L.A. Care Medi-Cal Dual. Formulary. lacare.org. LA1308E 08/18 EN Last Updated: 1/1/2019

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1 L.A. Care Medi-Cal Dual ormulary LA1308E 08/18 EN Last Updated: 1/1/2019 lacare.org

2 L.A. Care Medi-Cal Dual ormulary INTRODUCTION oreword The L.A. Care Medi-Cal Dual formulary is a preferred list of covered drugs, approved by the L.A. Care Health Plan Pharmacy Quality Oversight Committee. This formulary applies only to outpatient drugs and self-administered drugs not covered by your Medicare Prescription Drug Benefit. It does not apply to medications used in the inpatient setting or medical offices. The formulary is a continually reviewed and revised list of preferred drugs based on safety, clinical efficacy, and costeffectiveness. The formulary is updated monthly, updated documents are available online at: This drug listing is for L.A. Care Medi-Cal Dual members who also have a Medicare plan outside of L.A. Care. How to Use the ormulary The formulary drug listing begins on Page 4. Drugs 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 are only available in brand name formulations are listed in ALL CAPITAL letters. The formulary can be searched by using the Ctrl + function or the index. Drugs can be searched by the generic name, proprietary name, or therapeutic drug category. Generic and Brand Name Medications L.A. Care s Medi-Cal Dual Plan covers generic and brand name drugs. However, when available, DA approved generic drugs are to be used in all situations, regardless of the availability of a brand. Generic drugs generally cost less than brand name drugs. All drugs that are or become available generically are subject to review by L.A. Care s Pharmacy Quality Oversight Committee. A prescriber may request a brand name product in lieu of an approved generic, if the prescriber determines that there is a documented medical need for the brand equivalent. This type of request for coverage may be made using the Medication Request Process described on Page 3. Non-ormulary Medications Any drug not found in this formulary listing published by L.A. Care Health Plan shall be considered a non-formulary drug. If a drug is not found on this formulary it is possible that the drug would be covered through your Medicare Prescription Drug Benefit. If not, a prescriber may request an exception to coverage for a non-formulary drug if the prescriber determines that there is a documented medical need. This type of request for coverage may be made using the Medication Request Process described on Page 3. Benefit Coverage and Limitations This printed formulary does not provide information regarding the specific coverage and limitations an individual may have. The individual may have specific benefit inclusions, exclusions, and/or cost share which are not reflected in the formulary. The formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. Any specific questions regarding their coverage should be directed to L.A. Care Health Plan Member Services at (TTY: 711). L.A. Care Medi-Cal Dual (Updated 1/1/2019) 1

3 Restrictions on Medication Coverage Certain covered drugs may have additional requirements or limits on coverage. These are denoted throughout the document using the following symbols: Symbol Restriction Description NC Not Covered Drug that is non-formulary and will not be paid for by the plan without prior approval/prior authorization QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period Over the Counter Coverage of medication RS Restricted to Specialist Coverage may be dependent on the specialty of the prescribing physician PA Prior Authorization Requires specific physician request process SMKG Smoking Cessation Coverage for the treatment of smoking cessation drugs, which may have specific restrictions Coverage may require one or more prerequisite first step drugs to be tried before progressing to the second step drug Please refer to the formulary listing beginning on Page 4 for details regarding specific agents. L.A. Care Medi-Cal Dual (Updated 1/1/2019) 2

4 Medication Request Process ormulary Agents A. Prior Authorization (PA): These drugs require approval prior to being dispensed at a network pharmacy. Requests are reviewed with specific Prior Authorization guidelines. 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. Quantity Limits (QL): These drugs have quantity limits. If quantities exceeding the limit are necessary, an exception to coverage may be requested by the prescriber. Each request will be reviewed on individual patient need. Approval will be given if a documented medical need exists without compromising safety. C. Step Therapy (ST): These drugs require one or more first step drugs to be tried before progressing to the second step drug. If there is a medical need to use a second step drug without trying a first step drug, an exception to coverage may be requested by the prescriber. Each request will be reviewed on an individual patient need. Approval will be given if a documented medical need exists. Non-ormulary Agents A. Any drug not found on this list is considered non-formulary. Coverage for non-formulary agents may be requested by the prescriber. Each request will be reviewed on individual patient need. Approval will be given if a documented medical need exists. B. The Medication Request Process is generally not available for drugs that are specifically excluded by benefit design. or benefit exclusions refer to the General Exclusions section below. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical necessity. General Benefit Exclusions (Not Covered) Please note that this list is subject to change. A. Drugs specifically listed as not covered B. Any drug products used for cosmetic purposes C. Infertility agents D. Drugs used for erectile dysfunction E. Experimental drug products, or any drug product used in an experimental manner. Non self-administered injectable drug products are not covered unless otherwise specified in the formulary listing G. oreign drugs or drugs not approved by the United States ood & Drug Administration Pharmacist and Physician eedback The formulary is a tool to promote cost-effective prescription drug use. L.A. Care 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 or comments to L.A. Care via to Pharmacyandormulary@lacare.org. L.A. Care Medi-Cal Dual (Updated 1/1/2019) 3

5 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 the 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 Medi-Cal Dual ormulary Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category acetaminophen cap ANALGESICS - NONNARCOTIC acetaminophen chew tab ANALGESICS - NONNARCOTIC acetaminophen drops ANALGESICS - NONNARCOTIC acetaminophen elixir ANALGESICS - NONNARCOTIC acetaminophen ER tab ANALGESICS - NONNARCOTIC acetaminophen liquid ANALGESICS - NONNARCOTIC acetaminophen ODT ANALGESICS - NONNARCOTIC acetaminophen supp ANALGESICS - NONNARCOTIC ACETAMINOPHEN SYRUP ANALGESICS - NONNARCOTIC acetaminophen tab ANALGESICS - NONNARCOTIC ACETAMINOPHEN/BUERED ASPIRIN TAB (Only covered for members 4 ANALGESICS - NONNARCOTIC years and older) ACETAMINOPHEN/DEXTROMETHORPHAN LIQUID COUGH/COLD/ALLERGY acetaminophen/pamabrom/pyrilamine tab (Only covered for members 4 ANALGESICS - NONNARCOTIC years and older) ACETAMINOPHEN/PHENYLTOLOXAMINE TAB (Only covered for members 4 ANALGESICS - NONNARCOTIC years and older) ALLERGY MULTI-SYMPTOM DAY/NIGHT PAK (Covered for members 4-19 COUGH/COLD/ALLERGY years. Not covered if 3 and younger or 20 and older) ALLERGY/SINUS TAB HEADACHE COUGH/COLD/ALLERGY ALUMINUM HYDROXIDE GEL SUSP. ANTACIDS ammonium lactate cream (Coverage includes only) DERMATOLOGICALS ammonium lactate lotion (Coverage includes only) DERMATOLOGICALS analgesic balm DERMATOLOGICALS antacid chew tab ANTACIDS anti-nausea soln. (EMETROL equiv) ANTIEMETICS anumed supp ANORECTAL AGENTS AP-HIST DM SOLN COUGH/COLD/ALLERGY aritificial tears ophth soln. OPHTHALMIC AGENTS ARMOUR THYROID TAB, NATURE THROID TAB - THYROID AGENTS artificial tears ophth oint. OPHTHALMIC AGENTS artificial tears ophth soln. OPHTHALMIC AGENTS ascorbic acid cap VITAMINS ascorbic acid chew tab VITAMINS ascorbic acid ER tab VITAMINS ascorbic acid lozenge VITAMINS ascorbic acid syrup VITAMINS ascorbic acid tab MULTIVITAMINS ASCORBIC ACID WAER VITAMINS aspirin chew tab ANALGESICS - NONNARCOTIC aspirin EC tab ANALGESICS - NONNARCOTIC aspirin supp. ANALGESICS - NONNARCOTIC aspirin tab ANALGESICS - NONNARCOTIC ASSURE LANCET LOW LOW 25 GAUGE - BOX 100 (Limited to LTC MEDICAL DEVICES AND SUPPLIES Pharmacies) Page 1 of 38

6 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category ASSURE LANCET MICRO LOW 28 GAUGE - BOX 100 (Limited to LTC MEDICAL DEVICES AND SUPPLIES Pharmacies) ASSURE PLATINUM TEST STRIP - BOX 100 (Limited to LTC Pharmacies) DIAGNOSTIC PRODUCTS ASSURE PLATINUM TEST STRIP - BOX 50 (Limited to LTC Pharmacies) DIAGNOSTIC PRODUCTS ASSURE PRISM MULTI TEST STRIP (Limited to LTC Pharmacies) DIAGNOSTIC PRODUCTS atropine ophth oint - OPHTHALMIC AGENTS atropine ophth soln (ISOPTO ATROPINE equiv) - OPHTHALMIC AGENTS bacitracin oint. DERMATOLOGICALS bacitracin/polymyxin b oint DERMATOLOGICALS bacitracin/zinc oint. DERMATOLOGICALS b-complex/vitamin c/folic acid cap (NEPHROCAP equiv) - MULTIVITAMINS b-complex/vitamin c/folic acid tab (NEPHRO-VITE equiv) MULTIVITAMINS BELLADONNA ALKALOID/OPIUM SUPP - ULCER DRUGS BELVIQ TAB (QL = 2 tab/day) PA-QL ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A NOREXIANTS BELVIQ XR TAB (QL= 1 tab/day) PA-QL ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A NOREXIANTS BENADRYL-D SOLN COUGH/COLD/ALLERGY benzocaine/menthol lozenge MOUTH/THROAT/DENTAL AGENTS benzonatate cap (TESSALON PERLES equiv) - COUGH/COLD/ALLERGY benzoyl peroxide cream (QL = 30 gm/30 day) -QL DERMATOLOGICALS benzoyl peroxide gel (BREVOXYL equiv) (Coverage includes only; QL = -QL DERMATOLOGICALS 90 gm/30 day) BENZOYL PEROXIDE GEL 2.5% (QL= 1 tube/30 days) -QL DERMATOLOGICALS benzoyl peroxide liquid (BENZAC AC equiv) (Coverage includes only; QL -QL DERMATOLOGICALS = 237 ml/30 day) benzoyl peroxide lotion (Coverage includes only; QL = 340.2ml/30 day) -QL DERMATOLOGICALS BISACODYL ENEMA LAXATIVES bisacodyl supp. LAXATIVES bisacodyl tab LAXATIVES bismuth subsalicylate chew tab ANTIDIARRHEALS bismuth subsalicylate susp. ANTIDIARRHEALS bismuth subsalicylate tab ANTIDIARRHEALS brompheniramine/phenylephrine elixir COUGH/COLD/ALLERGY brompheniramine/phenylephrine liquid COUGH/COLD/ALLERGY BROMPHENIRAMINE/PHENYLEPHRINE TAB COUGH/COLD/ALLERGY BROMPHENIRAMINE/PSEUDOEPHEDRINE LIQUID COUGH/COLD/ALLERGY BROTAPP DM LIQUID COUGH/COLD/ALLERGY CALAMINE LOTION DERMATOLOGICALS CALCIUM ACETATE TAB (QL = 9 tab/day) -QL MINERALS & ELECTROLYTES calcium and phosphorus w/vitamin D tab MINERALS & ELECTROLYTES CALCIUM CARBONATE CAP MINERALS & ELECTROLYTES calcium carbonate chew tab MINERALS & ELECTROLYTES calcium carbonate susp ANTACIDS CALCIUM CARBONATE TAB ANTACIDS calcium carbonate w/ vitamin d cap MINERALS & ELECTROLYTES calcium carbonate w/ vitamin D chew tab MINERALS & ELECTROLYTES calcium carbonate w/ vitamin d tab MINERALS & ELECTROLYTES calcium carbonate w/ vitamind D tab MINERALS & ELECTROLYTES CALCIUM CARBONATE/VITAMIN D TAB MINERALS & ELECTROLYTES Page 2 of 38

