docDenver/Boulder & Northern Colorado HMO & Medicare Retiree Drug
download 
Report Transcription
Denver/Boulder & Northern Colorado HMO & Medicare Retiree Drug
Denver/Boulder & Northern Colorado Commercial HMO Drug Formulary & Denver/Boulder Medicare Retiree Drug Subsidy Formulary Listing The following is a listing of the drugs on the Denver/Boulder & Northern Colorado Commercial HMO drug Formulary and Denver/Boulder Medicare Retiree Drug Subsidy Formulary (non-Part D). This formulary applies only to outpatient drugs provided to members for self-administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The listing does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the formulary. Kaiser Permanente has many brand and generic medications on the formulary. In most cases, a generic equivalent is used when available. Members will be notified when a generic equivalent is dispensed. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay. Kaiser Permanente may implement programs, such as a therapeutic interchange program, to promote safe and effective drug therapy. In these cases the prescribing provider and member are notified prior to a change occurring. How to use this Formulary document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters. Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-preferred drug. You can search the list by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category. All dosage forms and strengths for a particular drug listed may not be formulary. Some drugs are available in more than one dosage form (example: tablet and injectable). Not all dosage forms of drugs are covered under the prescription drug benefit. Drugs that have at least one dosage form as an injectable on formulary are noted with an asterisk (*). Drugs that have certain strengths or forms (e.g., tablet, gel capsule, liquid) that are only available as brand drugs are subject to the brand cost share. Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. For example, Entocort EC®, a drug used for colitis, is restricted to physicians specialized in Gastroenterology. • Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit. Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 -1- • Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a specific days supply or quantity per copay. For example, Tarceva® is limited to a 30-day supply. In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment. • Restricted to Benefit: Some drugs are not covered unless the individual prescription benefit specifically covers such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless the prescription benefit specifically covers them. • Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first. • Restricted to a specific age: Some medications may be restricted to a certain age or age range. • Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules. The following are examples of exception requests: o Request to cover a drug that is not on our preferred product list o Request to waive coverage restrictions or limitations • Generally Kaiser Permanente will only approve requests for an exception if the alternative drugs included on the plan’s preferred product list, or existing utilization restrictions, would not be as effective in treating a condition or would cause adverse medical effects. Key: * (asterisk) = A drug where at least one of the dosage forms is an injectable. Some patients have a specific self-injectable coinsurance. (diamond) = A drug that is designated as a Specialty drug which may process at a Specialty tier of the individual prescription drug benefit, where applicable. † (dagger) = Certain strengths or forms of the drug (e.g., tablet, gel, liquid) are only available as brand drugs and are subject to the brand cost share. MD = A drug that is required to be written by a physician specialized in the treatment of certain conditions. PA = A drug that requires specific medical criteria be met prior to dispensing for prescription benefit. QL = A drug that has a quantity limit or is limited to a specific day supply. RB = A drug that is restricted to a certain benefit for coverage. ST = A drug that requires another class of medications be attempted prior to dispensing for prescription benefit. AG = A drug that is restricted to a specific age range. NC = A drug that is specifically excluded under certain benefit plans. This list of drugs should not be used to determine benefit issues such as prescription copay amounts. If you have questions about prescription benefits, please call Kaiser Permanente Member Services at 1-888-681-7878. The medications on this list are subject to change at any time throughout the year Drug Name ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA BILTRICIDE ANTI-INFECTIVE AGENTS ANTIBACTERIALS amoxicillin Drug Tier Requirements/Limits Brand Brand Generic/Brand † Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 -2- Drug Name Drug Tier amoxicillin & potassium clavulanate ampicillin AVELOX AZACTAM azithromycin bacitracin bacitracin & polymyxin B CAYSTON cefazolin sodium cefdinir cefepime cefotaxime sodium cefotetan ceftazidime ceftriaxone sodium cefuroxime axetil cefuroxime sodium cephalexin CIPRODEX ciprofloxacin hcl clarithromycin clindamycin hcl clindamycin palmitate hydrochloride clindamycin phosphate dicloxacillin sodium doxycycline hyclate doxycycline monohydrate erythromycin base erythromycin ethylsuccinate erythromycin lactobionate erythromycin sulfisoxazole GANTRISIN gentamicin sulfate INVANZ levofloxacin minocycline hcl neomycin sulfate penicillin g potassium penicillin g procaine Requirements/Limits Generic/Brand † Generic * Brand * Brand * Generic * Generic Generic Brand * Generic * Generic Generic * Generic/Brand * † Generic * Generic/Brand * † Generic * Generic/Brand † Generic * Generic Brand Generic/Brand * † Generic Generic/Brand † Generic Generic/Brand * † Generic Generic/Brand * † Generic Generic/Brand † Generic/Brand † Generic/Brand * † Generic/Brand † Brand Generic * Brand * Generic* Generic Generic Generic * Generic * Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 -3- Drug Name penicillin g sodium penicillin v potassium piperacillin-tazobactam PRIMAXIN I.M. streptomycin sulfate sulfamethoxazole-trimethoprim sulfasalazine SUPRAX TAZICEF tetracycline hcl tobramycin nebulization solution tobramycin sulfate TROBICIN VANCOCIN ISOOSMOTIC DEXTROSE vancomycin hcl ZYVOX ANTI-INFECTIVE AGENTS ANTIFUNGALS AMBISOME amphotericin b ANCOBON CANCIDAS fluconazole fluconazole in nacl griseofulvin microsize griseofulvin