Professional Documents
Culture Documents
Comprehensive Formulary
Comprehensive Formulary
Comprehensive Formulary
2014 Comprehensive
Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
This formulary was updated on 12/01/2013. For more recent information or other questions,
please contact the number for your Kaiser Permanente Region listed below, seven days a
week, 8 a.m. to 8 p.m. or visit kp.org/seniormedrx.
HAWAII REGION
Kaiser Permanente Senior Advantage (HMO)
Customer Service Center
1-800-805-2739 TTY 711
MID-ATLANTIC STATES REGION
(District of Columbia, Maryland,
and Virginia)
Kaiser Permanente Medicare Plus (Cost)
Member Service Contact Center
1-888-777-5536 TTY 711
NORTHWEST REGION
Kaiser Permanente Senior Advantage (HMO)
Membership Services
1-877-221-8221 TTY 711
Y0043_N010537_Final01 approved
HPMS Approved Formulary File Submission 00014088, Version 08
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to we, us, or our, it means Kaiser Permanente.
When it refers to plan or our plan, it means Kaiser Permanente Senior Advantage or Medicare
Plus, depending upon the region in which you are enrolled.
This document includes a list of the drugs (formulary) for our plan, which is current as of January 1,
2014. For an updated formulary, please visit our Web site at kp.org/seniormedrx or contact us.
Contact information for your Kaiser Permanente Region, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or copayments/coinsurance may change on January
1, 2014, and for group members, at other times in accord with your groups contract with us.
Kaiser Permanente is an HMO plan with a Medicare contract. Kaiser Permanente is a Cost plan
with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.
This information is available for free in other languages. Please call our customer service number
listed on the front and back covers.
Se puede obtener esta informacin gratis en otros idiomas. Srvase llamar al nmero de nuestro
servicio al cliente que aparece en la portada y contraportada.
This document is available in a different format for the visually impaired by calling our plan at the
number listed on the front and back covers for your Kaiser Permanente Region.
Alphabetical listing
Note: If your coverage is through an employersponsored group plan (including a union or trust
fund), you may have different drug benefits and cost
sharing, and you may have coverage for other
drugs that are not covered by Medicare Part D (nonPart D drugs). The amount you pay for non-Part D
drugs does not count toward your total out-of-pocket
expenditures, and if you are receiving Extra Help to
pay for your Medicare Part D prescription drugs,
you will not receive any Extra Help to pay for non-
Drug Name
Drug
Tier
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ALBENZA
3
BILTRICIDE
3
SKLICE
4
STROMECTOL
4
ANTIBACTERIALS
amikacin sulfate
2
amoxicillin
2
amoxicillin & pot
2
clavulanate
ampicillin
2
ampicillin & sulbactam
2
sodium
ampicillinsodium
2
AUGMENTIN
3
AVELOX
3
AVELOX
4
AVELOX ABC PACK
3
AZACTAM
3
AZACTAMIN ISO3
OSMOTIC DEXTROSE
azithromycin
2
aztreonam
2
AZULFIDINE
4
AZULFIDINE EN-TABS
4
bacitracin
2
BACTOCILL IN
3
DEXTROSE
BACTRIM
4
BACTRIM DS
4
BETHKIS NEB 300/4ML
5
BIAXIN
4
BIAXIN XL
4
BIAXIN XL PAC
4
BICILLIN C-R
4
BICILLIN L-A
3
CAYSTON
5
CEDAX
4
cefaclor
2
cefaclormonohydrate
2
cefadroxil
2
cefazolin in d5w
2
cefazolin sodium
2
Requirements
/Limits
MO
MO
MO
HI
MO
MO
MO
HI
HI
HI,MO
HI,MO
MO
HI
HI
HI,MO
HI
MO
MO
HI
MO
MO
MO
MO
MO
LD
MO
MO
MO
MO
HI
HI
Drug Name
CEFAZOLIN
SODIUM/DEXTROSE
cefdinir
cefepime hcl
cefixime
cefotaxime sodium
cefotetan disodium
cefoxitin sodium
CEFOXITIN SODIUM
cefpodoxime proxetil
cefprozil
ceftazidime
CEFTAZIDIME/
DEXTROSE
CEFTIN SUS 125/5ML
CEFTIN SUS 250/5ML
CEFTIN TAB 250MG
CEFTIN TAB 500MG
ceftriaxone sodium
CEFTRIAXONE/
DEXTROSE
cefuroxime axetil
cefuroxime sodium
CEFUROXIME/
DEXTROSE
cephalexin
chloramphenicol sodium
succinate
CIPRO SUSP
CIPRO
CIPRO I.V.-IN D5W
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin in d5w
ciprofloxacinciprofloxacin hcl
CLAFORAN
clarithromycin
CLEOCIN
CLEOCIN IN D5W
CLEOCIN PHOSPHATE
clindamycin hcl
clindamycin palmitate
hydrochloride
clindamycin phosphate
Drug
Tier
Requirements
/Limits
HI
2
2
2
2
2
2
3
2
2
2
MO
HI
MO
HI
HI
HI
HI
MO
MO
HI
HI
4
3
4
4
2
MO
MO
HI
HI
2
2
MO
HI
HI
MO
HI
3
4
4
2
2
2
MO
MO
HI
HI
MO
HI
MO
4
2
4
3
4
2
HI
MO
MO
HI
HI
MO
2
2
HI
Drug Name
clindamycin phosphate in
d5w
colistimethate sodium
COLY-MYCIN M
CUBICIN
demeclocycline hcl
dicloxacillin sodium
DIFICID
DORIBAX
DORYX
doxycycline
(monohydrate)
doxycycline hyclate
E.E.S. GRANULES
ERYPED 200
ERYPED 400
ERYTHROCIN
LACTOBIONATE
erythromycin base
erythromycin
ethylsuccinate
erythromycin lactobionate
erythromycin stearate
FORTAZ
FORTAZ
gentamicin in saline
gentamicin sulfate
imipenem-cilastatin
INVANZ
KEFLEX
KETEK
LEVAQUIN
levofloxacin
levofloxacin in d5w
LINCOCIN
MAXIPIME
meropenem
MERREM
MINOCIN
minocycline hcl
MOXATAG
nafcillin sodium
NALLPEN ISO-OSMOTIC
IN DEXTROSE
NALLPEN/DEXTROSE
Drug
Tier
Requirements
/Limits
HI
2
4
5
2
2
5
4
4
HI
HI
HI
MO
MO
MO
2
3
3
3
HI,MO
HI
MO
MO
2
2
3
4
2
2
2
3
4
4
4
2
2
4
3
2
4
4
2
4
2
HI
MO
HI
HI
HI
HI
HI
HI
MO
MO
HI,MO
HI,MO
HI
HI
HI
HI
HI
MO
MO
MO
HI
HI
HI
HI
MO
Drug Name
neomycin sulfate
NOROXIN
ofloxacin
oxacillin sodium
PCE
penicillin g potassium
PENICILLIN G
POTASSIUM IN ISOOSMOTIC DEXTROSE
penicillin g procaine
penicillin g sodium
penicillin v potassium
piperacillin sodiumtazobactam sodium
polymyxin b sulfate
PRIMAXIN I.M. INJ
500MG
PRIMAXIN IV INJ 250MG
PRIMAXIN IV INJ 500MG
SOLODYN
streptomycin sulfate
sulfadiazine
sulfamethoxazoletrimethoprim
sulfasalazine
SUPRAX
SYNERCID
TEFLARO
tetracycline hcl
ticarcillin & pot
clavulanate
TIMENTIN
TOBI NEB 300/5ML
TOBI PODHALER CAP
28MG
tobramycin sulfate
tobramycin sulfate in
saline
TYGACIL
UNASYN
UNASYN BULK PACK
VANCOCIN HCL
vancomycin hcl
VANCOMYCIN HCL IN
DEXTROSE
Drug
Tier
2
4
2
2
4
2
Requirements
/Limits
MO
MO
MO
HI
MO
HI
HI
2
2
2
HI
MO
HI
HI
3
4
4
4
2
2
HI
HI
MO
HI,MO
2
4
3
4
2
MO
MO
HI
HI
MO
HI
4
5
HI
MO
HI
HI
4
4
4
5
2
HI
HI
HI
HI
MO
HI,MO
Drug Name
VIBATIV
VIBRAMYCIN
VIBRAMYCIN
XIFAXAN
ZINACEF
ZINACEF IN ISOOSMOTIC DEXTROSE
ZINACEF IN ISOOSMOTIC DILUENT
ZITHROMAX INJ 500MG
ZITHROMAX POW 1GM
PAK
ZITHROMAX SUS
100/5ML
ZITHROMAX SUS
200/5ML
ZITHROMAX TAB
250MG
ZITHROMAX TAB
500MG
ZITHROMAX TAB
600MG
ZITHROMAX TRI-PAK
TAB TRI-PAK
ZITHROMAX Z-PAK TAB
Z-PAK
ZMAX SUS 2GM
ZOSYN
ZYVOX
ANTIFUNGALS
ABELCET
AMBISOME
amphotericin b
ANCOBON
CANCIDAS
DIFLUCAN
ERAXIS
fluconazole
fluconazole in dextrose
flucytosine
GRIS-PEG
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
ketoconazole
Drug
Tier
4
3
4
4
3
Requirements
/Limits
HI
MO
MO
HI
HI
HI
HI
3
4
4
4
MO
MO
MO
MO
MO
4
3
5
HI
HI
4
5
2
5
5
4
4
2
2
2
3
2
2
2
2
HI
HI
HI
HI
MO
HI
MO
HI
MO
MO
MO
MO
MO
MO
Drug Name
LAMISIL
MYCAMINE
NOXAFIL
nystatin
nystatin (mouth-throat)
ONMEL TAB 200MG
SPORANOX CAP 100MG
SPORANOX PULSEPAK
CAP PULSEPAK
SPORANOX SOL
10MG/ML
terbinafine hcl
VFEND IV INJ 200MG
VFEND SUS 40MG/ML
VFEND TAB 200MG
VFEND TAB 50MG
voriconazole
ANTIMYCOBACTERIALS
aminosalicylic acid
CAPASTAT SULFATE
cycloserine
dapsone
ethambutol hcl
isoniazid
isoniazid & rifampin
MYAMBUTOL
MYCOBUTIN
PRIFTIN
pyrazinamide
RIFADIN
rifampin
RIFATER
SIRTURO
TRECATOR
ANTIPROTOZOALS
ALINIA
atovaquone-proguanil hcl
chloroquine phosphate
COARTEM
DARAPRIM
FLAGYL
FLAGYL ER
hydroxychloroquine
sulfate
MALARONE
Drug
Tier
4
4
5
2
2
4
4
Requirements
/Limits
MO
HI
MO
MO
MO
MO
3
2
3
5
5
5
2
MO
HI
2
3
2
2
2
2
2
4
3
4
2
4
2
4
5
4
MO
HI
MO
MO
MO
MO
MO
MO
MO
MO
MO
HI,MO
HI,MO
MO
LD
MO
3
2
2
3
3
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
HI,MO
Drug Name
mefloquine hcl
MEPRON
METRO IV
metronidazole
metronidazole in nacl
NEBUPENT INH 300MG
paromomycin sulfate
PENTAM 300 INJ 300MG
PLAQUENIL
PRIMAQUINE
PHOSPHATE
QUALAQUIN
quinine sulfate
tinidazole
ANTIVIRALS
abacavir sulfate
acyclovir
acyclovir sodium
APTIVUS
ATRIPLA
BARACLUDE SOL
.05MG/ML
BARACLUDE TAB 0.5MG
BARACLUDE TAB 1MG
cidofovir
COMBIVIR
COMPLERA
COPEGUS
CRIXIVAN
CYTOVENE
didanosine
EDURANT
EMTRIVA
EPIVIR HBV SOL
5MG/ML
EPIVIR HBV TAB 100MG
EPIVIR SOL 10MG/ML
EPIVIR TAB 150MG
EPIVIR TAB 300MG
EPZICOM
famciclovir
FAMVIR
foscarnet sodium
FUZEON
ganciclovir sodium
Drug
Tier
2
5
3
2
2
3
2
4
4
Requirements
/Limits
MO
MO
4
2
2
MO
MO
2
2
2
5
5
MO
MO
HI
HI
MO
HI
MO
MO
3
5
5
2
5
5
4
3
4
2
5
3
HI
MO
MO
HI
MO
MO
3
3
3
4
4
5
2
4
2
5
2
MO
MO
MO
MO
MO
HI
HI
Drug Name
HEPSERA
INCIVEK
INFERGEN
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INTELENCE TAB 25MG
INVIRASE CAP 200MG
INVIRASE TAB 500MG
ISENTRESS CHW
100MG
ISENTRESS CHW 25MG
ISENTRESS TAB 400MG
KALETRA SOL
KALETRA TAB 10025MG
KALETRA TAB 20050MG
lamivudine
lamivudine-zidovudine
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
nevirapine
NORVIR
PEG-INTRON
PEG-INTRON REDIPEN
PEGASYS
PEGASYS PROCLICK
PREZISTA SUS
100MG/ML
PREZISTA TAB 150MG
PREZISTA TAB 400MG
PREZISTA TAB 600MG
PREZISTA TAB 75MG
PREZISTA TAB 800MG
REBETOL
RELENZA DISKHALER
RESCRIPTOR
RETROVIR CAP 100MG
RETROVIR IV INFUSION
INJ 10MG/ML
RETROVIR SYP
50MG/5ML
REYATAZ CAP 100MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
Drug
Tier
5
5
5
5
5
3
3
5
Requirements
/Limits
MO
MO
3
5
5
MO
MO
5
2
2
4
5
2
3
5
5
5
5
MO
MO
MO
MO
4
3
5
5
3
5
4
3
3
4
3
MO
MO
MO
MO
MO
HI
4
3
5
5
MO
Drug Name
REYATAZ CAP 300MG
ribavirin (hepatitis c)
rimantadine hydrochloride
SELZENTRY
stavudine
STRIBILD
SUSTIVA
SYNAGIS
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 12MG/ML
TAMIFLU SUS 6MG/ML
TIVICAY
TRIZIVIR
TRUVADA
TYZEKA
valacyclovir hcl
VALCYTE SOL 50MG/ML
VALCYTE TAB 450MG
VALTREX
VICTRELIS
VIDEX EC CAP 125MG
VIDEX EC CAP 200MG
VIDEX EC CAP 250MG
VIDEX EC CAP 400MG
VIDEX PEDIATRIC SOL
2GM
VIRACEPT
VIRAMUNE SUS
50MG/5ML
VIRAMUNE TAB 200MG
VIRAMUNE XR TAB
100MG
VIRAMUNE XR TAB
400MG
VIRAZOLE
VIREAD
VISTIDE
ZERIT
ZIAGEN SOL 20MG/ML
ZIAGEN TAB 300MG
zidovudine
ZOVIRAX
Drug
Tier
5
2
2
5
2
5
4
5
4
4
3
3
3
5
5
5
4
2
3
5
4
5
4
4
4
4
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
3
5
3
3
MO
MO
MO
3
5
5
4
3
4
2
4
MO
HI
MO
MO
HI,MO
MO
Drug
Tier
URINARY ANTI-INFECTIVES
FURADANTIN
4
HIPREX
4
MACROBID
4
MACRODANTIN CAP
4
100MG
MACRODANTIN CAP
3
25MG
methenamine hippurate
2
MONUROL
4
nitrofurantoin
2
nitrofurantoin
2
macrocrystal
nitrofurantoin monohyd
2
macro
PRIMSOL
3
trimethoprim
2
ANTIHISTAMINE DRUGS
ANTIHISTAMINE DRUGS
carbinoxamine maleate
2
cetirizine hcl
2
CLARINEX
4
CLARINEX REDITABS
4
CLARINEX-D 12 HOUR
4
CLARINEX-D 24 HOUR
4
clemastine fumarate
2
cyproheptadine hcl
2
desloratadine
2
dexchlorpheniramine
2
maleate
diphenhydramine hcl
2
levocetirizine
2
dihydrochloride
promethazine &
2
phenylephrine
promethazine hcl
2
SEMPREX-D
4
XYZAL
4
ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS
ABRAXANE
3
AFINITOR
5
AFINITOR DISPERZ
5
ALIMTA
3
ALKERAN
4
Drug Name
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
