2016 Kaiser Permanente FEHB Drug Formulary, Northern California

2016 Kaiser Permanente FEHB Drug Formulary, Northern California

2016 Kaiser Permanente Federal Employees Health Benefit
FEHB Drug Formulary
Northern California Region
60386410
Member Service Contact Center
24 hours a day, 7 days a week. Closed holidays.
1-800-464-4000
711 TTY
2016 Kaiser Permanente Federal Employees
Health Benefit (FEHB) Drug Formulary
Northern California Region
This document contains information about the drugs we cover when you participate in a Federal Employees
Health Benefits (FEHB) plan offered by Kaiser Permanente.
This formulary is effective May 1, 2016.
What is the Kaiser Permanente FEHB Drug Formulary?
A formulary is a list of drugs determined to be safe and effective for our members by our Pharmacy and
Therapeutics Committee. Use of formulary drugs enables Kaiser Permanente to provide high quality care to
you and your family at reasonable costs. Kaiser Permanente continually updates the formulary throughout the
year based on new medical evidence, considering the recommendations of appropriate physician experts.
How much will I pay for covered drugs?
The cost-sharing you will pay for most drugs depends on:
•
•
the tier in which your drug is categorized, and
whether your drug is included in our formulary. Preferred drugs are included in our formulary. Nonpreferred drugs are not included in our formulary.
We categorize prescription drugs into four tiers:
Drug
Tier
Type
Description
Tier 1
Generic drugs
Generic drugs are produced and sold under their generic names
after the patent on the brand-name drug expires. Although the price
is usually lower, the quality of generic drugs is the same as brandname drugs. Generic drugs are also just as effective as brand-name
drugs. The U.S. Food and Drug Administration (FDA) requires that a
generic drug contain the same active drug ingredient in the same
amount as the brand-name drug.
Tier 2
Preferred brandname drugs
Brand-name drugs are produced and sold under the original
manufacturer's brand name. Preferred brand-name drugs are listed
on our drug formulary.
Tier 3
Non-preferred
brand-name drugs
Non-preferred brand-name drugs are not listed on our drug
formulary and are not covered unless approved through the
exception process.
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 1
Drug
Tier
Tier 4
Type
Specialty drugs
Description
Specialty drugs are high-cost drugs that are on our specialty drug
list. Kaiser Permanente adopts the model used by most Medicare
plans to determine which drugs are in the specialty tier.
The amount you pay and other coverage information is determined by the outpatient prescription drug
benefit in your FEHB brochure (RI 73-003, See Section 5(f) Prescription drug benefits).
Some drugs may be covered at no cost or a different cost-sharing amount. Examples of these include tobacco
cessation medications, women’s contraceptive drugs and devices at no cost; fertility drugs and sexual
dysfunction drugs have different cost-sharing amounts. Cost-sharing for these drugs is listed in your FEHB
brochure.
All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure. To get a
copy of your FEHB brochure or if you have questions, please visit our website at kp.org/feds or call Member
Services at 1-800-464-4000, 24 hours a day, 7 days a week (closed holidays). For TTY for the hearing/speech
impaired, call 711.
How do I use the FEHB Drug Formulary?
Our formulary drugs are listed in this formulary by medical condition and alphabetically. We consider drugs
not listed on our formulary to be “non-preferred drugs”. You may pay higher cost-sharing for non-formulary
drugs that are medically necessary.
The cost-sharing you pay and other coverage information is determined by the outpatient prescription drug
benefit in your FEHB brochure (RI 73-003, See Section 5(f) Prescription drug benefits).
Formulary Drugs by Medical Condition
The formulary begins on page 4. The drugs in this formulary are grouped into categories depending on the
type of medical condition that they are used to treat. For example, drugs used to treat a heart condition
are listed under the category, “Cardiovascular Agents.” If you know the medical condition your drug is
used for, simply look for the category name in the list. Then look under the category name for your drug.
Formulary Drugs by Alphabetical Listing
If you are not sure what category to look under, the Index starting on page 22, provides an alphabetical
list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed.
Look in the Index to find the drug name and the page number where you can locate coverage information.
Turn to the page listed in the Index and find the name of the drug on the list. If you are using a computer
to view this document, you also use the search function (Ctrl F) to find the medication by name.
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 2
Columns on Medical Condition and Alphabetical Listings
There are three columns in the attached chart.
•
•
•
The first column lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs
are listed in lower-case italics (e.g. amoxicillin). Some drugs include different dosage forms and strengths.
All dosage forms and strengths for a particular drug listed may not be on the Formulary. Some drugs have
multiple dosage forms. In such cases, some dosages may be on the Formulary and others not. Some of
these drugs may be available only in a clinic setting.
The second column indicates drug tier. Some drugs may have more than one tier listed in this column. This
means that the amount you pay may vary based on the dosage or the way the drug is administered. You
will find cost-sharing for your drug in your FEHB brochure. To get a copy of your FEHB brochure or if you
have questions, please visit our website at kp.org/feds or call Member Services at 1-800-464-4000 (TTY
711), 24 hours a day, 7 days a week (closed holidays).
The third column indicates additional requirements or limits on coverage. These requirements and limits may
include:
QL = Quantity Limit. For certain drugs, we may limit the amount of the drug you can receive.
Additionally, when there is a national shortage of a drug, we may limit the quantity of
the drug dispensed.
Does the FEHB Drug Formulary ever change?
Yes, Kaiser Permanente continually updates the formulary based on new medical evidence, considering the
recommendations of appropriate physician experts and notifies our doctors, pharmacists, and other clinicians
about any changes. If a change in the formulary affects any of your prescriptions, your doctor or pharmacist
will let you know.
Our online formulary at kp.org/formulary is updated on a regular basis. To get updated information about the
drugs covered by Kaiser Permanente or if you have questions, please visit our website at kp.org/feds or call
Member Services at 1-800-464-4000, 24 hours a day, 7 days a week (closed holidays). For TTY for the
hearing/speech impaired, call 711.
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 3
Formulary Drugs by Medical Condition
Drug
Tier
Name of drug
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ALBENZA
BILTRICIDE
ANTIBACTERIALS
amikacin sulfate
amoxicillin
amoxicillin & pot
clavulanate
ampicillin & sulbactam
sodium
ampicillin sodium
AVELOX
AZACTAM IN DEXTROSE
azithromycin
aztreonam
BACTOCILL IN
DEXTROSE
BICILLIN L-A
CAYSTON
cefaclor
cefadroxil
cefazolin sodium
cefdinir
cefepime hcl
cefixime
cefotaxime sodium
cefotetan disodium
CEFOTETAN DISODIUMDEXTROSE
cefoxitin sodium
CEFOXITIN SODIUMDEXTROSE
cefpodoxime proxetil
ceftazidime
ceftriaxone sodium
CEFTRIAXONE SODIUM
IN DEXTROSE
CEFTRIAXONE SODIUMDEXTROSE
cefuroxime axetil
cefuroxime sodium
2
2
1
1, 2
1, 2
1, 2
1, 2
2
2
1, 2
1
2
2
4
1
1
1, 2
1
1
1, 2
1, 2
1
2
1
2
1
1
1
1
2
1
1, 2
Requirements
/ Limits
Drug
Tier
Name of drug
CEFUROXIME SODIUMDEXTROSE
cephalexin
CHLORAMPHENICOL
SOD SUCCINATE
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin in d5w
clarithromycin
CLEOCIN IN D5W
clindamycin hcl
clindamycin palmitate
hydrochloride
clindamycin phosphate
CUBICIN
demeclocycline hcl
dicloxacillin sodium
doxycycline (monohydrate)
doxycycline hyclate
ERYTHROCIN
LACTOBIONATE
FLUCONAZOLE IN
SODIUM CHLORIDE
gentamicin in saline
gentamicin sulfate
INVANZ
levofloxacin
levofloxacin in d5w
linezolid
meropenem
minocycline hcl
moxifloxacin hcl
nafcillin sodium
NALLPEN IN DEXTROSE
neomycin sulfate
PENICILLIN G POT IN
DEXTROSE
penicillin g potassium
PENICILLIN G PROCAINE
PENICILLIN G SODIUM
penicillin v potassium
piperacillin sodium-
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Requirements
/ Limits
2
1, 2
2
1
1
1
1
2
1
1, 2
1
4
1
1
1
1
2
2
1, 2
1
2
1
1
1, 4
1
1
1
1, 2
2
1
2
1
2
2
1
1
Page 4
Drug
Tier
Name of drug
tazobactam sodium
PRIMAXIN IV
STREPTOMYCIN
SULFATE
SULFADIAZINE
sulfamethoxazoletrimethoprim
sulfasalazine
SYNERCID
tobramycin
tobramycin sulfate
vancomycin hcl
VANCOMYCIN HCL IN
DEXTROSE
XIFAXAN
ZINACEF IN STERILE
WATER
ZOSYN
ANTIFUNGALS
ABELCET
AMPHOTERICIN B
CANCIDAS
fluconazole
fluconazole in dextrose
fluconazole in nacl
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
ketoconazole
nystatin
nystatin (mouth-throat)
terbinafine hcl
voriconazole
ANTIMYCOBACTERIALS
CAPASTAT SULFATE
DAPSONE
ethambutol hcl
isoniazid
PRIFTIN
pyrazinamide
rifabutin
rifampin
SEROMYCIN
TRECATOR
ANTIPROTOZOALS
ALINIA
Requirements
/ Limits
2
2
2
1, 2
1
2
1, 4
1
1
2
2
2
2
2
1
4
1
1
1
1
1, 2
1
1
1
1
1
1, 2
2
1, 2
1
1, 2
2
1
1
1
1
2
2
QL
Drug
Tier
Name of drug
atovaquone
atovaquone-proguanil hcl
chloroquine phosphate
COARTEM
DARAPRIM
hydroxychloroquine sulfate
mefloquine hcl
metronidazole
metronidazole in nacl
NEBUPENT
paromomycin sulfate
PRIMAQUINE
PHOSPHATE
YODOXIN
ANTIVIRALS
abacavir sulfate
abacavir sulfatelamivudine-zidovudine
acyclovir
acyclovir sodium
adefovir dipivoxil
APTIVUS
ATRIPLA
cidofovir
COMPLERA
CRIXIVAN
DAKLINZA
didanosine
EDURANT
EMTRIVA
entecavir
EPZICOM
famciclovir
FOSCAVIR
FUZEON
ganciclovir sodium
HARVONI
INFERGEN
INTELENCE
INVIRASE
ISENTRESS
KALETRA
lamivudine
lamivudine (hbv)
lamivudine-zidovudine
LEXIVA
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Requirements
/ Limits
1
1
1
2
2
1
1
1
1, 2
2
1
2
2
1, 2
1
1
1, 2
1
2
2
1
2
2
4
1, 2
2
2
1, 2
2
1
2
2
1
4
4
2
2
2
2
1
1
1
2
QL
QL
QL
Page 5
Name of drug
Drug
Tier
Requirements
/ Limits
nevirapine
1
NORVIR
2
PEG-INTRON
4
QL
PEGASYS
4
QL
PREZCOBIX
2
PREZISTA
2
RELENZA DISKHALER
2
RESCRIPTOR
2
REYATAZ
2
ribavirin (hepatitis c)
1
rimantadine hydrochloride
1
SELZENTRY
2
SOVALDI
4
QL
stavudine
1
STRIBILD
2
SUSTIVA
2
SYNAGIS
4
TAMIFLU
2
TIVICAY
2
TRIUMEQ
2
TRUVADA
2
valacyclovir hcl
1
valganciclovir hcl
1, 2
QL
VIRACEPT
2
VIRAZOLE
2
VIREAD
2
voriconazole
1
zidovudine
1, 2
URINARY ANTI-INFECTIVES
methenamine hippurate
1
nitrofurantoin
1
nitrofurantoin macrocrystal 1, 2
nitrofurantoin monohyd
1
macro
trimethoprim
1
ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
chlorpheniramine &
1
phenylephrine
cyproheptadine hcl
1
diphenhydramine hcl
1
promethazine hcl
1
ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS
ABRAXANE
2
ADCETRIS
2
Drug
Tier
Name of drug
AFINITOR
ALIMTA
ALKERAN
anastrozole
ARRANON
AVASTIN
azacitidine
bicalutamide
BICNU
bleomycin sulfate
BLINCYTO
capecitabine
CAPRELSA
cisplatin
cladribine
COMETRIQ (100 MG
DAILY DOSE)
cyclophosphamide
CYRAMZA
cytarabine
dacarbazine
DACOGEN
dactinomycin
daunorubicin hcl
DAUNOXOME
DEPOCYT
doxorubicin hcl
doxorubicin hcl liposomal
EMCYT
ERBITUX
ERIVEDGE
ERWINAZE
etoposide
exemestane
FASLODEX
fludarabine phosphate
fluorouracil
flutamide
GAZYVA
gemcitabine hcl
GLEEVEC
HERCEPTIN
HEXALEN
hydroxyurea
IBRANCE
idarubicin hcl
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
4
2
2
1
2
2
1
1
2
1
4
1
2
1
1
4
1, 2
4
1, 2
1, 2
2
1, 2
1
2
2
1
1, 2
2
2
4
2
1
1
4
1
1
1
4
1, 2
2
2
4
1
4
1, 2
Requirements
/ Limits
QL
QL
QL
QL
QL
QL
QL
Page 6
Drug
Tier
Name of drug
ifosfamide
IFOSFAMIDE-MESNA
IMBRUVICA
INTRON A
irinotecan hcl
ISTODAX
IXEMPRA KIT
JAKAFI
JEVTANA
KADCYLA
KEYTRUDA
KYPROLIS
LENVIMA 10 MG DAILY
DOSE
letrozole
LEUKERAN
leuprolide acetate
LOMUSTINE
LONSURF
LUPRON DEPOT
LUPRON DEPOT-PED
LYNPARZA
LYSODREN
MARQIBO
MATULANE
megestrol acetate
MEKINIST
melphalan hcl
mercaptopurine
methotrexate sodium
mitomycin
mitoxantrone hcl
MUSTARGEN
MYLERAN
NEXAVAR
OPDIVO
oxaliplatin
paclitaxel
pentostatin
PERJETA
POMALYST
PROLEUKIN
REVLIMID
RITUXAN
SPRYCEL
STIVARGA
1
1
4
4
1
2
2, 4
4
2
4
4
4
4
1
2
1, 2
2
4
2
2
4
2
4
4
1
4
1
1, 4
1
1
1
2
2
4
4
1
1
1
4
4
4
4
2
4
4
Requirements
/ Limits
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL, LD
QL
Name of drug
Drug
Tier
SUTENT
4
SYLVANT
4
TABLOID
2
TAFINLAR
4
tamoxifen citrate
1
TARCEVA
4
TARGRETIN
2
TASIGNA
4
TAXOTERE
2
temozolomide
1
TENIPOSIDE
2
THIOTEPA
2
topotecan hcl
1, 2
TORISEL
2
TREANDA
2
TRISENOX
2
TYKERB
4
UNITUXIN
4
VELCADE
2
VINBLASTINE SULFATE
2
vincristine sulfate
1
vinorelbine tartrate
1
VOTRIENT
4
XALKORI
4
XTANDI
4
ZANOSAR
2
ZELBORAF
4
ZYDELIG
4
ZYKADIA
4
ZYTIGA
4
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
atropine sulfate
1, 2
ATROVENT HFA
2
BELLADONNA
2
ALKALOIDS-OPIUM
chlordiazepoxide hcl1
clidinium bromide
dicyclomine hcl
1
DONNATAL
2
glycopyrrolate
1, 2
hyoscyamine sulfate
1, 2
ipratropium bromide
1
ipratropium bromide
1
(nasal)
PROPANTHELINE
2
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Requirements
/ Limits
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
Page 7
Name of drug
Drug
Tier
Requirements
/ Limits
BROMIDE
SCOPOLAMINE HBR
2
SPIRIVA RESPIMAT
2
AUTONOMIC DRUGS, MISCELLANEOUS
nicotine
1
nicotine polacrilex
1, 2
PARASYMPATHOMIMETIC (CHOLINERGIC)
AGENTS
bethanechol chloride
1
donepezil hydrochloride
1
ENLON
2
galantamine hydrobromide 1
neostigmine methylsulfate
1, 2
PHYSOSTIGMINE
2
SALICYLATE
pilocarpine hcl (oral)
1
PROSTIGMIN
2
pyridostigmine bromide
1, 2
SKELETAL MUSCLE RELAXANTS
atracurium besylate
1
baclofen
1, 2
cisatracurium besylate
1, 2
cyclobenzaprine hcl
1
dantrolene sodium
1, 2
methocarbamol
1
pancuronium bromide
1
QUELICIN
2
rocuronium bromide
1
tizanidine hcl
1
vecuronium bromide
1
SYMPATHOLYTIC (ADRENERGIC BLOCKING)
AGENTS
dihydroergotamine
1, 2
mesylate
ERGOMAR
2
guanfacine hcl
1
phenoxybenzamine hcl
1
PHENTOLAMINE
2
MESYLATE
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ADVAIR DISKUS
2
albuterol sulfate
1, 2
COMBIVENT
2
dobutamine hcl
1
dobutamine in d5w
1
dopamine hcl
1, 2
Name of drug
Drug
Tier
Requirements
/ Limits
dopamine in d5w
1
ephedrine sulfate
1
(pressors)
EPINEPHRINE
2
epinephrine hcl
1
METAPROTERENOL
