HMO Formulary (List of Covered Drugs)
HMO Formulary (List of Covered Drugs) Last Update: 11/04/2014 Please Note: This formulary drug list is applicable to the following product types: Signature HMO, Select HMO, Kaiser Permanente for Individuals and Families, Out-of-Area PPO, Deductible HMO, HSA-Qualified Deductible HMO, Added Choice, Added Choice with Deductible HMO, and Added Choice with Deductible HMO (HSA). HMO Formulary Drug List The following list contains the formulary, also known as the preferred drug list, approved by the Kaiser Permanente Pharmacy and Therapeutics Committee. This formulary applies only to outpatient drugs and self-administered drugs. It does not apply to medications used in inpatient settings or administered in one of the Kaiser Permanente medical centers. You may have specific exclusions, copays, or coinsurance amounts that are not reflected in the formulary drug list. Please consult your Evidence of Coverage, Membership Agreement, or federal brochure (RI 73-047) for additional information regarding your pharmacy benefits, including any specific limitations or exclusions. Generic and Brand Name Medications Kaiser Permanente covers generic and brand name drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Brand name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand name drug expires, other pharmaceutical companies may then manufacture and sell the FDA- approved generic version of the drug at lower prices. In most cases, your doctor will prescribe a generic drug if one is available. Generic drugs generally cost less than brand name drugs. Non-Formulary Medications The listing only includes drugs on the formulary. Any drug not found on this list is considered nonformulary. A non-formulary medication is generally available at a higher cost. Please consult your Evidence of Coverage, Membership Agreement, or federal brochure (RI 73-047) for additional information regarding coverage of non-formulary medications specific to your plan. 1 Using the Kaiser Permanente Formulary List When you look through the formulary drug listing, you will see that products available in a generic form are listed by their generic names. Medications that are only available as a brand name product are listed in BOLD AND ALL CAPITAL letters, except where multiple branded products exist. You can search the formulary drug list by using the “FIND” function in Adobe Reader, or by referencing the therapeutic drug category. In some cases, a particular drug may be listed on the formulary drug list, but only for certain strengths or in certain dosage forms. For example, some drugs are available in different milligram (mg) strengths (e.g., 5mg, 10mg), but only one strength may be on the formulary drug list. For drugs that are available in more than one dosage form (e.g., tablet, injectable), only one may be on the formulary drug list. Please remember that this list is subject to change and will be updated from time to time during the year. Any product not found on this list will be considered a non-formulary. Restrictions on medication coverage Some covered drugs may have additional requirements or limits on coverage. Please consult your Evidence of Coverage, Membership Agreement, or federal brochure (RI 73-047) for additional information regarding your pharmacy benefits, including any specific limitations or exclusions. • Higher copay: Some drugs may have a higher cost share. These drugs include, but are not limited to, infertility, growth hormone, and weight management medications. • Limited distribution: Some drugs may be subject to limited distribution or restricted access. A drug that is a limited distribution drug may only be available at one or a limited number of pharmacies. • Oral chemotherapy drugs: Drugs that fall under the District of Columbia and State of Maryland Oral Chemotherapy Parity Act. Cost shares for these drugs may be different for employer group plans not based in Washington, D.C., and Maryland. • Quantity limit: For certain drugs, Kaiser Permanente Pharmacy and Therapeutics Committee limits the amount of medication dispensed to a certain quantity per copay. • Restricted to benefit: Some drugs are not covered unless your benefits specifically cover such medications, such as drugs for sexual dysfunction. Key: HC = A drug that may have a higher copay. LD = A drug that may be subject to limited distribution. 