LA Care Medi-Cal & Healthy Kids Formulary

59 Pages·2014·1.76 MB·English

LA Care Medi-Cal & Healthy Kids Formulary
May 2014
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. All drugs are listed by their
generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index,
either by generic or proprietary name (in small capital letters) 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 by generic name. Where an FDA approved generic is
available for the listed generic name, the generic name is bolded.
For certain agents within the Drug Formulary, a recommended prescribing guideline may apply. These are denoted
throughout the document using the following symbols:
Symbol Restriction Description
AGE Age Edit Coverage may depend on patient age
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Symbol Restriction Description
COM Carve Out* Edit Carve out* for Medi-Cal members (covered by Medi-Cal fee-
for-service), no restrictions for Healthy Kids
COM/MD Carve Out* (Medi-Cal) / Carve out* for Medi-Cal members (covered by Medi-Cal fee-
Physician Specialty Edit for-service) / Coverage may depend on prescribing physician’s
(Healthy Families) specialty or board certification for Healthy Kids
COM/PA Carve Out* (Medi-Cal) Carve out* for Medi-Cal members (covered by Medi-Cal fee-
/ Prior Authorization (Healthy for-service) / Prior Authorization required for Healthy Kids
Families)
G Gender Edit Coverage may depend on patient gender
MD Physician Specialty Edit Coverage may depend on prescribing physician’s specialty or
board certification
PA Prior Authorization Requires specific physician request process
QL Quantity Limit Coverage may be limited to specific quantities per prescription
and/or time period
ST Step Therapy Coverage may depend on previous use of another drug
OTC Over the Counter Coverage of OTC medication for all lines of businesses,
including Healthy Families and Healthy Kids.
Please refer to the prescribing guideline appendix within this document for details regarding specific agents.
Carve Out is only for Medi-Cal members. L.A. Care Health Plan cannot cover the drugs in the following therapeutic
*
drug classes because they are covered and/or reviewed by the state Medical Fee for Service program.
Drugs indicated for the treatment of AIDS/HIV (excluding Didanosine and Zidovudine) , Psychosis, Alcohol &
Drug depenency, and Hemophilia.
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 1-888-839-9909 (TTY 1-866-522-2731).
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 bolded 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.
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.
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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 non-generically available drug 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 MedImpact at [phone].
2. Contacting MedImpact at [phone] and providing all necessary information requested.
MedImpact will provide an authorization number, specific for the medical need, for all approved requests. Non-
approved 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.
4. 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 side-
effect 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
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.
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In designing Therapeutic Interchange protocols, drug characteristics are considered including:
1. Efficacy
2. Effectiveness
3. Dosage Formulation
4. Safety
5. Cost
6. Pharmacoeconomic variables
5. General Exclusions
A. Over the Counter (OTC) medications or their equivalents are not covered for Healthy Families or Healthy Kids
members, unless otherwise specified in the Formulary listing. OTC medications are available for Medi-Cal
members subject to formulary coverage of these agents.
