KAISER PERMANENTE HMO FORMULARY
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
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