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SACRAMENTO COUNTY FORMULARY 2012
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4.1.2012 |
| CARDIOVASCULAR DRUGS |
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| Anti-anginal |
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Strengths Available |
Notes |
Medi-Cal |
| Nitrates |
Isosorbide Dinitrate (Isordil) |
5, 10, 20, 30, 40 (mg) |
|
Y |
| Isosorbide Mononitrate (ISMO, Imdur) |
20, 30, 60, 120 (mg) |
|
Y |
| Nitroglycerin Sublingual (Nitrostat) |
0.15, 0.3, 0.4, 0.6 (mg) |
|
Y |
| Nitroglycerin Ointment (Nitrobid) |
2% |
|
Y |
| Nitroglycerin Patch (Transderm-Nitro) |
0.1,0.2,0.3,0.4,0.6,0.8 (mg/hr) |
|
N |
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| Anti-hypertensives |
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Strengths Available |
Notes |
Medi-Cal |
| Angiotensin Converting Enzymes |
Benazepril (Lotensin) |
5, 10, 20, 40 (mg) |
|
Y |
| Lisinopril (Zestril, Prinivil) |
2.5, 5, 10, 20, 30, 40 (mg) |
|
Y |
| Quinapril (Accupril) |
5, 10, 20, 40 (mg) |
|
N |
| |
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| Angiotension Receptor Blockers |
Candesartan (Atacand) |
4,8,16,32 (mg) |
Free Drug - Astra Zeneca |
N |
| Losartan (Cozaar) |
25,50,100 (mg) |
|
Y |
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| Antiadrenergic Agents Peripherally Acting |
Doxazosin (Cardura) |
1, 2, 4, 8 (mg) |
|
Y |
| Prazosin (Minipress) |
1,2,5 (mg) |
|
Y |
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| Antiadrenergic Agents Centrally Acting |
Clonidine (Catapress) (PO & patches) |
0.1, 0.2, 0.3 (mg) |
|
Y |
| Guanabenz (Wytensin) |
4, 8 (mg) |
|
Y |
| Guanfacine (Tenex) |
1, 2 (mg) |
|
Y |
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| Beta-Blocking Agents |
Atenolol (Tenormin) |
25, 50, 100 (mg) |
|
Y |
| Metoprolol Tartrate (Lopressor) |
25, 50, 100 (mg) |
|
Y |
| Metoprolol Succinate 24h (Toprol XL) |
25, 50, 100, 200 (mg) |
|
Y |
| Propranolol (Inderal) |
RR: 10, 20, 40, 60 (mg) LA: 60, 80, 120, 160 (mg) |
|
Y |
| Carvedilol (Coreg) **
|
3.125, 6.25, 12.5, 25 (mg) |
CR nonform |
Y |
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| Calcium Channel Blockers |
Amlodipine (Norvasc) |
2.5, 5, 10 (mg) |
Free Drug - Pfizer |
Y |
| Nifedipine (Procardia XL) |
30, 60, 90 (mg) |
Free Drug - Pfizer |
Y |
| Diltiazem (Cardizem CD) |
120, 180, 240, 300, 360 (mg)
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|
Y |
| Verapamil (Calan, Isoptin, Calan SR, Isoptin SR) |
80, 120 (mg) SR: 120, 180, 240 (mg) |
|
Y |
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| Diuretics |
Furosemide (Lasix) |
20, 40 , 80 (mg) |
|
Y |
| Hydrochlorathiazide (HydroDiuril) |
25, 50, 100 (mg) |
|
Y |
| Metolazone (Zaroxolyn) |
2.5, 5, 10 (mg) |
|
Y |
| Spironolactone (Aldactone) |
25, 50, 100 (mg) |
|
Y |
| Triamterene/HCTZ (Maxzide) |
3.75/25, 75/50 (mg) |
|
Y |
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| Vasodilators |
Hydralazine (Apresoline) |
10, 25, 50, 100 (mg) |
|
Y |
| Minoxidil (Loniten) |
2.5, 10 (mg) |
|
N |
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| Combo Antihypertensives |
Benazepril/HCTZ (Lotensin HCT) |
10-12.5, 20-12.5, 20-25 (mg) |
|
Y |
| Losartan/HCTZ (Hyzaar) |
50-12.5, 100-12.5, 100-25 (mg) |
|
Y |
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| Anti-arrhythmic |
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Strengths Available |
Notes |
Medi-Cal |
| Cardiac Glycosides |
Digoxin (Lanoxin) |
0.125, 0.25 (mg) |
|
Y |
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| Miscellaneous |
Amiodarone (Cordarone, Pacerone) |
200 (mg) |
|
Y |
| Disopyramide (Norpace) |
100, 150 (mg) |
|
N |
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| Anti-lipemic |
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Strengths Available |
Notes |
Medi-Cal |
| Statins |
Atorvastatin (Lipitor) |
10,20,40 (mg) |
Free Drug - Pfizer 80mg nonform |
Y |
| Rosuvastatin (Crestor) |
5,10,20,40 (mg) |
Free Drug - Astra Zeneca |
Y |
| Simvastatin (Zocor) |
5,10,20,40 (mg) |
