L.A. Care Covered Drug Formulary (pdf)

• ABILIFY DISCMELT(TAB RDP DIS)(10MG)• ABILIFY DISCMELT(TAB RDP DIS)(15MG)• ABILIFY(SOLUTION)• ABILIFY(TAB)• ACIPHEX• ACTONEL WITH CALCIUM• ACTONEL(TAB)(150 MG)• ACTONEL(TAB)(30 MG)• ACTONEL(TAB)(35 MG)• ACTONEL(TAB)(5 MG)• ACTONEL(TAB)(75 MG)• ACTOPLUS MET• ACTOPLUS MET XR• ADCIRCA• ADOXA PAK• ADVAIR DISKUS• ADVAIR HFA• ADVICOR(TBMP 24HR)(1000-20MG)• ADVICOR(TBMP 24HR)(1000-40 MG)STEP THERAPY EDITSAt least 2 of Prior prescription for Abilify in 365 days or Citalopram Hbr in 365 daysor Paxil Cr in 365 days or Risperidone Odt in 365 days or Risperidone in 365 days orSelfemra in 365 days or Seroquel in 365 days or Venlafaxine Hcl Er in 365 days orZiprasidone Hcl in 365 days or Zoloft in 365 days or Zyprexa in 365 daysAt least 2 of Prior prescription for Abilify in 365 days or Citalopram Hbr in 365 daysor Paxil Cr in 365 days or Risperidone Odt in 365 days or Risperidone in 365 days orSelfemra in 365 days or Seroquel in 365 days or Venlafaxine Hcl Er in 365 days orZiprasidone Hcl in 365 days or Zoloft in 365 days or Zyprexa in 365 daysAt least 2 of Prior prescription for Abilify in 365 days or Citalopram Hbr in 365 daysor Paxil Cr in 365 days or Risperidone Odt in 365 days or Risperidone in 365 days orSelfemra in 365 days or Seroquel in 365 days or Venlafaxine Hcl Er in 365 days orZiprasidone Hcl in 365 days or Zoloft in 365 days or Zyprexa in 365 daysAt least 2 of Prior prescription for Abilify in 365 days or Citalopram Hbr in 365 daysor Paxil Cr in 365 days or Risperidone Odt in 365 days or Risperidone in 365 days orSelfemra in 365 days or Seroquel in 365 days or Venlafaxine Hcl Er in 365 days orZiprasidone Hcl in 365 days or Zoloft in 365 days or Zyprexa in 365 daysPrior prescription for Omeprazole in 120 days or Prevacid 24hr in 120 days orPrevacid in 120 days or Prilosec Otc in 120 days or Prilosec in 120 days or Protonixin 120 days or Zantac-ppi in 120 daysPrior prescription for Fosamax in 120 days or Ibandronate Sodium in 120 daysAt least 2 of Prior prescription for Actonel in 365 days or Fosamax in 365 days orIbandronate Sodium in 365 daysAt least 2 of Prior prescription for Actonel in 365 days or Fosamax in 365 days orIbandronate Sodium in 365 daysAt least 2 of Prior prescription for Actonel in 365 days or Fosamax in 365 days orIbandronate Sodium in 365 daysAt least 2 of Prior prescription for Actonel in 365 days or Fosamax in 365 days orIbandronate Sodium in 365 daysPrior prescription for Ibandronate Sodium in 120 daysPrior prescription for Avandamet in 120 days or Avandaryl in 120 days or Avandia in120 days or Chlorpropamide in 120 days or Glimepiride in 120 days or Glucotrol Xlin 120 days or Glyburide-metformin Hcl in 120 days or Metaglip in 120 days orMicronase in 120 days or Riomet in 120 days or Tolazamide in 120 days orTolbutamide in 120 daysPrior prescription for Avandamet in 120 days or Avandaryl in 120 days or Avandia in120 days or Chlorpropamide in 120 days or Glimepiride in 120 days or Glucotrol Xlin 120 days or Glyburide-metformin Hcl in 120 days or Metaglip in 120 days orMicronase in 120 days or Riomet in 120 days or Tolazamide in 120 days orTolbutamide in 120 daysPrior prescription for Revatio in 120 days or Sildenafil in 120 daysPrior prescription for Vibramycin in 120 daysPrior prescription for Advair Diskus in 120 days or Dulera in 120 daysPrior prescription for Advair Hfa in 120 days or Dulera in 120 daysAt least 2 of Prior prescription for Lipitor in 365 days or Mevacor in 365 days orPravastatin Sodium in 365 days or Zocor in 365 daysAt least 2 of Prior prescription for Lipitor in 365 days or Mevacor in 365 days orPravastatin Sodium in 365 days or Zocor in 365 days• ADVICOR(TBMP 24HR)(500MG-20MG) At least 2 of Prior prescription for Lipitor in 365 days or Mevacor in 365 days orPravastatin Sodium in 365 days or Zocor in 365 days• ADVICOR(TBMP 24HR)(750MG-20MG) At least 2 of Prior prescription for Lipitor in 365 days or Mevacor in 365 days orPravastatin Sodium in 365 days or Zocor in 365 days• ALTOPREV• AMETHYST• ANZEMET(TAB)(100 MG)• ANZEMET(TAB)(50 MG)• APLENZIN• ARCAPTA NEOHALER• ASACOL HDPreferred Drug List Medication Prescribing LimitationsAt least 2 of Prior prescription for Altoprev in 365 days or Lipitor in 365 days orMevacor in 365 days or Pravastatin Sodium in 365 days or Zocor in 365 daysPrior prescription for Norgestimate-ethinyl Estradiol in 120 daysPrior prescription for Anzemet in 120 days or Ondansetron Hcl in 120 days or ZofranOdt in 120 days or Zofran in 120 daysPrior prescription for Anzemet in 120 days or Ondansetron Hcl in 120 days or ZofranOdt in 120 days or Zofran in 120 daysPrior prescription for Zyban in 120 daysPrior prescription for Serevent in 120 daysPrior prescription for Apriso in 120 days or Colazal in 120 daysPage 64 of 91