Preferred Drug List Changes — 1st Quarter 2018
Date: 01/18/18
The list below details the Preferred Drug List (PDL) changes for the fourth quarter of 2017.The California Health & Wellness Pharmacy and Therapeutics (P&T) Committee reviews the PDL quarterly to determine placement of medications on the drug list and any limitations to coverage.
The P&T Committee consists of practicing physicians, pharmacists and other health care professionals.
Drug Name | PDL Status | Comments |
Orphenadrine Citrate ER 100mg tab (Norflex) | Add to PDL 2/1/2018 |
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Benzoyl Peroxide 6% Lotion Benzoyl Peroxide 4% (Panoxyl-4 Creamy Wash); Benzoyl Peroxide Bar 10% (Panoxyl) | Add to PDL 2/1/2018 |
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Paroxetine HCl SR 24HR 12.5mg, 25mg, 37.5mg (Paxil Cr) | Add to PDL 2/1/2018 |
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Levocetirizine Dihydrochloride 5mg tab (Xyzal) | Add to PDL 2/1/2018 |
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Rizatriptan Benzoate Oral Disintegrating 5mg, 10mg solutab (Maxalt-MLT) | Add to PDL 2/1/2018 |
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Famotidine 40mg/5ml susp (Pepcid) | Add to PDL 2/1/2018 |
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Lansoprazole Delayed Release 30mg cap (Prevacid) | Add to PDL 2/1/2018 | Quantity Limit = 2 per day |
Omeprazole Delayed Release 10mg cap (Prilosec) | Add to PDL 2/1/2018 | Quantity Limit = 2 per day |
Levetiracetam 1000mg tab (Keppra) | Add to PDL 2/1/2018 |
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Telmisartan 20mg, 40mg, 80mg tab (Micardis) | Add to PDL 2/1/2018
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Candesartan Cilexetil 4mg, 8mg, 16mg, 32mg tab (Atacand); Candesartan Cilexetil-Hydrochlorothiazide Tab 16-12.5mg, 32-12.5mg, 32-25mg tab (Atacand HCT) | Add to PDL 2/1/2018 |
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Lisinopril 2.5mg,5mg,10mg,20mg, 30mg,40mg tab (Zestril); Lisinopril & Hydrochlorothiazide 10-12.5mg, 20-12.5mg, 20-25mg tab (Zestoretic) | Remove Quantity Limit 2/1/2018 |
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Torsemide 20mg tab (Demadex) | Remove Quantity Limit 2/1/2018 |
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Ranitidine HCl 75mg/5ml syr (Zantac)
| Change Quantity Limit 2/1/2018 | Quantity Limit = 40ml per day |
Valacyclovir HCl 1gm tab (Valtrex) | Change Quantity Limit 2/1/2018 | Quantity Limit = 42 per 21 days |
Fluoxetine HCl 20mg/5ml sol (Prozac) | Change Quantity Limit 2/1/2018 | Quantity Limit – 600ml per 30 days |
Gabapentin 600mg tab, 100mg, 300mg, 400mg cap (Neurontin)
| Change Quantity Limit 2/1/2018 | Quantity Limit = 6 per day 600mg; 9 per day 100mg, 300mg, 400mg |
Methylphenidate HCl 5mg tab | Change Quantity Limit 2/1/2018 | Quantity Limit = 6 per day |
Glimepiride 1mg, 2mg tab (Amaryl)
| Change Quantity Limit 2/1/2018 | Quantity Limit = 4 per day |
Paroxetine HCl 10mg, 20mg tab (Paxil) | Change Quantity Limit 2/1/2018 | Quantity Limit = 3 per day; 6 per day 10mg |
Mirtazapine 15mg; Mirtazapine Orally Disintegrating 15mg solutab (Remeron)
Mirtazapine 30mg tab; Mirtazapine Disintegrating 30mg solutab (Remeron) | Change Quantity Limit 2/1/2018 | Quantity Limit = 3 per day 15mg; 1.5 per day 30mg |
