HMO Formulary
(List of Covered Drugs)
Last Update: 4/07/2015
Please Note: This formulary drug list is applicable to the following product types: Signature HMO, Select HMO, Kaiser
Permanente for Individuals and Families, Out-of-Area PPO, Deductible HMO, HSA-Qualified Deductible HMO, Added
Choice, Added Choice with Deductible HMO, and Added Choice with Deductible HMO (HSA).
HMO Formulary Drug List
The following list contains the formulary, also known as the preferred drug list, approved by the Kaiser
Permanente Pharmacy and Therapeutics Committee.
This formulary applies only to outpatient drugs and self-administered drugs. It does not apply to
medications used in inpatient settings or administered in one of the Kaiser Permanente medical
centers.
You may have specific exclusions, copays, or coinsurance amounts that are not reflected in the
formulary drug list. Please consult your Evidence of Coverage, Membership Agreement, or federal
brochure (RI 73-047) for additional information regarding your pharmacy benefits, including any
specific limitations or exclusions.
Generic and Brand Name Medications
Kaiser Permanente covers generic and brand name drugs. A generic drug is approved by the Food
and Drug Administration (FDA) as having the same active ingredient as the brand name drug.
Brand name drugs are manufactured and sold by the pharmaceutical company that originally
researched and developed the drug. When the patent on a brand name drug expires, other
pharmaceutical companies may then manufacture and sell the FDA- approved generic version of the
drug at lower prices.
In most cases, your doctor will prescribe a generic drug if one is available. Generic drugs generally
cost less than brand name drugs.
Non-Formulary Medications
The listing only includes drugs on the formulary. Any drug not found on this list is considered nonformulary. A non-formulary medication is generally available at a higher cost. Please consult your
Evidence of Coverage, Membership Agreement, or federal brochure (RI 73-047) for additional
information regarding coverage of non-formulary medications specific to your plan.
1
Using the Kaiser Permanente Formulary List
When you look through the formulary drug listing, you will see that products available in a generic
form are listed by their generic names. Medications that are only available as a brand name product
are listed in BOLD AND ALL CAPITAL letters, except where multiple branded products exist.
You can search the formulary drug list by using the “FIND” function in Adobe Reader, or by
referencing the therapeutic drug category.
In some cases, a particular drug may be listed on the formulary drug list, but only for certain strengths
or in certain dosage forms. For example, some drugs are available in different milligram (mg)
strengths (e.g., 5mg, 10mg), but only one strength may be on the formulary drug list. For drugs that
are available in more than one dosage form (e.g., tablet, injectable), only one may be on the formulary
drug list.
Please remember that this list is subject to change and will be updated from time to time during the
year. Any product not found on this list will be considered a non-formulary.
Restrictions on medication coverage
Some covered drugs may have additional requirements or limits on coverage. Please consult
your Evidence of Coverage, Membership Agreement, or federal brochure (RI 73-047) for additional
information regarding your pharmacy benefits, including any specific limitations or exclusions.
•
Higher copay: Some drugs may have a higher cost share. These drugs include, but are not limited to,
infertility, growth hormone, and weight management medications.
•
Limited distribution: Some drugs may be subject to limited distribution or restricted access. A drug that
is a limited distribution drug may only be available at one or a limited number of pharmacies.
•
Oral chemotherapy drugs: Drugs that fall under the District of Columbia and State of Maryland Oral
Chemotherapy Parity Act. Cost shares for these drugs may be different for employer group plans not
based in Washington, D.C., and Maryland.
•
Quantity limit: For certain drugs, Kaiser Permanente Pharmacy and Therapeutics Committee limits
the amount of medication dispensed to a certain quantity per copay.
•
Restricted to benefit: Some drugs are not covered unless your benefits specifically cover such
medications, such as drugs for sexual dysfunction.
Key:
HC = A drug that may have a higher copay.
LD = A drug that may be subject to limited distribution.
OC = A drug included under the District of Columbia and State of Maryland Oral Chemotherapy Parity
Act.
QL = A drug that has a quantity limit or is limited to a specific day supply.
RB = A drug that is restricted to a certain benefit for coverage.
For more information about the Kaiser Permanente Formulary Drug List, you may contact Member
Services at 301-468-6000 or 800-777-7902 (TTY 301-879-6380). Representatives are available
Monday through Friday, 7:30 a.m. until 5:30 p.m.
