L.A. Care Medi-Cal Dual Formulary

Transcription

1 L.A. Care MediCal Dual ormulary LA1308E 02/15_EN Last Updated: 4/1/2018

2 L.A. Care MediCal Dual ormulary INTRODUCTION oreword The L.A. Care MediCal 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 selfadministered 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 MediCal 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 MediCal 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. Nonormulary Medications Any drug not found in this formulary listing published by L.A. Care Health Plan shall be considered a nonformulary 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 nonformulary 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 MediCal Dual (Updated 4/1/2018) 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 nonformulary 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 MediCal Dual (Updated 4/1/2018) 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. Nonormulary Agents A. Any drug not found on this list is considered nonformulary. Coverage for nonformulary 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. Nonapproved 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 selfadministered 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 costeffective 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 MediCal Dual (Updated 4/1/2018) 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 MediCal Dual ormulary Alphabetical Index Last Updated 4/1/2018 Drug Name acetaminophen cap acetaminophen chew tab acetaminophen drops acetaminophen elixir acetaminophen ER tab acetaminophen liquid acetaminophen ODT acetaminophen supp ACETAMINOPHEN SYRUP acetaminophen tab ACETAMINOPHEN/BUERED ASPIRIN TAB (Only covered for members 4 years and older) ACETAMINOPHEN/DEXTROMETHORPHAN LIQUID acetaminophen/pamabrom/pyrilamine tab (Only covered for members 4 years and older) ACETAMINOPHEN/PHENYLTOLOXAMINE TAB (Only covered for members 4 years and older) ALCOHOL WIPES ALLERGY MULTISYMPTOM DAY/NIGHT PAK (Covered for members 419 years. Not covered if 3 and younger or 20 and older) ALLERGY/SINUS TAB HEADACHE ALUMINUM HYDROXIDE GEL SUSP. ammonium lactate cream (Coverage includes only) ammonium lactate lotion (Coverage includes only) analgesic balm antacid chew tab antinausea soln. (EMETROL equiv) ANTIVERT TAB (Coverage includes only) anumed supp ARMOUR THYROID TAB, NATURE THROID TAB artificial tears ophth oint. artificial tears ophth 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 ASSURE LANCET LOW LOW 25 GAUGE BOX 100 (Limited to LTC Pharmacies) Special Code Tier Category ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC DERMATOLOGICALS ANTACIDS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ANTACIDS ANTIEMETICS ANTIEMETICS ANORECTAL AGENTS THYROID AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS VITAMINS VITAMINS VITAMINS VITAMINS VITAMINS MULTIVITAMINS VITAMINS ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC ANALGESICS NONNARCOTIC MEDICAL DEVICES AND SUPPLIES OvertheCounter PA Prior Authorization QL Quantity Limit Page 1 of 38

6 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name ASSURE LANCET MICRO LOW 28 GAUGE BOX 100 (Limited to LTC Pharmacies) 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) atropine ophth oint atropine ophth soln (ISOPTO ATROPINE equiv) bacitracin oint. bacitracin/polymyxin b oint bacitracin/zinc oint. bcomplex/vitamin c/folic acid cap (NEPHROCAP equiv) bcomplex/vitamin c/folic acid tab (NEPHROVITE equiv) BELLADONNA ALKALOID/OPIUM SUPP BELVIQ TAB (QL = 2 tab/day) BELVIQ XR TAB (QL= 1 tab/day) BENADRYLD SOLN benzocaine/menthol lozenge benzonatate cap (TESSALON PERLES equiv) benzoyl peroxide cream (QL = 30 gm/30 day) benzoyl peroxide gel (BREVOXYL equiv) (Coverage includes only; QL = 90 gm/30 day) BENZOYL PEROXIDE GEL 2.5% (QL= 1 tube/30 days) benzoyl peroxide liquid (BENZAC AC equiv) (Coverage includes only; QL = 237 ml/30 day) benzoyl peroxide lotion (Coverage includes only; QL = 340.2ml/30 day) BISACODYL ENEMA bisacodyl supp. bisacodyl tab bismuth subsalicylate chew tab bismuth subsalicylate susp. bismuth subsalicylate tab brompheniramine/phenylephrine elixir brompheniramine/phenylephrine liquid BROMPHENIRAMINE/PHENYLEPHRINE TAB BROMPHENIRAMINE/PSEUDOEPHEDRINE LIQUID BROTAPP DM LIQUID CALAMINE LOTION CALCIUM ACETATE TAB (QL = 9 tab/day) calcium and phosphorus w/vitamin D tab 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 tab CALCIUM CARBONATE/VITAMIN D TAB Special Code Tier Category MEDICAL DEVICES AND SUPPLIES DIAGNOSTIC PRODUCTS DIAGNOSTIC PRODUCTS DIAGNOSTIC PRODUCTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS MULTIVITAMINS MULTIVITAMINS ULCER DRUGS PAQL ADHD/ANTINARCOLEPSY/ANTIOBESITY/A NOREXIANTS PAQL ADHD/ANTINARCOLEPSY/ANTIOBESITY/A NOREXIANTS MOUTH/THROAT/DENTAL AGENTS QL DERMATOLOGICALS QL DERMATOLOGICALS QL DERMATOLOGICALS QL DERMATOLOGICALS QL DERMATOLOGICALS LAXATIVES LAXATIVES LAXATIVES ANTIDIARRHEALS ANTIDIARRHEALS ANTIDIARRHEALS DERMATOLOGICALS QL MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES ANTACIDS ANTACIDS MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES OvertheCounter PA Prior Authorization QL Quantity Limit Page 2 of 38

