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Kaiser Permanente Hawaii Drug Formulary Our Commercial Drug Formulary Kaiser Permanente Hawaii uses a drug formulary to ensure that the most appropriate and effective prescription drugs are available to you. The formulary is a list of drugs that have been approved by our Pharmacy and Therapeutics (P&T) Committee. Committee members include pharmacists, physicians, nurses, and other allied health care professionals. Our drug formulary allows us to select drugs that are safe, effective, and a good value for you. We review our formulary regularly so that we can add new drugs and remove drugs that can be replaced by newer, more effective drugs. The formulary also helps us restrict drugs that can be toxic or otherwise dangerous if misused. Our drug formulary is considered a closed formulary, which means that drugs on the list are usually covered under the prescription drug benefit, if you have one. However, drugs on our formulary may not be automatically covered under your prescription benefit because these benefits vary depending on your plan. Please check with your Kaiser Permanente pharmacist when you have questions about whether a drug is on our formulary or if there are any restrictions or limitations to obtaining a drug. For information on our Medicare Part D formulary, please refer to our Senior Advantage section on the kp.org website. NON-FORMULARY DRUGS Non-formulary drugs are those that are not included on our drug formulary. These include new drugs that haven’t been reviewed yet, drugs that our clinicians and pharmacists have decided to leave off the formulary, or a different strength or dosage of a formulary drug that we don’t stock in our Kaiser Permanente pharmacies. Even though non-formulary drugs are generally not covered under our prescription drug benefit options, your Kaiser Permanente doctor can request a non-formulary drug for you when formulary alternatives have failed and the non-formulary drug is medically necessary, provided the drug is not excluded under the prescription drug benefit. If the request is accepted, you may purchase your prescription at your usual supplemental charge. Non-formulary drugs are not usually stocked in our pharmacies, so it may take a little longer to have your prescription filled for one of these drugs. SHARE INFORMATION WITH YOUR DOCTOR If you’re taking multiple drugs–including prescription or over-the-counter drugs, herbs, natural supplements, and even nutraceuticals (foods or parts of a food that provide health benefits)–be sure to share this information with your physician or pharmacist. Because some drugs interact with others, we want to be sure that you get the maximum benefit and the least risk from everything you consume. Bring all your drugs to each physician appointment or call one of our pharmacies and make an appointment with a pharmacist to review everything you’re taking.

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Page 1: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary

Our Commercial Drug Formulary Kaiser Permanente Hawaii uses a drug formulary to ensure that the most appropriate and effective prescription drugs are available to you. The formulary is a list of drugs that have been approved by our Pharmacy and Therapeutics (P&T) Committee. Committee members include pharmacists, physicians, nurses, and other allied health care professionals. Our drug formulary allows us to select drugs that are safe, effective, and a good value for you. We review our formulary regularly so that we can add new drugs and remove drugs that can be replaced by newer, more effective drugs. The formulary also helps us restrict drugs that can be toxic or otherwise dangerous if misused. Our drug formulary is considered a closed formulary, which means that drugs on the list are usually covered under the prescription drug benefit, if you have one. However, drugs on our formulary may not be automatically covered under your prescription benefit because these benefits vary depending on your plan. Please check with your Kaiser Permanente pharmacist when you have questions about whether a drug is on our formulary or if there are any restrictions or limitations to obtaining a drug. For information on our Medicare Part D formulary, please refer to our Senior Advantage section on the kp.org website. NON-FORMULARY DRUGS Non-formulary drugs are those that are not included on our drug formulary. These include new drugs that haven’t been reviewed yet, drugs that our clinicians and pharmacists have decided to leave off the formulary, or a different strength or dosage of a formulary drug that we don’t stock in our Kaiser Permanente pharmacies. Even though non-formulary drugs are generally not covered under our prescription drug benefit options, your Kaiser Permanente doctor can request a non-formulary drug for you when formulary alternatives have failed and the non-formulary drug is medically necessary, provided the drug is not excluded under the prescription drug benefit. If the request is accepted, you may purchase your prescription at your usual supplemental charge. Non-formulary drugs are not usually stocked in our pharmacies, so it may take a little longer to have your prescription filled for one of these drugs. SHARE INFORMATION WITH YOUR DOCTOR If you’re taking multiple drugs–including prescription or over-the-counter drugs, herbs, natural supplements, and even nutraceuticals (foods or parts of a food that provide health benefits)–be sure to share this information with your physician or pharmacist. Because some drugs interact with others, we want to be sure that you get the maximum benefit and the least risk from everything you consume. Bring all your drugs to each physician appointment or call one of our pharmacies and make an appointment with a pharmacist to review everything you’re taking.

Page 2: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier ABACAVIR ABACAVIR 300MG TABLET 2 ABIRATERONE ZYTIGA 250MG TABLET 3 ACARBOSE ACARBOSE 25MG TABLET 2 ACARBOSE ACARBOSE 50MG TABLET 2 ACARBOSE ACARBOSE 100MG TABLET 2 ACETAMINOPHEN W/ CODEINE ACETAMINOPHEN W/ CODEINE 300-30MG

TABLET 2

ACETAMINOPHEN W/ CODEINE ACETAMINOPHEN W/ CODEINE 300-60MG TABLET

2

ACETAMINOPHEN W/ CODEINE ACETAMINOPHEN W/ CODEINE 120-12/5ML ELIX 2 ACETAZOLAMIDE ACETAZOLAMIDE 125MG TABLET 2 ACETAZOLAMIDE ACETAZOLAMIDE 250MG TABLET 2 ACETAZOLAMIDE ACETAZOLAMIDE 500MG CP12 2 ACETIC ACID ACETIC ACID 0.25% FOR IRRIG SOL UD

SOLUTION 2

ACETIC ACID ACETIC ACID SOL 2% OTIC SOLUTION 2 ACETIC ACID ACETIC ACID SOL 5% SOLUTION 3 ACETIC ACID-ALUMINUM ACETIC ACID/ALUMINUM ACETAT SOL 2% OTIC

SOLUTION 2

ACETOHYDROXAMIC ACID LITHOSTAT 250MG TABLET 3 ACETYLCYSTEINE ACETYLCYSTEINE 10% SOLUTION 2 ACITRETIN ACITRETIN 10MG CAPSULE 2 ACITRETIN ACITRETIN 25MG CAPSULE 2 ACYCLOVIR ACYCLOVIR 200MG CAPSULE 2 ACYCLOVIR ACYCLOVIR 400MG TABLET 2 ACYCLOVIR ACYCLOVIR 800MG TABLET 2 ACYCLOVIR ACYCLOVIR 200MG/5ML SUSPENSION 2 ACYCLOVIR ACYCLOVIR 5% OINTMENT 2 ADALIMUMAB HUMIRA 20MG/0.4ML KIT 3 ADALIMUMAB HUMIRA 40MG/0.8ML KIT 3 ADAPALENE ADAPALENE 0.1% CREAM 2 ADAPALENE ADAPALENE 0.1% GEL 2 ADAPALENE DIFFERIN 0.3% GEL 3 ADAPALENE-BENZOYL EPIDUO GEL 0.1-2.5% GEL 3 ADEFOVIR HEPSERA 10MG TABLET 3 ALBENDAZOLE ALBENZA 200MG TABLET 3 ALBUTEROL ALBUTEROL SULFATE TAB 2MG 1 ALBUTEROL ALBUTEROL SULFATE TAB 4MG 1 ALBUTEROL ALBUTEROL SULFATE SYP 2MG/5ML 1 ALBUTEROL ALBUTEROL SULFATE NEB 0.083% UD 1 ALBUTEROL ALBUTEROL SULFATE NEB 0.5% 1 ALBUTEROL ALBUTEROL 1.25MG/3ML MIST 2

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Page 3: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier ALBUTEROL ALBUTEROL 108MCG/ACT AERO SPRAY 2 ALENDRONATE ALENDRONATE 10MG TABLET 2 ALENDRONATE ALENDRONATE 40MG TABLET 2 ALENDRONATE ALENDRONATE 70MG TABLET 2 ALLOPURINOL ALLOPURINOL 100MG TABLET 2 ALLOPURINOL ALLOPURINOL 20MG/ML SUSPENSION 2 ALPRAZOLAM ALPRAZOLAM 0.25MG TABLET 2 ALPRAZOLAM ALPRAZOLAM 0.5MG TABLET 2 ALUMINUM ALUMINUM 20% SOLUTION 2 ALVIMOPAN ENTEREG 12MG CAPSULE 3 AMANTADINE AMANTADINE 100MG CAPSULE 2 AMANTADINE AMANTADINE 50MG/5ML SYRUP 2 AMCINONIDE AMCINONIDE 0.1% CREAM 2 AMCINONIDE AMCINONIDE 0.1% OINTMENT 2 AMINOCAPROIC ACID AMINOCAPROIC 500MG TABLET 2 AMIODARONE AMIODARONE 200MG TABLET 2 AMITRIPTYLINE AMITRIPTYLINE HCL TAB 10MG 1 AMITRIPTYLINE AMITRIPTYLINE HCL TAB 25MG 1 AMITRIPTYLINE AMITRIPTYLINE HCL TAB 50MG 1 AMITRIPTYLINE AMITRIPTYLINE HCL TAB 75MG 1 AMLODIPINE AMLODIPINE 2.5MG TABLET 2 AMLODIPINE AMLODIPINE 1MG/ML SUSPENSION 2 AMLODIPINE AMLODIPINE 10MG TABLET 2 AMOXICILLIN AMOXICILLIN 250MG CAPSULE 2 AMOXICILLIN AMOXICILLIN 500MG CAPSULE 2 AMOXICILLIN AMOXICILLIN 400MG/5ML SUSPENSION 2 AMOXICILLIN/CLAVULANATE AMOXICILLIN & POT CLAVULA 500MG TABLET 2 AMOXICILLIN/CLAVULANATE AMOXICILLIN & POT CLAVULA 875MG TABLET 2 AMOXICILLIN/CLAVULANATE AMOXICILLIN & POT CLAVULA 400MG TAB

CHEW 2

AMOXICILLIN/CLAVULANATE AMOXICILLIN & POT CLAVULA 400/5ML SUSPENSION

2

AMOXICILLIN/CLAVULANATE AMOXICILLIN & POT CLAVULA 600-42.9ML SUSPENSION

2

AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 30MG TABLET

2

AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 10MG TABLET

2

AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 15MG TABLET

2

AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 20MG TABLET

2

AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 30MG 2

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Page 4: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier

TABLET AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 5MG CP24 2 AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 10MG CP24 2 AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 15MG CP24 2 AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 20MG CP24 2 AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 25MG CP24 2 AMPHETAMINE-DEXTROAMPHETA AMPHETAMINE-DEXTROAMPHETA 30MG CP24 2 ANAGRELIDE ANAGRELIDE 0.5MG CAPSULE 2 ANASTROZOLE ANASTROZOLE 1MG TABLET 2 ANTIPYRINE-BENZOCAINE ANTIPYRINE/BENZOCAINE DRO OTIC SOLUTION 2 ARIPIPRAZOLE ABILIFY 2MG TABLET 3 ARIPIPRAZOLE ABILIFY 5MG TABLET 3 ARIPIPRAZOLE ABILIFY 10MG TABLET 3 ARIPIPRAZOLE ABILIFY 15MG TABLET 3 ARIPIPRAZOLE ABILIFY 20MG TABLET 3 ARIPIPRAZOLE ABILIFY 30MG TABLET 3 ARIPIPRAZOLE ABILIFY 1MG/ML SOLUTION 3 ARTEMETHER-LUMEFANTRINE COARTEM TAB 20-120MG TABLET 3 ASPIRIN-DIPYRIDAMOLE AGGRENOX CAP 200-25MG UD CP12 3 ATENOLOL ATENOLOL TAB 25MG 1 ATENOLOL ATENOLOL TAB 50MG 1 ATOMOXETINE STRATTERA 10MG CAPSULE 3 ATOMOXETINE STRATTERA 18MG CAPSULE 3 ATOMOXETINE STRATTERA 25MG CAPSULE 3 ATOMOXETINE STRATTERA 40MG CAPSULE 3 ATOMOXETINE STRATTERA 60MG CAPSULE 3 ATOMOXETINE STRATTERA 80MG CAPSULE 3 ATOMOXETINE STRATTERA 100MG CAPSULE 3 ATORVASTATIN ATORVASTATIN 10MG TABLET 2 ATORVASTATIN ATORVASTATIN 20MG TABLET 2 ATORVASTATIN ATORVASTATIN 40MG TABLET 2 ATORVASTATIN ATORVASTATIN 80MG TABLET 2 ATOVAQUONE MEPRON 750MG/5ML SUSPENSION 3 ATROPINE ATROPINE 1% SOLUTION 2 AZATHIOPRINE AZATHIOPRINE 50MG TABLET 2 AZELASTINE AZELASTINE 137MCG/SPRAY SOLUTION 2 AZITHROMYCIN AZITHROMYCIN 250MG TABLET 2 AZITHROMYCIN AZITHROMYCIN 500MG TABLET 2 AZITHROMYCIN AZITHROMYCIN 600MG TABLET 2 AZITHROMYCIN AZITHROMYCIN 100MG/5ML SUSPENSION 2 AZITHROMYCIN AZITHROMYCIN 200MG/5ML SUSPENSION 2 BACITRACIN BACITRACIN 500UNIT/GM OINTMENT 2 BACLOFEN BACLOFEN 10MG TABLET 2