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 Kaiser Permanente Formulary Drug List, you may contact Member Services at 301-468-6000 or 800-777-7902 (TTY 301-879-6380). Representatives are available Monday through Friday, 7:30 a.m. until 5:30 p.m. 2 November 2014 DRUG NAME REQUIREMENTS AND LIMITS ANTIHISTAMINE DRUGS Cyproheptadine HCl Promethazine HCL DRUG NAME Sulfasalazine Sulfamethoxazole- Trimethoprim SUPRAX Tetracycline HCL ANTI-INFECTIVE AGENTS Tobramycin Neb Anthelmintics Vancomycin HCL ALBENZA VIVOTIF BERNA BILTRICIDE ZYVOX YODOXIN Antifungals Antibacterials Fluconazole Amoxicillin Griseofulvin Microsize Amoxicillin & Pot Clavulanate Griseofulvin Ultramicrosize Ampicillin Itraconazole Azithromycin Ketoconazole Cefaclor Nystatin Cefdinir Terbinafine Cefuroxime Axetil Voriconazole Cephalexin Antimycobacterials Ciprofloxacin DAPSONE Clarithromycin Ethambutol HCL Clindamycin Isoniazid Clindamycin Palmitate HCL Pyrazinamide Dicloxacillin Sodium Rifabutin Doxycycline Monohydrate Rifampin ERYPED SUSP Antiprotozoals Erythromycin Base Erythromycin Ethylsuccinate Erythromycin-Sulfisoxazole Levofloxacin Minocycline HCL Neomycin Sulfate Penicillin V Potassium REQUIREMENTS AND LIMITS Atovaquone Atovaquone-Proguanil HCL COARTEM Chloroquine Phosphate DARAPRIM Hydroxychloroquine Sulfate Mefloquine HCL Sulfadiazine 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 3 November 2014 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME REQUIREMENTS AND LIMITS Metronidazole REYATAZ NEBUPENT INH Ribavirin Primaquine Phosphate Rimantadine HCL Antivirals SELZENTRY Abacavir SOVALDI Abacavir-LamivudineZidovudine STRIBILD Adefovir Dipivoxil TAMIFLU Amantadine HCL TIVICAY APTIVUS TRUVADA ATRIPLA VALCYTE COMPLERA VICTRELIS CRIXIVAN VIRACEPT Didanosine Zidovudine EDURANT Urinary Anti-Infectives EMTRIVA Methenamine Hippurate Entecavir Nitrofurantoin EPZICOM INTELENCE Nitrofurantoin Monohyd Macro INVIRASE Nitrofurantoin Macrocrystals ISENTRESS Trimethoprim KALETRA ANTINEOPLASTIC AGENTS QL SUSTIVA Lamivudine QL Antineoplastic Agents Lamivudine-Zidovudine LEXIVA Nevirapine NORVIR PEGASYS QL PEGASYS PROCLICK QL PEG-INTRON QL PREZISTA RESCRIPTOR 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 AFINITOR OC ALKERAN OC Anastrozole OC Bicalutamide OC Capecitabine OC CEENU OC COMETRIQ KIT OC CYTOXAN OC EMCYT OC • Restricted Benefit—RB • Limited Distribution—LD • Quantity Limits—QL • Oral Chemo Drugs—OC 4 November 2014 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME REQUIREMENTS AND LIMITS Etoposide OC Tretinoin (Chemotherapy) OC Exemestane OC TYKERB OC Flutamide OC VANDETANIB OC GLEEVEC OC VOTRIENT OC HEXALEN OC XALKORI OC HYCAMTIN OC XTANDI OC Hydroxyurea OC ZELBORAF OC ICLUSIG OC ZYKADIA OC IMBRUVICA OC ZYTIGA OC INLYTA OC INTRON-A QL ANXIOLYTICS, SEDATIVES, AND HYPNOTICS JAKAFI OC Letrozole OC LEUKERAN OC LUPRON QL LUPRON DEPOT QL LUPRON DEPOT-PED QL LYSODREN OC Megestrol Acetate OC Mercaptopurine OC Barbiturates Phenobarbital Benzodiazepines Alprazolam Chlordiazepoxide HCL Clonazepam Clorazepate Dipotassium Diazepam Lorazepam Methotrexate Sodium MYLERAN OC Oxazepam NEXAVAR OC Temazepam Procarbazine HCL OC AUTONOMIC DRUGS SPRYCEL OC Anticholinergic Agents SUTENT OC ATROVENT HFA TABLOID OC Benztropine Mesylate Tamoxifen Citrate OC Dicyclomine HCL TARCEVA OC Hyoscyamine TARGRETIN OC Ipratropium Bromide (Nasal) TASIGNA OC Trihexyphenidyl HCL Temozolomide OC SPIRIVA 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 5 November 2014 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 EFFIENT Bethanechol Chloride Donepezil HCL Galantamine Hydrobromide Fondaparinux QL LOVENOX QL Pentoxifylline Neostigmine Bromide PRADAXA Pilocarpine HCL (ORAL) Warfarin Sodium Pyridostigmine Bromide Hematopoietic Agents Skeletal Muscle Relaxants Baclofen Cyclobenzaprine HCL NEUPOGEN QL PROCRIT/EPOGEN QL PROMACTA Dantrolene Sodium Methocarbamol CARDIOVASCULAR DRUGS Sympathomimetic (Adrenergic) Agents Alpha-Adrenergic Blocking Agents ADVAIR