray 0.65 % *
altazine 0.05% eye drops 0.05 % *
apraclonidine ophthalmic drops 0.5 %
artificial tears *
artificial tears 1.4 % drops 1.4 % *
artificial tears drops p/f, sterile 0.1-0.3 %
*
artificial tears drops sterile, lubricant
1-0.2-0.2 % *
artificial tears eye drops strl 0.1-0.3 % *
artificial tears eye ointment 83-15 % *
atropine ophthalmic drops 1 %
atropine ophthalmic ointment 1 %
(Genteal Pm)
(Zaditor)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
(Proparacaine HCl)
(Tetravisc)
(Little Remedies)
(Visine)
(Iopidine)
(Dextran
70/Hypromellose)
(Polyvinyl Alcohol)
(Dextran
70/Hypromellose/PF)
(Visine)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
(Tears Naturale)
(Genteal Pm)
(Isopto Atropine)
(Atropine Sulfate)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
154
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
atropine-care ophthalmic drops 1 %
ayr saline 0.65% nose drops 0.65 % *
ayr saline 0.65% nose spray 0.65 % *
azelastine nasal aerosol,spray 137 mcg
(0.1 %)
azelastine ophthalmic drops 0.05 %
bion tears eye drops 0.1-0.3 % *
(Isopto Atropine)
(Sodium Chloride)
(Little Remedies)
(Astepro)
(Azelastine HCl)
(Dextran
70/Hypromellose/PF)
carteolol ophthalmic drops 1 %
(Carteolol HCl)
cromolyn ophthalmic drops 4 %
(Cromolyn Sodium)
cvs eye allergy relief eye drp 0.025-0.3 % * (Opcon-A)
cvs eye drops dual action sterile 0.05-0.25 (Visine Allergy
%*
Relief)
cvs eye wash solution *
(Sodium/Potassium/S
od Chl)
cvs lubricant 0.5% eye drops sterile 0.5 % (Refresh Tears)
*
cvs lubricant dry eye rlf 1% 1 % *
(Carboxymethylcellul
ose Sodium)
cvs lubricant eye ointment p/f 57.3-42.5 % (Genteal Pm)
*
cvs lubricating eye drops dry eye soln
(Refresh Optive)
0.5-0.9 % *
cvs maximum redness relief drp 0.03-0.5 % (Advanced Eye Relief
*
Redness)
cvs natural tears drops 0.1-0.3 % *
(Dextran
70/Hypromellose/PF)
cvs redness relief drops original 0.012-0.2 (Naphazoline
%*
HCl/Peg 300)
cvs redness relief eye drops sterile
(Clear Eyes Redness
0.012-0.2 % *
Relief)
cvs saline 3% nasal mist 3 % *
(Sodium Chloride)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 25 days)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
155
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
cyclopentolate ophthalmic drops 0.5 %, 1
%, 2 %
CYSTARAN OPHTHALMIC DROPS
0.44 %
deep sea 0.65% nose spray 0.65 % *
dristan long lasting mist 0.05 % *
epinastine ophthalmic drops 0.05 %
eq gentle 0.3% eye drops 0.3 % *
eq revive plus 0.5% eye drops 0.5 % *
eql nasal decngstnt nose drops 1 % *
eye drops max relief,strl 0.05-0.1-1-1 % *
flucaine ophthalmic drops 0.25-0.5 %
for sty relief eye ointment *
GENTEAL GEL DROPS 0.25-0.3 % *
genteal tears 0.1%-0.3% drop 0.1-0.3 % *
homatropaire ophthalmic drops 5 %
homatropine hbr ophthalmic drops 5 %
(Cyclogyl)
(Little Remedies)
(Oxymetazoline HCl)
(Elestat)
(Genteal Mild To
Moderate)
(Carboxymethylcellul
ose Sodium)
(Phenylephrine HCl)
(Visine Advanced)
(Proparacaine/Fluore
scein Sod)
(Genteal Pm)
(Tears Naturale)
(Isopto
Homatropine)
(Isopto
Homatropine)
(Atrovent)
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
(Atrovent)
spray,non-aerosol 0.06 %
ketotifen fum 0.025% eye drops (otc)
(Zaditor)
0.025 % (0.035 %) *
LACRISERT OPHTHALMIC INSERT
5 MG
little remedies stuffy nose kt w/ nasal
(Little Remedies)
aspirator 0.65 % *
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
QL (30 per 28 days)
$0 (Tier 1)
QL (15 per 10 days)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
156
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
lubricant 0.6% eye drops 0.6 % *
lubricant pm eye ointment p/f 57.3-42.5 %
*
lubricant redness eye drops redness
relief,strl 0.03-0.5 % *
lubricant redness reliever drp 0.05-1 % *
lubrifresh pm eye ointment 83-15 % *
mucinex sinus-max nasal spray full force
0.05 % *
muro-128 2% eye drops 2 % *
muro-128 5% eye drops 5 % *
muro-128 5% eye ointment 5 % *
naphazoline ophthalmic drops 0.1 %
nasal decongestant 0.05% spray 0.05 % *
natural balance tears drops 0.4 % *
nature's tears drops 0.4 % *
neo-synephrine 12 hour spray 0.05 % *
ocean 0.65% nasal spray 0.65 % *
olopatadine ophthalmic drops 0.1 %
opti-clear 0.05% eye drops 0.05 % *
PATADAY OPHTHALMIC DROPS
0.2 %
phenylephrine hcl ophthalmic drops 10 %,
2.5 %
proparacaine ophthalmic drops 0.5 %
puralube ophthalmic ointment p/f, sterile,
outer 85-15 % *
pure & gentle eye drops lubricant 0.3 % *
(Propylene Glycol)
(Genteal Pm)
$0 (Tier 4)
$0 (Tier 4)
(Advanced Eye Relief
Redness)
(Tetrahydrozoline
HCl/Peg)
(Genteal Pm)
(Afrin)
$0 (Tier 4)
(Sodium Chloride)
(Sodium Chloride)
(Sodium Chloride)
(Naphazoline HCl)
(Afrin)
(Genteal Mild To
Moderate)
(Genteal Mild To
Moderate)
(Oxymetazoline HCl)
(Little Remedies)
(Patanol)
(Visine)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Mydfrin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Proparacaine HCl)
(Genteal Pm)
$0 (Tier 1)
$0 (Tier 4)
(Genteal Mild To
Moderate)
$0 (Tier 4)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
157
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
pv artificial tears 0.4 % *
pv lubricant 1.4 % eye drops 1.4 % *
pv pure-gentle eye drops sterile 0.3 % *
ra eye allergy relief drops 0.02675-0.315
%*
ra sterile eye drops 0.012-0.2 % *
ra sterile eye drops 0.03-0.5 % *
redness lubricant eye drops regular, strl
0.012-0.2 % *
redness relief eye drops 0.012-0.25 %,
0.03-0.5 % *
REFRESH TEARS 0.5% EYE DROPS
0.5 % *
retaine cmc 0.5% eye drops 0.5 % *
retaine hpmc 0.3% eye drops 0.3 % *
retaine pm eye ointment 80-20 % *
saline mist 0.65% nose spry 0.65 % *
sea soft 0.65% nasal mist 0.65 % *
sm eye wash solution *
sm nose drops 1 % *
sochlor 5% eye drops 5 % *
sodium chloride 5% eye drop 5 % *
sodium chloride 5% eye oint 5 % *
SYSTANE BALANCE 0.6% EYE
DROP CLINICAL STRENGTH 0.6 %
*
(Genteal Mild To
Moderate)
(Polyvinyl Alcohol)
(Genteal Mild To
Moderate)
(Opcon-A)
$0 (Tier 4)
(Naphazoline
HCl/Peg 300)
(Advanced Eye Relief
Redness)
(Naphazoline
HCl/Peg 300)
(Clear Eyes Redness
Relief)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Carboxymethylcellul
ose Sodium)
(Hypromellose/PF)
(Genteal Pm)
(Little Remedies)
(Little Remedies)
(Sodium/Potassium/S
od Chl)
(Phenylephrine HCl)
$0 (Tier 4)
(Sodium Chloride)
(Sodium Chloride)
(Sodium Chloride)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Min 2
Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
158
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
systane nighttime eye oint 94-3 % *
tears again 1.4 % drops 1.4 % *
tears naturale free drops u-d,36x.9ml,p/f
0.1-0.3 % *
tears naturale pm eye oint 94-3 % *
tetracaine hcl (pf) ophthalmic drops 0.5 %
vicks qlearquil 0.05% mist 0.05 % *
vicks sinex 12 hour spray 0.05 % *
VISINE MAX REDNESS RELIEF
DROP 0.05-1-0.36-0.2 % *
VISINE TOTALITY EYE DROPS 0.05
%-0.25 %- 1 %-0.36 % *
visine-a eye allergy drops 0.025-0.3 % *
wal-zyr 0.025% eye drops 0.025 % (0.035
%) *
zyrtec itchy eye 0.025% drops 0.025 %
(0.035 %) *
(Genteal Pm)
(Polyvinyl Alcohol)
(Dextran
70/Hypromellose/PF)
(Genteal Pm)
(Tetracaine HCl/PF)
(Oxymetazoline HCl)
(Afrin)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Opcon-A)
(Zaditor)
$0 (Tier 4)
$0 (Tier 4)
(Zaditor)
$0 (Tier 4)
(Acetic Acid)
(Carbamide Peroxide)
(Carbamide Peroxide)
(Bacitracin)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
(Bacitracin/Polymyxi
n B Sulfate)
(Sulfacetamide
Sodium)
$0 (Tier 1)
Eye, Ear, Nose, Throat
Anti-Infectives Agents
acetic acid otic solution 2 %
auraphene-b 6.5% ear drops 6.5 % *
auro 6.5% ear drops 6.5 % *
bacitracin ophthalmic ointment 500
unit/gram
bacitracin-polymyxin b ophthalmic
ointment 500-10,000 unit/gram
bleph-10 ophthalmic drops 10 %
CIPRODEX OTIC
DROPS,SUSPENSION 0.3-0.1 %
ciprofloxacin hcl ophthalmic drops 0.3 %
ciprofloxacin hcl otic dropperette 0.2 %
(Ciloxan)
(Cetraxal)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
159
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
COLY-MYCIN S OTIC
DROPS,SUSPENSION 3.3-3-10-0.5
MG/ML
debrox 6.5% ear drops 6.5 % *
ear drops 6.5% 6.5 % *
erythromycin ophthalmic ointment 5
mg/gram (0.5 %)
gatifloxacin ophthalmic drops 0.5 %
gentak ophthalmic ointment 0.3 % (3
mg/gram)
gentamicin ophthalmic drops 0.3 %
gentamicin ophthalmic ointment 0.3 % (3
mg/gram)
levofloxacin ophthalmic drops 0.5 %
MOXEZA OPHTHALMIC DROPS,
VISCOUS 0.5 %
murine 6.5% ear drops 6.5 % *
murine ear wax removal system 6.5 % *
NATACYN OPHTHALMIC
DROPS,SUSPENSION 5 %
neomycin-bacitracin-poly-hc ophthalmic
ointment 3.5-400-10,000 mg-unit/g-1%
neomycin-bacitracin-polymyxin
ophthalmic ointment 3.5-400-10,000
mg-unit-unit/g
neomycin-polymyxin b-dexameth
ophthalmic drops,suspension
3.5mg/ml-10,000 unit/ml-0.1 %
neomycin-polymyxin b-dexameth
ophthalmic ointment 3.5 mg/g-10,000
unit/g-0.1 %
neomycin-polymyxin-gramicidin
ophthalmic drops 1.75 mg-10,000
unit-0.025mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
(Carbamide Peroxide)
(Carbamide Peroxide)
(Ilotycin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
(Zymaxid)
(Garamycin)
$0 (Tier 1)
$0 (Tier 1)
(Garamycin)
(Garamycin)
$0 (Tier 1)
$0 (Tier 1)
(Levofloxacin)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Carbamide Peroxide)
(Carbamide Peroxide)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin
)
(Maxitrol)
$0 (Tier 1)
$0 (Tier 1)
(Maxitrol)
$0 (Tier 1)
(Neosporin)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
160
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
neomycin-polymyxin-hc ophthalmic
drops,suspension 3.5-10,000-10
mg-unit-mg/ml
neomycin-polymyxin-hc otic
drops,suspension 3.5-10,000-1
mg/ml-unit/ml-%
neomycin-polymyxin-hc otic solution
3.5-10,000-1 mg/ml-unit/ml-%
neo-polycin hc ophthalmic ointment
3.5-400-10,000 mg-unit/g-1%
neo-polycin ophthalmic ointment
3.5-400-10,000 mg-unit-unit/g
(Neomycin/Polymyxi
n B Sulf/HC)
$0 (Tier 1)
(Neomycin/Polymyxi
n B Sulf/HC)
$0 (Tier 1)
(Cortisporin)
$0 (Tier 1)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin
)
ofloxacin ophthalmic drops 0.3 %
(Floxin)
ofloxacin otic drops 0.3 %
(Floxin)
polymyxin b sulf-trimethoprim ophthalmic (Polytrim)
drops 10,000 unit- 1 mg/ml
sulfacetamide sodium ophthalmic drops 10 (Sulfacetamide
%
Sodium)
sulfacetamide sodium ophthalmic ointment (Sulfacetamide
10 %
Sodium)
sulfacetamide-prednisolone ophthalmic
(Sulfacetamide/Predn
drops 10 %-0.23 % (0.25 %)
isolone Sp)
TOBRADEX OPHTHALMIC
OINTMENT 0.3-0.1 %
TOBRADEX ST OPHTHALMIC
DROPS,SUSPENSION 0.3-0.05 %
tobramycin ophthalmic drops 0.3 %
(Tobrex)
tobramycin-dexamethasone ophthalmic
(Tobradex)
drops,suspension 0.3-0.1 %
trifluridine ophthalmic drops 1 %
(Viroptic)
VIGAMOX OPHTHALMIC DROPS
0.5 %
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
161
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ZIRGAN OPHTHALMIC GEL 0.15 %
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
ZYLET OPHTHALMIC
DROPS,SUSPENSION 0.3-0.5 %
Eye, Ear, Nose, Throat
Anti-Inflammatory Agents
ALREX OPHTHALMIC
DROPS,SUSPENSION 0.2 %
bromfenac ophthalmic drops 0.09 %
CHILD NASACORT ALLERGY 24
HR 55 MCG *
dexamethasone sodium phosphate
ophthalmic drops 0.1 %
diclofenac sodium ophthalmic drops 0.1 %
DUREZOL OPHTHALMIC DROPS
0.05 %
FLONASE ALLERGY RLF 50 MCG
SPR 120 METERED SPRAYS 50
MCG/ACTUATION *
flunisolide nasal spray,non-aerosol 25 mcg
(0.025 %)
fluorometholone ophthalmic
drops,suspension 0.1 %
flurbiprofen sodium ophthalmic drops 0.03
%
fluticasone nasal spray,suspension 50
mcg/actuation
ILEVRO OPHTHALMIC
DROPS,SUSPENSION 0.3 %
ketorolac ophthalmic drops 0.4 %, 0.5 %
LOTEMAX OPHTHALMIC
DROPS,GEL 0.5 %
(Bromfenac Sodium)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 4)
(Dexamethasone Sod
Phosphate)
(Diclofenac Sodium)
$0 (Tier 1)
(Flunisolide)
$0 (Tier 1)
(FML)
$0 (Tier 1)
(Ocufen)
$0 (Tier 1)
(Fluticasone
Propionate)
$0 (Tier 1)
(Acular)
ST
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
QL (50 per 25 days)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
162
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
LOTEMAX OPHTHALMIC
DROPS,SUSPENSION 0.5 %
LOTEMAX OPHTHALMIC
OINTMENT 0.5 %
NASACORT ALLERGY 24HR
SPRAY MULTI-SYMP,60 SPRAYS 55
MCG *
nasal allergy 24hr spray 55 mcg *
NEVANAC OPHTHALMIC
DROPS,SUSPENSION 0.1 %
prednisolone acetate ophthalmic
drops,suspension 1 %
prednisolone sodium phosphate ophthalmic
drops 1 %
PROLENSA OPHTHALMIC DROPS
0.07 %
RESTASIS OPHTHALMIC
DROPPERETTE 0.05 %
triamcinolone 55 mcg nasal spr (otc) 55
mcg *
XIIDRA OPHTHALMIC
DROPPERETTE 5 %
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
(Nasacort)
(Omnipred)
(Prednisolone Sod
Phosphate)
(Nasacort)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
QL (60 per 30 days)
$0 - $7.40
(Tier 2)
PA; QL (60 per 30
days)
Gastrointestinal Agents
Antiflatulents
bicarsim forte 125 mg tablet 125 mg *
cvs gas relief 125 mg chew tab extra
strength 125 mg *
cvs gas relief 125 mg softgel softgel 125
mg *
cvs gas relief 80 mg tab chew 80 mg *
gas relief 125 mg chew tablet max
str,lactose-free 125 mg *
(Simethicone)
(Gas-X)
$0 (Tier 4)
$0 (Tier 4)
(Phazyme)
$0 (Tier 4)
(Gas-X)
(Gas-X)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
163
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
gas relief 80 mg tablet chew lactose-free
80 mg *
gas-x extra strength softgel softgel,
ex-strength 125 mg *
gas-x ultra strength softgel 180 mg *
inf gas rel 20 mg/0.3 ml drop 20mg/0.3ml,
dye free 40 mg/0.6 ml *
mi-acid gas 80 mg tab chew 80 mg *
mytab gas 80 mg tablet chew 80 mg *
mytab gas max str 125 mg tab 125 mg *
simethicone 180 mg softgel 180 mg *
v-r anti-gas 166 mg softgel 166 mg *
(Gas-X)
$0 (Tier 4)
(Phazyme)
$0 (Tier 4)
(Phazyme)
(Simethicone)
$0 (Tier 4)
$0 (Tier 4)
(Gas-X)
(Gas-X)
(Gas-X)
(Phazyme)
(Phazyme)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Pepcid Ac)
$0 (Tier 4)
(Prevpac)
$0 (Tier 1)
(Cimetidine HCl)
(Cimetidine)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Tagamet Hb)
$0 (Tier 4)
(Nexium I.V.)
$0 (Tier 1)
(Famotidine)
$0 (Tier 1)
(Famotidine In
Nacl,Iso-Osm/PF)
(Famotidine)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
Antiulcer Agents And Acid
Suppressants
acid reducer 20 mg tablet maximum
strength 20 mg *
amoxicil-clarithromy-lansopraz oral
combo pack 500-500-30 mg
CARAFATE ORAL SUSPENSION 100
MG/ML
cimetidine hcl oral solution 300 mg/5 ml
cimetidine oral tablet 200 mg, 300 mg, 400
mg, 800 mg
cvs cimetidine 200 mg tablet (otc) 200 mg
*
esomeprazole sodium intravenous recon
soln 20 mg, 40 mg
famotidine (pf) intravenous solution 20
mg/2 ml
famotidine (pf)-nacl (iso-os) intravenous
piggyback 20 mg/50 ml
famotidine 40 mg/4 ml vial 25's,outer 10
mg/ml
(Rx Product Only)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
164
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
famotidine oral tablet 20 mg, 40 mg
gnp acid reducer 10 mg tablet 10 mg *
lansoprazole dr 15 mg capsule na/f (otc)
15 mg *
lansoprazole oral capsule,delayed
release(dr/ec) 15 mg, 30 mg
misoprostol oral tablet 100 mcg, 200 mcg
NEXIUM 24HR 22.3 MG CAPSULE
22.3 MG *
omeprazole dr 20 mg tablet 20 mg *
omeprazole mag dr 20.6 mg cap two
14-days course 20 mg *
omeprazole oral capsule,delayed
release(dr/ec) 10 mg, 20 mg, 40 mg
pantoprazole intravenous recon soln 40 mg
pantoprazole oral tablet,delayed release
(dr/ec) 20 mg, 40 mg
pub famotidine 20 mg tablet max strength
(otc) 20 mg *
pv acid relief 200 mg tablet 200 mg *
ra omeprazole-bicarb 20-1,100 3x14 day
course (otc) 20-1.1 mg-gram *
ranitidine 150 mg tablet maximum
strength (otc) 150 mg *
ranitidine 75 mg tablet s/f, sodium-free 75
mg *
ranitidine hcl injection solution 50 mg/2 ml
(25 mg/ml)
ranitidine hcl oral capsule 150 mg, 300 mg
ranitidine hcl oral syrup 15 mg/ml
ranitidine hcl oral tablet 150 mg, 300 mg
sucralfate oral suspension 100 mg/ml
sucralfate oral tablet 1 gram
Necessary Actions,
Restrictions, or
Limits on Use
(Pepcid)
(Pepcid Ac)
(Prevacid 24hr)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Rx Product Only)
(Prevacid)
$0 (Tier 1)
(Rx Product Only)
(Cytotec)
$0 (Tier 1)
$0 (Tier 4)
(Omeprazole)
(Omeprazole
Magnesium)
(Prilosec)
$0 (Tier 4)
$0 (Tier 4)
(Protonix IV)
(Protonix)
$0 (Tier 1)
$0 (Tier 1)
(Pepcid Ac)
$0 (Tier 4)
(Tagamet Hb)
(Zegerid Otc)
$0 (Tier 4)
$0 (Tier 4)
(Zantac)
$0 (Tier 4)
(Zantac)
$0 (Tier 4)
(Ranitidine HCl)
$0 (Tier 1)
(Rx Product Only)
(Ranitidine HCl)
(Ranitidine HCl)
(Zantac)
(Sucralfate)
(Carafate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
165
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
wal-zan 75 mg tablet 75 mg *
(Zantac)
$0 (Tier 4)
(Gaviscon)
$0 (Tier 4)
(Gaviscon)
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Aluminum
Hydroxide)
(Aluminum
Hydroxide)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
Gastrointestinal Agents, Other
acid gone antacid liquid 95-358 mg/15 ml
*
acid gone tablet chew 160-105 mg *
ALKA-SELTZER GOLD TAB EFF
344-1,050-1,000 MG *
almacone liquid 200-200-20 mg/5 ml *
almacone-2 liquid 400-400-40 mg/5 ml *
aluminum hydroxide gel 600 mg/5 ml *
aluminum hydroxide gel sugar-free 320
mg/5 ml *
AMITIZA ORAL CAPSULE 24 MCG,
8 MCG
antacid 1000-200 mg tab chew 1,000-200
mg *
antacid 675-135 mg tab chew ex-str, asstd
fruit 675-135 mg *
antacid chewable tablet peppermint flavor
550-110 mg *
antacid plus e-s liquid 500-450-40 mg/5 ml
*
antacid ultra tablet chew 400 mg (1,000
mg) *
antacid xtra strength chew tab
extra-strength 300 mg (750 mg) *
antacid-antigas liquid 200-200-20 mg/5 ml
*
anti-diarrheal 2 mg caplet caplet 2 mg *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Rolaids)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
(Rolaids)
$0 (Tier 4)
(Rolaids)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Tums)
$0 (Tier 4)
(Tums)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Imodium A-D)
$0 (Tier 4)
QL (60 per 30 days)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
166
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
bismatrol 525 mg/15 ml susp 525 mg/15 ml (Pepto-Bismol)
*
bismatrol suspension 262 mg/15 ml *
(Pepto-Bismol)
BUPHENYL ORAL TABLET 500 MG
calci-chew tablet 500 mg calcium (1,250
mg) *
calcium 500 mg chewable tablet tab
chew,p/f 500 mg calcium (1,250 mg) *
calcium antacid 500 mg chw tab assorted
fruit 200 mg calcium (500 mg) *
cal-gest 500 mg tablet chew 200 mg
calcium (500 mg) *
CARBAGLU ORAL TABLET,
DISPERSIBLE 200 MG
child soothe 400 mg tab chew 400 mg *
children pepto 400 mg tab chew bubble
gum, na/f 400 mg *
comfort gel max str susp max-str
400-400-40 mg/5 ml *
comfort gel suspension regular str, cherry
200-200-20 mg/5 ml *
constulose oral solution 10 gram/15 ml
cromolyn oral concentrate 100 mg/5 ml
cvs antacid supreme liquid 400-135 mg/5
ml *
$0 (Tier 4)
(Tums)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
(Tums)
$0 (Tier 4)
(Tums)
$0 (Tier 4)
(Tums)
$0 (Tier 4)
(Tums)
(Tums)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Lactulose)
(Gastrocrom)
(Calcium
Carb/Magnesium
Hydrox)
(Loperamide HCl)
cvs anti-diarrheal 2 mg sftgel softgel 2 mg
*
cvs anti-diarrheal suspension 262 mg/15 ml (Pepto-Bismol)
*
cvs heartburn relief chew tab 160-105 mg (Gaviscon)
*
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
167
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
cvs loperamide 1 mg/7.5 ml liq mint 1
mg/7.5 ml *
diamode 2 mg tablet outer, f/c 2 mg *
dicyclomine oral capsule 10 mg
dicyclomine oral solution 10 mg/5 ml
dicyclomine oral tablet 20 mg
diotame instydose 524 mg/30 ml 524
mg/30 ml *
diphenoxylate-atropine oral liquid
2.5-0.025 mg/5 ml
diphenoxylate-atropine oral tablet
2.5-0.025 mg
enulose oral solution 10 gram/15 ml
flanax antacid liquid 200-200-20 mg/5 ml
*
FLEET PEDIA-LAX TABLET CHEW
400 MG (170 MG) *
foaming antacid liquid 95-358 mg/15 ml *
GATTEX 5 MG 30-VIAL KIT 5 MG
GATTEX ONE-VIAL
SUBCUTANEOUS KIT 5 MG
GAVISCON ES TABLET CHEW
EXTRA STRENGTH 160-105 MG *
gelusil antacid & antigas liq 400-400-40
mg/5 ml *
gelusil tablet chewable cool mint
200-200-25 mg *
generlac oral solution 10 gram/15 ml
glycopyrrolate injection solution 0.2
mg/ml
glycopyrrolate oral tablet 1 mg, 2 mg
(Loperamide HCl)
$0 (Tier 4)
(Imodium A-D)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Bismuth
Subsalicylate)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Lactulose)
(Maalox Maximum
Strength)
$0 (Tier 1)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
(Gaviscon)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Almacone)
$0 (Tier 4)
(Lactulose)
(Robinul)
$0 (Tier 1)
$0 (Tier 1)
(Robinul)
$0 (Tier 1)
PA
PA
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
168
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
heartburn antacid chew tablet 160-105 mg
*
imodium a-d 1 mg/7.5 ml liquid mint 1
mg/7.5 ml *
kaopectate 262 mg/15 ml susp vanilla
flavor 262 mg/15 ml *
kaopectate extra strength liq peppermint
525 mg/15 ml *
kionex 15 gm/60 ml suspension 15-19.3
gram/60 ml
kionex oral powder
lactulose oral solution 10 gram/15 ml
LINZESS ORAL CAPSULE 145 MCG,
290 MCG
loperamide 1 mg/5 ml liquid 1 mg/5 ml *
loperamide oral capsule 2 mg
LOTRONEX ORAL TABLET 0.5 MG,
1 MG
maalox advanced suspension regular
strength 200-200-20 mg/5 ml *
MAALOX MAXIMUM STRENGTH
SUSP MINT, MAX STRENGTH
400-400-40 MG/5 ML *
MAG-AL LIQUID 200-200 MG/5 ML *
MAGNESIUM 400 MG CAPS 400 MG
*
magnesium 500 mg capsule s/f,na/f 500 mg
*
magnesium oxide 250 mg tablet 250 mg *
magnesium oxide 400 mg tablet
s/f,p/f,gluten-free 400 mg *
magnesium oxide 420 mg tablet 253mg
elem magnesium 420 mg *
(Gaviscon)
$0 (Tier 4)
(Loperamide HCl)
$0 (Tier 4)
(Pepto-Bismol)
$0 (Tier 4)
(Pepto-Bismol)
$0 (Tier 4)
(Sodium Polystyrene
Sulfon/Sorb)
(Sodium Polystyrene
Sulfon/Sorb)
(Lactulose)
$0 (Tier 1)
(Loperamide HCl)
(Loperamide HCl)
(Maalox Maximum
Strength)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
QL (30 per 30 days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Uromag)
$0 (Tier 4)
(Magox 400)
(Magox 400)
$0 (Tier 4)
$0 (Tier 4)
(Magox 400)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
169
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
magnesium oxide 500 mg tablet
p/f,s/f,lactose-free 500 mg *
MAGOX 400 TABLET S/F, GLUTEN
FREE 400 MG *
masanti liquid 400-400-40 mg/5 ml *
medi-first pep-t-med tab chew 262 mg *
methscopolamine oral tablet 2.5 mg, 5 mg
metoclopramide hcl injection solution 5
mg/ml
metoclopramide hcl oral solution 5 mg/5
ml
metoclopramide hcl oral tablet 10 mg, 5
mg
mi acid suspension 200-200-20 mg/5 ml,
400-400-40 mg/5 ml *
mi-acid ds tablet 700-300 mg *
mintox maximum strength susp max str,
lemon creme 400-400-40 mg/5 ml *
mintox plus tablet chewable 200-200-25
mg *
mintox suspension mint creme 200-200-20
mg/5 ml *
MOVANTIK ORAL TABLET 12.5
MG, 25 MG
NUTRESTORE ORAL POWDER IN
PACKET 5 GRAM
OCALIVA ORAL TABLET 10 MG, 5
MG
phillips 500 mg caplet 500 mg *
PHILLIPS' MOM TABLET CHEW 311
MG *
(Magox 400)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Pepto-Bismol
To-Go)
(Methscopolamine
Bromide)
(Metoclopramide
HCl)
(Metoclopramide
HCl)
(Reglan)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Rolaids)
(Maalox Maximum
Strength)
(Almacone)
$0 (Tier 4)
(Maalox Maximum
Strength)
$0 (Tier 4)
(Magox 400)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 4)
QL (30 per 30 days)
PA; QL (30 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
170
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
pink bismuth tablet chew 262 mg *
pv anti-diarrheal+gas relief caplet 2-125
mg *
pv foaming antacid chew tablet
ex-strength 160-105 mg *
pv supreme antacid suspension 400-135
mg/5 ml *
ra loperamide 1 mg/7.5 ml susp mint 1
mg/7.5 ml *
ra magnesium 500 mg capsule 500 mg *
RAVICTI ORAL LIQUID 1.1
GRAM/ML
RELISTOR ORAL TABLET 150 MG
RELISTOR SUBCUTANEOUS
SOLUTION 12 MG/0.6 ML
RELISTOR SUBCUTANEOUS
SYRINGE 12 MG/0.6 ML, 8 MG/0.4
ML
ri-gel ii suspension 400-400-40 mg/5 ml *
riginic suspension 131-31.7 mg/5 ml *
ri-mox plus suspension 225-200-25 mg/5
ml *
ri-mox suspension 200-200-20 mg/5 ml *
sm foaming antacid tablet chew 80-20 mg
*
sm stomach relief caplet 262 mg *
sodium bicarb 325 mg tablet 325 mg *
(Pepto-Bismol
To-Go)
(Imodium
Multi-Symptom
Relief)
(Gaviscon)
$0 (Tier 4)
(Calcium
Carb/Magnesium
Hydrox)
(Loperamide HCl)
$0 (Tier 4)
(Uromag)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Maalox Maximum
Strength)
(Gaviscon)
(Maalox Maximum
Strength)
(Maalox Maximum
Strength)
(Gaviscon)
$0 (Tier 4)
(Kaopectate)
(Sodium Bicarbonate)
$0 (Tier 4)
$0 (Tier 4)
PA
PA; QL (90 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
171
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
sodium bicarb 650 mg tablet 10 gr 650 mg
*
sodium polystyrene (sorb free) oral
suspension 15 gram/60 ml
sodium polystyrene sulfonate rectal enema
30 gram/120 ml
soothe 262 mg caplet caplet 262 mg *
soothe 262 mg/15 ml suspension s/f,cherry
262 mg/15 ml *
sps (with sorbitol) oral suspension 15-20
gram/60 ml
ursodiol oral capsule 300 mg
ursodiol oral tablet 250 mg, 500 mg
VIBERZI ORAL TABLET 100 MG, 75
MG
(Sodium Bicarbonate)
$0 (Tier 4)
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
Sulfonate)
(Kaopectate)
(Pepto-Bismol)
$0 (Tier 1)
(Sodium Polystyrene
Sulfon/Sorb)
(Actigall)
(Urso)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
ST; QL (60 per 30
days)
Laxatives
alophen pills 5 mg *
bisac-evac 10 mg suppository 10 mg *
bisacodyl 10 mg suppository 10 mg *
bisacodyl ec 5 mg tablet 5 mg *
biscolax 10 mg suppository 10 mg *
BLADDER CONTROL PAD X-LONG
9'S,X-LONG *
CASTOR OIL *
CEO-TWO SUPPOSITORY 0.9-0.6
GRAM *
chocolated laxative regular strength 15 mg
*
citroma solution *
CITRUCEL 500 MG CAPLET 500 MG
*
CITRUCEL POWDER *
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Sennosides)
$0 (Tier 4)
(Magnesium Citrate)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
172
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
COLACE 100 MG CAPSULE 100 MG
*
COLACE CLEAR 50 MG SOFTGEL
50 MG *
cvs castor oil 67% *
cvs child suppository *
cvs enema disposable 19-7 gram/118 ml *
cvs fiber 0.52 g capsule 0.52 gram *
cvs fiber therapy 500 mg caplt soluble,
caplet 500 mg *
cvs glycerin suppository child size *
cvs glycerin suppository laxative *
cvs kids 100 mg mini enema 100 mg/5 ml *
cvs laxative 15 mg pills pills, chocolate 15
mg *
cvs magnesium citrate soln *
cvs natural daily fiber powder 3.4
gram/5.8 gram *
cvs natural daily fiber powder 3.4 gram/7
gram *
cvs purelax powder 14 once-daily doses 17
gram/dose *
cvs purelax powder packet s/f, 10 daily
doses 17 gram *
cvs senna laxative 8.6 mg tab 8.6 mg *
cvs senna-extra 17.2 mg tablet 17.2 mg *
cvs stool softener 50 mg sftgl 50 mg *
cvs stool softener 50 mg softgel 50 mg *
cvs stool softener softgel softgel 240 mg *
cvs suppository *
doc-q-lace 100 mg softgel 100 mg *
docu liquid 50 mg/5 ml 50 mg/5 ml *
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
(Castor Oil)
(Glycerin)
(Enema)
(Metamucil)
(Citrucel)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Glycerin)
(Glycerin)
(Docusate Sodium)
(Sennosides)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Magnesium Citrate)
(Psyllium
Husk/Aspartame)
(Metamucil)
$0 (Tier 4)
$0 (Tier 4)
(Gavilax)
$0 (Tier 4)
(Miralax)
$0 (Tier 4)
(Senokot)
(Senokot)
(Colace Clear)
(Colace Clear)
(Surfak)
(Glycerin)
(Colace Clear)
(Docusate Sodium)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
173
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
docusate sodium 100 mg tablet crushable
100 mg *
docusate sodium 250 mg softgel softgel
250 mg *
docusol mini-enema outer 283 mg *
dok 100 mg softgel softgel 100 mg *
dok 100 mg tablet 100 mg *
dulcolax ss 100 mg softgel 100 mg *
enema disposable 19-7 gram/118 ml *
enema ready to use latex-free 19-7
gram/118 ml *
enemeez mini enema 5cc tubes, outer 283
mg/5 ml *
enemeez plus mini enema outer 283-20
mg/5 ml *
eq fiber therapy powder *
equalactin 500 mg tab chew 500 mg *
ex-lax chocolate chocolate 15 mg *
ex-lax pills 15 mg *
fiber tablet unboxed 625 mg *
fiber therapy (psyllium) oral powder *
fiber therapy powder 2 gram/19 gram *
fiber-lax captabs 500mg polycarbophil 625
mg *
fibertab oral tablet 625 mg *
fleet glycerin adult suppos *
fleet pedia-lax stool softener 50 mg/15 ml
*
fleet pedia-lax suppositories *
gavilyte-c oral recon soln 240-22.72-6.72
-5.84 gram
(Docusate Sodium)
$0 (Tier 4)
(Colace Clear)
$0 (Tier 4)
(Docusate Sodium)
(Colace Clear)
(Docusate Sodium)
(Colace Clear)
(Enema)
(Enema)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Docusate Sodium)
$0 (Tier 4)
(Docusol Plus)
$0 (Tier 4)
(Psyllium Seed (With
Sugar))
(Calcium
Polycarbophil)
(Sennosides)
(Senokot)
(Fibercon)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
(Citrucel)
(Fibercon)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Fibercon)
(Glycerin)
(Docusate Sodium)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Glycerin)
(Golytely)
$0 (Tier 4)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
174
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
gavilyte-g oral recon soln 236-22.74-6.74
-5.86 gram
gavilyte-n oral recon soln 420 gram
gentlelax powder 30 once-daily doses 17
gram/dose *
glycerin adult suppository *
glycerin suppository *
glycolax powder 7 doses (otc) 17
gram/dose *
healthylax powder packet 14x17gm, outer
17 gram *
hydrocil instant packet *
konsyl 520 mg capsule 0.52 gram *
konsyl fiber 625 mg caplet caplet, s/f 625
mg *
konsyl psyllium fiber packet orange,
gluten free 3.4 gram *
laxative 15 mg pills 15 mg *
laxative 15 mg pills 15 mg *
magic bullet 10 mg suppos 10 mg *
magnesium citrate solution lemon *
MILK OF MAGNESIA
CONCENTRATED 2,400 MG/10 ML *
milk of magnesia suspension 400 mg/5 ml
*
mineral oil enema latex-free *
mineral oil laxative *
MOVIPREP ORAL POWDER IN
PACKET 100-7.5-2.691 GRAM
natural fiber lax powder *
(Golytely)
$0 (Tier 1)
(Nulytely with Flavor
Packs)
(Gavilax)
$0 (Tier 1)
(Glycerin)
(Glycerin)
(Gavilax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Miralax)
$0 (Tier 4)
(Psyllium Seed)
(Metamucil)
(Fibercon)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Psyllium Husk (With
Sugar))
(Senokot)
(Senokot)
(Dulcolax)
(Magnesium Citrate)
$0 (Tier 4)
(Milk Of Magnesia)
$0 (Tier 4)
(Mineral Oil Enema)
(Mineral Oil)
$0 (Tier 4)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
(Psyllium Seed (With
Sugar))
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
175
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
oral saline laxative liquid s/f, ginger lemon
7.2-2.7 gram/15 ml *
