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SACRAMENTO COUNTY FORMULARY 2012

4.1.2012
CARDIOVASCULAR DRUGS
Anti-anginal  
 Strengths AvailableNotesMedi-Cal
NitratesIsosorbide 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
Anti-hypertensives
  Strengths AvailableNotesMedi-Cal
Angiotensin Converting EnzymesBenazepril (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
   
Angiotension Receptor BlockersCandesartan (Atacand)4,8,16,32 (mg)Free Drug - Astra ZenecaN
Losartan (Cozaar)25,50,100 (mg) Y
Antiadrenergic Agents Peripherally ActingDoxazosin (Cardura)1, 2, 4, 8 (mg) Y
Prazosin (Minipress)1,2,5 (mg) Y
   
Antiadrenergic Agents Centrally ActingClonidine (Catapress) (PO & patches)0.1, 0.2, 0.3 (mg) Y
Guanabenz (Wytensin)4, 8 (mg) Y
Guanfacine (Tenex)1, 2 (mg) Y
   
Beta-Blocking AgentsAtenolol (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 nonformY
   
Calcium Channel BlockersAmlodipine (Norvasc)2.5, 5, 10 (mg)Free Drug - PfizerY
Nifedipine (Procardia XL)30, 60, 90 (mg)Free Drug - PfizerY
Diltiazem (Cardizem CD)120, 180, 240, 300, 360 (mg)  Y
Verapamil (Calan, Isoptin, Calan SR, Isoptin SR)80, 120 (mg)                   SR: 120, 180, 240 (mg) Y
   
DiureticsFurosemide (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
     
VasodilatorsHydralazine (Apresoline)10, 25, 50, 100 (mg) Y
Minoxidil (Loniten)2.5, 10 (mg) N
 
Combo AntihypertensivesBenazepril/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
Anti-arrhythmic
  Strengths AvailableNotesMedi-Cal
Cardiac GlycosidesDigoxin (Lanoxin)0.125, 0.25 (mg) Y
MiscellaneousAmiodarone (Cordarone, Pacerone)200 (mg) Y
Disopyramide (Norpace)100, 150 (mg) N
Anti-lipemic
 Strengths AvailableNotesMedi-Cal
StatinsAtorvastatin (Lipitor)10,20,40 (mg)Free Drug - Pfizer                                           80mg nonformY
Rosuvastatin (Crestor)5,10,20,40 (mg)Free Drug - Astra ZenecaY
Simvastatin (Zocor)5,10,20,40 (mg)80mg nonformY
OtherCholestyramine (Questran)4 (gm) Y
Gemfibrozil (Lopid)600 (mg) Y
Niacin ER (Niaspan)500, 750, 1000 (mg) Y
CENTRAL NERVOUS SYSTEM DRUGS
Analgesics and Antipyretics
  Strengths AvailableNotesMedi-Cal
Antirheumatic DrugsHydroxychloroquine200 (mg) Y
Leflunomide (Arava)10, 20 (mg) Y
Methotrexatetab: 2.5, 5, 7.5, 10, 15 (mg)   inj:  25mg/ml Y
Sulfasalazine (Azulfidine)500 (mg) Y
MigrainesButalbital/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 - PfizerN
Narcotic AnalgesicsAcetaminophen/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
Methadone5, 10 (mg) Y
Morphine ER (MS Contin)15,30, 60 (mg) Y
Oxycodone Immediate Release5 (mg) Y
Anti-inflammatoryAspirin81, 325 (mg) Y
Celecoxib (Celebrex)100, 200 (mg)Free Drug - PfizerY
Ibuprofen (Motrin)200, 400, 600, 800 (mg) Y
Indomethacin (Indocin) **50, 75 (mg)ER nonformY
Meloxicam (Mobic)7.5, 15 (mg) Y
Naproxen Sodium (Naprosyn)250, 375, 500 (mg) Y
OtherTramadol (Ultram) **50 (mg)ER nonformY
Psychotropic Medications
  Strengths AvailableNotesMedi-Cal
SSRI’s & Aytypical AntidepressantsBupropion (Wellbutrin SR/XL) SR: 100, 150 (mg);                          XL: 150, 300 (mg)IR nonformY
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 nonformY
Sertraline (Zoloft)25, 50, 100 (mg) Y
Trazadone (Desyrel)50, 100, 150 (mg) Y
Venlafaxine (Effexor XR)37.5, 75, 150 (mg)IR nonformY
TricyclicsAmitriptyline (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
1st & 2nd Generation AntipsychoticsAripiprazole (Abilify)Tab: 10, 20, 30 (mg)             Discmelt nonformY
Chlorpromazine (Thorazine)50, 100, 200 (mg) Y
Clozapine (Clozaril)--fill at Broadway Rx25, 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)                 Free Drug - Eli Lilly (120 day supply)  Zydis nonformY
Paliperidone (Invega Sustenna) *IM inj: 39, 78, 117, 156, 234 (mg)Tabs nonform;                       IM inj nonform requiredN
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 ZenecaY
Risperidone (Risperdal)Tab:  0.25, 0.5, 1, 2, 3, 4 (mg)                                                 Consta:  12.5, 25, 37.5, 50 (mg)M-Tab nonformY
Ziprasidone (Geodon)20, 40, 60, 80 (mg)Free Drug - PfizerY
Mood StabilizersDivalproex Sodium (Depakote ER)250, 500 (mg)Sprinkle nonformY
Lamotrigine (Lamictal) **25, 100, 150, 200 (mg)XR nonformY
Lithium (LiCO, Lithobid)150, 300, 450 (mg) Y
Oxacarbazepine (Trileptal)150, 300, 600 (mg) Y
Carbamazepine (Tegretol) **200 (mg)XR nonformY
MiscellaneousHydroxyzine Pamoate (Vistaril)25, 50 (mg) Y
Prazosin (Minipress)1,2,5 (mg) Y
    
