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KAISER PERMANENTE FLEXIBLE CHOICE FORMULARY
Flexible Choice Formulary Last Update: 4/07/2015 The following is a list of the drugs on the Kaiser Permanente Mid-Atlantic States Flexible Choice formulary. The formulary is a list of prescription medications that are preferred for use under your plan. This list is approved by the Kaiser Permanente Mid-Atlantic States Pharmacy and Therapeutics Committee. The formulary applies only to outpatient drugs and self-administered drugs. It does not apply to medications used in a hospital or surgery center or medications administered in a doctor’s office or infusion center. The formulary does not provide information about your plan’s specific coverage, limitations, or exclusions. For additional information regarding your pharmacy benefits, please consult your Evidence of Coverage and/or Certificate of Insurance. There are many brand and generic medications on the Kaiser Permanente Flexible Choice formulary. In most cases, your provider will prescribe a generic equivalent. As a Kaiser Permanente Flexible Choice member, the amount you pay for your prescription is determined by the tier (e.g., generic, preferred brand name, non-preferred brand name, or non-formulary) along with where you decide to fill your prescription. You may want to consult your physician for a generic alternative that may cost you less or have your prescription filled at one of our convenient Kaiser Permanente medical center pharmacies. Under Option 1 of your plan, you may fill your prescription at a Kaiser Permanente medical center pharmacy. Your physician can send most prescriptions electronically from his or her office directly to the pharmacy, where you can pick up your medication. If your prescription is for a non-preferred brand name drug, your physician will need to request an exception to the formulary and document that the non-formulary drug is medically necessary for your treatment and that no formulary drug is suitable for you. Under Option 2 of your plan, MedImpact is the company Kaiser Permanente has chosen to manage the pharmacy benefits available to you. MedImpact has a network that consists of local and national pharmacies. A partial list of participating pharmacies* includes: • • • • • • Costco Harris Teeter Rite Aid Shoppers Food Warehouse Walgreens Wegmans • • • • • • CVS Giant Kmart Safeway Target Wal-Mart Not all locations within a pharmacy chain company are contracted with MedImpact; some are independently contracted. To verify if a pharmacy participates, please log on to medimpact.com. To obtain a complete list of participating pharmacies, call MedImpact customer service at 800-788-2949, 24 hours a day/seven days a week. Under Option 3 of your plan, you may fill your prescription at any pharmacy that is not part of Option 1 or Option 2. If you fill your prescription at an Option 3 out-of-network pharmacy, you should expect to pay for your prescription drugs and then submit a claim for reimbursement. *As of 5/1/14 1 How to use the formulary document Medications available in a generic form are listed by their generic name. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in BOLD and in all CAPITAL letters. Please remember that this formulary is subject to change and will be updated on a monthly basis. Any product not found in this formulary or in subsequent updates, will be considered a non-preferred drug. You can search the formulary by using the “FIND” function in Adobe Reader, or by the therapeutic drug category. All dosage forms and strengths for a particular drug may not be included in the formulary. This is because not all dosage forms of formulary drugs are covered under the prescription drug benefit. Some drugs are available in more than one dosage form (example: tablet and injectable). Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Higher copay: Some drugs may have a higher cost share. These drugs include infertility, sexual dysfunction, smoking cessation, growth hormone, and weight management medications. • Oral chemo: Drugs that fall under the District of Columbia and State of Maryland Chemo Parity Act. These drugs are subject to a different cost share for plans that are based out of Washington, D.C. and Maryland. • Quantity limit: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a certain quantity per copay. • Restricted to benefit: Some drugs are not covered unless the patient’s benefits specifically cover such medications. For example, Viagra and other drugs for sexual dysfunction are not covered unless the patient’s benefits specifically cover them. Key: HC = A drug that may have a higher copay. OC = A drug included under the District of Columbia and State of Maryland Oral Chemotherapy Parity Act. 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. For more information about the formulary or Option 1, please contact Member Services at 888-225-7202 (TTY 301-879-6380) Monday through Friday, 7:30 a.m. until 5:30 p.m. For information on Option 2 & 3, please contact Kaiser Permanente Insurance Company customer service at 800-3928649 Monday through Friday, 9 a.m. until 9 p.m. 2 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME ANTIHISTAMINE DRUGS Sulfasalazine Cyproheptadine HCl Sulfamethoxazole- Trimethoprim Promethazine HCL SUPRAX ANTI-INFECTIVEAGENTS Anthelmintics ALBENZA BILTRICIDE YODOXIN Antibacterials Amoxicillin Amoxicillin & Pot Clavulanate Ampicillin Azithromycin Cefaclor Cefdinir Cefuroxime Axetil Cephalexin Ciprofloxacin Clarithromycin Clindamycin Clindamycin Palmitate HCL Dicloxacillin Sodium Doxycycline Monohydrate ERYPED SUSP Tetracycline HCL Tobramycin Neb Vancomycin HCL VIVOTIF BERNA ZYVOX Antifungals Fluconazole Griseofulvin Microsize Griseofulvin Ultramicrosize Itraconazole Ketoconazole Nystatin Terbinafine Voriconazole Antimycobacterials DAPSONE Ethambutol HCL Isoniazid Pyrazinamide Rifabutin Rifampin Erythromycin Base Antiprotozoals Erythromycin Ethylsuccinate Atovaquone Erythromycin-Sulfisoxazole Atovaquone-Proguanil HCL Levofloxacin COARTEM Minocycline HCL Chloroquine Phosphate Neomycin Sulfate DARAPRIM Penicillin V Potassium Hydroxychloroquine Sulfate Sulfadiazine Mefloquine HCL LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC REQUIREMENTS AND LIMITS • Quantity Limits—QL • Oral Chemo Drugs—OC 3 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME RELENZA RESCRIPTOR Metronidazole NEBUPENT INH QL REYATAZ Primaquine Phosphate Ribavirin Antivirals Rimantadine HCL Abacavir SELZENTRY Abacavir-LamivudineZidovudine SOVALDI QL STRIBILD Adefovir Dipivoxil SUSTIVA Amantadine HCL TAMIFLU APTIVUS QL TIVICAY ATRIPLA TRUVADA COMPLERA VALCYTE SOLUTION CRIXIVAN Valganciclovir Didanosine VICTRELIS EDURANT VIRACEPT EMTRIVA Zidovudine Entecavir UrinaryAnti-Infectives EPIVIR SOLUTION Methenamine Hippurate EPZICOM Nitrofurantoin INTELENCE NitrofurantoinMonohyd Macro INVIRASE ISENTRESS HARVONI REQUIREMENTS AND LIMITS QL KALETRA Nitrofurantoin Macrocrystals Trimethoprim ANTINEOPLASTIC AGENTS Lamivudine Lamivudine-Zidovudine Antineoplastic Agents LEXIVA