Medi-Cal Update

Pharmacy | February 2011 | Bulletin 746

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1. Medi-Cal List of Contract Drugs

The following provider manual sections have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs, Drugs: Contract Drugs List Part 2 – Over-the-Counter Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications Drugs.

Drug Strength and/or Size Billing Unit
Addition, effective March 1, 2011
*ULIPRISTAL ACETATE      
  * Restricted to a maximum quantity of one tablet per dispensing with a maximum of six dispensings in any 12-month period and for females only.
    Tablets 30 mg ea
       
Changes, effective July 16, 2010
‡ * EVEROLIMUS
    * Restricted to use in the treatment of cancer only.
      Tablets 2.5 mg   ea
      5 mg   ea
    10 mg   ea
‡ * ETRAVIRINE
  * Restricted to use as combination therapy in the treatment of Human Immunodeficiency Virus (HIV) infection only.
    Tablets 100 mg   ea
      200 mg   ea
   
Changes, effective March 1, 2011
BUPROPION HCL
     
    * Tablets 75 mg   ea
      100 mg   ea
    * Restricted to NDC labeler code 00173 (GlaxoSmithKline) for the tablets only.
    * Tablets 150 mg   ea
      300 mg   ea
    * Restricted to NDC labeler codes 00173 (GlaxoSmithKline) and 64455 (BTA Pharmaceuticals, Inc) for the extended release (24-hour) tablets only.
    * Tablets, sustained release (12-hour) 100 mg   ea
      150 mg   ea
      200 mg   ea
    * Restricted to NDC labeler code 00173 (GlaxoSmithKline) for the sustained release (12-hour) tablets only.
  + * Tablets, sustained release for smoking cessation 150 mg   ea
           
  * Restricted to brand name Zyban only with NDC labeler code 00173 (GlaxoSmithKline) for smoking cessation only and Pharmacy must obtain a letter or certificate of enrollment for the patient from a behavioral modification smoking cessation program. to be part of a comprehensive smoking cessation treatment, which includes behavioral modification support. Also restricted to a maximum quantity of 60 tablets per dispensing and therapy lasting up to 12 weeks from the dispensing date of the first prescription and two courses of therapy per 12-month period separated by six months. Pharmacies no longer need to obtain or verify a letter or certificate prior to dispensing.
 
* ENOXAPARIN SODIUM      
  * Restricted to NDC labeler code 00075 (Aventis Pharmaceuticals) only and restricted to a maximum of twenty (20) syringes per dispensing and a maximum of two (2) dispensings per patient in any 12-month period.
    Prefilled syringe 30 mg ml
      40 mg ml
      60 mg ml
      80 mg ml
      100 mg ml
       
‡ * FLUCONAZOLE      
  * Restricted to use in cancer patients and in patients with Human Immunodeficiency Virus (HIV) infection and patients with coccidioidomycosis infection.
  * Injection 2 mg/ml 100 ml (saline)  
        200 ml (saline)  
        100 ml (dextrose)  
        200 ml (dextrose)  
    Tablets 50 mg  
      100 mg  
      *150 mg  
      200 mg  
  * Restricted to NDC labeler code 00049 (Pfizer, Inc.) for the injection and the 150 mg tablets only.
       
MICONAZOLE NITRATE      
  Vaginal suppositories 200 mg 3's ea
    ** Topical Cream 2% 15 Gm Gm
        30 Gm Gm
        85 Gm Gm
    ** Now only available as an Over-The-Counter (OTC) product. See Contract Drugs List Part 2 – Over-The-Counter Drugs.
‡ MICONAZOLE NITRATE      
    Topical Cream 2%   Gm
    Vaginal suppositories 100 mg 7's ea
    Vaginal cream 2% 45 Gm Gm
    Dual package      
    (15 Gm topical cream 2% and 3 vaginal suppositories 200 mg)   each package
         
MOXIFLOXACIN HCL      
  * Ophthalmic Solution 0.5% ml
  * Restricted to NDC labeler code 00065 (Alcon Laboratories, Inc.) brand name Vigamox® only, for ophthalmic solution only.  
  * Tablets 400 mg ea
  * Restricted to a maximum quantity per dispensing of ten (10) tablets and a maximum of two (2) dispensings in any 30-day period and to NDC labeler code 00085 (Schering Corporation) for tablets only.  
         