anastrozole
ARIMIDEX
AROMASIN
ARRANON
ARZERRA
AVASTIN
BCG VACCINE
bicalutamide
BICNU
bleomycin sulfate
BOSULIF
BUSULFEX
CAMPATH
CAMPTOSAR
CAPRELSA
carboplatin
CASODEX
CEENU
cisplatin
cladribine
CLOLAR
COMETRIQ
COSMEGEN
cyclophosphamide
cytarabine
dacarbazine
DACOGEN
daunorubicin hcl
DAUNOXOME
DOCEFREZ INJ 20MG
DOCEFREZ INJ 80MG
DOCETAXEL INJ
80MG/4ML
DOCETAXEL INJ
80MG/8ML
DOXIL
doxorubicin hcl
DROXIA
ELIGARD
ELLENCE
ELOXATIN INJ 100MG
ELOXATIN INJ 200MG
ELSPAR
EMCYT
epirubicin hcl
Drug
Tier
2
4
4
3
4
3
3
2
3
2
5
4
3
4
3
2
4
3
2
2
4
5
4
2
2
2
3
2
3
4
4
4
3
3
2
4
4
4
4
3
3
3
2
Requirements
/Limits
MO
LD
LD
PA
Drug Name
ERBITUX
ERIVEDGE
ETOPOPHOS
etoposide
exemestane
FARESTON
FASLODEX
FEMARA
FIRMAGON
fludarabine phosphate
fluorouracil
flutamide
FOLOTYN
GAZYVA
gemcitabine hcl
GEMZAR
GILOTRIF
GLEEVEC
HALAVEN
HERCEPTIN
HEXALEN
HYCAMTIN
HYDREA
hydroxyurea
ICLUSIG
IDAMYCIN PFS
idarubicin hcl
IFEX
ifosfamide
INLYTA
INTRON-A
INTRON-A W/DILUENT
irinotecan hcl
ISTODAX
IXEMPRA KIT
JAKAFI
JEVTANA
KADCYLA
KYPROLIS
letrozole
LEUKERAN
leuprolide acetate
LUPRON DEPOT
LUPRON DEPOT-PED
Drug
Tier
3
5
4
2
2
4
5
4
4
2
2
2
4
5
2
4
5
5
4
3
5
4
4
2
5
4
2
3
2
5
5
5
2
3
5
5
3
5
5
2
3
2
4
4
Requirements
/Limits
MO
MO
Drug Name
LUPRON DEPOT-PED
INJ 11.25MG
LUPRON DEPOT-PED
INJ 15MG
LUPRON DEPOT-PED
INJ 7.5MG
LYSODREN
MATULANE
MEGACE ORAL
megestrol acetate
MEKINIST
melphalan hcl
mercaptopurine
methotrexate sodium
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
NILANDRON
NIPENT
ONCASPAR
ONTAK
oxaliplatin
paclitaxel
pentostatin
PERJETA
POMALYST
PROLEUKIN
PURINETHOL
REVLIMID
RHEUMATREX
RITUXAN
SOLTAMOX
SPRYCEL
STIVARGA
SUTENT
SYLATRON
SYNRIBO
TABLOID
TAFINLAR
tamoxifen citrate
TARCEVA
TARGRETIN
TASIGNA
TAXOTERE INJ 20/0.5ML
Drug
Tier
Requirements
/Limits
4
4
3
3
5
4
2
5
2
2
2
2
2
3
5
3
4
3
3
2
2
2
5
5
5
4
5
4
3
4
5
5
5
4
5
3
5
2
5
5
5
3
MO
PA
MO
PA
MO
MO
MO
Drug Name
Drug
Tier
TAXOTERE INJ
3
80MG/2ML
TAXOTERE INJ
4
80MG/4ML
thiotepa
2
TICE BCG
3
topotecan hcl
2
TORISEL
3
TREANDA
3
TRELSTAR DEPOT
4
MIXJECT
TRELSTAR LA MIXJECT 4
TRELSTAR MIXJECT
4
tretinoin (chemotherapy)
2
TRISENOX
3
TYKERB
5
VALSTAR
3
VANTAS
3
VECTIBIX
4
VELCADE
3
VIDAZA
4
vinblastine sulfate
2
vincristine sulfate
2
vinorelbine tartrate
2
VOTRIENT
5
VUMON
3
XALKORI
5
XTANDI
5
YERVOY
3
ZALTRAP
5
ZANOSAR
3
ZELBORAF
5
ZOLINZA
5
ZYTIGA
5
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
atropine sulfate
2
ATROPINE SULFATE
3
ATROVENT
4
ATROVENT HFA
3
BENTYL
4
CANTIL
4
CUVPOSA SOL
3
1MG/5ML
dicyclomine hcl
2
Requirements
/Limits
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
2
1
Requirements
/Limits
MO
glycopyrrolate
ipratropium bromide
ipratropium bromide
2
(nasal)
methscopolamine
2
MO
bromide
PAMINE
4
MO
PAMINE FORTE
4
MO
propantheline bromide
2
MO
ROBINUL FORTE TAB
4
MO
2MG
ROBINUL TAB 1MG
4
MO
SPIRIVA HANDIHALER
3
MO
TUDORZA PRESSAIR
4
AUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX
4
CHANTIX STARTING
4
MONTH PAK
NICOTROL INHALER
3
INH
NICOTROL NS SPR
4
10MG/ML
PARASYMPATHOMIMETIC (CHOLINERGIC)
AGENTS
ARICEPT
4
MO
ARICEPT ODT
4
MO
bethanechol chloride
2
MO
cevimeline hcl
2
MO
donepezil hydrochloride
2
MO
EVOXAC
4
MO
EXELON
4
MO
galantamine
2
MO
hydrobromide
GUANIDINE HCL
4
MO
MESTINON SYP
3
60MG/5ML
MESTINON TAB 60MG
4
MO
MESTINON TIMESPAN
3
MO
TAB TIMESPAN
pilocarpine hcl (oral)
2
MO
pyridostigmine bromide
2
MO
RAZADYNE
4
MO
RAZADYNE ER
4
MO
REGONOL INJ 5MG/ML
3
rivastigmine tartrate
2
MO
Drug Requirements
Tier
/Limits
SALAGEN
4
MO
SKELETAL MUSCLE RELAXANTS
AMRIX
4
MO
baclofen
2
MO
carisoprodol
2
MO
carisoprodol w/ aspirin
2
MO
carisoprodol w/ aspirin &
2
codeine
chlorzoxazone
2
MO
cyclobenzaprine hcl
2
MO
DANTRIUM
4
MO
dantrolene sodium
2
MO
GABLOFEN
4
LIORESAL
4
INTRATHECAL
methocarbamol
2
MO
orphenadrine citrate
2
MO
PARAFON FORTE DSC
4
MO
SKELAXIN
4
MO
SOMA
4
MO
tizanidine hcl
2
MO
ZANAFLEX
4
MO
SYMPATHOLYTIC (ADRENERGIC BLOCKING)
AGENTS
alfuzosin hcl
2
MO
DIBENZYLINE
3
MO
dihydroergotamine
2
mesylate
ergoloid mesylates
2
MO
ergotamine tartrate
2
FLOMAX
4
MO
MIGRANAL
3
RAPAFLO
4
MO
tamsulosin hcl
2
MO
UROXATRAL
4
MO
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ACCUNEB NEB
4
0.63MG/3
ACCUNEB NEB
4
1.25MG/3
ADVAIR DISKUS AER
3
MO
100/50
ADVAIR DISKUS AER
3
MO
250/50
Drug Name
Drug Name
ADVAIR DISKUS AER
500/50
ADVAIR HFA AER
115/21
ADVAIR HFA AER
230/21
ADVAIR HFA AER 45/21
albuterol sulfate er tab
4mg er
albuterol sulfate er tab
8mg er
albuterol sulfate neb
0.083%
albuterol sulfate neb 0.5%
albuterol sulfate neb
0.63mg/3
albuterol sulfate neb
1.25mg/3
albuterol sulfate syp
2mg/5ml
albuterol sulfate tab 2mg
albuterol sulfate tab 4mg
ARCAPTA NEOHALER
AUVI-Q INJ 0.15MG
AUVI-Q INJ 0.3MG
BROVANA
COMBIVENT AER
COMBIVENT RESPIMAT
AER RESPIMAT
DUONEB SOL
EPIPEN 2-PAK INJ
0.3MG
EPIPEN-JR 2-PAK INJ 2PAK
FORADIL AEROLIZER
ipratropium-albuterol
levalbuterol hcl
MAXAIR AUTOHALER
metaproterenol sulfate
midodrine hcl
PERFOROMIST
PROAIR HFA AER
PROVENTIL HFA AER
HFA
SEREVENT DISKUS
Drug
Tier
Requirements
/Limits
MO
MO
MO
MO
MO
MO
1
1
2
2
2
2
2
4
4
4
4
3
MO
MO
MO
MO
MO
4
3
3
4
2
2
3
2
2
4
3
MO
MO
MO
MO
MO
MO
MO
Drug Requirements
Tier
/Limits
terbutaline sulfate
2
MO
TWINJECT INJ 0.15MG
3
TWINJECT INJ 0.3MG
3
VENTOLIN HFA AER
4
MO
vospire er tab 4mg
2
MO
vospire er tab 8mg
2
MO
XOPENEX
4
XOPENEX HFA
4
BLOOD FORMATION, COAGULATION, AND
THROMBOSIS
COAGULANTS AND ANTICOAGULANTS
AGGRENOX
4
MO
AGRYLIN
4
MO
AMICAR
3
MO
anagrelide hcl
2
MO
argatroban
2
HI
ARGATROBAN
4
HI
ARIXTRA
4
BRILINTA
3
MO
cilostazol
2
MO
clopidogrel bisulfate
2
MO
COUMADIN
4
HI,MO
CYKLOKAPRON INJ
3
HI
100MG/ML
EFFIENT
3
MO
ELIQUIS
4
MO
enoxaparin sodium
2
fondaparinux sodium
2
FRAGMIN
4
heparin (porcine) in
2
sodium chloride
heparin sod (porcine) in
2
HI
d5w
heparin sodium (porcine)
2
HI
HEPARIN
4
SODIUM/NACL 0.45%
INTEGRILIN
3
HI
LOVENOX
3
LYSTEDA TAB 650MG
4
MO
pentoxifylline
2
MO
PLAVIX
4
MO
PLETAL
4
MO
PRADAXA
4
MO
ticlopidine hcl
2
MO
tranexamic acid
2
HI,MO
Drug Name
Drug Requirements
Drug Requirements
Drug Name
Tier
/Limits
Tier
/Limits
TRENTAL
4
MO
FIBRICOR
4
MO
warfarin sodium
fluvastatin sodium
2
HI,MO
2
MO
gemfibrozil
XARELTO
4
MO
2
MO
HEMATOPOIETIC AGENTS
JUXTAPID
5
LD
KYNAMRO
5
ARANESP ALBUMIN
4
PA
FREE
LESCOL
4
MO
EPOGEN INJ 10000/ML
4
PA
LESCOL XL
4
MO
EPOGEN INJ 2000/ML
4
PA
LIPITOR
4
MO
EPOGEN INJ 20000/ML
4
PA
LIPOFEN
4
MO
EPOGEN INJ 3000/ML
4
PA
LIVALO
4
MO
EPOGEN INJ 4000/ML
4
PA
LOPID
4
MO
LEUKINE INJ 250MCG
3
HI
lovastatin
1
MO
LEUKINE INJ 500 MCG
4
LOVAZA
4
MO
MOZOBIL
4
MEVACOR
4
MO
NEULASTA
5
NIASPAN
4
MO
NEUMEGA
5
PRAVACHOL
4
MO
NEUPOGEN
5
pravastatin sodium
1
MO
PROCRIT INJ 10000/ML
3
PA
SIMCOR
4
MO
PROCRIT INJ 2000/ML
3
PA
simvastatin
1
MO
PROCRIT INJ 20000/ML
3
PA
TRICOR
4
MO
PROCRIT INJ 3000/ML
3
PA
TRILIPIX
4
MO
PROCRIT INJ 4000/ML
3
PA
VASCEPA
4
PROCRIT INJ 40000/ML
3
PA
VYTORIN
4
MO
PROMACTA
5
WELCHOL
4
MO
CARDIOVASCULAR DRUGS
ZETIA
4
MO
A-ADRENERGIC BLOCKING AGENTS
ZOCOR
4
MO
CARDURA
4
MO
CALCIUM-CHANNEL BLOCKING AGENTS
CARDURA XL
4
MO
ADALAT CC
4
MO
doxazosin mesylate
2
MO
amlodipine besylate
1
MO
MINIPRESS
4
MO
amlodipine besylate2
MO
benazepril hcl
prazosin hcl
2
MO
terazosin hcl
2
MO
AZOR
4
MO
ANTILIPEMIC AGENTS
CADUET
4
MO
ADVICOR
4
MO
CALAN
4
MO
ALTOPREV
4
MO
CALAN SR
4
MO
ANTARA
4
MO
CARDIZEM
4
MO
atorvastatin calcium
1
MO
CARDIZEM CD
4
MO
cholestyramine
2
MO
CARDIZEM LA
4
MO
cholestyramine light
diltiazem hcl
2
MO
2
HI,MO
COLESTID
4
MO
diltiazem hcl coated
2
MO
beads
colestipol hcl
2
MO
CRESTOR
4
MO
diltiazem hcl extended
2
MO
release beads
fenofibrate
2
MO
EXFORGE
4
MO
fenofibratemicronized
2
MO
EXFORGE HCT
4
MO
FENOGLIDE
4
MO
Kaiser Permanente 2014 Comprehensive Formulary 18
Drug Name
Drug Name
felodipine
isradipine
LOTREL
nicardipine hcl
nifedipine
nimodipine
nisoldipine
NORVASC
PROCARDIA
PROCARDIA XL
SULAR
TARKA
TIAZAC
TRIBENZOR
TWYNSTA
verapamil hcl
VERELAN
VERELAN PM
CARDIAC DRUGS
amiodarone hcl
CORDARONE
digoxin
DIGOXIN SOL
50MCG/ML
disopyramide phosphate
flecainide acetate
LANOXIN PEDIATRIC
INJ 0.1MG/ML
LANOXIN TAB 0.125MG
LANOXIN TAB 0.25MG
mexiletine hcl
MULTAQ
NEXTERONE
NORPACE CAP 100MG
NORPACE CAP 150MG
NORPACE CR CAP
100MG CR
NORPACE CR CAP
150MG CR
procainamide hcl
propafenone hcl
quinidine gluconate
QUINIDINE
GLUCONATE
quinidine sulfate
Drug
Tier
2
2
4
2
2
2
2
4
4
4
4
4
4
4
4
2
4
4
Requirements
/Limits
MO
MO
MO
HI,MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
HI,MO
MO
MO
2
4
2
HI,MO
MO
MO
3
2
2
MO
MO
3
4
4
2
4
4
4
4
MO
MO
MO
MO
HI
MO
MO
MO
MO
2
2
2
MO
MO
3
2
MO
Drug Name
Drug
Tier
4
4
4
3
Requirements
/Limits
MO
MO
MO
MO
RANEXA
RYTHMOL
RYTHMOL SR
TIKOSYN
HYPOTENSIVE AGENTS
CATAPRES
4
MO
CATAPRES-TTS-1
4
MO
CATAPRES-TTS-2
4
MO
CATAPRES-TTS-3
4
MO
clonidine & chlorthalidone 2
MO
clonidine hcl
2
MO
guanfacine hcl
2
MO
hydralazine hcl inj
2
20mg/ml
hydralazine hcl tab
2
MO
100mg
hydralazine hcl tab 10mg 1
MO
hydralazine hcl tab 25mg 1
MO
hydralazine hcl tab 50mg 2
MO
KAPVAY
4
MO
mecamylamine hcl
2
methyldopa
2
MO
methyldopa&
2
MO
hydrochlorothiazide
methyldopate hcl
2
HI
minoxidil
2
MO
PROGLYCEM
3
RESERPINE
3
MO
TENEX
4
MO
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
INHIBITORS
ACCUPRIL
4
MO
ACCURETIC
4
MO
ALDACTAZIDE
4
MO
ALDACTONE
4
MO
ALTACE
4
MO
AMTURNIDE
4
MO
ATACAND
4
MO
ATACANDHCT
4
MO
AVALIDE
4
MO
AVAPRO
4
MO
benazepril &
2
MO
hydrochlorothiazide
benazepril hcl
1
MO
BENICAR
4
MO
Drug Name
BENICAR HCT
candesartan cilexetilhydrochlorothiazide
captopril
captopril &
hydrochlorothiazide
COZAAR
DIOVAN
DIOVANHCT
EDARBI
EDARBYCLOR
enalapril maleate
enalapril maleate&
hydrochlorothiazide
eplerenone
eprosartan mesylate
fosinopril sodium
fosinopril sodium&
hydrochlorothiazide
HYZAAR
INSPRA
irbesartan
irbesartanhydrochlorothia
zide
lisinopril &
hydrochlorothiazide
lisinopril tab 10mg
lisinopril tab 2.5mg
lisinopril tab 20mg
lisinopril tab 30mg
lisinopril tab 40mg
lisinopril tab 5mg
losartan potassium
losartan potassium &
hydrochlorothiazide
LOTENSIN
LOTENSIN HCT
MAVIK
MICARDIS
MICARDIS HCT
moexipril hcl
moexiprilhydrochlorothiazide
perindopril erbumine
PRINIVIL
Drug
Tier
4
Requirements
/Limits
MO
MO
MO
MO
4
4
4
4
4
1
MO
MO
MO
MO
MO
MO
MO
2
2
2
MO
MO
MO
MO
4
4
2
MO
MO
MO
MO
MO
1
1
1
2
1
1
2
MO
MO
MO
MO
MO
MO
MO
MO
4
4
4
4
4
2
MO
MO
MO
MO
MO
MO
MO
2
4
MO
MO
Drug
Tier
4
2
Requirements
/Limits
MO
MO
MO
MO
MO
MO
1
2
4
4
4
4
4
2
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
4
4
4
MO
MO
MO
MO
5
5
4
4
MO
PA
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
PRINZIDE
quinapril hcl
quinaprilhydrochlorothiazide
ramipril
spironolactone &
hydrochlorothiazide
Drug Name
Drug
Tier
Requirements
/Limits
isosorbide mononitrate
2
MO
tab 10mg
isosorbide mononitrate
2
MO
tab 20mg
LETAIRIS
5
NITRO-DUR DIS
4
MO
0.1MG/HR
NITRO-DUR DIS
4
MO
0.2MG/HR
NITRO-DUR DIS
3
MO
0.3MG/HR
NITRO-DUR DIS
4
MO
0.4MG/HR
NITRO-DUR DIS
4
MO
0.6MG/HR
NITRO-DUR DIS
3
MO
0.8MG/HR
nitroglycerin
2
HI,MO
