Southern Colorado Commercial HMO Drug Formulary
Southern Colorado Commercial HMO Drug Formulary The following is a listing of the drugs on the Southern Colorado Commercial HMO Drug Formulary 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. 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 Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) -1- 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 Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) -2- Drug Name Drug Tier ANTIHISTAMINE DRUGS FIRST GENERATION ANTIHISTAMINES cyproheptadine hcl promethazine hcl ANTIHISTAMINE DRUGS SECOND GENERATION ANTIHISTAMINES None ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA BILTRICIDE STROMECTOL ANTI-INFECTIVE AGENTS ANTIBACTERIALS amoxicillin amoxicillin & potassium clavulanate ampicillin azithromycin CAYSTON cefaclor cefadroxil cefdinir cefprozil cefuroxime axetil cephalexin ciprofloxacin hcl ciprofloxacin-ciprofloxacin hcl clarithromycin clindamycin hcl dicloxacillin doxycycline erythromycin & sulfisoxazole erythromycin base erythromycin ethylsuccinate erythromycin stearate levofloxacin minocycline moxifloxacin neomycin sulfate NOROXIN penicillin V potassium SPECTRACEF sulfadiazine sulfamethoxazole & trimethoprim Requirements/Limits Generic Generic * Brand Brand Brand Generic Generic/Brand † Generic/Brand † Generic/Brand † Brand Generic Generic Generic Generic Generic/Brand † Generic Generic/Brand † Generic Generic Generic/Brand † Generic Generic Generic Generic/Brand † Generic/Brand † Brand Generic Generic Generic Generic/Brand † Brand Generic Brand Generic Generic PA Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) -3- Drug Name Drug Tier Requirements/Limits sulfasalazine SUPRAX tetracycline TOBI Podhaler tobramycin neb vancomycin ZYVOX ANTI-INFECTIVE AGENTS ANTIFUNGALS fluconazole griseofulvin ultramicrosize itraconazole ketoconazole nystatin terbinafine voriconazole ANTI-INFECTIVE AGENTS ANTIMYCOBACTERIALS DAPSONE ethambutol isoniazid pyrazinamide rifabutin rifampin ANTI-INFECTIVE AGENTS ANTIVIRALS abacavir sulfate acyclovir adenovir dipivoxil APTIVUS ATRIPLA BARACLUDE CRIXIVAN didanosine EMTRIVA EPIVIR HBV EPZICOM famciclovir GANCYCLOVIR INFERGEN INTELENCE INVIRASE ISENTRESS KALETRA Generic Brand Generic/Brand † Brand Generic Generic Brand * QL QL QL MD, PA, QL Generic Generic Generic/Brand † Generic Generic/Brand † Generic Generic MD MD Brand Generic Generic Generic Generic Generic Generic Generic Generic Brand Brand Brand Brand Generic/Brand † Brand Brand Brand Generic Brand Brand * Brand Brand Brand Brand QL QL PA, QL Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) -4- Drug Name Drug Tier lamivudine lamivudine-zidovudine LEXIVA nevirapine NORVIR PEGASYS PEG-INTRON PREZISTA RELENZA RESCRIPTOR REYATAZ ribavirin rimantadine SELZENTRY SOVALDI stavudine SUSTIVA TAMIFLU TRIZIVIR TRUVADA TYZEKA valacyclovir VALCYTE VIRACEPT VIRAZOLE VIREAD zidovudine ANTI-INFECTIVE AGENTS ANTIPROTOZOALS atovaquone/proguanil chloroquine phosphate DARAPRIM FUROXONE hydroxychloroquine sulfate mefloquine hcl metronidazole NEBUPENT paromomycin sulfate PRIMAQUINE PHOSPHATE YODOXIN ANTI-INFECTIVE AGENTS URINARY ANTI-INFECTIVES belladonna alkaloids, methenamine, methylene blue & phenyl salicylate Generic Generic Brand Generic Brand Brand * Brand * Brand Brand Brand Brand Generic Generic/Brand † Brand Brand Generic Brand Brand Brand Brand Brand Generic Brand Brand Brand Brand Generic Requirements/Limits PA, QL PA, QL QL MD, QL PA, QL QL QL MD, QL Generic Generic Brand Brand Generic Generic Generic Brand Generic Brand Generic Generic Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) -5- Drug Name Drug Tier nitrofurantoin macrocrystals nitrofurantoin monohydrate macrocystals nitrofurantoin suspension trimethoprim ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS AFINITOR ALKERAN anastrozole bicalutamide capecitabine CEENU cyclophosphamide ELIGARD EMCYT ETOPOSIDE exemestane flutamide GLEEVEC HEXALEN hydroxyurea INTRON-A IRESSA letrozole LEUKERAN leuprolide acetate LUPRON DEPOT LUPRON DEPOT-PED LYSODREN MATULANE megestrol acetate mercaptopurine methotrexate MYLERAN NEXAVAR NILANDRON SPRYCEL SUTENT TABLOID tamoxifen citrate TARCEVA TARGRETIN temozolomide tretinoin (chemo) Generic/Brand † Generic Generic Generic/Brand † Brand Brand * Generic Generic Generic Brand Brand Brand * Brand Brand Generic Generic Brand Brand Generic Brand * Brand Generic Brand Generic/Brand *† Brand * Brand * Brand Brand Generic Generic Generic/Brand *† Brand Brand Brand Brand Brand Brand Generic Brand Brand Generic Generic Requirements/Limits MD, QL PA QL MD, QL PA, QL QL PA PA PA QL QL MD, QL QL MD, QL QL QL QL QL Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) -6- Drug Name Drug Tier TYKERB Brand VOTRIENT Brand XTANDI Brand ZELBORAF Brand ZOLINZA Brand ZYTIGA Brand AUTONOMIC DRUGS PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride Generic cevimeline hcl Generic donepezil Generic galantamine hbr Generic galantamine hbr (extended release) Generic PROSTIGMIN Brand pyridostigmine bromide Generic/Brand † AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS belladonna alkaloids & phenobarbital Generic/Brand † chlordiazepoxide & clidinium Generic dicyclomine hcl Generic DONNATAL EXTENTABS Brand glycopyrrolate Generic hyoscyamine sulfate Generic ipratropium bromide (inhaled) Generic/Brand † ipratropium bromide (nasal) Generic SPIRIVA Brand AUTONOMIC DRUGS SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR DISKUS Brand ADVAIR HFA Brand albuterol sulfate Generic/Brand † COMBIVENT RESPIMAT Brand DULERA Brand ELIXOPHYLLIN Brand epinephrine hcl Generic/Brand *† levalbuterol hcl solution Generic MAXAIR AUTOHALER Brand metaproterenol sulfate Generic/Brand † midodrine hcl Generic SEREVENT DISKUS Brand terbutaline sulfate Generic XOPENEX HFA Brand AUTONOMIC DRUGS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS Requirements/Limits QL MD, QL PA, QL PA, QL QL PA, QL QL ST ST QL ST ST Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) -7- Drug Name Drug Tier Requirements/Limits DIBENZYLINE dihydroergotamine mesylate ERGOMAR tamsulosin hcl AUTONOMIC DRUGS SKELETAL MUSCLE RELAXANTS baclofen carisoprodol carisoprodol & aspirin cyclobenzaprine hcl dantrolene sodium methocarbamol tizanidine hcl BLOOD FORMATION, COAGULATION, AND THROMBOSIS ANTITHROMBOTIC AGENTS anagrelide hcl BRILINTA cilostazol clopidogrel EFFIENT fondaparinux FRAGMIN heparin sodium INNOHEP LOVENOX warfarin sodium BLOOD FORMATION, COAGULATION AND THROMBOSIS HEMATOPOIETIC AGENTS EPOGEN LEUKINE NEULASTA PROCRIT BLOOD FORMATION, COAGULATION, AND THROMBOSIS HEMORRHEOLOGIC AGENTS pentoxifylline BLOOD FORMATION, COAGULATION, AND THROMBOSIS ANTIHEMORRHAGIC AGENTS aminocaproic acid CARDIOVASCULAR DRUGS CARDIAC DRUGS amiodarone hcl digoxin disopyramide phosphate flecainide acetate Brand Generic/Brand *† Brand Generic