L.A. Care Cal MediConnect Plan
(Medicare-Medicaid Plan)
2014
Listahan ng mga Saklaw na Gamot
(Formulary)
MANGYARING BASAHIN: ANG DOKUMENTONG ITO AY NAGTATAGLAY NG IMPORMASYON TUNGKOL
SA MGA GAMOT NA SINASAKLAW NAMIN SA PLANONG ITO.
Ang Formulary na ito ay isinapanahon noong Nobyembre 28, 2014. Kung kayo ay may mga katanungan,
mangyaring tawagan ang Mga Serbisyong Pangmiyembro ng L.A. Care Cal MediConnect Plan sa 1-888-522-1298
(TTY: 1-888-212-4460), 24 na oras sa isang araw, 7 araw sa isang linggo, kabilang ang mga piyesta opisyal. Para sa
karagdagang impormasyon, bisitahin ang www.calmediconnectla.org.
H8258_15160_LAC 2014FormularyTA
Accepted Formulary ID: 14592.000 Version: 17
Ito ay isang listahan ng mga gamot na makukuha ng mga miyembro sa L.A. Care
Cal MediConnect Plan.
• Ang L.A. Care Health Plan ay isang planong pangkalusugan na nakikipagkontrata sa Medicare at
Medi-Cal upang magkaloob ng mga benepisyo ng parehong programa sa mga nakatala.
• Ang mga benepisyo, ang Listahan ng mga Saklaw na Gamot, at ang mga parmasya at
mga tagapagkaloob ng pangangalaga na kasama sa mga network ng
L.A. Care Cal MediConnect Plan, at/o mga kabahagi sa binabayaran ay maaaring
magbago pana-panahon sa buong taon at sa Enero 1 ng bawat taon.
• Laging matitingnan ninyo ang napapanahong Listahan ng mga Saklaw na Gamot ng
L.A. Care Cal MediConnect Plan online sa www.calmediconnectla.org o sa pamamagitan ng
pagtawag sa 1-888-522-1298 (TTY: 1-888-212-4460).
• Makakahingi rin kayo ng impormasyong ito sa ibang mga format, tulad ng Braille o malalaking
letra. Tumawag sa 1-888-522-1298 (TTY: 1-888-212-4460). Ang tawag ay libre.
• Maaaring may mga limitasyon at mga pagtatakda. Para sa karagdagang impormasyon, tawagan
ang Mga Serbisyong Pangmiyembro ng L.A. Care Cal MediConnect Plan.
• Ang mga kabahagi sa binabayaran para sa mga inireresetang gamot ay maaaring mag-iba batay
sa antas ng Karagdagang Tulong na natatanggap ninyo. Mangyaring tawagan ang plano para sa
mga karagdagang detalye.
• You can get this information for free in other languages. Call 1-888-522-1298
(TTY: 1-888-212-4460). The call is free.
• Puede obtener esta información gratis en otros idiomas. Llame al 1-888-522-1298
(TTY: 1-888-212-4460). La llamada es gratis.
•
• Այս տեղեկությունները անվճար կարող եք ստանալ այլ լեզուներով: Զանգահարեք
1-888-522-1298 հեռախոսահամարով (TTY` 1-888-212-4460): Զանգն անվճար է:
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• 이 정보는 다른 언어로도 무료로 구하실 수 있습니다. 1-888-522-1298
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• Вы можете бесплатно получить эту информацию на других языках. Позвоните по
номеру телефона 1-888-522-1298 (TTY: 1-888-212-4460). Звонок бесплатный.
• Makukuha ninyo ang impormasyong ito nang libre sa ibang mga wika. Tumawag sa
1-888-522-1298 (TTY: 1-888-212-4460). Ang tawag ay libre.
• 本資訊備有其他語言版本供您免費索取。請致電1-888-522-1298
(TTY: 1-888-212-4460)。這是免費電話。
• Quý vị có thể được cấp thông tin này miễn phí bằng nhiều ngôn ngữ. Vui lòng gọi số
1-888-522-1298 (TTY: 1-888-212-4460). Số điện thoại này miễn phí.
?
Kung kayo ay may mga katanungan, mangyaring tawagan ang L.A. Care Cal MediConnect Plan sa
1-888-522-1298 (TTY: 1-888-212-4460), 24 na oras sa isang araw, 7 araw sa isang linggo, kabilang ang mga
piyesta opisyal. Ang tawag ay libre. Para sa karagdagang impormasyon, bisitahin ang www.calmediconnectla.org.
i
Mga Madalas Itanong (Frequently Asked Questions, FAQ)
Hanapin dito ang mga sagot sa mga katanungan ninyo tungkol sa Listahan ng mga Saklaw na
Gamot. Mababasa ninyo ang lahat ng FAQ upang makakuha ng karagdagang kaalaman,
o makakahanap ng katanungan at sagot.
1. A
nu-anong mga inireresetang gamot ang nasa Listahan ng mga Saklaw na Gamot?
(Tinatawag namin ang Listahan ng mga Saklaw na Gamot na “Listahan ng Gamot”
sa maikli.)
Ang mga gamot sa Listahan ng Gamot ay ang mga gamot na saklaw ng L.A. Care
Cal MediConnect Plan. Ang mga gamot ay makukuha sa mga parmasyang nasa loob ng aming
network. Ang isang parmasya ay nasa aming network kung kami ay may kasunduan sa kanila na
makipagtrabaho sa amin at magkaloob ng mga serbisyo. Tinatawag namin ang mga parmasyang ito
na “mga parmasyang kasama sa network.”
Ang L.A. Care Cal MediConnect Plan ay sasaklaw sa lahat ng medikal na kailangan na mga gamot
na nasa Listahan ng Gamot kung:
• sinabi ng iyong doktor o ibang tagareseta na kailangan ninyo ang mga ito upang gumaling o
manatiling malusog, at
• kumukuha kayo ng inireresetang gamot sa isang parmasyang kasama sa network ng
L.A. Care Cal MediConnect Plan.
• Sa ilang kaso, kailangan ninyong gumawa ng isang bagay bago kayo makakuha ng gamot
(tingnan ang Katanungan 5).
• Makakakuha rin kayo ng napapanahong listahan ng mga gamot na sinasaklaw namin sa aming
website sa www.calmediconnectla.org o tawagan ang Mga Serbisyong Pangmiyembro sa
1-888-522-1298 (TTY: 1-888-212-4460).
2. Nagbabago ba ang Listahan ng Gamot?
Oo. Ang L.A. Care Cal MediConnect Plan ay maaaring magdagdag o magtanggal ng mga gamot
sa Listahan ng Gamot sa loob ng taon. Pangkaraniwan, ang Listahan ng Gamot ay magbabago
lamang kung:
• may dumating na isang mas murang gamot na gumaganang kasinghusay ng isang gamot na nasa
Listahan ng Gamot, o
• napag-alaman namin na ang isang gamot ay hindi ligtas.
Maaari rin naming baguhin ang aming mga tuntunin tungkol sa mga gamot. Halimbawa, magagawa
naming:
• Ipasiya na mag-atas o hindi mag-atas ng nauunang pag-aproba para sa isang gamot. (Nauunang
pag-aproba ay isang permiso mula sa L.A. Care Cal MediConnect Plan bago kayo makakuha ng
gamot.)
• Dagdagan o palitan ang dami ng gamot na makukuha ninyo (tinatawg na “mga limitasyon
sa dami”).
• Dagdagan o palitan ang step therapy na mga pagtatakda sa isang gamot. (Step therapy ay
nangangahulugang dapat ninyong subukan muna ang isang gamot bago namin saklawin ang
ibang gamot.)
(Para sa karagdagang impormasyon sa mga tuntuning ito sa gamot, tingnan ang pahina iv.)
ii
?
Kung kayo ay may mga katanungan, mangyaring tawagan ang L.A. Care Cal MediConnect Plan sa
1-888-522-1298 (TTY: 1-888-212-4460), 24 na oras sa isang araw, 7 araw sa isang linggo, kabilang ang mga
piyesta opisyal. Ang tawag ay libre. Para sa karagdagang impormasyon, bisitahin ang www.calmediconnectla.org.
Sasabihin namin sa inyo kapag ang isang gamot na ginagamit ninyo ay inalis sa Listahan ng Gamot.
Sasabihin din namin sa inyo kapag binago namin ang mga tuntunin sa pagsaklaw ng isang gamot.
Ang mga Katanungan 3, 4, at 7 sa ibaba ay may karagdagang impormasyon sa kung ano ang
mangyayari kapag ang Listahan ng Gamot ay binago.
• Laging matitingnan ninyo ang napapanahong Listahan ng mga Saklaw na Gamot ng
L.A. Care Cal MediConnect Plan online sa www.calmediconnectla.org.
• Matatawagan ninyo ang Mga Serbisyong Pangmiyembro upang tingnan ang kasalukuyang
Listahan ng Gamot sa 1-888-522-1298 (TTY: 1-888-212-4460).
3. A
no ang mangyayari kapag may dumating na isang mas murang gamot na
gumagana nang kasinghusay ng nasa Listahan ng Gamot ngayon?
Kung kayo ay umiinom ng isang gamot na tinanggal dahil may dumating na mas murang gamot na
katulad ang bisa, sasabihin namin sa inyo. Sasabihin namin sa inyo nang hindi kukulangin sa
60 araw bago namin tanggalin ito mula sa Listahan ng Gamot o kapag humingi kayo ng refill.
Kasunod ay makakakuha kayo ng 60-araw na suplay ng gamot bago tanggalin ang gamot mula
sa listahan ng gamot. Kayo ay bibigyan ng paunawa ng pagbabagong ito sa isang dokumentong
tinatawag na Paliwanag ng mga Benepisyo na nagpapakita ng mga gamot na tinanggal mula sa
Listahan ng Gamot sa loob ng 60 araw. Ang listahan ng mga gamot na tatanggalin ay inilalagay rin
sa website ng L.A. Care Cal MediConnect Plan, www.calmediconnectla.org.
4. Ano ang mangyayari kapag nalaman namin na ang isang gamot ay hindi ligtas?
Kung sinabi ng Pangasiwaan ng Pagkain at Gamot (Food and Drug Administration, FDA) na ang
isang gamot na iniinom ninyo ay hindi ligtas, agad naming tatanggalin ito sa Listahan ng Gamot.
Padadalhan din namin kayo ng liham na nagsasabi nito sa inyo. Bibigyan din namin ng paunawa ang
inyong tagapagkaloob ng pangangalaga upang masangguni ninyo siya sa paglipat sa isang gamot na
nasa Listahan ng Gamot na ligtas gamitin.
5. M
ayroon bang mga pagtatakda o mga limitasyon sa pagsaklaw ng gamot? O
mayroon bang mga iniaatas na aksiyon na dapat gawin upang makuha ang mga
partikular na gamot?
Oo, ang ilang gamot ay may mga tuntunin sa pagsaklaw o may mga limitasyon sa dami ng
makukuha ninyo. Sa ilang kaso, dapat kayong gumawa ng isang bagay bago ninyo makuha ang
gamot. Halimbawa:
• Nauunang pag-aproba (o nauunang awtorisasyon): Para sa ilang gamot, kayo o ang inyong
doktor ay dapat kumuha ng pag-aproba mula sa L.A. Care Cal MediConnect Plan bago kayo
kumuha ng inireresetang gamot. Kung hindi kayo kumuha ng pag-aproba, maaaring hindi
saklawin ng L.A. Care Cal MediConnect Plan ang gamot.
• Mga limitasyon sa dami: Kung minsan ang L.A. Care Cal MediConnect Plan ay naglilimita sa
dami ng gamot na makukuha ninyo.
• Step therapy: Kung minsan ang L.A. Care Cal MediConnect Plan ay nag-aatas na gumawa
kayo ng step therapy. Ito ay nangangahulugang kakailanganin ninyong subukan ang mga gamot
sa isang partikular na pagkakasunod-sunod para sa inyong kondisyong medikal. Maaaring
kailangan ninyong subukan ang isang gamot bago namin saklawin ang ibang gamot. Kung sa
palagay ng inyong doktor ang unang gamot ay hindi mabisa para sa inyo, sasaklawin namin
ang ikalawa.
?
Kung kayo ay may mga katanungan, mangyaring tawagan ang L.A. Care Cal MediConnect Plan sa
1-888-522-1298 (TTY: 1-888-212-4460), 24 na oras sa isang araw, 7 araw sa isang linggo, kabilang ang mga
piyesta opisyal. Ang tawag ay libre. Para sa karagdagang impormasyon, bisitahin ang www.calmediconnectla.org.
iii
Malalaman ninyo kung inyong gamot ay may karagdagang mga iniaatas o mga limitasyon sa
pamamagitan ng pagtingin sa mga talahanayan na nasa mga pahina 1–132. Makakakuha rin
kayo ng karagdagang impormasyon sa pamamagitan ng pagbisita sa aming website sa
www.calmediconnectla.org.
Makakahingi rin kayo ng “eksepsiyon” mula sa mga limitasyong ito. Mangyaring tingnan ang
Katanungan 11 para sa karagdagang impormasyon sa mga eksepsiyon.
► Kung kayo ay nasa isang nursing home o ibang pasilidad ng pangmatagalang pangangalaga at
nangangailangan ng isang gamot na wala sa Listahan ng Gamot, o kung hindi ninyo madaling
makukuha ang gamot na kailangan ninyo, makakatulong kami. Sasaklawin namin ang isang
31-araw na pang-emerhensiyang suplay ng gamot na kailangan ninyo (maliban kung kayo ay
may reseta para sa mas kaunting araw), kayo man ay bago o hindi bagong miyembro ng
L.A. Care Cal MediConnect Plan. Ito ay magbibigay sa inyo ng panahon upang kausapin ang
inyong doktor o ibang tagareseta. Siya ay makakatulong sa inyo na magpasiya kung may katulad
na gamot sa Listahan ng Gamot na magagamit ninyo o kung hihiling ng eksepsiyon.
Mangyaring tingnan ang Katanungan 11 para sa karagdagang impormasyon tungkol sa mga
eksepsiyon.
6. P
aano ninyo malalaman kung ang gamot na gusto ninyo ay may mga limitasyon o
kung may iniaatas na mga aksiyon na dapat gawin upang makuha ang gamot?
Ang Listahan ng mga Saklaw na Gamot sa pahina 1 ay may hanay na tinawag na “Kailangang mga
aksiyon, pagtatakda, o mga limitasyon sa paggamit.”
7. A
no ang mangyayari kung baguhin namin ang aming mga tuntunin sa kung paano
namin sinasaklaw ang ilan sa mga gamot? Halimbawa, kung magdagdag kami ng
nauunang awtorisasyon (pag-aproba), mga limitasyon sa dami, at/o step therapy na
mga pagtatakda sa isang gamot.
Sasabihin namin sa inyo kung kami ay magdaragdag ng nauunang pag-aproba, mga limitasyon sa
dami, at/o step therapy na mga pagtatakda sa isang gamot. Sasabihin namin sa inyo nang hindi
kukulangin sa 60 araw bago idagdag ang pagtatakda o kapag hihingi na kayo ng kasunod na refill
sa parmasya. Kasunod, makakakuha kayo ng isang 60-araw na suplay ng gamot bago gawin ang
pagbabago sa mga tuntunin sa pagsaklaw. Ito ay nagbibigay sa inyo ng panahon na kausapin ang
inyong doktor tungkol sa kung ano ang kasunod na dapat gawin.
8. Paano kayo makakahanap ng gamot sa Listahan ng Gamot?
May dalawang paraan upang mahanap ang isang gamot:
• Makakapaghanap kayo batay sa alpabeto (kung alam ninyo ang pagbaybay sa gamot), o
• Makakapaghanap kayo batay sa kondisyong medikal.
Upang maghanap batay sa alpabeto, pumunta sa seksiyon na Alpabetikal na Paglilista. Mahahanap
ninyo sa pamamagitan ng pagtingin sa indise sa dulo ng listahan. Ang mga gamot ay nakalista sa
alpabetikal na pagkakasunod-sunod.
Upang maghanap batay sa kondisyong medikal, hanapin ang seksiyon na tinawag na “Listahan
ng mga gamot batay sa kondisyong medikal” sa pahina 1. At saka hanapin ang inyong kondisyong
medikal. Halimbawa, kung kayo ay may kondisyon sa puso, dapat kayong maghanap sa kategoryang
iyon. Doon ninyo mahahanap ang mga gamot na gumagamot sa mga kondisyon sa puso.
iv
?
Kung kayo ay may mga katanungan, mangyaring tawagan ang L.A. Care Cal MediConnect Plan sa
1-888-522-1298 (TTY: 1-888-212-4460), 24 na oras sa isang araw, 7 araw sa isang linggo, kabilang ang mga
piyesta opisyal. Ang tawag ay libre. Para sa karagdagang impormasyon, bisitahin ang www.calmediconnectla.org.
9. Paano kung ang gamot na gusto ninyong inumin ay wala sa Listahan ng Gamot?
Kung hindi ninyo makita ang gamot sa Listahan ng Gamot, tawagan ang Mga Serbisyong
Pangmiyembro sa 1-888-522-1298 (TTY: 1-888-212-4460) at itanong ito. Kung nalaman ninyo
na hindi sasaklawin ng L.A. Care Cal MediConnect Plan ang gamot, maaari ninyong gawin ang isa
sa mga bagay na ito:
• Humingi sa Mga Serbisyong Pangmiyembro ng listahan ng mga gamot na tulad ng gamot na
gusto ninyong inumin. At saka ipakita ang listahan sa inyong doktor o ibang tagareseta. Siya ay
makakapagreseta ng gamot na nasa Listahan ng Gamot na tulad ng gamot na iniinom ninyo. O
• Mahihingi ninyo sa planong pangkalusugan na gumawa ng eksepsiyon upang masaklaw ang
inyong gamot. Mangyaring tingnan ang Katanungan 11 para sa karagdagang impormasyon
tungkol sa mga eksepsiyon.
10. P
aano kung kayo ay isang bagong miyembro ng L.A. Care Cal MediConnect Plan at
hindi makita ang inyong gamot sa Listahan ng Gamot o may problema sa pagkuna
ng inyong gamot?
Makakatulong kami. Maaari naming saklawin ang isang pansamantalang 30-araw na suplay ng
inyong gamot sa unang 90 araw na kayo ay miyembro ng L.A. Care Cal MediConnect Plan. Ito
ay magbibigay sa inyo ng panahon upang kausapin ang inyong doktor o ibang tagareseta. Siya
ay makakatulong sa inyo na magpasiya kung may katulad na gamot sa Listahan ng Gamot na
magagamit ninyo o kung hihiling ng eksepsiyon.
Sasaklawin namin ang isang 30-araw na suplay ng inyong gamot kung:
• kayo ay umiinom ng gamot na wala sa Listahan ng Gamot, o
• ang mga tuntunin ng planong pangkalusugan ay hindi nagpapahintulot sa inyo na kumuha ng
dami na itinagubilin ng tagareseta, o
• ang gamot ay nangangailangan ng nauunang pag-aproba ng L.A. Care Cal MediConnect Plan, o
• kayo ay umiinom ng isang gamot na bahagi ng isang step therapy na pagtatakda.
Kung kayo ay naninirahan sa isang nursing home o ibang pasilidad ng pangmatagalang
pangangalaga, maaari kayong kumuha ng refill ng inyong inireresetang gamot ng hanggang
98 araw. Maaari kayong kumuha ng refill ng gamot nang maraming beses sa 98 araw. Ito ay
nagbibigay sa inyong tagareseta ng panahon na palitan ang inyong mga gamot ng nasa Listahan ng
Gamot o humingi ng eksepsiyon.
Patakaran sa Paglipat
1. Para sa mga miyembrong wala sa pasilidad ng pangmatagalang pangangalaga: Sasaklawin
namin ang isang pansamantalang suplay ng inyong gamot nang isang beses lamang sa unang
90 araw ng taon ng kalendaryo.
2. Para sa mga miyembro na bago sa plano at naninirahan sa isang pasilidad ng
pangmatagalang pangangalaga:
Hindi namin sasaklawin ang isang pansamantalang suplay ng inyong gamot sa unang 90 araw ng
inyong pagiging miyembro sa plano. Ang unang suplay ay para sa pinakamataas na 31 araw, o
mas mababa kung ang inyong reseta ay isinulat para sa mas kaunting mga araw. Kung kailangan,
sasaklawin namin ang mga karagdagang refill sa unang 90 araw ninyo sa plano. Kung ang unang
suplay ay para sa isang brand-name na gamot, ito ay ibibigay sa mga hati na 14 araw hanggang
sa isang kabuuan na 31 araw o mas kaunti kung ang inyong reseta ay isinulat para sa mas kaunting
mga araw.
?
Kung kayo ay may mga katanungan, mangyaring tawagan ang L.A. Care Cal MediConnect Plan sa
1-888-522-1298 (TTY: 1-888-212-4460), 24 na oras sa isang araw, 7 araw sa isang linggo, kabilang ang mga
piyesta opisyal. Ang tawag ay libre. Para sa karagdagang impormasyon, bisitahin ang www.calmediconnectla.org.
v
3. Tawagan ang Mga Serbisyong Pangmiyembro ng L.A. Care Cal MediConnect Plan sa
1-888-522-1298 (TTY: 1-888-212-4460).
11. Makakahingi ba kayo ng eksepsiyon upang masaklaw ang inyong gamot?
Oo. Mahihingi ninyo sa L.A. Care Cal MediConnect Plan na gumawa ng eksepsiyon upang masakop
ang isang gamot na wala sa Listahan ng Gamot.
Mahihingi rin ninyo sa amin na baguhin ang mga tuntunin sa inyong gamot.
• Halimbawa, ang L.A. Care Cal MediConnect Plan ay maaaring maglimita sa dami ng gamot
na sasaklawin namin. Kung ang inyong gamot ay may limitasyon, mahihingi ninyo sa amin na
baguhin ang limitasyon at saklawin ang mas marami.
• Ibang mga halimbawa: Mahihingi ninyo sa amin na alisin ang step therapy na mga pagtatakda o
mga iniaatas na nauunang pag-aproba.
12. Gaano katagal ang pagkuha ng eksepsiyon?
Una, dapat kaming makatanggap ng pahayag mula sa inyong tagareseta na sumusuporta sa inyong
kahilingan para sa eksepsiyon. Pagkatapos naming matanggap ang pahayag, bibigyan namin kayo ng
desisyon sa inyong hiling na eksepsiyon sa loob ng 72 oras.
Kung sa palagay ninyo o ng inyong tagareseta ang inyong kalusugan ay mapipinsala kung
maghihintay kayo ng 72 oras para sa isang desisyon, makakahingi kayo ng pinabilis na eksepsiyon.
Ito ay isang mas mabilis na desisyon. Kung ang inyong tagareseta ay sumuporta sa inyong kahilingan,
bibigyan namin kayo ng desisyon sa loob ng 24 na oras pagkatapos matanggap ang pahayag ng
pagsuporta ng tagareseta.
13. Paano kayo makakahingi ng eksepsiyon?
Upang humingi ng eksepsiyon, tawagan ang Mga Serbisyong Pangmiyembro o ang aming
Departamento ng Parmasya. Ang inyong pangkat ng pangangalaga ay magtatrabahong kasama ninyo
at ng inyong tagapagkaloob upang tulungan kayong humingi ng eksepsiyon.
14. Ano ang generic na mga gamot?
Ang generic na mga gamot ay binubuo ng mga sangkap na katulad ng brand-name na mga gamot.
Ang mga ito ay karaniwang mas mura kaysa brand-name na gamot at ang mga pangalan ng mga ito
ay hindi gaanong kilala. Ang generric na mga gamot ay inaaprobahan ng Pangasiwaan ng Pagkain at
Gamot (Food and Drug Administration, FDA).
Ang L.A. Care Cal MediConnect Plan ay sumasaklaw sa pareho ng brand-name na mga gamot at
generic na mga gamot.
15. Ano ang OTC na mga gamot?
Ang OTC ay kumakatawan sa “over-the-counter.” Makakabili kayo ng OTC na mga gamot nang
walang reseta.
Ang L.A. Care Cal MediConnect ay sumasaklaw sa OTC na mga gamot. Maaari rin ninyong basahin
ang Listahan ng Gamot ng L.A. Care Cal MediConnect Plan Drug upang makita ang OTC na mga
gamot na saklaw.
vi
?
Kung kayo ay may mga katanungan, mangyaring tawagan ang L.A. Care Cal MediConnect Plan sa
1-888-522-1298 (TTY: 1-888-212-4460), 24 na oras sa isang araw, 7 araw sa isang linggo, kabilang ang mga
piyesta opisyal. Ang tawag ay libre. Para sa karagdagang impormasyon, bisitahin ang www.calmediconnectla.org.
16. S
inasaklaw ba ng L.A. Care Cal MediConnect Plan ang OTC na hindi-gamot na mga
produkto?
Ang L.A. Care Cal MediConnect Plan ay sumasaklaw sa ilang OTC na hindi-gamot na mga
produkto. Maaari rin ninyong basahin ang Listahan ng Gamot ng L.A. Care Cal MediConnect Plan
upang makita kung anong OTC na hindi-gamot na mga produkto ang saklaw.
17. Ano ang inyong kabahagi sa binabayaran?
Maaari rin ninyong basahin ang Listahan ng Gamot ng L.A. Care Cal MediConnect Plan upang
malaman ang tungkol sa kabahagi sa binabayaran para sa bawat gamot.
Ang mga miyembro ng L.A. Care Cal MediConnect Plan na naninirahan sa mga nursing home o
ibang mga pasilidad ng pangmatagalang pangangalaga ay hindi magkakaroon ng mga kabahagi sa
binabayaran. May mga miyembro na tumatanggap ng pangmatagalang pangangalaga sa komunidad
na hindi rin magkakaroon ng mga kabahagi sa binabayaran.
