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Y0043_N00016528_Final10_C HPMS Approved Formulary File Submission 00021410 Version 17
Kaiser Permanente
2021 Comprehensive Formulary (List of Covered Drugs) PLEASE READ THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 100121 For more recent information or other questions please contact the number for your Kaiser Permanente Region listed below seven days a week 8 am to 8 pm or visit kporgseniorrx
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Kaiser Permanente When it refers to ldquoplanrdquo or ldquoour planrdquo it means Kaiser Permanente Senior Advantage
This document includes a list of the drugs (formulary) for our plan which is current as of October 1 2021 For an updated formulary please visit our website at kporgseniorrx or call us Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages You must generally use network pharmacies to use your prescription drug benefit The formulary and pharmacy network may change at any time You will receive notice when necessary
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 1
What is the Kaiser Permanente Formulary
A formulary is a list of covered drugs selected by Kaiser Permanente in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a Kaiser Permanente network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages Can the formulary (drug list) change
Most changes in drug coverage happen on January 1 but Kaiser Permanente may add or remove drugs on the Drug List during the year or add new restrictions We must follow Medicare rules in making these changes
Changes that can affect you this year
In the below cases you will be affected by coverage changes during the year
New generic drugs
We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug with the same or fewer restrictions Also when adding the new generic drug we may decide to keep the brand name drug on our Drug List but immediately add new restrictions If you are
currently taking that brand name drug we may not tell you in advance before we make that change but we will later provide you with information about the specific change(s) we have made
bull If we make such a change you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will also include information on how to request an exception and you can also find information in the section below entitled ldquoHow do I request an exception to the Kaiser Permanente Formularyrdquo
Drugs removed from the market
If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our formulary and provide notice to members who take the drug
Other changes
We may make other changes that affect members currently taking a drug For instance we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug Or we may make changes based on new clinical guidelines If we remove drugs from our formulary or add prior authorization we must notify affected members of the change at least 30 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 30-day supply of the drug
bull If we make these other changes you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will include information
2 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
on how to request an exception You can find information in the section below entitled ldquoHow do I request an exception to the Kaiser Permanente Formularyrdquo
Changes that will not affect you if you are currently taking the drug
Generally if you are taking a drug on our 2021 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year You will not get direct notice this year about changes that do not affect you However on January 1 of the next year such changes would affect you and it is important to check the Drug List for the new benefit year for any changes to drugs
The enclosed formulary is current as of October 1 2021 To get updated information about the drugs covered by our plan please call us Contact information for your Kaiser Permanente Region appears on the front and back cover pages
In the event of a midyear non-maintenance formulary change we will provide details in the Medicare Part D Explanation of Benefits that we send you or Provision of Notice posted at kporgseniorrx
How do I use the formulary
There are two ways to find your drug within the formulary
Medical condition The formulary begins on page 6 The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat For example drugs used to treat a heart condition are listed under the category ldquoCardiovascular Drugsrdquo If you know what your drug is used for look for the category name in the list that begins on page 8 Then look under the category name for your drug Alphabetical listing
If you are not sure what category to look under you should look for your drug in the index that begins on page 66 The index provides an alphabetical list of all the drugs included in this document Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the index and find the name of your drug in the first column of the list What are generic drugs
Our plan covers both brand-name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug Generally generic drugs cost less than brand-name drugs Please see your Evidence of Coverage for more information
What are brand-name drugs
Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug When the patent on a brand-name drug expires other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices Please
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 3
see your Evidence of Coverage for more information
Are there any restrictions on my coverage
Some covered drugs may have additional requirements or limits on coverage These requirements and limits may include
bull Prior Authorization Our plan may require you or your network provider to get prior authorization for certain drugs This means that you will need to get approval from our plan before you fill your prescriptions If you donrsquot get approval we may not cover the drug
Note If your prescription has more than one refill remaining you can only get one refill at a time unless authorized because you will be away from our service area for an extended period of time For certain drugs we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive Also if there is a shortage in the marketplace we may fill your prescription for a limited quantity You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6 You can also get more information about the restrictions applied to specific covered drugs by visiting our website We have posted online a document that explains our prior authorization restriction You may also ask us to send you a copy Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages
You can ask us to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I request an exception to the Kaiser Permanente formularyrdquo for information about how to request an exception What if my drug is not on the formulary
If your drug is not included in this formulary (list of covered drugs) you should first check our Kaiser Permanente 2021 Comprehensive Formulary at kporgseniorrx or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region and confirm if your drug is covered If your Medicare Part D prescription drug is not on our Kaiser Permanente 2021 Comprehensive Formulary you have two options
bull You can ask your network provider to prescribe a similar drug that is included on our formulary
bull You can ask us to make an exception and cover your drug See the next section for information about how to request an exception
How do I request an exception to the Kaiser Permanente Formulary
You can ask us to make an exception to our coverage rules There are several types of exceptions that you can ask us to make
bull You can ask us to cover a drug even if it may not be in our Kaiser Permanente 2021 Comprehensive Formulary
4 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
bull You can ask us to waive coverage
restrictions or limits on your drug For example if your drug requires prior authorization you can ask us to waive the prior authorization requirement for your Part D drug
Generally we will only approve your request for an exception if the alternative drugs included on the planrsquos formulary or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception When you request a formulary or utilization restriction exception you should submit a statement from your network provider supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited (fast) exception if you or your network provider believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber
Please note You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare amp Medicaid Services (CMS) You cannot get an exception for drugs that are excluded under Medicare Part D Please refer to your Evidence of Coverage for more information about requesting exceptions including the appeals process What do I do before I can talk to my network provider about
changing my drugs or requesting an exception
In some cases you might be taking Medicare Part D drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your network provider to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your network provider to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan For each of your Part D drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide up to a maximum of a 30-day supply of medication After your first 30-day supply we may cover an additional refill as medically necessary After you have used these refills we will not pay for these drugs even if you have been a member of the plan less than 90 days
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug while you pursue a formulary exception
For current members with level of care changes if you enter into or are discharged from a hospital skilled nursing facility or long-term care facility to a different care setting or home this is what is known as a
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 5
level of care change When your level of care changes you may require an additional fill of your medication We will generally cover up to a one-month supply of your Part D drugs during this level of care transition period even if the drug is not on our Drug List
For more information
For more detailed information about your Kaiser Permanente prescription drug coverage please review your Evidence of Coverage and other plan materials If you have questions about our plan please call us Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048 Or visit httpwwwmedicaregov
6 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Kaiser Permanentersquos Formulary
The formulary below provides coverage information about the drugs covered by our plan If you have trouble finding your drug in the list turn to the index that begins on page 66 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg NEBUPENT) and generic drugs are listed in lower-case italics (eg ltamoxicillingt) The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number below Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy Northern CA ndash 1-888-218-6245 Monday through Friday 8 am to 8 pm Saturday 8 am to 6 pm and Sunday 9 am to 6 pm Southern CA ndash 1-866-206-2983 Monday through Friday 7 am to 7 pm Saturday 10 am to 2 pm
Colorado
Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday 8 am to 6 pm
Hawaii
Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday 800 am to 5 pm
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 7
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
8 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole tabs NDS emverm chew ivermectin tabs praziquantel tabs MO ANTIBACTERIALS amikacin sulfate soln amikacin sulfate soln injection HI amoxicillin caps amoxicillin chew amoxicillin susr amoxicillin tabs amoxicillin-pot clavulanate chew amoxicillin-pot clavulanate er tb12
amoxicillin-pot clavulanate susr amoxicillin-pot clavulanate tabs ampicillin caps ampicillin sodium solr ampicillin sodium solr injection 1gm 125mg HI
ampicillin sodium solr intravenous HI
ampicillin-sulbactam sodium solr ampicillin-sulbactam sodium solr injection HI
ampicillin-sulbactam sodium solr intravenous HI
ARIKAYCE SUSP PALDNDS AUGMENTIN SUSR AVYCAZ SOLR INTRAVENOUS HI AZITHROMYCIN PACK MO azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BAXDELA SOLR INTRAVENOUS HI
BAXDELA TABS MO
Drug Name RequirementsLimits
BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP cefaclor caps cefaclor er tb12 cefaclor susr cefadroxil caps cefadroxil susr cefadroxil tabs cefazolin sodium solr cefazolin sodium solr injection 1gm 10gm 500mg HI
cefdinir caps cefdinir susr cefepime hcl solr injection 1gm 2gm HI
cefixime caps cefixime susr cefotaxime sodium solr cefotetan disodium solr injection 1gm 2gm HI
cefoxitin sodium solr injection HI cefoxitin sodium solr intravenous 1gm 2gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 2gm 6gm HI
CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 75gm 750mg HI
cefuroxime sodium solr intravenous HI
cephalexin caps cephalexin susr cephalexin tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w soln ciprofloxacin in d5w soln intravenous HI
ciprofloxacin susr ciprofloxacin-ciproflox hcl er tb24 clarithromycin er tb24 clarithromycin susr clarithromycin tabs cleocin phosphate soln cleocin solr clindamycin hcl caps clindamycin palmitate hcl solr clindamycin phosphate in d5w soln intravenous HI
clindamycin phosphate soln clindamycin phosphate soln injection 300mg2ml 600mg4ml 900mg6ml
HI
colistimethate sodium (cba) solr injection HI
DALVANCE SOLR INTRAVENOUS HI
daptomycin solr intravenous 350mg 500mg HI
demeclocycline hcl tabs dicloxacillin sodium caps DIFICID SUSR NDS DIFICID TABS NDS DORYX MPC TBEC MO doxy 100 solr intravenous HI doxycycline hyclate caps 50mg 100mg MO
doxycycline hyclate tabs 20mg 75mg 100mg 150mg MO
doxycycline hyclate tbec 50mg 75mg 100mg 150mg 200mg MO
doxycycline monohydrate caps 50mg 75mg 100mg 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
Drug Name RequirementsLimits
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs FETROJA SOLR NDS FIRVANQ SOLR gentamicin in saline soln gentamicin in saline soln intravenous HI
gentamicin sulfate soln gentamicin sulfate soln injection HI imipenem-cilastatin solr intravenous HI
KIMYRSA SOLR NDS levofloxacin in d5w soln levofloxacin in d5w soln intravenous HI
levofloxacin soln levofloxacin soln intravenous HI levofloxacin tabs lincomycin hcl soln linezolid soln intravenous HI linezolid susr NDS linezolid tabs NDS meropenem solr intravenous 1gm 500mg HI
minocycline hcl caps 50mg 75mg 100mg MO
minocycline hcl er tb24 45mg 55mg 65mg 80mg 90mg 105mg 115mg 135mg
MO
minocycline hcl tabs 50mg 75mg 100mg MO
mondoxyne nl caps 75mg 100mg MO
morgidox caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 10 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium solr intravenous HI neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs okebo caps MO ORBACTIV SOLR NDS OXACILLIN SODIUM IN DEXTROSE SOLN INTRAVENOUS
HI
oxacillin sodium solr injection 1gm 2gm HI
oxacillin sodium solr intravenous HI PENICILLIN G POT IN DEXTROSE SOLN INTRAVENOUS
HI
penicillin g potassium solr injection HI
penicillin g procaine susp penicillin g sodium solr injection HI penicillin v potassium solr penicillin v potassium tabs piperacillin sod-tazobactam so solr
piperacillin sod-tazobactam so solr intravenous HI
polymyxin b sulfate solr injection HI RECARBRIO SOLR NDS SEYSARA TABS 60mg 100mg 150mg NDS
SIVEXTRO SOLR INTRAVENOUS HI
SIVEXTRO TABS NDS soloxide tbec MO streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
Drug Name RequirementsLimits
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO SUPRAX CAPS suprax chew suprax susr 100mg5ml 200mg5ml
SUPRAX SUSR 500 MG5ML SYNERCID SOLR targadox tabs MO tazicef solr injection 1gm 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS 400mg 600mg HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
VABOMERE SOLR INTRAVENOUS HI
vancomycin hcl caps vancomycin hcl solr VANCOMYCIN HCL SOLR 250 MG
vancomycin hcl solr intravenous 1gm 10gm 500mg HI
VIBRAMYCIN SYRP XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS XIMINO CP24 45mg 90mg 135mg MO
ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ZITHROMAX PACK MO ZOSYN SOLN INTRAVENOUS HI ZYVOX SOLN INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
ANTIFUNGALS ABELCET SUSP INTRAVENOUS HI
AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS ERAXIS SOLR INTRAVENOUS 50mg 100mg HI
fluconazole in sodium chloride soln intravenous HI
fluconazole susr fluconazole tabs flucytosine caps 250mg 500mg NDS griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs itraconazole caps ITRACONAZOLE SOLN MO ketoconazole tabs micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS NOXAFIL TBEC NDS nystatin susp nystatin tabs POSACONAZOLE SUSP NDS posaconazole tbec NDS terbinafine hcl tabs TOLSURA CAPS NDS voriconazole solr intravenous HI voriconazole susr voriconazole tabs ANTIMYCOBACTERIALS CAPASTAT SULFATE SOLR cycloserine caps dapsone tabs 25mg 100mg MO ethambutol hcl tabs 100mg 400mg MO
isoniazid soln
Drug Name RequirementsLimits
isoniazid syrp MO isoniazid tabs 100mg 300mg MO paser pack MO PRETOMANID TABS PRIFTIN TABS MO pyrazinamide tabs MO RIFABUTIN CAPS MO RIFADIN CAPS MO rifamate caps MO rifampin caps 150mg 300mg MO rifampin solr intravenous HI RIFATER TABS MO SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs BENZNIDAZOLE TABS 125mg 100mg MO
chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS DARAPRIM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS mefloquine hcl tabs metronidazole caps metronidazole in nacl soln metronidazole in nacl soln intravenous HI
metronidazole tabs NEBUPENT SOLR PA nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 12 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
quinine sulfate caps NDS SOLOSEC PACK tinidazole tabs ANTIVIRALS abacavir sulfate soln abacavir sulfate tabs MO abacavir sulfate-lamivudine tabs MO abacavir-lamivudine-zidovudine tabs MO
acyclovir caps MO acyclovir sodium soln intravenous HI
acyclovir susp MO acyclovir tabs 400mg 800mg MO adefovir dipivoxil tabs NDS APTIVUS CAPS MO APTIVUS SOLN MO atazanavir sulfate caps 150mg 200mg 300mg MO
BARACLUDE SOLN MO BIKTARVY TABS CABENUVA SUER cidofovir soln CIMDUO TABS MO COMPLERA TABS MO CRIXIVAN CAPS 200mg 400mg MO DAKLINZA TABS 30mg 60mg 90mg PANDS
DELSTRIGO TABS MO DESCOVY TABS MO didanosine cpdr 200mg 250mg 400mg MO
DOVATO TABS MO EDURANT TABS MO efavirenz caps 50mg 200mg MO efavirenz tabs MO efavirenz-emtricitab-tenofovir tabs MO
emtricitabine caps MO emtricitabine-tenofovir df tabs MO EMTRIVA SOLN MO entecavir tabs 05mg 1mg MO EPCLUSA TABS PANDS
Drug Name RequirementsLimits
EPIVIR HBV SOLN MO etravirine tabs 100mg 200mg MO EVOTAZ TABS MO famciclovir tabs 125mg 250mg 500mg MO
fosamprenavir calcium tabs MO FUZEON SOLR NDS ganciclovir sodium soln ganciclovir sodium solr GENVOYA TABS MO HARVONI PACK PANDS HARVONI TABS PANDS INTELENCE TABS 25mg MO INVIRASE CAPS MO INVIRASE TABS MO ISENTRESS CHEW 25mg 100mg MO
ISENTRESS HD TABS MO ISENTRESS PACK MO ISENTRESS TABS MO JULUCA TABS MO lamivudine soln MO lamivudine tabs 100mg 150mg 300mg MO
lamivudine-zidovudine tabs MO ledipasvir-sofosbuvir tabs PANDS LEXIVA SUSP MO lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO MAVYRET TABS PANDS nevirapine er tb24 100mg 400mg MO
nevirapine susp MO nevirapine tabs MO NORVIR CAPS MO NORVIR PACK MO NORVIR SOLN MO ODEFSEY TABS MO OLYSIO CAPS PANDS oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEG-INTRON REDIPEN KIT NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
PEGASYS PROCLICK SOLN 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN 180mcg05ml 180mcgml NDS
PEGINTRON KIT NDS PIFELTRO TABS MO PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
PREVYMIS SOLN 240mg12ml 480mg24ml NDS
PREVYMIS TABS 240mg 480mg NDS
PREZCOBIX TABS MO PREZISTA SUSP MO PREZISTA TABS 75mg 150mg 600mg 800mg MO
RAPIVAB SOLN NDS REBETOL SOLN MO RELENZA DISKHALER AEPB MO RESCRIPTOR TABS 100mg 200mg MO
RETROVIR SOLN MO REYATAZ PACK MO ribasphere caps MO ribasphere ribapak (1000 pack) tbpk MO
ribasphere ribapak (1200 pack) tbpk MO
ribasphere tabs MO ribavirin caps MO ribavirin solr ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg 150mg 300mg MO
sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS
Drug Name RequirementsLimits
SOVALDI TABS 200mg 400mg PANDS stavudine caps 15mg 20mg 30mg 40mg MO
STRIBILD TABS MO SYMFI LO TABS MO SYMFI TABS MO SYMTUZA TABS MO SYNAGIS SOLN 50mg05ml 100mgml NDS
tenofovir disoproxil fumarate tabs MO
TIVICAY PD TBSO MO TIVICAY TABS 10mg 25mg 50mg MO
TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEMLIDY TABS VIDEX EC CPDR 125mg 200mg 400mg MO
VIDEX SOLR 2gm 4gm MO VIEKIRA PAK TBPK PANDS VIEKIRA XR TB24 PANDS VIRACEPT TABS 250mg 625mg MO
VIREAD POWD MO VIREAD TABS 150mg MO VIREAD TABS 200mg 250mg MO VOCABRIA TABS MO VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS ZERIT CAPS 15mg 20mg 30mg 40mg MO
zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 14 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fosfomycin tromethamine pack MENAPHOSMBHYO1 TABS methenamine hippurate tabs METHENAMINE MANDELATE TABS
NITROFURANTOIN MACROCRYSTAL CAPS
NITROFURANTOIN MONOHYD MACRO CAPS
nitrofurantoin susp PHOSPHASAL TABS trimethoprim tabs MO URETRON DS TABS URIN DS TABS URYL TABS USTELL CAPS UTICAP CAPS UTIRA-C TABS UTRONA-C TABS ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate soln carbinoxamine maleate tabs cetirizine hcl soln CLARINEX SYRP CLARINEX-D 12 HOUR TB12 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln
Drug Name RequirementsLimits
promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs SEMPREX-D CAPS ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg 500mg NDS
ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS 25mg 5mg 75mg 10mg NDS
ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs ARRANON SOLN ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE INJ BELEODAQ SOLR NDS BELRAPZO SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS bexarotene caps NDS bicalutamide tabs BICNU SOLR bleomycin sulfate solr BLINCYTO SOLR NDS BORTEZOMIB SOLR BOSULIF TABS 100mg 400mg 500mg NDS
BRAFTOVI CAPS 50mg 75mg NDS BRUKINSA CAPS NDS busulfan soln CABOMETYX TABS 20mg 40mg 60mg NDS
CALQUENCE CAPS NDS CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR NDS cladribine soln clofarabine soln COMETRIQ (100 MG DAILY DOSE) KIT LDNDS
COMETRIQ (140 MG DAILY DOSE) KIT LDNDS
COMETRIQ (60 MG DAILY DOSE) KIT LDNDS
COPIKTRA CAPS 15mg 25mg NDS COTELLIC TABS NDS CYCLOPHOSPHAMIDE CAPS 25mg 50mg PA
CYCLOPHOSPHAMIDE SOLN 1gm5ml 500mg25ml NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr
Drug Name RequirementsLimits
dactinomycin solr DANYELZA SOLN NDS DARZALEX FASPRO SOLN NDS DARZALEX SOLN 400mg20ml 100mg5ml NDS
daunorubicin hcl soln DAURISMO TABS 25mg 100mg NDS decitabine solr DOCETAXEL (NON-ALCOHOL) SOLN 80mg4ml 160mg8ml 20mgml
NDS
docetaxel conc docetaxel soln doxorubicin hcl liposomal inj DOXORUBICIN HCL SOLN doxorubicin hcl solr DROXIA CAPS ELIGARD KIT ELLENCE SOLN ELZONRIS SOLN NDS EMCYT CAPS NDS EMPLICITI SOLR 300mg 400mg NDS
ENHERTU SOLR NDS epirubicin hcl soln ERBITUX SOLN ERIVEDGE CAPS NDS ERLEADA TABS NDS erlotinib hcl tabs 25mg 100mg 150mg NDS
ERWINASE SOLR NDS ERWINAZE SOLR NDS ETOPOPHOS SOLR NDS etoposide soln everolimus tabs 25mg 5mg 75mg NDS
EVOMELA SOLR NDS exemestane tabs FARYDAK CAPS 10mg 15mg 20mg LDNDS
FASLODEX SOLN NDS FENSOLVI (6 MONTH) KIT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 16 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
FIRMAGON (240 MG DOSE) SOLR
FIRMAGON SOLR floxuridine solr fludarabine phosphate soln fludarabine phosphate solr fluorouracil soln flutamide caps FOTIVDA CAPS 089mg 134mg NDS
fulvestrant soln NDS GAVRETO CAPS NDS GAZYVA SOLN NDS gemcitabine hcl soln gemcitabine hcl solr GILOTRIF TABS 20mg 30mg 40mg NDS
HERCEPTIN HYLECTA SOLN NDS HERCEPTIN SOLR 150mg 440mg NDS
HERZUMA SOLR 150mg 420mg NDS
HEXALEN CAPS NDS hydroxyurea caps IBRANCE CAPS 75mg 100mg 125mg NDS
IBRANCE TABS 75mg 100mg 125mg NDS
ICLUSIG TABS 10mg 15mg 30mg 45mg NDS
IDAMYCIN PFS SOLN idarubicin hcl soln IDHIFA TABS 50mg 100mg NDS ifosfamide soln IFOSFAMIDE SOLR imatinib mesylate tabs IMBRUVICA CAPS 70mg 140mg NDS
IMBRUVICA TABS 140mg 280mg 420mg 560mg NDS
IMFINZI SOLN 500mg10ml 120mg24ml NDS
INFUGEM SOLN NDS INLYTA TABS 1mg 5mg NDS
Drug Name RequirementsLimits
INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 10muml 6000000unitml NDS
INTRON A SOLR 10mu 18mu 50mu NDS
IRESSA TABS NDS irinotecan hcl soln IXEMPRA KIT SOLR NDS JAKAFI TABS 5mg 10mg 15mg 20mg 25mg NDS
JEMPERLI SOLN KADCYLA SOLR 100mg 160mg NDS KANJINTI SOLR 150mg 420mg NDS KEYTRUDA SOLN NDS KISQALI (200 MG DOSE) TBPK NDS KISQALI (400 MG DOSE) TBPK NDS KISQALI (600 MG DOSE) TBPK NDS KISQALI FEMARA (400 MG DOSE) TBPK NDS
KISQALI FEMARA (600 MG DOSE) TBPK NDS
KISQALI FEMARA (200 MG DOSE) TBPK NDS
KOSELUGO CAPS 10mg 25mg NDS KYPROLIS SOLR 10mg 30mg 60mg NDS
lapatinib ditosylate tabs NDS LARTRUVO SOLN 190mg19ml 500mg50ml NDS
LENVIMA (10 MG DAILY DOSE) CPPK LDNDS
LENVIMA (12 MG DAILY DOSE) CPPK LDNDS
LENVIMA (14 MG DAILY DOSE) CPPK LDNDS
LENVIMA (18 MG DAILY DOSE) CPPK LDNDS
LENVIMA (20 MG DAILY DOSE) CPPK LDNDS
LENVIMA (24 MG DAILY DOSE) CPPK LDNDS
LENVIMA (4 MG DAILY DOSE) CPPK LDNDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
LENVIMA (8 MG DAILY DOSE) CPPK LDNDS
letrozole tabs LEUKERAN TABS NDS leuprolide acetate kit LIBTAYO SOLN NDS LIPODOX 50 INJ LONSURF TABS NDS LORBRENA TABS 25mg 100mg NDS
LUMAKRAS TABS NDS LUMOXITI SOLR NDS LUPANETA PACK KIT LUPRON DEPOT (1-MONTH) KIT
LUPRON DEPOT (3-MONTH) KIT
LUPRON DEPOT (4-MONTH) KIT
LUPRON DEPOT (6-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT 75 MG
LUPRON DEPOT-PED (3-MONTH) KIT
LYNPARZA CAPS NDS LYNPARZA TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA SOLN NDS MARQIBO SUSP NDS MATULANE CAPS NDS megestrol acetate susp megestrol acetate tabs MEKINIST TABS 05mg 2mg NDS MEKTOVI TABS NDS melphalan hcl solr mercaptopurine tabs methotrexate sodium (pf) soln methotrexate sodium soln methotrexate sodium solr
Drug Name RequirementsLimits
methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS MUSTARGEN SOLR mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS NERLYNX TABS NDS NEXAVAR TABS NDS nilutamide tabs NINLARO CAPS 23mg 3mg 4mg NDS
NUBEQA TABS NDS ODOMZO CAPS NDS OGIVRI SOLR NDS ONIVYDE INJ NDS ONTRUZANT SOLR 150mg 420mg NDS
ONUREG TABS 200mg 300mg NDS OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml NDS
oxaliplatin soln oxaliplatin solr paclitaxel conc PADCEV SOLR 20mg 30mg NDS paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEPAXTO SOLR NDS PERJETA SOLN NDS PHESGO SOLN NDS PIQRAY (200 MG DAILY DOSE) TBPK NDS
PIQRAY (250 MG DAILY DOSE) TBPK NDS
PIQRAY (300 MG DAILY DOSE) TBPK NDS
POLIVY SOLR 30mg 140mg NDS POMALYST CAPS 1mg 2mg 3mg 4mg NDS
PORTRAZZA SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 18 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
POTELIGEO SOLN NDS PROLEUKIN SOLR NDS PURIXAN SUSP NDS QINLOCK TABS NDS RETEVMO CAPS 40mg 80mg NDS REVLIMID CAPS 25mg 5mg 10mg 15mg 20mg 25mg NDS
RIABNI SOLN 100mg10ml 500mg50ml NDS
RITUXAN HYCELA SOLN RITUXAN SOLN ROMIDEPSIN SOLN NDS ROZLYTREK CAPS 100mg 200mg NDS
RUBRACA TABS 200mg 250mg 300mg NDS
RUXIENCE SOLN 100mg10ml 500mg50ml NDS
RYBREVANT SOLN NDS RYDAPT CAPS NDS RYLAZE SOLN NDS SARCLISA SOLN 500mg25ml 100mg5ml NDS
SIKLOS TABS NDS SOLTAMOX SOLN SPRYCEL TABS 20mg 50mg 70mg 80mg 100mg 140mg NDS
STIVARGA TABS NDS sunitinib malate caps 125mg 25mg 375mg 50mg NDS
SUTENT CAPS 125mg 25mg 375mg 50mg NDS
SYLATRON KIT 600 MCG SYLATRON KIT SYLVANT SOLR 100mg 400mg NDS SYNRIBO SOLR NDS TABLOID TABS TABRECTA TABS 150mg 200mg NDS
TAFINLAR CAPS 50mg 75mg NDS TAGRISSO TABS 40mg 80mg NDS TALZENNA CAPS 025mg 1mg NDS tamoxifen citrate tabs
Drug Name RequirementsLimits
TARCEVA TABS 25mg 100mg 150mg NDS
TASIGNA CAPS 50mg 150mg 200mg NDS
TAZVERIK TABS NDS TECENTRIQ SOLN 840mg14ml 1200mg20ml NDS
temsirolimus soln TENIPOSIDE SOLN TEPADINA SOLR NDS TEPMETKO TABS NDS THALOMID CAPS 50mg 100mg 150mg 200mg NDS
thiotepa solr 15mg 100mg NDS TIBSOVO TABS NDS toposar soln TOPOTECAN HCL SOLN topotecan hcl solr toremifene citrate tabs NDS TRAZIMERA SOLR 150mg 420mg NDS
TRELSTAR MIXJECT SUSR tretinoin caps NDS trexall tabs 5mg 75mg 10mg 15mg PA
TRISENOX SOLN 10mg10ml NDS TRISENOX SOLN NDS TRODELVY SOLR NDS TRUSELTIQ (100MG DAILY DOSE) CPPK NDS
TRUSELTIQ (125MG DAILY DOSE) CPPK NDS
TRUSELTIQ (50MG DAILY DOSE) CPPK NDS
TRUSELTIQ (75MG DAILY DOSE) CPPK NDS
TRUXIMA SOLN 100mg10ml 500mg50ml NDS
TUKYSA TABS 50mg 150mg NDS TURALIO CAPS NDS TYKERB TABS NDS UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
VANTAS KIT VELCADE SOLR VENCLEXTA STARTING PACK TBPK NDS
VENCLEXTA TABS 10mg NDS VENCLEXTA TABS 50mg 100mg NDS
VERZENIO TABS 50mg 100mg 150mg 200mg NDS
vinblastine sulfate soln vincasar pfs soln vincristine sulfate soln vinorelbine tartrate soln VITRAKVI CAPS 25mg 100mg NDS VITRAKVI SOLN NDS VIZIMPRO TABS 15mg 30mg 45mg NDS
VOTRIENT TABS NDS VYXEOS SUSR NDS XALKORI CAPS 200mg 250mg NDS XATMEP SOLN PANDS XOSPATA TABS NDS XPOVIO (100 MG ONCE WEEKLY) TBPK 20mg 50mg NDS
XPOVIO (40 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (40 MG TWICE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (60 MG ONCE WEEKLY) TBPK 20mg 60mg NDS
XPOVIO (60 MG TWICE WEEKLY) TBPK NDS
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (80 MG TWICE WEEKLY) TBPK NDS
XTANDI CAPS NDS XTANDI TABS 40mg 80mg NDS YERVOY SOLN YONDELIS SOLR NDS YONSA TABS NDS ZALTRAP SOLN 100mg4ml 200mg8ml NDS
ZEJULA CAPS NDS
Drug Name RequirementsLimits
ZELBORAF TABS NDS ZEPZELCA SOLR NDS ZIRABEV SOLN 400mg16ml 100mg4ml NDS
ZOLINZA CAPS NDS ZYDELIG TABS 100mg 150mg NDS ZYKADIA CAPS NDS ZYKADIA TABS NDS ZYNLONTA SOLR NDS ZYTIGA TABS NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA AEPB MO ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO BEVESPI AEROSPHERE AERO MO chlordiazepoxide-clidinium caps CUVPOSA SOLN MO dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate pf sosy glycopyrrolate soln glycopyrrolate tabs 1mg 2mg MO INCRUSE ELLIPTA AEPB MO ipratropium bromide soln 002 PAMO ipratropium bromide soln 003 006 MO
LONHALA MAGNAIR REFILL KIT SOLN NDS
methscopolamine bromide tabs 25mg 5mg MO
propantheline bromide tabs MO SPIRIVA HANDIHALER CAPS MO SPIRIVA RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 20 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO NICOTROL NS SOLN MO PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride tabs 5mg 10mg 25mg 50mg MO
CEVIMELINE HCL CAPS MO donepezil hcl tabs 5mg 10mg 23mg MO
donepezil hcl tbdp 5mg 10mg MO galantamine hydrobromide er cp24 8mg 16mg 24mg MO
galantamine hydrobromide soln MO galantamine hydrobromide tabs 4mg 8mg 12mg MO
GUANIDINE HCL TABS MO MESTINON SOLN MO pilocarpine hcl tabs 5mg 75mg MO pyridostigmine bromide er tbcr MO pyridostigmine bromide soln MO pyridostigmine bromide tabs 30mg 60mg MO
REGONOL SOLN rivastigmine pt24 46mg24hr 95mg24hr 133mg24hr MO
rivastigmine tartrate caps 15mg 3mg 45mg 6mg MO
urecholine tabs 5mg 10mg 25mg 50mg MO
SKELETAL MUSCLE RELAXANTS baclofen soln baclofen tabs 5mg 10mg 20mg MO carisoprodol tabs 250mg 350mg PANDS carisoprodol-aspirin tabs PANDS carisoprodol-aspirin-codeine tabs PANDS
chlorzoxazone tabs 375mg 500mg 750mg NDS
Drug Name RequirementsLimits
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA lorzone tabs 375mg 750mg NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln revonto solr succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs vanadom tabs PANDS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl er tb24 MO dihydroergotamine mesylate soln NDS ergoloid mesylates tabs MO ergomar subl phenoxybenzamine hcl caps NDS silodosin caps 4mg 8mg MO tamsulosin hcl caps MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR HFA AERO MO albuterol sulfate er tb12 4mg 8mg MO
albuterol sulfate hfa aers MONDS albuterol sulfate nebu 0083 25mg05ml PAMO
albuterol sulfate nebu 063mg3ml 125mg3ml PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO ARCAPTA NEOHALER CAPS MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY EPIPEN 2-PAK SOAJ EPIPEN JR 2-PAK SOAJ formoterol fumarate nebu PAMO ipratropium-albuterol soln PAMO isoproterenol hcl soln levalbuterol hcl nebu 125mg05ml 031mg3ml 063mg3ml 125mg3ml
PAMO
levalbuterol tartrate aero MO metaproterenol sulfate syrp MO metaproterenol sulfate tabs 10mg 20mg MO
midodrine hcl tabs 25mg 5mg 10mg MO
norepinephrine bitartrate soln phenylephrine hcl soln PROAIR RESPICLICK AEPB MO SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
tizanidine hcl caps VENTOLIN HFA AERS MONDS BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS BERINERT KIT INTRAVENOUS HI FIRAZYR SOLN NDS icatibant acetate soln NDS OXBRYTA TABS NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS
Drug Name RequirementsLimits
COAGULANTS AND ANTICOAGULANTS aminocaproic acid soln MO aminocaproic acid tabs 500mg 1000mg MO
anagrelide hcl caps 05mg 1mg MO argatroban soln aspirin-dipyridamole er cp12 MO BEVYXXA CAPS 40mg 80mg MO BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
NDS
FRAGMIN SOLN 2500unit02ml 5000unit02ml 7500unit03ml 12500unit05ml 15000unit06ml 95000unit38ml 10000unitml 18000unt072ml
NDS
heparin (porcine) in nacl soln HEPARIN SOD (PORCINE) IN D5W SOLN
heparin sodium (porcine) pf soln PA heparin sodium (porcine) soln 1000unitml 5000unitml 10000unitml 20000unitml
PA
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg
MO
LOVENOX SOLN 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 22 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg PRADAXA CAPS 110mg 150mg MO
prasugrel hcl tabs 5mg 10mg MO tranexamic acid soln tranexamic acid tabs MO warfarin sodium tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 10mg
MO
XARELTO STARTER PACK TBPK MO
XARELTO TABS 25mg 10mg 15mg 20mg MO
ZONTIVITY TABS MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 25mcgml 40mcgml PANDS
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml
PANDS
FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MIRCERA SOSY 30mcg03ml 50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml
PA
MULPLETA TABS NDS
Drug Name RequirementsLimits
NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml NDS
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RETACRIT SOLN 20000unit2ml 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL TB24 4mg 8mg MO DEMSER CAPS NDS doxazosin mesylate tabs 1mg 2mg 4mg 8mg MO
metyrosine caps NDS prazosin hcl caps 1mg 2mg 5mg MO
terazosin hcl caps 1mg 2mg 5mg 10mg MO
ANTILIPEMIC AGENTS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
ALTOPREV TB24 20mg 40mg 60mg MO
ANTARA CAPS 30mg 90mg MO atorvastatin calcium tabs 10mg 20mg 40mg 80mg MO
cholestyramine light pack MO cholestyramine light powd MO cholestyramine pack MO cholestyramine powd MO colesevelam hcl pack MO colesevelam hcl tabs MO colestipol hcl gran MO colestipol hcl pack MO colestipol hcl tabs MO EVKEEZA SOLN 345mg23ml 1200mg8ml NDS
ezetimibe tabs MO ezetimibe-simvastatin tabs MO fenofibrate caps 50mg 134mg 150mg MO
fenofibrate micronized caps 43mg 67mg 130mg 200mg MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg MO
FENOFIBRIC ACID TABS 35mg 105mg MO
FIBRICOR TABS MO FLOLIPID SUSP 20mg5ml 40mg5ml MO
fluvastatin sodium caps 20mg 40mg MO
fluvastatin sodium er tb24 MO gemfibrozil tabs MO icosapent ethyl caps MO JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg PALDNDS
KYNAMRO SOSY PALDNDS LIVALO TABS 1mg 2mg 4mg MO lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
Drug Name RequirementsLimits
niacor tabs MO omega-3-acid ethyl esters caps MO pravastatin sodium tabs 10mg 20mg 40mg 80mg MO
prevalite pack MO prevalite powd MO questran light powd MO questran pack MO questran powd MO REPATHA PUSHTRONEX SYSTEM SOCT PANDS
REPATHA SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 05gm 1gm MO ZYPITAMAG TABS 1mg 2mg 4mg MO
BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl caps 200mg 400mg MO
atenolol tabs 25mg 50mg 100mg MO
atenolol-chlorthalidone tabs MO betaxolol hcl tabs 10mg 20mg MO bisoprolol fumarate tabs 5mg 10mg MO
bisoprolol-hydrochlorothiazide tabs MO
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg MO
carvedilol tabs 3125mg 625mg 125mg 25mg MO
DUTOPROL TB24 MO ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln INNOPRAN XL CP24 80mg 120mg MO
labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 24 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
metoprolol succinate er tb24 25mg 50mg 100mg 200mg MO
metoprolol tartrate soct metoprolol tartrate soln metoprolol tartrate tabs 25mg 50mg 100mg MO
metoprolol tartrate tabs 375mg 75mg MO
metoprolol-hydrochlorothiazide tabs MO
nadolol tabs 20mg 40mg 80mg MO nadolol-bendroflumethiazide tabs MO
pindolol tabs 5mg 10mg MO propranolol hcl er cp24 60mg 80mg 120mg 160mg MO
propranolol hcl soln 20mg5ml 40mg5ml MO
propranolol hcl tabs 10mg 20mg 40mg 60mg 80mg MO
propranolol-hctz tabs MO sorine tabs 80mg 120mg 160mg 240mg MO
sotalol hcl (af) tabs 80mg 120mg 160mg MO
sotalol hcl tabs 80mg 120mg 160mg 240mg MO
SOTYLIZE SOLN MO timolol maleate tabs 5mg 10mg 20mg MO
CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besy-benazepril hcl caps MO
amlodipine besylate tabs 25mg 5mg 10mg MO
amlodipine besylate-valsartan tabs MO
amlodipine-atorvastatin tabs MO amlodipine-olmesartan tabs MO amlodipine-valsartan-hctz tabs MO CARDENE IV SOLN CARDIZEM LA TB24 MO cartia xt cp24 120mg 180mg 240mg 300mg MO
Drug Name RequirementsLimits
CONSENSI TABS NDS dilt-xr cp24 120mg 180mg 240mg MO
diltiazem hcl er beads cp24 120mg 180mg 240mg 300mg 360mg 420mg
MO
DILTIAZEM HCL ER COATED BEADS CP24 120mg 180mg 240mg 300mg 360mg
MO
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg
MO
diltiazem hcl er cp12 60mg 90mg 120mg MO
diltiazem hcl er cp24 120mg 180mg 240mg MO
diltiazem hcl soln diltiazem hcl solr diltiazem hcl tabs 30mg 60mg 90mg 120mg MO
felodipine er tb24 25mg 5mg 10mg MO
isradipine caps 25mg 5mg MO matzim la tb24 180mg 240mg 300mg 360mg 420mg MO
nicardipine hcl caps 20mg 30mg MO nicardipine hcl soln nifedipine caps 10mg 20mg MO nifedipine er osmotic release tb24 30mg 60mg 90mg MO
nifedipine er tb24 30mg 60mg 90mg MO
nimodipine caps MO nisoldipine er tb24 85mg 17mg 20mg 255mg 30mg 34mg 40mg
MO
NYMALIZE SOLN 60mg20ml 6mgml NDS
olmesartan-amlodipine-hctz tabs MO taztia xt cp24 120mg 180mg 240mg 300mg 360mg MO
telmisartan-amlodipine tabs MO tiadylt er cp24 120mg 180mg 240mg 300mg 360mg 420mg MO
trandolapril-verapamil hcl er tbcr MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
VERAPAMIL HCL ER CP24 100mg 120mg 180mg 200mg 240mg 300mg 360mg
MO
verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 80mg 120mg MO verapamil hcl tabs MO VERELAN CP24 MO CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln inj DIGOXIN ORAL SOLN MO digoxin tabs 125mcg 250mcg MO disopyramide phosphate caps 100mg 150mg MO
dofetilide caps 125mcg 250mcg 500mcg MO
flecainide acetate tabs 50mg 100mg 150mg MO
ibutilide fumarate soln LANOXIN PEDIATRIC SOLN LANOXIN TABS 625mcg MO lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy LIDOCAINE IN D5W SOLN mexiletine hcl caps 150mg 200mg 250mg MO
milrinone lactate in dextrose soln milrinone lactate soln MULTAQ TABS NORPACE CR CP12 100mg 150mg MO
pacerone tabs 100mg 200mg 400mg MO
procainamide hcl soln
Drug Name RequirementsLimits
propafenone hcl er cp12 225mg 325mg 425mg MO
propafenone hcl tabs 150mg 225mg 300mg MO
quinidine gluconate er tbcr MO QUINIDINE GLUCONATE SOLN quinidine sulfate tabs 200mg 300mg MO
ranolazine er tb12 500mg 1000mg MO
VYNDAMAX CAPS NDS VYNDAQEL CAPS NDS HYPOTENSIVE AGENTS clonidine hcl (analgesia) soln clonidine hcl er tb12 MO clonidine hcl tabs 01mg 02mg 03mg MO
clonidine ptwk 01mg24hr 02mg24hr 03mg24hr MO
guanfacine hcl tabs 1mg 2mg MO hydralazine hcl soln hydralazine hcl tabs 10mg 25mg 50mg 100mg MO
methyldopa tabs 250mg 500mg MO methyldopa-hydrochlorothiazide tabs MO
minoxidil tabs 25mg 10mg MO nitropress soln nitroprusside sodium soln vecamyl tabs NDS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE TABS MO aliskiren fumarate tabs 150mg 300mg MO
benazepril hcl tabs 5mg 10mg 20mg 40mg MO
benazepril-hydrochlorothiazide tabs MO
candesartan cilexetil tabs 4mg 8mg 16mg 32mg MO
candesartan cilexetil-hctz tabs MO captopril tabs 125mg 25mg 50mg 100mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 26 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
captopril-hydrochlorothiazide tabs MO
CAROSPIR SUSP MO EDARBYCLOR TABS MO enalapril maleate tabs 25mg 5mg 10mg 20mg MO
enalapril-hydrochlorothiazide tabs MO
enalaprilat inj ENTRESTO TABS MO eplerenone tabs 25mg 50mg MO eprosartan mesylate tabs MO fosinopril sodium tabs 10mg 20mg 40mg MO
fosinopril sodium-hctz tabs MO irbesartan tabs 75mg 150mg 300mg MO
irbesartan-hydrochlorothiazide tabs MO
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg MO
lisinopril-hydrochlorothiazide tabs MO
losartan potassium tabs 25mg 50mg 100mg MO
losartan potassium-hctz tabs MO moexipril hcl tabs 75mg 15mg MO olmesartan medoxomil tabs 5mg 20mg 40mg MO
olmesartan medoxomil-hctz tabs MO perindopril erbumine tabs 2mg 4mg 8mg MO
QBRELIS SOLN MO quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO TEKTURNA HCT TABS MO
Drug Name RequirementsLimits
telmisartan tabs 20mg 40mg 80mg MO
telmisartan-hctz tabs MO trandolapril tabs 1mg 2mg 4mg MO valsartan tabs 40mg 80mg 160mg 320mg MO
valsartan-hydrochlorothiazide tabs MO
VASODILATING AGENTS alyq tabs PA BIDIL TABS MO dipyridamole tabs 25mg 50mg 75mg MO
GONITRO PACK MO isosorbide dinitrate er tbcr MO isosorbide dinitrate tabs 5mg 10mg 20mg 30mg MO
isosorbide mononitrate er tb24 30mg 60mg MO
isosorbide mononitrate er tb24 MO isosorbide mononitrate tabs 10mg 20mg MO
minitran pt24 01mghr 02mghr 04mghr 06mghr MO
nitro-bid oint MO NITRO-DUR PT24 03mghr 08mghr MO
nitroglycerin pt24 01mghr 02mghr 04mghr 06mghr MO
nitroglycerin soln MO nitroglycerin subl 03mg 04mg 06mg MO
sildenafil citrate soln PANDS sildenafil citrate susr PA sildenafil citrate tabs PAMO tadalafil (pah) tabs 20mg PA tadalafil tabs 25mg 5mg PA CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS acamprosate calcium tbec MO antabuse tabs 250mg 500mg MO disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
ABSTRAL SUBL 100mcg 200mcg 300mcg 400mcg 600mcg 800mcg
PANDS
acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ARYMO ER TBEA NDS ascomp-codeine caps NDS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
benzhydrocodone-acetaminophen tabs
bupap tabs buprenorphine hcl soln NDS buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
butalbital-acetaminophen caps NDS butalbital-acetaminophen tabs butalbital-apap-caff-cod caps NDS butalbital-apap-caffeine caps butalbital-apap-caffeine tabs butalbital-asa-caff-codeine caps NDS butalbital-aspirin-caffeine caps butalbital-aspirin-caffeine tabs butorphanol tartrate soln 1mgml 2mgml 10mgml NDS
BUTRANS PTWK NDS cataflam tabs NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
DEMEROL SOLN 25mg05ml 75mg15ml 100mg2ml 75mgml
PANDS
diclofenac potassium tabs diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs
Drug Name RequirementsLimits
DUEXIS TABS NDS DURAMORPH SOLN 05mgml 1mgml HINDS
dvorah tabs NDS EMBEDA CPCR NDS endocet tabs NDS esgic caps esgic tabs etodolac caps etodolac er tb24 etodolac tabs fenoprofen calcium caps fenoprofen calcium tabs fenortho caps fentanyl citrate (pf) soct NDS FENTANYL CITRATE (PF) SOLN 50mcgml 1000mcg20ml 2500mcg50ml
NDS
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fioricet caps fioricetcodeine caps NDS flurbiprofen tabs hydrocodone bitartrate er cp12 10mg 15mg 20mg 30mg 40mg 50mg
NDS
hydrocodone-acetaminophen soln NDS
hydrocodone-acetaminophen tabs NDS
hydrocodone-ibuprofen tabs NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 28 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd NDS hydromorphone hcl pf soln 50mg5ml 10mgml NDS
HYDROMORPHONE HCL SOLN 1mgml 2mgml NDS
hydromorphone hcl tabs 2mg 4mg 8mg NDS
ibu tabs ibudone tabs NDS ibuprofen lysine soln ibuprofen susp ibuprofen tabs ILARIS SOLN NDS indocin supp INDOCIN SUSP indomethacin caps INDOMETHACIN CAPS 20mg indomethacin er cpcr indomethacin sodium solr KADIAN CP24 NDS ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 300mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lodine tabs lorcet hd tabs NDS lorcet plus tabs NDS lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam caps meloxicam tabs meperidine hcl soln 50mg5ml 25mgml 50mgml 100mgml PANDS
meperidine hcl tabs 50mg 100mg NDS
Drug Name RequirementsLimits
methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl soln 5mg5ml 10mg5ml 10mgml NDS
methadone hcl tabs 5mg 10mg NDS mitigo soln MORPHINE SULFATE (CONCENTRATE) SOLN NDS
morphine sulfate (pf) soln 4mgml 10mgml NDS
MORPHINE SULFATE (PF) SOLN INTRAVENOUS HI
morphine sulfate er beads cp24 30mg 45mg 60mg 75mg 90mg 120mg
NDS
morphine sulfate er cp24 10mg 20mg 30mg 40mg 50mg 60mg 80mg 100mg
NDS
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg NDS
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml NDS
MORPHINE SULFATE SOLN HINDS MORPHINE SULFATE SOLN INJECTION 2mgml 4mgml 10mgml
HI
MORPHINE SULFATE SOLN INTRAVENOUS HI
morphine sulfate tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln nalfon tabs nalocet tabs NDS NAPRELAN TB24 naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
NUCYNTA ER TB12 50mg 100mg 150mg NDS
NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS 50mg 75mg NDS NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs oxaprozin tabs OXAYDO TABS NDS oxycodone hcl caps NDS oxycodone hcl conc NDS oxycodone hcl er t12a 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxycodone hcl soln NDS oxycodone hcl tabs 5mg 10mg 15mg 20mg 30mg NDS
oxycodone-acetaminophen soln NDS oxycodone-acetaminophen tabs NDS oxycodone-acetaminophen tabs 5-300mg 10-300mg NDS
oxycodone-aspirin tabs NDS oxycodone-ibuprofen tabs NDS OXYCONTIN T12A 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxymorphone hcl er tb12 5mg 75mg 10mg 15mg 20mg 30mg 40mg
NDS
oxymorphone hcl tabs 5mg 10mg NDS
panlor tabs NDS pentazocine-naloxone hcl tabs NDS percocet tabs NDS phrenilin forte caps PIROXICAM CAPS 10mg 20mg NDS pregabalin er tb24 825mg 165mg 330mg MO
primlev tabs NDS prolate soln NDS prolate tabs NDS QDOLO SOLN NDS
Drug Name RequirementsLimits
relafen ds tabs NDS ROXYBOND TABA 5mg 15mg 30mg NDS
SALSALATE TABS SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
SUBSYS LIQD 100mcg 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
sulindac tabs tencon tabs TIVORBEX CAPS tolmetin sodium caps tolmetin sodium tabs tramadol hcl er (biphasic) tb24 100mg 200mg 300mg NDS
tramadol hcl er cp24 100mg 150mg 200mg 300mg NDS
tramadol hcl er tb24 100mg 200mg 300mg NDS
tramadol hcl tabs 50mg 100mg NDS tramadol-acetaminophen tabs NDS trezix caps NDS tylenol with codeine 3 tabs NDS tylenol with codeine 4 tabs NDS vanatol lq soln vicodin es tabs NDS vicodin hp tabs NDS vicodin tabs NDS XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg NDS
zebutal caps ZIPSOR CAPS ZORVOLEX CAPS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS ADDERALL XR CP24 NDS ADZENYS ER SUER NDS ADZENYS XR-ODT TBED 31mg 63mg 94mg 125mg 157mg 188mg
NDS
amphetamine er suer NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 30 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
amphetamine sulfate tabs 5mg 10mg NDS
amphetamine-dextroamphet er cp24 NDS
amphetamine-dextroamphetamine tabs NDS
armodafinil tabs 50mg 150mg 200mg 250mg PA
caffeine citrate soln COTEMPLA XR-ODT TBED 86mg 173mg 259mg NDS
DAYTRANA PTCH 10mg9hr 15mg9hr 20mg9hr 30mg9hr NDS
dexmethylphenidate hcl er cp24 5mg 10mg 15mg 20mg 25mg 30mg 35mg 40mg
NDS
dexmethylphenidate hcl tabs 25mg 5mg 10mg NDS
dextroamphetamine sulfate er cp24 5mg 10mg 15mg NDS
dextroamphetamine sulfate soln NDS dextroamphetamine sulfate tabs 5mg 10mg 15mg 20mg 30mg NDS
DYANAVEL XR SUER NDS evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS methylphenidate hcl chew 25mg 5mg 10mg NDS
methylphenidate hcl er (cd) cpcr 10mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er (la) cp24 10mg 20mg 30mg 40mg 60mg
NDS
methylphenidate hcl er (xr) cp24 10mg 15mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg NDS
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg
NDS
methylphenidate hcl soln 5mg5ml 10mg5ml NDS
Drug Name RequirementsLimits
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS MYDAYIS CP24 NDS procentra soln NDS QUILLICHEW ER CHER 20mg 30mg 40mg NDS
QUILLIVANT XR SRER NDS relexxii tbcr NDS SUNOSI TABS 75mg 150mg NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
NDS
VYVANSE CHEW 10mg 20mg 30mg 40mg 50mg 60mg NDS
WAKIX TABS 445mg 178mg NDS zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg
NDS
ANTICONVULSANTS APTIOM TABS 200mg 400mg 600mg 800mg MO
BANZEL SUSP BANZEL TABS 200mg 400mg NDS BRIVIACT SOLN NDS BRIVIACT TABS 10mg 25mg 50mg 75mg 100mg NDS
carbamazepine chew MO carbamazepine er cp12 100mg 200mg 300mg MO
carbamazepine er tb12 100mg 200mg 400mg MO
carbamazepine susp MO carbamazepine tabs MO CELONTIN CAPS MO clobazam susp MO clobazam tabs 10mg 20mg MO clonazepam tabs 05mg 1mg 2mg NDS
clonazepam tbdp 0125mg 025mg 05mg 1mg 2mg NDS
DIACOMIT CAPS 250mg 500mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
DIACOMIT PACK 250mg 500mg NDS
DIASTAT ACUDIAL GEL 10mg 20mg NDS
DIASTAT PEDIATRIC GEL NDS diazepam gel 25mg 10mg 20mg NDS
dilantin caps 30mg 100mg MO dilantin infatabs chew MO divalproex sodium csdr MO divalproex sodium er tb24 250mg 500mg MO
divalproex sodium tbec 125mg 250mg 500mg MO
ELEPSIA XR TB24 1000mg 1500mg NDS
EPIDIOLEX SOLN PANDS epitol tabs MO ethosuximide caps MO ethosuximide soln MO felbamate susp MO felbamate tabs 400mg 600mg MO FINTEPLA SOLN NDS fosphenytoin sodium soln FYCOMPA SUSP NDS FYCOMPA TABS gabapentin caps 100mg 400mg MO gabapentin soln MO gabapentin tabs 600mg 800mg MO HORIZANT TBCR 300mg 600mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
lamotrigine kit MO lamotrigine starter kit-blue kit MO lamotrigine starter kit-green kit MO lamotrigine starter kit-orange kit MO lamotrigine tabs 25mg 100mg 150mg 200mg MO
lamotrigine tbdp 25mg 50mg 100mg 200mg MO
Drug Name RequirementsLimits
levetiracetam er tb24 500mg 750mg MO
levetiracetam in nacl soln levetiracetam soln MO levetiracetam tabs 250mg 500mg 750mg 1000mg MO
magnesium sulfate soln magnesium sulfate soln injection 50 HI
MAGNESIUM SULFATE SOLN INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml
HI
NAYZILAM SOLN NDS oxcarbazepine susp MO oxcarbazepine tabs 150mg 300mg 600mg MO
OXTELLAR XR TB24 150mg 300mg 600mg MO
PEGANONE TABS MO phenytek caps 200mg 300mg MO phenytoin chew MO phenytoin sodium extended caps 100mg 200mg 300mg MO
phenytoin sodium soln phenytoin susp MO pregabalin caps 25mg 50mg 75mg 100mg 150mg 200mg 225mg 300mg
MO
pregabalin soln MO primidone tabs 50mg 250mg MO roweepra tabs 500mg 750mg 1000mg MO
roweepra xr tb24 500mg 750mg MO rufinamide susp rufinamide tabs 200mg 400mg NDS SPRITAM TB3D 250mg 500mg 750mg 1000mg NDS
subvenite starter kit-blue kit MO subvenite starter kit-green kit MO subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 32 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
SYMPAZAN FILM 10mg 20mg tiagabine hcl tabs 2mg 4mg 12mg 16mg MO
topiramate cpsp 15mg 25mg MO topiramate er cs24 25mg 50mg 100mg 150mg 200mg MO
topiramate tabs 25mg 50mg 100mg 200mg MO
TROKENDI XR CP24 25mg 50mg 100mg 200mg MO
valproate sodium soln valproic acid caps MO valproic acid soln MO VALTOCO 10 MG DOSE LIQD NDS VALTOCO 15 MG DOSE LQPK NDS VALTOCO 20 MG DOSE LQPK NDS VALTOCO 5 MG DOSE LIQD NDS vigabatrin pack LDNDS vigabatrin tabs NDS vigadrone pack LDNDS VIMPAT SOLN VIMPAT TABS MO XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200 MG NDS XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ AJOVY SOSY almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs EMGALITY (300 MG DOSE) SOSY NDS
Drug Name RequirementsLimits
EMGALITY SOAJ EMGALITY SOSY ergotamine-caffeine tabs frovatriptan succinate tabs naratriptan hcl tabs NURTEC TBDP NDS ONZETRA XSAIL EXHP rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs TOSYMRA SOLN UBRELVY TABS 50mg 100mg NDS ZEMBRACE SYMTOUCH SOAJ zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ZOMIG SOLN ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl syrp MO amantadine hcl tabs MO APOKYN SOCT NDS benztropine mesylate soln benztropine mesylate tabs 05mg 1mg 2mg MO
bromocriptine mesylate caps MO bromocriptine mesylate tabs MO cabergoline tabs MO carbidopa tabs MO carbidopa-levodopa er tbcr MO carbidopa-levodopa tabs MO carbidopa-levodopa tbdp MO carbidopa-levodopa-entacapone tabs MO
DUOPA SUSP LD EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg NDS
pramipexole dihydrochloride er tb24 0375mg 075mg 15mg 225mg 3mg 375mg 45mg
MO
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg
MO
rasagiline mesylate tabs 05mg 1mg MO
ropinirole hcl er tb24 2mg 4mg 6mg 8mg 12mg MO
ropinirole hcl tabs 025mg 05mg 1mg 2mg 3mg 4mg 5mg
MO
RYTARY CPCR MO selegiline hcl caps MO selegiline hcl tabs MO tolcapone tabs MO trihexyphenidyl hcl soln MO trihexyphenidyl hcl tabs 2mg 5mg MO
ZELAPAR TBDP MO ANXIOLYTICS SEDATIVES AND HYPNOTICS alprazolam er tb24 05mg 1mg 2mg 3mg NDS
alprazolam intensol conc NDS alprazolam tabs 025mg 05mg 1mg 2mg NDS
alprazolam tbdp 025mg 05mg 1mg 2mg NDS
BELSOMRA TABS buspirone hcl tabs 5mg 10mg buspirone hcl tabs 75mg 15mg 30mg
chlordiazepoxide hcl caps 5mg 10mg 25mg NDS
clorazepate dipotassium tabs 375mg 75mg 15mg NDS
diazepam conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS
Drug Name RequirementsLimits
droperidol soln EDLUAR SUBL 5mg 10mg NDS estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP NDS hydroxyzine hcl soln hydroxyzine hcl syrp hydroxyzine hcl tabs hydroxyzine pamoate caps lorazepam intensol conc NDS LORAZEPAM SOLN 4mgml 2mgml NDS
lorazepam tabs 05mg 1mg 2mg NDS
meprobamate tabs midazolam hcl (pf) soln midazolam hcl soln midazolam hcl syrp nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs ROZEREM TABS seconal caps TEMAZEPAM CAPS 15mg 225mg 30mg 75mg NDS
triazolam tabs 0125mg 025mg NDS zaleplon caps 5mg 10mg NDS zolpidem tartrate er tbcr 625mg 125mg NDS
zolpidem tartrate subl 175mg 35mg NDS
zolpidem tartrate tabs 5mg 10mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 34 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS atomoxetine hcl caps 10mg 18mg 25mg 40mg 60mg 80mg 100mg
MO
AUSTEDO TABS 6mg 9mg 12mg LDNDS
EXSERVAN FILM NDS flumazenil soln guanfacine hcl er tb24 1mg 2mg 3mg 4mg MO
INGREZZA CAPS 40mg 60mg 80mg NDS
INGREZZA CPPK NDS memantine hcl er cp24 memantine hcl soln MO memantine hcl tabs 5mg 10mg MO NAMENDA XR TITRATION PACK CP24 MO
NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS SAVELLA TABS 125mg 25mg 50mg 100mg MO
SAVELLA TITRATION PACK MISC MO
tetrabenazine tabs 125mg 25mg NDS
TIGLUTIK SUSP NDS XYREM SOLN LDNDS XYWAV SOLN NDS MULTIPLE SCLEROSIS AGENTS AUBAGIO TABS 7mg 14mg PANDS AVONEX KIT NDS AVONEX PEN AJKT NDS AVONEX PREFILLED PSKT NDS BAFIERTAM CPDR NDS BETASERON KIT NDS dalfampridine er tb12 MO dimethyl fumarate cpdr dimethyl fumarate starter pack misc
Drug Name RequirementsLimits
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatiramer acetate sosy 20mgml 40mgml NDS
glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 2mg NDS OCREVUS SOLN PLEGRIDY SOSY NDS PONVORY STARTER PACK TBPK NDS
PONVORY TABS NDS REBIF REBIDOSE SOAJ 22mcg05ml 44mcg05ml NDS
REBIF REBIDOSE TITRATION PACK SOAJ NDS
REBIF SOSY 22mcg05ml 44mcg05ml NDS
REBIF TITRATION PACK SOSY NDS TECFIDERA CPDR 120mg 240mg NDS
TECFIDERA MISC NDS TYSABRI CONC INTRAVENOUS HI
ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS ZINBRYTA SOSY LDNDS OPIATE ANTAGONISTS BUNAVAIL FILM NDS buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
LUCEMYRA TABS NDS naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR NDS ZUBSOLV SUBL NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg NDS
ABILIFY MYCITE MAINTENANCE KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg NDS
amitriptyline hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
amoxapine tabs 25mg 50mg 100mg 150mg MO
APLENZIN TB24 174mg 348mg 522mg MO
aripiprazole soln MO aripiprazole tabs 2mg 5mg 10mg 15mg 20mg 30mg MO
aripiprazole tbdp 10mg 15mg MO ARISTADA INITIO PRSY NDS ARISTADA PRSY 441mg16ml 662mg24ml 882mg32ml 1064mg39ml
NDS
asenapine maleate subl 25mg 5mg 10mg MO
bupropion hcl er (smoking det) tb12 MO
bupropion hcl er (sr) tb12 100mg 150mg 200mg MO
bupropion hcl er (xl) tb24 150mg 300mg 450mg MO
bupropion hcl tabs 75mg 100mg MO CAPLYTA CAPS NDS chlordiazepoxide-amitriptyline tabs
chlorpromazine hcl soln
Drug Name RequirementsLimits
chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
clomipramine hcl caps 25mg 50mg 75mg MO
clozapine tabs 25mg 50mg 100mg 200mg NDS
clozapine tbdp 125mg 25mg 100mg 150mg 200mg NDS
compro supp MO desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
DESVENLAFAXINE ER TB24 50mg 100mg MO
desvenlafaxine succinate er tb24 25mg 50mg 100mg MO
doxepin hcl caps 10mg 25mg 50mg 75mg 100mg 150mg MO
doxepin hcl conc MO doxepin hcl tabs 3mg 6mg MO DRIZALMA SPRINKLE CSDR duloxetine hcl cpep 20mg 30mg 40mg 60mg MO
EQUETRO CP12 100mg 200mg 300mg MO
escitalopram oxalate soln MO escitalopram oxalate tabs 5mg 10mg 20mg MO
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg NDS
FANAPT TITRATION PACK TABS MO
FETZIMA CP24 20mg 40mg 80mg 120mg MO
FETZIMA TITRATION C4PK MO fluoxetine hcl (pmdd) tabs 10mg 20mg MO
fluoxetine hcl caps 10mg 20mg 40mg MO
fluoxetine hcl cpdr MO fluoxetine hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 36 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
GEODON SOLR haloperidol decanoate soln haloperidol lactate conc MO haloperidol lactate soln haloperidol tabs 05mg 1mg 2mg 5mg 10mg 20mg MO
imipramine hcl tabs 10mg 25mg 50mg MO
imipramine pamoate caps 75mg 100mg 125mg 150mg MO
INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 300mg 150mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
lithium carbonate tabs MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO
Drug Name RequirementsLimits
mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
nefazodone hcl tabs 50mg 100mg 150mg 200mg 250mg MO
nortriptyline hcl caps 10mg 25mg 50mg 75mg MO
nortriptyline hcl soln MO NUPLAZID CAPS NDS NUPLAZID TABS 10mg 17mg NDS olanzapine solr olanzapine tabs 25mg 5mg 75mg 10mg 15mg 20mg MO
olanzapine tbdp 5mg 10mg 15mg 20mg MO
olanzapine-fluoxetine hcl caps MO PALIPERIDONE ER TB24 15mg 3mg 6mg 9mg MO
paroxetine hcl er tb24 125mg 25mg 375mg MO
paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps MO PAXIL SUSP MO perphenazine tabs 2mg 4mg 8mg 16mg MO
perphenazine-amitriptyline tabs MO PERSERIS PRSY 90mg 120mg NDS PEXEVA TABS 10mg 20mg 30mg 40mg MO
phenelzine sulfate tabs MO pimozide tabs 1mg 2mg MO prochlorperazine edisylate soln prochlorperazine maleate tabs prochlorperazine supp MO protriptyline hcl tabs 5mg 10mg MO quetiapine fumarate er tb24 50mg 150mg 200mg 300mg 400mg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
quetiapine fumarate tabs 25mg 50mg 100mg 200mg 300mg 400mg
MO
REXULTI TABS 025mg 05mg 1mg 2mg 3mg 4mg NDS
RISPERDAL CONSTA SRER 125mg 25mg NDS
RISPERDAL CONSTA SRER 375mg 50mg NDS
risperidone soln MO risperidone tabs 025mg 05mg 1mg 2mg 3mg 4mg MO
risperidone tbdp 025mg 05mg 1mg 2mg 3mg 4mg MO
SAPHRIS SUBL 25mg 5mg 10mg NDS
SECUADO PT24 38mg24hr 57mg24hr 76mg24hr NDS
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
SILENOR TABS SPRAVATO (56 MG DOSE) SOPK NDS
SPRAVATO (84 MG DOSE) SOPK NDS
thioridazine hcl tabs 10mg 25mg 50mg 100mg MO
thiothixene caps 1mg 2mg 5mg 10mg MO
tofranil tabs 10mg 25mg 50mg MO tranylcypromine sulfate tabs MO trazodone hcl tabs 50mg 100mg 150mg MO
trazodone hcl tabs MO trifluoperazine hcl tabs 1mg 2mg 5mg 10mg MO
trimipramine maleate caps 25mg 50mg 100mg MO
TRINTELLIX TABS 5mg 10mg 20mg MO
venlafaxine hcl er cp24 375mg 75mg 150mg MO
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg MO
Drug Name RequirementsLimits
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
VRAYLAR CAPS 15mg 3mg 45mg 6mg NDS
VRAYLAR CPPK NDS ziprasidone hcl caps 20mg 40mg 60mg 80mg MO
ziprasidone mesylate solr ZYPREXA RELPREVV SUSR DIABETIC SUPPLIES DIABETIC SUPPLIES ALCOHOL PREP PADS MO BD INSULIN SYR ULTRAFINE II MISC MO
BD INSULIN SYRINGE MISC MO BD INSULIN SYRINGE UF MISC MO
BD PEN NEEDLE ORIGINAL UF MISC MO
CURITY GAUZE PADS MO OMNIPOD STARTER KIT NDS ELECTROLYTIC CALORIC AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS POT amp SOD CIT-CIT AC SOLN potassium citrate er tbcr 15meq 540mg 1080mg MO
SODIUM ACETATE SOLN SODIUM BICARBONATE SOLN SODIUM LACTATE SOLN INTRAVENOUS HI
TRICITRATES SOLN AMMONIA DETOXICANTS CARBAGLU TABS LD constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 38 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lactulose pack MO lactulose soln MO LITHOSTAT TABS MO RAVICTI LIQD NDS sod benz-sod phenylacet soln sodium phenylbutyrate powd NDS sodium phenylbutyrate tabs NDS CALORIC AGENTS AMINOSYN-PF SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (27510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42525) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (525) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (525) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN dextrose soln intravenous 5 10 HI
Drug Name RequirementsLimits
FREAMINE HBC SOLN INTRAVENOUS HI
HEPATAMINE SOLN INTRAVENOUS HI
INTRALIPID EMUL INTRAVENOUS 20gm100ml HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NEPHRAMINE SOLN INTRAVENOUS HI
NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE SOLN INTRAVENOUS HI
PROSOL SOLN INTRAVENOUS HI TRAVASOL SOLN INTRAVENOUS HI
TROPHAMINE SOLN INTRAVENOUS HI
DIURETICS AMILORIDE HCL TABS MO amiloride-hydrochlorothiazide tabs MO
bumetanide soln bumetanide tabs 05mg 1mg 2mg MO
chlorothiazide sodium solr chlorothiazide tabs 250mg 500mg MO
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI FUROSEMIDE TABS 40mg 80mg 20mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN SAMSCA TABS 15mg NDS TOLVAPTAN TABS 30mg 15mg NDS torsemide tabs 5mg 10mg 20mg 100mg MO
triamterene caps 50mg 100mg MO triamterene-hctz caps MO triamterene-hctz tabs MO ION-REMOVING AGENTS AURYXIA TABS PAMONDS FOSRENOL PACK 750mg 1000mg NDS
kionex susp MO lanthanum carbonate chew 500mg 750mg 1000mg MO
LOKELMA PACK 5gm 10gm MO sevelamer carbonate pack 08gm 24gm MO
sevelamer carbonate tabs MO sevelamer hcl tabs 400mg 800mg MO
sodium polystyrene sulfonate powd MO
sodium polystyrene sulfonate susp MO
sps susp MO VELPHORO CHEW NDS VELTASSA PACK 84gm 168gm 252gm NDS
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate (phos binder) tabs MO
CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
Drug Name RequirementsLimits
DEXTROSE-NACL SOLN INTRAVENOUS HI
DEXTROSE 10NACL 02 DEXTROSE 10NACL 045 HI
DEXTROSE 5NACL 0225 HI IONOSOL-MB IN D5W SOLN INTRAVENOUS HI
ISOLYTE-P IN D5W SOLN INTRAVENOUS HI
ISOLYTE-S SOLN INTRAVENOUS HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-033 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 TBCR MO klor-con m10 tbcr MO klor-con m15 tbcr MO klor-con m20 tbcr MO klor-con pack MO klor-con sprinkle cpcr 8meq 10meq MO
KLOR-CON TBCR MO LACTATED RINGERS SOLN magnesium sulfate in d5w soln NORMOSOL-M IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R SOLN INTRAVENOUS HI
PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 40 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
POTASSIUM CHLORIDE ER TBCR 8meq 10meq 20meq MO
POTASSIUM CHLORIDE IN DEXTROSE SOLN INTRAVENOUS
HI
potassium chloride in nacl soln intravenous HI
potassium chloride pack MO potassium chloride soln 10 20 MO
POTASSIUM CHLORIDE SOLN INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN SODIUM CHLORIDE SOLN INJECTION HI
SODIUM CHLORIDE SOLN INTRAVENOUS 045 09 3 5
HI
SODIUM PHOSPHATES SOLN TPN ELECTROLYTES CONC INTRAVENOUS HI
URICOSURIC AGENTS colchicine-probenecid tabs MO probenecid tabs MO ENZYMES ENZYMES ADAGEN SOLN ALDURAZYME SOLN CERDELGA CAPS NDS CEREZYME SOLR NDS CREON CPEP MO ELAPRASE SOLN NDS
Drug Name RequirementsLimits
ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME SOLR NDS miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PANCREAZE CPEP MO PERTZYE CPEP MO PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VIOKACE TABS MO VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE SOLN bacitracin oint bacitracin-polymyxin b oint BESIVANCE SUSP bleph-10 soln CETRAXAL SOLN chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
CIPROFLOXACIN-FLUOCINOLONE PF SOLN
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
MOXEZA SOLN moxifloxacin hcl (2x day) soln moxifloxacin hcl soln NATACYN SUSP neo-polycin oint neomycin-bacitracin zn-polymyx oint
neomycin-polymyxin-gramicidin soln
ofloxacin soln OTOVEL SOLN paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ZIRGAN GEL ANTI-INFLAMMATORY AGENTS ACUVAIL SOLN MO ALREX SUSP MO bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
BROMSITE SOLN MO CEQUA SOLN CIPRO HC SUSP MO CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO DUREZOL EMUL MO flac oil MO
Drug Name RequirementsLimits
FLAREX SUSP MO flunisolide soln MO fluocinolone acetonide oil MO fluorometholone susp MO flurbiprofen sodium soln MO fluticasone propionate susp MO FML FORTE SUSP MO FML OINT MO HYDROCORTISONE-ACETIC ACID SOLN MO
ILEVRO SUSP MO ILUVIEN IMPL INVELTYS SUSP MO ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX OINT MO LOTEMAX SUSP MO loteprednol etabonate susp MO MAXIDEX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint MO
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO NEVANAC SUSP MO OMNARIS SUSP MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
PROLENSA SOLN MO RESTASIS EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 42 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tobramycin-dexamethasone susp MO
XHANCE EXHU MO XIIDRA SOLN YUTIQ IMPL ZETONNA AERS MO ZYLET SUSP MO ANTIALLERGIC AGENTS ALOCRIL SOLN MO ALOMIDE SOLN MO azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO LASTACAFT SOLN MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
ALPHAGAN P SOLN MO betaxolol hcl soln MO BETIMOL SOLN 025 05 MO BETOPTIC-S SUSP MO bimatoprost soln MO BRIMONIDINE TARTRATE SOLN 02 015 MO
brinzolamide susp MO carteolol hcl soln MO COMBIGAN SOLN MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO
Drug Name RequirementsLimits
methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO SIMBRINZA SUSP MO timolol maleate pf soln MO timolol maleate solg 025 05 MO
timolol maleate soln 025 05 MO
TIMOPTIC OCUDOSE SOLN 25 MO
TIMOPTIC-XE SOLG 025 05 MO
TRAVATAN Z SOLN MO travoprost (bak free) soln MO VYZULTA SOLN MO XELPROS EMUL MO ZIOPTAN SOLN MO EENT DRUGS MISCELLANEOUS ACETIC ACID SOLN MO ALTAFRIN SOLN apraclonidine hcl soln MO ATROPINE SULFATE SOLN MO BEOVU SOLN NDS CYSTADROPS SOLN NDS CYSTARAN SOLN EYLEA SOLN EYLEA SOSY IOPIDINE SOLN MO LACRISERT INST MO LUCENTIS SOLN 03mg005ml 05mg005ml NDS
LUCENTIS SOSY 03mg005ml 05mg005ml NDS
OXERVATE SOLN NDS PHENYLEPHRINE HCL SOLN RHOPRESSA SOLN TEPEZZA SOLR NDS LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl soln lidocaine viscous hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
