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Kaiser Permanente

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.

Kaiser Permanente Regions


CALIFORNIA REGIONS
Kaiser Permanente Senior Advantage
(HMO) and Senior Advantage Medicare
Medi-Cal Plan (HMO SNP)
Member Service Contact Center
1-800-443-0815 TTY 711
COLORADO REGION
Kaiser Permanente Senior Advantage (HMO),
Senior Advantage Medicare Medicaid Plan
(HMO SNP), and Senior Advantage Plus
Choice (HMO-POS)
Member Service Contact Center
1-800-476-2167 TTY 711
GEORGIA REGION
Kaiser Permanente Senior Advantage (HMO)
and Senior Advantage Medicare Medicaid
Plan (HMO SNP)
Member Services
1-800-232-4404 TTY 711

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.

What is the Kaiser Permanente


formulary?
A formulary is a list of covered drugs selected
by our plan in consultation with a team of
health care providers, which represents the
prescription therapies believed to be a
necessary part of a quality treatment
program. Our plan will generally cover the
drugs listed on our formulary as long as the
drug is medically necessary, the prescription
is filled at a network pharmacy, and other
plan rules are followed. Our plan covers all
drugs that can be included in a Medicare
Part D prescription drug plan according to
Medicare requirements. For more
information on how to fill your prescriptions,
please review your Evidence of Coverage.

Can the formulary (drug list)


change?
Generally, if you are taking a drug on our
2014 formulary that was covered at the
beginning of the year, we will not discontinue
or reduce coverage of the drug during the
2014 coverage year except when a new, less
expensive generic drug becomes available or
when new adverse information about the
safety or effectiveness of a drug is released.
Other types of formulary changes, such as
removing a drug from our formulary, will not
affect members who are currently taking the
drug. It will remain available at the same costsharing for those members taking it for the
remainder of the coverage year. We feel it is
important that you have continued access for
the remainder of the coverage year to the
formulary drugs that were available when you
chose our plan, except for cases in which you
can save additional money or we can ensure
your safety.

If we remove drugs from our formulary, or add


prior authorization, or move a drug to a higher
cost-sharing tier, we must notify affected
members of the change at least 60 days
before the change becomes effective, or at
the time the member requests a refill of the
drug, at which time the member will receive a
60-day supply of the drug. If the Food and
Drug Administration (FDA) deems a drug on
our formulary to be unsafe or the drugs
manufacturer removes the drug from the
market, we will immediately remove the drug
from our formulary and provide notice to
members who take the drug. The enclosed
formulary is current as of January 1, 2014. To
get updated information about the drugs
covered by our plan, please contact us.
Contact information for your Kaiser
Permanente Region appears on the front and
back cover pages.
In the event of a midyear non-maintenance
formulary change, we will provide details in
the Medicare Part D Explanation of Benefits
or Provision of Notice posted at
kp.org/seniormedrx.

How do I use the formulary?


There are two ways to find your drug within
the formulary:
Medical condition

The formulary begins on page 8. The drugs


in this formulary are grouped into
categories depending on the type of
medical conditions that they are used to
treat. For example, drugs used to treat a
heart condition are listed under the category
Cardiovascular Drugs. If you know what
your drug is used for, look for the category
name in the list that begins on page 9. Then
look under the category name for your drug.

Kaiser Permanente 2014 Comprehensive Formulary 3

Alphabetical listing

What are specialty-tier drugs?

If you are not sure what category to look


under, you should look for your drug in the
index that begins on page 48. The index
provides an alphabetical list of all of the drugs
included in this document. Preferred generic
and brand-name drugs, nonpreferred generic
and brand-name drugs, specialty-tier drugs,
and injectable vaccines are listed in the index.
Look in the index and find your drug. Next to
your drug, you will see the page number
where you can find coverage information.
Turn to the page listed in the index and find
the name of your drug in the first column of
the list.

Specialty-tier drugs are very high-cost drugs


approved by the FDA that are on
our formulary.

What are generic drugs?


Our plan covers both brand-name drugs and
generic drugs. A generic drug is approved by
the FDA as having the same active ingredient
as the brand-name drug. Generally, generic
drugs cost less than brand-name and
specialty-tier drugs. Cost sharing for preferred
generic drugs may be different than for
nonpreferred generic drugs. Please see your
Evidence of Coverage for more information.

What are brand-name drugs?


Brand-name drugs are manufactured and
sold by the pharmaceutical company that
originally researched and developed the drug.
When the patent on a brand-name drug
expires, other pharmaceutical companies
may manufacture and sell an FDA-approved
generic version of the drug with the same
active ingredient(s) at lower prices. Cost
sharing for preferred brand-name drugs may
be different than for nonpreferred brand-name
drugs. Please see your Evidence of Coverage
for more information.

What are injectable Part D


vaccines?
Part D vaccines are certain injectable
vaccines that are covered under Medicare
Part D (for example, Zostavax for shingles,
Adacel for Diphtheria, Tetanus, and
Pertussis, which are approved by the FDA).

Are there any restrictions on


my coverage?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:

Prior Authorization: Our plan may


require you or your network provider to
get prior authorization for certain
drugs. This means that you will need
to get approval from our plan before
you fill your prescriptions. If you dont
get approval, we may not cover the
drug.

Note: If your prescription has more than one


refill remaining, you can only get one refill at a
time, unless authorized because you will be
away from our service area for an extended
period of time. For certain drugs, we may limit
the amount of an extended day supply
(amounts that exceed a 30-day supply) that
you can receive. Also, if there is a shortage in
the marketplace, we may charge one Part D
cost sharing for a limited quantity.
You can find out if your drug has any
additional requirements or limits by looking on
the formulary that begins on page 8. You can

Kaiser Permanente 2014 Comprehensive Formulary 4

also get more information about the


restrictions applied to specific covered drugs
by visiting our Web site. 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 can ask us to make an exception to
these restrictions or limits or for a list of other,
similar drugs that may treat your health
condition. See the section, How do I request
an exception to the Kaiser Permanente
formulary? on this page for information about
how to request an exception.

What if my drug is not on


the formulary?
If your drug is not included on this formulary
(list of covered drugs), you should first check
our Kaiser Permanente 2014 Comprehensive
Formulary at kp.org/seniormedrx or call our
plan at the number listed on the front and
back cover pages for your Kaiser Permanente
Region and confirm if your drug is covered.
Our plan covers all Medicare Part D drugs. In
the rare case that your Medicare Part D
prescription drug is not on our Kaiser
Permanente 2014 Comprehensive Formulary,
you have two options:

You can ask your network provider to


prescribe a similar drug that is
included on our formulary.

You can ask us to make an exception


and cover your drug. See the next
section for information about how to
request an exception.

How do I request an exception to


the Kaiser Permanente formulary?
You can ask us to make an exception to our
coverage rules. There are several types of
exceptions that you can ask us to make.

You can ask us to cover a drug even if


it may not be on our Kaiser
Permanente 2014 Comprehensive
Formulary. If approved, this drug will
be covered at a pre-determined costsharing level, and you would not be
able to ask us to provide the drug at a
lower cost-sharing level.

You can ask us to cover a Part D


formulary drug at a lower cost-sharing
level if this drug is not on the specialty
tier (Tier 5), subject to our tiering
exception process. If approved, this
would lower the amount you may pay
for your drug.

You can ask us to waive coverage


restrictions or limits on your drug. For
example, if your drug requires prior
authorization, you can ask us to waive
the prior authorization requirement for
your Part D drug.

Generally, we will only approve your request


for an exception if the alternative drugs
included on the plans formulary, the lower
cost-sharing drug or additional utilization
restrictions would not be as effective in
treating your condition or would cause you to
have adverse medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering or
utilization restriction exception. When you
request a formulary, tiering or utilization
restriction exception, you should submit a
statement from your network provider
supporting your request. Generally, we
must make our decision within 72 hours of
getting your prescribers supporting
statement. You can request an expedited
(fast) exception if you or your network
provider believes that your health could be
seriously harmed by waiting up to 72 hours
for a decision. If your request to expedite is
granted, we must give you a decision no later

Kaiser Permanente 2014 Comprehensive Formulary 5

than 24 hours after we get a supporting


statement from your network provider or other
prescriber.
Please note: You can only request an
exception for drugs that are considered
Medicare Part D prescription drugs by the
Centers for Medicare & Medicaid Services
(CMS). You cannot get an exception for drugs
that are excluded under Medicare Part D or
for obtaining a brand-name drug (Tier 3) at
the cost sharing that applies to generic drugs.
Please refer to your Evidence of Coverage for
more information about requesting
exceptions, including the appeals process.

What do I do before I can talk to


my network provider about
changing my drugs or requesting
an exception?
In rare cases, you might be taking Medicare
Part D drugs that are not on our formulary.
Or, you may be taking a drug that is on our
formulary but your ability to get it is limited.
For example, you may need a prior
authorization from us before you can fill your
prescription. You should talk to your network
provider to decide if you should switch to an
appropriate drug that we cover or request a
formulary exception so that we will cover the
drug you take. While you talk to your network
provider to determine the right course of
action for you, we may cover your drug in
certain cases during the first 90 days you are
a member of our plan.
For each of your Part D drugs that may not be
on our formulary or if your ability to get your
drugs is limited, we will cover a temporary
one-month supply (unless you have a
prescription written for fewer days) when you
go to a network pharmacy. After your first
one-month supply, we may cover an
additional refill, as medically necessary. After

you have used these refills, we will not pay for


these drugs.
If you are a resident of a long-term care
facility, we will allow you to refill your
prescription until we have provided you with
up to a 98-day transition supply, consistent
with the dispensing increment, (unless you
have a prescription written for fewer days).
We will cover more than one refill of these
drugs for the first 90 days you are a member
of our plan. If you need a drug that is not on
our formulary or if your ability to get your
drugs is limited, but you are past the first 90
days of membership in our plan, we will cover
a 31-day emergency supply of that drug
(unless you have a prescription written for
fewer days) while you pursue a formulary
exception.
As a current member of our plan, if you have
a covered inpatient stay in the hospital or in a
skilled nursing facility, the drugs you obtain
during your stay will be covered under your
medical benefit rather than your Medicare
Part D prescription drug coverage. When you
are discharged home or to a custodial level of
care at a long-term care facility, many
outpatient prescription drugs you obtain at a
pharmacy may be covered under your
Medicare Part D coverage. Since your drug
coverage is different depending on the setting
where you obtain the drug, it is possible that a
drug you were taking that was covered under
your medical benefit might not be covered by
Medicare Part D (for example, over-thecounter drugs, or cough medicine). If this
happens, you will have to pay full price for
that drug unless you have other coverage (for
example, employer-sponsored group
coverage).

Kaiser Permanente 2014 Comprehensive Formulary 6

date we last updated the formulary, appears


on the front and back cover pages.

For more information


For more detailed information about our
prescription drug coverage, please review
your Evidence of Coverage and other plan
materials.
If you have questions about our plan, please
contact us. Contact information for your
Kaiser Permanente Region, along with the

If you have general questions about Medicare


prescription drug coverage, please call
Medicare at 1-800-MEDICARE (1-800-6334227), 24 hours a day/7 days a week. TTY
users should call 1-877-486-2048. Or, visit
www.medicare.gov.

Kaiser Permanente 2014 Comprehensive Formulary 7

Kaiser Permanentes Formulary


The formulary that begins on the next page provides
coverage information about some of the drugs
covered by our plan. If you have trouble finding your
drug in the list, turn to the index that begins on page
48.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., ALBENZA)
and generic drugs are listed in lower-case italics
(e.g., amoxicillin).
The second column, Drug Tier, will indicate what
tier number the drug is in:
Tier 1 Preferred generic drugs
Tier 2 Nonpreferred generic drugs
Tier 3 Preferred brand-name drugs
Tier 4 Nonpreferred brand-name drugs

Part D drugs. Please check with your group benefits


administrator or see your Evidence of Coverage.
The information in the Requirements/Limits column
tells you if our plan has any special requirements for
coverage of your drug. Certain strengths or forms of
the drug may be subject to the utilization
management codes listed below.
HI = Home infusion drugs may be covered under
our medical benefit and obtained at home infusion
pharmacies. For more information, please consult
your pharmacy directory or call our plan at the
number listed on the front and back cover pages for
your Kaiser Permanente Region.
LD = Limited-distribution drugs can only be obtained
at certain specialty pharmacies. For more
information, consult your pharmacy directory or call
our plan at the number listed on the front and back
cover pages for your Kaiser Permanente Region.