80mg nonform |
Y |
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| Other |
Cholestyramine (Questran) |
4 (gm) |
|
Y |
| Gemfibrozil (Lopid) |
600 (mg) |
|
Y |
| Niacin ER (Niaspan) |
500, 750, 1000 (mg) |
|
Y |
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| CENTRAL NERVOUS SYSTEM DRUGS |
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| Analgesics and Antipyretics |
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Strengths Available |
Notes |
Medi-Cal |
| Antirheumatic Drugs |
Hydroxychloroquine |
200 (mg) |
|
Y |
| Leflunomide (Arava) |
10, 20 (mg) |
|
Y |
| Methotrexate |
tab: 2.5, 5, 7.5, 10, 15 (mg) inj: 25mg/ml |
|
Y |
| Sulfasalazine (Azulfidine) |
500 (mg) |
|
Y |
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| Migraines |
Butalbital/APAP/Caffeine (Fioricet) |
50-325-40 (mg) |
|
N |
| Butalbital/ASA/Caffeine (Fiorinal) |
50-325-40 (mg) |
|
N |
| Eletriptan (Relpax) (max # 12/month)
|
20, 40 (mg) |
Free Drug - Pfizer |
N |
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| Narcotic Analgesics |
Acetaminophen/Codeine #3 (Tylenol #3) |
30/300 (mg) |
|
Y |
| Acetaminophen/Hydrocodone (Norco) |
10/325 (mg) (only strength covered) |
|
N |
| Acetaminophen/Hydrocodone (Vicodin) |
5/500 (mg) (only strength covered) |
|
Y |
| Acetaminophen/Oxycodone (Percocet) |
5/325 (mg) |
|
Y |
| Methadone |
5, 10 (mg) |
|
Y |
| Morphine ER (MS Contin) |
15,30, 60 (mg) |
|
Y |
| Oxycodone Immediate Release |
5 (mg) |
|
Y |
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| Anti-inflammatory |
Aspirin |
81, 325 (mg) |
|
Y |
| Celecoxib (Celebrex) |
100, 200 (mg) |
Free Drug - Pfizer |
Y |
| Ibuprofen (Motrin) |
200, 400, 600, 800 (mg) |
|
Y |
| Indomethacin (Indocin) **
|
50, 75 (mg) |
ER nonform |
Y |
| Meloxicam (Mobic) |
7.5, 15 (mg) |
|
Y |
| Naproxen Sodium (Naprosyn) |
250, 375, 500 (mg) |
|
Y |
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| Other |
Tramadol (Ultram) **
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50 (mg) |
ER nonform |
Y |
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| Psychotropic Medications |
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Strengths Available |
Notes |
Medi-Cal |
| SSRI’s & Aytypical Antidepressants |
Bupropion (Wellbutrin SR/XL) |
SR: 100, 150 (mg); XL: 150, 300 (mg) |
IR nonform |
Y |
| Citalopram (Celexa) |
20, 40 (mg) |
|
N |
| Duloxetine (Cymbalta) |
20, 30, 60 (mg) |
Free Drug - Eli Lilly (120 day supply) |
Y |
| Escitalopram (Lexapro) |
10, 20 (mg) |
|
Y |
| Fluoxetine (Prozac) |
10, 20, 40 (mg) |
|
Y |
| Mirtazapine (Remeron) |
15, 30, 45 (mg) |
|
Y |
| Paroxetine (Paxil) **
|
10, 20, 30, 40 (mg) |
CR nonform |
Y |
| Sertraline (Zoloft) |
25, 50, 100 (mg) |
|
Y |
| Trazadone (Desyrel) |
50, 100, 150 (mg) |
|
Y |
| Venlafaxine (Effexor XR) |
37.5, 75, 150 (mg) |
IR nonform |
Y |
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| Tricyclics |
Amitriptyline (Elavil) |
10, 25, 50, 75, 100, 150 (mg) |
|
Y |
| Imipramine (Tofranil) |
10, 25, 50 (mg) |
|
Y |
| Desipramine (Norpramin) |
10, 25, 50, 100 (mg) |
|
Y |
| Nortriptyline (Pamelor) |
10, 25, 50, 75 (mg) |
|
Y |
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| 1st & 2nd Generation Antipsychotics |
Aripiprazole (Abilify) |
Tab: 10, 20, 30 (mg)
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Discmelt nonform |
Y |
| Chlorpromazine (Thorazine) |
50, 100, 200 (mg) |
|
Y |
| Clozapine (Clozaril)--fill at Broadway Rx |
25, 100 (mg) |
|
Y |
| Fluphenazine (Prolixin) |
tab: 5, 10 (mg) Dec Inj: 25 (mg) |
|
Y |
| Haloperidol (Haldol) |
tab: 0.5, 1, 2, 5, 10, 20 (mg) Dec Inj: 50, 100 (mg) |
|
Y |
| Olanzapine (Zyprexa) |
Tab: 2.5, 5, 7.5, 10, 15, 20 (mg)
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Free Drug - Eli Lilly (120 day supply) Zydis nonform |
Y |
| Paliperidone (Invega Sustenna) *
|
IM inj: 39, 78, 117, 156, 234 (mg) |
Tabs nonform; IM inj nonform required |
N |
| Perphenazine (Trilafon) |
2, 4, 8, 16 (mg) |
|
Y |
| Quetiapine (Seroquel, Seroquel XR) |
IR: 25, 50, 100, 200, 300, 400 (mg) XR: 50, 150, 200, 300, 400 (mg) |