ultramicrosize ketoconazole nystatin voriconazole ANTI-INFECTIVE AGENTS ANTIMYCOBACTERIALS dapsone ethambutol hcl isoniazid pyrazinamide rifampin ANTI-INFECTIVE AGENTS ANTIPROTOZOALS atovaquone atovaquone-proguanil Drug Tier Generic * Generic Generic/Brand * † Brand * Generic * Generic * Generic Brand Brand * Generic/Brand † Generic Generic/Brand * † Brand * Requirements/Limits Brand * Generic/Brand * Brand * Brand * Generic * Brand Brand * Generic * Generic * Generic/Brand † Generic Generic Generic Generic/Brand * † Generic Generic Generic Generic Generic * Generic Generic Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 -4- Drug Name Drug Tier Generic Brand Generic Generic Brand Generic * Generic Generic/Brand * † Generic chloroquine phosphate DARAPRIM hydroxychloroquine sulfate mefloquine hcl MEPRON metronidazole paromomycin sulfate pentamidine isethionate primaquine phosphate ANTI-INFECTIVE AGENTS ANTIVIRALS abacavir abacavir &lamivudine & zidovudine acyclovir adefovir amantadine hcl APTIVUS ATRIPLA COMPLERA CRIXIVAN didanosine EDURANT EMTRIVA entecavir EPZICOM famciclovir foscarnet sodium ganciclovir INCIVEK INTELENCE INVIRASE ISENTRESS KALETRA lamivudine lamivudine & zidovudine LEXIVA nevirapine NORVIR PEGASYS PREZISTA Requirements/Limits Generic/Brand † Generic Generic * Generic Generic Brand Brand Brand Brand Generic/Brand † Brand Brand Generic Brand Generic Generic * Generic * Brand * Brand Brand Brand Brand Generic/Brand † Generic Brand Generic/Brand † Brand Brand * Brand QL QL Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 -5- Drug Name RESCRIPTOR REYATAZ ribavirin rimantadine hydrochloride SELZENTRY SOVALDI stavudine STRIBILD SUSTIVA SYNAGIS TAMIFLU TIVICAY TRUVADA VALCYTE VICTRELIS VIRACEPT VIREAD zidovudine ANTI-INFECTIVE AGENTS URINARY ANTI-INFECTIVES methenamine hippurate nitrofurantoin macrocrystal nitrofurantoin monohyd macro PRIMSOL trimethoprim ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS cyproheptadine hcl diphenhydramine hcl promethazine hcl ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE AFINITOR anastrozole AVASTIN bicalutamdie BICNU W/DILUENT ABSOLUTE ETHANOL bleomycin sulfate capecitabine Drug Tier Brand Brand Generic Generic/Brand † Brand Brand Generic Brand Brand Brand * Brand Brand Brand Brand Brand * Brand Brand Generic/Brand † Requirements/Limits QL QL Generic Generic Generic Brand/Generic Generic Generic* Generic * Generic* Brand * Brand Generic Brand * Generic QL Brand * Generic * Generic Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 -6- Drug Name Drug Tier Generic * Brand Generic * Generic * Generic * Generic * Generic * Generic * Generic * Generic * Brand * Brand Brand * Generic * Generic Brand Generic * Generic/Brand * † Generic Brand * Brand Brand * Brand Generic Generic * Generic * Generic * Brand * Brand * Brand Generic/Brand * † Brand * Brand * Brand Brand Generic Generic/Brand * † Generic Generic * Generic * Generic * carboplatin CEENU cisplatin cyclophosphamide cytarabine dacarbazine dactinomycin daunorubicin hcl docetaxel doxorubicin hcl ELSPAR EMCYT ERBITUX etoposide exemestane FEMARA fludarabine phosphate fluorouracil flutamide GEMZAR GLEEVEC HERCEPTIN HEXALEN hydroxyurea idarubicin hcl ifosfamide ifosfamide & mesna INTRON-A INTRON-A W/DILUENT LEUKERAN leuprolide acetate LUPRON DEPOT LUPRON DEPOT-PED LYSODREN MATULANE megestrol acetate melphalan mercaptopurine methotrexate sodium mitomycin mitoxantrone hcl Requirements/Limits QL QL QL QL QL QL Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 -7- Drug Name Drug Tier Brand * Brand Brand Generic * Generic * Brand * Brand Brand Brand Generic Brand Brand Generic * Generic * Generic * Brand * Generic Brand Brand * Generic * Generic * Generic * Brand Brand Brand Brand Brand * Brand MUSTARGEN MYLERAN NEXAVAR paclitaxel pentostatin RITUXAN SPRYCEL SUTENT TABLOID tamoxifen citrate TARCEVA TASIGNA temozolomide thiotepa topotecan TORISEL tretinoin TYKERB VIDAZA vinblastine sulfate vincristine sulfate vinorelbine tartrate VOTRIENT XALKORI XTANDI ZELBORAF ZOLADEX ZYTIGA AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS atropine sulfate ATROVENT HFA benztropine mesylate clidinium / chlordiazepoxide dicyclomine hcl glycopyrrolate ipratropium bromide propantheline bromide scopolamine hydrobromide SPIRIVA HANDIHALER trihexyphenidyl hcl Requirements/Limits QL QL QL QL QL QL QL QL QL QL QL QL QL Generic * Brand Generic * Generic Generic/Brand * † Generic * Generic Generic Generic/Brand * † Brand Generic Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 -8- Drug Name Drug Tier Requirements/Limits AUTONOMIC DRUGS AUTONOMIC DRUGS, MISCELLANEOUS DIBENZYLINE Brand AUTONOMIC DRUGS PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride Generic donepezil hydrochloride Generic ENLON Brand * galantamine hydrobromide Generic MYTELASE Brand neostigmine methylsulfate Generic * pilocarpine hcl (oral) Generic/Brand † pyridostigmine bromide Generic/Brand † AUTONOMIC DRUGS SKELETAL MUSCLE RELAXANTS ANECTINE Brand * baclofen Generic cyclobenzaprine hcl Generic dantrolene sodium Generic/Brand * † methocarbamol Generic/Brand * † AUTONOMIC DRUGS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS ergoloid mesylates Generic phentolamine mesylate Generic * AUTONOMIC DRUGS SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR DISKUS Brand albuterol Generic albuterol sulfate Generic COMBIVENT Brand COMBIVENT RESPIMAT Brand DULERA Brand ephedrine sulfate (pressors) Generic * EPIPEN 2-PAK Brand * EPIPEN-JR 2-PAK Brand * FORADIL AEROLIZER Brand MAXAIR AUTOHALER Brand metaproterenol sulfate Generic phenylephrine hcl (pressors) Generic * SEREVENT DISKUS Brand terbutaline sulfate Generic * Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 -9- Drug Name Drug Tier BLOOD FORMATION, COAGULATION, AND THROMBOSIS COAGULANTS AND ANTICOAGULANTS ABBOKINASE Brand * ACTIVASE Brand * AGGRENOX Brand aminocaproic acid Generic * anagrelide hcl Generic clopidogrel Generic dipyridamole Generic fondaparinux Generic * BRILINTA Brand enoxaparin sodium Generic * EFFIENT Brand heparin sodium (porcine) Generic * pentoxifylline Generic tranexamic acid Generic * PRADAXA Brand warfarin sodium Generic BLOOD FORMATION, COAGULATION AND THROMBOSIS HEMATOPOIETIC AGENTS NEUPOGEN Brand * PROCRIT Brand * BLOOD FORMATION, COAGULATION AND THROMBOSIS HEMOSTATICS HELIXATE FS Brand * HUMATE-P Brand * KOGENATE FS Brand * RECOMBINATE Brand * REFACTO Brand * BLOOD FORMATION, COAGULATION AND THROMBOSIS IRON PREPARATIONS DEXFERRUM Brand * INFED Brand * VENOFER Brand * CARDIOVASCULAR