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Page 5: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier BALSALAZIDE BALSALAZIDE 750MG CAPSULE 2 BECAPLERMIN REGRANEX 0.01% GEL 3 BECLOMETHASONE QVAR 40MCG/ACT AERO SPRAY 3 BECLOMETHASONE QVAR 80MCG/ACT AERO SPRAY 3 BELLADONNA ALKALOIDS & BELLADONNA & OPIUM SUP 16.2-30 UD

SUPPOS. 3

BENZONATATE BENZONATATE 100MG CAPSULE 2 BENZTROPINE BENZTROPINE 0.5MG TABLET 2 BENZTROPINE BENZTROPINE 1MG TABLET 2 BENZTROPINE BENZTROPINE MESYLATE TAB 2MG 1 BETAMETHASONE BETAMETHASONE 0.05% CREAM 2 BETAMETHASONE BETAMETHASONE 0.05% OINTMENT 2 BETAMETHASONE BETAMETHASONE 0.1% LOTION 2 BETAXOLOL BETAXOLOL 0.5% SOLUTION 2 BETHANECHOL BETHANECHOL 25MG TABLET 2 BICALUTAMIDE BICALUTAMIDE 50MG TABLET 2 BISOPROLOL BISOPROLOL 5MG TABLET 2 BISOPROLOL BISOPROLOL 10MG TABLET 2 BISOPROLOL & HYDROCHLOROT BISOPROLOL FUMARATE/HYDROCH TAB

2.5/6.25 1

BISOPROLOL & HYDROCHLOROT BISOPROLOL FUMARATE/HYDROCH TAB 5/6.25MG

1

BISOPROLOL & HYDROCHLOROT BISOPROLOL FUMARATE/HYDROCH TAB 10/6.25 1 BOCEPREVIR VICTRELIS 200MG CAPSULE 3 BRIMONIDINE BRIMONIDINE 0.2% SOLUTION 2 BROMOCRIPTINE BROMOCRIPTINE 2.5MG TABLET 2 BUDESONIDE BUDESONIDE 3MG CP24 2 BUPRENORPHINE BUPRENORPHINE 2MG TAB SUBL 2 BUPRENORPHINE BUPRENORPHINE 8MG TAB SUBL 2 BUPRENORPHINE HCL-NALOXON BUPRENORPHINE NULL TAB SUBL 2 BUPRENORPHINE HCL-NALOXON BUPRENORPHINE NULL TAB SUBL 2 BUPROPION BUPROPION 100MG TB12 2 BUPROPION BUPROPION 150MG TB12 2 BUSPIRONE BUSPIRONE HCL TAB 5MG 1 BUSPIRONE BUSPIRONE HCL TAB 10MG 1 BUSPIRONE BUSPIRONE 15MG TABLET 2 BUTALBITAL-ACETAMINOPHEN- BUTALBITAL-ACETAMINOPHEN- TAB TABLET 2 BUTALBITAL-ASPIRIN-CAFFEI BUTALBITAL-ASPIRIN-CAFFEI TAB TABLET 2 BUTAMBEN-TETRACAINE-BENZO BUTAMBEN-TETRACAINE-BENZO AER

AEROSOL 2

CAFFEINE CITRATE CAFFEINE 20MG/ML SOLUTION 2 CALCIPOTRIENE CALCIPOTRIENE 0.005% SOLUTION 2 CALCIPOTRIENE CALCIPOTRIENE 0.005% CREAM 2

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Page 6: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier CALCITONIN CALCITONIN 200UNIT/ACT SOLUTION 2 CALCITRIOL CALCITRIOL 0.25MCG CAPSULE 2 CALCITRIOL CALCITRIOL 0.5MCG CAPSULE 2 CALCITRIOL CALCITRIOL 3MCG/GM OINTMENT 2 CAPECITABINE XELODA 150MG TABLET 3 CAPECITABINE XELODA 500MG TABLET 3 CAPTOPRIL CAPTOPRIL TAB 25MG 1 CAPTOPRIL CAPTOPRIL TAB 50MG 1 CAPTOPRIL CAPTOPRIL TAB 100MG 1 CARBAMAZEPINE CARBAMAZEPINE 200MG TABLET 2 CARBAMAZEPINE CARBAMAZEPINE 100MG TAB CHEW 2 CARBAMAZEPINE CARBAMAZEPINE 100MG/5ML SUSPENSION 2 CARBAMAZEPINE CARBAMAZEPINE 300MG CP12 2 CARBAMAZEPINE TEGRETOL-XR 100MG TB12 3 CARBAMAZEPINE CARBAMAZEPINE 200MG TB12 2 CARBAMAZEPINE CARBAMAZEPINE 400MG TB12 2 CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA 10-100MG TABLET 2 CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA 25-100MG TABLET 2 CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA 25-250MG TABLET 2 CARBIDOPA-LEVODOPA CARBIDOPA-LEVODOPA 50-200MG TABLET SA 2 CARISOPRODOL CARISOPRODOL 350MG TABLET 2 CARVEDILOL CARVEDILOL TAB 3.125MG 1 CARVEDILOL CARVEDILOL TAB 6.25MG 1 CARVEDILOL CARVEDILOL TAB 12.5MG 1 CARVEDILOL CARVEDILOL TAB 25MG 1 CEFAZOLIN CEFAZOLIN 50MG/ML SOLUTION 2 CEFDINIR CEFDINIR 125MG/5ML SUSPENSION 2 CEFPODOXIME CEFPODOXIME 100MG TABLET 2 CEFPODOXIME CEFPODOXIME 200MG TABLET 2 CELECOXIB CELEBREX 100MG CAPSULE 3 CELECOXIB CELEBREX 200MG CAPSULE 3 CEPHALEXIN CEPHALEXIN 250MG CAPSULE 2 CEPHALEXIN CEPHALEXIN 500MG CAPSULE 2 CEPHALEXIN CEPHALEXIN 250MG/5ML SUSPENSION 2 CHLORAMBUCIL LEUKERAN 2MG TABLET 3 CHLORDIAZEPOXIDE CHLORDIAZEPOXIDE 5MG CAPSULE 2 CHLORDIAZEPOXIDE CHLORDIAZEPOXIDE 10MG CAPSULE 2 CHLORDIAZEPOXIDE CHLORDIAZEPOXIDE 25MG CAPSULE 2 CHLORHEXIDINE CHLORHEXIDINE 0.12% SOLUTION 2 CHLOROQUINE CHLOROQUINE 250MG TABLET 2 CHLOROQUINE CHLOROQUINE 500MG TABLET 2 CHLORPROMAZINE CHLORPROMAZINE 10MG TABLET 2 CHLORPROMAZINE CHLORPROMAZINE 25MG TABLET 2

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Page 7: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier CHLORPROMAZINE CHLORPROMAZINE 50MG TABLET 2 CHLORPROMAZINE CHLORPROMAZINE 100MG TABLET 2 CHLORTHALIDONE CHLORTHALIDONE 25MG TABLET 2 CHLORTHALIDONE CHLORTHALIDONE 50MG TABLET 2 CHLORZOXAZONE CHLORZOXAZONE 500MG TABLET 2 CHOLESTYRAMINE CHOLESTYRAMINE 4GM POWDER 2 CHOLESTYRAMINE CHOLESTYRAMINE 4GM POWDER 2 CICLOPIROX CICLOPIROX 0.77% CREAM 2 CILOSTAZOL CILOSTAZOL 50MG TABLET 2 CILOSTAZOL CILOSTAZOL 100MG TABLET 2 CINACALCET SENSIPAR 30MG TABLET 3 CINACALCET SENSIPAR 60MG TABLET 3 CINACALCET SENSIPAR 90MG TABLET 3 CIPROFLOXACIN CIPROFLOXACIN 250MG TABLET 2 CIPROFLOXACIN CIPROFLOXACIN 500MG TABLET 2 CIPROFLOXACIN CIPROFLOXACIN 750MG TABLET 2 CIPROFLOXACIN CIPROFLOXACIN 0.3% SOLUTION 2 CIPROFLOXACIN-DEXAMETHASO CIPRODEX SUS 0.3-0.1% SUSPENSION 3 CITALOPRAM CITALOPRAM 10MG TABLET 2 CITALOPRAM CITALOPRAM HYDROBROMIDE TAB 20MG 1 CITALOPRAM CITALOPRAM HYDROBROMIDE TAB 40MG 1 CITRIC ACID & D-GLUCONIC RENACIDIN SOL IRR SOLUTION 3 CLARITHROMYCIN CLARITHROMYCIN 250MG TABLET 2 CLARITHROMYCIN CLARITHROMYCIN 500MG TABLET 2 CLARITHROMYCIN CLARITHROMYCIN 125MG/5ML SUSPENSION 2 CLIDINIUM & CHLORDIAZEPOX CLIDINIUM & CHLORDIAZEPOX 5-2.5MG

CAPSULE 2

CLINDAMYCIN CLINDAMYCIN 150MG CAPSULE 2 CLINDAMYCIN CLINDAMYCIN 300MG CAPSULE 2 CLINDAMYCIN CLINDAMYCIN 75MG/5ML SOLUTION 2 CLINDAMYCIN CLINDAMYCIN 2% CREAM 2 CLINDAMYCIN CLINDAMYCIN 1% SOLUTION 2 CLINDAMYCIN CLINDAMYCIN 1% GEL 2 CLINDAMYCIN PHOSPHATE-BEN CLINDAMYCIN PHOSPHATE-BEN 1.2-5% GEL 2 CLOBETASOL CLOBETASOL 0.05% SOLUTION 2 CLOBETASOL CLOBETASOL 0.05% CREAM 2 CLOBETASOL CLOBETASOL 0.05% OINTMENT 2 CLOMIPHENE CITRATE CLOMIPHENE 50MG TABLET 2 CLONAZEPAM CLONAZEPAM 0.5MG TABLET 2 CLONAZEPAM CLONAZEPAM 2MG TABLET 2 CLONIDINE CLONIDINE HCL TAB 0.1MG 1 CLONIDINE CLONIDINE HCL TAB 0.2MG 1 CLOPIDOGREL CLOPIDOGREL 75MG TABLET 2

Generated by Hawaii Pharmacy Analytics Services on November 11, 2013 at 4:07:53 PM

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Page 8: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier CLOPIDOGREL CLOPIDOGREL 300MG TABLET 2 CLORAZEPATE CLORAZEPATE 3.75MG TABLET 2 CLORAZEPATE CLORAZEPATE 7.5MG TABLET 2 CLORAZEPATE CLORAZEPATE 15MG TABLET 2 CLOTRIMAZOLE CLOTRIMAZOLE 10MG LOZENGE 2 CODEINE CODEINE 30MG TABLET 2 CODEINE CODEINE 60MG TABLET 3 COLCHICINE COLCHICINE 0.6MG TABLET 2 COLCHICINE W/ PROBENECID COLCHICINE W/ PROBENECID 500-0.5MG

