L.A. Care Covered Drug Formulary (pdf)

• ASTELIN Prior prescription for Astepro in 180 days or Patanase in 180 days or Wal-itin D 12Hour in 180 days or Wal-vert in 180 days or Zyrtec in 180 days or Zyrtec-d in 180days• ASTEPROPrior prescription for Azelastine Hcl in 180 days or Patanase in 180 days or Wal-itinD 12 Hour in 180 days or Wal-vert in 180 days or Zyrtec in 180 days or Zyrtec-d in180 days• ATACANDPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 days• ATACAND HCTPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 days• ATELVIAAt least 2 of Prior prescription for Fosamax in 365 days or Ibandronate Sodium in365 days• AUVI-QPrior prescription for Auvi-q in 120 days or Twinject in 120 days• AVANDAMETAt least 2 of Prior prescription for Pioglitazone Hcl in 120 days or Tolbutamide in120 days• AVANDARYLAt least 2 of Prior prescription for Pioglitazone Hcl in 120 days or Tolbutamide in120 days• AVANDIAAt least 2 of Prior prescription for Pioglitazone Hcl in 120 days or Tolbutamide in120 days• AVODARTPrior prescription for Doxazosin Mesylate in 120 days or Prazosin Hcl in 120 days orProscar in 120 days or Rapaflo in 120 days or Tamsulosin Hcl in 120 days orTerazosin Hcl in 120 days or Uroxatral in 120 days• AVONEXAt least 2 of Prior prescription for Copaxone in 365 days or Rebif in 365 days• AVONEX ADMINISTRATION PACK At least 2 of Prior prescription for Copaxone in 365 days or Rebif in 365 days• AXERTPrior prescription for Rizatriptan in 180 days or Sumatriptan Succinate in 180 days• AZORPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 days• BANZEL(ORAL SUSP)Prior prescription for Divalproex Sodium Er in 120 days or Lamotrigine in 120 daysor Trokendi Xr in 120 days or Valproic Acid in 120 days• BANZEL(TAB)(200 MG)Prior prescription for Divalproex Sodium Er in 120 days or Lamotrigine in 120 daysor Trokendi Xr in 120 days or Valproic Acid in 120 days• BANZEL(TAB)(400 MG)Prior prescription for Divalproex Sodium Er in 120 days or Lamotrigine in 120 daysor Trokendi Xr in 120 days or Valproic Acid in 120 days• BECONASE AQPrior prescription for Flunisolide in 365 days or Fluticasone Propionate in 365 daysor Nasarel in 365 days• BENICARPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 days• BENICAR HCTPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 days• BETASERON• BEYAZ• BINOSTO• BONIVA(TAB)(2.5 MG)• BYETTA(PEN INJCTR)(10MCG/0.04)• BYETTA(PEN INJCTR)(5MCG/0.02)• CALCIPOTRIENE• CELEBREXPreferred Drug List Medication Prescribing LimitationsAt least 2 of Prior prescription for Copaxone in 365 days or Rebif in 365 daysPrior prescription for in 365 days and Lo Loestrin Fe in 365 days and Loestrin 24 Fein 365 days and Microgestin Fe in 365 days and Microgestin in 365 days and Neconin 365 days and Ortho Micronor in 365 days and Ovcon-50 in 365 days and Pirmellain 365 days and Seasonique in 365 days and Sronyx in 365 days and Tri-legest Fe in365 days and Trinessa in 365 days and Viorele in 365 days and Zeosa in 365 daysAt least 2 of Prior prescription for Fosamax in 365 days or Ibandronate Sodium in365 daysPrior prescription for Fosamax in 120 days or Ibandronate Sodium in 120 daysPrior prescription for Chlorpropamide in 120 days or Glimepiride in 120 days orGlucotrol Xl in 120 days or Glyburide-metformin Hcl in 120 days or Glynase in 120days or Metaglip in 120 days or Micronase in 120 days or Pioglitazone Hcl in 120days or Pioglitazone-glimepiride in 120 days or Pioglitazone-metformin in 120 daysor Riomet in 120 days or Tolazamide in 120 days or Tolbutamide in 120 daysPrior prescription for Chlorpropamide in 120 days or Glimepiride in 120 days orGlucotrol Xl in 120 days or Glyburide-metformin Hcl in 120 days or Glynase in 120days or Metaglip in 120 days or Micronase in 120 days or Pioglitazone Hcl in 120days or Pioglitazone-glimepiride in 120 days or Pioglitazone-metformin in 120 daysor Riomet in 120 days or Tolazamide in 120 days or Tolbutamide in 120 daysPrior prescription for Topical Anti-inflammatory Steroidal in 120 daysAt least 2 of Prior prescription for in 120 days or Actron in 120 days or DiclofenacSodium in 120 days or Diclofenac Sodium-misoprostol in 120 days or Etodolac in120 days or Fenoprofen Calcium in 120 days or Flurbiprofen in 120 days orIbuprofen in 120 days or Ibuprohm in 120 days or Indocin in 120 days orIndomethacin in 120 days or Infants' Motrin in 120 days or Ketoprofen in 120 daysor Ketorolac Tromethamine in 120 days or Meclofenamate Sodium in 120 days orPage 65 of 91