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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

FORMULARY CODES

Age Limitation

Member must be within age requirements to use specific drug

Days Supply

Limited to specific days supply. Refer to note section

Dosage Form

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 Limit

Quantity guidelines exist for these items.

Prior Authorization

Requires prior authorization before dispensing of the medication.

Restricted Use

Refer to note section for the requirements

Refill Limitations

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)

Covered Product

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

CODE

AL

DS

DF

F

QL

PA

R

RL

SP

C

X

90

NTI

DEFINITION

NOTES

CHP/HF PROVIDER MANUAL 5/2004

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