APRISO CP24 MO balsalazide disodium caps MO colazal caps MO DELZICOL CPDR MO DIPENTUM CAPS NDS LIALDA TBEC MO mesalamine cpdr MO mesalamine enem MO mesalamine er cp24 MO mesalamine supp MO mesalamine tbec 12gm 800mg MO mesalamine-cleanser kit PENTASA CPCR 250mg 500mg MO
ANTIDIARRHEA AGENTS diphenoxylate-atropine liqd diphenoxylate-atropine tabs loperamide hcl caps MO MYTESI TBEC MO OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS AKYNZEO CAPS PA ANZEMET TABS 50mg 100mg PANDS aprepitant caps PANDS BONJESTA TBCR MO CESAMET CAPS PA dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
EMEND SUSR PANDS fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs
Drug Name RequirementsLimits
ondansetron hcl soln PA ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS TRANSDERM SCOP (15 MG) PT72
trimethobenzamide hcl caps PA VARUBI (180 MG DOSE) TBPK PANDS ZUPLENZ FILM 4mg 8mg PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc MO
CARAFATE SUSP MO cimetidine hcl soln MO cimetidine tabs 200mg 300mg 400mg 800mg MO
esomeprazole magnesium cpdr 20mg 40mg MO
esomeprazole magnesium pack 10mg 20mg 40mg MO
esomeprazole sodium solr ESOMEPRAZOLE STRONTIUM CPDR
famotidine premixed soln famotidine soln famotidine susr MO famotidine tabs 20mg 40mg MO lansoprazole cpdr 15mg 30mg MO lansoprazole tbdd 15mg 30mg MO misoprostol tabs 100mcg 200mcg MO
nizatidine caps 150mg 300mg MO nizatidine soln MO OMECLAMOX-PAK MISC MO omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 44 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PRILOSEC PACK 25mg 10mg MO PROTONIX PACK MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate tabs MO CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO GOLYTELY SOLR OSMOPREP TABS MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT PLENVU SOLR MO SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS AMITIZA CAPS 8mcg 24mcg MO BYLVAY (PELLETS) CPSP 200mcg 600mcg NDS
BYLVAY CAPS 400mcg 1200mcg NDS
CHOLBAM CAPS 50mg 250mg NDS ENTYVIO SOLR NDS GATTEX KIT PANDS GIMOTI SOLN NDS LINZESS CAPS 72mcg 145mcg 290mcg MO
lubiprostone caps 8mcg 24mcg MO
Drug Name RequirementsLimits
metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
MOVANTIK TABS 125mg 25mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS SYMPROIC TABS MO TRULANCE TABS MO ursodiol caps 300mg MO URSODIOL CAPS 200mg 400mg NDS
ursodiol tabs 250mg 500mg MO VIBERZI TABS 75mg 100mg NDS HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPS clovique caps NDS CUPRIMINE CAPS NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs 90mg 180mg 360mg NDS
deferasirox tbso 125mg NDS deferasirox tbso 250mg 500mg NDS deferiprone tabs NDS deferoxamine mesylate solr DEPEN TITRATABS TABS EXJADE TBSO 125mg 250mg 500mg NDS
FERRIPROX SOLN LDNDS FERRIPROX TABS 500mg 1000mg LDNDS
FERRIPROX TWICE-A-DAY TABS NDS
JADENU SPRINKLE PACK 90mg 180mg 360mg NDS
JADENU TABS 90mg 360mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
penicillamine caps penicillamine tabs trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP 05mg 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs MO decadron elix MO decadron tabs 5mg 75mg MO decadron tabs 4mg 6mg PAMO deltasone tabs PAMO DEPO-MEDROL SUSP dexabliss tbpk dexamethasone elix MO dexamethasone intensol conc MO dexamethasone sod phosphate pf soln
dexamethasone sodium phosphate soln
dexamethasone soln dexamethasone tabs 05mg 075mg 1mg 15mg 2mg 4mg 6mg
PAMO
dexamethasone tbpk MO dexpak 10 day tbpk MO dexpak 13 day tbpk MO dexpak 6 day tbpk MO dxevo 11-day tbpk EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
INTRAROSA INST KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp
Drug Name RequirementsLimits
methylprednisolone sodium succ solr
methylprednisolone tabs 4mg 8mg 16mg 32mg MO
methylprednisolone tbpk MO millipred dp tbpk millipred tabs MO ORTIKOS CP24 6mg 9mg NDS prednisolone sodium phosphate soln 5mg5ml 10mg5ml 20mg5ml 25mg5ml
MO
prednisolone sodium phosphate tbdp 10mg 15mg 30mg MO
prednisolone soln MO prednisone intensol conc PAMO prednisone soln PAMO prednisone tabs 1mg 25mg 5mg 10mg 20mg 50mg PAMO
prednisone tbpk PULMICORT FLEXHALER AEPB
RAYOS TBEC 1mg 2mg 5mg PAMO SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TRELEGY ELLIPTA AEPB MO triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
AVEED SOLN MO danazol caps 50mg 100mg 200mg MO
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs 25mg MO oxandrolone tabs MONDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 46 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
STRIANT MISC MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact
MO
testosterone soln MO XYOSTED SOAJ 50mg05ml 75mg05ml 100mg05ml MO
CONTRACEPTIVES altavera tabs MO alyacen 135 tabs MO amethia lo tabs MO amethia tabs MO apri tabs MO aranelle tabs MO ashlyna tabs MO aubra eq tabs MO aviane tabs MO balziva tabs MO blisovi 24 fe tabs MO blisovi fe 1530 tabs MO briellyn tabs MO camila tabs MO camrese lo tabs MO caziant tabs MO cryselle-28 tabs MO cyclafem 135 tabs MO cyclafem 777 tabs MO cyred eq tabs MO deblitane tabs MO delyla tabs MO desogestrel-ethinyl estradiol tabs MO dolishale tabs MO drospiren-eth estrad-levomefol tabs MO
drospirenone-ethinyl estradiol tabs MO
ELLA TABS MO eluryng ring MO emoquette tabs MO
Drug Name RequirementsLimits
enpresse-28 tabs MO enskyce tabs MO errin tabs MO estarylla tabs MO ethynodiol diac-eth estradiol tabs MO etonogestrel-ethinyl estradiol ring MO
falmina tabs MO fayosim tabs MO femynor tabs MO gemmily caps MO gianvi tabs MO hailey 24 fe tabs MO iclevia tabs MO incassia tabs MO introvale tabs MO isibloom tabs MO jasmiel tabs MO JOLIVETTE TABS MO juleber tabs MO junel 1530 tabs MO junel 120 tabs MO junel fe 1530 tabs MO junel fe 120 tabs MO junel fe 24 tabs MO kaitlib fe chew MO kariva tabs MO kelnor 135 tabs MO kelnor 150 tabs MO kurvelo tabs MO larin 1530 tabs MO larin 120 tabs MO larin fe 1530 tabs MO larin fe 120 tabs MO larissia tabs MO LAYOLIS FE CHEW MO leena tabs MO lessina tabs MO levonest tabs MO levonorg-eth estrad triphasic tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
levora 01530 (28) tabs MO LO LOESTRIN FE TABS MO loestrin 1530 (21) tabs MO loestrin 120 (21) tabs MO loestrin fe 1530 tabs MO loestrin fe 120 tabs MO loryna tabs MO low-ogestrel tabs MO lutera tabs MO lyleq tabs MO lyza tabs MO marlissa tabs MO melodetta 24 fe chew MO merzee caps MO mibelas 24 fe chew MO microgestin 1530 tabs MO microgestin 120 tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA TABS MO NATAZIA TABS MO necon 0535 (28) tabs MO NECON 777 TABS MO nikki tabs MO nora-be tabs MO norethin ace-eth estrad-fe caps MO norethin ace-eth estrad-fe chew MO norethin ace-eth estrad-fe tabs MO norethin-eth estradiol-fe chew MO norethindrone acet-ethinyl est tabs MO
norethindrone tabs MO norgestim-eth estrad triphasic tabs MO
norgestimate-eth estradiol tabs MO norlyroc tabs MO
Drug Name RequirementsLimits
nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO NUVARING RING MO nylia 777 tabs MO nymyo tabs MO ocella tabs MO ogestrel tabs MO orsythia tabs MO pimtrea tabs MO pirmella 135 tabs MO portia-28 tabs MO previfem tabs MO reclipsen tabs MO rivelsa tabs MO setlakin tabs MO sharobel tabs MO sprintec 28 tabs MO sronyx tabs MO syeda tabs MO tarina 24 fe tabs MO tarina fe 120 eq tabs MO tilia fe tabs MO tri-estarylla tabs MO tri-legest fe tabs MO tri-lo-estarylla tabs MO tri-lo-sprintec tabs MO tri-mili tabs MO tri-nymyo tabs MO tri-previfem tabs MO tri-sprintec tabs MO tri-vylibra lo tabs MO tri-vylibra tabs MO TRINESSA (28) TABS MO trivora (28) tabs MO tydemy tabs MO velivet tabs MO vestura tabs MO vienva tabs MO vyfemla tabs MO vylibra tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 48 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135e (28) tabs MO DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
ADMELOG SOLN MO ADMELOG SOLOSTAR SOPN MO AFREZZA POWD MO AFREZZA POWD 8 (90) amp 12 (90) UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO APIDRA SOLN PAMO APIDRA SOLOSTAR SOPN MO AVANDIA TABS 2mg 4mg MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD BYDUREON BCISE AUIJ BYDUREON PEN BYETTA 10 MCG PEN SOPN MO BYETTA 5 MCG PEN SOPN MO CYCLOSET TABS MO diazoxide susp glimepiride tabs 1mg 2mg 4mg MO glipizide er tb24 25mg 5mg 10mg MO
glipizide tabs 5mg 10mg MO glipizide-metformin hcl tabs MO GLUCAGEN HYPOKIT SOLR glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO GLYXAMBI TABS MO
Drug Name RequirementsLimits
HUMALOG JUNIOR KWIKPEN SOPN MO
HUMALOG KWIKPEN SOPN 100unitml 200unitml MO
HUMALOG MIX 5050 KWIKPEN SUPN MO
HUMALOG MIX 5050 SUSP MO HUMALOG MIX 7525 KWIKPEN SUPN MO
HUMALOG MIX 7525 SUSP MO HUMALOG SOCT MO HUMALOG SOLN PAMO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN PAMO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
INSULIN ASP PROT amp ASP FLEXPEN SUPN MO
INSULIN ASPART FLEXPEN SOPN MO
INSULIN ASPART PENFILL SOCT MO
INSULIN ASPART PROT amp ASPART SUSP MO
INSULIN ASPART SOLN PAMO INSULIN LISPRO (1 UNIT DIAL) SOPN MO
INSULIN LISPRO SOLN MO INVOKAMET TABS MO INVOKAMET XR TB24 MO INVOKANA TABS 100mg 300mg MO
JARDIANCE TABS 10mg 25mg MO JENTADUETO TABS MO JENTADUETO XR TB24 MO KAZANO TABS MO KORLYM TABS LDNDS LANTUS SOLN MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
LANTUS SOLOSTAR SOPN MO LEVEMIR FLEXTOUCH SOPN MO LEVEMIR SOLN MO metformin hcl er tb24 500mg 750mg MO
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO NOVOLIN 7030 SUSP MO NOVOLOG 7030 FLEXPEN RELION SUPN MO
NOVOLOG FLEXPEN RELION SOPN MO
NOVOLOG FLEXPEN SOPN MO NOVOLOG MIX 7030 FLEXPEN SUPN MO
NOVOLOG MIX 7030 RELION SUSP MO
NOVOLOG MIX 7030 SUSP MO NOVOLOG PENFILL SOCT MO NOVOLOG RELION SOLN PAMO NOVOLOG SOLN PAMO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO PROGLYCEM SUSP MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SOLIQUA SOPN MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO SYNJARDY TABS MO SYNJARDY XR TB24 MO tolazamide tabs 250mg 500mg MO
Drug Name RequirementsLimits
tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO ANGELIQ TABS MO CLIMARA PRO PTWK MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
COMBIPATCH PTTW MO DELESTROGEN OIL depo-estradiol oil DIVIGEL GEL MO dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
DUAVEE TABS MO ELESTRIN GEL MO estrace crea MO estrace tabs 05mg 1mg 2mg MO estradiol crea MO estradiol pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO EVAMIST SOLN MO fyavolv tabs MO IMVEXXY MAINTENANCE PACK INST 4mcg 10mcg MO
IMVEXXY STARTER PACK INST 4mcg 10mcg MO
jinteli tabs MO lopreeza tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 50 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
MENOSTAR PTWK MO mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO ORIAHNN CPPK NDS OSPHENA TABS MO prefest tabs MO PREMARIN SOLR PREMARIN TABS 03mg 045mg 0625mg 09mg 125mg
MO
PREMPHASE TABS MO PREMPRO TABS MO raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS NOVAREL SOLR 5000unit 10000unit PA
ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS PREGNYL SOLR PA TRIPTODUR SRER NDS OXYTOCICS carboprost tromethamine soln methergine tabs methylergonovine maleate soln methylergonovine maleate tabs OXYTOCIN SOLN PARATHYROID calcitonin (salmon) soln MO cinacalcet hcl tabs 30mg 60mg 90mg PANDS
FORTEO SOPN PANDS NATPARA CART 25mcg 50mcg 75mcg 100mcg LDNDS
Drug Name RequirementsLimits
SENSIPAR TABS 30mg 60mg 90mg PANDS
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PALDNDS DDAVP RHINAL TUBE SOLN MO desmopressin ace spray refrig soln MO
desmopressin acetate soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln DESMOPRESSIN ACETATE TABS 01mg 02mg MO
NOCDURNA SUBL 277mcg 553mcg MO
NOCTIVA EMUL 083mcg01ml 166mcg01ml MO
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO CRINONE GEL 4 8 PAMO DEPO-PROVERA SUSP 400mgml
DEPO-SUBQ PROVERA 104 SUSY
ENDOMETRIN INST PA hydroxyprogesterone caproate oil
hydroxyprogesterone caproate soln
MAKENA SOAJ NDS medroxyprogesterone acetate susp
medroxyprogesterone acetate susy
medroxyprogesterone acetate tabs 25mg 5mg 10mg MO
megestrol acetate susp MO norethindrone acetate tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS BYNFEZIA PEN SOPN NDS EGRIFTA SOLR NDS EGRIFTA SV SOLR NDS GENOTROPIN MINIQUICK SOLR 02mg PANDS
GENOTROPIN MINIQUICK SOLR 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
GENOTROPIN SOLR 5mg 12mg PANDS
HUMATROPE SOLR 5mg 6mg 12mg 24mg PANDS
INCRELEX SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
NUTROPIN AQ NUSPIN 20 SOPN PANDS
NUTROPIN AQ NUSPIN 5 SOPN PANDS
octreotide acetate soln OMNITROPE SOCT 5mg15ml 10mg15ml PANDS
OMNITROPE SOLR PANDS SAIZEN CLICKEASY SOLR PANDS SAIZEN SOLR 5mg 88mg PANDS SAIZENPREP SOLR PANDS SANDOSTATIN LAR DEPOT KIT 10mg 20mg 30mg NDS
SEROSTIM SOLR 4mg 5mg 6mg PANDS
SIGNIFOR LAR SRER 10mg 20mg 30mg 40mg 60mg NDS
SIGNIFOR SOLN 03mgml 06mgml 09mgml NDS
SOMATULINE DEPOT SOLN
Drug Name RequirementsLimits
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZOMACTON SOLR 5mg PANDS ZOMACTON SOLR PANDS ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVO-T TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVOTHYROXINE SODIUM SOLR
levothyroxine sodium tabs 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
liothyronine sodium soln liothyronine sodium tabs 5mcg 25mcg 50mcg MO
methimazole tabs 5mg 10mg MO propylthiouracil tabs MO tapazole tabs 5mg 10mg MO THYROLAR-1 TABS THYROLAR-12 TABS THYROLAR-14 TABS THYROLAR-2 TABS THYROLAR-3 TABS TIROSINT CAPS 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 52 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
137mcg 150mcg 175mcg 200mcg UNITHROID TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA REDUCTASE INHIBITORS dutasteride caps MO dutasteride-tamsulosin hcl caps MO finasteride tabs MO ANTIDOTES acetylcysteine soln 10 20 PAMO fomepizole soln KHAPZORY SOLR 175mg 300mg NDS
leucovorin calcium soln leucovorin calcium solr leucovorin calcium tabs 5mg 10mg 15mg 25mg MO
levoleucovorin calcium pf soln levoleucovorin calcium solr VISTOGARD PACK NDS VORAXAZE SOLR NDS ANTIGOUT AGENTS allopurinol sodium solr allopurinol tabs 100mg 300mg MO COLCHICINE CAPS MO colchicine tabs MO febuxostat tabs 40mg 80mg MO GLOPERBA SOLN MITIGARE CAPS MO ULORIC TABS 40mg 80mg MO BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 5mg 10mg 35mg 70mg MO
alendronate sodium tabs 40mg MO BINOSTO TBEF MO EVENITY SOSY NDS FOSAMAX PLUS D TABS MO IBANDRONATE SODIUM SOLN
Drug Name RequirementsLimits
ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr PROLIA SOSY risedronate sodium tabs 5mg 30mg 35mg 150mg MO
RISEDRONATE SODIUM TBEC MO XGEVA SOLN PANDS zoledronic acid conc zoledronic acid soln DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ACTPEN SOAJ NDS ACTEMRA SOSY NDS AVSOLA SOLR NDS CIMZIA KIT PANDS CIMZIA PREFILLED KIT PANDS CIMZIA STARTER KIT KIT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS ENBREL SOSY 25mg05ml 50mgml NDS
ENBREL SURECLICK SOAJ NDS HUMIRA PEDIATRIC CROHNS START PSKT NDS
HUMIRA PEN PNKT 40mg04ml 40mg08ml 80mg08ml
NDS
HUMIRA PEN-CDUCHS STARTER PNKT 40mg08ml 80mg08ml
NDS
HUMIRA PEN-PEDIATRIC UC START PNKT NDS
HUMIRA PEN-PSUVADOL HS START PNKT NDS
HUMIRA PEN-PSORUVEIT STARTER PNKT NDS
HUMIRA PSKT 10mg01ml 10mg02ml 20mg02ml 20mg04ml 40mg04ml 40mg08ml
NDS
INFLECTRA SOLR INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
KEVZARA SOAJ 150mg114ml 200mg114ml NDS
KEVZARA SOSY 150mg114ml 200mg114ml NDS
KINERET SOSY NDS leflunomide tabs 10mg 20mg MO OLUMIANT TABS 1mg 2mg NDS ORENCIA CLICKJECT SOAJ NDS ORENCIA SOLR NDS ORENCIA SOSY 50mg04ml 875mg07ml 125mgml NDS
OTEZLA TABS PANDS OTEZLA TBPK PANDS OTREXUP SOAJ RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 NDS SIMPONI ARIA SOLN NDS SIMPONI SOAJ 50mg05ml 100mgml NDS
SIMPONI SOSY 50mg05ml 100mgml NDS
XELJANZ SOLN NDS XELJANZ TABS 5mg 10mg NDS XELJANZ XR TB24 11mg 22mg NDS IMMUNE SUPPRESSANTS ASTAGRAF XL CP24 05mg 1mg PAMO
ASTAGRAF XL CP24 PA azasan tabs 75mg 100mg PAMO azathioprine sodium solr azathioprine tabs PAMO BENLYSTA SOAJ BENLYSTA SOLR BENLYSTA SOSY cyclosporine caps 25mg 100mg PAMO cyclosporine modified caps 25mg 50mg 100mg PAMO
cyclosporine modified soln PAMO cyclosporine soln PAMO
Drug Name RequirementsLimits
ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg PA GAMIFANT SOLN 50mg10ml 100mg20ml 10mg2ml NDS
gengraf caps 25mg 50mg 100mg PAMO
gengraf soln PAMO LUPKYNIS CAPS NDS MAVENCLAD (10 TABS) TBPK NDS MAVENCLAD (4 TABS) TBPK NDS MAVENCLAD (5 TABS) TBPK NDS MAVENCLAD (6 TABS) TBPK NDS MAVENCLAD (7 TABS) TBPK NDS MAVENCLAD (8 TABS) TBPK NDS MAVENCLAD (9 TABS) TBPK NDS mycophenolate mofetil caps PAMO mycophenolate mofetil hcl solr mycophenolate mofetil susr PAMO mycophenolate mofetil tabs PAMO mycophenolate sodium tbec 180mg 360mg PAMO
NULOJIX SOLR NDS PROGRAF PACK 02mg PA PROGRAF PACK PANDS PROGRAF SOLN PAMO SANDIMMUNE ORAL SOLN 100mgml PAMO
SAPHNELO SOLN NDS sirolimus soln PA sirolimus tabs 05mg 1mg 2mg PAMO tacrolimus caps 05mg 1mg 5mg PAMO
UPLIZNA SOLN ZORTRESS TABS 025mg PAMO ZORTRESS TABS 05mg 075mg 1mg PA
MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 54 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BOTOX SOLR 100unit 200unit PA bupivacaine hcl (pf) soln bupivacaine hcl soln BUPIVACAINE IN DEXTROSE SOLN
bupivacaine spinal soln bupivacaine-epinephrine (pf) soln
bupivacaine-epinephrine soln CARNITOR SOLN PAMO CARNITOR TABS PAMO chloroprocaine hcl (pf) soln CINRYZE SOLR INTRAVENOUS HI
citanest plain dental soln COSELA SOLR NDS CRYSVITA SOLN 10mgml 20mgml 30mgml NDS
CYSTADANE POWD LDNDS CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr DYSPORT SOLR 300unit 500unit PA
EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENSPRYNG SOSY NDS EVRYSDI SOLR NDS EXONDYS 51 SOLN 500mg10ml 100mg2ml NDS
FIRDAPSE TABS NDS FLUORITAB CHEW 025mg 05mg 1mg MO
FLUORITAB SOLN MO GALAFOLD CAPS NDS GIVLAARI SOLN NDS GRASTEK SUBL MO
Drug Name RequirementsLimits
HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS TABS NDS KUVAN PACK 100mg 500mg NDS KUVAN TABS NDS LACTATED RINGERS SOLN levocarnitine soln PAMO LEVOCARNITINE TABS PAMO lidocaine hcl (pf) soln lidocaine hcl soln lidocaine in dextrose soln lidocaine-epinephrine soln LUDENT CHEW 025mg 05mg 1mg MO
mesna soln MESNEX TABS NDS MYALEPT SOLR NDS NAFRINSE CHEW MO NAFRINSE DROPS SOLN MO nitisinone caps 2mg 5mg 10mg NDS NITYR TABS 2mg 5mg 10mg NDS NULIBRY SOLR NDS ODACTRA SUBL ONPATTRO SOLN NDS ORALAIR SUBL MO ORFADIN CAPS LDNDS ORFADIN SUSP LDNDS ORLADEYO CAPS 110mg 150mg NDS
OXLUMO SOLN PALFORZIA (12 MG DAILY DOSE) CSPK NDS
PALFORZIA (120 MG DAILY DOSE) CSPK NDS
PALFORZIA (160 MG DAILY DOSE) CSPK NDS
PALFORZIA (20 MG DAILY DOSE) CSPK NDS
PALFORZIA (200 MG DAILY DOSE) CSPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
PALFORZIA (240 MG DAILY DOSE) CSPK NDS
PALFORZIA (3 MG DAILY DOSE) CSPK NDS
PALFORZIA (300 MG MAINTENANCE) PACK NDS
PALFORZIA (300 MG TITRATION) PACK NDS
PALFORZIA (40 MG DAILY DOSE) CSPK NDS
PALFORZIA (6 MG DAILY DOSE) CSPK NDS
PALFORZIA (80 MG DAILY DOSE) CSPK NDS
PALFORZIA INITIAL ESCALATION CSPK NDS
PHYSIOLYTE SOLN PHYSIOSOL IRRIGATION SOLN
polocaine soln polocaine-mpf soln PROCYSBI CPDR 25mg 75mg NDS PROCYSBI PACK 75mg 300mg NDS REZUROCK TABS NDS RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln RUZURGI TABS NDS sapropterin dihydrochloride pack 100mg 500mg NDS
sapropterin dihydrochloride tabs NDS SENSORCAINE SOLN sensorcaine-mpf soln sensorcaine-mpfepinephrine soln
sensorcaineepinephrine soln SODIUM CHLORIDE SOLN MO SODIUM FLUORIDE CHEW 025mg 05mg 1mg MO
SODIUM FLUORIDE SOLN MO SODIUM FLUORIDE TABS MO STERILE WATER FOR IRRIGATION SOLN
Drug Name RequirementsLimits
TAKHZYRO SOLN NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VILTEPSO SOLN NDS VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR 50unit 100unit PA XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg NDS RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 200mg114ml 300mg2ml PANDS
FASENRA PEN SOAJ NDS FASENRA SOSY PA montelukast sodium chew 4mg 5mg MO
montelukast sodium pack MO montelukast sodium tabs MO NUCALA SOAJ PANDS NUCALA SOLR PANDS NUCALA SOSY PANDS zafirlukast tabs 10mg 20mg MO zileuton er tb12 NDS CYSTIC FIBROSIS BETHKIS NEBU PA
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 56 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CAYSTON SOLR LDNDS KALYDECO PACK 25mg 50mg 75mg PANDS
KALYDECO TABS PANDS KITABIS PAK NEBU PA ORKAMBI PACK NDS ORKAMBI TABS NDS SYMDEKO TBPK NDS TOBI PODHALER CAPS tobramycin nebu 300mg4ml 300mg5ml PA
TRIKAFTA TBPK LDNDS PULMONARY FIBROSIS ESBRIET CAPS PANDS ESBRIET TABS 267mg 801mg PANDS OFEV CAPS 100mg 150mg NDS RESPIRATORY AGENTS MISCELLANEOUS ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS 500mg 1000mg
HI
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact
MO
ASMANEX (120 METERED DOSES) AEPB MO
ASMANEX (30 METERED DOSES) AEPB 110mcginh MO
ASMANEX (30 METERED DOSES) AEPB MO
ASMANEX (60 METERED DOSES) AEPB MO
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
budesonide-formoterol fumarate aero
DALIRESP TABS 250mcg 500mcg MO
DULERA AERO MO
Drug Name RequirementsLimits
FLOVENT DISKUS AEPB 50mcgblist 100mcgblist 250mcgblist
MO
FLOVENT HFA AERO 44mcgact MO
FLOVENT HFA AERO 110mcgact 220mcgact MO
fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PROLASTIN-C SOLN INTRAVENOUS HI
PROLASTIN-C SOLR INTRAVENOUS HI
SYMBICORT AERO wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
ZEMAIRA SOLR INTRAVENOUS HI
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr LETAIRIS TABS 5mg 10mg NDS ORENITRAM TBCR 0125mg LDNDS ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TABS 625mg 125mg NDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
1000mcg 1200mcg 1400mcg 1600mcg UPTRAVI TBPK NDS VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS BIVIGAM SOLN 10gm100ml HI BIVIGAM SOLN 5gm50ml HI CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml
HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS 10gm200ml HI
GAMMAPLEX SOLN INTRAVENOUS 10gm100ml 20gm200ml 5gm50ml
HI
GAMUNEX-C SOLN INJECTION 10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml
HI
HYPERHEP B SOLN HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 5gm100ml HI
Drug Name RequirementsLimits
1gm20ml 2gm20ml 25gm500ml PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
PRIVIGEN SOLN INTRAVENOUS HI
VARIZIG SOLN XEMBIFY SOLN SUBCUTANEOUS 2gm10ml 4gm20ml 10gm50ml 1gm5ml
HI
TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP QUADRACEL SUSP TDVAX SUSP TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP DAPTACEL SUSP ENGERIX-B SUSP 10mcg05ml 20mcgml PA
GARDASIL 9 SUSP GARDASIL 9 SUSY HAVRIX SUSP HEPLISAV-B SOLN PA HIBERIX SOLR IMOVAX RABIES INJ INFANRIX SUSP IPOL INJ IXIARO SUSP M-M-R II SOLR MENACTRA INJ MENQUADFI INJ MENVEO SOLR PEDIARIX SUSP PEDVAX HIB SUSP
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 58 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN VAQTA SUSP VARIVAX INJ VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint AKTIPAK PACK MO AVC VAGINAL CREA BACTROBAN NASAL OINT BENZEPRO CREAMY WASH LIQD
BENZEPRO FOAMING CLOTHS MISC
BENZOYL PEROXIDE GEL NDS benzoyl peroxide-erythromycin gel MO
ciclopirox gel ciclopirox olamine crea ciclopirox olamine susp ciclopirox sham ciclopirox soln CLEOCIN SUPP clindacin-p swab MO clindamycin phos-benzoyl perox gel MO
clindamycin phosphate crea clindamycin phosphate foam MO clindamycin phosphate gel MO clindamycin phosphate lotn MO
Drug Name RequirementsLimits
clindamycin phosphate soln MO clindamycin phosphate swab MO CLINDESSE CREA clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn DENAVIR CREA econazole nitrate crea ERTACZO CREA ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA EXELDERM CREA EXELDERM SOLN gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ivermectin lotn ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham LULICONAZOLE CREA LUZU CREA mafenide acetate pack malathion lotn MENTAX CREA metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 59
Drug Name RequirementsLimits
mupirocin oint naftifine hcl crea naftifine hcl gel NAFTIN GEL NATROBA SUSP neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ORAVIG TABS ovide lotn oxiconazole nitrate crea OXISTAT LOTN permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SKLICE LOTN SODIUM SULFACETAMIDE SHAM
SODIUM SULFACETAMIDE WASH LIQD
SPINOSAD SUSP SSD CREA sulfacetamide sodium (acne) lotn MO SULFACETAMIDE SODIUM GEL
SULFACETAMIDE SODIUM LIQD
SULFAMYLON CREA tavaborole soln terconazole crea terconazole supp VANDAZOLE GEL XEPI CREA MO XERESE CREA ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) ala scalp lotn MO
Drug Name RequirementsLimits
ala-cort crea 1 25 MO alclometasone dipropionate crea MO alclometasone dipropionate oint MO amcinonide crea MO amcinonide lotn MO amcinonide oint MO anusol-hc crea MO apexicon e crea MO benzoyl perox-hydrocortisone lotn
BENZOYL PEROXIDE FORTE- HC LOTN NDS
beser lotn MO betamethasone dipropionate aug crea MO
betamethasone dipropionate aug gel MO
betamethasone dipropionate aug lotn MO
betamethasone dipropionate aug oint MO
betamethasone dipropionate crea MO
betamethasone dipropionate lotn MO BETAMETHASONE DIPROPIONATE OINT MO
betamethasone valerate crea MO betamethasone valerate foam MO BETAMETHASONE VALERATE LOTN MO
BETAMETHASONE VALERATE OINT MO
BRYHALI LOTN MO calcipotriene-betameth diprop oint MONDS
calcipotriene-betameth diprop susp NDS
CAPEX SHAM MO clobetasol propionate crea clobetasol propionate e crea MO clobetasol propionate emulsion foam
clobetasol propionate foam MO clobetasol propionate gel MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 60 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO CLOBEX SHAM MO CLOBEX SPRAY LIQD MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO clodan sham MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT MO DESONATE GEL MO desonide crea MO desonide gel MO desonide lotn MO desonide oint MO desowen lotn MO desoximetasone crea 005 025 MO
desoximetasone gel MO desoximetasone liqd MO desoximetasone oint 005 025 MO
desrx gel MO diclofenac sodium gel 1 3 MO diflorasone diacetate crea MO diflorasone diacetate oint MO DUOBRII LOTN MO ENSTILAR FOAM NDS epifoam foam fluocinolone acetonide body oil fluocinolone acetonide crea 001 0025 MO
fluocinolone acetonide oint MO fluocinolone acetonide scalp oil MO fluocinolone acetonide soln MO fluocinonide crea MO fluocinonide emulsified base crea MO
Drug Name RequirementsLimits
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO flurandrenolide crea MO flurandrenolide lotn MO flurandrenolide oint MO fluticasone propionate crea MO fluticasone propionate lotn MO fluticasone propionate oint MO halcinonide crea MO halobetasol propionate crea MO HALOBETASOL PROPIONATE FOAM NDS
halobetasol propionate oint MO HALOG CREA MO HALOG OINT MO hydrocortisone (perianal) crea 1 25 MO
hydrocortisone butyr lipo base crea
hydrocortisone butyrate crea MO hydrocortisone butyrate lotn MO HYDROCORTISONE BUTYRATE OINT MO
hydrocortisone butyrate soln MO hydrocortisone crea 1 25 MO hydrocortisone enem MO hydrocortisone lotn MO hydrocortisone oint 1 25 MO hydrocortisone valerate crea MO hydrocortisone valerate oint MO LEXETTE FOAM NDS micort-hc crea MO mometasone furoate crea MO mometasone furoate oint MO mometasone furoate soln MO neo-synalar crea MO nolix crea nolix lotn MO nystatin-triamcinolone crea MO nystatin-triamcinolone oint MO oralone pste MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 61
Drug Name RequirementsLimits
PANDEL CREA MO prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO psorcon crea MO TACLONEX SUSP NDS topicort crea 005 025 MO topicort gel MO topicort oint MO tovet foam MO triamcinolone acetonide aers MO triamcinolone acetonide crea 0025 01 05 MO
triamcinolone acetonide lotn 0025 01 MO
triamcinolone acetonide oint 0025 005 01 05 MO
triamcinolone acetonide pste MO trianex oint MO triderm crea 01 05 MO tritocin oint MO UCERIS FOAM MO ULTRAVATE LOTN NDS VANOXIDE-HC LOTN ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
LIDO-SORB LOTN LIDOCAINE HCL CREA lidocaine hcl lotn lidocaine hcl soln PA lidocaine hcl urethralmucosal gel MO
lidocaine hcl urethralmucosal prsy MO
lidocaine oint PAMO lidocaine ptch PAMO
Drug Name RequirementsLimits
LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea PA LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam texacort soln MO TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS ALTRENO LOTN PAMO AVITA CREA PAMO AVITA GEL PAMO KEPIVANCE SOLR NDS PANRETIN GEL NDS RETIN-A CREA 0025 005 01 PAMO
RETIN-A GEL 001 0025 PAMO RETIN-A MICRO GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 008 PAMO
RETIN-A MICRO PUMP GEL PANDS TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 62 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS ABSORICA CAPS 25mg 35mg NDS ABSORICA LD CAPS 8mg 16mg 24mg 32mg NDS
accutane caps 10mg 20mg 30mg 40mg NDS
acitretin caps 10mg 175mg 25mg NDS
ADAPALENE CREA MO adapalene gel 01 03 MO adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
AVAR CLEANSER EMUL AVAR-E EMOLLIENT CREA AVAR-E GREEN CREA azelaic acid gel MO AZELEX CREA MO BP 10-1 EMUL calcipotriene crea MO calcipotriene oint MO calcipotriene soln MO calcitrene oint MO CALCITRIOL OINT MO CARAC CREA CEROVEL LOTN claravis caps 10mg 20mg 30mg 40mg NDS
CONDYLOX GEL MO COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
Drug Name RequirementsLimits
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA MO DIFFERIN LOTN MO EPIDUO FORTE GEL MO FABIOR FOAM PAMO FINACEA FOAM MO fluorouracil crea 5 MO fluorouracil crea 5 fluorouracil soln 2 5 MO ILUMYA SOSY PA imiquimod crea 375 5 MO IMIQUIMOD PUMP CREA MO isotretinoin caps 10mg 20mg 30mg 40mg NDS
keralyt sham KLISYRI OINT NDS LACTIC ACID LOTN methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
ORACEA CPDR pimecrolimus crea MO podofilox soln MO RECTIV OINT MO REGRANEX GEL NDS RYNODERM CREA NDS SALEX SHAM SALICYLIC ACID CREA SALICYLIC ACID ER SOLN SALICYLIC ACID FOAM SALICYLIC ACID GEL SALICYLIC ACID LIQD SALICYLIC ACID SHAM SALICYLIC ACID WART REMOVER LIQD
SALICYLIC ACID-CLEANSER KIT
SALIMEZ CREA SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 63
Drug Name RequirementsLimits
SKYRIZI PEN SOAJ SKYRIZI SOSY SORILUX FOAM MO SSS 10-5 CREA STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
SULFACETAMIDE SODIUM-SULFUR CREA
SULFACETAMIDE SODIUM-SULFUR EMUL
SULFACETAMIDE SODIUM-SULFUR LIQD
SULFACETAMIDE SODIUM-SULFUR LOTN
SULFACETAMIDE SODIUM-SULFUR PADS
SULFACETAMIDE SODIUM-SULFUR SUSP
SULFACLEANSE 84 SUSP sulfamez wash emul TACROLIMUS OINT 01 003 MO
TALTZ SOAJ NDS TALTZ SOSY NDS tazarotene crea PAMO tazarotene foam PAMO TAZORAC CREA PAMO TAZORAC GEL 005 01 PAMO TOLAK CREA TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS VECTICAL OINT MO VEREGEN OINT MO WYNZORA CREA NDS XUREA CREA
Drug Name RequirementsLimits
zenatane caps 10mg 20mg 30mg 40mg NDS
ZYCLARA PUMP CREA MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline soln darifenacin hydrobromide er tb24 75mg 15mg MO
elixophyllin elix flavoxate hcl tabs MO MYRBETRIQ TB24 25mg 50mg MO oxybutynin chloride er tb24 5mg 10mg 15mg MO
oxybutynin chloride syrp MO oxybutynin chloride tabs MO solifenacin succinate tabs 5mg 10mg MO
theo-24 cp24 100mg 200mg 300mg 400mg MO
theophylline er tb12 100mg 200mg 300mg 450mg MO
theophylline er tb24 400mg 600mg MO
theophylline soln MO tolterodine tartrate er cp24 2mg 4mg MO
tolterodine tartrate tabs MO trospium chloride er cp24 MO trospium chloride tabs MO VITAMINS VITAMINS ADCF (05MGML) SOLN MO calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN MULTI-VITAMINFLUORIDEIRON SOLN
MO
MULTI-VITAMINFLUORIDE SOLN MO
MULTIVITAMINFLUORIDE CHEW MO
64 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
MVC-FLUORIDE CHEW MO paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS TRI-VITAMINFLUORIDE SOLN MO TRI-VITEFLUORIDE SOLN MO VITAMINS ACD-FLUORIDE SOLN MO
VP-PNV-DHA CAPS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 65
The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not and
you need an urgent refill please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 6 or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number on page 6 NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
66 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Index of Drugs
A abacavir sulfate soln 12 abacavir sulfate tabs 12 abacavir sulfate-lamivudine tabs 12 abacavir-lamivudine-zidovudine tabs 12 ABELCET SUSP INTRAVENOUS 11 ABILIFY MAINTENA PRSY 300mg 400mg
35 ABILIFY MAINTENA SRER 300mg 400mg
35 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
abiraterone acetate tabs 250mg 500mg 14 ABRAXANE SUSR 14 ABSORICA CAPS 25mg 35mg 62 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 62 ABSTRAL SUBL 100mcg 200mcg
300mcg 400mcg 600mcg 800mcg 27 acamprosate calcium tbec 26 acarbose tabs 25mg 50mg 100mg 48 accutane caps 10mg 20mg 30mg 40mg 62 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 27 acetaminophen-codeine soln 27 acetaminophen-codeine tabs 27 acetazolamide er cp12 42 acetazolamide sodium solr 42 acetazolamide tabs 125mg 250mg 42 ACETIC ACID SOLN 42 53 acetylcysteine soln 10 20 52 acitretin caps 10mg 175mg 25mg 62 ACTEMRA ACTPEN SOAJ 52 ACTEMRA SOSY 52 ACTHAR GEL 50 ACTHIB SOLR 57 ACTIMMUNE SOLN 53 ACUVAIL SOLN 41
acyclovir caps 12 acyclovir oint 58 acyclovir sodium soln intravenous 12 acyclovir susp 12 acyclovir tabs 400mg 800mg 12 ADACEL SUSP 57 ADAGEN SOLN 40 ADAKVEO SOLN 21 ADAPALENE CREA 62 adapalene gel 01 03 62 adapalene pads 62 adapalene soln 62 adapalene-benzoyl peroxide gel 62 ADAPALENE-BENZOYL PEROXIDE PADS
62 ADCF (05MGML) SOLN 63 adderall tabs 29 ADDERALL XR CP24 29 adefovir dipivoxil tabs 12 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 56 adenosine soln 25 ADMELOG SOLN 48 ADMELOG SOLOSTAR SOPN 48 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 20 ADZENYS ER SUER 29 ADZENYS XR-ODT TBED 31mg 63mg
94mg 125mg 157mg 188mg 29 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 25mg 5mg 75mg 10mg
14 AFREZZA POWD 48 AFREZZA POWD 8 (90) amp 12 (90) UNIT 48 AJOVY SOAJ 32 AJOVY SOSY 32 AKTIPAK PACK 58 AKYNZEO CAPS 43 ala scalp lotn 59 ala-cort crea 1 25 59 albendazole tabs 8
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 67
albuterol sulfate er tb12 4mg 8mg 20 albuterol sulfate hfa aers 20 albuterol sulfate nebu 0083 25mg05ml
20 albuterol sulfate nebu 063mg3ml
125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 59 alclometasone dipropionate oint 59 ALCOHOL PREP PADS 37 ALDACTAZIDE TABS 25 ALDURAZYME SOLN 40 ALECENSA CAPS 14 alendronate sodium soln 52 alendronate sodium tabs 40mg 52 alendronate sodium tabs 5mg 10mg
35mg 70mg 52 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 05mg 1mg
2mg 5mg 45 allopurinol sodium solr 52 allopurinol tabs 100mg 300mg 52 allzital tabs 27 almotriptan malate tabs 32 ALOCRIL SOLN 42 alogliptin benzoate tabs 625mg 125mg
25mg 48 ALOGLIPTIN-METFORMIN HCL TABS 48 alogliptin-pioglitazone tabs 48 ALOMIDE SOLN 42 ALOSETRON HCL TABS 05mg 1mg 43 ALPHAGAN P SOLN 42 alprazolam er tb24 05mg 1mg 2mg 3mg
33 alprazolam intensol conc 33 alprazolam tabs 025mg 05mg 1mg 2mg
33 alprazolam tbdp 025mg 05mg 1mg 2mg
33 ALREX SUSP 41 ALTACAINE SOLN 42 ALTAFRIN SOLN 42 altavera tabs 46 ALTOPREV TB24 20mg 40mg 60mg 23 ALTRENO LOTN 61
ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 56 alyacen 135 tabs 46 alyq tabs 26 amabelz tabs 49 amantadine hcl caps 32 amantadine hcl syrp 32 amantadine hcl tabs 32 AMBISOME SUSR INTRAVENOUS 11 ambrisentan tabs 56 amcinonide crea 59 amcinonide lotn 59 amcinonide oint 59 amethia lo tabs 46 amethia tabs 46 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 38 amiloride-hydrochlorothiazide tabs 38 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 63 AMINOSYN-PF SOLN INTRAVENOUS 38 amiodarone hcl soln 25 amiodarone hcl tabs 100mg 200mg
400mg 25 AMITIZA CAPS 8mcg 24mcg 44 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 amlodipine besy-benazepril hcl caps 24 amlodipine besylate tabs 25mg 5mg
10mg 24 amlodipine besylate-valsartan tabs 24 amlodipine-atorvastatin tabs 24 amlodipine-olmesartan tabs 24 amlodipine-valsartan-hctz tabs 24 ammonium lactate crea 62 ammonium lactate lotn 62 amnesteem caps 10mg 20mg 40mg 62 AMONDYS 45 SOLN 53 amoxapine tabs 25mg 50mg 100mg
150mg 35 amoxicill-clarithro-lansopraz misc 43 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8
68 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 29 amphetamine sulfate tabs 5mg 10mg 30 amphetamine-dextroamphet er cp24 30 amphetamine-dextroamphetamine tabs 30 amphotericin b solr intravenous 11 ampicillin caps 8 ampicillin sodium solr 8 ampicillin sodium solr injection 1gm 125mg
8 ampicillin sodium solr intravenous 8 ampicillin-sulbactam sodium solr 8 ampicillin-sulbactam sodium solr injection 8 ampicillin-sulbactam sodium solr
intravenous 8 ANADROL-50 TABS 45 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 61 anastrozole tabs 14 ANDRODERM PT24 2mg24hr 4mg24hr
45 ANGELIQ TABS 49 ANORO ELLIPTA AEPB 19 antabuse tabs 250mg 500mg 26 ANTARA CAPS 30mg 90mg 23 anusol-hc crea 59 ANZEMET TABS 50mg 100mg 43 apap-caff-dihydrocodeine tabs 27 apexicon e crea 59 APIDRA SOLN 48 APIDRA SOLOSTAR SOPN 48 APLENZIN TB24 174mg 348mg 522mg 35 APOKYN SOCT 32 apraclonidine hcl soln 42 aprepitant caps 43 apri tabs 46 APRISO CP24 43 APTIOM TABS 200mg 400mg 600mg
800mg 30 APTIVUS CAPS 12 APTIVUS SOLN 12 ARALAST NP SOLR INTRAVENOUS
500mg 1000mg 56 aranelle tabs 46 ARANESP (ALBUMIN FREE) SOLN
25mcgml 40mcgml 22
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml 22
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml 22
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 22
ARCALYST SOLR 53 ARCAPTA NEOHALER CAPS 20 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 54 ARIKAYCE SUSP 8 aripiprazole soln 35 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 35 aripiprazole tbdp 10mg 15mg 35 ARISTADA INITIO PRSY 35 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 35
armodafinil tabs 50mg 150mg 200mg 250mg 30
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact 56
ARRANON SOLN 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 54 ARYMO ER TBEA 27 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 57 ascomp-codeine caps 27 asenapine maleate subl 25mg 5mg 10mg
35 ashlyna tabs 46 ASMANEX (120 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
110mcginh 56 ASMANEX (60 METERED DOSES) AEPB
56 ASMANEX HFA AERO 100mcgact
200mcgact 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 69
ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 53 ASTAGRAF XL CP24 05mg 1mg 53 atazanavir sulfate caps 150mg 200mg
300mg 12 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 34 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 23 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 42 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 34 aubra eq tabs 46 AUGMENTIN SUSR 8 AURYXIA TABS 39 AUSTEDO TABS 6mg 9mg 12mg 34 AVANDIA TABS 2mg 4mg 48 AVAR CLEANSER EMUL 62 AVAR-E EMOLLIENT CREA 62 AVAR-E GREEN CREA 62 AVASTIN SOLN 14 AVC VAGINAL CREA 58 AVEED SOLN 45 aviane tabs 46 AVITA CREA 61 AVITA GEL 61 AVONEX KIT 34 AVONEX PEN AJKT 34 AVONEX PREFILLED PSKT 34 AVSOLA SOLR 52 AVYCAZ SOLR INTRAVENOUS 8 aygestin tabs 50 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 53 AZASITE SOLN 40 azathioprine sodium solr 53 azathioprine tabs 53 azelaic acid gel 62 azelastine hcl soln 005 01 015 42 azelastine-fluticasone susp 42 AZELEX CREA 62
AZITHROMYCIN PACK 8 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
B bacitracin oint 40 bacitracin solr 8 bacitracin-polymyxin b oint 40 bacitra-neomycin-polymyxin-hc oint 41 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 58 BAFIERTAM CPDR 34 balsalazide disodium caps 43 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 46 BANZEL SUSP 30 BANZEL TABS 200mg 400mg 30 BAQSIMI ONE PACK POWD 48 BAQSIMI TWO PACK POWD 48 BARACLUDE SOLN 12 BAVENCIO SOLN 14 BAXDELA SOLR INTRAVENOUS 8 BAXDELA TABS 8 BCG VACCINE INJ 14 BD INSULIN SYR ULTRAFINE II MISC 37 BD INSULIN SYRINGE MISC 37 BD INSULIN SYRINGE UF MISC 37 BD PEN NEEDLE ORIGINAL UF MISC 37 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 27 BELEODAQ SOLR 14 BELRAPZO SOLN 14 BELSOMRA TABS 33 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 15 BENDEKA SOLN 15 BENLYSTA SOAJ 53 BENLYSTA SOLR 53 BENLYSTA SOSY 53 BENZEPRO CREAMY WASH LIQD 58 BENZEPRO FOAMING CLOTHS MISC 58 benzhydrocodone-acetaminophen tabs 27 BENZNIDAZOLE TABS 125mg 100mg 11 benzoyl perox-hydrocortisone lotn 59
70 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
BENZOYL PEROXIDE FORTE- HC LOTN 59
BENZOYL PEROXIDE GEL 58 benzoyl peroxide-erythromycin gel 58 benztropine mesylate soln 32 benztropine mesylate tabs 05mg 1mg
2mg 32 BEOVU SOLN 42 bepotastine besilate soln 42 BERINERT KIT INTRAVENOUS 21 beser lotn 59 BESIVANCE SUSP 40 BESPONSA SOLR 15 betamethasone dipropionate aug crea 59 betamethasone dipropionate aug gel 59 betamethasone dipropionate aug lotn 59 betamethasone dipropionate aug oint 59 betamethasone dipropionate crea 59 betamethasone dipropionate lotn 59 BETAMETHASONE DIPROPIONATE OINT
59 betamethasone sod phos amp acet susp 45 betamethasone valerate crea 59 betamethasone valerate foam 59 BETAMETHASONE VALERATE LOTN 59 BETAMETHASONE VALERATE OINT 59 BETASERON KIT 34 betaxolol hcl soln 42 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 20 BETHKIS NEBU 55 BETIMOL SOLN 025 05 42 BETOPTIC-S SUSP 42 BEVESPI AEROSPHERE AERO 19 BEVYXXA CAPS 40mg 80mg 21 bexarotene caps 15 BEXSERO SUSY 57 bicalutamide tabs 15 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICNU SOLR 15 BIDIL TABS 26 BIKTARVY TABS 12 bimatoprost soln 42 BINOSTO TBEF 52 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23
BIVIGAM SOLN 10gm100ml 57 BIVIGAM SOLN 5gm50ml 57 bleomycin sulfate solr 15 bleph-10 soln 40 blephamide sop oint 41 BLEPHAMIDE SUSP 41 BLINCYTO SOLR 15 blisovi 24 fe tabs 46 blisovi fe 1530 tabs 46 BONJESTA TBCR 43 BOOSTRIX SUSP 57 BORTEZOMIB SOLR 15 bosentan tabs 56 BOSULIF TABS 100mg 400mg 500mg 15 BOTOX SOLR 100unit 200unit 54 BP 10-1 EMUL 62 BRAFTOVI CAPS 50mg 75mg 15 briellyn tabs 46 BRILINTA TABS 60mg 90mg 21 BRIMONIDINE TARTRATE SOLN 02
015 42 brinzolamide susp 42 BRIVIACT SOLN 30 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 30 bromfenac sodium (once-daily) soln 41 bromocriptine mesylate caps 32 bromocriptine mesylate tabs 32 BROMSITE SOLN 41 BRONCHITOL CAPS 56 BROVANA NEBU 20 BRUKINSA CAPS 15 BRYHALI LOTN 59 budesonide cpep 45 budesonide er tb24 45 budesonide susp 025mg2ml 05mg2ml
1mg2ml 56 budesonide-formoterol fumarate aero 56 bumetanide soln 38 bumetanide tabs 05mg 1mg 2mg 38 BUNAVAIL FILM 34 bupap tabs 27 bupivacaine hcl (pf) soln 54 bupivacaine hcl soln 54 BUPIVACAINE IN DEXTROSE SOLN 54 bupivacaine spinal soln 54 bupivacaine-epinephrine (pf) soln 54 bupivacaine-epinephrine soln 54 buprenorphine hcl soln 27
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 71
buprenorphine hcl subl 2mg 8mg 34 buprenorphine hcl-naloxone hcl film 34 buprenorphine hcl-naloxone hcl subl 34 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 27 bupropion hcl er (smoking det) tb12 35 bupropion hcl er (sr) tb12 100mg 150mg
200mg 35 bupropion hcl er (xl) tb24 150mg 300mg
450mg 35 bupropion hcl tabs 75mg 100mg 35 buspirone hcl tabs 5mg 10mg 33 buspirone hcl tabs 75mg 15mg 30mg 33 busulfan soln 15 butalbital-acetaminophen caps 27 butalbital-acetaminophen tabs 27 butalbital-apap-caff-cod caps 27 butalbital-apap-caffeine caps 27 butalbital-apap-caffeine tabs 27 butalbital-asa-caff-codeine caps 27 butalbital-aspirin-caffeine caps 27 butalbital-aspirin-caffeine tabs 27 butorphanol tartrate soln 1mgml 2mgml
10mgml 27 BUTRANS PTWK 27 BYDUREON BCISE AUIJ 48 BYDUREON PEN 48 BYETTA 10 MCG PEN SOPN 48 BYETTA 5 MCG PEN SOPN 48 BYLVAY (PELLETS) CPSP 200mcg
600mcg 44 BYLVAY CAPS 400mcg 1200mcg 44 BYNFEZIA PEN SOPN 51
C CABENUVA SUER 12 cabergoline tabs 32 CABLIVI KIT 22 CABOMETYX TABS 20mg 40mg 60mg 15 cafergot tabs 32 caffeine citrate soln 30 calcipotriene crea 62 calcipotriene oint 62 calcipotriene soln 62 calcipotriene-betameth diprop oint 59 calcipotriene-betameth diprop susp 59 calcitonin (salmon) soln 50 calcitrene oint 62 calcitriol caps 025mcg 05mcg 63
CALCITRIOL OINT 62 calcitriol soln 63 calcium acetate (phos binder) caps 39 calcium acetate (phos binder) tabs 39 CALCIUM GLUCONATE-NACL SOLN 39 CALQUENCE CAPS 15 camila tabs 46 camrese lo tabs 46 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 59 CAPLYTA CAPS 35 CAPRELSA TABS 100mg 300mg 15 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 26 CARAC CREA 62 CARAFATE SUSP 43 CARBAGLU TABS 37 carbamazepine chew 30 carbamazepine er cp12 100mg 200mg
300mg 30 carbamazepine er tb12 100mg 200mg
400mg 30 carbamazepine susp 30 carbamazepine tabs 30 carbidopa tabs 32 carbidopa-levodopa er tbcr 32 carbidopa-levodopa tabs 32 carbidopa-levodopa tbdp 32 carbidopa-levodopa-entacapone tabs 32 carbinoxamine maleate soln 14 carbinoxamine maleate tabs 14 carboplatin soln 15 carboprost tromethamine soln 50 CARDENE IV SOLN 24 CARDIZEM LA TB24 24 CARDURA XL TB24 4mg 8mg 22 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 15 CARNITOR SOLN 54 CARNITOR TABS 54 CAROSPIR SUSP 26 carteolol hcl soln 42
72 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
cartia xt cp24 120mg 180mg 240mg 300mg 24
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg 23
carvedilol tabs 3125mg 625mg 125mg 25mg 23
caspofungin acetate solr intravenous 50mg 70mg 11
cataflam tabs 27 CAYSTON SOLR 56 caziant tabs 46 cefaclor caps 8 cefaclor er tb12 8 cefaclor susr 8 cefadroxil caps 8 cefadroxil susr 8 cefadroxil tabs 8 cefazolin sodium solr 8 cefazolin sodium solr injection 1gm 10gm
500mg 8 cefdinir caps 8 cefdinir susr 8 cefepime hcl solr injection 1gm 2gm 8 cefixime caps 8 cefixime susr 8 cefotaxime sodium solr 8 cefotetan disodium solr injection 1gm 2gm 8 cefoxitin sodium solr injection 8 cefoxitin sodium solr intravenous 1gm 2gm
8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 2gm 6gm 8 CEFTIN SUSR 8 ceftriaxone sodium solr injection 1gm 2gm
250mg 500mg 8 ceftriaxone sodium solr intravenous 8 cefuroxime axetil tabs 8 cefuroxime sodium solr injection 75gm
750mg 8 cefuroxime sodium solr intravenous 8 celecoxib caps 27 CELONTIN CAPS 30 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 41
CERDELGA CAPS 40 CEREZYME SOLR 40 CEROVEL LOTN 62 CESAMET CAPS 43 cetirizine hcl soln 14 CETRAXAL SOLN 40 CEVIMELINE HCL CAPS 20 CHANTIX CONTINUING MONTH PAK
TABS 20 CHANTIX STARTING MONTH PAK TABS
20 CHANTIX TABS 05mg 1mg 20 CHEMET CAPS 44 chloramphenicol sod succinate solr 9 chlordiazepoxide hcl caps 5mg 10mg
25mg 33 chlordiazepoxide-amitriptyline tabs 35 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 40 chloroprocaine hcl (pf) soln 54 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 38 chlorothiazide tabs 250mg 500mg 38 chlorpromazine hcl soln 35 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 35 chlorthalidone tabs 25mg 50mg 38 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 44 cholestyramine light pack 23 cholestyramine light powd 23 cholestyramine pack 23 cholestyramine powd 23 CHORIONIC GONADOTROPIN SOLR 50 ciclopirox gel 58 ciclopirox olamine crea 58 ciclopirox olamine susp 58 ciclopirox sham 58 ciclopirox soln 58 cidofovir soln 12 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 40 CIMDUO TABS 12 cimetidine hcl soln 43 cimetidine tabs 200mg 300mg 400mg
800mg 43 CIMZIA KIT 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 73
CIMZIA PREFILLED KIT 52 CIMZIA STARTER KIT KIT 52 cinacalcet hcl tabs 30mg 60mg 90mg 50 CINQAIR SOLN 55 CINRYZE SOLR INTRAVENOUS 54 CIPRO HC SUSP 41 CIPRODEX SUSP 41 ciprofloxacin hcl soln (ophth) 40 CIPROFLOXACIN HCL SOLN (OTIC) 40 ciprofloxacin hcl tabs 9 ciprofloxacin in d5w soln 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 41 CIPROFLOXACIN-FLUOCINOLONE PF
SOLN 40 cisplatin soln 15 CISPLATIN SOLR 15 citalopram hydrobromide soln 35 citalopram hydrobromide tabs 10mg 20mg
40mg 35 citanest plain dental soln 54 cladribine soln 15 claravis caps 10mg 20mg 30mg 40mg 62 CLARINEX SYRP 14 CLARINEX-D 12 HOUR TB12 14 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 14 cleocin phosphate soln 9 cleocin solr 9 CLEOCIN SUPP 58 CLIMARA PRO PTWK 49 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
clindacin-p swab 58 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 58 clindamycin phosphate crea 58 clindamycin phosphate foam 58 clindamycin phosphate gel 58 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 58
clindamycin phosphate soln 9 58 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 58 CLINDESSE CREA 58 CLINIMIX EDEXTROSE (27510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42525) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (525) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (525) SOLN
INTRAVENOUS 38 clinisol sf soln intravenous 38 clobazam susp 30 clobazam tabs 10mg 20mg 30 clobetasol propionate crea 59 clobetasol propionate e crea 59 clobetasol propionate emulsion foam 59 clobetasol propionate foam 59 clobetasol propionate gel 59 clobetasol propionate liqd 60 clobetasol propionate lotn 60 clobetasol propionate oint 60 clobetasol propionate sham 60 clobetasol propionate soln 60 CLOBEX SHAM 60
74 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
CLOBEX SPRAY LIQD 60 clocortolone pivalate crea 60 clocortolone pivalate pump crea 60 clodan sham 60 clofarabine soln 15 clomipramine hcl caps 25mg 50mg 75mg
35 clonazepam tabs 05mg 1mg 2mg 30 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 30 clonidine hcl (analgesia) soln 25 clonidine hcl er tb12 25 clonidine hcl tabs 01mg 02mg 03mg 25 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 25 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 33 clotrimazole crea 58 clotrimazole soln 58 clotrimazole troc 58 clotrimazole-betamethasone crea 58 clotrimazole-betamethasone lotn 58 clovique caps 44 clozapine tabs 25mg 50mg 100mg 200mg
35 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 35 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 27 colazal caps 43 COLCHICINE CAPS 52 colchicine tabs 52 colchicine-probenecid tabs 40 colesevelam hcl pack 23 colesevelam hcl tabs 23 colestipol hcl gran 23 colestipol hcl pack 23 colestipol hcl tabs 23 colistimethate sodium (cba) solr injection 9 colocort enem 60 COLY-MYCIN S SUSP 41 COMBIGAN SOLN 42 COMBIPATCH PTTW 49 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 15 COMETRIQ (140 MG DAILY DOSE) KIT 15 COMETRIQ (60 MG DAILY DOSE) KIT 15
COMPLERA TABS 12 compro supp 35 CONDYLOX GEL 62 CONSENSI TABS 24 constulose soln 37 COPIKTRA CAPS 15mg 25mg 15 CORDRAN TAPE 60 CORLANOR TABS 5mg 75mg 25 cortisone acetate tabs 45 CORTISPORIN CREA 60 CORTISPORIN OINT 60 COSELA SOLR 54 COSENTYX (300 MG DOSE) SOSY 62 COSENTYX SENSOREADY (300 MG)
SOAJ 62 COSENTYX SENSOREADY PEN SOAJ 62 COSENTYX SOSY 75mg05ml 150mgml
62 COTELLIC TABS 15 COTEMPLA XR-ODT TBED 86mg
173mg 259mg 30 CREON CPEP 40 CRESEMBA CAPS 11 CRESEMBA SOLR 11 CRINONE GEL 4 8 50 CRIXIVAN CAPS 200mg 400mg 12 cromolyn sodium conc 55 cromolyn sodium nebu 55 cromolyn sodium soln 42 crotan lotn 58 cryselle-28 tabs 46 CRYSVITA SOLN 10mgml 20mgml
30mgml 54 CUPRIMINE CAPS 44 CURITY GAUZE PADS 37 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 57
CUVPOSA SOLN 19 cyclafem 135 tabs 46 cyclafem 777 tabs 46 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 15 CYCLOPHOSPHAMIDE SOLN 1gm5ml
500mg25ml 15 cyclophosphamide solr 15
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 75
cycloserine caps 11 CYCLOSET TABS 48 cyclosporine caps 25mg 100mg 53 cyclosporine modified caps 25mg 50mg
100mg 53 cyclosporine modified soln 53 cyclosporine soln 53 cyproheptadine hcl syrp 14 cyproheptadine hcl tabs 14 CYRAMZA SOLN 100mg10ml
500mg50ml 15 cyred eq tabs 46 CYSTADANE POWD 54 CYSTADROPS SOLN 42 CYSTAGON CAPS 50mg 150mg 54 CYSTARAN SOLN 42 cytarabine (pf) soln 15 cytarabine soln 15 CYTOGAM INJ 57
D dacarbazine solr 15 dactinomycin solr 15 DAKLINZA TABS 30mg 60mg 90mg 12 dalfampridine er tb12 34 DALIRESP TABS 250mcg 500mcg 56 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 45 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 62 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 57 daptomycin solr intravenous 350mg 500mg
9 DARAPRIM TABS 11 darifenacin hydrobromide er tb24 75mg
15mg 63 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 DAYTRANA PTCH 10mg9hr 15mg9hr
20mg9hr 30mg9hr 30 DDAVP RHINAL TUBE SOLN 50 deblitane tabs 46 decadron elix 45
decadron tabs 5mg 75mg 45 decadron tabs 4mg 6mg 45 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 44 deferasirox tabs 90mg 180mg 360mg 44 deferasirox tbso 125mg 44 deferasirox tbso 250mg 500mg 44 deferiprone tabs 44 deferoxamine mesylate solr 44 DELESTROGEN OIL 49 DELSTRIGO TABS 12 deltasone tabs 45 delyla tabs 46 DELZICOL CPDR 43 demeclocycline hcl tabs 9 DEMEROL SOLN 25mg05ml 75mg15ml
100mg2ml 75mgml 27 DEMSER CAPS 22 DENAVIR CREA 58 DEPEN TITRATABS TABS 44 depo-estradiol oil 49 DEPO-MEDROL SUSP 45 DEPO-PROVERA SUSP 400mgml 50 DEPO-SUBQ PROVERA 104 SUSY 50 depo-testosterone soln 100mgml
200mgml 45 DERMOTIC OIL 41 DESCOVY TABS 12 desipramine hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 desloratadine tabs 14 desloratadine tbdp 14 desmopressin ace spray refrig soln 50 desmopressin acetate
soln 50 DESMOPRESSIN ACETATE SOLN 50 desmopressin acetate spray soln 50 DESMOPRESSIN ACETATE TABS 01mg
02mg 50 desogestrel-ethinyl estradiol tabs 46 DESONATE GEL 60 desonide crea 60 desonide gel 60 desonide lotn 60 desonide oint 60 desowen lotn 60 desoximetasone crea 005 025 60 desoximetasone gel 60
76 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
desoximetasone liqd 60 desoximetasone oint 005 025 60 desrx gel 60 DESVENLAFAXINE ER TB24 50mg
100mg 35 desvenlafaxine succinate er tb24 25mg
50mg 100mg 35 dexabliss tbpk 45 dexamethasone elix 45 dexamethasone intensol conc 45 dexamethasone sod phosphate pf soln 45 dexamethasone sodium phosphate soln 41
45 dexamethasone soln 45 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 45 dexamethasone tbpk 45 dexchlorpheniramine maleate soln 14 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 30
dexmethylphenidate hcl tabs 25mg 5mg 10mg 30
dexpak 10 day tbpk 45 dexpak 13 day tbpk 45 dexpak 6 day tbpk 45 dexrazoxane hcl solr 54 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 30 dextroamphetamine sulfate soln 30 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 30 DEXTROSE 10NACL 02 39 DEXTROSE 5NACL 0225 39 DEXTROSE IN LACTATED RINGERS
SOLN 39 DEXTROSE SOLN 38 dextrose soln intravenous 5 10 38 DEXTROSE-NACL SOLN INTRAVENOUS
39 DIACOMIT CAPS 250mg 500mg 30 DIACOMIT PACK 250mg 500mg 31 DIASTAT ACUDIAL GEL 10mg 20mg 31 DIASTAT PEDIATRIC GEL 31 diazepam conc 33 diazepam gel 25mg 10mg 20mg 31 diazepam soln 5mg5ml 5mgml 33 diazepam tabs 2mg 5mg 10mg 33 diazoxide susp 48
diclofenac potassium tabs 27 diclofenac sodium er tb24 27 diclofenac sodium gel 1 3 60 diclofenac sodium soln 41 diclofenac sodium tbec 27 diclofenac-misoprostol tbec 27 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 12 DIFFERIN CREA 62 DIFFERIN LOTN 62 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 60 diflorasone diacetate oint 60 diflunisal tabs 27 digitek tabs 0125mg 025mg 25 digox tabs 25 DIGOXIN ORAL SOLN 25 digoxin soln inj 25 digoxin tabs 125mcg 250mcg 25 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 31 dilantin infatabs chew 31 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 24 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 24
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 24
diltiazem hcl er cp12 60mg 90mg 120mg 24
diltiazem hcl er cp24 120mg 180mg 240mg 24
diltiazem hcl soln 24 diltiazem hcl solr 24 diltiazem hcl tabs 30mg 60mg 90mg
120mg 24 dilt-xr cp24 120mg 180mg 240mg 24 dimenhydrinate soln 43 dimethyl fumarate cpdr 34 dimethyl fumarate starter pack misc 34 DIPENTUM CAPS 43 diphen elix 14 di-phen elix 14 diphenhydramine hcl elix 14
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diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 43 diphenoxylate-atropine tabs 43 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 57 dipyridamole tabs 25mg 50mg 75mg 26 disopyramide phosphate caps 100mg
150mg 25 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 38 divalproex sodium csdr 31 divalproex sodium er tb24 250mg 500mg 31 divalproex sodium tbec 125mg 250mg
500mg 31 DIVIGEL GEL 49 dobutamine hcl soln 21 DOBUTAMINE IN D5W SOLN 21 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 160mg8ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
25 dolishale tabs 46 donepezil hcl tabs 5mg 10mg 23mg 20 donepezil hcl tbdp 5mg 10mg 20 dopamine hcl soln 21 DOPAMINE IN D5W SOLN 21 DOPTELET TABS 22 DORYX MPC TBEC 9 dorzolamide hcl soln 42 dorzolamide hcl-timolol mal pf soln 42 dorzolamide hcl-timolol mal soln 42 dotti pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 49
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 35 doxepin hcl conc 35 doxepin hcl crea 61 doxepin hcl tabs 3mg 6mg 35 doxercalciferol caps 05mcg 1mcg 25mcg
63 DOXERCALCIFEROL SOLN 63 doxorubicin hcl liposomal inj 15 DOXORUBICIN HCL SOLN 15
doxorubicin hcl solr 15 doxy 100 solr intravenous 9 doxycycline hyclate caps 50mg 100mg 9 doxycycline hyclate tabs 20mg 75mg
100mg 150mg 9 doxycycline hyclate tbec 50mg 75mg
100mg 150mg 200mg 9 doxycycline monohydrate caps 50mg
75mg 100mg 150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 43 DRIZALMA SPRINKLE CSDR 35 dronabinol caps 25mg 5mg 10mg 43 droperidol soln 33 drospiren-eth estrad-levomefol tabs 46 drospirenone-ethinyl estradiol tabs 46 DROXIA CAPS 15 droxidopa caps 21 DUAKLIR PRESSAIR AEPB 19 DUAVEE TABS 49 DUEXIS TABS 27 DULERA AERO 56 duloxetine hcl cpep 20mg 30mg 40mg
60mg 35 DUOBRII LOTN 60 DUOPA SUSP 32 DUPIXENT SOPN 200mg114ml
300mg2ml 55 DUPIXENT SOSY 200mg114ml
300mg2ml 55 DURAMORPH SOLN 05mgml 1mgml 27 DUREZOL EMUL 41 DURYSTA IMPL 42 dutasteride caps 52 dutasteride-tamsulosin hcl caps 52 DUTOPROL TB24 23 dvorah tabs 27 dxevo 11-day tbpk 45 DYANAVEL XR SUER 30 DYSPORT SOLR 300unit 500unit 54
E ees 400 tabs 9 EASYGEL GEL 54 econazole nitrate crea 58 EDARBYCLOR TABS 26 EDLUAR SUBL 5mg 10mg 33
78 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 51 EGRIFTA SV SOLR 51 ELAPRASE SOLN 40 ELELYSO SOLR 40 ELEPSIA XR TB24 1000mg 1500mg 31 ELESTRIN GEL 49 eletriptan hydrobromide tabs 32 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 40 elixophyllin elix 63 ELLA TABS 46 ELLENCE SOLN 15 ELMIRON CAPS 54 eluryng ring 46 ELZONRIS SOLN 15 EMBEDA CPCR 27 EMCYT CAPS 15 EMEND SUSR 43 EMFLAZA SUSP 45 EMFLAZA TABS 6mg 18mg 30mg 36mg
45 EMGALITY (300 MG DOSE) SOSY 32 EMGALITY SOAJ 32 EMGALITY SOSY 32 emoquette tabs 46 EMPAVELI SOLN 54 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 32 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 26 enalaprilat inj 26 enalapril-hydrochlorothiazide tabs 26 ENBREL MINI SOCT 52 ENBREL SOLN 52 ENBREL SOLR 52 ENBREL SOSY 25mg05ml 50mgml 52 ENBREL SURECLICK SOAJ 52 ENDARI PACK 54 endocet tabs 27
ENDOMETRIN INST 50 ENGERIX-B SUSP 10mcg05ml 20mcgml
57 ENHERTU SOLR 15 enoxaparin sodium soln 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
enpresse-28 tabs 46 enskyce tabs 46 ENSPRYNG SOSY 54 ENSTILAR FOAM 60 entacapone tabs 33 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 26 ENTYVIO SOLR 44 enulose soln 37 ENVARSUS XR TB24 075mg 1mg 4mg53 EPCLUSA TABS 12 EPIDIOLEX SOLN 31 EPIDUO FORTE GEL 62 epifoam foam 60 epinastine hcl soln 42 epinephrine (anaphylaxis) soln 21 epinephrine soaj 21 EPINEPHRINE SOSY 21 EPIPEN 2-PAK SOAJ 21 EPIPEN JR 2-PAK SOAJ 21 epirubicin hcl soln 15 epitol tabs 31 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 26 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 22
epoprostenol sodium solr 56 eprosartan mesylate tabs 26 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 35 ERAXIS SOLR INTRAVENOUS 50mg
100mg 11 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 32 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 79
ERTACZO CREA 58 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 58 ery-tab tbec 9 ERYTHROCIN LACTOBIONATE SOLR
INTRAVENOUS 9 erythrocin stearate tabs 9 erythromycin base cpep 9 erythromycin base tabs 9 erythromycin base tbec 9 erythromycin ethylsuccinate susr 9 erythromycin ethylsuccinate tabs 9 erythromycin gel 58 erythromycin oint 40 erythromycin pads 58 erythromycin soln 58 ESBRIET CAPS 56 ESBRIET TABS 267mg 801mg 56 escitalopram oxalate soln 35 escitalopram oxalate tabs 5mg 10mg
20mg 35 esgic caps 27 esgic tabs 27 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 43 esomeprazole magnesium pack 10mg
20mg 40mg 43 esomeprazole sodium solr 43 ESOMEPRAZOLE STRONTIUM CPDR 43 estarylla tabs 46 estazolam tabs 1mg 2mg 33 estrace crea 49 estrace tabs 05mg 1mg 2mg 49 estradiol crea 49 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 49
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
estradiol tabs 10mcg 05mg 1mg 2mg 49 estradiol valerate oil 49 estradiol-norethindrone acet tabs 49 ESTRING RING 49 eszopiclone tabs 1mg 2mg 3mg 33
ethacrynic acid tabs 38 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 31 ethosuximide soln 31 ethynodiol diac-eth estradiol tabs 46 etodolac caps 27 etodolac er tb24 27 etodolac tabs 27 etonogestrel-ethinyl estradiol ring 46 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 EURAX CREA 58 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
EVAMIST SOLN 49 evekeo tabs 5mg 10mg 30 EVENITY SOSY 52 everolimus tabs 025mg 53 everolimus tabs 05mg 075mg 53 everolimus tabs 25mg 5mg 75mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 23 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 54 EXELDERM CREA 58 EXELDERM SOLN 58 exemestane tabs 15 EXJADE TBSO 125mg 250mg 500mg 44 EXONDYS 51 SOLN 500mg10ml
100mg2ml 54 EXSERVAN FILM 34 EXTAVIA KIT 34 EYLEA SOLN 42 EYLEA SOSY 42 ezetimibe tabs 23 ezetimibe-simvastatin tabs 23
F FABIOR FOAM 62 FABRAZYME SOLR 5mg 35mg 40 falmina tabs 46 famciclovir tabs 125mg 250mg 500mg 12 famotidine premixed soln 43 famotidine soln 43 famotidine susr 43 famotidine tabs 20mg 40mg 43
80 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg 35
FANAPT TITRATION PACK TABS 35 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 55 FASENRA SOSY 55 FASLODEX SOLN 15 fayosim tabs 46 febuxostat tabs 40mg 80mg 52 felbamate susp 31 felbamate tabs 400mg 600mg 31 felodipine er tb24 25mg 5mg 10mg 24 femynor tabs 46 fenofibrate caps 50mg 134mg 150mg 23 fenofibrate micronized caps 43mg 67mg
130mg 200mg 23 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 23 fenofibric acid cpdr 45mg 135mg 23 FENOFIBRIC ACID TABS 35mg 105mg 23 fenoprofen calcium caps 27 fenoprofen calcium tabs 27 fenortho caps 27 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 27 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 27
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg 27
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 27
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 27
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg 27
FERRIPROX SOLN 44 FERRIPROX TABS 500mg 1000mg 44 FERRIPROX TWICE-A-DAY TABS 44 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
35 FETZIMA TITRATION C4PK 35 fexmid tabs 20 FIBRICOR TABS 23 FINACEA FOAM 62 finasteride tabs 52 FINTEPLA SOLN 31
fioricet caps 27 fioricetcodeine caps 27 FIRAZYR SOLN 21 FIRDAPSE TABS 54 FIRMAGON (240 MG DOSE) SOLR 16 FIRMAGON SOLR 16 FIRVANQ SOLR 9 flac oil 41 FLAREX SUSP 41 flavoxate hcl tabs 63 FLEBOGAMMA DIF SOLN INTRAVENOUS
5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml 57
flecainide acetate tabs 50mg 100mg 150mg 25
FLOLIPID SUSP 20mg5ml 40mg5ml 23 FLOVENT DISKUS AEPB 50mcgblist
100mcgblist 250mcgblist 56 FLOVENT HFA AERO 110mcgact
220mcgact 56 FLOVENT HFA AERO 44mcgact 56 floxuridine solr 16 fluconazole in sodium chloride soln
intravenous 11 fluconazole susr 11 fluconazole tabs 11 flucytosine caps 250mg 500mg 11 fludarabine phosphate soln 16 fludarabine phosphate solr 16 fludrocortisone acetate tabs 45 flumazenil soln 34 flunisolide soln 41 fluocinolone acetonide body oil 60 fluocinolone acetonide crea 001 0025
60 fluocinolone acetonide oil 41 fluocinolone acetonide oint 60 fluocinolone acetonide scalp oil 60 fluocinolone acetonide soln 60 fluocinonide crea 60 fluocinonide emulsified base crea 60 FLUOCINONIDE GEL 60 fluocinonide oint 60 fluocinonide soln 60 FLUORITAB CHEW 025mg 05mg 1mg 54 FLUORITAB SOLN 54 fluorometholone susp 41 fluorouracil crea 5 62
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 81
fluorouracil crea 5 62 fluorouracil soln 16 62 fluorouracil soln 2 5 62 fluoxetine hcl (pmdd) tabs 10mg 20mg 35 fluoxetine hcl caps 10mg 20mg 40mg 35 fluoxetine hcl cpdr 35 fluoxetine hcl soln 35 fluoxetine hcl tabs 10mg 20mg 60mg 36 fluphenazine decanoate soln 36 fluphenazine hcl conc 36 fluphenazine hcl elix 36 fluphenazine hcl soln 36 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 36 flurandrenolide crea 60 flurandrenolide lotn 60 flurandrenolide oint 60 flurazepam hcl caps 15mg 30mg 33 flurbiprofen sodium soln 41 flurbiprofen tabs 27 flutamide caps 16 fluticasone propionate crea 60 fluticasone propionate lotn 60 fluticasone propionate oint 60 fluticasone propionate susp 41 fluticasone-salmeterol aepb 56 fluvastatin sodium caps 20mg 40mg 23 fluvastatin sodium er tb24 23 fluvoxamine maleate er cp24 100mg
150mg 36 fluvoxamine maleate tabs 25mg 50mg
100mg 36 FML FORTE SUSP 41 FML OINT 41 fomepizole soln 52 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 formoterol fumarate nebu 21 FORTEO SOPN 50 FOSAMAX PLUS D TABS 52 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 43 fosfomycin tromethamine pack 14 fosinopril sodium tabs 10mg 20mg 40mg
26 fosinopril sodium-hctz tabs 26 fosphenytoin sodium soln 31 FOSRENOL PACK 750mg 1000mg 39
FOTIVDA CAPS 089mg 134mg 16 FREAMINE HBC SOLN INTRAVENOUS 38 frovatriptan succinate tabs 32 FULPHILA SOSY 22 fulvestrant soln 16 furosemide soln 8mgml 10mgml 38 furosemide soln injection 38 FUROSEMIDE TABS 40mg 80mg 20mg38 FUZEON SOLR 12 fyavolv tabs 49 FYCOMPA SUSP 31 FYCOMPA TABS 31
G gabapentin caps 100mg 400mg 31 gabapentin soln 31 gabapentin tabs 600mg 800mg 31 GALAFOLD CAPS 54 galantamine hydrobromide er cp24 8mg
16mg 24mg 20 galantamine hydrobromide soln 20 galantamine hydrobromide tabs 4mg 8mg
12mg 20 GAMASTAN INJ 57 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 53 GAMMAGARD SD LESS IGA SOLR
INTRAVENOUS 5gm 10gm 57 GAMMAGARD SOLN INJECTION 57 GAMMAKED SOLN INJECTION 57 GAMMAPLEX SOLN INTRAVENOUS
10gm100ml 20gm200ml 5gm50ml 57 GAMMAPLEX SOLN INTRAVENOUS
10gm200ml 57 GAMUNEX-C SOLN INJECTION
10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml 57
ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 57 GARDASIL 9 SUSY 57 gatifloxacin soln 40 GATTEX KIT 44 gavilyte-c solr 44 gavilyte-g solr 44 gavilyte-h kit 44 gavilyte-n with flavor pack solr 44 GAVRETO CAPS 16 GAZYVA SOLN 16
82 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
gemcitabine hcl soln 16 gemcitabine hcl solr 16 gemfibrozil tabs 23 gemmily caps 46 generlac soln 37 gengraf caps 25mg 50mg 100mg 53 gengraf soln 53 GENOTROPIN MINIQUICK SOLR 02mg 51 GENOTROPIN MINIQUICK SOLR 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 51