7 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name calcium citrate tab calcium citrate w/ vitamin d tab CALCIUM GLUCONATE TAB CALCIUM LACTATE TAB calcium polycarbophil tab capsaicin cream capsaicin pad carbamide peroxide otic drop CATHLO ACTIVASE INJ 2MG CENHIST CHEW TAB cetirizine chew tab (ZYRTEC equiv) (QL = 1 tab/day) cetirizine syrup (ZYRTEC equiv) (Coverage includes only) cetirizine tab (ZYRTEC equiv) (QL = 1 tab/day) cetirizine/pseudoephedrine 12hour tab (ZYRTEC equiv) (QL = 1 tab/day) CHILDRENS PLUS COLD chlorhexidine gluconate liquid chlorpheniramine CR tab chlorpheniramine syrup chlorpheniramine tab 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 cholecalciferol cap cholecalciferol oral soln. cholecalciferol tab CHROMAGEN TAB clemastine tab (TAVIST equiv) (Coverage includes only) clotrimazole cream (Coverage includes only) clotrimazole vaginal cream CLOVERINE OINT COLD RELIE COMPLETE TAB COLD RELIE TAB PLUS COLD/LU CONGESTION PAK COLD/LU RELIE NIGHT D LIQUID CONCEPTROL GEL CONTRACEPTIVE ILM CONTRACEPTIVE OAM CONTRACEPTIVE GEL CONTRACEPTIVE SUPP CONTRAVE TAB (QL= 4 tabs/day) Special Code Tier Category QL QL QL PAQL MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES LAXATIVES DERMATOLOGICALS DERMATOLOGICALS OTIC AGENTS HEMATOLOGICAL AGENTS MISC. ANTIHISTAMINES ANTIHISTAMINES ANTIHISTAMINES ANTISEPTICS & DISINECTANTS ANTIHISTAMINES ANTIHISTAMINES ANTIHISTAMINES VITAMINS VITAMINS VITAMINS HEMATOPOIETIC AGENTS ANTIHISTAMINES DERMATOLOGICALS VAGINAL PRODUCTS DERMATOLOGICALS VAGINAL PRODUCTS VAGINAL PRODUCTS VAGINAL PRODUCTS VAGINAL PRODUCTS VAGINAL PRODUCTS ADHD/ANTINARCOLEPSY/ANTIOBESITY/A NOREXIANTS OvertheCounter PA Prior Authorization QL Quantity Limit Page 3 of 38