1, 2
SULFATE
midodrine hcl
1
norepinephrine bitartrate
1
phenylephrine hcl
1
(pressors)
SEREVENT DISKUS
2
STRIVERDI RESPIMAT
2
terbutaline sulfate
1
BLOOD DERIVATIVES
BLOOD DERIVATIVES
albumin, human
1
PLASMANATE
2
BLOOD FORMATION, COAGULATION, AND
THROMBOSIS
ANTIANEMIA DRUGS
INFED
2
polysaccharide iron
1
complex
PROFERRIN ES
2
PROFERRIN-FORTE
2
VENOFER
2
ANTIHEMORRHAGIC AGENTS
ADVATE
2
QL
ALPHANINE SD
2
QL
aminocaproic acid
1
BENEFIX
2
QL
GELFOAM SPONGE SIZE 2
HEMOFIL M
2
QL
HUMATE-P
2
QL
KCENTRA
2
KOGENATE FS
2
QL
NOVOSEVEN RT
2
PROFILNINE
2
QL
PROTAMINE SULFATE
2
RECOTHROM
2
tranexamic acid
1
XYNTHA
2
QL
ANTITHROMBOTIC AGENTS
ACTIVASE
2
anagrelide hcl
1
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 8
Name of drug
Drug
Tier
Requirements
/ Limits
ANGIOMAX
2
argatroban
1
ASPIRIN-DIPYRIDAMOLE
1
ER
BRILINTA
2
clopidogrel bisulfate
1
EFFIENT
2
heparin (porcine) in
1, 2
sodium chloride
heparin sod (porcine) in
1, 2
d5w
heparin sodium (porcine)
1
heparin sodium (porcine)
1
lock flush
INTEGRILIN
2
LOVENOX
2
QL
PRADAXA
2
PROFILNINE
2
REOPRO
2
THROMBATE III
2
TNKASE
2
warfarin sodium
1, 2
HEMATOPOIETIC AGENTS
LEUKINE
2
NEUMEGA
4
NEUPOGEN
4
QL
PROCRIT
2
QL
PROMACTA
4
QL
ZARXIO
4
QL
HEMORRHEOLOGIC AGENTS
pentoxifylline
1
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate
1
prazosin hcl
1
tamsulosin hcl
1
terazosin hcl
1
ANTILIPEMIC AGENTS
atorvastatin calcium
1
cholestyramine
1
cholestyramine light
1
colestipol hcl
1
fenofibrate
1
gemfibrozil
1
lovastatin
1
pravastatin sodium
1
Name of drug
Drug
Tier
Requirements
/ Limits
simvastatin
1
BETA-ADRENERGIC BLOCKING AGENTS
atenolol
1
atenolol & chlorthalidone
1
bisoprolol &
1
hydrochlorothiazide
bisoprolol fumarate
1
BREVIBLOC IN NACL
2
carvedilol
1
esmolol hcl
1
labetalol hcl
1
metoprolol tartrate
1
propranolol hcl
1
sotalol hcl
1
sotalol hcl (afib/afl)
1
CALCIUM-CHANNEL BLOCKING AGENTS
amlodipine besylate
1
CLEVIPREX
2
diltiazem hcl
1
diltiazem hcl coated beads 1
nicardipine hcl
1
nifedipine
1
nimodipine
1
verapamil hcl
1
CARDIAC DRUGS
adenosine
1
amiodarone hcl
1
digoxin
1, 2
disopyramide phosphate
1, 2
flecainide acetate
1
ibutilide fumarate
1, 2
lidocaine hcl (cardiac)
1, 2
lidocaine in d5w
1
mexiletine hcl
1
milrinone in dextrose
1
milrinone lactate
1
PROCAINAMIDE HCL
2
propafenone hcl
1
quinidine gluconate
1, 2
QUINIDINE SULFATE
1
TIKOSYN
2
HYPOTENSIVE AGENTS
CARDENE IV
2
clonidine hcl
1
hydralazine hcl
1
methyldopa
1
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 9
Name of drug
Drug
Tier
Requirements
/ Limits
minoxidil
1
NITROPRESS
2
RESERPINE
2
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
INHIBITORS
benazepril hcl
1
captopril
1
enalaprilat
1
lisinopril
1
lisinopril &
1
hydrochlorothiazide
losartan potassium
1
losartan potassium &
1
hydrochlorothiazide
spironolactone
1
spironolactone &
1
hydrochlorothiazide
valsartan
1
valsartan1
hydrochlorothiazide
SCLEROSING AGENTS
ETHAMOLIN
2
SOTRADECOL
2
VASODILATING AGENTS
alprostadil
1
CAVERJECT
2
dipyridamole
1
dipyridamole (diagnostic)
1
isosorbide dinitrate
1
isosorbide mononitrate
1
LETAIRIS
4
LD
LEVITRA
2
QL
nitroglycerin
1, 2
nitroglycerin in d5w
1, 2
papaverine hcl
1
REMODULIN
4
LD
sildenafil citrate
1
(pulmonary hypertension)
TRACLEER
4
LD
TYVASO
2
VENTAVIS
4
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
acetaminophen w/ codeine 1
alfentanil
1
buprenorphine hcl
1
Name of drug
Drug
Tier
Requirements
/ Limits
buprenorphine hcl1
naloxone hcl dihydrate
butorphanol tartrate
1
choline & mag salicylate
1
CODEINE SULFATE
1, 2
etodolac
1
fentanyl
1
QL
fentanyl citrate
1
hydrocodone1, 2
acetaminophen
hydromorphone hcl
1, 2
ibuprofen
1
indomethacin
1, 2
INDOMETHACIN SODIUM 1
INFUMORPH 200
2
ketorolac tromethamine
1
MECLOFENAMATE
2
SODIUM
mefenamic acid
1
meloxicam
1
meperidine hcl
1
methadone hcl
1, 2
morphine sulfate
1, 2
nabumetone
1
nalbuphine hcl
1
naproxen
1
NEOPROFEN
2
OFIRMEV
2
OPANA
2
oxycodone hcl
1
oxycodone w/
1
QL
acetaminophen
salsalate
1
sufentanil citrate
1
sulindac
1
tramadol hcl
1
tramadol-acetaminophen
1
ULTIVA
2
ANOREXIGENIC AGENTS AND RESPIRATORY
AND CEREBRAL STIMULANTS
amphetamine1, 2
dextroamphetamine
caffeine citrate
1
dexmethylphenidate hcl
1
dextroamphetamine sulfate 1
methylphenidate hcl
1, 2
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 10
Name of drug
Drug
Tier
VYVANSE
2
ANTICONVULSANTS
BANZEL
2
carbamazepine
1, 2
CELONTIN
2
clonazepam
1
divalproex sodium
1
EQUETRO
2
ethosuximide
1
felbamate
1
fosphenytoin sodium
1
gabapentin
1
lamotrigine
1, 2
levetiracetam
1
LEVETIRACETAM IN
2
NACL
magnesium sulfate
1, 2
oxcarbazepine
1, 2
phenytoin
1
phenytoin sodium
1
phenytoin sodium
1, 2
extended
primidone
1
SABRIL
4
topiramate
1
valproate sodium
1
valproic acid
1
ANTIMANIC AGENTS
LITHIUM
2
lithium carbonate
1
ANTIMIGRAINE AGENTS
CAFERGOT
2
naratriptan hcl
1
rizatriptan benzoate
1
SUMATRIPTAN
2
sumatriptan succinate
1
ANTIPARKINSONIAN AGENTS
amantadine hcl
1
APOKYN
4
AZILECT
2
benztropine mesylate
1
bromocriptine mesylate
1
cabergoline
1
carbidopa-levodopa
1, 2
CARBIDOPA-LEVODOPA1
ENTACAPONE
Requirements
/ Limits
QL
LD
Name of drug
Drug
Tier
Requirements
/ Limits
entacapone
1
LODOSYN
2
pramipexole
1
dihydrochloride
ropinirole hydrochloride
1
selegiline hcl
1
trihexyphenidyl hcl
1
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
alprazolam
1
buspirone hcl
1
chlordiazepoxide hcl
1
clorazepate dipotassium
1
DIASTAT ACUDIAL
2
diazepam
1, 2
droperidol
1
hydroxyzine hcl
1
hydroxyzine pamoate
1, 2
lorazepam
1
midazolam hcl
1
NEMBUTAL
2
oxazepam
1
phenobarbital
1, 2
PHENOBARBITAL
2
SODIUM
PRECEDEX
2
temazepam
1
zolpidem tartrate
1
CENTRAL NERVOUS SYSTEM AGENTS,
MISCELLANEOUS
acamprosate calcium
1
flumazenil
1
memantine hcl
1, 2
riluzole
1
selegiline hcl
1
GENERAL ANESTHETICS
BREVITAL SODIUM
2
etomidate
1
FORANE
2
ketamine hcl
1
propofol
1
OPIATE ANTAGONISTS
escitalopram oxalate
1
naloxone hcl
1, 2
naltrexone hcl
1, 2
PSYCHOTHERAPEUTIC AGENTS
amitriptyline hcl
1
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 11
Name of drug
Drug
Tier
Requirements
/ Limits
aripiprazole
1
bupropion hcl
1
chlorpromazine hcl
1, 2
citalopram hydrobromide
1
clomipramine hcl
1
clozapine
1
desipramine hcl
1
doxepin hcl
1, 2
duloxetine hcl
1
escitalopram oxalate
1
fluoxetine hcl
1
fluphenazine decanoate
1
fluphenazine hcl
1, 2
fluvoxamine maleate
1
haloperidol
1
haloperidol decanoate
1
haloperidol lactate
1
imipramine hcl
1
loxapine succinate
1
mirtazapine
1
nefazodone hcl
1, 2
nortriptyline hcl
1, 2
olanzapine
1
ORAP
2
paroxetine hcl
1
perphenazine
1
PERPHENAZINE2
AMITRIPTYLINE
phenelzine sulfate
1
prochlorperazine
1
prochlorperazine edisylate 1
prochlorperazine maleate
1
protriptyline hcl
1
quetiapine fumarate
1
risperidone
1
sertraline hcl
1
SURMONTIL
2
thioridazine hcl
1
thiothixene
1
tranylcypromine sulfate
1
trazodone hcl
1
trifluoperazine hcl
1
venlafaxine hcl
1
ziprasidone hcl
1
CONTRACEPTIVES (FOAMS, DEVICES)
CONTRACEPTIVES (FOAMS, DEVICES)
Drug
Tier
Name of drug
ORTHO DIAPHRAGM
ALL-FLEX
WIDE-SEAL DIAPHRAGM
60
DEVICES
DEVICES
AEROCHAMBER Z-STAT
PLUS
AEROTRACH PLUS
ALLERGIST SYRINGE
ASSESS FULL RANGE
PEAK METER
BD CATHETER TIP
SYRINGE
BD DISP NEEDLES
BD ECLIPSE SYRINGE
BD FILTER NEEDLE/5
MICRON
BD HYPODERMIC
NEEDLE
BD INSULIN SYR
ULTRAFINE II
BD LANCET DEVICE
BD LANCET ULTRAFINE
33G
BD LUER-LOK SYRINGE
BD PEN NEEDLE MINI
U/F
BD SAFETYGLIDE
SYRINGE/NEEDLE
BLUNT PLASTIC
CANNULA
DISPOSABLE POWER
INSUFLON
OMNITROPE PEN 5 INJ
DEVICE
ONETOUCH GLUCOSE
CONTROL LOW
CONTROL
ONETOUCH ULTRA MINI
PEDIATRIC SMALL MASK
PENLET II BLOOD
SAMPLER
POLYFIN QR INFUSION
SET 42"
syringe (disposable)
YALE DISP NEEDLES
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Requirements
/ Limits
2
2
2
2
2
2
2
2
2
2
2
1, 2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1, 2
2
Page 12
Name of drug
Drug
Tier
Requirements
/ Limits
DIAGNOSTIC AGENTS
DIAGNOSTIC AGENTS
ACETEST
2
adenosine (diagnostic)
1
ALBUSTIX
2
CANDIN
2
CHEMSTRIP 9
2
CHIRHOSTIM
2
CLINITEST
2
CONRAY
2
CORTROSYN
2
CREON
2
CYSTOGRAFIN
2
DIASTIX
2
E-Z-CAT DRY
2
EOVIST
2
fluorescein sodium
1
injection
fluorescein sodium topical
1
fluorescein w/ benoxinate
1
GADAVIST
2
GASTROGRAFIN
2
INDIGO CARMINE
2
KETO-DIASTIX
2
LEXISCAN
2
LUMASON
2
MAGNEVIST
2
METOPIRONE
2
MULTIHANCE
2
OMNIPAQUE
2
ONETOUCH ULTRA
2
BLUE
THYROGEN
2
TUBERSOL
2
ELECTROLYTIC, CALORIC, AND WATER
BALANCE
ACIDIFYING AGENTS
AMMONIUM CHLORIDE
2
ALKALINIZING AGENTS
potassium citrate
1
(alkalinizer)
potassium citrate-citric acid 1
sodium acetate
1
sodium bicarbonate
1
sodium citrate & citric acid 1
AMMONIA DETOXICANTS
Drug
Tier
Name of drug
lactulose
lactulose (encephalopathy)
LITHOSTAT
sodium phenylbutyrate
CALORIC AGENTS
AMINOSYN II
CLINIMIX E/DEXTROSE
(2.75/10)
CLINIMIX E/DEXTROSE
(2.75/5)
CLINIMIX E/DEXTROSE
(4.25/25)
CLINIMIX E/DEXTROSE
(5/15)
CLINIMIX E/DEXTROSE
(5/20)
CLINIMIX/DEXTROSE
(4.25/10)
CLINIMIX/DEXTROSE
(4.25/25)
dextrose
fat emulsion
PHENEX-1
DIURETICS
amiloride &
hydrochlorothiazide
bumetanide
CHLORTHALIDONE
EDECRIN
furosemide
hydrochlorothiazide
indapamide
mannitol
metolazone
SODIUM EDECRIN
torsemide
triamterene &
hydrochlorothiazide
ION-REMOVING AGENTS
RENVELA
sodium polystyrene
sulfonate
IRRIGATING SOLUTIONS
acetic acid
DIANEAL LOW
CALCIUM/1.5% DEX
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
1
1
2
1, 4
Requirements
/ Limits
QL
2
2
2
2
2
2
2
2
1, 2
1, 2
2
1
1
1
2
1
1
1
1
1
2
1
1
2
1
1
2
Page 13
Name of drug
Drug
Tier
ringer's irrigation
1
sodium chloride (gu
1
irrigant)
water for irrigation, sterile
1
REPLACEMENT PREPARATIONS
calcium acetate
1, 2
(phosphate binder)
calcium chloride
1
(dihydrate)
calcium gluconate
1
CHROMIC CHLORIDE
2
COPPER CHLORIDE
2
COPPER SULFATE
2
dextrose in lactated ringers 1
dextrose in ringers
1
dextrose w/ sodium
1, 2
chloride
HESPAN
2
HEXTEND
2
K-PHOS
2
KCL-LACTATED
2
RINGERS-D5W
lactated ringer's
1
LMD IN D5W
2
LMD IN NACL
2
MAGNESIUM SULFATE
2
IN D5W
potassium acetate
1
potassium bicarbonate
1
potassium chloride
1, 2
potassium chloride in
1
dextrose
potassium chloride in
1, 2
dextrose & sodium chloride
potassium chloride in nacl
1
potassium chloride
microencapsulated crystals 1
cr
potassium phosphates
1
ringer's
1
SELENIUM
2
sodium chloride
1
sodium phosphate
1
trace minerals (cr-cu-mn1, 2
zn)
ZINC TRACE METAL
2
Requirements
/ Limits
Name of drug
Drug
Tier
Requirements
/ Limits
URICOSURIC AGENTS
colchicine w/ probenecid
1
probenecid
1
ENZYMES
ENZYMES
ALDURAZYME
2
CEREZYME
4
ELAPRASE
4
ELITEK
2
FABRAZYME
4
HYLENEX
2
MYOZYME
4
NAGLAZYME
4
PROLASTIN-C
4
PULMOZYME
4
VIMIZIM
4
VORAXAZE
4
VPRIV
4
EYE, EAR, NOSE, AND THROAT (EENT)
PREPARATIONS
ANTI-INFECTIVES
BACITRACIN
1
bacitracin-polymyxin b
1
(ophth)
chlorhexidine gluconate
1
(mouth-throat)
ciprofloxacin hcl (ophth)
1
erythromycin (ophth)
1
gentamicin sulfate (ophth)
1
neomycin-bacitracin zn1
polymyxin
neomycin-polymyxin1
gramicidin
ofloxacin (ophth)
1
ofloxacin (otic)
1
polymyxin b-trimethoprim
1
sulfacetamide sodium
1
(ophth)
tobramycin (ophth)
1, 2
trifluridine
1
ZYMAXID
2
ANTI-INFLAMMATORY AGENTS
CIPRODEX
2
DEXAMETHASONE
1
SODIUM PHOSPHATE
diclofenac sodium (ophth)
1
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 14
Name of drug
Drug
Tier
flunisolide (nasal)
1
fluorometholone (ophth)
1, 2
flurbiprofen sodium
1
fluticasone propionate
1
(nasal)
ketorolac tromethamine
1
(ophth)
neomycin-polymy1
dexameth
neomycin-polymyxin-hc
1
(otic)
prednisolone acetate
1, 2
(ophth)
RESTASIS
2
RETISERT
2
sulfacetamide sod1, 2
prednisolone
VEXOL
2
ANTIALLERGIC AGENTS
ALOCRIL
2
azelastine hcl
1
cromolyn sodium (ophth)
1
ANTIGLAUCOMA AGENTS
acetazolamide
1
acetazolamide sodium
1
betaxolol hcl (ophth)
1
brimonidine tartrate
1
dorzolamide hcl
1
dorzolamide hcl-timolol
1
maleate
ISOPTO CARBACHOL
2
latanoprost
1
levobunolol hcl
1
LUMIGAN
2
methazolamide
1
MIOCHOL-E
2
PHOSPHOLINE IODIDE
2
pilocarpine hcl
1
timolol maleate (ophth)
1
EENT DRUGS, MISCELLANEOUS
acetic acid (otic)
1
ACETIC ACID-ALUMINUM
2
ACETATE
apraclonidine hcl
1, 2
EYLEA
2
HEALON5
2
Requirements
/ Limits
Name of drug
Drug
Tier
Requirements
/ Limits
LUCENTIS
2
MACUGEN
2
ophthalmic irrigation
1, 2
solution - intraocular
VISUDYNE
2
LOCAL ANESTHETICS
AKTEN
2
antipyrine-benzocaine
1
COCAINE HCL
2
lidocaine hcl (mouth1
throat)
proparacaine hcl
1, 2
tetracaine hcl (ophth)
1
MYDRIATICS
atropine sulfate
1, 2
(ophthalmic)
CYCLOMYDRIL
2
cyclopentolate hcl
1, 2
homatropine hbr
1, 2
tropicamide
1
VASOCONSTRICTORS
phenylephrine hcl (ophth)
1
GASTROINTESTINAL DRUGS
ANTI-INFLAMMATORY AGENTS
balsalazide disodium
1
mesalamine
1, 2
ANTIDIARRHEA AGENTS
bismuth subsalicylate
1
diphenoxylate w/ atropine
1, 2
ANTIEMETICS
dronabinol
1
EMEND
2
meclizine hcl
1
ondansetron
1
ondansetron hcl
1
TRANSDERM-SCOP (1.5
2
MG)
ANTIULCER AGENTS AND ACID SUPPRESSANTS
cimetidine hcl
1
famotidine
1
FAMOTIDINE PREMIXED 1
misoprostol
1
omeprazole
1
pantoprazole sodium
1, 2
ranitidine hcl
1
sucralfate
1, 2
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 15
Drug Requirements
Tier
/ Limits
CATHARTICS AND LAXATIVES
castor oil
1
MINERAL OIL LIGHT
2
peg 3350-kcl-sod bicarb1
sod chloride-sod sulfate
SORBITOL
2
CHOLELITHOLYTIC AGENTS
ursodiol
1
DIGESTANTS
CREON
2
PROKINETIC AGENTS
metoclopramide hcl
1
GOLD COMPOUNDS
GOLD COMPOUNDS
RIDAURA
2
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
BAL IN OIL
2
CHEMET
2
CUPRIMINE
2
deferoxamine mesylate
1
EXJADE
2, 4
QL
PENTETATE CALCIUM
2
TRISODIUM
PENTETATE ZINC
2
TRISODIUM
sodium thiosulfate
1
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
A-HYDROCORT
1, 2
ARISTOSPAN INTRA2
ARTICULAR
ASMANEX 120 METERED
2
DOSES
betamethasone sod
1
phosphate & acetate
budesonide
1
budesonide (inhalation)
1, 2
dexamethasone
1, 2
dexamethasone sodium
1
phosphate
FLOVENT HFA
2
fludrocortisone acetate
1
hydrocortisone
1
KENALOG
2
methylprednisolone
1
Name of drug
Name of drug
Drug
Tier
Requirements
/ Limits
methylprednisolone
1
acetate
methylprednisolone sod
1, 2
succ
prednisolone
1
prednisolone sodium
1
phosphate
prednisone
1, 2
QVAR
2
ANDROGENS
ANDRODERM
1, 2
ANDROID
2
ANDROXY
2
danazol
1
testosterone cypionate
1, 2
testosterone enanthate
1
ANTIDIABETIC AGENTS
glimepiride
1
glipizide
1
glipizide-metformin hcl
1
glyburide
1, 2
HUMALOG
2
HUMULIN 70/30
2
HUMULIN N
2
HUMULIN R
2
LANTUS
2
metformin hcl
1
pioglitazone hcl
1
TOLBUTAMIDE
2
ANTIHYPOGLYCEMIC AGENTS
GLUCAGEN
2
DIAGNOSTIC
GLUCAGON
2
EMERGENCY
CONTRACEPTIVES
desogestrel & ethinyl
1
estradiol
drospirenone-ethinyl
1
estradiol
ELLA
2
ethynodiol diacet & eth
1, 2
estrad
levonorgestrel & eth
1
estradiol
levonorgestrel-eth estradiol
1
(triphasic)
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 16
