L.A. Care Covered Drug Formulary (pdf)

IndexDEPO-PROVERA.....................................................14DEPO-SUBQ PROVERA 104.................................. 14DEPO-TESTOSTERONE(VIAL)(100 MG/ML)......36,7 3DEPO-TESTOSTERONE(VIAL)(200 MG/ML)......36,7 3DEPRIZINE...............................................................53DERMA-SMOOTHE-FS............................................19DERMATOP..............................................................19DERMOTIC...............................................................29DESIPRAMINE HCL...................................................8DESIRUDIN..............................................................35DESLORATADINE......................................................5DESLORATADINE/PSEUDOEPHEDRINE.................5DESMOPRESSIN (NONREFRIGERATED)............. 31DESMOPRESSIN ACETATE....................................31DESOGESTREL-ETHINYL ESTRADIOL.................14DESOG-ET ESTRA/ETHIN ESTRA......................... 14DESONATE.............................................................. 19DESONIDE...............................................................19DESONIDE/EMOLLIENT COMBO NO.3..................19DESONIDE/EMOLLIENT COMBO.NO 28................19DESONIDE/EMOLLIENT COMBO.NO 30................19DESONIL..................................................................19DESONIL + PLUS.................................................... 19DESOWEN............................................................... 19DESOXIMETASONE................................................ 19DESOXYN............................................................ 8, 59DESVENLAFAXINE SUCCINATE.............................. 8DETROL............................................................. 54, 66DETROL LA........................................................54, 66DEXAMETHASONE........................................... 32, 42DEXAMETHASONE INTENSOL.............................. 42DEXAMETHASONE SOD PHOSPHATE................. 32DEXASOL.................................................................32DEXCHLORPHENIRAMINE MALEATE..................... 5DEXEDRINE.........................................................8, 59DEXILANT.................................................... 53, 59, 66DEXLANSOPRAZOLE............................................. 53DEXMETHYLPHENIDATE HCL............................... 10DEXPAK................................................................... 42DEXTROAMPHETAMINE SULFATE..........................8DEXTROAMPHETAMINE/AMPHETAMINE............... 8DEXTROMETHORPHAN HBR/QUINIDINE.............46DHCODEINE BT/ACETAMINOPHN/CAFF.............. 47DHT.......................................................................... 57DIABETA...................................................................24DIABETIC SUPPLIES,MISCELL.............................. 27DIALYVITE 3000.......................................................57DIALYVITE 5000.......................................................57DIALYVITE 800 WITH IRON.................................... 56DIALYVITE SUPREME D......................................... 57DIALYVITE ZINC...................................................... 57DIAMOX SEQUELS................................................. 33DIAPHRAGM FITTING SET,ARCSPRNG................15DIAPHRAGMS, ARC-SPRING.................................15DIAPHRAGMS, COIL SPRING................................ 15DIAPHRAGMS, FLAT SPRING................................ 15DIAPHRAGMS, WIDE SEAL....................................15DIASCREEN 10(OTC)..............................................29DIASCREEN 2GK REAGENT(OTC)........................ 29DIASCREEN 3 REAGENT(OTC)............................. 29DIASCREEN 4OBL(OTC).........................................29DIASCREEN 5(OTC)................................................29DIASCREEN 6(OTC)................................................29DIASCREEN 7(OTC)................................................29DIASCREEN 8(OTC)................................................29DIASCREEN 9(OTC)................................................29DIASTAT............................................................. 50, 59DIASTAT ACUDIAL(KIT)(12.5-15-20).................50, 59DIASTAT ACUDIAL(KIT)(5-7.5-10MG)...............50, 59DIATX ZN..................................................................57DIAZEPAM............................................................8, 50DIAZOXIDE.............................................................. 28DIBENZYLINE.......................................................... 11DICHLOROACETIC ACID........................................21DICHLOROTETRAFLUOROETHANE..................... 22DICLOFENAC EPOLAMINE.....................................20DICLOFENAC POTASSIUM...............................42, 49DICLOFENAC SODIUM......................... 20, 22, 32, 42DICLOFENAC SODIUM/MISOPROSTOL................42DICLOXACILLIN SODIUM....................................... 38DICOPANOL...............................................................5DICYCLOMINE HCL.................................................52DIDANOSINE........................................................... 41DIDREX.................................................................... 57DIDRONEL............................................................... 31DIETHYLPROPION HCL..........................................57DIFENOXIN HCL/ATROPINE SULFATE.................. 