L.A. Care Covered Drug Formulary (pdf)

Preferred Drug List Medication Prescribing Limitations• FELBATOL(TAB)(400 MG) 9 tab per 1 days• FELBATOL(TAB)(600 MG) 6 tab per 1 days• FEMRING1 unit per 84 days• FLONASE16 ml per 30 days• FLOVENT DISKUS(DISKW/DEV)(100 MCG)2 inhalations per 1 days• FLOVENT DISKUS(DISKW/DEV)(250 MCG)4 inhalations per 1 days• FLOVENT DISKUS(DISKW/DEV)(50 MCG)2 inhalations per 1 days• FLOVENT HFA(AERW/ADAP)(110MCG)12 gm per 30 days• FLOVENT HFA(AERW/ADAP)(220 MCG)24 gm per 30 days• FLOVENT HFA(AERW/ADAP)(44MCG)21.2 gm per 30 days• FLUNISOLIDE25 ml per 30 days• FOCALIN2 tab per 1 days• FOCALIN XR1 cap per 1 days• FORADIL 60 inhalations per 30days• FORFIVO XL1 tab per 1 days• FORTEO2.4 ml per 28 days• FOSAMAX(SOLUTION) 75 ml per 7 days• FROVA3 tab per 5 days• FULYZAQ2 tab per 1 days• GABITRIL(TAB)(12 MG) 4 tab per 1 days• GABITRIL(TAB)(16 MG) 3 tab per 1 days• GABITRIL(TAB)(2 MG) 4 tab per 1 days• GABITRIL(TAB)(4 MG) 4 tab per 1 days• GEODON2 cap per 1 days• GRALISE(TAB ER 24H)(300 MG) 3 tab per 1 days• GRALISE(TAB ER 24H)(300-600MG)39 tab per 15 days• GRALISE(TAB ER 24H)(600 MG) 3 tab per 1 days• HORIZANT2 tab per 1 days• HYCET184 ml per 1 days• HYDROCODONE-ACETAMINOPHEN(CAP) 8 cap per 1 days• HYDROCODONE-ACETAMINOPHEN(SOLUTION)(10-325/CUP)184 ml per 1 days• HYDROCODONE-ACETAMINOPHEN(SOLUTION)(2.5-167/5) 120 ml per 1 days• HYDROCODONE-ACETAMINOPHEN(SOLUTION)(5-163/7.5) 184 ml per 1 days• HYDROCODONE-ACETAMINOPHEN(SOLUTION)(5-334MG/10)120 ml per 1 days• HYDROCODONE-ACETAMINOPHEN(SOLUTION)(7.5-500/CP)120 ml per 1 days• HYDROCODONE-ACETAMINOPHEN(TAB)(10MG-300MG)13 tab per 1 days• HYDROCODONE-ACETAMINOPHEN(TAB)(2.5-500MG)8 tab per 1 days• HYDROCODONE-ACETAMINOPHEN(TAB)(5MG-300MG)13 tab per 1 days• HYDROCODONE-ACETAMINOPHEN(TAB)(7.5-300MG)• IMITREX• IMITREX(CARTRIDGE)• IMITREX(PEN INJCTR)(4MG/0.5ML)• IMITREX(PEN INJCTR)(6MG/0.5ML)• IMITREX(TAB)• IMITREX(VIAL)• INTERMEZZO• INTUNIV• INVEGA(TAB ER 24H)(1.5 MG)• INVEGA(TAB ER 24H)(3 MG)• INVEGA(TAB ER 24H)(6 MG)• INVEGA(TAB ER 24H)(9 MG)• IPRIVASK• KAPIDEX• KYTRIL• LAMICTAL ODT(TAB RDPDIS)(100 MG)• LAMICTAL ODT(TAB RDPDIS)(200 MG)• LAMICTAL ODT(TAB RDPDIS)(25 MG)• LAMICTAL ODT(TAB RDPDIS)(50 MG)• LAMICTAL XR(TAB ER 24H)(100MG)• LAMICTAL XR(TAB ER 24H)(200MG)• LAMICTAL XR(TAB ER 24H)(25MG)• LAMICTAL XR(TAB ER 24H)(250MG)• LAMICTAL XR(TAB ER 24H)(300MG)• LAMICTAL XR(TAB ER 24H)(50MG)• LATUDA• LESCOL• LESCOL XL• LEVITRA• LINZESS• LIVALO• LORCET 10-650• LORCET PLUS• LORTAB(SOLUTION)• LORTAB(TAB)• LOVAZA• LUMIGAN• LUNESTA• LUVOX CR• MAGNACET• MARINOL• MAXALT• MAXALT MLT• MAXIDONE13 tab per 1 days6 spray per 15 days1 ml per 14 days1 ml per 14 days1 ml per 14 days3 tab per 5 days1 ml per 14 days1 tab per 1 days1 tab per 1 days1 tab per 1 days1 tab per 1 days2 tab per 1 days1 tab per 1 days6 vials per fill1 cap per 1 days8 tab per 30 days3 tab per 1 days2 tab per 1 days6 tab per 1 days6 tab per 1 days3 tab per 1 days2 tab per 1 days6 tab per 1 days2 tab per 1 days2 tab per 1 days6 tab per 1 days1 tab per 1 days2 cap per 1 days1 tab per 1 days1 tab per 5 days1 cap per 1 days1 tab per 1 days6 tab per 1 days6 tab per 1 days120 ml per 1 days8 tab per 1 days4 cap per 1 days1 ml per 12 days1 tab per 1 days2 cap per 1 days10 tab per 1 days2 cap per 1 days3 tab per 5 days3 tab per 5 days5 tab per 1 days• MENOSTAR1 patch per 7 days• METHYLPHENIDATE ER(CPMP50-50)(20 MG) 1 cap per 1 days• METHYLPHENIDATE ER(CPMP50-50)(30 MG) 2 cap per 1 daysPage 60 of 91