AFINITOR OC Nevirapine ALKERAN OC NORVIR Anastrozole OC PEGASYS QL Bicalutamide OC PEGASYS PROCLICK QL Capecitabine OC PEG-INTRON QL CEENU OC COMETRIQ KIT OC CYTOXAN OC PREZISTA LEGEND • Brand-name drugs are in bold type and all capital letters • For drugs not indicated in bold, generic drugs will be dispensed as the formulary agent • Higher Copay—HC • Restricted Benefit—RB • Limited Distribution—LD • Quantity Limits—QL • Oral Chemo Drugs—OC 4 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME EMCYT OC Tretinoin (Chemotherapy) Etoposide TYKERB Exemestane OC OC OC OC VANDETANIB OC Flutamide OC VOTRIENT OC GLEEVEC OC XALKORI OC HEXALEN OC XTANDI OC HYCAMTIN OC ZELBORAF OC Hydroxyurea OC ZYKADIA OC ICLUSIG OC ZYTIGA OC INLYTA OC ANXIOLYTICS, SEDATIVES, AND HYPNOTICS INTRON-A QL JAKAFI OC Letrozole OC LEUKERAN OC Benzodiazepines LUPRON QL Alprazolam LUPRON DEPOT QL Chlordiazepoxide HCL LUPRON DEPOT-PED QL Clonazepam LYSODREN OC Clorazepate Dipotassium Megestrol Acetate OC Diazepam Mercaptopurine OC Lorazepam IMBRUVICA Barbiturates Phenobarbital Oxazepam Methotrexate Sodium MYLERAN OC Temazepam NEXAVAR OC AUTONOMIC DRUGS Procarbazine HCL OC Anticholinergic Agents SPRYCEL OC SUTENT OC TABLOID OC Tamoxifen Citrate OC TARCEVA OC TARGRETIN OC TASIGNA OC Temozolomide OC ATROVENT HFA Benztropine Mesylate Dicyclomine HCL Hyoscyamine Ipratropium Bromide (Nasal) Trihexyphenidyl HCL SPIRIVA LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC REQUIREMENTS AND LIMITS • Quantity Limits—QL • Oral Chemo Drugs—OC 5 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Autonomic Drugs, Miscellaneous Anagrelide HCL DIBENZYLINE Aminocaproic Acid Ergoloid Mesylates BRILINTA Nicotrol Inhaler HC Parasympathomimetic (Cholinergic) Agents REQUIREMENTS AND LIMITS Cilostazol Clopidogrel Dipyridamole Bethanechol Chloride EFFIENT Donepezil HCL Fondaparinux QL Galantamine Hydrobromide LOVENOX QL Neostigmine Bromide Pentoxifylline Pilocarpine HCL (ORAL) PRADAXA Pyridostigmine Bromide Warfarin Sodium Skeletal Muscle Relaxants Hematopoietic Agents Baclofen NEUPOGEN QL Cyclobenzaprine HCL PROCRIT/EPOGEN QL Dantrolene Sodium PROMACTA Methocarbamol CARDIOVASCULAR DRUGS Sympathomimetic (Adrenergic) Agents Alpha-AdrenergicBlocking Agents ADVAIR DISKUS 100/50 Terazosin HCL Albuterol Neb Tamsulosin HCL COMBIVENT RESPIMAT AER Antilipemic Agents Epinephrine HCL QL EPIPEN QL PROAIR HFA SEREVENT DISKUS AER Terbutaline Sulfate Atorvastatin Calcium Cholestyramine Cholestyramine Light Colestipol Fenofibrate 54mg, 160mg Gemfibrozil BLOOD FORMATION, COAGULATION, AND THROMBOSIS Lovastatin Coagulants And Anticoagulants Pravastatin Sodium 20mg, 40mg, 80mg AGGRENOX Niacin LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC • Quantity Limits—QL • Oral Chemo Drugs—OC 6 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Simvastatin 20mg, 40mg, 80mg Beta-AdrenergicBlocking Agents Acebutolol HCL Atenolol/Chlorthalidone Atenolol HCL Bisoprolol/ Hydrochlorothiazide DRUG NAME REQUIREMENTS AND LIMITS Hypotensive Agents Acetazolamide Clonidine HCL Guanfacine HCL Hydralazine HCL Methazolamide Methyldopa Bisoprolol Fumarate Minoxidil Carvedilol Reserpine Labetalol HCL Metoprolol Succinate Renin-Angiotensin-Aldosterone System Inhibitors MetoprololTartrate Captopril Nadolol Enalapril Maleate Propranolol HCL Lisinopril Sotalol HCL Lisinopril/Hydrochlorothiazide Timolol Maleate Losartan Potassium Calcium-Channel Blocking Agents Losartan Potassium/HCTZ Amlodipine Besylate Diltiazem HCL Nifedipine Verapamil HCL Cardiac Drugs Amiodarone HCL