Generally, the cost sharing you will pay for your


drugs depends on your coverage stage, the type of
network pharmacy where you purchase your drugs,
and your drugs cost-sharing tier on our formulary.
Please refer to your Evidence of Coverage for the
details about your Medicare Part D prescription drug
coverage, including your cost-sharing amounts.

MO = Mail-order drugs. You may order prescription


refills of certain medications through our mail-order
service online at kp.org/refill or by phone or mobile
app, which may lower your costs for a three-month
supply. Additional drugs may be available for mail
order. Not all drugs can be mailed; restrictions and
limitations apply. For more information, please
contact your pharmacy or the phone number on the
prescription label, visit kp.org/seniormedrx, or call
our plan at the number listed on the front and back
cover pages for your Kaiser Permanente Region.

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-

PA = Prior authorization medications may be


covered under Medicare Part D or Medicare Part B
depending on how they are administered (e.g., via
infusion pump, nebulizer, or other Durable Medical
Equipment device), where they are administered (at
home or in a long-term care facility), and what
medical condition they are administered for. Prior
authorization may also apply to drugs for which
treatment for the medical condition will determine if
the drug is non-Part D (excluded) or covered.

Tier 5 Specialty-tier drugs


Tier 6 Injectable Part D vaccines

Kaiser Permanente 2014 Comprehensive Formulary 8

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

Kaiser Permanente 2014 Comprehensive Formulary 9

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

Kaiser Permanente 2014 Comprehensive Formulary 10

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

Kaiser Permanente 2014 Comprehensive Formulary 11

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

Kaiser Permanente 2014 Comprehensive Formulary 12

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

Kaiser Permanente 2014 Comprehensive Formulary 13

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

Kaiser Permanente 2014 Comprehensive Formulary 14

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

Kaiser Permanente 2014 Comprehensive Formulary 15

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

Kaiser Permanente 2014 Comprehensive Formulary 16

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

Kaiser Permanente 2014 Comprehensive Formulary 17

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

Kaiser Permanente 2014 Comprehensive Formulary 19

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

spironolactone tab 100mg

MO

spironolactone tab 25mg


spironolactone tab 50mg
TEKAMLO
TEKTURNA
TEKTURNA HCT
TEVETEN
TEVETEN HCT
trandolapril
UNIRETIC
UNIVASC
valsartanhydrochlorothiazide
VASERETIC
VASOTEC
ZESTORETIC
ZESTRIL
VASODILATING AGENTS
ADCIRCA
ADEMPAS
BIDIL
CIALIS
DILATRATE SR CAP
40MG
dipyridamole
ISORDIL TITRADOSE
TAB 40MG
ISORDIL TITRADOSE
TAB 5MG
isosorbide dinitrate
isosorbide mononitrate er
tab 120mg er
isosorbide mononitrate er
tab 30mg er
isosorbide mononitrate er
tab 60mg er

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

Kaiser Permanente 2014 Comprehensive Formulary 20

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

Kaiser Permanente 2014 Comprehensive Formulary 21

Drug Name

Drug
Tier
1
1
1
2
1
4
2
2

Requirements
/Limits
MO
MO
MO
MO
MO
MO
HI,MO
MO

propranolol hcl tab 10mg


propranolol hcl tab 20mg
propranolol hcl tab 40mg
propranolol hcl tab 60mg
propranolol hcl tab 80mg
SECTRAL
sotalol hcl
sotalol hcl (afib/afl)
SOTALOL
4
HI
HYDROCHLORIDE
TENORETIC 100
4
MO
TENORETIC 50
4
MO
TENORMIN
4
MO
timolol maleate
2
MO
TOPROL XL
4
MO
ZEBETA
4
MO
ZIAC
4
MO
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
ABSTRAL
4
acetaminophen w/
2
codeine
acetaminophen-caff2
dihydrocod
ACTIQ
4
ANAPROX
4
MO
ANAPROX DS
4
MO
ARTHROTEC 50
4
MO
ARTHROTEC 75
4
MO
AVINZA
4
BUPRENEX
4
buprenorphine hcl
2
butalbital-acetaminophen 2
butalbital-acetaminophen2
caffeine
butalbital-acetaminophen2
caffeine w/ codeine
butalbital-aspirin-caffeine 2
butalbital-aspirin-caffeine
2
w/cod
butorphanol tartrate
2
BUTRANS
4
CAMBIA
4
CATAFLAM
4
CELEBREX
4
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

Kaiser Permanente 2014 Comprehensive Formulary 22

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

Kaiser Permanente 2014 Comprehensive Formulary 24

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

Kaiser Permanente 2014 Comprehensive Formulary 25

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

Kaiser Permanente 2014 Comprehensive Formulary 27

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

Kaiser Permanente 2014 Comprehensive Formulary 28

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%

Kaiser Permanente 2014 Comprehensive Formulary 29

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

Kaiser Permanente 2014 Comprehensive Formulary 30

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

Kaiser Permanente 2014 Comprehensive Formulary 31

Drug Name

Drug
Tier
3

Requirements
/Limits
HI

ZINC TRACE METAL


URICOSURIC AGENTS
colchicine w/ probenecid
2
MO
probenecid
2
MO
ENZYMES
ENZYMES
ADAGEN
3
LD
ALDURAZYME
3
HI
CEREZYME
5
HI
ELAPRASE
5
ELELYSO
5
ELITEK
3
HI
FABRAZYME
5
HI
LUMIZYME
5
LD
MYOZYME
5
NAGLAZYME
5
PULMOZYME
5
SUCRAID
4
LD
VPRIV
5
EYE, EAR, NOSE, AND THROAT (EENT)
PREPARATIONS
ANTI-INFECTIVES
AZASITE
4
bacitracin (ophthalmic)
2
MO
bacitracin-polymyxin b
2
MO
(ophth)
BESIVANCE
4
BLEPH-10
4
chlorhexidine gluconate
2
(mouth-throat)
CILOXAN OIN 0.3% OP
3
MO
CILOXAN SOL 0.3% OP
4
ciprofloxacin hcl (ophth)
2
MO
erythromycin (ophth)
2
MO
gentamicin sulfate (ophth) 2
MO
levofloxacin (ophth)
2
MOXEZA
4
NATACYN
3
neomycin-bacitracin zn2
MO
polymyxin
neomycin-polymy2
gramicid
OCUFLOX
4
ofloxacin (ophth)
2
ofloxacin (otic)
2

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

Kaiser Permanente 2014 Comprehensive Formulary 32

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

Kaiser Permanente 2014 Comprehensive Formulary 33

Drug Name

Drug
Tier

ISOPTO CARPINE SOL


4
2% OP
ISOPTO CARPINE SOL
4
4% OP
ISTALOL
4
latanoprost
2
levobunolol hcl
2
LUMIGAN
3
methazolamide
2
metipranolol
2
PHOSPHOLINE IODIDE
3
PILOPINE HS GEL 4%
3
OP
RESCULA
4
SIMBRINZA
4
timolol maleate (ophth)
2
TIMOPTIC OCUDOSE
4
TIMOPTIC-XE
4
TRAVATAN Z
4
travoprost
2
TRUSOPT
4
XALATAN
4
ZIOPTAN
4
EENT DRUGS, MISCELLANEOUS
acetic acid (otic)
2
apraclonidine hcl
2
CYSTARAN
4
IOPIDINE SOL 0.5% OP
4
IOPIDINE SOL 1% OP
3
LACRISERT
3
LOCAL ANESTHETICS
lidocaine hcl (mouth2
throat)
proparacaine hcl
2
MYDRIATICS
tropicamide
2
VASOCONSTRICTORS
naphazoline hcl
2
tetrahydrozoline hcl
2
GASTROINTESTINAL DRUGS
ANTI-INFLAMMATORY AGENTS
APRISO CAP 0.375GM
4
ASACOL HD TAB 800MG 4
balsalazide disodium
2
CANASA SUP 1000MG
3

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

Kaiser Permanente 2014 Comprehensive Formulary 34

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

Kaiser Permanente 2014 Comprehensive Formulary 35

Drug Name

Drug
Tier

Requirements
/Limits

URSO FORTE TAB


3
MO
500MG
ursodiol
2
MO
GOLD COMPOUNDS
GOLD COMPOUNDS
RIDAURA
3
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
CHEMET
3
CUPRIMINE
3
DEPEN TITRATABS
3
EXJADE TAB 125MG
3
EXJADE TAB 250MG
5
EXJADE TAB 500MG
5
FERRIPROX
5
LD
SYPRINE
4
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
ARISTOSPAN INTRA3
ARTICULAR
ARISTOSPAN
3
INTRALESIONAL
budesonide
2
MO
CELESTONE
3
MO
CORTEF
4
MO
cortisone acetate
2
MO
DEPO-MEDROL INJ
3
20MG/ML
DEPO-MEDROL INJ
4
40MG/ML
DEPO-MEDROL INJ
4
80MG/ML
dexamethasone
2
PA,MO
dexamethasone sodium
2
phosphate
ENTOCORT EC
5
FLO-PRED
4
fludrocortisone acetate
2
MO
hydrocortisone
2
MO
hydrocortisone sod
2
succinate
KENALOG-10
3
KENALOG-40
3
MEDROL DOSEPAK
4
MO
PAK 4MG

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

Kaiser Permanente 2014 Comprehensive Formulary 36

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

Kaiser Permanente 2014 Comprehensive Formulary 37

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

Kaiser Permanente 2014 Comprehensive Formulary 38

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

Kaiser Permanente 2014 Comprehensive Formulary 39

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

HUMATROPE INJ 12MG


HUMATROPE INJ 24MG
HUMATROPE INJ 6MG
INCRELEX
NORDITROPIN
5
FLEXPRO INJ 10/1.5ML
NORDITROPIN
5
FLEXPRO INJ 15/1.5ML
NORDITROPIN
5
FLEXPRO INJ 5/1.5ML
NORDITROPIN
NORDIFLEX PEN INJ
5
30/3ML
NUTROPIN AQ INJ
5
10MG/2ML
NUTROPIN AQ NUSPIN
5
5 INJ NUSPIN 5
NUTROPIN AQ PEN INJ
5
10MG/2ML
NUTROPIN AQ PEN INJ
5
20MG/2ML
NUTROPIN INJ 10MG
5
OMNITROPE INJ
3
10/1.5ML
OMNITROPE INJ 5.8MG 3
OMNITROPE INJ
3
5/1.5ML
SAIZEN
5
SAIZEN CLICK.EASY
5
SEROSTIM
5
SIGNIFOR
5
SOMAVERT
5
LD
TEV-TROPIN INJ 5MG
5
ZORBTIVE
5
THYROID AND ANTITHYROID AGENTS
ARMOUR THYROID
3
MO
CYTOMEL
4
MO
levothyroxine sodium
2
MO
liothyronine sodium
2
HI,MO
methimazole
2
MO
propylthiouracil
2
MO
SYNTHROID
4
MO
THYROLAR-1
4
MO
THYROLAR-1/2
4
MO
THYROLAR-1/4
4
MO
Kaiser Permanente 2014 Comprehensive Formulary 40

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

Kaiser Permanente 2014 Comprehensive Formulary 41

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

Kaiser Permanente 2014 Comprehensive Formulary 42

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

Kaiser Permanente 2014 Comprehensive Formulary 43

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

Kaiser Permanente 2014 Comprehensive Formulary 44

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

Kaiser Permanente 2014 Comprehensive Formulary 46

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

The information in the Requirements/Limits column


tells you if our plan has any special requirements
for coverage of your drug. Certain strengths or
forms of the drug may be subject to the utilization
management codes listed below.
HI = Home infusion drugs may be covered under
our medical benefit and obtained at home infusion
pharmacies. For more information, please consult
your pharmacy directory or call our plan at the
number listed on the front and back cover pages for

your Kaiser Permanente Region.