peg 3350-electrolytes oral recon soln
236-22.74-6.74 -5.86 gram,
240-22.72-6.72 -5.84 gram
peg-electrolyte soln oral recon soln 420
gram
perdiem overnight relief tb 15 mg *
phillips' lax liqui-gels 100 mg *
PHILLIPS' MILK OF MAGNESIA 400
MG/5 ML *
phosphate oral saline laxative s/f, ginger
lemon 7.2-2.7 gram/15 ml *
polyethylene glycol 3350 oral powder 17
gram/dose
polyethylene glycol 3350 oral powder in
packet 17 gram
polyethylene glycol 3350 powd 14
once-daily doses (otc) 17 gram/dose *
polyethylene glycol 3350 powd 17 grams
pkts,outer (otc) 17 gram *
POLYETHYLENE GLYCOL 3350
POWD NF, PEG-75 *
polyethylene glycol 3350 powd outer,s/f
(otc) 17 gram *
promolaxin 100 mg tablet 100 mg *
psyllium capsule 0.4 gram *
pv enema *
pv fiber therapy powder *
pv senna 8.6 mg softgel 8.6 mg *
qc natural vegetable powder 48 doses, reg
flavor *
ra citrate of magnesia soln *
(Na Phos,M-B/Na
Phos,Di-Ba)
(Golytely)
$0 (Tier 4)
(Nulytely with Flavor
Packs)
(Senokot)
(Colace Clear)
$0 (Tier 1)
(Na Phos,M-B/Na
Phos,Di-Ba)
(Polyethylene Glycol
3350)
(Polyethylene Glycol
3350)
(Gavilax)
$0 (Tier 4)
(Miralax)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
(Miralax)
$0 (Tier 4)
(Docusate Sodium)
(Metamucil)
(Mineral Oil Enema)
(Methylcellulose)
(Sennosides)
(Psyllium Seed (With
Dextrose))
(Magnesium Citrate)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
176
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ra col-rite 50 mg softgel 50 mg *
ra enema twin pack 2 x 4.5oz, rtu 19-7
gram/118 ml *
ra laxative 17.2 mg tablet 17.2 mg *
ra laxative peg 3350 powder 14 once-daily
doses 17 gram/dose *
reguloid capsule 0.52 gram *
reguloid powder orange *
sani-supp adult suppository outer *
sani-supp pediatric suppos outer *
senexon 8.8 mg/5 ml liquid 8.8 mg/5 ml *
senexon tablet 8.6 mg *
senna 8.8 mg/5 ml syrup a/f, chocolate 8.8
mg/5 ml *
senna-lax 8.6 mg tablet 8.6 mg *
silace 50 mg/5 ml liquid 50 mg/5 ml *
silace 60 mg/15 ml syrup 60 mg/15 ml *
sm castor oil 95 % *
sm clearlax powder 14 once-daily doses 17
gram/dose *
sm fiber laxative 500 mg cplt 500 mg *
sm fiber laxative capsule 0.52 gram *
sm fiber smooth powder *
sm glycerin pediatric suppo *
sm laxative pediatric suppos *
sm senna laxative pills 25 mg *
smoothlax powder packet 10 once-daily
doses 17 gram *
trilyte with flavor packets oral recon soln
420 gram
wal-mucil 0.52 g capsule 0.52 gram *
(Colace Clear)
(Enema)
$0 (Tier 4)
$0 (Tier 4)
(Senokot)
(Gavilax)
$0 (Tier 4)
$0 (Tier 4)
(Metamucil)
(Psyllium Seed (With
Sugar))
(Glycerin)
(Glycerin)
(Sennosides)
(Senokot)
(Sennosides)
$0 (Tier 4)
$0 (Tier 4)
(Senokot)
(Docusate Sodium)
(Docusate Sodium)
(Castor Oil)
(Gavilax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Citrucel)
(Metamucil)
(Psyllium Seed)
(Glycerin)
(Glycerin)
(Senokot)
(Miralax)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Nulytely with Flavor
Packs)
(Metamucil)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
177
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Phosphate Binders
CALCIUM ACETATE 668 MG
TABLET 668 MG (169 MG
CALCIUM) *
calcium acetate oral capsule 667 mg
calcium acetate oral tablet 667 mg
eliphos oral tablet 667 mg
magnebind 400 oral tablet 400-200-1 mg
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
(Phoslo)
(Calcium Acetate)
(Calcium Acetate)
(Calcium
Carbonate/Mag
Carb/Fa)
PHOSLYRA ORAL SOLUTION 667
MG (169 MG CALCIUM)/5 ML
RENAGEL ORAL TABLET 400 MG,
800 MG
RENVELA ORAL POWDER IN
PACKET 0.8 GRAM, 2.4 GRAM
RENVELA ORAL TABLET 800 MG
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Genitourinary Agents
Antispasmodics, Urinary
MYRBETRIQ ORAL TABLET
EXTENDED RELEASE 24 HR 25 MG,
50 MG
oxybutynin chloride oral syrup 5 mg/5 ml (Oxybutynin
Chloride)
oxybutynin chloride oral tablet 5 mg
(Oxybutynin
Chloride)
oxybutynin chloride oral tablet extended
(Ditropan XL)
release 24hr 10 mg, 15 mg, 5 mg
tolterodine oral capsule,extended release
(Detrol LA)
24hr 2 mg, 4 mg
tolterodine oral tablet 1 mg, 2 mg
(Detrol)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
178
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
TOVIAZ ORAL TABLET
EXTENDED RELEASE 24 HR 4 MG,
8 MG
trospium oral capsule,extended release
24hr 60 mg
trospium oral tablet 20 mg
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
(Trospium Chloride)
$0 (Tier 1)
(Trospium Chloride)
$0 (Tier 1)
(Uroxatral)
$0 (Tier 1)
(Flomax)
$0 (Tier 1)
(Terazosin HCl)
$0 (Tier 1)
Genitourinary Agents,
Miscellaneous
alfuzosin oral tablet extended release 24
hr 10 mg
tamsulosin oral capsule,extended release
24hr 0.4 mg
terazosin oral capsule 1 mg, 10 mg, 2 mg,
5 mg
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln 2 gram, (Desferal)
500 mg
DEPEN TITRATABS ORAL TABLET
250 MG
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG, 250 MG, 500
MG
FERRIPROX ORAL SOLUTION 100
MG/ML
FERRIPROX ORAL TABLET 500 MG
sodium thiosulfate intravenous solution 1
(Sodium Thiosulfate)
gram/10 ml (100 mg/ml), 12.5 gram/50 ml
(250 mg/ml)
SYPRINE ORAL CAPSULE 250 MG
$0 (Tier 1)
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
179
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Hormonal Agents,
Stimulant/Replacement/Modifying
Androgens
ANDRODERM TRANSDERMAL
PATCH 24 HOUR 2 MG/24 HOUR, 4
MG/24 HR
ANDROGEL TRANSDERMAL GEL
IN METERED-DOSE PUMP 20.25
MG/1.25 GRAM (1.62 %)
ANDROGEL TRANSDERMAL GEL
IN PACKET 1.62 % (20.25 MG/1.25
GRAM), 1.62 % (40.5 MG/2.5 GRAM)
androxy oral tablet 10 mg
danazol oral capsule 100 mg, 200 mg, 50
mg
oxandrolone oral tablet 10 mg, 2.5 mg
testosterone cypionate intramuscular oil
100 mg/ml, 200 mg/ml
testosterone enanthate intramuscular oil
200 mg/ml
testosterone transdermal gel 50 mg/5 gram
(1 %)
testosterone transdermal gel in
metered-dose pump 1.25 gram/ actuation
(1 %)
testosterone transdermal gel in packet 1 %
(25 mg/2.5gram)
testosterone transdermal gel in packet 1 %
(50 mg/5 gram)
$0 - $7.40
(Tier 2)
PA; QL (30 per 30
days)
$0 - $7.40
(Tier 2)
PA; QL (150 per 30
days)
$0 - $7.40
(Tier 2)
PA; QL (150 per 30
days)
(Fluoxymesterone)
(Danazol)
$0 (Tier 1)
$0 (Tier 1)
(Oxandrin)
(Depo-Testosterone)
$0 (Tier 1)
$0 (Tier 1)
PA
(Testosterone
Enanthate)
(Testim)
$0 (Tier 1)
PA; QL (5 per 28 days)
$0 (Tier 1)
(Vogelxo)
$0 (Tier 1)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
(Androgel)
$0 (Tier 1)
(Testim)
$0 (Tier 1)
(Activella)
$0 (Tier 1)
PA; QL (300 per 30
days)
PA; QL (300 per 30
days)
Estrogens And Antiestrogens
amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg
PA-HRM; AGE (Max
64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
180
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
COMBIPATCH TRANSDERMAL
PATCH SEMIWEEKLY 0.05-0.14
MG/24 HR, 0.05-0.25 MG/24 HR
DUAVEE ORAL TABLET 0.45-20 MG
$0 - $7.40
(Tier 2)
(Vagifem)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
estradiol transdermal patch semiweekly
0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05
mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr
estradiol transdermal patch weekly 0.025
mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr,
0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24
hr
estradiol valerate intramuscular oil 10
mg/ml, 20 mg/ml, 40 mg/ml
estradiol-norethindrone acet oral tablet
0.5-0.1 mg, 1-0.5 mg
estropipate oral tablet 0.75 mg, 1.5 mg, 3
mg
FEMRING VAGINAL RING 0.05
MG/24 HR, 0.1 MG/24 HR
MENEST ORAL TABLET 0.3 MG,
0.625 MG, 1.25 MG, 2.5 MG
mimvey lo oral tablet 0.5-0.1 mg
(Vivelle-Dot)
$0 (Tier 1)
(Climara)
$0 (Tier 1)
(Delestrogen)
$0 (Tier 1)
(Activella)
$0 (Tier 1)
(Estropipate)
$0 (Tier 1)
(Activella)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
mimvey oral tablet 1-0.5 mg
(Activella)
$0 (Tier 1)
ESTRACE VAGINAL CREAM 0.01 %
(0.1 MG/GRAM)
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
PREMARIN INJECTION RECON
SOLN 25 MG
PREMARIN ORAL TABLET 0.3 MG,
0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (8 per
28 days); AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; QL (8 per
28 days); AGE (Max
64 Years)
PA-HRM; QL (4 per
28 days); AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (1 per 84 days)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
181
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
PREMARIN VAGINAL CREAM
0.625 MG/GRAM
PREMPHASE ORAL TABLET 0.625
MG (14)/ 0.625MG-5MG(14)
PREMPRO ORAL TABLET 0.3-1.5
MG, 0.45-1.5 MG, 0.625-2.5 MG,
0.625-5 MG
raloxifene oral tablet 60 mg
VAGIFEM VAGINAL TABLET 10
MCG
yuvafem vaginal tablet 10 mcg
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Evista)
(Vagifem)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
QL (18 per 28 days)
QL (18 per 28 days)
Glucocorticoids/Mineralocorti
coids
a-hydrocort injection recon soln 100 mg
betamethasone acet,sod phos injection
suspension 6 mg/ml
cortisone oral tablet 25 mg
dexamethasone oral elixir 0.5 mg/5 ml
dexamethasone oral tablet 0.5 mg, 0.75
mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg
dexamethasone sodium phosphate
injection solution 10 mg/ml, 4 mg/ml
fludrocortisone oral tablet 0.1 mg
(Hydrocortisone Sod
Succinate)
(Celestone)
$0 (Tier 1)
(Cortisone Acetate)
(Dexamethasone)
(Dexamethasone)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Dexamethasone Sod
Phosphate)
(Fludrocortisone
Acetate)
hydrocortisone oral tablet 10 mg, 20 mg, 5 (Cortef)
mg
methylprednisolone acetate injection
(Depo-Medrol)
suspension 40 mg/ml, 80 mg/ml
methylprednisolone oral tablet 16 mg, 32 (Medrol)
mg, 4 mg, 8 mg
methylprednisolone oral tablets,dose pack (Medrol)
4 mg
$0 (Tier 1)
PA BvD
PA BvD
PA BvD
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
182
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
methylprednisolone sodium succ injection
recon soln 125 mg, 40 mg
methylprednisolone ss 1 gm vl
mdv,latex-free 1,000 mg
prednisolone sodium phosphate oral
solution 15 mg/5 ml (3 mg/ml), 25 mg/5
ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5
ml)
prednisone oral solution 5 mg/5 ml
prednisone oral tablet 1 mg, 2.5 mg, 20
mg, 5 mg, 50 mg
prednisone oral tablet 10 mg
prednisone oral tablets,dose pack 10 mg,
10 mg (48 pack), 5 mg, 5 mg (48 pack)
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML
triamcinolone acetonide injection
suspension 10 mg/ml, 40 mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
(Solu-Medrol)
$0 (Tier 1)
(Solu-Medrol)
$0 (Tier 1)
(Pediapred)
$0 (Tier 1)
PA BvD
(Prednisone)
(Prednisone)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
(Prednisone)
(Prednisone)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
(Triamcinolone
Acetonide)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
Pituitary
desmopressin injection solution 4 mcg/ml
desmopressin nasal solution 0.1 mg/ml
(refrigerate)
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 ml)
desmopressin oral tablet 0.1 mg, 0.2 mg
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2
MG/0.25 ML, 0.4 MG/0.25 ML, 0.6
MG/0.25 ML, 0.8 MG/0.25 ML, 1
MG/0.25 ML, 1.2 MG/0.25 ML, 1.4
MG/0.25 ML, 1.6 MG/0.25 ML, 1.8
MG/0.25 ML, 2 MG/0.25 ML
(Desmopressin
Acetate)
(DDAVP)
$0 (Tier 1)
$0 (Tier 1)
QL (15 per 30 days)
(Desmopressin
Acetate)
(DDAVP)
$0 (Tier 1)
QL (15 per 30 days)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
183
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36
UNIT/ML), 5 MG/ML (15 UNIT/ML)
INCRELEX SUBCUTANEOUS
SOLUTION 10 MG/ML
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
30 MG
LUPRON DEPOT-PED
INTRAMUSCULAR KIT 11.25 MG,
15 MG, 7.5 MG (PED)
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN INJECTOR
10 MG/1.5 ML (6.7 MG/ML), 15
MG/1.5 ML (10 MG/ML), 30 MG/3 ML
(10 MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
octreotide acet 50 mcg/ml syr
(Octreotide Acetate)
outer,single-dose,10 50 mcg/ml (1 ml)
octreotide acetate injection solution 1,000 (Sandostatin)
mcg/ml, 100 mcg/ml, 200 mcg/ml, 500
mcg/ml
octreotide acetate injection solution 50
(Octreotide Acetate)
mcg/ml
SAIZEN CLICK.EASY
SUBCUTANEOUS CARTRIDGE 8.8
MG/1.5 ML (FNL)
SAIZEN SUBCUTANEOUS RECON
SOLN 5 MG, 8.8 MG
SANDOSTATIN LAR 10 MG KIT 10
MG
SANDOSTATIN LAR 20 MG KIT 20
MG
What the
drug will
cost you
(Tier level)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
PA
QL (1 per 84 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
184
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
SANDOSTATIN LAR 30 MG KIT 30
MG
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 10 MG, 20 MG, 30 MG
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
SUBCUTANEOUS SYRINGE 120
MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3
ML
SOMAVERT SUBCUTANEOUS
RECON SOLN 10 MG, 15 MG, 20 MG,
25 MG, 30 MG
SUPPRELIN LA IMPLANT KIT 50
MG (65 MCG/DAY)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
QL (1 per 28 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (1 per 360 days)
$0 - $7.40
(Tier 2)
QL (10 per 28 days)
(Hydroxyprogesteron
e Caproate)
(Depo-Provera)
$0 (Tier 1)
PA NSO
$0 (Tier 1)
QL (1 per 84 days)
(Depo-Provera)
$0 (Tier 1)
QL (1 per 84 days)
(Provera)
$0 (Tier 1)
(Megace Es)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Aygestin)
$0 (Tier 1)
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION 400
MG/ML
hydroxyprogesterone caproate
intramuscular oil 250 mg/ml
medroxyprogesterone intramuscular
suspension 150 mg/ml
medroxyprogesterone intramuscular
syringe 150 mg/ml
medroxyprogesterone oral tablet 10 mg,
2.5 mg, 5 mg
MEGACE ES ORAL SUSPENSION
625 MG/5 ML
megestrol oral suspension 400 mg/10 ml
(40 mg/ml), 625 mg/5 ml
norethindrone acetate oral tablet 5 mg
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
185
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
progesterone in oil intramuscular oil 50
mg/ml
progesterone micronized oral capsule 100
mg, 200 mg
(Progesterone)
$0 (Tier 1)
(Prometrium)
$0 (Tier 1)
(Levothyroxine
Sodium)
(Levoxyl)
$0 (Tier 1)
(Cytomel)
$0 (Tier 1)
(Tapazole)
(Propylthiouracil)
$0 (Tier 1)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
Thyroid And Antithyroid
Agents
levothyroxine intravenous recon soln 100
mcg, 200 mcg, 500 mcg
levothyroxine oral tablet 100 mcg, 112
mcg, 125 mcg, 137 mcg, 150 mcg, 175
mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg,
75 mcg, 88 mcg
liothyronine oral tablet 25 mcg, 5 mcg, 50
mcg
methimazole oral tablet 10 mg, 5 mg
propylthiouracil oral tablet 50 mg
$0 (Tier 1)
Immunological Agents
Immunological Agents
ARCALYST SUBCUTANEOUS
RECON SOLN 220 MG
ASTAGRAF XL ORAL
CAPSULE,EXTENDED RELEASE
24HR 0.5 MG, 1 MG, 5 MG
AUBAGIO ORAL TABLET 14 MG, 7
MG
azathioprine oral tablet 50 mg
azathioprine sodium injection recon soln
100 mg
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 6
GRAM
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Imuran)
(Azathioprine
Sodium)
PA BvD
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA; QL (28 per 28
days)
PA BvD
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
186
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
CELLCEPT INTRAVENOUS
INTRAVENOUS RECON SOLN 500
MG
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT 400 MG (200
MG X 2 VIALS)
CIMZIA SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200
MG/ML X 2)
cyclosporine intravenous solution 250
mg/5 ml
cyclosporine modified oral capsule 100
mg, 25 mg, 50 mg
cyclosporine modified oral solution 100
mg/ml
cyclosporine oral capsule 100 mg, 25 mg
ENBREL SUBCUTANEOUS RECON
SOLN 25 MG (1 ML)
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML (0.51), 50
MG/ML (0.98 ML)
ENBREL SURECLICK
SUBCUTANEOUS PEN INJECTOR
50 MG/ML (0.98 ML)
ENVARSUS XR ORAL TABLET
EXTENDED RELEASE 24 HR 0.75
MG, 1 MG, 4 MG
FLEBOGAMMA DIF
INTRAVENOUS SOLUTION 10 %, 5
%
GAMASTAN S/D
INTRAMUSCULAR SOLUTION
15-18 % RANGE
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
PA
(Sandimmune)
$0 (Tier 1)
PA BvD
(Neoral)
$0 (Tier 1)
PA BvD
(Neoral)
$0 (Tier 1)
PA BvD
(Sandimmune)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
PA
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
187
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
GAMMAGARD LIQUID INJECTION
SOLUTION 10 %
GAMMAPLEX INTRAVENOUS
SOLUTION 5 %
gengraf oral capsule 100 mg, 25 mg, 50
(Neoral)
mg
gengraf oral solution 100 mg/ml
(Neoral)
HUMIRA PEDIATRIC CROHN'S
START SUBCUTANEOUS SYRINGE
KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6
PACK)
HUMIRA PEN CROHN'S-UC-HS
START SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML
HUMIRA PEN PSORIASIS-UVEITIS
SUBCUTANEOUS PEN INJECTOR
KIT 40 MG/0.8 ML
HUMIRA PEN SUBCUTANEOUS
PEN INJECTOR KIT 40 MG/0.8 ML
HUMIRA SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2 ML, 20
MG/0.4 ML, 40 MG/0.8 ML
HYPERRAB S/D (PF)
INTRAMUSCULAR SOLUTION 150
UNIT/ML, 150 UNIT/ML (10 ML)
HYQVIA IG COMPONENT
SUBCUTANEOUS SOLUTION 10
GRAM/100 ML (10 %), 2.5 GRAM/25
ML (10 %), 20 GRAM/200 ML (10 %),
30 GRAM/300 ML (10 %), 5 GRAM/50
ML (10 %)
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
$0 - $7.40
(Tier 2)
PA BvD
PA
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
PA BvD
PA BvD
PA
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
188
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
HYQVIA SUBCUTANEOUS
SOLUTION 10 GRAM /100 ML (10 %),
2.5 GRAM /25 ML (10 %), 20 GRAM
/200 ML (10 %), 30 GRAM /300 ML (10
%), 5 GRAM /50 ML (10 %)
ILARIS (PF) SUBCUTANEOUS
RECON SOLN 180 MG/1.2 ML (150
MG/ML)
IMOGAM RABIES-HT (PF)
INTRAMUSCULAR SOLUTION 150
UNIT/ML
KINERET SUBCUTANEOUS
SYRINGE 100 MG/0.67 ML
leflunomide oral tablet 10 mg, 20 mg
mycophenolate mofetil oral capsule 250
mg
mycophenolate mofetil oral suspension for
reconstitution 200 mg/ml
mycophenolate mofetil oral tablet 500 mg
mycophenolate sodium oral tablet,delayed
release (dr/ec) 180 mg, 360 mg
NULOJIX INTRAVENOUS RECON
SOLN 250 MG
OCTAGAM INTRAVENOUS
SOLUTION 10 %, 5 %
ORENCIA (WITH MALTOSE)
INTRAVENOUS RECON SOLN 250
MG
ORENCIA SUBCUTANEOUS
SYRINGE 125 MG/ML
PRIVIGEN INTRAVENOUS
SOLUTION 10 %
PROGRAF INTRAVENOUS
SOLUTION 5 MG/ML
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
PA; QL (18.76 per 28
days)
(Arava)
(Cellcept)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Cellcept)
$0 (Tier 1)
PA BvD
(Cellcept)
(Myfortic)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
PA BvD
PA BvD
PA
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
189
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
RAPAMUNE ORAL SOLUTION 1
MG/ML
RIDAURA ORAL CAPSULE 3 MG
sirolimus oral tablet 0.5 mg, 1 mg, 2 mg
(Rapamune)
tacrolimus oral capsule 0.5 mg, 1 mg, 5
(Hecoria)
mg
TYSABRI INTRAVENOUS
SOLUTION 300 MG/15 ML
ZORTRESS ORAL TABLET 0.25 MG,
0.5 MG, 0.75 MG
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
PA BvD
PA BvD
Vaccines
ACTHIB (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
ADACEL(TDAP
ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE 2
LF-(2.5-5-3-5 MCG)-5LF/0.5 ML
BCG (TICE STRAIN) VIAL
LATEX-FREE, OUTER 50 MG
BCG VACCINE, LIVE (PF)
PERCUTANEOUS SUSPENSION
FOR RECONSTITUTION 50 MG
BEXSERO (PF) INTRAMUSCULAR
SYRINGE 50-50-50-25 MCG/0.5 ML
BOOSTRIX TDAP
INTRAMUSCULAR SUSPENSION
2.5-8-5 LF-MCG-LF/0.5ML
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
190
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
BOOSTRIX TDAP
INTRAMUSCULAR SYRINGE
2.5-8-5 LF-MCG-LF/0.5ML
CERVARIX VACCINE (PF)
INTRAMUSCULAR SYRINGE 20-20
MCG/0.5 ML
COMVAX (PF) INTRAMUSCULAR
SUSPENSION 5-7.5-125 MCG/0.5 ML
DAPTACEL (DTAP PEDIATRIC)
(PF) INTRAMUSCULAR
SUSPENSION 15-10-5
LF-MCG-LF/0.5ML
ENGERIX-B (PF)
INTRAMUSCULAR SYRINGE 20
MCG/ML
ENGERIX-B 20 MCG/ML VIAL
10'S,ADULT,P/F,OUTER 20 MCG/ML
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SUSPENSION 10
MCG/0.5 ML
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SYRINGE 10
MCG/0.5 ML
GARDASIL (PF) INTRAMUSCULAR
SUSPENSION 20-40-40-20 MCG/0.5
ML
GARDASIL (PF) INTRAMUSCULAR
SYRINGE 20-40-40-20 MCG/0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR SUSPENSION
0.5 ML
GARDASIL 9 (PF)
INTRAMUSCULAR SYRINGE 0.5
ML
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD; QL (3 per
365 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD; QL (3 per
365 days)
PA BvD; QL (3 per
365 days)
$0 - $7.40
(Tier 2)
PA BvD; QL (3 per
365 days)
$0 - $7.40
(Tier 2)
QL (1.5 per 365 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (1.5 per 365 days)
$0 - $7.40
(Tier 2)
QL (1.5 per 365 days)
QL (1.5 per 365 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
191
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML
HAVRIX (PF) INTRAMUSCULAR
SYRINGE 1,440 ELISA UNIT/ML, 720
ELISA UNIT/0.5 ML
HIBERIX (PF) INTRAMUSCULAR
RECON SOLN 10 MCG/0.5 ML
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN
2.5 UNIT
INFANRIX (DTAP) (PF)
INTRAMUSCULAR SUSPENSION
25-58-10 LF-MCG-LF/0.5ML
IPOL INJECTION SUSPENSION
40-8-32 UNIT/0.5 ML
IPOL INJECTION SYRINGE 40-8-32
UNIT/0.5 ML
IXIARO (PF) INTRAMUSCULAR
SYRINGE 6 MCG/0.5 ML
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10
LF/0.5 ML
KINRIX (PF) INTRAMUSCULAR
SYRINGE 25 LF-58 MCG-10 LF/0.5
ML
MENACTRA (PF)
INTRAMUSCULAR SOLUTION 4
MCG/0.5 ML
MENHIBRIX (PF)
INTRAMUSCULAR RECON SOLN
5-2.5 MCG/0.5 ML
MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN 50
MCG
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
192
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5
MCG/0.5 ML
MENVEO MENA COMPONENT (PF)
INTRAMUSCULAR RECON SOLN
10 MCG /0.5 ML (FINAL)
MENVEO MENCYW-135 COMPNT
(PF) INTRAMUSCULAR RECON
SOLN 5 MCG X 3/ 0.5 ML (FINAL)
M-M-R II (PF) SUBCUTANEOUS
RECON SOLN 1,000-12,500
TCID50/0.5 ML
PEDIARIX (PF) INTRAMUSCULAR
SYRINGE 10 MCG-25LF-25
MCG-10LF/0.5 ML
PEDVAX HIB (PF)
INTRAMUSCULAR SOLUTION 7.5
MCG/0.5 ML
PENTACEL (PF) INTRAMUSCULAR
KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10EXP3-4.3-33.99 TCID50/0.5
QUADRACEL (PF)
INTRAMUSCULAR SUSPENSION 15
LF-48 MCG- 5 LF UNIT/0.5ML
RABAVERT (PF)
INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 2.5 UNIT
RECOMBIVAX HB (PF)
INTRAMUSCULAR SUSPENSION 10
MCG/ML, 40 MCG/ML
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (2 per 365 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (2 per 365 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD; QL (3 per
365 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
193
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
RECOMBIVAX HB (PF)
INTRAMUSCULAR SYRINGE 10
MCG/ML, 5 MCG/0.5 ML
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION 10EXP6
CCID50/ML
ROTATEQ VACCINE ORAL
SUSPENSION 2 ML
TENIVAC (PF) INTRAMUSCULAR
SYRINGE 5-2 LF UNIT/0.5 ML
TETANUS TOXOID,ADSORBED
(PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT/0.5 ML
TETANUS,DIPHTHERIA TOX
PED(PF) INTRAMUSCULAR
SUSPENSION 5-25 LF UNIT/0.5 ML
TETANUS-DIPHTHERIA
TOXOIDS-TD INTRAMUSCULAR
SUSPENSION 2-2 LF UNIT/0.5 ML
TRUMENBA INTRAMUSCULAR
SYRINGE 120 MCG/0.5 ML
TWINRIX (PF) INTRAMUSCULAR
SUSPENSION 720 ELISA UNIT -20
MCG/ML
TWINRIX (PF) INTRAMUSCULAR
SYRINGE 720 ELISA UNIT -20
MCG/ML
TYPHIM VI INTRAMUSCULAR
SOLUTION 25 MCG/0.5 ML
TYPHIM VI INTRAMUSCULAR
SYRINGE 25 MCG/0.5 ML
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 50 UNIT/ML
What the
drug will
cost you
(Tier level)
$0 - $7.40
(Tier 2)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; QL (3 per
365 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
194
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
VAQTA (PF) INTRAMUSCULAR
SYRINGE 25 UNIT/0.5 ML, 50
UNIT/ML
VAQTA 25 UNITS/0.5 ML VIAL SDV,
OUTER 25 UNIT/0.5 ML
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 1,350 UNIT/0.5
ML
YF-VAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 10 EXP4.74
UNIT/0.5 ML
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR
RECONSTITUTION 19,400 UNIT/0.65
ML
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (2 per 365 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (1 per 365 days)
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease
Agents
alosetron oral tablet 0.5 mg, 1 mg
APRISO ORAL
CAPSULE,EXTENDED RELEASE
24HR 0.375 GRAM
ASACOL HD ORAL
TABLET,DELAYED RELEASE
(DR/EC) 800 MG
balsalazide oral capsule 750 mg
budesonide oral
capsule,delayed,extend.release 3 mg
DELZICOL ORAL CAPSULE (WITH
DEL REL TABLETS) 400 MG
DIPENTUM ORAL CAPSULE 250
MG
(Alosetron HCl)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Colazal)
(Entocort EC)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
195
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
mesalamine oral tablet,delayed release
(dr/ec) 800 mg
(Asacol Hd)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation solution 0.25 %
(Acetic Acid)
LACTATED RINGERS IRRIGATION
SOLUTION
ringers irrigation solution
(Ringers Solution)
sodium chloride irrigation solution 0.9 %
(Sodium Chloride
Irrig Solution)
sorbitol irrigation solution 3 %, 3.3 %
(Sorbitol Solution)
sorbitol-mannitol urethral solution
(Mannitol/Sorbitol
2.7-0.54 g/100 ml
Solution)
water for irrigation, sterile irrigation
(Water For
solution
Irrigation,Sterile)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
Metabolic Bone Disease Agents
Metabolic Bone Disease
Agents
alendronate oral solution 70 mg/75 ml
alendronate oral tablet 10 mg, 40 mg, 5
mg
alendronate oral tablet 35 mg, 70 mg
calcitonin (salmon) nasal
spray,non-aerosol 200 unit/actuation
calcitriol intravenous solution 1 mcg/ml
calcitriol oral capsule 0.25 mcg, 0.5 mcg
calcitriol oral solution 1 mcg/ml
doxercalciferol intravenous solution 4
mcg/2 ml
doxercalciferol oral capsule 0.5 mcg, 1
mcg, 2.5 mcg
(Alendronate
Sodium)
(Fosamax)
$0 (Tier 1)
(Fosamax)
(Miacalcin)
$0 (Tier 1)
$0 (Tier 1)
(Calcitriol)
(Rocaltrol)
(Rocaltrol)
(Doxercalciferol)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Hectorol)
$0 (Tier 1)
QL (300 per 28 days)
$0 (Tier 1)
QL (4 per 28 days)
QL (3.7 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
196
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
FORTEO SUBCUTANEOUS PEN
INJECTOR 20 MCG/DOSE - 600
MCG/2.4 ML
FORTICAL NASAL
SPRAY,NON-AEROSOL 200
UNIT/ACTUATION
ibandronate intravenous solution 3 mg/3
ml
ibandronate intravenous syringe 3 mg/3 ml
ibandronate oral tablet 150 mg
MIACALCIN INJECTION
SOLUTION 200 UNIT/ML
NATPARA SUBCUTANEOUS
CARTRIDGE 100 MCG/DOSE, 25
MCG/DOSE, 50 MCG/DOSE, 75
MCG/DOSE
paricalcitol hemodialysis port injection
solution 2 mcg/ml
PARICALCITOL HEMODIALYSIS
PORT INJECTION SOLUTION 5
MCG/ML
paricalcitol oral capsule 1 mcg, 2 mcg, 4
mcg
PROLIA SUBCUTANEOUS
SYRINGE 60 MG/ML
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
ZEMPLAR INTRAVENOUS
SOLUTION 2 MCG/ML, 5 MCG/ML
zoledronic acid intravenous solution 4
mg/5 ml
zoledronic acid-mannitol-water
intravenous piggyback 4 mg/100 ml
(Ibandronate
Sodium)
(Boniva)
(Boniva)
(Zemplar)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
PA; QL (2.4 per 28
days)
$0 - $7.40
(Tier 2)
QL (3.7 per 28 days)
$0 (Tier 1)
QL (3 per 84 days)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
QL (3 per 84 days)
QL (1 per 28 days)
PA; QL (2 per 28 days)
$0 (Tier 1)
$0 (Tier 1)
(Zemplar)
(Actonel)
(Actonel)
(Zometa)
(Zoledronic
Acid/Mannitol-Water
)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
QL (1 per 180 days)
QL (1 per 28 days)
QL (30 per 28 days)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
197
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
zoledronic acid-mannitol-water
intravenous solution 5 mg/100 ml
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100 ML
(Reclast)
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
QL (100 per 300 days)
$0 - $7.40
(Tier 2)
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic
Agents
ACTEMRA INTRAVENOUS
SOLUTION 200 MG/10 ML (20
MG/ML), 400 MG/20 ML (20 MG/ML),
80 MG/4 ML (20 MG/ML)
ACTEMRA SUBCUTANEOUS
SYRINGE 162 MG/0.9 ML
ACTIMMUNE SUBCUTANEOUS
SOLUTION 100 MCG/0.5 ML
allopurinol oral tablet 100 mg, 300 mg
amifostine crystalline intravenous recon
soln 500 mg
anticoag citrate phos dextrose solution
2.63-222 gram-mg/100ml
AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT 30 MCG
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT 30 MCG/0.5 ML
AVONEX INTRAMUSCULAR
SYRINGE KIT 30 MCG/0.5 ML
BENLYSTA INTRAVENOUS RECON
SOLN 120 MG, 400 MG
BETASERON SUBCUTANEOUS KIT
0.3 MG
bethanechol chloride oral tablet 10 mg, 25
mg, 5 mg, 50 mg
(Zyloprim)
(Ethyol)
(Citrate Phosphate
Dextros Soln)
(Urecholine)
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
PA
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
ST
ST
ST
PA
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
198
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
buspirone oral tablet 10 mg, 15 mg, 30 mg, (Buspirone HCl)
5 mg, 7.5 mg
CERDELGA ORAL CAPSULE 84 MG
CETYLEV ORAL TABLET,
EFFERVESCENT 2.5 GRAM, 500 MG
colchicine oral tablet 0.6 mg
COPAXONE SUBCUTANEOUS
SYRINGE 20 MG/ML, 40 MG/ML
CYSTADANE ORAL POWDER 1
GRAM/1.7 ML
droperidol injection solution 2.5 mg/ml
dutasteride oral capsule 0.5 mg
dutasteride-tamsulosin oral capsule, er
multiphase 24 hr 0.5-0.4 mg
ELMIRON ORAL CAPSULE 100 MG
(Colcrys)
(Droperidol)
(Avodart)
(Jalyn)
ergoloid oral tablet 1 mg
(Ergoloid Mesylates)
EXONDYS 51 INTRAVENOUS
SOLUTION 50 MG/ML
EXTAVIA SUBCUTANEOUS KIT 0.3
MG
finasteride oral tablet 5 mg
(Proscar)
fomepizole intravenous solution 1 gram/ml (Fomepizole)
FUSILEV INTRAVENOUS RECON
SOLN 50 MG
GAUZE PAD TOPICAL BANDAGE 2
X2"
GILENYA ORAL CAPSULE 0.5 MG
GLUCAGEN HYPOKIT INJECTION
RECON SOLN 1 MG
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
QL (30 per 30 days)
PA; LA
ST
QL (28 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
199
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
GLUCAGON EMERGENCY KIT
(HUMAN) INJECTION KIT 1 MG
gnp epsom salt granules 495 mg/5 gram *
guanidine oral tablet 125 mg
hydroxyzine hcl intramuscular solution 25
mg/ml, 50 mg/ml
hydroxyzine hcl oral solution 10 mg/5 ml
(Magnesium Sulfate)
(Guanidine HCl)
(Hydroxyzine HCl)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
(Hydroxyzine HCl)
$0 (Tier 1)
hydroxyzine hcl oral tablet 10 mg, 25 mg, (Hydroxyzine HCl)
50 mg
hydroxyzine pamoate oral capsule 100 mg, (Vistaril)
25 mg, 50 mg
INFLECTRA INTRAVENOUS
RECON SOLN 100 MG
KEVEYIS ORAL TABLET 50 MG
$0 (Tier 1)
LEMTRADA INTRAVENOUS
SOLUTION 12 MG/1.2 ML
leucovorin calcium 200 mg vial sdv, p/f,
latex-free 200 mg
leucovorin calcium injection recon soln 100
mg, 350 mg, 50 mg
leucovorin calcium oral tablet 10 mg, 15
mg, 25 mg, 5 mg
levocarnitine (with sugar) oral solution
100 mg/ml
levocarnitine oral tablet 330 mg
levoleucovorin intravenous recon soln 50
mg
licide spray 0.2-1 % *
