|
Medi-Cal Beneficiaries' Approved Medication List |
|
Generic Name
Representive Brand Name |
Strength and
Preparations |
If no other Rx
Benefit |
Medi-Cal Beneficiaries |
|
Care Mark
(BHS) 30 day limit with two refills
Default use is generics |
Medi-Cal or CalOPTIMA responsibility |
CalOPTIMA Prior Authorization/ Comments |
|
MAJOR TRANQUILIZERS |
|
Amitriptyline/Perphenazine
Triavil |
10/2, 10/4,
25/2, 25/4, 50/4 tabs |
|
|
Covered by
CalOptima |
|
Aripiprazole
Abilify |
5mg, 10mg, 15mg, 20mg, 30mg tabs |
Quantity
limit 31/mo for all tabs |
|
|
|
Chlorpromazine
Thorazine |
25mg, 50mg,
75mg, 100mg, 150mg, 200mg tab
100mg/ml Conc 25mg/ml inj |
|
|
|
|
Clozapine
Clozaril |
25mg, 100mg ,
tabs |
|
|
|
|
Fluphenazine
HCl
Prolixin |
1mg, 2.5mg,
5mg, 10mg tabs, 2.5mg/ml & 5mg/ml Conc, 2.5mg/ml
inj |
|
|
|
|
Fluphenazine
Decanoate
Prolixin Decanoate |
25mg/ml
Amps, Vial |
|
|
|
|
Haloperidol
Haldol |
0.5mg, 1mg,
2mg, 5mg, 10mg, 20mg tabs |
|
|
|
|
Haloperidol
Decanoate
Haldol Decanoate |
50mg/ml,
100mg/ml Amp, Vial |
|
|
|
|
Loxapine
succinate
Loxitane |
5mg, 10mg, 25mg, 50mg caps |
|
Medi-Cal TAR required |
|
|
Mesoridazine
Serentil |
10mg, 25mg, 50mg, 100mg tabs
25mg/ml inj,
25mg/ml liq |
|
|
|
|
Molindone HCl
Moban
|
5mg, 10mg, 25mg, 50mg, 100mg tabs 20mg/ml liq |
|
|
|
|
Olanzapine
Zyprexa |
2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg tabs
5mg, 10mg,
15mg, 20mg Zydis |
|
|
|
|
Perphanzine
Trilafon |
2mg, 4mg,
8mg, 16mg tabs
16mg/ 5ml liq
5mg/ml inj |
|
|
|
|
Pimozide
Orap |
1mg, 2mg
tabs |
|
|
|
|
Quetiapine
Seroquel |
25mg,
100mg, 200mg, 300mg tabs |
|
|
|
|
Risperidone
Risperdal |
.25mg, .5mg,
1mg, 2mg, 3mg, 4mg tabs
.5mg, 1mg, 2mg M-tabs
1mg/ml liq
25mg, 37.5mg, 50mg Consta |
Consta not on BHS |
Medi-Cal
TAR for Consta and M-tabs |
|
|
Thioridazine
Mellarill |
10mg, 15mg, 25mg, 50mg, 100mg, 150mg 200mg tabs
25mg/5ml, 100mg/5ml liq |
|
|
|
|
Thiothixene
Navane |
1mg, 2mg,
5mg, 10mg, 20mg caps
5mg/ml liq |
|
|
|
|
Trifluoperazine
Stelazine |
1mg, 2mg, 5mg,
10mg tabs
10mg/ml Liq, 2mg/ml inj |
|
|
|
|
Ziprasidone
Geodon |
20mg, 40mg, 60mg, 80mg
caps |
Quantity limit 62/mo for
20mg, 40mg, 60mg tabs |
|
|
|
Medi-Cal Beneficiaries' Approved Medication List |
|
Generic Name
Representive Brand Name |
Strength and
Preparations |
If no other Rx
Benefit |
Medi-Cal Beneficiaries |
|
Care Mark
(BHS)30 day limit with two refills
Default use is generics |
Medi-Cal or CalOPTIMA responsibility |
CalOPTIMA Prior Authorization / Comments |
|
ANTIDEPRESSANTS |
|
Amitriptyline
Elavil |
10mg, 25mg, 50mg, 75mg, 100mg, 150mg
tabs |
|
|
|
|
Amoxapine
Asendin |
25mg, 50mg, 100mg, 150mg tabs |
|
|
|
|
Bupropion
Wellbutrin |
75mg, 100mg
tabs
100mg, 150mg, 200mg, 300mg SR tabs
150mg, 300mg XL tabs |
150mg XL requires County TAR
Quan limit
31/mo for 300mg &
62/mo for 75, 100, 150, 200mg |
|
XL's
require CPAS.
