Commonwealth of Virginia Medicaid Program
Medicaid and FAMIS Preferred Drug List 2015
Last Update: 4/07/2015
This is a list of preferred drugs for Medicaid and FAMIS members under Kaiser Foundation Health Plan of
the Mid-Atlantic States, Inc. This list is approved by the Kaiser Permanente Mid-Atlantic States Pharmacy
and Therapeutics Committee. The preferred drug list has closed classes for which only the drugs listed
within the classes are covered. Generally, Kaiser Permanente will only approve a request for a nonpreferred drug if your prescribing doctor considers the drug to be medically necessary. If a non-preferred
drug is not medically necessary, but you want the non-preferred drug, you will be responsible for paying
the full cost of the drug.
The preferred drug list is only for outpatient and self-administered drugs. It is not for those used in
hospitals (inpatient settings), doctor’s offices, or infusion centers.
The preferred drug list does not provide detailed information on your Medicaid coverage. For additional
information regarding your pharmacy benefits, please call Member Services at 855-249-5025 from 7:30 a.m.
to 5:30 p.m., Monday through Friday.
Generic, brand name, and non-preferred medications
Kaiser Permanente has brand and generic drugs on the preferred drug list. A generic drug is approved by
the Food and Drug Administration (FDA) because it has the same active ingredient as the brand-name
drug. In most cases, your doctor will prescribe a generic drug if one is available.
Brand-name drugs are made 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 make and sell the FDA-approved generic version of the drug.
Drug Efficacy Study Implementation (DESI) Drugs
DESI drugs were first marketed between 1938 and 1962 were approved as safe but required no showing of
effectiveness for FDA approval. Beginning in 1962, all new drugs were required to be both safe and effective
before being marketed. Kaiser Permanente does not pay for DESI classified drugs or drugs identical, similar,
or related to DESI products.
1
How to use the preferred drug list document
Drugs available in generic form are listed by their generic name. Unless the drug has multiple brand names,
drugs available only in brand name are in BOLD and in all CAPITAL letters.
You can search the preferred drug list by using the “FIND” function in Adobe Reader (CTRL + F), or by
the therapeutic drug category.
All dosages and strengths for a drug may not be in the preferred drug list. Some drugs are available in
more than one dosage form (for example, tablet and injectable)
Please remember that this list will be updated on a monthly basis without prior notification. Any drug
not found on this list or in later updates is a non-preferred drug.
Restrictions on medication coverage:
Some covered drugs may have additional requirements or limits on coverage. Requirements and limits may
include:
• 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
• Prior Authorization: For some drugs, Kaiser Permanente will cover the medication if
certain criteria are met. To obtain additional information regarding drugs that require
Prior Authorization and the Prior Authorization Process, please contact Member Services
at 855-249-5025.
• Quantity Limit: For certain drugs, Kaiser Permanente limits the amount of medication
dispensed to a certain quantity per copay.
Key:
LD = A drug that may be subject to limited distribution
PA = A drug that needs prior authorization.
QL = A drug that has a quantity limit or is limited to a specific day supply.
For more information about our preferred drug list, please contact Member Services at 855-249-5025,
866-513-0008 TTY from 7:30 a.m. to 5:30 p.m., Monday through Friday.