TABLET 2

COLLAGENASE SANTYL 250UNIT/GM OINTMENT 3 CRESYL SOLUTION 3 CROMOLYN CROMOLYN 20MG/2ML MIST 2 CROMOLYN CROMOLYN 4% SOLUTION 2 CROTAMITON EURAX 10% CREAM 3 CYCLOBENZAPRINE CYCLOBENZAPRINE 10MG TABLET 2 CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 50MG TABLET 2 CYCLOSPORINE RESTASIS EMU 0.05% EMULSION 3 CYCLOSPORINE CYCLOSPORINE 25MG CAPSULE 2 CYCLOSPORINE CYCLOSPORINE 100MG CAPSULE 2 CYCLOSPORINE CYCLOSPORINE 100MG/ML SOLUTION 2 CYPROHEPTADINE CYPROHEPTADINE 4MG TABLET 2 CYPROHEPTADINE CYPROHEPTADINE 2MG/5ML SYRUP 2 DANAZOL DANAZOL 200MG CAPSULE 2 DAPSONE DAPSONE 100MG TABLET 2 DARUNAVIR PREZISTA 600MG TABLET 3 DARUNAVIR PREZISTA 800MG TABLET 3 DEFERASIROX EXJADE 250MG TBSO 3 DEFERASIROX EXJADE 500MG TBSO 3 DELAVIRDINE RESCRIPTOR 200MG TABLET 3 DEMECLOCYCLINE DEMECLOCYCLINE 150MG TABLET 2 DENOSUMAB PROLIA 60MG/ML SOLUTION 3 DESIPRAMINE DESIPRAMINE 10MG TABLET 2 DESIPRAMINE DESIPRAMINE 25MG TABLET 2 DESIPRAMINE DESIPRAMINE 50MG TABLET 2 DESMOPRESSIN DESMOPRESSIN 0.01% SOLUTION 2 DESMOPRESSIN DESMOPRESSIN 0.01% SOLUTION 2 DEXAMETHASONE DEXAMETHASONE 0.5MG TABLET 2 DEXAMETHASONE DEXAMETHASONE 0.75MG TABLET 2 DEXAMETHASONE DEXAMETHASONE 1.5MG TABLET 2 DEXAMETHASONE DEXAMETHASONE 4MG TABLET 2 DEXAMETHASONE DEXAMETHASONE 0.5MG/5ML ELIX 2 DEXAMETHASONE DEXAMETHASONE 0.5MG/5ML SOLUTION 2

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Page 9: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier DEXTROAMPHETAMINE DEXTROAMPHETAMINE 5MG TABLET 2 DEXTROAMPHETAMINE DEXTROAMPHETAMINE 5MG CAPSULE SA 2 DEXTROAMPHETAMINE DEXTROAMPHETAMINE 10MG CAPSULE SA 2 DEXTROAMPHETAMINE DEXTROAMPHETAMINE 15MG CAPSULE SA 2 DIAZEPAM DIAZEPAM 2MG TABLET 2 DIAZEPAM DIAZEPAM 5MG TABLET 2 DIAZEPAM DIAZEPAM 10MG TABLET 2 DIAZEPAM DIAZEPAM 1MG/ML SOLUTION 2 DIAZEPAM DIAZEPAM 2.5MG GEL 2 DIAZEPAM DIAZEPAM 10MG GEL 2 DIAZEPAM DIAZEPAM 20MG GEL 2 DICLOFENAC DICLOFENAC 50MG TABLET EC 2 DICLOFENAC DICLOFENAC 75MG TABLET EC 2 DICLOFENAC DICLOFENAC 0.1% SOLUTION 2 DICLOXACILLIN DICLOXACILLIN 250MG CAPSULE 2 DICLOXACILLIN DICLOXACILLIN 500MG CAPSULE 2 DICYCLOMINE DICYCLOMINE 10MG CAPSULE 2 DICYCLOMINE DICYCLOMINE 20MG TABLET 2 DICYCLOMINE DICYCLOMINE 10MG/5ML SOLUTION 3 DIDANOSINE DIDANOSINE 400MG CPDR 2 DIETHYLPROPION DIETHYLPROPION 25MG TABLET 3 DIETHYLPROPION DIETHYLPROPION 75MG TB24 2 DIFLORASONE DIFLORASONE 0.05% OINTMENT 2 DIFLUNISAL DIFLUNISAL 500MG TABLET 2 DIGOXIN DIGOXIN TAB 0.125MG 1 DIGOXIN DIGOXIN TAB 0.25MG 1 DIGOXIN DIGOXIN 0.05MG/ML SOLUTION 3 DIHYDROERGOTAMINE DIHYDROERGOTAMINE 1MG/ML SOLUTION 2 DILTIAZEM DILTIAZEM HCL TAB 30MG 1 DILTIAZEM DILTIAZEM HCL TAB 60MG 1 DILTIAZEM DILTIAZEM HCL TAB 90MG 1 DILTIAZEM DILTIAZEM 120MG CP24 2 DILTIAZEM DILTIAZEM 180MG CP24 2 DILTIAZEM DILTIAZEM 240MG CP24 2 DIPHENOXYLATE W/ ATROPINE DIPHENOXYLATE W/ ATROPINE 2.5MG TABLET 2 DIPHENOXYLATE W/ ATROPINE DIPHENOXYLATE W/ ATROPINE 2.5/5ML LIQUID 2 DIPYRIDAMOLE DIPYRIDAMOLE 25MG TABLET 2 DIPYRIDAMOLE DIPYRIDAMOLE 75MG TABLET 2 DISOPYRAMIDE DISOPYRAMIDE 100MG CAPSULE 2 DISOPYRAMIDE DISOPYRAMIDE 150MG CAPSULE 2 DISOPYRAMIDE NORPACE 100MG CP12 3 DISOPYRAMIDE NORPACE 150MG CP12 3 DISULFIRAM DISULFIRAM 250MG TABLET 2

Generated by Hawaii Pharmacy Analytics Services on November 11, 2013 at 4:07:53 PM

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Page 10: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier DIVALPROEX DIVALPROEX 125MG TABLET EC 2 DIVALPROEX DIVALPROEX 250MG TABLET EC 2 DIVALPROEX DIVALPROEX 500MG TABLET EC 2 DIVALPROEX DIVALPROEX 125MG CPSP 2 DIVALPROEX DIVALPROEX 250MG TB24 2 DIVALPROEX DIVALPROEX 500MG TB24 2 DONEPEZIL DONEPEZIL 10MG TABLET 2 DORNASE ALFA PULMOZYME 1MG/ML SOLUTION 3 DORZOLAMIDE DORZOLAMIDE 2% SOLUTION 2 DORZOLAMIDE HCL-TIMOLOL DORZOLAMIDE HCL/TIMOLOL MAL SOL 2-

0.5%OP SOLUTION 2

DOXAZOSIN DOXAZOSIN MESYLATE TAB 1MG 1 DOXAZOSIN DOXAZOSIN MESYLATE TAB 2MG 1 DOXAZOSIN DOXAZOSIN MESYLATE TAB 4MG 1 DOXAZOSIN DOXAZOSIN MESYLATE TAB 8MG 1 DOXEPIN DOXEPIN HCL CAP 10MG 1 DOXEPIN DOXEPIN HCL CAP 25MG 1 DOXEPIN DOXEPIN HCL CAP 50MG 1 DOXEPIN PRUDOXIN 5% CREAM 3 DOXYCYCLINE DOXYCYCLINE 50MG TABLET 2 DOXYCYCLINE DOXYCYCLINE 100MG TABLET 2 DOXYCYCLINE VIBRAMYCIN 25MG/5ML SUSPENSION 3 DOXYCYCLINE DOXYCYCLINE 50MG CAPSULE 2 DOXYCYCLINE DOXYCYCLINE 100MG CAPSULE 2 DOXYCYCLINE DOXYCYCLINE 20MG TABLET 2 DRONEDARONE MULTAQ 400MG TABLET 3 DULOXETINE CYMBALTA 20MG CPEP 3 DULOXETINE CYMBALTA 30MG CPEP 3 DULOXETINE CYMBALTA 60MG CPEP 3 ECONAZOLE NITRATE ECONAZOLE 1% CREAM 2 EFAVIRENZ SUSTIVA 200MG CAPSULE 3 EFAVIRENZ SUSTIVA 600MG TABLET 3 EFAVIRENZ-EMTRICITABINE-T ATRIPLA TAB TABLET 3 ELVITEGRAVIR-COBICISTAT-E STRIBILD TAB TABLET 3 EMTRICITABINE-RILPIVIRINE COMPLERA TAB TABLET 3 EMTRICITABINE-TENOFOVIR TRUVADA TAB TABLET 3 ENALAPRIL ENALAPRIL 1MG/ML SUSPENSION 2 ENOXAPARIN ENOXAPARIN 30MG/0.3ML SOLUTION 2 ENOXAPARIN ENOXAPARIN 40MG/0.4ML SOLUTION 2 ENOXAPARIN ENOXAPARIN 60MG/0.6ML SOLUTION 2 ENOXAPARIN ENOXAPARIN 80MG/0.8ML SOLUTION 2 ENOXAPARIN ENOXAPARIN 100MG/ML SOLUTION 2 ENOXAPARIN ENOXAPARIN 120MG/0.8ML SOLUTION 2

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Page 11: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier ENOXAPARIN ENOXAPARIN 150MG/ML SOLUTION 2 ENTACAPONE ENTACAPONE 200MG TABLET 2 ENTECAVIR BARACLUDE 0.5MG TABLET 3 ENTECAVIR BARACLUDE 1MG TABLET 3 ENTECAVIR BARACLUDE 0.05MG/ML SOLUTION 3 EPINEPHRINE EPIPEN-JR 1:2000 MISCELL. 3 EPINEPHRINE EPIPEN 0.3MG/0.3ML MISCELL. 3 EPINEPHRINE ADRENALIN 0.1% SOLUTION 3 EPOETIN ALFA PROCRIT 10000UNIT/ML SOLUTION 3 EPOETIN ALFA PROCRIT 20000UNIT/ML SOLUTION 3 EPOETIN ALFA PROCRIT 40000UNIT/ML SOLUTION 3 ERGOCALCIFEROL ERGOCALCIFEROL 50000IU CAPSULE 2 ERGOLOID ERGOLOID 1MG TABLET 2 ERGOTAMINE W/ CAFFEINE ERGOTAMINE W/ CAFFEINE 2/100MG SUPPOS. 2 ERLOTINIB TARCEVA 25MG TABLET 3 ERLOTINIB TARCEVA 100MG TABLET 3 ERLOTINIB TARCEVA 150MG TABLET 3 ERYTHROMYCIN ERYTHROMYCIN 250MG TABLET EC 2 ERYTHROMYCIN ERYTHROMYCIN 333MG TABLET EC 2 ERYTHROMYCIN ERYTHROMYCIN 400MG TABLET 2 ERYTHROMYCIN ERYPED 200MG/5ML SUSPENSION 3 ERYTHROMYCIN ERYPED 400MG/5ML SUSPENSION 3 ERYTHROMYCIN ERYTHROMYCIN 5MG/GM OINTMENT 2 ERYTHROMYCIN ERYTHROMYCIN 2% SOLUTION 2 ERYTHROMYCIN-SULFISOXAZOL ERYTHROMYCIN-SULFISOXAZOL 200-600ML

SUSPENSION 2

ESCITALOPRAM OXALATE ESCITALOPRAM 5MG TABLET 2 ESCITALOPRAM OXALATE ESCITALOPRAM 10MG TABLET 2 ESCITALOPRAM OXALATE ESCITALOPRAM 20MG TABLET 2 ESTERIFIED ESTROGENS & ME ESTERIFIED ESTROGENS & ME TAB TABLET 2 ESTERIFIED ESTROGENS & ME ESTERIFIED ESTROGENS & ME TAB TABLET 2 ESTRADIOL ESTRADIOL 0.5MG TABLET 2 ESTRADIOL ESTRADIOL 1MG TABLET 2 ESTRADIOL ESTRADIOL 2MG TABLET 2 ESTRADIOL ESTRADIOL 0.05MG/24HR PTWK 2 ESTRADIOL ESTRADIOL 0.1MG/24HR PTWK 2 ESTRADIOL ESTRING 2MG MISCELL. 3 ESTROGENS, CONJUGATED PREMARIN 0.625MG/GM CREAM 3 ESTROPIPATE ESTROPIPATE 0.75MG TABLET 2 ESTROPIPATE ESTROPIPATE 1.5MG TABLET 2 ESTROPIPATE ESTROPIPATE 3MG TABLET 2 ETANERCEPT ENBREL 50MG/ML SOLUTION 3 ETHAMBUTOL ETHAMBUTOL 400MG TABLET 2