NITROLINGUAL
3
MO
PUMPSPRAY SPR
PUMPSPRA
NITROMIST AER
4
MO
400MCG
NITROSTAT SUB 0.3MG 3
MO
NITROSTAT SUB 0.4MG 3
MO
NITROSTAT SUB 0.6MG 3
MO
OPSUMIT
5
LD
PERSANTINE
4
MO
REMODULIN
5
LD
REVATIO
5
sildenafil citrate
2
PA
(pulmonary hypertension)
TRACLEER
5
LD
TYVASO
4
LD
VENTAVIS
5
LD
-ADRENERGIC BLOCKING AGENTS
acebutolol hcl
2
MO
atenolol
1
MO
atenolol & chlorthalidone
1
MO
BETAPACE
4
MO
BETAPACE AF
4
MO
betaxolol hcl
2
MO
bisoprolol &
1
MO
hydrochlorothiazide
bisoprolol fumarate
2
MO
Drug Name
BYSTOLIC
carvedilol
COREG
COREG CR
CORGARD
CORZIDE
DUTOPROL
INDERAL LA
INNOPRAN XL
labetalol hcl
LEVATOL
LOPRESSOR
LOPRESSOR HCT
metoprolol &
hydrochlorothiazide
metoprolol succinate
metoprolol tartrate inj
1mg/ml
metoprolol tartrate tab
100mg
metoprolol tartrate tab
25mg
metoprolol tartrate tab
50mg
nadolol &
bendroflumethiazide
nadolol tab 20mg
nadolol tab 40mg
nadolol tab 80mg
pindolol
propranolol &
hydrochlorothiazide
propranolol hcl er cap
120mg er
propranolol hcl er cap
160mg er
propranolol hcl er cap
60mg er
propranolol hcl er cap
80mg er
propranolol hcl inj 1mg/ml
propranolol hcl sol
20mg/5ml
propranolol hcl sol
40mg/5ml
Drug
Tier
4
1
4
4
4
4
4
4
4
2
4
4
4
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
HI,MO
MO
HI,MO
MO
MO
MO
HI
MO
MO
MO
MO
1
1
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
HI
2
2
Drug Name
Drug
Tier
1
1
1
2
1
4
2
2
Requirements
/Limits
MO
MO
MO
MO
MO
MO
HI,MO
MO
Drug Name
CODEINE SULFATE TAB
15MG
CODEINE SULFATE TAB
30MG
CODEINE SULFATE TAB
60MG
CONZIP
DAYPRO
DEMEROL
diclofenac potassium
diclofenac sodium
diclofenac w/ misoprostol
diflunisal
DILAUDID INJ 1MG/ML
DILAUDID INJ 2MG/ML
DILAUDID INJ 4MG/ML
DILAUDID TAB 2MG
DILAUDID TAB 4MG
DILAUDID TAB 8MG
DILAUDID-5 LIQ 1MG/ML
DILAUDID-HP INJ
10MG/ML
DOLOPHINE HCL TAB
5MG
DOLOPHINE TAB 10MG
DUEXIS
DURAGESIC
EC-NAPROSYN
etodolac
EXALGO TAB 12MG
EXALGO TAB 16MG
EXALGO TAB 8MG
FELDENE
fenoprofen calcium
fentanyl
fentanyl citrate
FENTORA
FIORICET/CODEINE
FIORINAL
FIORINAL/CODEINE #3
flurbiprofen
GRALISE
GRALISE STARTER
hydrocodoneacetaminophen
Drug
Tier
Requirements
/Limits
3
3
4
4
4
4
2
2
2
2
4
4
4
4
4
4
3
MO
MO
MO
MO
MO
MO
4
4
4
4
4
4
2
4
4
4
4
2
2
2
4
4
4
4
2
4
4
MO
MO
MO
MO
MO
LD
MO
Drug Name
hydrocodone-ibuprofen
hydromorphone hcl
ibuprofen
ILARIS
INDOCIN
indomethacin
KADIAN CAP 100MG CR
KADIAN CAP 10MG CR
KADIAN CAP 200MG CR
KADIAN CAP 20MG CR
KADIAN CAP 30MG CR
KADIAN CAP 50MG CR
KADIAN CAP 60MG CR
KADIAN CAP 80MG CR
ketoprofen
ketorolac tromethamine
levorphanol tartrate
meclofenamate sodium
mefenamic acid
meloxicam
MELOXICAM
meperidine hcl
methadone hcl
METHADONE HCL INJ
10MG/ML
MOBIC
morphine sulfate
MORPHINE SULFATE
SOL 20MG/ML
MORPHINE SULFATE
TAB 15MG
MORPHINE SULFATE
TAB 30MG
MS CONTIN TAB 100MG
CR
MS CONTIN TAB 15MG
CR
MS CONTIN TAB 200MG
CR
MS CONTIN TAB 30MG
CR
MS CONTIN TAB 60MG
CR
nabumetone
nalbuphine hcl
Drug
Tier
2
2
2
5
4
2
4
4
4
4
4
4
4
4
2
2
2
2
2
2
4
2
2
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
3
4
2
MO
3
3
3
4
4
4
4
4
2
2
Drug Name
NALFON
NAPRELAN
NAPROSYN
naproxen
naproxen sodium
NUCYNTA
NUCYNTA ER
ONSOLIS
OPANA
OPANA ER (CRUSH
RESISTANT)
orphenadrine w/ aspirin &
caff
oxaprozin
OXECTA
oxycodone hcl
oxycodone w/
acetaminophen
oxycodone-aspirin
oxycodone-ibuprofen
OXYCONTIN
oxymorphone hcl
pentazocine w/ naloxone
pentazocineacetaminophen
PERCODAN
piroxicam
PONSTEL
ROXICODONE
SPRIX
SUBSYS
sulindac
SYNALGOS-DC
TALWIN
tolmetin sodium
tramadol hcl
tramadol-acetaminophen
ULTRACET
ULTRAM
ULTRAM ER
VICOPROFEN
VIMOVO
VOLTAREN-XR
Drug
Tier
4
4
4
2
2
4
4
4
4
Requirements
/Limits
MO
MO
MO
MO
MO
MO
LD
4
2
MO
2
4
2
MO
2
2
2
4
2
2
2
4
2
4
4
4
4
2
4
4
2
2
2
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
Kaiser Permanente 2014 Comprehensive Formulary 23
Drug Requirements
Tier
/Limits
ANOREXIGENIC AGENTS AND RESPIRATORY
AND CEREBRAL STIMULANTS
ADDERALL XR
3
amphetamine2
dextroamphetamine
CONCERTA TAB 18MG
4
CONCERTA TAB 27MG
4
CONCERTA TAB 36MG
4
CONCERTA TAB 54MG
4
DAYTRANA
4
DESOXYN
4
DEXEDRINE
4
dexmethylphenidate hcl
2
dextroamphetamine
2
sulfate
FOCALIN
4
FOCALIN XR
4
METADATE CD CAP
3
10MG
METADATE CD CAP
3
20MG
METADATE CD CAP
3
30MG
METADATE CD CAP
3
40MG
METADATE CD CAP
3
50MG
METADATE CD CAP
3
60MG
methamphetamine hcl
2
METHYLIN CHW 10MG
4
METHYLIN CHW 2.5MG
3
METHYLIN CHW 5MG
4
METHYLIN SOL
4
10MG/5ML
METHYLIN SOL
4
5MG/5ML
methylphenidate hcl
2
modafinil
2
NUVIGIL
4
PROVIGIL
4
QUILLIVANT XR SUS XR 4
RITALIN LA CAP 10MG
4
RITALIN LA CAP 20MG
4
RITALIN LA CAP 30MG
4
Drug Name
Drug Name
RITALIN LA CAP 40MG
RITALIN SR TAB 20MG
SR
RITALIN TAB 10MG
RITALIN TAB 20MG
RITALIN TAB 5MG
VYVANSE
ANTICONVULSANTS
BANZEL
carbamazepine
CARBATROL CAP
100MG
CARBATROL CAP
200MG
CARBATROL CAP
300MG
CELONTIN
clonazepam
DEPACON
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLES
DILANTIN
divalproex sodium
EQUETRO
ethosuximide
felbamate
FELBATOL
fosphenytoin sodium
gabapentin
GABITRIL
HORIZANT
KEPPRA
KEPPRA XR
KLONOPIN
LAMICTAL CHEWABLE
DISPERSIBLE CHW
25MG
LAMICTAL CHEWABLE
DISPERSIBLE CHW
5MG
LAMICTAL ODT TAB
100MG
Drug
Tier
4
Requirements
/Limits
4
4
4
4
3
3
2
MO
MO
MO
MO
MO
3
2
4
4
4
4
4
4
2
4
2
2
5
2
2
4
4
4
4
4
MO
MO
HI
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
LAMICTAL ODT TAB
200MG
LAMICTAL ODT TAB
25MG
LAMICTAL ODT TAB
50MG
LAMICTAL
STARTER/NOT TAKING
CARBAMAZEPINE KIT
START 49
LAMICTAL
STARTER/TAKING
CARBAMAZEPINE/NOT
TAKING VALPROATE
KIT START 98
LAMICTAL
STARTER/TAKING
VALPROATE KIT START
35
LAMICTAL TAB 100MG
LAMICTAL TAB 150MG
LAMICTAL TAB 200MG
LAMICTAL TAB 25MG
LAMICTAL XR KIT
LAMICTAL XR TAB
100MG
LAMICTAL XR TAB
200MG
LAMICTAL XR TAB
250MG
LAMICTAL XR TAB
25MG
LAMICTAL XR TAB
300MG
LAMICTAL XR TAB
50MG
lamotrigine
levetiracetam
LEVETIRACETAM
LYRICA
magnesium sulfate
MAGNESIUM SULFATE
MYSOLINE
NEURONTIN
ONFI
oxcarbazepine
Drug
Tier
Requirements
/Limits
MO
MO
MO
MO
MO
MO
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
3
4
2
3
4
4
4
2
MO
HI,MO
HI,MO
HI
HI
MO
MO
MO
MO
Drug Name
PEGANONE
phenytoin
phenytoin sodium
phenytoin sodium
extended
POTIGA
primidone
SABRIL
STAVZOR
TEGRETOL SUS
100/5ML
TEGRETOL TAB 200MG
TEGRETOL-XR TAB
100MG
TEGRETOL-XR TAB
200MG
TEGRETOL-XR TAB
400MG
tiagabine hcl
TOPAMAX
TOPAMAX SPRINKLE
topiramate
TRILEPTAL SUS
300MG/5M
TRILEPTAL TAB 150MG
TRILEPTAL TAB 300MG
TRILEPTAL TAB 600MG
valproate sodium
valproic acid
VIMPAT
ZARONTIN
ZONEGRAN
zonisamide
ANTIMIGRAINE AGENTS
ALSUMA
AMERGE
AXERT
ergotamine w/ caffeine
FROVA
IMITREX
IMITREX STATDOSE
REFILL
MAXALT
MAXALT-MLT
naratriptan hcl
Drug
Tier
4
2
2
Requirements
/Limits
MO
MO
MO
4
2
5
4
MO
MO
LD
MO
4
4
MO
MO
MO
MO
2
4
4
2
MO
MO
MO
MO
3
4
4
4
2
2
4
4
4
2
MO
MO
MO
HI
MO
HI
MO
MO
MO
4
4
4
2
4
4
4
4
4
2
Drug Requirements
Drug Requirements
Drug Name
Tier
/Limits
Tier
/Limits
RELPAX
4
AMBIEN
4
rizatriptan benzoate
2
AMBIEN CR
4
sumatriptan succinate
2
ATIVAN
4
buspirone hcl tab 10mg
SUMAVEL DOSEPRO
4
1
buspirone hcl tab 15mg
TREXIMET
4
2
buspirone hcl tab 30mg
ZOMIG
4
2
buspirone hcl tab 5mg
ZOMIG NASAL SPRAY
4
1
buspirone hcl tab 7.5mg
ZOMIG ZMT
4
2
ANTIPARKINSONIAN AGENTS
butabarbital sodium
2
amantadine hcl
2
MO
BUTISOL SODIUM
4
chlordiazepoxide hcl
APOKYN
5
2
clorazepate dipotassium
AZILECT
3
MO
2
benztropine mesylate
diazepam
2
MO
2
bromocriptine mesylate
2
MO
DIAZEPAM
4
cabergoline
2
MO
EDLUAR
4
carbidopa-levodopa
estazolam
2
MO
2
flurazepam hcl
COGENTIN
4
2
MO
COMTAN
3
MO
HALCION
4
hydroxyzine hcl
ELDEPRYL
4
MO
2
hydroxyzine pamoate
EMSAM
4
MO
2
entacapone
2
MO
LAZANDA
4
lorazepam
LODOSYN
3
MO
2
MO
MIRAPEX
4
MO
LUNESTA
4
meprobamate
MIRAPEX ER
4
MO
2
NEUPRO
4
NIRAVAM
4
oxazepam
PARLODEL
4
MO
2
phenobarbital
2
pramipexole
2
MO
dihydrochloride
RESTORIL
4
REQUIP
4
MO
ROZEREM
4
REQUIP XL
4
MO
secobarbital sodium
2
ropinirole hydrochloride
2
MO
SILENOR
4
selegiline hcl
2
MO
SONATA
4
SINEMET
4
MO
temazepam
2
SINEMET CR
4
MO
TRANXENE T
4
STALEVO 100
3
MO
triazolam
2
STALEVO 125
3
MO
VALIUM
4
STALEVO 150
3
MO
VISTARIL
4
STALEVO 200
3
MO
XANAX
4
STALEVO 50
3
MO
XANAX XR
4
STALEVO 75
3
MO
zaleplon
2
TASMAR
4
MO
zolpidem tartrate
2
trihexyphenidyl hcl
2
MO
ZOLPIMIST
4
CENTRAL NERVOUS SYSTEM AGENTS,
ZELAPAR
4
MO
MISCELLANEOUS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
CAMPRAL
3
MO
alprazolam
2
Kaiser Permanente 2014 Comprehensive Formulary 26
Drug Name
Drug Name
Drug
Tier
4
INTUNIV
NAMENDA SOL
3
10MG/5ML
NAMENDA TAB 10MG
3
NAMENDA TAB 5MG
3
NAMENDA TITRATION
3
PAK TAB 5-10MG
NAMENDA XR CAP
4
14MG
NAMENDA XR CAP
4
21MG
NAMENDA XR CAP
4
28MG
NAMENDA XR CAP 7MG 4
NAMENDA XR
TITRATION PACK CAP
4
TITRATIO
NUEDEXTA
3
RILUTEK
5
riluzole
2
SAVELLA
3
SAVELLA TITRATION
3
PACK
STRATTERA
4
XENAZINE
5
XYREM
5
OPIATE ANTAGONISTS
buprenorphine hcl2
naloxone hcl dihydrate
naloxone hcl
2
naltrexone hcl
2
SUBOXONE
4
VIVITROL
4
PSYCHOTHERAPEUTIC AGENTS
ABILIFY DISCMELT TAB
3
10MG
ABILIFY DISCMELT TAB
3
15MG
ABILIFY INJ 9.75MG
3
ABILIFY MAINTENA INJ
4
300MG
ABILIFY SOL 1MG/ML
3
ABILIFY TAB 10MG
3
ABILIFY TAB 15MG
3
ABILIFY TAB 20MG
3
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
LD
MO
MO
MO
MO
MO
Drug Name
ABILIFY TAB 2MG
ABILIFY TAB 30MG
ABILIFY TAB 5MG
amitriptyline hcl
amoxapine
ANAFRANIL
APLENZIN
bupropion hcl
bupropion hcl (smoking
deterrent)
CELEXA
chlordiazepoxideamitriptyline
chlorpromazine hcl
citalopram hydrobromide
sol 10mg/5ml
citalopram hydrobromide
tab 10mg
citalopram hydrobromide
tab 20mg
citalopram hydrobromide
tab 40mg
clomipramine hcl
clozapine
CLOZARIL TAB 100MG
CLOZARIL TAB 25MG
CYMBALTA
desipramine hcl
DESVENLAFAXINE ER
doxepin hcl cap 100mg
doxepin hcl cap 10mg
doxepin hcl cap 150mg
doxepin hcl cap 25mg
doxepin hcl cap 50mg
doxepin hcl cap 75mg
doxepin hcl con 10mg/ml
EFFEXOR XR CAP
150MG
EFFEXOR XR CAP
37.5MG
EFFEXOR XR CAP
75MG
escitalopram oxalate
FANAPT
Drug
Tier
3
3
3
2
2
4
4
2
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
MO
2
2
MO
MO
MO
2
2
4
4
4
2
4
1
1
2
1
1
1
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
4
MO
MO
Drug Name
FANAPT TITRATION
PACK
FAZACLO TAB 100/ODT
FAZACLO TAB 12.5/ODT
FAZACLO TAB 150MG
FAZACLO TAB 200MG
FAZACLO TAB 25MG
ODT
fluoxetine dr cap 90mg dr
FLUOXETINE HCL
fluoxetine hcl cap 10mg
fluoxetine hcl cap 20mg
fluoxetine hcl cap 40mg
fluoxetine hcl sol
20mg/5ml
fluoxetine hcl tab 10mg
fluoxetine hcl tab 20mg
fluphenazine decanoate
fluphenazine hcl
fluvoxamine maleate
FORFIVO XL
GEODON
GEODON
HALDOL
HALDOL DECANOATE
100
HALDOL DECANOATE
50
haloperidol
haloperidol decanoate
haloperidol lactate
imipramine hcl
imipramine pamoate
INVEGA
INVEGA SUSTENNA
LATUDA
LEXAPRO
lithium carbonate
LITHIUM CARBONATE
CAP 600MG
LITHIUM CITRATE
LITHOBID TAB 300MG
CR
loxapine succinate
LUVOX CR
Drug
Tier
Requirements
/Limits
MO
3
4
4
4
MO
MO
MO
MO
MO
2
4
1
1
1
MO
MO
MO
MO
MO
2
2
2
2
2
2
4
3
4
4
MO
MO
MO
MO
MO
MO
4
4
2
2
2
2
2
4
4
4
4
2
MO
MO
MO
MO
MO
MO
MO
MO
3
4
MO
2
4
MO
MO
Drug Name
maprotiline hcl
MARPLAN
mirtazapine
NARDIL
NAVANE
nefazodone hcl
NORPRAMIN