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
Erythromycin Base
Erythromycin Ethylsuccinate
Erythromycin-Sulfisoxazole
Levofloxacin
Minocycline HCL
Neomycin Sulfate
Penicillin V Potassium
Sulfadiazine
REQUIREMENTS
AND LIMITS
Antiprotozoals
Atovaquone
Atovaquone-Proguanil HCL
Chloroquine Phosphate
COARTEM
DARAPRIM
Hydroxychloroquine Sulfate
Mefloquine HCL
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
3
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Metronidazole
NEBUPENT INH
RESCRIPTOR
REYATAZ
Primaquine Phosphate
Ribavirin
Antivirals
Rimantadine HCL
Abacavir
SELZENTRY
Abacavir-LamivudineZidovudine
SOVALDI
Adefovir Dipivoxil
SUSTIVA
Amantadine HCL
TAMIFLU
APTIVUS
TIVICAY
ATRIPLA
TRUVADA
COMPLERA
VALCYTE SOLUTION
CRIXIVAN
Valganciclovir
Didanosine
VICTRELIS
EDURANT
VIRACEPT
Entecavir
Zidovudine
EMTRIVA
UrinaryAnti-Infectives
EPIVIR SOLUTION
Methenamine Hippurate
EPZICOM
Nitrofurantoin
INTELENCE
INVIRASE
NitrofurantoinMonohyd
Macro
ISENTRESS
Nitrofurantoin Macrocrystals
HARVONI
QL, PA
QL
Trimethoprim
ANTINEOPLASTIC AGENTS
Lamivudine
Antineoplastic Agents
Lamivudine-Zidovudine
AFINITOR
LEXIVA
ALKERAN
Nevirapine
Anastrozole
NORVIR
PEGASYS
QL
PEGASYS PROCLICK
QL
PEG-INTRON
QL
Bicalutamide
Capecitabine
CEENU
COMETRIQ KIT
PREZISTA
QL
CYTOXAN
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
QL, PA
STRIBILD
KALETRA
RELENZA
LEGEND
REQUIREMENTS
AND LIMITS
• Quantity Limits—QL
4
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
EMCYT
Temozolomide
Etoposide
Tretinoin (Chemotherapy)
Exemestane
TYKERB
Flutamide
VANDETANIB
GLEEVEC
VOTRIENT
HEXALEN
XALKORI
HYCAMTIN
XTANDI
Hydroxyurea
ZELBORAF
ICLUSIG
ZYKADIA
IMBRUVICA
ZYTIGA
INLYTA
INTRON-A
QL
JAKAFI
REQUIREMENTS
AND LIMITS
ANXIOLYTICS, SEDATIVES,
AND HYPNOTICS
Barbiturates
Letrozole
Phenobarbital
LEUKERAN
Benzodiazepines
LUPRON
QL
LUPRON DEPOT
QL
Alprazolam
LUPRON DEPOT-PED
QL
Chlordiazepoxide HCL
LYSODREN
Clonazepam
Megestrol Acetate
Clorazepate Dipotassium
Mercaptopurine
Diazepam
Methotrexate Sodium
Lorazepam
MYLERAN
Oxazepam
NEXAVAR
Temazepam
Procarbazine HCL
AUTONOMIC DRUGS
SPRYCEL
Anticholinergic Agents
SUTENT
TABLOID
Tamoxifen Citrate
TARCEVA
TARGRETIN
TASIGNA
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
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
5
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Autonomic Drugs, Miscellaneous
Anagrelide HCL
DIBENZYLINE
Aminocaproic Acid
Ergoloid Mesylates
BRILINTA
Nicotrol Inhaler
Cilostazol
Parasympathomimetic (Cholinergic)
Agents
REQUIREMENTS
AND LIMITS
Clopidogrel
Dipyridamole
EFFIENT
Bethanechol Chloride
Donepezil HCL
Galantamine Hydrobromide
Fondaparinux
QL
LOVENOX
QL
Pentoxifylline
Neostigmine Bromide
PRADAXA
Pilocarpine HCL (ORAL)
Pyridostigmine Bromide
Warfarin Sodium
Skeletal Muscle Relaxants
Hematopoietic Agents
Baclofen
Cyclobenzaprine HCL
NEUPOGEN
QL
PROCRIT/EPOGEN
QL
PROMACTA
Dantrolene Sodium
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
Simvastatin 20mg, 40mg,
80mg
