L.A. Care Medi-Cal Formulary

Transcription

1 L.A. Care MediCal ormulary LA1308E 02/15_EN Last Updated: 5/7/2015

2 L.A. Care MediCal ormulary INTRODUCTION oreword This document represents the efforts of L.A. Care Health Plan s Pharmacy and Therapeutics Committee (P&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 ormulary 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 P&T Committee. The ormulary is a continually reviewed and revised list of drugs, which mirror the prevailing clinical opinion of the P&T Committee. To accommodate the necessary changes of this document, monthly updates are available online at: As you use this ormulary, you are encouraged to review the information and provide your input and comments to the L.A. Care P&T Committee. The L.A. Care P&T Committee uses the following criteria in the evaluation of drug selection for the L.A. Care ormulary: 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 ormulary The ormulary 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 ormulary may be accessed by using the index, either by generic or proprietary name and by therapeutic drug category. Any nongenerically available drug not found in this ormulary listing, or any ormulary updates published by L.A. Care shall be considered a Nonormulary drug. All drugs are listed in each category in alphabetical order either by generic or proprietary name depending on what formulation is DA approved and on the market. or certain agents within the Drug ormulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols: L.A. Care Medi Cal (Updated )

3 Symbol Restriction Description IN Infertility Infertility drugs NC Not Covered Drug that is nonformulary and will not be paid for by the plan without prior approval/prior authorization 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 Coverage is available through a vaccine program LD Limited Distribution Coverage is available through a limited distributor or limited number of distributors Over the Counter Coverage of medication RS Restricted to Specialist Coverage may be dependent on the specialty of the prescribing physician SP MSP irst ill Available at Retail Pharmacy Mandatory Specialty Pharmacy Program 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 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. Carve Out Medications Drugs indicated for the treatment of: AIDS/HIV (excluding Didanosine and Zidovudine), Psychosis, Alcohol & Drug dependency, and Hemophilia are not on the formulary for MediCal members because these drugs may be covered and/or reviewed by the state Medical ee for Service program. Benefit Coverage and Limitations This printed ormulary 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 ormulary. The ormulary 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 (TTY ). Depending upon a member s specific benefit parameters, the following topics may apply: 1. Generic Substitution When available, DA approved generic drugs are to be used in all situations, regardless of the brand name L.A. Care Medi Cal (Updated )

4 indicated. The generic names are lower case in the formulary listing wherever an DA 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 P&T Committee. Drug product will be approved for generic substitution by the L.A. Care P&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. 2. Step Therapy L.A. Care uses Step Therapy to promote costeffective pharmaceutical management when there are multiple effective drugs to treat a condition. Drugs that are listed in the ormulary 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 orm. 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. ormulary Agents Drugs that are listed in the ormulary as Prior Authorization (PA) require evaluation, per L.A. Care P&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 P&T Committee, the request will not be approved and alternative therapy may be recommended. B. Nonormulary Agents Any generic or proprietary drug name not found in the ormulary listing, or any ormulary updates published by L.A. Care, shall be considered a Nonormulary drug. Coverage for nonformulary 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 ormulary Drugs is contraindicated in the patient. The patient has failed an appropriate trial of ormulary or related agents. The choices available in the ormulary are not suited for the present patient care need, and the drug selected is required for patient safety. The use of a ormulary 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. axing a fully completed and signed Medication Request orm to Navitus Health Solutions (855) Contacting Navitus at (844) and providing all necessary information requested. 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. 4. Therapeutic Interchange L.A. Care Medi Cal (Updated )

5 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 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 ormulation 3. Safety 4. Cost 5. Pharmacoeconomic variables 5. General Exclusions A. medications are available for MediCal 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.. Non selfadministered injectable drug products are not covered unless otherwise specified in the ormulary listing. G. oreign drugs or drugs not approved by the United States ood & Drug Administration are not covered. The P&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 ormulary is a tool to promote costeffective prescription drug use. The P&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 to [email protected] or by mail at the following address: Yana Paulson Pharm.D., Senior Director of Pharmacy & ormulary L.A. Care Health Plan 1055 W 7th Street, 4th loor Los Angeles, CA L.A. Care Medi Cal (Updated )

6 Search Tip: This is a large document, but you can search quickly and easily by clicking on the binocular icon on your toolbar. It will then display a search box for you to type in the name of drug you want to locate. If you do not know the correct spelling, you can start your search by entering just the first few letters of the name. L.A. Care Health Plan MediCal ormulary Alphabetical Index Drug Name 8MOP CAP a d oint acarbose tab (PRECOSE equiv) acebutolol cap (SECTRAL equiv) acetaminophen chew tab acetaminophen drops (Only covered for members 20 years and younger) acetaminophen elixir (Only covered for members 20 years and younger) acetaminophen er tab acetaminophen liquid (Only covered for members 20 years and younger) acetaminophen supp ACETAMINOPHEN SYRUP (Only covered for members 20 years and younger) acetaminophen tab acetaminophen/codeine soln. acetaminophen/codeine tab (TYLENOL/CODEINE equiv) acetaminophenpamabrompyrilamine tab (COVERED OR MEMBERS 4 YEARS AND OLDER) acetazolamide cap (DIAMOX SEQUEL equiv) acetazolamide tab ACETAZOLAMIDE TAB 125MG acetic acid otic soln (VOSOL equiv) ACETIC ACID/ALUMINUM ACETATE OTIC SOLN acetic acid/hydrocoritisone otic soln (VOSOL HC equiv) acetylcysteine soln ACIDIC VAGINAL JELLY acitretin cap (SORIATANE equiv) ACTIMMUNE INJ acyclovir cap (ZOVIRAX equiv) acyclovir oint (ZOVIRAX OINT equiv) acyclovir susp acyclovir tab (ZOVIRAX equiv) adapalene cream (DIERIN equiv) (acne only age 35 and older requires PA) adapalene gel 0.1% (DIERIN equiv) (acne only 35 or older requires PA) adapalene gel 0.3% (DIERIN equiv) (Acne Only 35 or older requires PA) ADCIRCA TAB (Product is mandated through Acaria Specialty Pharmacy.) ADDERALL XR CAP adefovir dipivoxil tab (HEPSERA equiv) ADVAIR DISKUS ADVAIR HA AEROCHAMBER AEROSPAN HA AINITOR DISPERZ (= 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) Special Code Tier Category MSP PA PA PA PASP SP PASP DERMATOLOGICALS DERMATOLOGICALS ANTIDIABETICS BETA BLOCKERS ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS NONNARCOTIC DIURETICS DIURETICS DIURETICS OTIC AGENTS OTIC AGENTS OTIC AGENTS COUGH/COLD/ALLERGY VAGINAL PRODUCTS DERMATOLOGICALS ANTINEOPLASTICS AND ADJUNCTIVE ANTIVIRALS DERMATOLOGICALS ANTIVIRALS ANTIVIRALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS CARDIOVASCULAR AGENTS MISC. ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIVIRALS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS MEDICAL DEVICES ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTINEOPLASTICS AND ADJUNCTIVE IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 1 of 99

7 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name AINITOR TAB (= 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) AGGRENOX CAP ALAMAST OPHTH SOLN albuterol neb. solution 0.083% albuterol neb. solution 0.5% albuterol sulfate er (VOSPIRE ER equiv) albuterol sulfate syrup albuterol sulfate tab albuterol/ipratropium nebulizer solution (DUONEB equiv) alclometasone cream (ACLOVATE equiv) alclometasone oint (ACLOVATE OINT equiv) ALCOHOL SWABS ALCOHOL WIPES alendronate tab (OSAMAX equiv) ALENDRONATE TAB 40MG ALERONN INJ alfuzosin hcl tab (UROXATRAL equiv) ALINIA SUSP ALKERAN TAB allopurinol tab (ZYLOPRIM equiv) ALOMIDE OPHTH SOLN alprazolam (XANAX equiv) aluminum chloride soln (DRYSOL equiv) ALUMINUM HYDROXIDE GEL SUSP. amcinonide cream (CYCLOCORT CREAM equiv) AMCINONIDE CREAM 0.1% AMCINONIDE OINT amiloride tab (MIDAMOR equiv) amiloride/hydrochlorothiazide tab aminocaproic acid syrup (AMICAR equiv) aminocaproic acid tab (AMICAR equiv) AMINOCAPROIC ACID/AMICAR 1000MG aminophylline tab amiodarone tab (PACERONE equiv) amitriptyline amlodipine tab (NORVASC equiv) amlodipine/ valsartan tab (EXORGE TAB equiv) amlodipine/atorvastatin tab (CADUET equiv) amlodipine/benazepril cap (LOTREL equiv) ammonium lactate cream ammonium lactate lotion amnesteem cap (ACCUTANE equiv) Special Code Tier Category PASP ANTINEOPLASTICS AND ADJUNCTIVE HEMATOLOGICAL AGENTS MISC. OPHTHALMIC AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS DERMATOLOGICALS DERMATOLOGICALS MEDICAL DEVICES DERMATOLOGICALS ENDOCRINE AND METABOLIC AGENTS MISC. ENDOCRINE AND METABOLIC AGENTS MISC. MSP ANTINEOPLASTICS AND ADJUNCTIVE GENITOURINARY AGENTS MISCELLANEOUS ANTIINECTIVE AGENTS MISC. ANTINEOPLASTICS AND ADJUNCTIVE GOUT AGENTS OPHTHALMIC AGENTS ANTIANXIETY AGENTS DERMATOLOGICALS ANTACIDS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DIURETICS DIURETICS HEMOSTATICS HEMOSTATICS HEMOSTATICS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIARRHYTHMICS ANTIDEPRESSANTS CALCIUM CHANNEL BLOCKERS ANTIHYPERTENSIVES CARDIOVASCULAR AGENTS MISC. ANTIHYPERTENSIVES DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 2 of 99

8 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name AMOXAPINE TAB amoxicillin cap amoxicillin chew tab AMOXICILLIN CHEW TAB 250MG amoxicillin susp (AMOXIL equiv) amoxicillin tab amoxicillin/clavulanate chew tab (AUGMENTIN equiv) amoxicillin/clavulanate susp (AUGMENTIN ES equiv) amoxicillin/clavulanate tab (AUGMENTIN equiv) amphetamine/dextroamphetamine tab (ADDERALL equiv) ampicillin cap AMPYRA TAB ( = 2 tab/day) anagrelide cap (AGRYLIN equiv) anastrozole tab (ARIMIDEX equiv) ANDROGEL 1.62% 1.25GM (= 1 packet/ day) ANDROGEL 1.62% 2.5GM (= 2 packet/ day) ANDROGEL 25MG (= 1 packet/day) ANDROGEL 50MG ( = 2 packets/day) ANDROGEL PUMP 1% ( = 4 bottle/30 days) ANDROGEL PUMP 1.62% ( = 2 bottle/30 days) ANDROXY TAB ANORO ELLIPTA INHALER antacid chew tab antinausea soln. antipyrine/benzocaine otic soln (AURALGAN OTIC equiv) APEXICON E CREAM (PSORCON E equiv) APHTHASOL PASTE APOKYN INJ. apraclonidine ophth soln (IOPIDINE equiv) apri tab (DESOGEN equiv) APRISO CAP aranelle tab (TRINORINYL equiv) artificial tears oint artificial tears soln ascorbic acid cap ascorbic acid chew tab ascorbic acid er tab ascorbic acid lozenge ascorbic acid syrup ascorbic acid tab ASCORBIC ACID WAER aspirin chew tab aspirin ec tab aspirin supp. aspirin tab ASPIRIN/ACETAMINOPHEN/CALCIUM CARBONATE TAB (COVERED OR MEMBERS 4 YEARS AND OLDER) aspirin/codeine tab Special Code Tier Category ANTIDEPRESSANTS PENICILLINS PENICILLINS PENICILLINS PENICILLINS PENICILLINS PENICILLINS PENICILLINS PENICILLINS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS PENICILLINS MSPPA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. HEMATOLOGICAL AGENTS MISC. ANTINEOPLASTICS AND ADJUNCTIVE PA ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA ANDROGENSANABOLIC PA ANDROGENSANABOLIC ANDROGENSANABOLIC ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTACIDS ANTIEMETICS OTIC AGENTS DERMATOLOGICALS MOUTH/THROAT/DENTAL AGENTS ANTIPARKINSON AGENTS OPHTHALMIC AGENTS CONTRACEPTIVES GASTROINTESTINAL AGENTS MISC. CONTRACEPTIVES OPHTHALMIC AGENTS OPHTHALMIC AGENTS VITAMINS VITAMINS VITAMINS VITAMINS VITAMINS MULTIVITAMINS VITAMINS ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS OPIOID IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 3 of 99

9 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name atenolol tab (TENORMIN equiv) atenolol/chlorthalidone tab (TENORETIC equiv) atorvastatin tab (LIPITOR equiv) atovaquone susp (MEPRON equiv) atovaquone/proguanil tab (MALARONE equiv) atropine ophth oint atropine ophth soln (ISOPTO ATROPINE equiv) ATROVENT HA AUBAGIO TAB ( = 1 tab/day) augmented betamethasone cream (DIPROLENE A CREAM equiv) augmented betamethasone lotion (DIPROLENE LOTION equiv) AVANDAMET TAB AVANDARYL TAB AVANDIA TAB AVC aviane tab (ALESSE equiv) AVODART AVONEX INJ (Product is mandated through Acaria Specialty Pharmacy.) AZASITE SOLN azathioprine tab (IMURAN equiv) azelastine nasal spray (ASTELIN equiv) AZILECT azithromycin susp (ZITHROMAX SUSP equiv) azithromycin tab (ZITHROMAX equiv) bacitracin oint BACITRACIN OPHTH OINT bacitracin/ neomycin/ polymyxin b ophth oint bacitracin/ polymyxin b ophth oint bacitracin/ polymyxin/ neomycin/ hydrocortisone ophth oint bacitracin/polymyxin b oint bacitracin/zinc oint. baclofen balsalazide cap (COLAZAL equiv) balziva tab (OVCON 35 equiv) BANZEL SUSP BANZEL TAB BD INSULIN SYRINGE BD PEN NEEDLE BELLADONNA ALKALOID/OPIUM SUPP. BELVIQ TAB ( = 2 tab/day) benazepril tab (LOTENSIN equiv) benazepril/hydrochlorothiazide tab (LOTENSIN HCT equiv) benzonatate cap (TESSALON equiv) benzoyl peroxide cream ( = 1 tube/30 day) benzoyl peroxide gel ( = 1 tube/30 day) benzoyl peroxide liquid ( = 1 bottle/30 day) benzoyl peroxide lotion ( = 1 bottle/30 day) Special Code Tier Category BETA BLOCKERS ANTIHYPERTENSIVES ANTIHYPERLIPIDEMICS ANTIINECTIVE AGENTS MISC. ANTIMALARIALS OPHTHALMIC AGENTS OPHTHALMIC AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS MSPPA PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. DERMATOLOGICALS DERMATOLOGICALS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS VAGINAL PRODUCTS CONTRACEPTIVES GENITOURINARY AGENTS MISCELLANEOUS MSP PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. OPHTHALMIC AGENTS ASSORTED CLASSES NASAL AGENTS SYSTEMIC AND TOPICAL ANTIPARKINSON AGENTS MACROLIDES MACROLIDES DERMATOLOGICALS OPHTHALMIC AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS DERMATOLOGICALS DERMATOLOGICALS MUSCULOSKELETAL THERAPY AGENTS GASTROINTESTINAL AGENTS MISC. CONTRACEPTIVES ANTICONVULSANTS ANTICONVULSANTS MEDICAL DEVICES MEDICAL DEVICES ULCER DRUGS PA ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES COUGH/COLD/ALLERGY DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 4 of 99

10 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name betamethasone augmented gel (DIPROLENE GEL equiv) betamethasone augmented oint (DIPROLENE OINT equiv) betamethasone diproprionate cream (DIPROSONE CREAM equiv) betamethasone diproprionate lotion betamethasone diproprionate oint (DIPROSONE OINT equiv) betamethasone valerate cream betamethasone valerate lotion betamethasone valerate oint betaxolol ophth soln betaxolol tab (KERLONE equiv) bethanechol tab (URECHOLINE equiv) BETIMOL OPHTH SOLN BETOPTICS OPHTH SOLN bicalutamide tab (CASODEX equiv) BILTRICIDE TAB BISACODYL ENEMA bisacodyl supp. bisacodyl tab bismuth subsalicylate chew tab bismuth subsalicylate susp. bismuth subsalicylate tab bisoprolol tab (ZEBETA equiv) bisoprolol/hydrochlorothiazide tab (ZIAC equiv) BLEPHAMIDE OPHTH SOLN BOSULI TAB (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) BREO ELLIPTA INHALER brimonidine ophth soln (ALPHAGAN P equiv) BROMDAY OPHTH SOLN bromfenac ophth soln (BROMDAY equiv) bromocriptine cap (PARLODEL equiv) bromocriptine tab (PARLODEL equiv) brompheniram/phenylephrine/dm soln (Only covered for members 4 years and older) budesonide susp (PULMICORT RESPULES equiv) bumetanide tab BUPHENYL TAB bupropion sr (WELLBUTRIN SR equiv) bupropion tab (ZYBAN equiv) (Limited to 180 days/plan year) bupropion XL tab (WELLBUTRIN XL equiv) buspirone tab (BUSPAR equiv) butorphanol nasal spray (STADOL equiv) (= Retail 1 bottle/fill, 2 fill/30 days; Mail Order 3 bottle/fill, 2 fill/90 days) BYDUREON INJ BYSTOLIC TAB cabergoline tab (DOSTINEX equiv) caffeine citrate oral soln (CACIT equiv) (Only covered for members less than 1 year old) Special Code Tier Category PASP SMKG DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS OPHTHALMIC AGENTS BETA BLOCKERS URINARY ANTISPASMODICS OPHTHALMIC AGENTS OPHTHALMIC AGENTS ANTINEOPLASTICS AND ADJUNCTIVE ANTHELMINTICS LAXATIVES LAXATIVES LAXATIVES ANTIDIARRHEALS ANTIDIARRHEALS ANTIDIARRHEALS BETA BLOCKERS ANTIHYPERTENSIVES OPHTHALMIC AGENTS ANTINEOPLASTICS AND ADJUNCTIVE ANTIASTHMATIC AND BRONCHODILATOR AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS COUGH/COLD/ALLERGY ANTIASTHMATIC AND BRONCHODILATOR AGENTS DIURETICS ENDOCRINE AND METABOLIC AGENTS MISC. ANTIDEPRESSANTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. ANTIDEPRESSANTS ANTIANXIETY AGENTS ANALGESICS OPIOID ANTIDIABETICS BETA BLOCKERS ENDOCRINE AND METABOLIC AGENTS MISC. ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 5 of 99

11 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name CALAMINE LOTION calcipotriene cream (DOVONEX CREAM equiv) calcipotriene oint calcipotriene soln (DOVONEX SOLN equiv) calcitriol cap (ROCALTROL equiv) calcitriol inj (CALCIJEX equiv) calcitriol soln (ROCALTROL SOLN. equiv) calcium acetate cap (PHOSLO equiv) CALCIUM ACETATE TAB ( = 9 tab/day) calcium and phosphorus w/vitamin D tab (RISACALD equiv) CALCIUM CARBONATE CAP calcium carbonate chew tab calcium carbonate susp. CALCIUM CARBONATE TAB calcium carbonate w/ vitamin d cap CALCIUM CARBONATE W/ VITAMIN D CHEW TAB calcium carbonate w/ vitamin d tab calcium carbonate w/ vitamind D chew tab calcium carbonate w/ vitamind D tab CALCIUM CARBONATE/GLUCONATE W/ VITAMIN D TAB calcium citrate tab calcium citrate w/ vitamin d tab CALCIUM GLUCONATE TAB calcium lactate tab calcium plycarbophil tab (IBERCON equiv) CANASA candesartan/hydrochlorothiazide tab (ATACAND HCT equiv) capecitabine tab (XELODA equiv) (Product is mandated through Acaria Specialty Pharmacy.) CAPRELSA TAB (Only available through Biologics ) capsaicin cream capsaicin pad captopril tab (CAPOTEN equiv) captopril/hydrochlorothiazide tab (CAPOZIDE equiv) CARAATE SUSP carbamazepine cap (CARBATROL equiv) carbamazepine chew tab (TEGRETOL CHEW equiv) carbamazepine susp. (TEGRETOL SUSP. equiv) carbamazepine tab (TEGRETOL equiv) carbamide peroxide otic drop carbidopa tab (LODOSYN equiv) CARBIDOPA/ LEVODOPA/ ENTACAPONE TAB (STALEVO TAB equiv) carbidopa/levodopa (SINEMET equiv) carbidopa/levodopa ER (SINEMET CR equiv) carbidopa/levodopa ODT (PARCOPA equiv) carisoprodol tab (SOMA equiv) carisoprodol/aspirin carteolol ophth soln Special Code Tier Category DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ENDOCRINE AND METABOLIC AGENTS MISC. MSP ENDOCRINE AND METABOLIC AGENTS MISC. ENDOCRINE AND METABOLIC AGENTS MISC. GASTROINTESTINAL AGENTS MISC. MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES ANTACIDS MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES LAXATIVES GASTROINTESTINAL AGENTS MISC. ANTIHYPERTENSIVES SP ANTINEOPLASTICS AND ADJUNCTIVE LDPA ANTINEOPLASTICS AND ADJUNCTIVE DERMATOLOGICALS DERMATOLOGICALS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ULCER DRUGS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS OTIC AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS ANTIPARKINSON AGENTS MUSCULOSKELETAL THERAPY AGENTS MUSCULOSKELETAL THERAPY AGENTS OPHTHALMIC AGENTS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 6 of 99

12 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name carvedilol tab (COREG equiv) CAYSTON INH SOLN (Only available through Cystic ibrosis Services or oundation Care Pharmacy ) CEENU CAP cefadroxil cap (DURICE equiv) cefadroxil susp (DURICE equiv) cefadroxil tab (DURICE equiv) cefdinir (OMNICE equiv) cefdinir cap (OMNICE equiv) cefprozil susp (CEZIL equiv) cefprozil tab (CEZIL equiv) cefuroxime susp (CETIN equiv) cefuroxime tab (CETIN equiv) celecoxib cap (CELEBREX CAP equiv) ( = 2 cap/ day) CELONTIN CAP cephalexin cap cephalexin susp CEPHALEXIN TAB cesia tab (CYCLESSA equiv) cetirizine chew ( = 1 TAB/DAY) cetirizine syrup (ZYRTEC equiv) cetirizine tab ( = 1 TAB/DAY) cetirizine/pseudoephedrine tab ( = 1 TAB/DAY) cevimeline cap (EVOXAC equiv) CHANTIX TAB (Limited to 180 days/plan year) CHEMET CAP chlordiazepoxide (LIBRIUM equiv) chlordiazepoxide/amitriptyline (LIMBITROL equiv) chlorhexidine gluconate liquid (HIBICLENS equiv) chlorhexidine gluconate soln chloroquine tab (ARALEN equiv) chlorothiazide tab CHLOROTHIAZIDE TAB 250MG chlorpheniramine cr tab (Only covered for members 2 years and older) chlorpheniramine syrup (Only covered for members 2 years and older) chlorpheniramine tab (Only covered for members 2 years and older) chlorpheniramine/acetaminophen tab (Only covered for members 4 years and older) chlorpheniramine/phenylephrine/apap effer tab (COVERED OR MEMBERS 419 YEARS) chlorpheniramine/phenylephrine/apap susp. (COVERED OR MEMBERS 419 YEARS ) chlorpheniramine/phenylephrine/apap tab (COVERED OR MEMBERS 419 YEARS) CHLORPHENIRAMINE/PSEUDOEPHEDRINE/IBUPROEN TAB (Only covered for members 4 years and older) chlorpropamide tab (DIABINESE equiv) CHLORTHALIDONE TAB chlorzoxazone (PARAON ORTE equiv) CHO MAG TRIS TAB Special Code Tier Category BETA BLOCKERS LDPA ANTIINECTIVE AGENTS MISC. SMKG ANTINEOPLASTICS AND ADJUNCTIVE CEPHALOSPORINS CEPHALOSPORINS CEPHALOSPORINS CEPHALOSPORINS CEPHALOSPORINS CEPHALOSPORINS CEPHALOSPORINS CEPHALOSPORINS CEPHALOSPORINS ANALGESICS ANTIINLAMMATORY ANTICONVULSANTS CEPHALOSPORINS CEPHALOSPORINS CEPHALOSPORINS CONTRACEPTIVES ANTIHISTAMINES ANTIHISTAMINES ANTIHISTAMINES COUGH/COLD/ALLERGY MOUTH/THROAT/DENTAL AGENTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. ANTIDOTES ANTIANXIETY AGENTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. ANTISEPTICS & DISINECTANTS MOUTH/THROAT/DENTAL AGENTS ANTIMALARIALS DIURETICS DIURETICS ANTIHISTAMINES ANTIHISTAMINES ANTIHISTAMINES COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY ANTIDIABETICS DIURETICS MUSCULOSKELETAL THERAPY AGENTS ANALGESICS NONNARCOTIC IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 7 of 99

13 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name cholecalciferol cap cholecalciferol oral soln. cholecalciferol tab cholestyramine lite powder (QUESTRAN LITE equiv) cholestyramine lite powder pack (QUESTRAN LITE equiv) cholestyramine powder (QUESTRAN equiv) cholestyramine powder pack (QUESTRAN equiv) choline magnesium trisalicylate tab CHROMAGEN ORTE TAB CHROMAGEN TAB ciclopirox cream (LOPROX CREAM equiv) ciclopirox gel (LOPROX GEL equiv) ciclopirox nail soln (PENLAC equiv) ciclopirox shampoo (LOPROX SHAMPOO equiv) ciclopirox topical susp (LOPROX SUSP equiv) cilostazol tab (PLETAL equiv) cimetidine (TAGAMET equiv) cimetidine soln CIPRODEX OTIC SUSP ciprofloxacin ophth soln (CILOXAN equiv) ciprofloxacin susp (CIPRO equiv) ciprofloxacin tab (CIPRO equiv) citalopram oral soln. (CELEXA equiv) citalopram tab (CELEXA equiv) clarithromycin susp (BIAXIN equiv) clarithromycin tab (BIAXIN equiv) CLARITIN REDITAB ( = 1 tab/day) clemastine fumarate tab clindamycin cap 150mg clindamycin cap 75mg (CLEOCIN equiv) clindamycin gel (CLEOCIN GEL equiv) clindamycin topical (CLEOCINT equiv) clindamycin vaginal cream (CLEOCIN VAGINAL CREAM equiv) CLINISTIX clobetasol propionate cream (TEMOVATE CREAM equiv) clobetasol propionate emollient cream (TEMOVATE E equiv) clobetasol propionate gel (TEMOVATE GEL equiv) clobetasol propionate oint (TEMOVATE OINT equiv) clobetasol propionate soln (TEMOVATE SOLN equiv) clonazepam tab (KLONOPIN equiv) clonidine patch (CATAPRESTTS equiv) clonidine tab (CATAPRES equiv) clopidogrel tab 75mg (PLAVIX 75MG TAB equiv) clorazepate (TRANXENET equiv) clotrimazole cream clotrimazole soln. clotrimazole troches (MYCELEX TROCHES equiv) clotrimazole vaginal cream clotrimazole/betamethasone cream (LORTRISONE CREAM equiv) clotrimazole/betamethasone lotion (LOTRISONE LOTION equiv) CLOVERINE OINT Special Code Tier Category VITAMINS VITAMINS VITAMINS ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS ANALGESICS NONNARCOTIC HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS HEMATOLOGICAL AGENTS MISC. ULCER DRUGS ULCER DRUGS OTIC AGENTS OPHTHALMIC AGENTS LUOROQUINOLONES LUOROQUINOLONES ANTIDEPRESSANTS ANTIDEPRESSANTS MACROLIDES MACROLIDES ANTIHISTAMINES ANTIHISTAMINES ANTIINECTIVE AGENTS MISC. ANTIINECTIVE AGENTS MISC. DERMATOLOGICALS DERMATOLOGICALS VAGINAL PRODUCTS DIAGNOSTIC PRODUCTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ANTICONVULSANTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES HEMATOLOGICAL AGENTS MISC. ANTIANXIETY AGENTS DERMATOLOGICALS DERMATOLOGICALS MOUTH/THROAT/DENTAL AGENTS VAGINAL PRODUCTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 8 of 99

14 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name codeine sulfate tab COLCHICINE TAB (COLCRYS TAB equiv) colchicine/probenecid tab colestipol tab (COLESTID equiv) COLYMYCIN S OTIC SUSP COMBIVENT INHALER COMBIVENT RESPIMAT COMETRIQ KIT (Limited to 2x15 day fills per month for first 3 months; Only available through Diplomat Pharmacy ) CONEX TAB (Only covered for members 4 years and older) CONTRACEPTIVE ILM CONTRACEPTIVE OAM CONTRACEPTIVE GEL CONTRACEPTIVE SUPP. COPAXONE INJ (Product is mandated through Acaria Specialty Pharmacy.) CORTE TAB CORTISONE ACETATE TAB CREON CAP cromolyn nasal spray CROMOLYN NEB SOLN. cromolyn nebulizer solution (INTAL equiv) cromolyn ophth soln (CROLOM equiv) cromolyn soln. (GASTROCROM equiv) cryselle tab (LO/OVRAL equiv) CUPRIMINE CAP cyanocobalamin inj cyanocobalamine er tab cyanocobalamine lozenge cyanocobalamine sl tab cyanocobalamine tab cyclobenzaprine 10mg (LEXERIL equiv) cyclobenzaprine 5mg (LEXERIL equiv) CYCLOGYL OPHTH SOLN 0.5%, 2% CYCLOMYDRIL OPHTH SOLN cyclopentolate ophth soln (CYCLOGYL equiv) CYCLOPHOSPHAMIDE CAP cyclophosphamide tab cyclosporine cap (SANDIMMUNE equiv) cyclosporine modified cap (NEORAL equiv) CYCLOSPORINE MODIIED CAP 50MG cyclosporine modified soln (NEORAL equiv) cyproheptadine syrup cyproheptadine tab CYSTAGON (Only available through PharmaCare ) CYTRA3 SYRUP (POLYCITRA SYRUP equiv) Special Code Tier Category LDPA MSP ANALGESICS OPIOID GOUT AGENTS GOUT AGENTS ANTIHYPERLIPIDEMICS OTIC AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTINEOPLASTICS AND ADJUNCTIVE COUGH/COLD/ALLERGY VAGINAL PRODUCTS VAGINAL PRODUCTS VAGINAL PRODUCTS VAGINAL PRODUCTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. CORTICOSTEROIDS CORTICOSTEROIDS DIGESTIVE AIDS NASAL AGENTS SYSTEMIC AND TOPICAL ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS OPHTHALMIC AGENTS GASTROINTESTINAL AGENTS MISC. CONTRACEPTIVES ASSORTED CLASSES HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS MUSCULOSKELETAL THERAPY AGENTS MUSCULOSKELETAL THERAPY AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE ASSORTED CLASSES ASSORTED CLASSES ASSORTED CLASSES ASSORTED CLASSES ANTIHISTAMINES ANTIHISTAMINES GENITOURINARY AGENTS MISCELLANEOUS GENITOURINARY AGENTS MISCELLANEOUS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 9 of 99

