L.A. Care Covered Drug Formulary (pdf)

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Preferred <strong>Drug</strong> 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
Preferred <strong>Drug</strong> List Medication Prescribing LimitationsPage 72 of 91
Page 6:
Commercial FormularyT1 budesonide P
Page 19 and 20: Commercial FormularyT3 triamcinolon
Page 21: Commercial FormularyOxidizing Agent
Page 24: Commercial FormularyT2 blood glucos
Page 28 and 29: Commercial FormularyT2 insulinLANTU
Page 30 and 31: Commercial FormularyENDOCRINE DISOR
Page 32 and 33: Commercial FormularyEye Sulfonamide
Page 34 and 35: Commercial FormularyT4 antihemophil
Page 36 and 37: Commercial FormularyT2 norethind ac
Page 38 and 39: Commercial FormularyTetracyclinesT1
Page 40 and 41: Commercial FormularyAntivirals, Hiv
Page 42 and 43: Commercial FormularyT1 etodolacT1 f
Page 44 and 45: Commercial FormularyT2 epinephrineE
Page 46 and 47: Commercial FormularyT2 butalbital/a
Page 48 and 49: Commercial FormularyT1 pentazocineh
Page 50 and 51: Commercial FormularyT1 levetiraceta
Page 52 and 53: Commercial FormularyUPPER GASTROINT
Page 54 and 55: Commercial FormularyGeriatric Vitam
Page 56 and 57: Commercial FormularyT1 fa/vitbcomp&
Page 58 and 59: Preferred Drug List Medication Pres
Page 64 and 65: • ASTELIN Prior prescription for
Page 74 and 75: Index- # -0.5 NORMAL SALINE........
Page 76 and 77: IndexBEXAROTENE....................
Page 78 and 79: IndexDEPO-PROVERA..................
Page 80 and 81: IndexFIRST-PROGESTERONE VGS 200....
Page 82 and 83: IndexIRON FUM&POLYSAC#1/FA/MV NO.18
Page 84 and 85: IndexMONOCLATE-P...................
Page 86 and 87: IndexPHENDIMETRAZINE TARTRATE......
Page 88 and 89: IndexSIMCOR(TBMP 24HR)(500MG-40MG).
Page 90: IndexVAGIFEM.......................
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L.A. Care Covered Drug Formulary (pdf)

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