8 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name cromolyn nasal soln. (NASALCROM equiv) cyanocobalamine ER tab cyanocobalamine inj. cyanocobalamine lozenge cyanocobalamine SL tab cyanocobalamine tab CYCLOMYDRIL OPHTH SOLN cyclopentolate ophth soln (CYCLOGYL equiv) DESITIN PASTE DEXBROMPHENIRAMINE/PHENYLEPHRINE/ACETAMINOPHEN TAB dexbrompheniramine/pseudoephedrine ER tab DEXBROMPHENIRAMINE/PSEUDOEPHEDRINE TAB dextromethorphan cap dextromethorphan liquid DEXTROMETHORPHAN LOZENGE dextromethorphan syrup DEXTROMETHORPHAN/ACETAMINOPHEN/CHLORPHENIRAMINE LIQUID dextromethorphan/acetaminophen/chlorpheniramine susp dextromethorphan/acetaminophen/chlorpheniramine tab DEXTROMETHORPHAN/ACETAMINOPHEN/DIPHENHYDRAMINE LIQUID DEXTROMETHORPHAN/BENZOCAINE LOZENGE dextromethorphan/doxylamine soln. dextromethorphan/doxylamine/acetaminophen cap dextromethorphan/doxylamine/acetaminophen liquid dextromethorphan/phenylephrine/acetaminophen cap dextromethorphan/phenylephrine/acetaminophen liquid dextromethorphan/phenylephrine/acetaminophen tab DIALYVITE TAB DIALYVITE/IRON TAB DIALYVITE/ZINC TAB DIETHYLTOLUAMIDE LOTION dimenhydrinate tab dimethicone gel (Coverage includes only) diphenhydramine (sleep) cap diphenhydramine (sleep) tab diphenhydramine cap (BENADRYL equiv) (Coverage includes only) diphenhydramine chew tab diphenhydramine cream diphenhydramine gel diphenhydramine liquid diphenhydramine rapid tab diphenhydramine spray DIPHENHYDRAMINE STRIP diphenhydramine tab diphenhydramine/acetaminophen (sleep) pack diphenhydramine/acetaminophen (sleep) tab Special Code Tier Category QL NASAL AGENTS SYSTEMIC AND TOPICAL HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS OPHTHALMIC AGENTS OPHTHALMIC AGENTS DERMATOLOGICALS MOUTH/THROAT/DENTAL AGENTS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS DERMATOLOGICALS ANTIEMETICS DERMATOLOGICALS HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS ANTIHISTAMINES ANTIHISTAMINES DERMATOLOGICALS DERMATOLOGICALS ANTIHISTAMINES ANTIHISTAMINES DERMATOLOGICALS ANTIHISTAMINES ANTIHISTAMINES HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS OvertheCounter PA Prior Authorization QL Quantity Limit Page 4 of 38

9 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name DIPHENHYDRAMINE/ACETAMINOPHEN LIQUID 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 diphenhydramine/zinc cream diphenhydramine/zinc spray DOCUSAL/ENEMEEZ MINI ENEMA docusate calcium cap docusate sodium cap docusate sodium enema docusate sodium liquid docusate sodium syrup docusate sodium tab doxylamine succinate tab doxylamine/phenylephrine/acetaminophen cap DULCOLAX BOWEL PREP KIT EPHEDRINE SULATE CAP ergocalciferol soln. ERGOCALCIEROL TAB eye wash soln. famotidine tab EMALE CONDOM ferocon cap ferrex 150 forte cap 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 IBER LIQUID LEET ENEMA LORIVA PLUS DROPS folbee tab OLIC ACID INJ folic acid tab UNGOID SOLN GALZIN CAP GEL DRESSING (QL = 2 packet/day) Special Code Tier Category HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS DERMATOLOGICALS DERMATOLOGICALS LAXATIVES LAXATIVES LAXATIVES LAXATIVES LAXATIVES LAXATIVES LAXATIVES HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS LAXATIVES ANTIASTHMATIC AND BRONCHODILATOR AGENTS VITAMINS VITAMINS OPHTHALMIC AGENTS ULCER DRUGS MEDICAL DEVICES AND SUPPLIES HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS LAXATIVES LAXATIVES MULTIVITAMINS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS DERMATOLOGICALS MINERALS & ELECTROLYTES QL DERMATOLOGICALS OvertheCounter PA Prior Authorization QL Quantity Limit Page 5 of 38

10 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name GLUCOSE CHEW TAB glucose gel glycerin gel glycerin liquid glycerin lotion (Coverage includes only) GLYCERIN SHAMPOO glycerin suppository guaifenesin DM/pseudoephedrine tab (Covered for members 4 years and older) guaifenesin ER tab (MUCINEX equiv) guaifenesin liquid guaifenesin syrup guaifenesin tab guaifenesin/acetaminophen tab guaifenesin/codeine phosphate liquid guaifenesin/codeine phosphate liquid (TUSSIORGANIDINS equiv) 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 hemorrhoidal oint HEPARIN LOCK LUSH IV SOLN heparin sodium (porcine) lock flush IV soln homatropine ophth soln (ISOPTO HOMATROPINE equiv) hydrocodone/homatropine soln. hydrocodone/homatropine syrup hydrocortisone acetate cream HYDROCORTISONE ACETATE OINT hydrocortisone aloe cream HYDROCORTISONE ALOE OINT hydrocortisone cream (Coverage includes only) hydrocortisone E/pramoxine cream (ANALPRAM E equiv) hydrocortisone gel hydrocortisone lotion (Coverage includes only) hydrocortisone oint (Coverage includes only) hydrocortisone topical soln. (Coverage includes only) hydrocortisone/pramoxine rectal cream (ANALPRAM HC equiv) hydrogen peroxide soln HYDROGEN PEROXIDE SOLN. hyoscyamine IR/SR tab (SYMAX equiv) hyoscyamine sulfate CR tab (LEVBID equiv) Special Code Tier Category ANTIDIABETICS ANTIDIABETICS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS LAXATIVES ANORECTAL AGENTS ANTICOAGULANTS ANTICOAGULANTS OPHTHALMIC AGENTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ANORECTAL AGENTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS ANORECTAL AGENTS ANTISEPTICS & DISINECTANTS ANTISEPTICS & DISINECTANTS ULCER DRUGS ULCER DRUGS OvertheCounter PA Prior Authorization QL Quantity Limit Page 6 of 38