DRUGS ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate Generic prazosin hcl Generic terazosin hcl Generic CARDIOVASCULAR DRUGS ANTILIPEMIC AGENTS Requirements/Limits QL QL Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 10 - Drug Name Drug Tier Generic Generic Generic Generic Generic Generic Generic Generic Requirements/Limits atorvastatin cholestyramine colestipol hcl fenofibrate gemfibrozil lovastatin pravastatin sodium simvastatin CARDIOVASCULAR DRUGS BETA-ADRENERGIC BLOCKING AGENTS acebutolol Generic atenolol Generic/Brand * † carvedilol Generic labetalol hcl Generic * metoprolol succinate Generic metoprolol tartrate Generic * propranolol hcl Generic * sotalol hcl Generic CARDIOVASCULAR DRUGS CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besylate Generic diltiazem hcl Generic * nifedipine Generic nimodipine Generic verapamil hcl Generic * CARDIOVASCULAR DRUGS CARDIAC DRUGS amiodarone hcl Generic * digoxin Generic * disopyramide phosphate Generic/Brand † dopamine hcl Generic * flecainide acetate Generic lidocaine hcl (cardiac) Generic * procainamide hcl Generic * propafenone hcl Generic quinidine gluconate Generic quinidine sulfate Generic TIKOSYN Brand CARDIOVASCULAR DRUGS HYPOTENSIVE AGENTS acetazolamide Generic* Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 11 - Drug Name Drug Tier Generic Generic Generic Generic Generic Generic Requirements/Limits clonidine hcl hydralazine hcl methazolamide methyldopa minoxidil reserpine CARDIOVASCULAR DRUGS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS captopril Generic lisinopril Generic lisinopril & hydrochlorothiazide Generic losartan Generic losartan & hydrochlorothiazide Generic spironolactone Generic spironolactone & Generic hydrochlorothiazide CARDIOVASCULAR DRUGS VASODILATING AGENTS ADCIRCA Brand epoprostenol sodium Generic * isosorbide dinitrate Generic/Brand † isosorbide mononitrate Generic LETAIRIS Brand QL OPSUMIT Brand QL nitroglycerin Generic/Brand * † sildenafil citrate (pulmonary Generic hypertention) TRACLEER Brand QL VENTAVIS Brand QL CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS acetaminophen w/ codeine Generic butorphanol tartrate Generic * choline & mag salicylate Generic codeine phosphate Generic etodolac Generic fentanyl transdermal system Generic fentanyl citrate Generic * flurbiprofen Generic hydrocodone-acetaminophen Generic hydromorphone hcl Generic * Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 12 - Drug Name Drug Tier Generic Brand * Generic/Brand † Generic Generic * Generic Generic Generic/Brand * † Generic Generic Generic Generic/Brand † Generic * Brand Generic * Generic Generic Requirements/Limits ibuprofen INDOCIN IV indomethacin ketoprofen ketorolac meloxicam methadone hcl morphine sulfate nabumetone naproxen oxycodone hcl oxycodone w/ acetaminophen salsalate SUBOXONE sufentanil citrate sulindac tramadol hcl CENTRAL NERVOUS SYSTEM AGENTS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS amphetamine-dextroamphetamine Generic/Brand † dextroamphetamine sulfate Generic methylphenidate hcl Generic methylphenidate hcl extended Generic CENTRAL NERVOUS SYSTEM AGENTS ANTICONVULSANTS carbamazepine Generic/Brand † CELONTIN Brand divalproex sodium Generic divalproex sodium sprinkles Generic ethosuximide Generic FELBATOL Brand felbamate Generic/Brand † gabapentin Generic lamotrigine Generic levetiracetam Generic levetiracetam extended Generic magnesium sulfate Generic * MEBARAL Brand oxcarbazepine Generic † phenobarbital Generic * Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 13 - Drug Name Drug Tier Generic/Brand † Generic * Generic Generic Generic Generic Generic * Generic/Brand † Generic phenytoin phenytoin sodium phenytoin sodium extended primidone topiramate topiramate sprinkle valproate sodium valproic acid zonisamide CENTRAL NERVOUS SYSTEM AGENTS ANTIMIGRAINE AGENTS butalbital & acetaminophen Generic butalbital, acetaminophen & Generic caffeine butalbital, aspirin & caffeine Generic CAFERGOT Brand dihydroergotamine mesylate Generic/Brand * † ERGOMAR Brand naratriptan Generic* rizatriptan Generic* sumatriptan Generic* CENTRAL NERVOUS SYSTEM AGENTS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS buspirone hcl Generic droperidol Generic * hydroxyzine hcl Generic * zolpidem tartrate Generic CENTRAL NERVOUS SYSTEM AGENTS BENZODIAZEPINES alprazolam Generic chlordiazepoxide Generic clonazepam Generic DIASTAT ACUDIAL Brand DIASTAT PEDIATRIC Brand diazepam Generic/Brand * † lorazepam Generic * midazolam Generic * oxazepam Generic/Brand † temazepam Generic triazolam Generic CENTRAL NERVOUS SYSTEM AGENTS Requirements/Limits QL QL QL QL QL Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 14 - Drug Name Drug Tier Requirements/Limits CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS CAMPRAL Brand carbidopa-levodopa Generic * COMTAN Brand NAMENDA Brand NAMENDA TITRATION PAK Brand pramipexole dihydrochloride Generic RILUTEK Brand ropinirole hydrochloride Generic SAVELLA Brand PA selegiline hcl Generic CENTRAL NERVOUS SYSTEM AGENTS OPIATE ANTAGONISTS naloxone hcl Generic * naltrexone hcl Generic CENTRAL NERVOUS SYSTEM AGENTS PSYCHOTHERAPEUTIC AGENTS ABILIFY Brand amitriptyline hcl Generic bupropion hcl Generic chlorpromazine hcl Generic * citalopram hydrobromide Generic clomipramine hcl Generic clozapine Generic desipramine hcl Generic doxepin hcl Generic fluoxetine hcl Generic fluphenazine decanoate Generic * fluphenazine hcl Generic * fluvoxamine maleate Generic GEODON Brand haloperidol Generic haloperidol decanoate Generic * haloperidol lactate Generic * imipramine hcl Generic lithium carbonate Generic lithium citrate Generic loxapine succinate Generic mirtazapine Generic nefazodone hcl Generic nortriptyline hcl Generic Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 15 - Drug Name Drug Tier ORAP Brand paroxetine hcl Generic perphenazine Generic phenelzine sulfate Generic prochlorperazine edisylate Generic * prochlorperazine maleate Generic risperidone Generic/Brand † SEROQUEL Brand sertraline hcl Generic thioridazine hcl Generic thiothixene Generic tranylcypromine sulfate Generic trazodone hcl Generic trifluoperazine hcl Generic venlafaxine hcl Generic ZYPREXA Brand ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS citric acid monohydrate Generic potassium citrate (alkalinizer) Generic potassium citrate-citric acid Generic sodium acetate Generic * sodium bicarbonate Generic * sodium citrate & citric acid Generic ELECTROLYTIC, CALORIC, AND WATER BALANCE AMMONIA DETOXICANTS lactulose Generic