KAISER PERMANENTE FLEXIBLE CHOICE FORMULARY

Flexible Choice Formulary
Last Update: 4/07/2015
The following is a list of the drugs on the Kaiser Permanente Mid-Atlantic States Flexible Choice
formulary. The formulary is a list of prescription medications that are preferred for use under your plan.
This list is approved by the Kaiser Permanente Mid-Atlantic States Pharmacy and Therapeutics
Committee. The formulary applies only to outpatient drugs and self-administered drugs. It does not
apply to medications used in a hospital or surgery center or medications administered in a doctor’s office
or infusion center. The formulary does not provide information about your plan’s specific coverage,
limitations, or exclusions. For additional information regarding your pharmacy benefits, please consult
your Evidence of Coverage and/or Certificate of Insurance.
There are many brand and generic medications on the Kaiser Permanente Flexible Choice formulary. In
most cases, your provider will prescribe a generic equivalent. As a Kaiser Permanente Flexible Choice
member, the amount you pay for your prescription is determined by the tier (e.g., generic, preferred
brand name, non-preferred brand name, or non-formulary) along with where you decide to fill your
prescription. You may want to consult your physician for a generic alternative that may cost you less or
have your prescription filled at one of our convenient Kaiser Permanente medical center pharmacies.
Under Option 1 of your plan, you may fill your prescription at a Kaiser Permanente medical center
pharmacy. Your physician can send most prescriptions electronically from his or her office directly to the
pharmacy, where you can pick up your medication. If your prescription is for a non-preferred brand
name drug, your physician will need to request an exception to the formulary and document that the
non-formulary drug is medically necessary for your treatment and that no formulary drug is suitable for
you.
Under Option 2 of your plan, MedImpact is the company Kaiser Permanente has chosen to manage the
pharmacy benefits available to you. MedImpact has a network that consists of local and national
pharmacies. A partial list of participating pharmacies* includes:
•
•
•
•
•
•
Costco
Harris Teeter
Rite Aid
Shoppers Food Warehouse
Walgreens
Wegmans
•
•
•
•
•
•
CVS
Giant
Kmart
Safeway
Target
Wal-Mart
Not all locations within a pharmacy chain company are contracted with MedImpact; some are
independently contracted. To verify if a pharmacy participates, please log on to medimpact.com. To
obtain a complete list of participating pharmacies, call MedImpact customer service at 800-788-2949, 24
hours a day/seven days a week.
Under Option 3 of your plan, you may fill your prescription at any pharmacy that is not part of Option 1 or
Option 2. If you fill your prescription at an Option 3 out-of-network pharmacy, you should expect to pay
for your prescription drugs and then submit a claim for reimbursement.
*As of 5/1/14
1
How to use the formulary document
Medications available in a generic form are listed by their generic name. With the exception of drugs
where multiple branded products exist, medications only available as a brand name product are listed in
BOLD and in all CAPITAL letters.
Please remember that this formulary is subject to change and will be updated on a monthly basis. Any
product not found in this formulary or in subsequent updates, will be considered a non-preferred drug.
You can search the formulary by using the “FIND” function in Adobe Reader, or by the therapeutic drug
category.
All dosage forms and strengths for a particular drug may not be included in the formulary. This is
because not all dosage forms of formulary drugs are covered under the prescription drug benefit.
Some drugs are available in more than one dosage form (example: tablet and injectable).
Restrictions on medication coverage:
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
• Higher copay: Some drugs may have a higher cost share. These drugs include infertility,
sexual dysfunction, smoking cessation, growth hormone, and weight management
medications.
• Oral chemo: Drugs that fall under the District of Columbia and State of Maryland Chemo
Parity Act. These drugs are subject to a different cost share for plans that are based out of
Washington, D.C. and Maryland.
• Quantity limit: For certain drugs, Kaiser Permanente limits the amount of medication
dispensed to a certain quantity per copay.
• Restricted to benefit: Some drugs are not covered unless the patient’s benefits specifically cover
such medications. For example, Viagra and other drugs for sexual dysfunction are not covered
unless the patient’s benefits specifically cover them.
Key:
HC = A drug that may have a higher copay.
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 formulary or Option 1, please contact Member Services at
888-225-7202 (TTY 301-879-6380) Monday through Friday, 7:30 a.m. until 5:30 p.m. For information on
Option 2 & 3, please contact Kaiser Permanente Insurance Company customer service at 800-3928649 Monday through Friday, 9 a.m. until 9 p.m.