Name of drug
Drug
Tier
Requirements
/ Limits
MIRENA
2
NECON 1/50 (28)
2
NECON 10/11 (28)
2
NEXPLANON
2
norethin acet & estrad-fe
1
norethindrone & eth
1
estradiol
norethindrone
1
(contraceptive)
norethindrone-eth estradiol
1
(triphasic)
norgestimate-ethinyl
1
estradiol
norgestimate-ethinyl
1
estradiol (triphasic)
NUVARING
2
OGESTREL
2
PLAN B ONE-STEP
2
XULANE
1
ESTROGENS AND ESTROGEN AGONISTSANTAGONISTS
clomiphene citrate
1
DEPO-ESTRADIOL
2
esterified estrogens &
1
methyltestosterone
ESTRACE
2
estradiol
1, 2
PREMARIN
2
raloxifene hcl
1
GONADOTROPINS
BRAVELLE
2
chorionic gonadotropin
1
MENOPUR
2
SYNAREL
2
PARATHYROID
FORTEO
4
FORTICAL
1
PITUITARY
ACTHAR HP
4
LD
DDAVP RHINAL TUBE
2
desmopressin acetate
1, 2
desmopressin acetate
1
spray
desmopressin acetate
1
spray refrigerated
vasopressin
1
Name of drug
Drug
Tier
Requirements
/ Limits
PROGESTINS
DEPO-PROVERA
2
ENDOMETRIN
2
medroxyprogesterone
1
acetate
medroxyprogesterone
1
acetate (contraceptive)
norethindrone acetate
1
progesterone
1
progesterone micronized
1
SOMATROPIN AGONISTS-ANTAGONISTS
NORDITROPIN FLEXPRO 2, 4
QL
SEROSTIM
4
QL
THYROID AND ANTITHYROID AGENTS
levothyroxine sodium
1, 2
liothyronine sodium
1
methimazole
1
propylthiouracil
1
SSKI
2
LOCAL ANESTHETICS
LOCAL ANESTHETICS
bupivacaine hcl
1
bupivacaine in dextrose
1
bupivacaine w/
1, 2
epinephrine
chloroprocaine hcl
1
lidocaine hcl (cardiac)
1, 2
lidocaine hcl (local anesth.) 1
lidocaine w/ epinephrine
1, 2
mepivacaine hcl
1
NAROPIN
2
TETRACAINE HCL
2
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
acetylcysteine
1
acetylcysteine (antidote)
1
ACTIMMUNE
4
alendronate sodium
1, 2
allopurinol
1
amifostine crystalline
1
AVONEX
4
QL
azathioprine
1
BOTOX
2
BOTOX COSMETIC
2
CERDELGA
4
QL
CINRYZE
4
QL
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 17
Drug
Tier
Name of drug
COLCHICINE
cyclosporine modified (for
microemulsion)
CYSTADANE
CYSTAGON
dexrazoxane
disulfiram
ELMIRON
ENBREL
ETIDRONATE DISODIUM
EXTAVIA
finasteride
FIRAZYR
FLUOR-A-DAY
FUSILEV
glatiramer acetate
GRASTEK
HUMIRA
KINERET
leflunomide
leucovorin calcium
levocarnitine (metabolic
modifiers)
mesna
methylene blue (antidote)
mycophenolate mofetil
MYOBLOC
octreotide acetate
OPSUMIT
ORENCIA
OTEZLA
pamidronate disodium
PREVIDENT
RASUVO
REMICADE
RIMSO-50
SANDIMMUNE
SENSIPAR
sirolimus
sodium fluoride
SOLIRIS
tacrolimus
THALOMID
THIOLA
TYSABRI
water for injection, sterile
Requirements
/ Limits
2
1, 2
2
2
1, 2
1, 2
2
4
1, 2
2
1
4
2
2
1
2
4
4
1
1
QL
QL
QL
QL
QL
QL
QL
1
1, 2
1
1
2
1, 4
4
4
4
1, 2
2
2
4
2
2
2, 4
1, 2
1, 2
2
1, 2
4
2
4
1
QL
QL
QL
QL
QL
LD
Drug
Tier
Name of drug
zoledronic acid
OXYTOCICS
OXYTOCICS
HEMABATE
methylergonovine maleate
MIFEPREX
oxytocin
PREPIDIL
PHARMACEUTICAL AIDS
PHARMACEUTICAL AIDS
ALOE VERA
ALPROSTADIL
ATROPINE SULFATE
MONOHYDRATE
BIOTIN
BORIC ACID
CANTHARIDIN
CARBAMAZEPINE
CHLORPROMAZINE HCL
CHOLESTEROL
ACETATE
CLINDAMYCIN HCL
CLOBETASOL
PROPIONATE
CLOTRIMAZOLE
COLLODION FLEXIBLE
CYSTEAMINE HCL
DEXAMETHASONE
DIPHENYLCYCLOPROPE
NONE
ESTRADIOL
GLYCERIN
GLYCOPYRROLATE
HALOPERIDOL
HYDROCORTISONE
HYDROXOCOBALAMIN
HYDROXYPROGESTERO
NE CAPROATE
INDOMETHACIN
KETAMINE HCL
L-ARGININE
L-CITRULLINE
L-ISOLEUCINE
L-VALINE
LACTIC ACID
LACTOSE
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Requirements
/ Limits
1
2
1
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Page 18
Name of drug
Drug
Tier
LACTOSE
2
MONOHYDRATE
LIDOCAINE HCL
2
METHADONE HCL
2
METHYLCELLULOSE
2
METOCLOPRAMIDE HCL
2
MONOHYDRATE
MORPHINE SULFATE
2
NEOMYCIN SULFATE
2
PHENOBARBITAL
2
PLURONIC F127
2
PODOPHYLLUM RESIN
2
POLYETHYLENE
2
GLYCOL 400
PROGESTERONE
2
MICRONIZED
PROGESTERONE
2
WETTABLE
PROPYLENE GLYCOL
2
QUINACRINE HCL
2
SALICYLIC ACID
2
SODIUM BENZOATE
2
SORBITOL
2
SQUARIC ACID
2
DIBUTYLESTER
SULFUR PRECIPITATED
2
TESTOSTERONE
2
THYMOL
2
TRANEXAMIC ACID
2
TRIAMCINOLONE
2
ACETONIDE
UREA
2
ZINC SULFATE
2
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORY AGENTS
ASMANEX HFA
2
COMBIVENT RESPIMAT
2
CROMOLYN SODIUM
1
DULERA
2
montelukast sodium
1
ANTITUSSIVES
benzonatate
1
guaifenesin-codeine
1
hydrocodone w/
1
homatropine
phenylephrine-chlorphen1
Requirements
/ Limits
Name of drug
Drug
Tier
Requirements
/ Limits
dm
PHENYLHISTINE DH
2
promethazine-dm
1
MUCOLYTIC AGENTS
sodium chloride (inhalant)
1
PULMONARY SURFACTANTS
CUROSURF
2
SURVANTA
2
RESPIRATORY AGENTS, MISCELLANEOUS
KALYDECO
4
QL
ORKAMBI
4
QL
SERUMS, TOXOIDS, AND VACCINES
SERUMS
ANTIVENIN
LATRODECTUS
2
MACTANS
CARIMUNE NF
2
CROFAB
2
DIGIFAB
2
FLUVIRIN
2
GAMASTAN S/D
2
GAMMAGARD
2
HYPERRAB S/D
2
HYPERTET S/D
2
MICRHOGAM ULTRA2
FILTERED PLUS
NABI-HB
2
VARIZIG
2
TOXOIDS
ADACEL
2
INFANRIX
2
TETANUS-DIPHTHERIA
2
TOXOIDS TD
VACCINES
ACTHIB
2
AFLURIA
2
AFLURIA
2
PRESERVATIVE FREE
BEXSERO
2
ENGERIX-B
2
FLUARIX
2
QUADRIVALENT
FLUBLOK
2
FLUCELVAX
2
FLUMIST
2
QUADRIVALENT
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 19
Name of drug
Drug
Tier
Requirements
/ Limits
FLUVIRIN
2
FLUVIRIN
2
PRESERVATIVE FREE
FLUZONE HIGH-DOSE
2
GARDASIL
2
GARDASIL 9
2
HAVRIX
2
IMOVAX RABIES
2
IPOL
2
IXIARO
2
KINRIX
2
M-M-R II
2
MENACTRA
2
MENOMUNE
2
MENVEO
2
PEDIARIX
2
PNEUMOVAX 23
2
PREVNAR 13
2
PROQUAD
2
RABAVERT
2
ROTARIX
2
ROTATEQ
2
THERACYS
2
TWINRIX
2
TYPHIM VI
2
VARIVAX
2
VIVOTIF
2
YF-VAX
2
ZOSTAVAX
2
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES
benzoyl peroxide1, 2
erythromycin
clindamycin phosphate
1
(topical)
clindamycin phosphate
1
vaginal
clindamycin phosphate1
benzoyl peroxide
clindamycin phosphatebenzoyl peroxide
1
(refrigerate)
clotrimazole
1
dakin's solution
1, 2
erythromycin (acne aid)
1, 2
GENTAMICIN SULFATE
2
Name of drug
Drug
Tier
Requirements
/ Limits
GNP GENTIAN VIOLET
2
iodoquinol-hc
1
ketoconazole (topical)
1
metronidazole (topical)
1
metronidazole vaginal
1
mupirocin
1
neomycin/polymyxin b gu
1
nystatin (topical)
1
permethrin
1, 2
PHISOHEX
2
selenium sulfide
1
silver sulfadiazine
1
ANTI-INFLAMMATORY AGENTS
alclometasone
1
dipropionate
betamethasone
1
dipropionate (topical)
betamethasone
1
dipropionate augmented
betamethasone valerate
1
clobetasol propionate
1, 2
CORDRAN
2
CORTISPORIN
2
DESONATE
2
desoximetasone
1
fluocinolone acetonide
1
fluocinonide
1
halobetasol propionate
1
hydrocortisone (intrarectal) 1
hydrocortisone (topical)
1
hydrocortisone acetate
1
(rectal)
mometasone furoate
1
nystatin-triamcinolone
1
PROCTOFOAM HC
1
triamcinolone acetonide
1
(mouth)
triamcinolone acetonide
1, 2
(topical)
ANTIPRURITICS AND LOCAL ANESTHETICS
lidocaine
1
lidocaine hcl
1
lidocaine-prilocaine
1
PHENOL
2
ASTRINGENTS
DRYSOL
2
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 20
Name of drug
Drug
Tier
Requirements
/ Limits
XERAC AC
2
CELL STIMULANTS AND PROLIFERANTS
KEPIVANCE
4
RETIN-A
2
RETIN-A MICRO
2
DEPIGMENTING AND PIGMENTING AGENTS
8-MOP
2
methoxsalen rapid
1
OXSORALEN
2
KERATOLYTIC AGENTS
PRASCION RA
2
sulfacetamide sodium w/
1
sulfur
SKIN AND MUCOUS MEMBRANE AGENTS,
MISCELLANEOUS
acitretin
1
AQUAPHOR
2
BENZOIN
2
BENZOIN COMPOUND
2
calcipotriene
1
capsaicin
1
COSENTYX
4
QL
DESITIN
2
DIFFERIN
2
DRITHO-CREME HP
2
ELIDEL
2
EPIDUO
2
fluorouracil (topical)
1, 2
imiquimod
1
isotretinoin
1
LEVULAN KERASTICK
2
PODOCON
2
podofilox
1, 2
SANTYL
2
STELARA
4
Name of drug
Drug
Tier
Requirements
/ Limits
tacrolimus (topical)
1
TARGRETIN
2
TAZORAC
2
VECTICAL
2
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
oxybutynin chloride
1
OXYTROL
2
trospium chloride
1
RESPIRATORY SMOOTH MUSCLE RELAXANTS
aminophylline
1
theophylline
1
theophylline in dextrose
1, 2
VITAMINS
MULTIVITAMIN PREPARATIONS
b-complex w/ c & folic acid 1
multiple vitamin
1
ped multivitamins w/fl &
1
iron
pediatric multivitamins w/fl 1
pediatric vitamins acd w/
1
fluoride
TRI-VIT/FLUORIDE/IRON 2
VITAMIN B COMPLEX
cyanocobalamin
1
FOLIC ACID
2
niacin
1, 2
thiamine hcl
1
VITAMIN D
calcitriol
1
ergocalciferol
1
VITAMIN K ACTIVITY
phytonadione
1, 2
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 21
Formulary Drugs by Alphabetical Listing
Index
8
8-MOP ------------------------------------------------------21
A
abacavir sulfate -------------------------------------------- 5
abacavir sulfate-lamivudine-zidovudine -------------- 5
ABELCET --------------------------------------------------- 5
ABRAXANE ------------------------------------------------- 6
acamprosate calcium ------------------------------------11
acetaminophen w/ codeine -----------------------------10
acetazolamide ---------------------------------------------15
acetazolamide sodium ----------------------------------15
ACETEST --------------------------------------------------13
acetic acid ---------------------------------------------13, 15
acetic acid (otic) ------------------------------------------15
ACETIC ACID-ALUMINUM ACETATE --------------15
acetylcysteine ---------------------------------------------17
acetylcysteine (antidote) --------------------------------17
acitretin -----------------------------------------------------21
ACTHAR HP -----------------------------------------------17
ACTHIB -----------------------------------------------------19
ACTIMMUNE ----------------------------------------------17
ACTIVASE -------------------------------------------------- 8
acyclovir ----------------------------------------------------- 5
acyclovir sodium ------------------------------------------- 5
ADACEL ----------------------------------------------------19
ADCETRIS -------------------------------------------------- 6
adefovir dipivoxil ------------------------------------------- 5
adenosine ---------------------------------------------- 9, 13
adenosine (diagnostic) ----------------------------------13
ADVAIR DISKUS ------------------------------------------ 8
ADVATE ----------------------------------------------------- 8
AEROCHAMBER Z-STAT PLUS ---------------------12
AEROTRACH PLUS -------------------------------------12
AFINITOR --------------------------------------------------- 6
AFLURIA ---------------------------------------------------19
AFLURIA PRESERVATIVE FREE -------------------19
A-HYDROCORT ------------------------------------------16
AKTEN------------------------------------------------------ 15
ALBENZA ----------------------------------------------------4
albumin, human --------------------------------------------8
ALBUSTIX ------------------------------------------------- 13
albuterol sulfate---------------------------------------------8
alclometasone dipropionate --------------------------- 20
ALDURAZYME ------------------------------------------- 14
alendronate sodium ------------------------------------- 17
alfentanil---------------------------------------------------- 10
ALIMTA -------------------------------------------------------6
ALINIA --------------------------------------------------------5
ALKERAN ----------------------------------------------------6
ALLERGIST SYRINGE --------------------------------- 12
allopurinol -------------------------------------------------- 17
ALOCRIL --------------------------------------------------- 15
ALOE VERA ----------------------------------------------- 18
ALPHANINE SD --------------------------------------------8
alprazolam ------------------------------------------------- 11
alprostadil -------------------------------------------------- 10
ALPROSTADIL ------------------------------------------- 18
amantadine hcl ------------------------------------------- 11
amifostine crystalline ------------------------------------ 17
amikacin sulfate --------------------------------------------4
amiloride & hydrochlorothiazide ---------------------- 13
aminocaproic acid------------------------------------------8
aminophylline --------------------------------------------- 21
AMINOSYN II --------------------------------------------- 13
amiodarone hcl ---------------------------------------------9
amitriptyline hcl ------------------------------------------- 11
amlodipine besylate ---------------------------------------9
AMMONIUM CHLORIDE------------------------------- 13
amoxicillin ----------------------------------------------------4
amoxicillin & pot clavulanate ----------------------------4
amphetamine-dextroamphetamine ------------------ 10
AMPHOTERICIN B ----------------------------------------5
ampicillin & sulbactam sodium --------------------------4
ampicillin sodium -------------------------------------------4
anagrelide hcl -----------------------------------------------8
anastrozole --------------------------------------------------6
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 22
ANDRODERM --------------------------------------------16
ANDROID --------------------------------------------------16
ANDROXY -------------------------------------------------16
ANGIOMAX ------------------------------------------------- 8
antipyrine-benzocaine -----------------------------------15
ANTIVENIN LATRODECTUS MACTANS ----------19
APOKYN----------------------------------------------------11
apraclonidine hcl ------------------------------------------15
APTIVUS ---------------------------------------------------- 5
AQUAPHOR -----------------------------------------------21
argatroban--------------------------------------------------- 8
aripiprazole-------------------------------------------------11
ARISTOSPAN INTRA-ARTICULAR -----------------16
ARRANON -------------------------------------------------- 6
ASMANEX 120 METERED DOSES -----------------16
ASMANEX HFA -------------------------------------------19
ASPIRIN-DIPYRIDAMOLE ER ------------------------- 8
ASSESS FULL RANGE PEAK METER -------------12
atenolol ------------------------------------------------------ 9
atenolol & chlorthalidone -------------------------------- 9
atorvastatin calcium --------------------------------------- 9
atovaquone ------------------------------------------------- 5
atovaquone-proguanil hcl -------------------------------- 5
atracurium besylate --------------------------------------- 8
ATRIPLA----------------------------------------------------- 5
atropine sulfate---------------------------------------- 7, 15
atropine sulfate (ophthalmic)---------------------------15
ATROPINE SULFATE MONOHYDRATE ----------18
ATROVENT HFA ------------------------------------------ 7
AVASTIN ---------------------------------------------------- 6
AVELOX ----------------------------------------------------- 4
AVONEX----------------------------------------------------17
azacitidine --------------------------------------------------- 6
AZACTAM IN DEXTROSE ------------------------------ 4
