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L.A. Care Health Plan
Medicare Advantage (HMO SNP)
2014 Formulary
Formulario para 2014
Please read: This document contains information
about the drugs we cover in this plan.
This formulary was updated on November 30,
2014. For more recent information or
other questions, please contact us, L.A. Care
Health
Plan
Member
Services,
at
1-888-522-1298 or, for TTY/TDD
users,
1-888-212-4460, 24 hours a day, 7 days a
week,
including
holidays,
or
visit
www.lacare.org.
Sírvase leer: Este documento contiene información
sobre medicamentos que cubrimos en este plan.
Este formulario se actualizó el 30 de
noviembre del 2014. Para la información más
reciente u otras preguntas, comuníquese con
nosotros en Servicios para los miembros de L.A.
Care Health Plan al teléfono 1-888-522-1298 o,
para
los
usuarios
de
TTY/TDD,
1-888-212-4460, las 24 horas del día, los 7
días de la semana, incluso los días festivos,
o visite www.lacare.org.
(List of Covered Drugs)
H2643_1085_2014FormularyA Accepted
H2643_1085_2014FormularyA SP Accepted
Formulary ID 14483.000 Version Number 18
Last Updated: 11/2014
(Lista de medicamentos cubiertos)
Note to existing members: This Formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means L.A. Care Health Plan.
When it refers to “plan” or “our plan,” it means L.A. Care Health Plan Medicare Advantage.
This document includes a list of the drugs (formulary) for our plan which is current as of
November 30, 2014. For an updated formulary, please contact us. Our contact information,
along with the date we last updated the formulary, appears on the front and back cover
pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or co-payments/co-insurance may change on
January 1, 2015.
Nota para los miembros existentes: Este Formulario ha cambiado desde el año pasado. Revise
este documento para verificar que todavía contiene los medicamentos que usted utiliza.
Cuando esta lista de medicamentos (formulario) se refiere a “nosotros” o “nuestro”, significa
L.A. Care Health Plan. Cuando se refiere a “plan” o “nuestro plan”, significa L.A. Care Health Plan
Medicare Advantage.
Este documento incluye una lista de los medicamentos (formulario) para nuestro plan, vigente a
partir del 30 de noviembre del 2014. Para obtener un formulario actualizado, comuníquese
con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización
del formulario, aparece en las páginas de la portada y contraportada.
Los beneficiarios deben usar las farmacias de la red para acceder a su beneficio de medicamentos
con receta. Los beneficios, el formulario, la red de farmacias, la prima y/o los pagos
compartidos/seguro compartido pueden cambiar el 1.° de enero de 2015.
i
What is the L.A. Care Health Plan Medicare Advantage
Formulary?
A formulary is a list of covered drugs selected by L.A. Care Health Plan Medicare Advantage
in consultation with a team of health care providers, which represents the prescription therapies
believed to be a necessary part of a quality treatment program. L.A. Care Health Plan Medicare
Advantage will generally cover the drugs listed in our formulary as long as the drug is medically
necessary, the prescription is filled at an L.A. Care Health Plan Medicare Advantage network
pharmacy, and other plan rules are followed. For more information on how to fill your
prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning
of the year, we will not discontinue or reduce coverage of the drug during the 2014 coverage
year except when a new, less expensive generic drug becomes available or when new adverse
information about the safety or effectiveness of a drug is released. Other types of formulary
changes, such as removing a drug from our formulary, will not affect members who are currently
taking the drug. It will remain available at the same cost sharing for those members taking it for
the remainder of the coverage year. We feel it is important that you have continued access for the
remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step
therapy restrictions on a drug, we must notify affected members of the change at least 60 days
before the change becomes effective, or at the time the member requests a refill of the drug, at
which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration
(FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug
from the market, we will immediately remove the drug from our formulary and provide notice
to members who take the drug. The enclosed formulary is current as of January 1, 2014. To get
updated information about the drugs covered by L.A. Care Health Plan Medicare Advantage,
please contact us. Our contact information appears on the front and back cover pages. In the
event of mid-year non-maintenance formulary changes, we will provide you with an errata
(correction) sheet for this formulary and update our website at www.lacare.org.
ii
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiac Drugs.” If you know what your drug is used for,
look for the category name in the list that begins on page 1. Then look under the category name for
your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index
and find your drug. Next to your drug, you will see the page number where you can find coverage
information. Turn to the page listed in the Index and find the name of your drug in the first
column of the list.
What are generic drugs?
L.A. Care Health Plan Medicare Advantage covers both brand-name drugs and generic drugs.
A generic drug is approved by the FDA as having the same active ingredient as the brand-name
drug. Generally, generic drugs cost less than brand-name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:
• Prior Authorization: L.A. Care Health Plan Medicare Advantage requires you or your
physician to get prior authorization for certain drugs. This means that you will need to get
approval from L.A. Care Health Plan Medicare Advantage before you fill your prescriptions.
If you don’t get approval, L.A. Care Health Plan Medicare Advantage may not cover the drug.
• Quantity Limits: For certain drugs, L.A. Care Health Plan Medicare Advantage limits
the amount of the drug that L.A. Care Health Plan Medicare Advantage will cover. For
example, L.A. Care Health Plan Medicare Advantage provides 62 capsules per prescription
for Geodon. This may be in addition to a standard one-month or three-month supply.
iii
• Step Therapy: In some cases, L.A. Care Health Plan Medicare Advantage requires you to
first try certain drugs to treat your medical condition before we will cover another drug for
that condition. For example, if Drug A and Drug B both treat your medical condition,
L.A. Care Health Plan Medicare Advantage may not cover Drug B unless you try Drug A
first. If Drug A does not work for you, L.A. Care Health Plan Medicare Advantage will then
cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary
that begins on page 1. You can also get more information about the restrictions applied to specific
covered drugs by visiting our website. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You can ask L.A. Care Health Plan Medicare Advantage to make an exception to these restrictions
or limits or for a list of other, similar drugs that may treat your health condition. See the section,
“How do I request an exception to the L.A. Care Health Plan Medicare Advantage Formulary?” on
page v for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Member Services and ask if your drug is covered.
If you learn that L.A. Care Health Plan Medicare Advantage does not cover your drug, you have
two options:
• You can ask Member Services for a list of similar drugs that are covered by L.A. Care Health Plan
Medicare Advantage. When you receive the list, show it to your doctor and ask him or her to
prescribe a similar drug that is covered by L.A. Care Health Plan Medicare Advantage.
• You can ask L.A. Care Health Plan Medicare Advantage to make an exception and cover
your drug. See next page for information about how to request an exception.
iv
How do I request an exception to the L.A. Care Health Plan
Medicare Advantage Formulary?
You can ask L.A. Care Health Plan Medicare Advantage to make an exception to our coverage
rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover a drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, L.A. Care Health Plan Medicare Advantage limits the amount of the drug that we
will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a
greater amount.
Generally, L.A. Care Health Plan Medicare Advantage will only approve your request for an
exception if the alternative drugs included on the plan’s formulary or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have
adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary or utilization
restriction exception. When you request a formulary or utilization restriction exception,
you should submit a statement from your prescriber or physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting
statement. You can request an expedited (fast) exception if you or your doctor believe that your
health could be seriously harmed by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
v
What do I do before I can talk to my doctor about changing
my drugs or requesting an exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that is on our formulary but your ability to get it
is limited. For example, you may need a prior authorization from us before you can fill your
prescription. You should talk to your doctor to decide if you should switch to an appropriate drug
that we cover or request a formulary exception so that we will cover the drug you take. While you
talk to your doctor to determine the right course of action for you, we may cover your drug in
certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited,
we will cover a temporary 30-day supply (unless you have a prescription written for fewer days)
when you go to a network pharmacy. After your first 30-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until
we have provided you with a 93-day transition supply, consistent with the dispensing increment
(unless you have a prescription written for fewer days). We will cover more than one refill of
these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on
our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of
membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary exception.
Note: You may experience a change in the level of care received and/or may be required to transition
from one facility or treatment site to another. Exceptions are available to you if you experience a
change in the level of care being received. If you experience a change in level of care, L.A. Care
Health Plan Medicare Advantage will cover a temporary 31-day supply (unless you have a
prescription written for fewer days).
vi
For more information
For more detailed information about your L.A. Care Health Plan Medicare Advantage
prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about L.A. Care Health Plan Medicare Advantage, please contact us. Our
contact information, along with the date we last updated the formulary, appears on the front and
back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY/TDD users should
call 1-877-486-2048. Or, visit www.medicare.gov.
L.A. Care Health Plan is a Coordinated Care plan with a Medicare contract and a contract with
the California Medicaid program. Enrollment in L.A. Care Health Plan depends on contract renewal.
This information is available for free in other languages and different formats, including large
print and audio. L.A. Care Health Plan also has free language interpreter services available for
non-English speakers. Please contact Member Services at 1-888-522-1298, 24 hours a day, 7 days
a week, including holidays, for more information. TTY/TDD users should call 1-888-212-4460.
Esta información está disponible de forma gratuita en otros idiomas y formatos diferentes,
incluyendo letra grande y audio. L.A. Care Health Plan también ofrece servicios de interpretación
de forma gratuita para las personas que no hablan inglés. Para mayores informes, comuníquese
con Servicios para los miembros al 1-888-522-1298, las 24 horas del día, los 7 días de la semana,
incluso los días festivos. Los usuarios de TTY/TDD deben llamar al 1-888-212-4460.
L.A. Care Health Plan Medicare Advantage Formulary
The formulary below provides coverage information about the drugs covered by
L.A. Care Health Plan Medicare Advantage. If you have trouble finding your drug in the list,
turn to the Index that begins on page I-1.
The first column of the chart lists the drug name. Brand-name drugs are capitalized
(e.g., CYMBALTA), and generic drugs are listed in lowercase italics (e.g., lexapro).
The information in the Requirements/Limits column tells you if L.A. Care Health Plan
Medicare Advantage has any special requirements for coverage of your drug.
vii
C O V E R A G E N O T E S A B B R E V I AT I O N S
The following abbreviations may be found within the body of this document:
A B B R E V I AT I O N
DESCRIPTION
E X P L A N AT I O N
Utilization Management Restrictions
PA
Prior Authorization
Restriction
PA BvD
Prior Authorization
Restriction for Part B
vs Part D Determination
PA NSO
Prior Authorization
Restriction for
New Starts Only
QL
Quantity Limit Restriction
ST
Step Therapy Restriction
You (or your physician) are required to get prior authorization from L.A. Care Health
Plan Medicare Advantage before you fill your prescription for this drug. Without
prior approval, L.A. Care Health Plan Medicare Advantage may not cover this drug.
This drug may be eligible for payment under Medicare Part B or Part D.
You (or your physician) are required to get prior authorization from L.A. Care
Health Plan Medicare Advantage to determine that this drug is covered under
Medicare Part D before you fill your prescription for this drug. Without prior
approval, L.A. Care Health Plan Medicare Advantage may not cover this drug.
If you are a new member, you (or your physician) are required to get prior
authorization from L.A. Care Health Plan Medicare Advantage before you fill
your prescription for this drug. Without prior approval, L.A. Care Health Plan
Medicare Advantage may not cover this drug.
L.A. Care Health Plan Medicare Advantage limits the amount of this drug that
is covered per prescription, or within a specific time frame.
Before L.A. Care Health Plan Medicare Advantage will provide coverage for
this drug, you must first try another drug(s) to treat your medical condition.
This drug may only be covered if the other drug(s) does not work for you.
Other Special Requirements for Coverage
viii
EX
Excluded Part D Drug
LA
Limited Access Drug
NM
Non-Mail-Order Drug
HI
Home Infusion Drug
This prescription drug is not normally covered in a Medicare Prescription Drug
Plan. The amount you pay when you fill a prescription for this drug does not
count towards your total drug costs (that is, the amount you pay does not help
you qualify for catastrophic coverage). In addition, if you are receiving Extra Help
to pay for your prescriptions, you will not get any Extra Help to pay for this drug.
This prescription may be available only at certain pharmacies. For more
information consult your Pharmacy Directory or call Member Services at
1-888-522-1298, 24 hours a day, 7 days a week, including holidays.
TTY/TDD users should call 1-888-212-4460.
You may be able to receive greater than a 1-month supply of most of the
drugs on your Formulary via mail order at a reduced cost share. Drugs not
available via your mail-order benefit are noted with “NM” in the notes
column of your Formulary.
This prescription drug may be covered under our medical benefit. For more
information, call Member Services at 1-888-522-1298, 4 hours a day, 7 days
a week, including holidays. TTY/TDD users should call 1-888-212-4460.
TIER 1 – GENERIC AND BRAND-NAME DRUGS
Your co-payment amount for generic drugs is: Your co-payment amount for brand-name drugs is:
Typically $1.20 per prescription*
Typically $3.60 per prescription*
*Co-payments may vary based on the low-income subsidy level you receive.
S T R E N G T H A N D D O S A G E F O R M A B B R E V I AT I O N S
adh. patch • adhesive patch
aer br act • aerosol, breath activated
aer pow • aerosol, powder
aer pow ba • aerosol powder, breath activated
aer refill • aerosol refill
aer w/adap • aerosol with adapter
ampul • ampule
blkbaginj • bulk bag injection
cap dr mp • capsule, delayed release multiphasic
cap ds pk • capsule, dose pack
cap er 12h • capsule, 12-hour extended release
cap er 24h • capsule, 24-hour extended release
cap er deg • capsule, extended release degradable
cap er pel • capsule, extended release pellets
cap mphase • capsule, multiphasic
cap.sa 24h • capsule, 24-hour sustained action
cap.sr 12h • capsule, 12-hour sustained release
cap.sr 24h • capsule, 24-hour sustained release
cap24h pct • capsule, 24-hour controlled-onset pellets
cap24h pel • capsule, 24-hour sustained release pellets
cap sprink •capsule, sprinkle
cap sr pel • capsule sustained release pellets
cap w/dev • capsule with device
capsule dr • capsule, delayed release
capsule er • capsule, extended release
capsule sa • capsule, sustained action
cmb cappad • combination: capsule, pad
cmb ont fm • combination: ointment, foam
cmb ont lt • combination: ointment, lotion
cmb tabpad • combination: tablet, pad
combo. pkg • combination package
cpmp 12hr • capsule, 12-hour multiphasic
cpmp 24hr • capsule, 24-hour multiphasic
cpmp 30-70 • capsule, multiphasic, 30%–70%
cpmp 50-50 • capsule, multiphasic, 50%–50%
cream(g), cream(gm) • cream (grams)
cream(ml) • cream (milliliters)
cream/appl • cream with applicator
cream, er (g) • cream, extended release (grams)
cream pack • cream, package
dehp fr bg • di(2-ethylhexyl)phthalate free bag
dis needle • disposable needle
disk w/dev • disk with inhalation device
disp syrin • disposable syringe
drops susp • drops, suspension
drps hpvis • drops, hyperviscous
emul adhes • emulsion adhesive
emul packt • emulsion packet
emulsn(g) • emulsion (grams)
foam/appl. • foam with applicator
froz.piggy • frozen piggyback
g • gram
gel/pf app • gel with prefilled applicator
gel (gm) • gel (grams)
gel (ml) • gel (milliliters)
gel md pmp • gel in metered dose pump
gel w/appl • gel with applicator
gel w/pump • gel with pump
gran pack • granule pack
hfa aer ad • hfa aerosol adapter
infus. btl • infusion bottle
insuln pen • insulin pen
ip soln • intraperitoneal solution
irrig soln • irrigating solution
iv soln. • intravenous solution
jel • jelly
jelly/app • jelly with applicator
jel/pf app • jelly with pre-filled applicator
ix
S T R E N G T H A N D D O S A G E F O R M A B B R E V I AT I O N S (cont’d)
kit cl&crm • kit: cleanser and cream
kt crm le • kit: cream, lotion emollient
kt lotn ce • kit: lotion, cream emollient
kt oint le • kit: ointment, lotion emollient
lotion, er • lotion, extended release
lozenge hd • lozenge handle
m.ht patch • medicated heated patch
ma buc tab • mucoadhesive buccal tablet
Mcg • microgram
med. pad • medicated pad
med. swab • medicated swab
med. tape • medicated tape
mg • milligram
ml • milliliter
muc er 12h • mucoadhesive system, 12-hour extended release
ndl fr inj • needle for injection
nl fm susp • nail film suspension
oint. (g), oint.(gm) • ointment (grams)
oral conc • oral concentrate
oral susp • oral suspension
paste (g) • paste (grams)
patch td24 • patch, 24-hour transdermal
patch td72 • patch, 72-hour transdermal
patch tdsw • patch, biweekly transdermal
patch tdwk • patch, weekly transdermal
pca syring • patient-controlled analgesic syringe
pca vial • patient-controlled analgesic vial
pellet(ea) • pellet (each)
pen ij kit • pen injector kit
pen injctr • pen injector
pggybk btl • piggyback bottle
plast. bag • plastic bag
powd pack • powder pack
sol md pmp • solution with multi-dose pump
sol w/appl • solution with applicator
sol/pf app • solution with pre-filled applicator
sol-gel • solution, gel-forming
soln recon • solution, reconstituted
soln(gram) • solution (grams)
spray susp • spray, suspension
x
spray/pump • spray with pump
stick(ea) • stick (each)
supp.rect • suppository, rectal
supp.vag • suppository, vaginal
suppos. • suppository
sus er 24h • suspension, 24-hour extended release
sus er rec • suspension, extended release reconstituted
sus mc rec • suspension, microcapsule reconstituted
suspdr pkt • suspension, delayed release packet
susp recon • suspension, reconstituted
syringekit • syringe kit
tab chew • tablet, chewable
tab er 12h • tablet, 12-hour extended release
tab er 24h • tablet, 24-hour extended release
tab er prt • tablet, extended release particles
tab er seq • tablet, extended release sequels
tab disper • tablet, dispersable
tab ds pk • tablet, dose pack
tab er 24 • tablet, 24-hour extended release
tab mphase • tablet, multiphasic
tab part • tablet, particles
tab rap dr • tablet, rapid disintegrating delayed release
tab rapdis • tablet, rapid disintegrating
tab subl • tablet, sublingual
tab.sr 12h • tablet, 12-hour sustained release
tab.sr 24h • tablet, 24-hour sustained release
tabergr24hr • tablet, 24-hour gradual extended release
tablet dr • tablet, delayed release
tablet, er • tablet, extended release
tablet eff • tablet, effervescent
tablet sa • tablet, sustained action
tablet sol • tablet, soluble
tb er dspk • tablet, extended release dose pack
tb mp dspk • tablet, multiphasic dose pack
tb rd dspk • tablet, rapid disintegrating dose pack
tbdspk 3mo • tablet, 3-month dose pack
tbmp 12hr • tablet, 12-hour multiphasic
tbmp 24hr • tablet, 24-hour multiphasic
u • unit
vag ring • vaginal ring
¿En qué consiste el Formulario de L.A. Care Health Plan
Medicare Advantage?
Un formulario es una lista de medicamentos cubiertos seleccionados por L.A. Care Health Plan
Medicare Advantage con el asesoramiento de un equipo de proveedores médicos, el cual representa
las terapias recetadas que se consideran una parte necesaria de un programa de tratamiento de
calidad. L.A. Care Health Plan Medicare Advantage generalmente cubrirá los medicamentos
enumerados en nuestro formulario siempre y cuando el medicamento sea médicamente necesario,
la receta se surta en una farmacia de la red de L.A. Care Health Plan Medicare Advantage y se
respeten otras reglas del plan. Para obtener más información sobre cómo surtir sus recetas, revise
su Evidencia de cobertura.
¿Puede cambiar el Formulario (lista de medicamentos)?
Generalmente, si está tomando un medicamento que figura en nuestro formulario de 2014 que
estaba cubierto a principios de año, no descontinuaremos ni reduciremos la cobertura de un
medicamento durante el año de cobertura de 2014, excepto cuando haya disponible un nuevo
medicamento genérico menos caro o cuando se divulgue nueva información adversa sobre la
efectividad o seguridad del mismo. Otros tipos de cambios en el formulario, tales como remover
un medicamento de nuestro formulario, no afectarán a los miembros que actualmente están
tomando el medicamento. Continuará disponible al mismo costo compartido para aquellos
miembros que están tomándolos por el resto del año cubierto. Creemos que es importante que
tenga acceso continuo por el resto del año cubierto a los medicamentos del formulario que estaban
disponibles cuando escogió nuestro plan, excepto para casos en los que puede ahorra dinero
adicional o podemos asegurar su bienestar.
Si retiramos medicamentos de nuestro formulario, o agregamos autorizaciones previas, límites
a la cantidad y/o restricciones a la terapia escalonada en un medicamento, debemos notificar a
los miembros afectados por dichos cambios por lo menos con 60 días de anticipación a que la
modificación entre en vigor, o cuando el miembro solicite volver a surtir el medicamento,
momento en el cual el miembro recibirá un suministro de 60 días del medicamento. Si la
Administración de Drogas y Alimentos de los Estados Unidos (FDA, por sus siglas en inglés)
considera que un medicamento en nuestro formulario no es seguro o el fabricante lo retira
del mercado, nosotros retiraremos de inmediato el medicamento de nuestro formulario y le
notificaremos a los miembros que utilizan el medicamento. El formulario anexo está actualizado
al 1.° de enero de 2014. Para obtener información actualizada sobre los medicamentos cubiertos
por L.A. Care Health Plan Medicare Advantage, comuníquese con nosotros. Nuestra información
de contacto aparece en la portada y contraportada. En caso que a mitad de año se hagan cambios
al formulario, aparte de cambios de mantenimiento, le proporcionaremos una fe de erratas
(corrección) para este formulario y actualizaremos nuestro sitio web en www.lacare.org.
xi
¿Cómo utilizo el Formulario?
Hay dos maneras de encontrar sus medicamentos en el formulario:
Condición médica
El formulario inicia en la página 1. Los medicamentos en este formulario están agrupados en
categorías, según el tipo de condiciones médicas a cuyo tratamiento se apliquen. Por ejemplo, los
medicamentos que se utilizan para tratar una condición cardíaca están listados en la categoría
“Medicamentos para el corazón”. Si sabe para qué se usa su medicamento, busque el nombre de la
categoría en la lista que empieza en la página 1. Luego busque dentro del nombre de categoría de su
medicamento.
Lista alfabética
Si no está seguro en cuál categoría buscar, debe buscar su medicamento en el índice que inicia
en la página I-1. El índice brinda una lista alfabética de todos los medicamentos incluidos en este
documento. En el índice se incluye tanto el nombre de marca como el nombre genérico. Busque
en el índice y ubique su medicamento. Junto a su medicamento, verá el número de página donde
hay información sobre su cobertura. Vaya a la página indicada en el índice y encuentre el nombre
de su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
L.A. Care Health Plan Medicare Advantage cubre tanto medicamentos de marca como
medicamentos genéricos. La FDA aprueba un medicamento genérico al contener el mismo
ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos
cuestan menos que los de marca registrada.
¿Existen restricciones en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura.
Estos requisitos y límites pueden incluir:
• Autorización previa: L.A. Care Health Plan Medicare Advantage requiere que usted o su
médico obtengan autorización previa para ciertos medicamentos. Esto significa que necesitará
obtener aprobación de L.A. Care Health Plan Medicare Advantage antes de surtir sus recetas.
Si no obtiene la aprobación, tal vez L.A. Care Health Plan Medicare Advantage no cubra el
medicamento.
• Límites de cantidad: Para ciertos medicamentos, L.A. Care Health Plan
Medicare Advantage limita la cantidad del medicamento que L.A. Care Health Plan
Medicare Advantage cubrirá. Por ejemplo, L.A. Care Health Plan Medicare Advantage
proporciona 62 cápsulas por receta para Geodon. Esto puede ser adicional al suministro
estándar de uno o tres meses.
xii
• Terapia por pasos: En algunos casos, L.A. Care Health Plan Medicare Advantage requiere
que primero use ciertos medicamentos para el tratamiento de su condición médica antes que
cubramos otro medicamento para esa condición. Por ejemplo, si tanto el medicamento A
como el medicamento B son para el tratamiento de su condición médica,
L.A. Care Health Plan Medicare Advantage quizás no cubra el medicamento B a menos que
primero pruebe el A. Si el medicamento A no le funciona, entonces L.A. Care Health Plan
Medicare Advantage cubrirá el medicamento B.
Puede averiguar si su medicamento tiene requisitos o límites adicionales consultando el formulario
que comienza en la página 1. También puede obtener más información sobre las restricciones
aplicadas a medicamentos cubiertos específicos visitando nuestro sitio web. Nuestra información
de contacto, junto con la fecha de la última actualización del formulario, aparece en las páginas de
la portada y contraportada.
Puede solicitar a L.A. Care Health Plan Medicare Advantage que haga una excepción a estas
restricciones o límites, o puede solicitar una lista de otros medicamentos similares que pueden
tratar su condición de salud. Consulte la sección, “¿Cómo solicito una excepción al formulario de
L.A. Care Health Plan Medicare Advantage?” en la página xiv para obtener información sobre
cómo solicitar una excepción.
¿Qué sucede si mi medicamento no está en el Formulario?
Si su medicamento no figura en este formulario (lista de medicamentos cubiertos), primero debe
ponerse en contacto con Servicios para los miembros y preguntar si dicho medicamento está
cubierto.
Si averigua que L.A. Care Health Plan Medicare Advantage no cubre su medicamento, tiene dos
opciones:
• Puede pedirle a Servicios para los miembros una lista de medicamentos similares que están
cubiertos por L.A. Care Health Plan Medicare Advantage. Cuando la reciba, muéstresela a su
médico y pídale que le recete un medicamento similar que sí está cubierto por
L.A. Care Health Plan Medicare Advantage.
• Puede pedirle a L.A. Care Health Plan Medicare Advantage que haga una excepción y cubra
su medicamento. Consulte la información en la siguiente página sobre cómo solicitar una
excepción.
xiii
¿Cómo solicito una excepción al Formulario de
L.A. Care Health Plan Medicare Advantage?
Puede pedirle a L.A. Care Health Plan Medicare Advantage que haga una excepción a las reglas
de cobertura. Existen varios tipos de excepciones que nos puede pedir.
• Puede pedirnos que cubramos un medicamento aunque no esté incluido en el formulario.
• Nos puede pedir que renunciemos a las restricciones de cobertura o límites en su medicamento.
Por ejemplo, para ciertos medicamentos L.A. Care Health Plan Medicare Advantage limita
la cantidad del medicamento que cubrirá. Si su medicamento tiene un límite en la cantidad,
nos puede pedir que renunciemos al límite y cubramos una mayor cantidad.
Por lo general, L.A. Care Health Plan Medicare Advantage solo aprobará su solicitud de excepción
si los medicamentos alternativos incluidos en el formulario del plan o las restricciones adicionales
de uso no son tan eficaces en el tratamiento de su condición y/o causarían que padezca efectos
adversos.
Debe contactarnos para obtener una decisión inicial de cobertura sobre una excepción al
formulario, o a las restricciones de uso. Cuando solicite una excepción a las restricciones
del formulario o de uso, deberá presentar una declaración de su médico respaldando
su solicitud. Por lo general, debemos tomar una decisión dentro de las primeras 72 horas de
recepción de la declaración de apoyo del médico que le recetó el medicamento. Puede solicitar una
excepción acelerada (rápida) si su médico o usted creen que su salud estará en peligro si esperan
la decisión hasta 72 horas. Si se concede su solicitud acelerada, debemos darle una decisión a más
tardar 24 horas después que obtengamos la declaración de apoyo de su médico u otro médico que
receta.
xiv
¿Qué debo hacer antes de hablar con mi médico sobre
cambiar mis medicamentos o solicitar una excepción?
Como un miembro nuevo o continuo de nuestro plan puede estar tomando medicamentos que
no están en nuestro formulario. O bien, usted puede estar tomando un medicamento que está en
nuestro formulario pero su capacidad de obtenerlo es limitada. Por ejemplo, quizás necesite nuestra
autorización previa antes de poder surtir su receta. Puede hablar con su médico para decidir si
debe cambiar a un medicamento apropiado que cubramos o solicitar una excepción al formulario
para que cubramos el medicamento que utiliza. Mientras consulta con su médico para determinar
el curso de acción correcto para usted, en ciertos casos podemos cubrir su medicamento durante
los primeros 90 días de su membresía en nuestro plan.
Para cada uno de sus medicamentos que no estén en nuestro formulario o si su capacidad de
obtenerlos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una
receta por menos días) cuando vaya a una farmacia de la red. Después de su primer suministro de
30 días, no pagaremos por esos medicamentos, incluso aunque haya sido miembro del plan menos
de 90 días.
