CHP/HEALTHY FAMILIES PROGRAM FORMULARY
PRESCRIPTION QUANTITY LIMITS Members may receive up to a thirty- (30) day supply of medication unless the drug is included on the CHP maintenance drug list. Only generic or NTI prescriptions may be issued for multiple months of refill but it is the responsibility of the dispensing pharmacist to confirm member eligibility each time the medication is dispensed.
COST INDEX This index reflects the cost per day of therapy or the cost per prescription based on accepted dosing regimens. When clinically appropriate, this guide may provide assistance when making an effective therapeutic selection relative to the cost index.
$ $$ $$$ $$$$ $$$$$
Least expensive product More expensive than $ More expensive than $$ More expensive than $$$ Very, very expensive relative to all of the above
Member must be within age requirements to use specific drug
Limited to specific days supply. Refer to note section
Indicates a specific restriction based on dosage form of the medication. Refer to note section
Frequency of Billing
These items may only be billed within specific intervals
Quantity guidelines exist for these items.
Requires prior authorization before dispensing of the medication.
Refer to note section for the requirements
These items may only be refilled within specific intervals/ time frames.
Step Protocol Therapy
May not be dispensed unless a specific protocol has been established with the patient. Refer to note section for requirement
Carve-Out FFS Medi-Cal
These items are covered for members and must be billed to EDS Medi-Cal Fee for Service (FFS)
Medication is covered and may be dispensed without any restriction.
90 Day Supply Allowed
Indicates this drug may be dispensed with a 90-day supply of medication
Narrow Therapeutic Index
Drug EXEMPT from mandatory generic substitution