GENOTROPIN SOLR 5mg 12mg 51 gentak oint 40 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 58 gentamicin sulfate oint 58 gentamicin sulfate soln 9 40 gentamicin sulfate soln injection 9 GENVOYA TABS 12 GEODON SOLR 36 gianvi tabs 46 GILENYA CAPS 025mg 05mg 34 GILOTRIF TABS 20mg 30mg 40mg 16 GIMOTI SOLN 44 GIVLAARI SOLN 54 GLASSIA SOLN INTRAVENOUS 56 glatiramer acetate sosy 20mgml 40mgml
34 glatopa sosy 20mgml 40mgml 34 glimepiride tabs 1mg 2mg 4mg 48 glipizide er tb24 25mg 5mg 10mg 48 glipizide tabs 5mg 10mg 48 glipizide-metformin hcl tabs 48 GLOPERBA SOLN 52 GLUCAGEN HYPOKIT SOLR 48 glucagon emergency kit 48 glyburide micronized tabs 15mg 3mg 6mg
48 glyburide tabs 125mg 25mg 5mg 48 glyburide-metformin tabs 48 glycate tabs 19 glycopyrrolate pf sosy 19 glycopyrrolate soln 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 61 GLYXAMBI TABS 48 GOLYTELY SOLR 44 GONITRO PACK 26
granisetron hcl soln 43 granisetron hcl tabs 43 GRANIX SOLN 480mcg16ml 300mcgml
22 GRANIX SOSY 300mcg05ml
480mcg08ml 22 GRASTEK SUBL 54 griseofulvin microsize susp 11 griseofulvin microsize tabs 11 griseofulvin ultramicrosize tabs 11 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 34 guanfacine hcl tabs 1mg 2mg 25 GUANIDINE HCL TABS 20 gynazole-1 crea 58
H HAEGARDA SOLR 2000unit 3000unit 54 hailey 24 fe tabs 46 halcinonide crea 60 halobetasol propionate crea 60 HALOBETASOL PROPIONATE FOAM 60 halobetasol propionate oint 60 HALOG CREA 60 HALOG OINT 60 haloperidol decanoate soln 36 haloperidol lactate conc 36 haloperidol lactate soln 36 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 36 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 57 heparin (porcine) in nacl soln 21 HEPARIN SOD (PORCINE) IN D5W SOLN
21 heparin sodium (porcine) pf soln 21 heparin sodium (porcine) soln 1000unitml
5000unitml 10000unitml 20000unitml 21
HEPATAMINE SOLN INTRAVENOUS 38 HEPLISAV-B SOLN 57 HERCEPTIN HYLECTA SOLN 16 HERCEPTIN SOLR 150mg 440mg 16 HERZUMA SOLR 150mg 420mg 16 HETLIOZ CAPS 33 HETLIOZ LQ SUSP 33 HEXALEN CAPS 16 HIBERIX SOLR 57
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 83
HORIZANT TBCR 300mg 600mg 31 HUMALOG JUNIOR KWIKPEN SOPN 48 HUMALOG KWIKPEN SOPN 100unitml
200unitml 48 HUMALOG MIX 5050 KWIKPEN SUPN 48 HUMALOG MIX 5050 SUSP 48 HUMALOG MIX 7525 KWIKPEN SUPN 48 HUMALOG MIX 7525 SUSP 48 HUMALOG SOCT 48 HUMALOG SOLN 48 humatin caps 11 HUMATROPE SOLR 5mg 6mg 12mg
24mg 51 HUMIRA PEDIATRIC CROHNS START
PSKT 52 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 52 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 52 HUMIRA PEN-PEDIATRIC UC START
PNKT 52 HUMIRA PEN-PSUVADOL HS START
PNKT 52 HUMIRA PEN-PSORUVEIT STARTER
PNKT 52 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 52
HUMULIN 7030 KWIKPEN SUPN 48 HUMULIN 7030 SUSP 48 HUMULIN N KWIKPEN SUPN 48 HUMULIN N SUSP 48 HUMULIN R SOLN 48 HUMULIN R U-500 (CONCENTRATED)
SOLN 48 HUMULIN R U-500 KWIKPEN SOPN 48 hydralazine hcl soln 25 hydralazine hcl tabs 10mg 25mg 50mg
100mg 25 hydrochlorothiazide caps 38 hydrochlorothiazide tabs 125mg 25mg
50mg 38 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 27 hydrocodone-acetaminophen soln 27 hydrocodone-acetaminophen tabs 27 hydrocodone-ibuprofen tabs 27 hydrocortisone (perianal) crea 1 25 60 hydrocortisone ace-pramoxine crea 61
hydrocortisone butyr lipo base crea 60 hydrocortisone butyrate crea 60 hydrocortisone butyrate lotn 60 HYDROCORTISONE BUTYRATE OINT 60 hydrocortisone butyrate soln 60 hydrocortisone crea 1 25 60 hydrocortisone enem 60 hydrocortisone lotn 60 hydrocortisone oint 1 25 60 hydrocortisone tabs 5mg 10mg 20mg 45 hydrocortisone valerate crea 60 hydrocortisone valerate oint 60 HYDROCORTISONE-ACETIC ACID SOLN
41 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 28 hydromorphone hcl liqd 28 hydromorphone hcl pf soln 50mg5ml
10mgml 28 HYDROMORPHONE HCL SOLN 1mgml
2mgml 28 hydromorphone hcl tabs 2mg 4mg 8mg 28 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 50 hydroxyprogesterone caproate soln 50 hydroxyurea caps 16 hydroxyzine hcl soln 33 hydroxyzine hcl syrp 33 hydroxyzine hcl tabs 33 hydroxyzine pamoate caps 33 HYPERHEP B SOLN 57 HYPERRAB SD SOLN 57 HYQVIA KIT 57
I IBANDRONATE SODIUM SOLN 52 ibandronate sodium tabs 52 IBRANCE CAPS 75mg 100mg 125mg 16 IBRANCE TABS 75mg 100mg 125mg 16 ibu tabs 28 ibudone tabs 28 ibuprofen lysine soln 28 ibuprofen susp 28 ibuprofen tabs 28 ibutilide fumarate soln 25 icatibant acetate soln 21 iclevia tabs 46 ICLUSIG TABS 10mg 15mg 30mg 45mg
16
84 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
icosapent ethyl caps 23 IDAMYCIN PFS SOLN 16 idarubicin hcl soln 16 IDHIFA TABS 50mg 100mg 16 ifosfamide soln 16 IFOSFAMIDE SOLR 16 ILARIS SOLN 28 ILEVRO SUSP 41 ILUMYA SOSY 62 ILUVIEN IMPL 41 imatinib mesylate tabs 16 IMBRUVICA CAPS 70mg 140mg 16 IMBRUVICA TABS 140mg 280mg 420mg
560mg 16 IMFINZI SOLN 500mg10ml 120mg24ml
16 imipenem-cilastatin solr intravenous 9 imipramine hcl tabs 10mg 25mg 50mg 36 imipramine pamoate caps 75mg 100mg
125mg 150mg 36 imiquimod crea 375 5 62 IMIQUIMOD PUMP CREA 62 IMOGAM RABIES-HT SOLN 57 IMOVAX RABIES INJ 57 IMPAVIDO CAPS 11 IMVEXXY MAINTENANCE PACK INST
4mcg 10mcg 49 IMVEXXY STARTER PACK INST 4mcg
10mcg 49 INBRIJA CAPS 33 incassia tabs 46 INCRELEX SOLN 51 INCRUSE ELLIPTA AEPB 19 indapamide tabs 125mg 25mg 38 indocin supp 28 INDOCIN SUSP 28 indomethacin caps 28 INDOMETHACIN CAPS 20mg 28 indomethacin er cpcr 28 indomethacin sodium solr 28 INFANRIX SUSP 57 INFLECTRA SOLR INTRAVENOUS 52 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 34 INGREZZA CPPK 34 INLYTA TABS 1mg 5mg 16 INNOPRAN XL CP24 80mg 120mg 23 INQOVI TABS 16 INREBIC CAPS 16
INSULIN ASP PROT amp ASP FLEXPEN SUPN 48
INSULIN ASPART FLEXPEN SOPN 48 INSULIN ASPART PENFILL SOCT 48 INSULIN ASPART PROT amp ASPART SUSP
48 INSULIN ASPART SOLN 48 INSULIN LISPRO (1 UNIT DIAL) SOPN 48 INSULIN LISPRO SOLN 48 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 38 INTRALIPID EMUL INTRAVENOUS
20gm100ml 38 INTRAROSA INST 45 INTRON A SOLN 10muml 6000000unitml
16 INTRON A SOLR 10mu 18mu 50mu 16 introvale tabs 46 INVEGA SUSTENNA SUSY 39mg025ml
36 INVEGA SUSTENNA SUSY 78mg05ml
117mg075ml 234mg15ml 156mgml 36
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml 36
INVELTYS SUSP 41 INVIRASE CAPS 12 INVIRASE TABS 12 INVOKAMET TABS 48 INVOKAMET XR TB24 48 INVOKANA TABS 100mg 300mg 48 IONOSOL-MB IN D5W SOLN
INTRAVENOUS 39 IOPIDINE SOLN 42 IPOL INJ 57 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 21 irbesartan tabs 75mg 150mg 300mg 26 irbesartan-hydrochlorothiazide tabs 26 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isibloom tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 85
ISOLYTE-P IN D5W SOLN INTRAVENOUS 39
ISOLYTE-S SOLN INTRAVENOUS 39 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 21 isosorbide dinitrate er tbcr 26 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 26 isosorbide mononitrate er tb24 26 isosorbide mononitrate er tb24 30mg 60mg
26 isosorbide mononitrate tabs 10mg 20mg 26 isotretinoin caps 10mg 20mg 30mg 40mg
62 isradipine caps 25mg 5mg 24 ISTURISA TABS 1mg 5mg 10mg 54 itraconazole caps 11 ITRACONAZOLE SOLN 11 ivermectin crea 58 ivermectin lotn 58 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 57
J JADENU SPRINKLE PACK 90mg 180mg
360mg 44 JADENU TABS 90mg 360mg 44 JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16 jantoven tabs 1mg 2mg 25mg 3mg 4mg
5mg 6mg 75mg 10mg 21 JARDIANCE TABS 10mg 25mg 48 jasmiel tabs 46 JEMPERLI SOLN 16 JENTADUETO TABS 48 JENTADUETO XR TB24 48 jinteli tabs 49 JOLIVETTE TABS 46 juleber tabs 46 JULUCA TABS 12 junel 1530 tabs 46 junel 120 tabs 46 junel fe 1530 tabs 46 junel fe 120 tabs 46 junel fe 24 tabs 46
JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg 23
JYNARQUE TABS 15mg 30mg 39 JYNARQUE TBPK 39
K KADCYLA SOLR 100mg 160mg 16 KADIAN CP24 28 kaitlib fe chew 46 KALYDECO PACK 25mg 50mg 75mg 56 KALYDECO TABS 56 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 40 kariva tabs 46 KAZANO TABS 48 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-033 MEQ 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 40-5-09 MEQ 39 KCL-LACTATED RINGERS-D5W SOLN
INTRAVENOUS 39 KEDRAB SOLN 57 kelnor 135 tabs 46 kelnor 150 tabs 46 KENALOG SUSP 45 KEPIVANCE SOLR 61 keralyt sham 62 KESIMPTA SOAJ 54 ketoconazole crea 58 ketoconazole foam 58 ketoconazole sham 58 ketoconazole tabs 11 ketodan foam 58 ketoprofen caps 28 ketoprofen er cp24 28 ketorolac tromethamine soln 28 41 ketorolac tromethamine soln 04 05 41 ketorolac tromethamine tabs 28 KEVEYIS TABS 54 KEVZARA SOAJ 150mg114ml
200mg114ml 53 KEVZARA SOSY 150mg114ml
200mg114ml 53 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 52 KHEDEZLA TB24 50mg 100mg 36 KIMYRSA SOLR 9
86 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
KINERET SOSY 53 KINRIX SUSP 57 kionex susp 39 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (200 MG DOSE) TBPK
16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KITABIS PAK NEBU 56 KLISYRI OINT 62 KLOR-CON 10 TBCR 39 klor-con m10 tbcr 39 klor-con m15 tbcr 39 klor-con m20 tbcr 39 klor-con pack 39 klor-con sprinkle cpcr 8meq 10meq 39 KLOR-CON TBCR 39 KORLYM TABS 48 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 37 K-TAB TBCR 39 kurvelo tabs 46 KUVAN PACK 100mg 500mg 54 KUVAN TABS 54 KYNAMRO SOSY 23 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 33 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 LACRISERT INST 42 LACTATED RINGERS SOLN 39 54 LACTIC ACID LOTN 62 lactulose encephalopathy soln 37 lactulose pack 38 lactulose soln 38 LAMICTAL XR KIT 31 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 31
lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg 31
lamotrigine kit 31 lamotrigine starter kit-blue kit 31 lamotrigine starter kit-green kit 31 lamotrigine starter kit-orange kit 31 lamotrigine tabs 25mg 100mg 150mg
200mg 31 lamotrigine tbdp 25mg 50mg 100mg
200mg 31 LANOXIN PEDIATRIC SOLN 25 LANOXIN TABS 625mcg 25 lansoprazole cpdr 15mg 30mg 43 lansoprazole tbdd 15mg 30mg 43 lanthanum carbonate chew 500mg 750mg
1000mg 39 LANTUS SOLN 48 LANTUS SOLOSTAR SOPN 49 lapatinib ditosylate tabs 16 larin 1530 tabs 46 larin 120 tabs 46 larin fe 1530 tabs 46 larin fe 120 tabs 46 larissia tabs 46 LARTRUVO SOLN 190mg19ml
500mg50ml 16 LASTACAFT SOLN 42 latanoprost soln 42 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 36 LAYOLIS FE CHEW 46 LAZANDA SOLN 100mcgact 300mcgact
400mcgact 28 ledipasvir-sofosbuvir tabs 12 leena tabs 46 leflunomide tabs 10mg 20mg 53 LEMTRADA SOLN 34 LENVIMA (10 MG DAILY DOSE) CPPK 16 LENVIMA (12 MG DAILY DOSE) CPPK 16 LENVIMA (14 MG DAILY DOSE) CPPK 16 LENVIMA (18 MG DAILY DOSE) CPPK 16 LENVIMA (20 MG DAILY DOSE) CPPK 16 LENVIMA (24 MG DAILY DOSE) CPPK 16 LENVIMA (4 MG DAILY DOSE) CPPK 16 LENVIMA (8 MG DAILY DOSE) CPPK 17 lessina tabs 46 LETAIRIS TABS 5mg 10mg 56 letrozole tabs 17 leucovorin calcium soln 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 87
leucovorin calcium solr 52 leucovorin calcium tabs 5mg 10mg 15mg
25mg 52 LEUKERAN TABS 17 LEUKINE SOLR 22 leuprolide acetate kit 17 levalbuterol hcl nebu 125mg05ml
031mg3ml 063mg3ml 125mg3ml 21 levalbuterol tartrate aero 21 LEVEMIR FLEXTOUCH SOPN 49 LEVEMIR SOLN 49 levetiracetam er tb24 500mg 750mg 31 levetiracetam in nacl soln 31 levetiracetam soln 31 levetiracetam tabs 250mg 500mg 750mg
1000mg 31 levobunolol hcl soln 42 levocarnitine soln 54 LEVOCARNITINE TABS 54 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 40 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 52 levoleucovorin calcium solr 52 levonest tabs 46 levonorgest-eth est amp eth est tabs 47 levonorgest-eth estrad 91-day tabs 47 levonorgestrel-ethinyl estrad tabs 47 levonorg-eth estrad triphasic tabs 46 levora 01530 (28) tabs 47 levorphanol tartrate tabs 2mg 3mg 28 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEVOTHYROXINE SODIUM SOLR 51 levothyroxine sodium tabs 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEXETTE FOAM 60 LEXIVA SUSP 12 LIALDA TBEC 43 LIBTAYO SOLN 17 lidocaine hcl (cardiac) pf sosy 25 lidocaine hcl (cardiac) sosy 25 lidocaine hcl (pf) soln 54 LIDOCAINE HCL CREA 61 lidocaine hcl lotn 61 lidocaine hcl soln 42 54 61 lidocaine hcl urethralmucosal gel 61 lidocaine hcl urethralmucosal prsy 61 LIDOCAINE IN D5W SOLN 25 lidocaine in dextrose soln 54 lidocaine oint 61 lidocaine ptch 61 lidocaine viscous hcl soln 42 lidocaine-epinephrine soln 54 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 61 LIDOCAINE-HYDROCORTISONE ACE KIT
61 lidocaine-prilocaine crea 61 lidocaine-tetracaine crea 61 LIDOCORT CREA 61 lidopin crea 61 LIDO-SORB LOTN 61 LIDOZION LOTN 61 lincomycin hcl soln 9 lindane sham 58 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 LINZESS CAPS 72mcg 145mcg 290mcg
44 liothyronine sodium soln 51 liothyronine sodium tabs 5mcg 25mcg
50mcg 51 LIPODOX 50 INJ 17 lisinopril tabs 25mg 5mg 10mg 20mg
30mg 40mg 26 lisinopril-hydrochlorothiazide tabs 26 LITHIUM CARBONATE CAPS 300mg
150mg 600mg 36 lithium carbonate er tbcr 300mg 450mg 36 lithium carbonate tabs 36
88 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
LITHIUM SOLN 36 LITHOSTAT TABS 38 LIVALO TABS 1mg 2mg 4mg 23 LO LOESTRIN FE TABS 47 lodine tabs 28 loestrin 1530 (21) tabs 47 loestrin 120 (21) tabs 47 loestrin fe 1530 tabs 47 loestrin fe 120 tabs 47 LOKELMA PACK 5gm 10gm 39 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 17 loperamide hcl caps 43 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 49 lorazepam intensol conc 33 LORAZEPAM SOLN 4mgml 2mgml 33 lorazepam tabs 05mg 1mg 2mg 33 LORBRENA TABS 25mg 100mg 17 lorcet hd tabs 28 lorcet plus tabs 28 lorcet tabs 28 lortab elix 28 loryna tabs 47 lorzone tabs 375mg 750mg 20 losartan potassium tabs 25mg 50mg
100mg 26 losartan potassium-hctz tabs 26 LOTEMAX GEL 41 LOTEMAX OINT 41 LOTEMAX SUSP 41 loteprednol etabonate susp 41 lovastatin tabs 10mg 20mg 40mg 23 LOVENOX SOLN 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
low-ogestrel tabs 47 loxapine succinate caps 5mg 10mg 25mg
50mg 36 lubiprostone caps 8mcg 24mcg 44 LUCEMYRA TABS 34 LUCENTIS SOLN 03mg005ml
05mg005ml 42 LUCENTIS SOSY 03mg005ml
05mg005ml 42 LUDENT CHEW 025mg 05mg 1mg 54 LULICONAZOLE CREA 58 LUMAKRAS TABS 17
LUMIGAN SOLN 42 LUMIZYME SOLR 40 LUMOXITI SOLR 17 LUPANETA PACK KIT 17 LUPKYNIS CAPS 53 LUPRON DEPOT (1-MONTH) KIT 17 LUPRON DEPOT (3-MONTH) KIT 17 LUPRON DEPOT (4-MONTH) KIT 17 LUPRON DEPOT (6-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 17 LUPRON DEPOT-PED (3-MONTH) KIT 17 lutera tabs 47 LUZU CREA 58 lyleq tabs 47 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 50
LYNPARZA CAPS 17 LYNPARZA TABS 100mg 150mg 17 LYSODREN TABS 17 lyza tabs 47
M mafenide acetate pack 58 magnesium sulfate in d5w soln 39 magnesium sulfate soln 31 magnesium sulfate soln injection 50 31 MAGNESIUM SULFATE SOLN
INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml 31
MAKENA SOAJ 50 malathion lotn 58 MANNITOL SOLN 39 maprotiline hcl tabs 25mg 50mg 75mg 36 MARGENZA SOLN 17 marlissa tabs 47 MARPLAN TABS 36 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 24 MAVENCLAD (10 TABS) TBPK 53 MAVENCLAD (4 TABS) TBPK 53 MAVENCLAD (5 TABS) TBPK 53 MAVENCLAD (6 TABS) TBPK 53 MAVENCLAD (7 TABS) TBPK 53 MAVENCLAD (8 TABS) TBPK 53
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 89
MAVENCLAD (9 TABS) TBPK 53 MAVYRET TABS 12 MAXIDEX SUSP 41 MAYZENT STARTER PACK TBPK 34 MAYZENT TABS 025mg 2mg 34 MENAPHOSMBHYO1 TABS 14 meclizine hcl tabs 43 meclofenamate sodium caps 28 MEDROL TABS 45 medroxyprogesterone acetate susp 50 medroxyprogesterone acetate susy 50 medroxyprogesterone acetate tabs 25mg
5mg 10mg 50 mefenamic acid caps 28 mefloquine hcl tabs 11 megestrol acetate susp 17 50 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 47 meloxicam caps 28 meloxicam tabs 28 melphalan hcl solr 17 memantine hcl er cp24 34 memantine hcl soln 34 memantine hcl tabs 5mg 10mg 34 MENACTRA INJ 57 menest tabs 03mg 0625mg 125mg 50 MENOSTAR PTWK 50 MENQUADFI INJ 57 MENTAX CREA 58 MENVEO SOLR 57 meperidine hcl soln 50mg5ml 25mgml
50mgml 100mgml 28 meperidine hcl tabs 50mg 100mg 28 meprobamate tabs 33 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 47 mesalamine cpdr 43 mesalamine enem 43 mesalamine er cp24 43 mesalamine supp 43 mesalamine tbec 12gm 800mg 43 mesalamine-cleanser kit 43 mesna soln 54 MESNEX TABS 54 MESTINON SOLN 20 metadate er tbcr 30
metaproterenol sulfate syrp 21 metaproterenol sulfate tabs 10mg 20mg 21 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 49 metformin hcl tabs 500mg 850mg 1000mg
49 methadone hcl conc 28 methadone hcl intensol conc 28 methadone hcl soln 5mg5ml 10mg5ml
10mgml 28 methadone hcl tabs 5mg 10mg 28 methamphetamine hcl tabs 30 methazolamide tabs 25mg 50mg 42 methenamine hippurate tabs 14 METHENAMINE MANDELATE TABS 14 methergine tabs 50 methimazole tabs 5mg 10mg 51 methitest tabs 45 methocarbamol soln 20 methocarbamol tabs 20 methotrexate sodium (pf) soln 17 methotrexate sodium soln 17 methotrexate sodium solr 17 methotrexate tabs 17 methoxsalen rapid caps 62 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 39 methyldopa tabs 250mg 500mg 25 methyldopa-hydrochlorothiazide tabs 25 methylergonovine maleate soln 50 methylergonovine maleate tabs 50 methylphenidate hcl chew 25mg 5mg
10mg 30 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 30 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 30 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 30
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 30
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 30
methylphenidate hcl soln 5mg5ml 10mg5ml 30
90 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
methylphenidate hcl tabs 5mg 10mg 20mg 30
methylprednisolone acetate susp 45 methylprednisolone sodium succ solr 45 methylprednisolone tabs 4mg 8mg 16mg
32mg 45 methylprednisolone tbpk 45 methyltestosterone caps 45 metoclopramide hcl soln 44 metoclopramide hcl tabs 5mg 10mg 44 metoclopramide hcl tbdp 5mg 10mg 44 metolazone tabs 25mg 5mg 10mg 39 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 24 metoprolol tartrate soct 24 metoprolol tartrate soln 24 metoprolol tartrate tabs 25mg 50mg
100mg 24 metoprolol tartrate tabs 375mg 75mg 24 metoprolol-hydrochlorothiazide tabs 24 metronidazole caps 11 metronidazole crea 58 metronidazole gel 58 metronidazole in nacl soln 11 metronidazole in nacl soln intravenous 11 metronidazole lotn 58 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
25 mibelas 24 fe chew 47 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 58 miconazole-zinc oxide-petrolat oint 58 micort-hc crea 60 microgestin 1530 tabs 47 microgestin 120 tabs 47 microgestin fe 1530 tabs 47 microgestin fe 120 tabs 47 midazolam hcl (pf) soln 33 midazolam hcl soln 33 midazolam hcl syrp 33 midodrine hcl tabs 25mg 5mg 10mg 21 miglitol tabs 25mg 50mg 100mg 49 miglustat caps 40 mili tabs 47 millipred dp tbpk 45 millipred tabs 45
milrinone lactate in dextrose soln 25 milrinone lactate soln 25 mimvey lo tabs 50 mimvey tabs 50 minitran pt24 01mghr 02mghr 04mghr
06mghr 26 minocycline hcl caps 50mg 75mg 100mg 9 minocycline hcl er tb24 45mg 55mg 65mg
80mg 90mg 105mg 115mg 135mg 9 minocycline hcl tabs 50mg 75mg 100mg 9 minoxidil tabs 25mg 10mg 25 MIRCERA SOSY 30mcg03ml
50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml 22
mirtazapine tabs 75mg 15mg 30mg 45mg 36
mirtazapine tbdp 15mg 30mg 45mg 36 misoprostol tabs 100mcg 200mcg 43 MITIGARE CAPS 52 mitigo soln 28 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 57 modafinil tabs 100mg 200mg 30 moexipril hcl tabs 75mg 15mg 26 molindone hcl tabs 5mg 10mg 25mg 36 mometasone furoate crea 60 mometasone furoate oint 60 mometasone furoate soln 60 mometasone furoate susp 41 mondoxyne nl caps 75mg 100mg 9 MONJUVI SOLR 17 MONONESSA TABS 47 montelukast sodium chew 4mg 5mg 55 montelukast sodium pack 55 montelukast sodium tabs 55 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 28 morphine sulfate (pf) soln 4mgml 10mgml
28 MORPHINE SULFATE (PF) SOLN
INTRAVENOUS 28 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 28 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 28
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morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 28
MORPHINE SULFATE SOLN 28 MORPHINE SULFATE SOLN 10mg5ml
20mg5ml 28 MORPHINE SULFATE SOLN INJECTION
2mgml 4mgml 10mgml 28 MORPHINE SULFATE SOLN
INTRAVENOUS 28 morphine sulfate tabs 15mg 30mg 28 MOVANTIK TABS 125mg 25mg 44 MOXEZA SOLN 41 moxifloxacin hcl (2x day) soln 41 moxifloxacin hcl in nacl soln intravenous 10 moxifloxacin hcl soln 41 moxifloxacin hcl tabs 10 MULPLETA TABS 22 MULTAQ TABS 25 MULTIVITAMINFLUORIDE CHEW 63 MULTI-VITAMINFLUORIDE SOLN 63 MULTI-VITAMINFLUORIDEIRON SOLN
63 mupirocin calcium crea 58 mupirocin oint 59 MUSTARGEN SOLR 17 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17 MVC-FLUORIDE CHEW 64 MYALEPT SOLR 54 MYCAPSSA CPDR 51 mycophenolate mofetil caps 53 mycophenolate mofetil hcl solr 53 mycophenolate mofetil susr 53 mycophenolate mofetil tabs 53 mycophenolate sodium tbec 180mg 360mg
53 MYDAYIS CP24 30 MYFEMBREE TABS 50 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 62 MYRBETRIQ TB24 25mg 50mg 63 MYTESI TBEC 43
N NABI-HB SOLN 57 nabumetone tabs 28 N-ACETYL-L-CYSTEINE CAPS 38 nadolol tabs 20mg 40mg 80mg 24 nadolol-bendroflumethiazide tabs 24
nafcillin sodium solr 10 nafcillin sodium solr injection 10 nafcillin sodium solr intravenous 10 NAFRINSE CHEW 54 NAFRINSE DROPS SOLN 54 naftifine hcl crea 59 naftifine hcl gel 59 NAFTIN GEL 59 NAGLAZYME SOLN 40 nalbuphine hcl soln 28 nalfon tabs 28 nalocet tabs 28 naloxone hcl soaj 34 naloxone hcl soct 34 naloxone hcl soln 34 naloxone hcl sosy 34 naltrexone hcl tabs 35 NAMENDA XR TITRATION PACK CP24 34 NAPRELAN TB24 28 naproxen sodium er tb24 28 naproxen sodium tabs 28 naproxen susp 28 naproxen tabs 28 naproxen tbec 28 naproxen-esomeprazole tbec 28 naratriptan hcl tabs 32 NARCAN LIQD 35 NATACYN SUSP 41 NATAZIA TABS 47 nateglinide tabs 60mg 120mg 49 NATPARA CART 25mcg 50mcg 75mcg
100mcg 50 NATROBA SUSP 59 NAYZILAM SOLN 31 NEBUPENT SOLR 11 necon 0535 (28) tabs 47 NECON 777 TABS 47 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 36 nembutal soln 33 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 41 neomycin-polymyxin b gu soln 59 neomycin-polymyxin-dexameth oint 41 neomycin-polymyxin-dexameth susp 41 neomycin-polymyxin-gramicidin soln 41 neomycin-polymyxin-hc soln 41 neomycin-polymyxin-hc susp 41 neo-polycin hc oint 41
92 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
neo-polycin oint 41 neo-synalar crea 60 NEPHRAMINE SOLN INTRAVENOUS 38 NERLYNX TABS 17 NEULASTA ONPRO PSKT 22 NEULASTA SOSY 22 NEUPOGEN SOLN 480mcg16ml
300mcgml 22 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 22 NEVANAC SUSP 41 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 40 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 23 niacor tabs 23 nicardipine hcl caps 20mg 30mg 24 nicardipine hcl soln 24 NICOTROL INHA 20 NICOTROL NS SOLN 20 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 47 nilutamide tabs 17 nimodipine caps 24 NINLARO CAPS 23mg 3mg 4mg 17 nisoldipine er tb24 85mg 17mg 20mg
255mg 30mg 34mg 40mg 24 nitazoxanide tabs 11 nitisinone caps 2mg 5mg 10mg 54 nitro-bid oint 26 NITRO-DUR PT24 03mghr 08mghr 26 NITROFURANTOIN MACROCRYSTAL
CAPS 14 NITROFURANTOIN MONOHYD MACRO
CAPS 14 nitrofurantoin susp 14 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 26 nitroglycerin soln 26 nitroglycerin subl 03mg 04mg 06mg 26 nitropress soln 25 nitroprusside sodium soln 25 NITYR TABS 2mg 5mg 10mg 54
NIVESTYM SOLN 480mcg16ml 300mcgml 22
NIVESTYM SOSY 300mcg05ml 480mcg08ml 22
nizatidine caps 150mg 300mg 43 nizatidine soln 43 NOCDURNA SUBL 277mcg 553mcg 50 NOCTIVA EMUL 083mcg01ml
166mcg01ml 50 nolix crea 60 nolix lotn 60 nora-be tabs 47 norco tabs 28 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 51
norepinephrine bitartrate soln 21 norethin ace-eth estrad-fe caps 47 norethin ace-eth estrad-fe chew 47 norethin ace-eth estrad-fe tabs 47 norethindrone acetate tabs 50 norethindrone acet-ethinyl est tabs 47 norethindrone tabs 47 norethindrone-eth estradiol tabs 50 norethin-eth estradiol-fe chew 47 norgesic forte tabs 28 norgestimate-eth estradiol tabs 47 norgestim-eth estrad triphasic tabs 47 norlyroc tabs 47 NORMOSOL-M IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R SOLN INTRAVENOUS 39 NORPACE CR CP12 100mg 150mg 25 nortrel 0535 (28) tabs 47 nortrel 135 (21) tabs 47 nortrel 135 (28) tabs 47 nortrel 777 tabs 47 nortriptyline hcl caps 10mg 25mg 50mg
75mg 36 nortriptyline hcl soln 36 NORVIR CAPS 12 NORVIR PACK 12 NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 34 NOVAREL SOLR 5000unit 10000unit 50 NOVOLIN 7030 SUSP 49
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 93
NOVOLOG 7030 FLEXPEN RELION SUPN 49
NOVOLOG FLEXPEN RELION SOPN 49 NOVOLOG FLEXPEN SOPN 49 NOVOLOG MIX 7030 FLEXPEN SUPN 49 NOVOLOG MIX 7030 RELION SUSP 49 NOVOLOG MIX 7030 SUSP 49 NOVOLOG PENFILL SOCT 49 NOVOLOG RELION SOLN 49 NOVOLOG SOLN 49 NOXAFIL SUSP 11 NOXAFIL TBEC 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 55 NUCALA SOLR 55 NUCALA SOSY 55 NUCYNTA ER TB12 200mg 250mg 29 NUCYNTA ER TB12 50mg 100mg 150mg
29 NUCYNTA TABS 29 NUCYNTA TABS 50mg 75mg 29 NUEDEXTA CAPS 34 NULIBRY SOLR 54 NULOJIX SOLR 53 NUPLAZID CAPS 36 NUPLAZID TABS 10mg 17mg 36 NURTEC TBDP 32 NUTRILIPID EMUL INTRAVENOUS 38 NUTROPIN AQ NUSPIN 10 SOPN 51 NUTROPIN AQ NUSPIN 20 SOPN 51 NUTROPIN AQ NUSPIN 5 SOPN 51 NUVARING RING 47 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 59 nylia 777 tabs 47 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 47 nystatin crea 59 nystatin oint 59 nystatin powd 59 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 60 nystatin-triamcinolone oint 60 nystop powd 59 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 44 ocella tabs 47 OCREVUS SOLN 34 OCTAGAM SOLN INTRAVENOUS
5gm100ml 1gm20ml 2gm20ml 25gm500ml 57
octreotide acetate soln 51 ODACTRA SUBL 54 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 56 ofloxacin soln 41 ofloxacin tabs 10 ogestrel tabs 47 OGIVRI SOLR 17 okebo caps 10 olanzapine solr 36 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 36 olanzapine tbdp 5mg 10mg 15mg 20mg
36 olanzapine-fluoxetine hcl caps 36 olmesartan medoxomil tabs 5mg 20mg
40mg 26 olmesartan medoxomil-hctz tabs 26 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 42 OLUMIANT TABS 1mg 2mg 53 OLYSIO CAPS 12 OMECLAMOX-PAK MISC 43 omega-3-acid ethyl esters caps 23 omeprazole cpdr 10mg 20mg 40mg 43 omeprazole-sodium bicarbonate caps 43 omeprazole-sodium bicarbonate pack 44 OMNARIS SUSP 41 OMNIPOD STARTER KIT 37 OMNITROPE SOCT 5mg15ml
10mg15ml 51 OMNITROPE SOLR 51 ondansetron hcl soln 43 ondansetron hcl tabs 4mg 8mg 24mg 43 ondansetron tbdp 4mg 8mg 43 ONIVYDE INJ 17 ONPATTRO SOLN 54 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 ONZETRA XSAIL EXHP 32
94 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml 17
OPIUM TINC 43 ORACEA CPDR 62 ORALAIR SUBL 54 oralone pste 60 ORAVIG TABS 59 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 53 ORENCIA SOLR 53 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 53 ORENITRAM TBCR 0125mg 56 ORENITRAM TBCR 025mg 1mg 25mg
5mg 56 ORFADIN CAPS 54 ORFADIN SUSP 54 ORGOVYX TABS 50 ORIAHNN CPPK 50 ORILISSA TABS 150mg 200mg 50 ORKAMBI PACK 56 ORKAMBI TABS 56 ORLADEYO CAPS 110mg 150mg 54 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 29 orphengesic forte tabs 29 orsythia tabs 47 ORTIKOS CP24 6mg 9mg 45 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 39 OSMOPREP TABS 44 OSPHENA TABS 50 OTEZLA TABS 53 OTEZLA TBPK 53 OTOVEL SOLN 41 OTREXUP SOAJ 53 ovide lotn 59 OXACILLIN SODIUM IN DEXTROSE SOLN
INTRAVENOUS 10 oxacillin sodium solr injection 1gm 2gm 10 oxacillin sodium solr intravenous 10 oxaliplatin soln 17 oxaliplatin solr 17 oxandrolone tabs 45 oxandrolone tabs 25mg 45 oxaprozin tabs 29
OXAYDO TABS 29 oxazepam caps 10mg 15mg 30mg 33 OXBRYTA TABS 21 oxcarbazepine susp 31 oxcarbazepine tabs 150mg 300mg 600mg
31 OXERVATE SOLN 42 oxiconazole nitrate crea 59 OXISTAT LOTN 59 OXLUMO SOLN 54 OXTELLAR XR TB24 150mg 300mg
600mg 31 oxybutynin chloride er tb24 5mg 10mg
15mg 63 oxybutynin chloride syrp 63 oxybutynin chloride tabs 63 oxycodone hcl caps 29 oxycodone hcl conc 29 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxycodone hcl soln 29 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 29 oxycodone-acetaminophen soln 29 oxycodone-acetaminophen tabs 29 oxycodone-acetaminophen tabs 5-300mg
10-300mg 29 oxycodone-aspirin tabs 29 oxycodone-ibuprofen tabs 29 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 29 oxymorphone hcl tabs 5mg 10mg 29 OXYTOCIN SOLN 50 OZEMPIC (025 OR 05 MGDOSE) SOPN
49 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 49
P pacerone tabs 100mg 200mg 400mg 25 paclitaxel conc 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
54 PALFORZIA (120 MG DAILY DOSE) CSPK
54
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 95
PALFORZIA (160 MG DAILY DOSE) CSPK 54
PALFORZIA (20 MG DAILY DOSE) CSPK 54
PALFORZIA (200 MG DAILY DOSE) CSPK 54
PALFORZIA (240 MG DAILY DOSE) CSPK 55
PALFORZIA (3 MG DAILY DOSE) CSPK 55 PALFORZIA (300 MG MAINTENANCE)
PACK 55 PALFORZIA (300 MG TITRATION) PACK
55 PALFORZIA (40 MG DAILY DOSE) CSPK
55 PALFORZIA (6 MG DAILY DOSE) CSPK 55 PALFORZIA (80 MG DAILY DOSE) CSPK
55 PALFORZIA INITIAL ESCALATION CSPK
55 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 36 palonosetron hcl soln 43 palonosetron hcl sosy 43 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 40 pamidronate disodium soln 52 pamidronate disodium solr 52 PANCREAZE CPEP 40 PANDEL CREA 61 panlor tabs 29 PANRETIN GEL 61 pantoprazole sodium pack 44 PANTOPRAZOLE SODIUM SOLR 44 pantoprazole sodium tbec 20mg 40mg 44 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 57
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 64 PARICALCITOL SOLN 64 paroex soln 41 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 36 paroxetine hcl tabs 10mg 20mg 36 paroxetine hcl tabs 30mg 40mg 36 paroxetine mesylate caps 36 paser pack 11
PAXIL SUSP 36 PEDIARIX SUSP 57 PEDVAX HIB SUSP 57 peg 3350electrolytes solr 44 peg 3350-kcl-na bicarb-nacl solr 44 peg-3350electrolytes solr 44 PEGANONE TABS 31 PEGASYS PROCLICK SOLN
135mcg05ml 180mcg05ml 13 PEGASYS SOLN 180mcg05ml
180mcgml 13 PEGINTRON KIT 13 PEG-INTRON REDIPEN KIT 12 PEG-PREP KIT 44 PEMAZYRE TABS 45mg 9mg 135mg 17 penicillamine caps 45 penicillamine tabs 45 PENICILLIN G POT IN DEXTROSE SOLN
INTRAVENOUS 10 penicillin g potassium solr injection 10 penicillin g procaine susp 10 penicillin g sodium solr injection 10 penicillin v potassium solr 10 penicillin v potassium tabs 10 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 43 pentazocine-naloxone hcl tabs 29 pentobarbital sodium soln 33 pentoxifylline er tbcr 22 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 44 percocet tabs 29 perindopril erbumine tabs 2mg 4mg 8mg
26 periogard soln 41 PERJETA SOLN 17 permethrin crea 59 perphenazine tabs 2mg 4mg 8mg 16mg
36 perphenazine-amitriptyline tabs 36 PERSERIS PRSY 90mg 120mg 36 PERTZYE CPEP 40 PEXEVA TABS 10mg 20mg 30mg 40mg
36 phenadoz supp 14 phenazo tabs 61 PHENAZOPYRIDINE HCL TABS 61 phenelzine sulfate tabs 36
96 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
phenergan soln 14 PHENOBARBITAL ELIX 33 PHENOBARBITAL SODIUM SOLN 33 PHENOBARBITAL TABS 33 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 21 PHENYLEPHRINE HCL SOLN 42 phenytek caps 200mg 300mg 31 phenytoin chew 31 phenytoin sodium extended caps 100mg
200mg 300mg 31 phenytoin sodium soln 31 phenytoin susp 31 PHESGO SOLN 17 PHOSLYRA SOLN 39 PHOSPHASAL TABS 14 PHOSPHOLINE IODIDE SOLR 42 phrenilin forte caps 29 PHYSIOLYTE SOLN 55 PHYSIOSOL IRRIGATION SOLN 55 PIFELTRO TABS 13 pilocarpine hcl soln 1 2 4 42 pilocarpine hcl tabs 5mg 75mg 20 pimecrolimus crea 62 pimozide tabs 1mg 2mg 36 pimtrea tabs 47 pindolol tabs 5mg 10mg 24 pioglitazone hcl tabs 15mg 30mg 45mg 49 pioglitazone hcl-glimepiride tabs 49 pioglitazone hcl-metformin hcl tabs 49 piperacillin sod-tazobactam so solr 10 piperacillin sod-tazobactam so solr
intravenous 10 PIQRAY (200 MG DAILY DOSE) TBPK 17 PIQRAY (250 MG DAILY DOSE) TBPK 17 PIQRAY (300 MG DAILY DOSE) TBPK 17 pirmella 135 tabs 47 PIROXICAM CAPS 10mg 20mg 29 PLASMA-LYTE 148 SOLN INTRAVENOUS
39 PLASMA-LYTE A SOLN INTRAVENOUS 39 PLEGRIDY SOPN 13 PLEGRIDY SOSY 13 34 PLEGRIDY STARTER PACK SOPN 13 PLEGRIDY STARTER PACK SOSY 13 plenamine soln intravenous 38 PLENVU SOLR 44 podofilox soln 62 POLIVY SOLR 30mg 140mg 17
polocaine soln 55 polocaine-mpf soln 55 polycin oint 41 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 41 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 34 PONVORY TABS 34 portia-28 tabs 47 PORTRAZZA SOLN 17 POSACONAZOLE SUSP 11 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 37 POTASSIUM ACETATE SOLN 39 potassium chloride crys er tbcr 10meq
20meq 40 potassium chloride er cpcr 8meq 10meq 40 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 40 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 40 potassium chloride in nacl soln intravenous
40 potassium chloride pack 40 potassium chloride soln 10 20 40 POTASSIUM CHLORIDE SOLN
INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml 40
potassium citrate er tbcr 15meq 540mg 1080mg 37
POTASSIUM PHOSPHATES SOLN 40 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 40 POTELIGEO SOLN 18 PR BENZOYL PEROXIDE WASH LIQD 59 PRADAXA CAPS 110mg 150mg 22 PRADAXA CAPS 75mg 22 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 33
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 33
PRAMOX GEL 61 prandin tabs 1mg 2mg 49 prasugrel hcl tabs 5mg 10mg 22 pravastatin sodium tabs 10mg 20mg
40mg 80mg 23 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 97
PRED MILD SUSP 41 PRED-G SOP OINT 41 PRED-G SUSP 41 prednicarbate crea 61 prednicarbate oint 61 prednisolone acetate susp 41 prednisolone sodium phosphate soln 41 45 prednisolone sodium phosphate soln
5mg5ml 10mg5ml 20mg5ml 25mg5ml 45
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 45
prednisolone soln 45 prednisone intensol conc 45 prednisone soln 45 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 45 prednisone tbpk 45 prefest tabs 50 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 31
pregabalin er tb24 825mg 165mg 330mg 29
pregabalin soln 31 PREGNYL SOLR 50 PREMARIN SOLR 50 PREMARIN TABS 03mg 045mg
0625mg 09mg 125mg 50 premasol soln intravenous 38 PREMPHASE TABS 50 PREMPRO TABS 50 PRENATAL TABS 64 PRETOMANID TABS 11 prevalite pack 23 prevalite powd 23 previfem tabs 47 PREVYMIS SOLN 240mg12ml
480mg24ml 13 PREVYMIS TABS 240mg 480mg 13 PREZCOBIX TABS 13 PREZISTA SUSP 13 PREZISTA TABS 75mg 150mg 600mg
800mg 13 PRIFTIN TABS 11 PRILOSEC PACK 25mg 10mg 44 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 31 primlev tabs 29
PRIVIGEN SOLN INTRAVENOUS 57 PROAIR RESPICLICK AEPB 21 probenecid tabs 40 procainamide hcl soln 25 PROCALAMINE SOLN INTRAVENOUS 38 procentra soln 30 prochlorperazine edisylate soln 36 prochlorperazine maleate tabs 36 prochlorperazine supp 36 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 40000unitml 22
proctofoam hc foam 61 procto-med hc crea 61 procto-pak crea 61 proctosol hc crea 61 proctozone-hc crea 61 PROCYSBI CPDR 25mg 75mg 55 PROCYSBI PACK 75mg 300mg 55 progesterone caps 100mg 200mg 51 progesterone oil 51 PROGLYCEM SUSP 49 PROGRAF PACK 53 PROGRAF PACK 02mg 53 PROGRAF SOLN 53 PROLASTIN-C SOLN INTRAVENOUS 56 PROLASTIN-C SOLR INTRAVENOUS 56 prolate soln 29 prolate tabs 29 PROLENSA SOLN 41 PROLEUKIN SOLR 18 PROLIA SOSY 52 PROMACTA PACK 125mg 25mg 22 PROMACTA TABS 125mg 25mg 50mg
75mg 22 promethazine hcl soln 14 promethazine hcl supp 14 promethazine hcl syrp 14 promethazine hcl tabs 14 promethazine-phenylephrine syrp 14 promethegan supp 14 propafenone hcl er cp12 225mg 325mg
425mg 25 propafenone hcl tabs 150mg 225mg
300mg 25 propantheline bromide tabs 19 proparacaine hcl soln 43 propranolol hcl er cp24 60mg 80mg
120mg 160mg 24
98 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
propranolol hcl soln 20mg5ml 40mg5ml 24 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 24 propranolol-hctz tabs 24 propylthiouracil tabs 51 PROQUAD SUSR 58 PROSOL SOLN INTRAVENOUS 38 PROTONIX PACK 44 protriptyline hcl tabs 5mg 10mg 36 psorcon crea 61 PULMICORT FLEXHALER AEPB 45 PULMOZYME SOLN 40 PURIXAN SUSP 18 PYLERA CAPS 44 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 20 pyridostigmine bromide soln 20 pyridostigmine bromide tabs 30mg 60mg 20 pyrimethamine tabs 11
Q QBRELIS SOLN 26 QDOLO SOLN 29 QINLOCK TABS 18 QUADRACEL SUSP 57 questran light powd 23 questran pack 23 questran powd 23 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 36 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 37 QUILLICHEW ER CHER 20mg 30mg
40mg 30 QUILLIVANT XR SRER 30 quinapril hcl tabs 5mg 10mg 20mg 40mg
26 quinapril-hydrochlorothiazide tabs 26 quinidine gluconate er tbcr 25 QUINIDINE GLUCONATE SOLN 25 quinidine sulfate tabs 200mg 300mg 25 quinine sulfate caps 12
R RABAVERT SUSR 58 rabeprazole sodium cpsp 44 rabeprazole sodium tbec 44 RADICAVA SOLN 34
raloxifene hcl tabs 50 ramelteon tabs 33 ramipril caps 125mg 25mg 5mg 10mg 26 ranolazine er tb12 500mg 1000mg 25 RAPIVAB SOLN 13 rasagiline mesylate tabs 05mg 1mg 33 RASUVO SOAJ 53 RAVICTI LIQD 38 RAYALDEE CPCR 64 RAYOS TBEC 1mg 2mg 5mg 45 REBETOL SOLN 13 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 34 REBIF REBIDOSE TITRATION PACK
SOAJ 34 REBIF SOSY 22mcg05ml 44mcg05ml 34 REBIF TITRATION PACK SOSY 34 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 47 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 58 RECTIV OINT 62 REGONOL SOLN 20 REGRANEX GEL 62 relafen ds tabs 29 RELENZA DISKHALER AEPB 13 relexxii tbcr 30 RELISTOR SOLN 8mg04ml 12mg06ml
44 RELISTOR TABS 44 reltone caps 200mg 400mg 44 REMICADE SOLR INTRAVENOUS 53 RENFLEXIS SOLR 53 repaglinide tabs 05mg 1mg 2mg 49 repaglinide-metformin hcl tabs 49 REPATHA PUSHTRONEX SYSTEM SOCT
23 REPATHA SOSY 23 REPATHA SURECLICK SOAJ 23 RESCRIPTOR TABS 100mg 200mg 13 RESTASIS EMUL 41 RETACRIT SOLN 20000unit2ml
2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml 22
RETEVMO CAPS 40mg 80mg 18 RETIN-A CREA 0025 005 01 61 RETIN-A GEL 001 0025 61
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 99
RETIN-A MICRO GEL 004 01 61 RETIN-A MICRO PUMP GEL 61 RETIN-A MICRO PUMP GEL 004 01
61 RETIN-A MICRO PUMP GEL 008 61 RETISERT IMPL 41 RETROVIR SOLN 13 REVCOVI SOLN 40 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 18 revonto solr 20 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 37 REYATAZ PACK 13 REZUROCK TABS 55 RHOPRESSA SOLN 42 RIABNI SOLN 100mg10ml 500mg50ml 18 ribasphere caps 13 ribasphere ribapak (1000 pack) tbpk 13 ribasphere ribapak (1200 pack) tbpk 13 ribasphere tabs 13 ribavirin caps 13 ribavirin solr 13 ribavirin tabs 13 RIDAURA CAPS 55 RIFABUTIN CAPS 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 RIFATER TABS 11 riluzole tabs 34 rimantadine hcl tabs 13 RIMSO-50 SOLN 55 RINGERS IRRIGATION SOLN 55 RINGERS SOLN 40 RINVOQ TB24 53 risedronate sodium tabs 5mg 30mg 35mg
150mg 52 RISEDRONATE SODIUM TBEC 52 RISPERDAL CONSTA SRER 125mg
25mg 37 RISPERDAL CONSTA SRER 375mg
50mg 37 risperidone soln 37 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 37 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 37
ritonavir tabs 13 RITUXAN HYCELA SOLN 18 RITUXAN SOLN 18 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 47 rizatriptan benzoate tabs 32 rizatriptan benzoate tbdp 32 ROMIDEPSIN SOLN 18 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 33 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 33 ropivacaine hcl soln 55 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 23 ROTARIX SUSR 58 ROTATEQ SOLN 58 roweepra tabs 500mg 750mg 1000mg 31 roweepra xr tb24 500mg 750mg 31 ROXYBOND TABA 5mg 15mg 30mg 29 ROZEREM TABS 33 ROZLYTREK CAPS 100mg 200mg 18 RUBRACA TABS 200mg 250mg 300mg 18 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 31 rufinamide tabs 200mg 400mg 31 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 18 RUZURGI TABS 55 RYBREVANT SOLN 18 ryclora soln 14 RYDAPT CAPS 18 RYLAZE SOLN 18 RYNODERM CREA 62 RYTARY CPCR 33 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 51 SAIZEN SOLR 5mg 88mg 51 SAIZENPREP SOLR 51 sajazir soln 21 SALEX SHAM 62 SALICYLIC ACID CREA 62 SALICYLIC ACID ER SOLN 62
100 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
SALICYLIC ACID FOAM 62 SALICYLIC ACID GEL 62 SALICYLIC ACID LIQD 62 SALICYLIC ACID SHAM 62 SALICYLIC ACID WART REMOVER LIQD
62 SALICYLIC ACID-CLEANSER KIT 62 SALIMEZ CREA 62 SALSALATE TABS 29 SAMSCA TABS 15mg 39 SANCUSO PTCH 43 SANDIMMUNE ORAL SOLN 100mgml 53 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 51 SANTYL OINT 62 SAPHNELO SOLN 53 SAPHRIS SUBL 25mg 5mg 10mg 37 sapropterin dihydrochloride pack 100mg
500mg 55 sapropterin dihydrochloride tabs 55 SARCLISA SOLN 500mg25ml 100mg5ml
18 SAVELLA TABS 125mg 25mg 50mg
100mg 34 SAVELLA TITRATION PACK MISC 34 scopolamine pt72 43 seconal caps 33 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 37 selegiline hcl caps 33 selegiline hcl tabs 33 selenium sulfide lotn 59 SELENIUM SULFIDE SHAM 59 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 150mg
300mg 13 SEMPREX-D CAPS 14 SENSIPAR TABS 30mg 60mg 90mg 50 SENSORCAINE SOLN 55 sensorcaineepinephrine soln 55 sensorcaine-mpf soln 55 sensorcaine-mpfepinephrine soln 55 SEREVENT DISKUS AEPB 21 SEROSTIM SOLR 4mg 5mg 6mg 51 sertraline hcl conc 37 sertraline hcl tabs 25mg 50mg 100mg 37 setlakin tabs 47 sevelamer carbonate pack 08gm 24gm 39 sevelamer carbonate tabs 39
sevelamer hcl tabs 400mg 800mg 39 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 47 SHINGRIX SUSR 58 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 51 SIGNIFOR SOLN 03mgml 06mgml
09mgml 51 SIKLOS TABS 18 sildenafil citrate soln 26 sildenafil citrate susr 26 sildenafil citrate tabs 26 SILENOR TABS 37 SILIQ SOSY 62 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 59 SIMBRINZA SUSP 42 SIMPONI ARIA SOLN 53 SIMPONI SOAJ 50mg05ml 100mgml 53 SIMPONI SOSY 50mg05ml 100mgml 53 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 23 sirolimus soln 53 sirolimus tabs 05mg 1mg 2mg 53 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKLICE LOTN 59 SKYRIZI (150 MG DOSE) PSKT 62 SKYRIZI PEN SOAJ 63 SKYRIZI SOSY 63 sod benz-sod phenylacet soln 38 SODIUM ACETATE SOLN 37 SODIUM BICARBONATE SOLN 37 SODIUM CHLORIDE (PF) SOLN 40 SODIUM CHLORIDE SOLN 40 55 SODIUM CHLORIDE SOLN INJECTION 40 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 55 SODIUM FLUORIDE SOLN 55 SODIUM FLUORIDE TABS 55 SODIUM LACTATE SOLN INTRAVENOUS
37 sodium phenylbutyrate powd 38 sodium phenylbutyrate tabs 38 SODIUM PHOSPHATES SOLN 40 sodium polystyrene sulfonate powd 39 sodium polystyrene sulfonate susp 39 SODIUM SULFACETAMIDE SHAM 59
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 101
SODIUM SULFACETAMIDE WASH LIQD 59
sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 63 SOLIQUA SOPN 49 SOLOSEC PACK 12 soloxide tbec 10 SOLTAMOX SOLN 18 SOLU-CORTEF SOLR 45 SOLU-MEDROL SOLR 45 SOMATULINE DEPOT SOLN 51 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 51 SORILUX FOAM 63 sorine tabs 80mg 120mg 160mg 240mg
24 sotalol hcl (af) tabs 80mg 120mg 160mg 24 sotalol hcl tabs 80mg 120mg 160mg
240mg 24 SOTYLIZE SOLN 24 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPINOSAD SUSP 59 SPIRIVA HANDIHALER CAPS 19 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 26 spironolactone-hctz tabs 26 SPRAVATO (56 MG DOSE) SOPK 37 SPRAVATO (84 MG DOSE) SOPK 37 sprintec 28 tabs 47 SPRITAM TB3D 250mg 500mg 750mg
1000mg 31 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 39 sronyx tabs 47 SSD CREA 59 SSS 10-5 CREA 63 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
63 STELARA SOSY 45mg05ml 90mgml 63 STERILE WATER FOR IRRIGATION SOLN
55 STIMATE SOLN 50 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18
STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml 40
streptomycin sulfate solr 10 STRIANT MISC 46 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 21 SUBLOCADE SOSY 100mg05ml
300mg15ml 29 SUBSYS LIQD 100mcg 200mcg 400mcg
600mcg 800mcg 1200mcg 1600mcg 29 subvenite starter kit-blue kit 31 subvenite starter kit-green kit 31 subvenite starter kit-orange kit 31 subvenite tabs 25mg 100mg 150mg
200mg 31 succinylcholine chloride soln 20 SUCRAID SOLN 40 sucralfate susp 44 sucralfate tabs 44 sulfacetamide sodium (acne) lotn 59 SULFACETAMIDE SODIUM GEL 59 SULFACETAMIDE SODIUM LIQD 59 sulfacetamide sodium oint 41 sulfacetamide sodium soln 41 SULFACETAMIDE SODIUM-SULFUR
CREA 63 SULFACETAMIDE SODIUM-SULFUR
EMUL 63 SULFACETAMIDE SODIUM-SULFUR
LIQD 63 SULFACETAMIDE SODIUM-SULFUR
LOTN 63 SULFACETAMIDE SODIUM-SULFUR
PADS 63 SULFACETAMIDE SODIUM-SULFUR
SUSP 63 sulfacetamide-prednisolone soln 41 SULFACLEANSE 84 SUSP 63 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 sulfamez wash emul 63 SULFAMYLON CREA 59 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 29 sumatriptan soln 32
102 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
sumatriptan succinate refill soct 32 sumatriptan succinate soaj 32 sumatriptan succinate soln 32 sumatriptan succinate sosy 32 sumatriptan succinate tabs 32 sunitinib malate caps 125mg 25mg
375mg 50mg 18 SUNOSI TABS 75mg 150mg 30 SUPRAX CAPS 10 suprax chew 10 suprax susr 100mg5ml 200mg5ml 10 SUPRAX SUSR 500 MG5ML 10 SUPREP BOWEL PREP KIT SOLN 44 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 47 SYLATRON KIT 18 SYLATRON KIT 600 MCG 18 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 56 SYMDEKO TBPK 56 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 49 SYMLINPEN 60 SOPN 49 SYMPAZAN FILM 10mg 20mg 32 SYMPAZAN FILM 5mg 31 SYMPROIC TABS 44 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 50 SYNDROS SOLN 43 SYNERCID SOLR 10 SYNJARDY TABS 49 SYNJARDY XR TB24 49 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 TACLONEX SUSP 61 tacrolimus caps 05mg 1mg 5mg 53 TACROLIMUS OINT 01 003 63 tadalafil (pah) tabs 20mg 26 tadalafil tabs 25mg 5mg 26 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 55 TALTZ SOAJ 63
TALTZ SOSY 63 TALZENNA CAPS 025mg 1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 51 taperdex 12-day tbpk 45 taperdex 6-day tbpk 45 taperdex 7-day tbpk 45 TARCEVA TABS 25mg 100mg 150mg 18 targadox tabs 10 TARGRETIN GEL 61 tarina 24 fe tabs 47 tarina fe 120 eq tabs 47 TASIGNA CAPS 50mg 150mg 200mg 18 tavaborole soln 59 TAVALISSE TABS 100mg 150mg 22 tazarotene crea 63 tazarotene foam 63 tazicef solr injection 1gm 2gm 6gm 10 TAZORAC CREA 63 TAZORAC GEL 005 01 63 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 57 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TECFIDERA CPDR 120mg 240mg 34 TECFIDERA MISC 34 TEFLARO SOLR INTRAVENOUS 400mg
600mg 10 TEGSEDI SOSY 55 TEKTURNA HCT TABS 26 telmisartan tabs 20mg 40mg 80mg 26 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 26 TEMAZEPAM CAPS 15mg 225mg 30mg
75mg 33 temsirolimus soln 18 tencon tabs 29 TENIPOSIDE SOLN 18 TENIVAC INJ 57 tenofovir disoproxil fumarate tabs 13 TEPADINA SOLR 18 TEPEZZA SOLR 42 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 21
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 103
terbutaline sulfate tabs 25mg 5mg 21 terconazole crea 59 terconazole supp 59 TERIPARATIDE (RECOMBINANT) SOPN
50 testosterone cypionate soln 100mgml
200mgml 46 testosterone enanthate soln 46 testosterone gel 1 162
2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact 46
testosterone soln 46 tetrabenazine tabs 125mg 25mg 34 TETRACAINE HCL SOLN 43 tetracycline hcl caps 250mg 500mg 10 texacort soln 61 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 63 theophylline er tb12 100mg 200mg
300mg 450mg 63 theophylline er tb24 400mg 600mg 63 theophylline soln 63 THIOLA EC TBEC 100mg 300mg 55 THIOLA TABS 55 thioridazine hcl tabs 10mg 25mg 50mg
100mg 37 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 37 THYROGEN SOLR 55 THYROLAR-1 TABS 51 THYROLAR-12 TABS 51 THYROLAR-14 TABS 51 THYROLAR-2 TABS 51 THYROLAR-3 TABS 51 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
32 TIBSOVO TABS 18 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 34 tilia fe tabs 47 timolol maleate pf soln 42 timolol maleate solg 025 05 42 timolol maleate soln 025 05 42 timolol maleate tabs 5mg 10mg 20mg 24 TIMOPTIC OCUDOSE SOLN 25 42
TIMOPTIC-XE SOLG 025 05 42 tinidazole tabs 12 tiopronin tabs 55 TIROSINT CAPS 13mcg 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
TIS-U-SOL SOLN 55 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 TIVORBEX CAPS 29 tizanidine hcl caps 20 21 tizanidine hcl tabs 20 TOBI PODHALER CAPS 56 TOBRADEX OINT 41 TOBRADEX ST SUSP 41 tobramycin nebu 300mg4ml 300mg5ml 56 tobramycin soln 41 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 42 TOBREX OINT 41 tofranil tabs 10mg 25mg 50mg 37 TOLAK CREA 63 tolazamide tabs 250mg 500mg 49 tolbutamide tabs 49 tolcapone tabs 33 tolmetin sodium caps 29 tolmetin sodium tabs 29 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 63 tolterodine tartrate tabs 63 TOLVAPTAN TABS 30mg 15mg 39 TOPEX TOPICAL ANESTHETIC AERO 61 topicort crea 005 025 61 topicort gel 61 topicort oint 61 topiramate cpsp 15mg 25mg 32 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 32 topiramate tabs 25mg 50mg 100mg
200mg 32 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
39 TOSYMRA SOLN 32
104 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
tovet foam 61 TPN ELECTROLYTES CONC
INTRAVENOUS 40 TRACLEER TABS 625mg 125mg 56 TRACLEER TBSO 56 TRADJENTA TABS 49 tramadol hcl er (biphasic) tb24 100mg
200mg 300mg 29 tramadol hcl er cp24 100mg 150mg
200mg 300mg 29 tramadol hcl er tb24 100mg 200mg 300mg
29 tramadol hcl tabs 50mg 100mg 29 tramadol-acetaminophen tabs 29 trandolapril tabs 1mg 2mg 4mg 26 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 22 tranexamic acid tabs 22 TRANSDERM SCOP (15 MG) PT72 43 tranylcypromine sulfate tabs 37 TRAVASOL SOLN INTRAVENOUS 38 TRAVATAN Z SOLN 42 travoprost (bak free) soln 42 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 37 trazodone hcl tabs 50mg 100mg 150mg 37 TRECATOR TABS 11 TRELEGY ELLIPTA AEPB 45 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 63 TREMFYA SOSY 63 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 56 tretinoin caps 18 tretinoin crea 0025 005 01 61 tretinoin gel 001 0025 005 61 tretinoin microsphere gel 004 01 61 tretinoin microsphere pump gel 004
01 62 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 29 triamcinolone acetonide aers 61 triamcinolone acetonide crea 0025
01 05 61 triamcinolone acetonide lotn 0025 01
61 triamcinolone acetonide oint 0025
005 01 05 61 triamcinolone acetonide pste 61
triamcinolone acetonide susp 45 triamterene caps 50mg 100mg 39 triamterene-hctz caps 39 triamterene-hctz tabs 39 trianex oint 61 triazolam tabs 0125mg 025mg 33 TRICITRATES SOLN 37 triderm crea 01 05 61 trientine hcl caps 45 tri-estarylla tabs 47 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 37 trifluridine soln 41 trihexyphenidyl hcl soln 33 trihexyphenidyl hcl tabs 2mg 5mg 33 TRIKAFTA TBPK 56 tri-legest fe tabs 47 tri-lo-estarylla tabs 47 tri-lo-sprintec tabs 47 trilyte solr 44 trimethobenzamide hcl caps 43 trimethoprim tabs 14 tri-mili tabs 47 trimipramine maleate caps 25mg 50mg
100mg 37 TRINESSA (28) TABS 47 TRINTELLIX TABS 5mg 10mg 20mg 37 tri-nymyo tabs 47 tri-previfem tabs 47 TRIPTODUR SRER 50 TRISENOX SOLN 18 TRISENOX SOLN 10mg10ml 18 tri-sprintec tabs 47 tritocin oint 61 TRIUMEQ TABS 13 TRI-VITAMINFLUORIDE SOLN 64 TRI-VITEFLUORIDE SOLN 64 trivora (28) tabs 47 tri-vylibra lo tabs 47 tri-vylibra tabs 47 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 32 TROPHAMINE SOLN INTRAVENOUS 38 trospium chloride er cp24 63 trospium chloride tabs 63 TRULANCE TABS 44 TRUMENBA SUSY 58
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 105
TRUSELTIQ (100MG DAILY DOSE) CPPK 18
TRUSELTIQ (125MG DAILY DOSE) CPPK 18
TRUSELTIQ (50MG DAILY DOSE) CPPK 18
TRUSELTIQ (75MG DAILY DOSE) CPPK 18
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 58 TYBOST TABS 13 tydemy tabs 47 TYKERB TABS 18 tylenol with codeine 3 tabs 29 tylenol with codeine 4 tabs 29 TYMLOS SOPN 50 TYPHIM VI SOLN 58 TYSABRI CONC INTRAVENOUS 34 TYVASO REFILL SOLN 56 TYVASO SOLN 56 TYVASO STARTER SOLN 56
U UBRELVY TABS 50mg 100mg 32 UCERIS FOAM 61 UDENYCA SOSY 22 UKONIQ TABS 18 ULORIC TABS 40mg 80mg 52 ULTOMIRIS SOLN 55 ULTRAVATE LOTN 61 UMECTA MOUSSE FOAM 63 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 52
UNITUXIN SOLN 18 UPLIZNA SOLN 53 UPTRAVI SOLR 56 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 56
UPTRAVI TBPK 57 UREA CREA 39 63 UREA LOTN 40 63 UREA-C40 LOTN 63 urecholine tabs 5mg 10mg 25mg 50mg 20
uredeb crea 63 URETRON DS TABS 14 URIN DS TABS 14 URSODIOL CAPS 200mg 400mg 44 ursodiol caps 300mg 44 ursodiol tabs 250mg 500mg 44 URYL TABS 14 USTELL CAPS 14 UTICAP CAPS 14 UTIRA-C TABS 14 UTRONA-C TABS 14
V VABOMERE SOLR INTRAVENOUS 10 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 63 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 32 valproic acid caps 32 valproic acid soln 32 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
26 valsartan-hydrochlorothiazide tabs 26 VALTOCO 10 MG DOSE LIQD 32 VALTOCO 15 MG DOSE LQPK 32 VALTOCO 20 MG DOSE LQPK 32 VALTOCO 5 MG DOSE LIQD 32 vanadom tabs 20 vanatol lq soln 29 vancomycin hcl caps 10 vancomycin hcl solr 10 VANCOMYCIN HCL SOLR 250 MG 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 VANDAZOLE GEL 59 VANOXIDE-HC LOTN 61 VANTAS KIT 19 VAQTA SUSP 58 VARIVAX INJ 58 VARIZIG SOLN 57 VARUBI (180 MG DOSE) TBPK 43 VASCEPA CAPS 05gm 1gm 23 VAXCHORA SUSR 58 vecamyl tabs 25 VECTICAL OINT 63 VELCADE SOLR 19 velivet tabs 47
106 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
VELPHORO CHEW 39 VELTASSA PACK 84gm 168gm 252gm
39 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 19 VENCLEXTA TABS 10mg 19 VENCLEXTA TABS 50mg 100mg 19 venlafaxine hcl er cp24 375mg 75mg
150mg 37 venlafaxine hcl er tb24 375mg 75mg
150mg 225mg 37 venlafaxine hcl tabs 25mg 375mg 50mg
75mg 100mg 37 VENTAVIS SOLN 10mcgml 20mcgml 57 VENTOLIN HFA AERS 21 VERAPAMIL HCL ER CP24 100mg
120mg 180mg 200mg 240mg 300mg 360mg 25
verapamil hcl er tbcr 120mg 180mg 240mg 25
verapamil hcl soln 25 verapamil hcl tabs 25 verapamil hcl tabs 80mg 120mg 25 VEREGEN OINT 63 VERELAN CP24 25 veripred 20 soln 45 VERSACLOZ SUSP 37 VERZENIO TABS 50mg 100mg 150mg
200mg 19 vestura tabs 47 VIBERZI TABS 75mg 100mg 44 VIBRAMYCIN SYRP 10 vicodin es tabs 29 vicodin hp tabs 29 vicodin tabs 29 VICTOZA SOPN 49 VIDEX EC CPDR 125mg 200mg 400mg 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 47 vigabatrin pack 32 vigabatrin tabs 32 vigadrone pack 32 VIIBRYD STARTER PACK KIT 37 VIIBRYD TABS 10mg 20mg 40mg 37 VILTEPSO SOLN 55 VIMIZIM SOLN 40 VIMPAT SOLN 32
VIMPAT TABS 32 vinblastine sulfate soln 19 vincasar pfs soln 19 vincristine sulfate soln 19 vinorelbine tartrate soln 19 VIOKACE TABS 40 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 52 VITAMINS ACD-FLUORIDE SOLN 64 VITRAKVI CAPS 25mg 100mg 19 VITRAKVI SOLN 19 VIVITROL SUSR 35 VIZIMPRO TABS 15mg 30mg 45mg 19 VOCABRIA TABS 13 VORAXAZE SOLR 52 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 19 VP-PNV-DHA CAPS 64 VPRIV SOLR 40 VRAYLAR CAPS 15mg 3mg 45mg 6mg
37 VRAYLAR CPPK 37 VUMERITY (STARTER) CPDR 55 VUMERITY CPDR 55 vyfemla tabs 47 vylibra tabs 47 VYNDAMAX CAPS 25 VYNDAQEL CAPS 25 VYONDYS 53 SOLN 55 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 30 VYVANSE CHEW 10mg 20mg 30mg
40mg 50mg 60mg 30 VYXEOS SUSR 19 VYZULTA SOLN 42
W WAKIX TABS 445mg 178mg 30 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 22 WATER FOR IRRIGATION STERILE
SOLN 55 wixela inhub aepb 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 107
wymzya fe chew 48 WYNZORA CREA 63
X XALKORI CAPS 200mg 250mg 19 XARELTO STARTER PACK TBPK 22 XARELTO TABS 25mg 10mg 15mg
20mg 22 XATMEP SOLN 19 XCOPRI (250 MG DAILY DOSE) TBPK 32 XCOPRI (350 MG DAILY DOSE) TBPK 32 XCOPRI TABS 200 MG 32 XCOPRI TABS 50mg 100mg 150mg 32 XCOPRI TBPK 32 XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
32 XELJANZ SOLN 53 XELJANZ TABS 5mg 10mg 53 XELJANZ XR TB24 11mg 22mg 53 XELPROS EMUL 42 XEMBIFY SOLN SUBCUTANEOUS
2gm10ml 4gm20ml 10gm50ml 1gm5ml 57
XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 55 XEOMIN SOLR 50unit 100unit 55 XEPI CREA 59 XERESE CREA 59 XERMELO TABS 43 XGEVA SOLN 52 XHANCE EXHU 42 XIFAXAN TABS 200mg 550mg 10 XIIDRA SOLN 42 XIMINO CP24 45mg 90mg 135mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 56 XOLAIR SOSY 75mg05ml 150mgml 56 XOSPATA TABS 19 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 19 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (40 MG TWICE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (60 MG ONCE WEEKLY) TBPK
20mg 60mg 19
XPOVIO (60 MG TWICE WEEKLY) TBPK 19
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg 19
XPOVIO (80 MG TWICE WEEKLY) TBPK 19
XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg 29
XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 48 XUREA CREA 63 XURIDEN PACK 55 xylocaine dental soln 55 XYOSTED SOAJ 50mg05ml 75mg05ml
100mg05ml 46 XYREM SOLN 34 XYWAV SOLN 34
Y YERVOY SOLN 19 YF-VAX INJ 58 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 42 yuvafem tabs 50
Z zafemy ptwk 48 zafirlukast tabs 10mg 20mg 55 zaleplon caps 5mg 10mg 33 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 48 zarontin soln 32 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 29 ZEJULA CAPS 19 ZELAPAR TBDP 33 ZELBORAF TABS 19 ZEMAIRA SOLR INTRAVENOUS 56 ZEMBRACE SYMTOUCH SOAJ 32 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
63 ZENPEP CPEP 40
108 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg 30
ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
34 ZEPOSIA CAPS 34 ZEPOSIA STARTER KIT CPPK 34 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERIT CAPS 15mg 20mg 30mg 40mg 13 ZERUVIA PTCH 61 ZETONNA AERS 42 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 55 ZINBRYTA SOSY 34 ZIONODIL 100 LOTN 61 ZIONODIL LOTN 61 ZIOPTAN SOLN 42 ziprasidone hcl caps 20mg 40mg 60mg
80mg 37 ziprasidone mesylate solr 37 ZIPSOR CAPS 29 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZIRGAN GEL 41 ZITHROMAX PACK 10 ZOKINVY CAPS 50mg 75mg 55 zoledronic acid conc 52 zoledronic acid soln 52
ZOLINZA CAPS 19 zolmitriptan soln 32 zolmitriptan tabs 32 zolmitriptan tbdp 32 zolpidem tartrate er tbcr 625mg 125mg 33 zolpidem tartrate subl 175mg 35mg 33 zolpidem tartrate tabs 5mg 10mg 33 ZOMACTON SOLR 51 ZOMACTON SOLR 5mg 51 ZOMIG SOLN 32 zonisamide caps 25mg 50mg 100mg 32 ZONTIVITY TABS 22 ZORBTIVE SOLR 51 ZORTRESS TABS 025mg 53 ZORTRESS TABS 05mg 075mg 1mg 53 ZORVOLEX CAPS 29 ZOSTAVAX SUSR 58 ZOSYN SOLN INTRAVENOUS 10 zovia 135e (28) tabs 48 ZUBSOLV SUBL 35 ZUPLENZ FILM 4mg 8mg 43 ZYCLARA PUMP CREA 63 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19 ZYKADIA TABS 19 ZYLET SUSP 42 ZYNLONTA SOLR 19 ZYPITAMAG TABS 1mg 2mg 4mg 23 ZYPREXA RELPREVV SUSR 37 ZYTIGA TABS 19 ZYVOX SOLN INTRAVENOUS 10
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request materials translated in your language at no cost to you You may also request these materials in
large text or in other formats to accommodate your needs at no cost to you For more information call
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You may submit a grievance in the following ways
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bull Online Use the online form on our website at kporg
Please call our Member Service Contact Center if you need help submitting a grievance
The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to
discrimination on the basis of race color national origin sex age or disability You may also
contact the Kaiser Permanente Civil Rights Coordinator directly at
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Civil RightsADA Coordinator
1800 Harrison St
16th Floor
Oakland CA 94612
Southern California
Civil RightsADA Coordinator
SCAL Compliance and Privacy
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Pasadena CA 91188
You can also file a civil rights complaint with the US Department of Health and Human Services
Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available
at ocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human
Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201
1-800-368-1019 1-800-537-7697 (TTY) Complaint forms are available at
hhsgovocrofficefileindexhtml
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English Language assistance
is available at no cost to you
24 hours a day 7 days a week
You can request interpreter
services materials translated
into your language or in
alternative formats Just call us
at 1-800-464-4000 24 hours a
day 7 days a week (closed
holidays) TTY users call 711
Arabic مجانا على مدار الساعة كافة متوفرة لك خدمات الترجمة الفورية
أيام الأسبوع بإمكانك طلب خدمة الترجمة الفورية أو ترجمة وثائق للغتك أو
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لمستخدمي خدمة على مدار الساعة كافة أيام الأسبوع )مغلق أيام العطلات(
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Armenian Ձեզ կարող է անվճար օգնություն
տրամադրվել լեզվի հարցում` օրը 24 ժամ շաբաթը
7 օր Դուք կարող եք պահանջել բանավոր
թարգմանչի ծառայություններ Ձեր լեզվով
թարգմանված կամ այլընտրանքային ձևաչափով
պատրաստված նյութեր Պարզապես զանգահարեք
մեզ` 1-800-464-4000 հեռախոսահամարով` օրը
24 ժամ` շաբաթը 7 օր (տոն օրերին փակ է) TTY-ից
օգտվողները պետք է զանգահարեն 711
Chinese 您每週 7天每天 24小時均可獲得免費語
言協助您可以申請口譯服務要求將資料翻譯成
您所用語言或轉換為其他格式我們每週 7天
每天 24小時均歡迎您打電話 1-800-757-7585 前來聯
絡(節假日 休息)聽障及語障專線 (TTY) 使用者
請撥 711
Farsi بدون روز هفته 7ساعت شبانروز و 24در زبانی خدمات
مترجم خدمات شما می توانید برای استهزینه در اختیار شما اخذ
صورتهای دیگر به زبان شما و یا به جزوات ترجمهشفاهی
روز هفته 7ساعت شبانروز و 24 کافیست در درخواست کنید
4000-464-800-1)به استثنای روزهای تعطیل( با ما به شماره
تماس بگیرند 711با شماره TTYتماس بگیرید کاربران
Hindi बिना किसी लागत ि दभाबिया सवाए कदन ि 24 घट
सपताह ि सातो कदन उपलबध ह आप एि दभाबिय िी सवाओ
ि बलए बिना किसी लागत ि सामबियो िो अपनी भािा म
अनवाद िरवान ि बलए या विबपपि परारपो ि बलए अनरोध
िर सित ह िस िवल हम 1-800-464-4000 पर कदन ि 24
घट सपताह ि सातो कदन (छटटियो वाल कदन िद रहता ह) िॉल
िर TTY उपयोगिताा 711 पर िॉल िर
Hmong Muajkwc pab txhais lus pub dawb rau koj
24 teev ib hnub twg 7 hnub ib lim tiam twg Koj thov
tau cov kev pab txhais lus muab cov ntaub ntawv
txhais ua koj hom lus los yog ua lwm homTsuas hu
rau 1-800-464-4000 24 teev ib hnub twg 7 hnub ib
lim tiam twg (cov hnub caiv kaw) Cov neeg siv
TTY hu 711
Japanese 当院では言語支援を無料で年中無休
終日ご利用いただけます通訳サービス日本語
に翻訳された資料あるいは資料を別の書式でも
依頼できますお気軽に 1-800-464-4000 までお電話
ください (祭日を除き年中無休)TTYユーザー
は 711にお電話ください
Khmer ជនយភាសា គមានឥតអសថលៃដលអនកឡ ើយ 24
ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ អនកអាចឡសនើស ឡសវាអនកបកបរប សភារៈបដលបានបកបរបឡៅជាភាសាបមែរ ឬជាទរងផោសងឡទៀត រានបតទរសពទមកឡយើង តាមឡលម 1-800-464-4000 បាន 24 ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ (បទថលៃប ណោយ) អនកឡរបើ TTY ឡៅឡលម 711
Korean 요일 및 시간에 관계없이 언어 지원
서비스를 무료로 이용하실 수 있습니다 귀하는
통역 서비스 귀하의 언어로 번역된 자료 또는 대체
형식의 자료를 요청할 수 있습니다 요일 및 시간에
관계없이 1-800-464-4000번으로 전화하십시오
(공휴일 휴무) TTY 사용자 번호 711
Laotian ການຊວຍເຫ ອດານພາສາມໃຫໂດຍບ ເສຽຄາ
ແກທານ ຕະຫ ອດ 24 ຊ ວໂມງ 7 ວນຕ ອາທດ ທານ
ສາມາດຮອງຂ ຮບບ ລການນາຍພາສາ ໃຫແປເອກະ
ສານເປນພາສາຂອງທານ ຫ ໃນຮບແບບອ ນ ພຽງ
ແຕໂທຣຫາພວກເຮ າທ 1-800-464-4000 ຕະຫ ອດ 24
ຊ ວໂມງ 7 ວນຕ ອາທດ (ປດວນພກຕາງໆ) ຜໃຊສາຍ
TTY ໂທຣ 711
Navajo Saad bee aacutekaacutersquoarsquoayeed naacutehoacuteloacute trsquoaacuteaacute jiikrsquoeacute
naadiin doo bibąąrsquo diacuteiacutersquo aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute
damoo naacuteaacutedleehjiacute Atah halnersquoeacute aacutekaacutersquoadoolwołiacutegiacuteiacute joacutekiacute
trsquoaacuteadoo lersquoeacute trsquoaacuteaacute hoacutehazaadjiacute hadilyąąrsquogo eacuteiacute doodaiirsquo
naacuteaacutenaacute laacute ałrsquoąą aacutedaatrsquoehiacutegiacuteiacute bee haacutedadilyaarsquogo Kojiacute
hodiilnih 1-800-464-4000 naadiin doo bibąąrsquo diacuteiacutersquo
aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute damoo naacutersquoaacutedleehjiacute
(Dahodiyin biniiyeacute ersquoersquoaahgo eacuteiacute darsquodeelkaal)
TTY chodeeyooliacuteniacutegiacuteiacute kojiacute hodiilnih 711
Punjabi ਬਿਨ ਾ ਬਿਸੀ ਲ ਗਤ ਦ ਬਦਨ ਦ 24 ਘਟ ਹਫਤ ਦ 7 ਬਦਨ
ਦਭ ਸੀਆ ਸਵ ਵ ਾ ਤਹ ਡ ਲਈ ਉਪਲਿਧ ਹ ਤਸੀ ਇਿ ਦਭ ਸੀਏ ਦੀ
ਮਦਦ ਲਈ ਸਮਗਰੀਆਾ ਨ ਆਪਣੀ ਭ ਸ ਬਵਚ ਅਨਵ ਦ ਿਰਵ ਉਣ
ਲਈ ਜ ਾ ਬਿਸ ਵਖ ਫ ਰਮਟ ਬਵਚ ਪਰ ਪਤ ਿਰਨ ਲਈ ਿਨਤੀ ਿਰ ਸਿਦ
ਹ ਿਸ ਬਸਰਫ਼ ਸ ਨ 1-800-464-4000 ਤ ਬਦਨ ਦ 24 ਘਟ ਹਫ਼ਤ
ਦ 7 ਬਦਨ (ਛਟੀਆਾ ਵ ਲ ਬਦਨ ਿਦ ਰਬਹਦ ਹ) ਫ਼ਨ ਿਰ TTY ਦ
ਉਪਯਗ ਿਰਨ ਵ ਲ 711 lsquoਤ ਫ਼ਨ ਿਰਨ
Russian Мы бесплатно обеспечиваем Вас услугами
перевода 24 часа в сутки 7 дней в неделю Вы можете
воспользоваться помощью устного переводчика
запросить перевод материалов на свой язык или
запросить их в одном из альтернативных форматов
Просто позвоните нам по телефону 1-800-464-4000
который доступен 24 часа в сутки 7 дней в неделю
(кроме праздничных дней) Пользователи линии TTY
могут звонить по номеру 711
Spanish Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al diacutea 7 diacuteas a la semana
Puede solicitar los servicios de un inteacuterprete que los
materiales se traduzcan a su idioma o en formatos
alternativos Solo llame al 1-800-788-0616 24 horas al
diacutea 7 diacuteas a la semana (cerrado los diacuteas festivos) Los
usuarios de TTY deben llamar al 711
Tagalog May magagamit na tulong sa wika nang wala
kang babayaran 24 na oras bawat araw 7 araw bawat
linggo Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format Tawagan lamang
kami sa 1-800-464-4000 24 na oras bawat araw 7 araw
bawat linggo (sarado sa mga pista opisyal) Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711
Thai เรามบรการลามฟรส าหรบคณตลอด 24 ชวโมง
ทกวนตลอดชวโมงท าการของเราคณสามารถขอใหลาม
ชวยตอบค าถามของคณทเกยวกบความคมครองการดแล
สขภาพของเราและคณยงสามารถขอใหมการแปลเอกสา
รเปนภาษาทคณใชไดโดยไมมการคดคาบรการเพยงโทร
หาเราทหมายเลข 1-800-464-4000 ตลอด 24
ชวโมงทกวน (ปดใหบรการในวนหยดราชการ) ผใช TTY
โปรดโทรไปท 711
Vietnamese Dịch vụ thocircng dịch được cung cấp miễn
phiacute cho quyacute vị 24 giờ mỗi ngagravey 7 ngagravey trong tuần Quyacute
vị coacute thể yecircu cầu dịch vụ thocircng dịch tagravei liệu phiecircn dịch
ra ngocircn ngữ của quyacute vị hoặc tagravei liệu bằng nhiều higravenh
thức khaacutec Quyacute vị chỉ cần gọi cho chuacuteng tocirci tại số
1-800-464-4000 24 giờ mỗi ngagravey 7 ngagravey trong tuần
(trừ caacutec ngagravey lễ) Người dugraveng TTY xin gọi 711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
Provide no cost aids and services to people with disabilities to communicate effectively with us such as
diams Qualified sign language interpreters
diams Written information in other formats such as large print audio and accessible electronic formats
Provide no cost language services to people whose primary language is not English such as
diams Qualified interpreters
diams Information written in other languages
If you need these services call Member Services at 1-800-476-2167 (TTY 711)8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana Aurora CO 80014 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
61102709_CO
Multi-language Interpreter Services
English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-476-2167 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-476-2167 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-476-2167 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-476-2167 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-476-2167 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-476-2167 (TTY 711)번으로 전화해 주십시오
Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-800-476-2167 (телетайп 711)
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-476-2167(TTY711)までお電話にてご連絡ください
Amharic ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው 711)
German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-800-476-2167 (TTY 711)
French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-800-476-2167 (ATS 711)
Farsi
ی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ دیریبگ تماس (TTY 711) 2167-476-800-1 با باشد
Arabic
ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم )117- (رقم ھاتف الصم والبكم 7612-674-008-1
Yoruba AKIYESI Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o E pe ero ibanisoro yi 1-800-476-2167 (TTY 711)
Cushite-Oromo XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 1-800-476-2167 (TTY 711)
Nepali
धयान िदनहोस तपाइल नपाली बोलनहनछ भन तपाइको िनिमत भाषा सहायता सवाह िनःशलक पमा उपलबध छ फोन गनरहोस 1-800-476-2167 (िटिटवाइ 711)
KAH2711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
bull Provide no cost aids and services to people with disabilities to communicateeffectively with us such asdiams Qualified sign language interpretersdiams Written information in other formats such as large print audio and accessible
electronic formatsbull Provide no cost language services to people whose primary language is not English
such asdiams Qualified interpretersdiams Information written in other languages
If you need these services call Member Services at 1-800-805-2739 (TTY 711) 8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd Honolulu HI 96813 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Kaiser Permanente is an HMO plan with a Medicare contract Enrollment in Kaiser Permanente depends on contract renewal
H1230_2017MLI accepted
Multi-language Interpreter Services English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-805-2739 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-805-2739 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-805-2739 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-805-2739 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-805-2739 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-805-2739 (TTY 711)번으로 전화해 주십시오
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-805-2739(TTY711)までお電話にてご連絡ください
Lao
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 1-800-805-2739 (TTY 711)
Ilocano PAKDAAR Nu saritaem ti Ilocano ti serbisyo para ti baddang ti lengguahe nga awanan bayadna ket sidadaan para kenyam Awagan ti 1-800-805-2739 (TTY 711)
Samoan MO LOU SILAFIA Afai e te tautala Gagana faa Sāmoa o loo iai auaunaga fesoasoan e fai fua e leai se totogi mo oe Telefoni mai 1-800-805-2739 (TTY 711)
Marshallese LALE Ntildee kwōj kōnono Kajin Ṃajōḷ kwomarontilde bōk jerbal in jipantilde ilo kajin ṇe aṃ ejjeḷọk wōṇāān Kaalọk 1-800-805-2739 (TTY 711)
Trukese MEI AUCHEA Ika iei foosun fonuomw Foosun Chuuk iwe en mei tongeni omw kopwe angei aninisin chiakku ese kamo Kori 1-800-805-2739 (TTY 711)
Hawaiian E NĀNĀ MAI Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo loaʻa ke kōkua manuahi iā ʻoe E kelepona iā 1-800-805-2739 (TTY 711)
Pohnpeian Ni songen mwohmw ohte komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei Call 1-800-805-2739 (TTY 711)
Bisayan ATENSYON Kung nagsulti ka og Cebuano aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe nga walay bayad Tawag sa 1-800-805-2739 (TTY 711)
Tongan FAKATOKANGArsquoI Kapau lsquooku ke Lea-Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai atu ha tokoni tarsquoetotongi pea teke lava lsquoo marsquou ia Telefoni mai 1-800-805-2739 (TTY 711)
485236276 102021
This formulary was updated on 100121 For more recent information or other questions please contact the number for your Kaiser Permanente Region listed below seven days a week 8 am to 8 pm or visit kporgseniorrx
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Foundation Health Plan Inc 393 E Walnut St Pasadena CA 91188-8514 Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E Dakota Ave Denver CO 80247 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Foundation Health Plan Inc 711 Kapiolani Blvd Honolulu HI 96813 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
kporgseniorrx Please recycle
Note to existing members This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Kaiser Permanente When it refers to ldquoplanrdquo or ldquoour planrdquo it means Kaiser Permanente Senior Advantage
This document includes a list of the drugs (formulary) for our plan which is current as of October 1 2021 For an updated formulary please visit our website at kporgseniorrx or call us Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages You must generally use network pharmacies to use your prescription drug benefit The formulary and pharmacy network may change at any time You will receive notice when necessary
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 1
What is the Kaiser Permanente Formulary
A formulary is a list of covered drugs selected by Kaiser Permanente in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a Kaiser Permanente network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages Can the formulary (drug list) change
Most changes in drug coverage happen on January 1 but Kaiser Permanente may add or remove drugs on the Drug List during the year or add new restrictions We must follow Medicare rules in making these changes
Changes that can affect you this year
In the below cases you will be affected by coverage changes during the year
New generic drugs
We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug with the same or fewer restrictions Also when adding the new generic drug we may decide to keep the brand name drug on our Drug List but immediately add new restrictions If you are
currently taking that brand name drug we may not tell you in advance before we make that change but we will later provide you with information about the specific change(s) we have made
bull If we make such a change you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will also include information on how to request an exception and you can also find information in the section below entitled ldquoHow do I request an exception to the Kaiser Permanente Formularyrdquo
Drugs removed from the market
If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our formulary and provide notice to members who take the drug
Other changes
We may make other changes that affect members currently taking a drug For instance we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug Or we may make changes based on new clinical guidelines If we remove drugs from our formulary or add prior authorization we must notify affected members of the change at least 30 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 30-day supply of the drug
bull If we make these other changes you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will include information
2 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
on how to request an exception You can find information in the section below entitled ldquoHow do I request an exception to the Kaiser Permanente Formularyrdquo
Changes that will not affect you if you are currently taking the drug
Generally if you are taking a drug on our 2021 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year You will not get direct notice this year about changes that do not affect you However on January 1 of the next year such changes would affect you and it is important to check the Drug List for the new benefit year for any changes to drugs
The enclosed formulary is current as of October 1 2021 To get updated information about the drugs covered by our plan please call us Contact information for your Kaiser Permanente Region appears on the front and back cover pages
In the event of a midyear non-maintenance formulary change we will provide details in the Medicare Part D Explanation of Benefits that we send you or Provision of Notice posted at kporgseniorrx
How do I use the formulary
There are two ways to find your drug within the formulary
Medical condition The formulary begins on page 6 The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat For example drugs used to treat a heart condition are listed under the category ldquoCardiovascular Drugsrdquo If you know what your drug is used for look for the category name in the list that begins on page 8 Then look under the category name for your drug Alphabetical listing
If you are not sure what category to look under you should look for your drug in the index that begins on page 66 The index provides an alphabetical list of all the drugs included in this document Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the index and find the name of your drug in the first column of the list What are generic drugs
Our plan covers both brand-name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug Generally generic drugs cost less than brand-name drugs Please see your Evidence of Coverage for more information
What are brand-name drugs
Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug When the patent on a brand-name drug expires other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices Please
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 3
see your Evidence of Coverage for more information
Are there any restrictions on my coverage
Some covered drugs may have additional requirements or limits on coverage These requirements and limits may include
bull Prior Authorization Our plan may require you or your network provider to get prior authorization for certain drugs This means that you will need to get approval from our plan before you fill your prescriptions If you donrsquot get approval we may not cover the drug
Note If your prescription has more than one refill remaining you can only get one refill at a time unless authorized because you will be away from our service area for an extended period of time For certain drugs we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive Also if there is a shortage in the marketplace we may fill your prescription for a limited quantity You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6 You can also get more information about the restrictions applied to specific covered drugs by visiting our website We have posted online a document that explains our prior authorization restriction You may also ask us to send you a copy Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages
You can ask us to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I request an exception to the Kaiser Permanente formularyrdquo for information about how to request an exception What if my drug is not on the formulary
If your drug is not included in this formulary (list of covered drugs) you should first check our Kaiser Permanente 2021 Comprehensive Formulary at kporgseniorrx or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region and confirm if your drug is covered If your Medicare Part D prescription drug is not on our Kaiser Permanente 2021 Comprehensive Formulary you have two options
bull You can ask your network provider to prescribe a similar drug that is included on our formulary
bull You can ask us to make an exception and cover your drug See the next section for information about how to request an exception
How do I request an exception to the Kaiser Permanente Formulary
You can ask us to make an exception to our coverage rules There are several types of exceptions that you can ask us to make
bull You can ask us to cover a drug even if it may not be in our Kaiser Permanente 2021 Comprehensive Formulary
4 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
bull You can ask us to waive coverage
restrictions or limits on your drug For example if your drug requires prior authorization you can ask us to waive the prior authorization requirement for your Part D drug
Generally we will only approve your request for an exception if the alternative drugs included on the planrsquos formulary or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception When you request a formulary or utilization restriction exception you should submit a statement from your network provider supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited (fast) exception if you or your network provider believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber
Please note You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare amp Medicaid Services (CMS) You cannot get an exception for drugs that are excluded under Medicare Part D Please refer to your Evidence of Coverage for more information about requesting exceptions including the appeals process What do I do before I can talk to my network provider about
changing my drugs or requesting an exception
In some cases you might be taking Medicare Part D drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your network provider to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your network provider to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan For each of your Part D drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide up to a maximum of a 30-day supply of medication After your first 30-day supply we may cover an additional refill as medically necessary After you have used these refills we will not pay for these drugs even if you have been a member of the plan less than 90 days
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug while you pursue a formulary exception
For current members with level of care changes if you enter into or are discharged from a hospital skilled nursing facility or long-term care facility to a different care setting or home this is what is known as a
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 5
level of care change When your level of care changes you may require an additional fill of your medication We will generally cover up to a one-month supply of your Part D drugs during this level of care transition period even if the drug is not on our Drug List
For more information
For more detailed information about your Kaiser Permanente prescription drug coverage please review your Evidence of Coverage and other plan materials If you have questions about our plan please call us Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048 Or visit httpwwwmedicaregov
6 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Kaiser Permanentersquos Formulary
The formulary below provides coverage information about the drugs covered by our plan If you have trouble finding your drug in the list turn to the index that begins on page 66 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg NEBUPENT) and generic drugs are listed in lower-case italics (eg ltamoxicillingt) The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number below Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy Northern CA ndash 1-888-218-6245 Monday through Friday 8 am to 8 pm Saturday 8 am to 6 pm and Sunday 9 am to 6 pm Southern CA ndash 1-866-206-2983 Monday through Friday 7 am to 7 pm Saturday 10 am to 2 pm
Colorado
Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday 8 am to 6 pm
Hawaii
Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday 800 am to 5 pm
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 7
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
8 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole tabs NDS emverm chew ivermectin tabs praziquantel tabs MO ANTIBACTERIALS amikacin sulfate soln amikacin sulfate soln injection HI amoxicillin caps amoxicillin chew amoxicillin susr amoxicillin tabs amoxicillin-pot clavulanate chew amoxicillin-pot clavulanate er tb12
amoxicillin-pot clavulanate susr amoxicillin-pot clavulanate tabs ampicillin caps ampicillin sodium solr ampicillin sodium solr injection 1gm 125mg HI
ampicillin sodium solr intravenous HI
ampicillin-sulbactam sodium solr ampicillin-sulbactam sodium solr injection HI
ampicillin-sulbactam sodium solr intravenous HI
ARIKAYCE SUSP PALDNDS AUGMENTIN SUSR AVYCAZ SOLR INTRAVENOUS HI AZITHROMYCIN PACK MO azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BAXDELA SOLR INTRAVENOUS HI
BAXDELA TABS MO
Drug Name RequirementsLimits
BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP cefaclor caps cefaclor er tb12 cefaclor susr cefadroxil caps cefadroxil susr cefadroxil tabs cefazolin sodium solr cefazolin sodium solr injection 1gm 10gm 500mg HI
cefdinir caps cefdinir susr cefepime hcl solr injection 1gm 2gm HI
cefixime caps cefixime susr cefotaxime sodium solr cefotetan disodium solr injection 1gm 2gm HI
cefoxitin sodium solr injection HI cefoxitin sodium solr intravenous 1gm 2gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 2gm 6gm HI
CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 75gm 750mg HI
cefuroxime sodium solr intravenous HI
cephalexin caps cephalexin susr cephalexin tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w soln ciprofloxacin in d5w soln intravenous HI
ciprofloxacin susr ciprofloxacin-ciproflox hcl er tb24 clarithromycin er tb24 clarithromycin susr clarithromycin tabs cleocin phosphate soln cleocin solr clindamycin hcl caps clindamycin palmitate hcl solr clindamycin phosphate in d5w soln intravenous HI
clindamycin phosphate soln clindamycin phosphate soln injection 300mg2ml 600mg4ml 900mg6ml
HI
colistimethate sodium (cba) solr injection HI
DALVANCE SOLR INTRAVENOUS HI
daptomycin solr intravenous 350mg 500mg HI
demeclocycline hcl tabs dicloxacillin sodium caps DIFICID SUSR NDS DIFICID TABS NDS DORYX MPC TBEC MO doxy 100 solr intravenous HI doxycycline hyclate caps 50mg 100mg MO
doxycycline hyclate tabs 20mg 75mg 100mg 150mg MO
doxycycline hyclate tbec 50mg 75mg 100mg 150mg 200mg MO
doxycycline monohydrate caps 50mg 75mg 100mg 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
Drug Name RequirementsLimits
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs FETROJA SOLR NDS FIRVANQ SOLR gentamicin in saline soln gentamicin in saline soln intravenous HI
gentamicin sulfate soln gentamicin sulfate soln injection HI imipenem-cilastatin solr intravenous HI
KIMYRSA SOLR NDS levofloxacin in d5w soln levofloxacin in d5w soln intravenous HI
levofloxacin soln levofloxacin soln intravenous HI levofloxacin tabs lincomycin hcl soln linezolid soln intravenous HI linezolid susr NDS linezolid tabs NDS meropenem solr intravenous 1gm 500mg HI
minocycline hcl caps 50mg 75mg 100mg MO
minocycline hcl er tb24 45mg 55mg 65mg 80mg 90mg 105mg 115mg 135mg
MO
minocycline hcl tabs 50mg 75mg 100mg MO
mondoxyne nl caps 75mg 100mg MO
morgidox caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 10 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium solr intravenous HI neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs okebo caps MO ORBACTIV SOLR NDS OXACILLIN SODIUM IN DEXTROSE SOLN INTRAVENOUS
HI
oxacillin sodium solr injection 1gm 2gm HI
oxacillin sodium solr intravenous HI PENICILLIN G POT IN DEXTROSE SOLN INTRAVENOUS
HI
penicillin g potassium solr injection HI
penicillin g procaine susp penicillin g sodium solr injection HI penicillin v potassium solr penicillin v potassium tabs piperacillin sod-tazobactam so solr
piperacillin sod-tazobactam so solr intravenous HI
polymyxin b sulfate solr injection HI RECARBRIO SOLR NDS SEYSARA TABS 60mg 100mg 150mg NDS
SIVEXTRO SOLR INTRAVENOUS HI
SIVEXTRO TABS NDS soloxide tbec MO streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
Drug Name RequirementsLimits
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO SUPRAX CAPS suprax chew suprax susr 100mg5ml 200mg5ml
SUPRAX SUSR 500 MG5ML SYNERCID SOLR targadox tabs MO tazicef solr injection 1gm 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS 400mg 600mg HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
VABOMERE SOLR INTRAVENOUS HI
vancomycin hcl caps vancomycin hcl solr VANCOMYCIN HCL SOLR 250 MG
vancomycin hcl solr intravenous 1gm 10gm 500mg HI
VIBRAMYCIN SYRP XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS XIMINO CP24 45mg 90mg 135mg MO
ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ZITHROMAX PACK MO ZOSYN SOLN INTRAVENOUS HI ZYVOX SOLN INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
ANTIFUNGALS ABELCET SUSP INTRAVENOUS HI
AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS ERAXIS SOLR INTRAVENOUS 50mg 100mg HI
fluconazole in sodium chloride soln intravenous HI
fluconazole susr fluconazole tabs flucytosine caps 250mg 500mg NDS griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs itraconazole caps ITRACONAZOLE SOLN MO ketoconazole tabs micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS NOXAFIL TBEC NDS nystatin susp nystatin tabs POSACONAZOLE SUSP NDS posaconazole tbec NDS terbinafine hcl tabs TOLSURA CAPS NDS voriconazole solr intravenous HI voriconazole susr voriconazole tabs ANTIMYCOBACTERIALS CAPASTAT SULFATE SOLR cycloserine caps dapsone tabs 25mg 100mg MO ethambutol hcl tabs 100mg 400mg MO
isoniazid soln
Drug Name RequirementsLimits
isoniazid syrp MO isoniazid tabs 100mg 300mg MO paser pack MO PRETOMANID TABS PRIFTIN TABS MO pyrazinamide tabs MO RIFABUTIN CAPS MO RIFADIN CAPS MO rifamate caps MO rifampin caps 150mg 300mg MO rifampin solr intravenous HI RIFATER TABS MO SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs BENZNIDAZOLE TABS 125mg 100mg MO
chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS DARAPRIM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS mefloquine hcl tabs metronidazole caps metronidazole in nacl soln metronidazole in nacl soln intravenous HI
metronidazole tabs NEBUPENT SOLR PA nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 12 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
quinine sulfate caps NDS SOLOSEC PACK tinidazole tabs ANTIVIRALS abacavir sulfate soln abacavir sulfate tabs MO abacavir sulfate-lamivudine tabs MO abacavir-lamivudine-zidovudine tabs MO
acyclovir caps MO acyclovir sodium soln intravenous HI
acyclovir susp MO acyclovir tabs 400mg 800mg MO adefovir dipivoxil tabs NDS APTIVUS CAPS MO APTIVUS SOLN MO atazanavir sulfate caps 150mg 200mg 300mg MO
BARACLUDE SOLN MO BIKTARVY TABS CABENUVA SUER cidofovir soln CIMDUO TABS MO COMPLERA TABS MO CRIXIVAN CAPS 200mg 400mg MO DAKLINZA TABS 30mg 60mg 90mg PANDS
DELSTRIGO TABS MO DESCOVY TABS MO didanosine cpdr 200mg 250mg 400mg MO
DOVATO TABS MO EDURANT TABS MO efavirenz caps 50mg 200mg MO efavirenz tabs MO efavirenz-emtricitab-tenofovir tabs MO
emtricitabine caps MO emtricitabine-tenofovir df tabs MO EMTRIVA SOLN MO entecavir tabs 05mg 1mg MO EPCLUSA TABS PANDS
Drug Name RequirementsLimits
EPIVIR HBV SOLN MO etravirine tabs 100mg 200mg MO EVOTAZ TABS MO famciclovir tabs 125mg 250mg 500mg MO
fosamprenavir calcium tabs MO FUZEON SOLR NDS ganciclovir sodium soln ganciclovir sodium solr GENVOYA TABS MO HARVONI PACK PANDS HARVONI TABS PANDS INTELENCE TABS 25mg MO INVIRASE CAPS MO INVIRASE TABS MO ISENTRESS CHEW 25mg 100mg MO
ISENTRESS HD TABS MO ISENTRESS PACK MO ISENTRESS TABS MO JULUCA TABS MO lamivudine soln MO lamivudine tabs 100mg 150mg 300mg MO
lamivudine-zidovudine tabs MO ledipasvir-sofosbuvir tabs PANDS LEXIVA SUSP MO lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO MAVYRET TABS PANDS nevirapine er tb24 100mg 400mg MO
nevirapine susp MO nevirapine tabs MO NORVIR CAPS MO NORVIR PACK MO NORVIR SOLN MO ODEFSEY TABS MO OLYSIO CAPS PANDS oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEG-INTRON REDIPEN KIT NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
PEGASYS PROCLICK SOLN 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN 180mcg05ml 180mcgml NDS
PEGINTRON KIT NDS PIFELTRO TABS MO PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
PREVYMIS SOLN 240mg12ml 480mg24ml NDS
PREVYMIS TABS 240mg 480mg NDS
PREZCOBIX TABS MO PREZISTA SUSP MO PREZISTA TABS 75mg 150mg 600mg 800mg MO
RAPIVAB SOLN NDS REBETOL SOLN MO RELENZA DISKHALER AEPB MO RESCRIPTOR TABS 100mg 200mg MO
RETROVIR SOLN MO REYATAZ PACK MO ribasphere caps MO ribasphere ribapak (1000 pack) tbpk MO
ribasphere ribapak (1200 pack) tbpk MO
ribasphere tabs MO ribavirin caps MO ribavirin solr ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg 150mg 300mg MO
sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS
Drug Name RequirementsLimits
SOVALDI TABS 200mg 400mg PANDS stavudine caps 15mg 20mg 30mg 40mg MO
STRIBILD TABS MO SYMFI LO TABS MO SYMFI TABS MO SYMTUZA TABS MO SYNAGIS SOLN 50mg05ml 100mgml NDS
tenofovir disoproxil fumarate tabs MO
TIVICAY PD TBSO MO TIVICAY TABS 10mg 25mg 50mg MO
TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEMLIDY TABS VIDEX EC CPDR 125mg 200mg 400mg MO
VIDEX SOLR 2gm 4gm MO VIEKIRA PAK TBPK PANDS VIEKIRA XR TB24 PANDS VIRACEPT TABS 250mg 625mg MO
VIREAD POWD MO VIREAD TABS 150mg MO VIREAD TABS 200mg 250mg MO VOCABRIA TABS MO VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS ZERIT CAPS 15mg 20mg 30mg 40mg MO
zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 14 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fosfomycin tromethamine pack MENAPHOSMBHYO1 TABS methenamine hippurate tabs METHENAMINE MANDELATE TABS
NITROFURANTOIN MACROCRYSTAL CAPS
NITROFURANTOIN MONOHYD MACRO CAPS
nitrofurantoin susp PHOSPHASAL TABS trimethoprim tabs MO URETRON DS TABS URIN DS TABS URYL TABS USTELL CAPS UTICAP CAPS UTIRA-C TABS UTRONA-C TABS ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate soln carbinoxamine maleate tabs cetirizine hcl soln CLARINEX SYRP CLARINEX-D 12 HOUR TB12 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln
Drug Name RequirementsLimits
promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs SEMPREX-D CAPS ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg 500mg NDS
ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS 25mg 5mg 75mg 10mg NDS
ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs ARRANON SOLN ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE INJ BELEODAQ SOLR NDS BELRAPZO SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS bexarotene caps NDS bicalutamide tabs BICNU SOLR bleomycin sulfate solr BLINCYTO SOLR NDS BORTEZOMIB SOLR BOSULIF TABS 100mg 400mg 500mg NDS
BRAFTOVI CAPS 50mg 75mg NDS BRUKINSA CAPS NDS busulfan soln CABOMETYX TABS 20mg 40mg 60mg NDS
CALQUENCE CAPS NDS CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR NDS cladribine soln clofarabine soln COMETRIQ (100 MG DAILY DOSE) KIT LDNDS
COMETRIQ (140 MG DAILY DOSE) KIT LDNDS
COMETRIQ (60 MG DAILY DOSE) KIT LDNDS
COPIKTRA CAPS 15mg 25mg NDS COTELLIC TABS NDS CYCLOPHOSPHAMIDE CAPS 25mg 50mg PA
CYCLOPHOSPHAMIDE SOLN 1gm5ml 500mg25ml NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr
Drug Name RequirementsLimits
dactinomycin solr DANYELZA SOLN NDS DARZALEX FASPRO SOLN NDS DARZALEX SOLN 400mg20ml 100mg5ml NDS
daunorubicin hcl soln DAURISMO TABS 25mg 100mg NDS decitabine solr DOCETAXEL (NON-ALCOHOL) SOLN 80mg4ml 160mg8ml 20mgml
NDS
docetaxel conc docetaxel soln doxorubicin hcl liposomal inj DOXORUBICIN HCL SOLN doxorubicin hcl solr DROXIA CAPS ELIGARD KIT ELLENCE SOLN ELZONRIS SOLN NDS EMCYT CAPS NDS EMPLICITI SOLR 300mg 400mg NDS
ENHERTU SOLR NDS epirubicin hcl soln ERBITUX SOLN ERIVEDGE CAPS NDS ERLEADA TABS NDS erlotinib hcl tabs 25mg 100mg 150mg NDS
ERWINASE SOLR NDS ERWINAZE SOLR NDS ETOPOPHOS SOLR NDS etoposide soln everolimus tabs 25mg 5mg 75mg NDS
EVOMELA SOLR NDS exemestane tabs FARYDAK CAPS 10mg 15mg 20mg LDNDS
FASLODEX SOLN NDS FENSOLVI (6 MONTH) KIT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 16 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
FIRMAGON (240 MG DOSE) SOLR
FIRMAGON SOLR floxuridine solr fludarabine phosphate soln fludarabine phosphate solr fluorouracil soln flutamide caps FOTIVDA CAPS 089mg 134mg NDS
fulvestrant soln NDS GAVRETO CAPS NDS GAZYVA SOLN NDS gemcitabine hcl soln gemcitabine hcl solr GILOTRIF TABS 20mg 30mg 40mg NDS
HERCEPTIN HYLECTA SOLN NDS HERCEPTIN SOLR 150mg 440mg NDS
HERZUMA SOLR 150mg 420mg NDS
HEXALEN CAPS NDS hydroxyurea caps IBRANCE CAPS 75mg 100mg 125mg NDS
IBRANCE TABS 75mg 100mg 125mg NDS
ICLUSIG TABS 10mg 15mg 30mg 45mg NDS
IDAMYCIN PFS SOLN idarubicin hcl soln IDHIFA TABS 50mg 100mg NDS ifosfamide soln IFOSFAMIDE SOLR imatinib mesylate tabs IMBRUVICA CAPS 70mg 140mg NDS
IMBRUVICA TABS 140mg 280mg 420mg 560mg NDS
IMFINZI SOLN 500mg10ml 120mg24ml NDS
INFUGEM SOLN NDS INLYTA TABS 1mg 5mg NDS
Drug Name RequirementsLimits
INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 10muml 6000000unitml NDS
INTRON A SOLR 10mu 18mu 50mu NDS
IRESSA TABS NDS irinotecan hcl soln IXEMPRA KIT SOLR NDS JAKAFI TABS 5mg 10mg 15mg 20mg 25mg NDS
JEMPERLI SOLN KADCYLA SOLR 100mg 160mg NDS KANJINTI SOLR 150mg 420mg NDS KEYTRUDA SOLN NDS KISQALI (200 MG DOSE) TBPK NDS KISQALI (400 MG DOSE) TBPK NDS KISQALI (600 MG DOSE) TBPK NDS KISQALI FEMARA (400 MG DOSE) TBPK NDS
KISQALI FEMARA (600 MG DOSE) TBPK NDS
KISQALI FEMARA (200 MG DOSE) TBPK NDS
KOSELUGO CAPS 10mg 25mg NDS KYPROLIS SOLR 10mg 30mg 60mg NDS
lapatinib ditosylate tabs NDS LARTRUVO SOLN 190mg19ml 500mg50ml NDS
LENVIMA (10 MG DAILY DOSE) CPPK LDNDS
LENVIMA (12 MG DAILY DOSE) CPPK LDNDS
LENVIMA (14 MG DAILY DOSE) CPPK LDNDS
LENVIMA (18 MG DAILY DOSE) CPPK LDNDS
LENVIMA (20 MG DAILY DOSE) CPPK LDNDS
LENVIMA (24 MG DAILY DOSE) CPPK LDNDS
LENVIMA (4 MG DAILY DOSE) CPPK LDNDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
LENVIMA (8 MG DAILY DOSE) CPPK LDNDS
letrozole tabs LEUKERAN TABS NDS leuprolide acetate kit LIBTAYO SOLN NDS LIPODOX 50 INJ LONSURF TABS NDS LORBRENA TABS 25mg 100mg NDS
LUMAKRAS TABS NDS LUMOXITI SOLR NDS LUPANETA PACK KIT LUPRON DEPOT (1-MONTH) KIT
LUPRON DEPOT (3-MONTH) KIT
LUPRON DEPOT (4-MONTH) KIT
LUPRON DEPOT (6-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT 75 MG
LUPRON DEPOT-PED (3-MONTH) KIT
LYNPARZA CAPS NDS LYNPARZA TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA SOLN NDS MARQIBO SUSP NDS MATULANE CAPS NDS megestrol acetate susp megestrol acetate tabs MEKINIST TABS 05mg 2mg NDS MEKTOVI TABS NDS melphalan hcl solr mercaptopurine tabs methotrexate sodium (pf) soln methotrexate sodium soln methotrexate sodium solr
Drug Name RequirementsLimits
methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS MUSTARGEN SOLR mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS NERLYNX TABS NDS NEXAVAR TABS NDS nilutamide tabs NINLARO CAPS 23mg 3mg 4mg NDS
NUBEQA TABS NDS ODOMZO CAPS NDS OGIVRI SOLR NDS ONIVYDE INJ NDS ONTRUZANT SOLR 150mg 420mg NDS
ONUREG TABS 200mg 300mg NDS OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml NDS
oxaliplatin soln oxaliplatin solr paclitaxel conc PADCEV SOLR 20mg 30mg NDS paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEPAXTO SOLR NDS PERJETA SOLN NDS PHESGO SOLN NDS PIQRAY (200 MG DAILY DOSE) TBPK NDS
PIQRAY (250 MG DAILY DOSE) TBPK NDS
PIQRAY (300 MG DAILY DOSE) TBPK NDS
POLIVY SOLR 30mg 140mg NDS POMALYST CAPS 1mg 2mg 3mg 4mg NDS
PORTRAZZA SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 18 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
POTELIGEO SOLN NDS PROLEUKIN SOLR NDS PURIXAN SUSP NDS QINLOCK TABS NDS RETEVMO CAPS 40mg 80mg NDS REVLIMID CAPS 25mg 5mg 10mg 15mg 20mg 25mg NDS
RIABNI SOLN 100mg10ml 500mg50ml NDS
RITUXAN HYCELA SOLN RITUXAN SOLN ROMIDEPSIN SOLN NDS ROZLYTREK CAPS 100mg 200mg NDS
RUBRACA TABS 200mg 250mg 300mg NDS
RUXIENCE SOLN 100mg10ml 500mg50ml NDS
RYBREVANT SOLN NDS RYDAPT CAPS NDS RYLAZE SOLN NDS SARCLISA SOLN 500mg25ml 100mg5ml NDS
SIKLOS TABS NDS SOLTAMOX SOLN SPRYCEL TABS 20mg 50mg 70mg 80mg 100mg 140mg NDS
STIVARGA TABS NDS sunitinib malate caps 125mg 25mg 375mg 50mg NDS
SUTENT CAPS 125mg 25mg 375mg 50mg NDS
SYLATRON KIT 600 MCG SYLATRON KIT SYLVANT SOLR 100mg 400mg NDS SYNRIBO SOLR NDS TABLOID TABS TABRECTA TABS 150mg 200mg NDS
TAFINLAR CAPS 50mg 75mg NDS TAGRISSO TABS 40mg 80mg NDS TALZENNA CAPS 025mg 1mg NDS tamoxifen citrate tabs
Drug Name RequirementsLimits
TARCEVA TABS 25mg 100mg 150mg NDS
TASIGNA CAPS 50mg 150mg 200mg NDS
TAZVERIK TABS NDS TECENTRIQ SOLN 840mg14ml 1200mg20ml NDS
temsirolimus soln TENIPOSIDE SOLN TEPADINA SOLR NDS TEPMETKO TABS NDS THALOMID CAPS 50mg 100mg 150mg 200mg NDS
thiotepa solr 15mg 100mg NDS TIBSOVO TABS NDS toposar soln TOPOTECAN HCL SOLN topotecan hcl solr toremifene citrate tabs NDS TRAZIMERA SOLR 150mg 420mg NDS
TRELSTAR MIXJECT SUSR tretinoin caps NDS trexall tabs 5mg 75mg 10mg 15mg PA
TRISENOX SOLN 10mg10ml NDS TRISENOX SOLN NDS TRODELVY SOLR NDS TRUSELTIQ (100MG DAILY DOSE) CPPK NDS
TRUSELTIQ (125MG DAILY DOSE) CPPK NDS
TRUSELTIQ (50MG DAILY DOSE) CPPK NDS
TRUSELTIQ (75MG DAILY DOSE) CPPK NDS
TRUXIMA SOLN 100mg10ml 500mg50ml NDS
TUKYSA TABS 50mg 150mg NDS TURALIO CAPS NDS TYKERB TABS NDS UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
VANTAS KIT VELCADE SOLR VENCLEXTA STARTING PACK TBPK NDS
VENCLEXTA TABS 10mg NDS VENCLEXTA TABS 50mg 100mg NDS
VERZENIO TABS 50mg 100mg 150mg 200mg NDS
vinblastine sulfate soln vincasar pfs soln vincristine sulfate soln vinorelbine tartrate soln VITRAKVI CAPS 25mg 100mg NDS VITRAKVI SOLN NDS VIZIMPRO TABS 15mg 30mg 45mg NDS
VOTRIENT TABS NDS VYXEOS SUSR NDS XALKORI CAPS 200mg 250mg NDS XATMEP SOLN PANDS XOSPATA TABS NDS XPOVIO (100 MG ONCE WEEKLY) TBPK 20mg 50mg NDS
XPOVIO (40 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (40 MG TWICE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (60 MG ONCE WEEKLY) TBPK 20mg 60mg NDS
XPOVIO (60 MG TWICE WEEKLY) TBPK NDS
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (80 MG TWICE WEEKLY) TBPK NDS
XTANDI CAPS NDS XTANDI TABS 40mg 80mg NDS YERVOY SOLN YONDELIS SOLR NDS YONSA TABS NDS ZALTRAP SOLN 100mg4ml 200mg8ml NDS
ZEJULA CAPS NDS
Drug Name RequirementsLimits
ZELBORAF TABS NDS ZEPZELCA SOLR NDS ZIRABEV SOLN 400mg16ml 100mg4ml NDS
ZOLINZA CAPS NDS ZYDELIG TABS 100mg 150mg NDS ZYKADIA CAPS NDS ZYKADIA TABS NDS ZYNLONTA SOLR NDS ZYTIGA TABS NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA AEPB MO ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO BEVESPI AEROSPHERE AERO MO chlordiazepoxide-clidinium caps CUVPOSA SOLN MO dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate pf sosy glycopyrrolate soln glycopyrrolate tabs 1mg 2mg MO INCRUSE ELLIPTA AEPB MO ipratropium bromide soln 002 PAMO ipratropium bromide soln 003 006 MO
LONHALA MAGNAIR REFILL KIT SOLN NDS
methscopolamine bromide tabs 25mg 5mg MO
propantheline bromide tabs MO SPIRIVA HANDIHALER CAPS MO SPIRIVA RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 20 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO NICOTROL NS SOLN MO PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride tabs 5mg 10mg 25mg 50mg MO
CEVIMELINE HCL CAPS MO donepezil hcl tabs 5mg 10mg 23mg MO
donepezil hcl tbdp 5mg 10mg MO galantamine hydrobromide er cp24 8mg 16mg 24mg MO
galantamine hydrobromide soln MO galantamine hydrobromide tabs 4mg 8mg 12mg MO
GUANIDINE HCL TABS MO MESTINON SOLN MO pilocarpine hcl tabs 5mg 75mg MO pyridostigmine bromide er tbcr MO pyridostigmine bromide soln MO pyridostigmine bromide tabs 30mg 60mg MO
REGONOL SOLN rivastigmine pt24 46mg24hr 95mg24hr 133mg24hr MO
rivastigmine tartrate caps 15mg 3mg 45mg 6mg MO
urecholine tabs 5mg 10mg 25mg 50mg MO
SKELETAL MUSCLE RELAXANTS baclofen soln baclofen tabs 5mg 10mg 20mg MO carisoprodol tabs 250mg 350mg PANDS carisoprodol-aspirin tabs PANDS carisoprodol-aspirin-codeine tabs PANDS
chlorzoxazone tabs 375mg 500mg 750mg NDS
Drug Name RequirementsLimits
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA lorzone tabs 375mg 750mg NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln revonto solr succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs vanadom tabs PANDS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl er tb24 MO dihydroergotamine mesylate soln NDS ergoloid mesylates tabs MO ergomar subl phenoxybenzamine hcl caps NDS silodosin caps 4mg 8mg MO tamsulosin hcl caps MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR HFA AERO MO albuterol sulfate er tb12 4mg 8mg MO
albuterol sulfate hfa aers MONDS albuterol sulfate nebu 0083 25mg05ml PAMO
albuterol sulfate nebu 063mg3ml 125mg3ml PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO ARCAPTA NEOHALER CAPS MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY EPIPEN 2-PAK SOAJ EPIPEN JR 2-PAK SOAJ formoterol fumarate nebu PAMO ipratropium-albuterol soln PAMO isoproterenol hcl soln levalbuterol hcl nebu 125mg05ml 031mg3ml 063mg3ml 125mg3ml
PAMO
levalbuterol tartrate aero MO metaproterenol sulfate syrp MO metaproterenol sulfate tabs 10mg 20mg MO
midodrine hcl tabs 25mg 5mg 10mg MO
norepinephrine bitartrate soln phenylephrine hcl soln PROAIR RESPICLICK AEPB MO SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
tizanidine hcl caps VENTOLIN HFA AERS MONDS BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS BERINERT KIT INTRAVENOUS HI FIRAZYR SOLN NDS icatibant acetate soln NDS OXBRYTA TABS NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS
Drug Name RequirementsLimits
COAGULANTS AND ANTICOAGULANTS aminocaproic acid soln MO aminocaproic acid tabs 500mg 1000mg MO
anagrelide hcl caps 05mg 1mg MO argatroban soln aspirin-dipyridamole er cp12 MO BEVYXXA CAPS 40mg 80mg MO BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
NDS
FRAGMIN SOLN 2500unit02ml 5000unit02ml 7500unit03ml 12500unit05ml 15000unit06ml 95000unit38ml 10000unitml 18000unt072ml
NDS
heparin (porcine) in nacl soln HEPARIN SOD (PORCINE) IN D5W SOLN
heparin sodium (porcine) pf soln PA heparin sodium (porcine) soln 1000unitml 5000unitml 10000unitml 20000unitml
PA
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg
MO
LOVENOX SOLN 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 22 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg PRADAXA CAPS 110mg 150mg MO
prasugrel hcl tabs 5mg 10mg MO tranexamic acid soln tranexamic acid tabs MO warfarin sodium tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 10mg
MO
XARELTO STARTER PACK TBPK MO
XARELTO TABS 25mg 10mg 15mg 20mg MO
ZONTIVITY TABS MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 25mcgml 40mcgml PANDS
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml
PANDS
FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MIRCERA SOSY 30mcg03ml 50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml
PA
MULPLETA TABS NDS
Drug Name RequirementsLimits
NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml NDS
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RETACRIT SOLN 20000unit2ml 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL TB24 4mg 8mg MO DEMSER CAPS NDS doxazosin mesylate tabs 1mg 2mg 4mg 8mg MO
metyrosine caps NDS prazosin hcl caps 1mg 2mg 5mg MO
terazosin hcl caps 1mg 2mg 5mg 10mg MO
ANTILIPEMIC AGENTS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
ALTOPREV TB24 20mg 40mg 60mg MO
ANTARA CAPS 30mg 90mg MO atorvastatin calcium tabs 10mg 20mg 40mg 80mg MO
cholestyramine light pack MO cholestyramine light powd MO cholestyramine pack MO cholestyramine powd MO colesevelam hcl pack MO colesevelam hcl tabs MO colestipol hcl gran MO colestipol hcl pack MO colestipol hcl tabs MO EVKEEZA SOLN 345mg23ml 1200mg8ml NDS
ezetimibe tabs MO ezetimibe-simvastatin tabs MO fenofibrate caps 50mg 134mg 150mg MO
fenofibrate micronized caps 43mg 67mg 130mg 200mg MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg MO
FENOFIBRIC ACID TABS 35mg 105mg MO
FIBRICOR TABS MO FLOLIPID SUSP 20mg5ml 40mg5ml MO
fluvastatin sodium caps 20mg 40mg MO
fluvastatin sodium er tb24 MO gemfibrozil tabs MO icosapent ethyl caps MO JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg PALDNDS
KYNAMRO SOSY PALDNDS LIVALO TABS 1mg 2mg 4mg MO lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
Drug Name RequirementsLimits
niacor tabs MO omega-3-acid ethyl esters caps MO pravastatin sodium tabs 10mg 20mg 40mg 80mg MO
prevalite pack MO prevalite powd MO questran light powd MO questran pack MO questran powd MO REPATHA PUSHTRONEX SYSTEM SOCT PANDS
REPATHA SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 05gm 1gm MO ZYPITAMAG TABS 1mg 2mg 4mg MO
BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl caps 200mg 400mg MO
atenolol tabs 25mg 50mg 100mg MO
atenolol-chlorthalidone tabs MO betaxolol hcl tabs 10mg 20mg MO bisoprolol fumarate tabs 5mg 10mg MO
bisoprolol-hydrochlorothiazide tabs MO
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg MO
carvedilol tabs 3125mg 625mg 125mg 25mg MO
DUTOPROL TB24 MO ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln INNOPRAN XL CP24 80mg 120mg MO
labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 24 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
metoprolol succinate er tb24 25mg 50mg 100mg 200mg MO
metoprolol tartrate soct metoprolol tartrate soln metoprolol tartrate tabs 25mg 50mg 100mg MO
metoprolol tartrate tabs 375mg 75mg MO
metoprolol-hydrochlorothiazide tabs MO
nadolol tabs 20mg 40mg 80mg MO nadolol-bendroflumethiazide tabs MO
pindolol tabs 5mg 10mg MO propranolol hcl er cp24 60mg 80mg 120mg 160mg MO
propranolol hcl soln 20mg5ml 40mg5ml MO
propranolol hcl tabs 10mg 20mg 40mg 60mg 80mg MO
propranolol-hctz tabs MO sorine tabs 80mg 120mg 160mg 240mg MO
sotalol hcl (af) tabs 80mg 120mg 160mg MO
sotalol hcl tabs 80mg 120mg 160mg 240mg MO
SOTYLIZE SOLN MO timolol maleate tabs 5mg 10mg 20mg MO
CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besy-benazepril hcl caps MO
amlodipine besylate tabs 25mg 5mg 10mg MO
amlodipine besylate-valsartan tabs MO
amlodipine-atorvastatin tabs MO amlodipine-olmesartan tabs MO amlodipine-valsartan-hctz tabs MO CARDENE IV SOLN CARDIZEM LA TB24 MO cartia xt cp24 120mg 180mg 240mg 300mg MO
Drug Name RequirementsLimits
CONSENSI TABS NDS dilt-xr cp24 120mg 180mg 240mg MO
diltiazem hcl er beads cp24 120mg 180mg 240mg 300mg 360mg 420mg
MO
DILTIAZEM HCL ER COATED BEADS CP24 120mg 180mg 240mg 300mg 360mg
MO
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg
MO
diltiazem hcl er cp12 60mg 90mg 120mg MO
diltiazem hcl er cp24 120mg 180mg 240mg MO
diltiazem hcl soln diltiazem hcl solr diltiazem hcl tabs 30mg 60mg 90mg 120mg MO
felodipine er tb24 25mg 5mg 10mg MO
isradipine caps 25mg 5mg MO matzim la tb24 180mg 240mg 300mg 360mg 420mg MO
nicardipine hcl caps 20mg 30mg MO nicardipine hcl soln nifedipine caps 10mg 20mg MO nifedipine er osmotic release tb24 30mg 60mg 90mg MO
nifedipine er tb24 30mg 60mg 90mg MO
nimodipine caps MO nisoldipine er tb24 85mg 17mg 20mg 255mg 30mg 34mg 40mg
MO
NYMALIZE SOLN 60mg20ml 6mgml NDS
olmesartan-amlodipine-hctz tabs MO taztia xt cp24 120mg 180mg 240mg 300mg 360mg MO
telmisartan-amlodipine tabs MO tiadylt er cp24 120mg 180mg 240mg 300mg 360mg 420mg MO
trandolapril-verapamil hcl er tbcr MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
VERAPAMIL HCL ER CP24 100mg 120mg 180mg 200mg 240mg 300mg 360mg
MO
verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 80mg 120mg MO verapamil hcl tabs MO VERELAN CP24 MO CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln inj DIGOXIN ORAL SOLN MO digoxin tabs 125mcg 250mcg MO disopyramide phosphate caps 100mg 150mg MO
dofetilide caps 125mcg 250mcg 500mcg MO
flecainide acetate tabs 50mg 100mg 150mg MO
ibutilide fumarate soln LANOXIN PEDIATRIC SOLN LANOXIN TABS 625mcg MO lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy LIDOCAINE IN D5W SOLN mexiletine hcl caps 150mg 200mg 250mg MO
milrinone lactate in dextrose soln milrinone lactate soln MULTAQ TABS NORPACE CR CP12 100mg 150mg MO
pacerone tabs 100mg 200mg 400mg MO
procainamide hcl soln
Drug Name RequirementsLimits
propafenone hcl er cp12 225mg 325mg 425mg MO
propafenone hcl tabs 150mg 225mg 300mg MO
quinidine gluconate er tbcr MO QUINIDINE GLUCONATE SOLN quinidine sulfate tabs 200mg 300mg MO
ranolazine er tb12 500mg 1000mg MO
VYNDAMAX CAPS NDS VYNDAQEL CAPS NDS HYPOTENSIVE AGENTS clonidine hcl (analgesia) soln clonidine hcl er tb12 MO clonidine hcl tabs 01mg 02mg 03mg MO
clonidine ptwk 01mg24hr 02mg24hr 03mg24hr MO
guanfacine hcl tabs 1mg 2mg MO hydralazine hcl soln hydralazine hcl tabs 10mg 25mg 50mg 100mg MO
methyldopa tabs 250mg 500mg MO methyldopa-hydrochlorothiazide tabs MO
minoxidil tabs 25mg 10mg MO nitropress soln nitroprusside sodium soln vecamyl tabs NDS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE TABS MO aliskiren fumarate tabs 150mg 300mg MO
benazepril hcl tabs 5mg 10mg 20mg 40mg MO
benazepril-hydrochlorothiazide tabs MO
candesartan cilexetil tabs 4mg 8mg 16mg 32mg MO
candesartan cilexetil-hctz tabs MO captopril tabs 125mg 25mg 50mg 100mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 26 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
captopril-hydrochlorothiazide tabs MO
CAROSPIR SUSP MO EDARBYCLOR TABS MO enalapril maleate tabs 25mg 5mg 10mg 20mg MO
enalapril-hydrochlorothiazide tabs MO
enalaprilat inj ENTRESTO TABS MO eplerenone tabs 25mg 50mg MO eprosartan mesylate tabs MO fosinopril sodium tabs 10mg 20mg 40mg MO
fosinopril sodium-hctz tabs MO irbesartan tabs 75mg 150mg 300mg MO
irbesartan-hydrochlorothiazide tabs MO
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg MO
lisinopril-hydrochlorothiazide tabs MO
losartan potassium tabs 25mg 50mg 100mg MO
losartan potassium-hctz tabs MO moexipril hcl tabs 75mg 15mg MO olmesartan medoxomil tabs 5mg 20mg 40mg MO
olmesartan medoxomil-hctz tabs MO perindopril erbumine tabs 2mg 4mg 8mg MO
QBRELIS SOLN MO quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO TEKTURNA HCT TABS MO
Drug Name RequirementsLimits
telmisartan tabs 20mg 40mg 80mg MO
telmisartan-hctz tabs MO trandolapril tabs 1mg 2mg 4mg MO valsartan tabs 40mg 80mg 160mg 320mg MO
valsartan-hydrochlorothiazide tabs MO
VASODILATING AGENTS alyq tabs PA BIDIL TABS MO dipyridamole tabs 25mg 50mg 75mg MO
GONITRO PACK MO isosorbide dinitrate er tbcr MO isosorbide dinitrate tabs 5mg 10mg 20mg 30mg MO
isosorbide mononitrate er tb24 30mg 60mg MO
isosorbide mononitrate er tb24 MO isosorbide mononitrate tabs 10mg 20mg MO
minitran pt24 01mghr 02mghr 04mghr 06mghr MO
nitro-bid oint MO NITRO-DUR PT24 03mghr 08mghr MO
nitroglycerin pt24 01mghr 02mghr 04mghr 06mghr MO
nitroglycerin soln MO nitroglycerin subl 03mg 04mg 06mg MO
sildenafil citrate soln PANDS sildenafil citrate susr PA sildenafil citrate tabs PAMO tadalafil (pah) tabs 20mg PA tadalafil tabs 25mg 5mg PA CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS acamprosate calcium tbec MO antabuse tabs 250mg 500mg MO disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
ABSTRAL SUBL 100mcg 200mcg 300mcg 400mcg 600mcg 800mcg
PANDS
acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ARYMO ER TBEA NDS ascomp-codeine caps NDS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
benzhydrocodone-acetaminophen tabs
bupap tabs buprenorphine hcl soln NDS buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
butalbital-acetaminophen caps NDS butalbital-acetaminophen tabs butalbital-apap-caff-cod caps NDS butalbital-apap-caffeine caps butalbital-apap-caffeine tabs butalbital-asa-caff-codeine caps NDS butalbital-aspirin-caffeine caps butalbital-aspirin-caffeine tabs butorphanol tartrate soln 1mgml 2mgml 10mgml NDS
BUTRANS PTWK NDS cataflam tabs NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
DEMEROL SOLN 25mg05ml 75mg15ml 100mg2ml 75mgml
PANDS
diclofenac potassium tabs diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs
Drug Name RequirementsLimits
DUEXIS TABS NDS DURAMORPH SOLN 05mgml 1mgml HINDS
dvorah tabs NDS EMBEDA CPCR NDS endocet tabs NDS esgic caps esgic tabs etodolac caps etodolac er tb24 etodolac tabs fenoprofen calcium caps fenoprofen calcium tabs fenortho caps fentanyl citrate (pf) soct NDS FENTANYL CITRATE (PF) SOLN 50mcgml 1000mcg20ml 2500mcg50ml
NDS
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fioricet caps fioricetcodeine caps NDS flurbiprofen tabs hydrocodone bitartrate er cp12 10mg 15mg 20mg 30mg 40mg 50mg
NDS
hydrocodone-acetaminophen soln NDS
hydrocodone-acetaminophen tabs NDS
hydrocodone-ibuprofen tabs NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 28 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd NDS hydromorphone hcl pf soln 50mg5ml 10mgml NDS
HYDROMORPHONE HCL SOLN 1mgml 2mgml NDS
hydromorphone hcl tabs 2mg 4mg 8mg NDS
ibu tabs ibudone tabs NDS ibuprofen lysine soln ibuprofen susp ibuprofen tabs ILARIS SOLN NDS indocin supp INDOCIN SUSP indomethacin caps INDOMETHACIN CAPS 20mg indomethacin er cpcr indomethacin sodium solr KADIAN CP24 NDS ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 300mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lodine tabs lorcet hd tabs NDS lorcet plus tabs NDS lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam caps meloxicam tabs meperidine hcl soln 50mg5ml 25mgml 50mgml 100mgml PANDS
meperidine hcl tabs 50mg 100mg NDS
Drug Name RequirementsLimits
methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl soln 5mg5ml 10mg5ml 10mgml NDS
methadone hcl tabs 5mg 10mg NDS mitigo soln MORPHINE SULFATE (CONCENTRATE) SOLN NDS
morphine sulfate (pf) soln 4mgml 10mgml NDS
MORPHINE SULFATE (PF) SOLN INTRAVENOUS HI
morphine sulfate er beads cp24 30mg 45mg 60mg 75mg 90mg 120mg
NDS
morphine sulfate er cp24 10mg 20mg 30mg 40mg 50mg 60mg 80mg 100mg
NDS
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg NDS
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml NDS
MORPHINE SULFATE SOLN HINDS MORPHINE SULFATE SOLN INJECTION 2mgml 4mgml 10mgml
HI
MORPHINE SULFATE SOLN INTRAVENOUS HI
morphine sulfate tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln nalfon tabs nalocet tabs NDS NAPRELAN TB24 naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
NUCYNTA ER TB12 50mg 100mg 150mg NDS
NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS 50mg 75mg NDS NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs oxaprozin tabs OXAYDO TABS NDS oxycodone hcl caps NDS oxycodone hcl conc NDS oxycodone hcl er t12a 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxycodone hcl soln NDS oxycodone hcl tabs 5mg 10mg 15mg 20mg 30mg NDS
oxycodone-acetaminophen soln NDS oxycodone-acetaminophen tabs NDS oxycodone-acetaminophen tabs 5-300mg 10-300mg NDS
oxycodone-aspirin tabs NDS oxycodone-ibuprofen tabs NDS OXYCONTIN T12A 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxymorphone hcl er tb12 5mg 75mg 10mg 15mg 20mg 30mg 40mg
NDS
oxymorphone hcl tabs 5mg 10mg NDS
panlor tabs NDS pentazocine-naloxone hcl tabs NDS percocet tabs NDS phrenilin forte caps PIROXICAM CAPS 10mg 20mg NDS pregabalin er tb24 825mg 165mg 330mg MO
primlev tabs NDS prolate soln NDS prolate tabs NDS QDOLO SOLN NDS
Drug Name RequirementsLimits
relafen ds tabs NDS ROXYBOND TABA 5mg 15mg 30mg NDS
SALSALATE TABS SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
SUBSYS LIQD 100mcg 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
sulindac tabs tencon tabs TIVORBEX CAPS tolmetin sodium caps tolmetin sodium tabs tramadol hcl er (biphasic) tb24 100mg 200mg 300mg NDS
tramadol hcl er cp24 100mg 150mg 200mg 300mg NDS
tramadol hcl er tb24 100mg 200mg 300mg NDS
tramadol hcl tabs 50mg 100mg NDS tramadol-acetaminophen tabs NDS trezix caps NDS tylenol with codeine 3 tabs NDS tylenol with codeine 4 tabs NDS vanatol lq soln vicodin es tabs NDS vicodin hp tabs NDS vicodin tabs NDS XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg NDS
zebutal caps ZIPSOR CAPS ZORVOLEX CAPS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS ADDERALL XR CP24 NDS ADZENYS ER SUER NDS ADZENYS XR-ODT TBED 31mg 63mg 94mg 125mg 157mg 188mg
NDS
amphetamine er suer NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 30 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
amphetamine sulfate tabs 5mg 10mg NDS
amphetamine-dextroamphet er cp24 NDS
amphetamine-dextroamphetamine tabs NDS
armodafinil tabs 50mg 150mg 200mg 250mg PA
caffeine citrate soln COTEMPLA XR-ODT TBED 86mg 173mg 259mg NDS
DAYTRANA PTCH 10mg9hr 15mg9hr 20mg9hr 30mg9hr NDS
dexmethylphenidate hcl er cp24 5mg 10mg 15mg 20mg 25mg 30mg 35mg 40mg
NDS
dexmethylphenidate hcl tabs 25mg 5mg 10mg NDS
dextroamphetamine sulfate er cp24 5mg 10mg 15mg NDS
dextroamphetamine sulfate soln NDS dextroamphetamine sulfate tabs 5mg 10mg 15mg 20mg 30mg NDS
DYANAVEL XR SUER NDS evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS methylphenidate hcl chew 25mg 5mg 10mg NDS
methylphenidate hcl er (cd) cpcr 10mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er (la) cp24 10mg 20mg 30mg 40mg 60mg
NDS
methylphenidate hcl er (xr) cp24 10mg 15mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg NDS
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg
NDS
methylphenidate hcl soln 5mg5ml 10mg5ml NDS
Drug Name RequirementsLimits
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS MYDAYIS CP24 NDS procentra soln NDS QUILLICHEW ER CHER 20mg 30mg 40mg NDS
QUILLIVANT XR SRER NDS relexxii tbcr NDS SUNOSI TABS 75mg 150mg NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
NDS
VYVANSE CHEW 10mg 20mg 30mg 40mg 50mg 60mg NDS
WAKIX TABS 445mg 178mg NDS zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg
NDS
ANTICONVULSANTS APTIOM TABS 200mg 400mg 600mg 800mg MO
BANZEL SUSP BANZEL TABS 200mg 400mg NDS BRIVIACT SOLN NDS BRIVIACT TABS 10mg 25mg 50mg 75mg 100mg NDS
carbamazepine chew MO carbamazepine er cp12 100mg 200mg 300mg MO
carbamazepine er tb12 100mg 200mg 400mg MO
carbamazepine susp MO carbamazepine tabs MO CELONTIN CAPS MO clobazam susp MO clobazam tabs 10mg 20mg MO clonazepam tabs 05mg 1mg 2mg NDS
clonazepam tbdp 0125mg 025mg 05mg 1mg 2mg NDS
DIACOMIT CAPS 250mg 500mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
DIACOMIT PACK 250mg 500mg NDS
DIASTAT ACUDIAL GEL 10mg 20mg NDS
DIASTAT PEDIATRIC GEL NDS diazepam gel 25mg 10mg 20mg NDS
dilantin caps 30mg 100mg MO dilantin infatabs chew MO divalproex sodium csdr MO divalproex sodium er tb24 250mg 500mg MO
divalproex sodium tbec 125mg 250mg 500mg MO
ELEPSIA XR TB24 1000mg 1500mg NDS
EPIDIOLEX SOLN PANDS epitol tabs MO ethosuximide caps MO ethosuximide soln MO felbamate susp MO felbamate tabs 400mg 600mg MO FINTEPLA SOLN NDS fosphenytoin sodium soln FYCOMPA SUSP NDS FYCOMPA TABS gabapentin caps 100mg 400mg MO gabapentin soln MO gabapentin tabs 600mg 800mg MO HORIZANT TBCR 300mg 600mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
lamotrigine kit MO lamotrigine starter kit-blue kit MO lamotrigine starter kit-green kit MO lamotrigine starter kit-orange kit MO lamotrigine tabs 25mg 100mg 150mg 200mg MO
lamotrigine tbdp 25mg 50mg 100mg 200mg MO
Drug Name RequirementsLimits
levetiracetam er tb24 500mg 750mg MO
levetiracetam in nacl soln levetiracetam soln MO levetiracetam tabs 250mg 500mg 750mg 1000mg MO
magnesium sulfate soln magnesium sulfate soln injection 50 HI
MAGNESIUM SULFATE SOLN INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml
HI
NAYZILAM SOLN NDS oxcarbazepine susp MO oxcarbazepine tabs 150mg 300mg 600mg MO
OXTELLAR XR TB24 150mg 300mg 600mg MO
PEGANONE TABS MO phenytek caps 200mg 300mg MO phenytoin chew MO phenytoin sodium extended caps 100mg 200mg 300mg MO
phenytoin sodium soln phenytoin susp MO pregabalin caps 25mg 50mg 75mg 100mg 150mg 200mg 225mg 300mg
MO
pregabalin soln MO primidone tabs 50mg 250mg MO roweepra tabs 500mg 750mg 1000mg MO
roweepra xr tb24 500mg 750mg MO rufinamide susp rufinamide tabs 200mg 400mg NDS SPRITAM TB3D 250mg 500mg 750mg 1000mg NDS
subvenite starter kit-blue kit MO subvenite starter kit-green kit MO subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 32 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
SYMPAZAN FILM 10mg 20mg tiagabine hcl tabs 2mg 4mg 12mg 16mg MO
topiramate cpsp 15mg 25mg MO topiramate er cs24 25mg 50mg 100mg 150mg 200mg MO
topiramate tabs 25mg 50mg 100mg 200mg MO
TROKENDI XR CP24 25mg 50mg 100mg 200mg MO
valproate sodium soln valproic acid caps MO valproic acid soln MO VALTOCO 10 MG DOSE LIQD NDS VALTOCO 15 MG DOSE LQPK NDS VALTOCO 20 MG DOSE LQPK NDS VALTOCO 5 MG DOSE LIQD NDS vigabatrin pack LDNDS vigabatrin tabs NDS vigadrone pack LDNDS VIMPAT SOLN VIMPAT TABS MO XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200 MG NDS XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ AJOVY SOSY almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs EMGALITY (300 MG DOSE) SOSY NDS
Drug Name RequirementsLimits
EMGALITY SOAJ EMGALITY SOSY ergotamine-caffeine tabs frovatriptan succinate tabs naratriptan hcl tabs NURTEC TBDP NDS ONZETRA XSAIL EXHP rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs TOSYMRA SOLN UBRELVY TABS 50mg 100mg NDS ZEMBRACE SYMTOUCH SOAJ zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ZOMIG SOLN ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl syrp MO amantadine hcl tabs MO APOKYN SOCT NDS benztropine mesylate soln benztropine mesylate tabs 05mg 1mg 2mg MO
bromocriptine mesylate caps MO bromocriptine mesylate tabs MO cabergoline tabs MO carbidopa tabs MO carbidopa-levodopa er tbcr MO carbidopa-levodopa tabs MO carbidopa-levodopa tbdp MO carbidopa-levodopa-entacapone tabs MO
DUOPA SUSP LD EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg NDS
pramipexole dihydrochloride er tb24 0375mg 075mg 15mg 225mg 3mg 375mg 45mg
MO
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg
MO
rasagiline mesylate tabs 05mg 1mg MO
ropinirole hcl er tb24 2mg 4mg 6mg 8mg 12mg MO
ropinirole hcl tabs 025mg 05mg 1mg 2mg 3mg 4mg 5mg
MO
RYTARY CPCR MO selegiline hcl caps MO selegiline hcl tabs MO tolcapone tabs MO trihexyphenidyl hcl soln MO trihexyphenidyl hcl tabs 2mg 5mg MO
ZELAPAR TBDP MO ANXIOLYTICS SEDATIVES AND HYPNOTICS alprazolam er tb24 05mg 1mg 2mg 3mg NDS
alprazolam intensol conc NDS alprazolam tabs 025mg 05mg 1mg 2mg NDS
alprazolam tbdp 025mg 05mg 1mg 2mg NDS
BELSOMRA TABS buspirone hcl tabs 5mg 10mg buspirone hcl tabs 75mg 15mg 30mg
chlordiazepoxide hcl caps 5mg 10mg 25mg NDS
clorazepate dipotassium tabs 375mg 75mg 15mg NDS
diazepam conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS
Drug Name RequirementsLimits
droperidol soln EDLUAR SUBL 5mg 10mg NDS estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP NDS hydroxyzine hcl soln hydroxyzine hcl syrp hydroxyzine hcl tabs hydroxyzine pamoate caps lorazepam intensol conc NDS LORAZEPAM SOLN 4mgml 2mgml NDS
lorazepam tabs 05mg 1mg 2mg NDS
meprobamate tabs midazolam hcl (pf) soln midazolam hcl soln midazolam hcl syrp nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs ROZEREM TABS seconal caps TEMAZEPAM CAPS 15mg 225mg 30mg 75mg NDS
triazolam tabs 0125mg 025mg NDS zaleplon caps 5mg 10mg NDS zolpidem tartrate er tbcr 625mg 125mg NDS
zolpidem tartrate subl 175mg 35mg NDS
zolpidem tartrate tabs 5mg 10mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 34 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS atomoxetine hcl caps 10mg 18mg 25mg 40mg 60mg 80mg 100mg
MO
AUSTEDO TABS 6mg 9mg 12mg LDNDS
EXSERVAN FILM NDS flumazenil soln guanfacine hcl er tb24 1mg 2mg 3mg 4mg MO
INGREZZA CAPS 40mg 60mg 80mg NDS
INGREZZA CPPK NDS memantine hcl er cp24 memantine hcl soln MO memantine hcl tabs 5mg 10mg MO NAMENDA XR TITRATION PACK CP24 MO
NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS SAVELLA TABS 125mg 25mg 50mg 100mg MO
SAVELLA TITRATION PACK MISC MO
tetrabenazine tabs 125mg 25mg NDS
TIGLUTIK SUSP NDS XYREM SOLN LDNDS XYWAV SOLN NDS MULTIPLE SCLEROSIS AGENTS AUBAGIO TABS 7mg 14mg PANDS AVONEX KIT NDS AVONEX PEN AJKT NDS AVONEX PREFILLED PSKT NDS BAFIERTAM CPDR NDS BETASERON KIT NDS dalfampridine er tb12 MO dimethyl fumarate cpdr dimethyl fumarate starter pack misc
Drug Name RequirementsLimits
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatiramer acetate sosy 20mgml 40mgml NDS
glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 2mg NDS OCREVUS SOLN PLEGRIDY SOSY NDS PONVORY STARTER PACK TBPK NDS
PONVORY TABS NDS REBIF REBIDOSE SOAJ 22mcg05ml 44mcg05ml NDS
REBIF REBIDOSE TITRATION PACK SOAJ NDS
REBIF SOSY 22mcg05ml 44mcg05ml NDS
REBIF TITRATION PACK SOSY NDS TECFIDERA CPDR 120mg 240mg NDS
TECFIDERA MISC NDS TYSABRI CONC INTRAVENOUS HI
ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS ZINBRYTA SOSY LDNDS OPIATE ANTAGONISTS BUNAVAIL FILM NDS buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
LUCEMYRA TABS NDS naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR NDS ZUBSOLV SUBL NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg NDS
ABILIFY MYCITE MAINTENANCE KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg NDS
amitriptyline hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
amoxapine tabs 25mg 50mg 100mg 150mg MO
APLENZIN TB24 174mg 348mg 522mg MO
aripiprazole soln MO aripiprazole tabs 2mg 5mg 10mg 15mg 20mg 30mg MO
aripiprazole tbdp 10mg 15mg MO ARISTADA INITIO PRSY NDS ARISTADA PRSY 441mg16ml 662mg24ml 882mg32ml 1064mg39ml
NDS
asenapine maleate subl 25mg 5mg 10mg MO
bupropion hcl er (smoking det) tb12 MO
bupropion hcl er (sr) tb12 100mg 150mg 200mg MO
bupropion hcl er (xl) tb24 150mg 300mg 450mg MO
bupropion hcl tabs 75mg 100mg MO CAPLYTA CAPS NDS chlordiazepoxide-amitriptyline tabs
chlorpromazine hcl soln
Drug Name RequirementsLimits
chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
clomipramine hcl caps 25mg 50mg 75mg MO
clozapine tabs 25mg 50mg 100mg 200mg NDS
clozapine tbdp 125mg 25mg 100mg 150mg 200mg NDS
compro supp MO desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
DESVENLAFAXINE ER TB24 50mg 100mg MO
desvenlafaxine succinate er tb24 25mg 50mg 100mg MO
doxepin hcl caps 10mg 25mg 50mg 75mg 100mg 150mg MO
doxepin hcl conc MO doxepin hcl tabs 3mg 6mg MO DRIZALMA SPRINKLE CSDR duloxetine hcl cpep 20mg 30mg 40mg 60mg MO
EQUETRO CP12 100mg 200mg 300mg MO
escitalopram oxalate soln MO escitalopram oxalate tabs 5mg 10mg 20mg MO
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg NDS
FANAPT TITRATION PACK TABS MO
FETZIMA CP24 20mg 40mg 80mg 120mg MO
FETZIMA TITRATION C4PK MO fluoxetine hcl (pmdd) tabs 10mg 20mg MO
fluoxetine hcl caps 10mg 20mg 40mg MO
fluoxetine hcl cpdr MO fluoxetine hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 36 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
GEODON SOLR haloperidol decanoate soln haloperidol lactate conc MO haloperidol lactate soln haloperidol tabs 05mg 1mg 2mg 5mg 10mg 20mg MO
imipramine hcl tabs 10mg 25mg 50mg MO
imipramine pamoate caps 75mg 100mg 125mg 150mg MO
INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 300mg 150mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
lithium carbonate tabs MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO
Drug Name RequirementsLimits
mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
nefazodone hcl tabs 50mg 100mg 150mg 200mg 250mg MO
nortriptyline hcl caps 10mg 25mg 50mg 75mg MO
nortriptyline hcl soln MO NUPLAZID CAPS NDS NUPLAZID TABS 10mg 17mg NDS olanzapine solr olanzapine tabs 25mg 5mg 75mg 10mg 15mg 20mg MO
olanzapine tbdp 5mg 10mg 15mg 20mg MO
olanzapine-fluoxetine hcl caps MO PALIPERIDONE ER TB24 15mg 3mg 6mg 9mg MO
paroxetine hcl er tb24 125mg 25mg 375mg MO
paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps MO PAXIL SUSP MO perphenazine tabs 2mg 4mg 8mg 16mg MO
perphenazine-amitriptyline tabs MO PERSERIS PRSY 90mg 120mg NDS PEXEVA TABS 10mg 20mg 30mg 40mg MO
phenelzine sulfate tabs MO pimozide tabs 1mg 2mg MO prochlorperazine edisylate soln prochlorperazine maleate tabs prochlorperazine supp MO protriptyline hcl tabs 5mg 10mg MO quetiapine fumarate er tb24 50mg 150mg 200mg 300mg 400mg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
quetiapine fumarate tabs 25mg 50mg 100mg 200mg 300mg 400mg
MO
REXULTI TABS 025mg 05mg 1mg 2mg 3mg 4mg NDS
RISPERDAL CONSTA SRER 125mg 25mg NDS
RISPERDAL CONSTA SRER 375mg 50mg NDS
risperidone soln MO risperidone tabs 025mg 05mg 1mg 2mg 3mg 4mg MO
risperidone tbdp 025mg 05mg 1mg 2mg 3mg 4mg MO
SAPHRIS SUBL 25mg 5mg 10mg NDS
SECUADO PT24 38mg24hr 57mg24hr 76mg24hr NDS
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
SILENOR TABS SPRAVATO (56 MG DOSE) SOPK NDS
SPRAVATO (84 MG DOSE) SOPK NDS
thioridazine hcl tabs 10mg 25mg 50mg 100mg MO
thiothixene caps 1mg 2mg 5mg 10mg MO
tofranil tabs 10mg 25mg 50mg MO tranylcypromine sulfate tabs MO trazodone hcl tabs 50mg 100mg 150mg MO
trazodone hcl tabs MO trifluoperazine hcl tabs 1mg 2mg 5mg 10mg MO
trimipramine maleate caps 25mg 50mg 100mg MO
TRINTELLIX TABS 5mg 10mg 20mg MO
venlafaxine hcl er cp24 375mg 75mg 150mg MO
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg MO
Drug Name RequirementsLimits
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
VRAYLAR CAPS 15mg 3mg 45mg 6mg NDS
VRAYLAR CPPK NDS ziprasidone hcl caps 20mg 40mg 60mg 80mg MO
ziprasidone mesylate solr ZYPREXA RELPREVV SUSR DIABETIC SUPPLIES DIABETIC SUPPLIES ALCOHOL PREP PADS MO BD INSULIN SYR ULTRAFINE II MISC MO
BD INSULIN SYRINGE MISC MO BD INSULIN SYRINGE UF MISC MO
BD PEN NEEDLE ORIGINAL UF MISC MO
CURITY GAUZE PADS MO OMNIPOD STARTER KIT NDS ELECTROLYTIC CALORIC AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS POT amp SOD CIT-CIT AC SOLN potassium citrate er tbcr 15meq 540mg 1080mg MO
SODIUM ACETATE SOLN SODIUM BICARBONATE SOLN SODIUM LACTATE SOLN INTRAVENOUS HI
TRICITRATES SOLN AMMONIA DETOXICANTS CARBAGLU TABS LD constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 38 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lactulose pack MO lactulose soln MO LITHOSTAT TABS MO RAVICTI LIQD NDS sod benz-sod phenylacet soln sodium phenylbutyrate powd NDS sodium phenylbutyrate tabs NDS CALORIC AGENTS AMINOSYN-PF SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (27510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42525) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (525) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (525) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN dextrose soln intravenous 5 10 HI
Drug Name RequirementsLimits
FREAMINE HBC SOLN INTRAVENOUS HI
HEPATAMINE SOLN INTRAVENOUS HI
INTRALIPID EMUL INTRAVENOUS 20gm100ml HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NEPHRAMINE SOLN INTRAVENOUS HI
NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE SOLN INTRAVENOUS HI
PROSOL SOLN INTRAVENOUS HI TRAVASOL SOLN INTRAVENOUS HI
TROPHAMINE SOLN INTRAVENOUS HI
DIURETICS AMILORIDE HCL TABS MO amiloride-hydrochlorothiazide tabs MO
bumetanide soln bumetanide tabs 05mg 1mg 2mg MO
chlorothiazide sodium solr chlorothiazide tabs 250mg 500mg MO
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI FUROSEMIDE TABS 40mg 80mg 20mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN SAMSCA TABS 15mg NDS TOLVAPTAN TABS 30mg 15mg NDS torsemide tabs 5mg 10mg 20mg 100mg MO
triamterene caps 50mg 100mg MO triamterene-hctz caps MO triamterene-hctz tabs MO ION-REMOVING AGENTS AURYXIA TABS PAMONDS FOSRENOL PACK 750mg 1000mg NDS
kionex susp MO lanthanum carbonate chew 500mg 750mg 1000mg MO
LOKELMA PACK 5gm 10gm MO sevelamer carbonate pack 08gm 24gm MO
sevelamer carbonate tabs MO sevelamer hcl tabs 400mg 800mg MO
sodium polystyrene sulfonate powd MO
sodium polystyrene sulfonate susp MO
sps susp MO VELPHORO CHEW NDS VELTASSA PACK 84gm 168gm 252gm NDS
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate (phos binder) tabs MO
CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
Drug Name RequirementsLimits
DEXTROSE-NACL SOLN INTRAVENOUS HI
DEXTROSE 10NACL 02 DEXTROSE 10NACL 045 HI
DEXTROSE 5NACL 0225 HI IONOSOL-MB IN D5W SOLN INTRAVENOUS HI
ISOLYTE-P IN D5W SOLN INTRAVENOUS HI
ISOLYTE-S SOLN INTRAVENOUS HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-033 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 TBCR MO klor-con m10 tbcr MO klor-con m15 tbcr MO klor-con m20 tbcr MO klor-con pack MO klor-con sprinkle cpcr 8meq 10meq MO