15 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name danazol cap (DANOCRINE equiv) dantrolene cap (DANTRIUM equiv) DANTROLENE CAP 100MG (DANTRIUM equiv) DAPSONE TAB DARAPRIM TAB demeclocycline tab (DECLOMYCIN equiv) DENAVIR CREAM desipramine (NORPRAMINE equiv) desmopressin acetate inj (DDAVP equiv) desmopressin acetate tab (DDAVP equiv) desmopressin nasal soln (DDAVP equiv) desonide cream desonide lotion desonide oint desoximetasone cream 0.25% (TOPICORT CREAM 0.25% equiv) desoximetasone gel (TOPICORT equiv) desoximetasone oint 0.25% (TOPICORT equiv) DEXAMETHASONE CONC dexamethasone ophth soln dexamethasone soln dexamethasone tab (DECADRON equiv) dextroamphetamine ER cap (DEXEDRINE equiv) dextroamphetamine tab (DEXEDRINE equiv) DEXTROMETHOR/ACETAMIN/DIPHEN LIQUID (COVERED OR MEMBERS 4 YEARS AND OLDER) dextromethorphan cap (Only covered for members 4 years and older) dextromethorphan er liquid (Only covered for members 4 years and older) dextromethorphan hb/doxylamine soln. (Only covered for members 4 years and older) dextromethorphan hbr/chlorpheniramine liquid (Only covered for members 4 years and older) dextromethorphan hbr/chlorpheniramine tab (Only covered for members 4 years and older) dextromethorphan liquid (Only covered for members 4 years and older) DEXTROMETHORPHAN LOZENGE (Only covered for members 4 years and older) dextromethorphan syrup (Only covered for members 4 years and older) dextromethorphan/phenylephrine liquid (Only covered for members 4 years and older) DEXTROMETHORPHAN/PHENYLEPHRINE STRIP (Only covered for members 4 years and older) DEXTROMETHORPHAN/PSEUDOEPHED DROPS (Only covered for members 4 years and older) DEXTROMETHORPHAN/PSEUDOEPHED ELIXIR (Only covered for members 4 years and older) dextromethorphan/pseudoephed syrup (Only covered for members 4 years and older) DEXTROMETHORPHN/ACETAMINOPH/CP LIQUID (COVERED OR MEMBERS 4 YEARS AND OLDER) dextromethorphn/acetaminoph/cp susp (COVERED OR MEMBERS 4 YEARS AND OLDER) Special Code Tier Category ANDROGENSANABOLIC MUSCULOSKELETAL THERAPY AGENTS MUSCULOSKELETAL THERAPY AGENTS ANTIINECTIVE AGENTS MISC. ANTIMALARIALS TETRACYCLINES DERMATOLOGICALS ANTIDEPRESSANTS ENDOCRINE AND METABOLIC AGENTS MISC. ENDOCRINE AND METABOLIC AGENTS MISC. ENDOCRINE AND METABOLIC AGENTS MISC. DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS CORTICOSTEROIDS OPHTHALMIC AGENTS CORTICOSTEROIDS CORTICOSTEROIDS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 10 of 99

16 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name dextromethorphn/acetaminoph/cp tab (COVERED OR MEMBERS 4 YEARS AND OLDER ) dialyvite tab (NEPHROVITE equiv) diazepam conc. DIAZEPAM SOLN diazepam tab (VALIUM equiv) DIAZEPAM/DIASTAT RECTAL GEL DIBENZYLINE CAP diclofenac potassium tab (CATALAM equiv) diclofenac sodium EC tab (VOLTAREN equiv) diclofenac sodium ophth (VOLTAREN equiv) diclofenac sodium XR tab (VOLTAREN XR equiv) dicloxacillin cap dicyclomine cap (BENTYL equiv) DICYCLOMINE SOLN dicyclomine tab (BENTYL equiv) didanosine DR cap (VIDEX EC equiv) DIETHYLTOLUAMIDE LOTION DIICID TAB (Step Therapy requires trial of VANCOCIN; = 20 tab/fill) DILORASONE CREAM diflorasone oint diflunisal (DOLOBID equiv) digoxin tab (LANOXIN equiv) dihydroergotamine (D.H.E. equiv) DILANTIN CAP 30MG diltiazem ER cap diltiazem tab (CARDIZEM equiv) dimenhydrin tab dimethicone gel diphenhydramine cap (Only covered for members 2 years and older) diphenhydramine chew tab (Only covered for members 2 years and older) diphenhydramine cream diphenhydramine gel diphenhydramine liquid (Only covered for members 2 years and older) diphenhydramine rapid tab (Only covered for members 2 years and older) diphenhydramine spray DIPHENHYDRAMINE STRIP (Only covered for members 2 years and older) diphenhydramine syrup (Only covered for members 2 years and older) diphenhydramine tab (Only covered for members 2 years and older) diphenhydramine/acetaminophen tab (Only covered for members 4 years and older) DIPHENHYDRAMINE/APAP LIQUID (COVERED OR MEMBERS 4 YEARS AND OLDER) diphenhydramine/apap tab (COVERED OR MEMBERS 4 YEARS AND OLDER) diphenhydramine/phenylephrine/apap liquid (COVERED OR MEMBERS 419 YEARS) diphenhydramine/phenylephrine/apap susp. (COVERED OR MEMBERS 419 YEARS) diphenhydramine/phenylephrine/apap tab (COVERED OR MEMBERS 419 YEARS) diphenoxylate/atropine liquid (LOMOTIL equiv) Special Code Tier Category COUGH/COLD/ALLERGY MULTIVITAMINS ANTIANXIETY AGENTS ANTIANXIETY AGENTS ANTIANXIETY AGENTS ANTICONVULSANTS ANTIHYPERTENSIVES ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY OPHTHALMIC AGENTS ANALGESICS ANTIINLAMMATORY PENICILLINS ULCER DRUGS ULCER DRUGS ULCER DRUGS SP ANTIVIRALS DERMATOLOGICALS ST MACROLIDES DERMATOLOGICALS DERMATOLOGICALS ANALGESICS NONNARCOTIC CARDIOTONICS MIGRAINE PRODUCTS ANTICONVULSANTS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS ANTIEMETICS DERMATOLOGICALS ANTIHISTAMINES ANTIHISTAMINES DERMATOLOGICALS DERMATOLOGICALS ANTIHISTAMINES ANTIHISTAMINES DERMATOLOGICALS ANTIHISTAMINES ANTIHISTAMINES ANTIHISTAMINES COUGH/COLD/ALLERGY HYPNOTICS HYPNOTICS COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY ANTIDIARRHEALS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 11 of 99

17 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name diphenoxylate/atropine tab (LOMOTIL equiv) dipyridamole tab (PERSANTINE equiv) disopyramide cap (NORPACE equiv) disopyramide ER cap (NORPACE CR equiv) disulfiram tab (ANTABUSE equiv) DIURIL ORAL SOLN divalproex ER tab (DEPAKOTE ER equiv) divalproex sprinkle cap (DEPAKOTE SPRINKLE equiv) divalproex tab (DEPAKOTE equiv) dm hb/pe/acetaminophen/chlorpheniramine liquid (Only covered for members 4 years and older) dm hb/pe/acetaminophen/chlorpheniramine susp. (Only covered for members 4 years and older) dm hb/pe/acetaminophen/chlorpheniramine tab (Only covered for members 4 years and older) dm hb/pseudoephed/acetamin/cp cap (Only covered for members 4 years and older) dm hb/pseudoephed/acetamin/cp packet (Only covered for members 4 years and older) dm hb/pseudoephed/acetamin/cp susp (Only covered for members 4 years and older) dm hb/pseudoephed/acetamin/cp tab (Only covered for members 4 years and older) dm/pe/acetaminophen/doxylamine liquid (Only covered for members 4 years and older) dm/pephed/acetaminoph/doxylam cap (Only covered for members 4 years and older) dm/pephed/acetaminoph/doxylam liquid (COVERED OR MEMBERS 419 YEARS) DM/PHENYLEPH/CHLORPHENIRAMINE LIQUID (Only covered for members 4 years and older) DM/PHENYLEPH/CHLORPHENIRAMINE SOLN. (Only covered for members 4 years and older) dm/pseudoephed/acetaminophen cap (COVERED OR MEMBERS 4 YEARS AND OLDER) dm/pseudoephed/acetaminophen tab (COVERED OR MEMBERS 4 YEARS AND OLDER) dmethorphan hb/acetaminophen liquid (Only covered for members 4 years and older) dmethorphan hb/pepd hcl/bpm elixir (Only covered for members 4 years and older) dmethorphan hb/pepd hcl/bpm syrup (Only covered for members between 2 and 4 years old) DMETHORPHAN HB/PEPHED HCL/CP CHEW TAB (Only covered for members 4 years and older) dmethorphan hb/pephed hcl/cp liquid (Only covered for members 4 years and older) DMETHORPHAN HB/PEPHED HCL/CP SYRUP (Only covered for members 4 years and older) dmethorphan/acetamin/doxylamn cap (COVERED OR MEMBERS 4 YEARS AND OLDER) dmethorphan/acetamin/doxylamn liquid (COVERED OR MEMBERS 4 YEARS AND OLDER) dmethorphan/pe/acetaminophen cap (Only covered for members 4 years and older) dmethorphan/pe/acetaminophen liquid (Only covered for members 4 years and older) Special Code Tier Category ANTIDIARRHEALS HEMATOLOGICAL AGENTS MISC. ANTIARRHYTHMICS ANTIARRHYTHMICS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. DIURETICS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 12 of 99

18 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name dmethorphan/pe/acetaminophen tab (Only covered for members 4 years and older) docusate calcium cap docusate sodium cap docusate sodium enema docusate sodium liquid docusate sodium syrup docusate sodium tab donepezil ODT (ARICEPT ODT equiv) (=1 tab/day) donepezil tab (ARICEPT equiv) (=2 tabs/day) donepezil tab 23mg (ARICEPT TAB 23MG equiv) (Step Therapy requires trial of donepezil 10mg; = 1 tab/day) dorzolamide ophth soln (TRUSOPT equiv) dorzolamide/ timolol ophth soln (COSOPT equiv) doxazosin tab (CARDURA equiv) doxepin cap doxercalciferol cap (HECTOROL equiv) (Product is mandated through Acaria Specialty Pharmacy.) doxycycline hyclate cap (VIBRAMYCIN equiv) doxycycline hyclate tab (VIBRATAB equiv) doxycycline monohydrate cap doxycycline monohydrate tab (ADOXA equiv) doxycycline susp doxylamine succinate tab dronabinol cap (MARINOL equiv) DROXIA CAP DULCOLAX BOWEL PREP KIT DULERA INHALER duloxetine cap (CYMBALTA equiv) ( = 2 cap/day) DUREZOL OPHTH EMULSION DYRENIUM CAP econazole cream (SPECTAZOLE CREAM equiv) EDECRIN TAB EIENT TAB ELIDEL CREAM ELIQUIS TAB ELLA TAB ELMIRON EMCYT CAP EMEND CAP (= 3 tab/day; Product is mandated through Acaria Specialty Pharmacy.) enalapril tab (VASOTEC equiv) enalapril/hydrochlorothiazide tab (VASERETIC equiv) ENBREL INJ (= 4 syringes/28 days; Product is mandated through Acaria Specialty Pharmacy.) ENBREL SURECLICK INJ (= 4 syringes/28 days; Product is mandated through Acaria Specialty Pharmacy.) ENDOMETRIN enoxaparin inj (LOVENOX equiv) (= 17 days supply; Product is mandated through Acaria Specialty Pharmacy.) Special Code Tier Category COUGH/COLD/ALLERGY LAXATIVES LAXATIVES LAXATIVES LAXATIVES LAXATIVES LAXATIVES PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. ST PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. OPHTHALMIC AGENTS OPHTHALMIC AGENTS ANTIHYPERTENSIVES ANTIDEPRESSANTS SP ENDOCRINE AND METABOLIC AGENTS MISC. TETRACYCLINES TETRACYCLINES TETRACYCLINES TETRACYCLINES TETRACYCLINES HYPNOTICS PA ANTIEMETICS HEMATOPOIETIC AGENTS LAXATIVES ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIDEPRESSANTS OPHTHALMIC AGENTS DIURETICS DERMATOLOGICALS DIURETICS HEMATOLOGICAL AGENTS MISC. DERMATOLOGICALS ANTICOAGULANTS CONTRACEPTIVES GENITOURINARY AGENTS MISCELLANEOUS ANTINEOPLASTICS AND ADJUNCTIVE SP ANTIEMETICS ANTIHYPERTENSIVES ANTIHYPERTENSIVES MSPPA ANALGESICS ANTIINLAMMATORY MSPPA ANALGESICS ANTIINLAMMATORY PA VAGINAL PRODUCTS SP ANTICOAGULANTS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 13 of 99

19 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name enpresse tab (TRILEVELEN equiv) entacapone tab (COMTAN equiv) entecavir tab (BARACLUDE equiv) (=1 tab/day. Product is mandated through Acaria Specialty Pharmacy.) EPANED SOLN EPHEDRINE SULATE CAP (COVERED OR MEMBERS 4 YEARS AND OLDER) EPIOAM AEROSOL EPIPEN INJ (=2 units/fill) EPIPENJR INJ (=2 units/fill) EPOGEN INJ (Product is mandated through Acaria Specialty Pharmacy.) eprosartan mesylate tab (TEVETEN equiv) EQUETRO ergocalciferol soln. ERGOCALCIEROL TAB ERIVEDGE CAP (Limited to 2x15 day fills per month for first 3 months) ERYPED SUSP erythromycin cap ERYTHROMYCIN ETHYLSUCCINATE TAB erythromycin gel erythromycin ophth oint erythromycin pad erythromycin soln ERYTHROMYCIN TAB (all forms except PCE) erythromycin/sulfisoxazole susp (PEDIAZOLE equiv) escitalopram soln (LEXAPRO SOLN equiv) escitalopram tab (LEXAPRO equiv) estazolam tab (PROSOM equiv) estradiol patch (VIVELLEDOT PATCH equiv) estradiol tab (ESTRACE equiv) ESTRING (3 copays per Rx) estropipate tab (OGEN equiv) eszopiclone tab (LUNESTA equiv) (=1 tab/day) ethambutol tab (MYAMBUTOL tab equiv) ethosuximide cap (ZARONTIN equiv) ethosuximide soln. (ZARONTIN equiv) etodolac cap etodolac tab etoposide cap EURAX CREAM EXELON PATCH EXELON SOLN. exemestane tab (AROMASIN equiv) EXJADE TAB eye wash soln. famotidine (PEPCID equiv) famotidine susp (PEPCID SUSP equiv) famotidine tab 10mg Special Code Tier Category CONTRACEPTIVES ANTIPARKINSON AGENTS MSP ANTIVIRALS ANTIHYPERTENSIVES ANTIASTHMATIC AND BRONCHODILATOR AGENTS DERMATOLOGICALS VASOPRESSORS VASOPRESSORS MSP HEMATOPOIETIC AGENTS ANTIHYPERTENSIVES ANTIPSYCHOTICS/ANTIMANIC AGENTS VITAMINS VITAMINS MSPPA ANTINEOPLASTICS AND ADJUNCTIVE MACROLIDES MACROLIDES MACROLIDES DERMATOLOGICALS OPHTHALMIC AGENTS DERMATOLOGICALS DERMATOLOGICALS MACROLIDES ANTIINECTIVE AGENTS MISC. ANTIDEPRESSANTS ANTIDEPRESSANTS HYPNOTICS ESTROGENS ESTROGENS VAGINAL PRODUCTS ESTROGENS HYPNOTICS ANTIMYCOBACTERIAL AGENTS ANTICONVULSANTS ANTICONVULSANTS ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY SP ANTINEOPLASTICS DERMATOLOGICALS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. ANTINEOPLASTICS AND ADJUNCTIVE MSP ANTIDOTES OPHTHALMIC AGENTS ULCER DRUGS ULCER DRUGS ULCER DRUGS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 14 of 99

20 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name ARESTON TAB ARXIGA TAB (= 1 tab/day) felbamate (ELBATOL equiv) felbamate susp. (ELBATOL SUSP. equiv) ELBATOL TAB EMALE CONDOMS fenofibrate cap (LOIBRA equiv) fenofibric acid DR cap (TRILIPIX equiv) fenoprofen calcium tab fentanyl patch (DURAGESIC equiv) ferrex 150 forte cap (NIEREX 150 ORTE equiv) ERRIPROX TAB (Only available through erriprox Total Care ) ferrous gluconate tab ferrous sulfate dr tab ferrous sulfate drops ferrous sulfate elixir ferrous sulfate er tab ERROUS SULATE LIQUID ferrous sulfate slow release tab ERROUS SULATE SYRUP ferrous sulfate tab IBER LIQUID INACEA INACEA PLUS KIT finasteride (PROSCAR equiv) flecainide tab (TAMBOCOR equiv) LEET ENEMA LOVENT DISKUS LOVENT HA fluconazole susp (DILUCAN equiv) fluconazole tab (DILUCAN equiv) flucytosine cap (ANCOBON equiv) fludrocortisone tab (LORINE equiv) flunisolide nasal spray (NASAREL equiv) (=2 bottles/fill) fluocinolone acetonide cream fluocinolone acetonide oint fluocinolone acetonide soln fluocinolone otic oil (DERMOTIC equiv) fluocinonide cream (LIDEX equiv) fluocinonide emollient cream fluocinonide gel fluocinonide oint fluocinonide soln LUORABON SOLN. fluorometholone ophth soln (ML LIQUIILM equiv) fluorouracil cream (EUDEX CREAM equiv) fluorouracil soln (EUDEX SOLN equiv) fluoxetine cap (PROZAC equiv) Special Code Tier Category ANTINEOPLASTICS AND ADJUNCTIVE ANTIDIABETICS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS MEDICAL DEVICES ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS ANALGESICS ANTIINLAMMATORY ANALGESICS OPIOID HEMATOPOIETIC AGENTS LDPA ANTIDOTES HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS LAXATIVES DERMATOLOGICALS DERMATOLOGICALS GENITOURINARY AGENTS MISCELLANEOUS ANTIARRHYTHMICS LAXATIVES ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIUNGALS ANTIUNGALS ANTIUNGALS CORTICOSTEROIDS NASAL AGENTS SYSTEMIC AND TOPICAL DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS OTIC AGENTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS MINERALS & ELECTROLYTES OPHTHALMIC AGENTS DERMATOLOGICALS DERMATOLOGICALS ANTIDEPRESSANTS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 15 of 99

21 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name fluoxetine liquid (PROZAC equiv) fluoxetine tab (PROZAC equiv) LURAZEPAM CAP flurbiprofen ophth soln (OCUEN equiv) flurbiprofen tab flutamide cap (EULEXIN equiv) fluticasone nasal spray (LONASE equiv) (=2 bottles/fill) fluticasone propionate cream (CUTIVATE equiv) fluticasone propionate lotion (CUTIVATE equiv) fluticasone propionate oint (CUTIVATE equiv) fluvastatin cap (LESCOL equiv) fluvoxamine (LUVOX equiv) fluvoxamine er cap (LUVOX CR equiv) (Step Therapy requires failure of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine) folbee plus cz tab (DIATX ZN equiv) folic acid tab fondaparinux soln (ARIXTRA equiv) (Product is mandated through Acaria Specialty Pharmacy.) ORADIL AEROLIZER ORTEO INJ (Product is mandated through Acaria Specialty Pharmacy.) ORTICAL NASAL SPRAY fosinopril tab (MONOPRIL equiv) fosinopril/hydrochlorothiazide tab (MONOPRIL HCT equiv) OSRENOL REESTYLE REEDOM LITE METER REESTYLE INSULINX TEST STRIP REESTYLE KIT INSULINX REESTYLE LITE METER REESTYLE METER REESTYLE TEST STRIP UNGOID SOLN UROSEMIDE SOLN furosemide tab (LASIX equiv) gabapentin cap (NEURONTIN equiv) gabapentin soln. (NEURONTIN SOLN equiv) gabapentin tab (NEURONTIN equiv) GABITRIL TAB 12MG, 16MG galantamine (RAZADYNE equiv) galantamine er (RAZADYNE ER equiv) GALANTAMINE SOLN (RAZADYNE SOLN equiv) GALZIN CAP GANCICLOVIR CAP GEL DRESSING ( = 2 box/30 day) gemfibrozil tab (LOPID equiv) GENOTROPIN INJ (Product is mandated through Acaria Specialty Pharmacy.) gentamicin ophth oint Special Code Tier Category ANTIDEPRESSANTS ANTIDEPRESSANTS HYPNOTICS OPHTHALMIC AGENTS ANALGESICS ANTIINLAMMATORY ANTINEOPLASTICS AND ADJUNCTIVE NASAL AGENTS SYSTEMIC AND TOPICAL DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ANTIHYPERLIPIDEMICS ANTIDEPRESSANTS ST ANTIDEPRESSANTS MULTIVITAMINS HEMATOPOIETIC AGENTS PASP ANTICOAGULANTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS MSP ENDOCRINE AND METABOLIC AGENTS MISC. ENDOCRINE AND METABOLIC AGENTS MISC. ANTIHYPERTENSIVES ANTIHYPERTENSIVES GASTROINTESTINAL AGENTS MISC. MEDICAL DEVICES DIAGNOSTIC PRODUCTS MEDICAL DEVICES MEDICAL DEVICES MEDICAL DEVICES DIAGNOSTIC PRODUCTS DERMATOLOGICALS DIURETICS DIURETICS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. MINERALS & ELECTROLYTES SP ANTIVIRALS DERMATOLOGICALS ANTIHYPERLIPIDEMICS MSPPA ENDOCRINE AND METABOLIC AGENTS MISC. OPHTHALMIC AGENTS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 16 of 99

22 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name gentamicin ophth soln gentamicin sulfate cream gentamicin sulfate oint gianvi tab/ ocella tab (YAZ/YASMIN equiv) GILOTRI TAB (=1 TAB/DAY) GLEEVEC TAB (= 3 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) glimepiride tab (AMARYL equiv) glipizide (GLUCOTROL equiv) glipizide ER tab (GLUCOTROL XL equiv) glipizide/metformin tab (METAGLIP equiv) GLUCAGEN HYPOKIT GLUCAGON KIT GLUCOSE CHEW TAB glucose gel GLUCOSE TAB glyburide micronized tab (GLYNASE equiv) glyburide tab (MICRONASE equiv) glyburide/metformin tab (GLUCOVANCE equiv) glycerin gel GLYCERIN LIQUID glycerin lotion GLYCERIN SHAMPOO glycerin suppository glycopyrrolate (ROBINUL equiv) granisetron tab (KYTRIL equiv) (= Retail 9 tabs/fill; Mail Order 27 tabs/fill) GRANIX INJ GRIULVIN SUSP griseofulvin micro tab (GRIULVIN V equiv) griseofulvin susp (GRIULVIN equiv) griseofulvin tab (GRISPEG equiv) guaifen/phenyleph/acetaminophn tab (Only covered for members 4 years and older) GUAIEN/PSEUDOEPHED/ACETAMINOP TAB (Only covered for members 4 years and older) guaifenesin ER tab (Only covered for members 4 years and older) guaifenesin liquid (Only covered for members 4 years and older) guaifenesin syrup (Only covered for members 4 years and older) guaifenesin tab (Only covered for members 4 years and older) guaifenesin/acetaminophen tab (Only covered for members 4 years and older) guaifenesin/codeine soln (BRONTEX equiv) guaifenesin/codeine syrup (TUSSIORGANI SYRUP equiv) (=240ml/per dispensing) guaifenesin/dextromethorphan cap (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/dextromethorphan liquid (COVERED OR MEMBERS 4 YEARS AND OLDER) GUAIENESIN/DEXTROMETHORPHAN PACK (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/dextromethorphan tab (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/dm/pseudoephedrine cap (COVERED OR MEMBERS 4 YEARS AND OLDER) Special Code Tier Category OPHTHALMIC AGENTS DERMATOLOGICALS DERMATOLOGICALS CONTRACEPTIVES PA ANTINEOPLASTICS AND ADJUNCTIVE PASP ANTINEOPLASTICS AND ADJUNCTIVE ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS DERMATOLOGICALS CHEMICALS DERMATOLOGICALS DERMATOLOGICALS LAXATIVES ULCER DRUGS ANTIEMETICS HEMATOPOIETIC AGENTS ANTIUNGALS ANTIUNGALS ANTIUNGALS ANTIUNGALS COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 17 of 99

23 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name guaifenesin/dmethorphan hb/pe liquid (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/dmethorphan hb/pe syrup (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/ephedrine hcl tab (Only covered for members 4 years and older) guaifenesin/phenylephrine hcl liquid (Only covered for members 4 years and older) guaifenesin/pseudoephedrne hcl cap (Only covered for members 4 years and older) guaifenesin/pseudoephedrne hcl syrup (Only covered for members 4 years and older) guanfacine IR tab (TENEX equiv) halobetasol propionate cream (ULTRAVATE equiv) halobetasol propionate oint (ULTRAVATE equiv) HARVONI TAB (=1 tab/day. Product is mandated through Acaria Specialty Pharmacy.) hc pramoxine cream (ANALPRAMHC equiv) hc pramoxine cream 11% (ANALPRAM HC equiv) HEMANGEOL SOLN (COVERED OR MEMBERS AGE 3 YEARS AND UNDER ONLY) HEXALEN CAP (Product is mandated through Acaria Specialty Pharmacy.) HIZENTRA INJ (Product is mandated through Acaria Specialty Pharmacy.) homatropine ophth soln (ISOPTO HOMATROPINE equiv) HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG PEN HUMALOG VIAL HUMIRA INJ (= 2 inj/28 days) HUMIRA PEN INJ (= 2 inj/28 days) HUMULIN 70/30 KWIKPEN HUMULIN 70/30 VIAL HUMULIN N KWIKPEN HUMULIN N U100 VIAL HUMULINR U100 HUMULINR U100 VIAL HYCAMTIN CAP (Product is mandated through Acaria Specialty Pharmacy.) hydralazine tab hydrochlorothiazide cap (MICROZIDE equiv) hydrochlorothiazide tab hydrocodone/acetaminophen soln (ZOLVIT SOLN equiv) hydrocodone/acetaminophen tab (LORTAB equiv) hydrocodone/homatropine syrup (HYCODAN equiv) hydrocortisone ac cream HYDROCORTISONE AC OINT hydrocortisone aloe cream HYDROCORTISONE ALOE OINT hydrocortisone butyrate cream (LOCOID equiv) hydrocortisone butyrate oint (LOCOID equiv) hydrocortisone butyrate soln (LOCOID equiv) hydrocortisone cream hydrocortisone enema Special Code Tier Category COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY ANTIHYPERTENSIVES DERMATOLOGICALS DERMATOLOGICALS MSPPA ANTIVIRALS ANORECTAL AGENTS ANORECTAL AGENTS BETA BLOCKERS SP ANTINEOPLASTICS AND ADJUNCTIVE MSP PASSIVE IMMUNIZING AGENTS OPHTHALMIC AGENTS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS MSPPA ANALGESICS ANTIINLAMMATORY MSPPA ANALGESICS ANTIINLAMMATORY ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS PASP ANTINEOPLASTICS ANTIHYPERTENSIVES DIURETICS DIURETICS ANALGESICS OPIOID ANALGESICS OPIOID COUGH/COLD/ALLERGY DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ANORECTAL AGENTS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 18 of 99

24 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name hydrocortisone gel hydrocortisone lotion hydrocortisone oint hydrocortisone tab (CORTE equiv) hydrocortisone topical soln. hydrocortisone valerate cream hydrocortisone valerate oint (WESTCORT equiv) HYDROGEN PEROXIDE SOLN. HYDROMORPHONE SUPP hydromorphone tab (DILAUDID equiv) hydroxychloroquine tab (PLAQUENIL equiv) hydroxyurea cap (HYDREA equiv) hydroxyzine pamoate (VISTARIL equiv) hydroxyzine syrup hydroxyzine tab hyoscyamine (LEVSIN equiv) hyoscyamine sulfate cr (LEVBID equiv) hyoscyamine sulfate sl tab (LEVSIN equiv) hyoscyamine tab (LEVSIN equiv) ibuprofen cap ibuprofen chew tab ibuprofen susp. ibuprofen tab ICLUSIG TAB 15MG (= 3 tab/day; Limited to 2x15 day fills per month for first 3 months; Only available through Biologics ) ICLUSIG TAB 45MG (= 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Only available through Biologics ) ILEVRO OPHTH SUSP imipramine (TORANIL equiv) imiquimod cream (ALDARA equiv) INCRELEX INJ (Product is mandated through Acaria Specialty Pharmacy.) indapamide tab INDOCIN SUPP. INDOCIN SUSP. indomethacin cap indomethacin CR cap (INDOCIN SR equiv) INANT ORMULA LIQUID INANT ORMULA POWDER INERGEN INJ (Product is mandated through Acaria Specialty Pharmacy.) INLYTA TAB (= 8 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) INTRONA INJ (Product is mandated through Acaria Specialty Pharmacy.) INTRONA KIT (Product is mandated through Acaria Specialty Pharmacy.) ipratropium nasal spray (ATROVENT equiv) ipratropium nebulizer solution (ATROVENT equiv) irbesartan tab (AVAPRO TAB equiv) irbesartan/hydrochlorothiazide tab (AVALIDE TAB equiv) Special Code Tier Category DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS CORTICOSTEROIDS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ANTISEPTICS & DISINECTANTS ANALGESICS OPIOID ANALGESICS OPIOID ANTIMALARIALS ANTINEOPLASTICS AND ADJUNCTIVE ANTIANXIETY AGENTS ANTIANXIETY AGENTS ANTIANXIETY AGENTS URINARY ANTISPASMODICS ULCER DRUGS ULCER DRUGS ULCER DRUGS ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY LDPA ANTINEOPLASTICS AND ADJUNCTIVE LDPA ANTINEOPLASTICS AND ADJUNCTIVE OPHTHALMIC AGENTS ANTIDEPRESSANTS DERMATOLOGICALS MSP ENDOCRINE AND METABOLIC AGENTS MISC. DIURETICS ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS MSP ANTIVIRALS PASP ANTINEOPLASTICS AND ADJUNCTIVE MSP ANTINEOPLASTICS AND ADJUNCTIVE MSP ANTINEOPLASTICS AND ADJUNCTIVE NASAL AGENTS SYSTEMIC AND TOPICAL ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 19 of 99