LD = Limited-distribution drugs can only be
obtained at certain specialty pharmacies. For more
information, consult your pharmacy directory or call
our plan at the number listed on the front and back
cover pages for your Kaiser Permanente Region.
MO = Mail-order drugs. You may order prescription
refills of certain medications through our mail-order
service online at kp.org/refill or by phone or
mobile app, which may lower your costs for a threemonth supply. Additional drugs may be available
for mail order. Not all drugs can be mailed;
restrictions and limitations apply. For more
information, please contact your pharmacy or the
phone number on the prescription label, visit
kp.org/seniormedrx, or call our plan at the
number listed on the front and back cover pages for
your Kaiser Permanente Region.
PA = Prior authorization medications may be
covered under Medicare Part D or Medicare Part B
depending on how they are administered (e.g., via
infusion pump, nebulizer, or other Durable Medical
Equipment device), where they are administered
(at home or in a long-term care facility), and what
medical condition they are administered for. Prior
authorization may also apply to drugs for which
treatment for the medical condition will determine if
the drug is non-Part D (excluded) or covered.

Kaiser Permanente 2014 Comprehensive Formulary 47

Index of Drugs

8
8-MOP ........................................................ 46
A

ACTOS TAB 30MG ..................................... 37


ACTOS TAB 45MG ..................................... 37
ACULAR ..................................................... 32
ACULAR LS ................................................ 32
ACUVAIL .................................................... 32
acyclovir ...................................................... 12
acyclovir sodium ......................................... 12
acyclovir topical .......................................... 44
ACZONE ..................................................... 46
ADACEL ..................................................... 43
ADAGEN .................................................... 32
ADALAT CC................................................ 18
adapalene ................................................... 46
ADCIRCA.................................................... 20
ADDERALL XR ........................................... 24
ADEMPAS .................................................. 20
ADVAIR DISKUS AER 100/50 .................... 16
ADVAIR DISKUS AER 250/50 .................... 16
ADVAIR DISKUS AER 500/50 .................... 17
ADVAIR HFA AER 115/21 .......................... 17
ADVAIR HFA AER 230/21 .......................... 17
ADVAIR HFA AER 45/21 ............................ 17
ADVICOR ................................................... 18
AFINITOR ................................................... 13
AFINITOR DISPERZ................................... 13
AGGRENOX ............................................... 17
AGRYLIN .................................................... 17
AKNE-MYCIN ............................................. 44
ALBENZA ..................................................... 9
albuterol sulfate er tab 4mg er .................... 17
albuterol sulfate er tab 8mg er .................... 17
albuterol sulfate neb 0.083% ...................... 17
albuterol sulfate neb 0.5% .......................... 17
albuterol sulfate neb 0.63mg/3 .................... 17
albuterol sulfate neb 1.25mg/3 .................... 17
albuterol sulfate syp 2mg/5ml ..................... 17
albuterol sulfate tab 2mg............................. 17
albuterol sulfate tab 4mg............................. 17
alclometasone dipropionate ........................ 45
alcohol swabs ............................................. 29
ALDACTAZIDE ........................................... 19
ALDACTONE .............................................. 19
ALDARA ..................................................... 46
ALDURAZYME ........................................... 32
alendronate sodium sol 70/75ml ................. 41
alendronate sodium tab 10mg..................... 41
alendronate sodium tab 35mg..................... 41
alendronate sodium tab 40mg..................... 41

abacavir sulfate .......................................... 12


ABELCET ................................................... 11
ABILIFY DISCMELT TAB 10MG ................ 27
ABILIFY DISCMELT TAB 15MG ................ 27
ABILIFY INJ 9.75MG .................................. 27
ABILIFY MAINTENA INJ 300MG ................ 27
ABILIFY SOL 1MG/ML ............................... 27
ABILIFY TAB 10MG ................................... 27
ABILIFY TAB 15MG ................................... 27
ABILIFY TAB 20MG ................................... 27
ABILIFY TAB 2MG ..................................... 27
ABILIFY TAB 30MG ................................... 27
ABILIFY TAB 5MG ..................................... 27
ABRAXANE ................................................ 13
ABSORICA ................................................. 46
ABSTRAL ................................................... 22
ACANYA .................................................... 44
acarbose .................................................... 37
ACCOLATE ................................................ 42
ACCUNEB NEB 0.63MG/3 ......................... 16
ACCUNEB NEB 1.25MG/3 ......................... 16
ACCUPRIL ................................................. 19
ACCURETIC .............................................. 19
acebutolol hcl ............................................. 21
acetaminophen w/ codeine ......................... 22
acetaminophen-caff-dihydrocod ................. 22
acetazolamide ............................................ 33
acetazolamide sodium ................................ 33
acetic acid (otic) ......................................... 34
acetylcysteine ............................................. 41
ACIPHEX ................................................... 34
ACTEMRA INJ 162/0.9............................... 41
ACTEMRA INJ 200/10ML ........................... 41
ACTHAR HP............................................... 39
ACTHIB ...................................................... 43
ACTIGALL CAP 300MG ............................. 35
ACTIMMUNE .............................................. 41
ACTIQ ........................................................ 22
ACTIVELLA ................................................ 39
ACTONEL .................................................. 41
ACTOPLUS MET ....................................... 37
ACTOPLUS MET XR.................................. 37
ACTOS TAB 15MG .................................... 37
Kaiser Permanente 2014 Comprehensive Formulary 48

alendronate sodium tab 5mg ...................... 41


alendronate sodium tab 70mg .................... 41
alfuzosin hcl................................................ 16
ALIMTA ...................................................... 13
ALINIA ........................................................ 11
ALKERAN................................................... 13
allopurinol ................................................... 41
allopurinol sodium ...................................... 41
ALOCRIL .................................................... 33
ALOMIDE ................................................... 33
ALOPRIM ................................................... 41
ALORA DIS 0.025MG................................. 39
ALORA DIS 0.05MG................................... 39
ALORA DIS 0.075MG................................. 39
ALORA DIS 0.1MG .................................... 39
ALOXI......................................................... 34
ALPHAGAN P ............................................ 33
alprazolam .................................................. 26
ALREX ....................................................... 32
ALSUMA .................................................... 25
ALTABAX ................................................... 44
ALTACE ..................................................... 19
ALTOPREV ................................................ 18
ALVESCO .................................................. 43
amantadine hcl ........................................... 26
AMARYL .................................................... 37
AMBIEN ..................................................... 26
AMBIEN CR ............................................... 26
AMBISOME ................................................ 11
amcinonide ................................................. 45
AMERGE .................................................... 25
AMEVIVE ................................................... 46
AMICAR ..................................................... 17
amifostine crystalline .................................. 41
amikacin sulfate............................................ 9
amiloride & hydrochlorothiazide.................. 30
amiloride hcl ............................................... 30
amino acid electrolyte infusion.................... 29
amino acid infusion ..................................... 29
aminophylline ............................................. 46
aminosalicylic acid ...................................... 11
AMINOSYN II INJ 10% ............................... 29
AMINOSYN II INJ 15% ............................... 29
AMINOSYN II INJ 7% ................................. 29
AMINOSYN II INJ 8.5% .............................. 29
AMINOSYN M INJ 3.5% ............................. 29
AMINOSYN-HBC INJ 7% ........................... 29
AMINOSYN-PF 7% INJ 7% ........................ 29
AMINOSYN-PF INJ 10% ............................ 29
amiodarone hcl ........................................... 19
AMITIZA ..................................................... 35

amitriptyline hcl ........................................... 27


amlodipine besylate .................................... 18
amlodipine besylate-benazepril hcl ............. 18
ammonium chloride..................................... 29
amoxapine .................................................. 27
amoxicillin ..................................................... 9
amoxicillin & pot clavulanate ......................... 9
amphetamine-dextroamphetamine ............. 24
amphotericin b ............................................ 11
ampicillin ....................................................... 9
ampicillin & sulbactam sodium ...................... 9
ampicillin sodium .......................................... 9
AMPYRA .................................................... 41
AMRIX ........................................................ 16
AMTURNIDE .............................................. 19
ANAFRANIL................................................ 27
anagrelide hcl ............................................. 17
ANAPROX .................................................. 22
ANAPROX DS ............................................ 22
anastrozole ................................................. 14
ANCOBON.................................................. 11
ANDRODERM DIS 2MG/24HR................... 36
ANDRODERM DIS 4MG/24HR................... 36
ANDROGEL GEL 1%(50MG) ..................... 36
ANDROGEL PUMP GEL 1.62% ................. 36
ANDROGEL PUMP GEL PUMP 1% ........... 36
ANGELIQ .................................................... 39
ANTARA ..................................................... 18
ANTIVENIN LATRODECTUS MAC TANS .. 43
ANTIVERT .................................................. 34
ANZEMET................................................... 34
APIDRA ...................................................... 37
APIDRA SOLOSTAR .................................. 37
APLENZIN .................................................. 27
APOKYN ..................................................... 26
apraclonidine hcl ......................................... 34
APRISO CAP 0.375GM .............................. 34
APTIVUS .................................................... 12
ARALAST NP ............................................. 43
ARANESP ALBUMIN FREE ....................... 18
ARAVA ....................................................... 41
ARCALYST ................................................. 41
ARCAPTA NEOHALER .............................. 17
argatroban .................................................. 17
ARGATROBAN........................................... 17
ARICEPT .................................................... 16
ARICEPT ODT............................................ 16
ARIMIDEX .................................................. 14
ARISTOSPAN INTRA-ARTICULAR ............ 36
ARISTOSPAN INTRALESIONAL................ 36
ARIXTRA .................................................... 17

Kaiser Permanente 2014 Comprehensive Formulary 49

ARMOUR THYROID .................................. 40


AROMASIN ................................................ 14
ARRANON ................................................. 14
ARTHROTEC 50 ........................................ 22
ARTHROTEC 75 ........................................ 22
ARZERRA .................................................. 14
ASACOL HD TAB 800MG .......................... 34
ASMANEX 120 METERED DOSES AER
220MCG ................................................. 43
ASMANEX 30 METERED DOSES AER
110MCG ................................................. 43
ASMANEX 30 METERED DOSES AER
220MCG ................................................. 43
ASMANEX 60 METERED DOSES AER
220MCG ................................................. 43
ASTELIN .................................................... 33
ASTEPRO .................................................. 33
ATACAND .................................................. 19
ATACAND HCT .......................................... 19
ATELVIA .................................................... 41
atenolol ....................................................... 21
atenolol & chlorthalidone ............................ 21
ATGAM ...................................................... 41
ATIVAN ...................................................... 26
atorvastatin calcium .................................... 18
atovaquone-proguanil hcl ........................... 11
ATRALIN GEL 0.05% ................................. 46
ATRIPLA .................................................... 12
atropine sulfate ........................................... 15
ATROPINE SULFATE ................................ 15
ATROVENT ................................................ 15
ATROVENT HFA ........................................ 15
AUBAGIO ................................................... 41
AUGMENTIN ................................................ 9
AUVI-Q INJ 0.15MG ................................... 17
AUVI-Q INJ 0.3MG ..................................... 17
AVALIDE .................................................... 19
AVANDAMET ............................................. 37
AVANDARYL.............................................. 37
AVANDIA ................................................... 37
AVAPRO .................................................... 19
AVASTIN .................................................... 14
AVC ............................................................ 44
AVELOX ....................................................... 9
AVELOX ABC PACK .................................... 9
AVINZA ...................................................... 22
AVODART .................................................. 41
AVONEX .................................................... 41
AVONEX PEN ............................................ 41
AXERT ....................................................... 25
AXID ........................................................... 34