azathioprine ------------------------------------------------17
azelastine hcl ----------------------------------------------15
AZILECT ----------------------------------------------------11
azithromycin ------------------------------------------------ 4
aztreonam --------------------------------------------------- 4
B
BACITRACIN ----------------------------------------------14
bacitracin-polymyxin b (ophth) ------------------------14
baclofen ------------------------------------------------------ 8
BACTOCILL IN DEXTROSE---------------------------- 4
BAL IN OIL -------------------------------------------------16
balsalazide disodium ------------------------------------ 15
BANZEL ---------------------------------------------------- 10
b-complex w/ c & folic acid----------------------------- 21
BD CATHETER TIP SYRINGE ----------------------- 12
BD DISP NEEDLES ------------------------------------- 12
BD ECLIPSE SYRINGE -------------------------------- 12
BD FILTER NEEDLE/5 MICRON -------------------- 12
BD HYPODERMIC NEEDLE -------------------------- 12
BD INSULIN SYR ULTRAFINE II -------------------- 12
BD LANCET DEVICE ----------------------------------- 12
BD LANCET ULTRAFINE 33G ----------------------- 12
BD LUER-LOK SYRINGE------------------------------ 12
BD PEN NEEDLE MINI U/F --------------------------- 12
BD SAFETYGLIDE SYRINGE/NEEDLE ----------- 12
BELLADONNA ALKALOIDS-OPIUM------------------7
benazepril hcl --------------------------------------------- 10
BENEFIX -----------------------------------------------------8
BENZOIN -------------------------------------------------- 21
BENZOIN COMPOUND -------------------------------- 21
benzonatate ----------------------------------------------- 19
benzoyl peroxide-erythromycin ----------------------- 20
benztropine mesylate ----------------------------------- 11
betamethasone dipropionate (topical)--------------- 20
betamethasone dipropionate augmented ---------- 20
betamethasone sod phosphate & acetate --------- 16
betamethasone valerate -------------------------------- 20
betaxolol hcl (ophth) ------------------------------------- 15
bethanechol chloride --------------------------------------8
BEXSERO ------------------------------------------------- 19
bicalutamide -------------------------------------------------6
BICILLIN L-A ------------------------------------------------4
BICNU --------------------------------------------------------6
BILTRICIDE -------------------------------------------------4
BIOTIN------------------------------------------------------ 18
bismuth subsalicylate ----------------------------------- 15
bisoprolol & hydrochlorothiazide -----------------------9
bisoprolol fumarate ----------------------------------------9
bleomycin sulfate-------------------------------------------6
BLINCYTO ---------------------------------------------------6
BLUNT PLASTIC CANNULA -------------------------- 12
BORIC ACID ---------------------------------------------- 18
BOTOX ----------------------------------------------------- 17
BOTOX COSMETIC------------------------------------- 17
BRAVELLE ------------------------------------------------ 17
BREVIBLOC IN NACL ------------------------------------9
BREVITAL SODIUM ------------------------------------ 11
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 23
BRILINTA---------------------------------------------------- 9
brimonidine tartrate --------------------------------------15
bromocriptine mesylate ---------------------------------11
budesonide-------------------------------------------------16
budesonide (inhalation) ---------------------------------16
bumetanide ------------------------------------------------13
bupivacaine hcl -------------------------------------------17
bupivacaine in dextrose ---------------------------------17
bupivacaine w/ epinephrine ----------------------------17
buprenorphine hcl ----------------------------------------10
buprenorphine hcl-naloxone hcl dihydrate----------10
bupropion hcl ----------------------------------------------11
buspirone hcl ----------------------------------------------11
butorphanol tartrate --------------------------------------10
C
cabergoline-------------------------------------------------11
CAFERGOT -----------------------------------------------11
caffeine citrate---------------------------------------------10
calcipotriene -----------------------------------------------21
calcitriol -----------------------------------------------------21
calcium acetate (phosphate binder) ------------------14
calcium chloride (dihydrate) ----------------------------14
calcium gluconate ----------------------------------------14
CANCIDAS-------------------------------------------------- 5
CANDIN-----------------------------------------------------13
CANTHARIDIN--------------------------------------------18
CAPASTAT SULFATE ----------------------------------- 5
capecitabine ------------------------------------------------ 6
CAPRELSA ------------------------------------------------- 6
capsaicin----------------------------------------------------21
captopril -----------------------------------------------------10
carbamazepine --------------------------------------------11
CARBAMAZEPINE---------------------------------------18
carbidopa-levodopa --------------------------------------11
CARBIDOPA-LEVODOPA-ENTACAPONE --------11
CARDENE IV ----------------------------------------------- 9
CARIMUNE NF -------------------------------------------19
carvedilol ---------------------------------------------------- 9
castor oil ----------------------------------------------------16
CAVERJECT ----------------------------------------------10
CAYSTON--------------------------------------------------- 4
cefaclor ------------------------------------------------------ 4
cefadroxil ---------------------------------------------------- 4
cefazolin sodium ------------------------------------------- 4
cefdinir ------------------------------------------------------- 4
cefepime hcl -------------------------------------------------4
cefixime-------------------------------------------------------4
cefotaxime sodium -----------------------------------------4
cefotetan disodium-----------------------------------------4
CEFOTETAN DISODIUM-DEXTROSE---------------4
cefoxitin sodium --------------------------------------------4
CEFOXITIN SODIUM-DEXTROSE --------------------4
cefpodoxime proxetil --------------------------------------4
ceftazidime --------------------------------------------------4
ceftriaxone sodium-----------------------------------------4
CEFTRIAXONE SODIUM IN DEXTROSE -----------4
CEFTRIAXONE SODIUM-DEXTROSE --------------4
cefuroxime axetil -------------------------------------------4
cefuroxime sodium-----------------------------------------4
CEFUROXIME SODIUM-DEXTROSE ----------------4
CELONTIN ------------------------------------------------ 11
cephalexin ---------------------------------------------------4
CERDELGA ----------------------------------------------- 17
CEREZYME ----------------------------------------------- 14
CHEMET --------------------------------------------------- 16
CHEMSTRIP 9-------------------------------------------- 13
CHIRHOSTIM --------------------------------------------- 13
CHLORAMPHENICOL SOD SUCCINATE ----------4
chlordiazepoxide hcl ---------------------------------- 7, 11
chlordiazepoxide hcl-clidinium bromide ---------------7
chlorhexidine gluconate (mouth-throat) ------------- 14
chloroprocaine hcl --------------------------------------- 17
chloroquine phosphate -----------------------------------5
chlorpheniramine & phenylephrine---------------------6
chlorpromazine hcl --------------------------------------- 12
CHLORPROMAZINE HCL ----------------------------- 18
CHLORTHALIDONE ------------------------------------ 13
CHOLESTEROL ACETATE --------------------------- 18
cholestyramine----------------------------------------------9
cholestyramine light ---------------------------------------9
choline & mag salicylate -------------------------------- 10
chorionic gonadotropin --------------------------------- 17
CHROMIC CHLORIDE --------------------------------- 14
cidofovir ------------------------------------------------------5
cimetidine hcl---------------------------------------------- 15
CINRYZE -------------------------------------------------- 17
CIPRODEX ------------------------------------------------ 14
ciprofloxacin -------------------------------------------- 4, 14
ciprofloxacin hcl --------------------------------------- 4, 14
ciprofloxacin hcl (ophth) -------------------------------- 14
ciprofloxacin in d5w ----------------------------------------4
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 24
cisatracurium besylate ----------------------------------- 8
cisplatin ------------------------------------------------------ 6
citalopram hydrobromide -------------------------------12
cladribine ---------------------------------------------------- 6
clarithromycin----------------------------------------------- 4
CLEOCIN IN D5W----------------------------------------- 4
CLEVIPREX ------------------------------------------------ 9
clindamycin hcl --------------------------------------------- 4
CLINDAMYCIN HCL -------------------------------------18
clindamycin palmitate hydrochloride ------------------ 4
clindamycin phosphate ------------------------------ 4, 20
clindamycin phosphate (topical) ----------------------20
clindamycin phosphate vaginal------------------------20
clindamycin phosphate-benzoyl peroxide ----------20
clindamycin phosphate-benzoyl peroxide
(refrigerate) ---------------------------------------------20
CLINIMIX E/DEXTROSE (2.75/10) ------------------13
CLINIMIX E/DEXTROSE (2.75/5) --------------------13
CLINIMIX E/DEXTROSE (4.25/25) ------------------13
CLINIMIX E/DEXTROSE (5/15)-----------------------13
CLINIMIX E/DEXTROSE (5/20)-----------------------13
CLINIMIX/DEXTROSE (4.25/10) ---------------------13
CLINIMIX/DEXTROSE (4.25/25) ---------------------13
CLINITEST -------------------------------------------------13
clobetasol propionate ------------------------------------20
CLOBETASOL PROPIONATE ------------------------18
clomiphene citrate ----------------------------------------17
clomipramine hcl ------------------------------------------12
clonazepam ------------------------------------------------11
clonidine hcl------------------------------------------------- 9
clopidogrel bisulfate --------------------------------------- 9
clorazepate dipotassium --------------------------------11
clotrimazole ------------------------------------------------20
CLOTRIMAZOLE -----------------------------------------18
clozapine ---------------------------------------------------12
COARTEM -------------------------------------------------- 5
COCAINE HCL --------------------------------------------15
CODEINE SULFATE ------------------------------------10
COLCHICINE----------------------------------------------18
colchicine w/ probenecid --------------------------------14
colestipol hcl ------------------------------------------------ 9
COLLODION FLEXIBLE --------------------------------18
COMBIVENT ------------------------------------------ 8, 19
COMBIVENT RESPIMAT ------------------------------19
COMETRIQ (100 MG DAILY DOSE) ----------------- 6
COMPLERA ------------------------------------------------ 5
CONRAY --------------------------------------------------- 13
COPPER CHLORIDE ----------------------------------- 14
COPPER SULFATE ------------------------------------- 14
CORDRAN ------------------------------------------------ 20
CORTISPORIN ------------------------------------------- 20
CORTROSYN--------------------------------------------- 13
COSENTYX ----------------------------------------------- 21
CREON ------------------------------------------------ 13, 16
CRIXIVAN ---------------------------------------------------5
CROFAB --------------------------------------------------- 19
CROMOLYN SODIUM ---------------------------------- 19
cromolyn sodium (ophth) ------------------------------- 15
CUBICIN -----------------------------------------------------4
CUPRIMINE ----------------------------------------------- 16
CUROSURF ----------------------------------------------- 19
cyanocobalamin ------------------------------------------ 21
cyclobenzaprine hcl ---------------------------------------8
CYCLOMYDRIL ------------------------------------------ 15
cyclopentolate hcl ---------------------------------------- 15
cyclophosphamide -----------------------------------------6
cyclosporine modified (for microemulsion) --------- 18
cyproheptadine hcl-----------------------------------------6
CYRAMZA ---------------------------------------------------6
CYSTADANE --------------------------------------------- 18
CYSTAGON ----------------------------------------------- 18
CYSTEAMINE HCL ------------------------------------- 18
CYSTOGRAFIN ------------------------------------------ 13
cytarabine ----------------------------------------------------6
D
dacarbazine -------------------------------------------------6
DACOGEN --------------------------------------------------6
dactinomycin ------------------------------------------------6
DAKLINZA ---------------------------------------------------5
danazol ----------------------------------------------------- 16
dantrolene sodium -----------------------------------------8
DAPSONE ---------------------------------------------------5
DARAPRIM --------------------------------------------------5
daunorubicin hcl --------------------------------------------6
DAUNOXOME ----------------------------------------------6
DDAVP RHINAL TUBE --------------------------------- 17
deferoxamine mesylate --------------------------------- 16
demeclocycline hcl-----------------------------------------4
DEPOCYT ---------------------------------------------------6
DEPO-ESTRADIOL ------------------------------------- 17
DEPO-PROVERA---------------------------------------- 17
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 25
desipramine hcl -------------------------------------------12
DESITIN ----------------------------------------------------21
desmopressin acetate -----------------------------------17
desmopressin acetate spray ---------------------------17
desmopressin acetate spray refrigerated -----------17
desogestrel & ethinyl estradiol ------------------------16