Free Drug - Astra Zeneca |
Y |
| Risperidone (Risperdal) |
Tab: 0.25, 0.5, 1, 2, 3, 4 (mg) Consta: 12.5, 25, 37.5, 50 (mg) |
M-Tab nonform |
Y |
| Ziprasidone (Geodon) |
20, 40, 60, 80 (mg) |
Free Drug - Pfizer |
Y |
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| Mood Stabilizers |
Divalproex Sodium (Depakote ER) |
250, 500 (mg) |
Sprinkle nonform |
Y |
| Lamotrigine (Lamictal) **
|
25, 100, 150, 200 (mg) |
XR nonform |
Y |
| Lithium (LiCO, Lithobid) |
150, 300, 450 (mg) |
|
Y |
| Oxacarbazepine (Trileptal) |
150, 300, 600 (mg) |
|
Y |
| Carbamazepine (Tegretol) **
|
200 (mg) |
XR nonform |
Y |
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| Miscellaneous |
Hydroxyzine Pamoate (Vistaril) |
25, 50 (mg) |
|
Y |
| Prazosin (Minipress) |
1,2,5 (mg) |
|
Y |
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| MAO Inhibitors |
Various * (Parnate, Marplan, Nardil, etc)
|
All need nonformulary |
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| Antianxiety |
| |
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Strengths Available |
Notes |
Medi-Cal |
| Benzodiazepines |
Chlordiazepoxide (Librium)
|
5, 10, 25 (mg) |
|
N |
| Clonazepam (Klonopin) |
0.5, 1, 2 (mg) |
|
Y |
| Diazepam (Valium) |
2, 5, 10 (mg) |
|
Y |
| Lorazepam (Ativan) |
0.5, 1, 2 (mg) |
|
Y |
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| Miscellaneous |
Buspirone (Buspar) |
5, 10, 15, 30 (mg) |
|
Y |
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| Miscellaneous CNS Medications |
| |
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Strengths Available |
Notes |
Medi-Cal |
| Sedatives and Hypnotics |
Temazepam (Restoril) |
7.5, 15, 30 (mg) |
|
Y |
| Zolpidem (Ambien) **
|
5, 10 (mg) |
CR nonform |
Y |
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| Anticonvulsants |
Carbemazepine (Tegretol) **
|
100, 200 (mg) |
XR nonform |
Y |
| Clonazepam (Klonopin) |
0.5, 1, 2 (mg) |
|
Y |
| Divalproex Sodium (Depakote DR/ER) |
DR: 125, 250, 500 (mg) ER: 250, 500 (mg) |
Sprinkle nonform |
Y |
| Ethosuximide (Zarontin) |
syrup: 250 mg/5 cc |
|
Y |
| Gabapentin (Neurontin) |
100, 300, 600, 800 (mg) |
|
Y |
| Lamotrigine (Lamictal) |
25, 100, 150, 200 (mg) |
|
Y |
| Levetiracetam (Keppra) **
|
250, 500, 750, 1000 (mg) |
XR nonform |
Y |
| Oxacarbezepine (Trileptal) |
150, 300, 600 (mg) |
|
Y |
| Phenobarbital |
15, 30, 60, 90, 100 (mg) |
|
Y |
| Phenytoin (Dilantin) **
|
30, 50, 100 (mg) |
ER nonform |
Y |
| Primidone (Mysoline) |
50, 250 (mg) |
|
Y |
| Topiramate (Topamax) |
25, 100, 200 (mg) |
|
Y |
| Valproic Acid (Depakene) |
250 (mg) |
|
Y |
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| Acetylcholinesterase Inhibitor |
Donepezil (Aricept) |
5, 10 (mg) |
|
Y |
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| N-Methyl-D-Aspartate Receptor Antagonist |
Memantine(Namenda) |
5, 10 (mg) |
|
N |
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| Skeletal Muscle Relaxants |
Baclofen (Lioresal) |
10, 20 (mg) |
|
Y |
| Cyclobenzaprine (Flexeril) |
10 (mg) |
|
N |
| Methocarbamol (Robaxin) |
500, 750 (mg) |
|
N |
| Diazepam (Valium) |
2, 5, 10 (mg) |
|
Y |
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| Antiparkinson Agents |
Amantadine (Symmetrel) |
100 (mg) |
|
Y |
| Benztropine (Cogentin) |
0.5, 1, 2 (mg) |
|
Y |
| Carbidopa/Levodopa (Sinemet/Sinemet CR) |
10-100, 25-100, 25-200, 25-250 (mg) |
|
Y |
| Diphenhydramine (Benadryl) |
25, 50 (mg) |
|
Y |
| Selegiline (Eldepryl) |
5 (mg) |
|
Y |
| Ropinirole (Requip) **
|
0.25, 0.5, 1,2,3,4,5 (mg) |
XL nonform |
Y |
| Trihexyphenidyl (Artane) |
2, 5 (mg) |
|
Y |
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| Stimulants |
Atomoxetine (Strattera)
|
10, 18, 25, 40, 60, 80, 100 (mg) |
|
N |
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| Misc Stimulants |
Various * (Adderal, Dexedrine, Ritalin, etc)
|
All need nonformulary |
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| Substance Dependence |
Acamprosate (Campral) |
333 (mg) |
|
N |
| Disulfram (Antabuse) |
250, 500 (mg) |
|
Y |
| Naltrexone |
25, 50, 100 (mg) |
|