AXIRON SOL 30MG/ACT ........................... 36


AZACTAM..................................................... 9
AZACTAM IN ISO-OSMOTIC DEXTROSE... 9
AZASITE ..................................................... 32
azathioprine ................................................ 41
azathioprine sodium .................................... 41
azelastine hcl .............................................. 33
azelastine hcl (ophth) .................................. 33
AZELEX ...................................................... 46
AZILECT ..................................................... 26
azithromycin.................................................. 9
AZOPT ........................................................ 33
AZOR.......................................................... 18
aztreonam ..................................................... 9
AZULFIDINE ................................................. 9
AZULFIDINE EN-TABS ................................ 9
B
bacitracin ...................................................... 9
bacitracin (ophthalmic) ................................ 32
bacitracin-polymyxin b (ophth) .................... 32
bacitracin-poly-neomycin-hc ....................... 32
baclofen ...................................................... 16
BACTOCILL IN DEXTROSE ......................... 9
BACTRIM...................................................... 9
BACTRIM DS................................................ 9
BACTROBAN ............................................. 44
BACTROBAN NASAL ................................. 44
balsalazide disodium................................... 34
BANZEL ...................................................... 24
BARACLUDE SOL .05MG/ML .................... 12
BARACLUDE TAB 0.5MG .......................... 12
BARACLUDE TAB 1MG ............................. 12
BCG VACCINE ........................................... 14
BECONASE AQ.......................................... 32
benazepril & hydrochlorothiazide ................ 19
benazepril hcl.............................................. 19
BENICAR .............................................. 19, 20
BENICAR HCT ........................................... 20
BENLYSTA ................................................. 41
BENTYL ...................................................... 15
BENZAMYCIN ............................................ 44
benzoyl peroxide-erythromycin ................... 44
benztropine mesylate .................................. 26
BEPREVE ................................................... 33
BERINERT.................................................. 41
BESIVANCE ............................................... 32
BETAGAN................................................... 33
betamethasone dipropionate (topical) ......... 45
betamethasone dipropionate augmented .... 45
betamethasone valerate ............................. 45

Kaiser Permanente 2014 Comprehensive Formulary 50

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

buspirone hcl tab 5mg................................. 26


buspirone hcl tab 7.5mg.............................. 26
BUSULFEX ................................................. 14
butabarbital sodium..................................... 26
butalbital-acetaminophen ............................ 22
butalbital-acetaminophen-caffeine .............. 22
butalbital-acetaminophen-caffeine w/ codeine
................................................................ 22
butalbital-aspirin-caffeine ............................ 22
butalbital-aspirin-caffeine w/cod .................. 22
BUTISOL SODIUM ..................................... 26
butoconazole nitrate (one dose).................. 44
butorphanol tartrate .................................... 22
BUTRANS................................................... 22
BYDUREON ............................................... 37
BYETTA ...................................................... 37
BYSTOLIC .................................................. 21
C
cabergoline ................................................. 26
CADUET ..................................................... 18
CALAN ........................................................ 18
CALAN SR .................................................. 18
calcipotriene................................................ 46
calcitonin (salmon) ...................................... 39
calcitriol ....................................................... 47
calcium acetate (phosphate binder) ............ 31
CAMBIA ...................................................... 22
CAMPATH .................................................. 14
CAMPRAL .................................................. 26
CAMPTOSAR ............................................. 14
CANASA SUP 1000MG .............................. 34
CANCIDAS ................................................. 11
candesartan cilexetil-hydrochlorothiazide ... 20
CANTIL ....................................................... 15
CAPASTAT SULFATE ................................ 11
CAPEX SHA 0.01% .................................... 45
CAPRELSA................................................. 14
captopril ...................................................... 20
captopril & hydrochlorothiazide ................... 20
CARAC CRE 0.5% ..................................... 46
CARAFATE SUS 1GM/10ML ...................... 34
CARAFATE TAB 1GM ................................ 35
CARBAGLU ................................................ 29
carbamazepine ........................................... 24
CARBATROL CAP 100MG ......................... 24
CARBATROL CAP 200MG ......................... 24
CARBATROL CAP 300MG ......................... 24
carbidopa-levodopa .................................... 26
carbinoxamine maleate ............................... 13
carboplatin .................................................. 14

Kaiser Permanente 2014 Comprehensive Formulary 51

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

CELLCEPT INTRAVENOUS ...................... 41


CELLCEPT SUS 200MG/ML ...................... 41
CELLCEPT TAB 500MG............................. 41
CELONTIN.................................................. 24
CENESTIN.................................................. 39
cephalexin..................................................... 9
CEREZYME ................................................ 32
CERVARIX ................................................. 43
CESAMET .................................................. 34
cetirizine hcl ................................................ 13
cevimeline hcl ............................................. 16
CHANTIX .................................................... 16
CHANTIX STARTING MONTH PAK ........... 16
CHEMET .................................................... 36
chenodiol .................................................... 35
chloramphenicol sodium succinate ............... 9
chlordiazepoxide hcl ................................... 26
chlordiazepoxide-amitriptyline ..................... 27
chlorhexidine gluconate (mouth-throat) ....... 32
chloroquine phosphate................................ 11
chlorothiazide.............................................. 30
chlorothiazide sodium ................................. 30
chlorpromazine hcl ...................................... 27
chlorpropamide ........................................... 37
chlorthalidone ............................................. 30
chlorzoxazone............................................. 16
cholestyramine............................................ 18
cholestyramine light .................................... 18
chorionic gonadotropin................................ 39
CIALIS ........................................................ 20
ciclopirox ..................................................... 44
ciclopirox olamine ....................................... 44
cidofovir ...................................................... 12
cilostazol ..................................................... 17
CILOXAN OIN 0.3% OP ............................. 32
CILOXAN SOL 0.3% OP ............................. 32
cimetidine.................................................... 35
cimetidine hcl .............................................. 35
CIMZIA ....................................................... 41
CINRYZE .................................................... 41
CIPRO .......................................................... 9
CIPRO HC .................................................. 32
CIPRO I.V.-IN D5W ...................................... 9
CIPRO SUSP................................................ 9
CIPRODEX ................................................. 32
ciprofloxacin .................................................. 9
ciprofloxacin hcl ............................................ 9
ciprofloxacin hcl (ophth) .............................. 32
ciprofloxacin in d5w....................................... 9
ciprofloxacin-ciprofloxacin hcl ....................... 9
cisplatin ....................................................... 14

Kaiser Permanente 2014 Comprehensive Formulary 52

citalopram hydrobromide sol 10mg/5ml ...... 27


citalopram hydrobromide tab 10mg ............ 27
citalopram hydrobromide tab 20mg ............ 27
citalopram hydrobromide tab 40mg ............ 27
cladribine .................................................... 14
CLAFORAN .................................................. 9
CLARINEX ................................................. 13
CLARINEX REDITABS............................... 13
CLARINEX-D 12 HOUR ............................. 13
CLARINEX-D 24 HOUR ............................. 13
clarithromycin ............................................... 9
clemastine fumarate ................................... 13
CLEOCIN ..................................................... 9
CLEOCIN CRE 2% VAG ............................ 44
CLEOCIN IN D5W ........................................ 9
CLEOCIN PHOSPHATE .............................. 9
CLEOCIN SUP 100MG .............................. 44
CLEOCIN-T ................................................ 44
CLIMARA DIS 0.025MG ............................. 39
CLIMARA DIS 0.0375MG ........................... 39
CLIMARA DIS 0.05MG ............................... 39
CLIMARA DIS 0.06MG ............................... 39
CLIMARA DIS 0.075MG ............................. 39
CLIMARA DIS 0.1MG ................................. 39
CLIMARA PRO ........................................... 39
CLINDAGEL ............................................... 44
clindamycin hcl ............................................. 9
clindamycin palmitate hydrochloride ............. 9
clindamycin phosphate ................................. 9
clindamycin phosphate & cleanser ............. 44
clindamycin phosphate (topical) ................. 44
clindamycin phosphate in d5w .................... 10
clindamycin phosphate vaginal ................... 44
clindamycin phosphate-benzoyl peroxide ... 44
CLINIMIX 2.75%/DEXTROSE 5% INJ
2.75/D5W ................................................ 29
CLINIMIX 4.25%/DEXTROSE 10% ............ 29
CLINIMIX 4.25%/DEXTROSE 20% ............ 30
CLINIMIX 4.25%/DEXTROSE 25% ............ 30
CLINIMIX 4.25%/DEXTROSE 5% .............. 30
CLINIMIX 5%/DEXTROSE 15% ................. 30
CLINIMIX 5%/DEXTROSE 20% ................. 30
CLINIMIX 5%/DEXTROSE 25% ................. 30
CLINIMIX E 2.75%/DEXTROSE 10% ......... 30
CLINIMIX E 2.75%/DEXTROSE 5% ........... 30
CLINIMIX E 4.25%/DEXTROSE 10% ......... 30
CLINIMIX E 4.25%/DEXTROSE 25% ......... 30
CLINIMIX E 4.25%/DEXTROSE 5% ........... 30
CLINIMIX E 5%/DEXTROSE 15%.............. 30
CLINIMIX E 5%/DEXTROSE 20%.............. 30
CLINIMIX E 5%/DEXTROSE 25%.............. 30

clobetasol propionate .................................. 45


clobetasol propionate emollient base .......... 45
CLOBEX ..................................................... 45
CLODERM PUMP ...................................... 45
CLOLAR ..................................................... 14
clomipramine hcl ......................................... 27
clonazepam ................................................ 24
clonidine & chlorthalidone ........................... 19
clonidine hcl ................................................ 19
clopidogrel bisulfate .................................... 17
clorazepate dipotassium ............................. 26
clotrimazole................................................. 44
clotrimazole (topical) ................................... 44
clotrimazole w/ betamethasone................... 44
clozapine .................................................... 27
CLOZARIL TAB 100MG .............................. 27
CLOZARIL TAB 25MG................................ 27
COARTEM .................................................. 11
CODEINE SULFATE TAB 15MG ................ 22
CODEINE SULFATE TAB 30MG ................ 22
CODEINE SULFATE TAB 60MG ................ 22
COGENTIN ................................................. 26
COLAZAL ................................................... 34
colchicine w/ probenecid ............................. 32
COLCRYS .................................................. 41
COLESTID .................................................. 18
colestipol hcl ............................................... 18
colistimethate sodium ................................. 10
COLY-MYCIN M ......................................... 10
COLY-MYCIN S .......................................... 32
COLYTE-FLAVOR PACKS ......................... 35
COMBIGAN ................................................ 33
COMBIPATCH ............................................ 39
COMBIVENT AER ...................................... 17
COMBIVENT RESPIMAT AER RESPIMAT 17
COMBIVIR .................................................. 12
COMETRIQ ................................................ 14
COMPLERA................................................ 12
COMTAN .................................................... 26
COMVAX .................................................... 43
CONCERTA TAB 18MG ............................. 24
CONCERTA TAB 27MG ............................. 24
CONCERTA TAB 36MG ............................. 24
CONCERTA TAB 54MG ............................. 24
CONDYLOX................................................ 46
CONZIP ...................................................... 22
COPAXONE ............................................... 41
COPEGUS .................................................. 12
CORDARONE ............................................ 19
CORDRAN TAPE ....................................... 45
COREG ...................................................... 21

Kaiser Permanente 2014 Comprehensive Formulary 53

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

Kaiser Permanente 2014 Comprehensive Formulary 54

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

DILAUDID INJ 4MG/ML .............................. 22


DILAUDID TAB 2MG .................................. 22
DILAUDID TAB 4MG .................................. 22
DILAUDID TAB 8MG .................................. 22
DILAUDID-5 LIQ 1MG/ML .......................... 22
DILAUDID-HP INJ 10MG/ML ...................... 22
diltiazem hcl ................................................ 18
diltiazem hcl coated beads .......................... 18
diltiazem hcl extended release beads ......... 18
DIOVAN ...................................................... 20
DIOVAN HCT.............................................. 20
DIPENTUM ................................................. 34
diphenhydramine hcl ................................... 13
diphenoxylate w/ atropine ........................... 34
DIPROLENE ............................................... 45
DIPROLENE AF ......................................... 45
dipyridamole ............................................... 20
disopyramide phosphate ............................. 19
disulfiram .................................................... 41
DITROPAN XL ............................................ 46
DIURIL ........................................................ 30
divalproex sodium ....................................... 24
DIVIGEL GEL 1MG/GM .............................. 39
DOCEFREZ INJ 20MG ............................... 14
DOCEFREZ INJ 80MG ............................... 14
DOCETAXEL INJ 80MG/4ML ..................... 14
DOCETAXEL INJ 80MG/8ML ..................... 14
DOLOPHINE HCL TAB 5MG ...................... 22
DOLOPHINE TAB 10MG ............................ 22
donepezil hydrochloride .............................. 16
DORIBAX.................................................... 10
DORYX ....................................................... 10
dorzolamide hcl........................................... 33
dorzolamide hcl-timolol maleate.................. 33
DOVONEX .................................................. 46
doxazosin mesylate .................................... 18
doxepin hcl cap 100mg ............................... 27
doxepin hcl cap 10mg ................................. 27
doxepin hcl cap 150mg ............................... 27
doxepin hcl cap 25mg ................................. 27
doxepin hcl cap 50mg ................................. 27
doxepin hcl cap 75mg ................................. 27
doxepin hcl con 10mg/ml ............................ 27
DOXIL ......................................................... 14
doxorubicin hcl ............................................ 14
doxycycline (monohydrate) ......................... 10
doxycycline hyclate ..................................... 10
dronabinol ................................................... 34
drospirenone-ethinyl estradiol ..................... 37
DROXIA ...................................................... 14
DUETACT ................................................... 38