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
6
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Beta-AdrenergicBlocking Agents
Hypotensive Agents
Acebutolol HCL
Acetazolamide
Atenolol/Chlorthalidone
Clonidine HCL
Atenolol HCL
Guanfacine HCL
Bisoprolol/
Hydrochlorothiazide
Hydralazine HCL
Bisoprolol Fumarate
Carvedilol
Labetalol HCL
Metoprolol Succinate
MetoprololTartrate
Nadolol
Propranolol HCL
Sotalol HCL
Timolol Maleate
REQUIREMENTS
AND LIMITS
Methazolamide
Methyldopa
Minoxidil
Reserpine
Renin-Angiotensin-Aldosterone
System Inhibitors
Captopril
Enalapril Maleate
Lisinopril
Lisinopril/Hydrochlorothiazide
Calcium-Channel Blocking Agents
Losartan Potassium
Amlodipine Besylate
Losartan Potassium/HCTZ
Diltiazem HCL
Spironolactone
Nifedipine
Verapamil HCL
Spironolactone/
Hydrochlorothiazide
Cardiac Drugs
Vasodilating Agents
Amiodarone HCL
ADEMPAS
Digoxin
Isosorbide Dinitrate
Disopyramide Phosphate
Isosorbide Mononitrate
Flecainide Acetate
Nitroglycerin Patch
Mexiletine HCL
Nitroglycerin
Propafenone HCL
NITROSTAT SL
Quinidine Gluconate
OPSUMIT
Quinidine Sulfate
Papaverine HCL
Quinidine Sulfate ER
Sildenafil Citrate
TIKOSYN
CENTRAL NERVOUS SYSTEM AGENTS
Analgesics and Antipyretics
Acetaminophen/Codeine
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
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
Ibuprofen
Gabapentin
Indomethacin
Lamotrigine
Ketoprofen
Levetiracetam
Meloxicam
Levetiracetam XR
Meperidine HCL
Methsuximide
Methadone HCL
Oxcarbazepine
Morphine Sulfate
Phenobarbital
Nabumetone
Phenytoin Sodium
Naproxen
Primidone
Oxycodone HCL
Topiramate
Oxycodone/Acetaminophen
Valproate Sodium
Salsalate
Valproic Acid
Sulindac
Antimigraine Agents
Tramadol HCL
Ergotamine/Caffeine
Anorexigenic Agents and Respiratory
and Cerebral Stimulants
Naratriptan HCL
QL
Rizatriptan Benzoate ODT
QL
ADDERALL XR
Sumatriptan
QL
Amphetamine/
Detroamphetamine (Mixed)
Anxiolytics, Sedatives, and Hypnotics
Ethosuximide
Buspirone HCL
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
8
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
Hydroxyzine HCL
Lithium Carbonate
Hydroxyzine Pamoate
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
REQUIREMENTS
AND LIMITS
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
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
9
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Diuretics
Amiloride/
Hydrochlorothazide
DRUG NAME
EYE, EAR, NOSE, AND THROAT (EENT)
PREPARATIONS
Antiallergic Agents
Amiloride HCL
Azelastine HCL
Bumetanide
Cromolyn Sodium (OP)
Chlorothiazide
Chlorthalidone
Furosemide
Hydrochlorothiazide
Indapamide
Metolazone
Triamterene/
Hydrochlorothiazide
Ion-Removing Agents
RENVELA
Anti-Infectives
Bacitracin (OP)
Bacitracin/Polymyxin B (OP)
Ciprofloxacin (OP)
Erythromycin (OP)
Gentamicin Sulfate (OP)
NATACYN
Neomycin/Bacitracin/
Polymyxin
Sodium Polystyrene Sulfonate
Neomycin/Polymyxin/
Gramicid
Replacement Preparations
Ofloxacin (OP)
Calcium Acetate
Ofloxacin (OTIC)
ELIPHOS
Polymyxin B/Trimethoprim
PHOSLYRA
