Download Quick Reference Formulary

L.A. Care Covered Direct
Quick Reference
Formulary
www.lacare.org
LA1308D 02/15_EN
Last Updated: 3/1/2016
Effective: 3/1/2016
L.A. Care Covered Direct Formulary
INTRODUCTION
Foreword
This document represents the efforts of L.A. Care Health Plan’s Pharmacy Therapeutics and New Technology
Committee (PT&T) to provide physicians and pharmacists with a method to begin to evaluate the various drug products
available. The medical treatment of patients is frequently relative to the practical application of drug therapy. Due to the
vast availability of medication therapy and treatment modalities, a reasonable program of drug product selection and
drug usage must be developed. The goal of the L.A. Care Formulary is to enhance the physician and pharmacist’s
abilities to provide optimal cost effective drug therapy for patients.
The development, maintenance, and improvement of this process are evolutionary and require constant attention. This
is accomplished by the L.A. Care PT&T Committee. The Formulary is a continually reviewed and revised list of drugs,
which mirror the prevailing clinical opinion of the PT&T Committee. Unfortunately, this dynamic process does not allow
this document to be completely accurate at all times. To accommodate the necessary changes of this document,
updates are available online at: http://www.lacare.org. As you use this Formulary, you are encouraged to review the
information and provide your input and comments to the L.A. Care PT&T Committee.
The L.A. Care PT&T Committee uses the following criteria in the evaluation of drug selection for the L.A. Care
Formulary:
• Drug safety profile
• Drug efficacy
• Comparison of relevant drug benefits to current formulary agents of similar use, while minimizing duplications
• Equitable cost and outcomes of the total cost of drug and medical care
How to Use the Formulary
The Formulary is a list of covered and preferred drug agents for L.A. Care members. Drugs that are available in
generic formulations are listed by their generic names and it’s most common proprietary (branded) name is capitalized
next to the generic name in parenthesis. Drugs that only come in Brand name formulations are listed by the proprietary
(Brand) name. The Formulary may be accessed by using the index, either by generic or proprietary name and by
therapeutic drug category. Any non-generically available drug not found in this Formulary listing, or any Formulary
updates published by L.A. Care shall be considered a Non-Formulary drug.
All drugs are listed in each category in alphabetical order either by generic or proprietary name depending on
what formulation is FDA approved and on the market.
For certain agents within the Drug Formulary, a recommended prescribing guideline may apply. These are denoted
throughout the document using the following symbols:
L.A. Care Covered Direct (Updated 3/1/2016)
Symbol
Restriction
Description
INF
Infertility
Infertility drugs
NC
Not Covered
Drug that is non-formulary and will not be paid for by the plan
without prior approval/prior authorization
QL
Quantity Limit
Coverage may be limited to specific quantities per prescription
and/or time period
SP
Specialty Pharmacy
Availability
Drug is considered a specialty drug and is available through the
specialty pharmacy vendor, however they are not restricted to a
specific pharmacy
VAC
Vaccine Program
Coverage is available through a vaccine program
LD
Limited Distribution
Coverage is available through a limited distributor or limited
number of distributors
OTC
Over the Counter
Coverage of OTC medication
RS
Restricted to Specialist
Coverage may be dependent on the specialty of the prescribing
physician
SPF
First Fill Available at Retail
Pharmacy
Initial fill can be dispensed at a contracted retail pharmacy and
all subsequent fills MUST be dispensed at the specialty
pharmacy provider of the plans choice
MSP
Mandatory Specialty Pharmacy
Program
All fills, including the initial fill MUST be dispensed at
the specialty pharmacy provider of the plans choice
PA
Prior Authorization
Requires specific physician request process
SMKG
Smoking Cessation
Coverage for the treatment of smoking cessation drugs, which
may have specific restrictions
ST
Step Therapy
Coverage may depend on previous use of another drug
Please refer to the prescribing guideline appendix within this document for details regarding specific agents.
Benefit Coverage and Limitations
This printed Formulary does not provide information regarding the specific coverage and limitations an individual
member may have. Many members have specific benefit inclusions, exclusions, copays, or a lack of coverage, which
are not reflected in the Formulary.