QL QL Generic Generic Generic Generic Generic Generic/Brand *† Generic Generic Brand Generic Generic Brand * Generic* Brand * Generic/Brand *† Brand * Brand * Generic QL QL QL Brand * Brand * Brand * Brand * PA, QL MD, QL PA, QL PA, QL PA, QL QL Generic Generic/Brand † Generic/Brand † Generic/Brand † Generic/Brand † Generic Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) -8- Drug Name Drug Tier mexiletine hcl propafenone hcl quinidine gluconate quinidine sulfate TIKOSYN CARDIOVASCULAR DRUGS ANTILIPEMIC AGENTS cholestyramine cholestyramine light CRESTOR fenofibrate fenofibrate (micronized) gemfibrozil lovastatin NIASPAN pravastatin simvastatin CARDIOVASCULAR DRUGS HYPOTENSIVE AGENTS clonidine hcl guanfacine hcl hydralazine hcl methyldopa RESERPINE CARDIOVASCULAR DRUGS VASODILATING AGENTS ADCIRCA alprostadil CAVERJECT CIALIS dipyridamole EDEX isosorbide dinitrate isosorbide mononitrate LETAIRIS LEVITRA MUSE nitroglycerin sildenafil citrate (REVATIO) TRACLEER VIAGRA CARDIOVASCULAR DRUGS ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate Generic Generic Generic Generic Brand Generic Generic Brand Generic Generic Generic Generic Brand Generic Generic Requirements/Limits PA Generic Generic Generic Generic Brand Brand Generic * Brand * Brand Generic Brand * Generic/Brand † Generic Brand Brand Brand Generic/Brand † Generic Brand Brand MD, QL QL, RB QL, RB QL, RB QL, RB MD, QL QL, RB QL, RB MD MD, QL QL, RB Generic Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) -9- Drug Name Drug Tier prazosin hcl Generic terazosin hcl Generic CARDIOVASCULAR DRUGS BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl Generic atenolol Generic atenolol & chlorthalidone Generic bisoprolol fumarate Generic bisoprolol fumarate & hydrochlorothiazide Generic BYSTOLIC Brand carvedilol Generic COREG CR Brand labetalol hcl Generic metoprolol succinate Generic metoprolol tartrate Generic nadolol Generic pindolol Generic propranolol hcl Generic sotalol hcl Generic CARDIOVASCULAR DRUGS CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besylate Generic amlodipine besylate & benazepril hcl Generic CARDENE SR Brand diltiazem hcl Generic/Brand † Generic diltiazem hcl coated beads Generic diltiazem hcl extended release beads EXFORGE Brand EXFORGE HCT Brand felodipine Generic isradipine Generic/Brand † nifedipine Generic TARKA Brand verapamil hcl Generic CARDIOVASCULAR DRUGS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS benazepril & hydrochlorothiazide Generic benazepril hcl Generic captopril Generic CAPTOPRIL & HYDROCHLOROTHIAZIE Brand enalapril maleate Generic fosinopril sodium Generic fosinopril sodium & hydrochlorothiazide Generic lisinopril Generic Requirements/Limits ST ST Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 10 - Drug Name Drug Tier Requirements/Limits lisinopril & hydrochlorothiazide losartan potassium losartan potassium & hydrochlorothiazide moexipril & hydrochlorothiazide moexipril hcl quinapril & hydrochlorothiazide quinapril hcl ramipril spironolactone spironolactone & hydrochlorothiazide valsartan valsartan & hydrochlorothiazide CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS acetaminophen with codeine buprenorphine HCl & naloxone HCl butalbital, acetaminophen & caffeine butalbital, acetaminophen, caffeine & codeine butalbital, aspirin & caffeine butalbital, aspirin, caffeine & codeine CELEBREX choline magnesium trisalicylate diclofenac sodium etodolac fenoprofen calcium fentanyl fentanyl citrate hydrocodone & acetaminophen hydromorphone hcl ibuprofen indomethacin KETOPROFEN (extended release) ketorolac tromethamine meclofenamate sodium methadone hcl morphine sulfate morphine sulfate (extended release) nabumetone naproxen naproxen sodium oxaprozin oxycodone & acetaminophen oxycodone & aspirin oxycodone hcl Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic ST ST Generic Generic Generic Generic Generic Generic Brand Generic Generic Generic Generic/Brand † Generic Generic Generic Generic/Brand † Generic Generic/Brand † Brand Generic Generic Generic Generic/Brand † Generic Generic Generic Generic Generic Generic Generic Generic PA QL, ST MD, PA, QL MD, PA, QL QL QL QL Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 11 - Drug Name Drug Tier salsalate sulindac tramadol hcl CENTRAL NERVOUS SYSTEM AGENTS OPIATE ANTAGONISTS naltrexone hcl CENTRAL NERVOUS SYSTEM AGENTS ANTICONVULSANTS carbamazepine carbamazepine (extended release) CELONTIN clonazepam divalproex sodium divalproex sodium (extended release) ethosuximide felbamate gabapentin lamotrigine levetiracetam oxcarbazepine phenytoin phenytoin sodium (extended release) primidone tiagabine topiramate valproate sodium valproic acid zonisamide CENTRAL NERVOUS SYSTEM AGENTS PSYCHOTHERAPEUTIC AGENTS ABILIFY ABILIFY DISCMELT amitriptyline hcl AMOXAPINE bupropion hcl bupropion hcl (smoking deterrent) chlordiazepoxide & amitriptyline chlorpromazine hcl citalopram hydrobromide clomipramine hcl desipramine hcl doxepin hcl escitalopram oxalate fluoxetine hcl Generic Generic Generic Requirements/Limits Generic Generic Generic/Brand † Brand Generic Generic Generic Generic Brand Generic/Brand † Generic Generic Generic Generic/Brand † Generic/Brand † Generic Generic Generic Generic Generic Generic Brand Brand Generic Brand Generic Generic Generic Generic Generic Generic Generic Generic Generic Generic MD QL MD MD, QL MD, QL QL ST, QL Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 12 - Drug Name Drug Tier fluphenazine hcl Generic fluvoxamine maleate Generic haloperidol Generic haloperidol lactate Generic imipramine hcl Generic imipramine pamoate Generic/Brand † loxapine succinate Generic maprotiline hcl Generic mirtazapine Generic MOBAN Brand NEFAZODONE HCL Brand nortriptyline hcl Generic olanzapine Generic olanzapine ODT Generic paroxetine hcl Generic paroxetine hcl (extended release) Generic/Brand † perphenazine Generic phenelzine sulfate Generic prochlorperazine maleate Generic protriptyline hcl Generic quetiapine fumarate Generic risperidone Generic sertraline hcl Generic SURMONTIL Brand thioridazine hcl Generic thiothixene Generic/Brand † tranylcypromine sulfate Generic trazodone hcl Generic trifluoperazine hcl Generic venlafaxine hcl Generic venlafaxine hcl (extended release) Generic/Brand † ziprasidone hcl Generic CENTRAL NERVOUS SYSTEM AGENTS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS, MISCELLANEOUS amphetamine & dextroamphetamine Generic dexmethylphenidate hcl Generic dextroamphetamine sulfate Generic FOCALIN XR Brand methylphenidate hcl Generic methylphenidate hcl (extended release) Generic/Brand † modafinil Generic CENTRAL NERVOUS SYSTEM AGENTS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS Requirements/Limits MD MD, QL MD, QL QL MD MD, QL MD, QL MD MD, QL QL QL QL QL QL QL PA, QL Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 13 - Drug Name Drug Tier