N |
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| RESPIRATORY DRUGS |
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| Asthma / COPD |
| |
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Strengths Available |
Notes |
Medi-Cal |
| Bronchodilators |
Albuterol (Proventil HFA) |
17 (Gram) |
|
Y |
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Ipratroprium (Atrovent)
|
14.7, 14 (Gram) |
|
Y |
|
Salmeterol Diskus (Serevent)
|
60 (Gram) |
Free Drug - Glaxo |
Y |
| Tiotropium (Spiriva) |
18 (mcg) |
Free Drug - Boehringer Ingelheim
|
Y |
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| Combination Inhalers |
Albuterol/Ipratroprium (Combivent) |
14.7 (Gram) |
|
Y |
| Budesonide/Formoterol (Symbicort) |
80-4.5, 160-4.5 (mcg) |
Free Drug - Astra Zeneca |
Y |
| Flovent/Serevent (Advair) |
100-50, 250-50, 500-50 (mcg) |
Free Drug - Glaxo |
Y |
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| Corticosteroids |
Fluticasone (Flovent) |
44, 110, 220 (mcg/actuation) |
Free Drug - Glaxo |
Y |
| Beclomethasone (QVAR) |
40, 80 (mcg/actuation) |
|
Y |
| Dexamethasone (Decadron) |
0.5, 1, 1, 4 (mg) |
|
Y |
| Prednisone |
1, 2.5, 5, 10, 20, 50 (mg) |
|
Y |
|
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| Xanthine Derivatives |
Theophylline, SR (Theodur, Uniphyl) |
100, 200, 300, 400, 450 (mg) |
|
Y |
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| Miscellaneous |
Montelukast (Singular) |
10 (mg) |
Free Drug - Merck (90 day supply) |
Y |
| Zafirlukast (Accolate) |
10, 20 (mg) |
Free Drug - Astra Zeneca |
N |
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|
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| Allergy / Cough / Cold |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Antihistamines |
Chlorpheniramine (Chlor-Trimeton) |
4 (mg) |
|
Y |
| Diphenhydramine (Benadryl) |
25, 50 (mg) |
|
Y |
| Loratadine (Claritin) |
10 (mg) |
|
N |
|
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|
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| Decongestants |
Phenylephrine (Sudogest PE) |
10 (mg) |
|
Y |
| Pseudoephedrine (Sudafed) |
30, 60 (mg) |
|
Y |
| Decon. &Antihist. Combo's |
Tripolidine/Phenylephrine (Actifed PE) |
|
|
Y |
|
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| Expectorants/Cough |
Guaifenesin (Robitussin) |
|
|
Y |
| Guaifenesin/Codeine (Robitussin w/Codeine) |
|
|
Y |
| Guaifenesin/Dextromethorphan (Robitussin DM/Diabetic DM) |
|
|
Y |
| Promethazine / Codeine (Phenergan w/Codeine) |
|
|
Y |
|
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| ANTI-INFECTIVES |
|
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| Antibiotics |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Penicillins |
Amoxicillin (Trimox) |
250, 500 (mg) |
|
Y |
| Amoxicillin/Clavulanate (Augmentin) **
|
250, 500, 875, 1000 (mg) |
XR nonform |
Y |
| Dicloxacillin (Dynapen) |
125, 250, 500 (mg) |
|
Y |
| Penicillin V Potassium |
125, 250, 500 (mg) |
|
Y |
|
|
|
|
|
| Cephalosporins |
Cefpodoxime (Vantin) |
200 (mg) |
Restricted to in-clinic dispensing for STD |
Y |
| Ceftriaxone (Rocephin) |
Inj: 250, 500, 1000, 2000 (mg) |
|
Y |
| Cephalexin (Keflex) |
250, 500 (mg) |
|
Y |
|
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|
|
|
| Tetracyclines |
Doxycycline (Vibramycin) |
20, 50, 100 (mg) |
|
Y |
| Minocycline (Minocin) |
50, 100 (mg) |
|
N |
| Tetracycline (Sumycin) |
250, 500 (mg) |
|
Y |
|
|
|
|
|
| Macrolides |
Azithromycin (Z-Pak, Tri-Pak) |
tab: 250, 500 (mg) liquid: 100/5, 200/5 (mg/5cc) Powder: 1gm |
Free Drug - Pfizer |
Y |
| Clarithromycin (Biaxin) **
|
250, 500 (mg) |
Restricted to H.Pylori |
Y |
| Erthryomycin (Ery-Tab) |
Base: 250, 500 (mg); Stearate: 250, 500 (mg) |
|
Y |
|
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|
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| Quinolones |
Ciprofloxacin (Cipro) |
250, 500, 750 (mg) |
|
Y |
| Levofloxacin (Levaquin) |
250, 500, 750 (mg) |
|
Y |
|
|
|
|
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| Miscellaneous |
Clindamycin (Cleocin) |
75, 150, 300 (mg) |
|
