Kaiser Permanente comprehensive formulary

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Kaiser Permanente comprehensive formulary
Kaiser Permanente
2017 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 09/01/16. 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)
and Senior Advantage Medicare Medicaid
Plan (HMO SNP)
Member Services
1-800-476-2167 TTY 711
MID-ATLANTIC STATES REGION
(District of Columbia, Maryland,
and Virginia)
Kaiser Permanente Medicare Plus (Cost)
Member Services
1-888-777-5536 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)
and Senior Advantage Medicare Medicaid
Plan (HMO SNP)
Member Services
1-800-805-2739 TTY 711
NORTHWEST REGION
Kaiser Permanente Senior Advantage (HMO)
Membership Services
1-877-221-8221 TTY 711
Y0043_N016752_Final01 approved
HPMS Approved Formulary File Submission 00017154, Version 8
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, 2017. For an updated formulary, please visit our website at kp.org/seniormedrx or call
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. The formulary,
pharmacy network and/or provider network may change at any time. You will receive notice when
necessary. This information is not a complete description of benefits. Contact the plan for more
information. Limitations, copayments, and restrictions may apply. Benefits and/or
copayments/coinsurance may change on January 1 of each year, and for group members, at other
times in accord with your group’s contract with us.
In California, Kaiser Permanente is an HMO plan and a Cost plan with a Medicare contract. In
Hawaii, Oregon, Washington, Colorado, and Georgia, Kaiser Permanente is an HMO plan with a
Medicare contract. In Virginia, Maryland, and the District of Columbia, 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 the Member Services number
listed on the front and back covers.
Esta información está disponible gratis en otros idiomas. Por favor llame al número de Servicios a
los Miembros que aparece en la portada y la contraportada.
本資訊的其他語言版本為免費提供。請致電列於封面和封底的會員服務電話號碼。
What is the Kaiser Permanente
Formulary?
A formulary is a list of covered drugs selected
by Kaiser Permanente 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 Kaiser Permanente network
pharmacy, and other plan rules are followed.
For more information on how to fill your
prescriptions, please review your Evidence
of Coverage.
Our plan covers all drugs that can be
included in a Medicare Part D prescription
drug plan according to Medicare
requirements. Contact information for your
Kaiser Permanente Region, along with the
date we last updated the formulary, appears
on the front and back cover pages.
Can the formulary (drug list)
change?
Generally, if you are taking a drug on our
2017 formulary that was covered at the
beginning of the year, we will not discontinue
or reduce coverage of the drug during the
2017 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 drug’s
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, 2017. To
get updated information about the drugs
covered by our plan, please call us. Contact
information for your Kaiser Permanente
Region appears on the front and back cover
pages.
In the event of a midyear nonmaintenance formulary change, we will
provide details in the Medicare Part D
Explanation of Benefits that we send
you 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 6. 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
Kaiser Permanente 2017 Comprehensive Formulary • 1
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 8. Then look under the category
name for your drug.
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.
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 55. The index
provides an alphabetical list of all of the drugs
included in this document. Preferred generic
and generic drugs, preferred brand-name and
nonpreferred 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
generic 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:
•
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
2 • Kaiser Permanente 2017 Comprehensive Formulary
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 don’t
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 fill your prescription
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 6. You can
also get more information about the
restrictions applied to specific covered drugs
by visiting our website. We have posted
online a document that explains our prior
authorization restriction. You may also ask us
to send you a copy. Contact information for
your Kaiser Permanente Region, along with
the date we last updated the formulary,
appears on the front and back cover pages.
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 2017 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 2017 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
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 2017
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.
Kaiser Permanente 2017 Comprehensive Formulary • 3
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 plan’s 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 prescriber’s supporting
statement. You can request an expedited
(fast) exception if you or your network
provider believe 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
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
30-day supply (unless you have a prescription
written for fewer days) when you go to a
network pharmacy. After your first 30-day
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
4 • Kaiser Permanente 2017 Comprehensive Formulary
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).
For more information
For more detailed information about your
Kaiser Permanente prescription drug
coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about our plan, please
call 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.
If you have general questions about Medicare
prescription drug coverage, please call
Medicare at 1-800-MEDICARE
(1-800-633-4227) 24 hours a day/7 days a
week. TTY users should call
1-877-486-2048. Or, visit
http://www.medicare.gov.
Kaiser Permanente 2017 Comprehensive Formulary • 5
Kaiser Permanente’s Formulary
The formulary below provides coverage information about the drugs covered by our plan. If you
have trouble finding your drug in the list, turn to the index that begins on page 55.
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 – Generic drugs
Tier 3 – Preferred brand-name drugs
Tier 4 – Nonpreferred brand-name drugs
Tier 5 – Specialty-tier drugs
Tier 6 – Injectable Part D vaccines
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 drug’s 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.
Note: If your coverage is through an employer-sponsored 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 (non-Part 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-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.
6 • Kaiser Permanente 2017 Comprehensive Formulary
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. Please contact us 10 days before your refills run out. Generally, you
should receive them within 10 days. If not, please contact the mail-order phone number for your
Kaiser Permanente Region in the chart below or the phone number on the prescription label for
assistance. Additional drugs may be available for mail order. Not all drugs can be mailed;
restrictions and limitations apply. For more information, please visit kp.org/seniormedrx or call the
appropriate regional phone number below.
Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy
Northern CA – 1-888-218-6245
Monday through Friday, 8 a.m. to 6 p.m.
Colorado
Georgia
Hawaii
Mid-Atlantic
States
Northwest
Southern CA – 1-866-206-2983
Monday through Friday, 7 a.m. to 7 p.m.
Kaiser Permanente Mail Order Pharmacy
1-866-523-6059
Monday through Friday, 8 a.m. to 6 p.m.
Kaiser Permanente Refill Pharmacy
770-434-2008 or toll free 1-888-662-4579
Seven days a week, 24 hours
Kaiser Permanente Automated Refill Center
808-643-7979 (Oahu and neighbor islands)
Monday through Friday, 8:30 a.m. to 5 p.m.
Kaiser Permanente Mid-Atlantic Automated Refill Center
703-466-4900 or toll-free 1-800-733-6345
Monday through Friday, 7 a.m. to 6 p.m., Saturday, 8:30 a.m. to 4 p.m.
Kaiser Permanente Mail-Delivery Pharmacy
1-800-548-9809
Monday through Friday, 8 a.m. to 4:30 p.m.
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for
possible adverse effects and to avoid medication waste.
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 2017 Comprehensive Formulary • 7
Drug
Tier
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ALBENZA
3
BILTRICIDE
3
ivermectin
2
mebendazole
2
SKLICE
4
STROMECTOL
4
ANTIBACTERIALS
amikacin sulfate
2
amoxicillin
2
amoxicillin & pot
2
clavulanate
ampicillin
2
ampicillin & sulbactam
2
sodium
ampicillin sodium
2
AUGMENTIN
3
AVELOX SOLN
3
AVELOX
4
AVELOX ABC PACK
4
AVYCAZ
4
AZACTAM IN
3
DEXTROSE
azithromycin
2
AZITHROMYCIN
3
PACK 1 GM
aztreonam
2
AZULFIDINE
4
AZULFIDINE EN4
TABS
bacitracin
2
BACTOCILL IN
3
DEXTROSE
BACTRIM
4
BACTRIM DS
4
BETHKIS
5
BIAXIN
4
BICILLIN C-R
4
BICILLIN C-R 900/300 4
BICILLIN L-A
3
CAYSTON
5
CEDAX
4
cefaclor
2
cefaclor monohydrate
2
Drug Name
Requirements/
Limits
HI
HI
HI
HI
HI
HI
HI,MO
MO
HI
HI
MO
MO
PA
LD
Drug Name
cefadroxil
cefazolin sodium
cefdinir
cefepime hcl
cefixime
cefotaxime sodium
cefotetan disodium
cefoxitin sodium
CEFOXITIN SODIUMDEXTROSE
cefpodoxime proxetil
cefprozil
ceftazidime
CEFTAZIDIME AND
DEXTROSE
CEFTIN SUSR 125
MG/5ML
CEFTIN SUSR 250
MG/5ML
CEFTIN TABS 250 MG
CEFTIN TABS 500 MG
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
CEFUROXIMEDEXTROSE
cephalexin
chloramphenicol
sodium succinate
CIPRO
CIPRO IN D5W
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin in d5w
ciprofloxacinciprofloxacin hcl
CLAFORAN
clarithromycin
CLEOCIN
CLEOCIN IN D5W
CLEOCIN
PHOSPHATE
clindamycin hcl
clindamycin palmitate
hydrochloride
Drug
Tier
2
2
2
2
2
2
2
2
Requirements/
Limits
HI
HI
HI
HI
HI
3
HI
2
2
2
HI
3
HI
4
3
4
4
2
2
2
HI
3
HI
HI
2
2
4
4
2
2
2
HI
HI
HI
HI
2
4
2
4
3
HI
4
HI
HI
2
2
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
8 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
clindamycin phosphate
clindamycin phosphate
in d5w
colistimethate sodium
CUBICIN
DALVANCE
demeclocycline hcl
dicloxacillin sodium
DIFICID
DORIBAX
doxycycline
(monohydrate)
doxycycline hyclate
E.E.S. GRANULES
ERYPED 200
ERYPED 400
erythromycin base
erythromycin
ethylsuccinate
erythromycin
lactobionate
erythromycin stearate
FORTAZ SOLR 1 GM
FORTAZ SOLR 2 GM
FORTAZ SOLR 6 GM
gentamicin in saline
gentamicin sulfate
imipenem-cilastatin
INVANZ
KETEK
KITABIS PAK
LEVAQUIN
levofloxacin
levofloxacin in d5w
LINCOCIN
lincomycin hcl
linezolid
MAXIPIME SOLR 1
GM
MAXIPIME SOLR 2
GM
meropenem
MERREM
MINOCIN
minocycline hcl
Drug
Tier
2
Requirements/
Limits
HI,MO
2
HI
2
5
5
2
2
5
4
HI
HI
2
MO
2
4
4
4
2
HI,MO
NDS
HI
MO
2
2
2
3
3
4
2
2
2
3
4
5
4
2
2
4
2
2
HI
HI
HI
HI
HI
HI
HI
HI
PA
HI
HI
HI
HI
HI,NDS
4
HI
4
HI
2
4
4
2
HI
HI
MO
MO
Drug Name
moxifloxacin hcl
MOXIFLOXACIN HCL
nafcillin sodium
NAFCILLIN SODIUM
IN DEXTROSE
neomycin sulfate
ofloxacin
ORBACTIV
oxacillin sodium
PCE
PENICILLIN G POT IN
DEXTROSE
penicillin g potassium
penicillin g procaine
penicillin g sodium
penicillin v potassium
piperacillin sodiumtazobactam sodium
polymyxin b sulfate
PRIMAXIN IV
SIVEXTRO
SOLODYN
streptomycin sulfate
sulfadiazine
sulfamethoxazoletrimethoprim
sulfasalazine
SUPRAX
SYNERCID
TEFLARO
TETRACYCLINE HCL
TOBI
TOBI PODHALER
tobramycin
tobramycin sulfate
TYGACIL
UNASYN
VANCOCIN HCL
vancomycin hcl
VANCOMYCIN HCL IN
DEXTROSE
VIBRAMYCIN
XIFAXAN
ZERBAXA
Drug
Tier
2
4
2
Requirements/
Limits
HI
HI
HI
3
HI
2
2
5
2
4
HI
3
HI
2
2
2
2
HI
2
HI
2
4
5
4
2
2
HI
HI
NDS
MO
2
HI,MO
2
4
3
4
4
5
5
2
2
4
4
5
2
HI
HI
HI
MO
PA
PA
HI
HI
HI
NDS
HI,NDS
3
HI
4
4
4
MO
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 9
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
2
4
4
5
2
2
4
Requirements/
Limits
ketoconazole
ZINACEF IN STERILE
3
HI
WATER
LAMISIL
ZINACEF SOLR 1.5
MYCAMINE
HI
4
HI
GM
NOXAFIL
ZINACEF SOLR 7.5
nystatin
4
HI
GM
nystatin (mouth-throat)
ZINACEF SOLR 750
ONMEL TABS 200 MG
4
HI
MG
SPORANOX CAPS
4
ZITHROMAX PACK 1
100 MG
3
MO
GM
SPORANOX SOLN 10
3
ZITHROMAX SOLR
MG/ML
4
HI
500 MG
terbinafine hcl
2
ZITHROMAX SUSR
VFEND
IV
SOLR
200
4
MO
4
HI
100 MG/5ML
MG
ZITHROMAX SUSR
VFEND SUSR 40
4
MO
5
200 MG/5ML
MG/ML
ZITHROMAX TABS
VFEND TABS 200 MG 5
4
MO
250 MG
VFEND TABS 50 MG
5
ZITHROMAX TABS
voriconazole
2
HI
4
MO
500 MG
ANTIMYCOBACTERIALS
ZITHROMAX TABS
aminosalicylic acid
2
MO
4
MO
600 MG
CAPASTAT SULFATE 3
HI
ZITHROMAX TRI-PAK
dapsone
2
MO
4
MO
TABS 500 MG
ethambutol hcl
2
MO
ZITHROMAX Z-PAK
isoniazid
2
MO
4
MO
TABS 250 MG
isoniazid & rifampin
2
MO
ZMAX SUSR 2 GM
4
MO
MYAMBUTOL
4
MO
ZOSYN
4
HI
MYCOBUTIN
4
MO
ZYVOX
5
HI,NDS
PRIFTIN
4
MO
ANTIFUNGALS
pyrazinamide
2
MO
ABELCET
4
HI
rifabutin
2
MO
AMBISOME
5
HI
RIFADIN
4
HI,MO
amphotericin b
2
HI
rifampin
2
HI,MO
ANCOBON
5
RIFATER
4
MO
CANCIDAS
5
HI
SIRTURO
5
NDS
CRESEMBA
5
NDS
TRECATOR
4
MO
DIFLUCAN
4
ANTIPROTOZOALS
ERAXIS
4
HI
ALINIA
3
fluconazole
2
atovaquone
2
NDS
fluconazole in nacl
2
HI
atovaquone-proguanil
2
flucytosine
2
hcl
GRIS-PEG
4
chloroquine phosphate 2
griseofulvin microsize
2
COARTEM
3
griseofulvin
DARAPRIM
3
2
ultramicrosize
FLAGYL
4
itraconazole
2
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
10 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
hydroxychloroquine
sulfate
IMPAVIDO
MALARONE
mefloquine hcl
MEPRON
METRO
metronidazole
metronidazole in nacl
NEBUPENT SOLR 300
MG
paromomycin sulfate
PENTAM SOLR 300
MG
PLAQUENIL
PRIMAQUINE
PHOSPHATE
QUALAQUIN
quinine sulfate
TINDAMAX
tinidazole
ANTIVIRALS
abacavir sulfate
abacavir sulfatelamivudine-zidovudine
acyclovir
acyclovir sodium
adefovir dipivoxil
APTIVUS
ATRIPLA
BARACLUDE SOLN
0.05 MG/ML
BARACLUDE TABS
0.5 MG
BARACLUDE TABS 1
MG
cidofovir
COMBIVIR
COMPLERA
COPEGUS
CRIXIVAN
CYTOVENE
DAKLINZA
DESCOVY
didanosine
Drug
Tier
Requirements/
Limits
2
MO
5
4
2
5
3
2
2
NDS
3
PA
NDS
HI
HI
2
4
4
MO
3
4
2
4
2
NDS
NDS
2
MO
2
MO
2
2
2
3
3
MO
HI
NDS
MO
MO
3
MO
5
5
2
4
3
4
3
4
5
4
2
HI
MO
MO
MO
MO
HI
PA,NDS
MO
MO
Drug Name
EDURANT
EMTRIVA
entecavir
EPCLUSA
EPIVIR HBV SOLN 5
MG/ML
EPIVIR HBV TABS
100 MG
EPIVIR SOLN 10
MG/ML
EPIVIR TABS 150 MG
EPIVIR TABS 300 MG
EPZICOM
EVOTAZ
famciclovir
FAMVIR
FLUMADINE
FUZEON
ganciclovir sodium
GENVOYA
HARVONI
HEPSERA
INFERGEN
INTELENCE
INVIRASE
ISENTRESS
KALETRA
lamivudine
lamivudine (hbv)
lamivudine-zidovudine
LEXIVA SUSP 50
MG/ML
LEXIVA TABS 700 MG
nevirapine
NORVIR
ODEFSEY
OLYSIO
PEG-INTRON
PEG-INTRON
REDIPEN
PEG-INTRON
REDIPEN PAK 4
PEGASYS
PEGASYS PROCLICK
PEGINTRON
Drug
Tier
3
3
2
5
Requirements/
Limits
MO
MO
MO
NDS
3
MO
4
MO
3
MO
4
4
3
4
2
4
4
3
2
4
5
5
5
3
3
3
3
2
2
2
MO
MO
MO
MO
MO
MO
MO
NDS
HI
MO
PA,NDS
NDS
NDS
MO
MO
MO
MO
MO
MO
MO
4
MO
3
2
3
4
5
5
MO
MO
MO
MO
PA,NDS
NDS
5
NDS
5
NDS
5
5
5
NDS
NDS
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 11
Drug Name
PLEGRIDY
PLEGRIDY STARTER
PACK
PREZCOBIX
PREZISTA
RAPIVAB
REBETOL
RELENZA
DISKHALER
RESCRIPTOR
RETROVIR CAPS 100
MG
RETROVIR SOLN 10
MG/ML
RETROVIR SYRP 50
MG/5ML
REYATAZ
ribavirin (hepatitis c)
rimantadine
hydrochloride
SELZENTRY
SOVALDI
stavudine
STRIBILD
SUSTIVA
SYNAGIS
TAMIFLU
TECHNIVIE
TIVICAY TABS 10 MG
TIVICAY TABS 25 MG
TIVICAY TABS 50 MG
TRIUMEQ
TRIZIVIR
TRUVADA TABS 100150 MG
TRUVADA TABS 133200 MG
TRUVADA TABS 167250 MG
TRUVADA TABS 200300 MG
TYZEKA
valacyclovir hcl
VALCYTE SOLR 50
MG/ML
Drug
Tier
5
Requirements/
Limits
NDS
5
NDS
3
3
5
4
MO
MO
3
MO
3
MO
4
MO
MO
3
HI
4
MO
3
2
MO
MO
2
MO
3
5
2
3
3
5
3
5
4
4
3
3
4
MO
PA,NDS
MO
MO
MO
4
MO
4
MO
PA,NDS
MO
MO
MO
MO
MO
MO
4
MO
3
MO
4
2
NDS
MO
3
NDS
Drug Name
Drug
Tier
VALCYTE TABS 450
5
MG
valganciclovir hcl
2
VALTREX
4
VICTRELIS
5
VIDEX EC CPDR 125
4
MG
VIDEX EC CPDR 200
4
MG
VIDEX EC CPDR 250
4
MG
VIDEX EC CPDR 400
4
MG
VIDEX SOLR 2 GM
3
VIEKIRA PAK
5
VIEKIRA XR
5
VIRACEPT
3
VIRAMUNE
4
VIRAMUNE XR
4
VIRAZOLE
3
VIREAD POWD 40
3
MG/GM
VIREAD TABS 150
3
MG
VIREAD TABS 200
4
MG
VIREAD TABS 250
4
MG
VIREAD TABS 300
3
MG
VISTIDE
5
VITEKTA
4
ZEPATIER
5
ZERIT
4
ZIAGEN SOLN 20
3
MG/ML
ZIAGEN TABS 300
4
MG
zidovudine
2
ZOVIRAX
4
URINARY ANTI-INFECTIVES
FURADANTIN
4
HIPREX
4
MACROBID
4
MACRODANTIN
4
Requirements/
Limits
NDS
NDS
MO
MO
MO
MO
MO
MO
PA,NDS
PA,NDS
MO
MO
MO
MO
MO
MO
MO
MO
MO
HI
MO
PA,NDS
MO
MO
MO
HI,MO
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
12 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
Drug
Tier
methenamine
2
hippurate
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-D 12
4
HOUR
clemastine fumarate
2
cyproheptadine hcl
2
desloratadine
2
diphenhydramine hcl
2
KARBINAL ER
4
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
ALECENSA
5
ALIMTA
3
ALKERAN SOLR 50
4
MG
anastrozole
2
ARIMIDEX
4
AROMASIN
4
ARRANON
3
ARZERRA
5
AVASTIN
3
azacitidine
2
Requirements/
Limits
MO
MO
NDS
NDS
NDS
Drug Name
BCG VACCINE
BELEODAQ
BENDEKA SOLN 100
MG/4ML
BEXAROTENE
bicalutamide
BICNU
bleomycin sulfate
BLINCYTO
BOSULIF
BUSULFEX
CABOMETYX
CAMPTOSAR
CAPRELSA
carboplatin
CASODEX
cisplatin
cladribine
CLOLAR
COMETRIQ (100 MG
DAILY DOSE)
COMETRIQ (140 MG
DAILY DOSE)
COMETRIQ (60 MG
DAILY DOSE)
COSMEGEN
COTELLIC
CYCLOPHOSPHAMID
E
CYRAMZA
cytarabine
dacarbazine
DACOGEN
DARZALEX
daunorubicin hcl
decitabine
DOCEFREZ SOLR 20
MG
DOCETAXEL (NONALCOHOL) SOLN 160
MG/8ML
DOCETAXEL (NONALCOHOL) SOLN 20
MG/ML
Drug
Tier
3
5
Requirements/
Limits
5
5
2
3
2
5
5
4
5
4
3
2
4
2
2
4
NDS
5
LD,NDS
5
LD,NDS
5
LD,NDS
4
5
NDS
4
PA
NDS
NDS
LD,NDS
5
2
2
4
5
2
2
4
5
5
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 13
Drug Name
Drug
Tier
Requirements/
Limits
DOCETAXEL (NONALCOHOL) SOLN 80
MG/4ML
DOCETAXEL CONC
20 MG/0.5ML
DOCETAXEL CONC
80 MG/2ML
DOCETAXEL CONC
80 MG/4ML
DOCETAXEL SOLN
80 MG/8ML
DOXIL
doxorubicin hcl
doxorubicin hcl
liposomal
DROXIA
ELIGARD KIT 22.5 MG
ELIGARD KIT 30 MG
ELIGARD KIT 45 MG
ELIGARD KIT 7.5 MG
ELLENCE
ELSPAR
EMCYT
EMPLICITI
ERBITUX
ERIVEDGE
ERWINAZE
ETOPOPHOS
etoposide
EVOMELA SOLR 50
MG
exemestane
FARESTON
FARYDAK
FASLODEX
FEMARA
FIRMAGON
fludarabine phosphate
fluorouracil
flutamide
FOLOTYN
GAZYVA
gemcitabine hcl
GEMZAR
GILOTRIF
Drug Name
Drug
Tier
3
Requirements/
Limits
NDS
GLEEVEC
5
GLEOSTINE CAPS 10
3
MG
GLEOSTINE CAPS
3
3
100 MG
GLEOSTINE CAPS 40
3
3
MG
GLEOSTINE CAPS 5
4
4
MG
HALAVEN
4
3
HERCEPTIN
3
4
HEXALEN
5
2
HYCAMTIN
4
HYDREA
4
2
hydroxyurea
2
4
IBRANCE
5
NDS
4
ICLUSIG
5
LD,NDS
4
IDAMYCIN PFS
4
4
idarubicin hcl
2
4
IFEX
3
4
ifosfamide
2
3
imatinib mesylate
2
NDS
3
NDS
IMBRUVICA
5
NDS
5
INLYTA
5
NDS
3
INTRON A
5
NDS
5
NDS
IRESSA
5
NDS
4
irinotecan hcl
2
4
ISTODAX
3
2
IXEMPRA KIT
5
JAKAFI
5
NDS
5
NDS
JEVTANA
3
2
KADCYLA
5
4
KEYTRUDA
5
5
LD,NDS
KYPROLIS
5
NDS
5
NDS
LENVIMA 10 MG
5
LD,NDS
4
DAILY DOSE
4
LENVIMA 14 MG
5
LD,NDS
2
DAILY DOSE
2
HI,MO
LENVIMA 18 MG
5
LD,NDS
2
DAILY DOSE
4
LENVIMA 20 MG
5
LD,NDS
5
DAILY DOSE
2
LENVIMA 24 MG
5
LD,NDS
DAILY DOSE
4
LENVIMA 8 MG DAILY
5
NDS
5
LD,NDS
DOSE
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
14 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
letrozole
LEUKERAN
leuprolide acetate
LOMUSTINE CAPS 10
MG
LOMUSTINE CAPS
100 MG
LOMUSTINE CAPS 40
MG
LONSURF
LUPANETA PACK
LUPRON DEPOT KIT
11.25 MG
LUPRON DEPOT KIT
22.5 MG
LUPRON DEPOT KIT
3.75 MG
LUPRON DEPOT KIT
30 MG
LUPRON DEPOT KIT
45 MG
LUPRON DEPOT KIT
7.5 MG
LUPRON DEPOT-PED
LYNPARZA
LYSODREN
MARQIBO
MATULANE
MEGACE ORAL
megestrol acetate
MEKINIST
melphalan hcl
mercaptopurine
methotrexate sodium
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
NILANDRON
NINLARO
NIPENT
ODOMZO
ONCASPAR
ONIVYDE
OPDIVO
Drug
Tier
2
3
2
Requirements/
Limits
3
3
3
5
4
NDS
3
3
3
3
3
3
3
5
3
5
5
4
2
5
2
2
2
2
2
3
5
3
5
4
5
3
5
5
NDS
NDS
NDS
MO
NDS
NDS
NDS
PA
NDS
NDS
NDS
Drug Name
oxaliplatin
paclitaxel
PERJETA
POMALYST
PORTRAZZA
PROLEUKIN
PURIXAN
REVLIMID
RHEUMATREX
RITUXAN
SOLTAMOX
SPRYCEL
STIVARGA
SUTENT
SYLATRON
SYLVANT
SYNRIBO
TABLOID
TAFINLAR
TAGRISSO
tamoxifen citrate
TARCEVA
TARGRETIN
TASIGNA
TAXOTERE CONC 80
MG/4ML
TECENTRIQ
TENIPOSIDE
thiotepa
TICE BCG
topotecan hcl
TORISEL
TREANDA SOLR 100
MG
TRELSTAR MIXJECT
tretinoin
(chemotherapy)
TRISENOX
TYKERB
UNITUXIN
VALSTAR
VANTAS
VECTIBIX
VELCADE
Drug
Tier
2
2
5
5
5
5
5
5
4
3
4
5
5
5
4
5
5
3
5
5
2
5
5
5
Requirements/
Limits
NDS
NDS
NDS
PA
NDS
NDS
NDS
NDS
NDS
NDS
NDS
NDS
NDS
4
5
3
2
3
2
3
NDS
3
4
2
3
5
5
3
3
4
3
NDS
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 15
Drug Name
Drug
Tier
Requirements/
Limits
VENCLEXTA
STARTING PACK
5
TBPK 10 & 50 & 100
MG
VENCLEXTA TABS 10
4
MG
VENCLEXTA TABS
5
100 MG
VENCLEXTA TABS 50
4
MG
VIDAZA
4
vinblastine sulfate
2
vincristine sulfate
2
vinorelbine tartrate
2
VOTRIENT
5
XALKORI
5
XTANDI
5
YERVOY
3
YONDELIS
5
ZALTRAP
5
ZANOSAR
3
ZELBORAF
5
ZOLINZA
5
ZYDELIG
5
ZYKADIA
5
ZYTIGA
5
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
ANORO ELLIPTA
4
atropine sulfate
2
ATROPINE SULFATE 4
ATROVENT
4
ATROVENT HFA
3
BENTYL
4
CUVPOSA SOLN 1
3
MG/5ML
dicyclomine hcl
2
glycopyrrolate
2
INCRUSE ELLIPTA
4
ipratropium bromide
1
ipratropium bromide
2