7 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category calcium citrate tab MINERALS & ELECTROLYTES calcium citrate w/ vitamin d tab MINERALS & ELECTROLYTES CALCIUM GLUCONATE TAB MINERALS & ELECTROLYTES CALCIUM LACTATE TAB MINERALS & ELECTROLYTES calcium polycarbophil tab LAXATIVES capsaicin cream DERMATOLOGICALS capsaicin pad DERMATOLOGICALS carbamide peroxide otic drop OTIC AGENTS CATHLO ACTIVASE INJ 2MG - HEMATOLOGICAL AGENTS - MISC. CENHIST CHEW TAB COUGH/COLD/ALLERGY cetirizine chew tab (ZYRTEC equiv) (QL = 1 tab/day) -QL ANTIHISTAMINES cetirizine syrup (ZYRTEC equiv) (Coverage includes only) ANTIHISTAMINES cetirizine tab (ZYRTEC equiv) (QL = 1 tab/day) -QL ANTIHISTAMINES cetirizine/pseudoephedrine 12-hour tab (ZYRTEC equiv) (QL = 1 tab/day) -QL COUGH/COLD/ALLERGY CHILDRENS PLUS COLD - COUGH/COLD/ALLERGY chlorhexidine gluconate liquid ANTISEPTICS & DISINECTANTS chlorpheniramine CR tab ANTIHISTAMINES chlorpheniramine syrup ANTIHISTAMINES chlorpheniramine tab ANTIHISTAMINES chlorpheniramine/acetaminophen tab COUGH/COLD/ALLERGY chlorpheniramine/dextromethorphan liquid COUGH/COLD/ALLERGY chlorpheniramine/dextromethorphan tab COUGH/COLD/ALLERGY chlorpheniramine/phenylephrine liquid COUGH/COLD/ALLERGY chlorpheniramine/phenylephrine tab COUGH/COLD/ALLERGY chlorpheniramine/phenylephrine/acetaminophen effer tab COUGH/COLD/ALLERGY chlorpheniramine/phenylephrine/acetaminophen tab COUGH/COLD/ALLERGY chlorpheniramine/phenylephrine/aspirin effer tab COUGH/COLD/ALLERGY CHLORPHENIRAMINE/PSEUDOEPHEDRINE CHEW TAB COUGH/COLD/ALLERGY chlorpheniramine/pseudoephedrine syrup COUGH/COLD/ALLERGY chlorpheniramine/pseudoephedrine tab COUGH/COLD/ALLERGY CHLORPHENIRAMINE/PSEUDOEPHEDRINE/IBUPROEN TAB COUGH/COLD/ALLERGY cholecalciferol cap VITAMINS cholecalciferol oral soln. VITAMINS cholecalciferol tab VITAMINS CHROMAGEN TAB - HEMATOPOIETIC AGENTS clemastine tab (TAVIST equiv) (Coverage includes only) ANTIHISTAMINES clotrimazole cream (Coverage includes only) DERMATOLOGICALS clotrimazole vaginal cream VAGINAL PRODUCTS CLOVERINE OINT DERMATOLOGICALS COLD RELIE COMPLETE TAB COUGH/COLD/ALLERGY COLD RELIE TAB PLUS COUGH/COLD/ALLERGY COLD/LU CONGESTION PAK COUGH/COLD/ALLERGY COLD/LU RELIE NIGHT D LIQUID COUGH/COLD/ALLERGY CONCEPTROL GEL VAGINAL PRODUCTS CONTRACEPTIVE ILM VAGINAL PRODUCTS CONTRACEPTIVE OAM VAGINAL PRODUCTS CONTRACEPTIVE GEL VAGINAL PRODUCTS CONTRACEPTIVE SUPP VAGINAL PRODUCTS CONTRAVE TAB (QL= 4 tabs/day) PA-QL ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A NOREXIANTS Page 3 of 38

8 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category cromolyn nasal soln. (NASALCROM equiv) NASAL AGENTS - SYSTEMIC AND TOPICAL cyanocobalamine ER tab HEMATOPOIETIC AGENTS cyanocobalamine inj. - HEMATOPOIETIC AGENTS cyanocobalamine lozenge HEMATOPOIETIC AGENTS cyanocobalamine SL tab -QL HEMATOPOIETIC AGENTS cyanocobalamine tab HEMATOPOIETIC AGENTS CYCLOMYDRIL OPHTH SOLN - OPHTHALMIC AGENTS cyclopentolate ophth soln (CYCLOGYL equiv) - OPHTHALMIC AGENTS DESITIN PASTE DERMATOLOGICALS DEXBROMPHENIRAMINE/PHENYLEPHRINE/ACETAMINOPHEN TAB COUGH/COLD/ALLERGY dexbrompheniramine/pseudoephedrine ER tab COUGH/COLD/ALLERGY DEXBROMPHENIRAMINE/PSEUDOEPHEDRINE TAB COUGH/COLD/ALLERGY dextromethorphan cap COUGH/COLD/ALLERGY dextromethorphan liquid COUGH/COLD/ALLERGY DEXTROMETHORPHAN LOZENGE COUGH/COLD/ALLERGY dextromethorphan syrup COUGH/COLD/ALLERGY DEXTROMETHORPHAN/ACETAMINOPHEN/CHLORPHENIRAMINE LIQUID COUGH/COLD/ALLERGY dextromethorphan/acetaminophen/chlorpheniramine susp COUGH/COLD/ALLERGY dextromethorphan/acetaminophen/chlorpheniramine tab COUGH/COLD/ALLERGY DEXTROMETHORPHAN/ACETAMINOPHEN/DIPHENHYDRAMINE LIQUID COUGH/COLD/ALLERGY DEXTROMETHORPHAN/BENZOCAINE LOZENGE MOUTH/THROAT/DENTAL AGENTS dextromethorphan/doxylamine soln. COUGH/COLD/ALLERGY dextromethorphan/doxylamine/acetaminophen cap COUGH/COLD/ALLERGY dextromethorphan/doxylamine/acetaminophen liquid COUGH/COLD/ALLERGY dextromethorphan/phenylephrine/acetaminophen cap COUGH/COLD/ALLERGY dextromethorphan/phenylephrine/acetaminophen liquid COUGH/COLD/ALLERGY dextromethorphan/phenylephrine/acetaminophen tab COUGH/COLD/ALLERGY DIALYVITE TAB - MULTIVITAMINS DIALYVITE/IRON TAB MULTIVITAMINS DIALYVITE/ZINC TAB MULTIVITAMINS DIETHYLTOLUAMIDE LOTION DERMATOLOGICALS dimenhydrinate tab ANTIEMETICS dimethicone gel (Coverage includes only) DERMATOLOGICALS diphenhydramine (sleep) cap HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS diphenhydramine (sleep) tab HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS diphenhydramine cap (BENADRYL equiv) (Coverage includes only) ANTIHISTAMINES diphenhydramine chew tab ANTIHISTAMINES diphenhydramine cream DERMATOLOGICALS diphenhydramine gel DERMATOLOGICALS diphenhydramine liquid ANTIHISTAMINES diphenhydramine rapid tab ANTIHISTAMINES diphenhydramine spray DERMATOLOGICALS DIPHENHYDRAMINE STRIP ANTIHISTAMINES diphenhydramine tab ANTIHISTAMINES diphenhydramine/acetaminophen (sleep) pack HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS diphenhydramine/acetaminophen (sleep) tab HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Page 4 of 38

9 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category DIPHENHYDRAMINE/ACETAMINOPHEN LIQUID HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS diphenhydramine/acetaminophen tab COUGH/COLD/ALLERGY diphenhydramine/phenylephrine liquid COUGH/COLD/ALLERGY diphenhydramine/phenylephrine soln. COUGH/COLD/ALLERGY diphenhydramine/phenylephrine tab COUGH/COLD/ALLERGY diphenhydramine/phenylephrine/acetaminophen liquid COUGH/COLD/ALLERGY diphenhydramine/phenylephrine/acetaminophen susp. COUGH/COLD/ALLERGY diphenhydramine/phenylephrine/acetaminophen tab COUGH/COLD/ALLERGY DIPHENHYDRAMINE/PSEUDOEPHEDRINE TAB COUGH/COLD/ALLERGY diphenhydramine/pseudoephedrine/acetaminophen tab COUGH/COLD/ALLERGY diphenhydramine/zinc cream DERMATOLOGICALS diphenhydramine/zinc spray DERMATOLOGICALS DOCUSAL/ENEMEEZ MINI ENEMA LAXATIVES docusate calcium cap LAXATIVES docusate sodium cap LAXATIVES docusate sodium enema LAXATIVES docusate sodium liquid LAXATIVES docusate sodium syrup LAXATIVES docusate sodium tab LAXATIVES doxylamine succinate tab HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS doxylamine/phenylephrine/acetaminophen cap COUGH/COLD/ALLERGY DULCOLAX BOWEL PREP KIT LAXATIVES EPHEDRINE SULATE CAP ANTIASTHMATIC AND BRONCHODILATOR AGENTS ergocalciferol soln. VITAMINS ERGOCALCIEROL TAB VITAMINS eye wash soln. OPHTHALMIC AGENTS famotidine tab ULCER DRUGS EMALE CONDOM MEDICAL DEVICES AND SUPPLIES ferocon cap - HEMATOPOIETIC AGENTS ferrex 150 forte cap - HEMATOPOIETIC AGENTS ferrous gluconate tab HEMATOPOIETIC AGENTS ferrous sulfate DR tab HEMATOPOIETIC AGENTS ferrous sulfate ER tab HEMATOPOIETIC AGENTS ERROUS SULATE LIQUID HEMATOPOIETIC AGENTS ferrous sulfate slow release tab HEMATOPOIETIC AGENTS ferrous sulfate soln HEMATOPOIETIC AGENTS ERROUS SULATE SYRUP HEMATOPOIETIC AGENTS ferrous sulfate tab HEMATOPOIETIC AGENTS IBER LIQUID LAXATIVES LEET ENEMA LAXATIVES LORIVA PLUS DROPS - MULTIVITAMINS folbee tab - HEMATOPOIETIC AGENTS OLIC ACID INJ - HEMATOPOIETIC AGENTS folic acid tab HEMATOPOIETIC AGENTS UNGOID SOLN DERMATOLOGICALS GALZIN CAP - MINERALS & ELECTROLYTES GEL DRESSING (QL = 2 packet/day) -QL DERMATOLOGICALS Page 5 of 38

10 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category GLUCOSE CHEW TAB ANTIDIABETICS glucose gel ANTIDIABETICS glycerin gel DERMATOLOGICALS glycerin liquid DERMATOLOGICALS GLYCERIN LOTION (Coverage includes only) DERMATOLOGICALS GLYCERIN SHAMPOO DERMATOLOGICALS glycerin suppository LAXATIVES guaifenesin DM/pseudoephedrine tab (Covered for members 4 years and COUGH/COLD/ALLERGY older) guaifenesin ER tab (MUCINEX equiv) COUGH/COLD/ALLERGY guaifenesin liquid COUGH/COLD/ALLERGY guaifenesin syrup COUGH/COLD/ALLERGY guaifenesin tab COUGH/COLD/ALLERGY guaifenesin/acetaminophen tab COUGH/COLD/ALLERGY guaifenesin/codeine phosphate liquid COUGH/COLD/ALLERGY guaifenesin/codeine phosphate liquid (TUSSI-ORGANIDIN-S equiv) COUGH/COLD/ALLERGY GUAIENESIN/CODEINE SYRUP COUGH/COLD/ALLERGY guaifenesin/dextromethorphan cap COUGH/COLD/ALLERGY guaifenesin/dextromethorphan ER tab COUGH/COLD/ALLERGY guaifenesin/dextromethorphan liquid COUGH/COLD/ALLERGY GUAIENESIN/DEXTROMETHORPHAN PACK COUGH/COLD/ALLERGY guaifenesin/dextromethorphan tab COUGH/COLD/ALLERGY guaifenesin/ephedrine hcl tab COUGH/COLD/ALLERGY GUAIENESIN/PHENYLEPHRINE HCL SYRUP COUGH/COLD/ALLERGY guaifenesin/phenylephrine hcl tab COUGH/COLD/ALLERGY guaifenesin/pseudoephedrine hcl cap COUGH/COLD/ALLERGY guaifenesin/pseudoephedrine hcl syrup COUGH/COLD/ALLERGY guaifenesin/pseudoephedrine hcl tab COUGH/COLD/ALLERGY guaifenesin/pseudoephedrine tab COUGH/COLD/ALLERGY HDC DM SYRUP COUGH/COLD/ALLERGY HEMORRHOIDAL OINT ANORECTAL AGENTS HEPARIN LOCK LUSH IV SOLN - ANTICOAGULANTS heparin sodium (porcine) lock flush IV soln - ANTICOAGULANTS homatropine ophth soln (ISOPTO HOMATROPINE equiv) - OPHTHALMIC AGENTS hydrocodone/homatropine soln. - COUGH/COLD/ALLERGY hydrocodone/homatropine syrup - COUGH/COLD/ALLERGY hydrocortisone acetate cream DERMATOLOGICALS HYDROCORTISONE ACETATE OINT DERMATOLOGICALS hydrocortisone aloe cream DERMATOLOGICALS HYDROCORTISONE ALOE OINT DERMATOLOGICALS hydrocortisone cream (Coverage includes only) DERMATOLOGICALS hydrocortisone E/pramoxine cream (ANALPRAM E equiv) - ANORECTAL AGENTS hydrocortisone gel DERMATOLOGICALS hydrocortisone lotion (Coverage includes only) DERMATOLOGICALS hydrocortisone oint (Coverage includes only) DERMATOLOGICALS hydrocortisone topical soln. (Coverage includes only) DERMATOLOGICALS hydrocortisone/pramoxine rectal cream (ANALPRAM HC equiv) - ANORECTAL AGENTS hydrogen peroxide soln ANTISEPTICS & DISINECTANTS HYDROGEN PEROXIDE SOLN. ANTISEPTICS & DISINECTANTS hyoscyamine IR/SR tab (SYMAX equiv) - ULCER DRUGS Page 6 of 38