25 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name IRESSA TAB (Only available through Iressa Access Program ) isonarif cap (RIAMATE equiv) ISONIAZID SYRUP isoniazid tab ISOPTO CARBACHOL OPHTH SOLN ISOPTO HOMATROPINE OPHTH SOLN 2% ISOPTO HOMATROPINE OPHTH SOLN 5% ISOPTO HYOSCINE OPHTH SOLN isosorbide dinitrate ER tab isosorbide dinitrate SL tab isosorbide dinitrate tab isosorbide mononitrate ER tab (IMDUR equiv) isosorbide mononitrate tab (MONOKET equiv) isradipine cap itraconazole cap (SPORANOX equiv) IV PREP WIPES ivermectin tab (STROMECTOL TAB equiv) JAKAI TAB (=2 tabs/day) JALYN CAP JANUMET TAB JANUMET XR TAB JANUVIA TAB (= 1 tab/day) JARDIANCE TAB (=1 tab/day) junel E tab (LOESTRIN E equiv) junel tab (LOESTRIN equiv) JUVISYNC TAB KALYDECO TAB (=2 tab/day) kariva tab (MIRCETTE equiv) kelnor tab (DEMULEN equiv) ketoconazole cream (NIZORAL CREAM equiv) ketoconazole shampoo (NIZORAL SHAMPOO equiv) ketoconazole tab (NIZORAL equiv) KETODIASTIX ketoprofen cap ketorolac ophth soln (ACULAR/ACULAR LS equiv) ketorolac tab ( = 5 days treatment (20 tabs/5 days)) KETOSTIX ketotifen ophth soln KINERET INJ (= 28 inj/28 days; Product is mandated through Acaria Specialty Pharmacy.) KLORCON M15 CAP KOMBIGLYZE XR TAB KONSYL POWDER KONSYL POWDER PACKET KORLYM TAB (Only available through CuraScript ) KOVIA OINT KPHOS TAB KUVAN POWDER PACK Special Code Tier Category LD PA MSPPA MSPPA PA LDPA PA ANTINEOPLASTICS AND ADJUNCTIVE ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS ANTIANGINAL AGENTS CALCIUM CHANNEL BLOCKERS ANTIUNGALS ANTISEPTICS & DISINECTANTS ANTHELMINTICS ANTINEOPLASTICS AND ADJUNCTIVE GENITOURINARY AGENTS MISCELLANEOUS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS CONTRACEPTIVES CONTRACEPTIVES ANTIDIABETICS RESPIRATORY AGENTS MISC. CONTRACEPTIVES CONTRACEPTIVES DERMATOLOGICALS DERMATOLOGICALS ANTIUNGALS DIAGNOSTIC PRODUCTS ANALGESICS ANTIINLAMMATORY OPHTHALMIC AGENTS ANALGESICS ANTIINLAMMATORY DIAGNOSTIC PRODUCTS OPHTHALMIC AGENTS ANALGESICS ANTIINLAMMATORY MINERALS & ELECTROLYTES ANTIDIABETICS LAXATIVES LAXATIVES ANTIDIABETICS DERMATOLOGICALS MINERALS & ELECTROLYTES ENDOCRINE AND METABOLIC AGENTS MISC. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 20 of 99

26 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name KUVAN TAB labetalol tab (NORMODYNE equiv) LACRISERT OPHTH INSERT lactulose lamotrigine chew tab (LAMICTAL CHEW equiv) lamotrigine tab (LAMICTAL equiv) LANCET KIT LANCETS lansoprazole cap 15mg ( = 56 unit/30 day) LANTUS INJ LANTUS SOLOSTAR INJ latanoprost ophth soln (XALATAN OPHTH SOLN equiv) (= 2.5ml/ 30 days) leflunomide tab (ARAVA equiv) LESCOL XL CAP letrozole tab (EMARA equiv) leucovorin tab LEUKERAN TAB (Product is mandated through Acaria Specialty Pharmacy.) LEUKINE INJ (Product is mandated through Acaria Specialty Pharmacy.) levetiracetam oral soln (KEPPRA ORAL SOLN equiv) levetiracetam tab (KEPPRA equiv) levobunolol ophth soln (BETAGAN equiv) levocarnitine cap levocarnitine soln (CARNITOR equiv) levocarnitine tab levofloxacin ophth soln (QUIXIN equiv) levofloxacin soln (LEVAQUIN equiv) levofloxacin tab (LEVAQUIN equiv) levonorgestrel tab (PLANB equiv) LEVORPHANOL TAB levothyroxine tab (SYNTHROID equiv) LIALDA TAB LICE B GONE SHAMPOO lidocaine cream (LIDAMANTLE equiv) lidocaine gel (XYLOCAINE equiv) lidocaine oint lidocaine soln (XYLOCAINE equiv) lidocaine viscous soln lidocaine/ hydrocortisone cream lidocaine/prilocaine cream (EMLA equiv) LINZESS CAP ( = 1 cap/day) liothyronine tab (CYTOMEL equiv) lisinopril tab (PRINIVIL equiv) lisinopril/hydrochlorothiazide tab (ZESTORETIC equiv) LOHISTD LIQUID (Only covered for members 4 years and older) LOMUSTINE CAP loperamide cap loperamide liquid Special Code Tier Category MSPPA ENDOCRINE AND METABOLIC AGENTS MISC. BETA BLOCKERS OPHTHALMIC AGENTS GASTROINTESTINAL AGENTS MISC. ANTICONVULSANTS ANTICONVULSANTS MEDICAL DEVICES MEDICAL DEVICES ULCER DRUGS ANTIDIABETICS ANTIDIABETICS OPHTHALMIC AGENTS ANALGESICS ANTIINLAMMATORY PA ANTIHYPERLIPIDEMICS ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE SP ANTINEOPLASTICS AND ADJUNCTIVE MSP HEMATOPOIETIC AGENTS ANTICONVULSANTS ANTICONVULSANTS OPHTHALMIC AGENTS NUTRIENTS ENDOCRINE AND METABOLIC AGENTS MISC. NUTRIENTS OPHTHALMIC AGENTS LUOROQUINOLONES LUOROQUINOLONES CONTRACEPTIVES ANALGESICS OPIOID THYROID AGENTS GASTROINTESTINAL AGENTS MISC. DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS MOUTH/THROAT/DENTAL AGENTS ANORECTAL AGENTS DERMATOLOGICALS GASTROINTESTINAL AGENTS MISC. THYROID AGENTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES COUGH/COLD/ALLERGY ANTINEOPLASTICS AND ADJUNCTIVE ANTIDIARRHEALS ANTIDIARRHEALS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 21 of 99

27 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name loperamide tab loratadine ODT ( = 1 tab/day) loratadine syrup ( = 240ml/30 day; Covered for members age 2 through 5 years) loratadine tab (CLARITIN equiv) ( = 1 tab/day; Covered for members 2 years and older) loratadine/pseudoephedrine tab ( = 1 tab/day) lorazepam soln lorazepam tab (ATIVAN equiv) losartan tab (COZAAR equiv) losartan/hydrochlorothiazide tab (HYZAAR equiv) lovastatin tab (MEVACOR equiv) lubricating jelly LYRICA CAP LYRICA SOLN. LYSODREN TAB magnesium citrate soln. magnesium hydroxide susp. magnesium oxide tab MAGNESIUM/ALUMINUM HYDROXIDE CHEW magnesium/aluminum hydroxide/simethicone chew tab MAGNESIUM/ALUMINUM HYDROXIDE/SIMETHICONE SUSP MALARONE TAB maldemar tab (SCOPACE equiv) MALE CONDOMS MAPROTILINE TAB MATULANE CAP matzim LA tab (CARDIZEM LA equiv) MAXIDEX OPHTH SOLN meclizine chew tab meclizine tab MECLOENAMATE CAP MEDIGRAINE TAB medroxyprogesterone tab (PROVERA equiv) mefloquine tab (LARIAM equiv) megestrol susp (MEGACE equiv) megestrol tab (MEGACE equiv) meloxicam tab (MOBIC equiv) meperidine tab (DEMEROL equiv) MEPHYTON meprobamate mercaptopurine tab (PURINETHOL equiv) mesalamine enema (ROWASA equiv) MESNEX TAB (Product is mandated through Acaria Specialty Pharmacy.) MESTINON TIMESPAN METAPROTERENOL SYRUP metformin ER tab (GLUCOPHAGE XR equiv) Special Code Tier Category ANTIDIARRHEALS ANTIHISTAMINES ANTIHISTAMINES ANTIHISTAMINES COUGH/COLD/ALLERGY ANTIANXIETY AGENTS ANTIANXIETY AGENTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIHYPERLIPIDEMICS DERMATOLOGICALS PA ANTICONVULSANTS PA ANTICONVULSANTS SP ANTINEOPLASTICS AND ADJUNCTIVE LAXATIVES LAXATIVES MINERALS & ELECTROLYTES ANTACIDS ANTACIDS ANTACIDS ANTIMALARIALS ANTIEMETICS MEDICAL DEVICES ANTIDEPRESSANTS ANTINEOPLASTICS AND ADJUNCTIVE CALCIUM CHANNEL BLOCKERS OPHTHALMIC AGENTS ANTIEMETICS ANTIEMETICS ANALGESICS ANTIINLAMMATORY COUGH/COLD/ALLERGY PROGESTINS ANTIMALARIALS ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE ANALGESICS ANTIINLAMMATORY ANALGESICS OPIOID VITAMINS ANTIANXIETY AGENTS ANTINEOPLASTICS AND ADJUNCTIVE GASTROINTESTINAL AGENTS MISC. SP ANTINEOPLASTICS AND ADJUNCTIVE ANTIMYASTHENIC AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIDIABETICS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 22 of 99

28 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name metformin tab (GLUCOPHAGE equiv) methadone soln. methadone tab (DOLOPHINE equiv) methadose tab methamphetamine (DESOXYN equiv) methazolamide tab (NEPTAZANE equiv) methenamine hippurate (HIPREX equiv) methenamine mandelate methimazole tab (TAPAZOLE equiv) methocarbamol tab (ROBAXIN equiv) methotrexate inj (Product is mandated through Acaria Specialty Pharmacy.) methotrexate tab methoxsalen cap (OXSORALEN ULTRA equiv) METHYLCLOTHIAZIDE TAB methyldopa tab methyldopa/hydrochlorothiazide tab methylergonovine tab (METHERGINE equiv) ( = 28 tab/fill; 1 fill/365 days) methylin ER tab (RITALIN SR equiv) methylphenidate (RITALIN equiv) methylphenidate cap cd (METADATE CD CAP equiv) methylphenidate cap er (RITALIN LA CAP equiv) METHYLPHENIDATE ER/CONCERTA TAB methylphenidate soln (METHYLIN SOLN equiv) methylprednisolone dose pack (MEDROL DOSE PACK equiv) methylprednisolone tab (MEDROL equiv) METIPRANOLOL OPHTH SOLN metoclopramide (REGLAN equiv) metoclopramide soln metolazone tab (ZAROXOLYN equiv) metoprolol ER tab (TOPROL XL equiv) metoprolol tab (LOPRESSOR equiv) metoprolol/hydrochlorothiazide tab (LOPRESSOR HCT equiv) metronidazole cap (LAGYL equiv) metronidazole cream (METROCREAM equiv) metronidazole gel (METROGEL equiv) metronidazole lotion (METROLOTION equiv) metronidazole tab (LAGYL equiv) metronidazole vaginal gel (METROGEL VAGINAL GEL equiv) mexiletine cap MIACALCIN INJ miconazole cream miconazole nitrate aerosol miconazole nitrate powder miconazole oint. Special Code Tier Category ANTIDIABETICS ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS DIURETICS URINARY ANTIINECTIVES URINARY ANTIINECTIVES THYROID AGENTS MUSCULOSKELETAL THERAPY AGENTS MSP ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE DERMATOLOGICALS DIURETICS ANTIHYPERTENSIVES ANTIHYPERTENSIVES OXYTOCICS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS CORTICOSTEROIDS CORTICOSTEROIDS OPHTHALMIC AGENTS GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. DIURETICS BETA BLOCKERS BETA BLOCKERS ANTIHYPERTENSIVES ANTIINECTIVE AGENTS MISC. DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ANTIINECTIVE AGENTS MISC. VAGINAL PRODUCTS ANTIARRHYTHMICS MSP ENDOCRINE AND METABOLIC AGENTS MISC. DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 23 of 99

29 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name miconazole vaginal cream miconazole vaginal kit miconazole vaginal supp. midodrine tab (PROAMATINE equiv) MIGERGOT SUPP. MILK O MAGNESIA CHEW TAB mineral oil mineral oil enema MINERAL OIL LIGHT mineral oil/petrolatum cream mineral oil/petrolatum lotion mineral oil/petrolatum oint minocycline cap (MINOCIN equiv) minocycline tab (DYNACIN equiv) minoxidil tab mirtazapine (REMERON equiv) mirtazapine odt (REMERON SOLUTAB equiv) misoprostol (CYTOTEC equiv) modafinil tab (PROVIGIL TAB equiv) ( = 1 tab/day) moexipril tab (UNIVASC equiv) moexipril/hydrochlorothiazide tab (UNIRETIC equiv) mometasone cream (ELOCON equiv) mometasone oint (ELOCON equiv) mometasone soln (ELOCON equiv) mononessa tab (ORTHOCYCLEN equiv) montelukast chew tab (SINGULAIR CHEW TAB equiv) montelukast granules (SINGULAIR GRANULES equiv) montelukast tab (SINGULAIR equiv) morphine sulfate ER tab (MS CONTIN equiv) morphine sulfate oral soln. morphine sulfate supp. morphine sulfate tab MOVIPREP (= 1 bottle/fill) MOXEZA OPHTH SOLN/ VIGAMOX OPHTH SOLN moxifloxacin tab (AVELOX equiv) MULTAQ TAB multigen folic tab (CHROMAGEN A equiv) multigen plus tab (CHROMAGEN ORTE equiv) multigen tab (CHROMAGEN equiv) multiple vitamin liquid multiple vitamin tab multiple vitamins w/ minerals tab multivitamin w/ iron chew tab multivitamin w/ iron tab mupirocin cream (BACTROBAN equiv) mupirocin oint (BACTROBAN OINT equiv) mycophenolate cap (CELLCEPT equiv) mycophenolate DR tab (MYORTIC equiv) Special Code Tier Category VAGINAL PRODUCTS VAGINAL PRODUCTS VAGINAL PRODUCTS VASOPRESSORS MIGRAINE PRODUCTS LAXATIVES DERMATOLOGICALS LAXATIVES DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS TETRACYCLINES TETRACYCLINES ANTIHYPERTENSIVES ANTIDEPRESSANTS ANTIDEPRESSANTS ULCER DRUGS PA ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS CONTRACEPTIVES ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID LAXATIVES OPHTHALMIC AGENTS LUOROQUINOLONES ANTIARRHYTHMICS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS DERMATOLOGICALS DERMATOLOGICALS SP ASSORTED CLASSES ASSORTED CLASSES IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 24 of 99

30 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name mycophenolate mofetil susp (CELLCEPT SUSP equiv) mycophenolate tab (CELLCEPT equiv) MYLERAN TAB nabumetone tab nadolol tab (CORGARD equiv) NATIN CREAM NATIN GEL NAMENDA NAMENDA XR CAP (= 1 cap/day) NAPHAZOLINE OPHTH SOLN. naphazoline/pheniramine ophth drops naproxen EC tab (NAPROSYN EC equiv) naproxen sodium tab (ANAPROX equiv) naproxen susp. (NAPROSYN equiv) naproxen tab (NAPROSYN equiv) naratriptan tab (AMERGE equiv) ( = Retail 9 tabs/fill, 2 fill/30 days; Mail Order 27 tab/fill, 2 fill/90 days) NASACORT NASAL SPRAY () (= 2 bottles/fill) NASAL MOIST GEL nature thyroid tab (ARMOUR THYROID equiv) NEBUPENT NEB SOLN NEBUSAL NEB 6% necon tab (ORTHONOVUM equiv) necon tab 1/50 NEAZODONE TAB nefazodone tab 250mg (SERZONE equiv) neomycin tab neomycin/ polymyxin b/ gramicidin ophth soln (NEOSPORIN OPHTH equiv) neomycin/ polymyxin/ dexamethasone ophth oint (MAXITROL equiv) neomycin/ polymyxin/ dexamethasone ophth soln (MAXITROL equiv) neomycin/ polymyxin/ hydrocortisone ophth soln (CORTISPORIN equiv) neomycin/bacitracin/polymyxin b oint neomycin/bacitracin/polymyxin b/pramoxine oint neomycin/polymixin/hydrocoritisone otic susp (CORTISPORIN equiv) neomycin/polymyxin b/pramoxine cream NEOTUSS PLUS LIQUID NEPHRON A TAB NEULASTA INJ (Product is mandated through Acaria Specialty Pharmacy.) NEUMEGA INJ (Product is mandated through Acaria Specialty Pharmacy.) NEUPRO PATCH NEVANAC OPHTH SUSP NEXAVAR TAB (Limited to 2 x 15 day fills per month for first 3 months) niacin er cap niacin ER tab (NIASPAN equiv) niacin tab NIACIN TR TAB () (SLONIACIN equiv) niacinamide tab nicardipine cap Special Code Tier Category SP ASSORTED CLASSES SP ASSORTED CLASSES ANTINEOPLASTICS AND ADJUNCTIVE ANALGESICS ANTIINLAMMATORY BETA BLOCKERS DERMATOLOGICALS DERMATOLOGICALS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. OPHTHALMIC AGENTS OPHTHALMIC AGENTS ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY MIGRAINE PRODUCTS NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL THYROID AGENTS MSP ANTIINECTIVE AGENTS MISC. COUGH/COLD/ALLERGY CONTRACEPTIVES CONTRACEPTIVES ANTIDEPRESSANTS ANTIDEPRESSANTS AMINOGLYCOSIDES OPHTHALMIC AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS DERMATOLOGICALS DERMATOLOGICALS OTIC AGENTS DERMATOLOGICALS COUGH/COLD/ALLERGY HEMATOPOIETIC AGENTS MSP HEMATOPOIETIC AGENTS MSP HEMATOPOIETIC AGENTS ANTIPARKINSON AGENTS OPHTHALMIC AGENTS MSPPA ANTINEOPLASTICS AND ADJUNCTIVE VITAMINS ANTIHYPERLIPIDEMICS VITAMINS VITAMINS VITAMINS CALCIUM CHANNEL BLOCKERS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 25 of 99

31 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name nicotine gum (NICORETTE equiv) (Limited to 180 days/plan year) nicotine lozenge (COMMIT LOZENGE equiv) (Limited to 180 days/plan year) nicotine patch (NICODERM CQ equiv) (Limited to 180 days/plan year) NICOTROL INHALER (Limited to 180 days/plan year) NICOTROL NASAL SPRAY (Limited to 180 days/plan year) nifedipine cap (PROCARDIA equiv) nifedipine ER tab (ADALAT CC equiv) NIEREX150 ORTE CAP NILANDRON TAB nisoldipine tab (SULAR equiv) nitrofurantion cap (MACROBID equiv) nitrofurantoin monohydrate (MACROBID equiv) nitrofurantoin susp (URADANTIN equiv) nitroglycerin patch (NITRODUR equiv) NITROSTAT SL TAB nizatidine cap (AXID equiv) norabe tab (NORAQD equiv) norethindrone tab (AYGESTIN equiv) NORPACE CR CAP nortriptyline cap (PAMELOR equiv) nortriptyline soln (PAMELOR equiv) NORTRIPTYLINE SOLN. NOXAIL SUSP NUCYNTA NUCYNTA ER (= 2 tabs/day) NUEDEXTA CAP ( = 2 cap/day) NUTRITIONAL SUPPLEMENT LIQUID NUTRITIONAL SUPPLEMENT POWDER NUVARING nystatin cream (MYCOSTATIN CREAM equiv) nystatin oint nystatin powder nystatin susp nystatin tab nystatin topical powder NYSTATIN VAGINAL TAB nystatin/triamcinolone cream nystatin/triamcinolone oint octreotide inj (SANDOSTATIN equiv) (Product is mandated through Acaria Specialty Pharmacy.) ofloxacin ophth soln (OCULOX equiv) ofloxacin otic soln ofloxacin tab (LOXIN equiv) OLOXACIN TAB 400MG Special Code Tier Category SMKG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. SMKG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. SMKG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. SMKG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. SMKG PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS HEMATOPOIETIC AGENTS ANTINEOPLASTICS AND ADJUNCTIVE CALCIUM CHANNEL BLOCKERS URINARY ANTIINECTIVES URINARY ANTIINECTIVES URINARY ANTIINECTIVES ANTIANGINAL AGENTS ANTIANGINAL AGENTS ULCER DRUGS CONTRACEPTIVES PROGESTINS ANTIARRHYTHMICS ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIUNGALS ANALGESICS OPIOID ANALGESICS OPIOID PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS CONTRACEPTIVES DERMATOLOGICALS DERMATOLOGICALS ANTIUNGALS MOUTH/THROAT/DENTAL AGENTS ANTIUNGALS DERMATOLOGICALS VAGINAL PRODUCTS DERMATOLOGICALS DERMATOLOGICALS MSP ENDOCRINE AND METABOLIC AGENTS MISC. OPHTHALMIC AGENTS OTIC AGENTS LUOROQUINOLONES LUOROQUINOLONES IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 26 of 99

32 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name olanzapine/ fluoxetine cap (SYMBYAX CAP equiv) omedia otic soln omega3 fatty acid cap (ISH OIL equiv) omega3acid ethyl esters cap (LOVAZA equiv) omeprazole cap omeprazole cap 10mg (PRILOSEC equiv) omeprazole cap 20mg (PRILOSEC equiv) omeprazole cap 40mg (PRILOSEC equiv) ondansetron (ZORAN equiv) ondansetron ODT (ZORAN ODT equiv) ondansetron oral soln (ZORAN ORAL SOLN equiv) ONI TAB ONGLYZA TAB (= 1 tab/day) OPSUMIT TAB ORACIT ORENCIA SC INJ (= 4 inj/28 days) orphenadrine citrate ER oxandrolone tab (OXANDRIN equiv) oxaprozin tab (DAYPRO equiv) oxazepam oxcarbazepine susp. (TRILEPTAL equiv) oxcarbazepine tab (TRILEPTAL equiv) OXISTAT CREAM OXISTAT LOTION oxybutynin ER tab (DITROPAN XL equiv) oxybutynin syrup oxybutynin tab oxycodone cap (OXYIR equiv) oxycodone soln oxycodone tab (ROXICODONE equiv) oxycodone/acetaminophen cap (TYLOX equiv) oxycodone/acetaminophen tab (PERCOCET equiv) oxycodone/aspirin tab (PERCODAN equiv) OXYCONTIN CR TAB (= 120 tab/30 days) OXYIR oxymetazolin spray (Only covered for members 4 years and older) pantoprazole tab (PROTONIX equiv) papainurea oint (ACCUZYME OINT equiv) parcaine ophth soln (ALCAINE equiv) paricalcitol cap (ZEMPLAR equiv) (Product is mandated through Acaria Specialty Pharmacy.) paroxetine er (PAXIL CR equiv) paroxetine tab (PAXIL equiv) PATADAY OPHTH SOLN PATANASE NASAL SPRAY pe/acetamin/diphenhydramin/cpm tab (COVERED OR MEMBERS 419 YEARS) PEAK LOW METER pediatric electrolyte soln. PEDIATRIC MASK Special Code Tier Category PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. OTIC AGENTS NUTRIENTS ANTIHYPERLIPIDEMICS ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS ANTIEMETICS ANTIEMETICS ANTIEMETICS PA ANTICONVULSANTS ANTIDIABETICS PA CARDIOVASCULAR AGENTS MISC. GENITOURINARY AGENTS MISCELLANEOUS MSPPA ANALGESICS ANTIINLAMMATORY MUSCULOSKELETAL THERAPY AGENTS ANDROGENSANABOLIC ANALGESICS ANTIINLAMMATORY ANTIANXIETY AGENTS ANTICONVULSANTS ANTICONVULSANTS DERMATOLOGICALS DERMATOLOGICALS URINARY ANTISPASMODICS URINARY ANTISPASMODICS URINARY ANTISPASMODICS ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID ANALGESICS OPIOID PA ANALGESICS OPIOID ANALGESICS OPIOID NASAL AGENTS SYSTEMIC AND TOPICAL ULCER DRUGS DERMATOLOGICALS OPHTHALMIC AGENTS SP ENDOCRINE AND METABOLIC AGENTS MISC. ANTIDEPRESSANTS ANTIDEPRESSANTS OPHTHALMIC AGENTS NASAL AGENTS SYSTEMIC AND TOPICAL COUGH/COLD/ALLERGY MEDICAL DEVICES MINERALS & ELECTROLYTES MEDICAL DEVICES IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 27 of 99

33 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name pediatric multiple vitamins/fluoride chew tab pediatric multiple vitamins/fluoride soln pediatric multiple vitamins/fluoride/iron soln. pediatric multivitamin adc drops PEDIATRIC MULTIVITAMIN CHEW TAB pediatric multivitamin w/ iron chew tab pediatric multivitamin w/ iron drops pediatric multivitamin w/ minerals gummy pediatric multivitamin w/ vitamin c soln. pediatric multivitamin w/ vitamin c w/ iron chew tab peg 3350/electrolytes (GOLYTELY/COLYTE equiv) PEGANONE TAB PEGASYS INJ (Product is mandated through Acaria Specialty Pharmacy.) PEGASYS KIT (Product is mandated through Acaria Specialty Pharmacy.) penicillin vk soln penicillin vk tab pentazocine/acetaminophen tab (TALACEN equiv) pentoxifylline ER tab (TRENTAL equiv) perindopril tab (ACEON equiv) permethrin cream (ELIMITE CREAM equiv) permethrin liquid permethrin lotion permethrin spray PERPHENAZINE/ AMITRIPTYLINE TAB petrolatum oint PETROLATUM/LANOLIN/ZINC OXIDE/MINERAL OIL OINT. phenazopyridine tab (PYRIDIUM equiv) pheniramine/phenylephrine/acetaminophen packet (Only covered for members 19 years and younger) phenobarbital elixir phenobarbital tab phentermine cap (ADIPEX equiv) ( = 1 cap/day) phentermine tab (ADIPEX equiv) ( = 1 tab/day) phenyldphrine/brompheniramine chew liquid (Only covered for members 4 years and older) phenyldphrine/brompheniramine elixir (Only covered for members 4 years and older) PHENYLDPHRINE/BROMPHENIRAMINE TAB (Only covered for members 4 years and older) PHENYLEPH/ACETAMIN/DEXBROMPHENIRAMINE TAB (COVERED OR MEMBERS 419 YEARS) PHENYLEPHRINE DROPS (Only covered for members 4 years and older) phenylephrine nasal drops (Only covered for members 4 years and older) phenylephrine ophth soln (MYRIN OPHTH SOLN. equiv) phenylephrine tab (Only covered for members 4 years and older) phenylephrine/acetamin/doxylamine cap (COVERED OR MEMBERS 419 YEARS) phenylephrine/acetaminophen cap (Only covered for members 4 years and older) phenylephrine/acetaminophen pack (Only covered for members 4 years and older) Special Code Tier Category MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS LAXATIVES ANTICONVULSANTS MSP ANTIVIRALS MSPST ANTIVIRALS PENICILLINS PENICILLINS ANALGESICS OPIOID HEMATOLOGICAL AGENTS MISC. ANTIHYPERTENSIVES DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. DERMATOLOGICALS DERMATOLOGICALS GENITOURINARY AGENTS MISCELLANEOUS COUGH/COLD/ALLERGY HYPNOTICS HYPNOTICS PA ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS PA ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL OPHTHALMIC AGENTS NASAL AGENTS SYSTEMIC AND TOPICAL COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 28 of 99

34 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name phenylephrine/acetaminophen tab (Only covered for members 4 years and older) phenylephrine/chlorpheniramine liquid (Only covered for members 2 years and older) phenylephrine/chlorpheniramine tab (Only covered for members 4 years and older) phenylephrine/diphenhydramine liquid (Only covered for members 4 years and older) phenylephrine/diphenhydramine solution (Only covered for members 4 years and older) phenylephrine/diphenhydramine tab (Only covered for members 4 years and older) phenylephrine/dm/acetaminop/gg liquid (COVERED OR MEMBERS 4 YEARS AND OLDER ) phenylephrine/dm/acetaminop/gg tab (COVERED OR MEMBERS 4 YEARS AND OLDER) PHENYLTOLOXAMINEACETAMINOPHEN TAB (COVERED OR MEMBERS 4 YEARS AND OLDER) PHENYTEK CAP phenytoin cap (DILANTIN CAP equiv) phenytoin chew tab (DILANTIN INATABS equiv) phenytoin susp. (DILANTIN equiv) PHOSLYRA SOLN phospha 250 neutral tab (KPHOS NEUTRAL equiv) PHOSPHOLINE OPHTH SOLN pilocarpine ophth soln (ISOPTO CARPINE equiv) pilocarpine tab (SALAGEN equiv) pindolol tab pioglitazone tab (ACTOS TAB equiv) pioglitazone/glimepiride tab (DUETACT TAB equiv) pioglitazone/metformin tab (ACTOPLUS MET equiv) piperonyl butox/pyrethrins/permethrin kit piperonyl butoxide/pyrethrins liquid PIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO piroxicam cap (ELDENE equiv) podofilox soln (CONDYLOX equiv) polyethylene glycol powder polyethylene glycol powder packet polymyxin b/ trimethoprim ophth soln (POLYTRIM equiv) potassium bicarbonate effer tab potassium chloride effer tab potassium chloride ER cap (MICROK CAP equiv) potassium chloride ER tab (KLORCON TAB equiv) potassium chloride liquid potassium chloride micro cap (KDUR CAP equiv) potassium chloride powder packet (KLORCON equiv) potassium citrate and citric acid granule (POLYCITRA equiv) potassium citrate tab CR (UROCITK TAB equiv) potassium citrate/citric acid soln. POTIGA TAB (= 3 tab/ day) povidoneiodine soln. Special Code Tier Category COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY ANALGESICS NONNARCOTIC ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS GASTROINTESTINAL AGENTS MISC. MINERALS & ELECTROLYTES OPHTHALMIC AGENTS OPHTHALMIC AGENTS MOUTH/THROAT/DENTAL AGENTS BETA BLOCKERS ANTIDIABETICS ANTIDIABETICS ANTIDIABETICS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ANALGESICS ANTIINLAMMATORY DERMATOLOGICALS LAXATIVES LAXATIVES OPHTHALMIC AGENTS MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES GENITOURINARY AGENTS MISCELLANEOUS GENITOURINARY AGENTS MISCELLANEOUS GENITOURINARY AGENTS MISCELLANEOUS ANTICONVULSANTS ANTISEPTICS & DISINECTANTS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 29 of 99

35 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name PRADAXA CAP pramipexole tab (MIRAPEX TAB equiv) PRAMOSONE CREAM PRASCION RA CREAM pravastatin tab (PRAVACHOL equiv) prazosin cap (MINIPRESS equiv) PRECISION XTRA METER PRECISION XTRA TEST STRIP PRED MILD OPHTH SOLN PREDG OPHTH SOLN prednicarbate cream (DERMATOP equiv) prednicarbate oint (DERMATOP equiv) prednisolone ODT (ORAPRED ODT equiv) prednisolone ophth soln (PRED ORTE equiv) PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN prednisolone soln (PEDIAPRED equiv) prednisolone syrup (PRELONE equiv) PREDNISONE PAK PREDNISONE SOLN PREDNISONE TAB PREMARIN TAB PREMARIN VAGINAL CREAM PREMPHASE TAB/ PREMPRO TAB PRENATAL VITAMIN PRENATAL VITAMIN (RX ONLY) PREVACID ( = 56 cap/30 day; Step Therapy requires trial of lansoprazole and pantoprazole) PREVIDENT 5000 PLUS CREAM PREVIDENT ORAL RINSE PRIMAQUINE TAB primidone tab (MYSOLINE equiv) probenecid tab PROCHIEVE prochlorperazine supp. prochlorperazine tab PROCRIT INJ (Product is mandated through Acaria Specialty Pharmacy.) PROCTOOAM HC OAM proctosol cream (ANUSOL HC equiv) progesterone cap (PROMETRIUM CAP equiv) PROLEUKIN INJ (Product is mandated through Acaria Specialty Pharmacy.) PROMACTA TAB promethazine DM syrup promethazine supp promethazine syrup promethazine tab PROMETHAZINE VC SYRUP promethazine vc w/codeine (PHENERGAN VC W/CODIENE equiv) promethazine w/codeine (PHENERGAN W/CODIENE equiv) propafenone ER tab (RYTHMOL SR equiv) propafenone tab (RHYTHMOL equiv) Special Code Tier Category ANTICOAGULANTS ANTIPARKINSON AGENTS DERMATOLOGICALS DERMATOLOGICALS ANTIHYPERLIPIDEMICS ANTIHYPERTENSIVES MEDICAL DEVICES DIAGNOSTIC PRODUCTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS DERMATOLOGICALS DERMATOLOGICALS CORTICOSTEROIDS OPHTHALMIC AGENTS OPHTHALMIC AGENTS CORTICOSTEROIDS CORTICOSTEROIDS CORTICOSTEROIDS CORTICOSTEROIDS CORTICOSTEROIDS ESTROGENS VAGINAL PRODUCTS ESTROGENS MULTIVITAMINS MULTIVITAMINS ST ULCER DRUGS MOUTH/THROAT/DENTAL AGENTS MOUTH/THROAT/DENTAL AGENTS ANTIMALARIALS ANTICONVULSANTS GOUT AGENTS PA VAGINAL PRODUCTS ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIPSYCHOTICS/ANTIMANIC AGENTS MSP HEMATOPOIETIC AGENTS ANORECTAL AGENTS ANORECTAL AGENTS PROGESTINS MSP ANTINEOPLASTICS AND ADJUNCTIVE MSPPA HEMATOPOIETIC AGENTS COUGH/COLD/ALLERGY ANTIHISTAMINES ANTIHISTAMINES ANTIHISTAMINES COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY ANTIARRHYTHMICS ANTIARRHYTHMICS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 30 of 99