alprazolam Generic buspirone hcl Generic chlordiazepoxide hcl Generic clorazepate dipotassium Generic diazepam Generic/Brand *† estazolam Generic flurazepam hcl Generic hydroxyzine hcl Generic hydroxyzine pamoate Generic lorazepam Generic oxazepam Generic phenobarbital Generic temazepam Generic/Brand † triazolam Generic zaleplon Generic zolpidem tartrate Generic CENTRAL NERVOUS SYSTEM AGENTS ANTIMANIC AGENTS lithium carbonate Generic/Brand † lithium carbonate (extended release) Generic/Brand † CENTRAL NERVOUS SYSTEM AGENTS ANTIMIGRAINE AGENTS CAFERGOT Brand naratriptan Generic rizatriptan Generic sumatriptan succinate Generic/Brand *† zolmitriptan Generic/Brand zolmitriptan ODT Generic CENTRAL NERVOUS SYSTEM AGENTS ANTIPARKINSONIAN AGENTS amantadine hcl Generic APOKYN Brand * benztropine mesylate Generic bromocriptine mesylate Generic cabergoline Generic carbidopa & levodopa Generic carbidopa & levodopa (extended release) Generic entacapone Generic pramipexole dihydrochloride Generic ropinirole hcl Generic selegiline hcl Generic trihexyphenidyl hcl Generic CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS Requirements/Limits QL (7.5mg, 30mg) QL QL QL QL, ST QL, ST QL QL, ST QL, ST MD, QL MD Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 14 - Drug Name Drug Tier Requirements/Limits riluzole SAVELLA ELECTROLYTIC, CALORIC AND WATER BALANCE ALKALINIZING AGENTS potassium & sodium citrates w/ citric acid potassium citrate sodium citrate & citric acid ELECTROLYTIC, CALORIC AND WATER BALANCE AMMONIA DETOXICANTS lactulose ELECTROLYTIC, CALORIC AND WATER BALANCE REPLACEMENT PREPARATIONS calcium acetate (phosphate binder) potassium bicarb & potassium chloride potassium chloride ELECTROLYTIC, CALORIC AND WATER BALANCE ION-REMOVING AGENTS RENAGEL RENVELA RENVELA PAK sodium polystyrene sulfonate ELECTROLYTIC, CALORIC AND WATER BALANCE DIURETICS bumetanide chlorthalidone furosemide hydrochlorothiazide indapamide metolazone torsemide triamterene & hydrochlorothiazide ELECTROLYTIC, CALORIC AND WATER BALANCE URICOSURIC AGENTS COLCRYS probenecid probenecid & colchicine ENZYMES ENZYMES PULMOZYME RESPIRATORY TRACT AGENTS ANTITUSSIVES benzonatate guaifenesin & codeine hydrocodone & homatropine Generic Brand MD, QL QL Generic Generic Generic Generic Generic/Brand † Generic/Brand † Generic/Brand † Brand Brand Brand Generic Generic Generic Generic Generic Generic Generic Generic Generic Brand Generic Generic Brand QL Generic Generic Generic Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 15 - Drug Name Drug Tier hydrocodone polistirex & chlorpheniramine polistirex Generic RESPIRATORY TRACT AGENTS RESPIRATORY TRACT ANTI-INFLAMMATORY AGENTS cromolyn sodium Generic/Brand † montelukast sodium Generic montelukast sodium (packets) Generic zafirlukast Generic RESPIRATORY TRACT AGENTS RESPIRATORY TRACT AGENTS, MISCELLANEOUS sodium chloride for nebulization Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTIALLERGIC AGENTS ALAMAST Brand ALOCRIL (ophthalmic) Brand ALOMIDE (ophthalmic) Brand azelastine hcl spray Generic azelastine hcl (ophthalmic) Generic/Brand † cromolyn sodium (ophthalmic) Generic PATANOL Brand EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS EENT ANTI-INFECTIVES bacitracin & polymyxin B (ophthalmic) Generic bacitracin (ophthalmic) Brand chlorhexidine gluconate (dental) Generic ciprofloxacin hcl (ophthalmic) Generic erythromycin (ophthalmic) Generic gatifloxacin (ophthalmic) Generic gentamicin sulfate (ophthalmic) Generic neomycin, bacitracin & polymyxin B (ophth) Generic ofloxacin (ophthalmic) Generic ofloxacin (otic) Generic polymyxin B & trimethoprim Generic sulfacetamide sodium (ophthalmic) Generic/Brand † tobramycin sulfate (ophthalmic) Generic/Brand † trifluridine (ophthalmic) Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS EENT ANTI-INFLAMMATORY AGENTS BLEPHAMIDE (ophthalmic) Brand BLEPHAMIDE S.O.P. Brand CIPRO HC (otic) Brand CIPRODEX Brand COLY-MYCIN-S (otic) Brand diclofenac sodium (ophthalmic) Generic FLAREX Brand Requirements/Limits ST, QL QL QL, ST MD Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 16 - Drug Name Drug Tier FLUNISOLIDE (nasal) fluorometholone (ophthalmic) flurbiprofen sodium (ophthalmic) fluticasone propionate (nasal) FML FORTE hydrocortisone & acetic acid (otic) ketorolac tromethamine (ophthalmic) NASONEX neomycin, polymyxin, bacitracin & hydrocortisone (ophthalmic) neomycin, polymyxin & dexamethasone (ophthalmic) NEOMYCIN, POLYMYXIN & DEXAMETHASONE (ophthalmic) neomycin, polymyxin & hydrocortisone (otic) POLY-PRED (ophthalmic) PRED-G (ophthalmic) PRED-G S.O.P. (ophthalmic) prednisolone acetate (ophthalmic) prednisolone sodium phosphate (ophth) sulfacetamide sodium & prednisolone sodium phosphate (ophth) tobramycin sulfate & dexamethasone (ophth) EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS LOCAL ANESTHETICS antipyrine, benzocaine & polycosanol benzocaine & antipyrine (otic) lidocaine hcl (mouth-throat) EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS MYDRIATICS atropine sulfate (ophthalmic) dipivefrin (ophthalmic) tropicamide (ophthalmic) EYE, EAR, NOSE AND THROAT (EENT) PREPARATION ANTIGLAUCOMA AGENTS acetazolamide AZOPT (ophthalmic) betaxolol hcl (ophthalmic) BETIMOL brimonidine tartrate carteolol hcl (ophthalmic) dorzolamide hcl & timolol maleate (ophth) dorzolamide hcl (ophthalmic) latanoprost Brand Generic Generic Generic Brand Generic Generic/Brand † Brand Requirements/Limits Generic/Brand † Generic Brand Generic Brand Brand Brand Generic/Brand † Generic Generic Generic/Brand † Generic/Brand Generic Generic Generic Generic Generic Generic Brand Generic/Brand † Brand Generic/Brand † Generic Generic Generic Generic Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 17 - Drug Name Drug Tier levobunolol hcl (ophthalmic) methazolamide METIPRANOLOL (ophthalmic) PHOSPHOLINE IODIDE (ophthalmic) pilocarpine hcl (ophthalmic) timolol maleate (ophthalmic) EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS EENT DRUGS, MISCELLANEOUS acetic acid & aluminum acetate acetic acid (otic) GASTROINTESTINAL DRUGS ANTIDIARRHEA AGENTS diphenoxylate & atropine GASTROINTESTINAL DRUGS CATHARTICS AND LAXATIVES polyethylene glycol 3350, potassium chloride, sodium bicarbonate, sodium chloride & sodium sulfate polyethylene glycol 3350, potassium chloride, sodium bicarbonate & sodium chloride GASTROINTESTINAL DRUGS CHOLELITHOLYTIC AGENTS ursodiol GASTROINTESTINAL DRUGS DIGESTANTS amylase 12,000 units; lipase 4,000 units; protease 12,000 units amylase 16,600 units; lipase 5,000 units; protease 18,750 units amylase 20,000 units; lipase 4,500 units; protease 25,000 units amylase 27,000 units; lipase 5,000 units; protease 17,000 units amylase 30,000 units; lipase 10,000 units; protease 30,000 units amylase 30,000 units; lipase 8,000 units; protease 30,000 units amylase 33,200 units; lipase 10,000 units; protease 37,500 