L.A. Care Covered Drug Formulary (pdf)

Commercial FormularyEye SulfonamidesT1 proparacaine/fluores FLUORESCEINceinsodPROPARACAINET3 proparacaine/fluoresce FLUORESCEINinsodPROPARACAINE HCLT1 tetracaine hcl TETCAINET3 tetracaine hcl TETRAVISCT3 tetracaine hcl TETRAVISC FORTET1 tetracaine hcl/pf TETRACAINE HCLT3 na sulfacetm/prednis OPTIMYDspT1 na sulfacetm/prednis SULFALONEspT1 sulfacetamide SULFACsodiumT1 sulfacetamide SULFACETAMIDEsodiumSODIUMT1 sulfacetamide/predni SULFACETAMIDEsolonespPREDNISOLONET2 sulfacetm na/prednisol BLEPHAMIDEacT2 sulfacetm na/prednisol BLEPHAMIDE S.O.P.acEye VasoconstrictorsT1 naphazoline hclT1 naphazolinehcl/antazolineT1 phenylephrine hclOphthalmic AntibioticsALBALONNAPHAZOLINE HCLW/ANTAZOLINEPHENYLEPHRINEHCLT3 azithromycin AZASITET1 bacitracinBACITRACINT1 bacitracin/polymyxin POLYCIN-Bb sulfateT2 besifloxacin hcl BESIVANCET1 ciprofloxacin hcl CILOXAN(DROPS)T2 ciprofloxacin hcl CILOXAN(OINT)T1 erythromycin base ROMYCINT2 gatifloxacinZYMART2 gatifloxacinZYMAXIDT1 gentamicin sulfate GARAMYCINT3 levofloxacinIQUIXT1 levofloxacin QUIXINT2 moxifloxacin hcl MOXEZAT2 moxifloxacin hcl VIGAMOXT3 natamycinNATACYNT1 neomyNEO-POLYCINsulf/bacitra/polymyxin bT1 neomycin/polymyxn NEOSPORINb/gramicidinT1 ofloxacinOCUFLOXT3 oxy-tcn hcl/polymyx b TERAKsulfT3 oxytetracycline/polymy TERRAMYCIN WITHx b sulfPOLYMYXINT1 polymyxin b POLYTRIMsulf/trimethoprimT1 tobramycin TOBRAMYCINT2 tobramycinTOBREXOphthalmic Anti-inflammatoryImmunomodulator-typeT2 cyclosporineRESTASISOphthalmic Mast Cell StabilizersT1 cromolyn sodiumT2 lodoxamidetromethamineT2 nedocromil sodiumT2 pemirolast potassiumCROMOLYN SODIUMALOMIDEALOCRILALAMASTOphthalmic Preparations, MiscellaneousT3 doxycycline/eyelid clns ALODOXno.2&3EYE - GLAUCOMACarbonic Anhydrase InhibitorsT1 acetazolamideT1 acetazolamideT1 methazolamideACETAZOLAMIDEDIAMOX SEQUELSNEPTAZANEMiotics/other Intraoc. Pressure ReducersT3 apraclonidine hcl IOPIDINE(DROPERETTE)T1 apraclonidine hcl IOPIDINE(DROPS)T1 betaxolol hcl BETAXOLOL HCLT2 betaxolol hcl BETOPTIC ST2 bimatoprost LUMIGAN QLT2 brimonidine tartrate ALPHAGANP(DROPS)(0.1 %)T1 brimonidine tartrate ALPHAGANP(DROPS)(0.15 %)T1 brimonidine tartrate BRIMONIDINETARTRATET3 brimonidineCOMBIGANtartrate/timololT2 brinzolamide AZOPTT2 carbacholISOPTO CARBACHOLT1 carteolol hcl CARTEOLOL HCLT3 demecarium bromide HUMORSOLT1 dorzolamide hcl TRUSOPTT1 dorzolamide COSOPThcl/timolol maleatT3 echothiophate iodide PHOSPHOLINEIODIDET1 latanoprost XALATANT1 levobunolol hcl BETAGANT1 metipranolol OPTIPRANOLOLT1 pilocarpine hcl ISOPTOCARPINE(DROPS)(1%)T1 pilocarpine hcl ISOPTOCARPINE(DROPS)(2%)T1 pilocarpine hcl ISOPTOCARPINE(DROPS)(4%)Page 33 of 91