MAO InhibitorsVarious * (Parnate, Marplan, Nardil, etc)All need nonformulary  
Antianxiety
  Strengths AvailableNotesMedi-Cal
BenzodiazepinesChlordiazepoxide (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
MiscellaneousBuspirone (Buspar)5, 10, 15, 30 (mg) Y
Miscellaneous CNS Medications
  Strengths AvailableNotesMedi-Cal
Sedatives and HypnoticsTemazepam (Restoril)7.5, 15, 30 (mg) Y
Zolpidem (Ambien) **5, 10 (mg)CR nonformY
AnticonvulsantsCarbemazepine (Tegretol) **100, 200 (mg)XR nonformY
Clonazepam (Klonopin)0.5, 1, 2 (mg) Y
Divalproex Sodium (Depakote DR/ER)DR: 125, 250, 500 (mg)                 ER:  250, 500 (mg)Sprinkle nonformY
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 nonformY
Oxacarbezepine (Trileptal)150, 300, 600 (mg) Y
Phenobarbital15, 30, 60, 90, 100 (mg) Y
Phenytoin (Dilantin) **30, 50, 100 (mg)ER nonformY
Primidone (Mysoline)50, 250 (mg) Y
Topiramate (Topamax)25, 100, 200 (mg) Y
Valproic Acid (Depakene)250 (mg) Y
Acetylcholinesterase InhibitorDonepezil (Aricept)5, 10 (mg) Y
N-Methyl-D-Aspartate Receptor AntagonistMemantine(Namenda)5, 10 (mg) N
Skeletal Muscle RelaxantsBaclofen (Lioresal)10, 20 (mg) Y
Cyclobenzaprine (Flexeril)10 (mg) N
Methocarbamol (Robaxin)500, 750 (mg) N
Diazepam (Valium)2, 5, 10 (mg) Y
Antiparkinson AgentsAmantadine (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 nonformY
Trihexyphenidyl (Artane)2, 5 (mg) Y
StimulantsAtomoxetine (Strattera) 10, 18, 25, 40, 60, 80, 100 (mg) N
Misc StimulantsVarious * (Adderal, Dexedrine, Ritalin, etc)All need nonformulary  
Substance DependenceAcamprosate (Campral)333 (mg) N
Disulfram (Antabuse)250, 500 (mg) Y
Naltrexone25, 50, 100 (mg) N
RESPIRATORY DRUGS
Asthma / COPD
  Strengths AvailableNotesMedi-Cal
BronchodilatorsAlbuterol (Proventil HFA)17 (Gram) Y
 Ipratroprium (Atrovent) 14.7, 14 (Gram) Y
 Salmeterol Diskus (Serevent) 60 (Gram)Free Drug - GlaxoY
Tiotropium (Spiriva)18 (mcg)Free Drug - Boehringer Ingelheim Y
Combination InhalersAlbuterol/Ipratroprium (Combivent)14.7 (Gram) Y
Budesonide/Formoterol (Symbicort)80-4.5, 160-4.5 (mcg)Free Drug - Astra ZenecaY
Flovent/Serevent (Advair)100-50, 250-50, 500-50 (mcg)Free Drug - GlaxoY
CorticosteroidsFluticasone (Flovent)44, 110, 220 (mcg/actuation)Free Drug - GlaxoY
Beclomethasone (QVAR)40, 80 (mcg/actuation) Y
Dexamethasone (Decadron)0.5, 1, 1, 4 (mg) Y
Prednisone1, 2.5, 5, 10, 20, 50 (mg) Y
Xanthine DerivativesTheophylline, SR (Theodur, Uniphyl)100, 200, 300, 400, 450 (mg) Y
MiscellaneousMontelukast (Singular)10 (mg)Free Drug - Merck         (90 day supply)Y
Zafirlukast (Accolate)10, 20 (mg)Free Drug - Astra ZenecaN
Allergy / Cough / Cold
  Strengths AvailableNotesMedi-Cal
AntihistaminesChlorpheniramine (Chlor-Trimeton)4 (mg) Y
Diphenhydramine (Benadryl)25, 50 (mg) Y
Loratadine (Claritin)10 (mg) N
DecongestantsPhenylephrine (Sudogest PE)10 (mg) Y
Pseudoephedrine (Sudafed)30, 60 (mg) Y
Decon. &Antihist. Combo'sTripolidine/Phenylephrine (Actifed PE)  Y
 