2
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
ANTIHISTAMINE DRUGS
Cyproheptadine HCl
Promethazine HCL
DRUG NAME
Sulfasalazine
Sulfamethoxazole- Trimethoprim
SUPRAX
Tetracycline HCL
ANTI-INFECTIVEAGENTS
Tobramycin Neb
Anthelmintics
Vancomycin HCL
ALBENZA
VIVOTIF BERNA
BILTRICIDE
ZYVOX
YODOXIN
Antifungals
Antibacterials
Fluconazole
Amoxicillin
Griseofulvin Microsize
Amoxicillin & Pot Clavulanate
Griseofulvin Ultramicrosize
Ampicillin
Itraconazole
Azithromycin
Ketoconazole
Cefaclor
Nystatin
Cefdinir
Terbinafine
Cefuroxime Axetil
Voriconazole
Cephalexin
Antimycobacterials
Ciprofloxacin
DAPSONE
Clarithromycin
Ethambutol HCL
Clindamycin
Isoniazid
Clindamycin Palmitate HCL
Pyrazinamide
Dicloxacillin Sodium
Rifabutin
Doxycycline Monohydrate
Rifampin
ERYPED SUSP
Antiprotozoals
Erythromycin Base
Erythromycin Ethylsuccinate
Erythromycin-Sulfisoxazole
Levofloxacin
Minocycline HCL
Neomycin Sulfate
Penicillin V Potassium
REQUIREMENTS
AND LIMITS
Atovaquone
Atovaquone-Proguanil HCL
COARTEM
Chloroquine Phosphate
DARAPRIM
Hydroxychloroquine Sulfate
Mefloquine HCL
Sulfadiazine
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
3
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Metronidazole
NEBUPENT INH
RELENZA
RESCRIPTOR
Primaquine Phosphate
REYATAZ
Antivirals
Ribavirin
Abacavir
Rimantadine HCL
Abacavir-LamivudineZidovudine
SELZENTRY
Adefovir Dipivoxil
STRIBILD
Amantadine HCL
SUSTIVA
APTIVUS
TAMIFLU
ATRIPLA
TIVICAY
COMPLERA
TRUVADA
CRIXIVAN
VALCYTE SOLUTION
Didanosine
Valganciclovir
EDURANT
VICTRELIS
EMTRIVA
VIRACEPT
Entecavir
Zidovudine
EPIVIR SOLUTION
UrinaryAnti-Infectives
EPZICOM
Methenamine Hippurate
INTELENCE
Nitrofurantoin
INVIRASE
NitrofurantoinMonohyd
Macro
SOVALDI
ISENTRESS
HARVONI
QL
REQUIREMENTS
AND LIMITS
QL
QL
QL
Nitrofurantoin Macrocrystals
KALETRA
Trimethoprim
Lamivudine
ANTINEOPLASTIC AGENTS
Lamivudine-Zidovudine
Antineoplastic Agents
LEXIVA
Nevirapine
NORVIR
PEGASYS
QL
PEGASYS PROCLICK
QL
PEG-INTRON
QL
PREZISTA
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
AFINITOR
OC
ALKERAN
OC
Anastrozole
OC
Bicalutamide
OC
Capecitabine
CEENU
OC
OC
COMETRIQ KIT
CYTOXAN
OC
OC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
4
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
REQUIREMENTS
AND LIMITS
EMCYT
OC
Temozolomide
OC
Etoposide
Tretinoin (Chemotherapy)
Exemestane
OC
OC
TYKERB
OC
OC
Flutamide
OC
VANDETANIB
OC
GLEEVEC
OC
VOTRIENT
OC
HEXALEN
OC
XALKORI
OC
HYCAMTIN
OC
XTANDI
OC
Hydroxyurea
OC
ZELBORAF
OC
ICLUSIG
OC
ZYKADIA
OC
IMBRUVICA
OC
ZYTIGA
OC
INLYTA
OC
INTRON-A
QL
ANXIOLYTICS, SEDATIVES,
AND HYPNOTICS
JAKAFI
OC
Letrozole
OC
LEUKERAN
OC
LUPRON
QL
Benzodiazepines
LUPRON DEPOT
QL
Alprazolam
LUPRON DEPOT-PED
QL
Chlordiazepoxide HCL
LYSODREN
OC
Clonazepam
Megestrol Acetate
OC
Clorazepate Dipotassium
Mercaptopurine
OC
Diazepam
Barbiturates
Phenobarbital
Lorazepam
Methotrexate Sodium
MYLERAN
OC
Oxazepam
NEXAVAR
OC
Temazepam
Procarbazine HCL
OC
AUTONOMIC DRUGS
SPRYCEL
OC
Anticholinergic Agents
SUTENT
OC
TABLOID
OC
Tamoxifen Citrate
OC
TARCEVA
OC
TARGRETIN
OC
TASIGNA
OC
ATROVENT HFA
Benztropine Mesylate
Dicyclomine HCL
Hyoscyamine
Ipratropium Bromide (Nasal)