36 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name PROPANTHELINE TAB propranolol ER cap (INDERAL LA equiv) PROPRANOLOL SOLN propranolol tab propranolol/hydrochlorothiazide tab propylthiouracil tab PROSTIGMIN PSEUDOEPH/DM/GUAIEN/ACETAMIN PACKET (COVERED OR MEMBERS 4 YEARS AND OLDER ) pseudoeph/dm/guaifen/acetamin tab (COVERED OR MEMBERS 4 YEARS AND OLDER ) pseudoephed/acetaminoph/diphenhydramine tab (COVERED OR MEMBERS 419 YEARS) pseudoephedrine ER tab ( = 2 tab/day; Covered for members 4 years and older) pseudoephedrine syrup ( = 1200ml/30 day; Covered for members 4 years and older) pseudoephedrine tab 30mg ( = 8 tab/day; Covered for members 2 years and older) pseudoephedrine tab 60mg ( = 4 tab/day; Covered for members 2 years and older) pseudoephedrine/acetaminophen tab (Only covered for members 4 years and older) pseudoephedrine/brompheniramine liquid (Only covered for members 4 years and older) PSEUDOEPHEDRINE/CHLORPHENIRAMINE CHEW TAB (Only covered for members 4 years and older) pseudoephedrine/chlorpheniramine syrup (Only covered for members 4 years and older) pseudoephedrine/chlorpheniramine tab (Only covered for members 4 years and older) pseudoephedrine/dexbrompheniramine er tab (Only covered for members 4 years and older) PSEUDOEPHEDRINE/DIPHENHYDRAMINE TAB (Only covered for members 4 years and older) PSEUDOEPHEDRINE/IBUPROEN CAP (Only covered for members 4 years and older) pseudoephedrine/ibuprofen susp. (Only covered for members 4 years and older) pseudoephedrine/ibuprofen tab (Only covered for members 4 years and older) pseudoephedrine/naproxen tab (Only covered for members 4 years and older) pseudoephedrine/triprolidine tab (Only covered for members 4 years and older) psyllium cap (METAMUCIL equiv) psyllium powder (METAMUCIL equiv) PULMICORT LEXHALER PULMICORT RESPULE 1mg/2ml PULMOZYME (Product is mandated through Acaria Specialty Pharmacy.) pyrazinamide tab pyridostigmine tab (MESTINON equiv) pyridoxine er tab pyridoxine tab Special Code Tier Category ULCER DRUGS BETA BLOCKERS BETA BLOCKERS BETA BLOCKERS ANTIHYPERTENSIVES THYROID AGENTS ANTIMYASTHENIC AGENTS COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY LAXATIVES LAXATIVES ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS MSP RESPIRATORY AGENTS MISC. ANTIMYCOBACTERIAL AGENTS ANTIMYASTHENIC AGENTS VITAMINS VITAMINS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 31 of 99

37 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name PYRILAMINE/PE/DEXTROMETHORPHAN LIQUID (Only covered for members 4 years and older) QNASL NASAL SPRAY QSYMIA CAP ( = 1 cap/day) QUILLIVANT XR SUSP. quinapril tab (ACCUPRIL equiv) quinapril/hydrochlorothiazide tab (ACCURETIC equiv) quinidine gluconate CR tab quinidine sulfate tab rabeprazole tab (ACIPHEX TAB equiv) raloxifene tab (EVISTA equiv) ramipril cap (ALTACE equiv) RANEXA TAB ranitidine cap (ZANTAC equiv) ranitidine syrup (ZANTAC equiv) ranitidine tab (Rx Only) (ZANTAC equiv) ranitidine tab 75mg RAPALO (Restricted to Specialist (Urology)) RAPAMUNE SOLN REBETOL SOLN REGRANEX GEL ( = 2 15gm tubes/fill) RELENZA DISKHALER (=20 units/fill) RELISTOR INJ (Product is mandated through Acaria Specialty Pharmacy.) RENAGEL renaphro cap (NEPHROCAP equiv) RENVELA RENVELA TAB repaglinide tab (PRANDIN equiv) RESTASIS OPHTH EMULSION (Restricted to Ophthalmologist or Optometrist) REVLIMID CAP ( = 1 cap/day) ribasphere cap (REBETOL equiv) (Product is mandated through Acaria Specialty Pharmacy.) RIBATAB (Product is mandated through Acaria Specialty Pharmacy.) ribavirin tab (COPEGUS equiv) (Product is mandated through Acaria Specialty Pharmacy.) RIDAURA CAP rifabutin cap (MYCOBUTIN equiv) rifampin cap (RIADIN equiv) riluzole tab (RILUTEK equiv) rimantadine tab (LUMADINE equiv) rivastigmine cap (EXELON equiv) rizatriptan (MAXALT equiv) ( = Retail 12 tab/fill, 3 fill/60 day; Mail Order 36 tab/fill, 2 fill/90 day) rizatriptan ODT (MAXALT MLT equiv) ( = Retail 12 tab/fill, 3 fill/60 day; Mail Order 36 tab/fill, 2 fill/90 day) ropinirole (REQUIP equiv) ROXICET SOLN. 325mg/5ml SABRIL POWDER (Only available through SHARE program 88845SHARE ( )) Special Code Tier Category COUGH/COLD/ALLERGY NASAL AGENTS SYSTEMIC AND TOPICAL PA ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ANTIARRHYTHMICS ANTIARRHYTHMICS ULCER DRUGS ENDOCRINE AND METABOLIC AGENTS MISC. ANTIHYPERTENSIVES ANTIANGINAL AGENTS ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS RS GENITOURINARY AGENTS MISCELLANEOUS SP ASSORTED CLASSES MSP ANTIVIRALS DERMATOLOGICALS ANTIVIRALS MSPPA GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. MULTIVITAMINS GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. ANTIDIABETICS RS OPHTHALMIC AGENTS MSPPA ASSORTED CLASSES MSP ANTIVIRALS MSP ANTIVIRALS MSP ANTIVIRALS ANALGESICS ANTIINLAMMATORY ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS NEUROMUSCULAR AGENTS ANTIVIRALS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. MIGRAINE PRODUCTS MIGRAINE PRODUCTS ANTIPARKINSON AGENTS ANALGESICS OPIOID LD ANTICONVULSANTS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 32 of 99

38 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name SABRIL TAB (Only available through SHARE program 88845SHARE ( )) salicylic acid gel salicylic acid liquid salicylic acid pad salicylic acid shampoo (SALEX equiv) salicylic acid soln salicylic acid strip saline nasal spray salsalate SANDIMMUNE SOLN 100MG/ML SANTYL OINT SAVELLA (=2 TAB/DAY) SCOTTUSSIN SOLN. (Only covered for members 4 years and older) SECONAL selegiline selenium sulfide lotion selenium sulfide shampoo (SELSEB equiv) sennosides tab sennosides/docusate sodium tab SENSIPAR TAB (Product is mandated through Acaria Specialty Pharmacy.) SEREVENT DISKUS sertraline (ZOLOT equiv) SEVELAMER CARBONATE TAB SIGNIOR INJ (= 2 vials/day; Only available through Accredo ) sildenafil tab (REVATIO TAB equiv) silver sulfadiazine cream (SILVADENE CREAM equiv) SIMBRINZA OPHTH SUSP SIMCOR TAB simethicone cap simethicone chew tab simethicone drops simethicone liquid SIMETHICONE STRIPS simvastatin tab (ZOCOR equiv) (80mg is Not Covered) sirolimus tab (RAPAMUNE equiv) SIVEXTRO TAB (=6 tab/fill) SKIN CLEANSER smz/tmp (DS) tab (BACTRIM DS equiv) smz/tmp susp (SEPTRA SUSP equiv) sodium bicarbonate tab sodium chloride irrigation/decyl glucoside soln sodium chloride neb sodium chloride ophth oint. sodium chloride ophth soln. SODIUM CHLORIDE SPRAY sodium chloride tab sodium citrate and citric acid soln (BICITRA equiv) Special Code Tier Category LD SP LDPA PA SP PA ANTICONVULSANTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS NASAL AGENTS SYSTEMIC AND TOPICAL ANALGESICS NONNARCOTIC ASSORTED CLASSES DERMATOLOGICALS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. COUGH/COLD/ALLERGY HYPNOTICS ANTIPARKINSON AGENTS DERMATOLOGICALS DERMATOLOGICALS LAXATIVES LAXATIVES ENDOCRINE AND METABOLIC AGENTS MISC. ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIDEPRESSANTS GASTROINTESTINAL AGENTS MISC. ENDOCRINE AND METABOLIC AGENTS MISC. CARDIOVASCULAR AGENTS MISC. DERMATOLOGICALS OPHTHALMIC AGENTS ANTIHYPERLIPIDEMICS GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. ANTIHYPERLIPIDEMICS ASSORTED CLASSES ANTIINECTIVE AGENTS MISC. DERMATOLOGICALS ANTIINECTIVE AGENTS MISC. ANTIINECTIVE AGENTS MISC. ANTACIDS DERMATOLOGICALS COUGH/COLD/ALLERGY OPHTHALMIC AGENTS OPHTHALMIC AGENTS DERMATOLOGICALS MINERALS & ELECTROLYTES GENITOURINARY AGENTS MISCELLANEOUS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 33 of 99

39 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name sodium fluoride chew tab (LURIDE equiv) sodium fluoride cream (PREVIDENT 5000 PLUS equiv) sodium fluoride gel (PREVIDENT GEL equiv) sodium fluoride paste (PREVIDENT 5000 BOOSTER equiv) sodium fluoride rinse (PREVIDENT ORAL RINSE equiv) sodium fluoride soln. (LURIDE SOLN. equiv) SODIUM LUORIDE TAB sodium phenylbutyrate powder (BUPHENYL POWDER equiv) sodium phosphate enema sodium phosphate soln. sodium polystyrene powder (KAYEXALATE equiv) sodium polystyrene soln (SPS equiv) sodium sulfacetamide wash (OVACE WASH equiv) sodium sulfacetamide/sulfur cream (PLEXION SCT equiv) sodium sulfacetamide/sulfur emulsion (ROSAC WASH equiv) sodium sulfacetamide/sulfur gel (ROSULA equiv) sodium sulfacetamide/sulfur lotion (SULACET R equiv) sodium sulfacetamide/sulfur pad (PLEXION CLEANSING CLOTH equiv) SOMAVERT INJ (Only available through Walgreens ) SORIATANE CK KIT sotalol A tab (BETAPACE A equiv) sotalol tab (BETAPACE equiv) SOVALDI TAB (= 1 tab/day. Product is mandated through Acaria Specialty Pharmacy.) SPINOSAD SUSP (= 1 bottle/ fill) SPIRIVA HANDIHALER (or use with Handihaler device) SPIRIVA RESPIMAT spironolactone tab (ALDACTONE equiv) spironolactone/hydrochlorothiazide tab (ALDACTAZIDE equiv) SPRYCEL TAB (= 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) SPRYCEL TAB 20MG (= 3 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) SSKI SOLN. STIMATE NASAL SOLN STIVARGA TAB ( = 4 tab/day; Limited to 2 x 15 day fills per month for first 3 months) STRATTERA CAP sucralfate tab (CARAATE equiv) SUDAED ER TAB ( = 1 tab/day; Covered for member 4 years and older) sulfacetamide sodium ophth soln (BLEPH10 equiv) sulfacetamide sodium/ prednisolone ophth soln SULADIAZINE TAB SULAMYLON CREAM sulfasalazine sulfasalazine ec sulindac tab (CLINORIL equiv) Special Code Tier Category MINERALS & ELECTROLYTES MOUTH/THROAT/DENTAL AGENTS MOUTH/THROAT/DENTAL AGENTS MOUTH/THROAT/DENTAL AGENTS MOUTH/THROAT/DENTAL AGENTS MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES ENDOCRINE AND METABOLIC AGENTS MISC. LAXATIVES LAXATIVES ASSORTED CLASSES ASSORTED CLASSES DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS LD ENDOCRINE AND METABOLIC AGENTS MISC. DERMATOLOGICALS BETA BLOCKERS BETA BLOCKERS MSPPA ANTIVIRALS DERMATOLOGICALS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS DIURETICS DIURETICS PASP ANTINEOPLASTICS AND ADJUNCTIVE PASP ANTINEOPLASTICS AND ADJUNCTIVE MINERALS & ELECTROLYTES ENDOCRINE AND METABOLIC AGENTS MISC. MSPPA ANTINEOPLASTICS AND ADJUNCTIVE ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ULCER DRUGS NASAL AGENTS SYSTEMIC AND TOPICAL OPHTHALMIC AGENTS OPHTHALMIC AGENTS SULONAMIDES DERMATOLOGICALS GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. ANALGESICS ANTIINLAMMATORY IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 34 of 99

40 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name sumatriptan inj (IMITREX equiv) ( = Retail 4 inj/fill, 2 fill/30 days; Mail Order 12 inj/fill, 2 fill/90 days) SUMATRIPTAN INJ 6MG/0.5ML ( = Retail 4 inj/fill, 2 fill/30 days; Mail Order 12 inj/fill, 2 fill/90 days ) sumatriptan tab (IMITREX equiv) ( = Retail 9 tab/fill, 2 fill/30 days; Mail Order 27 tab/fill, 2 fill/90 days) SUMATRIPTAN/ IMITREX NASAL SPRAY ( = Retail 6 sprays/fill, 2 fills/30 days; Mail Order 18 sprays/fill, 2 fills/90 days) SUTENT CAP (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) SYMBICORT SYNAREL NASAL SOLN (Product is mandated through Acaria Specialty Pharmacy.) TABLOID TAB tacrolimus cap (PROGRA equiv) TAMILU CAP ( = 10 caps/fill) TAMILU SUSP 12MG/ML (= 125ml/fill) TAMILU SUSP 6MG/ML (= 250ml/fill) tamoxifen tab (NOLVADEX equiv) tamsulosin (LOMAX equiv) TARCEVA TAB (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) TARGRETIN CAP (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) TARGRETIN GEL (Product is mandated through Acaria Specialty Pharmacy.) TECIDERA CAP (Product is mandated through Acaria Specialty Pharmacy.) TECIDERA STARTER PACK (Product is mandated through Acaria Specialty Pharmacy.) temazepam 15mg (RESTORIL equiv) temazepam 30mg (RESTORIL equiv) temozolomide cap (TEMODAR equiv) (Product is mandated through Acaria Specialty Pharmacy.) terazosin cap (HYTRIN equiv) terbinafine cream ( = 1 tube/30 day; Covered for members 12 years and older) terbinafine tab (LAMISIL equiv) terbutaline sulfate (BRETHINE equiv) terconazole cream (TERAZOL equiv) terconazole supp. (TERAZOL equiv) testosterone cypionate inj (DEPOTESTOSTERONE INJ. equiv) tetrahydrozoline ophth soln. tetrahydrozoline/zinc sulfate ophth drops THALOMID CAP (Product is mandated through Acaria Specialty Pharmacy.) theophylline cr THEOPHYLLINE ELIXIR theophylline er tab (UNIPHYL equiv) theophylline soln Special Code Tier Category PASP MSP PASP PASP SP MSP MSP SP PASP MIGRAINE PRODUCTS MIGRAINE PRODUCTS MIGRAINE PRODUCTS MIGRAINE PRODUCTS ANTINEOPLASTICS AND ADJUNCTIVE ANTIASTHMATIC AND BRONCHODILATOR AGENTS ENDOCRINE AND METABOLIC AGENTS MISC. ANTINEOPLASTICS AND ADJUNCTIVE ASSORTED CLASSES ANTIVIRALS ANTIVIRALS ANTIVIRALS ANTINEOPLASTICS AND ADJUNCTIVE GENITOURINARY AGENTS MISCELLANEOUS ANTINEOPLASTICS AND ADJUNCTIVE ANTINEOPLASTICS AND ADJUNCTIVE DERMATOLOGICALS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. HYPNOTICS HYPNOTICS ANTINEOPLASTICS AND ADJUNCTIVE ANTIHYPERTENSIVES DERMATOLOGICALS ANTIUNGALS ANTIASTHMATIC AND BRONCHODILATOR AGENTS VAGINAL PRODUCTS VAGINAL PRODUCTS ANDROGENSANABOLIC OPHTHALMIC AGENTS OPHTHALMIC AGENTS ASSORTED CLASSES ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 35 of 99

41 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name thiamine tab THROAT LOZENGE (Only covered for members 19 years and younger) THYROLAR TAB ticlopidine tab (TICLID equiv) tigabine tab (GABITRIL equiv) TIKOSYN CAP (Product is mandated through Acaria Specialty Pharmacy.) timolol maleate ophth gel (TIMOPTICXE equiv) timolol maleate ophth soln (TIMOPTIC equiv) timolol maleate tab tioconazole vaginal oint. tizanidine tab (ZANALEX TAB equiv) TOBI PODHALER TOBRADEX OPHTH OINT tobramycin neb (TOBI equiv) tobramycin ophth soln (TOBREX equiv) tobramycin/ dexamethasone ophth soln (TOBRADEX equiv) tolazamide tab (TOLINASE equiv) TOLBUTAMIDE TAB tolmetin cap TOLMETIN TAB tolnaftate aerosol tolnaftate cream tolnaftate powder tolnaftate spray tolterodine cap SR (DETROL LA equiv) tolterodine tab (DETROL TAB equiv) TOPICORT CREAM 0.05%/ DESOXIMETASONE CREAM 0.05% topiramate sprinkle cap (TOPAMAX SPRINKLE equiv) topiramate tab (TOPAMAX equiv) torsemide tab (DEMADEX equiv) TOVIAZ TAB TRACLEER TAB (Only available through Accredo AND PharmaCare ) tramadol tab (ULTRAM equiv) trandolapril tab (MAVIK equiv) tranex acid tab (LYSTEDA equiv) trazodone tab tretinoin cap (VESANOID equiv) tretinoin cream (Acne only age 35 and older requires PA) tretinoin gel (Acne only age 35 and older requires PA) triamcinolone cream triamcinolone in orabase paste triamcinolone lotion triamcinolone oint TRIAMINIC NASAL SOLN. (Only covered for members 4 years and older) TRIAMINIC STRIP (Only covered for members 4 years and older) triamterene/hydrochlorothiazide cap (DYAZIDE equiv) triamterene/hydrochlorothiazide tab (MAXZIDE equiv) triazolam tab (HALCION equiv) tricitrates soln. (POLYCITRALC equiv) Special Code Tier Category SP MSPPA MSPPA PA SP PA PA VITAMINS MOUTH/THROAT/DENTAL AGENTS THYROID AGENTS HEMATOLOGICAL AGENTS MISC. ANTICONVULSANTS ANTIARRHYTHMICS OPHTHALMIC AGENTS OPHTHALMIC AGENTS BETA BLOCKERS VAGINAL PRODUCTS MUSCULOSKELETAL THERAPY AGENTS AMINOGLYCOSIDES OPHTHALMIC AGENTS AMINOGLYCOSIDES OPHTHALMIC AGENTS OPHTHALMIC AGENTS ANTIDIABETICS ANTIDIABETICS ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS URINARY ANTISPASMODICS URINARY ANTISPASMODICS DERMATOLOGICALS ANTICONVULSANTS ANTICONVULSANTS DIURETICS URINARY ANTISPASMODICS CARDIOVASCULAR AGENTS MISC. ANALGESICS OPIOID ANTIHYPERTENSIVES HEMOSTATICS ANTIDEPRESSANTS ANTINEOPLASTICS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS MOUTH/THROAT/DENTAL AGENTS DERMATOLOGICALS DERMATOLOGICALS NASAL AGENTS SYSTEMIC AND TOPICAL COUGH/COLD/ALLERGY DIURETICS DIURETICS HYPNOTICS GENITOURINARY AGENTS MISCELLANEOUS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 36 of 99

42 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name tricon cap (TRINSICON equiv) trifluridine ophth soln (VIROPTIC equiv) trilyte (NULYTELY equiv) trimethobenzamide cap (TIGAN equiv) trimethoprim tab trinessa tab (ORTHO TRICYCLEN equiv) trivit/iron/fluoride tab tropicamide ophth soln (MYDRIACYL equiv) TUDORZA PRESSAIR TYKERB TAB TYVASO INH SOLN (Only available through Accredo ) UCORT CREAM ULORIC (Step Therapy requires failure of allopurinol.) URAMAXIN CREAM (Only RX version covered/ version NOT covered) urea cream 40% (CARMOL equiv) urea cream 50% (KERALAC equiv) urea gel 40% urea gel 50% urea lotion (KERALAC LOTION equiv) urea susp 40% (UMECTA equiv) ursodiol caps (ACTIGALL equiv) valacyclovir tab (VALTREX equiv) VALCHLOR GEL (=4 TUBES/30 DAYS) VALCYTE SOLN valganciclovir tab (VALCYTE equiv) valproic acid cap (DEPAKENE equiv) valproic acid syrup (DEPAKENE equiv) valsartan tab (DIOVAN equiv) valsartan/hydrochlorothiazide tab (DIOVAN HCT TAB equiv) vancomycin cap (VANCOCIN CAP equiv) (= 56 cap/ fill; Step Therapy requires trial of vancomycin soln) VANCOMYCIN SOLN KIT vapor inhaler (Only covered for members 4 years and older) vaporizing steam (COVERED OR MEMBERS 419 YEARS) vaporizing steam liquid (COVERED OR MEMBERS 419 YEARS) VECTICAL OINT venlafaxine ER cap (EEXOR XR equiv) venlafaxine ER tab (VENLAAXINE ER TAB equiv) VENLAAXINE ER TAB 225MG VENTAVIS INH SOLN (Only available through Accredo ) VENTOLIN HA (= 2 inhalers/fill, 2 fills/30 days) verapamil SR cap (VERELAN equiv) verapamil SR tab (CALAN SR, ISOPTIN SR equiv) verapamil tab (CALAN equiv) VEXOL OPHTH SUSP VGO 20 KIT (=1 KIT/DAY) VGO 30 KIT (=1 KIT/DAY) VGO 40 KIT (=1 KIT/DAY) VICTOZA INJ Special Code Tier Category HEMATOPOIETIC AGENTS OPHTHALMIC AGENTS LAXATIVES ANTIEMETICS ANTIINECTIVE AGENTS MISC. CONTRACEPTIVES MULTIVITAMINS OPHTHALMIC AGENTS ANTIASTHMATIC AND BRONCHODILATOR AGENTS MSPPA ANTINEOPLASTICS AND ADJUNCTIVE LDPA CARDIOVASCULAR AGENTS MISC. DERMATOLOGICALS ST GOUT AGENTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS GASTROINTESTINAL AGENTS MISC. ANTIVIRALS PA DERMATOLOGICALS SP ANTIVIRALS SP ANTIVIRALS ANTICONVULSANTS ANTICONVULSANTS ANTIHYPERTENSIVES ANTIHYPERTENSIVES ST ANTIINECTIVE AGENTS MISC. ANTIINECTIVE AGENTS MISC. COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY DERMATOLOGICALS ANTIDEPRESSANTS ANTIDEPRESSANTS ANTIDEPRESSANTS LDPA CARDIOVASCULAR AGENTS MISC. ANTIASTHMATIC AND BRONCHODILATOR AGENTS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS OPHTHALMIC AGENTS MEDICAL DEVICES MEDICAL DEVICES MEDICAL DEVICES ANTIDIABETICS IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 37 of 99

43 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name VIIBRYD TAB VIMPAT SOLN VIMPAT TAB ( = 2 tab/day) vitamin a d oint. vitamin B complex cap vitamin d (RX strength only) VIVELLEDOT PATCH VIVOTI CAP (=4 caps/fill) voriconazole susp (VEND equiv) voriconazole tab (VEND equiv) VOTRIENT TAB (Limited to 2x15 day fills per month for first 3 months) VYVANSE warfarin tab (COUMADIN equiv) WELCHOL PAK WELCHOL TAB XALKORI CAP XARELTO STARTER PACK XARELTO TAB XENAZINE TAB (Only available through Xenazine Support Program ) XENICAL CAP ( = 3 cap/day) XIGDUO TAB XR 5/1000MG (= 2 tab/day ) XIGDUO XR TAB (= 1 tab/day) XTANDI CAP (= 4 cap/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) xulane patch (ORTHOEVRA equiv) XYREM SOLN (=540ml/30 days; Only available through Xyrem Central Pharmacy ) zaleplon cap (SONATA equiv) ZAVESCA CAP ZELBORA TAB (Limited to 2 x 15 day fills per month for first 3 months) ZETIA TAB ( = 1 tab/day) zidovudine cap (RETROVIR equiv) zidovudine syrup (RETROVIR equiv) zidovudine tab (RETROVIR equiv) zinc oxide oint ZINC OXIDE PASTE zinc sulfate cap ZIRGAN OPHTH GEL ZOLINZA CAP (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) zolpidem tab 10mg (AMBIEN equiv) (Male = 1 tab/day; emale = 0.5 tab/day) zolpidem tab 5mg (AMBIEN equiv) ( = 1 tab/day) zonisamide cap (ZONEGRAN equiv) ZORTRESS TAB (Product is mandated through Acaria Specialty Pharmacy.) ZYDELIG TAB (Limited to 2x15 day fills per month for first 3 months; Only available through Diplomat Pharmacy ) Special Code Tier Category VAC PA PA MSPPA MSPPA LDPA PA PASP LDPA MSPPA PASP PASP LDPA ANTIDEPRESSANTS ANTICONVULSANTS ANTICONVULSANTS DERMATOLOGICALS MULTIVITAMINS VITAMINS ESTROGENS VACCINES ANTIUNGALS ANTIUNGALS ANTINEOPLASTICS AND ADJUNCTIVE ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTICOAGULANTS ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS ANTINEOPLASTICS AND ADJUNCTIVE ANTICOAGULANTS ANTICOAGULANTS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. ADHD/ANTINARCOLEPSY/ANTIOBESITY/ ANOREXIANTS ANTIDIABETICS ANTIDIABETICS ANTINEOPLASTICS AND ADJUNCTIVE CONTRACEPTIVES PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. HYPNOTICS HEMATOPOIETIC AGENTS ANTINEOPLASTICS AND ADJUNCTIVE ANTIHYPERLIPIDEMICS ANTIVIRALS ANTIVIRALS ANTIVIRALS DERMATOLOGICALS DERMATOLOGICALS MINERALS & ELECTROLYTES OPHTHALMIC AGENTS ANTINEOPLASTICS AND ADJUNCTIVE HYPNOTICS HYPNOTICS ANTICONVULSANTS ASSORTED CLASSES ANTINEOPLASTICS AND ADJUNCTIVE IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 38 of 99

44 L.A. Care Health Plan MediCal ormulary Cont. Alphabetical Index Drug Name ZYLET OPHTH SUSP ( = Retail 5ml/fill; Mail Order 15ml/fill (10ml bottle is Not Covered)) ZYTIGA TAB (Product is mandated through Acaria Specialty Pharmacy.) ZYVOX SUSP ZYVOX TAB Special Code Tier Category OPHTHALMIC AGENTS PASP ANTINEOPLASTICS AND ADJUNCTIVE PA ANTIINECTIVE AGENTS MISC. PA ANTIINECTIVE AGENTS MISC. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 39 of 99

45 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ADHD/ANTINARCOLEPSY/ANTIOBESITY/ANOREXIANTS AMPHETAMINES ADDERALL XR CAP amphetamine/dextroamphetamine tab (ADDERALL equiv) dextroamphetamine ER cap (DEXEDRINE equiv) dextroamphetamine tab (DEXEDRINE equiv) methamphetamine (DESOXYN equiv) VYVANSE ANALEPTICS caffeine citrate oral soln (CACIT equiv) (Only covered for members less than 1 year old) ANOREXIANTS NONAMPHETAMINE phentermine cap (ADIPEX equiv) ( = 1 cap/day) PA phentermine tab (ADIPEX equiv) ( = 1 tab/day) PA QSYMIA CAP ( = 1 cap/day) PA ANTIOBESITY AGENTS BELVIQ TAB ( = 2 tab/day) PA XENICAL CAP ( = 3 cap/day) PA ATTENTIONDEICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS STRATTERA CAP STIMULANTS MISC. methylin ER tab (RITALIN SR equiv) methylphenidate (RITALIN equiv) methylphenidate cap cd (METADATE CD CAP equiv) methylphenidate cap er (RITALIN LA CAP equiv) METHYLPHENIDATE ER/CONCERTA TAB methylphenidate soln (METHYLIN SOLN equiv) modafinil tab (PROVIGIL TAB equiv) ( = 1 tab/day) PA QUILLIVANT XR SUSP. AMINOGLYCOSIDES AMINOGLYCOSIDES neomycin tab TOBI PODHALER MSPPA tobramycin neb (TOBI equiv) MSPPA ANALGESICS ANTIINLAMMATORY ANTITNALPHA MONOCLONAL ANTIBODIES HUMIRA INJ (= 2 inj/28 days) MSPPA HUMIRA PEN INJ (= 2 inj/28 days) MSPPA GOLD COMPOUNDS RIDAURA CAP INTERLEUKIN1 RECEPTOR ANTAGONIST (IL1RA) KINERET INJ (= 28 inj/28 days; Product is mandated through Acaria Specialty Pharmacy.) PA NONSTEROIDAL ANTIINLAMMATORY AGENTS (NSAIDS) celecoxib cap (CELEBREX CAP equiv) ( = 2 cap/ day) diclofenac potassium tab (CATALAM equiv) diclofenac sodium EC tab (VOLTAREN equiv) diclofenac sodium XR tab (VOLTAREN XR equiv) etodolac cap etodolac tab Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 40 of 99