Kaiser Permanente 2014 Comprehensive Formulary 55

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

Kaiser Permanente 2014 Comprehensive Formulary 56

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

Kaiser Permanente 2014 Comprehensive Formulary 57

FLUOXETINE HCL ..................................... 28


fluoxetine hcl cap 10mg .............................. 28
fluoxetine hcl cap 20mg .............................. 28
fluoxetine hcl cap 40mg .............................. 28
fluoxetine hcl sol 20mg/5ml ........................ 28
fluoxetine hcl tab 10mg............................... 28
fluoxetine hcl tab 20mg............................... 28
fluoxymesterone ......................................... 36
fluphenazine decanoate ............................. 28
fluphenazine hcl ......................................... 28
flurazepam hcl ............................................ 26
flurbiprofen ................................................. 22
flurbiprofen sodium ..................................... 32
flutamide ..................................................... 14
fluticasone propionate ................................ 45
fluticasone propionate (nasal)..................... 32
fluvastatin sodium ....................................... 18
fluvoxamine maleate................................... 28
FML FORTE SUS 0.25% OP...................... 32
FML LIQUIFILM SUS 0.1% OP .................. 33
FML OIN 0.1% OP ..................................... 33
FOCALIN .................................................... 24
FOCALIN XR .............................................. 24
FOLOTYN .................................................. 14
fomepizole .................................................. 41
fondaparinux sodium .................................. 17
FORADIL AEROLIZER............................... 17
FORFIVO XL .............................................. 28
FORTAMET................................................ 38
FORTAZ ..................................................... 10
FORTEO .................................................... 39
FORTESTA GEL 10MG/ACT ..................... 36
FORTICAL SPR 200/ACT .......................... 39
FOSAMAX .................................................. 41
FOSAMAX PLUS D .................................... 41
foscarnet sodium ........................................ 12
fosinopril sodium ........................................ 20
fosinopril sodium & hydrochlorothiazide ..... 20
fosphenytoin sodium................................... 24
FOSRENOL................................................ 31
FRAGMIN ................................................... 17
FREAMINE III 3% INJ 3% .......................... 30
FREAMINE III INJ 8.5% ............................. 30
FROVA ....................................................... 25
FULYZAQ ................................................... 34
FURADANTIN ............................................ 13
furosemide inj 10mg/ml .............................. 30
furosemide sol 10mg/ml ............................. 30
furosemide sol 8mg/ml ............................... 30
furosemide tab 20mg .................................. 30
furosemide tab 40mg .................................. 30

furosemide tab 80mg .................................. 30


FUSILEV ..................................................... 41
FUZEON ..................................................... 12
G
gabapentin .................................................. 24
GABITRIL ................................................... 24
GABLOFEN ................................................ 16
galantamine hydrobromide ......................... 16
GAMASTAN S/D......................................... 43
GAMMAGARD LIQUID ............................... 43
GAMMAGARD S/D ..................................... 43
GAMMAPLEX ............................................. 43
GAMUNEX.................................................. 43
GAMUNEX-C .............................................. 43
ganciclovir sodium ...................................... 12
GARDASIL.................................................. 43
GASTROCROM.......................................... 42
GATTEX ..................................................... 35
gauze pads & dressings .............................. 29
GAZYVA ..................................................... 14
GELNIQUE ................................................. 46
GELNIQUE GEL 3% ................................... 46
gemcitabine hcl ........................................... 14
gemfibrozil .................................................. 18
GEMZAR .................................................... 14
GENERESS FE .......................................... 37
GENOTROPIN INJ 12MG ........................... 40
GENOTROPIN INJ 5MG ............................. 40
GENOTROPIN MINIQUICK INJ 0.2MG ...... 40
GENOTROPIN MINIQUICK INJ 0.4MG ...... 40
GENOTROPIN MINIQUICK INJ 0.6MG ...... 40
GENOTROPIN MINIQUICK INJ 0.8MG ...... 40
GENOTROPIN MINIQUICK INJ 1.2MG ...... 40
GENOTROPIN MINIQUICK INJ 1.4MG ...... 40
GENOTROPIN MINIQUICK INJ 1.6MG ...... 40
GENOTROPIN MINIQUICK INJ 1.8MG ...... 40
GENOTROPIN MINIQUICK INJ 1MG ......... 40
GENOTROPIN MINIQUICK INJ 2MG ......... 40
gentamicin in saline .................................... 10
gentamicin sulfate ....................................... 10
gentamicin sulfate (ophth) ........................... 32
gentamicin sulfate (topical) ......................... 44
GEODON .................................................... 28
GIAZO ........................................................ 34
GILENYA .................................................... 41
GILOTRIF ................................................... 14
GLASSIA .................................................... 43
GLEEVEC ................................................... 14
glimepiride .................................................. 38
glipizide er tab 10mg ................................... 38

Kaiser Permanente 2014 Comprehensive Formulary 58

glipizide er tab 2.5mg ................................. 38


glipizide er tab 5mg .................................... 38
glipizide tab 10mg ...................................... 38
glipizide tab 5mg ........................................ 38
glipizide-metformin hcl ................................ 38
GLUCAGEN HYPOKIT............................... 38
GLUCAGON EMERGENCY KIT ................ 38
GLUCOPHAGE .......................................... 38
GLUCOPHAGE XR .................................... 38
GLUCOTROL ............................................. 38
GLUCOTROL XL........................................ 38
GLUCOVANCE .......................................... 38
GLUMETZA ................................................ 38
glyburide ..................................................... 38
glyburide micronized................................... 38
glyburide-metformin .................................... 38
glycopyrrolate ............................................. 16
GLYNASE .................................................. 38
GLYSET ..................................................... 38
GOLYTELY ................................................ 35
GRALISE .................................................... 22
GRALISE STARTER .................................. 22
granisetron hcl ............................................ 34
griseofulvin microsize ................................. 11
griseofulvin ultramicrosize .......................... 11
GRIS-PEG .................................................. 11
guanfacine hcl ............................................ 19
GUANIDINE HCL ....................................... 16
H
HALAVEN................................................... 14
HALCION ................................................... 26
HALDOL ..................................................... 28
HALDOL DECANOATE 100 ....................... 28
HALDOL DECANOATE 50 ......................... 28
HALFLYTELY BOWEL PREP/FLAVOR
PACKS ................................................... 35
halobetasol propionate ............................... 45
HALOG ....................................................... 45
haloperidol .................................................. 28
haloperidol decanoate ................................ 28
haloperidol lactate ...................................... 28
HAVRIX ...................................................... 43
HECTOROL ............................................... 47
HELIDAC .................................................... 35
HEMABATE................................................ 41
heparin (porcine) in sodium chloride ........... 17
heparin sod (porcine) in d5w ...................... 17
heparin sodium (porcine) ............................ 17
HEPARIN SODIUM/NACL 0.45%............... 17
HEPSERA .................................................. 12

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

Kaiser Permanente 2014 Comprehensive Formulary 59

HYPERRHO S/D ........................................ 43


HYPERTET S/D ......................................... 43
HYZAAR ..................................................... 20
I
ibandronate sodium .................................... 41
ibuprofen .................................................... 23
ICLUSIG ..................................................... 14
IDAMYCIN PFS .......................................... 14
idarubicin hcl .............................................. 14
IFEX ........................................................... 14
ifosfamide ................................................... 14
ILARIS ........................................................ 23
ILEVRO ...................................................... 33
imipenem-cilastatin ..................................... 10
imipramine hcl ............................................ 28
imipramine pamoate ................................... 28
imiquimod ................................................... 46
IMITREX ..................................................... 25
IMITREX STATDOSE REFILL.................... 25
IMOGAM RABIES-HT ................................ 43
IMOVAX RABIES (H.D.C.V.) ...................... 43
IMURAN ..................................................... 41
INCIVEK ..................................................... 12
INCRELEX ................................................. 40
indapamide ................................................. 30
INDERAL LA .............................................. 21
INDOCIN .................................................... 23
indomethacin .............................................. 23
INFANRIX................................................... 43
INFERGEN ................................................. 12
INLYTA ....................................................... 14
INNOPRAN XL ........................................... 21
INSPRA ...................................................... 20
insulin pen needle ...................................... 29
insulin syringe/needle u-100 ....................... 29
INTEGRILIN ............................................... 17
INTELENCE TAB 100MG ........................... 12
INTELENCE TAB 200MG ........................... 12
INTELENCE TAB 25MG............................. 12
INTRALIPID INJ 30% ................................. 30
INTRON-A .................................................. 14
INTRON-A W/DILUENT ............................. 14
INTUNIV ..................................................... 27
INVANZ ...................................................... 10
INVEGA ...................................................... 28
INVEGA SUSTENNA ................................. 28
INVIRASE CAP 200MG.............................. 12
INVIRASE TAB 500MG .............................. 12
INVOKANA ................................................. 38
IONOSOL-B/DEXTROSE 5% ..................... 31

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

KADIAN CAP 200MG CR ........................... 23


KADIAN CAP 20MG CR ............................. 23
KADIAN CAP 30MG CR ............................. 23
KADIAN CAP 50MG CR ............................. 23
KADIAN CAP 60MG CR ............................. 23
KADIAN CAP 80MG CR ............................. 23
KALETRA SOL ........................................... 12
KALETRA TAB 100-25MG ......................... 12
KALETRA TAB 200-50MG ......................... 12
KALYDECO ................................................ 43
KAPVAY ..................................................... 19
KAYEXALATE ............................................ 31
KAZANO .................................................... 38
KCL 0.15%/D5W/LR ................................... 31
KCL 0.15%/D5W/NACL 0.225% INJ 0.15/0.2
............................................................... 31
KCL 0.3%/D5W/NACL 0.9% INJ 0.3/0.9% . 31
KEFLEX ..................................................... 10
KENALOG .................................................. 45
KENALOG-10 ............................................. 36
KENALOG-40 ............................................. 36
KEPIVANCE ............................................... 46
KEPPRA ..................................................... 24
KEPPRA XR ............................................... 24
KETEK ....................................................... 10
ketoconazole .............................................. 11
ketoconazole & cleanser ............................ 44
ketoconazole (topical)................................. 44
ketoprofen .................................................. 23
ketorolac tromethamine .............................. 23
ketorolac tromethamine (ophth) .................. 33
KINERET .................................................... 41
KLARON .................................................... 44
KLONOPIN ................................................. 24
KOMBIGLYZE XR ...................................... 38
KORLYM .................................................... 38
K-TABS TAB 10MEQ CR ........................... 31
KUVAN ....................................................... 41
KYNAMRO ................................................. 18
KYPROLIS ................................................. 14
L
labetalol hcl ................................................ 21
LAC-HYDRIN ............................................. 46
LACRISERT ............................................... 34
lactated ringer's .......................................... 31
lactated ringer's (irrigation) ......................... 31
lactic acid (ammonium lactate) ................... 46
lactulose ..................................................... 29
lactulose (encephalopathy) ......................... 29