Tobramycin Sulfate (OP)
Potassium Phosphate
Dibasic/Monobasic
Trifluridine
Potassium Bicarbonate
Anti-Inflammatory Agents
Potassium Chloride
Bacitracin/Polymyxin/
Neomycin/HC
Potassium Phosphate
Monobasic
REQUIREMENTS
AND LIMITS
ZYMAXID
CIPRODEX OTIC
Uricosuric Agents
COLY-MYCIN S OTIC
Probenecid
Dexamethasone (OP)
ENZYMES
Fluorometholone (OP)
Flunisolide
Enzymes
PULMOZYME SOL
VPRIV
LEGEND
Flurbiprofen (OP)
Fluticasone Propionate
Hydrocortisone/Acetic Acid (OTIC)
Ketorolac Tromethamine
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
10
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Neomycin/Polymyxin/
Dexameth
Neomycin/Polymyxin/HC
DRUG NAME
REQUIREMENTS
AND LIMITS
Vasoconstrictors
Phenylephrine HCL (OP)
PRED-G
GASTROINTESTINAL DRUGS
Prednisolone Acetate
Antidiarrhea Agents
Prednisolone Sodium
Phosphate
Diphenoxylate/Atropine
Sulfacetamide Sodium/
Prednisolone
EMEND
Antiemetics
Tobramycin/Dexamethasone
Ondansetron HCL
VEXOL
Prochlorperazine
EENTDrugs,Miscellaneous
TRANSDERM-SCOP
Acetic Acid (OTIC)
Anti-Inflammatory Agents
Acetic Acid/Aluminum
Acetate
Balsalazide Disodium
Brimonidine Tartrate
LIALDA
Carbachol (OP)
Mesalamine Enema
Dorzolamide
PENTASA
Dorzolamide/Timolol
Antiulcer Agents and Acid Suppressants
Latanoprost
Levobunolol HCL
Metipranolol
CANASA
Famotidine
Misoprostol
Omeprazole
Local Anesthetics
Pantoprazole
Benzocaine/Antipyrine
Ranitidine HCL
Lidocaine HCL
Sucralfate
Proparacaine HCL
Digestants
Tetracaine HCL
CREON
Mydriatics
ZENPEP
Atropine Sulfate
GIDrugs,Miscellaneous
CYCLOMYDRIL
Homatropine HBR
Tropicamide
Metoclopramide HCL
PEG 3350-KCL-Sodium
Bicarb-Sodium ChlorideSodium Sulfate
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
11
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Ursodiol
DRUG NAME
HEAVY METAL ANTAGONISTS
Ethynodiol Diacetate/Ethinyl
Estradiol
Heavy Metal Antagonists
Levonorgestrel/Ethinyl
Estradiol
EXJADE
HORMONES AND SYNTHETIC
SUBSTITUTES
Adrenals
ASMANEX
Budesonide
Cortisone Acetate
Dexamethasone
Levonorgestrel/Ethinyl
Estradiol (Triphasic)
NEXPLANON
Norethindrone
Norethindrone/Ethinyl
Estradiol
Norethindrone Acetate/
Ethinyl Estradiol
FLOVENT HFA
Norethindrone/Ethinyl
Estradiol (Triphasic)
Fludrocortisone Acetate
NUVARING
Hydrocortisone
ORTHO EVRA PATCH
Methlyprednisolone
PLAN B ONE-STEP
MILLIPRED
Diabetic Agents
Prednisolone
Acarbose
Prednisolone Sodium
Phosphate
Glipizide
Prednisone
GLUCAGON EMERGENCY
KIT
QVAR
HUMALOG VIAL
Androgens
HUMULIN 70/30 VIAL
Danocrine
HUMULIN N VIAL
DEPO-TESTOSTERONE
HUMULIN R VIAL
Contraceptives
LANTUS VIAL
Desogestrel/Ethinyl Estradiol
Drospirenone/Ethinyl
Estradiol
ELLA
REQUIREMENTS
AND LIMITS
Metformin HCL
Metformin ER
Pioglitazone HCL
Estrogens and Antiestrogens
CLIMARA
Estradiol
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
12
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
PREMARIN VAGINAL
CREAM
DRUG NAME
REQUIREMENTS
AND LIMITS
AVONEX
QL
Azathioprine
Raloxifene
Bromocriptine Mesylate
IUD
Colchicine
MIRENA
COPAXONE 20MG/ML
Parathyroid