units amylase 48,000 units; lipase 16,000 units; protease 48,000 units amylase 55,000 units; lipase 10,000 units; protease 34,000 units amylase 56,000 units; lipase 20,000 units; protease 44,000 units amylase 60,000 units; lipase Generic Generic Brand Brand Generic Generic Requirements/Limits Generic Generic Generic Generic/Brand † Generic Generic Generic/Brand † Generic/Brand † Generic/Brand † Generic/Brand † Generic/Brand † Generic/Brand † Generic/Brand † Generic/Brand † Generic/Brand † Generic/Brand † Generic/Brand † Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 18 - Drug Name Drug Tier 16,000 units; protease 60,000 units amylase 66,400 units; lipase 20,000 units; protease 75,000 units amylase 82,000 units; lipase 15,000 units; protease 51,000 units amylase 109,000 units; lipase 20,000 units; protease 68,000 units GASTROINTESTINAL DRUGS ANTIEMETICS ANTIVERT EMEND ondansetron hcl GASTROINTESTINAL DRUGS ANTIULCER AGENTS AND ACID SUPPRESSANTS famotidine misoprostol omeprazole pantoprazole sodium PREVACID SOLUTAB ranitidine hcl sucralfate GASTROINTESTINAL DRUGS PROKINETIC AGENTS metoclopramide hcl GASTROINTESTINAL DRUGS GI ANTI-INFLAMMATORY AGENTS APRISO LIALDA sulfasalazine GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CUPRIMINE HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ASMANEX budesonide (oral) budesonide (nebulized) CELESTONE CORTISONE ACETATE DEXAMETHASONE FLOVENT DISKUS FLOVENT HFA Requirements/Limits Generic/Brand † Generic/Brand † Generic/Brand † Brand Brand Generic Generic Generic Generic Generic Brand Generic Generic/Brand † MD, QL QL ST Generic Brand Brand Generic Brand Brand Brand Generic Generic Brand Brand Brand Brand Brand MD, QL Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 19 - Drug Name Drug Tier fludrocortisone acetate hydrocortisone methylprednisolone prednisolone prednisolone sodium phosphate prednisone PULMICORT FLEXHALER QVAR HORMONES AND SYNTHETIC SUBSTITUTES ANDROGENS ANDRODERM ANDROXY AXIRON danazol METHITEST testosterone cypionate testosterone enanthate HORMONES AND SYNTHETIC SUBSTITUTES CONTRACEPTIVES Generic Generic Generic/Brand † Generic Generic Generic/Brand † Brand Brand Brand Brand Brand Generic Brand Generic/Brand *† Brand/Generic *† Requirements/Limits PA, QL QL PA, QL PA, QL PA, QL Possible Brands desogestrel & ethinyl estradiol (monophasic) Generic/Brand † desogestrel & ethinyl estradiol (triphasic) Generic drospirenone & ethinyl estradiol Brand ethynodiol diacetate & ethinyl estradiol Generic levonorgestrel & ethinyl estradiol (monophasic) Generic/Brand † levonorgestrel & ethinyl estradiol (91-day) Generic/Brand † levonorgestrel & ethinyl estradiol (triphasic) Generic levonorgestrel (emergency oral contraceptive) norethindrone & ethinyl estradiol (biphasic) Generic/Brand † Brand norethindrone & ethinyl estradiol (monophasic) Generic/Brand † norethindrone & ethinyl estradiol (triphasic) Generic/Brand † APRI, DESOGEN, KARIVA, MIRCETTE, ORTHO-CEPT CESIA, CYCLESSA, VELIVET YASMIN KELNOR, ZOVIA 1/35E, ZOVIA 1/50E LESSINA, NORDETTE, PORTIA JOLESSA, SEASONIQUE ENPRESSE, TRIVORA NECON 10/11 MODICON, NORTREL 0.5/35, NORTREL 1/35, ORTHO-NOVUM 1/35 NECON 7/7/7, NORTREL 7/7/7, ORTHO-NOVUM 7/7/7, TRI-NORINYL Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 20 - Drug Name Drug Tier Requirements/Limits norethindrone & mestranol Generic/Brand † norethindrone (contraceptive) Generic/Brand † norethindrone acetate & ethinyl estradiol Generic/Brand † norethindrone acetate, estradiol & iron Generic/Brand † norgestimate & ethinyl estradiol (monophasic) Generic/Brand † norgestimate & ethinyl estradiol (triphasic) Generic/Brand † norgestrel & ethinyl estradiol Generic/Brand † NECON 1/50, ORTHO-NOVUM 1/50 NOR-QD, NORA-BE, ORTHO-MICRONOR LOESTRIN 1/20, MICROGESTIN 1/20, LOESTRIN 1.5/30, MICROGESTIN 1.5/30 LOESTRIN FE 1/20, MICROGESTIN FE 1/20, LOESTRIN FE 1.5/30, MICROGESTIN FE 1.5/30 PREVIFEM, SPRINTEC, ORTHO-CYCLEN ORTHO TRI-CYCLEN, TRI-PREVIFEM, TRI-SPRINTEC CRYSELLE, LO/OVRAL, LOW-OGESTREL, OGESTREL PA, QL PA, QL NUVARING ORTHO EVRA PLAN B HORMONES AND SYNTHETIC SUBSTITUTES ANTIDIABETIC AGENTS acarbose glimepiride glipizide glipizide (extended release) glyburide glyburide & metformin hcl HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/50 HUMALOG MIX 50/50 PEN HUMALOG MIX 75/25 HUMALOG MIX 75/25 PEN HUMULIN R U-500 INSULIN ISOPHANE & REGULAR (HUMAN) PEN INSULIN ISOPHANE & REGULAR (HUMAN) INSULIN ISOPHANE (HUMAN) INSULIN ISOPHANE (HUMAN) PEN INSULIN REGULAR (HUMAN) Brand Brand Brand Generic Generic Generic Generic Generic Generic Brand Brand Brand Brand Brand Brand Brand Brand PA PA PA PA Brand Brand Brand Brand PA Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 21 - Drug Name Drug Tier LANTUS Brand LANTUS FOR OPTICLIK Brand LANTUS SOLOSTAR Brand LEVEMIR Brand LEVEMIR FLEXTOUCH Brand metformin hcl Generic metformin hcl (extended release) Generic NOVOLOG Brand NOVOLOG FLEXPEN Brand NOVOLOG MIX 70/30 FLEXPEN Brand NOVOLOG MIX 70/30 Brand pioglitazone hcl Generic tolazamide Generic TOLBUTAMIDE Brand HORMONES AND SYNTHETIC SUBSTITUTES ANTIHYPOGLYCEMIC AGENTS glucagon hcl Brand † HORMONES AND SYNTHETIC SUBSTITUTES ESTROGENS AND ESTROGEN AGONISTS-ANTAGONISTS COMBIPATCH Brand esterified estrogens & methyltestosterone Generic ESTRACE VAGINAL Brand estradiol (oral) Generic/Brand † estradiol (transdermal) Generic/Brand † estropipate Generic FEMHRT LOW DOSE Brand PREMARIN Brand PREMPHASE Brand PREMPRO Brand raloxifene Generic VAGIFEM Brand HORMONES AND SYNTHETIC SUBSTITUTES GONADOTROPINS BRAVELLE Brand * chorionic gonadotropin Generic * FOLLISTIM AQ Brand * GONAL-F Brand * MENOPUR Brand * OVIDREL Brand * HORMONES AND SYNTHETIC SUBSTITUTES PARATHYROID calcitonin (salmon) Generic FORTEO Brand * HORMONES AND SYNTHETIC SUBSTITUTES Requirements/Limits PA PA PA PA PA RB RB RB RB RB RB QL PA, QL Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 22 - Drug Name PITUITARY ACTHAR HP desmopressin acetate HORMONES AND SYNTHETIC SUBSTITUTES SOMATROPIN AGONISTS AND ANTAGONISTS OMNITROPE HORMONES AND SYNTHETIC SUBSTITUTES PROGESTINS medroxyprogesterone acetate norethindrone acetate progesterone, micronized HORMONES AND SYNTHETIC SUBSTITUTES THYROID AND ANTITHYROID AGENTS levothyroxine sodium liothyronine methimazole propylthiouracil SSKI thyroid THYROLAR OXYTOCICS OXYTOCICS ERGOTRATE MALEATE methylergonovine SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir AVC BACTROBAN NASAL benzoyl peroxide & erythromycin ciclopirox ciclopiroxolamine clindamycin phosphate (topical) clindamycin phosphate (vaginal) clotrimazole clotrimazole & betamethasone dipropionate clotrimazole (topical) erythromycin (topical) EURAX EXELDERM GENTAMICIN SULFATE (topical) ketoconazole (topical) lindane metronidazole (topical) Drug Tier Requirements/Limits Brand * Generic * PA, QL Brand * PA, QL Generic Generic Generic RB Generic/Brand † Generic