DESONATE------------------------------------------------20
desoximetasone ------------------------------------------20
dexamethasone -------------------------------------------16
DEXAMETHASONE --------------------------------14, 18
dexamethasone sodium phosphate ------------------16
DEXAMETHASONE SODIUM PHOSPHATE -----14
dexmethylphenidate hcl ---------------------------------10
dexrazoxane -----------------------------------------------18
dextroamphetamine sulfate ----------------------------10
dextrose ------------------------------ 5, 9, 13, 14, 17, 21
dextrose in lactated ringers ----------------------------14
dextrose in ringers----------------------------------------14
dextrose w/ sodium chloride ---------------------------14
DIANEAL LOW CALCIUM/1.5% DEX ---------------13
DIASTAT ACUDIAL --------------------------------------11
DIASTIX ----------------------------------------------------13
diazepam ---------------------------------------------------11
diclofenac sodium (ophth) ------------------------------14
dicloxacillin sodium---------------------------------------- 4
dicyclomine hcl --------------------------------------------- 7
didanosine--------------------------------------------------- 5
DIFFERIN --------------------------------------------------21
DIGIFAB ----------------------------------------------------19
digoxin ------------------------------------------------------- 9
dihydroergotamine mesylate ---------------------------- 8
diltiazem hcl------------------------------------------------- 9
diltiazem hcl coated beads ------------------------------ 9
diphenhydramine hcl-------------------------------------- 6
diphenoxylate w/ atropine ------------------------------15
DIPHENYLCYCLOPROPENONE --------------------18
dipyridamole -----------------------------------------------10
dipyridamole (diagnostic) -------------------------------10
disopyramide phosphate--------------------------------- 9
DISPOSABLE POWER ---------------------------------12
disulfiram ---------------------------------------------------18
divalproex sodium ----------------------------------------11
dobutamine hcl --------------------------------------------- 8
dobutamine in d5w ---------------------------------------- 8
donepezil hydrochloride ---------------------------------- 8
DONNATAL ------------------------------------------------- 7
dopamine hcl ------------------------------------------------8
dopamine in d5w -------------------------------------------8
dorzolamide hcl ------------------------------------------- 15
dorzolamide hcl-timolol maleate ---------------------- 15
doxazosin mesylate ---------------------------------------9
doxepin hcl ------------------------------------------------ 12
doxorubicin hcl ----------------------------------------------6
doxorubicin hcl liposomal --------------------------------6
doxycycline (monohydrate) ------------------------------4
doxycycline hyclate ----------------------------------------4
DRITHO-CREME HP ----------------------------------- 21
dronabinol -------------------------------------------------- 15
droperidol -------------------------------------------------- 11
drospirenone-ethinyl estradiol ------------------------- 16
DRYSOL --------------------------------------------------- 21
DULERA --------------------------------------------------- 19
duloxetine hcl --------------------------------------------- 12
E
EDECRIN -------------------------------------------------- 13
EDURANT ---------------------------------------------------5
EFFIENT -----------------------------------------------------9
ELAPRASE ------------------------------------------------ 14
ELIDEL ----------------------------------------------------- 21
ELITEK ----------------------------------------------------- 14
ELLA -------------------------------------------------------- 16
ELMIRON -------------------------------------------------- 18
EMCYT -------------------------------------------------------6
EMEND ----------------------------------------------------- 15
EMTRIVA ----------------------------------------------------5
enalaprilat -------------------------------------------------- 10
ENBREL ---------------------------------------------------- 18
ENDOMETRIN-------------------------------------------- 17
ENGERIX-B ----------------------------------------------- 19
ENLON -------------------------------------------------------8
entacapone ------------------------------------------------ 11
entecavir -----------------------------------------------------5
EOVIST----------------------------------------------------- 13
ephedrine sulfate (pressors)-----------------------------8
EPIDUO ---------------------------------------------------- 21
EPINEPHRINE ---------------------------------------------8
epinephrine hcl ---------------------------------------------8
EPZICOM ----------------------------------------------------5
EQUETRO ------------------------------------------------- 11
ERBITUX-----------------------------------------------------6
ergocalciferol ---------------------------------------------- 21
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 26
ERGOMAR-------------------------------------------------- 8
ERIVEDGE-------------------------------------------------- 6
ERWINAZE ------------------------------------------------- 6
ERYTHROCIN LACTOBIONATE---------------------- 4
erythromycin (acne aid) ---------------------------------20
erythromycin (ophth) -------------------------------------14
escitalopram oxalate --------------------------------11, 12
esmolol hcl -------------------------------------------------- 9
esterified estrogens & methyltestosterone ---------17
ESTRACE --------------------------------------------------17
estradiol ------------------------------------------------16, 17
ESTRADIOL ------------------------------------------17, 18
ethambutol hcl---------------------------------------------- 5
ETHAMOLIN-----------------------------------------------10
ethosuximide ----------------------------------------------11
ethynodiol diacet & eth estrad -------------------------16
ETIDRONATE DISODIUM -----------------------------18
etodolac -----------------------------------------------------10
etomidate ---------------------------------------------------11
etoposide ---------------------------------------------------- 6
exemestane ------------------------------------------------- 6
EXJADE ----------------------------------------------------16
EXTAVIA ---------------------------------------------------18
EYLEA ------------------------------------------------------15
E-Z-CAT DRY ---------------------------------------------13
F
FABRAZYME ----------------------------------------------14
famciclovir --------------------------------------------------- 5
famotidine --------------------------------------------------15
FAMOTIDINE PREMIXED -----------------------------15
FASLODEX ------------------------------------------------- 6
fat emulsion ------------------------------------------------13
felbamate ---------------------------------------------------11
fenofibrate --------------------------------------------------- 9
fentanyl -----------------------------------------------------10
fentanyl citrate---------------------------------------------10
finasteride --------------------------------------------------18
FIRAZYR ---------------------------------------------------18
flecainide acetate ------------------------------------------ 9
FLOVENT HFA -------------------------------------------16
FLUARIX QUADRIVALENT----------------------------19
FLUBLOK --------------------------------------------------19
FLUCELVAX-----------------------------------------------19
fluconazole -------------------------------------------------- 5
fluconazole in dextrose----------------------------------- 5
fluconazole in nacl -----------------------------------------5
FLUCONAZOLE IN SODIUM CHLORIDE -----------4
flucytosine ---------------------------------------------------5
fludarabine phosphate ------------------------------------6
fludrocortisone acetate---------------------------------- 16
flumazenil -------------------------------------------------- 11
FLUMIST QUADRIVALENT --------------------------- 20
flunisolide (nasal) ---------------------------------------- 14
fluocinolone acetonide ---------------------------------- 20
fluocinonide ------------------------------------------------ 20
FLUOR-A-DAY ------------------------------------------- 18
fluorescein sodium injection --------------------------- 13
fluorescein sodium topical ----------------------------- 13
fluorescein w/ benoxinate ------------------------------ 13
fluorometholone (ophth) -------------------------------- 15
fluorouracil ---------------------------------------------- 6, 21
fluorouracil (topical)-------------------------------------- 21
fluoxetine hcl ---------------------------------------------- 12
fluphenazine decanoate -------------------------------- 12
fluphenazine hcl ------------------------------------------ 12
flurbiprofen sodium -------------------------------------- 15
flutamide -----------------------------------------------------6
fluticasone propionate (nasal) ------------------------- 15
FLUVIRIN --------------------------------------------- 19, 20
FLUVIRIN PRESERVATIVE FREE ------------------ 20
fluvoxamine maleate ------------------------------------ 12
FLUZONE HIGH-DOSE -------------------------------- 20
FOLIC ACID ----------------------------------------------- 21
FORANE --------------------------------------------------- 11
FORTEO --------------------------------------------------- 17
FORTICAL ------------------------------------------------- 17
FOSCAVIR --------------------------------------------------5
fosphenytoin sodium ------------------------------------ 11
furosemide ------------------------------------------------- 13
FUSILEV --------------------------------------------------- 18
FUZEON -----------------------------------------------------5
G
gabapentin ------------------------------------------------- 11
GADAVIST ------------------------------------------------ 13
galantamine hydrobromide ------------------------------8
GAMASTAN S/D ----------------------------------------- 19
GAMMAGARD -------------------------------------------- 19
ganciclovir sodium -----------------------------------------5
GARDASIL ------------------------------------------------ 20
GARDASIL 9 ---------------------------------------------- 20
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
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GASTROGRAFIN ----------------------------------------13
GAZYVA ----------------------------------------------------- 6
GELFOAM SPONGE SIZE 100 ------------------------ 8
gemcitabine hcl -------------------------------------------- 6
gemfibrozil--------------------------------------------------- 9
gentamicin in saline --------------------------------------- 4
gentamicin sulfate ------------------------------------ 4, 14
GENTAMICIN SULFATE -------------------------------20
gentamicin sulfate (ophth) ------------------------------14
glatiramer acetate ----------------------------------------18
GLEEVEC --------------------------------------------------- 6
glimepiride--------------------------------------------------16
glipizide -----------------------------------------------------16
glipizide-metformin hcl ----------------------------------16
GLUCAGEN DIAGNOSTIC ----------------------------16
GLUCAGON EMERGENCY ---------------------------16
glyburide ----------------------------------------------------16
GLYCERIN -------------------------------------------------18
glycopyrrolate ---------------------------------------------- 7
GLYCOPYRROLATE------------------------------------18
GNP GENTIAN VIOLET --------------------------------20
GRASTEK --------------------------------------------------18
griseofulvin microsize ------------------------------------- 5
griseofulvin ultramicrosize ------------------------------- 5
guaifenesin-codeine -------------------------------------19
guanfacine hcl ---------------------------------------------- 8
homatropine hbr ------------------------------------------ 15
HUMALOG ------------------------------------------------ 16
HUMATE-P --------------------------------------------------8
HUMIRA ---------------------------------------------------- 18
HUMULIN 70/30 ------------------------------------------ 16
HUMULIN N ----------------------------------------------- 16
HUMULIN R ----------------------------------------------- 16
hydralazine hcl ----------------------------------------------9
hydrochlorothiazide ------------------------------ 9, 10, 13
hydrocodone w/ homatropine ------------------------- 19
hydrocodone-acetaminophen ------------------------- 10
hydrocortisone --------------------------------------- 16, 20
HYDROCORTISONE ----------------------------------- 18
hydrocortisone (intrarectal) ---------------------------- 20
hydrocortisone (topical) --------------------------------- 20
hydrocortisone acetate (rectal) ----------------------- 20
hydromorphone hcl -------------------------------------- 10
HYDROXOCOBALAMIN ------------------------------- 18
hydroxychloroquine sulfate ------------------------------5
HYDROXYPROGESTERONE CAPROATE ------- 18
hydroxyurea -------------------------------------------------6
hydroxyzine hcl ------------------------------------------- 11
hydroxyzine pamoate ----------------------------------- 11
HYLENEX -------------------------------------------------- 14
hyoscyamine sulfate---------------------------------------7
HYPERRAB S/D ----------------------------------------- 19
HYPERTET S/D ------------------------------------------ 19
H
halobetasol propionate ----------------------------------20
haloperidol -------------------------------------------------12
HALOPERIDOL -------------------------------------------18
haloperidol decanoate -----------------------------------12
haloperidol lactate ----------------------------------------12
HARVONI --------------------------------------------------- 5
HAVRIX -----------------------------------------------------20
HEALON5 --------------------------------------------------15
HEMABATE------------------------------------------------18
HEMOFIL M ------------------------------------------------ 8
heparin (porcine) in sodium chloride ------------------ 9