nortriptyline hcl cap 10mg
nortriptyline hcl cap 25mg
nortriptyline hcl cap 50mg
nortriptyline hcl cap 75mg
olanzapine
olanzapine-fluoxetine hcl
OLEPTRO
ORAP
PAMELOR
PARNATE
paroxetine hcl er tab
12.5mg
paroxetine hcl er tab
25mg er
paroxetine hcl er tab
37.5mg
paroxetine hcl tab 10mg
paroxetine hcl tab 20mg
paroxetine hcl tab 30mg
paroxetine hcl tab 40mg
PAXIL
PAXIL CR
perphenazine
perphenazineamitriptyline
PEXEVA
phenelzine sulfate
PRISTIQ
prochlorperazine
prochlorperazine
edisylate
prochlorperazinemaleate
protriptyline hcl
PROZAC
PROZAC WEEKLY
quetiapine fumarate
REMERON
REMERON SOLTAB
Drug
Tier
2
4
2
4
3
2
4
1
1
2
2
2
2
4
3
4
4
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
1
2
2
4
4
2
MO
MO
MO
MO
MO
MO
MO
MO
4
2
4
2
MO
MO
MO
MO
2
2
2
4
4
2
4
4
MO
MO
MO
MO
MO
MO
MO
Drug Name
RISPERDAL
RISPERDAL CONSTA
RISPERDAL M-TAB
risperidone
SAPHRIS
SARAFEM
SEROQUEL
SEROQUEL XR
sertraline hcl
SURMONTIL
SYMBYAX
thioridazine hcl
thiothixene
TOFRANIL-PM
tranylcypromine sulfate
trazodone hcl tab 100mg
trazodone hcl tab 150mg
trazodone hcl tab 300mg
trazodone hcl tab 50mg
trifluoperazine hcl
trimipramine maleate
venlafaxine hcl
VENLAFAXINE HCL ER
TAB 150MG ER
VENLAFAXINE HCL ER
TAB 225MG ER
VENLAFAXINE HCL ER
TAB 37.5 ER
VENLAFAXINE HCL ER
TAB 75MG ER
VIIBRYD
WELLBUTRIN
WELLBUTRINSR
WELLBUTRIN XL
ziprasidone hcl
ZOLOFT
ZYBAN
ZYPREXA
ZYPREXA ZYDIS
DIABETIC SUPPLIES
DIABETIC SUPPLIES
alcohol swabs
gauze pads & dressings
insulin pen needle
Drug
Tier
4
4
4
2
4
4
4
4
2
4
4
2
2
4
2
1
1
2
1
2
2
2
Requirements
/Limits
MO
MO
MO
MO
MO
4
4
4
4
2
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
Requirements
/Limits
insulin syringe/needle u2
100
syringe/needle (disp) 1 ml 2
ELECTROLYTIC, CALORIC, AND WATER
BALANCE
ACIDIFYING AND ALKALINIZING AGENTS
ammonium chloride
2
HI
POTASSIUM CITRATE
3
MO
TAB 1080MG
POTASSIUM CITRATE
3
MO
TAB 540MG
SODIUM LACTATE INJ
3
HI
1/6M
SODIUM LACTATE INJ
4
HI
5MEQ/ML
UROCIT-K 10 TAB
4
MO
UROCIT-K 15 TAB
4
MO
UROCIT-K 5 TAB
4
MO
AMMONIA DETOXICANTS
BUPHENYL
5
CARBAGLU
4
LD,MO
lactulose
2
MO
lactulose
2
(encephalopathy)
RAVICTI
5
sodium phenylbutyrate
2
CALORIC AGENTS
amino acid electrolyte
2
HI
infusion
amino acid infusion
2
HI
AMINOSYN II INJ 10%
4
HI
AMINOSYN II INJ 15%
4
HI
AMINOSYN II INJ 7%
4
HI
AMINOSYN II INJ 8.5%
4
HI
AMINOSYN M INJ 3.5%
4
HI
AMINOSYN-HBC INJ 7% 4
HI
AMINOSYN-PF 7% INJ
4
HI
7%
AMINOSYN-PF INJ 10%
4
HI
CLINIMIX
3
HI
2.75%/DEXTROSE 5%
INJ 2.75/D5W
CLINIMIX
3
HI
4.25%/DEXTROSE 10%
Drug Name
CLINIMIX
4.25%/DEXTROSE 20%
CLINIMIX
4.25%/DEXTROSE 25%
CLINIMIX
4.25%/DEXTROSE 5%
CLINIMIX
5%/DEXTROSE 15%
CLINIMIX
5%/DEXTROSE 20%
CLINIMIX
5%/DEXTROSE 25%
CLINIMIX E
2.75%/DEXTROSE 10%
CLINIMIX E
2.75%/DEXTROSE 5%
CLINIMIX E
4.25%/DEXTROSE 10%
CLINIMIX E
4.25%/DEXTROSE 25%
CLINIMIX E
4.25%/DEXTROSE 5%
CLINIMIX E
5%/DEXTROSE 15%
CLINIMIX E
5%/DEXTROSE 20%
CLINIMIX E
5%/DEXTROSE 25%
DEXTRAN HM
dextrose
fat emulsion
FREAMINE III 3% INJ 3%
FREAMINE III INJ 8.5%
INTRALIPID INJ 30%
LIPOSYN III INJ 10%
LIPOSYN III INJ 20%
NEPHRAMINE INJ 5.4%
PROCALAMINE INJ 3%
PROSOL INJ 20%
RENAMIN INJ 6.5%
TROPHAMINE INJ 10%
TROPHAMINE INJ 6%
DIURETICS
amiloride &
hydrochlorothiazide
Drug
Tier
Requirements
/Limits
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
3
2
2
3
4
4
3
4
3
3
4
3
3
3
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
HI
MO
Drug Name
amiloride hcl
bumetanide inj 0.25/ml
bumetanide tab 0.5mg
bumetanide tab 1mg
bumetanide tab 2mg
chlorothiazide
chlorothiazide sodium
chlorthalidone
DEMADEX
DIURIL
DYAZIDE
DYRENIUM
EDECRIN
furosemide inj 10mg/ml
furosemide sol 10mg/ml
furosemide sol 8mg/ml
furosemide tab 20mg
furosemide tab 40mg
furosemide tab 80mg
hydrochlorothiazide cap
12.5mg
hydrochlorothiazide tab
12.5mg
hydrochlorothiazide tab
25mg
hydrochlorothiazide tab
50mg
indapamide
LASIX
MAXZIDE
MAXZIDE-25
methyclothiazide
metolazone
MICROZIDE
SAMSCA
SODIUM DIURIL
SODIUM EDECRIN
torsemide
triamterene/
hydrochlorothiazide cap
37.5-25
triamterene/
hydrochlorothiazide tab
37.5-25
Drug
Tier
2
2
1
1
2
2
2
2
4
3
4
3
3
2
2
2
1
1
1
Requirements
/Limits
MO
MO
MO
MO
MO
1
4
4
4
2
2
4
4
4
3
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
HI
MO
MO
MO
MO
MO
HI
MO
MO
MO
HI
HI
HI,MO
Drug Name
Drug
Tier
Requirements
/Limits
triamterene/
hydrochlorothiazide tab
1
MO
75-50mg
ION-REMOVING AGENTS
FOSRENOL
5
KAYEXALATE
4
MO
RENAGEL
4
MO
RENVELA PAK 0.8GM
4
MO
RENVELA PAK 2.4GM
3
MO
RENVELA TAB 800MG
4
MO
sodium polystyrene
2
MO
sulfonate
IRRIGATING SOLUTIONS
irrigation solutions,
2
physiological
lactated ringer's
2
(irrigation)
ringer's irrigation
2
sodium chloride (gu
2
irrigant)
water for irrigation, sterile 2
REPLACEMENT PREPARATIONS
calcium acetate
2
MO
(phosphate binder)
DEXTROSE 10%/NACL
3
HI
0.45% INJ 0.45%
DEXTROSE 5%
/ELECTROLYTE #48
3
HI
VIAFLEX
DEXTROSE 10%/NACL
3
HI
0.2% INJ 0.2%
DEXTROSE 5%/NACL
4
HI
0.225% INJ 0.225%
dextrose in lactated
2
HI
ringers
dextrose w/ sodium
2
HI
chloride
electrolyte-h in dextrose
2
HI
electrolyte-m in dextrose
2
HI
electrolyte-s
2
HI
IONOSOL-B/DEXTROSE
4
HI
5%
IONOSOL4
HI
MB/DEXTROSE 5%
Drug Name
ISOLYTE-P/DEXTROSE
5%
K-TABS TAB 10MEQ CR
KCL 0.15%/D5W/LR
KCL 0.15%/D5W/NACL
0.225% INJ 0.15/0.2
KCL 0.3%/D5W/NACL
0.9% INJ 0.3/0.9%
lactated ringer's
MAGNESIUM SULFATE
IN D5W
NORMOSOL-R
NORMOSOL-R IN D5W
parenteral electrolytes
PHOSLO CAP 667MG
PHOSLYRA SOL
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-56/D5W
potassium chloride
POTASSIUM CHLORIDE
0.15% /NACL 0.45%
VIAFLEX INJ .15-0.45
POTASSIUM CHLORIDE
0.3%/ NACL 0.9% INJ
0.3-0.9
potassium chloride in
dextrose
potassium chloride in
dextrose & sodium
chloride
potassium chloride in nacl
POTASSIUM CHLORIDE
INJ 10MEQ
POTASSIUM CHLORIDE
INJ 20MEQ
POTASSIUM CHLORIDE
INJ 30MEQ
POTASSIUM CHLORIDE
INJ 40MEQ
potassium chloride
microencapsulated
crystals cr
ringer's inj
sodium chloride
Drug
Tier
Requirements
/Limits
HI
3
3
MO
HI
HI
HI
HI
HI
4
4
2
4
3
3
3
3
2
HI
HI
HI
MO
HI
HI
HI
HI
HI
HI
HI
HI
HI
MO
2
2
HI
HI
HI
HI
HI
HI,MO
Drug Name
Drug
Tier
3
Requirements
/Limits
HI
Drug Name
Drug
Tier
2
4
polymyxin b-trimethoprim
POLYTRIM
sulfacetamide sodium
2
(ophth)
tobramycin sulfate (ophth) 2
TOBREX OIN 0.3% OP
3
TOBREX SOL 0.3% OP
4
trifluridine
2
VIGAMOX
4
VIROPTIC
4
ZIRGAN
4
ZYMAXID
3
ANTI-INFLAMMATORY AGENTS
ACULAR
4
ACULAR LS
4
ACUVAIL
4
ALREX
4
bacitracin-poly-neomycin2
hc
BECONASE AQ
4
BLEPHAMIDE
3
BROMDAY
4
bromfenac sodium
2
(ophth)
CIPRO HC
4
CIPRODEX
3
COLY-MYCIN S
3
CORTISPORIN
4
CORTISPORIN-TC
3
DERMOTIC
4
dexamethasone sodium
2
phosphate (ophth)
diclofenac sodium (ophth) 2
DUREZOL
4
FLAREX
4
FLONASE
4
flunisolide (nasal)
2
fluocinolone acetonide
2
(otic)
flurbiprofen sodium
2
fluticasone propionate
2
(nasal)
FML FORTE SUS 0.25%
3
OP
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
FML LIQUIFILM SUS
0.1% OP
FML OIN 0.1% OP
hydrocortisone w/acetic
acid
ILEVRO
ketorolac tromethamine
(ophth)
LOTEMAX
MAXIDEX
MAXITROL
NASACORT AQ
NASONEX
neomycin-polymydexameth
neomycin-polymyxin-hc
(ophth)
neomycin-polymyxin-hc
(otic)
NEVANAC
OCUFEN
OMNARIS
OMNIPRED SUS 1% OP
PRED FORTE SUS 1%
OP
PRED MILD SUS 0.12%
OP
PRED-G
PRED-G S.O.P.
prednisolone acetate
(ophth)
prednisolone sodium
phosphate (ophth)
PROLENSA
QNASL
RESTASIS
RHINOCORT AQUA
sulfacetamide sodprednisolone
TOBRADEX OIN 0.30.1%
TOBRADEX ST SUS 0.30.05
TOBRADEX SUS 0.30.1%
Drug
Tier
Requirements
/Limits
4
3
MO
2
4
2
4
4
4
4
4
MO
MO
MO
2
2
4
4
4
4
4
3
3
3
MO
2
2
4
4
4
4
2
MO
MO
4
4
Drug Name
Drug
Tier
tobramycin2
dexamethasone
triamcinolone acetonide
2
(nasal)
VERAMYST
4
VEXOL
4
ZETONNA
4
ZYLET
4
ANTIALLERGIC AGENTS
ALOCRIL
3
ALOMIDE
4
ASTELIN
4
ASTEPRO
4
azelastine hcl
2
azelastine hcl (ophth)
2
BEPREVE
4
cromolyn sodium (ophth)
2
DYMISTA
4
ELESTAT
4
EMADINE
4
epinastine hcl (ophth)
2
LASTACAFT
4
OPTIVAR
4
PATADAY
4
PATANASE
4
PATANOL
4
ANTIGLAUCOMA AGENTS
acetazolamide
2
acetazolamide sodium
2
ALPHAGAN P
4
AZOPT
4
BETAGAN
4
betaxolol hcl (ophth)
2
BETIMOL
4
BETOPTIC-S
4
brimonidine tartrate
2
carteolol hcl (ophth)
2
COMBIGAN
4
COSOPT
4
DIAMOX
4
dorzolamide hcl
2
dorzolamide hcl-timolol
2
maleate
ISOPTO CARPINE SOL
4
1% OP
Requirements
/Limits
MO
MO
HI
MO
Drug Name
Drug
Tier
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
4
4
5
4
3
4
2
COLAZAL
DELZICOL CAP 400MG
DIPENTUM
GIAZO
LIALDA TAB 1.2GM
LOTRONEX
mesalamine w/ cleanser
PENTASA CAP 250MG
3
CR
PENTASA CAP 500MG
3
CR
SFROWASA ENE 4GM
4
ANTIDIARRHEA AGENTS
diphenoxylate w/ atropine 2
FULYZAQ
4
LOMOTIL
4
loperamide hcl
2
MOTOFEN
4
ANTIEMETICS
ALOXI
4
ANTIVERT
4
ANZEMET
4
CESAMET
4
dronabinol
2
EMEND CAP 125MG
3
EMEND CAP 40MG
4
EMEND CAP 80MG
3
EMEND PAK 80 & 125
4
granisetron hcl
2
MARINOL
4
meclizine hcl
2
ondansetron
2
ondansetron hcl
2
SANCUSO
4
TIGAN
4
TRANSDERM-SCOP
3
trimethobenzamide hcl
2
ZOFRAN
4
ZOFRAN ODT
4
ANTIULCER AGENTS AND ACID
SUPPRESSANTS
ACIPHEX
4
AXID
4
CARAFATE SUS
3
1GM/10ML
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
HI
MO
PA,HI,MO
PA
PA,MO
PA,MO
PA,MO
PA,MO
PA,HI,MO
MO
PA,MO
PA,MO
MO
PA,MO
MO
PA,MO
PA,MO
PA,MO
MO
Drug
Tier
CARAFATE TAB 1GM
4
cimetidine
2
cimetidine hcl
2
CYTOTEC
4
DEXILANT
4
famotidine
2
famotidine in nacl
2
HELIDAC
4
lansoprazole
2
misoprostol
2
NEXIUM
4
NEXIUM I.V.
4
nizatidine
2
OMECLAMOX-PAK
4
omeprazole
2
pantoprazole sodium
2
PEPCID
4
PREVACID
4
PREVACID SOLUTAB
4
PREVPAC
4
PRILOSEC
4
PROTONIX INJ 40MG
3
PROTONIX PAK
3
PROTONIX TAB 20MG
4
PROTONIX TAB 40MG
4
PYLERA
4
ranitidine hcl
2
sucralfate
2
ZANTAC INJ
3
ZANTAC
4
ZEGERID
4
CATHARTICS AND LAXATIVES
COLYTE-FLAVOR
4
PACKS
GOLYTELY
4
HALFLYTELY BOWEL
4
PREP/FLAVOR PACKS
MOVIPREP
4
NULYTELY/FLAVOR
4
PACKS
OSMOPREP
4
peg 3350-kcl-sod bicarb2
sod chloride-sod sulfate
Drug Name
Requirements
/Limits
MO
MO
MO
MO
HI,MO
HI
MO
MO
MO
MO
HI
MO
MO
MO
HI,MO
MO
MO
MO
MO
MO
HI
MO
MO
MO
MO
HI,MO
MO
HI
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
peg 3350-potassium
chloride-sod bicarbonate- 2
sod chloride
polyethylene glycol 3350
2
PREPOPIK
4
SUPREP BOWEL PREP
4
DIGESTANTS
CREON CAP 12000UNT
3
CREON CAP 24000UNT
3
CREON CAP 3000UNIT
3
CREON CAP 36000UNT
3
CREON CAP 6000UNIT
3
PANCREAZE CAP
4
10500UNT
PANCREAZE CAP
4
16800UNT
PANCREAZE CAP
4
21000UNT
PANCREAZE CAP
4
4200UNIT
PERTZYE CAP
4
ULTRESA CAP
4
13800UNT
ULTRESA CAP
4
20700UNT
ULTRESA CAP
4
23000UNT
VIOKACE TAB
4
ZENPEP CAP 10000UNT 3
ZENPEP CAP 15000UNT 3
ZENPEP CAP 20000UNT 3
ZENPEP CAP 25000UNT 4
ZENPEP CAP 3000UNIT 4
ZENPEP CAP 5000UNIT 3
GI DRUGS, MISCELLANEOUS
ACTIGALL CAP 300MG
4
AMITIZA
3
chenodiol
2
GATTEX
5
LINZESS
4
metoclopramide hcl
2
METOZOLV ODT
4
REGLAN
4
RELISTOR
4
URSO 250 TAB 250MG
3
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
HI,MO
MO
MO
MO
Drug Name
Drug
Tier
Requirements
/Limits
Drug Name
MEDROL TAB 16MG
MEDROL TAB 2MG
MEDROL TAB 32MG
MEDROL TAB 4MG
MEDROL TAB 8MG
methylprednisolone
methylprednisolone
acetate
methylprednisolone sod
succ
ORAPRED ODT
prednisolone
prednisolone sodium