Expectorants/CoughGuaifenesin (Robitussin)  Y
Guaifenesin/Codeine (Robitussin w/Codeine)  Y
Guaifenesin/Dextromethorphan (Robitussin DM/Diabetic DM)  Y
Promethazine / Codeine (Phenergan w/Codeine)  Y
ANTI-INFECTIVES
Antibiotics
  Strengths AvailableNotesMedi-Cal
PenicillinsAmoxicillin (Trimox)250, 500 (mg) Y
Amoxicillin/Clavulanate (Augmentin) **250, 500, 875, 1000 (mg)XR nonformY
Dicloxacillin (Dynapen)125, 250, 500 (mg) Y
Penicillin V Potassium125, 250, 500 (mg) Y
CephalosporinsCefpodoxime (Vantin)200 (mg)Restricted to in-clinic dispensing for STDY
Ceftriaxone (Rocephin)Inj: 250, 500, 1000, 2000 (mg) Y
Cephalexin (Keflex)250, 500 (mg) Y
TetracyclinesDoxycycline (Vibramycin)20, 50, 100 (mg) Y
Minocycline (Minocin)50, 100 (mg) N
Tetracycline (Sumycin)250, 500 (mg) Y
MacrolidesAzithromycin (Z-Pak, Tri-Pak)tab: 250, 500 (mg)                                 liquid:  100/5, 200/5 (mg/5cc)                              Powder: 1gmFree Drug - PfizerY
Clarithromycin (Biaxin) **250, 500 (mg)Restricted to H.PyloriY
Erthryomycin (Ery-Tab)Base: 250, 500 (mg); Stearate: 250, 500 (mg) Y
QuinolonesCiprofloxacin (Cipro)250, 500, 750 (mg) Y
Levofloxacin (Levaquin)250, 500, 750 (mg) Y
MiscellaneousClindamycin (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)800-160 (mg) Y
Antifungal Agents
  Strengths AvailableNotesMedi-Cal
SystemicFluconazole (Diflucan)50, 100, 150, 200 (mg)Free Drug - PfizerY
Griseofulvin (Grifulvin V,Gris-PEG)Microsize: 500 (mg)            Ultramicosize:  125, 250 (mg) Y
Terbinafine (Lamisil)Tab: 250 (mg)topical non-formY
Miscellaneous
  Strengths AvailableNotesMedi-Cal
AntiviralAcyclovir (Zovirax)200, 400, 800 (mg) Y
LeprostaticDapsone25, 100 (mg) Y
AntihelminticsMebendazole (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
AmebicidesChloroquine Phosphate (Aralen)250 (mg) Y
Metronidazole (Flagyl)250, 500 (mg) Y
Primaquine Phosphate26.3 (mg) Y
ENDROCRINE AND METABOLIC AGENTS
Hormones
  Strengths AvailableNotesMedi-Cal
Adrenal CorticosteroidsDexamethasone (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
Prednisone1, 2.5, 5, 10, 20, 50 (mg) Y
EstrogensConjugated 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 coveredY
ProgestinsMedroxyprogesterone (Provera)2.5, 5, 10 (mg) Y
 