The Formulary applies only to outpatient drugs provided to members, and does not apply to medications used in
inpatient settings. If a member has any specific questions regarding their coverage, they should contact their L.A. Care
Health Plan Member Services department at 1-855-222-4239 (TTY 1-855-576-1620).
Depending upon a member’s specific benefit parameters, the following topics
may apply:
1.
Generic Substitution
• When available, FDA approved generic drugs are to be used in all situations, regardless of the brand name
indicated. The generic names are lower case in the formulary listing wherever an FDA approved generic
drug product is available. Greater economy is realized through the use of generic equivalents. This policy
is not meant to preclude or supplant any state statutes that may exist. All drugs that are or become
available generically are subject to review by L.A. Care’s PT&T Committee.
• Drug product will be approved for generic substitution by the L.A. Care PT&T Committee.
L.A. Care Covered Direct (Updated 3/1/2016)
This list is reviewed and updated periodically based on the clinical literature and available pharmacokinetic
principles of the drug products.
If a member or physician requests a brand name product in lieu of an approved generic, the member and the
physician determines that there is a documented medical need for the brand equivalent, a request for coverage
may be made using the medication request process.
2.
Step Therapy
L.A. Care uses Step Therapy to promote cost-effective pharmaceutical management when there are multiple
effective drugs to treat a condition. Drugs that are listed in the Formulary as Step Therapy (ST) require one or
more “prerequisite” first step drugs to be tried before progressing to the second step drug. If medically necessary,
a second step medication can be obtained without first trying a first step medication by submitting a completed
Medication Request Form. Each request will be reviewed on an individual patient need. Approval will be given if a
documented medical need exists. The following basic guidelines are used:
• The use of the first step drug is contraindicated in the patient.
• The first step drug is not suited for the present patient care need, and the drug selected is required for patient
safety.
• The use of the first step drug may provoke an underlying condition, which would be detrimental to patient care.
3.
Medication Request Process
Depending upon plan benefit design, a medication request process may apply as follows:
A. Formulary Agents
Drugs that are listed in the Formulary as Prior Authorization (PA) require evaluation, per L.A. Care PT&T
Committee Prior Authorization guidelines prior to dispensing at a network pharmacy. Each request will be
reviewed on individual patient need. If the request does not meet the guidelines established by the PT&T
Committee, the request will not be approved and alternative therapy may be recommended.
B. Non-Formulary Agents
Any generic or proprietary drug name not found in the Formulary listing, or any Formulary updates published by
L.A. Care, shall be considered a Non-Formulary drug. Coverage for non-formulary agents may be applied for
in advance by the physician. Each request will be reviewed on individual patient need. Approval will be given if
a documented medical need exists. The following basic guidelines are used:
• The use of Formulary Drugs is contraindicated in the patient.
• The patient has failed an appropriate trial of Formulary or related agents.
• The choices available in the Formulary are not suited for the present patient care need, and the drug
selected is required for patient safety.
• The use of a Formulary drug may provoke an underlying condition, which would be detrimental to patient
care.
C. Obtaining Coverage
Coverage, questions or information regarding the medication request or formulary process may be obtained
by:
1. Faxing a fully completed and signed Medication Request Form to Navitus Health Solutions (855)878-9210.
2. Contacting Navitus at (844)268-9787 and providing all necessary information requested.
4.
Navitus will provide an authorization number, specific for the medical need, for all approved requests. Nonapproved requests may be appealed. The prescriber must provide information to support the appeal on the
basis of medical necessity. Prior Authorization is generally not available for drugs that are specifically
excluded by benefit design.
Therapeutic Interchange
L.A. Care may use Therapeutic Interchange to promote rational pharmaceutical therapy when evidence suggests
that outcomes can be improved by substituting a drug that is therapeutically equivalent but chemically different
from the prescribed drug. Improved outcomes include, but are not limited to, enhanced compliance, superior sideeffect or risk profile, clinically superior results, and equivalent clinical results at a reduced cost. Therapeutic
Interchange protocols are never automatic; a dispensing provider may not substitute an alternate, therapeutically
L.A. Care Covered Direct (Updated 3/1/2016)
equivalent, drug for a prescribed drug without the knowledge and authorization of the prescribing practitioner.