LAMICTAL CHEWABLE DISPERSIBLE CHW


25MG ...................................................... 24
LAMICTAL CHEWABLE DISPERSIBLE CHW
5MG ........................................................ 24
LAMICTAL ODT TAB 100MG ..................... 24
LAMICTAL ODT TAB 200MG ..................... 25
LAMICTAL ODT TAB 25MG ....................... 25
LAMICTAL ODT TAB 50MG ....................... 25
LAMICTAL STARTER/NOT TAKING
CARBAMAZEPINE KIT START 49 ......... 25
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT TAKING
VALPROATE KIT START 98 .................. 25
LAMICTAL STARTER/TAKING VALPROATE
KIT START 35 ......................................... 25
LAMICTAL TAB 100MG .............................. 25
LAMICTAL TAB 150MG .............................. 25
LAMICTAL TAB 200MG .............................. 25
LAMICTAL TAB 25MG................................ 25
LAMICTAL XR KIT ...................................... 25
LAMICTAL XR TAB 100MG ........................ 25
LAMICTAL XR TAB 200MG ........................ 25
LAMICTAL XR TAB 250MG ........................ 25
LAMICTAL XR TAB 25MG .......................... 25
LAMICTAL XR TAB 300MG ........................ 25
LAMICTAL XR TAB 50MG .......................... 25
LAMISIL ...................................................... 11
lamivudine................................................... 12
lamivudine-zidovudine ................................ 12
lamotrigine .................................................. 25
LANOXIN PEDIATRIC INJ 0.1MG/ML ........ 19
LANOXIN TAB 0.125MG ............................ 19
LANOXIN TAB 0.25MG .............................. 19
lansoprazole ............................................... 35
LANTUS INJ 100/ML .................................. 38
LANTUS SOLOSTAR INJ SOLOSTAR....... 38
LASIX ......................................................... 30
LASTACAFT ............................................... 33
latanoprost .................................................. 34
LATUDA ..................................................... 28
LAZANDA ................................................... 26
leflunomide ................................................. 41
LESCOL ..................................................... 18
LESCOL XL ................................................ 18
LETAIRIS .................................................... 21
letrozole ...................................................... 14
leucovorin calcium ...................................... 41
LEUKERAN ................................................ 14
LEUKINE INJ 250MCG ............................... 18
LEUKINE INJ 500 MCG .............................. 18
leuprolide acetate ....................................... 14

Kaiser Permanente 2014 Comprehensive Formulary 61

levalbuterol hcl ........................................... 17


LEVAQUIN ................................................. 10
LEVATOL ................................................... 21
LEVEMIR ................................................... 38
LEVEMIR FLEXPEN .................................. 38
levetiracetam .............................................. 25
LEVETIRACETAM ..................................... 25
levobunolol hcl............................................ 34
levocarnitine (metabolic modifiers) ............. 41
levocetirizine dihydrochloride...................... 13
levofloxacin................................................. 10
levofloxacin (ophth) .................................... 32
levofloxacin in d5w ..................................... 10
levonorgestrel & eth estradiol ..................... 37
levonorgestrel-eth estradiol (triphasic) ........ 37
levonorgestrel-ethinyl estradiol (91-day) ..... 37
levonorgestrel-ethinyl estradiol (continuous)
............................................................... 37
levorphanol tartrate .................................... 23
levothyroxine sodium .................................. 40
LEXAPRO .................................................. 28
LEXIVA SUS 50MG/ML .............................. 12
LEXIVA TAB 700MG .................................. 12
LIALDA TAB 1.2GM ................................... 34
lidocaine ..................................................... 45
lidocaine hcl................................................ 45
lidocaine hcl (local anesth.) ........................ 42
lidocaine hcl (mouth-throat) ........................ 34
lidocaine-prilocaine ..................................... 45
LIDODERM ................................................ 45
LINCOCIN .................................................. 10
lindane ........................................................ 44
LINZESS .................................................... 35
LIORESAL INTRATHECAL ........................ 16
liothyronine sodium .................................... 40
LIPITOR ..................................................... 18
LIPOFEN .................................................... 18
LIPOSYN III INJ 10% ................................. 30
LIPOSYN III INJ 20% ................................. 30
lisinopril & hydrochlorothiazide ................... 20
lisinopril tab 10mg ...................................... 20
lisinopril tab 2.5mg ..................................... 20
lisinopril tab 20mg ...................................... 20
lisinopril tab 30mg ...................................... 20
lisinopril tab 40mg ...................................... 20
lisinopril tab 5mg ........................................ 20
lithium carbonate ........................................ 28
LITHIUM CARBONATE CAP 600MG ......... 28
LITHIUM CITRATE ..................................... 28
LITHOBID TAB 300MG CR ........................ 28
LIVALO ....................................................... 18

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

Kaiser Permanente 2014 Comprehensive Formulary 62

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

METADATE CD CAP 10MG ....................... 24


METADATE CD CAP 20MG ....................... 24
METADATE CD CAP 30MG ....................... 24
METADATE CD CAP 40MG ....................... 24
METADATE CD CAP 50MG ....................... 24
METADATE CD CAP 60MG ....................... 24
metaproterenol sulfate ................................ 17
metformin hcl er tab 1000mg ...................... 38
metformin hcl er tab 500mg er .................... 38
metformin hcl er tab 750mg er .................... 38
metformin hcl tab 1000mg .......................... 38
metformin hcl tab 500mg ............................ 38
metformin hcl tab 850mg ............................ 38
methadone hcl ............................................ 23
METHADONE HCL INJ 10MG/ML .............. 23
methamphetamine hcl................................. 24
methazolamide ........................................... 34
methenamine hippurate .............................. 13
methimazole ............................................... 40
methocarbamol ........................................... 16
methotrexate sodium .................................. 15
methscopolamine bromide .......................... 16
methyclothiazide ......................................... 30
methyldopa ................................................. 19
methyldopa & hydrochlorothiazide .............. 19
methyldopate hcl ......................................... 19
methylergonovine maleate .......................... 42
METHYLIN CHW 10MG ............................. 24
METHYLIN CHW 2.5MG ............................ 24
METHYLIN CHW 5MG ............................... 24
METHYLIN SOL 10MG/5ML ....................... 24
METHYLIN SOL 5MG/5ML ......................... 24
methylphenidate hcl .................................... 24
methylprednisolone ..................................... 36
methylprednisolone acetate ........................ 36
methylprednisolone sod succ ...................... 36
methyltestosterone ..................................... 36
metipranolol ................................................ 34
metoclopramide hcl ..................................... 35
metolazone ................................................. 30
metoprolol & hydrochlorothiazide ................ 21
metoprolol succinate ................................... 21
metoprolol tartrate inj 1mg/ml...................... 21
metoprolol tartrate tab 100mg ..................... 21
metoprolol tartrate tab 25mg ....................... 21
metoprolol tartrate tab 50mg ....................... 21
METOZOLV ODT ....................................... 35
METRO IV .................................................. 12
METROCREAM .......................................... 44
METROGEL................................................ 44
METROGEL-VAGINAL ............................... 44

Kaiser Permanente 2014 Comprehensive Formulary 63

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

MS CONTIN TAB 200MG CR ..................... 23


MS CONTIN TAB 30MG CR ....................... 23
MS CONTIN TAB 60MG CR ....................... 23
MULTAQ ..................................................... 19
mupirocin .................................................... 44
mupirocin calcium (topical) ......................... 44
MUSTARGEN ............................................. 15
MYAMBUTOL ............................................. 11
MYCAMINE ................................................ 11
MYCOBUTIN .............................................. 11
mycophenolate mofetil ................................ 42
MYFORTIC ................................................. 42
MYOZYME.................................................. 32
MYRBETRIQ .............................................. 46
MYSOLINE ................................................. 25
N
NABI-HB ..................................................... 43
nabumetone ................................................ 23
nadolol & bendroflumethiazide .................... 21
nadolol tab 20mg ........................................ 21
nadolol tab 40mg ........................................ 21
nadolol tab 80mg ........................................ 21
nafcillin sodium ........................................... 10
NAFTIN....................................................... 44
NAGLAZYME .............................................. 32
nalbuphine hcl............................................. 23
NALFON ..................................................... 23
NALLPEN ISO-OSMOTIC IN DEXTROSE . 10
NALLPEN/DEXTROSE ............................... 10
naloxone hcl................................................ 27
naltrexone hcl ............................................. 27
NAMENDA SOL 10MG/5ML ....................... 27
NAMENDA TAB 10MG ............................... 27
NAMENDA TAB 5MG ................................. 27
NAMENDA TITRATION PAK TAB 5-10MG 27
NAMENDA XR CAP 14MG ......................... 27
NAMENDA XR CAP 21MG ......................... 27
NAMENDA XR CAP 28MG ......................... 27
NAMENDA XR CAP 7MG ........................... 27
NAMENDA XR TITRATION PACK CAP
TITRATIO................................................ 27
naphazoline hcl ........................................... 34
NAPRELAN ................................................ 23
NAPROSYN................................................ 23
naproxen ..................................................... 23
naproxen sodium ........................................ 23
naratriptan hcl ............................................. 25
NARDIL ...................................................... 28
NASACORT AQ.......................................... 33
NASONEX .................................................. 33

Kaiser Permanente 2014 Comprehensive Formulary 64

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

NITROMIST AER 400MCG ........................ 21


NITROSTAT SUB 0.3MG ........................... 21
NITROSTAT SUB 0.4MG ........................... 21
NITROSTAT SUB 0.6MG ........................... 21
nizatidine .................................................... 35
NIZORAL .................................................... 44
NORDETTE-28 ........................................... 37
NORDITROPIN FLEXPRO INJ 10/1.5ML ... 40
NORDITROPIN FLEXPRO INJ 15/1.5ML ... 40
NORDITROPIN FLEXPRO INJ 5/1.5ML ..... 40
NORDITROPIN NORDIFLEX PEN INJ
30/3ML .................................................... 40
norethin acet & estrad-fe............................. 37
norethindrone & eth estradiol ...................... 37
norethindrone & ethinyl estradiol-fe ............ 37
norethindrone (contraceptive) ..................... 37
norethindrone acet & eth estra .................... 37
norethindrone acetate ................................. 40
norethindrone acetate-ethinyl estradiol ....... 39
norethindrone acetate-ethinyl estradiol-fe ... 37
norethindrone-eth estradiol (biphasic) ......... 37
norethindrone-eth estradiol (triphasic) ........ 37
norgestimate-ethinyl estradiol ..................... 37
norgestimate-ethinyl estradiol (triphasic)..... 37
norgestrel & ethinyl estradiol ....................... 37
NORINYL 1+35 ........................................... 37
NORMOSOL-R ........................................... 31
NORMOSOL-R IN D5W .............................. 31
NOROXIN ................................................... 10
NORPACE CAP 100MG ............................. 19
NORPACE CAP 150MG ............................. 19
NORPACE CR CAP 100MG CR ................. 19
NORPACE CR CAP 150MG CR ................. 19
NORPRAMIN .............................................. 28
NOR-QD ..................................................... 37
nortriptyline hcl cap 10mg ........................... 28
nortriptyline hcl cap 25mg ........................... 28
nortriptyline hcl cap 50mg ........................... 28
nortriptyline hcl cap 75mg ........................... 28
NORVASC .................................................. 19
NORVIR ...................................................... 12
NOVOLIN 70/30 INJ 70/30 ......................... 38
NOVOLIN N INJ U-100 ............................... 38
NOVOLIN R INJ U-100 ............................... 38
NOVOLOG.................................................. 38
NOVOLOG FLEXPEN ................................ 38
NOVOLOG MIX 70/30 ................................ 38
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN................................................ 38
NOXAFIL .................................................... 11
NUCYNTA .................................................. 23