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Page 12: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier ETHOSUXIMIDE ETHOSUXIMIDE 250MG CAPSULE 2 ETODOLAC ETODOLAC 200MG CAPSULE 2 ETODOLAC ETODOLAC 300MG CAPSULE 2 ETODOLAC ETODOLAC 400MG TABLET 2 ETODOLAC ETODOLAC 500MG TABLET 2 ETOPOSIDE ETOPOSIDE 50MG CAPSULE 2 EZETIMIBE ZETIA 10MG TABLET 3 EZETIMIBE-SIMVASTATIN VYTORIN TAB 10-80MG TABLET 3 FAMCICLOVIR FAMCICLOVIR 500MG TABLET 2 FEBUXOSTAT ULORIC 40MG TABLET 3 FEBUXOSTAT ULORIC 80MG TABLET 3 FELODIPINE FELODIPINE 2.5MG TB24 2 FELODIPINE FELODIPINE 5MG TB24 2 FELODIPINE FELODIPINE 10MG TB24 2 FENOFIBRATE FENOFIBRATE 54MG TABLET 2 FENOFIBRATE FENOFIBRATE 160MG TABLET 2 FENTANYL FENTANYL 25MCG/HR PT72 2 FENTANYL FENTANYL 50MCG/HR PT72 2 FENTANYL FENTANYL 75MCG/HR PT72 2 FENTANYL FENTANYL 100MCG/HR PT72 2 FILGRASTIM NEUPOGEN 300MCG/0.5ML SOLUTION 3 FILGRASTIM NEUPOGEN 480MCG/0.8ML SOLUTION 3 FINASTERIDE FINASTERIDE 5MG TABLET 2 FLAVOXATE FLAVOXATE 100MG TABLET 2 FLECAINIDE FLECAINIDE 100MG TABLET 2 FLUCONAZOLE FLUCONAZOLE 100MG TABLET 2 FLUCONAZOLE FLUCONAZOLE 150MG TABLET 2 FLUCONAZOLE FLUCONAZOLE 200MG TABLET 2 FLUDROCORTISONE FLUDROCORTISONE 0.1MG TABLET 2 FLUOCINOLONE FLUOCINOLONE 0.01% OIL 2 FLUOCINOLONE FLUOCINOLONE 0.01% SOLUTION 2 FLUOCINOLONE FLUOCINOLONE 0.01% CREAM 2 FLUOCINONIDE FLUOCINONIDE 0.05% SOLUTION 2 FLUOCINONIDE FLUOCINONIDE 0.05% GEL 2 FLUOCINONIDE FLUOCINONIDE 0.05% OINTMENT 2 FLUOCINONIDE FLUOCINONIDE 0.05% CREAM 2 FLUOROMETHOLONE FLUOROMETHOLONE 0.1% SUSPENSION 2 FLUOROMETHOLONE FML OIN 0.1% OINTMENT 3 FLUOROURACIL CARAC 0.5% CREAM 3 FLUOROURACIL FLUOROURACIL 5% CREAM 2 FLUOXETINE FLUOXETINE HCL CAP 10MG 1 FLUOXETINE FLUOXETINE HCL CAP 20MG 1 FLUOXYMESTERONE FLUOXYMESTERONE 10MG TABLET 2

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Page 13: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier FLUPHENAZINE FLUPHENAZINE 2.5MG TABLET 2 FLURANDRENOLIDE CORDRAN 4MCG/SQCM TAPE 3 FLUTICASONE FLUTICASONE 50MCG/ACT SUSPENSION 2 FLUTICASONE-SALMETEROL ADVAIR DISKUS AER 100/50 AEPB 3 FLUTICASONE-SALMETEROL ADVAIR DISKUS AER 250/50 AEPB 3 FLUTICASONE-SALMETEROL ADVAIR DISKUS AER 500/50 AEPB 3 FOLIC ACID FOLIC 1MG/ML SOLUTION 2 FUROSEMIDE FUROSEMIDE TAB 20MG 1 FUROSEMIDE FUROSEMIDE TAB 40MG 1 FUROSEMIDE FUROSEMIDE 10MG/ML SOLUTION 2 GABAPENTIN GABAPENTIN 100MG CAPSULE 2 GABAPENTIN GABAPENTIN 300MG CAPSULE 2 GABAPENTIN GABAPENTIN 400MG CAPSULE 2 GABAPENTIN GABAPENTIN 600MG TABLET 2 GABAPENTIN GABAPENTIN 800MG TABLET 2 GALANTAMINE GALANTAMINE 4MG TABLET 2 GALANTAMINE GALANTAMINE 8MG TABLET 2 GALANTAMINE GALANTAMINE 12MG TABLET 2 GALANTAMINE GALANTAMINE 8MG CP24 2 GALANTAMINE GALANTAMINE 16MG CP24 2 GALANTAMINE GALANTAMINE 24MG CP24 2 GATIFLOXACIN GATIFLOXACIN 0.5% SOLUTION 2 GEMFIBROZIL GEMFIBROZIL 600MG TABLET 2 GENTAMICIN GENTAMICIN 0.3% SOLUTION 2 GENTAMICIN GENTAMICIN 0.3% SOLUTION 2 GENTAMICIN GENTAMICIN 0.3% OINTMENT 2 GENTAMICIN GENTAMICIN 0.1% CREAM 2 GENTAMICIN GENTAMICIN 0.1% OINTMENT 2 GENTAMICIN-PREDNISOLONE PRED-G SUS OP SUSPENSION 3 GLATIRAMER COPAXONE 20MG/ML KIT 3 GLIPIZIDE GLIPIZIDE TAB 5MG 1 GLIPIZIDE GLIPIZIDE TAB 10MG 1 GLIPIZIDE GLIPIZIDE 2.5MG TB24 2 GLIPIZIDE GLIPIZIDE 5MG TB24 2 GLIPIZIDE GLIPIZIDE 10MG TB24 2 GLIPIZIDE-METFORMIN GLIPIZIDE-METFORMIN HCL 5-500MG TABLET 2 GLUCAGON GLUCAGON 1MG KIT 3 GLUCAGON GLUCAGEN 1MG SOLUTION 3 GLYBURIDE GLYBURIDE 2.5MG TABLET 2 GLYBURIDE GLYBURIDE 5MG TABLET 2 GLYBURIDE-METFORMIN GLYBURIDE-METFORMIN 5/500MG TABLET 2 GLYCOPYRROLATE GLYCOPYRROLATE 1MG TABLET 2 GRISEOFULVIN GRISEOFULVIN 250MG TABLET 2

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Page 14: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier GUAIFENESIN-CODEINE GUAIFENESIN-CODEINE AC SYRUP 2 HALOPERIDOL HALOPERIDOL 0.5MG TABLET 2 HALOPERIDOL HALOPERIDOL 2MG TABLET 2 HALOPERIDOL HALOPERIDOL 5MG TABLET 2 HALOPERIDOL HALOPERIDOL 2MG/ML LIQUID 2 HYDRALAZINE HYDRALAZINE HCL TAB 10MG 1 HYDRALAZINE HYDRALAZINE HCL TAB 25MG 1 HYDRALAZINE HYDRALAZINE 50MG TABLET 2 HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE TAB 25MG 1 HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE TAB 50MG 1 HYDROCODONE POLISTIREX-CH HYDROCODONE POLISTIREX-CH POLS LIQUID 2 HYDROCODONE W/ HOMATROPIN HYDROCODONE W/ HOMATROPIN 5-1.5/5ML

SYRUP 2

HYDROCODONE-ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 10-325MG TABLET

2

HYDROCODONE-ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 5-325MG TABLET

2

HYDROCODONE-ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET

2

HYDROCODONE-ACETAMINOPHEN HYDROCODONE-ACETAMINOPHEN 7.5-325ML SOLUTION

2

HYDROCORTISONE HYDROCORTISONE 5MG TABLET 2 HYDROCORTISONE HYDROCORTISONE 10MG TABLET 2 HYDROCORTISONE HYDROCORTISONE 20MG TABLET 2 HYDROCORTISONE HYDROCORTISONE 25MG SUPPOS. 2 HYDROCORTISONE HYDROCORTISONE 100MG/60ML ENEMA 2 HYDROCORTISONE HYDROCORTISONE ACETATE W/ 2.5-1% CREAM 2 HYDROCORTISONE HYDROCORTISONE ACETATE W/ AER FOAM 2 HYDROCORTISONE HYDROCORTISONE 2.5% CREAM 2 HYDROCORTISONE HYDROCORTISONE 2.5% OINTMENT 2 HYDROCORTISONE HYDROCORTISONE 0.2% CREAM 2 HYDROCORTISONE HYDROCORTISONE 0.2% OINTMENT 2 HYDROCORTISONE BUTYRATE HYDROCORTISONE 0.1% SOLUTION 2 HYDROCORTISONE BUTYRATE HYDROCORTISONE 0.1% CREAM 2 HYDROCORTISONE BUTYRATE HYDROCORTISONE 0.1% OINTMENT 2 HYDROCORTISONE W/ACETIC ACETIC ACID/HYDROCORTISONE DRO

SOLUTION 2

HYDROMORPHONE HYDROMORPHONE 2MG TABLET 2 HYDROXYCHLOROQUINE HYDROXYCHLOROQUINE 200MG TABLET 2 HYDROXYUREA HYDROXYUREA 500MG CAPSULE 2 HYDROXYZINE HYDROXYZINE 10MG/5ML SYRUP 2 IBUPROFEN IBUPROFEN 400MG TABLET 2 IBUPROFEN IBUPROFEN 600MG TABLET 2

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Page 15: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier IBUPROFEN IBUPROFEN 800MG TABLET 2 IMATINIB GLEEVEC 100MG TABLET 3 IMATINIB GLEEVEC 400MG TABLET 3 IMIPRAMINE IMIPRAMINE 25MG TABLET 2 IMIPRAMINE IMIPRAMINE 50MG TABLET 2 IMIQUIMOD IMIQUIMOD 5% CREAM 2 IMMUNE GLOBULIN HIZENTRA 1GM/5ML SOLUTION 3 IMMUNE GLOBULIN HIZENTRA 2GM/10ML SOLUTION 3 IMMUNE GLOBULIN HIZENTRA 4GM/20ML SOLUTION 3 INDINAVIR CRIXIVAN 400MG CAPSULE 3 INDOMETHACIN INDOMETHACIN 25MG CAPSULE 2 INDOMETHACIN INDOMETHACIN 50MG CAPSULE 2 INDOMETHACIN INDOMETHACIN 50MG SUPPOS. 2 INSULIN GLARGINE LANTUS INJ 100U/ML SOLUTION 3 INSULIN ISOPHANE HUMULIN N INJ U-100 SUSPENSION 2 INSULIN ISOPHANE & REG HUMULIN 70/30 SUSPENSION 2 INSULIN LISPRO HUMALOG INJ 100U/ML SOLUTION 3 INSULIN LISPRO PROTAMINE HUMALOG MIX 75/25 SUSPENSION 3 INSULIN REGULAR HUMULIN R INJ U-100 SOLUTION 2 INSULIN REGULAR HUMULIN R INJ U-500 SOLUTION 3 INTERFERON BETA-1B INTERFERON BETA-1B 0.3MG SOLUTION 2 IODOQUINOL-HC IODOQUINOL-HC CREAM 2 IPRATROPIUM IPRATROPIUM 0.03% SOLUTION 2 IPRATROPIUM IPRATROPIUM BROMIDE SOL INHAL UD 1 IPRATROPIUM ATROVENT 17MCG/ACT AERO SPRAY 3 IPRATROPIUM-ALBUTEROL COMBIVENT RESPIMAT AER AERO SPRAY 3 ISONIAZID ISONIAZID 100MG TABLET 2 ISONIAZID ISONIAZID 300MG TABLET 2 ISONIAZID ISONIAZID 50MG/5ML SYRUP 2 ISONIAZID & RIFAMPIN ISONIAZID & RIFAMPIN CAP CAPSULE 2 ISOSORBIDE ISOSORBIDE 10MG TABLET 2 ISOSORBIDE ISOSORBIDE 20MG TABLET 2 ISOSORBIDE ISOSORBIDE 40MG TABLET SA 2 ISOTRETINOIN ISOTRETINOIN 10MG CAPSULE 2 ISOTRETINOIN ISOTRETINOIN 30MG CAPSULE 2 ISOTRETINOIN ISOTRETINOIN 40MG CAPSULE 2 ITRACONAZOLE ITRACONAZOLE 100MG CAPSULE 2 ITRACONAZOLE SPORANOX 10MG/ML SOLUTION 3 KETOCONAZOLE KETOCONAZOLE 200MG TABLET 2 KETOROLAC KETOROLAC 0.4% SOLUTION 2 LABETALOL LABETALOL 200MG TABLET 2 LABETALOL LABETALOL 10MG/ML SUSPENSION 2 LACTULOSE LACTULOSE 10GM/15ML SOLUTION 2