phosphate
prednisone
RAYOS
SOLU-CORTEF
SOLU-MEDROL INJ
125MG
SOLU-MEDROL INJ 1GM
SOLU-MEDROL INJ 2GM
SOLU-MEDROL INJ
40MG
SOLU-MEDROL INJ
500MG
UCERIS
ANDROGENS
ANDRODERM DIS
2MG/24HR
ANDRODERM DIS
4MG/24HR
ANDROGEL GEL
1%(50MG)
ANDROGEL PUMP GEL
1.62%
ANDROGEL PUMP GEL
PUMP 1%
AXIRON SOL 30MG/ACT
danazol
DELATESTRYL
fluoxymesterone
FORTESTA GEL
10MG/ACT
methyltestosterone
oxandrolone
Drug
Tier
4
3
4
4
4
2
Requirements
/Limits
MO
MO
MO
MO
MO
MO
2
2
4
2
MO
MO
MO
2
4
3
PA,MO
PA
4
3
3
3
3
5
3
3
4
4
3
4
2
4
2
MO
4
2
2
MO
Drug Name
TESTIM GEL 1%(50MG)
testosterone cypionate
testosterone enanthate
CONTRACEPTIVES
BEYAZ
BREVICON-28
CYCLESSA
DESOGEN
desogestrel & ethinyl
estradiol
desogestrel-ethinyl
estradiol (biphasic)
desogestrel-ethinyl
estradiol (triphasic)
drospirenone-ethinyl
estradiol
ELLA
ESTROSTEP FE
ethynodiol diacet & eth
estrad
FEMCON FE
GENERESS FE
levonorgestrel & eth
estradiol
levonorgestrel-eth
estradiol (triphasic)
levonorgestrel-ethinyl
estradiol (91-day)
levonorgestrel-ethinyl
estradiol (continuous)
LO LOESTRIN FE
LOESTRIN 24 FE
LOSEASONIQUE
MINASTRIN 24 FE
MODICON
NOR-QD
NORDETTE-28
norethin acet & estrad-fe
norethindrone & eth
estradiol
norethindrone & ethinyl
estradiol-fe
norethindrone
(contraceptive)
Drug
Tier
4
2
2
Requirements
/Limits
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
3
4
MO
MO
MO
4
4
MO
MO
MO
MO
MO
MO
4
4
4
4
4
4
4
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
norethindrone acet & eth
estra
norethindrone acetateethinyl estradiol-fe
norethindrone-eth
estradiol (biphasic)
norethindrone-eth
estradiol (triphasic)
norgestimate-ethinyl
estradiol
norgestimate-ethinyl
estradiol (triphasic)
norgestrel & ethinyl
estradiol
NORINYL 1+35
NUVARING
ORTHO EVRA
ORTHO MICRONOR
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CEPT
ORTHO-CYCLEN
ORTHO-NOVUM 7/7/7
PLAN B ONE-STEP
SAFYRAL
SEASONIQUE
TRI-NORINYL 28
YASMIN 28
YAZ
DIABETIC AGENTS
acarbose
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS TAB 15MG
ACTOS TAB 30MG
ACTOS TAB 45MG
AMARYL
APIDRA
APIDRA SOLOSTAR
AVANDAMET
AVANDARYL
AVANDIA
BYDUREON
BYETTA
chlorpropamide
Drug
Tier
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
4
3
4
4
4
4
4
4
4
3
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
4
4
3
4
4
4
4
4
4
4
4
4
4
2
MO
MO
MO
MO
MO
MO
MO
LD,MO
LD,MO
LD,MO
MO
Drug Name
CYCLOSET
DIABETA
DUETACT
FORTAMET
glimepiride
glipizide er tab 10mg
glipizide er tab 2.5mg
glipizide er tab 5mg
glipizide tab 10mg
glipizide tab 5mg
glipizide-metformin hcl
GLUCAGEN HYPOKIT
GLUCAGON
EMERGENCY KIT
GLUCOPHAGE
GLUCOPHAGE XR
GLUCOTROL
GLUCOTROL XL
GLUCOVANCE
GLUMETZA
glyburide
glyburide micronized
glyburidemetformin
GLYNASE
GLYSET
HUMALOG INJ 100/ML
HUMALOG KWIKPEN
INJ 100/ML
HUMALOG MIX 50/50
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25
KWIKPEN
HUMULIN 70/30 INJ
70/30
HUMULIN 70/30 PEN INJ
70/30
HUMULIN N INJ U-100
HUMULIN N U-100 PEN
INJ U-100
HUMULIN R INJ U-100
HUMULIN R U-500
(CONCENTRATED) INJ
U-500
Drug
Tier
4
4
4
4
1
2
2
2
1
1
2
3
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
3
4
4
4
4
4
4
2
2
2
4
4
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
4
4
4
4
3
4
3
4
3
3
PA
Drug Name
INVOKANA
JANUMET
JANUMET XR
JANUVIA
JENTADUETO
JUVISYNC
KAZANO
KOMBIGLYZE XR
KORLYM
LANTUS INJ 100/ML
LANTUS SOLOSTAR INJ
SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
metformin hcl er tab
1000mg
metformin hcl er tab
500mg er
metformin hcl er tab
750mg er
metformin hcl tab 1000mg
metformin hcl tab 500mg
metformin hcl tab 850mg
nateglinide
NESINA
NOVOLIN 70/30 INJ
70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
ONGLYZA
OSENI
pioglitazone hcl
pioglitazone
hclglimepiride
pioglitazone hclmetformin hcl
PRANDIMET
PRANDIN
PRECOSE
RIOMET
Drug
Tier
4
4
4
4
4
4
4
4
5
3
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
LD
4
4
4
2
MO
MO
MO
1
1
1
2
4
MO
MO
MO
MO
MO
4
4
4
4
4
4
PA
4
4
4
2
MO
MO
MO
MO
MO
4
3
4
4
MO
MO
MO
Drug Requirements
Tier
/Limits
STARLIX
4
MO
SYMLINPEN 120
4
SYMLINPEN 60
4
tolazamide
2
MO
tolbutamide
2
MO
TRADJENTA
4
MO
VICTOZA
4
ESTROGENS AND ANTIESTROGENS
ACTIVELLA
4
MO
ALORA DIS 0.025MG
4
MO
ALORA DIS 0.05MG
4
MO
ALORA DIS 0.075MG
4
MO
ALORA DIS 0.1MG
4
MO
ANGELIQ
4
MO
CENESTIN
4
MO
CLIMARA DIS 0.025MG
3
MO
CLIMARA DIS 0.0375MG 3
MO
CLIMARA DIS 0.05MG
3
MO
CLIMARA DIS 0.06MG
3
MO
CLIMARA DIS 0.075MG
3
MO
CLIMARA DIS 0.1MG
3
MO
CLIMARA PRO
4
MO
COMBIPATCH
4
MO
DELESTROGEN
4
DIVIGEL GEL 1MG/GM
4
MO
ELESTRIN GEL 0.06%
4
MO
ENJUVIA
4
MO
esterified estrogens
2
MO
estradiol
2
MO
estradiol & norethindrone
2
MO
acetate
estradiol cypionate
2
estradiol vaginal
2
MO
estradiol valerate
2
estradiol-norgestimate
2
MO
ESTRING
3
MO
estropipate
2
MO
EVAMIST SPR 1.53MG
4
EVISTA
3
MO
FEMRING
4
MO
MENOSTAR DIS 14MCG 4
MO
MINIVELLE DIS
4
MO
0.0375MG
MINIVELLE DIS 0.05MG
4
MO
MINIVELLE DIS 0.075MG 4
MO
Drug Name
Drug Name
MINIVELLE DIS 0.1MG
norethindrone acetateethinyl estradiol
PREMARIN
PREMARIN INJ 25MG
PREMARIN TAB 0.3MG
PREMARIN TAB 0.45MG
PREMARIN TAB
0.625MG
PREMARIN TAB 0.9MG
PREMARIN TAB 1.25MG
PREMPHASE
PREMPRO
VAGIFEM
VIVELLE-DOT DIS
0.025MG
VIVELLE-DOT DIS
0.0375MG
VIVELLE-DOT DIS
0.05MG
VIVELLE-DOT DIS
0.075MG
VIVELLE-DOT DIS
0.1MG
GONADOTROPINS
chorionic gonadotropin
SYNAREL
PARATHYROID
calcitonin (salmon)
FORTEO
FORTICAL SPR 200/ACT
MIACALCIN INJ 200/ML
MIACALCIN SPR
200/ACT
PITUITARY
ACTHAR HP
DDAVP
DDAVP INJ 4MCG/ML
DDAVP TAB 0.1MG
DDAVP TAB 0.2MG
desmopressin acetate
desmopressin acetate
spray refrigerated
STIMATE SOL 1.5MG/ML
Drug
Tier
4
Requirements
/Limits
MO
MO
3
3
4
4
MO
MO
4
4
4
4
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
3
2
5
3
3
PA
4
5
4
4
4
4
2
MO
MO
MO
MO
2
3
Drug Name
Drug
Tier
Requirements
/Limits
PROGESTINS
CRINONE
4
MO
DEPO-PROVERA
3
DEPO-PROVERA
CONTRACEPTIVE INJ
4
150MG/ML
DEPO-SUBQ PROVERA
3
104 INJ 104
ENDOMETRIN
4
MO
medroxyprogesterone
2
MO
acetate
medroxyprogesterone
2
acetate (contraceptive)
MEGACE ES
4
norethindrone acetate
2
MO
progesterone micronized
2
MO
PROMETRIUM
4
MO
PROVERA
4
MO
SOMATOTROPIN AGONISTS AND
ANTAGONISTS
EGRIFTA
5
GENOTROPIN INJ 12MG 4
GENOTROPIN INJ 5MG
5
GENOTROPIN
4
MINIQUICK INJ 0.2MG
GENOTROPIN
4
MINIQUICK INJ 0.4MG
GENOTROPIN
4
MINIQUICK INJ 0.6MG
GENOTROPIN
4
MINIQUICK INJ 0.8MG
GENOTROPIN
4
MINIQUICK INJ 1.2MG
GENOTROPIN
4
MINIQUICK INJ 1.4MG
GENOTROPIN
4
MINIQUICK INJ 1.6MG
GENOTROPIN
4
MINIQUICK INJ 1.8MG
GENOTROPIN
4
MINIQUICK INJ 1MG
GENOTROPIN
4
MINIQUICK INJ 2MG
HUMATROPE COMBO
5
PACK INJ 5MG
Drug Name
Drug
Tier
5
5
5
5
Requirements
/Limits
Drug Requirements
Tier
/Limits
THYROLAR-2
4
MO
THYROLAR-3
4
MO
TIROSINT
4
MO
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
acetylcysteine
2
PA
ACTEMRA INJ 162/0.9
5
ACTEMRA INJ 200/10ML 4
HI
ACTIMMUNE
5
LD
ACTONEL
4
alendronate sodium sol
2
70/75ml
alendronate sodium tab
1
10mg
alendronate sodium tab
2
35mg
alendronate sodium tab
2
40mg
alendronate sodium tab
2
5mg
alendronate sodium tab
1
70mg
allopurinol
2
allopurinol sodium
2
HI
ALOPRIM
4
HI
amifostine crystalline
2
HI
AMPYRA
5
ARAVA
4
ARCALYST
5
ATELVIA
4
ATGAM
4
HI
AUBAGIO
5
AVODART
4
AVONEX
5
AVONEX PEN
5
azathioprine
2
PA
azathioprine sodium
2
HI
BENLYSTA
5
BERINERT
5
BETASERON
5
BINOSTO
4
BONIVA
4
PA,HI
BOTOX
3
CARNITOR
4
PA,HI
CELLCEPT CAP 250MG
4
PA
Drug Name
Drug Name
CELLCEPT
INTRAVENOUS
CELLCEPT SUS
200MG/ML
CELLCEPT TAB 500MG
CIMZIA
CINRYZE
COLCRYS
COPAXONE
cyclosporine
cyclosporine modified (for
microemulsion)
CYSTADANE
CYSTAGON CAP 150MG
CYSTAGON CAP 50MG
DEMSER
dexrazoxane
DIDRONEL
disulfiram
DYSPORT
ELMIRON
ENBREL
ENBREL SURECLICK
etidronate disodium
EXTAVIA
finasteride
FIRAZYR
fomepizole
FOSAMAX
FOSAMAX PLUS D
FUSILEV
GILENYA
HEMABATE
HUMIRA
HUMIRA PEN-CROHNS
DISEASE STARTER
ibandronate sodium
IMURAN
JALYN
KINERET
KUVAN
leflunomide
leucovorin calcium
levocarnitine (metabolic
modifiers)
Drug
Tier
Requirements
/Limits
PA,HI
PA
4
5
5
3
5
2
PA
PA
4
4
4
4
2
4
2
4
3
5
5
2
5
2
5
2
4
4
4
5
3
5
LD
HI
PA,HI
HI
HI
HI
5
2
4
4
5
5
2
2
PA,HI
PA
PA,HI
HI
Drug Name
lidocaine hcl (local
anesth.)
mesna
MESNEX INJ 1GM
MESNEX TAB 400MG
methylergonovine
maleate
MIFEPREX
mycophenolate mofetil
MYFORTIC
NEORAL CAP 100MG
NEORAL CAP 25MG
NEORAL SOL 100MG/ML
NULOJIX
octreotide acetate
ORENCIA
ORFADIN
pamidronate disodium
PROCYSBI CAP 25MG
PROCYSBI CAP 75MG
PROGRAF CAP 0.5MG
PROGRAF CAP 1MG
PROGRAF CAP 5MG
PROGRAF INJ 5MG/ML
PROLIA SOL 60MG/ML
PROSCAR
RAPAMUNE SOL
1MG/ML
RAPAMUNE TAB 0.5MG
RAPAMUNE TAB 1MG
RAPAMUNE TAB 2MG
REBIF
REBIF TITRATION PACK
RECLAST
REMICADE
RIMSO-50
SANDIMMUNE
SANDOSTATIN INJ
1000MCG
SANDOSTATIN INJ
100MCG
SANDOSTATIN INJ
200MCG
SANDOSTATIN INJ
500MCG
Drug
Tier
Requirements
/Limits
2
2
4
3
HI
HI
2
3
2
3
4
4
3
5
2
5
5
2
5
5
4
4
4
3
4
4
PA
PA
PA
PA
PA
PA,HI
LD
HI
PA
PA
PA
PA,HI
PA
4
5
5
5
5
4
5
3
3
PA
PA
PA
4
4
4
4
HI
PA,HI
Drug Name
Drug
Tier
SANDOSTATIN INJ
4
50MCG/ML
SANDOSTATIN LAR
5
DEPOT KIT LAR 10MG
SANDOSTATIN LAR
5
DEPOT KIT LAR 20MG
SANDOSTATIN LAR
5
DEPOT KIT LAR 30MG
SENSIPAR TAB 30MG
3
SENSIPAR TAB 60MG
5
SENSIPAR TAB 90MG
5
SIMPONI
5
SIMPONI ARIA
5
SIMULECT
4
SKELID
4
SODIUM FLUORIDE
3
SOMATULINE DEPOT
4
tacrolimus
2
TECFIDERA
5
TECFIDERA STARTER
5
PACK
THALOMID
5
THYMOGLOBULIN
4
TYSABRI
5
ULORIC
4
VORAXAZE
5
XELJANZ
5
XEOMIN
4
XGEVA INJ
5
XYLOCAINE
4
ZAVESCA
5
ZINECARD
3
zoledronic acid
2
ZOMETA
4
ZORTRESS TAB 0.25MG 4
ZORTRESS TAB 0.5MG
5
ZORTRESS TAB 0.75MG 5
ZYLOPRIM
4
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORY AGENTS
ACCOLATE
4
cromolyn sodium
2
cromolyn sodium
2
(mastocytosis)
GASTROCROM
4
Requirements
/Limits
PA,HI
PA,HI
HI
LD
LD
HI
HI
HI
PA
PA
PA
MO
Drug Requirements
Tier
/Limits
montelukast sodium
2
MO
SINGULAIR
3
MO
zafirlukast
2
MO
ZYFLO CR TAB 600MG
5
ZYFLO TAB 600MG
4
MO
RESPIRATORY AGENTS, MISCELLANEOUS
ALVESCO
4
MO
ARALAST NP
5
ASMANEX 120
METERED DOSES AER
3
MO
220MCG
ASMANEX 30 METERED
3
MO
DOSES AER 110MCG
ASMANEX 30 METERED
4
MO
DOSES AER 220MCG
ASMANEX 60 METERED
3
MO
DOSES AER 220MCG
budesonide (inhalation)
2
MO
DALIRESP
4
MO
DULERA
3
MO
FLOVENT DISKUS
4
MO
FLOVENT HFA AER
4
MO
110MCG
FLOVENT HFA AER
4
MO
220MCG
FLOVENT HFA AER
3
MO
44MCG
GLASSIA
5
KALYDECO
5
PROLASTIN-C
5
PULMICORT
3
MO
FLEXHALER INH
180MCG
PULMICORT
4
MO
FLEXHALER INH 90MCG
PULMICORT SUS
4
0.25MG/2
PULMICORT SUS
4
0.5MG/2
PULMICORT SUS
4
1MG/2ML
QVAR
3
MO
SYMBICORT
4
MO
XOLAIR
5
ZEMAIRA
5
Drug Name
Drug Requirements
Tier
/Limits
SERUMS, TOXOIDS, AND VACCINES
SERUMS
ANTIVENIN
LATRODECTUS MAC
3
TANS
CARIMUNE
3
PA,HI
NANOFILTERED
CYTOGAM
3
HI
FLEBOGAMMA DIF
3
HI
GAMASTAN S/D
3
GAMMAGARD LIQUID
3
PA,HI
GAMMAGARD S/D
3
HI
GAMMAPLEX
3
PA,HI
GAMUNEX
3
HI
GAMUNEX-C
3
HI
HYPERRHO S/D
3
HYPERTET S/D
3
IMOGAM RABIES-HT
3
NABI-HB
3
OCTAGAM
3
HI
PRIVIGEN
3
PA,HI
RHOPHYLAC
3
TOXOIDS
TETANUS TOXOID
3
ADSORBED
TETANUS/DIPHTHERIA
TOXOID S-ADSORBED
6
ADULT
VACCINES
ACTHIB
6
ADACEL
6
BOOSTRIX
6
CERVARIX
6
COMVAX
6
DAPTACEL
6
ENGERIX-B
6
PA
GARDASIL
6
HAVRIX
6
IMOVAX RABIES
6
(H.D.C.V.)