44DIFFERIN(CREAM)............................................17, 58DIFFERIN(GEL W/PUMP)..................................17, 58DIFFERIN(GEL)(0.1 %)......................................17, 58DIFFERIN(GEL)(0.3 %)......................................17, 58DIFFERIN(LOTION)........................................... 17, 58DIFFERIN(MED SWAB)..................................... 17, 58DIFICID.........................................................38, 59, 66DIFIL-G FORTE..........................................................6DIFLORASONE DIACETATE................................... 19DIFLORASONE DIACETATE/EMOLL...................... 19DIFLUCAN................................................................39DIFLUNISAL.............................................................47DIFLUPREDNATE.................................................... 32DIGEX NF.................................................................52DIGOXIN...................................................................10DIHYDROCODEINE/ASPIRIN/CAFFEIN.................47DIHYDROCODEINE-BPM-PE..................................15DIHYDROERGOTAMINE MESYLATE..................... 49DIHYDROTACHYSTEROL.......................................57DILANTIN................................................................. 51DILANTIN(CAP)(100 MG)........................................ 51DILANTIN(CAP)(30 MG).......................................... 51DILANTIN-125.......................................................... 51DILATRATE-SR........................................................ 14DILAUDID.................................................................48DILAUDID(AMPUL)(1 MG/ML).................................48DILAUDID(AMPUL)(2 MG/ML).................................48DILAUDID(AMPUL)(4 MG/ML).................................48DILAUDID-HP...........................................................48DILEX-G 200.............................................................. 6DILEX-G(LIQUID).......................................................6DILEX-G(TAB)............................................................ 6DILTIAZEM 24HR ER............................................... 12DILTIAZEM HCL....................................................... 12DINOPROSTONE.....................................................15DIOVAN.............................................................. 11, 66DIOVAN HCT............................................................ 11DIOXYBENZONE/HYDROQUINONE...................... 22DIOXYBENZONE/PDO/HYDROQUINONE..............22DIPENTUM.........................................................43, 66DIPHENHYDRAMINE HCL........................................ 5DIPHENHYDRAMINE TANNATE............................... 5DIPHENOXYLATE HCL/ATROPINE........................ 44DIPHENOXYLATE-ATROPINE................................ 44DIPIVEFRIN HCL..................................................... 34DIPROLENE.............................................................19DIPROLENE AF....................................................... 19DIPYRIDAMOLE.......................................................35DISOPYRAMIDE PHOSPHATE............................... 10DISULFIRAM..............................................................8DIURIL......................................................................13DIVALPROEX SODIUM............................................50DIVIGEL................................................................... 36DM/PHENYLEPH/CHLORPHENIRAMINE...............16D-METHORPHAN HB/P-EPD HCL/BPM................. 16D-METHORPHAN HB/PROMETH HCL................... 16DOCUSATE SODIUM/FA/MV&IRON/MIN................55DOFETILIDE.............................................................10DOLASETRON MESYLATE....................................... 6DOLGIC PLUS......................................................... 47DOLOPHINE HCL.................................................... 48DONATUSS XP........................................................ 16DONEPEZIL HCL....................................................... 7DONNATAL...............................................................52DORAL....................................................................... 9DORNASE ALFA...................................................... 46DORYX..................................................................... 39DORZOLAMIDE HCL............................................... 33DORZOLAMIDE HCL/TIMOLOL MALEAT............... 33DOVONEX..........................................................23, 66DOXAZOSIN MESYLATE...................................10, 11DOXEPIN HCL................................................. 8, 9, 20DOXERCALCIFEROL.............................................. 31DOXYCYCLINE CALCIUM.......................................39DOXYCYCLINE HYCLATE.................................39, 46DOXYCYCLINE MONOHY/SKIN CLNSR9.............. 39DOXYCYCLINE MONOHYDRATE...........................39DOXYCYCLINE/EYELID CLNS NO.2&3..................33DOXYCYCLINE/OMEGA-3 #1/EYE MSK................ 39DOXYCYCLINE/SALICY/OCT/ZINC OX..................39DOXYCYCLINE/SKIN CLEANSER #19................... 39DOXYLAMINE SUCCINATE.......................................5DRISDOL..................................................................57DRITHOCREME HP...........................................23, 66DRITHO-SCALP.......................................................23DRONABINOL............................................................6DRONEDARONE HCL............................................. 10DROPLET LANCING DEVICE(OTC)....................... 28DROSPIR/ETH ESTRA/LEVOMEFOL CA............... 14DROSPIRENONE/ESTRADIOL............................... 