L.A. Care Covered Drug Formulary (pdf)

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Preferred <strong>Drug</strong> 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
Preferred <strong>Drug</strong> List Medication Prescribing Limitations• VANDETANIB• VECAMYL• VENTAVIS• VICTRELIS• VOTRIENT• XALKORI• XELJANZ• XELODA• XTANDI• ZELBORAF• ZORBTIVE• ZYCLARA• ZYTIGA• ZYVOXPage 74 of 91
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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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