(nasal)
methscopolamine
2
bromide
propantheline bromide 2
Drug Name
Drug
Tier
Requirements/
Limits
ROBINUL SOLN 0.4
4
MG/2ML
NDS
ROBINUL TABS 1 MG 4
MO
ROBINUL-FORTE
4
MO
TABS 2 MG
NDS
SPIRIVA
HANDIHALER CAPS
4
MO
NDS
18 MCG
SPIRIVA RESPIMAT
NDS
4
MO
AERS 1.25 MCG/ACT
SPIRIVA RESPIMAT
3
MO
AERS 2.5 MCG/ACT
STIOLTO RESPIMAT
4
MO
TUDORZA PRESSAIR 4
MO
AUTONOMIC DRUGS, MISCELLANEOUS
NDS
NDS
CHANTIX
4
MO
NDS
CHANTIX
CONTINUING MONTH 4
MO
PAK
CHANTIX STARTING
4
MO
MONTH PAK
NICOTROL INHA 10
NDS
3
MO
MG
NDS
NICOTROL NS SOLN
NDS
4
MO
10 MG/ML
NDS
PARASYMPATHOMIMETIC (CHOLINERGIC)
NDS
AGENTS
ARICEPT
4
MO
bethanechol chloride
2
MO
MO
cevimeline
hcl
2
MO
MO
donepezil
MO
2
MO
hydrochloride
MO
EVOXAC
4
MO
MO
EXELON
4
MO
MO
galantamine
2
MO
MO
hydrobromide
GUANIDINE HCL
4
MO
MO
MESTINON SYRP 60
MO
3
MO
MG/5ML
MO
MESTINON TABS 60
PA,MO
4
MO
MG
MO
MESTINON TBCR 180
4
MO
MG
MO
pilocarpine hcl (oral)
2
MO
pyridostigmine
bromide
2
MO
MO
RAZADYNE
4
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
16 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Requirements/
Tier
Limits
ergoloid mesylates
RAZADYNE ER
2
MO
ergotamine tartrate
REGONOL SOLN 10
2
3
MO
MG/2ML
FLOMAX
4
MO
rivastigmine
2
MO
MIGRANAL
3
NDS
rivastigmine tartrate
2
MO
phenoxybenzamine hcl 2
MO
SALAGEN
4
MO
RAPAFLO
4
MO
SKELETAL MUSCLE RELAXANTS
tamsulosin hcl
2
MO
AMRIX
4
PA
UROXATRAL
4
MO
baclofen
2
PA,MO
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
carisoprodol
2
PA,NDS
ADRENALIN SOLN 1
4
carisoprodol w/ aspirin 2
PA,NDS
MG/ML
carisoprodol w/ aspirin
ADVAIR DISKUS
4
MO
2
PA,NDS
& codeine
ADVAIR HFA
4
MO
chlorzoxazone
2
albuterol sulfate er
2
MO
cyclobenzaprine hcl
tb12 4 mg
2
PA
albuterol sulfate er
DANTRIUM
4
2
MO
tb12 8 mg
dantrolene sodium
2
albuterol sulfate nebu
GABLOFEN SOLN
1
PA,MO
3
PA
(2.5 mg/3ml) 0.083%
10000 MCG/20ML
albuterol sulfate nebu
GABLOFEN SOLN
1
PA,MO,NDS
3
PA
(5 mg/ml) 0.5%
20000 MCG/20ML
albuterol sulfate nebu
GABLOFEN SOLN
2
PA,MO
3
PA
0.63 mg/3ml
40000 MCG/20ML
albuterol sulfate nebu
GABLOFEN SOLN 50
2
PA,MO
3
PA
1.25 mg/3ml
MCG/ML
albuterol sulfate syrp 2
LIORESAL SOLN 0.05
2
MO
4
PA
mg/5ml
MG/ML
albuterol sulfate tabs 2
LIORESAL SOLN 10
2
MO
4
PA
mg
MG/20ML
albuterol sulfate tabs 4
LIORESAL SOLN 10
2
MO
4
PA
mg
MG/5ML
ARCAPTA
LIORESAL SOLN 40
4
MO
4
PA
NEOHALER
MG/20ML
AUVI-Q SOAJ 0.3
metaxalone
2
3
MG/0.3ML
methocarbamol
2
BROVANA
4
PA,MO
orphenadrine citrate
2
COMBIVENT
SKELAXIN
4
RESPIMAT AERS 203
MO
SOMA
4
PA,NDS
100 MCG/ACT
tizanidine hcl
2
DUONEB SOLN 0.5ZANAFLEX
4
4
PA,MO
2.5 (3) MG/3ML
SYMPATHOLYTIC (ADRENERGIC BLOCKING)
epinephrine
2
AGENTS
EPIPEN 2-PAK SOAJ
alfuzosin hcl
2
MO
3
0.3 MG/0.3ML
DIBENZYLINE
3
MO
EPIPEN JR 2-PAK
dihydroergotamine
4
2
NDS
SOAJ 0.15 MG/0.3ML
mesylate
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Drug Name
Drug
Tier
4
Requirements/
Limits
MO
Drug Name
Kaiser Permanente 2017 Comprehensive Formulary • 17
Drug Name
Drug
Tier
4
2
2
3
2
2
5
4
Requirements/
Limits
MO
PA,MO
PA,MO
MO
MO
MO
NDS
PA,MO
Drug Name
Drug
Tier
4
3
4
2
2
4
Requirements/
Limits
MO
MO
MO
NDS
NDS
NDS
FORADIL AEROLIZER
DURLAZA
ipratropium-albuterol
EFFIENT
levalbuterol hcl
ELIQUIS
enoxaparin sodium
MAXAIR AUTOHALER
metaproterenol sulfate
fondaparinux sodium
midodrine hcl
FRAGMIN
heparin sod (porcine)
NORTHERA
2
HI
in d5w
PERFOROMIST
heparin sodium
PROAIR HFA AERS
2
HI
(porcine)
108 (90 BASE)
4
MO
MCG/ACT
INTEGRILIN
3
HI
PROAIR RESPICLICK
LOVENOX
3
NDS
AEPB 108 (90 BASE)
4
MO
LYSTEDA
4
MO
MCG/ACT
pentoxifylline
2
MO
PROVENTIL HFA
PLAVIX
4
MO
AERS 108 (90 BASE)
4
MO
PRADAXA
3
MO
MCG/ACT
SAVAYSA
4
MO
SEREVENT DISKUS
3
MO
tranexamic acid
2
HI,MO
STRIVERDI
warfarin sodium
1
MO
3
MO
RESPIMAT
XARELTO
4
MO
terbutaline sulfate
2
MO
XARELTO STARTER
4
MO
VENTOLIN HFA AERS
PACK
108 (90 BASE)
3
MO
ZONTIVITY
4
MO
MCG/ACT
HEMATOPOIETIC AGENTS
vospire er tb12 4 mg
2
MO
ARANESP (ALBUMIN
4
PA,NDS
vospire er tb12 8 mg
2
MO
FREE)
XOPENEX
4
PA,MO
EPOGEN
3
PA,NDS
XOPENEX
GRANIX
5
4
PA,MO
CONCENTRATE
LEUKINE
3
HI,NDS
XOPENEX HFA
4
MO
MIRCERA
4
PA
BLOOD FORMATION, COAGULATION, AND
MOZOBIL
4
THROMBOSIS
NEULASTA
5
NDS
COAGULANTS AND ANTICOAGULANTS
NEUMEGA
5
AGGRENOX
4
MO
NEUPOGEN
5
NDS
AGRYLIN
4
MO
NPLATE
4
NDS
AMICAR
3
MO
PROCRIT
3
PA,NDS
anagrelide hcl
2
MO
PROMACTA
5
NDS
argatroban
2
HI
ZARXIO
5
NDS
ARGATROBAN
4
HI
CARDIOVASCULAR DRUGS
ARIXTRA
4
NDS
A-ADRENERGIC BLOCKING AGENTS
aspirin-dipyridamole
2
MO
CARDURA
4
MO
BRILINTA
3
MO
CARDURA XL
4
MO
cilostazol
2
MO
doxazosin mesylate
2
MO
clopidogrel bisulfate
2
MO
MINIPRESS
4
MO
COUMADIN
4
MO
prazosin hcl
2
MO
CYKLOKAPRON
4
HI
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
18 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
terazosin hcl
ANTILIPEMIC AGENTS
ALTOPREV
ANTARA
atorvastatin calcium
cholestyramine
cholestyramine light
choline fenofibrate
COLESTID
colestipol hcl
CRESTOR
fenofibrate
FENOFIBRATE
fenofibrate micronized
fenofibric acid
FENOFIBRIC ACID
FENOGLIDE
FIBRICOR
fluvastatin sodium
gemfibrozil
JUXTAPID
KYNAMRO
LESCOL XL
LIPITOR
LIPOFEN
LIVALO
LOPID
lovastatin
LOVAZA
niacin
(antihyperlipidemic)
NIASPAN
omega-3-acid ethyl
esters
PRALUENT
PRAVACHOL
pravastatin sodium
REPATHA
REPATHA
PUSHTRONEX
SYSTEM
REPATHA
SURECLICK
rosuvastatin calcium
simvastatin
Drug
Tier
2
Requirements/
Limits
MO
4
4
1
2
2
2
4
2
4
2
4
2
2
4
4
4
2
2
5
5
4
4
4
4
4
1
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA,LD,NDS
PA,LD,NDS
MO
MO
MO
MO
MO
MO
MO
2
MO
4
MO
2
MO
5
4
2
5
PA,NDS
MO
MO
PA,NDS
5
PA,NDS
5
PA,NDS
2
1
MO
MO
Drug Requirements/
Tier
Limits
TRICOR
4
MO
TRIGLIDE
4
MO
TRILIPIX
4
MO
VASCEPA
4
MO
VYTORIN
4
MO
WELCHOL
4
MO
ZETIA
4
MO
ZOCOR
4
MO
CALCIUM-CHANNEL BLOCKING AGENTS
ADALAT CC
4
MO
amlodipine besylate
1
MO
amlodipine besylate2
MO
atorvastatin calcium
amlodipine besylate2
MO
benazepril hcl
amlodipine besylate2
MO
valsartan
amlodipine-valsartan2
MO
hydrochlorothiazide
AZOR
4
MO
CADUET
4
MO
CALAN
4
MO
CALAN SR
4
MO
CARDENE IV
4
HI
CARDIZEM
4
MO
CARDIZEM CD
4
MO
CARDIZEM LA
4
MO
CLEVIPREX
3
diltiazem hcl
2
HI,MO
diltiazem hcl coated
2
MO
beads
diltiazem hcl extended
2
MO
release beads
EXFORGE
4
MO
EXFORGE HCT
4
MO
felodipine
2
MO
isradipine
2
MO
LOTREL
4
MO
nicardipine hcl
2
HI,MO
nifedipine
2
MO
nimodipine
2
MO
nisoldipine
2
MO
NORVASC
4
MO
PROCARDIA
4
MO
PROCARDIA XL
4
MO
Drug Name
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 19
Drug Name
Drug
Tier
4
4
2
4
Requirements/
Limits
MO
MO
MO
MO
Drug Name
Drug
Tier
2
Requirements/
Limits
MO
quinidine gluconate
SULAR
TARKA
QUINIDINE
3
MO
GLUCONATE
telmisartan-amlodipine
quinidine sulfate
2
MO
TIAZAC
RANEXA
4
MO
trandolapril-verapamil
2
MO
hcl
RYTHMOL
4
MO
TRIBENZOR
4
MO
RYTHMOL SR
4
MO
TWYNSTA
4
MO
TIKOSYN
4
MO
verapamil hcl
HYPOTENSIVE AGENTS
2
HI,MO
VERELAN
4
MO
CATAPRES
4
MO
VERELAN PM
4
MO
CATAPRES-TTS-1
4
MO
CARDIAC DRUGS
CATAPRES-TTS-2
4
MO
amiodarone hcl
2
HI,MO
CATAPRES-TTS-3
4
MO
clonidine &
CORLANOR
4
MO
2
MO
chlorthalidone
digoxin
2
MO
clonidine hcl
2
MO
DIGOXIN SOLN 0.05
3
MO
clonidine hcl (adhd)
MG/ML
2
MO
disopyramide
guanfacine hcl
2
MO
2
MO
phosphate
hydralazine hcl soln 20
2
dofetilide
mg/ml
2
MO
flecainide acetate
hydralazine hcl tabs 10
2
MO
1
MO
mg
LANOXIN PEDIATRIC
3
hydralazine hcl tabs
SOLN 0.1 MG/ML
2
MO
100 mg
LANOXIN SOLN 0.25
4
hydralazine hcl tabs 25
MG/ML
1
MO
mg
LANOXIN TABS 125
4
MO
hydralazine hcl tabs 50
MCG
2
MO
mg
LANOXIN TABS 187.5
4
MO
MCG
KAPVAY
4
MO
mecamylamine hcl
LANOXIN TABS 250
2
NDS
4
MO
MCG
methyldopa
2
MO
LANOXIN TABS 62.5
methyldopa &
4
MO
2
MO
MCG
hydrochlorothiazide
mexiletine hcl
2
MO
methyldopate hcl
2
HI
MULTAQ
4
MO
minoxidil
2
MO
NEXTERONE
4
HI
PROGLYCEM
3
MO
NORPACE CAPS 100
RESERPINE
3
MO
4
MO
MG
TENEX
4
MO
NORPACE CAPS 150
RENIN-ANGIOTENSIN-ALDOSTERONE
4
MO
MG
SYSTEM INHIBITORS
NORPACE CR CP12
ACCUPRIL
4
MO
3
MO
100 MG
ACCURETIC
4
MO
NORPACE CR CP12
ALDACTAZIDE
4
MO
3
MO
150 MG
ALDACTONE
4
MO
procainamide hcl
2
ALTACE
4
MO
propafenone hcl
2
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
20 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
ATACAND
ATACAND HCT
AVALIDE
AVAPRO
benazepril &
hydrochlorothiazide
benazepril hcl
BENICAR
BENICAR HCT
candesartan cilexetil
candesartan cilexetilhydrochlorothiazide
captopril
captopril &
hydrochlorothiazide
COZAAR
DIOVAN
DIOVAN HCT
EDARBI
EDARBYCLOR
enalapril maleate
enalapril maleate &
hydrochlorothiazide
ENTRESTO
EPANED
eplerenone
eprosartan mesylate
fosinopril sodium
fosinopril sodium &
hydrochlorothiazide
HYZAAR
INSPRA
irbesartan
irbesartanhydrochlorothiazide
lisinopril &
hydrochlorothiazide
lisinopril tabs 10 mg
lisinopril tabs 2.5 mg
lisinopril tabs 20 mg
lisinopril tabs 30 mg
lisinopril tabs 40 mg
lisinopril tabs 5 mg
losartan potassium
Drug
Tier
4
4
4
4
Requirements/
Limits
MO
MO
MO
MO
2
MO
1
4
4
2
MO
MO
MO
MO
2
MO
2
MO
2
MO
4
4
4
4
4
2
MO
MO
MO
MO
MO
MO
2
MO
4
4
2
2
2
MO
MO
MO
MO
MO
2
MO
4
4
2
MO
MO
MO
2
MO
1
MO
1
1
1
2
1
1
2
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
losartan potassium &
2
hydrochlorothiazide
LOTENSIN
4
MAVIK
4
MICARDIS
4
MICARDIS HCT
4
moexipril hcl
2
moexipril2
hydrochlorothiazide
perindopril erbumine
2
PRINIVIL
4
quinapril hcl
2
quinapril2
hydrochlorothiazide
ramipril
2
spironolactone &
2
hydrochlorothiazide
spironolactone tabs
2
100 mg
spironolactone tabs 25
1
mg
spironolactone tabs 50
2
mg
TEKTURNA
4
TEKTURNA HCT
4
telmisartan
2
telmisartan2
hydrochlorothiazide
trandolapril
2
valsartan
2
valsartan2
hydrochlorothiazide
VASERETIC
4
VASOTEC
4
ZESTORETIC
4
ZESTRIL
4
VASODILATING AGENTS
ADCIRCA
5
BIDIL
4
CIALIS
4
dipyridamole
2
ISORDIL TITRADOSE 4
isosorbide dinitrate
2
isosorbide mononitrate
2
er tb24 120 mg
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA
MO
PA,NDS
MO
MO
MO
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 21
Drug Name
Drug
Tier
Requirements/
Limits
isosorbide mononitrate
1
MO
er tb24 30 mg
isosorbide mononitrate
1
MO
er tb24 60 mg
isosorbide mononitrate
2
MO
tabs 10 mg
isosorbide mononitrate
2
MO
tabs 20 mg
NITRO-DUR PT24 0.1
4
MO
MG/HR
NITRO-DUR PT24 0.2
4
MO
MG/HR
NITRO-DUR PT24 0.3
3
MO
MG/HR
NITRO-DUR PT24 0.4
4
MO
MG/HR
NITRO-DUR PT24 0.6
4
MO
MG/HR
NITRO-DUR PT24 0.8
3
MO
MG/HR
nitroglycerin
2
HI,MO
NITROLINGUAL SOLN
4
MO
0.4 MG/SPRAY
NITROMIST AERS
4
MO
400 MCG/SPRAY
NITROSTAT SUBL 0.3
3
MO
MG
NITROSTAT SUBL 0.4
3
MO
MG
NITROSTAT SUBL 0.6
3
MO
MG
PERSANTINE
4
MO
REVATIO SOLN 10
5
MG/12.5ML
REVATIO SUSR 10
4
PA,NDS
MG/ML
REVATIO TABS 20
5
PA,NDS
MG
sildenafil citrate
(pulmonary
2
PA,MO,NDS
hypertension)
ß-ADRENERGIC BLOCKING AGENTS
acebutolol hcl
2
MO
atenolol
1
MO
atenolol &
2
MO
chlorthalidone
Drug Name
Drug
Tier
4
2
Requirements/
Limits
MO
MO
BETAPACE
betaxolol hcl
bisoprolol &
1
MO
hydrochlorothiazide
bisoprolol fumarate
2
MO
BYSTOLIC
4
MO
carvedilol
1
MO
COREG
4
MO
COREG CR
4
MO
CORGARD
4
MO
CORZIDE
4
MO
DUTOPROL
4
MO
INDERAL LA
4
MO
INNOPRAN XL
4
MO
labetalol hcl
2
HI,MO
LOPRESSOR
4
MO
LOPRESSOR HCT
4
MO
metoprolol &
2
MO
hydrochlorothiazide
metoprolol succinate
2
MO
metoprolol tartrate soln
2
1 mg/ml
metoprolol tartrate tabs
1
MO
100 mg
metoprolol tartrate tabs
1
MO
25 mg
metoprolol tartrate tabs
1
MO
50 mg
nadolol &
2
MO
bendroflumethiazide
nadolol tabs 20 mg
1
MO
nadolol tabs 40 mg
1
MO
nadolol tabs 80 mg
2
MO
pindolol
2
MO
propranolol &
2
MO
hydrochlorothiazide
propranolol hcl er cp24
2
MO
120 mg
propranolol hcl er cp24
2
MO
160 mg
propranolol hcl er cp24
2
MO
60 mg
propranolol hcl er cp24
2
MO
80 mg
propranolol hcl soln 1
2
HI
mg/ml
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
22 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
Drug
Tier
Requirements/
Limits
propranolol hcl soln 20
2
MO
mg/5ml
propranolol hcl soln 40
2
MO
mg/5ml
propranolol hcl tabs 10
1
MO
mg
propranolol hcl tabs 20
1
MO
mg
propranolol hcl tabs 40
1
MO
mg
propranolol hcl tabs 60
2
MO
mg
propranolol hcl tabs 80
1
MO
mg
SECTRAL
4
MO
sotalol hcl
2
MO
sotalol hcl (afib/afl)
2
MO
SOTYLIZE
4
MO
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
PA,NDS
acetaminophen w/
2
NDS
codeine
acetaminophen-caff2
NDS
dihydrocod
ACTIQ
4
PA,NDS
ANAPROX DS
4
ARTHROTEC
4
AVINZA
4
NDS
BELBUCA
4
NDS
BUPRENEX
4
NDS
buprenorphine hcl
2
NDS
butalbital2
acetaminophen
butalbitalacetaminophen2
caffeine
Drug Name
butalbitalacetaminophencaffeine w/ codeine
butalbital-aspirincaffeine
butalbital-aspirincaffeine w/cod
butorphanol tartrate
BUTRANS
CAMBIA
CELEBREX
celecoxib
CODEINE SULFATE
CONZIP
DAYPRO
DEMEROL
diclofenac potassium
diclofenac sodium
diclofenac w/
misoprostol
diflunisal
DILAUDID
DOLOPHINE TABS 10
MG
DOLOPHINE TABS 5
MG
DUEXIS
DURAGESIC-100
DURAGESIC-12
DURAGESIC-25
DURAGESIC-50
DURAGESIC-75
EC-NAPROSYN
EMBEDA
etodolac
EXALGO
FELDENE
fenoprofen calcium
FENOPROFEN
CALCIUM
fentanyl
fentanyl citrate
FENTORA
FIORINAL
Drug
Tier
Requirements/
Limits
2
NDS
2
2
NDS
2
4
4
4
2
3
4
4
4
2
2
NDS
NDS
NDS
NDS
PA,NDS
MO
2
2
4
NDS
4
NDS
4
NDS
4
4
4
4
4
4
4
4
2
4
4
2
NDS
NDS
NDS
NDS
NDS
NDS
NDS
NDS
4
2
2
4
4
PA,NDS
PA,NDS
PA,NDS
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 23
Drug Requirements/
Tier
Limits
morphine sulfate beads 2
FIORINAL/CODEINE
NDS
4
NDS
#3
MORPHINE SULFATE
3
NDS
flurbiprofen
2
TABS 15 MG
GRALISE
4
MORPHINE SULFATE
3
NDS
TABS 30 MG
GRALISE STARTER
4
MS CONTIN TBCR
hydrocodone4
NDS
2
NDS
100 MG
acetaminophen
MS CONTIN TBCR 15
hydrocodone-ibuprofen 2
NDS
4
NDS
MG
hydromorphone hcl
2
NDS
MS CONTIN TBCR
HYSINGLA ER
4
PA,NDS
4
NDS
200 MG
ibuprofen
2
MS CONTIN TBCR 30
ILARIS
5
NDS
4
NDS
MG
INDOCIN
4
MS CONTIN TBCR 60
indomethacin
2
4
NDS
MG
KADIAN CP24 10 MG
4
NDS
nabumetone
2
KADIAN CP24 100 MG 4
NDS
nalbuphine
hcl
2
NDS
KADIAN CP24 20 MG
4
NDS
NAPRELAN
4
KADIAN CP24 200 MG 4
NDS
NAPROSYN
4
KADIAN CP24 30 MG
4
NDS
naproxen
2
KADIAN CP24 40 MG
4
NDS
naproxen
sodium
2
KADIAN CP24 50 MG
4
NDS
NUCYNTA
4
NDS
KADIAN CP24 60 MG
4
NDS
NUCYNTA
ER
4
NDS
KADIAN CP24 80 MG
4
NDS
OPANA
4
NDS
ketoprofen
2
OPANA ER
4
NDS
ketorolac
2
MO
oxaprozin
2
tromethamine
oxycodone hcl
2
NDS
LAZANDA
4
PA,NDS
OXYCODONE
HCL
levorphanol tartrate
2
NDS
4
NDS
ER
meclofenamate sodium 2
oxycodone w/
mefenamic acid
2
2
NDS
acetaminophen
meloxicam
2
oxycodone-aspirin
2
NDS
meperidine hcl
2
PA,NDS
oxycodone-ibuprofen
2
NDS
methadone hcl
2
NDS
OXYCONTIN
4
NDS
METHADONE HCL
3
NDS
oxymorphone hcl
2
NDS
SOLN 10 MG/ML
pentazocine
w/
MOBIC
4
2
NDS
naloxone
morphine sulfate
2
NDS
PERCODAN
4
NDS
MORPHINE SULFATE
4
NDS
piroxicam
2
NDS
(PF) SOLN 10 MG/ML
PONSTEL
4
MORPHINE SULFATE
4
NDS
ROXICODONE
4
NDS
(PF) SOLN 2 MG/ML
SUBSYS
4
PA,NDS
MORPHINE SULFATE
4
NDS
sulindac
2
(PF) SOLN 4 MG/ML
SYNALGOS-DC
4
NDS
MORPHINE SULFATE
4
NDS
TALWIN
4
NDS
(PF) SOLN 8 MG/ML
TIVORBEX
4
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Drug Name
Drug
Tier
Requirements/
Limits
24 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
Drug Name
Drug
Tier
2
2
Requirements/
Limits
tolmetin sodium
tramadol hcl
NDS
tramadol2
NDS
acetaminophen
ULTRACET
4
NDS
ULTRAM
4
NDS
ULTRAM ER
4
NDS
VICOPROFEN
4
NDS
VIMOVO
4
NDS
VIVLODEX
4
XARTEMIS XR
4
NDS
XTAMPZA ER
4
NDS
ZIPSOR
4
ZOHYDRO ER
4
PA,NDS
ZORVOLEX
4
ANOREXIGENIC AGENTS AND RESPIRATORY
AND CEREBRAL STIMULANTS
ADDERALL TABS 10
4
NDS
MG
ADDERALL TABS 15
4
NDS
MG
ADDERALL TABS 30
4
NDS
MG
ADDERALL XR CP24
3
NDS
10 MG
ADDERALL XR CP24
3
NDS
15 MG
ADDERALL XR CP24
3
NDS
20 MG
ADDERALL XR CP24
3
NDS
25 MG
ADDERALL XR CP24
3
NDS
30 MG
ADDERALL XR CP24
3
NDS
5 MG
ADZENYS XR-ODT
4
NDS
amphetamine sulfate
2
NDS
amphetamine2
NDS
dextroamphetamine
APTENSIO XR CP24
3
NDS
10 MG
APTENSIO XR CP24
3
NDS
15 MG
APTENSIO XR CP24
3
NDS
20 MG
Drug Name
APTENSIO XR CP24
30 MG
APTENSIO XR CP24
40 MG
APTENSIO XR CP24
50 MG
APTENSIO XR CP24
60 MG
armodafinil
CONCERTA TBCR 18
MG
CONCERTA TBCR 27
MG
CONCERTA TBCR 36
MG
CONCERTA TBCR 54
MG
DAYTRANA
DESOXYN
DEXEDRINE
dexmethylphenidate
hcl
dextroamphetamine
sulfate
DYANAVEL XR
FOCALIN
FOCALIN XR
METADATE CD CPCR
10 MG
METADATE CD CPCR
20 MG
METADATE CD CPCR
30 MG
METADATE CD CPCR
40 MG
METADATE CD CPCR
50 MG
METADATE CD CPCR
60 MG
methamphetamine hcl
METHYLIN CHEW 10
MG
METHYLIN CHEW 2.5
MG
METHYLIN CHEW 5
MG
Drug
Tier
Requirements/
Limits
3
NDS
3
NDS
3
NDS
3
NDS
2
PA
4
NDS
4
NDS
4
NDS
4
NDS
4
4
4
NDS
PA,NDS
NDS
2
NDS
2
NDS
4
4
4
NDS
NDS
NDS
4
NDS
4
NDS
4
NDS
4
NDS
4
NDS
4
NDS
2
PA,NDS
4
NDS
4
NDS
4
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 25
Drug Name
METHYLIN SOLN 10
MG/5ML
METHYLIN SOLN 5
MG/5ML
methylphenidate hcl
modafinil
NUVIGIL
PROVIGIL
QUILLICHEW ER
CHER 20 MG
QUILLICHEW ER
CHER 30 MG
QUILLICHEW ER
CHER 40 MG
QUILLIVANT XR
SUSR 25 MG/5ML
RITALIN LA CP24 10
MG
RITALIN LA CP24 20
MG
RITALIN LA CP24 30
MG
RITALIN LA CP24 40
MG
RITALIN LA CP24 60
MG
RITALIN TABS 10 MG
RITALIN TABS 20 MG
RITALIN TABS 5 MG
VYVANSE
ANTICONVULSANTS
APTIOM
BANZEL
BRIVIACT SOLN 10
MG/ML
BRIVIACT SOLN 50
MG/5ML
BRIVIACT TABS 10
MG
BRIVIACT TABS 100
MG
BRIVIACT TABS 25
MG
BRIVIACT TABS 50
MG
Drug
Tier
Requirements/
Limits
4
NDS
4
NDS
2
2
4
4
NDS
PA,NDS
PA
PA,NDS
4
NDS
4
NDS
4
NDS
4
NDS
4
NDS
4
NDS
4
NDS
4
NDS
4
NDS
4
4
4
3
NDS
NDS
NDS
NDS
4
3
MO
MO
5
NDS
4
NDS
5
NDS
5
NDS
5
NDS
5
NDS
Drug Name
BRIVIACT TABS 75
MG
carbamazepine
CARBATROL
CELONTIN
CEREBYX
clonazepam
DEPACON
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE
SPRINKLES
DILANTIN
divalproex sodium
EQUETRO
ethosuximide
felbamate
FELBATOL
fosphenytoin sodium
FYCOMPA
gabapentin
GABITRIL
HORIZANT
KEPPRA SOLN 100
MG/ML
KEPPRA TABS 1000
MG
KEPPRA TABS 250
MG
KEPPRA TABS 500
MG
KEPPRA TABS 750
MG
KEPPRA XR TB24 500
MG
KEPPRA XR TB24 750
MG
KLONOPIN
LAMICTAL CHEW 25
MG
LAMICTAL CHEW 5
MG
LAMICTAL ODT TBDP
100 MG
Drug
Tier
Requirements/
Limits
5
NDS
2
4
3
4
2
4
4
4
4
MO
MO
MO
4
MO
4
2
4
2
2
5
2
4
2
4
4
MO
MO
MO
MO
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
NDS
4
MO
4
MO
4
MO
NDS
HI
MO
MO
MO
NDS
MO
MO
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
26 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
LAMICTAL ODT TBDP
200 MG
LAMICTAL ODT TBDP
25 MG
LAMICTAL ODT TBDP
50 MG
LAMICTAL STARTER
KIT 25 (35) MG
LAMICTAL STARTER
KIT 25 (42)-100 (7) MG
LAMICTAL STARTER
KIT 25 (84)-100(14)
MG
LAMICTAL TABS 100
MG
LAMICTAL TABS 150
MG
LAMICTAL TABS 200
MG
LAMICTAL TABS 25
MG
LAMICTAL XR KIT 25
& 50 & 100 MG
LAMICTAL XR KIT 25
(21)-50 (7) MG
LAMICTAL XR KIT 50
& 100 & 200 MG
LAMICTAL XR TB24
100 MG
LAMICTAL XR TB24
200 MG
LAMICTAL XR TB24
25 MG
LAMICTAL XR TB24
250 MG
LAMICTAL XR TB24
300 MG
LAMICTAL XR TB24
50 MG
lamotrigine
levetiracetam
LEVETIRACETAM IN
NACL
LYRICA
magnesium sulfate
Drug
Tier
Requirements/
Limits
4
MO
4
MO
4
MO
3
MO
3
MO
3
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
2
2
MO
HI,MO
3
4
2
MO
HI
Drug Name
Drug
Tier
MAGNESIUM
3
SULFATE
MYSOLINE
4
NEURONTIN
4
ONFI
4
oxcarbazepine
2
OXTELLAR XR
4
PEGANONE
4
phenytoin
2
phenytoin sodium
2
phenytoin sodium
2
extended
POTIGA
4
primidone
2
QUDEXY XR
4
SABRIL
5
SPRITAM TB3D 1000
5
MG
SPRITAM TB3D 250
4
MG
SPRITAM TB3D 500
4
MG
SPRITAM TB3D 750
5
MG
TEGRETOL
4
TEGRETOL-XR
4
tiagabine hcl
2
TOPAMAX
4
TOPAMAX SPRINKLE 4
topiramate
2
TRILEPTAL
4
TROKENDI XR
4
valproate sodium
2
valproic acid
2
VIMPAT
4
ZARONTIN
4
ZONEGRAN
4
zonisamide
2
ANTIMIGRAINE AGENTS
almotriptan malate
2
AMERGE
4
AXERT
4
ergotamine w/ caffeine 2
FROVA
4
frovatriptan succinate
2
Requirements/
Limits
HI
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
LD,NDS
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
HI,MO
MO
HI,MO
MO
MO
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 27
Drug Name
Drug
Tier
4
IMITREX
IMITREX STATDOSE
4
REFILL
MAXALT
4
MAXALT-MLT
4
naratriptan hcl
2
ONZETRA XSAIL
4
RELPAX
4
rizatriptan benzoate
2
SUMATRIPTAN
4
sumatriptan succinate
2
SUMAVEL DOSEPRO 4
TREXIMET
4
ZEMBRACE
4
SYMTOUCH
zolmitriptan
2
ZOMIG
4
ZOMIG ZMT
4
ANTIPARKINSONIAN AGENTS
amantadine hcl
2
APOKYN
5
AZILECT
3
benztropine mesylate
2
bromocriptine mesylate 2
cabergoline
2
carbidopa
2
carbidopa-levodopa
2
carbidopa-levodopa2
entacapone
COGENTIN
4
COMTAN
4
DUOPA
4
ELDEPRYL
4
EMSAM
4
entacapone
2
LODOSYN
3
MIRAPEX
4
MIRAPEX ER
4
NEUPRO
4
pramipexole
2
dihydrochloride
REQUIP
4
REQUIP XL
4
ropinirole hydrochloride 2
RYTARY
4
Requirements/
Limits
MO
NDS
MO
MO
MO
MO
MO
LD,MO
MO
MO
LD
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Requirements/
Tier
Limits
selegiline hcl
2
MO
SINEMET
4
MO
SINEMET CR
4
MO
STALEVO 100
4
MO
STALEVO 125
4
MO
STALEVO 150
4
MO
STALEVO 200
4
MO
STALEVO 50
4
MO
STALEVO 75
4
MO
TASMAR
4
MO
tolcapone
2
MO
trihexyphenidyl hcl
2
MO
ZELAPAR
4
MO
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
alprazolam
2
NDS
AMBIEN
4
NDS
AMBIEN CR
4
NDS
ATIVAN
4
NDS
BELSOMRA
4
buspirone hcl
2
BUTISOL SODIUM
4
chlordiazepoxide hcl
2
NDS
clorazepate
2
NDS
dipotassium
DIASTAT ACUDIAL
3
NDS
DIASTAT PEDIATRIC
3
NDS
diazepam
2
NDS
diazepam
2
NDS
(anticonvulsant)
EDLUAR
4
NDS
estazolam
2
NDS
eszopiclone
2
NDS
flurazepam hcl
2
NDS
HALCION
4
NDS
HETLIOZ
5
NDS
hydroxyzine hcl
2
hydroxyzine pamoate
2
INTERMEZZO
4
NDS
lorazepam
2
NDS
LUNESTA
4
NDS
meprobamate
2
midazolam hcl
2
NDS
oxazepam
2
NDS
phenobarbital
2
PHENOBARBITAL
4
Drug Name
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
28 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Requirements/
Tier
Limits
RESTORIL
4
NDS
ROZEREM
4
SILENOR
4
SONATA
4
NDS
temazepam