11 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name 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) ibuprofen cap ibuprofen chew tab ibuprofen susp (ADVIL, MOTRIN equiv) (Coverage includes only) ibuprofen tab (Coverage includes only) INANT ORMULA LIQUID INANT ORMULA POWDER INJECTAER INJ IRON POLYSACCHARIDE/THREONIC ACID/B12/A CAP ISOPTO HYOSCINE OPHTH SOLN IV PREP WIPES KETOSTIX ketotifen ophth soln (ZADITOR equiv) KONSYL POWDER KONSYL POWDER PACKET KPHOS TAB LANAPHILIC UREA OINT lansoprazole cap (PREVACID equiv) (Coverage includes only. QL = 56 cap/30 day) LCARNITINE CAP levocarnitine cap LEVOCARNITINE TAB levonorgestrel tab (PLAN B equiv) (Coverage includes only) LICE B GONE SHAMPOO LICE TREATMENT KIT lidocaine anorectal cream lidocaine gel (XYLOCAINE equiv) lidocaine soln (XYLOCAINE equiv) lidocaine/hydrocortisone cream (ANAMANTLE equiv) LOHISTD LIQUID loperamide cap (IMODIUM equiv) (Coverage includes only) loperamide liquid loperamide tab loratadine ODT (CLARITIN equiv) (QL = 1 tab/day) loratadine syrup (CLARITIN equiv) (QL = 240ml/30 day; Covered for members age 2 through 5 years) loratadine tab (CLARITIN equiv) (QL = 1 tab/day; Covered for members 2 years and older) loratadine/pseudoephedrine 12hour tab (CLARITIND equiv) (QL = 2 tab/day) loratadine/pseudoephedrine 24hour tab (CLARITIND equiv) (QL = 1 tab/day) lubricating jelly magnesium citrate soln. magnesium hydroxide chew tab Special Code Tier Category ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS ULCER DRUGS ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY ANALGESICS ANTIINLAMMATORY PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS PA DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS OPHTHALMIC AGENTS ANTISEPTICS & DISINECTANTS DIAGNOSTIC PRODUCTS OPHTHALMIC AGENTS LAXATIVES LAXATIVES MINERALS & ELECTROLYTES DERMATOLOGICALS QL ULCER DRUGS NUTRIENTS NUTRIENTS NUTRIENTS CONTRACEPTIVES DERMATOLOGICALS DERMATOLOGICALS ANORECTAL AGENTS DERMATOLOGICALS DERMATOLOGICALS ANORECTAL AGENTS ANTIDIARRHEALS ANTIDIARRHEALS ANTIDIARRHEALS QL ANTIHISTAMINES QL ANTIHISTAMINES QL ANTIHISTAMINES QL QL DERMATOLOGICALS LAXATIVES LAXATIVES OvertheCounter PA Prior Authorization QL Quantity Limit Page 7 of 38