Y |
| Linezolid (Zyvox) |
600 (mg) |
Restricted to hospital discharge Free Drug - Pfizer (RSVP) |
N |
| Metronidazole (Flagyl) |
250, 500 (mg) |
|
Y |
| Nitrofurantoin (Macrodantin, Macrobid) |
Macrodantin: 50, 100 (mg); Macrobid: 100 (mg) |
|
Y |
| Sulfamethox/Trimeth (Bactrim DS) |
(mg) |
|
Y |
|
|
|
|
|
| Antifungal Agents |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Systemic |
Fluconazole (Diflucan) |
50, 100, 150, 200 (mg) |
Free Drug - Pfizer |
Y |
| Griseofulvin (Grifulvin V,Gris-PEG) |
Microsize: 500 (mg) Ultramicosize: 125, 250 (mg) |
|
Y |
| Terbinafine (Lamisil) |
Tab: 250 (mg) |
topical non-form |
Y |
|
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|
|
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| Miscellaneous |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Antiviral |
Acyclovir (Zovirax) |
200, 400, 800 (mg) |
|
Y |
|
|
|
|
|
| Leprostatic |
Dapsone |
25, 100 (mg) |
|
Y |
|
|
|
|
|
| Antihelmintics |
Mebendazole (Vermox) |
100 (mg) |
|
Y |
| Praziquantel (Biltricide) |
600 (mg) |
|
N |
| Pyrantel Pamoate (Antiminth) |
62.5 (mg/caplet), 250 (mg/chew) |
|
Y |
| Thiabendazole (Mintezol) |
500 (mg) |
|
Y |
|
|
|
|
|
| Amebicides |
Chloroquine Phosphate (Aralen) |
250 (mg) |
|
Y |
| Metronidazole (Flagyl) |
250, 500 (mg) |
|
Y |
| Primaquine Phosphate |
26.3 (mg) |
|
Y |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| ENDROCRINE AND METABOLIC AGENTS |
|
|
|
|
|
| Hormones |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Adrenal Corticosteroids |
Dexamethasone (Decadron) |
0.5, 1, 2, 4 (mg) |
|
Y |
| Fludrocortisone (Florinef) |
0.1 (mg) |
|
Y |
| Hydrocortisone (Cortisol, Cortef) |
5, 10, 20 (mg) |
|
Y |
| Methylprednisolone (Medrol) |
4 (mg) |
|
N |
| Methylprednisolone Sod. Succinate (Solu-Medrol) (special order) |
Inj: 40, 125, 500, 1000 (mg) |
|
N |
| Prednisone |
1, 2.5, 5, 10, 20, 50 (mg) |
|
Y |
|
|
|
|
|
| Estrogens |
Conjugated Estrogens (Premarin) |
tab: 0.3, 0.625, 0.9, 1.25, 2.5 (mg) cream: 0.625 (mg/gm) |
|
Y |
| Estradiol (Estrace, Climara) |
Tab: 0.5, 1, 2 (mg) Patch: 0.025, 0.05, 0.075, 0.1 (mg) |
once-weekly patch is covered |
Y |
|
|
|
|
|
| Progestins |
Medroxyprogesterone (Provera) |
2.5, 5, 10 (mg) |
|
Y |
|
|
|
|
|
| Oral Contraceptives |
Desogestrel/Ethinyl estradiol (various) |
0.15-0.03 (mg) |
Restricted to dx other than contraception, use Family Planning for OC |
Y |
| Levonorgestrel/Ethinyl estradiol (various) |
0.1-0.02 (mg) |
Y |
| Norethindrone (various) |
0.35 (mg) |
Y |
| Norgestrel/Ethinyl estradiol (various) |
0.3-0.03 (mg) |
Y |
|
|
|
|
|
| Biphosphonates |
Alendronate (Fosamax) |
5,10, 35, 70 (mg) |
|
Y |
|
|
|
|
|
| Anti-Diabetic Agents |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Insulins |
Lente Insulin (Novolin L) |
100 Units/cc |
|
Y |
| NPH Insulin (Novolin NPH) |
100 Units/cc |
Pen nonform |
Y |
| Regular Insulin (Novolin R) |
100 Units/cc |
Pen nonform |
Y |
| 70/30 Insulin (Novolin 70/30) |
100 Units/cc |
Pen nonform |
Y |
| Glargine (Lantus) |
100 Units/cc |
Pen nonform |
Y |
| Humalog (Lispro) |
100 Units/cc |
Pen nonform |
Y |
|
|
|
|
|
| Sulfonylureas |
Glipizide XL (Glucotrol XL) |
2.5, 5, 10 (mg) |
Free Drug - Pfizer |
N |
| Glipizide (Glucotrol) |
5, 10 (mg) |
|
Y |
| Glyburide (Diabeta, Micronase) |
1.25, 2.5, 5 (mg) |
|
Y |
|
|
|
|
|
| Biguanides |
Metformin (Glucophage/Glucophage XR) |
500, 850, 1000 (mg) |
|
Y |
|
|
|
|
|
| Glitazones |
Pioglitazone (Actos) |
15, 30, 45 (mg) |
Free Drug - Takeda (90 day supply) |
Y |
|
|
|
|
|
| Glucose Elevating |
Glucagon |
only injection 1 mg/vial |
|
Y |
| Glucose Tablets |
5 (gram) |
|
N |
| Glucose Gel |
24 (grams/tube) |
|
N |
|
|
|
|
|
| Testing Supplies |
Blood glucose monitoring strip (True Result) |
#100/90days non-insulin #100/30days insulin |
greater qty requires nonform |
N |
|
|
|
|
|
| Thyroid and Anti-Thyroid |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Thyroid Hormones |
Levothyroxine (Synthroid) |
0.025, 0.05, 0.075, 0.088, 0.1, 0. 112, 0.125, 0.137, 0.15, 0.175, 0.2, 0.3 (mg) |
|
Y |
|
|
|
|
|
| Anti-Thyroid Agents |
