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