L.A. Care Covered Drug Formulary (pdf)

Preferred Drug List Medication Prescribing Limitations• TWYNSTA• UCERIS• VECTICAL• VERAMYST• VESICARE• VICTOZA 2-PAK• VICTOZA 3-PAK• VIIBRYD(TAB DS PK)• VIIBRYD(TAB)• VIMOVO• VIMPAT(TAB)• VYTORIN(TAB)(10 MG-10MG)• VYTORIN(TAB)(10 MG-20MG)• VYTORIN(TAB)(10 MG-40MG)• VYVANSE• XIFAXAN(TAB)(550 MG)• XYZAL(SOLUTION)• ZEGERID(CAP)• ZEGERID(PACKET)• ZETONNA• ZIOPTAN• ZITHRANOL• ZITHRANOL-RR• ZOLPIMIST• ZOMIG(SPRAY)• ZOMIG(TAB)• ZUPLENZ(FILM)(4 MG)• ZUPLENZ(FILM)(8 MG)Prior prescription for Captopril-hydrochlorothiazide in 120 days or LosartanPotassium in 120 daysPrior prescription for Colazal in 120 daysPrior prescription for Topical Anti-inflammatory Steroidal in 120 daysPrior prescription for Flunisolide in 365 days or Fluticasone Propionate in 365 daysor Nasarel in 365 daysPrior prescription for Oxybutynin Chloride Er in 120 days or Oxybutynin Chloride in120 daysAt least 2 of Prior prescription for Bydureon in 365 days or Tolbutamide in 365 daysAt least 2 of Prior prescription for Bydureon in 365 days or Tolbutamide in 365 daysPrior 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 daysPrior 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 daysPrior prescription for Naproxen in 120 days or Wal-proxen in 120 daysAt 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 or Vimpat in 365 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 Lipitor in 120 days or Vytorin in 120 daysPrior prescription for Lipitor in 120 days or Vytorin in 120 daysPrior prescription for Amphetamine Salt Combo in 120 days or Ritalin in 120 daysPrior prescription for Lactulose 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 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 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 Flunisolide in 365 days or Fluticasone Propionate in 365 daysor Nasarel in 365 daysAt least 2 of Prior prescription for Travatan Z in 365 days or Xalatan in 365 daysPrior prescription for Topical Anti-inflammatory Steroidal in 120 daysPrior prescription for Topical Anti-inflammatory Steroidal in 120 daysPrior prescription for Zolpidem Tartrate in 120 daysPrior prescription for Rizatriptan in 180 days or Sumatriptan Succinate in 180 daysPrior prescription for Rizatriptan in 180 days or Sumatriptan Succinate in 180 daysPrior prescription for Ondansetron Hcl in 120 days or Zofran Odt in 120 days orZofran in 120 days or Zuplenz in 120 daysPrior prescription for Ondansetron Hcl in 120 days or Zofran Odt in 120 days orZofran in 120 days or Zuplenz in 120 daysPage 71 of 91