heparin sod (porcine) in d5w---------------------------- 9
heparin sodium (porcine) -------------------------------- 9
heparin sodium (porcine) lock flush ------------------- 9
HERCEPTIN ------------------------------------------------ 6
HESPAN ----------------------------------------------------14
HEXALEN --------------------------------------------------- 6
HEXTEND --------------------------------------------------14
I
IBRANCE ----------------------------------------------------6
ibuprofen --------------------------------------------------- 10
ibutilide fumarate -------------------------------------------9
idarubicin hcl ------------------------------------------------6
ifosfamide ----------------------------------------------------6
IFOSFAMIDE-MESNA ------------------------------------6
IMBRUVICA -------------------------------------------------6
imipramine hcl -------------------------------------------- 12
imiquimod -------------------------------------------------- 21
IMOVAX RABIES ---------------------------------------- 20
indapamide ------------------------------------------------ 13
INDIGO CARMINE -------------------------------------- 13
indomethacin ---------------------------------------------- 10
INDOMETHACIN------------------------------------ 10, 18
INDOMETHACIN SODIUM ---------------------------- 10
INFANRIX-------------------------------------------------- 19
INFED---------------------------------------------------------8
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
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INFERGEN-------------------------------------------------- 5
INFUMORPH 200 ----------------------------------------10
INSUFLON -------------------------------------------------12
INTEGRILIN ------------------------------------------------ 9
INTELENCE ------------------------------------------------ 5
INTRON A --------------------------------------------------- 6
INVANZ ------------------------------------------------------ 4
INVIRASE --------------------------------------------------- 5
iodoquinol-hc ----------------------------------------------20
IPOL ---------------------------------------------------------20
ipratropium bromide--------------------------------------- 7
ipratropium bromide (nasal) ----------------------------- 7
irinotecan hcl ----------------------------------------------- 7
ISENTRESS ------------------------------------------------ 5
isoniazid ----------------------------------------------------- 5
ISOPTO CARBACHOL ---------------------------------15
isosorbide dinitrate ---------------------------------------10
isosorbide mononitrate ----------------------------------10
isotretinoin--------------------------------------------------21
ISTODAX ---------------------------------------------------- 7
IXEMPRA KIT ---------------------------------------------- 7
IXIARO ------------------------------------------------------20
J
JAKAFI ------------------------------------------------------- 7
JEVTANA---------------------------------------------------- 7
K
KADCYLA --------------------------------------------------- 7
KALETRA --------------------------------------------------- 5
KALYDECO ------------------------------------------------19
KCENTRA --------------------------------------------------- 8
KCL-LACTATED RINGERS-D5W --------------------14
KENALOG--------------------------------------------------16
KEPIVANCE -----------------------------------------------21
ketamine hcl -----------------------------------------------11
KETAMINE HCL ------------------------------------------18
ketoconazole ------------------------------------------ 5, 20
ketoconazole (topical) -----------------------------------20
KETO-DIASTIX -------------------------------------------13
ketorolac tromethamine ----------------------------10, 15
ketorolac tromethamine (ophth) -----------------------15
KEYTRUDA ------------------------------------------------- 7
KINERET ---------------------------------------------------18
KINRIX ------------------------------------------------------20
KOGENATE FS -------------------------------------------- 8
K-PHOS ---------------------------------------------------- 14
KYPROLIS---------------------------------------------------7
L
labetalol hcl --------------------------------------------------9
lactated ringer's ------------------------------------------- 14
LACTIC ACID --------------------------------------------- 18
LACTOSE--------------------------------------------- 18, 19
LACTOSE MONOHYDRATE ------------------------- 19
lactulose ---------------------------------------------------- 13
lactulose (encephalopathy) ---------------------------- 13
lamivudine ---------------------------------------------------5
lamivudine (hbv) --------------------------------------------5
lamivudine-zidovudine ------------------------------------5
lamotrigine ------------------------------------------------- 11
LANTUS ---------------------------------------------------- 16
L-ARGININE ---------------------------------------------- 18
latanoprost ------------------------------------------------- 15
L-CITRULLINE-------------------------------------------- 18
leflunomide ------------------------------------------------ 18
LENVIMA 10 MG DAILY DOSE ------------------------7
LETAIRIS -------------------------------------------------- 10
letrozole ------------------------------------------------------7
leucovorin calcium --------------------------------------- 18
LEUKERAN -------------------------------------------------7
LEUKINE -----------------------------------------------------9
leuprolide acetate ------------------------------------------7
levetiracetam ---------------------------------------------- 11
LEVETIRACETAM IN NACL -------------------------- 11
LEVITRA --------------------------------------------------- 10
levobunolol hcl -------------------------------------------- 15
levocarnitine (metabolic modifiers)------------------- 18
levofloxacin --------------------------------------------------4
levofloxacin in d5w -----------------------------------------4
levonorgestrel & eth estradiol ------------------------- 16
levonorgestrel-eth estradiol (triphasic) -------------- 16
levothyroxine sodium ------------------------------------ 17
LEVULAN KERASTICK -------------------------------- 21
LEXISCAN ------------------------------------------------- 13
LEXIVA -------------------------------------------------------5
lidocaine --------------------------------------- 9, 15, 17, 20
lidocaine hcl ---------------------------------- 9, 15, 17, 20
LIDOCAINE HCL ----------------------------------------- 19
lidocaine hcl (cardiac) -------------------------------- 9, 17
lidocaine hcl (local anesth.) ---------------------------- 17
lidocaine hcl (mouth-throat)---------------------------- 15
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
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lidocaine in d5w -------------------------------------------- 9
lidocaine w/ epinephrine --------------------------------17
lidocaine-prilocaine---------------------------------------20
linezolid ------------------------------------------------------ 4
liothyronine sodium --------------------------------------17
lisinopril -----------------------------------------------------10
lisinopril & hydrochlorothiazide ------------------------10
L-ISOLEUCINE -------------------------------------------18
LITHIUM ----------------------------------------------------11
lithium carbonate -----------------------------------------11
LITHOSTAT------------------------------------------------13
LMD IN D5W ----------------------------------------------14
LMD IN NACL ---------------------------------------------14
LODOSYN -------------------------------------------------11
LOMUSTINE------------------------------------------------ 7
LONSURF --------------------------------------------------- 7
lorazepam --------------------------------------------------11
losartan potassium ---------------------------------------10
losartan potassium & hydrochlorothiazide ----------10
lovastatin ---------------------------------------------------- 9
LOVENOX--------------------------------------------------- 9
loxapine succinate----------------------------------------12
LUCENTIS -------------------------------------------------15
LUMASON -------------------------------------------------13
LUMIGAN --------------------------------------------------15
LUPRON DEPOT------------------------------------------ 7
LUPRON DEPOT-PED ---------------------------------- 7
L-VALINE ---------------------------------------------------18
LYNPARZA ------------------------------------------------- 7
LYSODREN------------------------------------------------- 7
M
MACUGEN -------------------------------------------------15
magnesium sulfate ---------------------------------------11
MAGNESIUM SULFATE IN D5W --------------------14
MAGNEVIST ----------------------------------------------13
mannitol -----------------------------------------------------13
MARQIBO --------------------------------------------------- 7
MATULANE ------------------------------------------------- 7
meclizine hcl -----------------------------------------------15
MECLOFENAMATE SODIUM-------------------------10
medroxyprogesterone acetate-------------------------17
medroxyprogesterone acetate (contraceptive) ----17
mefenamic acid -------------------------------------------10
mefloquine hcl ---------------------------------------------- 5
megestrol acetate ----------------------------------------- 7
MEKINIST ---------------------------------------------------7
meloxicam ------------------------------------------------- 10
melphalan hcl -----------------------------------------------7
memantine hcl -------------------------------------------- 11
MENACTRA ----------------------------------------------- 20
MENOMUNE ---------------------------------------------- 20
MENOPUR ------------------------------------------------ 17
MENVEO --------------------------------------------------- 20
meperidine hcl -------------------------------------------- 10
mepivacaine hcl ------------------------------------------ 17
mercaptopurine ---------------------------------------------7
meropenem --------------------------------------------------4
mesalamine ----------------------------------------------- 15
mesna------------------------------------------------------- 18
METAPROTERENOL SULFATE -----------------------8
metformin hcl ---------------------------------------------- 16
methadone hcl -------------------------------------------- 10
METHADONE HCL -------------------------------------- 19
methazolamide ------------------------------------------- 15
methenamine hippurate ----------------------------------6
methimazole ----------------------------------------------- 17
methocarbamol ---------------------------------------------8
methotrexate sodium --------------------------------------7
methoxsalen rapid --------------------------------------- 21
METHYLCELLULOSE ---------------------------------- 19
methyldopa --------------------------------------------------9
methylene blue (antidote) ------------------------------ 18
methylergonovine maleate ----------------------------- 18
methylphenidate hcl ------------------------------------- 10
methylprednisolone -------------------------------------- 16
methylprednisolone acetate --------------------------- 16
methylprednisolone sod succ ------------------------- 16
metoclopramide hcl -------------------------------------- 16
METOCLOPRAMIDE HCL MONOHYDRATE ---- 19
metolazone ------------------------------------------------ 13
METOPIRONE-------------------------------------------- 13
metoprolol tartrate -----------------------------------------9
metronidazole ------------------------------------------ 5, 20
metronidazole (topical)---------------------------------- 20
metronidazole in nacl -------------------------------------5
metronidazole vaginal ----------------------------------- 20
mexiletine hcl------------------------------------------------9
MICRHOGAM ULTRA-FILTERED PLUS ---------- 19
midazolam hcl--------------------------------------------- 11
midodrine hcl ------------------------------------------------8
MIFEPREX ------------------------------------------------ 18
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
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milrinone in dextrose-------------------------------------- 9
milrinone lactate ------------------------------------------- 9
MINERAL OIL LIGHT------------------------------------16
minocycline hcl --------------------------------------------- 4
minoxidil ----------------------------------------------------- 9
MIOCHOL-E -----------------------------------------------15
MIRENA ----------------------------------------------------17
mirtazapine-------------------------------------------------12
misoprostol -------------------------------------------------15
mitomycin---------------------------------------------------- 7
mitoxantrone hcl ------------------------------------------- 7
M-M-R II ----------------------------------------------------20
mometasone furoate -------------------------------------20
montelukast sodium--------------------------------------19
morphine sulfate ------------------------------------------10
MORPHINE SULFATE ----------------------------------19
moxifloxacin hcl -------------------------------------------- 4
MULTIHANCE ---------------------------------------------13
multiple vitamin -------------------------------------------21
mupirocin ---------------------------------------------------20
MUSTARGEN ---------------------------------------------- 7
mycophenolate mofetil ----------------------------------18
MYLERAN--------------------------------------------------- 7
MYOBLOC -------------------------------------------------18
MYOZYME -------------------------------------------------14
N
NABI-HB ----------------------------------------------------19
nabumetone -----------------------------------------------10
nafcillin sodium --------------------------------------------- 4
NAGLAZYME ----------------------------------------------14
nalbuphine hcl ---------------------------------------------10
NALLPEN IN DEXTROSE ------------------------------ 4
naloxone hcl ------------------------------------------10, 11
naltrexone hcl ---------------------------------------------11