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:
Chairperson, Pharmacy & Therapeutics Committee
L.A. Care Health Plan
1055 W 7th Street, 9th Floor
Los Angeles, CA 90017
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Formulary
ALLERGY Nasal Antihistamine
T1 azelastine hcl ASTEPRO
2nd Gen Antihistamine & Decongestant T1 azelastine hcl AZELASTINE HCL
Nasal Anti-inflammatory Steroids
Combinations
T1 budesonide BUDESONIDE PA
T1 cetirizine CETIRIZINE- QL
T1 budesonide RHINOCORT AQUA PA
hcl/pseudoephedrinePSEUDOEPHEDRINE
T1 flunisolide FLUNISOLIDE
ER(OTC)
T1 fluticasone furoate VERAMYST PA, QL
T1 fexofenadine/pseudo ALLERGY RELIEF ST
T1 fluticasone FLUTICASONE QL
ephedrine D(OTC)
propionate PROPIONATE
T1 loratadine/pseudoep LORATADINE-D(TAB QL
T1 mometasone furoate NASONEX PA, QL
hedrine ER 12H)(OTC)
T1 triamcinolone TRIAMCINOLONE
T1 loratadine/pseudoep LORATADINE-D(TAB QL
acetonide ACETONIDE
hedrine ER 24H)(OTC)
T1 p-ephed ALLERGY RELIEF D- QL Nasal Mast Cell Stabilizers Agents
sul/loratadine 24(OTC)
T1 cromolyn sodium CROMOLYN
Antihistamines - 1st Generation SODIUM(OTC)
T1 chlorpheniramine ALLERGY(OTC) ANTIEMESIS/ANTIVERTIGO
maleate
T1 chlorpheniramine DIABETIC
Antiemetic/antivertigo Agents
maleate TUSSIN(OTC)
T1 clemastine fumarate CLEMASTINE T1 aprepitant EMEND ST
FUMARATE T1 dimenhydrinate DRIMINATE(OTC)
T1 clemastine fumarate CLEMASTINE T1 doxylamine/pyridoxine DICLEGIS PA
FUMARATE(OTC) hcl
T1 cyproheptadine hcl CYPROHEPTADINE T1 dronabinol DRONABINOL PA
HCL T1 granisetron hcl GRANISETRON HCL QL
T1 dexchlorpheniramineDEXCHLORPHENIRA T1 meclizine hcl MECLIZINE HCL
maleate MINE MALEATE T1 meclizine hcl MECLIZINE
T1 diphenhydramine hclDIPHENHYDRAMINE HCL(OTC)
HCL T1 ondansetron ONDANSETRON QL
T1 diphenhydramine hclDIPHENHYDRAMINE ODT(TAB RDP DIS)(4
HCL(OTC) MG)
T1 hydroxyzine hcl HYDROXYZINE HCL T1 ondansetron ONDANSETRON QL
T1 hydroxyzine pamoateHYDROXYZINE ODT(TAB RDP DIS)(8
PAMOATE MG)
T1 promethazine hcl PROMETHAZINE HCLAGE T1 ondansetron hcl ONDANSETRON HCL
T1 phosp ANTI-NAUSEA(OTC)
Antihistamines - 2nd Generation
acid/dextrose/fructos
T1 cetirizine hcl CETIRIZINE HCL e
T1 cetirizine hcl CETIRIZINE T1 prochlorperazine COMPAZINE
HCL(SOLUTION) edisylate
(OTC) T1 prochlorperazine PROCHLORPERAZIN
T1 cetirizine hcl CETIRIZINE HCL(TABPA, QL maleate E MALEATE
CHEW)(OTC) T1 promethazine hcl PROMETHEGAN AGE
T1 cetirizine hcl CETIRIZINE QL T1 trimethobenzamide TRIMETHOBENZAMI
HCL(TAB)(OTC) hcl DE HCL
T1 fexofenadine hcl FEXOFENADINE HCLST
ASTHMA
T1 fexofenadine hcl FEXOFENADINE ST
HCL(OTC)
T1 levocetirizine LEVOCETIRIZINE AGE Beta-adrenergic Agents
dihydrochloride DIHYDROCHLORIDE
T1 albuterol sulfate ALBUTEROL
T1 loratadine CHILDREN'S PA, QL
SULFATE
CLARITIN(OTC)
T1 albuterol sulfate VENTOLIN HFA QL
T1 loratadine LORATADINE(SOLUTIAGE,
T1 arformoterol tartrate BROVANA ST
