Medi-Cal Code 1 Drug List

Code 1 drugs are restricted to certain medical conditions or specific circumstances. If the prescribed medication meets the Code 1 description, Providers are encouraged to document the Code 1 description on the prescription. If the Provider does not provide appropriate documentation on the prescription, the dispensing Pharmacist is responsible for verifying that Code 1 requirements are met prior to dispensing the drug. The pharmacist must document that applicable Code 1 requirements have been satisfied and make available all such records for on-site audits. If Code 1 requirements are not met, Provider will need to submit a “Prescription Drug Prior Authorization Form” for the prescribed medication for review.

IEHP is a generic-mandatory plan and requires dispensing of FDA-approved, equivalent generics of brand-name products.

Formulary Code 1 List 

Brand Name

Generic Name

Strength/Dosage Form

Code 1 Descriptions

Amino Acids

Parenteral Amino Acid 15% No.1

15 % IV solution

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same product was started before discharge.  There is a maximum of 10 days supply per dispensing within this 10-day period.

Cedax

Ceftibuten

180 mg/5 mL oral suspension

Restricted to use after failure of first line antibiotic therapy.

Cedax

Ceftibuten

400 mg capsule

Restricted to use after failure of first line antibiotic therapy.

Compazine

Prochlorperazine

5 mg/mL vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same product was started before discharge.  There is a maximum of 10 days supply per dispensing within this 10-day period.

Cytotec

Misoprostol

100 mcg tablet

1) Restricted to use as adjunct therapy with Mifepristone (Mifeprex) as abortifacient.  Limit 2 (200mcg) tablets. OR 2) Restricted to use in NSAID induced ulcer prophylaxis. Must have concurrent use of NSAID.

Cytotec

Misoprostol

200 mcg tablet

1) Restricted to use as adjunct therapy with Mifepristone (Mifeprex) as abortifacient.  Limit 2 (200mcg) tablets. OR 2) Restricted to use in NSAID induced ulcer prophylaxis. Must have concurrent use of NSAID.

DDAVP

Desmopressin

0.1 mg tablet

Restricted to use in the management of primary nocturnal enuresis.

DDAVP

Desmopressin

0.2 mg tablet

Restricted to use in the management of primary nocturnal enuresis.

Depo-Testosterone

Testosterone Cypionate

100 mg/mL vial

Restricted to the treatment of primary hypogonadism (congenital or acquired) and hypogonadotropic hypogonadism (congenital or acquired).

Depo-Testosterone

Testosterone Cypionate

200 mg/mL vial

Restricted to the treatment of primary hypogonadism (congenital or acquired) and hypogonadotropic hypogonadism (congenital or acquired).

Dextrose 5%-0.45% Nacl-Kcl

Dextrose 5%-0.45% Nacl-Kcl

20 mEq/L IV solution

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same product was started before discharge.  There is a maximum of 10 days supply per dispensing within this 10-day period.

Eliquis

Apixaban

2.5 mg tablet

Confirmed diagnosis of 1) deep venous thrombosis (DVT) and/or pulmonary embolism (PE) OR 2) DVT thromboprophylaxis following hip or knee replacement surgery.

Eliquis

Apixaban

5 mg tablet

Confirmed diagnosis of 1) deep venous thrombosis (DVT) and/or pulmonary embolism (PE) OR 2) DVT thromboprophylaxis following hip or knee replacement surgery.

Emend

Aprepitant

125 mg capsule

Reserved for use if prescribed by oncologists or hematologists.

Emend

Aprepitant

40 mg capsule

Reserved for use if prescribed by oncologists or hematologists.

Emend

Aprepitant

80 mg capsule

Reserved for use if prescribed by oncologists or hematologists.

Emend Tripack

Aprepitant

125 mg - 80 mg capsule dose pack

Reserved for use if prescribed by oncologists or hematologists.

Epogen

Epoetin Alfa

2000/mL vial

Restricted to use for the treatment of anemia due to: zidovudine therapy, cancer chemotherapy or chronic renal failure.

Epogen

Epoetin Alfa

3000/mL vial

Restricted to use for the treatment of anemia due to: zidovudine therapy, cancer chemotherapy or chronic renal failure.

Epogen

Epoetin Alfa

4000/mL vial

Restricted to use for the treatment of anemia due to: zidovudine therapy, cancer chemotherapy or chronic renal failure.

Epogen

Epoetin Alfa

10000/mL vial

Restricted to use for the treatment of anemia due to: zidovudine therapy, cancer chemotherapy or chronic renal failure.

Epogen

Epoetin Alfa

20000/mL vial

Restricted to use for the treatment of anemia due to: zidovudine therapy, cancer chemotherapy or chronic renal failure.

Epogen

Epoetin Alfa

20000/2 mL vial

Restricted to use for the treatment of anemia due to: zidovudine therapy, cancer chemotherapy or chronic renal failure.