Si usted es residente de un centro de atención a largo plazo, le permitiremos resurtir su receta hasta
que le hayamos proporcionado un suministro de transición de 93 días, consistente con el aumento
del surtido (a menos que tenga una receta por menos días). Cubriremos más de un surtido de
esos medicamentos por los primeros 90 días en que es miembro de nuestro plan. Si necesita un
medicamento que no está en nuestro formulario o su capacidad de obtenerlos es limitada, pero
han transcurrido los primeros 90 días de su membresía en nuestro plan, cubriremos un suministro
de emergencia de 31 días del medicamento (a menos que tenga una receta por menos días)
mientras busca una excepción al formulario.
Nota: Puede que experimente un cambio en el nivel de atención recibida y/o se le puede pedir que
vaya de un centro de tratamiento a otro. Existen excepciones para usted si ha sufrido un
cambio en el nivel de atención que ha estado recibiendo. Si sufre un cambio en el nivel de
atención, L.A. Care Health Plan Medicare Advantage cubrirá un suministro temporal de 31 días
(a menos que tenga una receta escrita por menos días).
xv
Para más información
Para información más detallada sobre su cobertura de medicamentos recetados de
L.A. Care Health Plan Medicare Advantage, revise su Evidencia de cobertura y otros materiales
del plan.
Si tiene preguntas sobre L.A. Care Health Plan Medicare Advantage, comuníquese con nosotros.
Nuestra información de contacto, junto con la fecha de la última actualización del formulario,
aparece en las páginas de la portada y contraportada.
Si tiene preguntas generales sobre la cobertura de medicamentos con receta de Medicare,
llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas al día, los 7 días de la
semana. Los usuarios de TTY/TDD deben llamar al 1-877-486-2048. O visite
www.medicare.gov.
L.A. Care Health Plan es un plan de salud con servicios de atención médica coordinada que tiene
contractos con Medicare y el programa California Medicaid. La inscripción en
L.A. Care Health Plan depende de la renovación del contrato.
Esta información está disponible de forma gratuita en otros idiomas y formatos diferentes,
incluyendo letra grande y audio. L.A. Care Health Plan también ofrece servicios de interpretación
de forma gratuita para las personas que no hablan inglés. Para mayores informes, comuníquese
con Servicios para los miembros al 1-888-522-1298, las 24 horas del día, los 7 días de la semana,
incluso los días festivos. Los usuarios de TTY/TDD deben llamar al 1-888-212-4460.
Formulario de L.A. Care Health Plan Medicare Advantage
El formulario en la página 1 proporciona información sobre la cobertura de los medicamentos
cubiertos por L.A. Care Health Plan Medicare Advantage. Si tiene problemas para ubicar su
medicamento en la lista, vaya al índice que empieza en la página I-1.
La primera columna de la tabla detalla el nombre del medicamento. Los nombres de marca van
en mayúsculas (p. ej., CYMBALTA), y los medicamentos genéricos en cursiva y minúsculas
(p. ej., lexapro).
La información en la columna de Requisitos/Límites le dice si L.A. Care Health Plan
Medicare Advantage tiene algún requisito especial de cobertura para su medicamento.
xvi
A B R E V I AT U R A S D E N O TA S D E C O B E R T U R A
Las siguientes abreviaturas pueden encontrarse dentro del cuerpo de este documento:
ABREVIATURA
DESCRIPCIÓN
E X P L I C AC I Ó N
Restricciones a la administración de uso
PA
PA BvD
PA NSO
QL
ST
Restricción de
autorización previa
Usted (o su médico) deben obtener una autorización previa de L.A. Care Health Plan
Medicare Advantage antes de surtir su receta para este medicamento. Sin una autorización
previa, L.A. Care Health Plan Medicare Advantage no podrá cubrir este medicamento.
Restricción de
Este medicamento puede ser elegible para su pago bajo la Parte B o Parte D de Medicare.
autorización previa
Usted (o su médico) deben obtener una autorización previa de L.A. Care Health Plan
para la determinación Medicare Advantage para determinar que este medicamento está cubierto por la Parte D
de la Parte B vs.
de Medicare, antes de surtir su receta. Sin una autorización previa, L.A. Care Health Plan
Parte D
Medicare Advantage no podrá cubrir este medicamento.
Restricción de
Si es un miembro nuevo, usted (o su médico) deben obtener una autorización previa
autorización previa
de L.A. Care Health Plan Medicare Advantage antes de surtir su receta para este
sólo para los
medicamento. Sin una autorización previa, L.A. Care Health Plan Medicare Advantage
miembros nuevos
no podrá cubrir este medicamento.
Restricción por
L.A. Care Health Plan Medicare Advantage limita la cantidad de este medicamento que
limitación de cantidad queda cubierta por cada prescripción, o dentro de tiempo específico.
Restricción de
Antes que L.A. Care Health Plan Medicare Advantage proporcione cobertura para este
terapia por pasos
medicamento, usted primero debe utilizar otro medicamento(s) para el tratamiento
de su condición médica. Este medicamento(s) sólo será cubierto si otros
medicamentos no funcionan para usted.
Otros requisitos especiales de cobertura
EX
Medicamento de la
Parte D excluido
LA
Medicamento de
acceso limitado
NM
Medicamento que
no se puede enviar
por postal
HI
Medicamento de
infusión casera
Este medicamento recetado normalmente no está cubierto en un Plan de Medicamentos
Recetados de Medicare. La cantidad que usted paga cuando surte una receta para este
medicamento no se contabiliza para sus costos totales de medicamentos (es decir, la
cantidad que paga no le ayuda a calificar para la cobertura catastrófica). Además, si está
recibiendo Ayuda adicional para pagar sus medicamentos recetados, no recibirá
ninguna Ayuda adicional para pagar este medicamento.
Esta receta puede estar disponible solo en ciertas farmacias. Para mayores informes
consulte su Directorio de farmacias o llame a Servicios para los miembros al
1-888-522-1298, las 24 horas del día, los 7 días de la semana, incluso los días
festivos. Los usuarios de TTY/TDD deben llamar al 1-888-212-4460.
Usted puede recibir un suministro de más de 1 mes para la mayoría de medicamentos
en su formulario por medio de un pedido por correo postal a costo compartido
reducido. Los medicamentos que no están disponibles por correo tienen la anotación
“NM” en la columna de notas de su formulario.
Este medicamento recetado quizás esté cubierto bajo nuestro beneficio médico. Para
mayores informes, comuníquese con Servicios para los miembros al 1-888-522-1298,
las 24 horas del día, los 7 días de la semana, incluso los días festivos. Los usuarios de
TTY/TDD deben llamar al 1-888-212-4460.
xvii
N I V E L 1 - M E D I C A M E N T O S G E N É R I CO S Y D E M A R C A
El monto de su pago compartido por
medicamentos genéricos es:
El monto de su pago compartido por
medicamentos de marca es:
Típicamente $1.20 por receta*
Típicamente $3.60 por receta*
*Los copagos pueden variar en base al nivel de subsidio por bajos ingresos que recibe.
A B R E V I AT U R A S D E P O T E N C I A Y D O S I S
adh. patch • parche adhesivo
aer br act • aerosol, activado por aliento
aer pow • aerosol, polvo
aer pow ba • aerosol de polvo, activado por aliento
aer refill • relleno de aerosol
aer w/adap • aerosol con adaptador
ampul • ampolleta
blkbaginj • inyección de bolsa a granel
cap dr mp • cápsula, multifásica de liberación retardada
cap ds pk • cápsula, paquete de dosis
cap er 12h • cápsula, liberación prolongada de 12 horas
cap er 24h • cápsula, liberación prolongada de 24 horas
cap er deg • cápsula, liberación prolongada degradable
cap er pel • cápsula, gránulos de liberación prolongada
cap mphase • cápsula, multifásica
cap.sa 24h • cápsula, acción prolongada de 24 horas
cap.sr 12h • cápsula, liberación prolongada de 12 horas
cap.sr 24h • cápsula, liberación prolongada de 24 horas
cap24h pct • cápsula, gránulos de liberación controlada de 24 horas
cap24h pel • cápsula, gránulos de liberación prolongada de 24 horas
cap sprink • cápsula, dispersable
cap sr pel • cápsula, gránulos de liberación prolongada
cap w/dev • cápsula con dispositivo
capsule dr • cápsula, liberación retardada
capsule er • cápsula, liberación prolongada
capsule sa • cápsula, acción prolongada
cmb cappad • combinación: cápsula, compresa
cmb ont fm • combinación: ungüento, espuma
cmb ont lt • combinación: ungüento, loción
cmb tabpad • combinación: tableta, compresa
combo. pkg • paquete de combinación
cpmp 12hr • cápsula, multifásica de 12 horas
cpmp 24hr • cápsula, multifásica de 24 horas
cpmp 30-70 • cápsula, multifásica, 30%–70%
xviii
cpmp 50-50 • cápsula, multifásica, 50%–50%
cream(g), cream(gm) • crema (gramos)
cream(ml) • crema (mililitros)
cream/appl • crema con aplicador
cream, er (g) • crema, liberación prolongada (gramos)
cream pack • crema, paquete
dehp fr bg • bolsa libre de di-2-etilhexilftalato
dis needle • aguja desechable
disk w/dev • disco con dispositivo de inhalación
disp syrin • jeringa desechable
drops susp • gotas, suspensión
drps hpvis • gotas, hiperviscosas
emul adhes • adhesivo de emulsión
emul packt • paquete de emulsión
emulsn(g) • emulsión (gramos)
foam/appl. • espuma con aplicador
froz.piggy • piggyback congelado
g • gramo
gel/pf app • gel aplicador pre-llenado
gel (gm) • gel (gramos)
gel (ml) • gel (mililitros)
gel md pmp • gel en bomba de dosis medida
gel w/appl • gel con aplicador
gel w/pump • gel con bomba
gran pack • paquete de gránulos
hfa aer ad • adaptador de aerosol hfa
infus. btl • envase de infusión
insuln pen • pluma de insulina
ip soln • solución intraperitoneal
irrig soln • solución de irrigación
iv soln. • solución intravenosa
jel • jalea
jelly/app • jalea con aplicador
jel/pf app • jalea con aplicador pre-llenado
A B R E V I AT U R A S D E P O T E N C I A Y D O S I S (C O N T.)
kit cl&crm • kit: limpiador y crema
kt crm le • kit: crema, loción emoliente
kt lotn ce • kit: loción, crema emoliente
kt oint le • kit: ungüento, loción emoliente
lotion, er • loción, liberación prolongada
lozenge hd • comprimido con aplicador bucal
m.ht patch • parche térmico medicado
ma buc tab • tableta bucal mucoadhesiva
Mcg • microgramo
med. pad • compresa medicada
med. swab • hisopo medicado
med. tape • cinta medicada
mg • miligramo
ml • mililitro
muc er 12h • sistema mucoadhesivo, liberación prolongada de 12 horas
ndl fr inj • aguja para inyección
nl fm susp • suspensión de esmalte de uñas
oint. (g), oint.(gm) • ungüento (gramos)
oral conc • concentrado oral
oral susp • suspensión oral
paste (g) • pasta (gramos)
patch td24 • parche, transdérmico de 24 horas
patch td72 • parche, transdérmico de 72 horas
patch tdsw • parche, transdérmico quincenal
patch tdwk • parche, transdérmico semanal
pca syring • analgésico en jeringa controlado por el paciente
pca vial • analgésico en ampolla controlado por el paciente
pellet(ea) • gránulo (cada uno)
pen ij kit • kit de inyector de pluma
pen injctr • inyector de pluma
pggybk btl • envase piggyback
plast. bag • bolsa plástica
powd pack • paquete de polvo
sol md pmp • solución con bomba multi-dosis
sol w/appl • solución con aplicador
sol/pf app • solución con aplicador pre-llenado
sol-gel • solución, gelificante
soln recon • solución, reconstituida
soln(gram) • solución (gramos)
spray susp • aerosol, suspensión
spray/pump • aerosol con bomba
stick(ea) • palillo (cada uno)
supp.rect • supositorio, rectal
supp.vag • supositorio, vaginal
suppos. • supositorio
sus er 24h • suspensión, liberación prolongada de 24 horas
sus er rec • suspensión, liberación prolongada reconstituida
sus mc rec • suspensión, micro-cápsula reconstituida
suspdr pkt • suspensión, paquete de liberación retrasada
susp recon • suspensión, reconstituida
syringekit • kit de jeringa
tab chew • tableta, masticable
tab er 12h • tableta, liberación prolongada de 12 horas
tab er 24h • tableta, liberación prolongada de 24 horas
tab er prt • tableta, partículas de liberación prolongada
tab er seq • tableta, efectos de liberación prolongada
tab disper • tableta, dispersable
tab ds pk • tableta, paquete de dosis
tab er 24 • tableta, liberación prolongada de 24 horas
tab mphase • tableta, multifásica
tab part • tableta, partículas
tab rap dr • tableta, desintegración rápida con liberación retardada
tab rapdis • tableta, desintegración rápida
tab subl • tableta, sublingual
tab.sr 12h • tableta, liberación prolongada de 12 horas
tab.sr 24h • tableta, liberación prolongada de 24 horas
tabergr24hr • tableta, liberación gradual prolongada de 24 horas
tablet dr • tableta, liberación retardada
tablet, er • tableta, liberación prolongada
tablet eff • tableta, efervescente
tablet sa • tableta, acción prolongada
tablet sol • tableta, soluble
tb er dspk • tableta, paquete de dosis de liberación prolongada
tb mp dspk • tableta, paquete de dosis multifásica
tb rd dspk • tableta, paquete de dosis de desintegración rápida
tbdspk 3mo • tableta, paquete de dosis de 3 meses
tbmp 12hr • tableta, multifásica de 12 horas
tbmp 24hr • tableta, multifásica de 24 horas
u • unidad
vag ring • anillo vaginal
xix
Index of Drugs
Índice de medicamentos
Drug Name
Drug Tier
Requirements/Limits
1
QL: 180 in tablet: 300mg-60mg
30 days
QL: 360 in tablet: 300mg-15mg,
30 days
300mg-30mg
(injectable)
PA, QL:
solution, (High Risk Med
2700 in 30 for Ages 65 and Older)
days
PA, QL:
tablet: 50-325-40, (High
180 in 30 Risk Med for Ages 65 and
days
Older)
PA, QL:
capsule: 50-300-30, (High
180 in 30 Risk Med for Ages 65 and
days
Older)
PA, QL:
capsule: 50-325-30, (High
180 in 30 Risk Med for Ages 65 and
days
Older)
PA, QL:
tablet: 50mg-325mg, (High
180 in 30 Risk Med for Ages 65 and
days
Older)
syringe, vial
QL: 5 in
spray
28 days
QL: 4 in
patch tdwk: 5mcg/hr,
28 days
10mcg/hr, 15mcg/hr,
20mcg/hr
QL: 4 in
patch tdwk: 7.5mcg/hr
28 days
QL: 2500
in 30 days
QL: 180 in tablet
30 days
PA, QL:
(High Risk Med for Ages 65
180 in 30 and Older)
days
PA, QL:
120 in 30
days
PA
Analgesics
Analgesics, Miscellaneous
acetaminophen with
(Vopac)
codeine
acetaminophen with
(Vopac)
codeine
buprenorphine hcl
(Buprenorphine HCl)
butalb/acetaminophen/
(Dolgic Lq)
caffeine
1
1
1
butalb/acetaminophen/
caffeine
(Esgic)
1
butalbit/acetamin/caff/
codeine
(Fioricet with Codeine)
1
butalbit/acetamin/caff/
codeine
(Fioricet with Codeine)
1
butalbital/acetaminophen (Tencon)
1
butorphanol tartrate
butorphanol tartrate
1
1
(Butorphanol Tartrate)
(Butorphanol Tartrate)
BUTRANS
1
BUTRANS
1
codeine phos/
acetaminophen
codeine sulfate
(Codeine Phos/
acetaminophen)
(Codeine Sulfate)
1
codeine/butalbital/asa/
caffein
(Fiorinal w/Codeine #3)
1
fentanyl citrate
(Actiq)
1
fentanyl
(Duragesic)
1
1
1
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
(Hycet)
1
(Hycet)
1
(Hycet)
1
(Norco)
1
(Norco)
1
(Norco)
1
hydrocodone/
acetaminophen
(Norco)
1
hydrocodone/
acetaminophen
hydrocodone/ibuprofen
(Norco)
1
(Ibudone)
1
hydromorphone hcl
(Dilaudid)
1
hydromorphone hcl
(Dilaudid)
1
hydromorphone hcl
(Dilaudid)
1
hydromorphone hcl
hydromorphone hcl/pf
hydromorphone hcl/pf
(Hydromorphone HCl)
(Dilaudid)
(Hydromorphone HCl/
PF)
(Combunox)
1
1
1
ibuprofen/oxycodone hcl
1
LAZANDA
1
levorphanol tartrate
(Levo-dromoran)
1
methadone hcl
methadone hcl
(Methadone HCl)
(Methadone HCl)
1
1
methadone hcl
(Methadose)
1
Requirements/Limits
QL: 2025
in 30 days
QL: 2700
in 30 days
QL: 2700
in 30 days
QL: 150 in
30 days
QL: 180 in
30 days
QL: 240 in
30 days
solution: 10-300/15
solution: 7.5-325/15
solution: 7.5-500/15, 10325/15
tablet: 7.5-750mg, 10750mg
tablet: 7.5-650mg, 10660mg, 10mg-650mg
capsule, tablet: 2.5-500mg,
5mg-500mg, 7.5-500mg,
10mg-500mg
QL: 360 in tablet: 2.5-325mg, 5mg30 days
325mg, 7.5-325mg, 10mg325mg
QL: 390 in tablet: 5mg-300mg, 7.530 days
300mg, 10mg-300mg
QL: 150 in
30 days
QL: 1200 liquid
in 30 days
QL: 180 in tablet: 2mg, 4mg
30 days
QL: 240 in tablet: 8mg
30 days
syringe
ampul
vial
QL: 28 in
30 days
PA, QL:
30 in 30
days
QL: 180 in
30 days
QL: 1800
in 30 days
QL: 1800
in 30 days
vial
solution
oral conc
2
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
methadone hcl
(Methadose)
1
methadone hcl
(Methadose)
1
morphine sulfate
(Morphine Sulfate)
1
morphine sulfate
morphine sulfate
(Morphine Sulfate)
(MS Contin)
1
1
morphine sulfate
(MS Contin)
1
morphine sulfate
(MSIR)
1
morphine sulfate
(MSIR)
1
morphine sulfate
(MSIR)
1
morphine sulfate/0.9%
nacl/pf
morphine sulfate/pf
MORPHINE SULFATE
(Morphine Sulfate/0.9%
Nacl/PF)
(Morphine Sulfate/PF)
1
nalbuphine hcl
NUCYNTA ER
(Nalbuphine HCl)
1
1
1
1
NUCYNTA
1
OFIRMEV
oxycodone hcl
(Dazidox)
1
1
oxycodone hcl
(Oxycodone HCl)
1
oxycodone hcl/
acetaminophen
oxycodone hcl/
acetaminophen
oxycodone hcl/
acetaminophen
(Alcet)
1
(Alcet)
1
(Alcet)
1
oxycodone hcl/
acetaminophen
(Oxycodone HCl/
acetaminophen)
1
Requirements/Limits
QL: 360 in tablet
30 days
QL: 90 in tablet sol
30 days
ampul, cartridge: 8mg/ml,
10mg/ml, 15mg/ml; pen
injctr, supp.rect, syringe,
vial, vial port
cartridge: 2mg/ml, 4mg/ml
QL: 120 in tablet er: 30mg, 60mg,
30 days
100mg
QL: 180 in tablet er: 15mg, 200mg
30 days
QL: 200 in solution: 100mg/5ml
30 days
QL: 300 in solution: 20mg/5ml
30 days
QL: 700 in solution: 10mg/5ml
30 days
QL: 180 in
30 days
QL: 60 in
30 days
QL: 181 in
30 days
QL: 180 in
30 days
QL: 1300
in 30 days
QL: 180 in
30 days
QL: 240 in
30 days
QL: 360 in
30 days
QL: 1800
in 30 days
capsule, oral conc, tablet
solution
tablet: 10mg-650mg
capsule, tablet: 5mg-500mg,
7.5-500mg
tablet: 2.5-325mg, 5mg325mg, 7.5-325mg, 10mg325mg
solution
3
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
oxycodone hcl/aspirin
Drug Tier
(Endodan)
1
OXYCONTIN
1
OXYCONTIN
1
oxymorphone hcl
(Opana ER)
1
oxymorphone hcl
(Opana ER)
1
oxymorphone hcl
(Opana)
1
tramadol hcl
(Ultram)
1
tramadol hcl/
acetaminophen
XARTEMIS XR
(Ultracet)
1
1
Nonsteroidal Anti-inflammatory Agents
butalbital/aspirin/caffeine (Fiorinal)
1
CALDOLOR
CELEBREX
1
1
choline sal/mag salicylate (Choline Sal/mag
Salicylate)
diclofenac potassium
(Cataflam)
diclofenac sodium
(Voltaren)
1
diclofenac sodium/
misoprostol
diflunisal
etodolac
fenoprofen calcium
FLECTOR
flurbiprofen
ibuprofen
indomethacin sodium
(Arthrotec 50)
1
(Diflunisal)
(Etodolac)
(Fenoprofen Calcium)
1
1
1
1
1
1
1
Requirements/Limits
QL: 360 in
30 days
QL: 120 in
30 days
QL: 60 in
30 days
QL: 120 in
30 days
QL: 60 in
30 days
QL: 180 in
30 days
QL: 240 in
30 days
QL: 240 in
30 days
QL: 360 in
30 days
PA, QL:
180 in 30
days
tab er 12h: 10mg, 15mg,
20mg, 30mg, 40mg, 60mg
tab er 12h: 30mg, 40mg
tab er 12h: 5mg, 7.5mg,
10mg, 15mg, 20mg
tablet
tablet
(High Risk Med for Ages 65
and Older)
ST, QL: 60
in 30 days
1
1
(Ansaid)
(Motrin)
(Indocin I.v.)