Ang mga kabahagi sa binabayaran ay nakalista batay sa mga tier. Depende sa antas ng inyong
pagiging karapat-dapat sa Medi-Cal, babayaran ninyo ang mga sumusunod:
Generic na mga Gamot
Para sa Tier 1 at Tier 3 na mga gamot kayo ay magbabayad ng:
• $0 na kabahagi sa binabayaran; o
• $1.20 na kabahagi sa binabayaran; o
• $2.55 na kabahagi sa binabayaran
Brand name na mga Gamot
Para sa Tier 2 at Tier 4 na mga gamot kayo ay magbabayad ng:
• $0 na kabahagi sa binabayaran; o
• $3.60 na kabahagi sa binabayaran; o
• $6.35 na kabahagi sa binabayaran
Di-Medicare na Over the Counter (OTC) na mga Gamot
Para sa Tier 5 na mga gamot kayo magbabayad ng $0 na kabahagi sa binabayaran.
Listahan ng mga Saklaw na Gamot
Ang listahan ng mga saklaw na gamot na nagsisimula sa susunod na pahina ay nagbibigay sa inyo ng
impormasyon tungkol sa mga gamot na saklaw ng L.A. Care Cal MediConnect Plan. Kung kayo ay
nahihirapan sa paghahanap ng inyong gamot sa listahan, pumunta sa Indise na nagsisimula sa
pahina I-1.
Ang unang hanay ng chart ay naglilista ng pangalan ng gamot. Ang brand-name na mga gamot ay
nasa malalaking letra (halimbawa, CYMBALTA) at ang generic na mga gamot ay nakalista sa maliliit
na letrang italika (halimbawa, lexapro).
Ang impormasyon sa hanay na “Kailangang mga aksiyon, pagtatakda, o limitasyon sa paggamit”
ay nagsasabi sa inyo kung ang L.A. Care Cal MediConnect Plan ay may mga tuntunin para sa
pagsaklaw ng inyong gamot.
?
Kung kayo ay may mga katanungan, mangyaring tawagan ang L.A. Care Cal MediConnect Plan sa
1-888-522-1298 (TTY: 1-888-212-4460), 24 na oras sa isang araw, 7 araw sa isang linggo, kabilang ang mga
piyesta opisyal. Ang tawag ay libre. Para sa karagdagang impormasyon, bisitahin ang www.calmediconnectla.org.
vii
MGA PAGPAPAIKLI NG MGA PAGSULAT SA PAGSAKLAW
PAGPAPAIKLI
PA
PA BvD
PA NSO
QL
ST
PAGLALARAWAN
PALIWANAG
Mga Pagtatakda sa Pamamahala ng Paggamit
Pagtatakda sa Nauunang
Awtorisasyon
Kayo (o ang inyong doktor) ay inaatasang kumuha ng nauunang awtorisasyon
mula sa L.A. Care Cal MediConnect Plan bago kayo kumuha ng inireresetang
gamot na ito. Kung walang nauunang pag-aproba, ang L.A. Care
Cal MediConnect Plan ay maaaring hindi sumaklaw sa gamot na ito.
Ang gamot na ito ay maaaring karapat-dapat para sa pagbabayad sa ilalim ng
Pagtatakda sa Nauunang
Awtorisasyon para sa Part B Medicare Part B o Part D. Kayo (o ang inyong doktor) ay inaatasang kumuha ng
nauunang awtorisasyon mula sa L.A. Care Cal MediConnect Plan upang
vs Part D na Pagpapasiya
mapagpasiyahan kung ang gamot na ito ay saklaw sa ilalim ng Medicare Part D
bago kumuha ng inireresetang gamot na ito. Kung walang nauunang
pag-aproba, ang L.A. Care Cal MediConnect Plan ay maaaring hindi sumaklaw sa
gamot na ito.
Kung ito ay isang bagong reseta para sa inyo, iyon ay, ito ang unang
Pagtatakda sa Nauunang
Awtorisasyon para sa Bagong pagkakataon na ang gamot ay inireseta sa inyo, kayo (o ang inyong doktor) ay
inaatasan na kumuha ng nauunang awtorisasyon mula sa L.A. Care
Pagsisimula Lamang
Cal MediConnect Plan bago kayo kumuha ng inireresetang gamot na ito. Kung
walang nauunang pag-aproba, ang L.A. Care Cal MediConnect Plan ay maaaring
hindi sumaklaw sa gamot na ito.
Pagtatakda sa Limitasyon sa Ang L.A. Care Cal MediConnect Plan ay naglilimita sa dami na sasaklawin sa loob
Dami
ng isang partikular na takdang panahon para sa gamot na ito.
Step Therapy na Pagtatakda Bago magkaloob ang L.A. Care Cal MediConnect Plan ng pagsaklaw para sa
gamot na ito, dapat munang subukan ninyo ang ibang (mga) gamot na nasa
formulary upang gamutin ang inyong kondisyong medikal. Ang gamot na ito ay
maaari lamang saklawin kung ang ibang (mga) gamot ay hindi
nagkakabisa para sa inyo.
Ibang mga Natatanging Iniaatas para sa Pagsaklaw
LA
Ang inireresetang gamot na ito ay maaari lamang makuha sa mga partikular na
parmasya. Para sa karagdagang impormasyon sumangguni sa inyong
Direktoryo ng Tagapagkaloob/Parmasya o tawagan ang Mga Serbisyong
Pangmiyembro sa 1-888-522-1298 (TTY: 1-888-212-4460), 24 na oras sa
isang araw, 7 araw sa isang linggo, kabilang ang mga piyesta opisyal
Tala: Ang asterisko (*) sa tabi ng isang gamot ay nangangahulugang ang gamot ay hindi isang “Part D
na gamot.” Ang halagang ibinabayad ninyo kapag kumukuha kayo ng inireresetang gamot na ito ay
hindi ibinibilang sa inyong kabuuang mga gastos sa gamot (iyon ay, ang halagang ibinabayad ninyo ay
hindi tumutulong sa inyo na maging kuwalipikado para sa Pagsaklaw sa Sakuna).
Ang mga gamot na ito ay mayroon ding magkakaibang tuntunin para sa apela. Ang apela ay isang
pormal na paraan ng paghingi sa amin na repasuhin ang isang desisyon na ginawa tungkol sa inyong
pagsaklaw at upang baguhin ito kung sa palagay ninyo ay nagkamali kami. Halimbawa, maaari naming
ipasiya na ang isang gamot na gusto ninyo ay hindi sinasaklaw o hindi na sinasaklaw ng Medicare of
Medi-Cal. Kung kayo o ang inyong doktor ay hindi sumasang-ayon sa aming desisyon, maaari kayong
umapela. Kung mayroon kayong katanungan, tawagan ang Mga Serbisyong Pangmiyembro sa
1-888-522-1298 (TTY: 1-888-212-4460). Maaari rin ninyong basahin ang Handbuk ng Miyembro
upang malaman kung paano dapat iapela ang isang desisyon.
viii
?
Gamot na May Limitadong
Paggamit
Kung kayo ay may mga katanungan, mangyaring tawagan ang L.A. Care Cal MediConnect Plan sa
1-888-522-1298 (TTY: 1-888-212-4460), 24 na oras sa isang araw, 7 araw sa isang linggo, kabilang ang mga
piyesta opisyal. Ang tawag ay libre. Para sa karagdagang impormasyon, bisitahin ang www.calmediconnectla.org.
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
Analgesics
Analgesics, Miscellaneous
acetaminophen *
(Acetaminophen)
$0 (Tier 5)
acetaminophen *
(Acetaminophen)
$0 (Tier 5)
acetaminophen *
acetaminophen with
codeine
acetaminophen with
codeine
buprenorphine hcl
(Tylenol)
(Vopac)
butalb/acetaminophen/
caffeine
(Dolgic Lq)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
butalb/acetaminophen/
caffeine
(Esgic)
$0 - $6.35
(Tier 1)
butalbit/acetamin/caff/
codeine
(Fioricet with Codeine)
$0 - $6.35
(Tier 1)
(Vopac)
(Buprenorphine HCl)
butalbital/acetaminophen (Tencon)
$0 - $6.35
(Tier 1)
butorphanol tartrate
(Butorphanol Tartrate)
butorphanol tartrate
(Butorphanol Tartrate)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
BUTRANS
PA, QL:
240 in 30
days
PA, QL:
30 in 30
days
PA
QL: 180 in
30 days
QL: 360 in
30 days
elixir, solution
PA, QL:
2700 in 30
days
PA, QL:
180 in 30
days
PA, QL:
180 in 30
days
PA, QL:
180 in 30
days
solution, (High Risk Med
for Ages 65 and Older)
QL: 5 in
28 days
QL: 4 in
28 days
spray
drops, drops susp: 100mg/ml
drops susp: 80mg/0.8ml
tablet: 300mg-60mg
tablet: 300mg-15mg,
300mg-30mg
(injectable)
tablet, (High Risk Med for
Ages 65 and Older)
capsule: 50-325-30, (High
Risk Med for Ages 65 and
Older)
tablet: 50mg-325mg, (High
Risk Med for Ages 65 and
Older)
syringe, vial
patch tdwk: 5mcg/hr,
10mcg/hr, 15mcg/hr,
20mcg/hr
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
1
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
codeine phos/
acetaminophen
codeine sulfate
(Codeine Phos/
acetaminophen)
(Codeine Sulfate)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
codeine/butalbital/asa/
caffein
(Fiorinal w/Codeine #3)
fentanyl citrate
(Actiq)
$0 - $6.35
(Tier 1)
fentanyl
(Duragesic)
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
hydrocodone/
acetaminophen
(Hycet)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
hydrocodone/
acetaminophen
(Norco)
$0 - $6.35
(Tier 1)
hydrocodone/
acetaminophen
hydrocodone/ibuprofen
(Norco)
hydromorphone hcl
(Dilaudid)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
(Hycet)
(Hycet)
(Norco)
(Norco)
(Norco)
(Ibudone)
QL: 2500
in 30 days
QL: 180 in
30 days
PA, QL:
(High Risk Med for Ages 65
180 in 30 and Older)
days
PA, QL:
120 in 30
days
PA
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
2
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
hydromorphone hcl
(Dilaudid)
hydromorphone hcl
(Dilaudid)
hydromorphone hcl
(Hydromorphone HCl)
hydromorphone hcl/pf
(Hydromorphone HCl/
PF)
(Combunox)
ibuprofen/oxycodone hcl
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
LAZANDA
levorphanol tartrate
(Levo-dromoran)
methadone hcl
(Methadone HCl)
methadone hcl
(Methadone HCl)
methadone hcl
(Methadose)
methadone hcl
(Methadose)
morphine sulfate
(Morphine Sulfate)
morphine sulfate
(Morphine Sulfate)
morphine sulfate
(MS Contin)
morphine sulfate
(MS Contin)
morphine sulfate
(MSIR)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
QL: 180 in tablet: 2mg, 4mg
30 days
QL: 240 in tablet: 8mg
30 days
syringe
vial
QL: 28 in
30 days
PA, QL:
30 in 30
days
QL: 180 in
30 days
vial
QL: 1800 solution
in 30 days
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
30 days
QL: 180 in
30 days
QL: 200 in
30 days
tablet er: 30mg, 60mg,
100mg
tablet er: 15mg, 200mg
solution: 100mg/5ml
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
3
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
morphine sulfate
(MSIR)
morphine sulfate
(MSIR)
morphine sulfate/0.9%
nacl/pf
morphine sulfate/pf
(Morphine Sulfate/0.9%
Nacl/PF)
(Morphine Sulfate/PF)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
MORPHINE SULFATE
nalbuphine hcl
(Nalbuphine HCl)
NUCYNTA ER
NUCYNTA
OFIRMEV
oxycodone hcl
(Dazidox)
oxycodone hcl
(Oxycodone HCl)
oxycodone hcl/
acetaminophen
oxycodone hcl/
acetaminophen
oxycodone hcl/
acetaminophen
(Alcet)
oxycodone hcl/
acetaminophen
oxycodone hcl/aspirin
(Oxycodone HCl/
acetaminophen)
(Endodan)
(Alcet)
(Alcet)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
QL: 300 in solution: 20mg/5ml
30 days
QL: 700 in solution: 10mg/5ml
30 days
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
QL: 1800
in 30 days
QL: 360 in
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
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
4
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
OXYCONTIN
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
OXYCONTIN
oxymorphone hcl
(Opana ER)
oxymorphone hcl
(Opana ER)
oxymorphone hcl
(Opana)
tramadol hcl
(Ultram)
tramadol hcl/
acetaminophen
XARTEMIS XR
(Ultracet)
Nonsteroidal Anti-inflammatory Agents
aspirin *
(Bayer Chewable)
$0 (Tier 5)
aspirin/calcium
(Aspirin/calcium
carbonate/mag *
Carbonate/mag)
butalbital/aspirin/caffeine (Fiorinal)
$0 (Tier 5)
CALDOLOR
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
CELEBREX
choline sal/mag salicylate (Choline Sal/mag
Salicylate)
diclofenac potassium
(Cataflam)
diclofenac sodium
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
(Voltaren)
tab er 12h: 80mg
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
tab chew, tablet dr: 81mg,
325mg
tablet: 325mg, 500mg
PA, QL:
180 in 30
days
(High Risk Med for Ages 65
and Older)
ST, QL: 60
in 30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
5
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
diclofenac sodium/
misoprostol
diflunisal
(Arthrotec 50)
etodolac
(Etodolac)
fenoprofen calcium
(Fenoprofen Calcium)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
(Diflunisal)
FLECTOR
flurbiprofen
(Ansaid)
ibuprofen *
ibuprofen
(Children's Motrin)
(Motrin)
indomethacin sodium
(Indocin I.v.)
indomethacin
(Indocin SR)
indomethacin
(Indomethacin)
$0 - $6.35
(Tier 1)
indomethacin
(Indomethacin)
$0 - $6.35
(Tier 1)
ketoprofen
(Ketoprofen)
ketorolac tromethamine
ketorolac tromethamine
(Ketorolac
Tromethamine)
(Toradol)
mefenamic acid
(Ponstel)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA
PA, QL:
60 in 30
days
PA, QL:
120 in 30
days
PA, QL:
240 in 30
days
oral susp: 100mg/5ml
oral susp: 100mg/5ml;
tablet: 400mg, 600mg,
800mg
(High Risk Med for Ages 65
and Older)
capsule er, (High Risk Med
for Ages 65 and Older)
capsule: 50mg, (High Risk
Med for Ages 65 and Older)
capsule: 25mg, (High Risk
Med for Ages 65 and Older)
cap24h pel, capsule
QL: 40 in
30 days
QL: 20 in
30 days
vial: 15mg/ml
tablet, vial: 60mg/2ml
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
6
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
meloxicam
(Mobic)
nabumetone
(Relafen)
naproxen sodium
(Anaprox)
naproxen
(Naprosyn)
piroxicam
(Feldene)
salsalate
(Salflex)
sulindac
(Clinoril)
tolmetin sodium
(Tolmetin Sodium)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
VOLTAREN
tablet: 275mg, 550mg
(Topical Gel)
Anesthetics
Local Anesthetics
cocaine hcl
(Cocaine HCl)
lidocaine hcl
(Xylocaine)
lidocaine hcl
(Xylocaine)
lidocaine hcl
(Xylocaine)
lidocaine hcl/pf
(Xylocaine-MPF)
lidocaine
(Lidocaine)
lidocaine/prilocaine
(EMLA)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
disp syrin, solution: 4%
PA BvD
jel (ml), jel/pf app, solution:
2%, 40mg/ml
vial, (PA for ESRD Only)
PA BvD
(PA for ESRD Only)
PA BvD
oint. (g), (PA for ESRD
Only)
(PA for ESRD Only)
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
7
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
LIDODERM
$0 - $6.35
(Tier 1)
Anti-addiction/substance Abuse Treatment Agents
Anti-addiction/substance Abuse Treatment Agents
acamprosate calcium
(Campral)
$0 - $6.35
(Tier 1)
buprenorphine hcl
(Subutex)
$0 - $6.35
(Tier 1)
buprenorphine hcl/
naloxone hcl
(Suboxone)
$0 - $6.35
(Tier 1)
CAMPRAL
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
CHANTIX
CHANTIX
CHANTIX
disulfiram
(Antabuse)
naloxone hcl
(Naloxone HCl)
naltrexone hcl
(Revia)
nicotine *
(Nicoderm Cq)
NICOTROL
$0 - $6.35
(Tier 2)
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: 1mg/ml
PA, QL:
patch td24: 21mg/24hr
224 in 365
days
QL: 2016
in 365
days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
8
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
SUBOXONE
$0 - $6.35
(Tier 2)
SUBOXONE
$0 - $6.35
(Tier 2)
ZUBSOLV
$0 - $6.35
(Tier 2)
PA, QL:
60 in 30
days
PA, QL:
90 in 30
days
PA, QL:
90 in 30
days
film: 12mg-3mg
QL: 60 in
30 days
QL: 90 in
30 days
QL: 120 in
30 days
QL: 300 in
30 days
QL: 90 in
30 days
tab er 24h: 1mg, 2mg, 3mg
film: 2mg-0.5mg, 4mg-1mg,
8mg-2mg
Antianxiety Agents
Benzodiazepines
alprazolam
(Xanax XR)
alprazolam
(Xanax)
chlordiazepoxide hcl
(Librium)
clonazepam
(Klonopin)
clonazepam
(Klonopin)
clorazepate dipotassium
(Tranxene T-tab)
clorazepate dipotassium
(Tranxene T-tab)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
DIASTAT ACUDIAL
diazepam
(Diastat)
diazepam
(Diazepam)
diazepam
(Valium)
tab er 24h: 0.5mg; tab
rapdis, tablet
tab rapdis: 2mg; tablet: 2mg
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
kit
QL: 1200 oral conc, solution
in 30 days
QL: 120 in tablet
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
9
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
diazepam
(Valium)
estazolam
(Prosom)
flurazepam hcl
(Dalmane)
lorazepam
(Ativan)
lorazepam
(Ativan)
lorazepam
(Lorazepam)
midazolam hcl
(Midazolam HCl)
midazolam hcl
(Versed)
midazolam hcl/pf
(Midazolam HCl/PF)
ONFI
ONFI
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
temazepam
(Restoril)
triazolam
(Halcion)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
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
QL: 30 in
30 days
QL: 30 in
30 days
syringe
syringe, vial
tablet
oral conc
syrup
syringe
oral susp
tablet: 10mg, 20mg
Antibacterials
Aminoglycosides
BETHKIS
$0 - $6.35
(Tier 2)
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
10
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
gentamicin in nacl, isoosm
(Gentamicin In Nacl,
Iso-osm)
$0 - $6.35
(Tier 1)
gentamicin sulfate
(Garamycin)
gentamicin sulfate/pf
(Gentamicin Sulfate/PF)
kanamycin sulfate
(Kanamycin Sulfate)
neomycin sulfate
(Neomycin Sulfate)
streptomycin sulfate
(Streptomycin Sulfate)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
TOBI PODHALER
tobramycin in 0.225%
nacl
tobramycin sulfate
(Tobi)
(Nebcin)
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)
piggyback: 60mg/50ml,
70mg/50ml, 80mg/100ml,
80mg/50ml, 90mg/100ml,
100mg/0.1l
QL: 224 in
28 days
PA BvD
piggyback: 60mg/50ml
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
11
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
clindamycin phosphate/
d5w
colistin (colistimethate
na)
CUBICIN
(Cleocin Phosphate In
D5w)
(Coly-mycin M
Parenteral)
FUROXONE
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
methenamine hippurate
(Urex)
nitrofurantoin
macrocrystal
(Macrodantin)
nitrofurantoin
(Furadantin)
$0 - $6.35
(Tier 1)
polymyxin b sulfate
(Polymyxin B Sulfate)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
SYNERCID
trimethoprim
(Trimethoprim)
vancomycin hcl
(Vancocin HCl)
vancomycin hcl
(Vancomycin HCl)
vancomycin hcl/d5w
(Vancomycin HCl/D5W)
VANCOMYCIN HCL
PA BvD
(PA for ESRD Only)
PA, QL:
120 in 30
days
(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
PA BvD
vial: 1g, 10g, (PA for ESRD
Only)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
12
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
XIFAXAN
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
XIFAXAN
ZYVOX
Cephalosporins
cefaclor
(Ceclor)
cefadroxil
(Cefadroxil)
cefazolin sodium
(Ancef)
cefazolin sodium/
dextrose,iso
cefdinir
(Cefazolin Sodium/
dextrose, Iso)
(Omnicef)
cefditoren pivoxil
(Spectracef)
cefepime hcl
(Maxipime)
CEFEPIME
CEFEPIME-DEXTROSE
cefotaxime sodium
(Claforan)
cefotetan disod/
dextrose,iso
cefotetan disodium
(Cefotetan Disod/
dextrose, Iso)
(Cefotetan Disodium)
cefoxitin sodium
(Mefoxin)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA, QL: 9 tablet: 200mg
in 30 days
ST, QL: 60 tablet: 550mg
in 30 days
piggyback
tablet: 400mg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
13
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
cefoxitin sodium/
dextrose,iso
cefpodoxime proxetil
(Cefoxitin Sodium/
dextrose, Iso)
(Vantin)
cefprozil
(Cefzil)
ceftazidime pentahydrate
(Fortaz)
ceftibuten dihydrate
(Cedax)
ceftriaxone na/
dextrose,iso
ceftriaxone sodium
(Ceftriaxone Na/
dextrose, Iso)
(Rocephin)
cefuroxime axetil
(Ceftin)
cefuroxime sodium
(Zinacef)
cefuroxime sodium/
dextrose,iso
cephalexin
(Cefuroxime Sodium/
dextrose, Iso)
(Keflex)
cephalexin
(Keflex)
SUPRAX
TAZICEF IN
DEXTROSE
tea tree oil
(Tea Tree Oil)
Macrolides
azithromycin
(Zithromax)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
vial
capsule: 250mg, 500mg;
susp recon, tablet
capsule: 750mg
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
14
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
clarithromycin
(Biaxin)
DIFICID
ery e-succ/sulfisoxazole
(Pediazole)
ERY-TAB
ERYTHROCIN
LACTOBIONATE
erythromycin base
(Erythromycin Base)
erythromycin
ethylsuccinate
erythromycin stearate
(Erythromycin
Ethylsuccinate)
(Erythromycin Stearate)
KETEK
Miscellaneous B-lactam Antibiotics
aztreonam
(Azactam)
CAYSTON
imipenem/cilastatin
sodium
INVANZ
(Primaxin)
INVANZ
meropenem
(Merrem)
Penicillins
amoxicillin trihydrate
(Amoxicillin Trihydrate)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
QL: 20 in
10 days
vial port: 500mg
tablet, tablet dr
tablet
ST
LA
vial
vial port
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
15
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
amoxicillin
(Amoxil)
amoxicillin/potassium
clav
ampicillin sodium
(Augmentin)
ampicillin sodium/
sulbactam na
ampicillin trihydrate
(Unasyn)
(Totacillin-N)
(Ampicillin Trihydrate)
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
(Dicloxacillin Sodium)
NAFCILL IN
DEXTROSE
nafcillin sodium
(Unipen)
oxacillin sodium
(Oxacillin Sodium)
oxacillin sodium/
dextrose,iso
pen g pot/dextrose-water
penicillin g potassium
(Oxacillin Sodium/
dextrose, Iso)
(Pen G Pot/dextrosewater)
(Penicillin G Potassium)
penicillin g potassium/
d5w
penicillin g procaine
(Penicillin G Potassium/
D5W)
(Penicillin G Procaine)
penicillin v potassium
(Veetids 500)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
vial
vial
vial
froz.piggy: 2mm/50ml,
3mm/50ml
syringe: 1.2mm/2ml
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
16
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
piperacillin sodium/
tazobactam
Quinolones
AVELOX ABC PACK
(Zosyn)
AVELOX IV
ciprofloxacin hcl
(Cipro)
ciprofloxacin lactate
(Cipro I.V.)
ciprofloxacin lactate/d5w (Cipro I.V.)