KLOR-CON TBCR MO LACTATED RINGERS SOLN magnesium sulfate in d5w soln NORMOSOL-M IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R SOLN INTRAVENOUS HI
PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 40 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
POTASSIUM CHLORIDE ER TBCR 8meq 10meq 20meq MO
POTASSIUM CHLORIDE IN DEXTROSE SOLN INTRAVENOUS
HI
potassium chloride in nacl soln intravenous HI
potassium chloride pack MO potassium chloride soln 10 20 MO
POTASSIUM CHLORIDE SOLN INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN SODIUM CHLORIDE SOLN INJECTION HI
SODIUM CHLORIDE SOLN INTRAVENOUS 045 09 3 5
HI
SODIUM PHOSPHATES SOLN TPN ELECTROLYTES CONC INTRAVENOUS HI
URICOSURIC AGENTS colchicine-probenecid tabs MO probenecid tabs MO ENZYMES ENZYMES ADAGEN SOLN ALDURAZYME SOLN CERDELGA CAPS NDS CEREZYME SOLR NDS CREON CPEP MO ELAPRASE SOLN NDS
Drug Name RequirementsLimits
ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME SOLR NDS miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PANCREAZE CPEP MO PERTZYE CPEP MO PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VIOKACE TABS MO VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE SOLN bacitracin oint bacitracin-polymyxin b oint BESIVANCE SUSP bleph-10 soln CETRAXAL SOLN chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
CIPROFLOXACIN-FLUOCINOLONE PF SOLN
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
MOXEZA SOLN moxifloxacin hcl (2x day) soln moxifloxacin hcl soln NATACYN SUSP neo-polycin oint neomycin-bacitracin zn-polymyx oint
neomycin-polymyxin-gramicidin soln
ofloxacin soln OTOVEL SOLN paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ZIRGAN GEL ANTI-INFLAMMATORY AGENTS ACUVAIL SOLN MO ALREX SUSP MO bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
BROMSITE SOLN MO CEQUA SOLN CIPRO HC SUSP MO CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO DUREZOL EMUL MO flac oil MO
Drug Name RequirementsLimits
FLAREX SUSP MO flunisolide soln MO fluocinolone acetonide oil MO fluorometholone susp MO flurbiprofen sodium soln MO fluticasone propionate susp MO FML FORTE SUSP MO FML OINT MO HYDROCORTISONE-ACETIC ACID SOLN MO
ILEVRO SUSP MO ILUVIEN IMPL INVELTYS SUSP MO ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX OINT MO LOTEMAX SUSP MO loteprednol etabonate susp MO MAXIDEX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint MO
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO NEVANAC SUSP MO OMNARIS SUSP MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
PROLENSA SOLN MO RESTASIS EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 42 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tobramycin-dexamethasone susp MO
XHANCE EXHU MO XIIDRA SOLN YUTIQ IMPL ZETONNA AERS MO ZYLET SUSP MO ANTIALLERGIC AGENTS ALOCRIL SOLN MO ALOMIDE SOLN MO azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO LASTACAFT SOLN MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
ALPHAGAN P SOLN MO betaxolol hcl soln MO BETIMOL SOLN 025 05 MO BETOPTIC-S SUSP MO bimatoprost soln MO BRIMONIDINE TARTRATE SOLN 02 015 MO
brinzolamide susp MO carteolol hcl soln MO COMBIGAN SOLN MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO
Drug Name RequirementsLimits
methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO SIMBRINZA SUSP MO timolol maleate pf soln MO timolol maleate solg 025 05 MO
timolol maleate soln 025 05 MO
TIMOPTIC OCUDOSE SOLN 25 MO
TIMOPTIC-XE SOLG 025 05 MO
TRAVATAN Z SOLN MO travoprost (bak free) soln MO VYZULTA SOLN MO XELPROS EMUL MO ZIOPTAN SOLN MO EENT DRUGS MISCELLANEOUS ACETIC ACID SOLN MO ALTAFRIN SOLN apraclonidine hcl soln MO ATROPINE SULFATE SOLN MO BEOVU SOLN NDS CYSTADROPS SOLN NDS CYSTARAN SOLN EYLEA SOLN EYLEA SOSY IOPIDINE SOLN MO LACRISERT INST MO LUCENTIS SOLN 03mg005ml 05mg005ml NDS
LUCENTIS SOSY 03mg005ml 05mg005ml NDS
OXERVATE SOLN NDS PHENYLEPHRINE HCL SOLN RHOPRESSA SOLN TEPEZZA SOLR NDS LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl soln lidocaine viscous hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
APRISO CP24 MO balsalazide disodium caps MO colazal caps MO DELZICOL CPDR MO DIPENTUM CAPS NDS LIALDA TBEC MO mesalamine cpdr MO mesalamine enem MO mesalamine er cp24 MO mesalamine supp MO mesalamine tbec 12gm 800mg MO mesalamine-cleanser kit PENTASA CPCR 250mg 500mg MO
ANTIDIARRHEA AGENTS diphenoxylate-atropine liqd diphenoxylate-atropine tabs loperamide hcl caps MO MYTESI TBEC MO OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS AKYNZEO CAPS PA ANZEMET TABS 50mg 100mg PANDS aprepitant caps PANDS BONJESTA TBCR MO CESAMET CAPS PA dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
EMEND SUSR PANDS fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs
Drug Name RequirementsLimits
ondansetron hcl soln PA ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS TRANSDERM SCOP (15 MG) PT72
trimethobenzamide hcl caps PA VARUBI (180 MG DOSE) TBPK PANDS ZUPLENZ FILM 4mg 8mg PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc MO
CARAFATE SUSP MO cimetidine hcl soln MO cimetidine tabs 200mg 300mg 400mg 800mg MO
esomeprazole magnesium cpdr 20mg 40mg MO
esomeprazole magnesium pack 10mg 20mg 40mg MO
esomeprazole sodium solr ESOMEPRAZOLE STRONTIUM CPDR
famotidine premixed soln famotidine soln famotidine susr MO famotidine tabs 20mg 40mg MO lansoprazole cpdr 15mg 30mg MO lansoprazole tbdd 15mg 30mg MO misoprostol tabs 100mcg 200mcg MO
nizatidine caps 150mg 300mg MO nizatidine soln MO OMECLAMOX-PAK MISC MO omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 44 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PRILOSEC PACK 25mg 10mg MO PROTONIX PACK MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate tabs MO CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO GOLYTELY SOLR OSMOPREP TABS MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT PLENVU SOLR MO SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS AMITIZA CAPS 8mcg 24mcg MO BYLVAY (PELLETS) CPSP 200mcg 600mcg NDS
BYLVAY CAPS 400mcg 1200mcg NDS
CHOLBAM CAPS 50mg 250mg NDS ENTYVIO SOLR NDS GATTEX KIT PANDS GIMOTI SOLN NDS LINZESS CAPS 72mcg 145mcg 290mcg MO
lubiprostone caps 8mcg 24mcg MO
Drug Name RequirementsLimits
metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
MOVANTIK TABS 125mg 25mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS SYMPROIC TABS MO TRULANCE TABS MO ursodiol caps 300mg MO URSODIOL CAPS 200mg 400mg NDS
ursodiol tabs 250mg 500mg MO VIBERZI TABS 75mg 100mg NDS HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPS clovique caps NDS CUPRIMINE CAPS NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs 90mg 180mg 360mg NDS
deferasirox tbso 125mg NDS deferasirox tbso 250mg 500mg NDS deferiprone tabs NDS deferoxamine mesylate solr DEPEN TITRATABS TABS EXJADE TBSO 125mg 250mg 500mg NDS
FERRIPROX SOLN LDNDS FERRIPROX TABS 500mg 1000mg LDNDS
FERRIPROX TWICE-A-DAY TABS NDS
JADENU SPRINKLE PACK 90mg 180mg 360mg NDS
JADENU TABS 90mg 360mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
penicillamine caps penicillamine tabs trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP 05mg 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs MO decadron elix MO decadron tabs 5mg 75mg MO decadron tabs 4mg 6mg PAMO deltasone tabs PAMO DEPO-MEDROL SUSP dexabliss tbpk dexamethasone elix MO dexamethasone intensol conc MO dexamethasone sod phosphate pf soln
dexamethasone sodium phosphate soln
dexamethasone soln dexamethasone tabs 05mg 075mg 1mg 15mg 2mg 4mg 6mg
PAMO
dexamethasone tbpk MO dexpak 10 day tbpk MO dexpak 13 day tbpk MO dexpak 6 day tbpk MO dxevo 11-day tbpk EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
INTRAROSA INST KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp
Drug Name RequirementsLimits
methylprednisolone sodium succ solr
methylprednisolone tabs 4mg 8mg 16mg 32mg MO
methylprednisolone tbpk MO millipred dp tbpk millipred tabs MO ORTIKOS CP24 6mg 9mg NDS prednisolone sodium phosphate soln 5mg5ml 10mg5ml 20mg5ml 25mg5ml
MO
prednisolone sodium phosphate tbdp 10mg 15mg 30mg MO
prednisolone soln MO prednisone intensol conc PAMO prednisone soln PAMO prednisone tabs 1mg 25mg 5mg 10mg 20mg 50mg PAMO
prednisone tbpk PULMICORT FLEXHALER AEPB
RAYOS TBEC 1mg 2mg 5mg PAMO SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TRELEGY ELLIPTA AEPB MO triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
AVEED SOLN MO danazol caps 50mg 100mg 200mg MO
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs 25mg MO oxandrolone tabs MONDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 46 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
STRIANT MISC MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact
MO
testosterone soln MO XYOSTED SOAJ 50mg05ml 75mg05ml 100mg05ml MO
CONTRACEPTIVES altavera tabs MO alyacen 135 tabs MO amethia lo tabs MO amethia tabs MO apri tabs MO aranelle tabs MO ashlyna tabs MO aubra eq tabs MO aviane tabs MO balziva tabs MO blisovi 24 fe tabs MO blisovi fe 1530 tabs MO briellyn tabs MO camila tabs MO camrese lo tabs MO caziant tabs MO cryselle-28 tabs MO cyclafem 135 tabs MO cyclafem 777 tabs MO cyred eq tabs MO deblitane tabs MO delyla tabs MO desogestrel-ethinyl estradiol tabs MO dolishale tabs MO drospiren-eth estrad-levomefol tabs MO
drospirenone-ethinyl estradiol tabs MO
ELLA TABS MO eluryng ring MO emoquette tabs MO
Drug Name RequirementsLimits
enpresse-28 tabs MO enskyce tabs MO errin tabs MO estarylla tabs MO ethynodiol diac-eth estradiol tabs MO etonogestrel-ethinyl estradiol ring MO
falmina tabs MO fayosim tabs MO femynor tabs MO gemmily caps MO gianvi tabs MO hailey 24 fe tabs MO iclevia tabs MO incassia tabs MO introvale tabs MO isibloom tabs MO jasmiel tabs MO JOLIVETTE TABS MO juleber tabs MO junel 1530 tabs MO junel 120 tabs MO junel fe 1530 tabs MO junel fe 120 tabs MO junel fe 24 tabs MO kaitlib fe chew MO kariva tabs MO kelnor 135 tabs MO kelnor 150 tabs MO kurvelo tabs MO larin 1530 tabs MO larin 120 tabs MO larin fe 1530 tabs MO larin fe 120 tabs MO larissia tabs MO LAYOLIS FE CHEW MO leena tabs MO lessina tabs MO levonest tabs MO levonorg-eth estrad triphasic tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
levora 01530 (28) tabs MO LO LOESTRIN FE TABS MO loestrin 1530 (21) tabs MO loestrin 120 (21) tabs MO loestrin fe 1530 tabs MO loestrin fe 120 tabs MO loryna tabs MO low-ogestrel tabs MO lutera tabs MO lyleq tabs MO lyza tabs MO marlissa tabs MO melodetta 24 fe chew MO merzee caps MO mibelas 24 fe chew MO microgestin 1530 tabs MO microgestin 120 tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA TABS MO NATAZIA TABS MO necon 0535 (28) tabs MO NECON 777 TABS MO nikki tabs MO nora-be tabs MO norethin ace-eth estrad-fe caps MO norethin ace-eth estrad-fe chew MO norethin ace-eth estrad-fe tabs MO norethin-eth estradiol-fe chew MO norethindrone acet-ethinyl est tabs MO
norethindrone tabs MO norgestim-eth estrad triphasic tabs MO
norgestimate-eth estradiol tabs MO norlyroc tabs MO
Drug Name RequirementsLimits
nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO NUVARING RING MO nylia 777 tabs MO nymyo tabs MO ocella tabs MO ogestrel tabs MO orsythia tabs MO pimtrea tabs MO pirmella 135 tabs MO portia-28 tabs MO previfem tabs MO reclipsen tabs MO rivelsa tabs MO setlakin tabs MO sharobel tabs MO sprintec 28 tabs MO sronyx tabs MO syeda tabs MO tarina 24 fe tabs MO tarina fe 120 eq tabs MO tilia fe tabs MO tri-estarylla tabs MO tri-legest fe tabs MO tri-lo-estarylla tabs MO tri-lo-sprintec tabs MO tri-mili tabs MO tri-nymyo tabs MO tri-previfem tabs MO tri-sprintec tabs MO tri-vylibra lo tabs MO tri-vylibra tabs MO TRINESSA (28) TABS MO trivora (28) tabs MO tydemy tabs MO velivet tabs MO vestura tabs MO vienva tabs MO vyfemla tabs MO vylibra tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 48 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135e (28) tabs MO DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
ADMELOG SOLN MO ADMELOG SOLOSTAR SOPN MO AFREZZA POWD MO AFREZZA POWD 8 (90) amp 12 (90) UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO APIDRA SOLN PAMO APIDRA SOLOSTAR SOPN MO AVANDIA TABS 2mg 4mg MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD BYDUREON BCISE AUIJ BYDUREON PEN BYETTA 10 MCG PEN SOPN MO BYETTA 5 MCG PEN SOPN MO CYCLOSET TABS MO diazoxide susp glimepiride tabs 1mg 2mg 4mg MO glipizide er tb24 25mg 5mg 10mg MO
glipizide tabs 5mg 10mg MO glipizide-metformin hcl tabs MO GLUCAGEN HYPOKIT SOLR glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO GLYXAMBI TABS MO
Drug Name RequirementsLimits
HUMALOG JUNIOR KWIKPEN SOPN MO
HUMALOG KWIKPEN SOPN 100unitml 200unitml MO
HUMALOG MIX 5050 KWIKPEN SUPN MO
HUMALOG MIX 5050 SUSP MO HUMALOG MIX 7525 KWIKPEN SUPN MO
HUMALOG MIX 7525 SUSP MO HUMALOG SOCT MO HUMALOG SOLN PAMO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN PAMO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
INSULIN ASP PROT amp ASP FLEXPEN SUPN MO
INSULIN ASPART FLEXPEN SOPN MO
INSULIN ASPART PENFILL SOCT MO
INSULIN ASPART PROT amp ASPART SUSP MO
INSULIN ASPART SOLN PAMO INSULIN LISPRO (1 UNIT DIAL) SOPN MO
INSULIN LISPRO SOLN MO INVOKAMET TABS MO INVOKAMET XR TB24 MO INVOKANA TABS 100mg 300mg MO
JARDIANCE TABS 10mg 25mg MO JENTADUETO TABS MO JENTADUETO XR TB24 MO KAZANO TABS MO KORLYM TABS LDNDS LANTUS SOLN MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
LANTUS SOLOSTAR SOPN MO LEVEMIR FLEXTOUCH SOPN MO LEVEMIR SOLN MO metformin hcl er tb24 500mg 750mg MO
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO NOVOLIN 7030 SUSP MO NOVOLOG 7030 FLEXPEN RELION SUPN MO
NOVOLOG FLEXPEN RELION SOPN MO
NOVOLOG FLEXPEN SOPN MO NOVOLOG MIX 7030 FLEXPEN SUPN MO
NOVOLOG MIX 7030 RELION SUSP MO
NOVOLOG MIX 7030 SUSP MO NOVOLOG PENFILL SOCT MO NOVOLOG RELION SOLN PAMO NOVOLOG SOLN PAMO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO PROGLYCEM SUSP MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SOLIQUA SOPN MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO SYNJARDY TABS MO SYNJARDY XR TB24 MO tolazamide tabs 250mg 500mg MO
Drug Name RequirementsLimits
tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO ANGELIQ TABS MO CLIMARA PRO PTWK MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
COMBIPATCH PTTW MO DELESTROGEN OIL depo-estradiol oil DIVIGEL GEL MO dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
DUAVEE TABS MO ELESTRIN GEL MO estrace crea MO estrace tabs 05mg 1mg 2mg MO estradiol crea MO estradiol pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO EVAMIST SOLN MO fyavolv tabs MO IMVEXXY MAINTENANCE PACK INST 4mcg 10mcg MO
IMVEXXY STARTER PACK INST 4mcg 10mcg MO
jinteli tabs MO lopreeza tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 50 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
MENOSTAR PTWK MO mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO ORIAHNN CPPK NDS OSPHENA TABS MO prefest tabs MO PREMARIN SOLR PREMARIN TABS 03mg 045mg 0625mg 09mg 125mg
MO
PREMPHASE TABS MO PREMPRO TABS MO raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS NOVAREL SOLR 5000unit 10000unit PA
ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS PREGNYL SOLR PA TRIPTODUR SRER NDS OXYTOCICS carboprost tromethamine soln methergine tabs methylergonovine maleate soln methylergonovine maleate tabs OXYTOCIN SOLN PARATHYROID calcitonin (salmon) soln MO cinacalcet hcl tabs 30mg 60mg 90mg PANDS
FORTEO SOPN PANDS NATPARA CART 25mcg 50mcg 75mcg 100mcg LDNDS
Drug Name RequirementsLimits
SENSIPAR TABS 30mg 60mg 90mg PANDS
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PALDNDS DDAVP RHINAL TUBE SOLN MO desmopressin ace spray refrig soln MO
desmopressin acetate soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln DESMOPRESSIN ACETATE TABS 01mg 02mg MO
NOCDURNA SUBL 277mcg 553mcg MO
NOCTIVA EMUL 083mcg01ml 166mcg01ml MO
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO CRINONE GEL 4 8 PAMO DEPO-PROVERA SUSP 400mgml
DEPO-SUBQ PROVERA 104 SUSY
ENDOMETRIN INST PA hydroxyprogesterone caproate oil
hydroxyprogesterone caproate soln
MAKENA SOAJ NDS medroxyprogesterone acetate susp
medroxyprogesterone acetate susy
medroxyprogesterone acetate tabs 25mg 5mg 10mg MO
megestrol acetate susp MO norethindrone acetate tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS BYNFEZIA PEN SOPN NDS EGRIFTA SOLR NDS EGRIFTA SV SOLR NDS GENOTROPIN MINIQUICK SOLR 02mg PANDS
GENOTROPIN MINIQUICK SOLR 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
GENOTROPIN SOLR 5mg 12mg PANDS
HUMATROPE SOLR 5mg 6mg 12mg 24mg PANDS
INCRELEX SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
NUTROPIN AQ NUSPIN 20 SOPN PANDS
NUTROPIN AQ NUSPIN 5 SOPN PANDS
octreotide acetate soln OMNITROPE SOCT 5mg15ml 10mg15ml PANDS
OMNITROPE SOLR PANDS SAIZEN CLICKEASY SOLR PANDS SAIZEN SOLR 5mg 88mg PANDS SAIZENPREP SOLR PANDS SANDOSTATIN LAR DEPOT KIT 10mg 20mg 30mg NDS
SEROSTIM SOLR 4mg 5mg 6mg PANDS
SIGNIFOR LAR SRER 10mg 20mg 30mg 40mg 60mg NDS
SIGNIFOR SOLN 03mgml 06mgml 09mgml NDS
SOMATULINE DEPOT SOLN
Drug Name RequirementsLimits
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZOMACTON SOLR 5mg PANDS ZOMACTON SOLR PANDS ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVO-T TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVOTHYROXINE SODIUM SOLR
levothyroxine sodium tabs 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
liothyronine sodium soln liothyronine sodium tabs 5mcg 25mcg 50mcg MO
methimazole tabs 5mg 10mg MO propylthiouracil tabs MO tapazole tabs 5mg 10mg MO THYROLAR-1 TABS THYROLAR-12 TABS THYROLAR-14 TABS THYROLAR-2 TABS THYROLAR-3 TABS TIROSINT CAPS 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 52 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
137mcg 150mcg 175mcg 200mcg UNITHROID TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA REDUCTASE INHIBITORS dutasteride caps MO dutasteride-tamsulosin hcl caps MO finasteride tabs MO ANTIDOTES acetylcysteine soln 10 20 PAMO fomepizole soln KHAPZORY SOLR 175mg 300mg NDS
leucovorin calcium soln leucovorin calcium solr leucovorin calcium tabs 5mg 10mg 15mg 25mg MO
levoleucovorin calcium pf soln levoleucovorin calcium solr VISTOGARD PACK NDS VORAXAZE SOLR NDS ANTIGOUT AGENTS allopurinol sodium solr allopurinol tabs 100mg 300mg MO COLCHICINE CAPS MO colchicine tabs MO febuxostat tabs 40mg 80mg MO GLOPERBA SOLN MITIGARE CAPS MO ULORIC TABS 40mg 80mg MO BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 5mg 10mg 35mg 70mg MO
alendronate sodium tabs 40mg MO BINOSTO TBEF MO EVENITY SOSY NDS FOSAMAX PLUS D TABS MO IBANDRONATE SODIUM SOLN
Drug Name RequirementsLimits
ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr PROLIA SOSY risedronate sodium tabs 5mg 30mg 35mg 150mg MO
RISEDRONATE SODIUM TBEC MO XGEVA SOLN PANDS zoledronic acid conc zoledronic acid soln DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ACTPEN SOAJ NDS ACTEMRA SOSY NDS AVSOLA SOLR NDS CIMZIA KIT PANDS CIMZIA PREFILLED KIT PANDS CIMZIA STARTER KIT KIT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS ENBREL SOSY 25mg05ml 50mgml NDS
ENBREL SURECLICK SOAJ NDS HUMIRA PEDIATRIC CROHNS START PSKT NDS
HUMIRA PEN PNKT 40mg04ml 40mg08ml 80mg08ml
NDS
HUMIRA PEN-CDUCHS STARTER PNKT 40mg08ml 80mg08ml
NDS
HUMIRA PEN-PEDIATRIC UC START PNKT NDS
HUMIRA PEN-PSUVADOL HS START PNKT NDS
HUMIRA PEN-PSORUVEIT STARTER PNKT NDS
HUMIRA PSKT 10mg01ml 10mg02ml 20mg02ml 20mg04ml 40mg04ml 40mg08ml
NDS
INFLECTRA SOLR INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
KEVZARA SOAJ 150mg114ml 200mg114ml NDS
KEVZARA SOSY 150mg114ml 200mg114ml NDS
KINERET SOSY NDS leflunomide tabs 10mg 20mg MO OLUMIANT TABS 1mg 2mg NDS ORENCIA CLICKJECT SOAJ NDS ORENCIA SOLR NDS ORENCIA SOSY 50mg04ml 875mg07ml 125mgml NDS
OTEZLA TABS PANDS OTEZLA TBPK PANDS OTREXUP SOAJ RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 NDS SIMPONI ARIA SOLN NDS SIMPONI SOAJ 50mg05ml 100mgml NDS
SIMPONI SOSY 50mg05ml 100mgml NDS
XELJANZ SOLN NDS XELJANZ TABS 5mg 10mg NDS XELJANZ XR TB24 11mg 22mg NDS IMMUNE SUPPRESSANTS ASTAGRAF XL CP24 05mg 1mg PAMO
ASTAGRAF XL CP24 PA azasan tabs 75mg 100mg PAMO azathioprine sodium solr azathioprine tabs PAMO BENLYSTA SOAJ BENLYSTA SOLR BENLYSTA SOSY cyclosporine caps 25mg 100mg PAMO cyclosporine modified caps 25mg 50mg 100mg PAMO
cyclosporine modified soln PAMO cyclosporine soln PAMO
Drug Name RequirementsLimits
ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg PA GAMIFANT SOLN 50mg10ml 100mg20ml 10mg2ml NDS
gengraf caps 25mg 50mg 100mg PAMO
gengraf soln PAMO LUPKYNIS CAPS NDS MAVENCLAD (10 TABS) TBPK NDS MAVENCLAD (4 TABS) TBPK NDS MAVENCLAD (5 TABS) TBPK NDS MAVENCLAD (6 TABS) TBPK NDS MAVENCLAD (7 TABS) TBPK NDS MAVENCLAD (8 TABS) TBPK NDS MAVENCLAD (9 TABS) TBPK NDS mycophenolate mofetil caps PAMO mycophenolate mofetil hcl solr mycophenolate mofetil susr PAMO mycophenolate mofetil tabs PAMO mycophenolate sodium tbec 180mg 360mg PAMO
NULOJIX SOLR NDS PROGRAF PACK 02mg PA PROGRAF PACK PANDS PROGRAF SOLN PAMO SANDIMMUNE ORAL SOLN 100mgml PAMO
SAPHNELO SOLN NDS sirolimus soln PA sirolimus tabs 05mg 1mg 2mg PAMO tacrolimus caps 05mg 1mg 5mg PAMO
UPLIZNA SOLN ZORTRESS TABS 025mg PAMO ZORTRESS TABS 05mg 075mg 1mg PA
MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 54 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BOTOX SOLR 100unit 200unit PA bupivacaine hcl (pf) soln bupivacaine hcl soln BUPIVACAINE IN DEXTROSE SOLN
bupivacaine spinal soln bupivacaine-epinephrine (pf) soln
bupivacaine-epinephrine soln CARNITOR SOLN PAMO CARNITOR TABS PAMO chloroprocaine hcl (pf) soln CINRYZE SOLR INTRAVENOUS HI
citanest plain dental soln COSELA SOLR NDS CRYSVITA SOLN 10mgml 20mgml 30mgml NDS
CYSTADANE POWD LDNDS CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr DYSPORT SOLR 300unit 500unit PA
EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENSPRYNG SOSY NDS EVRYSDI SOLR NDS EXONDYS 51 SOLN 500mg10ml 100mg2ml NDS
FIRDAPSE TABS NDS FLUORITAB CHEW 025mg 05mg 1mg MO
FLUORITAB SOLN MO GALAFOLD CAPS NDS GIVLAARI SOLN NDS GRASTEK SUBL MO
Drug Name RequirementsLimits
HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS TABS NDS KUVAN PACK 100mg 500mg NDS KUVAN TABS NDS LACTATED RINGERS SOLN levocarnitine soln PAMO LEVOCARNITINE TABS PAMO lidocaine hcl (pf) soln lidocaine hcl soln lidocaine in dextrose soln lidocaine-epinephrine soln LUDENT CHEW 025mg 05mg 1mg MO
mesna soln MESNEX TABS NDS MYALEPT SOLR NDS NAFRINSE CHEW MO NAFRINSE DROPS SOLN MO nitisinone caps 2mg 5mg 10mg NDS NITYR TABS 2mg 5mg 10mg NDS NULIBRY SOLR NDS ODACTRA SUBL ONPATTRO SOLN NDS ORALAIR SUBL MO ORFADIN CAPS LDNDS ORFADIN SUSP LDNDS ORLADEYO CAPS 110mg 150mg NDS
OXLUMO SOLN PALFORZIA (12 MG DAILY DOSE) CSPK NDS
PALFORZIA (120 MG DAILY DOSE) CSPK NDS
PALFORZIA (160 MG DAILY DOSE) CSPK NDS
PALFORZIA (20 MG DAILY DOSE) CSPK NDS
PALFORZIA (200 MG DAILY DOSE) CSPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
PALFORZIA (240 MG DAILY DOSE) CSPK NDS
PALFORZIA (3 MG DAILY DOSE) CSPK NDS
PALFORZIA (300 MG MAINTENANCE) PACK NDS
PALFORZIA (300 MG TITRATION) PACK NDS
PALFORZIA (40 MG DAILY DOSE) CSPK NDS
PALFORZIA (6 MG DAILY DOSE) CSPK NDS
PALFORZIA (80 MG DAILY DOSE) CSPK NDS
PALFORZIA INITIAL ESCALATION CSPK NDS
PHYSIOLYTE SOLN PHYSIOSOL IRRIGATION SOLN
polocaine soln polocaine-mpf soln PROCYSBI CPDR 25mg 75mg NDS PROCYSBI PACK 75mg 300mg NDS REZUROCK TABS NDS RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln RUZURGI TABS NDS sapropterin dihydrochloride pack 100mg 500mg NDS
sapropterin dihydrochloride tabs NDS SENSORCAINE SOLN sensorcaine-mpf soln sensorcaine-mpfepinephrine soln
sensorcaineepinephrine soln SODIUM CHLORIDE SOLN MO SODIUM FLUORIDE CHEW 025mg 05mg 1mg MO
SODIUM FLUORIDE SOLN MO SODIUM FLUORIDE TABS MO STERILE WATER FOR IRRIGATION SOLN
Drug Name RequirementsLimits
TAKHZYRO SOLN NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VILTEPSO SOLN NDS VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR 50unit 100unit PA XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg NDS RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 200mg114ml 300mg2ml PANDS
FASENRA PEN SOAJ NDS FASENRA SOSY PA montelukast sodium chew 4mg 5mg MO
montelukast sodium pack MO montelukast sodium tabs MO NUCALA SOAJ PANDS NUCALA SOLR PANDS NUCALA SOSY PANDS zafirlukast tabs 10mg 20mg MO zileuton er tb12 NDS CYSTIC FIBROSIS BETHKIS NEBU PA
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 56 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CAYSTON SOLR LDNDS KALYDECO PACK 25mg 50mg 75mg PANDS
KALYDECO TABS PANDS KITABIS PAK NEBU PA ORKAMBI PACK NDS ORKAMBI TABS NDS SYMDEKO TBPK NDS TOBI PODHALER CAPS tobramycin nebu 300mg4ml 300mg5ml PA
TRIKAFTA TBPK LDNDS PULMONARY FIBROSIS ESBRIET CAPS PANDS ESBRIET TABS 267mg 801mg PANDS OFEV CAPS 100mg 150mg NDS RESPIRATORY AGENTS MISCELLANEOUS ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS 500mg 1000mg
HI
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact
MO
ASMANEX (120 METERED DOSES) AEPB MO
ASMANEX (30 METERED DOSES) AEPB 110mcginh MO
ASMANEX (30 METERED DOSES) AEPB MO
ASMANEX (60 METERED DOSES) AEPB MO
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
budesonide-formoterol fumarate aero
DALIRESP TABS 250mcg 500mcg MO
DULERA AERO MO
Drug Name RequirementsLimits
FLOVENT DISKUS AEPB 50mcgblist 100mcgblist 250mcgblist
MO
FLOVENT HFA AERO 44mcgact MO
FLOVENT HFA AERO 110mcgact 220mcgact MO
fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PROLASTIN-C SOLN INTRAVENOUS HI
PROLASTIN-C SOLR INTRAVENOUS HI
SYMBICORT AERO wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
ZEMAIRA SOLR INTRAVENOUS HI
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr LETAIRIS TABS 5mg 10mg NDS ORENITRAM TBCR 0125mg LDNDS ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TABS 625mg 125mg NDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
1000mcg 1200mcg 1400mcg 1600mcg UPTRAVI TBPK NDS VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS BIVIGAM SOLN 10gm100ml HI BIVIGAM SOLN 5gm50ml HI CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml
HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS 10gm200ml HI
GAMMAPLEX SOLN INTRAVENOUS 10gm100ml 20gm200ml 5gm50ml
HI
GAMUNEX-C SOLN INJECTION 10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml
HI
HYPERHEP B SOLN HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 5gm100ml HI
Drug Name RequirementsLimits
1gm20ml 2gm20ml 25gm500ml PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
PRIVIGEN SOLN INTRAVENOUS HI
VARIZIG SOLN XEMBIFY SOLN SUBCUTANEOUS 2gm10ml 4gm20ml 10gm50ml 1gm5ml
HI
TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP QUADRACEL SUSP TDVAX SUSP TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP DAPTACEL SUSP ENGERIX-B SUSP 10mcg05ml 20mcgml PA
GARDASIL 9 SUSP GARDASIL 9 SUSY HAVRIX SUSP HEPLISAV-B SOLN PA HIBERIX SOLR IMOVAX RABIES INJ INFANRIX SUSP IPOL INJ IXIARO SUSP M-M-R II SOLR MENACTRA INJ MENQUADFI INJ MENVEO SOLR PEDIARIX SUSP PEDVAX HIB SUSP
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 58 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN VAQTA SUSP VARIVAX INJ VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint AKTIPAK PACK MO AVC VAGINAL CREA BACTROBAN NASAL OINT BENZEPRO CREAMY WASH LIQD
BENZEPRO FOAMING CLOTHS MISC
BENZOYL PEROXIDE GEL NDS benzoyl peroxide-erythromycin gel MO
ciclopirox gel ciclopirox olamine crea ciclopirox olamine susp ciclopirox sham ciclopirox soln CLEOCIN SUPP clindacin-p swab MO clindamycin phos-benzoyl perox gel MO
clindamycin phosphate crea clindamycin phosphate foam MO clindamycin phosphate gel MO clindamycin phosphate lotn MO
Drug Name RequirementsLimits
clindamycin phosphate soln MO clindamycin phosphate swab MO CLINDESSE CREA clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn DENAVIR CREA econazole nitrate crea ERTACZO CREA ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA EXELDERM CREA EXELDERM SOLN gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ivermectin lotn ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham LULICONAZOLE CREA LUZU CREA mafenide acetate pack malathion lotn MENTAX CREA metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 59
Drug Name RequirementsLimits
mupirocin oint naftifine hcl crea naftifine hcl gel NAFTIN GEL NATROBA SUSP neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ORAVIG TABS ovide lotn oxiconazole nitrate crea OXISTAT LOTN permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SKLICE LOTN SODIUM SULFACETAMIDE SHAM
SODIUM SULFACETAMIDE WASH LIQD
SPINOSAD SUSP SSD CREA sulfacetamide sodium (acne) lotn MO SULFACETAMIDE SODIUM GEL
SULFACETAMIDE SODIUM LIQD
SULFAMYLON CREA tavaborole soln terconazole crea terconazole supp VANDAZOLE GEL XEPI CREA MO XERESE CREA ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) ala scalp lotn MO
Drug Name RequirementsLimits
ala-cort crea 1 25 MO alclometasone dipropionate crea MO alclometasone dipropionate oint MO amcinonide crea MO amcinonide lotn MO amcinonide oint MO anusol-hc crea MO apexicon e crea MO benzoyl perox-hydrocortisone lotn
BENZOYL PEROXIDE FORTE- HC LOTN NDS
beser lotn MO betamethasone dipropionate aug crea MO
betamethasone dipropionate aug gel MO
betamethasone dipropionate aug lotn MO
betamethasone dipropionate aug oint MO
betamethasone dipropionate crea MO
betamethasone dipropionate lotn MO BETAMETHASONE DIPROPIONATE OINT MO
betamethasone valerate crea MO betamethasone valerate foam MO BETAMETHASONE VALERATE LOTN MO
BETAMETHASONE VALERATE OINT MO
BRYHALI LOTN MO calcipotriene-betameth diprop oint MONDS
calcipotriene-betameth diprop susp NDS
CAPEX SHAM MO clobetasol propionate crea clobetasol propionate e crea MO clobetasol propionate emulsion foam
clobetasol propionate foam MO clobetasol propionate gel MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 60 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO CLOBEX SHAM MO CLOBEX SPRAY LIQD MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO clodan sham MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT MO DESONATE GEL MO desonide crea MO desonide gel MO desonide lotn MO desonide oint MO desowen lotn MO desoximetasone crea 005 025 MO
desoximetasone gel MO desoximetasone liqd MO desoximetasone oint 005 025 MO
desrx gel MO diclofenac sodium gel 1 3 MO diflorasone diacetate crea MO diflorasone diacetate oint MO DUOBRII LOTN MO ENSTILAR FOAM NDS epifoam foam fluocinolone acetonide body oil fluocinolone acetonide crea 001 0025 MO
fluocinolone acetonide oint MO fluocinolone acetonide scalp oil MO fluocinolone acetonide soln MO fluocinonide crea MO fluocinonide emulsified base crea MO
Drug Name RequirementsLimits
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO flurandrenolide crea MO flurandrenolide lotn MO flurandrenolide oint MO fluticasone propionate crea MO fluticasone propionate lotn MO fluticasone propionate oint MO halcinonide crea MO halobetasol propionate crea MO HALOBETASOL PROPIONATE FOAM NDS
halobetasol propionate oint MO HALOG CREA MO HALOG OINT MO hydrocortisone (perianal) crea 1 25 MO
hydrocortisone butyr lipo base crea
hydrocortisone butyrate crea MO hydrocortisone butyrate lotn MO HYDROCORTISONE BUTYRATE OINT MO
hydrocortisone butyrate soln MO hydrocortisone crea 1 25 MO hydrocortisone enem MO hydrocortisone lotn MO hydrocortisone oint 1 25 MO hydrocortisone valerate crea MO hydrocortisone valerate oint MO LEXETTE FOAM NDS micort-hc crea MO mometasone furoate crea MO mometasone furoate oint MO mometasone furoate soln MO neo-synalar crea MO nolix crea nolix lotn MO nystatin-triamcinolone crea MO nystatin-triamcinolone oint MO oralone pste MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 61
Drug Name RequirementsLimits
PANDEL CREA MO prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO psorcon crea MO TACLONEX SUSP NDS topicort crea 005 025 MO topicort gel MO topicort oint MO tovet foam MO triamcinolone acetonide aers MO triamcinolone acetonide crea 0025 01 05 MO
triamcinolone acetonide lotn 0025 01 MO
triamcinolone acetonide oint 0025 005 01 05 MO
triamcinolone acetonide pste MO trianex oint MO triderm crea 01 05 MO tritocin oint MO UCERIS FOAM MO ULTRAVATE LOTN NDS VANOXIDE-HC LOTN ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
LIDO-SORB LOTN LIDOCAINE HCL CREA lidocaine hcl lotn lidocaine hcl soln PA lidocaine hcl urethralmucosal gel MO
lidocaine hcl urethralmucosal prsy MO
lidocaine oint PAMO lidocaine ptch PAMO
Drug Name RequirementsLimits
LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea PA LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam texacort soln MO TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS ALTRENO LOTN PAMO AVITA CREA PAMO AVITA GEL PAMO KEPIVANCE SOLR NDS PANRETIN GEL NDS RETIN-A CREA 0025 005 01 PAMO
RETIN-A GEL 001 0025 PAMO RETIN-A MICRO GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 008 PAMO
RETIN-A MICRO PUMP GEL PANDS TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 62 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS ABSORICA CAPS 25mg 35mg NDS ABSORICA LD CAPS 8mg 16mg 24mg 32mg NDS
accutane caps 10mg 20mg 30mg 40mg NDS
acitretin caps 10mg 175mg 25mg NDS
ADAPALENE CREA MO adapalene gel 01 03 MO adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
AVAR CLEANSER EMUL AVAR-E EMOLLIENT CREA AVAR-E GREEN CREA azelaic acid gel MO AZELEX CREA MO BP 10-1 EMUL calcipotriene crea MO calcipotriene oint MO calcipotriene soln MO calcitrene oint MO CALCITRIOL OINT MO CARAC CREA CEROVEL LOTN claravis caps 10mg 20mg 30mg 40mg NDS
CONDYLOX GEL MO COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
Drug Name RequirementsLimits
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA MO DIFFERIN LOTN MO EPIDUO FORTE GEL MO FABIOR FOAM PAMO FINACEA FOAM MO fluorouracil crea 5 MO fluorouracil crea 5 fluorouracil soln 2 5 MO ILUMYA SOSY PA imiquimod crea 375 5 MO IMIQUIMOD PUMP CREA MO isotretinoin caps 10mg 20mg 30mg 40mg NDS
keralyt sham KLISYRI OINT NDS LACTIC ACID LOTN methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
ORACEA CPDR pimecrolimus crea MO podofilox soln MO RECTIV OINT MO REGRANEX GEL NDS RYNODERM CREA NDS SALEX SHAM SALICYLIC ACID CREA SALICYLIC ACID ER SOLN SALICYLIC ACID FOAM SALICYLIC ACID GEL SALICYLIC ACID LIQD SALICYLIC ACID SHAM SALICYLIC ACID WART REMOVER LIQD
SALICYLIC ACID-CLEANSER KIT
SALIMEZ CREA SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 63
Drug Name RequirementsLimits
SKYRIZI PEN SOAJ SKYRIZI SOSY SORILUX FOAM MO SSS 10-5 CREA STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
SULFACETAMIDE SODIUM-SULFUR CREA
SULFACETAMIDE SODIUM-SULFUR EMUL
SULFACETAMIDE SODIUM-SULFUR LIQD
SULFACETAMIDE SODIUM-SULFUR LOTN
SULFACETAMIDE SODIUM-SULFUR PADS
SULFACETAMIDE SODIUM-SULFUR SUSP
SULFACLEANSE 84 SUSP sulfamez wash emul TACROLIMUS OINT 01 003 MO
TALTZ SOAJ NDS TALTZ SOSY NDS tazarotene crea PAMO tazarotene foam PAMO TAZORAC CREA PAMO TAZORAC GEL 005 01 PAMO TOLAK CREA TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS VECTICAL OINT MO VEREGEN OINT MO WYNZORA CREA NDS XUREA CREA
Drug Name RequirementsLimits
zenatane caps 10mg 20mg 30mg 40mg NDS
ZYCLARA PUMP CREA MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline soln darifenacin hydrobromide er tb24 75mg 15mg MO
elixophyllin elix flavoxate hcl tabs MO MYRBETRIQ TB24 25mg 50mg MO oxybutynin chloride er tb24 5mg 10mg 15mg MO
oxybutynin chloride syrp MO oxybutynin chloride tabs MO solifenacin succinate tabs 5mg 10mg MO
theo-24 cp24 100mg 200mg 300mg 400mg MO
theophylline er tb12 100mg 200mg 300mg 450mg MO
theophylline er tb24 400mg 600mg MO
theophylline soln MO tolterodine tartrate er cp24 2mg 4mg MO
tolterodine tartrate tabs MO trospium chloride er cp24 MO trospium chloride tabs MO VITAMINS VITAMINS ADCF (05MGML) SOLN MO calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN MULTI-VITAMINFLUORIDEIRON SOLN
MO
MULTI-VITAMINFLUORIDE SOLN MO
MULTIVITAMINFLUORIDE CHEW MO
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Drug Name RequirementsLimits
MVC-FLUORIDE CHEW MO paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS TRI-VITAMINFLUORIDE SOLN MO TRI-VITEFLUORIDE SOLN MO VITAMINS ACD-FLUORIDE SOLN MO
VP-PNV-DHA CAPS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 65
The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not and
you need an urgent refill please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 6 or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number on page 6 NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
66 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Index of Drugs
A abacavir sulfate soln 12 abacavir sulfate tabs 12 abacavir sulfate-lamivudine tabs 12 abacavir-lamivudine-zidovudine tabs 12 ABELCET SUSP INTRAVENOUS 11 ABILIFY MAINTENA PRSY 300mg 400mg
35 ABILIFY MAINTENA SRER 300mg 400mg
35 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
abiraterone acetate tabs 250mg 500mg 14 ABRAXANE SUSR 14 ABSORICA CAPS 25mg 35mg 62 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 62 ABSTRAL SUBL 100mcg 200mcg
300mcg 400mcg 600mcg 800mcg 27 acamprosate calcium tbec 26 acarbose tabs 25mg 50mg 100mg 48 accutane caps 10mg 20mg 30mg 40mg 62 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 27 acetaminophen-codeine soln 27 acetaminophen-codeine tabs 27 acetazolamide er cp12 42 acetazolamide sodium solr 42 acetazolamide tabs 125mg 250mg 42 ACETIC ACID SOLN 42 53 acetylcysteine soln 10 20 52 acitretin caps 10mg 175mg 25mg 62 ACTEMRA ACTPEN SOAJ 52 ACTEMRA SOSY 52 ACTHAR GEL 50 ACTHIB SOLR 57 ACTIMMUNE SOLN 53 ACUVAIL SOLN 41
acyclovir caps 12 acyclovir oint 58 acyclovir sodium soln intravenous 12 acyclovir susp 12 acyclovir tabs 400mg 800mg 12 ADACEL SUSP 57 ADAGEN SOLN 40 ADAKVEO SOLN 21 ADAPALENE CREA 62 adapalene gel 01 03 62 adapalene pads 62 adapalene soln 62 adapalene-benzoyl peroxide gel 62 ADAPALENE-BENZOYL PEROXIDE PADS
62 ADCF (05MGML) SOLN 63 adderall tabs 29 ADDERALL XR CP24 29 adefovir dipivoxil tabs 12 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 56 adenosine soln 25 ADMELOG SOLN 48 ADMELOG SOLOSTAR SOPN 48 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 20 ADZENYS ER SUER 29 ADZENYS XR-ODT TBED 31mg 63mg
94mg 125mg 157mg 188mg 29 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 25mg 5mg 75mg 10mg
14 AFREZZA POWD 48 AFREZZA POWD 8 (90) amp 12 (90) UNIT 48 AJOVY SOAJ 32 AJOVY SOSY 32 AKTIPAK PACK 58 AKYNZEO CAPS 43 ala scalp lotn 59 ala-cort crea 1 25 59 albendazole tabs 8
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 67
albuterol sulfate er tb12 4mg 8mg 20 albuterol sulfate hfa aers 20 albuterol sulfate nebu 0083 25mg05ml
20 albuterol sulfate nebu 063mg3ml
125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 59 alclometasone dipropionate oint 59 ALCOHOL PREP PADS 37 ALDACTAZIDE TABS 25 ALDURAZYME SOLN 40 ALECENSA CAPS 14 alendronate sodium soln 52 alendronate sodium tabs 40mg 52 alendronate sodium tabs 5mg 10mg
35mg 70mg 52 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 05mg 1mg
2mg 5mg 45 allopurinol sodium solr 52 allopurinol tabs 100mg 300mg 52 allzital tabs 27 almotriptan malate tabs 32 ALOCRIL SOLN 42 alogliptin benzoate tabs 625mg 125mg
25mg 48 ALOGLIPTIN-METFORMIN HCL TABS 48 alogliptin-pioglitazone tabs 48 ALOMIDE SOLN 42 ALOSETRON HCL TABS 05mg 1mg 43 ALPHAGAN P SOLN 42 alprazolam er tb24 05mg 1mg 2mg 3mg
33 alprazolam intensol conc 33 alprazolam tabs 025mg 05mg 1mg 2mg
33 alprazolam tbdp 025mg 05mg 1mg 2mg
33 ALREX SUSP 41 ALTACAINE SOLN 42 ALTAFRIN SOLN 42 altavera tabs 46 ALTOPREV TB24 20mg 40mg 60mg 23 ALTRENO LOTN 61
ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 56 alyacen 135 tabs 46 alyq tabs 26 amabelz tabs 49 amantadine hcl caps 32 amantadine hcl syrp 32 amantadine hcl tabs 32 AMBISOME SUSR INTRAVENOUS 11 ambrisentan tabs 56 amcinonide crea 59 amcinonide lotn 59 amcinonide oint 59 amethia lo tabs 46 amethia tabs 46 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 38 amiloride-hydrochlorothiazide tabs 38 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 63 AMINOSYN-PF SOLN INTRAVENOUS 38 amiodarone hcl soln 25 amiodarone hcl tabs 100mg 200mg
400mg 25 AMITIZA CAPS 8mcg 24mcg 44 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 amlodipine besy-benazepril hcl caps 24 amlodipine besylate tabs 25mg 5mg
10mg 24 amlodipine besylate-valsartan tabs 24 amlodipine-atorvastatin tabs 24 amlodipine-olmesartan tabs 24 amlodipine-valsartan-hctz tabs 24 ammonium lactate crea 62 ammonium lactate lotn 62 amnesteem caps 10mg 20mg 40mg 62 AMONDYS 45 SOLN 53 amoxapine tabs 25mg 50mg 100mg
150mg 35 amoxicill-clarithro-lansopraz misc 43 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8
68 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 29 amphetamine sulfate tabs 5mg 10mg 30 amphetamine-dextroamphet er cp24 30 amphetamine-dextroamphetamine tabs 30 amphotericin b solr intravenous 11 ampicillin caps 8 ampicillin sodium solr 8 ampicillin sodium solr injection 1gm 125mg
8 ampicillin sodium solr intravenous 8 ampicillin-sulbactam sodium solr 8 ampicillin-sulbactam sodium solr injection 8 ampicillin-sulbactam sodium solr
intravenous 8 ANADROL-50 TABS 45 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 61 anastrozole tabs 14 ANDRODERM PT24 2mg24hr 4mg24hr
45 ANGELIQ TABS 49 ANORO ELLIPTA AEPB 19 antabuse tabs 250mg 500mg 26 ANTARA CAPS 30mg 90mg 23 anusol-hc crea 59 ANZEMET TABS 50mg 100mg 43 apap-caff-dihydrocodeine tabs 27 apexicon e crea 59 APIDRA SOLN 48 APIDRA SOLOSTAR SOPN 48 APLENZIN TB24 174mg 348mg 522mg 35 APOKYN SOCT 32 apraclonidine hcl soln 42 aprepitant caps 43 apri tabs 46 APRISO CP24 43 APTIOM TABS 200mg 400mg 600mg
800mg 30 APTIVUS CAPS 12 APTIVUS SOLN 12 ARALAST NP SOLR INTRAVENOUS
500mg 1000mg 56 aranelle tabs 46 ARANESP (ALBUMIN FREE) SOLN
25mcgml 40mcgml 22
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml 22
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml 22
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 22
ARCALYST SOLR 53 ARCAPTA NEOHALER CAPS 20 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 54 ARIKAYCE SUSP 8 aripiprazole soln 35 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 35 aripiprazole tbdp 10mg 15mg 35 ARISTADA INITIO PRSY 35 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 35
armodafinil tabs 50mg 150mg 200mg 250mg 30
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact 56
ARRANON SOLN 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 54 ARYMO ER TBEA 27 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 57 ascomp-codeine caps 27 asenapine maleate subl 25mg 5mg 10mg
35 ashlyna tabs 46 ASMANEX (120 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
110mcginh 56 ASMANEX (60 METERED DOSES) AEPB
56 ASMANEX HFA AERO 100mcgact
200mcgact 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 69
ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 53 ASTAGRAF XL CP24 05mg 1mg 53 atazanavir sulfate caps 150mg 200mg
300mg 12 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 34 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 23 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 42 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 34 aubra eq tabs 46 AUGMENTIN SUSR 8 AURYXIA TABS 39 AUSTEDO TABS 6mg 9mg 12mg 34 AVANDIA TABS 2mg 4mg 48 AVAR CLEANSER EMUL 62 AVAR-E EMOLLIENT CREA 62 AVAR-E GREEN CREA 62 AVASTIN SOLN 14 AVC VAGINAL CREA 58 AVEED SOLN 45 aviane tabs 46 AVITA CREA 61 AVITA GEL 61 AVONEX KIT 34 AVONEX PEN AJKT 34 AVONEX PREFILLED PSKT 34 AVSOLA SOLR 52 AVYCAZ SOLR INTRAVENOUS 8 aygestin tabs 50 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 53 AZASITE SOLN 40 azathioprine sodium solr 53 azathioprine tabs 53 azelaic acid gel 62 azelastine hcl soln 005 01 015 42 azelastine-fluticasone susp 42 AZELEX CREA 62
AZITHROMYCIN PACK 8 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
B bacitracin oint 40 bacitracin solr 8 bacitracin-polymyxin b oint 40 bacitra-neomycin-polymyxin-hc oint 41 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 58 BAFIERTAM CPDR 34 balsalazide disodium caps 43 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 46 BANZEL SUSP 30 BANZEL TABS 200mg 400mg 30 BAQSIMI ONE PACK POWD 48 BAQSIMI TWO PACK POWD 48 BARACLUDE SOLN 12 BAVENCIO SOLN 14 BAXDELA SOLR INTRAVENOUS 8 BAXDELA TABS 8 BCG VACCINE INJ 14 BD INSULIN SYR ULTRAFINE II MISC 37 BD INSULIN SYRINGE MISC 37 BD INSULIN SYRINGE UF MISC 37 BD PEN NEEDLE ORIGINAL UF MISC 37 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 27 BELEODAQ SOLR 14 BELRAPZO SOLN 14 BELSOMRA TABS 33 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 15 BENDEKA SOLN 15 BENLYSTA SOAJ 53 BENLYSTA SOLR 53 BENLYSTA SOSY 53 BENZEPRO CREAMY WASH LIQD 58 BENZEPRO FOAMING CLOTHS MISC 58 benzhydrocodone-acetaminophen tabs 27 BENZNIDAZOLE TABS 125mg 100mg 11 benzoyl perox-hydrocortisone lotn 59
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BENZOYL PEROXIDE FORTE- HC LOTN 59
BENZOYL PEROXIDE GEL 58 benzoyl peroxide-erythromycin gel 58 benztropine mesylate soln 32 benztropine mesylate tabs 05mg 1mg
2mg 32 BEOVU SOLN 42 bepotastine besilate soln 42 BERINERT KIT INTRAVENOUS 21 beser lotn 59 BESIVANCE SUSP 40 BESPONSA SOLR 15 betamethasone dipropionate aug crea 59 betamethasone dipropionate aug gel 59 betamethasone dipropionate aug lotn 59 betamethasone dipropionate aug oint 59 betamethasone dipropionate crea 59 betamethasone dipropionate lotn 59 BETAMETHASONE DIPROPIONATE OINT
59 betamethasone sod phos amp acet susp 45 betamethasone valerate crea 59 betamethasone valerate foam 59 BETAMETHASONE VALERATE LOTN 59 BETAMETHASONE VALERATE OINT 59 BETASERON KIT 34 betaxolol hcl soln 42 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 20 BETHKIS NEBU 55 BETIMOL SOLN 025 05 42 BETOPTIC-S SUSP 42 BEVESPI AEROSPHERE AERO 19 BEVYXXA CAPS 40mg 80mg 21 bexarotene caps 15 BEXSERO SUSY 57 bicalutamide tabs 15 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICNU SOLR 15 BIDIL TABS 26 BIKTARVY TABS 12 bimatoprost soln 42 BINOSTO TBEF 52 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23
BIVIGAM SOLN 10gm100ml 57 BIVIGAM SOLN 5gm50ml 57 bleomycin sulfate solr 15 bleph-10 soln 40 blephamide sop oint 41 BLEPHAMIDE SUSP 41 BLINCYTO SOLR 15 blisovi 24 fe tabs 46 blisovi fe 1530 tabs 46 BONJESTA TBCR 43 BOOSTRIX SUSP 57 BORTEZOMIB SOLR 15 bosentan tabs 56 BOSULIF TABS 100mg 400mg 500mg 15 BOTOX SOLR 100unit 200unit 54 BP 10-1 EMUL 62 BRAFTOVI CAPS 50mg 75mg 15 briellyn tabs 46 BRILINTA TABS 60mg 90mg 21 BRIMONIDINE TARTRATE SOLN 02
015 42 brinzolamide susp 42 BRIVIACT SOLN 30 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 30 bromfenac sodium (once-daily) soln 41 bromocriptine mesylate caps 32 bromocriptine mesylate tabs 32 BROMSITE SOLN 41 BRONCHITOL CAPS 56 BROVANA NEBU 20 BRUKINSA CAPS 15 BRYHALI LOTN 59 budesonide cpep 45 budesonide er tb24 45 budesonide susp 025mg2ml 05mg2ml
1mg2ml 56 budesonide-formoterol fumarate aero 56 bumetanide soln 38 bumetanide tabs 05mg 1mg 2mg 38 BUNAVAIL FILM 34 bupap tabs 27 bupivacaine hcl (pf) soln 54 bupivacaine hcl soln 54 BUPIVACAINE IN DEXTROSE SOLN 54 bupivacaine spinal soln 54 bupivacaine-epinephrine (pf) soln 54 bupivacaine-epinephrine soln 54 buprenorphine hcl soln 27
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 71
buprenorphine hcl subl 2mg 8mg 34 buprenorphine hcl-naloxone hcl film 34 buprenorphine hcl-naloxone hcl subl 34 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 27 bupropion hcl er (smoking det) tb12 35 bupropion hcl er (sr) tb12 100mg 150mg
200mg 35 bupropion hcl er (xl) tb24 150mg 300mg
450mg 35 bupropion hcl tabs 75mg 100mg 35 buspirone hcl tabs 5mg 10mg 33 buspirone hcl tabs 75mg 15mg 30mg 33 busulfan soln 15 butalbital-acetaminophen caps 27 butalbital-acetaminophen tabs 27 butalbital-apap-caff-cod caps 27 butalbital-apap-caffeine caps 27 butalbital-apap-caffeine tabs 27 butalbital-asa-caff-codeine caps 27 butalbital-aspirin-caffeine caps 27 butalbital-aspirin-caffeine tabs 27 butorphanol tartrate soln 1mgml 2mgml
10mgml 27 BUTRANS PTWK 27 BYDUREON BCISE AUIJ 48 BYDUREON PEN 48 BYETTA 10 MCG PEN SOPN 48 BYETTA 5 MCG PEN SOPN 48 BYLVAY (PELLETS) CPSP 200mcg
600mcg 44 BYLVAY CAPS 400mcg 1200mcg 44 BYNFEZIA PEN SOPN 51
C CABENUVA SUER 12 cabergoline tabs 32 CABLIVI KIT 22 CABOMETYX TABS 20mg 40mg 60mg 15 cafergot tabs 32 caffeine citrate soln 30 calcipotriene crea 62 calcipotriene oint 62 calcipotriene soln 62 calcipotriene-betameth diprop oint 59 calcipotriene-betameth diprop susp 59 calcitonin (salmon) soln 50 calcitrene oint 62 calcitriol caps 025mcg 05mcg 63
CALCITRIOL OINT 62 calcitriol soln 63 calcium acetate (phos binder) caps 39 calcium acetate (phos binder) tabs 39 CALCIUM GLUCONATE-NACL SOLN 39 CALQUENCE CAPS 15 camila tabs 46 camrese lo tabs 46 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 59 CAPLYTA CAPS 35 CAPRELSA TABS 100mg 300mg 15 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 26 CARAC CREA 62 CARAFATE SUSP 43 CARBAGLU TABS 37 carbamazepine chew 30 carbamazepine er cp12 100mg 200mg
300mg 30 carbamazepine er tb12 100mg 200mg
400mg 30 carbamazepine susp 30 carbamazepine tabs 30 carbidopa tabs 32 carbidopa-levodopa er tbcr 32 carbidopa-levodopa tabs 32 carbidopa-levodopa tbdp 32 carbidopa-levodopa-entacapone tabs 32 carbinoxamine maleate soln 14 carbinoxamine maleate tabs 14 carboplatin soln 15 carboprost tromethamine soln 50 CARDENE IV SOLN 24 CARDIZEM LA TB24 24 CARDURA XL TB24 4mg 8mg 22 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 15 CARNITOR SOLN 54 CARNITOR TABS 54 CAROSPIR SUSP 26 carteolol hcl soln 42
72 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
cartia xt cp24 120mg 180mg 240mg 300mg 24
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg 23
carvedilol tabs 3125mg 625mg 125mg 25mg 23
caspofungin acetate solr intravenous 50mg 70mg 11
cataflam tabs 27 CAYSTON SOLR 56 caziant tabs 46 cefaclor caps 8 cefaclor er tb12 8 cefaclor susr 8 cefadroxil caps 8 cefadroxil susr 8 cefadroxil tabs 8 cefazolin sodium solr 8 cefazolin sodium solr injection 1gm 10gm
500mg 8 cefdinir caps 8 cefdinir susr 8 cefepime hcl solr injection 1gm 2gm 8 cefixime caps 8 cefixime susr 8 cefotaxime sodium solr 8 cefotetan disodium solr injection 1gm 2gm 8 cefoxitin sodium solr injection 8 cefoxitin sodium solr intravenous 1gm 2gm
8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 2gm 6gm 8 CEFTIN SUSR 8 ceftriaxone sodium solr injection 1gm 2gm
250mg 500mg 8 ceftriaxone sodium solr intravenous 8 cefuroxime axetil tabs 8 cefuroxime sodium solr injection 75gm
750mg 8 cefuroxime sodium solr intravenous 8 celecoxib caps 27 CELONTIN CAPS 30 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 41
CERDELGA CAPS 40 CEREZYME SOLR 40 CEROVEL LOTN 62 CESAMET CAPS 43 cetirizine hcl soln 14 CETRAXAL SOLN 40 CEVIMELINE HCL CAPS 20 CHANTIX CONTINUING MONTH PAK
TABS 20 CHANTIX STARTING MONTH PAK TABS
20 CHANTIX TABS 05mg 1mg 20 CHEMET CAPS 44 chloramphenicol sod succinate solr 9 chlordiazepoxide hcl caps 5mg 10mg
25mg 33 chlordiazepoxide-amitriptyline tabs 35 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 40 chloroprocaine hcl (pf) soln 54 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 38 chlorothiazide tabs 250mg 500mg 38 chlorpromazine hcl soln 35 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 35 chlorthalidone tabs 25mg 50mg 38 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 44 cholestyramine light pack 23 cholestyramine light powd 23 cholestyramine pack 23 cholestyramine powd 23 CHORIONIC GONADOTROPIN SOLR 50 ciclopirox gel 58 ciclopirox olamine crea 58 ciclopirox olamine susp 58 ciclopirox sham 58 ciclopirox soln 58 cidofovir soln 12 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 40 CIMDUO TABS 12 cimetidine hcl soln 43 cimetidine tabs 200mg 300mg 400mg
800mg 43 CIMZIA KIT 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 73
CIMZIA PREFILLED KIT 52 CIMZIA STARTER KIT KIT 52 cinacalcet hcl tabs 30mg 60mg 90mg 50 CINQAIR SOLN 55 CINRYZE SOLR INTRAVENOUS 54 CIPRO HC SUSP 41 CIPRODEX SUSP 41 ciprofloxacin hcl soln (ophth) 40 CIPROFLOXACIN HCL SOLN (OTIC) 40 ciprofloxacin hcl tabs 9 ciprofloxacin in d5w soln 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 41 CIPROFLOXACIN-FLUOCINOLONE PF
SOLN 40 cisplatin soln 15 CISPLATIN SOLR 15 citalopram hydrobromide soln 35 citalopram hydrobromide tabs 10mg 20mg
40mg 35 citanest plain dental soln 54 cladribine soln 15 claravis caps 10mg 20mg 30mg 40mg 62 CLARINEX SYRP 14 CLARINEX-D 12 HOUR TB12 14 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 14 cleocin phosphate soln 9 cleocin solr 9 CLEOCIN SUPP 58 CLIMARA PRO PTWK 49 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
clindacin-p swab 58 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 58 clindamycin phosphate crea 58 clindamycin phosphate foam 58 clindamycin phosphate gel 58 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 58
clindamycin phosphate soln 9 58 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 58 CLINDESSE CREA 58 CLINIMIX EDEXTROSE (27510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42525) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (525) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (525) SOLN
INTRAVENOUS 38 clinisol sf soln intravenous 38 clobazam susp 30 clobazam tabs 10mg 20mg 30 clobetasol propionate crea 59 clobetasol propionate e crea 59 clobetasol propionate emulsion foam 59 clobetasol propionate foam 59 clobetasol propionate gel 59 clobetasol propionate liqd 60 clobetasol propionate lotn 60 clobetasol propionate oint 60 clobetasol propionate sham 60 clobetasol propionate soln 60 CLOBEX SHAM 60
74 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
CLOBEX SPRAY LIQD 60 clocortolone pivalate crea 60 clocortolone pivalate pump crea 60 clodan sham 60 clofarabine soln 15 clomipramine hcl caps 25mg 50mg 75mg
35 clonazepam tabs 05mg 1mg 2mg 30 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 30 clonidine hcl (analgesia) soln 25 clonidine hcl er tb12 25 clonidine hcl tabs 01mg 02mg 03mg 25 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 25 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 33 clotrimazole crea 58 clotrimazole soln 58 clotrimazole troc 58 clotrimazole-betamethasone crea 58 clotrimazole-betamethasone lotn 58 clovique caps 44 clozapine tabs 25mg 50mg 100mg 200mg
35 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 35 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 27 colazal caps 43 COLCHICINE CAPS 52 colchicine tabs 52 colchicine-probenecid tabs 40 colesevelam hcl pack 23 colesevelam hcl tabs 23 colestipol hcl gran 23 colestipol hcl pack 23 colestipol hcl tabs 23 colistimethate sodium (cba) solr injection 9 colocort enem 60 COLY-MYCIN S SUSP 41 COMBIGAN SOLN 42 COMBIPATCH PTTW 49 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 15 COMETRIQ (140 MG DAILY DOSE) KIT 15 COMETRIQ (60 MG DAILY DOSE) KIT 15
COMPLERA TABS 12 compro supp 35 CONDYLOX GEL 62 CONSENSI TABS 24 constulose soln 37 COPIKTRA CAPS 15mg 25mg 15 CORDRAN TAPE 60 CORLANOR TABS 5mg 75mg 25 cortisone acetate tabs 45 CORTISPORIN CREA 60 CORTISPORIN OINT 60 COSELA SOLR 54 COSENTYX (300 MG DOSE) SOSY 62 COSENTYX SENSOREADY (300 MG)
SOAJ 62 COSENTYX SENSOREADY PEN SOAJ 62 COSENTYX SOSY 75mg05ml 150mgml
62 COTELLIC TABS 15 COTEMPLA XR-ODT TBED 86mg
173mg 259mg 30 CREON CPEP 40 CRESEMBA CAPS 11 CRESEMBA SOLR 11 CRINONE GEL 4 8 50 CRIXIVAN CAPS 200mg 400mg 12 cromolyn sodium conc 55 cromolyn sodium nebu 55 cromolyn sodium soln 42 crotan lotn 58 cryselle-28 tabs 46 CRYSVITA SOLN 10mgml 20mgml
30mgml 54 CUPRIMINE CAPS 44 CURITY GAUZE PADS 37 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 57
CUVPOSA SOLN 19 cyclafem 135 tabs 46 cyclafem 777 tabs 46 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 15 CYCLOPHOSPHAMIDE SOLN 1gm5ml
500mg25ml 15 cyclophosphamide solr 15
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 75
cycloserine caps 11 CYCLOSET TABS 48 cyclosporine caps 25mg 100mg 53 cyclosporine modified caps 25mg 50mg
100mg 53 cyclosporine modified soln 53 cyclosporine soln 53 cyproheptadine hcl syrp 14 cyproheptadine hcl tabs 14 CYRAMZA SOLN 100mg10ml
500mg50ml 15 cyred eq tabs 46 CYSTADANE POWD 54 CYSTADROPS SOLN 42 CYSTAGON CAPS 50mg 150mg 54 CYSTARAN SOLN 42 cytarabine (pf) soln 15 cytarabine soln 15 CYTOGAM INJ 57
D dacarbazine solr 15 dactinomycin solr 15 DAKLINZA TABS 30mg 60mg 90mg 12 dalfampridine er tb12 34 DALIRESP TABS 250mcg 500mcg 56 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 45 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 62 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 57 daptomycin solr intravenous 350mg 500mg
9 DARAPRIM TABS 11 darifenacin hydrobromide er tb24 75mg
15mg 63 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 DAYTRANA PTCH 10mg9hr 15mg9hr
20mg9hr 30mg9hr 30 DDAVP RHINAL TUBE SOLN 50 deblitane tabs 46 decadron elix 45
decadron tabs 5mg 75mg 45 decadron tabs 4mg 6mg 45 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 44 deferasirox tabs 90mg 180mg 360mg 44 deferasirox tbso 125mg 44 deferasirox tbso 250mg 500mg 44 deferiprone tabs 44 deferoxamine mesylate solr 44 DELESTROGEN OIL 49 DELSTRIGO TABS 12 deltasone tabs 45 delyla tabs 46 DELZICOL CPDR 43 demeclocycline hcl tabs 9 DEMEROL SOLN 25mg05ml 75mg15ml
100mg2ml 75mgml 27 DEMSER CAPS 22 DENAVIR CREA 58 DEPEN TITRATABS TABS 44 depo-estradiol oil 49 DEPO-MEDROL SUSP 45 DEPO-PROVERA SUSP 400mgml 50 DEPO-SUBQ PROVERA 104 SUSY 50 depo-testosterone soln 100mgml
200mgml 45 DERMOTIC OIL 41 DESCOVY TABS 12 desipramine hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 desloratadine tabs 14 desloratadine tbdp 14 desmopressin ace spray refrig soln 50 desmopressin acetate
soln 50 DESMOPRESSIN ACETATE SOLN 50 desmopressin acetate spray soln 50 DESMOPRESSIN ACETATE TABS 01mg
02mg 50 desogestrel-ethinyl estradiol tabs 46 DESONATE GEL 60 desonide crea 60 desonide gel 60 desonide lotn 60 desonide oint 60 desowen lotn 60 desoximetasone crea 005 025 60 desoximetasone gel 60
76 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
desoximetasone liqd 60 desoximetasone oint 005 025 60 desrx gel 60 DESVENLAFAXINE ER TB24 50mg
100mg 35 desvenlafaxine succinate er tb24 25mg
50mg 100mg 35 dexabliss tbpk 45 dexamethasone elix 45 dexamethasone intensol conc 45 dexamethasone sod phosphate pf soln 45 dexamethasone sodium phosphate soln 41
45 dexamethasone soln 45 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 45 dexamethasone tbpk 45 dexchlorpheniramine maleate soln 14 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 30
dexmethylphenidate hcl tabs 25mg 5mg 10mg 30
dexpak 10 day tbpk 45 dexpak 13 day tbpk 45 dexpak 6 day tbpk 45 dexrazoxane hcl solr 54 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 30 dextroamphetamine sulfate soln 30 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 30 DEXTROSE 10NACL 02 39 DEXTROSE 5NACL 0225 39 DEXTROSE IN LACTATED RINGERS
SOLN 39 DEXTROSE SOLN 38 dextrose soln intravenous 5 10 38 DEXTROSE-NACL SOLN INTRAVENOUS
39 DIACOMIT CAPS 250mg 500mg 30 DIACOMIT PACK 250mg 500mg 31 DIASTAT ACUDIAL GEL 10mg 20mg 31 DIASTAT PEDIATRIC GEL 31 diazepam conc 33 diazepam gel 25mg 10mg 20mg 31 diazepam soln 5mg5ml 5mgml 33 diazepam tabs 2mg 5mg 10mg 33 diazoxide susp 48
diclofenac potassium tabs 27 diclofenac sodium er tb24 27 diclofenac sodium gel 1 3 60 diclofenac sodium soln 41 diclofenac sodium tbec 27 diclofenac-misoprostol tbec 27 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 12 DIFFERIN CREA 62 DIFFERIN LOTN 62 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 60 diflorasone diacetate oint 60 diflunisal tabs 27 digitek tabs 0125mg 025mg 25 digox tabs 25 DIGOXIN ORAL SOLN 25 digoxin soln inj 25 digoxin tabs 125mcg 250mcg 25 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 31 dilantin infatabs chew 31 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 24 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 24
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 24
diltiazem hcl er cp12 60mg 90mg 120mg 24
diltiazem hcl er cp24 120mg 180mg 240mg 24
diltiazem hcl soln 24 diltiazem hcl solr 24 diltiazem hcl tabs 30mg 60mg 90mg
120mg 24 dilt-xr cp24 120mg 180mg 240mg 24 dimenhydrinate soln 43 dimethyl fumarate cpdr 34 dimethyl fumarate starter pack misc 34 DIPENTUM CAPS 43 diphen elix 14 di-phen elix 14 diphenhydramine hcl elix 14
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 77
diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 43 diphenoxylate-atropine tabs 43 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 57 dipyridamole tabs 25mg 50mg 75mg 26 disopyramide phosphate caps 100mg
150mg 25 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 38 divalproex sodium csdr 31 divalproex sodium er tb24 250mg 500mg 31 divalproex sodium tbec 125mg 250mg
500mg 31 DIVIGEL GEL 49 dobutamine hcl soln 21 DOBUTAMINE IN D5W SOLN 21 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 160mg8ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
25 dolishale tabs 46 donepezil hcl tabs 5mg 10mg 23mg 20 donepezil hcl tbdp 5mg 10mg 20 dopamine hcl soln 21 DOPAMINE IN D5W SOLN 21 DOPTELET TABS 22 DORYX MPC TBEC 9 dorzolamide hcl soln 42 dorzolamide hcl-timolol mal pf soln 42 dorzolamide hcl-timolol mal soln 42 dotti pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 49
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 35 doxepin hcl conc 35 doxepin hcl crea 61 doxepin hcl tabs 3mg 6mg 35 doxercalciferol caps 05mcg 1mcg 25mcg
63 DOXERCALCIFEROL SOLN 63 doxorubicin hcl liposomal inj 15 DOXORUBICIN HCL SOLN 15
doxorubicin hcl solr 15 doxy 100 solr intravenous 9 doxycycline hyclate caps 50mg 100mg 9 doxycycline hyclate tabs 20mg 75mg
100mg 150mg 9 doxycycline hyclate tbec 50mg 75mg
100mg 150mg 200mg 9 doxycycline monohydrate caps 50mg
75mg 100mg 150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 43 DRIZALMA SPRINKLE CSDR 35 dronabinol caps 25mg 5mg 10mg 43 droperidol soln 33 drospiren-eth estrad-levomefol tabs 46 drospirenone-ethinyl estradiol tabs 46 DROXIA CAPS 15 droxidopa caps 21 DUAKLIR PRESSAIR AEPB 19 DUAVEE TABS 49 DUEXIS TABS 27 DULERA AERO 56 duloxetine hcl cpep 20mg 30mg 40mg
60mg 35 DUOBRII LOTN 60 DUOPA SUSP 32 DUPIXENT SOPN 200mg114ml
300mg2ml 55 DUPIXENT SOSY 200mg114ml
300mg2ml 55 DURAMORPH SOLN 05mgml 1mgml 27 DUREZOL EMUL 41 DURYSTA IMPL 42 dutasteride caps 52 dutasteride-tamsulosin hcl caps 52 DUTOPROL TB24 23 dvorah tabs 27 dxevo 11-day tbpk 45 DYANAVEL XR SUER 30 DYSPORT SOLR 300unit 500unit 54
E ees 400 tabs 9 EASYGEL GEL 54 econazole nitrate crea 58 EDARBYCLOR TABS 26 EDLUAR SUBL 5mg 10mg 33
78 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 51 EGRIFTA SV SOLR 51 ELAPRASE SOLN 40 ELELYSO SOLR 40 ELEPSIA XR TB24 1000mg 1500mg 31 ELESTRIN GEL 49 eletriptan hydrobromide tabs 32 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 40 elixophyllin elix 63 ELLA TABS 46 ELLENCE SOLN 15 ELMIRON CAPS 54 eluryng ring 46 ELZONRIS SOLN 15 EMBEDA CPCR 27 EMCYT CAPS 15 EMEND SUSR 43 EMFLAZA SUSP 45 EMFLAZA TABS 6mg 18mg 30mg 36mg
45 EMGALITY (300 MG DOSE) SOSY 32 EMGALITY SOAJ 32 EMGALITY SOSY 32 emoquette tabs 46 EMPAVELI SOLN 54 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 32 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 26 enalaprilat inj 26 enalapril-hydrochlorothiazide tabs 26 ENBREL MINI SOCT 52 ENBREL SOLN 52 ENBREL SOLR 52 ENBREL SOSY 25mg05ml 50mgml 52 ENBREL SURECLICK SOAJ 52 ENDARI PACK 54 endocet tabs 27
ENDOMETRIN INST 50 ENGERIX-B SUSP 10mcg05ml 20mcgml
57 ENHERTU SOLR 15 enoxaparin sodium soln 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
enpresse-28 tabs 46 enskyce tabs 46 ENSPRYNG SOSY 54 ENSTILAR FOAM 60 entacapone tabs 33 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 26 ENTYVIO SOLR 44 enulose soln 37 ENVARSUS XR TB24 075mg 1mg 4mg53 EPCLUSA TABS 12 EPIDIOLEX SOLN 31 EPIDUO FORTE GEL 62 epifoam foam 60 epinastine hcl soln 42 epinephrine (anaphylaxis) soln 21 epinephrine soaj 21 EPINEPHRINE SOSY 21 EPIPEN 2-PAK SOAJ 21 EPIPEN JR 2-PAK SOAJ 21 epirubicin hcl soln 15 epitol tabs 31 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 26 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 22
epoprostenol sodium solr 56 eprosartan mesylate tabs 26 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 35 ERAXIS SOLR INTRAVENOUS 50mg
100mg 11 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 32 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 79
ERTACZO CREA 58 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 58 ery-tab tbec 9 ERYTHROCIN LACTOBIONATE SOLR
INTRAVENOUS 9 erythrocin stearate tabs 9 erythromycin base cpep 9 erythromycin base tabs 9 erythromycin base tbec 9 erythromycin ethylsuccinate susr 9 erythromycin ethylsuccinate tabs 9 erythromycin gel 58 erythromycin oint 40 erythromycin pads 58 erythromycin soln 58 ESBRIET CAPS 56 ESBRIET TABS 267mg 801mg 56 escitalopram oxalate soln 35 escitalopram oxalate tabs 5mg 10mg
20mg 35 esgic caps 27 esgic tabs 27 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 43 esomeprazole magnesium pack 10mg
20mg 40mg 43 esomeprazole sodium solr 43 ESOMEPRAZOLE STRONTIUM CPDR 43 estarylla tabs 46 estazolam tabs 1mg 2mg 33 estrace crea 49 estrace tabs 05mg 1mg 2mg 49 estradiol crea 49 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 49
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
estradiol tabs 10mcg 05mg 1mg 2mg 49 estradiol valerate oil 49 estradiol-norethindrone acet tabs 49 ESTRING RING 49 eszopiclone tabs 1mg 2mg 3mg 33
ethacrynic acid tabs 38 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 31 ethosuximide soln 31 ethynodiol diac-eth estradiol tabs 46 etodolac caps 27 etodolac er tb24 27 etodolac tabs 27 etonogestrel-ethinyl estradiol ring 46 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 EURAX CREA 58 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
EVAMIST SOLN 49 evekeo tabs 5mg 10mg 30 EVENITY SOSY 52 everolimus tabs 025mg 53 everolimus tabs 05mg 075mg 53 everolimus tabs 25mg 5mg 75mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 23 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 54 EXELDERM CREA 58 EXELDERM SOLN 58 exemestane tabs 15 EXJADE TBSO 125mg 250mg 500mg 44 EXONDYS 51 SOLN 500mg10ml
100mg2ml 54 EXSERVAN FILM 34 EXTAVIA KIT 34 EYLEA SOLN 42 EYLEA SOSY 42 ezetimibe tabs 23 ezetimibe-simvastatin tabs 23
F FABIOR FOAM 62 FABRAZYME SOLR 5mg 35mg 40 falmina tabs 46 famciclovir tabs 125mg 250mg 500mg 12 famotidine premixed soln 43 famotidine soln 43 famotidine susr 43 famotidine tabs 20mg 40mg 43
80 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg 35
FANAPT TITRATION PACK TABS 35 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 55 FASENRA SOSY 55 FASLODEX SOLN 15 fayosim tabs 46 febuxostat tabs 40mg 80mg 52 felbamate susp 31 felbamate tabs 400mg 600mg 31 felodipine er tb24 25mg 5mg 10mg 24 femynor tabs 46 fenofibrate caps 50mg 134mg 150mg 23 fenofibrate micronized caps 43mg 67mg
130mg 200mg 23 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 23 fenofibric acid cpdr 45mg 135mg 23 FENOFIBRIC ACID TABS 35mg 105mg 23 fenoprofen calcium caps 27 fenoprofen calcium tabs 27 fenortho caps 27 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 27 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 27
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg 27
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 27
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 27
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg 27
FERRIPROX SOLN 44 FERRIPROX TABS 500mg 1000mg 44 FERRIPROX TWICE-A-DAY TABS 44 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
