L.A. Care Covered Drug Formulary (pdf)

Commercial FormularyT1 pentazocinehcl/naloxone hclT3 pentazocine lactateT1 propoxyphene hclT1 propoxyphenehcl/acetaminophenTALWIN NXT1 propoxypheneQLnap/acetaminophenT1 propoxyphene DARVOCET A500 QLnap/acetaminophenT1 propoxyphene DARVOCET-N 100 QLnap/acetaminophenT1 propoxyphene DARVOCET-N 50 QLnap/acetaminophenT3 propoxyphene DARVON-NnapsylateT2 tapentadol hcl NUCYNTA QLT2 tapentadol hcl NUCYNTA ER QLT3 tramadol hcl CONZIP QL, STT3 tramadol hclT3 tramadol hclT1 tramadol hclT1 tramadol hclT1 tramadol hclT1 tramadolhcl/acetaminophenAntimigraine PreparationsRYBIX ODTRYZOLTTRAMADOL QL, STHCL(CPMP 25-75)TRAMADOL HCL(TABER 24H)ULTRAMULTRACETT1 sumatriptansuccinateT2 sumatriptansuccinateT1 sumatriptansuccinateT1 sumatriptansuccinateT1 sumatriptansuccinateT1 sumatriptansuccinateT2 sumatriptansuccinateT1 sumatriptansuccinateIMITREX(CARTRIDG QLE)IMITREX(PEN QLINJCTR)(4 MG/0.5ML)IMITREX(PEN QLINJCTR)(6 MG/0.5ML)IMITREX(TAB) QLIMITREX(VIAL)SUMATRIPTANSUCCINATE(CARTRIDGE)SUMATRIPTANSUCCINATE(DISPSYRINGE)(4MG/0.5ML)SUMATRIPTANSUCCINATE(DISPSYRINGE)(6MG/0.5ML)QLQLQLQLT3 sumatriptan succinate SUMAVEL DOSEPRO QL, STT2 zolmitriptan ZOMIG(SPRAY) QL, STT2 zolmitriptan ZOMIG(TAB) QL, STNarc.& Non-sal.analgesic,barbiturate&xanthine CmbT1 butalbit/acetamin/caffFIORICET WITH/codeineCODEINENarcotic & Salicylate Analgesics, Barb.&XanthineT1 codeine/butalbital/asa/caffeinFIORINAL WITHCODEINE #3Narcotic Analgesic & Non-salicylateAnalgesic CombT1 acetaminophen withcodeineT2 acetaminophen withcodeineT1 acetaminophen withcodeineT1 acetaminophen withcodeineT1 codeinephos/acetaminophenTALWINDARVONPROPOXYPHENEHCL-ACETAMINOPHENBALACET 325T3 almotriptan malate AXERT QL, STT3 diclofenac potassium CAMBIA QLT1 dihydroergotamine D.H.E.45QLmesylateT3 dihydroergotamine MIGRANALQLmesylateT3 eletriptan hbr RELPAX QL, STT3 ergotamine tartrate ERGOMAR QLT2 ergotamineCAFERGOT QLtartrate/caffeineT1 ergotamine MIGERGOT QLtartrate/caffeineT3 frovatriptan succinate FROVA QL, STT1 isomethept/dichlphn/ ISOMETHEPTacetaminopDICHLORALP-ACETAMINT1 isometheptene MIGRALmucateT3 isometheptene/acetam MIGRALAMinoph/caffT3 isometheptene/acetam MIGRATENinoph/caffT1 isometheptene/aceta PRODRINminoph/caffT1 naratriptan hcl AMERGE QLT1 rizatriptan benzoate MAXALT QLT1 rizatriptan benzoate MAXALT MLT QLT1 sumatriptan IMITREX QLT3 sumatriptanTREXIMETQL, STsucc/naproxen sodT3 sumatriptan succinate ALSUMAQLACETAMINOPHEN-CODEINECAPITAL W-CODEINETYLENOL-CODEINENO.3TYLENOL-CODEINENO.4ACETAMINOPHENW/CODEINENarcotic Withdrawal Therapy AgentsT3 buprenorphine hcl BUPRENEXT1 buprenorphine hcl BUPRENORPHINEHCLT1 buprenorphine hcl SUBUTEX PAT2 buprenorphine SUBOXONE(FILM)hcl/naloxone hclT1 buprenorphinehcl/naloxone hclSUBOXONE(TABSUBL)PAPage 49 of 91