tab er 12h: 80mg
gel (gram), tab er 24h, tablet
dr
PA
oral susp: 100mg/5ml; tablet
(High Risk Med for Ages 65
and Older)
4
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
indomethacin
(Indocin SR)
1
indomethacin
(Indomethacin)
1
indomethacin
(Indomethacin)
1
ketoprofen
ketorolac tromethamine
1
1
ketorolac tromethamine
(Ketoprofen)
(Ketorolac
Tromethamine)
(Toradol)
ketorolac tromethamine
(Toradol)
1
ketorolac tromethamine
(Toradol)
1
mefenamic acid
meloxicam
nabumetone
naproxen sodium
naproxen
piroxicam
salsalate
sulindac
tolmetin sodium
VOLTAREN
(Ponstel)
(Mobic)
(Relafen)
(Anaprox)
(Naprosyn)
(Feldene)
(Salflex)
(Clinoril)
(Tolmetin Sodium)
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
PA, QL:
60 in 30
days
PA, QL:
120 in 30
days
PA, QL:
240 in 30
days
capsule er, (High Risk Med
for Ages 65 and Older)
QL: 40 in
30 days
QL: 20 in
30 days
QL: 20 in
30 days
QL: 40 in
30 days
vial: 15mg/ml
capsule: 50mg, (High Risk
Med for Ages 65 and Older)
capsule: 25mg, (High Risk
Med for Ages 65 and Older)
cartridge: 30mg/ml
tablet, vial: 60mg/2ml
cartridge: 15mg/ml
(Topical Gel)
Anesthetics
Local Anesthetics
cocaine hcl
(Cocaine HCl)
lidocaine hcl
(Xylocaine)
lidocaine hcl
(Xylocaine)
1
1
1
lidocaine hcl
lidocaine hcl/pf
(Xylocaine)
(Xylocaine-MPF)
1
1
PA BvD
PA BvD
lidocaine
(Lidocaine)
1
PA BvD
lidocaine/prilocaine
LIDODERM
(EMLA)
1
1
PA BvD
disp syrin, solution: 4%
jel (ml), jel/pf app, solution:
2%, 40mg/ml
vial, (PA for ESRD Only)
ampul: 15mg/ml, 40mg/ml,
(PA for ESRD Only)
oint. (g), (PA for ESRD
Only)
(PA for ESRD Only)
5
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Anti-addiction/substance Abuse Treatment Agents
Anti-addiction/substance Abuse Treatment Agents
acamprosate calcium
(Campral)
1
buprenorphine hcl
(Subutex)
1
buprenorphine hcl/
naloxone hcl
(Suboxone)
1
CAMPRAL
CHANTIX
1
1
CHANTIX
1
CHANTIX
1
disulfiram
naloxone hcl
naloxone hcl
naltrexone hcl
NICOTROL
(Antabuse)
(Naloxone HCl)
(Naloxone HCl)
(Revia)
1
1
1
1
1
SUBOXONE
1
SUBOXONE
1
ZUBSOLV
1
PA, QL:
90 in 30
days
PA, QL:
90 in 30
days
tab ds pk
QL: 168 in tablet: 0.5mg, 1mg
84 days
QL: 53 in tab ds pk
28 days
QL: 56 in tablet: 1mg
28 days
syringe: 0.4mg/ml; vial
syringe: 1mg/ml
QL: 2016
in 365
days
PA, QL:
60 in 30
days
PA, QL:
90 in 30
days
PA, QL:
90 in 30
days
film: 12mg-3mg
film: 2mg-0.5mg, 4mg-1mg,
8mg-2mg
Antianxiety Agents
Benzodiazepines
alprazolam
(Xanax XR)
1
alprazolam
(Xanax)
1
chlordiazepoxide hcl
(Librium)
1
clonazepam
(Klonopin)
1
QL: 60 in
30 days
QL: 90 in
30 days
QL: 120 in
30 days
QL: 300 in
30 days
tab er 24h: 1mg, 2mg, 3mg
tab er 24h: 0.5mg; tab
rapdis, tablet
tab rapdis: 2mg; tablet: 2mg
6
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
clonazepam
(Klonopin)
1
clorazepate dipotassium
(Tranxene T-tab)
1
clorazepate dipotassium
(Tranxene T-tab)
1
DIASTAT ACUDIAL
diazepam
diazepam
(Diastat)
(Diazepam)
1
1
1
diazepam
(Valium)
1
diazepam
(Valium)
1
estazolam
(Prosom)
1
flurazepam hcl
(Dalmane)
1
lorazepam
(Ativan)
1
lorazepam
(Ativan)
1
lorazepam
(Lorazepam)
1
midazolam hcl
(Midazolam HCl)
1
midazolam hcl
(Versed)
1
midazolam hcl/pf
(Midazolam HCl/PF)
1
ONFI
1
ONFI
1
ONFI
1
temazepam
(Restoril)
1
Requirements/Limits
QL: 90 in
30 days
tab rapdis: 0.125mg,
0.25mg, 0.5mg, 1mg; tablet:
0.5mg, 1mg
QL: 120 in tablet: 15mg
30 days
QL: 60 in tablet: 3.75mg, 7.5mg
30 days
QL: 1200
in 30 days
QL: 120 in
30 days
QL: 2 in
28 days
QL: 30 in
30 days
QL: 30 in
30 days
QL: 2 in
30 days
QL: 90 in
30 days
QL: 150 in
30 days
QL: 10 in
30 days
QL: 2 in
30 days
QL: 2 in
30 days
PA NSO,
QL: 480 in
30 days
PA NSO,
QL: 60 in
30 days
PA NSO,
QL: 60 in
30 days
QL: 30 in
30 days
kit
oral conc, solution
tablet
syringe
syringe, vial
tablet
oral conc
syrup
syringe
oral susp
tablet: 10mg, 20mg
tablet: 5mg
7
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
triazolam
Drug Tier
(Halcion)
Requirements/Limits
1
QL: 30 in
30 days
1
1
PA BvD
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl, isoosm
gentamicin in nacl, isoosm
gentamicin sulfate
gentamicin sulfate/pf
kanamycin sulfate
neomycin sulfate
streptomycin sulfate
TOBI PODHALER
(Gentamicin In Nacl,
Iso-osm)
(Gentamicin In Nacl,
Iso-osm)
piggyback: 100mg/50ml
1
(Garamycin)
(Gentamicin Sulfate/PF)
(Kanamycin Sulfate)
(Neomycin Sulfate)
(Streptomycin Sulfate)
1
1
1
1
1
1
tobramycin in 0.225%
(Tobi)
nacl
tobramycin sulfate
(Nebcin)
tobramycin/sodium
(Tobramycin/sodium
chloride
Chloride)
tobramycin/sodium
(Tobramycin/sodium
chloride
Chloride)
Antibacterials, Miscellaneous
bacitracin
(Bacitracin)
chloramphenicol sod succ (Chloramphenicol Sod
Succ)
clindamycin hcl
(Cleocin HCl)
clindamycin palmitate hcl (Cleocin Palmitate)
clindamycin phosphate
(Cleocin Phosphate)
clindamycin phosphate/
(Cleocin Phosphate In
d5w
D5w)
colistin (colistimethate
(Coly-mycin M
na)
Parenteral)
CUBICIN
FUROXONE
methenamine hippurate
(Urex)
1
piggyback: 60mg/50ml,
70mg/50ml, 80mg/100ml,
80mg/50ml, 90mg/100ml,
100mg/0.1l
QL: 224 in
28 days
PA BvD
1
1
piggyback: 60mg/50ml
1
piggyback: 80mg/100ml
1
1
1
1
1
1
vial port
1
1
1
1
PA BvD
(PA for ESRD Only)
8
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Requirements/Limits
nitrofurantoin
macrocrystal
(Macrodantin)
1
nitrofurantoin
(Furadantin)
1
polymyxin b sulfate
SYNERCID
trimethoprim
vancomycin hcl
vancomycin hcl
(Polymyxin B Sulfate)
(Trimethoprim)
(Vancocin HCl)
(Vancomycin HCl)
1
1
1
1
1
PA BvD
vancomycin hcl
(Vancomycin HCl)
1
PA BvD
vancomycin hcl/d5w
VANCOMYCIN HCL
XIFAXAN
(Vancomycin HCl/D5W)
1
1
1
XIFAXAN
1
ZYVOX
Cephalosporins
cefaclor
cefadroxil
cefazolin sodium
cefazolin sodium/
dextrose,iso
cefazolin sodium/
dextrose,iso
cefdinir
cefditoren pivoxil
cefditoren pivoxil
cefepime hcl
CEFEPIME
CEFEPIME-DEXTROSE
cefotaxime sodium
cefotetan disod/
dextrose,iso
1
(Ceclor)
(Cefadroxil)
(Ancef)
(Cefazolin Sodium/
dextrose, Iso)
(Cefazolin Sodium/
dextrose, Iso)
(Omnicef)
(Spectracef)
(Spectracef)
(Maxipime)
(High Risk Med. QL applies
to all members; PA required
for 65 years and older with
over 90 days cumulative use
of nitrofurantoin drugs)
PA, QL:
(High Risk Med. QL applies
2400 in 30 to all members; PA required
days
for 65 years and older with
over 90 days cumulative use
of nitrofurantoin drugs)
capsule
vial: 1g, 10g, (PA for ESRD
Only)
vial: 750mg, (PA for ESRD
Only)
PA, QL: 9 tablet: 200mg
in 30 days
ST, QL: 60 tablet: 550mg
in 30 days
1
1
1
1
froz.piggy
1
piggyback
1
1
1
1
1
1
1
1
(Claforan)
(Cefotetan Disod/
dextrose, Iso)
PA, QL:
120 in 30
days
tablet: 200mg
tablet: 400mg
9
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
cefotetan disodium
cefoxitin sodium
cefoxitin sodium/
dextrose,iso
cefpodoxime proxetil
cefprozil
ceftazidime pentahydrate
ceftazidime pentahydrate
ceftibuten dihydrate
ceftriaxone na/
dextrose,iso
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
cefuroxime sodium/
dextrose,iso
cephalexin
(Cefotetan Disodium)
(Mefoxin)
(Cefoxitin Sodium/
dextrose, Iso)
(Vantin)
(Cefzil)
(Fortaz)
(Fortaz)
(Cedax)
(Ceftriaxone Na/
dextrose, Iso)
(Rocephin)
(Ceftin)
(Zinacef)
(Cefuroxime Sodium/
dextrose, Iso)
(Keflex)
1
1
1
cephalexin
SUPRAX
TAZICEF IN
DEXTROSE
tea tree oil
Macrolides
azithromycin
clarithromycin
DIFICID
(Keflex)
1
1
1
(Tea Tree Oil)
1
(Zithromax)
(Biaxin)
1
1
1
ery e-succ/sulfisoxazole
ERY-TAB
ERYTHROCIN
LACTOBIONATE
ERYTHROCIN
LACTOBIONATE
erythromycin base
erythromycin base
erythromycin
ethylsuccinate
erythromycin
ethylsuccinate
erythromycin stearate
KETEK
(Pediazole)
Requirements/Limits
1
1
1
1
1
1
vial
vial port
1
1
1
1
tablet
1
(Eryc)
(Erythromycin Base)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Ethylsuccinate)
(Erythromycin Stearate)
capsule: 250mg, 500mg;
susp recon, tablet
capsule: 750mg
tab chew, tablet
QL: 20 in
10 days
1
1
1
vial port: 1g
1
vial port: 500mg
1
1
1
capsule dr
tablet, tablet dr
susp recon
1
tablet
1
1
ST
10
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Miscellaneous B-lactam Antibiotics
aztreonam
(Azactam)
CAYSTON
imipenem/cilastatin
(Primaxin)
sodium
INVANZ
INVANZ
meropenem
(Merrem)
Penicillins
amoxicillin trihydrate
(Amoxicillin Trihydrate)
amoxicillin
(Amoxil)
amoxicillin/potassium
clav
ampicillin sodium
ampicillin sodium
ampicillin sodium/
sulbactam na
ampicillin sodium/
sulbactam na
ampicillin trihydrate
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
NAFCILL IN
DEXTROSE
nafcillin sodium
nafcillin sodium
oxacillin sodium
oxacillin sodium/
dextrose,iso
pen g pot/dextrose-water
pen g pot/dextrose-water
penicillin g potassium
penicillin g potassium/
d5w
penicillin g procaine
penicillin g procaine
penicillin v potassium
1
1
1
1
1
1
1
1
Requirements/Limits
LA
vial
vial port
capsule, susp recon, tab
chew, tablet
(Augmentin)
1
(Totacillin-N)
(Totacillin-N)
(Unasyn)
1
1
1
vial
vial port
vial
(Unasyn)
1
vial port
(Ampicillin Trihydrate)
1
1
1
1
1
(Dicloxacillin Sodium)
(Unipen)
(Unipen)
(Oxacillin Sodium)
(Oxacillin Sodium/
dextrose, Iso)
(Pen G Pot/dextrosewater)
(Pen G Pot/dextrosewater)
(Penicillin G Potassium)
(Penicillin G Potassium/
D5W)
(Penicillin G Procaine)
(Penicillin G Procaine)
(Veetids 500)
1
1
1
1
vial
vial port
1
froz.piggy: 1mm/50ml
1
froz.piggy: 2mm/50ml,
3mm/50ml
1
1
1
1
1
syringe: 1.2mm/2ml
syringe: 600000/ml
11
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
piperacillin sodium/
tazobactam
Quinolones
AVELOX ABC PACK
AVELOX IV
ciprofloxacin hcl
ciprofloxacin lactate
ciprofloxacin lactate/d5w
ciprofloxacin
ciprofloxacin/ciprofloxa
hcl
levofloxacin
levofloxacin/d5w
moxifloxacin hcl
nalidixic acid
ofloxacin
Sulfonamides
sulfadiazine
sulfamethoxazole/
trimethoprim
sulfasalazine
Tetracyclines
demeclocycline hcl
doxycycline hyclate
doxycycline hyclate
Drug Tier
(Zosyn)
1
(Cipro)
(Cipro I.V.)
(Cipro I.V.)
(Ciprofloxacin)
(Cipro XR)
1
1
1
1
1
1
1
(Levaquin)
(Levaquin)
(Avelox)
(Nalidixic Acid)
(Floxin)
1
1
1
1
1
(Sulfadiazine)
(Septra)
1
1
(Azulfidine)
1
(Declomycin)
(Morgidox)
(Morgidox)
1
1
1
doxycycline monohydrate (Adoxa)
doxycycline monohydrate (Adoxa)
1
1
MINOCIN
minocycline hcl
tetracycline hcl
TYGACIL
1
1
1
1
(Dynacin)
(Ala-tet)
Requirements/Limits
capsule dr, tablet: 100mg
capsule, tablet: 20mg; tablet
dr, vial
capsule: 150mg
capsule: 75mg, 100mg; susp
recon, tablet
vial
Anticancer Agents
Anticancer Agents
ABRAXANE
ADCETRIS
1
1
AFINITOR DISPERZ
1
PA NSO,
QL: 3 in
21 days
PA NSO,
QL: 112 in
28 days
12
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
AFINITOR
1
ALIMTA
anastrozole
ARRANON
ARZERRA
1
1
1
1
AVASTIN
azacitidine
BELEODAQ
BEXXAR
bicalutamide
BICNU
bleomycin sulfate
BOSULIF
(Arimidex)
1
1
1
1
1
1
1
1
(Vidaza)
(Casodex)
(Bleomycin Sulfate)
BOSULIF
1
BUSULFEX
CAPRELSA
1
1
CAPRELSA
1
carboplatin
CEENU
CEENU
cisplatin
cladribine
CLOLAR
COMETRIQ
(Carboplatin)
1
1
1
1
1
1
1
cyclophosphamide
(Cyclophosphamide)
1
cyclophosphamide
(Cytoxan)
1
(Cisplatin)
(Leustatin)
Requirements/Limits
PA NSO,
QL: 28 in
28 days
PA NSO
PA NSO,
QL: 80 in
30 days
PA NSO
PA NSO
PA BvD
PA NSO, tablet: 100mg
QL: 120 in
30 days
PA NSO, tablet: 500mg
QL: 30 in
30 days
PA NSO,
QL: 30 in
30 days
PA NSO,
QL: 60 in
30 days
tablet: 300mg
tablet: 100mg
capsule: 100mg
capsule: 10mg, 40mg
PA BvD
PA NSO,
QL: 112 in
28 days
PA BvD,
tablet
ST
PA BvD
vial
13
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
CYCLOPHOSPHAMIDE
CYRAMZA
cytarabine/pf
cytarabine/pf
dacarbazine
dactinomycin
daunorubicin hcl
DAUNOXOME
decitabine
DOCEFREZ
docetaxel
docetaxel
doxorubicin hcl pegliposomal
doxorubicin hcl
DROXIA
ELIGARD
1
1
1
1
1
1
1
1
1
1
1
1
1
(Cytarabine/PF)
(Cytarabine/PF)
(Dtic-Dome IV)
(Cosmegen)
(Cerubidine)
(Dacogen)
(Taxotere)
(Taxotere)
(Doxil)
(Adriamycin RDF)
1
1
1
ELIGARD
1
ELIGARD
1
ELIGARD
1
ELSPAR
EMCYT
epirubicin hcl
ERBITUX
ERIVEDGE
1
1
1
1
1
(Ellence)
ERWINAZE
ETOPOPHOS
etoposide
exemestane
FARESTON
FASLODEX
FIRMAGON
floxuridine
1
1
1
1
1
1
1
1
(Etoposide)
(Aromasin)
(FUDR)
Requirements/Limits
PA BvD,
ST
PA NSO
PA BvD
PA BvD
vial: 1g, 100mg
vial: 500mg
vial: 20mg/2ml, 20mg/ml(1)
vial: fnl20mg/2
PA BvD
PA BvD
vial: 10mg
QL: 1 in
112 days
QL: 1 in
168 days
QL: 1 in
28 days
QL: 1 in
84 days
syringe: 30mg
syringe: 45mg
syringe: 7.5mg
syringe: 22.5mg
PA NSO
PA NSO,
QL: 30 in
30 days
PA NSO,
QL: 60 in
30 days
PA NSO
PA BvD
14
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
fludarabine phosphate
fluorouracil
fluorouracil
flutamide
FOLOTYN
GAZYVA
gemcitabine hcl
GILOTRIF
Drug Tier
(Fludara)
(Fluorouracil)
(Fluorouracil)
(Flutamide)
1
1
1
1
1
1
1
1
(Gemzar)
GLEEVEC
1
GLEEVEC
1
HALAVEN
1
HERCEPTIN
HEXALEN
hydroxyurea
ICLUSIG
1
1
1
1
(Hydrea)
ICLUSIG
idarubicin hcl
ifosfamide
ifosfamide/mesna
IMBRUVICA
1
(Idamycin Pfs)
(Ifex)
(Ifex-mesnex)
1
1
1
1
INLYTA
1
INLYTA
1
irinotecan hcl
ISTODAX
(Camptosar)
1
1
Requirements/Limits
PA BvD
PA BvD
vial: 1g/20ml
vial: 500mg/10ml
PA NSO
PA NSO,
QL: 30 in
30 days
PA NSO,
QL: 60 in
30 days
PA NSO,
QL: 90 in
30 days
PA NSO,
QL: 24 in
28 days
PA NSO
PA NSO,
QL: 30 in
30 days
PA NSO,
QL: 60 in
30 days
tablet: 400mg
tablet: 100mg
tablet: 45mg
tablet: 15mg
PA BvD
PA BvD
kit: 1g-1g, 3g-1g
PA NSO,
QL: 120 in
30 days
PA NSO, tablet: 1mg
QL: 180 in
30 days
PA NSO, tablet: 5mg
QL: 60 in
30 days
PA NSO
15
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
IXEMPRA
JAKAFI
1
1
JEVTANA
KADCYLA
1
1
KYPROLIS
1
letrozole
LEUKERAN
leuprolide acetate
(Femara)
lomustine
LUPRON DEPOT
(Ceenu)
1
1
1
(Leuprolide Acetate)
1
1
LUPRON DEPOT
1
LUPRON DEPOT
1
LUPRON DEPOT-PED
1
LUPRON DEPOT-PED
1
LYSODREN
MARQIBO
1
1
MATULANE
MEGACE ES
megestrol acetate
MEKINIST
1
1
1
1
(Megace)
MEKINIST
melphalan hcl
mercaptopurine
1
(Alkeran)
(Purinethol)
Requirements/Limits
PA NSO,
QL: 60 in
30 days
PA NSO,
QL: 2 in
21 days
PA NSO,
QL: 6 in
21 days
PA NSO
QL: 2 in
28 days
QL: 1 in
168 days
QL: 1 in
28 days
QL: 1 in
84 days
QL: 1 in
112 days
QL: 1 in
28 days
syringekit: 45mg
syringekit: 3.75mg
syringekit: 11.25mg, 22.5mg
syringekit: 30mg
kit, syringekit: 11.25mg
PA NSO,
QL: 4 in
28 days
PA NSO,
QL: 30 in
30 days
PA NSO,
QL: 90 in
30 days
tablet: 2mg
tablet: 0.5mg
1
1
16
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
methotrexate sodium
(Methotrexate Sodium)
1
methotrexate sodium
methotrexate sodium/pf
(Methotrexate Sodium)
(Methotrexate Sodium/
PF)
(Mitomycin)
(Novantrone)
1
1
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
NILANDRON
ONCASPAR
ONTAK
oxaliplatin
paclitaxel
pentostatin
PERJETA
1
1
1
1
1
1
1
1
1
1
1
(Eloxatin)
(Taxol)
(Nipent)
POMALYST
1
PROLEUKIN
PURIXAN
REVLIMID
1
1
1
RITUXAN
SOLTAMOX
SPRYCEL
1
1
1
STIVARGA
1
SUTENT
1
SYLVANT
SYLVANT
1
1
Requirements/Limits
PA BvD,
ST
PA BvD
PA BvD
tablet
vial
PA BvD
PA NSO,
QL: 120 in
30 days
PA NSO,
QL: 14 in
21 days
PA NSO,
QL: 21 in
28 days
LA, PA
NSO, QL:
28 in 28
days
PA NSO
PA NSO,
QL: 30 in
30 days
PA NSO,
QL: 84 in
28 days
PA NSO,
QL: 30 in
30 days
PA NSO
PA NSO
vial: 100mg
vial: 400mg
17
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
SYNRIBO
1
TABLOID
TAFINLAR
1
1
tamoxifen citrate
TARCEVA
(Nolvadex)
1
1
TARGRETIN
1
TASIGNA
1
TEMODAR
teniposide
thiotepa
topotecan hcl
TORISEL
1
1
1
1
1
(Teniposide)
(Thiotepa)
(Hycamtin)
TREANDA
TRELSTAR
1
1
TRELSTAR
1
TRELSTAR
1
tretinoin
TREXALL
TRISENOX
TYKERB
VALSTAR
VECTIBIX
VELCADE
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
(Tretinoin)
1
1
1
1
1
1
1
1
1
1
(Vinblastine Sulfate)
(Vincristine Sulfate)
(Navelbine)
Requirements/Limits
PA NSO,
QL: 28 in
28 days
PA NSO,
QL: 120 in
30 days
PA NSO,
QL: 30 in
30 days
PA NSO,
QL: 420 in
30 days
PA NSO,
QL: 112 in
28 days
PA NSO
(vial only)
PA BvD,
QL: 4 in
28 days
QL: 1 in
168 days
QL: 1 in
28 days
QL: 1 in
84 days
vial
syringe: 3.75mg/2ml
syringe: 11.25/2ml
(capsule: 10mg)
PA BvD,
ST
PA NSO
PA NSO
PA BvD
PA BvD
18
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
VOTRIENT
1
VUMON
XALKORI
1
1
XTANDI
1
YERVOY
ZALTRAP
ZANOSAR
ZELBORAF
1
1
1
1
ZOLADEX
1
ZOLADEX
1
ZOLINZA
ZYDELIG
1
1
ZYKADIA
1
ZYTIGA
1
Requirements/Limits
PA NSO,
QL: 120 in
30 days
PA NSO,
QL: 60 in
30 days
PA NSO,
QL: 120 in
30 days
PA NSO
PA NSO
PA NSO,
QL: 240 in
30 days
QL: 1 in
implant: 3.6mg
28 days
QL: 1 in
implant: 10.8mg
84 days
PA NSO,
QL: 60 in
30 days
PA NSO,
QL: 140 in
28 days
PA NSO,
QL: 120 in
30 days
Anticholinergic Agents
Antimuscarinics/antispasmodics
ANORO ELLIPTA
1
atropine sulfate
atropine sulfate
propantheline bromide
(Atropine Sulfate)
(Atropine Sulfate)
(Propantheline Bromide)
1
1
1
(Tegretol)
1
1
1
QL: 60 in
30 days
syringe
vial
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine
ST
ST
19
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
CELONTIN
DILANTIN
divalproex sodium
ethosuximide
felbamate
fosphenytoin sodium
FYCOMPA
gabapentin
GABITRIL
LAMICTAL
lamotrigine
lamotrigine
levetiracetam in nacl
(iso-os)
levetiracetam
LUMINAL SODIUM
Drug Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
(Depakote ER)
(Zarontin)
(Felbatol)
(Cerebyx)
(Neurontin)
(Lamictal (blue))
(Lamictal)
(Levetiracetam In Nacl
(iso-os))
(Keppra)
1
1
LYRICA
1
LYRICA
1
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital sodium
(Trileptal)
(Phenobarbital Sodium)
1
1
1
1
phenobarbital
(Phenobarbital)
1
phenobarbital
(Phenobarbital)
1
phenobarbital
(Phenobarbital)
1
(Dilantin)
1
1
PHENYTEK
phenytoin sodium
extended
phenytoin sodium
phenytoin sodium
phenytoin
POTIGA
(Phenytoin Sodium)
(Phenytoin Sodium)
(Dilantin)
1
1
1
1
Requirements/Limits
capsule: 30mg
ST
tablet: 12mg, 16mg
tb chw dsp: 2mg
tab ds pk
tab er 24, tablet, tb chw dsp
QL: 2 in
syringe
30 days
QL: 90 in capsule
30 days
QL: 900 in solution
30 days
ST
QL: 2 in
30 days
QL: 1500
in 30 days
QL: 200 in
30 days
QL: 90 in
30 days
vial: 65mg/ml, 130mg/ml
elixir: 20mg/5ml
tablet: 30mg
tablet: 15mg, 16.2mg,
32.4mg, 60mg, 64.8mg,
97.2mg, 100mg
ampul
syringe
ST, QL:
270 in 30
days
tablet: 50mg
20
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
POTIGA
primidone
QUDEXY XR
SABRIL
TEGRETOL XR
tiagabine hcl
topiramate
topiramate
TRILEPTAL
TROKENDI XR
valproic acid (as sodium
salt)
valproic acid
VIMPAT
1
(Mysoline)
1
1
1
1
1
1
1
1
1
1
(Gabitril)
(Topamax)
(Topiramate)
(Depakene)
(Depakene)
1
1
VIMPAT
1
VIMPAT
1
zonisamide
(Zonegran)
Requirements/Limits
ST, QL: 90 tablet: 200mg, 300mg,
in 30 days 400mg
ST
tab er 12h: 100mg
cap sprink, tablet
cap spr 24
oral susp
ST
ST, QL:
solution
1200 in 30
days
ST, QL:
vial
200 in 5
days
ST, QL: 60 tablet
in 30 days
1
Antidementia Agents
Antidementia Agents
donepezil hcl
(Aricept)
1
EXELON
1
EXELON
1
galantamine hbr
(Razadyne ER)
1
galantamine hbr
(Razadyne)
1
galantamine hbr
(Razadyne)
1
NAMENDA XR
1
NAMENDA XR
1
QL: 30 in
30 days
QL: 232 in
30 days
QL: 30 in
30 days
QL: 30 in
30 days
QL: 200 in
30 days
QL: 60 in
30 days
QL: 28 in
28 days
QL: 30 in
30 days
solution
patch td24
cap24h pel
solution
tablet
cap24 dspk
cap spr 24
21
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
NAMENDA
1
NAMENDA
1
NAMENDA
1
rivastigmine tartrate
(Exelon)
1
(Amitriptyline HCl)
1
amoxapine
BRINTELLIX
bupropion hcl
citalopram hydrobromide
citalopram hydrobromide
(Amoxapine)
(Wellbutrin XL)
(Celexa)
(Celexa)
1
1
1
1
1
clomipramine hcl
(Anafranil)
1
Requirements/Limits
QL: 360 in solution
30 days
QL: 49 in tab ds pk
28 days
QL: 60 in tablet
30 days
QL: 60 in
30 days
Antidepressants
Antidepressants
amitriptyline hcl
desipramine hcl
(Norpramin)
DESVENLAFAXINE ER
1
1
doxepin hcl
(Doxepin HCl)
1
duloxetine hcl
(Cymbalta)
1
duloxetine hcl
(Cymbalta)
1
EMSAM
1
escitalopram oxalate
(Lexapro)
1
escitalopram oxalate
(Lexapro)
1
FETZIMA
fluoxetine hcl
fluvoxamine maleate
imipramine hcl
(Prozac)
(Fluvoxamine Maleate)
(Tofranil)
1
1
1
1
imipramine pamoate
(Tofranil-PM)
1
PA NSO
(High Risk Med for Ages 65
and Older)
ST
QL: 30 in
30 days
PA NSO
solution
tablet
(High Risk Med for Ages 65
and Older)
ST, QL: 30
in 30 days
PA NSO
(High Risk Med for Ages 65
and Older)
QL: 30 in capsule dr: 30mg
30 days
QL: 60 in capsule dr: 20mg, 60mg
30 days
QL: 30 in
30 days
QL: 30 in tablet
30 days
QL: 697 in solution
30 days
ST
PA NSO
PA NSO
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
22
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
KHEDEZLA
1
maprotiline hcl
MARPLAN
mirtazapine
nefazodone hcl
nortriptyline hcl
olanzapine/fluoxetine hcl
paroxetine hcl
PAXIL
perphenazine/
amitriptyline hcl
phenelzine sulfate
PRISTIQ ER
(Maprotiline HCl)
protriptyline hcl
sertraline hcl
SILENOR
(Vivactil)
(Zoloft)
tranylcypromine sulfate
trazodone hcl
trimipramine maleate
(Parnate)
(Trazodone HCl)
(Trimipramine Maleate)
VENLAFAXINE HCL
ER
venlafaxine hcl
VIIBRYD
1
1
1
1
1
1
1
1
1
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Symbyax)