35 FETZIMA TITRATION C4PK 35 fexmid tabs 20 FIBRICOR TABS 23 FINACEA FOAM 62 finasteride tabs 52 FINTEPLA SOLN 31
fioricet caps 27 fioricetcodeine caps 27 FIRAZYR SOLN 21 FIRDAPSE TABS 54 FIRMAGON (240 MG DOSE) SOLR 16 FIRMAGON SOLR 16 FIRVANQ SOLR 9 flac oil 41 FLAREX SUSP 41 flavoxate hcl tabs 63 FLEBOGAMMA DIF SOLN INTRAVENOUS
5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml 57
flecainide acetate tabs 50mg 100mg 150mg 25
FLOLIPID SUSP 20mg5ml 40mg5ml 23 FLOVENT DISKUS AEPB 50mcgblist
100mcgblist 250mcgblist 56 FLOVENT HFA AERO 110mcgact
220mcgact 56 FLOVENT HFA AERO 44mcgact 56 floxuridine solr 16 fluconazole in sodium chloride soln
intravenous 11 fluconazole susr 11 fluconazole tabs 11 flucytosine caps 250mg 500mg 11 fludarabine phosphate soln 16 fludarabine phosphate solr 16 fludrocortisone acetate tabs 45 flumazenil soln 34 flunisolide soln 41 fluocinolone acetonide body oil 60 fluocinolone acetonide crea 001 0025
60 fluocinolone acetonide oil 41 fluocinolone acetonide oint 60 fluocinolone acetonide scalp oil 60 fluocinolone acetonide soln 60 fluocinonide crea 60 fluocinonide emulsified base crea 60 FLUOCINONIDE GEL 60 fluocinonide oint 60 fluocinonide soln 60 FLUORITAB CHEW 025mg 05mg 1mg 54 FLUORITAB SOLN 54 fluorometholone susp 41 fluorouracil crea 5 62
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fluorouracil crea 5 62 fluorouracil soln 16 62 fluorouracil soln 2 5 62 fluoxetine hcl (pmdd) tabs 10mg 20mg 35 fluoxetine hcl caps 10mg 20mg 40mg 35 fluoxetine hcl cpdr 35 fluoxetine hcl soln 35 fluoxetine hcl tabs 10mg 20mg 60mg 36 fluphenazine decanoate soln 36 fluphenazine hcl conc 36 fluphenazine hcl elix 36 fluphenazine hcl soln 36 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 36 flurandrenolide crea 60 flurandrenolide lotn 60 flurandrenolide oint 60 flurazepam hcl caps 15mg 30mg 33 flurbiprofen sodium soln 41 flurbiprofen tabs 27 flutamide caps 16 fluticasone propionate crea 60 fluticasone propionate lotn 60 fluticasone propionate oint 60 fluticasone propionate susp 41 fluticasone-salmeterol aepb 56 fluvastatin sodium caps 20mg 40mg 23 fluvastatin sodium er tb24 23 fluvoxamine maleate er cp24 100mg
150mg 36 fluvoxamine maleate tabs 25mg 50mg
100mg 36 FML FORTE SUSP 41 FML OINT 41 fomepizole soln 52 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 formoterol fumarate nebu 21 FORTEO SOPN 50 FOSAMAX PLUS D TABS 52 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 43 fosfomycin tromethamine pack 14 fosinopril sodium tabs 10mg 20mg 40mg
26 fosinopril sodium-hctz tabs 26 fosphenytoin sodium soln 31 FOSRENOL PACK 750mg 1000mg 39
FOTIVDA CAPS 089mg 134mg 16 FREAMINE HBC SOLN INTRAVENOUS 38 frovatriptan succinate tabs 32 FULPHILA SOSY 22 fulvestrant soln 16 furosemide soln 8mgml 10mgml 38 furosemide soln injection 38 FUROSEMIDE TABS 40mg 80mg 20mg38 FUZEON SOLR 12 fyavolv tabs 49 FYCOMPA SUSP 31 FYCOMPA TABS 31
G gabapentin caps 100mg 400mg 31 gabapentin soln 31 gabapentin tabs 600mg 800mg 31 GALAFOLD CAPS 54 galantamine hydrobromide er cp24 8mg
16mg 24mg 20 galantamine hydrobromide soln 20 galantamine hydrobromide tabs 4mg 8mg
12mg 20 GAMASTAN INJ 57 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 53 GAMMAGARD SD LESS IGA SOLR
INTRAVENOUS 5gm 10gm 57 GAMMAGARD SOLN INJECTION 57 GAMMAKED SOLN INJECTION 57 GAMMAPLEX SOLN INTRAVENOUS
10gm100ml 20gm200ml 5gm50ml 57 GAMMAPLEX SOLN INTRAVENOUS
10gm200ml 57 GAMUNEX-C SOLN INJECTION
10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml 57
ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 57 GARDASIL 9 SUSY 57 gatifloxacin soln 40 GATTEX KIT 44 gavilyte-c solr 44 gavilyte-g solr 44 gavilyte-h kit 44 gavilyte-n with flavor pack solr 44 GAVRETO CAPS 16 GAZYVA SOLN 16
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gemcitabine hcl soln 16 gemcitabine hcl solr 16 gemfibrozil tabs 23 gemmily caps 46 generlac soln 37 gengraf caps 25mg 50mg 100mg 53 gengraf soln 53 GENOTROPIN MINIQUICK SOLR 02mg 51 GENOTROPIN MINIQUICK SOLR 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 51
GENOTROPIN SOLR 5mg 12mg 51 gentak oint 40 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 58 gentamicin sulfate oint 58 gentamicin sulfate soln 9 40 gentamicin sulfate soln injection 9 GENVOYA TABS 12 GEODON SOLR 36 gianvi tabs 46 GILENYA CAPS 025mg 05mg 34 GILOTRIF TABS 20mg 30mg 40mg 16 GIMOTI SOLN 44 GIVLAARI SOLN 54 GLASSIA SOLN INTRAVENOUS 56 glatiramer acetate sosy 20mgml 40mgml
34 glatopa sosy 20mgml 40mgml 34 glimepiride tabs 1mg 2mg 4mg 48 glipizide er tb24 25mg 5mg 10mg 48 glipizide tabs 5mg 10mg 48 glipizide-metformin hcl tabs 48 GLOPERBA SOLN 52 GLUCAGEN HYPOKIT SOLR 48 glucagon emergency kit 48 glyburide micronized tabs 15mg 3mg 6mg
48 glyburide tabs 125mg 25mg 5mg 48 glyburide-metformin tabs 48 glycate tabs 19 glycopyrrolate pf sosy 19 glycopyrrolate soln 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 61 GLYXAMBI TABS 48 GOLYTELY SOLR 44 GONITRO PACK 26
granisetron hcl soln 43 granisetron hcl tabs 43 GRANIX SOLN 480mcg16ml 300mcgml
22 GRANIX SOSY 300mcg05ml
480mcg08ml 22 GRASTEK SUBL 54 griseofulvin microsize susp 11 griseofulvin microsize tabs 11 griseofulvin ultramicrosize tabs 11 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 34 guanfacine hcl tabs 1mg 2mg 25 GUANIDINE HCL TABS 20 gynazole-1 crea 58
H HAEGARDA SOLR 2000unit 3000unit 54 hailey 24 fe tabs 46 halcinonide crea 60 halobetasol propionate crea 60 HALOBETASOL PROPIONATE FOAM 60 halobetasol propionate oint 60 HALOG CREA 60 HALOG OINT 60 haloperidol decanoate soln 36 haloperidol lactate conc 36 haloperidol lactate soln 36 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 36 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 57 heparin (porcine) in nacl soln 21 HEPARIN SOD (PORCINE) IN D5W SOLN
21 heparin sodium (porcine) pf soln 21 heparin sodium (porcine) soln 1000unitml
5000unitml 10000unitml 20000unitml 21
HEPATAMINE SOLN INTRAVENOUS 38 HEPLISAV-B SOLN 57 HERCEPTIN HYLECTA SOLN 16 HERCEPTIN SOLR 150mg 440mg 16 HERZUMA SOLR 150mg 420mg 16 HETLIOZ CAPS 33 HETLIOZ LQ SUSP 33 HEXALEN CAPS 16 HIBERIX SOLR 57
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HORIZANT TBCR 300mg 600mg 31 HUMALOG JUNIOR KWIKPEN SOPN 48 HUMALOG KWIKPEN SOPN 100unitml
200unitml 48 HUMALOG MIX 5050 KWIKPEN SUPN 48 HUMALOG MIX 5050 SUSP 48 HUMALOG MIX 7525 KWIKPEN SUPN 48 HUMALOG MIX 7525 SUSP 48 HUMALOG SOCT 48 HUMALOG SOLN 48 humatin caps 11 HUMATROPE SOLR 5mg 6mg 12mg
24mg 51 HUMIRA PEDIATRIC CROHNS START
PSKT 52 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 52 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 52 HUMIRA PEN-PEDIATRIC UC START
PNKT 52 HUMIRA PEN-PSUVADOL HS START
PNKT 52 HUMIRA PEN-PSORUVEIT STARTER
PNKT 52 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 52
HUMULIN 7030 KWIKPEN SUPN 48 HUMULIN 7030 SUSP 48 HUMULIN N KWIKPEN SUPN 48 HUMULIN N SUSP 48 HUMULIN R SOLN 48 HUMULIN R U-500 (CONCENTRATED)
SOLN 48 HUMULIN R U-500 KWIKPEN SOPN 48 hydralazine hcl soln 25 hydralazine hcl tabs 10mg 25mg 50mg
100mg 25 hydrochlorothiazide caps 38 hydrochlorothiazide tabs 125mg 25mg
50mg 38 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 27 hydrocodone-acetaminophen soln 27 hydrocodone-acetaminophen tabs 27 hydrocodone-ibuprofen tabs 27 hydrocortisone (perianal) crea 1 25 60 hydrocortisone ace-pramoxine crea 61
hydrocortisone butyr lipo base crea 60 hydrocortisone butyrate crea 60 hydrocortisone butyrate lotn 60 HYDROCORTISONE BUTYRATE OINT 60 hydrocortisone butyrate soln 60 hydrocortisone crea 1 25 60 hydrocortisone enem 60 hydrocortisone lotn 60 hydrocortisone oint 1 25 60 hydrocortisone tabs 5mg 10mg 20mg 45 hydrocortisone valerate crea 60 hydrocortisone valerate oint 60 HYDROCORTISONE-ACETIC ACID SOLN
41 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 28 hydromorphone hcl liqd 28 hydromorphone hcl pf soln 50mg5ml
10mgml 28 HYDROMORPHONE HCL SOLN 1mgml
2mgml 28 hydromorphone hcl tabs 2mg 4mg 8mg 28 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 50 hydroxyprogesterone caproate soln 50 hydroxyurea caps 16 hydroxyzine hcl soln 33 hydroxyzine hcl syrp 33 hydroxyzine hcl tabs 33 hydroxyzine pamoate caps 33 HYPERHEP B SOLN 57 HYPERRAB SD SOLN 57 HYQVIA KIT 57
I IBANDRONATE SODIUM SOLN 52 ibandronate sodium tabs 52 IBRANCE CAPS 75mg 100mg 125mg 16 IBRANCE TABS 75mg 100mg 125mg 16 ibu tabs 28 ibudone tabs 28 ibuprofen lysine soln 28 ibuprofen susp 28 ibuprofen tabs 28 ibutilide fumarate soln 25 icatibant acetate soln 21 iclevia tabs 46 ICLUSIG TABS 10mg 15mg 30mg 45mg
16
84 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
icosapent ethyl caps 23 IDAMYCIN PFS SOLN 16 idarubicin hcl soln 16 IDHIFA TABS 50mg 100mg 16 ifosfamide soln 16 IFOSFAMIDE SOLR 16 ILARIS SOLN 28 ILEVRO SUSP 41 ILUMYA SOSY 62 ILUVIEN IMPL 41 imatinib mesylate tabs 16 IMBRUVICA CAPS 70mg 140mg 16 IMBRUVICA TABS 140mg 280mg 420mg
560mg 16 IMFINZI SOLN 500mg10ml 120mg24ml
16 imipenem-cilastatin solr intravenous 9 imipramine hcl tabs 10mg 25mg 50mg 36 imipramine pamoate caps 75mg 100mg
125mg 150mg 36 imiquimod crea 375 5 62 IMIQUIMOD PUMP CREA 62 IMOGAM RABIES-HT SOLN 57 IMOVAX RABIES INJ 57 IMPAVIDO CAPS 11 IMVEXXY MAINTENANCE PACK INST
4mcg 10mcg 49 IMVEXXY STARTER PACK INST 4mcg
10mcg 49 INBRIJA CAPS 33 incassia tabs 46 INCRELEX SOLN 51 INCRUSE ELLIPTA AEPB 19 indapamide tabs 125mg 25mg 38 indocin supp 28 INDOCIN SUSP 28 indomethacin caps 28 INDOMETHACIN CAPS 20mg 28 indomethacin er cpcr 28 indomethacin sodium solr 28 INFANRIX SUSP 57 INFLECTRA SOLR INTRAVENOUS 52 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 34 INGREZZA CPPK 34 INLYTA TABS 1mg 5mg 16 INNOPRAN XL CP24 80mg 120mg 23 INQOVI TABS 16 INREBIC CAPS 16
INSULIN ASP PROT amp ASP FLEXPEN SUPN 48
INSULIN ASPART FLEXPEN SOPN 48 INSULIN ASPART PENFILL SOCT 48 INSULIN ASPART PROT amp ASPART SUSP
48 INSULIN ASPART SOLN 48 INSULIN LISPRO (1 UNIT DIAL) SOPN 48 INSULIN LISPRO SOLN 48 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 38 INTRALIPID EMUL INTRAVENOUS
20gm100ml 38 INTRAROSA INST 45 INTRON A SOLN 10muml 6000000unitml
16 INTRON A SOLR 10mu 18mu 50mu 16 introvale tabs 46 INVEGA SUSTENNA SUSY 39mg025ml
36 INVEGA SUSTENNA SUSY 78mg05ml
117mg075ml 234mg15ml 156mgml 36
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml 36
INVELTYS SUSP 41 INVIRASE CAPS 12 INVIRASE TABS 12 INVOKAMET TABS 48 INVOKAMET XR TB24 48 INVOKANA TABS 100mg 300mg 48 IONOSOL-MB IN D5W SOLN
INTRAVENOUS 39 IOPIDINE SOLN 42 IPOL INJ 57 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 21 irbesartan tabs 75mg 150mg 300mg 26 irbesartan-hydrochlorothiazide tabs 26 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isibloom tabs 46
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ISOLYTE-P IN D5W SOLN INTRAVENOUS 39
ISOLYTE-S SOLN INTRAVENOUS 39 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 21 isosorbide dinitrate er tbcr 26 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 26 isosorbide mononitrate er tb24 26 isosorbide mononitrate er tb24 30mg 60mg
26 isosorbide mononitrate tabs 10mg 20mg 26 isotretinoin caps 10mg 20mg 30mg 40mg
62 isradipine caps 25mg 5mg 24 ISTURISA TABS 1mg 5mg 10mg 54 itraconazole caps 11 ITRACONAZOLE SOLN 11 ivermectin crea 58 ivermectin lotn 58 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 57
J JADENU SPRINKLE PACK 90mg 180mg
360mg 44 JADENU TABS 90mg 360mg 44 JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16 jantoven tabs 1mg 2mg 25mg 3mg 4mg
5mg 6mg 75mg 10mg 21 JARDIANCE TABS 10mg 25mg 48 jasmiel tabs 46 JEMPERLI SOLN 16 JENTADUETO TABS 48 JENTADUETO XR TB24 48 jinteli tabs 49 JOLIVETTE TABS 46 juleber tabs 46 JULUCA TABS 12 junel 1530 tabs 46 junel 120 tabs 46 junel fe 1530 tabs 46 junel fe 120 tabs 46 junel fe 24 tabs 46
JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg 23
JYNARQUE TABS 15mg 30mg 39 JYNARQUE TBPK 39
K KADCYLA SOLR 100mg 160mg 16 KADIAN CP24 28 kaitlib fe chew 46 KALYDECO PACK 25mg 50mg 75mg 56 KALYDECO TABS 56 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 40 kariva tabs 46 KAZANO TABS 48 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-033 MEQ 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 40-5-09 MEQ 39 KCL-LACTATED RINGERS-D5W SOLN
INTRAVENOUS 39 KEDRAB SOLN 57 kelnor 135 tabs 46 kelnor 150 tabs 46 KENALOG SUSP 45 KEPIVANCE SOLR 61 keralyt sham 62 KESIMPTA SOAJ 54 ketoconazole crea 58 ketoconazole foam 58 ketoconazole sham 58 ketoconazole tabs 11 ketodan foam 58 ketoprofen caps 28 ketoprofen er cp24 28 ketorolac tromethamine soln 28 41 ketorolac tromethamine soln 04 05 41 ketorolac tromethamine tabs 28 KEVEYIS TABS 54 KEVZARA SOAJ 150mg114ml
200mg114ml 53 KEVZARA SOSY 150mg114ml
200mg114ml 53 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 52 KHEDEZLA TB24 50mg 100mg 36 KIMYRSA SOLR 9
86 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
KINERET SOSY 53 KINRIX SUSP 57 kionex susp 39 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (200 MG DOSE) TBPK
16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KITABIS PAK NEBU 56 KLISYRI OINT 62 KLOR-CON 10 TBCR 39 klor-con m10 tbcr 39 klor-con m15 tbcr 39 klor-con m20 tbcr 39 klor-con pack 39 klor-con sprinkle cpcr 8meq 10meq 39 KLOR-CON TBCR 39 KORLYM TABS 48 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 37 K-TAB TBCR 39 kurvelo tabs 46 KUVAN PACK 100mg 500mg 54 KUVAN TABS 54 KYNAMRO SOSY 23 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 33 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 LACRISERT INST 42 LACTATED RINGERS SOLN 39 54 LACTIC ACID LOTN 62 lactulose encephalopathy soln 37 lactulose pack 38 lactulose soln 38 LAMICTAL XR KIT 31 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 31
lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg 31
lamotrigine kit 31 lamotrigine starter kit-blue kit 31 lamotrigine starter kit-green kit 31 lamotrigine starter kit-orange kit 31 lamotrigine tabs 25mg 100mg 150mg
200mg 31 lamotrigine tbdp 25mg 50mg 100mg
200mg 31 LANOXIN PEDIATRIC SOLN 25 LANOXIN TABS 625mcg 25 lansoprazole cpdr 15mg 30mg 43 lansoprazole tbdd 15mg 30mg 43 lanthanum carbonate chew 500mg 750mg
1000mg 39 LANTUS SOLN 48 LANTUS SOLOSTAR SOPN 49 lapatinib ditosylate tabs 16 larin 1530 tabs 46 larin 120 tabs 46 larin fe 1530 tabs 46 larin fe 120 tabs 46 larissia tabs 46 LARTRUVO SOLN 190mg19ml
500mg50ml 16 LASTACAFT SOLN 42 latanoprost soln 42 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 36 LAYOLIS FE CHEW 46 LAZANDA SOLN 100mcgact 300mcgact
400mcgact 28 ledipasvir-sofosbuvir tabs 12 leena tabs 46 leflunomide tabs 10mg 20mg 53 LEMTRADA SOLN 34 LENVIMA (10 MG DAILY DOSE) CPPK 16 LENVIMA (12 MG DAILY DOSE) CPPK 16 LENVIMA (14 MG DAILY DOSE) CPPK 16 LENVIMA (18 MG DAILY DOSE) CPPK 16 LENVIMA (20 MG DAILY DOSE) CPPK 16 LENVIMA (24 MG DAILY DOSE) CPPK 16 LENVIMA (4 MG DAILY DOSE) CPPK 16 LENVIMA (8 MG DAILY DOSE) CPPK 17 lessina tabs 46 LETAIRIS TABS 5mg 10mg 56 letrozole tabs 17 leucovorin calcium soln 52
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leucovorin calcium solr 52 leucovorin calcium tabs 5mg 10mg 15mg
25mg 52 LEUKERAN TABS 17 LEUKINE SOLR 22 leuprolide acetate kit 17 levalbuterol hcl nebu 125mg05ml
031mg3ml 063mg3ml 125mg3ml 21 levalbuterol tartrate aero 21 LEVEMIR FLEXTOUCH SOPN 49 LEVEMIR SOLN 49 levetiracetam er tb24 500mg 750mg 31 levetiracetam in nacl soln 31 levetiracetam soln 31 levetiracetam tabs 250mg 500mg 750mg
1000mg 31 levobunolol hcl soln 42 levocarnitine soln 54 LEVOCARNITINE TABS 54 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 40 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 52 levoleucovorin calcium solr 52 levonest tabs 46 levonorgest-eth est amp eth est tabs 47 levonorgest-eth estrad 91-day tabs 47 levonorgestrel-ethinyl estrad tabs 47 levonorg-eth estrad triphasic tabs 46 levora 01530 (28) tabs 47 levorphanol tartrate tabs 2mg 3mg 28 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEVOTHYROXINE SODIUM SOLR 51 levothyroxine sodium tabs 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEXETTE FOAM 60 LEXIVA SUSP 12 LIALDA TBEC 43 LIBTAYO SOLN 17 lidocaine hcl (cardiac) pf sosy 25 lidocaine hcl (cardiac) sosy 25 lidocaine hcl (pf) soln 54 LIDOCAINE HCL CREA 61 lidocaine hcl lotn 61 lidocaine hcl soln 42 54 61 lidocaine hcl urethralmucosal gel 61 lidocaine hcl urethralmucosal prsy 61 LIDOCAINE IN D5W SOLN 25 lidocaine in dextrose soln 54 lidocaine oint 61 lidocaine ptch 61 lidocaine viscous hcl soln 42 lidocaine-epinephrine soln 54 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 61 LIDOCAINE-HYDROCORTISONE ACE KIT
61 lidocaine-prilocaine crea 61 lidocaine-tetracaine crea 61 LIDOCORT CREA 61 lidopin crea 61 LIDO-SORB LOTN 61 LIDOZION LOTN 61 lincomycin hcl soln 9 lindane sham 58 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 LINZESS CAPS 72mcg 145mcg 290mcg
44 liothyronine sodium soln 51 liothyronine sodium tabs 5mcg 25mcg
50mcg 51 LIPODOX 50 INJ 17 lisinopril tabs 25mg 5mg 10mg 20mg
30mg 40mg 26 lisinopril-hydrochlorothiazide tabs 26 LITHIUM CARBONATE CAPS 300mg
150mg 600mg 36 lithium carbonate er tbcr 300mg 450mg 36 lithium carbonate tabs 36
88 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
LITHIUM SOLN 36 LITHOSTAT TABS 38 LIVALO TABS 1mg 2mg 4mg 23 LO LOESTRIN FE TABS 47 lodine tabs 28 loestrin 1530 (21) tabs 47 loestrin 120 (21) tabs 47 loestrin fe 1530 tabs 47 loestrin fe 120 tabs 47 LOKELMA PACK 5gm 10gm 39 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 17 loperamide hcl caps 43 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 49 lorazepam intensol conc 33 LORAZEPAM SOLN 4mgml 2mgml 33 lorazepam tabs 05mg 1mg 2mg 33 LORBRENA TABS 25mg 100mg 17 lorcet hd tabs 28 lorcet plus tabs 28 lorcet tabs 28 lortab elix 28 loryna tabs 47 lorzone tabs 375mg 750mg 20 losartan potassium tabs 25mg 50mg
100mg 26 losartan potassium-hctz tabs 26 LOTEMAX GEL 41 LOTEMAX OINT 41 LOTEMAX SUSP 41 loteprednol etabonate susp 41 lovastatin tabs 10mg 20mg 40mg 23 LOVENOX SOLN 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
low-ogestrel tabs 47 loxapine succinate caps 5mg 10mg 25mg
50mg 36 lubiprostone caps 8mcg 24mcg 44 LUCEMYRA TABS 34 LUCENTIS SOLN 03mg005ml
05mg005ml 42 LUCENTIS SOSY 03mg005ml
05mg005ml 42 LUDENT CHEW 025mg 05mg 1mg 54 LULICONAZOLE CREA 58 LUMAKRAS TABS 17
LUMIGAN SOLN 42 LUMIZYME SOLR 40 LUMOXITI SOLR 17 LUPANETA PACK KIT 17 LUPKYNIS CAPS 53 LUPRON DEPOT (1-MONTH) KIT 17 LUPRON DEPOT (3-MONTH) KIT 17 LUPRON DEPOT (4-MONTH) KIT 17 LUPRON DEPOT (6-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 17 LUPRON DEPOT-PED (3-MONTH) KIT 17 lutera tabs 47 LUZU CREA 58 lyleq tabs 47 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 50
LYNPARZA CAPS 17 LYNPARZA TABS 100mg 150mg 17 LYSODREN TABS 17 lyza tabs 47
M mafenide acetate pack 58 magnesium sulfate in d5w soln 39 magnesium sulfate soln 31 magnesium sulfate soln injection 50 31 MAGNESIUM SULFATE SOLN
INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml 31
MAKENA SOAJ 50 malathion lotn 58 MANNITOL SOLN 39 maprotiline hcl tabs 25mg 50mg 75mg 36 MARGENZA SOLN 17 marlissa tabs 47 MARPLAN TABS 36 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 24 MAVENCLAD (10 TABS) TBPK 53 MAVENCLAD (4 TABS) TBPK 53 MAVENCLAD (5 TABS) TBPK 53 MAVENCLAD (6 TABS) TBPK 53 MAVENCLAD (7 TABS) TBPK 53 MAVENCLAD (8 TABS) TBPK 53
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 89
MAVENCLAD (9 TABS) TBPK 53 MAVYRET TABS 12 MAXIDEX SUSP 41 MAYZENT STARTER PACK TBPK 34 MAYZENT TABS 025mg 2mg 34 MENAPHOSMBHYO1 TABS 14 meclizine hcl tabs 43 meclofenamate sodium caps 28 MEDROL TABS 45 medroxyprogesterone acetate susp 50 medroxyprogesterone acetate susy 50 medroxyprogesterone acetate tabs 25mg
5mg 10mg 50 mefenamic acid caps 28 mefloquine hcl tabs 11 megestrol acetate susp 17 50 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 47 meloxicam caps 28 meloxicam tabs 28 melphalan hcl solr 17 memantine hcl er cp24 34 memantine hcl soln 34 memantine hcl tabs 5mg 10mg 34 MENACTRA INJ 57 menest tabs 03mg 0625mg 125mg 50 MENOSTAR PTWK 50 MENQUADFI INJ 57 MENTAX CREA 58 MENVEO SOLR 57 meperidine hcl soln 50mg5ml 25mgml
50mgml 100mgml 28 meperidine hcl tabs 50mg 100mg 28 meprobamate tabs 33 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 47 mesalamine cpdr 43 mesalamine enem 43 mesalamine er cp24 43 mesalamine supp 43 mesalamine tbec 12gm 800mg 43 mesalamine-cleanser kit 43 mesna soln 54 MESNEX TABS 54 MESTINON SOLN 20 metadate er tbcr 30
metaproterenol sulfate syrp 21 metaproterenol sulfate tabs 10mg 20mg 21 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 49 metformin hcl tabs 500mg 850mg 1000mg
49 methadone hcl conc 28 methadone hcl intensol conc 28 methadone hcl soln 5mg5ml 10mg5ml
10mgml 28 methadone hcl tabs 5mg 10mg 28 methamphetamine hcl tabs 30 methazolamide tabs 25mg 50mg 42 methenamine hippurate tabs 14 METHENAMINE MANDELATE TABS 14 methergine tabs 50 methimazole tabs 5mg 10mg 51 methitest tabs 45 methocarbamol soln 20 methocarbamol tabs 20 methotrexate sodium (pf) soln 17 methotrexate sodium soln 17 methotrexate sodium solr 17 methotrexate tabs 17 methoxsalen rapid caps 62 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 39 methyldopa tabs 250mg 500mg 25 methyldopa-hydrochlorothiazide tabs 25 methylergonovine maleate soln 50 methylergonovine maleate tabs 50 methylphenidate hcl chew 25mg 5mg
10mg 30 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 30 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 30 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 30
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 30
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 30
methylphenidate hcl soln 5mg5ml 10mg5ml 30
90 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
methylphenidate hcl tabs 5mg 10mg 20mg 30
methylprednisolone acetate susp 45 methylprednisolone sodium succ solr 45 methylprednisolone tabs 4mg 8mg 16mg
32mg 45 methylprednisolone tbpk 45 methyltestosterone caps 45 metoclopramide hcl soln 44 metoclopramide hcl tabs 5mg 10mg 44 metoclopramide hcl tbdp 5mg 10mg 44 metolazone tabs 25mg 5mg 10mg 39 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 24 metoprolol tartrate soct 24 metoprolol tartrate soln 24 metoprolol tartrate tabs 25mg 50mg
100mg 24 metoprolol tartrate tabs 375mg 75mg 24 metoprolol-hydrochlorothiazide tabs 24 metronidazole caps 11 metronidazole crea 58 metronidazole gel 58 metronidazole in nacl soln 11 metronidazole in nacl soln intravenous 11 metronidazole lotn 58 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
25 mibelas 24 fe chew 47 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 58 miconazole-zinc oxide-petrolat oint 58 micort-hc crea 60 microgestin 1530 tabs 47 microgestin 120 tabs 47 microgestin fe 1530 tabs 47 microgestin fe 120 tabs 47 midazolam hcl (pf) soln 33 midazolam hcl soln 33 midazolam hcl syrp 33 midodrine hcl tabs 25mg 5mg 10mg 21 miglitol tabs 25mg 50mg 100mg 49 miglustat caps 40 mili tabs 47 millipred dp tbpk 45 millipred tabs 45
milrinone lactate in dextrose soln 25 milrinone lactate soln 25 mimvey lo tabs 50 mimvey tabs 50 minitran pt24 01mghr 02mghr 04mghr
06mghr 26 minocycline hcl caps 50mg 75mg 100mg 9 minocycline hcl er tb24 45mg 55mg 65mg
80mg 90mg 105mg 115mg 135mg 9 minocycline hcl tabs 50mg 75mg 100mg 9 minoxidil tabs 25mg 10mg 25 MIRCERA SOSY 30mcg03ml
50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml 22
mirtazapine tabs 75mg 15mg 30mg 45mg 36
mirtazapine tbdp 15mg 30mg 45mg 36 misoprostol tabs 100mcg 200mcg 43 MITIGARE CAPS 52 mitigo soln 28 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 57 modafinil tabs 100mg 200mg 30 moexipril hcl tabs 75mg 15mg 26 molindone hcl tabs 5mg 10mg 25mg 36 mometasone furoate crea 60 mometasone furoate oint 60 mometasone furoate soln 60 mometasone furoate susp 41 mondoxyne nl caps 75mg 100mg 9 MONJUVI SOLR 17 MONONESSA TABS 47 montelukast sodium chew 4mg 5mg 55 montelukast sodium pack 55 montelukast sodium tabs 55 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 28 morphine sulfate (pf) soln 4mgml 10mgml
28 MORPHINE SULFATE (PF) SOLN
INTRAVENOUS 28 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 28 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 28
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 91
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 28
MORPHINE SULFATE SOLN 28 MORPHINE SULFATE SOLN 10mg5ml
20mg5ml 28 MORPHINE SULFATE SOLN INJECTION
2mgml 4mgml 10mgml 28 MORPHINE SULFATE SOLN
INTRAVENOUS 28 morphine sulfate tabs 15mg 30mg 28 MOVANTIK TABS 125mg 25mg 44 MOXEZA SOLN 41 moxifloxacin hcl (2x day) soln 41 moxifloxacin hcl in nacl soln intravenous 10 moxifloxacin hcl soln 41 moxifloxacin hcl tabs 10 MULPLETA TABS 22 MULTAQ TABS 25 MULTIVITAMINFLUORIDE CHEW 63 MULTI-VITAMINFLUORIDE SOLN 63 MULTI-VITAMINFLUORIDEIRON SOLN
63 mupirocin calcium crea 58 mupirocin oint 59 MUSTARGEN SOLR 17 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17 MVC-FLUORIDE CHEW 64 MYALEPT SOLR 54 MYCAPSSA CPDR 51 mycophenolate mofetil caps 53 mycophenolate mofetil hcl solr 53 mycophenolate mofetil susr 53 mycophenolate mofetil tabs 53 mycophenolate sodium tbec 180mg 360mg
53 MYDAYIS CP24 30 MYFEMBREE TABS 50 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 62 MYRBETRIQ TB24 25mg 50mg 63 MYTESI TBEC 43
N NABI-HB SOLN 57 nabumetone tabs 28 N-ACETYL-L-CYSTEINE CAPS 38 nadolol tabs 20mg 40mg 80mg 24 nadolol-bendroflumethiazide tabs 24
nafcillin sodium solr 10 nafcillin sodium solr injection 10 nafcillin sodium solr intravenous 10 NAFRINSE CHEW 54 NAFRINSE DROPS SOLN 54 naftifine hcl crea 59 naftifine hcl gel 59 NAFTIN GEL 59 NAGLAZYME SOLN 40 nalbuphine hcl soln 28 nalfon tabs 28 nalocet tabs 28 naloxone hcl soaj 34 naloxone hcl soct 34 naloxone hcl soln 34 naloxone hcl sosy 34 naltrexone hcl tabs 35 NAMENDA XR TITRATION PACK CP24 34 NAPRELAN TB24 28 naproxen sodium er tb24 28 naproxen sodium tabs 28 naproxen susp 28 naproxen tabs 28 naproxen tbec 28 naproxen-esomeprazole tbec 28 naratriptan hcl tabs 32 NARCAN LIQD 35 NATACYN SUSP 41 NATAZIA TABS 47 nateglinide tabs 60mg 120mg 49 NATPARA CART 25mcg 50mcg 75mcg
100mcg 50 NATROBA SUSP 59 NAYZILAM SOLN 31 NEBUPENT SOLR 11 necon 0535 (28) tabs 47 NECON 777 TABS 47 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 36 nembutal soln 33 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 41 neomycin-polymyxin b gu soln 59 neomycin-polymyxin-dexameth oint 41 neomycin-polymyxin-dexameth susp 41 neomycin-polymyxin-gramicidin soln 41 neomycin-polymyxin-hc soln 41 neomycin-polymyxin-hc susp 41 neo-polycin hc oint 41
92 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
neo-polycin oint 41 neo-synalar crea 60 NEPHRAMINE SOLN INTRAVENOUS 38 NERLYNX TABS 17 NEULASTA ONPRO PSKT 22 NEULASTA SOSY 22 NEUPOGEN SOLN 480mcg16ml
300mcgml 22 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 22 NEVANAC SUSP 41 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 40 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 23 niacor tabs 23 nicardipine hcl caps 20mg 30mg 24 nicardipine hcl soln 24 NICOTROL INHA 20 NICOTROL NS SOLN 20 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 47 nilutamide tabs 17 nimodipine caps 24 NINLARO CAPS 23mg 3mg 4mg 17 nisoldipine er tb24 85mg 17mg 20mg
255mg 30mg 34mg 40mg 24 nitazoxanide tabs 11 nitisinone caps 2mg 5mg 10mg 54 nitro-bid oint 26 NITRO-DUR PT24 03mghr 08mghr 26 NITROFURANTOIN MACROCRYSTAL
CAPS 14 NITROFURANTOIN MONOHYD MACRO
CAPS 14 nitrofurantoin susp 14 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 26 nitroglycerin soln 26 nitroglycerin subl 03mg 04mg 06mg 26 nitropress soln 25 nitroprusside sodium soln 25 NITYR TABS 2mg 5mg 10mg 54
NIVESTYM SOLN 480mcg16ml 300mcgml 22
NIVESTYM SOSY 300mcg05ml 480mcg08ml 22
nizatidine caps 150mg 300mg 43 nizatidine soln 43 NOCDURNA SUBL 277mcg 553mcg 50 NOCTIVA EMUL 083mcg01ml
166mcg01ml 50 nolix crea 60 nolix lotn 60 nora-be tabs 47 norco tabs 28 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 51
norepinephrine bitartrate soln 21 norethin ace-eth estrad-fe caps 47 norethin ace-eth estrad-fe chew 47 norethin ace-eth estrad-fe tabs 47 norethindrone acetate tabs 50 norethindrone acet-ethinyl est tabs 47 norethindrone tabs 47 norethindrone-eth estradiol tabs 50 norethin-eth estradiol-fe chew 47 norgesic forte tabs 28 norgestimate-eth estradiol tabs 47 norgestim-eth estrad triphasic tabs 47 norlyroc tabs 47 NORMOSOL-M IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R SOLN INTRAVENOUS 39 NORPACE CR CP12 100mg 150mg 25 nortrel 0535 (28) tabs 47 nortrel 135 (21) tabs 47 nortrel 135 (28) tabs 47 nortrel 777 tabs 47 nortriptyline hcl caps 10mg 25mg 50mg
75mg 36 nortriptyline hcl soln 36 NORVIR CAPS 12 NORVIR PACK 12 NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 34 NOVAREL SOLR 5000unit 10000unit 50 NOVOLIN 7030 SUSP 49
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 93
NOVOLOG 7030 FLEXPEN RELION SUPN 49
NOVOLOG FLEXPEN RELION SOPN 49 NOVOLOG FLEXPEN SOPN 49 NOVOLOG MIX 7030 FLEXPEN SUPN 49 NOVOLOG MIX 7030 RELION SUSP 49 NOVOLOG MIX 7030 SUSP 49 NOVOLOG PENFILL SOCT 49 NOVOLOG RELION SOLN 49 NOVOLOG SOLN 49 NOXAFIL SUSP 11 NOXAFIL TBEC 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 55 NUCALA SOLR 55 NUCALA SOSY 55 NUCYNTA ER TB12 200mg 250mg 29 NUCYNTA ER TB12 50mg 100mg 150mg
29 NUCYNTA TABS 29 NUCYNTA TABS 50mg 75mg 29 NUEDEXTA CAPS 34 NULIBRY SOLR 54 NULOJIX SOLR 53 NUPLAZID CAPS 36 NUPLAZID TABS 10mg 17mg 36 NURTEC TBDP 32 NUTRILIPID EMUL INTRAVENOUS 38 NUTROPIN AQ NUSPIN 10 SOPN 51 NUTROPIN AQ NUSPIN 20 SOPN 51 NUTROPIN AQ NUSPIN 5 SOPN 51 NUVARING RING 47 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 59 nylia 777 tabs 47 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 47 nystatin crea 59 nystatin oint 59 nystatin powd 59 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 60 nystatin-triamcinolone oint 60 nystop powd 59 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 44 ocella tabs 47 OCREVUS SOLN 34 OCTAGAM SOLN INTRAVENOUS
5gm100ml 1gm20ml 2gm20ml 25gm500ml 57
octreotide acetate soln 51 ODACTRA SUBL 54 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 56 ofloxacin soln 41 ofloxacin tabs 10 ogestrel tabs 47 OGIVRI SOLR 17 okebo caps 10 olanzapine solr 36 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 36 olanzapine tbdp 5mg 10mg 15mg 20mg
36 olanzapine-fluoxetine hcl caps 36 olmesartan medoxomil tabs 5mg 20mg
40mg 26 olmesartan medoxomil-hctz tabs 26 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 42 OLUMIANT TABS 1mg 2mg 53 OLYSIO CAPS 12 OMECLAMOX-PAK MISC 43 omega-3-acid ethyl esters caps 23 omeprazole cpdr 10mg 20mg 40mg 43 omeprazole-sodium bicarbonate caps 43 omeprazole-sodium bicarbonate pack 44 OMNARIS SUSP 41 OMNIPOD STARTER KIT 37 OMNITROPE SOCT 5mg15ml
10mg15ml 51 OMNITROPE SOLR 51 ondansetron hcl soln 43 ondansetron hcl tabs 4mg 8mg 24mg 43 ondansetron tbdp 4mg 8mg 43 ONIVYDE INJ 17 ONPATTRO SOLN 54 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 ONZETRA XSAIL EXHP 32
94 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml 17
OPIUM TINC 43 ORACEA CPDR 62 ORALAIR SUBL 54 oralone pste 60 ORAVIG TABS 59 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 53 ORENCIA SOLR 53 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 53 ORENITRAM TBCR 0125mg 56 ORENITRAM TBCR 025mg 1mg 25mg
5mg 56 ORFADIN CAPS 54 ORFADIN SUSP 54 ORGOVYX TABS 50 ORIAHNN CPPK 50 ORILISSA TABS 150mg 200mg 50 ORKAMBI PACK 56 ORKAMBI TABS 56 ORLADEYO CAPS 110mg 150mg 54 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 29 orphengesic forte tabs 29 orsythia tabs 47 ORTIKOS CP24 6mg 9mg 45 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 39 OSMOPREP TABS 44 OSPHENA TABS 50 OTEZLA TABS 53 OTEZLA TBPK 53 OTOVEL SOLN 41 OTREXUP SOAJ 53 ovide lotn 59 OXACILLIN SODIUM IN DEXTROSE SOLN
INTRAVENOUS 10 oxacillin sodium solr injection 1gm 2gm 10 oxacillin sodium solr intravenous 10 oxaliplatin soln 17 oxaliplatin solr 17 oxandrolone tabs 45 oxandrolone tabs 25mg 45 oxaprozin tabs 29
OXAYDO TABS 29 oxazepam caps 10mg 15mg 30mg 33 OXBRYTA TABS 21 oxcarbazepine susp 31 oxcarbazepine tabs 150mg 300mg 600mg
31 OXERVATE SOLN 42 oxiconazole nitrate crea 59 OXISTAT LOTN 59 OXLUMO SOLN 54 OXTELLAR XR TB24 150mg 300mg
600mg 31 oxybutynin chloride er tb24 5mg 10mg
15mg 63 oxybutynin chloride syrp 63 oxybutynin chloride tabs 63 oxycodone hcl caps 29 oxycodone hcl conc 29 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxycodone hcl soln 29 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 29 oxycodone-acetaminophen soln 29 oxycodone-acetaminophen tabs 29 oxycodone-acetaminophen tabs 5-300mg
10-300mg 29 oxycodone-aspirin tabs 29 oxycodone-ibuprofen tabs 29 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 29 oxymorphone hcl tabs 5mg 10mg 29 OXYTOCIN SOLN 50 OZEMPIC (025 OR 05 MGDOSE) SOPN
49 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 49
P pacerone tabs 100mg 200mg 400mg 25 paclitaxel conc 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
54 PALFORZIA (120 MG DAILY DOSE) CSPK
54
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 95
PALFORZIA (160 MG DAILY DOSE) CSPK 54
PALFORZIA (20 MG DAILY DOSE) CSPK 54
PALFORZIA (200 MG DAILY DOSE) CSPK 54
PALFORZIA (240 MG DAILY DOSE) CSPK 55
PALFORZIA (3 MG DAILY DOSE) CSPK 55 PALFORZIA (300 MG MAINTENANCE)
PACK 55 PALFORZIA (300 MG TITRATION) PACK
55 PALFORZIA (40 MG DAILY DOSE) CSPK
55 PALFORZIA (6 MG DAILY DOSE) CSPK 55 PALFORZIA (80 MG DAILY DOSE) CSPK
55 PALFORZIA INITIAL ESCALATION CSPK
55 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 36 palonosetron hcl soln 43 palonosetron hcl sosy 43 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 40 pamidronate disodium soln 52 pamidronate disodium solr 52 PANCREAZE CPEP 40 PANDEL CREA 61 panlor tabs 29 PANRETIN GEL 61 pantoprazole sodium pack 44 PANTOPRAZOLE SODIUM SOLR 44 pantoprazole sodium tbec 20mg 40mg 44 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 57
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 64 PARICALCITOL SOLN 64 paroex soln 41 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 36 paroxetine hcl tabs 10mg 20mg 36 paroxetine hcl tabs 30mg 40mg 36 paroxetine mesylate caps 36 paser pack 11
PAXIL SUSP 36 PEDIARIX SUSP 57 PEDVAX HIB SUSP 57 peg 3350electrolytes solr 44 peg 3350-kcl-na bicarb-nacl solr 44 peg-3350electrolytes solr 44 PEGANONE TABS 31 PEGASYS PROCLICK SOLN
135mcg05ml 180mcg05ml 13 PEGASYS SOLN 180mcg05ml
180mcgml 13 PEGINTRON KIT 13 PEG-INTRON REDIPEN KIT 12 PEG-PREP KIT 44 PEMAZYRE TABS 45mg 9mg 135mg 17 penicillamine caps 45 penicillamine tabs 45 PENICILLIN G POT IN DEXTROSE SOLN
INTRAVENOUS 10 penicillin g potassium solr injection 10 penicillin g procaine susp 10 penicillin g sodium solr injection 10 penicillin v potassium solr 10 penicillin v potassium tabs 10 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 43 pentazocine-naloxone hcl tabs 29 pentobarbital sodium soln 33 pentoxifylline er tbcr 22 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 44 percocet tabs 29 perindopril erbumine tabs 2mg 4mg 8mg
26 periogard soln 41 PERJETA SOLN 17 permethrin crea 59 perphenazine tabs 2mg 4mg 8mg 16mg
36 perphenazine-amitriptyline tabs 36 PERSERIS PRSY 90mg 120mg 36 PERTZYE CPEP 40 PEXEVA TABS 10mg 20mg 30mg 40mg
36 phenadoz supp 14 phenazo tabs 61 PHENAZOPYRIDINE HCL TABS 61 phenelzine sulfate tabs 36
96 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
phenergan soln 14 PHENOBARBITAL ELIX 33 PHENOBARBITAL SODIUM SOLN 33 PHENOBARBITAL TABS 33 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 21 PHENYLEPHRINE HCL SOLN 42 phenytek caps 200mg 300mg 31 phenytoin chew 31 phenytoin sodium extended caps 100mg
200mg 300mg 31 phenytoin sodium soln 31 phenytoin susp 31 PHESGO SOLN 17 PHOSLYRA SOLN 39 PHOSPHASAL TABS 14 PHOSPHOLINE IODIDE SOLR 42 phrenilin forte caps 29 PHYSIOLYTE SOLN 55 PHYSIOSOL IRRIGATION SOLN 55 PIFELTRO TABS 13 pilocarpine hcl soln 1 2 4 42 pilocarpine hcl tabs 5mg 75mg 20 pimecrolimus crea 62 pimozide tabs 1mg 2mg 36 pimtrea tabs 47 pindolol tabs 5mg 10mg 24 pioglitazone hcl tabs 15mg 30mg 45mg 49 pioglitazone hcl-glimepiride tabs 49 pioglitazone hcl-metformin hcl tabs 49 piperacillin sod-tazobactam so solr 10 piperacillin sod-tazobactam so solr
intravenous 10 PIQRAY (200 MG DAILY DOSE) TBPK 17 PIQRAY (250 MG DAILY DOSE) TBPK 17 PIQRAY (300 MG DAILY DOSE) TBPK 17 pirmella 135 tabs 47 PIROXICAM CAPS 10mg 20mg 29 PLASMA-LYTE 148 SOLN INTRAVENOUS
39 PLASMA-LYTE A SOLN INTRAVENOUS 39 PLEGRIDY SOPN 13 PLEGRIDY SOSY 13 34 PLEGRIDY STARTER PACK SOPN 13 PLEGRIDY STARTER PACK SOSY 13 plenamine soln intravenous 38 PLENVU SOLR 44 podofilox soln 62 POLIVY SOLR 30mg 140mg 17
polocaine soln 55 polocaine-mpf soln 55 polycin oint 41 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 41 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 34 PONVORY TABS 34 portia-28 tabs 47 PORTRAZZA SOLN 17 POSACONAZOLE SUSP 11 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 37 POTASSIUM ACETATE SOLN 39 potassium chloride crys er tbcr 10meq
20meq 40 potassium chloride er cpcr 8meq 10meq 40 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 40 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 40 potassium chloride in nacl soln intravenous
40 potassium chloride pack 40 potassium chloride soln 10 20 40 POTASSIUM CHLORIDE SOLN
INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml 40
potassium citrate er tbcr 15meq 540mg 1080mg 37
POTASSIUM PHOSPHATES SOLN 40 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 40 POTELIGEO SOLN 18 PR BENZOYL PEROXIDE WASH LIQD 59 PRADAXA CAPS 110mg 150mg 22 PRADAXA CAPS 75mg 22 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 33
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 33
PRAMOX GEL 61 prandin tabs 1mg 2mg 49 prasugrel hcl tabs 5mg 10mg 22 pravastatin sodium tabs 10mg 20mg
40mg 80mg 23 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 97
PRED MILD SUSP 41 PRED-G SOP OINT 41 PRED-G SUSP 41 prednicarbate crea 61 prednicarbate oint 61 prednisolone acetate susp 41 prednisolone sodium phosphate soln 41 45 prednisolone sodium phosphate soln
5mg5ml 10mg5ml 20mg5ml 25mg5ml 45
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 45
prednisolone soln 45 prednisone intensol conc 45 prednisone soln 45 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 45 prednisone tbpk 45 prefest tabs 50 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 31
pregabalin er tb24 825mg 165mg 330mg 29
pregabalin soln 31 PREGNYL SOLR 50 PREMARIN SOLR 50 PREMARIN TABS 03mg 045mg
0625mg 09mg 125mg 50 premasol soln intravenous 38 PREMPHASE TABS 50 PREMPRO TABS 50 PRENATAL TABS 64 PRETOMANID TABS 11 prevalite pack 23 prevalite powd 23 previfem tabs 47 PREVYMIS SOLN 240mg12ml
480mg24ml 13 PREVYMIS TABS 240mg 480mg 13 PREZCOBIX TABS 13 PREZISTA SUSP 13 PREZISTA TABS 75mg 150mg 600mg
800mg 13 PRIFTIN TABS 11 PRILOSEC PACK 25mg 10mg 44 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 31 primlev tabs 29
PRIVIGEN SOLN INTRAVENOUS 57 PROAIR RESPICLICK AEPB 21 probenecid tabs 40 procainamide hcl soln 25 PROCALAMINE SOLN INTRAVENOUS 38 procentra soln 30 prochlorperazine edisylate soln 36 prochlorperazine maleate tabs 36 prochlorperazine supp 36 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 40000unitml 22
proctofoam hc foam 61 procto-med hc crea 61 procto-pak crea 61 proctosol hc crea 61 proctozone-hc crea 61 PROCYSBI CPDR 25mg 75mg 55 PROCYSBI PACK 75mg 300mg 55 progesterone caps 100mg 200mg 51 progesterone oil 51 PROGLYCEM SUSP 49 PROGRAF PACK 53 PROGRAF PACK 02mg 53 PROGRAF SOLN 53 PROLASTIN-C SOLN INTRAVENOUS 56 PROLASTIN-C SOLR INTRAVENOUS 56 prolate soln 29 prolate tabs 29 PROLENSA SOLN 41 PROLEUKIN SOLR 18 PROLIA SOSY 52 PROMACTA PACK 125mg 25mg 22 PROMACTA TABS 125mg 25mg 50mg
75mg 22 promethazine hcl soln 14 promethazine hcl supp 14 promethazine hcl syrp 14 promethazine hcl tabs 14 promethazine-phenylephrine syrp 14 promethegan supp 14 propafenone hcl er cp12 225mg 325mg
425mg 25 propafenone hcl tabs 150mg 225mg
300mg 25 propantheline bromide tabs 19 proparacaine hcl soln 43 propranolol hcl er cp24 60mg 80mg
120mg 160mg 24
98 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
propranolol hcl soln 20mg5ml 40mg5ml 24 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 24 propranolol-hctz tabs 24 propylthiouracil tabs 51 PROQUAD SUSR 58 PROSOL SOLN INTRAVENOUS 38 PROTONIX PACK 44 protriptyline hcl tabs 5mg 10mg 36 psorcon crea 61 PULMICORT FLEXHALER AEPB 45 PULMOZYME SOLN 40 PURIXAN SUSP 18 PYLERA CAPS 44 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 20 pyridostigmine bromide soln 20 pyridostigmine bromide tabs 30mg 60mg 20 pyrimethamine tabs 11
Q QBRELIS SOLN 26 QDOLO SOLN 29 QINLOCK TABS 18 QUADRACEL SUSP 57 questran light powd 23 questran pack 23 questran powd 23 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 36 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 37 QUILLICHEW ER CHER 20mg 30mg
40mg 30 QUILLIVANT XR SRER 30 quinapril hcl tabs 5mg 10mg 20mg 40mg
26 quinapril-hydrochlorothiazide tabs 26 quinidine gluconate er tbcr 25 QUINIDINE GLUCONATE SOLN 25 quinidine sulfate tabs 200mg 300mg 25 quinine sulfate caps 12
R RABAVERT SUSR 58 rabeprazole sodium cpsp 44 rabeprazole sodium tbec 44 RADICAVA SOLN 34
raloxifene hcl tabs 50 ramelteon tabs 33 ramipril caps 125mg 25mg 5mg 10mg 26 ranolazine er tb12 500mg 1000mg 25 RAPIVAB SOLN 13 rasagiline mesylate tabs 05mg 1mg 33 RASUVO SOAJ 53 RAVICTI LIQD 38 RAYALDEE CPCR 64 RAYOS TBEC 1mg 2mg 5mg 45 REBETOL SOLN 13 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 34 REBIF REBIDOSE TITRATION PACK
SOAJ 34 REBIF SOSY 22mcg05ml 44mcg05ml 34 REBIF TITRATION PACK SOSY 34 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 47 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 58 RECTIV OINT 62 REGONOL SOLN 20 REGRANEX GEL 62 relafen ds tabs 29 RELENZA DISKHALER AEPB 13 relexxii tbcr 30 RELISTOR SOLN 8mg04ml 12mg06ml
44 RELISTOR TABS 44 reltone caps 200mg 400mg 44 REMICADE SOLR INTRAVENOUS 53 RENFLEXIS SOLR 53 repaglinide tabs 05mg 1mg 2mg 49 repaglinide-metformin hcl tabs 49 REPATHA PUSHTRONEX SYSTEM SOCT
23 REPATHA SOSY 23 REPATHA SURECLICK SOAJ 23 RESCRIPTOR TABS 100mg 200mg 13 RESTASIS EMUL 41 RETACRIT SOLN 20000unit2ml
2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml 22
RETEVMO CAPS 40mg 80mg 18 RETIN-A CREA 0025 005 01 61 RETIN-A GEL 001 0025 61
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 99
RETIN-A MICRO GEL 004 01 61 RETIN-A MICRO PUMP GEL 61 RETIN-A MICRO PUMP GEL 004 01
61 RETIN-A MICRO PUMP GEL 008 61 RETISERT IMPL 41 RETROVIR SOLN 13 REVCOVI SOLN 40 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 18 revonto solr 20 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 37 REYATAZ PACK 13 REZUROCK TABS 55 RHOPRESSA SOLN 42 RIABNI SOLN 100mg10ml 500mg50ml 18 ribasphere caps 13 ribasphere ribapak (1000 pack) tbpk 13 ribasphere ribapak (1200 pack) tbpk 13 ribasphere tabs 13 ribavirin caps 13 ribavirin solr 13 ribavirin tabs 13 RIDAURA CAPS 55 RIFABUTIN CAPS 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 RIFATER TABS 11 riluzole tabs 34 rimantadine hcl tabs 13 RIMSO-50 SOLN 55 RINGERS IRRIGATION SOLN 55 RINGERS SOLN 40 RINVOQ TB24 53 risedronate sodium tabs 5mg 30mg 35mg
150mg 52 RISEDRONATE SODIUM TBEC 52 RISPERDAL CONSTA SRER 125mg
25mg 37 RISPERDAL CONSTA SRER 375mg
50mg 37 risperidone soln 37 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 37 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 37
ritonavir tabs 13 RITUXAN HYCELA SOLN 18 RITUXAN SOLN 18 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 47 rizatriptan benzoate tabs 32 rizatriptan benzoate tbdp 32 ROMIDEPSIN SOLN 18 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 33 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 33 ropivacaine hcl soln 55 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 23 ROTARIX SUSR 58 ROTATEQ SOLN 58 roweepra tabs 500mg 750mg 1000mg 31 roweepra xr tb24 500mg 750mg 31 ROXYBOND TABA 5mg 15mg 30mg 29 ROZEREM TABS 33 ROZLYTREK CAPS 100mg 200mg 18 RUBRACA TABS 200mg 250mg 300mg 18 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 31 rufinamide tabs 200mg 400mg 31 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 18 RUZURGI TABS 55 RYBREVANT SOLN 18 ryclora soln 14 RYDAPT CAPS 18 RYLAZE SOLN 18 RYNODERM CREA 62 RYTARY CPCR 33 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 51 SAIZEN SOLR 5mg 88mg 51 SAIZENPREP SOLR 51 sajazir soln 21 SALEX SHAM 62 SALICYLIC ACID CREA 62 SALICYLIC ACID ER SOLN 62
100 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
SALICYLIC ACID FOAM 62 SALICYLIC ACID GEL 62 SALICYLIC ACID LIQD 62 SALICYLIC ACID SHAM 62 SALICYLIC ACID WART REMOVER LIQD
62 SALICYLIC ACID-CLEANSER KIT 62 SALIMEZ CREA 62 SALSALATE TABS 29 SAMSCA TABS 15mg 39 SANCUSO PTCH 43 SANDIMMUNE ORAL SOLN 100mgml 53 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 51 SANTYL OINT 62 SAPHNELO SOLN 53 SAPHRIS SUBL 25mg 5mg 10mg 37 sapropterin dihydrochloride pack 100mg
500mg 55 sapropterin dihydrochloride tabs 55 SARCLISA SOLN 500mg25ml 100mg5ml
18 SAVELLA TABS 125mg 25mg 50mg
100mg 34 SAVELLA TITRATION PACK MISC 34 scopolamine pt72 43 seconal caps 33 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 37 selegiline hcl caps 33 selegiline hcl tabs 33 selenium sulfide lotn 59 SELENIUM SULFIDE SHAM 59 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 150mg
300mg 13 SEMPREX-D CAPS 14 SENSIPAR TABS 30mg 60mg 90mg 50 SENSORCAINE SOLN 55 sensorcaineepinephrine soln 55 sensorcaine-mpf soln 55 sensorcaine-mpfepinephrine soln 55 SEREVENT DISKUS AEPB 21 SEROSTIM SOLR 4mg 5mg 6mg 51 sertraline hcl conc 37 sertraline hcl tabs 25mg 50mg 100mg 37 setlakin tabs 47 sevelamer carbonate pack 08gm 24gm 39 sevelamer carbonate tabs 39
sevelamer hcl tabs 400mg 800mg 39 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 47 SHINGRIX SUSR 58 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 51 SIGNIFOR SOLN 03mgml 06mgml
09mgml 51 SIKLOS TABS 18 sildenafil citrate soln 26 sildenafil citrate susr 26 sildenafil citrate tabs 26 SILENOR TABS 37 SILIQ SOSY 62 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 59 SIMBRINZA SUSP 42 SIMPONI ARIA SOLN 53 SIMPONI SOAJ 50mg05ml 100mgml 53 SIMPONI SOSY 50mg05ml 100mgml 53 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 23 sirolimus soln 53 sirolimus tabs 05mg 1mg 2mg 53 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKLICE LOTN 59 SKYRIZI (150 MG DOSE) PSKT 62 SKYRIZI PEN SOAJ 63 SKYRIZI SOSY 63 sod benz-sod phenylacet soln 38 SODIUM ACETATE SOLN 37 SODIUM BICARBONATE SOLN 37 SODIUM CHLORIDE (PF) SOLN 40 SODIUM CHLORIDE SOLN 40 55 SODIUM CHLORIDE SOLN INJECTION 40 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 55 SODIUM FLUORIDE SOLN 55 SODIUM FLUORIDE TABS 55 SODIUM LACTATE SOLN INTRAVENOUS
37 sodium phenylbutyrate powd 38 sodium phenylbutyrate tabs 38 SODIUM PHOSPHATES SOLN 40 sodium polystyrene sulfonate powd 39 sodium polystyrene sulfonate susp 39 SODIUM SULFACETAMIDE SHAM 59
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 101
SODIUM SULFACETAMIDE WASH LIQD 59
sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 63 SOLIQUA SOPN 49 SOLOSEC PACK 12 soloxide tbec 10 SOLTAMOX SOLN 18 SOLU-CORTEF SOLR 45 SOLU-MEDROL SOLR 45 SOMATULINE DEPOT SOLN 51 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 51 SORILUX FOAM 63 sorine tabs 80mg 120mg 160mg 240mg
24 sotalol hcl (af) tabs 80mg 120mg 160mg 24 sotalol hcl tabs 80mg 120mg 160mg
240mg 24 SOTYLIZE SOLN 24 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPINOSAD SUSP 59 SPIRIVA HANDIHALER CAPS 19 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 26 spironolactone-hctz tabs 26 SPRAVATO (56 MG DOSE) SOPK 37 SPRAVATO (84 MG DOSE) SOPK 37 sprintec 28 tabs 47 SPRITAM TB3D 250mg 500mg 750mg
1000mg 31 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 39 sronyx tabs 47 SSD CREA 59 SSS 10-5 CREA 63 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
63 STELARA SOSY 45mg05ml 90mgml 63 STERILE WATER FOR IRRIGATION SOLN
55 STIMATE SOLN 50 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18
STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml 40
streptomycin sulfate solr 10 STRIANT MISC 46 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 21 SUBLOCADE SOSY 100mg05ml
300mg15ml 29 SUBSYS LIQD 100mcg 200mcg 400mcg
600mcg 800mcg 1200mcg 1600mcg 29 subvenite starter kit-blue kit 31 subvenite starter kit-green kit 31 subvenite starter kit-orange kit 31 subvenite tabs 25mg 100mg 150mg
200mg 31 succinylcholine chloride soln 20 SUCRAID SOLN 40 sucralfate susp 44 sucralfate tabs 44 sulfacetamide sodium (acne) lotn 59 SULFACETAMIDE SODIUM GEL 59 SULFACETAMIDE SODIUM LIQD 59 sulfacetamide sodium oint 41 sulfacetamide sodium soln 41 SULFACETAMIDE SODIUM-SULFUR
CREA 63 SULFACETAMIDE SODIUM-SULFUR
EMUL 63 SULFACETAMIDE SODIUM-SULFUR
LIQD 63 SULFACETAMIDE SODIUM-SULFUR
LOTN 63 SULFACETAMIDE SODIUM-SULFUR
PADS 63 SULFACETAMIDE SODIUM-SULFUR
SUSP 63 sulfacetamide-prednisolone soln 41 SULFACLEANSE 84 SUSP 63 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 sulfamez wash emul 63 SULFAMYLON CREA 59 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 29 sumatriptan soln 32
102 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
sumatriptan succinate refill soct 32 sumatriptan succinate soaj 32 sumatriptan succinate soln 32 sumatriptan succinate sosy 32 sumatriptan succinate tabs 32 sunitinib malate caps 125mg 25mg
375mg 50mg 18 SUNOSI TABS 75mg 150mg 30 SUPRAX CAPS 10 suprax chew 10 suprax susr 100mg5ml 200mg5ml 10 SUPRAX SUSR 500 MG5ML 10 SUPREP BOWEL PREP KIT SOLN 44 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 47 SYLATRON KIT 18 SYLATRON KIT 600 MCG 18 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 56 SYMDEKO TBPK 56 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 49 SYMLINPEN 60 SOPN 49 SYMPAZAN FILM 10mg 20mg 32 SYMPAZAN FILM 5mg 31 SYMPROIC TABS 44 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 50 SYNDROS SOLN 43 SYNERCID SOLR 10 SYNJARDY TABS 49 SYNJARDY XR TB24 49 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 TACLONEX SUSP 61 tacrolimus caps 05mg 1mg 5mg 53 TACROLIMUS OINT 01 003 63 tadalafil (pah) tabs 20mg 26 tadalafil tabs 25mg 5mg 26 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 55 TALTZ SOAJ 63
TALTZ SOSY 63 TALZENNA CAPS 025mg 1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 51 taperdex 12-day tbpk 45 taperdex 6-day tbpk 45 taperdex 7-day tbpk 45 TARCEVA TABS 25mg 100mg 150mg 18 targadox tabs 10 TARGRETIN GEL 61 tarina 24 fe tabs 47 tarina fe 120 eq tabs 47 TASIGNA CAPS 50mg 150mg 200mg 18 tavaborole soln 59 TAVALISSE TABS 100mg 150mg 22 tazarotene crea 63 tazarotene foam 63 tazicef solr injection 1gm 2gm 6gm 10 TAZORAC CREA 63 TAZORAC GEL 005 01 63 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 57 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TECFIDERA CPDR 120mg 240mg 34 TECFIDERA MISC 34 TEFLARO SOLR INTRAVENOUS 400mg
600mg 10 TEGSEDI SOSY 55 TEKTURNA HCT TABS 26 telmisartan tabs 20mg 40mg 80mg 26 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 26 TEMAZEPAM CAPS 15mg 225mg 30mg
75mg 33 temsirolimus soln 18 tencon tabs 29 TENIPOSIDE SOLN 18 TENIVAC INJ 57 tenofovir disoproxil fumarate tabs 13 TEPADINA SOLR 18 TEPEZZA SOLR 42 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 21
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 103
terbutaline sulfate tabs 25mg 5mg 21 terconazole crea 59 terconazole supp 59 TERIPARATIDE (RECOMBINANT) SOPN
50 testosterone cypionate soln 100mgml
200mgml 46 testosterone enanthate soln 46 testosterone gel 1 162
2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact 46
testosterone soln 46 tetrabenazine tabs 125mg 25mg 34 TETRACAINE HCL SOLN 43 tetracycline hcl caps 250mg 500mg 10 texacort soln 61 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 63 theophylline er tb12 100mg 200mg
300mg 450mg 63 theophylline er tb24 400mg 600mg 63 theophylline soln 63 THIOLA EC TBEC 100mg 300mg 55 THIOLA TABS 55 thioridazine hcl tabs 10mg 25mg 50mg
100mg 37 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 37 THYROGEN SOLR 55 THYROLAR-1 TABS 51 THYROLAR-12 TABS 51 THYROLAR-14 TABS 51 THYROLAR-2 TABS 51 THYROLAR-3 TABS 51 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
32 TIBSOVO TABS 18 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 34 tilia fe tabs 47 timolol maleate pf soln 42 timolol maleate solg 025 05 42 timolol maleate soln 025 05 42 timolol maleate tabs 5mg 10mg 20mg 24 TIMOPTIC OCUDOSE SOLN 25 42
TIMOPTIC-XE SOLG 025 05 42 tinidazole tabs 12 tiopronin tabs 55 TIROSINT CAPS 13mcg 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
TIS-U-SOL SOLN 55 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 TIVORBEX CAPS 29 tizanidine hcl caps 20 21 tizanidine hcl tabs 20 TOBI PODHALER CAPS 56 TOBRADEX OINT 41 TOBRADEX ST SUSP 41 tobramycin nebu 300mg4ml 300mg5ml 56 tobramycin soln 41 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 42 TOBREX OINT 41 tofranil tabs 10mg 25mg 50mg 37 TOLAK CREA 63 tolazamide tabs 250mg 500mg 49 tolbutamide tabs 49 tolcapone tabs 33 tolmetin sodium caps 29 tolmetin sodium tabs 29 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 63 tolterodine tartrate tabs 63 TOLVAPTAN TABS 30mg 15mg 39 TOPEX TOPICAL ANESTHETIC AERO 61 topicort crea 005 025 61 topicort gel 61 topicort oint 61 topiramate cpsp 15mg 25mg 32 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 32 topiramate tabs 25mg 50mg 100mg
200mg 32 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
39 TOSYMRA SOLN 32
104 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
tovet foam 61 TPN ELECTROLYTES CONC
INTRAVENOUS 40 TRACLEER TABS 625mg 125mg 56 TRACLEER TBSO 56 TRADJENTA TABS 49 tramadol hcl er (biphasic) tb24 100mg
200mg 300mg 29 tramadol hcl er cp24 100mg 150mg
200mg 300mg 29 tramadol hcl er tb24 100mg 200mg 300mg
29 tramadol hcl tabs 50mg 100mg 29 tramadol-acetaminophen tabs 29 trandolapril tabs 1mg 2mg 4mg 26 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 22 tranexamic acid tabs 22 TRANSDERM SCOP (15 MG) PT72 43 tranylcypromine sulfate tabs 37 TRAVASOL SOLN INTRAVENOUS 38 TRAVATAN Z SOLN 42 travoprost (bak free) soln 42 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 37 trazodone hcl tabs 50mg 100mg 150mg 37 TRECATOR TABS 11 TRELEGY ELLIPTA AEPB 45 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 63 TREMFYA SOSY 63 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 56 tretinoin caps 18 tretinoin crea 0025 005 01 61 tretinoin gel 001 0025 005 61 tretinoin microsphere gel 004 01 61 tretinoin microsphere pump gel 004
01 62 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 29 triamcinolone acetonide aers 61 triamcinolone acetonide crea 0025
01 05 61 triamcinolone acetonide lotn 0025 01
61 triamcinolone acetonide oint 0025
005 01 05 61 triamcinolone acetonide pste 61
triamcinolone acetonide susp 45 triamterene caps 50mg 100mg 39 triamterene-hctz caps 39 triamterene-hctz tabs 39 trianex oint 61 triazolam tabs 0125mg 025mg 33 TRICITRATES SOLN 37 triderm crea 01 05 61 trientine hcl caps 45 tri-estarylla tabs 47 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 37 trifluridine soln 41 trihexyphenidyl hcl soln 33 trihexyphenidyl hcl tabs 2mg 5mg 33 TRIKAFTA TBPK 56 tri-legest fe tabs 47 tri-lo-estarylla tabs 47 tri-lo-sprintec tabs 47 trilyte solr 44 trimethobenzamide hcl caps 43 trimethoprim tabs 14 tri-mili tabs 47 trimipramine maleate caps 25mg 50mg
100mg 37 TRINESSA (28) TABS 47 TRINTELLIX TABS 5mg 10mg 20mg 37 tri-nymyo tabs 47 tri-previfem tabs 47 TRIPTODUR SRER 50 TRISENOX SOLN 18 TRISENOX SOLN 10mg10ml 18 tri-sprintec tabs 47 tritocin oint 61 TRIUMEQ TABS 13 TRI-VITAMINFLUORIDE SOLN 64 TRI-VITEFLUORIDE SOLN 64 trivora (28) tabs 47 tri-vylibra lo tabs 47 tri-vylibra tabs 47 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 32 TROPHAMINE SOLN INTRAVENOUS 38 trospium chloride er cp24 63 trospium chloride tabs 63 TRULANCE TABS 44 TRUMENBA SUSY 58
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 105
TRUSELTIQ (100MG DAILY DOSE) CPPK 18
TRUSELTIQ (125MG DAILY DOSE) CPPK 18
TRUSELTIQ (50MG DAILY DOSE) CPPK 18
TRUSELTIQ (75MG DAILY DOSE) CPPK 18
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 58 TYBOST TABS 13 tydemy tabs 47 TYKERB TABS 18 tylenol with codeine 3 tabs 29 tylenol with codeine 4 tabs 29 TYMLOS SOPN 50 TYPHIM VI SOLN 58 TYSABRI CONC INTRAVENOUS 34 TYVASO REFILL SOLN 56 TYVASO SOLN 56 TYVASO STARTER SOLN 56
U UBRELVY TABS 50mg 100mg 32 UCERIS FOAM 61 UDENYCA SOSY 22 UKONIQ TABS 18 ULORIC TABS 40mg 80mg 52 ULTOMIRIS SOLN 55 ULTRAVATE LOTN 61 UMECTA MOUSSE FOAM 63 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 52
UNITUXIN SOLN 18 UPLIZNA SOLN 53 UPTRAVI SOLR 56 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 56
UPTRAVI TBPK 57 UREA CREA 39 63 UREA LOTN 40 63 UREA-C40 LOTN 63 urecholine tabs 5mg 10mg 25mg 50mg 20
uredeb crea 63 URETRON DS TABS 14 URIN DS TABS 14 URSODIOL CAPS 200mg 400mg 44 ursodiol caps 300mg 44 ursodiol tabs 250mg 500mg 44 URYL TABS 14 USTELL CAPS 14 UTICAP CAPS 14 UTIRA-C TABS 14 UTRONA-C TABS 14
V VABOMERE SOLR INTRAVENOUS 10 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 63 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 32 valproic acid caps 32 valproic acid soln 32 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
26 valsartan-hydrochlorothiazide tabs 26 VALTOCO 10 MG DOSE LIQD 32 VALTOCO 15 MG DOSE LQPK 32 VALTOCO 20 MG DOSE LQPK 32 VALTOCO 5 MG DOSE LIQD 32 vanadom tabs 20 vanatol lq soln 29 vancomycin hcl caps 10 vancomycin hcl solr 10 VANCOMYCIN HCL SOLR 250 MG 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 VANDAZOLE GEL 59 VANOXIDE-HC LOTN 61 VANTAS KIT 19 VAQTA SUSP 58 VARIVAX INJ 58 VARIZIG SOLN 57 VARUBI (180 MG DOSE) TBPK 43 VASCEPA CAPS 05gm 1gm 23 VAXCHORA SUSR 58 vecamyl tabs 25 VECTICAL OINT 63 VELCADE SOLR 19 velivet tabs 47
106 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
VELPHORO CHEW 39 VELTASSA PACK 84gm 168gm 252gm
39 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 19 VENCLEXTA TABS 10mg 19 VENCLEXTA TABS 50mg 100mg 19 venlafaxine hcl er cp24 375mg 75mg
150mg 37 venlafaxine hcl er tb24 375mg 75mg
150mg 225mg 37 venlafaxine hcl tabs 25mg 375mg 50mg
75mg 100mg 37 VENTAVIS SOLN 10mcgml 20mcgml 57 VENTOLIN HFA AERS 21 VERAPAMIL HCL ER CP24 100mg
120mg 180mg 200mg 240mg 300mg 360mg 25
verapamil hcl er tbcr 120mg 180mg 240mg 25
verapamil hcl soln 25 verapamil hcl tabs 25 verapamil hcl tabs 80mg 120mg 25 VEREGEN OINT 63 VERELAN CP24 25 veripred 20 soln 45 VERSACLOZ SUSP 37 VERZENIO TABS 50mg 100mg 150mg
200mg 19 vestura tabs 47 VIBERZI TABS 75mg 100mg 44 VIBRAMYCIN SYRP 10 vicodin es tabs 29 vicodin hp tabs 29 vicodin tabs 29 VICTOZA SOPN 49 VIDEX EC CPDR 125mg 200mg 400mg 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 47 vigabatrin pack 32 vigabatrin tabs 32 vigadrone pack 32 VIIBRYD STARTER PACK KIT 37 VIIBRYD TABS 10mg 20mg 40mg 37 VILTEPSO SOLN 55 VIMIZIM SOLN 40 VIMPAT SOLN 32
VIMPAT TABS 32 vinblastine sulfate soln 19 vincasar pfs soln 19 vincristine sulfate soln 19 vinorelbine tartrate soln 19 VIOKACE TABS 40 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 52 VITAMINS ACD-FLUORIDE SOLN 64 VITRAKVI CAPS 25mg 100mg 19 VITRAKVI SOLN 19 VIVITROL SUSR 35 VIZIMPRO TABS 15mg 30mg 45mg 19 VOCABRIA TABS 13 VORAXAZE SOLR 52 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 19 VP-PNV-DHA CAPS 64 VPRIV SOLR 40 VRAYLAR CAPS 15mg 3mg 45mg 6mg
37 VRAYLAR CPPK 37 VUMERITY (STARTER) CPDR 55 VUMERITY CPDR 55 vyfemla tabs 47 vylibra tabs 47 VYNDAMAX CAPS 25 VYNDAQEL CAPS 25 VYONDYS 53 SOLN 55 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 30 VYVANSE CHEW 10mg 20mg 30mg
40mg 50mg 60mg 30 VYXEOS SUSR 19 VYZULTA SOLN 42
W WAKIX TABS 445mg 178mg 30 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 22 WATER FOR IRRIGATION STERILE
SOLN 55 wixela inhub aepb 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 107
wymzya fe chew 48 WYNZORA CREA 63
X XALKORI CAPS 200mg 250mg 19 XARELTO STARTER PACK TBPK 22 XARELTO TABS 25mg 10mg 15mg
20mg 22 XATMEP SOLN 19 XCOPRI (250 MG DAILY DOSE) TBPK 32 XCOPRI (350 MG DAILY DOSE) TBPK 32 XCOPRI TABS 200 MG 32 XCOPRI TABS 50mg 100mg 150mg 32 XCOPRI TBPK 32 XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
32 XELJANZ SOLN 53 XELJANZ TABS 5mg 10mg 53 XELJANZ XR TB24 11mg 22mg 53 XELPROS EMUL 42 XEMBIFY SOLN SUBCUTANEOUS
2gm10ml 4gm20ml 10gm50ml 1gm5ml 57
XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 55 XEOMIN SOLR 50unit 100unit 55 XEPI CREA 59 XERESE CREA 59 XERMELO TABS 43 XGEVA SOLN 52 XHANCE EXHU 42 XIFAXAN TABS 200mg 550mg 10 XIIDRA SOLN 42 XIMINO CP24 45mg 90mg 135mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 56 XOLAIR SOSY 75mg05ml 150mgml 56 XOSPATA TABS 19 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 19 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (40 MG TWICE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (60 MG ONCE WEEKLY) TBPK
20mg 60mg 19
XPOVIO (60 MG TWICE WEEKLY) TBPK 19
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg 19
XPOVIO (80 MG TWICE WEEKLY) TBPK 19
XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg 29
XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 48 XUREA CREA 63 XURIDEN PACK 55 xylocaine dental soln 55 XYOSTED SOAJ 50mg05ml 75mg05ml
100mg05ml 46 XYREM SOLN 34 XYWAV SOLN 34
Y YERVOY SOLN 19 YF-VAX INJ 58 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 42 yuvafem tabs 50
Z zafemy ptwk 48 zafirlukast tabs 10mg 20mg 55 zaleplon caps 5mg 10mg 33 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 48 zarontin soln 32 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 29 ZEJULA CAPS 19 ZELAPAR TBDP 33 ZELBORAF TABS 19 ZEMAIRA SOLR INTRAVENOUS 56 ZEMBRACE SYMTOUCH SOAJ 32 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
63 ZENPEP CPEP 40
108 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg 30
ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
34 ZEPOSIA CAPS 34 ZEPOSIA STARTER KIT CPPK 34 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERIT CAPS 15mg 20mg 30mg 40mg 13 ZERUVIA PTCH 61 ZETONNA AERS 42 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 55 ZINBRYTA SOSY 34 ZIONODIL 100 LOTN 61 ZIONODIL LOTN 61 ZIOPTAN SOLN 42 ziprasidone hcl caps 20mg 40mg 60mg
80mg 37 ziprasidone mesylate solr 37 ZIPSOR CAPS 29 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZIRGAN GEL 41 ZITHROMAX PACK 10 ZOKINVY CAPS 50mg 75mg 55 zoledronic acid conc 52 zoledronic acid soln 52
ZOLINZA CAPS 19 zolmitriptan soln 32 zolmitriptan tabs 32 zolmitriptan tbdp 32 zolpidem tartrate er tbcr 625mg 125mg 33 zolpidem tartrate subl 175mg 35mg 33 zolpidem tartrate tabs 5mg 10mg 33 ZOMACTON SOLR 51 ZOMACTON SOLR 5mg 51 ZOMIG SOLN 32 zonisamide caps 25mg 50mg 100mg 32 ZONTIVITY TABS 22 ZORBTIVE SOLR 51 ZORTRESS TABS 025mg 53 ZORTRESS TABS 05mg 075mg 1mg 53 ZORVOLEX CAPS 29 ZOSTAVAX SUSR 58 ZOSYN SOLN INTRAVENOUS 10 zovia 135e (28) tabs 48 ZUBSOLV SUBL 35 ZUPLENZ FILM 4mg 8mg 43 ZYCLARA PUMP CREA 63 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19 ZYKADIA TABS 19 ZYLET SUSP 42 ZYNLONTA SOLR 19 ZYPITAMAG TABS 1mg 2mg 4mg 23 ZYPREXA RELPREVV SUSR 37 ZYTIGA TABS 19 ZYVOX SOLN INTRAVENOUS 10
Nondiscrimination Notice
Kaiser Permanente does not discriminate on the basis of age race ethnicity color national origin
cultural background ancestry religion sex gender identity gender expression sexual orientation
marital status physical or mental disability source of payment genetic information citizenship
primary language or immigration status
Language assistance services are available from our Member Service Contact Center 24 hours a day
7 days a week (except closed holidays) Interpreter services including sign language are available at
no cost to you during all hours of operation Auxiliary aids and services for individuals with
disabilities are available at no cost to you during all hours of operation We can also provide you your
family and friends with any special assistance needed to access our facilities and services You may
request materials translated in your language at no cost to you You may also request these materials in
large text or in other formats to accommodate your needs at no cost to you For more information call
1-800-464-4000 (TTY 711)
A grievance is any expression of dissatisfaction expressed by you or your authorized representative
through the grievance process For example if you believe that we have discriminated against you you
can file a grievance Please refer to your Evidence of Coverage or Certificate of Insurance or speak
with a Member Services representative for the dispute-resolution options that apply to you
You may submit a grievance in the following ways
bull By phone Call member services at 1-800-464-4000 (TTY 711) 24 hours a day
7 days a week (except closed holidays)
bull By mail Call us at 1-800-464-4000 (TTY 711) and ask to have a form sent to you
bull In person Fill out a Complaint or Benefit ClaimRequest form at a member services office
located at a Plan Facility (go to your provider directory at kporgfacilities for addresses)
bull Online Use the online form on our website at kporg
Please call our Member Service Contact Center if you need help submitting a grievance
The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to
discrimination on the basis of race color national origin sex age or disability You may also
contact the Kaiser Permanente Civil Rights Coordinator directly at
Northern California
Civil RightsADA Coordinator
1800 Harrison St
16th Floor
Oakland CA 94612
Southern California
Civil RightsADA Coordinator
SCAL Compliance and Privacy
393 East Walnut St
Pasadena CA 91188
You can also file a civil rights complaint with the US Department of Health and Human Services
Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available
at ocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human
Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201
1-800-368-1019 1-800-537-7697 (TTY) Complaint forms are available at
hhsgovocrofficefileindexhtml
Language Assistance Services
English Language assistance
is available at no cost to you
24 hours a day 7 days a week
You can request interpreter
services materials translated
into your language or in
alternative formats Just call us
at 1-800-464-4000 24 hours a
day 7 days a week (closed
holidays) TTY users call 711
Arabic مجانا على مدار الساعة كافة متوفرة لك خدمات الترجمة الفورية
أيام الأسبوع بإمكانك طلب خدمة الترجمة الفورية أو ترجمة وثائق للغتك أو
4000-464-800-1 لصيغ أخرى ما عليك سوى الاتصال بنا على الرقم
لمستخدمي خدمة على مدار الساعة كافة أيام الأسبوع )مغلق أيام العطلات(
(711الرقم ) الهاتف النصي يرجي الاتصال على
Armenian Ձեզ կարող է անվճար օգնություն
տրամադրվել լեզվի հարցում` օրը 24 ժամ շաբաթը
7 օր Դուք կարող եք պահանջել բանավոր
թարգմանչի ծառայություններ Ձեր լեզվով
թարգմանված կամ այլընտրանքային ձևաչափով
պատրաստված նյութեր Պարզապես զանգահարեք
մեզ` 1-800-464-4000 հեռախոսահամարով` օրը
24 ժամ` շաբաթը 7 օր (տոն օրերին փակ է) TTY-ից
օգտվողները պետք է զանգահարեն 711
Chinese 您每週 7天每天 24小時均可獲得免費語
言協助您可以申請口譯服務要求將資料翻譯成
您所用語言或轉換為其他格式我們每週 7天
每天 24小時均歡迎您打電話 1-800-757-7585 前來聯
絡(節假日 休息)聽障及語障專線 (TTY) 使用者
請撥 711
Farsi بدون روز هفته 7ساعت شبانروز و 24در زبانی خدمات
مترجم خدمات شما می توانید برای استهزینه در اختیار شما اخذ
صورتهای دیگر به زبان شما و یا به جزوات ترجمهشفاهی
روز هفته 7ساعت شبانروز و 24 کافیست در درخواست کنید
4000-464-800-1)به استثنای روزهای تعطیل( با ما به شماره
تماس بگیرند 711با شماره TTYتماس بگیرید کاربران
Hindi बिना किसी लागत ि दभाबिया सवाए कदन ि 24 घट