Fortaz

Ceftazidime

1 g vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Fortaz

Ceftazidime

2 g vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Fortaz

Ceftazidime

6 g vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Garamycin

Gentamicin

40 mg/mL vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Granix

Tbo-Filgastrim

300 mcg/0.5 mL syringe

Restricted to hematologist, oncologist or HIV/infectious disease specialist.

Granix

Tbo-Filgastrim

480 mcg/0.8 mL syringe

Restricted to hematologist, oncologist or HIV/infectious disease specialist.

Humatin

Paromomycin

250 mg capsule

Restricted to use in acute and chronic intestinal amebiasis.

Kefzol

Cefazolin

1g vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Kefzol

Cefazolin

10 g vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Levaquin

Levofloxacin/D5W

500 mg/0.1 L piggyback

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Levaquin

Levofloxacin/D5W

750 mg/.15 L piggyback

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Metro IV

Metronidazole

500 mg/0.1 L piggyback

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same product was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Mycobutin

Rifabutin

150 mg capsule

Restricted to use in the prevention of disseminated Mycobacterium Avium Complex (MAC) disease in patients with advanced HIV infection.

Nutrilipid

Fat Emulsions

20% emulsion

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same product was started before discharge.  There is a maximum of 10 days supply per dispensing within this 10-day period.

Omnicef

Cefdinir

125 mg/5 mL oral suspension

Restricted to use after failure of first line antibiotic therapy.

Omnicef

Cefdinir

250 mg/5 mL oral suspension

Restricted to use after failure of first line antibiotic therapy.

Omnicef

Cefdinir

300 mg capsule

Restricted to use after failure of first line antibiotic therapy.

Penicillin G Potassium

Penicillin G Potassium

5 MMU vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Penicillin G Sodium

Penicillin G Sodium

5 MMU vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Parlodel

Bromocriptine

2.5 mg tablet

Reserved for the treatment of amenorrhea, galactorrhea and acromegaly.

Parlodel

Bromocriptine

5 mg capsule

Reserved for the treatment of amenorrhea, galactorrhea and acromegaly.

Patanol

Olopatadine

0.1 % eye drops

Restricted to use after first line therapy failure or prescribed by an ophthalmologist or optometrist (first line therapy include naphazoline/pheniramine drops, cromolyn drops).

Retin-A

Tretinoin

0.025 % topical gel

Restricted to use in the treatment of acne vulgaris.

Retin-A

Tretinoin

0.01 % topical gel

Restricted to use in the treatment of acne vulgaris.

Retin-A

Tretinoin

0.025 % topical cream

Restricted to use in the treatment of acne vulgaris.

Retin-A

Tretinoin

0.05 % topical cream

Restricted to use in the treatment of acne vulgaris.

Retin-A

Tretinoin

0.1 % topical cream

Restricted to use in the treatment of acne vulgaris.

Rocephin

Ceftriaxone

10 g vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Rocephin

Ceftriaxone

250 g vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Rocephin

Ceftriaxone

500 g vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Suprax

Cefixime

100 mg/5 mL oral suspension

Restricted to use after failure of first line antibiotic therapy.  

Suprax

Cefixime

200 mg/5 mL oral suspension

Restricted to use after failure of first line antibiotic therapy.  

Unasyn

Ampicillin /Sulbactam

3 g vial

Restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when I.V. therapy with the same antibiotic was started before discharge.  There is a maximum of 10 days supply per dispensing within the 10-day period.

Xarelto

Rivaroxaban

10 mg tablet

Confirmed diagnosis of 1) deep venous thrombosis (DVT) and/or pulmonary embolism (PE) OR 2) DVT thromboprophylaxis following hip or knee replacement surgery.

Xarelto

Rivaroxaban

15 mg tablet

Confirmed diagnosis of 1) deep venous thrombosis (DVT) and/or pulmonary embolism (PE) OR 2) DVT thromboprophylaxis following hip or knee replacement surgery.

Xarelto

Rivaroxaban

20 mg tablet

Confirmed diagnosis of 1) deep venous thrombosis (DVT) and/or pulmonary embolism (PE) OR 2) DVT thromboprophylaxis following hip or knee replacement surgery.

Xarelto Starter Pack

Rivaroxaban

15 mg-20 mg tablet dose pack

Confirmed diagnosis of 1) deep venous thrombosis (DVT) and/or pulmonary embolism (PE) OR 2) DVT thromboprophylaxis following hip or knee replacement surgery.

Zarxio

Filgrastrim-Sndz

300 mcg/0.5 mL syringe

Restricted to hematologist, oncologist or HIV/infectious disease specialist.

Zarxio

Filgrastrim-Sndz

480 mcg/0.8 mL syringe

Restricted to hematologist, oncologist or HIV/infectious disease specialist.

July 2017 [07/01/2017]