Kaiser Permanente 2014 Comprehensive Formulary 65

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

Kaiser Permanente 2014 Comprehensive Formulary 66

paroxetine hcl er tab 25mg er ..................... 28


paroxetine hcl er tab 37.5mg ...................... 28
paroxetine hcl tab 10mg ............................. 28
paroxetine hcl tab 20mg ............................. 28
paroxetine hcl tab 30mg ............................. 28
paroxetine hcl tab 40mg ............................. 28
PATADAY................................................... 33
PATANASE ................................................ 33
PATANOL................................................... 33
PAXIL ......................................................... 28
PAXIL CR ................................................... 28
PCE ............................................................ 10
PEDVAX HIB .............................................. 44
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate ..................................................... 35
peg 3350-potassium chloride-sod
bicarbonate-sod chloride......................... 35
PEGANONE ............................................... 25
PEGASYS .................................................. 12
PEGASYS PROCLICK ............................... 12
PEG-INTRON ............................................. 12
PEG-INTRON REDIPEN ............................ 12
penicillin g potassium ................................. 10
PENICILLIN G POTASSIUM IN ISOOSMOTIC DEXTROSE .......................... 10
penicillin g procaine .................................... 10
penicillin g sodium ...................................... 10
penicillin v potassium.................................. 10
PENNSAID ................................................. 46
PENTAM 300 INJ 300MG .......................... 12
PENTASA CAP 250MG CR ....................... 34
PENTASA CAP 500MG CR ....................... 34
pentazocine w/ naloxone ............................ 23
pentazocine-acetaminophen ...................... 23
pentostatin .................................................. 15
pentoxifylline............................................... 17
PEPCID ...................................................... 35
PERCODAN ............................................... 23
PERFOROMIST ......................................... 17
perindopril erbumine ................................... 20
PERJETA ................................................... 15
permethrin .................................................. 44
perphenazine.............................................. 28
perphenazine-amitriptyline ......................... 28
PERSANTINE ............................................ 21
PERTZYE CAP .......................................... 35
PEXEVA ..................................................... 28
phenelzine sulfate ...................................... 28
phenobarbital.............................................. 26
phenytoin .................................................... 25
phenytoin sodium ....................................... 25

phenytoin sodium extended ........................ 25


PHISOHEX ................................................. 44
PHOSLO CAP 667MG ................................ 31
PHOSLYRA SOL ........................................ 31
PHOSPHOLINE IODIDE ............................. 34
PICATO ...................................................... 46
pilocarpine hcl (oral).................................... 16
PILOPINE HS GEL 4% OP ......................... 34
pindolol ....................................................... 21
pioglitazone hcl ........................................... 38
pioglitazone hcl-glimepiride ......................... 38
pioglitazone hcl-metformin hcl..................... 38
piperacillin sodium-tazobactam sodium ...... 10
piroxicam .................................................... 23
PLAN B ONE-STEP .................................... 37
PLAQUENIL................................................ 12
PLASMA-LYTE A ........................................ 31
PLASMA-LYTE-148 .................................... 31
PLASMA-LYTE-56/D5W ............................. 31
PLAVIX ....................................................... 17
PLETAL ...................................................... 17
podofilox ..................................................... 46
polyethylene glycol 3350............................. 35
polymyxin b sulfate ..................................... 10
polymyxin b-trimethoprim ............................ 32
POLYTRIM ................................................. 32
POMALYST ................................................ 15
PONSTEL ................................................... 23
potassium chloride ...................................... 31
POTASSIUM CHLORIDE 0.15% /NACL
0.45% VIAFLEX INJ .15-0.45 .................. 31
POTASSIUM CHLORIDE 0.3%/ NACL 0.9%
INJ 0.3-0.9 .............................................. 31
potassium chloride in dextrose.................... 31
potassium chloride in dextrose & sodium
chloride ................................................... 31
potassium chloride in nacl ........................... 31
POTASSIUM CHLORIDE INJ 10MEQ ........ 31
POTASSIUM CHLORIDE INJ 20MEQ ........ 31
POTASSIUM CHLORIDE INJ 30MEQ ........ 31
POTASSIUM CHLORIDE INJ 40MEQ ........ 31
potassium chloride microencapsulated
crystals cr ................................................ 31
POTASSIUM CITRATE TAB 1080MG ........ 29
POTASSIUM CITRATE TAB 540MG .......... 29
POTIGA ...................................................... 25
PRADAXA................................................... 17
pramipexole dihydrochloride ....................... 26
PRANDIMET............................................... 38
PRANDIN.................................................... 38
PRAVACHOL.............................................. 18

Kaiser Permanente 2014 Comprehensive Formulary 67

pravastatin sodium ..................................... 18


prazosin hcl ................................................ 18
PRECOSE .................................................. 38
PRED FORTE SUS 1% OP ........................ 33
PRED MILD SUS 0.12% OP ...................... 33
PRED-G ..................................................... 33
PRED-G S.O.P. .......................................... 33
prednicarbate ............................................. 45
prednisolone ............................................... 36
prednisolone acetate (ophth) ...................... 33
prednisolone sodium phosphate ................. 36
prednisolone sodium phosphate (ophth)..... 33
prednisone.................................................. 36
PREMARIN ................................................ 39
PREMARIN INJ 25MG ............................... 39
PREMARIN TAB 0.3MG ............................. 39
PREMARIN TAB 0.45MG ........................... 39
PREMARIN TAB 0.625MG ......................... 39
PREMARIN TAB 0.9MG ............................. 39
PREMARIN TAB 1.25MG ........................... 39
PREMPHASE ............................................. 39
PREMPRO ................................................. 39
PREPOPIK ................................................. 35
PREVACID ................................................. 35
PREVACID SOLUTAB ............................... 35
PREVPAC .................................................. 35
PREZISTA SUS 100MG/ML ....................... 12
PREZISTA TAB 150MG ............................. 12
PREZISTA TAB 400MG ............................. 12
PREZISTA TAB 600MG ............................. 12
PREZISTA TAB 75MG ............................... 12
PREZISTA TAB 800MG ............................. 12
PRIFTIN ..................................................... 11
PRILOSEC ................................................. 35
PRIMAQUINE PHOSPHATE ...................... 12
PRIMAXIN I.M. INJ 500MG ........................ 10
PRIMAXIN IV INJ 250MG ........................... 10
PRIMAXIN IV INJ 500MG ........................... 10
primidone ................................................... 25
PRIMSOL ................................................... 13
PRINIVIL .................................................... 20
PRINZIDE................................................... 20
PRISTIQ ..................................................... 28
PRIVIGEN .................................................. 43
PROAIR HFA AER ..................................... 17
probenecid.................................................. 32
procainamide hcl ........................................ 19
PROCALAMINE INJ 3% ............................. 30
PROCARDIA .............................................. 19
PROCARDIA XL......................................... 19
prochlorperazine ......................................... 28

prochlorperazine edisylate .......................... 28


prochlorperazine maleate ........................... 28
PROCRIT INJ 10000/ML ............................ 18
PROCRIT INJ 2000/ML .............................. 18
PROCRIT INJ 20000/ML ............................ 18
PROCRIT INJ 3000/ML .............................. 18
PROCRIT INJ 4000/ML .............................. 18
PROCRIT INJ 40000/ML ............................ 18
PROCYSBI CAP 25MG .............................. 42
PROCYSBI CAP 75MG .............................. 42
progesterone micronized ............................ 40
PROGLYCEM ............................................. 19
PROGRAF CAP 0.5MG .............................. 42
PROGRAF CAP 1MG ................................. 42
PROGRAF CAP 5MG ................................. 42
PROGRAF INJ 5MG/ML ............................. 42
PROLASTIN-C............................................ 43
PROLENSA ................................................ 33
PROLEUKIN ............................................... 15
PROLIA SOL 60MG/ML .............................. 42
PROMACTA ............................................... 18
promethazine & phenylephrine ................... 13
promethazine hcl ........................................ 13
PROMETRIUM ........................................... 40
propafenone hcl .......................................... 19
propantheline bromide ................................ 16
proparacaine hcl ......................................... 34
propranolol & hydrochlorothiazide............... 21
propranolol hcl er cap 120mg er ................. 21
propranolol hcl er cap 160mg er ................. 21
propranolol hcl er cap 60mg er ................... 21
propranolol hcl er cap 80mg er ................... 21
propranolol hcl inj 1mg/ml ........................... 21
propranolol hcl sol 20mg/5ml ...................... 21
propranolol hcl sol 40mg/5ml ...................... 21
propranolol hcl tab 10mg ............................ 22
propranolol hcl tab 20mg ............................ 22
propranolol hcl tab 40mg ............................ 22
propranolol hcl tab 60mg ............................ 22
propranolol hcl tab 80mg ............................ 22
propylthiouracil............................................ 40
PROQUAD.................................................. 44
PROSCAR .................................................. 42
PROSOL INJ 20% ...................................... 30
PROTONIX INJ 40MG ................................ 35
PROTONIX PAK ......................................... 35
PROTONIX TAB 20MG .............................. 35
PROTONIX TAB 40MG .............................. 35
PROTOPIC ................................................. 46
protriptyline hcl............................................ 28
PROVENTIL HFA AER HFA ....................... 17

Kaiser Permanente 2014 Comprehensive Formulary 68

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

RISPERDAL CONSTA ............................... 29


RISPERDAL M-TAB ................................... 29
risperidone.................................................. 29
RITALIN LA CAP 10MG ............................. 24
RITALIN LA CAP 20MG ............................. 24
RITALIN LA CAP 30MG ............................. 24
RITALIN LA CAP 40MG ............................. 24
RITALIN SR TAB 20MG SR ....................... 24
RITALIN TAB 10MG ................................... 24
RITALIN TAB 20MG ................................... 24
RITALIN TAB 5MG ..................................... 24
RITUXAN ................................................... 15
rivastigmine tartrate .................................... 16
rizatriptan benzoate .................................... 26
ROBINUL FORTE TAB 2MG ...................... 16
ROBINUL TAB 1MG ................................... 16
ROCALTROL CAP 0.25MCG ..................... 47
ROCALTROL CAP 0.5MCG ....................... 47
ROCALTROL SOL 1MCG/ML .................... 47
ropinirole hydrochloride .............................. 26
ROTATEQ .................................................. 44
ROXICODONE ........................................... 23
ROZEREM ................................................. 26
RYTHMOL .................................................. 19
RYTHMOL SR ............................................ 19
S
SABRIL ...................................................... 25
SAFYRAL ................................................... 37
SAIZEN ...................................................... 40
SAIZEN CLICK.EASY ................................ 40
SALAGEN .................................................. 16
SAMSCA .................................................... 30
SANCTURA................................................ 46
SANCTURA XR.......................................... 46
SANCUSO.................................................. 34
SANDIMMUNE ........................................... 42
SANDOSTATIN INJ 1000MCG .................. 42
SANDOSTATIN INJ 100MCG .................... 42
SANDOSTATIN INJ 200MCG .................... 42
SANDOSTATIN INJ 500MCG .................... 42
SANDOSTATIN INJ 50MCG/ML ................ 42
SANDOSTATIN LAR DEPOT KIT LAR 10MG
............................................................... 42
SANDOSTATIN LAR DEPOT KIT LAR 20MG
............................................................... 42
SANDOSTATIN LAR DEPOT KIT LAR 30MG
............................................................... 42
SANTYL ..................................................... 46
SAPHRIS ................................................... 29
SARAFEM .................................................. 29

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

Kaiser Permanente 2014 Comprehensive Formulary 70

SOLU-MEDROL INJ 2GM .......................... 36


SOLU-MEDROL INJ 40MG ........................ 36
SOLU-MEDROL INJ 500MG ...................... 36
SOMA ......................................................... 16
SOMATULINE DEPOT ............................... 42
SOMAVERT ............................................... 40
SONATA .................................................... 26
SORIATANE............................................... 46
SORILUX ................................................... 46
sotalol hcl ................................................... 22
sotalol hcl (afib/afl) ..................................... 22
SOTALOL HYDROCHLORIDE................... 22
SPINOSAD ................................................. 44
SPIRIVA HANDIHALER ............................. 16
spironolactone & hydrochlorothiazide ......... 20
spironolactone tab 100mg .......................... 20
spironolactone tab 25mg ............................ 20
spironolactone tab 50mg ............................ 20
SPORANOX CAP 100MG .......................... 11
SPORANOX PULSEPAK CAP PULSEPAK 11
SPORANOX SOL 10MG/ML ...................... 11
SPRIX ........................................................ 23
SPRYCEL................................................... 15
STALEVO 100 ............................................ 26
STALEVO 125 ............................................ 26
STALEVO 150 ............................................ 26
STALEVO 200 ............................................ 26
STALEVO 50 .............................................. 26
STALEVO 75 .............................................. 26
STARLIX .................................................... 39
stavudine .................................................... 13
STAVZOR .................................................. 25
STELARA ................................................... 46
STIMATE SOL 1.5MG/ML .......................... 39
STIVARGA ................................................. 15
STRATTERA .............................................. 27
streptomycin sulfate.................................... 10
STRIBILD ................................................... 13
STROMECTOL ............................................ 9
SUBOXONE ............................................... 27
SUBSYS ..................................................... 23
SUCRAID ................................................... 32
sucralfate .................................................... 35
SULAR ....................................................... 19
sulfacetamide sodium (acne) ...................... 45
sulfacetamide sodium (ophth)..................... 32
sulfacetamide sod-prednisolone ................. 33
sulfadiazine ................................................ 10
sulfamethoxazole-trimethoprim................... 10
SULFAMYLON CRE 85MG/GM ................. 45
SULFAMYLON PAK 5% ............................. 45