2
NDS
TRANXENE-T
4
NDS
triazolam
2
NDS
VALIUM
4
NDS
VISTARIL
4
XANAX
4
NDS
XANAX XR
4
NDS
zaleplon
2
NDS
zolpidem tartrate
2
NDS
ZOLPIMIST
4
NDS
CENTRAL NERVOUS SYSTEM AGENTS,
MISCELLANEOUS
acamprosate calcium
2
MO
guanfacine hcl (adhd)
2
MO
INTUNIV
4
MO
memantine hcl
2
MO
NAMENDA
4
MO
NAMENDA
4
MO
TITRATION PAK
NAMENDA XR
4
MO
NAMENDA XR
4
MO
TITRATION PACK
NAMZARIC
4
NDS
NUEDEXTA
3
NDS
RILUTEK
5
riluzole
2
MO
SAVELLA
3
MO
SAVELLA TITRATION
3
MO
PACK
STRATTERA
4
MO
tetrabenazine
2
NDS
XENAZINE
5
NDS
XYREM
5
LD,NDS
OPIATE ANTAGONISTS
BUNAVAIL
4
NDS
buprenorphine hcl2
NDS
naloxone hcl dihydrate
EVZIO SOAJ 0.4
4
MG/0.4ML
naloxone hcl
2
naltrexone hcl
2
Drug Name
Drug Name
Drug
Tier
Requirements/
Limits
NARCAN LIQD 4
3
MG/0.1ML
SUBOXONE
4
NDS
VIVITROL
4
NDS
ZUBSOLV
4
NDS
PSYCHOTHERAPEUTIC AGENTS
ABILIFY
4
MO
ABILIFY MAINTENA
4
amitriptyline hcl
2
MO
amoxapine
2
MO
ANAFRANIL
4
MO
APLENZIN
4
MO
aripiprazole
2
MO
ARISTADA
5
NDS
BRINTELLIX
4
MO
BRISDELLE
4
MO
bupropion hcl
2
MO
bupropion hcl (smoking
2
MO
deterrent)
CELEXA
4
MO
chlordiazepoxide2
amitriptyline
chlorpromazine hcl
2
MO
citalopram
hydrobromide soln 10
2
MO
mg/5ml
citalopram
hydrobromide tabs 10
2
MO
mg
citalopram
hydrobromide tabs 20
1
MO
mg
citalopram
hydrobromide tabs 40
1
MO
mg
clomipramine hcl
2
MO
clozapine
2
NDS
CLOZARIL
4
NDS
CYMBALTA
4
MO
desipramine hcl
2
MO
DESVENLAFAXINE
4
MO
ER
doxepin hcl
2
MO
duloxetine hcl
2
MO
EFFEXOR XR
4
MO
escitalopram oxalate
2
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 29
Drug Name
Drug
Tier
4
Requirements/
Limits
MO
Drug Name
Drug
Tier
4
2
2
4
2
2
4
2
4
2
5
2
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
NDS
MO
FANAPT
LITHOBID
loxapine succinate
FANAPT TITRATION
4
MO
PACK
maprotiline hcl
FAZACLO
4
NDS
MARPLAN
FETZIMA
4
MO
mirtazapine
FETZIMA TITRATION
4
MO
molindone hcl
FLUOXETINE HCL
4
MO
NARDIL
fluoxetine hcl caps 10
nefazodone hcl
1
MO
mg
NORPRAMIN
fluoxetine hcl caps 20
nortriptyline hcl
1
MO
mg
NUPLAZID
fluoxetine hcl caps 40
olanzapine
1
MO
mg
olanzapine-fluoxetine
2
MO
fluoxetine hcl cpdr 90
hcl
2
MO
mg
ORAP
4
MO
fluoxetine hcl soln 20
paliperidone
2
MO
2
MO
mg/5ml
PAMELOR
4
MO
fluoxetine hcl tabs 10
PARNATE
4
MO
2
MO
mg
paroxetine hcl er tb24
2
MO
fluoxetine hcl tabs 20
12.5 mg
2
MO
mg
paroxetine hcl er tb24
2
MO
fluphenazine
25 mg
2
decanoate
paroxetine hcl er tb24
2
MO
fluphenazine hcl
2
MO
37.5 mg
fluvoxamine maleate
2
MO
paroxetine hcl tabs 10
1
MO
FORFIVO XL
4
MO
mg
GEODON SOLN
3
MO
paroxetine hcl tabs 20
1
MO
GEODON
4
MO
mg
HALDOL
4
paroxetine hcl tabs 30
2
MO
HALDOL
mg
4
DECANOATE
paroxetine hcl tabs 40
2
MO
haloperidol
2
MO
mg
haloperidol decanoate
2
PAXIL
4
MO
haloperidol lactate
2
MO
PAXIL CR
4
MO
imipramine hcl
2
MO
perphenazine
2
MO
imipramine pamoate
2
MO
perphenazine2
MO
INVEGA
4
MO
amitriptyline
INVEGA SUSTENNA
4
NDS
PEXEVA
4
MO
INVEGA TRINZA
4
phenelzine sulfate
2
MO
KHEDEZLA
4
MO
pimozide
2
MO
LATUDA
5
PRISTIQ
4
MO
LEXAPRO
4
MO
prochlorperazine
2
MO
LITHIUM
3
MO
prochlorperazine
2
lithium carbonate
edisylate
2
MO
prochlorperazine
LITHIUM
4
MO
2
maleate
CARBONATE
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
30 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
protriptyline hcl
PROZAC
PROZAC WEEKLY
quetiapine fumarate
REMERON
REMERON SOLTAB
REXULTI
RISPERDAL
RISPERDAL CONSTA
RISPERDAL M-TAB
risperidone
SAPHRIS
SARAFEM
SEROQUEL
SEROQUEL XR
sertraline hcl
SURMONTIL
SYMBYAX
thioridazine hcl
thiothixene
tranylcypromine sulfate
trazodone hcl tabs 100
mg
trazodone hcl tabs 150
mg
trazodone hcl tabs 300
mg
trazodone hcl tabs 50
mg
trifluoperazine hcl
trimipramine maleate
TRINTELLIX
venlafaxine hcl
VENLAFAXINE HCL
ER
VERSACLOZ
VIIBRYD
VIIBRYD STARTER
PACK
VRAYLAR CAPS 1.5
MG
VRAYLAR CAPS 3 MG
VRAYLAR CAPS 4.5
MG
VRAYLAR CAPS 6 MG
Drug
Tier
2
4
4
2
4
4
4
4
4
4
2
4
4
4
4
2
4
4
2
2
2
Requirements/
Limits
MO
MO
MO
MO
MO
MO
NDS
MO
NDS
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
MO
1
MO
2
MO
1
MO
2
2
4
2
MO
MO
MO
MO
4
MO
4
4
NDS
MO
4
MO
5
NDS
5
NDS
5
NDS
5
NDS
Drug Name
Drug
Tier
Requirements/
Limits
VRAYLAR CPPK 1.5 &
4
NDS
3 MG
WELLBUTRIN
4
MO
WELLBUTRIN SR
4
MO
WELLBUTRIN XL
4
MO
ziprasidone hcl
2
MO
ZOLOFT
4
MO
ZYBAN
4
MO
ZYPREXA
4
MO
ZYPREXA RELPREVV 4
ZYPREXA ZYDIS
4
MO
DIABETIC SUPPLIES
DIABETIC SUPPLIES
alcohol swabs
2
MO
gauze pads &
2
MO
dressings
insulin pen needle
2
MO
insulin syringe/needle
2
MO
u-100
ELECTROLYTIC, CALORIC, AND WATER
BALANCE
ACIDIFYING AND ALKALINIZING AGENTS
ammonium chloride
2
HI
potassium citrate
2
MO
(alkalinizer)
SODIUM LACTATE
4
HI
UROCIT-K 10
4
MO
UROCIT-K 15
4
MO
UROCIT-K 5
4
MO
AMMONIA DETOXICANTS
BUPHENYL
5
NDS
CARBAGLU
4
LD
lactulose
2
MO
lactulose
2
MO
(encephalopathy)
LITHOSTAT
4
MO
RAVICTI
5
NDS
sodium phenylbutyrate 2
NDS
CALORIC AGENTS
amino acid electrolyte
2
HI
infusion
amino acid infusion
2
HI
AMINOSYN II SOLN
4
HI
10 %
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 31
Drug Name
AMINOSYN II SOLN
15 %
AMINOSYN II SOLN 7
%
AMINOSYN II SOLN
8.5 %
AMINOSYN-HBC
SOLN 7 %
AMINOSYN-PF SOLN
10 %
AMINOSYN-PF SOLN
7%
AMINOSYN-RF SOLN
5.2 %
AMINOSYN/ELECTRO
LYTES SOLN 7 %
CLINIMIX
E/DEXTROSE
(2.75/10)
CLINIMIX
E/DEXTROSE (2.75/5)
CLINIMIX
E/DEXTROSE
(4.25/10)
CLINIMIX
E/DEXTROSE
(4.25/25)
CLINIMIX
E/DEXTROSE (4.25/5)
CLINIMIX
E/DEXTROSE (5/15)
CLINIMIX
E/DEXTROSE (5/20)
CLINIMIX
E/DEXTROSE (5/25)
CLINIMIX/DEXTROSE
(2.75/5)
CLINIMIX/DEXTROSE
(4.25/10)
CLINIMIX/DEXTROSE
(4.25/20)
CLINIMIX/DEXTROSE
(4.25/25)
CLINIMIX/DEXTROSE
(4.25/5)
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
CLINIMIX/DEXTROSE
3
HI
(5/15)
CLINIMIX/DEXTROSE
4
HI
3
HI
(5/20)
CLINIMIX/DEXTROSE
4
HI
3
HI
(5/25)
dextrose
2
HI
4
HI
fat emulsion
2
HI
FREAMINE HBC
4
HI
4
HI
SOLN 6.9 %
HEPATAMINE SOLN 8
4
HI
4
HI
%
INTRALIPID EMUL 30
4
HI
4
HI
%
LIPOSYN III EMUL 10
4
HI
3
HI
%
NEPHRAMINE SOLN
3
HI
3
HI
5.4 %
PROCALAMINE SOLN
3
HI
3%
3
HI
PROSOL SOLN 20 %
4
HI
TRAVASOL SOLN 10
4
HI
3
HI
%
TROPHAMINE SOLN
3
HI
10 %
3
HI
TROPHAMINE SOLN
3
HI
6%
DIURETICS
3
HI
amiloride &
1
MO
hydrochlorothiazide
3
HI
amiloride hcl
2
MO
bumetanide
soln
0.25
3
HI
2
mg/ml
bumetanide tabs 0.5
3
HI
1
MO
mg
bumetanide tabs 1 mg 1
MO
3
HI
bumetanide tabs 2 mg 2
MO
chlorothiazide
2
MO
3
HI
chlorothiazide sodium
2
HI
chlorthalidone
2
MO
3
HI
DEMADEX
4
MO
DIURIL
3
MO
3
HI
DYAZIDE
4
MO
DYRENIUM
3
MO
3
HI
EDECRIN
3
MO
ethacrynate sodium
2
HI
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
4
HI
32 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
4
3
Requirements/
Limits
MO
MO
furosemide soln 10
KAYEXALATE
2
HI,MO
mg/ml
RENAGEL
furosemide soln 8
RENVELA PACK 0.8
2
MO
3
MO
mg/ml
GM
furosemide tabs 20 mg 1
MO
RENVELA PACK 2.4
4
MO
furosemide tabs 40 mg 1
MO
GM
furosemide tabs 80 mg 1
MO
RENVELA TABS 800
4
MO
MG
hydrochlorothiazide
1
MO
caps 12.5 mg
sodium polystyrene
2
MO
sulfonate
hydrochlorothiazide
2
MO
tabs 12.5 mg
VELPHORO
4
MO
hydrochlorothiazide
VELTASSA
4
NDS
1
MO
tabs 25 mg
IRRIGATING SOLUTIONS
hydrochlorothiazide
irrigation solutions,
1
MO
2
MO
tabs 50 mg
physiological
indapamide
1
MO
lactated ringer's
2
MO
(irrigation)
LASIX
4
MO
ringer's irrigation
MAXZIDE
4
MO
2
MO
sodium chloride (gu
MAXZIDE-25
4
MO
2
MO
irrigant)
methyclothiazide
2
MO
water for irrigation,
metolazone
2
MO
2
MO
sterile
MICROZIDE
4
MO
REPLACEMENT PREPARATIONS
SAMSCA
4
NDS
calcium acetate
SODIUM DIURIL
4
HI
2
MO
(phosphate binder)
SODIUM EDECRIN
3
HI
DEXTROSE
torsemide
2
MO
5%/ELECTROLYTE
3
HI
triamterene-hctz caps
2
MO
#48
37.5-25 mg
dextrose in lactated
triamterene-hctz caps
2
HI
2
MO
ringers
50-25 mg
dextrose w/ sodium
triamterene-hctz tabs
2
HI
1
MO
chloride
37.5-25 mg
DEXTROSE-NACL
triamterene-hctz tabs
3
HI
1
MO
SOLN 10-0.2 %
75-50 mg
DEXTROSE-NACL
ION-REMOVING AGENTS
3
HI
SOLN 10-0.45 %
AURYXIA
4
MO
DEXTROSE-NACL
FOSRENOL CHEW
4
HI
4
MO
SOLN 5-0.225 %
1000 MG
IONOSOL-B IN D5W
4
HI
FOSRENOL CHEW
4
MO
IONOSOL-MB
IN
D5W
4
HI
500 MG
ISOLYTE-P IN D5W
4
HI
FOSRENOL CHEW
4
MO
ISOLYTE-S
4
HI
750 MG
K-TAB
TBCR
10
MEQ
3
MO
FOSRENOL PACK
5
K-TAB TBCR 20 MEQ 4
MO
1000 MG
K-TAB
TBCR
8
MEQ
4
MO
FOSRENOL PACK
5
750 MG
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 33
Drug Name
KCL IN DEXTROSENACL SOLN 20-50.225 MEQ/L-%-%
KCL IN DEXTROSENACL SOLN 40-5-0.9
MEQ/L-%-%
KCL-LACTATED
RINGERS-D5W
lactated ringer's
MAGNESIUM
SULFATE IN D5W
NORMOSOL-M IN
D5W
NORMOSOL-R IN
D5W
NORMOSOL-R PH 7.4
parenteral electrolytes
PHOSLO CAPS 667
MG
PHOSLYRA SOLN 667
MG/5ML
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN
D5W
potassium chloride
potassium chloride in
dextrose
potassium chloride in
dextrose & sodium
chloride
potassium chloride in
nacl
potassium chloride
microencapsulated
crystals cr
ringer's
sodium chloride
ZINC TRACE METAL
URICOSURIC AGENTS
colchicine w/
probenecid
probenecid
ENZYMES
ENZYMES
ADAGEN
Drug
Tier
Requirements/
Limits
4
HI
3
HI
3
HI
2
HI
3
HI
4
HI
4
HI
4
2
HI
HI
4
MO
3
MO
3
3
HI
HI
3
HI
2
HI,MO
2
HI
2
HI
2
HI
2
MO
2
2
3
HI
HI,MO
HI
2
MO
2
MO
3
LD
Drug Requirements/
Tier
Limits
ALDURAZYME
3
HI
CEREZYME
5
HI,NDS
ELAPRASE
5
ELELYSO
5
NDS
ELITEK SOLR 1.5 MG 3
HI
ELITEK SOLR 7.5 MG 4
HI
FABRAZYME
5
HI
KANUMA
5
LUMIZYME
5
MYOZYME
5
NAGLAZYME
5
PULMOZYME
5
PA
STRENSIQ
5
NDS
SUCRAID
4
LD
VIMIZIM
5
HI
VPRIV
5
NDS
EYE, EAR, NOSE, AND THROAT (EENT)
PREPARATIONS
ANTI-INFECTIVES
AZASITE
4
bacitracin (ophthalmic) 2
bacitracin-polymyxin b
2
(ophth)
BESIVANCE
4
BLEPH-10
4
chlorhexidine
gluconate (mouth2
throat)
CILOXAN OINT 0.3 % 3
CILOXAN SOLN 0.3 % 4
ciprofloxacin hcl
2
(ophth)
erythromycin (ophth)
2
gatifloxacin (ophth)
2
gentamicin sulfate
2
(ophth)
levofloxacin (ophth)
2
MOXEZA
4
NATACYN
3
neomycin-bacitracin
2
zn-polymyxin
neomycin-polymyxin2
gramicidin
OCUFLOX
4
ofloxacin (ophth)
2
Drug Name
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
34 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
Drug
Tier
2
Requirements/
Limits
ofloxacin (otic)
polymyxin b2
trimethoprim
POLYTRIM
4
sulfacetamide sodium
2
(ophth)
tobramycin (ophth)
2
TOBREX OINT 0.3 %
3
TOBREX SOLN 0.3 % 4
trifluridine
2
VIGAMOX
4
VIROPTIC
4
ZIRGAN
4
ZYMAXID
3
ANTI-INFLAMMATORY AGENTS
ACULAR
4
MO
ACULAR LS
4
MO
ACUVAIL
4
MO
ALREX
4
MO
bacitracin-poly2
MO
neomycin-hc
BECONASE AQ
4
MO
BLEPHAMIDE
3
MO
bromfenac sodium
2
MO
(ophth)
budesonide (nasal)
2
MO
CIPRO HC
4
MO
CIPRODEX
3
MO
COLY-MYCIN S
3
MO
CORTISPORIN-TC
3
MO
dexamethasone
sodium phosphate
2
MO
(ophth)
diclofenac sodium
2
MO
(ophth)
DUREZOL
4
MO
FLAREX
4
MO
flunisolide (nasal)
2
MO
fluocinolone acetonide
2
MO
(otic)
fluorometholone
2
MO
(ophth)
flurbiprofen sodium
2
MO
fluticasone propionate
2
MO
(nasal)
Drug Name
FML FORTE SUSP
0.25 %
FML LIQUIFILM SUSP
0.1 %
FML OINT 0.1 %
hydrocortisone
w/acetic acid
ILEVRO
ketorolac
tromethamine (ophth)
LOTEMAX
MAXIDEX
MAXITROL
mometasone furoate
(nasal)
NASONEX
neomycin-polymydexameth
neomycin-polymyxinhc (ophth)
neomycin-polymyxinhc (otic)
NEVANAC
OCUFEN
OMNARIS
OMNIPRED SUSP 1 %
PRED FORTE SUSP 1
%
PRED MILD SUSP
0.12 %
PRED-G
PRED-G S.O.P.
prednisolone acetate
(ophth)
prednisolone sodium
phosphate (ophth)
PROLENSA
QNASL
QNASL CHILDRENS
RESTASIS
RHINOCORT AQUA
sulfacetamide sodprednisolone
TOBRADEX OINT 0.30.1 %
Drug
Tier
Requirements/
Limits
3
MO
4
MO
3
MO
2
MO
4
MO
2
MO
4
4
4
MO
MO
MO
2
MO
4
MO
2
MO
2
MO
2
MO
4
4
4
4
MO
MO
MO
MO
4
MO
3
MO
3
3
MO
MO
2
MO
2
MO
4
4
4
3
4
MO
MO
MO
MO
MO
2
MO
3
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 35
Drug Name
Drug
Tier
TOBRADEX ST SUSP
4
0.3-0.05 %
TOBRADEX SUSP
4
0.3-0.1 %
tobramycin2
dexamethasone
VERAMYST
4
VEXOL
3
ZETONNA
4
ZYLET
4
ANTIALLERGIC AGENTS
ALOCRIL
4
ALOMIDE
4
ASTEPRO
4
azelastine hcl
2
azelastine hcl (ophth)
2
BEPREVE
4
cromolyn sodium
2
(ophth)
DYMISTA
4
ELESTAT
4
EMADINE
4
epinastine hcl (ophth)
2
LASTACAFT
4
olopatadine hcl
2
olopatadine hcl (nasal) 2
PATADAY
4
PATANASE
4
PATANOL
4
PAZEO
4
ANTIGLAUCOMA AGENTS
acetazolamide
2
acetazolamide sodium 2
ALPHAGAN P
4
AZOPT
4
BETAGAN
4
betaxolol hcl (ophth)
2
BETIMOL
4
BETOPTIC-S
4
bimatoprost
2
brimonidine tartrate
2
carteolol hcl (ophth)
2
COMBIGAN
4
COSOPT
4
DIAMOX SEQUELS
4
Requirements/
Limits
MO
MO
MO
MO
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
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
2
Requirements/
Limits
MO
dorzolamide hcl
dorzolamide hcl-timolol
2
MO
maleate
ISOPTO CARPINE
4
MO
ISTALOL
4
MO
latanoprost
2
MO
levobunolol hcl
2
MO
LUMIGAN
3
MO
methazolamide
2
MO
metipranolol
2
MO
PHOSPHOLINE
3
MO
IODIDE
pilocarpine hcl
2
MO
SIMBRINZA
4
MO
timolol maleate (ophth) 2
MO
TIMOPTIC OCUDOSE 4
MO
TIMOPTIC-XE
4
MO
TRAVATAN Z
4
MO
travoprost
2
MO
TRUSOPT
4
MO
XALATAN
4
MO
ZIOPTAN
4
MO
EENT DRUGS, MISCELLANEOUS
acetic acid (otic)
2
MO
apraclonidine hcl
2
MO
atropine sulfate
2
MO
(ophthalmic)
CYSTARAN
4
IOPIDINE SOLN 0.5 % 4
MO
IOPIDINE SOLN 1 %
3
MO
LACRISERT
3
MO
naphazoline hcl
2
MO
LOCAL ANESTHETICS
lidocaine hcl (mouth2
MO
throat)
proparacaine hcl
2
MO
GASTROINTESTINAL DRUGS
ANTI-INFLAMMATORY AGENTS
alosetron hcl
2
NDS
APRISO CP24 0.375
4
MO
GM
ASACOL HD TBEC
4
MO
800 MG
balsalazide disodium
2
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
36 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Requirements/
Tier
Limits
CANASA SUPP 1000
ZOFRAN ODT
4
PA
3
MO
MG
ZUPLENZ
4
PA
DELZICOL CPDR 400
ANTIULCER AGENTS AND ACID
4
MO
MG
SUPPRESSANTS
DIPENTUM
5
ACIPHEX
4
MO
GIAZO
4
MO
ACIPHEX SPRINKLE
4
MO
LIALDA TBEC 1.2 GM 3
MO
amoxicillinclarithromycin w/
LOTRONEX
4
NDS
2
MO
lansoprazole
mesalamine w/
2
MO
cleanser
CARAFATE SUSP 1
3
MO
GM/10ML
PENTASA CPCR 250
3
MO
MG
CARAFATE TABS 1
4
MO
GM
PENTASA CPCR 500
3
MO
cimetidine
MG
2
MO
cimetidine hcl
SFROWASA ENEM 4
2
MO
4
MO
GM/60ML
CYTOTEC
4
MO
ANTIDIARRHEA AGENTS
DEXILANT
4
MO
diphenoxylate w/
esomeprazole
2
2
MO
atropine
magnesium
LOMOTIL
4
esomeprazole sodium
2
HI
loperamide hcl
2
MO
famotidine
2
HI,MO
ANTIEMETICS
famotidine in nacl
2
HI
AKYNZEO
4
PA,NDS
lansoprazole
2
MO
ALOXI
4
HI
misoprostol
2
MO
ANZEMET
4
PA,HI,NDS
NEXIUM
4
MO
CESAMET
4
PA
NEXIUM I.V.
4
HI
dronabinol
2
PA
nizatidine
2
MO
EMEND
4
PA,NDS
OMECLAMOX-PAK
4
MO
EMEND CAPS 125
omeprazole
2
MO
3
PA,NDS
MG
omeprazole-sodium
2
MO
EMEND CAPS 40 MG 4
PA,NDS
bicarbonate
EMEND CAPS 80 &
pantoprazole sodium
2
HI,MO
4
PA,NDS
125 MG
PEPCID
4
MO
EMEND CAPS 80 MG 3
PA,NDS
PREVACID
4
MO
granisetron hcl
2
PA,HI
PREVACID SOLUTAB 4
MO
MARINOL
4
PA
PREVPAC
4
MO
meclizine hcl
2
PRILOSEC
4
MO
ondansetron
2
PA
PROTONIX PACK 40
3
MO
ondansetron hcl
2
PA,HI
MG
SANCUSO
4
NDS
PROTONIX SOLR 40
4
HI
TIGAN
4
PA
MG
TRANSDERM-SCOP
PROTONIX TBEC 20
3
4
MO
(1.5 MG)
MG
trimethobenzamide hcl 2
PA
PROTONIX TBEC 40
4
MO
MG
VARUBI
4
PA,NDS
PYLERA
4
MO
ZOFRAN
4
PA,HI
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Kaiser Permanente 2017 Comprehensive Formulary • 37
Drug Requirements/
Tier
Limits
rabeprazole sodium
2
MO
ranitidine hcl
2
HI,MO
sucralfate
2
MO
ZANTAC
4
HI,MO
ZEGERID
4
MO
CATHARTICS AND LAXATIVES
bisacodyl-peg 3350-pot
chloride-sod bicarb-sod 2
MO
chloride
COLYTE WITH
4
MO
FLAVOR PACKS
GOLYTELY
4
MO
MOVIPREP
4
MO
NULYTELY WITH
4
MO
FLAVOR PACKS
OSMOPREP
4
MO
peg 3350-kcl-sod
bicarb-sod chloride-sod 2
MO
sulfate
peg 3350-potassium
chloride-sod
2
MO
bicarbonate-sod
chloride
polyethylene glycol
2
MO
3350
PREPOPIK
4
MO
SUPREP BOWEL
4
MO
PREP
DIGESTANTS
CREON CPEP 12000
3
MO
UNIT
CREON CPEP 24000
3
MO
UNIT
CREON CPEP 30003
MO
9500 UNIT
CREON CPEP 36000
3
MO
UNIT
CREON CPEP 6000
3
MO
UNIT
PANCREAZE CPEP
4
MO
10500 UNIT
PANCREAZE CPEP
4
MO
16800 UNIT
PANCREAZE CPEP
4
MO
21000 UNIT
Drug Name
Drug Name
Drug
Tier
Requirements/
Limits
PANCREAZE CPEP
4
MO
4200 UNIT
PERTZYE CPEP
4
MO
16000 UNIT
PERTZYE CPEP 8000
4
MO
UNIT
VIOKACE TABS 10440
4
MO
UNIT
VIOKACE TABS 20880
4
MO
UNIT
ZENPEP CPEP 10000
3
MO
UNIT
ZENPEP CPEP 15000
3
MO
UNIT
ZENPEP CPEP 20000
3
MO
UNIT
ZENPEP CPEP 25000
3
MO
UNIT
ZENPEP CPEP 30003
MO
10000 UNIT
ZENPEP CPEP 40000
3
MO
UNIT
ZENPEP CPEP 5000
3
MO
UNIT
GI DRUGS, MISCELLANEOUS
ACTIGALL
4
MO
AMITIZA
4
MO
chenodiol
2
MO
CHOLBAM
5
NDS
ENTYVIO
5
GATTEX
5
NDS
LINZESS
3
MO
metoclopramide hcl
2
HI,MO
METOZOLV ODT
4
MO
MOVANTIK
4
MO
NUTRESTORE
4
MO
OCALIVA
5
NDS
REGLAN
4
MO
RELISTOR
4
URSO 250
4
MO
URSO FORTE
4
MO
ursodiol
2
MO
VIBERZI
5
NDS
GOLD COMPOUNDS
GOLD COMPOUNDS
RIDAURA
3
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
38 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Requirements/
Drug Requirements/
Drug Name
Tier
Limits
Tier
Limits
HEAVY METAL ANTAGONISTS
MEDROL TABS 16
4
MO
MG
HEAVY METAL ANTAGONISTS
MEDROL TABS 2 MG 3
MO
CHEMET
3
MEDROL TABS 32
CUPRIMINE CAPS
4
MO
4
MG
250 MG
MEDROL TABS 4 MG 4
MO
DEPEN TITRATABS
3
TABS 250 MG
MEDROL TABS 8 MG 4
MO
EXJADE TBSO 125
MEDROL TBPK 4 MG 4
MO
3
NDS
MG
methylprednisolone
2
MO
EXJADE TBSO 250
methylprednisolone
5
NDS
2
MG
acetate
EXJADE TBSO 500
methylprednisolone
5
NDS
2
MG
sod succ
FERRIPROX
5
LD,NDS
ORAPRED ODT
4
MO
JADENU TABS 180
prednisolone
2
MO
5
NDS
MG
prednisolone sodium
2
MO
JADENU TABS 360
phosphate
5
NDS
MG
prednisone
2
PA,MO
JADENU TABS 90 MG 5
NDS
RAYOS
4
PA,MO
SYPRINE
4
NDS
SOLU-CORTEF
3
HORMONES AND SYNTHETIC SUBSTITUTES
SOLU-MEDROL SOLR
4
ADRENALS
125 MG
ARISTOSPAN INTRASOLU-MEDROL SOLR
3
3
ARTICULAR
2 GM
ARISTOSPAN
SOLU-MEDROL SOLR
3
3
INTRALESIONAL
40 MG
BREO ELLIPTA
4
MO
SOLU-MEDROL SOLR
3
budesonide
2
PA,MO,NDS
500 MG
CELESTONE
3
MO
UCERIS
5
NDS
ANDROGENS
CORTEF
4
MO
cortisone acetate
2
MO
ANADROL-50
4
MO
DEPO-MEDROL
ANDRODERM PT24 2
3
3
MO
SUSP 20 MG/ML
MG/24HR
DEPO-MEDROL
ANDRODERM PT24 4
4
3
MO
SUSP 40 MG/ML
MG/24HR
DEPO-MEDROL
ANDROGEL GEL
4
SUSP 80 MG/ML
20.25 MG/1.25GM
4
MO
(1.62%)
dexamethasone
2
PA,MO
ANDROGEL GEL 25
dexamethasone
4
MO
2
HI,MO
MG/2.5GM (1%)
sodium phosphate
ANDROGEL GEL 40.5
ENTOCORT EC
5
4
MO
MG/2.5GM (1.62%)
fludrocortisone acetate 2
MO
ANDROGEL GEL 50
hydrocortisone
2
MO
4
MO
MG/5GM (1%)
hydrocortisone sod
2
succinate
KENALOG
3
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Drug Name
Kaiser Permanente 2017 Comprehensive Formulary • 39
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
levonorgestrel-eth
ANDROGEL PUMP
2
MO
estradiol (triphasic)
GEL 20.25 MG/ACT
4
MO
(1.62%)
levonorgestrel-ethinyl
2
MO
estradiol (91-day)
AVEED
4
MO
levonorgestrel-ethinyl
AXIRON SOLN 30
4
MO
2
MO
estradiol (continuous)
MG/ACT
danazol
2
MO
LO LOESTRIN FE
4
MO
FORTESTA GEL 10
LOSEASONIQUE
4
MO
4
MO
MG/ACT (2%)
MINASTRIN 24 FE
4
MO
methyltestosterone
2
MO
MODICON (28)
4
MO
NATESTO GEL 5.5
NATAZIA
4
MO
4
MO
MG/ACT
NECON 1/50 (28)
4
MO
oxandrolone
2
MO
NOR-QD
4
MO
STRIANT MISC 30 MG 4
MO
norelgestromin-ethinyl
2
MO
TESTIM GEL 50
estradiol
4
MO
MG/5GM (1%)
norethin acet & estrad2
MO
testosterone
2
MO
fe
testosterone cypionate 2
MO
norethindrone & eth
2
MO
testosterone enanthate 2
estradiol
MO
norethindrone & ethinyl
TESTOSTERONE
2
MO
estradiol-fe
GEL 25 MG/2.5GM
4
MO
(1%)
norethindrone
2
MO
(contraceptive)
VOGELXO GEL 50
4
MO
MG/5GM (1%)
norethindrone acet &
2
MO
eth estra
VOGELXO PUMP GEL
4
MO
12.5 MG/ACT (1%)
norethindrone acetate2
MO
CONTRACEPTIVES
ethinyl estradiol-fe
norethindrone-eth
BEYAZ
4
MO
2
MO
estradiol (biphasic)
BREVICON (28)
4
MO
norethindrone-eth
CYCLESSA
4
MO
2
MO
estradiol (triphasic)
DESOGEN
4
MO
norgestimate-ethinyl
desogestrel & ethinyl
2
MO
2
MO
estradiol
estradiol
norgestimate-ethinyl
desogestrel-ethinyl
2
MO
2
MO
estradiol (triphasic)
estradiol (biphasic)
norgestrel & ethinyl
desogestrel-ethinyl
2
MO
2
MO
estradiol
estradiol (triphasic)
NORINYL 1+35 (28)
4
MO
drospirenone-ethinyl
2
MO
NORINYL 1+50 (28)
4
MO
estradiol
NUVARING
3
MO
ELLA
3
MO
ORTHO MICRONOR
4
MO
ethynodiol diacet & eth
2
MO
estrad
ORTHO TRI-CYCLEN
4
MO
(28)
FEMCON FE
4
MO
ORTHO TRI-CYCLEN
GENERESS FE
4
MO
4
MO
LO
levonorgestrel & eth
2
MO
ORTHO-CYCLEN (28) 4
MO
estradiol
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
40 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
ORTHO-NOVUM 1/35
(28)
ORTHO-NOVUM 7/7/7
(28)
PLAN B ONE-STEP
QUARTETTE
SAFYRAL
SEASONIQUE
TRI-NORINYL (28)
YASMIN 28
YAZ
DIABETIC AGENTS
acarbose
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS
AFREZZA POWD 4
(30) & 8 (60) UNIT
AFREZZA POWD 4
(60) & 8 (30) UNIT
AFREZZA POWD 4
UNIT
AFREZZA POWD 8
(60)& 12 (30) UNIT
alogliptin benzoate
ALOGLIPTINMETFORMIN HCL
alogliptin-pioglitazone
AMARYL
APIDRA
APIDRA SOLOSTAR
AVANDIA
BYDUREON
BYETTA 10 MCG PEN
BYETTA 5 MCG PEN
chlorpropamide
CYCLOSET
DUETACT
FARXIGA
FORTAMET
glimepiride
glipizide er tb24 10 mg
glipizide er tb24 2.5 mg
glipizide er tb24 5 mg
glipizide tabs 10 mg
Drug
Tier
Requirements/
Limits
4
MO
4
MO
3
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
2
4
4
4
MO
MO
MO
MO
4
MO
4
MO
4
MO
4
MO
2
MO
4
MO
2
4
4
4
4
4
4
4
2
4
4
4
4
1
2
2
2
1
MO
MO
PA,MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
glipizide tabs 5 mg
glipizide-metformin hcl
GLUCAGEN HYPOKIT
GLUCAGON
EMERGENCY
GLUCOPHAGE
GLUCOPHAGE XR
GLUCOTROL
GLUCOTROL XL
GLUCOVANCE
GLUMETZA
glyburide
glyburide micronized
glyburide-metformin
GLYNASE
GLYSET
GLYXAMBI
HUMALOG KWIKPEN
SOPN 100 UNIT/ML
HUMALOG KWIKPEN
SOPN 200 UNIT/ML
HUMALOG MIX 50/50
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25
KWIKPEN
HUMALOG SOCT 100
UNIT/ML
HUMALOG SOLN 100
UNIT/ML
HUMULIN 70/30
HUMULIN 70/30
KWIKPEN
HUMULIN N
KWIKPEN SUPN 100
UNIT/ML
HUMULIN N SUSP
100 UNIT/ML
HUMULIN R SOLN