Drugs may be considered for Therapeutic Interchange if they are:
1. High risk
2. High volume
3. High cost
4. Overused in routine conditions.
In designing Therapeutic Interchange protocols, drug characteristics are considered including:
1. Efficacy
2. Dosage Formulation
3. Safety
4. Cost
5. Pharmacoeconomic variables
5.
General Exclusions
A. Over the Counter (OTC) medications or their equivalents are not covered for L.A. Care Covered Direct
members, unless otherwise specified in the Formulary listing.
B. Drugs specifically listed as not covered are not covered.
C. Any drug products used for cosmetic purposes are not covered.
D. Infertility Agents
E. Experimental drug products, or any drug product used in an experimental manner, are not covered.
F. Non self-administered injectable drug products are not covered unless otherwise specified in the Formulary
listing.
G. Foreign drugs or drugs not approved by the United States Food & Drug Administration are not covered.
The PT&T Committee recognizes that not all medical needs can be met with this document and encourage
inquiries about alternative therapies.
Pharmacist and Physician Communication
The Formulary is a tool to promote cost-effective prescription drug use. The PT&T Committee has made every attempt
to create a document that meets all therapeutic needs; however, the art of medicine makes this a formidable task. L.A.
Care welcomes the participation of physicians, pharmacists, and ancillary medical providers, in this dynamic process.
Physicians and pharmacists are highly encouraged to direct any suggestions, comments or formulary additions to L.A.
Care via e-mail to [email protected] or by mail at the following address:
Yana Paulson Pharm. D., Senior Director of Pharmacy & Formulary
L.A. Care Health Plan
1055 W 7th Street, 4th Floor
Los Angeles, CA 90017
L.A. Care Covered Direct (Updated 3/1/2016)
Quick Reference Formulary - L.A. Care Covered Formulary and L.A. Care Covered Direct Formulary
This document is subject to change. The most updated version of this document, as well as a complete formulary listing, are available at www.navitus.com or upon request.
Drugs will be filled as generics when acceptable generic equivalents are available. This document is copyrighted by Navitus Health Solutions® and may be reprinted for
personal use only. Reproduction of this document for any other reason is expressly prohibited, unless prior written consent is obtained from Navitus.
Reading the Drug List
Generic drugs are listed in all lower case letters. Brand name drugs are listed in all upper case letters. Each drug product is assigned a coverage tier, shown to the right of each
drug product.
Relative Cost to Member
Tier 1
Tier 2
Tier 3
Formulary generics and some lower cost brand products
Formulary, brand products and some higher cost generic products
Non-preferred formulary products
$
$$
$$$$
Cases where drug products are followed by parentheses indicate that the entry relates to a certain dosage form, e.g. ESTRACE (vaginal cream) or more than one form of the
drug, e.g. ZOMIG (ZMT). Quantity limits are for prescriptions filled at retail pharmacies. Please consult the complete version of the formulary for mail order quantity limits.
All newly approved drugs on the market will initially NOT be covered, pending further review by the Navitus P&T Committee.