Trihexyphenidyl HCL
SPIRIVA
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
5
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Autonomic Drugs, Miscellaneous
Anagrelide HCL
DIBENZYLINE
Aminocaproic Acid
Ergoloid Mesylates
BRILINTA
Nicotrol Inhaler
HC
Parasympathomimetic (Cholinergic)
Agents
REQUIREMENTS
AND LIMITS
Cilostazol
Clopidogrel
Dipyridamole
Bethanechol Chloride
EFFIENT
Donepezil HCL
Fondaparinux
QL
Galantamine Hydrobromide
LOVENOX
QL
Neostigmine Bromide
Pentoxifylline
Pilocarpine HCL (ORAL)
PRADAXA
Pyridostigmine Bromide
Warfarin Sodium
Skeletal Muscle Relaxants
Hematopoietic Agents
Baclofen
NEUPOGEN
QL
Cyclobenzaprine HCL
PROCRIT/EPOGEN
QL
Dantrolene Sodium
PROMACTA
Methocarbamol
CARDIOVASCULAR DRUGS
Sympathomimetic (Adrenergic) Agents
Alpha-AdrenergicBlocking Agents
ADVAIR DISKUS 100/50
Terazosin HCL
Albuterol Neb
Tamsulosin HCL
COMBIVENT RESPIMAT
AER
Antilipemic Agents
Epinephrine HCL
QL
EPIPEN
QL
PROAIR HFA
SEREVENT DISKUS AER
Terbutaline Sulfate
Atorvastatin Calcium
Cholestyramine
Cholestyramine Light
Colestipol
Fenofibrate 54mg, 160mg
Gemfibrozil
BLOOD FORMATION, COAGULATION,
AND THROMBOSIS
Lovastatin
Coagulants And Anticoagulants
Pravastatin Sodium 20mg,
40mg, 80mg
AGGRENOX
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
Niacin
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
6
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Simvastatin 20mg, 40mg, 80mg
Beta-AdrenergicBlocking Agents
Acebutolol HCL
Atenolol/Chlorthalidone
Atenolol HCL
Bisoprolol/
Hydrochlorothiazide
DRUG NAME
REQUIREMENTS
AND LIMITS
Hypotensive Agents
Acetazolamide
Clonidine HCL
Guanfacine HCL
Hydralazine HCL
Methazolamide
Methyldopa
Bisoprolol Fumarate
Minoxidil
Carvedilol
Reserpine
Labetalol HCL
Metoprolol Succinate
Renin-Angiotensin-Aldosterone
System Inhibitors
MetoprololTartrate
Captopril
Nadolol
Enalapril Maleate
Propranolol HCL
Lisinopril
Sotalol HCL
Lisinopril/Hydrochlorothiazide
Timolol Maleate
Losartan Potassium
Calcium-Channel Blocking Agents
Losartan Potassium/HCTZ
Amlodipine Besylate
Diltiazem HCL
Nifedipine
Verapamil HCL
Cardiac Drugs
Amiodarone HCL
Digoxin
Disopyramide Phosphate
Flecainide Acetate
Mexiletine HCL
Propafenone HCL
Quinidine Gluconate
Quinidine Sulfate
Spironolactone
Spironolactone/
Hydrochlorothiazide
Vasodilating Agents
ADEMPAS
Isosorbide Dinitrate
Isosorbide Mononitrate
Nitroglycerin Patch
Nitroglycerin
NITROSTAT SL
OPSUMIT
Papaverine HCL
Sildenafil Citrate
Quinidine Sulfate ER
CENTRAL NERVOUS SYSTEM AGENTS
TIKOSYN
Analgesics and Antipyretics
Acetaminophen/Codeine
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will
• Limited Distribution—LD
be dispensed as the formulary agent
• Quantity Limits—QL
• Higher Copay—HC
• Oral Chemo Drugs—OC
7
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Buprenorphine HCL/
Naloxone HCL SL
Dextroamphetamine Sulfate
Butalbital/Acetaminophen/
Caffeine
Methylphenidate HCL CD, ER
Butalbital/Aspirin/Caffeine
REQUIREMENTS
AND LIMITS
Methylphenidate HCL
VYVANSE
Codeine Phosphate
Anticonvulsants
Codeine Sulfate
BANZEL
Diclofenac Sodium
Carbamazepine
Etodolac
Carbamazepine ER