11 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category hyoscyamine sulfate CR tab (LEVBID equiv) - ULCER DRUGS hyoscyamine sulfate elixir - ULCER DRUGS hyoscyamine sulfate ODT (ANASPAZ equiv) - ULCER DRUGS hyoscyamine sulfate SL tab (LEVSIN SL equiv) - ULCER DRUGS hyoscyamine sulfate soln - ULCER DRUGS hyoscyamine sulfate SR cap (LEVSINEX equiv) - ULCER DRUGS hyoscyamine sulfate tab (LEVSIN equiv) - ULCER DRUGS ibuprofen cap ANALGESICS - ANTI-INLAMMATORY ibuprofen chew tab ANALGESICS - ANTI-INLAMMATORY ibuprofen susp (ADVIL, MOTRIN equiv) (Coverage includes only) ANALGESICS - ANTI-INLAMMATORY ibuprofen tab (Coverage includes only) ANALGESICS - ANTI-INLAMMATORY INANT ORMULA LIQUID -PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS INANT ORMULA POWDER -PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS INJECTAER INJ - HEMATOPOIETIC AGENTS IRON POLYSACCHARIDE/THREONIC ACID/B12/A CAP - HEMATOPOIETIC AGENTS ISOPTO HYOSCINE OPHTH SOLN - OPHTHALMIC AGENTS ITCH RELIE EXT CREAM DERMATOLOGICALS IV PREP WIPES ANTISEPTICS & DISINECTANTS KETOSTIX DIAGNOSTIC PRODUCTS ketotifen ophth soln (ZADITOR equiv) OPHTHALMIC AGENTS KONSYL POWDER LAXATIVES KONSYL POWDER PACKET LAXATIVES K-PHOS TAB - MINERALS & ELECTROLYTES LANAPHILIC UREA OINT DERMATOLOGICALS lansoprazole cap (PREVACID equiv) (Coverage includes only. QL = 56 -QL ULCER DRUGS cap/30 day) L-CARNITINE CAP NUTRIENTS levocarnitine cap NUTRIENTS levocarnitine tab NUTRIENTS levonorgestrel tab (PLAN B equiv) (Coverage includes only) CONTRACEPTIVES LICE B GONE SHAMPOO DERMATOLOGICALS LICE TREATMENT KIT DERMATOLOGICALS lidocaine anorectal cream ANORECTAL AGENTS lidocaine gel (XYLOCAINE equiv) - DERMATOLOGICALS lidocaine soln (XYLOCAINE equiv) - DERMATOLOGICALS lidocaine/hydrocortisone cream (ANAMANTLE equiv) - ANORECTAL AGENTS LOHIST-D LIQUID COUGH/COLD/ALLERGY loperamide cap (IMODIUM equiv) (Coverage includes only) ANTIDIARRHEALS loperamide liquid ANTIDIARRHEALS loperamide tab ANTIDIARRHEALS loratadine ODT (CLARITIN equiv) (QL = 1 tab/day) -QL ANTIHISTAMINES loratadine syrup (CLARITIN equiv) (QL = 240ml/30 day; Covered for members -QL ANTIHISTAMINES age 2 through 5 years) loratadine tab (CLARITIN equiv) (QL = 1 tab/day; Covered for members 2 -QL ANTIHISTAMINES years and older) loratadine/pseudoephedrine 12-hour tab (CLARITIN-D equiv) (QL = 2 tab/day) -QL COUGH/COLD/ALLERGY loratadine/pseudoephedrine 24-hour tab (CLARITIN-D equiv) (QL = 1 tab/day) -QL COUGH/COLD/ALLERGY lubricating jelly DERMATOLOGICALS Page 7 of 38

12 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category magnesium citrate soln. LAXATIVES magnesium hydroxide chew tab LAXATIVES magnesium hydroxide susp. LAXATIVES magnesium oxide tab ANTACIDS magnesium tab MINERALS & ELECTROLYTES MAGNESIUM/ALUMINUM HYDROXIDE CHEW TAB ANTACIDS magnesium/aluminum hydroxide/simethicone chew tab ANTACIDS MAGNESIUM/ALUMINUM HYDROXIDE/SIMETHICONE SUSP ANTACIDS MALE CONDOM MEDICAL DEVICES AND SUPPLIES MALE CONDOMS MEDICAL DEVICES AND SUPPLIES MAOX TAB ANTACIDS meclizine chew tab (BONINE equiv) ANTIEMETICS meclizine tab (ANTIVERT equiv) (Coverage includes only) ANTIEMETICS MEDI-TUSSIN CAP COUGH/COLD/ALLERGY menthol lozenge (Covered for members 19 years and younger; Not covered MOUTH/THROAT/DENTAL AGENTS for 20 years and older) MICONAZOLE 3 SUPP 200MG (Coverage includes only) VAGINAL PRODUCTS miconazole cream DERMATOLOGICALS miconazole nitrate aerosol DERMATOLOGICALS miconazole nitrate aerosol powder DERMATOLOGICALS miconazole nitrate powder DERMATOLOGICALS MICONAZOLE NITRATE SOLN. DERMATOLOGICALS MICONAZOLE NITRATE SPRAY DERMATOLOGICALS miconazole oint. DERMATOLOGICALS miconazole vaginal cream VAGINAL PRODUCTS MICONAZOLE VAGINAL KIT VAGINAL PRODUCTS miconazole vaginal supp kit VAGINAL PRODUCTS MILK O MAGNESIA CHEW TAB LAXATIVES mineral oil DERMATOLOGICALS mineral oil (Coverage includes only) LAXATIVES mineral oil enema LAXATIVES MINERAL OIL LIGHT LAXATIVES mineral oil/petrolatum cream DERMATOLOGICALS MINERAL OIL/PETROLATUM CREAM (Coverage includes only) DERMATOLOGICALS mineral oil/petrolatum lotion DERMATOLOGICALS mineral oil/petrolatum oint DERMATOLOGICALS moisturel lotion (Coverage includes only) DERMATOLOGICALS multigen plus tab - HEMATOPOIETIC AGENTS multigen tab (CHROMAGEN equiv) - HEMATOPOIETIC AGENTS multigen/folic acid tab (CHROMAGEN A equiv) - HEMATOPOIETIC AGENTS multiple vitamin liquid MULTIVITAMINS multiple vitamin tab MULTIVITAMINS multivitamin w/ iron chew tab MULTIVITAMINS multivitamin w/ iron tab MULTIVITAMINS multivitamin/minerals tab (STROVITE equiv) MULTIVITAMINS NAPHAZOLINE OPHTH SOLN. - OPHTHALMIC AGENTS naphazoline/pheniramine ophth drops OPHTHALMIC AGENTS NASACORT NASAL SPRAY (QL = 2 bottle/fill; Coverage includes -QL NASAL AGENTS - SYSTEMIC AND TOPICAL only) NASAL MOIST GEL NASAL AGENTS - SYSTEMIC AND TOPICAL Page 8 of 38

13 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category neomycin/bacitracin/polymyxin b oint DERMATOLOGICALS neomycin/bacitracin/polymyxin b/pramoxine oint DERMATOLOGICALS neomycin/polymyxin b/pramoxine cream DERMATOLOGICALS NEOTUSS PLUS LIQUID COUGH/COLD/ALLERGY NEPHRON A TAB - HEMATOPOIETIC AGENTS niacin cap VITAMINS niacin CR tab (SLO-NIACIN equiv) VITAMINS niacin tab VITAMINS NIACIN TR TAB VITAMINS niacinamide tab VITAMINS nicotine gum (NICORETTE equiv) (Limited to 180 days per plan year) -QL PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. nicotine lozenge (COMMIT equiv) (Limited to 180 days per plan year) -QL PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. nicotine patch (NICODERM equiv) (Coverage includes only. Limited to 182 -QL PSYCHOTHERAPEUTIC AND days per plan year) NEUROLOGICAL AGENTS - MISC. NINJACO-XG LIQUID COUGH/COLD/ALLERGY NORTEMP SUSP INANTS ANALGESICS - NONNARCOTIC np thyroid tab (ARMOUR THYROID, NATURE THROID equiv) - THYROID AGENTS NUTRITIONAL SUPPLEMENT LIQUID -PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS NUTRITIONAL SUPPLEMENT POWDER -PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS omega-3 fatty acid cap NUTRIENTS omeprazole cap (Coverage includes only) ULCER DRUGS oxymetazoline nasal spray (ARIN NASAL equiv) NASAL AGENTS - SYSTEMIC AND TOPICAL PAIN RELIE COUGH/COLD SYRUP COUGH/COLD/ALLERGY PAIN RELIE PAK DAY AND NIGHT HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS PAIN RELIEVE PM TAB HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS PECTIN LOZENGE (Covered for members 19 years and younger; Not covered MOUTH/THROAT/DENTAL AGENTS for 20 years and older) pediatric electrolyte soln. MINERALS & ELECTROLYTES pediatric multiple vitamin ACD/fluoride soln. - MULTIVITAMINS pediatric multiple vitamin ACD/fluoride/iron drops - MULTIVITAMINS pediatric multiple vitamin/fluoride chew tab - MULTIVITAMINS pediatric multiple vitamin/fluoride soln. - MULTIVITAMINS pediatric multiple vitamins/fluoride/iron soln - MULTIVITAMINS pediatric multivitamin adc drops MULTIVITAMINS PEDIATRIC MULTIVITAMIN CHEW TAB MULTIVITAMINS pediatric multivitamin w/ iron chew tab MULTIVITAMINS pediatric multivitamin w/ iron drops MULTIVITAMINS pediatric multivitamin w/ minerals gummy MULTIVITAMINS pediatric multivitamin w/ vitamin c soln. MULTIVITAMINS pediatric multivitamin w/ vitamin c w/ iron chew tab MULTIVITAMINS permethrin liquid DERMATOLOGICALS permethrin lotion DERMATOLOGICALS permethrin spray DERMATOLOGICALS petrolatum oint DERMATOLOGICALS Page 9 of 38

14 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category PETROLATUM/LANOLIN/ZINC OXIDE/MINERAL OIL OINT. DERMATOLOGICALS phenazopyridine tab (PYRIDIUM equiv) - GENITOURINARY AGENTS - MISCELLANEOUS pheniramine/phenylephrine/acetaminophen packet (Covered for members 19 COUGH/COLD/ALLERGY years and younger; Not covered for 20 years and older) phentermine cap (ADIPEX equiv) (QL = 1 cap/day) PA-QL ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A NOREXIANTS phentermine tab (ADIPEX equiv) (QL = 1 tab/day) PA-QL ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A NOREXIANTS PHENYLEPHRINE DROPS NASAL AGENTS - SYSTEMIC AND TOPICAL phenylephrine nasal soln. NASAL AGENTS - SYSTEMIC AND TOPICAL phenylephrine ophth soln (MYDRIN equiv) - OPHTHALMIC AGENTS phenylephrine tab NASAL AGENTS - SYSTEMIC AND TOPICAL phenylephrine/acetaminophen cap COUGH/COLD/ALLERGY phenylephrine/acetaminophen powder pack COUGH/COLD/ALLERGY phenylephrine/acetaminophen tab COUGH/COLD/ALLERGY PHENYLEPHRINE/ACETAMINOPHEN/CAEINE TAB COUGH/COLD/ALLERGY phenylephrine/acetaminophen/guaifenesin tab COUGH/COLD/ALLERGY phenylephrine/brompheniramine/dm elixir COUGH/COLD/ALLERGY phenylephrine/brompheniramine/dm soln. COUGH/COLD/ALLERGY phenylephrine/chlorpheniramine/acetaminophen/dm liquid COUGH/COLD/ALLERGY phenylephrine/chlorpheniramine/acetaminophen/dm susp. COUGH/COLD/ALLERGY phenylephrine/chlorpheniramine/acetaminophen/dm tab COUGH/COLD/ALLERGY phenylephrine/chlorpheniramine/dm liquid COUGH/COLD/ALLERGY PHENYLEPHRINE/CHLORPHENIRAMINE/DM SOLN. COUGH/COLD/ALLERGY PHENYLEPHRINE/DEXTROMETHORPHAN LIQUID COUGH/COLD/ALLERGY phenylephrine/dextromethorphan soln. COUGH/COLD/ALLERGY PHENYLEPHRINE/DEXTROMETHORPHAN STRIP COUGH/COLD/ALLERGY phenylephrine/doxylamine/acetaminophen/dm liquid COUGH/COLD/ALLERGY phenylephrine/guaifenesin/acetaminophen/dm liquid COUGH/COLD/ALLERGY phenylephrine/guaifenesin/acetaminophen/dm tab COUGH/COLD/ALLERGY phenylephrine/guaifenesin/dm syrup COUGH/COLD/ALLERGY PHENYLEPHRINE/PYRILAMINE/DM LIQUID COUGH/COLD/ALLERGY phospha 250 neutral tab (K-PHOS NEUTRAL equiv) - MINERALS & ELECTROLYTES phytonadione tab - VITAMINS piperonyl butoxide/pyrethrins liquid DERMATOLOGICALS PIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO DERMATOLOGICALS piperonyl butoxide/pyrethrins/permethrin kit DERMATOLOGICALS polyethylene glycol 3350 powder (Coverage includes only) LAXATIVES POLYETHYLENE GLYCOL 8000 GRANULES - PHARMACEUTICAL ADJUVANTS polyethylene glycol packet (MIRALAX equiv) (Coverage includes only) LAXATIVES POVIDONE-IODINE SOLN ANTISEPTICS & DISINECTANTS povidone-iodine soln. ANTISEPTICS & DISINECTANTS PRAMOSONE CREAM - DERMATOLOGICALS PRENATAL VITAMIN (Coverage includes only) MULTIVITAMINS PREPARATION H CREAM ANORECTAL AGENTS PREPARATION H OINT ANORECTAL AGENTS preparation h supp ANORECTAL AGENTS PREVACID CAP (QL = 56 cap/30 day; Step Therapy requires trial of -QL-ST ULCER DRUGS lansoprazole and pantoprazole) Page 10 of 38