Topiramate 25mg, 50mg, 100mg, 200mg tab (Topamax)
| Change Quantity Limit 2/1/2018 | Quantity Limit = 2 per day 200mg; 4 per day 100mg; 6 per day 25mg, 50mg |
Bupropion HCl SR 12HR 100mg, 150mg tab (Wellbutrin SR)
| Change Quantity Limit 2/1/2018 | Quantity Limit = 3 per day 150mg; 4 per day 100mg |
Metoprolol Succinate SR 24HR 25mg, 50mg, 100mg tab (Toprol XL); Metoprolol Tartrate 25mg, 50mg, 100mg tab (Lopressor) | Change Quantity Limit 2/1/2018 | Quantity Limit = 4 per day SR 25mg, 50mg, 100mg; 4.5 per day 25mg, 50mg,100mg
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Buspirone HCl 5mg, 10mg, 15mg tab (Buspar) | Change Quantity Limit 2/1/2018 | Quantity Limit = 4 per day 15mg; 6 per day 5mg, 10mg |
Sertraline HCl 25mg, 50mg tab (Zoloft) | Change Quantity Limit 2/1/2018 | Quantity Limit = 4 per day |
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Levetiracetam 500mg tab (Keppra)
| Change Quantity Limit 2/1/2018 | Quantity Limit = 6 per day |
Levetiracetam SR 24HR 500mg, 750mg tab (Keppra XR)
| Add to PDL with PA Restrictions 2/1/2018 | Step Therapy = must try Levetiracetam immediate release first |
Lamotrigine SR 24HR 25mg, 50mg, 100mg, 200mg, 250mg, 300mg tab (Lamictal XR) | Add to PDL with PA Restrictions 2/1/2018 | Step Therapy = must try Lamotrigine immediate release first |
Olmesartan-Amlodipine-Hydrochlorothiazide Tab 20-5-12.5mg, 40-5-12.5mg, 40-5-25mg, 40-10-12.5mg, 40-10-25mg tab (Tribenzor) | Add to PDL with PA Restrictions 2/1/2018 | Step Therapy = must try Losartan or Irbesartan first |
Amlodipine Besylate-Olmesartan Medoxomil Tab 5-20mg, 5-40mg, 10-20mg, 10-40mg tab (Azor) | Add to PDL with PA Restrictions 2/1/2018 | Step Therapy = must try Losartan or Irbesartan first |
Olmesartan Medoxomil 5mg, 20mg, 40mg tab (Benicar); Olmesartan Medoxomil-Hydrochlorothiazide 20-12.5mg, 40-12.5mg, 40-25mg tab (Benicar HCT) | Add to PDL with PA Restrictions 2/1/2018 | Step Therapy = must try Losartan or Irbesartan first |
Hydrochlorothiazide 5-160-12.5mg, 5-160-25mg, 10-160-12.5mg, 10-160-25mg,10-320-25mg tab (Exforge HCT) | Add to PDL with PA Restrictions 2/1/2018 | Step Therapy = must try Losartan or Irbesartan first |
Amlodipine Besylate-Valsartan 5-160mg tab (Exforge) | Add to PDL with PA Restrictions 2/1/2018 | Step Therapy = must try Losartan or Irbesartan first |
Glycopyrrolate 15.6mcg Inhal cap (Seebri Neohaler)
| Add to PDL with PA Restrictions 2/1/2018 | PA Required; Quantity Limit = 1 inhaler per month (2 caps per day) |
Ondansetron Orally Disintegrating 4mg, 8mg Solutab; Ondansetron HCl 4mg, 8mg tab (Zofran) | Change Quantity Limit 3/1/2018 | Quantity Limit = 20 per 30 days |
Omeprazole Delayed Release 20mg Cap (Prilosec) | Change Quantity Limit 3/1/2018 | Quantity Limit = 2 per day |
Lansoprazole Delayed Release 15mg cap (Prevacid) | Change Quantity Limit 3/1/2018 | Quantity Limit = 2 per day |
Non-Insulin Utilizers TrueTrack Test Strips TrueTrack Blood Glucose Test Strips | Change Quantity Limits 3/1/2018 | Non-Insulin Utilizer Quantity Limit = 100 strips per 90 days |
Non-Insulin Utilizers True Metrix Blood Glucose Test Strips True Metrix Self-Monitoring Blood Glucose Test Strips | Change Quantity Limits 3/1/2018 | Non-Insulin Utilizer Quantity Limit = 100 strips per 90 days for |