Fentanyl
Diazepam (Anticonvulsant)
Hydrocodone/
Acetaminophen
Divalproex Sodium
Hydromorphone HCL
Gabapentin
Ibuprofen
Lamotrigine
Indomethacin
Levetiracetam
Ketoprofen
Levetiracetam XR
Meloxicam
Methsuximide
Meperidine HCL
Oxcarbazepine
Methadone HCL
Phenobarbital
Morphine Sulfate
Phenytoin Sodium
Nabumetone
Primidone
Naproxen
Topiramate
Oxycodone HCL
Valproate Sodium
Oxycodone/Acetaminophen
Valproic Acid
Salsalate
Antimigraine Agents
Sulindac
Ergotamine/Caffeine
Tramadol HCL
Naratriptan HCL
QL
Anorexigenic Agents and Respiratory
and Cerebral Stimulants
Rizatriptan Benzoate ODT
QL
Sumatriptan
QL
ADDERALL XR
Amphetamine/
Detroamphetamine (Mixed)
Ethosuximide
Anxiolytics, Sedatives, and Hypnotics
Buspirone HCL
Hydroxyzine HCL
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold,generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
8
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Hydroxyzine Pamoate
DRUG NAME
REQUIREMENTS
AND LIMITS
Lithium Citrate
Zaleplon
QL
Maprotiline HCL
Zolpidem Tartrate
QL
Mirtazapine
Central Nervous System Agents,
Miscellaneous
Nefazodone HCL
Carbidopa/Levodopa, ER
Olanzapine
Entacapone
ORAP
LODOSYN
Paroxetine HCL
NAMENDA
Perphenazine
Pramipexole Dihydrochloride
Phenelzine Sulfate
Riluzole
Prochlorperazine Maleate
Ropinirole HCL
Protriptyline HCL
Selegiline
Quetiapine
Opiate Antagonists
Risperidone
EVZIO
Sertraline HCL
Naltrexone HCL
Thioridazine HCL
Psychotherapeutic Agents
Amitriptyline HCL
Bupropion HCL, SR, XL
Chlorpromazine HCL
Citalopram HCL
Clozapine
Desipramine HCL
Nortriptyline HCL
Thiothixene
Trazodone HCL
Trifluoperazine HCL
Venlafaxine HCL
Ziprasidone HCL
ELECTROLYTIC, CALORIC,
AND WATER BALANCE
Doxepine HCL
Acidifying and Alkalinizing Agents
Duloxetine HCL
Potassium & Sodium Acid
Phosphates
Escitalopram Oxalate
Fluoxetine HCL
Fluphenazine HCL
Potassium Citrate(Alkalinizer)
Sodium Citrate & Citric Acid
Fluvoxamine Maleate
Ammonia Detoxicants
Haloperidol
Lactulose
Imipramine HCL
Diuretics
Lithium Carbonate
Amiloride/
Hydrochlorothazide
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold,generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
9
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Amiloride HCL
Bumetanide
Chlorothiazide
Chlorthalidone
Furosemide
Hydrochlorothiazide
DRUG NAME
EYE, EAR, NOSE, AND THROAT (EENT)
PREPARATIONS
Antiallergic Agents
Azelastine HCL
Cromolyn Sodium (OP)
Indapamide
Anti-Infectives
Metolazone
Bacitracin (OP)
Triamterene/
Hydrochlorothiazide
Bacitracin/Polymyxin B (OP)
Ion-Removing Agents
Erythromycin (OP)
RENVELA
Gentamicin Sulfate (OP)
Sodium Polystyrene Sulfonate
NATACYN
Replacement Preparations
Neomycin/Bacitracin/
Polymyxin
Calcium Acetate
Ciprofloxacin (OP)
ELIPHOS
Neomycin/Polymyxin/
Gramicid
PHOSLYRA
Ofloxacin (OP)
Potassium Phosphate
Dibasic/Monobasic
Ofloxacin (OTIC)
Potassium Bicarbonate
Sulfacetamide
Potassium Chloride
Tobramycin Sulfate (OP)
Potassium Phosphate
Monobasic
Trifluridine
Uricosuric Agents
Probenecid
ENZYMES
Enzymes
PULMOZYME SOL
VPRIV
REQUIREMENTS
AND LIMITS
Polymyxin B/Trimethoprim
ZYMAXID
Anti-Inflammatory Agents
Bacitracin/Polymyxin/
Neomycin/HC