INFANRIX
6
IPOL INACTIVATED IPV
6
IXIARO
6
M-M-R II W/DILUENT 10
6
DOSE
Drug Name
Drug Name
Drug
Tier
6
Requirements
/Limits
MENACTRA
MENOMUNE-A/C/Y/W6
135
MENVEO
6
PEDVAX HIB
6
PROQUAD
6
RABAVERT
6
RECOMBIVAX HB
6
PA
ROTATEQ
6
TWINRIX
6
TYPHIM VI
6
VAQTA
6
VARIVAX
6
YF-VAX
6
ZOSTAVAX
6
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN AND MUCOUS
MEMBRANE)
ACANYA
4
MO
acyclovir topical
2
MO
AKNE-MYCIN
3
MO
ALTABAX
4
MO
AVC
3
MO
BACTROBAN
3
MO
BACTROBAN
4
MO
BACTROBAN NASAL
3
MO
BENZAMYCIN
4
MO
benzoyl peroxide2
MO
erythromycin
butoconazole nitrate (one
2
dose)
ciclopirox
2
MO
ciclopirox olamine
2
MO
CLEOCIN CRE 2% VAG
4
MO
CLEOCIN SUP 100MG
3
MO
CLEOCIN-T
4
MO
CLINDAGEL
4
MO
clindamycin phosphate &
2
MO
cleanser
clindamycin phosphate
2
MO
(topical)
clindamycin phosphate
2
MO
vaginal
clindamycin phosphate2
MO
benzoyl peroxide
Drug Name
clotrimazole
clotrimazole (topical)
clotrimazole w/
betamethasone
DENAVIR
econazole nitrate
erythromycin (acne aid)
EURAX
EVOCLIN
EXELDERM
EXTINA
gentamicin sulfate
(topical)
ketoconazole & cleanser
ketoconazole (topical)
KLARON
lindane
LOPROX SHAMPOO
LOTRISONE
mafenide acetate
malathion
MENTAX
METROCREAM
METROGEL
METROGEL-VAGINAL
METROLOTION
metronidazole (topical)
metronidazole vaginal
miconazole nitrate vaginal
mupirocin
mupirocin calcium
(topical)
NAFTIN
neomycin/polymyxin b gu
NIZORAL
nystatin (topical)
OVIDE
OXISTAT
permethrin
PHISOHEX
selenium sulfide
SILVADENE
silver sulfadiazine
SPINOSAD
Drug
Tier
2
2
Requirements
/Limits
MO
MO
MO
4
2
2
4
4
4
4
MO
MO
MO
MO
MO
2
2
4
2
4
4
2
2
4
4
4
4
4
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
2
4
2
4
4
2
3
2
4
2
4
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
Requirements
/Limits
sulfacetamide sodium
2
(acne)
SULFAMYLON CRE
3
MO
85MG/GM
SULFAMYLON PAK 5%
4
TERAZOL 3
4
MO
TERAZOL 7
4
MO
terconazole vaginal
2
MO
ULESFIA
4
MO
XERESE
4
MO
ZOVIRAX
4
MO
ANTI-INFLAMMATORY AGENTS (SKIN AND
MUCOUS MEMBRANE)
alclometasone
2
MO
dipropionate
amcinonide
2
MO
betamethasone
2
MO
dipropionate (topical)
betamethasone
2
MO
dipropionate augmented
betamethasone valerate
2
MO
CAPEX SHA 0.01%
3
clobetasol propionate
2
MO
clobetasol propionate
2
MO
emollient base
CLOBEX
4
CLODERM PUMP
4
MO
CORDRAN TAPE
3
MO
CORTIFOAM
4
MO
CORTISPORIN
3
MO
CUTIVATE
4
MO
DERMA-SMOOTHE/FS
4
MO
BODY OIL OIL /FS BODY
DERMATOP
4
MO
DESONATE
4
MO
desonide
2
MO
DESOWEN
4
MO
desoximetasone
2
MO
DESOXIMETASONE
4
MO
diflorasone diacetate
2
MO
DIPROLENE
4
MO
DIPROLENE AF
4
MO
ELOCON
4
MO
fluocinolone acetonide
2
MO
fluocinonide
2
MO
Drug Name
Drug
Tier
Requirements
/Limits
fluocinonide emulsified
2
MO
base
fluticasone propionate
2
MO
halobetasol propionate
2
MO
HALOG
4
MO
hydrocortisone
2
(intrarectal)
hydrocortisone (rectal)
2
MO
hydrocortisone (topical)
2
MO
hydrocortisone butyrate
2
MO
hydrocortisone valerate
2
MO
KENALOG
3
LOCOID
4
MO
LOCOID LIPOCREAM
4
MO
LUXIQ
4
MO
mometasone furoate
2
MO
nystatin-triamcinolone
2
MO
OLUX-E
4
PANDEL
4
MO
prednicarbate
2
MO
SYNALAR CREAM KIT
4
MO
TACLONEX OIN
5
TACLONEX SUS
4
TEMOVATE
4
MO
TOPICORT
4
MO
triamcinolone acetonide
2
MO
(mouth)
triamcinolone acetonide
2
MO
(topical)
ULTRAVATE
4
MO
urea-hc acetate
2
MO
VANOS
4
MO
VERDESO
4
WESTCORT
4
MO
ANTIPRURITICS AND LOCAL ANESTHETICS
EMLA
4
PA,MO
hydrocortisone acetate w/
2
pramoxine
lidocaine
2
MO
lidocaine hcl
2
MO
lidocaine-prilocaine
2
PA,MO
LIDODERM
4
MO
SYNERA
4
MO
XYLOCAINE
4
ZONALON
4
MO
Kaiser Permanente 2014 Comprehensive Formulary 45
Drug Requirements
Tier
/Limits
CELL STIMULANTS AND PROLIFERANTS
ATRALIN GEL 0.05%
4
PA,MO
KEPIVANCE
5
HI
RETIN-A CRE 0.025%
3
PA,MO
RETIN-A CRE 0.05%
3
PA,MO
RETIN-A CRE 0.1%
3
PA,MO
RETIN-A GEL 0.01%
3
PA,MO
RETIN-A GEL 0.025%
3
PA,MO
RETIN-A MICRO
3
PA,MO
tretinoin
2
PA,MO
tretinoin w/ cleanser &
2
PA,MO
moisturizer
SKIN AND MUCOUS MEMBRANE AGENTS,
MISCELLANEOUS
8-MOP
3
ABSORICA
4
ACZONE
4
MO
adapalene
2
MO
ALDARA
4
MO
AMEVIVE
5
AZELEX
3
MO
calcipotriene
2
MO
CARAC CRE 0.5%
3
MO
CONDYLOX
3
MO
DIFFERIN CRE 0.1%
3
MO
DIFFERIN GEL 0.1%
3
MO
DIFFERIN GEL 0.3%
3
MO
DIFFERIN LOT 0.1%
4
DOVONEX
4
MO
EFUDEX CRE 5%
4
MO
ELIDEL
3
MO
EPIDUO
3
MO
FINACEA
3
MO
FLECTOR
4
MO
FLUOROPLEX CRE 1%
3
MO
fluorouracil (topical)
2
MO
imiquimod
2
MO
isotretinoin
2
LAC-HYDRIN
4
MO
lactic acid (ammonium
2
MO
lactate)
ORACEA
4
MO
OXSORALEN
3
OXSORALEN ULTRA
3
PANRETIN
5
Drug Name
Drug
Tier
PENNSAID
4
PICATO
4
podofilox
2
PROTOPIC
3
PRUDOXIN
3
RECTIV
4
REGRANEX
5
SANTYL
3
SOLARAZE
4
SORIATANE
5
SORILUX
4
STELARA
5
TARGRETIN
3
TAZORAC
4
UVADEX
4
VALCHLOR
5
VECTICAL
3
VELTIN
4
VEREGEN
4
VOLTAREN
4
ZIANA
4
ZYCLARA
4
SMOOTH MUSCLE RELAXANTS
SMOOTH MUSCLE RELAXANTS
aminophylline
2
DETROL
4
DETROL LA
4
DITROPAN XL
4
ENABLEX
4
flavoxate hcl
2
GELNIQUE
4
GELNIQUE GEL 3%
4
LUFYLLIN
4
MYRBETRIQ
4
oxybutynin chloride
2
OXYTROL DIS 3.9MG/24 3
SANCTURA
4
SANCTURA XR
4
theophylline
2
tolterodine tartrate
2
TOVIAZ
4
trospium chloride
2
VESICARE
4
Drug Name
Requirements
/Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
LD
MO
MO
MO
MO
MO
MO
HI
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
VITAMINS
VITAMINS
calcitriol
HECTOROL
niacin (antihyperlipidemic)
ROCALTROL CAP
0.25MCG
ROCALTROL CAP
0.5MCG
ROCALTROL SOL
1MCG/ML
TRINATAL RX 1
VINATE CALCIUM
VITASPIRE
ZEMPLAR
Drug
Tier
Requirements
/Limits
2
4
2
PA,HI,MO
PA,HI,MO
MO
PA,MO
PA,MO
PA
3
3
3
4
MO
MO
MO
PA,HI,MO
Index of Drugs
8
8-MOP ........................................................ 46
A
BETAPACE ................................................ 21
BETAPACE AF........................................... 21
BETASERON ............................................. 41
betaxolol hcl ............................................... 21
betaxolol hcl (ophth) ................................... 33
bethanechol chloride .................................. 16
BETHKIS NEB 300/4ML ............................... 9
BETIMOL ................................................... 33
BETOPTIC-S .............................................. 33
BEYAZ ....................................................... 37
BIAXIN ......................................................... 9
BIAXIN XL .................................................... 9
BIAXIN XL PAC ............................................ 9
bicalutamide ............................................... 14
BICILLIN C-R ............................................... 9
BICILLIN L-A ................................................ 9
BICNU ........................................................ 14
BIDIL .......................................................... 20
BILTRICIDE.................................................. 9
BINOSTO ................................................... 41
bisoprolol & hydrochlorothiazide ................. 21
bisoprolol fumarate ..................................... 21
bleomycin sulfate........................................ 14
BLEPH-10 .................................................. 32
BLEPHAMIDE ............................................ 32
BONIVA ...................................................... 41
BOOSTRIX ................................................. 43
BOSULIF .................................................... 14
BOTOX ....................................................... 41
BREVICON-28 ........................................... 37
BRILINTA ................................................... 17
brimonidine tartrate .................................... 33
BROMDAY ................................................. 32
bromfenac sodium (ophth) .......................... 32
bromocriptine mesylate .............................. 26
BROVANA .................................................. 17
budesonide ................................................. 36
budesonide (inhalation) .............................. 43
bumetanide inj 0.25/ml ............................... 30
bumetanide tab 0.5mg ................................ 30
bumetanide tab 1mg ................................... 30
bumetanide tab 2mg ................................... 30
BUPHENYL ................................................ 29
BUPRENEX................................................ 22
buprenorphine hcl ....................................... 22
buprenorphine hcl-naloxone hcl dihydrate .. 27
bupropion hcl .............................................. 27
bupropion hcl (smoking deterrent) .............. 27
buspirone hcl tab 10mg .............................. 26
buspirone hcl tab 15mg .............................. 26
buspirone hcl tab 30mg .............................. 26
CARDIZEM................................................. 18
CARDIZEM CD .......................................... 18
CARDIZEM LA ........................................... 18
CARDURA.................................................. 18
CARDURA XL ............................................ 18
CARIMUNE NANOFILTERED .................... 43
carisoprodol ................................................ 16
carisoprodol w/ aspirin ................................ 16
carisoprodol w/ aspirin & codeine ............... 16
CARNITOR................................................. 41
carteolol hcl (ophth) .................................... 33
carvedilol .................................................... 21
CASODEX .................................................. 14
CATAFLAM ................................................ 22
CATAPRES ................................................ 19
CATAPRES-TTS-1 ..................................... 19
CATAPRES-TTS-2 ..................................... 19
CATAPRES-TTS-3 ..................................... 19
CAYSTON .................................................... 9
CEDAX ......................................................... 9
CEENU ....................................................... 14
cefaclor ......................................................... 9
cefaclor monohydrate ................................... 9
cefadroxil ...................................................... 9
cefazolin in d5w ............................................ 9
cefazolin sodium ........................................... 9
CEFAZOLIN SODIUM/DEXTROSE ............. 9
cefdinir .......................................................... 9
cefepime hcl ................................................. 9
cefixime ........................................................ 9
cefotaxime sodium ....................................... 9
cefotetan disodium ....................................... 9
cefoxitin sodium ............................................ 9
CEFOXITIN SODIUM ................................... 9
cefpodoxime proxetil..................................... 9
cefprozil ........................................................ 9
ceftazidime ................................................... 9
CEFTAZIDIME/DEXTROSE ......................... 9
CEFTIN SUS 125/5ML ................................. 9
CEFTIN SUS 250/5ML ................................. 9
CEFTIN TAB 250MG .................................... 9
CEFTIN TAB 500MG .................................... 9
ceftriaxone sodium ....................................... 9
CEFTRIAXONE/DEXTROSE ....................... 9
cefuroxime axetil .......................................... 9
cefuroxime sodium ....................................... 9
CEFUROXIME/DEXTROSE ......................... 9
CELEBREX ................................................ 22
CELESTONE.............................................. 36
CELEXA ..................................................... 27
CELLCEPT CAP 250MG ............................ 41
COREG CR ................................................ 21
CORGARD ................................................. 21
CORTEF .................................................... 36
CORTIFOAM .............................................. 45
cortisone acetate ........................................ 36
CORTISPORIN .................................... 32, 45
CORTISPORIN-TC..................................... 32
CORZIDE ................................................... 21
COSMEGEN .............................................. 14
COSOPT .................................................... 33
COUMADIN ................................................ 17
COZAAR .................................................... 20
CREON CAP 12000UNT ............................ 35
CREON CAP 24000UNT ............................ 35
CREON CAP 3000UNIT ............................. 35
CREON CAP 36000UNT ............................ 35
CREON CAP 6000UNIT ............................. 35
CRESTOR .................................................. 18
CRINONE ................................................... 40
CRIXIVAN .................................................. 12
cromolyn sodium ........................................ 42
cromolyn sodium (mastocytosis) ................ 42
cromolyn sodium (ophth) ............................ 33
CUBICIN .................................................... 10
CUPRIMINE ............................................... 36
CUTIVATE.................................................. 45
CUVPOSA SOL 1MG/5ML ......................... 15
CYCLESSA ................................................ 37
cyclobenzaprine hcl .................................... 16
cyclophosphamide ...................................... 14
cycloserine ................................................. 11
CYCLOSET ................................................ 38
cyclosporine ............................................... 41
cyclosporine modified (for microemulsion).. 41
CYKLOKAPRON INJ 100MG/ML ............... 17
CYMBALTA ................................................ 27
cyproheptadine hcl ..................................... 13
CYSTADANE ............................................. 41
CYSTAGON CAP 150MG .......................... 41
CYSTAGON CAP 50MG ............................ 41
CYSTARAN ................................................ 34
cytarabine ................................................... 14
CYTOGAM ................................................. 43
CYTOMEL .................................................. 40
CYTOTEC .................................................. 35
CYTOVENE................................................ 12
D
dacarbazine ................................................ 14
DACOGEN ................................................. 14
DALIRESP.................................................. 43
danazol ....................................................... 36
DANTRIUM ................................................. 16
dantrolene sodium ...................................... 16
dapsone ...................................................... 11
DAPTACEL ................................................. 43
DARAPRIM ................................................. 11
daunorubicin hcl .......................................... 14
DAUNOXOME ............................................ 14
DAYPRO .................................................... 22
DAYTRANA ................................................ 24
DDAVP ....................................................... 39
DDAVP INJ 4MCG/ML ................................ 39
DDAVP TAB 0.1MG .................................... 39
DDAVP TAB 0.2MG .................................... 39
DELATESTRYL .......................................... 36
DELESTROGEN......................................... 39
DELZICOL CAP 400MG ............................. 34
DEMADEX .................................................. 30
demeclocycline hcl ...................................... 10
DEMEROL .................................................. 22
DEMSER .................................................... 41
DENAVIR .................................................... 44
DEPACON .................................................. 24
DEPAKENE ................................................ 24
DEPAKOTE ................................................ 24
DEPAKOTE ER .......................................... 24
DEPAKOTE SPRINKLES ........................... 24
DEPEN TITRATABS ................................... 36
DEPO-MEDROL INJ 20MG/ML .................. 36
DEPO-MEDROL INJ 40MG/ML .................. 36
DEPO-MEDROL INJ 80MG/ML .................. 36
DEPO-PROVERA ....................................... 40
DEPO-PROVERA CONTRACEPTIVE INJ
150MG/ML .............................................. 40
DEPO-SUBQ PROVERA 104 INJ 104 ........ 40
DERMA-SMOOTHE/FS BODY OIL OIL /FS
BODY ...................................................... 45
DERMATOP ............................................... 45
DERMOTIC................................................. 32
desipramine hcl........................................... 27
desloratadine .............................................. 13
desmopressin acetate ................................. 39
desmopressin acetate spray refrigerated .... 39
DESOGEN .................................................. 37
desogestrel & ethinyl estradiol .................... 37
desogestrel-ethinyl estradiol (biphasic) ....... 37
desogestrel-ethinyl estradiol (triphasic) ....... 37
DESONATE ................................................ 45
desonide ..................................................... 45
DESOWEN ................................................. 45
desoximetasone.......................................... 45
DESOXIMETASONE .................................. 45
DESOXYN .................................................. 24
DESVENLAFAXINE ER ............................. 27
DETROL ..................................................... 46
DETROL LA ............................................... 46
dexamethasone .......................................... 36
dexamethasone sodium phosphate ............ 36
dexamethasone sodium phosphate (ophth) 32
dexchlorpheniramine maleate..................... 13
DEXEDRINE .............................................. 24
DEXILANT .................................................. 35
dexmethylphenidate hcl .............................. 24
dexrazoxane ............................................... 41
DEXTRAN HM............................................ 30
dextroamphetamine sulfate ........................ 24
dextrose ..................................................... 30
DEXTROSE 10%/NACL 0.2% INJ 0.2%..... 31
DEXTROSE 10%/NACL 0.45% INJ 0.45%. 31
DEXTROSE 5% /ELECTROLYTE #48
VIAFLEX ................................................. 31
DEXTROSE 5%/NACL 0.225% INJ 0.225%31
dextrose in lactated ringers ........................ 31
dextrose w/ sodium chloride ....................... 31
DIABETA .................................................... 38
DIAMOX ..................................................... 33
diazepam .................................................... 26
DIAZEPAM ................................................. 26
DIBENZYLINE ............................................ 16
diclofenac potassium .................................. 22
diclofenac sodium ....................................... 22
diclofenac sodium (ophth) .......................... 32
diclofenac w/ misoprostol ........................... 22
dicloxacillin sodium ..................................... 10
dicyclomine hcl ........................................... 15
didanosine .................................................. 12
DIDRONEL ................................................. 41
DIFFERIN CRE 0.1% ................................. 46
DIFFERIN GEL 0.1%.................................. 46
DIFFERIN GEL 0.3%.................................. 46
DIFFERIN LOT 0.1% .................................. 46
DIFICID ...................................................... 10
diflorasone diacetate .................................. 45
DIFLUCAN ................................................. 11
diflunisal ..................................................... 22
digoxin ........................................................ 19
DIGOXIN SOL 50MCG/ML ......................... 19
dihydroergotamine mesylate ...................... 16
DILANTIN ................................................... 24
DILATRATE SR CAP 40MG ....................... 20
DILAUDID INJ 1MG/ML.............................. 22
DILAUDID INJ 2MG/ML.............................. 22
DUEXIS ...................................................... 22
DULERA ..................................................... 43
DUONEB SOL ............................................ 17
DURAGESIC .............................................. 22
DUREZOL .................................................. 32
DUTOPROL ............................................... 21
DYAZIDE .................................................... 30
DYMISTA ................................................... 33
DYRENIUM ................................................ 30
DYSPORT .................................................. 41
E
E.E.S. GRANULES .................................... 10
EC-NAPROSYN ......................................... 22
econazole nitrate ........................................ 44
EDARBI ...................................................... 20
EDARBYCLOR........................................... 20
EDECRIN ................................................... 30
EDLUAR ..................................................... 26
EDURANT .................................................. 12
EFFEXOR XR CAP 150MG ....................... 27
EFFEXOR XR CAP 37.5MG ...................... 27
EFFEXOR XR CAP 75MG ......................... 27
EFFIENT .................................................... 17
EFUDEX CRE 5% ...................................... 46
EGRIFTA .................................................... 40
ELAPRASE ................................................ 32
ELDEPRYL................................................. 26
electrolyte-h in dextrose ............................. 31
electrolyte-m in dextrose ............................ 31
electrolyte-s ................................................ 31
ELELYSO ................................................... 32
ELESTAT ................................................... 33
ELESTRIN GEL 0.06%............................... 39
ELIDEL ....................................................... 46
ELIGARD ................................................... 14
ELIQUIS ..................................................... 17
ELITEK ....................................................... 32
ELLA .......................................................... 37
ELLENCE ................................................... 14
ELMIRON ................................................... 41
ELOCON .................................................... 45
ELOXATIN INJ 100MG............................... 14
ELOXATIN INJ 200MG............................... 14
ELSPAR ..................................................... 14
EMADINE ................................................... 33
EMCYT ....................................................... 14
EMEND CAP 125MG ................................. 34
EMEND CAP 40MG ................................... 34
EMEND CAP 80MG ................................... 34
EMEND PAK 80 & 125 ............................... 34
EMLA .......................................................... 45
EMSAM ...................................................... 26
EMTRIVA .................................................... 12
ENABLEX ................................................... 46
enalapril maleate ........................................ 20
enalapril maleate & hydrochlorothiazide ..... 20
ENBREL ..................................................... 41
ENBREL SURECLICK ................................ 41
ENDOMETRIN............................................ 40
ENGERIX-B ................................................ 43
ENJUVIA .................................................... 39
enoxaparin sodium ..................................... 17
entacapone ................................................. 26
ENTOCORT EC.......................................... 36
EPIDUO ...................................................... 46
epinastine hcl (ophth).................................. 33
EPIPEN 2-PAK INJ 0.3MG ......................... 17
EPIPEN-JR 2-PAK INJ 2-PAK .................... 17
epirubicin hcl ............................................... 14
EPIVIR HBV SOL 5MG/ML ......................... 12
EPIVIR HBV TAB 100MG ........................... 12
EPIVIR SOL 10MG/ML ............................... 12
EPIVIR TAB 150MG ................................... 12
EPIVIR TAB 300MG ................................... 12
eplerenone .................................................. 20
EPOGEN INJ 10000/ML ............................. 18
EPOGEN INJ 2000/ML ............................... 18
EPOGEN INJ 20000/ML ............................. 18
EPOGEN INJ 3000/ML ............................... 18
EPOGEN INJ 4000/ML ............................... 18
eprosartan mesylate ................................... 20
EPZICOM ................................................... 12
EQUETRO .................................................. 24
ERAXIS ...................................................... 11
ERBITUX .................................................... 14
ergoloid mesylates ...................................... 16
ergotamine tartrate ..................................... 16