mesna intravenous solution 100 mg/ml
MESNEX ORAL TABLET 400 MG
$0 (Tier 1)
(Leucovorin Calcium)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(Leucovorin Calcium)
$0 (Tier 1)
(Leucovorin Calcium)
$0 (Tier 1)
(Levocarnitine (With
Sugar))
(Carnitor)
(Fusilev)
$0 (Tier 1)
(Piperonyl
Butoxide/Pyrethrins)
(Mesnex)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA
PA NSO; QL (120 per
30 days)
PA
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
200
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
MESTINON ORAL SYRUP 60 MG/5
ML
MESTINON TIMESPAN ORAL
TABLET EXTENDED RELEASE 180
MG
morrhuate sodium intravenous solution 5
(Sodium Morrhuate)
%
ORENCIA CLICKJECT
SUBCUTANEOUS AUTO-INJECTOR
125 MG/ML
ORFADIN ORAL SUSPENSION 4
MG/ML
OTEZLA ORAL TABLET 30 MG
OTEZLA STARTER ORAL
TABLETS,DOSE PACK 10 MG (4)-20
MG (4)-30 MG (47), 10 MG (4)-20 MG
(4)-30 MG(19)
OTREXUP (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.4 ML,
12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5
MG/0.4 ML, 20 MG/0.4 ML, 22.5
MG/0.4 ML, 25 MG/0.4 ML, 7.5
MG/0.4 ML
PANTILINERS PAD *
PLEGRIDY SUBCUTANEOUS PEN
INJECTOR 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
PLEGRIDY SUBCUTANEOUS
SYRINGE 125 MCG/0.5 ML, 63
MCG/0.5 ML- 94 MCG/0.5 ML
POLYETHYLENE GLYCOL 3350
GRAN *
probenecid oral tablet 500 mg
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
ST
ST
$0 (Tier 4)
(Probenecid)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
201
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
probenecid-colchicine oral tablet 500-0.5
mg
PROCYSBI ORAL CAPSULE,
DELAYED REL SPRINKLE 25 MG,
75 MG
pyridostigmine bromide oral tablet 60 mg
pyridostigmine bromide oral tablet
extended release 180 mg
RASUVO (PF) SUBCUTANEOUS
AUTO-INJECTOR 10 MG/0.2 ML,
12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5
MG/0.35 ML, 20 MG/0.4 ML, 22.5
MG/0.45 ML, 25 MG/0.5 ML, 27.5
MG/0.55 ML, 30 MG/0.6 ML, 7.5
MG/0.15 ML
REBIF (WITH ALBUMIN)
SUBCUTANEOUS SYRINGE 22
MCG/0.5 ML, 44 MCG/0.5 ML
REBIF REBIDOSE SUBCUTANEOUS
PEN INJECTOR 22 MCG/0.5 ML, 44
MCG/0.5 ML, 8.8MCG/0.2ML-22
MCG/0.5ML (6)
REBIF TITRATION PACK
SUBCUTANEOUS SYRINGE
8.8MCG/0.2ML-22 MCG/0.5ML (6)
REMICADE INTRAVENOUS
RECON SOLN 100 MG
SENSIPAR ORAL TABLET 30 MG, 60
MG, 90 MG
SIGNIFOR SUBCUTANEOUS
SOLUTION 0.3 MG/ML (1 ML), 0.6
MG/ML (1 ML), 0.9 MG/ML (1 ML)
SIMPONI ARIA INTRAVENOUS
SOLUTION 12.5 MG/ML
(Probenecid/Colchici
ne)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 - $7.40
(Tier 2)
(Mestinon)
(Mestinon)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
PA
QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
202
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML, 50 MG/0.5
ML
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML, 50 MG/0.5 ML
STELARA INTRAVENOUS
SOLUTION 130 MG/26 ML
STELARA SUBCUTANEOUS
SYRINGE 45 MG/0.5 ML, 90 MG/ML
STERILE PADS 2" X 2" 2 X 2 "
SYNAREL NASAL
SPRAY,NON-AEROSOL 2 MG/ML
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240
MG (46), 240 MG
THALOMID ORAL CAPSULE 100
MG, 150 MG, 200 MG, 50 MG
TYBOST ORAL TABLET 150 MG
ULORIC ORAL TABLET 40 MG, 80
MG
XELJANZ ORAL TABLET 5 MG
XELJANZ XR ORAL TABLET
EXTENDED RELEASE 24 HR 11 MG
ZINBRYTA SUBCUTANEOUS
SYRINGE 150 MG/ML
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA
$0 - $7.40
(Tier 2)
QL (60 per 30 days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
PA
PA
QL (14 per 30 days)
QL (30 per 30 days)
PA; QL (60 per 30
days)
PA; QL (30 per 30
days)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
203
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended
release 500 mg
acetazolamide oral tablet 125 mg, 250 mg
acetazolamide sodium injection recon soln
500 mg
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT OPHTHALMIC
DROPS,SUSPENSION 1 %
betaxolol ophthalmic drops 0.5 %
bimatoprost ophthalmic drops 0.03 %
brimonidine ophthalmic drops 0.15 %, 0.2
%
COMBIGAN OPHTHALMIC DROPS
0.2-0.5 %
dorzolamide ophthalmic drops 2 %
dorzolamide-timolol ophthalmic drops
22.3-6.8 mg/ml
latanoprost ophthalmic drops 0.005 %
levobunolol ophthalmic drops 0.25 %, 0.5
%
LUMIGAN OPHTHALMIC DROPS
0.01 %
methazolamide oral tablet 25 mg, 50 mg
metipranolol ophthalmic drops 0.3 %
PHOSPHOLINE IODIDE
OPHTHALMIC DROPS 0.125 %
pilocarpine hcl ophthalmic drops 1 %, 2 %,
4%
SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION 1-0.2 %
(Diamox Sequels)
$0 (Tier 1)
(Acetazolamide)
(Acetazolamide
Sodium)
$0 (Tier 1)
$0 (Tier 1)
(Betaxolol HCl)
(Bimatoprost)
(Alphagan P)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Trusopt)
(Cosopt)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Xalatan)
(Betagan)
$0 (Tier 1)
$0 (Tier 1)
(Neptazane)
(Metipranolol)
(Isopto Carpine)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
(drops: 0.15%, 0.20%)
QL (2.5 per 25 days)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
204
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
timolol maleate ophthalmic drops 0.25 %,
0.5 %
timolol maleate ophthalmic gel forming
solution 0.25 %, 0.5 %
TRAVATAN Z OPHTHALMIC
DROPS 0.004 %
travoprost (benzalkonium) ophthalmic
drops 0.004 %
(Timoptic)
$0 (Tier 1)
(Timoptic-Xe)
$0 (Tier 1)
(Travoprost
(Benzalkonium))
$0 - $7.40
(Tier 2)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
QL (2.5 per 25 days)
QL (2.5 per 25 days)
Replacement Preparations
Replacement Preparations
calci-mix 1.25 gm capsule 500 mg calcium
(1,250 mg) *
calcitrate + vit d caplet 315-250 mg-unit *
calcitrate 200 mg (950 mg) tab 200 mg
(950 mg) *
cal-citrate plus vitamin d tab 250-100
mg-unit *
calcium 500+d tablet chew 500
mg(1,250mg) -400 unit *
calcium 500-vit d3 200 tablet 500
mg(1,250mg) -200 unit *
calcium 600 + vit d 400 caplet s/f, p/f,
caplet 600 mg(1,500mg) -400 unit *
calcium 600 + vit d 400 softgl 600
mg(1,500mg) -400 unit *
(Calcium Carbonate)
$0 (Tier 4)
(Citracal-Vitamin D)
(Calcium Citrate)
$0 (Tier 4)
$0 (Tier 4)
(Calcium
Citrate/Vitamin D2)
(Calcium 600 + Vit
D)
(Caltrate 600 Plus
D3)
(Caltrate 600 Plus
D3)
(Calcium
Carbonate/Vitamin
D3)
calcium 600 + vit d tablet 600-125 mg-unit (Caltrate 600 Plus
*
D3)
calcium 600 + vitamin d sftgl rapid
(Calcium
release, sftgl 600 mg(1,500mg) -500 unit Carbonate/Vitamin
*
D3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
205
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
calcium 600+d softgel 600 mg calcium200 unit *
calcium 600-vit d3 200 tablet 600
mg(1,500mg) -200 unit *
calcium 600-vit d3 400 tablet 600
mg(1,500mg) -400 unit *
calcium adult gummies 250 mg calcium350 unit *
calcium carbonate 648 mg tab 260 mg
calcium (648 mg) *
calcium chloride intravenous solution 100
mg/ml (10 %)
calcium chloride intravenous syringe 100
mg/ml (10 %)
calcium citrate - vit d caplet caplet, coated
315-200 mg-unit *
calcium citrate malate with d 250-100
mg-unit *
calcium citrate with d tablet p/f,s/f
200-125 mg-unit *
calcium cit-vit d 250-200 cplt s/f, p/f,
caplet 250 mg calcium- 200 unit *
calcium cit-vit d 250-200 tab p/f,coated,no
lact 250 mg calcium- 200 unit *
calcium gluconate 50 mg tablet 50 mg
calcium *
calcium gluconate 500 mg tab 45 mg (500
mg) *
calcium gluconate 648 mg tab 61 mg (648
mg) *
calcium gluconate 650 mg tab 60 mg (650
mg) *
(Calcium
Carbonate/Vitamin
D3)
(Caltrate 600 Plus
D3)
(Caltrate 600 Plus
D3)
(Citracal + D3)
$0 (Tier 4)
(Calcium Carbonate)
$0 (Tier 4)
(Calcium Chloride)
$0 (Tier 1)
(Calcium Chloride)
$0 (Tier 1)
(Citracal-Vitamin D)
$0 (Tier 4)
(Calcium Cit
Malate/Vitamin D3)
(Citracal-Vitamin D)
$0 (Tier 4)
(Citracal-Vitamin D)
$0 (Tier 4)
(Citracal-Vitamin D)
$0 (Tier 4)
(Calcium Gluconate)
$0 (Tier 4)
(Calcium Gluconate)
$0 (Tier 4)
(Calcium Gluconate)
$0 (Tier 4)
(Calcium Gluconate)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
206
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
calcium gluconate intravenous solution
100 mg/ml (10%)
calcium gummies 250 mg calcium- 500
unit *
calcium lactate 648 mg tablet 84 mg (648
mg) *
calcium with magnesium tab 300-300 mg *
calcium with vit d tablet 600-125 mg-unit
*
calcium with vit d tablet caplet,s/f,na/f,p/f
1,500-200 mg-unit *
CALTRATE 600 + D SOFT CHEW
TAB VANILLA CREME 600 MG
(1,500 MG)-800 UNIT *
CALTRATE 600 PLUS D3 TABLET
600 MG(1,500MG) -800 UNIT *
citracal + d maximum caplet 315-250
mg-unit *
citrus calcium + d tablet 315-250 mg-unit
*
citrus calcium-vit d 200-250 200 mg
calcium -250 unit *
cvs calcium + vit d3 gummies 250-400
mg-unit *
cvs calcium + vitamin d3 sftgl absorbable
600 mg(1,500mg) -500 unit *
(Calcium Gluconate)
$0 (Tier 1)
(Citracal + D3)
$0 (Tier 4)
(Calcium Lactate)
$0 (Tier 4)
(Calcium/Magnesium
)
(Calcium
Carbonate/Vitamin
D2)
(Calcium
Citrate/Vitamin D2)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Citracal-Vitamin D)
$0 (Tier 4)
(Citracal-Vitamin D)
$0 (Tier 4)
(Citracal-Vitamin D)
$0 (Tier 4)
(Citracal + D3)
$0 (Tier 4)
(Calcium
Carbonate/Vitamin
D3)
cvs calcium 500 + vit d tablet oyster shell (Caltrate 600 Plus
500 mg(1,250mg) -125 unit *
D3)
cvs calcium 600-vit d3 800 tab p/f,
(Caltrate 600 Plus
s/f,gluten-free 600 mg(1,500mg) -800 unit D3)
*
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
207
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
cvs magnesium 250 mg tablet 250 mg *
cvs pediatric electrolyte soln *
cvs pediatric electrolyte soln a/f, p/f *
d10 %-0.45 % sodium chloride intravenous
parenteral solution
d2.5 %-0.45 % sodium chloride
intravenous parenteral solution
d5 % and 0.9 % sodium chloride
intravenous parenteral solution
d5 %-0.45 % sodium chloride intravenous
parenteral solution
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
dextrose 5 %-lactated ringers intravenous
parenteral solution
dextrose 5%-0.2 % sod chloride
intravenous parenteral solution
dextrose 5%-0.3 % sod.chloride
intravenous parenteral solution
dextrose with sodium chloride intravenous
parenteral solution 5-0.2 %
dextrose-kcl-nacl intravenous solution
5-0.224-0.225 %
effer-k oral tablet, effervescent 25 meq
electrolyte-48 in d5w intravenous
parenteral solution
eql calcium 600 mg + d softgel 600
mg(1,500mg) -100 unit *
eql children's calcium gummies 100 mg
calcium -100 unit *
gnp calcium 500-vit d3 600 tab 500mg
(1,250mg) -600 unit *
(Magnesium)
(Pedialyte)
(Pedialyte)
(Dextrose 10 % and
0.45 % NaCl)
(Dextrose 2.5 % and
0.45 % NaCl)
(Dextrose 5 % and 0.9
% NaCl)
(Dextrose 5 %-0.45 %
NaCl)
(Dextrose 10 % and
0.2 % NaCl)
(Dextrose
5%-Lactated Ringers)
(Dextrose 5 %-0.2 %
NaCl)
(Dextrose 5 % and 0.3
% NaCl)
(Dextrose 5 %-0.2 %
NaCl)
(Potassium
Chloride/D5-0.2%Na
Cl)
(Klor-Con-Ef)
(Electrolyte-48
Solution/D5W)
(Calcium
Carbonate/Vitamin
D3)
(Calcium Phos
Tribas/Vitamin D2)
(Caltrate 600 Plus
D3)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
208
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
hm calcium citrate-vit d cplt caplet,
gluten-free 315-250 mg-unit *
HYPERLYTE CR INTRAVENOUS
SOLUTION 25-20-5-5-30-30 MEQ/20
ML
IONOSOL-B IN D5W
INTRAVENOUS PARENTERAL
SOLUTION 5 %
IONOSOL-MB IN D5W
INTRAVENOUS PARENTERAL
SOLUTION 5 %
ISOLYTE M IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL
SOLUTION
ISOLYTE-H IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL
SOLUTION 5 %
ISOLYTE-P IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL
SOLUTION 5 %
ISOLYTE-S INTRAVENOUS
PARENTERAL SOLUTION
k-effervescent oral tablet, effervescent 25
meq
KLOR-CON 10 ORAL TABLET
EXTENDED RELEASE 10 MEQ
klor-con m10 oral tablet,er
particles/crystals 10 meq
klor-con m15 oral tablet,er
particles/crystals 15 meq
klor-con m20 oral tablet,er
particles/crystals 20 meq
klor-con sprinkle oral capsule, extended
release 10 meq, 8 meq
(Citracal-Vitamin D)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Klor-Con-Ef)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
209
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
(Calcium
Carbonate/Vitamin
D3)
liquid calcium 600-vit d3 sfgl
(Calcium
softgel,p/f,gluten-f 600 mg(1,500mg) -500 Carbonate/Vitamin
unit *
D3)
liquid calcium with vitamin d softgel, s/f,
(Calcium
p/f 600 mg calcium- 200 unit *
Carbonate/Vitamin
D3)
mag delay dr 64 mg tablet 64 mg *
(Slow-Mag)
mag64 dr 64 mg tablet 64 mg *
(Slow-Mag)
magbid er 84 mg tablet 84 mg *
(Mag-Tab SR)
mag-g 500 mg tablet 27 mg (500 mg) *
(Magonate)
magnesium 200 mg tablet
(Magnesium)
salt,starch,s/f,p/f 200 mg *
magnesium 250 mg tablet 250 mg *
(Magnesium)
MAGNESIUM CHLORIDE 64 MG
TAB SLOW, E/C, W/CALCIUM 64
MG *
magnesium chloride injection solution 200 (Magnesium
mg/ml (20 %)
Chloride)
MAGNESIUM CITRATE 100 MG
TAB 100 MG *
magnesium gluc 500 mg tablet 27 mg (500 (Magonate)
mg) *
magnesium sulfate in d5w intravenous
(Magnesium
piggyback 1 gram/100 ml, 4 gram/100 ml Sulfate/D5W)
magnesium sulfate in water intravenous
(Magnesium Sulfate
parenteral solution 20 gram/500 ml (4 %), in Water)
40 gram/1,000 ml (4 %)
magnesium sulfate in water intravenous
(Magnesium Sulfate
piggyback 2 gram/50 ml (4 %), 4
in Water)
gram/100 ml (4 %), 4 gram/50 ml (8 %)
liquid calcium 600-vit d3 sfgl 600
mg(1,500mg) -400 unit *
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
210
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
magnesium sulfate injection solution 4
meq/ml (50 %)
magnesium sulfate injection syringe 4
meq/ml
MAGONATE 27 MG TABLET 27 MG
(500 MG) *
MAGONATE 54 MG/5 ML LIQUID 54
MG/5 ML *
natural calcium 500 mg tablet 500 mg
calcium (1,250 mg) *
NORMOSOL-M IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL
SOLUTION
NORMOSOL-R PH 7.4
INTRAVENOUS PARENTERAL
SOLUTION
nu-mag 71.5 mg tablet 71.5 mg *
NUTRILYTE II INTRAVENOUS
SOLUTION 35-20-5 MEQ/20 ML
NUTRILYTE INTRAVENOUS
SOLUTION 25-40.6-5 MEQ/20 ML
oralyte electrolyte soln *
oralyte freezer pops *
oysco 500-vit d3 200 tablet 500
mg(1,250mg) -200 unit *
oysco-500 tablet 500 mg calcium (1,250
mg) *
oyster shell 500-vit d3 200 tb 500
mg(1,250mg) -200 unit *
oyster shell calcium 500 mg tb 500mg
elemental ca 500 mg calcium (1,250 mg) *
oyster shell calcium tablet 500
mg(1,250mg) -400 unit *
(Magnesium Sulfate)
$0 (Tier 1)
(Magnesium Sulfate)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
(Calcium Carbonate)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Slow-Mag)
(Pedialyte)
(Pedialyte)
(Caltrate 600 Plus
D3)
(Calcium Carbonate)
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Caltrate 600 Plus
D3)
(Calcium Carbonate)
$0 (Tier 4)
(Caltrate 600 Plus
D3)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
211
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
oyster shell calcium-vit d tab
p/f,s/f,gluten-free 500 mg(1,250mg) -400
unit *
oystercal-d 500 mg-400 unit tb 500
mg(1,250mg) -400 unit *
PEDIALYTE SOLUTION *
pediatric electrolyte pwd pack natural
flavor 10.6-4.7 meq/8.5 gram *
pediatric electrolyte solution *
phospha 250 neutral oral tablet 250 mg
PLASMA-LYTE 148 INTRAVENOUS
PARENTERAL SOLUTION
PLASMA-LYTE A INTRAVENOUS
PARENTERAL SOLUTION
PLASMA-LYTE-56 IN 5 %
DEXTROSE INTRAVENOUS
PARENTERAL SOLUTION 5 %
potassium acetate intravenous solution 2
meq/ml, 4 meq/ml
potassium bicarb and chloride oral tablet,
effervescent 25 meq
potassium bicarb-citric acid oral tablet,
effervescent 25 meq
potassium chlorid-d5-0.45%nacl
intravenous parenteral solution 10 meq/l,
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in 0.9%nacl
intravenous parenteral solution 20 meq/l,
40 meq/l
potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 30 meq/l, 40
meq/l
potassium chloride in lr-d5 intravenous
parenteral solution 20 meq/l
(Caltrate 600 Plus
D3)
$0 (Tier 4)
(Caltrate 600 Plus
D3)
$0 (Tier 4)
(Pedialyte)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
(Pedialyte)
(K-Phos Neutral)
$0 (Tier 4)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(Potassium Acetate)
$0 (Tier 1)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
$0 (Tier 1)
(Potassium
Chloride/D5-0.45nacl
)
(Potassium Chloride
In 0.9%NaCl)
$0 (Tier 1)
(Potassium Chloride
In D5w)
$0 (Tier 1)
(Potassium Chloride
In Lr-D5)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
212
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
potassium chloride intravenous piggyback
10 meq/100 ml, 20 meq/100 ml, 30
meq/100 ml, 40 meq/100 ml
potassium chloride intravenous solution 2
meq/ml
potassium chloride oral capsule, extended
release 10 meq, 8 meq
potassium chloride oral liquid 20 meq/15
ml, 40 meq/15 ml
potassium chloride oral packet 20 meq
potassium chloride oral tablet extended
release 8 meq
potassium chloride oral tablet,er
particles/crystals 10 meq
potassium chloride oral tablet,er
particles/crystals 20 meq
potassium chloride-0.45 % nacl
intravenous parenteral solution 20 meq/l
potassium chloride-d5-0.2%nacl
intravenous parenteral solution 10 meq/l,
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride-d5-0.3%nacl
intravenous parenteral solution 20 meq/l
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
(Klor-Con)
(Klor-Con 10)
$0 (Tier 1)
$0 (Tier 1)
(Klor-Con 10)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
(Potassium
Chloride-0.45%
NaCl)
(Potassium
Chloride/D5-0.2%Na
Cl)
(Potassium
Chloride/D5-0.3%Na
Cl)
(Potassium
Chloride/D5-0.9%Na
Cl)
(Urocit-K)
$0 (Tier 1)
potassium chloride-d5-0.9%nacl
intravenous parenteral solution 20 meq/l,
40 meq/l
potassium citrate oral tablet extended
release 10 meq (1,080 mg), 15 meq, 5 meq
(540 mg)
potassium citrate-citric acid oral packet
(Potassium
3,300-1,002 mg
Citrate/Citric Acid)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
213
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
potassium cl 10 meq/50 ml sol 10 meq/50
ml
potassium cl 20 meq/50 ml sol 20 meq/50
ml
potassium cl er 10 meq tablet 10 meq
potassium cl er 10 meq tablet f/c 10 meq
potassium cl er 20 meq tablet 20 meq
potassium phosphate m-/d-basic
intravenous solution 3 mmol/ml
ra pediatric electrolyte soln a/f *
ra pediatric freezer pops *
ringers intravenous parenteral solution
risacal-d tablet 105-120 mg-unit *
sm calcium 600-vit d3 800 tab 600
mg(1,500mg) -800 unit *
sm magnesium 250 mg tablet 250 mg *
sm pediatric electrolyte soln *
sodium acetate intravenous solution 2
meq/ml, 4 meq/ml
sodium bicarbonate intravenous solution 1
meq/ml (8.4 %)
sodium bicarbonate intravenous syringe 10
meq/10 ml (8.4 %), 4.2 % (0.5 meq/ml),
7.5 % (0.9 meq/ml), 8.4 % (1 meq/ml)
sodium chloride 0.45 % intravenous
parenteral solution 0.45 %
sodium chloride 0.9 % intravenous
parenteral solution 0.9 %
sodium chloride 3 % intravenous
parenteral solution 3 %
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride)
$0 (Tier 1)
(Potassium Chloride)
(Klor-Con 10)
(Potassium Chloride)
(Potassium
Phos,M-Basic-D-Basi
c)
(Pedialyte)
(Pedialyte)
(Ringers Solution)
(Calcium Phosphate
Dibas/Vit D3)
(Caltrate 600 Plus
D3)
(Magnesium)
(Pedialyte)
(Sodium Acetate)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Sodium Bicarbonate)
$0 (Tier 1)
(Sodium Bicarbonate)
$0 (Tier 1)
(Sodium Chloride
0.45 %)
(0.9 % Sodium
Chloride)
(Sodium Chloride 3
%)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
214
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
sodium chloride 5 % intravenous
parenteral solution 5 %
sodium chloride intravenous parenteral
solution 2.5 meq/ml, 4 meq/ml
sodium lactate intravenous solution 5
meq/ml
sodium phosphate intravenous solution 3
mmol/ml
TPN ELECTROLYTES II IV SOLN
25'S,20ML/50ML FTV 18-18-5-4.5-35
MEQ/20 ML
TPN ELECTROLYTES
INTRAVENOUS SOLUTION 35-20-5
MEQ/20 ML
virt-phos 250 neutral oral tablet 250 mg
(Sodium Chloride 5
%)
(Sodium Chloride)
$0 (Tier 1)
(Sodium Lactate)
$0 (Tier 1)
(Sodium
Phos,M-Basic-D-Basi
c)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
(K-Phos Neutral)
$0 (Tier 1)
Respiratory Tract Agents
Anti-Inflammatories, Inhaled
Corticosteroids
ADVAIR DISKUS INHALATION
BLISTER WITH DEVICE 100-50
MCG/DOSE, 250-50 MCG/DOSE,
500-50 MCG/DOSE
ADVAIR HFA INHALATION HFA
AEROSOL INHALER 115-21
MCG/ACTUATION, 230-21
MCG/ACTUATION, 45-21
MCG/ACTUATION
BREO ELLIPTA INHALATION
BLISTER WITH DEVICE 100-25
MCG/DOSE, 200-25 MCG/DOSE
$0 - $7.40
(Tier 2)
QL (60 per 30 days)
$0 - $7.40
(Tier 2)
QL (12 per 28 days)
$0 - $7.40
(Tier 2)
QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
215
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
DULERA INHALATION HFA
AEROSOL INHALER 100-5
MCG/ACTUATION, 200-5
MCG/ACTUATION
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50
MCG/ACTUATION
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 250
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 220
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 44
MCG/ACTUATION
QVAR INHALATION AEROSOL 40
MCG/ACTUATION, 80
MCG/ACTUATION
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
QL (13 per 28 days)
$0 - $7.40
(Tier 2)
QL (60 per 30 days)
$0 - $7.40
(Tier 2)
QL (120 per 30 days)
$0 - $7.40
(Tier 2)
QL (12 per 28 days)
$0 - $7.40
(Tier 2)
QL (24 per 28 days)
$0 - $7.40
(Tier 2)
QL (21.2 per 28 days)
$0 - $7.40
(Tier 2)
QL (17.4 per 25 days)
Antileukotrienes
montelukast oral granules in packet 4 mg
montelukast oral tablet 10 mg
montelukast oral tablet,chewable 4 mg, 5
mg
zafirlukast oral tablet 10 mg, 20 mg
(Singulair)
(Singulair)
(Singulair)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Accolate)
$0 (Tier 1)
(Albuterol Sulfate)
$0 (Tier 1)
(Albuterol Sulfate)
$0 (Tier 1)
Bronchodilators
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,
2.5 mg /3 ml (0.083 %), 5 mg/ml
albuterol sulfate oral syrup 2 mg/5 ml
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
216
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
albuterol sulfate oral tablet 2 mg, 4 mg
albuterol sulfate oral tablet extended
release 12 hr 4 mg, 8 mg
ATROVENT HFA INHALATION
HFA AEROSOL INHALER 17
MCG/ACTUATION
COMBIVENT RESPIMAT
INHALATION MIST 20-100
MCG/ACTUATION
ipratropium bromide inhalation solution
0.02 %
ipratropium-albuterol inhalation solution
for nebulization 0.5 mg-3 mg(2.5 mg
base)/3 ml
metaproterenol oral syrup 10 mg/5 ml
metaproterenol oral tablet 10 mg, 20 mg
(Albuterol Sulfate)
(Vospire ER)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
QL (25.8 per 28 days)
$0 - $7.40
(Tier 2)
QL (8 per 30 days)
(Ipratropium
Bromide)
(Ipratropium/Albuter
ol Sulfate)
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
(Metaproterenol
Sulfate)
(Metaproterenol
Sulfate)
$0 (Tier 1)
PROAIR HFA INHALATION HFA
AEROSOL INHALER 90
MCG/ACTUATION
PROAIR RESPICLICK
INHALATION AEROSOL POWDR
BREATH ACTIVATED 90
MCG/ACTUATION
SEREVENT DISKUS INHALATION
BLISTER WITH DEVICE 50
MCG/DOSE
SPIRIVA RESPIMAT INHALATION
MIST 1.25 MCG/ACTUATION, 2.5
MCG/ACTUATION
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE,
W/INHALATION DEVICE 18 MCG
$0 (Tier 1)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
217
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
STRIVERDI RESPIMAT
INHALATION MIST 2.5
MCG/ACTUATION
terbutaline oral tablet 2.5 mg, 5 mg
terbutaline subcutaneous solution 1 mg/ml
theochron oral tablet extended release 12
hr 100 mg, 200 mg, 300 mg
theophylline in dextrose 5 % intravenous
parenteral solution 200 mg/100 ml, 200
mg/50 ml, 400 mg/250 ml, 400 mg/500 ml,
800 mg/250 ml
theophylline oral solution 80 mg/15 ml
theophylline oral tablet extended release
12 hr 100 mg, 200 mg, 300 mg, 450 mg
theophylline oral tablet extended release
24 hr 400 mg, 600 mg
TUDORZA PRESSAIR
INHALATION AEROSOL POWDR
BREATH ACTIVATED 400
MCG/ACTUATION, 400
MCG/ACTUATION (30 ACTUAT)
VENTOLIN HFA INHALATION
HFA AEROSOL INHALER 90
MCG/ACTUATION
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
(Terbutaline Sulfate)
(Terbutaline Sulfate)
(Theophylline
Anhydrous)
(Theophylline/D5W)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
QL (2 per 28 days)
$0 - $7.40
(Tier 2)
Respiratory Tract Agents,
Other
acetylcysteine intravenous solution 200
(Acetadote)
mg/ml (20 %)
acetylcysteine solution 100 mg/ml (10 %), (Acetadote)
200 mg/ml (20 %)
CINQAIR INTRAVENOUS
SOLUTION 10 MG/ML
$0 (Tier 1)
PA BvD
$0 (Tier 1)
PA BvD
$0 - $7.40
(Tier 2)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
218
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
cromolyn inhalation solution for
(Cromolyn Sodium)
nebulization 20 mg/2 ml
cromolyn sodium nasal spray 5.2 mg/spray (Nasalcrom)
(4 %) *
DALIRESP ORAL TABLET 500 MCG
ESBRIET ORAL CAPSULE 267 MG
KALYDECO ORAL GRANULES IN
PACKET 50 MG, 75 MG
KALYDECO ORAL TABLET 150 MG
NUCALA SUBCUTANEOUS RECON
SOLN 100 MG
OFEV ORAL CAPSULE 100 MG, 150
MG
ORKAMBI ORAL TABLET 100-125
MG, 200-125 MG
PROLASTIN-C INTRAVENOUS
RECON SOLN 1,000 MG
sodium chloride 0.9% inhal vl u-d, suv, p/f (Pulmosal)
(rx) 0.9 % *
XOLAIR SUBCUTANEOUS RECON
SOLN 150 MG
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
QL (30 per 30 days)
$0 - $7.40
(Tier 2)
PA
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
PA; LA; QL (1 per 28
days)
PA
PA; QL (120 per 30
days)
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg
carisoprodol oral tablet 250 mg, 350 mg
(Baclofen)
(Soma)
$0 (Tier 1)
$0 (Tier 1)
chlorzoxazone oral tablet 500 mg
(Parafon Forte DSC)
$0 (Tier 1)
PA-HRM; QL (120 per
30 days); AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
219
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
cyclobenzaprine oral tablet 10 mg, 5 mg
(Fexmid)
dantrolene oral capsule 100 mg, 25 mg, 50 (Dantrium)
mg
metaxall oral tablet 800 mg
(Skelaxin)
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; AGE (Max
64 Years)
$0 (Tier 1)
$0 (Tier 1)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
PA-HRM; AGE (Max
64 Years)
metaxalone oral tablet 400 mg, 800 mg
(Skelaxin)
$0 (Tier 1)
methocarbamol oral tablet 500 mg, 750
mg
revonto intravenous recon soln 20 mg
tizanidine oral capsule 2 mg, 4 mg, 6 mg
tizanidine oral tablet 2 mg, 4 mg
(Robaxin)
$0 (Tier 1)
(Dantrium)
(Zanaflex)
(Zanaflex)
$0 (Tier 1)
$0 (Tier 1)
$0 (Tier 1)
(Nuvigil)
$0 (Tier 1)
PA
QL (30 per 30 days)
(Lunesta)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
Sleep Disorder Agents
Sleep Disorder Agents
armodafinil oral tablet 150 mg, 200 mg,
250 mg, 50 mg
BELSOMRA ORAL TABLET 10 MG,
15 MG, 20 MG, 5 MG
eszopiclone oral tablet 1 mg, 2 mg, 3 mg
HETLIOZ ORAL CAPSULE 20 MG
ROZEREM ORAL TABLET 8 MG
XYREM ORAL SOLUTION 500
MG/ML
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA-HRM; QL (30 per
30 days); AGE (Max
64 Years)
PA
LA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
220
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
zaleplon oral capsule 10 mg, 5 mg
(Sonata)
$0 (Tier 1)
zolpidem oral tablet 10 mg, 5 mg
(Ambien)
$0 (Tier 1)
zolpidem oral tablet,ext release multiphase (Ambien CR)
12.5 mg, 6.25 mg
$0 (Tier 1)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any
non-benzodiazepine
hypnotic drug); QL (60
per 30 days); AGE
(Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any
non-benzodiazepine
hypnotic drug); QL (30
per 30 days); AGE
(Max 64 Years)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any
non-benzodiazepine
hypnotic drug); QL (30
per 30 days); AGE
(Max 64 Years)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
221
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
Name of Drug
What the
drug will
cost you
(Tier level)
Necessary Actions,
Restrictions, or
Limits on Use
Urine And Feces Contents
Ketones
CHEMSTRIP K *
KETONE CARE TEST STRIPS *
KETONE TEST STRIPS *
KETOSTIX REAGENT STRIPS *
TRUEPLUS KETONE TEST STRIPS *
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Urine And Feces Contents
KETO-DIASTIX REAGENT STRIPS *
$0 (Tier 4)
Vasodilating Agents
Vasodilating Agents
ADCIRCA ORAL TABLET 20 MG
ADEMPAS ORAL TABLET 0.5 MG, 1
MG, 1.5 MG, 2 MG, 2.5 MG
epoprostenol (glycine) intravenous recon (Flolan)
soln 0.5 mg, 1.5 mg
LETAIRIS ORAL TABLET 10 MG, 5
MG
OPSUMIT ORAL TABLET 10 MG
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG,
0.25 MG, 1 MG, 2.5 MG
REMODULIN INJECTION
SOLUTION 1 MG/ML, 10 MG/ML, 2.5
MG/ML, 5 MG/ML
sildenafil intravenous solution 10 mg/12.5 (Revatio)
ml
sildenafil oral tablet 20 mg
(Revatio)
TRACLEER ORAL TABLET 125 MG,
62.5 MG
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 (Tier 1)
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA BvD
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
PA
$0 - $7.40
(Tier 2)
PA BvD
$0 (Tier 1)
PA; QL (37.5 per 1
day)
PA; QL (90 per 30
days)
PA; LA; QL (60 per 30
days)
$0 (Tier 1)
$0 - $7.40
(Tier 2)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
222
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
TYVASO INHALATION SOLUTION
FOR NEBULIZATION 1.74 MG/2.9
ML (0.6 MG/ML)
TYVASO REFILL KIT INHALATION
SOLUTION FOR NEBULIZATION
1.74 MG/2.9 ML (0.6 MG/ML)
TYVASO STARTER KIT
INHALATION SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML
UPTRAVI ORAL TABLET 1,000
MCG, 1,200 MCG, 1,400 MCG, 1,600
MCG, 400 MCG, 600 MCG, 800 MCG
UPTRAVI ORAL TABLET 200 MCG
UPTRAVI ORAL TABLETS,DOSE
PACK 200 MCG (140)- 800 MCG (60)
Necessary Actions,
Restrictions, or
Limits on Use
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA BvD
$0 - $7.40
(Tier 2)
PA; QL (60 per 30
days)
$0 - $7.40
(Tier 2)
$0 - $7.40
(Tier 2)
PA; QL (240 per 30
days)
PA; QL (200 per 365
days)
Vitamins And Minerals
Vitamins And Minerals
abaneu-sl tablet sl 600-600 mcg *
(Cyanocobalamin/Me
cobalamin)
(Om-3/Calcium/D3/F
a/Mv Cmb 13)
advanced am/pm combo pack
650-1000-800 mg *
AQUASOL A 50,000 UNITS/ML VIAL
SDV, LATEX-FREE 50,000 UNIT/ML
*
ascorbic acid 500 mg/ml vial 500 mg/ml * (Ascorbic Acid)
b-12 1,000 mcg sub tablet 1,000-400 mcg * (Cyanocobalamin/Fol
ic Acid)
b-12 2,500 mcg tablet sl 2,500 mcg *
(B-12)
b-12 500 mcg tablet 500 mcg *
(B-12)
b-12 dots 500 mcg tablet 500 mcg *
(B-12)
bacmin caplet 27-1 mg *
(Multivit, Min
Cmb#20/Iron/Fa)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
223
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
b-complex 100 injection 100-2-100-2-2
mg/ml *
b-complex with c tablet *
B-NATAL 25 MG THERAPOPS 25
MG *
calcidol drops 8,000 unit/ml *
child ferrous sulfate 15 mg/ml 15 mg iron
(75 mg)/ml *
corvita 150 tablet 150-1.25-120-10 mg *
cvs b-12 1,000 mcg/15 ml liq 1,000 mcg/15
ml *
cvs children's vit d 400 unit 400 unit *
cvs daily multiple tablet *
cvs daily multiple tablet for women *
cvs iron 27 mg tablet 240 mg (27 mg iron)
*
cvs men's multi-vit tablet *
cvs prenatal gummy vitamins 400 mcg-35
mg -25 mg-5 mg *
cvs prenatal vitamin tablet *
(Vitamins
B1,B2,B3,B5,And B6)
(Vita-Bee with C)
$0 (Tier 3)
(Drisdol)
(Fer-In-Sol)
$0 (Tier 4)
$0 (Tier 4)
(Corvite 150)
(Cyanocobalamin
(Vitamin B-12))
(Vitamin D3)
(Multivitamin)