A complete version of the Navitus Formulary, as well as information on prior authorization and clinical programs, are available at www.navitus.com
ADHD/ ANTI-NARCOLEPSY/
ANTI-OBESITY/
ANOREXIANTS
ADDERALL XR CAP
amphetamine/
dextroamphetamine tab
dexmethylphenidate ER
cap
dexmethylphenidate tab
methylphenidate ER cap
methylphenidate tab
VYVANSE CAP
DAYTRANA PATCH
STRATTERA CAP
1
1
1
1
1
1
2
3
3
AMINOGLYCOSIDES
TOBI PODHALER
MSP RS
4
ANALGESICS ANTI-INFLAMMATORY
celecoxib cap
QL
diclofenac sodium EC tab
diclofenac sodium XR tab
diclofenac/ misoprostol DR
tab
ibuprofen tab
ketorolac tab
QL
meloxicam tab
nabumetone tab
piroxicam cap
sulindac tab
ENBREL INJ
MSP PA QL
ENBREL SURECLICK INJ MSP PA QL
HUMIRA INJ
MSP PA QL
HUMIRA PEN INJ
MSP PA QL
1
1
1
1
1
1
1
1
1
1
4
4
4
4
ANALGESICS - OPIOID
acetaminophen/ codeine
tab
fentanyl patch
hydrocodone/
acetaminophen tab
morphine sulfate ER tab
oxycodone/
acetaminophen tab
tramadol tab
OXYCONTIN CR TAB
1
1
1
1
1
QL
1
2
ANTIANGINAL AGENTS
RANEXA TAB
2
ANTIANXIETY AGENTS
alprazolam tab
buspirone tab
hydroxyzine tab
lorazepam tab
1
1
1
1
ANTIARRHYTHMICS
MULTAQ TAB
2
ANTIASTHMATIC AND
BRONCHODILATOR AGENTS
albuterol neb soln 0.083%
albuterol neb soln 0.5%
albuterol neb soln 0.63mg
albuterol neb soln 1.25mg
NC
INF
MSP
QL
1
1
1
1
albuterol/ ipratropium neb
soln
ARNUITY ELLIPTA
INHALER
ASMANEX HFA INHALER
ASMANEX INHALER
budesonide inh susp
FLOVENT DISKUS
INHALER
FLOVENT HFA INHALER
ipratropium neb soln
montelukast chew tab
montelukast tab
ADVAIR DISKUS
INHALER
ADVAIR HFA INHALER
BREO ELLIPTA INHALER
COMBIVENT INHALER
COMBIVENT RESPIMAT
INHALER
DULERA INHALER
INCRUSE ELLIPTA
INHALER
SEREVENT DISKUS
INHALER
SPIRIVA HANDIHALER
VENTOLIN HFA INHALERQL
XOPENEX HFA INHALER QL ST
PROVENTIL HFA
INHALER
PULMICORT FLEXHALER
QVAR INHALER
SYMBICORT INHALER
TUDORZA PRESSAIR
INHALER
SMKG Smoking Cessation
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
NC
NC
NC
NC
NC
ANTICOAGULANTS
warfarin tab
PRADAXA CAP
1
2
ANTICONVULSANTS
carbamazepine ER tab
carbamazepine tab
clonazepam tab
divalproex sodium DR tab
gabapentin cap
lamotrigine ER tab
lamotrigine tab
levetiracetam tab
phenytoin cap
topiramate tab
BANZEL TAB
LYRICA CAP
VIMPAT TAB
QL
1
1
1
1
1
1
1
1
1
1
2
2
2
ANTIDEPRESSANTS
amitriptyline tab
bupropion ER tab
bupropion XL tab
citalopram soln
citalopram tab
duloxetine EC cap
escitalopram tab
fluoxetine cap
fluoxetine tab
mirtazapine tab
NEFAZODONE TAB
Not Covered
Infertility
Mandatory Specialty Pharmacy Program
Quantity Limit
1
QL
1
1
1
1
1
1
1
1
1
1
1
1
nefazodone tab 50mg,
250mg
nortriptyline cap
paroxetine tab
sertraline conc
sertraline tab
trazodone tab
venlafaxine ER cap
venlafaxine ER tab
venlafaxine tab
PEXEVA TAB
PRISTIQ TAB
1
1
1
1
1
1
1
1
3
3
ST
ST
ANTIDIABETICS
glipizide ER tab
glipizide tab
glyburide tab
metformin tab
pioglitazone tab
pioglitazone/ metformin
tab
AVANDAMET TAB
AVANDIA TAB