ON)(OTC) QL
T1 formoterol fumarate FORADIL PA
T1 loratadine LORATADINE(TAB AGE,
T1 levalbuterol hcl LEVALBUTEROL HCLST
RDP DIS)(OTC) QL
T1 metaproterenol METAPROTERENOL
T1 loratadine LORATADINE(TAB) QL
sulfate SULFATE
(OTC)
T1 salmeterol xinafoate SEREVENT DISKUS PA
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Formulary
T1 terbutaline sulfate TERBUTALINE T1 inhaler, assist devices AEROCHAMBER MINIAGE,
SULFATE QL
T1 inhaler, assist devices AEROCHAMBER AGE,
Beta-adrenergic And Anticholinergic
PLUS FLOW-VU QL
T1 inhaler, assist devices AEROCHAMBER AGE,
Combinations
PLUS Z STAT QL
T1 ipratropium/albuterol COMBIVENT T1 inhaler, assist devices BREATHERITE AGE,
sulfate QL
T1 ipratropium/albuterol COMBIVENT T1 inhaler, assist devices BREATHRITE AGE,
sulfate RESPIMAT QL
T1 ipratropium/albuterolIPRATROPIUM- T1 inhaler, assist devices EASIVENT AGE,
sulfate ALBUTEROL QL
T1 inhaler, assist devices E-Z SPACER AGE,
Beta-adrenergic And Glucocorticoid
QL
T1 inhaler, assist devices LITEAIRE AGE,
Combinations
QL
T1 budesonide/formoterol SYMBICORT PA T1 inhaler, assist devices MICROCHAMBER AGE,
fumarate QL
T1 fluticasone/salmeterol ADVAIR DISKUS PA T1 inhaler, assist devices MICROSPACER AGE,
T1 fluticasone/salmeterol ADVAIR HFA PA QL
T1 fluticasone/vilanterol BREO ELLIPTA PA T1 inhaler, assist devices MONAGHAN Z STAT AGE,
T1 mometasone/formoter DULERA QL
ol T1 inhaler, assist devices POCKET CHAMBER AGE,
QL
General Bronchodilator Agents
T1 inhaler, assist devices PRIMEAIRE AGE,
T1 ipratropium bromide ATROVENT HFA QL
T1 ipratropium bromide IPRATROPIUM T1 inhaler, assist devices PROCHAMBER AGE,
BROMIDE QL
T1 tiotropium bromide SPIRIVA T1 inhaler, assist devices RITEFLO AGE,
QL
Glucocorticoids, Orally Inhaled
T1 inhaler, assist devices VORTEX AGE,
T1 beclomethasone QVAR QL
dipropionate T1 inhaler, assist devices VORTEX VHC FROG AGE,
T1 budesonide BUDESONIDE AGE MASK QL
T1 budesonide PULMICORT AGE T1 inhaler, assist devices VORTEX VHC AGE,
T1 budesonide PULMICORT ST LADYBUG MASK QL
FLEXHALER T1 inhaler, assist devices WATCHHALER AGE,
T1 fluticasone propionate FLOVENT DISKUS QL
T1 fluticasone propionate FLOVENT HFA T1 inhaler, assist devices WINDMILL AGE,
T1 mometasone furoate ASMANEX(AER POW ST TRAINER(OTC) QL
BA)(110MCG(30)) T1 inhaler,assist EASIVENT AGE,
T1 mometasone furoate ASMANEX(AER POW ST device,accesory QL
BA)(220MCG 120) T1 inhaler,assist LITETOUCH AGE,
T1 mometasone furoate ASMANEX(AER POW PA device,accesory QL
BA)(220MCG(14)) T1 inhaler,assist MOUTHPIECE(OTC) AGE,
T1 mometasone furoate ASMANEX(AER POW PA device,accesory QL
BA)(220MCG(30)) T1 inhaler,assist ONE WAY AGE,
T1 mometasone furoate ASMANEX(AER POW ST device,accesory MOUTHPIECE(OTC) QL
BA)(220MCG(60)) T1 inhaler,assist OPTICHAMBER AGE,
device,accesory QL
Leukotriene Receptor Antagonists
