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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 7 – Preferred TAR-Approved Drugs List.

Changes, effective August 1, 2008
Drug Strength and/or Size Billing Unit
FERROUS SULFATE    
  Tablets 200 mg ea
  325 mg ea
  Drops 15 mg/0.6 ml  50 ml ml
    118 cc cc
  Liquid     ml
* Suspension drops 15 mg/1.5 ml 118 ml ml
* Restricted to NDC labeler code 24478 (Nextwave Pharmaceuticals) for the suspension drops only.

Changes, effective October 21, 2008
Drug Strength and/or Size Billing Unit
‡ NORGESTREL AND ETHINYL ESTRADIOL
  Tablets 0.3 mg – 30 mcg Tablets from 21 tablet packet ea
    Tablets from 28 tablet packet ea
  0.5 mg – 50 mcg Tablets from 21 tablet packet ea
    Tablets from 28 tablet packet ea
(NDC labeler code 00008 [Wyeth Laboratories] only.)

Change, effective October 24, 2008
Drug Strength and/or Size Billing Unit
‡ * DARUNAVIR    
   * Restricted to use as combination therapy in the treatment of Human Immunodeficiency Virus (HIV) infection.
  Tablets 300 mg   ea
  400 mg   ea
  600 mg   ea

Change, effective November 6, 2008

Drug

 Strength and/or Size Billing Unit
AMLODIPINE BESYLATE    
* Restricted to NDC labeler code 00069 (Pfizer Inc.) only.  
  + Tablets 2.5 mg   ea
  5 mg   ea
  10 mg   ea
     
AZITHROMYCIN    
  * Tablets 250 mg   ea
  * Restricted to a maximum quantity per dispensing of eight (8) tablets and a maximum of two (2) dispensings in any 30-day period and to NDC labeler code 00069 (Pfizer Inc.) for the 250 mg tablets.
 
  * Tablets 500 mg   ea
  * Restricted to a maximum quantity per dispensing of four (4) tablets and a maximum of two (2) dispensings in any 30-day period and to NDC labeler code 00069 (Pfizer Inc.) for the 500 mg tablets.
       
  ‡ * Tablets 600 mg   ea
    * Restricted to use in the prevention of infections caused by Mycobacterium organisms and to NDC labeler code 00069 (Pfizer Inc.) for the 600 mg tablets.
       
  + * Powder packet 1 Gm   ea
    * Restricted to NDC labeler code 00069 (Pfizer Inc.) for the powder packets.
       
  * Suspension 100 mg/5 cc 15 cc cc
  200 mg/5 cc 15 cc cc
    22.5 cc cc
  * Restricted to use for individuals less than eight years old with otitis media infection and to NDC labeler code 00069 (Pfizer Inc.) for the suspension.
       
  Ophthalmic solution 1% 2.5 cc cc
       
SIMVASTATIN      
  * Restricted to NDC labeler Code 00006 (Merck & Co., Inc) only.
  + Tablets 5 mg   ea
  10 mg   ea
  20 mg   ea
  40 mg   ea
  80 mg   ea
 
TERBINAFINE HCL      
  Tablets 250 mg   ea
(NDC labeler code 00078 [Novartis Pharmaceuticals Corporation] only.)

‡ Drug is exempt from the monthly claim line limit
+ Frequency of billing requirement

Change, effective December 1, 2008

Drug

 Strength and/or Size  

Billing Unit

GALANTAMINE HYDROBROMIDE

     
* Tablets 4 mg   ea
  8 mg   ea
  12 mg   ea
* Restricted to treatment of mild to moderate dementia of the Alzheimer’s type and to claims with dates of service on or before January 31, 2008. Continuing care for a date of service on or after February 1, 2008 is available when all of the following conditions are met: 1) the recipient has a Medi-Cal paid claim for this drug on or before January 31, 2008; and 2) a claim has been submitted and paid at least every 100 days; and 3) the claim being submitted is within 100 days of the date of service of the last paid claim submitted.
       
* Extended-release capsules 8 mg   ea
16 mg   ea
24 mg   ea
* Restricted to treatment of mild to moderate dementia of the Alzheimer’s type and to NDC labeler code 50458 (Janssen Pharmaceutica Products L.P.) only.
       
* Solution 4 mg/ml   ml
* Restricted to treatment of mild to moderate dementia of the Alzheimer’s type and to claims with dates of service on or before January 31, 2008. Continuing care for a date of service on or after February 1, 2008 is available when all of the following conditions are met: 1) the recipient has a Medi-Cal paid claim for this drug on or before January 31, 2008; and 2) a claim has been submitted and paid at least every 100 days; and 3) the claim being submitted is within 100 days of the date of service of the last paid claim submitted.

Change, effective January 1, 2009

Drug

 Strength and/or Size  

Billing Unit
* ETANERCEPT      
* Injectable biologic response modifier. Restricted to claims submitted with dates of service from January 1, 2006 through December 31, 2008 only.
    Injection kit 25 mg   ea
    Injection, prefilled syringe 50 mg/0.98 ml   ml
    Injection, SURECLICK syringe 50 mg/0.98 ml   ml

+ Frequency of billing requirement