L.A. Care Covered Drug Formulary (pdf)

Commercial FormularyT3 ceftibuten dihydrateCEDAXChemotherapeutics, Antibacterial, Misc.T3 fosfomycinMONUROLtromethamineT3 methen/m-blue/sal/na URELLEphos/hyosT1 methen/m-blue/sal/naUTAphos/hyosT1 methen/sod URYLphos/meth blue/hyosT1 methenam/me HYOPHENblue/ba/salicy/hyoT2 methenam/me PROSED-DSblue/ba/salicy/hyoT3 methenamine UREXhippurateT1 methenamine METHENAMINEmandelateMANDELATET2 mth/me blue/sod PHOSPHASALphos/phen/hyosT1 mth/me blue/sod UR N-Cphos/phen/hyosT2 mth/me blue/sod URETRON D-Sphos/phen/hyosT3 mth/me blue/sod URIBELphos/phen/hyosT2 mth/me blue/sod URIN D.S.phos/phen/hyosT2 trimethoprim PRIMSOLT1 trimethoprim TRIMETHOPRIMKetolidesT2 telithromycinMacrolidesT1 azithromycinT1 azithromycinT2 azithromycinT2 azithromycinT1 clarithromycinT1 ery e-succ/sulfisoxazoleT2 erythromycin baseT1 erythromycin baseT2 erythromycin baseT2 erythromycinethylsuccinateT2 erythromycinethylsuccinateT2 erythromycinethylsuccinateT2 erythromycinethylsuccinateT1 erythromycinethylsuccinateKETEKZITHROMAXZITHROMAX TRI-PAKZMAXZMAX PEDIATRICBIAXINERYTHROMYCIN-SULFISOXAZOLEERY-TABERYTHROMYCINPCEE.E.S. 200ERYPED 200ERYPED 400ERYTHROMYCINETHYLSUCCINATE(SUSP RECON)ERYTHROMYCINETHYLSUCCINATE(TAB)T1 erythromycinstearateERYTHROCINSTEARATET2 fidaxomicin DIFICID QL, STNitrofuran DerivativesT2 furazolidoneT1 nitrofurantoinT1 nitrofurantoinmacrocrystalT2 nitrofurantoinmacrocrystalT1 nitrofurantoinmacrocrystalT2 nitrofurantoinmonohyd/m-crystOxazolidinonesFUROXONEFURADANTINMACRODANTIN(CAP)(100 MG)MACRODANTIN(CAP)(25 MG)MACRODANTIN(CAP)(50 MG)MACROBIDT2 linezolid ZYVOX PAPenicillinsT1 amoxicillinAMOXICILLINT1 amoxicillinAMOXILT3 amoxicillinMOXATAGT1 amoxicillin trihydrate AMOXICILLINT1 amoxicillin/potassiu AMOX TRmclavPOTASSIUMCLAVULANATET1 amoxicillin/potassiu AUGMENTIN ES-600m clavT2 amoxicillin/potassium AUGMENTIN(SUSPclavRECON)(125-31.25/)T1 amoxicillin/potassiu AUGMENTIN(SUSPm clavRECON)(250-62.5/5)T1 amoxicillin/potassiu AUGMENTIN(SUSPm clavRECON)(400-57MG/5)T2 amoxicillin/potassium AUGMENTIN(TABclavCHEW)T1 amoxicillin/potassiu AUGMENTIN(TAB)m clavT1 ampicillin trihydrateAMPICILLINTRIHYDRATET1 dicloxacillin sodium DICLOXACILLINT3 oxacillin sodiumT1 penicillin vpotassiumQuinolonesSODIUMBACTOCILLPENICILLIN VPOTASSIUMT2 ciprofloxacin CIPROT1 ciprofloxacin hcl CIPROT1 ciprofloxacin hcl CIPROFLOXACINHCLT3 ciprofloxacin hcl PROQUIN XRT1 ciprofloxacin/ciproflo CIPRO XRxa hclT3 gemifloxacin mesylate FACTIVET1 levofloxacin LEVAQUINT1 levofloxacin LEVOFLOXACINT3 lomefloxacin hcl MAXAQUINT2 moxifloxacin hcl AVELOXT2 moxifloxacin hcl AVELOX ABC PACKT1 nalidixic acid NALIDIXIC ACIDT3 nalidixic acid NEGGRAMT3 norfloxacinNOROXINT1 ofloxacinOFLOXACINPage 38 of 91