46 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANALGESICS ANTIINLAMMATORY Cont. fenoprofen calcium tab flurbiprofen tab ibuprofen cap ibuprofen chew tab ibuprofen susp. ibuprofen tab INDOCIN SUPP. INDOCIN SUSP. indomethacin cap indomethacin CR cap (INDOCIN SR equiv) ketoprofen cap ketorolac tab ( = 5 days treatment (20 tabs/5 days)) MECLOENAMATE CAP meloxicam tab (MOBIC equiv) nabumetone tab naproxen EC tab (NAPROSYN EC equiv) naproxen sodium tab (ANAPROX equiv) naproxen susp. (NAPROSYN equiv) naproxen tab (NAPROSYN equiv) oxaprozin tab (DAYPRO equiv) piroxicam cap (ELDENE equiv) sulindac tab (CLINORIL equiv) tolmetin cap TOLMETIN TAB PYRIMIDINE SYNTHESIS INHIBITORS leflunomide tab (ARAVA equiv) SELECTIVE COSTIMULATION MODULATORS ORENCIA SC INJ (= 4 inj/28 days) MSPPA SOLUBLE TUMOR NECROSIS ACTOR RECEPTOR AGENTS ENBREL INJ (= 4 syringes/28 days; Product is mandated through Acaria Specialty Pharmacy.) MSPPA ENBREL SURECLICK INJ (= 4 syringes/28 days; Product is mandated through Acaria Specialty Pharmacy.) MSPPA ANALGESICS NONNARCOTIC ANALGESIC COMBINATIONS acetaminophenpamabrompyrilamine tab (COVERED OR MEMBERS 4 YEARS AND OLDER) ASPIRIN/ACETAMINOPHEN/CALCIUM CARBONATE TAB (COVERED OR MEMBERS 4 YEARS AND OLDER) PHENYLTOLOXAMINEACETAMINOPHEN TAB (COVERED OR MEMBERS 4 YEARS AND OLDER) ANALGESICS OTHER acetaminophen chew tab acetaminophen drops (Only covered for members 20 years and younger) acetaminophen elixir (Only covered for members 20 years and younger) acetaminophen er tab acetaminophen liquid (Only covered for members 20 years and younger) acetaminophen supp ACETAMINOPHEN SYRUP (Only covered for members 20 years and younger) acetaminophen tab SALICYLATES aspirin chew tab aspirin ec tab Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 41 of 99

47 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANALGESICS NONNARCOTIC Cont. aspirin supp. aspirin tab CHO MAG TRIS TAB choline magnesium trisalicylate tab diflunisal (DOLOBID equiv) salsalate ANALGESICS OPIOID OPIOID AGONISTS codeine sulfate tab fentanyl patch (DURAGESIC equiv) HYDROMORPHONE SUPP hydromorphone tab (DILAUDID equiv) LEVORPHANOL TAB meperidine tab (DEMEROL equiv) METHADONE SOLN. methadone tab (DOLOPHINE equiv) methadose tab morphine sulfate ER tab (MS CONTIN equiv) morphine sulfate oral soln. morphine sulfate supp. morphine sulfate tab NUCYNTA NUCYNTA ER (= 2 tabs/day) oxycodone cap (OXYIR equiv) oxycodone soln (ROXICODONE equiv) oxycodone tab (ROXICODONE equiv) OXYCONTIN CR TAB ( = 120 tab/30 days) PA OXYIR tramadol tab (ULTRAM equiv) OPIOID COMBINATIONS acetaminophen/codeine soln. acetaminophen/codeine tab (TYLENOL/CODEINE equiv) aspirin/codeine tab hydrocodone/acetaminophen soln (ZOLVIT SOLN equiv) hydrocodone/acetaminophen tab (LORTAB equiv) oxycodone/acetaminophen cap (TYLOX equiv) oxycodone/acetaminophen tab (PERCOCET equiv) oxycodone/aspirin tab (PERCODAN equiv) pentazocine/acetaminophen tab (TALACEN equiv) ROXICET SOLN. 325mg/5ml OPIOID PARTIAL AGONISTS butorphanol nasal spray (STADOL equiv) (= Retail 1 bottle/fill, 2 fill/30 days; Mail Order 3 bottle/fill, 2 fill/90 days) ANDROGENSANABOLIC ANABOLIC STEROIDS oxandrolone tab (OXANDRIN equiv) ANDROGENS ANDROGEL 1.62% 1.25GM (= 1 packet/ day) PA ANDROGEL 1.62% 2.5GM (= 2 packet/ day) PA Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 42 of 99

48 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANDROGENSANABOLIC Cont. ANDROGEL 25MG (= 1 packet/day) PA ANDROGEL 50MG ( = 2 packets/day) PA ANDROGEL PUMP 1% ( = 4 bottle/30 days) PA ANDROGEL PUMP 1.62% ( = 2 bottle/30 days) PA ANDROXY TAB danazol cap (DANOCRINE equiv) testosterone cypionate inj (DEPOTESTOSTERONE INJ. equiv) ANORECTAL AGENTS INTRARECTAL STEROIDS hydrocortisone enema RECTAL COMBINATIONS hc pramoxine cream (ANALPRAMHC equiv) hc pramoxine cream 11% (ANALPRAM HC equiv) lidocaine/ hydrocortisone cream PROCTOOAM HC OAM RECTAL STEROIDS proctosol cream (ANUSOL HC equiv) ANTACIDS ANTACID COMBINATIONS antacid chew tab MAGNESIUM/ALUMINUM HYDROXIDE CHEW magnesium/aluminum hydroxide/simethicone chew tab magnesium/aluminum hydroxide/simethicone susp ANTACIDS ALUMINUM SALTS ALUMINUM HYDROXIDE GEL SUSP. ANTACIDS BICARBONATE sodium bicarbonate tab ANTACIDS CALCIUM SALTS calcium carbonate chew tab CALCIUM CARBONATE TAB ANTACIDS MAGNESIUM SALTS magnesium oxide tab ANTHELMINTICS ANTHELMINTICS BILTRICIDE TAB ivermectin tab (STROMECTOL TAB equiv) ANTIANGINAL AGENTS ANTIANGINALSOTHER RANEXA TAB NITRATES isosorbide dinitrate ER tab isosorbide dinitrate SL tab isosorbide dinitrate tab isosorbide mononitrate ER tab (IMDUR equiv) isosorbide mononitrate tab (MONOKET equiv) nitroglycerin patch (NITRODUR equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 43 of 99

49 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTIANGINAL AGENTS Cont. NITROSTAT SL TAB ANTIANXIETY AGENTS ANTIANXIETY AGENTS MISC. buspirone tab (BUSPAR equiv) hydroxyzine pamoate (VISTARIL equiv) hydroxyzine syrup hydroxyzine tab meprobamate BENZODIAZEPINES alprazolam (XANAX equiv) chlordiazepoxide (LIBRIUM equiv) clorazepate (TRANXENET equiv) diazepam conc. DIAZEPAM SOLN diazepam tab (VALIUM equiv) lorazepam soln lorazepam tab (ATIVAN equiv) oxazepam ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE IA disopyramide cap (NORPACE equiv) disopyramide ER cap (NORPACE CR equiv) NORPACE CR CAP quinidine gluconate CR tab quinidine sulfate tab ANTIARRHYTHMICS TYPE IB mexiletine cap ANTIARRHYTHMICS TYPE IC flecainide tab (TAMBOCOR equiv) propafenone ER tab (RYTHMOL SR equiv) propafenone tab (RHYTHMOL equiv) ANTIARRHYTHMICS TYPE III amiodarone tab (PACERONE equiv) MULTAQ TAB TIKOSYN CAP (Product is mandated through Acaria Specialty Pharmacy.) SP ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIINLAMMATORY AGENTS CROMOLYN NEB SOLN. cromolyn nebulizer solution (INTAL equiv) BRONCHODILATORS ANTICHOLINERGICS ATROVENT HA ipratropium nebulizer solution (ATROVENT equiv) SPIRIVA HANDIHALER (or use with Handihaler device) SPIRIVA RESPIMAT TUDORZA PRESSAIR LEUKOTRIENE MODULATORS montelukast chew tab (SINGULAIR CHEW TAB equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 44 of 99

50 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTIASTHMATIC AND BRONCHODILATOR AGENTS Cont. montelukast granules (SINGULAIR GRANULES equiv) montelukast tab (SINGULAIR equiv) STEROID INHALANTS AEROSPAN HA budesonide susp (PULMICORT RESPULES equiv) LOVENT DISKUS LOVENT HA PULMICORT LEXHALER PULMICORT RESPULE 1mg/2ml SYMPATHOMIMETICS ADVAIR DISKUS ADVAIR HA albuterol neb. solution 0.083% albuterol neb. solution 0.5% albuterol sulfate er (VOSPIRE ER equiv) albuterol sulfate syrup albuterol sulfate tab albuterol/ipratropium nebulizer solution (DUONEB equiv) ANORO ELLIPTA INHALER BREO ELLIPTA INHALER COMBIVENT INHALER COMBIVENT RESPIMAT DULERA INHALER EPHEDRINE SULATE CAP (COVERED OR MEMBERS 4 YEARS AND OLDER) ORADIL AEROLIZER METAPROTERENOL SYRUP SEREVENT DISKUS SYMBICORT terbutaline sulfate (BRETHINE equiv) VENTOLIN HA (= 2 inhalers/fill. 2 fills/30 days) XANTHINES aminophylline tab theophylline cr THEOPHYLLINE ELIXIR theophylline er tab (UNIPHYL equiv) theophylline soln ANTICOAGULANTS COUMARIN ANTICOAGULANTS warfarin tab (COUMADIN equiv) DIRECT ACTOR XA INHIBITORS ELIQUIS TAB XARELTO STARTER PACK XARELTO TAB HEPARINS AND HEPARINOIDLIKE AGENTS enoxaparin inj (LOVENOX equiv) (= 17 days supply; Product is mandated through Acaria Specialty Pharmacy.) SP fondaparinux soln (ARIXTRA equiv) (Product is mandated through Acaria Specialty Pharmacy.) PASP THROMBIN INHIBITORS PRADAXA CAP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 45 of 99

51 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTICONVULSANTS ANTICONVULSANTS BENZODIAZEPINES clonazepam tab (KLONOPIN equiv) DIAZEPAM/DIASTAT RECTAL GEL ONI TAB PA ANTICONVULSANTS MISC. BANZEL SUSP BANZEL TAB carbamazepine cap (CARBATROL equiv) carbamazepine chew tab (TEGRETOL CHEW equiv) carbamazepine susp. (TEGRETOL SUSP. equiv) carbamazepine tab (TEGRETOL equiv) gabapentin cap (NEURONTIN equiv) gabapentin soln. (NEURONTIN SOLN equiv) gabapentin tab (NEURONTIN equiv) lamotrigine chew tab (LAMICTAL CHEW equiv) lamotrigine tab (LAMICTAL equiv) levetiracetam oral soln (KEPPRA ORAL SOLN equiv) levetiracetam tab (KEPPRA equiv) LYRICA CAP PA LYRICA SOLN. PA oxcarbazepine susp. (TRILEPTAL equiv) oxcarbazepine tab (TRILEPTAL equiv) POTIGA TAB (= 3 tab/ day) primidone tab (MYSOLINE equiv) topiramate sprinkle cap (TOPAMAX SPRINKLE equiv) topiramate tab (TOPAMAX equiv) VIMPAT SOLN VIMPAT TAB ( = 2 tab/day) zonisamide cap (ZONEGRAN equiv) CARBAMATES felbamate (ELBATOL equiv) felbamate susp. (ELBATOL SUSP. equiv) ELBATOL TAB GABA MODULATORS GABITRIL TAB 12MG, 16MG SABRIL POWDER (Only available through SHARE program 88845SHARE ( )) LD SABRIL TAB (Only available through SHARE program 88845SHARE ( )) LD tigabine tab (GABITRIL equiv) HYDANTOINS DILANTIN CAP 30MG PEGANONE TAB PHENYTEK CAP phenytoin cap (DILANTIN CAP equiv) phenytoin chew tab (DILANTIN INATABS equiv) phenytoin susp. (DILANTIN equiv) SUCCINIMIDES CELONTIN CAP ethosuximide cap (ZARONTIN equiv) ethosuximide soln. (ZARONTIN equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 46 of 99

52 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTICONVULSANTS Cont. VALPROIC ACID divalproex ER tab (DEPAKOTE ER equiv) divalproex sprinkle cap (DEPAKOTE SPRINKLE equiv) divalproex tab (DEPAKOTE equiv) valproic acid cap (DEPAKENE equiv) valproic acid syrup (DEPAKENE equiv) ANTIDEPRESSANTS ALPHA2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine (REMERON equiv) mirtazapine odt (REMERON SOLUTAB equiv) ANTIDEPRESSANTS MISC. bupropion sr (WELLBUTRIN SR equiv) bupropion tab (WELLBUTRIN equiv) bupropion XL tab (WELLBUTRIN XL equiv) MAPROTILINE TAB MODIIED CYCLICS NEAZODONE TAB nefazodone tab 250mg (SERZONE equiv) trazodone tab VIIBRYD TAB SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram oral soln. (CELEXA equiv) citalopram tab (CELEXA equiv) escitalopram soln (LEXAPRO SOLN equiv) escitalopram tab (LEXAPRO equiv) fluoxetine cap (PROZAC equiv) fluoxetine liquid (PROZAC equiv) fluoxetine tab (PROZAC equiv) fluvoxamine (LUVOX equiv) fluvoxamine er cap (LUVOX CR equiv) (Step Therapy requires failure of sertraline, fluoxetine, citalopram, paroxetine or ST fluvoxamine) paroxetine er (PAXIL CR equiv) paroxetine tab (PAXIL equiv) sertraline (ZOLOT equiv) SEROTONINNOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) duloxetine cap (CYMBALTA equiv) ( = 2 cap/day) venlafaxine ER cap (EEXOR XR equiv) venlafaxine ER tab (VENLAAXINE ER TAB equiv) VENLAAXINE ER TAB 225MG TRICYCLIC AGENTS amitriptyline AMOXAPINE TAB desipramine (NORPRAMINE equiv) doxepin cap imipramine (TORANIL equiv) nortriptyline cap (PAMELOR equiv) nortriptyline soln (PAMELOR equiv) NORTRIPTYLINE SOLN. Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 47 of 99

53 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTIDIABETICS ALPHAGLUCOSIDASE INHIBITORS acarbose tab (PRECOSE equiv) ANTIDIABETIC COMBINATIONS AVANDAMET TAB AVANDARYL TAB glipizide/metformin tab (METAGLIP equiv) glyburide/metformin tab (GLUCOVANCE equiv) JANUMET TAB JANUMET XR TAB JUVISYNC TAB KOMBIGLYZE XR TAB pioglitazone/glimepiride tab (DUETACT TAB equiv) pioglitazone/metformin tab (ACTOPLUS MET equiv) XIGDUO TAB XR 5/1000MG (= 2 tab/day ) XIGDUO XR TAB (= 1 tab/day) BIGUANIDES metformin ER tab (GLUCOPHAGE XR equiv) metformin tab (GLUCOPHAGE equiv) DIABETIC OTHER GLUCAGEN HYPOKIT GLUCAGON KIT GLUCOSE CHEW TAB glucose gel GLUCOSE TAB KORLYM TAB (Only available through CuraScript ) LDPA DIPEPTIDYL PEPTIDASE4 (DPP4) INHIBITORS JANUVIA TAB (= 1 tab/day) ONGLYZA TAB (= 1 tab/day) INCRETIN MIMETIC AGENTS (GLP1 RECEPTOR AGONISTS) BYDUREON INJ VICTOZA INJ INSULIN HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG PEN HUMALOG VIAL HUMULIN 70/30 KWIKPEN HUMULIN 70/30 VIAL HUMULIN N KWIKPEN HUMULIN N U100 VIAL HUMULINR U100 HUMULINR U100 VIAL LANTUS INJ LANTUS SOLOSTAR INJ INSULIN SENSITIZING AGENTS AVANDIA TAB pioglitazone tab (ACTOS TAB equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 48 of 99

54 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTIDIABETICS Cont. MEGLITINIDE ANALOGUES repaglinide tab (PRANDIN equiv) SODIUMGLUCOSE COTRANSPORTER 2 (SGLT2) INHIBITORS ARXIGA TAB (= 1 tab/day) JARDIANCE TAB (=1 tab/day) SULONYLUREAS chlorpropamide tab (DIABINESE equiv) glimepiride tab (AMARYL equiv) glipizide (GLUCOTROL equiv) glipizide ER tab (GLUCOTROL XL equiv) glyburide micronized tab (GLYNASE equiv) glyburide tab (MICRONASE equiv) tolazamide tab (TOLINASE equiv) TOLBUTAMIDE TAB ANTIDIARRHEALS ANTIDIARRHEAL AGENTS MISC. bismuth subsalicylate chew tab bismuth subsalicylate susp. bismuth subsalicylate tab ANTIPERISTALTIC AGENTS diphenoxylate/atropine liquid (LOMOTIL equiv) diphenoxylate/atropine tab (LOMOTIL equiv) loperamide cap loperamide liquid loperamide tab ANTIDOTES ANTIDOTES CHELATING AGENTS CHEMET CAP EXJADE TAB MSP ERRIPROX TAB (Only available through erriprox Total Care ) LDPA ANTIEMETICS 5HT3 RECEPTOR ANTAGONISTS granisetron tab (KYTRIL equiv) (= Retail 9 tabs/fill; Mail Order 27 tabs/fill) ondansetron (ZORAN equiv) ondansetron ODT (ZORAN ODT equiv) ondansetron oral soln (ZORAN ORAL SOLN equiv) ANTIEMETICS ANTICHOLINERGIC dimenhydrin tab maldemar tab (SCOPACE equiv) meclizine chew tab meclizine tab trimethobenzamide cap (TIGAN equiv) ANTIEMETICS MISCELLANEOUS antinausea soln. dronabinol cap (MARINOL equiv) PA SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS EMEND CAP (= 3 tab/day; Product is mandated through Acaria Specialty Pharmacy.) SP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 49 of 99

55 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTIUNGALS ANTIUNGALS flucytosine cap (ANCOBON equiv) GRIULVIN SUSP griseofulvin micro tab (GRIULVIN V equiv) griseofulvin susp (GRIULVIN equiv) griseofulvin tab (GRISPEG equiv) nystatin powder nystatin tab terbinafine tab (LAMISIL equiv) IMIDAZOLERELATED ANTIUNGALS fluconazole susp (DILUCAN equiv) fluconazole tab (DILUCAN equiv) itraconazole cap (SPORANOX equiv) PA ketoconazole tab (NIZORAL equiv) NOXAIL SUSP voriconazole susp (VEND equiv) PA voriconazole tab (VEND equiv) PA ANTIHISTAMINES ANTIHISTAMINES ALKYLAMINES chlorpheniramine cr tab (Only covered for members 2 years and older) chlorpheniramine syrup (Only covered for members 2 years and older) chlorpheniramine tab (Only covered for members 2 years and older) ANTIHISTAMINES ETHANOLAMINES clemastine fumarate tab diphenhydramine cap (Only covered for members 2 years and older) diphenhydramine chew tab (Only covered for members 2 years and older) diphenhydramine liquid (Only covered for members 2 years and older) diphenhydramine rapid tab (Only covered for members 2 years and older) DIPHENHYDRAMINE STRIP (Only covered for members 2 years and older) diphenhydramine syrup (Only covered for members 2 years and older) diphenhydramine tab (Only covered for members 2 years and older) ANTIHISTAMINES NONSEDATING cetirizine chew ( = 1 TAB/DAY) cetirizine syrup (ZYRTEC equiv) cetirizine tab ( = 1 TAB/DAY) CLARITIN REDITAB ( = 1 tab/day) loratadine ODT ( = 1 tab/day) loratadine syrup ( = 240ml/30 day; Covered for members age 2 through 5 years) loratadine tab (CLARITIN equiv) ( = 1 tab/day; Covered for members 2 years and older) ANTIHISTAMINES PHENOTHIAZINES promethazine supp promethazine syrup promethazine tab ANTIHISTAMINES PIPERIDINES cyproheptadine syrup cyproheptadine tab ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS MISC. Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 50 of 99

56 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTIHYPERLIPIDEMICS Cont. omega3acid ethyl esters cap (LOVAZA equiv) BILE ACID SEQUESTRANTS cholestyramine lite powder (QUESTRAN LITE equiv) cholestyramine lite powder pack (QUESTRAN LITE equiv) cholestyramine powder (QUESTRAN equiv) cholestyramine powder pack (QUESTRAN equiv) colestipol tab (COLESTID equiv) WELCHOL PAK WELCHOL TAB IBRIC ACID DERIVATIVES fenofibrate cap (LOIBRA equiv) fenofibric acid DR cap (TRILIPIX equiv) gemfibrozil tab (LOPID equiv) HMG COA REDUCTASE INHIBITORS atorvastatin tab (LIPITOR equiv) fluvastatin cap (LESCOL equiv) LESCOL XL CAP PA lovastatin tab (MEVACOR equiv) pravastatin tab (PRAVACHOL equiv) SIMCOR TAB simvastatin tab (ZOCOR equiv) (80mg is Not Covered) INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ZETIA TAB ( = 1 tab/day) NICOTINIC ACID DERIVATIVES niacin ER tab (NIASPAN equiv) ANTIHYPERTENSIVES ACE INHIBITORS benazepril tab (LOTENSIN equiv) captopril tab (CAPOTEN equiv) enalapril tab (VASOTEC equiv) EPANED SOLN fosinopril tab (MONOPRIL equiv) lisinopril tab (PRINIVIL equiv) moexipril tab (UNIVASC equiv) perindopril tab (ACEON equiv) quinapril tab (ACCUPRIL equiv) ramipril cap (ALTACE equiv) trandolapril tab (MAVIK equiv) AGENTS OR PHEOCHROMOCYTOMA DIBENZYLINE CAP ANGIOTENSIN II RECEPTOR ANTAGONISTS eprosartan mesylate tab (TEVETEN equiv) irbesartan tab (AVAPRO TAB equiv) losartan tab (COZAAR equiv) valsartan tab (DIOVAN equiv) ANTIADRENERGIC ANTIHYPERTENSIVES clonidine patch (CATAPRESTTS equiv) clonidine tab (CATAPRES equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 51 of 99

57 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTIHYPERTENSIVES Cont. doxazosin tab (CARDURA equiv) guanfacine IR tab (TENEX equiv) methyldopa tab prazosin cap (MINIPRESS equiv) terazosin cap (HYTRIN equiv) ANTIHYPERTENSIVE COMBINATIONS amlodipine/ valsartan tab (EXORGE TAB equiv) amlodipine/benazepril cap (LOTREL equiv) atenolol/chlorthalidone tab (TENORETIC equiv) benazepril/hydrochlorothiazide tab (LOTENSIN HCT equiv) bisoprolol/hydrochlorothiazide tab (ZIAC equiv) candesartan/hydrochlorothiazide tab (ATACAND HCT equiv) captopril/hydrochlorothiazide tab (CAPOZIDE equiv) enalapril/hydrochlorothiazide tab (VASERETIC equiv) fosinopril/hydrochlorothiazide tab (MONOPRIL HCT equiv) irbesartan/hydrochlorothiazide tab (AVALIDE TAB equiv) lisinopril/hydrochlorothiazide tab (ZESTORETIC equiv) losartan/hydrochlorothiazide tab (HYZAAR equiv) methyldopa/hydrochlorothiazide tab metoprolol/hydrochlorothiazide tab (LOPRESSOR HCT equiv) moexipril/hydrochlorothiazide tab (UNIRETIC equiv) propranolol/hydrochlorothiazide tab quinapril/hydrochlorothiazide tab (ACCURETIC equiv) valsartan/hydrochlorothiazide tab (DIOVAN HCT TAB equiv) VASODILATORS hydralazine tab minoxidil tab ANTIINECTIVE AGENTS MISC. ANTIINECTIVE AGENTS MISC. CAYSTON INH SOLN (Only available through Cystic ibrosis Services or oundation Care Pharmacy LDPA ) metronidazole cap (LAGYL equiv) metronidazole tab (LAGYL equiv) NEBUPENT NEB SOLN MSP trimethoprim tab vancomycin cap (VANCOCIN CAP equiv) (= 56 cap/ fill; Step Therapy requires trial of vancomycin soln) ST VANCOMYCIN SOLN KIT ANTIINECTIVE MISC. COMBINATIONS erythromycin/sulfisoxazole susp (PEDIAZOLE equiv) smz/tmp (DS) tab (BACTRIM DS equiv) smz/tmp susp (SEPTRA SUSP equiv) ANTIPROTOZOAL AGENTS ALINIA SUSP atovaquone susp (MEPRON equiv) LEPROSTATICS DAPSONE TAB LINCOSAMIDES clindamycin cap 150mg clindamycin cap 75mg (CLEOCIN equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 52 of 99

58 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTIINECTIVE AGENTS MISC. Cont. OXAZOLIDINONES SIVEXTRO TAB (=6 tab/fill) PA ZYVOX SUSP PA ZYVOX TAB PA ANTIMALARIALS ANTIMALARIAL COMBINATIONS atovaquone/proguanil tab (MALARONE equiv) MALARONE TAB ANTIMALARIALS chloroquine tab (ARALEN equiv) DARAPRIM TAB hydroxychloroquine tab (PLAQUENIL equiv) mefloquine tab (LARIAM equiv) PRIMAQUINE TAB ANTIMYASTHENIC AGENTS ANTIMYASTHENIC AGENTS MESTINON TIMESPAN PROSTIGMIN pyridostigmine tab (MESTINON equiv) ANTIMYCOBACTERIAL AGENTS ANTI TB COMBINATIONS isonarif cap (RIAMATE equiv) ANTIMYCOBACTERIAL AGENTS ethambutol tab (MYAMBUTOL tab equiv) ISONIAZID SYRUP isoniazid tab pyrazinamide tab rifabutin cap (MYCOBUTIN equiv) rifampin cap (RIADIN equiv) ANTINEOPLASTICS ANTINEOPLASTICS MISC. tretinoin cap (VESANOID equiv) SP MITOTIC INHIBITORS etoposide cap SP TOPOISOMERASE I INHIBITORS HYCAMTIN CAP (Product is mandated through Acaria Specialty Pharmacy.) PASP ANTINEOPLASTICS AND ADJUNCTIVE ALKYLATING AGENTS AINITOR TAB (= 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria PASP Specialty Pharmacy.) ALKERAN TAB CEENU CAP CYCLOPHOSPHAMIDE CAP cyclophosphamide tab HEXALEN CAP (Product is mandated through Acaria Specialty Pharmacy.) SP LEUKERAN TAB (Product is mandated through Acaria Specialty Pharmacy.) SP LOMUSTINE CAP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 53 of 99

59 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTINEOPLASTICS AND ADJUNCTIVE Cont. MYLERAN TAB temozolomide cap (TEMODAR equiv) (Product is mandated through Acaria Specialty Pharmacy.) SP ANTIMETABOLITES capecitabine tab (XELODA equiv) (Product is mandated through Acaria Specialty Pharmacy.) SP mercaptopurine tab (PURINETHOL equiv) methotrexate inj (Product is mandated through Acaria Specialty Pharmacy.) MSP methotrexate tab TABLOID TAB ANTINEOPLASTIC HEDGEHOG PATHWAY INHIBITORS ERIVEDGE CAP (Limited to 2x15 day fills per month for first 3 months) MSPPA ANTINEOPLASTIC HORMONAL AGENTS anastrozole tab (ARIMIDEX equiv) bicalutamide tab (CASODEX equiv) EMCYT CAP exemestane tab (AROMASIN equiv) ARESTON TAB flutamide cap (EULEXIN equiv) letrozole tab (EMARA equiv) LYSODREN TAB SP megestrol susp (MEGACE equiv) megestrol tab (MEGACE equiv) NILANDRON TAB tamoxifen tab (NOLVADEX equiv) ZYTIGA TAB (Product is mandated through Acaria Specialty Pharmacy.) PASP ANTINEOPLASTIC HORMONAL AND RELATED AGENTS XTANDI CAP (= 4 cap/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria PASP Specialty Pharmacy.) ANTINEOPLASTIC ENZYME INHIBITORS AINITOR DISPERZ (= 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through PASP Acaria Specialty Pharmacy.) BOSULI TAB (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty PASP Pharmacy.) CAPRELSA TAB (Only available through Biologics ) LDPA COMETRIQ KIT (Limited to 2x15 day fills per month for first 3 months; Only available through Diplomat Pharmacy LDPA ) GILOTRI TAB (=1 TAB/DAY) PA GLEEVEC TAB (= 3 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria PASP Specialty Pharmacy.) ICLUSIG TAB 15MG (= 3 tab/day; Limited to 2x15 day fills per month for first 3 months; Only available through Biologics LDPA ) ICLUSIG TAB 45MG (= 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Only available through Biologics LDPA ) INLYTA TAB (= 8 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria PASP Specialty Pharmacy.) IRESSA TAB (Only available through Iressa Access Program ) LD JAKAI TAB (=2 tabs/day) MSPPA NEXAVAR TAB (Limited to 2 x 15 day fills per month for first 3 months) MSPPA SPRYCEL TAB (= 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria PASP Specialty Pharmacy.) SPRYCEL TAB 20MG (= 3 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through PASP Acaria Specialty Pharmacy.) STIVARGA TAB ( = 4 tab/day; Limited to 2 x 15 day fills per month for first 3 months) MSPPA Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 54 of 99

60 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTINEOPLASTICS AND ADJUNCTIVE Cont. SUTENT CAP (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty PASP Pharmacy.) TARCEVA TAB (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty PASP Pharmacy.) TYKERB TAB MSPPA VOTRIENT TAB (Limited to 2x15 day fills per month for first 3 months) MSPPA XALKORI CAP MSPPA ZELBORA TAB (Limited to 2 x 15 day fills per month for first 3 months) MSPPA ZOLINZA CAP (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty PASP Pharmacy.) ZYDELIG TAB (Limited to 2x15 day fills per month for first 3 months; Only available through Diplomat Pharmacy LDPA ) ANTINEOPLASTICS MISC. ACTIMMUNE INJ MSP ALERONN INJ MSP hydroxyurea cap (HYDREA equiv) INTRONA INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP INTRONA KIT (Product is mandated through Acaria Specialty Pharmacy.) MSP MATULANE CAP PROLEUKIN INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP TARGRETIN CAP (Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy.) PASP CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS leucovorin tab MESNEX TAB (Product is mandated through Acaria Specialty Pharmacy.) SP ANTIPARKINSON AGENTS ANTIPARKINSON ADJUVANTS carbidopa tab (LODOSYN equiv) ANTIPARKINSON COMT INHIBITORS entacapone tab (COMTAN equiv) ANTIPARKINSON DOPAMINERGICS APOKYN INJ. bromocriptine cap (PARLODEL equiv) bromocriptine tab (PARLODEL equiv) CARBIDOPA/ LEVODOPA/ ENTACAPONE TAB (STALEVO TAB equiv) carbidopa/levodopa (SINEMET equiv) carbidopa/levodopa ER (SINEMET CR equiv) carbidopa/levodopa ODT (PARCOPA equiv) NEUPRO PATCH pramipexole tab (MIRAPEX TAB equiv) ropinirole (REQUIP equiv) ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS AZILECT selegiline ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIPSYCHOTICS MISC. EQUETRO PHENOTHIAZINES prochlorperazine supp. Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 55 of 99