CIPRODEX OTIC
COLY-MYCIN S OTIC
Dexamethasone (OP)
Fluorometholone (OP)
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
10
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Flunisolide
Proparacaine HCL
Flurbiprofen (OP)
Tetracaine HCL
Fluticasone Propionate
Mydriatics
Hydrocortisone/Acetic Acid
(OTIC)
Atropine Sulfate
Ketorolac Tromethamine
Neomycin/Polymyxin/
Dexameth
REQUIREMENTS
AND LIMITS
CYCLOMYDRIL
Homatropine HBR
Tropicamide
Neomycin/Polymyxin/HC
Vasoconstrictors
PRED-G
Phenylephrine HCL (OP)
Prednisolone Acetate
GASTROINTESTINAL DRUGS
Prednisolone Sodium
Phosphate
Antidiarrhea Agents
Sulfacetamide Sodium/
Prednisolone
Tobramycin/Dexamethasone
VEXOL
Diphenoxylate/Atropine
Antiemetics
EMEND
Ondansetron HCL
EENTDrugs,Miscellaneous
Prochlorperazine
Acetic Acid (OTIC)
TRANSDERM-SCOP
Acetic Acid/Aluminum
Acetate
Anti-Inflammatory Agents
Brimonidine Tartrate
Carbachol (OP)
Dorzolamide
Dorzolamide/Timolol
Latanoprost
Balsalazide Disodium
CANASA
LIALDA
Mesalamine Enema
PENTASA
Levobunolol HCL
Antiulcer Agents and Acid Suppressants
Metipranolol
Famotidine
Timolol (OP)
Misoprostol
Local Anesthetics
Omeprazole
Benzocaine/Antipyrine
Lidocaine HCL
Pantoprazole
Ranitidine HCL
Sucralfate
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
11
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Digestants
Androgens
CREON
Danocrine
ZENPEP
DEPO-TESTOSTERONE
GIDrugs,Miscellaneous
Contraceptives
Metoclopramide HCL
Desogestrel/Ethinyl Estradiol
PEG 3350-KCL-Sodium
Bicarb-Sodium ChlorideSodium Sulfate
Drospirenone/Ethinyl
Estradiol
Ursodiol
HEAVY METAL ANTAGONISTS
Heavy Metal Antagonists
EXJADE
HORMONES AND SYNTHETIC
SUBSTITUTES
ELLA
Ethynodiol Diacetate/Ethinyl
Estradiol
Levonorgestrel/Ethinyl
Estradiol
Levonorgestrel/Ethinyl
Estradiol (Triphasic)
NEXPLANON
Adrenals
Norethindrone
ASMANEX
Norethindrone/Ethinyl
Estradiol
Budesonide
Cortisone Acetate
Dexamethasone
Norethindrone Acetate/
Ethinyl Estradiol
FLOVENT HFA
Norethindrone/Ethinyl
Estradiol (Triphasic)
Fludrocortisone Acetate
PLAN B ONE-STEP
Hydrocortisone
Diabetic Agents
Methlyprednisolone
MILLIPRED
Prednisolone
Prednisolone Sodium
Phosphate
Prednisone
QVAR
REQUIREMENTS
AND LIMITS
Acarbose
Glipizide
GLUCAGON EMERGENCY
KIT
HUMALOG VIAL
HUMULIN 70/30 VIAL
HUMULIN N VIAL
HUMULIN R VIAL
LANTUS VIAL
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
12
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Metformin HCL
DRUG NAME
REQUIREMENTS
AND LIMITS
Somatotropin Agonist and Antagonist
Metformin ER
OMNITROPE
Pioglitazone HCL
Estrogens and Antiestrogens
CLIMARA
QL
Thyroid and Antithyroid Agents
Levothyroxine Sodium
Liothyronine Sodium
Estradiol
Methimazole
Esterified Estrogens/Methyl
Testosterone
Propylthiouracil
Thyroid
PREMARIN VAGINAL
CREAM
Raloxifene
MISCELLANEOUS THERAPEUTIC
AGENTS
Gonadotropins
Miscellaneous Therapeutic Agents
BRAVELLE
HC, QL
Acamprosate Calcium
Chorionic Gonadotropin
HC, QL
ACTIMMUNE
Clomiphene Citrate
HC
Alendronate Sodium
FOLLISTIM
HC, QL
Allopurinol
Ganirelix Acetate
HC, QL
AVONEX
GONAL-F
HC, QL
Azathioprine
MENOPUR
HC, QL
Bromocriptine Mesylate
IUD
MIRENA
Parathyroid
FORTICAL
QL