15 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category PROCTOOAM HC OAM - ANORECTAL AGENTS promethazine DM syrup - COUGH/COLD/ALLERGY PROMETHAZINE VC/CODEINE SYRUP promethazine/codeine syrup (PHENERGAN/CODIENE equiv) - - COUGH/COLD/ALLERGY COUGH/COLD/ALLERGY pseudoephedrine ER (12hr) tab (QL = 2 tab/day; Covered for members 4 -QL NASAL AGENTS - SYSTEMIC AND TOPICAL years and older) pseudoephedrine liquid (SUDAED equiv) (QL = 1200ml/30 day; Covered for -QL NASAL AGENTS - SYSTEMIC AND TOPICAL members 4 years and older) pseudoephedrine syrup (SUDAED equiv) (QL = 1200ml/30 day; Covered for -QL NASAL AGENTS - SYSTEMIC AND TOPICAL members 4 years and older) pseudoephedrine tab NASAL AGENTS - SYSTEMIC AND TOPICAL pseudoephedrine/acetaminophen tab COUGH/COLD/ALLERGY PSEUDOEPHEDRINE/ACETAMINOPHEN/DEXTROMETHORPHAN CAP (Only COUGH/COLD/ALLERGY covered for members age 4 years or older) PSEUDOEPHEDRINE/ACETAMINOPHEN/DEXTROMETHORPHAN TAB (Only COUGH/COLD/ALLERGY covered for members age 4 years or older) pseudoephedrine/acetaminophen/dm cap COUGH/COLD/ALLERGY pseudoephedrine/acetaminophen/dm tab COUGH/COLD/ALLERGY PSEUDOEPHEDRINE/ACETAMINOPHEN/GUAIENESIN TAB COUGH/COLD/ALLERGY pseudoephedrine/brompheniramine/dm elixir COUGH/COLD/ALLERGY pseudoephedrine/brompheniramine/dm syrup (Covered for age 2 thru 4 COUGH/COLD/ALLERGY years.) pseudoephedrine/chlorpheniramine/acetaminophen/dm cap COUGH/COLD/ALLERGY pseudoephedrine/chlorpheniramine/acetaminophen/dm packet COUGH/COLD/ALLERGY pseudoephedrine/chlorpheniramine/acetaminophen/dm susp COUGH/COLD/ALLERGY pseudoephedrine/chlorpheniramine/acetaminophen/dm tab COUGH/COLD/ALLERGY PSEUDOEPHEDRINE/CHLORPHENIRAMINE/CODEINE LIQUID COUGH/COLD/ALLERGY PSEUDOEPHEDRINE/CHLORPHENIRAMINE/DEXTROMETHORPHAN/ACETAMINO COUGH/COLD/ALLERGY PHEN CAP (Only covered for members age 4 years or older) PSEUDOEPHEDRINE/CHLORPHENIRAMINE/DM CHEW TAB COUGH/COLD/ALLERGY pseudoephedrine/chlorpheniramine/dm liquid COUGH/COLD/ALLERGY PSEUDOEPHEDRINE/DM ELIXIR COUGH/COLD/ALLERGY PSEUDOEPHEDRINE/DM LIQUID COUGH/COLD/ALLERGY pseudoephedrine/dm syrup COUGH/COLD/ALLERGY pseudoephedrine/doxylamine/acetaminophen/dm cap COUGH/COLD/ALLERGY pseudoephedrine/doxylamine/acetaminophen/dm liquid COUGH/COLD/ALLERGY PSEUDOEPHEDRINE/DOXYLAMINE/DEXTROMETHORPHAN/ACETAMINOPHEN COUGH/COLD/ALLERGY CAP (Only covered for members age 4 years or older) PSEUDOEPHEDRINE/GUAIENESIN/ACETAMINOPHEN/DM PACKET COUGH/COLD/ALLERGY pseudoephedrine/guaifenesin/acetaminophen/dm tab COUGH/COLD/ALLERGY pseudoephedrine/guaifenesin/dm cap COUGH/COLD/ALLERGY pseudoephedrine/guaifenesin/dm syrup COUGH/COLD/ALLERGY PSEUDOEPHEDRINE/GUAIENESIN/DM TAB (Covered for members 4 years COUGH/COLD/ALLERGY and older) PSEUDOEPHEDRINE/IBUPROEN CAP COUGH/COLD/ALLERGY pseudoephedrine/ibuprofen susp. COUGH/COLD/ALLERGY pseudoephedrine/ibuprofen tab COUGH/COLD/ALLERGY pseudoephedrine/naproxen tab COUGH/COLD/ALLERGY PSYLLIUM CAP LAXATIVES psyllium powder LAXATIVES Page 11 of 38

16 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category pyridoxine CR tab VITAMINS pyridoxine tab VITAMINS QSYMIA CAP (QL = 1 cap/day) PA-QL ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/A NOREXIANTS ranitidine tab 75mg ULCER DRUGS RECTICARE CREAM ANORECTAL AGENTS REENESEN PE TAB COUGH/COLD/ALLERGY REENESEN TAB COUGH/COLD/ALLERGY RERESH OPHTH DROPS OPHTHALMIC AGENTS RERESH PLUS DROPS OPHTHALMIC AGENTS RISCAL-D TAB MINERALS & ELECTROLYTES ROBITUSSIN COUGH AND COLD LIQUID COUGH/COLD/ALLERGY ROBITUSSIN SYRUP COUGH/COLD/ALLERGY salicylic acid gel DERMATOLOGICALS salicylic acid liquid DERMATOLOGICALS salicylic acid pad DERMATOLOGICALS salicylic acid shampoo - DERMATOLOGICALS salicylic acid soln DERMATOLOGICALS salicylic acid strip DERMATOLOGICALS saline nasal spray NASAL AGENTS - SYSTEMIC AND TOPICAL SCOT-TUSSIN LIQUID COUGH/COLD/ALLERGY selenium sulfide lotion - DERMATOLOGICALS sennosides tab LAXATIVES sennosides/docusate sodium tab LAXATIVES SILPHEN COUGH SYRUP ANTIHISTAMINES simethicone cap GASTROINTESTINAL AGENTS - MISC. simethicone chew tab GASTROINTESTINAL AGENTS - MISC. simethicone drops GASTROINTESTINAL AGENTS - MISC. simethicone liquid GASTROINTESTINAL AGENTS - MISC. SIMETHICONE STRIPS GASTROINTESTINAL AGENTS - MISC. SKIN CLEANSER DERMATOLOGICALS SM COUGH/SORE THROAT LIQUID COUGH/COLD/ALLERGY sodium bicarbonate tab ANTACIDS sodium chloride flush IV soln - MINERALS & ELECTROLYTES sodium chloride inj 0.9% - MINERALS & ELECTROLYTES sodium chloride ophth oint. OPHTHALMIC AGENTS sodium chloride ophth soln. OPHTHALMIC AGENTS SODIUM CHLORIDE SPRAY DERMATOLOGICALS sodium chloride tab MINERALS & ELECTROLYTES sodium fluoride cream (PREVIDENT equiv) - MOUTH/THROAT/DENTAL AGENTS sodium fluoride gel (PREVIDENT equiv) - MOUTH/THROAT/DENTAL AGENTS sodium fluoride paste (PREVIDENT equiv) - MOUTH/THROAT/DENTAL AGENTS sodium fluoride rinse (PREVIDENT equiv) - MOUTH/THROAT/DENTAL AGENTS sodium fluoride/potassium nitrate paste (PREVIDENT equiv) - MOUTH/THROAT/DENTAL AGENTS sodium phosphate enema LAXATIVES sodium phosphate soln. LAXATIVES SSKI SOLN - COUGH/COLD/ALLERGY SUDAED ER (24HR) TAB (QL= 1 tab/day; Covered for members 4 years and -QL NASAL AGENTS - SYSTEMIC AND TOPICAL older) SUDAED TRIPLE ACTION TAB COUGH/COLD/ALLERGY Page 12 of 38

17 L.A. Care Medi-Cal Dual ormulary Cont. Alphabetical Index Last Updated 1/1/2019 Drug Name Special Code Tier Category terbinafine cream (LAMISIL AT equiv) (QL = 30gm/30 day; Covered for -QL DERMATOLOGICALS members 12 years and older) tetrahydrozoline ophth soln. OPHTHALMIC AGENTS tetrahydrozoline/zinc sulfate ophth drops OPHTHALMIC AGENTS thera-gesic cream DERMATOLOGICALS thiamine mononitrate tab VITAMINS thiamine tab VITAMINS throat lozenge MOUTH/THROAT/DENTAL AGENTS tioconazole vaginal oint. VAGINAL PRODUCTS tolnaftate aerosol DERMATOLOGICALS tolnaftate cream DERMATOLOGICALS tolnaftate powder DERMATOLOGICALS tolnaftate spray DERMATOLOGICALS TRIACTING COLD SYRUP COUGH/COLD/ALLERGY TRIAMINIC NASAL SPRAY NASAL AGENTS - SYSTEMIC AND TOPICAL TRIAMINIC STRIPS COUGH/COLD/ALLERGY triprolidine/pseudoephedrine tab COUGH/COLD/ALLERGY TRI-VI-SOL DROPS MULTIVITAMINS tropicamide ophth soln (MYDRIACYL equiv) - OPHTHALMIC AGENTS tussin C liquid COUGH/COLD/ALLERGY TUSSIN COUGH/COLD LIQUID COUGH/COLD/ALLERGY tussin PE liquid (NARIZ equiv) COUGH/COLD/ALLERGY TYLENOL CAP ANALGESICS - NONNARCOTIC URAMAXIN CREAM - DERMATOLOGICALS urea lotion - DERMATOLOGICALS vapor inhaler COUGH/COLD/ALLERGY vaporizing steam COUGH/COLD/ALLERGY vaporizing steam - menthol COUGH/COLD/ALLERGY vcf vaginal gel (CONCEPTROL equiv) VAGINAL PRODUCTS VENELEX OINT - DERMATOLOGICALS VENOER INJ - HEMATOPOIETIC AGENTS VICKS DAYQUIL LIQUID MUCUS DM COUGH/COLD/ALLERGY vitamin a-d oint. DERMATOLOGICALS vitamin B complex cap MULTIVITAMINS VITAMIN B-12 TAB HEMATOPOIETIC AGENTS VITAMIN C SYRUP 500MG/5ML VITAMINS VITAMIN C TAB VITAMINS vitamin D cap - VITAMINS WAL-LU COLD PAK DAYTIME COUGH/COLD/ALLERGY wound cleanser DERMATOLOGICALS zinc oxide oint. DERMATOLOGICALS zinc oxide paste DERMATOLOGICALS zinc sulfate cap MINERALS & ELECTROLYTES Page 13 of 38

18 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ANOREXIANTS NON-AMPHETAMINE phentermine cap (ADIPEX equiv) (QL = 1 cap/day) PA-QL phentermine tab (ADIPEX equiv) (QL = 1 tab/day) PA-QL QSYMIA CAP (QL = 1 cap/day) PA-QL ANTI-OBESITY AGENTS BELVIQ TAB (QL = 2 tab/day) PA-QL BELVIQ XR TAB (QL= 1 tab/day) PA-QL CONTRAVE TAB (QL= 4 tabs/day) PA-QL ANALGESICS - ANTI-INLAMMATORY NONSTEROIDAL ANTI-INLAMMATORY AGENTS (NSAIDS) ibuprofen cap ibuprofen chew tab ibuprofen susp (ADVIL, MOTRIN equiv) (Coverage includes only) ibuprofen tab (Coverage includes only) ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS ACETAMINOPHEN/BUERED ASPIRIN TAB (Only covered for members 4 years and older) acetaminophen/pamabrom/pyrilamine tab (Only covered for members 4 years and older) ACETAMINOPHEN/PHENYLTOLOXAMINE TAB (Only covered for members 4 years and older) ANALGESICS OTHER acetaminophen cap acetaminophen chew tab acetaminophen drops acetaminophen elixir acetaminophen ER tab acetaminophen liquid acetaminophen ODT acetaminophen supp ACETAMINOPHEN SYRUP acetaminophen tab NORTEMP SUSP INANTS TYLENOL CAP SALICYLATES aspirin chew tab aspirin EC tab aspirin supp. ASPIRIN TAB ANORECTAL AGENTS RECTAL COMBINATIONS anumed supp HEMORRHOIDAL OINT hydrocortisone E/pramoxine cream (ANALPRAM E equiv) - hydrocortisone/pramoxine rectal cream (ANALPRAM HC equiv) - lidocaine/hydrocortisone cream (ANAMANTLE equiv) - PREPARATION H CREAM Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 14 of 38