सपताह ि सातो कदन उपलबध ह आप एि दभाबिय िी सवाओ
ि बलए बिना किसी लागत ि सामबियो िो अपनी भािा म
अनवाद िरवान ि बलए या विबपपि परारपो ि बलए अनरोध
िर सित ह िस िवल हम 1-800-464-4000 पर कदन ि 24
घट सपताह ि सातो कदन (छटटियो वाल कदन िद रहता ह) िॉल
िर TTY उपयोगिताा 711 पर िॉल िर
Hmong Muajkwc pab txhais lus pub dawb rau koj
24 teev ib hnub twg 7 hnub ib lim tiam twg Koj thov
tau cov kev pab txhais lus muab cov ntaub ntawv
txhais ua koj hom lus los yog ua lwm homTsuas hu
rau 1-800-464-4000 24 teev ib hnub twg 7 hnub ib
lim tiam twg (cov hnub caiv kaw) Cov neeg siv
TTY hu 711
Japanese 当院では言語支援を無料で年中無休
終日ご利用いただけます通訳サービス日本語
に翻訳された資料あるいは資料を別の書式でも
依頼できますお気軽に 1-800-464-4000 までお電話
ください (祭日を除き年中無休)TTYユーザー
は 711にお電話ください
Khmer ជនយភាសា គមានឥតអសថលៃដលអនកឡ ើយ 24
ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ អនកអាចឡសនើស ឡសវាអនកបកបរប សភារៈបដលបានបកបរបឡៅជាភាសាបមែរ ឬជាទរងផោសងឡទៀត រានបតទរសពទមកឡយើង តាមឡលម 1-800-464-4000 បាន 24 ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ (បទថលៃប ណោយ) អនកឡរបើ TTY ឡៅឡលម 711
Korean 요일 및 시간에 관계없이 언어 지원
서비스를 무료로 이용하실 수 있습니다 귀하는
통역 서비스 귀하의 언어로 번역된 자료 또는 대체
형식의 자료를 요청할 수 있습니다 요일 및 시간에
관계없이 1-800-464-4000번으로 전화하십시오
(공휴일 휴무) TTY 사용자 번호 711
Laotian ການຊວຍເຫ ອດານພາສາມໃຫໂດຍບ ເສຽຄາ
ແກທານ ຕະຫ ອດ 24 ຊ ວໂມງ 7 ວນຕ ອາທດ ທານ
ສາມາດຮອງຂ ຮບບ ລການນາຍພາສາ ໃຫແປເອກະ
ສານເປນພາສາຂອງທານ ຫ ໃນຮບແບບອ ນ ພຽງ
ແຕໂທຣຫາພວກເຮ າທ 1-800-464-4000 ຕະຫ ອດ 24
ຊ ວໂມງ 7 ວນຕ ອາທດ (ປດວນພກຕາງໆ) ຜໃຊສາຍ
TTY ໂທຣ 711
Navajo Saad bee aacutekaacutersquoarsquoayeed naacutehoacuteloacute trsquoaacuteaacute jiikrsquoeacute
naadiin doo bibąąrsquo diacuteiacutersquo aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute
damoo naacuteaacutedleehjiacute Atah halnersquoeacute aacutekaacutersquoadoolwołiacutegiacuteiacute joacutekiacute
trsquoaacuteadoo lersquoeacute trsquoaacuteaacute hoacutehazaadjiacute hadilyąąrsquogo eacuteiacute doodaiirsquo
naacuteaacutenaacute laacute ałrsquoąą aacutedaatrsquoehiacutegiacuteiacute bee haacutedadilyaarsquogo Kojiacute
hodiilnih 1-800-464-4000 naadiin doo bibąąrsquo diacuteiacutersquo
aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute damoo naacutersquoaacutedleehjiacute
(Dahodiyin biniiyeacute ersquoersquoaahgo eacuteiacute darsquodeelkaal)
TTY chodeeyooliacuteniacutegiacuteiacute kojiacute hodiilnih 711
Punjabi ਬਿਨ ਾ ਬਿਸੀ ਲ ਗਤ ਦ ਬਦਨ ਦ 24 ਘਟ ਹਫਤ ਦ 7 ਬਦਨ
ਦਭ ਸੀਆ ਸਵ ਵ ਾ ਤਹ ਡ ਲਈ ਉਪਲਿਧ ਹ ਤਸੀ ਇਿ ਦਭ ਸੀਏ ਦੀ
ਮਦਦ ਲਈ ਸਮਗਰੀਆਾ ਨ ਆਪਣੀ ਭ ਸ ਬਵਚ ਅਨਵ ਦ ਿਰਵ ਉਣ
ਲਈ ਜ ਾ ਬਿਸ ਵਖ ਫ ਰਮਟ ਬਵਚ ਪਰ ਪਤ ਿਰਨ ਲਈ ਿਨਤੀ ਿਰ ਸਿਦ
ਹ ਿਸ ਬਸਰਫ਼ ਸ ਨ 1-800-464-4000 ਤ ਬਦਨ ਦ 24 ਘਟ ਹਫ਼ਤ
ਦ 7 ਬਦਨ (ਛਟੀਆਾ ਵ ਲ ਬਦਨ ਿਦ ਰਬਹਦ ਹ) ਫ਼ਨ ਿਰ TTY ਦ
ਉਪਯਗ ਿਰਨ ਵ ਲ 711 lsquoਤ ਫ਼ਨ ਿਰਨ
Russian Мы бесплатно обеспечиваем Вас услугами
перевода 24 часа в сутки 7 дней в неделю Вы можете
воспользоваться помощью устного переводчика
запросить перевод материалов на свой язык или
запросить их в одном из альтернативных форматов
Просто позвоните нам по телефону 1-800-464-4000
который доступен 24 часа в сутки 7 дней в неделю
(кроме праздничных дней) Пользователи линии TTY
могут звонить по номеру 711
Spanish Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al diacutea 7 diacuteas a la semana
Puede solicitar los servicios de un inteacuterprete que los
materiales se traduzcan a su idioma o en formatos
alternativos Solo llame al 1-800-788-0616 24 horas al
diacutea 7 diacuteas a la semana (cerrado los diacuteas festivos) Los
usuarios de TTY deben llamar al 711
Tagalog May magagamit na tulong sa wika nang wala
kang babayaran 24 na oras bawat araw 7 araw bawat
linggo Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format Tawagan lamang
kami sa 1-800-464-4000 24 na oras bawat araw 7 araw
bawat linggo (sarado sa mga pista opisyal) Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711
Thai เรามบรการลามฟรส าหรบคณตลอด 24 ชวโมง
ทกวนตลอดชวโมงท าการของเราคณสามารถขอใหลาม
ชวยตอบค าถามของคณทเกยวกบความคมครองการดแล
สขภาพของเราและคณยงสามารถขอใหมการแปลเอกสา
รเปนภาษาทคณใชไดโดยไมมการคดคาบรการเพยงโทร
หาเราทหมายเลข 1-800-464-4000 ตลอด 24
ชวโมงทกวน (ปดใหบรการในวนหยดราชการ) ผใช TTY
โปรดโทรไปท 711
Vietnamese Dịch vụ thocircng dịch được cung cấp miễn
phiacute cho quyacute vị 24 giờ mỗi ngagravey 7 ngagravey trong tuần Quyacute
vị coacute thể yecircu cầu dịch vụ thocircng dịch tagravei liệu phiecircn dịch
ra ngocircn ngữ của quyacute vị hoặc tagravei liệu bằng nhiều higravenh
thức khaacutec Quyacute vị chỉ cần gọi cho chuacuteng tocirci tại số
1-800-464-4000 24 giờ mỗi ngagravey 7 ngagravey trong tuần
(trừ caacutec ngagravey lễ) Người dugraveng TTY xin gọi 711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
Provide no cost aids and services to people with disabilities to communicate effectively with us such as
diams Qualified sign language interpreters
diams Written information in other formats such as large print audio and accessible electronic formats
Provide no cost language services to people whose primary language is not English such as
diams Qualified interpreters
diams Information written in other languages
If you need these services call Member Services at 1-800-476-2167 (TTY 711)8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana Aurora CO 80014 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
61102709_CO
Multi-language Interpreter Services
English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-476-2167 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-476-2167 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-476-2167 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-476-2167 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-476-2167 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-476-2167 (TTY 711)번으로 전화해 주십시오
Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-800-476-2167 (телетайп 711)
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-476-2167(TTY711)までお電話にてご連絡ください
Amharic ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው 711)
German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-800-476-2167 (TTY 711)
French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-800-476-2167 (ATS 711)
Farsi
ی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ دیریبگ تماس (TTY 711) 2167-476-800-1 با باشد
Arabic
ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم )117- (رقم ھاتف الصم والبكم 7612-674-008-1
Yoruba AKIYESI Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o E pe ero ibanisoro yi 1-800-476-2167 (TTY 711)
Cushite-Oromo XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 1-800-476-2167 (TTY 711)
Nepali
धयान िदनहोस तपाइल नपाली बोलनहनछ भन तपाइको िनिमत भाषा सहायता सवाह िनःशलक पमा उपलबध छ फोन गनरहोस 1-800-476-2167 (िटिटवाइ 711)
KAH2711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
bull Provide no cost aids and services to people with disabilities to communicateeffectively with us such asdiams Qualified sign language interpretersdiams Written information in other formats such as large print audio and accessible
electronic formatsbull Provide no cost language services to people whose primary language is not English
such asdiams Qualified interpretersdiams Information written in other languages
If you need these services call Member Services at 1-800-805-2739 (TTY 711) 8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd Honolulu HI 96813 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Kaiser Permanente is an HMO plan with a Medicare contract Enrollment in Kaiser Permanente depends on contract renewal
H1230_2017MLI accepted
Multi-language Interpreter Services English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-805-2739 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-805-2739 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-805-2739 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-805-2739 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-805-2739 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-805-2739 (TTY 711)번으로 전화해 주십시오
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-805-2739(TTY711)までお電話にてご連絡ください
Lao
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 1-800-805-2739 (TTY 711)
Ilocano PAKDAAR Nu saritaem ti Ilocano ti serbisyo para ti baddang ti lengguahe nga awanan bayadna ket sidadaan para kenyam Awagan ti 1-800-805-2739 (TTY 711)
Samoan MO LOU SILAFIA Afai e te tautala Gagana faa Sāmoa o loo iai auaunaga fesoasoan e fai fua e leai se totogi mo oe Telefoni mai 1-800-805-2739 (TTY 711)
Marshallese LALE Ntildee kwōj kōnono Kajin Ṃajōḷ kwomarontilde bōk jerbal in jipantilde ilo kajin ṇe aṃ ejjeḷọk wōṇāān Kaalọk 1-800-805-2739 (TTY 711)
Trukese MEI AUCHEA Ika iei foosun fonuomw Foosun Chuuk iwe en mei tongeni omw kopwe angei aninisin chiakku ese kamo Kori 1-800-805-2739 (TTY 711)
Hawaiian E NĀNĀ MAI Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo loaʻa ke kōkua manuahi iā ʻoe E kelepona iā 1-800-805-2739 (TTY 711)
Pohnpeian Ni songen mwohmw ohte komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei Call 1-800-805-2739 (TTY 711)
Bisayan ATENSYON Kung nagsulti ka og Cebuano aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe nga walay bayad Tawag sa 1-800-805-2739 (TTY 711)
Tongan FAKATOKANGArsquoI Kapau lsquooku ke Lea-Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai atu ha tokoni tarsquoetotongi pea teke lava lsquoo marsquou ia Telefoni mai 1-800-805-2739 (TTY 711)
485236276 102021
This formulary was updated on 100121 For more recent information or other questions please contact the number for your Kaiser Permanente Region listed below seven days a week 8 am to 8 pm or visit kporgseniorrx
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Foundation Health Plan Inc 393 E Walnut St Pasadena CA 91188-8514 Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E Dakota Ave Denver CO 80247 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Foundation Health Plan Inc 711 Kapiolani Blvd Honolulu HI 96813 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
kporgseniorrx Please recycle
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 1
What is the Kaiser Permanente Formulary
A formulary is a list of covered drugs selected by Kaiser Permanente in consultation with a team of health care providers which represents the prescription therapies believed to be a necessary part of a quality treatment program Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary the prescription is filled at a Kaiser Permanente network pharmacy and other plan rules are followed For more information on how to fill your prescriptions please review your Evidence of Coverage Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages Can the formulary (drug list) change
Most changes in drug coverage happen on January 1 but Kaiser Permanente may add or remove drugs on the Drug List during the year or add new restrictions We must follow Medicare rules in making these changes
Changes that can affect you this year
In the below cases you will be affected by coverage changes during the year
New generic drugs
We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug with the same or fewer restrictions Also when adding the new generic drug we may decide to keep the brand name drug on our Drug List but immediately add new restrictions If you are
currently taking that brand name drug we may not tell you in advance before we make that change but we will later provide you with information about the specific change(s) we have made
bull If we make such a change you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will also include information on how to request an exception and you can also find information in the section below entitled ldquoHow do I request an exception to the Kaiser Permanente Formularyrdquo
Drugs removed from the market
If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our formulary and provide notice to members who take the drug
Other changes
We may make other changes that affect members currently taking a drug For instance we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug Or we may make changes based on new clinical guidelines If we remove drugs from our formulary or add prior authorization we must notify affected members of the change at least 30 days before the change becomes effective or at the time the member requests a refill of the drug at which time the member will receive a 30-day supply of the drug
bull If we make these other changes you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will include information
2 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
on how to request an exception You can find information in the section below entitled ldquoHow do I request an exception to the Kaiser Permanente Formularyrdquo
Changes that will not affect you if you are currently taking the drug
Generally if you are taking a drug on our 2021 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year You will not get direct notice this year about changes that do not affect you However on January 1 of the next year such changes would affect you and it is important to check the Drug List for the new benefit year for any changes to drugs
The enclosed formulary is current as of October 1 2021 To get updated information about the drugs covered by our plan please call us Contact information for your Kaiser Permanente Region appears on the front and back cover pages
In the event of a midyear non-maintenance formulary change we will provide details in the Medicare Part D Explanation of Benefits that we send you or Provision of Notice posted at kporgseniorrx
How do I use the formulary
There are two ways to find your drug within the formulary
Medical condition The formulary begins on page 6 The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat For example drugs used to treat a heart condition are listed under the category ldquoCardiovascular Drugsrdquo If you know what your drug is used for look for the category name in the list that begins on page 8 Then look under the category name for your drug Alphabetical listing
If you are not sure what category to look under you should look for your drug in the index that begins on page 66 The index provides an alphabetical list of all the drugs included in this document Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the index and find the name of your drug in the first column of the list What are generic drugs
Our plan covers both brand-name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug Generally generic drugs cost less than brand-name drugs Please see your Evidence of Coverage for more information
What are brand-name drugs
Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug When the patent on a brand-name drug expires other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices Please
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 3
see your Evidence of Coverage for more information
Are there any restrictions on my coverage
Some covered drugs may have additional requirements or limits on coverage These requirements and limits may include
bull Prior Authorization Our plan may require you or your network provider to get prior authorization for certain drugs This means that you will need to get approval from our plan before you fill your prescriptions If you donrsquot get approval we may not cover the drug
Note If your prescription has more than one refill remaining you can only get one refill at a time unless authorized because you will be away from our service area for an extended period of time For certain drugs we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive Also if there is a shortage in the marketplace we may fill your prescription for a limited quantity You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6 You can also get more information about the restrictions applied to specific covered drugs by visiting our website We have posted online a document that explains our prior authorization restriction You may also ask us to send you a copy Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages
You can ask us to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I request an exception to the Kaiser Permanente formularyrdquo for information about how to request an exception What if my drug is not on the formulary
If your drug is not included in this formulary (list of covered drugs) you should first check our Kaiser Permanente 2021 Comprehensive Formulary at kporgseniorrx or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region and confirm if your drug is covered If your Medicare Part D prescription drug is not on our Kaiser Permanente 2021 Comprehensive Formulary you have two options
bull You can ask your network provider to prescribe a similar drug that is included on our formulary
bull You can ask us to make an exception and cover your drug See the next section for information about how to request an exception
How do I request an exception to the Kaiser Permanente Formulary
You can ask us to make an exception to our coverage rules There are several types of exceptions that you can ask us to make
bull You can ask us to cover a drug even if it may not be in our Kaiser Permanente 2021 Comprehensive Formulary
4 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
bull You can ask us to waive coverage
restrictions or limits on your drug For example if your drug requires prior authorization you can ask us to waive the prior authorization requirement for your Part D drug
Generally we will only approve your request for an exception if the alternative drugs included on the planrsquos formulary or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception When you request a formulary or utilization restriction exception you should submit a statement from your network provider supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited (fast) exception if you or your network provider believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber
Please note You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare amp Medicaid Services (CMS) You cannot get an exception for drugs that are excluded under Medicare Part D Please refer to your Evidence of Coverage for more information about requesting exceptions including the appeals process What do I do before I can talk to my network provider about
changing my drugs or requesting an exception
In some cases you might be taking Medicare Part D drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your network provider to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your network provider to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan For each of your Part D drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide up to a maximum of a 30-day supply of medication After your first 30-day supply we may cover an additional refill as medically necessary After you have used these refills we will not pay for these drugs even if you have been a member of the plan less than 90 days
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug while you pursue a formulary exception
For current members with level of care changes if you enter into or are discharged from a hospital skilled nursing facility or long-term care facility to a different care setting or home this is what is known as a
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 5
level of care change When your level of care changes you may require an additional fill of your medication We will generally cover up to a one-month supply of your Part D drugs during this level of care transition period even if the drug is not on our Drug List
For more information
For more detailed information about your Kaiser Permanente prescription drug coverage please review your Evidence of Coverage and other plan materials If you have questions about our plan please call us Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048 Or visit httpwwwmedicaregov
6 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Kaiser Permanentersquos Formulary
The formulary below provides coverage information about the drugs covered by our plan If you have trouble finding your drug in the list turn to the index that begins on page 66 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg NEBUPENT) and generic drugs are listed in lower-case italics (eg ltamoxicillingt) The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number below Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy Northern CA ndash 1-888-218-6245 Monday through Friday 8 am to 8 pm Saturday 8 am to 6 pm and Sunday 9 am to 6 pm Southern CA ndash 1-866-206-2983 Monday through Friday 7 am to 7 pm Saturday 10 am to 2 pm
Colorado
Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday 8 am to 6 pm
Hawaii
Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday 800 am to 5 pm
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 7
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
8 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole tabs NDS emverm chew ivermectin tabs praziquantel tabs MO ANTIBACTERIALS amikacin sulfate soln amikacin sulfate soln injection HI amoxicillin caps amoxicillin chew amoxicillin susr amoxicillin tabs amoxicillin-pot clavulanate chew amoxicillin-pot clavulanate er tb12
amoxicillin-pot clavulanate susr amoxicillin-pot clavulanate tabs ampicillin caps ampicillin sodium solr ampicillin sodium solr injection 1gm 125mg HI
ampicillin sodium solr intravenous HI
ampicillin-sulbactam sodium solr ampicillin-sulbactam sodium solr injection HI
ampicillin-sulbactam sodium solr intravenous HI
ARIKAYCE SUSP PALDNDS AUGMENTIN SUSR AVYCAZ SOLR INTRAVENOUS HI AZITHROMYCIN PACK MO azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BAXDELA SOLR INTRAVENOUS HI
BAXDELA TABS MO
Drug Name RequirementsLimits
BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP cefaclor caps cefaclor er tb12 cefaclor susr cefadroxil caps cefadroxil susr cefadroxil tabs cefazolin sodium solr cefazolin sodium solr injection 1gm 10gm 500mg HI
cefdinir caps cefdinir susr cefepime hcl solr injection 1gm 2gm HI
cefixime caps cefixime susr cefotaxime sodium solr cefotetan disodium solr injection 1gm 2gm HI
cefoxitin sodium solr injection HI cefoxitin sodium solr intravenous 1gm 2gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 2gm 6gm HI
CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 75gm 750mg HI
cefuroxime sodium solr intravenous HI
cephalexin caps cephalexin susr cephalexin tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w soln ciprofloxacin in d5w soln intravenous HI
ciprofloxacin susr ciprofloxacin-ciproflox hcl er tb24 clarithromycin er tb24 clarithromycin susr clarithromycin tabs cleocin phosphate soln cleocin solr clindamycin hcl caps clindamycin palmitate hcl solr clindamycin phosphate in d5w soln intravenous HI
clindamycin phosphate soln clindamycin phosphate soln injection 300mg2ml 600mg4ml 900mg6ml
HI
colistimethate sodium (cba) solr injection HI
DALVANCE SOLR INTRAVENOUS HI
daptomycin solr intravenous 350mg 500mg HI
demeclocycline hcl tabs dicloxacillin sodium caps DIFICID SUSR NDS DIFICID TABS NDS DORYX MPC TBEC MO doxy 100 solr intravenous HI doxycycline hyclate caps 50mg 100mg MO
doxycycline hyclate tabs 20mg 75mg 100mg 150mg MO
doxycycline hyclate tbec 50mg 75mg 100mg 150mg 200mg MO
doxycycline monohydrate caps 50mg 75mg 100mg 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
Drug Name RequirementsLimits
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs FETROJA SOLR NDS FIRVANQ SOLR gentamicin in saline soln gentamicin in saline soln intravenous HI
gentamicin sulfate soln gentamicin sulfate soln injection HI imipenem-cilastatin solr intravenous HI
KIMYRSA SOLR NDS levofloxacin in d5w soln levofloxacin in d5w soln intravenous HI
levofloxacin soln levofloxacin soln intravenous HI levofloxacin tabs lincomycin hcl soln linezolid soln intravenous HI linezolid susr NDS linezolid tabs NDS meropenem solr intravenous 1gm 500mg HI
minocycline hcl caps 50mg 75mg 100mg MO
minocycline hcl er tb24 45mg 55mg 65mg 80mg 90mg 105mg 115mg 135mg
MO
minocycline hcl tabs 50mg 75mg 100mg MO
mondoxyne nl caps 75mg 100mg MO
morgidox caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 10 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium solr intravenous HI neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs okebo caps MO ORBACTIV SOLR NDS OXACILLIN SODIUM IN DEXTROSE SOLN INTRAVENOUS
HI
oxacillin sodium solr injection 1gm 2gm HI
oxacillin sodium solr intravenous HI PENICILLIN G POT IN DEXTROSE SOLN INTRAVENOUS
HI
penicillin g potassium solr injection HI
penicillin g procaine susp penicillin g sodium solr injection HI penicillin v potassium solr penicillin v potassium tabs piperacillin sod-tazobactam so solr
piperacillin sod-tazobactam so solr intravenous HI
polymyxin b sulfate solr injection HI RECARBRIO SOLR NDS SEYSARA TABS 60mg 100mg 150mg NDS
SIVEXTRO SOLR INTRAVENOUS HI
SIVEXTRO TABS NDS soloxide tbec MO streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
Drug Name RequirementsLimits
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO SUPRAX CAPS suprax chew suprax susr 100mg5ml 200mg5ml
SUPRAX SUSR 500 MG5ML SYNERCID SOLR targadox tabs MO tazicef solr injection 1gm 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS 400mg 600mg HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
VABOMERE SOLR INTRAVENOUS HI
vancomycin hcl caps vancomycin hcl solr VANCOMYCIN HCL SOLR 250 MG
vancomycin hcl solr intravenous 1gm 10gm 500mg HI
VIBRAMYCIN SYRP XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS XIMINO CP24 45mg 90mg 135mg MO
ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ZITHROMAX PACK MO ZOSYN SOLN INTRAVENOUS HI ZYVOX SOLN INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
ANTIFUNGALS ABELCET SUSP INTRAVENOUS HI
AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS ERAXIS SOLR INTRAVENOUS 50mg 100mg HI
fluconazole in sodium chloride soln intravenous HI
fluconazole susr fluconazole tabs flucytosine caps 250mg 500mg NDS griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs itraconazole caps ITRACONAZOLE SOLN MO ketoconazole tabs micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS NOXAFIL TBEC NDS nystatin susp nystatin tabs POSACONAZOLE SUSP NDS posaconazole tbec NDS terbinafine hcl tabs TOLSURA CAPS NDS voriconazole solr intravenous HI voriconazole susr voriconazole tabs ANTIMYCOBACTERIALS CAPASTAT SULFATE SOLR cycloserine caps dapsone tabs 25mg 100mg MO ethambutol hcl tabs 100mg 400mg MO
isoniazid soln
Drug Name RequirementsLimits
isoniazid syrp MO isoniazid tabs 100mg 300mg MO paser pack MO PRETOMANID TABS PRIFTIN TABS MO pyrazinamide tabs MO RIFABUTIN CAPS MO RIFADIN CAPS MO rifamate caps MO rifampin caps 150mg 300mg MO rifampin solr intravenous HI RIFATER TABS MO SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs BENZNIDAZOLE TABS 125mg 100mg MO
chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS DARAPRIM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS mefloquine hcl tabs metronidazole caps metronidazole in nacl soln metronidazole in nacl soln intravenous HI
metronidazole tabs NEBUPENT SOLR PA nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 12 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
quinine sulfate caps NDS SOLOSEC PACK tinidazole tabs ANTIVIRALS abacavir sulfate soln abacavir sulfate tabs MO abacavir sulfate-lamivudine tabs MO abacavir-lamivudine-zidovudine tabs MO
acyclovir caps MO acyclovir sodium soln intravenous HI
acyclovir susp MO acyclovir tabs 400mg 800mg MO adefovir dipivoxil tabs NDS APTIVUS CAPS MO APTIVUS SOLN MO atazanavir sulfate caps 150mg 200mg 300mg MO
BARACLUDE SOLN MO BIKTARVY TABS CABENUVA SUER cidofovir soln CIMDUO TABS MO COMPLERA TABS MO CRIXIVAN CAPS 200mg 400mg MO DAKLINZA TABS 30mg 60mg 90mg PANDS
DELSTRIGO TABS MO DESCOVY TABS MO didanosine cpdr 200mg 250mg 400mg MO
DOVATO TABS MO EDURANT TABS MO efavirenz caps 50mg 200mg MO efavirenz tabs MO efavirenz-emtricitab-tenofovir tabs MO
emtricitabine caps MO emtricitabine-tenofovir df tabs MO EMTRIVA SOLN MO entecavir tabs 05mg 1mg MO EPCLUSA TABS PANDS
Drug Name RequirementsLimits
EPIVIR HBV SOLN MO etravirine tabs 100mg 200mg MO EVOTAZ TABS MO famciclovir tabs 125mg 250mg 500mg MO
fosamprenavir calcium tabs MO FUZEON SOLR NDS ganciclovir sodium soln ganciclovir sodium solr GENVOYA TABS MO HARVONI PACK PANDS HARVONI TABS PANDS INTELENCE TABS 25mg MO INVIRASE CAPS MO INVIRASE TABS MO ISENTRESS CHEW 25mg 100mg MO
ISENTRESS HD TABS MO ISENTRESS PACK MO ISENTRESS TABS MO JULUCA TABS MO lamivudine soln MO lamivudine tabs 100mg 150mg 300mg MO
lamivudine-zidovudine tabs MO ledipasvir-sofosbuvir tabs PANDS LEXIVA SUSP MO lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO MAVYRET TABS PANDS nevirapine er tb24 100mg 400mg MO
nevirapine susp MO nevirapine tabs MO NORVIR CAPS MO NORVIR PACK MO NORVIR SOLN MO ODEFSEY TABS MO OLYSIO CAPS PANDS oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEG-INTRON REDIPEN KIT NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
PEGASYS PROCLICK SOLN 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN 180mcg05ml 180mcgml NDS
PEGINTRON KIT NDS PIFELTRO TABS MO PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
PREVYMIS SOLN 240mg12ml 480mg24ml NDS
PREVYMIS TABS 240mg 480mg NDS
PREZCOBIX TABS MO PREZISTA SUSP MO PREZISTA TABS 75mg 150mg 600mg 800mg MO
RAPIVAB SOLN NDS REBETOL SOLN MO RELENZA DISKHALER AEPB MO RESCRIPTOR TABS 100mg 200mg MO
RETROVIR SOLN MO REYATAZ PACK MO ribasphere caps MO ribasphere ribapak (1000 pack) tbpk MO
ribasphere ribapak (1200 pack) tbpk MO
ribasphere tabs MO ribavirin caps MO ribavirin solr ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg 150mg 300mg MO
sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS
Drug Name RequirementsLimits
SOVALDI TABS 200mg 400mg PANDS stavudine caps 15mg 20mg 30mg 40mg MO
STRIBILD TABS MO SYMFI LO TABS MO SYMFI TABS MO SYMTUZA TABS MO SYNAGIS SOLN 50mg05ml 100mgml NDS
tenofovir disoproxil fumarate tabs MO
TIVICAY PD TBSO MO TIVICAY TABS 10mg 25mg 50mg MO
TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEMLIDY TABS VIDEX EC CPDR 125mg 200mg 400mg MO
VIDEX SOLR 2gm 4gm MO VIEKIRA PAK TBPK PANDS VIEKIRA XR TB24 PANDS VIRACEPT TABS 250mg 625mg MO
VIREAD POWD MO VIREAD TABS 150mg MO VIREAD TABS 200mg 250mg MO VOCABRIA TABS MO VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS ZERIT CAPS 15mg 20mg 30mg 40mg MO
zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 14 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fosfomycin tromethamine pack MENAPHOSMBHYO1 TABS methenamine hippurate tabs METHENAMINE MANDELATE TABS
NITROFURANTOIN MACROCRYSTAL CAPS
NITROFURANTOIN MONOHYD MACRO CAPS
nitrofurantoin susp PHOSPHASAL TABS trimethoprim tabs MO URETRON DS TABS URIN DS TABS URYL TABS USTELL CAPS UTICAP CAPS UTIRA-C TABS UTRONA-C TABS ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate soln carbinoxamine maleate tabs cetirizine hcl soln CLARINEX SYRP CLARINEX-D 12 HOUR TB12 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln
Drug Name RequirementsLimits
promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs SEMPREX-D CAPS ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg 500mg NDS
ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS 25mg 5mg 75mg 10mg NDS
ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs ARRANON SOLN ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE INJ BELEODAQ SOLR NDS BELRAPZO SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS bexarotene caps NDS bicalutamide tabs BICNU SOLR bleomycin sulfate solr BLINCYTO SOLR NDS BORTEZOMIB SOLR BOSULIF TABS 100mg 400mg 500mg NDS
BRAFTOVI CAPS 50mg 75mg NDS BRUKINSA CAPS NDS busulfan soln CABOMETYX TABS 20mg 40mg 60mg NDS
CALQUENCE CAPS NDS CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR NDS cladribine soln clofarabine soln COMETRIQ (100 MG DAILY DOSE) KIT LDNDS
COMETRIQ (140 MG DAILY DOSE) KIT LDNDS
COMETRIQ (60 MG DAILY DOSE) KIT LDNDS
COPIKTRA CAPS 15mg 25mg NDS COTELLIC TABS NDS CYCLOPHOSPHAMIDE CAPS 25mg 50mg PA
CYCLOPHOSPHAMIDE SOLN 1gm5ml 500mg25ml NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr
Drug Name RequirementsLimits
dactinomycin solr DANYELZA SOLN NDS DARZALEX FASPRO SOLN NDS DARZALEX SOLN 400mg20ml 100mg5ml NDS
daunorubicin hcl soln DAURISMO TABS 25mg 100mg NDS decitabine solr DOCETAXEL (NON-ALCOHOL) SOLN 80mg4ml 160mg8ml 20mgml
NDS
docetaxel conc docetaxel soln doxorubicin hcl liposomal inj DOXORUBICIN HCL SOLN doxorubicin hcl solr DROXIA CAPS ELIGARD KIT ELLENCE SOLN ELZONRIS SOLN NDS EMCYT CAPS NDS EMPLICITI SOLR 300mg 400mg NDS
ENHERTU SOLR NDS epirubicin hcl soln ERBITUX SOLN ERIVEDGE CAPS NDS ERLEADA TABS NDS erlotinib hcl tabs 25mg 100mg 150mg NDS
ERWINASE SOLR NDS ERWINAZE SOLR NDS ETOPOPHOS SOLR NDS etoposide soln everolimus tabs 25mg 5mg 75mg NDS
EVOMELA SOLR NDS exemestane tabs FARYDAK CAPS 10mg 15mg 20mg LDNDS
FASLODEX SOLN NDS FENSOLVI (6 MONTH) KIT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 16 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
FIRMAGON (240 MG DOSE) SOLR
FIRMAGON SOLR floxuridine solr fludarabine phosphate soln fludarabine phosphate solr fluorouracil soln flutamide caps FOTIVDA CAPS 089mg 134mg NDS
fulvestrant soln NDS GAVRETO CAPS NDS GAZYVA SOLN NDS gemcitabine hcl soln gemcitabine hcl solr GILOTRIF TABS 20mg 30mg 40mg NDS
HERCEPTIN HYLECTA SOLN NDS HERCEPTIN SOLR 150mg 440mg NDS
HERZUMA SOLR 150mg 420mg NDS
HEXALEN CAPS NDS hydroxyurea caps IBRANCE CAPS 75mg 100mg 125mg NDS
IBRANCE TABS 75mg 100mg 125mg NDS
ICLUSIG TABS 10mg 15mg 30mg 45mg NDS
IDAMYCIN PFS SOLN idarubicin hcl soln IDHIFA TABS 50mg 100mg NDS ifosfamide soln IFOSFAMIDE SOLR imatinib mesylate tabs IMBRUVICA CAPS 70mg 140mg NDS
IMBRUVICA TABS 140mg 280mg 420mg 560mg NDS
IMFINZI SOLN 500mg10ml 120mg24ml NDS
INFUGEM SOLN NDS INLYTA TABS 1mg 5mg NDS
Drug Name RequirementsLimits
INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 10muml 6000000unitml NDS
INTRON A SOLR 10mu 18mu 50mu NDS
IRESSA TABS NDS irinotecan hcl soln IXEMPRA KIT SOLR NDS JAKAFI TABS 5mg 10mg 15mg 20mg 25mg NDS
JEMPERLI SOLN KADCYLA SOLR 100mg 160mg NDS KANJINTI SOLR 150mg 420mg NDS KEYTRUDA SOLN NDS KISQALI (200 MG DOSE) TBPK NDS KISQALI (400 MG DOSE) TBPK NDS KISQALI (600 MG DOSE) TBPK NDS KISQALI FEMARA (400 MG DOSE) TBPK NDS
KISQALI FEMARA (600 MG DOSE) TBPK NDS
KISQALI FEMARA (200 MG DOSE) TBPK NDS
KOSELUGO CAPS 10mg 25mg NDS KYPROLIS SOLR 10mg 30mg 60mg NDS
lapatinib ditosylate tabs NDS LARTRUVO SOLN 190mg19ml 500mg50ml NDS
LENVIMA (10 MG DAILY DOSE) CPPK LDNDS
LENVIMA (12 MG DAILY DOSE) CPPK LDNDS
LENVIMA (14 MG DAILY DOSE) CPPK LDNDS
LENVIMA (18 MG DAILY DOSE) CPPK LDNDS
LENVIMA (20 MG DAILY DOSE) CPPK LDNDS
LENVIMA (24 MG DAILY DOSE) CPPK LDNDS
LENVIMA (4 MG DAILY DOSE) CPPK LDNDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
LENVIMA (8 MG DAILY DOSE) CPPK LDNDS
letrozole tabs LEUKERAN TABS NDS leuprolide acetate kit LIBTAYO SOLN NDS LIPODOX 50 INJ LONSURF TABS NDS LORBRENA TABS 25mg 100mg NDS
LUMAKRAS TABS NDS LUMOXITI SOLR NDS LUPANETA PACK KIT LUPRON DEPOT (1-MONTH) KIT
LUPRON DEPOT (3-MONTH) KIT
LUPRON DEPOT (4-MONTH) KIT
LUPRON DEPOT (6-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT 75 MG
LUPRON DEPOT-PED (3-MONTH) KIT
LYNPARZA CAPS NDS LYNPARZA TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA SOLN NDS MARQIBO SUSP NDS MATULANE CAPS NDS megestrol acetate susp megestrol acetate tabs MEKINIST TABS 05mg 2mg NDS MEKTOVI TABS NDS melphalan hcl solr mercaptopurine tabs methotrexate sodium (pf) soln methotrexate sodium soln methotrexate sodium solr
Drug Name RequirementsLimits
methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS MUSTARGEN SOLR mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS NERLYNX TABS NDS NEXAVAR TABS NDS nilutamide tabs NINLARO CAPS 23mg 3mg 4mg NDS
NUBEQA TABS NDS ODOMZO CAPS NDS OGIVRI SOLR NDS ONIVYDE INJ NDS ONTRUZANT SOLR 150mg 420mg NDS
ONUREG TABS 200mg 300mg NDS OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml NDS
oxaliplatin soln oxaliplatin solr paclitaxel conc PADCEV SOLR 20mg 30mg NDS paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEPAXTO SOLR NDS PERJETA SOLN NDS PHESGO SOLN NDS PIQRAY (200 MG DAILY DOSE) TBPK NDS
PIQRAY (250 MG DAILY DOSE) TBPK NDS
PIQRAY (300 MG DAILY DOSE) TBPK NDS
POLIVY SOLR 30mg 140mg NDS POMALYST CAPS 1mg 2mg 3mg 4mg NDS
PORTRAZZA SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 18 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
POTELIGEO SOLN NDS PROLEUKIN SOLR NDS PURIXAN SUSP NDS QINLOCK TABS NDS RETEVMO CAPS 40mg 80mg NDS REVLIMID CAPS 25mg 5mg 10mg 15mg 20mg 25mg NDS
RIABNI SOLN 100mg10ml 500mg50ml NDS
RITUXAN HYCELA SOLN RITUXAN SOLN ROMIDEPSIN SOLN NDS ROZLYTREK CAPS 100mg 200mg NDS
RUBRACA TABS 200mg 250mg 300mg NDS
RUXIENCE SOLN 100mg10ml 500mg50ml NDS
RYBREVANT SOLN NDS RYDAPT CAPS NDS RYLAZE SOLN NDS SARCLISA SOLN 500mg25ml 100mg5ml NDS
SIKLOS TABS NDS SOLTAMOX SOLN SPRYCEL TABS 20mg 50mg 70mg 80mg 100mg 140mg NDS
STIVARGA TABS NDS sunitinib malate caps 125mg 25mg 375mg 50mg NDS
SUTENT CAPS 125mg 25mg 375mg 50mg NDS
SYLATRON KIT 600 MCG SYLATRON KIT SYLVANT SOLR 100mg 400mg NDS SYNRIBO SOLR NDS TABLOID TABS TABRECTA TABS 150mg 200mg NDS
TAFINLAR CAPS 50mg 75mg NDS TAGRISSO TABS 40mg 80mg NDS TALZENNA CAPS 025mg 1mg NDS tamoxifen citrate tabs
Drug Name RequirementsLimits
TARCEVA TABS 25mg 100mg 150mg NDS
TASIGNA CAPS 50mg 150mg 200mg NDS
TAZVERIK TABS NDS TECENTRIQ SOLN 840mg14ml 1200mg20ml NDS
temsirolimus soln TENIPOSIDE SOLN TEPADINA SOLR NDS TEPMETKO TABS NDS THALOMID CAPS 50mg 100mg 150mg 200mg NDS
thiotepa solr 15mg 100mg NDS TIBSOVO TABS NDS toposar soln TOPOTECAN HCL SOLN topotecan hcl solr toremifene citrate tabs NDS TRAZIMERA SOLR 150mg 420mg NDS
TRELSTAR MIXJECT SUSR tretinoin caps NDS trexall tabs 5mg 75mg 10mg 15mg PA
TRISENOX SOLN 10mg10ml NDS TRISENOX SOLN NDS TRODELVY SOLR NDS TRUSELTIQ (100MG DAILY DOSE) CPPK NDS
TRUSELTIQ (125MG DAILY DOSE) CPPK NDS
TRUSELTIQ (50MG DAILY DOSE) CPPK NDS
TRUSELTIQ (75MG DAILY DOSE) CPPK NDS
TRUXIMA SOLN 100mg10ml 500mg50ml NDS
TUKYSA TABS 50mg 150mg NDS TURALIO CAPS NDS TYKERB TABS NDS UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
VANTAS KIT VELCADE SOLR VENCLEXTA STARTING PACK TBPK NDS
VENCLEXTA TABS 10mg NDS VENCLEXTA TABS 50mg 100mg NDS
VERZENIO TABS 50mg 100mg 150mg 200mg NDS
vinblastine sulfate soln vincasar pfs soln vincristine sulfate soln vinorelbine tartrate soln VITRAKVI CAPS 25mg 100mg NDS VITRAKVI SOLN NDS VIZIMPRO TABS 15mg 30mg 45mg NDS
VOTRIENT TABS NDS VYXEOS SUSR NDS XALKORI CAPS 200mg 250mg NDS XATMEP SOLN PANDS XOSPATA TABS NDS XPOVIO (100 MG ONCE WEEKLY) TBPK 20mg 50mg NDS
XPOVIO (40 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (40 MG TWICE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (60 MG ONCE WEEKLY) TBPK 20mg 60mg NDS
XPOVIO (60 MG TWICE WEEKLY) TBPK NDS
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (80 MG TWICE WEEKLY) TBPK NDS
XTANDI CAPS NDS XTANDI TABS 40mg 80mg NDS YERVOY SOLN YONDELIS SOLR NDS YONSA TABS NDS ZALTRAP SOLN 100mg4ml 200mg8ml NDS
ZEJULA CAPS NDS
Drug Name RequirementsLimits
ZELBORAF TABS NDS ZEPZELCA SOLR NDS ZIRABEV SOLN 400mg16ml 100mg4ml NDS
ZOLINZA CAPS NDS ZYDELIG TABS 100mg 150mg NDS ZYKADIA CAPS NDS ZYKADIA TABS NDS ZYNLONTA SOLR NDS ZYTIGA TABS NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA AEPB MO ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO BEVESPI AEROSPHERE AERO MO chlordiazepoxide-clidinium caps CUVPOSA SOLN MO dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate pf sosy glycopyrrolate soln glycopyrrolate tabs 1mg 2mg MO INCRUSE ELLIPTA AEPB MO ipratropium bromide soln 002 PAMO ipratropium bromide soln 003 006 MO
LONHALA MAGNAIR REFILL KIT SOLN NDS
methscopolamine bromide tabs 25mg 5mg MO
propantheline bromide tabs MO SPIRIVA HANDIHALER CAPS MO SPIRIVA RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 20 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO NICOTROL NS SOLN MO PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride tabs 5mg 10mg 25mg 50mg MO
CEVIMELINE HCL CAPS MO donepezil hcl tabs 5mg 10mg 23mg MO
donepezil hcl tbdp 5mg 10mg MO galantamine hydrobromide er cp24 8mg 16mg 24mg MO
galantamine hydrobromide soln MO galantamine hydrobromide tabs 4mg 8mg 12mg MO
GUANIDINE HCL TABS MO MESTINON SOLN MO pilocarpine hcl tabs 5mg 75mg MO pyridostigmine bromide er tbcr MO pyridostigmine bromide soln MO pyridostigmine bromide tabs 30mg 60mg MO
REGONOL SOLN rivastigmine pt24 46mg24hr 95mg24hr 133mg24hr MO
rivastigmine tartrate caps 15mg 3mg 45mg 6mg MO
urecholine tabs 5mg 10mg 25mg 50mg MO
SKELETAL MUSCLE RELAXANTS baclofen soln baclofen tabs 5mg 10mg 20mg MO carisoprodol tabs 250mg 350mg PANDS carisoprodol-aspirin tabs PANDS carisoprodol-aspirin-codeine tabs PANDS
chlorzoxazone tabs 375mg 500mg 750mg NDS
Drug Name RequirementsLimits
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA lorzone tabs 375mg 750mg NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln revonto solr succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs vanadom tabs PANDS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl er tb24 MO dihydroergotamine mesylate soln NDS ergoloid mesylates tabs MO ergomar subl phenoxybenzamine hcl caps NDS silodosin caps 4mg 8mg MO tamsulosin hcl caps MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR HFA AERO MO albuterol sulfate er tb12 4mg 8mg MO
albuterol sulfate hfa aers MONDS albuterol sulfate nebu 0083 25mg05ml PAMO
albuterol sulfate nebu 063mg3ml 125mg3ml PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO ARCAPTA NEOHALER CAPS MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY EPIPEN 2-PAK SOAJ EPIPEN JR 2-PAK SOAJ formoterol fumarate nebu PAMO ipratropium-albuterol soln PAMO isoproterenol hcl soln levalbuterol hcl nebu 125mg05ml 031mg3ml 063mg3ml 125mg3ml
PAMO
levalbuterol tartrate aero MO metaproterenol sulfate syrp MO metaproterenol sulfate tabs 10mg 20mg MO
midodrine hcl tabs 25mg 5mg 10mg MO
norepinephrine bitartrate soln phenylephrine hcl soln PROAIR RESPICLICK AEPB MO SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
tizanidine hcl caps VENTOLIN HFA AERS MONDS BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS BERINERT KIT INTRAVENOUS HI FIRAZYR SOLN NDS icatibant acetate soln NDS OXBRYTA TABS NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS
Drug Name RequirementsLimits
COAGULANTS AND ANTICOAGULANTS aminocaproic acid soln MO aminocaproic acid tabs 500mg 1000mg MO
anagrelide hcl caps 05mg 1mg MO argatroban soln aspirin-dipyridamole er cp12 MO BEVYXXA CAPS 40mg 80mg MO BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
NDS
FRAGMIN SOLN 2500unit02ml 5000unit02ml 7500unit03ml 12500unit05ml 15000unit06ml 95000unit38ml 10000unitml 18000unt072ml
NDS
heparin (porcine) in nacl soln HEPARIN SOD (PORCINE) IN D5W SOLN
heparin sodium (porcine) pf soln PA heparin sodium (porcine) soln 1000unitml 5000unitml 10000unitml 20000unitml
PA
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg
MO
LOVENOX SOLN 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 22 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg PRADAXA CAPS 110mg 150mg MO
prasugrel hcl tabs 5mg 10mg MO tranexamic acid soln tranexamic acid tabs MO warfarin sodium tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 10mg
MO
XARELTO STARTER PACK TBPK MO
XARELTO TABS 25mg 10mg 15mg 20mg MO
ZONTIVITY TABS MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 25mcgml 40mcgml PANDS
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml
PANDS
FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MIRCERA SOSY 30mcg03ml 50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml
PA
MULPLETA TABS NDS
Drug Name RequirementsLimits
NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml NDS
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RETACRIT SOLN 20000unit2ml 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL TB24 4mg 8mg MO DEMSER CAPS NDS doxazosin mesylate tabs 1mg 2mg 4mg 8mg MO
metyrosine caps NDS prazosin hcl caps 1mg 2mg 5mg MO
terazosin hcl caps 1mg 2mg 5mg 10mg MO
ANTILIPEMIC AGENTS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
ALTOPREV TB24 20mg 40mg 60mg MO
ANTARA CAPS 30mg 90mg MO atorvastatin calcium tabs 10mg 20mg 40mg 80mg MO
cholestyramine light pack MO cholestyramine light powd MO cholestyramine pack MO cholestyramine powd MO colesevelam hcl pack MO colesevelam hcl tabs MO colestipol hcl gran MO colestipol hcl pack MO colestipol hcl tabs MO EVKEEZA SOLN 345mg23ml 1200mg8ml NDS
ezetimibe tabs MO ezetimibe-simvastatin tabs MO fenofibrate caps 50mg 134mg 150mg MO
fenofibrate micronized caps 43mg 67mg 130mg 200mg MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg MO
FENOFIBRIC ACID TABS 35mg 105mg MO
FIBRICOR TABS MO FLOLIPID SUSP 20mg5ml 40mg5ml MO
fluvastatin sodium caps 20mg 40mg MO
fluvastatin sodium er tb24 MO gemfibrozil tabs MO icosapent ethyl caps MO JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg PALDNDS
KYNAMRO SOSY PALDNDS LIVALO TABS 1mg 2mg 4mg MO lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
Drug Name RequirementsLimits
niacor tabs MO omega-3-acid ethyl esters caps MO pravastatin sodium tabs 10mg 20mg 40mg 80mg MO
prevalite pack MO prevalite powd MO questran light powd MO questran pack MO questran powd MO REPATHA PUSHTRONEX SYSTEM SOCT PANDS
REPATHA SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 05gm 1gm MO ZYPITAMAG TABS 1mg 2mg 4mg MO
BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl caps 200mg 400mg MO
atenolol tabs 25mg 50mg 100mg MO
atenolol-chlorthalidone tabs MO betaxolol hcl tabs 10mg 20mg MO bisoprolol fumarate tabs 5mg 10mg MO
bisoprolol-hydrochlorothiazide tabs MO
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg MO
carvedilol tabs 3125mg 625mg 125mg 25mg MO
DUTOPROL TB24 MO ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln INNOPRAN XL CP24 80mg 120mg MO
labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 24 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
metoprolol succinate er tb24 25mg 50mg 100mg 200mg MO
metoprolol tartrate soct metoprolol tartrate soln metoprolol tartrate tabs 25mg 50mg 100mg MO
metoprolol tartrate tabs 375mg 75mg MO
metoprolol-hydrochlorothiazide tabs MO
nadolol tabs 20mg 40mg 80mg MO nadolol-bendroflumethiazide tabs MO
pindolol tabs 5mg 10mg MO propranolol hcl er cp24 60mg 80mg 120mg 160mg MO
propranolol hcl soln 20mg5ml 40mg5ml MO
propranolol hcl tabs 10mg 20mg 40mg 60mg 80mg MO
propranolol-hctz tabs MO sorine tabs 80mg 120mg 160mg 240mg MO
sotalol hcl (af) tabs 80mg 120mg 160mg MO
sotalol hcl tabs 80mg 120mg 160mg 240mg MO
SOTYLIZE SOLN MO timolol maleate tabs 5mg 10mg 20mg MO
CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besy-benazepril hcl caps MO
amlodipine besylate tabs 25mg 5mg 10mg MO
amlodipine besylate-valsartan tabs MO
amlodipine-atorvastatin tabs MO amlodipine-olmesartan tabs MO amlodipine-valsartan-hctz tabs MO CARDENE IV SOLN CARDIZEM LA TB24 MO cartia xt cp24 120mg 180mg 240mg 300mg MO
Drug Name RequirementsLimits
CONSENSI TABS NDS dilt-xr cp24 120mg 180mg 240mg MO
diltiazem hcl er beads cp24 120mg 180mg 240mg 300mg 360mg 420mg
MO
DILTIAZEM HCL ER COATED BEADS CP24 120mg 180mg 240mg 300mg 360mg
MO
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg
MO
diltiazem hcl er cp12 60mg 90mg 120mg MO
diltiazem hcl er cp24 120mg 180mg 240mg MO
diltiazem hcl soln diltiazem hcl solr diltiazem hcl tabs 30mg 60mg 90mg 120mg MO
felodipine er tb24 25mg 5mg 10mg MO
isradipine caps 25mg 5mg MO matzim la tb24 180mg 240mg 300mg 360mg 420mg MO
nicardipine hcl caps 20mg 30mg MO nicardipine hcl soln nifedipine caps 10mg 20mg MO nifedipine er osmotic release tb24 30mg 60mg 90mg MO
nifedipine er tb24 30mg 60mg 90mg MO
nimodipine caps MO nisoldipine er tb24 85mg 17mg 20mg 255mg 30mg 34mg 40mg
MO
NYMALIZE SOLN 60mg20ml 6mgml NDS
olmesartan-amlodipine-hctz tabs MO taztia xt cp24 120mg 180mg 240mg 300mg 360mg MO
telmisartan-amlodipine tabs MO tiadylt er cp24 120mg 180mg 240mg 300mg 360mg 420mg MO
trandolapril-verapamil hcl er tbcr MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
VERAPAMIL HCL ER CP24 100mg 120mg 180mg 200mg 240mg 300mg 360mg
MO
verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 80mg 120mg MO verapamil hcl tabs MO VERELAN CP24 MO CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln inj DIGOXIN ORAL SOLN MO digoxin tabs 125mcg 250mcg MO disopyramide phosphate caps 100mg 150mg MO
dofetilide caps 125mcg 250mcg 500mcg MO
flecainide acetate tabs 50mg 100mg 150mg MO
ibutilide fumarate soln LANOXIN PEDIATRIC SOLN LANOXIN TABS 625mcg MO lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy LIDOCAINE IN D5W SOLN mexiletine hcl caps 150mg 200mg 250mg MO
milrinone lactate in dextrose soln milrinone lactate soln MULTAQ TABS NORPACE CR CP12 100mg 150mg MO
pacerone tabs 100mg 200mg 400mg MO
procainamide hcl soln
Drug Name RequirementsLimits
propafenone hcl er cp12 225mg 325mg 425mg MO
propafenone hcl tabs 150mg 225mg 300mg MO
quinidine gluconate er tbcr MO QUINIDINE GLUCONATE SOLN quinidine sulfate tabs 200mg 300mg MO
ranolazine er tb12 500mg 1000mg MO
VYNDAMAX CAPS NDS VYNDAQEL CAPS NDS HYPOTENSIVE AGENTS clonidine hcl (analgesia) soln clonidine hcl er tb12 MO clonidine hcl tabs 01mg 02mg 03mg MO
clonidine ptwk 01mg24hr 02mg24hr 03mg24hr MO
guanfacine hcl tabs 1mg 2mg MO hydralazine hcl soln hydralazine hcl tabs 10mg 25mg 50mg 100mg MO
methyldopa tabs 250mg 500mg MO methyldopa-hydrochlorothiazide tabs MO
minoxidil tabs 25mg 10mg MO nitropress soln nitroprusside sodium soln vecamyl tabs NDS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE TABS MO aliskiren fumarate tabs 150mg 300mg MO
benazepril hcl tabs 5mg 10mg 20mg 40mg MO
benazepril-hydrochlorothiazide tabs MO
candesartan cilexetil tabs 4mg 8mg 16mg 32mg MO
candesartan cilexetil-hctz tabs MO captopril tabs 125mg 25mg 50mg 100mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 26 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
captopril-hydrochlorothiazide tabs MO
CAROSPIR SUSP MO EDARBYCLOR TABS MO enalapril maleate tabs 25mg 5mg 10mg 20mg MO
enalapril-hydrochlorothiazide tabs MO
enalaprilat inj ENTRESTO TABS MO eplerenone tabs 25mg 50mg MO eprosartan mesylate tabs MO fosinopril sodium tabs 10mg 20mg 40mg MO
fosinopril sodium-hctz tabs MO irbesartan tabs 75mg 150mg 300mg MO
irbesartan-hydrochlorothiazide tabs MO
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg MO
lisinopril-hydrochlorothiazide tabs MO
losartan potassium tabs 25mg 50mg 100mg MO
losartan potassium-hctz tabs MO moexipril hcl tabs 75mg 15mg MO olmesartan medoxomil tabs 5mg 20mg 40mg MO
olmesartan medoxomil-hctz tabs MO perindopril erbumine tabs 2mg 4mg 8mg MO
QBRELIS SOLN MO quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO TEKTURNA HCT TABS MO
Drug Name RequirementsLimits
telmisartan tabs 20mg 40mg 80mg MO
telmisartan-hctz tabs MO trandolapril tabs 1mg 2mg 4mg MO valsartan tabs 40mg 80mg 160mg 320mg MO
valsartan-hydrochlorothiazide tabs MO
VASODILATING AGENTS alyq tabs PA BIDIL TABS MO dipyridamole tabs 25mg 50mg 75mg MO
GONITRO PACK MO isosorbide dinitrate er tbcr MO isosorbide dinitrate tabs 5mg 10mg 20mg 30mg MO
isosorbide mononitrate er tb24 30mg 60mg MO
isosorbide mononitrate er tb24 MO isosorbide mononitrate tabs 10mg 20mg MO
minitran pt24 01mghr 02mghr 04mghr 06mghr MO
nitro-bid oint MO NITRO-DUR PT24 03mghr 08mghr MO
nitroglycerin pt24 01mghr 02mghr 04mghr 06mghr MO
nitroglycerin soln MO nitroglycerin subl 03mg 04mg 06mg MO
sildenafil citrate soln PANDS sildenafil citrate susr PA sildenafil citrate tabs PAMO tadalafil (pah) tabs 20mg PA tadalafil tabs 25mg 5mg PA CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS acamprosate calcium tbec MO antabuse tabs 250mg 500mg MO disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
ABSTRAL SUBL 100mcg 200mcg 300mcg 400mcg 600mcg 800mcg
PANDS
acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ARYMO ER TBEA NDS ascomp-codeine caps NDS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
benzhydrocodone-acetaminophen tabs
bupap tabs buprenorphine hcl soln NDS buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
butalbital-acetaminophen caps NDS butalbital-acetaminophen tabs butalbital-apap-caff-cod caps NDS butalbital-apap-caffeine caps butalbital-apap-caffeine tabs butalbital-asa-caff-codeine caps NDS butalbital-aspirin-caffeine caps butalbital-aspirin-caffeine tabs butorphanol tartrate soln 1mgml 2mgml 10mgml NDS
BUTRANS PTWK NDS cataflam tabs NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
DEMEROL SOLN 25mg05ml 75mg15ml 100mg2ml 75mgml
PANDS
diclofenac potassium tabs diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs
Drug Name RequirementsLimits
DUEXIS TABS NDS DURAMORPH SOLN 05mgml 1mgml HINDS
dvorah tabs NDS EMBEDA CPCR NDS endocet tabs NDS esgic caps esgic tabs etodolac caps etodolac er tb24 etodolac tabs fenoprofen calcium caps fenoprofen calcium tabs fenortho caps fentanyl citrate (pf) soct NDS FENTANYL CITRATE (PF) SOLN 50mcgml 1000mcg20ml 2500mcg50ml
NDS
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fioricet caps fioricetcodeine caps NDS flurbiprofen tabs hydrocodone bitartrate er cp12 10mg 15mg 20mg 30mg 40mg 50mg
NDS
hydrocodone-acetaminophen soln NDS
hydrocodone-acetaminophen tabs NDS
hydrocodone-ibuprofen tabs NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 28 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd NDS hydromorphone hcl pf soln 50mg5ml 10mgml NDS
HYDROMORPHONE HCL SOLN 1mgml 2mgml NDS
hydromorphone hcl tabs 2mg 4mg 8mg NDS
ibu tabs ibudone tabs NDS ibuprofen lysine soln ibuprofen susp ibuprofen tabs ILARIS SOLN NDS indocin supp INDOCIN SUSP indomethacin caps INDOMETHACIN CAPS 20mg indomethacin er cpcr indomethacin sodium solr KADIAN CP24 NDS ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 300mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lodine tabs lorcet hd tabs NDS lorcet plus tabs NDS lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam caps meloxicam tabs meperidine hcl soln 50mg5ml 25mgml 50mgml 100mgml PANDS
meperidine hcl tabs 50mg 100mg NDS
Drug Name RequirementsLimits
methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl soln 5mg5ml 10mg5ml 10mgml NDS
methadone hcl tabs 5mg 10mg NDS mitigo soln MORPHINE SULFATE (CONCENTRATE) SOLN NDS
morphine sulfate (pf) soln 4mgml 10mgml NDS
MORPHINE SULFATE (PF) SOLN INTRAVENOUS HI
morphine sulfate er beads cp24 30mg 45mg 60mg 75mg 90mg 120mg
NDS
morphine sulfate er cp24 10mg 20mg 30mg 40mg 50mg 60mg 80mg 100mg
NDS
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg NDS
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml NDS
MORPHINE SULFATE SOLN HINDS MORPHINE SULFATE SOLN INJECTION 2mgml 4mgml 10mgml
HI
MORPHINE SULFATE SOLN INTRAVENOUS HI
morphine sulfate tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln nalfon tabs nalocet tabs NDS NAPRELAN TB24 naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
NUCYNTA ER TB12 50mg 100mg 150mg NDS
NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS 50mg 75mg NDS NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs oxaprozin tabs OXAYDO TABS NDS oxycodone hcl caps NDS oxycodone hcl conc NDS oxycodone hcl er t12a 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxycodone hcl soln NDS oxycodone hcl tabs 5mg 10mg 15mg 20mg 30mg NDS
oxycodone-acetaminophen soln NDS oxycodone-acetaminophen tabs NDS oxycodone-acetaminophen tabs 5-300mg 10-300mg NDS
oxycodone-aspirin tabs NDS oxycodone-ibuprofen tabs NDS OXYCONTIN T12A 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxymorphone hcl er tb12 5mg 75mg 10mg 15mg 20mg 30mg 40mg
NDS
oxymorphone hcl tabs 5mg 10mg NDS
panlor tabs NDS pentazocine-naloxone hcl tabs NDS percocet tabs NDS phrenilin forte caps PIROXICAM CAPS 10mg 20mg NDS pregabalin er tb24 825mg 165mg 330mg MO
primlev tabs NDS prolate soln NDS prolate tabs NDS QDOLO SOLN NDS
Drug Name RequirementsLimits
relafen ds tabs NDS ROXYBOND TABA 5mg 15mg 30mg NDS
SALSALATE TABS SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
SUBSYS LIQD 100mcg 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
sulindac tabs tencon tabs TIVORBEX CAPS tolmetin sodium caps tolmetin sodium tabs tramadol hcl er (biphasic) tb24 100mg 200mg 300mg NDS
tramadol hcl er cp24 100mg 150mg 200mg 300mg NDS
tramadol hcl er tb24 100mg 200mg 300mg NDS
tramadol hcl tabs 50mg 100mg NDS tramadol-acetaminophen tabs NDS trezix caps NDS tylenol with codeine 3 tabs NDS tylenol with codeine 4 tabs NDS vanatol lq soln vicodin es tabs NDS vicodin hp tabs NDS vicodin tabs NDS XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg NDS
zebutal caps ZIPSOR CAPS ZORVOLEX CAPS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS ADDERALL XR CP24 NDS ADZENYS ER SUER NDS ADZENYS XR-ODT TBED 31mg 63mg 94mg 125mg 157mg 188mg
NDS
amphetamine er suer NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 30 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
amphetamine sulfate tabs 5mg 10mg NDS
amphetamine-dextroamphet er cp24 NDS
amphetamine-dextroamphetamine tabs NDS
armodafinil tabs 50mg 150mg 200mg 250mg PA
caffeine citrate soln COTEMPLA XR-ODT TBED 86mg 173mg 259mg NDS
DAYTRANA PTCH 10mg9hr 15mg9hr 20mg9hr 30mg9hr NDS
dexmethylphenidate hcl er cp24 5mg 10mg 15mg 20mg 25mg 30mg 35mg 40mg
NDS
dexmethylphenidate hcl tabs 25mg 5mg 10mg NDS
dextroamphetamine sulfate er cp24 5mg 10mg 15mg NDS
dextroamphetamine sulfate soln NDS dextroamphetamine sulfate tabs 5mg 10mg 15mg 20mg 30mg NDS
DYANAVEL XR SUER NDS evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS methylphenidate hcl chew 25mg 5mg 10mg NDS
methylphenidate hcl er (cd) cpcr 10mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er (la) cp24 10mg 20mg 30mg 40mg 60mg
NDS
methylphenidate hcl er (xr) cp24 10mg 15mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg NDS
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg
NDS
methylphenidate hcl soln 5mg5ml 10mg5ml NDS
Drug Name RequirementsLimits
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS MYDAYIS CP24 NDS procentra soln NDS QUILLICHEW ER CHER 20mg 30mg 40mg NDS
QUILLIVANT XR SRER NDS relexxii tbcr NDS SUNOSI TABS 75mg 150mg NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
NDS
VYVANSE CHEW 10mg 20mg 30mg 40mg 50mg 60mg NDS
WAKIX TABS 445mg 178mg NDS zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg
NDS
ANTICONVULSANTS APTIOM TABS 200mg 400mg 600mg 800mg MO
BANZEL SUSP BANZEL TABS 200mg 400mg NDS BRIVIACT SOLN NDS BRIVIACT TABS 10mg 25mg 50mg 75mg 100mg NDS
carbamazepine chew MO carbamazepine er cp12 100mg 200mg 300mg MO
carbamazepine er tb12 100mg 200mg 400mg MO
carbamazepine susp MO carbamazepine tabs MO CELONTIN CAPS MO clobazam susp MO clobazam tabs 10mg 20mg MO clonazepam tabs 05mg 1mg 2mg NDS
clonazepam tbdp 0125mg 025mg 05mg 1mg 2mg NDS
DIACOMIT CAPS 250mg 500mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
DIACOMIT PACK 250mg 500mg NDS
DIASTAT ACUDIAL GEL 10mg 20mg NDS
DIASTAT PEDIATRIC GEL NDS diazepam gel 25mg 10mg 20mg NDS
dilantin caps 30mg 100mg MO dilantin infatabs chew MO divalproex sodium csdr MO divalproex sodium er tb24 250mg 500mg MO
divalproex sodium tbec 125mg 250mg 500mg MO
ELEPSIA XR TB24 1000mg 1500mg NDS
EPIDIOLEX SOLN PANDS epitol tabs MO ethosuximide caps MO ethosuximide soln MO felbamate susp MO felbamate tabs 400mg 600mg MO FINTEPLA SOLN NDS fosphenytoin sodium soln FYCOMPA SUSP NDS FYCOMPA TABS gabapentin caps 100mg 400mg MO gabapentin soln MO gabapentin tabs 600mg 800mg MO HORIZANT TBCR 300mg 600mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
lamotrigine kit MO lamotrigine starter kit-blue kit MO lamotrigine starter kit-green kit MO lamotrigine starter kit-orange kit MO lamotrigine tabs 25mg 100mg 150mg 200mg MO
lamotrigine tbdp 25mg 50mg 100mg 200mg MO
Drug Name RequirementsLimits
levetiracetam er tb24 500mg 750mg MO
levetiracetam in nacl soln levetiracetam soln MO levetiracetam tabs 250mg 500mg 750mg 1000mg MO
magnesium sulfate soln magnesium sulfate soln injection 50 HI
MAGNESIUM SULFATE SOLN INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml
HI
NAYZILAM SOLN NDS oxcarbazepine susp MO oxcarbazepine tabs 150mg 300mg 600mg MO
OXTELLAR XR TB24 150mg 300mg 600mg MO
PEGANONE TABS MO phenytek caps 200mg 300mg MO phenytoin chew MO phenytoin sodium extended caps 100mg 200mg 300mg MO
phenytoin sodium soln phenytoin susp MO pregabalin caps 25mg 50mg 75mg 100mg 150mg 200mg 225mg 300mg
MO
pregabalin soln MO primidone tabs 50mg 250mg MO roweepra tabs 500mg 750mg 1000mg MO
roweepra xr tb24 500mg 750mg MO rufinamide susp rufinamide tabs 200mg 400mg NDS SPRITAM TB3D 250mg 500mg 750mg 1000mg NDS
subvenite starter kit-blue kit MO subvenite starter kit-green kit MO subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 32 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
SYMPAZAN FILM 10mg 20mg tiagabine hcl tabs 2mg 4mg 12mg 16mg MO
topiramate cpsp 15mg 25mg MO topiramate er cs24 25mg 50mg 100mg 150mg 200mg MO
topiramate tabs 25mg 50mg 100mg 200mg MO
TROKENDI XR CP24 25mg 50mg 100mg 200mg MO
valproate sodium soln valproic acid caps MO valproic acid soln MO VALTOCO 10 MG DOSE LIQD NDS VALTOCO 15 MG DOSE LQPK NDS VALTOCO 20 MG DOSE LQPK NDS VALTOCO 5 MG DOSE LIQD NDS vigabatrin pack LDNDS vigabatrin tabs NDS vigadrone pack LDNDS VIMPAT SOLN VIMPAT TABS MO XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200 MG NDS XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ AJOVY SOSY almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs EMGALITY (300 MG DOSE) SOSY NDS
Drug Name RequirementsLimits
EMGALITY SOAJ EMGALITY SOSY ergotamine-caffeine tabs frovatriptan succinate tabs naratriptan hcl tabs NURTEC TBDP NDS ONZETRA XSAIL EXHP rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs TOSYMRA SOLN UBRELVY TABS 50mg 100mg NDS ZEMBRACE SYMTOUCH SOAJ zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ZOMIG SOLN ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl syrp MO amantadine hcl tabs MO APOKYN SOCT NDS benztropine mesylate soln benztropine mesylate tabs 05mg 1mg 2mg MO
bromocriptine mesylate caps MO bromocriptine mesylate tabs MO cabergoline tabs MO carbidopa tabs MO carbidopa-levodopa er tbcr MO carbidopa-levodopa tabs MO carbidopa-levodopa tbdp MO carbidopa-levodopa-entacapone tabs MO
DUOPA SUSP LD EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg NDS
pramipexole dihydrochloride er tb24 0375mg 075mg 15mg 225mg 3mg 375mg 45mg
MO
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg
MO
rasagiline mesylate tabs 05mg 1mg MO
ropinirole hcl er tb24 2mg 4mg 6mg 8mg 12mg MO
ropinirole hcl tabs 025mg 05mg 1mg 2mg 3mg 4mg 5mg
MO
RYTARY CPCR MO selegiline hcl caps MO selegiline hcl tabs MO tolcapone tabs MO trihexyphenidyl hcl soln MO trihexyphenidyl hcl tabs 2mg 5mg MO
ZELAPAR TBDP MO ANXIOLYTICS SEDATIVES AND HYPNOTICS alprazolam er tb24 05mg 1mg 2mg 3mg NDS
alprazolam intensol conc NDS alprazolam tabs 025mg 05mg 1mg 2mg NDS
alprazolam tbdp 025mg 05mg 1mg 2mg NDS
BELSOMRA TABS buspirone hcl tabs 5mg 10mg buspirone hcl tabs 75mg 15mg 30mg
chlordiazepoxide hcl caps 5mg 10mg 25mg NDS
clorazepate dipotassium tabs 375mg 75mg 15mg NDS
diazepam conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS
Drug Name RequirementsLimits
droperidol soln EDLUAR SUBL 5mg 10mg NDS estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP NDS hydroxyzine hcl soln hydroxyzine hcl syrp hydroxyzine hcl tabs hydroxyzine pamoate caps lorazepam intensol conc NDS LORAZEPAM SOLN 4mgml 2mgml NDS
lorazepam tabs 05mg 1mg 2mg NDS
meprobamate tabs midazolam hcl (pf) soln midazolam hcl soln midazolam hcl syrp nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs ROZEREM TABS seconal caps TEMAZEPAM CAPS 15mg 225mg 30mg 75mg NDS
triazolam tabs 0125mg 025mg NDS zaleplon caps 5mg 10mg NDS zolpidem tartrate er tbcr 625mg 125mg NDS
zolpidem tartrate subl 175mg 35mg NDS
zolpidem tartrate tabs 5mg 10mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 34 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS atomoxetine hcl caps 10mg 18mg 25mg 40mg 60mg 80mg 100mg
MO
AUSTEDO TABS 6mg 9mg 12mg LDNDS
EXSERVAN FILM NDS flumazenil soln guanfacine hcl er tb24 1mg 2mg 3mg 4mg MO
INGREZZA CAPS 40mg 60mg 80mg NDS
INGREZZA CPPK NDS memantine hcl er cp24 memantine hcl soln MO memantine hcl tabs 5mg 10mg MO NAMENDA XR TITRATION PACK CP24 MO
NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS SAVELLA TABS 125mg 25mg 50mg 100mg MO
SAVELLA TITRATION PACK MISC MO
tetrabenazine tabs 125mg 25mg NDS
TIGLUTIK SUSP NDS XYREM SOLN LDNDS XYWAV SOLN NDS MULTIPLE SCLEROSIS AGENTS AUBAGIO TABS 7mg 14mg PANDS AVONEX KIT NDS AVONEX PEN AJKT NDS AVONEX PREFILLED PSKT NDS BAFIERTAM CPDR NDS BETASERON KIT NDS dalfampridine er tb12 MO dimethyl fumarate cpdr dimethyl fumarate starter pack misc
Drug Name RequirementsLimits
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatiramer acetate sosy 20mgml 40mgml NDS
glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 2mg NDS OCREVUS SOLN PLEGRIDY SOSY NDS PONVORY STARTER PACK TBPK NDS
PONVORY TABS NDS REBIF REBIDOSE SOAJ 22mcg05ml 44mcg05ml NDS
REBIF REBIDOSE TITRATION PACK SOAJ NDS
REBIF SOSY 22mcg05ml 44mcg05ml NDS
REBIF TITRATION PACK SOSY NDS TECFIDERA CPDR 120mg 240mg NDS
TECFIDERA MISC NDS TYSABRI CONC INTRAVENOUS HI
ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS ZINBRYTA SOSY LDNDS OPIATE ANTAGONISTS BUNAVAIL FILM NDS buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
LUCEMYRA TABS NDS naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR NDS ZUBSOLV SUBL NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg NDS
ABILIFY MYCITE MAINTENANCE KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg NDS
amitriptyline hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
amoxapine tabs 25mg 50mg 100mg 150mg MO
APLENZIN TB24 174mg 348mg 522mg MO
aripiprazole soln MO aripiprazole tabs 2mg 5mg 10mg 15mg 20mg 30mg MO
aripiprazole tbdp 10mg 15mg MO ARISTADA INITIO PRSY NDS ARISTADA PRSY 441mg16ml 662mg24ml 882mg32ml 1064mg39ml
NDS
asenapine maleate subl 25mg 5mg 10mg MO
bupropion hcl er (smoking det) tb12 MO
bupropion hcl er (sr) tb12 100mg 150mg 200mg MO
bupropion hcl er (xl) tb24 150mg 300mg 450mg MO
bupropion hcl tabs 75mg 100mg MO CAPLYTA CAPS NDS chlordiazepoxide-amitriptyline tabs
chlorpromazine hcl soln
Drug Name RequirementsLimits
chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
clomipramine hcl caps 25mg 50mg 75mg MO
clozapine tabs 25mg 50mg 100mg 200mg NDS
clozapine tbdp 125mg 25mg 100mg 150mg 200mg NDS
compro supp MO desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
DESVENLAFAXINE ER TB24 50mg 100mg MO
desvenlafaxine succinate er tb24 25mg 50mg 100mg MO
doxepin hcl caps 10mg 25mg 50mg 75mg 100mg 150mg MO
doxepin hcl conc MO doxepin hcl tabs 3mg 6mg MO DRIZALMA SPRINKLE CSDR duloxetine hcl cpep 20mg 30mg 40mg 60mg MO
EQUETRO CP12 100mg 200mg 300mg MO
escitalopram oxalate soln MO escitalopram oxalate tabs 5mg 10mg 20mg MO
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg NDS
FANAPT TITRATION PACK TABS MO
FETZIMA CP24 20mg 40mg 80mg 120mg MO
FETZIMA TITRATION C4PK MO fluoxetine hcl (pmdd) tabs 10mg 20mg MO
fluoxetine hcl caps 10mg 20mg 40mg MO
fluoxetine hcl cpdr MO fluoxetine hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 36 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
GEODON SOLR haloperidol decanoate soln haloperidol lactate conc MO haloperidol lactate soln haloperidol tabs 05mg 1mg 2mg 5mg 10mg 20mg MO
imipramine hcl tabs 10mg 25mg 50mg MO
imipramine pamoate caps 75mg 100mg 125mg 150mg MO
INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 300mg 150mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