T1 inhaler,assist OPTICHAMBER AGE,
T1 montelukast sodium MONTELUKAST device,accesory DIAMOND QL
SODIUM T1 inhaler,assist PANDA MASK(OTC) AGE,
T1 zafirlukast ZAFIRLUKAST PA device,accesory QL
T1 inhaler,assist PEDIATRIC AGE,
Mast Cell Stabilizers
device,accesory MASK(OTC) QL
T1 cromolyn sodium CROMOLYN SODIUM T1 inhaler,assist PEDIATRIC PANDA AGE,
device,accesory MASK(OTC) QL
Respiratory Aids,devices,equipment
T1 inhaler,assist SIDESTREAM AGE,
T1 inhaler, assist devices ACE AEROSOL AGE, device,accesory PEDIATRIC(OTC) QL
CLOUD ENHANCER QL T1 inhaler,assist SILICONE MASK AGE,
device,accesory QL
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Formulary
T1 inhaler,assist SILICONE AGE,
AUTONOMIC NERVOUS SYSTEM
device,accesory MASK(OTC) QL
T1 inhaler,assist VORTEX FROG AGE,
device,accesory MASK(OTC) QL DISORDERS
T1 inhaler,assist VORTEX LADYBUG AGE,
device,accesory MASK(OTC) QL Alzheimer's Therapy, Nmda Receptor
T1 inhaler,assist VORTEX(OTC) AGE,
device,accesory QL Antagonists
T1 peak flow meter AIRZONE PEAK
T1 memantine hcl NAMENDA ST
FLOW METER(OTC)
T1 memantine hcl NAMENDA XR ST
T1 peak flow meter AIRZONE(OTC)
T1 peak flow meter ASSESS(OTC) Cholinesterase Inhibitors
T1 peak flow meter ASTHMA
T1 donepezil hcl DONEPEZIL HCL
CHECK(OTC)
T1 galantamine hbr GALANTAMINE HBR
T1 peak flow meter ASTHMAMENTOR(OT
T1 neostigmine bromide PROSTIGMIN
C)
T1 pyridostigmine MESTINON
T1 peak flow meter IN-CHECK NASAL
bromide
WITH MASK(OTC)
T1 pyridostigmine PYRIDOSTIGMINE
T1 peak flow meter IN-CHECK
bromide BROMIDE
ORAL(OTC)
T1 rivastigmine EXELON
T1 peak flow meter INCHECK(OTC)
T1 rivastigmine tartrate EXELON
T1 peak flow meter MICROLIFE PEAK
T1 rivastigmine tartrate RIVASTIGMINE
FLOW(OTC)
T1 peak flow meter MINI-WRIGHT PEAK BEHAVIORAL HEALTH -
FLOW METER
T1 peak flow meter PEAK FLOW
ANTIDEPRESSANTS
METER(OTC)
T1 peak flow meter PEAK-AIR(OTC)
T1 peak flow meter PERSONAL Alpha-2 Receptor Antagonist
BEST(OTC)
T1 peak flow meter PIKO 1(OTC) Antidepressants
T1 peak flow meter POCKET PEAK(OTC)
T1 mirtazapine MIRTAZAPINE
T1 peak flow meter POCKETPEAK(OTC)
T1 peak flow meter TRUZONE PEAK Norepinephrine And Dopamine Reuptake
FLOW METER
T1 peak flow meter/inh AEROGEAR ASTHMA Inhib
asst dev ACTION KIT
T1 bupropion hcl BUPROPION XL(TAB QL
T1 peak flow meter/inh ASTHMAPACK
ER 24H)(150 MG)
asst dev CHILDREN'S
T1 bupropion hcl BUPROPION XL(TAB
T1 spirometers and IN-CHECK DIAL(OTC)AGE,
ER 24H)(300 MG)
accessories QL
T1 spirometers and PFLEX TRAINER AGE, Selective Serotonin Reuptake Inhibitor
accessories QL
T1 citalopram CITALOPRAM AGE,
T1 spirometers and THRESHOLD IMT AGE,
hydrobromide HBR(SOLUTION) QL
accessories QL
T1 citalopram CITALOPRAM AGE,
T1 spirometers and THRESHOLD PEP AGE,
hydrobromide HBR(TAB)(10 MG) QL
accessories QL
T1 citalopram CITALOPRAM AGE,
T1 spirometers and WINDMILL AGE,