(Paxil)
(Perphenazine/
amitriptyline HCl)
(Nardil)
1
1
1
1
1
1
1
1
Requirements/Limits
ST, QL: 30
in 30 days
PA NSO
oral susp
(High Risk Med for Ages 65
and Older)
ST, QL: 30
in 30 days
QL: 30 in
30 days
PA NSO
(High Risk Med for Ages 65
and Older)
1
(Effexor XR)
1
1
PA NSO,
QL: 30 in
30 days
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
1
BYDUREON PEN
1
BYDUREON
1
BYETTA
1
QL: 90 in
30 days
ST, QL: 4
in 28 days
ST, QL: 4
in 28 days
ST, QL:
1.2 in 28
days
pen injctr: 5mcg/0.02
23
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
BYETTA
1
CYCLOSET
1
GLYSET
1
INVOKAMET
1
INVOKAMET
1
INVOKANA
1
INVOKANA
1
JANUMET XR
1
JANUMET XR
1
JANUMET
1
JANUVIA
1
JENTADUETO
1
JUVISYNC
1
KORLYM
1
metformin hcl
(Fortamet)
1
metformin hcl
(Glucophage)
1
metformin hcl
(Glucophage)
1
metformin hcl
(Glucophage)
1
nateglinide
(Starlix)
1
PRANDIMET
1
Requirements/Limits
ST, QL:
2.4 in 28
days
QL: 180 in
30 days
QL: 90 in
30 days
ST, QL:
120 in 30
days
ST, QL: 60
in 30 days
ST, QL: 30
in 30 days
ST, QL: 60
in 30 days
QL: 30 in
30 days
QL: 60 in
30 days
QL: 60 in
30 days
QL: 30 in
30 days
QL: 60 in
30 days
QL: 30 in
30 days
PA, QL:
112 in 28
days
QL: 120 in
30 days
QL: 150 in
30 days
QL: 60 in
30 days
QL: 90 in
30 days
QL: 90 in
30 days
QL: 150 in
30 days
pen injctr: 10mcg/0.04
tablet: 50mg-500mg
tablet: 50-1000mg, 1501000mg, 150-500mg
tablet: 300mg
tablet: 100mg
tbmp 24hr: 50mg-500mg,
100-1000mg
tbmp 24hr: 50-1000mg
tab er 24h: 500mg
tablet: 500mg
tab er 24, tablet: 1000mg
tab er 24h: 750mg; tablet:
850mg
24
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
repaglinide
Drug Tier
(Prandin)
1
SYMLIN
1
SYMLINPEN 120
1
SYMLINPEN 60
1
TANZEUM
TRADJENTA
1
1
VICTOZA 3-PAK
1
Insulins
HUMALOG MIX 50-50
1
HUMALOG MIX 50-50
1
HUMALOG MIX 75-25
1
HUMALOG MIX 75-25
1
HUMALOG
1
HUMALOG
1
HUMULIN 70-30
1
HUMULIN 70-30
1
HUMULIN N
1
HUMULIN N
1
HUMULIN R
1
LANTUS SOLOSTAR
1
LANTUS
1
Requirements/Limits
QL: 240 in
30 days
PA, QL:
20 in 28
days
PA, QL:
10.8 in 28
days
PA, QL: 6
in 28 days
ST
QL: 30 in
30 days
PA, QL: 9
in 28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
insuln pen
vial
insuln pen
vial
cartridge
vial
insuln pen
vial
insuln pen
vial
25
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
LEVEMIR FLEXPEN
1
LEVEMIR
1
NOVOLIN 70-30
1
NOVOLIN 70-30
1
NOVOLIN N
1
NOVOLIN N
1
NOVOLIN R
1
NOVOLIN R
1
NOVOLOG FLEXPEN
1
NOVOLOG MIX 70-30
FLEXPEN
NOVOLOG MIX 70-30
1
NOVOLOG
1
1
Sulfonylureas
glimepiride
(Amaryl)
1
glimepiride
(Amaryl)
1
glipizide
(Glucotrol XL)
1
glipizide
(Glucotrol)
1
glipizide
(Glucotrol)
1
glipizide/metformin hcl
(Metaglip)
1
glipizide/metformin hcl
(Metaglip)
1
glyburide
(Micronase)
1
Requirements/Limits
ST, QL: 30
in 28 days
ST, QL: 40
in 28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 30 in
28 days
QL: 30 in
28 days
QL: 40 in
28 days
QL: 40 in
28 days
QL: 30 in
30 days
QL: 60 in
30 days
QL: 30 in
30 days
QL: 120 in
30 days
QL: 60 in
30 days
QL: 120 in
30 days
QL: 240 in
30 days
PA, QL:
120 in 30
days
cartridge
vial
cartridge
vial
cartridge
vial
tablet: 1mg, 2mg
tablet: 4mg
tab er 24: 2.5mg, 5mg
tablet: 10mg
tab er 24: 10mg; tablet: 5mg
tablet: 2.5-500mg, 5mg500mg
tablet: 2.5-250mg
tablet: 5mg, (High Risk
Med for Ages 65 and Older)
26
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
glyburide
(Micronase)
1
glyburide,micronized
(Glynase)
1
glyburide,micronized
(Glynase)
1
glyburide/metformin hcl
(Glucovance)
1
glyburide/metformin hcl
(Glucovance)
1
tolazamide
(Tolazamide)
1
tolazamide
(Tolazamide)
1
tolbutamide
(Tolbutamide)
1
Thiazolidinediones
ACTOPLUS MET XR
1
AVANDAMET
1
AVANDARYL
1
AVANDIA
1
pioglitazone hcl
(Actos)
1
pioglitazone hcl/
glimepiride
pioglitazone hcl/
metformin hcl
(Duetact)
1
(Actoplus Met)
1
Requirements/Limits
PA, QL:
30 in 30
days
PA, QL:
30 in 30
days
PA, QL:
60 in 30
days
PA, QL:
120 in 30
days
PA, QL:
240 in 30
days
QL: 120 in
30 days
QL: 60 in
30 days
QL: 180 in
30 days
tablet: 1.25mg, 2.5mg,
(High Risk Med for Ages 65
and Older)
tablet: 1.5mg, 3mg, (High
Risk Med for Ages 65 and
Older)
tablet: 6mg, (High Risk
Med for Ages 65 and Older)
tablet: 2.5-500mg, 5mg500mg, (High Risk Med for
Ages 65 and Older)
tablet: 1.25-250mg, (High
Risk Med for Ages 65 and
Older)
tablet: 250mg
tablet: 500mg
QL: 60 in
30 days
PA, QL:
60 in 30
days
PA, QL:
30 in 30
days
PA, QL:
30 in 30
days
QL: 30 in
30 days
QL: 30 in
30 days
QL: 90 in
30 days
Antifungals
Antifungals
ABELCET
1
PA BvD
27
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
amphotericin b
CANCIDAS
ciclopirox olamine
ciclopirox
clotrimazole
clotrimazole/
betamethasone dip
econazole nitrate
ERAXIS (WATER
DILUENT)
EXELDERM
fluconazole in nacl,isoosm
fluconazole
flucytosine
griseofulvin
ultramicrosize
griseofulvin, microsize
itraconazole
ketoconazole
NOXAFIL
NOXAFIL
nystatin
nystatin/triamcin
SPORANOX
terbinafine hcl
voriconazole
Drug Tier
(Amphotericin B)
1
1
1
1
1
1
(Loprox)
(Penlac)
(Mycelex)
(Lotrisone)
(Spectazole)
Requirements/Limits
PA BvD
1
1
(Diflucan in Saline)
1
1
(Diflucan)
(Ancobon)
(Gris-peg)
1
1
1
(Griseofulvin,
Microsize)
(Sporanox)
(Kuric)
1
1
1
1
1
1
1
1
1
1
(Nystatin)
(Mycogen II)
(Lamisil)
(Vfend)
oral susp, tablet dr
vial
solution
Antihistamines
Antihistamines
carbinoxamine maleate
1
PA
liquid: 4mg/5ml; tablet: 4mg
carbinoxamine maleate
(Carbinoxamine
Maleate)
(Palgic)
1
PA
clemastine fumarate
(Clemastine Fumarate)
1
PA
clemastine fumarate
(Clemastine Fumarate)
1
PA
clemastine fumarate
(Tavist)
1
PA
liquid: 4mg/5ml; tablet:
4mg, (High Risk Med for
Ages 65 and Older)
syrup, tablet: 2.68mg, (High
Risk Med for Ages 65 and
Older)
tablet: 1.34mg, (High Risk
Med for Ages 65 and Older)
syrup, tablet: 2.68mg
28
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
cyproheptadine hcl
(Cyproheptadine HCl)
1
diphenhydramine hcl
diphenhydramine hcl
levocetirizine
dihydrochloride
p-epd tan/chlor-tan
promethazine hcl
(Benadryl)
(Diphenhydramine HCl)
(Xyzal)
1
1
1
(P-epd Tan/chlor-tan)
(Promethazine HCl)
1
1
tripelennamine hcl
(Tripelennamine HCl)
1
Requirements/Limits
PA
(High Risk Med for Ages 65
and Older)
vial
syringe
PA
(High Risk Med for Ages 65
and Older)
QL: 30 in
28 days
QL: 4 in
28 days
QL: 40 in
28 days
QL: 18 in
28 days
QL: 18 in
28 days
QL: 18 in
28 days
QL: 4 in
28 days
QL: 4 in
28 days
QL: 12 in
28 days
QL: 12 in
28 days
ampul
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
AVC
clindamycin phosphate
metronidazole
miconazole nitrate
sod propion/inositol/
aa14/urea
terconazole
1
1
1
1
1
(Cleocin)
(Metrogel-vaginal)
(Monistat 3)
(Sod Propion/inositol/
aa14/urea)
(Terazol 3)
1
Antimigraine Agents
Antimigraine Agents
dihydroergotamine
(D.H.E. 45)
mesylate
dihydroergotamine
(Migranal)
mesylate
ERGOMAR
1
1
1
naratriptan hcl
(Amerge)
1
rizatriptan benzoate
(Maxalt Mlt)
1
sumatriptan succinate
(Imitrex)
1
sumatriptan succinate
(Imitrex)
1
sumatriptan succinate
(Imitrex)
1
sumatriptan
(Imitrex)
1
zolmitriptan
(Zomig)
1
spray/pump
tablet
cartridge: 4mg/0.5ml
cartridge: 6mg/0.5ml; vial
29
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE
dapsone
(Dapsone)
ethambutol hcl
(Myambutol)
isoniazid
(Isoniazid)
PASER
PRIFTIN
rifabutin
(Mycobutin)
rifampin
(Rifadin)
RIFATER
SEROMYCIN
SIRTURO
1
1
1
1
1
1
1
1
1
1
1
TRECATOR
1
PA, QL:
188 in 168
days
Antinausea Agents
Antinausea Agents
CESAMET
dimenhydrinate
dronabinol
EMEND
1
(Dimenhydrinate)
(Marinol)
1
1
1
EMEND
1
EMEND
1
EMEND
1
granisetron hcl
granisetron hcl
granisetron hcl
granisetron hcl/pf
meclizine hcl
ondansetron hcl
ondansetron hcl
ondansetron
(Granisetron HCl)
(Kytril)
(Kytril)
(Kytril)
(Antivert)
(Zofran)
(Zofran)
(Zofran Odt)
1
1
1
1
1
1
1
1
QL: 180 in
30 days
PA BvD,
QL: 1 per
fill
PA BvD,
QL: 2 per
fill
PA BvD,
QL: 3 per
fill
QL: 2 in
28 days
PA BvD
PA BvD
PA BvD
PA BvD
capsule: 40mg, 125mg
capsule: 80mg
cap ds pk
vial
solution
vial
tablet
vial
solution, tablet
30
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
prochlorperazine
edisylate
prochlorperazine maleate
promethazine hcl
promethazine hcl
Drug Tier
(Compazine)
1
(Compazine)
(Promethazine HCl)
(Promethazine HCl)
1
1
1
Requirements/Limits
PA
PA
supp.rect, tablet
supp.rect, tablet, (High Risk
Med for Ages 65 and Older)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone
(Mepron)
atovaquone/proguanil hcl (Malarone)
BILTRICIDE
COARTEM
DARAPRIM
HALFAN
hydroxychloroquine
(Plaquenil)
sulfate
mefloquine hcl
(Lariam)
metronidazole
(Flagyl)
metronidazole/sodium
(Metro IV)
chloride
NEBUPENT
paromomycin sulfate
(Paromomycin Sulfate)
PENTAM 300
pentamidine isethionate
(Pentam 300)
PRIMAQUINE
quinine sulfate
STROMECTOL
tinidazole
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Qualaquin)
1
(Tindamax)
1
1
PA BvD
QL: 90 in
30 days
PA, QL:
42 in 30
days
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
(Amantadine HCl)
APOKYN
1
1
AZILECT
benztropine mesylate
benztropine mesylate
1
1
1
(Benztropine Mesylate)
(Benztropine Mesylate)
QL: 60 in
30 days
PA
PA
(High Risk Med for Ages 65
and Older)
31
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
bromocriptine mesylate
cabergoline
carbidopa
carbidopa/levodopa
carbidopa/levodopa/
entacapone
entacapone
NEUPRO
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet 10-100)
(Stalevo 50)
1
1
1
1
1
(Comtan)
1
1
pramipexole di-hcl
ropinirole hcl
selegiline hcl
trihexyphenidyl hcl
(Mirapex)
(Requip)
(Eldepryl)
(Trihexyphenidyl HCl)
1
1
1
1
Requirements/Limits
ST, QL: 30
in 30 days
PA
(High Risk Med for Ages 65
and Older)
ST, QL: 60
in 30 days
ST, QL: 90
in 30 days
QL: 1 in
28 days
ST, QL:
161.2 in 28
days
ST, QL: 30
in 30 days
ST, QL: 60
in 30 days
ST, QL:
900 in 30
days
tab rapdis: 15mg
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT
1
ABILIFY DISCMELT
1
ABILIFY MAINTENA
1
ABILIFY
1
ABILIFY
1
ABILIFY
1
ABILIFY
1
ADASUVE
chlorpromazine hcl
chlorpromazine hcl
clozapine
(Chlorpromazine HCl)
(Chlorpromazine HCl)
(Clozaril)
1
1
1
1
clozapine
(Clozaril)
1
clozapine
(Clozaril)
1
tab rapdis: 10mg
vial
tablet: 5mg, 10mg, 15mg,
20mg, 30mg
tablet: 2mg
solution
ampul, tablet
oral conc.
QL: 135 in tablet: 200mg
30 days
QL: 270 in tablet: 100mg
30 days
QL: 90 in tablet: 25mg, 50mg
30 days
32
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
clozapine
Drug Tier
(Fazaclo)
1
FANAPT
1
FANAPT
1
FAZACLO
1
FAZACLO
1
fluphenazine decanoate
fluphenazine hcl
GEODON
haloperidol decanoate
haloperidol lactate
haloperidol
INVEGA SUSTENNA
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
ST, QL: 90
in 30 days
ST, QL: 60
in 30 days
ST, QL: 8
in 28 days
ST, QL:
120 in 30
days
ST, QL:
180 in 30
days
tab rapdis
QL: 6 in
28 days
vial
QL: 0.25
in 28 days
QL: 0.5 in
28 days
QL: 0.75
in 28 days
QL: 1 in
28 days
QL: 1.5 in
28 days
ST, QL: 30
in 30 days
ST, QL: 60
in 30 days
ST, QL: 30
in 30 days
ST, QL: 60
in 30 days
syringe: 39mg/0.25
QL: 31 in
30 days
tab rapdis: 20mg
tablet
tab ds pk
tab rapdis: 200mg
tab rapdis: 150mg
1
1
1
(Haloperidol Decanoate)
(Haloperidol Lactate)
(Haloperidol)
1
1
1
1
INVEGA SUSTENNA
1
INVEGA SUSTENNA
1
INVEGA SUSTENNA
1
INVEGA SUSTENNA
1
INVEGA
1
INVEGA
1
LATUDA
1
LATUDA
1
loxapine succinate
MOBAN
olanzapine
Requirements/Limits
(Loxitane)
1
1
1
(Zyprexa Zydis)
syringe: 78mg/0.5ml
syringe: 117mg/0.75
syringe: 156mg/ml
syringe: 234mg/1.5
tab er 24: 1.5mg, 3mg, 9mg
tab er 24: 6mg
tablet: 20mg, 40mg, 60mg,
120mg
tablet: 80mg
33
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
olanzapine
(Zyprexa)
1
ORAP
perphenazine
quetiapine fumarate
(Perphenazine)
(Seroquel)
1
1
1
Requirements/Limits
QL: 30 in
30 days
thioridazine hcl
(Thioridazine HCl)
1
QL: 90 in
30 days
QL: 4 in
28 days
QL: 120 in
30 days
QL: 480 in
30 days
QL: 60 in
30 days
ST, QL: 60
in 30 days
ST, QL: 30
in 30 days
ST, QL: 60
in 30 days
PA NSO
thioridazine hcl
(Thioridazine HCl)
1
PA NSO
thiothixene
trifluoperazine hcl
VERSACLOZ
(Navane)
(Trifluoperazine HCl)
1
1
1
ziprasidone hcl
(Geodon)
RISPERDAL CONSTA
1
risperidone
(Risperdal M-tab)
1
risperidone
(Risperdal)
1
risperidone
(Risperdal)
1
SAPHRIS
1
SEROQUEL XR
1
SEROQUEL XR
1
1
ZYPREXA RELPREVV
1
tab rapdis: 5mg, 10mg,
15mg; tablet, vial
tab rapdis: 3mg, 4mg
solution
tab rapdis: 0.25mg, 0.5mg,
1mg, 2mg; tablet
tab er 24h: 200mg
tab er 24h: 50mg, 150mg,
300mg, 400mg
oral conc., (High Risk Med
for Ages 65 and Older)
tablet, (High Risk Med for
Ages 65 and Older)
ST, QL:
540 in 30
days
QL: 60 in
30 days
QL: 2 in
28 days
Antivirals (systemic)
Antiretrovirals
abacavir sulfate
abacavir/lamivudine/
zidovudine
APTIVUS
APTIVUS
ATRIPLA
COMPLERA
(Ziagen)
(Trizivir)
1
1
1
1
1
1
capsule
solution
34
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
CRIXIVAN
didanosine
EDURANT
EMTRIVA
EPIVIR HBV
EPIVIR
EPZICOM
FUZEON
INTELENCE
INVIRASE
ISENTRESS
KALETRA
lamivudine
lamivudine/zidovudine
LEXIVA
nevirapine
NORVIR
PREZISTA
PREZISTA
RESCRIPTOR
RETROVIR
REYATAZ
SELZENTRY
stavudine
STRIBILD
SUSTIVA
SUSTIVA
Drug Tier
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Videx EC)
(Epivir)
(Combivir)
(Viramune)
solution
solution
oral susp, tablet: 75mg,
150mg, 600mg, 800mg
tablet: 400mg
1
1
1
1
1
1
1
1
1
(Zerit)
TIVICAY
TRIUMEQ
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE XR
VIREAD
ZIAGEN
zidovudine
(Retrovir)
Antivirals, Miscellaneous
foscarnet sodium
(Foscavir)
RELENZA
rimantadine hcl
(Flumadine)
vial
capsule: 100mg
capsule: 50mg, 200mg;
tablet
1
1
1
1
1
1
1
1
1
1
1
1
tab er 24h: 100mg
solution
PA BvD
35
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Requirements/Limits
SYNAGIS
TAMIFLU
1
1
TAMIFLU
1
TAMIFLU
1
TAMIFLU
1
Hcv Protease Inhibitors
INCIVEK
1
OLYSIO
1
VICTRELIS
1
Interferons
ALFERON N
INTRON A
1
1
INTRON A
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON 4-PACK
1
1
1
1
1
1
PA NSO
PA
PA
PA
PA
PA NSO,
QL: 1 in
28 days
Nucleosides And Nucleotides
acyclovir sodium
(Acyclovir Sodium)
acyclovir
(Zovirax)
adefovir dipivoxil
(Hepsera)
BARACLUDE
cidofovir
(Vistide)
entecavir
(Baraclude)
famciclovir
(Famvir)
ganciclovir sodium
(Cytovene)
ribavirin
(Rebetol)
1
1
1
1
1
1
1
1
1
PA BvD
QL: 42 in
180 days
QL: 48 in
180 days
QL: 540 in
180 days
QL: 84 in
180 days
capsule: 75mg
capsule: 45mg
susp recon
capsule: 30mg
PA, QL:
168 in 28
days
PA, QL:
28 in 28
days
PA, QL:
336 in 28
days
PA NSO
pen ij kit, vial: 18mmunit,
50mmunit
vial: 6mmunit/ml, 10mmunit
PA BvD
capsule, tab ds pk: 400400mg, 600-400mg; tablet
36
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
ribavirin
SOVALDI
TYZEKA
valacyclovir hcl
VALCYTE
Drug Tier
(Ribatab)
1
1
Requirements/Limits
tab ds pk: 200-400mg
PA, QL:
28 in 28
days
1
1
1
(Valtrex)
tablet
Blood Products/modifiers/volume Expanders
Anticoagulants
CEPROTIN
ELIQUIS
enoxaparin sodium
(Lovenox)
1
1
1
enoxaparin sodium
(Lovenox)
1
enoxaparin sodium
(Lovenox)
1
enoxaparin sodium
(Lovenox)
1
enoxaparin sodium
(Lovenox)
1
enoxaparin sodium
(Lovenox)
1
fondaparinux sodium
(Arixtra)
1
fondaparinux sodium
(Arixtra)
1
fondaparinux sodium
(Arixtra)
1
fondaparinux sodium
(Arixtra)
1
heparin sod,pork in
0.45% nacl
heparin sodium,porcine
heparin sodium,porcine/
d5w
heparin sodium,porcine/
d5w
heparin sodium,porcine/
ns/pf
heparin sodium,porcine/
pf
(Heparin Sod,pork In
0.45% NaCl)
(Hep-lock)
(Heparin Sodium,
porcine/D5W)
(Heparin Sodium,
porcine/D5W)
(Heparin Sodium,
porcine/ns/PF)
(Heparin Sodium,
porcine/PF)
1
1
1
1
QL: 13.6
in 30 days
QL: 18 in
30 days
QL: 20.4
in 30 days
QL: 27.2
in 30 days
QL: 34 in
30 days
QL: 36 in
30 days
QL: 12 in
30 days
QL: 15 in
30 days
QL: 18 in
30 days
QL: 24 in
30 days
syringe: 40mg/0.4ml
PA BvD
(PA for ESRD Only)
iv soln: 12500/250, 25000/
500
iv soln: 20k/500ml, 25000/
250
syringe: 30mg/0.3ml
syringe: 60mg/0.6ml
syringe: 80mg/0.8ml,
120mg/.8ml
syringe: 150mg/ml
syringe: 100mg/ml; vial
syringe: 5mg/0.4ml
syringe: 2.5mg/0.5
syringe: 7.5mg/0.6
syringe: 10mg/0.8ml
1
1
vial port
37
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
heparin sodium,porcine/
pf
heparin sodium,porcine/
pf
IPRIVASK
Drug Tier
(Heparin Sodium,
porcine/PF)
(Monoject Prefill
Advanced)
Requirements/Limits
1
PA BvD
vial, (PA for ESRD Only)
1
PA BvD
syringe, (PA for ESRD
Only)
1
PA, QL:
24 in 28
days
PA, QL:
60 in 30
days
PRADAXA
1
warfarin sodium
(Coumadin)
XARELTO
Blood Formation Modifiers
BERINERT
1
1
CINRYZE
1
EPOGEN
1
GRANIX
LEUKINE
LEUKINE
MOZOBIL
1
1
1
1
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT
1
1
1
1
PROCRIT
1
PROMACTA
1
Hematologic Agents, Miscellaneous
aminocaproic acid
(Amicar)
anagrelide hcl
(Agrylin)
protamine sulfate
(Protamine Sulfate)
1
1
1
1
PA, QL: 9
in 30 days
PA, QL:
20 in 28
days
PA, QL:
12 in 28
days
vial: 250mcg
vial: 500mcg/ml
PA, QL:
9.6 per fill
PA, QL:
12 in 28
days
PA, QL: 6
in 28 days
PA, QL:
30 in 30
days
vial: 2000/ml, 3000/ml,
4000/ml, 10000/ml, 20000/
ml
vial: 40000/ml
PA BvD
(PA for ESRD Only)
38
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
tranexamic acid
Drug Tier
(Lysteda)
1
tranexamic acid
(Tranexamic Acid)
Platelet-aggregation Inhibitors
AGGRENOX
1
BRILINTA
cilostazol
clopidogrel bisulfate
EFFIENT
1
1
1
1
1
(Pletal)
(Plavix)
pentoxifylline
(Trental)
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN (HUMAN)
ALBUMINAR-25
ALBUMINAR-5
ALBURX
ALBUTEIN
BUMINATE
FLEXBUMIN
KEDBUMIN
PLASBUMIN-25
PLASBUMIN-5
STERILE DILUENT
Requirements/Limits
QL: 30 in
30 days
tablet
vial
QL: 60 in
30 days
QL: 30 in
30 days
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Caloric Agents
Caloric Agents
AMINO ACIDS
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN M
AMINOSYN with
ELECTROLYTES
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN
1
1
1
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
iv soln: 10%
iv soln: 15%
iv soln: 7%
iv soln: 8.5%
iv soln: 8.5%
iv soln: 10%
iv soln: 3.5%
iv soln: 7%
iv soln: 8.5%
iv soln: 8.5%
39
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF
AMINOSYN-RF
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINISOL
cysteine hcl
dextrose 10 % and 0.2 %
nacl
dextrose 10 % and 0.2 %
nacl
dextrose 10 % and 0.9 %
nacl
dextrose 10%-0.5 normal
saline
dextrose 10%-water
dextrose 2.5 % in water
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Cysteine HCl)
(Dextrose 10 % and 0.2
% NaCl)
(Dextrose 10 % and 0.2
% NaCl)
(Dextrose 10 % and 0.9
% NaCl)
(Dextrose 10%-0.5
Normal Saline)
(Dextrose 10%-water)
(Dextrose 2.5 % in
Water)
dextrose 2.5% in half
(Dextrose 2.5% In Half
ringers
Ringers)
dextrose 2.5%-0.5normal (Dextrose 2.5%-0.5
saline
Normal Saline)
dextrose 20%-water
(Dextrose 20%-water)
dextrose 25 % in water
(Dextrose 25 % in
Water)
dextrose 40%-water
(Dextrose 40%-water)
Requirements/Limits
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
iv soln: 10%
iv soln: 7%
iv soln: 2.75%
iv soln: 2.75%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 5%
iv soln: 5%
iv soln: 5%
iv soln: 5%
iv soln: 2.75%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 5%
iv soln: 5%
iv soln: 5%
dehp fr bg
1
iv soln
1
1
1
1
PA BvD
PA BvD
1
1
1
1
PA BvD
PA BvD
1
PA BvD
40
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
dextrose 5 % and 0.3 %
nacl
dextrose 5 % and 0.9 %
nacl
dextrose 5 % in water
dextrose 5 %-0.2 % nacl
(Dextrose 5 % and 0.3 %
NaCl)
(Dextrose 5 % and 0.9 %
NaCl)
(Dextrose 5 % in Water)
(Dextrose 5 %-0.2 %
NaCl)
dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 %
NaCl)
dextrose 5% in ringers
(Dextrose 5% In
Ringers)
dextrose 5%-lactated
(Dextrose 5%-Lactated
ringers
Ringers)
dextrose 50 % in water
(Dextrose 50 % in
Water)
dextrose 60 % in water
(Dextrose 60 % in
Water)
dextrose 70%-water
(Dextrose 70%-water)
FREAMINE HBC
FREAMINE III
FREAMINE III
fructose 10%
(Fructose 10%)
HEPATAMINE
HEPATASOL
INTRALIPID
INTRALIPID
KABIVEN
LIPOSYN II
LIPOSYN III
LIPOSYN III
NEPHRAMINE
NOVAMINE
PERIKABIVEN
PREMASOL
PREMASOL
PROCALAMINE
PROSOL
QUICK MIX with
LYTES
TRAVAMULSION
TRAVASOL W/
DEXTROSE
Requirements/Limits
1
1
1
1
1
1
1
1
PA BvD
1
PA BvD
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
1
PA BvD
PA BvD
iv soln: 10%
iv soln: 8.5%
emulsion: 10%
emulsion: 20%, 30%
emulsion: 10%, 20%
emulsion: 30%
iv soln: 10%
iv soln: 6%
41
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
TRAVASOL W/
ELECTROLYTES
TRAVASOL W/
ELECTROLYTES
TRAVASOL with
DEXTROSE
TRAVASOL with
DEXTROSE
TRAVASOL with
DEXTROSE
TRAVASOL with
ELECTROLYTES
TRAVASOL
TRAVASOL
TRAVASOL
TRAVASOL
TRAVERT IN NORMAL
SALINE
TRAVERT
TRAVERT
TROPHAMINE
TROPHAMINE
Requirements/Limits
1
PA BvD
iv soln.: 5.5%
1
PA BvD
iv soln.: 8.5%
1
PA BvD
iv soln: 8.5%
1
PA BvD
iv soln: 8.5%
1
PA BvD
iv soln: 8.5%
1
PA BvD
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
iv soln.