12 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name magnesium hydroxide susp. magnesium oxide tab magnesium tab MAGNESIUM/ALUMINUM HYDROXIDE CHEW TAB magnesium/aluminum hydroxide/simethicone chew tab MAGNESIUM/ALUMINUM HYDROXIDE/SIMETHICONE SUSP MALE CONDOM MALE CONDOMS meclizine chew tab (BONINE equiv) meclizine tab (ANTIVERT equiv) (Coverage includes only) MEDITUSSIN CAP menthol lozenge (Covered for members 19 years and younger; Not covered for 20 years and older) MEPHYTON TAB MICONAZOLE 3 SUPP 200MG (Coverage includes only) miconazole cream miconazole nitrate aerosol miconazole nitrate aerosol powder miconazole nitrate powder MICONAZOLE NITRATE SOLN. MICONAZOLE NITRATE SPRAY miconazole oint. miconazole vaginal cream MICONAZOLE VAGINAL KIT miconazole vaginal supp kit MILK O MAGNESIA CHEW TAB mineral oil MINERAL OIL (Coverage includes only) mineral oil enema MINERAL OIL LIGHT mineral oil/petrolatum cream mineral oil/petrolatum cream (Coverage includes only) mineral oil/petrolatum lotion mineral oil/petrolatum oint moisturel lotion (Coverage includes only) multigen plus tab multigen tab (CHROMAGEN equiv) multigen/folic acid tab (CHROMAGEN A equiv) multiple vitamin liquid multiple vitamin tab multivitamin w/ iron chew tab multivitamin w/ iron tab multivitamin/minerals tab (STROVITE equiv) NAPHAZOLINE OPHTH SOLN. naphazoline/pheniramine ophth drops NASACORT NASAL SPRAY (QL = 2 bottle/fill; Coverage includes only) NASAL MOIST GEL neomycin/bacitracin/polymyxin b oint neomycin/bacitracin/polymyxin b/pramoxine oint Special Code Tier Category LAXATIVES ANTACIDS MINERALS & ELECTROLYTES ANTACIDS ANTACIDS ANTACIDS MEDICAL DEVICES AND SUPPLIES MEDICAL DEVICES AND SUPPLIES ANTIEMETICS ANTIEMETICS MOUTH/THROAT/DENTAL AGENTS VITAMINS VAGINAL PRODUCTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS VAGINAL PRODUCTS VAGINAL PRODUCTS VAGINAL PRODUCTS LAXATIVES DERMATOLOGICALS LAXATIVES LAXATIVES DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS HEMATOPOIETIC AGENTS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS OPHTHALMIC AGENTS OPHTHALMIC AGENTS QL NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL DERMATOLOGICALS DERMATOLOGICALS OvertheCounter PA Prior Authorization QL Quantity Limit Page 8 of 38

13 Drug Name neomycin/polymyxin b/pramoxine cream NEOTUSS PLUS LIQUID NEPHRON A TAB niacin cap niacin CR tab (SLONIACIN equiv) niacin tab NIACIN TR TAB niacinamide tab nicotine gum (NICORETTE equiv) (Limited to 180 days per plan year) nicotine lozenge (COMMIT equiv) (Limited to 180 days per plan year) L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Special Code Tier Category QL QL nicotine patch (NICODERM equiv) (Coverage includes only. Limited to 182 QL days per plan year) NINJACOXG LIQUID NORTEMP SUSP INANTS np thyroid tab (ARMOUR THYROID, NATURE THROID equiv) NUTRITIONAL SUPPLEMENT LIQUID PA NUTRITIONAL SUPPLEMENT POWDER omega3 fatty acid cap omeprazole cap (Coverage includes only) oxymetazoline nasal spray (ARIN NASAL equiv) PAIN RELIE COUGH/COLD SYRUP PAIN RELIE PAK DAY AND NIGHT PAIN RELIEVE PM TAB pectin lozenge (Covered for members 19 years and younger; Not covered for 20 years and older) pediatric electrolyte soln. pediatric multiple vitamin ACD/fluoride soln. pediatric multiple vitamin ACD/fluoride/iron drops pediatric multiple vitamin/fluoride chew tab pediatric multiple vitamin/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 permethrin liquid permethrin lotion permethrin spray petrolatum oint PETROLATUM/LANOLIN/ZINC OXIDE/MINERAL OIL OINT. phenazopyridine tab (PYRIDIUM equiv) PA DERMATOLOGICALS HEMATOPOIETIC AGENTS VITAMINS VITAMINS VITAMINS VITAMINS VITAMINS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC. ANALGESICS NONNARCOTIC THYROID AGENTS DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS DIETARY PRODUCTS/DIETARY MANAGEMENT PRODUCTS NUTRIENTS ULCER DRUGS NASAL AGENTS SYSTEMIC AND TOPICAL HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS MOUTH/THROAT/DENTAL AGENTS MINERALS & ELECTROLYTES MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS MULTIVITAMINS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS GENITOURINARY AGENTS MISCELLANEOUS OvertheCounter PA Prior Authorization QL Quantity Limit Page 9 of 38