100 UNIT/ML
HUMULIN R U-500
(CONCENTRATED)
SOLN 500 UNIT/ML
Drug
Tier
1
2
4
Requirements/
Limits
MO
MO
3
4
4
4
4
4
4
2
2
2
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
4
MO
3
MO
3
MO
3
MO
3
MO
3
MO
3
PA,MO
3
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 41
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
HUMULIN R U-500
NOVOLOG MIX 70/30
4
MO
KWIKPEN SOPN 500
4
MO
FLEXPEN
UNIT/ML
NOVOLOG PENFILL
4
MO
INVOKAMET
4
MO
ONGLYZA
4
MO
INVOKANA
4
MO
OSENI
4
MO
JANUMET
4
MO
pioglitazone hcl
2
MO
JANUMET XR
4
MO
pioglitazone hcl2
MO
glimepiride
JANUVIA
4
MO
pioglitazone hclJARDIANCE
4
MO
2
MO
metformin hcl
JENTADUETO
4
MO
PRANDIN
4
MO
JENTADUETO XR
4
MO
PRECOSE
4
MO
KAZANO
4
MO
repaglinide
2
MO
KOMBIGLYZE XR
4
MO
repaglinide-metformin
KORLYM
5
LD,NDS
2
MO
hcl
LANTUS SOLN 100
3
MO
RIOMET
4
UNIT/ML
STARLIX
4
MO
LANTUS SOLOSTAR
4
MO
SOPN 100 UNIT/ML
SYMLINPEN 120
4
MO
LEVEMIR
4
MO
SYMLINPEN 60
4
MO
LEVEMIR
SYNJARDY
4
MO
4
MO
FLEXTOUCH
TANZEUM
4
MO
metformin hcl er (osm)
tolazamide
2
MO
2
MO
tb24 1000 mg
tolbutamide
2
MO
metformin hcl er tb24
TOUJEO SOLOSTAR
1
MO
4
MO
500 mg
SOPN 300 UNIT/ML
metformin hcl er tb24
TRADJENTA
4
MO
2
MO
750 mg
TRESIBA
4
MO
metformin hcl tabs
FLEXTOUCH
1
MO
1000 mg
TRULICITY
4
MO
metformin hcl tabs 500
VICTOZA
4
MO
1
MO
mg
XIGDUO XR
4
MO
metformin hcl tabs 850
ESTROGENS
AND
ANTIESTROGENS
1
MO
mg
ACTIVELLA
4
MO
miglitol
2
MO
ALORA PTTW 0.025
4
MO
nateglinide
2
MO
MG/24HR
NESINA
4
MO
ALORA PTTW 0.05
4
MO
NOVOLIN 70/30
3
MO
MG/24HR
NOVOLIN N RELION
ALORA PTTW 0.075
4
MO
4
MO
SUSP 100 UNIT/ML
MG/24HR
NOVOLIN N SUSP
ALORA PTTW 0.1
4
MO
4
MO
100 UNIT/ML
MG/24HR
NOVOLIN R SOLN
ANGELIQ
4
MO
4
PA,MO
100 UNIT/ML
CLIMARA PRO
4
MO
NOVOLOG
4
PA,MO
CLIMARA PTWK 0.025
3
MO
NOVOLOG FLEXPEN 4
MO
MG/24HR
NOVOLOG MIX 70/30 4
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
42 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
3
Requirements/
Limits
MO
CLIMARA PTWK
PREMARIN
3
MO
0.0375 MG/24HR
PREMARIN SOLR 25
3
CLIMARA PTWK 0.05
MG
3
MO
MG/24HR
PREMARIN TABS 0.3
4
MO
CLIMARA PTWK 0.06
MG
3
MO
MG/24HR
PREMARIN TABS 0.45
4
MO
CLIMARA PTWK 0.075
MG
3
MO
MG/24HR
PREMARIN TABS
4
MO
CLIMARA PTWK 0.1
0.625 MG
3
MO
MG/24HR
PREMARIN TABS 0.9
4
MO
COMBIPATCH
4
MO
MG
DELESTROGEN
4
PREMARIN TABS 1.25
4
MO
MG
DIVIGEL GEL 0.5
4
MO
MG/0.5GM
PREMPHASE
4
MO
DUAVEE
4
MO
PREMPRO
4
MO
raloxifene hcl
ELESTRIN GEL 0.52
2
MO
4
MO
MG/0.87 GM (0.06%)
VAGIFEM
3
MO
esterified estrogens
2
MO
VIVELLE-DOT PTTW
4
MO
estradiol
2
MO
0.025 MG/24HR
estradiol &
VIVELLE-DOT PTTW
2
MO
4
MO
norethindrone acetate
0.0375 MG/24HR
estradiol cypionate
2
VIVELLE-DOT PTTW
4
MO
0.05 MG/24HR
estradiol vaginal
2
MO
VIVELLE-DOT PTTW
estradiol valerate
2
4
MO
0.075 MG/24HR
estradiol-norgestimate 2
MO
VIVELLE-DOT PTTW
ESTRING
3
MO
4
MO
0.1 MG/24HR
estropipate
2
MO
GONADOTROPINS
EVAMIST SOLN 1.53
4
MO
chorionic gonadotropin 2
PA
MG/SPRAY
SYNAREL
3
MO
EVISTA
4
MO
PARATHYROID
FEMHRT LOW DOSE
4
MO
calcitonin (salmon)
2
MO
FEMRING
4
MO
FORTEO
5
PA,NDS
MENOSTAR PTWK 14
4
MO
FORTICAL SOLN 200
MCG/24HR
3
MO
UNIT/ACT
MINIVELLE PTTW
4
MO
MIACALCIN SOLN 200
0.025 MG/24HR
4
MO
UNIT/ACT
MINIVELLE PTTW
4
MO
MIACALCIN SOLN 200
0.0375 MG/24HR
3
UNIT/ML
MINIVELLE PTTW
4
MO
NATPARA
5
LD,NDS
0.05 MG/24HR
PITUITARY
MINIVELLE PTTW
4
MO
0.075 MG/24HR
DDAVP
4
MO
MINIVELLE PTTW 0.1
DDAVP RHINAL TUBE 4
MO
4
MO
MG/24HR
DDAVP SOLN 4
4
MO
norethindrone acetateMCG/ML
2
MO
ethinyl estradiol
DDAVP TABS 0.1 MG 4
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 43
Drug Name
Drug
Tier
4
2
Requirements/
Limits
MO
MO
DDAVP TABS 0.2 MG
desmopressin acetate
desmopressin acetate
2
MO
refrigerated
desmopressin acetate
2
MO
spray refrigerated
HP ACTHAR
5
PA,NDS
STIMATE SOLN 1.5
3
MO
MG/ML
PROGESTINS
CRINONE
4
PA,MO
DEPO-PROVERA
3
DEPO-PROVERA
4
SUSP 150 MG/ML
DEPO-SUBQ
PROVERA 104 SUSP
3
104 MG/0.65ML
hydroxyprogesterone
caproate
2
(antineoplastic)
MAKENA
4
medroxyprogesterone
2
MO
acetate
medroxyprogesterone
2
acetate (contraceptive)
MEGACE ES
4
MO
megestrol acetate
2
MO
(appetite)
norethindrone acetate
2
MO
progesterone
2
MO
micronized
PROMETRIUM
4
MO
PROVERA
4
MO
SOMATOTROPIN AGONISTS AND
ANTAGONISTS
EGRIFTA
5
NDS
GENOTROPIN
MINIQUICK SOLR 0.2 4
PA,NDS
MG
GENOTROPIN
MINIQUICK SOLR 0.4 4
PA,NDS
MG
GENOTROPIN
MINIQUICK SOLR 0.6 4
PA,NDS
MG
Drug Name
GENOTROPIN
MINIQUICK SOLR 0.8
MG
GENOTROPIN
MINIQUICK SOLR 1
MG
GENOTROPIN
MINIQUICK SOLR 1.2
MG
GENOTROPIN
MINIQUICK SOLR 1.4
MG
GENOTROPIN
MINIQUICK SOLR 1.6
MG
GENOTROPIN
MINIQUICK SOLR 1.8
MG
GENOTROPIN
MINIQUICK SOLR 2
MG
GENOTROPIN SOLR
12 MG
GENOTROPIN SOLR
5 MG
HUMATROPE SOLR
12 MG
HUMATROPE SOLR
24 MG
HUMATROPE SOLR 5
MG
HUMATROPE SOLR 6
MG
INCRELEX
NORDITROPIN
FLEXPRO SOLN 10
MG/1.5ML
NORDITROPIN
FLEXPRO SOLN 15
MG/1.5ML
NORDITROPIN
FLEXPRO SOLN 30
MG/3ML
NORDITROPIN
FLEXPRO SOLN 5
MG/1.5ML
Drug
Tier
Requirements/
Limits
4
PA,NDS
4
PA,NDS
4
PA,NDS
4
PA,NDS
4
PA,NDS
4
PA,NDS
4
PA,NDS
4
PA,NDS
5
PA,NDS
5
PA,NDS
5
PA,NDS
5
PA,NDS
5
PA,NDS
5
NDS
5
PA,NDS
5
PA,NDS
5
PA,NDS
5
PA,NDS
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
44 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Requirements/
Tier
Limits
NUTROPIN AQ
TIROSINT
4
MO
NUSPIN 10 SOLN 10
5
PA,NDS
TRIOSTAT
4
HI
MG/2ML
MISCELLANEOUS THERAPEUTIC AGENTS
NUTROPIN AQ
MISCELLANEOUS THERAPEUTIC AGENTS
NUSPIN 20 SOLN 20
5
PA,NDS
acetylcysteine
2
PA,MO
MG/2ML
ACTEMRA SOLN 200
4
HI,NDS
NUTROPIN AQ
MG/10ML
NUSPIN 5 SOLN 5
5
PA,NDS
ACTEMRA SOLN 400
4
HI,NDS
MG/2ML
MG/20ML
NUTROPIN AQ PEN
ACTEMRA SOLN 80
5
PA,NDS
4
HI,NDS
SOLN 10 MG/2ML
MG/4ML
NUTROPIN AQ PEN
ACTEMRA SOSY 162
5
PA,NDS
5
NDS
SOLN 20 MG/2ML
MG/0.9ML
OMNITROPE SOLN
ACTIMMUNE
5
LD,NDS
3
PA,NDS
10 MG/1.5ML
ACTONEL
4
MO
OMNITROPE SOLN 5
alendronate
sodium
3
PA,NDS
2
MO
MG/1.5ML
soln 70 mg/75ml
OMNITROPE SOLR
alendronate sodium
3
PA,NDS
1
MO
5.8 MG
tabs 10 mg
SAIZEN
5
PA,NDS
alendronate sodium
2
MO
SAIZEN CLICK.EASY
5
PA,NDS
tabs 35 mg
SEROSTIM
5
PA,NDS
alendronate sodium
2
MO
SIGNIFOR
5
NDS
tabs 40 mg
SIGNIFOR LAR
5
NDS
alendronate sodium
2
MO
SOMAVERT
5
LD,NDS
tabs 5 mg
TEV-TROPIN SOLR 5
alendronate sodium
5
PA,NDS
1
MO
MG
tabs 70 mg
ZOMACTON SOLR 10
allopurinol
2
MO
5
PA,NDS
MG
ALOPRIM
4
HI
ZOMACTON SOLR 5
amifostine crystalline
2
HI
4
PA,NDS
MG
AMPYRA
5
NDS
ZORBTIVE
5
PA,NDS
ARAVA
4
MO
THYROID AND ANTITHYROID AGENTS
ARCALYST
5
NDS
CYTOMEL
4
MO
ASTAGRAF XL CP24
4
PA,MO
levothyroxine sodium
2
MO
0.5 MG
LEVOTHYROXINE
ASTAGRAF XL CP24
4
MO
4
PA,MO
SODIUM
1 MG
liothyronine sodium
2
HI,MO
ASTAGRAF XL CP24
5
PA
methimazole
2
MO
5 MG
propylthiouracil
2
MO
ATELVIA
4
MO
SYNTHROID
4
MO
ATGAM
4
HI
THYROLAR-1
4
AUBAGIO
5
PA,NDS
THYROLAR-1/2
4
AVODART
4
MO
THYROLAR-1/4
4
AVONEX
5
NDS
THYROLAR-2
4
AVONEX PEN
5
NDS
THYROLAR-3
4
AVONEX PREFILLED 5
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Kaiser Permanente 2017 Comprehensive Formulary • 45
Drug Name
Drug
Tier
2
2
5
5
Requirements/
Limits
PA,MO
PA,MO
Drug Name
Drug
Tier
Requirements/
Limits
azathioprine
ENVARSUS XR TB24
4
PA,MO
1 MG
azathioprine sodium
ENVARSUS XR TB24
BENLYSTA
4
PA,MO
4 MG
BERINERT
etidronate disodium
2
MO
BETASERON KIT 0.3
5
NDS
EXTAVIA KIT 0.3 MG
3
NDS
MG
finasteride
2
MO
BINOSTO
4
MO
FIRAZYR
5
NDS
BONIVA
4
PA,HI,MO
fomepizole
2
HI
BOTOX SOLR 100
3
PA
UNIT
FOSAMAX
4
MO
BOTOX SOLR 200
FOSAMAX PLUS D
4
MO
4
PA
UNIT
FUSILEV
4
HI
CARNITOR
4
PA,HI,MO
GILENYA
5
NDS
CELLCEPT
4
PA,MO
glatiramer acetate
2
NDS
CELLCEPT
GRASTEK
4
MO
4
HI
INTRAVENOUS
HEMABATE
3
CERDELGA
5
NDS
HUMIRA
5
NDS
CIMZIA
5
NDS
HUMIRA PEDIATRIC
5
NDS
CIMZIA PREFILLED
5
NDS
CROHNS START
CINRYZE
5
HI,NDS
HUMIRA PEN
5
NDS
colchicine
2
MO
HUMIRA PEN5
NDS
COLCHICINE CAPS
CROHNS STARTER
3
MO
0.6 MG
HUMIRA PEN5
NDS
COLCRYS TABS 0.6
PSORIASIS STARTER
4
MO
MG
ibandronate sodium
2
PA,HI,MO
COPAXONE
5
NDS
IMURAN
4
PA,MO
cyclosporine
2
PA,HI,MO
JALYN
4
MO
cyclosporine modified
KEVEYIS
5
NDS
2
PA,MO
(for microemulsion)
KINERET
5
NDS
CYSTADANE
4
LD,NDS
KUVAN
5
NDS
CYSTAGON CAPS
leflunomide
2
MO
3
LD,NDS
150 MG
LEMTRADA
5
CYSTAGON CAPS 50
leucovorin calcium
2
HI,MO
3
LD,NDS
MG
levocarnitine
2
PA,HI,MO
DEMSER
4
MO
(metabolic modifiers)
dexrazoxane
2
HI
levoleucovorin calcium 2
HI,MO
disulfiram
2
MO
lidocaine hcl (local
2
dutasteride
2
MO
anesth.)
dutasteride-tamsulosin
mesna
2
HI,NDS
2
MO
hcl
MESNEX SOLN 100
4
HI
DYSPORT
4
PA
MG/ML
ELMIRON
3
MO
MESNEX TABS 400
3
NDS
ENBREL
5
NDS
MG
ENBREL SURECLICK 5
NDS
methylergonovine
2
maleate
ENVARSUS XR TB24
4
PA,MO
0.75 MG
MIFEPREX
3
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
46 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
MITIGARE CAPS 0.6
MG
MYALEPT
mycophenolate mofetil
mycophenolate sodium
MYFORTIC
NEORAL CAPS 100
MG
NEORAL CAPS 25 MG
NEORAL SOLN 100
MG/ML
NULOJIX
octreotide acetate
ORALAIR
ORENCIA
ORENCIA CLICKJECT
ORFADIN
OTEZLA
OTREXUP SOAJ 10
MG/0.4ML
OTREXUP SOAJ 15
MG/0.4ML
OTREXUP SOAJ 17.5
MG/0.4ML
OTREXUP SOAJ 20
MG/0.4ML
OTREXUP SOAJ 22.5
MG/0.4ML
OTREXUP SOAJ 25
MG/0.4ML
OTREXUP SOAJ 7.5
MG/0.4ML
pamidronate disodium
PROCYSBI CPDR 25
MG
PROCYSBI CPDR 75
MG
PROGRAF CAPS 0.5
MG
PROGRAF CAPS 1
MG
PROGRAF CAPS 5
MG
PROGRAF SOLN 5
MG/ML
Drug
Tier
Requirements/
Limits
4
MO
5
2
2
4
NDS
PA,MO
PA,MO
PA,MO
4
PA,MO
4
PA,MO
3
PA,MO
5
2
4
5
5
5
5
HI
NDS
MO
NDS
NDS
LD,NDS
PA,NDS
4
4
4
4
4
4
4
2
HI
5
NDS
5
NDS
4
PA,MO
4
PA,MO
4
PA,MO
3
HI
Drug Name
PROLIA SOLN 60
MG/ML
PROSCAR
RAGWITEK
RAPAMUNE
RASUVO SOAJ 10
MG/0.2ML
RASUVO SOAJ 12.5
MG/0.25ML
RASUVO SOAJ 15
MG/0.3ML
RASUVO SOAJ 17.5
MG/0.35ML
RASUVO SOAJ 20
MG/0.4ML
RASUVO SOAJ 22.5
MG/0.45ML
RASUVO SOAJ 25
MG/0.5ML
RASUVO SOAJ 27.5
MG/0.55ML
RASUVO SOAJ 30
MG/0.6ML
RASUVO SOAJ 7.5
MG/0.15ML
REBIF
REBIF REBIDOSE
REBIF REBIDOSE
TITRATION PACK
REBIF TITRATION
PACK
RECLAST
REMICADE
RIMSO-50
risedronate sodium
RUCONEST
SANDIMMUNE
SANDOSTATIN LAR
DEPOT KIT 10 MG
SANDOSTATIN LAR
DEPOT KIT 20 MG
SANDOSTATIN LAR
DEPOT KIT 30 MG
SANDOSTATIN SOLN
100 MCG/ML
Drug
Tier
Requirements/
Limits
4
NDS
4
4
4
MO
MO
PA,MO
3
3
3
3
3
3
3
3
3
3
5
5
NDS
NDS
5
NDS
5
NDS
4
5
3
2
5
3
HI
5
NDS
5
NDS
5
NDS
MO
NDS
PA,HI,MO
4
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 47
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
4
Requirements/
Limits
HI
SANDOSTATIN SOLN
ZOMETA
4
1000 MCG/ML
ZORTRESS TABS
4
PA,MO
SANDOSTATIN SOLN
0.25 MG
4
200 MCG/ML
ZORTRESS TABS 0.5
5
PA
SANDOSTATIN SOLN
MG
4
50 MCG/ML
ZORTRESS TABS
5
PA
SANDOSTATIN SOLN
0.75 MG
4
500 MCG/ML
ZYLOPRIM
4
MO
SENSIPAR TABS 30
RESPIRATORY TRACT AGENTS
3
NDS
MG
ANTI-INFLAMMATORY AGENTS
SENSIPAR TABS 60
ACCOLATE
4
MO
5
NDS
MG
CINQAIR
5
NDS
SENSIPAR TABS 90
cromolyn
sodium
2
PA,MO
5
NDS
MG
cromolyn sodium
2
MO
SIMPONI
5
NDS
(mastocytosis)
SIMPONI ARIA
5
NDS
GASTROCROM
4
MO
SIMULECT
4
HI
montelukast sodium
2
MO
sirolimus
2
PA,MO
NUCALA
5
NDS
SODIUM FLUORIDE
3
MO
SINGULAIR
4
MO
SOMATULINE DEPOT 4
zafirlukast
2
MO
tacrolimus
2
PA,HI,MO
ZYFLO CR TB12 600
5
TECFIDERA
5
NDS
MG
THALOMID
5
NDS
ZYFLO TABS 600 MG 4
MO
THIOLA
4
MO
RESPIRATORY AGENTS, MISCELLANEOUS
THYMOGLOBULIN
4
HI
AEROSPAN
4
MO
TYBOST
3
MO
ALVESCO
4
MO
TYSABRI
5
ARALAST NP
5
ULORIC
4
MO
ARNUITY ELLIPTA
4
MO
VISTOGARD
5
ASMANEX 120
VORAXAZE
5
METERED DOSES
4
MO
XELJANZ
5
NDS
AEPB 220 MCG/INH
XELJANZ XR
5
NDS
ASMANEX 30
METERED DOSES
4
MO
XEOMIN SOLR 100
4
PA
AEPB
110
MCG/INH
UNIT
ASMANEX 30
XEOMIN SOLR 200
5
PA
METERED DOSES
4
MO
UNIT
AEPB
220
MCG/INH
XEOMIN SOLR 50
4
PA
ASMANEX 60
UNIT
METERED DOSES
4
MO
XGEVA SOLN 120
5
NDS
AEPB 220 MCG/INH
MG/1.7ML
ASMANEX HFA AERO
XURIDEN
5
3
MO
100 MCG/ACT
XYLOCAINE
4
ASMANEX HFA AERO
ZAVESCA
5
LD,NDS
3
MO
200 MCG/ACT
ZINBRYTA
5
NDS
budesonide (inhalation) 2
PA,MO
ZINECARD
4
HI
DALIRESP
4
MO
zoledronic acid
2
HI
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
48 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
Drug
Tier
3
5
4
Requirements/
Limits
MO
PA,NDS
MO
Drug Requirements/
Tier
Limits
VENTAVIS
5
PA,LD,NDS
SERUMS, TOXOIDS, AND VACCINES
SERUMS
BIVIGAM SOLN 10
3
HI
GM/100ML
CARIMUNE NF SOLR
4
HI
12 GM
CARIMUNE NF SOLR
4
HI
6 GM
CYTOGAM
3
HI
FLEBOGAMMA DIF
4
HI
SOLN 0.5 GM/10ML
FLEBOGAMMA DIF
4
HI
SOLN 2.5 GM/50ML
FLEBOGAMMA DIF
4
HI
SOLN 20 GM/400ML
FLEBOGAMMA DIF
3
HI
SOLN 5 GM/100ML
FLEBOGAMMA DIF
4
HI
SOLN 5 GM/50ML
GAMASTAN S/D
3
PA
GAMMAGARD S/D
3
HI
LESS IGA SOLR 5 GM
GAMMAGARD S/D
3
HI
SOLR 10 GM
GAMMAGARD SOLN
3
HI
2.5 GM/25ML
GAMMAKED SOLN 1
3
HI
GM/10ML
GAMMAPLEX SOLN
3
HI
10 GM/200ML
GAMUNEX-C SOLN 1
3
HI
GM/10ML
GAMUNEX-C SOLN
3
HI
10 GM/100ML
GAMUNEX-C SOLN
3
HI
2.5 GM/25ML
GAMUNEX-C SOLN
3
HI
20 GM/200ML
GAMUNEX-C SOLN
4
HI
40 GM/400ML
GAMUNEX-C SOLN 5
3
HI
GM/50ML
HYPERRAB S/D
3
HYPERRHO S/D
3
HYPERTET S/D
3
Drug Name
DULERA
ESBRIET
FLOVENT DISKUS
FLOVENT HFA AERO
4
MO
110 MCG/ACT
FLOVENT HFA AERO
4
MO
220 MCG/ACT
FLOVENT HFA AERO
3
MO
44 MCG/ACT
GLASSIA
5
KALYDECO
5
PA,NDS
OFEV
5
NDS
ORKAMBI
5
NDS
PROLASTIN-C
5
PULMICORT
FLEXHALER AEPB
3
MO
180 MCG/ACT
PULMICORT
FLEXHALER AEPB 90 4
MO
MCG/ACT
PULMICORT SUSP
4
PA,MO
0.25 MG/2ML
PULMICORT SUSP
4
PA,MO
0.5 MG/2ML
PULMICORT SUSP 1
4
PA,MO
MG/2ML
QVAR
3
MO
SYMBICORT
4
MO
XOLAIR
5
NDS
ZEMAIRA
5
VASODILATING AGENTS
ADEMPAS
5
NDS
LETAIRIS
5
NDS
OPSUMIT
5
NDS
ORENITRAM TBCR
4
LD,NDS
0.125 MG
ORENITRAM TBCR
5
LD,NDS
0.25 MG
ORENITRAM TBCR 1
5
LD,NDS
MG
ORENITRAM TBCR
5
LD,NDS
2.5 MG
REMODULIN
5
PA,LD
TRACLEER
5
NDS
TYVASO
4
PA,LD
UPTRAVI
5
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 49
Drug Name
Drug
Tier
5
3
3
Requirements/
Limits
PA,NDS
Drug Requirements/
Tier
Limits
MENOMUNE
6
MENVEO
6
PEDVAX HIB
6
PROQUAD
6
RABAVERT
6
RECOMBIVAX HB
6
PA
ROTARIX
6
ROTATEQ
6
TRUMENBA
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
AKNE-MYCIN OINT 2
3
MO
%
ALTABAX
4
AVC VAGINAL
3
BACTROBAN
4
BACTROBAN NASAL
3
BENZACLIN
4
MO
BENZAMYCIN
4
MO
benzoyl peroxide2
MO
erythromycin
butoconazole nitrate
2
(one dose)
ciclopirox
2
ciclopirox olamine
2
CLEOCIN CREA 2 %
4
CLEOCIN SUPP 100
3
MG
CLEOCIN-T
4
MO
CLINDAGEL
4
MO
clindamycin phosphate
2
MO
& cleanser
clindamycin phosphate
2
MO
(topical)
clindamycin phosphate
2
vaginal
Drug Name
HYQVIA
IMOGAM RABIES-HT
NABI-HB
OCTAGAM SOLN 1
4
HI
GM/20ML
OCTAGAM SOLN 2
3
HI
GM/20ML
OCTAGAM SOLN 25
3
HI
GM/500ML
OCTAGAM SOLN 5
3
HI
GM/100ML
PRIVIGEN SOLN 20
3
HI
GM/200ML
PRIVIGEN SOLN 40
4
HI
GM/400ML
RHOPHYLAC
3
VARIZIG
6
TOXOIDS
DIPHTHERIATETANUS TOXOIDS
6
DT
QUADRACEL
6
TENIVAC
6
TETANUSDIPHTHERIA
6
TOXOIDS TD
VACCINES
ACTHIB
6
ADACEL
6
BEXSERO
6
BOOSTRIX
6
CERVARIX
6
COMVAX
6
DAPTACEL
6
ENGERIX-B
6
PA
GARDASIL
6
GARDASIL 9
6
HAVRIX
6
HIBERIX
6
IMOVAX RABIES
6
INFANRIX
6
IPOL
6
IXIARO
6
M-M-R II
6
MENACTRA
6
MENHIBRIX
6
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
50 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
clindamycin
phosphate-benzoyl
peroxide
clindamycin
phosphate-benzoyl
peroxide (refrigerate)
CLINDESSE
clotrimazole
clotrimazole (topical)
clotrimazole w/
betamethasone
DENAVIR
DUAC
econazole nitrate
ELIMITE
ERTACZO
ERYGEL GEL 2 %
erythromycin (acne
aid)
EURAX
EVOCLIN
EXELDERM
EXTINA
gentamicin sulfate
(topical)
JUBLIA
KERYDIN
ketoconazole (topical)
KLARON
lindane
LOPROX
LOTRISONE
LUZU
malathion
MENTAX
METROCREAM
METROGEL
METROGEL-VAGINAL
METROLOTION
metronidazole (topical)
metronidazole vaginal
miconazole nitrate
vaginal
mupirocin
mupirocin calcium
2
(topical)
2
MO
naftifine hcl
2
NAFTIFINE HCL
4
2
MO
NAFTIN
4
neomycin/polymyxin b
2
4
gu
2
NIZORAL
4
2
NORITATE
4
NUVESSA
4
2
nystatin (topical)
2
4
ONEXTON
4
MO
4
MO
ORAVIG
4
2
oxiconazole nitrate
2
4
OXISTAT
4
4
permethrin
2
4
MO
selenium sulfide
2
SILVADENE
4
2
MO
silver sulfadiazine
2
4
SOOLANTRA
4
4
MO
sulfacetamide sodium
2
MO
4
(acne)
4
SULFAMYLON CREA
3
85 MG/GM
2
SULFAMYLON PACK
4
4
5%
4
TERAZOL 3
4
2
TERAZOL 7
4
4
MO
terconazole vaginal
2
2
XERESE
4
4
ZOVIRAX TOPICAL
4
4
ANTI-INFLAMMATORY AGENTS (SKIN AND
4
MUCOUS MEMBRANE)
2
alclometasone
2
MO
dipropionate
4
amcinonide
4
2
MO
betamethasone
4
2
MO
dipropionate (topical)
4
betamethasone
4
dipropionate
2
MO
2
augmented
2
betamethasone
2
MO
2
valerate
calcipotriene2
betamethasone
2
MO
dipropionate
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 51
Drug Name
Drug
Tier
3
2
Requirements/
Limits
MO
MO
Drug Requirements/
Tier
Limits
hydrocortisone valerate 2
MO
KENALOG
3
MO
LOCOID
4
MO
mometasone furoate
2
MO
neomycin-fluocinolone 2
MO
nystatin-triamcinolone
2
MO
OLUX FOAM 0.05 %
4
MO
PANDEL
4
MO
prednicarbate
2
MO
SYNALAR (CREAM)
4
MO
TACLONEX OINT
5
0.005-0.064 %
TACLONEX SUSP
4
MO
0.005-0.064 %
TOPICORT
4
MO
TOPICORT SPRAY
4
MO
triamcinolone
2
MO
acetonide (mouth)
triamcinolone
2
MO
acetonide (topical)
UCERIS FOAM
4
MO
ULTRAVATE CREA
4
MO
0.05 %
ULTRAVATE LOTN
5
NDS
0.05 %
ULTRAVATE OINT
4
MO
0.05 %
VANOS
4
MO
ANTIPRURITICS AND LOCAL ANESTHETICS
doxepin hcl
2
MO
(antipruritic)
EMLA
4
PA,MO
lidocaine
2
PA,MO
lidocaine hcl
2
MO
lidocaine-prilocaine
2
PA,MO
LIDOCAINE4
PA
TETRACAINE
LIDODERM
4
PA,MO
PLIAGLIS
4
PA
PRUDOXIN
3
MO
SYNERA
4
PA
ZONALON
3
MO
CELL STIMULANTS AND PROLIFERANTS
ATRALIN GEL 0.05 % 4
PA,MO
KEPIVANCE
5
HI
Drug Name
CAPEX
clobetasol propionate
clobetasol propionate
2
MO
emollient base
CLOBEX LOTN 0.05 % 3
MO
CLOBEX SHAM 0.05
4
MO
%
CLOBEX SPRAY LIQD
3
MO
0.05 %
CLODERM PUMP
4
MO
CORDRAN
3
MO
CORTISPORIN
3
MO
CUTIVATE
4
MO
DERMATOP
4
MO
DESONATE GEL 0.05
3
MO
%
desonide
2
MO
DESOWEN CREA
4
MO
0.05 %
desoximetasone
2
MO
DESOXIMETASONE
4
MO
diflorasone diacetate
2
MO
diflorasone diacetate
2
MO
emollient base
DIPROLENE
4
MO
DIPROLENE AF
4
MO
ELOCON
4
MO
ENSTILAR FOAM
4
MO
0.005-0.064 %
fluocinolone acetonide 2
MO
fluocinonide
2
MO
fluocinonide emulsified
2
MO
base
flurandrenolide
2
MO
fluticasone propionate
2
MO
halobetasol propionate 2
MO,NDS
HALOG
4
MO
hydrocortisone
2
MO
(intrarectal)
hydrocortisone (rectal) 2
MO
hydrocortisone (topical) 2
MO
hydrocortisone
2
MO
butyrate
hydrocortisone
butyrate hydrophilic
2
MO
lipo base
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
52 • Kaiser Permanente 2017 Comprehensive Formulary
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
4
4
3
Requirements/
Limits
MO
MO
MO
RETIN-A CREA 0.025
DOVONEX
3
PA,MO
%
EFUDEX CREA 5 %
RETIN-A CREA 0.05
ELIDEL
3
PA,MO
%
EPIDUO FORTE GEL
4
MO
RETIN-A CREA 0.1 % 3
PA,MO
0.3-2.5 %
RETIN-A GEL 0.01 %
3
PA,MO
EPIDUO GEL 0.1-2.5
3
MO
RETIN-A GEL 0.025 % 3
PA,MO
%
RETIN-A MICRO GEL
FABIOR
4
MO
3
PA,MO
0.04 %
FINACEA FOAM 15 % 4
MO
RETIN-A MICRO GEL
FINACEA GEL 15 %
3
MO
3
PA,MO
0.1 %
FLECTOR
4
PA,MO
RETIN-A MICRO
FLUOROPLEX CREA
4
PA,MO
3
MO
PUMP GEL 0.04 %
1%
RETIN-A MICRO
fluorouracil (topical)
2
MO
4
PA,MO
PUMP GEL 0.08 %
imiquimod
2
MO
RETIN-A MICRO
isotretinoin
2
NDS
4
PA,MO
PUMP GEL 0.1 %
lactic acid (ammonium
2
MO
tretinoin
2
PA,MO,NDS
lactate)
tretinoin microsphere
2
PA,MO
methoxsalen rapid
2
MO
tretinoin w/ cleanser &
MIRVASO
4
MO
2
PA,MO
moisturizer
ORACEA
4
SKIN AND MUCOUS MEMBRANE AGENTS,
OXSORALEN
3
MO
MISCELLANEOUS
OXSORALEN ULTRA
4
MO
8-MOP
3
MO
PANRETIN
5
ABSORICA
4
NDS
PENNSAID
4
MO
acitretin
2
MO
PICATO
4
MO
ACZONE
4
MO
podofilox
2
MO
adapalene
2
MO
PROTOPIC
4
MO
ALDARA
4
MO
RECTIV
4
MO
AZELEX
3
MO
REGRANEX
5
calcipotriene
2
MO
RYNODERM
5
NDS
CALCITRIOL
3
PA,HI,MO
SANTYL
3
MO
CARAC CREA 0.5 %
3
MO
SOLARAZE
4
MO
CONDYLOX
3
MO
SORIATANE
5
COSENTYX
5
NDS
SORILUX
4
MO
COSENTYX
STELARA
5
PA,NDS
5
NDS
SENSOREADY PEN
tacrolimus (topical)
2
MO
diclofenac sodium
TALTZ
5
NDS
2
MO
(actinic keratoses)
TARGRETIN GEL
3
NDS
diclofenac sodium
TAZORAC
3
PA,MO
2
MO
(topical)
TOLAK CREA 4 %
4
DIFFERIN CREA 0.1
UVADEX
4
4
MO
%
VALCHLOR
5
NDS
DIFFERIN GEL 0.1 %
3
MO
VECTICAL
3
MO
DIFFERIN GEL 0.3 %
4
MO
VELTIN
4
MO
DIFFERIN LOTN 0.1 % 4
MO
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
Kaiser Permanente 2017 Comprehensive Formulary • 53
Drug Requirements/
Tier
Limits
VEREGEN
4
MO
VOLTAREN
4
MO
ZIANA
4
MO
ZYCLARA
4
MO
ZYCLARA PUMP
4
MO
SMOOTH MUSCLE RELAXANTS
SMOOTH MUSCLE RELAXANTS
aminophylline
2
HI
darifenacin
2
MO
hydrobromide
DETROL
4
MO
DETROL LA
4
MO
DITROPAN XL
4
MO
ENABLEX
4
MO
flavoxate hcl
2
MO
GELNIQUE
4
MO
MYRBETRIQ
4
MO
Drug Name
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
Drug Name
oxybutynin chloride
OXYTROL
theophylline
tolterodine tartrate
TOVIAZ
trospium chloride
VESICARE
VITAMINS
VITAMINS
calcitriol
doxercalciferol
HECTOROL
paricalcitol
ROCALTROL
VINATE CALCIUM
VP-PNV-DHA
ZEMPLAR
Drug
Tier
2
3
2
2
4
2
4
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
2
2
4
2
4
3
3
4
PA,HI,MO
PA,HI,MO
PA,HI,MO
PA,HI,MO
PA,MO
MO
MO
PA,HI,MO
three-month supply. Please contact us 10 days
before your refills run out. Generally, you should
receive them within 10 days. If not, please contact
the mail-order phone number for your Kaiser
Permanente Region in the chart on page 7 or the
phone number on the prescription label for
assistance. Additional drugs may be available for
mail order. Not all drugs can be mailed; restrictions
and limitations apply. For more information, please
visit kp.org/seniormedrx or call the appropriate
regional phone number on page 7.
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 al apply to drugs for which
treatment for the medical condition will determine if
the drug is non-Part D (excluded) or covered.
You can find information on what the abbreviations on this table mean by going to the beginning or end of this
table.