iv soln: 10%
iv soln: 5.5%
iv soln: 8.5%
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
iv soln: 10%
iv soln: 5%
iv soln: 10%
iv soln: 6%
QL: 4 in
28 days
QL: 8 in
28 days
patch tdwk: 0.1mg/24hr,
0.2mg/24hr
patch tdwk: 0.3mg/24hr
PA
(High Risk Med for Ages 65
and Older)
Cardiovascular Agents
Alpha-adrenergic Agents
clonidine hcl
(Catapres)
clonidine hcl/
(Clonidine HCl/
chlorthalidone
chlorthalidone)
clonidine
(Catapres-tts 1)
1
1
1
clonidine
(Catapres-tts 1)
1
doxazosin mesylate
guanfacine hcl
(Cardura)
(Tenex)
1
1
midodrine hcl
(Proamatine)
phenylephrine hcl
(Vazculep)
prazosin hcl
(Minipress)
Angiotensin Ii Receptor Antagonists
BENICAR HCT
BENICAR
candesartan cilexetil
(Atacand)
1
1
1
1
1
1
42
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
candesartan/
(Atacand HCT)
hydrochlorothiazid
DIOVAN
eprosartan mesylate
(Teveten)
irbesartan
(Avapro)
irbesartan/
(Avalide)
hydrochlorothiazide
losartan potassium
(Cozaar)
losartan/
(Hyzaar)
hydrochlorothiazide
telmisartan
(Micardis)
telmisartan/
(Micardis HCT)
hydrochlorothiazid
TRIBENZOR
valsartan/
(Diovan HCT)
hydrochlorothiazide
Angiotensin-converting Enzyme Inhibitors
benazepril hcl
(Lotensin)
benazepril/
(Lotensin HCT)
hydrochlorothiazide
captopril
(Capoten)
captopril/
(Capozide)
hydrochlorothiazide
enalapril maleate
(Vasotec)
enalapril/
(Vaseretic)
hydrochlorothiazide
enalaprilat dihydrate
(Enalaprilat Dihydrate)
fosinopril sodium
(Monopril)
fosinopril/
(Monopril HCT)
hydrochlorothiazide
lisinopril
(Zestril)
lisinopril/
(Prinzide)
hydrochlorothiazide
moexipril hcl
(Univasc)
moexipril/
(Uniretic)
hydrochlorothiazide
perindopril erbumine
(Aceon)
quinapril hcl
(Accupril)
quinapril/
(Accuretic)
hydrochlorothiazide
ramipril
(Altace)
trandolapril
(Mavik)
1
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
43
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Antiarrhythmic Agents
amiodarone hcl
(Amiodarone HCl)
amiodarone hcl
(Cordarone)
disopyramide phosphate (Norpace)
flecainide acetate
(Tambocor)
lidocaine hcl/d5w/pf
(Lidocaine HCl/d5w/PF)
lidocaine hcl/pf
(Lidocaine HCl/PF)
1
1
1
1
1
1
lidocaine hcl/pf
1
(Lidocaine HCl/PF)
mexiletine hcl
(Mexitil)
MULTAQ
procainamide hcl
(Procainamide HCl)
procainamide hcl
(Procainamide HCl)
PRONESTYL
propafenone hcl
(Rythmol)
quinidine gluconate
(Quinidine Gluconate)
quinidine sulfate
(Quinidine Sulfate)
TIKOSYN
XYLOCAINE
Beta-Adrenergic Blocking Agents
acebutolol hcl
(Sectral)
atenolol
(Tenormin)
atenolol/chlorthalidone
(Tenoretic 50)
betaxolol hcl
(Kerlone)
bisoprolol fumarate
(Zebeta)
bisoprolol fumarate/hctz (Ziac)
BYSTOLIC
carvedilol
(Coreg)
COREG CR
DUTOPROL
esmolol hcl
(Esmolol HCl)
labetalol hcl
(Trandate)
metoprolol succinate
(Toprol XL)
metoprolol tartrate
(Lopressor)
metoprolol/
(Lopressor HCT)
hydrochlorothiazide
nadolol
(Corgard)
pindolol
(Pindolol)
propranolol hcl
(Propranolol HCl)
propranolol/
(Propranolol/
hydrochlorothiazid
hydrochlorothiazid)
Requirements/Limits
syringe
ampul, tablet
PA BvD
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
iv soln: 2mg/ml, 8mg/ml
syringe, vial: 100mg/ml,
200mg/ml
vial: 20mg/ml, (PA for
ESRD Only)
capsule, tablet sa
vial
PA BvD
1
1
1
1
44
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Requirements/Limits
sotalol hcl
(Betapace)
SOTALOL HCL
timolol maleate
(Timolol Maleate)
Calcium-Channel Blocking Agents
diltiazem hcl
(Cardizem CD)
verapamil hcl
(Calan)
1
1
1
verapamil hcl
(Verapamil HCl)
Cardiovascular Agents, Miscellaneous
digoxin
(Lanoxin)
1
1
PA, QL:
30 in 30
days
digoxin
1
PA
1
PA, QL:
75 in 30
days
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
1
(Lanoxin)
DIGOXIN
dobutamine hcl
dobutamine hcl/d5w
dopamine hcl
dopamine hcl/d5w
dopamine hcl/dextrose
5%-water
ephedrine sulfate
epinephrine
epinephrine
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethanolamine oleate
FIRAZYR
hydralazine hcl
hydralazine/
hydrochlorothiazid
LANOXIN
(Dobutamine HCl)
(Dobutamine HCl/D5W)
(Dopamine HCl)
(Dopamine HCl/D5W)
(Dopamine HCl/dextrose
5%-water)
(Ephedrine Sulfate)
(Adrenaclick)
(Epinephrine)
milrinone lactate
(Milrinone Lactate)
ampul, cap24h pct, cap24h
pel, tablet, tablet er
syringe
1
1
1
1
1
1
1
1
1
(Ethanolamine Oleate)
(Apresoline)
(Hydralazine/
hydrochlorothiazid)
tablet, (High Risk Med for
Ages 65 and Older and Dose
is Greater Than 125mcg Per
Day)
ampul, (High Risk Med for
Ages 65 and Older)
(High Risk Med for Ages 65
and Older and Dose is
Greater Than 125mcg Per
Day)
auto injct, syringe
ampul
1
PA, QL:
30 in 30
days
1
PA BvD
tablet: 62.5mcg, 187.5mcg,
(High Risk Med for Ages 65
and Older and Dose is
Greater Than 125mcg Per
Day)
45
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
milrinone lactate/d5w
(Primacor in 5%
Dextrose)
norepinephrine bitartrate (Levophed Bitartrate)
ORENITRAM ER
papaverine hcl
(Papaverine HCl)
RANEXA
VECAMYL
Dihydropyridines
amlodipine besylate
(Norvasc)
amlodipine besylate/
(Lotrel)
benazepril
AZOR
CLEVIPREX
EXFORGE HCT
EXFORGE
felodipine
(Plendil)
isradipine
(Dynacirc)
nicardipine hcl
(Nicardipine HCl)
nifedipine
(Adalat CC)
nifedipine
(Procardia XL)
Diuretics
amiloride hcl
amiloride/
hydrochlorothiazide
bumetanide
chlorothiazide sodium
chlorothiazide
chlorthalidone
DYRENIUM
furosemide
furosemide
hydrochlorothiazide
indapamide
methyclothiazide
metolazone
torsemide
triamterene/
hydrochlorothiazid
Dyslipidemics
amlodipine/atorvastatin
Requirements/Limits
1
PA BvD
1
1
1
1
1
PA BvD
PA
PA
1
1
1
1
1
1
1
1
1
1
1
(Midamor)
(Amiloride/
hydrochlorothiazide)
(Bumex)
(Diuril Sodium)
(Chlorothiazide)
(Chlorthalidone)
tablet er: 90mg
tab er 24, tablet er: 30mg,
60mg
1
1
(Furosemide)
(Lasix)
1
1
1
1
1
1
1
(Hydrochlorothiazide)
(Lozol)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
(Maxzide)
1
1
1
1
1
1
(Caduet)
1
syringe: 10mg/ml
solution, syringe: 10mg/ml;
tablet, vial
46
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
atorvastatin calcium
cholestyramine (with
sugar)
cholestyramine/
aspartame
colestipol hcl
CRESTOR
fenofibrate
nanocrystallized
fenofibrate
fenofibrate,micronized
fenofibric acid (choline)
fenofibric acid
fluvastatin sodium
gemfibrozil
KYNAMRO
(Lipitor)
(Questran)
1
1
(Questran Light)
1
(Colestid)
1
1
1
lovastatin
niacin
omega-3 acid ethyl esters
pravastatin sodium
simvastatin
(Mevacor)
(Niaspan)
(Lovaza)
(Pravachol)
(Zocor)
(Tricor)
(Lofibra)
(Antara)
(Trilipix)
(Fibricor)
(Lescol)
(Lopid)
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
tablet
PA, QL: 4
in 28 days
tab er 24h, tablet
QL: 30 in
30 days
VASCEPA
1
WELCHOL
1
ZETIA
1
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
1
spironolact/
(Aldactazide)
1
hydrochlorothiazid
spironolactone
(Aldactone)
1
Vasodilators
isosorbide dinitrate
(Isordil)
1
isosorbide dinitrate
isosorbide mononitrate
minoxidil
NITRO-BID
nitroglycerin
(Isosorbide Dinitrate)
(Imdur)
(Minoxidil)
(Nitro-dur)
1
1
1
1
1
nitroglycerin
(Nitro-dur)
1
tab subl: 2.5mg; tablet,
tablet er
tab subl: 5mg
QL: 30 in
30 days
QL: 60 in
30 days
patch td24: 0.1mg/hr,
0.2mg/hr, 0.6mg/hr
patch td24: 0.4mg/hr
47
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
nitroglycerin
nitroglycerin
nitroglycerin/d5w
NITROSTAT
nylidrin hcl
PROGLYCEM
Drug Tier
Requirements/Limits
1
1
1
1
1
1
vial: 50mg/10ml
vial: 5mg/ml
(Nitroglycerin)
(Nitroglycerin)
(Nitroglycerin/D5W)
(Nylidrin HCl)
Central Nervous System Agents
Central Nervous System Agents
AMPYRA
1
caffeine citrated
(Cafcit)
caffeine/sodium benzoate (Caffeine/sodium
Benzoate)
clonidine hcl
(Kapvay)
dexmethylphenidate hcl
(Focalin)
1
1
dextroamphetamine
sulfate
dextroamphetamine
sulfate
dextroamphetamine/
amphetamine
dextroamphetamine/
amphetamine
flumazenil
INTUNIV
(Dexedrine)
1
(Dexedrine)
1
(Adderall XR)
1
(Adderall)
1
(Romazicon)
1
1
lithium carbonate
lithium citrate
methylphenidate hcl
(Eskalith)
(Lithium Citrate)
(Concerta)
1
1
1
methylphenidate hcl
(Concerta)
1
methylphenidate hcl
(Methylin)
1
methylphenidate hcl
(Ritalin)
1
methylphenidate hcl
(Ritalin)
1
1
1
PA, QL:
60 in 30
days
QL: 60 in
30 days
QL: 120 in
30 days
QL: 180 in
30 days
QL: 30 in
30 days
QL: 60 in
30 days
tablet
capsule er
tablet: 5mg, 10mg
cap er 24h: 5mg, 10mg,
15mg
cap er 24h: 20mg, 25mg,
30mg; tablet
QL: 30 in
30 days
QL: 30 in
30 days
cpbp 30-70, cpbp 50-50:
20mg, 40mg; tab er 24:
18mg, 27mg, 54mg
QL: 60 in cpbp 50-50: 30mg; tab er
30 days
24: 36mg
QL: 900 in solution
30 days
QL: 90 in tablet er: 10mg
30 days
QL: 90 in tablet, tablet er: 20mg
30 days
48
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
1
1
1
1
(Rilutek)
STRATTERA
XENAZINE
1
1
Requirements/Limits
QL: 60 in
30 days
QL: 60 in
30 days
PA, QL:
112 in 28
days
Contraceptives
Contraceptives
desog-e.estradiol/
e.estradiol
desogestrel-ethinyl
estradiol
ethinyl estradiol/
drospirenone
ethynodiol d-ethinyl
estradiol
levonorgestrel
levonorgestrel-ethin
estradiol
levonorgestrel-ethin
estradiol
l-norgest-eth estr/ethin
estra
l-norgest-eth estr/ethin
estra
norelgestromin/
ethin.estradiol
noreth-ethinyl estradiol/
iron
norethindrone ac-eth
estradiol
norethindrone
norethindronee.estradiol-iron
norethindrone-ethinyl
estrad
norethindrone-mestranol
(Mircette)
1
(Desogen)
1
(Yaz)
1
(Demulen 1/50-28)
1
(Plan B)
(Nordette-8)
1
1
(Seasonale)
1
(Seasonique)
1
(Seasonique)
1
(Ortho Evra)
1
(Femcon Fe)
1
(Loestrin)
1
(Nor-Q-D)
(Loestrin Fe)
1
1
(Modicon)
1
(Ortho-novum)
1
QL: 91 in
84 days
QL: 91 in
84 days
QL: 91 in
84 days
tablet: 0.1-0.02, 0.15-0.03,
6-5-10
tbdspk 3mo
tbdspk 3mo: 100-20(84)
tbdspk 3mo: 150-30(84)
tablet: 0.4-0.035, 0.5-0.035,
1mg-35mcg, 7-9-5, 7daysx3,
10-11
49
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
norgestimate-ethinyl
estradiol
norgestrel-ethinyl
estradiol
NUVARING
Drug Tier
(Ortho-cyclen)
1
(Ovral-21)
1
1
ORTHO EVRA
1
Requirements/Limits
ST, QL: 1
in 28 days
ST, QL: 3
in 28 days
Dental And Oral Agents
Dental And Oral Agents
cevimeline hcl
(Evoxac)
chlorhexidine gluconate (Peridex)
KEPIVANCE
pilocarpine hcl
(Salagen)
triamcinolone acetonide (Triamcinolone
Acetonide)
1
1
1
1
1
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acyclovir
adapalene
alcohol antiseptic pads
aluminum chloride
ammonium lactate
ANACAINE
calcipotriene
calcipotriene/
betamethasone
calcitriol
CARAC
CONDYLOX
DENAVIR
FLUOROPLEX
fluorouracil
imiquimod
LEVULAN
mafenide acetate
1
1
1
(Soriatane)
(Zovirax)
(Adapalene)
(Alcohol Antiseptic
Pads)
(Drysol)
(Lac-hydrin)
QL: 30 in
30 days
1
1
1
1
1
1
1
(Dovonex)
(Taclonex)
(Vectical)
(Efudex)
(Aldara)
1
1
1
1
1
1
1
(Mafenide Acetate)
1
1
gel (gram)
PA NSO,
QL: 24 in
30 days
50
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
methoxsalen, rapid
METVIXIA
OXSORALEN-ULTRA
PANRETIN
PICATO
Drug Tier
(Oxsoralen-ultra)
1
1
1
1
1
PICATO
podofilox
podophyllum resin
potassium hydroxide
SANTYL
silver nitrate applicator
1
(Condylox)
(Pododerm)
(Potassium Hydroxide)
Requirements/Limits
QL: 2 in
56 days
QL: 3 in
56 days
gel (ea): 0.05%
QL: 15 in
30 days
cream (g)
gel (ea): 0.015%
1
1
1
1
1
(Silver Nitrate
Applicator)
UVADEX
VALCHLOR
XERAC AC
ZOVIRAX
1
1
1
1
Dermatological Antibacterials
clindamycin phos/benzoyl (Duac)
perox
clindamycin phosphate
(Cleocin T)
erythromycin base/
(Emgel)
ethanol
erythromycin/benzoyl
(Benzamycin)
peroxide
gentamicin sulfate
(Gentamicin Sulfate)
metronidazole
(Nydamax)
mupirocin calcium
(Bactroban)
mupirocin
(Centany)
neomy sulf/polymyxin b
(Neosporin G.U.
sulfate
Irrigant)
selenium sulfide
(Selenium Sulfide)
selenium sulfide
(Selseb)
silver nitrate
(Silver Nitrate)
silver sulfadiazine
(Silvadene)
sulfacetamide sodium
(Klaron)
THERMAZENE
Dermatological Anti-inflammatory Agents
alclometasone
(Aclovate)
dipropionate
1
gel (gram): 1%-5%
1
1
1
1
1
1
1
1
1
1
1
1
1
1
suspension
shampoo
1
51
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
APEXICON E
betamethasone
dipropionate
betamethasone valerate
Drug Tier
1
1
(Del-beta)
(Betamethasone
Valerate)
betamethasone/propylene (Diprolene AF)
glyc
clobetasol propionate
(Temovate)
clocortolone pivalate
(Cloderm)
CLODERM
CORDRAN
CORDRAN
desonide
(Desowen)
desoximetasone
(Topicort)
diflorasone diacetate
(Psorcon)
ELIDEL
fluocinonide
(Vanos)
1
fluticasone propionate
halobetasol propionate
hydrocortisone acetate
(Cutivate)
(Ultravate)
(Hydrocortisone
Acetate)
(Nuzon)
1
1
1
(Carmol HC)
1
(Hydrocortisone
Butyrate)
(Hydrocortisone
Valerate)
(Hydrocortisone)
(Hytone)
1
hydrocortisone acetate/
aloe v
hydrocortisone acetate/
urea
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone
hydrocortisone
LOCOID
mometasone furoate
prednicarbate
PROTOPIC
PROTOPIC
triamcinolone acetonide
triamcinolone acetonide
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
cream (g), lotion, oint. (g)
med. tape
PA
(PA for Ages < 2)
cream (g): 0.05%; gel
(gram), oint. (g), solution
cream (g), oint. (g)
1
1
1
1
1
1
1
1
1
1
(Elocon)
(Dermatop)
(Triamcinolone
Acetonide)
(Triderm)
1
cream(gm)
cream (g), cream/appl,
enema, lotion, oint. (g)
cream (g)
PA
PA
(0.03%; PA for Ages < 2)
(0.1%; PA for Ages < 15)
cream (g), lotion, oint. (g):
0.025%, 0.1%, 0.5%
cream, oint. (g): 0.05%
52
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Dermatological Retinoids
adapalene
(Differin)
TARGRETIN
1
1
TAZORAC
tretinoin microspheres
(Retin-a Micro)
tretinoin
(Retin-A)
Scabicides And Pediculicides
EURAX
malathion
(Ovide)
permethrin
(Elimite)
spinosad
(Natroba)
1
1
1
Requirements/Limits
PA NSO,
QL: 60 in
28 days
PA
PA
1
1
1
1
Devices
Devices
needles, insulin
disposable
syring wndl,disp,insul,0.3ml
syring wndl,disp,insul,0.5ml
syring w-o ndl,disp,insul,
1ml
(Needles, Insulin
Disposable)
(Syring Wndl,disp,insul,0.3ml)
(Syring Wndl,disp,insul,0.5ml)
(Syring W-o
Ndl,disp,insul, 1ml)
1
1
1
1
Enzyme Replacement/modifiers
Enzyme Replacement/modifiers
ADAGEN
ALDURAZYME
CEREZYME
CHENODAL
1
1
1
1
CIMZIA
1
CREON
ELAPRASE
ELELYSO
ELITEK
FABRAZYME
KRYSTEXXA
KUVAN
LINZESS
1
1
1
1
1
1
1
1
PA, QL:
210 in 30
days
PA, QL: 3
in 28 days
QL: 30 in
30 days
53
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
lipase/protease/amylase
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
VIMIZIM
VPRIV
ZAVESCA
Drug Tier
(Zenpep)
1
1
1
1
1
1
1
1
1
1
ZENPEP
Requirements/Limits
PA BvD
PA
QL: 90 in
30 days
1
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Anti-infectives Agents
acetic acid
(Vosol)
acetic acid/
(Vosol HC)
hydrocortisone
bacitracin
(Bacitracin)
bacitracin/polymyxin b
(Polycin-b)
sulfate
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CIPRO HC
CIPRODEX
ciprofloxacin hcl
(Cetraxal)
ciprofloxacin hcl
(Ciloxan)
COLY-MYCIN S
CORTISPORIN-TC
erythromycin base
(Ilotycin)
gatifloxacin
(Zymaxid)
gentamicin sulfate
(Garamycin)
levofloxacin
(Quixin)
MOXEZA
NATACYN
neo/polymyx b sulf/
(Maxitrol)
dexameth
neomy sulf/bacitra/
(Neo-polycin)
polymyxin b
neomy sulf/bacitrac zn/
(Triple Antibiotic HC)
poly/hc
neomycin sulfate/dex na (Neomycin Sulfate/dex
ph
Na Ph)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
droperette
drops
1
1
1
54
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
neomycin/polymyxin b
(Oticin HC)
1
sulf/hc
neomycin/polymyxn b/
(Neosporin)
1
gramicidin
ofloxacin
(Floxin)
1
polymyxin b sulf/
(Polytrim)
1
trimethoprim
sulfacetamide sodium
(Sulfac)
1
sulfacetamide/
(Sulfacetamide/
1
prednisolone sp
prednisolone Sp)
tobramycin sulfate
(Tobramycin Sulfate)
1
tobramycin/
(Tobradex)
1
dexamethasone
trifluridine
(Viroptic)
1
VIGAMOX
1
ZYLET
1
Eye, Ear, Nose, Throat Anti-inflammatory Agents
ALREX
1
BROMDAY
1
bromfenac sodium
(Bromfenac Sodium)
1
dexamethasone sod
(Ak-dex)
1
phosphate
diclofenac sodium
(Voltaren)
1
DUREZOL
1
fluorometholone
(FML)
1
flurbiprofen sodium
(Ocufen)
1
ILEVRO
1
ketorolac tromethamine
(Acular)
1
LOTEMAX
1
NEVANAC
1
prednisolone acetate
(Omnipred)
1
prednisolone sod
(Prednisol)
1
phosphate
PROLENSA
1
RESTASIS
1
Eye, Ear, Nose, Throat Drugs, Miscellaneous
AKTEN
apraclonidine hcl
(Iopidine)
atropine sulfate
(Isopto Atropine)
Requirements/Limits
PA, QL:
60 in 30
days
1
1
1
55
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
azelastine hcl
(Astelin)
1
azelastine hcl
carteolol hcl
cromolyn sodium
CYCLOGYL
cyclopentolate hcl
CYSTARAN
epinastine hcl
homatropine hbr
ISOPTO
HOMATROPINE
LACRISERT
naphazoline hcl/
antazoline
PATADAY
PATANOL
phenylephrine hcl
proparacaine hcl
proparacaine/fluorescein
sod
tetracaine hcl/pf
TYZINE
TYZINE
(Optivar)
(Carteolol HCl)
(Cromolyn Sodium)
1
1
1
1
1
1
1
1
1
(Cyclogyl)
(Elestat)
(Isopto Homatropine)
Requirements/Limits
QL: 30 in
25 days
spray/pump
drops
drops: 0.5%
drops: 2%
1
1
(Naphazoline HCl/
antazoline)
1
1
1
1
1
(Mydfrin)
(Ophthetic)
(Proparacaine/
fluorescein Sod)
(Tetracaine HCl/PF)
1
1
1
ST
ST
drops: 0.05%
drops: 0.1%; spray
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
CARAFATE
cimetidine hcl
(Cimetidine HCl)
cimetidine hcl
(Cimetidine HCl)
cimetidine in 0.9 % nacl (Cimetidine In 0.9 %
NaCl)
cimetidine
(Tagamet)
esomeprazole sodium
(Nexium I.v.)
famotidine in nacl,iso(Famotidine In Nacl,isoosm/pf
osm/PF)
famotidine
(Pepcid)
famotidine
(Pepcid)
lansoprazole
(Prevacid)
lansoprazole/amoxiciln/ (Prevpac)
clarith
misoprostol
(Cytotec)
nizatidine
(Axid)
1
1
1
1
oral susp
solution
vial
1
1
1
(Rx Product Only)
1
1
1
1
(Rx Product Only)
(Rx Product Only)
1
1
56
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
omeprazole
(Prilosec)
pantoprazole sodium
(Protonix)
ranitidine hcl
(Zantac)
sucralfate
(Carafate)
sucralfate
(Sucralfate)
Gastrointestinal Agents, Other
AMITIZA
1
1
1
1
1
BUPHENYL
CARBAGLU
cromolyn sodium
dicyclomine hcl
diphenoxylate hcl/
atropine
FULYZAQ
1
1
1
1
1
glycopyrrolate
isopropamide/
prochlorperazine
lactulose
lactulose
loperamide hcl
methscopolamine
bromide
metoclopramide hcl
metoclopramide hcl
NUTRESTORE
paregoric
RAVICTI
RELISTOR
1
(Gastrocrom)
(Bentyl)
(Lomotil)
1
(Rx Product Only)
tablet
oral susp
QL: 60 in
30 days
tablet
QL: 60 in
30 days
(Robinul)
(Isopropamide/
prochlorperazine)
(Lactulose)
(Lactulose)
(Loperamide HCl)
(Pamine)
1
1
1
1
1
1
solution: 10; syrup
solution: 10g/15ml
(Metoclopramide HCl)
(Reglan)
1
1
1
1
1
1
disp syrin
solution, tablet, vial
(Paregoric)
RELISTOR
sodium phenylbutyrate
ursodiol
Laxatives
MOVIPREP
peg 3350/na
sulf,bicarb,cl/kcl
polyethylene glycol 3350
Requirements/Limits
1
(Buphenyl)
(Actigall)
1
1
(Golytely)
1
1
(Miralax)
1
PA
PA, QL:
28 in 28
days
PA, QL:
28 in 28
days
syringe: 12mg/0.6ml
syringe: 8mg/0.4ml
57
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
sodium chloride/nahco3/ (Nulytely with Flavor
kcl/peg
Packs)
Phosphate Binders
calcium acetate
(Phoslo)
calcium carbonate/mag
(Calcium Carbonate/mag
carb/fa
Carb/fa)
PHOSLYRA
RENAGEL
RENVELA
sodium polystyrene
(Sodium Polystyrene
sulfonate
Sulfonate)
sodium polystyrene
(Sps)
sulfonate
1
Requirements/Limits
1
1
1
1
1
1
oral susp
1
enema
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
(Urispas)
oxybutynin chloride
(Ditropan)
tolterodine tartrate
(Detrol)
trospium chloride
(Sanctura)
VESICARE
1
1
1
1
1
tab er 24, tablet
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine mesylate
(Desferal)
edetate disodium
(Edetate Disodium)
EXJADE
FERRIPROX
GALZIN
na nitrite/na thiosul/amyl (Na Nitrite/na Thiosul/
nit
amyl Nit)
sodium thiosulfate
(Sodium Thiosulfate)
SYPRINE
1
1
1
1
1
1
PA BvD
1
1
Hormonal Agents, Stimulant/replacement/modifying
Androgens
ANADROL-50
ANDRODERM
1
1
ANDROGEL
1
PA, QL:
30 in 30
days
PA, QL:
150 in 30
days
gel md pmp
58
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
ANDROGEL
1
ANDROGEL
1
AXIRON
1
danazol
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
(Danocrine)
(Fluoxymesterone)
(Oxandrin)
(Testosterone Cypionate)
(Delatestryl)
1
1
1
1
1
Requirements/Limits
PA, QL:
150 in 30
days
PA, QL:
300 in 30
days
PA, QL:
180 in 28
days
1
DUAVEE
1
ESTRACE
estradiol valerate
estradiol valerate
estradiol
(Delestrogen)
(Delestrogen)
(Climara)
1
1
1
1
estradiol
(Estrace)
1
PA, QL: 4
in 28 days
PA
estradiol/norethindrone
acet
estradiol/norethindrone
acet
ESTRASORB
(Activella)
1
PA
(Activella)
1
PA
estropipate
(Ogen)
1
FEMRING
1
MENEST
1
norethindrone ac-eth
estradiol
(Femhrt)
1
gel packet: 50mg(1%)
PA
PA, QL: 5
in 28 days
Estrogens and Antiestrogens
COMBIPATCH
1
gel packet: 1.25g-1.62
PA, QL: 8
in 28 days
PA
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
cream/appl
vial: 10mg/ml
vial: 20mg/ml, 40mg/ml
patch tdwk, (High Risk
Med for Ages 65 and Older)
tablet, (High Risk Med for
Ages 65 and Older)
(High Risk Med for Ages 65
and Older)
PA, QL:
(High Risk Med for Ages 65
97.44 in 28 and Older)
days
PA
(High Risk Med for Ages 65
and Older)
QL: 1 in
84 days
PA
(High Risk Med for Ages 65
and Older)
PA
(High Risk Med for Ages 65
and Older)
59
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Requirements/Limits
PREMARIN
PREMARIN
1
1
PA
PREMPHASE
1
PA
PREMPRO
1
PA
raloxifene hcl
VAGIFEM
(Evista)
1
1
VIVELLE-DOT
1
Glucocorticoids/mineralocorticoids
A-HYDROCORT
betamet acet/betamet na (Celestone)
ph
cortisone acetate
(Cortisone Acetate)
dexamethasone acetate
(Dexamethasone
Acetate)
dexamethasone sod
(Dexamethasone Sod
phosphate
Phosphate)
dexamethasone
(Dexamethasone)
fludrocortisone acetate
(Fludrocortisone
Acetate)
hydrocortisone sod
(Hydrocortisone Sod
succinate
Succinate)
hydrocortisone
(Cortef)
methylprednisolone
(Depo-medrol)
acetate
methylprednisolone sod
(A-methapred)
succ
methylprednisolone sod
(A-methapred)
succ
methylprednisolone
(Medrol)
prednisolone acetate
(Prednisolone Acetate)
prednisolone sod
(Orapred)
phosphate
prednisolone
(Prednisolone)
PREDNISONE
INTENSOL
prednisone
(Prednisone)
prednisone
(Sterapred Ds)
QL: 18 in
28 days
PA, QL: 8
in 28 days
cream/appl, vial
tablet, (High Risk Med for
Ages 65 and Older)
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
1
1
PA BvD
PA BvD
1
1
PA BvD
PA BvD
1
PA BvD
1
1
PA BvD
1
PA BvD
1
1
PA BvD
PA BvD
1
PA BvD
vial: 40mg, 125mg
1
PA BvD
vial: 500mg, 1000mg
1
1
1
PA BvD
PA BvD
PA BvD
1
1
PA BvD
PA BvD
1
1
PA BvD
PA BvD
solution, tablet
tab ds pk
60
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
SOLU-CORTEF
SOLU-MEDROL
triamcinolone acetonide
UCERIS
Pituitary
DDAVP
desmopressin
(nonrefrigerated)
desmopressin acetate
desmopressin acetate
GENOTROPIN
HUMATROPE
INCRELEX
NORDITROPIN
FLEXPRO
NORDITROPIN
NORDIFLEX
NORDITROPIN
NOVAREL
NUTROPIN AQ
NUSPIN
NUTROPIN AQ
NUTROPIN
NUTROPIN
octreotide acetate
OMNITROPE
SAIZEN
SAIZEN
SANDOSTATIN LAR
SEROSTIM
SOMATULINE DEPOT
Drug Tier
(Triamcinolone
Acetonide)
1
1
1
PA BvD
PA BvD
PA BvD
1
ST
(DDAVP)
1
1
(DDAVP)
(Desmopressin Acetate)
1
1
1
1
1
1
(Sandostatin)
ampul: 15mcg/ml
QL: 15 in
30 days
QL: 15 in
30 days
PA
PA
tablet, vial
solution
PA
PA
1
1
1
PA
1
1
1
1
1
1
1
1
1
1
PA
PA
PA
vial: 10mg
vial: 5mg
PA
PA
PA
cartridge, vial: 5mg
vial: 8.8mg
1
1
1
TEV-TROPIN
VANTAS
1
1
(Pitressin)
vial: 40mg/ml
1
SOMAVERT
SOMAVERT
SUPPRELIN LA
vasopressin
Requirements/Limits
PA
PA
QL: 1 in
28 days
vial: 10mg, 15mg, 20mg
vial: 25mg, 30mg
QL: 1 in
360 days
PA
QL: 1 in
360 days
1
61
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Requirements/Limits
ZORBTIVE
Progestins
DEPO-PROVERA
1
PA
1
QL: 10 in
28 days
vial: 400mg/ml
medroxyprogesterone
(Medroxyprogesterone
acet
Acet)
medroxyprogesterone
(Depo-provera)
acetate
medroxyprogesterone
(Depo-provera)
acetate
medroxyprogesterone
(Provera)
acetate
norethindrone acetate
(Aygestin)
progesterone
(Progesterone)
progesterone,micronized (Prometrium)
Thyroid and Antithyroid Agents
levothyroxine sodium
(Levothyroxine Sodium)
levothyroxine sodium
(Levoxyl)
liothyronine sodium
(Cytomel)
methimazole
(Tapazole)
methimazole
(Tapazole)
propylthiouracil
(Propylthiouracil)
1
QL: 1 in
84 days
QL: 1 in
84 days
syringe
1
1
1
vial
tablet
1
1
1
1
1
1
1
1
1
vial: 200mcg, 500mcg
tablet, vial: 100mcg
tablet: 20mg
tablet: 5mg, 10mg
Immunological Agents
Immunological Agents
ARCALYST
ASTAGRAF XL
AUBAGIO
azathioprine sodium
azathioprine
CARIMUNE NF
NANOFILTERED
CELLCEPT
CELLCEPT
cyclosporine
cyclosporine, modified
ENBREL
1
1
1
(Azathioprine Sodium)
(Imuran)
1
1
1
1
1
1
1
1
(Sandimmune)
(Neoral)
ENBREL
1
PA BvD
PA, QL:
28 in 28
days
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA, QL:
7.84 in 28
days
PA, QL: 8
in 28 days
susp recon
vial
pen injctr
vial
62
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
ENBREL
1
FLEBOGAMMA DIF
FLEBOGAMMA
GAMASTAN S-D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C
HUMIRA
1
1
1
1
1
1
1
HUMIRA
1
HYPERRAB S-D
HYPERRHO S-D
ILARIS
1
1
1
IMOGAM RABIES-HT
KINERET
1
1
leflunomide
(Arava)
MICRHOGAM ULTRAFILTERED PLUS
mycophenolate mofetil
(Cellcept)
mycophenolate sodium
(Myfortic)
NULOJIX
OCTAGAM
ORENCIA
1
1
ORENCIA
1
PRIVIGEN
PROGRAF
RAPAMUNE
RHOGAM ULTRAFILTERED PLUS
RHOPHYLAC
RIDAURA
sirolimus
tacrolimus
1
1
1
1
1
1
1
1
1
1
1
1
1
(Rapamune)
(Hecoria)
Requirements/Limits
PA, QL:
8.16 in 28
days
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA, QL: 4
in 28 days
PA, QL: 6
in 28 days
syringe
kit, pen ij kit: 40mg/0.8ml
pen ij kit: 40mg/0.8ml,
(Starter Kit)
PA, QL: 2
in 28 days
PA, QL:
18.76 in 28
days
PA BvD
PA BvD
PA BvD
PA BvD
PA, QL: 4
in 28 days
PA, QL: 4
in 28 days
PA BvD
PA BvD
PA BvD
syringe
vial
ampul
solution, tablet: 1mg, 2mg
PA BvD
PA BvD
63
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
TYSABRI
1
WINRHO SDF
ZORTRESS
1
1
Vaccines
ACTHIB
ADACEL TDAP
ADACEL TDAP
BCG VACCINE (TICE
STRAIN)
BOOSTRIX TDAP
CERVARIX
COMVAX
DAPTACEL DTAP
DIPHTHERIATETANUS TOXOIDSPED
ENGERIX-B ADULT
ENGERIX-B
PEDIATRICADOLESCENT
GARDASIL
HAVRIX
HAVRIX
IMOVAX RABIES
VACCINE
INFANRIX DTAP
INFANRIX PF
IPOL
IXIARO
JE-VAX
KINRIX
MENACTRA
MENHIBRIX
MENOMUNE-A-C-YW-135
MENVEO A-C-Y-W135-DIP
M-M-R II VACCINE
1
1
1
1
Requirements/Limits
LA, PA,
QL: 15 in
28 days
PA BvD,
QL: 120 in
30 days
syringe
vial
PA BvD
1
1
1
1
1
1
1
1
1
1
1
PA BvD
PA BvD
syringe: 1440/ml
syringe: 720/0.5ml; vial
PA BvD
1
1
1
1
1
1
1
1
1
1
1
64
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
PEDIARIX
PEDVAXHIB
PENTACEL ACTHIB
COMPONENT
PENTACEL DTAP-IPV
COMPONENT
PENTACEL
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TE ANATOXAL
BERNA
TENIVAC
TETANUS
DIPHTHERIA
TOXOIDS
TETANUS TOXOID
ADSORBED
THERACYS
TWINRIX
TWINRIX
TYPHIM VI
VAQTA
VARIVAX VACCINE
YF-VAX
ZOSTAVAX
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
PA BvD
PA BvD
PA BvD
1
1
1
PA BvD
1
1
1
1
1
1
1
1
PA BvD
syringe
vial
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
balsalazide disodium
(Colazal)
budesonide
(Entocort EC)
DIPENTUM
1
1
1
1
ST
Irrigating Solutions
Irrigating Solutions
acetic acid
(Acetic Acid)
GLYCINE
LACTATED RINGERS
mannitol/sorbitol solution (Mannitol/sorbitol
Solution)
ringers solution
(Tis-u-sol)
1
1
1
1
1
65
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
sodium chloride irrig
solution
sorbitol solution
urologic solution-g
water for
irrigation,sterile
Drug Tier
(Sodium Chloride Irrig
Solution)
(Sorbitol Solution)
(Urologic Solution-g)
(Water for Irrigation,
Sterile)
Requirements/Limits
1
1
1
1
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL
1
ACTONEL
1
ACTONEL
1
alendronate sodium
alendronate sodium
(Fosamax)
(Fosamax)
1
1
alendronate sodium
(Fosamax)
1
calcitonin,salmon,syntheti
c
calcitriol
doxercalciferol
etidronate disodium
FORTEO
(Miacalcin)
1
(Rocaltrol)
(Hectorol)
(Didronel)
1
1
1
1
FORTICAL
1
ibandronate sodium
(Boniva)
1
ibandronate sodium
(Ibandronate Sodium)
1
MIACALCIN
pamidronate disodium
paricalcitol
PROLIA
(Aredia)
(Zemplar)
1
1
1
1
risedronate sodium
(Actonel)
1
ST, QL: 1 tablet: 150mg
in 28 days
ST, QL: 30 tablet: 5mg, 30mg
in 30 days
ST, QL: 4 tablet: 35mg
in 28 days
tablet: 5mg, 10mg, 40mg
QL: 300 in solution
28 days
QL: 4 in
tablet: 35mg, 70mg
28 days
QL: 3.7 in
28 days
PA BvD
(PA for ESRD Only)
PA BvD
(PA for ESRD Only)
PA, QL: 3