ciprofloxacin
(Ciprofloxacin)
ciprofloxacin/ciprofloxa
hcl
levofloxacin
(Cipro XR)
levofloxacin/d5w
(Levaquin)
moxifloxacin hcl
(Avelox)
nalidixic acid
(Nalidixic Acid)
ofloxacin
(Floxin)
Sulfonamides
sulfadiazine
(Sulfadiazine)
sulfamethoxazole/
trimethoprim
sulfasalazine
(Levaquin)
(Septra)
(Azulfidine)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
17
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
Tetracyclines
demeclocycline hcl
(Declomycin)
doxycycline hyclate
(Morgidox)
doxycycline monohydrate (Adoxa)
doxycycline monohydrate (Adoxa)
MINOCIN
minocycline hcl
(Dynacin)
tetracycline hcl
(Ala-tet)
TYGACIL
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
capsule, tablet: 20mg; tablet
dr, vial
capsule: 150mg
capsule: 75mg, 100mg; susp
recon, tablet
vial
Anticancer Agents
Anticancer Agents
ABRAXANE
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ADCETRIS
AFINITOR DISPERZ
$0 - $6.35
(Tier 2)
AFINITOR
$0 - $6.35
(Tier 2)
ALIMTA
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
anastrozole
(Arimidex)
PA NSO,
QL: 3 in
21 days
PA NSO,
QL: 112 in
28 days
PA NSO,
QL: 28 in
28 days
PA NSO
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
18
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
ARRANON
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ARZERRA
AVASTIN
azacitidine
(Vidaza)
BELEODAQ
BEXXAR
bicalutamide
(Casodex)
BICNU
bleomycin sulfate
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
(Bleomycin Sulfate)
BOSULIF
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
BOSULIF
$0 - $6.35
(Tier 2)
BUSULFEX
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
CAPRELSA
CAPRELSA
carboplatin
$0 - $6.35
(Tier 2)
(Carboplatin)
PA NSO,
QL: 80 in
30 days
PA NSO
PA NSO
vial: 14mg/ml
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
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
19
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
CEENU
cisplatin
(Cisplatin)
cladribine
(Leustatin)
CLOLAR
COMETRIQ
cyclophosphamide
(Cyclophosphamide)
cyclophosphamide
(Cytoxan)
CYCLOPHOSPHAMIDE
CYRAMZA
cytarabine/pf
(Cytarabine/PF)
dacarbazine
(Dtic-Dome IV)
dactinomycin
(Cosmegen)
daunorubicin hcl
(Cerubidine)
DAUNOXOME
decitabine
(Dacogen)
DOCEFREZ
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
capsule: 10mg, 40mg
PA BvD
PA NSO,
QL: 112 in
28 days
PA BvD,
tablet
ST
PA BvD
vial
PA BvD,
ST
PA NSO
PA BvD
vial: 1g, 100mg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
20
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
docetaxel
(Taxotere)
doxorubicin hcl pegliposomal
doxorubicin hcl
(Doxil)
(Adriamycin RDF)
DROXIA
ELIGARD
ELIGARD
ELIGARD
ELIGARD
ELSPAR
EMCYT
epirubicin hcl
(Ellence)
ERBITUX
ERIVEDGE
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ERWINAZE
$0 - $6.35
(Tier 2)
ETOPOPHOS
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
etoposide
(Etoposide)
vial: 20mg/2ml, 20mg/ml(1)
PA BvD
PA BvD
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
vial
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
21
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
exemestane
(Aromasin)
FARESTON
FASLODEX
FIRMAGON
floxuridine
(FUDR)
fludarabine phosphate
(Fludara)
fluorouracil
(Fluorouracil)
flutamide
(Flutamide)
FOLOTYN
GAZYVA
gemcitabine hcl
(Gemzar)
GILOTRIF
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
GLEEVEC
$0 - $6.35
(Tier 2)
GLEEVEC
$0 - $6.35
(Tier 2)
HALAVEN
$0 - $6.35
(Tier 2)
PA NSO
PA BvD
PA BvD
vial: 1g/20ml
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
tablet: 400mg
tablet: 100mg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
22
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
HERCEPTIN
HEXALEN
hydroxyurea
(Hydrea)
ICLUSIG
ICLUSIG
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
idarubicin hcl
(Idamycin Pfs)
ifosfamide
(Ifex)
ifosfamide/mesna
(Ifex-mesnex)
IMBRUVICA
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
INLYTA
$0 - $6.35
(Tier 2)
INLYTA
$0 - $6.35
(Tier 2)
irinotecan hcl
(Camptosar)
ISTODAX
IXEMPRA
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA NSO
PA NSO,
QL: 30 in
30 days
PA NSO,
QL: 60 in
30 days
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
23
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
JAKAFI
$0 - $6.35
(Tier 2)
JEVTANA
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
KADCYLA
KYPROLIS
letrozole
$0 - $6.35
(Tier 2)
(Femara)
LEUKERAN
leuprolide acetate
(Leuprolide Acetate)
lomustine
(Ceenu)
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT-PED
LUPRON DEPOT-PED
LYSODREN
MARQIBO
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
24
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
MATULANE
MEGACE ES
megestrol acetate
(Megace)
MEKINIST
MEKINIST
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
melphalan hcl
(Alkeran)
mercaptopurine
(Purinethol)
methotrexate sodium
(Methotrexate Sodium)
methotrexate sodium
(Methotrexate Sodium)
methotrexate sodium/pf
mitomycin
(Methotrexate Sodium/
PF)
(Mitomycin)
mitoxantrone hcl
(Novantrone)
MUSTARGEN
NEXAVAR
NILANDRON
ONCASPAR
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA NSO,
QL: 30 in
30 days
PA NSO,
QL: 90 in
30 days
tablet: 2mg
PA BvD,
ST
PA BvD
tablet
tablet: 0.5mg
vial
PA BvD
PA BvD
PA NSO,
QL: 120 in
30 days
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
25
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
ONTAK
oxaliplatin
(Eloxatin)
paclitaxel
(Taxol)
pentostatin
(Nipent)
PERJETA
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
POMALYST
$0 - $6.35
(Tier 2)
PROLEUKIN
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PURIXAN
REVLIMID
RITUXAN
SOLTAMOX
SPRYCEL
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
STIVARGA
$0 - $6.35
(Tier 2)
SUTENT
$0 - $6.35
(Tier 2)
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
26
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
SYLVANT
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
SYNRIBO
TABLOID
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
TAFINLAR
tamoxifen citrate
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
(Nolvadex)
TARCEVA
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
TARGRETIN
$0 - $6.35
(Tier 2)
TASIGNA
$0 - $6.35
(Tier 2)
TEMODAR
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
teniposide
(Teniposide)
thiotepa
(Thiotepa)
topotecan hcl
(Hycamtin)
TORISEL
TREANDA
PA NSO
vial: 100mg
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, (Vial only)
PA BvD,
QL: 4 in
28 days
$0 - $6.35
(Tier 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
27
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
TRELSTAR
TRELSTAR
TRELSTAR
tretinoin
(Tretinoin)
TREXALL
TRISENOX
TYKERB
VALSTAR
VECTIBIX
VELCADE
vinblastine sulfate
(Vinblastine Sulfate)
vincristine sulfate
(Vincristine Sulfate)
vinorelbine tartrate
(Navelbine)
VOTRIENT
VUMON
XALKORI
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
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
PA NSO,
QL: 120 in
30 days
PA NSO,
QL: 60 in
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
28
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
XTANDI
$0 - $6.35
(Tier 2)
YERVOY
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ZALTRAP
ZANOSAR
ZELBORAF
ZOLADEX
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ZOLADEX
ZOLINZA
ZYDELIG
ZYKADIA
$0 - $6.35
(Tier 2)
ZYTIGA
$0 - $6.35
(Tier 2)
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
atropine sulfate
(Atropine Sulfate)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
QL: 60 in
30 days
syringe
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
29
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
atropine sulfate
(Atropine Sulfate)
propantheline bromide
(Propantheline Bromide)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
vial
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine
(Tegretol)
CELONTIN
DILANTIN
divalproex sodium
(Depakote ER)
ethosuximide
(Zarontin)
felbamate
(Felbatol)
fosphenytoin sodium
(Cerebyx)
FYCOMPA
gabapentin
(Neurontin)
GABITRIL
LAMICTAL
lamotrigine
(Lamictal (blue))
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
ST
ST
ST
tab ds pk
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
30
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
lamotrigine
(Lamictal)
levetiracetam in nacl
(iso-os)
levetiracetam
(Levetiracetam In Nacl
(iso-os))
(Keppra)
LUMINAL SODIUM
LYRICA
LYRICA
oxcarbazepine
(Trileptal)
OXTELLAR XR
PEGANONE
phenobarbital sodium
(Phenobarbital Sodium)
phenobarbital
(Phenobarbital)
phenobarbital
(Phenobarbital)
phenobarbital
(Phenobarbital)
PHENYTEK
phenytoin sodium
extended
phenytoin sodium
(Dilantin)
(Phenytoin Sodium)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
31
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
phenytoin
(Dilantin)
POTIGA
POTIGA
primidone
(Mysoline)
QUDEXY XR
SABRIL
TEGRETOL XR
tiagabine hcl
(Gabitril)
topiramate
(Topamax)
topiramate
(Topiramate)
TRILEPTAL
TROKENDI XR
valproic acid (as sodium
salt)
valproic acid
(Depakene)
(Depakene)
VIMPAT
VIMPAT
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ST, QL:
tablet: 50mg
270 in 30
days
ST, QL: 90 tablet: 200mg, 300mg,
in 30 days 400mg
ST
cap sprink, tablet
cap spr 24
ST
ST, QL:
solution
1200 in 30
days
ST, QL:
vial
200 in 5
days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
32
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
VIMPAT
zonisamide
(Zonegran)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
ST, QL: 60 tablet
in 30 days
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 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
QL: 360 in
30 days
QL: 49 in
28 days
QL: 60 in
30 days
QL: 60 in
30 days
$0 - $6.35
(Tier 1)
PA NSO
Antidementia Agents
Antidementia Agents
donepezil hcl
(Aricept)
EXELON
EXELON
galantamine hbr
(Razadyne ER)
galantamine hbr
(Razadyne)
galantamine hbr
(Razadyne)
NAMENDA XR
NAMENDA XR
NAMENDA
NAMENDA
NAMENDA
rivastigmine tartrate
(Exelon)
solution
patch td24
cap24h pel
solution
tablet
cap24 dspk
cap spr 24
solution
tab ds pk
tablet
Antidepressants
Antidepressants
amitriptyline hcl
(Amitriptyline HCl)
(High Risk Med for Ages 65
and Older)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
33
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
amoxapine
(Amoxapine)
BRINTELLIX
bupropion hcl
(Wellbutrin XL)
citalopram hydrobromide (Celexa)
citalopram hydrobromide (Celexa)
clomipramine hcl
(Anafranil)
desipramine hcl
(Norpramin)
DESVENLAFAXINE ER
doxepin hcl
(Doxepin HCl)
duloxetine hcl
(Cymbalta)
duloxetine hcl
(Cymbalta)
EMSAM
escitalopram oxalate
(Lexapro)
escitalopram oxalate
(Lexapro)
FETZIMA
fluoxetine hcl
(Prozac)
fluvoxamine maleate
(Fluvoxamine Maleate)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
ST
solution
QL: 30 in
30 days
PA NSO
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
34
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
imipramine hcl
(Tofranil)
imipramine pamoate
(Tofranil-PM)
KHEDEZLA
maprotiline hcl
(Maprotiline HCl)
MARPLAN
mirtazapine
(Remeron)
nefazodone hcl
(Nefazodone HCl)
nortriptyline hcl
(Pamelor)
olanzapine/fluoxetine hcl
(Symbyax)
paroxetine hcl
(Paxil)
PAXIL
perphenazine/
amitriptyline hcl
phenelzine sulfate
(Perphenazine/
amitriptyline HCl)
(Nardil)
PRISTIQ ER
protriptyline hcl
(Vivactil)
sertraline hcl
(Zoloft)
SILENOR
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA NSO
PA NSO
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
ST, QL: 30
in 30 days
PA NSO
(High Risk Med for Ages 65
and Older)
ST, QL: 30
in 30 days
QL: 30 in
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
35
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
tranylcypromine sulfate
(Parnate)
trazodone hcl
(Trazodone HCl)
trimipramine maleate
(Trimipramine Maleate)
VENLAFAXINE HCL
ER
VENLAFAXINE HCL
ER
venlafaxine hcl
(Effexor XR)
VIIBRYD
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA NSO
(High Risk Med for Ages 65
and Older)
tab er 24: 37.5mg, 75mg,
150mg
tab er 24: 225mg
PA NSO,
QL: 30 in
30 days
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
BYDUREON PEN
BYDUREON
BYETTA
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
BYETTA
$0 - $6.35
(Tier 2)
CYCLOSET
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
GLYSET
QL: 90 in
30 days
ST, QL: 4
in 28 days
ST, QL: 4
in 28 days
ST, QL:
pen injctr: 5mcg/0.02
1.2 in 28
days
ST, QL:
pen injctr: 10mcg/0.04
2.4 in 28
days
QL: 180 in
30 days
QL: 90 in
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
36
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
INVOKAMET
$0 - $6.35
(Tier 2)
INVOKAMET
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
INVOKANA
INVOKANA
JANUMET XR
JANUMET XR
JANUMET
JANUVIA
JENTADUETO
JUVISYNC
KORLYM
metformin hcl
(Fortamet)
metformin hcl
(Glucophage)
metformin hcl
(Glucophage)
metformin hcl
(Glucophage)
nateglinide
(Starlix)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
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
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
37
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
PRANDIMET
repaglinide
(Prandin)
SYMLIN
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
SYMLINPEN 120
$0 - $6.35
(Tier 2)
SYMLINPEN 60
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
TANZEUM
TRADJENTA
VICTOZA 3-PAK
Insulins
HUMALOG MIX 50-50
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMALOG MIX 75-25
HUMALOG
HUMALOG
HUMULIN 70-30
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
QL: 150 in
30 days
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
insuln pen
vial
insuln pen
vial
cartridge
vial
insuln pen
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
38
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
HUMULIN 70-30
HUMULIN N
HUMULIN N
HUMULIN R
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXPEN
LEVEMIR
NOVOLIN 70-30
NOVOLIN 70-30
NOVOLIN N
NOVOLIN N
NOVOLIN R
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
FLEXPEN
NOVOLOG MIX 70-30
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
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
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
vial
insuln pen
vial
cartridge
vial
cartridge
vial
cartridge
vial
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
39
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
NOVOLOG
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
QL: 40 in
28 days
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
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
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
Sulfonylureas
glimepiride
(Amaryl)
glimepiride
(Amaryl)
glipizide
(Glucotrol XL)
glipizide
(Glucotrol)
glipizide
(Glucotrol)
glipizide/metformin hcl
(Metaglip)
glipizide/metformin hcl
(Metaglip)
glyburide
(Micronase)
glyburide
(Micronase)
$0 - $6.35
(Tier 1)
glyburide,micronized
(Glynase)
$0 - $6.35
(Tier 1)
glyburide,micronized
(Glynase)
$0 - $6.35
(Tier 1)
glyburide/metformin hcl
(Glucovance)
$0 - $6.35
(Tier 1)
glyburide/metformin hcl
(Glucovance)
$0 - $6.35
(Tier 1)
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)
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)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
40
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
tolazamide
(Tolazamide)
tolazamide
(Tolazamide)
tolbutamide
(Tolbutamide)
Thiazolidinediones
ACTOPLUS MET XR
AVANDAMET
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
QL: 120 in tablet: 250mg
30 days
QL: 60 in tablet: 500mg
30 days
QL: 180 in
30 days
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
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
AVANDARYL
$0 - $6.35
(Tier 2)
AVANDIA
$0 - $6.35
(Tier 2)
pioglitazone hcl
(Actos)
pioglitazone hcl/
glimepiride
pioglitazone hcl/
metformin hcl
(Duetact)
(Actoplus Met)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
Antifungals
Antifungals
ABELCET
amphotericin b
(Amphotericin B)
CANCIDAS
ciclopirox olamine
(Loprox)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
PA BvD
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
41
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
ciclopirox
(Penlac)
clotrimazole *
(Gyne-lotrimin)
clotrimazole
(Mycelex)
clotrimazole/
betamethasone dip
econazole nitrate
(Lotrisone)
(Spectazole)
ERAXIS (WATER
DILUENT)
EXELDERM
fluconazole in nacl,isoosm
fluconazole
(Diflucan in Saline)
flucytosine
(Ancobon)
griseofulvin
ultramicrosize
griseofulvin, microsize
(Gris-peg)
(Diflucan)
itraconazole
(Griseofulvin,
Microsize)
(Sporanox)
ketoconazole
(Kuric)
LOTRIMIN ULTRA *
miconazole nitrate *
(Miconazole Nitrate)
NOXAFIL
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 (Tier 5)
$0 - $6.35
(Tier 2)
cream (g): 1%; cream/appl,
solution: 1%; spray
cream (g): 1%; solution: 1%;
troche
cmb pf crm, cream (g),
cream/appl: 2%; kit, oint.
(g): 2%; supp.vag
oral susp, tablet dr
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
42
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
nystatin
(Nystatin)
nystatin/triamcin
(Mycogen II)
SPORANOX
terbinafine hcl
(Lamisil)
tolnaftate *
voriconazole
(Tinactin)
(Vfend)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
tablet
cream (g): 1%; solution
Antihistamines
Antihistamines
carbinoxamine maleate
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA
liquid: 4mg/5ml; tablet: 4mg
carbinoxamine maleate
(Carbinoxamine
Maleate)
(Palgic)
PA
chlorpheniramine
maleate *
clemastine fumarate
(Chlorpheniramine
Maleate)
(Clemastine Fumarate)
$0 (Tier 5)
PA NSO
liquid: 4mg/5ml; tablet:
4mg, (High Risk Med for
Ages 65 and Older)
syrup, tablet
$0 - $6.35
(Tier 1)
PA
clemastine fumarate
(Tavist-1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
PA
CONEX *
cyproheptadine hcl
(Cyproheptadine HCl)
diphenhydramine hcl *
(Diphenhydramine HCl)
PA NSO
PA
PA NSO
syrup, tablet: 2.68mg, (High
Risk Med for Ages 65 and
Older)
tablet: 1.34mg
(High Risk Med for Ages 65
and Older)
capsule: 25mg, 50mg; elixir,
liquid: 12.5mg/5ml; tablet:
25mg, 50mg, (High Risk
Med for Ages 65 and Older)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
43
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
diphenhydramine hcl *
(Zzzquil)
$0 (Tier 5)
diphenhydramine hcl
(Diphenhydramine HCl)
levocetirizine
dihydrochloride
loratadine *
p-epd tan/chlor-tan
(Xyzal)
p-ephed hcl/d-bromp mal
*
phenylephrine/
brompheniramine *
phenylephrine/
chlorpheniramine *
phenylephrine/
diphenhydramine *
phenylephrine/
triprolidine *
POLY HIST FORTE *
promethazine hcl
(P-ephed HCl/d-bromp
Mal)
(Dimetapp)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
pseudoephed/
chlorpheniramine *
pseudoephed/
chlorpheniramine *
pseudoephedrine/
brompheniramin *
pseudoephedrine/
triprolidine *
RU-HIST-D *
TRIAMINIC COLDALLERGY PE *
(Pseudoephed/
chlorpheniramine)
(Pseudoephed/
chlorpheniramine)
(Brovex Psb)
(Claritin)
(P-epd Tan/chlor-tan)
PA NSO
capsule: 25mg, 50mg; elixir,
liquid: 12.5mg/5ml; tablet:
25mg, 50mg
syringe
PA NSO
PA NSO
$0 (Tier 5)
PA NSO
liquid, oral susp, solution
(Triaminic Cold-allergy
Pe)
(Alahist Lq)
$0 (Tier 5)
PA NSO
liquid
$0 (Tier 5)
PA NSO
liquid: 2.5-6.25/5; solution
(Phenylephrine/
triprolidine)
$0 (Tier 5)
PA NSO
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
PA NSO
PA
PA NSO
tablet: 10mg-25mg
(High Risk Med for Ages 65
and Older)
liquid, syrup
$0 (Tier 5)
PA
tablet: 60mg-4mg
$0 (Tier 5)
PA NSO
liquid: 15-1mg/5ml
$0 (Tier 5)
PA NSO
$0 (Tier 5)
$0 (Tier 5)
PA NSO
PA NSO
(Promethazine HCl)
(Pseudoephedrine/
triprolidine)
tablet
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
44
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
tripelennamine hcl
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
(Tripelennamine HCl)
$0 - $6.35
(Tier 1)
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
AVC
clindamycin phosphate
(Cleocin)
metronidazole
(Metrogel-vaginal)
miconazole nitrate
(Monistat 3)
sod propion/inositol/
aa14/urea
terconazole
(Sod Propion/inositol/
aa14/urea)
(Terazol 3)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
Antimigraine Agents
Antimigraine Agents
dihydroergotamine
(D.H.E. 45)
mesylate
dihydroergotamine
(Migranal)
mesylate
ERGOMAR
naratriptan hcl
(Amerge)
rizatriptan benzoate
(Maxalt Mlt)
sumatriptan succinate
(Imitrex)
sumatriptan succinate
(Imitrex)
sumatriptan
(Imitrex)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
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: 12 in
28 days
ampul
spray/pump
tablet
cartridge: 6mg/0.5ml; vial
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
45
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
zolmitriptan
(Zomig)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
QL: 12 in
28 days
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE
dapsone
(Dapsone)
ethambutol hcl
(Myambutol)
isoniazid
(Isoniazid)
PASER
PRIFTIN
rifabutin
(Mycobutin)
rifampin
(Rifadin)
RIFATER
SEROMYCIN
SIRTURO
TRECATOR
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA, QL:
188 in 168
days
$0 - $6.35
(Tier 2)
Antinausea Agents
Antinausea Agents
CESAMET
$0 - $6.35
(Tier 2)
QL: 180 in
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
46
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
dimenhydrinate
(Dimenhydrinate)
dronabinol
(Marinol)
EMEND
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
EMEND
$0 - $6.35
(Tier 2)
EMEND
$0 - $6.35
(Tier 2)
EMEND
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
granisetron hcl
(Kytril)
granisetron hcl
(Kytril)
granisetron hcl/pf
(Kytril)
meclizine hcl *
(Meclizine HCl)
meclizine hcl
(Antivert)
ondansetron hcl
(Zofran)
ondansetron hcl
(Zofran)
ondansetron
(Zofran Odt)
prochlorperazine
(Compazine)
edisylate
prochlorperazine maleate (Compazine)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
vial
PA BvD,
QL: 1 per
fill
PA BvD,
QL: 2 per
fill
PA BvD,
QL: 3 per
fill
QL: 2 in
28 days
capsule: 40mg, 125mg
capsule: 80mg
cap ds pk
vial
vial
PA BvD
tablet
PA NSO
tab chew, tablet: 12.5mg,
25mg
tablet: 12.5mg, 25mg
vial
PA BvD
solution, tablet
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
47
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
promethazine hcl
(Promethazine HCl)
promethazine hcl
(Promethazine HCl)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA
PA
(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
sulfate
mefloquine hcl
(Plaquenil)
metronidazole
(Flagyl)
metronidazole/sodium
chloride
NEBUPENT
(Metro IV)
paromomycin sulfate
(Paromomycin Sulfate)
(Lariam)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
48
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
PENTAM 300
pentamidine isethionate
(Pentam 300)
PRIMAQUINE
quinine sulfate
(Qualaquin)
STROMECTOL
tinidazole
(Tindamax)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
QL: 90 in
30 days
PA, QL:
42 in 30
days
capsule
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
(Amantadine HCl)
APOKYN
AZILECT
benztropine mesylate
(Benztropine Mesylate)
benztropine mesylate
(Benztropine Mesylate)
bromocriptine mesylate
(Parlodel)
cabergoline
(Cabergoline)
carbidopa
(Lodosyn)
carbidopa/levodopa
(Sinemet 10-100)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
QL: 60 in
30 days
PA
PA
(High Risk Med for Ages 65
and Older)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
49
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
carbidopa/levodopa/
entacapone
entacapone
(Stalevo 50)
(Comtan)
NEUPRO
pramipexole di-hcl
(Mirapex)
ropinirole hcl
(Requip)
selegiline hcl
(Eldepryl)
trihexyphenidyl hcl
(Trihexyphenidyl HCl)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
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
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY
ABILIFY
ABILIFY
ABILIFY
ADASUVE
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
tab rapdis: 10mg
vial
tablet: 5mg, 10mg, 15mg,
20mg, 30mg
tablet: 2mg
solution
$0 - $6.35
(Tier 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
50
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
chlorpromazine hcl
(Chlorpromazine HCl)
clozapine
(Clozaril)
clozapine
(Clozaril)
clozapine
(Clozaril)
clozapine
(Fazaclo)
FANAPT
FANAPT
FAZACLO
FAZACLO
fluphenazine decanoate
fluphenazine hcl
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
GEODON
haloperidol decanoate
(Haloperidol Decanoate)
haloperidol lactate
(Haloperidol Lactate)
haloperidol
(Haloperidol)
INVEGA SUSTENNA
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
ampul, tablet
QL: 135 in
30 days
QL: 270 in
30 days
QL: 90 in
30 days
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
tablet: 200mg
tablet: 100mg
tablet: 25mg, 50mg
tab rapdis
tablet
tab ds pk
tab rapdis: 200mg
tab rapdis: 150mg
QL: 6 in
28 days
QL: 0.25
in 28 days
syringe: 39mg/0.25
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
51
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA
INVEGA
LATUDA
LATUDA
loxapine succinate
(Loxitane)
MOBAN
olanzapine
(Zyprexa Zydis)
olanzapine
(Zyprexa)
ORAP
perphenazine
(Perphenazine)
quetiapine fumarate
(Seroquel)
RISPERDAL CONSTA
risperidone
(Risperdal M-tab)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
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: 78mg/0.5ml
QL: 31 in
30 days
QL: 30 in
30 days
tab rapdis: 20mg
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
tab rapdis: 5mg, 10mg,
15mg; tablet, vial
QL: 90 in
30 days
QL: 4 in
28 days
QL: 120 in tab rapdis: 3mg, 4mg
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
52
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
risperidone
(Risperdal)
risperidone
(Risperdal)
SAPHRIS
SEROQUEL XR
SEROQUEL XR
thioridazine hcl
(Thioridazine HCl)
thiothixene
(Navane)
trifluoperazine hcl
(Trifluoperazine HCl)
VERSACLOZ
ziprasidone hcl
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
(Geodon)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
(Ziagen)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ZYPREXA RELPREVV
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
solution
tab rapdis: 0.25mg, 0.5mg,
1mg, 2mg; tablet
tab er 24h: 200mg
tab er 24h: 50mg, 150mg,
300mg, 400mg
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
(Trizivir)
APTIVUS
capsule
solution
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
53
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
ATRIPLA
COMPLERA
CRIXIVAN
didanosine
(Videx EC)
EDURANT
EMTRIVA
EPIVIR HBV
EPIVIR
EPZICOM
FUZEON
INTELENCE
INVIRASE
ISENTRESS
KALETRA
lamivudine
(Epivir)
lamivudine/zidovudine
(Combivir)
LEXIVA
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
solution
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
54
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
nevirapine
(Viramune)
NORVIR
PREZISTA
PREZISTA
RESCRIPTOR
RETROVIR
REYATAZ
SELZENTRY
stavudine
(Zerit)
STRIBILD
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE XR
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
oral susp, tablet: 75mg,
150mg, 600mg, 800mg
tablet: 400mg
capsule: 50mg, 200mg;
tablet
tab er 24h: 100mg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
55
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
VIREAD
ZIAGEN
zidovudine
(Retrovir)
Antivirals, Miscellaneous
foscarnet sodium
(Foscavir)
RELENZA
rimantadine hcl
(Flumadine)
SYNAGIS
TAMIFLU
TAMIFLU
TAMIFLU
TAMIFLU
Hcv Protease Inhibitors
INCIVEK
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
$0 - $6.35
(Tier 2)
PA, QL:
168 in 28
days
PA, QL:
28 in 28
days
PA, QL:
336 in 28
days
OLYSIO
$0 - $6.35
(Tier 2)
VICTRELIS
$0 - $6.35
(Tier 2)
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
56
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
Interferons
ALFERON N
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
INTRON A
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON 4-PACK
Nucleosides And Nucleotides
acyclovir sodium
(Acyclovir Sodium)
acyclovir
(Zovirax)
adefovir dipivoxil
(Hepsera)
BARACLUDE
cidofovir
(Vistide)
entecavir
(Baraclude)
famciclovir
(Famvir)
ganciclovir sodium
(Cytovene)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA NSO
vial: 6mmunit/ml, 10mmunit
PA
PA
PA
PA
PA NSO,
QL: 1 in
28 days
PA BvD
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
57
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
ribavirin
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
(Rebetol)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
SOVALDI
TYZEKA
valacyclovir hcl
capsule, tab ds pk: 400400mg, 600-400mg; tablet
PA, QL:
28 in 28
days
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
(Valtrex)
VALCYTE
Blood Products/modifiers/volume Expanders
Anticoagulants
CEPROTIN
ELIQUIS
enoxaparin sodium
(Lovenox)
enoxaparin sodium
(Lovenox)
enoxaparin sodium
(Lovenox)
enoxaparin sodium
(Lovenox)
enoxaparin sodium
(Lovenox)
enoxaparin sodium
(Lovenox)
fondaparinux sodium
(Arixtra)
fondaparinux sodium
(Arixtra)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 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
syringe: 40mg/0.4ml
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
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
58
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
fondaparinux sodium
(Arixtra)
fondaparinux sodium
(Arixtra)
heparin sod,pork in
0.45% nacl
heparin sodium,porcine
(Heparin Sod,pork In
0.45% NaCl)
(Hep-lock)
heparin sodium,porcine/
d5w
heparin sodium,porcine/
ns/pf
heparin sodium,porcine/
pf
heparin sodium,porcine/
pf
IPRIVASK
(Heparin Sodium,
porcine/D5W)
(Heparin Sodium,
porcine/ns/PF)
(Heparin Sodium,
porcine/PF)
(Monoject Prefill
Advanced)
PRADAXA
warfarin sodium
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
(Coumadin)
XARELTO
Blood Formation Modifiers
BERINERT
CINRYZE
QL: 18 in
30 days
QL: 24 in
30 days
syringe: 7.5mg/0.6
PA BvD
vial: 5000/ml, 10000/ml,
20000/ml, (PA for ESRD
Only)
iv soln: 20k/500ml, 25000/
250
syringe: 10mg/0.8ml
vial port
PA BvD
syringe: 5000/0.5ml, (PA
for ESRD Only)
PA, QL:
24 in 28
days
PA, QL:
60 in 30
days
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA, QL: 9
in 30 days
PA, QL:
20 in 28
days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
59
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
EPOGEN
$0 - $6.35
(Tier 2)
GRANIX
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
LEUKINE
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT
PROCRIT
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PROMACTA
Hematologic Agents, Miscellaneous
aminocaproic acid
(Amicar)
anagrelide hcl
(Agrylin)
protamine sulfate
(Protamine Sulfate)
tranexamic acid
(Lysteda)
tranexamic acid
(Tranexamic Acid)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA, QL:
12 in 28
days
vial: 250mcg
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)
QL: 30 in
30 days
tablet
vial
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
60
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
Platelet-aggregation Inhibitors
AGGRENOX
BRILINTA
cilostazol
(Pletal)
clopidogrel bisulfate
(Plavix)
EFFIENT
pentoxifylline
(Trental)
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN (HUMAN)
ALBUMINAR-25
ALBUMINAR-5
ALBURX
ALBUTEIN
BUMINATE
FLEXBUMIN
KEDBUMIN
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
QL: 60 in
30 days
QL: 30 in
30 days
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
61
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
PLASBUMIN-25
PLASBUMIN-5
STERILE DILUENT
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
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
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
PA BvD
iv soln: 10%
PA BvD
iv soln: 15%
PA BvD
iv soln: 7%
PA BvD
iv soln: 8.5%
PA BvD
iv soln: 8.5%
PA BvD
PA BvD
PA BvD
iv soln: 10%
PA BvD
iv soln: 3.5%
PA BvD
iv soln: 7%
PA BvD
iv soln: 8.5%
PA BvD
iv soln: 8.5%
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
62
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
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
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
PA BvD
iv soln: 10%
PA BvD
iv soln: 7%
PA BvD
PA BvD
iv soln: 2.75%
PA BvD
iv soln: 2.75%
PA BvD
iv soln: 4.25%
PA BvD
iv soln: 4.25%
PA BvD
iv soln: 4.25%
PA BvD
iv soln: 5%
PA BvD
iv soln: 5%
PA BvD
iv soln: 5%
PA BvD
iv soln: 5%
PA BvD
iv soln: 2.75%
PA BvD
iv soln: 4.25%
PA BvD
iv soln: 4.25%
PA BvD
iv soln: 4.25%
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
63
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINISOL
cysteine hcl
(Cysteine HCl)
dextrose 10 % and 0.2 %
nacl
dextrose 10 % and 0.9 %
nacl
dextrose 10%-0.5 normal
saline
dextrose 10%-water
(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
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 40%-water
(Dextrose 25 % in
Water)
(Dextrose 40%-water)
dextrose 5 % and 0.3 %
nacl
(Dextrose 5 % and 0.3 %
NaCl)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA BvD
iv soln: 4.25%
PA BvD
iv soln: 5%
PA BvD
iv soln: 5%
PA BvD
iv soln: 5%
PA BvD
PA BvD
dehp fr bg
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
64
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
dextrose 5 % and 0.9 %
nacl
dextrose 5 % in water
(Dextrose 5 % and 0.9 %
NaCl)
(Dextrose 5 % in Water)
dextrose 5 %-0.2 % nacl
(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
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
iv soln: 10%
PA BvD
iv soln: 8.5%
PA BvD
PA BvD
PA BvD
PA BvD
emulsion: 10%
PA BvD
emulsion: 20%, 30%
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
65
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
KABIVEN
LIPOSYN II
LIPOSYN III
LIPOSYN III
NEPHRAMINE
NOVAMINE
PERIKABIVEN
PREMASOL
PREMASOL
PROCALAMINE
PROSOL
QUICK MIX with
LYTES
TRAVAMULSION
TRAVASOL W/
DEXTROSE
TRAVASOL W/
ELECTROLYTES
TRAVASOL W/
ELECTROLYTES
TRAVASOL with
DEXTROSE
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
PA BvD
PA BvD
emulsion: 10%, 20%
PA BvD
emulsion: 30%
PA BvD
PA BvD
PA BvD
PA BvD
iv soln: 10%
PA BvD
iv soln: 6%
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
iv soln.: 5.5%
PA BvD
iv soln.: 8.5%
PA BvD
iv soln: 8.5%
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
66
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
TRAVASOL with
DEXTROSE
TRAVASOL with
DEXTROSE
TRAVASOL with
ELECTROLYTES
TRAVASOL
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
TRAVASOL
TRAVASOL
TRAVASOL
TRAVERT IN NORMAL
SALINE
TRAVERT
TRAVERT
TROPHAMINE
TROPHAMINE
PA BvD
iv soln: 8.5%
PA BvD
iv soln: 8.5%
PA BvD
PA BvD
iv soln.