hydrobromide HBR(TAB)(20 MG) QL
accessories TRAINER(OTC) QL
T1 citalopram CITALOPRAM AGE,
Xanthines hydrobromide HBR(TAB)(40 MG) QL
T1 escitalopram oxalate ESCITALOPRAM
T1 aminophylline AMINOPHYLLINE
OXALATE
T1 caffeine citrated CAFFEINE CITRATE QL
T1 fluoxetine hcl FLUOXETINE HCL
T1 theophylline anhydrousTHEO-24
T1 fluvoxamine maleate FLUVOXAMINE ST
T1 theophylline THEOPHYLLINE
MALEATE(CAP ER
anhydrous ANHYDROUS
24H)
T1 fluvoxamine maleate FLUVOXAMINE
MALEATE(TAB)
T1 paroxetine hcl PAROXETINE AGE,
HCL(TAB ER 24H) QL, ST
T1 paroxetine hcl PAROXETINE AGE
HCL(TAB)
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Formulary
T1 paroxetine hcl PAXIL AGE T1 chlordiazepoxide hcl CHLORDIAZEPOXIDE
T1 sertraline hcl SERTRALINE HCL HCL
T1 clorazepate CLORAZEPATE
Serotonin-2 Antagonist/reuptake Inhibitors
dipotassium DIPOTASSIUM
T1 nefazodone hcl NEFAZODONE HCL T1 diazepam DIAZEPAM
T1 trazodone hcl TRAZODONE HCL T1 lorazepam LORAZEPAM
T1 meprobamate MEPROBAMATE
Serotonin-norepinephrine Reuptake-inhib
T1 oxazepam OXAZEPAM
T1 duloxetine hcl DULOXETINE HCL PA
Barbiturates
T1 levomilnacipran FETZIMA PA
hydrochloride T1 phenobarbital PHENOBARBITAL
T1 venlafaxine hcl VENLAFAXINE HCL
Hypnotics, Melatonin Mt1/mt2 Receptor
ER
Ssri & 5ht1a Partial Agonist Antidepressant Agonists
T1 vilazodone VIIBRYD PA T1 ramelteon ROZEREM QL, ST
hydrochloride
Narcolepsy And Sleep Disorder Therapy
Tricyclic Antidepressant/benzodiazepine
Agents
Combinatns
T1 modafinil MODAFINIL PA, QL
T1 amitrip CHLORDIAZEPOXIDE
Sedative-hypnotics,non-barbiturate
hcl/chlordiazepoxide -AMITRIPTYLINE
T1 diphenhydramine hclSLEEP TABS(OTC)
Tricyclic Antidepressant/phenothiazine
T1 diphenhydramine hcl ZZZQUIL(OTC)
T1 doxepin hcl SILENOR QL, ST
Combinatns
T1 doxylamine UNISOM SLEEP
T1 perphenazine/amitripPERPHENAZINE- succinate AID(OTC)
tyline hcl AMITRIPTYLINE T1 estazolam ESTAZOLAM
T1 eszopiclone ESZOPICLONE QL, ST
Tricyclic Antidepressants & Rel. Non-sel. Ru-
T1 flurazepam hcl FLURAZEPAM HCL
T1 temazepam TEMAZEPAM
inhib
T1 triazolam TRIAZOLAM
T1 amitriptyline hcl AMITRIPTYLINE HCL T1 zaleplon ZALEPLON QL
T1 amoxapine AMOXAPINE T1 zolpidem tartrate EDLUAR QL, ST
T1 clomipramine hcl CLOMIPRAMINE HCL T1 zolpidem tartrate INTERMEZZO QL, ST
T1 desipramine hcl DESIPRAMINE HCL T1 zolpidem tartrate ZOLPIDEM QL
T1 doxepin hcl DOXEPIN HCL TARTRATE
T1 imipramine hcl IMIPRAMINE HCL T1 zolpidem tartrate ZOLPIMIST QL, ST
T1 imipramine pamoate IMIPRAMINE
Tx For Attention Deficit-
PAMOATE
T1 maprotiline hcl MAPROTILINE HCL
hyperact(adhd)/narcolepsy
T1 nortriptyline hcl NORTRIPTYLINE HCL
T1 protriptyline hcl PROTRIPTYLINE HCL T1 dexmethylphenidate DEXMETHYLPHENID PA
hcl ATE HCL ER
BEHAVIORAL HEALTH - OTHER
T1 methylphenidate hcl METHYLPHENIDATE AGE,
ER(TAB ER 24H)(18 QL
Adrenergics, Aromatic, Non-catecholamine MG)
T1 methylphenidate hcl METHYLPHENIDATE AGE,