54 • Kaiser Permanente 2017 Comprehensive Formulary
Index of Drugs
8
8-MOP ..................................................... 53
A
abacavir sulfate ....................................... 11
abacavir sulfate-lamivudine-zidovudine ... 11
ABELCET ................................................ 10
ABILIFY ................................................... 29
ABILIFY MAINTENA ................................ 29
ABRAXANE ............................................. 13
ABSORICA .............................................. 53
ABSTRAL ................................................ 23
acamprosate calcium ............................... 29
ACANYA .................................................. 50
acarbose .................................................. 41
ACCOLATE ............................................. 48
ACCUPRIL .............................................. 20
ACCURETIC............................................ 20
acebutolol hcl........................................... 22
acetaminophen w/ codeine ...................... 23
acetaminophen-caff-dihydrocod............... 23
acetazolamide ......................................... 36
acetazolamide sodium ............................. 36
acetic acid (otic) ....................................... 36
acetylcysteine .......................................... 45
ACIPHEX ................................................. 37
ACIPHEX SPRINKLE .............................. 37
acitretin .................................................... 53
ACTEMRA SOLN 200 MG/10ML ............. 45
ACTEMRA SOLN 400 MG/20ML ............. 45
ACTEMRA SOLN 80 MG/4ML ................. 45
ACTEMRA SOSY 162 MG/0.9ML ............ 45
ACTHIB ................................................... 50
ACTIGALL ............................................... 38
ACTIMMUNE ........................................... 45
ACTIQ ..................................................... 23
ACTIVELLA ............................................. 42
ACTONEL................................................ 45
ACTOPLUS MET ..................................... 41
ACTOPLUS MET XR ............................... 41
ACTOS .................................................... 41
ACULAR .................................................. 35
ACULAR LS............................................. 35
ACUVAIL ................................................. 35
acyclovir ............................................. 11, 50
acyclovir sodium....................................... 11
acyclovir topical ........................................ 50
ACZONE .................................................. 53
ADACEL................................................... 50
ADAGEN .................................................. 34
ADALAT CC ............................................. 19
adapalene ................................................ 53
ADCIRCA ................................................. 21
ADDERALL TABS 10 MG ........................ 25
ADDERALL TABS 15 MG ........................ 25
ADDERALL TABS 30 MG ........................ 25
ADDERALL XR CP24 10 MG................... 25
ADDERALL XR CP24 15 MG................... 25
ADDERALL XR CP24 20 MG................... 25
ADDERALL XR CP24 25 MG................... 25
ADDERALL XR CP24 30 MG................... 25
ADDERALL XR CP24 5 MG..................... 25
adefovir dipivoxil ...................................... 11
ADEMPAS ............................................... 49
ADRENALIN SOLN 1 MG/ML .................. 17
ADVAIR DISKUS ..................................... 17
ADVAIR HFA ........................................... 17
ADZENYS XR-ODT ................................. 25
AEROSPAN ............................................. 48
AFINITOR ................................................ 13
AFINITOR DISPERZ ................................ 13
AFREZZA POWD 4 (30) & 8 (60) UNIT ... 41
AFREZZA POWD 4 (60) & 8 (30) UNIT ... 41
AFREZZA POWD 4 UNIT ........................ 41
AFREZZA POWD 8 (60)& 12 (30) UNIT .. 41
AGGRENOX ............................................ 18
AGRYLIN ................................................. 18
AKNE-MYCIN OINT 2 % .......................... 50
AKYNZEO ................................................ 37
ALBENZA................................................... 8
albuterol sulfate er tb12 4 mg ................... 17
albuterol sulfate er tb12 8 mg ................... 17
albuterol sulfate nebu (2.5 mg/3ml) 0.083%
............................................................. 17
albuterol sulfate nebu (5 mg/ml) 0.5% ...... 17
albuterol sulfate nebu 0.63 mg/3ml .......... 17
albuterol sulfate nebu 1.25 mg/3ml .......... 17
albuterol sulfate syrp 2 mg/5ml ................ 17
albuterol sulfate tabs 2 mg ....................... 17
albuterol sulfate tabs 4 mg ....................... 17
Kaiser Permanente 2017 Comprehensive Formulary • 55
alclometasone dipropionate ..................... 51
alcohol swabs .......................................... 31
ALDACTAZIDE ........................................ 20
ALDACTONE........................................... 20
ALDARA .................................................. 53
ALDURAZYME ........................................ 34
ALECENSA ............................................. 13
alendronate sodium soln 70 mg/75ml ...... 45
alendronate sodium tabs 10 mg............... 45
alendronate sodium tabs 35 mg............... 45
alendronate sodium tabs 40 mg............... 45
alendronate sodium tabs 5 mg................. 45
alendronate sodium tabs 70 mg............... 45
alfuzosin hcl ............................................. 17
ALIMTA ................................................... 13
ALINIA ..................................................... 10
ALKERAN SOLR 50 MG ......................... 13
allopurinol ................................................ 45
almotriptan malate ................................... 27
ALOCRIL ................................................. 36
alogliptin benzoate ................................... 41
ALOGLIPTIN-METFORMIN HCL ............. 41
alogliptin-pioglitazone .............................. 41
ALOMIDE ................................................ 36
ALOPRIM ................................................ 45
ALORA PTTW 0.025 MG/24HR............... 42
ALORA PTTW 0.05 MG/24HR................. 42
ALORA PTTW 0.075 MG/24HR............... 42
ALORA PTTW 0.1 MG/24HR................... 42
alosetron hcl ............................................ 36
ALOXI ...................................................... 37
ALPHAGAN P.......................................... 36
alprazolam ............................................... 28
ALREX ..................................................... 35
ALTABAX ................................................ 50
ALTACE .................................................. 20
ALTOPREV ............................................. 19
ALVESCO................................................ 48
amantadine hcl ........................................ 28
AMARYL .................................................. 41
AMBIEN ................................................... 28
AMBIEN CR............................................. 28
AMBISOME ............................................. 10
amcinonide .............................................. 51
AMERGE ................................................. 27
AMICAR .................................................. 18
amifostine crystalline ............................... 45
amikacin sulfate ......................................... 8
amiloride & hydrochlorothiazide ............... 32
amiloride hcl ............................................. 32
amino acid electrolyte infusion ................. 31
amino acid infusion .................................. 31
aminophylline ........................................... 54
aminosalicylic acid ................................... 10
AMINOSYN II SOLN 10 % ....................... 31
AMINOSYN II SOLN 15 % ....................... 32
AMINOSYN II SOLN 7 % ......................... 32
AMINOSYN II SOLN 8.5 % ...................... 32
AMINOSYN/ELECTROLYTES SOLN 7 %
............................................................. 32
AMINOSYN-HBC SOLN 7 % ................... 32
AMINOSYN-PF SOLN 10 % .................... 32
AMINOSYN-PF SOLN 7 % ...................... 32
AMINOSYN-RF SOLN 5.2 % ................... 32
amiodarone hcl ........................................ 20
AMITIZA ................................................... 38
amitriptyline hcl ........................................ 29
amlodipine besylate ................................. 19
amlodipine besylate-atorvastatin calcium . 19
amlodipine besylate-benazepril hcl .......... 19
amlodipine besylate-valsartan .................. 19
amlodipine-valsartan-hydrochlorothiazide 19
ammonium chloride .................................. 31
amoxapine ............................................... 29
amoxicillin ............................................ 8, 37
amoxicillin & pot clavulanate ...................... 8
amoxicillin-clarithromycin w/ lansoprazole 37
amphetamine sulfate ................................ 25
amphetamine-dextroamphetamine ........... 25
amphotericin b ......................................... 10
ampicillin .................................................... 8
ampicillin & sulbactam sodium ................... 8
ampicillin sodium ........................................ 8
AMPYRA .................................................. 45
AMRIX ..................................................... 17
ANADROL-50 .......................................... 39
ANAFRANIL ............................................. 29
anagrelide hcl ........................................... 18
ANAPROX DS ......................................... 23
anastrozole .............................................. 13
ANCOBON ............................................... 10
ANDRODERM PT24 2 MG/24HR ............ 39
ANDRODERM PT24 4 MG/24HR ............ 39
ANDROGEL GEL 20.25 MG/1.25GM
(1.62%) ................................................. 39
ANDROGEL GEL 25 MG/2.5GM (1%) ..... 39
ANDROGEL GEL 40.5 MG/2.5GM (1.62%)
............................................................. 39
56 • Kaiser Permanente 2017 Comprehensive Formulary
ANDROGEL GEL 50 MG/5GM (1%) ....... 39
ANDROGEL PUMP GEL 20.25 MG/ACT
(1.62%) ................................................ 40
ANGELIQ................................................. 42
ANORO ELLIPTA .................................... 16
ANTARA .................................................. 19
ANZEMET ............................................... 37
APIDRA ................................................... 41
APIDRA SOLOSTAR ............................... 41
APLENZIN ............................................... 29
APOKYN.................................................. 28
apraclonidine hcl ...................................... 36
APRISO CP24 0.375 GM ........................ 36
APTENSIO XR CP24 10 MG ................... 25
APTENSIO XR CP24 15 MG ................... 25
APTENSIO XR CP24 20 MG ................... 25
APTENSIO XR CP24 30 MG ................... 25
APTENSIO XR CP24 40 MG ................... 25
APTENSIO XR CP24 50 MG ................... 25
APTENSIO XR CP24 60 MG ................... 25
APTIOM ................................................... 26
APTIVUS ................................................. 11
ARALAST NP .......................................... 48
ARANESP (ALBUMIN FREE) .................. 18
ARAVA .................................................... 45
ARCALYST.............................................. 45
ARCAPTA NEOHALER ........................... 17
argatroban ............................................... 18
ARGATROBAN ....................................... 18
ARICEPT ................................................. 16
ARIMIDEX ............................................... 13
aripiprazole .............................................. 29
ARISTADA............................................... 29
ARISTOSPAN INTRA-ARTICULAR ........ 39
ARISTOSPAN INTRALESIONAL ............ 39
ARIXTRA ................................................. 18
armodafinil ............................................... 25
ARNUITY ELLIPTA.................................. 48
AROMASIN ............................................. 13
ARRANON............................................... 13
ARTHROTEC .......................................... 23
ARZERRA ............................................... 13
ASACOL HD TBEC 800 MG .................... 36
ASMANEX 120 METERED DOSES AEPB
220 MCG/INH ...................................... 48
ASMANEX 30 METERED DOSES AEPB
110 MCG/INH ...................................... 48
ASMANEX 30 METERED DOSES AEPB
220 MCG/INH ...................................... 48
ASMANEX 60 METERED DOSES AEPB
220 MCG/INH ....................................... 48
ASMANEX HFA AERO 100 MCG/ACT .... 48
ASMANEX HFA AERO 200 MCG/ACT .... 48
aspirin-dipyridamole ................................. 18
ASTAGRAF XL CP24 0.5 MG .................. 45
ASTAGRAF XL CP24 1 MG ..................... 45
ASTAGRAF XL CP24 5 MG ..................... 45
ASTEPRO ................................................ 36
ATACAND ................................................ 21
ATACAND HCT ....................................... 21
ATELVIA .................................................. 45
atenolol .................................................... 22
atenolol & chlorthalidone .......................... 22
ATGAM .................................................... 45
ATIVAN .................................................... 28
atorvastatin calcium ................................. 19
atovaquone .............................................. 10
atovaquone-proguanil hcl ......................... 10
ATRALIN GEL 0.05 %.............................. 52
ATRIPLA .................................................. 11
atropine sulfate .................................. 16, 36
ATROPINE SULFATE.............................. 16
atropine sulfate (ophthalmic) .................... 36
ATROVENT ............................................. 16
ATROVENT HFA ..................................... 16
AUBAGIO................................................. 45
AUGMENTIN ............................................. 8
AURYXIA ................................................. 33
AUVI-Q SOAJ 0.3 MG/0.3ML ................... 17
AVALIDE .................................................. 21
AVANDIA ................................................. 41
AVAPRO .................................................. 21
AVASTIN.................................................. 13
AVC VAGINAL ......................................... 50
AVEED ..................................................... 40
AVELOX..................................................... 8
AVELOX ABC PACK.................................. 8
AVELOX SOLN .......................................... 8
AVINZA .................................................... 23
AVODART................................................ 45
AVONEX .................................................. 45
AVONEX PEN.......................................... 45
AVONEX PREFILLED.............................. 45
AVYCAZ..................................................... 8
AXERT ..................................................... 27
AXIRON SOLN 30 MG/ACT ..................... 40
azacitidine ................................................ 13
AZACTAM IN DEXTROSE ......................... 8
Kaiser Permanente 2017 Comprehensive Formulary • 57
AZASITE.................................................. 34
azathioprine ............................................. 46
azathioprine sodium................................. 46
azelastine hcl ........................................... 36
azelastine hcl (ophth)............................... 36
AZELEX ................................................... 53
AZILECT .................................................. 28
azithromycin .............................................. 8
AZITHROMYCIN PACK 1 GM ................... 8
AZOPT .................................................... 36
AZOR ...................................................... 19
aztreonam.................................................. 8
AZULFIDINE.............................................. 8
AZULFIDINE EN-TABS ............................. 8
B
bacitracin ....................................... 8, 34, 35
bacitracin (ophthalmic) ............................. 34
bacitracin-polymyxin b (ophth) ................. 34
bacitracin-poly-neomycin-hc .................... 35
baclofen ................................................... 17
BACTOCILL IN DEXTROSE...................... 8
BACTRIM .................................................. 8
BACTRIM DS ............................................ 8
BACTROBAN .......................................... 50
BACTROBAN NASAL.............................. 50
balsalazide disodium ............................... 36
BANZEL .................................................. 26
BARACLUDE SOLN 0.05 MG/ML ........... 11
BARACLUDE TABS 0.5 MG .................... 11
BARACLUDE TABS 1 MG ....................... 11
BCG VACCINE ........................................ 13
BECONASE AQ ...................................... 35
BELBUCA ................................................ 23
BELEODAQ ............................................. 13
BELSOMRA............................................. 28
benazepril & hydrochlorothiazide ............. 21
benazepril hcl .......................................... 21
BENDEKA SOLN 100 MG/4ML ............... 13
BENICAR................................................. 21
BENICAR HCT ........................................ 21
BENLYSTA .............................................. 46
BENTYL .................................................. 16
BENZACLIN ............................................ 50
BENZAMYCIN ......................................... 50
benzoyl peroxide-erythromycin ................ 50
benztropine mesylate............................... 28
BEPREVE................................................ 36
BERINERT .............................................. 46
BESIVANCE ............................................ 34
BETAGAN ................................................ 36
betamethasone dipropionate (topical) ...... 51
betamethasone dipropionate augmented . 51
betamethasone valerate ........................... 51
BETAPACE .............................................. 22
BETASERON KIT 0.3 MG ........................ 46
betaxolol hcl ....................................... 22, 36
betaxolol hcl (ophth) ................................. 36
bethanechol chloride ................................ 16
BETHKIS.................................................... 8
BETIMOL ................................................. 36
BETOPTIC-S ........................................... 36
BEXAROTENE ........................................ 13
BEXSERO................................................ 50
BEYAZ ..................................................... 40
BIAXIN ....................................................... 8
bicalutamide ............................................. 13
BICILLIN C-R ............................................. 8
BICILLIN C-R 900/300 ............................... 8
BICILLIN L-A .............................................. 8
BICNU ...................................................... 13
BIDIL ........................................................ 21
BILTRICIDE ............................................... 8
bimatoprost .............................................. 36
BINOSTO ................................................. 46
bisacodyl-peg 3350-pot chloride-sod bicarbsod chloride .......................................... 38
bisoprolol & hydrochlorothiazide .............. 22
bisoprolol fumarate................................... 22
BIVIGAM SOLN 10 GM/100ML ................ 49
bleomycin sulfate ..................................... 13
BLEPH-10 ................................................ 34
BLEPHAMIDE .......................................... 35
BLINCYTO ............................................... 13
BONIVA ................................................... 46
BOOSTRIX .............................................. 50
BOSULIF.................................................. 13
BOTOX SOLR 100 UNIT ......................... 46
BOTOX SOLR 200 UNIT ......................... 46
BREO ELLIPTA ....................................... 39
BREVICON (28) ....................................... 40
BRILINTA ................................................. 18
brimonidine tartrate .................................. 36
BRINTELLIX ............................................ 29
BRISDELLE ............................................. 29
BRIVIACT SOLN 10 MG/ML .................... 26
BRIVIACT SOLN 50 MG/5ML .................. 26
BRIVIACT TABS 10 MG .......................... 26
58 • Kaiser Permanente 2017 Comprehensive Formulary
BRIVIACT TABS 100 MG ........................ 26
BRIVIACT TABS 25 MG .......................... 26
BRIVIACT TABS 50 MG .......................... 26
BRIVIACT TABS 75 MG .......................... 26
bromfenac sodium (ophth) ....................... 35
bromocriptine mesylate............................ 28
BROVANA ............................................... 17
budesonide .................................. 35, 39, 48
budesonide (inhalation) ........................... 48
budesonide (nasal) .................................. 35
bumetanide soln 0.25 mg/ml .................... 32
bumetanide tabs 0.5 mg .......................... 32
bumetanide tabs 1 mg ............................. 32
bumetanide tabs 2 mg ............................. 32
BUNAVAIL ............................................... 29
BUPHENYL ............................................. 31
BUPRENEX ............................................. 23
buprenorphine hcl .............................. 23, 29
buprenorphine hcl-naloxone hcl dihydrate 29
bupropion hcl ........................................... 29
bupropion hcl (smoking deterrent) ........... 29
buspirone hcl ........................................... 28
BUSULFEX.............................................. 13
butalbital-acetaminophen......................... 23
butalbital-acetaminophen-caffeine ........... 23
butalbital-acetaminophen-caffeine w/
codeine ................................................ 23
butalbital-aspirin-caffeine ......................... 23
butalbital-aspirin-caffeine w/cod............... 23
BUTISOL SODIUM .................................. 28
butoconazole nitrate (one dose) .............. 50
butorphanol tartrate ................................. 23
BUTRANS ............................................... 23
BYDUREON ............................................ 41
BYETTA 10 MCG PEN ............................ 41
BYETTA 5 MCG PEN .............................. 41
BYSTOLIC ............................................... 22
C
cabergoline .............................................. 28
CABOMETYX .......................................... 13
CADUET .................................................. 19
CALAN .................................................... 19
CALAN SR............................................... 19
calcipotriene ...................................... 51, 53
calcipotriene-betamethasone dipropionate
............................................................. 51
calcitonin (salmon) ................................... 43
calcitriol ................................................... 54
CALCITRIOL ............................................ 53
calcium acetate (phosphate binder) ......... 33
CAMBIA ................................................... 23
CAMPTOSAR .......................................... 13
CANASA SUPP 1000 MG ........................ 37
CANCIDAS .............................................. 10
candesartan cilexetil................................. 21
candesartan cilexetil-hydrochlorothiazide. 21
CAPASTAT SULFATE ............................. 10
CAPEX ..................................................... 52
CAPRELSA .............................................. 13
captopril ................................................... 21
captopril & hydrochlorothiazide ................ 21
CARAC CREA 0.5 % ............................... 53
CARAFATE SUSP 1 GM/10ML ................ 37
CARAFATE TABS 1 GM .......................... 37
CARBAGLU ............................................. 31
carbamazepine ........................................ 26
CARBATROL ........................................... 26
carbidopa ................................................. 28
carbidopa-levodopa.................................. 28
carbidopa-levodopa-entacapone .............. 28
carbinoxamine maleate ............................ 13
carboplatin ............................................... 13
CARDENE IV ........................................... 19
CARDIZEM .............................................. 19
CARDIZEM CD ........................................ 19
CARDIZEM LA ......................................... 19
CARDURA ............................................... 18
CARDURA XL .......................................... 18
CARIMUNE NF SOLR 12 GM .................. 49
CARIMUNE NF SOLR 6 GM .................... 49
carisoprodol ............................................. 17
carisoprodol w/ aspirin ............................. 17
carisoprodol w/ aspirin & codeine ............. 17
CARNITOR .............................................. 46
carteolol hcl (ophth).................................. 36
carvedilol .................................................. 22
CASODEX ............................................... 13
CATAPRES.............................................. 20
CATAPRES-TTS-1................................... 20
CATAPRES-TTS-2................................... 20
CATAPRES-TTS-3................................... 20
CAYSTON.................................................. 8
CEDAX....................................................... 8
cefaclor ...................................................... 8
cefaclor monohydrate................................. 8
cefadroxil.................................................... 8
cefazolin sodium ........................................ 8
Kaiser Permanente 2017 Comprehensive Formulary • 59
cefdinir ....................................................... 8
cefepime hcl .............................................. 8
cefixime ..................................................... 8
cefotaxime sodium ..................................... 8
cefotetan disodium..................................... 8
cefoxitin sodium ......................................... 8
CEFOXITIN SODIUM-DEXTROSE ........... 8
cefpodoxime proxetil .................................. 8
cefprozil ..................................................... 8
ceftazidime ................................................ 8
CEFTAZIDIME AND DEXTROSE.............. 8
CEFTIN SUSR 125 MG/5ML ..................... 8
CEFTIN SUSR 250 MG/5ML ..................... 8
CEFTIN TABS 250 MG.............................. 8
CEFTIN TABS 500 MG.............................. 8
ceftriaxone sodium..................................... 8
cefuroxime axetil ........................................ 8
cefuroxime sodium..................................... 8
CEFUROXIME-DEXTROSE ...................... 8
CELEBREX ............................................. 23
celecoxib ................................................. 23
CELESTONE ........................................... 39
CELEXA .................................................. 29
CELLCEPT .............................................. 46
CELLCEPT INTRAVENOUS ................... 46
CELONTIN .............................................. 26
cephalexin ................................................. 8
CERDELGA ............................................. 46
CEREBYX ............................................... 26
CEREZYME............................................. 34
CERVARIX .............................................. 50
CESAMET ............................................... 37
cetirizine hcl ............................................. 13
cevimeline hcl .......................................... 16
CHANTIX ................................................. 16
CHANTIX CONTINUING MONTH PAK ... 16
CHANTIX STARTING MONTH PAK ........ 16
CHEMET ................................................. 39
chenodiol ................................................. 38
chloramphenicol sodium succinate ............ 8
chlordiazepoxide hcl ................................ 28
chlordiazepoxide-amitriptyline.................. 29
chlorhexidine gluconate (mouth-throat).... 34
chloroquine phosphate ............................ 10
chlorothiazide .......................................... 32
chlorothiazide sodium .............................. 32
chlorpromazine hcl................................... 29
chlorpropamide ........................................ 41
chlorthalidone .......................................... 32
chlorzoxazone .......................................... 17
CHOLBAM ............................................... 38
cholestyramine ......................................... 19
cholestyramine light ................................. 19
choline fenofibrate .................................... 19
chorionic gonadotropin ............................. 43
CIALIS ..................................................... 21
ciclopirox .................................................. 50
ciclopirox olamine..................................... 50
cidofovir.................................................... 11
cilostazol .................................................. 18
CILOXAN OINT 0.3 %.............................. 34
CILOXAN SOLN 0.3 % ............................ 34
cimetidine ................................................. 37
cimetidine hcl ........................................... 37
CIMZIA ..................................................... 46
CIMZIA PREFILLED ................................ 46
CINQAIR .................................................. 48
CINRYZE ................................................. 46
CIPRO ................................................. 8, 35
CIPRO HC ............................................... 35
CIPRO IN D5W .......................................... 8
CIPRODEX .............................................. 35
ciprofloxacin ......................................... 8, 34
ciprofloxacin hcl ................................... 8, 34
ciprofloxacin hcl (ophth) ........................... 34
ciprofloxacin in d5w .................................... 8
ciprofloxacin-ciprofloxacin hcl..................... 8
cisplatin .................................................... 13
citalopram hydrobromide soln 10 mg/5ml . 29
citalopram hydrobromide tabs 10 mg ....... 29
citalopram hydrobromide tabs 20 mg ....... 29
citalopram hydrobromide tabs 40 mg ....... 29
cladribine.................................................. 13
CLAFORAN ............................................... 8
CLARINEX ............................................... 13
CLARINEX-D 12 HOUR ........................... 13
clarithromycin ............................................. 8
clemastine fumarate ................................. 13
CLEOCIN ............................................. 8, 50
CLEOCIN CREA 2 % ............................... 50
CLEOCIN IN D5W...................................... 8
CLEOCIN PHOSPHATE ............................ 8
CLEOCIN SUPP 100 MG ......................... 50
CLEOCIN-T.............................................. 50
CLEVIPREX ............................................. 19
CLIMARA PRO ........................................ 42
CLIMARA PTWK 0.025 MG/24HR ........... 42
CLIMARA PTWK 0.0375 MG/24HR ......... 43
60 • Kaiser Permanente 2017 Comprehensive Formulary
CLIMARA PTWK 0.05 MG/24HR ............. 43
CLIMARA PTWK 0.06 MG/24HR ............. 43
CLIMARA PTWK 0.075 MG/24HR ........... 43
CLIMARA PTWK 0.1 MG/24HR............... 43
CLINDAGEL ............................................ 50
clindamycin hcl .......................................... 8
clindamycin palmitate hydrochloride .......... 8
clindamycin phosphate .................. 9, 50, 51
clindamycin phosphate & cleanser .......... 50
clindamycin phosphate (topical)............... 50
clindamycin phosphate in d5w ................... 9
clindamycin phosphate vaginal ................ 50
clindamycin phosphate-benzoyl peroxide 51
clindamycin phosphate-benzoyl peroxide
(refrigerate) .......................................... 51
CLINDESSE ............................................ 51
CLINIMIX E/DEXTROSE (2.75/10) .......... 32
CLINIMIX E/DEXTROSE (2.75/5) ............ 32
CLINIMIX E/DEXTROSE (4.25/10) .......... 32
CLINIMIX E/DEXTROSE (4.25/25) .......... 32
CLINIMIX E/DEXTROSE (4.25/5) ............ 32
CLINIMIX E/DEXTROSE (5/15) ............... 32
CLINIMIX E/DEXTROSE (5/20) ............... 32
CLINIMIX E/DEXTROSE (5/25) ............... 32
CLINIMIX/DEXTROSE (2.75/5) ............... 32
CLINIMIX/DEXTROSE (4.25/10) ............. 32
CLINIMIX/DEXTROSE (4.25/20) ............. 32
CLINIMIX/DEXTROSE (4.25/25) ............. 32
CLINIMIX/DEXTROSE (4.25/5) ............... 32
CLINIMIX/DEXTROSE (5/15) .................. 32
CLINIMIX/DEXTROSE (5/20) .................. 32
CLINIMIX/DEXTROSE (5/25) .................. 32
clobetasol propionate............................... 52
clobetasol propionate emollient base ....... 52
CLOBEX LOTN 0.05 % ........................... 52
CLOBEX SHAM 0.05 %........................... 52
CLOBEX SPRAY LIQD 0.05 %................ 52
CLODERM PUMP ................................... 52
CLOLAR .................................................. 13
clomipramine hcl ...................................... 29
clonazepam ............................................. 26
clonidine & chlorthalidone ........................ 20
clonidine hcl ............................................. 20
clonidine hcl (adhd).................................. 20
clopidogrel bisulfate ................................. 18
clorazepate dipotassium .......................... 28
clotrimazole ............................................. 51
clotrimazole (topical) ................................ 51
clotrimazole w/ betamethasone ............... 51
clozapine .................................................. 29
CLOZARIL ............................................... 29
COARTEM ............................................... 10
CODEINE SULFATE................................ 23
COGENTIN .............................................. 28
colchicine ........................................... 34, 46
COLCHICINE CAPS 0.6 MG.................... 46
colchicine w/ probenecid .......................... 34
COLCRYS TABS 0.6 MG ......................... 46
COLESTID ............................................... 19
colestipol hcl ............................................ 19
colistimethate sodium................................. 9
COLY-MYCIN S ....................................... 35
COLYTE WITH FLAVOR PACKS ............ 38
COMBIGAN ............................................. 36
COMBIPATCH ......................................... 43
COMBIVENT RESPIMAT AERS 20-100
MCG/ACT ............................................. 17
COMBIVIR ............................................... 11
COMETRIQ (100 MG DAILY DOSE) ....... 13
COMETRIQ (140 MG DAILY DOSE) ....... 13
COMETRIQ (60 MG DAILY DOSE) ......... 13
COMPLERA ............................................. 11
COMTAN ................................................. 28
COMVAX ................................................. 50
CONCERTA TBCR 18 MG....................... 25
CONCERTA TBCR 27 MG....................... 25
CONCERTA TBCR 36 MG....................... 25
CONCERTA TBCR 54 MG....................... 25
CONDYLOX ............................................. 53
CONZIP ................................................... 23
COPAXONE............................................. 46
COPEGUS ............................................... 11
CORDRAN ............................................... 52
COREG .................................................... 22
COREG CR.............................................. 22
CORGARD............................................... 22
CORLANOR............................................. 20
CORTEF .................................................. 39
cortisone acetate ...................................... 39
CORTISPORIN .................................. 35, 52
CORTISPORIN-TC .................................. 35
CORZIDE ................................................. 22
COSENTYX ............................................. 53
COSENTYX SENSOREADY PEN ........... 53
COSMEGEN ............................................ 13
COSOPT .................................................. 36
COTELLIC ............................................... 13
COUMADIN ............................................. 18
Kaiser Permanente 2017 Comprehensive Formulary • 61
COZAAR.................................................. 21
CREON CPEP 12000 UNIT ..................... 38
CREON CPEP 24000 UNIT ..................... 38
CREON CPEP 3000-9500 UNIT.............. 38
CREON CPEP 36000 UNIT ..................... 38
CREON CPEP 6000 UNIT ....................... 38
CRESEMBA ............................................ 10
CRESTOR ............................................... 19
CRINONE ................................................ 44
CRIXIVAN................................................ 11
cromolyn sodium ............................... 36, 48
cromolyn sodium (mastocytosis).............. 48
cromolyn sodium (ophth) ......................... 36
CUBICIN .................................................... 9
CUPRIMINE CAPS 250 MG .................... 39
CUTIVATE ............................................... 52
CUVPOSA SOLN 1 MG/5ML ................... 16
CYCLESSA ............................................. 40
cyclobenzaprine hcl ................................. 17
CYCLOPHOSPHAMIDE .......................... 13
CYCLOSET ............................................. 41
cyclosporine............................................. 46
cyclosporine modified (for microemulsion)46
CYKLOKAPRON ..................................... 18
CYMBALTA ............................................. 29
cyproheptadine hcl .................................. 13
CYRAMZA ............................................... 13
CYSTADANE ........................................... 46
CYSTAGON CAPS 150 MG .................... 46
CYSTAGON CAPS 50 MG ...................... 46
CYSTARAN ............................................. 36
cytarabine ................................................ 13
CYTOGAM .............................................. 49
CYTOMEL ............................................... 45
CYTOTEC ............................................... 37
CYTOVENE ............................................. 11
D
dacarbazine ............................................. 13
DACOGEN .............................................. 13
DAKLINZA ............................................... 11
DALIRESP ............................................... 48
DALVANCE ............................................... 9
danazol .................................................... 40
DANTRIUM.............................................. 17
dantrolene sodium ................................... 17
dapsone ................................................... 10
DAPTACEL.............................................. 50
DARAPRIM.............................................. 10
darifenacin hydrobromide ......................... 54
DARZALEX .............................................. 13
daunorubicin hcl ....................................... 13
DAYPRO .................................................. 23
DAYTRANA ............................................. 25
DDAVP............................................... 43, 44
DDAVP RHINAL TUBE ............................ 43
DDAVP SOLN 4 MCG/ML ........................ 43
DDAVP TABS 0.1 MG.............................. 43
DDAVP TABS 0.2 MG.............................. 44
decitabine................................................. 13
DELESTROGEN ...................................... 43
DELZICOL CPDR 400 MG ....................... 37
DEMADEX ............................................... 32
demeclocycline hcl ..................................... 9
DEMEROL ............................................... 23
DEMSER.................................................. 46
DENAVIR ................................................. 51
DEPACON ............................................... 26
DEPAKENE ............................................. 26
DEPAKOTE ............................................. 26
DEPAKOTE ER ....................................... 26
DEPAKOTE SPRINKLES ........................ 26
DEPEN TITRATABS TABS 250 MG ........ 39
DEPO-MEDROL SUSP 20 MG/ML .......... 39
DEPO-MEDROL SUSP 40 MG/ML .......... 39
DEPO-MEDROL SUSP 80 MG/ML .......... 39
DEPO-PROVERA .................................... 44
DEPO-PROVERA SUSP 150 MG/ML ...... 44
DEPO-SUBQ PROVERA 104 SUSP 104
MG/0.65ML ........................................... 44
DERMATOP ............................................. 52
DESCOVY ............................................... 11
desipramine hcl ........................................ 29
desloratadine ........................................... 13
desmopressin acetate .............................. 44
desmopressin acetate refrigerated ........... 44
desmopressin acetate spray refrigerated . 44
DESOGEN ............................................... 40
desogestrel & ethinyl estradiol ................. 40
desogestrel-ethinyl estradiol (biphasic) .... 40
desogestrel-ethinyl estradiol (triphasic) .... 40
DESONATE GEL 0.05 % ......................... 52
desonide .................................................. 52
DESOWEN CREA 0.05 %........................ 52
desoximetasone ....................................... 52
DESOXIMETASONE ............................... 52
DESOXYN ............................................... 25
DESVENLAFAXINE ER ........................... 29
62 • Kaiser Permanente 2017 Comprehensive Formulary
DETROL .................................................. 54
DETROL LA............................................. 54
dexamethasone ................................. 35, 39
dexamethasone sodium phosphate ... 35, 39
dexamethasone sodium phosphate (ophth)
............................................................. 35
DEXEDRINE............................................ 25
DEXILANT ............................................... 37
dexmethylphenidate hcl ........................... 25
dexrazoxane ............................................ 46
dextroamphetamine sulfate ..................... 25
dextrose ............................................. 32, 33
DEXTROSE 5%/ELECTROLYTE #48 ..... 33
dextrose in lactated ringers ...................... 33
dextrose w/ sodium chloride .................... 33