Oral ContraceptivesDesogestrel/Ethinyl estradiol (various)0.15-0.03 (mg)Restricted to dx other than contraception, use Family Planning for OCY
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
BiphosphonatesAlendronate (Fosamax)5,10, 35, 70 (mg) Y
Anti-Diabetic Agents
  Strengths AvailableNotesMedi-Cal
InsulinsLente Insulin (Novolin L)100 Units/cc Y
NPH Insulin (Novolin NPH)100 Units/ccPen nonformY
Regular Insulin (Novolin R)100 Units/ccPen nonformY
70/30 Insulin (Novolin 70/30)100 Units/ccPen nonformY
Glargine (Lantus)100 Units/ccPen nonformY
Humalog (Lispro)100 Units/ccPen nonformY
SulfonylureasGlipizide XL (Glucotrol XL)2.5, 5, 10 (mg)Free Drug - PfizerN
Glipizide (Glucotrol)5, 10 (mg) Y
Glyburide (Diabeta, Micronase)1.25, 2.5, 5 (mg) Y
BiguanidesMetformin (Glucophage/Glucophage XR)500, 850, 1000 (mg) Y
GlitazonesPioglitazone (Actos)15, 30, 45 (mg)Free Drug - Takeda (90 day supply)Y
Glucose ElevatingGlucagononly injection 1 mg/vial Y
Glucose Tablets5 (gram) N
Glucose Gel24 (grams/tube) N
Testing SuppliesBlood glucose monitoring strip (True Result)#100/90days non-insulin         #100/30days insulingreater qty requires nonformN
Thyroid and Anti-Thyroid
  Strengths AvailableNotesMedi-Cal
Thyroid HormonesLevothyroxine (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 AgentsPropylthiouracil (PTU)50 (mg) Y
Methimazole (Tapazole)5, 10 (mg) Y
GASTROINTESTINAL DRUGS
  Strengths AvailableNotesMedi-Cal
H-2 BlockersRanitidine (Zantac)150, 300 (mg) Y
PPI'sEsomeprazole (Nexium)20, 40 (mg)Free Drug - Astra ZenecaY
Omeprazole (Prilosec)20, 40 (mg) N
AntacidsCalcium Carbonate650, 1250 (mg) Y
Milk of Magnesium (MOM)Susp: 400mg/5cc, 800mg/5cc N
Al Hydroxide/Mg Hydroxide/Simethicone (Mylanta Extra Strength)400-400-40 (mg/ 5mL) Y
Anti-Cholinergics/   AntispasmodicsBelladonna Alkaloids/Phenobarbital                  (Donnatal)0.0194/0.0065/0.1037/          16.2 (mg)        Y
Dicyclomine (Bentyl)10, 20 (mg) Y
LaxativesBisacodyl (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 Oil99.9 (%) N  
Psyllium Powder (Genfiber)3.4 (gram/teaspoon) N  
Anti-Diarrheal AgentsAtropine/Diphenoxylate (Lomotil)2.5 (mg) Y
Kaolin/Pectin (Kaopectate)  N
Loperamide (Immodium)2 (mg) N
 