ELECTROLYTIC, CALORIC, AND WATER BALANCE DIURETICS amiloride & hydrochlorothiazide Generic amiloride hcl Generic bumetanide Generic chlorothiazide Generic chlorthalidone Generic DYRENIUM Brand EDECRIN Brand * furosemide Generic * hydrochlorothiazide Generic metolazone Generic SODIUM EDECRIN Brand * Requirements/Limits Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 16 - Drug Name Drug Tier triamterene & Generic hydrochlorothiazide ELECTROLYTIC, CALORIC, AND WATER BALANCE ION-REMOVING AGENTS RENAGEL Brand RENVELA Brand sodium polystyrene sulfonate Generic ELECTROLYTIC, CALORIC, AND WATER BALANCE IRRIGATING SOLUTIONS acetic acid Generic lactated ringer's (irrigation) Generic* ringer's irrigation Generic* sodium chloride (gu irrigant) Generic* water for irrigation, sterile Generic* ELECTROLYTIC, CALORIC, AND WATER BALANCE REPLACEMENT PREPARATIONS calcium chloride (dihydrate) Generic* calcium gluconate Generic* electrolyte concentrate solution Generic* ELIPHOS Brand K-PHOS Brand * PHOSLO Brand potassium phosphate dibasic monobasic w/sodium phosphate Generic * monobasic potassium acetate Generic * potassium chloride Generic/Brand * † potassium chloride Generic microencapsulated crystals cr potassium phosphate dibasic Generic * sodium phosphate Generic* zinc (trace metals) Generic * ELECTROLYTIC, CALORIC, AND WATER BALANCE URICOSURIC AGENTS probenecid Generic ENZYMES ENZYMES ADAGEN Brand * PULMOZYME Brand ERECTILE DYSFUNCTION PHOSPHODIESTERACE-5 ENZYME INHIBITOR Requirements/Limits QL Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 17 - Drug Name Drug Tier Brand Brand CIALIS LEVITRA ERECTILE DYSFUNCTION PROSTAGLANDIN VASODILATORS alprostadil Generic/Brand * † EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin-polymyxin b (ophth) Generic erythromycin (ophth) Generic gentamicin sulfate (ophth) Generic ofloxacin (ophth) Generic ofloxacin (otic) Generic polymyxin b-trimethoprim Generic sodium sulfacetamide Generic & phenylephrine tobramycin sulfate (ophth) Generic/Brand † trifluridine Generic ZYMAXID Brand EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFLAMMATORY AGENTS CIPRODEX Brand COLY-MYCIN S OTIC Brand dexamethasone sodium phosphate Generic/Brand † (ophth) diclofenac (ophth) Generic flunisolide (nasal) Generic fluorometholone (ophth) Generic/Brand † flurbiprofen sodium Generic fluticasone propionate (nasal) Generic ketorolac (ophth) Generic LOTEMAX Brand MAXIDEX Brand neomycin-polymycinGeneric dexamethasone neomycin-polymyxinGeneric hydrocortisone (ophth) neomycin-polymyxinGeneric hydrocortisone (otic) PRED-G Brand prednisolone acetate (ophth) Generic Requirements/Limits RB RB RB Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 18 - Drug Name Drug Tier Requirements/Limits prednisolone sodium phosphate Generic (ophth) RESTASIS Brand † sulfacetamide sod-prednisolone Generic/Brand † EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTIALLERGIC AGENTS azelastine Generic cromolyn sodium (ophth) Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS EENT DRUGS, MISCELLANEOUS acetic acid (otic) Generic acetic acid-aluminum acetate Generic betaxolol hcl Generic brimonidine tartrate Generic CRESYLATE Brand dorzolamide Generic dorzolamide/timolol Generic EYLEA Brand* latanoprost Generic levobunolol hcl Generic LACRISERT Brand LUCENTIS Brand* MACUGEN Brand * PHOSPHOLINE IODIDE Brand pilocarpine hcl Generic/Brand † timolol maleate (ophth) Generic VISUDYNE Brand * EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS LOCAL ANESTHETICS benzocaine & antipyrine Generic lidocaine hcl (mouth-throat) Generic proparacaine hcl Generic tetracaine hcl (ophth) Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS MYDRIATICS atropine sulfate (ophthalmic) Generic CYCLOMYDRIL Brand cyclopentolate hcl Generic homatropine hbr Generic/Brand † ISOPTO HYOSCINE Brand tropicamide Generic Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 19 - Drug Name Drug Tier EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS VASOCONSTRICTORS ADRENALIN Brand * phenylephrine hcl (ophth) Generic GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS balsalazide Generic mesalamine Generic/Brand † GASTROINTESTINAL DRUGS ANTIDIARRHEA AGENTS diphenoxylate w/ atropine Generic paregoric Generic GASTROINTESTINAL DRUGS ANTIEMETICS dimenhydrinate Generic * dronabinol Generic EMEND Brand ondansetron Generic * ondansetron hcl Generic * prochlorperazine Generic * SCOPACE Brand TRANSDERM-SCOP Brand GASTROINTESTINAL DRUGS ANTIULCER AGENTS AND ACID SUPPRESSANTS cimetidine hcl Generic famotidine Generic * famotidine in nacl Generic * misoprostol Generic omeprazole Generic pantoprazole Generic ranitidine hcl Generic * sucralfate Generic GASTROINTESTINAL DRUGS DIGESTANTS CREON Brand PANCRELIPASE Brand ZENPEP Brand GASTROINTESTINAL DRUGS GI DRUGS, MISCELLANEOUS LINZESS Brand metoclopramide hcl Generic * Requirements/Limits PA Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 20 - Drug Name Drug Tier peg 3350-kcl-sod bicarb-sod Generic chloride-sod sulfate ursodiol Generic GOLD COMPOUNDS GOLD COMPOUNDS MYOCHRYSINE Brand * RIDAURA Brand HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET Brand CUPRIMINE Brand deferoxamine mesylate Generic * EXJADE Brand pysostigmine salicylate Generic * HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ARISTOSPAN INTRABrand * ARTICULAR ARISTOSPAN Brand * INTRALESIONAL ASMANEX 120 METERED Brand DOSES ASMANEX 60 METERED Brand DOSES betamethasone acetateGeneric * betamethasone sodium phosphate Budesonide Respules Generic cortisone acetate Generic dexamethasone Generic/Brand * † dexamethasone sodium phosphate Generic * ENTOCORT EC Brand FLOVENT HFA Brand fludrocortisone acetate Generic hydrocortisone Generic/Brand * † KENALOG-10 Brand * KENALOG-40 Brand * methylprednisolone Generic * methylprednisolone acetate Generic * methylprednisolone sod succ Generic * prednisolone Generic prednisone Generic Requirements/Limits QL Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 21 - Drug Name Drug Tier QVAR Brand SOLU-CORTEF Brand * HORMONES AND SYNTHETIC SUBSTITUTES ANDROGENS ANADROL-50 Brand ANDRODERM Brand danazol Generic METHITEST Brand TESTOSTERONE Brand * testosterone cypionate Generic * TESTRED Brand HORMONES AND SYNTHETIC SUBSTITUTES CONTRACEPTIVES desogestrel-ethinyl estradiol Generic ethynodiol diacet & eth estrad Generic levonorgestrel & eth estradiol Generic levonorgestrel-eth estradiol Generic (triphasic) norethindrone Generic norethin acet & estrad-fe Generic norethindrone & mestranol Generic/Brand † norethindrone & eth estradiol