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L.A. Care Covered Drug Formulary (pdf)

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IndexHEMOCYTE............................................................. 56HEMOCYTE PLUS...................................................55HEMOCYTE-F..........................................................55HEMOFIL M..............................................................34HEPARIN FLUSH..................................................... 35HEPARIN SOD,PORCINE-0.9 % NACL...................35HEPARIN SODIUM...................................................35HEPARIN SODIUM IN 5% DEXTROSE................... 35HEPARIN SODIUM,PORCINE................................. 35HEPARIN SODIUM,PORCINE/D5W........................ 35HEPARIN SODIUM,PORCINE/NS........................... 35HEPARIN SODIUM,PORCINE/NS/PF......................35HEPARIN SODIUM,PORCINE/PF............................35HEPARIN SODIUM-NS............................................ 35HEP-LOCK............................................................... 35HEP-PAK CVC..........................................................35HEPSERA................................................................ 41HEXACHLOROPHENE............................................ 17HEXALEN.................................................................45HISTEX SR...............................................................15HISTRELIN AC...................................................31, 32HIZENTRA..........................................................37, 73HOMATROPAIRE..................................................... 34HOMATROPINE HBR...............................................34HOMEOPATHIC DRUGS................................... 34, 44HORIZANT................................................... 46, 60, 67HPR.......................................................................... 20HPR PLUS................................................................20HUM INSULIN NPH/REG INSULIN HM................... 28HUMALOG................................................................29HUMALOG MIX 50-50..............................................29HUMALOG MIX 75-25..............................................29HUMATE-P............................................................... 35HUMATROPE..................................................... 31, 73HUMIRA..............................................................42, 73HUMORSOL.............................................................33HUMULIN 50-50(OTC)............................................. 28HUMULIN 70-30(OTC)............................................. 28HUMULIN N(OTC)....................................................29HUMULIN R..............................................................29HUMULIN R(OTC)....................................................29HYALURO/DL-E AC/E12/ALLAN/SHEA...................20HYALURON SOD/ALLANTOIN/ALOE XT................ 22HYALURONATE SODIUM........................................22HYALURONATE SODIUM/HE-CELL/PEG............... 22HYCAMTIN...............................................................45HYCET............................................................... 47, 60HYDRALAZINE HCL.................................................11HYDRALAZINE/HYDROCHLOROTHIAZID............. 11HYDRALAZINE/RESERPIN/HCTZ...........................11HYDRA-ZIDE............................................................ 11HYDREA...................................................................45HYDRO.....................................................................29HYDRO 35................................................................21HYDROCHLOROTHIAZIDE.....................................13HYDROCHLOROTHIAZIDE/RESERPINE............... 11HYDROCODONE BIT/ACETAMINOPHEN........ 47, 48HYDROCODONE BIT/HOMATROP ME-BR............ 16HYDROCODONE BIT-IBUPROFEN........................ 47HYDROCODONE/CHLORPHEN POLIS..................16HYDROCODONE/IBUPROFEN...............................47HYDROCODONE-ACETAMINOPHEN(CAP)......47,6 0HYDROCODONE-ACETAMINOPHEN(SOLUTION)(10-325/CUP)......47,6 0HYDROCODONE-ACETAMINOPHEN(SOLUTION)(2.5-167/5)...... 47, 60HYDROCODONE-ACETAMINOPHEN(SOLUTION)(5-163/7.5)...... 47, 60HYDROCODONE-ACETAMINOPHEN(SOLUTION)(5-334MG/10)......47,6 0HYDROCODONE-ACETAMINOPHEN(SOLUTION)(7.5-500/CP)......47,6 0HYDROCODONE-ACETAMINOPHEN(TAB)(10MG-300MG)...............................................................47, 60HYDROCODONE-ACETAMINOPHEN(TAB)(2.5-325MG).....................................................................47HYDROCODONE-ACETAMINOPHEN(TAB)(2.5-500MG).....................................................................47, 60HYDROCODONE-ACETAMINOPHEN(TAB)(5MG-300MG)...............................................................48, 60HYDROCODONE-ACETAMINOPHEN(TAB)(7.5-300MG)...............................................................48, 60HYDROCODONE-HOMATROPINE MBR................ 16HYDROCORT/PRAMOXIN/EMOL/PRAM#1............43HYDROCORT/PRAMOXN/SKN CLNSR#16............43HYDROCORT/SAL ACID/SULF/SHMP#1................19HYDROCORTISONE................................... 19, 42, 44HYDROCORTISONE AC/LIDOCAINE......... 22, 43, 44HYDROCORTISONE ACETATE.............................. 