(Multivitamin)
(Fergon)
$0 (Tier 3)
$0 (Tier 4)
(Multivitamin)
(Pnv62/Fa/Om3/Dha/
Epa/Fish Oil)
(Prenatal Vit
Calc,Iron,Folic)
cvs vitamin d3 1,000 unit sfgl softgel 1,000 (Vitamin D3)
unit *
cvs women's prenatal + dha 28-975-200
(Pnv with
mg-mcg-mg *
Ca,No.61/Iron/Fa/Dh
a)
cyanocobalamin 1,000 mcg/ml 25's 1,000 (Cyanocobalamin
mcg/ml *
(Vitamin B-12))
d3 dots 2,000 unit tablet p/f 2,000 unit *
(Vitamin D3)
D3-50 50,000 UNITS CAPSULE
S/F,D/F,P/F 50,000 UNIT *
daily multiple vitamin tab sugar coated * (Multivitamin)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
224
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
daily prenatal combo pack 28-800-440
mg-mcg-mg *
daily value multivitamin tab s/f *
daily vitamin formula tablet *
daily vitamin tablet p/f,na/f *
daily vite tablet s/f, p/f *
daily vite tablet s/f,p/f *
daily-vite tablet *
ddrops 1,000 unit/drop 1,000 unit/drop *
ddrops 2,000 unit/drop 2,000 unit/drop *
decara 50,000 unit softgel 50,000 unit *
delta d3 400 unit tablet lactose free, s/f
400 unit *
dialyvite 3,000 tablet 3-70-15 mg-mcg-mg
*
dialyvite 800 with iron tab 29-800 mg-mcg
*
dialyvite tablet 100-1 mg *
dialyvite with zinc tablet 1-100-300-50
mg-mg-mcg-mg *
(One-A-Day
Women'S Prenatal
Dha)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Just D)
(Just D)
(Vitamin D3)
(Vitamin D3)
$0 (Tier 4)
(Folic Acid/B
Cplx/C/Selen/Zinc)
(Iron Fum/Fa/Vit
Bcomp,C)
(Folic Acid/Vit
Bcomp,C)
(Vit B Cplx
#11/Fa/C/Biot/Zn
Ox)
$0 (Tier 3)
DRISDOL 8,000 UNITS/ML DROPS
8,000 UNIT/ML *
d-vi-sol 400 units/ml drop 400 unit/ml *
elfolate 7.5 mg tablet 7.5 mg *
(Just D)
(Levomefolate
Calcium)
eql one daily essential tablet *
(Multivitamin)
eql prenatal vitamin tablet 28 mg iron- 800 (Prenatal Vit
mcg *
No.128/Iron/Fa)
ergocalciferol 8,000 units/ml 8,000 unit/ml (Drisdol)
*
Necessary Actions,
Restrictions, or
Limits on Use
PA
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
225
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
EXPECTA PRENATAL COMBO
PACK 28 MG IRON-800 MCG-200
MG *
ezfe forte capsule 155-1,000 mg iron-mcg
*
fabb tablet 2.2-25-1 mg *
FEOSOL 45 MG CAPLET
CPLT,NATURAL RELEASE 45 MG *
feosol 65 mg tablet 325 mg (65 mg iron) *
ferocon capsule 110-0.5 mg *
ferretts 325 mg tablet 325 mg (106 mg
iron) *
FERRETTS IRON 18 MG TABLET
CHW 18 MG IRON *
ferrex 150 forte capsule 150-25-1
mg-mcg-mg *
ferrex 150 forte plus capsule 150-60-25-1
mg-mg-mcg-mg *
ferrex 28 tablet 151-200-1-0.8 mg *
ferrocite plus tablet 106 mg iron- 1 mg *
ferrocite tablet 324 mg (106 mg iron) *
ferrogels forte softgel 460-60-0.01-1 mg *
ferrous fumarate 324 mg tab 324 mg (106
mg iron) *
ferrous gluconate 240 mg tab
240mg=27mg elemental 240 mg (27 mg
iron) *
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
PA
(Pnv No.23-Iron Ps
Complex-Fa)
(Foltx)
$0 (Tier 4)
PA
(Slow Fe)
(Iron Fum/Vit
C/B12-If/Fa)
(Ferrous Fumarate)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Iron Ps Cmplx/Vit
B12/Fa)
(Iron
Aspgly,Ps/C/B12/Fa/
Ca/Suc)
(Iron/C/Folic
Acd/Mv
Cmb11/Calc)
(Iron/Fa/Vit
Bcomp,C/Minerals)
(Ferrous Fumarate)
(Iron Fumarate/Vit
C/Vit B12/Fa)
(Ferrous Fumarate)
$0 (Tier 3)
(Fergon)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
226
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
ferrous gluconate 324 mg tab 324 mg (36
mg iron), 324 mg (37.5 mg iron), 324 mg
(38 mg iron) *
ferrous sulf 220 mg/5 ml elix 220 mg (44
mg iron)/5 ml *
ferrous sulf 300 mg/5 ml liq 300 mg (60
mg iron)/5 ml *
ferrous sulfate 325 mg tablet red 325 mg
(65 mg iron) *
folbee plus cz tablet 5-1.5-25 mg *
folbee plus tablet 5 mg *
folbee tablet 2.5-25-1 mg *
folbic tablet a/f,s/f,lactose free 2.5-25-2
mg *
folic acid 0.8 mg tablet 800 mcg *
folic acid 1 mg tablet (rx) 1 mg *
folic acid 1,000 mcg tablet p/f,s/f (otc) 1
mg *
folic acid 2.5 mg tablet 2.5-25-2 mg *
folic acid 400 mcg tablet
s/f,p/f,lactose-free 400 mcg *
folic acid 5 mg/ml vial latex-free 5 mg/ml
*
folic acid-vit b6-vit b12 tab 2.2-25-0.5 mg
*
folivane-f capsule 125-1-40-3 mg *
folivane-plus capsule 125-1 mg *
folplex 2.2 tablet 2.2-25-0.5 mg *
gnp one daily essential tablet *
gs prenatal vitamins tablet 28-800 mg-mcg
*
(Fergon)
$0 (Tier 4)
(Ferrous Sulfate)
$0 (Tier 4)
(Ferrous Sulfate)
$0 (Tier 4)
(Slow Fe)
$0 (Tier 4)
(Folic Acid/Vit
Bcomp,C/Cu/Znox)
(Folic Acid/Vit
Bcomp,C)
(Foltx)
(Foltx)
$0 (Tier 3)
(Folic Acid)
(Folic Acid)
(Folic Acid)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
(Foltx)
(Folic Acid)
$0 (Tier 3)
$0 (Tier 4)
(Folic Acid)
$0 (Tier 3)
(Foltx)
$0 (Tier 3)
(Integra F)
(Integra Plus)
(Foltx)
(Multivitamin)
(Pnv133/Ferrous
Fumarate/Fa)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
PA; AGE (Max 46
Years)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
227
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
hematinic-folic acid tablet 324 mg (106
mg iron)-1 mg *
hematinic-vitamin-mineral tab 106 mg
iron- 1 mg *
hematogen fa softgel 200-250-0.01-1 mg *
hematogen forte softgel 460-60-0.01-1 mg
*
hematogen softgel 200 (66)-10-250
mg-mg-mcg-mg *
hemocyte tablet u-u,blister pk 324 mg
(106 mg iron) *
hydroxocobalamin 1,000 mcg/ml 1,000
mcg/ml *
ICAR 15 MG/1.25 ML SUSPENSION
15 MG/1.25 ML *
iferex 150 forte capsule 150-25-1
mg-mcg-mg *
iron 27 mg tablet 236 mg (27 mg iron) *
iron 28 mg tablet 256 mg (28 mg iron) *
kpn tablet *
liquid b12 1,000 mcg/15 ml *
l-methylfolate 7.5 mg tablet 7.5 mg *
l-methylfolate calcium 7.5 mg labeled as
med food (otc) 7.5 mg *
MEPHYTON 5 MG TABLET 5 MG *
metafolbic tablet 6-5-50-1 mg *
multigen caplet 70 mg-150 mg-10 mcg-2
mg-75 mg *
(Hemocyte-F)
$0 (Tier 3)
(Iron/Fa/Vit
Bcomp,C/Minerals)
(Iron Fumarate/Vit
C/Vit B12/Fa)
(Iron Fumarate/Vit
C/Vit B12/Fa)
(Iron Fum/Vit C/Vit
B12/Stomc)
(Ferrous Fumarate)
$0 (Tier 3)
(Hydroxocobalamin)
$0 (Tier 3)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
(Iron Ps Cmplx/Vit
B12/Fa)
(Fergon)
(Fergon)
(Prenatal Vit
Calc,Iron,Folic)
(Cyanocobalamin
(Vitamin B-12))
(Levomefolate
Calcium)
(Levomefolate
Calcium)
(Cerefolin)
(Iron
Ag/C/B12/Ca/Suc.Aci
d/Stom)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
228
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
multigen folic caplet 70-150-10-1-2
mg-mg-mcg-mg-mg *
multigen plus caplet 151-60-10-1
mg-mg-mcg-mg *
multiple vitamins tablet one daily *
multi-vitamin daily tablet *
multivitamins men tablet *
multivitamins tablet *
multivit-fluor 0.5 mg tab chew chewable,
d/f, s/f 0.5 mg
myferon-150 forte capsule 150-25-1
mg-mcg-mg *
NASCOBAL 500 MCG NASAL
SPRAY 500 MCG/SPRAY *
nephplex rx tablet 1-60-300-12.5
mg-mg-mcg-mg *
nephron fa tablet 66.6-75-1 mg *
(Iron
Aspgly/C/B12/Fa/CaTh/Suc)
(Iron
Fum,Ag/C/B12/Folic/
Ca/Suc)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Pedi M.Vit No.17
with Fluoride)
(Iron Ps Cmplx/Vit
B12/Fa)
(Vit B Cmplx
No3/Fa/C/Biot/Zinc)
(Iron
Fum/Docusate/Fa/Bc
omp,C)
nephro-vite rx tablet 1-60-300 mg-mg-mcg (Vit B Cmplx
*
3/Fa/Vit C/Biotin)
neurin-sl tablet sl 600-600 mcg *
(Cyanocobalamin/Me
cobalamin)
niacinamide 100 mg tablet 100 mg *
(Niacinamide)
niacinamide er 500 mg tablet 500 mg *
(Niacinamide)
once daily tablet *
(Multivitamin)
ONE A DAY PRENATAL DHA
PACK 30 LIQ GELS,30 TABS 28 MG
IRON- 800 MCG *
one daily essential tablet *
(Multivitamin)
one daily multivitamin tab *
(Multivitamin)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 1)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
229
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
one daily tablet *
one daily tablet men's formula *
one-a-day essential tablet *
ONE-A-DAY PRENATAL 1 DHA
SFGL 28 MG IRON- 800 MCG-235
MG *
optimal d3 50,000 units cap 50,000 unit *
PERFECT IRON 25 MG TABLET 25
MG IRON *
perry prenatal capsule 13.5-0.4 mg *
pharmacist multi-vite tab *
pnv prenatal plus multivit tab s/f,
gluten-free 27 mg iron- 1 mg
poly-iron 150 forte capsule 150-25-1
mg-mcg-mg *
poly-vita with iron drops 1,500 unit-400
unit-10 mg/ml *
polyvitamin w-iron drops 1,500 unit-400
unit-10 mg/ml *
prenatal + dha combo pack 28 mg iron975 mcg-200 mg *
prenatal 19 chewable tablet (otc) 29 mg
iron- 1 mg *
PRENATAL DHA+COMPLETE
PRENATAL 30-975-300
MG-MCG-MG *
prenatal formula tablet 28 mg iron- 800
mcg *
prenatal formula tablet 9 mg iron- 500
mcg *
prenatal gummies 400-32.5 mcg-mg *
(Multivitamin)
(Multivitamin)
(Multivitamin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
PA
(Vitamin D3)
$0 (Tier 4)
$0 (Tier 4)
(Pnv with Ca
No.36/Iron/Fa)
(Multivitamin)
(Pnv with
Ca,No.72/Iron/Fa)
(Iron Ps Cmplx/Vit
B12/Fa)
(Ped Multivit
#46/Iron Sulfate)
(Ped Multivit
#46/Iron Sulfate)
(Prenatal Vit #91/Fe
Fum/Fa/Dha)
(Pnv No.118/Iron
Fumarate/Fa)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 - $7.40
(Tier 2)
$0 (Tier 3)
(All Rx Prenatal
Vitamins Covered)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Max 4
Years)
PA; AGE (Max 4
Years)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Prenatal)
$0 (Tier 4)
PA
(Prenatal Vits
#90/Iron Fum/Fa)
(Pnv103/Fa/Omega3/
Dha/Fish Oil)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
230
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
PRENATAL MULTI + DHA
SOFTGEL P/F, GLUTEN-FREE 27
MG IRON-800 MCG-228 MG *
prenatal multi-dha softgel 27mg iron- 800
mcg-250 mg *
prenatal multivitamins tablet 28 mg iron800 mcg *
prenatal one daily tablet 27 mg iron- 800
mcg *
prenatal one tablet 30 mg iron- 800 mcg *
prenatal tablet (otc) 27-0.8 mg *
prenatal tablet (otc) 27-0.8 mg *
prenatal tablet 27 mg iron- 800 mcg *
prenatal tablet 28 mg iron- 800 mcg *
PRENATAL TABLET 28 MG IRON800 MCG *
prenatal vitamin plus low iron oral tablet
27 mg iron- 1 mg
prenatal vitamin tablet 27 mg iron- 800
mcg *
prenatal vitamin tablet 28 mg iron- 800
mcg *
prenatal vitamins tablet phosphorus free
28 mg iron- 800 mcg *
prenatal-1 capsule 30-975-200 mg-mcg-mg
*
PROFE FORTE CAPSULE 155-1,000
MG IRON-MCG *
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
PA
(Prenatal
No.40/Iron/Fa/Dha)
(Prenatal)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Prenatal Vit
No.129/Iron/Fa)
(Prenatal Vit
#108/Iron/Fa)
(Prenatal Vit
No.130/Iron/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Prenatal
Vit#96/Ferrous
Fum/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Pnv with
Ca,No.72/Iron/Fa)
(Prenatal Vit
No.124/Iron/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Prenatal)
$0 - $7.40
(Tier 2)
$0 (Tier 4)
(All Rx Prenatal
Vitamins Covered)
PA
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Pnv No.25/Iron
Fumarate/Fa/Dha)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
231
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
pv prenatal formula tablet 28 mg iron- 800
mcg *
pv prenatal formula tablet 28 mg iron- 800
mcg *
pyridoxine 100 mg/ml vial 25's 100 mg/ml
*
pyridoxine 250 mg tablet 250 mg *
ra one daily prenatal dha pack 30's tab &
30's cap 28-800-440 mg-mcg-mg *
ra one daily tablet p/f *
ra prenatal tablet 28 mg iron- 800 mcg *
ra vitamin b-12 1,000 mcg tab
timed-release 1,000 mcg *
ra vitamin d3 1,000 unit tab
s/f,gluten/f,yeast/f 1,000 unit *
ra vitamin e 400 unit softgel p/f,s/f,softgel
400 unit *
renal caps softgel 1 mg *
rena-vite rx tablet 1-60-300 mg-mg-mcg *
reno caps softgel 1 mg *
riboflavin 100 mg tablet 100 mg *
riboflavin 50 mg tablet 50 mg *
right step prenatal vit tab 27-0.8 mg *
se-tan plus capsule 162-115.2-1 mg *
siderol tablet *
Necessary Actions,
Restrictions, or
Limits on Use
(Prenatal Vit
No.131/Iron/Fa)
(Prenatal Vit/Iron
Fumarate/Fa)
(Pyridoxine HCl)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Pyridoxine HCl)
(One-A-Day
Women'S Prenatal
Dha)
(Multivitamin)
(Prenatal Vit/Iron
Fumarate/Fa)
(B-12)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
(Vitamin D3)
$0 (Tier 4)
(Vitamin E)
$0 (Tier 4)
(B Complex W-C
No.20/Folic Acid)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
(B Complex W-C
No.20/Folic Acid)
(Riboflavin)
(Riboflavin)
(Prenatal Vit/Iron
Fumarate/Fa)
(Tandem Plus)
(Iron/Liver Ext/Vit
Bcomp,C/Min)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
232
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
SIMILAC PRENATAL COMBO
PACK 27 MG IRON-800 MCG-200
MG *
sm multivitamins tablet *
sm one daily prenatal combo pk 28 mg
iron- 800 mcg *
sm prenatal vitamins tablet 28 mg iron800 mcg *
sm vitamin d3 4,000 unit sftgl softgel,
gluten-free 4,000 unit *
sodium fluoride oral tablet 1 mg fluoride
(2.2 mg)
strovite forte caplet 10-1 mg *
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
PA
(Multivitamin)
(One-A-Day
Women'S Prenatal
Dha)
(Prenatal)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
PA
(Vitamin D3)
$0 (Tier 4)
(Pedi M.Vit No.17
with Fluoride)
(Multivit, Iron, Min
#5, Fa)
$0 (Tier 1)
STROVITE ONE CAPLET 1-1,000-15-5
MG-UNIT-MG-MG *
STUART ONE CAPSULE 27 MG
IRON- 800 MCG-200 MG *
super multivitamin tablet *
(Multivitamin)
support-500 softgel *
(B Complex with
Vitamin C)
tab-a-vite tablet *
(Multivitamin)
taron forte capsule 150-60-25-1
(Iron
mg-mg-mcg-mg *
Bg,Ps/Vitc/B12/Fa/Ca
lcium)
thera-d 2000 tablet 2,000 unit *
(Vitamin D3)
THERANATAL CORE NUTRITION
TAB 27-1 MG *
THERANATAL ONE SOFTGEL 27
MG IRON-1000 MCG-300 MG *
THERANATAL OVAVITE COMBO
PACK 18-1-125 MG-MG-UNIT *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
PA
$0 (Tier 4)
$0 (Tier 4)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
233
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
THERANATAL PLUS COMBO PACK
27 MG IRON- 1 MG-300 MG *
thiamine 200 mg/2 ml vial 25's,mdv,outer
100 mg/ml *
thiamine 250 mg tablet 250 mg *
thiamine 500 mg tablet 500 mg *
tl gard rx tablet 2.2-25-1 mg *
tl-hem 150 caplet 150-1-50 mg *
trigels-f forte softgel 460-60-0.01-1 mg *
$0 (Tier 4)
(Thiamine HCl)
(Thiamine HCl)
(Thiamine HCl)
(Foltx)
(Hemax)
(Iron Fumarate/Vit
C/Vit B12/Fa)
tri-vi-sol drops 750 unit-35 mg -400
(Vit A Palmitate/Vit
unit/ml *
C/Vit D3)
tri-vita drops 1,500-35-400
(Pedi Multivit
unit-mg-unit/ml *
A,C,And D3 No.21)
tri-vitamin drops 1,500-35-400
(Pedi Multivit
unit-mg-unit/ml *
A,C,And D3 No.21)
v-c forte capsule 1 mg *
(Multivitamin-Miner
als No.7/Fa)
vic-forte capsule 1 mg *
(Multivitamin-Miner
als No.7/Fa)
vinacal b prenatal combo pack 20 mg
(Prenatal #48/Iron
iron-1 mg -25 mg/25 mg *
Cb,Glu/Fa/B6)
vit d2 1.25 mg (50,000 unit) 50,000 unit * (Drisdol)
vit e nat'l blnd 1,000 unit cp 1,000 unit *
(Vitamin E Mixed)
vitacel tablet 800-250-750 mcg *
(Biocel)
vitafol caplet 65-1 mg *
(Fe
Fumarate/Cal/E/Fa/
Multivit)
VITAFOL FE+ (WITH DOCUSATE)
ORAL CAPSULE 90 MG IRON-1 MG
-50 MG-200 MG
vital-d rx tablet 1,750-60-1-12.5
(B Cmplx 4/Vit
unit-mg-mg-mg *
D3/C/Fa/Zinc Ox)
Necessary Actions,
Restrictions, or
Limits on Use
PA
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
PA; AGE (Max 4
Years)
PA; AGE (Max 4
Years)
PA; AGE (Max 4
Years)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 4)
PA
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 - $7.40
(Tier 2)
$0 (Tier 3)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
234
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
vitamin a 10,000 units capsule soluble
10,000 unit *
vitamin b-1 100 mg tablet 100 mg *
vitamin b-1 50 mg tablet 50 mg *
vitamin b-12 1,000 mcg tablet 1,000 mcg *
vitamin b-12 100 mcg tablet 100 mcg *
vitamin b-12 250 mcg tablet 250 mcg *
vitamin b12 500 mcg tablet 500 mcg *
vitamin b-12 tr 1,000 mcg tab lactose free
1,000 mcg *
vitamin b-2 25 mg tablet 25 mg *
vitamin b-2 50 mg tablet 50 mg *
vitamin b-6 100 mg tablet 100 mg *
vitamin b-6 25 mg tablet 25 mg *
vitamin b-6 250 mg tablet p/f 250 mg *
vitamin b-6 50 mg capsule 50 mg *
vitamin b-6 50 mg tablet 50 mg *
vitamin b-6 sr 200 mg tablet 200 mg *
vitamin c 1,000 mg tablet 1,000 mg *
vitamin c 100 mg tablet 100 mg *
vitamin c 250 mg tablet 250 mg *
vitamin c 500 mg tablet 500 mg *
vitamin c 500 mg tablet buffered 500 mg *
vitamin d 1,000 unit tablet 1,000 unit *
vitamin d 400 unit tablet p/f,na/f,s/f 400
unit *
VITAMIN D2 2,000 UNIT TABLET
2,000 UNIT *
vitamin d2 400 unit tablet
s/f,l/f,y/f,gluten/f 400 unit *
vitamin d3 1,000 unit tablet s/f,p/f 1,000
unit *
(Vitamin A)
$0 (Tier 4)
(Thiamine HCl)
(Thiamine HCl)
(B-12)
(B-12)
(B-12)
(B-12)
(Cyanocobalamin
(Vitamin B-12))
(Riboflavin)
(Riboflavin)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Pyridoxine HCl)
(Ascorbic Acid)
(Ascorbic Acid)
(Ascorbic Acid)
(Ascorbic Acid)
(Ascorbate Calcium)
(Vitamin D3)
(Ergocalciferol
(Vitamin D2))
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Ergocalciferol
(Vitamin D2))
(Vitamin D3)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
235
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Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
vitamin d3 1,000 units softgel softgel, p/f,
s/f 1,000 unit *
vitamin d3 10,000 unit softgel softgel
10,000 unit *
vitamin d3 10,000 unit softgel
softgel,p/f,s/f 10,000 unit *
vitamin d3 2,000 unit softgel 2,000 unit *
vitamin d3 2,000 unit tablet s/f,p/f 2,000
unit *
VITAMIN D3 400 UNIT SOFTGEL
SOFTGEL,P/F,S/F 400 UNIT *
vitamin d3 400 unit tab chew orange, p/f
400 unit *
vitamin d3 400 unit tablet s/f,p/f 400 unit *
vitamin d3 400 unit/5 ml liq 400 unit/5 ml
*
vitamin d3 400 unit/ml drop a/f, s/f, fruit
400 unit/ml *
vitamin d3 5,000 unit capsule s/f, p/f 5,000
unit *
VITAMIN D3 5,000 UNIT TABLET
S/F, P/F, 5,000 UNIT *
vitamin d3 5,000 unit/ml drops a/f,
p/f,gluten-free 5,000 unit/ml *
VITAMIN D3 LIQUID 1 MILLION
UNIT/GRAM *
vitamin e 1,000 units capsule 1,000 unit *
vitamin e 100 unit softgel softgel 100 unit
*
vitamin e 200 unit capsule 200 unit *
vitamin e 400 unit softgel
softgel,s/f,p/f,na/f 400 unit *
(Vitamin D3)
$0 (Tier 4)
(Vitamin D3)
$0 (Tier 4)
(Vitamin D3)
$0 (Tier 4)
(Vitamin D3)
(Vitamin D3)
$0 (Tier 4)
$0 (Tier 4)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
(Vitamin D3)
$0 (Tier 4)
(Vitamin D3)
(Cholecalciferol
(Vitamin D3))
(Just D)
$0 (Tier 4)
$0 (Tier 4)
(Vitamin D3)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
(Just D)
$0 (Tier 4)
$0 (Tier 4)
(Vitamin E)
(Vitamin E
(Dl,Tocopheryl
Acet))
(Vitamin E)
(Vitamin E
(Dl,Tocopheryl
Acet))
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
236
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
What the
drug will
cost you
(Tier level)
Name of Drug
vitamin k 100 mcg tablet p/f, gluten-free
100 mcg *
vitamin k-1 10 mg/ml ampul
25's,latex-free 10 mg/ml *
vitamins for hair tablet *
VITA-RESPA TABLET 2.2-25-1.3 MG
*
vp-vite rx tablet 1-60-300 mg-mg-mcg *
wee care 15 mg/1.25 ml susp 15 mg/1.25
ml *
(Phytonadione)
$0 (Tier 4)
(Phytonadione)
$0 (Tier 3)
(Multivitamin)
$0 (Tier 4)
$0 (Tier 3)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
(Icar)
$0 (Tier 3)
Necessary Actions,
Restrictions, or
Limits on Use
$0 (Tier 4)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
237
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
238
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
Effective: December 01, 2016
INDEX
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CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
ADVANCED GLUC METER
TEST STRIP ................................................ 133
ADVANCED TRAVEL
LANCETS ...................................................... 127
ADVIL ..................................................................... 10
ADVOCATE LANCET
............................................................................ 127, 128
ADVOCATE REDI-CODE
........................................................................................... 128
ADVOCATE REDI-CODE+
........................................................................................... 128
ADVOCATE TEST STRIPS
........................................................................................... 128
AEROCHAMBER MINI ....... 128
AEROCHAMBER MV .............. 128
AEROCHAMBER PLUS
FLOW-VU ...................................................... 128
AEROCHAMBER PLUS
FLOW-VU,M MSK ......................... 128
AEROCHAMBER PLUS Z
STAT MD MSK .................................... 128
AEROCHAMBER WITH
FLOWSIGNAL ...................................... 128
AEROCHAMBER Z-STAT
PLUS-FLW SG ....................................... 128
AEROTRACH PLUS ................... 128
AEROVENT PLUS .......................... 128
af ........................................................................................ 51
afeditab cr ............................................................. 96
AFINITOR ....................................................... 28
AFINITOR DISPERZ .................... 28
AGAMATRIX AMP TEST
STRIPS ................................................................ 128
a-hydrocort ...................................................... 182
AIMSCO ........................................................... 106
AKTEN (PF) .............................................. 154
AKYNZEO ....................................................... 63
ala-cort .................................................................. 121
ala-hist ir ................................................................ 54
ALA-HIST PE .............................................. 54
ala-scalp ............................................................... 121
alavert ......................................................................... 54
Index
acetazolamide sodium ....................... 204
acetic acid ........................................... 159, 196
acetylcysteine ................................................ 218
acid gone antacid ..................................... 166
acid gone antacid e.strength ..... 166
acid reducer (famotidine)
............................................................................ 164, 165
acid relief (cimetidine) .................... 165
acitretin ................................................................. 117
acne and blackhead terminator
........................................................................................... 117
acne foaming wash ................................. 117
acne medication .......................... 117, 119
ACNE MEDICATION ............... 117
acne-clear ........................................................... 117
ACTEMRA ................................................... 198
ACTHIB (PF) ............................................ 190
ACTI-LANCE LANCETS .... 127
ACTIMMUNE ........................................ 198
ACURA TEST STRIPS ............. 127
acyclovir ................................................... 77, 117
acyclovir sodium ........................................... 77
ADACEL(TDAP
ADOLESN/ADULT)(PF) ...... 190
ADAGEN ........................................................ 152
adapalene ............................................................ 125
ADCETRIS ...................................................... 27
ADCIRCA ...................................................... 222
adefovir ..................................................................... 77
ADEMPAS .................................................... 222
adriamycin ............................................................ 27
adrucil .............................................................. 27, 28
adult nasal decongestant ............... 116
adult wal-tussin .......................................... 114
ADVAIR DISKUS ............................ 215
ADVAIR HFA ........................................ 215
advanced am-pm ....................................... 223
advanced exfoliating cleanser
........................................................................................... 118
advanced eye relief (mo-wpet)
........................................................................................... 154
Index
Index
12 hour relief ..................................................... 54
1ST TIER UNILET
COMFORTOUCH ............................ 126
3 day vaginal ..................................................... 54
8-MOP ................................................................... 117
abacavir .................................................................... 71
abacavir-lamivudine ................................ 71
abacavir-lamivudine-zidovudine
............................................................................................... 71
abaneu-sl ............................................................. 223
ABELCET .......................................................... 50
ABILIFY MAINTENA ................. 67
ABRAXANE .................................................. 27
acamprosate ....................................................... 14
acarbose ................................................................... 46
ACCU-CHEK ACTIVE TEST
........................................................................................... 126
ACCU-CHEK AVIVA ................ 127
ACCU-CHEK AVIVA PLUS
TEST STRP .................................................. 126
ACCU-CHEK COMPACT
PLUS TEST .................................................. 127
ACCU-CHEK FASTCLIX ... 127
ACCU-CHEK MULTICLIX
LANCET .......................................................... 127
ACCU-CHEK SAFE-T-PRO
........................................................................................... 127
ACCU-CHEK SAFE-T-PRO
PLUS ....................................................................... 127
ACCU-CHEK SMARTVIEW
TEST STRIP ................................................ 127
ACCU-CHEK SOFTCLIX
LANCETS ...................................................... 127
ACCUTREND GLUCOSE
........................................................................................... 127
ACE AEROSOL CLOUD
ENHANCER ............................................. 127
acebutolol ............................................................... 90
acephen ......................................................................... 3
acetaminophen .................................................... 3
acetaminophen-codeine ........................... 3
acetazolamide ............................................... 204
Effective: December 01, 2016
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Formulary ID:16506.000 Version: 19
ampicillin sodium ........................................ 24
ampicillin-sulbactam .............................. 24
AMPYRA ........................................................ 103
ANACAINE ................................................ 117
anagrelide .............................................................. 81
anastrozole ........................................................... 28
ANDRODERM ..................................... 180
ANDROGEL ............................................. 180
androxy ................................................................. 180
antacid (calcium carb-mag hyd)
........................................................................................... 166
antacid anti-gas ......................................... 166
antacid exst (ca carb-mag hyd)
........................................................................................... 166
antacid extra-strength ...................... 166
antacid supreme ......................................... 167
antibiotic plus (pramoxine) ..... 120
anticoag citrate phos dextrose
........................................................................................... 198
anti-diarrheal ................................................ 167
anti-diarrheal (lope)-anti-gas
........................................................................................... 171
anti-diarrheal (loperamide)
............................................................................ 166, 167
antifungal ............................................................... 54
anti-fungal ............................................................ 51
antifungal (tolnaftate) ........................ 50
antifungal cream .......................................... 50
anti-gas maximum strength ....... 164
APOKYN ............................................................ 66
apraclonidine ................................................. 154
apri .............................................................................. 106
APRISO .............................................................. 195
aprodine ................................................................... 55
APTIOM ............................................................... 38
APTIVUS ............................................................. 71
aquanil hc ........................................................... 121
AQUASOL A ............................................. 223
aranelle (28) ................................................. 106
ARCALYST ................................................ 186
aripiprazole .............................................. 67, 68
ARISTADA ..................................................... 68
armodafinil ....................................................... 220
artificial tears (petro/min) ........ 154
artificial tears (pf) ................................ 154
Index
amethia lo .......................................................... 106
amifostine crystalline ......................... 198
amiloride ................................................................. 97
amiloride-hydrochlorothiazide
............................................................................................... 97
AMINO ACIDS 15 % ....................... 81
aminocaproic acid ...................................... 81
AMINOSYN 10 % ................................. 81
AMINOSYN 3.5 % ............................... 81
AMINOSYN 7 % ..................................... 82
AMINOSYN 7 % WITH
ELECTROLYTES ................................. 82
AMINOSYN 8.5 % ............................... 82
AMINOSYN 8.5
%-ELECTROLYTES ........................ 82
AMINOSYN II 10 % .......................... 82
AMINOSYN II 15 % .......................... 82
AMINOSYN II 7 % ............................. 82
AMINOSYN II 8.5 % ........................ 82
AMINOSYN II 8.5
%-ELECTROLYTES ........................ 82
AMINOSYN M 3.5 % ...................... 82
AMINOSYN-HBC 7% .................... 82
AMINOSYN-PF 10 % ..................... 82
AMINOSYN-PF 7 %
(SULFITE-FREE) ................................. 82
AMINOSYN-RF 5.2 % .................. 83
amiodarone .......................................................... 89
AMITIZA ........................................................ 166