61 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ANTIPSYCHOTICS/ANTIMANIC AGENTS Cont. prochlorperazine tab ANTISEPTICS & DISINECTANTS ANTISEPTIC COMBINATIONS IV PREP WIPES ANTISEPTICS & DISINECTANTS HYDROGEN PEROXIDE SOLN. CHLORINE ANTISEPTICS chlorhexidine gluconate liquid (HIBICLENS equiv) IODINE ANTISEPTICS povidoneiodine soln. ANTIVIRALS ANTIRETROVIRALS didanosine DR cap (VIDEX EC equiv) SP zidovudine cap (RETROVIR equiv) zidovudine syrup (RETROVIR equiv) zidovudine tab (RETROVIR equiv) CMV AGENTS GANCICLOVIR CAP SP VALCYTE SOLN SP valganciclovir tab (VALCYTE equiv) SP HEPATITIS AGENTS adefovir dipivoxil tab (HEPSERA equiv) SP entecavir tab (BARACLUDE equiv) (=1 tab/day. Product is mandated through Acaria Specialty Pharmacy.) MSP HARVONI TAB (=1 tab/day. Product is mandated through Acaria Specialty Pharmacy.) MSPPA INERGEN INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP PEGASYS INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP PEGASYS KIT (Product is mandated through Acaria Specialty Pharmacy.) MSPST REBETOL SOLN MSP ribasphere cap (REBETOL equiv) (Product is mandated through Acaria Specialty Pharmacy.) MSP RIBATAB (Product is mandated through Acaria Specialty Pharmacy.) MSP ribavirin tab (COPEGUS equiv) (Product is mandated through Acaria Specialty Pharmacy.) MSP SOVALDI TAB (= 1 tab/day. Product is mandated through Acaria Specialty Pharmacy.) MSPPA HERPES AGENTS acyclovir cap (ZOVIRAX equiv) acyclovir susp acyclovir tab (ZOVIRAX equiv) valacyclovir tab (VALTREX equiv) INLUENZA AGENTS RELENZA DISKHALER (=20 units/fill) rimantadine tab (LUMADINE equiv) TAMILU CAP ( = 10 caps/fill) TAMILU SUSP 12MG/ML (= 125ml/fill) TAMILU SUSP 6MG/ML (= 250ml/fill) ASSORTED CLASSES CHELATING AGENTS CUPRIMINE CAP IMMUNOMODULATORS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 56 of 99

62 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ASSORTED CLASSES Cont. REVLIMID CAP ( = 1 cap/day) MSPPA THALOMID CAP (Product is mandated through Acaria Specialty Pharmacy.) PASP IMMUNOSUPPRESSIVE AGENTS azathioprine tab (IMURAN equiv) cyclosporine cap (SANDIMMUNE equiv) cyclosporine modified cap (NEORAL equiv) CYCLOSPORINE MODIIED CAP 50MG cyclosporine modified soln (NEORAL equiv) mycophenolate cap (CELLCEPT equiv) SP mycophenolate DR tab (MYORTIC equiv) mycophenolate mofetil susp (CELLCEPT SUSP equiv) SP mycophenolate tab (CELLCEPT equiv) SP RAPAMUNE SOLN SP SANDIMMUNE SOLN 100MG/ML sirolimus tab (RAPAMUNE equiv) SP tacrolimus cap (PROGRA equiv) ZORTRESS TAB (Product is mandated through Acaria Specialty Pharmacy.) PASP POTASSIUM REMOVING RESINS sodium polystyrene powder (KAYEXALATE equiv) sodium polystyrene soln (SPS equiv) BETA BLOCKERS ALPHABETA BLOCKERS carvedilol tab (COREG equiv) labetalol tab (NORMODYNE equiv) BETA BLOCKERS CARDIOSELECTIVE acebutolol cap (SECTRAL equiv) atenolol tab (TENORMIN equiv) betaxolol tab (KERLONE equiv) bisoprolol tab (ZEBETA equiv) BYSTOLIC TAB metoprolol ER tab (TOPROL XL equiv) metoprolol tab (LOPRESSOR equiv) BETA BLOCKERS NONSELECTIVE HEMANGEOL SOLN (COVERED OR MEMBERS AGE 3 YEARS AND UNDER ONLY) nadolol tab (CORGARD equiv) pindolol tab propranolol ER cap (INDERAL LA equiv) PROPRANOLOL SOLN propranolol tab sotalol A tab (BETAPACE A equiv) sotalol tab (BETAPACE equiv) timolol maleate tab CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS amlodipine tab (NORVASC equiv) diltiazem ER cap (DILACOR XR equiv) diltiazem tab (CARDIZEM equiv) isradipine cap Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 57 of 99

63 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier CALCIUM CHANNEL BLOCKERS Cont. matzim LA tab (CARDIZEM LA equiv) nicardipine cap nifedipine cap (PROCARDIA equiv) nifedipine ER tab (ADALAT CC equiv) nisoldipine tab (SULAR equiv) verapamil SR cap (VERELAN equiv) verapamil SR tab (CALAN SR, ISOPTIN SR equiv) verapamil tab (CALAN equiv) CARDIOTONICS CARDIAC GLYCOSIDES digoxin tab (LANOXIN equiv) CARDIOVASCULAR AGENTS MISC. CARDIOVASCULAR AGENTS MISC. COMBINATIONS amlodipine/atorvastatin tab (CADUET equiv) PROSTAGLANDIN VASODILATORS TYVASO INH SOLN (Only available through Accredo ) LDPA VENTAVIS INH SOLN (Only available through Accredo ) LDPA PULMONARY HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS OPSUMIT TAB PA TRACLEER TAB (Only available through Accredo AND PharmaCare ) PA PULMONARY HYPERTENSION PHOSPHODIESTERASE INHIBITORS ADCIRCA TAB (Product is mandated through Acaria Specialty Pharmacy.) PASP sildenafil tab (REVATIO TAB equiv) PA CEPHALOSPORINS CEPHALOSPORINS 1ST GENERATION cefadroxil cap (DURICE equiv) cefadroxil susp (DURICE equiv) cefadroxil tab (DURICE equiv) cephalexin cap cephalexin susp CEPHALEXIN TAB CEPHALOSPORINS 2ND GENERATION cefprozil susp (CEZIL equiv) cefprozil tab (CEZIL equiv) cefuroxime susp (CETIN equiv) cefuroxime tab (CETIN equiv) CEPHALOSPORINS 3RD GENERATION cefdinir (OMNICE equiv) cefdinir cap (OMNICE equiv) CHEMICALS LIQUIDS GLYCERIN LIQUID CONTRACEPTIVES COMBINATION CONTRACEPTIVES ORAL apri tab (DESOGEN equiv) aranelle tab (TRINORINYL equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 58 of 99

64 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier CONTRACEPTIVES Cont. aviane tab (ALESSE equiv) balziva tab (OVCON 35 equiv) cesia tab (CYCLESSA equiv) cryselle tab (LO/OVRAL equiv) enpresse tab (TRILEVELEN equiv) gianvi tab/ ocella tab (YAZ/YASMIN equiv) junel E tab (LOESTRIN E equiv) junel tab (LOESTRIN equiv) kariva tab (MIRCETTE equiv) kelnor tab (DEMULEN equiv) mononessa tab (ORTHOCYCLEN equiv) necon tab (ORTHONOVUM equiv) necon tab 1/50 trinessa tab (ORTHO TRICYCLEN equiv) COMBINATION CONTRACEPTIVES TRANSDERMAL xulane patch (ORTHOEVRA equiv) COMBINATION CONTRACEPTIVES VAGINAL NUVARING EMERGENCY CONTRACEPTIVES ELLA TAB levonorgestrel tab (PLANB equiv) PROGESTIN CONTRACEPTIVES ORAL norabe tab (NORAQD equiv) CORTICOSTEROIDS GLUCOCORTICOSTEROIDS CORTE TAB CORTISONE ACETATE TAB DEXAMETHASONE CONC dexamethasone soln dexamethasone tab (DECADRON equiv) hydrocortisone tab (CORTE equiv) methylprednisolone dose pack (MEDROL DOSE PACK equiv) methylprednisolone tab (MEDROL equiv) prednisolone ODT (ORAPRED ODT equiv) prednisolone soln (PEDIAPRED equiv) prednisolone syrup (PRELONE equiv) PREDNISONE PAK PREDNISONE SOLN PREDNISONE TAB MINERALOCORTICOIDS fludrocortisone tab (LORINE equiv) COUGH/COLD/ALLERGY ANTITUSSIVES benzonatate cap (TESSALON equiv) dextromethorphan cap (Only covered for members 4 years and older) dextromethorphan er liquid (Only covered for members 4 years and older) dextromethorphan liquid (Only covered for members 4 years and older) DEXTROMETHORPHAN LOZENGE (Only covered for members 4 years and older) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 59 of 99

65 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier COUGH/COLD/ALLERGY Cont. dextromethorphan syrup (Only covered for members 4 years and older) hydrocodone/homatropine syrup (HYCODAN equiv) TRIAMINIC STRIP (Only covered for members 4 years and older) COUGH/COLD/ALLERGY COMBINATIONS brompheniram/phenylephrine/dm soln (Only covered for members 4 years and older) cetirizine/pseudoephedrine tab ( = 1 TAB/DAY) chlorpheniramine/acetaminophen tab (Only covered for members 4 years and older) chlorpheniramine/phenylephrine/apap effer tab (COVERED OR MEMBERS 419 YEARS) chlorpheniramine/phenylephrine/apap susp. (COVERED OR MEMBERS 419 YEARS ) chlorpheniramine/phenylephrine/apap tab (COVERED OR MEMBERS 419 YEARS) CHLORPHENIRAMINE/PSEUDOEPHEDRINE/IBUPROEN TAB (Only covered for members 4 years and older) CONEX TAB (Only covered for members 4 years and older) DEXTROMETHOR/ACETAMIN/DIPHEN LIQUID (COVERED OR MEMBERS 4 YEARS AND OLDER) dextromethorphan hb/doxylamine soln. (Only covered for members 4 years and older) dextromethorphan hbr/chlorpheniramine liquid (Only covered for members 4 years and older) dextromethorphan hbr/chlorpheniramine tab (Only covered for members 4 years and older) dextromethorphan/phenylephrine liquid (Only covered for members 4 years and older) DEXTROMETHORPHAN/PHENYLEPHRINE STRIP (Only covered for members 4 years and older) DEXTROMETHORPHAN/PSEUDOEPHED DROPS (Only covered for members 4 years and older) DEXTROMETHORPHAN/PSEUDOEPHED ELIXIR (Only covered for members 4 years and older) dextromethorphan/pseudoephed syrup (Only covered for members 4 years and older) DEXTROMETHORPHN/ACETAMINOPH/CP LIQUID (COVERED OR MEMBERS 4 YEARS AND OLDER ) dextromethorphn/acetaminoph/cp susp (COVERED OR MEMBERS 4 YEARS AND OLDER) dextromethorphn/acetaminoph/cp tab (COVERED OR MEMBERS 4 YEARS AND OLDER ) diphenhydramine/acetaminophen tab (Only covered for members 4 years and older) diphenhydramine/phenylephrine/apap liquid (COVERED OR MEMBERS 419 YEARS) diphenhydramine/phenylephrine/apap susp. (COVERED OR MEMBERS 419 YEARS) diphenhydramine/phenylephrine/apap tab (COVERED OR MEMBERS 419 YEARS) dm hb/pe/acetaminophen/chlorpheniramine liquid (Only covered for members 4 years and older) dm hb/pe/acetaminophen/chlorpheniramine susp. (Only covered for members 4 years and older) dm hb/pe/acetaminophen/chlorpheniramine tab (Only covered for members 4 years and older) dm hb/pseudoephed/acetamin/cp cap (Only covered for members 4 years and older) dm hb/pseudoephed/acetamin/cp packet (Only covered for members 4 years and older) dm hb/pseudoephed/acetamin/cp susp (Only covered for members 4 years and older) dm hb/pseudoephed/acetamin/cp tab (Only covered for members 4 years and older) dm/pe/acetaminophen/doxylamine liquid (Only covered for members 4 years and older) dm/pephed/acetaminoph/doxylam cap (Only covered for members 4 years and older) dm/pephed/acetaminoph/doxylam liquid (COVERED OR MEMBERS 419 YEARS) DM/PHENYLEPH/CHLORPHENIRAMINE LIQUID (Only covered for members 4 years and older) DM/PHENYLEPH/CHLORPHENIRAMINE SOLN. (Only covered for members 4 years and older) dm/pseudoephed/acetaminophen cap (COVERED OR MEMBERS 4 YEARS AND OLDER) dm/pseudoephed/acetaminophen tab (COVERED OR MEMBERS 4 YEARS AND OLDER) dmethorphan hb/acetaminophen liquid (Only covered for members 4 years and older) dmethorphan hb/pepd hcl/bpm elixir (Only covered for members 4 years and older) dmethorphan hb/pepd hcl/bpm syrup (Only covered for members between 2 and 4 years old) DMETHORPHAN HB/PEPHED HCL/CP CHEW TAB (Only covered for members 4 years and older) dmethorphan hb/pephed hcl/cp liquid (Only covered for members 4 years and older) DMETHORPHAN HB/PEPHED HCL/CP SYRUP (Only covered for members 4 years and older) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 60 of 99

66 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier COUGH/COLD/ALLERGY Cont. dmethorphan/acetamin/doxylamn cap (COVERED OR MEMBERS 4 YEARS AND OLDER) dmethorphan/acetamin/doxylamn liquid (COVERED OR MEMBERS 4 YEARS AND OLDER) dmethorphan/pe/acetaminophen cap (Only covered for members 4 years and older) dmethorphan/pe/acetaminophen liquid (Only covered for members 4 years and older) dmethorphan/pe/acetaminophen tab (Only covered for members 4 years and older) guaifen/phenyleph/acetaminophn tab (Only covered for members 4 years and older) GUAIEN/PSEUDOEPHED/ACETAMINOP TAB (Only covered for members 4 years and older) guaifenesin/acetaminophen tab (Only covered for members 4 years and older) guaifenesin/codeine soln (BRONTEX equiv) guaifenesin/codeine syrup (TUSSIORGANI SYRUP equiv) (=240ml/per dispensing) guaifenesin/dextromethorphan cap (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/dextromethorphan liquid (COVERED OR MEMBERS 4 YEARS AND OLDER) GUAIENESIN/DEXTROMETHORPHAN PACK (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/dextromethorphan tab (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/dm/pseudoephedrine cap (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/dmethorphan hb/pe liquid (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/dmethorphan hb/pe syrup (COVERED OR MEMBERS 4 YEARS AND OLDER) guaifenesin/ephedrine hcl tab (Only covered for members 4 years and older) guaifenesin/phenylephrine hcl liquid (Only covered for members 4 years and older) guaifenesin/pseudoephedrne hcl cap (Only covered for members 4 years and older) guaifenesin/pseudoephedrne hcl syrup (Only covered for members 4 years and older) LOHISTD LIQUID (Only covered for members 4 years and older) loratadine/pseudoephedrine tab ( = 2 tab/day) MEDIGRAINE TAB NEOTUSS PLUS LIQUID pe/acetamin/diphenhydramin/cpm tab (COVERED OR MEMBERS 419 YEARS) pheniramine/phenylephrine/acetaminophen packet (Only covered for members 19 years and younger) phenyldphrine/brompheniramine chew liquid (Only covered for members 4 years and older) phenyldphrine/brompheniramine elixir (Only covered for members 4 years and older) PHENYLDPHRINE/BROMPHENIRAMINE TAB (Only covered for members 4 years and older) PHENYLEPH/ACETAMIN/DEXBROMPHENIRAMINE TAB (COVERED OR MEMBERS 419 YEARS) phenylephrine/acetamin/doxylamine cap (COVERED OR MEMBERS 419 YEARS) phenylephrine/acetaminophen cap (Only covered for members 4 years and older) phenylephrine/acetaminophen pack (Only covered for members 4 years and older) phenylephrine/acetaminophen tab (Only covered for members 4 years and older) phenylephrine/chlorpheniramine liquid (Only covered for members 2 years and older) phenylephrine/chlorpheniramine tab (Only covered for members 4 years and older) phenylephrine/diphenhydramine liquid (Only covered for members 4 years and older) phenylephrine/diphenhydramine solution (Only covered for members 4 years and older) phenylephrine/diphenhydramine tab (Only covered for members 4 years and older) phenylephrine/dm/acetaminop/gg liquid (COVERED OR MEMBERS 4 YEARS AND OLDER ) phenylephrine/dm/acetaminop/gg tab (COVERED OR MEMBERS 4 YEARS AND OLDER) promethazine DM syrup PROMETHAZINE VC SYRUP promethazine vc w/codeine (PHENERGAN VC W/CODIENE equiv) promethazine w/codeine (PHENERGAN W/CODIENE equiv) PSEUDOEPH/DM/GUAIEN/ACETAMIN PACKET (COVERED OR MEMBERS 4 YEARS AND OLDER ) pseudoeph/dm/guaifen/acetamin tab (COVERED OR MEMBERS 4 YEARS AND OLDER ) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 61 of 99

67 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier COUGH/COLD/ALLERGY Cont. pseudoephed/acetaminoph/diphenhydramine tab (COVERED OR MEMBERS 419 YEARS) pseudoephedrine/acetaminophen tab (Only covered for members 4 years and older) pseudoephedrine/brompheniramine liquid (Only covered for members 4 years and older) PSEUDOEPHEDRINE/CHLORPHENIRAMINE CHEW TAB (Only covered for members 4 years and older) pseudoephedrine/chlorpheniramine syrup (Only covered for members 4 years and older) pseudoephedrine/chlorpheniramine tab (Only covered for members 4 years and older) pseudoephedrine/dexbrompheniramine er tab (Only covered for members 4 years and older) PSEUDOEPHEDRINE/DIPHENHYDRAMINE TAB (Only covered for members 4 years and older) PSEUDOEPHEDRINE/IBUPROEN CAP (Only covered for members 4 years and older) pseudoephedrine/ibuprofen susp. (Only covered for members 4 years and older) pseudoephedrine/ibuprofen tab (Only covered for members 4 years and older) pseudoephedrine/naproxen tab (Only covered for members 4 years and older) pseudoephedrine/triprolidine tab (Only covered for members 4 years and older) PYRILAMINE/PE/DEXTROMETHORPHAN LIQUID (Only covered for members 4 years and older) SCOTTUSSIN SOLN. (Only covered for members 4 years and older) EXPECTORANTS guaifenesin ER tab (Only covered for members 4 years and older) guaifenesin liquid (Only covered for members 4 years and older) guaifenesin syrup (Only covered for members 4 years and older) guaifenesin tab (Only covered for members 4 years and older) MISC. RESPIRATORY INHALANTS NEBUSAL NEB 6% sodium chloride neb vapor inhaler (Only covered for members 4 years and older) vaporizing steam (COVERED OR MEMBERS 419 YEARS) vaporizing steam liquid (COVERED OR MEMBERS 419 YEARS) MUCOLYTICS acetylcysteine soln DERMATOLOGICALS ACNE PRODUCTS adapalene cream (DIERIN equiv) (acne only age 35 and older requires PA) PA adapalene gel 0.1% (DIERIN equiv) (acne only 35 or older requires PA) PA adapalene gel 0.3% (DIERIN equiv) (Acne Only 35 or older requires PA) PA amnesteem cap (ACCUTANE equiv) benzoyl peroxide cream ( = 1 tube/30 day) benzoyl peroxide gel ( = 1 tube/30 day) benzoyl peroxide liquid ( = 1 bottle/30 day) benzoyl peroxide lotion ( = 1 bottle/30 day) clindamycin gel (CLEOCIN GEL equiv) clindamycin topical (CLEOCINT equiv) erythromycin gel erythromycin pad erythromycin soln PRASCION RA CREAM sodium sulfacetamide/sulfur cream (PLEXION SCT equiv) sodium sulfacetamide/sulfur emulsion (ROSAC WASH equiv) sodium sulfacetamide/sulfur gel (ROSULA equiv) sodium sulfacetamide/sulfur lotion (SULACET R equiv) sodium sulfacetamide/sulfur pad (PLEXION CLEANSING CLOTH equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 62 of 99

68 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier DERMATOLOGICALS Cont. tretinoin cream (Acne only age 35 and older requires PA) PA tretinoin gel (Acne only age 35 and older requires PA) PA ANTIBIOTICS TOPICAL bacitracin oint bacitracin/polymyxin b oint bacitracin/zinc oint. gentamicin sulfate cream gentamicin sulfate oint mupirocin cream (BACTROBAN equiv) mupirocin oint (BACTROBAN OINT equiv) neomycin/bacitracin/polymyxin b oint neomycin/bacitracin/polymyxin b/pramoxine oint neomycin/polymyxin b/pramoxine cream ANTIUNGALS TOPICAL ciclopirox cream (LOPROX CREAM equiv) ciclopirox gel (LOPROX GEL equiv) ciclopirox nail soln (PENLAC equiv) ciclopirox shampoo (LOPROX SHAMPOO equiv) ciclopirox topical susp (LOPROX SUSP equiv) clotrimazole cream clotrimazole soln. clotrimazole/betamethasone cream (LORTRISONE CREAM equiv) clotrimazole/betamethasone lotion (LOTRISONE LOTION equiv) CLOVERINE OINT econazole cream (SPECTAZOLE CREAM equiv) UNGOID SOLN ketoconazole cream (NIZORAL CREAM equiv) ketoconazole shampoo (NIZORAL SHAMPOO equiv) miconazole cream miconazole nitrate aerosol miconazole nitrate powder miconazole oint. NATIN CREAM NATIN GEL nystatin cream (MYCOSTATIN CREAM equiv) nystatin oint nystatin topical powder nystatin/triamcinolone cream nystatin/triamcinolone oint OXISTAT CREAM OXISTAT LOTION terbinafine cream ( = 1 tube/30 day; Covered for members 12 years and older) tolnaftate aerosol tolnaftate cream tolnaftate powder tolnaftate spray ANTIHISTAMINESTOPICAL diphenhydramine cream diphenhydramine gel diphenhydramine spray Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 63 of 99

69 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier DERMATOLOGICALS Cont. ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS TOPICAL fluorouracil cream (EUDEX CREAM equiv) fluorouracil soln (EUDEX SOLN equiv) TARGRETIN GEL (Product is mandated through Acaria Specialty Pharmacy.) SP VALCHLOR GEL (=4 TUBES/30 DAYS) PA ANTIPSORIATICS 8MOP CAP acitretin cap (SORIATANE equiv) calcipotriene cream (DOVONEX CREAM equiv) calcipotriene oint calcipotriene soln (DOVONEX SOLN equiv) methoxsalen cap (OXSORALEN ULTRA equiv) SORIATANE CK KIT VECTICAL OINT ANTISEBORRHEIC PRODUCTS selenium sulfide lotion selenium sulfide shampoo (SELSEB equiv) sodium sulfacetamide wash (OVACE WASH equiv) ANTIVIRALS TOPICAL acyclovir oint (ZOVIRAX OINT equiv) DENAVIR CREAM BATH PRODUCTS glycerin gel mineral oil BURN PRODUCTS silver sulfadiazine cream (SILVADENE CREAM equiv) SULAMYLON CREAM CORTICOSTEROIDS TOPICAL alclometasone cream (ACLOVATE equiv) alclometasone oint (ACLOVATE OINT equiv) amcinonide cream (CYCLOCORT CREAM equiv) AMCINONIDE CREAM 0.1% AMCINONIDE OINT APEXICON E CREAM (PSORCON E equiv) augmented betamethasone cream (DIPROLENE A CREAM equiv) augmented betamethasone lotion (DIPROLENE LOTION equiv) betamethasone augmented gel (DIPROLENE GEL equiv) betamethasone augmented oint (DIPROLENE OINT equiv) betamethasone diproprionate cream (DIPROSONE CREAM equiv) betamethasone diproprionate lotion betamethasone diproprionate oint (DIPROSONE OINT equiv) betamethasone valerate cream betamethasone valerate lotion betamethasone valerate oint clobetasol propionate cream (TEMOVATE CREAM equiv) clobetasol propionate emollient cream (TEMOVATE E equiv) clobetasol propionate gel (TEMOVATE GEL equiv) clobetasol propionate oint (TEMOVATE OINT equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 64 of 99

70 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier DERMATOLOGICALS Cont. clobetasol propionate soln (TEMOVATE SOLN equiv) desonide cream desonide lotion desonide oint desoximetasone cream 0.25% (TOPICORT CREAM 0.25% equiv) desoximetasone gel (TOPICORT equiv) desoximetasone oint 0.25% (TOPICORT equiv) DILORASONE CREAM diflorasone oint EPIOAM AEROSOL fluocinolone acetonide cream fluocinolone acetonide oint fluocinolone acetonide soln fluocinonide cream (LIDEX equiv) fluocinonide emollient cream fluocinonide gel fluocinonide oint fluocinonide soln fluticasone propionate cream (CUTIVATE equiv) fluticasone propionate lotion (CUTIVATE equiv) fluticasone propionate oint (CUTIVATE equiv) halobetasol propionate cream (ULTRAVATE equiv) halobetasol propionate oint (ULTRAVATE equiv) hydrocortisone ac cream HYDROCORTISONE AC OINT hydrocortisone aloe cream HYDROCORTISONE ALOE OINT hydrocortisone butyrate cream (LOCOID equiv) hydrocortisone butyrate oint (LOCOID equiv) hydrocortisone butyrate soln (LOCOID equiv) hydrocortisone cream hydrocortisone gel hydrocortisone lotion hydrocortisone oint hydrocortisone topical soln. hydrocortisone valerate cream hydrocortisone valerate oint (WESTCORT equiv) mometasone cream (ELOCON equiv) mometasone oint (ELOCON equiv) mometasone soln (ELOCON equiv) PRAMOSONE CREAM prednicarbate cream (DERMATOP equiv) prednicarbate oint (DERMATOP equiv) TOPICORT CREAM 0.05%/ DESOXIMETASONE CREAM 0.05% triamcinolone cream triamcinolone lotion triamcinolone oint UCORT CREAM DIAPER RASH PRODUCTS a d oint Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 65 of 99

71 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier DERMATOLOGICALS Cont. EMOLLIENT/KERATOLYTIC AGENTS URAMAXIN CREAM (Only RX version covered/ version NOT covered) urea cream 40% (CARMOL equiv) urea cream 50% (KERALAC equiv) urea gel 40% urea gel 50% urea lotion (KERALAC LOTION equiv) urea susp 40% (UMECTA equiv) EMOLLIENTS ammonium lactate cream ammonium lactate lotion glycerin liquid glycerin lotion mineral oil/petrolatum cream petrolatum oint vitamin a d oint. ENZYMES TOPICAL KOVIA OINT papainurea oint (ACCUZYME OINT equiv) SANTYL OINT IMMUNOMODULATING AGENTS TOPICAL imiquimod cream (ALDARA equiv) IMMUNOSUPPRESSIVE AGENTS TOPICAL ELIDEL CREAM KERATOLYTIC/ANTIMITOTIC AGENTS podofilox soln (CONDYLOX equiv) salicylic acid gel salicylic acid liquid salicylic acid pad salicylic acid shampoo (SALEX equiv) salicylic acid soln salicylic acid strip LINIMENTS capsaicin cream LOCAL ANESTHETICS TOPICAL capsaicin cream capsaicin pad lidocaine cream (LIDAMANTLE equiv) lidocaine gel (XYLOCAINE equiv) lidocaine oint lidocaine soln (XYLOCAINE equiv) lidocaine/prilocaine cream (EMLA equiv) MISC. DERMATOLOGICAL PRODUCTS mineral oil/petrolatum cream MISC. TOPICAL ALCOHOL WIPES aluminum chloride soln (DRYSOL equiv) CALAMINE LOTION Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 66 of 99

72 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier DERMATOLOGICALS Cont. DIETHYLTOLUAMIDE LOTION GEL DRESSING ( = 2 box/30 day) glycerin liquid GLYCERIN SHAMPOO lubricating jelly mineral oil MINERAL OIL LIGHT mineral oil/petrolatum cream mineral oil/petrolatum lotion mineral oil/petrolatum oint PETROLATUM/LANOLIN/ZINC OXIDE/MINERAL OIL OINT. SKIN CLEANSER SODIUM CHLORIDE SPRAY zinc oxide oint ZINC OXIDE PASTE ROSACEA AGENTS INACEA INACEA PLUS KIT metronidazole cream (METROCREAM equiv) metronidazole gel (METROGEL equiv) metronidazole lotion (METROLOTION equiv) SCABICIDES & PEDICULICIDES dimethicone gel EURAX CREAM LICE B GONE SHAMPOO permethrin cream (ELIMITE CREAM equiv) permethrin liquid permethrin lotion permethrin spray piperonyl butox/pyrethrins/permethrin kit piperonyl butoxide/pyrethrins liquid piperonyl butoxide/pyrethrins shampoo SPINOSAD SUSP (= 1 bottle/ fill) WOUND CARE PRODUCTS REGRANEX GEL ( = 2 15gm tubes/fill) sodium chloride irrigation/decyl glucoside soln DIAGNOSTIC PRODUCTS DIAGNOSTIC PRODUCTS, MISC. REESTYLE TEST STRIP DIAGNOSTIC TESTS CLINISTIX REESTYLE INSULINX TEST STRIP REESTYLE TEST STRIP KETODIASTIX KETOSTIX PRECISION XTRA TEST STRIP DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS INANT OODS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 67 of 99

73 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS Cont. INANT ORMULA LIQUID PA INANT ORMULA POWDER PA NUTRITIONAL SUPPLEMENTS NUTRITIONAL SUPPLEMENT LIQUID PA NUTRITIONAL SUPPLEMENT POWDER PA DIGESTIVE AIDS DIGESTIVE ENZYMES CREON CAP DIURETICS CARBONIC ANHYDRASE INHIBITORS acetazolamide cap (DIAMOX SEQUEL equiv) acetazolamide tab ACETAZOLAMIDE TAB 125MG methazolamide tab (NEPTAZANE equiv) DIURETIC COMBINATIONS amiloride/hydrochlorothiazide tab spironolactone/hydrochlorothiazide tab (ALDACTAZIDE equiv) triamterene/hydrochlorothiazide cap (DYAZIDE equiv) triamterene/hydrochlorothiazide tab (MAXZIDE equiv) LOOP DIURETICS bumetanide tab EDECRIN TAB UROSEMIDE SOLN furosemide tab (LASIX equiv) torsemide tab (DEMADEX equiv) POTASSIUM SPARING DIURETICS amiloride tab (MIDAMOR equiv) DYRENIUM CAP spironolactone tab (ALDACTONE equiv) THIAZIDES AND THIAZIDELIKE DIURETICS chlorothiazide tab CHLOROTHIAZIDE TAB 250MG CHLORTHALIDONE TAB DIURIL ORAL SOLN hydrochlorothiazide cap (MICROZIDE equiv) hydrochlorothiazide tab indapamide tab METHYLCLOTHIAZIDE TAB metolazone tab (ZAROXOLYN equiv) ENDOCRINE AND METABOLIC AGENTS MISC. BONE DENSITY REGULATORS alendronate tab (OSAMAX equiv) ALENDRONATE TAB 40MG ORTICAL NASAL SPRAY CALCIUM REGULATORS MISC. ORTEO INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP MIACALCIN INJ MSP Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 68 of 99