Colchicine
COPAXONE 20MG/ML
QL
Cromolyn Sodium
Disulfiram
ELMIRON
Pituitary
ENBREL
Desmopressin Acetate
Etidronate Disodium
Progestins
EXTAVIA
Medroxyprogesterone
Acetate
Finasteride
Norethindrone Acetate
GENGRAF
Progesterone Micronized
HUMIRA
FIRAZYR
QL
QL
QL
QL
Leflunomide
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
13
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Leucovorin Calcium
MESNEX
Acetylcysteine
QL
READI-CAT
REBIF
QL
REVLIMID
OC
SANDIMMUNE
Sodium Chloride (Inhalant)
SKIN AND MUCOUS
MEMBRANE AGENTS
Anti-Infectives (Skin and Mucous
Membrane)
Benzoyl Peroxide/
Erythromycin
SENSIPAR
Sodium Fluoride
Ciclopirox Olamine
Tacrolimus
THALOMID
REQUIREMENTS
AND LIMITS
Respiratory Agents, Miscellaneous
Mycophenolate Mofetil
ORENCIA
DRUG NAME
OC
VOLUMEN
Clindamycin Phosphate
Clioquinol/Hydrocortisone
Clotrimazole Troche
Vitamins
Erythromycin
Folic Acid
Gentamicin Sulfate
Iron Complex
Ketoconazole
Phytonadione
Metronidazole
Potassium Aminobenzoate
Mupirocin
Pyridoxine HCL
Nystatin
OXYTOCICS
Permethrin
Oxytocics
Salicylic Acid
Methylergonovine Maleate
Selenium Sulfide
RESPIRATORY TRACT AGENTS
Silver Nitrate/Potassium
Nitrate
Anti-Inflammatory Agents
Silver Sulfadiazine
Cromolyn Sodium
DULERA
Anti-Inflammatory Agents
(Skin and Mucous Membrane)
Montelukast Sodium
Betamethasone Dipropionate
Antitussives
Betamethasone Valerate
Benzonatate
Clobetasol Propionate
Guaifenesin/Codeine
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
14
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Clobetasol Propionate
Emollient Base
CORDRAN
Desoximetasone
Diflorasone Diacetate
DRUG NAME
REQUIREMENTS
AND LIMITS
Methoxsalen
OXSORALEN LOT
PHISOHEX LIQ
Podofilox
Sulfacetamide Sodium
Fluocinolone Acetonide
SANTYL
Fluocinonide
VECTICAL
Halobetasol Propionate
Hydrocortisone (Rectal)
SMOOTH MUSCLE RELAXANTS
Hydrocortisone (Topical)
Smooth Muscle Relaxants
Hydrocortisone Butyrate
Aminophylline
Hydrocortisone Valerate
Oxybutynin Chloride
Mometasone Furoate
Oxybutynin Chloride XL
Nystatin/Triamcinolone
Theophylline
PROCTOFORM
Trospium ER
Tacrolimus
Trospium
Triamcinolone Acetonide
VASODILATING AGENTS
Cell Stimulants and Proliferants
Miscellaneous Therapeutic Agents
Tretinion
Yohimbine HCL
Skin and Mucous Membrane Agents,
Miscellaneous
Phosphodiesterase Inhibitors
8-MOP
Acitretin
HC, QL
CAVERJECT
HC, RB
EDEX
HC, RB
MUSE
HC, RB
Aluminum Chloride
AZELEX
VITAMINS
DIFFERIN
Vitamins
EPIDUO
Calcitriol
Fluorouracil
Pediatric Multivitamins/
Fluoride
Imiquimod
Isotretinoin
Lidocaine HCL
Lidocaine/Prilocaine
LEGEND
• Brand-name drugs are in bold type and all capital letters
• For drugs not indicated in bold, generic drugs will
be dispensed as the formulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
15
DRUG NAME
REQUIREMENTS
AND LIMITS
Pediatric Multivitamins/
Fluoride/Iron
Pediatric Multivitamins ACD/
Fluoride
Pediatric Multivitamins ACD/
Fluoride/Iron
Prenatal Vitamins
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Fordrugs notindicated inbold,genericdrugswill be
dispensed as theformulary agent
• Higher Copay—HC
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
16