BYDUREON INJ
QL
BYDUREON PEN INJ
QL
FARXIGA TAB
QL
JANUMET TAB
JANUMET XR TAB
JANUVIA TAB
QL
KOMBIGLYZE XR TAB
LANTUS INJ
LANTUS SOLOSTAR INJ
LEVEMIR FLEXPEN INJ
LEVEMIR INJ
NOVOLIN INJ
OTC
NOVOLOG FLEXPEN INJ
NOVOLOG INJ
NOVOLOG MIX FLEXPEN
INJ
NOVOLOG PENFILL INJ
ONGLYZA TAB
QL
TOUJEO SOLOSTAR INJ
VICTOZA INJ
QL
HUMALOG INJ
ST
HUMALOG KWIKPEN INJ ST
HUMALOG MIX INJ
ST
ST
HUMALOG MIX
KWIKPEN INJ
HUMULIN MIX INJ
OTC ST
HUMULIN MIX PEN INJ OTC ST
HUMULIN N INJ
OTC ST
HUMULIN N PEN INJ
OTC ST
HUMULIN R INJ
OTC ST
JENTADUETO TAB
PA QL
NESINA TAB
PA QL
TRADJENTA TAB
PA QL
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
ANTIEMETICS
ondansetron tab
1
ANTIFUNGALS
fluconazole susp
fluconazole tab
griseofulvin micro tab
griseofulvin susp
itraconazole cap
ketoconazole tab
PA
generic =small letters
1
1
1
1
1
1
nystatin tab
terbinafine tab
voriconazole tab
RS
ANTIHISTAMINES
cetirizine cap
OTC
Limited Distribution
Over-the-Counter
Restricted to Specialist
M
PA
SF
SP
Available through Specialty Pharmacy Program
ST
NC
ANTIHYPERLIPIDEMICS
atorvastatin tab
cholestyramine powder
fluvastatin cap
gemfibrozil tab
lovastatin tab
NIASPAN ER TAB
pravastatin tab
simvastatin tab
TRILIPIX CAP
CRESTOR TAB
SIMCOR TAB
ZETIA TAB
ADVICOR TAB
QL
QL
1
1
1
1
1
1
1
1
1
2
2
2
3
ANTIHYPERTENSIVES
amlodipine/ valsartan tab
amlodipine/ benazepril cap
benazepril tab
benazepril/
hydrochlorothiazide tab
bisoprolol/
hydrochlorothiazide tab
candesartan tab
candesartan/
hydrochlorothiazide tab
captopril tab
clonidine patch
doxazosin tab
enalapril tab
enalapril/
hydrochlorothiazide tab
irbesartan/
hydrochlorothiazide tab
lisinopril tab
lisinopril/
hydrochlorothiazide tab
losartan tab
losartan/
hydrochlorothiazide tab
metoprolol/
hydrochlorothiazide tab
phenoxybenzamine cap
terazosin cap
valsartan tab
valsartan/
hydrochlorothiazide tab
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ANTI-INFECTIVE AGENTS MISC.
clindamycin cap 150mg
erythromycin/ sulfisoxazole
susp
metronidazole cap
metronidazole tab
smz/ tmp (DS) tab
vancomycin cap
QL ST
clindamycin cap 300mg
1
1
1
1
1
1
NC
ANTIMALARIALS
hydroxychloroquine tab
BRANDS =CAPITAL LETTERS
LD
OTC
RS
1
1
1
Medical Benefit
Prior Authorization
Limited to two 15 day fills per month for first 3
months
Step Therapy
Last Updated 3/1/2016
1
Quick Reference Formulary - L.A. Care Covered Formulary and L.A. Care Covered Direct Formulary
This document is subject to change. The most updated version of this document, as well as a complete formulary listing, are available at www.navitus.com or upon request.
Drugs will be filled as generics when acceptable generic equivalents are available. This document is copyrighted by Navitus Health Solutions® and may be reprinted for
personal use only. Reproduction of this document for any other reason is expressly prohibited, unless prior written consent is obtained from Navitus.