Ulcerative ColitisMesalamine (Asacol only)400 (mg) N
Sulfasalazine (Azulfidine)500 (mg) Y
Digestive EnzymesPancrealipase (Zenpep)5000, 1500, 10000, 20000 (U)  Y
Anti-emetic/              AntivertigoMeclizine (Antivert)12.5, 25 (mg) Y
Ondansetron (Zofran)4, 8 (mg)ODT nonformY
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 DrugsLactulose (Enulose)10 gram/ 15 mL N
Metoclopramide (Reglan)5, 10 (mg) Y
Sucralfate (Carafate)Tab: 1 (gm)  Suspension: 1gm/10ml Y
AntiflatulantSimethicone (Mylicon)80, 125 (mg) N
EYES, EARS, NOSE, and THROAT
Ophthalmics
  Strengths AvailableNotesMedi-Cal
Beta-BlockersBetaxolol (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
SympathomimeticsDipivefrin (Propine)0.1  (%) Y
Epinephrine0.5, 1, 2 (%) Y
CholinergicsCarbachol (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 InhibitorsAcetazolamide (Diamox)125, 250 (mg) Y
Dorzolamide (Trusopt)2 (%) Y
Misc. Glaucoma MedsBimatoprost (Lumigan)0.01, 0.03 (%) Y
Brimonidine (Alphagan)0.15, 0.1, 0.2 (%) Y
CombinationsDorzolamide/Timolol (Cosopt)2-5 (%) Y
Pilocarpine/Epinephrine1, 2, 3, 4, 6 (%) Y
AntiCholinergicsAtropine0.5, 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/ AntihistaminicsKetotifen (Zaditor)0.025 (%) N
Naphazoline (Naphcon)0.1(%) Y
Naphazoline/Antazoline (Naphcon A)0.05-0.5 (%) Y
 
Mast Cell StabilizerCromolyn (Crolom)4 (%) Y
 
Opthalmic CorticosteroidsDexamethasone (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 AntibioticsCiprofloxacin (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’sDexamethasone/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
PainDiclofenac (Voltaren)0.1 (%) Y
Ketoralac (Acular)0.4, 0.5 (%) Y
Miscellaneous Opthal PrepArtificial 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
Puralube150 (mg) light mineral oil and 850 (mg) white petrolatum per (gram) N
Otics
  Strengths AvailableNotesMedi-Cal
Otic PreparationsAcetic 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 AvailableNotesMedi-Cal
Nasal SteroidsBeclomethasone (Beconase AQ)42 (mcg)/actuation Y
Budesonide (Rhinocort Aqua)32 mcg/actuationFree Drug - Astra ZenecaN
Misc.Normal Saline (Ocean Spray)0.65% N
Throat 
  Strengths AvailableNotesMedi-Cal
Misc.Lidocaine, viscous2 (%) N
Magic Mouth Washvarious preparations N
Phenol/Menthol Lozenges (Cepastat)29 mg phenol/lozenge N
DERMATOLOGICAL
  Strengths AvailableNotesMedi-Cal
Topical Anti-infectivesBacitracin500 (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
AntifungalClotrimazole (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/ PediculocidesPermethrins (NIX - cream rinse, Elimite - cream)1, 5 (%) Y
CorticosteroidsClobetasol (Temovate) cr,oint,soln0.05 (%) N
Fluocinolone (Synalar) cr,oint,soln0.01 (%) Y
Fluocinonide (Lidex) cr,oint,soln0.05 (%) Y
Hydrocortisone (various)1, 2.5 (%) Y
Triamcinolone (Kenalog)0.025, 0.1 (%) Y
AnestheticsLidocaine Ointment5 (%) N
EmollientsPetrolatum/Mineral Wax (Eucerin)  N
Vitamin A and D Ointment  N
Antispetics/                 GermacidesChlorhexidine (Hibiclens)4 (%) N
Povidine/Iodine (Betadine)10 (%) N
ImmunomodulatorsImiquimod (Aldara)5 (%) Y
Wet Dressing and SoaksAluminum 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 AgentsSilver Nitrate10, 25, 50 (%) N
Antiseborrheic AgentsCoal Tar Shampoo Neutrogena T-Gel is 0.5 (%) coal tar N
Selenium Sulfide 2.5% (Selsun)lotion/shampoo: 2.5 (%) N
AntiPsoriatic AgentsAnthralin (Dritho-Scalp)0.5, 1 (%) N
Calcipotriene (Dovonex)0.005 (%) Y
Selenium Sulfide (Selsun)lotion/shampoo: 2.5 (%) N
Acne ProductsBenzoyl Peroxide (Benzac 5% Gel)5 (%) Y
Clindamycin (Cleocin T)  1 (%) N
Anorectal PreparationsHemorrhoidal Suppositories (Anusol)0.25 (%) N
Hemorrhoidal Suppositories with HC (Anusol HC)25 (mg) N
Misc. TopicalsCalamine  Y
Capsaisin0.025 (%) N
HEMATOLOGICAL AGENTS
     