PA BvD
iv soln: 10%
PA BvD
iv soln: 5.5%
PA BvD
iv soln: 8.5%
PA BvD
PA BvD
iv soln: 10%
PA BvD
iv soln: 5%
PA BvD
iv soln: 10%
PA BvD
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
Cardiovascular Agents
Alpha-adrenergic Agents
clonidine hcl
(Catapres)
clonidine hcl/
chlorthalidone
clonidine
(Clonidine HCl/
chlorthalidone)
(Catapres-tts 1)
clonidine
(Catapres-tts 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
67
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
doxazosin mesylate
(Cardura)
guanfacine hcl
(Tenex)
midodrine hcl
(Proamatine)
phenylephrine hcl *
phenylephrine hcl
(Sudafed Pe)
(Vazculep)
prazosin hcl
(Minipress)
Angiotensin Ii Receptor Antagonists
BENICAR HCT
BENICAR
candesartan cilexetil
(Atacand)
candesartan/
hydrochlorothiazid
DIOVAN
(Atacand HCT)
eprosartan mesylate
(Teveten)
irbesartan
(Avapro)
irbesartan/
hydrochlorothiazide
losartan potassium
(Avalide)
losartan/
hydrochlorothiazide
telmisartan
(Hyzaar)
(Cozaar)
(Micardis)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA
(High Risk Med for Ages 65
and Older)
tablet
vial
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
68
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
telmisartan/
hydrochlorothiazid
TRIBENZOR
(Micardis HCT)
valsartan/
(Diovan HCT)
hydrochlorothiazide
Angiotensin-converting Enzyme Inhibitors
benazepril hcl
(Lotensin)
benazepril/
hydrochlorothiazide
captopril
(Lotensin HCT)
captopril/
hydrochlorothiazide
enalapril maleate
(Capozide)
enalapril/
hydrochlorothiazide
enalaprilat dihydrate
(Vaseretic)
fosinopril sodium
(Monopril)
fosinopril/
hydrochlorothiazide
lisinopril
(Monopril HCT)
lisinopril/
hydrochlorothiazide
moexipril hcl
(Prinzide)
moexipril/
hydrochlorothiazide
(Uniretic)
(Capoten)
(Vasotec)
(Enalaprilat Dihydrate)
(Zestril)
(Univasc)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
69
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
perindopril erbumine
(Aceon)
quinapril hcl
(Accupril)
quinapril/
hydrochlorothiazide
ramipril
(Accuretic)
trandolapril
(Mavik)
(Altace)
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)
lidocaine hcl/pf
(Lidocaine HCl/PF)
mexiletine hcl
(Mexitil)
MULTAQ
procainamide hcl
(Procainamide HCl)
PRONESTYL
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
syringe
ampul, tablet
PA BvD
syringe, vial: 100mg/ml,
200mg/ml
vial: 20mg/ml, (PA for
ESRD Only)
vial
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
70
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
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)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
71
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
labetalol hcl
(Trandate)
metoprolol succinate
(Toprol XL)
metoprolol tartrate
(Lopressor)
metoprolol/
hydrochlorothiazide
nadolol
(Lopressor HCT)
pindolol
(Pindolol)
propranolol hcl
(Propranolol HCl)
propranolol/
hydrochlorothiazid
sotalol hcl
(Propranolol/
hydrochlorothiazid)
(Betapace)
(Corgard)
SOTALOL HCL
timolol maleate
(Timolol Maleate)
Calcium-Channel Blocking Agents
diltiazem hcl
(Cardizem CD)
verapamil hcl
(Calan)
verapamil hcl
(Verapamil HCl)
digoxin
Cardiovascular Agents, Miscellaneous
(Lanoxin)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
ampul, cap24h pct, cap24h
pel, tablet, tablet er
syringe
PA, QL:
30 in 30
days
tablet, (High Risk Med for
Ages 65 and Older and Dose
is Greater Than 125mcg Per
Day)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
72
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
digoxin
(Lanoxin)
DIGOXIN
dobutamine hcl
(Dobutamine HCl)
dobutamine hcl/d5w
(Dobutamine HCl/D5W)
dopamine hcl
(Dopamine HCl)
dopamine hcl/d5w
(Dopamine HCl/D5W)
dopamine hcl/dextrose
5%-water
ephedrine sulfate
(Dopamine HCl/dextrose
5%-water)
(Ephedrine Sulfate)
epinephrine
(Adrenaclick)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethanolamine oleate
(Ethanolamine Oleate)
FIRAZYR
hydralazine hcl
(Apresoline)
hydralazine/
hydrochlorothiazid
(Hydralazine/
hydrochlorothiazid)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA BvD
PA, QL:
75 in 30
days
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)
PA BvD
PA BvD
PA BvD
PA BvD
ampul
auto injct, syringe
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
73
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
LANOXIN
milrinone lactate
(Milrinone Lactate)
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/
benazepril
AZOR
(Lotrel)
CLEVIPREX
EXFORGE HCT
EXFORGE
felodipine
(Plendil)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
PA, QL:
30 in 30
days
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
(High Risk Med for Ages 65
and Older and Dose is
Greater Than 125mcg Per
Day)
PA BvD
PA BvD
PA
PA
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
74
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
isradipine
(Dynacirc)
nicardipine hcl
(Nicardipine HCl)
nifedipine
(Adalat CC)
nifedipine
(Procardia XL)
Diuretics
amiloride hcl
(Midamor)
amiloride/
hydrochlorothiazide
bumetanide
(Amiloride/
hydrochlorothiazide)
(Bumex)
chlorothiazide sodium
(Diuril Sodium)
chlorothiazide
(Chlorothiazide)
chlorthalidone
(Chlorthalidone)
DYRENIUM
furosemide
(Furosemide)
furosemide
(Lasix)
hydrochlorothiazide
(Hydrochlorothiazide)
indapamide
(Lozol)
methyclothiazide
(Methyclothiazide)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
tablet er: 90mg
tab er 24, tablet er: 30mg,
60mg
syringe: 10mg/ml
solution, syringe: 10mg/ml;
tablet, vial
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
75
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
metolazone
(Zaroxolyn)
torsemide
(Demadex)
triamterene/
hydrochlorothiazid
Dyslipidemics
amlodipine/atorvastatin
(Maxzide)
atorvastatin calcium
(Lipitor)
cholestyramine (with
sugar)
cholestyramine/
aspartame
colestipol hcl
(Questran)
(Caduet)
(Questran Light)
(Colestid)
CRESTOR
fenofibrate
nanocrystallized
fenofibrate
(Tricor)
fenofibrate,micronized
(Antara)
fenofibric acid (choline)
(Trilipix)
fenofibric acid
(Fibricor)
fluvastatin sodium
(Lescol)
gemfibrozil
(Lopid)
(Lofibra)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
tablet
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
76
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
KYNAMRO
lovastatin
(Mevacor)
niacin *
(Niacin)
niacin
(Niaspan)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
omega-3 acid ethyl esters (Lovaza)
$0 - $6.35
(Tier 1)
pravastatin sodium
(Pravachol)
$0 - $6.35
(Tier 1)
simvastatin
(Zocor)
$0 - $6.35
(Tier 1)
VASCEPA
$0 - $6.35
(Tier 2)
WELCHOL
$0 - $6.35
(Tier 2)
ZETIA
$0 - $6.35
(Tier 2)
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
$0 - $6.35
(Tier 1)
spironolact/
(Aldactazide)
$0 - $6.35
hydrochlorothiazid
(Tier 1)
spironolactone
(Aldactone)
$0 - $6.35
(Tier 1)
Vasodilators
isosorbide dinitrate
(Isordil)
$0 - $6.35
(Tier 1)
isosorbide mononitrate
(Imdur)
$0 - $6.35
(Tier 1)
PA, QL: 4
in 28 days
capsule er: 500mg; tablet:
500mg; tablet er: 750mg,
1000mg
tab er 24h, tablet: 500mg
QL: 30 in
30 days
tab subl: 2.5mg; tablet,
tablet er
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
77
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
minoxidil
(Minoxidil)
NITRO-BID
nitroglycerin
(Nitro-dur)
nitroglycerin
(Nitro-dur)
nitroglycerin
(Nitroglycerin)
nitroglycerin
(Nitroglycerin)
nitroglycerin/d5w
(Nitroglycerin/D5W)
NITROSTAT
nylidrin hcl
(Nylidrin HCl)
PROGLYCEM
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
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
vial: 50mg/10ml
vial: 5mg/ml
Central Nervous System Agents
Central Nervous System Agents
AMPYRA
caffeine citrated
(Cafcit)
caffeine/sodium benzoate (Caffeine/sodium
Benzoate)
clonidine hcl
(Kapvay)
dexmethylphenidate hcl
(Focalin)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA, QL:
60 in 30
days
QL: 60 in
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
78
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
dextroamphetamine
sulfate
dextroamphetamine
sulfate
dextroamphetamine/
amphetamine
dextroamphetamine/
amphetamine
flumazenil
(Dexedrine)
(Dexedrine)
(Adderall XR)
(Adderall)
(Romazicon)
INTUNIV
lithium carbonate
(Eskalith)
lithium citrate
(Lithium Citrate)
methylphenidate hcl
(Concerta)
methylphenidate hcl
(Concerta)
methylphenidate hcl
(Methylin)
methylphenidate hcl
(Ritalin)
methylphenidate hcl
(Ritalin)
NUEDEXTA
QUILLIVANT XR
riluzole
(Rilutek)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
QL: 120 in
30 days
QL: 180 in
30 days
QL: 30 in
30 days
QL: 60 in
30 days
capsule er
tablet
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
QL: 60 in
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
79
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
SAVELLA
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
STRATTERA
XENAZINE
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
norelgestromin/
ethin.estradiol
noreth-ethinyl estradiol/
iron
norethindrone ac-eth
estradiol
norethindrone
(Mircette)
(Desogen)
(Yaz)
(Demulen 1/50-28)
(Plan B)
(Nordette-8)
(Seasonale)
(Seasonique)
(Ortho Evra)
(Femcon Fe)
(Loestrin)
(Nor-Q-D)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
tablet: 0.75mg, 1.5mg
tablet
QL: 91 in
84 days
QL: 91 in
84 days
tbdspk 3mo
tbdspk 3mo: 150-30(84)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
80
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
norethindronee.estradiol-iron
norethindrone-ethinyl
estrad
norethindrone-mestranol
(Loestrin Fe)
norgestimate-ethinyl
estradiol
norgestrel-ethinyl
estradiol
NUVARING
(Ortho-cyclen)
(Modicon)
(Ortho-novum)
(Ovral-21)
ORTHO EVRA
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ST, QL: 1
in 28 days
ST, QL: 3
in 28 days
$0 (Tier 3)
PA NSO
Cough And Cold Products
Cough And Cold Products
d-methorphan hb/
(D-methorphan Hb/
prometh hcl *
prometh HCl)
guaifenesin/codeine
(M-clear Wc)
phosphate *
promethazine hcl/codeine (Promethazine HCl/
*
codeine)
promethazine/phenyleph/ (Promethazine/
codeine *
phenyleph/codeine)
pseudoephedrine hcl *
(Sudafed)
$0 (Tier 5)
liquid: 100-10mg/5
$0 (Tier 3)
PA NSO
$0 (Tier 3)
PA NSO
$0 (Tier 5)
PA NSO
liquid, tablet: 30mg
Dental And Oral Agents
Dental And Oral Agents
cevimeline hcl
(Evoxac)
chlorhexidine gluconate
(Peridex)
KEPIVANCE
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
81
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
pilocarpine hcl
(Salagen)
triamcinolone acetonide
(Triamcinolone
Acetonide)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
82
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
(Soriatane)
acyclovir
(Zovirax)
adapalene
(Adapalene)
alcohol antiseptic pads
aluminum chloride
(Alcohol Antiseptic
Pads)
(Drysol)
ammonium lactate
(Lac-hydrin)
ANACAINE
benzoyl peroxide *
calcipotriene
(Panoxyl)
(Dovonex)
calcipotriene/
betamethasone
calcitriol
(Taclonex)
(Vectical)
CARAC
CONDYLOX
DENAVIR
FLUOROPLEX
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
QL: 30 in
30 days
solution
cream (g): 12%; lotion: 12%
gel (gram): 10%
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
83
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
fluorouracil
(Efudex)
imiquimod
(Aldara)
LEVULAN
mafenide acetate
(Mafenide Acetate)
methoxsalen, rapid
(Oxsoralen-ultra)
METVIXIA
OXSORALEN-ULTRA
PANRETIN
PICATO
PICATO
podofilox
(Condylox)
podophyllum resin
(Pododerm)
potassium hydroxide
(Potassium Hydroxide)
SANTYL
silver nitrate applicator
(Silver Nitrate
Applicator)
UVADEX
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA NSO,
QL: 24 in
30 days
QL: 2 in
56 days
QL: 3 in
56 days
gel (ea): 0.05%
gel (ea): 0.015%
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
84
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
VALCHLOR
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
XERAC AC
ZOVIRAX
Dermatological Antibacterials
bacitracin zinc *
(Bacitracin Zinc)
clindamycin phos/benzoyl (Duac)
perox
clindamycin phosphate
(Cleocin T)
erythromycin base/
ethanol
erythromycin/benzoyl
peroxide
gentamicin sulfate
(Emgel)
metronidazole
(Nydamax)
mupirocin calcium
(Bactroban)
mupirocin
(Centany)
neomy sulf/polymyxin b
sulfate
selenium sulfide
(Neosporin G.U.
Irrigant)
(Selenium Sulfide)
silver nitrate
(Silver Nitrate)
silver sulfadiazine
(Silvadene)
sulfacetamide sodium
(Klaron)
(Benzamycin)
(Gentamicin Sulfate)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
QL: 15 in
30 days
ampul
suspension
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
85
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
THERMAZENE
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
Dermatological Anti-inflammatory Agents
alclometasone
(Aclovate)
dipropionate
APEXICON E
betamethasone
dipropionate
betamethasone valerate
(Del-beta)
clocortolone pivalate
(Cloderm)
(Betamethasone
Valerate)
betamethasone/propylene (Diprolene AF)
glyc
clobetasol propionate
(Temovate)
CLODERM
CORDRAN
desonide
(Desowen)
desoximetasone
(Topicort)
diflorasone diacetate
(Psorcon)
ELIDEL
fluocinonide
(Vanos)
fluticasone propionate
(Cutivate)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
med. tape
PA
(PA for Ages < 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
86
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
halobetasol propionate
(Ultravate)
hydrocortisone *
hydrocortisone *
(Hydrocortisone)
(Hydrocortisone)
hydrocortisone acetate *
(Hydrocortisone
Acetate)
(Hydrocortisone
Acetate)
(Nuzon)
hydrocortisone acetate
hydrocortisone acetate/
aloe v
hydrocortisone acetate/
urea
hydrocortisone butyrate
(Carmol HC)
hydrocortisone
(Hydrocortisone
Butyrate)
(Hydrocortisone
Valerate)
(Hydrocortisone)
hydrocortisone
(Hytone)
hydrocortisone/aloe vera
*
LOCOID
(Hydrocortisone/aloe
Vera)
mometasone furoate
(Elocon)
prednicarbate
(Dermatop)
hydrocortisone valerate
PROTOPIC
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 (Tier 5)
cream (g): 1%
cream (g): 1%; lotion: 1%;
oint. (g): 0.5%, 1%;
solution: 1%
cream (g), oint. (g)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
suppos.
cream(gm)
cream (g): 1%, 2.5%; cream/
appl, enema, lotion: 2%,
2.5%; oint. (g): 1%, 2.5%
$0 (Tier 5)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA
(0.03%; PA for Ages < 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
87
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
PROTOPIC
triamcinolone acetonide
triamcinolone acetonide
(Triamcinolone
Acetonide)
(Triderm)
Dermatological Retinoids
adapalene
(Differin)
TARGRETIN
TAZORAC
tretinoin microspheres
(Retin-a Micro)
tretinoin
(Retin-A)
Scabicides And Pediculicides
EURAX
malathion
(Ovide)
permethrin *
permethrin
(Nix)
(Elimite)
spinosad
(Natroba)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA
(0.1%; PA for Ages < 15)
cream (g), lotion, oint. (g):
0.025%, 0.1%, 0.5%
cream, oint. (g): 0.05%
PA NSO,
QL: 60 in
28 days
PA
PA
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
liquid
cream (g)
Devices
Devices
needles, insulin
disposable
NESSI SPACER *
(Needles, Insulin
Disposable)
$0 - $6.35
(Tier 1)
$0 (Tier 4)
QL: 2 in
365 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
88
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
syring wndl,disp,insul,0.3ml
syring wndl,disp,insul,0.5ml
syring w-o ndl,disp,insul,
1ml
(Syring Wndl,disp,insul,0.3ml)
(Syring Wndl,disp,insul,0.5ml)
(Syring W-o
Ndl,disp,insul, 1ml)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
Enzyme Replacement/modifiers
Enzyme Replacement/modifiers
ADAGEN
ALDURAZYME
CEREZYME
CHENODAL
CIMZIA
CREON
ELAPRASE
ELELYSO
ELITEK
FABRAZYME
KRYSTEXXA
KUVAN
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA, QL:
210 in 30
days
PA, QL: 3
in 28 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
89
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
LINZESS
lipase/protease/amylase
(Zenpep)
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
VIMIZIM
VPRIV
ZAVESCA
ZENPEP
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
QL: 30 in
30 days
PA BvD
PA
QL: 90 in
30 days
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Anti-infectives Agents
acetic acid
(Vosol)
$0 - $6.35
(Tier 1)
acetic acid/
(Vosol HC)
$0 - $6.35
hydrocortisone
(Tier 1)
bacitracin
(Bacitracin)
$0 - $6.35
(Tier 1)
bacitracin/polymyxin b
(Polycin-b)
$0 - $6.35
sulfate
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
90
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CIPRO HC
CIPRODEX
ciprofloxacin hcl
(Ciloxan)
COLY-MYCIN S
CORTISPORIN-TC
erythromycin base
(Ilotycin)
gatifloxacin
(Zymaxid)
gentamicin sulfate
(Garamycin)
levofloxacin
(Quixin)
MOXEZA
NATACYN
neo/polymyx b sulf/
dexameth
neomy sulf/bacitra/
polymyxin b
neomy sulf/bacitrac zn/
poly/hc
neomycin sulfate/dex na
ph
(Maxitrol)
(Neo-polycin)
(Triple Antibiotic HC)
(Neomycin Sulfate/dex
Na Ph)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
drops
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
91
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
neomycin/polymyxin b
sulf/hc
neomycin/polymyxn b/
gramicidin
ofloxacin
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
(Oticin HC)
$0 - $6.35
(Tier 1)
(Neosporin)
$0 - $6.35
(Tier 1)
(Floxin)
$0 - $6.35
(Tier 1)
polymyxin b sulf/
(Polytrim)
$0 - $6.35
trimethoprim
(Tier 1)
sulfacetamide sodium
(Sulfac)
$0 - $6.35
(Tier 1)
sulfacetamide/
(Sulfacetamide/
$0 - $6.35
prednisolone sp
prednisolone Sp)
(Tier 1)
tobramycin sulfate
(Tobramycin Sulfate)
$0 - $6.35
(Tier 1)
tobramycin/
(Tobradex)
$0 - $6.35
dexamethasone
(Tier 1)
trifluridine
(Viroptic)
$0 - $6.35
(Tier 1)
VIGAMOX
$0 - $6.35
(Tier 2)
ZYLET
$0 - $6.35
(Tier 2)
Eye, Ear, Nose, Throat Anti-inflammatory Agents
ALREX
$0 - $6.35
(Tier 2)
BROMDAY
$0 - $6.35
(Tier 2)
bromfenac sodium
(Bromfenac Sodium)
$0 - $6.35
(Tier 1)
dexamethasone sod
(Ak-dex)
$0 - $6.35
phosphate
(Tier 1)
diclofenac sodium
(Voltaren)
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
92
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
DUREZOL
fluorometholone
(FML)
flurbiprofen sodium
(Ocufen)
ILEVRO
ketorolac tromethamine
(Acular)
LOTEMAX
NEVANAC
prednisolone acetate
(Omnipred)
prednisolone sod
phosphate
PROLENSA
(Prednisol)
RESTASIS
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
Eye, Ear, Nose, Throat Drugs, Miscellaneous
AKTEN
$0 - $6.35
(Tier 2)
apraclonidine hcl
(Iopidine)
$0 - $6.35
(Tier 1)
atropine sulfate
(Isopto Atropine)
$0 - $6.35
(Tier 1)
azelastine hcl
(Astelin)
$0 - $6.35
(Tier 1)
azelastine hcl
(Optivar)
$0 - $6.35
(Tier 1)
PA, QL:
60 in 30
days
QL: 30 in
25 days
spray/pump
drops
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
93
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
carteolol hcl
(Carteolol HCl)
cromolyn sodium
(Cromolyn Sodium)
CYCLOGYL
cyclopentolate hcl
(Cyclogyl)
CYSTARAN
epinastine hcl
(Elestat)
homatropine hbr
(Isopto Homatropine)
ISOPTO
HOMATROPINE
LACRISERT
naphazoline hcl/
antazoline
PATADAY
(Naphazoline HCl/
antazoline)
PATANOL
phenylephrine hcl
(Mydfrin)
proparacaine hcl
(Ophthetic)
proparacaine/fluorescein (Proparacaine/
sod
fluorescein Sod)
tetracaine hcl/pf
(Tetracaine HCl/PF)
TYZINE
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
ST
ST
drops: 2.5%, 10%
drops: 0.05%
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
94
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
CARAFATE
cimetidine hcl
(Cimetidine HCl)
cimetidine in 0.9 % nacl
cimetidine
(Cimetidine In 0.9 %
NaCl)
(Tagamet)
esomeprazole sodium
(Nexium I.v.)