T1 dextroamphetamine DEXTROAMPHETAMI
ER(TAB ER 24H)(27 QL
sulfate NE SULFATE
MG)
T1 dextroamphetamine/ AMPHETAMINE SALT AGE,
T1 methylphenidate hcl METHYLPHENIDATE AGE,
amphetamine COMBO QL
ER(TAB ER 24H)(36 QL
Anti-alcoholic Preparations MG)
T1 methylphenidate hcl METHYLPHENIDATE AGE,
T1 disulfiram DISULFIRAM
ER(TAB ER 24H)(54 QL
Anti-anxiety Drugs MG)
T1 alprazolam ALPRAZOLAM
T1 alprazolam ALPRAZOLAM
INTENSOL
T1 buspirone hcl BUSPIRONE HCL
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Formulary
T1 quinapril/hydrochlor QUINAPRIL-
CARDIOVASCULAR DISEASE -
othiazide HYDROCHLOROTHIA
ZIDE
ARRHYTHMIA
Alpha/beta-adrenergic Blocking Agents
Antiarrhythmics T1 carvedilol CARVEDILOL
T1 labetalol hcl LABETALOL HCL
T1 amiodarone hcl AMIODARONE HCL
T1 disopyramide DISOPYRAMIDE Alpha-adrenergic Blocking Agents
phosphate PHOSPHATE
T1 doxazosin mesylate DOXAZOSIN
T1 disopyramide NORPACE CR
MESYLATE
phosphate
T1 phenoxybenzamine hclDIBENZYLINE
T1 dofetilide TIKOSYN
T1 prazosin hcl PRAZOSIN HCL
T1 flecainide acetate FLECAINIDE
T1 terazosin hcl TERAZOSIN HCL
ACETATE
T1 mexiletine hcl MEXILETINE HCL Angioten.receptr Antag./cal.chanl
T1 procainamide hcl PROCAINAMIDE HCL
T1 procainamide hcl PRONESTYL Blkr/thiazide Cb
T1 propafenone hcl PROPAFENONE HCL
T1 amlodipine/valsartan/hEXFORGE HCT ST
T1 quinidine gluconate QUINIDINE
cthiazid
GLUCONATE
T1 olmesartan/amlodipin/ TRIBENZOR ST
T1 quinidine sulfate QUINIDINE SULFATE
hcthiazid
CARDIOVASCULAR DISEASE - Angiotensin Receptor Antag./thiazide
CARDIAC STIMULANT Diuretic Comb
T1 azilsartan EDARBYCLOR ST
Digitalis Glycosides med/chlorthalidone
T1 candesartan/hydrochCANDESARTAN-
T1 digoxin DIGOX
lorothiazid HYDROCHLOROTHIA
T1 digoxin DIGOXIN
ZID
CARDIOVASCULAR DISEASE - T1 eprosartan/hydrochloroTEVETEN HCT ST
thiazide
HYPERTENSION T1 irbesartan/hydrochlo IRBESARTAN-
rothiazide HYDROCHLOROTHIA
ZIDE
Ace Inhibitor/calcium Channel Blocker
T1 losartan/hydrochloro LOSARTAN-
thiazide HYDROCHLOROTHIA
Combination
ZIDE
T1 amlodipine AMLODIPINE T1 olmesartan/hydrochlor BENICAR HCT ST
besylate/benazepril BESYLATE- othiazide
BENAZEPRIL T1 telmisartan/hydrochl TELMISARTAN-
orothiazid HYDROCHLOROTHIA
Ace Inhibitor/thiazide & Thiazide-like Diuretic
ZID
T1 benazepril/hydrochloBENAZEPRIL- T1 valsartan/hydrochlor VALSARTAN-
rothiazide HYDROCHLOROTHIA othiazide HYDROCHLOROTHIA
ZIDE ZIDE
T1 captopril/hydrochlor CAPTOPRIL-
Angiotensin Receptor Antgnst &
othiazide HYDROCHLOROTHIA
ZIDE
Calc.channel Blockr
T1 enalapril/hydrochloroENALAPRIL-
thiazide HYDROCHLOROTHIA T1 amlodipine AZOR ST
ZIDE bes/olmesartan med
T1 fosinopril/hydrochlorFOSINOPRIL- T1 amlodipine/valsartan EXFORGE ST
othiazide HYDROCHLOROTHIA
Antihypertensives, Ace Inhibitors
ZIDE
T1 lisinopril/hydrochloroLISINOPRIL- T1 benazepril hcl BENAZEPRIL HCL
thiazide HYDROCHLOROTHIA T1 captopril CAPTOPRIL
