L.A. Care Covered Drug Formulary (pdf)

Preferred Drug List Medication Prescribing Limitations• NEUPRO Prior prescription for Neupro in 120 days or Pramipexole Dihydrochloride in 120days or Ropinirole Hcl in 120 days• NEXIUMPrior 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 days• NUVARINGPrior prescription for Norgestimate-ethinyl Estradiol in 120 days• OLEPTRO ERPrior prescription for Oleptro Er in 120 days or Trazodone Hcl in 120 days• OMNARISPrior prescription for Flunisolide in 365 days or Fluticasone Propionate in 365 daysor Nasarel in 365 days• ONFIPrior prescription for Lamotrigine in 120 days or Trokendi Xr in 120 days• ONGLYZAPrior prescription for Januvia in 120 days or Jentadueto in 120 days• ORACEAPrior prescription for Vibramycin in 120 days• ORTHO EVRAPrior prescription for Norgestimate-ethinyl Estradiol in 120 days• ORTHO TRI-CYCLEN LOPrior prescription for Norgestimate-ethinyl Estradiol in 120 days• OSENIPrior prescription for Janumet Xr in 120 days or Jentadueto in 120 days or Juvisyncin 120 days or Tradjenta in 120 days• OVCON-50Prior prescription for Norgestimate-ethinyl Estradiol in 120 days• OXTELLAR XR(TAB ER 24H)(150 MG) At least 2 of Prior prescription for Divalproex Sodium Er in 365 days or Lamotriginein 365 days or Levetiracetam in 365 days or Neurontin in 365 days or Oxtellar Xr in365 days or Tegretol Xr in 365 days or Trileptal in 365 days or Trokendi Xr in 365days or Valproic Acid in 365 days or Zonisamide in 365 days• OXTELLAR XR(TAB ER 24H)(300 MG) At least 2 of Prior prescription for Divalproex Sodium Er in 365 days or Lamotriginein 365 days or Levetiracetam in 365 days or Neurontin in 365 days or Oxtellar Xr in365 days or Tegretol Xr in 365 days or Trileptal in 365 days or Trokendi Xr in 365days or Valproic Acid in 365 days or Zonisamide in 365 days• OXTELLAR XR(TAB ER 24H)(600 MG) At least 2 of Prior prescription for Divalproex Sodium Er in 365 days or Lamotriginein 365 days or Levetiracetam in 365 days or Neurontin in 365 days or Oxtellar Xr in365 days or Tegretol Xr in 365 days or Trileptal in 365 days or Trokendi Xr in 365days or Valproic Acid in 365 days or Zonisamide in 365 days• OXYTROLPrior prescription for Oxybutynin Chloride Er in 120 days or Oxybutynin Chloride in120 days• PATANASEPrior prescription for Astepro in 180 days or Azelastine Hcl 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• PENTASA Prior prescription for Apriso in 120 days or Colazal in 120 days or Pentasa in 120days• PEXEVAPrior prescription for Paxil in 120 days• POTIGA(TAB)(200 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• POTIGA(TAB)(300 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• POTIGA(TAB)(400 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• POTIGA(TAB)(50 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• PRISTIQ ERPrior prescription for Citalopram Hbr in 120 days or Lexapro in 120 days or Paxil Crin 120 days or Prozac in 120 days or Remeron in 120 days or Sarafem in 120 days orSelfemra in 120 days or Zoloft in 120 days or Zyban in 120 days• PROTONIX(GRANPKT DR) Prior prescription for Omeprazole Magnesium in 120 days or Omeprazole in 120days or Prilosec Otc in 120 days or Prilosec in 120 days or Protonix in 120 days orZantac-ppi in 120 days• PROTOPICPrior prescription for Protopic in 120 days or Topical Anti-inflammatory Steroidal in120 days• PSORIATECPrior prescription for Topical Anti-inflammatory Steroidal in 120 days• QNASLPrior prescription for Flunisolide in 365 days or Fluticasone Propionate in 365 daysor Nasarel in 365 days• QUILLIVANT XRPrior prescription for Methylphenidate Hcl Cd in 120 days or Ritalin La in 120 daysPage 69 of 91