Quan limit 62/mo for 200mg SR
& 120/mo for 100 and 150 mg SR |
|
Bupropion
Zyban |
150mg tab |
Quantity limit
62/mo |
|
CPAS required |
|
Citalopram
Celexa |
20mg, 40mg tabs |
10mg
requires county TAR
Quantity limit 62/mo for all tabs |
|
CPAS unless
failed at least 6 week trial of fluoxetine. Quantity limit 15/mo
20mg, and 31/mo 40mg |
|
Clomipramine
Anafranil |
25mg, 50mg, 75mg caps |
Quantity limit 124/mo for all tabs |
|
Quantity limit 124/mo for all tabs |
|
Desipramine
HCL
Norpramin |
10mg, 25mg, 50mg, 75mg, 100mg, 150mg tabs |
|
|
|
|
Doxepin
Sinequan |
10mg, 25mg, 50mg, 75mg, 100mg, 150mg caps
10mg/ml liq |
|
|
|
|
Escitalopram
Lexapro |
10mg, 20mg
tabs |
|
|
CPAS
required |
|
Fluoxetine
Prozac |
10mg, 20mg
caps (Not tabs)
20mg/5ml liq
90mg Pulvule |
40mg
caps requires county TAR
Quan limit 124/mo for 20mg, 31/mo for 10 & 10/mo for 90mg |
|
10mg
limited to #31 per month Max dose 80mg/d |
|
Fluvoxamine
Luvox |
25mg, 50mg, 100mg tabs |
Quan limit
31/mo for 25mg, 45/mo for 50mg & 93/mo for 100mg |
|
Limit 25mg
#31/mo, 50mg #45/mo, 100mg #93/mo
Max dose 300mg/d |
|
Imipramine
Tofranil |
10mg, 25mg, 50mg tabs |
|
|
|
|
Maprotiline
Ludiomil |
25mg, 50mg,
75mg tabs |
|
|
CPAS
required |
|
Mirtazapine
Remeron |
15mg, 30mg, 45mg tabs
15mg, 30mg, 45mg Sol-tabs |
Quan limit
31/mo for
15mg tab & all Sol-tabs, 62/mo for 30 & 45 mg tabs |
|
Quantity
limit 31/mo for all tabs and Sol-tabs |
|
Nefazadone
Serzone |
50mg, 100mg, 150mg, 200mg, 250mg tabs |
|
|
Quantity
limit 62/mo for all tabs |
|
Nortriptyline
HCl
Aventyl |
10mg, 25mg, 50mg, 75mg caps |
|
|
|
|
Paroxetine
Paxil |
10mg, 20mg,
30mg, 40mg tabs 12.5mg, 25mg , 37.5mg CR tabs |
Quan limit
62/mo for 30mg & 40mg, and 31/mo for all others |
|
CPAS
unless failed at least 6 week trial of fluoxetine. Quanity
limit 62/mo 30mg. CPAS req for > 60mg/d or CR |
|
Protriptyline
Vivactyl |
5mg, 10mg tabs |
|
|
|
|
Sertraline
Zoloft |
25mg, 50mg, 100mg tabs |
Quan limit
31/mo for 25mg, 15/mo for 50mg, &
93/mo for 100mg |
|
CPAS
unless failed at least 6 week trial of fluoxetine. Limit 31/mo
for 25mg, 15/mo for 50mg, & 62/mo for 100mg |
|
Trazodone
Desyrel |
50mg, 100mg, 150mg |
|
|
|
|
Trimipramine
Surmontil |
25mg, 50mg,
100mg caps |
|
|
|
|
Venlafaxine
Effexor |
25mg, 37.5mg, 50mg, 75mg, 100mg tabs
37.5mg, 75mg, 150mg XR caps |