19 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier ANORECTAL AGENTS Cont. PREPARATION H OINT preparation h supp PROCTOOAM HC OAM - RECTAL LOCAL ANESTHETICS lidocaine anorectal cream RECTICARE CREAM ANTACIDS ANTACID COMBINATIONS antacid chew tab MAGNESIUM/ALUMINUM HYDROXIDE CHEW TAB 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 susp CALCIUM CARBONATE TAB ANTACIDS - MAGNESIUM SALTS magnesium oxide tab MAOX TAB ANTIASTHMATIC AND BRONCHODILATOR AGENTS SYMPATHOMIMETICS EPHEDRINE SULATE CAP ANTICOAGULANTS HEPARINS AND HEPARINOID-LIKE AGENTS HEPARIN LOCK LUSH IV SOLN - heparin sodium (porcine) lock flush IV soln - ANTIDIABETICS DIABETIC OTHER GLUCOSE CHEW TAB glucose gel ANTIDIARRHEALS ANTIDIARRHEAL AGENTS - MISC. bismuth subsalicylate chew tab bismuth subsalicylate susp. bismuth subsalicylate tab ANTIPERISTALTIC AGENTS loperamide cap (IMODIUM equiv) (Coverage includes only) loperamide liquid loperamide tab Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 15 of 38

20 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier ANTIEMETICS - ANTICHOLINERGIC ANTIEMETICS dimenhydrinate tab meclizine chew tab (BONINE equiv) meclizine tab (ANTIVERT equiv) (Coverage includes only) ANTIEMETICS - MISCELLANEOUS anti-nausea soln. (EMETROL equiv) ANTIHISTAMINES ANTIHISTAMINES - ALKYLAMINES chlorpheniramine CR tab chlorpheniramine syrup chlorpheniramine tab ANTIHISTAMINES - ETHANOLAMINES clemastine tab (TAVIST equiv) (Coverage includes only) diphenhydramine cap (BENADRYL equiv) (Coverage includes only) diphenhydramine chew tab diphenhydramine liquid diphenhydramine rapid tab DIPHENHYDRAMINE STRIP diphenhydramine tab SILPHEN COUGH SYRUP ANTIHISTAMINES - NON-SEDATING cetirizine chew tab (ZYRTEC equiv) (QL = 1 tab/day) -QL cetirizine syrup (ZYRTEC equiv) (Coverage includes only) cetirizine tab (ZYRTEC equiv) (QL = 1 tab/day) -QL loratadine ODT (CLARITIN equiv) (QL = 1 tab/day) -QL loratadine syrup (CLARITIN equiv) (QL = 240ml/30 day; Covered for members age 2 through 5 years) -QL loratadine tab (CLARITIN equiv) (QL = 1 tab/day; Covered for members 2 years and older) -QL ANTISEPTICS & DISINECTANTS ANTISEPTIC COMBINATIONS IV PREP WIPES ANTISEPTICS & DISINECTANTS hydrogen peroxide soln HYDROGEN PEROXIDE SOLN. CHLORINE ANTISEPTICS chlorhexidine gluconate liquid IODINE ANTISEPTICS POVIDONE-IODINE SOLN povidone-iodine soln. CHEMICALS LIQUIDS GLYCERIN LIQUID CONTRACEPTIVES EMERGENCY CONTRACEPTIVES levonorgestrel tab (PLAN B equiv) (Coverage includes only) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 16 of 38

21 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier ANTITUSSIVES COUGH/COLD/ALLERGY benzonatate cap (TESSALON PERLES equiv) - dextromethorphan cap dextromethorphan liquid DEXTROMETHORPHAN LOZENGE dextromethorphan syrup hydrocodone/homatropine soln. - hydrocodone/homatropine syrup - ROBITUSSIN SYRUP TRIAMINIC STRIPS COUGH/COLD/ALLERGY COMBINATIONS ACETAMINOPHEN/DEXTROMETHORPHAN LIQUID ALLERGY MULTI-SYMPTOM DAY/NIGHT PAK (Covered for members 4-19 years. Not covered if 3 and younger or 20 and older) ALLERGY/SINUS TAB HEADACHE AP-HIST DM SOLN BENADRYL-D SOLN brompheniramine/phenylephrine elixir brompheniramine/phenylephrine liquid BROMPHENIRAMINE/PHENYLEPHRINE TAB BROMPHENIRAMINE/PSEUDOEPHEDRINE LIQUID BROTAPP DM LIQUID CENHIST CHEW TAB cetirizine/pseudoephedrine 12-hour tab (ZYRTEC equiv) (QL = 1 tab/day) -QL CHILDRENS PLUS COLD - chlorpheniramine/acetaminophen tab chlorpheniramine/dextromethorphan liquid chlorpheniramine/dextromethorphan tab chlorpheniramine/phenylephrine liquid chlorpheniramine/phenylephrine tab chlorpheniramine/phenylephrine/acetaminophen effer tab chlorpheniramine/phenylephrine/acetaminophen tab chlorpheniramine/phenylephrine/aspirin effer tab CHLORPHENIRAMINE/PSEUDOEPHEDRINE CHEW TAB chlorpheniramine/pseudoephedrine syrup chlorpheniramine/pseudoephedrine tab CHLORPHENIRAMINE/PSEUDOEPHEDRINE/IBUPROEN TAB COLD RELIE COMPLETE TAB COLD RELIE TAB PLUS COLD/LU CONGESTION PAK COLD/LU RELIE NIGHT D LIQUID DEXBROMPHENIRAMINE/PHENYLEPHRINE/ACETAMINOPHEN TAB dexbrompheniramine/pseudoephedrine ER tab DEXBROMPHENIRAMINE/PSEUDOEPHEDRINE TAB DEXTROMETHORPHAN/ACETAMINOPHEN/CHLORPHENIRAMINE LIQUID dextromethorphan/acetaminophen/chlorpheniramine susp Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 17 of 38

22 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier COUGH/COLD/ALLERGY Cont. dextromethorphan/acetaminophen/chlorpheniramine tab DEXTROMETHORPHAN/ACETAMINOPHEN/DIPHENHYDRAMINE LIQUID dextromethorphan/doxylamine soln. dextromethorphan/doxylamine/acetaminophen cap dextromethorphan/doxylamine/acetaminophen liquid dextromethorphan/phenylephrine/acetaminophen cap dextromethorphan/phenylephrine/acetaminophen liquid dextromethorphan/phenylephrine/acetaminophen tab diphenhydramine/acetaminophen tab diphenhydramine/phenylephrine liquid diphenhydramine/phenylephrine soln. diphenhydramine/phenylephrine tab diphenhydramine/phenylephrine/acetaminophen liquid diphenhydramine/phenylephrine/acetaminophen susp. diphenhydramine/phenylephrine/acetaminophen tab DIPHENHYDRAMINE/PSEUDOEPHEDRINE TAB diphenhydramine/pseudoephedrine/acetaminophen tab doxylamine/phenylephrine/acetaminophen cap guaifenesin DM/pseudoephedrine tab (Covered for members 4 years and older) guaifenesin/acetaminophen tab guaifenesin/codeine phosphate liquid guaifenesin/codeine phosphate liquid (TUSSI-ORGANIDIN-S equiv) GUAIENESIN/CODEINE SYRUP guaifenesin/dextromethorphan cap guaifenesin/dextromethorphan ER tab guaifenesin/dextromethorphan liquid GUAIENESIN/DEXTROMETHORPHAN PACK guaifenesin/dextromethorphan tab guaifenesin/ephedrine hcl tab GUAIENESIN/PHENYLEPHRINE HCL SYRUP guaifenesin/phenylephrine hcl tab guaifenesin/pseudoephedrine hcl cap guaifenesin/pseudoephedrine hcl syrup guaifenesin/pseudoephedrine hcl tab GUAIENESIN/PSEUDOEPHEDRINE TAB HDC DM SYRUP LOHIST-D LIQUID loratadine/pseudoephedrine 12-hour tab (CLARITIN-D equiv) (QL = 2 tab/day) -QL loratadine/pseudoephedrine 24-hour tab (CLARITIN-D equiv) (QL = 1 tab/day) -QL MEDI-TUSSIN CAP NEOTUSS PLUS LIQUID NINJACO-XG LIQUID PAIN RELIE COUGH/COLD SYRUP pheniramine/phenylephrine/acetaminophen packet (Covered for members 19 years and younger; Not covered for 20 years and older) phenylephrine/acetaminophen cap phenylephrine/acetaminophen powder pack Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 18 of 38

23 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier COUGH/COLD/ALLERGY Cont. phenylephrine/acetaminophen tab PHENYLEPHRINE/ACETAMINOPHEN/CAEINE TAB phenylephrine/acetaminophen/guaifenesin tab phenylephrine/brompheniramine/dm elixir phenylephrine/brompheniramine/dm soln. phenylephrine/chlorpheniramine/acetaminophen/dm liquid phenylephrine/chlorpheniramine/acetaminophen/dm susp. phenylephrine/chlorpheniramine/acetaminophen/dm tab PHENYLEPHRINE/CHLORPHENIRAMINE/DM LIQUID PHENYLEPHRINE/CHLORPHENIRAMINE/DM SOLN. PHENYLEPHRINE/DEXTROMETHORPHAN LIQUID phenylephrine/dextromethorphan soln. PHENYLEPHRINE/DEXTROMETHORPHAN STRIP phenylephrine/doxylamine/acetaminophen/dm liquid phenylephrine/guaifenesin/acetaminophen/dm liquid phenylephrine/guaifenesin/acetaminophen/dm tab phenylephrine/guaifenesin/dm syrup PHENYLEPHRINE/PYRILAMINE/DM LIQUID promethazine DM syrup - PROMETHAZINE VC/CODEINE SYRUP - promethazine/codeine syrup (PHENERGAN/CODIENE equiv) - pseudoephedrine/acetaminophen tab PSEUDOEPHEDRINE/ACETAMINOPHEN/DEXTROMETHORPHAN CAP (Only covered for members age 4 years or older) PSEUDOEPHEDRINE/ACETAMINOPHEN/DEXTROMETHORPHAN TAB (Only covered for members age 4 years or older) pseudoephedrine/acetaminophen/dm cap pseudoephedrine/acetaminophen/dm tab PSEUDOEPHEDRINE/ACETAMINOPHEN/GUAIENESIN TAB pseudoephedrine/brompheniramine/dm elixir pseudoephedrine/brompheniramine/dm syrup (Covered for age 2 thru 4 years.) pseudoephedrine/chlorpheniramine/acetaminophen/dm cap pseudoephedrine/chlorpheniramine/acetaminophen/dm packet pseudoephedrine/chlorpheniramine/acetaminophen/dm susp pseudoephedrine/chlorpheniramine/acetaminophen/dm tab PSEUDOEPHEDRINE/CHLORPHENIRAMINE/CODEINE LIQUID PSEUDOEPHEDRINE/CHLORPHENIRAMINE/DEXTROMETHORPHAN/ACETAMINOPHEN CAP (Only covered for members age 4 years or older) PSEUDOEPHEDRINE/CHLORPHENIRAMINE/DM CHEW TAB pseudoephedrine/chlorpheniramine/dm liquid PSEUDOEPHEDRINE/DM ELIXIR PSEUDOEPHEDRINE/DM LIQUID pseudoephedrine/dm syrup pseudoephedrine/doxylamine/acetaminophen/dm cap pseudoephedrine/doxylamine/acetaminophen/dm liquid PSEUDOEPHEDRINE/DOXYLAMINE/DEXTROMETHORPHAN/ACETAMINOPHEN CAP (Only covered for members age 4 years or older) PSEUDOEPHEDRINE/GUAIENESIN/ACETAMINOPHEN/DM PACKET pseudoephedrine/guaifenesin/acetaminophen/dm tab Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 19 of 38