14 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name pheniramine/phenylephrine/acetaminophen packet (Covered for members 19 years and younger; Not covered for 20 years and older) phentermine cap (ADIPEX equiv) (QL = 1 cap/day) phentermine tab (ADIPEX equiv) (QL = 1 tab/day) PHENYLEPHRINE DROPS phenylephrine nasal soln. phenylephrine ophth soln (MYDRIN equiv) phenylephrine tab phenylephrine/acetaminophen cap phenylephrine/acetaminophen powder pack 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 phospha 250 neutral tab (KPHOS NEUTRAL equiv) piperonyl butoxide/pyrethrins liquid PIPERONYL BUTOXIDE/PYRETHRINS SHAMPOO piperonyl butoxide/pyrethrins/permethrin kit polyethylene glycol 3350 powder (Coverage includes only) POLYETHYLENE GLYCOL 8000 GRANULES polyethylene glycol packet (MIRALAX equiv) (Coverage includes only) POVIDONEIODINE SOLN povidoneiodine soln. PRAMOSONE CREAM PRENATAL VITAMIN (Coverage includes only) PREPARATION H CREAM PREPARATION H OINT preparation h supp PREVACID CAP (QL = 56 cap/30 day; Step Therapy requires trial of lansoprazole and pantoprazole) PROCTOOAM HC OAM promethazine DM syrup promethazine/codeine syrup (PHENERGAN/CODIENE equiv) Special Code Tier Category PAQL ADHD/ANTINARCOLEPSY/ANTIOBESITY/A NOREXIANTS PAQL ADHD/ANTINARCOLEPSY/ANTIOBESITY/A NOREXIANTS NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL OPHTHALMIC AGENTS NASAL AGENTS SYSTEMIC AND TOPICAL MINERALS & ELECTROLYTES DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS LAXATIVES PHARMACEUTICAL ADJUVANTS LAXATIVES ANTISEPTICS & DISINECTANTS ANTISEPTICS & DISINECTANTS DERMATOLOGICALS MULTIVITAMINS ANORECTAL AGENTS ANORECTAL AGENTS ANORECTAL AGENTS QLST ULCER DRUGS ANORECTAL AGENTS OvertheCounter PA Prior Authorization QL Quantity Limit Page 10 of 38

15 Drug Name L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 pseudoephedrine ER (12hr) tab (QL = 2 tab/day; Covered for members 4 QL years and older) pseudoephedrine liquid (SUDAED equiv) (QL = 1200ml/30 day; Covered for QL members 4 years and older) pseudoephedrine syrup (SUDAED equiv) (QL = 1200ml/30 day; Covered for QL members 4 years and older) pseudoephedrine tab pseudoephedrine/acetaminophen tab PSEUDOEPHEDRINE/ACETAMINOPHEN/DEXTROMETHORPHAN CAP (Onl covered for members age 4 years or older) PSEUDOEPHEDRINE/ACETAMINOPHEN/DEXTROMETHORPHAN TAB (Onl 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/ACET PHEN 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/ACETAMINOP CAP (Only covered for members age 4 years or older) PSEUDOEPHEDRINE/GUAIENESIN/ACETAMINOPHEN/DM PACKET pseudoephedrine/guaifenesin/acetaminophen/dm tab pseudoephedrine/guaifenesin/dm cap pseudoephedrine/guaifenesin/dm syrup PSEUDOEPHEDRINE/IBUPROEN CAP pseudoephedrine/ibuprofen susp. pseudoephedrine/ibuprofen tab pseudoephedrine/naproxen tab PSYLLIUM CAP psyllium powder pyridoxine CR tab pyridoxine tab QSYMIA CAP (QL = 1 cap/day) PAQL ranitidine tab 75mg RECTICARE CREAM Special Code Tier Category NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL NASAL AGENTS SYSTEMIC AND TOPICAL LAXATIVES LAXATIVES VITAMINS VITAMINS ADHD/ANTINARCOLEPSY/ANTIOBESITY/A NOREXIANTS ULCER DRUGS ANORECTAL AGENTS OvertheCounter PA Prior Authorization QL Quantity Limit Page 11 of 38

16 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name REENESEN PE TAB REENESEN TAB RERESH DROPS RERESH PLUS DROPS RISCALD TAB ROBITUSSIN COUGH AND COLD LIQUID ROBITUSSIN SYRUP salicylic acid gel salicylic acid liquid salicylic acid pad salicylic acid shampoo salicylic acid soln salicylic acid strip saline nasal spray SCOTTUSSIN LIQUID selenium sulfide lotion 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 flush IV soln sodium chloride inj 0.9% sodium chloride ophth oint. sodium chloride ophth soln. SODIUM CHLORIDE SPRAY sodium chloride tab 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) sodium phosphate enema sodium phosphate soln. SUDAED ER (24HR) TAB (QL= 1 tab/day; Covered for members 4 years and older) SUDAED TRIPLE ACTION TAB terbinafine cream (LAMISIL AT equiv) (QL = 30gm/30 day; Covered for members 12 years and older) tetrahydrozoline ophth soln. tetrahydrozoline/zinc sulfate ophth drops theragesic cream thiamine mononitrate tab thiamine tab Special Code Tier Category OPHTHALMIC AGENTS OPHTHALMIC AGENTS MINERALS & ELECTROLYTES DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS NASAL AGENTS SYSTEMIC AND TOPICAL DERMATOLOGICALS LAXATIVES LAXATIVES ANTIHISTAMINES GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. GASTROINTESTINAL AGENTS MISC. DERMATOLOGICALS ANTACIDS MINERALS & ELECTROLYTES MINERALS & ELECTROLYTES OPHTHALMIC AGENTS OPHTHALMIC AGENTS DERMATOLOGICALS MINERALS & ELECTROLYTES MOUTH/THROAT/DENTAL AGENTS MOUTH/THROAT/DENTAL AGENTS MOUTH/THROAT/DENTAL AGENTS MOUTH/THROAT/DENTAL AGENTS MOUTH/THROAT/DENTAL AGENTS LAXATIVES LAXATIVES QL NASAL AGENTS SYSTEMIC AND TOPICAL QL DERMATOLOGICALS OPHTHALMIC AGENTS OPHTHALMIC AGENTS DERMATOLOGICALS VITAMINS VITAMINS OvertheCounter PA Prior Authorization QL Quantity Limit Page 12 of 38