Quan limit
93/mo for tabs, 31/mo for 37.5 mg, 75mg XR & 62/mo for 150mg XR |
|
Quan limit
93/mo for tabs, 31/mo for 37.5 mg, 75mg XR & 62/mo for 150mg XR |
|
Medi-Cal Beneficiaries' Approved Medication
List |
|
Generic Name
Representive Brand Name |
Strength and
Preparations |
If no other Rx
Benefit |
Medi-Cal Beneficiaries |
|
Care Mark
(BHS) 30 day limit with two refills
Default use is generics |
Medi-Cal or CalOPTIMA responsibility |
CalOPTIMA Prior Authorization/ Comments |
|
MAOI ANTIDEPRESSANTS |
|
Phenelzine
Nardil |
15mg tab |
|
Medi-Cal
TAR required |
|
|
Selegiline
Eldepryl |
5mg tab |
|
|
Parkinson's (limit #62) |
|
Tranylcypromine
Parnate |
10mg tab |
|
Medi-Cal TAR required |
|
|
Medi-Cal Beneficiaries' Approved Medication List |
|
Generic Name
Representive Brand Name |
Strength and
Preparations |
If no other Rx
Benefit |
Medi-Cal Beneficiaries |
|
Care Mark
(BHS) 30 day limit with two refills
Default use is generics |
Medi-Cal or CalOPTIMA responsibility |
CalOPTIMA Prior Authorization/ Comments |
|
ANTI-ANXIETY / HYPNOTICS |
|
Alprazolam
Xanax |
.25mg,
.5mg, 1mg, 2mg tabs |
|
|
|
|
Buspirone
Buspar |
5mg, 10mg, 15mg tabs |
|
|
|
|
Chloral
Hydrate |
500mg cap, 500 mg supp, 250mg/5ml, 500mg/ml |
|
|
|
|
Chlordiazepoxide
Librium |
5mg, 10mg,
25mg caps |
|
|
|
|
Clonazepam
Klonopin |
.5mg, 1mg,
2mg tabs |
|
|
|
|
Diazepam
Valium |
2mg, 5mg,
10mg tabs |
|
|
|
|
Flurazepam
Dalmane |
15mg, 30mg caps |
|
|
Insomnia (under age 65) |
|
Lorazepam
Ativan |
0.5 mg, 1.0
mg, 2.0mg tabs
2mg/ml, 4mg/ml inj |
|
|
|
|
Oxazepam
Serax |
10mg, 15mg, 30mg caps |
|
|
|
|
Temazepam
Restoril |
7.5mg 15mg, 30mg tabs |
|
|
Insomnia |
|
Triazolam
Halcion |
0.125mg, 0.25mg tabs |
|
|
Insomnia (limit #31) |
|
Zaleplon
Sonata |
5 mg, 10 mg caps |
Quantity
limit 20/mo for all tabs |
|
Over 55 & limit #20 per month |
|
Zolpidem
Ambien |
5 mg, 10 mg tabs |
Quantity
limit 20/mo for all tabs |
|
Over 55 & limit #31 per month |
|
Medi-Cal Beneficiaries' Approved Medication List |
|
Generic Name
Representive Brand Name |
Strength and
Preparations |
If no other Rx
Benefit |
Medi-Cal Beneficiaries |
|
Care Mark
(BHS) 30 day limit with two refills
Default use is generics |
Medi-Cal or CalOPTIMA responsibility |
CalOPTIMA Prior Authorization / Comments |
|
MOOD STABILIZERS |