  Strengths AvailableNotesMedi-Cal
Blood ModifiersFerrous Gluconate225, 300, 324 (mg) N
Ferrous Sulfate325, 160 (SR)  (mg) Y
AnticoagulantsWarfarin (Coumadin)1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 (mg) Y
AntiplateletsAspirin81, 325 (mg) Y
Clopidogrel (Plavix)75 (mg)Free Drug - BMS            (90 day supply)N
MiscellaneousCilostal (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 AvailableNotesMedi-Cal
Drugs for GoutAllopurinol (Zyloprim) 100, 300 (mg) Y
Colchicine0.5, 0.6 (mg) Y
Probenecid500 (mg) Y
Alpha-Adrenergic BlockerDoxazosin (Cardura)1,2,4,8 (mg) Y
Tamsulosin (Flomax)0.4 (mg) Y
5-Alpha-Reductase InhibitorDutasteride (Avodart)0.5 (mg) Y
Finasteride (Proscar)5 (mg) N
Urinary AlkalizersSodium Bicarbonate650 (mg) N
AnticholinergicsOxybutynin (Ditropan) ** 5 (mg)XL nonformY
Tolterodine LA (Detrol LA) 1, 2 (mg)Free Drug - Pfizer          IR nonform Y
CholinergicsBethanecol Chloride (Urecholine)5, 10, 25, 50 (mg) Y
Polymeric Phosphate BindersCalcium Acetate (Phos Lo)667 (mg) Y
Sevelamer (Renagel)400, 800 (mg) Y
DiureticsFurosemide (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 AvailableNotesMedi-Cal
Antifungal AgentsClotrimazole (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-infectivesClindamycin (Cleocin)cream: 2 (%)                        supp: 100 (mg) Y
Metronidazole (MetroGel-Vaginal)Gel: 0.75 (%) Y
NUTRITION
  Strengths AvailableNotesMedi-Cal
VitaminsCyanocobalamin (Vit B-12)inj: 100, 1000 (mcg/cc)                                   tab:500, 1000 (mcg) Y
Folic Acid1 (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 CombinationsMultivitamins  N
Multivitamins with minerals  N
Prenatal Vitamins with minerals  Y
Vitamin B with C (Nephrovite)  N
Minerals and ElectrolytesPotassium Chloride (K-Dur, Slow-K)8, 10, 20 (mEq) Y
Calcium Carbonate Oscal:  500 (mg)            Oscal D:  500/200 (mg) Y
Antineoplastic Agents & Immunosupressant AgentsRestricted 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.