Propylthiouracil (PTU) |
50 (mg) |
|
Y |
| Methimazole (Tapazole) |
5, 10 (mg) |
|
Y |
|
|
|
|
|
| GASTROINTESTINAL DRUGS |
|
|
|
|
|
| |
|
Strengths Available |
Notes |
Medi-Cal |
| H-2 Blockers |
Ranitidine (Zantac) |
150, 300 (mg) |
|
Y |
|
|
|
|
|
| PPI's |
Esomeprazole (Nexium) |
20, 40 (mg) |
Free Drug - Astra Zeneca |
Y |
| Omeprazole (Prilosec) |
20, 40 (mg) |
|
N |
|
|
|
|
|
| Antacids |
Calcium Carbonate |
650, 1250 (mg) |
|
Y |
| Milk of Magnesium (MOM) |
Susp: 400mg/5cc, 800mg/5cc |
|
N |
| Al Hydroxide/Mg Hydroxide/Simethicone (Mylanta Extra Strength) |
-40 (mg/ 5mL) |
|
Y |
|
|
|
|
|
| Anti-Cholinergics/ Antispasmodics |
Belladonna Alkaloids/Phenobarbital (Donnatal) |
0.0194/0.0065/0.1037/ 16.2 (mg)
|
|
Y |
| Dicyclomine (Bentyl) |
10, 20 (mg) |
|
Y |
|
|
|
|
|
| Laxatives |
Bisacodyl (Dulcolax) |
tab: 5 (mg) supp: 10 (mg) |
|
Y |
| Bowel Evacuants (X-Prep Bowel Kit) |
|
|
N
|
| Docusate Sodium (Colace) |
100, 250 (mg) |
|
Y |
| Enemas (Fleets Phospha) |
7.2 g monobasic sodium phosphate, 2.7 g dibasic sodium phosphate |
|
N
|
| Mineral Oil |
99.9 (%) |
|
N
|
| Psyllium Powder (Genfiber) |
3.4 (gram/teaspoon) |
|
N
|
|
|
|
|
|
| Anti-Diarrheal Agents |
Atropine/Diphenoxylate (Lomotil) |
2.5 (mg) |
|
Y |
| Kaolin/Pectin (Kaopectate) |
|
|
N |
| Loperamide (Immodium) |
2 (mg) |
|
N |
|
|
|
|
|
| Ulcerative Colitis |
Mesalamine (Asacol only) |
400 (mg) |
|
N |
| Sulfasalazine (Azulfidine) |
500 (mg) |
|
Y |
|
|
|
|
|
| Digestive Enzymes |
Pancrealipase (Zenpep) |
5000, 1500, 10000, 20000 (U)
|
|
Y |
|
|
|
|
|
| Anti-emetic/ Antivertigo |
Meclizine (Antivert) |
12.5, 25 (mg) |
|
Y |
| Ondansetron (Zofran) |
4, 8 (mg) |
ODT nonform |
Y |
| Prochloperazine (Compazine) |
tab: 5, 10, 25 (mg) supp: 2.5, 25 (mg) |
|
Y |
| Promethazine (Phenergan)
|
tab/supp:12.5, 25, 50 (mg) |
|
Y |
|
|
|
|
|
| Miscellaneous GI Drugs |
Lactulose (Enulose) |
10 gram/ 15 mL |
|
N |
| Metoclopramide (Reglan) |
5, 10 (mg) |
|
Y |
| Sucralfate (Carafate) |
Tab: 1 (gm) Suspension: 1gm/10ml |
|
Y |
|
|
|
|
|
| Antiflatulant |
Simethicone (Mylicon) |
80, 125 (mg) |
|
N |
|
|
|
|
|
| EYES, EARS, NOSE, and THROAT |
|
|
|
|
|
| Ophthalmics |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Beta-Blockers |
Betaxolol (Betoptic, Betoptic S) |
0.25, 0,5 (%) |
|
Y |
| Carteolol (Ocupress) |
1 (%) |
|
Y |
| Metipranolol (Optipranolol) |
0.3 (%) |
|
Y |
| Timolol Maleate (Timoptic) |
0.25, 0.5 (%) |
|
Y |
|
|
|
|
|
| Sympathomimetics |
Dipivefrin (Propine) |
0.1 (%) |
|
Y |
| Epinephrine |
0.5, 1, 2 (%) |
|
Y |
|
|
|
|
|
| Cholinergics |
Carbachol (Isoptocarbachol) |
0.75, 1.5, 2.25, 3 (%) |
|
Y |
| Pilocarpine (Isoptocarpine) |
0.25, 0.5, 1, 2, 3, 4, 5, 6, 8, 10 (%) |
|
Y |
|
|
|
|
|
| Carbonic Anhydrase Inhibitors |
Acetazolamide (Diamox) |
125, 250 (mg) |
|
Y |
| Dorzolamide (Trusopt) |
2 (%) |
|
Y |
|
|
|
|
|
| Misc. Glaucoma Meds |
Bimatoprost (Lumigan) |
0.01, 0.03 (%) |
|
Y |
| Brimonidine (Alphagan) |
0.15, 0.1, 0.2 (%) |
|
Y |
|
|
|
|
|
| Combinations |
Dorzolamide/Timolol (Cosopt) |
2-5 (%) |
|
Y |
| Pilocarpine/Epinephrine |
1, 2, 3, 4, 6 (%) |
|
Y |
|
|
|
|
|
| AntiCholinergics |
Atropine |
0.5, 1, 2, 3, 4 (%) |
|
Y |
| Cyclopentolate (Cyclogel) |
0.5, 1, 2 (%) |
|
Y |
| Homatropine (Isopto Homatropine) |
2, 5 (%) |
|
Y |
| Scopolamine (Isopto Hyoscine) |
0.25 (%) |
|
Y |
|
|
|
|
|
| Decongestants/ Antihistaminics |
Ketotifen (Zaditor) |
0.025 (%) |
|
N |
| Naphazoline (Naphcon) |
0.1(%) |
|
Y |
| Naphazoline/Antazoline (Naphcon A) |
0.05-0.5 (%) |
|
Y |
|
|
|
|
|
| Mast Cell Stabilizer |
Cromolyn (Crolom) |
4 (%) |
|
Y |
|
|
|
|
|
| Opthalmic Corticosteroids |
Dexamethasone (Maxidex) |
0.1 (%) |
|
Y |
| Fluoromethalone (FML , FML Forte)) |
0.1, 0.25 (%) |
|
Y |
| Loteprednol (Lotemax) |
0.2, 0.5 (%) |
|
Y |
| Prednisolone (Pred Mild) |
0.12-0.125, 1 (%) |
|
Y |
| Rimexolone (Vexol) |
1 (%) |
|
Y |
|
|
|
|
|
| Opthalmic Antibiotics |
Ciprofloxacin (Ciloxan) |
0.3 (%) |
|
Y |
| Erythromycin Ointment (Illotycin) |
none listed |
|
Y |
| Gentamicin (Garamycin) |
0.3 (%) |
|
Y |
| Moxifloxacin (Vigamox) |
0.5 (%) |