24 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier COUGH/COLD/ALLERGY Cont. pseudoephedrine/guaifenesin/dm cap pseudoephedrine/guaifenesin/dm syrup PSEUDOEPHEDRINE/GUAIENESIN/DM TAB (Covered for members 4 years and older) PSEUDOEPHEDRINE/IBUPROEN CAP pseudoephedrine/ibuprofen susp. pseudoephedrine/ibuprofen tab pseudoephedrine/naproxen tab REENESEN PE TAB REENESEN TAB ROBITUSSIN COUGH AND COLD LIQUID SCOT-TUSSIN LIQUID SM COUGH/SORE THROAT LIQUID SUDAED TRIPLE ACTION TAB TRIACTING COLD SYRUP triprolidine/pseudoephedrine tab tussin C liquid TUSSIN COUGH/COLD LIQUID tussin PE liquid (NARIZ equiv) VICKS DAYQUIL LIQUID MUCUS DM WAL-LU COLD PAK DAYTIME EXPECTORANTS guaifenesin ER tab (MUCINEX equiv) guaifenesin liquid guaifenesin syrup guaifenesin tab SSKI SOLN - MISC. RESPIRATORY INHALANTS vapor inhaler vaporizing steam vaporizing steam - menthol DERMATOLOGICALS ACNE PRODUCTS benzoyl peroxide cream (QL = 30 gm/30 day) -QL benzoyl peroxide gel (BREVOXYL equiv) (Coverage includes only; QL = 90 gm/30 day) -QL BENZOYL PEROXIDE GEL 2.5% (QL= 1 tube/30 days) -QL benzoyl peroxide liquid (BENZAC AC equiv) (Coverage includes only; QL = 237 ml/30 day) -QL benzoyl peroxide lotion (Coverage includes only; QL = 340.2ml/30 day) -QL ANTIBIOTICS - TOPICAL bacitracin oint. bacitracin/polymyxin b oint bacitracin/zinc oint. neomycin/bacitracin/polymyxin b oint neomycin/bacitracin/polymyxin b/pramoxine oint neomycin/polymyxin b/pramoxine cream ANTIUNGALS - TOPICAL clotrimazole cream (Coverage includes only) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 20 of 38

25 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier DERMATOLOGICALS Cont. CLOVERINE OINT UNGOID SOLN miconazole cream miconazole nitrate aerosol miconazole nitrate aerosol powder miconazole nitrate powder MICONAZOLE NITRATE SOLN. MICONAZOLE NITRATE SPRAY miconazole oint. terbinafine cream (LAMISIL AT equiv) (QL = 30gm/30 day; Covered for members 12 years and older) -QL tolnaftate aerosol tolnaftate cream tolnaftate powder tolnaftate spray ANTIHISTAMINES-TOPICAL diphenhydramine cream diphenhydramine gel diphenhydramine spray diphenhydramine/zinc cream diphenhydramine/zinc spray ITCH RELIE EXT CREAM ANTISEBORRHEIC PRODUCTS MINERAL OIL/PETROLATUM CREAM (Coverage includes only) selenium sulfide lotion - BATH PRODUCTS glycerin gel mineral oil CORTICOSTEROIDS - TOPICAL hydrocortisone acetate cream HYDROCORTISONE ACETATE OINT hydrocortisone aloe cream HYDROCORTISONE ALOE OINT hydrocortisone cream (Coverage includes only) hydrocortisone gel hydrocortisone lotion (Coverage includes only) hydrocortisone oint (Coverage includes only) hydrocortisone topical soln. (Coverage includes only) PRAMOSONE CREAM - DIAPER RASH PRODUCTS vitamin a-d oint. EMOLLIENT/KERATOLYTIC AGENTS LANAPHILIC UREA OINT URAMAXIN CREAM - urea lotion - EMOLLIENTS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 21 of 38

26 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier DERMATOLOGICALS Cont. ammonium lactate cream (Coverage includes only) ammonium lactate lotion (Coverage includes only) glycerin liquid glycerin lotion (Coverage includes only) mineral oil/petrolatum cream (Coverage includes only) petrolatum oint vitamin a-d oint. KERATOLYTIC/ANTIMITOTIC AGENTS salicylic acid gel salicylic acid liquid salicylic acid pad salicylic acid shampoo - salicylic acid soln salicylic acid strip LINIMENTS analgesic balm capsaicin cream thera-gesic cream LOCAL ANESTHETICS - TOPICAL capsaicin pad lidocaine gel (XYLOCAINE equiv) - lidocaine soln (XYLOCAINE equiv) - MISC. DERMATOLOGICAL PRODUCTS GLYCERIN LOTION (Coverage includes only) MISC. TOPICAL CALAMINE LOTION DESITIN PASTE DIETHYLTOLUAMIDE LOTION GEL DRESSING (QL = 2 packet/day) -QL glycerin liquid GLYCERIN SHAMPOO lubricating jelly mineral oil MINERAL OIL LIGHT mineral oil/petrolatum cream mineral oil/petrolatum lotion mineral oil/petrolatum oint moisturel lotion (Coverage includes only) PETROLATUM/LANOLIN/ZINC OXIDE/MINERAL OIL OINT. SKIN CLEANSER SODIUM CHLORIDE SPRAY zinc oxide oint. zinc oxide paste SCABICIDES & PEDICULICIDES dimethicone gel (Coverage includes only) LICE B GONE SHAMPOO Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 22 of 38

27 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier DERMATOLOGICALS Cont. LICE TREATMENT KIT permethrin liquid permethrin lotion permethrin spray piperonyl butoxide/pyrethrins liquid piperonyl butoxide/pyrethrins shampoo piperonyl butoxide/pyrethrins/permethrin kit WOUND CARE PRODUCTS VENELEX OINT - wound cleanser DIAGNOSTIC PRODUCTS DIAGNOSTIC TESTS ASSURE PLATINUM TEST STRIP - BOX 100 (Limited to LTC Pharmacies) ASSURE PLATINUM TEST STRIP - BOX 50 (Limited to LTC Pharmacies) ASSURE PRISM MULTI TEST STRIP (Limited to LTC Pharmacies) KETOSTIX DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS INANT OODS INANT ORMULA LIQUID -PA INANT ORMULA POWDER -PA NUTRITIONAL SUPPLEMENTS NUTRITIONAL SUPPLEMENT LIQUID -PA NUTRITIONAL SUPPLEMENT POWDER -PA GASTROINTESTINAL AGENTS - MISC. ANTILATULENTS simethicone cap simethicone chew tab simethicone drops simethicone liquid SIMETHICONE STRIPS GENITOURINARY AGENTS - MISCELLANEOUS URINARY ANALGESICS phenazopyridine tab (PYRIDIUM equiv) - HEMATOLOGICAL AGENTS - MISC. THROMBOLYTIC ENZYMES CATHLO ACTIVASE INJ 2MG - HEMATOPOIETIC AGENTS COBALAMINS cyanocobalamine ER tab cyanocobalamine inj. - cyanocobalamine lozenge cyanocobalamine SL tab -QL cyanocobalamine tab VITAMIN B-12 TAB Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 23 of 38

28 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier OLIC ACID/OLATES HEMATOPOIETIC AGENTS Cont. OLIC ACID INJ - folic acid tab HEMATOPOIETIC MIXTURES CHROMAGEN TAB - ferocon cap - ferrex 150 forte cap - folbee tab - IRON POLYSACCHARIDE/THREONIC ACID/B12/A CAP - multigen plus tab - multigen tab (CHROMAGEN equiv) - multigen/folic acid tab (CHROMAGEN A equiv) - NEPHRON A TAB - IRON ferrous gluconate tab ferrous sulfate DR tab ferrous sulfate ER tab ERROUS SULATE LIQUID ferrous sulfate slow release tab ferrous sulfate soln ERROUS SULATE SYRUP ferrous sulfate tab INJECTAER INJ - VENOER INJ - HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS ANTIHISTAMINE HYPNOTICS diphenhydramine (sleep) cap diphenhydramine (sleep) tab diphenhydramine/acetaminophen (sleep) pack diphenhydramine/acetaminophen (sleep) tab DIPHENHYDRAMINE/ACETAMINOPHEN LIQUID doxylamine succinate tab PAIN RELIE PAK DAY AND NIGHT PAIN RELIEVE PM TAB LAXATIVES BULK LAXATIVES calcium polycarbophil tab IBER LIQUID KONSYL POWDER KONSYL POWDER PACKET psyllium cap psyllium powder LAXATIVE COMBINATIONS sennosides/docusate sodium tab LAXATIVES - MISCELLANEOUS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 24 of 38

29 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier LAXATIVES Cont. LEET ENEMA glycerin suppository polyethylene glycol 3350 powder (Coverage includes only) polyethylene glycol packet (MIRALAX equiv) (Coverage includes only) LUBRICANT LAXATIVES mineral oil (Coverage includes only) mineral oil enema MINERAL OIL LIGHT SALINE LAXATIVES magnesium citrate soln. magnesium hydroxide chew tab 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 DOCUSAL/ENEMEEZ MINI ENEMA docusate calcium cap docusate sodium cap docusate sodium enema docusate sodium liquid docusate sodium syrup docusate sodium tab MEDICAL DEVICES AND SUPPLIES CONTRACEPTIVES EMALE CONDOM MALE CONDOM MALE CONDOMS DIABETIC SUPPLIES ASSURE LANCET LOW LOW 25 GAUGE - BOX 100 (Limited to LTC Pharmacies) ASSURE LANCET MICRO LOW 28 GAUGE - BOX 100 (Limited to LTC Pharmacies) MINERALS & ELECTROLYTES CALCIUM CALCIUM ACETATE TAB (QL = 9 tab/day) -QL calcium and phosphorus w/vitamin D tab CALCIUM CARBONATE CAP calcium carbonate chew tab calcium carbonate tab calcium carbonate w/ vitamin d cap Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 25 of 38

30 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier MINERALS & ELECTROLYTES Cont. calcium carbonate w/ vitamin D chew tab calcium carbonate w/ vitamin d tab calcium carbonate w/ vitamind D tab CALCIUM CARBONATE/VITAMIN D TAB calcium citrate tab calcium citrate w/ vitamin d tab CALCIUM GLUCONATE TAB CALCIUM LACTATE TAB RISCAL-D TAB ELECTROLYTE MIXTURES pediatric electrolyte soln. MAGNESIUM magnesium oxide tab magnesium tab MINERAL COMBINATIONS calcium citrate tab PHOSPHATE K-PHOS TAB - phospha 250 neutral tab (K-PHOS NEUTRAL equiv) - SODIUM sodium chloride flush IV soln - sodium chloride inj 0.9% - sodium chloride tab ZINC GALZIN CAP - zinc sulfate cap MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL benzocaine/menthol lozenge DENTAL PRODUCTS sodium fluoride cream (PREVIDENT equiv) - sodium fluoride gel (PREVIDENT equiv) - sodium fluoride paste (PREVIDENT equiv) - sodium fluoride rinse (PREVIDENT equiv) - sodium fluoride/potassium nitrate paste (PREVIDENT equiv) - LOZENGES DEXTROMETHORPHAN/BENZOCAINE LOZENGE menthol lozenge (Covered for members 19 years and younger; Not covered for 20 years and older) PECTIN LOZENGE (Covered for members 19 years and younger; Not covered for 20 years and older) throat lozenge MULTIVITAMINS B-COMPLEX VITAMINS vitamin B complex cap B-COMPLEX W/ OLIC ACID Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 26 of 38

31 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier MULTIVITAMINS Cont. b-complex/vitamin c/folic acid cap (NEPHROCAP equiv) - b-complex/vitamin c/folic acid tab (NEPHRO-VITE equiv) DIALYVITE TAB - DIALYVITE/IRON TAB DIALYVITE/ZINC TAB BIOLAVONOID PRODUCTS ascorbic acid tab MULTIPLE VITAMINS W/ IRON multivitamin w/ iron tab MULTIPLE VITAMINS W/ MINERALS multivitamin w/ iron chew tab multivitamin/minerals tab (STROVITE equiv) MULTIVITAMINS multiple vitamin liquid multiple vitamin tab PED MULTI VITAMINS W/L & E pediatric multiple vitamin ACD/fluoride/iron drops - pediatric multiple vitamins/fluoride/iron soln - PED MV W/ LUORIDE LORIVA PLUS DROPS - pediatric multiple vitamin ACD/fluoride soln. - pediatric multiple vitamin/fluoride chew tab - pediatric multiple vitamin/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/ minerals gummy 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 TRI-VI-SOL DROPS PRENATAL VITAMINS PRENATAL VITAMIN (Coverage includes only) NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL AGENTS - MISC. NASAL MOIST GEL saline nasal spray NASAL ANTIALLERGY cromolyn nasal soln. (NASALCROM equiv) NASAL STEROIDS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 27 of 38

32 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier NASAL AGENTS - SYSTEMIC AND TOPICAL Cont. NASACORT NASAL SPRAY (QL = 2 bottle/fill; Coverage includes only) -QL SYMPATHOMIMETIC DECONGESTANTS oxymetazoline nasal spray (ARIN NASAL equiv) PHENYLEPHRINE DROPS phenylephrine nasal soln. phenylephrine tab pseudoephedrine ER (12hr) tab (QL = 2 tab/day; Covered for members 4 years and older) -QL pseudoephedrine liquid (SUDAED equiv) (QL = 1200ml/30 day; Covered for members 4 years and older) -QL pseudoephedrine syrup (SUDAED equiv) (QL = 1200ml/30 day; Covered for members 4 years and older) -QL pseudoephedrine tab SUDAED ER (24HR) TAB (QL= 1 tab/day; Covered for members 4 years and older) -QL TRIAMINIC NASAL SPRAY NUTRIENTS MISC. NUTRITIONAL SUBSTANCES omega-3 fatty acid cap PROTEINS L-CARNITINE CAP levocarnitine cap levocarnitine tab OPHTHALMIC AGENTS ARTIICIAL TEARS AND LUBRICANTS aritificial tears ophth soln. artificial tears ophth oint. artificial tears ophth soln. RERESH OPHTH DROPS RERESH PLUS DROPS CYCLOPLEGIC MYDRIATICS atropine ophth oint - atropine ophth soln (ISOPTO ATROPINE equiv) - CYCLOMYDRIL OPHTH SOLN - cyclopentolate ophth soln (CYCLOGYL equiv) - homatropine ophth soln (ISOPTO HOMATROPINE equiv) - ISOPTO HYOSCINE OPHTH SOLN - tropicamide ophth soln (MYDRIACYL equiv) - OPHTHALMIC DECONGESTANTS NAPHAZOLINE OPHTH SOLN. - naphazoline/pheniramine ophth drops phenylephrine ophth soln (MYDRIN equiv) - tetrahydrozoline ophth soln. tetrahydrozoline/zinc sulfate ophth drops OPHTHALMICS - MISC. eye wash soln. ketotifen ophth soln (ZADITOR equiv) sodium chloride ophth oint. sodium chloride ophth soln. Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 28 of 38