famotidine *
famotidine in nacl,isoosm/pf
famotidine
(Pepcid Ac)
(Famotidine In Nacl,isoosm/PF)
(Pepcid)
famotidine
(Pepcid)
lansoprazole
(Prevacid 24hr)
lansoprazole
(Prevacid)
lansoprazole/amoxiciln/
clarith
misoprostol
(Prevpac)
nizatidine
(Axid)
(Cytotec)
omeprazole *
(Omeprazole)
omeprazole magnesium * (Omeprazole
Magnesium)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 (Tier 5)
solution
tablet: 200mg, 300mg,
400mg, 800mg, (Rx
Product Only)
tablet: 20mg
oral susp, tablet: 20mg,
40mg; vial
oral susp, tablet: 20mg,
40mg; vial, (Rx Product
Only)
capsule dr: 15mg
capsule dr: 15mg, 30mg,
(Rx Product Only)
tablet dr
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
95
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
omeprazole
(Prilosec)
pantoprazole sodium
(Protonix)
PRILOSEC OTC *
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
ranitidine hcl *
ranitidine hcl
(Zantac)
(Zantac)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
sucralfate
(Carafate)
$0 - $6.35
(Tier 1)
Gastrointestinal Agents, Other
aluminum hydroxide *
(Alternagel)
AMITIZA
bismuth subsalicylate *
BUPHENYL
(Pepto-bismol)
CALCIUM *
calcium carbonate *
CARBAGLU
(Tums)
cromolyn sodium
(Gastrocrom)
dicyclomine hcl
(Bentyl)
diphenoxylate hcl/
atropine
FULYZAQ
(Lomotil)
glycopyrrolate
(Robinul)
$0 (Tier 5)
$0 - $6.35
(Tier 2)
$0 (Tier 5)
$0 - $6.35
(Tier 2)
$0 (Tier 5)
$0 (Tier 5)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
capsule dr
QL: 62 in
31 days
tablet: 150mg
capsule, syrup, tablet:
150mg, 300mg; vial, (Rx
Product Only)
tablet
QL: 60 in
30 days
tab chew: 500(1250)
QL: 60 in
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
96
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
isopropamide/
prochlorperazine
lactulose
(Isopropamide/
prochlorperazine)
(Lactulose)
lactulose
(Lactulose)
loperamide hcl
(Loperamide HCl)
mag hydrox/al hydrox/
simeth *
methscopolamine
bromide
metoclopramide hcl
(Rulox)
metoclopramide hcl
(Reglan)
(Pamine)
(Metoclopramide HCl)
mg trisilicate/alh/nahco3/ (Gaviscon)
aa *
NUTRESTORE
paregoric
(Paregoric)
RAVICTI
RELISTOR
sodium phenylbutyrate
(Buphenyl)
ursodiol
(Actigall)
Laxatives
bisacodyl *
docusate sodium *
(Dulcolax)
(Colace)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
solution: 10; syrup
solution: 10g/15ml
capsule: 2mg
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
disp syrin
solution, tablet, vial
tab chew: 20-80mg
PA
PA, QL:
28 in 28
days
syringe: 12mg/0.6ml
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 (Tier 5)
supp.rect
capsule: 100mg, 250mg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
97
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
MOVIPREP
peg 3350/na
sulf,bicarb,cl/kcl
polyethylene glycol 3350
(Golytely)
(Miralax)
sodium chloride/nahco3/ (Nulytely with Flavor
kcl/peg
Packs)
Phosphate Binders
calcium acetate
(Phoslo)
calcium carbonate/mag
carb/fa
PHOSLYRA
(Calcium Carbonate/mag
Carb/fa)
RENAGEL
RENVELA
sodium polystyrene
sulfonate
(Sodium Polystyrene
Sulfonate)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
powder: 17g/dose
oral susp
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
(Urispas)
oxybutynin chloride
(Ditropan)
tolterodine tartrate
(Detrol)
trospium chloride
(Sanctura)
VESICARE
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
98
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
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
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA BvD
Hormonal Agents, Stimulant/replacement/modifying
Androgens
ANADROL-50
ANDRODERM
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ANDROGEL
$0 - $6.35
(Tier 2)
ANDROGEL
$0 - $6.35
(Tier 2)
ANDROGEL
$0 - $6.35
(Tier 2)
PA, QL:
30 in 30
days
PA, QL:
150 in 30
days
PA, QL:
150 in 30
days
PA, QL:
300 in 30
days
gel md pmp
gel packet: 1.25g-1.62
gel packet: 50mg(1%)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
99
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
AXIRON
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
danazol
(Danocrine)
fluoxymesterone
(Fluoxymesterone)
oxandrolone
(Oxandrin)
testosterone cypionate
(Testosterone Cypionate)
testosterone enanthate
(Delatestryl)
Estrogens and Antiestrogens
COMBIPATCH
DUAVEE
ESTRACE
estradiol valerate
(Delestrogen)
estradiol
(Climara)
estradiol
(Estrace)
estradiol/norethindrone
acet
estradiol/norethindrone
acet
ESTRASORB
(Activella)
(Activella)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA, QL:
180 in 28
days
PA
PA, QL: 5
in 28 days
PA, QL: 8
in 28 days
PA
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
vial: 20mg/ml, 40mg/ml
PA, QL: 4
in 28 days
PA
patch tdwk, (High Risk
Med for Ages 65 and Older)
tablet, (High Risk Med for
Ages 65 and Older)
PA
PA
(High Risk Med for Ages 65
and Older)
PA, QL:
(High Risk Med for Ages 65
97.44 in 28 and Older)
days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
100
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
estropipate
(Ogen)
FEMRING
MENEST
norethindrone ac-eth
estradiol
PREMARIN
(Femhrt)
PREMARIN
PREMPHASE
PREMPRO
raloxifene hcl
(Evista)
VAGIFEM
VIVELLE-DOT
Glucocorticoids/mineralocorticoids
A-HYDROCORT
betamet acet/betamet na
ph
cortisone acetate
(Celestone)
dexamethasone acetate
(Dexamethasone
Acetate)
(Dexamethasone Sod
Phosphate)
dexamethasone sod
phosphate
(Cortisone Acetate)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA BvD
QL: 1 in
84 days
PA
PA
PA
PA
PA
QL: 18 in
28 days
PA, QL: 8
in 28 days
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
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)
PA BvD
PA BvD
PA BvD
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
101
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
dexamethasone
(Dexamethasone)
fludrocortisone acetate
(Fludrocortisone
Acetate)
(Hydrocortisone Sod
Succinate)
(Cortef)
hydrocortisone sod
succinate
hydrocortisone
methylprednisolone
acetate
methylprednisolone sod
succ
methylprednisolone
(Depo-medrol)
prednisolone acetate
(Prednisolone Acetate)
prednisolone sod
phosphate
prednisolone
(Orapred)
(A-methapred)
(Medrol)
(Prednisolone)
PREDNISONE
INTENSOL
prednisone
(Prednisone)
prednisone
(Sterapred Ds)
SOLU-CORTEF
SOLU-MEDROL
triamcinolone acetonide
(Triamcinolone
Acetonide)
UCERIS
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
vial: 500mg, 1000mg
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
solution, tablet
PA BvD
tab ds pk
PA BvD
PA BvD
PA BvD
ST
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
102
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
Pituitary
DDAVP
desmopressin
(nonrefrigerated)
desmopressin acetate
(DDAVP)
desmopressin acetate
(Desmopressin Acetate)
(DDAVP)
GENOTROPIN
HUMATROPE
INCRELEX
NORDITROPIN
FLEXPRO
NORDITROPIN
NORDIFLEX
NORDITROPIN
NOVAREL
NUTROPIN AQ
NUSPIN
NUTROPIN AQ
NUTROPIN
NUTROPIN
octreotide acetate
(Sandostatin)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
QL: 15 in
30 days
tablet, vial
QL: 15 in
30 days
PA
solution
PA
PA
PA
PA
PA
PA
PA
vial: 10mg
PA
vial: 5mg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
103
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
OMNITROPE
SAIZEN
SAIZEN
SANDOSTATIN LAR
SEROSTIM
SOMATULINE DEPOT
SOMAVERT
SUPPRELIN LA
TEV-TROPIN
VANTAS
vasopressin
(Pitressin)
ZORBTIVE
Progestins
DEPO-PROVERA
medroxyprogesterone
acet
medroxyprogesterone
acetate
medroxyprogesterone
acetate
(Medroxyprogesterone
Acet)
(Depo-provera)
(Depo-provera)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
QL: 10 in
28 days
PA
cartridge, vial: 5mg
PA
vial: 8.8mg
PA
QL: 1 in
28 days
vial: 10mg, 15mg, 20mg
QL: 1 in
360 days
PA
QL: 1 in
360 days
PA
QL: 1 in
84 days
QL: 1 in
84 days
syringe
vial
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
104
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
medroxyprogesterone
acetate
norethindrone acetate
(Provera)
progesterone
(Progesterone)
progesterone,micronized
(Prometrium)
(Aygestin)
Thyroid and Antithyroid Agents
levothyroxine sodium
(Levothyroxine Sodium)
levothyroxine sodium
(Levoxyl)
liothyronine sodium
(Cytomel)
methimazole
(Tapazole)
potassium iodide *
propylthiouracil
(Potassium Iodide)
(Propylthiouracil)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
tablet
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 4)
$0 - $6.35
(Tier 1)
vial: 200mcg, 500mcg
tablet, vial: 100mcg
tablet: 5mg, 10mg
solution: 1g/ml
Immunological Agents
Immunological Agents
ARCALYST
ASTAGRAF XL
AUBAGIO
azathioprine sodium
(Azathioprine Sodium)
azathioprine
(Imuran)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA BvD
PA, QL:
28 in 28
days
PA BvD
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
105
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
CARIMUNE NF
NANOFILTERED
CELLCEPT
CELLCEPT
cyclosporine
(Sandimmune)
cyclosporine, modified
(Neoral)
ENBREL
ENBREL
ENBREL
FLEBOGAMMA DIF
FLEBOGAMMA
GAMASTAN S-D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C
HUMIRA
HUMIRA
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
PA BvD
susp recon
PA BvD
vial
PA BvD
PA BvD
PA, QL:
7.84 in 28
days
PA, QL: 8
in 28 days
PA, QL:
8.16 in 28
days
PA BvD
pen injctr
vial
syringe
PA BvD
PA BvD
PA BvD
PA BvD
PA, QL: 4
in 28 days
PA, QL: 6
in 28 days
kit, pen ij kit: 40mg/0.8ml
pen ij kit: 40mg/0.8ml,
(Starter Kit)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
106
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
HYPERRAB S-D
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
HYPERRHO S-D
ILARIS
IMOGAM RABIES-HT
KINERET
leflunomide
(Arava)
MICRHOGAM ULTRAFILTERED PLUS
mycophenolate mofetil
(Cellcept)
mycophenolate sodium
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
(Myfortic)
NULOJIX
OCTAGAM
ORENCIA
ORENCIA
PRIVIGEN
PROGRAF
RAPAMUNE
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
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
syringe
vial
PA BvD
PA BvD
solution, tablet: 1mg, 2mg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
107
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
RHOGAM ULTRAFILTERED PLUS
RHOPHYLAC
RIDAURA
sirolimus
(Rapamune)
tacrolimus
(Hecoria)
TYSABRI
WINRHO SDF
ZORTRESS
Vaccines
ACTHIB
ADACEL TDAP
ADACEL TDAP
BCG VACCINE (TICE
STRAIN)
BOOSTRIX TDAP
CERVARIX
COMVAX
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
PA BvD
LA, PA,
QL: 15 in
28 days
PA BvD,
QL: 120 in
30 days
syringe
vial
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
108
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
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
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
PA BvD
syringe: 1440/ml
syringe: 720/0.5ml; vial
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
109
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
MENOMUNE-A-C-YW-135
MENVEO A-C-Y-W135-DIP
M-M-R II VACCINE
PEDIARIX
PEDVAXHIB
PENTACEL ACTHIB
COMPONENT
PENTACEL DTAP-IPV
COMPONENT
PENTACEL
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TE ANATOXAL
BERNA
TENIVAC
TETANUS
DIPHTHERIA
TOXOIDS
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA BvD
PA BvD
PA BvD
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
110
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
TETANUS TOXOID
ADSORBED
THERACYS
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
TWINRIX
TYPHIM VI
VAQTA
VARIVAX VACCINE
YF-VAX
ZOSTAVAX
PA BvD
PA BvD
syringe
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
balsalazide disodium
(Colazal)
budesonide
(Entocort EC)
DIPENTUM
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
ST
Irrigating Solutions
Irrigating Solutions
acetic acid
(Acetic Acid)
GLYCINE
LACTATED RINGERS
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
111
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
mannitol/sorbitol solution (Mannitol/sorbitol
Solution)
ringers solution
(Tis-u-sol)
sodium chloride irrig
solution
sorbitol solution
(Sodium Chloride Irrig
Solution)
(Sorbitol Solution)
urologic solution-g
(Urologic Solution-g)
water for
irrigation,sterile
(Water for Irrigation,
Sterile)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
irrig soln: 0.9%
irrig soln: n/a
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL
ACTONEL
ACTONEL
alendronate sodium
(Fosamax)
alendronate sodium
(Fosamax)
alendronate sodium
(Fosamax)
calcitonin,salmon,syntheti (Miacalcin)
c
calcitriol
(Rocaltrol)
doxercalciferol
(Hectorol)
etidronate disodium
(Didronel)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 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)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
112
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
FORTEO
FORTICAL
ibandronate sodium
(Boniva)
ibandronate sodium
(Ibandronate Sodium)
MIACALCIN
pamidronate disodium
(Aredia)
paricalcitol
(Zemplar)
PROLIA
risedronate sodium
(Actonel)
XGEVA
ZEMPLAR
zoledronic acid
(Zometa)
zoledronic acid/
mannitol&water
zoledronic acid/
mannitol&water
ZOMETA
(Reclast)
(Zoledronic Acid/
mannitol&water)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
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
tablet
vial, (PA for ESRD Only)
(PA for ESRD Only)
PA BvD
(PA for ESRD Only)
PA BvD
(PA for ESRD Only)
PA, QL: 1
in 180
days
QL: 1 in
28 days
PA, QL:
1.7 in 28
days
PA BvD
vial, (PA for ESRD Only)
QL: 100 in infus. btl
300 days
piggyback
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
113
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA
$0 - $6.35
(Tier 2)
ACTEMRA
$0 - $6.35
(Tier 2)
ACTIMMUNE
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
allopurinol sodium
(Aloprim)
allopurinol
(Zyloprim)
amifostine crystalline
(Ethyol)
ammonium chloride
(Ammonium Chloride)
AVODART
AVONEX
ADMINISTRATION
PACK
AVONEX
BENLYSTA
BETASERON
bethanechol chloride
(Urecholine)
BOTOX
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
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
vial: 200unit
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
114
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
BOTOX
buspirone hcl
(Buspar)
citrate phosphate dextros (Citrate Phosphate
soln
Dextros Soln)
colchicine/probenecid
(Colchicine/probenecid)
COLCRYS
COPAXONE
CYSTADANE
dexrazoxane
(Totect)
droperidol
(Droperidol)
DUODOTE
DYSPORT
ELMIRON
EXTAVIA
finasteride
(Proscar)
fomepizole
(Antizol)
FUSILEV
gauze bandage
(Gauze Bandage)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
QL: 4 in
90 days
vial: 100unit
ST
tablet: 5mg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
115
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
GILENYA
$0 - $6.35
(Tier 2)
GLUCAGEN
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
GLUCAGON
EMERGENCY KIT
glutethimide
(Glutethimide)
guanidine hcl
(Guanidine HCl)
H.P. ACTHAR
hydroxyzine hcl
(Hydroxyzine HCl)
hydroxyzine pamoate
(Vistaril)
JALYN
KALBITOR
leucovorin calcium
(Leucovorin Calcium)
levocarnitine (with sugar) (Carnitor)
levocarnitine
(Carnitor)
LITHOSTAT
mesna
(Mesnex)
MESNEX
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
PA, QL:
28 in 28
days
PA, QL:
35 in 28
days
PA
PA
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
QL: 30 in
30 days
PA BvD
(PA for ESRD Only)
PA BvD
tablet, vial, (PA for ESRD
Only)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
116
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
MESTINON
methylene blue
(Methylene Blue)
methylergonovine
maleate
MYOBLOC
(Methergine)
MYTELASE
neostigmine methylsulfate (Neostigmine
Methylsulfate)
NPLATE
OTEZLA
physostigmine salicylate
PRALIDOXIME
CHLORIDE
probenecid
(Physostigmine
Salicylate)
(Probenecid)
PROCYSBI
PROSTIGMIN
PROTOPAM
CHLORIDE
pyridostigmine bromide
(Mestinon)
REBIF REBIDOSE
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
tablet
QL: 1 in
90 days
PA, QL: 8
in 28 days
PA, QL:
60 in 30
days
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
117
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
REBIF
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
REGONOL
REMICADE
SENSIPAR
SIGNIFOR
SIMPONI ARIA
SIMPONI
$0 - $6.35
(Tier 2)
SIMPONI
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
SIMULECT
sodium morrhuate
(Sodium Morrhuate)
sodium tetradecyl sulfate
(Sodium Tetradecyl
Sulfate)
SOLIRIS
STELARA
STELARA
$0 - $6.35
(Tier 2)
SYNAREL
$0 - $6.35
(Tier 2)
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
PA, QL:
10 in 360
days
PA, QL: 5
in 360
days
pen injctr
syringe
syringe: 45mg/0.5ml
syringe: 90mg/ml
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
118
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
TECFIDERA
$0 - $6.35
(Tier 2)
TECFIDERA
$0 - $6.35
(Tier 2)
THALOMID
$0 - $6.35
(Tier 2)
ULORIC
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
VORAXAZE
XELJANZ
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
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
ST
(Drops: 0.15%, 0.20%)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
119
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
dorzolamide hcl
(Trusopt)
dorzolamide hcl/timolol
maleat
ISOPTO CARPINE
(Cosopt)
ISTALOL
latanoprost
(Xalatan)
levobunolol hcl
(Betagan)
LUMIGAN
methazolamide
(Neptazane)
metipranolol
(Optipranolol)
PHOSPHOLINE
IODIDE
pilocarpine hcl
(Isopto Carpine)
PILOPINE HS
SIMBRINZA
timolol maleate
(Timoptic)
TRAVATAN Z
travoprost
(benzalkonium)
(Travatan)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
drops: 0.5%
QL: 2.5 in
25 days
QL: 2.5 in
25 days
QL: 2.5 in
25 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
120
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
Replacement Preparations
Replacement Preparations
0.9 % sodium chloride
(0.9 % Sodium Chloride)
calcium carbonate *
(Caltrate 600)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
calcium carbonate/
vitamin d3 *
calcium chloride
(Os-cal 500+d)
$0 (Tier 5)
(Calcium Chloride)
calcium gluconate *
(Calcium Gluconate)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
calcium gluconate
(Calcium Gluconate)
calcium lactate *
(Calcium Lactate)
calcium phosphate dibas/ (Dical-d)
vit d3 *
citric acid/sodium citrate (Bicitra)
dex 2.5%-half str
lact.ringers
DEXTROSE W/
ELECTROLYTE A
DEXTROSE W/
ELECTROLYTE B
electrolyte-48 solution/
d5w
electrolyte-48/fructose
10%
electrolyte-48/fructose
5%
electrolyte-75 solution/
d5w
(Dex 2.5%-half Str
Lact.ringers)
(Electrolyte-48 Solution/
D5W)
(Electrolyte-48/fructose
10%)
(Electrolyte-48/fructose
5%)
(Electrolyte-75 Solution/
D5W)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 (Tier 5)
iv soln
capsule, oral susp, tablet:
260mg(648), 500(1250)
various dosage and/or
strengths are available
PA BvD
tablet: 45(500)mg,
60(648)mg
vial, (PA for ESRD Only)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
121
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
electrolyte-75/fructose
5%
HYPERLYTE CR
(Electrolyte-75/fructose
5%)
HYPERLYTE R
IONOSOL B with
DEXTROSE 5%
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 Chloride)
magnesium sulfate in
water
magnesium sulfate
(Magnesium Sulfate in
Water)
(Magnesium Sulfate)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
vial
infus. btl
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
122
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
magnesium sulfate
(Magnesium Sulfate)
magnesium sulfate/d5w
(Magnesium Sulfate/
D5W)
NORMOSOL-M and
DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE II
NUTRILYTE
phosphorus #1
(K-phos Neutral)
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
(Pot Chloride/pot
Bicarb/cit Ac)
(Potassium Acetate)
potassium bicarbonate/cit
ac
potassium chlorid/d100.2%nacl
potassium chloride in
0.9%nacl
potassium chloride in
d5w
(Potassium Bicarbonate/
cit Ac)
(Potassium Chlorid/d100.2%NaCl)
(Potassium Chloride In
0.9%NaCl)
(Potassium Chloride In
D5w)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
syringe, vial
iv soln: 20meq/l, 40meq/l
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
123
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
potassium chloride in lrd5
potassium chloride
(Potassium Chloride In
Lr-d5)
(Kaochlor)
potassium chloride
(K-dur)
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 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)
potassium phos,m-basicd-basic
ringers solution
(Potassium Phos,mbasic-d-basic)
(Ringers Solution)
(Potassium Gluconate)
SHOHL'S MODIFIED
sod/pot/k cit/sod cit/cit
acid
sodium acetate
(Polycitra-lc)
(Sodium Acetate)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 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
packet: 3300-1002
elixir
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
124
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
sodium bicarbonate
(Sodium Bicarbonate)
sodium chloride 0.45 %
sodium chloride 3%
(Sodium Chloride 0.45
%)
(Sodium Chloride 3%)
sodium chloride 5%
(Sodium Chloride 5%)
sodium chloride for
inhalation *
sodium chloride
(Pulmosal)
sodium chloride
(Sodium Chloride)
sodium lactate
(Sodium Lactate)
(Sodium Chloride)
SODIUM LACTATE
sodium phos,m-basic-dbasic
TPN ELECTROLYTES
TRAVERTELECTROLYTE NO.1
TRAVERTELECTROLYTE NO.2
TRAVERTELECTROLYTE NO.2
TRAVERTELECTROLYTE NO.3
TRAVERTELECTROLYTE NO.4
zinc sulfate *
(Sodium Phos,m-basicd-basic)
(Zinc Sulfate)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 5)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 (Tier 3)
vial-neb: 0.9%
vial: 2.5meq/ml
vial: 4meq/ml
iv soln: 10%
iv soln: 5%
capsule: 220(50)mg; tablet:
220mg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
125
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
zinc sulfate *
(Zinc Sulfate)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 (Tier 3)
tablet: 220mg
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
$0 - $6.35
(Tier 2)
ADVAIR HFA
$0 - $6.35
(Tier 2)
BREO ELLIPTA
$0 - $6.35
(Tier 2)
DULERA
$0 - $6.35
(Tier 2)
FLOVENT DISKUS
$0 - $6.35
(Tier 2)
FLOVENT DISKUS
$0 - $6.35
(Tier 2)
FLOVENT HFA
$0 - $6.35
(Tier 2)
FLOVENT HFA
$0 - $6.35
(Tier 2)
FLOVENT HFA
$0 - $6.35
(Tier 2)
flunisolide
(Nasarel)
$0 - $6.35
(Tier 1)
fluticasone propionate
(Flonase)
$0 - $6.35
(Tier 1)
NASONEX
$0 - $6.35
(Tier 2)
QNASL
$0 - $6.35
(Tier 2)
QVAR
$0 - $6.35
(Tier 2)
triamcinolone acetonide (Nasacort Aq)
$0 - $6.35
(Tier 1)
Antileukotrienes
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: 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
blst w/dev: 250mcg
blst w/dev: 50mcg, 100mcg
aer w/adap: 110mcg
aer w/adap: 44mcg
aer w/adap: 220mcg
spray: 25mcg
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
126
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
montelukast sodium
(Singulair)
zafirlukast
(Accolate)
Bronchodilators
albuterol sulfate *
albuterol sulfate
(Accuneb)
(Accuneb)
albuterol sulfate
(Albuterol Sulfate)
aminophylline
(Aminophylline)
ATROVENT HFA
COMBIVENT
RESPIMAT
COMBIVENT
FORADIL
ipratropium bromide
(Atrovent)
ipratropium bromide
(Atrovent)
metaproterenol sulfate
(Metaproterenol Sulfate)
PROAIR HFA
SEREVENT DISKUS
SPIRIVA
terbutaline sulfate
(Brethine)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 3)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
PA BvD
vial-neb: 2.5mg/3ml
solution, vial-neb: 0.63mg/
3ml, 1.25mg/3ml
syrup, tab er 12h, tablet
liquid
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
spray: 42mcg
spray: 21mcg
QL: 17 in
25 days
QL: 60 in
30 days
QL: 30 in
30 days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
127
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
theophylline anhydrous
(Theochron)
theophylline/d5w
(Theophylline/D5W)
VENTOLIN HFA
Respiratory Tract Agents, Other
acetylcysteine
(Acetadote)
ARALAST NP
cromolyn sodium
(Intal)
DALIRESP
KALYDECO
XOLAIR
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
ZEMAIRA
QL: 36 in
25 days
PA BvD
PA BvD
ampul-neb
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)
chlorzoxazone
(Parafon Forte DSC)
chlorzoxazone/
acetaminophen
(Chlorzoxazone/
acetaminophen)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA, QL:
120 in 30
days
PA
PA
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)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
128
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
cyclobenzaprine hcl
(Fexmid)
dantrolene sodium
(Dantrium)
metaxalone
(Skelaxin)
methocarbamol
(Robaxin)
tizanidine hcl
(Zanaflex)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA
(High Risk Med for Ages 65
and Older)
capsule
PA
(High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65
and Older)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
QL: 120 in tablet: 30mg
30 days
QL: 473 in elixir: 30mg/5ml
30 days
QL: 60 in tablet: 50mg
30 days
PA, QL:
60 in 30
days
PA
Sleep Disorder Agents
Sleep Disorder Agents
BUTISOL SODIUM
BUTISOL SODIUM
BUTISOL SODIUM
modafinil
(Provigil)
ROZEREM
XYREM
zaleplon
(Sonata)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 1)
LA
PA, QL:
60 in 30
days
(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)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
129
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
Name of Drug
zolpidem tartrate
(Ambien)
$0 - $6.35
(Tier 1)
PA, QL:
30 in 30
days
(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)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
PA
Vasodilating Agents
Vasodilating Agents
ADCIRCA
ADEMPAS
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
alprostadil
(Prostin Vr Pediatric)
epoprostenol sodium
(glycine)
ISOVEX
(Flolan)
LETAIRIS
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
PA, QL:
60 in 30
days
PA, QL:
90 in 30
days
PA
PA BvD
PA, QL:
30 in 30
days
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
130
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
OPSUMIT
$0 - $6.35
(Tier 2)
REMODULIN
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
REVATIO
sildenafil citrate
(Revatio)
$0 - $6.35
(Tier 1)
TRACLEER
$0 - $6.35
(Tier 2)
TYVASO
$0 - $6.35
(Tier 2)
$0 - $6.35
(Tier 2)
VENTAVIS
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
Vitamins and Minerals
Vitamins and Minerals
AQUA-MEPHYTON *
AQUASOL A *
ASCOR L 500 *
ascorbic acid *
(Ascor L Nc)
b cmplx 4/vit d3/c/fa/zinc (B Cmplx 4/vit D3/c/fa/
ox *
zinc Ox)
b complex & c no.20/folic (Nephrocaps)
acid *
b complex with vitamin c (B Complex with
*
Vitamin C)
cyanocobalamin (vitamin (Cyanocobalamin
b-12) *
(vitamin B-12))
cyanocobalamin *
(Cyanocobalamin)
$0 (Tier 4)
$0 (Tier 4)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
ampul: 10mg/ml
$0 (Tier 3)
capsule: 1mg
$0 (Tier 3)
capsule: n/a; vial: n/a
$0 (Tier 3)
vial
$0 (Tier 3)
vial
ampul, vial
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
131
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
cyanocobalamin/fa/
pyridoxine *
(Foltx)
$0 (Tier 3)
cyanocobalamin/
mecobalamin *
e ac succ/fa/vit bcomp&c/
zn/se *
ergocalciferol (vitamin
d2) *
fa/vit bcomp&c/se/min
aa/zn *
fe fumarate/cal/e/fa/
multivit *
fe fumarate/doss/fa/
bcomp&c *
fe fumarate/fa/vit
bcomp&c *
fe fumarate/vit c/b12/
stomc *
fe fumarate/vit c/b12-if/fa
*
ferrous fumarate/folic
acid *
ferrous sulfate *
ferrous sulfate/vit c/fa *
folic acid *
folic acid/mu-vits-min th
*