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

Kaiser Permanente 2014 Comprehensive Formulary 71

TEGRETOL SUS 100/5ML ......................... 25


TEGRETOL TAB 200MG ........................... 25
TEGRETOL-XR TAB 100MG ..................... 25
TEGRETOL-XR TAB 200MG ..................... 25
TEGRETOL-XR TAB 400MG ..................... 25
TEKAMLO .................................................. 20
TEKTURNA ................................................ 20
TEKTURNA HCT ........................................ 20
temazepam................................................. 26
TEMOVATE................................................ 45
TENEX ....................................................... 19
TENORETIC 100 ........................................ 22
TENORETIC 50.......................................... 22
TENORMIN ................................................ 22
TERAZOL 3 ................................................ 45
TERAZOL 7 ................................................ 45
terazosin hcl ............................................... 18
terbinafine hcl ............................................. 11
terbutaline sulfate ....................................... 17
terconazole vaginal .................................... 45
TESTIM GEL 1%(50MG) ............................ 37
testosterone cypionate ............................... 37
testosterone enanthate ............................... 37
TETANUS TOXOID ADSORBED ............... 43
TETANUS/DIPHTHERIA TOXOID SADSORBED ADULT ............................... 43
tetracycline hcl............................................ 10
tetrahydrozoline hcl .................................... 34
TEVETEN ................................................... 20
TEVETEN HCT .......................................... 20
TEV-TROPIN INJ 5MG............................... 40
THALOMID ................................................. 42
theophylline ................................................ 46
thioridazine hcl ........................................... 29
thiotepa ...................................................... 15
thiothixene .................................................. 29
THYMOGLOBULIN .................................... 42
THYROLAR-1............................................. 40
THYROLAR-1/2 .......................................... 40
THYROLAR-1/4 .......................................... 40
THYROLAR-2............................................. 41
THYROLAR-3............................................. 41
tiagabine hcl ............................................... 25
TIAZAC ...................................................... 19
ticarcillin & pot clavulanate ......................... 10
TICE BCG .................................................. 15
ticlopidine hcl .............................................. 17
TIGAN ........................................................ 34
TIKOSYN ................................................... 19
TIMENTIN .................................................. 10
timolol maleate ........................................... 22

timolol maleate (ophth) ............................... 34


TIMOPTIC OCUDOSE................................ 34
TIMOPTIC-XE............................................. 34
tinidazole .................................................... 12
TIROSINT ................................................... 41
TIVICAY ...................................................... 13
tizanidine hcl ............................................... 16
TOBI NEB 300/5ML .................................... 10
TOBI PODHALER CAP 28MG .................... 10
TOBRADEX OIN 0.3-0.1% ......................... 33
TOBRADEX ST SUS 0.3-0.05 .................... 33
TOBRADEX SUS 0.3-0.1% ........................ 33
tobramycin sulfate ....................................... 10
tobramycin sulfate (ophth) .......................... 32
tobramycin sulfate in saline ......................... 10
tobramycin-dexamethasone ........................ 33
TOBREX OIN 0.3% OP .............................. 32
TOBREX SOL 0.3% OP.............................. 32
TOFRANIL-PM ........................................... 29
tolazamide .................................................. 39
tolbutamide ................................................. 39
tolmetin sodium ........................................... 23
tolterodine tartrate ....................................... 46
TOPAMAX .................................................. 25
TOPAMAX SPRINKLE................................ 25
TOPICORT ................................................. 45
topiramate ................................................... 25
topotecan hcl .............................................. 15
TOPROL XL................................................ 22
TORISEL .................................................... 15
torsemide .................................................... 30
TOVIAZ ....................................................... 46
TRACLEER................................................. 21
TRADJENTA............................................... 39
tramadol hcl ................................................ 23
tramadol-acetaminophen ............................ 23
trandolapril .................................................. 20
tranexamic acid........................................... 17
TRANSDERM-SCOP .................................. 34
TRANXENE T ............................................. 26
tranylcypromine sulfate ............................... 29
TRAVATAN Z ............................................. 34
travoprost .................................................... 34
trazodone hcl tab 100mg ............................ 29
trazodone hcl tab 150mg ............................ 29
trazodone hcl tab 300mg ............................ 29
trazodone hcl tab 50mg .............................. 29
TREANDA................................................... 15
TRECATOR ................................................ 11
TRELSTAR DEPOT MIXJECT.................... 15
TRELSTAR LA MIXJECT ........................... 15

Kaiser Permanente 2014 Comprehensive Formulary 72

TRELSTAR MIXJECT ................................ 15


TRENTAL ................................................... 18
tretinoin ...................................................... 46
tretinoin (chemotherapy)............................. 15
tretinoin w/ cleanser & moisturizer .............. 46
TREXIMET ................................................. 26
triamcinolone acetonide (mouth) ................ 45
triamcinolone acetonide (nasal) .................. 33
triamcinolone acetonide (topical) ................ 45
triamterene/hydrochlorothiazide cap 37.5-25
............................................................... 30
triamterene/hydrochlorothiazide tab 37.5-25
............................................................... 30
triamterene/hydrochlorothiazide tab 75-50mg
............................................................... 31
triazolam ..................................................... 26
TRIBENZOR............................................... 19
TRICOR ..................................................... 18
trifluoperazine hcl ....................................... 29
trifluridine .................................................... 32
trihexyphenidyl hcl ...................................... 26
TRILEPTAL SUS 300MG/5M ..................... 25
TRILEPTAL TAB 150MG............................ 25
TRILEPTAL TAB 300MG............................ 25
TRILEPTAL TAB 600MG............................ 25
TRILIPIX ..................................................... 18
trimethobenzamide hcl ............................... 34
trimethoprim ............................................... 13
trimipramine maleate .................................. 29
TRINATAL RX 1 ......................................... 47
TRI-NORINYL 28 ....................................... 37
TRISENOX ................................................. 15
TRIZIVIR .................................................... 13
TROPHAMINE INJ 10% ............................. 30
TROPHAMINE INJ 6% ............................... 30
tropicamide ................................................. 34
trospium chloride ........................................ 46
TRUSOPT .................................................. 34
TRUVADA .................................................. 13
TUDORZA PRESSAIR ............................... 16
TWINJECT INJ 0.15MG ............................. 17
TWINJECT INJ 0.3MG ............................... 17
TWINRIX .................................................... 44
TWYNSTA .................................................. 19
TYGACIL .................................................... 10
TYKERB ..................................................... 15
TYPHIM VI ................................................. 44
TYSABRI .................................................... 42
TYVASO ..................................................... 21
TYZEKA ..................................................... 13

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

VIVELLE-DOT DIS 0.0375MG .................... 39


VIVELLE-DOT DIS 0.05MG ........................ 39
VIVELLE-DOT DIS 0.075MG ...................... 39
VIVELLE-DOT DIS 0.1MG .......................... 39
VIVITROL ................................................... 27
VOLTAREN ................................................ 46
VOLTAREN-XR .......................................... 23
VORAXAZE ................................................ 42
voriconazole................................................ 11
vospire er tab 4mg ...................................... 17
vospire er tab 8mg ...................................... 17
VOTRIENT.................................................. 15
VPRIV ......................................................... 32
VUMON ...................................................... 15
VYTORIN .................................................... 18
VYVANSE ................................................... 24
W
warfarin sodium .......................................... 18
water for irrigation, sterile............................ 31
WELCHOL .................................................. 18
WELLBUTRIN............................................. 29
WELLBUTRIN SR ....................................... 29
WELLBUTRIN XL ....................................... 29
WESTCORT ............................................... 45
X
XALATAN ................................................... 34
XALKORI .................................................... 15
XANAX ....................................................... 26
XANAX XR.................................................. 26
XARELTO ................................................... 18
XELJANZ .................................................... 42
XENAZINE .................................................. 27
XEOMIN ..................................................... 42
XERESE ..................................................... 45
XGEVA INJ ................................................. 42
XIFAXAN .................................................... 11
XOLAIR ...................................................... 43
XOPENEX .................................................. 17
XOPENEX HFA .......................................... 17
XTANDI ...................................................... 15
XYLOCAINE ......................................... 42, 45
XYREM ....................................................... 27
XYZAL ........................................................ 13
Y
YASMIN 28 ................................................. 37
YAZ............................................................. 37
YERVOY ..................................................... 15

Kaiser Permanente 2014 Comprehensive Formulary 74

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

ZITHROMAX POW 1GM PAK .................... 11


ZITHROMAX SUS 100/5ML........................ 11
ZITHROMAX SUS 200/5ML........................ 11
ZITHROMAX TAB 250MG .......................... 11
ZITHROMAX TAB 500MG .......................... 11
ZITHROMAX TAB 600MG .......................... 11
ZITHROMAX TRI-PAK TAB TRI-PAK ......... 11
ZITHROMAX Z-PAK TAB Z-PAK ................ 11
ZMAX SUS 2GM ......................................... 11
ZOCOR....................................................... 18
ZOFRAN ..................................................... 34
ZOFRAN ODT ............................................ 34
zoledronic acid ............................................ 42
ZOLINZA .................................................... 15
ZOLOFT ..................................................... 29
zolpidem tartrate ......................................... 26
ZOLPIMIST ................................................. 26
ZOMETA ..................................................... 42
ZOMIG ........................................................ 26
ZOMIG NASAL SPRAY .............................. 26
ZOMIG ZMT................................................ 26
ZONALON .................................................. 45
ZONEGRAN ............................................... 25
zonisamide.................................................. 25
ZORBTIVE .................................................. 40
ZORTRESS TAB 0.25MG ........................... 42
ZORTRESS TAB 0.5MG............................. 42
ZORTRESS TAB 0.75MG ........................... 42
ZOSTAVAX................................................. 44
ZOSYN ....................................................... 11
ZOVIRAX .............................................. 13, 45
ZYBAN ........................................................ 29
ZYCLARA ................................................... 46
ZYFLO CR TAB 600MG ............................. 43
ZYFLO TAB 600MG.................................... 43
ZYLET ........................................................ 33
ZYLOPRIM ................................................. 42
ZYMAXID .................................................... 32
ZYPREXA ................................................... 29
ZYPREXA ZYDIS ....................................... 29
ZYTIGA ....................................................... 15
ZYVOX ....................................................... 11

Kaiser Permanente 2014 Comprehensive Formulary 75

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.

Kaiser Permanente Regions


CALIFORNIA REGIONS
Kaiser Foundation Health Plan, Inc.
393 E. Walnut St.
Pasadena, CA 91188-8514
Kaiser Permanente Senior Advantage
(HMO) and Senior Advantage Medicare
Medi-Cal Plan (HMO SNP)

HAWAII REGION
Kaiser Foundation Health Plan, Inc.
711 Kapiolani Blvd.
Tower Suite 400
Honolulu, HI 96813
Kaiser Permanente Senior Advantage
(HMO)

Member Service Contact Center


1-800-443-0815 TTY 711

Customer Service Center


1-800-805-2739 TTY 711

COLORADO REGION
Kaiser Foundation Health Plan of Colorado
2500 South Havana Street
Aurora, CO 80014-1622

MID-ATLANTIC STATES REGION


(District of Columbia, Maryland,
and Virginia)
Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc.
2101 East Jefferson Street
Rockville, MD 20852

Kaiser Permanente Senior Advantage


(HMO), Senior Advantage Medicare
Medicaid Plan (HMO SNP), and Senior
Advantage Plus Choice (HMO-POS)

Kaiser Permanente Medicare Plus (Cost)

Member Service Contact Center


1-800-476-2167 TTY 711

Member Service Contact Center


1-888-777-5536 TTY 711

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

Kaiser Permanente Senior Advantage


(HMO) and Senior Advantage Medicare
Medicaid Plan (HMO SNP)
Member Services
1-800-232-4404 TTY 711

kp.org/seniormedrx
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MOM 60174808 01/2014

Kaiser Permanente Senior Advantage


(HMO)
Membership Services
1-877-221-8221 TTY 711