in 28 days
QL: 3.7 in
28 days
QL: 1 in
28 days
PA BvD,
QL: 3 in
84 days
PA BvD
PA BvD
PA BvD
PA, QL: 1
in 180
days
QL: 1 in
28 days
tablet
vial, (PA for ESRD Only)
vial, (PA for ESRD Only)
(PA for ESRD Only)
(PA for ESRD Only)
66
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
XGEVA
1
ZEMPLAR
zoledronic acid
zoledronic acid/
mannitol&water
zoledronic acid/
mannitol&water
ZOMETA
1
1
1
(Zometa)
(Reclast)
(Zoledronic Acid/
mannitol&water)
1
Requirements/Limits
PA, QL:
1.7 in 28
days
PA BvD
vial, (PA for ESRD Only)
QL: 100 in infus. btl
300 days
piggyback
1
infus. btl
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA
1
ACTEMRA
1
ACTIMMUNE
allopurinol sodium
allopurinol
amifostine crystalline
ammonium chloride
AVODART
AVONEX
ADMINISTRATION
PACK
AVONEX
BENLYSTA
BETASERON
bethanechol chloride
BOTOX
1
1
1
1
1
1
1
(Aloprim)
(Zyloprim)
(Ethyol)
(Ammonium Chloride)
1
1
1
1
1
(Urecholine)
BOTOX
buspirone hcl
citrate phosphate dextros
soln
colchicine/probenecid
COLCRYS
COPAXONE
1
(Buspar)
(Citrate Phosphate
Dextros Soln)
(Colchicine/probenecid)
PA, QL:
3.6 in 28
days
PA, QL:
40 in 30
days
syringe
vial
ST
ST
PA, QL: 2
in 28 days
ST
QL: 1 in
90 days
QL: 4 in
90 days
vial: 200unit
vial: 100unit
1
1
1
1
1
67
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
CYSTADANE
dexrazoxane
droperidol
DUODOTE
DYSPORT
ELMIRON
EXTAVIA
finasteride
fomepizole
FUSILEV
gauze bandage
GILENYA
GLUCAGEN
GLUCAGON
EMERGENCY KIT
glutethimide
guanidine hcl
H.P. ACTHAR
Drug Tier
1
1
1
1
1
1
1
1
1
1
1
1
(Totect)
(Droperidol)
(Proscar)
(Antizol)
(Gauze Bandage)
Requirements/Limits
ST
PA, QL:
28 in 28
days
1
1
(Glutethimide)
(Guanidine HCl)
1
1
1
hydroxyzine hcl
(Hydroxyzine HCl)
1
PA, QL:
35 in 28
days
PA
hydroxyzine pamoate
(Vistaril)
1
PA
1
QL: 30 in
30 days
JALYN
KALBITOR
leucovorin calcium
levocarnitine (with sugar)
levocarnitine
LITHOSTAT
mesna
MESNEX
MESTINON
methylene blue
methylergonovine
maleate
methylergonovine
maleate
(Methylene Blue)
(Methergine)
1
1
1
1
1
1
1
1
1
1
(Methergine)
1
(Leucovorin Calcium)
(Carnitor)
(Carnitor)
(Mesnex)
PA BvD
PA BvD
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
(PA for ESRD Only)
(PA for ESRD Only)
tablet
syrup, tablet er
ampul
tablet
68
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
MYOBLOC
1
MYTELASE
neostigmine methylsulfate (Neostigmine
Methylsulfate)
NPLATE
1
1
OTEZLA
1
physostigmine salicylate
PRALIDOXIME
CHLORIDE
probenecid
PROCYSBI
PROSTIGMIN
PROTOPAM
CHLORIDE
pyridostigmine bromide
REBIF REBIDOSE
REBIF
REGONOL
REMICADE
SENSIPAR
SIGNIFOR
1
(Physostigmine
Salicylate)
Requirements/Limits
QL: 1 in
90 days
PA, QL: 8
in 28 days
PA, QL:
60 in 30
days
1
1
(Probenecid)
1
1
1
1
(Mestinon)
1
1
1
1
1
1
1
SIMPONI ARIA
1
SIMPONI
1
SIMPONI
1
SIMULECT
sodium morrhuate
sodium tetradecyl sulfate
1
1
1
(Sodium Morrhuate)
(Sodium Tetradecyl
Sulfate)
SOLIRIS
PA
QL: 60 in
30 days
PA, QL:
24 in 28
days
PA, QL:
0.5 in 28
days
PA, QL: 3
in 28 days
PA BvD
pen injctr
syringe
1
69
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
STELARA
1
STELARA
1
STELARA
1
SYNAREL
TECFIDERA
1
1
TECFIDERA
1
THALOMID
1
ULORIC
1
VORAXAZE
XELJANZ
1
1
Requirements/Limits
PA, QL:
10 in 360
days
PA, QL:
10 in 360
days
PA, QL: 5
in 360
days
syringe: 45mg/0.5ml
vial
syringe: 90mg/ml
PA, QL:
capsule dr: 120mg
14 in 30
days
PA, QL:
capsule dr: 120-240mg,
60 in 30
240mg
days
PA NSO,
QL: 60 in
30 days
ST, QL: 30
in 30 days
PA, QL:
60 in 30
days
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide sodium
(Acetazolamide Sodium)
acetazolamide
(Acetazolamide)
ALPHAGAN P
AZOPT
betaxolol hcl
(Betaxolol HCl)
BETIMOL
brimonidine tartrate
(Alphagan P)
COMBIGAN
dorzolamide hcl
(Trusopt)
dorzolamide hcl/timolol
(Cosopt)
maleat
ISOPTO CARPINE
ISTALOL
latanoprost
(Xalatan)
levobunolol hcl
(Betagan)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
drops: 0.1%
ST
(drops: 0.15%, 0.20%)
drops: 8%
drops: 0.25%
70
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
levobunolol hcl
LUMIGAN
(Betagan)
1
1
methazolamide
metipranolol
PHOSPHOLINE
IODIDE
pilocarpine hcl
PILOPINE HS
SIMBRINZA
timolol maleate
TRAVATAN Z
(Neptazane)
(Optipranolol)
1
1
1
(Isopto Carpine)
1
1
1
1
1
travoprost
(benzalkonium)
(Travatan)
(Timoptic)
1
Requirements/Limits
drops: 0.5%
QL: 2.5 in
25 days
QL: 2.5 in
25 days
QL: 2.5 in
25 days
Replacement Preparations
Replacement Preparations
0.9 % sodium chloride
(0.9 % Sodium Chloride)
calcium chloride
(Calcium Chloride)
calcium gluconate
(Calcium Gluconate)
citric acid/sodium citrate (Bicitra)
dex 2.5%-half str
(Dex 2.5%-half Str
lact.ringers
Lact.ringers)
DEXTROSE W/
ELECTROLYTE A
DEXTROSE W/
ELECTROLYTE B
electrolyte-48 solution/
(Electrolyte-48 Solution/
d5w
D5W)
electrolyte-48/fructose
(Electrolyte-48/fructose
10%
10%)
electrolyte-48/fructose
(Electrolyte-48/fructose
5%
5%)
electrolyte-75 solution/
(Electrolyte-75 Solution/
d5w
D5W)
electrolyte-75/fructose
(Electrolyte-75/fructose
5%
5%)
HYPERLYTE CR
HYPERLYTE R
IONOSOL B with
DEXTROSE 5%
1
1
1
1
1
PA BvD
(PA for ESRD Only)
1
1
1
1
1
1
1
1
1
1
71
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
IONOSOL MBDEXTROSE 5%
IONOSOL TDEXTROSE 5%
ISOLYTE E
ISOLYTE H W/
DEXTROSE
ISOLYTE M W/
DEXTROSE
ISOLYTE P with
DEXTROSE
ISOLYTE R W/
DEXTROSE
ISOLYTE S with
DEXTROSE
ISOLYTE S
K-PHOS NO.2
magnesium chloride
magnesium sulfate in
water
magnesium sulfate
magnesium sulfate
magnesium sulfate/d5w
NORMOSOL-M and
DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE II
NUTRILYTE
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE 56 IN
DEXTROSE
PLASMA-LYTE A PH
7.4
PLASMA-LYTE M IN
DEXTROSE
pot chloride/pot bicarb/
cit ac
potassium acetate
potassium bicarbonate/cit
ac
Drug Tier
Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
(Magnesium Chloride)
(Magnesium Sulfate in
Water)
(Magnesium Sulfate)
(Magnesium Sulfate)
(Magnesium Sulfate/
D5W)
1
1
1
infus. btl
syringe, vial
1
1
1
1
1
1
1
(K-phos Neutral)
1
1
(Pot Chloride/pot
Bicarb/cit Ac)
(Potassium Acetate)
(Potassium Bicarbonate/
cit Ac)
1
1
1
72
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
potassium chlorid/d100.2%nacl
potassium chloride in
0.9%nacl
potassium chloride in
d5w
potassium chloride in
d5w
potassium chloride in lrd5
potassium chloride
potassium chloride
(Potassium Chlorid/d100.2%NaCl)
(Potassium Chloride In
0.9%NaCl)
(Potassium Chloride In
D5w)
(Potassium Chloride In
D5w)
(Potassium Chloride In
Lr-d5)
(Kaochlor)
(K-dur)
1
potassium chloride/d50.2%nacl
potassium chloride/d50.2%nacl
potassium chloride/d50.25ns
potassium chloride/d50.3%nacl
potassium chloride/d50.45nacl
potassium chloride/d50.9%nacl
potassium chloride0.45% nacl
potassium citrate/citric
acid
potassium gluconate
potassium phos,m-basicd-basic
ringers solution
SHOHL'S MODIFIED
sod/pot/k cit/sod cit/cit
acid
sodium acetate
sodium bicarbonate
sodium chloride 0.45 %
(Potassium Chloride/d50.2%NaCl)
(Potassium Chloride/d50.2%NaCl)
(Potassium Chloride/D50.25 NS)
(Potassium Chloride/d50.3%NaCl)
(Potassium Chloride/d50.45NaCl)
(Potassium Chloride/d50.9%NaCl)
(Potassium Chloride0.45% NaCl)
(Polycitra-k)
1
(Potassium Gluconate)
(Potassium Phos,mbasic-d-basic)
(Ringers Solution)
1
1
sodium chloride 3%
sodium chloride 5%
Requirements/Limits
1
1
iv soln: 10meq/l, 30meq/l
1
iv soln: 20meq/l, 40meq/l
1
1
1
1
liquid, packet, tablet sa
capsule er, piggyback,
syringe, tab er prt, tablet er
iv soln: 10meq/l, 30meq/l,
40meq/l
iv soln: 20meq/l
1
1
1
1
1
1
1
1
1
(Polycitra-lc)
(Sodium Acetate)
(Sodium Bicarbonate)
(Sodium Chloride 0.45
%)
(Sodium Chloride 3%)
(Sodium Chloride 5%)
1
1
1
1
1
73
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
sodium chloride
sodium chloride
sodium lactate
SODIUM LACTATE
sodium phos,m-basic-dbasic
TPN ELECTROLYTES
TRAVERTELECTROLYTE NO.1
TRAVERTELECTROLYTE NO.2
TRAVERTELECTROLYTE NO.2
TRAVERTELECTROLYTE NO.3
TRAVERTELECTROLYTE NO.4
Drug Tier
Requirements/Limits
1
1
1
1
1
vial: 2.5meq/ml
vial: 4meq/ml
(Sodium Chloride)
(Sodium Chloride)
(Sodium Lactate)
(Sodium Phos,m-basicd-basic)
1
1
1
iv soln: 10%
1
iv soln: 5%
1
1
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
1
ADVAIR HFA
1
BREO ELLIPTA
1
DULERA
1
FLOVENT DISKUS
1
FLOVENT DISKUS
1
FLOVENT HFA
1
FLOVENT HFA
1
FLOVENT HFA
1
flunisolide
(Nasarel)
1
flunisolide
(Nasarel)
1
QL: 60 in
30 days
QL: 12 in
28 days
QL: 60 in
30 days
QL: 13 in
28 days
QL: 120 in
30 days
QL: 60 in
30 days
QL: 12 in
28 days
QL: 21.2
in 28 days
QL: 24 in
28 days
QL: 50 in
25 days
QL: 50 in
25 days
blst w/dev: 250mcg
blst w/dev: 50mcg, 100mcg
aer w/adap: 110mcg
aer w/adap: 44mcg
aer w/adap: 220mcg
spray: 25mcg
spray: 29mcg
74
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
fluticasone propionate
Drug Tier
(Flonase)
1
NASONEX
1
QNASL
1
QVAR
1
triamcinolone acetonide
(Nasacort Aq)
1
Antileukotrienes
montelukast sodium
(Singulair)
zafirlukast
(Accolate)
Bronchodilators
albuterol sulfate
(Accuneb)
albuterol sulfate
aminophylline
aminophylline
ATROVENT HFA
QL: 16 in
30 days
QL: 34 in
28 days
QL: 8.7 in
28 days
QL: 17.4
in 25 days
QL: 16.5
in 30 days
1
1
1
(Albuterol Sulfate)
(Aminophylline)
(Aminophylline)
1
1
1
1
COMBIVENT
RESPIMAT
COMBIVENT
1
FORADIL
1
1
ipratropium bromide
(Atrovent)
1
ipratropium bromide
(Atrovent)
1
metaproterenol sulfate
PROAIR HFA
(Metaproterenol Sulfate)
1
1
SEREVENT DISKUS
1
SPIRIVA
1
terbutaline sulfate
theophylline anhydrous
theophylline/d5w
Requirements/Limits
(Brethine)
(Theochron)
(Theophylline/D5W)
PA BvD
QL: 25.8
in 28 days
QL: 8 in
30 days
QL: 29.4
in 30 days
QL: 62 in
30 days
QL: 15 in
10 days
QL: 30 in
28 days
solution, vial-neb: 0.63mg/
3ml, 1.25mg/3ml
syrup, tab er 12h, tablet
liquid
vial
spray: 42mcg
spray: 21mcg
QL: 17 in
25 days
QL: 60 in
30 days
QL: 30 in
30 days
1
1
1
75
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
Requirements/Limits
VENTOLIN HFA
1
QL: 36 in
25 days
Respiratory Tract Agents, Other
acetylcysteine
(Acetadote)
ARALAST NP
cromolyn sodium
(Intal)
DALIRESP
1
1
1
1
PA BvD
KALYDECO
1
XOLAIR
1
ZEMAIRA
1
PA BvD
QL: 30 in
30 days
PA, QL:
60 in 30
days
PA, QL: 6
in 28 days
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
(Baclofen)
carisoprodol
(Soma)
1
1
carisoprodol
(Soma)
1
chlorzoxazone
(Parafon Forte DSC)
1
PA, QL:
120 in 30
days
PA, QL:
120 in 30
days
PA
chlorzoxazone/
acetaminophen
cyclobenzaprine hcl
(Chlorzoxazone/
acetaminophen)
(Fexmid)
1
PA
1
PA
dantrolene sodium
dantrolene sodium
metaxalone
(Dantrium)
(Dantrium)
(Skelaxin)
1
1
1
PA
methocarbamol
(Robaxin)
1
PA
tizanidine hcl
(Zanaflex)
1
tablet: 250mg, (High Risk
Med for Ages 65 and Older)
tablet: 350mg, (High Risk
Med for Ages 65 and Older)
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
capsule
vial
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
Sleep Disorder Agents
Sleep Disorder Agents
BUTISOL SODIUM
1
BUTISOL SODIUM
1
QL: 120 in tablet: 30mg
30 days
QL: 473 in elixir: 30mg/5ml
30 days
76
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
BUTISOL SODIUM
modafinil
1
(Provigil)
1
ROZEREM
XYREM
zaleplon
(Sonata)
1
1
1
zolpidem tartrate
(Ambien)
1
Requirements/Limits
QL: 60 in
30 days
PA, QL:
60 in 30
days
LA
PA, QL:
60 in 30
days
PA, QL:
30 in 30
days
tablet: 50mg
(High Risk Med. QL applies
to all members; PA required
for 65 years and older with
over 90 days cumulative use
with any nonbenzodiazepine hypnotic
drug)
(High Risk Med. QL applies
to all members; PA required
for 65 years and older with
over 90 days cumulative use
with any nonbenzodiazepine hypnotic
drug)
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
alfuzosin hcl
(Uroxatral)
phentolamine mesylate
(Phentolamine Mesylate)
tamsulosin hcl
(Flomax)
terazosin hcl
(Hytrin)
1
1
1
1
PA
Vasodilating Agents
Vasodilating Agents
ADCIRCA
1
ADEMPAS
1
alprostadil
epoprostenol sodium
(glycine)
ISOVEX
LETAIRIS
(Prostin Vr Pediatric)
(Flolan)
1
1
1
1
PA, QL:
60 in 30
days
PA, QL:
90 in 30
days
PA
PA BvD
PA, QL:
30 in 30
days
77
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
Drug Name
Drug Tier
OPSUMIT
1
REMODULIN
REVATIO
1
1
sildenafil citrate
(Revatio)
1
TRACLEER
1
TYVASO
VENTAVIS
1
1
Requirements/Limits
PA, QL:
30 in 30
days
PA BvD
PA, QL:
37.5 in 1
day
PA, QL:
90 in 30
days
LA, PA,
QL: 60 in
30 days
PA BvD
PA BvD
vial
Vitamins and Minerals
Vitamins and Minerals
LOZI-FLUR
pedi m.vit no.17 with
(Pedi M.vit No.17 with
fluoride
Fluoride)
pedi mvi no.12/sodium
(Multivitamins with
fluoride
Fluoride)
pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/
fa)
1
1
1
1
(All Rx Prenatal Vitamins
Covered)
78
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
INDEX
0.9 % sodium chloride .......... 71
8-MOP................................... 50
abacavir sulfate ..................... 34
abacavir/lamivudine/zidovudine
........................................... 34
ABELCET............................. 27
ABILIFY ............................... 32
ABILIFY DISCMELT .......... 32
ABILIFY MAINTENA ........ 32
ABRAXANE ........................ 12
acamprosate calcium .............. 6
acarbose ................................ 23
acebutolol hcl ........................ 44
acetaminophen with codeine ... 1
acetazolamide ....................... 70
acetazolamide sodium ........... 70
acetic acid ....................... 54, 65
acetic acid/hydrocortisone .... 54
acetylcysteine ........................ 76
acitretin ................................. 50
ACTEMRA ........................... 67
ACTHIB ................................ 64
ACTIMMUNE ...................... 67
ACTONEL ............................ 66
ACTOPLUS MET XR .......... 27
acyclovir .......................... 36, 50
acyclovir sodium ................... 36
ADACEL TDAP ................... 64
ADAGEN .............................. 53
adapalene ........................ 50, 53
ADASUVE ........................... 32
ADCETRIS ........................... 12
ADCIRCA............................. 77
adefovir dipivoxil .................. 36
ADEMPAS ........................... 77
ADVAIR DISKUS................ 74
ADVAIR HFA ...................... 74
AFINITOR ............................ 13
AFINITOR DISPERZ ........... 12
AGGRENOX ........................ 39
A-HYDROCORT ................. 60
AKTEN ................................. 55
ALBENZA ............................ 31
ALBUKED-25 ...................... 39
ALBUKED-5 ........................ 39
ALBUMIN HUMAN ............ 39
ALBUMINAR-25 ................. 39
ALBUMINAR-5 ................... 39
ALBURX .............................. 39
ALBUTEIN........................... 39
albuterol sulfate .................... 75
alclometasone dipropionate .. 51
alcohol antiseptic pads ......... 50
ALDURAZYME................... 53
alendronate sodium............... 66
ALFERON N ........................ 36
alfuzosin hcl .......................... 77
ALIMTA ............................... 13
ALINIA ................................. 31
allopurinol............................. 67
allopurinol sodium ................ 67
ALPHAGAN P ..................... 70
alprazolam .............................. 6
alprostadil ............................. 77
ALREX ................................. 55
aluminum chloride ................ 50
amantadine hcl ...................... 31
amifostine crystalline ............ 67
amiloride hcl ......................... 46
amiloride/hydrochlorothiazide
........................................... 46
AMINO ACIDS .................... 39
aminocaproic acid ................ 38
aminophylline........................ 75
AMINOSYN ......................... 39
AMINOSYN II ..................... 39
AMINOSYN M .................... 39
AMINOSYN with
ELECTROLYTES ............ 39
AMINOSYN-HBC ............... 40
AMINOSYN-PF ................... 40
AMINOSYN-RF ................... 40
amiodarone hcl ..................... 44
AMITIZA .............................. 57
amitriptyline hcl .................... 22
amlodipine besylate .............. 46
amlodipine besylate/benazepril
........................................... 46
amlodipine/atorvastatin ........ 46
ammonium chloride .............. 67
ammonium lactate ................. 50
amoxapine ............................. 22
amoxicillin............................. 11
amoxicillin trihydrate............ 11
amoxicillin/potassium clav.... 11
amphotericin b ...................... 28
ampicillin sodium .................. 11
ampicillin sodium/sulbactam na
........................................... 11
ampicillin trihydrate ............. 11
AMPYRA ............................. 48
ANACAINE .......................... 50
ANADROL-50 ...................... 58
anagrelide hcl ....................... 38
anastrozole ............................ 13
ANDRODERM ..................... 58
ANDROGEL................... 58, 59
ANORO ELLIPTA ............... 19
APEXICON E ....................... 52
APOKYN .............................. 31
apraclonidine hcl .................. 55
APRISO ................................ 65
APTIOM ............................... 19
APTIVUS .............................. 34
ARALAST NP ...................... 76
ARCALYST ......................... 62
ARRANON ........................... 13
ARZERRA ............................ 13
ASTAGRAF XL ................... 62
atenolol ................................. 44
atenolol/chlorthalidone ......... 44
atorvastatin calcium.............. 47
atovaquone ............................ 31
I-1
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
atovaquone/proguanil hcl ..... 31
ATRIPLA .............................. 34
atropine sulfate ............... 19, 55
ATROVENT HFA ................ 75
AUBAGIO ............................ 62
AVANDAMET ..................... 27
AVANDARYL ..................... 27
AVANDIA ............................ 27
AVASTIN ............................. 13
AVC ...................................... 29
AVELOX ABC PACK ......... 12
AVELOX IV ......................... 12
AVODART ........................... 67
AVONEX .............................. 67
AVONEX
ADMINISTRATION PACK
........................................... 67
AXIRON ............................... 59
azacitidine ............................. 13
azathioprine .......................... 62
azathioprine sodium .............. 62
azelastine hcl ......................... 56
AZILECT .............................. 31
azithromycin .......................... 10
AZOPT .................................. 70
AZOR .................................... 46
aztreonam .............................. 11
bacitracin .......................... 8, 54
bacitracin/polymyxin b sulfate
........................................... 54
baclofen ................................. 76
balsalazide disodium............. 65
BANZEL ............................... 19
BARACLUDE ...................... 36
BCG VACCINE TICE
STRAIN ............................ 64
BELEODAQ ......................... 13
benazepril hcl ........................ 43
benazepril/hydrochlorothiazide
........................................... 43
BENICAR ............................. 42
BENICAR HCT .................... 42
BENLYSTA .......................... 67
benztropine mesylate ............. 31
BERINERT ........................... 38
betamet acet/betamet na ph .. 60
betamethasone dipropionate . 52
betamethasone valerate ........ 52
betamethasone/propylene glyc
........................................... 52
BETASERON ....................... 67
betaxolol hcl .................... 44, 70
bethanechol chloride ............. 67
BETHKIS ................................ 8
BETIMOL ............................. 70
BEXXAR .............................. 13
bicalutamide.......................... 13
BICILLIN C-R ...................... 11
BICILLIN L-A ...................... 11
BICNU .................................. 13
BILTRICIDE ........................ 31
bisoprolol fumarate............... 44
bisoprolol fumarate/hctz ....... 44
bleomycin sulfate .................. 13
BLEPHAMIDE ..................... 54
BLEPHAMIDE S.O.P. ......... 54
BOOSTRIX TDAP ............... 64
BOSULIF .............................. 13
BOTOX ................................. 67
BREO ELLIPTA ................... 74
BRILINTA ............................ 39
brimonidine tartrate .............. 70
BRINTELLIX ....................... 22
BROMDAY .......................... 55
bromfenac sodium ................. 55
bromocriptine mesylate ......... 32
budesonide ............................ 65
bumetanide ............................ 46
BUMINATE ......................... 39
BUPHENYL ......................... 57
buprenorphine hcl ............... 1, 6
buprenorphine hcl/naloxone hcl
............................................. 6
bupropion hcl ........................ 22
buspirone hcl ......................... 67
BUSULFEX .......................... 13
butalb/acetaminophen/caffeine 1
butalbit/acetamin/caff/codeine 1
butalbital/acetaminophen ....... 1
butalbital/aspirin/caffeine ....... 4
BUTISOL SODIUM ....... 76, 77
butorphanol tartrate................ 1
BUTRANS .............................. 1
BYDUREON ........................ 23
BYDUREON PEN ................ 23
BYETTA ......................... 23, 24
BYSTOLIC ........................... 44
cabergoline ........................... 32
caffeine citrated .................... 48
caffeine/sodium benzoate ...... 48
calcipotriene ......................... 50
calcipotriene/betamethasone 50
calcitonin,salmon,synthetic ... 66
calcitriol .......................... 50, 66
calcium acetate ..................... 58
calcium carbonate/mag carb/fa
........................................... 58
calcium chloride.................... 71
calcium gluconate ................. 71
CALDOLOR ........................... 4
CAMPRAL ............................. 6
CANCIDAS .......................... 28
candesartan cilexetil ............. 42
candesartan/hydrochlorothiazid
........................................... 43
CAPASTAT SULFATE ....... 30
CAPRELSA .......................... 13
captopril ................................ 43
captopril/hydrochlorothiazide
........................................... 43
CARAC ................................. 50
CARAFATE ......................... 56
CARBAGLU......................... 57
carbamazepine ...................... 19
carbidopa .............................. 32
carbidopa/levodopa .............. 32
carbidopa/levodopa/entacapone
........................................... 32
carbinoxamine maleate ......... 28
carboplatin ............................ 13
CARIMUNE NF
NANOFILTERED ............ 62
I-2
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
carisoprodol .......................... 76
carteolol hcl .......................... 56
carvedilol .............................. 44
CAYSTON............................ 11
CEENU ................................. 13
cefaclor ................................... 9
cefadroxil ................................ 9
cefazolin sodium...................... 9
cefazolin sodium/dextrose,iso . 9
cefdinir .................................... 9
cefditoren pivoxil .................... 9
CEFEPIME ............................. 9
cefepime hcl ............................ 9
CEFEPIME-DEXTROSE ....... 9
cefotaxime sodium ................... 9
cefotetan disod/dextrose,iso .... 9
cefotetan disodium ................ 10
cefoxitin sodium .................... 10
cefoxitin sodium/dextrose,iso 10
cefpodoxime proxetil ............. 10
cefprozil................................. 10
ceftazidime pentahydrate ...... 10
ceftibuten dihydrate .............. 10
ceftriaxone na/dextrose,iso ... 10
ceftriaxone sodium ................ 10
cefuroxime axetil ................... 10
cefuroxime sodium ................ 10
cefuroxime sodium/dextrose,iso
........................................... 10
CELEBREX ............................ 4
CELLCEPT ........................... 62
CELONTIN........................... 20
cephalexin ............................. 10
CEPROTIN ........................... 37
CEREZYME ......................... 53
CERVARIX .......................... 64
CESAMET ............................ 30
cevimeline hcl........................ 50
CHANTIX............................... 6
CHENODAL......................... 53
chloramphenicol sod succ ....... 8
chlordiazepoxide hcl ............... 6
chlorhexidine gluconate ........ 50
chlorothiazide ....................... 46
chlorothiazide sodium ........... 46
chlorpromazine hcl ............... 32
chlorthalidone ....................... 46
chlorzoxazone ....................... 76
chlorzoxazone/acetaminophen
........................................... 76
cholestyramine (with sugar) . 47
cholestyramine/aspartame .... 47
choline sal/mag salicylate ....... 4
ciclopirox .............................. 28
ciclopirox olamine ................ 28
cidofovir ................................ 36
cilostazol ............................... 39
cimetidine .............................. 56
cimetidine hcl ........................ 56
cimetidine in 0.9 % nacl........ 56
CIMZIA ................................ 53
CINRYZE ............................. 38
CIPRO HC ............................ 54
CIPRODEX........................... 54
ciprofloxacin ......................... 12
ciprofloxacin hcl ............. 12, 54
ciprofloxacin lactate ............. 12
ciprofloxacin lactate/d5w...... 12
ciprofloxacin/ciprofloxa hcl .. 12
cisplatin ................................. 13
citalopram hydrobromide ..... 22
citrate phosphate dextros soln
........................................... 67
citric acid/sodium citrate ...... 71
cladribine .............................. 13
clarithromycin ....................... 10
clemastine fumarate .............. 28
CLEVIPREX......................... 46
clindamycin hcl ....................... 8
clindamycin palmitate hcl ....... 8
clindamycin phos/benzoyl perox
........................................... 51
clindamycin phosphate 8, 29, 51
clindamycin phosphate/d5w .... 8
CLINIMIX ............................ 40
CLINIMIX E ......................... 40
CLINISOL ............................ 40
clobetasol propionate............ 52
clocortolone pivalate ............ 52
CLODERM ........................... 52
CLOLAR............................... 13
clomipramine hcl .................. 22
clonazepam ......................... 6, 7
clonidine ................................ 42
clonidine hcl .................... 42, 48
clonidine hcl/chlorthalidone . 42
clopidogrel bisulfate ............. 39
clorazepate dipotassium.......... 7
clotrimazole........................... 28
clotrimazole/betamethasone dip
........................................... 28
clozapine ......................... 32, 33
COARTEM ........................... 31
cocaine hcl .............................. 5
codeine phos/acetaminophen .. 1
codeine sulfate ........................ 1
codeine/butalbital/asa/caffein . 1
colchicine/probenecid ........... 67
COLCRYS ............................ 67
colestipol hcl ......................... 47
colistin (colistimethate na) ...... 8
COLY-MYCIN S .................. 54
COMBIGAN ......................... 70
COMBIPATCH .................... 59
COMBIVENT ....................... 75
COMBIVENT RESPIMAT .. 75
COMETRIQ .......................... 13
COMPLERA ......................... 34
COMVAX ............................. 64
CONDYLOX ........................ 50
COPAXONE ......................... 67
CORDRAN ........................... 52
COREG CR........................... 44
cortisone acetate ................... 60
CORTISPORIN-TC .............. 54
CREON ................................. 53
CRESTOR............................. 47
CRIXIVAN ........................... 35