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Page 16: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier LACTULOSE LACTULOSE 10GM/15ML SOLUTION 2 LAMIVUDINE LAMIVUDINE 150MG TABLET 2 LAMIVUDINE LAMIVUDINE 300MG TABLET 2 LAMIVUDINE-ZIDOVUDINE LAMIVUDINE-ZIDOVUDINE 150/300MG TABLET 2 LAMOTRIGINE LAMOTRIGINE 25MG TABLET 2 LAMOTRIGINE LAMOTRIGINE 100MG TABLET 2 LAMOTRIGINE LAMOTRIGINE 150MG TABLET 2 LAMOTRIGINE LAMOTRIGINE 200MG TABLET 2 LAMOTRIGINE LAMOTRIGINE 25MG TAB CHEW 2 LATANOPROST LATANOPROST 0.005% SOLUTION 2 LEFLUNOMIDE LEFLUNOMIDE 20MG TABLET 2 LENALIDOMIDE REVLIMID 5MG CAPSULE 3 LENALIDOMIDE REVLIMID 10MG CAPSULE 3 LETROZOLE LETROZOLE 2.5MG TABLET 2 LEUCOVORIN LEUCOVORIN 5MG TABLET 2 LEVETIRACETAM LEVETIRACETAM 250MG TABLET 2 LEVETIRACETAM LEVETIRACETAM 500MG TABLET 2 LEVETIRACETAM LEVETIRACETAM 750MG TABLET 2 LEVETIRACETAM LEVETIRACETAM 1000MG TABLET 2 LEVOBUNOLOL LEVOBUNOLOL 0.5% SOLUTION 2 LEVOCARNITINE LEVOCARNITINE 1GM/10ML SOLUTION 2 LEVOFLOXACIN LEVOFLOXACIN 250MG TABLET 2 LEVOFLOXACIN LEVOFLOXACIN 500MG TABLET 2 LEVOFLOXACIN LEVOFLOXACIN 750MG TABLET 2 LEVOFLOXACIN LEVOFLOXACIN 25MG/ML SOLUTION 2 LEVOTHYROXINE LEVOTHYROXINE 25MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 50MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 75MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 88MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 100MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 112MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 125MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 137MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 150MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 175MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 200MCG TABLET 2 LEVOTHYROXINE LEVOTHYROXINE 300MCG TABLET 2 LIDOCAINE LIDOCAINE 2% SOLUTION 2 LIDOCAINE LIDOCAINE 5% OINTMENT 2 LIDOCAINE LIDOCAINE 5% PTCH 2 LIDOCAINE LIDOCAINE 4% SOLUTION 2 LIDOCAINE LIDOCAINE 2% GEL 2 LIDOCAINE-PRILOCAINE LIDOCAINE-PRILOCAINE 2.5-2.5% CREAM 2

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Page 17: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier LIDOCAINE-PRILOCAINE LIDOCAINE-PRILOCAINE 2.5-2.5% KIT 2 LINEZOLID ZYVOX 600MG TABLET 3 LINEZOLID ZYVOX 100MG/5ML SUSPENSION 3 LIOTHYRONINE LIOTHYRONINE 25MCG TABLET 2 LISINOPRIL LISINOPRIL TAB 2.5MG 1 LISINOPRIL LISINOPRIL TAB 5MG 1 LISINOPRIL LISINOPRIL TAB 10MG 1 LISINOPRIL LISINOPRIL TAB 20MG 1 LISINOPRIL LISINOPRIL 30MG TABLET 2 LISINOPRIL LISINOPRIL TAB 40MG 1 LISINOPRIL & HYDROCHLOROT LISINOPRIL/HYDROCHLOROTHIAZ TAB 10-12.5 1 LISINOPRIL & HYDROCHLOROT LISINOPRIL/HYDROCHLOROTHIAZ TAB 20-12.5 1 LISINOPRIL & HYDROCHLOROT LISINOPRIL/HYDROCHLOROTHIAZ TAB 20-25MG 1 LITHIUM LITHIUM 300MG CAPSULE 2 LITHIUM LITHIUM 300MG TABLET SA 2 LITHIUM LITHIUM 450MG TABLET SA 2 LOPINAVIR-RITONAVIR KALETRA TAB 200-50MG TABLET 3 LORAZEPAM LORAZEPAM 0.5MG TABLET 2 LORAZEPAM LORAZEPAM 1MG TABLET 2 LORAZEPAM LORAZEPAM 2MG TABLET 2 LORAZEPAM LORAZEPAM 2MG/ML LIQUID 2 LOSARTAN LOSARTAN 25MG TABLET 2 LOSARTAN LOSARTAN 50MG TABLET 2 LOSARTAN LOSARTAN 100MG TABLET 2 LOSARTAN/HYDROCHLOROTHIAZIDE CANDESARTAN CILEXETIL-HYD 16-12.5MG

TABLET 2

LOSARTAN/HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM & HYDR 50-12.5MG TABLET

2

LOSARTAN/HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM & HYDR 100-12.5MG TABLET

2

LOSARTAN/HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM & HYDR 100-25MG TABLET

2

MALATHION MALATHION 0.5% LOTION 2 MEDROXYPROGESTERONE MEDROXYPROGESTERONE 2.5MG TABLET 2 MEDROXYPROGESTERONE MEDROXYPROGESTERONE 5MG TABLET 2 MEDROXYPROGESTERONE MEDROXYPROGESTERONE 10MG TABLET 2 MEFLOQUINE MEFLOQUINE 250MG TABLET 2 MEGESTROL MEGESTROL 40MG TABLET 2 MEGESTROL MEGESTROL 40MG/ML SUSPENSION 2 MELOXICAM MELOXICAM 7.5MG TABLET 2 MELOXICAM MELOXICAM 15MG TABLET 2 MELPHALAN ALKERAN 2MG TABLET 3 MEMANTINE NAMENDA 5MG TABLET 3

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Page 18: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier MEMANTINE NAMENDA 10MG TABLET 3 MEMANTINE NAMENDA TITRATION PAK TAB 5-10MG UD

TABLET 3

MERCAPTOPURINE MERCAPTOPURINE 50MG TABLET 2 MESALAMINE LIALDA 1.2GM TABLET EC 3 MESALAMINE MESALAMINE 4GM ENEMA 2 METFORMIN METFORMIN HCL TAB 500MG 1 METFORMIN METFORMIN HCL TAB 850MG 1 METFORMIN METFORMIN HCL TAB 1000MG 1 METHADONE METHADONE 5MG TABLET 2 METHADONE METHADONE 10MG TABLET 2 METHAZOLAMIDE METHAZOLAMIDE 50MG TABLET 2 METHENAMINE METHENAMINE 1GM TABLET 2 METHIMAZOLE METHIMAZOLE 5MG TABLET 2 METHIMAZOLE METHIMAZOLE 10MG TABLET 2 METHOCARBAMOL METHOCARBAMOL 500MG TABLET 2 METHOCARBAMOL METHOCARBAMOL 750MG TABLET 2 METHOTREXATE METHOTREXATE 2.5MG TABLET 2 METHSUXIMIDE CELONTIN 300MG CAPSULE 3 METHYLDOPA METHYLDOPA TAB 250MG 1 METHYLDOPA METHYLDOPA TAB 500MG 1 METHYLERGONOVINE METHYLERGONOVINE 0.2MG TABLET 2 METHYLNALTREXONE RELISTOR 12MG/0.6ML KIT 3 METHYLPHENIDATE METHYLPHENIDATE 10MG CAPSULE SA 2 METHYLPHENIDATE METHYLPHENIDATE 20MG CAPSULE SA 2 METHYLPHENIDATE METHYLPHENIDATE 30MG CAPSULE SA 2 METHYLPHENIDATE METHYLPHENIDATE 40MG CAPSULE SA 2 METHYLPHENIDATE METHYLPHENIDATE 50MG CAPSULE SA 2 METHYLPHENIDATE METHYLPHENIDATE 60MG CAPSULE SA 2 METHYLPHENIDATE METHYLPHENIDATE 5MG TABLET 2 METHYLPHENIDATE METHYLPHENIDATE 10MG TABLET 2 METHYLPHENIDATE METHYLPHENIDATE 20MG TABLET SA 2 METHYLPHENIDATE METHYLPHENIDATE 18MG TABLET SA 2 METHYLPHENIDATE METHYLPHENIDATE 27MG TABLET SA 2 METHYLPHENIDATE METHYLPHENIDATE 36MG TABLET SA 2 METHYLPHENIDATE METHYLPHENIDATE 54MG TABLET SA 2 METHYLPREDNISOLONE METHYLPREDNISOLONE 4MG TABLET 2 METHYLPREDNISOLONE METHYLPREDNISOLONE 16MG TABLET 2 METHYLTESTOSTERONE METHYLTESTOSTERONE 10MG TABLET 2 METOCLOPRAMIDE METOCLOPRAMIDE 10MG TABLET 2 METOCLOPRAMIDE METOCLOPRAMIDE 5MG/5ML SOLUTION 2 METOLAZONE METOLAZONE 2.5MG TABLET 2 METOLAZONE METOLAZONE 5MG TABLET 2

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Page 19: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier METOPROLOL METOPROLOL 25MG TB24 2 METOPROLOL METOPROLOL 50MG TB24 2 METOPROLOL METOPROLOL 100MG TB24 2 METOPROLOL METOPROLOL TARTRATE TAB 25MG 1 METOPROLOL METOPROLOL TARTRATE TAB 50MG 1 METRONIDAZOLE METRONIDAZOLE 250MG TABLET 2 METRONIDAZOLE METRONIDAZOLE 500MG TABLET 2 METRONIDAZOLE METRONIDAZOLE 0.75% CREAM 2 METRONIDAZOLE METRONIDAZOLE 0.75% GEL 2 MEXILETINE MEXILETINE 150MG CAPSULE 2 MIDAZOLAM MIDAZOLAM 2MG/ML SYRUP 2 MIDODRINE MIDODRINE 2.5MG TABLET 2 MIDODRINE MIDODRINE 5MG TABLET 2 MIDODRINE MIDODRINE 10MG TABLET 2 MINOCYCLINE MINOCYCLINE 50MG CAPSULE 2 MINOXIDIL MINOXIDIL 2.5MG TABLET 2 MINOXIDIL MINOXIDIL 10MG TABLET 2 MIRTAZAPINE MIRTAZAPINE 7.5MG TABLET 2 MIRTAZAPINE MIRTAZAPINE 15MG TABLET 2 MIRTAZAPINE MIRTAZAPINE 30MG TABLET 2 MISOPROSTOL MISOPROSTOL 100MCG TABLET 2 MISOPROSTOL MISOPROSTOL 200MCG TABLET 2 MOMETASONE ASMANEX 110MCG/INH AEPB 3 MOMETASONE ASMANEX 220MCG/INH AEPB 3 MOMETASONE MOMETASONE 0.1% CREAM 2 MOMETASONE MOMETASONE 0.1% OINTMENT 2 MOMETASONE FUROATE-FORMOT DULERA AER 100-5MCG AEROSOL 3 MOMETASONE FUROATE-FORMOT DULERA AER 200-5MCG AEROSOL 3 MONTELUKAST MONTELUKAST 10MG TABLET 2 MONTELUKAST MONTELUKAST 4MG TAB CHEW 2 MONTELUKAST MONTELUKAST 5MG TAB CHEW 2 MORPHINE MORPHINE 15MG TABLET 3 MORPHINE MORPHINE 30MG TABLET 3 MORPHINE MORPHINE 15MG TABLET SA 2 MORPHINE MORPHINE 30MG TABLET SA 2 MORPHINE MORPHINE 60MG TB12 2 MORPHINE MORPHINE 100MG TB12 2 MORPHINE MORPHINE 10MG/5ML SOLUTION 2 MORPHINE MORPHINE 20MG/ML SOLUTION 2 MORPHINE MORPHINE SULFATE SUP 10MG UD SUPPOS. 3 MOXIFLOXACIN AVELOX 400MG TABLET 3 MOXIFLOXACIN VIGAMOX DRO 0.5% SOLUTION 3 MUPIROCIN BACTROBAN 2% OINTMENT 3