ANTIMYCOBACTERIAL
AGENTS
rifampin cap
1
ANTINEOPLASTICS AND
ADJUNCTIVE THERAPIES
tamoxifen tab
anastrozole tab
letrozole tab
methotrexate tab
AFINITOR DISPERZ
AFINITOR TAB
IMBRUVICA CAP
$0
1
1
1
MSP PA QL 4
SF
MSP PA QL 4
SF
LD PA QL SF 4
ANTIPARKINSON AGENTS
amantadine cap
carbidopa/ levodopa tab
ropinirole ER tab
ropinirole tab
selegiline cap
AZILECT TAB
1
1
1
1
1
2
ANTIPSYCHOTICS/
ANTIMANIC AGENTS
clozapine tab
lithium carbonate cap
lithium carbonate tab
olanzapine ODT
olanzapine tab
quetiapine tab
risperidone tab
ziprasidone cap
ABILIFY SOLN
ABILIFY TAB
PA
1
1
1
1
1
1
1
1
3
NC
ANTIVIRALS
acyclovir cap
acyclovir susp
nevirapine tab
rimantadine tab
valacyclovir tab
zidovudine cap
RELENZA DISKHALER
TAMIFLU CAP
entecavir tab
FUZEON INJ
PEG-INTRON INJ
PEGASYS INJ
SP
SP
QL
QL
MSP QL
SP
MSP
MSP ST
1
1
1
1
1
1
2
2
4
4
4
4
ASSORTED CLASSES
azathioprine tab
cyclosporine cap
SP
mycophenolate mofetil tab SP
1
4
4
BETA BLOCKERS
atenolol tab
carvedilol tab
labetalol tab
metoprolol ER tab
metoprolol tab
nadolol tab
propranolol tab
BYSTOLIC TAB
1
1
1
1
1
1
1
2
CALCIUM CHANNEL
BLOCKERS
amlodipine tab
diltiazem ER cap
diltiazem ER tab
diltiazem tab
felodipine ER tab
nifedipine cap
nifedipine ER tab
nisoldipine ER tab
verapamil SR cap
verapamil SR tab
1
1
1
1
1
1
1
1
1
1
CEPHALOSPORINS
cefaclor cap
cefadroxil cap
cefdinir cap
NC
INF
MSP
QL
cefdinir susp
cefpodoxime proxetil tab
cefprozil susp
cefprozil tab
cefuroxime susp
cephalexin cap
CONTRACEPTIVES
necon tab
NUVARING
tri-nessa (LO) tab
YASMIN TAB
YAZ TAB
$0
$0
$0
$0
$0
CORTICOSTEROIDS
1
methylprednisolone dose
pack
prednisolone soln
PREDNISONE TAB
1
1
COUGH/ COLD/ ALLERGY
guaifenesin/ codeine syrupOTC QL
1
DERMATOLOGICALS
adapalene cream
PA
adapalene gel 0.1%
PA
calcipotriene cream
clindamycin gel
clindamycin/ benzoyl
peroxide gel
clotrimazole/
betamethasone cream
DIFFERIN GEL 0.3%
PA
erythromycin gel
imiquimod cream
isotretinoin cap
ketoconazole cream
lidocaine patch
QL
lidocaine/ prilocaine cream
metronidazole cream
metronidazole gel
mupirocin cream
mupirocin oint
nystatin cream
nystatin/ triamcinolone oint
tacrolimus oint
tretinoin cream
PA
tretinoin gel
PA
ZOVIRAX OINT
ELIDEL CREAM
AZELEX CREAM
PA
TAZORAC CREAM
TAZORAC GEL
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
3
3
3
DIAGNOSTIC PRODUCTS
ACCU-CHEK TEST STRIPOTC
FREESTYLE LITE TEST OTC
STRIP
FREESTYLE TEST STRIPOTC
PRECISION XTRA TEST OTC
STRIP
TEST STRIP (all other test OTC
strips)
2
2
2
2
NC
DIGESTIVE AIDS
PANCRELIPASE CAP
PERTZYE CAP
ZENPEP CAP
ST
ST
ST
3
3
3
DIURETICS
acetazolamide ER cap
amiloride/
hydrochlorothiazide tab
CHLORTHALIDONE TAB
furosemide tab
hydrochlorothiazide tab
spironolactone tab
triamterene/
hydrochlorothiazide cap
triamterene/
hydrochlorothiazide tab
1
1
1
1
1
1
1
1
1
1
1
Not Covered
Infertility
Mandatory Specialty Pharmacy Program
Quantity Limit
SMKG Smoking Cessation
1
1
1
1
1
1
ENDOCRINE AND
METABOLIC AGENTS MISC.