amitriptyline ...................................................... 43
amlodipine ............................................................. 96
amlodipine-atorvastatin ..................... 98
amlodipine-benazepril ........................... 96
amlodipine-valsartan .............................. 96
amlodipine-valsartan-hcthiazid
............................................................................................... 96
ammonium lactate .................................. 117
amoxapine ............................................................ 43
amoxicil-clarithromy-lansopraz
........................................................................................... 164
amoxicillin ............................................................ 23
amoxicillin-pot clavulanate
.................................................................................... 23, 24
amphotericin b ................................................ 50
ampicillin ................................................................ 24
Index
Index
alaway ..................................................................... 154
ALBENZA ......................................................... 65
albuterol sulfate .......................... 216, 217
alcaine ..................................................................... 154
alclometasone ............................................... 121
ALCOHOL PADS .............................. 117
ALCOHOL PREP PADS ........ 117
ALDURAZYME ................................. 152
ALECENSA .................................................... 28
alendronate ...................................................... 196
alfuzosin ............................................................... 179
ALIMTA ............................................................... 28
ALINIA .................................................................. 65
ALKA-SELTZER GOLD ...... 166
ALLEGRA ALLERGY ................ 55
aller-chlor .............................................................. 55
allergy (chlorpheniramine) ........... 55
allergy (diphenhydramine) ........... 56
allergy and sinus relief .............. 58, 59
allergy relief (clemastine) .............. 59
allerhist-1 ............................................................... 55
allopurinol ......................................................... 198
ALLZITAL ........................................................... 3
almacone ............................................................. 166
almacone-2 ....................................................... 166
aloe vesta antifungal (micon) .... 50
alophen ................................................................... 172
alosetron .............................................................. 195
ALPHAGAN P ....................................... 204
alprazolam ............................................................ 15
ALREX ............................................................... 162
altacaine ............................................................... 154
altamist ................................................................. 154
altavera (28) ................................................. 106
altazine .................................................................. 154
ALTERNATE SITE LANCET
........................................................................................... 128
aluminum hydroxide gel ................. 166
alyacen 1/35 (28) ................................... 106
alyacen 7/7/7 (28) ................................. 106
amabelz ................................................................. 180
amantadine hcl ................................................ 66
ambi 60pse-4cpm ......................................... 55
AMBISOME ................................................... 50
amethia .................................................................. 106
Effective: December 01, 2016
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Formulary ID:16506.000 Version: 19
BD SAFETY-LOK
DETACHABLE NEEDL ........ 146
BD SAFETY-LOK WITH
LUER-LOK ................................................. 146
BD TUBERCULIN SLIP-TIP
........................................................................................... 131
BD TUBERCULIN SYRINGE
............................................................................ 130, 131
BD ULTRA FINE LANCETS
........................................................................................... 131
BD ULTRA-FINE II
LANCETS ...................................................... 131
bekyree (28) .................................................. 106
BELBUCA ............................................................. 3
BELEODAQ ................................................... 28
BELSOMRA ............................................... 220
benadryl allergy ............................................ 55
BENADRYL ALLERGY .......... 56
benazepril ............................................................... 88
benazepril-hydrochlorothiazide
............................................................................................... 88
BENDEKA ....................................................... 28
BENICAR .......................................................... 87
BENICAR HCT ........................................ 87
BENLYSTA ................................................. 198
benzonatate ..................................................... 114
benzoyl peroxide ........................ 117, 118
benztropine .......................................................... 66
beta-hc .................................................................... 121
betamethasone acet,sod phos
........................................................................................... 182
betamethasone dipropionate ..... 121
betamethasone valerate .... 121, 122
betamethasone, augmented ........ 122
BETASERON ........................................... 198
betaxolol .................................................. 90, 204
bethanechol chloride ............................ 198
BETHKIS ............................................................ 16
bexarotene ............................................................ 28
BEXSERO (PF) ...................................... 190
BG-STAR ........................................................ 131
bicalutamide ....................................................... 28
bicarsim forte ................................................ 163
BICILLIN C-R ............................................ 24
BICILLIN L-A ............................................ 24
Index
AVONEX (WITH ALBUMIN)
........................................................................................... 198
ayr saline ............................................................. 155
azacitidine ............................................................. 28
azathioprine .................................................... 186
azathioprine sodium ............................. 186
azelastine ............................................................ 155
AZILECT ............................................................ 66
azithromycin ...................................................... 22
AZOPT ................................................................. 204
AZOR ........................................................................ 96
aztreonam .............................................................. 23
azurette (28) ................................................. 106
b complex 100 .............................................. 224
b-12 dots .............................................................. 223
bacitracin .................................. 17, 120, 159
bacitracin-polymyxin b ..... 120, 159
bacitraycin plus .......................................... 120
baclofen ................................................................. 219
bacmin .................................................................... 223
balsalazide ........................................................ 195
balziva (28) .................................................... 106
banophen ................................................................. 55
banophen allergy .......................................... 55
BANZEL .............................................................. 38
baza antifungal ............................................... 50
BCG VACCINE, LIVE (PF)
........................................................................................... 190
b-complex with vitamin c .............. 224
BD BULK LUER-LOK
NON-STERILE ...................................... 129
BD INSULIN PEN NEEDLE
UF SHORT ................................................... 131
BD INSULIN SYRINGE
ULTRA-FINE ........................... 129, 130
BD INTEGRA SYRINGE .... 130
BD LUER-LOK SYRINGE
............................................................................ 129, 130
BD MICROTAINER LANCET
........................................................................................... 130
BD SAFETYGLIDE
SYRINGE ....................................................... 130
BD SAFETYGLIDE TB REG
BEVEL ................................................................. 130
Index
Index
artificial tears (polyvin alc) ..... 154
artificial tears(dext70-hypro)
........................................................................................... 154
artificial tears(hypromellose)
........................................................................................... 158
artificial tears(pg-hypm-glyc)
........................................................................................... 154
ASACOL HD ............................................. 195
ascomp with codeine ................................... 3
ascorbic acid (vitamin c) ............. 223
ashlyna ................................................................... 106
aspirin .............................................................. 10, 11
aspirin, buffered ............................................ 11
aspirin-dipyridamole ............................... 81
aspir-low .................................................................. 11
ASSURE 4 STRIPS .......................... 128
ASSURE HAEMOLANCE
PLUS ........................................................ 128, 129
ASSURE ID INSULIN
SAFETY ............................................................ 129
ASSURE LANCE ............................... 129
ASSURE LANCE PLUS .......... 129
ASSURE PLATINUM ................ 129
ASSURE PRISM MULTI
STRIP .................................................................... 129
ASTAGRAF XL ................................... 186
atenolol ..................................................................... 90
atenolol-chlorthalidone ....................... 90
athlete's foot ............................................ 50, 51
atorvastatin ......................................................... 98
atovaquone ........................................................... 65
atovaquone-proguanil ............................ 65
ATRIPLA ............................................................ 71
atropine .......................................... 37, 38, 154
atropine-care ................................................. 155
ATROVENT HFA ............................ 217
AUBAGIO ..................................................... 186
aubra ......................................................................... 106
auraphene-b ..................................................... 159
auro eardrops ................................................ 159
AVASTIN ........................................................... 28
AVC VAGINAL ....................................... 61
aviane ....................................................................... 106
AVONEX ......................................................... 198
Effective: December 01, 2016
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Formulary ID:16506.000 Version: 19
calcium phosphate-vitamin d3
Index
bupropion hcl (smoking deter)
.................................................................................... 14, 43
buspirone ............................................................. 199
butalbital compound w/codeine .... 4
butalbital-acetaminop-caf-cod ...... 4
butalbital-acetaminophen .................... 4
butalbital-acetaminophen-caff ...... 4
butalbital-aspirin-caffeine ................... 4
BUTRANS ............................................................ 4
BYSTOLIC ........................................................ 90
cabergoline ........................................................... 66
CABOMETYX ............................................ 29
caffeine citrated ......................................... 103
caffeine-sodium benzoate ............. 103
calamine-zinc oxide ............... 118, 119
calci-chew ........................................................... 167
calcidol ................................................................... 224
calci-mix .............................................................. 205
calcipotriene ................................................... 118
calcitonin (salmon) .............................. 196
calcitrate ............................................................. 205
cal-citrate ........................................................... 205
calcitrate-vitamin d ............................... 205
calcitrene ............................................................. 118
calcitriol ................................................ 118, 196
calcium 500 + d (d3) ......................... 207
calcium 600 + d(3) ............... 205, 206
calcium 600 with vitamin d3 ..... 210
CALCIUM ACETATE ............... 178
calcium acetate ........................................... 178
calcium adult (calcium phos)
........................................................................................... 206
calcium antacid .......................................... 167
calcium carbonate .................... 167, 206
calcium carbonate-vitamin d2
........................................................................................... 207
calcium carbonate-vitamin d3
............................... 205, 206, 207, 208, 214
calcium chloride ........................................ 206
calcium citrate malate-vit d3 ... 206
calcium citrate-vitamin d2 .......... 207
calcium citrate-vitamin d3
............................................................................ 206, 209
calcium gluconate ..................... 206, 207
calcium lactate ............................................ 207
Index
Index
BIDIL ..................................................................... 102
bimatoprost ..................................................... 204
bion tears (pf) ............................................. 155
BIONIME RIGHTEST TEST
STRIPS ................................................................ 145
bisac-evac ........................................................... 172
bisacodyl .............................................................. 172
biscolax ................................................................. 172
bismatrol ............................................................. 167
bisoprolol fumarate .................................. 90
bisoprolol-hydrochlorothiazide
............................................................................................... 90
bleomycin ............................................................... 28
bleph-10 ................................................................ 159
BLINCYTO ...................................................... 28
blisovi 24 fe ...................................................... 106
blisovi fe 1.5/30 (28) .......................... 106
blisovi fe 1/20 (28) ................................ 106
BLOOD GLUCOSE TEST
.............................................. 131, 139, 143, 152
B-NATAL THERAPOPS ........ 224
BOOSTRIX TDAP ............. 190, 191
BOSULIF ............................................................ 28
BREATHERITE RIGID
SPACER-MASK .................................. 131
BREATHERITE VALVED
MDI SPACER .......................................... 131
BREO ELLIPTA .................................. 215
briellyn ................................................................... 106
BRILINTA ........................................................ 81
brimonidine ...................................................... 204
BRINTELLIX .............................................. 43
BRIVIACT ........................................................ 38
bromfenac .......................................................... 162
bromocriptine ................................................... 66
budesonide ......................................................... 195
bufferin ...................................................................... 11
BULLSEYE MINI SAFETY
LANCETS ...................................................... 131
bumetanide ........................................................... 97
BUPHENYL ............................................... 167
buprenorphine hcl ................................ 3, 14
buprenorphine-naloxone .................... 14
buproban ................................................................. 43
bupropion hcl .................................................... 43
207
calcium-magnesium .............................. 207
CALDOLOR .................................................. 11
cal-gest antacid .......................................... 167
CALTRATE 600 + D ..................... 207
CALTRATE WITH VITAMIN
D3 ................................................................................ 207
camila ...................................................................... 106
camrese ................................................................. 107
camrese lo .......................................................... 107
CANCIDAS ..................................................... 51
candesartan ......................................................... 87
candesartan-hydrochlorothiazid
............................................................................................... 87
capacet .......................................................................... 4
CAPASTAT ..................................................... 62
CAPRELSA ..................................................... 29
captopril ................................................................... 88
captopril-hydrochlorothiazide ... 88
CARAFATE ............................................... 164
CARBAGLU .............................................. 167
carbamazepine ................................................ 38
carbidopa ................................................................ 66
carbidopa-levodopa .................................. 66
carbidopa-levodopa-entacapone
............................................................................................... 66
CAREONE THIN LANCET
........................................................................................... 131
CARESENS LANCETS ............ 131
CARESENS N TEST STRIPS
........................................................................................... 131
CARIMUNE NF
NANOFILTERED ........................... 186
carisoprodol .................................................... 219
carteolol ............................................................... 155
cartia xt .................................................................... 91
carvedilol ................................................................ 90
CASTOR OIL ............................................ 172
castor oil ............................................... 173, 177
CAYSTON ........................................................ 23
caziant (28) .................................................... 107
cefaclor ...................................................................... 19
cefadroxil .................................................... 19, 20
cefazolin ................................................................... 20
...........................................................................................
Effective: December 01, 2016
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CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
ciclopirox-ure-camph-menth-euc
............................................................................................... 51
cilostazol ................................................................. 81
cimetidine ........................................................... 164
cimetidine hcl ................................................ 164
CIMZIA ............................................................. 187
CIMZIA POWDER FOR
RECONST ...................................................... 187
CINQAIR ........................................................ 218
CINRYZE .......................................................... 79
CIPRODEX .................................................. 159
ciprofloxacin ...................................................... 25
ciprofloxacin hcl ............................ 25, 159
ciprofloxacin in 5 % dextrose
.................................................................................... 25, 26
ciprofloxacin lactate ............................... 25
citalopram ............................................................. 43
citracal + d maximum ...................... 207
citrate of magnesia ................................ 176
citroma ................................................................... 172
CITRUCEL .................................................. 172
CITRUCEL (SUCROSE) ........ 172
citrus calcium ................................................ 207
clarithromycin ................................................. 22
clearasil daily clear(benzoyl)
........................................................................................... 118
clearlax ................................................................. 177
CLEVER CHEK LANCETS
........................................................................................... 131
CLEVER CHOICE
CHAMBER-LRG MASK ...... 132
CLEVER CHOICE MICRO
TEST STRIP ................................................ 132
CLEVER CHOICE PRO ......... 132
CLEVER CHOICE TALK
TEST ....................................................................... 132
CLEVER CHOICE TEST
STRIPS ................................................................ 132
CLEVER CHOICE VOICE+
TEST ....................................................................... 132
CLEVIPREX .................................................. 96
clindamycin hcl ............................................... 17
clindamycin in 5 % dextrose ........ 17
clindamycin palmitate hcl ................ 17
clindamycin pediatric ............................. 17
Index
child triaminic cold-allergy ............ 56
child wal-tap cold-allergy ................ 56
CHILDREN'S ADVIL .................... 11
children's allegra allergy ................... 56
children's aller-tec ...................................... 56
children's calcium gummies ........ 208
children's chest congestion .......... 114
CHILDREN'S NASACORT
........................................................................................... 162
children's non-aspirin ......................... 4, 5
children's pain reliever .............................. 9
children's pain-fever relief ................... 4
children's pepto ........................................... 167
children's silfedrine ................................ 114
children's soothe ........................................ 167
children's sudafed ..................................... 114
children's tactinal ............................................ 4
children's vitamin d ................................ 224
children's wal-dryl allergy ............... 56
children's wal-zyr ......................................... 56
child's benadryl-d allergy-sin ....... 56
chloramphenicol sod succinate
............................................................................................... 17
chlordiazepoxide hcl ............................... 16
chlorhexidine gluconate .................. 116
chloroquine phosphate .......................... 65
chlorothiazide ................................................... 97
chlorothiazide sodium ........................... 97
chlorpheniramine maleate ............... 56
chlorpromazine ............................................... 68
chlorthalidone .................................................. 97
chlorzoxazone .............................................. 219
chocolate laxative ................................... 172
CHOICEDM CLARUS ............. 131
CHOLECALCIFEROL (VIT
D3)(BULK) ................................................... 236
cholecalciferol (vitamin d3)
............................................................................ 224, 236
CHOLECALCIFEROL
(VITAMIN D3) ....................................... 224
cholestyramine (with sugar) ....... 98
cholestyramine light ................................ 98
choline,magnesium salicylate ..... 11
ciclopirox ............................................................... 51
Index
Index
cefazolin in dextrose (iso-os) .... 20
cefdinir ....................................................................... 20
cefditoren pivoxil ......................................... 20
cefepime ................................................................... 20
CEFEPIME IN DEXTROSE 5
% ........................................................................................ 20
CEFEPIME IN
DEXTROSE,ISO-OSM .................. 20
cefotaxime ............................................................ 20
cefoxitin ................................................................... 20
cefoxitin in dextrose, iso-osm ..... 20
cefpodoxime ....................................................... 20
cefprozil .................................................................... 20
ceftazidime ........................................................... 21
ceftibuten ................................................................ 21
ceftriaxone ........................................................... 21
ceftriaxone in dextrose,iso-os .... 21
cefuroxime axetil ........................................ 21
cefuroxime sodium .................................... 21
celecoxib .................................................................. 11
CELLCEPT INTRAVENOUS
........................................................................................... 187
CELONTIN ..................................................... 38
CEO-TWO ...................................................... 172
cephalexin ............................................................. 21
CEPROTIN (BLUE BAR) ........ 78
CERDELGA ............................................... 199
CEREZYME ............................................... 152
CERVARIX VACCINE (PF)
........................................................................................... 191
cetirizine .................................................................. 55
CETYLEV ...................................................... 199
cevimeline ........................................................... 116
CHANTIX ......................................................... 14
CHANTIX CONTINUING
MONTH BOX .............................................. 14
CHANTIX STARTING
MONTH BOX .............................................. 14
CHEMSTRIP K ..................................... 222
cheratussin ac ............................................... 114
child allergy relf(cetirizine) ......... 56
child dometuss-da ....................................... 56
child mucinex chest congestion
........................................................................................... 114
child suppository ....................................... 173
Effective: December 01, 2016
17, 61, 120
CLINIMIX 5%/D15W
SULFITE FREE ....................................... 83
CLINIMIX 5%/D25W
SULFITE-FREE ...................................... 83
CLINIMIX 2.75%/D5W
SULFIT FREE ............................................ 83
CLINIMIX 4.25%/D10W SULF
FREE ......................................................................... 83
CLINIMIX 4.25%/D5W
SULFIT FREE ............................................ 83
CLINIMIX 4.25%-D20W
SULF-FREE ................................................... 83
CLINIMIX 4.25%-D25W
SULF-FREE ................................................... 83
CLINIMIX
5%-D20W(SULFITE-FREE)
............................................................................................... 83
CLINIMIX E 2.75%/D10W
SUL FREE ......................................................... 83
CLINIMIX E 2.75%/D5W
SULF FREE .................................................... 83
CLINIMIX E 4.25%/D10W
SUL FREE ......................................................... 84
CLINIMIX E 4.25%/D25W
SUL FREE ......................................................... 84
CLINIMIX E 4.25%/D5W
SULF FREE .................................................... 84
CLINIMIX E 5%/D15W
SULFIT FREE ............................................ 84
CLINIMIX E 5%/D20W
SULFIT FREE ............................................ 84
CLINIMIX E 5%/D25W
SULFIT FREE ............................................ 84
CLINISOL SF 15 % ............................. 84
clobetasol ............................................................ 122
clobetasol-emollient ............................. 122
clocortolone pivalate ........................... 122
clomipramine .................................................... 43
clonazepam .......................................................... 16
clonidine ................................................................... 86
clonidine hcl ......................................... 86, 103
clopidogrel ............................................................ 81
clorazepate dipotassium ..................... 16
.....................................................................