Generic Generic Brand Generic/Brand † Brand Brand Generic Generic Brand Brand Generic Generic Generic Generic Generic Generic Generic Generic Generic Brand Brand Brand Generic Generic Generic/Brand † MD Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 23 - Drug Name Drug Tier Requirements/Limits metronidazole (vaginal) Generic MICONAZOLE 3 Brand mupirocin (topical) Generic NAFTIN Brand nystatin (topical) Generic permethrin Generic selenium sulfide Generic silver sulfadiazine Generic sulfacetamide sodium (topical) Generic SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) APEXICON E Brand augmented betamethasone dipropionate Generic betamethasone dipropionate (topical) Generic betamethasone valerate Generic clobetasol propionate Generic clobetasol propionate emollient base Generic CLODERM Brand CORDRAN Brand CORTIFOAM Brand CORTISPORIN Brand desonide Generic desoximetasone Generic diflorasone diacetate Generic EPIFOAM Brand fluocinolone acetonide Generic fluocinonide Generic fluocinonide emulsified base Generic fluticasone propionate Generic/Brand † halobetasol propionate Generic hydrocortisone (intrarectal) Generic hydrocortisone (rectal) Generic hydrocortisone (topical) Generic hydrocortisone acetate (rectal) Generic hydrocortisone valerate Generic KENALOG Brand mometasone furoate Generic nystatin & triamcinolone Generic triamcinolone acetonide (mouth) Generic triamcinolone acetonide (topical) Generic SKIN AND MUCOUS MEMBRANE AGENTS ANTIPRURITICS AND LOCAL ANESTHETICS hydrocortisone acetate & pramoxine Generic/Brand † lidocaine hcl Generic Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 24 - Drug Name Drug Tier phenazopyridine hcl Generic SKIN AND MUCOUS MEMBRANE AGENTS CELL STIMULANTS AND PROLIFERANTS tretinoin Generic SKIN AND MUCOUS MEMBRANE AGENTS PIGMENTING AND DEPIGMENTING AGENTS OXSORALEN Brand SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS adapalene Generic aluminum chloride Generic AMEVIVE Brand * calcipotriene Generic/Brand † DRITHO-CREME HP Brand DRITHO-SCALP Brand ELIDEL Brand FINACEA Brand fluorouracil (topical) Generic/Brand † imiquimod Generic isotretinoin Generic podofilox Generic/Brand † PROTOPIC Brand REGRANEX Brand TARGRETIN Brand TAZORAC Brand VECTICAL (topical) Brand SMOOTH MUSCLE RELAXANTS GENITOURINARY SMOOTH MUSCLE RELAXANTS flavoxate hcl Generic oxybutynin chloride Generic oxybutynin chloride (extended release) Generic tolterodine tartrate Generic tolterodine tartrate (extended release) Generic SMOOTH MUSCLE RELAXANTS RESPIRATORY SMOOTH MUSCLE RELAXANTS AMINOPHYLLINE Brand theophylline Generic/Brand † VITAMINS VITAMIN B COMPLEX folic acid Generic VITAMINS VITAMIN D calcitriol Generic ergocalciferol Generic Requirements/Limits PA, QL MD PA, QL MD, PA, QL MD MD PA, QL QL QL ST Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 25 - Drug Name Drug Tier VITAMINS VITAMIN K ACTIVITY MEPHYTON VITAMINS PRENATAL VITAMINS PRENATAL VITAMIN WITH DOCUSATE, FERROUS FUMARATE & FOLIC ACID PRENATAL VITAMIN WITH DOCUSATE, IRON CARBONYL & FOLIC ACID PRENATAL VITAMIN WITH FERROUS FUMARATE & FOLIC ACID PRENATAL VITAMIN WITH IRON CARBONYL & FOLIC ACID PRENATAL VITAMIN WITH MINERALS, IRON & FOLIC ACID PRENATAL VITAMIN WITH SELENIUM, FERROUS FUMARATE & FOLIC ACID PRENATAL VITAMIN WITHOUT VITAMIN A, WITH IRON CARBONYL, DOCUSATE & FOLIC ACID VITAMINS PEDIATRIC MULTIVITAMINS pediatric multivitamins with fluoride pediatric vitamins A, C, D, with fluoride MISCELLANEOUS THERAPEUTIC AGENTS ALCOHOL DETERRENTS disulfiram MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA-REDUCTASE INHIBITORS finasteride MISCELLANEOUS THERAPEUTIC AGENTS ANTIDOTES acetylcysteine leucovorin calcium MISCELLANEOUS THERAPEUTIC AGENTS ANTIGOUT AGENTS allopurinol COLCRYS MISCELLANEOUS THERAPEUTIC AGENTS BIOLOGIC RESPONSE MODIFIERS COPAXONE REBIF REVLIMID THALOMID MISCELLANEOUS THERAPEUTIC AGENTS BONE RESORPTION INHIBITORS Requirements/Limits Brand Brand Brand Brand Brand Brand Brand Brand Generic/Brand † Generic/Brand † Generic Generic MD Generic Generic/Brand *† Generic Brand Brand * Brand * Brand Brand MD, QL MD, QL QL QL Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 26 - Drug Name Drug Tier alendronate sodium ETIDRONATE DISODIUM FOSAMAX PLUS D MISCELLANEOUS THERAPEUTIC AGENTS CARIOSTATIC AGENTS sodium fluoride MISCELLANEOUS THERAPEUTIC AGENTS DISEASE-MODIFYING ANTIRHEUMATIC DRUGS ENBREL HUMIRA leflunomide MISCELLANEOUS THERAPEUTIC AGENTS IMMUNOSUPPRESSIVE AGENTS azathioprine cyclosporine cyclosporine modified (for microemulsion) mycophenolate mofetil mycophenolate sodium RAPAMUNE tacrolimus MISCELLANEOUS THERAPEUTIC AGENTS PROTECTIVE AGENTS ELMIRON MISCELLANEOUS THERAPEUTIC AGENTS OTHER MISCELLANEOUS THERAPEUTIC AGENTS CYSTAGON FIRAZYR levocarnitine yohimbine hcl Generic Brand Brand Requirements/Limits Generic Brand * Brand * Generic MD, QL MD, QL MD Generic Generic/Brand † Generic/Brand † Generic Generic Brand Generic Brand Brand Brand * Generic/Brand † Generic PA QL RB Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 27 - INDEX OF DRUGS Kaiser Permanente Southern Colorado Commercial HMO Comprehensive Formulary Index 5 5-ALPHA-REDUCTASE INHIBITORS 26 A abacavir sulfate ABILIFY ABILIFY DISCMELT acarbose acebutolol hcl acetaminophen with codeine acetazolamide acetic acid & aluminum acetate acetic acid (otic) acetylcysteine ACTHAR HP acyclovir adapalene ADCIRCA adenovir dipivoxil ADRENALS ADVAIR DISKUS ADVAIR HFA AFINITOR ALAMAST ALBENZA albuterol sulfate ALCOHOL DETERRENTS alendronate sodium ALKALINIZING AGENTS ALKERAN allopurinol ALOCRIL (ophthalmic) ALOMIDE (ophthalmic) ALPHA-ADRENERGIC BLOCKING AGENTS alprazolam alprostadil aluminum chloride amantadine hcl AMEVIVE aminocaproic acid AMINOPHYLLINE amiodarone hcl amitriptyline hcl amlodipine besylate amlodipine besylate & benazepril hcl AMMONIA DETOXICANTS AMOXAPINE amoxicillin amoxicillin & potassium 4 12 12 21 10 11 17 18 18 26 23 4, 23 25 9 4 19 7 7 6 16 3 7 26 27 15 6 26 16 16 9 14 9 25 14 25 8 25 8 12 10 10 15 12 3 3 amphetamine & dextroamphetamine 13 ampicillin 3 amylase 109,000 units; lipase 20,000 units; protease 68,000 units 19 amylase 12,000 units; lipase 4,000 units; protease 12,000 units 18 amylase 16,600 units; lipase 5,000 units; protease 18,750 units 18, 19 amylase 20,000 units; lipase 4,500 units; protease 25,000 units 18 amylase 27,000 units; lipase 5,000 units; protease 17,000 units 18 amylase 30,000 units; lipase 10,000 units; protease 30,000 units 18 amylase 30,000 units; lipase 8,000 units; protease 30,000 units 18 amylase 33,200 units; lipase 10,000 units; protease 37,500 units 18 amylase 48,000 units; lipase 16,000 units; protease 48,000 units 18 amylase 55,000 units; lipase 10,000 units; protease 34,000 units 18 amylase 56,000 units; lipase 20,000 units; protease 44,000 units 18 amylase 60,000 units; lipase 16,000 units; protease 60,000 units 18 amylase 82,000 units; lipase 