2
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
ANTIHISTAMINE DRUGS
Sulfasalazine
Cyproheptadine HCl
Sulfamethoxazole- Trimethoprim
Promethazine HCL
SUPRAX
ANTI-INFECTIVEAGENTS
Anthelmintics
ALBENZA
BILTRICIDE
YODOXIN
Antibacterials
Amoxicillin
Amoxicillin & Pot Clavulanate
Ampicillin
Azithromycin
Cefaclor
Cefdinir
Cefuroxime Axetil
Cephalexin
Ciprofloxacin
Clarithromycin
Clindamycin
Clindamycin Palmitate HCL
Dicloxacillin Sodium
Doxycycline Monohydrate
ERYPED SUSP
Tetracycline HCL
Tobramycin Neb
Vancomycin HCL
VIVOTIF BERNA
ZYVOX
Antifungals
Fluconazole
Griseofulvin Microsize
Griseofulvin Ultramicrosize
Itraconazole
Ketoconazole
Nystatin
Terbinafine
Voriconazole
Antimycobacterials
DAPSONE
Ethambutol HCL
Isoniazid
Pyrazinamide
Rifabutin
Rifampin
Erythromycin Base
Antiprotozoals
Erythromycin Ethylsuccinate
Atovaquone
Erythromycin-Sulfisoxazole
Atovaquone-Proguanil HCL
Levofloxacin
COARTEM
Minocycline HCL
Chloroquine Phosphate
Neomycin Sulfate
DARAPRIM
Penicillin V Potassium
Hydroxychloroquine Sulfate
Sulfadiazine
Mefloquine HCL
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
REQUIREMENTS
AND LIMITS
• Quantity Limits—QL
• Oral Chemo Drugs—OC
3
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
RELENZA
RESCRIPTOR
Metronidazole
NEBUPENT INH
QL
REYATAZ
Primaquine Phosphate
Ribavirin
Antivirals
Rimantadine HCL
Abacavir
SELZENTRY
Abacavir-LamivudineZidovudine
SOVALDI
QL
STRIBILD
Adefovir Dipivoxil
SUSTIVA
Amantadine HCL
TAMIFLU
APTIVUS
QL
TIVICAY
ATRIPLA
TRUVADA
COMPLERA
VALCYTE SOLUTION
CRIXIVAN
Valganciclovir
Didanosine
VICTRELIS
EDURANT
VIRACEPT
EMTRIVA
Zidovudine
Entecavir
UrinaryAnti-Infectives
EPIVIR SOLUTION
Methenamine Hippurate
EPZICOM
Nitrofurantoin
INTELENCE
NitrofurantoinMonohyd
Macro
INVIRASE
ISENTRESS
HARVONI
REQUIREMENTS
AND LIMITS
QL
KALETRA
Nitrofurantoin Macrocrystals
Trimethoprim
ANTINEOPLASTIC AGENTS
Lamivudine
Lamivudine-Zidovudine
Antineoplastic Agents
LEXIVA
AFINITOR
OC
Nevirapine
ALKERAN
OC
NORVIR
Anastrozole
OC
PEGASYS
QL
Bicalutamide
OC
PEGASYS PROCLICK
QL
Capecitabine
OC
PEG-INTRON
QL
CEENU
OC
COMETRIQ KIT
OC
CYTOXAN
OC
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
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• Oral Chemo Drugs—OC
4
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
EMCYT
OC
Tretinoin (Chemotherapy)
Etoposide
TYKERB
Exemestane
OC
OC
OC
OC
VANDETANIB
OC
Flutamide
OC
VOTRIENT
OC
GLEEVEC
OC
XALKORI
OC
HEXALEN
OC
XTANDI
OC
HYCAMTIN
OC
ZELBORAF
OC
Hydroxyurea
OC
ZYKADIA
OC
ICLUSIG
OC
ZYTIGA
OC
INLYTA
OC
ANXIOLYTICS, SEDATIVES,
AND HYPNOTICS
INTRON-A
QL
JAKAFI
OC
Letrozole
OC
LEUKERAN
OC
Benzodiazepines
LUPRON
QL
Alprazolam
LUPRON DEPOT
QL
Chlordiazepoxide HCL
LUPRON DEPOT-PED
QL
Clonazepam
LYSODREN
OC
Clorazepate Dipotassium
Megestrol Acetate
OC
Diazepam
Mercaptopurine
OC
Lorazepam
IMBRUVICA
Barbiturates
Phenobarbital
Oxazepam
Methotrexate Sodium
MYLERAN
OC
Temazepam
NEXAVAR
OC
AUTONOMIC DRUGS
Procarbazine HCL
OC
Anticholinergic Agents
SPRYCEL
OC
SUTENT
OC
TABLOID
OC
Tamoxifen Citrate
OC
TARCEVA
OC
TARGRETIN
OC
TASIGNA
OC
Temozolomide
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
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
REQUIREMENTS
AND LIMITS
• 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
Niacin
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
• 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
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
Acetaminophen/Codeine
• Restricted Benefit—RB
• Limited Distribution—LD
• Quantity Limits—QL
• 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
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
• 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
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
• 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
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
• 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
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
• 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
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
• 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
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
• 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
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
• 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
• Restricted Benefit—RB
• For drugs not indicated in bold, generic drugs will be
• Limited Distribution—LD
dispensed as the formulary agent
• Higher Copay—HC
• Quantity Limits—QL
• Oral Chemo Drugs—OC
16