|
Y |
| Ofloxacin (Ocuflox) |
0.3 (%) |
|
Y |
| Polymyxin/Bacitracin (Ak-Poly Bac) |
none listed |
|
Y |
| Polymyxin/Neomycin/Bacitracin (Neosporin) |
none listed |
|
Y |
| Sulfacetamide (Bleph-10) |
10, 15, 30 (%) |
|
Y |
| Trimethoprim/Polymixin (Polytrim) |
none listed |
|
Y |
|
|
|
|
|
| Corticosteroid/Abx Combo’s |
Dexamethasone/Neomycin/Polymyxin (Maxitrol) |
none listed |
|
Y |
| Prednisolone/Neomycin/Polymyxin (Poly-Pred) |
none listed |
|
Y |
| Sulfacetamide/Prednisolone (Blephamide) |
10-0.2 (%) |
|
Y |
| Tobramycin/Dexamethasone (Tobradex) |
0.3-0.1 (%) |
|
Y |
|
|
|
|
|
| Pain |
Diclofenac (Voltaren) |
0.1 (%) |
|
Y |
| Ketoralac (Acular) |
0.4, 0.5 (%) |
|
Y |
|
|
|
|
|
| Miscellaneous Opthal Prep |
Artificial Tears
|
1.4 (%) |
|
N |
| Bimatoprost (Lumigan) |
0.03 (%) |
|
Y |
| Brimonidine (Alphagan) |
0.15, 0.1, 0.2 (%) |
|
Y |
| Muro 128 Ointment and Solution
|
oint: 5 (%), soln: 2, 5 (%) |
|
Y |
| Puralube |
150 (mg) light mineral oil and 850 (mg) white petrolatum per (gram) |
|
N |
|
|
|
|
|
| Otics |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Otic Preparations |
Acetic Acid (Vosol) |
0.25 (%) |
|
Y |
| Acetic Acid/Hydrocortisone (Vosol HC) |
2-1 (%) |
|
Y |
| Benzocaine/Antipyrine (Auralgan) |
|
|
Y |
| Carbamide Peroxide (Debrox) |
6.5 (%) |
|
N |
| Ciprofloxacin/Dexamethasone (Ciprodex) |
0.3-0.1 (%) |
|
Y |
| Polymyxin B/ Neomycin/ Hydrocortisone (Cortisporin) |
|
|
Y |
|
|
|
|
|
| Nose |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Nasal Steroids |
Beclomethasone (Beconase AQ) |
42 (mcg)/actuation |
|
Y |
| Budesonide (Rhinocort Aqua) |
32 mcg/actuation |
Free Drug - Astra Zeneca |
N |
|
|
|
|
|
| Misc. |
Normal Saline (Ocean Spray) |
0.65% |
|
N |
|
|
|
|
|
| Throat |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Misc. |
Lidocaine, viscous |
2 (%) |
|
N |
| Magic Mouth Wash |
various preparations |
|
N |
| Phenol/Menthol Lozenges (Cepastat) |
29 mg phenol/lozenge |
|
N |
|
|
|
|
|
| DERMATOLOGICAL |
|
|
|
|
|
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Topical Anti-infectives |
Bacitracin |
500 (units/gram) |
|
Y |
| Metronidazole (Metrocream) |
0.75 (%) |
|
N |
| Mupirocin (Bactroban)) |
2 (%) |
|
N |
| Neomycin/Bacitracin/Polymixin (Neosporin) |
3.5 (gram)-400(units)-5000(units) per (Gram) |
|
N |
| Silver Sulfadiazine (Silvadene) |
1 (%) |
|
Y |
|
|
|
|
|
| Antifungal |
Clotrimazole (Lotrimin) |
1 (%) |
|
Y |
| Ketoconazole (Nizoral) |
2 (%) |
|
Y |
| Miconazole (Monistat-Derm) |
2 (%) |
|
Y |
| Nystatin (Mycostatin) |
100,000 (Units/gm) |
|
Y |
| Selenium Sulfide (Selsun) |
lotion: 2.5 (%) |
|
N |
| Tolnaftate (Tinactin) |
1 (%) |
|
Y |
|
|
|
|
|
| Scabicides/ Pediculocides |
Permethrins (NIX - cream rinse, Elimite - cream) |
1, 5 (%) |
|
Y |
|
|
|
|
|
| Corticosteroids |
Clobetasol (Temovate) cr,oint,soln |
0.05 (%) |
|
N |
| Fluocinolone (Synalar) cr,oint,soln |
0.01 (%) |
|
Y |
| Fluocinonide (Lidex) cr,oint,soln |
0.05 (%) |
|
Y |
| Hydrocortisone (various) |
1, 2.5 (%) |
|
Y |
| Triamcinolone (Kenalog) |
0.025, 0.1 (%) |
|
Y |
|
|
|
|
|
| Anesthetics |
Lidocaine Ointment |
5 (%) |
|
N |
|
|
|
|
|
| Emollients |
Petrolatum/Mineral Wax (Eucerin) |
|
|
N |
| Vitamin A and D Ointment |
|
|
N |
|
|
|
|
|
| Antispetics/ Germacides |
Chlorhexidine (Hibiclens) |
4 (%) |
|
N |
| Povidine/Iodine (Betadine) |
10 (%) |
|
N |
|
|
|
|
|
| Immunomodulators |
Imiquimod (Aldara) |
5 (%) |
|
Y |
|
|
|
|
|
| Wet Dressing and Soaks |
Aluminum Acetate (Domeboro) |
1191(mg) of aluminum sulfate and 938 (mg) of calcium acetate per packet |
|
N |
| Sodium Hypochlorite (Dakins Solution) |
0.25, 0.5 (%) |
|
N |
|
|
|
|
|
| Cauterizing Agents |
Silver Nitrate |
10, 25, 50 (%) |
|
N |
|
|
|
|
|
| Antiseborrheic Agents |
Coal Tar Shampoo
|
Neutrogena T-Gel is 0.5 (%) coal tar |
|
N |
| Selenium Sulfide 2.5% (Selsun) |
lotion/shampoo: 2.5 (%) |
|
N |
|
|
|
|
|
| AntiPsoriatic Agents |
Anthralin (Dritho-Scalp) |
0.5, 1 (%) |
|
N |
| Calcipotriene (Dovonex) |
0.005 (%) |
|
Y |
| Selenium Sulfide (Selsun) |
lotion/shampoo: 2.5 (%) |
|
N |
|
|
|
|
|
| Acne Products |