15,000 units; protease 51,000 units 19 anagrelide hcl 8 ANALGESICS AND ANTIPYRETICS 11 anastrozole 6 ANDRODERM 20 ANDROGENS 20 ANDROXY 20 ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL 13 ANTHELMINTICS 3 ANTIALLERGIC AGENTS 16 ANTIBACTERIALS 3 ANTICHOLINERGIC AGENTS 7 ANTICONVULSANTS 12 ANTIDIARRHEA AGENTS 18 ANTIDOTES 26 ANTIEMETICS 19 ANTIFUNGALS 4 ANTIGLAUCOMA AGENTS 17 ANTIGOUT AGENTS 26 ANTIHEMORRHAGIC AGENTS 8 ANTIHISTAMINE DRUGS 3 ANTIHYPOGLYCEMIC AGENTS 22 ANTI-INFECTIVE AGENTS 3, 4, 5 Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 28 - ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) 23 ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 24 ANTILIPEMIC AGENTS 9 ANTIMANIC AGENTS 14 ANTIMIGRAINE AGENTS 14 ANTIMYCOBACTERIALS 4 ANTINEOPLASTIC AGENTS 6 ANTIPARKINSONIAN AGENTS 14 ANTIPROTOZOALS 5 ANTIPRURITICS AND LOCAL ANESTHETICS 24 antipyrine, benzocaine & polycosanol 17 ANTITHROMBOTIC AGENTS 8 ANTITUSSIVES 15 ANTIULCER AGENTS AND ACID SUPPRESSANTS 19 ANTIVERT 19 ANTIVIRALS 4 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS 13 APEXICON E 24 APOKYN 14 APRI 20 APRISO 19 APTIVUS 4 ASMANEX 19 atenolol 10 atenolol & chlorthalidone 10 atovaquone/proguanil 5 ATRIPLA 4 atropine sulfate (ophthalmic) 17 augmented betamethasone dipropionate 24 AUTONOMIC DRUGS 7, 8 AVC 23 AXIRON 20 azathioprine 27 azelastine hcl (ophthalmic) 16 azelastine hcl spray 16 azithromycin 3 AZOPT (ophthalmic) 17 B bacitracin & polymyxin B (ophthalmic) bacitracin (ophthalmic) baclofen BACTROBAN NASAL BARACLUDE belladonna alkaloids & phenobarbital belladonna alkaloids, benazepril & hydrochlorothiazide benazepril hcl benzocaine & antipyrine (otic) benzonatate benzoyl peroxide & erythromycin benztropine mesylate BETA-ADRENERGIC BLOCKING AGENTS betamethasone dipropionate (topical) betamethasone valerate 16 16 8 23 4 7 5 10 10 17 15 23 14 10 24 24 betaxolol hcl (ophthalmic) bethanechol chloride BETIMOL bicalutamide BILTRICIDE BIOLOGIC RESPONSE MODIFIERS bisoprolol fumarate bisoprolol fumarate & hydrochlorothiazide BLEPHAMIDE (ophthalmic) BLEPHAMIDE S.O.P. BLOOD FORMATION, COAGULATION AND THROMBOSIS BLOOD FORMATION, COAGULATION, AND THROMBOSIS BONE RESORPTION INHIBITORS BRAVELLE BRILINTA brimonidine tartrate bromocriptine mesylate budesonide (nebulized) budesonide (oral) bumetanide buprenorphine HCl & naloxone HCL bupropion hcl bupropion hcl (smoking deterrent) buspirone hcl butalbital, acetaminophen & caffeine butalbital, acetaminophen, caffeine & codeine butalbital, aspirin & caffeine butalbital, aspirin, caffeine & codeine BYSTOLIC 17 7 17 6 3 26 10 10 16 16 8 8 26 22 8 17 14 19 19 15 11 12 12 14 11 11 11 11 10 C cabergoline 14 CAFERGOT 14 calcipotriene 25 calcitonin (salmon) 22 calcitriol 25 calcium acetate (phosphate binde)r 15 CALCIUM-CHANNEL BLOCKING AGENTS 10 captopril 10 CAPTOPRIL & HYDROCHLOROTHIAZIE 10 carbamazepine 12 carbamazepine (extended release) 12 carbidopa & levodopa 14 carbidopa & levodopa (extended release) 14 CARDENE SR 10 CARDIAC DRUGS 8 CARDIOVASCULAR DRUGS 8, 9, 10 CARIOSTATIC AGENTS 27 carisoprodol 8 carisoprodol & aspirin 8 carteolol hcl (ophthalmic) 17 carvedilol 10 CATHARTICS AND LAXATIVES 18 CAVERJECT 9 CAYSTON 3 CEENU 6 Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 29 - cefaclor 3 cefadroxil 3 cefdinir 3 cefprozil 3 cefuroxime axetil 3 CELEBREX 11 CELESTONE 19 CELL STIMULANTS AND PROLIFERANTS 25 CELONTIN 12 CENTRAL NERVOUS SYSTEM AGENTS 11, 12, 13, 14 CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS 14 cephalexin 3 CESIA 20 cevimeline hcl 7 chlordiazepoxide & amitriptyline 12 chlordiazepoxide & clidinium 7 chlordiazepoxide hcl 14 chlorhexidine gluconate (dental) 16 chloroquine phosphate 5 chlorpromazine hcl 12 chlorthalidone 15 CHOLELITHOLYTIC AGENTS 18 cholestyramine 9 cholestyramine light 9 choline magnesium trisalicylate 11 chorionic gonadotropin 22 CIALIS 9 ciclopiroxolamine 23 cilostazol 8 CIPRO HC (otic) 16 CIPRODEX 16 ciprofloxacin hcl 3 ciprofloxacin hcl (ophthalmic) 16 ciprofloxacin-ciprofloxacin hcl 3 citalopram hydrobromide 12 clarithromycin 3 clindamycin hcl 3 clindamycin phosphate (topical) 23 clindamycin phosphate (vaginal) 23 clobetasol propionate 24 clobetasol propionate emollient base 24 CLODERM 24 clomipramine hcl 12 clonazepam 12 clonidine hcl 9 clopidogrel 8 clorazepate dipotassium 14 clotrimazole 23 clotrimazole & betamethasone dipropionate 23 clotrimazole (topical) 23 COLCRYS 15, 26 COLY-MYCIN-S (otic) 16 COMBIPATCH 22 COMBIVENT RESPIMAT 7 CONTRACEPTIVES 20 COPAXONE 26 CORDRAN 24 COREG CR CORTIFOAM CORTISONE ACETATE CORTISPORIN CRESTOR CRIXIVAN cromolyn sodium cromolyn sodium (ophthalmic) CRYSELLE CUPRIMINE CYCLESSA cyclobenzaprine hcl cyclophosphamide cyclosporine modified (for microemulsion) cyproheptadine hcl CYSTAGON 10 24 19 24 9 4 16 16 21 19 20 8 6 27 3 27 D danazol 20 dantrolene sodium 8 dapsone 4 DARAPRIM 5 desipramine hcl 12 desmopressin acetate 23 DESOGEN 20 desogestrel & ethinyl estradiol (monophasic) 20 desogestrel & ethinyl estradiol (triphasic) 20 desonide 24 desoximetasone 24 dexamethasone 19 dexmethylphenidate hcl 13 dextroamphetamine sulfate 13 diazepam 14 DIBENZYLINE 8 diclofenac sodium 11 diclofenac sodium (ophthalmic) 16 dicloxacillin 3 dicyclomine hcl 7 didanosine 4 diflorasone diacetate 24 DIGESTANTS 18 digoxin 8 dihydroergotamine mesylate 8 diltiazem hcl 10 diltiazem hcl coated beads 10 diltiazem hcl extended release beads 10 diphenoxylate & atropine 18 dipivefrin (ophthalmic) 17 dipyridamole 9 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS 27 disopyramide phosphate 8 disulfiram 26 DIURETICS 15 divalproex sodium 12 divalproex sodium (extended release) 12 donepezil 7 DONNATAL EXTENTABS 7 Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 30 - dorzolamide hcl & timolol maleate (ophthalmic) dorzolamide hcl (ophthalmic) doxazosin mesylate doxepin hcl doxycycline DRITHO-CREME HP DRITHO-SCALP drospirenone & ethinyl estradiol DULERA 17 17 9 12 3 25 25 20 7 E EDEX EENT ANTI-INFECTIVES EENT ANTI-INFLAMMATORY AGENTS EENT DRUGS, MISCELLANEOUS EFFIENT ELECTROLYTIC, CALORIC AND WATER BALANCE ELIDEL ELIGARD ELIXOPHYLLIN ELMIRON EMCYT EMEND EMTRIVA enalapril maleate ENBREL ENPRESSE entacapone ENZYMES epinephrine hcl EPIVIR HBV EPOGEN EPZICOM ergocalciferol ERGOMAR ERGOTRATE MALEATE erythromycin (ophthalmic) erythromycin (topical) erythromycin base erythromycin ethylsuccinate erythromycin stearate erythromycin sulfisoxazole escitalopram oxalate estazolam esterified estrogens & methyltestosterone ESTRACE VAGINAL estradiol (oral) estradiol (transdermal) ESTROGENS AND ESTROGEN AGONISTSANTAGONISTS estropipate ethambutol ethosuximide ethynodiol diacetate & ethinyl estradiol etidronate disodium etodolac etoposide EURAX EXELDERM exemestane EXFORGE EXFORGE HCT EYE, EAR, NOSE AND THROAT (EENT) PREPARATION EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS 23 23 6 10 10 17 16, 17, 18 F 9 