ergotamine w/ caffeine ................................ 25
ERIVEDGE ................................................. 14
ERYPED 200 .............................................. 10
ERYPED 400 .............................................. 10
ERYTHROCIN LACTOBIONATE................ 10
erythromycin (acne aid) .............................. 44
erythromycin (ophth) ................................... 32
erythromycin base ...................................... 10
erythromycin ethylsuccinate ........................ 10
erythromycin lactobionate ........................... 10
erythromycin stearate ................................. 10
escitalopram oxalate ................................... 27
estazolam ................................................... 26
esterified estrogens..................................... 39
estradiol ...................................................... 39
estradiol & norethindrone acetate ............... 39
estradiol cypionate ..................................... 39
estradiol vaginal ......................................... 39
estradiol valerate ........................................ 39
estradiol-norgestimate ................................ 39
ESTRING ................................................... 39
estropipate.................................................. 39
ESTROSTEP FE ........................................ 37
ethambutol hcl ............................................ 11
ethosuximide .............................................. 24
ethynodiol diacet & eth estrad .................... 37
etidronate disodium .................................... 41
etodolac ...................................................... 22
ETOPOPHOS............................................. 14
etoposide .................................................... 14
EURAX ....................................................... 44
EVAMIST SPR 1.53MG.............................. 39
EVISTA ...................................................... 39
EVOCLIN ................................................... 44
EVOXAC .................................................... 16
EXALGO TAB 12MG .................................. 22
EXALGO TAB 16MG .................................. 22
EXALGO TAB 8MG .................................... 22
EXELDERM................................................ 44
EXELON ..................................................... 16
exemestane ................................................ 14
EXFORGE .................................................. 18
EXFORGE HCT ......................................... 18
EXJADE TAB 125MG ................................. 36
EXJADE TAB 250MG ................................. 36
EXJADE TAB 500MG ................................. 36
EXTAVIA .................................................... 41
EXTINA ...................................................... 44
F
FABRAZYME ............................................. 32
famciclovir .................................................. 12
famotidine ................................................... 35
famotidine in nacl ....................................... 35
FAMVIR ...................................................... 12
FANAPT ..................................................... 27
FANAPT TITRATION PACK ....................... 28
FARESTON ................................................ 14
FASLODEX ................................................ 14
fat emulsion ................................................ 30
FAZACLO TAB 100/ODT ........................... 28
FAZACLO TAB 12.5/ODT .......................... 28
FAZACLO TAB 150MG .............................. 28
FAZACLO TAB 200MG .............................. 28
FAZACLO TAB 25MG ODT ........................ 28
felbamate .................................................... 24
FELBATOL ................................................. 24
FELDENE ................................................... 22
felodipine .................................................... 19
FEMARA ..................................................... 14
FEMCON FE............................................... 37
FEMRING ................................................... 39
fenofibrate ................................................... 18
fenofibrate micronized................................. 18
FENOGLIDE ............................................... 18
fenoprofen calcium ..................................... 22
fentanyl ....................................................... 22
fentanyl citrate ............................................ 22
FENTORA................................................... 22
FERRIPROX ............................................... 36
FIBRICOR................................................... 18
FINACEA .................................................... 46
finasteride ................................................... 41
FIORICET/CODEINE .................................. 22
FIORINAL ................................................... 22
FIORINAL/CODEINE #3 ............................. 22
FIRAZYR .................................................... 41
FIRMAGON ................................................ 14
FLAGYL ...................................................... 11
FLAGYL ER ................................................ 11
FLAREX ...................................................... 32
flavoxate hcl ................................................ 46
FLEBOGAMMA DIF .................................... 43
flecainide acetate ........................................ 19
FLECTOR ................................................... 46
FLOMAX ..................................................... 16
FLONASE ................................................... 32
FLO-PRED.................................................. 36
FLOVENT DISKUS ..................................... 43
FLOVENT HFA AER 110MCG.................... 43
FLOVENT HFA AER 220MCG.................... 43
FLOVENT HFA AER 44MCG...................... 43
fluconazole.................................................. 11
fluconazole in dextrose ............................... 11
flucytosine ................................................... 11
fludarabine phosphate ................................ 14
fludrocortisone acetate................................ 36
flunisolide (nasal) ........................................ 32
fluocinolone acetonide ................................ 45
fluocinolone acetonide (otic) ....................... 32
fluocinonide................................................. 45
fluocinonide emulsified base ....................... 45
FLUOROPLEX CRE 1% ............................. 46
fluorouracil .................................................. 14
fluorouracil (topical)..................................... 46
fluoxetine dr cap 90mg dr ........................... 28
HERCEPTIN ............................................... 14
HEXALEN ................................................... 14
HIPREX ...................................................... 13
HORIZANT ................................................. 24
HUMALOG INJ 100/ML .............................. 38
HUMALOG KWIKPEN INJ 100/ML ............. 38
HUMALOG MIX 50/50 ................................ 38
HUMALOG MIX 50/50 KWIKPEN ............... 38
HUMALOG MIX 75/25 ................................ 38
HUMALOG MIX 75/25 KWIKPEN ............... 38
HUMATROPE COMBO PACK INJ 5MG ..... 40
HUMATROPE INJ 12MG ............................ 40
HUMATROPE INJ 24MG ............................ 40
HUMATROPE INJ 6MG .............................. 40
HUMIRA ..................................................... 41
HUMIRA PEN-CROHNS DISEASE
STARTER ............................................... 41
HUMULIN 70/30 INJ 70/30 ......................... 38
HUMULIN 70/30 PEN INJ 70/30 ................. 38
HUMULIN N INJ U-100 ............................... 38
HUMULIN N U-100 PEN INJ U-100 ............ 38
HUMULIN R INJ U-100 ............................... 38
HUMULIN R U-500 (CONCENTRATED) INJ
U-500 ...................................................... 38
HYCAMTIN ................................................. 14
hydralazine hcl inj 20mg/ml ......................... 19
hydralazine hcl tab 100mg .......................... 19
hydralazine hcl tab 10mg ............................ 19
hydralazine hcl tab 25mg ............................ 19
hydralazine hcl tab 50mg ............................ 19
HYDREA ..................................................... 14
hydrochlorothiazide cap 12.5mg ................. 30
hydrochlorothiazide tab 12.5mg .................. 30
hydrochlorothiazide tab 25mg ..................... 30
hydrochlorothiazide tab 50mg ..................... 30
hydrocodone-acetaminophen ..................... 22
hydrocodone-ibuprofen ............................... 23
hydrocortisone ............................................ 36
hydrocortisone (intrarectal) ......................... 45
hydrocortisone (rectal) ................................ 45
hydrocortisone (topical) ............................... 45
hydrocortisone acetate w/ pramoxine ......... 45
hydrocortisone butyrate .............................. 45
hydrocortisone sod succinate ..................... 36
hydrocortisone valerate............................... 45
hydrocortisone w/acetic acid ....................... 33
hydromorphone hcl ..................................... 23
hydroxychloroquine sulfate ......................... 11
hydroxyurea ................................................ 14
hydroxyzine hcl ........................................... 26
hydroxyzine pamoate .................................. 26
IONOSOL-MB/DEXTROSE 5% .................. 31
IOPIDINE SOL 0.5% OP ............................. 34
IOPIDINE SOL 1% OP................................ 34
IPOL INACTIVATED IPV ............................ 43
ipratropium bromide .................................... 16
ipratropium bromide (nasal) ........................ 16
ipratropium-albuterol ................................... 17
irbesartan .................................................... 20
irbesartan-hydrochlorothiazide .................... 20
irinotecan hcl............................................... 14
irrigation solutions, physiological................. 31
ISENTRESS CHW 100MG ......................... 12
ISENTRESS CHW 25MG ........................... 12
ISENTRESS TAB 400MG ........................... 12
ISOLYTE-P/DEXTROSE 5% ...................... 31
isoniazid ...................................................... 11
isoniazid & rifampin ..................................... 11
ISOPTO CARPINE SOL 1% OP ................. 33
ISOPTO CARPINE SOL 2% OP ................. 34
ISOPTO CARPINE SOL 4% OP ................. 34
ISORDIL TITRADOSE TAB 40MG ............. 20
ISORDIL TITRADOSE TAB 5MG ............... 20
isosorbide dinitrate ...................................... 20
isosorbide mononitrate er tab 120mg er...... 20
isosorbide mononitrate er tab 30mg er........ 20
isosorbide mononitrate er tab 60mg er........ 20
isosorbide mononitrate tab 10mg ................ 21
isosorbide mononitrate tab 20mg ................ 21
isotretinoin .................................................. 46
isradipine .................................................... 19
ISTALOL ..................................................... 34
ISTODAX .................................................... 14
itraconazole ................................................ 11
IXEMPRA KIT ............................................. 14
IXIARO ....................................................... 43
J
JAKAFI ....................................................... 14
JALYN ........................................................ 41
JANUMET ................................................... 38
JANUMET XR ............................................. 38
JANUVIA .................................................... 38
JENTADUETO ............................................ 38
JEVTANA.................................................... 14
JUVISYNC .................................................. 38
JUXTAPID .................................................. 18
K
KADCYLA ................................................... 14
KADIAN CAP 100MG CR ........................... 23
KADIAN CAP 10MG CR ............................. 23
Kaiser Permanente 2014 Comprehensive Formulary 60
LO LOESTRIN FE ...................................... 37
LOCOID ...................................................... 45
LOCOID LIPOCREAM ................................ 45
LODOSYN .................................................. 26
LOESTRIN 24 FE ....................................... 37
LOMOTIL .................................................... 34
loperamide hcl ............................................ 34
LOPID ......................................................... 18
LOPRESSOR ............................................. 21
LOPRESSOR HCT ..................................... 21
LOPROX SHAMPOO.................................. 44
lorazepam ................................................... 26
losartan potassium ...................................... 20
losartan potassium & hydrochlorothiazide... 20
LOSEASONIQUE ....................................... 37
LOTEMAX................................................... 33
LOTENSIN .................................................. 20
LOTENSIN HCT ......................................... 20
LOTREL ...................................................... 19
LOTRISONE ............................................... 44
LOTRONEX ................................................ 34
lovastatin .................................................... 18
LOVAZA ..................................................... 18
LOVENOX .................................................. 17
loxapine succinate ...................................... 28
LUFYLLIN ................................................... 46
LUMIGAN ................................................... 34
LUMIZYME ................................................. 32
LUNESTA ................................................... 26
LUPRON DEPOT ....................................... 14
LUPRON DEPOT-PED ............................... 14
LUPRON DEPOT-PED INJ 11.25MG ......... 15
LUPRON DEPOT-PED INJ 15MG .............. 15
LUPRON DEPOT-PED INJ 7.5MG ............. 15
LUVOX CR ................................................. 28
LUXIQ ......................................................... 45
LYRICA ....................................................... 25
LYSODREN ................................................ 15
LYSTEDA TAB 650MG ............................... 17
M
MACROBID ................................................ 13
MACRODANTIN CAP 100MG .................... 13
MACRODANTIN CAP 25MG ...................... 13
mafenide acetate ........................................ 44
magnesium sulfate ...................................... 25
MAGNESIUM SULFATE............................. 25
MAGNESIUM SULFATE IN D5W ............... 31
MALARONE................................................ 11
malathion .................................................... 44
maprotiline hcl............................................. 28
MARINOL ................................................... 34
MARPLAN .................................................. 28
MATULANE ................................................ 15
MAVIK ........................................................ 20
MAXAIR AUTOHALER ............................... 17
MAXALT ..................................................... 25
MAXALT-MLT............................................. 25
MAXIDEX ................................................... 33
MAXIPIME .................................................. 10
MAXITROL ................................................. 33
MAXZIDE ................................................... 30
MAXZIDE-25 .............................................. 30
mecamylamine hcl ...................................... 19
meclizine hcl ............................................... 34
meclofenamate sodium .............................. 23
MEDROL DOSEPAK PAK 4MG ................. 36
MEDROL TAB 16MG ................................. 36
MEDROL TAB 2MG ................................... 36
MEDROL TAB 32MG ................................. 36
MEDROL TAB 4MG ................................... 36
MEDROL TAB 8MG ................................... 36
medroxyprogesterone acetate .................... 40
medroxyprogesterone acetate (contraceptive)
............................................................... 40
mefenamic acid .......................................... 23
mefloquine hcl ............................................ 12
MEGACE ES .............................................. 40
MEGACE ORAL ......................................... 15
megestrol acetate ....................................... 15
MEKINIST .................................................. 15
meloxicam .................................................. 23
MELOXICAM .............................................. 23
melphalan hcl ............................................. 15
MENACTRA ............................................... 44
MENOMUNE-A/C/Y/W-135 ........................ 44
MENOSTAR DIS 14MCG ........................... 39
MENTAX .................................................... 44
MENVEO .................................................... 44
meperidine hcl ............................................ 23
meprobamate ............................................. 26
MEPRON ................................................... 12
mercaptopurine .......................................... 15
meropenem ................................................ 10
MERREM ................................................... 10
mesalamine w/ cleanser ............................. 34
mesna ........................................................ 42
MESNEX INJ 1GM ..................................... 42
MESNEX TAB 400MG................................ 42
MESTINON SYP 60MG/5ML ...................... 16
MESTINON TAB 60MG .............................. 16
MESTINON TIMESPAN TAB TIMESPAN .. 16
METROLOTION ......................................... 44
metronidazole ............................................. 12
metronidazole (topical) ............................... 44
metronidazole in nacl.................................. 12
metronidazole vaginal................................. 44
MEVACOR ................................................. 18
mexiletine hcl.............................................. 19
MIACALCIN INJ 200/ML............................. 39
MIACALCIN SPR 200/ACT ........................ 39
MICARDIS .................................................. 20
MICARDIS HCT ......................................... 20
miconazole nitrate vaginal .......................... 44
MICROZIDE ............................................... 30
midodrine hcl .............................................. 17
MIFEPREX ................................................. 42
MIGRANAL................................................. 16
MINASTRIN 24 FE ..................................... 37
MINIPRESS................................................ 18
MINIVELLE DIS 0.0375MG ........................ 39
MINIVELLE DIS 0.05MG ............................ 39
MINIVELLE DIS 0.075MG .......................... 39
MINIVELLE DIS 0.1MG .............................. 39
MINOCIN .................................................... 10
minocycline hcl ........................................... 10
minoxidil ..................................................... 19
MIRAPEX ................................................... 26
MIRAPEX ER ............................................. 26
mirtazapine ................................................. 28
misoprostol ................................................. 35
mitomycin ................................................... 15
mitoxantrone hcl ......................................... 15
M-M-R II W/DILUENT 10 DOSE ................. 43
MOBIC ....................................................... 23
modafinil ..................................................... 24
MODICON .................................................. 37
moexipril hcl ............................................... 20
moexipril-hydrochlorothiazide ..................... 20
mometasone furoate................................... 45
montelukast sodium.................................... 43
MONUROL ................................................. 13
morphine sulfate ......................................... 23
MORPHINE SULFATE SOL 20MG/ML ...... 23
MORPHINE SULFATE TAB 15MG ............ 23
MORPHINE SULFATE TAB 30MG ............ 23
MOTOFEN ................................................. 34
MOVIPREP ................................................ 35
MOXATAG ................................................. 10
MOXEZA .................................................... 32
MOZOBIL ................................................... 18
MS CONTIN TAB 100MG CR..................... 23
MS CONTIN TAB 15MG CR ...................... 23
NATACYN .................................................. 32
nateglinide .................................................. 38
NAVANE .................................................... 28
NEBUPENT INH 300MG ............................ 12
nefazodone hcl ........................................... 28
neomycin sulfate ........................................ 10
neomycin/polymyxin b gu ........................... 44
neomycin-bacitracin zn-polymyxin .............. 32
neomycin-polymy-dexameth ....................... 33
neomycin-polymy-gramicid ......................... 32
neomycin-polymyxin-hc (ophth) .................. 33
neomycin-polymyxin-hc (otic) ..................... 33
NEORAL CAP 100MG................................ 42
NEORAL CAP 25MG.................................. 42
NEORAL SOL 100MG/ML .......................... 42
NEPHRAMINE INJ 5.4% ............................ 30
NESINA ...................................................... 38
NEULASTA ................................................ 18
NEUMEGA ................................................. 18
NEUPOGEN ............................................... 18
NEUPRO .................................................... 26
NEURONTIN .............................................. 25
NEVANAC .................................................. 33
nevirapine ................................................... 12
NEXAVAR .................................................. 15
NEXIUM ..................................................... 35
NEXIUM I.V. ............................................... 35
NEXTERONE ............................................. 19
niacin (antihyperlipidemic) .......................... 47
NIASPAN ................................................... 18
nicardipine hcl ............................................ 19
NICOTROL INHALER INH ......................... 16
NICOTROL NS SPR 10MG/ML .................. 16
nifedipine .................................................... 19
NILANDRON .............................................. 15
nimodipine .................................................. 19
NIPENT ...................................................... 15
NIRAVAM ................................................... 26
nisoldipine .................................................. 19
NITRO-DUR DIS 0.1MG/HR ...................... 21
NITRO-DUR DIS 0.2MG/HR ...................... 21
NITRO-DUR DIS 0.3MG/HR ...................... 21
NITRO-DUR DIS 0.4MG/HR ...................... 21
NITRO-DUR DIS 0.6MG/HR ...................... 21
NITRO-DUR DIS 0.8MG/HR ...................... 21
nitrofurantoin .............................................. 13
nitrofurantoin macrocrystal ......................... 13
nitrofurantoin monohyd macro .................... 13
nitroglycerin ................................................ 21
NITROLINGUAL PUMPSPRAY SPR
PUMPSPRA ........................................... 21
NUCYNTA ER ............................................ 23
NUEDEXTA ................................................ 27
NULOJIX .................................................... 42
NULYTELY/FLAVOR PACKS..................... 35
NUTROPIN AQ INJ 10MG/2ML.................. 40
NUTROPIN AQ NUSPIN 5 INJ NUSPIN 5 . 40
NUTROPIN AQ PEN INJ 10MG/2ML ......... 40
NUTROPIN AQ PEN INJ 20MG/2ML ......... 40
NUTROPIN INJ 10MG................................ 40
NUVARING ................................................ 37
NUVIGIL ..................................................... 24
nystatin ....................................................... 11
nystatin (mouth-throat) ............................... 11
nystatin (topical) ......................................... 44
nystatin-triamcinolone................................. 45
O
OCTAGAM ................................................. 43
octreotide acetate ....................................... 42
OCUFEN .................................................... 33
OCUFLOX .................................................. 32
ofloxacin ..................................................... 10
ofloxacin (ophth) ......................................... 32