DEXTROSE-NACL SOLN 10-0.2 % ........ 33
DEXTROSE-NACL SOLN 10-0.45 % ...... 33
DEXTROSE-NACL SOLN 5-0.225 % ...... 33
DIAMOX SEQUELS................................. 36
DIASTAT ACUDIAL ................................. 28
DIASTAT PEDIATRIC ............................. 28
diazepam ................................................. 28
diazepam (anticonvulsant) ....................... 28
DIBENZYLINE ......................................... 17
diclofenac potassium ............................... 23
diclofenac sodium ........................ 23, 35, 53
diclofenac sodium (actinic keratoses) ...... 53
diclofenac sodium (ophth) ........................ 35
diclofenac sodium (topical) ...................... 53
diclofenac w/ misoprostol ......................... 23
dicloxacillin sodium .................................... 9
dicyclomine hcl ........................................ 16
didanosine ............................................... 11
DIFFERIN CREA 0.1 % ........................... 53
DIFFERIN GEL 0.1 % .............................. 53
DIFFERIN GEL 0.3 % .............................. 53
DIFFERIN LOTN 0.1 % ........................... 53
DIFICID ..................................................... 9
diflorasone diacetate................................ 52
diflorasone diacetate emollient base ........ 52
DIFLUCAN............................................... 10
diflunisal .................................................. 23
digoxin ..................................................... 20
DIGOXIN SOLN 0.05 MG/ML .................. 20
dihydroergotamine mesylate .................... 17
DILANTIN ................................................ 26
DILAUDID ................................................ 23
diltiazem hcl ............................................. 19
diltiazem hcl coated beads ...................... 19
diltiazem hcl extended release beads ...... 19
DIOVAN ................................................... 21
DIOVAN HCT ........................................... 21
DIPENTUM .............................................. 37
diphenhydramine hcl ................................ 13
diphenoxylate w/ atropine ........................ 37
DIPHTHERIA-TETANUS TOXOIDS DT ... 50
DIPROLENE ............................................ 52
DIPROLENE AF ....................................... 52
dipyridamole ............................................. 21
disopyramide phosphate .......................... 20
disulfiram.................................................. 46
DITROPAN XL ......................................... 54
DIURIL ..................................................... 32
divalproex sodium .................................... 26
DIVIGEL GEL 0.5 MG/0.5GM .................. 43
DOCEFREZ SOLR 20 MG ....................... 13
DOCETAXEL (NON-ALCOHOL) SOLN 160
MG/8ML................................................ 13
DOCETAXEL (NON-ALCOHOL) SOLN 20
MG/ML.................................................. 13
DOCETAXEL (NON-ALCOHOL) SOLN 80
MG/4ML................................................ 14
DOCETAXEL CONC 20 MG/0.5ML ......... 14
DOCETAXEL CONC 80 MG/2ML ............ 14
DOCETAXEL CONC 80 MG/4ML ............ 14
DOCETAXEL SOLN 80 MG/8ML ............. 14
dofetilide................................................... 20
DOLOPHINE TABS 10 MG ...................... 23
DOLOPHINE TABS 5 MG ........................ 23
donepezil hydrochloride ........................... 16
DORIBAX ................................................... 9
dorzolamide hcl ........................................ 36
dorzolamide hcl-timolol maleate ............... 36
DOVONEX ............................................... 53
doxazosin mesylate.................................. 18
doxepin hcl ......................................... 29, 52
doxepin hcl (antipruritic) ........................... 52
doxercalciferol .......................................... 54
DOXIL ...................................................... 14
doxorubicin hcl ......................................... 14
doxorubicin hcl liposomal ......................... 14
doxycycline (monohydrate) ........................ 9
doxycycline hyclate .................................... 9
dronabinol ................................................ 37
drospirenone-ethinyl estradiol .................. 40
DROXIA ................................................... 14
DUAC ....................................................... 51
DUAVEE .................................................. 43
Kaiser Permanente 2017 Comprehensive Formulary • 63
DUETACT................................................ 41
DUEXIS ................................................... 23
DULERA .................................................. 49
duloxetine hcl........................................... 29
DUONEB SOLN 0.5-2.5 (3) MG/3ML ...... 17
DUOPA .................................................... 28
DURAGESIC-100 .................................... 23
DURAGESIC-12 ...................................... 23
DURAGESIC-25 ...................................... 23
DURAGESIC-50 ...................................... 23
DURAGESIC-75 ...................................... 23
DUREZOL ............................................... 35
DURLAZA ................................................ 18
dutasteride ............................................... 46
dutasteride-tamsulosin hcl ....................... 46
DUTOPROL............................................. 22
DYANAVEL XR ....................................... 25
DYAZIDE ................................................. 32
DYMISTA................................................. 36
DYRENIUM ............................................. 32
DYSPORT ............................................... 46
E
E.E.S. GRANULES .................................... 9
EC-NAPROSYN ...................................... 23
econazole nitrate ..................................... 51
EDARBI ................................................... 21
EDARBYCLOR ........................................ 21
EDECRIN ................................................ 32
EDLUAR .................................................. 28
EDURANT ............................................... 11
EFFEXOR XR.......................................... 29
EFFIENT.................................................. 18
EFUDEX CREA 5 % ................................ 53
EGRIFTA ................................................. 44
ELAPRASE.............................................. 34
ELDEPRYL .............................................. 28
ELELYSO ................................................ 34
ELESTAT................................................. 36
ELESTRIN GEL 0.52 MG/0.87 GM (0.06%)
............................................................. 43
ELIDEL .................................................... 53
ELIGARD KIT 22.5 MG............................ 14
ELIGARD KIT 30 MG............................... 14
ELIGARD KIT 45 MG............................... 14
ELIGARD KIT 7.5 MG.............................. 14
ELIMITE .................................................. 51
ELIQUIS .................................................. 18
ELITEK SOLR 1.5 MG ............................. 34
ELITEK SOLR 7.5 MG ............................. 34
ELLA ........................................................ 40
ELLENCE................................................. 14
ELMIRON................................................. 46
ELOCON .................................................. 52
ELSPAR ................................................... 14
EMADINE................................................. 36
EMBEDA .................................................. 23
EMCYT .................................................... 14
EMEND .................................................... 37
EMEND CAPS 125 MG ............................ 37
EMEND CAPS 40 MG .............................. 37
EMEND CAPS 80 & 125 MG ................... 37
EMEND CAPS 80 MG .............................. 37
EMLA ....................................................... 52
EMPLICITI ............................................... 14
EMSAM .................................................... 28
EMTRIVA ................................................. 11
ENABLEX ................................................ 54
enalapril maleate ...................................... 21
enalapril maleate & hydrochlorothiazide... 21
ENBREL................................................... 46
ENBREL SURECLICK ............................. 46
ENGERIX-B ............................................. 50
enoxaparin sodium ................................... 18
ENSTILAR FOAM 0.005-0.064 % ............ 52
entacapone .............................................. 28
entecavir .................................................. 11
ENTOCORT EC ....................................... 39
ENTRESTO ............................................. 21
ENTYVIO ................................................. 38
ENVARSUS XR TB24 0.75 MG ............... 46
ENVARSUS XR TB24 1 MG .................... 46
ENVARSUS XR TB24 4 MG .................... 46
EPANED .................................................. 21
EPCLUSA ................................................ 11
EPIDUO FORTE GEL 0.3-2.5 % .............. 53
EPIDUO GEL 0.1-2.5 % ........................... 53
epinastine hcl (ophth) ............................... 36
epinephrine .............................................. 17
EPIPEN 2-PAK SOAJ 0.3 MG/0.3ML ....... 17
EPIPEN JR 2-PAK SOAJ 0.15 MG/0.3ML17
EPIVIR HBV SOLN 5 MG/ML................... 11
EPIVIR HBV TABS 100 MG ..................... 11
EPIVIR SOLN 10 MG/ML ......................... 11
EPIVIR TABS 150 MG ............................. 11
EPIVIR TABS 300 MG ............................. 11
eplerenone ............................................... 21
EPOGEN.................................................. 18
64 • Kaiser Permanente 2017 Comprehensive Formulary
eprosartan mesylate ................................ 21
EPZICOM ................................................ 11
EQUETRO ............................................... 26
ERAXIS ................................................... 10
ERBITUX ................................................. 14
ergoloid mesylates ................................... 17
ergotamine tartrate .................................. 17
ergotamine w/ caffeine............................. 27
ERIVEDGE .............................................. 14
ERTACZO ............................................... 51
ERWINAZE.............................................. 14
ERYGEL GEL 2 % ................................... 51
ERYPED 200 ............................................. 9
ERYPED 400 ............................................. 9
erythromycin (acne aid) ........................... 51
erythromycin (ophth) ................................ 34
erythromycin base ..................................... 9
erythromycin ethylsuccinate ...................... 9
erythromycin lactobionate .......................... 9
erythromycin stearate ................................ 9
ESBRIET ................................................. 49
escitalopram oxalate ................................ 29
esomeprazole magnesium ....................... 37
esomeprazole sodium.............................. 37
estazolam ................................................ 28
esterified estrogens ................................. 43
estradiol ................................................... 43
estradiol & norethindrone acetate ............ 43
estradiol cypionate ................................... 43
estradiol vaginal ....................................... 43
estradiol valerate ..................................... 43
estradiol-norgestimate ............................. 43
ESTRING................................................. 43
estropipate ............................................... 43
eszopiclone.............................................. 28
ethacrynate sodium ................................. 32
ethambutol hcl ......................................... 10
ethosuximide ........................................... 26
ethynodiol diacet & eth estrad.................. 40
etidronate disodium ................................. 46
etodolac ................................................... 23
ETOPOPHOS .......................................... 14
etoposide ................................................. 14
EURAX .................................................... 51
EVAMIST SOLN 1.53 MG/SPRAY .......... 43
EVISTA .................................................... 43
EVOCLIN ................................................. 51
EVOMELA SOLR 50 MG ......................... 14
EVOTAZ .................................................. 11
EVOXAC .................................................. 16
EVZIO SOAJ 0.4 MG/0.4ML .................... 29
EXALGO .................................................. 23
EXELDERM ............................................. 51
EXELON .................................................. 16
exemestane ............................................. 14
EXFORGE ............................................... 19
EXFORGE HCT ....................................... 19
EXJADE TBSO 125 MG ........................... 39
EXJADE TBSO 250 MG ........................... 39
EXJADE TBSO 500 MG ........................... 39
EXTAVIA KIT 0.3 MG............................... 46
EXTINA .................................................... 51
F
FABIOR.................................................... 53
FABRAZYME ........................................... 34
famciclovir ................................................ 11
famotidine ................................................ 37
famotidine in nacl ..................................... 37
FAMVIR ................................................... 11
FANAPT ................................................... 30
FANAPT TITRATION PACK .................... 30
FARESTON ............................................. 14
FARXIGA ................................................. 41
FARYDAK ................................................ 14
FASLODEX .............................................. 14
fat emulsion.............................................. 32
FAZACLO ................................................ 30
felbamate ................................................. 26
FELBATOL............................................... 26
FELDENE ................................................ 23
felodipine.................................................. 19
FEMARA .................................................. 14
FEMCON FE ............................................ 40
FEMHRT LOW DOSE .............................. 43
FEMRING ................................................ 43
fenofibrate ................................................ 19
FENOFIBRATE ........................................ 19
fenofibrate micronized .............................. 19
fenofibric acid ........................................... 19
FENOFIBRIC ACID .................................. 19
FENOGLIDE ............................................ 19
fenoprofen calcium ................................... 23
FENOPROFEN CALCIUM ....................... 23
fentanyl .................................................... 23
fentanyl citrate .......................................... 23
FENTORA ................................................ 23
FERRIPROX ............................................ 39
Kaiser Permanente 2017 Comprehensive Formulary • 65
FETZIMA ................................................. 30
FETZIMA TITRATION ............................. 30
FIBRICOR ............................................... 19
FINACEA FOAM 15 %............................. 53
FINACEA GEL 15 % ................................ 53
finasteride ................................................ 46
FIORINAL .......................................... 23, 24
FIORINAL/CODEINE #3 .......................... 24
FIRAZYR ................................................. 46
FIRMAGON ............................................. 14
FLAGYL ................................................... 10
FLAREX .................................................. 35
flavoxate hcl............................................. 54
FLEBOGAMMA DIF SOLN 0.5 GM/10ML 49
FLEBOGAMMA DIF SOLN 2.5 GM/50ML 49
FLEBOGAMMA DIF SOLN 20 GM/400ML
............................................................. 49
FLEBOGAMMA DIF SOLN 5 GM/100ML 49
FLEBOGAMMA DIF SOLN 5 GM/50ML .. 49
flecainide acetate ..................................... 20
FLECTOR ................................................ 53
FLOMAX .................................................. 17
FLOVENT DISKUS .................................. 49
FLOVENT HFA AERO 110 MCG/ACT..... 49
FLOVENT HFA AERO 220 MCG/ACT..... 49
FLOVENT HFA AERO 44 MCG/ACT....... 49
fluconazole .............................................. 10
fluconazole in nacl ................................... 10
flucytosine................................................ 10
fludarabine phosphate ............................. 14
fludrocortisone acetate ............................ 39
FLUMADINE ............................................ 11
flunisolide (nasal) ..................................... 35
fluocinolone acetonide ....................... 35, 52
fluocinolone acetonide (otic) .................... 35
fluocinonide ............................................. 52
fluocinonide emulsified base .................... 52
fluorometholone (ophth) ........................... 35
FLUOROPLEX CREA 1 % ...................... 53
fluorouracil ......................................... 14, 53
fluorouracil (topical) ................................. 53
FLUOXETINE HCL .................................. 30
fluoxetine hcl caps 10 mg ........................ 30
fluoxetine hcl caps 20 mg ........................ 30
fluoxetine hcl caps 40 mg ........................ 30
fluoxetine hcl cpdr 90 mg ......................... 30
fluoxetine hcl soln 20 mg/5ml................... 30
fluoxetine hcl tabs 10 mg ......................... 30
fluoxetine hcl tabs 20 mg ......................... 30
fluphenazine decanoate ........................... 30
fluphenazine hcl ....................................... 30
flurandrenolide ......................................... 52
flurazepam hcl .......................................... 28
flurbiprofen ......................................... 24, 35
flurbiprofen sodium................................... 35
flutamide .................................................. 14
fluticasone propionate ........................ 35, 52
fluticasone propionate (nasal) .................. 35
fluvastatin sodium .................................... 19
fluvoxamine maleate ................................ 30
FML FORTE SUSP 0.25 % ...................... 35
FML LIQUIFILM SUSP 0.1 %................... 35
FML OINT 0.1 % ...................................... 35
FOCALIN ................................................. 25
FOCALIN XR ........................................... 25
FOLOTYN ................................................ 14
fomepizole................................................ 46
fondaparinux sodium ................................ 18
FORADIL AEROLIZER ............................ 18
FORFIVO XL............................................ 30
FORTAMET ............................................. 41
FORTAZ SOLR 1 GM ................................ 9
FORTAZ SOLR 2 GM ................................ 9
FORTAZ SOLR 6 GM ................................ 9
FORTEO .................................................. 43
FORTESTA GEL 10 MG/ACT (2%).......... 40
FORTICAL SOLN 200 UNIT/ACT ............ 43
FOSAMAX ............................................... 46
FOSAMAX PLUS D.................................. 46
fosinopril sodium ...................................... 21
fosinopril sodium & hydrochlorothiazide ... 21
fosphenytoin sodium ................................ 26
FOSRENOL CHEW 1000 MG .................. 33
FOSRENOL CHEW 500 MG .................... 33
FOSRENOL CHEW 750 MG .................... 33
FOSRENOL PACK 1000 MG ................... 33
FOSRENOL PACK 750 MG ..................... 33
FRAGMIN ................................................ 18
FREAMINE HBC SOLN 6.9 % ................. 32
FROVA..................................................... 27
frovatriptan succinate ............................... 27
FURADANTIN .......................................... 12
furosemide soln 10 mg/ml ........................ 33
furosemide soln 8 mg/ml .......................... 33
furosemide tabs 20 mg ............................. 33
furosemide tabs 40 mg ............................. 33
furosemide tabs 80 mg ............................. 33
FUSILEV .................................................. 46
66 • Kaiser Permanente 2017 Comprehensive Formulary
FUZEON .................................................. 11
FYCOMPA ............................................... 26
G
gabapentin ............................................... 26
GABITRIL ................................................ 26
GABLOFEN SOLN 10000 MCG/20ML .... 17
GABLOFEN SOLN 20000 MCG/20ML .... 17
GABLOFEN SOLN 40000 MCG/20ML .... 17
GABLOFEN SOLN 50 MCG/ML .............. 17
galantamine hydrobromide ...................... 16
GAMASTAN S/D ..................................... 49
GAMMAGARD S/D LESS IGA SOLR 5 GM
............................................................. 49
GAMMAGARD S/D SOLR 10 GM ........... 49
GAMMAGARD SOLN 2.5 GM/25ML ....... 49
GAMMAKED SOLN 1 GM/10ML ............. 49
GAMMAPLEX SOLN 10 GM/200ML ........ 49
GAMUNEX-C SOLN 1 GM/10ML ............ 49
GAMUNEX-C SOLN 10 GM/100ML ........ 49
GAMUNEX-C SOLN 2.5 GM/25ML ......... 49
GAMUNEX-C SOLN 20 GM/200ML ........ 49
GAMUNEX-C SOLN 40 GM/400ML ........ 49
GAMUNEX-C SOLN 5 GM/50ML ............ 49
ganciclovir sodium ................................... 11
GARDASIL .............................................. 50
GARDASIL 9 ........................................... 50
GASTROCROM ...................................... 48
gatifloxacin (ophth) .................................. 34
GATTEX .................................................. 38
gauze pads & dressings .......................... 31
GAZYVA .................................................. 14
GELNIQUE .............................................. 54
gemcitabine hcl ........................................ 14
gemfibrozil ............................................... 19
GEMZAR ................................................. 14
GENERESS FE ....................................... 40
GENOTROPIN MINIQUICK SOLR 0.2 MG
............................................................. 44
GENOTROPIN MINIQUICK SOLR 0.4 MG
............................................................. 44
GENOTROPIN MINIQUICK SOLR 0.6 MG
............................................................. 44
GENOTROPIN MINIQUICK SOLR 0.8 MG
............................................................. 44
GENOTROPIN MINIQUICK SOLR 1 MG 44
GENOTROPIN MINIQUICK SOLR 1.2 MG
............................................................. 44
GENOTROPIN MINIQUICK SOLR 1.4 MG
............................................................. 44
GENOTROPIN MINIQUICK SOLR 1.6 MG
............................................................. 44
GENOTROPIN MINIQUICK SOLR 1.8 MG
............................................................. 44
GENOTROPIN MINIQUICK SOLR 2 MG . 44
GENOTROPIN SOLR 12 MG................... 44
GENOTROPIN SOLR 5 MG..................... 44
gentamicin in saline.................................... 9
gentamicin sulfate .......................... 9, 34, 51
gentamicin sulfate (ophth) ........................ 34
gentamicin sulfate (topical)....................... 51
GENVOYA ............................................... 11
GEODON ................................................. 30
GEODON SOLN ...................................... 30
GIAZO ...................................................... 37
GILENYA ................................................. 46
GILOTRIF ................................................ 14
GLASSIA.................................................. 49
glatiramer acetate .................................... 46
GLEEVEC ................................................ 14
GLEOSTINE CAPS 10 MG ...................... 14
GLEOSTINE CAPS 100 MG .................... 14
GLEOSTINE CAPS 40 MG ...................... 14
GLEOSTINE CAPS 5 MG ........................ 14
glimepiride................................................ 41
glipizide er tb24 10 mg ............................. 41
glipizide er tb24 2.5 mg ............................ 41
glipizide er tb24 5 mg ............................... 41
glipizide tabs 10 mg ................................. 41
glipizide tabs 5 mg ................................... 41
glipizide-metformin hcl ............................. 41
GLUCAGEN HYPOKIT ............................ 41
GLUCAGON EMERGENCY..................... 41
GLUCOPHAGE ........................................ 41
GLUCOPHAGE XR .................................. 41
GLUCOTROL........................................... 41
GLUCOTROL XL ..................................... 41
GLUCOVANCE ........................................ 41
GLUMETZA ............................................. 41
glyburide .................................................. 41
glyburide micronized ................................ 41
glyburide-metformin ................................. 41
glycopyrrolate ........................................... 16
GLYNASE ................................................ 41
GLYSET ................................................... 41
GLYXAMBI ............................................... 41
GOLYTELY .............................................. 38
Kaiser Permanente 2017 Comprehensive Formulary • 67
GRALISE ................................................. 24
GRALISE STARTER ............................... 24
granisetron hcl ......................................... 37
GRANIX ................................................... 18
GRASTEK ............................................... 46
griseofulvin microsize .............................. 10
griseofulvin ultramicrosize ....................... 10
GRIS-PEG ............................................... 10
guanfacine hcl ................................... 20, 29
guanfacine hcl (adhd) .............................. 29
GUANIDINE HCL .................................... 16
H
HALAVEN ................................................ 14
HALCION................................................. 28
HALDOL .................................................. 30
HALDOL DECANOATE ........................... 30
halobetasol propionate ............................ 52
HALOG .................................................... 52
haloperidol ............................................... 30
haloperidol decanoate ............................. 30
haloperidol lactate ................................... 30
HARVONI ................................................ 11
HAVRIX ................................................... 50
HECTOROL............................................. 54
HEMABATE ............................................. 46
heparin sod (porcine) in d5w.................... 18
heparin sodium (porcine) ......................... 18
HEPATAMINE SOLN 8 % ....................... 32
HEPSERA ............................................... 11
HERCEPTIN ............................................ 14
HETLIOZ ................................................. 28
HEXALEN ................................................ 14
HIBERIX .................................................. 50
HIPREX ................................................... 12
HORIZANT .............................................. 26
HP ACTHAR ............................................ 44
HUMALOG KWIKPEN SOPN 100 UNIT/ML
............................................................. 41
HUMALOG KWIKPEN SOPN 200 UNIT/ML
............................................................. 41
HUMALOG MIX 50/50 ............................. 41
HUMALOG MIX 50/50 KWIKPEN ............ 41
HUMALOG MIX 75/25 ............................. 41
HUMALOG MIX 75/25 KWIKPEN ............ 41
HUMALOG SOCT 100 UNIT/ML ............. 41
HUMALOG SOLN 100 UNIT/ML.............. 41
HUMATROPE SOLR 12 MG ................... 44
HUMATROPE SOLR 24 MG ................... 44
HUMATROPE SOLR 5 MG ...................... 44
HUMATROPE SOLR 6 MG ...................... 44
HUMIRA ................................................... 46
HUMIRA PEDIATRIC CROHNS START .. 46
HUMIRA PEN .......................................... 46
HUMIRA PEN-CROHNS STARTER ........ 46
HUMIRA PEN-PSORIASIS STARTER..... 46
HUMULIN 70/30 ....................................... 41
HUMULIN 70/30 KWIKPEN ..................... 41
HUMULIN N KWIKPEN SUPN 100
UNIT/ML ............................................... 41
HUMULIN N SUSP 100 UNIT/ML ............ 41
HUMULIN R SOLN 100 UNIT/ML ............ 41
HUMULIN R U-500 (CONCENTRATED)
SOLN 500 UNIT/ML ............................. 41
HUMULIN R U-500 KWIKPEN SOPN 500
UNIT/ML ............................................... 42
HYCAMTIN .............................................. 14
hydralazine hcl soln 20 mg/ml .................. 20
hydralazine hcl tabs 10 mg....................... 20
hydralazine hcl tabs 100 mg..................... 20
hydralazine hcl tabs 25 mg....................... 20
hydralazine hcl tabs 50 mg....................... 20
HYDREA .................................................. 14
hydrochlorothiazide caps 12.5 mg ............ 33
hydrochlorothiazide tabs 12.5 mg ............ 33
hydrochlorothiazide tabs 25 mg ............... 33
hydrochlorothiazide tabs 50 mg ............... 33
hydrocodone-acetaminophen ................... 24
hydrocodone-ibuprofen ............................ 24
hydrocortisone ............................. 35, 39, 52
hydrocortisone (intrarectal)....................... 52
hydrocortisone (rectal) ............................. 52
hydrocortisone (topical) ............................ 52
hydrocortisone butyrate ............................ 52
hydrocortisone butyrate hydrophilic lipo
base ..................................................... 52
hydrocortisone sod succinate ................... 39
hydrocortisone valerate ............................ 52
hydrocortisone w/acetic acid .................... 35
hydromorphone hcl .................................. 24
hydroxychloroquine sulfate....................... 11
hydroxyprogesterone caproate
(antineoplastic) ..................................... 44
hydroxyurea ............................................. 14
hydroxyzine hcl ........................................ 28
hydroxyzine pamoate ............................... 28
HYPERRAB S/D ...................................... 49
HYPERRHO S/D ...................................... 49
68 • Kaiser Permanente 2017 Comprehensive Formulary
HYPERTET S/D ...................................... 49
HYQVIA ................................................... 50
HYSINGLA ER ........................................ 24
HYZAAR .................................................. 21
I
ibandronate sodium ................................. 46
IBRANCE................................................. 14
ibuprofen ................................................. 24
ICLUSIG .................................................. 14
IDAMYCIN PFS ....................................... 14
idarubicin hcl............................................ 14
IFEX ........................................................ 14
ifosfamide ................................................ 14
ILARIS ..................................................... 24
ILEVRO ................................................... 35
imatinib mesylate ..................................... 14
IMBRUVICA............................................. 14
imipenem-cilastatin .................................... 9
imipramine hcl ......................................... 30
imipramine pamoate ................................ 30
imiquimod ................................................ 53
IMITREX .................................................. 28
IMITREX STATDOSE REFILL ................. 28
IMOGAM RABIES-HT.............................. 50
IMOVAX RABIES .................................... 50
IMPAVIDO ............................................... 11
IMURAN .................................................. 46
INCRELEX............................................... 44
INCRUSE ELLIPTA ................................. 16
indapamide .............................................. 33
INDERAL LA............................................ 22
INDOCIN ................................................. 24
indomethacin ........................................... 24
INFANRIX ................................................ 50
INFERGEN .............................................. 11
INLYTA .................................................... 14
INNOPRAN XL ........................................ 22
INSPRA ................................................... 21
insulin pen needle .................................... 31
insulin syringe/needle u-100 .................... 31
INTEGRILIN ............................................ 18
INTELENCE ............................................ 11
INTERMEZZO ......................................... 28
INTRALIPID EMUL 30 % ......................... 32
INTRON A ............................................... 14
INTUNIV .................................................. 29
INVANZ ..................................................... 9
INVEGA ................................................... 30
INVEGA SUSTENNA ............................... 30
INVEGA TRINZA...................................... 30
INVIRASE ................................................ 11
INVOKAMET ............................................ 42
INVOKANA .............................................. 42
IONOSOL-B IN D5W ................................ 33
IONOSOL-MB IN D5W ............................. 33
IOPIDINE SOLN 0.5 % ............................ 36
IOPIDINE SOLN 1 % ............................... 36
IPOL......................................................... 50
ipratropium bromide ................................. 16
ipratropium bromide (nasal) ..................... 16
ipratropium-albuterol ................................ 18
irbesartan ................................................. 21
irbesartan-hydrochlorothiazide ................. 21
IRESSA .................................................... 14
irinotecan hcl ............................................ 14
irrigation solutions, physiological .............. 33
ISENTRESS............................................. 11
ISOLYTE-P IN D5W ................................. 33
ISOLYTE-S .............................................. 33
isoniazid ................................................... 10
isoniazid & rifampin .................................. 10
ISOPTO CARPINE................................... 36
ISORDIL TITRADOSE ............................. 21
isosorbide dinitrate ................................... 21
isosorbide mononitrate er tb24 120 mg .... 21
isosorbide mononitrate er tb24 30 mg ...... 22
isosorbide mononitrate er tb24 60 mg ...... 22
isosorbide mononitrate tabs 10 mg .......... 22
isosorbide mononitrate tabs 20 mg .......... 22
isotretinoin................................................ 53
isradipine.................................................. 19
ISTALOL .................................................. 36
ISTODAX ................................................. 14
itraconazole.............................................. 10
ivermectin................................................... 8
IXEMPRA KIT .......................................... 14
IXIARO ..................................................... 50
J
JADENU TABS 180 MG ........................... 39
JADENU TABS 360 MG ........................... 39
JADENU TABS 90 MG ............................. 39
JAKAFI ..................................................... 14
JALYN ...................................................... 46
JANUMET ................................................ 42
JANUMET XR .......................................... 42
JANUVIA .................................................. 42
Kaiser Permanente 2017 Comprehensive Formulary • 69
JARDIANCE ............................................ 42
JENTADUETO......................................... 42
JENTADUETO XR ................................... 42
JEVTANA ................................................ 14
JUBLIA .................................................... 51
JUXTAPID ............................................... 19
K
KADCYLA ................................................ 14
KADIAN CP24 10 MG.............................. 24
KADIAN CP24 100 MG ............................ 24
KADIAN CP24 20 MG.............................. 24
KADIAN CP24 200 MG ............................ 24
KADIAN CP24 30 MG.............................. 24
KADIAN CP24 40 MG.............................. 24
KADIAN CP24 50 MG.............................. 24
KADIAN CP24 60 MG.............................. 24
KADIAN CP24 80 MG.............................. 24
KALETRA ................................................ 11
KALYDECO ............................................. 49
KANUMA ................................................. 34
KAPVAY .................................................. 20
KARBINAL ER ......................................... 13
KAYEXALATE ......................................... 33
KAZANO .................................................. 42
KCL IN DEXTROSE-NACL SOLN 20-50.225 MEQ/L-%-% ............................... 34
KCL IN DEXTROSE-NACL SOLN 40-5-0.9
MEQ/L-%-% ......................................... 34
KCL-LACTATED RINGERS-D5W ........... 34
KENALOG ......................................... 39, 52
KEPIVANCE ............................................ 52
KEPPRA SOLN 100 MG/ML .................... 26
KEPPRA TABS 1000 MG ........................ 26
KEPPRA TABS 250 MG .......................... 26
KEPPRA TABS 500 MG .......................... 26
KEPPRA TABS 750 MG .......................... 26
KEPPRA XR TB24 500 MG ..................... 26
KEPPRA XR TB24 750 MG ..................... 26
KERYDIN................................................. 51
KETEK ....................................................... 9
ketoconazole ..................................... 10, 51
ketoconazole (topical) .............................. 51
ketoprofen................................................ 24
ketorolac tromethamine ..................... 24, 35
ketorolac tromethamine (ophth) ............... 35
KEVEYIS ................................................. 46
KEYTRUDA ............................................. 14
KHEDEZLA.............................................. 30
KINERET ................................................. 46
KITABIS PAK ............................................. 9
KLARON .................................................. 51
KLONOPIN .............................................. 26
KOMBIGLYZE XR .................................... 42
KORLYM .................................................. 42
K-TAB TBCR 10 MEQ .............................. 33
K-TAB TBCR 20 MEQ .............................. 33
K-TAB TBCR 8 MEQ................................ 33
KUVAN..................................................... 46
KYNAMRO ............................................... 19
KYPROLIS ............................................... 14
L
labetalol hcl .............................................. 22
LACRISERT ............................................. 36
lactated ringer's .................................. 33, 34
lactated ringer's (irrigation) ....................... 33
lactic acid (ammonium lactate) ................. 53
lactulose ................................................... 31
lactulose (encephalopathy) ...................... 31
LAMICTAL CHEW 25 MG ........................ 26
LAMICTAL CHEW 5 MG .......................... 26
LAMICTAL ODT TBDP 100 MG ............... 26
LAMICTAL ODT TBDP 200 MG ............... 27
LAMICTAL ODT TBDP 25 MG ................. 27
LAMICTAL ODT TBDP 50 MG ................. 27
LAMICTAL STARTER KIT 25 (35) MG .... 27
LAMICTAL STARTER KIT 25 (42)-100 (7)
MG ....................................................... 27
LAMICTAL STARTER KIT 25 (84)-100(14)
MG ....................................................... 27
LAMICTAL TABS 100 MG........................ 27
LAMICTAL TABS 150 MG........................ 27
LAMICTAL TABS 200 MG........................ 27
LAMICTAL TABS 25 MG ......................... 27
LAMICTAL XR KIT 25 & 50 & 100 MG ..... 27
LAMICTAL XR KIT 25 (21)-50 (7) MG...... 27
LAMICTAL XR KIT 50 & 100 & 200 MG ... 27
LAMICTAL XR TB24 100 MG .................. 27
LAMICTAL XR TB24 200 MG .................. 27
LAMICTAL XR TB24 25 MG .................... 27
LAMICTAL XR TB24 250 MG .................. 27
LAMICTAL XR TB24 300 MG .................. 27
LAMICTAL XR TB24 50 MG .................... 27
LAMISIL ................................................... 10
lamivudine ................................................ 11
lamivudine (hbv) ....................................... 11
lamivudine-zidovudine .............................. 11
70 • Kaiser Permanente 2017 Comprehensive Formulary
lamotrigine ............................................... 27
LANOXIN PEDIATRIC SOLN 0.1 MG/ML 20
LANOXIN SOLN 0.25 MG/ML.................. 20
LANOXIN TABS 125 MCG ...................... 20
LANOXIN TABS 187.5 MCG ................... 20
LANOXIN TABS 250 MCG ...................... 20
LANOXIN TABS 62.5 MCG ..................... 20
lansoprazole ............................................ 37
LANTUS SOLN 100 UNIT/ML.................. 42
LANTUS SOLOSTAR SOPN 100 UNIT/ML
............................................................. 42
LASIX ...................................................... 33
LASTACAFT ............................................ 36
latanoprost ............................................... 36
LATUDA .................................................. 30
LAZANDA ................................................ 24
leflunomide .............................................. 46
LEMTRADA ............................................. 46
LENVIMA 10 MG DAILY DOSE ............... 14
LENVIMA 14 MG DAILY DOSE ............... 14
LENVIMA 18 MG DAILY DOSE ............... 14
LENVIMA 20 MG DAILY DOSE ............... 14
LENVIMA 24 MG DAILY DOSE ............... 14
LENVIMA 8 MG DAILY DOSE ................. 14
LESCOL XL ............................................. 19
LETAIRIS................................................. 49
letrozole ................................................... 15
leucovorin calcium ................................... 46
LEUKERAN ............................................. 15
LEUKINE ................................................. 18
leuprolide acetate .................................... 15
levalbuterol hcl ......................................... 18
LEVAQUIN ................................................ 9