ZIDE T1 enalapril maleate ENALAPRIL
T1 moexipril/hydrochlor MOEXIPRIL- MALEATE
othiazide HYDROCHLOROTHIA T1 fosinopril sodium FOSINOPRIL
ZIDE SODIUM
LA Care Page 9 of 59
Formulary
T1 lisinopril LISINOPRIL
Calcium Channel Blocking Agents
T1 moexipril hcl MOEXIPRIL HCL
T1 quinapril hcl QUINAPRIL HCL T1 amlodipine besylate AMLODIPINE
T1 ramipril RAMIPRIL BESYLATE
T1 trandolapril TRANDOLAPRIL T1 diltiazem hcl DILTIAZEM 24HR ER
T1 felodipine FELODIPINE ER
Antihypertensives, Angiotensin Receptor
T1 nicardipine hcl NICARDIPINE HCL
T1 nifedipine NIFEDIPINE ER
Antagonist
T1 verapamil hcl VERAPAMIL ER
T1 azilsartan medoxomil EDARBI ST
Loop Diuretics
T1 candesartan cilexetil CANDESARTAN
CILEXETIL T1 bumetanide BUMETANIDE
T1 eprosartan mesylate EPROSARTAN T1 furosemide FUROSEMIDE
MESYLATE
Potassium Sparing Diuretics
T1 irbesartan IRBESARTAN
T1 losartan potassium LOSARTAN T1 eplerenone EPLERENONE ST
POTASSIUM T1 spironolactone SPIRONOLACTONE
T1 olmesartan medoxomilBENICAR ST
Potassium Sparing Diuretics In Combination
T1 telmisartan TELMISARTAN
T1 valsartan DIOVAN ST T1 spironolact/hydrochl SPIRONOLACTONE-
orothiazid HCTZ
Antihypertensives, Sympatholytic
T1 triamterene/hydrochl TRIAMTERENE-HCTZ
T1 clonidine CLONIDINE QL orothiazid
T1 clonidine hcl CLONIDINE HCL
Pulm.anti-htn,sel.c-gmp Phosphodiesterase
T1 guanfacine hcl GUANFACINE HCL
T1 methyldopa ALDOMET
T5 Inhib
T1 methyldopa METHYLDOPA
T1 reserpine RESERPINE T1 sildenafil citrate SILDENAFIL PA
Antihypertensives, Vasodilators Pulmonary Anti-htn, Endothelin Receptor
T1 hydralazine hcl HYDRALAZINE HCL
Antagonist
T1 minoxidil MINOXIDIL
T1 ambrisentan LETAIRIS PA
Beta-adrenergic Blocking Agents
T1 bosentan TRACLEER PA
T1 acebutolol hcl ACEBUTOLOL HCL
Renin Inhib, Direct/calc. Channel
T1 atenolol ATENOLOL
T1 bisoprolol fumarate BISOPROLOL
Blkr/thiazide Cb
FUMARATE
T1 metoprolol succinateMETOPROLOL T1 aliskiren/amlodipin/hct AMTURNIDE PA
SUCCINATE hiazide
T1 metoprolol tartrate METOPROLOL
Renin Inhibitor, Direct
TARTRATE
T1 nadolol NADOLOL T1 aliskiren hemifumarateTEKTURNA PA
T1 nebivolol hcl BYSTOLIC ST
Renin Inhibitor, Direct & Calcium Channel
T1 pindolol PINDOLOL
T1 propranolol hcl PROPRANOLOL HCL
Blocker
T1 sotalol hcl SOTALOL
T1 timolol maleate TIMOLOL MALEATE T1 aliskiren/amlodipine TEKAMLO PA
besylate
Beta-adrenergic Blocking Agents/thiazide &
Renin Inhibitor, Direct/thiazide Diuretic
Related
Comb
T1 atenolol/chlorthalido ATENOLOL-
ne CHLORTHALIDONE T1 aliskiren/hydrochlorothiTEKTURNA HCT PA, ST
T1 bisoprolol BISOPROLOL- azide
fumarate/hctz HYDROCHLOROTHIA
Thiazide And Related Diuretics
ZIDE
T1 metoprolol/hydrochloMETOPROLOL- T1 chlorthalidone CHLORTHALIDONE
rothiazide HYDROCHLOROTHIA T1 hydrochlorothiazide HYDROCHLOROTHIA
ZIDE ZIDE
T1 indapamide INDAPAMIDE
T1 metolazone METOLAZONE
LA Care Page 10 of 59