16 16 18 8 15 25 6 7 27 6 19 4 10 27 20 14 15 7 4 8 4 25 8 23 16 23 3 3 3 3 12 14 22 22 22 22 22 22 4 12 20 27 11 6 famciclovir famotidine felbamate felodipine FEMHRT FEMHRT LOW DOSE fenofibrate fenofibrate (micronized) fenoprofen calcium fentanyl fentanyl citrate FINACEA finasteride FIRAZYR FIRST GENERATION ANTIHISTAMINES FLAREX flavoxate hcl flecainide acetate FLOVENT DISKUS FLOVENT HFA fluconazole fludrocortisone acetate flunisolide (nasal) fluocinolone acetonide fluocinonide fluocinonide emulsified base fluorometholone (ophthalmic) fluorouracil (topical) fluoxetine hcl fluphenazine hcl flurazepam hcl flurbiprofen sodium (ophthalmic) flutamide fluticasone propionate fluticasone propionate (nasal) fluvoxamine maleate FML FORTE FOCALIN XR folic acid FOLLISTIM AQ fondaparinux FORTEO FOSAMAX PLUS D fosinopril sodium fosinopril sodium & hydrochlorothiazide FRAGMIN furosemide Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 31 - 4 19 12 10 22 22 9 9 11 11 11 25 26 27 3 16 25 8 19 19 4 20 17 24 24 24 17 25 12 13 14 17 6 24 17 13 17 13 25 22 8 22 27 10 10 8 15 FUROXONE 5 G gabapentin galantamine hbr galantamine hbr (extended release) GANCYCLOVIR GASTROINTESTINAL DRUGS gatifloxacin (ophthalmic) gemfibrozil GENITOURINARY SMOOTH MUSCLE RELAXANTS GENTAMICIN SULFATE gentamicin sulfate (ophthalmic) GENTAMICIN SULFATE (topical) GI ANTI-INFLAMMATORY AGENTS GLEEVEC glimepiride glipizide glipizide (extended release) glucagon hcl glyburide glyburide & metformin hcl glycopyrrolate GOLD COMPOUNDS GONADOTROPINS GONAL-F griseofulvin ultramicrosize guaifenesin & codeine guanfacine hcl 12 7 7 4 18, 19 16 9 25 23 16 23 19 6 21 21 21 22 21 21 7 19 22 22 4 15 9 H halobetasol propionate 24 haloperidol 13 haloperidol lactate 13 HEAVY METAL ANTAGONISTS 19 HEMATOPOIETIC AGENTS 8 HEMORRHEOLOGIC AGENTS 8 heparin sodium 8 HEXALEN 6 HORMONES AND SYNTHETIC SUBSTITUTES 19, 20, 21, 22, 23 HUMALOG 21 HUMALOG KWIKPEN 21 HUMALOG MIX 50/50 21 HUMALOG MIX 50/50 PEN 21 HUMALOG MIX 75/25 21 HUMALOG MIX 75/25 PEN 21 HUMIRA 27 HUMULIN R U-500 21 hydralazine hcl 9 hydrochlorothiazide 15 hydrocodone & acetaminophen 11 hydrocodone & homatropine 15 hydrocodone polistirex & chlorpheniramine polistirex 16 hydrocortisone 20 hydrocortisone & acetic acid (otic) 17 hydrocortisone (intrarectal) hydrocortisone (rectal) hydrocortisone (topical) hydrocortisone acetate & pramoxine hydrocortisone acetate (rectal) hydrocortisone valerate hydromorphone hcl hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl hydroxyzine pamoate hyoscyamine sulfate HYPOTENSIVE AGENTS 24 24 24 24 24 24 11 5 6 14 14 7 9 I ibuprofen imipramine hcl imipramine pamoate imiquomod IMMUNOSUPPRESSIVE AGENTS indapamide indomethacin INFERGEN INNOHEP INSULIN ISOPHANE & INSULIN ISOPHANE (HUMAN) INSULIN REGULAR (HUMAN) INTELENCE INTRON-A INVIRASE ION-REMOVING AGENTS ipratropium bromide (inhaled ipratropium bromide (nasal) IRESSA ISENTRESS isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine itraconazole 11 13 13 25 27 15 11 4 8 21 21 21 4 6 4 15 7 7 6 4 4 9 9 25 10 4 J JOLESSA 20 K KALETRA KARIVA KELNOR KENALOG ketoconazole ketoprofen ketoprofen (extended release) ketorolac tromethamine ketorolac tromethamine (ophthalmic)) Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 32 - 4 20 20 24 4, 23 11 11 11 17 L labetalol hcl lactulose lamivudine lamivudine-zidovudine lamotrigine LANTUS LANTUS FOR OPTICLIK LANTUS SOLOSTAR latanoprost leflunomide LESSINA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate levalbuterol hcl solution LEVEMIR LEVEMIR FLEXTOUCH levetiracetam LEVITRA levobunolol hcl (ophthalmic) levocarnitine levofloxacin levonorgestrel & ethinyl estradiol (91-day) levonorgestrel & ethinyl estradiol (monophasic) levonorgestrel & ethinyl estradiol (triphasic) levonorgestrel (emergency oral contraceptive levothyroxine sodium LEXIVA LIALDA lidocaine hcl lidocaine hcl (mouth-throat) lindane liothyronine lisinopril lisinopril & hydrochlorothiazide lithium carbonate lithium carbonate (extended release) LO/OVRAL LOCAL ANESTHETICS LOESTRIN 1.5/30 LOESTRIN 1/20 LOESTRIN FE 1.5/30 LOESTRIN FE 1/20 lorazepam losartan potassium losartan potassium & hydrochlorothiazide lovastatin LOVENOX LOW-OGESTREL loxapine succinate LUPRON DEPOT LUPRON DEPOT-PED LYSODREN M 10 15 5 5 12 22 22 22 17 27 20 9 6 26 6 8 6 7 22 22 12 9 18 27 3 20 20 20 20 23 5 19 24 17 23 23 10 11 14 14 21 17 21 21 21 21 14 11 11 9 8 21 13 6 6 6 maprotiline hcl 13 MATULANE 6 MAXAIR AUTOHALER 7 meclofenamate sodium 11 medroxyprogesterone acetate 23 mefloquine hcl 5 megestrol acetate 6 MENOPUR 22 MEPHYTON 26 mercaptopurine 6 metaproterenol sulfate 7 metformin hcl 22 metformin hcl (extended release) 22 methadone hcl 11 methazolamide 18 methimazole 23 METHITEST 20 methocarbamol 8 methotrexate 6 methyldopa 9 methylergonovine 23 methylphenidate hcl 13 methylphenidate hcl (extended release) 13 methylprednisolone 20 metipranolol (ophthalmic) 18 metoclopramide hcl 19 metolazone 15 metoprolol succinate 10 metoprolol tartrate 10 metronidazole 5 metronidazole (topical) 23 metronidazole (vaginal) 24 mexiletine hcl 9 MICONAZOLE 3 24 miconazole nitrate 24 MICROGESTIN 1.5/30 21 MICROGESTIN 1/20 21 MICROGESTIN FE 1.5/30 21 MICROGESTIN FE 1/20 21 midodrine hcl 7 minocycline 3 MIRCETTE 20 mirtazapine 13 MISCELLANEOUS THERAPEUTIC AGENTS 26, 27 misoprostol 19 MOBAN 13 modafinil 13 MODICON 20 moexipril & hydrochlorothiazide 11 moexipril hcl 11 mometasone furoate 24 montelukast sodium 16 montelukast sodium(packets) 16 morphine sulfate 11 morphine sulfate (extended release) 11 moxifloxacin 3 mupirocin (topical) 24 Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 33 - MUSE mycophenolate mofetil MYDRIATICS MYLERAN 9 27 17 6 N nabumetone nadolol NAFTIN naltrexone hcl naproxen naproxen sodium naratriptan NASONEX NEBUPENT NECON 1/50 NECON 10/11 NECON 7/7/7 NEFAZODONE HCL neomycin sulfate neomycin, bacitracin & polymyxin B (ophthalmic) NEOMYCIN, POLYMYXIN & neomycin, polymyxin & dexamethasone (ophthalmic) neomycin, polymyxin & hydrocortisone (otic) neomycin, polymyxin, bacitracin & hydrocortisone (ophthalmic) NEULASTA nevirapine NEXAVAR NIASPAN nifedipine NILANDRON nitrofurantoin macrocrystals nitrofurantoin monohydrate macrocystals nitrofurantoin suspension nitroglycerin NORA-BE NORDETTE norethindrone & ethinyl estradiol (biphasic) norethindrone & ethinyl estradiol (monophasic) norethindrone & ethinyl estradiol (triphasic) norethindrone & mestranol norethindrone (contraceptive) norethindrone acetate norethindrone acetate & ethinyl estradiol norethindrone acetate, estradiol, & iron norgestimate & ethinyl estradiol (monophasic) norgestimate & ethinyl estradiol (triphasic) norgestrel & ethinyl estradiol NOROXIN NOR-QD NORTREL 0.5/35 NORTREL 1/35, NORTREL 7/7/7 nortriptyline hcl NORVIR NOVOLOG NOVOLOG FLEXPEN 11 10 24 12 11 11 14 17 5 21 20 20 13 3 16 17 17 17 17 8 5 6 9 10 6 6 6 6 9 21 20 20 20 20 21 21 