Generic/Brand † norethindrone acet & eth estra Generic norethindrone-eth estradiol Generic/Brand † (triphasic) norgestimate-ethinyl estradiol Generic norgestimate-ethinyl estradiol Generic (triphasic) HORMONES AND SYNTHETIC SUBSTITUTES DIABETIC AGENTS acarbose Generic glimepiride Generic glipizide Generic glyburide Generic GLUCAGON EMERGENCY Brand * KIT HUMALOG Brand * humulin 70/30 Generic * humulin n Generic * humulin r Generic * Requirements/Limits Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 22 - Drug Name Drug Tier Requirements/Limits HUMULIN R U-500 Brand * (CONCENTRATED) LANTUS Brand * PA metformin hcl Generic/Brand † tolbutamide Generic HORMONES AND SYNTHETIC SUBSTITUTES ESTROGENS AND ANTIESTROGENS clomiphene citrate Generic RB DEPO-ESTRADIOL Brand * estradiol Generic/Brand * † estrogens with methyltestosterone Generic ESTRING Brand estropipate Generic EVISTA Brand NEXPLANON Brand * PREMARIN INJECTION Brand * PREMARIN W/APPLICATOR Brand VAGIFEM Brand HORMONES AND SYNTHETIC SUBSTITUTES FOLLICLE STIMULATING HORMONES / LUTENIZING HORMONES BRAVELLE Brand * RB MENOPUR Brand * RB HORMONES AND SYNTHETIC SUBSTITUTES GONADOTROPINS chorionic gonadotropin Generic * RB FACTREL Brand * SYNAREL Brand HORMONES AND SYNTHETIC SUBSTITUTES PARATHYROID calcitonin (salmon) Generic/Brand * † HORMONES AND SYNTHETIC SUBSTITUTES PITUITARY ACTHAR HP Brand * PA, QL desmopressin acetate Generic desmopressin acetate refrigerated Generic desmopressin acetate spray Generic desmopressin acetate spray Generic refrigerated vasopressin Generic * HORMONES AND SYNTHETIC SUBSTITUTES PROGESTINS Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 23 - Drug Name Drug Tier Brand * Generic * DEPO-PROVERA medroxyprogesterone acetate medroxyprogesterone acetate Generic/Brand * † (contraceptive) norethindrone acetate Generic progesterone Generic HORMONES AND SYNTHETIC SUBSTITUTES SOMATOTROPIN AGONISTS AND ANTAGONISTS OMNITROPE Brand PREFILLED CARTRIDGE HORMONES AND SYNTHETIC SUBSTITUTES THYROID AND ANTITHYROID AGENTS levothyroxine sodium Generic liothyronine sodium Generic methimazole Generic potassium iodide Generic propylthiouracil Generic thyroid Generic INTRAVENOUS SOLUTIONS DEXTROSE dextrose 5% in water Generic * dextrose 5% in nacl 0.2% Generic * dextrose 5% in nacl 0.45% Generic * dextrose 5% in nacl 0.9% Generic * dextrose 10% in water Generic * dextrose 5% in lactated ringer’s Generic * INTRAVENOUS SOLUTIONS MISCELLANEOUS sterile water Generic * ringer’s injection Generic * lactated ringer’s Generic * sodium bicarbonate Generic * mannitol injection Generic * INTRAVENOUS SOLUTIONS NUTRITIONAL PRODUCTS amino acid solutions Generic * dextrose high concentration Generic * in water INTRALIPID Brand * LIPOSYN III Brand * INTRAVENOUS SOLUTIONS Requirements/Limits PA Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 24 - Drug Name Drug Tier SODIUM CHLORIDE (NACL, SALINE) nacl 0.45%, ½ normal saline Generic * nacl 0.9%, normal saline Generic * nacl 3% Generic * nacl 5% Generic * IRRIGATION SOLUTIONS IRRIGATION SOLUTIONS sterile water Generic * sodium chloride 0.9% Generic * lactated ringer’s Generic * ringer’s irrigation Generic * acetic acid 0.25% Generic irrigation solution G Generic glycine 1.5% Generic sorbitol urologic 3% Generic * MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine Generic alendronate sodium Generic/Brand † allopurinol Generic ARALAST Brand * AVONEX Brand * azathioprine Generic BOTOX Brand * bromocriptine mesylate Generic bupivacaine hcl Generic * bupivacaine w/ epinephrine Generic* cabergoline Generic CEREZYME Brand * COLCRYS Brand COPAXONE Brand * cyclosporine modified Generic CYSTAGON Brand DIDRONEL Brand disulfiram Generic/Brand † ELMIRON Brand ENBREL Brand * ENBREL SURECLICK Brand * ETHYOL Brand * EXTAVIA Generic* finasteride Generic Requirements/Limits PA, QL QL PA, QL QL QL QL Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 25 - Drug Name Drug Tier Brand * Brand Brand * Generic * Brand * Generic Generic * FIRAZYR GILENYA HUMIRA ketamine hcl KINERET leflunomide leucovorin calcium levocarnitine (metabolic Generic * modifiers) lidocaine hcl (local anesth.) Generic * mesna Generic * mycophenolate mofetil Generic/Brand † OCTREOTIDE ACETATE Brand/Generic * ORENCIA Brand * pamidronate disodium Generic * REMICADE Brand * REVLIMID Brand RIMSO-50 Brand * SANDIMMUNE Brand SENSIPAR Brand sirolimus Generic SORIATANE Brand tacrolimus Generic/Brand * † tamsulosin Generic THALOMID Brand THIOLA Brand VPRIV Brand * ZEMAIRA Brand * ZOMETA Brand * OXYTOCICS OXYTOCICS methylergonovine maleate Generic * HEMABATE Brand * oxytocin Generic * RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS cromolyn sodium Generic/Brand † montelukast sodium Generic RESPIRATORY TRACT AGENTS RESPIRATORY AGENTS, MISCELLANEOUS acetylcysteine Generic Requirements/Limits QL PA, QL QL QL QL QL QL QL QL QL QL Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 26 - Drug Name benzonatate guaifenesin / codeine hydrocodone / chlorpheniramine hydrocodone / homatropine ipratropium bromide (nasal) sodium chloride (inhalant) sterile water SERUMS, TOXOIDS, AND VACCINES SERUMS GAMUNEX-C HYPERRHO S/D HYPERTET S/D immune globulin (human) iv IMOGAM RABIES-HT NABI-HB RESPIGAM VARIZIG RHOPHYLAC SERUMS, TOXOIDS, AND VACCINES TOXOIDS ADACEL DECAVAC DIPTHERIA/TETANUS TOXOID PEDIATRIC INFANRIX SERUMS, TOXOIDS, AND VACCINES VACCINES ACTHIB ATTENUVAX GARDASIL HAVRIX HIBERIX IMOVAX RABIES (H.D.C.V.) IPOL INACTIVATED IPV MENACTRA MENOMUNE-A/C/Y/W-135 MERUVAX II W/DILUENT 10 DOSE MUMPSVAX W/DILUENT 10 DOSE PEDIARIX Drug Tier Generic Generic Generic Generic Generic Generic Generic Requirements/Limits Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 27 - Drug Name Drug Tier Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Brand * Requirements/Limits PEDVAX HIB PREVNAR 13 PROQUAD RABAVERT RECOMBIVAX HB ROTARIX ROTATEQ THERACYS TICE BCG VAQTA VARIVAX ZOSTAVAX SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) BACTROBAN NASAL Brand benzoyl peroxide-erythromycin Generic gel ciclopirox olamine Generic clindamycin phosphate (topical) Generic/Brand † clindamycin phosphate vaginal Generic/Brand † clotrimazole troche Generic erythromycin (acne aid) Generic/Brand † gentamicin sulfate (topical) Generic iodoquinol / hydrocortisone Generic ketoconazole (topical) Generic metronidazole (topical) Generic metronidazole vaginal Generic mupirocin Generic/Brand † nystatin Generic permethrin Generic selenium sulfide Generic silver sulfadiazine Generic terbinafine hcl Generic SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) alclometasone dipropionate Generic ANALPRAM-HC Brand aug betamethasone dipropionate Generic betamethasone dipropionate Generic (topical) betamethasone valerate Generic Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 28 - Drug Name Drug Tier Brand Generic Generic Brand Generic Generic Generic Generic Generic Generic Generic/Brand † Generic/Brand † Generic/ Brand † Brand Generic Generic Brand Requirements/Limits CARMOL-HC clotrimazole-betamethasone clobetasol propionate CORDRAN TAPE desonide fluocinolone acetonide fluocinonide fluocinonide emulsified base halobetasol hydrocortisone (intrarectal) hydrocortisone (rectal) hydrocortisone (topical) hydrocortisone butyrate LOCOID LIPOCREAM mometasone furoate nystatin-triamcinolone PROCTOFOAM-HC SKIN AND MUCOUS MEMBRANE AGENTS CELL STIMULANTS AND PROLIFERANTS tretinoin Generic SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS 8-MOP CAPSULE Brand aluminum chloride Generic/Brand † AZELEX Brand calcipotriene Generic DIFFERIN Brand DRITHO-SCALP Brand FINACEA Brand fluorouracil (topical) Generic/Brand † imiquimod Generic isotretinoin Generic lidocaine Generic/Brand † lidocaine hcl Generic* lidocaine-prilocaine Generic OXSORALEN ULTRA Brand para-aminobenzoic acid Generic PHISOHEX Brand podofilox Generic/Brand † PROTOPIC Brand PSORIATEC Brand Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 29 - Drug Name SANTYL sulfacetamide sodium TAZORAC trypsin, balsam peru & castor oil VECTICAL XERAC AC SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS oxybutynin chloride OXYTROL theophylline VITAMINS VITAMINS AQUASOL A calcitriol cyanocobalamin DRISDOL folic acid phytonadione pyridoxine thiamine Drug Tier Brand Generic Brand Requirements/Limits Generic Brand Brand Generic/Brand † Brand Generic/Brand † Brand * Generic Generic * Brand Generic * Generic * Generic * Generic * INDEX OF DRUGS Kaiser Permanente Commercial Comprehensive Formulary Index ACTHAR HP ACTHIB ACTIVASE acyclovir ADACEL ADAGEN ADCIRCA adefovir ADRENALIN ADVAIR DISKUS AFINITOR AGGRENOX ALBENZA albuterol albuterol sulfate alclometasone dipropionate alendronate sodium allopurinol alprazolam alprostadil 8 8-MOP 29 A ABBOKINASE ABILIFY ABRAXANE acarbose acebutolol ACETADOTE acetaminophen w/ codeine acetazolamide acetic acid acetic acid (otic) acetic acid 0.25% acetic acid-aluminum acetate acetylcysteine 10 15 6 22 11 25 12 11 17, 19 19 25 19 26 Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 30 - 23 27 10 5 27 17 12 5 20 9 6 10 2 9 9 28 25 25 14 18 aluminum chloride amantadine hcl AMBISOME amiloride & hydrochlorothiazide amiloride hcl amino acid solutions aminocaproic acid amiodarone hcl amitriptyline hcl amlodipine besylate amoxicillin amoxicillin & potassium clavulanate amphetamine-dextroamphetamine amphotericin b ampicillin ANADROL-50 anagrelide hcl ANALPRAM-HC anastrozole ANCOBON ANDRODERM ANECTINE APTIVUS AQUASOL A ARALAST ARISTOSPAN INTRA-ARTICULAR ARISTOSPAN INTRALESIONAL ASMANEX 120 METERED DOSES ASMANEX 60 METERED DOSES atenolol atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine sulfate atropine sulfate (ophthalmic) ATROVENT HFA ATTENUVAX aug betamethasone dipropionate avacavir avacavir & lamivudine & zidovudine AVASTIN AVELOX AVONEX AZACTAM azathioprine azelastine azelastine AZELEX azithromycin 29 5 4 16 16 24 10 11 15 11 2 3 13 4 3 22 10 28 6 4 22 9 5 30 25 21 21 21 21 11 11 4 4 5 8, 19 19 8 27 28 5 5 6 3 25 3 25 19 19 29 3 BACTROBAN NASAL balsalazide benzocaine & antipyrine benzonatate benzoyl peroxide-erythromycin benztropine mesylate betamethasone acetate betamethasone dipropionate (topical) betamethasone sodium phosphate betamethasone valerate betaxolol hcl bethanechol chloride bicalutamide BICNU W/DILUENT ABSOLUTE ETHANOL BILTRICIDE bleomycin sulfate BOTOX BRAVELLE BRILINTA brimonidine tartrate bromocriptine mesylate budesonide respules bumetanide bupivacaine hcl bupivacaine w/ epinephrine bupropion hcl buspirone hcl butalbital & acetaminophen butalbital, acetaminophen & caffeine butalbital, aspirin & caffeine butorphanol tartrate C cabergoline CAFERGOT calcipotriene calcitonin (salmon) calcitriol calcium chloride (dihydrate) calcium gluconate CAMPRAL CANCIDAS capecitabine captopril carbamazepine carbidopa-levodopa carboplatin CARMOL-HC carvedilol CAYSTON CEENU cefazolin sodium cefdinir cefepime cefotaxime sodium cefotetan ceftazidime B bacitracin bacitracin & polymyxin B bacitracin-polymyxin b (ophth) baclofen BACTROBAN 28 20 19 27 28 8 21 28 21 28 19 9 6 6 2 6 25 23 10 19 25 21 16 25 25 15 14 14 14 14 12 3, 18 3 18 9 28 Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 31 - 25 14 29 23 30 17 17 15 4 6 12 13 15 7 29 11 3 7 3 3 3 3 3 3 ceftriaxone sodium cefuroxime axetil cefuroxime sodium CELONTIN cephalexin CEREZYME CHEMET chlordiazepoxide chloroquine phosphate chlorothiazide chlorpromazine hcl chlorthalidone cholestyramine choline & mag salicylate chorionic gonadotropin CIALIS ciclopirox olamine cimetidine hcl CIPRODEX ciprofloxacin hcl cisplatin citalopram hydrobromide citric acid monohydrate clarithromycin clidinium / chlordiazepoxide clindamycin hcl clindamycin palmitate hydrochloride clindamycin phosphate clindamycin phosphate (topical) clindamycin phosphate vaginal clobetasol propionate clomiphene citrate clomipramine hcl clonazepam clonidine hcl clopidogrel clotrimazole clotrimazole-betamethasone clozapine codeine phosphate COLCRYS colestipol hcl COLY-MYCIN S OTIC COMBIVENT COMBIVENT RESPIMAT COMPLERA COMTAN COPAXONE CORDRAN CORDRAN TAPE cortisone acetate CREON CRESYLATE CRIXIVAN cromolyn sodium cromolyn sodium (ophth) CUPRIMINE cyanocobalamin 3 3 3 13 3 25 21 14 5 16 15 16 11 12 23 18 28 20 3, 18 3 7 15 16 3 8 3 3 3, 28 28 28 29 23 15 14 12 10 28 29 15 12 25 11 18 9 9 5 15 25 29 29 21 20 19 5 19, 26 19 21 30 cyclobenzaprine hcl CYCLOMYDRIL cyclopentolate hcl cyclophosphamide cyclosporine modified cyproheptadine hcl CYSTAGON cytarabine 9 19 19 7 25 6 25 7 D dacarbazine dactinomycin danazol dantrolene sodium dapsone DARAPRIM daunorubicin hcl DECAVAC deferoxamine mesylate DEPO-ESTRADIOL DEPO-PROVERA desipramine hcl desmopressin acetate desmopressin acetate refrigerated desmopressin acetate spray desmopressin acetate spray refrigerated desogestrel-ethinyl estradiol desonide dexamethasone dexamethasone sodium phosphate dexamethasone sodium phosphate (ophth) DEXFERRUM dextroamphetamine sulfate dextrose 10% in water dextrose 5% in lactated ringer’s dextrose 5% in nacl 0.2% dextrose 5% in nacl 0.45% dextrose 5% in nacl 0.9% dextrose 5% in water dextrose high concentration DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam DIBENZYLINE diclofenac (ophth) dicloxacillin sodium dicyclomine hcl didanosine DIDRONEL DIFFERIN digoxin dihydroergotamine mesylate diltiazem hcl dimenhydrinate diphenhydramine hcl diphenoxylate w/ atropine DIPTHERIA/TETANUS TOXOID PEDIATRIC 7 7 22 9 4 5 7 27 21 23 24 15 23 23 23 23 22 29 18, 21 18, 21 18 10 13 24 24 24 24 24 24 24 14 14 14 9 18 3 8 5 25 29 11 14 11 20 6 20 27 Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 32 - dipyridamole disopyramide phosphate disulfiram divalproex sodium divalproex sodium sprinkles docetaxel donepezil hydrochloride dopamine hcl dorzolamide dorzolamide/timolol doxazosin mesylate doxepin hcl doxorubicin hcl doxycycline hyclate doxycycline monohydrate DRISDOL DRITHO-SCALP dronabinol droperidol DULERA DYRENIUM 10 11 25 13 13 7 9 11 19 19 10 15 7 3 3 30 29 20 14 9 16 ethambutol hcl ethosuximide ethynodiol diacet & eth estrad ETHYOL etodolac etoposide EVISTA exemestane EXJADE EXTAVIA EYLEA F FACTREL famciclovir famotidine famotidine in nacl felbamate FELBATOL FEMARA fenofibrate fentanyl fentanyl citrate fentanyl transdermal system FINACEA finasteride FIRAZYR flecainide acetate FLOVENT HFA fluconazole fluconazole in nacl fludarabine phosphate fludrocortisone acetate flunisolide (nasal) fluocinolone acetonide fluocinonide fluocinonide emulsified base fluorometholone (ophth) fluorouracil fluorouracil (topical) fluoxetine hcl fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone propionate fluticasone propionate (nasal) fluvoxamine maleate folic acid fondaparinux FORADIL AEROLIZER foscarnet sodium furosemide E EDECRIN EDURANT EFFIENT electrolyte-2 in invert sugar ELIPHOS ELMIRON ELSPAR EMCYT EMEND EMTRIVA ENBREL ENBREL SURECLICK ENLON enoxaparin sodium ) entecavir ENTOCORT EC ephedrine sulfate (pressors) EPIPEN 2-PAK EPIPEN-JR 2-PAK epoprostenol sodium EPZICOM ERBITUX ergoloid mesylates ERGOMAR erythromycin (acne aid erythromycin (ophth) erythromycin base erythromycin ethylsuccinate erythromycin lactobionate erythromycin sulfisoxazole estradiol ESTRING estrogens with methyltestosterone estropipate 4 13 22 25 12 7 23 7 21 25 19 16 5 10 17 17 25 7 7 20 5 25 25 9 10 5 21 9 9 9 12 5 7 9 14 28 18 3 3 3 3 22, 23 23 23 23 23 5 20 20 13 13 7 11 12 12 12 29 25 26 11 21 4 4 7 21 18 29 29 29 18 7, 29 29 15 15 15 12, 18 18 7 18 18 15 30 10 9 5 16 Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 33 - hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl HYPERRHO S/D HYPERTET S/D G gabapentin galantamine hydrobromide GAMUNEX-C ganciclovir GANTRISIN GARDASIL gemfibrozil GEMZAR gentamicin sulfate gentamicin sulfate (ophth) gentamicin sulfate (topical) GEODON GILENYA GLEEVEC glimepiride glipizide GLUCAGON EMERGENCY KIT glyburide glycine 1.5% glycopyrrolate griseofulvin microsize griseofulvin ultramicrosize guaifenesin / codeine 13 9 27 5 3 27 11 7 3, 18, 28 18 28 15 26 7 22 22 22 22 25 8 4 4 27 I ibuprofen idarubicin hcl ifosfamide ifosfamide & mesna imipramine hcl imiquimod immune globulin (human) iv IMOGAM RABIES-HT IMOVAX RABIES (H.D.C.V.) INCIVEK INDOCIN IV indomethacin INFANRIX INFED INTELENCE INTRALIPID INTRON-A INTRON-A W/DILUENT INVANZ INVIRASE iodoquinol / hydrocortisone IPOL INACTIVATED IPV ipratropium bromide ipratropium bromide (nasal) irrigation solution G ISENTRESS isoniazid ISOPTO HYOSCINE isosorbide dinitrate isosorbide mononitrate isotretinoin H halobetasol haloperidol haloperidol decanoate haloperidol lactate HAVRIX HELIXATE FS HEMABATE heparin sodium (porcine) HERCEPTIN HEXALEN HIBERIX homatropine hbr HUMALOG HUMATE-P HUMIRA humulin 70/30 humulin n humulin r HUMULIN R U-500 (CONCENTRATED) hydralazine hcl hydrochlorothiazide hydrocodone / chlorpheniramine hydrocodone / homatropine hydrocodone-acetaminophen hydrocortisone hydrocortisone (intrarectal) hydrocortisone (rectal) hydrocortisone (topical) hydrocortisone butyrate hydromorphone hcl 5 7 14 27 27 29 15 15 15 27 10 26 10 7 7 27 19 22 10 26 22 22 22 23 12 12, 16, 17 27 27 12 21, 29 29 29 29 29 12 13 7 7 7 15 29 27 27 27 5 13 13 27 10 5 24 7 7 3 5 28 27 8, 27 27 25 5 4 19 12 12 29 K KALETRA KENALOG-10 KENALOG-40 ketamine hcl ketoconazole ketoconazole (topical) ketoprofen ketorolac KINERET KOGENATE FS K-PHOS 5 21 21 26 4, 28 28 13 13, 18 26 10 17 L labetalol hcl LACRISERT Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 34 - 11 19 lactated ringer’s lactated ringer's lactated ringer's (irrigation) lactulose lamivudine lamivudine & zidovudine lamotrigine LANTUS latanoprost leflunomide LETAIRIS leucovorin calcium LEUKERAN leuprolide acetate levetiracetam levetiracetam extended LEVITRA levobunolol hcl levocarnitine (metabolic modifiers) levofloxacin levonorgestrel & eth estradiol levonorgestrel-eth estradiol (triphasic) levothyroxine sodium LEXIVA lidocaine lidocaine hcl lidocaine hcl (cardiac) lidocaine hcl (local anesth.) lidocaine hcl (mouth-throat) lidocaine-prilocaine LINZESS liothyronine sodium LIPOSYN LIPOSYN III lisinopril lisinopril & hydrochlorothiazide lithium carbonate lithium citrate LOCOID LIPOCREAM lorazepam losartan losartan & hydrochlorothiazide LOTEMAX lovastatin loxapine succinate LUCENTIS LUPRON DEPOT LUPRON DEPOT-PED LYSODREN 24, 25 17 17 16 5 5 13 23 19 26 12 26 7 7 13 13 18 19 26 3 22 22 24 5 11, 19, 26, 29 11, 19, 26, 29 11 26 19 29 20 24 24 24 12 12 15 15 29 14 12 12 18 11 15 19 7 7 7 MEBARAL medroxyprogesterone acetate medroxyprogesterone acetate (contraceptive) mefloquine hcl megestrol acetate meloxicam melphalan MENACTRA MENOMUNE-A/C/Y/W-135 MENOPUR MEPRON mercaptopurine MERUVAX II W/DILUENT 10 DOSE mesalamine mesna metaproterenol sulfate metformin hcl methadone hcl methazolamide methenamine hippurate methimazole METHITEST methocarbamol methotrexate sodium methyldopa methylgonovine maleate methylphenidate hcl methylphenidate hcl extended methylprednisolone methylprednisolone acetate methylprednisolone sod succ metoclopramide hcl metolazone metoprolol succinate metoprolol tartrate metronidazole metronidazole (topical) metronidazole vaginal midazolam minocycline hcl minoxidil mirtazapine misoprostol mitomycin mitoxantrone hcl mometasone furoate montelukast sodium morphine sulfate MUMPSVAX W/DILUENT 10 DOSE mupirocin MUSTARGEN mycophenolate mofetil MYLERAN MYOCHRYSINE MYTELASE M MACUGEN magnesium sulfate mannitol injection MATULANE MAXAIR AUTOHALER MAXIDEX 19 13 24 7 9 18 13 24 24 5 7 13 7 27 27 23 5 7 27 20 7, 26 9 23 13 12 6 24 22 9 7 12 26 13 13 21 21 21 20 16 11 11 5, 28 28 28 14 3 12 15 20 7 7 29 26 13 27 28 8 26 8 21 9 Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 