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CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
CONTOUR NEXT STRIPS
Index
clorpres ...................................................................... 86
clotrimazole ........................................................ 51
clotrimazole-7 .................................................. 51
clotrimazole-betamethasone ........ 51
clozapine ................................................................. 68
COAGUCHEK LANCETS
........................................................................................... 132
COARTEM ...................................................... 65
codeine sulfate ..................................................... 4
COLACE .......................................................... 173
COLACE CLEAR .............................. 173
colchicine ............................................................ 199
cold and cough (diphenhydr-pe)
............................................................................................... 56
cold-allergy-sinus ........................................ 56
colestipol ................................................................. 98
colistin (colistimethate na) ........... 17
colocort ................................................................. 122
COLOR LANCETS ......................... 146
col-rite .................................................................... 177
COLY-MYCIN S ................................. 160
COMBIGAN .............................................. 204
COMBIPATCH ...................................... 181
COMBIVENT RESPIMAT
........................................................................................... 217
COMETRIQ .................................................... 29
COMFORT EZ LANCETS
........................................................................................... 132
comfort gel ....................................................... 167
comfort gel extra strength ........... 167
COMFORT LANCETS ............. 132
COMPACT SPACE
CHAMBER .................................................. 132
COMPACT SPACE
CHAMBER PLUS ............................. 132
COMPLERA .................................................. 72
compoz ....................................................................... 56
compro ....................................................................... 63
COMVAX (PF) ....................................... 191
CONDOMS-PREM
LUBRICATED ....................................... 107
CONDYLOX ............................................. 118
CONEX .................................................................. 56
conex ............................................................................ 56
constulose ........................................................... 167
Index
Index
clindamycin phosphate
...........................................................................................
CONTOUR TEST STRIPS
132
132
CONTROL AST TEST ............... 132
CONTROL G3 ........................................ 132
COOL GLUCOSE TEST
STRIP .................................................................... 132
COPAXONE ............................................... 199
CORLANOR ................................................. 92
cormax ................................................................... 122
cortaid ..................................................................... 122
cortisone ............................................................... 182
cortizone-10 .................................................... 122
CORTIZONE-10 .................................. 122
corvita 150 ........................................................ 224
COSENTYX ................................................ 118
COSENTYX (2 SYRINGES)
........................................................................................... 118
COSENTYX PEN ............................... 118
COSENTYX PEN (2 PENS)
........................................................................................... 118
COTELLIC ....................................................... 29
CREON ............................................................... 152
critic-aid clear af ......................................... 51
CRIXIVAN ...................................................... 72
cromolyn ................................ 155, 167, 219
cryselle (28) ................................................... 107
CUBICIN ............................................................. 18
cyanocobalamin (vitamin b-12)
.............................................. 223, 224, 232, 235
cyclafem 1/35 (28) ............................... 107
cyclafem 7/7/7 (28) ............................. 107
cyclobenzaprine ......................................... 220
cyclopentolate .............................................. 156
cyclophosphamide ...................................... 29
CYCLOPHOSPHAMIDE ......... 29
CYCLOSET ..................................................... 46
cyclosporine .................................................... 187
cyclosporine modified ........................ 187
cyproheptadine ............................................... 57
CYRAMZA ...................................................... 29
cyred .......................................................................... 107
CYSTADANE .......................................... 199
CYSTARAN ............................................... 156
...........................................................................................
Effective: December 01, 2016
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CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
dextrose 5%-0.3 % sod.chloride
........................................................................................... 208
dextrose 50 % in water (d50w)
............................................................................................... 85
dextrose 70 % in water (d70w)
............................................................................................... 85
dextrose with sodium chloride
........................................................................................... 208
dextrose-kcl-nacl ..................................... 208
diabetic tussin ex ...................................... 115
dialyvite ................................................................ 225
dialyvite 3000 ................................................ 225
dialyvite 800 with iron ...................... 225
diamode ................................................................. 168
DIATRUE PLUS TEST STRIP
........................................................................................... 133
diazepam ................................................................. 16
diazepam intensol ........................................ 16
diclofenac potassium ............................... 11
diclofenac sodium ......................... 11, 162
diclofenac-misoprostol ......................... 11
dicloxacillin ......................................................... 24
dicyclomine ...................................................... 168
didanosine .............................................................. 72
DIFICID ............................................................... 22
diflunisal .................................................................. 11
digitek ......................................................................... 93
digox ............................................................................. 93
digoxin ............................................................ 93, 94
DIGOXIN ........................................................... 93
dihydroergotamine .................................... 61
DILANTIN ...................................................... 38
diltiazem hcl ............................................ 91, 92
dilt-xr .......................................................................... 92
dimaphen (pe) ................................................ 57
dimenhydrinate ............................................... 63
dimetapp cold-congestion ................. 57
diotame instydose .................................... 168
DIPENTUM ................................................ 195
diphenhist ............................................................... 57
diphenhydramine hcl ............................... 57
diphenhydramine-phenylephrine
............................................................................................... 54
diphenoxylate-atropine .................... 168
dipyridamole ...................................................... 81
Index
delta d3 .................................................................. 225
delyla (28) ....................................................... 107
DELZICOL ................................................... 195
DEMSER ............................................................. 92
DEPEN TITRATABS .................. 179
DEPO-PROVERA ............................. 185
dermafungal ........................................................ 51
dermarest eczema (hydrocort)
........................................................................................... 123
DESCOVY ......................................................... 72
desenex ...................................................................... 52
desenex spray ................................................... 52
desipramine ......................................................... 43
desmopressin .................................................. 183
desog-e.estradiol/e.estradiol ..... 107
desogestrel-ethinyl estradiol ..... 107
desonide ................................................................ 123
desoximetasone .......................................... 123
dex4 glucose ....................................................... 84
dex4 glucose bits .......................................... 84
dexamethasone ........................................... 182
dexamethasone sodium phosphate
............................................................................ 162, 182
dexmethylphenidate ............................. 104
dextroamphetamine ............................. 104
dextroamphetamine-amphetamine
........................................................................................... 104
dextrose .................................................................... 84
dextrose 10 % and 0.2 % nacl
........................................................................................... 208
dextrose 10 % in water (d10w)
............................................................................................... 84
dextrose 20 % in water (d20w)
............................................................................................... 84
dextrose 25 % in water (d25w)
............................................................................................... 84
dextrose 40 % in water (d40w)
............................................................................................... 85
dextrose 5 % in ringers ........................ 85
dextrose 5 % in water (d5w) ...... 85
dextrose 5 %-lactated ringers
........................................................................................... 208
dextrose 5%-0.2 % sod chloride
........................................................................................... 208
Index
Index
cysteine (l-cysteine) ............................... 84
d10 %-0.45 % sodium chloride
........................................................................................... 208
d2.5 %-0.45 % sodium chloride
........................................................................................... 208
d3 dots .................................................................... 224
d5 % and 0.9 % sodium chloride
........................................................................................... 208
d5 %-0.45 % sodium chloride
........................................................................................... 208
dactinomycin ..................................................... 29
daily fiber (psyllium-sucrose)
........................................................................................... 173
daily multiple ................................................. 224
daily multi-vitamin ................................ 229
daily prenatal ................................................ 225
daily value ......................................................... 225
daily vitamin ................................................... 225
daily vitamin formula ......................... 225
dailyhist-1 .............................................................. 57
daily-vite .............................................................. 225
DAKLINZA .................................................... 76
DALIRESP .................................................... 219
DALLERGY
(DEXBROMPHENIRAMN-PE
) ........................................................................................... 57
danazol ................................................................... 180
dantrolene .......................................................... 220
dapsone ..................................................................... 62
DAPTACEL (DTAP
PEDIATRIC) (PF) ............................. 191
daptomycin .......................................................... 18
DARAPRIM .................................................. 65
DARZALEX .................................................. 29
dasetta 1/35 (28) ..................................... 107
dasetta 7/7/7 (28) .................................. 107
dayhist allergy ................................................. 57
daysee ...................................................................... 107
ddrops ...................................................................... 225
deblitane ............................................................... 107
debrox ..................................................................... 160
decara ...................................................................... 225
decitabine ............................................................... 29
deep sea nasal ............................................... 156
deferoxamine ................................................. 179
Effective: December 01, 2016
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CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
EFFIENT ............................................................ 81
ELAPRASE .................................................. 152
electrolyte-48 in d5w ........................... 208
ELEMENT COMPACT TEST
STRIPS ................................................................ 134
ELEMENT TEST STRIPS .... 134
elfolate ................................................................... 225
ELIDEL .............................................................. 123
ELIGARD .......................................................... 30
ELIGARD (3 MONTH) ............... 30
ELIGARD (4 MONTH) ............... 30
ELIGARD (6 MONTH) ............... 30
elinest ....................................................................... 107
eliphos ..................................................................... 178
ELIQUIS ............................................................... 78
ELITEK .............................................................. 153
ELLA ...................................................................... 107
ELMIRON ..................................................... 199
elon dual defense .......................................... 52
elta tar .................................................................... 118
EMBRACE BLOOD
GLUCOSE SYSTEM .................... 134
EMBRACE EVO TEST
STRIPS ................................................................ 134
EMBRACE LANCETS .............. 134
EMBRACE PRO TEST
STRIPS ................................................................ 134
EMCYT .................................................................. 30
EMEND ................................................................. 63
emoquette ........................................................... 107
EMPLICITI ...................................................... 30
EMSAM ................................................................. 44
EMTRIVA ......................................................... 72
EMVERM .......................................................... 65
enalapril maleate ......................................... 88
enalaprilat ............................................................. 88
enalapril-hydrochlorothiazide .... 88
ENBREL ........................................................... 187
ENBREL SURECLICK ............ 187
endocet .......................................................................... 5
endodan ........................................................................ 5
endur-acin .............................................................. 98
enema ......................................... 174, 176, 177
enema disposable ....................... 173, 174
enemeez ................................................................. 174
Index
e.e.s. 400 .................................................................. 22
e.e.s. granules ................................................... 22
ear drops (carbamide peroxide)
........................................................................................... 160
EASIVENT HOLDING
CHAMBER .................................................. 133
EASY COMFORT LANCETS
........................................................................................... 133
EASY GLUCO G2 ............................ 133
EASY PLUS ................................................ 133
EASY PLUS II TEST .................... 133
EASY STEP .................................................. 133
EASY TALK GLUCOSE TEST
........................................................................................... 133
EASY TOUCH ........................................ 134
EASY TOUCH FLIPLOCK
SYRINGE ....................................................... 133
EASY TOUCH LANCETS
........................................................................................... 133
EASY TOUCH SAFETY
LANCETS ...................................................... 133
EASY TOUCH
SHEATHLOCK SYRG-NDL
........................................................................................... 134
EASY TOUCH TEST STRIP
........................................................................................... 133
EASY TOUCH TWIST
LANCETS ...................................................... 134
EASY TRAK GLUCOSE TEST
........................................................................................... 134
EASY TWIST AND CAP
LANCETS ...................................................... 134
EASYGLUCO PLUS .................... 134
EASYGLUCO TEST ..................... 134
EASYMAX ................................................... 134
EASYMAX 15 .......................................... 134
ECLIPSE SYRINGE ...................... 129
econazole ................................................................ 52
econtra ez ........................................................... 107
ecotrin ......................................................................... 11
ed a-hist .................................................................... 57
ed chlorped jr .................................................... 57
ed-chlorped .......................................................... 57
EDURANT ...................................................... 72
effer-k ...................................................................... 208
Index
Index
disopyramide phosphate ..................... 89
disulfiram ............................................................... 14
divalproex ................................................... 38, 39
dobutamine .......................................................... 94
dobutamine in d5w ..................................... 94
doc-q-lace ........................................................... 173
docu ............................................................................ 173
docusate sodium ........................................ 174
docusol ................................................................... 174
dofetilide ................................................................. 89
dok ............................................................................... 174
donepezil ................................................................. 42
dopamine ................................................................. 94
dopamine in 5 % dextrose ................ 94
dorzolamide ..................................................... 204
dorzolamide-timolol ............................. 204
doxazosin ............................................................... 86
doxepin ...................................................................... 44
doxercalciferol ............................................ 196
doxorubicin, peg-liposomal ........... 29
doxy-100 ................................................................. 26
doxycycline hyclate ....................... 26, 27
doxycycline monohydrate ................ 27
dramamine ............................................................ 63
dramamine less drowsy ....................... 63
driminate ................................................................. 63
DRISDOL ....................................................... 225
dristan long lasting ................................ 156
dronabinol ............................................................. 63
droperidol ........................................................... 199
DROPLET LANCETS ................ 133
drospirenone-ethinyl estradiol
........................................................................................... 107
DROXIA .............................................................. 29
dry mouth ........................................................... 117
DUAVEE ......................................................... 181
dulcolax stool softener (dss) ... 174
DULERA ......................................................... 216
duloxetine .............................................................. 44
DUREZOL .................................................... 162
dutasteride ........................................................ 199
dutasteride-tamsulosin ..................... 199
d-vi-sol .................................................................... 225
DYRENIUM ................................................. 97
e.c. prin ..................................................................... 12
Effective: December 01, 2016
22, 23
erythromycin with ethanol .......... 120
ESBRIET .......................................................... 219
escitalopram oxalate .............................. 44
esmolol ....................................................................... 90
esomeprazole sodium .......................... 164
estarylla ................................................................ 108
ESTRACE ....................................................... 181
estradiol ................................................................ 181
estradiol valerate ...................................... 181
estradiol-norethindrone acet .... 181
estropipate ........................................................ 181
eszopiclone ........................................................ 220
ethambutol ............................................................ 62
ethamolin ................................................................ 95
ethosuximide ...................................................... 39
etodolac .................................................................... 12
ETOPOPHOS ................................................ 30
etoposide ................................................................. 30
EVENCARE G2 .................................... 134
EVENCARE G3 TEST ............... 135
EVENCARE MINI GLUCOSE
TEST STR ....................................................... 135
EVENCARE TEST ........................... 135
EVOLUTION TEST STRIPS
........................................................................................... 135
EVOTAZ .............................................................. 72
EXEL SYRINGE ................................. 135
exemestane ........................................................... 30
EXJADE ............................................................ 179
ex-lax (sennosides) .............................. 174
EXONDYS 51 ........................................... 199
EXPECTA PRENATAL .......... 226
expectorant ...................................................... 115
EXTAVIA ....................................................... 199
eye allergy relief ......................... 155, 158
eye drops ............................................................. 155
eye drops (with povidone) .......... 156
eye wash ................................................ 155, 158
E-Z JECT LANCETS
............................................................. 135, 136, 144
E-Z JECT THIN LANCETS
........................................................................................... 144
EZ SMART LANCETS ............. 135
....................................................................................
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CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
EZ SMART PLUS TEST ......... 135
EZ SMART TEST .............................. 135
E-Z SPACER .............................................. 135
ezfe forte .............................................................. 226
fabb ............................................................................. 226
FABRAZYME ........................................ 153
fallback solo ................................................... 108
falmina (28) .................................................. 108
famciclovir ............................................................ 77
famotidine ........................................... 164, 165
famotidine (pf) .......................................... 164
famotidine (pf)-nacl (iso-os)
........................................................................................... 164
FANAPT .............................................................. 68
FANTASY ..................................................... 108
FARESTON .................................................... 30
FARYDAK ...................................................... 30
FASLODEX .................................................... 30
felbamate ................................................................ 39
felodipine ................................................................ 96
FEMRING .................................................... 181
femynor ................................................................. 108
fenofibrate ............................................................ 98
fenofibrate micronized ......................... 98
fenofibrate nanocrystallized ......... 98
fenofibric acid .................................................. 99
fenofibric acid (choline) ................... 99
fenoprofen ............................................................. 12
fentanyl ......................................................................... 5
fentanyl citrate ................................................... 5
FEOSOL ............................................................ 226
feosol ........................................................................ 226
ferocon ................................................................... 226
ferretts .................................................................... 226
FERRETTS CARBONYL
IRON ...................................................................... 226
ferrex 150 forte .......................................... 226
ferrex 150 forte plus ............................ 226
ferrex 28 .............................................................. 226
FERRIPROX ............................................. 179
ferrocite ................................................................ 226
ferrocite plus .................................................. 226
ferrogels forte ............................................... 226
ferrous fumarate ....................................... 226
ferrous gluconate ........ 226, 227, 228
Index
erythromycin ethylsuccinate
Index
Index
enemeez plus ................................................... 174
ENGERIX-B (PF) .............................. 191
ENGERIX-B PEDIATRIC (PF)
........................................................................................... 191
enoxaparin ............................................................ 78
enpresse ................................................................. 108
enskyce .................................................................. 108
entacapone ............................................................ 66
entecavir .................................................................. 77
entre-hist pse ..................................................... 58
ENTRESTO ..................................................... 87
enulose .................................................................... 168
ENVARSUS XR ................................... 187
EPCLUSA .......................................................... 76
ephedrine sulfate .......................................... 94
epinastine ............................................................ 156
epinephrine ................................................ 94, 95
epinephrine hcl (pf) ................................. 94
EPIPEN .................................................................. 95
EPIPEN 2-PAK .......................................... 95
EPIPEN JR 2-PAK ............................... 95
epitol ............................................................................. 39
EPIVIR HBV .................................................. 72
eplerenone .......................................................... 102
EPOGEN .............................................................. 79
epoprostenol (glycine) ..................... 222
epsom salt .......................................................... 200
EPZICOM .......................................................... 72
eq gentle ............................................................... 156
equalactin ........................................................... 174
ergocalciferol (vitamin d2)
............................................................. 225, 234, 235
ERGOCALCIFEROL
(VITAMIN D2) ....................................... 235
ergoloid ................................................................. 199
ERGOMAR ..................................................... 61
ERIVEDGE ..................................................... 30
errin ............................................................................ 108
ery pads ................................................................. 120
ery-tab ........................................................................ 22
ERY-TAB ............................................................ 22
ERYTHROCIN ......................................... 22
erythrocin (as stearate) .................... 22
erythromycin ...................................... 23, 160
Effective: December 01, 2016
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CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
FORA TEST STRIP ........................ 136
FORA TN'G VOICE TEST
STRIPS ................................................................ 136
FORA V10 ...................................................... 136
FORA V12 GLUCOSE ............... 136
FORA V20 ...................................................... 136
FORA V30A ................................................ 136
FORACARE GD20 ......................... 137
FORACARE GD40 ......................... 137
FORACARE LANCETS ......... 137
FORTEO .......................................................... 197
FORTICAL .................................................. 197
FORTISCARE GLUCOSE
TEST STRIPS ........................................... 137
foscarnet .................................................................. 75
fosinopril ................................................................. 88
fosinopril-hydrochlorothiazide
............................................................................................... 88
fosphenytoin ....................................................... 39
FREAMINE HBC 6.9 % .............. 85
FREAMINE III 10 % ........................ 85
FREESTYLE INSULINX ..... 137
FREESTYLE INSULINX
TEST STRIPS ........................................... 137
FREESTYLE LANCETS ....... 137
FREESTYLE LITE STRIPS
........................................................................................... 137
FREESTYLE PRECISION
NEO STRIPS .............................................. 137
FREESTYLE TEST ......................... 137
FREESTYLE UNISTIK 2 ..... 137
fungi cure ................................................................ 52
FUNGI-NAIL .............................................. 52
fungoid-d ................................................................. 52
furosemide ............................................................. 97
FUSILEV ......................................................... 199
FUZEON ............................................................. 72
FYCOMPA ....................................................... 39
G-4 TEST ......................................................... 137
gabapentin ............................................................ 39
GABITRIL ........................................................ 39
galantamine ........................................................ 42
GAMASTAN S/D ............................... 187
GAMMAGARD LIQUID .... 188
GAMMAPLEX ...................................... 188
Index
floxuridine ............................................................. 30
flucaine .................................................................. 156
fluconazole ........................................................... 52
fluconazole in dextrose(iso-o)
............................................................................................... 52
fluconazole in nacl (iso-osm) ..... 52
flucytosine ............................................................. 52
fludrocortisone ............................................ 182
flumazenil ........................................................... 104
flunisolide ........................................................... 162
fluocinonide ..................................................... 123
fluorometholone ........................................ 162
fluorouracil ........................................... 30, 118
fluoxetine ............................................................... 44
fluphenazine decanoate ....................... 68
fluphenazine hcl ............................................. 68
flurbiprofen .......................................................... 12
flurbiprofen sodium .............................. 162
flutamide ................................................................. 30
fluticasone .......................................... 123, 162
fluvoxamine ........................................................ 44
foaming acne face wash .................. 118
foaming antacid .......................... 168, 171
foaming antacid extra strength
........................................................................................... 171
folbee ........................................................................ 227
folbee plus .......................................................... 227
folbic ......................................................................... 227
folic acid .............................................................. 227
folic acid-vit b6-vit b12 .................... 227
folivane-f ............................................................. 227
folivane-plus .................................................... 227
folplex 2.2 .......................................................... 227
fomepizole ......................................................... 199
fondaparinux ..................................................... 78
for sty relief ..................................................... 156
FORA D10 ..................................................... 136
FORA D15G ............................................... 136
FORA D20 ..................................................... 136
FORA D40-G31 TEST STRIPS
........................................................................................... 136
FORA G20 ..................................................... 136
FORA G30A ............................................... 136
FORA GD50 TEST STRIPS
........................................................................................... 136
Index
Index
ferrous sulfate ............................... 224, 227
FETZIMA .......................................................... 44
feverall ........................................................................... 5
FEVERALL ........................................................ 5
fexofenadine ....................................................... 58
fiber (calcium polycarbophil)
........................................................................................... 174
fiber laxative (methylcellulo)
........................................................................................... 177
fiber laxative (psyllium husk)
............................................................................ 173, 177
fiber smooth .................................................... 177
fiber therapy (m-cell/sugar) .... 174
fiber therapy (m-cellulose) ........ 173
fiber therapy (psyllium) ................ 174
fiber therapy (psyllium/sugar)
........................................................................................... 174
fiber therapy sugar free ................... 176
fiber-lax ................................................................ 174
fibertab .................................................................. 174
FIFTY50 SAFETY SEAL
LANCETS ...................................................... 136
FIFTY50 TEST STRIP ............... 136
finasteride .......................................................... 199
FINE 30 UNIVERSAL
LANCETS ...................................................... 136
FINGERSTIX LANCETS .... 136
FIRAZYR .......................................................... 95
FIRST CHOICE LANCETS
THIN ...................................................................... 126
fish oil ............................................... 98, 99, 101
fish oil extra strength ............................ 99
fish oil omega 3-6-9 .................................. 99
fish oil pearls ..................................................... 99
flanax antacid .............................................. 168
FLEBOGAMMA DIF ................. 187
flecainide ................................................................. 89
FLECTOR .......................................................... 12
fleet glycerin (adult) .......................... 174
fleet glycerin (child) ........................... 174
FLEXICHAMBER ........................... 136
FLONASE ALLERGY
RELIEF .............................................................. 162
FLOVENT DISKUS ...................... 216
FLOVENT HFA ................................... 216
Effective: December 01, 2016
I-11
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
griseofulvin microsize ............................ 52
guanfacine .............................................. 87, 104
guanidine ............................................................. 200
GYNOL II ...................................................... 108
halobetasol propionate ..................... 123
haloperidol ............................................................ 69
haloperidol decanoate ........................... 69
haloperidol lactate ..................................... 69
HARVONI ......................................................... 76
HAVRIX (PF) ........................................... 192
HEALTHPRO TEST STRIPS
........................................................................................... 138
HEALTHY ACCENTS
UNILET LANCET ........................... 138
healthylax .......................................................... 175
heartburn antacid .................................... 169
heartburn relief ........................................... 167
heather ................................................................... 108
hematinic plus vit/minerals ......... 228
hematinic/folic acid ............................... 228
hematogen ......................................................... 228
hematogen fa ................................................. 228
hematogen forte ......................................... 228
hemocyte ............................................................. 228
heparin (porcine) ....................................... 79
heparin (porcine) in 5 % dex
.................................................................................... 78, 79
heparin (porcine) in nacl (pf)
............................................................................................... 78
heparin(porcine) in 0.45% nacl
............................................................................................... 79
heparin, porcine (pf) ............................. 79
HEPATAMINE 8% ............................. 85
HEPATASOL 8 % .................................. 85
HERCEPTIN ................................................. 31
HETLIOZ ........................................................ 220
HEXALEN ........................................................ 31
HIBERIX (PF) ......................................... 192
histex pe ................................................................... 58
homatropaire ................................................. 156
homatropine hbr ........................................ 156
HONGO CURA SPRAY ............ 52
HUMIRA ......................................................... 188
HUMIRA PEDIATRIC
CROHN'S START ............................. 188
Index
GILENYA ...................................................... 199
GILOTRIF ........................................................ 31
glenmax peb ....................................................... 58
GLEOSTINE ................................................. 31
glimepiride ................................................. 49, 50
glipizide .................................................................... 50
glipizide-metformin .................................. 50
GLUCAGEN HYPOKIT ....... 199
GLUCAGON EMERGENCY
KIT (HUMAN) ...................................... 200
gluco burst ............................................................ 85
GLUCO NAVII TEST STRIP
........................................................................................... 137
GLUCOCARD 01 SENSOR
PLUS ....................................................................... 137
GLUCOCARD EXPRESSION
........................................................................................... 137
GLUCOCARD SHINE TEST
STRIPS ................................................................ 138
GLUCOCARD VITAL
SENSOR ............................................................ 138
GLUCOCARD VITAL TEST
STRIPS ................................................................ 138
GLUCOCOM GLUCOSE ..... 138
GLUCOCOM LANCETS ...... 138
glucose ........................................................................ 85
glucose bits ........................................................... 84
glucose gel ............................................................. 85
GLUCOSOURCE .............................. 138
glutose 15 ............................................................... 85
glyburide ................................................................. 50
glyburide micronized .............................. 50
glyburide-metformin ............................... 50
glycerin (adult) .......................... 173, 175
glycerin (child) ........................... 173, 177
glycolax ................................................................ 175
glycopyrrolate .............................................. 168
glydo ............................................................................. 13
GLYXAMBI ................................................... 46
GM100 .................................................................. 145
GMATE LANCETS ........................ 138
GMATE TEST STRIPS ............. 138
granisetron (pf) ............................................ 63
granisetron hcl ................................................ 63
GRANIX .............................................................. 80
Index
Index
ganciclovir sodium ..................................... 77
GARDASIL (PF) ................................. 191
GARDASIL 9 (PF) ........................... 191
gas relief ............................................... 163, 164
gas relief extra strength ................. 163
gas-x extra strength ............................. 164
gas-x ultra-strength .............................. 164
gatifloxacin ...................................................... 160
GATTEX 30-VIAL ............................ 168
GATTEX ONE-VIAL .................. 168
GAUZE PAD ............................................ 199
gavilyte-c ............................................................. 174
gavilyte-g ............................................................ 175
gavilyte-n ............................................................ 175
GAVISCON EXTRA
STRENGTH ............................................... 168
GAZYVA ............................................................. 30
GE100 BLOOD GLUCOSE
TEST STRIP ................................................ 137
gelusil antacid and anti-gas ....... 168
gemfibrozil ........................................................... 99
generlac ................................................................. 168
gengraf ................................................................... 188
GENOTROPIN ...................................... 184
GENOTROPIN MINIQUICK
........................................................................................... 183
GENSTRIP TEST STRIP ....... 137
gentak ...................................................................... 160
gentamicin ............................... 16, 120, 160
gentamicin in nacl (iso-osm) ...... 16
gentamicin sulfate (ped) (pf) ... 16
gentamicin sulfate (pf) ....................... 17
GENTEAL GEL ................................... 156
genteal tears ................................................... 156
gentlelax .............................................................. 175
GENULTIMATE TEST ........... 137
GENVOYA ...................................................... 72
GEODON ........................................................... 69
gianvi (28) ....................................................... 108
gildagia .................................................................. 108
gildess 1.5/30 (21) ................................. 108
gildess 1/20 (21) ...................................... 108
gildess 24 fe ..................................................... 108
gildess fe 1.5/30 (28) ......................... 108
gildess fe 1/20 (28) ............................... 108
Effective: December 01, 2016
I-12
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
INVEGA SUSTENNA ................... 69
INVEGA TRINZA ............................... 69
INVIRASE ........................................................ 72
INVOKAMET ............................................. 47
INVOKAMET XR ................................ 47
INVOKANA .................................................. 47
inzo antifungal ................................................ 52
IONOSOL-B IN D5W .................. 209
IONOSOL-MB IN D5W ........... 209
IPOL ........................................................................ 192
ipratropium bromide ............ 156, 217
ipratropium-albuterol ........................ 217
IPRIVASK ......................................................... 79
irbesartan ............................................................... 87
irbesartan-hydrochlorothiazide
............................................................................................... 87
IRESSA ................................................................... 32
iron high potency ...................................... 224
ISENTRESS ......................................... 72, 73
ISOLYTE M IN 5 %
DEXTROSE ................................................ 209
ISOLYTE-H IN 5 %
DEXTROSE ................................................ 209
ISOLYTE-P IN 5 %
DEXTROSE ................................................ 209
ISOLYTE-S ................................................... 209
isoniazid ................................................................... 62
isosorbide dinitrate ................................ 102
isosorbide mononitrate ..................... 102
isradipine ................................................................ 96
itraconazole ........................................................ 52
ivermectin .............................................................. 65
IXEMPRA ......................................................... 32
IXIARO (PF) .............................................. 192
JAKAFI ................................................................. 32
jantoven .................................................................... 79
JANUMET ........................................................ 47
JANUMET XR .......................................... 47
JANUVIA ........................................................... 47
JARDIANCE ................................................ 47
jencycla ................................................................. 108
JENTADUETO ......................................... 47
JENTADUETO XR ............................ 47
jolessa ...................................................................... 108
jolivette .................................................................. 108
Index
ICLUSIG .............................................................. 31
iferex 150 forte ........................................... 228
ifosfamide .............................................................. 31
ifosfamide-mesna ......................................... 31
ILARIS (PF) ................................................ 189
ILEVRO ............................................................. 162
imatinib ..................................................................... 31
IMBRUVICA ................................................ 31
imipenem-cilastatin .................................. 23
imipramine hcl ................................................. 45
imipramine pamoate ............................... 45
imiquimod .......................................................... 118
IMLYGIC ........................................................... 31
imodium a-d .................................................... 169
IMOGAM RABIES-HT (PF)
........................................................................................... 189
IMOVAX RABIES VACCINE
(PF) ............................................................................ 192
INCONTROL SUPER THIN
LANCETS ...................................................... 138
INCONTROL ULTRA THIN
LANCETS ...................................................... 138
INCRELEX .................................................. 184
indapamide ........................................................... 97
indomethacin ..................................................... 12
indomethacin sodium .............................. 12
INFANRIX (DTAP) (PF) ...... 192
infants gas relief ........................................ 164
infant's ibuprofen ......................................... 12
INFINITY TEST STRIPS ..... 138
INFLECTRA ............................................. 200
INJECT EASE LANCETS
............................................................................ 138, 139
INLYTA ................................................................ 31
INSPIRACHAMBER ................... 139
INSPIRACHAMBER WITH
MASK-MED .............................................. 139
INSULIN SYRINGE-NEEDLE
U-100 ....................................................................... 139
INTELENCE ................................................. 72
INTRALIPID ................................................ 85
INTRON A ....................................................... 76
introvale ............................................................... 108
INVACARE LANCETS ........... 139
INVANZ ............................................................... 23
Index
Index
HUMIRA PEN ....................................... 188
HUMIRA PEN
CROHN'S-UC-HS START
........................................................................................... 188
HUMIRA PEN
PSORIASIS-UVEITIS ................. 188
HUMULIN R U-500 (CONC)
KWIKPEN ........................................................ 48
HUMULIN R U-500
(CONCENTRATED) ....................... 49
hydralazine .......................................................... 95
hydrochlorothiazide ................................. 97
hydrocil instant ........................................... 175
hydrocodone-acetaminophen ........... 5
hydrocodone-ibuprofen ........................... 5
hydrocortisone ............... 123, 124, 182
hydrocortisone acet-aloe vera
........................................................................................... 124
hydrocortisone acetate ..................... 123
hydrocortisone butyrate ................. 124
hydrocortisone butyr-emollient
........................................................................................... 124
hydrocortisone valerate ................... 124
hydromorphone .......................................... 5, 6
hydromorphone (pf) .................................. 5
hydroskin ............................................................ 123
hydroxocobalamin ................................. 228
hydroxychloroquine ................................. 65
hydroxyprogesterone caproate
........................................................................................... 185
hydroxyurea ....................................................... 31
hydroxyzine hcl .......................................... 200
hydroxyzine pamoate ......................... 200
HYPERLYTE CR .............................. 209
HYPERRAB S/D (PF) ................. 188
HYQVIA ........................................................... 189
HYQVIA IG COMPONENT
........................................................................................... 188
HYSINGLA ER ............................................ 6
ibandronate ...................................................... 197
IBRANCE .......................................................... 31
ibuprofen .......................................... 11, 12, 13
ibuprofen jr strength ............................... 12
ICAR ....................................................................... 228
ichthammol ...................................................... 118
Effective: December 01, 2016
I-13
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
larin fe 1.5/30 (28) ............................... 109
larin fe 1/20 (28) ..................................... 109
larissia .................................................................... 110
LARTRUVO .................................................. 32
latanoprost ....................................................... 204
LATUDA ............................................................. 69
laxative (glycerin-pediatric) ... 177
laxative (sennosides)
............................................................. 173, 175, 177
laxative peg 3350 ..................................... 177
laxative pills regular ............................ 175
LAZANDA ........................................................... 6
leena 28 ................................................................. 110
leflunomide ....................................................... 189
LEMTRADA ............................................. 200
LENVIMA ......................................................... 32
lessina ...................................................................... 110
LETAIRIS ...................................................... 222
letrozole .................................................................... 32
leucovorin calcium .................................. 200
LEUKERAN .................................................. 32
LEUKINE .......................................................... 80
leuprolide ................................................................ 32
levetiracetam ..................................................... 40
levobunolol ........................................................ 204
levocarnitine ................................................... 200
levocarnitine (with sugar) .......... 200
levocetirizine ...................................................... 58
levofloxacin .......................................... 26, 160
levofloxacin in d5w ................................... 26
levoleucovorin ............................................... 200
levomefolate calcium .......................... 228
levonest (28) ................................................. 110
levonorgestrel ................................................ 110
levonorgestrel-ethinyl estrad .... 110
levonorg-eth estrad triphasic ... 110
levora-28 .............................................................. 110
levothyroxine ................................................. 186
LEXIVA ................................................................. 73
LIBERTY TEST .................................... 139
lice bedding spray .................................... 125
lice cream rinse ........................................... 126
lice killing ........................................................... 126
lice solution ...................................................... 126
lice treatment ................................................ 126
Index
KINNEY BRAND LANCETS
........................................................................................... 139
KINRIX (PF) ............................................. 192
kionex ...................................................................... 169
kionex (with sorbitol) ...................... 169
KLOR-CON 10 ....................................... 209
klor-con m10 .................................................. 209
klor-con m15 .................................................. 209
klor-con m20 .................................................. 209
klor-con sprinkle ....................................... 209
konsyl (sugar) ............................................ 175
konsyl fiber ...................................................... 175
konsyl sugar-free ...................................... 175
KORLYM ........................................................... 47
kpn ............................................................................... 228
KRYSTEXXA .......................................... 153
kurvelo .................................................................... 109
KUVAN ............................................................. 153
KYNAMRO .................................................... 99
KYPROLIS ...................................................... 32
l norgest/e.estradiol-e.estrad .... 109
labetalol ................................................................... 90
LACRISERT .............................................. 156
LACTATED RINGERS ........... 196
lactulose ............................................................... 169
LAMICTAL .................................................... 39
LAMISIL (AEROSOL) .................. 52
lamisil af .................................................................. 52
LAMISIL AT ................................................. 53
lamivudine ............................................................. 73
lamivudine-zidovudine .......................... 73
lamotrigine ................................................ 39, 40
LANCETS ...................................................................