Digoxin Disopyramide Phosphate Flecainide Acetate Mexiletine HCL Propafenone HCL Quinidine Gluconate Quinidine Sulfate Spironolactone Spironolactone/ Hydrochlorothiazide Vasodilating Agents ADEMPAS Isosorbide Dinitrate Isosorbide Mononitrate Nitroglycerin Patch Nitroglycerin NITROSTAT SL OPSUMIT Papaverine HCL Sildenafil Citrate Quinidine Sulfate ER CENTRAL NERVOUS SYSTEM AGENTS TIKOSYN Analgesics and Antipyretics LEGEND • Brand-name drugs are in bold type and all capital letters • For drugs not indicated in bold, generic drugs will be dispensed as the formulary agent • Higher Copay—HC Acetaminophen/Codeine • Restricted Benefit—RB • Limited Distribution—LD • Quantity Limits—QL • Oral Chemo Drugs—OC 7 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Buprenorphine HCL/ Naloxone HCL SL Dextroamphetamine Sulfate Butalbital/Acetaminophen/ Caffeine Methylphenidate HCL CD, ER Butalbital/Aspirin/Caffeine REQUIREMENTS AND LIMITS Methylphenidate HCL VYVANSE Codeine Phosphate Anticonvulsants Codeine Sulfate BANZEL Diclofenac Sodium Carbamazepine Etodolac Carbamazepine ER Fentanyl Diazepam (Anticonvulsant) Hydrocodone/ Acetaminophen Divalproex Sodium Hydromorphone HCL Gabapentin Ibuprofen Lamotrigine Indomethacin Levetiracetam Ketoprofen Levetiracetam XR Meloxicam Methsuximide Meperidine HCL Oxcarbazepine Methadone HCL Phenobarbital Morphine Sulfate Phenytoin Sodium Nabumetone Primidone Naproxen Topiramate Oxycodone HCL Valproate Sodium Oxycodone/Acetaminophen Valproic Acid Salsalate Antimigraine Agents Sulindac Ergotamine/Caffeine Tramadol HCL Naratriptan HCL QL Anorexigenic Agents and Respiratory and Cerebral Stimulants Rizatriptan Benzoate ODT QL Sumatriptan QL ADDERALL XR Amphetamine/ Detroamphetamine (Mixed) Ethosuximide Anxiolytics, Sedatives, and Hypnotics Buspirone HCL Hydroxyzine HCL LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC • Quantity Limits—QL • Oral Chemo Drugs—OC 8 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Hydroxyzine Pamoate DRUG NAME REQUIREMENTS AND LIMITS Lithium Citrate Zaleplon QL Maprotiline HCL Zolpidem Tartrate QL Mirtazapine Central Nervous System Agents, Miscellaneous Nefazodone HCL Carbidopa/Levodopa, ER Olanzapine Entacapone ORAP LODOSYN Paroxetine HCL NAMENDA Perphenazine Pramipexole Dihydrochloride Phenelzine Sulfate Riluzole Prochlorperazine Maleate Ropinirole HCL Protriptyline HCL Selegiline Quetiapine Opiate Antagonists Risperidone EVZIO Sertraline HCL Naltrexone HCL Thioridazine HCL Psychotherapeutic Agents Amitriptyline HCL Bupropion HCL, SR, XL Chlorpromazine HCL Citalopram HCL Clozapine Desipramine HCL Nortriptyline HCL Thiothixene Trazodone HCL Trifluoperazine HCL Venlafaxine HCL Ziprasidone HCL ELECTROLYTIC, CALORIC, AND WATER BALANCE Doxepine HCL Acidifying and Alkalinizing Agents Duloxetine HCL Potassium & Sodium Acid Phosphates Escitalopram Oxalate Fluoxetine HCL Fluphenazine HCL Potassium Citrate(Alkalinizer) Sodium Citrate & Citric Acid Fluvoxamine Maleate Ammonia Detoxicants Haloperidol Lactulose Imipramine HCL Diuretics Lithium Carbonate Amiloride/ Hydrochlorothazide LEGEND • Brand-name drugs are in bold type and all capital letters • For drugs not indicated in bold, generic drugs will be dispensed as the formulary agent • Higher Copay—HC • Restricted Benefit—RB • Limited Distribution—LD • Quantity Limits—QL • Oral Chemo Drugs—OC 9 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Amiloride HCL Bumetanide Chlorothiazide Chlorthalidone Furosemide Hydrochlorothiazide DRUG NAME EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS Antiallergic Agents Azelastine HCL Cromolyn Sodium (OP) Indapamide Anti-Infectives Metolazone Bacitracin (OP) Triamterene/ Hydrochlorothiazide Bacitracin/Polymyxin B (OP) Ion-Removing Agents Erythromycin (OP) RENVELA Gentamicin Sulfate (OP) Sodium Polystyrene Sulfonate NATACYN Replacement Preparations Neomycin/Bacitracin/ Polymyxin Calcium Acetate Ciprofloxacin (OP) ELIPHOS Neomycin/Polymyxin/ Gramicid PHOSLYRA Ofloxacin (OP) Potassium Phosphate Dibasic/Monobasic Ofloxacin (OTIC) Potassium Bicarbonate Sulfacetamide Potassium Chloride Tobramycin Sulfate (OP) Potassium Phosphate Monobasic Trifluridine Uricosuric Agents Probenecid ENZYMES Enzymes PULMOZYME SOL VPRIV REQUIREMENTS AND LIMITS Polymyxin B/Trimethoprim ZYMAXID Anti-Inflammatory Agents Bacitracin/Polymyxin/ Neomycin/HC CIPRODEX OTIC COLY-MYCIN S OTIC Dexamethasone (OP) Fluorometholone (OP) LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC • Quantity Limits—QL • Oral Chemo Drugs—OC 10 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Flunisolide Proparacaine HCL Flurbiprofen (OP) Tetracaine HCL Fluticasone Propionate Mydriatics Hydrocortisone/Acetic Acid (OTIC) Atropine Sulfate Ketorolac Tromethamine Neomycin/Polymyxin/ Dexameth REQUIREMENTS AND LIMITS CYCLOMYDRIL Homatropine HBR Tropicamide Neomycin/Polymyxin/HC Vasoconstrictors PRED-G Phenylephrine HCL (OP) Prednisolone Acetate GASTROINTESTINAL DRUGS Prednisolone Sodium Phosphate Antidiarrhea Agents Sulfacetamide Sodium/ Prednisolone Tobramycin/Dexamethasone VEXOL Diphenoxylate/Atropine Antiemetics EMEND Ondansetron HCL EENTDrugs,Miscellaneous Prochlorperazine Acetic Acid (OTIC) TRANSDERM-SCOP Acetic Acid/Aluminum Acetate Anti-Inflammatory Agents Brimonidine Tartrate Carbachol (OP) Dorzolamide Dorzolamide/Timolol Latanoprost Balsalazide Disodium CANASA LIALDA Mesalamine Enema PENTASA Levobunolol HCL Antiulcer Agents and Acid Suppressants Metipranolol Famotidine Timolol (OP) Misoprostol Local Anesthetics Omeprazole Benzocaine/Antipyrine Lidocaine HCL Pantoprazole Ranitidine HCL Sucralfate LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC • Quantity Limits—QL • Oral Chemo Drugs—OC 11 April 2015 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Digestants Androgens CREON Danocrine ZENPEP DEPO-TESTOSTERONE GIDrugs,Miscellaneous Contraceptives Metoclopramide HCL Desogestrel/Ethinyl Estradiol PEG 3350-KCL-Sodium Bicarb-Sodium ChlorideSodium Sulfate Drospirenone/Ethinyl Estradiol Ursodiol HEAVY METAL ANTAGONISTS Heavy Metal Antagonists EXJADE HORMONES AND SYNTHETIC SUBSTITUTES ELLA Ethynodiol Diacetate/Ethinyl Estradiol Levonorgestrel/Ethinyl Estradiol Levonorgestrel/Ethinyl Estradiol (Triphasic) NEXPLANON Adrenals Norethindrone ASMANEX Norethindrone/Ethinyl Estradiol Budesonide Cortisone Acetate Dexamethasone Norethindrone Acetate/ Ethinyl Estradiol FLOVENT HFA Norethindrone/Ethinyl Estradiol (Triphasic) Fludrocortisone Acetate PLAN B ONE-STEP Hydrocortisone Diabetic Agents Methlyprednisolone MILLIPRED Prednisolone Prednisolone Sodium Phosphate Prednisone QVAR REQUIREMENTS AND LIMITS Acarbose Glipizide GLUCAGON EMERGENCY KIT HUMALOG VIAL HUMULIN 70/30 VIAL HUMULIN N VIAL HUMULIN R VIAL LANTUS VIAL LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC • Quantity Limits—QL • Oral Chemo Drugs—OC 12 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Metformin HCL DRUG NAME REQUIREMENTS AND LIMITS Somatotropin Agonist and Antagonist Metformin ER OMNITROPE Pioglitazone HCL Estrogens and Antiestrogens CLIMARA QL Thyroid and Antithyroid Agents Levothyroxine Sodium