Cromolyn Sodium
FORTICAL
Disulfiram
QL
ELMIRON
Pituitary
ENBREL
Desmopressin Acetate
QL
Etidronate Disodium
Progestins
EXTAVIA
Medroxyprogesterone
Acetate
Finasteride
Norethindrone Acetate
GENGRAF
Progesterone Micronized
HUMIRA
Somatotropin Agonist and Antagonist
Leflunomide
OMNITROPE
Leucovorin Calcium
FIRAZYR
QL, PA
Thyroid and Antithyroid Agents
MESNEX
Levothyroxine Sodium
Mycophenolate Mofetil
Liothyronine Sodium
ORENCIA
Methimazole
READI-CAT
Propylthiouracil
REBIF
Thyroid
REVLIMID
MISCELLANEOUS THERAPEUTIC
AGENTS
Miscellaneous Therapeutic Agents
Acamprosate Calcium
ACTIMMUNE
Alendronate Sodium
Allopurinol
QL
QL
QL
QL
QL
SANDIMMUNE
SENSIPAR
Sodium Fluoride
Tacrolimus
THALOMID
VOLUMEN
Vitamins
Folic Acid
Iron Complex
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
13
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Phytonadione
DRUG NAME
Pyridoxine HCL
Metronidazole
Mupirocin
OXYTOCICS
Nystatin
Oxytocics
Methylergonovine Maleate
RESPIRATORY TRACT AGENTS
REQUIREMENTS
AND LIMITS
Permethrin
Salicylic Acid
Selenium Sulfide
Anti-Inflammatory Agents
Silver Nitrate/Potassium
Nitrate
Cromolyn Sodium
Silver Sulfadiazine
DULERA
Anti-Inflammatory Agents
(Skin and Mucous Membrane)
Montelukast Sodium
Antitussives
Benzonatate
Guaifenesin/Codeine
Betamethasone Dipropionate
Betamethasone Valerate
Clobetasol Propionate
Respiratory Agents, Miscellaneous
Clobetasol Propionate
Emollient Base
Acetylcysteine
CORDRAN
Sodium Chloride (Inhalant)
Desoximetasone
SKIN AND MUCOUS
MEMBRANE AGENTS
Anti-Infectives (Skin and Mucous
Membrane)
Diflorasone Diacetate
Fluocinolone Acetonide
Fluocinonide
Halobetasol Propionate
Benzoyl Peroxide/
Erythromycin
Hydrocortisone (Rectal)
Ciclopirox Olamine
Hydrocortisone Butyrate
Clindamycin Phosphate
Hydrocortisone Valerate
Clotrimazole Troche
Mometasone Furoate
Erythromycin
Nystatin/Triamcinolone
Gentamicin Sulfate
PROCTOFORM
Ketoconazole
Tacrolimus
Hydrocortisone (Topical)
Triamcinolone Acetonide
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
14
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
DRUG NAME
REQUIREMENTS
AND LIMITS
Cell Stimulants and Proliferants
SMOOTH MUSCLE RELAXANTS
Tretinoin
Smooth Muscle Relaxants
Skin and Mucous Membrane Agents,
Miscellaneous
Aminophylline
8-MOP
Acitretin
Aluminum Chloride
AZELEX
DIFFERIN
EPIDUO
Oxybutynin Chloride
Oxybutynin Chloride XL
Theophylline
Trospium
Trospium ER
VITAMINS
Fluorouracil
Vitamins
Imiquimod
Calcitriol
Isotretinoin
Pediatric Multivitamins/
Fluoride
Lidocaine HCL
Lidocaine/Prilocaine
Methoxsalen
OXSORALEN LOT
PHISOHEX LIQ
Pediatric Multivitamins/
Fluoride/Iron
Pediatric Multivitamins ACD/
Fluoride
Podofilox
Pediatric Multivitamins ACD/
Fluoride/Iron
Sulfacetamide Sodium
Prenatal Vitamins
SANTYL
VECTICAL
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
15
April 2015
Over the Counter Drug Coverage
Along with prescription benefits, Kaiser Permanente covers the following over-the-counter medications with
a written or verbal prescription from a provider.