33 L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 DrugName Special Code Tier OTIC AGENTS - MISCELLANEOUS OTIC AGENTS carbamide peroxide otic drop PHARMACEUTICAL ADJUVANTS SEMI SOLID VEHICLES MINERAL OIL/PETROLATUM CREAM (Coverage includes only) POLYETHYLENE GLYCOL 8000 GRANULES - PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. SMOKING DETERRENTS nicotine gum (NICORETTE equiv) (Limited to 180 days per plan year) -QL nicotine lozenge (COMMIT equiv) (Limited to 180 days per plan year) -QL nicotine patch (NICODERM equiv) (Coverage includes only. Limited to 182 days per plan year) -QL THYROID AGENTS THYROID HORMONES ARMOUR THYROID TAB, NATURE THROID TAB - np thyroid tab (ARMOUR THYROID, NATURE THROID equiv) - ULCER DRUGS ANTISPASMODICS BELLADONNA ALKALOID/OPIUM SUPP - hyoscyamine IR/SR tab (SYMAX equiv) - hyoscyamine sulfate CR tab (LEVBID equiv) - hyoscyamine sulfate elixir - hyoscyamine sulfate ODT (ANASPAZ equiv) - hyoscyamine sulfate SL tab (LEVSIN SL equiv) - hyoscyamine sulfate soln - hyoscyamine sulfate SR cap (LEVSINEX equiv) - hyoscyamine sulfate tab (LEVSIN equiv) - H-2 ANTAGONISTS famotidine tab ranitidine tab 75mg PROTON PUMP INHIBITORS lansoprazole cap (PREVACID equiv) (Coverage includes only. QL = 56 cap/30 day) -QL omeprazole cap (Coverage includes only) PREVACID CAP (QL = 56 cap/30 day; Step Therapy requires trial of lansoprazole and pantoprazole) -QL-ST VAGINAL PRODUCTS SPERMICIDES CONCEPTROL GEL CONTRACEPTIVE ILM CONTRACEPTIVE OAM CONTRACEPTIVE GEL CONTRACEPTIVE SUPP vcf vaginal gel (CONCEPTROL equiv) VAGINAL ANTI-INECTIVES clotrimazole vaginal cream MICONAZOLE 3 SUPP 200MG (Coverage includes only) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 29 of 38

34 DrugName miconazole vaginal cream MICONAZOLE VAGINAL KIT miconazole vaginal supp kit tioconazole vaginal oint. OIL SOLUBLE VITAMINS cholecalciferol cap cholecalciferol oral soln. cholecalciferol tab ergocalciferol soln. ERGOCALCIEROL TAB phytonadione tab vitamin D cap 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 cap niacin CR tab (SLO-NIACIN equiv) niacin tab NIACIN TR TAB niacinamide tab pyridoxine CR tab pyridoxine tab thiamine mononitrate tab thiamine tab VITAMIN C SYRUP 500MG/5ML VITAMIN C TAB L.A. Care Medi-Cal Dual ormulary Category/Class Last Updated* 1/1/2019 VAGINAL PRODUCTS Cont. VITAMINS Special Code - - Tier Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. Page 30 of 38

35 L.A. Care Medi-Cal Dual ormulary Prior Authorization Drug List Last Updated* 1/1/2019 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 BELVIQ TAB BELVIQ XR TAB CONTRAVE TAB INANT ORMULA LIQUID INANT ORMULA POWDER NUTRITIONAL SUPPLEMENT LIQUID NUTRITIONAL SUPPLEMENT POWDER phentermine cap phentermine tab QSYMIA CAP Tier # for Drug Copay (if prior auth is approved) Page 31 of 38

36 L.A. Care Medi-Cal Dual ormulary Last Updated* 1/1/2019 Over-the-Counter () The following drugs are a covered benefit with a prescription Over-the-Counter () Medications acetaminophen cap acetaminophen ER tab ACETAMINOPHEN SYRUP acetaminophen/pamabrom/p yrilamine tab ALUMINUM HYDROXIDE GEL SUSP. antacid chew tab aritificial tears ophth soln. ascorbic acid chew tab ascorbic acid tab aspirin supp. ASSURE PLATINUM TEST STRIP - BOX 100 bacitracin/polymyxin b oint benzocaine/menthol lozenge benzoyl peroxide liquid bisacodyl tab brompheniramine/phenylephri ne elixir BROTAPP DM LIQUID CALCIUM CARBONATE CAP calcium carbonate w/ vitamin d cap CALCIUM CARBONATE/VITAMIN D TAB CALCIUM LACTATE TAB carbamide peroxide otic drop cetirizine tab chlorpheniramine syrup acetaminophen chew tab acetaminophen liquid acetaminophen tab ACETAMINOPHEN/PHENYL TOLOXAMINE TAB ammonium lactate cream anti-nausea soln. artificial tears ophth oint. ascorbic acid ER tab ASCORBIC ACID WAER ASPIRIN TAB ASSURE PLATINUM TEST STRIP - BOX 50 bacitracin/zinc oint. benzoyl peroxide cream benzoyl peroxide lotion bismuth subsalicylate chew tab brompheniramine/phenylephri ne liquid CALAMINE LOTION calcium carbonate chew tab calcium carbonate w/ vitamin D chew tab calcium citrate tab calcium polycarbophil tab CENHIST CHEW TAB cetirizine/pseudoephedrine 12-hour tab chlorpheniramine tab acetaminophen drops acetaminophen ODT ACETAMINOPHEN/BUER ED ASPIRIN TAB ALLERGY MULTI-SYMPTOM DAY/NIGHT PAK ammonium lactate lotion anumed supp artificial tears ophth soln. ascorbic acid lozenge aspirin chew tab ASSURE LANCET LOW LOW 25 GAUGE - BOX 100 ASSURE PRISM MULTI TEST STRIP b-complex/vitamin c/folic acid tab benzoyl peroxide gel BISACODYL ENEMA bismuth subsalicylate susp. BROMPHENIRAMINE/PHEN YLEPHRINE TAB CALCIUM ACETATE TAB calcium carbonate susp calcium carbonate w/ vitamin d tab calcium citrate w/ vitamin d tab capsaicin cream cetirizine chew tab chlorhexidine gluconate liquid chlorpheniramine/acetaminop hen tab acetaminophen elixir acetaminophen supp acetaminophen/dextromethor phan liquid ALLERGY/SINUS TAB HEADACHE analgesic balm AP-HIST DM SOLN ascorbic acid cap ascorbic acid syrup aspirin EC tab ASSURE LANCET MICRO LOW 28 GAUGE - BOX 100 bacitracin oint. BENADRYL-D SOLN BENZOYL PEROXIDE GEL 2.5% bisacodyl supp. bismuth subsalicylate tab BROMPHENIRAMINE/PSEU DOEPHEDRINE LIQUID calcium and phosphorus w/vitamin D tab calcium carbonate tab calcium carbonate w/ vitamind D tab CALCIUM GLUCONATE TAB capsaicin pad cetirizine syrup chlorpheniramine CR tab chlorpheniramine/dextrometh orphan liquid Page 32 of 38

37 chlorpheniramine/dextrometh chlorpheniramine/phenylephri chlorpheniramine/phenylephri chlorpheniramine/phenylephri orphan tab ne liquid ne tab ne/acetaminophen effer tab chlorpheniramine/phenylephri chlorpheniramine/phenylephri CHLORPHENIRAMINE/PSE chlorpheniramine/pseudoeph ne/acetaminophen tab ne/aspirin effer tab UDOEPHEDRINE CHEW edrine syrup TAB chlorpheniramine/pseudoeph edrine tab cholecalciferol tab CLOVERINE OINT COLD/LU RELIE NIGHT D LIQUID CONTRACEPTIVE GEL cyanocobalamine lozenge DEXBROMPHENIRAMINE/P HENYLEPHRINE/ACETAMIN OPHEN TAB dextromethorphan liquid dextromethorphan/acetamino phen/chlorpheniramine susp dextromethorphan/doxylamin e soln. dextromethorphan/phenyleph rine/acetaminophen liquid DIETHYLTOLUAMIDE LOTION diphenhydramine (sleep) tab diphenhydramine gel DIPHENHYDRAMINE STRIP DIPHENHYDRAMINE/ACET AMINOPHEN LIQUID diphenhydramine/phenylephri ne tab DIPHENHYDRAMINE/PSEU DOEPHEDRINE TAB DOCUSAL/ENEMEEZ MINI ENEMA docusate sodium liquid doxylamine/phenylephrine/ac etaminophen cap ERGOCALCIEROL TAB ferrous gluconate tab ferrous sulfate slow release tab IBER LIQUID GEL DRESSING CHLORPHENIRAMINE/PSE UDOEPHEDRINE/IBUPRO EN TAB clemastine tab COLD RELIE COMPLETE TAB CONCEPTROL GEL CONTRACEPTIVE SUPP cyanocobalamine SL tab dexbrompheniramine/pseudo ephedrine ER tab DEXTROMETHORPHAN LOZENGE dextromethorphan/acetamino phen/chlorpheniramine tab dextromethorphan/doxylamin e/acetaminophen cap dextromethorphan/phenyleph rine/acetaminophen tab dimenhydrinate tab diphenhydramine cap diphenhydramine liquid diphenhydramine tab diphenhydramine/acetaminop hen tab diphenhydramine/phenylephri ne/acetaminophen liquid diphenhydramine/pseudoeph edrine/acetaminophen tab docusate calcium cap docusate sodium syrup DULCOLAX BOWEL PREP KIT eye wash soln. ferrous sulfate DR tab ferrous sulfate soln LEET ENEMA GLUCOSE CHEW TAB cholecalciferol cap clotrimazole cream COLD RELIE TAB PLUS CONTRACEPTIVE ILM cromolyn nasal soln. cyanocobalamine tab DEXBROMPHENIRAMINE/P SEUDOEPHEDRINE TAB dextromethorphan syrup DEXTROMETHORPHAN/AC ETAMINOPHEN/DIPHENHY DRAMINE LIQUID dextromethorphan/doxylamin e/acetaminophen liquid DIALYVITE/IRON TAB dimethicone gel diphenhydramine chew tab diphenhydramine rapid tab diphenhydramine/acetaminop hen (sleep) pack diphenhydramine/phenylephri ne liquid diphenhydramine/phenylephri ne/acetaminophen susp. diphenhydramine/zinc cream docusate sodium cap docusate sodium tab EPHEDRINE SULATE CAP famotidine tab ferrous sulfate ER tab ERROUS SULATE SYRUP folic acid tab glucose gel cholecalciferol oral soln. clotrimazole vaginal cream COLD/LU CONGESTION PAK CONTRACEPTIVE OAM cyanocobalamine ER tab DESITIN PASTE dextromethorphan cap DEXTROMETHORPHAN/AC ETAMINOPHEN/CHLORPHE NIRAMINE LIQUID DEXTROMETHORPHAN/BE NZOCAINE LOZENGE dextromethorphan/phenyleph rine/acetaminophen cap DIALYVITE/ZINC TAB diphenhydramine (sleep) cap diphenhydramine cream diphenhydramine spray diphenhydramine/acetaminop hen (sleep) tab diphenhydramine/phenylephri ne soln. diphenhydramine/phenylephri ne/acetaminophen tab diphenhydramine/zinc spray docusate sodium enema doxylamine succinate tab ergocalciferol soln. EMALE CONDOM ERROUS SULATE LIQUID ferrous sulfate tab UNGOID SOLN glycerin gel Page 33 of 38