DISKUS 100/50 Terazosin HCL Albuterol Neb Tamsulosin HCL COMBIVENT RESPIMAT AER Antilipemic Agents Atorvastatin Calcium Epinephrine HCL QL EPIPEN QL PROAIR HFA SEREVENT DISKUS AER Terbutaline Sulfate Cholestyramine Cholestyramine Light Colestipol Fenofibrate 54mg, 160mg Gemfibrozil BLOOD FORMATION, COAGULATION, AND THROMBOSIS Lovastatin Coagulants And Anticoagulants Pravastatin Sodium 20mg, 40mg, 80mg AGGRENOX 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 Niacin • Restricted Benefit—RB • Limited Distribution—LD • Quantity Limits—QL • Oral Chemo Drugs—OC 6 November 2014 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Simvastatin 20mg, 40mg, 80mg Hypotensive Agents Beta-Adrenergic Blocking Agents Acetazolamide Acebutolol HCL Atenolol/Chlorthalidone Atenolol HCL Bisoprolol/ Hydrochlorothiazide REQUIREMENTS AND LIMITS Clonidine HCL Guanfacine HCL Hydralazine HCL Methazolamide Methyldopa Bisoprolol Fumarate Minoxidil Carvedilol Reserpine Labetalol HCL Metoprolol Succinate Renin-Angiotensin-Aldosterone System Inhibitors Metoprolol Tartrate 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 Quinidine Sulfate ER TIKOSYN Spironolactone Spironolactone/ Hydrochlorothiazide Vasodilating Agents ADEMPAS Isosorbide Dinitrate Isosorbide Mononitrate Nitroglycerin Patch Nitroglycerin NITROSTAT SL OPSUMIT Papaverine HCL Sildenafil Citrate CENTRAL NERVOUS SYSTEM AGENTS Analgesics and Antipyretics Acetaminophen/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 • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC 7 November 2014 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Buprenorphine HCL/ Naloxone HCL SL Dextroamphetamine Sulfate Butalbital/Acetaminophen/ Caffeine Methylphenidate HCL CD, ER Butalbital/Aspirin/Caffeine Codeine Phosphate REQUIREMENTS AND LIMITS Methylphenidate HCL VYVANSE 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 Anxiolytics, Sedatives, and Hypnotics Amphetamine/ Detroamphetamine (Mixed) Buspirone HCL Ethosuximide Hydroxyzine HCL 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 8 November 2014 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 Naltrexone HCL Psychotherapeutic Agents Amitriptyline HCL Bupropion HCL, SR, XL Chlorpromazine HCL Citalopram HCL Clozapine Desipramine HCL Nortriptyline HCL Sertraline HCL Thioridazine HCL Thiothixene Trazodone HCL Trifluoperazine HCL Venlafaxine HCL Ziprasidone HCL ELECTROLYTIC, CALORIC, AND WATER BALANCE Doxepine HCL Duloxetine HCL Escitalopram Oxalate Fluoxetine HCL Fluphenazine HCL Fluvoxamine Maleate Acidifying and Alkalinizing Agents Potassium & Sodium Acid Phosphates Potassium Citrate (Alkalinizer) Sodium Citrate & Citric Acid Haloperidol Ammonia Detoxicants Imipramine HCL Lactulose Lithium Carbonate Diuretics 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 Amiloride/ Hydrochlorothazide • Restricted Benefit—RB • Limited Distribution—LD • Quantity Limits—QL • Oral Chemo Drugs—OC 9 November 2014 DRUG NAME REQUIREMENTS AND LIMITS Amiloride HCL Bumetanide Chlorothiazide Chlorthalidone Furosemide Hydrochlorothiazide Indapamide DRUG NAME EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS Antiallergic Agents Azelastine HCL Cromolyn Sodium (OP) Anti-Infectives Metolazone Bacitracin (OP) Triamterene/ Hydrochlorothiazide Bacitracin/Polymyxin B (OP) Ion-Removing Agents Erythromycin (OP) RENVELA Sodium Polystyrene Sulfonate Replacement Preparations Calcium Acetate Ciprofloxacin (OP) Gentamicin Sulfate (OP) NATACYN Neomycin/Bacitracin/ Polymyxin 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 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 REQUIREMENTS AND LIMITS Polymyxin B/Trimethoprim ZYMAXID Anti-Inflammatory Agents Bacitracin/Polymyxin/ Neomycin/HC CIPRODEX OTIC COLY-MYCIN S OTIC Dexamethasone (OP) Fluorometholone (OP) • Restricted Benefit—RB • Limited Distribution—LD • Quantity Limits—QL • Oral Chemo Drugs—OC 10 November 2014 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 Diphenoxylate/Atropine Tobramycin/Dexamethasone EMEND VEXOL Antiemetics Ondansetron HCL EENT Drugs, Miscellaneous Prochlorperazine Acetic Acid (OTIC) TRANSDERM-SCOP Acetic Acid/Aluminum Acetate Anti-Inflammatory Agents Brimonidine Tartrate