LEVEMIR ................................................. 42
LEVEMIR FLEXTOUCH .......................... 42
levetiracetam ........................................... 27
LEVETIRACETAM IN NACL .................... 27
levobunolol hcl ......................................... 36
levocarnitine (metabolic modifiers) .......... 46
levocetirizine dihydrochloride ................... 13
levofloxacin .......................................... 9, 34
levofloxacin (ophth).................................. 34
levofloxacin in d5w..................................... 9
levoleucovorin calcium............................. 46
levonorgestrel & eth estradiol .................. 40
levonorgestrel-eth estradiol (triphasic) ..... 40
levonorgestrel-ethinyl estradiol (91-day) .. 40
levonorgestrel-ethinyl estradiol (continuous)
............................................................. 40
levorphanol tartrate .................................. 24
levothyroxine sodium ............................... 45
LEVOTHYROXINE SODIUM ................... 45
LEXAPRO ................................................ 30
LEXIVA SUSP 50 MG/ML ........................ 11
LEXIVA TABS 700 MG ............................ 11
LIALDA TBEC 1.2 GM ............................. 37
lidocaine ....................................... 36, 46, 52
lidocaine hcl ................................. 36, 46, 52
lidocaine hcl (local anesth.) ...................... 46
lidocaine hcl (mouth-throat) ...................... 36
lidocaine-prilocaine .................................. 52
LIDOCAINE-TETRACAINE ...................... 52
LIDODERM .............................................. 52
LINCOCIN .................................................. 9
lincomycin hcl ............................................. 9
lindane ..................................................... 51
linezolid ...................................................... 9
LINZESS .................................................. 38
LIORESAL SOLN 0.05 MG/ML ................ 17
LIORESAL SOLN 10 MG/20ML ............... 17
LIORESAL SOLN 10 MG/5ML ................. 17
LIORESAL SOLN 40 MG/20ML ............... 17
liothyronine sodium .................................. 45
LIPITOR ................................................... 19
LIPOFEN.................................................. 19
LIPOSYN III EMUL 10 % ......................... 32
lisinopril & hydrochlorothiazide ................. 21
lisinopril tabs 10 mg ................................. 21
lisinopril tabs 2.5 mg ................................ 21
lisinopril tabs 20 mg ................................. 21
lisinopril tabs 30 mg ................................. 21
lisinopril tabs 40 mg ................................. 21
lisinopril tabs 5 mg ................................... 21
LITHIUM................................................... 30
lithium carbonate ...................................... 30
LITHIUM CARBONATE ........................... 30
LITHOBID ................................................ 30
LITHOSTAT ............................................. 31
LIVALO .................................................... 19
LO LOESTRIN FE .................................... 40
LOCOID ................................................... 52
LODOSYN ............................................... 28
LOMOTIL ................................................. 37
LOMUSTINE CAPS 10 MG ...................... 15
LOMUSTINE CAPS 100 MG .................... 15
LOMUSTINE CAPS 40 MG ...................... 15
LONSURF ................................................ 15
loperamide hcl .......................................... 37
Kaiser Permanente 2017 Comprehensive Formulary • 71
LOPID...................................................... 19
LOPRESSOR .......................................... 22
LOPRESSOR HCT .................................. 22
LOPROX.................................................. 51
lorazepam ................................................ 28
losartan potassium................................... 21
losartan potassium & hydrochlorothiazide 21
LOSEASONIQUE .................................... 40
LOTEMAX ............................................... 35
LOTENSIN............................................... 21
LOTREL .................................................. 19
LOTRISONE ............................................ 51
LOTRONEX ............................................. 37
lovastatin ................................................. 19
LOVAZA .................................................. 19
LOVENOX ............................................... 18
loxapine succinate ................................... 30
LUMIGAN ................................................ 36
LUMIZYME .............................................. 34
LUNESTA ................................................ 28
LUPANETA PACK ................................... 15
LUPRON DEPOT KIT 11.25 MG ............. 15
LUPRON DEPOT KIT 22.5 MG ............... 15
LUPRON DEPOT KIT 3.75 MG ............... 15
LUPRON DEPOT KIT 30 MG .................. 15
LUPRON DEPOT KIT 45 MG .................. 15
LUPRON DEPOT KIT 7.5 MG ................. 15
LUPRON DEPOT-PED ............................ 15
LUZU ....................................................... 51
LYNPARZA.............................................. 15
LYRICA ................................................... 27
LYSODREN ............................................. 15
LYSTEDA ................................................ 18
M
MACROBID ............................................. 12
MACRODANTIN ...................................... 12
magnesium sulfate................................... 27
MAGNESIUM SULFATE ................... 27, 34
MAGNESIUM SULFATE IN D5W ............ 34
MAKENA ................................................. 44
MALARONE ............................................ 11
malathion ................................................. 51
maprotiline hcl ......................................... 30
MARINOL ................................................ 37
MARPLAN ............................................... 30
MARQIBO................................................ 15
MATULANE ............................................. 15
MAVIK ..................................................... 21
MAXAIR AUTOHALER ............................ 18
MAXALT................................................... 28
MAXALT-MLT .......................................... 28
MAXIDEX ................................................. 35
MAXIPIME SOLR 1 GM ............................. 9
MAXIPIME SOLR 2 GM ............................. 9
MAXITROL............................................... 35
MAXZIDE ................................................. 33
MAXZIDE-25 ............................................ 33
mebendazole ............................................. 8
mecamylamine hcl ................................... 20
meclizine hcl ............................................ 37
meclofenamate sodium ............................ 24
MEDROL TABS 16 MG ............................ 39
MEDROL TABS 2 MG .............................. 39
MEDROL TABS 32 MG ............................ 39
MEDROL TABS 4 MG .............................. 39
MEDROL TABS 8 MG .............................. 39
MEDROL TBPK 4 MG .............................. 39
medroxyprogesterone acetate.................. 44
medroxyprogesterone acetate
(contraceptive) ...................................... 44
mefenamic acid ........................................ 24
mefloquine hcl .......................................... 11
MEGACE ES ............................................ 44
MEGACE ORAL ....................................... 15
megestrol acetate............................... 15, 44
megestrol acetate (appetite)..................... 44
MEKINIST ................................................ 15
meloxicam ................................................ 24
melphalan hcl ........................................... 15
memantine hcl .......................................... 29
MENACTRA ............................................. 50
MENHIBRIX ............................................. 50
MENOMUNE ............................................ 50
MENOSTAR PTWK 14 MCG/24HR ......... 43
MENTAX .................................................. 51
MENVEO ................................................. 50
meperidine hcl .......................................... 24
meprobamate ........................................... 28
MEPRON ................................................. 11
mercaptopurine ........................................ 15
meropenem ................................................ 9
MERREM ................................................... 9
mesalamine w/ cleanser ........................... 37
mesna ...................................................... 46
MESNEX SOLN 100 MG/ML.................... 46
MESNEX TABS 400 MG .......................... 46
MESTINON SYRP 60 MG/5ML ................ 16
72 • Kaiser Permanente 2017 Comprehensive Formulary
MESTINON TABS 60 MG ........................ 16
MESTINON TBCR 180 MG ..................... 16
METADATE CD CPCR 10 MG ................ 25
METADATE CD CPCR 20 MG ................ 25
METADATE CD CPCR 30 MG ................ 25
METADATE CD CPCR 40 MG ................ 25
METADATE CD CPCR 50 MG ................ 25
METADATE CD CPCR 60 MG ................ 25
metaproterenol sulfate ............................. 18
metaxalone .............................................. 17
metformin hcl er (osm) tb24 1000 mg ...... 42
metformin hcl er tb24 500 mg .................. 42
metformin hcl er tb24 750 mg .................. 42
metformin hcl tabs 1000 mg .................... 42
metformin hcl tabs 500 mg ...................... 42
metformin hcl tabs 850 mg ...................... 42
methadone hcl ......................................... 24
METHADONE HCL SOLN 10 MG/ML ..... 24
methamphetamine hcl ............................. 25
methazolamide ........................................ 36
methenamine hippurate ........................... 13
methimazole ............................................ 45
methocarbamol ........................................ 17
methotrexate sodium ............................... 15
methoxsalen rapid ................................... 53
methscopolamine bromide ....................... 16
methyclothiazide ...................................... 33
methyldopa .............................................. 20
methyldopa & hydrochlorothiazide ........... 20
methyldopate hcl ..................................... 20
methylergonovine maleate ....................... 46
METHYLIN CHEW 10 MG ....................... 25
METHYLIN CHEW 2.5 MG ...................... 25
METHYLIN CHEW 5 MG ......................... 25
METHYLIN SOLN 10 MG/5ML ................ 26
METHYLIN SOLN 5 MG/5ML .................. 26
methylphenidate hcl ................................. 26
methylprednisolone.................................. 39
methylprednisolone acetate ..................... 39
methylprednisolone sod succ................... 39
methyltestosterone .................................. 40
metipranolol ............................................. 36
metoclopramide hcl.................................. 38
metolazone .............................................. 33
metoprolol & hydrochlorothiazide............. 22
metoprolol succinate ................................ 22
metoprolol tartrate soln 1 mg/ml .............. 22
metoprolol tartrate tabs 100 mg ............... 22
metoprolol tartrate tabs 25 mg ................. 22
metoprolol tartrate tabs 50 mg ................. 22
METOZOLV ODT ..................................... 38
METRO .................................................... 11
METROCREAM ....................................... 51
METROGEL ............................................. 51
METROGEL-VAGINAL ............................ 51
METROLOTION ....................................... 51
metronidazole .................................... 11, 51
metronidazole (topical) ............................. 51
metronidazole in nacl ............................... 11
metronidazole vaginal .............................. 51
mexiletine hcl ........................................... 20
MIACALCIN SOLN 200 UNIT/ACT .......... 43
MIACALCIN SOLN 200 UNIT/ML ............. 43
MICARDIS ............................................... 21
MICARDIS HCT ....................................... 21
miconazole nitrate vaginal ........................ 51
MICROZIDE ............................................. 33
midazolam hcl .......................................... 28
midodrine hcl ............................................ 18
MIFEPREX............................................... 46
miglitol ...................................................... 42
MIGRANAL .............................................. 17
MINASTRIN 24 FE ................................... 40
MINIPRESS ............................................. 18
MINIVELLE PTTW 0.025 MG/24HR......... 43
MINIVELLE PTTW 0.0375 MG/24HR....... 43
MINIVELLE PTTW 0.05 MG/24HR .......... 43
MINIVELLE PTTW 0.075 MG/24HR......... 43
MINIVELLE PTTW 0.1 MG/24HR ............ 43
MINOCIN ................................................... 9
minocycline hcl ........................................... 9
minoxidil ................................................... 20
MIRAPEX ................................................. 28
MIRAPEX ER ........................................... 28
MIRCERA ................................................ 18
mirtazapine .............................................. 30
MIRVASO ................................................ 53
misoprostol............................................... 37
MITIGARE CAPS 0.6 MG ........................ 47
mitomycin ................................................. 15
mitoxantrone hcl ....................................... 15
M-M-R II ................................................... 50
MOBIC ..................................................... 24
modafinil................................................... 26
MODICON (28) ........................................ 40
moexipril hcl ............................................. 21
moexipril-hydrochlorothiazide................... 21
molindone hcl ........................................... 30
Kaiser Permanente 2017 Comprehensive Formulary • 73
mometasone furoate .......................... 35, 52
mometasone furoate (nasal) .................... 35
montelukast sodium ................................. 48
MONUROL .............................................. 13
morphine sulfate ...................................... 24
MORPHINE SULFATE (PF) SOLN 10
MG/ML ................................................. 24
MORPHINE SULFATE (PF) SOLN 2
MG/ML ................................................. 24
MORPHINE SULFATE (PF) SOLN 4
MG/ML ................................................. 24
MORPHINE SULFATE (PF) SOLN 8
MG/ML ................................................. 24
morphine sulfate beads ........................... 24
MORPHINE SULFATE TABS 15 MG ...... 24
MORPHINE SULFATE TABS 30 MG ...... 24
MOVANTIK .............................................. 38
MOVIPREP.............................................. 38
MOXEZA ................................................. 34
moxifloxacin hcl ......................................... 9
MOXIFLOXACIN HCL ............................... 9
MOZOBIL ................................................ 18
MS CONTIN TBCR 100 MG .................... 24
MS CONTIN TBCR 15 MG ...................... 24
MS CONTIN TBCR 200 MG .................... 24
MS CONTIN TBCR 30 MG ...................... 24
MS CONTIN TBCR 60 MG ...................... 24
MULTAQ.................................................. 20
mupirocin ................................................. 51
mupirocin calcium (topical) ...................... 51
MUSTARGEN.......................................... 15
MYALEPT ................................................ 47
MYAMBUTOL .......................................... 10
MYCAMINE ............................................. 10
MYCOBUTIN ........................................... 10
mycophenolate mofetil ............................. 47
mycophenolate sodium ............................ 47
MYFORTIC .............................................. 47
MYOZYME .............................................. 34
MYRBETRIQ ........................................... 54
MYSOLINE .............................................. 27
N
NABI-HB .................................................. 50
nabumetone............................................. 24
nadolol & bendroflumethiazide................. 22
nadolol tabs 20 mg .................................. 22
nadolol tabs 40 mg .................................. 22
nadolol tabs 80 mg .................................. 22
nafcillin sodium .......................................... 9
NAFCILLIN SODIUM IN DEXTROSE ........ 9
naftifine hcl ............................................... 51
NAFTIFINE HCL ...................................... 51
NAFTIN .................................................... 51
NAGLAZYME ........................................... 34
nalbuphine hcl .......................................... 24
naloxone hcl ............................................. 29
naltrexone hcl ........................................... 29
NAMENDA ............................................... 29
NAMENDA TITRATION PAK ................... 29
NAMENDA XR ......................................... 29
NAMENDA XR TITRATION PACK ........... 29
NAMZARIC .............................................. 29
naphazoline hcl ........................................ 36
NAPRELAN.............................................. 24
NAPROSYN ............................................. 24
naproxen .................................................. 24
naproxen sodium...................................... 24
naratriptan hcl .......................................... 28
NARCAN LIQD 4 MG/0.1ML .................... 29
NARDIL .................................................... 30
NASONEX ............................................... 35
NATACYN ................................................ 34
NATAZIA .................................................. 40
nateglinide................................................ 42
NATESTO GEL 5.5 MG/ACT ................... 40
NATPARA ................................................ 43
NEBUPENT SOLR 300 MG ..................... 11
NECON 1/50 (28) ..................................... 40
nefazodone hcl ......................................... 30
neomycin sulfate ........................................ 9
neomycin/polymyxin b gu ......................... 51
neomycin-bacitracin zn-polymyxin ........... 34
neomycin-fluocinolone ............................. 52
neomycin-polymy-dexameth .................... 35
neomycin-polymyxin-gramicidin ............... 34
neomycin-polymyxin-hc (ophth) ............... 35
neomycin-polymyxin-hc (otic) ................... 35
NEORAL CAPS 100 MG .......................... 47
NEORAL CAPS 25 MG ............................ 47
NEORAL SOLN 100 MG/ML .................... 47
NEPHRAMINE SOLN 5.4 % .................... 32
NESINA.................................................... 42
NEULASTA .............................................. 18
NEUMEGA ............................................... 18
NEUPOGEN ............................................ 18
NEUPRO.................................................. 28
NEURONTIN............................................ 27
74 • Kaiser Permanente 2017 Comprehensive Formulary
NEVANAC ............................................... 35
nevirapine ................................................ 11
NEXAVAR ............................................... 15
NEXIUM .................................................. 37
NEXIUM I.V. ............................................ 37
NEXTERONE .......................................... 20
niacin (antihyperlipidemic) ....................... 19
NIASPAN ................................................. 19
nicardipine hcl.......................................... 19
NICOTROL INHA 10 MG ......................... 16
NICOTROL NS SOLN 10 MG/ML ............ 16
nifedipine ................................................. 19
NILANDRON ........................................... 15
nimodipine ............................................... 19
NINLARO................................................. 15
NIPENT ................................................... 15
nisoldipine................................................ 19
NITRO-DUR PT24 0.1 MG/HR ................ 22
NITRO-DUR PT24 0.2 MG/HR ................ 22
NITRO-DUR PT24 0.3 MG/HR ................ 22
NITRO-DUR PT24 0.4 MG/HR ................ 22
NITRO-DUR PT24 0.6 MG/HR ................ 22
NITRO-DUR PT24 0.8 MG/HR ................ 22
nitrofurantoin............................................ 13
nitrofurantoin macrocrystal ...................... 13
nitrofurantoin monohyd macro ................. 13
nitroglycerin ............................................. 22
NITROLINGUAL SOLN 0.4 MG/SPRAY .. 22
NITROMIST AERS 400 MCG/SPRAY ..... 22
NITROSTAT SUBL 0.3 MG ..................... 22
NITROSTAT SUBL 0.4 MG ..................... 22
NITROSTAT SUBL 0.6 MG ..................... 22
nizatidine ................................................. 37
NIZORAL ................................................. 51
NORDITROPIN FLEXPRO SOLN 10
MG/1.5ML ............................................ 44
NORDITROPIN FLEXPRO SOLN 15
MG/1.5ML ............................................ 44
NORDITROPIN FLEXPRO SOLN 30
MG/3ML ............................................... 44
NORDITROPIN FLEXPRO SOLN 5
MG/1.5ML ............................................ 44
norelgestromin-ethinyl estradiol ............... 40
norethin acet & estrad-fe ......................... 40
norethindrone & eth estradiol ................... 40
norethindrone & ethinyl estradiol-fe ......... 40
norethindrone (contraceptive) .................. 40
norethindrone acet & eth estra................. 40
norethindrone acetate .................. 40, 43, 44
norethindrone acetate-ethinyl estradiol ... 40,
43
norethindrone acetate-ethinyl estradiol-fe 40
norethindrone-eth estradiol (biphasic) ...... 40
norethindrone-eth estradiol (triphasic) ...... 40
norgestimate-ethinyl estradiol .................. 40
norgestimate-ethinyl estradiol (triphasic) .. 40
norgestrel & ethinyl estradiol .................... 40
NORINYL 1+35 (28) ................................. 40
NORINYL 1+50 (28) ................................. 40
NORITATE ............................................... 51
NORMOSOL-M IN D5W........................... 34
NORMOSOL-R IN D5W ........................... 34
NORMOSOL-R PH 7.4 ............................ 34
NORPACE CAPS 100 MG ....................... 20
NORPACE CAPS 150 MG ....................... 20
NORPACE CR CP12 100 MG .................. 20
NORPACE CR CP12 150 MG .................. 20
NORPRAMIN ........................................... 30
NOR-QD .................................................. 40
NORTHERA ............................................. 18
nortriptyline hcl ......................................... 30
NORVASC ............................................... 19
NORVIR ................................................... 11
NOVOLIN 70/30 ....................................... 42
NOVOLIN N RELION SUSP 100 UNIT/ML
............................................................. 42
NOVOLIN N SUSP 100 UNIT/ML ............ 42
NOVOLIN R SOLN 100 UNIT/ML ............ 42
NOVOLOG ............................................... 42
NOVOLOG FLEXPEN.............................. 42
NOVOLOG MIX 70/30.............................. 42
NOVOLOG MIX 70/30 FLEXPEN ............ 42
NOVOLOG PENFILL ............................... 42
NOXAFIL.................................................. 10
NPLATE ................................................... 18
NUCALA .................................................. 48
NUCYNTA................................................ 24
NUCYNTA ER .......................................... 24
NUEDEXTA ............................................. 29
NULOJIX .................................................. 47
NULYTELY WITH FLAVOR PACKS ........ 38
NUPLAZID ............................................... 30
NUTRESTORE ........................................ 38
NUTROPIN AQ NUSPIN 10 SOLN 10
MG/2ML................................................ 45
NUTROPIN AQ NUSPIN 20 SOLN 20
MG/2ML................................................ 45
Kaiser Permanente 2017 Comprehensive Formulary • 75
NUTROPIN AQ NUSPIN 5 SOLN 5
MG/2ML ............................................... 45
NUTROPIN AQ PEN SOLN 10 MG/2ML . 45
NUTROPIN AQ PEN SOLN 20 MG/2ML . 45
NUVARING.............................................. 40
NUVESSA ............................................... 51
NUVIGIL .................................................. 26
nystatin ........................................ 10, 51, 52
nystatin (mouth-throat)............................. 10
nystatin (topical) ...................................... 51
nystatin-triamcinolone .............................. 52
O
OCALIVA ................................................. 38
OCTAGAM SOLN 1 GM/20ML ................ 50
OCTAGAM SOLN 2 GM/20ML ................ 50
OCTAGAM SOLN 25 GM/500ML ............ 50
OCTAGAM SOLN 5 GM/100ML .............. 50
octreotide acetate .................................... 47
OCUFEN ................................................. 35
OCUFLOX ............................................... 34
ODEFSEY ............................................... 11
ODOMZO ................................................ 15
OFEV....................................................... 49
ofloxacin ........................................ 9, 34, 35
ofloxacin (ophth) ...................................... 34
ofloxacin (otic) ......................................... 35
olanzapine ............................................... 30
olanzapine-fluoxetine hcl ......................... 30
olopatadine hcl ........................................ 36
olopatadine hcl (nasal) ............................. 36
OLUX FOAM 0.05 % ............................... 52
OLYSIO ................................................... 11
OMECLAMOX-PAK ................................. 37
omega-3-acid ethyl esters ....................... 19
omeprazole .............................................. 37
omeprazole-sodium bicarbonate.............. 37
OMNARIS ................................................ 35
OMNIPRED SUSP 1 % ........................... 35
OMNITROPE SOLN 10 MG/1.5ML .......... 45
OMNITROPE SOLN 5 MG/1.5ML ............ 45
OMNITROPE SOLR 5.8 MG.................... 45
ONCASPAR ............................................ 15
ondansetron............................................. 37
ondansetron hcl ....................................... 37
ONEXTON ............................................... 51
ONFI ........................................................ 27
ONGLYZA ............................................... 42
ONIVYDE ................................................ 15
ONMEL TABS 200 MG ............................ 10
ONZETRA XSAIL ..................................... 28
OPANA .................................................... 24
OPANA ER .............................................. 24
OPDIVO ................................................... 15
OPSUMIT................................................. 49
ORACEA .................................................. 53
ORALAIR ................................................. 47
ORAP ....................................................... 30
ORAPRED ODT ....................................... 39
ORAVIG ................................................... 51
ORBACTIV................................................. 9
ORENCIA................................................. 47
ORENCIA CLICKJECT ............................ 47
ORENITRAM TBCR 0.125 MG ................ 49
ORENITRAM TBCR 0.25 MG .................. 49
ORENITRAM TBCR 1 MG ....................... 49
ORENITRAM TBCR 2.5 MG .................... 49
ORFADIN ................................................. 47
ORKAMBI ................................................ 49
orphenadrine citrate ................................. 17
ORTHO MICRONOR ............................... 40
ORTHO TRI-CYCLEN (28) ...................... 40
ORTHO TRI-CYCLEN LO ........................ 40
ORTHO-CYCLEN (28) ............................. 40
ORTHO-NOVUM 1/35 (28) ...................... 41
ORTHO-NOVUM 7/7/7 (28) ..................... 41
OSENI ...................................................... 42
OSMOPREP ............................................ 38
OTEZLA ................................................... 47
OTREXUP SOAJ 10 MG/0.4ML ............... 47
OTREXUP SOAJ 15 MG/0.4ML ............... 47
OTREXUP SOAJ 17.5 MG/0.4ML ............ 47
OTREXUP SOAJ 20 MG/0.4ML ............... 47
OTREXUP SOAJ 22.5 MG/0.4ML ............ 47
OTREXUP SOAJ 25 MG/0.4ML ............... 47
OTREXUP SOAJ 7.5 MG/0.4ML .............. 47
oxacillin sodium .......................................... 9
oxaliplatin ................................................. 15
oxandrolone ............................................. 40
oxaprozin ................................................. 24
oxazepam ................................................ 28
oxcarbazepine .......................................... 27
oxiconazole nitrate ................................... 51
OXISTAT.................................................. 51
OXSORALEN........................................... 53
OXSORALEN ULTRA .............................. 53
OXTELLAR XR ........................................ 27
oxybutynin chloride .................................. 54
76 • Kaiser Permanente 2017 Comprehensive Formulary
oxycodone hcl.......................................... 24
OXYCODONE HCL ER ........................... 24
oxycodone w/ acetaminophen ................. 24
oxycodone-aspirin ................................... 24
oxycodone-ibuprofen ............................... 24
OXYCONTIN ........................................... 24
oxymorphone hcl ..................................... 24
OXYTROL ............................................... 54
P
paclitaxel ................................................. 15
paliperidone ............................................. 30
PAMELOR ............................................... 30
pamidronate disodium ............................. 47
PANCREAZE CPEP 10500 UNIT ............ 38
PANCREAZE CPEP 16800 UNIT ............ 38
PANCREAZE CPEP 21000 UNIT ............ 38
PANCREAZE CPEP 4200 UNIT .............. 38
PANDEL .................................................. 52
PANRETIN .............................................. 53
pantoprazole sodium ............................... 37
parenteral electrolytes ............................. 34
paricalcitol................................................ 54
PARNATE................................................ 30
paromomycin sulfate................................ 11
paroxetine hcl er tb24 12.5 mg ................ 30
paroxetine hcl er tb24 25 mg ................... 30
paroxetine hcl er tb24 37.5 mg ................ 30
paroxetine hcl tabs 10 mg ........................ 30
paroxetine hcl tabs 20 mg ........................ 30
paroxetine hcl tabs 30 mg ........................ 30
paroxetine hcl tabs 40 mg ........................ 30
PATADAY ................................................ 36
PATANASE ............................................. 36
PATANOL ................................................ 36
PAXIL ...................................................... 30
PAXIL CR ................................................ 30
PAZEO .................................................... 36
PCE ........................................................... 9
PEDVAX HIB ........................................... 50
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate .................................................. 38
peg 3350-potassium chloride-sod
bicarbonate-sod chloride ...................... 38
PEGANONE ............................................ 27
PEGASYS ............................................... 11
PEGASYS PROCLICK ............................ 11
PEGINTRON ........................................... 11
PEG-INTRON .......................................... 11
PEG-INTRON REDIPEN .......................... 11
PEG-INTRON REDIPEN PAK 4............... 11
PENICILLIN G POT IN DEXTROSE .......... 9
penicillin g potassium ................................. 9
penicillin g procaine.................................... 9
penicillin g sodium ...................................... 9
penicillin v potassium ................................. 9
PENNSAID............................................... 53
PENTAM SOLR 300 MG .......................... 11
PENTASA CPCR 250 MG........................ 37
PENTASA CPCR 500 MG........................ 37
pentazocine w/ naloxone .......................... 24
pentoxifylline ............................................ 18
PEPCID.................................................... 37
PERCODAN............................................. 24
PERFOROMIST ....................................... 18
perindopril erbumine ................................ 21
PERJETA ................................................. 15
permethrin ................................................ 51
perphenazine ........................................... 30
perphenazine-amitriptyline ....................... 30
PERSANTINE .......................................... 22
PERTZYE CPEP 16000 UNIT.................. 38
PERTZYE CPEP 8000 UNIT.................... 38
PEXEVA................................................... 30
phenelzine sulfate .................................... 30
phenobarbital ........................................... 28
PHENOBARBITAL ................................... 28
phenoxybenzamine hcl ............................ 17
phenytoin ................................................. 27
phenytoin sodium ..................................... 27
phenytoin sodium extended ..................... 27
PHOSLO CAPS 667 MG .......................... 34
PHOSLYRA SOLN 667 MG/5ML ............. 34
PHOSPHOLINE IODIDE .......................... 36
PICATO.................................................... 53
pilocarpine hcl .................................... 16, 36
pilocarpine hcl (oral) ................................. 16
pimozide................................................... 30
pindolol..................................................... 22
pioglitazone hcl ........................................ 42
pioglitazone hcl-glimepiride ...................... 42
pioglitazone hcl-metformin hcl .................. 42
piperacillin sodium-tazobactam sodium...... 9
piroxicam.................................................. 24
PLAN B ONE-STEP ................................. 41
PLAQUENIL ............................................. 11
PLASMA-LYTE 148 ................................. 34
PLASMA-LYTE A ..................................... 34
Kaiser Permanente 2017 Comprehensive Formulary • 77
PLASMA-LYTE-56 IN D5W ..................... 34
PLAVIX .................................................... 18
PLEGRIDY .............................................. 12
PLEGRIDY STARTER PACK .................. 12
PLIAGLIS................................................. 52
podofilox .................................................. 53
polyethylene glycol 3350 ......................... 38
polymyxin b sulfate .................................... 9
polymyxin b-trimethoprim ......................... 35
POLYTRIM .............................................. 35
POMALYST ............................................. 15
PONSTEL ................................................ 24
PORTRAZZA ........................................... 15
potassium chloride ................................... 34
potassium chloride in dextrose ................ 34
potassium chloride in dextrose & sodium
chloride ................................................ 34
potassium chloride in nacl ....................... 34
potassium chloride microencapsulated
crystals cr ............................................. 34
potassium citrate (alkalinizer) .................. 31
POTIGA ................................................... 27
PRADAXA ............................................... 18
PRALUENT ............................................. 19
pramipexole dihydrochloride .................... 28
PRANDIN ................................................ 42
PRAVACHOL .......................................... 19
pravastatin sodium................................... 19
prazosin hcl ............................................. 18
PRECOSE ............................................... 42
PRED FORTE SUSP 1 % ........................ 35
PRED MILD SUSP 0.12 % ...................... 35
PRED-G .................................................. 35
PRED-G S.O.P. ....................................... 35
prednicarbate........................................... 52
prednisolone ...................................... 35, 39
prednisolone acetate (ophth) ................... 35
prednisolone sodium phosphate ........ 35, 39
prednisolone sodium phosphate (ophth) .. 35
prednisone ............................................... 39
PREMARIN.............................................. 43
PREMARIN SOLR 25 MG ....................... 43
PREMARIN TABS 0.3 MG ....................... 43
PREMARIN TABS 0.45 MG ..................... 43
PREMARIN TABS 0.625 MG ................... 43
PREMARIN TABS 0.9 MG ....................... 43
PREMARIN TABS 1.25 MG ..................... 43
PREMPHASE .......................................... 43
PREMPRO .............................................. 43
PREPOPIK............................................... 38
PREVACID............................................... 37
PREVACID SOLUTAB ............................. 37
PREVPAC ................................................ 37
PREZCOBIX ............................................ 12
PREZISTA ............................................... 12
PRIFTIN ................................................... 10
PRILOSEC ............................................... 37
PRIMAQUINE PHOSPHATE ................... 11
PRIMAXIN IV ............................................. 9
primidone ................................................. 27
PRIMSOL ................................................. 13
PRINIVIL .................................................. 21
PRISTIQ................................................... 30
PRIVIGEN SOLN 20 GM/200ML .............. 50
PRIVIGEN SOLN 40 GM/400ML .............. 50
PROAIR HFA AERS 108 (90 BASE)
MCG/ACT ............................................. 18
PROAIR RESPICLICK AEPB 108 (90
BASE) MCG/ACT ................................. 18
probenecid ............................................... 34
procainamide hcl ...................................... 20
PROCALAMINE SOLN 3 % ..................... 32
PROCARDIA............................................ 19
PROCARDIA XL ...................................... 19
prochlorperazine ...................................... 30
prochlorperazine edisylate ....................... 30
prochlorperazine maleate ......................... 30
PROCRIT ................................................. 18
PROCYSBI CPDR 25 MG ........................ 47
PROCYSBI CPDR 75 MG ........................ 47
progesterone micronized .......................... 44
PROGLYCEM .......................................... 20
PROGRAF CAPS 0.5 MG ........................ 47
PROGRAF CAPS 1 MG ........................... 47
PROGRAF CAPS 5 MG ........................... 47
PROGRAF SOLN 5 MG/ML ..................... 47
PROLASTIN-C ......................................... 49
PROLENSA ............................................. 35
PROLEUKIN ............................................ 15
PROLIA SOLN 60 MG/ML........................ 47
PROMACTA............................................. 18
promethazine & phenylephrine................. 13
promethazine hcl ...................................... 13
PROMETRIUM ........................................ 44
propafenone hcl ....................................... 20
propantheline bromide ............................. 16
proparacaine hcl ...................................... 36
propranolol & hydrochlorothiazide ............ 22
78 • Kaiser Permanente 2017 Comprehensive Formulary
propranolol hcl er cp24 120 mg ............... 22
propranolol hcl er cp24 160 mg ............... 22
propranolol hcl er cp24 60 mg ................. 22
propranolol hcl er cp24 80 mg ................. 22
propranolol hcl soln 1 mg/ml .................... 22
propranolol hcl soln 20 mg/5ml ................ 23
propranolol hcl soln 40 mg/5ml ................ 23
propranolol hcl tabs 10 mg ...................... 23
propranolol hcl tabs 20 mg ...................... 23
propranolol hcl tabs 40 mg ...................... 23
propranolol hcl tabs 60 mg ...................... 23
propranolol hcl tabs 80 mg ...................... 23
propylthiouracil ........................................ 45
PROQUAD .............................................. 50
PROSCAR ............................................... 47
PROSOL SOLN 20 % .............................. 32
PROTONIX PACK 40 MG ....................... 37
PROTONIX SOLR 40 MG ....................... 37
PROTONIX TBEC 20 MG ........................ 37
PROTONIX TBEC 40 MG ........................ 37
PROTOPIC .............................................. 53
protriptyline hcl ........................................ 31
PROVENTIL HFA AERS 108 (90 BASE)
MCG/ACT ............................................ 18
PROVERA ............................................... 44
PROVIGIL................................................ 26
PROZAC.................................................. 31
PROZAC WEEKLY .................................. 31
PRUDOXIN.............................................. 52
PULMICORT FLEXHALER AEPB 180
MCG/ACT ............................................ 49
PULMICORT FLEXHALER AEPB 90
MCG/ACT ............................................ 49
PULMICORT SUSP 0.25 MG/2ML .......... 49
PULMICORT SUSP 0.5 MG/2ML ............ 49
PULMICORT SUSP 1 MG/2ML ............... 49
PULMOZYME .......................................... 34
PURIXAN................................................. 15
PYLERA .................................................. 37
pyrazinamide ........................................... 10
pyridostigmine bromide............................ 16
Q
QNASL .................................................... 35
QNASL CHILDRENS ............................... 35
QUADRACEL .......................................... 50
QUALAQUIN ........................................... 11
QUARTETTE ........................................... 41
QUDEXY XR ........................................... 27
quetiapine fumarate ................................. 31
QUILLICHEW ER CHER 20 MG .............. 26
QUILLICHEW ER CHER 30 MG .............. 26
QUILLICHEW ER CHER 40 MG .............. 26
QUILLIVANT XR SUSR 25 MG/5ML ........ 26
