Care 1st Health Plan Healthy Families Drug Formulary Last Updated: Dec 2005 Care 1st Pharmacy Department Phone: 877-RX-CARE1 (877-792-2731) Fax: 626-299-0914 Therapeutic Class: Analgesics Therapeutic Subclass: Analgesics, Narcotic
Quantity Limit: 8 ounces (240 ml) per 30
Quantity Limit: 6 ounces (180 mls) per 30
Quantity Limit: 4 ounces (120 mls) per 30
Page 1 of 18
Limited to 5mg-325mg strength; Quantity Limit: 100 tablets per 30 days
Therapeutic Subclass: Analgesics, Non-Narcotic Therapeutic Subclass: Antirheumatics Therapeutic Subclass: Cyclooxygenase Inhibitor Therapeutic Subclass: Migraine
Quantity Limit: 6 tablets / Rx ; Fill Limit: 1 fill
Quantity Limit: 2 inj/Rx; Fill Limit: 1 fill per 30 days
Quantity Limit: 6 sprays/Rx; Fill Limit: 1 fill per 30 days
Therapeutic Subclass: NSAIDs Page 2 of 18 Therapeutic Class: Anti-Infectives Therapeutic Subclass: Amebacides Therapeutic Subclass: Aminoglycosides Therapeutic Subclass: Anaerobic Antiprotozoal-Antibacterial Agents Therapeutic Subclass: Anti-mycobacterium Agents Therapeutic Subclass: Antifungal Agents Therapeutic Subclass: Antifungal Antibiotics
PA required unless treating Tinea Capitis. Age restriction: <= 12 yrs; Quantity Limit: 600mls / month; Fill Limit: 2 months / year
PA required, unless treatment for "Tinea Capitis" with fill limit of 60 days in 1 year.
PA required, unless treatment for "Tinea
Capitis" with fill limit of 60 days in 1 year. Therapeutic Subclass: Antileprotic Therapeutic Subclass: Antimalarials Page 3 of 18 Therapeutic Subclass: Antiparasitics Therapeutic Subclass: Antitubercular Antibiotics Therapeutic Subclass: Antivirals Therapeutic Subclass: Cephalosporins
Stepped Therapy: Requires trial of first or
second generation Cephalosporin in past 3 weeks
Therapeutic Subclass: Lincosamides Therapeutic Subclass: Macrolides Therapeutic Subclass: Miscellaneous Anti-Infectives Page 4 of 18 Therapeutic Subclass: Nitrofurantoin Derivatives Therapeutic Subclass: Penicillins
Quantity Limit: 300ml/Rx; Fill Limit: 1 fill per 30 days
Quantity Limit: 40 tablets/Rx; Fill Limit: 1 fill per 30 days
Therapeutic Subclass: Quinolones Therapeutic Subclass: Sulfonamides Therapeutic Subclass: Tetracyclines
Quantity Limit: 60 tablets per 30 days; Age Limit >= 18 yrs
Page 5 of 18 Therapeutic Class: Cardiovascular Medications Therapeutic Subclass: Angiotensin Converting Enzyme Inhibitor Combinations Therapeutic Subclass: Angiotensin Converting Enzyme Inhibitors Therapeutic Subclass: Antiadrenegic Agents, Centrally Acting Therapeutic Subclass: Beta Blockers, Non-Selective Therapeutic Subclass: Cardiac Glycosides Therapeutic Subclass: Diuretics, Loop Diuretics Therapeutic Subclass: Diuretics, Potassium Sparing Diuretics Therapeutic Subclass: Diuretics, Thiazides and Related Diuretics Therapeutic Class: Central Nervous System Page 6 of 18 Therapeutic Subclass: Antianxiety Drugs Therapeutic Subclass: Antidepressants
Quantity Limit: # 30 (10mg) per 30 days / #90 (20mg) per 30 days. Therapeutic Subclass: CNS Non-Stimulants Therapeutic Subclass: CNS Stimulants
Dexedrine / Adderall. Limited to ages 6-16.
Quantity Limit: One (1) capsule per day.
Dexedrine / Adderall. Limited to ages 6-16. Quantity Limit: One (1) tablet per day.