17 L.A. Care MediCal Dual ormulary Cont. Alphabetical Index Last Updated 4/1/2018 Drug Name throat lozenge tioconazole vaginal oint. tolnaftate aerosol tolnaftate cream tolnaftate powder tolnaftate spray TRIACTING COLD SYRUP TRIAMINIC NASAL SPRAY TRIAMINIC STRIPS triprolidine/pseudoephedrine tab TRIVISOL DROPS tropicamide ophth soln (MYDRIACYL equiv) tussin C liquid TUSSIN COUGH/COLD LIQUID tussin PE liquid (NARIZ equiv) TYLENOL CAP URAMAXIN CREAM urea lotion vapor inhaler vaporizing steam vaporizing steam menthol vcf vaginal gel (CONCEPTROL equiv) VENELEX OINT VENOER INJ VICKS DAYQUIL LIQUID MUCUS DM vitamin ad oint. vitamin B complex cap VITAMIN C SYRUP 500MG/5ML VITAMIN C TAB vitamin D cap WALLU COLD PAK DAYTIME wound cleanser zinc oxide oint. zinc oxide paste zinc sulfate cap Special Code Tier Category MOUTH/THROAT/DENTAL AGENTS VAGINAL PRODUCTS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS NASAL AGENTS SYSTEMIC AND TOPICAL MULTIVITAMINS OPHTHALMIC AGENTS ANALGESICS NONNARCOTIC DERMATOLOGICALS DERMATOLOGICALS VAGINAL PRODUCTS DERMATOLOGICALS HEMATOPOIETIC AGENTS DERMATOLOGICALS MULTIVITAMINS VITAMINS VITAMINS VITAMINS DERMATOLOGICALS DERMATOLOGICALS DERMATOLOGICALS MINERALS & ELECTROLYTES OvertheCounter PA Prior Authorization QL Quantity Limit Page 13 of 38

18 L.A. Care MediCal Dual ormulary Category/Class Last Updated* 4/1/2018 DrugName Special Code Tier ADHD/ANTINARCOLEPSY/ANTIOBESITY/ANOREXIANTS ANOREXIANTS NONAMPHETAMINE phentermine cap (ADIPEX equiv) (QL = 1 cap/day) PAQL phentermine tab (ADIPEX equiv) (QL = 1 tab/day) PAQL QSYMIA CAP (QL = 1 cap/day) PAQL ANTIOBESITY AGENTS BELVIQ TAB (QL = 2 tab/day) PAQL BELVIQ XR TAB (QL= 1 tab/day) PAQL CONTRAVE TAB (QL= 4 tabs/day) PAQL ANALGESICS ANTIINLAMMATORY NONSTEROIDAL ANTIINLAMMATORY 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. OvertheCounter PA Prior Authorization QL Quantity Limit Page 14 of 38

19 L.A. Care MediCal Dual ormulary Category/Class Last Updated* 4/1/2018 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 ANTIASTHMATIC AND BRONCHODILATOR AGENTS SYMPATHOMIMETICS EPHEDRINE SULATE CAP ANTICOAGULANTS HEPARINS AND HEPARINOIDLIKE 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 ANTIEMETICS Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. OvertheCounter PA Prior Authorization QL Quantity Limit Page 15 of 38

20 L.A. Care MediCal Dual ormulary Category/Class Last Updated* 4/1/2018 DrugName Special Code Tier ANTIEMETICS ANTICHOLINERGIC ANTIEMETICS Cont. ANTIVERT TAB (Coverage includes only) dimenhydrinate tab meclizine chew tab (BONINE equiv) meclizine tab (ANTIVERT equiv) (Coverage includes only) ANTIEMETICS MISCELLANEOUS antinausea 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 NONSEDATING 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 POVIDONEIODINE SOLN povidoneiodine soln. CHEMICALS LIQUIDS GLYCERIN LIQUID CONTRACEPTIVES EMERGENCY CONTRACEPTIVES Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. OvertheCounter PA Prior Authorization QL Quantity Limit Page 16 of 38