raloxifene tab
ACTONEL TAB
alendronate tab
ibandronate tab 150mg
FORTEO INJ
$0
1
1
1
4
QL ST
MSP
ESTROGENS
estradiol patch
estradiol tab
estradiol/ norethindrone
tab
PREMARIN TAB
PREMPRO TAB
1
1
1
2
2
FLUOROQUINOLONES
ciprofloxacin ER tab
ciprofloxacin tab
levofloxacin tab
moxifloxacin tab
ofloxacin tab
1
1
1
1
1
GASTROINTESTINAL
AGENTS - MISC.
AMITIZA CAP
CIMZIA INJ
ST
3
MSP PA QL 4
GENITOURINARY AGENTS MISCELLANEOUS
alfuzosin SR tab
finasteride tab
tamsulosin cap
1
1
1
GOUT AGENTS
allopurinol tab
ULORIC TAB
1
2
ST
HEMATOLOGICAL AGENTS MISC.
clopidogrel tab 75mg
1
HYPNOTICS
phenobarbital tab
temazepam cap 15mg
temazepam cap 30mg
zaleplon cap
zolpidem tab 10mg
zolpidem tab 5mg
ROZEREM TAB
1
1
1
1
1
1
3
QL
QL
QL
MACROLIDES
azithromycin susp
azithromycin tab
clarithromycin tab
DIFICID TAB
ERYTHROMYCIN TAB
1
1
1
2
3
QL ST
MEDICAL DEVICES AND
SUPPLIES
OTC
ACCU-CHEK AVIVA
PLUS METER
FREESTYLE FREEDOM OTC
LITE METER
FREESTYLE LITE METEROTC
OTC
PRECISION XTRA
METER
B-D INSULIN SYRINGE OTC
B-D PEN NEEDLE
OTC
OTC
FREESTYLE INSULIN
SYRINGE
NOVOFINE PEN NEEDLEOTC
OTC
NOVOTWIST PEN
NEEDLE
OTC
PRECISION INSULIN
SYRINGE
$0
$0
$0
$0
1
1
1
QL
QL
QL
QL
generic =small letters
clotrimazole troches
nystatin susp
Limited Distribution
Over-the-Counter
Restricted to Specialist
M
PA
SF
SP
Available through Specialty Pharmacy Program
ST
3
3
NC
1
1
budesonide nasal spray
flunisolide nasal spray
fluticasone nasal spray
NASONEX NASAL
SPRAY
VERAMYST NASAL
SPRAY
BECONASE AQ NASAL
SPRAY
QL ST
QL
QL
QL
1
1
1
2
QL
2
QL ST
3
OPHTHALMIC AGENTS
azelastine ophth soln
bacitracin/ polymyxin b
ophth oint
ciprofloxacin ophth soln
dorzolamide/ timolol ophth
soln
gentamicin ophth soln
ketorolac ophth soln
ketotifen ophth soln
OTC
latanoprost ophth soln
QL
neomycin/ polymyxin/
hydrocortisone ophth soln
ofloxacin ophth soln
pilocarpine ophth soln
prednisolone ophth soln
timolol maleate ophth soln
tobramycin ophth soln
tobramycin/
dexamethasone ophth soln
ALPHAGAN P OPHTH
SOLN 0.1%
ALREX OPHTH SUSP/
LOTEMAX OPHTH SUSP
AZOPT OPHTH SUSP
BETIMOL OPHTH SOLN
LUMIGAN OPHTH SOLN QL
PATADAY OPHTH SOLN QL
PROLENSA OPHTH
SOLN
RS
RESTASIS OPHTH
EMULSION
TOBRADEX OPHTH OINT
QL
TRAVATAN Z OPHTH
SOLN
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
OTIC AGENTS
1
1
1
1
amoxicillin cap
amoxicillin/ clavulanate ER
tab
amoxicillin/ clavulanate tab
penicillin vk tab
1
1
1
2
PENICILLINS
BRANDS =CAPITAL LETTERS
LD
OTC
RS
3
3
NASAL AGENTS - SYSTEMIC
AND TOPICAL
1
1
1
1
1
1
1
1
2
MOUTH/ THROAT/ DENTAL
AGENTS
acetic acid otic soln
neomycin/ polymixin/
hydrocoritisone otic susp
ofloxacin otic soln
CIPRODEX OTIC SUSP
MIGRAINE PRODUCTS