naproxen----------------------------------------------------10
naratriptan hcl ---------------------------------------------11
NAROPIN --------------------------------------------------17
NEBUPENT ------------------------------------------------- 5
NECON 1/50 (28)-----------------------------------------17
NECON 10/11 (28) ---------------------------------------17
nefazodone hcl --------------------------------------------12
NEMBUTAL ------------------------------------------------11
neomycin sulfate ------------------------------------------- 4
NEOMYCIN SULFATE ----------------------------------19
neomycin/polymyxin b gu -------------------------------20
neomycin-bacitracin zn-polymyxin ------------------- 14
neomycin-polymy-dexameth -------------------------- 15
neomycin-polymyxin-gramicidin ---------------------- 14
neomycin-polymyxin-hc (otic) ------------------------- 15
NEOPROFEN --------------------------------------------- 10
neostigmine methylsulfate -------------------------------8
NEUMEGA --------------------------------------------------9
NEUPOGEN ------------------------------------------------9
nevirapine ----------------------------------------------------5
NEXAVAR ---------------------------------------------------7
NEXPLANON --------------------------------------------- 17
niacin -------------------------------------------------------- 21
nicardipine hcl-----------------------------------------------9
nicotine -------------------------------------------------------8
nicotine polacrilex ------------------------------------------8
nifedipine -----------------------------------------------------9
nimodipine ---------------------------------------------------9
nitrofurantoin ------------------------------------------------6
nitrofurantoin macrocrystal-------------------------------6
nitrofurantoin monohyd macro --------------------------6
nitroglycerin ----------------------------------------------- 10
nitroglycerin in d5w -------------------------------------- 10
NITROPRESS ----------------------------------------------9
NORDITROPIN FLEXPRO ---------------------------- 17
norepinephrine bitartrate ---------------------------------8
norethin acet & estrad-fe ------------------------------- 17
norethindrone & eth estradiol ------------------------- 17
norethindrone (contraceptive) ------------------------- 17
norethindrone acetate ----------------------------------- 17
norethindrone-eth estradiol (triphasic) -------------- 17
norgestimate-ethinyl estradiol ------------------------- 17
norgestimate-ethinyl estradiol (triphasic) ----------- 17
nortriptyline hcl-------------------------------------------- 12
NORVIR ------------------------------------------------------5
NOVOSEVEN RT ------------------------------------------8
NUVARING ------------------------------------------------ 17
nystatin -------------------------------------------------- 5, 20
nystatin (mouth-throat) ------------------------------------5
nystatin (topical) ------------------------------------------ 20
nystatin-triamcinolone ----------------------------------- 20
O
octreotide acetate ---------------------------------------- 18
OFIRMEV -------------------------------------------------- 10
ofloxacin (ophth)------------------------------------------ 14
ofloxacin (otic) -------------------------------------------- 14
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
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OGESTREL ------------------------------------------------17
olanzapine--------------------------------------------------12
omeprazole ------------------------------------------------15
OMNIPAQUE ----------------------------------------------13
OMNITROPE PEN 5 INJ DEVICE -------------------12
ondansetron -----------------------------------------------15
ondansetron hcl -------------------------------------------15
ONETOUCH GLUCOSE CONTROL LOW
CONTROL ----------------------------------------------12
ONETOUCH ULTRA BLUE ----------------------------13
ONETOUCH ULTRA MINI -----------------------------12
OPANA -----------------------------------------------------10
OPDIVO ----------------------------------------------------- 7
ophthalmic irrigation solution - intraocular ----------15
OPSUMIT --------------------------------------------------18
ORAP -------------------------------------------------------12
ORENCIA --------------------------------------------------18
ORKAMBI --------------------------------------------------19
ORTHO DIAPHRAGM ALL-FLEX --------------------12
OTEZLA ----------------------------------------------------18
oxaliplatin ---------------------------------------------------- 7
oxazepam --------------------------------------------------11
oxcarbazepine ---------------------------------------------11
OXSORALEN ---------------------------------------------21
oxybutynin chloride---------------------------------------21
oxycodone hcl ---------------------------------------------10
oxycodone w/ acetaminophen -------------------------10
oxytocin -----------------------------------------------------18
OXYTROL --------------------------------------------------21
P
paclitaxel----------------------------------------------------- 7
pamidronate disodium -----------------------------------18
pancuronium bromide ------------------------------------ 8
pantoprazole sodium ------------------------------------15
papaverine hcl---------------------------------------------10
paromomycin sulfate-------------------------------------- 5
paroxetine hcl ---------------------------------------------12
ped multivitamins w/fl & iron ---------------------------21
PEDIARIX --------------------------------------------------20
pediatric multivitamins w/fl -----------------------------21
PEDIATRIC SMALL MASK ----------------------------12
pediatric vitamins acd w/ fluoride ---------------------21
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 16
PEGASYS --------------------------------------------------- 5
PEG-INTRON ---------------------------------------------- 5
PENICILLIN G POT IN DEXTROSE ------------------4
penicillin g potassium -------------------------------------4
PENICILLIN G PROCAINE ------------------------------4
PENICILLIN G SODIUM----------------------------------4
penicillin v potassium -------------------------------------4
PENLET II BLOOD SAMPLER ----------------------- 12
PENTETATE CALCIUM TRISODIUM -------------- 16
PENTETATE ZINC TRISODIUM --------------------- 16
pentostatin ---------------------------------------------------7
pentoxifylline ------------------------------------------------9
PERJETA ----------------------------------------------------7
permethrin ------------------------------------------------- 20
perphenazine --------------------------------------------- 12
PERPHENAZINE-AMITRIPTYLINE ----------------- 12
phenelzine sulfate---------------------------------------- 12
PHENEX-1 ------------------------------------------------- 13
phenobarbital --------------------------------------------- 11
PHENOBARBITAL---------------------------------- 11, 19
PHENOBARBITAL SODIUM -------------------------- 11
PHENOL --------------------------------------------------- 20
PHENTOLAMINE MESYLATE -------------------------8
phenoxybenzamine hcl _____________________8
phenylephrine hcl (ophth) ------------------------------ 15
phenylephrine hcl (pressors) ----------------------------8
phenylephrine-chlorphen-dm -------------------------- 19
PHENYLHISTINE DH ----------------------------------- 19
phenytoin--------------------------------------------------- 11
phenytoin sodium ---------------------------------------- 11
phenytoin sodium extended --------------------------- 11
PHISOHEX ------------------------------------------------ 20
PHOSPHOLINE IODIDE ------------------------------- 15
PHYSOSTIGMINE SALICYLATE ----------------------8
phytonadione ---------------------------------------------- 21
pilocarpine hcl------------------------------------------ 8, 15
pilocarpine hcl (oral) ---------------------------------------8
pioglitazone hcl ------------------------------------------- 16
piperacillin sodium-tazobactam sodium --------------4
PLAN B ONE-STEP ------------------------------------- 17
PLASMANATE----------------------------------------------8
PLURONIC F127----------------------------------------- 19
PNEUMOVAX 23 ---------------------------------------- 20
PODOCON ------------------------------------------------ 21
podofilox---------------------------------------------------- 21
PODOPHYLLUM RESIN ------------------------------- 19
POLYETHYLENE GLYCOL 400 --------------------- 19
POLYFIN QR INFUSION SET 42 -------------------- 12
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
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polymyxin b-trimethoprim -------------------------------14
polysaccharide iron complex---------------------------- 8
POMALYST ------------------------------------------------- 7
potassium acetate ----------------------------------------14
potassium bicarbonate ----------------------------------14
potassium chloride ---------------------------------------14
potassium chloride in dextrose ------------------------14
potassium chloride in dextrose & sodium chloride14
potassium chloride in nacl ------------------------------14
potassium chloride microencapsulated crystals cr14
potassium citrate (alkalinizer)--------------------------13
potassium citrate-citric acid ----------------------------13
potassium phosphates ----------------------------------14
PRADAXA --------------------------------------------------- 9
pramipexole dihydrochloride ---------------------------11
PRASCION RA -------------------------------------------21
pravastatin sodium ---------------------------------------- 9
prazosin hcl ------------------------------------------------- 9
PRECEDEX------------------------------------------------11
prednisolone ------------------------------------------15, 16
prednisolone acetate (ophth) --------------------------15
prednisolone sodium phosphate ----------------------16
prednisone -------------------------------------------------16
PREMARIN ------------------------------------------------17
PREPIDIL --------------------------------------------------18
PREVIDENT -----------------------------------------------18
PREVNAR 13 ---------------------------------------------20
PREZCOBIX ------------------------------------------------ 6
PREZISTA -------------------------------------------------- 6
PRIFTIN ----------------------------------------------------- 5
PRIMAQUINE PHOSPHATE --------------------------- 5
PRIMAXIN IV ----------------------------------------------- 4
primidone ---------------------------------------------------11
probenecid -------------------------------------------------14
PROCAINAMIDE HCL ----------------------------------- 9
prochlorperazine ------------------------------------------12
prochlorperazine edisylate -----------------------------12
prochlorperazine maleate ------------------------------12
PROCRIT---------------------------------------------------- 9
PROCTOFOAM HC--------------------------------------20
PROFERRIN ES ------------------------------------------- 8
PROFERRIN-FORTE ------------------------------------ 8
PROFILNINE -------------------------------------------- 8, 9
progesterone ----------------------------------------------17
progesterone micronized -------------------------------17
PROGESTERONE MICRONIZED -------------------19
PROGESTERONE WETTABLE ---------------------- 19
PROLASTIN-C-------------------------------------------- 14
PROLEUKIN ------------------------------------------------7
PROMACTA -------------------------------------------------9
promethazine hcl -------------------------------------------6
promethazine-dm ---------------------------------------- 19
propafenone hcl --------------------------------------------9
PROPANTHELINE BROMIDE --------------------------7
proparacaine hcl------------------------------------------ 15
propofol ----------------------------------------------------- 11
propranolol hcl ----------------------------------------------9
PROPYLENE GLYCOL--------------------------------- 19
propylthiouracil-------------------------------------------- 17
PROQUAD ------------------------------------------------ 20
PROSTIGMIN -----------------------------------------------8
PROTAMINE SULFATE ----------------------------------8
protriptyline hcl-------------------------------------------- 12
PULMOZYME --------------------------------------------- 14
pyrazinamide ------------------------------------------------5
pyridostigmine bromide -----------------------------------8
Q
QUELICIN ---------------------------------------------------8
quetiapine fumarate ------------------------------------- 12
QUINACRINE HCL -------------------------------------- 19
quinidine gluconate ----------------------------------------9
QUINIDINE SULFATE ------------------------------------9
QVAR ------------------------------------------------------- 16
R
RABAVERT ----------------------------------------------- 20
raloxifene hcl ---------------------------------------------- 17
ranitidine hcl ----------------------------------------------- 15
RASUVO --------------------------------------------------- 18
RECOTHROM ----------------------------------------------8
RELENZA DISKHALER ----------------------------------6
REMICADE ------------------------------------------------ 18
REMODULIN ---------------------------------------------- 10
RENVELA -------------------------------------------------- 13
REOPRO-----------------------------------------------------9
RESCRIPTOR ----------------------------------------------6
RESERPINE ------------------------------------------------9
RESTASIS ------------------------------------------------- 15
RETIN-A---------------------------------------------------- 21
RETIN-A MICRO ----------------------------------------- 21
RETISERT ------------------------------------------------- 15
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 33
REVLIMID --------------------------------------------------- 7
REYATAZ --------------------------------------------------- 6
ribavirin (hepatitis c) -------------------------------------- 6
RIDAURA---------------------------------------------------16
rifabutin ------------------------------------------------------ 5