folic acid/vit bcomp&c/
cu/znox *
folic acid/vitamin b comp
w-c *
HEMOCYTE *
HEMOCYTE-F *
(Cyanocobalamin/
mecobalamin)
(E Ac Succ/fa/vit
Bcomp&c/zn/se)
(Drisdol)
$0 (Tier 3)
(Fa/vit Bcomp&c/se/min
Aa/zn)
(Fe Fumarate/cal/e/fa/
multivit)
(Fe Fumarate/doss/fa/
bcomp&c)
(Fe Fumarate/fa/vit
Bcomp&c)
(Chromagen)
$0 (Tier 3)
(Fe Fumarate/vit C/b12if/fa)
(Hemocyte-f)
$0 (Tier 3)
(Ferrous Sulfate)
(Ferrous Sulfate/vit C/fa)
(Folic Acid)
(Folic Acid/mu-vits-min
Th)
(Diatx Zn)
$0 (Tier 5)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
(Folic Acid/vitamin B
Comp W-c)
$0 (Tier 3)
tablet: 0.5-2.2-25, 1-2.225mg, 1-2.5-25mg, 2-2.525mg
$0 (Tier 3)
$0 (Tier 3)
capsule
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
capsule: 110-0.5mg
$0 (Tier 3)
solution, tablet
tablet er: 105-500-.8
tablet: 1mg; vial
$0 (Tier 3)
$0 (Tier 4)
$0 (Tier 4)
tablet: 0.5mg, 1mg-100mg,
5mg
solution
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
132
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
hydroxocobalamin *
iron ag&fum/c/fa/mv
cmb11/ca-t *
iron ag/c/b12/ca/suc.acid/
stom *
iron aspgly&ps/c/b12/fa/
ca/suc *
iron aspgly/c/b12/fa/cath/suc *
iron bg&ps/vit c/b12/fa/
ca thr *
iron fum & ag/c/b12/fa/
ca/succ *
iron fum & p/fa/vit b & c
no.9 *
iron fum & ps cmp/fa/vit
c/b3 *
iron fum&polysac#1/fa/
mv no.18 *
iron fumarate/vit c/vit
b12/fa *
iron ps cmplx/vit b12/fa *
iron,carb/dss/b12if/fa/mvmn *
iron/b cplx/b12/liver
extract *
iron/fa/vitamin b comp wc/min *
iron/liver ext/vit
bcomp&c/min *
LOZI-FLUR
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
(Hydroxocobalamin)
(Iron Ag&fum/c/fa/mv
Cmb11/ca-t)
(Iron Ag/c/b12/ca/
suc.acid/stom)
(Niferex-150 Forte)
$0 (Tier 3)
$0 (Tier 3)
vial: 1000mcg/ml
$0 (Tier 3)
tablet: 70-150-10
(Chromagen Fa)
$0 (Tier 3)
(Iron Bg&ps/vit C/b12/
fa/ca Thr)
(Chromagen Forte)
$0 (Tier 3)
(Integra Plus)
$0 (Tier 3)
(Integra F)
$0 (Tier 3)
(Tandem Plus)
$0 (Tier 3)
(Iron Fumarate/vit C/vit
B12/fa)
(Niferex-150 Forte)
(Hemax)
$0 (Tier 3)
(Iron/b Cplx/b12/liver
Extract)
(Iron/fa/vitamin B Comp
W-c/min)
(Iron/liver Ext/vit
Bcomp&c/min)
$0 (Tier 3)
MEPHYTON *
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 - $6.35
(Tier 1)
$0 (Tier 3)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
133
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
multivit, iron, min #5, fa * (Multivit, Iron, Min #5,
Fa)
multivit, iron, min #6, fa * (Multivit, Iron, Min #6,
Fa)
multivit, min cmb#20/
(Multivit, Min Cmb#20/
iron/fa *
iron/fa)
multivitamin *
(Multivitamin)
multivitamins with min
(Multivitamins with Min
no.7/fa *
No.7/fa)
multivits w(Multivits Wiron,hematinic *
iron,hematinic)
multivits,therap w(Multivits,therap Wfe,hematin *
fe,hematin)
multivits-min/fa/lycopene/ (Biocel)
lut *
NASCOBAL *
om-3/ca carb/d3/fa/mv
(Encora)
cmb 13 *
pedi m.vit no.17 with
(Pedi M.vit No.17 with
fluoride
Fluoride)
pedi mvi no.12/sodium
(Multivitamins with
fluoride
Fluoride)
PHYSICIANS EZ USE
B-12 *
phytonadione *
(Aqua-mephyton)
pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/
fa)
prenatal vit/iron
(Classic Prenatal)
fumarate/fa *
pyridoxine hcl *
(Pyridoxine HCl)
pyridoxine hcl *
(Pyridoxine HCl)
STROVITE ONE *
thiamine hcl *
(Thiamine HCl)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 5)
$0 (Tier 3)
PA
$0 (Tier 3)
drops
capsule
$0 (Tier 3)
$0 (Tier 3)
tablet: 800-250mcg
$0 (Tier 4)
$0 (Tier 3)
$0 - $6.35
(Tier 1)
$0 - $6.35
(Tier 1)
$0 (Tier 3)
$0 (Tier 3)
$0 - $6.35
(Tier 2)
$0 (Tier 5)
$0 (Tier 3)
$0 (Tier 5)
$0 (Tier 3)
$0 (Tier 3)
ampul
(All Rx Prenatal Vitamins
Covered)
PA
vial
tablet: 50mg
vial
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
134
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
Name of Drug
vit b cmplx 3/fa/vit c/
biotin *
vit b cmplx no3/fa/c/biot/
zinc *
vit b cplx #11/fa/c/biot/zn
ox *
vitamin b comp and vit c
no.6 *
vitamin b complex *
vitamins b1,b2,b3,b5,&
b6 *
VITA-RESPA *
(Vit B Cmplx 3/fa/vit C/
biotin)
(Vit B Cmplx No3/fa/c/
biot/zinc)
(Vit B Cplx #11/fa/c/
biot/zn Ox)
(Vitamin B Comp and
Vit C No.6)
(Vitamin B Complex)
(Vitamins
B1,b2,b3,b5,& B6)
What the
Drug Will Necessary Actions, Restrictions, or
Cost You
Limits on Use
(Tier Level)
$0 (Tier 3)
tablet: 1mg-60mg
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
$0 (Tier 3)
capsule: n/a; vial
$0 (Tier 3)
* = Not a Part D Drug; EX = Excluded Part D Drug; LA = Limited Access Drug; NM = Non Mail-order Drug;
PA = Prior Authorization Required; PA BvD = Prior Authorization Required for Part B vs Part D Coverage
Determination; PA NSO = Prior Authorization Required for New Starts Only; QL = Quantity Limit Applies;
ST = Step Therapy Required
135
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
INDEX
0.9 % sodium chloride ........ 121
8-MOP................................... 83
abacavir sulfate ..................... 53
abacavir/lamivudine/zidovudine
........................................... 53
ABELCET............................. 41
ABILIFY ............................... 50
ABILIFY DISCMELT .......... 50
ABILIFY MAINTENA ........ 50
ABRAXANE ........................ 18
acamprosate calcium .............. 8
acarbose ................................ 36
acebutolol hcl ........................ 71
acetaminophen * ..................... 1
acetaminophen with codeine ... 1
acetazolamide ..................... 119
acetazolamide sodium ......... 119
acetic acid ..................... 90, 111
acetic acid/hydrocortisone .... 90
acetylcysteine ...................... 128
acitretin ................................. 83
ACTEMRA ......................... 114
ACTHIB .............................. 108
ACTIMMUNE .................... 114
ACTONEL .......................... 112
ACTOPLUS MET XR .......... 41
acyclovir .......................... 57, 83
acyclovir sodium ................... 57
ADACEL TDAP ................. 108
ADAGEN .............................. 89
adapalene ........................ 83, 88
ADASUVE ........................... 50
ADCETRIS ........................... 18
ADCIRCA........................... 130
adefovir dipivoxil .................. 57
ADEMPAS ......................... 130
ADVAIR DISKUS.............. 126
ADVAIR HFA .................... 126
AFINITOR ............................ 18
AFINITOR DISPERZ ........... 18
AGGRENOX ........................ 61
A-HYDROCORT ............... 101
AKTEN ................................. 93
ALBENZA ............................ 48
ALBUKED-25 ...................... 61
ALBUKED-5 ........................ 61
ALBUMIN HUMAN ............ 61
ALBUMINAR-25 ................. 61
ALBUMINAR-5 ................... 61
ALBURX .............................. 61
ALBUTEIN........................... 61
albuterol sulfate .................. 127
albuterol sulfate * ............... 127
alclometasone dipropionate .. 86
alcohol antiseptic pads ......... 83
ALDURAZYME................... 89
alendronate sodium............. 112
ALFERON N ........................ 57
alfuzosin hcl ........................ 130
ALIMTA ............................... 18
ALINIA ................................. 48
allopurinol........................... 114
allopurinol sodium .............. 114
ALPHAGAN P ................... 119
alprazolam .............................. 9
alprostadil ........................... 130
ALREX ................................. 92
aluminum chloride ................ 83
aluminum hydroxide *........... 96
amantadine hcl ...................... 49
amifostine crystalline .......... 114
amiloride hcl ......................... 75
amiloride/hydrochlorothiazide
........................................... 75
AMINO ACIDS .................... 62
aminocaproic acid ................ 60
aminophylline...................... 127
AMINOSYN ......................... 62
AMINOSYN II ..................... 62
AMINOSYN M .................... 62
AMINOSYN with
ELECTROLYTES ............ 62
AMINOSYN-HBC ............... 63
AMINOSYN-PF ................... 63
AMINOSYN-RF ................... 63
amiodarone hcl ..................... 70
AMITIZA .............................. 96
amitriptyline hcl .................... 33
amlodipine besylate .............. 74
amlodipine besylate/benazepril
........................................... 74
amlodipine/atorvastatin ........ 76
ammonium chloride ............ 114
ammonium lactate ................. 83
amoxapine ............................. 34
amoxicillin............................. 16
amoxicillin trihydrate............ 15
amoxicillin/potassium clav.... 16
amphotericin b ...................... 41
ampicillin sodium .................. 16
ampicillin sodium/sulbactam na
........................................... 16
ampicillin trihydrate ............. 16
AMPYRA ............................. 78
ANACAINE .......................... 83
ANADROL-50 ...................... 99
anagrelide hcl ....................... 60
anastrozole ............................ 18
ANDRODERM ..................... 99
ANDROGEL......................... 99
ANORO ELLIPTA ............... 29
APEXICON E ....................... 86
APOKYN .............................. 49
apraclonidine hcl .................. 93
APRISO .............................. 111
APTIOM ............................... 30
APTIVUS .............................. 53
AQUA-MEPHYTON * ...... 131
AQUASOL A *................... 131
ARALAST NP .................... 128
ARCALYST ....................... 105
ARRANON ........................... 19
ARZERRA ............................ 19
I-1
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
ASCOR L 500 * .................. 131
ascorbic acid * .................... 131
aspirin * .................................. 5
aspirin/calcium carbonate/mag
*........................................... 5
ASTAGRAF XL ................. 105
atenolol ................................. 71
atenolol/chlorthalidone ......... 71
atorvastatin calcium.............. 76
atovaquone ............................ 48
atovaquone/proguanil hcl ..... 48
ATRIPLA .............................. 54
atropine sulfate ......... 29, 30, 93
ATROVENT HFA .............. 127
AUBAGIO .......................... 105
AVANDAMET ..................... 41
AVANDARYL ..................... 41
AVANDIA ............................ 41
AVASTIN ............................. 19
AVC ...................................... 45
AVELOX ABC PACK ......... 17
AVELOX IV ......................... 17
AVODART ......................... 114
AVONEX ............................ 114
AVONEX
ADMINISTRATION PACK
......................................... 114
AXIRON ............................. 100
azacitidine ............................. 19
azathioprine ........................ 105
azathioprine sodium ............ 105
azelastine hcl ......................... 93
AZILECT .............................. 49
azithromycin .......................... 14
AZOPT ................................ 119
AZOR .................................... 74
aztreonam .............................. 15
b cmplx 4/vit d3/c/fa/zinc ox *
......................................... 131
b complex & c no.20/folic acid
*....................................... 131
b complex with vitamin c *.. 131
bacitracin ........................ 11, 90
bacitracin zinc * .................... 85
bacitracin/polymyxin b sulfate
........................................... 90
baclofen ............................... 128
balsalazide disodium........... 111
BANZEL ............................... 30
BARACLUDE ...................... 57
BCG VACCINE TICE
STRAIN .......................... 108
BELEODAQ ......................... 19
benazepril hcl ........................ 69
benazepril/hydrochlorothiazide
........................................... 69
BENICAR ............................. 68
BENICAR HCT .................... 68
BENLYSTA ........................ 114
benzoyl peroxide * ................ 83
benztropine mesylate ............. 49
BERINERT ........................... 59
betamet acet/betamet na ph 101
betamethasone dipropionate . 86
betamethasone valerate ........ 86
betamethasone/propylene glyc
........................................... 86
BETASERON ..................... 114
betaxolol hcl .................. 71, 119
bethanechol chloride ........... 114
BETHKIS .............................. 10
BETIMOL ........................... 119
BEXXAR .............................. 19
bicalutamide.......................... 19
BICILLIN C-R ...................... 16
BICILLIN L-A ...................... 16
BICNU .................................. 19
BILTRICIDE ........................ 48
bisacodyl * ............................ 97
bismuth subsalicylate * ......... 96
bisoprolol fumarate............... 71
bisoprolol fumarate/hctz ....... 71
bleomycin sulfate .................. 19
BLEPHAMIDE ..................... 91
BLEPHAMIDE S.O.P. ......... 91
BOOSTRIX TDAP ............. 108
BOSULIF .............................. 19
BOTOX ....................... 114, 115
BREO ELLIPTA ................. 126
BRILINTA ............................ 61
brimonidine tartrate ............ 119
BRINTELLIX ....................... 34
BROMDAY .......................... 92
bromfenac sodium ................. 92
bromocriptine mesylate ......... 49
budesonide .......................... 111
bumetanide ............................ 75
BUMINATE ......................... 61
BUPHENYL ......................... 96
buprenorphine hcl ............... 1, 8
buprenorphine hcl/naloxone hcl
............................................. 8
bupropion hcl ........................ 34
buspirone hcl ....................... 115
BUSULFEX .......................... 19
butalb/acetaminophen/caffeine 1
butalbit/acetamin/caff/codeine 1
butalbital/acetaminophen ....... 1
butalbital/aspirin/caffeine ....... 5
BUTISOL SODIUM ........... 129
butorphanol tartrate................ 1
BUTRANS .............................. 1
BYDUREON ........................ 36
BYDUREON PEN ................ 36
BYETTA ............................... 36
BYSTOLIC ........................... 71
cabergoline ........................... 49
caffeine citrated .................... 78
caffeine/sodium benzoate ...... 78
calcipotriene ......................... 83
calcipotriene/betamethasone 83
calcitonin,salmon,synthetic . 112
calcitriol ........................ 83, 112
CALCIUM * ......................... 96
calcium acetate ..................... 98
calcium carbonate * ...... 96, 121
calcium carbonate/mag carb/fa
........................................... 98
calcium carbonate/vitamin d3 *
......................................... 121
calcium chloride.................. 121
calcium gluconate ............... 121
I-2
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
calcium gluconate * ............ 121
calcium lactate * ................. 121
calcium phosphate dibas/vit d3
*....................................... 121
CALDOLOR ........................... 5
CAMPRAL ............................. 8
CANCIDAS .......................... 41
candesartan cilexetil ............. 68
candesartan/hydrochlorothiazid
........................................... 68
CAPASTAT SULFATE ....... 46
CAPRELSA .......................... 19
captopril ................................ 69
captopril/hydrochlorothiazide
........................................... 69
CARAC ................................. 83
CARAFATE ......................... 95
CARBAGLU......................... 96
carbamazepine ...................... 30
carbidopa .............................. 49
carbidopa/levodopa .............. 49
carbidopa/levodopa/entacapone
........................................... 50
carbinoxamine maleate ......... 43
carboplatin ............................ 19
CARIMUNE NF
NANOFILTERED .......... 106
carisoprodol ........................ 128
carteolol hcl .......................... 94
carvedilol .............................. 71
CAYSTON............................ 15
CEENU ................................. 20
cefaclor ................................. 13
cefadroxil .............................. 13
cefazolin sodium.................... 13
cefazolin sodium/dextrose,iso 13
cefdinir .................................. 13
cefditoren pivoxil .................. 13
CEFEPIME ........................... 13
cefepime hcl .......................... 13
CEFEPIME-DEXTROSE ..... 13
cefotaxime sodium ................. 13
cefotetan disod/dextrose,iso .. 13
cefotetan disodium ................ 13
cefoxitin sodium .................... 13
cefoxitin sodium/dextrose,iso 14
cefpodoxime proxetil ............. 14
cefprozil................................. 14
ceftazidime pentahydrate ...... 14
ceftibuten dihydrate .............. 14
ceftriaxone na/dextrose,iso ... 14
ceftriaxone sodium ................ 14
cefuroxime axetil ................... 14
cefuroxime sodium ................ 14
cefuroxime sodium/dextrose,iso
........................................... 14
CELEBREX ............................ 5
CELLCEPT ......................... 106
CELONTIN........................... 30
cephalexin ............................. 14
CEPROTIN ........................... 58
CEREZYME ......................... 89
CERVARIX ........................ 108
CESAMET ............................ 46
cevimeline hcl........................ 81
CHANTIX............................... 8
CHENODAL......................... 89
chloramphenicol sod succ ..... 11
chlordiazepoxide hcl ............... 9
chlorhexidine gluconate ........ 81
chlorothiazide ....................... 75
chlorothiazide sodium ........... 75
chlorpheniramine maleate * . 43
chlorpromazine hcl ............... 51
chlorthalidone ....................... 75
chlorzoxazone ..................... 128
chlorzoxazone/acetaminophen
......................................... 128
cholestyramine (with sugar) . 76
cholestyramine/aspartame .... 76
choline sal/mag salicylate ....... 5
ciclopirox .............................. 42
ciclopirox olamine ................ 41
cidofovir ................................ 57
cilostazol ............................... 61
cimetidine .............................. 95
cimetidine hcl ........................ 95
cimetidine in 0.9 % nacl........ 95
CIMZIA ................................ 89
CINRYZE ............................. 59
CIPRO HC ............................ 91
CIPRODEX........................... 91
ciprofloxacin ......................... 17
ciprofloxacin hcl ............. 17, 91
ciprofloxacin lactate ............. 17
ciprofloxacin lactate/d5w...... 17
ciprofloxacin/ciprofloxa hcl .. 17
cisplatin ................................. 20
citalopram hydrobromide ..... 34
citrate phosphate dextros soln
......................................... 115
citric acid/sodium citrate .... 121
cladribine .............................. 20
clarithromycin ....................... 15
clemastine fumarate .............. 43
CLEVIPREX......................... 74
clindamycin hcl ..................... 11
clindamycin palmitate hcl ..... 11
clindamycin phos/benzoyl perox
........................................... 85
clindamycin phosphate... 11, 45,
85
clindamycin phosphate/d5w .. 12
CLINIMIX ...................... 63, 64
CLINIMIX E ......................... 63
CLINISOL ............................ 64
clobetasol propionate............ 86
clocortolone pivalate ............ 86
CLODERM ........................... 86
CLOLAR............................... 20
clomipramine hcl .................. 34
clonazepam ............................. 9
clonidine ................................ 67
clonidine hcl .................... 67, 78
clonidine hcl/chlorthalidone . 67
clopidogrel bisulfate ............. 61
clorazepate dipotassium.......... 9
clotrimazole........................... 42
clotrimazole *........................ 42
clotrimazole/betamethasone dip
........................................... 42
clozapine ............................... 51
I-3
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
COARTEM ........................... 48
cocaine hcl .............................. 7
codeine phos/acetaminophen .. 2
codeine sulfate ........................ 2
codeine/butalbital/asa/caffein . 2
colchicine/probenecid ......... 115
COLCRYS .......................... 115
colestipol hcl ......................... 76
colistin (colistimethate na) .... 12
COLY-MYCIN S .................. 91
COMBIGAN ....................... 119
COMBIPATCH .................. 100
COMBIVENT ..................... 127
COMBIVENT RESPIMAT 127
COMETRIQ .......................... 20
COMPLERA ......................... 54
COMVAX ........................... 108
CONDYLOX ........................ 83
CONEX * .............................. 43
COPAXONE ....................... 115
CORDRAN ........................... 86
COREG CR........................... 71
cortisone acetate ................. 101
CORTISPORIN-TC .............. 91
CREON ................................. 89
CRESTOR............................. 76
CRIXIVAN ........................... 54
cromolyn sodium ..... 94, 96, 128
CUBICIN .............................. 12
cyanocobalamin (vitamin b-12)
*....................................... 131
cyanocobalamin * ............... 131
cyanocobalamin/fa/pyridoxine *
......................................... 132
cyanocobalamin/mecobalamin
*....................................... 132
cyclobenzaprine hcl ............ 129
CYCLOGYL ......................... 94
cyclopentolate hcl ................. 94
cyclophosphamide ................. 20
CYCLOPHOSPHAMIDE..... 20
CYCLOSET .......................... 36
cyclosporine ........................ 106
cyclosporine, modified ........ 106
cyproheptadine hcl ................ 43
CYRAMZA........................... 20
CYSTADANE .................... 115
CYSTARAN ......................... 94
cysteine hcl ............................ 64
cytarabine/pf ......................... 20
dacarbazine ........................... 20
dactinomycin ......................... 20
DALIRESP ......................... 128
danazol ................................ 100
dantrolene sodium ............... 129
dapsone ................................. 46
DAPTACEL DTAP ............ 109
DARAPRIM ......................... 48
daunorubicin hcl ................... 20
DAUNOXOME .................... 20
DDAVP ............................... 103
decitabine .............................. 20
deferoxamine mesylate .......... 99
demeclocycline hcl ................ 18
DENAVIR............................. 83
DEPO-PROVERA .............. 104
desipramine hcl ..................... 34
desmopressin (nonrefrigerated)
......................................... 103
desmopressin acetate .......... 103
desog-e.estradiol/e.estradiol . 80
desogestrel-ethinyl estradiol . 80
desonide ................................ 86
desoximetasone ..................... 86
DESVENLAFAXINE ER..... 34
dex 2.5%-half str lact.ringers
......................................... 121
dexamethasone .................... 102
dexamethasone acetate ....... 101
dexamethasone sod phosphate
................................... 92, 101
dexmethylphenidate hcl ......... 78
dexrazoxane ........................ 115
dextroamphetamine sulfate ... 79
dextroamphetamine/
amphetamine ..................... 79
dextrose 10 % and 0.2 % nacl
........................................... 64
dextrose 10 % and 0.9 % nacl
........................................... 64
dextrose 10%-0.5 normal saline
........................................... 64
dextrose 10%-water .............. 64
dextrose 2.5 % in water ........ 64
dextrose 2.5% in half ringers 64
dextrose 2.5%-0.5normal saline
........................................... 64
dextrose 20%-water .............. 64
dextrose 25 % in water ......... 64
dextrose 40%-water .............. 64
dextrose 5 % and 0.3 % nacl 64
dextrose 5 % and 0.9 % nacl 65
dextrose 5 % in water ........... 65
dextrose 5 %-0.2 % nacl ....... 65
dextrose 5 %-0.45 % nacl ..... 65
dextrose 5% in ringers .......... 65
dextrose 5%-lactated ringers 65
dextrose 50 % in water ......... 65
dextrose 60 % in water ......... 65
dextrose 70%-water .............. 65
DEXTROSE W/
ELECTROLYTE A ........ 121
DEXTROSE W/
ELECTROLYTE B ......... 121
DIASTAT ACUDIAL ............ 9
diazepam ........................... 9, 10
diclofenac potassium ............... 5
diclofenac sodium ............. 5, 92
diclofenac sodium/misoprostol 6
dicloxacillin sodium .............. 16
dicyclomine hcl ..................... 96
didanosine ............................. 54
DIFICID ................................ 15
diflorasone diacetate ............. 86
diflunisal ................................. 6
digoxin............................. 72, 73
DIGOXIN ............................. 73
dihydroergotamine mesylate . 45
DILANTIN ........................... 30
diltiazem hcl .......................... 72
dimenhydrinate ..................... 47
DIOVAN ............................... 68
I-4
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
DIPENTUM ........................ 111
diphenhydramine hcl ............. 44
diphenhydramine hcl * .... 43, 44
diphenoxylate hcl/atropine.... 96
DIPHTHERIA-TETANUS
TOXOIDS-PED .............. 109
disopyramide phosphate ....... 70
disulfiram ................................ 8
divalproex sodium ................. 30
d-methorphan hb/prometh hcl *
........................................... 81
dobutamine hcl ...................... 73
dobutamine hcl/d5w .............. 73
DOCEFREZ .......................... 20
docetaxel ............................... 21
docusate sodium * ................. 97
donepezil hcl ......................... 33
dopamine hcl ......................... 73
dopamine hcl/d5w ................. 73
dopamine hcl/dextrose 5%water ................................. 73
dorzolamide hcl ................... 120
dorzolamide hcl/timolol maleat
......................................... 120
doxazosin mesylate................ 68
doxepin hcl ............................ 34
doxercalciferol .................... 112
doxorubicin hcl ..................... 21
doxorubicin hcl peg-liposomal
........................................... 21
doxycycline hyclate ............... 18
doxycycline monohydrate...... 18
dronabinol ............................. 47
droperidol ........................... 115
DROXIA ............................... 21
DUAVEE ............................ 100
DULERA ............................ 126
duloxetine hcl ........................ 34
DUODOTE ......................... 115
DUREZOL ............................ 93
DUTOPROL ......................... 71
DYRENIUM ......................... 75
DYSPORT .......................... 115
e ac succ/fa/vit bcomp&c/zn/se
*....................................... 132
econazole nitrate ................... 42
edetate disodium ................... 99
EDURANT ........................... 54
EFFIENT............................... 61
ELAPRASE .......................... 89
electrolyte-48 solution/d5w . 121
electrolyte-48/fructose 10% 121
electrolyte-48/fructose 5% .. 121
electrolyte-75 solution/d5w . 121
electrolyte-75/fructose 5% .. 122
ELELYSO ............................. 89
ELIDEL................................. 86