cromolyn sodium ....... 56, 57, 76
CUBICIN ................................ 8
cyclobenzaprine hcl .............. 76
CYCLOGYL ......................... 56
I-3
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
cyclopentolate hcl ................. 56
cyclophosphamide ................. 13
CYCLOPHOSPHAMIDE..... 14
CYCLOSET .......................... 24
cyclosporine .......................... 62
cyclosporine, modified .......... 62
cyproheptadine hcl ................ 29
CYRAMZA........................... 14
CYSTADANE ...................... 68
CYSTARAN ......................... 56
cysteine hcl ............................ 40
cytarabine/pf ......................... 14
dacarbazine ........................... 14
dactinomycin ......................... 14
DALIRESP ........................... 76
danazol .................................. 59
dantrolene sodium ................. 76
dapsone ................................. 30
DAPTACEL DTAP .............. 64
DARAPRIM ......................... 31
daunorubicin hcl ................... 14
DAUNOXOME .................... 14
DDAVP ................................. 61
decitabine .............................. 14
deferoxamine mesylate .......... 58
demeclocycline hcl ................ 12
DENAVIR............................. 50
DEPO-PROVERA ................ 62
desipramine hcl ..................... 22
desmopressin (nonrefrigerated)
........................................... 61
desmopressin acetate ............ 61
desog-e.estradiol/e.estradiol . 49
desogestrel-ethinyl estradiol . 49
desonide ................................ 52
desoximetasone ..................... 52
DESVENLAFAXINE ER..... 22
dex 2.5%-half str lact.ringers 71
dexamethasone ...................... 60
dexamethasone acetate ......... 60
dexamethasone sod phosphate
..................................... 55, 60
dexmethylphenidate hcl ......... 48
dexrazoxane .......................... 68
dextroamphetamine sulfate ... 48
dextroamphetamine/
amphetamine ..................... 48
dextrose 10 % and 0.2 % nacl
........................................... 40
dextrose 10 % and 0.9 % nacl
........................................... 40
dextrose 10%-0.5 normal saline
........................................... 40
dextrose 10%-water .............. 40
dextrose 2.5 % in water ........ 40
dextrose 2.5% in half ringers 40
dextrose 2.5%-0.5normal saline
........................................... 40
dextrose 20%-water .............. 40
dextrose 25 % in water ......... 40
dextrose 40%-water .............. 40
dextrose 5 % and 0.3 % nacl 41
dextrose 5 % and 0.9 % nacl 41
dextrose 5 % in water ........... 41
dextrose 5 %-0.2 % nacl ....... 41
dextrose 5 %-0.45 % nacl ..... 41
dextrose 5% in ringers .......... 41
dextrose 5%-lactated ringers 41
dextrose 50 % in water ......... 41
dextrose 60 % in water ......... 41
dextrose 70%-water .............. 41
DEXTROSE W/
ELECTROLYTE A .......... 71
DEXTROSE W/
ELECTROLYTE B ........... 71
DIASTAT ACUDIAL ............ 7
diazepam ................................. 7
diclofenac potassium ............... 4
diclofenac sodium ............. 4, 55
diclofenac sodium/misoprostol 4
dicloxacillin sodium .............. 11
dicyclomine hcl ..................... 57
didanosine ............................. 35
DIFICID ................................ 10
diflorasone diacetate............. 52
diflunisal ................................. 4
digoxin................................... 45
DIGOXIN ............................. 45
dihydroergotamine mesylate . 29
DILANTIN ........................... 20
diltiazem hcl .......................... 45
dimenhydrinate ..................... 30
DIOVAN ............................... 43
DIPENTUM .......................... 65
diphenhydramine hcl ............. 29
diphenoxylate hcl/atropine.... 57
DIPHTHERIA-TETANUS
TOXOIDS-PED ................ 64
disopyramide phosphate ....... 44
disulfiram ................................ 6
divalproex sodium ................. 20
dobutamine hcl ...................... 45
dobutamine hcl/d5w .............. 45
DOCEFREZ .......................... 14
docetaxel ............................... 14
donepezil hcl ......................... 21
dopamine hcl ......................... 45
dopamine hcl/d5w ................. 45
dopamine hcl/dextrose 5%water ................................. 45
dorzolamide hcl ..................... 70
dorzolamide hcl/timolol maleat
........................................... 70
doxazosin mesylate................ 42
doxepin hcl ............................ 22
doxercalciferol ...................... 66
doxorubicin hcl ..................... 14
doxorubicin hcl peg-liposomal
........................................... 14
doxycycline hyclate ............... 12
doxycycline monohydrate...... 12
dronabinol ............................. 30
droperidol ............................. 68
DROXIA ............................... 14
DUAVEE .............................. 59
DULERA .............................. 74
duloxetine hcl ........................ 22
DUODOTE ........................... 68
DUREZOL ............................ 55
DUTOPROL ......................... 44
DYRENIUM ......................... 46
DYSPORT ............................ 68
I-4
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
econazole nitrate ................... 28
edetate disodium ................... 58
EDURANT ........................... 35
EFFIENT............................... 39
ELAPRASE .......................... 53
electrolyte-48 solution/d5w ... 71
electrolyte-48/fructose 10% .. 71
electrolyte-48/fructose 5% .... 71
electrolyte-75 solution/d5w ... 71
electrolyte-75/fructose 5% .... 71
ELELYSO ............................. 53
ELIDEL................................. 52
ELIGARD ............................. 14
ELIQUIS ............................... 37
ELITEK................................. 53
ELMIRON ............................ 68
ELSPAR ................................ 14
EMCYT................................. 14
EMEND ................................ 30
EMSAM ................................ 22
EMTRIVA ............................ 35
enalapril maleate .................. 43
enalapril/hydrochlorothiazide
........................................... 43
enalaprilat dihydrate ............ 43
ENBREL ......................... 62, 63
ENGERIX-B ADULT .......... 64
ENGERIX-B PEDIATRICADOLESCENT ................ 64
enoxaparin sodium ................ 37
entacapone ............................ 32
entecavir ................................ 36
ephedrine sulfate ................... 45
epinastine hcl ........................ 56
epinephrine ........................... 45
EPIPEN 2-PAK ..................... 45
EPIPEN JR 2-PAK ............... 45
epirubicin hcl ........................ 14
EPIVIR .................................. 35
EPIVIR HBV ........................ 35
eplerenone ............................. 47
EPOGEN ............................... 38
epoprostenol sodium (glycine)
........................................... 77
eprosartan mesylate .............. 43
EPZICOM ............................. 35
ERAXIS WATER DILUENT28
ERBITUX ............................. 14
ERGOMAR........................... 29
ERIVEDGE........................... 14
ERWINAZE .......................... 14
ery e-succ/sulfisoxazole ........ 10
ERY-TAB ............................. 10
ERYTHROCIN
LACTOBIONATE ............ 10
erythromycin base ........... 10, 54
erythromycin base/ethanol .... 51
erythromycin ethylsuccinate . 10
erythromycin stearate ........... 10
erythromycin/benzoyl peroxide
........................................... 51
escitalopram oxalate ............. 22
esmolol hcl ............................ 44
esomeprazole sodium ............ 56
estazolam................................. 7
ESTRACE ............................. 59
estradiol ................................ 59
estradiol valerate .................. 59
estradiol/norethindrone acet . 59
ESTRASORB ....................... 59
estropipate............................. 59
ethambutol hcl ....................... 30
ethanolamine oleate .............. 45
ethinyl estradiol/drospirenone
........................................... 49
ethosuximide ......................... 20
ethynodiol d-ethinyl estradiol 49
etidronate disodium .............. 66
etodolac ................................... 4
ETOPOPHOS ....................... 14
etoposide ............................... 14
EURAX ................................. 53
EXELDERM ......................... 28
EXELON............................... 21
exemestane ............................ 14
EXFORGE ............................ 46
EXFORGE HCT ................... 46
EXJADE ............................... 58
EXTAVIA ............................. 68
FABRAZYME ...................... 53
famciclovir ............................ 36
famotidine ............................. 56
famotidine in nacl,iso-osm/pf 56
FANAPT ............................... 33
FARESTON .......................... 14
FASLODEX .......................... 14
FAZACLO ............................ 33
felbamate ............................... 20
felodipine............................... 46
FEMRING............................. 59
fenofibrate ............................. 47
fenofibrate nanocrystallized.. 47
fenofibrate,micronized .......... 47
fenofibric acid ....................... 47
fenofibric acid (choline) ........ 47
fenoprofen calcium.................. 4
fentanyl .................................... 1
fentanyl citrate ........................ 1
FERRIPROX......................... 58
FETZIMA ............................. 22
finasteride ............................. 68
FIRAZYR ............................. 45
FIRMAGON ......................... 14
flavoxate hcl .......................... 58
FLEBOGAMMA .................. 63
FLEBOGAMMA DIF ........... 63
flecainide acetate .................. 44
FLECTOR ............................... 4
FLEXBUMIN ....................... 39
FLOVENT DISKUS ............. 74
FLOVENT HFA ................... 74
floxuridine ............................. 14
fluconazole ............................ 28
fluconazole in nacl,iso-osm... 28
flucytosine ............................. 28
fludarabine phosphate .......... 15
fludrocortisone acetate ......... 60
flumazenil .............................. 48
flunisolide.............................. 74
fluocinonide........................... 52
fluorometholone .................... 55
FLUOROPLEX..................... 50
I-5
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
fluorouracil ..................... 15, 50
fluoxetine hcl ......................... 22
fluoxymesterone .................... 59
fluphenazine decanoate ......... 33
fluphenazine hcl .................... 33
flurazepam hcl ......................... 7
flurbiprofen ............................. 4
flurbiprofen sodium............... 55
flutamide ............................... 15
fluticasone propionate .... 52, 75
fluvastatin sodium ................. 47
fluvoxamine maleate ............. 22
FOLOTYN ............................ 15
fomepizole ............................. 68
fondaparinux sodium ............ 37
FORADIL ............................. 75
FORTEO ............................... 66
FORTICAL ........................... 66
foscarnet sodium ................... 35
fosinopril sodium .................. 43
fosinopril/hydrochlorothiazide
........................................... 43
fosphenytoin sodium.............. 20
FREAMINE HBC ................. 41
FREAMINE III ..................... 41
fructose 10% ......................... 41
FULYZAQ ............................ 57
furosemide ............................. 46
FUROXONE ........................... 8
FUSILEV .............................. 68
FUZEON ............................... 35
FYCOMPA ........................... 20
gabapentin............................. 20
GABITRIL ............................ 20
galantamine hbr .................... 21
GALZIN ................................ 58
GAMASTAN S-D ................ 63
GAMMAGARD LIQUID ..... 63
GAMMAPLEX ..................... 63
GAMUNEX-C ...................... 63
ganciclovir sodium ................ 36
GARDASIL .......................... 64
gatifloxacin ........................... 54
gauze bandage ...................... 68
GAZYVA .............................. 15
gemcitabine hcl ..................... 15
gemfibrozil ............................ 47
GENOTROPIN ..................... 61
gentamicin in nacl, iso-osm .... 8
gentamicin sulfate ....... 8, 51, 54
gentamicin sulfate/pf ............... 8
GEODON .............................. 33
GILENYA ............................. 68
GILOTRIF ............................ 15
GLEEVEC ............................ 15
glimepiride ............................ 26
glipizide ................................. 26
glipizide/metformin hcl ......... 26
GLUCAGEN......................... 68
GLUCAGON EMERGENCY
KIT .................................... 68
glutethimide........................... 68
glyburide ......................... 26, 27
glyburide,micronized ............ 27
glyburide/metformin hcl ........ 27
GLYCINE ............................. 65
glycopyrrolate ....................... 57
GLYSET ............................... 24
granisetron hcl ...................... 30
granisetron hcl/pf .................. 30
GRANIX ............................... 38
griseofulvin ultramicrosize ... 28
griseofulvin, microsize .......... 28
guanfacine hcl ....................... 42
guanidine hcl ......................... 68
H.P. ACTHAR ...................... 68
HALAVEN ........................... 15
HALFAN .............................. 31
halobetasol propionate ......... 52
haloperidol ............................ 33
haloperidol decanoate .......... 33
haloperidol lactate ................ 33
HAVRIX ............................... 64
heparin sod,pork in 0.45% nacl
........................................... 37
heparin sodium,porcine ........ 37
heparin sodium,porcine/d5w. 37
heparin sodium,porcine/ns/pf 37
heparin sodium,porcine/pf ... 37,
38
HEPATAMINE..................... 41
HEPATASOL ....................... 41
HERCEPTIN......................... 15
HEXALEN ............................ 15
homatropine hbr.................... 56
HUMALOG .......................... 25
HUMALOG MIX 50-50 ....... 25
HUMALOG MIX 75-25 ....... 25
HUMATROPE ...................... 61
HUMIRA .............................. 63
HUMULIN 70-30 ................. 25
HUMULIN N ........................ 25
HUMULIN R ........................ 25
hydralazine hcl ...................... 45
hydralazine/hydrochlorothiazid
........................................... 45
hydrochlorothiazide .............. 46
hydrocodone/acetaminophen .. 2
hydrocodone/ibuprofen ........... 2
hydrocortisone ................ 52, 60
hydrocortisone acetate .......... 52
hydrocortisone acetate/aloe v 52
hydrocortisone acetate/urea . 52
hydrocortisone butyrate ........ 52
hydrocortisone sod succinate 60
hydrocortisone valerate ........ 52
hydromorphone hcl ................. 2
hydromorphone hcl/pf ............. 2
hydroxychloroquine sulfate ... 31
hydroxyurea .......................... 15
hydroxyzine hcl ..................... 68
hydroxyzine pamoate ............ 68
HYPERLYTE CR ................. 71
HYPERLYTE R.................... 71
HYPERRAB S-D .................. 63
HYPERRHO S-D.................. 63
ibandronate sodium .............. 66
ibuprofen ................................. 4
ibuprofen/oxycodone hcl ......... 2
ICLUSIG ............................... 15
idarubicin hcl ........................ 15
ifosfamide .............................. 15
I-6
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
ifosfamide/mesna................... 15
ILARIS .................................. 63
ILEVRO ................................ 55
IMBRUVICA ........................ 15
imipenem/cilastatin sodium .. 11
imipramine hcl ...................... 22
imipramine pamoate ............. 22
imiquimod ............................. 50
IMOGAM RABIES-HT........ 63
IMOVAX RABIES VACCINE
........................................... 64
INCIVEK .............................. 36
INCRELEX ........................... 61
indapamide............................ 46
indomethacin ........................... 5
indomethacin sodium .............. 4
INFANRIX DTAP ................ 64
INFANRIX PF ...................... 64
INLYTA ................................ 15
INTELENCE......................... 35
INTRALIPID ........................ 41
INTRON A............................ 36
INTUNIV .............................. 48
INVANZ ............................... 11
INVEGA ............................... 33
INVEGA SUSTENNA ......... 33
INVIRASE ............................ 35
INVOKAMET ...................... 24
INVOKANA ......................... 24
IONOSOL B with DEXTROSE
5% ..................................... 71
IONOSOL MB-DEXTROSE
5% ..................................... 72
IONOSOL T-DEXTROSE 5%
........................................... 72
IPOL ...................................... 64
ipratropium bromide ............. 75
IPRIVASK ............................ 38
irbesartan .............................. 43
irbesartan/hydrochlorothiazide
........................................... 43
irinotecan hcl ........................ 15
ISENTRESS .......................... 35
ISOLYTE E .......................... 72
ISOLYTE H W/DEXTROSE 72
ISOLYTE M W/DEXTROSE72
ISOLYTE P with DEXTROSE
........................................... 72
ISOLYTE R W/DEXTROSE 72
ISOLYTE S ........................... 72
ISOLYTE S with DEXTROSE
........................................... 72
isoniazid ................................ 30
isopropamide/prochlorperazine
........................................... 57
ISOPTO CARPINE .............. 70
ISOPTO HOMATROPINE .. 56
isosorbide dinitrate ............... 47
isosorbide mononitrate ......... 47
ISOVEX ................................ 77
isradipine .............................. 46
ISTALOL .............................. 70
ISTODAX ............................. 15
itraconazole........................... 28
IXEMPRA............................. 16
IXIARO................................. 64
JAKAFI ................................. 16
JALYN .................................. 68
JANUMET ............................ 24
JANUMET XR ..................... 24
JANUVIA ............................. 24
JENTADUETO ..................... 24
JE-VAX................................. 64
JEVTANA............................. 16
JUVISYNC ........................... 24
KABIVEN............................. 41
KADCYLA ........................... 16
KALBITOR .......................... 68
KALETRA ............................ 35
KALYDECO......................... 76
kanamycin sulfate.................... 8
KEDBUMIN ......................... 39
KEPIVANCE ........................ 50
KETEK ................................. 10
ketoconazole .......................... 28
ketoprofen ............................... 5
ketorolac tromethamine .... 5, 55
KHEDEZLA ......................... 23
KINERET ............................. 63
KINRIX................................. 64
KORLYM ............................. 24
K-PHOS NO.2 ...................... 72
KRYSTEXXA ...................... 53
KUVAN ................................ 53
KYNAMRO .......................... 47
KYPROLIS ........................... 16
labetalol hcl .......................... 44
LACRISERT ......................... 56
LACTATED RINGERS ....... 65
lactulose ................................ 57
LAMICTAL .......................... 20
lamivudine ............................. 35
lamivudine/zidovudine .......... 35
lamotrigine ............................ 20
LANOXIN ............................ 45
lansoprazole .......................... 56
lansoprazole/amoxiciln/clarith
........................................... 56
LANTUS ............................... 25
LANTUS SOLOSTAR ......... 25
latanoprost ............................ 70
LATUDA .............................. 33
LAZANDA ............................. 2
leflunomide ............................ 63
LETAIRIS ............................. 77
letrozole................................. 16
leucovorin calcium ................ 68
LEUKERAN ......................... 16
LEUKINE ............................. 38
leuprolide acetate.................. 16
LEVEMIR ............................. 26
LEVEMIR FLEXPEN .......... 26
levetiracetam ......................... 20
levetiracetam in nacl (iso-os) 20
levobunolol hcl ................ 70, 71
levocarnitine ......................... 68
levocarnitine (with sugar) ..... 68
levocetirizine dihydrochloride
........................................... 29
levofloxacin ..................... 12, 54
levofloxacin/d5w ................... 12
levonorgestrel ....................... 49
I-7
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
levonorgestrel-ethin estradiol 49
levorphanol tartrate ................ 2
levothyroxine sodium ............ 62
LEVULAN ............................ 50
LEXIVA ................................ 35
lidocaine .................................. 5
lidocaine hcl ............................ 5
lidocaine hcl/d5w/pf .............. 44
lidocaine hcl/pf.................. 5, 44
lidocaine/prilocaine ................ 5
LIDODERM ........................... 5
LINZESS............................... 53
liothyronine sodium .............. 62
lipase/protease/amylase ........ 54
LIPOSYN II .......................... 41
LIPOSYN III ......................... 41
lisinopril ................................ 43
lisinopril/hydrochlorothiazide
........................................... 43
lithium carbonate .................. 48
lithium citrate ........................ 48
LITHOSTAT......................... 68
l-norgest-eth estr/ethin estra . 49
LOCOID ............................... 52
lomustine ............................... 16
loperamide hcl ...................... 57
lorazepam ................................ 7
losartan potassium ................ 43
losartan/hydrochlorothiazide 43
LOTEMAX ........................... 55
LOTRONEX ......................... 54
lovastatin ............................... 47
loxapine succinate ................. 33
LOZI-FLUR .......................... 78
LUMIGAN ............................ 71
LUMINAL SODIUM ........... 20
LUMIZYME ......................... 54
LUPRON DEPOT ................. 16
LUPRON DEPOT-PED ........ 16
LYRICA ................................ 20
LYSODREN ......................... 16
mafenide acetate ................... 50
magnesium chloride .............. 72
magnesium sulfate................. 72
magnesium sulfate in water .. 72
magnesium sulfate/d5w ......... 72
malathion .............................. 53
mannitol/sorbitol solution ..... 65
maprotiline hcl ...................... 23
MARPLAN ........................... 23
MARQIBO ............................ 16
MATULANE ........................ 16
meclizine hcl.......................... 30
medroxyprogesterone acet .... 62
medroxyprogesterone acetate 62
mefenamic acid ....................... 5
mefloquine hcl ....................... 31
MEGACE ES ........................ 16
megestrol acetate .................. 16
MEKINIST ........................... 16
meloxicam ............................... 5
melphalan hcl ........................ 16
MENACTRA ........................ 64
MENEST............................... 59
MENHIBRIX ........................ 64
MENOMUNE-A-C-Y-W-135
........................................... 64
MENVEO A-C-Y-W-135-DIP
........................................... 64
mercaptopurine ..................... 16
meropenem ............................ 11
mesna .................................... 68
MESNEX .............................. 68
MESTINON .......................... 68
metaproterenol sulfate .......... 75
metaxalone ............................ 76
metformin hcl ........................ 24
methadone hcl ..................... 2, 3
methazolamide ...................... 71
methenamine hippurate ........... 8
methimazole .......................... 62
methocarbamol ..................... 76
methotrexate sodium ............. 17
methotrexate sodium/pf ......... 17
methoxsalen, rapid ................ 51
methscopolamine bromide .... 57
methyclothiazide ................... 46
methylene blue ...................... 68
methylergonovine maleate .... 68
methylphenidate hcl .............. 48
methylprednisolone ............... 60
methylprednisolone acetate .. 60
methylprednisolone sod succ 60
metipranolol .......................... 71
metoclopramide hcl ............... 57
metolazone ............................ 46
metoprolol succinate ............. 44
metoprolol tartrate ................ 44
metoprolol/hydrochlorothiazide
........................................... 44
metronidazole ............ 29, 31, 51
metronidazole/sodium chloride
........................................... 31
METVIXIA ........................... 51
mexiletine hcl ........................ 44
MIACALCIN ........................ 66
miconazole nitrate ................. 29
MICRHOGAM ULTRAFILTERED PLUS ............. 63
midazolam hcl ......................... 7
midazolam hcl/pf ..................... 7
midodrine hcl ........................ 42
milrinone lactate ................... 45
milrinone lactate/d5w ........... 46
MINOCIN ............................. 12
minocycline hcl ..................... 12
minoxidil ............................... 47
mirtazapine ........................... 23
misoprostol............................ 56
mitomycin .............................. 17
mitoxantrone hcl ................... 17
M-M-R II VACCINE ............ 64
MOBAN ................................ 33
modafinil ............................... 77
moexipril hcl ......................... 43
moexipril/hydrochlorothiazide
........................................... 43
mometasone furoate .............. 52
montelukast sodium ............... 75
morphine sulfate...................... 3
MORPHINE SULFATE ......... 3
morphine sulfate/0.9% nacl/pf 3
I-8
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
morphine sulfate/pf ................. 3
MOVIPREP .......................... 57
MOXEZA ............................. 54
moxifloxacin hcl .................... 12
MOZOBIL ............................ 38
MULTAQ ............................. 44
mupirocin .............................. 51
mupirocin calcium ................ 51
MUSTARGEN ...................... 17
mycophenolate mofetil .......... 63
mycophenolate sodium .......... 63
MYOBLOC........................... 69
MYOZYME .......................... 54
MYTELASE ......................... 69
na nitrite/na thiosul/amyl nit. 58
nabumetone ............................. 5
nadolol .................................. 44
NAFCILL IN DEXTROSE... 11
nafcillin sodium..................... 11
NAGLAZYME ..................... 54
nalbuphine hcl ......................... 3
nalidixic acid ......................... 12
naloxone hcl ............................ 6
naltrexone hcl.......................... 6
NAMENDA .......................... 22
NAMENDA XR.................... 21
naphazoline hcl/antazoline ... 56
naproxen ................................. 5
naproxen sodium ..................... 5
naratriptan hcl ...................... 29
NASONEX ........................... 75
NATACYN ........................... 54
nateglinide............................. 24
NEBUPENT .......................... 31
needles, insulin disposable.... 53