Carbachol (OP) Dorzolamide Dorzolamide/Timolol Latanoprost Levobunolol HCL Balsalazide Disodium CANASA LIALDA Mesalamine Enema PENTASA Antiulcer Agents and Acid Suppressants LUMIGAN Famotidine Metipranolol Misoprostol Timolol (OP) Omeprazole Local Anesthetics Benzocaine/Antipyrine Lidocaine HCL 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 Pantoprazole Ranitidine HCL Sucralfate • Restricted Benefit—RB • Limited Distribution—LD • Quantity Limits—QL • Oral Chemo Drugs—OC 11 November 2014 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Digestants Androgens CREON Danocrine ZENPEP DEPO-TESTOSTERONE GI Drugs, Miscellaneous Contraceptives Metoclopramide HCL Desogestrel/Ethinyl Estradiol PEG 3350-KCL-Sodium Bicarb-Sodium ChlorideSodium Sulfate Drospirenone/Ethinyl Estradiol Ursodiol Ethynodiol Diacetate/Ethinyl Estradiol HEAVY METAL ANTAGONISTS Heavy Metal Antagonists EXJADE HORMONES AND SYNTHETIC SUBSTITUTES ELLA 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 • 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 12 November 2014 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME REQUIREMENTS AND LIMITS Metformin HCL Somatotropin Agonist and Antagonist Metformin ER OMNITROPE Pioglitazone HCL QL Thyroid and Antithyroid Agents Estrogens and Antiestrogens CLIMARA Levothyroxine Sodium Liothyronine Sodium Estradiol Methimazole Esterified Estrogens/Methyl Testosterone Propylthiouracil Thyroid PREMARIN VAGINAL CREAM MISCELLANEOUS THERAPEUTIC AGENTS Raloxifene Miscellaneous Therapeutic Agents Gonadotropins 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 COLCRYS COPAXONE 20MG/ML QL Cromolyn Sodium Disulfiram FORTICAL ELMIRON Pituitary ENBREL Desmopressin Acetate Etidronate Disodium Progestins EXTAVIA Medroxyprogesterone Acetate QL QL QL Finasteride FIRAZYR Norethindrone Acetate GENGRAF Progesterone Micronized HUMIRA QL QL Leflunomide 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 13 November 2014 DRUG NAME REQUIREMENTS AND LIMITS Leucovorin Calcium Acetylcysteine Mycophenolate Mofetil Sodium Chloride (Inhalant) QL READI-CAT REBIF QL REVLIMID OC SANDIMMUNE 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 MESNEX ORENCIA DRUG NAME Clindamycin Phosphate OC VOLUMEN Clioquinol/Hydrocortisone Clotrimazole Troche Vitamins Erythromycin Folic Acid Gentamicin Sulfate Iron Complex Ketoconazole Phytonadione Metronidazole Potassium Aminobenzoate Mupirocin Pyridoxine HCL Nystatin OXYTOCICS Permethrin Oxytocics Methylergonovine Maleate Salicylic Acid Selenium Sulfide RESPIRATORY TRACT AGENTS Silver Nitrate/Potassium Nitrate Anti-Inflammatory Agents Silver Sulfadiazine Cromolyn Sodium Anti-Inflammatory Agents (Skin and Mucous Membrane) DULERA Montelukast Sodium Betamethasone Dipropionate Antitussives Betamethasone Valerate Benzonatate Clobetasol Propionate Guaifenesin/Codeine 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 14 November 2014 DRUG NAME REQUIREMENTS AND LIMITS DRUG NAME Clobetasol Propionate Emollient Base Podofilox CORDRAN OXSORALEN LOT Desonide OXSORALEN ULTRA Desoximetasone PHISOHEX LIQ Diflorasone Diacetate SANTYL Fluocinolone Acetonide VECTICAL Fluocinonide REQUIREMENTS AND LIMITS Sulfacetamide Sodium SMOOTH MUSCLE RELAXANTS Halobetasol Propionate Hydrocortisone (Rectal) Smooth Muscle Relaxants Hydrocortisone (Topical) Aminophylline Hydrocortisone Butyrate Oxybutynin Chloride Hydrocortisone Valerate Oxybutynin Chloride XL Mometasone Furoate OXYTROL DIS Nystatin/Triamcinolone Theophylline PROCTOFORM Trospium ER PROTOPIC Trospium Triamcinolone Acetonide VASODILATING AGENTS Cell Stimulants and Proliferants Miscellaneous Therapeutic Agents Tretinion Yohimbine HCL Skin and Mucous Membrane Agents, Miscellaneous Phosphodiesterase Inhibitors CAVERJECT HC, RB 8-MOP EDEX HC, RB Acitretin MUSE HC, RB Aluminum Chloride AZELEX VITAMINS DIFFERIN Vitamins EPIDUO Calcitriol Fluorouracil Pediatric Multivitamins/ Fluoride Imiquimod HC, QL Isotretinoin Lidocaine HCL Lidocaine/Prilocaine 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 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 • 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 16
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