35 - oxybutynin chloride oxycodone hcl oxycodone w/ acetaminophen oxytocin OXYTROL N NABI-HB nabumetone nacl 0.45%, ½ normal saline nacl 0.9%, normal saline nacl 3% nacl 5% naloxone hcl naltrexone hcl NAMENDA NAMENDA TITRATION PAK naproxen naratriptan nefazodone hcl neomycin sulfate neomycin-polymycin-dexamethasone neomycin-polymyxin-hydrocortisone (ophth) neomycin-polymyxin-hydrocortisone (otic) neostigmine methylsulfate NEUPOGEN nevirapine NEXAVAR NEXPLANON nifedipine NIMODIPINE nitrofurantoin macrocrystal nitrofurantoin monohyd macro nitroglycerin norethin acet & estrad-fe norethindrone & eth estradiol norethindrone & mestranol norethindrone acet & eth estra norethindrone acetate norethindrone-eth estradiol (triphasic) norgestimate-ethinyl estradiol norgestimate-ethinyl estradiol (triphasic) nortriptyline hcl NORVIR nystatin NYSTATIN nystatin-triamcinolone 27 13 25 25 25 25 15 15 15 15 13 14 15 3 18 18 18 9 10 5 8 23 11 11 6 6 12 22 22 22 22 24 22 22 22 15 5 4, 29 28 29 P paclitaxel 8 pamidronate disodium 26 PANCRELIPASE 20 pantoprazole 20 para-aminobenzoic acid 29 paregoric 20 paromomycin sulfate 5 paroxetine hcl 16 PEDIARIX 27 PEDVAX HIB 28 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 21 PEGASYS 5 penicillin g potassium 3 penicillin g procaine 3 penicillin g sodium 4 penicillin v potassium 4 pentamidine isethionate 5 pentostatin 8 pentoxifylline 10 permethrin 28 perphenazine 16 phenelzine sulfate 16 phenobarbital 13 phentolamine mesylate 9 phenylephrine hcl (ophth) 20 phenylephrine hcl (pressors) 9 phenytoin 14 phenytoin sodium 14 phenytoin sodium extended 14 PHISOHEX 29 PHOSLO 17 PHOSPHOLINE IODIDE 19 physostigmine salicylate 21 phytonadione 30 pilocarpine hcl 9, 19 pilocarpine hcl (oral) 9 piperacillin-tazobactam 4 podofilox 29 polymyxin b-trimethoprim 18 potassium acetate 17 potassium chloride 17 potassium chloride microencapsulated crystals cr 17 potassium citrate (alkalinizer) 16 potassium citrate-citric acid 16 potassium iodide 24 potassium phosphate dibasic 17 potassium phosphate dibasic & monobasic w/ sodium phosphate monobasic 17 PRADAXA 10 pramipexole dihydrochloride 15 O OCTREOTIDE ACETATE ofloxacin (ophth) ofloxacin (otic) omeprazole OMNITROPE PREFILLED CARTRIDGE ondansetron ondansetron hcl OPSUMIT ORAP ORENCIA oxazepam oxcarbazepine OXSORALEN ULTRA 30 13 13 26 30 26 18 18 20 24 20 20 12 16 26 14 13 29 Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 36 - pravastatin sodium prazosin hcl PRED-G prednisolone prednisolone acetate (ophth) prednisolone sodium phosphate prednisolone sodium phosphate (ophth) prednisone PREMARIN INJECTION PREMARIN W/APPLICATOR PREVNAR 13 PREZISTA PRIMAQUINE PHOSPHATE PRIMAXIN I.M. primidone PRIMSOL probenecid procainamide hcl prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCTOFOAM-HC progesterone promethazine hcl propafenone hcl propantheline bromide proparacaine hcl propranolol hcl propylthiouracil PROQUAD PROTOPIC PSORIATEC PULMOZYME pyrazinamide pyridostigmine bromide pyridoxine 11 10 18 18, 19, 21 18 19 19 21 23 23 28 5 5 4 14 6 17 11 16, 20 16 16 10 29 24 6 11 8 19 11 24 28 29 29 17 4 9 30 REVLIMID REYATAZ RHOPHYLAC ribavirin (hepatitis c) RIDAURA rifampin RILUTEK rimantadine hydrochloride RIMSO-50 ringer’s injection ringer’s irrigation ringer's irrigation risperidone RITUXAN rizatriptan ropinirole hydrochloride ROTARIX ROTATEQ S salsalate SANDIMMUNE SANTYL SAVELLA SCOPACE scopolamine hydrobromide selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL sertraline hcl sildenafil citrate (pulmonary hypertention) silver sulfadiazine simvastatin sirolimus sodium acetate sodium bicarbonate sodium chloride sodium chloride (gu irrigant) sodium chloride (inhalant) sodium chloride 0.9% sodium citrate & citric acid SODIUM EDECRIN sodium phosphate sodium polystyrene sulfonate sodium sulfacetamide & phenylephrine SOLU-CORTEF sorbitol urologic 3% SORIATANE sotalol hcl SOVALDI SPIRIVA HANDIHALER spironolactone spironolactone & hydrochlorothiazide SPRYCEL Q quinidine gluconate quinidine sulfate QVAR 11 11 22 R RABAVERT ranitidine hcl RECOMBINATE RECOMBIVAX HB REFACTO REMICADE RENAGEL RENVELA RESCRIPTOR RESERPINE RESPIGAM RESTASIS 26 6 27 6 21 4 15 6 26 24 25 17 16 8 14 15 28 28 28 20 10 28 10 26 17 17 6 12 27 19 13 26 30 15 20 8 15 28 6 26 9 16 16 12 28 11 26 16 16, 24 17, 27 17 27 25 16 16 17, 18, 19, 21 17 18 22 25 26 11 6 8 12 12 8 Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 37 - stavudine sterile water streptomycin sulfate STRIBILD SUBOXONE sucralfate sufentanil citrate sulfacetamide sodium sulfacetamide sod-prednisolone sulfamethoxazole-trimethoprim sulfasalazine sulindac sumatriptan SUPRAX SUSTIVA SUTENT SYNAGIS SYNAREL 6 24, 25, 27 4 6 13 20 13 30 19 4 4 13 14 4 6 8 6 23 TOLBUTAMIDE topiramate topiramate sprinkle topotecan TORISEL TRACLEER tramadol hcl tranexmic acid TRANSDERM-SCOP tranylcypromine sulfate trazodone hcl tretinoin triamterene & hydrochlorothiazide triazolam trifluoperazine hcl trifluridine trihexyphenidyl hcl trimethoprim TROBICIN tropicamide TRUVADA trypsin, balsam peru & castor TYKERB T TABLOID tacrolimus TAMIFLU tamoxifen citrate tamsulosin TARCEVA TASIGNA TAZICEF TAZORAC temazepam temozolomide terazosin hcl terbinafine hcl terbutaline sulfate TESTOSTERONE testosterone cypionate TESTRED TETANUS TOXOID tetracaine hcl (ophth) tetracycline hcl THALOMID theophylline THERACYS thiamine THIOLA thioridazine hcl thiotepa thiothixene thyroid TICE BCG TIKOSYN timolol maleate timolol maleate (ophth) TIVICAY tobramycin nebulization solution tobramycin sulfate tobramycin sulfate (ophth) 8 26 6 8 26 8 8 4 30 14 8 10 28 9 22 22 22 27 19 4 26 30 28 30 26 16 8 16 24 28 11 19 19 6 4 4, 18 18 23 14 14 8 8 12 13 10 20 16 16 8, 29 17 14 16 18 8 6, 18 4 19 6 30 8 U ursodiol 21 V VAGIFEM VALCYTE valproate sodium valproic acid VANCOCIN ISO-OSMOTIC DEXTROSE vancomycin hcl VAQTA VARIVAX VARIZIG vasopressin VECTICAL venlafaxine hcl VENOFER VENTAVIS verapamil hcl VICTRELIS VIDAZA VINBLASTINE SULFATE vincristine sulfate vinorelbine tartrate VIRACEPT VIREAD VISUDYNE voriconazole VOTRIENT VPRIV Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 38 - 23 6 14 14 4 4 28 28 27 23 30 16 10 12 11 6 8 8 8 8 6 6 19 4 8 26 ZEMAIRA ZENPEP zidovudine zinc (trace metals) ZOLADEX zolpidem tartrate ZOMETA zonisamide ZOSTAVAX ZYMAXID ZYPREXA ZYTIGA ZYVOX W warfarin sodium water for irrigation, sterile 10 17 X XALKORI XERAC AC XTANDI 8 30 8 Z ZELBORAF 8 Kaiser Permanente Denver/Boulder and Northern Colorado Commercial Formulary – December 2014 - 39 - 26 20 6 17 8 14 26 14 28 18 16 8 4