almotriptan tab
naratriptan tab
rizatriptan ODT
rizatriptan tab
sumatriptan inj
QL
sumatriptan tab
QL
sumatriptan vial inj
QL
zolmitriptan ODT
QL
zolmitriptan tab
QL
QL
SUMATRIPTAN/
IMITREX NASAL SPRAY
FROVA TAB
QL
QL
MIGRANAL/
DIHYDROERGOTAMINE
SPRAY
RELPAX TAB
QL
SUMAVEL DOSEPRO INJQL
acetaminophen/
isometheptene/ dichloral
cap
Medical Benefit
Prior Authorization
Limited to two 15 day fills per month for first 3
months
Step Therapy
Last Updated 3/1/2016
1
1
1
1
Quick Reference Formulary - L.A. Care Covered Formulary and L.A. Care Covered Direct Formulary
This document is subject to change. The most updated version of this document, as well as a complete formulary listing, are available at www.navitus.com or upon request.
Drugs will be filled as generics when acceptable generic equivalents are available. This document is copyrighted by Navitus Health Solutions® and may be reprinted for
personal use only. Reproduction of this document for any other reason is expressly prohibited, unless prior written consent is obtained from Navitus.
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS MISC.
bupropion SR tab
CHANTIX PAK
CHANTIX TAB
nicotine gum
nicotine lozenge
nicotine patch
NICOTROL INHALER
NICOTROL NASAL
SPRAY
donepezil ODT
donepezil tab
galantamine ER cap
galantamine tab
memantine tab
rivastigmine cap
NAMENDA XR CAP
EXTAVIA INJ
QL SMKG
QL SMKG
QL SMKG
OTC QL
SMKG
OTC QL
SMKG
OTC QL
SMKG
QL SMKG
QL SMKG
$0
$0
$0
$0
QL
QL
1
1
1
1
1
1
2
4
QL
MSP ST
$0
$0
$0
$0
TETRACYCLINES
doxycycline hyclate cap
minocycline cap
1
1
THYROID AGENTS
liothyronine tab
methimazole tab
SYNTHROID TAB
THYROLAR TAB
1
1
1
2
ULCER DRUGS
cimetidine tab
famotidine susp
famotidine tab
pantoprazole EC tab
PREVACID OTC CAP
OTC
rabeprazole EC tab
ZEGERID CAP OTC
OTC
DEXILANT CAP
QL ST
PRILOSEC OTC DR TAB
1
1
1
1
1
1
1
3
NC
URINARY ANTI-INFECTIVES
nitrofurantoin monohydrate
cap
1
URINARY ANTISPASMODICS
oxybutynin ER tab
oxybutynin tab
tolterodine SR cap
tolterodine tab
VESICARE TAB
ENABLEX TAB
TOVIAZ TAB
PA
PA
1
1
1
1
2
3
3
VAGINAL PRODUCTS
2
ESTRACE VAGINAL
CREAM
PREMARIN VAGINAL
CREAM
2
VASOPRESSORS
EPIPEN INJ
EPIPEN-JR INJ
ADRENACLICK INJ
AUVI-Q INJ
EPINEPHRINE INJ
NC
INF
MSP
QL
QL
QL
QL ST
QL ST
QL ST
2
2
3
3
3
Not Covered
Infertility
Mandatory Specialty Pharmacy Program
Quantity Limit
SMKG Smoking Cessation
generic =small letters
BRANDS =CAPITAL LETTERS
LD
OTC
RS
Limited Distribution
Over-the-Counter
Restricted to Specialist
M
PA
SF
SP
Available through Specialty Pharmacy Program
ST
Medical Benefit
Prior Authorization
Limited to two 15 day fills per month for first 3
months
Step Therapy
Last Updated 3/1/2016