130, 131, 133, 136, 143, 144, 146
LANCETS, SUPER THIN ... 139
LANCETS,THIN ... 139, 146, 148
LANCETS,ULTRA THIN
............................................................................ 139, 152
LANOXIN ......................................................... 95
lansoprazole .................................................... 165
LANTUS .............................................................. 49
LANTUS SOLOSTAR .................... 49
larin 1.5/30 (21) ....................................... 109
larin 1/20 (21) ............................................ 109
larin 24 fe ........................................................... 109
Index
Index
juleber ...................................................................... 108
junel 1.5/30 (21) ...................................... 108
junel 1/20 (21) ............................................ 108
junel fe 1.5/30 (28) ............................... 109
junel fe 1/20 (28) .................................... 109
junel fe 24 ........................................................... 109
JUXTAPID ....................................................... 99
KABIVEN .......................................................... 85
KALETRA ........................................................ 73
KALYDECO .............................................. 219
KANUMA ..................................................... 153
kaopectate (bismuth subsalicy)
........................................................................................... 169
kaopectate ex str (bismuth ss)
........................................................................................... 169
kariva (28) ...................................................... 109
k-effervescent ................................................ 209
kelnor 1/35 (28) ....................................... 109
ketoconazole ...................................................... 52
KETO-DIASTIX .................................. 222
KETONE CARE .................................. 222
KETONE URINE TEST ......... 222
ketoprofen ............................................................. 12
ketorolac .................................................. 12, 162
KETOSTIX ................................................... 222
ketotifen fumarate ................................. 156
KEVEYIS ........................................................ 200
KEYTRUDA ................................................. 32
kids mini enema ......................................... 173
kimidess (28) ............................................... 109
KIMONO
CONDOMS(NON-LUBRICAT
ED) ............................................................................. 109
KIMONO MAXX CONDOMS
........................................................................................... 109
KIMONO MICROTHIN
AQUA LUBE CON ......................... 109
KIMONO MICROTHIN
CONDOMS .................................................. 109
KIMONO MICROTHIN
LARGE CONDOMS ..................... 109
KIMONO TEXTURED
CONDOMS .................................................. 109
KINERET ....................................................... 189
Effective: December 01, 2016
I-14
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
MAGNESIUM OXIDE ............. 169
magnesium oxide ........ 169, 170, 171
magnesium sulfate .................................. 211
magnesium sulfate in d5w ............ 210
magnesium sulfate in water ....... 210
MAGONATE ............................................ 211
MAGONATE (MAGNESIUM
CARB) .................................................................. 211
MAGOX ............................................................ 170
MAJOR COMFORT ..................... 140
malathion ............................................................ 126
mapap (acetaminophen) ...................... 6
mapap extra strength ................................ 6
maprotiline ........................................................... 45
mar-cof cg ......................................................... 115
margesic ...................................................................... 6
marlissa ................................................................. 110
MARPLAN ...................................................... 45
masanti double strength .................. 170
MATULANE ................................................ 33
matzim la ................................................................ 92
maxepa .................................................................. 100
MAXIMA ........................................................ 140
maximum redness relief .................. 155
meclizine .................................................................. 64
MEDI-LANCE LANCETS
........................................................................................... 140
MEDISENSE THIN
LANCETS ...................................................... 140
MEDLANCE PLUS LANCETS
........................................................................................... 140
medroxyprogesterone ........................ 185
MEDSAVER SYRINGE ......... 130
mefenamic acid ............................................... 12
mefloquine ............................................................. 65
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................................................... 21
MEGACE ES ............................................. 185
megestrol ................................................. 33, 185
MEKINIST ....................................................... 33
meloxicam ................................................. 12, 13
memantine ............................................................. 42
MENACTRA (PF) ............................ 192
MENEST .......................................................... 181
MENHIBRIX (PF) ............................ 192
Index
low-ogestrel (28) ..................................... 110
loxapine succinate ...................................... 69
lubricant dry eye relief ..................... 155
lubricant eye .................................... 155, 157
lubricant eye (polyv alcohol)
........................................................................................... 158
lubricant eye (propyl glycol)
........................................................................................... 157
lubricant eye drops ................................ 155
lubricant redness reliever .............. 157
lubricating drops ....................................... 155
lubrifresh pm .................................................. 157
LUMIGAN ................................................... 204
LUPRON DEPOT ................................. 33
LUPRON DEPOT (3 MONTH)
............................................................................................... 33
LUPRON DEPOT (4 MONTH)
............................................................................................... 33
LUPRON DEPOT (6 MONTH)
............................................................................................... 33
LUPRON DEPOT-PED ........... 184
LUPRON DEPOT-PED (3
MONTH) .......................................................... 184
lutera (28) ........................................................ 110
LYNPARZA ................................................... 33
LYRICA ................................................................ 40
LYSODREN ................................................... 33
lyza .............................................................................. 110
maalox advanced ..................................... 169
MAALOX MAXIMUM
STRENGTH ............................................... 169
mag 64 .................................................................... 210
MAG-AL .......................................................... 169
magbid er ............................................................ 210
mag-delay .......................................................... 210
MAGELLAN SYRINGE ....... 139
mag-g ....................................................................... 210
magnebind 400 ............................................ 178
magnesium .......................... 208, 210, 214
MAGNESIUM CHLORIDE
........................................................................................... 210
magnesium chloride .............................. 210
magnesium citrate ................... 173, 175
MAGNESIUM CITRATE .... 210
magnesium gluconate ......................... 210
Index
Index
lice treatment (permethrin) ...... 126
licide spray ....................................................... 200
lidocaine ................................................................... 14
lidocaine (pf) ........................................ 13, 89
lidocaine hcl ........................................................ 14
lidocaine in 5 % dextrose (pf)
............................................................................................... 89
lidocaine viscous ........................................... 14
lidocaine-prilocaine .................................. 14
linezolid .................................................................... 18
LINZESS .......................................................... 169
liothyronine ...................................................... 186
lipodox ....................................................................... 32
lipodox 50 .............................................................. 32
liquid antacid extra strength .... 166
liquid b 12 .......................................................... 228
liquid calcium with vitamin d ... 210
liquituss gg ........................................................ 115
lisinopril ................................................................... 88
lisinopril-hydrochlorothiazide .... 88
LITE TOUCH LANCETS ..... 139
LITEAIRE MDI CHAMBER
........................................................................................... 139
lithium carbonate ..................................... 104
lithium citrate ............................................... 104
little remedies ............................................... 156
LIVALO ................................................................. 99
l-methylfolate ............................................... 228
lohist - d ................................................................... 58
lomaira ................................................................... 104
lomedia 24 fe ................................................. 110
lomustine ................................................................. 32
LONSURF ........................................................ 33
loperamide ........................... 168, 169, 171
loratadine ............................................................... 58
lorazepam .............................................................. 16
lorcet (hydrocodone) ................................ 6
lorcet hd ....................................................................... 6
lorcet plus .................................................................. 6
loryna (28) ...................................................... 110
losartan ..................................................................... 87
losartan-hydrochlorothiazide ...... 87
LOTEMAX .................................... 162, 163
LOTRONEX ............................................... 169
lovastatin ................................................................ 99
Effective: December 01, 2016
I-15
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
mintox plus ....................................................... 170
MIRCERA ........................................................ 80
mirtazapine .......................................................... 45
misoprostol ....................................................... 165
mitoxantrone ..................................................... 34
M-M-R II (PF) ......................................... 193
moexipril ................................................................. 88
moexipril-hydrochlorothiazide
............................................................................................... 89
molindone ............................................................... 69
mometasone .................................................... 124
MONAGHAN Z STAT
CHAMBER-MD MSK ............... 140
MONISTAT 3 ............................................... 53
monistat 7 .............................................................. 53
MONOJECT LUER-LOCK
TIP .............................................................................. 140
MONOJECT PHARMACY
TRAY LUER ............................................. 141
MONOJECT PHARMACY
TRAY REG TIP .................................... 141
MONOJECT SAFETY LUER
LOCK TIP ...................................................... 141
MONOJECT SAFETY
SYRINGES ................................................... 146
MONOJECT SYRINGE
............................................................................ 140, 141
MONOJECT TB ................................... 141
MONOJECT TB LUER LOK
........................................................................................... 141
MONOJECT TB SAFETY
SYRINGE ....................................................... 141
MONOJECT TUBERCULIN
SYRINGE ......................... 140, 141, 149
MONOLET LANCETS ............. 141
MONOLET THIN LANCETS
........................................................................................... 141
mono-linyah .................................................... 111
mononessa (28) ......................................... 111
montelukast ..................................................... 216
morphine .............................................................. 7, 8
MORPHINE ....................................................... 7
morphine (pf) in 0.9 % nacl ............. 7
morphine concentrate ................................ 7
morphine in dextrose 5 % .................... 7
Index
metronidazole ......................... 18, 61, 120
metronidazole in nacl (iso-os)
............................................................................................... 18
mexiletine .............................................................. 89
mg217 psoriasis ......................................... 118
MIACALCIN ............................................ 197
mi-acid ................................................................... 170
mi-acid gas relief ...................................... 164
micatin ....................................................................... 53
miconazole 7 ...................................................... 53
miconazole nitrate ............... 51, 52, 53
miconazole-3 ...................................................... 53
miconazole-3 prefil,cream,wipe
............................................................................................... 54
MICRO BLOOD GLUCOSE
........................................................................................... 144
MICRO THIN LANCETS .... 140
MICROCHAMBER ....................... 140
MICRODOT BLOOD
GLUCOSE SYSTEM .................... 140
MICRODOT XTRA BLOOD
GLUCOSE ..................................................... 140
microgestin 1.5/30 (21) .................. 110
microgestin 1/20 (21) ....................... 110
microgestin fe 1.5/30 (28) .......... 110
microgestin fe 1/20 (28) ................ 111
micro-guard ........................................................ 53
MICROLET LANCET ............... 140
MICROSPACER ................................. 140
midodrine ............................................................... 87
miglitol ...................................................................... 48
milk of magnesia ...................................... 175
MILK OF MAGNESIA
CONCENTRATED ......................... 175
milrinone ................................................................. 95
milrinone in 5 % dextrose ................ 95
mimvey ................................................................... 181
mimvey lo ........................................................... 181
mineral oil .......................................................... 175
mineral oil laxative ............................... 175
minitran ................................................................ 102
minocycline .......................................................... 27
minoxidil ............................................................. 103
mintox ..................................................................... 170
mintox maximum strength ......... 170
Index
Index
MENOMUNE - A/C/Y/W-135
(PF) ............................................................................ 192
men's multi-vitamin ............................... 224
MENVEO A-C-Y-W-135-DIP
(PF) ............................................................................ 193
MENVEO MENA
COMPONENT (PF) ........................ 193
MENVEO MENCYW-135
COMPNT (PF) ........................................ 193
MEPHYTON ............................................. 228
mercaptopurine .............................................. 33
meropenem ........................................................... 23
mesalamine ...................................................... 196
mesna ....................................................................... 200
MESNEX ......................................................... 200
MESTINON ................................................ 201
MESTINON TIMESPAN ...... 201
metafolbic .......................................................... 228
metaproterenol ............................................ 217
metaxall ............................................................... 220
metaxalone ....................................................... 220
metformin ................................................... 47, 48
methadone ................................................................. 6
methadose ................................................................. 7
methazolamide ............................................ 204
methenamine hippurate ....................... 18
methimazole .................................................... 186
methocarbamol ........................................... 220
methotrexate sodium .................. 33, 34
methotrexate sodium (pf) .............. 33
methoxsalen rapid .................................. 118
methscopolamine ...................................... 170
methyclothiazide .......................................... 97
methylphenidate ......................... 104, 105
methylprednisolone ............................... 182
methylprednisolone acetate ....... 182
methylprednisolone sodium succ
........................................................................................... 183
metipranolol .................................................... 204
metoclopramide hcl ............................... 170
metolazone ........................................................... 97
metoprolol succinate ............................... 90
metoprolol ta-hydrochlorothiaz
............................................................................................... 90
metoprolol tartrate ................................... 91
Effective: December 01, 2016
I-16
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
neo-synephrine 12 h spr (oxym)
........................................................................................... 157
nephplex rx ...................................................... 229
NEPHRAMINE 5.4 % ..................... 85
nephron fa .......................................................... 229
nephro-vite rx ............................................... 229
NEULASTA .................................................... 80
NEUMEGA ..................................................... 80
NEUPOGEN .................................................. 80
NEUPRO ............................................................. 66
neurin-sl ................................................................ 229
NEUTEK 2TEK TEST STRIPS
........................................................................................... 141
NEVANAC ................................................... 163
nevirapine ............................................................... 73
NEXAVAR ....................................................... 34
NEXIUM 24HR .................................... 165
next choice one dose ............................ 111
niacin ........................................................................ 100
niacin (inositol niacinate)
............................................................................ 100, 101
niacin flush free ............................... 98, 100
niacinamide ....................................... 100, 229
niacor ....................................................................... 100
nicardipine ............................................................ 96
nicorelief .................................................................. 15
nicorette ................................................................... 15
nicotine ...................................................................... 15
nicotine (polacrilex) .............................. 15
NICOTROL ..................................................... 15
nifedical xl ............................................................ 96
nifedipine ................................................................ 96
nikki (28) .......................................................... 111
NILANDRON ............................................. 34
nilutamide .............................................................. 34
ninjacof-xg ........................................................ 115
NINLARO ......................................................... 34
NITRO-BID ................................................. 103
nitrofurantoin macrocrystal ......... 18
nitrofurantoin monohyd/m-cryst
.................................................................................... 18, 19
nitroglycerin ................................................... 103
nitroglycerin in 5 % dextrose
........................................................................................... 103
NITROSTAT ............................................. 103
Index
naphazoline ...................................................... 157
naproxen ................................................................. 13
naproxen sodium ............................... 11, 13
naratriptan ........................................................... 61
NARCAN ........................................................... 15
NASACORT ............................................... 163
nasal allergy ................................................... 163
nasal and sinus decongestant ... 115
nasal decongestant (oxymetazl)
........................................................................................... 157
nasal decongestant (pe) ................. 156
NASCOBAL ................................................ 229
NATACYN ................................................... 160
nateglinide ............................................................. 48
NATPARA .................................................... 197
natural balance ........................................... 157
natural calcium ........................................... 211
natural daily fiber ................................... 173
natural fiber laxative therapy
........................................................................................... 175
natural tears (pf) .................................... 155
natural vegetable ...................................... 176
nature's tears (hypromellose)
........................................................................................... 157
NEBUPENT .................................................... 65
necon 0.5/35 (28) ................................... 111
necon 1/35 (28) ......................................... 111
necon 1/50 (28) ......................................... 111
necon 10/11 (28) ..................................... 111
necon 7/7/7 (28) ....................................... 111
nefazodone ............................................................ 45
neomycin ................................................................. 17
neomycin-bacitracin-poly-hc ... 160
neomycin-bacitracin-polymyxin
........................................................................................... 160
neomycin-polymyxin b gu ............ 120
neomycin-polymyxin b-dexameth
........................................................................................... 160
neomycin-polymyxin-gramicidin
........................................................................................... 160
neomycin-polymyxin-hc ................. 161
neo-polycin ....................................................... 161
neo-polycin hc .............................................. 161
neosporin + pain relief ...................... 121
neosporin anti-itch ................................. 124
Index
Index
morrhuate sodium ................................... 201
motion sickness .............................................. 63
motion sickness (meclizine) ......... 64
MOVANTIK .............................................. 170
MOVIPREP .................................................. 175
MOXEZA ........................................................ 160
moxifloxacin ...................................................... 26
MOZOBIL .......................................................... 80
mucinex sinus-max ................................ 157
MULTAQ ........................................................... 89
multi antibiotic plus .............................. 120
multigen ................................................................ 228
multigen folic ................................................. 229
multigen plus .................................................. 229
multiple vitamins ...................................... 229
multivitamin ..................................... 229, 233
multivitamin with fluoride ........... 229
mupirocin ............................................................ 120
mupirocin calcium .................................. 120
murine ear ......................................................... 160
murine ear wax removal system
........................................................................................... 160
muro 128 ............................................................. 157
my way ................................................................... 111
myco nail a ........................................................... 53
mycophenolate mofetil ..................... 189
mycophenolate sodium ..................... 189
myferon 150 forte ................................... 229
MYGLUCOHEALTH ................. 141
MYGLUCOHEALTH
LANCETS ...................................................... 141
MYOZYME ................................................. 153
MYRBETRIQ ........................................... 178
mytab gas ........................................................... 164
mytab gas maximum strength
........................................................................................... 164
myzilra ................................................................... 111
nabumetone ......................................................... 13
nadolol ....................................................................... 91
nafcillin ..................................................................... 24
NAGLAZYME ....................................... 153
naloxone .................................................................. 14
naltrexone ............................................................. 15
NAMENDA XR ....................................... 42
NAMZARIC .................................................. 43
Effective: December 01, 2016
I-17
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
ON CALL LANCET ...................... 142
ON CALL PLUS LANCET
........................................................................................... 142
ON CALL PLUS TEST STRIP
........................................................................................... 142
ON CALL VIVID TEST STRIP
........................................................................................... 142
ONCASPAR ................................................... 34
once daily ........................................................... 229
ondansetron ......................................................... 64
ondansetron hcl .............................................. 64
ondansetron hcl (pf) ............................... 64
ONE A DAY WOMEN'S
PRENATAL DHA ............................ 229
one daily ................................................ 230, 232
one daily essential ..... 225, 227, 229
one daily multivitamin ...................... 229
one daily prenatal ..................... 232, 233
one-a-day essential ................................ 230
ONE-A-DAY WOMEN'S
PRENATAL 1 .......................................... 230
one-per-day omega-3 .......................... 100
ONETOUCH DELICA
LANCETS ...................................................... 142
ONETOUCH FINEPOINT
LANCETS ...................................................... 142
ONETOUCH ULTRA TEST
........................................................................................... 142
ONETOUCH ULTRASOFT
LANCETS ...................................................... 142
ONETOUCH VERIO ................... 142
ONFI ........................................................... 16, 124
ON-THE-GO LANCETS ........ 146
opcicon one-step ........................................ 112
OPDIVO ................................................................ 34
OPSUMIT ....................................................... 222
OPTICHAMBER ADULT
MASK-LARGE ..................................... 142
OPTICHAMBER DIAMOND
VHC .......................................................................... 142
opti-clear ............................................................. 157
optimal d3 .......................................................... 230
option 2 ................................................................. 112
OPTIUM EZ ............................................... 142
OPTIUM TEST ...................................... 142
Index
NOVOLOG PENFILL .................... 49
NOXAFIL .......................................................... 53
NUCALA ........................................................ 219
NUCYNTA .......................................................... 8
NUCYNTA ER ............................................. 8
NUEDEXTA .............................................. 105
NULOJIX ........................................................ 189
nu-mag ................................................................... 211
NUPLAZID ..................................................... 69
NUTRESTORE ..................................... 170
NUTRILIPID ............................................... 86
NUTRILYTE ............................................ 211
NUTRILYTE II ..................................... 211
NUVARING .............................................. 112
nyamyc ...................................................................... 53
nystatin ..................................................................... 53
nystatin-triamcinolone ......................... 53
nystop .......................................................................... 53
nyt-time sleep ................................................... 59
obagi nu-derm tolereen .................... 124
OCALIVA ....................................................... 170
ocean nasal ....................................................... 157
ocella ........................................................................ 112
OCTAGAM .................................................. 189
octreotide acetate .................................... 184
ODEFSEY .......................................................... 73
ODOMZO ........................................................... 34
OFEV ..................................................................... 219
ofloxacin .................................................. 26, 161
ogestrel (28) .................................................. 112
olanzapine .................................................. 69, 70
olanzapine-fluoxetine ............................ 45
olopatadine ....................................................... 157
OLYSIO ................................................................. 76
omega 3 fish oil .............................................. 98
omega-3 acid ethyl esters ............. 100
omega-3 fatty acids .................................. 98
omega-3 fatty acids-fish oil
................................................................................ 99, 100
omeprazole ....................................................... 165
omeprazole magnesium ................... 165
omeprazole-sodium bicarbonate
........................................................................................... 165
ON CALL EXPRESS TEST
STRIP .................................................................... 142
Index
Index
NIX CREME RINSE .................... 126
NIZORAL A-D .......................................... 53
nohist-lq ................................................................... 58
non-aspirin extra strength .................. 9
non-aspirin jr strength .............................. 5
nora-be ................................................................... 111
NORDITROPIN FLEXPRO
........................................................................................... 184
norepinephrine bitartrate ................. 95
norethindrone (contraceptive)
........................................................................................... 111
norethindrone acetate ........................ 185
norethindrone ac-eth estradiol
........................................................................................... 111
norethindrone-e.estradiol-iron
........................................................................................... 111
norgestimate-ethinyl estradiol
........................................................................................... 111
norlyroc ................................................................. 111
NORMOSOL-M IN 5 %
DEXTROSE ................................................ 211
NORMOSOL-R PH 7.4 ............. 211
nortemp ........................................................................ 8
NORTHERA ................................................. 87
nortrel 0.5/35 (28) ................................ 112
nortrel 1/35 (21) ...................................... 112
nortrel 1/35 (28) ...................................... 112
nortrel 7/7/7 (28) .................................... 112
nortriptyline ........................................................ 45
NORVIR ............................................................... 73
nose drops .......................................................... 158
NOVA MAX GLUCOSE TEST
........................................................................................... 142
NOVA SAFETY LANCETS
........................................................................................... 142
NOVA SUREFLEX LANCETS
........................................................................................... 142
NOVOLIN 70/30 ....................................... 49
NOVOLIN N ................................................. 49
NOVOLIN R .................................................. 49
NOVOLOG ...................................................... 49
NOVOLOG FLEXPEN ................. 49
NOVOLOG MIX 70-30 .................. 49
NOVOLOG MIX 70-30
FLEXPEN .......................................................... 49
Effective: December 01, 2016
I-18
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
phenadoz ................................................................. 64
phenelzine .............................................................. 45
phenobarbital .................................................... 40
phenobarbital sodium ............................ 40
phentermine ..................................................... 105
phenylephrine hcl .......................... 87, 157
phenylhistine dh ......................................... 115
phenytoin ................................................................ 40
phenytoin sodium ......................................... 41
phenytoin sodium extended ........... 41
philith ....................................................................... 112
phillips .................................................................... 170
phillips liqui-gels ....................................... 176
PHILLIPS MILK OF
MAGNESIA ................................. 170, 176
PHOSLYRA ................................................ 178
phospha 250 neutral ............................. 212
phosphate laxative ................................. 176
PHOSPHOLINE IODIDE ..... 204
phytonadione (vitamin k1) ........ 237
PICATO ............................................................. 119
pilocarpine hcl ............................... 117, 204
pimozide ................................................................... 70
pimtrea (28) .................................................. 112
pindolol ..................................................................... 91
pink bismuth ................................................... 171
pin-x .............................................................................. 65
pioglitazone ......................................................... 48
pioglitazone-glimepiride .................... 48
pioglitazone-metformin ....................... 48
piperacillin-tazobactam ...................... 25
pirmella ................................................................. 112
piroxicam ............................................................... 13
PLASMA-LYTE 148 ...................... 212
PLASMA-LYTE A ............................ 212
PLASMA-LYTE-56 IN 5 %
DEXTROSE ................................................ 212
PLEGRIDY .................................................. 201
POCKET CHAMBER ................. 143
podactin .................................................................... 54
podocon ................................................................. 119
podofilox ............................................................. 119
polyethylene glycol 3350 ............... 176
POLYETHYLENE GLYCOL
3350 ........................................................................... 176
Index
PARICALCITOL ................................ 197
paromomycin .................................................... 65
paroxetine hcl ................................................... 45
PASER ..................................................................... 62
PATADAY .................................................... 157
PAXIL ...................................................................... 45
PEDIA-LAX ............................................... 168
pedia-lax stool softener ................... 174
PEDIALYTE .............................................. 212
PEDIARIX (PF) .................................... 193
pediatric electrolyte
............................................................. 208, 212, 214
pediatric freezer pops ......................... 214
PEDIAVENT ................................................. 58
PEDVAX HIB (PF) .......................... 193
peg 3350-electrolytes .......................... 176
PEGANONE .................................................. 40
PEGASYS ........................................................... 77
PEGASYS PROCLICK ................. 77
peg-electrolyte soln ............................... 176
PEGINTRON ............................................... 77
PEN NEEDLE, DIABETIC
........................................................................................... 143
penicillin g pot in dextrose .............. 25
penicillin g potassium ............................ 25
penicillin g procaine ................................. 25
penicillin v potassium ............................. 25
PENTACEL (PF) ................................. 193
PENTAM ............................................................. 65
pentoxifylline .................................................... 81
pep-t-med ............................................................ 170
perdiem overnight relief .................. 176
PERFECT IRON ................................. 230
PERIKABIVEN ........................................ 86
perindopril erbumine ............................... 89
periogard ............................................................. 117
permethrin ......................................................... 126
perphenazine ...................................................... 70
perphenazine-amitriptyline ............ 45
perry prenatal ............................................... 230
persa-gel ............................................................... 119
pfizerpen-g ............................................................ 25
pharbetol ..................................................................... 9
PHARMACIST CHOICE ...... 143
pharmacist favorite multi-vit ... 230
Index
Index
OPTUMRX .................................................. 142
oral saline laxative ................................ 176
oralone ................................................................... 117
oralyte ..................................................................... 211
ORENCIA ...................................................... 189
ORENCIA (WITH MALTOSE)
........................................................................................... 189
ORENCIA CLICKJECT ......... 201
ORENITRAM ......................................... 222
ORFADIN ...................................... 153, 201
ORKAMBI .................................................... 219
orsythia ................................................................. 112
OTEZLA ........................................................... 201
OTEZLA STARTER ..................... 201
OTREXUP (PF) ..................................... 201
oxacillin ........................................................ 24, 25
oxacillin in dextrose(iso-osm)
............................................................................................... 25
oxandrolone .................................................... 180
oxcarbazepine .................................................. 40
OXTELLAR XR ...................................... 40
oxybutynin chloride .............................. 178
oxycodone ................................................................. 8
oxycodone-acetaminophen ................. 8
oxycodone-aspirin .......................................... 8
OXYCONTIN .......................................... 8, 9
oxymorphone ........................................................ 9
oysco 500/d ...................................................... 211
oysco-500 ............................................................ 211
oyster shell calcium 500 .................. 211
oyster shell calcium-vit d3
............................................................................ 211, 212
oystercal-d ........................................................ 212
pacerone ................................................................... 89
pain relief ................................................................... 9
pain reliever jr strength ........................... 9
paliperidone ........................................................ 70
pancrelipase 5000 .................................... 153
panoxyl .................................................................. 119
panoxyl-4 ............................................................ 119
PANRETIN .................................................. 119
PANTILINERS ...................................... 201
pantoprazole ................................................... 165
papaverine .................................................. 95, 96
paricalcitol ........................................................ 197
Effective: December 01, 2016
I-19
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
prenatal vit-iron fumarate-fa ... 231
prenatal with dha-folic acid ....... 230
prenatal-1 ........................................................... 231
preparation h hydrocortisone
........................................................................................... 124
PRESSURE ACTIVATED
LANCETS ...................................................... 143
PREVAIL BLADDER
CONTROL PAD .................................. 172
prevalite ................................................................ 101
previfem ................................................................ 112
PREZCOBIX ................................................. 73
PREZISTA ............................................. 73, 74
PRIFTIN .............................................................. 62
PRIMAQUINE .......................................... 65
PRIMEAIRE .............................................. 143
primidone ............................................................... 41
PRISTIQ ............................................................... 45
PRIVIGEN .................................................... 189
PRO COMFORT LANCETS
........................................................................................... 143
PROAIR HFA .......................................... 217
PROAIR RESPICLICK ............ 217
probenecid ......................................................... 201
probenecid-colchicine ......................... 202
procainamide ..................................................... 89
PROCALAMINE 3% ........................ 86
PROCHAMBER .................................. 143
prochlorperazine ........................................... 64
prochlorperazine edisylate .............. 64
prochlorperazine maleate ................. 64
PROCRIT ........................................................... 80
procto-med hc ............................................... 124
procto-pak ......................................................... 124
proctosol hc ..................................................... 125
proctozone-hc ............................................... 125
PROCYSBI .................................................... 202
PRODIGY LANCETS ................ 143
PRODIGY NO CODING ...... 143
PRODIGY TWIST TOP
LANCET .......................................................... 144
PROFE FORTE ..................................... 231
progesterone in oil .................................. 186
progesterone micronized ................ 186
PROGLYCEM ........................................ 103
Index
PRECISION PCX PLUS TEST
........................................................................................... 143
PRECISION PCX TEST .......... 143
PRECISION POINT OF CARE
TEST ....................................................................... 143
PRECISION Q-I-D TEST ...... 143
PRECISION XTRA TEST .... 143
prednicarbate ................................................ 124
prednisolone acetate ............................ 163
prednisolone sodium phosphate
............................................................................ 163, 183
prednisone .......................................................... 183
PREMARIN ................................. 181, 182
PREMASOL 10 % .................................. 86
PREMASOL 6 % ...................................... 86
PREMIUM V10 ..................................... 143
PREMPHASE ........................................... 182
PREMPRO .................................................... 182
prenatal ................................... 227, 231, 233
PRENATAL ................................................ 231
prenatal + dha ............................................. 230
prenatal 19 ........................................................ 230
PRENATAL
DHA+COMPLETE
PRENATAL ................................................ 230
prenatal formula ........................ 230, 232
prenatal gummy ......................................... 224
PRENATAL MULTI-DHA
........................................................................................... 231
prenatal multi-dha (algal oil)
........................................................................................... 231
prenatal multivitamins ...................... 231
prenatal one .................................................... 231
prenatal one daily .................................... 231
prenatal plus (calcium carb) ... 230
prenatal tablet .............................................. 232
prenatal vit no.90-iron fum-fa
........................................................................................... 230
prenatal vit#96-ferrous fum-fa
........................................................................................... 231
prenatal vitamin .......... 224, 225, 231
prenatal vitamin plus low iron
........................................................................................... 231
prenatal vitamin with minerals
........................................................................................... 231
Index
Index
POLYETHYLENE GLYCOL
3350(BULK) ................................................. 201
poly-iron 150 forte ................................. 230
polymyxin b sulfate .................................. 19
polymyxin b sulf-trimethoprim
........................................................................................... 161
polysporin .......................................................... 121
poly-vita (iron) .......................................... 230
poly-vitamin with iron ....................... 230
POMALYST ................................................... 34
portia ........................................................................ 112
PORTRAZZA .............................................. 34
potassium acetate .................................... 212
potassium bicarb and chloride
........................................................................................... 212
potassium bicarb-citric acid ...... 212
potassium chlorid-d5-0.45%nacl
........................................................................................... 212
potassium chloride .................. 213, 214
potassium chloride in 0.9%nacl
........................................................................................... 212
potassium chloride in 5 % dex
........................................................................................... 212
potassium chloride in lr-d5 ......... 212
potassium chloride-0.45 % nacl
........................................................................................... 213
potassium chloride-d5-0.2%nacl
........................................................................................... 213
potassium chloride-d5-0.3%nacl
........................................................................................... 213
potassium chloride-d5-0.9%nacl
........................................................................................... 213
potassium citrate ...................................... 213
potassium citrate-citric acid ..... 213
potassium hydroxide ........................... 119
potassium phosphate m-/d-basic
........................................................................................... 214
POTIGA ................................................................ 41
PRADAXA ....................................................... 79
PRALUENT PEN .............................. 100
PRALUENT SYRINGE .......... 101
pramipexole ........................................................ 67
pravastatin ........................................................ 101
prazosin .................................................................... 87
Effective: December 01, 2016
I-20
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
RELION ULTRA THIN PLUS
LANCETS ...................................................... 145
RELISTOR ................................................... 171
remedy phytoplex antifungal ....... 54
REMICADE ............................................... 202
REMODULIN ......................................... 222
RENAGEL .................................................... 178
renal caps ........................................................... 232
rena-vite rx ....................................................... 232
reno caps ............................................................. 232
RENVELA ..................................................... 178
repaglinide ............................................................ 48
repaglinide-metformin .......................... 48
REPATHA PUSHTRONEX
........................................................................................... 101
REPATHA SURECLICK ...... 101
REPATHA SYRINGE ................ 101
reprexain .................................................................... 9
RESCRIPTOR ............................................. 74
RESTASIS ...................................................... 163
retaine cmc ....................................................... 158
retaine hpmc ................................................... 158
retaine pm .......................................................... 158
RETROVIR ..................................................... 74
REVEAL TEST STRIP .............. 145
revive plus .......................................................... 156
REVLIMID ...................................................... 34
revonto ................................................................... 220
REXULTI ........................................................... 70
REYATAZ ........................................................ 74
ribasphere .............................................................. 77
riboflavin (vitamin b2) .................... 232
rid complete lice elim kit ............... 126
rid lice killing ................................................ 126
RIDAURA .................................................... 190
rifabutin ................................................................... 62
rifampin .................................................................... 62
RIFATER ........................................................... 62
ri-gel ii .................................................................... 171
right step prenatal vitamins ....... 232
RIGHTEST GL300 LANCETS
........................................................................................... 145
RIGHTEST GS250S TEST
STRIPS ................................................................ 145
Index
quinapril ................................................................... 89
quinapril-hydrochlorothiazide ... 89
quinidine gluconate ................................... 90
quinidine sulfate ............................................ 90
quinine sulfate .................................................. 66
QUINTET AC .......................................... 144
QUINTET GLUCOSE TEST
STRIPS ................................................................ 144
QVAR .................................................................... 216
RABAVERT (PF) ............................... 193
raloxifene ........................................................... 182
ramipril ..................................................................... 89
RANEXA ............................................................ 96
ranitidine hcl .................................................. 165
RAPAMUNE ............................................ 190
RASUVO (PF) .......................................... 202
RAVICTI .......................................................... 171
react ........................................................................... 112
REBIF (WITH ALBUMIN)
........................................................................................... 202
REBIF REBIDOSE .......................... 202
REBIF TITRATION PACK
........................................................................................... 202
reclipsen (28) ............................................... 112
RECOMBIVAX HB (PF)
............................................................................ 193, 194
recort plus .......................................................... 125
redness relief ................................... 155, 158
redness reliever lubricant
............................................................................ 155, 158
reese's pinworm medicine ................. 66
REFRESH TEARS ........................... 158
REFUAH PLUS ................................... 144
reguloid ................................................................. 177
relcof c .................................................................... 115
RELENZA DISKHALER ......... 75
RELIAMED LANCET .............. 144
RELIAMED SAFETY SEAL
LANCETS ...................................................... 144
RELION CONFIRM-MICRO
........................................................................................... 144
RELION PRIME TEST
STRIPS ................................................................ 144
RELION THIN LANCETS
........................................................................................... 145
Index
Index
PROGRAF .................................................... 189
PROLASTIN-C ...................................... 219
PROLENSA ................................................. 163
PROLEUKIN ............................................... 34
PROLIA ............................................................. 197
PROMACTA ................................................. 80
promethazine .......................................... 58, 64
promethazine vc-codeine ................ 115
promethazine-codeine ........................ 115
promethazine-dm ..................................... 115
promethegan ...................................................... 64
promolaxin ....................................................... 176
propafenone ............................................. 89, 90
propantheline .................................................... 38
proparacaine .................................................. 157
propranolol .......................................................... 91
propranolol-hydrochlorothiazid
............................................................................................... 91
propylthiouracil ......................................... 186
PROQUAD (PF) ................................... 193
PROSOL 20 % .............................................. 86
protamine ............................................................... 81
protriptyline ........................................................ 45
pseudoephedrine hcl ............................. 115
psyllium husk ................................................. 176
PULMOZYME ....................................... 153
puralube ................................................................ 157
pure and gentle eye ................. 157, 158
purelax ................................................................... 173
PURIXAN ......................................................... 34
PUSH BUTTON SAFETY
LANCETS ...................................................... 144
pyrazinamide ..................................................... 62
pyridostigmine bromide .................. 202
pyridoxine (vitamin b6) ................ 232
pyrilamine-phenylephrine ..... 58, 59
q-dryl ............................................................................ 59
q-pap ................................................................................ 9
q-pap extra strength ................................... 9
q-tapp .......................................................................... 59
q-tussin ................................................................... 115
QUADRACEL (PF) ........................ 193
quasense ............................................................... 112
quetiapine ............................................................... 70
QUILLIVANT XR ............................ 105
Effective: December 01, 2016
I-21
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
sinus nighttime ................................................ 59
sirolimus ............................................................... 190
SIRTURO ........................................................... 62
SMART SENSE LANCETS
........................................................................................... 146
SMART SENSE TEST STRIPS
........................................................................................... 146
SMARTEST LANCET ............... 146
SMARTEST TEST ............................ 146
smoflipid .................................................................. 86
smoothlax .......................................................... 177
sochlor .................................................................... 158
sodium acetate ............................................. 214
sodium bicarbonate
............................................................. 171, 172, 214
sodium chloride .......................................................