44HYDROCORTISONE ACETATE/ALOE V................ 19HYDROCORTISONE ACETATE/UREA................... 19HYDROCORTISONE BUTYRATE........................... 19HYDROCORTISONE BUTYRATE/EMOLL.............. 19HYDROCORTISONE PROBUTATE.........................19HYDROCORTISONE VALERATE............................ 19HYDROCORTISONE/ALOE POL/IODOQU............. 17HYDROCORTISONE/EMOL NO.45.........................19HYDROCORTISONE/IODOQUIN/ALOE#2..............17HYDROCORTISONE/IODOQUINOL....................... 17HYDROCORTISONE/LIDOCAINE/ALOE................ 43HYDROCORTISONE/LIDOCAINE/CLNS6.............. 22HYDROCORTISONE/PRAMOXINE.............22, 43, 44HYDROCORTISONE/PRAMOXINE/ALOE.............. 22HYDROCORTISONE/PRAMOXINE/EMOLL............22HYDROCORTISONE/SAL ACID/SULFUR...............19HYDROCORTISONE/SKIN CLNSR #25..................19HYDROCORTISONE-ACETIC ACID....................... 29HYDROCORTISONE-IODOQUINOL....................... 17HYDROCORTISONE-PRAMOXINE...................43, 44HYDROFLUMETHIAZIDE........................................ 13HYDROGEN PEROXIDE......................................... 22HYDRO-IODOQUINOL 2-1...................................... 17HYDROMORPHONE HCL....................................... 48HYDROMORPHONE HCL/PF..................................48HYDROQUINONE..............................................22, 23HYDROQUINONE MICROSPHERES......................22HYDROQUINONE/ASCORBIC ACID.......................22HYDROQUINONE/AVOBENZ/OCTINOX.................23HYDROQUINONE/FERRIC OXIDE......................... 23HYDROQUINONE/VIT C/VIT E ACET..................... 23HYDROXOCOBALAMIN.......................................... 57HYDROXYAMPHETAMINE/TROPICAMIDE............ 34HYDROXYCHLOROQUINE SULFATE.................... 40HYDROXYPROPYL CELLULOSE........................... 34HYDROXYUREA................................................35, 45HYDROXYZINE HCL..................................................5HYDROXYZINE PAMOATE........................................5HYLASE................................................................... 22HYLATOPIC..............................................................20HYLATOPIC PLUS................................................... 20HYOPHEN................................................................38HYOSC SUL/PHENYLTOLOXAMINE CIT............... 52HYOSCYAMINE....................................................... 52HYOSCYAMINE SULFATE.......................................52HYOSCYAMINE SULFATE(CAP ER 12H)............... 52HYOSCYAMINE SULFATE(DROPS)....................... 52HYOSCYAMINE SULFATE(ELIXIR).........................52HYOSCYAMINE SULFATE(TAB ER 12H)................52HYOSCYAMINE SULFATE(TAB MPHASE)............. 52HYOSCYAMINE SULFATE(TAB RDP DIS)..............52HYOSCYAMINE SULFATE(TAB SUBL)................... 52HYOSCYAMINE SULFATE(TAB)..............................52HYPOLANCE(OTC)..................................................28HYZAAR................................................................... 11- I -IBANDRONATE SODIUM.........................................31IBUPROFEN.............................................................43IBUPROFEN/FAMOTIDINE......................................42IBUPROFEN/IRR CNT-IRRIT CMB #2.....................43IBUPROFEN/OXYCODONE HCL............................ 47ICATIBANT ACETATE.............................................. 42ICLUSIG............................................................. 45, 73ICOSAPENT ETHYL................................................ 14ICY HOT(OTC)......................................................... 21I-FOL PLUS.............................................................. 55ILEVRO.................................................................... 32ILOPERIDONE........................................................... 9ILOPROST................................................................12IMATINIB MESYLATE.............................................. 45IMDUR......................................................................14IMIPRAMINE HCL...................................................... 8IMIPRAMINE PAMOATE............................................ 8IMIQUIMOD..............................................................37IMITREX............................................................. 49, 60IMITREX(CARTRIDGE)......................................49, 60IMITREX(PEN INJCTR)(4 MG/0.5ML)............... 49, 60IMITREX(PEN INJCTR)(6 MG/0.5ML)............... 49, 60IMITREX(TAB).................................................... 49, 60IMITREX(VIAL)...................................................49, 60IMMUNE GLOB,GAM CAPRYLATE(IGG)................37IMMUNE GLOBULIN,GAMMA(IGG)........................ 37IMURAN....................................................................37INCIVEK............................................................. 41, 73INCONTROL LANCING DEVICE(OTC)................... 28INCRELEX..........................................................31, 73INDACATEROL MALEATE.........................................6INDAPAMIDE............................................................13INDERAL LA.............................................................12INDINAVIR SULFATE............................................... 