L.A. Care Covered Drug Formulary (pdf)

• KAPIDEX• KAZANO• KOMBIGLYZE XR• KYTRILPrior 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 Janumet Xr in 120 days or Jentadueto in 120 days or Juvisyncin 120 days or Tradjenta in 120 daysPrior prescription for Januvia in 120 days or Jentadueto in 120 daysPrior prescription for Ondansetron Hcl in 120 days or Zofran Odt in 120 days orZofran in 120 daysPrior prescription for Lamictal Odt in 120 days or Lamotrigine in 120 daysPrior prescription for Lamictal Odt in 120 days or Lamotrigine in 120 daysPrior prescription for Lamictal Odt in 120 days or Lamotrigine in 120 days• LAMICTAL ODT (BLUE)• LAMICTAL ODT (GREEN)• LAMICTAL ODT (ORANGE)• LAMICTAL ODT(TAB RDP DIS)(100MG)Prior prescription for Lamictal Odt in 120 days or Lamotrigine in 120 days• LAMICTAL ODT(TAB RDP DIS)(200MG)Prior prescription for Lamictal Odt in 120 days or Lamotrigine in 120 days• LAMICTAL ODT(TAB RDP DIS)(25 MG) Prior prescription for Lamictal Odt in 120 days or Lamotrigine in 120 days• LAMICTAL ODT(TAB RDP DIS)(50 MG) Prior prescription for Lamictal Odt in 120 days or Lamotrigine in 120 days• LAMICTAL XR (BLUE)Prior prescription for Lamotrigine in 120 days• LAMICTAL XR (GREEN)Prior prescription for Lamotrigine in 120 days• LAMICTAL XR (ORANGE)Prior prescription for Lamotrigine in 120 days• LAMICTAL XR(TAB ER 24H)(100 MG) Prior prescription for Lamotrigine in 120 days• LAMICTAL XR(TAB ER 24H)(200 MG) Prior prescription for Lamotrigine in 120 days• LAMICTAL XR(TAB ER 24H)(25 MG) Prior prescription for Lamotrigine in 120 days• LAMICTAL XR(TAB ER 24H)(250 MG) Prior prescription for Lamotrigine in 120 days• LAMICTAL XR(TAB ER 24H)(300 MG) Prior prescription for Lamotrigine in 120 days• LAMICTAL XR(TAB ER 24H)(50 MG) Prior prescription for Lamotrigine in 120 days• LATUDA 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• LESCOLAt least 2 of Prior prescription for Lescol in 365 days or Lipitor in 365 days orMevacor in 365 days or Pravastatin Sodium in 365 days or Zocor in 365 days• LESCOL XLAt 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• LEVEMIRPrior prescription for Lantus Solostar in 120 days• LEVEMIR FLEXPENPrior prescription for Lantus Solostar in 120 days• LIALDAPrior prescription for Apriso in 120 days or Colazal in 120 days• LIPOFENPrior prescription for Lofibra in 120 days or Lopid in 120 days or Tricor in 120 days• LIVALOAt least 2 of Prior prescription for Lipitor in 365 days or Livalo in 3650 days orMevacor in 365 days or Pravastatin Sodium in 365 days or Zocor in 365 days• LO LOESTRIN FEPrior prescription for Norgestimate-ethinyl Estradiol in 120 days• LOESTRIN 24 FEPrior prescription for Norgestimate-ethinyl Estradiol in 120 days• LUNESTAPrior prescription for Zolpidem Tartrate in 180 days• LUVOX CRPrior prescription for Citalopram Hbr in 120 days or Lexapro in 120 days or LuvoxCr in 120 days or Paxil Cr in 120 days or Prozac in 120 days or Remeron in 120 daysor Sarafem in 120 days or Selfemra in 120 days or Zoloft in 120 days or Zyban in120 days• LYBRELPrior prescription for Norgestimate-ethinyl Estradiol in 120 days• MARINOLAt least 3 of Prior prescription for Emend in 365 days or Marinol in 365 days orMethylprednisolone in 365 days or Zofran in 365 days• MICARDISPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 days• MICARDIS HCTPrior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 days• MIRAPEX ER Prior prescription for Mirapex Er in 120 days or Pramipexole Dihydrochloride in 120• MYRBETRIQ• NATAZIA• NESINAPreferred Drug List Medication Prescribing Limitationsdays or Ropinirole Hcl in 120 daysAt least 2 of Prior prescription for Enablex in 365 days or Gelnique in 365 days orOxybutynin Chloride in 365 days or Oxytrol in 365 days or Tolterodine Tartrate in365 days or Toviaz in 365 days or Trospium Chloride in 365 days or Vesicare in 365daysPrior prescription for Microgestin in 120 days or Ortho Micronor in 120 days orOrtho-novum in 120 days or Ovral-28 in 120 days or Seasonique in 120 days orSkyla in 120 days or Tri-legest Fe in 120 days or Trinessa in 120 days or Trivora-28in 120 days or Velivet in 120 days or Viorele in 120 days or Zarah in 120 days orZenchent in 120 days or Zeosa in 120 days or Zovia 1-50e in 120 daysPrior prescription for Janumet Xr in 120 days or Jentadueto in 120 days or Juvisyncin 120 days or Tradjenta in 120 daysPage 68 of 91