ELIGARD ............................. 21
ELIQUIS ............................... 58
ELITEK................................. 89
ELMIRON .......................... 115
ELSPAR ................................ 21
EMCYT................................. 21
EMEND ................................ 47
EMSAM ................................ 34
EMTRIVA ............................ 54
enalapril maleate .................. 69
enalapril/hydrochlorothiazide
........................................... 69
enalaprilat dihydrate ............ 69
ENBREL ............................. 106
ENGERIX-B ADULT ........ 109
ENGERIX-B PEDIATRICADOLESCENT .............. 109
enoxaparin sodium ................ 58
entacapone ............................ 50
entecavir ................................ 57
ephedrine sulfate ................... 73
epinastine hcl ........................ 94
epinephrine ........................... 73
EPIPEN 2-PAK ..................... 73
EPIPEN JR 2-PAK ............... 73
epirubicin hcl ........................ 21
EPIVIR .................................. 54
EPIVIR HBV ........................ 54
eplerenone ............................. 77
EPOGEN ............................... 60
epoprostenol sodium (glycine)
......................................... 130
eprosartan mesylate .............. 68
EPZICOM ............................. 54
ERAXIS WATER DILUENT42
ERBITUX ............................. 21
ergocalciferol (vitamin d2) *
......................................... 132
ERGOMAR........................... 45
ERIVEDGE........................... 21
ERWINAZE .......................... 21
ery e-succ/sulfisoxazole ........ 15
ERY-TAB ............................. 15
ERYTHROCIN
LACTOBIONATE ............ 15
erythromycin base ........... 15, 91
erythromycin base/ethanol .... 85
erythromycin ethylsuccinate . 15
erythromycin stearate ........... 15
erythromycin/benzoyl peroxide
........................................... 85
escitalopram oxalate ............. 34
esmolol hcl ............................ 71
esomeprazole sodium ............ 95
estazolam............................... 10
ESTRACE ........................... 100
estradiol .............................. 100
estradiol valerate ................ 100
estradiol/norethindrone acet100
ESTRASORB ..................... 100
estropipate........................... 101
ethambutol hcl ....................... 46
ethanolamine oleate .............. 73
ethinyl estradiol/drospirenone
........................................... 80
ethosuximide ......................... 30
ethynodiol d-ethinyl estradiol 80
etidronate disodium ............ 112
etodolac ................................... 6
ETOPOPHOS ....................... 21
etoposide ............................... 21
EURAX ................................. 88
EXELDERM ......................... 42
EXELON............................... 33
I-5
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
exemestane ............................ 22
EXFORGE ............................ 74
EXFORGE HCT ................... 74
EXJADE ............................... 99
EXTAVIA ........................... 115
fa/vit bcomp&c/se/min aa/zn *
......................................... 132
FABRAZYME ...................... 89
famciclovir ............................ 57
famotidine ............................. 95
famotidine * .......................... 95
famotidine in nacl,iso-osm/pf 95
FANAPT ............................... 51
FARESTON .......................... 22
FASLODEX .......................... 22
FAZACLO ............................ 51
fe fumarate/cal/e/fa/multivit *
......................................... 132
fe fumarate/doss/fa/bcomp&c *
......................................... 132
fe fumarate/fa/vit bcomp&c *
......................................... 132
fe fumarate/vit c/b12/stomc *
......................................... 132
fe fumarate/vit c/b12-if/fa * 132
felbamate ............................... 30
felodipine............................... 74
FEMRING........................... 101
fenofibrate ............................. 76
fenofibrate nanocrystallized.. 76
fenofibrate,micronized .......... 76
fenofibric acid ....................... 76
fenofibric acid (choline) ........ 76
fenoprofen calcium.................. 6
fentanyl .................................... 2
fentanyl citrate ........................ 2
FERRIPROX......................... 99
ferrous fumarate/folic acid *
......................................... 132
ferrous sulfate * .................. 132
ferrous sulfate/vit c/fa * ...... 132
FETZIMA ............................. 34
finasteride ........................... 115
FIRAZYR ............................. 73
FIRMAGON ......................... 22
flavoxate hcl .......................... 98
FLEBOGAMMA ................ 106
FLEBOGAMMA DIF ......... 106
flecainide acetate .................. 70
FLECTOR ............................... 6
FLEXBUMIN ....................... 61
FLOVENT DISKUS ........... 126
FLOVENT HFA ................. 126
floxuridine ............................. 22
fluconazole ............................ 42
fluconazole in nacl,iso-osm... 42
flucytosine ............................. 42
fludarabine phosphate .......... 22
fludrocortisone acetate ....... 102
flumazenil .............................. 79
flunisolide............................ 126
fluocinonide........................... 86
fluorometholone .................... 93
FLUOROPLEX..................... 83
fluorouracil ..................... 22, 84
fluoxetine hcl ......................... 34
fluoxymesterone .................. 100
fluphenazine decanoate ......... 51
fluphenazine hcl .................... 51
flurazepam hcl ....................... 10
flurbiprofen ............................. 6
flurbiprofen sodium............... 93
flutamide ............................... 22
fluticasone propionate .. 86, 126
fluvastatin sodium ................. 76
fluvoxamine maleate ............. 34
folic acid *........................... 132
folic acid/mu-vits-min th * .. 132
folic acid/vit bcomp&c/cu/znox
*....................................... 132
folic acid/vitamin b comp w-c *
......................................... 132
FOLOTYN ............................ 22
fomepizole ........................... 115
fondaparinux sodium ...... 58, 59
FORADIL ........................... 127
FORTEO ............................. 113
FORTICAL ......................... 113
foscarnet sodium ................... 56
fosinopril sodium .................. 69
fosinopril/hydrochlorothiazide
........................................... 69
fosphenytoin sodium.............. 30
FREAMINE HBC ................. 65
FREAMINE III ..................... 65
fructose 10% ......................... 65
FULYZAQ ............................ 96
furosemide ............................. 75
FUROXONE ......................... 12
FUSILEV ............................ 115
FUZEON ............................... 54
FYCOMPA ........................... 30
gabapentin............................. 30
GABITRIL ............................ 30
galantamine hbr .................... 33
GALZIN ................................ 99
GAMASTAN S-D .............. 106
GAMMAGARD LIQUID... 106
GAMMAPLEX ................... 106
GAMUNEX-C .................... 106
ganciclovir sodium ................ 57
GARDASIL ........................ 109
gatifloxacin ........................... 91
gauze bandage .................... 115
GAZYVA .............................. 22
gemcitabine hcl ..................... 22
gemfibrozil ............................ 76
GENOTROPIN ................... 103
gentamicin in nacl, iso-osm .. 11
gentamicin sulfate ..... 11, 85, 91
gentamicin sulfate/pf ............. 11
GEODON .............................. 51
GILENYA ........................... 116
GILOTRIF ............................ 22
GLEEVEC ............................ 22
glimepiride ............................ 40
glipizide ................................. 40
glipizide/metformin hcl ......... 40
GLUCAGEN....................... 116
GLUCAGON EMERGENCY
KIT .................................. 116
glutethimide......................... 116
I-6
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
glyburide ............................... 40
glyburide,micronized ............ 40
glyburide/metformin hcl ........ 40
GLYCINE ........................... 111
glycopyrrolate ....................... 96
GLYSET ............................... 36
granisetron hcl ...................... 47
granisetron hcl/pf .................. 47
GRANIX ............................... 60
griseofulvin ultramicrosize ... 42
griseofulvin, microsize .......... 42
guaifenesin/codeine phosphate
*......................................... 81
guanfacine hcl ....................... 68
guanidine hcl ....................... 116
H.P. ACTHAR .................... 116
HALAVEN ........................... 22
HALFAN .............................. 48
halobetasol propionate ......... 87
haloperidol ............................ 51
haloperidol decanoate .......... 51
haloperidol lactate ................ 51
HAVRIX ............................. 109
HEMOCYTE * ................... 132
HEMOCYTE-F * ................ 132
heparin sod,pork in 0.45% nacl
........................................... 59
heparin sodium,porcine ........ 59
heparin sodium,porcine/d5w. 59
heparin sodium,porcine/ns/pf 59
heparin sodium,porcine/pf .... 59
HEPATAMINE..................... 65
HEPATASOL ....................... 65
HERCEPTIN......................... 23
HEXALEN ............................ 23
homatropine hbr.................... 94
HUMALOG .......................... 38
HUMALOG MIX 50-50 ....... 38
HUMALOG MIX 75-25 ....... 38
HUMATROPE .................... 103
HUMIRA ............................ 106
HUMULIN 70-30 ........... 38, 39
HUMULIN N ........................ 39
HUMULIN R ........................ 39
hydralazine hcl ...................... 73
hydralazine/hydrochlorothiazid
........................................... 73
hydrochlorothiazide .............. 75
hydrocodone/acetaminophen .. 2
hydrocodone/ibuprofen ........... 2
hydrocortisone .............. 87, 102
hydrocortisone * ................... 87
hydrocortisone acetate .......... 87
hydrocortisone acetate * ....... 87
hydrocortisone acetate/aloe v 87
hydrocortisone acetate/urea . 87
hydrocortisone butyrate ........ 87
hydrocortisone sod succinate
......................................... 102
hydrocortisone valerate ........ 87
hydrocortisone/aloe vera * ... 87
hydromorphone hcl ............. 2, 3
hydromorphone hcl/pf ............. 3
hydroxocobalamin *............ 133
hydroxychloroquine sulfate ... 48
hydroxyurea .......................... 23
hydroxyzine hcl ................... 116
hydroxyzine pamoate .......... 116
HYPERLYTE CR ............... 122
HYPERLYTE R.................. 122
HYPERRAB S-D ................ 107
HYPERRHO S-D................ 107
ibandronate sodium ............ 113
ibuprofen ................................. 6
ibuprofen * .............................. 6
ibuprofen/oxycodone hcl ......... 3
ICLUSIG ............................... 23
idarubicin hcl ........................ 23
ifosfamide .............................. 23
ifosfamide/mesna................... 23
ILARIS ................................ 107
ILEVRO ................................ 93
IMBRUVICA ........................ 23
imipenem/cilastatin sodium .. 15
imipramine hcl ...................... 35
imipramine pamoate ............. 35
imiquimod ............................. 84
IMOGAM RABIES-HT...... 107
IMOVAX RABIES VACCINE
......................................... 109
INCIVEK .............................. 56
INCRELEX ......................... 103
indapamide ............................ 75
indomethacin ........................... 6
indomethacin sodium .............. 6
INFANRIX DTAP .............. 109
INFANRIX PF .................... 109
INLYTA ................................ 23
INTELENCE......................... 54
INTRALIPID ........................ 65
INTRON A............................ 57
INTUNIV .............................. 79
INVANZ ............................... 15
INVEGA ............................... 52
INVEGA SUSTENNA ... 51, 52
INVIRASE ............................ 54
INVOKAMET ...................... 37
INVOKANA ......................... 37
IONOSOL B with DEXTROSE
5% ................................... 122
IONOSOL MB-DEXTROSE
5% ................................... 122
IONOSOL T-DEXTROSE 5%
......................................... 122
IPOL .................................... 109
ipratropium bromide ........... 127
IPRIVASK ............................ 59
irbesartan .............................. 68
irbesartan/hydrochlorothiazide
........................................... 68
irinotecan hcl ........................ 23
iron ag&fum/c/fa/mv cmb11/cat * .................................... 133
iron ag/c/b12/ca/suc.acid/stom
*....................................... 133
iron aspgly&ps/c/b12/fa/ca/suc
*....................................... 133
iron aspgly/c/b12/fa/ca-th/suc *
......................................... 133
iron bg&ps/vit c/b12/fa/ca thr *
......................................... 133
I-7
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
iron fum & ag/c/b12/fa/ca/succ
*....................................... 133
iron fum & p/fa/vit b & c no.9 *
......................................... 133
iron fum & ps cmp/fa/vit c/b3 *
......................................... 133
iron fum&polysac#1/fa/mv
no.18 *............................. 133
iron fumarate/vit c/vit b12/fa *
......................................... 133
iron ps cmplx/vit b12/fa * ... 133
iron,carb/dss/b12if/fa/mv-mn *
......................................... 133
iron/b cplx/b12/liver extract *
......................................... 133
iron/fa/vitamin b comp w-c/min
*....................................... 133
iron/liver ext/vit bcomp&c/min
*....................................... 133
ISENTRESS .......................... 54
ISOLYTE E ........................ 122
ISOLYTE H W/DEXTROSE
......................................... 122
ISOLYTE M W/DEXTROSE
......................................... 122
ISOLYTE P with DEXTROSE
......................................... 122
ISOLYTE R W/DEXTROSE
......................................... 122
ISOLYTE S ......................... 122
ISOLYTE S with DEXTROSE
......................................... 122
isoniazid ................................ 46
isopropamide/prochlorperazine
........................................... 97
ISOPTO CARPINE ............ 120
ISOPTO HOMATROPINE .. 94
isosorbide dinitrate ............... 77
isosorbide mononitrate ......... 77
ISOVEX .............................. 130
isradipine .............................. 75
ISTALOL ............................ 120
ISTODAX ............................. 23
itraconazole........................... 42
IXEMPRA............................. 23
IXIARO............................... 109
JAKAFI ................................. 24
JALYN ................................ 116
JANUMET ............................ 37
JANUMET XR ..................... 37
JANUVIA ............................. 37
JENTADUETO ..................... 37
JE-VAX............................... 109
JEVTANA............................. 24
JUVISYNC ........................... 37
KABIVEN............................. 66
KADCYLA ........................... 24
KALBITOR ........................ 116
KALETRA ............................ 54
KALYDECO....................... 128
kanamycin sulfate.................. 11
KEDBUMIN ......................... 61
KEPIVANCE ........................ 81
KETEK ................................. 15
ketoconazole .......................... 42
ketoprofen ............................... 6
ketorolac tromethamine .... 6, 93
KHEDEZLA ......................... 35
KINERET ........................... 107
KINRIX............................... 109
KORLYM ............................. 37
K-PHOS NO.2 .................... 122
KRYSTEXXA ...................... 89
KUVAN ................................ 89
KYNAMRO .......................... 77
KYPROLIS ........................... 24
labetalol hcl .......................... 72
LACRISERT ......................... 94
LACTATED RINGERS ..... 111
lactulose ................................ 97
LAMICTAL .......................... 30
lamivudine ............................. 54
lamivudine/zidovudine .......... 54
lamotrigine ...................... 30, 31
LANOXIN ............................ 74
lansoprazole .......................... 95
lansoprazole/amoxiciln/clarith
........................................... 95
LANTUS ............................... 39
LANTUS SOLOSTAR ......... 39
latanoprost .......................... 120
LATUDA .............................. 52
LAZANDA ............................. 3
leflunomide .......................... 107
LETAIRIS ........................... 130
letrozole................................. 24
leucovorin calcium .............. 116
LEUKERAN ......................... 24
LEUKINE ............................. 60
leuprolide acetate.................. 24
LEVEMIR ............................. 39
LEVEMIR FLEXPEN .......... 39
levetiracetam ......................... 31
levetiracetam in nacl (iso-os) 31
levobunolol hcl .................... 120
levocarnitine ....................... 116
levocarnitine (with sugar) ... 116
levocetirizine dihydrochloride
........................................... 44
levofloxacin ..................... 17, 91
levofloxacin/d5w ................... 17
levonorgestrel ....................... 80
levonorgestrel-ethin estradiol 80
levorphanol tartrate ................ 3
levothyroxine sodium .......... 105
LEVULAN ............................ 84
LEXIVA ................................ 54
lidocaine .................................. 7
lidocaine hcl ............................ 7
lidocaine hcl/d5w/pf .............. 70
lidocaine hcl/pf.................. 7, 70
lidocaine/prilocaine ................ 7
LIDODERM ........................... 8
LINZESS............................... 90
liothyronine sodium ............ 105
lipase/protease/amylase ........ 90
LIPOSYN II .......................... 66
LIPOSYN III ......................... 66
lisinopril ................................ 69
lisinopril/hydrochlorothiazide
........................................... 69
lithium carbonate .................. 79
I-8
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
lithium citrate ........................ 79
LITHOSTAT....................... 116
l-norgest-eth estr/ethin estra . 80
LOCOID ............................... 87
lomustine ............................... 24
loperamide hcl ...................... 97
loratadine * ........................... 44
lorazepam .............................. 10
losartan potassium ................ 68
losartan/hydrochlorothiazide 68
LOTEMAX ........................... 93
LOTRIMIN ULTRA * .......... 42
LOTRONEX ......................... 90
lovastatin ............................... 77
loxapine succinate ................. 52
LOZI-FLUR ........................ 133
LUMIGAN .......................... 120
LUMINAL SODIUM ........... 31
LUMIZYME ......................... 90
LUPRON DEPOT ................. 24
LUPRON DEPOT-PED ........ 24
LYRICA ................................ 31
LYSODREN ......................... 24
mafenide acetate ................... 84
mag hydrox/al hydrox/simeth *
........................................... 97
magnesium chloride ............ 122
magnesium sulfate....... 122, 123
magnesium sulfate in water 122
magnesium sulfate/d5w ....... 123
malathion .............................. 88
mannitol/sorbitol solution ... 112
maprotiline hcl ...................... 35
MARPLAN ........................... 35
MARQIBO ............................ 24
MATULANE ........................ 25
meclizine hcl.......................... 47
meclizine hcl *....................... 47
medroxyprogesterone acet .. 104
medroxyprogesterone acetate
................................. 104, 105
mefenamic acid ....................... 6
mefloquine hcl ....................... 48
MEGACE ES ........................ 25
megestrol acetate .................. 25
MEKINIST ........................... 25
meloxicam ............................... 7
melphalan hcl ........................ 25
MENACTRA ...................... 109
MENEST............................. 101
MENHIBRIX ...................... 109
MENOMUNE-A-C-Y-W-135
......................................... 110
MENVEO A-C-Y-W-135-DIP
......................................... 110
MEPHYTON * ................... 133
mercaptopurine ..................... 25
meropenem ............................ 15
mesna .................................. 116
MESNEX ............................ 116
MESTINON ........................ 117
metaproterenol sulfate ........ 127
metaxalone .......................... 129
metformin hcl ........................ 37
methadone hcl ......................... 3
methazolamide .................... 120
methenamine hippurate ......... 12
methimazole ........................ 105
methocarbamol ................... 129
methotrexate sodium ............. 25
methotrexate sodium/pf ......... 25
methoxsalen, rapid ................ 84
methscopolamine bromide .... 97
methyclothiazide ................... 75
methylene blue .................... 117
methylergonovine maleate .. 117
methylphenidate hcl .............. 79
methylprednisolone ............. 102
methylprednisolone acetate 102
methylprednisolone sod succ
......................................... 102
metipranolol ........................ 120
metoclopramide hcl ............... 97
metolazone ............................ 76
metoprolol succinate ............. 72
metoprolol tartrate ................ 72
metoprolol/hydrochlorothiazide
........................................... 72
metronidazole ............ 45, 48, 85
metronidazole/sodium chloride
........................................... 48
METVIXIA ........................... 84
mexiletine hcl ........................ 70
mg trisilicate/alh/nahco3/aa *
........................................... 97
MIACALCIN ...................... 113
miconazole nitrate ................. 45
miconazole nitrate * .............. 42
MICRHOGAM ULTRAFILTERED PLUS ........... 107
midazolam hcl ....................... 10
midazolam hcl/pf ................... 10
midodrine hcl ........................ 68
milrinone lactate ................... 74
milrinone lactate/d5w ........... 74
MINOCIN ............................. 18
minocycline hcl ..................... 18
minoxidil ............................... 78
mirtazapine ........................... 35
misoprostol............................ 95
mitomycin .............................. 25
mitoxantrone hcl ................... 25
M-M-R II VACCINE .......... 110
MOBAN ................................ 52
modafinil ............................. 129
moexipril hcl ......................... 69
moexipril/hydrochlorothiazide
........................................... 69
mometasone furoate .............. 87
montelukast sodium ............. 127
morphine sulfate.................. 3, 4
MORPHINE SULFATE ......... 4
morphine sulfate/0.9% nacl/pf 4
morphine sulfate/pf ................. 4
MOVIPREP .......................... 98
MOXEZA ............................. 91
moxifloxacin hcl .................... 17
MOZOBIL ............................ 60
MULTAQ ............................. 70
multivit, iron, min #5, fa *... 134
multivit, iron, min #6, fa *... 134
I-9
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
multivit, min cmb#20/iron/fa *
......................................... 134
multivitamin * ..................... 134
multivitamins with min no.7/fa *
......................................... 134
multivits w-iron,hematinic * 134
multivits,therap w-fe,hematin *
......................................... 134
multivits-min/fa/lycopene/lut *
......................................... 134
mupirocin .............................. 85
mupirocin calcium ................ 85
MUSTARGEN ...................... 25
mycophenolate mofetil ........ 107
mycophenolate sodium ........ 107
MYOBLOC......................... 117
MYOZYME .......................... 90
MYTELASE ....................... 117
na nitrite/na thiosul/amyl nit. 99
nabumetone ............................. 7
nadolol .................................. 72
NAFCILL IN DEXTROSE... 16
nafcillin sodium..................... 16
NAGLAZYME ..................... 90
nalbuphine hcl ......................... 4
nalidixic acid ......................... 17
naloxone hcl ............................ 8
naltrexone hcl.......................... 8
NAMENDA .......................... 33
NAMENDA XR.................... 33
naphazoline hcl/antazoline ... 94
naproxen ................................. 7
naproxen sodium ..................... 7
naratriptan hcl ...................... 45
NASCOBAL * .................... 134
NASONEX ......................... 126
NATACYN ........................... 91
nateglinide............................. 37
NEBUPENT .......................... 48
needles, insulin disposable.... 88
nefazodone hcl ...................... 35
neo/polymyx b sulf/dexameth 91
neomy sulf/bacitra/polymyxin b
........................................... 91
neomy sulf/bacitrac zn/poly/hc
........................................... 91
neomy sulf/polymyxin b sulfate
........................................... 85
neomycin sulfate.................... 11
neomycin sulfate/dex na ph ... 91
neomycin/polymyxin b sulf/hc 92
neomycin/polymyxn b/
gramicidin ......................... 92
neostigmine methylsulfate ... 117
NEPHRAMINE .................... 66
NESSI SPACER * ................ 88
NEULASTA ......................... 60
NEUMEGA........................... 60
NEUPOGEN ......................... 60
NEUPRO............................... 50
NEVANAC ........................... 93
nevirapine ............................. 55
NEXAVAR ........................... 25
niacin..................................... 77
niacin *.................................. 77
nicardipine hcl ...................... 75
nicotine *................................. 8
NICOTROL ............................ 8
nifedipine............................... 75
NILANDRON ....................... 25
NITRO-BID .......................... 78
nitrofurantoin ........................ 12
nitrofurantoin macrocrystal .. 12
nitroglycerin .......................... 78
nitroglycerin/d5w .................. 78
NITROSTAT ........................ 78
nizatidine ............................... 95
NORDITROPIN ................. 103
NORDITROPIN FLEXPRO103
NORDITROPIN NORDIFLEX
......................................... 103
norelgestromin/ethin.estradiol
........................................... 80
norepinephrine bitartrate...... 74
noreth-ethinyl estradiol/iron . 80
norethindrone........................ 80
norethindrone acetate ......... 105
norethindrone ac-eth estradiol
................................... 80, 101