* NICOTINE      
  * Pharmacy must obtain a letter or certificate of enrollment for the patient from a behavioral modification smoking cessation program. Also restricted to (1) a quantity of 14 patches per dispensing; (2) three dispensings in a 42-day period; and (3) therapy lasting up to six weeks from the dispensing date of the first prescription.
    Transdermal patch 5 mg/16hr ea
    10 mg/16 hr ea
    15 mg/16hr
  (NDC labeler code 00009 [Pharmacia and Upjohn Company] only.)
  * To be part of comprehensive smoking cessation treatment, which includes behavioral modification support.  Also restricted to (1) a maximum quantity of 28 patches per dispensing; (2) one dispensing in a ny 25-day period and eight dispensings within a 12-month period; (3) therapy lasting up to 14 weeks from the dispensing date of the first prescription with a maximum of two courses of therapy per 12 months (no break mandated); and (4) NDC labeler code 00135 (GlaxoSmithKline) for the transdermal system only .
  * Transdermal system 7 mg/24 hr   ea
    14 mg/24 hr   ea
    21 mg/24 hr   ea
       
Note: Pharmacies no longer need to obtain or verify a letter or certificate prior to dispensing.

Reminder: The following is a chart that contains NDCs with corresponding UPC (bar code).
NDC Product Description UPC (12 digit) Count Unit Old 00766 NDC
00135-0195-02 NICODERM CQ 14 MG/24HR PATCH 307661430208 14.000 ea 00766143020
00135-0194-03 NICODERM CQ 21 MG/24HR PATCH 307661470204 21.000 ea 00766147020
00135-0145-01 NICODERM CQ 21 MG/24HR PATCH 307661450107 7.000 ea 00766145010
00135-0145-02 NICODERM CQ 21 MG/24HR PATCH 307661450206 14.000 ea 00766145020
00135-0194-01 NICODERM CQ 21 MG/24HR PATCH 307661420506 7.000 ea 00766142050
00135-0194-02 NICODERM CQ 21 MG/24HR PATCH 307661420209 14.000 ea 00766142020
00135-0196-02 NICODERM CQ 7 MG/24HR PATCH 307661440207 14.000 ea 00766144020
  * Pharmacy must obtain a letter or certificate of enrollment for the patient from a behavioral modification smoking cessation program. Also restricted to (1) a quantity of 14 patches per dispensing; (2) five dispensings in a 70-day period; (3) therapy lasting up to ten weeks from the dispensing date of the first prescription; and (4) NDC labeler code 00135 (GlaxoSmithKline) only.
  ** Transdermal patch 7 mg/24 hr ea
    14 mg/24 hr ea
    21 mg/24 hr ea
(NDC labeler code 00009 [Pharmacia and Upjohn Company] only.)
  ** Currently no longer manufactured or available.  
* SUMATRIPTAN SUCCINATE/NAPROXEN SODIUM    
  * Restricted to NDC labeler code 00173 (GlaxoSmithKline) only, and to a maximum quantity per dispensing of nine (9) tablets, and a maximum of three (3) dispensings in any 12-month period.
    Tablets 85 mg /500 mg ea
 
‡ Drug is exempt from the monthly drug claim line limit.

This information is reflected in the following provider manual:

Provider Manual(s) Page(s) Updated
Pharmacy drugs cdl p1a (19); drugs cdl p1b (2, 9, 12, 52, 56); drugs cdl p1d (6, 19); drugs cdl p2 (8 –10); drugs cdl p4 (13)
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