rifampin ------------------------------------------------------ 5
riluzole ------------------------------------------------------11
rimantadine hydrochloride ------------------------------- 6
RIMSO-50 --------------------------------------------------18
risperidone -------------------------------------------------12
RITUXAN ---------------------------------------------------- 7
rizatriptan benzoate --------------------------------------11
rocuronium bromide--------------------------------------- 8
ropinirole hydrochloride ---------------------------------11
ROTARIX ---------------------------------------------------20
ROTATEQ--------------------------------------------------20
S
SABRIL -----------------------------------------------------11
SALICYLIC ACID -----------------------------------------19
salsalate ----------------------------------------------------10
SANDIMMUNE --------------------------------------------18
SANTYL ----------------------------------------------------21
SCOPOLAMINE HBR ------------------------------------ 7
selegiline hcl -----------------------------------------------11
SELENIUM -------------------------------------------------14
selenium sulfide -------------------------------------------20
SELZENTRY ----------------------------------------------- 6
SENSIPAR -------------------------------------------------18
SEREVENT DISKUS ------------------------------------- 8
SEROMYCIN ----------------------------------------------- 5
SEROSTIM ------------------------------------------------17
sertraline hcl -----------------------------------------------12
sildenafil citrate (pulmonary hypertension) ---------10
silver sulfadiazine ----------------------------------------20
simvastatin -------------------------------------------------- 9
sirolimus ----------------------------------------------------18
sodium acetate --------------------------------------------13
SODIUM BENZOATE -----------------------------------19
sodium bicarbonate --------------------------------------13
sodium chloride ---------------------------------- 9, 14, 19
sodium chloride (gu irrigant) ---------------------------14
sodium chloride (inhalant) ------------------------------19
sodium citrate & citric acid -----------------------------13
SODIUM EDECRIN --------------------------------------13
sodium fluoride --------------------------------------------18
sodium phenylbutyrate ---------------------------------- 13
sodium phosphate ---------------------------------- 14, 16
sodium polystyrene sulfonate ------------------------- 13
sodium thiosulfate---------------------------------------- 16
SOLIRIS ---------------------------------------------------- 18
SORBITOL ------------------------------------------- 16, 19
sotalol hcl ----------------------------------------------------9
sotalol hcl (afib/afl) -----------------------------------------9
SOTRADECOL ------------------------------------------- 10
SOVALDI-----------------------------------------------------6
SPIRIVA RESPIMAT --------------------------------------7
spironolactone -------------------------------------------- 10
spironolactone & hydrochlorothiazide --------------- 10
SPRYCEL ----------------------------------------------------7
SQUARIC ACID DIBUTYLESTER ------------------- 19
SSKI --------------------------------------------------------- 17
stavudine -----------------------------------------------------6
STELARA -------------------------------------------------- 21
STIVARGA --------------------------------------------------7
STREPTOMYCIN SULFATE ----------------------------4
STRIBILD ----------------------------------------------------6
STRIVERDI RESPIMAT ----------------------------------8
sucralfate--------------------------------------------------- 15
sufentanil citrate ------------------------------------------ 10
sulfacetamide sodium (ophth)------------------------- 14
sulfacetamide sodium w/ sulfur ----------------------- 21
sulfacetamide sod-prednisolone ---------------------- 15
SULFADIAZINE --------------------------------------------5
sulfamethoxazole-trimethoprim -------------------------5
sulfasalazine ------------------------------------------------5
SULFUR PRECIPITATED ----------------------------- 19
sulindac----------------------------------------------------- 10
SUMATRIPTAN ------------------------------------------ 11
sumatriptan succinate ----------------------------------- 11
SURMONTIL ---------------------------------------------- 12
SURVANTA ----------------------------------------------- 19
SUSTIVA -----------------------------------------------------6
SUTENT------------------------------------------------------7
SYLVANT ----------------------------------------------------7
SYNAGIS ----------------------------------------------------6
SYNAREL -------------------------------------------------- 17
SYNERCID --------------------------------------------------5
syringe (disposable) ------------------------------------- 12
T
TABLOID -----------------------------------------------------7
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
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tacrolimus ---------------------------------------------18, 21
tacrolimus (topical) ---------------------------------------21
TAFINLAR--------------------------------------------------- 7
TAMIFLU ---------------------------------------------------- 6
tamoxifen citrate ------------------------------------------- 7
tamsulosin hcl ---------------------------------------------- 9
TARCEVA --------------------------------------------------- 7
TARGRETIN ------------------------------------------- 7, 21
TASIGNA ---------------------------------------------------- 7
TAXOTERE ------------------------------------------------- 7
TAZORAC --------------------------------------------------21
temazepam ------------------------------------------------11
temozolomide ---------------------------------------------- 7
TENIPOSIDE ----------------------------------------------- 7
terazosin hcl ------------------------------------------------ 9
terbinafine hcl ---------------------------------------------- 5
terbutaline sulfate ----------------------------------------- 8
TESTOSTERONE ----------------------------------------19
testosterone cypionate ----------------------------------16
testosterone enanthate----------------------------------16
TETANUS-DIPHTHERIA TOXOIDS TD ------------19
TETRACAINE HCL --------------------------------------17
tetracaine hcl (ophth) ------------------------------------15
THALOMID-------------------------------------------------18
theophylline ------------------------------------------------21
theophylline in dextrose ---------------------------------21
THERACYS ------------------------------------------------20
thiamine hcl ------------------------------------------------21
THIOLA -----------------------------------------------------18
thioridazine hcl --------------------------------------------12
THIOTEPA -------------------------------------------------- 7
thiothixene--------------------------------------------------12
THROMBATE III ------------------------------------------- 9
THYMOL----------------------------------------------------19
THYROGEN -----------------------------------------------13
TIKOSYN ---------------------------------------------------- 9
timolol maleate (ophth) ----------------------------------15
TIVICAY ----------------------------------------------------- 6
tizanidine hcl ------------------------------------------------ 8
TNKASE ----------------------------------------------------- 9
tobramycin --------------------------------------------- 5, 14
tobramycin (ophth) ---------------------------------------14
tobramycin sulfate ----------------------------------------- 5
TOLBUTAMIDE -------------------------------------------16
topiramate --------------------------------------------------11
topotecan hcl ----------------------------------------------- 7
TORISEL -----------------------------------------------------7
torsemide -------------------------------------------------- 13
trace minerals (cr-cu-mn-zn) -------------------------- 14
TRACLEER ------------------------------------------------ 10
tramadol hcl ----------------------------------------------- 10
tramadol-acetaminophen ------------------------------- 10
tranexamic acid ---------------------------------------------8
TRANEXAMIC ACID ------------------------------------ 19
TRANSDERM-SCOP (1.5 MG) ----------------------- 15
tranylcypromine sulfate --------------------------------- 12
trazodone hcl ---------------------------------------------- 12
TREANDA ---------------------------------------------------7
TRECATOR -------------------------------------------------5
TRIAMCINOLONE ACETONIDE --------------------- 19
triamcinolone acetonide (mouth) --------------------- 20
triamcinolone acetonide (topical) --------------------- 20
triamterene & hydrochlorothiazide ------------------- 13
trifluoperazine hcl ---------------------------------------- 12
trifluridine--------------------------------------------------- 14
trihexyphenidyl hcl --------------------------------------- 11
trimethoprim ---------------------------------------- 5, 6, 14
TRISENOX --------------------------------------------------7
TRIUMEQ ----------------------------------------------------6
TRI-VIT/FLUORIDE/IRON ----------------------------- 21
tropicamide ------------------------------------------------ 15
trospium chloride ----------------------------------------- 21
TRUVADA ---------------------------------------------------6
TUBERSOL ----------------------------------------------- 13
TWINRIX --------------------------------------------------- 20
TYKERB------------------------------------------------------7
TYPHIM VI ------------------------------------------------- 20
TYSABRI --------------------------------------------------- 18
TYVASO --------------------------------------------------- 10
U
ULTIVA ----------------------------------------------------- 10
UNITUXIN ---------------------------------------------------7
UREA ------------------------------------------------------- 19
ursodiol ----------------------------------------------------- 16
V
valacyclovir hcl----------------------------------------------6
valganciclovir hcl -------------------------------------------6
valproate sodium ----------------------------------------- 11
valproic acid ----------------------------------------------- 11
valsartan --------------------------------------------------- 10
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 35
valsartan-hydrochlorothiazide -------------------------10
vancomycin hcl--------------------------------------------- 5
VANCOMYCIN HCL IN DEXTROSE ----------------- 5
VARIVAX ---------------------------------------------------20
VARIZIG ----------------------------------------------------19
vasopressin ------------------------------------------------17
VECTICAL -------------------------------------------------21
vecuronium bromide -------------------------------------- 8
VELCADE --------------------------------------------------- 7
venlafaxine hcl --------------------------------------------12
VENOFER--------------------------------------------------- 8
VENTAVIS -------------------------------------------------10
verapamil hcl ----------------------------------------------- 9
VEXOL ------------------------------------------------------15
VIMIZIM -----------------------------------------------------14
VINBLASTINE SULFATE ------------------------------- 7
vincristine sulfate ------------------------------------------ 7
vinorelbine tartrate ---------------------------------------- 7
VIRACEPT -------------------------------------------------- 6
VIRAZOLE -------------------------------------------------- 6
VIREAD ------------------------------------------------------ 6
VISUDYNE -------------------------------------------------15
VIVOTIF ----------------------------------------------------20
VORAXAZE ------------------------------------------------14
voriconazole --------------------------------------------- 5, 6
VOTRIENT -------------------------------------------------- 7
VPRIV -------------------------------------------------------14
VYVANSE --------------------------------------------------10
W
warfarin sodium -------------------------------------------- 9
water for injection, sterile -------------------------------18
water for irrigation, sterile -------------------------------14
WIDE-SEAL DIAPHRAGM 60 ------------------------ 12
X
XALKORI-----------------------------------------------------7
XERAC AC ------------------------------------------------ 21
XIFAXAN -----------------------------------------------------5
XTANDI-------------------------------------------------------7
XULANE---------------------------------------------------- 17
XYNTHA -----------------------------------------------------8
Y
YALE DISP NEEDLES---------------------------------- 12
YF-VAX ----------------------------------------------------- 20
YODOXIN ----------------------------------------------------5
Z
ZANOSAR ---------------------------------------------------7
ZARXIO ------------------------------------------------------9
ZELBORAF --------------------------------------------------7
zidovudine ----------------------------------------------- 5, 6
ZINACEF IN STERILE WATER ------------------------5
ZINC SULFATE ------------------------------------------ 19
ZINC TRACE METAL ----------------------------------- 14
ziprasidone hcl -------------------------------------------- 12
zoledronic acid -------------------------------------------- 18
zolpidem tartrate ----------------------------------------- 11
ZOSTAVAX ------------------------------------------------ 20
ZOSYN -------------------------------------------------------5
ZYDELIG -----------------------------------------------------7
ZYKADIA -----------------------------------------------------7
ZYMAXID -------------------------------------------------- 14
ZYTIGA -------------------------------------------------------7
2016 Kaiser Permanente Federal Employees Health Benefit Formulary
(Northern California Region)
Page 36
Northern California Region Member Services
24 hours a day, seven days a week (closed holidays)
1-800-464-4000 English
1-800-788-0616 Spanish
1-800-757-7585 Chinese dialects
TTY 711 for the hearing/speech impaired
Please recycle.
60462410 5/2016