Carbamazepine
Tegretol |
100mg, 200mg, 400mg, 100mg/5ml |
|
|
|
|
Divalproex
Sodium
Depakote |
125mg, 250mg, 500mg |
|
|
|
|
Gabapentin
Neurontin |
100mg, 300mg, 400mg, 600mg, 800mg |
|
|
Quan limit
186/mo for 100mg, 300mg, 400mg, 600mg
& 124/mo for 800mg |
|
Lamotrogine
Lamictal |
25mg, 100mg, 150mg, 200mg |
|
|
|
|
Lithium |
150mg,
300mg, 600mg caps, 300mg tab, 300mg CR tab (Lithobid), 450mg CR
tab (Eskalith) 300mg/5ml |
|
Medi-Cal TAR for
Eskalith 450mg |
|
|
Topiramate
Topamax |
25mg, 100mg,
200mg tabs |
Quan limit 186/mo for 25mg, 93/mo for 50mg, &
62/mo for 100mg & 200mg |
|
Quan limit
186/mo for 25mg, 93/mo for 50mg, & 62/mo for 100mg & 200mg |
|
Valproic Acid
Depakene |
250mg, 250mg/5ml |
|
|
|
|
Medi-Cal Beneficiaries' Approved Medication List |
|
Generic Name
Representive Brand Name |
Strength and
Preparations |
If no other Rx
Benefit |
Medi-Cal Beneficiaries |
|
Care Mark
(BHS) 30 day limit with two refills
Default use is generics |
Medi-Cal or CalOPTIMA responsibility |
CalOPTIMA Prior Authorization / Comments |
|
MEDICATIONS Primarily Used for SIDE
EFFECTS |
|
Amantadine
Symmetrel |
100mg, 50mg/ml |
|
|
|
|
Benzotropine
Mesylate
Cogentin |
0.5mg, 1mg, 2mg |
|
|
|
|
Biperiden
Akineton |
2mg |
|
Medi-Cal TAR required
|
|
|
Diphenhydramine
Benadryl |
12.5mg, 25mg, 50mg, 10mg/ml, 50mg/ml |
|
|
|
|
Hydroxyzine
HCl
Atarax |
10mg, 25mg, 50mg, 100mg, 10mg/5ml |
|
|
|
|
Hydroxyzine
Pamoate
Vistaril |
25mg, 50mg |
|
|
|
|
Triphexyphenidyl
Artane |
2mg, 5mg, 2mg/5ml |
|
|
|
|
Medi-Cal Beneficiaries' Approved Medication List |
|
Generic Name
Representive Brand Name |
Strength and
Preparations |
If no other Rx
Benefit |
Medi-Cal Beneficiaries |
|
Care Mark
(BHS) 30 day limit with two refills
Default use is generics |
Medi-Cal or CalOPTIMA responsibility |
CalOPTIMA Prior Authorization / Comments |
|
Non-Specific or Non-Psychoactive MEDICATIONS |
Atenolol
Tenormin |
25mg, 50 mg, 100mg tabs |
|
|
|
|
Clondine HCl
Catapress |
0.1mg,
0.2mg, 0.3mg tabs
0.1, 0.2, 0.3 patches |
|
|
|
|
Cyanocobalamin
Vitamin B-12 |
100mcg/ml,
1000mcg/ml |
|
|
|
|
Docusate
Sodium
Colace |
100mg,
240mg, 250 mg caps |
|
|
|
|
Disulfiram
Antabuse |
250mg,
500mg tabs |
|
|
|
|
Donepezil
Aricept |
5mg, 10mg
tabs |
Not
available |
|
Quanity
limit #31/mo and requires MMSE score of 10-26 and Alzheimer's dx