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Page 20: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier MUPIROCIN MUPIROCIN 2% OINTMENT 2 MYCOPHENOLATE MYCOPHENOLATE 250MG CAPSULE 2 MYCOPHENOLATE MYCOPHENOLATE 500MG TABLET 2 NABUMETONE NABUMETONE 500MG TABLET 2 NABUMETONE NABUMETONE 750MG TABLET 2 NADOLOL NADOLOL TAB 40MG 1 NADOLOL NADOLOL 80MG TABLET 2 NAFARELIN SYNAREL 2MG/ML SOLUTION 3 NALTREXONE NALTREXONE 50MG TABLET 2 NAPHAZOLINE NAPHAZOLINE 0.1% SOLUTION 2 NAPROXEN NAPROXEN 250MG TABLET 2 NAPROXEN NAPROXEN 500MG TABLET 2 NAPROXEN NAPROXEN 275MG TABLET 2 NEFAZODONE NEFAZODONE 50MG TABLET 2 NEFAZODONE NEFAZODONE 100MG TABLET 2 NEFAZODONE NEFAZODONE 150MG TABLET 2 NEFAZODONE NEFAZODONE 200MG TABLET 2 NEFAZODONE NEFAZODONE 250MG TABLET 2 NELFINAVIR VIRACEPT 250MG TABLET 3 NEOMYCIN NEOMYCIN 500MG TABLET 2 NEOMYCIN-BACITRACIN ZN-PO NEOMYCIN/BACITRACIN/POLYMYX OIN OP

OINTMENT 2

NEOMYCIN-POLYMY-DEXAMETH NEOMYCIN-POLYMYXIN-DEXAMETH SUS 0.1% OP SUSPENSION

2

NEOMYCIN-POLYMY-DEXAMETH NEOMYCIN-POLYMYXIN-DEXAMETH OIN 0.1% OP OINTMENT

2

NEOMYCIN-POLYMY-GRAMICID NEOMYCIN/POLYMYXIN/GRAMICID SOL OP SOLUTION

2

NEOMYCIN-POLYMYXIN-HC NEOMYCIN/POLYMYXIN/HYDROCOR SUS 1% OTIC SUSPENSION

2

NEVIRAPINE NEVIRAPINE 200MG TABLET 2 NEVIRAPINE VIRAMUNE 400MG TB24 3 NICOTINE NICOTROL 10MG INHALER 3 NICOTINE NICOTINE 7MG/24HR PT24 2 NICOTINE NICOTINE 14MG/24HR PT24 2 NICOTINE NICOTINE 21MG/24HR PT24 2 NICOTINE GUM 3 NICOTINE GUM 3 NIFEDIPINE NIFEDIPINE 10MG CAPSULE 2 NIFEDIPINE NIFEDIPINE 30MG TB24 2 NIFEDIPINE NIFEDIPINE 60MG TB24 2 NIFEDIPINE NIFEDIPINE 90MG TB24 2 NILOTINIB TASIGNA 150MG CAPSULE 3

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Page 21: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier NILOTINIB TASIGNA 200MG CAPSULE 3 NIMODIPINE NIMODIPINE 30MG CAPSULE 2 NITROFURANTOIN NITROFURANTOIN 25MG/5ML SUSPENSION 2 NITROFURANTOIN MACRODANTIN 25MG CAPSULE 3 NITROFURANTOIN NITROFURANTOIN 50MG CAPSULE 2 NITROFURANTOIN NITROFURANTOIN 100MG CAPSULE 2 NITROGLYCERIN NITROGLYCERIN 2.5MG CAPSULE SA 2 NITROGLYCERIN NITROSTAT 0.3MG TAB SUBL 3 NITROGLYCERIN NITROSTAT 0.4MG TAB SUBL 3 NITROGLYCERIN NITROSTAT 0.6MG TAB SUBL 3 NITROGLYCERIN NITROGLYCERIN 0.3% OINTMENT 2 NITROGLYCERIN NITROGLYCERIN 0.1MG/HR PT24 2 NITROGLYCERIN NITROGLYCERIN 0.2MG/HR PT24 2 NITROGLYCERIN NITRO-DUR 0.3MG/HR ADH. PATCH 3 NITROGLYCERIN NITROGLYCERIN 0.4MG/HR PT24 2 NORETHINDRONE NORETHINDRONE 5MG TABLET 2 NORTRIPTYLINE NORTRIPTYLINE HCL CAP 10MG 1 NORTRIPTYLINE NORTRIPTYLINE HCL CAP 25MG 1 NORTRIPTYLINE NORTRIPTYLINE 50MG CAPSULE 2 NORTRIPTYLINE NORTRIPTYLINE 75MG CAPSULE 2 NYSTATIN NYSTATIN 500000U TABLET 2 NYSTATIN NYSTATIN 100000UNIT/ML SUSPENSION 2 NYSTATIN NYSTATIN 100000U/GM POWDER 2 NYSTATIN NYSTATIN 100000U/GM CREAM 2 NYSTATIN NYSTATIN 100000UNIT/GM OINTMENT 2 NYSTATIN-TRIAMCINOLONE NYSTATIN-TRIAMCINOLONE CRE CREAM 2 NYSTATIN-TRIAMCINOLONE NYSTATIN-TRIAMCINOLONE OIN OINTMENT 2 OCTREOTIDE OCTREOTIDE 0.1MG/ML SOLUTION 2 OCTREOTIDE OCTREOTIDE 0.5MG/ML SOLUTION 2 OFLOXACIN OFLOXACIN 0.3% SOLUTION 2 OLANZAPINE OLANZAPINE 2.5MG TABLET 2 OLANZAPINE OLANZAPINE 5MG TABLET 2 OLANZAPINE OLANZAPINE 7.5MG TABLET 2 OLANZAPINE OLANZAPINE 10MG TABLET 2 OLANZAPINE OLANZAPINE 15MG TABLET 2 OLANZAPINE OLANZAPINE 20MG TABLET 2 OMEPRAZOLE OMEPRAZOLE 2MG/ML SOLUTION 2 OMEPRAZOLE-SODIUM ZEGERID 20MG POWDER 3 OMEPRAZOLE-SODIUM ZEGERID 40MG POWDER 3 ONDANSETRON ONDANSETRON 4MG TBDP 2 ONDANSETRON ONDANSETRON 8MG TBDP 2 ONDANSETRON ONDANSETRON 4MG TABLET 2 ONDANSETRON ONDANSETRON 8MG TABLET 2

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Page 22: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier ONDANSETRON ONDANSETRON 4MG/5ML SOLUTION 2 OPHTHALMIC BSS SOL OP SOLUTION 2 OSELTAMIVIR OSELTAMIVIR 6MG/ML SUSPENSION 3 OSELTAMIVIR TAMIFLU 6MG/ML SUSPENSION 3 OXAZEPAM OXAZEPAM 10MG CAPSULE 2 OXAZEPAM OXAZEPAM 15MG CAPSULE 2 OXAZEPAM OXAZEPAM 30MG CAPSULE 2 OXCARBAZEPINE OXCARBAZEPINE 150MG TABLET 2 OXCARBAZEPINE OXCARBAZEPINE 300MG TABLET 2 OXCARBAZEPINE OXCARBAZEPINE 600MG TABLET 2 OXICONAZOLE NITRATE OXISTAT 1% CREAM 3 OXYBUTYNIN OXYTROL 3.9MG/24HR PTTW 3 OXYBUTYNIN OXYBUTYNIN 5MG TABLET 2 OXYBUTYNIN OXYBUTYNIN 5MG/5ML SYRUP 2 OXYBUTYNIN OXYBUTYNIN 5MG TB24 2 OXYBUTYNIN OXYBUTYNIN 10MG TB24 2 OXYBUTYNIN OXYBUTYNIN 15MG TB24 2 OXYCODONE OXYCODONE 5MG TABLET 2 OXYCODONE OXYCODONE 5MG/5ML SOLUTION 3 OXYCODONE W/ ACETAMINOPHE OXYCODONE W/ ACETAMINOPHE 5-325MG

TABLET 2

OXYCODONE-ASPIRIN OXYCODONE-ASPIRIN TAB TABLET 2 OXYMORPHONE OPANA 5MG TB12 3 OXYMORPHONE OPANA 10MG TB12 3 OXYMORPHONE OPANA 20MG TB12 3 OXYMORPHONE TAB 12HR D 3 OXYMORPHONE TAB 12HR D 3 OXYMORPHONE TAB 12HR D 3 PANCRELIPASE PANCRELIPASE (LIPASE-PROT 5000UNIT CPEP 2 PANCRELIPASE ZENPEP CAP 10000UNT CPEP 3 PANCRELIPASE ZENPEP CAP 15000UNT CPEP 3 PANCRELIPASE ZENPEP CAP 20000UNT CPEP 3 PANTOPRAZOLE PANTOPRAZOLE 40MG TABLET EC 2 PAROXETINE PAROXETINE HCL TAB 10MG 1 PAROXETINE PAROXETINE HCL TAB 20MG 1 PAROXETINE PAROXETINE 30MG TABLET 2 PAROXETINE PAROXETINE 40MG TABLET 2 PED MULTIVITAMINS W/FL & PEDIATRIC MULTIVITAMINS W/FLUORIDE

DROPS SOLUTION 2

PEDIATRIC MULTIVITAMINS W PEDIATRIC MULTIVITAMINS W/FLUORIDE 0.25MG TAB CHEW

2

PEDIATRIC MULTIVITAMINS W PEDIATRIC MULTIVITAMINS W/FLUORIDE 0.5MG TAB CHEW

2

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Page 23: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier PEDIATRIC MULTIVITAMINS W PEDIATRIC MULTIVITAMINS W/FLUORIDE 1MG

TAB CHEW 2

PEDIATRIC MULTIVITAMINS W PEDIATRIC MULTIVITAMINS W/FLUORIDE 0.25MG SOLUTION

2

PEDIATRIC MULTIVITAMINS W PEDIATRIC MULTIVITAMINS W/FLUORIDE 0.5MG SOLUTION

2

PEDIATRIC VITAMINS ACD W/FLUORIDE

PEDIATRIC VITAMINS ACD W/FLUORIDE 0.25MG SOLUTION

2

PEG 3350-KCL-SOD BICARB-S PEG 3350-KCL-SOD BICARB-S SOL SOLUTION 2 PEGINTERFERON ALFA-2A PEGASYS 180MCG/ML SOLUTION 3 PEGINTERFERON ALFA-2A PEGASYS 180MCG/0.5ML SOLUTION 3 PEGINTERFERON ALFA-2A PEGASYS 180MCG/0.5ML KIT 3 PEGINTERFERON ALFA-2B PEG-INTRON 80MCG/0.5ML KIT 3 PEGINTERFERON ALFA-2B PEG-INTRON 120MCG/0.5ML KIT 3 PEGINTERFERON ALFA-2B PEG-INTRON 150MCG/0.5ML KIT 3 PEGINTERFERON ALFA-2B SYLATRON 296MCG KIT 3 PEGINTERFERON ALFA-2B SYLATRON 444MCG KIT 3 PEGINTERFERON ALFA-2B SYLATRON 888MCG KIT 3 PENICILLAMINE DEPEN 250MG TABLET 3 PENICILLIN PENICILLIN 250MG TABLET 2 PENICILLIN PENICILLIN 500MG TABLET 2 PENICILLIN PENICILLIN 125MG/5ML SOLUTION 2 PENICILLIN PENICILLIN 250MG/5ML SOLUTION 2 PENTAFLUOROPROPANE-TETRAF GEBAUERS PAIN EASE AER MD STRM