21 L.A. Care MediCal Dual ormulary Category/Class Last Updated* 4/1/2018 DrugName Special Code Tier CONTRACEPTIVES Cont. levonorgestrel tab (PLAN B equiv) (Coverage includes only) ANTITUSSIVES benzonatate cap (TESSALON PERLES equiv) dextromethorphan cap dextromethorphan liquid DEXTROMETHORPHAN LOZENGE dextromethorphan syrup hydrocodone/homatropine soln. hydrocodone/homatropine syrup ROBITUSSIN SYRUP TRIAMINIC STRIPS COMBINATIONS ACETAMINOPHEN/DEXTROMETHORPHAN LIQUID ALLERGY MULTISYMPTOM DAY/NIGHT PAK (Covered for members 419 years. Not covered if 3 and younger or 20 and older) ALLERGY/SINUS TAB HEADACHE BENADRYLD SOLN brompheniramine/phenylephrine elixir brompheniramine/phenylephrine liquid BROMPHENIRAMINE/PHENYLEPHRINE TAB BROMPHENIRAMINE/PSEUDOEPHEDRINE LIQUID BROTAPP DM LIQUID CENHIST CHEW TAB cetirizine/pseudoephedrine 12hour 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 Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. OvertheCounter PA Prior Authorization QL Quantity Limit Page 17 of 38

22 L.A. Care MediCal Dual ormulary Category/Class Last Updated* 4/1/2018 DrugName Special Code Tier Cont. dextromethorphan/acetaminophen/chlorpheniramine susp 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 (TUSSIORGANIDINS equiv) 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 LOHISTD LIQUID loratadine/pseudoephedrine 12hour tab (CLARITIND equiv) (QL = 2 tab/day) QL loratadine/pseudoephedrine 24hour tab (CLARITIND equiv) (QL = 1 tab/day) QL MEDITUSSIN CAP NEOTUSS PLUS LIQUID NINJACOXG LIQUID PAIN RELIE COUGH/COLD SYRUP PAIN RELIEVE PM TAB pheniramine/phenylephrine/acetaminophen packet (Covered for members 19 years and younger; Not covered for 20 years and older) phenylephrine/acetaminophen cap Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. OvertheCounter PA Prior Authorization QL Quantity Limit Page 18 of 38

23 L.A. Care MediCal Dual ormulary Category/Class Last Updated* 4/1/2018 DrugName Special Code Tier Cont. phenylephrine/acetaminophen powder pack 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/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 membe 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. OvertheCounter PA Prior Authorization QL Quantity Limit Page 19 of 38

24 L.A. Care MediCal Dual ormulary Category/Class Last Updated* 4/1/2018 DrugName Special Code Tier Cont. pseudoephedrine/guaifenesin/dm cap pseudoephedrine/guaifenesin/dm syrup PSEUDOEPHEDRINE/IBUPROEN CAP pseudoephedrine/ibuprofen susp. pseudoephedrine/ibuprofen tab pseudoephedrine/naproxen tab REENESEN PE TAB REENESEN TAB ROBITUSSIN COUGH AND COLD LIQUID SCOTTUSSIN 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 WALLU COLD PAK DAYTIME EXPECTORANTS guaifenesin ER tab (MUCINEX equiv) guaifenesin liquid guaifenesin syrup guaifenesin tab 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) CLOVERINE OINT UNGOID SOLN Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. OvertheCounter PA Prior Authorization QL Quantity Limit Page 20 of 38

25 L.A. Care MediCal Dual ormulary Category/Class Last Updated* 4/1/2018 DrugName Special Code Tier DERMATOLOGICALS Cont. 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 ANTIHISTAMINESTOPICAL diphenhydramine cream diphenhydramine gel diphenhydramine spray diphenhydramine/zinc cream diphenhydramine/zinc spray ANTISEBORRHEIC PRODUCTS 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 ad oint. EMOLLIENT/KERATOLYTIC AGENTS LANAPHILIC UREA OINT URAMAXIN CREAM urea lotion EMOLLIENTS ammonium lactate cream (Coverage includes only) ammonium lactate lotion (Coverage includes only) glycerin liquid glycerin lotion (Coverage includes only) Note: Unless otherwise specifically noted, all strengths and forms of products listed in the formulary are covered. OvertheCounter PA Prior Authorization QL Quantity Limit Page 21 of 38