L.A. Care Covered Drug Formulary (pdf)

Preferred Drug List Medication Prescribing Limitations• EXFORGEPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 days• EXFORGE HCTPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 days• EXTAVIAAt least 2 of Prior prescription for Copaxone in 365 days or Rebif in 365 days• FANAPT(TAB DS PK) At least 2 of Prior prescription for Risperidone Odt in 365 days or Risperidone in 365days or Seroquel in 365 days or Ziprasidone Hcl in 365 days or Zyprexa in 365 days• FANAPT(TAB) At least 2 of Prior prescription for Risperidone Odt in 365 days or Risperidone in 365days or Seroquel in 365 days or Ziprasidone Hcl in 365 days or Zyprexa in 365 days• FAZACLO At least 2 of Prior prescription for Fazaclo in 365 days or Risperidone Odt in 365days or Risperidone in 365 days or Seroquel in 365 days or Ziprasidone Hcl in 365days or Zyprexa in 365 days• FELBATOL(ORAL SUSP)Prior prescription for Lamotrigine in 120 days or Trokendi Xr in 120 days• FELBATOL(TAB)(400 MG)Prior prescription for Lamotrigine in 120 days or Trokendi Xr in 120 days• FELBATOL(TAB)(600 MG)Prior prescription for Lamotrigine in 120 days or Trokendi Xr in 120 days• FENOGLIDEPrior prescription for Lofibra in 120 days or Lopid in 120 days or Tricor in 120 days• FORADILPrior prescription for Serevent in 120 days• FORFIVO XLPrior prescription for Wellbutrin Sr in 120 days or Wellbutrin Xl in 120 days orWellbutrin in 120 days or Zyban in 120 days• FROVAPrior prescription for Rizatriptan in 180 days or Sumatriptan Succinate in 180 days• FULYZAQPrior prescription for Antiretrovirals in 120 days• GABITRIL(TAB)(12 MG)At least 2 of Prior prescription for in 365 days or Divalproex Sodium Er in 365 daysor Lamotrigine in 365 days or Levetiracetam in 365 days or Neurontin in 365 days orTegretol Xr in 365 days or Trileptal in 365 days or Trokendi Xr in 365 days orValproic Acid in 365 days• GABITRIL(TAB)(16 MG)At least 2 of Prior prescription for in 365 days or Divalproex Sodium Er in 365 daysor Lamotrigine in 365 days or Levetiracetam in 365 days or Neurontin in 365 days orTegretol Xr in 365 days or Trileptal in 365 days or Trokendi Xr in 365 days orValproic Acid in 365 days• GABITRIL(TAB)(2 MG)At least 2 of Prior prescription for in 365 days or Divalproex Sodium Er in 365 daysor Lamotrigine in 365 days or Levetiracetam in 365 days or Neurontin in 365 days orTegretol Xr in 365 days or Trileptal in 365 days or Trokendi Xr in 365 days orValproic Acid in 365 days• GABITRIL(TAB)(4 MG)At least 2 of Prior prescription for in 365 days or Divalproex Sodium Er in 365 daysor Lamotrigine in 365 days or Levetiracetam in 365 days or Neurontin in 365 days orTegretol Xr in 365 days or Trileptal in 365 days or Trokendi Xr in 365 days orValproic Acid in 365 days• GELNIQUEPrior prescription for Oxybutynin Chloride Er in 120 days or Oxybutynin Chloride in120 days• GIANVIPrior prescription for Generess Fe in 365 days and Lo Loestrin Fe in 365 days andLoestrin 24 Fe in 365 days and Lybrel in 365 days and Microgestin in 365 days andNecon in 365 days and Ortho-novum in 365 days and Pirmella in 365 days andSeasonique in 365 days and Sronyx in 365 days and Trivora-28 in 365 days andVelivet in 365 days and Wera in 365 days and Zovia 1-50e in 365 days• GIAZOPrior prescription for Apriso in 120 days or Colazal in 120 days• GLUMETZAPrior prescription for Glumetza in 120 days or Metformin Hcl Er in 120 days• GRALISE(TAB ER 24H)(300 MG) Prior prescription for in 120 days or Gralise in 120 days or Neurontin in 120 days• GRALISE(TAB ER 24H)(300-600 MG) Prior prescription for in 120 days or Gralise in 120 days or Neurontin in 120 days• GRALISE(TAB ER 24H)(600 MG) Prior prescription for in 120 days or Gralise in 120 days or Neurontin in 120 days• HORIZANT Prior prescription for Neurontin in 120 days or Pramipexole Dihydrochloride in 120days or Ropinirole Hcl in 120 days• INTERMEZZOPrior prescription for Intermezzo in 120 days or Zolpidem Tartrate in 120 days• INVEGA(TAB ER 24H)(1.5 MG) At least 2 of Prior prescription for Risperidone Odt in 365 days or Risperidone in 365days or Seroquel in 365 days or Ziprasidone Hcl in 365 days or Zyprexa in 365 days• INVEGA(TAB ER 24H)(3 MG) At least 2 of Prior prescription for Risperidone Odt in 365 days or Risperidone in 365days or Seroquel in 365 days or Ziprasidone Hcl in 365 days or Zyprexa in 365 days• INVEGA(TAB ER 24H)(6 MG) At least 2 of Prior prescription for Risperidone Odt in 365 days or Risperidone in 365days or Seroquel in 365 days or Ziprasidone Hcl in 365 days or Zyprexa in 365 days• INVEGA(TAB ER 24H)(9 MG) At least 2 of Prior prescription for Risperidone Odt in 365 days or Risperidone in 365days or Seroquel in 365 days or Ziprasidone Hcl in 365 days or Zyprexa in 365 days• JALYNPrior prescription for in 120 days or Doxazosin Mesylate in 120 days or Prazosin Hclin 120 days or Proscar in 120 days or Rapaflo in 120 days or Tamsulosin Hcl in 120days or Terazosin Hcl in 120 days or Uroxatral in 120 daysPage 67 of 91