38 GLYCERIN LIQUID guaifenesin DM/pseudoephedrine tab guaifenesin tab guaifenesin/dextromethorpha n cap guaifenesin/dextromethorpha n tab guaifenesin/pseudoephedrine hcl cap HDC DM SYRUP hydrocortisone aloe cream hydrocortisone lotion HYDROGEN PEROXIDE SOLN. ibuprofen tab IV PREP WIPES KONSYL POWDER PACKET levocarnitine cap LICE TREATMENT KIT loperamide liquid loratadine tab magnesium citrate soln. magnesium tab MALE CONDOM meclizine tab miconazole cream MICONAZOLE NITRATE SOLN. MICONAZOLE VAGINAL KIT mineral oil enema mineral oil/petrolatum oint multivitamin w/ iron chew tab NASACORT NASAL SPRAY neomycin/polymyxin b/pramoxine cream niacin tab glycerin lotion guaifenesin ER tab guaifenesin/acetaminophen tab guaifenesin/dextromethorpha n ER tab guaifenesin/ephedrine hcl tab guaifenesin/pseudoephedrine hcl syrup hemorrhoidal oint HYDROCORTISONE ALOE OINT hydrocortisone oint ibuprofen cap INANT ORMULA LIQUID KETOSTIX LANAPHILIC UREA OINT LEVOCARNITINE TAB lidocaine anorectal cream loperamide tab loratadine/pseudoephedrine 12-hour tab magnesium hydroxide chew tab MAGNESIUM/ALUMINUM HYDROXIDE CHEW TAB MALE CONDOMS MEDI-TUSSIN CAP miconazole nitrate aerosol MICONAZOLE NITRATE SPRAY miconazole vaginal supp kit MINERAL OIL LIGHT moisturel lotion multivitamin w/ iron tab NASAL MOIST GEL NEOTUSS PLUS LIQUID NIACIN TR TAB GLYCERIN SHAMPOO guaifenesin liquid guaifenesin/codeine phosphate liquid guaifenesin/dextromethorpha n liquid GUAIENESIN/PHENYLEPH RINE HCL SYRUP guaifenesin/pseudoephedrine hcl tab hydrocortisone acetate cream hydrocortisone cream hydrocortisone topical soln. ibuprofen chew tab INANT ORMULA POWDER ketotifen ophth soln lansoprazole cap levonorgestrel tab LOHIST-D LIQUID loratadine ODT loratadine/pseudoephedrine 24-hour tab magnesium hydroxide susp. magnesium/aluminum hydroxide/simethicone chew tab MAOX TAB menthol lozenge miconazole nitrate aerosol powder miconazole oint. MILK O MAGNESIA CHEW TAB mineral oil/petrolatum cream multiple vitamin liquid multivitamin/minerals tab neomycin/bacitracin/polymyx in b oint niacin cap niacinamide tab glycerin suppository guaifenesin syrup GUAIENESIN/CODEINE SYRUP GUAIENESIN/DEXTROMET HORPHAN PACK guaifenesin/phenylephrine hcl tab GUAIENESIN/PSEUDOEP HEDRINE TAB HYDROCORTISONE ACETATE OINT hydrocortisone gel hydrogen peroxide soln ibuprofen susp ITCH RELIE EXT CREAM KONSYL POWDER L-CARNITINE CAP LICE B GONE SHAMPOO loperamide cap loratadine syrup lubricating jelly magnesium oxide tab magnesium/aluminum hydroxide/simethicone susp meclizine chew tab MICONAZOLE 3 SUPP 200MG miconazole nitrate powder miconazole vaginal cream mineral oil mineral oil/petrolatum lotion multiple vitamin tab naphazoline/pheniramine ophth drops neomycin/bacitracin/polymyx in b/pramoxine oint niacin CR tab nicotine gum Page 34 of 38

39 nicotine lozenge NUTRITIONAL SUPPLEMENT LIQUID oxymetazoline nasal spray PECTIN LOZENGE pediatric multivitamin w/ iron chew tab pediatric multivitamin w/ vitamin c w/ iron chew tab petrolatum oint phenylephrine nasal soln. phenylephrine/acetaminophe n tab phenylephrine/bromphenirami ne/dm soln. phenylephrine/chlorphenirami ne/dm liquid PHENYLEPHRINE/DEXTRO METHORPHAN STRIP phenylephrine/guaifenesin/d m syrup piperonyl butoxide/pyrethrins/permethri n kit povidone-iodine soln. preparation h supp pseudoephedrine syrup PSEUDOEPHEDRINE/ACET AMINOPHEN/DEXTROMETH ORPHAN TAB pseudoephedrine/bromphenir amine/dm elixir pseudoephedrine/chlorphenir amine/acetaminophen/dm susp PSEUDOEPHEDRINE/CHLO RPHENIRAMINE/DM CHEW TAB pseudoephedrine/dm syrup nicotine patch NUTRITIONAL SUPPLEMENT POWDER PAIN RELIE COUGH/COLD SYRUP pediatric electrolyte soln. pediatric multivitamin w/ iron drops permethrin liquid PETROLATUM/LANOLIN/ZIN C OXIDE/MINERAL OIL OINT. phenylephrine tab PHENYLEPHRINE/ACETAMI NOPHEN/CAEINE TAB phenylephrine/chlorphenirami ne/acetaminophen/dm liquid PHENYLEPHRINE/CHLORP HENIRAMINE/DM SOLN. phenylephrine/doxylamine/ac etaminophen/dm liquid PHENYLEPHRINE/PYRILAM INE/DM LIQUID polyethylene glycol 3350 powder PRENATAL VITAMIN PREVACID CAP pseudoephedrine tab pseudoephedrine/acetaminop hen/dm cap pseudoephedrine/bromphenir amine/dm syrup pseudoephedrine/chlorphenir amine/acetaminophen/dm tab pseudoephedrine/chlorphenir amine/dm liquid pseudoephedrine/doxylamine /acetaminophen/dm cap NINJACO-XG LIQUID omega-3 fatty acid cap PAIN RELIE PAK DAY AND NIGHT pediatric multivitamin adc drops pediatric multivitamin w/ minerals gummy permethrin lotion pheniramine/phenylephrine/a cetaminophen packet phenylephrine/acetaminophe n cap phenylephrine/acetaminophe n/guaifenesin tab phenylephrine/chlorphenirami ne/acetaminophen/dm susp. PHENYLEPHRINE/DEXTRO METHORPHAN LIQUID phenylephrine/guaifenesin/ac etaminophen/dm liquid piperonyl butoxide/pyrethrins liquid polyethylene glycol packet PREPARATION H CREAM pseudoephedrine ER (12hr) tab PSEUDOEPHEDRINE/ACET AMINOPHEN TAB pseudoephedrine/acetaminop hen/dm tab pseudoephedrine/chlorphenir amine/acetaminophen/dm cap PSEUDOEPHEDRINE/CHLO RPHENIRAMINE/CODEINE LIQUID PSEUDOEPHEDRINE/DM ELIXIR pseudoephedrine/doxylamine /acetaminophen/dm liquid NORTEMP SUSP INANTS omeprazole cap PAIN RELIEVE PM TAB PEDIATRIC MULTIVITAMIN CHEW TAB pediatric multivitamin w/ vitamin c soln. permethrin spray PHENYLEPHRINE DROPS phenylephrine/acetaminophe n powder pack phenylephrine/bromphenirami ne/dm elixir phenylephrine/chlorphenirami ne/acetaminophen/dm tab phenylephrine/dextromethorp han soln. phenylephrine/guaifenesin/ac etaminophen/dm tab piperonyl butoxide/pyrethrins shampoo POVIDONE-IODINE SOLN PREPARATION H OINT pseudoephedrine liquid PSEUDOEPHEDRINE/ACET AMINOPHEN/DEXTROMETH ORPHAN CAP PSEUDOEPHEDRINE/ACET AMINOPHEN/GUAIENESIN TAB pseudoephedrine/chlorphenir amine/acetaminophen/dm packet PSEUDOEPHEDRINE/CHLO RPHENIRAMINE/DEXTROM ETHORPHAN/ACETAMINOP HEN CAP PSEUDOEPHEDRINE/DM LIQUID Page 35 of 38

40 PSEUDOEPHEDRINE/DOXY PSEUDOEPHEDRINE/GUAI pseudoephedrine/guaifenesin pseudoephedrine/guaifenesin LAMINE/DEXTROMETHORP ENESIN/ACETAMINOPHE /acetaminophen/dm tab /dm cap HAN/ACETAMINOPHEN N/DM PACKET CAP pseudoephedrine/guaifenesin PSEUDOEPHEDRINE/GUAI PSEUDOEPHEDRINE/IBUP pseudoephedrine/ibuprofen /dm syrup ENESIN/DM TAB ROEN CAP susp. pseudoephedrine/ibuprofen pseudoephedrine/naproxen PSYLLIUM CAP psyllium powder tab tab pyridoxine CR tab pyridoxine tab ranitidine tab 75mg RECTICARE CREAM REENESEN PE TAB REENESEN TAB RERESH OPHTH DROPS RERESH PLUS DROPS RISCAL-D TAB ROBITUSSIN COUGH AND ROBITUSSIN SYRUP salicylic acid gel COLD LIQUID salicylic acid liquid salicylic acid pad salicylic acid soln salicylic acid strip saline nasal spray SCOT-TUSSIN LIQUID sennosides tab sennosides/docusate sodium tab SILPHEN COUGH SYRUP simethicone cap simethicone chew tab simethicone drops simethicone liquid SIMETHICONE STRIPS SKIN CLEANSER SM COUGH/SORE THROAT LIQUID sodium bicarbonate tab sodium chloride ophth oint. sodium chloride ophth soln. SODIUM CHLORIDE SPRAY sodium chloride tab sodium phosphate enema sodium phosphate soln. SUDAED ER (24HR) TAB SUDAED TRIPLE ACTION terbinafine cream tetrahydrozoline ophth soln. tetrahydrozoline/zinc sulfate TAB ophth drops thera-gesic cream thiamine mononitrate tab thiamine tab throat lozenge tioconazole vaginal oint. tolnaftate aerosol tolnaftate cream tolnaftate powder tolnaftate spray TRIACTING COLD SYRUP TRIAMINIC NASAL SPRAY TRIAMINIC STRIPS triprolidine/pseudoephedrine TRI-VI-SOL DROPS tussin C liquid TUSSIN COUGH/COLD tab LIQUID tussin PE liquid TYLENOL CAP vapor inhaler vaporizing steam vaporizing steam - menthol vcf vaginal gel VICKS DAYQUIL LIQUID vitamin a-d oint. MUCUS DM vitamin B complex cap VITAMIN B-12 TAB VITAMIN C SYRUP VITAMIN C TAB 500MG/5ML WAL-LU COLD PAK wound cleanser zinc oxide oint. ZINC OXIDE PASTE DAYTIME zinc sulfate cap Page 36 of 38

41 L.A. Care Medi-Cal Dual ormulary Last Updated* 1/1/2019 Step Therapy (ST) The following drugs are covered on the formulary with a Step Therapy. Step Therapy (ST) Medications Drug Name PREVACID CAP Step Therapy Requirements QL = 56 cap/30 day; Step Therapy requires trial of lansoprazole and pantoprazole Page 37 of 38

42 L.A. Care Medi-Cal Dual ormulary Last Updated* 1/1/2019 Quantity Limit (QL) The following drugs are covered on the formulary with a Quantity Limit. Drug Name BELVIQ TAB BELVIQ XR TAB benzoyl peroxide cream benzoyl peroxide gel BENZOYL PEROXIDE GEL 2.5% benzoyl peroxide liquid benzoyl peroxide lotion CALCIUM ACETATE TAB cetirizine chew tab cetirizine tab cetirizine/pseudoephedrine 12-hour tab CONTRAVE TAB cyanocobalamine SL tab GEL DRESSING lansoprazole cap loratadine ODT loratadine syrup loratadine tab loratadine/pseudoephedrine 12-hour tab loratadine/pseudoephedrine 24-hour tab NASACORT NASAL SPRAY nicotine gum nicotine lozenge nicotine patch phentermine cap phentermine tab PREVACID CAP pseudoephedrine ER (12hr) tab pseudoephedrine liquid pseudoephedrine syrup QSYMIA CAP SUDAED ER (24HR) TAB terbinafine cream Quantity Limit (QL) Medications Quantity Limit QL = 2 tab/day QL= 1 tab/day QL = 30 gm/30 day Coverage includes only; QL = 90 gm/30 day QL= 1 tube/30 days Coverage includes only; QL = 237 ml/30 day Coverage includes only; QL = 340.2ml/30 day QL = 9 tab/day QL = 1 tab/day QL = 1 tab/day QL = 1 tab/day QL= 4 tabs/day QL = 2 packet/day Coverage includes only. QL = 56 cap/30 day QL = 1 tab/day QL = 240ml/30 day; Covered for members age 2 through 5 years QL = 1 tab/day; Covered for members 2 years and older QL = 2 tab/day QL = 1 tab/day QL = 2 bottle/fill; Coverage includes only Limited to 180 days per plan year Limited to 180 days per plan year Coverage includes only. Limited to 182 days per plan year QL = 1 cap/day QL = 1 tab/day QL = 56 cap/30 day; Step Therapy requires trial of lansoprazole and pantoprazole QL = 2 tab/day; Covered for members 4 years and older QL = 1200ml/30 day; Covered for members 4 years and older QL = 1200ml/30 day; Covered for members 4 years and older QL = 1 cap/day QL= 1 tab/day; Covered for members 4 years and older QL = 30gm/30 day; Covered for members 12 years and older Page 38 of 38

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