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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 and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications Drugs.

Changes, Clarification of Code I, effective immediately
Drug Strength and/or Size Billing Unit
* AMPHETAMINE, MIXED SALTS      
  (AMPHETAMINE SULFATE, AMPHETAMINE ASPARATE, DEXTROAMPHETAMINE SULFATE AND DEXTROAMPHETAMINE SACCHARATE)
* Restricted to use in Attention Deficit Disorder in individuals between from 4 years and through 16 years of age only.
    Tablets 5 mg   ea
  7.5 mg   ea
  10 mg   ea
  12.5 mg   ea
  15 mg   ea
  20 mg   ea
  30 mg   ea
 
* DEXMETHYLPHENIDATE HCL      
* Restricted to use in Attention Deficit Disorder in individuals between from 4 years and through 16 years of age and to NDC labeler code 00078 (Novartis Pharmaceutical Corporation) only.
    Capsules, extended release 5 mg   ea
  10 mg   ea
  15 mg   ea
  20 mg   ea
       
* DEXTROAMPHETAMINE SULFATE      
* Restricted to use in Attention Deficit Disorder in individuals between from 4 years and through
16 years of age only.
    Tablets 5 mg   ea
  10 mg   ea
 
* LISDEXAMFETAMINE DIMESYLATE
* Restricted to use in Attention Deficit Disorder in individuals between from 4 years and through
16 years of age only.
    Capsules 20 mg   ea
  30 mg   ea
  40 mg   ea
  50 mg   ea
  60 mg   ea
  70 mg   ea
 
METHYLPHENIDATE HCL      
  * Tablets 5 mg   ea
  10 mg   ea
  20 mg   ea
  * Restricted to use in Attention Deficit Disorder in individuals between from 4 years and through 16 years of age only.
 
  * Tablets, extended release 18 mg   ea
  27 mg   ea
  36 mg   ea
  54 mg   ea
  * Restricted to use in Attention Deficit Disorders in individuals between from 4 years and through 16 years of age and with a Medi-Cal fee-for-service paid claim for this drug prior to December 1, 2004, and a claim has been submitted and paid at least every 100 days, and the claim being submitted is within 100 days of the date of service of the last paid claim submitted.
 
* PEMOLINE
* Restricted to use in Attention Deficit Disorders in individuals between from 4 years and through 16 years of age with a Medi-Cal fee-for-service paid claim for this drug prior to December 1, 2005, and with the claim being submitted within 100 days of the date of service of the last paid claim submitted.
    Tablets or capsules 18.75 mg   ea
  37.5 mg   ea
  75 mg   ea
    Tablets (chewable) 37.5 mg   ea

Change, effective September 17, 2008
Drug Strength and/or Size Billing Unit
‡ * TIPRANAVIR    
* Restricted to use as combination therapy in the treatment of Human Immunodeficiency Virus (HIV) infection.
    Capsules 250 mg   ea
    Oral solution 100 mg/cc   cc

Changes, effective September 22, 2008
Drug Strength and/or Size Billing Unit
‡ TOPOTECAN HCL    
  Capsules 0.25 mg   ea
  1 mg   ea
  Powder for injection 4 mg /vial   ea

Changes, effective November 1, 2008
Drug Strength and/or Size Billing Unit
* ALFUZOSIN HCL        
* Restricted to NDC labeler code 00024 (Sanofi-Aventis, US LLC) only.
  + Tablets, extended release 10 mg   ea
 
METRONIDAZOLE      
  Oral tablets 250 mg   ea
  500 mg   ea
  Injection 500 mg/100 cc   cc
  Powder for injection 500 mg vial ea
  * Topical gel 0.75 % 28.4 Gm Gm
  * Restricted to claims submitted with dates of service from March 1, 1994 through December 31, 2005.
  * Vaginal gel 0.75 % 70 Gm Gm
  * Restricted to NDC labeler code 00089 (3M) and NDC labeler code 29336 (Graceway Pharmaceuticals, LLC) for vaginal gel only.
 
OLOPATADINE HCL
  Ophthalmic solution 0.1 % cc
  0.2 % cc
  Nasal spray 0.6 % Gm
     
* ZIPRASIDONE HCL
* Restricted to individuals 6 years of age and older and to NDC labeler code 00049 (Pfizer, Inc.) only.
    Capsules 20 mg ea
  40 mg ea
  60 mg ea
  80 mg ea

Changes, effective January 1, 2009
Drug Strength and/or Size Billing Unit
* MOMETASONE FUROATE    
* Restricted to claims submitted with dates of service from October 1, 2005 through December 31, 2008 only.
    Oral powder for inhalation 30 inhalations/0.24 Gm Gm
  60 inhalations/0.24 Gm Gm
  120 inhalations/0.24 Gm Gm
     
‡ * NORELGESTROMIN AND ETHINYL ESTRADIOL  
  * Restricted to claims submitted with dates of service from March 2, 2002 through December 31, 2008 only.
    Transdermal patch 6 mg – 0.75 mg ea
Note: Payment limited to a minimum dispensing quantity of three cycles except with the initial prescription or when uthorization is obtained.
 
OXYBUTYNIN CHLORIDE  
  + Tablets 5 mg   ea
  * + Tablets, extended release 5 mg   ea
  10 mg   ea
  15 mg   ea
  * Restricted to NDC labeler code 17314 (Alza Corporation) and to claims submitted with dates of service from December 1, 1998 through December 31, 2008 for extended release tablets only.