158, 196, 215, 219
sodium chloride 0.45 % .................... 214
sodium chloride 0.9 % ....................... 214
sodium chloride 3 % ............................. 214
sodium chloride 5 % ............................. 215
sodium fluoride ........................................... 233
sodium lactate .............................................. 215
sodium phosphate .................................... 215
sodium polystyrene (sorb free)
........................................................................................... 172
sodium polystyrene sulfonate
........................................................................................... 172
sodium thiosulfate ................................... 179
SOFT TOUCH LANCETS ... 147
SOLTAMOX .................................................. 34
SOLU-CORTEF (PF) ................... 183
SOLUS V2 LANCETS ................. 147
SOLUS V2 TEST STRIPS ...... 147
SOMATULINE DEPOT .......... 185
SOMAVERT ............................................... 185
soothe (bismuth subsalicylate)
........................................................................................... 172
soothe regular strength .................... 172
sorbitol ................................................................... 196
sorbitol-mannitol ...................................... 196
sorine ............................................................................ 91
sotalol .......................................................................... 91
sotalol af .................................................................. 91
SOVALDI ........................................................... 76
Index
sani-supp (adult) ..................................... 177
sani-supp (infant) .................................. 177
SANTYL ........................................................... 119
SAPHRIS (BLACK CHERRY)
............................................................................................... 70
SAVELLA ....................................................... 105
scalp itch-dandruff relief ............... 119
scot-tussin expectorant .................... 116
sea soft nasal mist ................................... 158
sea-omega 30 ................................................. 101
selegiline hcl ....................................................... 67
selenium sulfide .......................................... 121
SELZENTRY ................................................ 74
senexon .................................................................. 177
senna .......................................................... 176, 177
senna lax ............................................................. 177
senna laxative ................................ 173, 177
senna-extra ...................................................... 173
SENSIPAR .................................................... 202
SEREVENT DISKUS .................. 217
SEROSTIM ................................................... 185
sertraline ...................................................... 45, 46
se-tan plus .......................................................... 232
setlakin .................................................................. 112
sharobel ................................................................. 112
siderol ...................................................................... 232
SIGNIFOR .................................................... 202
silace ......................................................................... 177
siladryl sa ............................................................... 59
silapap ............................................................................ 9
sildenafil ............................................................... 222
SILENOR ............................................................ 46
siltussin sa ......................................................... 116
silver nitrate .................................................... 121
silver sulfadiazine .................................... 121
SIMBRINZA .............................................. 204
simethicone ...................................................... 164
SIMILAC PRENATAL ............. 233
simply sleep ......................................................... 59
SIMPONI ......................................................... 203
SIMPONI ARIA ................................... 202
simvastatin ........................................................ 101
SINGLE-LET ............................................ 146
sinus and allergy(pseudoephed)
............................................................................................... 59
Index
Index
RIGHTEST GS260 TEST
STRIPS ................................................................ 145
RIGHTEST GS550 TEST
STRIPS ................................................................ 145
riginic ....................................................................... 171
riluzole .................................................................... 105
rimantadine ......................................................... 75
ri-mox ..................................................................... 171
ri-mox plus ....................................................... 171
ringers ...................................................... 196, 214
risacal-d ................................................................ 214
risedronate ........................................................ 197
RISPERDAL CONSTA ................ 70
risperidone ............................................................ 70
RITEFLO AEROCHAMBER
........................................................................................... 145
ritifed ........................................................................... 59
RITUXAN ......................................................... 34
rivastigmine ......................................................... 43
rivastigmine tartrate ............................... 43
rizatriptan ............................................................. 61
robafen ................................................................... 116
ropinirole ................................................................ 67
rosadan .................................................................. 121
rosuvastatin ..................................................... 101
ROTARIX ...................................................... 194
ROTATEQ VACCINE ............... 194
ROWEEPRA .................................................. 41
roxicet ............................................................................ 9
ROZEREM ................................................... 220
RYMED
(DEXCHLORPHENIRAMINE
-PE) ................................................................................ 59
SABRIL .................................................................. 41
SAFESNAP SYRINGE ............. 145
SAFETY LANCETS ...................... 145
SAFETY SEAL LANCETS
........................................................................................... 145
SAFETY-LET LANCETS ..... 146
SAIZEN .............................................................. 184
SAIZEN CLICK.EASY ............. 184
saline mist .......................................................... 158
saline nasal mist ........................................ 155
SANDOSTATIN LAR DEPOT
............................................................................ 184, 185
Effective: December 01, 2016
I-22
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
tactinal extra strength .......................... 10
TAFINLAR ..................................................... 35
TAGRISSO ....................................................... 35
TALTZ AUTOINJECTOR
........................................................................................... 119
TALTZ SYRINGE ............................ 119
TAMIFLU .............................................. 75, 76
tamoxifen ............................................................... 35
tamsulosin .......................................................... 179
TARCEVA ........................................................ 35
TARGRETIN ............................................... 35
tarina fe 1/20 (28) ................................. 112
taron forte ......................................................... 233
TASIGNA ........................................................... 35
tazicef .......................................................................... 21
TAZORAC .................................................... 125
taztia xt .................................................................... 92
TD GOLD TEST STRIP .......... 148
tears again (pva) ..................................... 159
tears naturale free (pf) ................... 159
tears naturale pm ..................................... 159
TECENTRIQ ................................................. 35
TECFIDERA ............................................. 203
TECHLITE LANCETS .............. 148
TECHNIVIE ................................................... 76
TEFLARO ......................................................... 22
TELCARE LANCETS ................ 148
TELCARE TEST STRIPS ..... 148
telmisartan ........................................................... 87
telmisartan-hydrochlorothiazid
............................................................................................... 87
TEMODAR ...................................................... 35
tencon .......................................................................... 10
TENIVAC (PF) ....................................... 194
terazosin ............................................................... 179
terbinafine hcl .................................................. 54
terbutaline ......................................................... 218
terconazole ........................................................... 61
TERUMO SYRINGE .................. 148
TEST N'GO TEST .............................. 148
testosterone ...................................................... 180
testosterone cypionate ...................... 180
testosterone enanthate ...................... 180
Index
sulfatrim .................................................................. 26
sulindac ..................................................................... 13
sumatriptan ......................................................... 61
sumatriptan succinate ................ 61, 62
super multivitamin ................................. 233
SUPER THIN LANCETS ..... 147
SUPER TWIN EPA-DHA ..... 101
suphedrin ............................................................. 116
support-500 ...................................................... 233
suppository adult ...................................... 173
SUPPRELIN LA .................................. 185
SUPRAX .............................................................. 21
supreme antacid ......................................... 171
SURE COMFORT LANCETS
........................................................................................... 147
SURE-LANCE ........................................ 147
SURE-LANCE ULTRA THIN
........................................................................................... 147
SURE-TEST EASYPLUS
MINI ....................................................................... 148
SURE-TOUCH LANCET ..... 148
SURGUARD2 SAFETY ......... 148
SURMONTIL .............................................. 46
SUSTIVA ............................................................. 74
SUTENT ............................................................... 35
syeda ......................................................................... 112
SYLATRON ................................................... 77
SYLVANT ......................................................... 35
SYMLINPEN 120 ................................... 48
SYMLINPEN 60 ...................................... 48
SYNAGIS ........................................................... 75
SYNAREL ..................................................... 203
SYNERCID ..................................................... 19
SYNJARDY .................................................... 48
SYNRIBO ........................................................... 35
SYPRINE ........................................................ 179
SYRINGE (DISPOSABLE)
............................................................................ 130, 135
SYRINGE 3CC/25GX1" ........... 135
SYSTANE BALANCE ............... 158
systane nighttime ..................................... 159
tab-a-vite ............................................................. 233
TABLOID ........................................................... 35
tacrolimus ........................................... 125, 190
tactinal .......................................................................... 9
Index
Index
SPACE CHAMBER PLUS ... 147
SPIRIVA RESPIMAT .................. 217
SPIRIVA WITH
HANDIHALER .................................... 217
spironolactone .............................................. 102
spironolacton-hydrochlorothiaz
........................................................................................... 102
sprintec (28) .................................................. 112
SPRITAM ........................................................... 41
SPRYCEL ................................................ 34, 35
sps (with sorbitol) ................................. 172
sronyx ..................................................................... 112
ssd ................................................................................. 121
st joseph aspirin ............................................. 13
st. joseph aspirin ........................................... 13
stavudine ................................................................. 74
STELARA ...................................................... 203
STERILANCE TL ............................. 147
sterile eye drops ......................................... 158
STERILE PADS .................................... 203
STIOLTO RESPIMAT ................... 38
STIVARGA ...................................................... 35
stomach relief ............................................... 171
stool softener ................................................. 173
stop lice ................................................................. 126
STRATTERA ............................................ 105
STRENSIQ .................................................... 153
streptomycin ...................................................... 17
STRIBILD .......................................................... 74
STRIVERDI RESPIMAT ...... 218
strovite forte ................................................... 233
STROVITE ONE ................................. 233
STUART ONE ........................................ 233
sucralfate ............................................................ 165
sudafed ................................................................... 116
sudogest ................................................................ 116
sudogest sinus and allergy ............... 59
sulfacetamide sodium ......................... 161
sulfacetamide sodium (acne)
........................................................................................... 121
sulfacetamide-prednisolone ........ 161
sulfadiazine .......................................................... 26
sulfamethoxazole-trimethoprim
............................................................................................... 26
sulfasalazine ....................................................... 26
Effective: December 01, 2016
194
TETANUS,DIPHTHERIA
TOX PED(PF) .......................................... 194
TETANUS-DIPHTHERIA
TOXOIDS-TD .......................................... 194
tetrabenazine ................................................. 106
tetracaine hcl (pf) .................................. 159
tetracycline .......................................................... 27
THALOMID ............................................... 203
the magic bullet .......................................... 175
theochron ............................................................ 218
theophylline ..................................................... 218
theophylline in dextrose 5 % .... 218
thera-d .................................................................... 233
THERANATAL .................................... 233
THERANATAL ONE ................. 233
THERANATAL OVAVITE
........................................................................................... 233
THERANATAL PLUS .............. 234
thiamine hcl (vitamin b1) ............ 234
THIN LANCETS ................................. 146
thioridazine .......................................................... 71
thiotepa ..................................................................... 35
thiothixene ............................................................ 71
tiagabine .................................................................. 41
TICE BCG ...................................................... 190
tilia fe ....................................................................... 113
timolol maleate ................................ 91, 205
tioconazole ........................................................... 51
TIVICAY ............................................................. 74
tizanidine ............................................................. 220
tl gard rx ............................................................. 234
tl-hem 150 .......................................................... 234
TOBI PODHALER .............................. 17
TOBRADEX ............................................... 161
TOBRADEX ST .................................... 161
tobramycin ........................................................ 161
tobramycin in 0.225 % nacl ........... 17
tobramycin in 0.9 % nacl .................. 17
tobramycin sulfate ..................................... 17
tobramycin-dexamethasone ...... 161
TOLAK ............................................................... 119
tolazamide ............................................................. 50
...........................................................................................
I-23
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
trifluoperazine ................................................. 71
trifluridine ......................................................... 161
trigels-f forte .................................................. 234
trihexyphenidyl .............................................. 67
tri-legest fe ....................................................... 113
tri-linyah .............................................................. 113
tri-lo-estarylla .............................................. 113
tri-lo-marzia ................................................... 113
tri-lo-sprintec ................................................ 113
trilyte with flavor packets ............ 177
trimethoprim ...................................................... 19
trimipramine ...................................................... 46
trinessa (28) .................................................. 113
TRINTELLIX .............................................. 46
triple paste af .................................................... 54
tri-previfem (28) ..................................... 113
tri-sprintec (28) ........................................ 113
TRIUMEQ ........................................................ 74
tri-vi-sol ................................................................ 234
tri-vita ..................................................................... 234
tri-vitamin .......................................................... 234
trivora (28) ..................................................... 113
TROKENDI XR ...................................... 41
TROPHAMINE 10 % ....................... 86
TROPHAMINE 6% ............................. 86
trospium ............................................................... 179
TRUE METRIX GLUCOSE
TEST STRIP ................................................ 148
TRUEPLUS KETONE ............... 222
TRUEPLUS LANCETS
............................................................................ 148, 149
TRUETEST TEST STRIPS
........................................................................................... 149
TRUETRACK SMART
SYSTEM ........................................................... 144
TRUETRACK TEST .................... 149
TRULICITY ................................................... 48
TRUMENBA ............................................. 194
TRUSTEX LATEX CONDOM
........................................................................................... 113
TRUSTEX LUBRICATED
CONDOMS .................................................. 113
TRUSTEX NON-LUB
CONDOMS .................................................. 113
Index
tolbutamide .......................................................... 50
tolmetin ..................................................................... 13
tolnaftate ................................................................ 54
tolterodine ......................................................... 178
TOPCARE UNIVERSAL1
LANCET .......................................................... 148
topiragen ................................................................. 41
topiramate ............................................................ 41
toposar ....................................................................... 35
torsemide ................................................................ 97
TOUJEO SOLOSTAR ..................... 49
TOVIAZ ............................................................. 179
TPN ELECTROLYTES ............ 215
TPN ELECTROLYTES II .... 215
TRACLEER ................................................ 222
TRADJENTA ............................................... 48
tramadol .................................................................. 10
tramadol-acetaminophen .................. 10
trandolapril .......................................................... 89
tranexamic acid ............................................. 81
TRANSDERM-SCOP ..................... 64
tranylcypromine ............................................ 46
TRAVASOL 10 % ................................... 86
TRAVATAN Z ....................................... 205
travel sickness (meclizine) ............ 64
travoprost (benzalkonium) ....... 205
trazodone ................................................................ 46
TREANDA ....................................................... 36
TRECATOR ................................................... 63
TRELSTAR ..................................................... 36
tretinoin ................................................................ 125
tretinoin (chemotherapy) ................ 36
tretinoin microspheres ...................... 125
TREXALL ......................................................... 36
triacting orange ............................................. 59
triamcinolone acetonide
.............................................. 117, 125, 163, 183
TRIAMINIC COLD AND
COUGHNT(PE) ....................................... 59
triamterene-hydrochlorothiazid
............................................................................................... 97
trianex .................................................................... 125
TRIBENZOR ................................................ 88
tri-buffered aspirin .................................... 13
tri-estarylla ...................................................... 113
Index
Index
TETANUS
TOXOID,ADSORBED (PF)
Effective: December 01, 2016
I-24
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
vancomycin .......................................................... 19
vancomycin in 0.9% sodium cl ... 19
vancomycin in dextrose 5 % ......... 19
VANISHPOINT SYRINGE
........................................................................................... 152
VAQTA (PF) ................................ 194, 195
VARIVAX (PF) ...................................... 195
VASCEPA ....................................................... 102
vazobid-pd ............................................................. 59
v-c forte ................................................................. 234
VELCADE ......................................................... 36
velivet triphasic regimen (28)
........................................................................................... 113
VENCLEXTA .............................................. 36
VENCLEXTA STARTING
PACK ........................................................................ 36
venlafaxine ........................................................... 46
VENTOLIN HFA ............................... 218
verapamil ................................................................ 92
VERSACLOZ ............................................... 71
vestura (28) .................................................... 113
VGO 40 ................................................................ 152
VIBERZI ........................................................... 172
vic-forte ................................................................. 234
vicks qlearquil(oxymetazoline)
........................................................................................... 159
vicks sinex 12-hour ................................ 159
vicodin ........................................................................ 10
vicodin es ................................................................ 10
vicodin hp ............................................................... 10
VICTOZA 3-PAK ................................... 48
VIDEX 2 GRAM PEDIATRIC
............................................................................................... 74
VIDEX 4 GRAM PEDIATRIC
............................................................................................... 74
VIEKIRA PAK .......................................... 76
VIEKIRA XR ............................................... 76
vienva ....................................................................... 114
VIGAMOX .................................................... 161
VIIBRYD ............................................................. 46
VIMIZIM ......................................................... 153
VIMPAT ............................................................... 42
vinacal b ............................................................... 234
vinorelbine ............................................................. 37
viorele (28) ..................................................... 114
Index
ULTRATRAK ULTIMATE
........................................................................................... 150
UNILET COMFORTOUCH
LANCET .......................................................... 150
UNILET EXCELITE II
LANCET .......................................................... 150
UNILET EXCELITE LANCET
........................................................................................... 150
UNILET GP LANCET .............. 150
UNILET LANCET ............ 146, 151
UNILET SUPER THIN
LANCETS ...................................................... 144
unisom sleepgels ............................................ 59
UNISTIK 3 COMFORT
LANCET .......................................................... 151
UNISTIK 3 EXTRA LANCET
........................................................................................... 151
UNISTIK 3 GENTLE .................. 151
UNISTIK 3 LANCETS .............. 151
UNISTIK 3 NORMAL
LANCET .......................................................... 151
UNISTIK CZT LANCET ....... 151
UNISTIK SAFETY ......................... 151
UNISTIK TOUCH LANCETS
........................................................................................... 151
UNISTRIP1 TEST STRIP ..... 151
UNITUXIN ..................................................... 36
UNIVERSAL 1 LANCETS
............................................................. 138, 139, 151
UPTRAVI ....................................................... 223
ursodiol .................................................................. 172
VAGIFEM ..................................................... 182
vaginal contraceptive foam ........ 113
vagistat-1 ................................................................ 54
vagistat-3 ................................................................ 54
valacyclovir ......................................................... 77
VALCHLOR ............................................... 119
valganciclovir .................................................... 77
valproate sodium .......................................... 42
valproic acid ....................................................... 42
valproic acid (as sodium salt) ... 42
valsartan .................................................................. 88
valsartan-hydrochlorothiazide ... 88
VALSTAR .......................................................... 36
valu-tapp decongestant .................... 116
Index
Index
TRUSTEX-RIA
LUB/SPERMICIDE ........................ 113
TRUSTEX-RIA NON-LUB
CONDOMS .................................................. 113
TRUVADA ...................................................... 74
trymine cg .......................................................... 116
TUBERCULIN SYRINGE
............................................................................ 135, 149
TUBERCULIN-ALLERGY
SYRINGES ................................................... 135
TUDORZA PRESSAIR ............ 218
TWINRIX (PF) ....................................... 194
TYBOST ............................................................ 203
TYGACIL .......................................................... 27
TYKERB .............................................................. 36
TYPHIM VI ................................................. 194
TYSABRI ........................................................ 190
TYVASO ........................................................... 223
TYVASO REFILL KIT ............. 223
TYVASO STARTER KIT ..... 223
TYZEKA .............................................................. 77
u-cort ........................................................................ 125
ULORIC ............................................................ 203
ULTILET BASIC LANCETS
........................................................................................... 149
ULTILET CLASSIC
LANCETS ...................................................... 149
ULTILET LANCETS ................... 149
ULTILET SAFETY LANCETS
........................................................................................... 149
ULTIMA TEST STRIPS
............................................................................ 145, 149
ultra strength antacid ........................ 166
ULTRA THIN II LANCETS
........................................................................................... 150
ULTRA THIN LANCETS
............................................................................ 133, 150
ULTRA THIN PLUS
LANCETS ...................................................... 145
ULTRA TLC LANCETS ........ 150
ULTRALANCE LANCETS
........................................................................................... 150
ULTRA-THIN II LANCETS
........................................................................................... 150
ULTRATRAK ......................................... 150
Effective: December 01, 2016
I-25
CommuniCare Advantage Cal MediConnect Plan 2016 Formulary
Formulary ID:16506.000 Version: 19
ZELBORAF .................................................... 37
ZEMPLAR .................................................... 197
zenatane ............................................................... 119
zenchent (28) ............................................... 114
ZENPEP ............................................................ 154
ZEPATIER ........................................................ 76
zephrex-d ............................................................ 116
ZETIA ................................................................... 102
ZIAGEN ............................................................... 75
zidovudine .............................................................. 75
ZINBRYTA ................................................. 203
ziprasidone hcl ................................................. 71
ZIRGAN ........................................................... 162
ZOLADEX ........................................................ 37
zoledronic acid ............................................ 197
zoledronic acid-mannitol-water
............................................................................ 197, 198
ZOLINZA ........................................................... 37
zolmitriptan ........................................................ 62
zolpidem ............................................................... 221
ZOMETA ......................................................... 198
zonisamide ............................................................ 42
ZORTRESS .................................................. 190
ZOSTAVAX (PF) ................................ 195
zovia 1/35e (28) ........................................ 114
zovia 1/50e (28) ........................................ 114
ZOVIRAX ...................................................... 119
z-sleep ......................................................................... 58
ZUBSOLV .......................................................... 15
ZYDELIG .......................................................... 37
ZYKADIA ......................................................... 37
ZYLET ................................................................. 162
ZYPREXA RELPREVV .............. 71
zyrtec itchy eye drops (keto)
........................................................................................... 159
ZYTIGA ................................................................ 37
ZYVOX ................................................................... 19
Index
wal-finate ............................................................... 60
wal-finate-d ......................................................... 60
wal-itin ....................................................................... 60
wal-mucil fiber ............................................ 177
wal-phed .................................................... 60, 116
wal-phed pe sinus and allergy ..... 60
wal-profen ............................................................. 13
wal-sleep z ............................................................. 60
wal-som (diphenhydramine) ....... 60
wal-tap ....................................................................... 60
wal-zan 75 ......................................................... 166
wal-zyr (cetirizine) .................................. 60
wal-zyr (ketotifen) ............................... 159
warfarin .................................................................... 79
water for irrigation, sterile ......... 196
WAVESENSE JAZZ ...................... 152
WAVESENSE PRESTO ........... 152
wee care ................................................................ 237
WELCHOL ................................................... 102
wera (28) ........................................................... 114
WIDE-SEAL DIAPHRAGM 70
........................................................................................... 114
women's prenatal + dha .................. 224
XALKORI ......................................................... 37
XARELTO ........................................................ 79
XELJANZ ....................................................... 203
XELJANZ XR .......................................... 203
XIFAXAN ......................................................... 19
XIIDRA ............................................................. 163
XOLAIR ............................................................ 219
XTANDI ............................................................... 37
xulane ...................................................................... 114
xylon 10 .................................................................... 10
XYREM ............................................................. 220
YERVOY ............................................................. 37
YF-VAX (PF) ............................................ 195
YONDELIS ...................................................... 37
yuvafem ................................................................. 182
zafirlukast ......................................................... 216
zaleplon ................................................................. 221
zarah ......................................................................... 114
ZARXIO ............................................................... 80
ZAVESCA ...................................................... 153
zeasorb (miconazole) ........................... 54
zebutal ........................................................................ 10
Index
Index
VIRACEPT ....................................................... 75
VIRAMUNE XR ..................................... 75
VIRAZOLE ...................................................... 77
VIREAD ............................................................... 75
virt-phos 250 neutral ........................... 215
virtussin ac ........................................................ 116
VISINE MAX REDNESS
RELIEF .............................................................. 159
VISINE TOTALITY ....................... 159
visine-a ................................................................... 159
vitacel (with lutein) ............................. 234
vitafol ....................................................................... 234
VITAFOL FE+ (WITH
DOCUSATE) ............................................. 234
vital-d rx .............................................................. 234
vitamin a .............................................................. 235
vitamin b-1 ........................................................ 235
vitamin b12-folic acid ........................ 223
vitamin b-2 ........................................................ 235
vitamin b-6 ........................................................ 235
vitamin c .............................................................. 235
vitamin d3 ............. 232, 233, 235, 236
VITAMIN D3 ............................................ 236
vitamin e ............................................... 232, 236
vitamin e (dl, acetate) ...................... 236
vitamin e natural blend .................... 234
vitamin k1 .......................................................... 237
vitamins for hair ........................................ 237
VITA-RESPA ............................................ 237
VITEKTA ........................................................... 75
VOLTAREN ................................................... 13
voriconazole ........................................................ 54
VORTEX HOLDING
CHAMBER .................................................. 152
VORTEX VHC FROG
MASK-CHILD ....................................... 152
VOTRIENT ...................................................... 37
VPRIV ................................................................... 153
vp-vite rx ............................................................. 237
VRAYLAR ....................................................... 71
vyfemla (28) .................................................. 114
wal-act d cold and allergy ................ 60
wal-dram ................................................................. 65
wal-dryl allergy .............................................. 60
wal-fex allergy ................................................ 60
Effective: December 01, 2016
H5172_Formulary2016 v12 Approved
This formulary was updated on 11/25/2016. For more recent information or other
questions, please contact CommuniCare Advantage Cal MediConnect Plan
Member Services, at 1-888-244-4430 or, for TTY users,
1-855-266- 4584, twenty-four hours a day, seven days a week, or visit www.chgsd.com.