L.A. Care Covered Drug Formulary (pdf)

Preferred Drug List Medication Prescribing LimitationsPRIOR AUTHORIZATION RESRICTION• ABSTRAL• ACTIQ• ADCIRCA• AFINITOR• ALDARA• AMPYRA• AMTURNIDE• ANDRODERM(PATCH TD24)(2.5MG/24HR)• ANDRODERM(PATCH TD24)(4 MG/24 HR)• ANDRODERM(PATCH TD24)(5 MG/24 HR)• ANDROGEL• APOKYN• ARANESP• AUBAGIO• AXIRON• BERINERT• BOSULIF• CAPRELSA• CAYSTON• CIMZIA• COMETRIQ• DELATESTRYL• DEPO-TESTOSTERONE(VIAL)(100 MG/ML)• DEPO-TESTOSTERONE(VIAL)(200 MG/ML)• EGRIFTA• ELIQUIS• ENBREL• EPOGEN• ERIVEDGE• FENTORA• FIRAZYR• FORTESTA• GAMMAKED• GAMUNEX-C• GATTEX• GENOTROPIN• GILENYA• GLEEVEC• HIZENTRA• HUMATROPE• HUMIRA• ICLUSIG• INCIVEK• INCRELEX• INFERGEN• INLYTA• INTRON A(PEN INJ KIT)(10MM/0.2ML)• INTRON A(PEN INJ KIT)(3MM/0.2 ML)• INTRON A(PEN INJ KIT)(5MM/0.2ML)• INTRON A(VIAL)• INVERSINE• IPRIVASK• IRESSA• JAKAFI• JUXTAPID• KALYDECO• KINERET• KORLYM• KYNAMRO• LAZANDA• LETAIRIS• LEUKINE• NEULASTA• NEUPOGEN• NEXAVAR• NORDITROPIN• NORDITROPIN FLEXPRO• NORDITROPIN NORDIFLEX• NUEDEXTA• NUTROPIN• NUTROPIN AQ• NUTROPIN AQ NUSPIN• NUVIGIL• OMNITROPE• OMONTYS• ONSOLIS• ORENCIA• PEGASYS• PEGASYS PROCLICK• PEGINTRON• PEGINTRON REDIPEN• POMALYST(CAP)(1 MG)• POMALYST(CAP)(2 MG)• POMALYST(CAP)(3 MG)• POMALYST(CAP)(4 MG)• PRADAXA• PROCRIT• PROMACTA• PROVIGIL• PULMOZYME• QSYMIA• QUTENZA• RAVICTI• RELISTOR• REMODULIN• REVLIMID• SAIZEN• SEROSTIM• SIMPONI• SOLARAZE• SPRYCEL• STIVARGA• STRIANT• SUBOXONE(TAB SUBL)• SUBSYS• SUBUTEX• SUCRAID• SUTENT• SYLATRON• SYLATRON 4-PACK• TARCEVA• TARGRETIN• TASIGNA• TEKAMLO• TEKTURNA• TEKTURNA HCT• TEMODAR• TESTIM• TESTOSTERONE CYPIONATE• TESTOSTERONE ENANTHATE• TEV-TROPIN• THALOMID• TOBI• TRACLEER• TYVASO• VALTURNAPage 73 of 91