36DROXIA....................................................................35DRYSOL................................................................... 20DUALVIT F................................................................55DUETACT........................................................... 24, 66DUEXIS........................................................ 42, 59, 66DULERA............................................................... 6, 59DULOXETINE HCL.....................................................8DUONEB.................................................................... 6DURABAC................................................................ 47DURAGESIC...................................................... 47, 59DURAMORPH.......................................................... 48DURASAL.................................................................21DURAXIN..................................................................47DUREZOL.................................................................32DUTASTERIDE.........................................................53DUTASTERIDE/TAMSULOSIN HCL........................ 53DUTOPROL..............................................................12DYAZIDE.................................................................. 12DYGASE...................................................................51DYLIX......................................................................... 7DYMISTA........................................................ 5, 59, 66DYNACIN..................................................................39DYNACIRC CR.........................................................12DYPHYLLINE............................................................. 7DYRENIUM...............................................................12DYTAN........................................................................5- E -E AC SUCC/FA/VIT BCOMP&C/ZN/SE................... 56E.E.S. 200................................................................ 38EASPRIN..................................................................47EASY CHECK CONTROL SOLUTION(OTC)......25,2 6EASY CHECK(OTC).................................................26EASY CLICK(OTC)...................................................28EASY STEP(OTC)..............................................25, 26EASY TALK(OTC).................................................... 25EASY TOUCH LANCING DEVICE(OTC)................. 28EASY TOUCH(OTC)................................................ 24EASY TRAK(OTC)..............................................25, 26EASYGLUCO PLUS CONTROL NORMAL(OTC)......2 6EASYMAX SPEAKING(OTC)...................................26EASYMAX(OTC)................................................ 25, 26ECHOTHIOPHATE IODIDE......................................33ECLIPSE CONTROL SOLUTION(OTC).............25, 26ECLIPSE(OTC).........................................................26EC-NAPROSYN....................................................... 43ECONAZOLE NITRATE........................................... 17EDARBI...............................................................11, 66EDARBYCLOR................................................... 11, 66EDECRIN..................................................................12EDEX..................................................................30, 59EDLUAR......................................................... 9, 59, 66EDURANT................................................................ 41EFALIZUMAB........................................................... 23EFAVIRENZ.............................................................. 41EFAVIRENZ/EMTRICITAB/TENOFOVIR................. 41EFFER-K.................................................................. 30EFFIENT.............................................................35, 59EFLORNITHINE HCL............................................... 23EFUDEX................................................................... 22EGRIFTA............................................................ 31, 73ELDEPRYL............................................................... 50ELDOPAQUE FORTE.............................................. 23ELECT WTR/SOD CH/SOD HY/HYP AC.................22ELEMENT COMPACT CONTROL SOLN(OTC)......25, 26ELEMENT CONTROL SOLUTION(OTC)...........25, 26ELEMENT PLUS CONTROL SOLUTION(OTC)......25, 26ELESTAT.................................................................. 32ELESTRIN................................................................ 36ELETRIPTAN HBR................................................... 49ELIDEL......................................................... 23, 58, 66ELIGARD..................................................................31ELIMITE....................................................................18ELIQUIS....................................................... 35, 59, 73ELLA.........................................................................15ELMIRON................................................................. 54ELOCON...................................................................19ELTROMBOPAG OLAMINE..................................... 35ELVITEGR/COBICIST/EMTRIC/TENOF.................. 41EMADINE................................................................. 32EMBEDA...................................................................48EMBRACE GLUCOSE CONTROL SOLN(OTC)......26EMCYT..................................................................... 46EMEDASTINE DIFUMARATE.................................. 32EMEND(CAP DS PK)........................................... 5, 59Page 79 of 91