nefazodone hcl ...................... 23
neo/polymyx b sulf/dexameth 54
neomy sulf/bacitra/polymyxin b
........................................... 54
neomy sulf/bacitrac zn/poly/hc
........................................... 54
neomy sulf/polymyxin b sulfate
........................................... 51
neomycin sulfate...................... 8
neomycin sulfate/dex na ph ... 54
neomycin/polymyxin b sulf/hc 55
neomycin/polymyxn b/
gramicidin ......................... 55
neostigmine methylsulfate ..... 69
NEPHRAMINE .................... 41
NEULASTA ......................... 38
NEUMEGA........................... 38
NEUPOGEN ......................... 38
NEUPRO............................... 32
NEVANAC ........................... 55
nevirapine ............................. 35
NEXAVAR ........................... 17
niacin..................................... 47
nicardipine hcl ...................... 46
NICOTROL ............................ 6
nifedipine............................... 46
NILANDRON ....................... 17
NITRO-BID .......................... 47
nitrofurantoin .......................... 9
nitrofurantoin macrocrystal .... 9
nitroglycerin .................... 47, 48
nitroglycerin/d5w .................. 48
NITROSTAT ........................ 48
nizatidine ............................... 56
NORDITROPIN ................... 61
NORDITROPIN FLEXPRO . 61
NORDITROPIN NORDIFLEX
........................................... 61
norelgestromin/ethin.estradiol
........................................... 49
norepinephrine bitartrate...... 46
noreth-ethinyl estradiol/iron . 49
norethindrone........................ 49
norethindrone acetate ........... 62
norethindrone ac-eth estradiol
..................................... 49, 59
norethindrone-e.estradiol-iron
........................................... 49
norethindrone-ethinyl estrad 49
norethindrone-mestranol ...... 49
norgestimate-ethinyl estradiol
........................................... 50
norgestrel-ethinyl estradiol ... 50
NORMOSOL-M and
DEXTROSE ...................... 72
NORMOSOL-R PH 7.4 ........ 72
nortriptyline hcl .................... 23
NORVIR ............................... 35
NOVAMINE ......................... 41
NOVAREL ........................... 61
NOVOLIN 70-30 .................. 26
NOVOLIN N ........................ 26
NOVOLIN R ......................... 26
NOVOLOG ........................... 26
NOVOLOG FLEXPEN ........ 26
NOVOLOG MIX 70-30 ........ 26
NOVOLOG MIX 70-30
FLEXPEN ......................... 26
NOXAFIL ............................. 28
NPLATE ............................... 69
NUCYNTA ............................. 3
NUCYNTA ER ....................... 3
NUEDEXTA ......................... 49
NULOJIX .............................. 63
NUTRESTORE..................... 57
NUTRILYTE ........................ 72
NUTRILYTE II .................... 72
NUTROPIN .......................... 61
NUTROPIN AQ.................... 61
NUTROPIN AQ NUSPIN .... 61
NUVARING ......................... 50
nylidrin hcl ............................ 48
nystatin .................................. 28
nystatin/triamcin ................... 28
OCTAGAM .......................... 63
octreotide acetate .................. 61
OFIRMEV............................... 3
ofloxacin .......................... 12, 55
olanzapine ....................... 33, 34
olanzapine/fluoxetine hcl ...... 23
OLYSIO ................................ 36
omega-3 acid ethyl esters...... 47
omeprazole ............................ 57
OMNITROPE ....................... 61
ONCASPAR ......................... 17
ondansetron........................... 30
ondansetron hcl ..................... 30
I-9
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
ONFI ....................................... 7
ONTAK................................. 17
OPSUMIT ............................. 78
ORAP .................................... 34
ORENCIA ............................. 63
ORENITRAM ER ................. 46
ORFADIN ............................. 54
ORTHO EVRA ..................... 50
OTEZLA ............................... 69
oxacillin sodium .................... 11
oxacillin sodium/dextrose,iso 11
oxaliplatin ............................. 17
oxandrolone .......................... 59
oxcarbazepine ....................... 20
OXSORALEN-ULTRA ........ 51
OXTELLAR XR ................... 20
oxybutynin chloride ............... 58
oxycodone hcl.......................... 3
oxycodone hcl/acetaminophen 3
oxycodone hcl/aspirin ............. 4
OXYCONTIN ......................... 4
oxymorphone hcl ..................... 4
paclitaxel ............................... 17
pamidronate disodium .......... 66
PANRETIN ........................... 51
pantoprazole sodium ............. 57
papaverine hcl ....................... 46
paregoric ............................... 57
paricalcitol ............................ 66
paromomycin sulfate ............. 31
paroxetine hcl........................ 23
PASER .................................. 30
PATADAY ........................... 56
PATANOL ............................ 56
PAXIL ................................... 23
pedi m.vit no.17 with fluoride 78
pedi mvi no.12/sodium fluoride
........................................... 78
PEDIARIX ............................ 65
PEDVAXHIB ....................... 65
peg 3350/na sulf,bicarb,cl/kcl57
PEGANONE ......................... 20
PEGASYS ............................. 36
PEGASYS PROCLICK ........ 36
PEGINTRON ........................ 36
PEGINTRON REDIPEN ...... 36
pen g pot/dextrose-water....... 11
penicillin g potassium ........... 11
penicillin g potassium/d5w ... 11
penicillin g procaine ............. 11
penicillin v potassium ........... 11
PENTACEL .......................... 65
PENTACEL ACTHIB
COMPONENT.................. 65
PENTACEL DTAP-IPV
COMPONENT.................. 65
PENTAM 300 ....................... 31
pentamidine isethionate ........ 31
pentostatin ............................. 17
pentoxifylline ......................... 39
p-epd tan/chlor-tan ............... 29
PERIKABIVEN .................... 41
perindopril erbumine ............ 43
PERJETA .............................. 17
permethrin ............................. 53
perphenazine ......................... 34
perphenazine/amitriptyline hcl
........................................... 23
phenelzine sulfate .................. 23
phenobarbital ........................ 20
phenobarbital sodium ........... 20
phentolamine mesylate .......... 77
phenylephrine hcl ............ 42, 56
PHENYTEK ......................... 20
phenytoin ............................... 20
phenytoin sodium .................. 20
phenytoin sodium extended ... 20
PHOSLYRA ......................... 58
PHOSPHOLINE IODIDE .... 71
phosphorus #1 ....................... 72
physostigmine salicylate ....... 69
PICATO ................................ 51
pilocarpine hcl ................ 50, 71
PILOPINE HS ....................... 71
pindolol ................................. 44
pioglitazone hcl ..................... 27
pioglitazone hcl/glimepiride . 27
pioglitazone hcl/metformin hcl
........................................... 27
piperacillin sodium/tazobactam
........................................... 12
piroxicam ................................ 5
PLASBUMIN-25 .................. 39
PLASBUMIN-5 .................... 39
PLASMA-LYTE 148 ............ 72
PLASMA-LYTE 56 IN
DEXTROSE ...................... 72
PLASMA-LYTE A PH 7.4 ... 72
PLASMA-LYTE M IN
DEXTROSE ...................... 72
pnv with ca,no.72/iron/fa ...... 78
podofilox ............................... 51
podophyllum resin ................. 51
polyethylene glycol 3350....... 57
polymyxin b sulf/trimethoprim
........................................... 55
polymyxin b sulfate ................. 9
POMALYST ......................... 17
pot chloride/pot bicarb/cit ac 72
potassium acetate .................. 72
potassium bicarbonate/cit ac 72
potassium chlorid/d100.2%nacl ........................... 73
potassium chloride ................ 73
potassium chloride in 0.9%nacl
........................................... 73
potassium chloride in d5w .... 73
potassium chloride in lr-d5 ... 73
potassium chloride/d50.2%nacl ........................... 73
potassium chloride/d5-0.25ns 73
potassium chloride/d50.3%nacl ........................... 73
potassium chloride/d5-0.45nacl
........................................... 73
potassium chloride/d50.9%nacl ........................... 73
potassium chloride-0.45% nacl
........................................... 73
potassium citrate/citric acid . 73
potassium gluconate.............. 73
I-10
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
potassium hydroxide ............. 51
potassium phos,m-basic-d-basic
........................................... 73
POTIGA .......................... 20, 21
PRADAXA ........................... 38
PRALIDOXIME CHLORIDE
........................................... 69
pramipexole di-hcl ................ 32
PRANDIMET ....................... 24
pravastatin sodium ................ 47
prazosin hcl ........................... 42
prednicarbate ........................ 52
prednisolone.......................... 60
prednisolone acetate ....... 55, 60
prednisolone sod phosphate. 55,
60
prednisone ............................. 60
PREDNISONE INTENSOL . 60
PREMARIN .......................... 60
PREMASOL ......................... 41
PREMPHASE ....................... 60
PREMPRO ............................ 60
PREZISTA ............................ 35
PRIFTIN ............................... 30
PRIMAQUINE ..................... 31
primidone .............................. 21
PRISTIQ ER ......................... 23
PRIVIGEN ............................ 63
PROAIR HFA ....................... 75
probenecid............................. 69
procainamide hcl .................. 44
PROCALAMINE .................. 41
prochlorperazine edisylate.... 31
prochlorperazine maleate ..... 31
PROCRIT .............................. 38
PROCYSBI ........................... 69
progesterone ......................... 62
progesterone,micronized ....... 62
PROGLYCEM ...................... 48
PROGRAF ............................ 63
PROLENSA .......................... 55
PROLEUKIN ........................ 17
PROLIA ................................ 66
PROMACTA ........................ 38
promethazine hcl ............. 29, 31
PRONESTYL ....................... 44
propafenone hcl .................... 44
propantheline bromide .......... 19
proparacaine hcl ................... 56
proparacaine/fluorescein sod 56
propranolol hcl ..................... 44
propranolol/hydrochlorothiazid
........................................... 44
propylthiouracil .................... 62
PROQUAD ........................... 65
PROSOL ............................... 41
PROSTIGMIN ...................... 69
protamine sulfate .................. 38
PROTOPAM CHLORIDE.... 69
PROTOPIC ........................... 52
protriptyline hcl .................... 23
PULMOZYME ..................... 54
PURIXAN ............................. 17
pyridostigmine bromide ........ 69
QNASL ................................. 75
QUDEXY XR ....................... 21
quetiapine fumarate .............. 34
QUICK MIX with LYTES.... 41
QUILLIVANT XR................ 49
quinapril hcl .......................... 43
quinapril/hydrochlorothiazide
........................................... 43
quinidine gluconate............... 44
quinidine sulfate .................... 44
quinine sulfate ....................... 31
QVAR ................................... 75
RABAVERT ......................... 65
raloxifene hcl ........................ 60
ramipril ................................. 43
RANEXA .............................. 46
ranitidine hcl ......................... 57
RAPAMUNE ........................ 63
RAVICTI .............................. 57
REBIF ................................... 69
REBIF REBIDOSE ............... 69
RECOMBIVAX HB ............. 65
REGONOL ........................... 69
RELENZA ............................ 35
RELISTOR ........................... 57
REMICADE .......................... 69
REMODULIN....................... 78
RENAGEL ............................ 58
RENVELA ............................ 58
repaglinide ............................ 25
RESCRIPTOR ...................... 35
RESTASIS ............................ 55
RETROVIR........................... 35
REVATIO ............................. 78
REVLIMID ........................... 17
REYATAZ ............................ 35
RHOGAM ULTRAFILTERED PLUS ............. 63
RHOPHYLAC ...................... 63
ribavirin .......................... 36, 37
RIDAURA ............................ 63
rifabutin................................. 30
rifampin ................................. 30
RIFATER .............................. 30
riluzole .................................. 49
rimantadine hcl ..................... 35
ringers solution ............... 65, 73
risedronate sodium................ 66
RISPERDAL CONSTA ........ 34
risperidone ............................ 34
RITUXAN............................. 17
rivastigmine tartrate ............. 22
rizatriptan benzoate .............. 29
ropinirole hcl ........................ 32
ROTARIX ............................. 65
ROTATEQ ............................ 65
ROZEREM ........................... 77
SABRIL ................................ 21
SAIZEN ................................ 61
salsalate .................................. 5
SANDOSTATIN LAR.......... 61
SANTYL ............................... 51
SAPHRIS .............................. 34
SAVELLA ............................ 49
selegiline hcl ......................... 32
selenium sulfide ..................... 51
SELZENTRY ........................ 35
SENSIPAR ............................ 69
I-11
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
SEREVENT DISKUS ........... 75
SEROMYCIN ....................... 30
SEROQUEL XR ................... 34
SEROSTIM ........................... 61
sertraline hcl ......................... 23
SHOHL'S MODIFIED .......... 73
SIGNIFOR ............................ 69
sildenafil citrate .................... 78
SILENOR .............................. 23
silver nitrate .......................... 51
silver nitrate applicator ........ 51
silver sulfadiazine ................. 51
SIMBRINZA......................... 71
SIMPONI .............................. 69
SIMPONI ARIA ................... 69
SIMULECT........................... 69
simvastatin ............................ 47
sirolimus................................ 63
SIRTURO ............................. 30
sod propion/inositol/aa14/urea
........................................... 29
sod/pot/k cit/sod cit/cit acid .. 73
sodium acetate ...................... 73
sodium bicarbonate............... 73
sodium chloride..................... 74
sodium chloride 0.45 % ........ 73
sodium chloride 3% .............. 73
sodium chloride 5% .............. 73
sodium chloride irrig solution
........................................... 66
sodium chloride/nahco3/kcl/peg
........................................... 58
sodium lactate ....................... 74
SODIUM LACTATE............ 74
sodium morrhuate ................. 69
sodium phenylbutyrate .......... 57
sodium phos,m-basic-d-basic 74
sodium polystyrene sulfonate 58
sodium tetradecyl sulfate ...... 69
sodium thiosulfate ................. 58
SOLIRIS ............................... 69
SOLTAMOX ........................ 17
SOLU-CORTEF ................... 61
SOLU-MEDROL .................. 61
SOMATULINE DEPOT ....... 61
SOMAVERT......................... 61
sorbitol solution .................... 66
sotalol hcl .............................. 45
SOTALOL HCL ................... 45
SOVALDI ............................. 37
spinosad ................................ 53
SPIRIVA ............................... 75
spironolact/hydrochlorothiazid
........................................... 47
spironolactone....................... 47
SPORANOX ......................... 28
SPRYCEL ............................. 17
stavudine ............................... 35
STELARA............................. 70
STERILE DILUENT ............ 39
STIVARGA .......................... 17
STRATTERA ....................... 49
streptomycin sulfate ................ 8
STRIBILD............................. 35
STROMECTOL .................... 31
SUBOXONE ........................... 6
sucralfate............................... 57
sulfacetamide sodium ...... 51, 55
sulfacetamide/prednisolone sp
........................................... 55
sulfadiazine ........................... 12
sulfamethoxazole/trimethoprim
........................................... 12
sulfasalazine.......................... 12
sulindac ................................... 5
sumatriptan ........................... 29
sumatriptan succinate ........... 29
SUPPRELIN LA ................... 61
SUPRAX ............................... 10
SUSTIVA .............................. 35
SUTENT ............................... 17
SYLATRON 4-PACK .......... 36
SYLVANT ............................ 17
SYMLIN ............................... 25
SYMLINPEN 120 ................. 25
SYMLINPEN 60 ................... 25
SYNAGIS ............................. 36
SYNAREL ............................ 70
SYNERCID............................. 9
SYNRIBO ............................. 18
SYPRINE .............................. 58
syring w-ndl,disp,insul,0.3ml 53
syring w-ndl,disp,insul,0.5ml 53
syring w-o ndl,disp,insul, 1ml 53
TABLOID ............................. 18
tacrolimus ............................. 63
TAFINLAR ........................... 18
TAMIFLU ............................. 36
tamoxifen citrate ................... 18
tamsulosin hcl ....................... 77
TANZEUM ........................... 25
TARCEVA............................ 18
TARGRETIN .................. 18, 53
TASIGNA ............................. 18
TAZICEF IN DEXTROSE ... 10
TAZORAC ............................ 53
TE ANATOXAL BERNA .... 65
tea tree oil ............................. 10
TECFIDERA......................... 70
TEGRETOL XR ................... 21
telmisartan ............................ 43
telmisartan/hydrochlorothiazid
........................................... 43
temazepam............................... 7
TEMODAR ........................... 18
teniposide .............................. 18
TENIVAC ............................. 65
terazosin hcl .......................... 77
terbinafine hcl ....................... 28
terbutaline sulfate ................. 75
terconazole ............................ 29
testosterone cypionate ........... 59
testosterone enanthate .......... 59
TETANUS DIPHTHERIA
TOXOIDS ......................... 65
TETANUS TOXOID
ADSORBED ..................... 65
tetracaine hcl/pf .................... 56
tetracycline hcl ...................... 12
TEV-TROPIN ....................... 61
THALOMID ......................... 70
theophylline anhydrous ......... 75
I-12
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
theophylline/d5w ................... 75
THERACYS ......................... 65
THERMAZENE ................... 51
thioridazine hcl ..................... 34
thiotepa ................................. 18
thiothixene ............................. 34
tiagabine hcl.......................... 21
TIKOSYN ............................. 44
timolol maleate................ 45, 71
tinidazole ............................... 31
TIVICAY .............................. 35
tizanidine hcl ......................... 76
TOBI PODHALER ................. 8
tobramycin in 0.225% nacl ..... 8
tobramycin sulfate ............. 8, 55
tobramycin/dexamethasone... 55
tobramycin/sodium chloride ... 8
tolazamide ............................. 27
tolbutamide ........................... 27
tolmetin sodium ....................... 5
tolterodine tartrate ................ 58
topiramate ............................. 21
topotecan hcl ......................... 18
TORISEL .............................. 18
torsemide ............................... 46
TPN ELECTROLYTES........ 74
TRACLEER .......................... 78
TRADJENTA ....................... 25
tramadol hcl ............................ 4
tramadol hcl/acetaminophen .. 4
trandolapril ........................... 43
tranexamic acid ..................... 39
tranylcypromine sulfate ........ 23
TRAVAMULSION............... 41
TRAVASOL ......................... 42
TRAVASOL W/DEXTROSE
........................................... 41
TRAVASOL W/
ELECTROLYTES ............ 42
TRAVASOL with DEXTROSE
........................................... 42
TRAVASOL with
ELECTROLYTES ............ 42
TRAVATAN Z ..................... 71
TRAVERT ............................ 42
TRAVERT IN NORMAL
SALINE ............................ 42
TRAVERT-ELECTROLYTE
NO.1 .................................. 74
TRAVERT-ELECTROLYTE
NO.2 .................................. 74
TRAVERT-ELECTROLYTE
NO.3 .................................. 74
TRAVERT-ELECTROLYTE
NO.4 .................................. 74
travoprost (benzalkonium) .... 71
trazodone hcl ......................... 23
TREANDA ........................... 18
TRECATOR ......................... 30
TRELSTAR .......................... 18
tretinoin ........................... 18, 53
tretinoin microspheres .......... 53
TREXALL ............................ 18
triamcinolone acetonide. 50, 52,
61, 75
triamterene/hydrochlorothiazid
........................................... 46
triazolam ................................. 8
TRIBENZOR ........................ 43
trifluoperazine hcl ................. 34
trifluridine ............................. 55
trihexyphenidyl hcl ................ 32
TRILEPTAL ......................... 21
trimethoprim ........................... 9
trimipramine maleate ............ 23
tripelennamine hcl ................ 29
TRISENOX ........................... 18
TRIUMEQ ............................ 35
TROKENDI XR.................... 21
TROPHAMINE .................... 42
trospium chloride .................. 58
TRUVADA ........................... 35
TWINRIX ............................. 65
TYGACIL ............................. 12
TYKERB............................... 18
TYPHIM VI .......................... 65
TYSABRI ............................. 64
TYVASO .............................. 78
TYZEKA............................... 37
TYZINE ................................ 56
UCERIS ................................ 61
ULORIC ................................ 70
urologic solution-g ................ 66
ursodiol ................................. 57
UVADEX .............................. 51
VAGIFEM ............................ 60
valacyclovir hcl ..................... 37
VALCHLOR ......................... 51
VALCYTE ............................ 37
valproic acid ......................... 21
valproic acid (as sodium salt)21
valsartan/hydrochlorothiazide
........................................... 43
VALSTAR ............................ 18
vancomycin hcl........................ 9
VANCOMYCIN HCL ............ 9
vancomycin hcl/d5w ................ 9
VANTAS .............................. 61
VAQTA................................. 65
VARIVAX VACCINE ......... 65
VASCEPA ............................ 47
vasopressin ............................ 61
VECAMYL ........................... 46
VECTIBIX ............................ 18
VELCADE ............................ 18
venlafaxine hcl ...................... 23
VENLAFAXINE HCL ER ... 23
VENTAVIS........................... 78
VENTOLIN HFA ................. 76
verapamil hcl ........................ 45
VERSACLOZ ....................... 34
VESICARE ........................... 58
VICTOZA 3-PAK ................. 25
VICTRELIS .......................... 36
VIDEX .................................. 35
VIGAMOX ........................... 55
VIIBRYD .............................. 23
VIMIZIM .............................. 54
VIMPAT ............................... 21
vinblastine sulfate ................. 18
vincristine sulfate .................. 18
vinorelbine tartrate ............... 18
I-13
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
VIRACEPT ........................... 35
VIRAMUNE XR .................. 35
VIREAD ............................... 35
VIVELLE-DOT .................... 60
VOLTAREN ........................... 5
VORAXAZE......................... 70
voriconazole .......................... 28
VOTRIENT........................... 19
VPRIV................................... 54
VUMON ............................... 19
warfarin sodium .................... 38
water for irrigation,sterile .... 66
WELCHOL ........................... 47
WINRHO SDF ...................... 64
XALKORI............................. 19
XARELTO ............................ 38
XARTEMIS XR...................... 4
XELJANZ ............................. 70
XENAZINE .......................... 49
XERAC AC .......................... 51
XGEVA................................. 67
XIFAXAN............................... 9
XOLAIR ............................... 76
XTANDI ............................... 19
XYLOCAINE ....................... 44
XYREM ................................ 77
YERVOY .............................. 19
YF-VAX ............................... 65
zafirlukast.............................. 75
zaleplon ................................. 77
ZALTRAP............................. 19
ZANOSAR ............................ 19
ZAVESCA ............................ 54
ZELBORAF .......................... 19
ZEMAIRA ............................ 76
ZEMPLAR ............................ 67
ZENPEP ................................ 54
ZETIA ................................... 47
ZIAGEN ................................ 35
zidovudine ............................. 35
ziprasidone hcl ...................... 34
ZOLADEX ............................ 19
zoledronic acid ...................... 67
zoledronic acid/
mannitol&water ................ 67
ZOLINZA ............................. 19
zolmitriptan ........................... 29
zolpidem tartrate ................... 77
ZOMETA .............................. 67
zonisamide............................. 21
ZORBTIVE ........................... 62
ZORTRESS........................... 64
ZOSTAVAX ......................... 65
ZOVIRAX............................. 51
ZUBSOLV .............................. 6
ZYDELIG ............................. 19
ZYKADIA ............................ 19
ZYLET .................................. 55
ZYPREXA RELPREVV ...... 34
ZYTIGA ................................ 19
ZYVOX................................... 9
I-14
L.A. Care Health Plan 2014 Part D Formulary
Formulary ID: 14483.000, Version: 18
Effective: December 01, 2014
NOTES/NOTAS:
NOTES/NOTAS:
NOTES/NOTAS:
NOTES/NOTAS:
NOTES/NOTAS:
This formulary was updated on November 30, 2014. For more recent information or
other questions, please contact us, L.A. Care Health Plan Member Services, at 1-888-522-1298
or, for TTY/TDD users, 1-888-212-4460, 24 hours a day, 7 days a week, including holidays,
or visit www.lacare.org.
Este formulario se actualizó el 30 de noviembre del 2014. Para la información más reciente u
otras preguntas, comuníquese con nosotros en Servicios para los miembros de L.A. Care Health
Plan al teléfono 1-888-522-1298 o, para los usuarios de TTY/TDD, 1-888-212-4460, las 24 horas del
día, los 7 días de la semana, incluso los días festivos, o visite www.lacare.org.
www.lacare.org
LA0437 EN/SP Web