AEROSOL 3

PENTAMIDINE NEBUPENT 300MG MIST 3 PENTOSAN ELMIRON 100MG CAPSULE 3 PENTOXIFYLLINE PENTOXIFYLLINE 400MG TABLET SA 2 PERMETHRIN PERMETHRIN 5% CREAM 2 PERPHENAZINE PERPHENAZINE 2MG TABLET 2 PERPHENAZINE PERPHENAZINE 4MG TABLET 2 PHENOBARBITAL PHENOBARBITAL 15MG TABLET 2 PHENOBARBITAL PHENOBARBITAL 16.2MG TABLET 2 PHENOBARBITAL PHENOBARBITAL 32.4MG TABLET 2 PHENOBARBITAL PHENOBARBITAL 64.8MG TABLET 2 PHENOBARBITAL PHENOBARBITAL 97.2MG TABLET 2 PHENOBARBITAL PHENOBARBITAL 20MG/5ML ELIX 2 PHENTERMINE PHENTERMINE 15MG CAPSULE 2 PHENTERMINE PHENTERMINE 30MG CAPSULE 2 PHENYLEPH-PROMETHAZINE W/ PHENYLEPH-PROMETHAZINE W/ CODEINE

SYRUP 2

PHENYTOIN PHENYTOIN 50MG TAB CHEW 2 PHENYTOIN PHENYTOIN 100MG/4ML SUSPENSION 2

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Page 24: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier PHENYTOIN PHENYTOIN 30MG CAPSULE 2 PHENYTOIN PHENYTOIN 100MG CAPSULE 2 PHYTONADIONE MEPHYTON 5MG TABLET 3 PILOCARPINE PILOCARPINE 1% SOLUTION 2 PILOCARPINE PILOCARPINE 2% SOLUTION 2 PILOCARPINE PILOCARPINE 4% SOLUTION 2 PILOCARPINE PILOPINE HS 4% GEL 3 PIMECROLIMUS ELIDEL 1% CREAM 3 PIOGLITAZONE PIOGLITAZONE 15MG TABLET 2 PIOGLITAZONE PIOGLITAZONE 30MG TABLET 2 PIOGLITAZONE PIOGLITAZONE 45MG TABLET 2 PIROXICAM PIROXICAM 10MG CAPSULE 2 PIROXICAM PIROXICAM 20MG CAPSULE 2 PODOFILOX PODOFILOX 0.5% SOLUTION 2 POLYMYXIN B-TRIMETHOPRIM TRIMETHOPRIM SULFATE/POLYMY SOL

POLYMYXN SOLUTION 2

POSACONAZOLE NOXAFIL 40MG/ML SUSPENSION 3 POTASSIUM POTABA 500MG TABLET 3 POTASSIUM POTASSIUM 10MEQ TABLET SA 2 POTASSIUM POTASSIUM 10% LIQUID 2 POTASSIUM POTASSIUM 20MEQ POWDER 2 POTASSIUM CITRATE POTASSIUM 540MG TABLET SA 2 POTASSIUM CITRATE POTASSIUM 1080MG TABLET SA 2 POTASSIUM CITRATE-CITRIC POTASSIUM CITRATE-CITRIC ACD SOLUTION 2 POTASSIUM IODIDE SSKI 1GM/ML SOLUTION 3 POVIDONE-IODINE BETADINE OPHTHALMIC 5% SOLUTION 3 PRAMIPEXOLE PRAMIPEXOLE 0.125MG TABLET 2 PRAMIPEXOLE PRAMIPEXOLE 0.25MG TABLET 2 PRAMIPEXOLE PRAMIPEXOLE 1MG TABLET 2 PRAMIPEXOLE PRAMIPEXOLE 1.5MG TABLET 2 PRAMOXINE-HC PRAMOXINE-HC 1% LOTION 2 PRAMOXINE-HC PRAMOXINE-HC 2.5% LOTION 2 PRASUGREL EFFIENT 5MG TABLET 3 PRASUGREL EFFIENT 10MG TABLET 3 PRAVASTATIN PRAVASTATIN 10MG TABLET 2 PRAVASTATIN PRAVASTATIN 20MG TABLET 2 PRAVASTATIN PRAVASTATIN 40MG TABLET 2 PRAVASTATIN PRAVASTATIN 80MG TABLET 2 PRAZIQUANTEL BILTRICIDE 600MG TABLET 3 PRAZOSIN PRAZOSIN HCL CAP 1MG 1 PRAZOSIN PRAZOSIN HCL CAP 2MG 1 PRAZOSIN PRAZOSIN HCL CAP 5MG 1 PREDNISOLONE PREDNISOLONE 15MG/5ML SOLUTION 2

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Page 25: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier PREDNISOLONE PREDNISOLONE 15MG/5ML SOLUTION 2 PREDNISOLONE PREDNISOLONE 6.7MG/5ML LIQUID 2 PREDNISOLONE PRED MILD 0.12% SUSPENSION 3 PREDNISOLONE PREDNISOLONE 1% SUSPENSION 2 PREDNISONE PREDNISONE 1MG TABLET 2 PREDNISONE PREDNISONE 5MG TABLET 2 PREDNISONE PREDNISONE 10MG TABLET 2 PREDNISONE PREDNISONE 20MG TABLET 2 PREDNISONE PREDNISONE 50MG TABLET 2 PREDNISONE PREDNISONE 5MG/5ML SOLUTION 2 PREDNISONE PREDNISONE 5MG TABLET 2 PREGABALIN LYRICA 25MG CAPSULE 3 PREGABALIN LYRICA 50MG CAPSULE 3 PREGABALIN LYRICA 75MG CAPSULE 3 PREGABALIN LYRICA 100MG CAPSULE 3 PREGABALIN LYRICA 150MG CAPSULE 3 PREGABALIN LYRICA 200MG CAPSULE 3 PREGABALIN LYRICA 225MG CAPSULE 3 PREGABALIN LYRICA 300MG CAPSULE 3 PRIMIDONE PRIMIDONE 50MG TABLET 2 PRIMIDONE PRIMIDONE 250MG TABLET 2 PROBENECID PROBENECID 500MG TABLET 2 PROCHLORPERAZINE PROCHLORPERAZINE 25MG SUPPOS. 2 PROCHLORPERAZINE PROCHLORPERAZINE 5MG TABLET 2 PROCHLORPERAZINE PROCHLORPERAZINE 10MG TABLET 2 PROGESTERONE PROGESTERONE 100MG CAPSULE 2 PROGESTERONE PROGESTERONE 200MG CAPSULE 2 PROMETHAZINE PROMETHAZINE 12.5MG TABLET 2 PROMETHAZINE PROMETHAZINE 25MG TABLET 2 PROMETHAZINE PROMETHAZINE 6.25MG/5ML SYRUP 2 PROMETHAZINE PROMETHAZINE 25MG SUPPOS. 2 PROMETHAZINE PROMETHAZINE 50MG SUPPOS. 2 PROMETHAZINE & PHENYLEPHR PROMETHAZINE & PHENYLEPHR PLAIN SYRUP 2 PROMETHAZINE W/CODEINE PROMETHAZINE W/CODEINE 6.25-10ML SYRUP 2 PROPRANOLOL PROPRANOLOL HCL TAB 10MG 1 PROPRANOLOL PROPRANOLOL HCL TAB 20MG 1 PROPRANOLOL PROPRANOLOL HCL TAB 40MG 1 PROPRANOLOL PROPRANOLOL HCL TAB 80MG 1 PROPRANOLOL PROPRANOLOL 20MG/5ML SOLUTION 2 PROPYLTHIOURACIL PROPYLTHIOURACIL 50MG TABLET 2 PYRAZINAMIDE PYRAZINAMIDE 500MG TABLET 2 PYRIDOSTIGMINE PYRIDOSTIGMINE 60MG TABLET 2 PYRIDOSTIGMINE MESTINON 180MG TABLET SA 3

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Page 26: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier QUETIAPINE QUETIAPINE 25MG TABLET 2 QUETIAPINE QUETIAPINE 50MG TABLET 2 QUETIAPINE QUETIAPINE 100MG TABLET 2 QUETIAPINE QUETIAPINE 200MG TABLET 2 QUETIAPINE QUETIAPINE 300MG TABLET 2 QUETIAPINE QUETIAPINE 400MG TABLET 2 QUINIDINE QUINIDINE 324MG TABLET SA 2 QUINIDINE QUINIDINE 300MG TABLET SA 2 RALOXIFENE EVISTA 60MG TABLET 3 RANITIDINE RANITIDINE 15MG/ML SYRUP 2 RESERPINE RESERPINE 0.1MG TABLET 3 RIBAVIRIN RIBAVIRIN 200MG CAPSULE 2 RIFABUTIN MYCOBUTIN 150MG CAPSULE 3 RIFAMPIN RIFAMPIN 10MG/ML SUSPENSION 2 RIFAXIMIN XIFAXAN 550MG TABLET 3 RIMANTADINE RIMANTADINE 100MG TABLET 2 RISEDRONATE ACTONEL 5MG TABLET 3 RISEDRONATE ACTONEL 35MG TABLET 3 RISPERIDONE RISPERIDONE 0.25MG TABLET 2 RISPERIDONE RISPERIDONE 0.5MG TABLET 2 RISPERIDONE RISPERIDONE 1MG TABLET 2 RISPERIDONE RISPERIDONE 2MG TABLET 2 RISPERIDONE RISPERIDONE 3MG TABLET 2 RISPERIDONE RISPERIDONE 4MG TABLET 2 RISPERIDONE RISPERIDONE 1MG/ML SOLUTION 2 RITONAVIR NORVIR 100MG TABLET 3 RITONAVIR NORVIR 80MG/ML SOLUTION 3 ROPINIROLE ROPINIROLE 0.25MG TABLET 2 ROPINIROLE ROPINIROLE 0.5MG TABLET 2 ROPINIROLE ROPINIROLE 1MG TABLET 2 ROPINIROLE ROPINIROLE 2MG TABLET 2 SALMETEROL SEREVENT 50MCG/DOSE AEPB 3 SALSALATE SALSALATE 750MG TABLET 2 SAQUINAVIR INVIRASE 200MG CAPSULE 3 SCOPOLAMINE TRANSDERM-SCOP 1.5MG PT72 3 SELEGILINE SELEGILINE 5MG CAPSULE 2 SELENIUM SELENIUM 2.5% SHAMPOO 2 SERTRALINE SERTRALINE 25MG TABLET 2 SERTRALINE SERTRALINE 50MG TABLET 2 SERTRALINE SERTRALINE 100MG TABLET 2 SEVELAMER RENVELA 800MG TABLET 3 SEVELAMER RENVELA 2.4GM POWDER 3 SILDENAFIL CITRATE SILDENAFIL 2.5MG/ML SUSPENSION (for PAH) 2

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Page 27: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier SILVER NITRATE SILVER NITRATE 0.5% SOLUTION 3 SILVER NITRATE-POTASSIUM ARZOL SILVER NITRATE APP LI MIS NITR APP

MISCELL. 3

SILVER SULFADIAZINE SILVER SULFADIAZINE 1% CREAM 2 SIMVASTATIN SIMVASTATIN 5MG TABLET 2 SIMVASTATIN SIMVASTATIN 10MG TABLET 2 SIMVASTATIN SIMVASTATIN 20MG TABLET 2 SIMVASTATIN SIMVASTATIN 40MG TABLET 2 SIMVASTATIN SIMVASTATIN 80MG TABLET 2 SIROLIMUS RAPAMUNE 1MG TABLET 3 SIROLIMUS RAPAMUNE 1MG/ML SOLUTION 3 SITAGLIPTIN JANUVIA 25MG TABLET 3 SITAGLIPTIN JANUVIA 50MG TABLET 3 SITAGLIPTIN JANUVIA 100MG TABLET 3 SODIUM SODIUM CHLORIDE 0.9% ARTHR SOL 0.9% IRR

SOLUTION 2

SODIUM CITRATE & CITRIC SODIUM CITRATE & CITRIC A CITR SOLUTION 2 SODIUM FLUORIDE SODIUM FLUORIDE 0.25MG TAB CHEW 2 SODIUM FLUORIDE SODIUM FLUORIDE 0.5MG TAB CHEW 2 SODIUM FLUORIDE SODIUM FLUORIDE 1MG TAB CHEW 2 SODIUM FLUORIDE FLURA-DROPS DRO 0.25MG/DROP SOLUTION 3 SODIUM POLYSTYRENE SODIUM POLYSTYRENE 15GM/60ML