Benzoyl Peroxide (Benzac 5% Gel) |
5 (%) |
|
Y |
| Clindamycin (Cleocin T)
|
1 (%) |
|
N |
|
|
|
|
|
| Anorectal Preparations |
Hemorrhoidal Suppositories (Anusol) |
0.25 (%) |
|
N |
| Hemorrhoidal Suppositories with HC (Anusol HC) |
25 (mg) |
|
N |
|
|
|
|
|
| Misc. Topicals |
Calamine |
|
|
Y |
| Capsaisin |
0.025 (%) |
|
N |
|
|
|
|
|
| HEMATOLOGICAL AGENTS |
| |
|
|
|
|
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Blood Modifiers |
Ferrous Gluconate |
225, 300, 324 (mg) |
|
N |
| Ferrous Sulfate |
325, 160 (SR) (mg) |
|
Y |
|
|
|
|
|
| Anticoagulants |
Warfarin (Coumadin) |
1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 (mg) |
|
Y |
|
|
|
|
|
| Antiplatelets |
Aspirin |
81, 325 (mg) |
|
Y |
| Clopidogrel (Plavix) |
75 (mg) |
Free Drug - BMS (90 day supply) |
N |
|
|
|
|
|
| Miscellaneous |
Cilostal (Pletal) |
50, 100 (mg) |
|
Y |
| Enoxaparin (Lovenox) |
30mg/0.3mL; 40mg/0.4mL; 60mg/0.6mL; 80mg/0.8mL; 100mg/mL |
|
Y |
| Pentoxyfylline (Trental) |
400 (mg) |
|
Y |
|
|
|
|
|
| GENITOURINARY and RENAL |
|
|
|
|
|
| Renal/Urology |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Drugs for Gout |
Allopurinol (Zyloprim) |
100, 300 (mg) |
|
Y |
| Colchicine |
0.5, 0.6 (mg) |
|
Y |
| Probenecid |
500 (mg) |
|
Y |
|
|
|
|
|
| Alpha-Adrenergic Blocker |
Doxazosin (Cardura) |
1,2,4,8 (mg) |
|
Y |
| Tamsulosin (Flomax) |
0.4 (mg) |
|
Y |
|
|
|
|
|
| 5-Alpha-Reductase Inhibitor |
Dutasteride (Avodart) |
0.5 (mg) |
|
Y |
| Finasteride (Proscar) |
5 (mg) |
|
N |
|
|
|
|
|
| Urinary Alkalizers |
Sodium Bicarbonate |
650 (mg) |
|
N |
|
|
|
|
|
| Anticholinergics |
Oxybutynin (Ditropan) **
|
5 (mg) |
XL nonform |
Y |
| Tolterodine LA (Detrol LA)
|
1, 2 (mg) |
Free Drug - Pfizer IR nonform
|
Y |
|
|
|
|
|
| Cholinergics |
Bethanecol Chloride (Urecholine) |
5, 10, 25, 50 (mg) |
|
Y |
|
|
|
|
|
| Polymeric Phosphate Binders |
Calcium Acetate (Phos Lo) |
667 (mg) |
|
Y |
| Sevelamer (Renagel) |
400, 800 (mg) |
|
Y |
|
|
|
|
|
| Diuretics |
Furosemide (Lasix) |
20, 40, 80 (mg) |
|
Y |
| Hydrochlorathiazide (HydroDiuril, Esidrix) |
25, 50 (mg) |
|
Y |
| Metolazone (Zaroxolyn) |
2.5, 5, 10 (mg) |
|
Y |
| Spironolactone (Aldactone) |
25, 50 (mg) |
|
Y |
| Triamterene/HCTZ (Maxzide, Maxzide-25) |
37.5/25, 75/50 (mg) |
|
Y |
|
|
|
|
|
| Vaginal Products |
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Antifungal Agents |
Clotrimazole (Gyne-Lotrimin) |
45, 90 (Gram) |
|
Y |
| Miconazole (Monistat-7) |
Supp: 100, 200 (mg) cream: 2 (%) |
|
Y |
| Nystatin (Mycostatin) |
cr/oint: 100,000 Units/gm |
|
Y |
| Terconazole (Terazol) |
cream: 0.4, 0.8 (%) supp: 80 (mg) |
|
Y |
|
|
|
|
|
| Anti-infectives |
Clindamycin (Cleocin) |
cream: 2 (%) supp: 100 (mg) |
|
Y |
| Metronidazole (MetroGel-Vaginal) |
Gel: 0.75 (%) |
|
Y |
|
|
|
|
|
| NUTRITION |
|
|
|
|
|
| |
|
Strengths Available |
Notes |
Medi-Cal |
| Vitamins |
Cyanocobalamin (Vit B-12) |
inj: 100, 1000 (mcg/cc) tab:500, 1000 (mcg) |
|
Y |
| Folic Acid |
1 (mg) |
|
Y |
| Phytonadione (Vit K) |
5 (mg) |
|
Y |
| Thiamine (Vit B-1) |
50, 100 (mg) |
|
N |
| Pyridoxine (Vit B-6) |
25, 50 (mg) |
|
Y |
| Ascorbic Acid (Vit C) |
250, 500 (mg) |
|
N |
| Cholecalciferol (Vit D) |
400, 1000 (IU) |
|
N |
| Calcitriol (Rocaltrol) |
0.25, 0.5 (mcg) |
|
Y |
|
|
|
|
|
| Vitamin Combinations |
Multivitamins |
|
|
N |
| Multivitamins with minerals |
|
|
N |
| Prenatal Vitamins with minerals |
|
|
Y |
| Vitamin B with C (Nephrovite) |
|
|
N |
|
|
|
|
|
| Minerals and Electrolytes |
Potassium Chloride (K-Dur, Slow-K) |
8, 10, 20 (mEq) |
|
Y |
| Calcium Carbonate
|
Oscal: 500 (mg) Oscal D: 500/200 (mg) |
|
Y |
|
|
|
|
|
| Antineoplastic Agents & Immunosupressant Agents |
Restricted to consults only. Case Managed. |
|
|
|
|
|
|
|
|
|
* = these drugs need to have a nonformulary request form attached to the prescription when written
|
|
** = the long acting (LA), extended release (ER) or controlled release (CR) formulations of these drugs are not covered.
|
|
|
|
|
|
|
Please note that Soma and Oxycontin are not avaible from Pharmacy. We do not stock it or order it.
|
|
|