norethindrone-e.estradiol-iron
........................................... 81
norethindrone-ethinyl estrad 81
norethindrone-mestranol ...... 81
norgestimate-ethinyl estradiol
........................................... 81
norgestrel-ethinyl estradiol ... 81
NORMOSOL-M and
DEXTROSE .................... 123
NORMOSOL-R PH 7.4 ...... 123
nortriptyline hcl .................... 35
NORVIR ............................... 55
NOVAMINE ......................... 66
NOVAREL ......................... 103
NOVOLIN 70-30 .................. 39
NOVOLIN N ........................ 39
NOVOLIN R ......................... 39
NOVOLOG ........................... 40
NOVOLOG FLEXPEN ........ 39
NOVOLOG MIX 70-30 ........ 39
NOVOLOG MIX 70-30
FLEXPEN ......................... 39
NOXAFIL ............................. 42
NPLATE ............................. 117
NUCYNTA ............................. 4
NUCYNTA ER ....................... 4
NUEDEXTA ......................... 79
NULOJIX ............................ 107
NUTRESTORE..................... 97
NUTRILYTE ...................... 123
NUTRILYTE II .................. 123
NUTROPIN ........................ 103
NUTROPIN AQ.................. 103
NUTROPIN AQ NUSPIN .. 103
NUVARING ......................... 81
nylidrin hcl ............................ 78
nystatin .................................. 43
nystatin/triamcin ................... 43
OCTAGAM ........................ 107
octreotide acetate ................ 103
OFIRMEV............................... 4
ofloxacin .......................... 17, 92
I-10
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
olanzapine ............................. 52
olanzapine/fluoxetine hcl ...... 35
OLYSIO ................................ 56
om-3/ca carb/d3/fa/mv cmb 13
*....................................... 134
omega-3 acid ethyl esters...... 77
omeprazole ............................ 96
omeprazole * ......................... 95
omeprazole magnesium * ...... 95
OMNITROPE ..................... 104
ONCASPAR ......................... 25
ondansetron........................... 47
ondansetron hcl ..................... 47
ONFI ..................................... 10
ONTAK................................. 26
OPSUMIT ........................... 131
ORAP .................................... 52
ORENCIA ........................... 107
ORENITRAM ER ................. 74
ORFADIN ............................. 90
ORTHO EVRA ..................... 81
OTEZLA ............................. 117
oxacillin sodium .................... 16
oxacillin sodium/dextrose,iso 16
oxaliplatin ............................. 26
oxandrolone ........................ 100
oxcarbazepine ....................... 31
OXSORALEN-ULTRA ........ 84
OXTELLAR XR ................... 31
oxybutynin chloride ............... 98
oxycodone hcl.......................... 4
oxycodone hcl/acetaminophen 4
oxycodone hcl/aspirin ............. 4
OXYCONTIN ......................... 5
oxymorphone hcl ..................... 5
paclitaxel ............................... 26
pamidronate disodium ........ 113
PANRETIN ........................... 84
pantoprazole sodium ............. 96
papaverine hcl ....................... 74
paregoric ............................... 97
paricalcitol .......................... 113
paromomycin sulfate ............. 48
paroxetine hcl........................ 35
PASER .................................. 46
PATADAY ........................... 94
PATANOL ............................ 94
PAXIL ................................... 35
pedi m.vit no.17 with fluoride
......................................... 134
pedi mvi no.12/sodium fluoride
......................................... 134
PEDIARIX .......................... 110
PEDVAXHIB ..................... 110
peg 3350/na sulf,bicarb,cl/kcl98
PEGANONE ......................... 31
PEGASYS ............................. 57
PEGASYS PROCLICK ........ 57
PEGINTRON ........................ 57
PEGINTRON REDIPEN ...... 57
pen g pot/dextrose-water....... 16
penicillin g potassium ........... 16
penicillin g potassium/d5w ... 16
penicillin g procaine ............. 16
penicillin v potassium ........... 16
PENTACEL ........................ 110
PENTACEL ACTHIB
COMPONENT................ 110
PENTACEL DTAP-IPV
COMPONENT................ 110
PENTAM 300 ....................... 49
pentamidine isethionate ........ 49
pentostatin ............................. 26
pentoxifylline ......................... 61
p-epd tan/chlor-tan ............... 44
p-ephed hcl/d-bromp mal * ... 44
PERIKABIVEN .................... 66
perindopril erbumine ............ 70
PERJETA .............................. 26
permethrin ............................. 88
permethrin * .......................... 88
perphenazine ......................... 52
perphenazine/amitriptyline hcl
........................................... 35
phenelzine sulfate .................. 35
phenobarbital ........................ 31
phenobarbital sodium ........... 31
phentolamine mesylate ........ 130
phenylephrine hcl ............ 68, 94
phenylephrine hcl * ............... 68
phenylephrine/
brompheniramine * ........... 44
phenylephrine/
chlorpheniramine * ........... 44
phenylephrine/diphenhydramine
*......................................... 44
phenylephrine/triprolidine * . 44
PHENYTEK ......................... 31
phenytoin ............................... 32
phenytoin sodium .................. 31
phenytoin sodium extended ... 31
PHOSLYRA ......................... 98
PHOSPHOLINE IODIDE .. 120
phosphorus #1 ..................... 123
PHYSICIANS EZ USE B-12 *
......................................... 134
physostigmine salicylate ..... 117
phytonadione * .................... 134
PICATO ................................ 84
pilocarpine hcl .............. 82, 120
PILOPINE HS ..................... 120
pindolol ................................. 72
pioglitazone hcl ..................... 41
pioglitazone hcl/glimepiride . 41
pioglitazone hcl/metformin hcl
........................................... 41
piperacillin sodium/tazobactam
........................................... 17
piroxicam ................................ 7
PLASBUMIN-25 .................. 62
PLASBUMIN-5 .................... 62
PLASMA-LYTE 148 .......... 123
PLASMA-LYTE 56 IN
DEXTROSE .................... 123
PLASMA-LYTE A PH 7.4 . 123
PLASMA-LYTE M IN
DEXTROSE .................... 123
pnv with ca,no.72/iron/fa .... 134
podofilox ............................... 84
podophyllum resin ................. 84
POLY HIST FORTE *.......... 44
polyethylene glycol 3350....... 98
I-11
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
polymyxin b sulf/trimethoprim
........................................... 92
polymyxin b sulfate ............... 12
POMALYST ......................... 26
pot chloride/pot bicarb/cit ac
......................................... 123
potassium acetate ................ 123
potassium bicarbonate/cit ac
......................................... 123
potassium chlorid/d100.2%nacl ......................... 123
potassium chloride .............. 124
potassium chloride in 0.9%nacl
......................................... 123
potassium chloride in d5w .. 123
potassium chloride in lr-d5 . 124
potassium chloride/d50.2%nacl ......................... 124
potassium chloride/d5-0.25ns
......................................... 124
potassium chloride/d50.3%nacl ......................... 124
potassium chloride/d5-0.45nacl
......................................... 124
potassium chloride/d50.9%nacl ......................... 124
potassium chloride-0.45% nacl
......................................... 124
potassium citrate/citric acid 124
potassium gluconate............ 124
potassium hydroxide ............. 84
potassium iodide * .............. 105
potassium phos,m-basic-d-basic
......................................... 124
POTIGA ................................ 32
PRADAXA ........................... 59
PRALIDOXIME CHLORIDE
......................................... 117
pramipexole di-hcl ................ 50
PRANDIMET ....................... 38
pravastatin sodium ................ 77
prazosin hcl ........................... 68
prednicarbate ........................ 87
prednisolone........................ 102
prednisolone acetate ..... 93, 102
prednisolone sod phosphate. 93,
102
prednisone ........................... 102
PREDNISONE INTENSOL 102
PREMARIN ........................ 101
PREMASOL ......................... 66
PREMPHASE ..................... 101
PREMPRO .......................... 101
prenatal vit/iron fumarate/fa *
......................................... 134
PREZISTA ............................ 55
PRIFTIN ............................... 46
PRILOSEC OTC * ................ 96
PRIMAQUINE ..................... 49
primidone .............................. 32
PRISTIQ ER ......................... 35
PRIVIGEN .......................... 107
PROAIR HFA ..................... 127
probenecid........................... 117
procainamide hcl .................. 70
PROCALAMINE .................. 66
prochlorperazine edisylate.... 47
prochlorperazine maleate ..... 47
PROCRIT .............................. 60
PROCYSBI ......................... 117
progesterone ....................... 105
progesterone,micronized ..... 105
PROGLYCEM ...................... 78
PROGRAF .......................... 107
PROLENSA .......................... 93
PROLEUKIN ........................ 26
PROLIA .............................. 113
PROMACTA ........................ 60
promethazine hcl ............. 44, 48
promethazine hcl/codeine * .. 81
promethazine/phenyleph/
codeine * ........................... 81
PRONESTYL ....................... 70
propafenone hcl .................... 71
propantheline bromide .......... 30
proparacaine hcl ................... 94
proparacaine/fluorescein sod 94
propranolol hcl ..................... 72
propranolol/hydrochlorothiazid
........................................... 72
propylthiouracil .................. 105
PROQUAD ......................... 110
PROSOL ............................... 66
PROSTIGMIN .................... 117
protamine sulfate .................. 60
PROTOPAM CHLORIDE.. 117
PROTOPIC ..................... 87, 88
protriptyline hcl .................... 35
pseudoephed/chlorpheniramine
*......................................... 44
pseudoephedrine hcl * .......... 81
pseudoephedrine/
brompheniramin * ............. 44
pseudoephedrine/triprolidine *
........................................... 44
PULMOZYME ..................... 90
PURIXAN ............................. 26
pyridostigmine bromide ...... 117
pyridoxine hcl *................... 134
QNASL ............................... 126
QUDEXY XR ....................... 32
quetiapine fumarate .............. 52
QUICK MIX with LYTES.... 66
QUILLIVANT XR................ 79
quinapril hcl .......................... 70
quinapril/hydrochlorothiazide
........................................... 70
quinidine gluconate ............... 71
quinidine sulfate .................... 71
quinine sulfate ....................... 49
QVAR ................................. 126
RABAVERT ....................... 110
raloxifene hcl ...................... 101
ramipril ................................. 70
RANEXA .............................. 74
ranitidine hcl ......................... 96
ranitidine hcl * ...................... 96
RAPAMUNE ...................... 107
RAVICTI .............................. 97
REBIF ................................. 118
REBIF REBIDOSE ............. 117
RECOMBIVAX HB ........... 110
I-12
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
REGONOL ......................... 118
RELENZA ............................ 56
RELISTOR ........................... 97
REMICADE ........................ 118
REMODULIN..................... 131
RENAGEL ............................ 98
RENVELA ............................ 98
repaglinide ............................ 38
RESCRIPTOR ...................... 55
RESTASIS ............................ 93
RETROVIR........................... 55
REVATIO ........................... 131
REVLIMID ........................... 26
REYATAZ ............................ 55
RHOGAM ULTRAFILTERED PLUS ........... 108
RHOPHYLAC .................... 108
ribavirin ................................ 58
RIDAURA .......................... 108
rifabutin................................. 46
rifampin ................................. 46
RIFATER .............................. 46
riluzole .................................. 79
rimantadine hcl ..................... 56
ringers solution ........... 112, 124
risedronate sodium.............. 113
RISPERDAL CONSTA ........ 52
risperidone ...................... 52, 53
RITUXAN............................. 26
rivastigmine tartrate ............. 33
rizatriptan benzoate .............. 45
ropinirole hcl ........................ 50
ROTARIX ........................... 110
ROTATEQ .......................... 110
ROZEREM ......................... 129
RU-HIST-D *........................ 44
SABRIL ................................ 32
SAIZEN .............................. 104
salsalate .................................. 7
SANDOSTATIN LAR........ 104
SANTYL ............................... 84
SAPHRIS .............................. 53
SAVELLA ............................ 80
selegiline hcl ......................... 50
selenium sulfide..................... 85
SELZENTRY ........................ 55
SENSIPAR .......................... 118
SEREVENT DISKUS ......... 127
SEROMYCIN ....................... 46
SEROQUEL XR ................... 53
SEROSTIM ......................... 104
sertraline hcl ......................... 35
SHOHL'S MODIFIED ........ 124
SIGNIFOR .......................... 118
sildenafil citrate .................. 131
SILENOR .............................. 35
silver nitrate .......................... 85
silver nitrate applicator ........ 84
silver sulfadiazine ................. 85
SIMBRINZA....................... 120
SIMPONI ............................ 118
SIMPONI ARIA ................. 118
SIMULECT......................... 118
simvastatin ............................ 77
sirolimus.............................. 108
SIRTURO ............................. 46
sod propion/inositol/aa14/urea
........................................... 45
sod/pot/k cit/sod cit/cit acid 124
sodium acetate .................... 124
sodium bicarbonate............. 125
sodium chloride................... 125
sodium chloride 0.45 % ...... 125
sodium chloride 3% ............ 125
sodium chloride 5% ............ 125
sodium chloride for inhalation *
......................................... 125
sodium chloride irrig solution
......................................... 112
sodium chloride/nahco3/kcl/peg
........................................... 98
sodium lactate ..................... 125
SODIUM LACTATE.......... 125
sodium morrhuate ............... 118
sodium phenylbutyrate .......... 97
sodium phos,m-basic-d-basic
......................................... 125
sodium polystyrene sulfonate 98
sodium tetradecyl sulfate .... 118
sodium thiosulfate ................. 99
SOLIRIS ............................. 118
SOLTAMOX ........................ 26
SOLU-CORTEF ................. 102
SOLU-MEDROL ................ 102
SOMATULINE DEPOT ..... 104
SOMAVERT....................... 104
sorbitol solution .................. 112
sotalol hcl .............................. 72
SOTALOL HCL ................... 72
SOVALDI ............................. 58
spinosad ................................ 88
SPIRIVA ............................. 127
spironolact/hydrochlorothiazid
........................................... 77
spironolactone....................... 77
SPORANOX ......................... 43
SPRYCEL ............................. 26
stavudine ............................... 55
STELARA........................... 118
STERILE DILUENT ............ 62
STIVARGA .......................... 26
STRATTERA ....................... 80
streptomycin sulfate .............. 11
STRIBILD............................. 55
STROMECTOL .................... 49
STROVITE ONE * ............. 134
SUBOXONE ........................... 9
sucralfate............................... 96
sulfacetamide sodium ...... 85, 92
sulfacetamide/prednisolone sp
........................................... 92
sulfadiazine ........................... 17
sulfamethoxazole/trimethoprim
........................................... 17
sulfasalazine.......................... 17
sulindac ................................... 7
sumatriptan ........................... 45
sumatriptan succinate ........... 45
SUPPRELIN LA ................. 104
SUPRAX ............................... 14
SUSTIVA .............................. 55
SUTENT ............................... 26
I-13
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
SYLATRON 4-PACK .......... 57
SYLVANT ............................ 27
SYMLIN ............................... 38
SYMLINPEN 120 ................. 38
SYMLINPEN 60 ................... 38
SYNAGIS ............................. 56
SYNAREL .......................... 118
SYNERCID........................... 12
SYNRIBO ............................. 27
SYPRINE .............................. 99
syring w-ndl,disp,insul,0.3ml 89
syring w-ndl,disp,insul,0.5ml 89
syring w-o ndl,disp,insul, 1ml 89
TABLOID ............................. 27
tacrolimus ........................... 108
TAFINLAR ........................... 27
TAMIFLU ............................. 56
tamoxifen citrate ................... 27
tamsulosin hcl ..................... 130
TANZEUM ........................... 38
TARCEVA............................ 27
TARGRETIN .................. 27, 88
TASIGNA ............................. 27
TAZICEF IN DEXTROSE ... 14
TAZORAC ............................ 88
TE ANATOXAL BERNA .. 110
tea tree oil ............................. 14
TECFIDERA....................... 119
TEGRETOL XR ................... 32
telmisartan ............................ 68
telmisartan/hydrochlorothiazid
........................................... 69
temazepam............................. 10
TEMODAR ........................... 27
teniposide .............................. 27
TENIVAC ........................... 110
terazosin hcl ........................ 130
terbinafine hcl ....................... 43
terbutaline sulfate ............... 127
terconazole ............................ 45
testosterone cypionate ......... 100
testosterone enanthate ........ 100
TETANUS DIPHTHERIA
TOXOIDS ....................... 110
TETANUS TOXOID
ADSORBED ................... 111
tetracaine hcl/pf .................... 94
tetracycline hcl ...................... 18
TEV-TROPIN ..................... 104
THALOMID ....................... 119
theophylline anhydrous ....... 128
theophylline/d5w ................. 128
THERACYS ....................... 111
THERMAZENE ................... 86
thiamine hcl * ...................... 134
thioridazine hcl ..................... 53
thiotepa ................................. 27
thiothixene ............................. 53
tiagabine hcl.......................... 32
TIKOSYN ............................. 71
timolol maleate.............. 72, 120
tinidazole ............................... 49
TIVICAY .............................. 55
tizanidine hcl ....................... 129
TOBI PODHALER ............... 11
tobramycin in 0.225% nacl ... 11
tobramycin sulfate........... 11, 92
tobramycin/dexamethasone... 92
tobramycin/sodium chloride . 11
tolazamide ............................. 41
tolbutamide ........................... 41
tolmetin sodium ....................... 7
tolnaftate * ............................ 43
tolterodine tartrate ................ 98
topiramate ............................. 32
topotecan hcl ......................... 27
TORISEL .............................. 27
torsemide ............................... 76
TPN ELECTROLYTES...... 125
TRACLEER ........................ 131
TRADJENTA ....................... 38
tramadol hcl ............................ 5
tramadol hcl/acetaminophen .. 5
trandolapril ........................... 70
tranexamic acid ..................... 60
tranylcypromine sulfate ........ 36
TRAVAMULSION............... 66
TRAVASOL ......................... 67
TRAVASOL W/DEXTROSE
........................................... 66
TRAVASOL W/
ELECTROLYTES ............ 66
TRAVASOL with DEXTROSE
..................................... 66, 67
TRAVASOL with
ELECTROLYTES ............ 67
TRAVATAN Z ................... 120
TRAVERT ............................ 67
TRAVERT IN NORMAL
SALINE ............................ 67
TRAVERT-ELECTROLYTE
NO.1 ................................ 125
TRAVERT-ELECTROLYTE
NO.2 ................................ 125
TRAVERT-ELECTROLYTE
NO.3 ................................ 125
TRAVERT-ELECTROLYTE
NO.4 ................................ 125
travoprost (benzalkonium) .. 120
trazodone hcl ......................... 36
TREANDA ........................... 27
TRECATOR ......................... 46
TRELSTAR .......................... 28
tretinoin ........................... 28, 88
tretinoin microspheres .......... 88
TREXALL ............................ 28
triamcinolone acetonide. 82, 88,
102, 126
TRIAMINIC COLDALLERGY PE * ............... 44
triamterene/hydrochlorothiazid
........................................... 76
triazolam ............................... 10
TRIBENZOR ........................ 69
trifluoperazine hcl ................. 53
trifluridine ............................. 92
trihexyphenidyl hcl ................ 50
TRILEPTAL ......................... 32
trimethoprim ......................... 12
trimipramine maleate ............ 36
tripelennamine hcl ................ 45
TRISENOX ........................... 28
I-14
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
TRIUMEQ ............................ 55
TROKENDI XR.................... 32
TROPHAMINE .................... 67
trospium chloride .................. 98
TRUVADA ........................... 55
TWINRIX ........................... 111
TYGACIL ............................. 18
TYKERB............................... 28
TYPHIM VI ........................ 111
TYSABRI ........................... 108
TYVASO ............................ 131
TYZEKA............................... 58
TYZINE ................................ 94
UCERIS .............................. 102
ULORIC .............................. 119
urologic solution-g .............. 112
ursodiol ................................. 97
UVADEX .............................. 84
VAGIFEM .......................... 101
valacyclovir hcl ..................... 58
VALCHLOR ......................... 85
VALCYTE ............................ 58
valproic acid ......................... 32
valproic acid (as sodium salt)32
valsartan/hydrochlorothiazide
........................................... 69
VALSTAR ............................ 28
vancomycin hcl...................... 12
VANCOMYCIN HCL .......... 12
vancomycin hcl/d5w .............. 12
VANTAS ............................ 104
VAQTA............................... 111
VARIVAX VACCINE ....... 111
VASCEPA ............................ 77
vasopressin .......................... 104
VECAMYL ........................... 74
VECTIBIX ............................ 28
VELCADE ............................ 28
venlafaxine hcl ...................... 36
VENLAFAXINE HCL ER ... 36
VENTAVIS......................... 131
VENTOLIN HFA ............... 128
verapamil hcl ........................ 72
VERSACLOZ ....................... 53
VESICARE ........................... 98
VICTOZA 3-PAK ................. 38
VICTRELIS .......................... 56
VIDEX .................................. 55
VIGAMOX ........................... 92
VIIBRYD .............................. 36
VIMIZIM .............................. 90
VIMPAT ......................... 32, 33
vinblastine sulfate ................. 28
vincristine sulfate .................. 28
vinorelbine tartrate ............... 28
VIRACEPT ........................... 55
VIRAMUNE XR .................. 55
VIREAD ............................... 56
vit b cmplx 3/fa/vit c/biotin *
......................................... 135
vit b cmplx no3/fa/c/biot/zinc *
......................................... 135
vit b cplx #11/fa/c/biot/zn ox *
......................................... 135
vitamin b comp and vit c no.6 *
......................................... 135
vitamin b complex * ............ 135
vitamins b1,b2,b3,b5,& b6 * 135
VITA-RESPA * .................. 135
VIVELLE-DOT .................. 101
VOLTAREN ........................... 7
VORAXAZE....................... 119
voriconazole .......................... 43
VOTRIENT........................... 28
VPRIV................................... 90
VUMON ............................... 28
warfarin sodium .................... 59
water for irrigation,sterile .. 112
WELCHOL ........................... 77
WINRHO SDF .................... 108
XALKORI............................. 28
XARELTO ............................ 59
XARTEMIS XR...................... 5
XELJANZ ........................... 119
XENAZINE .......................... 80
XERAC AC .......................... 85
XGEVA............................... 113
XIFAXAN............................. 13
XOLAIR ............................. 128
XTANDI ............................... 29
XYLOCAINE ....................... 71
XYREM .............................. 129
YERVOY .............................. 29
YF-VAX ............................. 111
zafirlukast............................ 127
zaleplon ............................... 129
ZALTRAP............................. 29
ZANOSAR ............................ 29
ZAVESCA ............................ 90
ZELBORAF .......................... 29
ZEMAIRA .......................... 128
ZEMPLAR .......................... 113
ZENPEP ................................ 90
ZETIA ................................... 77
ZIAGEN ................................ 56
zidovudine ............................. 56
zinc sulfate * ............... 125, 126
ziprasidone hcl ...................... 53
ZOLADEX ............................ 29
zoledronic acid .................... 113
zoledronic acid/
mannitol&water .............. 113
ZOLINZA ............................. 29
zolmitriptan ........................... 46
zolpidem tartrate ................. 130
ZOMETA ............................ 113
zonisamide............................. 33
ZORBTIVE ......................... 104
ZORTRESS......................... 108
ZOSTAVAX ....................... 111
ZOVIRAX............................. 85
ZUBSOLV .............................. 9
ZYDELIG ............................. 29
ZYKADIA ............................ 29
ZYLET .................................. 92
ZYPREXA RELPREVV ...... 53
ZYTIGA ................................ 29
ZYVOX................................. 13
I-15
L.A. Care Cal MediConnect MMP 2014 Formulary
Formulary ID: 14592.000, Version: 17
Effective: December 01, 2014
MGA TALA:
MGA TALA:
MGA TALA:
MGA TALA:
MGA TALA:
www.calmediconnectla.org
LA0959 TA 03/14