DRUG NAME
REQUIREMENTS
AND LIMITS
ANALGESICS
Acetaminophen
Aspirin
DRUG NAME
Neomycin-BacitracinPolymyxin
ANTI-FLATULENTS
Aspirin Buffered
Simethicone
Ibuprofen
ANTI-FUNGALS
Naproxen Sodium
Clotrimazole (Topical)
ANTACIDS
Aluminum Hydroxide
Calcium Carbonate
Magnesium Hydroxide/
Aluminum Hydroxide
Magnesium Hydroxide/
Aluminum Hydroxide/
Simethicone
Sodium Bicarbonate
Clotrimazole Vaginal
Miconazole Nitrate (Topical)
Miconazole Vaginal
Terbinafine HCL (Topical)
ANTI-HISTAMINES
Brompheniramine/
Phenylephrine
Cetirizine HCL
ANTI-DIARREHEALS
Cetirizine HCL/
Pseudoephedrine
Bismuth Subsalicylate
Chlorpheniramine Maleate
Loperamide HCL
Diphenhydramine HCL
ANTI-EMETICS
Dimenhydrinate
Meclizine HCL
Fexofenadine HCL
Fexofenadine HCL/
Pseudoephedrine
Loratadine
ANTI-ITCH, TOPICAL
Loratadine/Pseudoephedrine
Camphor/Menthol
COUGH & COLD
Diphenhydramine/Zinc Acetate
Hydrocortisone
Chlorpheniramine/
Dextromethorphan
Pramoxine/Calamine
Dextromethorphan
ANTI-BIOTICS, TOPICAL
Dextromethorphan/
Doxylamine/Acetaminophen
Bacitracin
REQUIREMENTS
AND LIMITS
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
16
April 2015
DRUG NAME
REQUIREMENTS
AND LIMITS
Dextromethorphan/
Guaifenesin
Dextromethorphan/
Phenylephrine/
Acetaminophen
Guaifenesin
DRUG NAME
HEMORRHOIDPREPARATIONS
Phenylephrine/Shark Liver
Oil/Mineral Oil/Petrolatum
HISTAMINE-2 RECEPTOR ANTAGONIST
Famotidine
Phenylephrine/
Brompheniramine
Dextromethorphan
Ranitidine HCL
Phenylephrine/
Dextromethorphan/
Guaifenesin
Ferrous Fumarate/Vitamin C
Phenylephrine/Guaifenesin
CONTRACEPTIVES
Condoms
Levonorgestrel
Nonoxynol-9
IRON SUPPLEMENTS
Ferrous Sulfate
LAXATIVES
Bisacodyl
Bisacodyl/Mag Citrate
Docusate Sodium
Glycerin (Laxative)
Magnesium Citrate
DECONGESTANTS
Magnesium Hydroxide
Phenylephrine HCL
Polyethlene Glycol 3350
Pseudoephedrine HCL
Sennosides
DERMATOLOGICAL AGENTS
Sennosides/Docusate
Sodium
Ammonium Lactate
REQUIREMENTS
AND LIMITS
Benzoyl Peroxide
NICOTINE CESSATION
Emollient
Nicotine Gum
Urea
Nicotine Lozenges
Zinc Oxide (Topical)
Nicotine Patches
EYES, EARS, & NOSE PREPARATIONS
PEDIATRIC ELECTROLYTE SOLUTION
Carbamide Peroxide (Otic)
Oral Electrolytes
Carboxymethylcellulose
Sodium
PEDICULICIDES
Ketotifen Fumarate
Naphazoline/Pheniramine
NASACORT ALLERGY
Permethrin
PROTON PUMP INHIBITORS
Lansoprazole
Omeprazole
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
17
DRUG NAME
REQUIREMENTS
AND LIMITS
SUPPLEMENTS/VITAMINS
Calcium Carbonate/Vitamin
D
Multivitamins
Multivitamins/Iron
Multivitamins/Minerals
Niacin
Pediatric Multivitamins
LEGEND
• Brand-name drugs are in bold type and all capital letters
• Limited Distribution—LD
• For drugs not indicated in bold, generic drugs will be
• Prior Authorization—PA
dispensed as the formulary agent
• Quantity Limits—QL
18