74 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier ENDOCRINE AND METABOLIC AGENTS MISC. Cont. GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT INJ (Only available through Walgreens ) LD GROWTH HORMONES GENOTROPIN INJ (Product is mandated through Acaria Specialty Pharmacy.) MSPPA HORMONE RECEPTOR MODULATORS raloxifene tab (EVISTA equiv) INSULINLIKE GROWTH ACTORS (SOMATOMEDINS) INCRELEX INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS SYNAREL NASAL SOLN (Product is mandated through Acaria Specialty Pharmacy.) MSP METABOLIC MODIIERS BUPHENYL TAB calcitriol cap (ROCALTROL equiv) calcitriol inj (CALCIJEX equiv) MSP calcitriol soln (ROCALTROL SOLN. equiv) doxercalciferol cap (HECTOROL equiv) (Product is mandated through Acaria Specialty Pharmacy.) SP KUVAN POWDER PACK PA KUVAN TAB MSPPA levocarnitine soln (CARNITOR equiv) levocarnitine tab (CARNITOR equiv) paricalcitol cap (ZEMPLAR equiv) (Product is mandated through Acaria Specialty Pharmacy.) SP SENSIPAR TAB (Product is mandated through Acaria Specialty Pharmacy.) SP sodium phenylbutyrate powder (BUPHENYL POWDER equiv) POSTERIOR PITUITARY HORMONES desmopressin acetate inj (DDAVP equiv) desmopressin acetate tab (DDAVP equiv) desmopressin nasal soln (DDAVP equiv) STIMATE NASAL SOLN PROLACTIN INHIBITORS cabergoline tab (DOSTINEX equiv) SOMATOSTATIC AGENTS octreotide inj (SANDOSTATIN equiv) (Product is mandated through Acaria Specialty Pharmacy.) MSP SIGNIOR INJ (= 2 vials/day; Only available through Accredo ) LDPA ESTROGENS ESTROGEN COMBINATIONS PREMPHASE TAB/ PREMPRO TAB ESTROGENS estradiol patch (VIVELLEDOT PATCH equiv) estradiol tab (ESTRACE equiv) estropipate tab (OGEN equiv) PREMARIN TAB VIVELLEDOT PATCH LUOROQUINOLONES LUOROQUINOLONES ciprofloxacin susp (CIPRO equiv) ciprofloxacin tab (CIPRO equiv) levofloxacin soln (LEVAQUIN equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 69 of 99

75 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier LUOROQUINOLONES Cont. levofloxacin tab (LEVAQUIN equiv) moxifloxacin tab (AVELOX equiv) ofloxacin tab (LOXIN equiv) OLOXACIN TAB 400MG GASTROINTESTINAL AGENTS MISC. ANTILATULENTS simethicone cap simethicone chew tab simethicone drops simethicone liquid SIMETHICONE STRIPS GALLSTONE SOLUBILIZING AGENTS ursodiol caps (ACTIGALL equiv) GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn soln. (GASTROCROM equiv) GASTROINTESTINAL STIMULANTS metoclopramide (REGLAN equiv) metoclopramide soln INLAMMATORY BOWEL AGENTS APRISO CAP balsalazide cap (COLAZAL equiv) CANASA LIALDA TAB mesalamine enema (ROWASA equiv) sulfasalazine sulfasalazine ec INTESTINAL ACIDIIERS lactulose IRRITABLE BOWEL SYNDROME (IBS) AGENTS LINZESS CAP ( = 1 cap/day) PERIPHERAL OPIOID RECEPTOR ANTAGONISTS RELISTOR INJ (Product is mandated through Acaria Specialty Pharmacy.) MSPPA PHOSPHATE BINDER AGENTS calcium acetate cap (PHOSLO equiv) OSRENOL PHOSLYRA SOLN RENAGEL RENVELA RENVELA TAB SEVELAMER CARBONATE TAB GENITOURINARY AGENTS MISCELLANEOUS ALKALINIZERS CYTRA3 SYRUP (POLYCITRA SYRUP equiv) ORACIT potassium citrate and citric acid granule (POLYCITRA equiv) potassium citrate tab CR (UROCITK TAB equiv) potassium citrate/citric acid soln. Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 70 of 99

76 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier GENITOURINARY AGENTS MISCELLANEOUS Cont. sodium citrate and citric acid soln (BICITRA equiv) tricitrates soln. (POLYCITRALC equiv) CYSTINOSIS AGENTS CYSTAGON (Only available through PharmaCare ) INTERSTITIAL CYSTITIS AGENTS ELMIRON PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl tab (UROXATRAL equiv) AVODART finasteride (PROSCAR equiv) JALYN CAP RAPALO (Restricted to Specialist (Urology)) RS tamsulosin (LOMAX equiv) URINARY ANALGESICS phenazopyridine tab (PYRIDIUM equiv) GOUT AGENTS GOUT AGENT COMBINATIONS colchicine/probenecid tab GOUT AGENTS allopurinol tab (ZYLOPRIM equiv) COLCHICINE TAB (COLCRYS TAB equiv) ULORIC (Step Therapy requires failure of allopurinol.) ST URICOSURICS probenecid tab HEMATOLOGICAL AGENTS MISC. HEMATORHEOLOGIC AGENTS pentoxifylline ER tab (TRENTAL equiv) PLATELET AGGREGATION INHIBITORS AGGRENOX CAP anagrelide cap (AGRYLIN equiv) cilostazol tab (PLETAL equiv) clopidogrel tab 75mg (PLAVIX 75MG TAB equiv) dipyridamole tab (PERSANTINE equiv) EIENT TAB ticlopidine tab (TICLID equiv) HEMATOPOIETIC AGENTS AGENTS OR GAUCHER DISEASE ZAVESCA CAP AGENTS OR SICKLE CELL ANEMIA DROXIA CAP COBALAMINS cyanocobalamin inj cyanocobalamine er tab cyanocobalamine lozenge cyanocobalamine sl tab cyanocobalamine tab Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 71 of 99

77 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier HEMATOPOIETIC AGENTS Cont. OLIC ACID/OLATES folic acid tab HEMATOPOIETIC GROWTH ACTORS EPOGEN INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP GRANIX INJ LEUKINE INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP NEULASTA INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP NEUMEGA INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP PROCRIT INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP PROMACTA TAB MSPPA HEMATOPOIETIC MIXTURES CHROMAGEN ORTE TAB CHROMAGEN TAB ferrex 150 forte cap (NIEREX 150 ORTE equiv) multigen folic tab (CHROMAGEN A equiv) multigen plus tab (CHROMAGEN ORTE equiv) multigen tab (CHROMAGEN equiv) NEPHRON A TAB NIEREX150 ORTE CAP tricon cap (TRINSICON equiv) IRON ferrous gluconate tab ferrous sulfate dr tab ferrous sulfate drops ferrous sulfate elixir ferrous sulfate er tab ERROUS SULATE LIQUID ferrous sulfate slow release tab ERROUS SULATE SYRUP ferrous sulfate tab HEMOSTATICS HEMOSTATICS SYSTEMIC aminocaproic acid syrup (AMICAR equiv) aminocaproic acid tab (AMICAR equiv) AMINOCAPROIC ACID/AMICAR 1000MG tranex acid tab (LYSTEDA equiv) HYPNOTICS ANTIHISTAMINE HYPNOTICS diphenhydramine cap diphenhydramine tab DIPHENHYDRAMINE/APAP LIQUID (COVERED OR MEMBERS 4 YEARS AND OLDER) diphenhydramine/apap tab (COVERED OR MEMBERS 4 YEARS AND OLDER) doxylamine succinate tab BARBITURATE HYPNOTICS phenobarbital elixir phenobarbital tab SECONAL NONBARBITURATE HYPNOTICS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 72 of 99

78 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier HYPNOTICS Cont. estazolam tab (PROSOM equiv) eszopiclone tab (LUNESTA equiv) (=1 tab/day) LURAZEPAM CAP temazepam 15mg (RESTORIL equiv) temazepam 30mg (RESTORIL equiv) triazolam tab (HALCION equiv) zaleplon cap (SONATA equiv) zolpidem tab 10mg (AMBIEN equiv) (Male = 1 tab/day; emale = 0.5 tab/day) zolpidem tab 5mg (AMBIEN equiv) ( = 1 tab/day) LAXATIVES BULK LAXATIVES calcium plycarbophil tab (IBERCON equiv) IBER LIQUID KONSYL POWDER KONSYL POWDER PACKET psyllium cap (METAMUCIL equiv) psyllium powder (METAMUCIL equiv) LAXATIVE COMBINATIONS MOVIPREP (= 1 bottle/fill) peg 3350/electrolytes (GOLYTELY/COLYTE equiv) sennosides/docusate sodium tab trilyte (NULYTELY equiv) LAXATIVES MISCELLANEOUS LEET ENEMA glycerin suppository lactulose polyethylene glycol powder polyethylene glycol powder packet LUBRICANT LAXATIVES MINERAL OIL mineral oil enema MINERAL OIL LIGHT SALINE LAXATIVES magnesium citrate soln. magnesium hydroxide susp. MILK O MAGNESIA CHEW TAB sodium phosphate enema sodium phosphate soln. STIMULANT LAXATIVES BISACODYL ENEMA bisacodyl supp. bisacodyl tab DULCOLAX BOWEL PREP KIT sennosides tab SURACTANT LAXATIVES docusate calcium cap docusate sodium cap docusate sodium enema Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 73 of 99

79 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier LAXATIVES Cont. docusate sodium liquid docusate sodium syrup docusate sodium tab MACROLIDES AZITHROMYCIN azithromycin susp (ZITHROMAX SUSP equiv) azithromycin tab (ZITHROMAX equiv) CLARITHROMYCIN clarithromycin susp (BIAXIN equiv) clarithromycin tab (BIAXIN equiv) ERYTHROMYCINS ERYPED SUSP erythromycin cap ERYTHROMYCIN ETHYLSUCCINATE TAB ERYTHROMYCIN TAB (all forms except PCE) IDAXOMICIN DIICID TAB (Step Therapy requires trial of VANCOCIN; = 20 tab/fill) ST MEDICAL DEVICES CONTRACEPTIVES EMALE CONDOMS MALE CONDOMS DIABETIC SUPPLIES REESTYLE REEDOM LITE METER REESTYLE KIT INSULINX REESTYLE LITE METER REESTYLE METER LANCET KIT LANCETS PRECISION XTRA METER VGO 20 KIT (=1 KIT/DAY) VGO 30 KIT (=1 KIT/DAY) VGO 40 KIT (=1 KIT/DAY) MISC. DEVICES ALCOHOL SWABS PARENTERAL THERAPY SUPPLIES BD INSULIN SYRINGE BD PEN NEEDLE RESPIRATORY AIDS PEDIATRIC MASK RESPIRATORY THERAPY SUPPLIES AEROCHAMBER PEAK LOW METER MIGRAINE PRODUCTS MIGRAINE COMBINATIONS MIGERGOT SUPP. MIGRAINE PRODUCTS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 74 of 99

80 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier MIGRAINE PRODUCTS Cont. dihydroergotamine (D.H.E. equiv) SEROTONIN AGONISTS naratriptan tab (AMERGE equiv) ( = Retail 9 tabs/fill, 2 fill/30 days; Mail Order 27 tab/fill, 2 fill/90 days) rizatriptan (MAXALT equiv) ( = Retail 12 tab/fill, 3 fill/60 day; Mail Order 36 tab/fill, 2 fill/90 day) rizatriptan ODT (MAXALT MLT equiv) ( = Retail 12 tab/fill, 3 fill/60 day; Mail Order 36 tab/fill, 2 fill/90 day) sumatriptan inj (IMITREX equiv) ( = Retail 4 inj/fill, 2 fill/30 days; Mail Order 12 inj/fill, 2 fill/90 days) SUMATRIPTAN INJ 6MG/0.5ML ( = Retail 4 inj/fill, 2 fill/30 days; Mail Order 12 inj/fill, 2 fill/90 days ) sumatriptan tab (IMITREX equiv) ( = Retail 9 tab/fill, 2 fill/30 days; Mail Order 27 tab/fill, 2 fill/90 days) SUMATRIPTAN/ IMITREX NASAL SPRAY ( = Retail 6 sprays/fill, 2 fills/30 days; Mail Order 18 sprays/fill, 2 fills/90 days) MINERALS & ELECTROLYTES CALCIUM CALCIUM ACETATE TAB ( = 9 tab/day) calcium and phosphorus w/vitamin D tab (RISACALD equiv) CALCIUM CARBONATE CAP calcium carbonate chew tab calcium carbonate susp. calcium carbonate tab calcium carbonate w/ vitamin d cap CALCIUM CARBONATE W/ VITAMIN D CHEW TAB calcium carbonate w/ vitamin d tab calcium carbonate w/ vitamind D chew tab calcium carbonate w/ vitamind D tab CALCIUM CARBONATE/GLUCONATE W/ VITAMIN D TAB calcium citrate tab calcium citrate w/ vitamin d tab CALCIUM GLUCONATE TAB CALCIUM LACTATE TAB ELECTROLYTE MIXTURES pediatric electrolyte soln. LUORIDE LUORABON SOLN. sodium fluoride chew tab (LURIDE equiv) sodium fluoride soln. (LURIDE SOLN. equiv) SODIUM LUORIDE TAB IODINE PRODUCTS SSKI SOLN. MAGNESIUM magnesium oxide tab MINERAL COMBINATIONS calcium citrate tab PHOSPHATE KPHOS TAB phospha 250 neutral tab (KPHOS NEUTRAL equiv) POTASSIUM KLORCON M15 CAP potassium bicarbonate effer tab Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 75 of 99

81 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier MINERALS & ELECTROLYTES Cont. potassium chloride effer tab potassium chloride ER cap (MICROK CAP equiv) potassium chloride ER tab (KLORCON TAB equiv) potassium chloride liquid potassium chloride micro cap (KDUR CAP equiv) potassium chloride powder packet (KLORCON equiv) SODIUM sodium chloride tab ZINC GALZIN CAP zinc sulfate cap MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL lidocaine viscous soln throat lozenge ANTIALLERGY AGENTS MOUTH/THROAT APHTHASOL PASTE ANTIINECTIVES THROAT clotrimazole troches (MYCELEX TROCHES equiv) nystatin susp ANTISEPTICS MOUTH/THROAT chlorhexidine gluconate soln DENTAL PRODUCTS PREVIDENT 5000 PLUS CREAM PREVIDENT ORAL RINSE sodium fluoride cream (PREVIDENT 5000 PLUS equiv) sodium fluoride gel (PREVIDENT GEL equiv) sodium fluoride paste (PREVIDENT 5000 BOOSTER equiv) sodium fluoride rinse (PREVIDENT ORAL RINSE equiv) LOZENGES throat lozenge (Only covered for members 19 years and younger) STEROIDS MOUTH/THROAT triamcinolone in orabase paste THROAT PRODUCTS MISC. cevimeline cap (EVOXAC equiv) pilocarpine tab (SALAGEN equiv) MULTIVITAMINS BCOMPLEX VITAMINS vitamin B complex cap BCOMPLEX W/ OLIC ACID dialyvite tab (NEPHROVITE equiv) folbee plus cz tab (DIATX ZN equiv) renaphro cap (NEPHROCAP equiv) BIOLAVONOID PRODUCTS ascorbic acid tab MULTIPLE VITAMINS W/ IRON Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 76 of 99

82 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier MULTIVITAMINS Cont. multivitamin w/ iron tab MULTIPLE VITAMINS W/ MINERALS multiple vitamins w/ minerals tab multivitamin w/ iron chew tab MULTIVITAMINS multiple vitamin liquid multiple vitamin tab PED MULTI VITAMINS W/L & E pediatric multiple vitamins/fluoride/iron soln. trivit/iron/fluoride tab PED MULTIPLE VITAMINS W/ MINERALS pediatric multivitamin w/ minerals gummy PED MV W/ LUORIDE pediatric multiple vitamins/fluoride chew tab pediatric multiple vitamins/fluoride soln PED MV W/ IRON pediatric multivitamin w/ iron chew tab pediatric multivitamin w/ iron drops PEDIATRIC MULTIPLE VITAMINS PEDIATRIC MULTIVITAMIN CHEW TAB pediatric multivitamin w/ vitamin c soln. pediatric multivitamin w/ vitamin c w/ iron chew tab PEDIATRIC VITAMINS pediatric multivitamin adc drops PEDIATRIC MULTIVITAMIN CHEW TAB PRENATAL VITAMINS PRENATAL VITAMIN PRENATAL VITAMIN (RX ONLY) MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS baclofen carisoprodol tab (SOMA equiv) chlorzoxazone (PARAON ORTE equiv) cyclobenzaprine 10mg (LEXERIL equiv) cyclobenzaprine 5mg (LEXERIL equiv) methocarbamol tab (ROBAXIN equiv) orphenadrine citrate ER tizanidine tab (ZANALEX TAB equiv) DIRECT MUSCLE RELAXANTS dantrolene cap (DANTRIUM equiv) DANTROLENE CAP 100MG (DANTRIUM equiv) MUSCLE RELAXANT COMBINATIONS carisoprodol/aspirin NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS MISC. NASAL MOIST GEL Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 77 of 99

83 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier NASAL AGENTS SYSTEMIC AND TOPICAL Cont. saline nasal spray NASAL ANTIALLERGY azelastine nasal spray (ASTELIN equiv) cromolyn nasal spray PATANASE NASAL SPRAY NASAL ANTICHOLINERGICS ipratropium nasal spray (ATROVENT equiv) NASAL STEROIDS flunisolide nasal spray (NASAREL equiv) (=2 bottles/fill) fluticasone nasal spray (LONASE equiv) (=2 bottles/fill) NASACORT NASAL SPRAY () (= 2 bottles/fill) QNASL NASAL SPRAY SYMPATHOMIMETIC DECONGESTANTS oxymetazolin spray (Only covered for members 4 years and older) PHENYLEPHRINE DROPS (Only covered for members 4 years and older) phenylephrine nasal drops (Only covered for members 4 years and older) phenylephrine tab (Only covered for members 4 years and older) pseudoephedrine ER tab ( = 2 tab/day; Covered for members 4 years and older) pseudoephedrine syrup ( = 1200ml/30 day; Covered for members 4 years and older) pseudoephedrine tab 30mg ( = 8 tab/day; Covered for members 2 years and older) pseudoephedrine tab 60mg ( = 4 tab/day; Covered for members 2 years and older) SUDAED ER TAB ( = 1 tab/day; Covered for member 4 years and older) TRIAMINIC NASAL SOLN. (Only covered for members 4 years and older) NEUROMUSCULAR AGENTS ALS AGENTS riluzole tab (RILUTEK equiv) NUTRIENTS MISC. NUTRITIONAL SUBSTANCES omega3 fatty acid cap (ISH OIL equiv) PROTEINS levocarnitine cap LEVOCARNITINE TAB OPHTHALMIC AGENTS ARTIICIAL TEARS AND LUBRICANTS artificial tears oint artificial tears soln LACRISERT OPHTH INSERT BETABLOCKERS OPHTHALMIC betaxolol ophth soln BETIMOL OPHTH SOLN BETOPTICS OPHTH SOLN carteolol ophth soln dorzolamide/ timolol ophth soln (COSOPT equiv) levobunolol ophth soln (BETAGAN equiv) METIPRANOLOL OPHTH SOLN timolol maleate ophth gel (TIMOPTICXE equiv) timolol maleate ophth soln (TIMOPTIC equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 78 of 99

84 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier OPHTHALMIC AGENTS Cont. CYCLOPLEGIC MYDRIATICS atropine ophth oint atropine ophth soln (ISOPTO ATROPINE equiv) CYCLOGYL OPHTH SOLN 0.5%, 2% CYCLOMYDRIL OPHTH SOLN cyclopentolate ophth soln (CYCLOGYL equiv) homatropine ophth soln (ISOPTO HOMATROPINE equiv) ISOPTO HOMATROPINE OPHTH SOLN 2% ISOPTO HOMATROPINE OPHTH SOLN 5% ISOPTO HYOSCINE OPHTH SOLN tropicamide ophth soln (MYDRIACYL equiv) MIOTICS ISOPTO CARBACHOL OPHTH SOLN PHOSPHOLINE OPHTH SOLN pilocarpine ophth soln (ISOPTO CARPINE equiv) OPHTHALMIC ADRENERGIC AGENTS apraclonidine ophth soln (IOPIDINE equiv) brimonidine ophth soln (ALPHAGAN P equiv) SIMBRINZA OPHTH SUSP OPHTHALMIC ANTIINECTIVES AZASITE SOLN BACITRACIN OPHTH OINT bacitracin/ neomycin/ polymyxin b ophth oint bacitracin/ polymyxin b ophth oint ciprofloxacin ophth soln (CILOXAN equiv) erythromycin ophth oint gentamicin ophth oint gentamicin ophth soln levofloxacin ophth soln (QUIXIN equiv) MOXEZA OPHTH SOLN/ VIGAMOX OPHTH SOLN neomycin/ polymyxin b/ gramicidin ophth soln (NEOSPORIN OPHTH equiv) ofloxacin ophth soln (OCULOX equiv) polymyxin b/ trimethoprim ophth soln (POLYTRIM equiv) sulfacetamide sodium ophth soln (BLEPH10 equiv) tobramycin ophth soln (TOBREX equiv) trifluridine ophth soln (VIROPTIC equiv) ZIRGAN OPHTH GEL OPHTHALMIC DECONGESTANTS NAPHAZOLINE OPHTH SOLN. naphazoline/pheniramine ophth drops phenylephrine ophth soln (MYRIN OPHTH SOLN. equiv) tetrahydrozoline ophth soln. tetrahydrozoline/zinc sulfate ophth drops OPHTHALMIC IMMUNOMODULATORS RESTASIS OPHTH EMULSION (Restricted to Ophthalmologist or Optometrist) RS OPHTHALMIC LOCAL ANESTHETICS parcaine ophth soln (ALCAINE equiv) OPHTHALMIC STEROIDS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 79 of 99

85 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier OPHTHALMIC AGENTS Cont. bacitracin/ polymyxin/ neomycin/ hydrocortisone ophth oint BLEPHAMIDE OPHTH SOLN dexamethasone ophth soln DUREZOL OPHTH EMULSION fluorometholone ophth soln (ML LIQUIILM equiv) MAXIDEX OPHTH SOLN neomycin/ polymyxin/ dexamethasone ophth oint (MAXITROL equiv) neomycin/ polymyxin/ dexamethasone ophth soln (MAXITROL equiv) neomycin/ polymyxin/ hydrocortisone ophth soln (CORTISPORIN equiv) PRED MILD OPHTH SOLN PREDG OPHTH SOLN prednisolone ophth soln (PRED ORTE equiv) PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN sulfacetamide sodium/ prednisolone ophth soln TOBRADEX OPHTH OINT tobramycin/ dexamethasone ophth soln (TOBRADEX equiv) VEXOL OPHTH SUSP ZYLET OPHTH SUSP ( = Retail 5ml/fill; Mail Order 15ml/fill (10ml bottle is Not Covered)) OPHTHALMICS MISC. ALAMAST OPHTH SOLN ALOMIDE OPHTH SOLN BROMDAY OPHTH SOLN bromfenac ophth soln (BROMDAY equiv) cromolyn ophth soln (CROLOM equiv) diclofenac sodium ophth (VOLTAREN equiv) dorzolamide ophth soln (TRUSOPT equiv) eye wash soln. flurbiprofen ophth soln (OCUEN equiv) ILEVRO OPHTH SUSP ketorolac ophth soln (ACULAR/ACULAR LS equiv) ketotifen ophth soln NEVANAC OPHTH SUSP PATADAY OPHTH SOLN sodium chloride ophth oint. sodium chloride ophth soln. PROSTAGLANDINS OPHTHALMIC latanoprost ophth soln (XALATAN OPHTH SOLN equiv) (= 2.5ml/ 30 days) OTIC AGENTS OTIC AGENTS MISCELLANEOUS acetic acid otic soln (VOSOL equiv) ACETIC ACID/ALUMINUM ACETATE OTIC SOLN carbamide peroxide otic drop OTIC ANALGESICS omedia otic soln OTIC ANTIINECTIVES ofloxacin otic soln OTIC COMBINATIONS antipyrine/benzocaine otic soln (AURALGAN OTIC equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 80 of 99

86 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier OTIC AGENTS Cont. CIPRODEX OTIC SUSP COLYMYCIN S OTIC SUSP neomycin/polymixin/hydrocoritisone otic susp (CORTISPORIN equiv) OTIC STEROIDS acetic acid/hydrocoritisone otic soln (VOSOL HC equiv) fluocinolone otic oil (DERMOTIC equiv) OXYTOCICS OXYTOCICS methylergonovine tab (METHERGINE equiv) ( = 28 tab/fill; 1 fill/365 days) PASSIVE IMMUNIZING AGENTS IMMUNE SERUMS HIZENTRA INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP PENICILLINS AMINOPENICILLINS amoxicillin cap amoxicillin chew tab AMOXICILLIN CHEW TAB 250MG amoxicillin susp (AMOXIL equiv) amoxicillin tab ampicillin cap NATURAL PENICILLINS penicillin vk soln penicillin vk tab PENICILLIN COMBINATIONS amoxicillin/clavulanate chew tab (AUGMENTIN equiv) amoxicillin/clavulanate susp (AUGMENTIN ES equiv) amoxicillin/clavulanate tab (AUGMENTIN equiv) PENICILLINASERESISTANT PENICILLINS dicloxacillin cap PROGESTINS PROGESTINS medroxyprogesterone tab (PROVERA equiv) norethindrone tab (AYGESTIN equiv) progesterone cap (PROMETRIUM CAP equiv) PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. AGENTS OR CHEMICAL DEPENDENCY disulfiram tab (ANTABUSE equiv) ANTICATAPLECTIC AGENTS XYREM SOLN (=540ml/30 days; Only available through Xyrem Central Pharmacy ) LDPA ANTIDEMENTIA AGENTS donepezil ODT (ARICEPT ODT equiv) (=1 tab/day) donepezil tab (ARICEPT equiv) (=2 tabs/day) donepezil tab 23mg (ARICEPT TAB 23MG equiv) (Step Therapy requires trial of donepezil 10mg; = 1 tab/day) ST EXELON PATCH EXELON SOLN. galantamine (RAZADYNE equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 81 of 99

87 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. Cont. galantamine er (RAZADYNE ER equiv) GALANTAMINE SOLN (RAZADYNE SOLN equiv) NAMENDA NAMENDA XR CAP (= 1 cap/day) rivastigmine cap (EXELON equiv) COMBINATION PSYCHOTHERAPEUTICS chlordiazepoxide/amitriptyline (LIMBITROL equiv) olanzapine/ fluoxetine cap (SYMBYAX CAP equiv) PERPHENAZINE/ AMITRIPTYLINE TAB IBROMYALGIA AGENTS SAVELLA (=2 TAB/DAY) MOVEMENT DISORDER DRUG THERAPY XENAZINE TAB (Only available through Xenazine Support Program ) LDPA MULTIPLE SCLEROSIS AGENTS AMPYRA TAB ( = 2 tab/day) MSPPA AUBAGIO TAB ( = 1 tab/day) MSPPA AVONEX INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP COPAXONE INJ (Product is mandated through Acaria Specialty Pharmacy.) MSP TECIDERA CAP (Product is mandated through Acaria Specialty Pharmacy.) MSP TECIDERA STARTER PACK (Product is mandated through Acaria Specialty Pharmacy.) MSP PSEUDOBULBAR AECT (PBA) AGENTS NUEDEXTA CAP ( = 2 cap/day) SMOKING DETERRENTS bupropion tab (ZYBAN equiv) (Limited to 180 days/plan year) SMKG CHANTIX TAB (Limited to 180 days/plan year) SMKG nicotine gum (NICORETTE equiv) (Limited to 180 days/plan year) SMKG nicotine lozenge (COMMIT LOZENGE equiv) (Limited to 180 days/plan year) SMKG nicotine patch (NICODERM CQ equiv) (Limited to 180 days/plan year) SMKG NICOTROL INHALER (Limited to 180 days/plan year) SMKG NICOTROL NASAL SPRAY (Limited to 180 days/plan year) SMKG RESPIRATORY AGENTS MISC. CYSTIC IBROSIS AGENTS KALYDECO TAB (=2 tab/day) MSPPA PULMOZYME (Product is mandated through Acaria Specialty Pharmacy.) MSP SULONAMIDES SULONAMIDES SULADIAZINE TAB TETRACYCLINES TETRACYCLINES demeclocycline tab (DECLOMYCIN equiv) doxycycline hyclate cap (VIBRAMYCIN equiv) doxycycline hyclate tab (VIBRATAB equiv) doxycycline monohydrate cap doxycycline monohydrate tab (ADOXA equiv) doxycycline susp minocycline cap (MINOCIN equiv) minocycline tab (DYNACIN equiv) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 82 of 99

88 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier THYROID AGENTS ANTITHYROID AGENTS methimazole tab (TAPAZOLE equiv) propylthiouracil tab THYROID HORMONES levothyroxine tab (SYNTHROID equiv) liothyronine tab (CYTOMEL equiv) nature thyroid tab (ARMOUR THYROID equiv) THYROLAR TAB ULCER DRUGS ANTISPASMODICS BELLADONNA ALKALOID/OPIUM SUPP. dicyclomine cap (BENTYL equiv) DICYCLOMINE SOLN dicyclomine tab (BENTYL equiv) glycopyrrolate (ROBINUL equiv) hyoscyamine sulfate cr (LEVBID equiv) hyoscyamine sulfate sl tab (LEVSIN equiv) hyoscyamine tab (LEVSIN equiv) PROPANTHELINE TAB H2 ANTAGONISTS cimetidine (TAGAMET equiv) cimetidine soln famotidine (PEPCID equiv) famotidine susp (PEPCID SUSP equiv) famotidine tab 10mg nizatidine cap (AXID equiv) ranitidine cap (ZANTAC equiv) ranitidine syrup (ZANTAC equiv) ranitidine tab (Rx Only) (ZANTAC equiv) ranitidine tab 75mg MISC. ANTIULCER CARAATE SUSP sucralfate tab (CARAATE equiv) PROTON PUMP INHIBITORS lansoprazole cap 15mg ( = 56 unit/30 day) omeprazole cap omeprazole cap 10mg (PRILOSEC equiv) omeprazole cap 20mg (PRILOSEC equiv) omeprazole cap 40mg (PRILOSEC equiv) pantoprazole tab (PROTONIX equiv) PREVACID ( = 56 cap/30 day; Step Therapy requires trial of lansoprazole and pantoprazole) ST rabeprazole tab (ACIPHEX TAB equiv) ULCER DRUGS PROSTAGLANDINS misoprostol (CYTOTEC equiv) URINARY ANTIINECTIVES URINARY ANTIINECTIVES methenamine hippurate (HIPREX equiv) methenamine mandelate Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 83 of 99

89 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier URINARY ANTIINECTIVES Cont. nitrofurantion cap (MACROBID equiv) nitrofurantoin monohydrate (MACROBID equiv) nitrofurantoin susp (URADANTIN equiv) URINARY ANTISPASMODICS URINARY ANTISPASMODIC ANTIMUSCARINICS (ANTICHOLIN) (NEW) oxybutynin ER tab (DITROPAN XL equiv) oxybutynin syrup oxybutynin tab tolterodine tab (DETROL TAB equiv) TOVIAZ TAB URINARY ANTISPASMODIC ANTIMUSCARINICS (ANTICHOLINERGIC) tolterodine cap SR (DETROL LA equiv) URINARY ANTISPASMODICS hyoscyamine (LEVSIN equiv) URINARY ANTISPASMODICS CHOLINERGIC AGONISTS (NEW) bethanechol tab (URECHOLINE equiv) VACCINES BACTERIAL VACCINES VIVOTI CAP (=4 caps/fill) VAC VAGINAL PRODUCTS MISCELLANEOUS VAGINAL PRODUCTS ACIDIC VAGINAL JELLY SPERMICIDES CONTRACEPTIVE ILM CONTRACEPTIVE OAM CONTRACEPTIVE GEL CONTRACEPTIVE SUPP. VAGINAL ANTIINECTIVES AVC clindamycin vaginal cream (CLEOCIN VAGINAL CREAM equiv) clotrimazole vaginal cream metronidazole vaginal gel (METROGEL VAGINAL GEL equiv) miconazole vaginal cream MICONAZOLE VAGINAL KIT miconazole vaginal supp. NYSTATIN VAGINAL TAB terconazole cream (TERAZOL equiv) terconazole supp. (TERAZOL equiv) tioconazole vaginal oint. VAGINAL ESTROGENS ESTRING (3 copays per Rx) PREMARIN VAGINAL CREAM VAGINAL PROGESTINS ENDOMETRIN PA PROCHIEVE PA VASOPRESSORS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 84 of 99