on Rx |
|
DDAVP
Desmopressin |
0.01% nasal
spray |
|
|
|
|
Folic Acid |
1mg tab |
|
|
|
|
Guanfacine HCl
Tenex |
1mg, 2mg |
|
|
|
|
Levothyroxine
Sodium
Synthroid/Levoxyl |
25mcg,
50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg,
175mcg, 200mcg, 300mcg tabs |
|
|
|
|
Liothyronine
Cytomel |
5 mcg,
25mcg, 50mcg tabs
10mcg/ml inj |
|
|
|
|
Nicoderm
Transdermal Patch |
7mg, 14mg, 21mg patches |
|
|
|
|
Nicotine
Gum
Polacrilex |
2mg, 4mg gum |
|
|
|
|
Propanolol
Inderal |
10mg, 20mg,
40mg, 60mg, 80mg, 90mg tabs, 1mg/ml, 20mg/5ml, 40mg/5ml, 80mg/ml
inj |
|
|
|
|
Pyridoxine
Vitamin B-6 |
10mg, 25 mg,
50mg, 100mg, 200mg, 250mg, 500mg tabs
100mg, 200mg, 500mg CR tabs
100mg/ml inj |
|
|
|
|
Thiamine
Vitamin B-1 |
50mg,
100mg, 250mg, 500mg tabs
50mg cap
100mg/ml inj |
|
|
|
|
Thyroid
Extract
Armour Thryoid |
15mcg,
30mcg, 60mcg, 90mcg, 120mcg, 180mcg, 240mcg, 300mcg tabs |
|
|
|
|
Vitamin -
Multi
Multi-vitamins |
various |
|
|
|
|
Medi-Cal Beneficiaries' Approved Medication List |
|
Generic Name
Representive Brand Name |
Strength and
Preparations |
If no other Rx
Benefit |
Medi-Cal Beneficiaries |
|
Care Mark
(BHS) 30 day limit with two refills
Default use is generics |
Medi-Cal or CalOPTIMA responsibility |
CalOPTIMA Prior Authorization / Comments |
|
PSYCHOSTIMULANT MEDICATIONS |
|
Amphetamine/
Dextroamphetamine
Adderall |
5mg,
7.5mg,
10mg, 12.5mg, 15mg, 20mg, 30mg tabs |
|
|
|
|
Amphetamine/
Dextroamphetamine XR
Adderall XR |
10mg, 20mg, 30mg caps |
|
|
|
|
Atomoxetine
Strattera |
10mg, 18mg,
25mg, 40mg, 60mg caps |
|
|
CPAS
required
(for more than one tablet per day) |
|
Dextroamphetamine
Dexedrine |
5 mg, 10 mg |
|
|
|
|
Dextroamphetamine
Dexedrine Spansules
|
5mg, 10mg, 15mg caps |
|
|
|
|
Dexmethylphenidate
Focalin |
2.5mg, 5mg,
10mg tabs |
Requires
County TAR |
|
|
|
Methylphenidate HCl
Methylin
Ritalin |
5mg, 10mg,
20mg tabs |
|
|
|
|
Methylphenidate ER
Metadate ER
Methylin ER
Ritalin SR |
10mg, 20mg
ER tabs
20mg SR tabs
5 Hr |
|
|
|
|
Methylphenidate
(Long-Acting)
Metadate CD
Ritalin LA |
20mg CD
caps
8 Hr (14/6)
20mg, 30mg, 40mg LA caps
(50/50) |
|
|
|
|
Methylphenidate
(with trilayer core)
Concerta |
18mg, 27mg,
36mg, 54mg caps
(14/4), (21/6),
(28/8), (42/12) |
|
|
|
|
Pemoline
Cylert |
18.75mg, 37.5mg, 75mg tabs
37.5 chew tab |
|
|
|
