L.A. Care Covered Drug Formulary (pdf)

Preferred Drug List Medication Prescribing Limitations• CESAMET• CLARINEX(SYRUP)• CLARINEX(TAB RDP DIS)• CLARINEX(TAB)• CLARINEX-D 12 HOUR• CLARINEX-D 24 HOUR• CONZIP• CRESTOR(TAB)(10 MG)• CRESTOR(TAB)(20 MG)• CRESTOR(TAB)(40 MG)• CRESTOR(TAB)(5 MG)• CYCLOSET• DALIRESP• DELZICOL• DETROL• DETROL LA• DEXILANT• DIFICID• DIOVAN• DIPENTUM• DOVONEX• DRITHOCREME HP• DUETACT• DUEXIS• DYMISTA• EDARBI• EDARBYCLOR• EDLUAR• ELIDEL• ENABLEXMobic in 120 days or Motrin in 120 days or Nalfon in 120 days or Naprelan in 120days or Naproxen Sodium in 120 days or Naproxen in 120 days or Oxaprozin in 120days or Phenylbutazone in 120 days or Piroxicam in 120 days or Ponstel in 120 daysor Relafen in 120 days or Sulindac in 120 days or Tolmetin Sodium in 120 days orToradol in 120 days or Voltaren in 120 days or Voltaren-xr in 120 days or Wal-profenin 120 days or Wal-proxen in 120 days or Zipsor in 120 daysPrior prescription for Ondansetron Hcl in 120 days or Zofran Odt in 120 days orZofran in 120 daysPrior prescription for Wal-itin D 12 Hour in 180 days or Wal-vert in 180 days orXyzal in 180 days or Zyrtec in 180 days or Zyrtec-d in 180 daysPrior prescription for Wal-itin D 12 Hour in 180 days or Wal-vert in 180 days orXyzal in 180 days or Zyrtec in 180 days or Zyrtec-d in 180 daysPrior prescription for Wal-itin D 12 Hour in 180 days or Wal-vert in 180 days orXyzal in 180 days or Zyrtec in 180 days or Zyrtec-d in 180 daysPrior prescription for Wal-itin D 12 Hour in 180 days or Wal-vert in 180 days orXyzal in 180 days or Zyrtec in 180 days or Zyrtec-d in 180 daysPrior prescription for Wal-itin D 12 Hour in 180 days or Wal-vert in 180 days orXyzal in 180 days or Zyrtec in 180 days or Zyrtec-d in 180 daysPrior prescription for Conzip in 120 days or Tramadol Hcl in 120 days or Ultram Erin 120 daysPrior prescription for Crestor in 120 days or Lipitor in 120 daysPrior prescription for Crestor in 120 days or Lipitor in 120 daysPrior prescription for Crestor in 120 days or Lipitor 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 daysPrior prescription for Glyburide-metformin Hcl in 180 days or Metaglip in 180 daysor Riomet in 180 daysPrior prescription for Arcapta Neohaler in 120 days or Atrovent Hfa in 120 days orCombivent in 120 days or Foradil in 120 days or Serevent Diskus in 120 days orSpiriva in 120 daysPrior prescription for Apriso in 120 days or Colazal in 120 daysPrior prescription for Oxybutynin Chloride Er in 120 days or Oxybutynin Chloride in120 daysPrior prescription for Oxybutynin Chloride Er in 120 days or Oxybutynin Chloride in120 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 Vancomycin HCl in 120 daysPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 daysPrior prescription for Apriso in 120 days or Colazal in 120 daysPrior prescription for Topical Anti-inflammatory Steroidal in 120 daysPrior prescription for Topical Anti-inflammatory Steroidal 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 Etodolac in 120 days or Flurbiprofen in 120 days orIndomethacin in 120 days or Ketoprofen in 120 days or Meclofenamate Sodium in120 days or Mobic in 120 days or Nalfon in 120 days or Oxaprozin in 120 days orPiroxicam in 120 days or Relafen in 120 days or Sulindac in 120 days or TolmetinSodium in 120 days or Toradol in 120 days or Voltaren-xr in 120 days or Wal-profenin 120 days or Wal-proxen in 120 daysPrior prescription for Flunisolide in 365 days or Fluticasone Propionate in 365 daysor Nasarel in 365 daysPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 daysPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 daysPrior prescription for Zolpidem Tartrate in 180 daysPrior prescription for Topical Anti-inflammatory Steroidal in 120 daysPrior prescription for Oxybutynin Chloride Er in 120 days or Oxybutynin Chloride in120 daysPage 66 of 91