90 L.A. Care Health Plan MediCal ormulary Category/Class DrugName Special Code Tier VASOPRESSORS Cont. ANAPHYLAXIS THERAPY AGENTS EPIPEN INJ (=2 units/fill) EPIPENJR INJ (=2 units/fill) VASOPRESSORS midodrine tab (PROAMATINE equiv) VITAMINS MISC. NUTRITIONAL ACTORS PRENATAL VITAMIN (RX ONLY) OIL SOLUBLE VITAMINS cholecalciferol cap cholecalciferol oral soln. cholecalciferol tab ergocalciferol soln. ERGOCALCIEROL TAB MEPHYTON vitamin d (RX strength only) WATER SOLUBLE VITAMINS ascorbic acid cap ascorbic acid chew tab ascorbic acid er tab ascorbic acid lozenge ascorbic acid syrup ascorbic acid tab ASCORBIC ACID WAER niacin er cap niacin tab NIACIN TR TAB () (SLONIACIN equiv) niacinamide tab pyridoxine er tab pyridoxine tab thiamine tab Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. IN Infertility LD Limited Distribution MSP Mandatory Specialty Pharmacy Program NC Not Covered OvertheCounter PA Prior Authorization SP Available through Specialty Pharmacy Program SP irst ill available at Retail Pharmacy ST Step Therapy Page 85 of 99

91 L.A. Care Health Plan MediCal ormulary Prior Authorization Drug List Some products on the ormulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions regarding prior authorizations. Drug Name adapalene cream adapalene gel 0.1% adapalene gel 0.3% ADCIRCA TAB AINITOR DISPERZ AINITOR TAB AMPYRA TAB ANDROGEL 1.62% 1.25GM ANDROGEL 1.62% 2.5GM ANDROGEL 25MG ANDROGEL 50MG ANDROGEL PUMP 1% ANDROGEL PUMP 1.62% AUBAGIO TAB BELVIQ TAB BOSULI TAB CAPRELSA TAB CAYSTON INH SOLN COMETRIQ KIT dronabinol cap ENBREL INJ ENBREL SURECLICK INJ ENDOMETRIN ERIVEDGE CAP ERRIPROX TAB fondaparinux soln GENOTROPIN INJ GILOTRI TAB GLEEVEC TAB HARVONI TAB HUMIRA INJ HUMIRA PEN INJ HYCAMTIN CAP ICLUSIG TAB 15MG ICLUSIG TAB 45MG INANT ORMULA LIQUID INANT ORMULA POWDER INLYTA TAB itraconazole cap JAKAI TAB KALYDECO TAB KINERET INJ KORLYM TAB KUVAN POWDER PACK KUVAN TAB Tier # for Drug Copay (if prior auth is approved) Page 86 of 99

92 L.A. Care Health Plan MediCal ormulary cont. Prior Authorization Drug List Some products on the ormulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions regarding prior authorizations. Drug Name LESCOL XL CAP LYRICA CAP LYRICA SOLN. modafinil tab NEXAVAR TAB NUTRITIONAL SUPPLEMENT LIQUID NUTRITIONAL SUPPLEMENT POWDER ONI TAB OPSUMIT TAB ORENCIA SC INJ OXYCONTIN CR TAB phentermine cap phentermine tab PROCHIEVE PROMACTA TAB QSYMIA CAP RELISTOR INJ REVLIMID CAP SIGNIOR INJ sildenafil tab SIVEXTRO TAB SOVALDI TAB SPRYCEL TAB SPRYCEL TAB 20MG STIVARGA TAB SUTENT CAP TARCEVA TAB TARGRETIN CAP THALOMID CAP TOBI PODHALER tobramycin neb TRACLEER TAB tretinoin cream tretinoin gel TYKERB TAB TYVASO INH SOLN VALCHLOR GEL VENTAVIS INH SOLN voriconazole susp voriconazole tab VOTRIENT TAB XALKORI CAP XENAZINE TAB XENICAL CAP XTANDI CAP Tier # for Drug Copay (if prior auth is approved) Page 87 of 99

93 L.A. Care Health Plan MediCal ormulary cont. Prior Authorization Drug List Some products on the ormulary are only covered with a prior authorization approval. Drug products requiring prior authorization are listed below. The pharmacy will also alert members if the medication prescribed requires prior authorization. Please call Customer Service if you have further questions regarding prior authorizations. Drug Name XYREM SOLN ZELBORA TAB ZOLINZA CAP ZORTRESS TAB ZYDELIG TAB ZYTIGA TAB ZYVOX SUSP ZYVOX TAB Tier # for Drug Copay (if prior auth is approved) Page 88 of 99

94 L.A. Care Health Plan MediCal ormulary OvertheCounter () The following drugs are a covered benefit with a prescription OvertheCounter () Medications a d oint acetaminophen chew tab acetaminophen drops acetaminophen elixir acetaminophen er tab acetaminophen liquid acetaminophen supp ACETAMINOPHEN SYRUP acetaminophen tab acetaminophenpamabrompyrilamine AEROCHAMBER ALCOHOL SWABS tab ALCOHOL WIPES ALUMINUM HYDROXIDE ammonium lactate cream ammonium lactate lotion GEL SUSP. antacid chew tab antinausea soln. artificial tears oint artificial tears soln ascorbic acid cap ascorbic acid chew tab ascorbic acid er tab ascorbic acid lozenge ascorbic acid syrup ascorbic acid tab ASCORBIC ACID WAER aspirin chew tab aspirin ec tab aspirin supp. aspirin tab ASPIRIN/ACETAMINOPHE N/CALCIUM CARBONATE TAB bacitracin oint bacitracin/polymyxin b oint bacitracin/zinc oint. BD INSULIN SYRINGE BD PEN NEEDLE benzoyl peroxide cream benzoyl peroxide gel benzoyl peroxide liquid benzoyl peroxide lotion BISACODYL ENEMA bisacodyl supp. bisacodyl tab bismuth subsalicylate chew tab bismuth subsalicylate susp. bismuth subsalicylate tab brompheniram/phenylephrin e/dm soln CALAMINE LOTION calcium and phosphorus CALCIUM CARBONATE calcium carbonate chew tab w/vitamin D tab CAP calcium carbonate susp. CALCIUM CARBONATE TAB calcium carbonate w/ vitamin d cap CALCIUM CARBONATE W/ VITAMIN D CHEW TAB calcium carbonate w/ vitamin d tab calcium carbonate w/ vitamind D chew tab calcium carbonate w/ vitamind D tab CALCIUM CARBONATE/GLUCONATE W/ VITAMIN D TAB calcium citrate tab calcium citrate w/ vitamin d CALCIUM GLUCONATE calcium lactate tab tab TAB calcium plycarbophil tab capsaicin cream capsaicin pad carbamide peroxide otic drop cetirizine chew cetirizine syrup cetirizine tab cetirizine/pseudoephedrine tab chlorhexidine gluconate chlorpheniramine cr tab chlorpheniramine syrup chlorpheniramine tab liquid chlorpheniramine/acetamino chlorpheniramine/phenyleph chlorpheniramine/phenyleph chlorpheniramine/phenyleph phen tab CHLORPHENIRAMINE/PSE UDOEPHEDRINE/IBUPRO EN TAB rine/apap effer tab rine/apap susp. rine/apap tab cholecalciferol cap cholecalciferol oral soln. cholecalciferol tab CLARITIN REDITAB clemastine fumarate tab CLINISTIX clotrimazole cream clotrimazole vaginal cream CLOVERINE OINT CONEX TAB CONTRACEPTIVE ILM CONTRACEPTIVE OAM CONTRACEPTIVE GEL CONTRACEPTIVE SUPP. cromolyn nasal spray cyanocobalamine er tab cyanocobalamine lozenge cyanocobalamine sl tab cyanocobalamine tab DEXTROMETHOR/ACETA MIN/DIPHEN LIQUID dextromethorphan hbr/chlorpheniramine liquid dextromethorphan cap dextromethorphan er liquid dextromethorphan hb/doxylamine soln. dextromethorphan dextromethorphan liquid DEXTROMETHORPHAN hbr/chlorpheniramine tab LOZENGE Page 89 of 99

95 dextromethorphan syrup dextromethorphan/phenylep hrine liquid DEXTROMETHORPHAN/P HENYLEPHRINE STRIP DEXTROMETHORPHAN/P SEUDOEPHED DROPS DEXTROMETHORPHAN/P SEUDOEPHED ELIXIR dextromethorphan/pseudoep hed syrup DEXTROMETHORPHN/AC ETAMINOPH/CP LIQUID dextromethorphn/acetamino ph/cp susp dextromethorphn/acetamino dialyvite tab DIETHYLTOLUAMIDE dimenhydrin tab ph/cp tab LOTION dimethicone gel diphenhydramine cap diphenhydramine chew tab diphenhydramine cream diphenhydramine gel diphenhydramine liquid diphenhydramine rapid tab diphenhydramine spray DIPHENHYDRAMINE STRIP diphenhydramine syrup diphenhydramine tab diphenhydramine/acetamino phen tab DIPHENHYDRAMINE/APAP LIQUID diphenhydramine/apap tab diphenhydramine/phenylephr ine/apap liquid diphenhydramine/phenylephr ine/apap susp. diphenhydramine/phenylephr ine/apap tab dm hb/pe/acetaminophen/chlorp dm hb/pe/acetaminophen/chlorp dm hb/pe/acetaminophen/chlorp dm hb/pseudoephed/acetamin/c p cap dm/pe/acetaminophen/doxyl amine liquid DM/PHENYLEPH/CHLORP HENIRAMINE SOLN. dmethorphan hb/pepd hcl/bpm elixir DMETHORPHAN HB/PEPHED HCL/CP SYRUP dmethorphan/pe/acetamino phen liquid heniramine liquid dm hb/pseudoephed/acetamin/c p packet dm/pephed/acetaminoph/do xylam cap dm/pseudoephed/acetamino phen cap dmethorphan hb/pepd hcl/bpm syrup dmethorphan/acetamin/dox ylamn cap heniramine susp. dm hb/pseudoephed/acetamin/c p susp dm/pephed/acetaminoph/do xylam liquid dm/pseudoephed/acetamino phen tab DMETHORPHAN HB/PEPHED HCL/CP CHEW TAB dmethorphan/acetamin/dox ylamn liquid heniramine tab dm hb/pseudoephed/acetamin/c p tab DM/PHENYLEPH/CHLORP HENIRAMINE LIQUID dmethorphan hb/acetaminophen liquid dmethorphan hb/pephed hcl/cp liquid dmethorphan/pe/acetamino phen cap dmethorphan/pe/acetamino docusate calcium cap docusate sodium cap phen tab docusate sodium enema docusate sodium liquid docusate sodium syrup docusate sodium tab doxylamine succinate tab DULCOLAX BOWEL PREP EPHEDRINE SULATE ergocalciferol soln. KIT CAP ERGOCALCIEROL TAB eye wash soln. famotidine tab 10mg EMALE CONDOMS ferrous gluconate tab ferrous sulfate dr tab ferrous sulfate drops ferrous sulfate elixir ferrous sulfate er tab ERROUS SULATE LIQUID ferrous sulfate slow release tab ERROUS SULATE SYRUP ferrous sulfate tab IBER LIQUID LEET ENEMA folic acid tab REESTYLE REEDOM REESTYLE INSULINX REESTYLE KIT INSULINX REESTYLE LITE METER LITE METER TEST STRIP REESTYLE METER REESTYLE TEST STRIP UNGOID SOLN GLUCOSE CHEW TAB glucose gel GLUCOSE TAB glycerin gel glycerin liquid glycerin lotion GLYCERIN SHAMPOO glycerin suppository guaifen/phenyleph/acetamin ophn tab GUAIEN/PSEUDOEPHED/ guaifenesin ER tab guaifenesin liquid guaifenesin syrup ACETAMINOP TAB guaifenesin tab guaifenesin/acetaminophen guaifenesin/codeine soln guaifenesin/codeine syrup tab guaifenesin/dextromethorph an cap guaifenesin/dextromethorph an liquid GUAIENESIN/DEXTROME THORPHAN PACK guaifenesin/dextromethorph an tab guaifenesin/dm/pseudoephe drine cap guaifenesin/dmethorphan hb/pe liquid guaifenesin/dmethorphan hb/pe syrup guaifenesin/ephedrine hcl tab guaifenesin/phenylephrine guaifenesin/pseudoephedrn guaifenesin/pseudoephedrn HUMULIN 70/30 KWIKPEN hcl liquid e hcl cap e hcl syrup HUMULIN 70/30 VIAL HUMULIN N KWIKPEN HUMULIN N U100 VIAL HUMULINR U100 Page 90 of 99

96 HUMULINR U100 VIAL hydrocortisone ac cream HYDROCORTISONE AC hydrocortisone aloe cream OINT HYDROCORTISONE ALOE hydrocortisone cream hydrocortisone gel hydrocortisone lotion OINT hydrocortisone oint hydrocortisone topical soln. HYDROGEN PEROXIDE ibuprofen cap SOLN. ibuprofen chew tab ibuprofen susp. ibuprofen tab INANT ORMULA LIQUID INANT ORMULA IV PREP WIPES KETODIASTIX KETOSTIX POWDER ketotifen ophth soln KONSYL POWDER KONSYL POWDER LANCET KIT PACKET LANCETS lansoprazole cap 15mg levocarnitine cap levocarnitine tab levonorgestrel tab LICE B GONE SHAMPOO LOHISTD LIQUID loperamide cap loperamide liquid loperamide tab loratadine ODT loratadine syrup loratadine tab loratadine/pseudoephedrine lubricating jelly magnesium citrate soln. tab magnesium hydroxide susp. magnesium oxide tab MAGNESIUM/ALUMINUM HYDROXIDE CHEW magnesium/aluminum hydroxide/simethicone chew tab magnesium/aluminum MALE CONDOMS meclizine chew tab meclizine tab hydroxide/simethicone susp MEDIGRAINE TAB miconazole cream miconazole nitrate aerosol miconazole nitrate powder miconazole oint. miconazole vaginal cream MICONAZOLE VAGINAL miconazole vaginal supp. KIT MILK O MAGNESIA mineral oil mineral oil enema MINERAL OIL LIGHT CHEW TAB mineral oil/petrolatum cream mineral oil/petrolatum lotion mineral oil/petrolatum oint multiple vitamin liquid multiple vitamin tab multivitamin w/ iron chew tab multivitamin w/ iron tab naphazoline/pheniramine ophth drops NASACORT NASAL SPRAY () NASAL MOIST GEL neomycin/bacitracin/polymyx in b oint neomycin/bacitracin/polymyx in b/pramoxine oint neomycin/polymyxin NEOTUSS PLUS LIQUID niacin er cap niacin tab b/pramoxine cream NIACIN TR TAB () niacinamide tab nicotine gum nicotine lozenge nicotine patch NUTRITIONAL NUTRITIONAL omega3 fatty acid cap SUPPLEMENT LIQUID SUPPLEMENT POWDER omeprazole cap oxymetazolin spray pe/acetamin/diphenhydramin PEAK LOW METER /cpm tab pediatric electrolyte soln. PEDIATRIC MASK pediatric multivitamin adc drops PEDIATRIC MULTIVITAMIN CHEW TAB pediatric multivitamin w/ iron chew tab pediatric multivitamin w/ iron drops pediatric multivitamin w/ minerals gummy pediatric multivitamin w/ vitamin c soln. pediatric multivitamin w/ permethrin liquid permethrin lotion permethrin spray vitamin c w/ iron chew tab petrolatum oint phenyldphrine/bromphenira mine elixir PETROLATUM/LANOLIN/ZI NC OXIDE/MINERAL OIL OINT. PHENYLDPHRINE/BROMP HENIRAMINE TAB pheniramine/phenylephrine/ acetaminophen packet PHENYLEPH/ACETAMIN/D EXBROMPHENIRAMINE TAB phenylephrine nasal drops phenylephrine tab phenylephrine/acetamin/dox ylamine cap phenylephrine/acetaminophe phenylephrine/acetaminophe phenylephrine/chlorphenira n pack n tab mine liquid phenyldphrine/bromphenira mine chew liquid PHENYLEPHRINE DROPS phenylephrine/acetaminophe n cap phenylephrine/chlorphenira mine tab Page 91 of 99

97 phenylephrine/diphenhydram ine liquid phenylephrine/dm/acetamino p/gg tab PIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO PRECISION XTRA METER PSEUDOEPH/DM/GUAIEN /ACETAMIN PACKET pseudoephedrine syrup pseudoephedrine/chlorpheni ramine syrup PSEUDOEPHEDRINE/IBUP ROEN CAP pseudoephedrine/triprolidine tab pyridoxine tab phenylephrine/diphenhydram ine solution PHENYLTOLOXAMINEAC ETAMINOPHEN TAB polyethylene glycol powder PRECISION XTRA TEST STRIP pseudoeph/dm/guaifen/acet amin tab pseudoephedrine/acetamino phen tab phenylephrine/diphenhydram ine tab piperonyl butox/pyrethrins/permethrin kit polyethylene glycol powder packet PRENATAL VITAMIN pseudoephed/acetaminoph/ diphenhydramine tab pseudoephedrine/brompheni ramine liquid phenylephrine/dm/acetamino p/gg liquid piperonyl butoxide/pyrethrins liquid povidoneiodine soln. PREVACID pseudoephedrine ER tab PSEUDOEPHEDRINE/CHL ORPHENIRAMINE CHEW TAB PSEUDOEPHEDRINE/DIPH ENHYDRAMINE TAB pseudoephedrine/naproxen tab pseudoephedrine/chlorpheni ramine tab pseudoephedrine/dexbromp heniramine er tab pseudoephedrine/ibuprofen pseudoephedrine/ibuprofen susp. tab psyllium cap psyllium powder pyridoxine er tab PYRILAMINE/PE/DEXTRO ranitidine tab 75mg salicylic acid gel METHORPHAN LIQUID salicylic acid liquid salicylic acid pad salicylic acid soln salicylic acid strip saline nasal spray SCOTTUSSIN SOLN. sennosides tab sennosides/docusate sodium tab simethicone cap simethicone chew tab simethicone drops simethicone liquid SIMETHICONE STRIPS SKIN CLEANSER sodium bicarbonate tab sodium chloride irrigation/decyl glucoside soln sodium chloride ophth oint. sodium chloride ophth soln. SODIUM CHLORIDE sodium chloride tab SPRAY sodium phosphate enema sodium phosphate soln. SUDAED ER TAB terbinafine cream tetrahydrozoline ophth soln. tetrahydrozoline/zinc sulfate thiamine tab throat lozenge ophth drops tioconazole vaginal oint. tolnaftate aerosol tolnaftate cream tolnaftate powder tolnaftate spray TRIAMINIC NASAL SOLN. TRIAMINIC STRIP vapor inhaler vaporizing steam vaporizing steam liquid vitamin a d oint. vitamin B complex cap zinc oxide oint ZINC OXIDE PASTE Page 92 of 99

98 L.A. Care Health Plan MediCal ormulary Mandatory Specialty Pharmacy (MSP) Navitus utilizes a specialty pharmacy, experienced in handling specialty drugs, to coordinate personalized support for members impacted by chronic illnesses and complex diseases. Specialty drugs are only available for a one month supply due to their high cost and use The following drugs are required to be filled through a Specialty Pharmacy provider. Mandatory Specialty Pharmacy (MSP) Medications ACTIMMUNE INJ ALERONN INJ AMPYRA TAB AUBAGIO TAB AVONEX INJ calcitriol inj CAPRELSA TAB CAYSTON INH SOLN COMETRIQ KIT COPAXONE INJ ENBREL INJ ENBREL SURECLICK INJ entecavir tab EPOGEN INJ ERIVEDGE CAP EXJADE TAB ERRIPROX TAB ORTEO INJ GENOTROPIN INJ HARVONI TAB HIZENTRA INJ HUMIRA INJ HUMIRA PEN INJ ICLUSIG TAB 15MG ICLUSIG TAB 45MG INCRELEX INJ INERGEN INJ INTRONA INJ INTRONA KIT IRESSA TAB JAKAI TAB KALYDECO TAB KORLYM TAB KUVAN TAB LEUKINE INJ methotrexate inj MIACALCIN INJ NEBUPENT NEB SOLN NEULASTA INJ NEUMEGA INJ NEXAVAR TAB octreotide inj ORENCIA SC INJ PEGASYS INJ PEGASYS KIT PROCRIT INJ PROLEUKIN INJ PROMACTA TAB PULMOZYME REBETOL SOLN RELISTOR INJ REVLIMID CAP ribasphere cap RIBATAB ribavirin tab SABRIL POWDER SABRIL TAB SIGNIOR INJ SOMAVERT INJ SOVALDI TAB STIVARGA TAB SYNAREL NASAL SOLN TECIDERA CAP TECIDERA STARTER PACK TOBI PODHALER tobramycin neb TYKERB TAB TYVASO INH SOLN VENTAVIS INH SOLN VOTRIENT TAB XALKORI CAP XENAZINE TAB XYREM SOLN ZELBORA TAB ZYDELIG TAB Page 93 of 99

99 L.A. Care Health Plan MediCal ormulary Step Therapy (ST) The following drugs are covered on the formulary with a Step Therapy. Step Therapy (ST) Medications Drug Name DIICID TAB donepezil tab 23mg fluvoxamine er cap PEGASYS KIT PREVACID ULORIC vancomycin cap Step Therapy Requirements Step Therapy requires trial of VANCOCIN; = 20 tab/fill Step Therapy requires trial of donepezil 10mg; = 1 tab/day Step Therapy requires failure of sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine Product is mandated through Acaria Specialty Pharmacy. = 56 cap/30 day; Step Therapy requires trial of lansoprazole and pantoprazole Step Therapy requires failure of allopurinol. = 56 cap/ fill; Step Therapy requires trial of vancomycin soln Page 94 of 99

100 L.A. Care Health Plan MediCal ormulary Smoking Cessation Agents Drug Name bupropion tab( Limited to 180 days/plan year) CHANTIX TAB( Limited to 180 days/plan year) nicotine gum( Limited to 180 days/plan year) nicotine lozenge( Limited to 180 days/plan year) nicotine patch( Limited to 180 days/plan year) NICOTROL INHALER( Limited to 180 days/plan year) NICOTROL NASAL SPRAY( Limited to 180 days/plan year) Tier # for Drug Copay Page 95 of 99

101 L.A. Care Health Plan MediCal ormulary Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Drug Name AINITOR DISPERZ AINITOR TAB AMPYRA TAB ANDROGEL 1.62% 1.25GM ANDROGEL 1.62% 2.5GM ANDROGEL 25MG ANDROGEL 50MG ANDROGEL PUMP 1% ANDROGEL PUMP 1.62% AUBAGIO TAB BELVIQ TAB benzoyl peroxide cream benzoyl peroxide gel benzoyl peroxide liquid benzoyl peroxide lotion bupropion tab butorphanol nasal spray CALCIUM ACETATE TAB celecoxib cap cetirizine chew cetirizine tab cetirizine/pseudoephedrine tab CHANTIX TAB CLARITIN REDITAB DIICID TAB donepezil ODT donepezil tab donepezil tab 23mg duloxetine cap EMEND CAP ENBREL INJ ENBREL SURECLICK INJ enoxaparin inj entecavir tab EPIPEN INJ EPIPENJR INJ eszopiclone tab ARXIGA TAB flunisolide nasal spray fluticasone nasal spray GEL DRESSING GILOTRI TAB Quantity Limit () Medications Quantity Limit = 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy. = 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy. = 2 tab/day = 1 packet/ day = 2 packet/ day = 1 packet/day = 2 packets/day = 4 bottle/30 days = 2 bottle/30 days = 1 tab/day = 2 tab/day = 1 tube/30 day = 1 tube/30 day = 1 bottle/30 day = 1 bottle/30 day Limited to 180 days/plan year = Retail 1 bottle/fill, 2 fill/30 days; Mail Order 3 bottle/fill, 2 fill/90 days = 9 tab/day = 2 cap/ day = 1 TAB/DAY = 1 TAB/DAY = 1 TAB/DAY Limited to 180 days/plan year = 1 tab/day Step Therapy requires trial of VANCOCIN; = 20 tab/fill =1 tab/day =2 tabs/day Step Therapy requires trial of donepezil 10mg; = 1 tab/day = 2 cap/day = 3 tab/day; Product is mandated through Acaria Specialty Pharmacy. = 4 syringes/28 days; Product is mandated through Acaria Specialty Pharmacy. = 4 syringes/28 days; Product is mandated through Acaria Specialty Pharmacy. = 17 days supply; Product is mandated through Acaria Specialty Pharmacy. =1 tab/day. Product is mandated through Acaria Specialty Pharmacy. =2 units/fill =2 units/fill =1 tab/day = 1 tab/day =2 bottles/fill =2 bottles/fill = 2 box/30 day =1 TAB/DAY Page 96 of 99

102 L.A. Care Health Plan MediCal ormulary Cont. Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Drug Name GLEEVEC TAB granisetron tab guaifenesin/codeine syrup HARVONI TAB HUMIRA INJ HUMIRA PEN INJ ICLUSIG TAB 15MG ICLUSIG TAB 45MG INLYTA TAB JAKAI TAB JANUVIA TAB JARDIANCE TAB KALYDECO TAB ketorolac tab KINERET INJ lansoprazole cap 15mg latanoprost ophth soln LINZESS CAP loratadine ODT loratadine syrup loratadine tab loratadine/pseudoephedrine tab methylergonovine tab mineral oil modafinil tab MOVIPREP NAMENDA XR CAP naratriptan tab NASACORT NASAL SPRAY () nicotine gum nicotine lozenge nicotine patch NICOTROL INHALER NICOTROL NASAL SPRAY NUCYNTA ER NUEDEXTA CAP ONGLYZA TAB ORENCIA SC INJ OXYCONTIN CR TAB phentermine cap phentermine tab Quantity Limit () Medications Quantity Limit = 3 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy. = Retail 9 tabs/fill; Mail Order 27 tabs/fill =240ml/per dispensing =1 tab/day. Product is mandated through Acaria Specialty Pharmacy. = 2 inj/28 days = 2 inj/28 days = 3 tab/day; Limited to 2x15 day fills per month for first 3 months; Only available through Biologics = 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Only available through Biologics = 8 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy. =2 tabs/day = 1 tab/day =1 tab/day =2 tab/day = 5 days treatment (20 tabs/5 days) = 28 inj/28 days; Product is mandated through Acaria Specialty Pharmacy. = 56 unit/30 day = 2.5ml/ 30 days = 1 cap/day = 1 tab/day = 240ml/30 day; Covered for members age 2 through 5 years = 1 tab/day; Covered for members 2 years and older = 1 tab/day = 28 tab/fill; 1 fill/365 days = 1 tab/day = 1 bottle/fill = 1 cap/day = Retail 9 tabs/fill, 2 fill/30 days; Mail Order 27 tab/fill, 2 fill/90 days = 2 bottles/fill Limited to 180 days/plan year Limited to 180 days/plan year Limited to 180 days/plan year Limited to 180 days/plan year Limited to 180 days/plan year = 2 tabs/day = 2 cap/day = 1 tab/day = 4 inj/28 days = 120 tab/30 days = 1 cap/day = 1 tab/day Page 97 of 99

103 L.A. Care Health Plan MediCal ormulary Cont. Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Drug Name Quantity Limit () Medications Quantity Limit POTIGA TAB = 3 tab/ day PREVACID = 56 cap/30 day; Step Therapy requires trial of lansoprazole and pantoprazole pseudoephedrine ER tab = 2 tab/day; Covered for members 4 years and older pseudoephedrine syrup = 1200ml/30 day; Covered for members 4 years and older pseudoephedrine tab 30mg = 8 tab/day; Covered for members 2 years and older pseudoephedrine tab 60mg = 4 tab/day; Covered for members 2 years and older QSYMIA CAP = 1 cap/day REGRANEX GEL = 2 15gm tubes/fill RELENZA DISKHALER =20 units/fill REVLIMID CAP = 1 cap/day rizatriptan = Retail 12 tab/fill, 3 fill/60 day; Mail Order 36 tab/fill, 2 fill/90 day rizatriptan ODT = Retail 12 tab/fill, 3 fill/60 day; Mail Order 36 tab/fill, 2 fill/90 day SAVELLA =2 TAB/DAY SIGNIOR INJ = 2 vials/day; Only available through Accredo SIVEXTRO TAB =6 tab/fill SOVALDI TAB = 1 tab/day. Product is mandated through Acaria Specialty Pharmacy. SPINOSAD SUSP = 1 bottle/ fill SPRYCEL TAB = 1 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy. SPRYCEL TAB 20MG = 3 tab/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy. STIVARGA TAB = 4 tab/day; Limited to 2 x 15 day fills per month for first 3 months SUDAED ER TAB = 1 tab/day; Covered for member 4 years and older sumatriptan inj = Retail 4 inj/fill, 2 fill/30 days; Mail Order 12 inj/fill, 2 fill/90 days SUMATRIPTAN INJ 6MG/0.5ML = Retail 4 inj/fill, 2 fill/30 days; Mail Order 12 inj/fill, 2 fill/90 days sumatriptan tab = Retail 9 tab/fill, 2 fill/30 days; Mail Order 27 tab/fill, 2 fill/90 days SUMATRIPTAN/ IMITREX NASAL SPRAY = Retail 6 sprays/fill, 2 fills/30 days; Mail Order 18 sprays/fill, 2 fills/90 days TAMILU CAP = 10 caps/fill TAMILU SUSP 12MG/ML = 125ml/fill TAMILU SUSP 6MG/ML = 250ml/fill terbinafine cream = 1 tube/30 day; Covered for members 12 years and older VALCHLOR GEL =4 TUBES/30 DAYS vancomycin cap = 56 cap/ fill; Step Therapy requires trial of vancomycin soln VENTOLIN HA = 2 inhalers/fill. 2 fills/30 days VGO 20 KIT =1 KIT/DAY VGO 30 KIT =1 KIT/DAY VGO 40 KIT =1 KIT/DAY VIMPAT TAB = 2 tab/day VIVOTI CAP =4 caps/fill XENICAL CAP = 3 cap/day XIGDUO TAB XR 5/1000MG = 2 tab/day XIGDUO XR TAB = 1 tab/day XTANDI CAP = 4 cap/day; Limited to 2x15 day fills per month for first 3 months; Product is mandated through Acaria Specialty Pharmacy. XYREM SOLN =540ml/30 days; Only available through Xyrem Central Pharmacy Page 98 of 99

104 L.A. Care Health Plan MediCal ormulary Cont. Quantity Limit () The following drugs are covered on the formulary with a Quantity Limit. Drug Name ZETIA TAB zolpidem tab 10mg zolpidem tab 5mg ZYLET OPHTH SUSP Quantity Limit () Medications Quantity Limit = 1 tab/day Male = 1 tab/day; emale = 0.5 tab/day = 1 tab/day = Retail 5ml/fill; Mail Order 15ml/fill (10ml bottle is Not Covered) Page 99 of 99