Limited to ages 6-16 only; Quantity Limit: 1 tablet per day
Limited to ages 6-16 only; Quantity Limit: 1 tablet per day. Therapeutic Subclass: Other Central Nervous System Drugs Therapeutic Class: Dermatologicals Therapeutic Subclass: Anorectals Therapeutic Subclass: Antiseborrheic Agents Page 7 of 18 Therapeutic Subclass: Keratolytics Therapeutic Subclass: Miscellaneous Topicals Therapeutic Subclass: Scabicides and Pediculocides Therapeutic Subclass: Toipcal Antibiotic Therapeutic Subclass: Topical Anti-Infectives Therapeutic Subclass: Topical Antibiotic Therapeutic Subclass: Topical Antifungals Therapeutic Subclass: Topical Corticosteroids in Combination Therapeutic Subclass: Topical Corticosteroids: Group II (High Potency) Therapeutic Subclass: Topical Corticosteroids: Group III (Medium Potency) Page 8 of 18 Therapeutic Subclass: Topical Corticosteroids: Group IV (Low Potency) Therapeutic Subclass: Topical Immunomodulator Therapeutic Subclass: Vitamin A Derivatives Therapeutic Class: Ear, Nose and Throat Medications Therapeutic Subclass: Corticosteroids, Nasal Inhaled Therapeutic Subclass: Miscellaneous Otic Products Therapeutic Subclass: Nasal Antihistamine Therapeutic Subclass: Otic Steroid/Anti-Infective Combinations Therapeutic Subclass: Throat Medications Therapeutic Class: Endocrine Medications Therapeutic Subclass: Antithyroid Drugs Therapeutic Subclass: Contraceptives, Biphasic Oral Contraceptives
May be dispensed as a three (3) months supply
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May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
Therapeutic Subclass: Contraceptives, Monophasic Oral Contraceptives
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
Therapeutic Subclass: Contraceptives, Other Transdermal Contraceptive Devices Therapeutic Subclass: Contraceptives, Progestin Only Oral Contraceptives
May be dispensed as a three (3) months supply
May be dispensed as a three (3) month supply
Therapeutic Subclass: Contraceptives, Triphasic Oral Contraceptives
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
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May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
May be dispensed as a three (3) months supply
Therapeutic Subclass: Contraceptives, Triphasic Oral Contracetptives
May be dispensed as a three (3) months supply
Therapeutic Subclass: Diabetic Supplies Therapeutic Subclass: Glucagon Therapeutic Subclass: Insulins Therapeutic Subclass: Oral Hypoglycemics
Stepped Therapy: Requires concomitant use
Stepped Therapy: Requires concomitant use
Therapeutic Subclass: Other Endocrine Drugs
Limited to 8-14 years of age for a duration of
Page 11 of 18 Therapeutic Subclass: Post-Coital Contraception
Quantity Limit: 1 pack (2 tablets) per prescription.
Quantity Limit: 1 pack (4 tablets) per prescription. Therapeutic Subclass: Progestins Therapeutic Subclass: Systemic Corticosteroids, Glucocorticoids Therapeutic Subclass: Thyroid Hormones
50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg
75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg
Therapeutic Class: Gastrointestinal Medications Therapeutic Subclass: Anticholinergic, Antispasmodics Therapeutic Subclass: Antidiarrheal Preparations Therapeutic Subclass: Antiemetics Page 12 of 18 Therapeutic Subclass: Antiulcer Drugs, H2 Antagonists Therapeutic Subclass: Antiulcer Drugs, Other Antiulcer and Gastrointestinal Products Therapeutic Subclass: Antiulcer Drugs, Proton Pump Inhibitors
Step Therapy: Requires trial of H2 Blocker in past 90 days
Therapeutic Subclass: Belladonna Alkaloids Therapeutic Subclass: Bowel Antiinflammatory Agents Therapeutic Subclass: Intestinal Motility Stimulants Therapeutic Subclass: Laxatives and Cathartics Therapeutic Class: Genitourinary Therapeutic Subclass: Anticholinergic, Antispasmodics Therapeutic Subclass: Cholinergic Drugs Page 13 of 18 Therapeutic Subclass: Urinary Analgesics Therapeutic Subclass: Vaginal Anti-Infectives
Quantity Limit: Two (2 ) 150mg tablets in 30 days
Therapeutic Subclass: Vaginal, Estrogen Therapeutic Class: Hematological Agents Therapeutic Subclass: Anticoagulant Drugs Therapeutic Class: Neuromuscular Therapeutic Subclass: Anticonvulsants
Quantity Limit: 120 tablets in 30 days. Page 14 of 18 Therapeutic Subclass: Skeletal Muscle Relaxants Therapeutic Class: Ophthalmic Medications Therapeutic Subclass: Antibiotic / Steroid Combinations Therapeutic Subclass: Antibiotics Therapeutic Subclass: Eye Antiinflammatory Agents Therapeutic Subclass: Eye Sulfonamides Therapeutic Subclass: Sympathomimetics Therapeutic Class: Respiratory Medications Therapeutic Subclass: Antiasthmatics, Adrenergic Stimulants, Inhalers Page 15 of 18
Step Therapy: Requires use of Inhaled Corticosteroids in past 90 days
Step Therapy: Requires use of Inhaled Corticosteroids in past 90 days
Therapeutic Subclass: Antiasthmatics, Adrenergic Stimulants, Oral Formulation Therapeutic Subclass: Antiasthmatics, Adrenergic Stimulants, Solutions Therapeutic Subclass: Antiasthmatics, Combination Products, Inhalers Therapeutic Subclass: Antiasthmatics, General Bronchodilator Agents Therapeutic Subclass: Antiasthmatics, Leukotriene Inhibitors Therapeutic Subclass: Antiasthmatics, Mast Cell Stabilizers Therapeutic Subclass: Antiasthmatics, Oral Inhaled Corticosteroids Therapeutic Subclass: Antiasthmatics, Other Respiratory Drugs and Devices Page 16 of 18 Therapeutic Subclass: Antiasthmatics, Xanthine Derivatives Therapeutic Subclass: Antihistamines, Antitussives and Expectorants Therapeutic Subclass: Antihistamines, Combination Products Therapeutic Subclass: Antihistamines, Decongestant Products Therapeutic Subclass: Antihistamines, Single Entity Products
Quantity Limit: 150mls per 30 days, Age Limit </= 6 yrs of age
Therapeutic Subclass: Expectorants Therapeutic Class: Sympathomimetics Therapeutic Subclass: Sympathomimetics Page 17 of 18 Therapeutic Class: Vitamins/Minerals/Electrolytes/Supplements Therapeutic Subclass: Minerals Therapeutic Subclass: Potassium Supplements Therapeutic Subclass: Prenatal Vitamins Therapeutic Subclass: Vitamins Page 18 of 18
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