41INDOCIN...................................................................43INDOCIN SR.............................................................43INDOMETHACIN......................................................43INFASURF................................................................46INFERGEN......................................................... 41, 73INFINITY CONTROL SOLUTION(OTC)..............25-27INFLUENZA A (H1N1) 2009.....................................37INFLUENZA A(H1N1)VAC 2009 LIVE......................37INFLUENZA VACC,TRI 2008(LIVE)......................... 37INFLUENZA VACC,TRI 2009 (LIVE)........................ 37INFLUENZA VACC,TRI 2010 (LIVE)........................ 37INFLUENZA VACC,TRI 2011 (LIVE)........................ 37INGENOL MEBUTATE............................................. 22INLYTA................................................................45, 73INNOHEP................................................................. 35INNOPRAN XL......................................................... 12INOMAX....................................................................12INOVA.......................................................................21INOVA 4-1.................................................................21INOVA 8-2.................................................................21INSPRA.................................................................... 12INSULIN ASPART.................................................... 28INSULIN DETEMIR.................................................. 28INSULIN GLARGINE,HUM.REC.ANLOG.......... 28, 29INSULIN GLULISINE................................................29INSULIN LISPRO..................................................... 29INSULIN NPL/INSULIN LISPRO.............................. 29INSULIN REGULAR, HUMAN..................................29INSULN ASP PRT/INSULIN ASPART......................29INTAL..........................................................................7INTEGRA F...............................................................55INTEGRA PLUS....................................................... 55INTELENCE..............................................................41INTERFERON ALFA-2B,RECOMB.......................... 37INTERFERON ALFACON-1..................................... 41INTERFERON ALFA-N3...........................................37INTERFERON BETA-1A...........................................46INTERFERON BETA-1A/ALBUMIN..........................46INTERFERON BETA-1B...........................................46INTERFERON GAMMA-1B,RECOMB..................... 37INTERMEZZO................................................ 9, 60, 67INTROL.....................................................................12INTRON A(PEN INJ KIT)(10MM/0.2ML)............ 37, 73INTRON A(PEN INJ KIT)(3MM/0.2 ML)............. 37, 73INTRON A(PEN INJ KIT)(5MM/0.2ML).............. 37, 73INTRON A(VIAL)................................................ 37, 73INTUNIV............................................................. 10, 60INVEGA(TAB ER 24H)(1.5 MG)..................... 9, 60, 67INVEGA(TAB ER 24H)(3 MG)........................ 9, 60, 67INVEGA(TAB ER 24H)(6 MG)........................ 9, 60, 67INVEGA(TAB ER 24H)(9 MG)........................ 9, 60, 67INVERSINE.........................................................11, 73INVIRASE.................................................................41IODINE/POTASSIUM IODIDE.................................. 17IODOFLEX................................................................16IODOQUINOL...........................................................40IODOQUINOL/ALOE POLYSACCHAR #1............... 17IODOSORB.............................................................. 16IONAMIN.................................................................. 57IOPIDINE(DROPERETTE).......................................33IOPIDINE(DROPS)...................................................33IPECAC.................................................................... 52IPRATROPIUM BROMIDE................................... 6, 46IPRATROPIUM/ALBUTEROL SULFATE....................6IPRIVASK..................................................... 35, 60, 73IQUIX........................................................................33IRBESARTAN........................................................... 11IRBESARTAN/HYDROCHLOROTHIAZIDE..............11IRESSA.............................................................. 45, 73IROFOL.................................................................... 55IRON.........................................................................55IRON &IRON ASP GLY/FA/MV,MIN27..................... 55IRON &IRON ASP GLY/FA/MV,MIN38..................... 55IRON AG&FUM/C/FA/MV CMB11/CA-T...................55IRON AG/C/B12/CA/SUC.ACID/STOM.................... 55IRON ASPGLY&PS CMPLX/C/SUCAC....................55IRON ASPGLY&PS/C/B12/FA/CA/SUC................... 55IRON ASPGLY/C/B12/FA/CA-TH/SUC.....................55IRON BG&PS/VIT C/B12/FA/CA THR......................55IRON BISGLY & PS/FA/B&C#12/SUC..................... 55IRON FUM & AG/C/B12/FA/CA/SUCC.....................55IRON FUM & BISGLY/FA/C/E/B12........................... 55IRON FUM & P/FA/VIT B & C NO.9......................... 55IRON FUM & PS CMP/FA/VIT C/B3.........................55Page 82 of 91

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