Liothyronine Sodium Estradiol Methimazole Esterified Estrogens/Methyl Testosterone Propylthiouracil Thyroid PREMARIN VAGINAL CREAM Raloxifene MISCELLANEOUS THERAPEUTIC AGENTS Gonadotropins Miscellaneous Therapeutic Agents BRAVELLE HC, QL Acamprosate Calcium Chorionic Gonadotropin HC, QL ACTIMMUNE Clomiphene Citrate HC Alendronate Sodium FOLLISTIM HC, QL Allopurinol Ganirelix Acetate HC, QL AVONEX GONAL-F HC, QL Azathioprine MENOPUR HC, QL Bromocriptine Mesylate IUD MIRENA Parathyroid FORTICAL QL Colchicine COPAXONE 20MG/ML QL Cromolyn Sodium Disulfiram ELMIRON Pituitary ENBREL Desmopressin Acetate Etidronate Disodium Progestins EXTAVIA Medroxyprogesterone Acetate Finasteride Norethindrone Acetate GENGRAF Progesterone Micronized HUMIRA FIRAZYR QL QL QL QL Leflunomide LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC • Quantity Limits—QL • Oral Chemo Drugs—OC 13 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Leucovorin Calcium MESNEX Acetylcysteine QL READI-CAT REBIF QL REVLIMID OC SANDIMMUNE Sodium Chloride (Inhalant) SKIN AND MUCOUS MEMBRANE AGENTS Anti-Infectives (Skin and Mucous Membrane) Benzoyl Peroxide/ Erythromycin SENSIPAR Sodium Fluoride Ciclopirox Olamine Tacrolimus THALOMID REQUIREMENTS AND LIMITS Respiratory Agents, Miscellaneous Mycophenolate Mofetil ORENCIA DRUG NAME OC VOLUMEN Clindamycin Phosphate Clioquinol/Hydrocortisone Clotrimazole Troche Vitamins Erythromycin Folic Acid Gentamicin Sulfate Iron Complex Ketoconazole Phytonadione Metronidazole Potassium Aminobenzoate Mupirocin Pyridoxine HCL Nystatin OXYTOCICS Permethrin Oxytocics Salicylic Acid Methylergonovine Maleate Selenium Sulfide RESPIRATORY TRACT AGENTS Silver Nitrate/Potassium Nitrate Anti-Inflammatory Agents Silver Sulfadiazine Cromolyn Sodium DULERA Anti-Inflammatory Agents (Skin and Mucous Membrane) Montelukast Sodium Betamethasone Dipropionate Antitussives Betamethasone Valerate Benzonatate Clobetasol Propionate Guaifenesin/Codeine LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC • Quantity Limits—QL • Oral Chemo Drugs—OC 14 April 2015 DRUG NAME REQUIREMENTS AND LIMITS Clobetasol Propionate Emollient Base CORDRAN Desoximetasone Diflorasone Diacetate DRUG NAME REQUIREMENTS AND LIMITS Methoxsalen OXSORALEN LOT PHISOHEX LIQ Podofilox Sulfacetamide Sodium Fluocinolone Acetonide SANTYL Fluocinonide VECTICAL Halobetasol Propionate Hydrocortisone (Rectal) SMOOTH MUSCLE RELAXANTS Hydrocortisone (Topical) Smooth Muscle Relaxants Hydrocortisone Butyrate Aminophylline Hydrocortisone Valerate Oxybutynin Chloride Mometasone Furoate Oxybutynin Chloride XL Nystatin/Triamcinolone Theophylline PROCTOFORM Trospium ER Tacrolimus Trospium Triamcinolone Acetonide VASODILATING AGENTS Cell Stimulants and Proliferants Miscellaneous Therapeutic Agents Tretinion Yohimbine HCL Skin and Mucous Membrane Agents, Miscellaneous Phosphodiesterase Inhibitors 8-MOP Acitretin HC, QL CAVERJECT HC, RB EDEX HC, RB MUSE HC, RB Aluminum Chloride AZELEX VITAMINS DIFFERIN Vitamins EPIDUO Calcitriol Fluorouracil Pediatric Multivitamins/ Fluoride Imiquimod Isotretinoin Lidocaine HCL Lidocaine/Prilocaine LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC • Quantity Limits—QL • Oral Chemo Drugs—OC 15 DRUG NAME REQUIREMENTS AND LIMITS Pediatric Multivitamins/ Fluoride/Iron Pediatric Multivitamins ACD/ Fluoride Pediatric Multivitamins ACD/ Fluoride/Iron Prenatal Vitamins LEGEND • Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD dispensed as the formulary agent • Higher Copay—HC • Quantity Limits—QL • Oral Chemo Drugs—OC 16