quinapril hcl .............................................. 21
quinapril-hydrochlorothiazide ................... 21
quinidine gluconate .................................. 20
QUINIDINE GLUCONATE ....................... 20
quinidine sulfate ....................................... 20
quinine sulfate .......................................... 11
QVAR ....................................................... 49
R
RABAVERT.............................................. 50
rabeprazole sodium.................................. 38
RAGWITEK .............................................. 47
raloxifene hcl ............................................ 43
ramipril ..................................................... 21
RANEXA .................................................. 20
ranitidine hcl ............................................. 38
RAPAFLO ................................................ 17
RAPAMUNE ............................................. 47
RAPIVAB ................................................. 12
RASUVO SOAJ 10 MG/0.2ML ................. 47
RASUVO SOAJ 12.5 MG/0.25ML ............ 47
RASUVO SOAJ 15 MG/0.3ML ................. 47
RASUVO SOAJ 17.5 MG/0.35ML ............ 47
RASUVO SOAJ 20 MG/0.4ML ................. 47
RASUVO SOAJ 22.5 MG/0.45ML ............ 47
RASUVO SOAJ 25 MG/0.5ML ................. 47
RASUVO SOAJ 27.5 MG/0.55ML ............ 47
RASUVO SOAJ 30 MG/0.6ML ................. 47
RASUVO SOAJ 7.5 MG/0.15ML .............. 47
RAVICTI ................................................... 31
RAYOS .................................................... 39
RAZADYNE ....................................... 16, 17
RAZADYNE ER ....................................... 17
REBETOL ................................................ 12
REBIF ...................................................... 47
REBIF REBIDOSE ................................... 47
REBIF REBIDOSE TITRATION PACK..... 47
REBIF TITRATION PACK ........................ 47
RECLAST ................................................ 47
RECOMBIVAX HB ................................... 50
RECTIV .................................................... 53
REGLAN .................................................. 38
REGONOL SOLN 10 MG/2ML ................. 17
REGRANEX ............................................. 53
Kaiser Permanente 2017 Comprehensive Formulary • 79
RELENZA DISKHALER ........................... 12
RELISTOR............................................... 38
RELPAX .................................................. 28
REMERON .............................................. 31
REMERON SOLTAB ............................... 31
REMICADE.............................................. 47
REMODULIN ........................................... 49
RENAGEL ............................................... 33
RENVELA PACK 0.8 GM ........................ 33
RENVELA PACK 2.4 GM ........................ 33
RENVELA TABS 800 MG ........................ 33
repaglinide ............................................... 42
repaglinide-metformin hcl ........................ 42
REPATHA................................................ 19
REPATHA PUSHTRONEX SYSTEM ...... 19
REPATHA SURECLICK .......................... 19
REQUIP ................................................... 28
REQUIP XL ............................................. 28
RESCRIPTOR ......................................... 12
RESERPINE ............................................ 20
RESTASIS ............................................... 35
RESTORIL............................................... 29
RETIN-A CREA 0.025 % ......................... 53
RETIN-A CREA 0.05 % ........................... 53
RETIN-A CREA 0.1 % ............................. 53
RETIN-A GEL 0.01 % .............................. 53
RETIN-A GEL 0.025 % ............................ 53
RETIN-A MICRO GEL 0.04 % ................. 53
RETIN-A MICRO GEL 0.1 % ................... 53
RETIN-A MICRO PUMP GEL 0.04 % ...... 53
RETIN-A MICRO PUMP GEL 0.08 % ...... 53
RETIN-A MICRO PUMP GEL 0.1 % ........ 53
RETROVIR CAPS 100 MG ...................... 12
RETROVIR SOLN 10 MG/ML .................. 12
RETROVIR SYRP 50 MG/5ML ................ 12
REVATIO SOLN 10 MG/12.5ML.............. 22
REVATIO SUSR 10 MG/ML .................... 22
REVATIO TABS 20 MG ........................... 22
REVLIMID................................................ 15
REXULTI ................................................. 31
REYATAZ ................................................ 12
RHEUMATREX ....................................... 15
RHINOCORT AQUA ................................ 35
RHOPHYLAC .......................................... 50
ribavirin (hepatitis c)................................. 12
RIDAURA ................................................ 38
rifabutin .................................................... 10
RIFADIN .................................................. 10
rifampin .................................................... 10
RIFATER.................................................. 10
RILUTEK .................................................. 29
riluzole ..................................................... 29
rimantadine hydrochloride ........................ 12
RIMSO-50 ................................................ 47
RIOMET ................................................... 42
risedronate sodium................................... 47
RISPERDAL............................................. 31
RISPERDAL CONSTA ............................. 31
RISPERDAL M-TAB................................. 31
risperidone ............................................... 31
RITALIN LA CP24 10 MG ........................ 26
RITALIN LA CP24 20 MG ........................ 26
RITALIN LA CP24 30 MG ........................ 26
RITALIN LA CP24 40 MG ........................ 26
RITALIN LA CP24 60 MG ........................ 26
RITALIN TABS 10 MG ............................. 26
RITALIN TABS 20 MG ............................. 26
RITALIN TABS 5 MG ............................... 26
RITUXAN ................................................. 15
rivastigmine .............................................. 17
rivastigmine tartrate.................................. 17
rizatriptan benzoate.................................. 28
ROBINUL SOLN 0.4 MG/2ML .................. 16
ROBINUL TABS 1 MG ............................. 16
ROBINUL-FORTE TABS 2 MG ................ 16
ROCALTROL ........................................... 54
ropinirole hydrochloride ............................ 28
rosuvastatin calcium................................. 19
ROTARIX ................................................. 50
ROTATEQ................................................ 50
ROXICODONE ........................................ 24
ROZEREM ............................................... 29
RUCONEST ............................................. 47
RYNODERM ............................................ 53
RYTARY .................................................. 28
RYTHMOL ............................................... 20
RYTHMOL SR ......................................... 20
S
SABRIL .................................................... 27
SAFYRAL................................................. 41
SAIZEN .................................................... 45
SAIZEN CLICK.EASY .............................. 45
SALAGEN ................................................ 17
SAMSCA .................................................. 33
SANCUSO ............................................... 37
SANDIMMUNE ........................................ 47
SANDOSTATIN LAR DEPOT KIT 10 MG 47
80 • Kaiser Permanente 2017 Comprehensive Formulary
SANDOSTATIN LAR DEPOT KIT 20 MG 47
SANDOSTATIN LAR DEPOT KIT 30 MG 47
SANDOSTATIN SOLN 100 MCG/ML ...... 47
SANDOSTATIN SOLN 1000 MCG/ML .... 48
SANDOSTATIN SOLN 200 MCG/ML ...... 48
SANDOSTATIN SOLN 50 MCG/ML ........ 48
SANDOSTATIN SOLN 500 MCG/ML ...... 48
SANTYL .................................................. 53
SAPHRIS ................................................. 31
SARAFEM ............................................... 31
SAVAYSA ................................................ 18
SAVELLA................................................. 29
SAVELLA TITRATION PACK .................. 29
SEASONIQUE ......................................... 41
SECTRAL ................................................ 23
selegiline hcl ............................................ 28
selenium sulfide ....................................... 51
SELZENTRY ........................................... 12
SEMPREX-D ........................................... 13
SENSIPAR TABS 30 MG ........................ 48
SENSIPAR TABS 60 MG ........................ 48
SENSIPAR TABS 90 MG ........................ 48
SEREVENT DISKUS ............................... 18
SEROQUEL............................................. 31
SEROQUEL XR....................................... 31
SEROSTIM .............................................. 45
sertraline hcl ............................................ 31
SFROWASA ENEM 4 GM/60ML ............. 37
SIGNIFOR ............................................... 45
SIGNIFOR LAR ....................................... 45
sildenafil citrate (pulmonary hypertension)
............................................................. 22
SILENOR ................................................. 29
SILVADENE ............................................ 51
silver sulfadiazine .................................... 51
SIMBRINZA ............................................. 36
SIMPONI ................................................. 48
SIMPONI ARIA ........................................ 48
SIMULECT .............................................. 48
simvastatin............................................... 19
SINEMET................................................. 28
SINEMET CR .......................................... 28
SINGULAIR ............................................. 48
sirolimus .................................................. 48
SIRTURO ................................................ 10
SIVEXTRO ................................................ 9
SKELAXIN ............................................... 17
SKLICE ...................................................... 8
sodium chloride ................................. 33, 34
sodium chloride (gu irrigant) ..................... 33
SODIUM DIURIL ...................................... 33
SODIUM EDECRIN.................................. 33
SODIUM FLUORIDE................................ 48
SODIUM LACTATE.................................. 31
sodium phenylbutyrate ............................. 31
sodium polystyrene sulfonate ................... 33
SOLARAZE .............................................. 53
SOLODYN ................................................. 9
SOLTAMOX ............................................. 15
SOLU-CORTEF ....................................... 39
SOLU-MEDROL SOLR 125 MG .............. 39
SOLU-MEDROL SOLR 2 GM .................. 39
SOLU-MEDROL SOLR 40 MG ................ 39
SOLU-MEDROL SOLR 500 MG .............. 39
SOMA ...................................................... 17
SOMATULINE DEPOT ............................ 48
SOMAVERT ............................................. 45
SONATA .................................................. 29
SOOLANTRA ........................................... 51
SORIATANE ............................................ 53
SORILUX ................................................. 53
sotalol hcl ................................................. 23
sotalol hcl (afib/afl) ................................... 23
SOTYLIZE................................................ 23
SOVALDI ................................................. 12
SPIRIVA HANDIHALER CAPS 18 MCG .. 16
SPIRIVA RESPIMAT AERS 1.25 MCG/ACT
............................................................. 16
SPIRIVA RESPIMAT AERS 2.5 MCG/ACT
............................................................. 16
spironolactone & hydrochlorothiazide....... 21
spironolactone tabs 100 mg ..................... 21
spironolactone tabs 25 mg ....................... 21
spironolactone tabs 50 mg ....................... 21
SPORANOX CAPS 100 MG .................... 10
SPORANOX SOLN 10 MG/ML ................ 10
SPRITAM TB3D 1000 MG ....................... 27
SPRITAM TB3D 250 MG ......................... 27
SPRITAM TB3D 500 MG ......................... 27
SPRITAM TB3D 750 MG ......................... 27
SPRYCEL ................................................ 15
STALEVO 100 ......................................... 28
STALEVO 125 ......................................... 28
STALEVO 150 ......................................... 28
STALEVO 200 ......................................... 28
STALEVO 50 ........................................... 28
STALEVO 75 ........................................... 28
STARLIX .................................................. 42
Kaiser Permanente 2017 Comprehensive Formulary • 81
stavudine ................................................. 12
STELARA ................................................ 53
STIMATE SOLN 1.5 MG/ML .................... 44
STIOLTO RESPIMAT .............................. 16
STIVARGA .............................................. 15
STRATTERA ........................................... 29
STRENSIQ .............................................. 34
streptomycin sulfate ................................... 9
STRIANT MISC 30 MG............................ 40
STRIBILD ................................................ 12
STRIVERDI RESPIMAT .......................... 18
STROMECTOL.......................................... 8
SUBOXONE ............................................ 29
SUBSYS .................................................. 24
SUCRAID ................................................ 34
sucralfate ................................................. 38
SULAR .................................................... 20
sulfacetamide sodium (acne) ................... 51
sulfacetamide sodium (ophth) .................. 35
sulfacetamide sod-prednisolone .............. 35
sulfadiazine................................................ 9
sulfamethoxazole-trimethoprim .................. 9
SULFAMYLON CREA 85 MG/GM ........... 51
SULFAMYLON PACK 5 % ...................... 51
sulfasalazine .............................................. 9
sulindac ................................................... 24
SUMATRIPTAN ....................................... 28
sumatriptan succinate .............................. 28
SUMAVEL DOSEPRO............................. 28
SUPRAX .................................................... 9
SUPREP BOWEL PREP ......................... 38
SURMONTIL ........................................... 31
SUSTIVA ................................................. 12
SUTENT .................................................. 15
SYLATRON ............................................. 15
SYLVANT ................................................ 15
SYMBICORT ........................................... 49
SYMBYAX ............................................... 31
SYMLINPEN 120 ..................................... 42
SYMLINPEN 60 ....................................... 42
SYNAGIS................................................. 12
SYNALAR (CREAM)................................ 52
SYNALGOS-DC ...................................... 24
SYNAREL ................................................ 43
SYNERA .................................................. 52
SYNERCID ................................................ 9
SYNJARDY ............................................. 42
SYNRIBO ................................................ 15
SYNTHROID ........................................... 45
SYPRINE ................................................. 39
T
TABLOID.................................................. 15
TACLONEX OINT 0.005-0.064 % ............ 52
TACLONEX SUSP 0.005-0.064 % ........... 52
tacrolimus........................................... 48, 53
tacrolimus (topical) ................................... 53
TAFINLAR................................................ 15
TAGRISSO .............................................. 15
TALTZ ...................................................... 53
TALWIN ................................................... 24
TAMIFLU.................................................. 12
tamoxifen citrate ....................................... 15
tamsulosin hcl .......................................... 17
TANZEUM................................................ 42
TARCEVA ................................................ 15
TARGRETIN ...................................... 15, 53
TARGRETIN GEL .................................... 53
TARKA ..................................................... 20
TASIGNA ................................................. 15
TASMAR .................................................. 28
TAXOTERE CONC 80 MG/4ML ............... 15
TAZORAC ................................................ 53
TECENTRIQ ............................................ 15
TECFIDERA............................................. 48
TECHNIVIE .............................................. 12
TEFLARO .................................................. 9
TEGRETOL.............................................. 27
TEGRETOL-XR ....................................... 27
TEKTURNA.............................................. 21
TEKTURNA HCT ..................................... 21
telmisartan ......................................... 20, 21
telmisartan-amlodipine ............................. 20
telmisartan-hydrochlorothiazide ............... 21
temazepam .............................................. 29
TENEX ..................................................... 20
TENIPOSIDE ........................................... 15
TENIVAC ................................................. 50
TENORETIC 100 ..................................... 23
TENORETIC 50 ....................................... 23
TENORMIN .............................................. 23
TERAZOL 3 ............................................. 51
TERAZOL 7 ............................................. 51
terazosin hcl ............................................. 19
terbinafine hcl ........................................... 10
terbutaline sulfate ..................................... 18
terconazole vaginal .................................. 51
TESTIM GEL 50 MG/5GM (1%) ............... 40
82 • Kaiser Permanente 2017 Comprehensive Formulary
testosterone ............................................. 40
testosterone cypionate............................. 40
testosterone enanthate ............................ 40
TESTOSTERONE GEL 25 MG/2.5GM (1%)
............................................................. 40
TETANUS-DIPHTHERIA TOXOIDS TD .. 50
tetrabenazine ........................................... 29
TETRACYCLINE HCL ............................... 9
TEV-TROPIN SOLR 5 MG ...................... 45
THALOMID .............................................. 48
theophylline ............................................. 54
THIOLA ................................................... 48
thioridazine hcl ......................................... 31
thiotepa .................................................... 15
thiothixene ............................................... 31
THYMOGLOBULIN.................................. 48
THYROLAR-1 .......................................... 45
THYROLAR-1/2 ....................................... 45
THYROLAR-1/4 ....................................... 45
THYROLAR-2 .......................................... 45
THYROLAR-3 .......................................... 45
tiagabine hcl ............................................ 27
TIAZAC.................................................... 20
TICE BCG................................................ 15
TIGAN ..................................................... 37
TIKOSYN ................................................. 20
timolol maleate .................................. 23, 36
timolol maleate (ophth) ............................ 36
TIMOPTIC OCUDOSE ............................ 36
TIMOPTIC-XE ......................................... 36
TINDAMAX .............................................. 11
tinidazole ................................................. 11
TIROSINT ................................................ 45
TIVICAY TABS 10 MG............................. 12
TIVICAY TABS 25 MG............................. 12
TIVICAY TABS 50 MG............................. 12
TIVORBEX .............................................. 24
tizanidine hcl ............................................ 17
TOBI .......................................................... 9
TOBI PODHALER ..................................... 9
TOBRADEX OINT 0.3-0.1 % ................... 35
TOBRADEX ST SUSP 0.3-0.05 % .......... 36
TOBRADEX SUSP 0.3-0.1 % .................. 36
tobramycin ..................................... 9, 35, 36
tobramycin (ophth) ................................... 35
tobramycin sulfate ..................................... 9
tobramycin-dexamethasone .................... 36
TOBREX OINT 0.3 % .............................. 35
TOBREX SOLN 0.3 % ............................. 35
TOLAK CREA 4 % ................................... 53
tolazamide................................................ 42
tolbutamide .............................................. 42
tolcapone ................................................. 28
tolmetin sodium ........................................ 25
tolterodine tartrate .................................... 54
TOPAMAX ............................................... 27
TOPAMAX SPRINKLE ............................. 27
TOPICORT .............................................. 52
TOPICORT SPRAY ................................. 52
topiramate ................................................ 27
topotecan hcl ............................................ 15
TOPROL XL ............................................. 23
TORISEL.................................................. 15
torsemide ................................................. 33
TOUJEO SOLOSTAR SOPN 300 UNIT/ML
............................................................. 42
TOVIAZ .................................................... 54
TRACLEER .............................................. 49
TRADJENTA ............................................ 42
tramadol hcl ............................................. 25
tramadol-acetaminophen ......................... 25
trandolapril ......................................... 20, 21
trandolapril-verapamil hcl ......................... 20
tranexamic acid ........................................ 18
TRANSDERM-SCOP (1.5 MG) ................ 37
TRANXENE-T .......................................... 29
tranylcypromine sulfate ............................ 31
TRAVASOL SOLN 10 % .......................... 32
TRAVATAN Z ........................................... 36
travoprost ................................................. 36
trazodone hcl tabs 100 mg ....................... 31
trazodone hcl tabs 150 mg ....................... 31
trazodone hcl tabs 300 mg ....................... 31
trazodone hcl tabs 50 mg ......................... 31
TREANDA SOLR 100 MG........................ 15
TRECATOR ............................................. 10
TRELSTAR MIXJECT .............................. 15
TRESIBA FLEXTOUCH ........................... 42
tretinoin .............................................. 15, 53
tretinoin (chemotherapy) .......................... 15
tretinoin microsphere................................ 53
tretinoin w/ cleanser & moisturizer ........... 53
TREXIMET ............................................... 28
triamcinolone acetonide (mouth) .............. 52
triamcinolone acetonide (topical) .............. 52
triamterene-hctz caps 37.5-25 mg ............ 33
triamterene-hctz caps 50-25 mg ............... 33
triamterene-hctz tabs 37.5-25 mg ............ 33
Kaiser Permanente 2017 Comprehensive Formulary • 83
triamterene-hctz tabs 75-50 mg ............... 33
triazolam .................................................. 29
TRIBENZOR ............................................ 20
TRICOR ................................................... 19
trifluoperazine hcl .................................... 31
trifluridine ................................................. 35
TRIGLIDE ................................................ 19
trihexyphenidyl hcl ................................... 28
TRILEPTAL ............................................. 27
TRILIPIX .................................................. 19
trimethobenzamide hcl............................. 37
trimethoprim............................................. 13
trimipramine maleate ............................... 31
TRI-NORINYL (28) .................................. 41
TRINTELLIX ............................................ 31
TRIOSTAT ............................................... 45
TRISENOX .............................................. 15
TRIUMEQ ................................................ 12
TRIZIVIR.................................................. 12
TROKENDI XR ........................................ 27
TROPHAMINE SOLN 10 % ..................... 32
TROPHAMINE SOLN 6 % ....................... 32
trospium chloride ..................................... 54
TRULICITY .............................................. 42
TRUMENBA ............................................ 50
TRUSOPT ............................................... 36
TRUVADA TABS 100-150 MG ................ 12
TRUVADA TABS 133-200 MG ................ 12
TRUVADA TABS 167-250 MG ................ 12
TRUVADA TABS 200-300 MG ................ 12
TUDORZA PRESSAIR ............................ 16
TWINRIX ................................................. 50
TWYNSTA ............................................... 20
TYBOST .................................................. 48
TYGACIL ................................................... 9
TYKERB .................................................. 15
TYPHIM VI............................................... 50
TYSABRI ................................................. 48
TYVASO .................................................. 49
TYZEKA .................................................. 12
U
UCERIS ............................................. 39, 52
UCERIS FOAM........................................ 52
ULORIC ................................................... 48
ULTRACET.............................................. 25
ULTRAM .................................................. 25
ULTRAM ER ............................................ 25
ULTRAVATE CREA 0.05 %..................... 52
ULTRAVATE LOTN 0.05 % ..................... 52
ULTRAVATE OINT 0.05 % ...................... 52
UNASYN .................................................... 9
UNITUXIN ................................................ 15
UPTRAVI ................................................. 49
UROCIT-K 10........................................... 31
UROCIT-K 15........................................... 31
UROCIT-K 5............................................. 31
UROXATRAL ........................................... 17
URSO 250................................................ 38
URSO FORTE ......................................... 38
ursodiol .................................................... 38
UVADEX .................................................. 53
V
VAGIFEM ................................................. 43
valacyclovir hcl ......................................... 12
VALCHLOR.............................................. 53
VALCYTE SOLR 50 MG/ML .................... 12
VALCYTE TABS 450 MG ......................... 12
valganciclovir hcl ...................................... 12
VALIUM.................................................... 29
valproate sodium ...................................... 27
valproic acid ............................................. 27
valsartan .................................................. 21
valsartan-hydrochlorothiazide .................. 21
VALSTAR................................................. 15
VALTREX................................................. 12
VANCOCIN HCL ........................................ 9
vancomycin hcl .......................................... 9
VANCOMYCIN HCL IN DEXTROSE.......... 9
VANOS .................................................... 52
VANTAS................................................... 15
VAQTA ..................................................... 50
VARIVAX ................................................. 50
VARIZIG................................................... 50
VARUBI.................................................... 37
VASCEPA ................................................ 19
VASERETIC............................................. 21
VASOTEC ................................................ 21
VECTIBIX................................................. 15
VECTICAL ............................................... 53
VELCADE ................................................ 15
VELPHORO ............................................. 33
VELTASSA .............................................. 33
VELTIN .................................................... 53
VENCLEXTA STARTING PACK TBPK 10 &
50 & 100 MG ........................................ 16
VENCLEXTA TABS 10 MG ...................... 16
84 • Kaiser Permanente 2017 Comprehensive Formulary
VENCLEXTA TABS 100 MG ................... 16
VENCLEXTA TABS 50 MG ..................... 16
venlafaxine hcl ......................................... 31
VENLAFAXINE HCL ER .......................... 31
VENTAVIS ............................................... 49
VENTOLIN HFA AERS 108 (90 BASE)
MCG/ACT ............................................ 18
VERAMYST ............................................. 36
verapamil hcl ........................................... 20
VEREGEN ............................................... 54
VERELAN ................................................ 20
VERELAN PM ......................................... 20
VERSACLOZ ........................................... 31
VESICARE .............................................. 54
VEXOL .................................................... 36
VFEND IV SOLR 200 MG ........................ 10
VFEND SUSR 40 MG/ML ........................ 10
VFEND TABS 200 MG ............................ 10
VFEND TABS 50 MG .............................. 10
VIBERZI .................................................. 38
VIBRAMYCIN ............................................ 9
VICOPROFEN ......................................... 25
VICTOZA ................................................. 42
VICTRELIS .............................................. 12
VIDAZA ................................................... 16
VIDEX EC CPDR 125 MG ....................... 12
VIDEX EC CPDR 200 MG ....................... 12
VIDEX EC CPDR 250 MG ....................... 12
VIDEX EC CPDR 400 MG ....................... 12
VIDEX SOLR 2 GM ................................. 12
VIEKIRA PAK .......................................... 12
VIEKIRA XR ............................................ 12
VIGAMOX ................................................ 35
VIIBRYD .................................................. 31
VIIBRYD STARTER PACK ...................... 31
VIMIZIM ................................................... 34
VIMOVO .................................................. 25
VIMPAT ................................................... 27
VINATE CALCIUM................................... 54
vinblastine sulfate .................................... 16
vincristine sulfate ..................................... 16
vinorelbine tartrate ................................... 16
VIOKACE TABS 10440 UNIT .................. 38
VIOKACE TABS 20880 UNIT .................. 38
VIRACEPT............................................... 12
VIRAMUNE.............................................. 12
VIRAMUNE XR ........................................ 12
VIRAZOLE ............................................... 12
VIREAD POWD 40 MG/GM ..................... 12
VIREAD TABS 150 MG ............................ 12
VIREAD TABS 200 MG ............................ 12
VIREAD TABS 250 MG ............................ 12
VIREAD TABS 300 MG ............................ 12
VIROPTIC ................................................ 35
VISTARIL ................................................. 29
VISTIDE ................................................... 12
VISTOGARD ............................................ 48
VITEKTA .................................................. 12
VIVELLE-DOT PTTW 0.025 MG/24HR .... 43
VIVELLE-DOT PTTW 0.0375 MG/24HR .. 43
VIVELLE-DOT PTTW 0.05 MG/24HR ...... 43
VIVELLE-DOT PTTW 0.075 MG/24HR .... 43
VIVELLE-DOT PTTW 0.1 MG/24HR ........ 43
VIVITROL................................................. 29
VIVLODEX ............................................... 25
VOGELXO GEL 50 MG/5GM (1%)........... 40
VOGELXO PUMP GEL 12.5 MG/ACT (1%)
............................................................. 40
VOLTAREN.............................................. 54
VORAXAZE ............................................. 48
voriconazole ............................................. 10
vospire er tb12 4 mg ................................ 18
vospire er tb12 8 mg ................................ 18
VOTRIENT ............................................... 16
VP-PNV-DHA ........................................... 54
VPRIV ...................................................... 34
VRAYLAR CAPS 1.5 MG ......................... 31
VRAYLAR CAPS 3 MG ............................ 31
VRAYLAR CAPS 4.5 MG ......................... 31
VRAYLAR CAPS 6 MG ............................ 31
VRAYLAR CPPK 1.5 & 3 MG................... 31
VYTORIN ................................................. 19
VYVANSE ................................................ 26
W
warfarin sodium ........................................ 18
water for irrigation, sterile ......................... 33
WELCHOL ............................................... 19
WELLBUTRIN .......................................... 31
WELLBUTRIN SR .................................... 31
WELLBUTRIN XL..................................... 31
X
XALATAN................................................. 36
XALKORI ................................................. 16
XANAX ..................................................... 29
XANAX XR ............................................... 29
Kaiser Permanente 2017 Comprehensive Formulary • 85
XARELTO ................................................ 18
XARELTO STARTER PACK.................... 18
XARTEMIS XR ........................................ 25
XELJANZ ................................................. 48
XELJANZ XR ........................................... 48
XENAZINE............................................... 29
XEOMIN SOLR 100 UNIT ....................... 48
XEOMIN SOLR 200 UNIT ....................... 48
XEOMIN SOLR 50 UNIT ......................... 48
XERESE .................................................. 51
XGEVA SOLN 120 MG/1.7ML ................. 48
XIFAXAN ................................................... 9
XIGDUO XR ............................................ 42
XOLAIR ................................................... 49
XOPENEX ............................................... 18
XOPENEX CONCENTRATE ................... 18
XOPENEX HFA ....................................... 18
XTAMPZA ER.......................................... 25
XTANDI ................................................... 16
XURIDEN ................................................ 48
XYLOCAINE ............................................ 48
XYREM .................................................... 29
XYZAL ..................................................... 13
Y
YASMIN 28 .............................................. 41
YAZ ......................................................... 41
YERVOY.................................................. 16
YF-VAX ................................................... 50
YONDELIS .............................................. 16
Z
zafirlukast ................................................ 48
zaleplon ................................................... 29
ZALTRAP ................................................ 16
ZANAFLEX .............................................. 17
ZANOSAR ............................................... 16
ZANTAC .................................................. 38
ZARONTIN .............................................. 27
ZARXIO ................................................... 18
ZAVESCA ................................................ 48
ZEBETA .................................................. 23
ZEGERID................................................. 38
ZELAPAR ................................................ 28
ZELBORAF.............................................. 16
ZEMAIRA................................................. 49
ZEMBRACE SYMTOUCH ....................... 28
ZEMPLAR................................................ 54
ZENPEP CPEP 10000 UNIT .................... 38
ZENPEP CPEP 15000 UNIT .................... 38
ZENPEP CPEP 20000 UNIT .................... 38
ZENPEP CPEP 25000 UNIT .................... 38
ZENPEP CPEP 3000-10000 UNIT ........... 38
ZENPEP CPEP 40000 UNIT .................... 38
ZENPEP CPEP 5000 UNIT ...................... 38
ZEPATIER ............................................... 12
ZERBAXA .................................................. 9
ZERIT ...................................................... 12
ZESTORETIC .......................................... 21
ZESTRIL .................................................. 21
ZETIA ....................................................... 19
ZETONNA ................................................ 36
ZIAC......................................................... 23
ZIAGEN SOLN 20 MG/ML ....................... 12
ZIAGEN TABS 300 MG ............................ 12
ZIANA ...................................................... 54
zidovudine ................................................ 12
ZINACEF IN STERILE WATER ............... 10
ZINACEF SOLR 1.5 GM .......................... 10
ZINACEF SOLR 7.5 GM .......................... 10
ZINACEF SOLR 750 MG ......................... 10
ZINBRYTA ............................................... 48
ZINC TRACE METAL............................... 34
ZINECARD............................................... 48
ZIOPTAN ................................................. 36
ziprasidone hcl ......................................... 31
ZIPSOR.................................................... 25
ZIRGAN ................................................... 35
ZITHROMAX PACK 1 GM........................ 10
ZITHROMAX SOLR 500 MG.................... 10
ZITHROMAX SUSR 100 MG/5ML ........... 10
ZITHROMAX SUSR 200 MG/5ML ........... 10
ZITHROMAX TABS 250 MG .................... 10
ZITHROMAX TABS 500 MG .................... 10
ZITHROMAX TABS 600 MG .................... 10
ZITHROMAX TRI-PAK TABS 500 MG ..... 10
ZITHROMAX Z-PAK TABS 250 MG......... 10
ZMAX SUSR 2 GM .................................. 10
ZOCOR .................................................... 19
ZOFRAN .................................................. 37
ZOFRAN ODT .......................................... 37
ZOHYDRO ER ......................................... 25
zoledronic acid ......................................... 48
ZOLINZA .................................................. 16
zolmitriptan............................................... 28
ZOLOFT ................................................... 31
zolpidem tartrate ...................................... 29
86 • Kaiser Permanente 2017 Comprehensive Formulary
ZOLPIMIST.............................................. 29
ZOMACTON SOLR 10 MG ...................... 45
ZOMACTON SOLR 5 MG ........................ 45
ZOMETA.................................................. 48
ZOMIG ..................................................... 28
ZOMIG ZMT ............................................ 28
ZONALON ............................................... 52
ZONEGRAN ............................................ 27
zonisamide .............................................. 27
ZONTIVITY .............................................. 18
ZORBTIVE............................................... 45
ZORTRESS TABS 0.25 MG .................... 48
ZORTRESS TABS 0.5 MG ...................... 48
ZORTRESS TABS 0.75 MG .................... 48
ZORVOLEX ............................................. 25
ZOSTAVAX ............................................. 50
ZOSYN .................................................... 10
ZOVIRAX ........................................... 12, 51
ZUBSOLV ................................................ 29
ZUPLENZ................................................. 37
ZYBAN ..................................................... 31
ZYCLARA ................................................ 54
ZYCLARA PUMP ..................................... 54
ZYDELIG.................................................. 16
ZYFLO CR TB12 600 MG ........................ 48
ZYFLO TABS 600 MG ............................. 48
ZYKADIA.................................................. 16
ZYLET ...................................................... 36
ZYLOPRIM............................................... 48
ZYMAXID ................................................. 35
ZYPREXA ................................................ 31
ZYPREXA RELPREVV ............................ 31
ZYPREXA ZYDIS ..................................... 31
ZYTIGA .................................................... 16
ZYVOX ..................................................... 10
Kaiser Permanente 2017 Comprehensive Formulary • 87
This formulary was updated on 09/01/16. 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)
Member Service Contact Center
1-800-443-0815 TTY 711
COLORADO REGION
Kaiser Foundation Health Plan of Colorado
10350 E. Dakota Ave.
Denver, CO 80247
Kaiser Permanente Senior Advantage
(HMO) and Senior Advantage Medicare
Medicaid Plan (HMO SNP)
Member Services
1-800-476-2167 TTY 711
GEORGIA REGION
Kaiser Foundation Health Plan
of Georgia, Inc.
Nine Piedmont Center
3495 Piedmont Rd. NE
Atlanta, GA 30305
Kaiser Permanente Senior Advantage
(HMO) and Senior Advantage Medicare
Medicaid Plan (HMO SNP)
Member Services
1-800-232-4404 TTY 711
kp.org/seniormedrx
Please recycle.
60424016 09/2016
HAWAII REGION
Kaiser Foundation Health Plan, Inc.
711 Kapiolani Blvd.
Tower Suite 400
Honolulu, HI 96813
Kaiser Permanente Senior Advantage
(HMO) and Senior Advantage Medicare
Medicaid Plan (HMO SNP)
Member Services
1-800-805-2739 TTY 711
MID-ATLANTIC STATES REGION
(District of Columbia, Maryland,
and Virginia)
Kaiser Foundation Health Plan
of the Mid-Atlantic States, Inc.
2101 East Jefferson St.
Rockville, MD 20852
Kaiser Permanente Medicare Plus (Cost)
Member Services
1-888-777-5536 TTY 711
NORTHWEST REGION
Kaiser Foundation Health Plan
of the Northwest
500 NE Multnomah St., Suite 100
Portland, OR 97232
Kaiser Permanente Senior Advantage
(HMO)
Membership Services
1-877-221-8221 TTY 711

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