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C:\docume~1\bhebdon\locals~1\temp\healthy families formulary_012706.snp

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 Page 9 of 18
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 Page 10 of 18
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

Source: http://www.vantagebss.com/images/PLAN_CAFCC_Care_1st_healthy-families-formulary.pdf

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