SUSPENSION 2

SOMATROPIN SOMATROPIN 5MG/1.5ML SOLUTION 2 SOMATROPIN SOMATROPIN 10MG/1.5ML SOLUTION 2 SOMATROPIN NORDITROPIN 15MG/1.5ML SOLUTION 3 SORAFENIB NEXAVAR 200MG TABLET 3 SOTALOL SOTALOL HCL TAB 80MG 1 SOTALOL SOTALOL 160MG TABLET 2 SPIRONOLACTONE SPIRONOLACTONE TAB 25MG 1 SPIRONOLACTONE & HCTZ SPIRONOLACTONE & HCTZ 5/5ML SUSPENSION 2 STAVUDINE STAVUDINE 20MG CAPSULE 2 STAVUDINE STAVUDINE 30MG CAPSULE 2 STAVUDINE STAVUDINE 40MG CAPSULE 2 SUCRALFATE CARAFATE 100MG/ML SUSPENSION 3 SULFACETAMIDE SULFACETAMIDE 10% SOLUTION 2 SULFACETAMIDE SOD-PREDNIS SULFACETAMIDE SODIUM/PREDNI SOL OP

SOLUTION 2

SULFACETAMIDE SOD-PREDNIS BLEPHAMIDE-S.O.P. OIN S.O.P. OINTMENT 2 SULFAMETHOXAZOLE-TRIMETHO SULFAMETHOXAZOLE-TRIMETHO 400-80MG

TABLET 2

SULFAMETHOXAZOLE-TRIMETHO SULFAMETHOXAZOLE-TRIMETHO 800-160MG TABLET

2

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Page 28: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier SULFAMETHOXAZOLE-TRIMETHO SULFAMETHOXAZOLE-TRIMETHO 200-40/5ML

SUSPENSION 2

SULFASALAZINE SULFASALAZINE 500MG TABLET EC 2 SULINDAC SULINDAC 150MG TABLET 2 SULINDAC SULINDAC 200MG TABLET 2 SUMATRIPTAN SUMATRIPTAN 5MG/ACT SOLUTION 2 SUMATRIPTAN SUMATRIPTAN 20MG/ACT SOLUTION 2 SUMATRIPTAN SUMATRIPTAN 25MG TABLET 2 SUMATRIPTAN SUMATRIPTAN 50MG TABLET 2 SUMATRIPTAN SUMATRIPTAN 100MG TABLET 2 SUMATRIPTAN SUMATRIPTAN 6MG/0.5ML SOLUTION 2 SUNITINIB SUTENT 12.5MG CAPSULE 3 SUNITINIB SUTENT 25MG CAPSULE 3 SUNITINIB SUTENT 50MG CAPSULE 3 TACROLIMUS PROTOPIC 0.03% OINTMENT 3 TACROLIMUS PROTOPIC 0.1% OINTMENT 3 TACROLIMUS TACROLIMUS 0.5MG CAPSULE 2 TACROLIMUS TACROLIMUS 1MG CAPSULE 2 TACROLIMUS TACROLIMUS 0.5MG/ML SUSPENSION 2 TAMOXIFEN CITRATE TAMOXIFEN 10MG TABLET 2 TAMSULOSIN TAMSULOSIN 0.4MG CAPSULE 2 TAZAROTENE TAZORAC 0.05% CREAM 3 TAZAROTENE TAZORAC 0.1% CREAM 3 TAZAROTENE TAZORAC 0.05% GEL 3 TAZAROTENE TAZORAC 0.1% GEL 3 TELAPREVIR INCIVEK 375MG TABLET 3 TEMAZEPAM TEMAZEPAM 15MG CAPSULE 2 TEMAZEPAM TEMAZEPAM 30MG CAPSULE 2 TEMOZOLOMIDE TEMOZOLOMIDE 5MG CAPSULE 2 TEMOZOLOMIDE TEMOZOLOMIDE 20MG CAPSULE 2 TEMOZOLOMIDE TEMOZOLOMIDE 100MG CAPSULE 2 TEMOZOLOMIDE TEMOZOLOMIDE 250MG CAPSULE 2 TENOFOVIR VIREAD 300MG TABLET 3 TERAZOSIN TERAZOSIN HCL CAP 1MG 1 TERAZOSIN TERAZOSIN HCL CAP 2MG 1 TERAZOSIN TERAZOSIN HCL CAP 5MG 1 TERAZOSIN TERAZOSIN HCL CAP 10MG 1 TERBINAFINE TERBINAFINE 250MG TABLET 2 TERBUTALINE TERBUTALINE 5MG TABLET 2 TERCONAZOLE TERCONAZOLE 0.4% CREAM 2 TERCONAZOLE TERCONAZOLE 80MG SUPPOS. 2 TERIPARATIDE FORTEO 600MCG/2.4ML SOLUTION 3 TESTOSTERONE ANDROGEL 1% GEL 3

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Page 29: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier TESTOSTERONE FIRST-TESTOSTERONE 2% OINTMENT 3 TETRACAINE TETRACAINE 0.5% LPOP 2 THALIDOMIDE THALOMID 50MG CAPSULE 3 THALIDOMIDE THALOMID 100MG CAPSULE 3 THALIDOMIDE THALOMID 200MG CAPSULE 3 THEOPHYLLINE THEOPHYLLINE 100MG TB12 2 THEOPHYLLINE THEOPHYLLINE 200MG TB12 2 THEOPHYLLINE THEOPHYLLINE 300MG TB12 2 THEOPHYLLINE THEOPHYLLINE 450MG TB12 2 THIORIDAZINE THIORIDAZINE 10MG TABLET 2 THIORIDAZINE THIORIDAZINE 25MG TABLET 2 THIORIDAZINE THIORIDAZINE 50MG TABLET 2 THIORIDAZINE THIORIDAZINE 100MG TABLET 2 THIOTHIXENE THIOTHIXENE 5MG CAPSULE 2 THYROID THYROID 15MG TABLET 2 THYROID THYROID 30MG TABLET 2 THYROID THYROID 60MG TABLET 2 THYROID THYROID 120MG TABLET 2 THYROID THYROID 180MG TABLET 2 THYROID THYROID 300MG TABLET 2 TICAGRELOR BRILINTA 90MG TABLET 3 TIMOLOL TIMOLOL 10MG TABLET 2 TIMOLOL TIMOLOL 0.25% SOLUTION 2 TIMOLOL TIMOLOL 0.5% SOLUTION 2 TINIDAZOLE TINDAMAX 500MG TABLET 3 TIOTROPIUM SPIRIVA 18MCG CAPSULE 3 TIZANIDINE TIZANIDINE 2MG TABLET 2 TIZANIDINE TIZANIDINE 4MG TABLET 2 TOBRAMYCIN TOBRAMYCIN 0.3% SOLUTION 2 TOBRAMYCIN TOBREX OIN 0.3% OINTMENT 3 TOLAZAMIDE TOLAZAMIDE 250MG TABLET 2 TOLBUTAMIDE TOLBUTAMIDE 500MG TABLET 2 TOLMETIN TOLMETIN 200MG TABLET 2 TOPIRAMATE TOPIRAMATE 25MG TABLET 2 TOPIRAMATE TOPIRAMATE 50MG TABLET 2 TOPIRAMATE TOPIRAMATE 100MG TABLET 2 TOPIRAMATE TOPIRAMATE 200MG TABLET 2 TOPIRAMATE TOPIRAMATE 15MG CPSP 2 TOPIRAMATE TOPIRAMATE 25MG CPSP 2 TRAMADOL TRAMADOL 50MG TABLET 2 TRAZODONE TRAZODONE HCL TAB 50MG 1 TRETINOIN TRETINOIN 0.025% CREAM 2 TRETINOIN TRETINOIN 0.05% CREAM 2

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Page 30: Kaiser Hawaii Drug formulary - Kaiser Permanente

Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier TRETINOIN TRETINOIN 0.1% CREAM 2 TRETINOIN TRETINOIN 0.01% GEL 2 TRETINOIN RETIN-A 0.04% GEL 3 TRETINOIN RETIN-A 0.1% GEL 3 TRIAMCINOLONE TRIAMCINOLONE 0.1% PASTE 2 TRIAMCINOLONE KENALOG AER SPRAY AERO SPRAY 3 TRIAMCINOLONE TRIAMCINOLONE 0.025% CREAM 2 TRIAMCINOLONE TRIAMCINOLONE 0.1% CREAM 2 TRIAMCINOLONE TRIAMCINOLONE 0.5% CREAM 2 TRIAMCINOLONE TRIAMCINOLONE 0.025% OINTMENT 2 TRIAMCINOLONE TRIAMCINOLONE 0.1% OINTMENT 2 TRIAMTERENE & HYDROCHLORO TRIAMTERENE/HYDROCHLOROTHIA TAB 75-

50MG 1

TRIAZOLAM TRIAZOLAM 0.125MG TABLET 2 TRIAZOLAM TRIAZOLAM 0.25MG TABLET 2 TRIFLUOPERAZINE TRIFLUOPERAZINE 2MG TABLET 2 TRIFLUOPERAZINE TRIFLUOPERAZINE 5MG TABLET 2 TRIFLUOPERAZINE TRIFLUOPERAZINE 10MG TABLET 2 TRIFLURIDINE TRIFLURIDINE 1% SOLUTION 2 TRIHEXYPHENIDYL TRIHEXYPHENIDYL 2MG TABLET 2 TRIMETHOPRIM TRIMETHOPRIM 100MG TABLET 2 TROSPIUM TROSPIUM 20MG TABLET 2 TROSPIUM TROSPIUM 60MG CP24 2 UREA UREA 40% CREAM 2 URSODIOL URSODIOL 300MG CAPSULE 2 USTEKINUMAB STELARA 45MG/0.5ML SOLUTION 3 USTEKINUMAB STELARA 90MG/ML SOLUTION 3 VALGANCICLOVIR VALCYTE 450MG TABLET 3 VALGANCICLOVIR VALCYTE 50MG/ML SOLUTION 3 VALPROATE VALPROATE 250MG/5ML SYRUP 2 VALPROIC ACID VALPROIC 250MG CAPSULE 2 VANCOMYCIN VANCOMYCIN 25MG/ML SOLUTION 2 VANCOMYCIN VANCOMYCIN 50MG/ML SOLUTION 2 VARENICLINE CHANTIX 0.5MG TABLET 3 VARENICLINE CHANTIX 1MG TABLET 3 VARENICLINE CHANTIX PAK TABLET 3 VENLAFAXINE VENLAFAXINE 25MG TABLET 2 VENLAFAXINE VENLAFAXINE 37.5MG TABLET 2 VENLAFAXINE VENLAFAXINE 75MG TABLET 2 VENLAFAXINE VENLAFAXINE 100MG TABLET 2 VENLAFAXINE VENLAFAXINE 37.5MG CP24 2 VENLAFAXINE VENLAFAXINE 75MG CP24 2 VENLAFAXINE VENLAFAXINE 150MG CP24 2

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Kaiser Permanente Hawaii Drug Formulary GENERIC NAME PRODUCT NAME Tier VERAPAMIL VERAPAMIL HCL TAB 80MG 1 VERAPAMIL VERAPAMIL HCL TAB 120MG 1 VERAPAMIL VERAPAMIL 240MG TABLET SA 2 WARFARIN WARFARIN SODIUM TAB 1MG 1 WARFARIN WARFARIN SODIUM TAB 2MG 1 WARFARIN WARFARIN SODIUM TAB 2.5MG 1 WARFARIN WARFARIN SODIUM TAB 3MG 1 WARFARIN WARFARIN SODIUM TAB 4MG 1 WARFARIN WARFARIN SODIUM TAB 5MG 1 WARFARIN WARFARIN SODIUM TAB 6MG 1 WARFARIN WARFARIN SODIUM TAB 7.5MG 1 WARFARIN WARFARIN SODIUM TAB 10MG 1 WATER STERILE WATER IRRIGATION PL SOL IRRIG UD

SOLUTION 2

WOUND DRESSINGS SILVASORB GEL GEL 3 ZIDOVUDINE ZIDOVUDINE 100MG CAPSULE 2 ZIDOVUDINE ZIDOVUDINE 300MG TABLET 2 ZIPRASIDONE ZIPRASIDONE 20MG CAPSULE 2 ZIPRASIDONE ZIPRASIDONE 40MG CAPSULE 2 ZIPRASIDONE ZIPRASIDONE 60MG CAPSULE 2 ZIPRASIDONE ZIPRASIDONE 80MG CAPSULE 2 ZOLPIDEM ZOLPIDEM 5MG TABLET 2 ZOLPIDEM ZOLPIDEM 10MG TABLET 2

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