ofloxacin (otic) ............................................ 32
olanzapine .................................................. 28
olanzapine-fluoxetine hcl ............................ 28
OLEPTRO .................................................. 28
OLUX-E ...................................................... 45
OMECLAMOX-PAK .................................... 35
omeprazole................................................. 35
OMNARIS................................................... 33
OMNIPRED SUS 1% OP ........................... 33
OMNITROPE INJ 10/1.5ML ....................... 40
OMNITROPE INJ 5.8MG ............................ 40
OMNITROPE INJ 5/1.5ML ......................... 40
ONCASPAR ............................................... 15
ondansetron ............................................... 34
ondansetron hcl .......................................... 34
ONFI........................................................... 25
ONGLYZA .................................................. 38
ONMEL TAB 200MG .................................. 11
ONSOLIS ................................................... 23
ONTAK ....................................................... 15
OPANA ....................................................... 23
OPANA ER (CRUSH RESISTANT) ............ 23
OPSUMIT ................................................... 21
OPTIVAR ................................................... 33
ORACEA .................................................... 46
ORAP ......................................................... 28
ORAPRED ODT ......................................... 36
ORENCIA ................................................... 42
ORFADIN.................................................... 42
orphenadrine citrate .................................... 16
orphenadrine w/ aspirin & caff..................... 23
ORTHO EVRA ............................................ 37
ORTHO MICRONOR .................................. 37
ORTHO TRI-CYCLEN ................................ 37
ORTHO TRI-CYCLEN LO ........................... 37
ORTHO-CEPT ............................................ 37
ORTHO-CYCLEN ....................................... 37
ORTHO-NOVUM 7/7/7 ............................... 37
OSENI ........................................................ 38
OSMOPREP ............................................... 35
OVIDE ........................................................ 44
oxacillin sodium .......................................... 10
oxaliplatin .................................................... 15
oxandrolone ................................................ 36
oxaprozin .................................................... 23
oxazepam ................................................... 26
oxcarbazepine ............................................ 25
OXECTA ..................................................... 23
OXISTAT .................................................... 44
OXSORALEN ............................................. 46
OXSORALEN ULTRA ................................. 46
oxybutynin chloride ..................................... 46
oxycodone hcl ............................................. 23
oxycodone w/ acetaminophen .................... 23
oxycodone-aspirin ....................................... 23
oxycodone-ibuprofen .................................. 23
OXYCONTIN .............................................. 23
oxymorphone hcl ........................................ 23
OXYTROL DIS 3.9MG/24 ........................... 46
P
paclitaxel ..................................................... 15
PAMELOR .................................................. 28
pamidronate disodium................................. 42
PAMINE ...................................................... 16
PAMINE FORTE ......................................... 16
PANCREAZE CAP 10500UNT ................... 35
PANCREAZE CAP 16800UNT ................... 35
PANCREAZE CAP 21000UNT ................... 35
PANCREAZE CAP 4200UNIT .................... 35
PANDEL ..................................................... 45
PANRETIN.................................................. 46
pantoprazole sodium................................... 35
PARAFON FORTE DSC ............................. 16
parenteral electrolytes................................. 31
PARLODEL................................................. 26
PARNATE ................................................... 28
paromomycin sulfate ................................... 12
paroxetine hcl er tab 12.5mg ...................... 28
PROVERA .................................................. 40
PROVIGIL .................................................. 24
PROZAC .................................................... 28
PROZAC WEEKLY..................................... 28
PRUDOXIN ................................................ 46
PULMICORT FLEXHALER INH 180MCG .. 43
PULMICORT FLEXHALER INH 90MCG .... 43
PULMICORT SUS 0.25MG/2 ..................... 43
PULMICORT SUS 0.5MG/2 ....................... 43
PULMICORT SUS 1MG/2ML ..................... 43
PULMOZYME ............................................. 32
PURINETHOL ............................................ 15
PYLERA ..................................................... 35
pyrazinamide .............................................. 11
pyridostigmine bromide .............................. 16
Q
QNASL ....................................................... 33
QUALAQUIN .............................................. 12
quetiapine fumarate .................................... 28
QUILLIVANT XR SUS XR .......................... 24
quinapril hcl ................................................ 20
quinapril-hydrochlorothiazide ...................... 20
quinidine gluconate .................................... 19
QUINIDINE GLUCONATE.......................... 19
quinidine sulfate ......................................... 19
quinine sulfate ............................................ 12
QVAR ......................................................... 43
R
REGRANEX................................................ 46
RELENZA DISKHALER .............................. 12
RELISTOR .................................................. 35
RELPAX ..................................................... 26
REMERON ................................................. 28
REMERON SOLTAB .................................. 28
REMICADE ................................................. 42
REMODULIN .............................................. 21
RENAGEL................................................... 31
RENAMIN INJ 6.5% .................................... 30
RENVELA PAK 0.8GM ............................... 31
RENVELA PAK 2.4GM ............................... 31
RENVELA TAB 800MG .............................. 31
REQUIP ...................................................... 26
REQUIP XL................................................. 26
RESCRIPTOR ............................................ 12
RESCULA ................................................... 34
RESERPINE ............................................... 19
RESTASIS .................................................. 33
RESTORIL .................................................. 26
RETIN-A CRE 0.025% ................................ 46
RETIN-A CRE 0.05% .................................. 46
RETIN-A CRE 0.1% .................................... 46
RETIN-A GEL 0.01% .................................. 46
RETIN-A GEL 0.025% ................................ 46
RETIN-A MICRO ........................................ 46
RETROVIR CAP 100MG ............................ 12
RETROVIR IV INFUSION INJ 10MG/ML .... 12
RETROVIR SYP 50MG/5ML....................... 12
REVATIO .................................................... 21
REVLIMID ................................................... 15
REYATAZ CAP 100MG .............................. 12
REYATAZ CAP 150MG .............................. 12
REYATAZ CAP 200MG .............................. 12
REYATAZ CAP 300MG .............................. 13
RHEUMATREX ........................................... 15
RHINOCORT AQUA ................................... 33
RHOPHYLAC ............................................. 43
ribavirin (hepatitis c) .................................... 13
RIDAURA.................................................... 36
RIFADIN ..................................................... 11
rifampin ....................................................... 11
RIFATER .................................................... 11
RILUTEK .................................................... 27
riluzole ........................................................ 27
rimantadine hydrochloride ........................... 13
RIMSO-50 ................................................... 42
ringer's inj ................................................... 31
ringer's irrigation ......................................... 31
RIOMET ...................................................... 38
RISPERDAL ............................................... 29
RABAVERT ................................................ 44
ramipril ....................................................... 20
RANEXA .................................................... 19
ranitidine hcl ............................................... 35
RAPAFLO................................................... 16
RAPAMUNE SOL 1MG/ML ........................ 42
RAPAMUNE TAB 0.5MG ........................... 42
RAPAMUNE TAB 1MG .............................. 42
RAPAMUNE TAB 2MG .............................. 42
RAVICTI ..................................................... 29
RAYOS ....................................................... 36
RAZADYNE ................................................ 16
RAZADYNE ER .......................................... 16
REBETOL................................................... 12
REBIF......................................................... 42
REBIF TITRATION PACK .......................... 42
RECLAST ................................................... 42
RECOMBIVAX HB ..................................... 44
RECTIV ...................................................... 46
REGLAN .................................................... 35
REGONOL INJ 5MG/ML ............................ 16
Kaiser Permanente 2014 Comprehensive Formulary 69
SAVELLA .................................................... 27
SAVELLA TITRATION PACK ..................... 27
SEASONIQUE ............................................ 37
secobarbital sodium .................................... 26
SECTRAL ................................................... 22
selegiline hcl ............................................... 26
selenium sulfide .......................................... 44
SELZENTRY............................................... 13
SEMPREX-D .............................................. 13
SENSIPAR TAB 30MG ............................... 42
SENSIPAR TAB 60MG ............................... 42
SENSIPAR TAB 90MG ............................... 42
SEREVENT DISKUS .................................. 17
SEROQUEL ................................................ 29
SEROQUEL XR .......................................... 29
SEROSTIM ................................................. 40
sertraline hcl ............................................... 29
SFROWASA ENE 4GM .............................. 34
SIGNIFOR .................................................. 40
sildenafil citrate (pulmonary hypertension) .. 21
SILENOR .................................................... 26
SILVADENE................................................ 44
silver sulfadiazine ....................................... 44
SIMBRINZA ................................................ 34
SIMCOR ..................................................... 18
SIMPONI .................................................... 42
SIMPONI ARIA ........................................... 42
SIMULECT.................................................. 42
simvastatin .................................................. 18
SINEMET .................................................... 26
SINEMET CR.............................................. 26
SINGULAIR ................................................ 43
SIRTURO.................................................... 11
SKELAXIN .................................................. 16
SKELID ....................................................... 42
SKLICE ......................................................... 9
sodium chloride........................................... 31
sodium chloride (gu irrigant) ....................... 31
SODIUM DIURIL ......................................... 30
SODIUM EDECRIN .................................... 30
SODIUM FLUORIDE .................................. 42
SODIUM LACTATE INJ 1/6M ..................... 29
SODIUM LACTATE INJ 5MEQ/ML ............. 29
sodium phenylbutyrate ................................ 29
sodium polystyrene sulfonate...................... 31
SOLARAZE................................................. 46
SOLODYN .................................................. 10
SOLTAMOX ................................................ 15
SOLU-CORTEF .......................................... 36
SOLU-MEDROL INJ 125MG ...................... 36
SOLU-MEDROL INJ 1GM .......................... 36
sulfasalazine ............................................... 10
sulindac ...................................................... 23
sumatriptan succinate ................................. 26
SUMAVEL DOSEPRO ................................ 26
SUPRAX ..................................................... 10
SUPREP BOWEL PREP ............................ 35
SURMONTIL............................................... 29
SUSTIVA .................................................... 13
SUTENT ..................................................... 15
SYLATRON ................................................ 15
SYMBICORT .............................................. 43
SYMBYAX .................................................. 29
SYMLINPEN 120 ........................................ 39
SYMLINPEN 60 .......................................... 39
SYNAGIS .................................................... 13
SYNALAR CREAM KIT............................... 45
SYNALGOS-DC .......................................... 23
SYNAREL ................................................... 39
SYNERA ..................................................... 45
SYNERCID ................................................. 10
SYNRIBO.................................................... 15
SYNTHROID............................................... 40
SYPRINE .................................................... 36
syringe/needle (disp) 1 ml ........................... 29
T
TABLOID .................................................... 15
TACLONEX OIN ......................................... 45
TACLONEX SUS ........................................ 45
tacrolimus ................................................... 42
TAFINLAR .................................................. 15
TALWIN ...................................................... 23
TAMIFLU CAP 30MG ................................. 13
TAMIFLU CAP 45MG ................................. 13
TAMIFLU CAP 75MG ................................. 13
TAMIFLU SUS 12MG/ML ........................... 13
TAMIFLU SUS 6MG/ML ............................. 13
tamoxifen citrate ......................................... 15
tamsulosin hcl ............................................. 16
TARCEVA ................................................... 15
TARGRETIN ......................................... 15, 46
TARKA ........................................................ 19
TASIGNA .................................................... 15
TASMAR ..................................................... 26
TAXOTERE INJ 20/0.5ML .......................... 15
TAXOTERE INJ 80MG/2ML........................ 15
TAXOTERE INJ 80MG/4ML........................ 15
TAZORAC................................................... 46
TECFIDERA ............................................... 42
TECFIDERA STARTER PACK ................... 42
TEFLARO ................................................... 10
U
UCERIS ...................................................... 36
ULESFIA ..................................................... 45
ULORIC ...................................................... 42
ULTRACET ................................................. 23
ULTRAM ..................................................... 23
ULTRAM ER ............................................... 23
ULTRAVATE............................................... 45
ULTRESA CAP 13800UNT ......................... 35
ULTRESA CAP 20700UNT ......................... 35
ULTRESA CAP 23000UNT ......................... 35
UNASYN ..................................................... 10
UNASYN BULK PACK ................................ 10
UNIRETIC ................................................... 20
UNIVASC .................................................... 20
urea-hc acetate ........................................... 45
UROCIT-K 10 TAB...................................... 29
UROCIT-K 15 TAB...................................... 29
UROCIT-K 5 TAB ....................................... 29
UROXATRAL .............................................. 16
URSO 250 TAB 250MG .............................. 35
URSO FORTE TAB 500MG ........................ 36
ursodiol ....................................................... 36
UVADEX ..................................................... 46
V
VAGIFEM.................................................... 39
valacyclovir hcl ............................................ 13
VALCHLOR ................................................ 46
VALCYTE SOL 50MG/ML ........................... 13
VALCYTE TAB 450MG ............................... 13
VALIUM ...................................................... 26
valproate sodium ........................................ 25
valproic acid ................................................ 25
valsartan-hydrochlorothiazide ..................... 20
VALSTAR ................................................... 15
VALTREX ................................................... 13
VANCOCIN HCL ......................................... 10
vancomycin hcl ........................................... 10
VANCOMYCIN HCL IN DEXTROSE .......... 10
VANOS ....................................................... 45
VANTAS ..................................................... 15
VAQTA ....................................................... 44
VARIVAX .................................................... 44
VASCEPA ................................................... 18
VASERETIC ............................................... 20
VASOTEC................................................... 20
VECTIBIX ................................................... 15
VECTICAL .................................................. 46
VELCADE ................................................... 15
VELTIN ....................................................... 46
Kaiser Permanente 2014 Comprehensive Formulary 73
venlafaxine hcl............................................ 29
VENLAFAXINE HCL ER TAB 150MG ER .. 29
VENLAFAXINE HCL ER TAB 225MG ER .. 29
VENLAFAXINE HCL ER TAB 37.5 ER ....... 29
VENLAFAXINE HCL ER TAB 75MG ER .... 29
VENTAVIS.................................................. 21
VENTOLIN HFA AER ................................. 17
VERAMYST................................................ 33
verapamil hcl .............................................. 19
VERDESO .................................................. 45
VEREGEN .................................................. 46
VERELAN................................................... 19
VERELAN PM ............................................ 19
VESICARE ................................................. 46
VEXOL ....................................................... 33
VFEND IV INJ 200MG ................................ 11
VFEND SUS 40MG/ML .............................. 11
VFEND TAB 200MG................................... 11
VFEND TAB 50MG..................................... 11
VIBATIV ..................................................... 11
VIBRAMYCIN ............................................. 11
VICOPROFEN............................................ 23
VICTOZA .................................................... 39
VICTRELIS ................................................. 13
VIDAZA ...................................................... 15
VIDEX EC CAP 125MG.............................. 13
VIDEX EC CAP 200MG.............................. 13
VIDEX EC CAP 250MG.............................. 13
VIDEX EC CAP 400MG.............................. 13
VIDEX PEDIATRIC SOL 2GM .................... 13
VIGAMOX................................................... 32
VIIBRYD ..................................................... 29
VIMOVO ..................................................... 23
VIMPAT ...................................................... 25
VINATE CALCIUM ..................................... 47
vinblastine sulfate ....................................... 15
vincristine sulfate ........................................ 15
vinorelbine tartrate ...................................... 15
VIOKACE TAB ........................................... 35
VIRACEPT ................................................. 13
VIRAMUNE SUS 50MG/5ML...................... 13
VIRAMUNE TAB 200MG ............................ 13
VIRAMUNE XR TAB 100MG ...................... 13
VIRAMUNE XR TAB 400MG ...................... 13
VIRAZOLE.................................................. 13
VIREAD ...................................................... 13
VIROPTIC .................................................. 32
VISTARIL ................................................... 26
VISTIDE ..................................................... 13
VITASPIRE................................................. 47
VIVELLE-DOT DIS 0.025MG ..................... 39
YF-VAX ...................................................... 44
Z
zafirlukast ................................................... 43
zaleplon ...................................................... 26
ZALTRAP ................................................... 15
ZANAFLEX ................................................. 16
ZANOSAR .................................................. 15
ZANTAC ..................................................... 35
ZANTAC INJ............................................... 35
ZARONTIN ................................................. 25
ZAVESCA................................................... 42
ZEBETA ..................................................... 22
ZEGERID ................................................... 35
ZELAPAR ................................................... 26
ZELBORAF ................................................ 15
ZEMAIRA ................................................... 43
ZEMPLAR .................................................. 47
ZENPEP CAP 10000UNT .......................... 35
ZENPEP CAP 15000UNT .......................... 35
ZENPEP CAP 20000UNT .......................... 35
ZENPEP CAP 25000UNT .......................... 35
ZENPEP CAP 3000UNIT ........................... 35
ZENPEP CAP 5000UNIT ........................... 35
ZERIT ......................................................... 13
ZESTORETIC............................................. 20
ZESTRIL .................................................... 20
ZETIA ......................................................... 18
ZETONNA .................................................. 33
ZIAC ........................................................... 22
ZIAGEN SOL 20MG/ML ............................. 13
ZIAGEN TAB 300MG ................................. 13
ZIANA......................................................... 46
zidovudine .................................................. 13
ZINACEF .................................................... 11
ZINACEF IN ISO-OSMOTIC DEXTROSE .. 11
ZINACEF IN ISO-OSMOTIC DILUENT ...... 11
ZINC TRACE METAL ................................. 32
ZINECARD ................................................. 42
ZIOPTAN .................................................... 34
ziprasidone hcl ........................................... 29
ZIRGAN...................................................... 32
ZITHROMAX INJ 500MG ........................... 11
This formulary was updated on 12/01/2013. For more recent information or other questions,
please contact the number for your Kaiser Permanente Region listed below, seven days a
week, 8 a.m. to 8 p.m. or visit kp.org/seniormedrx.
HAWAII REGION
Kaiser Foundation Health Plan, Inc.
711 Kapiolani Blvd.
Tower Suite 400
Honolulu, HI 96813
Kaiser Permanente Senior Advantage
(HMO)
COLORADO REGION
Kaiser Foundation Health Plan of Colorado
2500 South Havana Street
Aurora, CO 80014-1622
GEORGIA REGION
Kaiser Foundation Health Plan
of Georgia, Inc.
Nine Piedmont Center
3495 Piedmont Road NE
Atlanta, GA 30305
NORTHWEST REGION
Kaiser Foundation Health Plan
of the Northwest
500 NE Multnomah Street, Suite 100
Portland, OR 97232
kp.org/seniormedrx
Please recycle.
MOM 60174808 01/2014