23 21 21 21 21 21 3 21 20 20 20 13 5 22 22 NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 FLEXPEN NUVARING nystatin nystatin & triamcinolone nystatin (topical) 22 22 21 4 24 24 O ofloxacin (ophthalmic) ofloxacin (otic) OGESTREL olanzapin olanzapine ODT omeprazole OMNITROPE ondansetron hcl OPIATE ANTAGONISTS ORTHO EVRA ORTHO TRI-CYCLEN ORTHO-CEPT ORTHO-CYCLEN ORTHO-MICRONOR ORTHO-NOVUM 1/35 ORTHO-NOVUM 1/50 ORTHO-NOVUM 7/7/7 OTHER MISCELLANEOUS THERAPEUTIC AGENTS OVIDREL oxaprozin oxazepam oxcarbazepine OXSORALEN oxybutynin chloride oxybutynin chloride (extended release) oxycodone & acetaminophen oxycodone & aspirin oxycodone hcl OXYTOCICS 16 16 21 13 13 19 23 19 12 21 21 20 21 21 20 21 20 27 22 11 14 12 25 25 25 11 11 11 23 P pantoprazole sodium PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS PARATHYROID paromomycin sulfate paroxetine hcl paroxetine hcl (extended release) PATANOL PEDIATRIC MULTIVITAMINS pediatric multivitamins with fluoride pediatric vitamins A, C, D, with fluoride PEGASYS PEG-INTRON penicillin V potassium pentoxifylline permethrin perphenazine Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 34 - 19 7 22 5 13 13 16 26 26 26 5 5 3 8 24 13 phenazopyridine hcl 25 phenelzine 13 phenobarbital 14 phenytoin 12 phenytoin sodium (extended release) 12 PHOSPHOLINE IODIDE (ophthalmic) 18 PIGMENTING AND DEPIGMENTING AGENTS 25 pilocarpine hcl (ophthalmic) 18 pindolol 10 pioglitazone hcl 22 PITUITARY 23 PLAN B 21 podofilox 25 polyethylene glycol 3350, 18 polyethylene glycol 3350, potassium chloride, sodium bicarbonate & sodium chloride 18 polymyxin B & trimethoprim 16 POLY-PRED (ophthalmic) 17 PORTIA 20 potassium and sodium citrates with citric acid 15 potassium bicarbonate & potassium chloride 15 potassium chloride 15 potassium citrate 15 pramipexole dihydrochloride 14 PRAMOXINE-HC 24 pravastatin 9 prazosin hcl 10 PRED-G (ophthalmic) 17 PRED-G S.O.P. (ophthalmic) 17 prednisolone 20 prednisolone acetate (ophthalmic) 17 prednisolone sodium phosphate 20 prednisolone sodium phosphate (ophthalmic) 17 prednisone 20 PREMARIN 22 PREMPHASE 22 PREMPRO 22 prenatal vitamin with docusate, ferrous fumarate, & folic acid 26 PRENATAL VITAMIN WITH DOCUSATE, IRON CARBONYL & FOLIC ACID 26 PRENATAL VITAMIN WITH FERROUS FUMARATE & FOLIC ACID 26 PRENATAL VITAMIN WITH IRON CARBONYL & FOLIC ACID 26 PRENATAL VITAMIN WITH MINERALS, IRON & FOLIC ACID 26 PRENATAL VITAMIN WITH SELENIUM, FERROUS FUMARATE & FOLIC ACID 26 PRENATAL VITAMIN WITHOUT VITAMIN A, WITH IRON CARBONYL, DOCUSATE & FOLIC ACID 26 PRENATAL VITAMINS 26 PREVACID SOLUTAB 19 PREVIFEM 21 PREZISTA 5 PRIMAQUINE PHOSPHATE 5 primidone 12 probenecid 15 probenecid & colchicine 15 prochlorperazine maleate PROCRIT progesterone, micronized PROGESTINS PROKINETIC AGENTS promethazine hcl propafenone hcl propranolol hcl propylthiouracil PROSTIGMIN PROTECTIVE AGENTS PROTOPIC protriptyline hcl PSYCHOTHERAPEUTIC AGENTS PULMICORT FLEXHALER PULMOZYME pyrazinamide pyridostigmine bromide 13 8 23 23 19 3 9 10 23 7 27 25 13 12 20 15 4 7 Q quetiapine fumarate quinapril & hydrochlorothiazide quinapril hcl quinidine gluconate quinidine sulfate QVAR 13 11 11 9 9 20 R raloxifene 22 ramipril 11 ranitidine hcl 19 RAPAMUNE 27 REBIF 26 REGRANEX 25 RELENZA 5 RENAGEL 15 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS 10 RENVELA 15 RENVELA PAK 15 REPLACEMENT PREPARATIONS 15 RESCRIPTOR 5 reserpine 9 RESPIRATORY SMOOTH MUSCLE RELAXANTS25 RESPIRATORY TRACT AGENTS 15, 16 RESPIRATORY TRACT AGENTS, MISCELLANEOUS 16 RESPIRATORY TRACT ANTI-INFLAMMATORY AGENTS 16 REVLIMID 26 REYATAZ 5 ribavirin 5 RIDAURA 19 rifabutin 4 rifampin 4 riluzole 15 rimantadine 5 Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 35 - risperidone rizatriptan ropinirole hcl 13 14 14 S salsalate 12 SAVELLA 15 SEASONIQUE 20 SECOND GENERATION ANTIHISTAMINES 3 selegiline hcl 14 selenium sulfide 24 SELZENTRY 5 SEREVENT DISKUS 7 sertraline hcl 13 sildenafil citrate (REVATIO) 9 silver sulfadiazine 24 simvastatin 9 SKELETAL MUSCLE RELAXANTS 8 SKIN AND MUCOUS MEMBRANE AGENTS 23, 24, 25 SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS 25 SMOOTH MUSCLE RELAXANTS 25 sodium chloride for nebulization 16 sodium citrate & citric acid 15 sodium fluoride 27 sodium polystyrene sulfonate 15 SOMATROPIN AGONISTS AND ANTAGONISTS 23 sotalol hcl 10 SOVALDI 5 SPECTRACEF 3 SPIRIVA 7 spironolactone 11 spironolactone & hydrochlorothiazide 11 SPRINTEC 21 SPRYCEL 6 SSKI 23 stavudine 5 STROMECTOL 3 sucralfate 19 sulfacetamide sodium & prednisolone sodium phosphate (ophthalmic) 17 sulfacetamide sodium (ophthalmic) 16 sulfacetamide sodium (topical) 24 sulfadiazine 3 sulfamethoxazole & trimethoprim 3 sulfasalazine 4, 19 sulindac 12 sumatriptan succinate 14 SUPRAX 4 SUSTIVA 5 SUTENT 6 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS 7 SYMPATHOMIMETIC (ADRENERGIC) AGENTS 7 T TABLOID tacrolimus TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN TARKA TAZORAC temazepam temozolomide terazosin hcl terbinafine terbutaline sulfate testosterone testosterone cypionate testosterone enanthate tetracycline THALOMID theophylline thioridazine hcl thiothixene thyroid THYROID AND ANTITHYROID AGENTS THYROLAR tiagabine TIKOSYN timolol maleate (ophthalmic) tizanidine hcl TOBI Podhaler tobramycin neb tobramycin sulfate & dexamethasone (ophth) tobramycin sulfate (ophthalmic) tolazamide TOLBUTAMIDE tolterodine tartrate tolterodine tartrate (extended release) topiramate torsemide TRACLEER tramadol hcl tranylcypromine sulfate trazodone hcl tretinoin tretinoin (chemo) triamcinolone acetonide (mouth) triamcinolone acetonide (topical) triamterene & hydrochlorothiazide triazolam trifluoperazine hcl trifluridine (ophth) trihexyphenidyl hcl trimethoprim TRI-NORINYL TRI-PREVIFEM TRI-SPRINTEC TRIVORA Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 36 - 6 27 5 6 8 6 6, 25 10 25 14 6 10 4 7 20 20 20 4 26 25 13 13 23 23 23 12 9 18 8 4 4 17 16 22 22 25 25 12 15 9 12 13 13 25 6 24 24 15 14 13 16 14 6 20 21 21 20 TRIZIVIR tropicamide (ophthalmic) TRUVADA TYKERB TYZEKA 5 17 5 7 5 voriconazole VOTRIENT 4 7 W warfarin sodium 8 U URICOSURIC AGENTS URINARY ANTI-INFECTIVES ursodiol 15 5 18 X XOPENEX HFA XTANDI V VAGIFEM valacyclovir VALCYTE valproic acid valsartan valsartan & hydrochlorothiazide vancomycin VASODILATING AGENTS VECTICAL VELIVET venlafaxine hcl venlafaxine hcl (extended release) verapamil hcl VIAGRA VIRACEPT VIREAD VITAMIN B COMPLEX VITAMIN D VITAMIN K ACTIVITY VITAMINS 7 7 Y 22 5 5 12 11 11 4 9 25 20 13 13 10 9 5 5 25 25 26 25, 26 YASMIN YODOXIN yohimbine hcl 20 5 27 Z zafirlukast zaleplon ZELBORAF zidovudine ziprasidone hcl ZOLINZA zolmitriptan zolmitriptan ODT zolpidem tartrate zonisamide ZOVIA 1/35E ZOVIA 1/50E ZYTIGA ZYVOX Kaiser Permanente Southern Colorado Commercial HMO Formulary (December 16, 2014) - 37 - 16 14 7 5 13 7 14 14 14 12 20 20 7 4
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