lithium carbonate tabs MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO
Drug Name RequirementsLimits
mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
nefazodone hcl tabs 50mg 100mg 150mg 200mg 250mg MO
nortriptyline hcl caps 10mg 25mg 50mg 75mg MO
nortriptyline hcl soln MO NUPLAZID CAPS NDS NUPLAZID TABS 10mg 17mg NDS olanzapine solr olanzapine tabs 25mg 5mg 75mg 10mg 15mg 20mg MO
olanzapine tbdp 5mg 10mg 15mg 20mg MO
olanzapine-fluoxetine hcl caps MO PALIPERIDONE ER TB24 15mg 3mg 6mg 9mg MO
paroxetine hcl er tb24 125mg 25mg 375mg MO
paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps MO PAXIL SUSP MO perphenazine tabs 2mg 4mg 8mg 16mg MO
perphenazine-amitriptyline tabs MO PERSERIS PRSY 90mg 120mg NDS PEXEVA TABS 10mg 20mg 30mg 40mg MO
phenelzine sulfate tabs MO pimozide tabs 1mg 2mg MO prochlorperazine edisylate soln prochlorperazine maleate tabs prochlorperazine supp MO protriptyline hcl tabs 5mg 10mg MO quetiapine fumarate er tb24 50mg 150mg 200mg 300mg 400mg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
quetiapine fumarate tabs 25mg 50mg 100mg 200mg 300mg 400mg
MO
REXULTI TABS 025mg 05mg 1mg 2mg 3mg 4mg NDS
RISPERDAL CONSTA SRER 125mg 25mg NDS
RISPERDAL CONSTA SRER 375mg 50mg NDS
risperidone soln MO risperidone tabs 025mg 05mg 1mg 2mg 3mg 4mg MO
risperidone tbdp 025mg 05mg 1mg 2mg 3mg 4mg MO
SAPHRIS SUBL 25mg 5mg 10mg NDS
SECUADO PT24 38mg24hr 57mg24hr 76mg24hr NDS
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
SILENOR TABS SPRAVATO (56 MG DOSE) SOPK NDS
SPRAVATO (84 MG DOSE) SOPK NDS
thioridazine hcl tabs 10mg 25mg 50mg 100mg MO
thiothixene caps 1mg 2mg 5mg 10mg MO
tofranil tabs 10mg 25mg 50mg MO tranylcypromine sulfate tabs MO trazodone hcl tabs 50mg 100mg 150mg MO
trazodone hcl tabs MO trifluoperazine hcl tabs 1mg 2mg 5mg 10mg MO
trimipramine maleate caps 25mg 50mg 100mg MO
TRINTELLIX TABS 5mg 10mg 20mg MO
venlafaxine hcl er cp24 375mg 75mg 150mg MO
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg MO
Drug Name RequirementsLimits
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
VRAYLAR CAPS 15mg 3mg 45mg 6mg NDS
VRAYLAR CPPK NDS ziprasidone hcl caps 20mg 40mg 60mg 80mg MO
ziprasidone mesylate solr ZYPREXA RELPREVV SUSR DIABETIC SUPPLIES DIABETIC SUPPLIES ALCOHOL PREP PADS MO BD INSULIN SYR ULTRAFINE II MISC MO
BD INSULIN SYRINGE MISC MO BD INSULIN SYRINGE UF MISC MO
BD PEN NEEDLE ORIGINAL UF MISC MO
CURITY GAUZE PADS MO OMNIPOD STARTER KIT NDS ELECTROLYTIC CALORIC AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS POT amp SOD CIT-CIT AC SOLN potassium citrate er tbcr 15meq 540mg 1080mg MO
SODIUM ACETATE SOLN SODIUM BICARBONATE SOLN SODIUM LACTATE SOLN INTRAVENOUS HI
TRICITRATES SOLN AMMONIA DETOXICANTS CARBAGLU TABS LD constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 38 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lactulose pack MO lactulose soln MO LITHOSTAT TABS MO RAVICTI LIQD NDS sod benz-sod phenylacet soln sodium phenylbutyrate powd NDS sodium phenylbutyrate tabs NDS CALORIC AGENTS AMINOSYN-PF SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (27510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42525) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (525) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (525) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN dextrose soln intravenous 5 10 HI
Drug Name RequirementsLimits
FREAMINE HBC SOLN INTRAVENOUS HI
HEPATAMINE SOLN INTRAVENOUS HI
INTRALIPID EMUL INTRAVENOUS 20gm100ml HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NEPHRAMINE SOLN INTRAVENOUS HI
NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE SOLN INTRAVENOUS HI
PROSOL SOLN INTRAVENOUS HI TRAVASOL SOLN INTRAVENOUS HI
TROPHAMINE SOLN INTRAVENOUS HI
DIURETICS AMILORIDE HCL TABS MO amiloride-hydrochlorothiazide tabs MO
bumetanide soln bumetanide tabs 05mg 1mg 2mg MO
chlorothiazide sodium solr chlorothiazide tabs 250mg 500mg MO
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI FUROSEMIDE TABS 40mg 80mg 20mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN SAMSCA TABS 15mg NDS TOLVAPTAN TABS 30mg 15mg NDS torsemide tabs 5mg 10mg 20mg 100mg MO
triamterene caps 50mg 100mg MO triamterene-hctz caps MO triamterene-hctz tabs MO ION-REMOVING AGENTS AURYXIA TABS PAMONDS FOSRENOL PACK 750mg 1000mg NDS
kionex susp MO lanthanum carbonate chew 500mg 750mg 1000mg MO
LOKELMA PACK 5gm 10gm MO sevelamer carbonate pack 08gm 24gm MO
sevelamer carbonate tabs MO sevelamer hcl tabs 400mg 800mg MO
sodium polystyrene sulfonate powd MO
sodium polystyrene sulfonate susp MO
sps susp MO VELPHORO CHEW NDS VELTASSA PACK 84gm 168gm 252gm NDS
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate (phos binder) tabs MO
CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
Drug Name RequirementsLimits
DEXTROSE-NACL SOLN INTRAVENOUS HI
DEXTROSE 10NACL 02 DEXTROSE 10NACL 045 HI
DEXTROSE 5NACL 0225 HI IONOSOL-MB IN D5W SOLN INTRAVENOUS HI
ISOLYTE-P IN D5W SOLN INTRAVENOUS HI
ISOLYTE-S SOLN INTRAVENOUS HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-033 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 TBCR MO klor-con m10 tbcr MO klor-con m15 tbcr MO klor-con m20 tbcr MO klor-con pack MO klor-con sprinkle cpcr 8meq 10meq MO
KLOR-CON TBCR MO LACTATED RINGERS SOLN magnesium sulfate in d5w soln NORMOSOL-M IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R SOLN INTRAVENOUS HI
PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 40 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
POTASSIUM CHLORIDE ER TBCR 8meq 10meq 20meq MO
POTASSIUM CHLORIDE IN DEXTROSE SOLN INTRAVENOUS
HI
potassium chloride in nacl soln intravenous HI
potassium chloride pack MO potassium chloride soln 10 20 MO
POTASSIUM CHLORIDE SOLN INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN SODIUM CHLORIDE SOLN INJECTION HI
SODIUM CHLORIDE SOLN INTRAVENOUS 045 09 3 5
HI
SODIUM PHOSPHATES SOLN TPN ELECTROLYTES CONC INTRAVENOUS HI
URICOSURIC AGENTS colchicine-probenecid tabs MO probenecid tabs MO ENZYMES ENZYMES ADAGEN SOLN ALDURAZYME SOLN CERDELGA CAPS NDS CEREZYME SOLR NDS CREON CPEP MO ELAPRASE SOLN NDS
Drug Name RequirementsLimits
ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME SOLR NDS miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PANCREAZE CPEP MO PERTZYE CPEP MO PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VIOKACE TABS MO VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE SOLN bacitracin oint bacitracin-polymyxin b oint BESIVANCE SUSP bleph-10 soln CETRAXAL SOLN chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
CIPROFLOXACIN-FLUOCINOLONE PF SOLN
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
MOXEZA SOLN moxifloxacin hcl (2x day) soln moxifloxacin hcl soln NATACYN SUSP neo-polycin oint neomycin-bacitracin zn-polymyx oint
neomycin-polymyxin-gramicidin soln
ofloxacin soln OTOVEL SOLN paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ZIRGAN GEL ANTI-INFLAMMATORY AGENTS ACUVAIL SOLN MO ALREX SUSP MO bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
BROMSITE SOLN MO CEQUA SOLN CIPRO HC SUSP MO CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO DUREZOL EMUL MO flac oil MO
Drug Name RequirementsLimits
FLAREX SUSP MO flunisolide soln MO fluocinolone acetonide oil MO fluorometholone susp MO flurbiprofen sodium soln MO fluticasone propionate susp MO FML FORTE SUSP MO FML OINT MO HYDROCORTISONE-ACETIC ACID SOLN MO
ILEVRO SUSP MO ILUVIEN IMPL INVELTYS SUSP MO ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX OINT MO LOTEMAX SUSP MO loteprednol etabonate susp MO MAXIDEX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint MO
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO NEVANAC SUSP MO OMNARIS SUSP MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
PROLENSA SOLN MO RESTASIS EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 42 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tobramycin-dexamethasone susp MO
XHANCE EXHU MO XIIDRA SOLN YUTIQ IMPL ZETONNA AERS MO ZYLET SUSP MO ANTIALLERGIC AGENTS ALOCRIL SOLN MO ALOMIDE SOLN MO azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO LASTACAFT SOLN MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
ALPHAGAN P SOLN MO betaxolol hcl soln MO BETIMOL SOLN 025 05 MO BETOPTIC-S SUSP MO bimatoprost soln MO BRIMONIDINE TARTRATE SOLN 02 015 MO
brinzolamide susp MO carteolol hcl soln MO COMBIGAN SOLN MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO
Drug Name RequirementsLimits
methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO SIMBRINZA SUSP MO timolol maleate pf soln MO timolol maleate solg 025 05 MO
timolol maleate soln 025 05 MO
TIMOPTIC OCUDOSE SOLN 25 MO
TIMOPTIC-XE SOLG 025 05 MO
TRAVATAN Z SOLN MO travoprost (bak free) soln MO VYZULTA SOLN MO XELPROS EMUL MO ZIOPTAN SOLN MO EENT DRUGS MISCELLANEOUS ACETIC ACID SOLN MO ALTAFRIN SOLN apraclonidine hcl soln MO ATROPINE SULFATE SOLN MO BEOVU SOLN NDS CYSTADROPS SOLN NDS CYSTARAN SOLN EYLEA SOLN EYLEA SOSY IOPIDINE SOLN MO LACRISERT INST MO LUCENTIS SOLN 03mg005ml 05mg005ml NDS
LUCENTIS SOSY 03mg005ml 05mg005ml NDS
OXERVATE SOLN NDS PHENYLEPHRINE HCL SOLN RHOPRESSA SOLN TEPEZZA SOLR NDS LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl soln lidocaine viscous hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
APRISO CP24 MO balsalazide disodium caps MO colazal caps MO DELZICOL CPDR MO DIPENTUM CAPS NDS LIALDA TBEC MO mesalamine cpdr MO mesalamine enem MO mesalamine er cp24 MO mesalamine supp MO mesalamine tbec 12gm 800mg MO mesalamine-cleanser kit PENTASA CPCR 250mg 500mg MO
ANTIDIARRHEA AGENTS diphenoxylate-atropine liqd diphenoxylate-atropine tabs loperamide hcl caps MO MYTESI TBEC MO OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS AKYNZEO CAPS PA ANZEMET TABS 50mg 100mg PANDS aprepitant caps PANDS BONJESTA TBCR MO CESAMET CAPS PA dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
EMEND SUSR PANDS fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs
Drug Name RequirementsLimits
ondansetron hcl soln PA ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS TRANSDERM SCOP (15 MG) PT72
trimethobenzamide hcl caps PA VARUBI (180 MG DOSE) TBPK PANDS ZUPLENZ FILM 4mg 8mg PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc MO
CARAFATE SUSP MO cimetidine hcl soln MO cimetidine tabs 200mg 300mg 400mg 800mg MO
esomeprazole magnesium cpdr 20mg 40mg MO
esomeprazole magnesium pack 10mg 20mg 40mg MO
esomeprazole sodium solr ESOMEPRAZOLE STRONTIUM CPDR
famotidine premixed soln famotidine soln famotidine susr MO famotidine tabs 20mg 40mg MO lansoprazole cpdr 15mg 30mg MO lansoprazole tbdd 15mg 30mg MO misoprostol tabs 100mcg 200mcg MO
nizatidine caps 150mg 300mg MO nizatidine soln MO OMECLAMOX-PAK MISC MO omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 44 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PRILOSEC PACK 25mg 10mg MO PROTONIX PACK MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate tabs MO CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO GOLYTELY SOLR OSMOPREP TABS MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT PLENVU SOLR MO SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS AMITIZA CAPS 8mcg 24mcg MO BYLVAY (PELLETS) CPSP 200mcg 600mcg NDS
BYLVAY CAPS 400mcg 1200mcg NDS
CHOLBAM CAPS 50mg 250mg NDS ENTYVIO SOLR NDS GATTEX KIT PANDS GIMOTI SOLN NDS LINZESS CAPS 72mcg 145mcg 290mcg MO
lubiprostone caps 8mcg 24mcg MO
Drug Name RequirementsLimits
metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
MOVANTIK TABS 125mg 25mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS SYMPROIC TABS MO TRULANCE TABS MO ursodiol caps 300mg MO URSODIOL CAPS 200mg 400mg NDS
ursodiol tabs 250mg 500mg MO VIBERZI TABS 75mg 100mg NDS HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPS clovique caps NDS CUPRIMINE CAPS NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs 90mg 180mg 360mg NDS
deferasirox tbso 125mg NDS deferasirox tbso 250mg 500mg NDS deferiprone tabs NDS deferoxamine mesylate solr DEPEN TITRATABS TABS EXJADE TBSO 125mg 250mg 500mg NDS
FERRIPROX SOLN LDNDS FERRIPROX TABS 500mg 1000mg LDNDS
FERRIPROX TWICE-A-DAY TABS NDS
JADENU SPRINKLE PACK 90mg 180mg 360mg NDS
JADENU TABS 90mg 360mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
penicillamine caps penicillamine tabs trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP 05mg 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs MO decadron elix MO decadron tabs 5mg 75mg MO decadron tabs 4mg 6mg PAMO deltasone tabs PAMO DEPO-MEDROL SUSP dexabliss tbpk dexamethasone elix MO dexamethasone intensol conc MO dexamethasone sod phosphate pf soln
dexamethasone sodium phosphate soln
dexamethasone soln dexamethasone tabs 05mg 075mg 1mg 15mg 2mg 4mg 6mg
PAMO
dexamethasone tbpk MO dexpak 10 day tbpk MO dexpak 13 day tbpk MO dexpak 6 day tbpk MO dxevo 11-day tbpk EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
INTRAROSA INST KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp
Drug Name RequirementsLimits
methylprednisolone sodium succ solr
methylprednisolone tabs 4mg 8mg 16mg 32mg MO
methylprednisolone tbpk MO millipred dp tbpk millipred tabs MO ORTIKOS CP24 6mg 9mg NDS prednisolone sodium phosphate soln 5mg5ml 10mg5ml 20mg5ml 25mg5ml
MO
prednisolone sodium phosphate tbdp 10mg 15mg 30mg MO
prednisolone soln MO prednisone intensol conc PAMO prednisone soln PAMO prednisone tabs 1mg 25mg 5mg 10mg 20mg 50mg PAMO
prednisone tbpk PULMICORT FLEXHALER AEPB
RAYOS TBEC 1mg 2mg 5mg PAMO SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TRELEGY ELLIPTA AEPB MO triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
AVEED SOLN MO danazol caps 50mg 100mg 200mg MO
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs 25mg MO oxandrolone tabs MONDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 46 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
STRIANT MISC MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact
MO
testosterone soln MO XYOSTED SOAJ 50mg05ml 75mg05ml 100mg05ml MO
CONTRACEPTIVES altavera tabs MO alyacen 135 tabs MO amethia lo tabs MO amethia tabs MO apri tabs MO aranelle tabs MO ashlyna tabs MO aubra eq tabs MO aviane tabs MO balziva tabs MO blisovi 24 fe tabs MO blisovi fe 1530 tabs MO briellyn tabs MO camila tabs MO camrese lo tabs MO caziant tabs MO cryselle-28 tabs MO cyclafem 135 tabs MO cyclafem 777 tabs MO cyred eq tabs MO deblitane tabs MO delyla tabs MO desogestrel-ethinyl estradiol tabs MO dolishale tabs MO drospiren-eth estrad-levomefol tabs MO
drospirenone-ethinyl estradiol tabs MO
ELLA TABS MO eluryng ring MO emoquette tabs MO
Drug Name RequirementsLimits
enpresse-28 tabs MO enskyce tabs MO errin tabs MO estarylla tabs MO ethynodiol diac-eth estradiol tabs MO etonogestrel-ethinyl estradiol ring MO
falmina tabs MO fayosim tabs MO femynor tabs MO gemmily caps MO gianvi tabs MO hailey 24 fe tabs MO iclevia tabs MO incassia tabs MO introvale tabs MO isibloom tabs MO jasmiel tabs MO JOLIVETTE TABS MO juleber tabs MO junel 1530 tabs MO junel 120 tabs MO junel fe 1530 tabs MO junel fe 120 tabs MO junel fe 24 tabs MO kaitlib fe chew MO kariva tabs MO kelnor 135 tabs MO kelnor 150 tabs MO kurvelo tabs MO larin 1530 tabs MO larin 120 tabs MO larin fe 1530 tabs MO larin fe 120 tabs MO larissia tabs MO LAYOLIS FE CHEW MO leena tabs MO lessina tabs MO levonest tabs MO levonorg-eth estrad triphasic tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
levora 01530 (28) tabs MO LO LOESTRIN FE TABS MO loestrin 1530 (21) tabs MO loestrin 120 (21) tabs MO loestrin fe 1530 tabs MO loestrin fe 120 tabs MO loryna tabs MO low-ogestrel tabs MO lutera tabs MO lyleq tabs MO lyza tabs MO marlissa tabs MO melodetta 24 fe chew MO merzee caps MO mibelas 24 fe chew MO microgestin 1530 tabs MO microgestin 120 tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA TABS MO NATAZIA TABS MO necon 0535 (28) tabs MO NECON 777 TABS MO nikki tabs MO nora-be tabs MO norethin ace-eth estrad-fe caps MO norethin ace-eth estrad-fe chew MO norethin ace-eth estrad-fe tabs MO norethin-eth estradiol-fe chew MO norethindrone acet-ethinyl est tabs MO
norethindrone tabs MO norgestim-eth estrad triphasic tabs MO
norgestimate-eth estradiol tabs MO norlyroc tabs MO
Drug Name RequirementsLimits
nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO NUVARING RING MO nylia 777 tabs MO nymyo tabs MO ocella tabs MO ogestrel tabs MO orsythia tabs MO pimtrea tabs MO pirmella 135 tabs MO portia-28 tabs MO previfem tabs MO reclipsen tabs MO rivelsa tabs MO setlakin tabs MO sharobel tabs MO sprintec 28 tabs MO sronyx tabs MO syeda tabs MO tarina 24 fe tabs MO tarina fe 120 eq tabs MO tilia fe tabs MO tri-estarylla tabs MO tri-legest fe tabs MO tri-lo-estarylla tabs MO tri-lo-sprintec tabs MO tri-mili tabs MO tri-nymyo tabs MO tri-previfem tabs MO tri-sprintec tabs MO tri-vylibra lo tabs MO tri-vylibra tabs MO TRINESSA (28) TABS MO trivora (28) tabs MO tydemy tabs MO velivet tabs MO vestura tabs MO vienva tabs MO vyfemla tabs MO vylibra tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 48 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135e (28) tabs MO DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
ADMELOG SOLN MO ADMELOG SOLOSTAR SOPN MO AFREZZA POWD MO AFREZZA POWD 8 (90) amp 12 (90) UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO APIDRA SOLN PAMO APIDRA SOLOSTAR SOPN MO AVANDIA TABS 2mg 4mg MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD BYDUREON BCISE AUIJ BYDUREON PEN BYETTA 10 MCG PEN SOPN MO BYETTA 5 MCG PEN SOPN MO CYCLOSET TABS MO diazoxide susp glimepiride tabs 1mg 2mg 4mg MO glipizide er tb24 25mg 5mg 10mg MO
glipizide tabs 5mg 10mg MO glipizide-metformin hcl tabs MO GLUCAGEN HYPOKIT SOLR glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO GLYXAMBI TABS MO
Drug Name RequirementsLimits
HUMALOG JUNIOR KWIKPEN SOPN MO
HUMALOG KWIKPEN SOPN 100unitml 200unitml MO
HUMALOG MIX 5050 KWIKPEN SUPN MO
HUMALOG MIX 5050 SUSP MO HUMALOG MIX 7525 KWIKPEN SUPN MO
HUMALOG MIX 7525 SUSP MO HUMALOG SOCT MO HUMALOG SOLN PAMO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN PAMO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
INSULIN ASP PROT amp ASP FLEXPEN SUPN MO
INSULIN ASPART FLEXPEN SOPN MO
INSULIN ASPART PENFILL SOCT MO
INSULIN ASPART PROT amp ASPART SUSP MO
INSULIN ASPART SOLN PAMO INSULIN LISPRO (1 UNIT DIAL) SOPN MO
INSULIN LISPRO SOLN MO INVOKAMET TABS MO INVOKAMET XR TB24 MO INVOKANA TABS 100mg 300mg MO
JARDIANCE TABS 10mg 25mg MO JENTADUETO TABS MO JENTADUETO XR TB24 MO KAZANO TABS MO KORLYM TABS LDNDS LANTUS SOLN MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
LANTUS SOLOSTAR SOPN MO LEVEMIR FLEXTOUCH SOPN MO LEVEMIR SOLN MO metformin hcl er tb24 500mg 750mg MO
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO NOVOLIN 7030 SUSP MO NOVOLOG 7030 FLEXPEN RELION SUPN MO
NOVOLOG FLEXPEN RELION SOPN MO
NOVOLOG FLEXPEN SOPN MO NOVOLOG MIX 7030 FLEXPEN SUPN MO
NOVOLOG MIX 7030 RELION SUSP MO
NOVOLOG MIX 7030 SUSP MO NOVOLOG PENFILL SOCT MO NOVOLOG RELION SOLN PAMO NOVOLOG SOLN PAMO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO PROGLYCEM SUSP MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SOLIQUA SOPN MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO SYNJARDY TABS MO SYNJARDY XR TB24 MO tolazamide tabs 250mg 500mg MO
Drug Name RequirementsLimits
tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO ANGELIQ TABS MO CLIMARA PRO PTWK MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
COMBIPATCH PTTW MO DELESTROGEN OIL depo-estradiol oil DIVIGEL GEL MO dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
DUAVEE TABS MO ELESTRIN GEL MO estrace crea MO estrace tabs 05mg 1mg 2mg MO estradiol crea MO estradiol pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO EVAMIST SOLN MO fyavolv tabs MO IMVEXXY MAINTENANCE PACK INST 4mcg 10mcg MO
IMVEXXY STARTER PACK INST 4mcg 10mcg MO
jinteli tabs MO lopreeza tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 50 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
MENOSTAR PTWK MO mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO ORIAHNN CPPK NDS OSPHENA TABS MO prefest tabs MO PREMARIN SOLR PREMARIN TABS 03mg 045mg 0625mg 09mg 125mg
MO
PREMPHASE TABS MO PREMPRO TABS MO raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS NOVAREL SOLR 5000unit 10000unit PA
ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS PREGNYL SOLR PA TRIPTODUR SRER NDS OXYTOCICS carboprost tromethamine soln methergine tabs methylergonovine maleate soln methylergonovine maleate tabs OXYTOCIN SOLN PARATHYROID calcitonin (salmon) soln MO cinacalcet hcl tabs 30mg 60mg 90mg PANDS
FORTEO SOPN PANDS NATPARA CART 25mcg 50mcg 75mcg 100mcg LDNDS
Drug Name RequirementsLimits
SENSIPAR TABS 30mg 60mg 90mg PANDS
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PALDNDS DDAVP RHINAL TUBE SOLN MO desmopressin ace spray refrig soln MO
desmopressin acetate soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln DESMOPRESSIN ACETATE TABS 01mg 02mg MO
NOCDURNA SUBL 277mcg 553mcg MO
NOCTIVA EMUL 083mcg01ml 166mcg01ml MO
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO CRINONE GEL 4 8 PAMO DEPO-PROVERA SUSP 400mgml
DEPO-SUBQ PROVERA 104 SUSY
ENDOMETRIN INST PA hydroxyprogesterone caproate oil
hydroxyprogesterone caproate soln
MAKENA SOAJ NDS medroxyprogesterone acetate susp
medroxyprogesterone acetate susy
medroxyprogesterone acetate tabs 25mg 5mg 10mg MO
megestrol acetate susp MO norethindrone acetate tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS BYNFEZIA PEN SOPN NDS EGRIFTA SOLR NDS EGRIFTA SV SOLR NDS GENOTROPIN MINIQUICK SOLR 02mg PANDS
GENOTROPIN MINIQUICK SOLR 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
GENOTROPIN SOLR 5mg 12mg PANDS
HUMATROPE SOLR 5mg 6mg 12mg 24mg PANDS
INCRELEX SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
NUTROPIN AQ NUSPIN 20 SOPN PANDS
NUTROPIN AQ NUSPIN 5 SOPN PANDS
octreotide acetate soln OMNITROPE SOCT 5mg15ml 10mg15ml PANDS
OMNITROPE SOLR PANDS SAIZEN CLICKEASY SOLR PANDS SAIZEN SOLR 5mg 88mg PANDS SAIZENPREP SOLR PANDS SANDOSTATIN LAR DEPOT KIT 10mg 20mg 30mg NDS
SEROSTIM SOLR 4mg 5mg 6mg PANDS
SIGNIFOR LAR SRER 10mg 20mg 30mg 40mg 60mg NDS
SIGNIFOR SOLN 03mgml 06mgml 09mgml NDS
SOMATULINE DEPOT SOLN
Drug Name RequirementsLimits
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZOMACTON SOLR 5mg PANDS ZOMACTON SOLR PANDS ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVO-T TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVOTHYROXINE SODIUM SOLR
levothyroxine sodium tabs 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
liothyronine sodium soln liothyronine sodium tabs 5mcg 25mcg 50mcg MO
methimazole tabs 5mg 10mg MO propylthiouracil tabs MO tapazole tabs 5mg 10mg MO THYROLAR-1 TABS THYROLAR-12 TABS THYROLAR-14 TABS THYROLAR-2 TABS THYROLAR-3 TABS TIROSINT CAPS 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 52 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
137mcg 150mcg 175mcg 200mcg UNITHROID TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA REDUCTASE INHIBITORS dutasteride caps MO dutasteride-tamsulosin hcl caps MO finasteride tabs MO ANTIDOTES acetylcysteine soln 10 20 PAMO fomepizole soln KHAPZORY SOLR 175mg 300mg NDS
leucovorin calcium soln leucovorin calcium solr leucovorin calcium tabs 5mg 10mg 15mg 25mg MO
levoleucovorin calcium pf soln levoleucovorin calcium solr VISTOGARD PACK NDS VORAXAZE SOLR NDS ANTIGOUT AGENTS allopurinol sodium solr allopurinol tabs 100mg 300mg MO COLCHICINE CAPS MO colchicine tabs MO febuxostat tabs 40mg 80mg MO GLOPERBA SOLN MITIGARE CAPS MO ULORIC TABS 40mg 80mg MO BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 5mg 10mg 35mg 70mg MO
alendronate sodium tabs 40mg MO BINOSTO TBEF MO EVENITY SOSY NDS FOSAMAX PLUS D TABS MO IBANDRONATE SODIUM SOLN
Drug Name RequirementsLimits
ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr PROLIA SOSY risedronate sodium tabs 5mg 30mg 35mg 150mg MO
RISEDRONATE SODIUM TBEC MO XGEVA SOLN PANDS zoledronic acid conc zoledronic acid soln DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ACTPEN SOAJ NDS ACTEMRA SOSY NDS AVSOLA SOLR NDS CIMZIA KIT PANDS CIMZIA PREFILLED KIT PANDS CIMZIA STARTER KIT KIT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS ENBREL SOSY 25mg05ml 50mgml NDS
ENBREL SURECLICK SOAJ NDS HUMIRA PEDIATRIC CROHNS START PSKT NDS
HUMIRA PEN PNKT 40mg04ml 40mg08ml 80mg08ml
NDS
HUMIRA PEN-CDUCHS STARTER PNKT 40mg08ml 80mg08ml
NDS
HUMIRA PEN-PEDIATRIC UC START PNKT NDS
HUMIRA PEN-PSUVADOL HS START PNKT NDS
HUMIRA PEN-PSORUVEIT STARTER PNKT NDS
HUMIRA PSKT 10mg01ml 10mg02ml 20mg02ml 20mg04ml 40mg04ml 40mg08ml
NDS
INFLECTRA SOLR INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
KEVZARA SOAJ 150mg114ml 200mg114ml NDS
KEVZARA SOSY 150mg114ml 200mg114ml NDS
KINERET SOSY NDS leflunomide tabs 10mg 20mg MO OLUMIANT TABS 1mg 2mg NDS ORENCIA CLICKJECT SOAJ NDS ORENCIA SOLR NDS ORENCIA SOSY 50mg04ml 875mg07ml 125mgml NDS
OTEZLA TABS PANDS OTEZLA TBPK PANDS OTREXUP SOAJ RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 NDS SIMPONI ARIA SOLN NDS SIMPONI SOAJ 50mg05ml 100mgml NDS
SIMPONI SOSY 50mg05ml 100mgml NDS
XELJANZ SOLN NDS XELJANZ TABS 5mg 10mg NDS XELJANZ XR TB24 11mg 22mg NDS IMMUNE SUPPRESSANTS ASTAGRAF XL CP24 05mg 1mg PAMO
ASTAGRAF XL CP24 PA azasan tabs 75mg 100mg PAMO azathioprine sodium solr azathioprine tabs PAMO BENLYSTA SOAJ BENLYSTA SOLR BENLYSTA SOSY cyclosporine caps 25mg 100mg PAMO cyclosporine modified caps 25mg 50mg 100mg PAMO
cyclosporine modified soln PAMO cyclosporine soln PAMO
Drug Name RequirementsLimits
ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg PA GAMIFANT SOLN 50mg10ml 100mg20ml 10mg2ml NDS
gengraf caps 25mg 50mg 100mg PAMO
gengraf soln PAMO LUPKYNIS CAPS NDS MAVENCLAD (10 TABS) TBPK NDS MAVENCLAD (4 TABS) TBPK NDS MAVENCLAD (5 TABS) TBPK NDS MAVENCLAD (6 TABS) TBPK NDS MAVENCLAD (7 TABS) TBPK NDS MAVENCLAD (8 TABS) TBPK NDS MAVENCLAD (9 TABS) TBPK NDS mycophenolate mofetil caps PAMO mycophenolate mofetil hcl solr mycophenolate mofetil susr PAMO mycophenolate mofetil tabs PAMO mycophenolate sodium tbec 180mg 360mg PAMO
NULOJIX SOLR NDS PROGRAF PACK 02mg PA PROGRAF PACK PANDS PROGRAF SOLN PAMO SANDIMMUNE ORAL SOLN 100mgml PAMO
SAPHNELO SOLN NDS sirolimus soln PA sirolimus tabs 05mg 1mg 2mg PAMO tacrolimus caps 05mg 1mg 5mg PAMO
UPLIZNA SOLN ZORTRESS TABS 025mg PAMO ZORTRESS TABS 05mg 075mg 1mg PA
MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 54 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BOTOX SOLR 100unit 200unit PA bupivacaine hcl (pf) soln bupivacaine hcl soln BUPIVACAINE IN DEXTROSE SOLN
bupivacaine spinal soln bupivacaine-epinephrine (pf) soln
bupivacaine-epinephrine soln CARNITOR SOLN PAMO CARNITOR TABS PAMO chloroprocaine hcl (pf) soln CINRYZE SOLR INTRAVENOUS HI
citanest plain dental soln COSELA SOLR NDS CRYSVITA SOLN 10mgml 20mgml 30mgml NDS
CYSTADANE POWD LDNDS CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr DYSPORT SOLR 300unit 500unit PA
EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENSPRYNG SOSY NDS EVRYSDI SOLR NDS EXONDYS 51 SOLN 500mg10ml 100mg2ml NDS
FIRDAPSE TABS NDS FLUORITAB CHEW 025mg 05mg 1mg MO
FLUORITAB SOLN MO GALAFOLD CAPS NDS GIVLAARI SOLN NDS GRASTEK SUBL MO
Drug Name RequirementsLimits
HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS TABS NDS KUVAN PACK 100mg 500mg NDS KUVAN TABS NDS LACTATED RINGERS SOLN levocarnitine soln PAMO LEVOCARNITINE TABS PAMO lidocaine hcl (pf) soln lidocaine hcl soln lidocaine in dextrose soln lidocaine-epinephrine soln LUDENT CHEW 025mg 05mg 1mg MO
mesna soln MESNEX TABS NDS MYALEPT SOLR NDS NAFRINSE CHEW MO NAFRINSE DROPS SOLN MO nitisinone caps 2mg 5mg 10mg NDS NITYR TABS 2mg 5mg 10mg NDS NULIBRY SOLR NDS ODACTRA SUBL ONPATTRO SOLN NDS ORALAIR SUBL MO ORFADIN CAPS LDNDS ORFADIN SUSP LDNDS ORLADEYO CAPS 110mg 150mg NDS
OXLUMO SOLN PALFORZIA (12 MG DAILY DOSE) CSPK NDS
PALFORZIA (120 MG DAILY DOSE) CSPK NDS
PALFORZIA (160 MG DAILY DOSE) CSPK NDS
PALFORZIA (20 MG DAILY DOSE) CSPK NDS
PALFORZIA (200 MG DAILY DOSE) CSPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
PALFORZIA (240 MG DAILY DOSE) CSPK NDS
PALFORZIA (3 MG DAILY DOSE) CSPK NDS
PALFORZIA (300 MG MAINTENANCE) PACK NDS
PALFORZIA (300 MG TITRATION) PACK NDS
PALFORZIA (40 MG DAILY DOSE) CSPK NDS
PALFORZIA (6 MG DAILY DOSE) CSPK NDS
PALFORZIA (80 MG DAILY DOSE) CSPK NDS
PALFORZIA INITIAL ESCALATION CSPK NDS
PHYSIOLYTE SOLN PHYSIOSOL IRRIGATION SOLN
polocaine soln polocaine-mpf soln PROCYSBI CPDR 25mg 75mg NDS PROCYSBI PACK 75mg 300mg NDS REZUROCK TABS NDS RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln RUZURGI TABS NDS sapropterin dihydrochloride pack 100mg 500mg NDS
sapropterin dihydrochloride tabs NDS SENSORCAINE SOLN sensorcaine-mpf soln sensorcaine-mpfepinephrine soln
sensorcaineepinephrine soln SODIUM CHLORIDE SOLN MO SODIUM FLUORIDE CHEW 025mg 05mg 1mg MO
SODIUM FLUORIDE SOLN MO SODIUM FLUORIDE TABS MO STERILE WATER FOR IRRIGATION SOLN
Drug Name RequirementsLimits
TAKHZYRO SOLN NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VILTEPSO SOLN NDS VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR 50unit 100unit PA XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg NDS RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 200mg114ml 300mg2ml PANDS
FASENRA PEN SOAJ NDS FASENRA SOSY PA montelukast sodium chew 4mg 5mg MO
montelukast sodium pack MO montelukast sodium tabs MO NUCALA SOAJ PANDS NUCALA SOLR PANDS NUCALA SOSY PANDS zafirlukast tabs 10mg 20mg MO zileuton er tb12 NDS CYSTIC FIBROSIS BETHKIS NEBU PA
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 56 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CAYSTON SOLR LDNDS KALYDECO PACK 25mg 50mg 75mg PANDS
KALYDECO TABS PANDS KITABIS PAK NEBU PA ORKAMBI PACK NDS ORKAMBI TABS NDS SYMDEKO TBPK NDS TOBI PODHALER CAPS tobramycin nebu 300mg4ml 300mg5ml PA
TRIKAFTA TBPK LDNDS PULMONARY FIBROSIS ESBRIET CAPS PANDS ESBRIET TABS 267mg 801mg PANDS OFEV CAPS 100mg 150mg NDS RESPIRATORY AGENTS MISCELLANEOUS ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS 500mg 1000mg
HI
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact
MO
ASMANEX (120 METERED DOSES) AEPB MO
ASMANEX (30 METERED DOSES) AEPB 110mcginh MO
ASMANEX (30 METERED DOSES) AEPB MO
ASMANEX (60 METERED DOSES) AEPB MO
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
budesonide-formoterol fumarate aero
DALIRESP TABS 250mcg 500mcg MO
DULERA AERO MO
Drug Name RequirementsLimits
FLOVENT DISKUS AEPB 50mcgblist 100mcgblist 250mcgblist
MO
FLOVENT HFA AERO 44mcgact MO
FLOVENT HFA AERO 110mcgact 220mcgact MO
fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PROLASTIN-C SOLN INTRAVENOUS HI
PROLASTIN-C SOLR INTRAVENOUS HI
SYMBICORT AERO wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
ZEMAIRA SOLR INTRAVENOUS HI
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr LETAIRIS TABS 5mg 10mg NDS ORENITRAM TBCR 0125mg LDNDS ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TABS 625mg 125mg NDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
1000mcg 1200mcg 1400mcg 1600mcg UPTRAVI TBPK NDS VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS BIVIGAM SOLN 10gm100ml HI BIVIGAM SOLN 5gm50ml HI CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml
HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS 10gm200ml HI
GAMMAPLEX SOLN INTRAVENOUS 10gm100ml 20gm200ml 5gm50ml
HI
GAMUNEX-C SOLN INJECTION 10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml
HI
HYPERHEP B SOLN HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 5gm100ml HI
Drug Name RequirementsLimits
1gm20ml 2gm20ml 25gm500ml PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
PRIVIGEN SOLN INTRAVENOUS HI
VARIZIG SOLN XEMBIFY SOLN SUBCUTANEOUS 2gm10ml 4gm20ml 10gm50ml 1gm5ml
HI
TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP QUADRACEL SUSP TDVAX SUSP TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP DAPTACEL SUSP ENGERIX-B SUSP 10mcg05ml 20mcgml PA
GARDASIL 9 SUSP GARDASIL 9 SUSY HAVRIX SUSP HEPLISAV-B SOLN PA HIBERIX SOLR IMOVAX RABIES INJ INFANRIX SUSP IPOL INJ IXIARO SUSP M-M-R II SOLR MENACTRA INJ MENQUADFI INJ MENVEO SOLR PEDIARIX SUSP PEDVAX HIB SUSP
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 58 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN VAQTA SUSP VARIVAX INJ VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint AKTIPAK PACK MO AVC VAGINAL CREA BACTROBAN NASAL OINT BENZEPRO CREAMY WASH LIQD
BENZEPRO FOAMING CLOTHS MISC
BENZOYL PEROXIDE GEL NDS benzoyl peroxide-erythromycin gel MO
ciclopirox gel ciclopirox olamine crea ciclopirox olamine susp ciclopirox sham ciclopirox soln CLEOCIN SUPP clindacin-p swab MO clindamycin phos-benzoyl perox gel MO
clindamycin phosphate crea clindamycin phosphate foam MO clindamycin phosphate gel MO clindamycin phosphate lotn MO
Drug Name RequirementsLimits
clindamycin phosphate soln MO clindamycin phosphate swab MO CLINDESSE CREA clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn DENAVIR CREA econazole nitrate crea ERTACZO CREA ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA EXELDERM CREA EXELDERM SOLN gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ivermectin lotn ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham LULICONAZOLE CREA LUZU CREA mafenide acetate pack malathion lotn MENTAX CREA metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 59
Drug Name RequirementsLimits
mupirocin oint naftifine hcl crea naftifine hcl gel NAFTIN GEL NATROBA SUSP neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ORAVIG TABS ovide lotn oxiconazole nitrate crea OXISTAT LOTN permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SKLICE LOTN SODIUM SULFACETAMIDE SHAM
SODIUM SULFACETAMIDE WASH LIQD
SPINOSAD SUSP SSD CREA sulfacetamide sodium (acne) lotn MO SULFACETAMIDE SODIUM GEL
SULFACETAMIDE SODIUM LIQD
SULFAMYLON CREA tavaborole soln terconazole crea terconazole supp VANDAZOLE GEL XEPI CREA MO XERESE CREA ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) ala scalp lotn MO
Drug Name RequirementsLimits
ala-cort crea 1 25 MO alclometasone dipropionate crea MO alclometasone dipropionate oint MO amcinonide crea MO amcinonide lotn MO amcinonide oint MO anusol-hc crea MO apexicon e crea MO benzoyl perox-hydrocortisone lotn
BENZOYL PEROXIDE FORTE- HC LOTN NDS
beser lotn MO betamethasone dipropionate aug crea MO
betamethasone dipropionate aug gel MO
betamethasone dipropionate aug lotn MO
betamethasone dipropionate aug oint MO
betamethasone dipropionate crea MO
betamethasone dipropionate lotn MO BETAMETHASONE DIPROPIONATE OINT MO
betamethasone valerate crea MO betamethasone valerate foam MO BETAMETHASONE VALERATE LOTN MO
BETAMETHASONE VALERATE OINT MO
BRYHALI LOTN MO calcipotriene-betameth diprop oint MONDS
calcipotriene-betameth diprop susp NDS
CAPEX SHAM MO clobetasol propionate crea clobetasol propionate e crea MO clobetasol propionate emulsion foam
clobetasol propionate foam MO clobetasol propionate gel MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 60 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO CLOBEX SHAM MO CLOBEX SPRAY LIQD MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO clodan sham MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT MO DESONATE GEL MO desonide crea MO desonide gel MO desonide lotn MO desonide oint MO desowen lotn MO desoximetasone crea 005 025 MO
desoximetasone gel MO desoximetasone liqd MO desoximetasone oint 005 025 MO
desrx gel MO diclofenac sodium gel 1 3 MO diflorasone diacetate crea MO diflorasone diacetate oint MO DUOBRII LOTN MO ENSTILAR FOAM NDS epifoam foam fluocinolone acetonide body oil fluocinolone acetonide crea 001 0025 MO
fluocinolone acetonide oint MO fluocinolone acetonide scalp oil MO fluocinolone acetonide soln MO fluocinonide crea MO fluocinonide emulsified base crea MO
Drug Name RequirementsLimits
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO flurandrenolide crea MO flurandrenolide lotn MO flurandrenolide oint MO fluticasone propionate crea MO fluticasone propionate lotn MO fluticasone propionate oint MO halcinonide crea MO halobetasol propionate crea MO HALOBETASOL PROPIONATE FOAM NDS
halobetasol propionate oint MO HALOG CREA MO HALOG OINT MO hydrocortisone (perianal) crea 1 25 MO
hydrocortisone butyr lipo base crea
hydrocortisone butyrate crea MO hydrocortisone butyrate lotn MO HYDROCORTISONE BUTYRATE OINT MO
hydrocortisone butyrate soln MO hydrocortisone crea 1 25 MO hydrocortisone enem MO hydrocortisone lotn MO hydrocortisone oint 1 25 MO hydrocortisone valerate crea MO hydrocortisone valerate oint MO LEXETTE FOAM NDS micort-hc crea MO mometasone furoate crea MO mometasone furoate oint MO mometasone furoate soln MO neo-synalar crea MO nolix crea nolix lotn MO nystatin-triamcinolone crea MO nystatin-triamcinolone oint MO oralone pste MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 61
Drug Name RequirementsLimits
PANDEL CREA MO prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO psorcon crea MO TACLONEX SUSP NDS topicort crea 005 025 MO topicort gel MO topicort oint MO tovet foam MO triamcinolone acetonide aers MO triamcinolone acetonide crea 0025 01 05 MO
triamcinolone acetonide lotn 0025 01 MO
triamcinolone acetonide oint 0025 005 01 05 MO
triamcinolone acetonide pste MO trianex oint MO triderm crea 01 05 MO tritocin oint MO UCERIS FOAM MO ULTRAVATE LOTN NDS VANOXIDE-HC LOTN ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
LIDO-SORB LOTN LIDOCAINE HCL CREA lidocaine hcl lotn lidocaine hcl soln PA lidocaine hcl urethralmucosal gel MO
lidocaine hcl urethralmucosal prsy MO
lidocaine oint PAMO lidocaine ptch PAMO
Drug Name RequirementsLimits
LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea PA LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam texacort soln MO TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS ALTRENO LOTN PAMO AVITA CREA PAMO AVITA GEL PAMO KEPIVANCE SOLR NDS PANRETIN GEL NDS RETIN-A CREA 0025 005 01 PAMO
RETIN-A GEL 001 0025 PAMO RETIN-A MICRO GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 008 PAMO
RETIN-A MICRO PUMP GEL PANDS TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 62 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS ABSORICA CAPS 25mg 35mg NDS ABSORICA LD CAPS 8mg 16mg 24mg 32mg NDS
accutane caps 10mg 20mg 30mg 40mg NDS
acitretin caps 10mg 175mg 25mg NDS
ADAPALENE CREA MO adapalene gel 01 03 MO adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
AVAR CLEANSER EMUL AVAR-E EMOLLIENT CREA AVAR-E GREEN CREA azelaic acid gel MO AZELEX CREA MO BP 10-1 EMUL calcipotriene crea MO calcipotriene oint MO calcipotriene soln MO calcitrene oint MO CALCITRIOL OINT MO CARAC CREA CEROVEL LOTN claravis caps 10mg 20mg 30mg 40mg NDS
CONDYLOX GEL MO COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
Drug Name RequirementsLimits
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA MO DIFFERIN LOTN MO EPIDUO FORTE GEL MO FABIOR FOAM PAMO FINACEA FOAM MO fluorouracil crea 5 MO fluorouracil crea 5 fluorouracil soln 2 5 MO ILUMYA SOSY PA imiquimod crea 375 5 MO IMIQUIMOD PUMP CREA MO isotretinoin caps 10mg 20mg 30mg 40mg NDS
keralyt sham KLISYRI OINT NDS LACTIC ACID LOTN methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
ORACEA CPDR pimecrolimus crea MO podofilox soln MO RECTIV OINT MO REGRANEX GEL NDS RYNODERM CREA NDS SALEX SHAM SALICYLIC ACID CREA SALICYLIC ACID ER SOLN SALICYLIC ACID FOAM SALICYLIC ACID GEL SALICYLIC ACID LIQD SALICYLIC ACID SHAM SALICYLIC ACID WART REMOVER LIQD
SALICYLIC ACID-CLEANSER KIT
SALIMEZ CREA SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 63
Drug Name RequirementsLimits
SKYRIZI PEN SOAJ SKYRIZI SOSY SORILUX FOAM MO SSS 10-5 CREA STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
SULFACETAMIDE SODIUM-SULFUR CREA
SULFACETAMIDE SODIUM-SULFUR EMUL
SULFACETAMIDE SODIUM-SULFUR LIQD
SULFACETAMIDE SODIUM-SULFUR LOTN
SULFACETAMIDE SODIUM-SULFUR PADS
SULFACETAMIDE SODIUM-SULFUR SUSP
SULFACLEANSE 84 SUSP sulfamez wash emul TACROLIMUS OINT 01 003 MO
TALTZ SOAJ NDS TALTZ SOSY NDS tazarotene crea PAMO tazarotene foam PAMO TAZORAC CREA PAMO TAZORAC GEL 005 01 PAMO TOLAK CREA TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS VECTICAL OINT MO VEREGEN OINT MO WYNZORA CREA NDS XUREA CREA
Drug Name RequirementsLimits
zenatane caps 10mg 20mg 30mg 40mg NDS
ZYCLARA PUMP CREA MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline soln darifenacin hydrobromide er tb24 75mg 15mg MO
elixophyllin elix flavoxate hcl tabs MO MYRBETRIQ TB24 25mg 50mg MO oxybutynin chloride er tb24 5mg 10mg 15mg MO
oxybutynin chloride syrp MO oxybutynin chloride tabs MO solifenacin succinate tabs 5mg 10mg MO
theo-24 cp24 100mg 200mg 300mg 400mg MO
theophylline er tb12 100mg 200mg 300mg 450mg MO
theophylline er tb24 400mg 600mg MO
theophylline soln MO tolterodine tartrate er cp24 2mg 4mg MO
tolterodine tartrate tabs MO trospium chloride er cp24 MO trospium chloride tabs MO VITAMINS VITAMINS ADCF (05MGML) SOLN MO calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN MULTI-VITAMINFLUORIDEIRON SOLN
MO
MULTI-VITAMINFLUORIDE SOLN MO
MULTIVITAMINFLUORIDE CHEW MO
64 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
MVC-FLUORIDE CHEW MO paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS TRI-VITAMINFLUORIDE SOLN MO TRI-VITEFLUORIDE SOLN MO VITAMINS ACD-FLUORIDE SOLN MO
VP-PNV-DHA CAPS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 65
The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not and
you need an urgent refill please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 6 or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number on page 6 NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
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Index of Drugs
A abacavir sulfate soln 12 abacavir sulfate tabs 12 abacavir sulfate-lamivudine tabs 12 abacavir-lamivudine-zidovudine tabs 12 ABELCET SUSP INTRAVENOUS 11 ABILIFY MAINTENA PRSY 300mg 400mg
35 ABILIFY MAINTENA SRER 300mg 400mg
35 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
abiraterone acetate tabs 250mg 500mg 14 ABRAXANE SUSR 14 ABSORICA CAPS 25mg 35mg 62 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 62 ABSTRAL SUBL 100mcg 200mcg
300mcg 400mcg 600mcg 800mcg 27 acamprosate calcium tbec 26 acarbose tabs 25mg 50mg 100mg 48 accutane caps 10mg 20mg 30mg 40mg 62 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 27 acetaminophen-codeine soln 27 acetaminophen-codeine tabs 27 acetazolamide er cp12 42 acetazolamide sodium solr 42 acetazolamide tabs 125mg 250mg 42 ACETIC ACID SOLN 42 53 acetylcysteine soln 10 20 52 acitretin caps 10mg 175mg 25mg 62 ACTEMRA ACTPEN SOAJ 52 ACTEMRA SOSY 52 ACTHAR GEL 50 ACTHIB SOLR 57 ACTIMMUNE SOLN 53 ACUVAIL SOLN 41
acyclovir caps 12 acyclovir oint 58 acyclovir sodium soln intravenous 12 acyclovir susp 12 acyclovir tabs 400mg 800mg 12 ADACEL SUSP 57 ADAGEN SOLN 40 ADAKVEO SOLN 21 ADAPALENE CREA 62 adapalene gel 01 03 62 adapalene pads 62 adapalene soln 62 adapalene-benzoyl peroxide gel 62 ADAPALENE-BENZOYL PEROXIDE PADS
62 ADCF (05MGML) SOLN 63 adderall tabs 29 ADDERALL XR CP24 29 adefovir dipivoxil tabs 12 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 56 adenosine soln 25 ADMELOG SOLN 48 ADMELOG SOLOSTAR SOPN 48 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 20 ADZENYS ER SUER 29 ADZENYS XR-ODT TBED 31mg 63mg
94mg 125mg 157mg 188mg 29 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 25mg 5mg 75mg 10mg
14 AFREZZA POWD 48 AFREZZA POWD 8 (90) amp 12 (90) UNIT 48 AJOVY SOAJ 32 AJOVY SOSY 32 AKTIPAK PACK 58 AKYNZEO CAPS 43 ala scalp lotn 59 ala-cort crea 1 25 59 albendazole tabs 8
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albuterol sulfate er tb12 4mg 8mg 20 albuterol sulfate hfa aers 20 albuterol sulfate nebu 0083 25mg05ml
20 albuterol sulfate nebu 063mg3ml
125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 59 alclometasone dipropionate oint 59 ALCOHOL PREP PADS 37 ALDACTAZIDE TABS 25 ALDURAZYME SOLN 40 ALECENSA CAPS 14 alendronate sodium soln 52 alendronate sodium tabs 40mg 52 alendronate sodium tabs 5mg 10mg
35mg 70mg 52 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 05mg 1mg
2mg 5mg 45 allopurinol sodium solr 52 allopurinol tabs 100mg 300mg 52 allzital tabs 27 almotriptan malate tabs 32 ALOCRIL SOLN 42 alogliptin benzoate tabs 625mg 125mg
25mg 48 ALOGLIPTIN-METFORMIN HCL TABS 48 alogliptin-pioglitazone tabs 48 ALOMIDE SOLN 42 ALOSETRON HCL TABS 05mg 1mg 43 ALPHAGAN P SOLN 42 alprazolam er tb24 05mg 1mg 2mg 3mg
33 alprazolam intensol conc 33 alprazolam tabs 025mg 05mg 1mg 2mg
33 alprazolam tbdp 025mg 05mg 1mg 2mg
33 ALREX SUSP 41 ALTACAINE SOLN 42 ALTAFRIN SOLN 42 altavera tabs 46 ALTOPREV TB24 20mg 40mg 60mg 23 ALTRENO LOTN 61
ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 56 alyacen 135 tabs 46 alyq tabs 26 amabelz tabs 49 amantadine hcl caps 32 amantadine hcl syrp 32 amantadine hcl tabs 32 AMBISOME SUSR INTRAVENOUS 11 ambrisentan tabs 56 amcinonide crea 59 amcinonide lotn 59 amcinonide oint 59 amethia lo tabs 46 amethia tabs 46 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 38 amiloride-hydrochlorothiazide tabs 38 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 63 AMINOSYN-PF SOLN INTRAVENOUS 38 amiodarone hcl soln 25 amiodarone hcl tabs 100mg 200mg
400mg 25 AMITIZA CAPS 8mcg 24mcg 44 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 amlodipine besy-benazepril hcl caps 24 amlodipine besylate tabs 25mg 5mg
10mg 24 amlodipine besylate-valsartan tabs 24 amlodipine-atorvastatin tabs 24 amlodipine-olmesartan tabs 24 amlodipine-valsartan-hctz tabs 24 ammonium lactate crea 62 ammonium lactate lotn 62 amnesteem caps 10mg 20mg 40mg 62 AMONDYS 45 SOLN 53 amoxapine tabs 25mg 50mg 100mg
150mg 35 amoxicill-clarithro-lansopraz misc 43 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8
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amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 29 amphetamine sulfate tabs 5mg 10mg 30 amphetamine-dextroamphet er cp24 30 amphetamine-dextroamphetamine tabs 30 amphotericin b solr intravenous 11 ampicillin caps 8 ampicillin sodium solr 8 ampicillin sodium solr injection 1gm 125mg
8 ampicillin sodium solr intravenous 8 ampicillin-sulbactam sodium solr 8 ampicillin-sulbactam sodium solr injection 8 ampicillin-sulbactam sodium solr
intravenous 8 ANADROL-50 TABS 45 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 61 anastrozole tabs 14 ANDRODERM PT24 2mg24hr 4mg24hr
45 ANGELIQ TABS 49 ANORO ELLIPTA AEPB 19 antabuse tabs 250mg 500mg 26 ANTARA CAPS 30mg 90mg 23 anusol-hc crea 59 ANZEMET TABS 50mg 100mg 43 apap-caff-dihydrocodeine tabs 27 apexicon e crea 59 APIDRA SOLN 48 APIDRA SOLOSTAR SOPN 48 APLENZIN TB24 174mg 348mg 522mg 35 APOKYN SOCT 32 apraclonidine hcl soln 42 aprepitant caps 43 apri tabs 46 APRISO CP24 43 APTIOM TABS 200mg 400mg 600mg
800mg 30 APTIVUS CAPS 12 APTIVUS SOLN 12 ARALAST NP SOLR INTRAVENOUS
500mg 1000mg 56 aranelle tabs 46 ARANESP (ALBUMIN FREE) SOLN
25mcgml 40mcgml 22
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml 22
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml 22
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 22
ARCALYST SOLR 53 ARCAPTA NEOHALER CAPS 20 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 54 ARIKAYCE SUSP 8 aripiprazole soln 35 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 35 aripiprazole tbdp 10mg 15mg 35 ARISTADA INITIO PRSY 35 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 35
armodafinil tabs 50mg 150mg 200mg 250mg 30
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact 56
ARRANON SOLN 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 54 ARYMO ER TBEA 27 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 57 ascomp-codeine caps 27 asenapine maleate subl 25mg 5mg 10mg
35 ashlyna tabs 46 ASMANEX (120 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
110mcginh 56 ASMANEX (60 METERED DOSES) AEPB
56 ASMANEX HFA AERO 100mcgact
200mcgact 56
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ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 53 ASTAGRAF XL CP24 05mg 1mg 53 atazanavir sulfate caps 150mg 200mg
300mg 12 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 34 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 23 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 42 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 34 aubra eq tabs 46 AUGMENTIN SUSR 8 AURYXIA TABS 39 AUSTEDO TABS 6mg 9mg 12mg 34 AVANDIA TABS 2mg 4mg 48 AVAR CLEANSER EMUL 62 AVAR-E EMOLLIENT CREA 62 AVAR-E GREEN CREA 62 AVASTIN SOLN 14 AVC VAGINAL CREA 58 AVEED SOLN 45 aviane tabs 46 AVITA CREA 61 AVITA GEL 61 AVONEX KIT 34 AVONEX PEN AJKT 34 AVONEX PREFILLED PSKT 34 AVSOLA SOLR 52 AVYCAZ SOLR INTRAVENOUS 8 aygestin tabs 50 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 53 AZASITE SOLN 40 azathioprine sodium solr 53 azathioprine tabs 53 azelaic acid gel 62 azelastine hcl soln 005 01 015 42 azelastine-fluticasone susp 42 AZELEX CREA 62
AZITHROMYCIN PACK 8 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
B bacitracin oint 40 bacitracin solr 8 bacitracin-polymyxin b oint 40 bacitra-neomycin-polymyxin-hc oint 41 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 58 BAFIERTAM CPDR 34 balsalazide disodium caps 43 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 46 BANZEL SUSP 30 BANZEL TABS 200mg 400mg 30 BAQSIMI ONE PACK POWD 48 BAQSIMI TWO PACK POWD 48 BARACLUDE SOLN 12 BAVENCIO SOLN 14 BAXDELA SOLR INTRAVENOUS 8 BAXDELA TABS 8 BCG VACCINE INJ 14 BD INSULIN SYR ULTRAFINE II MISC 37 BD INSULIN SYRINGE MISC 37 BD INSULIN SYRINGE UF MISC 37 BD PEN NEEDLE ORIGINAL UF MISC 37 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 27 BELEODAQ SOLR 14 BELRAPZO SOLN 14 BELSOMRA TABS 33 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 15 BENDEKA SOLN 15 BENLYSTA SOAJ 53 BENLYSTA SOLR 53 BENLYSTA SOSY 53 BENZEPRO CREAMY WASH LIQD 58 BENZEPRO FOAMING CLOTHS MISC 58 benzhydrocodone-acetaminophen tabs 27 BENZNIDAZOLE TABS 125mg 100mg 11 benzoyl perox-hydrocortisone lotn 59
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BENZOYL PEROXIDE FORTE- HC LOTN 59
BENZOYL PEROXIDE GEL 58 benzoyl peroxide-erythromycin gel 58 benztropine mesylate soln 32 benztropine mesylate tabs 05mg 1mg
2mg 32 BEOVU SOLN 42 bepotastine besilate soln 42 BERINERT KIT INTRAVENOUS 21 beser lotn 59 BESIVANCE SUSP 40 BESPONSA SOLR 15 betamethasone dipropionate aug crea 59 betamethasone dipropionate aug gel 59 betamethasone dipropionate aug lotn 59 betamethasone dipropionate aug oint 59 betamethasone dipropionate crea 59 betamethasone dipropionate lotn 59 BETAMETHASONE DIPROPIONATE OINT
59 betamethasone sod phos amp acet susp 45 betamethasone valerate crea 59 betamethasone valerate foam 59 BETAMETHASONE VALERATE LOTN 59 BETAMETHASONE VALERATE OINT 59 BETASERON KIT 34 betaxolol hcl soln 42 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 20 BETHKIS NEBU 55 BETIMOL SOLN 025 05 42 BETOPTIC-S SUSP 42 BEVESPI AEROSPHERE AERO 19 BEVYXXA CAPS 40mg 80mg 21 bexarotene caps 15 BEXSERO SUSY 57 bicalutamide tabs 15 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICNU SOLR 15 BIDIL TABS 26 BIKTARVY TABS 12 bimatoprost soln 42 BINOSTO TBEF 52 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23
BIVIGAM SOLN 10gm100ml 57 BIVIGAM SOLN 5gm50ml 57 bleomycin sulfate solr 15 bleph-10 soln 40 blephamide sop oint 41 BLEPHAMIDE SUSP 41 BLINCYTO SOLR 15 blisovi 24 fe tabs 46 blisovi fe 1530 tabs 46 BONJESTA TBCR 43 BOOSTRIX SUSP 57 BORTEZOMIB SOLR 15 bosentan tabs 56 BOSULIF TABS 100mg 400mg 500mg 15 BOTOX SOLR 100unit 200unit 54 BP 10-1 EMUL 62 BRAFTOVI CAPS 50mg 75mg 15 briellyn tabs 46 BRILINTA TABS 60mg 90mg 21 BRIMONIDINE TARTRATE SOLN 02
015 42 brinzolamide susp 42 BRIVIACT SOLN 30 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 30 bromfenac sodium (once-daily) soln 41 bromocriptine mesylate caps 32 bromocriptine mesylate tabs 32 BROMSITE SOLN 41 BRONCHITOL CAPS 56 BROVANA NEBU 20 BRUKINSA CAPS 15 BRYHALI LOTN 59 budesonide cpep 45 budesonide er tb24 45 budesonide susp 025mg2ml 05mg2ml
1mg2ml 56 budesonide-formoterol fumarate aero 56 bumetanide soln 38 bumetanide tabs 05mg 1mg 2mg 38 BUNAVAIL FILM 34 bupap tabs 27 bupivacaine hcl (pf) soln 54 bupivacaine hcl soln 54 BUPIVACAINE IN DEXTROSE SOLN 54 bupivacaine spinal soln 54 bupivacaine-epinephrine (pf) soln 54 bupivacaine-epinephrine soln 54 buprenorphine hcl soln 27
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buprenorphine hcl subl 2mg 8mg 34 buprenorphine hcl-naloxone hcl film 34 buprenorphine hcl-naloxone hcl subl 34 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 27 bupropion hcl er (smoking det) tb12 35 bupropion hcl er (sr) tb12 100mg 150mg
200mg 35 bupropion hcl er (xl) tb24 150mg 300mg
450mg 35 bupropion hcl tabs 75mg 100mg 35 buspirone hcl tabs 5mg 10mg 33 buspirone hcl tabs 75mg 15mg 30mg 33 busulfan soln 15 butalbital-acetaminophen caps 27 butalbital-acetaminophen tabs 27 butalbital-apap-caff-cod caps 27 butalbital-apap-caffeine caps 27 butalbital-apap-caffeine tabs 27 butalbital-asa-caff-codeine caps 27 butalbital-aspirin-caffeine caps 27 butalbital-aspirin-caffeine tabs 27 butorphanol tartrate soln 1mgml 2mgml
10mgml 27 BUTRANS PTWK 27 BYDUREON BCISE AUIJ 48 BYDUREON PEN 48 BYETTA 10 MCG PEN SOPN 48 BYETTA 5 MCG PEN SOPN 48 BYLVAY (PELLETS) CPSP 200mcg
600mcg 44 BYLVAY CAPS 400mcg 1200mcg 44 BYNFEZIA PEN SOPN 51
C CABENUVA SUER 12 cabergoline tabs 32 CABLIVI KIT 22 CABOMETYX TABS 20mg 40mg 60mg 15 cafergot tabs 32 caffeine citrate soln 30 calcipotriene crea 62 calcipotriene oint 62 calcipotriene soln 62 calcipotriene-betameth diprop oint 59 calcipotriene-betameth diprop susp 59 calcitonin (salmon) soln 50 calcitrene oint 62 calcitriol caps 025mcg 05mcg 63
CALCITRIOL OINT 62 calcitriol soln 63 calcium acetate (phos binder) caps 39 calcium acetate (phos binder) tabs 39 CALCIUM GLUCONATE-NACL SOLN 39 CALQUENCE CAPS 15 camila tabs 46 camrese lo tabs 46 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 59 CAPLYTA CAPS 35 CAPRELSA TABS 100mg 300mg 15 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 26 CARAC CREA 62 CARAFATE SUSP 43 CARBAGLU TABS 37 carbamazepine chew 30 carbamazepine er cp12 100mg 200mg
300mg 30 carbamazepine er tb12 100mg 200mg
400mg 30 carbamazepine susp 30 carbamazepine tabs 30 carbidopa tabs 32 carbidopa-levodopa er tbcr 32 carbidopa-levodopa tabs 32 carbidopa-levodopa tbdp 32 carbidopa-levodopa-entacapone tabs 32 carbinoxamine maleate soln 14 carbinoxamine maleate tabs 14 carboplatin soln 15 carboprost tromethamine soln 50 CARDENE IV SOLN 24 CARDIZEM LA TB24 24 CARDURA XL TB24 4mg 8mg 22 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 15 CARNITOR SOLN 54 CARNITOR TABS 54 CAROSPIR SUSP 26 carteolol hcl soln 42
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cartia xt cp24 120mg 180mg 240mg 300mg 24
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg 23
carvedilol tabs 3125mg 625mg 125mg 25mg 23
caspofungin acetate solr intravenous 50mg 70mg 11
cataflam tabs 27 CAYSTON SOLR 56 caziant tabs 46 cefaclor caps 8 cefaclor er tb12 8 cefaclor susr 8 cefadroxil caps 8 cefadroxil susr 8 cefadroxil tabs 8 cefazolin sodium solr 8 cefazolin sodium solr injection 1gm 10gm
500mg 8 cefdinir caps 8 cefdinir susr 8 cefepime hcl solr injection 1gm 2gm 8 cefixime caps 8 cefixime susr 8 cefotaxime sodium solr 8 cefotetan disodium solr injection 1gm 2gm 8 cefoxitin sodium solr injection 8 cefoxitin sodium solr intravenous 1gm 2gm
8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 2gm 6gm 8 CEFTIN SUSR 8 ceftriaxone sodium solr injection 1gm 2gm
250mg 500mg 8 ceftriaxone sodium solr intravenous 8 cefuroxime axetil tabs 8 cefuroxime sodium solr injection 75gm
750mg 8 cefuroxime sodium solr intravenous 8 celecoxib caps 27 CELONTIN CAPS 30 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 41
CERDELGA CAPS 40 CEREZYME SOLR 40 CEROVEL LOTN 62 CESAMET CAPS 43 cetirizine hcl soln 14 CETRAXAL SOLN 40 CEVIMELINE HCL CAPS 20 CHANTIX CONTINUING MONTH PAK
TABS 20 CHANTIX STARTING MONTH PAK TABS
20 CHANTIX TABS 05mg 1mg 20 CHEMET CAPS 44 chloramphenicol sod succinate solr 9 chlordiazepoxide hcl caps 5mg 10mg
25mg 33 chlordiazepoxide-amitriptyline tabs 35 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 40 chloroprocaine hcl (pf) soln 54 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 38 chlorothiazide tabs 250mg 500mg 38 chlorpromazine hcl soln 35 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 35 chlorthalidone tabs 25mg 50mg 38 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 44 cholestyramine light pack 23 cholestyramine light powd 23 cholestyramine pack 23 cholestyramine powd 23 CHORIONIC GONADOTROPIN SOLR 50 ciclopirox gel 58 ciclopirox olamine crea 58 ciclopirox olamine susp 58 ciclopirox sham 58 ciclopirox soln 58 cidofovir soln 12 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 40 CIMDUO TABS 12 cimetidine hcl soln 43 cimetidine tabs 200mg 300mg 400mg
800mg 43 CIMZIA KIT 52
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CIMZIA PREFILLED KIT 52 CIMZIA STARTER KIT KIT 52 cinacalcet hcl tabs 30mg 60mg 90mg 50 CINQAIR SOLN 55 CINRYZE SOLR INTRAVENOUS 54 CIPRO HC SUSP 41 CIPRODEX SUSP 41 ciprofloxacin hcl soln (ophth) 40 CIPROFLOXACIN HCL SOLN (OTIC) 40 ciprofloxacin hcl tabs 9 ciprofloxacin in d5w soln 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 41 CIPROFLOXACIN-FLUOCINOLONE PF
SOLN 40 cisplatin soln 15 CISPLATIN SOLR 15 citalopram hydrobromide soln 35 citalopram hydrobromide tabs 10mg 20mg
40mg 35 citanest plain dental soln 54 cladribine soln 15 claravis caps 10mg 20mg 30mg 40mg 62 CLARINEX SYRP 14 CLARINEX-D 12 HOUR TB12 14 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 14 cleocin phosphate soln 9 cleocin solr 9 CLEOCIN SUPP 58 CLIMARA PRO PTWK 49 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
clindacin-p swab 58 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 58 clindamycin phosphate crea 58 clindamycin phosphate foam 58 clindamycin phosphate gel 58 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 58
clindamycin phosphate soln 9 58 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 58 CLINDESSE CREA 58 CLINIMIX EDEXTROSE (27510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42525) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (525) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (525) SOLN
INTRAVENOUS 38 clinisol sf soln intravenous 38 clobazam susp 30 clobazam tabs 10mg 20mg 30 clobetasol propionate crea 59 clobetasol propionate e crea 59 clobetasol propionate emulsion foam 59 clobetasol propionate foam 59 clobetasol propionate gel 59 clobetasol propionate liqd 60 clobetasol propionate lotn 60 clobetasol propionate oint 60 clobetasol propionate sham 60 clobetasol propionate soln 60 CLOBEX SHAM 60
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CLOBEX SPRAY LIQD 60 clocortolone pivalate crea 60 clocortolone pivalate pump crea 60 clodan sham 60 clofarabine soln 15 clomipramine hcl caps 25mg 50mg 75mg
35 clonazepam tabs 05mg 1mg 2mg 30 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 30 clonidine hcl (analgesia) soln 25 clonidine hcl er tb12 25 clonidine hcl tabs 01mg 02mg 03mg 25 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 25 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 33 clotrimazole crea 58 clotrimazole soln 58 clotrimazole troc 58 clotrimazole-betamethasone crea 58 clotrimazole-betamethasone lotn 58 clovique caps 44 clozapine tabs 25mg 50mg 100mg 200mg
35 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 35 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 27 colazal caps 43 COLCHICINE CAPS 52 colchicine tabs 52 colchicine-probenecid tabs 40 colesevelam hcl pack 23 colesevelam hcl tabs 23 colestipol hcl gran 23 colestipol hcl pack 23 colestipol hcl tabs 23 colistimethate sodium (cba) solr injection 9 colocort enem 60 COLY-MYCIN S SUSP 41 COMBIGAN SOLN 42 COMBIPATCH PTTW 49 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 15 COMETRIQ (140 MG DAILY DOSE) KIT 15 COMETRIQ (60 MG DAILY DOSE) KIT 15
COMPLERA TABS 12 compro supp 35 CONDYLOX GEL 62 CONSENSI TABS 24 constulose soln 37 COPIKTRA CAPS 15mg 25mg 15 CORDRAN TAPE 60 CORLANOR TABS 5mg 75mg 25 cortisone acetate tabs 45 CORTISPORIN CREA 60 CORTISPORIN OINT 60 COSELA SOLR 54 COSENTYX (300 MG DOSE) SOSY 62 COSENTYX SENSOREADY (300 MG)
SOAJ 62 COSENTYX SENSOREADY PEN SOAJ 62 COSENTYX SOSY 75mg05ml 150mgml
62 COTELLIC TABS 15 COTEMPLA XR-ODT TBED 86mg
173mg 259mg 30 CREON CPEP 40 CRESEMBA CAPS 11 CRESEMBA SOLR 11 CRINONE GEL 4 8 50 CRIXIVAN CAPS 200mg 400mg 12 cromolyn sodium conc 55 cromolyn sodium nebu 55 cromolyn sodium soln 42 crotan lotn 58 cryselle-28 tabs 46 CRYSVITA SOLN 10mgml 20mgml
30mgml 54 CUPRIMINE CAPS 44 CURITY GAUZE PADS 37 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 57
CUVPOSA SOLN 19 cyclafem 135 tabs 46 cyclafem 777 tabs 46 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 15 CYCLOPHOSPHAMIDE SOLN 1gm5ml
500mg25ml 15 cyclophosphamide solr 15
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 75
cycloserine caps 11 CYCLOSET TABS 48 cyclosporine caps 25mg 100mg 53 cyclosporine modified caps 25mg 50mg
100mg 53 cyclosporine modified soln 53 cyclosporine soln 53 cyproheptadine hcl syrp 14 cyproheptadine hcl tabs 14 CYRAMZA SOLN 100mg10ml
500mg50ml 15 cyred eq tabs 46 CYSTADANE POWD 54 CYSTADROPS SOLN 42 CYSTAGON CAPS 50mg 150mg 54 CYSTARAN SOLN 42 cytarabine (pf) soln 15 cytarabine soln 15 CYTOGAM INJ 57
D dacarbazine solr 15 dactinomycin solr 15 DAKLINZA TABS 30mg 60mg 90mg 12 dalfampridine er tb12 34 DALIRESP TABS 250mcg 500mcg 56 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 45 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 62 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 57 daptomycin solr intravenous 350mg 500mg
9 DARAPRIM TABS 11 darifenacin hydrobromide er tb24 75mg
15mg 63 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 DAYTRANA PTCH 10mg9hr 15mg9hr
20mg9hr 30mg9hr 30 DDAVP RHINAL TUBE SOLN 50 deblitane tabs 46 decadron elix 45
decadron tabs 5mg 75mg 45 decadron tabs 4mg 6mg 45 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 44 deferasirox tabs 90mg 180mg 360mg 44 deferasirox tbso 125mg 44 deferasirox tbso 250mg 500mg 44 deferiprone tabs 44 deferoxamine mesylate solr 44 DELESTROGEN OIL 49 DELSTRIGO TABS 12 deltasone tabs 45 delyla tabs 46 DELZICOL CPDR 43 demeclocycline hcl tabs 9 DEMEROL SOLN 25mg05ml 75mg15ml
100mg2ml 75mgml 27 DEMSER CAPS 22 DENAVIR CREA 58 DEPEN TITRATABS TABS 44 depo-estradiol oil 49 DEPO-MEDROL SUSP 45 DEPO-PROVERA SUSP 400mgml 50 DEPO-SUBQ PROVERA 104 SUSY 50 depo-testosterone soln 100mgml
200mgml 45 DERMOTIC OIL 41 DESCOVY TABS 12 desipramine hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 desloratadine tabs 14 desloratadine tbdp 14 desmopressin ace spray refrig soln 50 desmopressin acetate
soln 50 DESMOPRESSIN ACETATE SOLN 50 desmopressin acetate spray soln 50 DESMOPRESSIN ACETATE TABS 01mg
02mg 50 desogestrel-ethinyl estradiol tabs 46 DESONATE GEL 60 desonide crea 60 desonide gel 60 desonide lotn 60 desonide oint 60 desowen lotn 60 desoximetasone crea 005 025 60 desoximetasone gel 60
76 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
desoximetasone liqd 60 desoximetasone oint 005 025 60 desrx gel 60 DESVENLAFAXINE ER TB24 50mg
100mg 35 desvenlafaxine succinate er tb24 25mg
50mg 100mg 35 dexabliss tbpk 45 dexamethasone elix 45 dexamethasone intensol conc 45 dexamethasone sod phosphate pf soln 45 dexamethasone sodium phosphate soln 41
45 dexamethasone soln 45 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 45 dexamethasone tbpk 45 dexchlorpheniramine maleate soln 14 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 30
dexmethylphenidate hcl tabs 25mg 5mg 10mg 30
dexpak 10 day tbpk 45 dexpak 13 day tbpk 45 dexpak 6 day tbpk 45 dexrazoxane hcl solr 54 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 30 dextroamphetamine sulfate soln 30 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 30 DEXTROSE 10NACL 02 39 DEXTROSE 5NACL 0225 39 DEXTROSE IN LACTATED RINGERS
SOLN 39 DEXTROSE SOLN 38 dextrose soln intravenous 5 10 38 DEXTROSE-NACL SOLN INTRAVENOUS
39 DIACOMIT CAPS 250mg 500mg 30 DIACOMIT PACK 250mg 500mg 31 DIASTAT ACUDIAL GEL 10mg 20mg 31 DIASTAT PEDIATRIC GEL 31 diazepam conc 33 diazepam gel 25mg 10mg 20mg 31 diazepam soln 5mg5ml 5mgml 33 diazepam tabs 2mg 5mg 10mg 33 diazoxide susp 48
diclofenac potassium tabs 27 diclofenac sodium er tb24 27 diclofenac sodium gel 1 3 60 diclofenac sodium soln 41 diclofenac sodium tbec 27 diclofenac-misoprostol tbec 27 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 12 DIFFERIN CREA 62 DIFFERIN LOTN 62 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 60 diflorasone diacetate oint 60 diflunisal tabs 27 digitek tabs 0125mg 025mg 25 digox tabs 25 DIGOXIN ORAL SOLN 25 digoxin soln inj 25 digoxin tabs 125mcg 250mcg 25 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 31 dilantin infatabs chew 31 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 24 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 24
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 24
diltiazem hcl er cp12 60mg 90mg 120mg 24
diltiazem hcl er cp24 120mg 180mg 240mg 24
diltiazem hcl soln 24 diltiazem hcl solr 24 diltiazem hcl tabs 30mg 60mg 90mg
120mg 24 dilt-xr cp24 120mg 180mg 240mg 24 dimenhydrinate soln 43 dimethyl fumarate cpdr 34 dimethyl fumarate starter pack misc 34 DIPENTUM CAPS 43 diphen elix 14 di-phen elix 14 diphenhydramine hcl elix 14
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 77
diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 43 diphenoxylate-atropine tabs 43 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 57 dipyridamole tabs 25mg 50mg 75mg 26 disopyramide phosphate caps 100mg
150mg 25 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 38 divalproex sodium csdr 31 divalproex sodium er tb24 250mg 500mg 31 divalproex sodium tbec 125mg 250mg
500mg 31 DIVIGEL GEL 49 dobutamine hcl soln 21 DOBUTAMINE IN D5W SOLN 21 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 160mg8ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
25 dolishale tabs 46 donepezil hcl tabs 5mg 10mg 23mg 20 donepezil hcl tbdp 5mg 10mg 20 dopamine hcl soln 21 DOPAMINE IN D5W SOLN 21 DOPTELET TABS 22 DORYX MPC TBEC 9 dorzolamide hcl soln 42 dorzolamide hcl-timolol mal pf soln 42 dorzolamide hcl-timolol mal soln 42 dotti pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 49
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 35 doxepin hcl conc 35 doxepin hcl crea 61 doxepin hcl tabs 3mg 6mg 35 doxercalciferol caps 05mcg 1mcg 25mcg
63 DOXERCALCIFEROL SOLN 63 doxorubicin hcl liposomal inj 15 DOXORUBICIN HCL SOLN 15
doxorubicin hcl solr 15 doxy 100 solr intravenous 9 doxycycline hyclate caps 50mg 100mg 9 doxycycline hyclate tabs 20mg 75mg
100mg 150mg 9 doxycycline hyclate tbec 50mg 75mg
100mg 150mg 200mg 9 doxycycline monohydrate caps 50mg
75mg 100mg 150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 43 DRIZALMA SPRINKLE CSDR 35 dronabinol caps 25mg 5mg 10mg 43 droperidol soln 33 drospiren-eth estrad-levomefol tabs 46 drospirenone-ethinyl estradiol tabs 46 DROXIA CAPS 15 droxidopa caps 21 DUAKLIR PRESSAIR AEPB 19 DUAVEE TABS 49 DUEXIS TABS 27 DULERA AERO 56 duloxetine hcl cpep 20mg 30mg 40mg
60mg 35 DUOBRII LOTN 60 DUOPA SUSP 32 DUPIXENT SOPN 200mg114ml
300mg2ml 55 DUPIXENT SOSY 200mg114ml
300mg2ml 55 DURAMORPH SOLN 05mgml 1mgml 27 DUREZOL EMUL 41 DURYSTA IMPL 42 dutasteride caps 52 dutasteride-tamsulosin hcl caps 52 DUTOPROL TB24 23 dvorah tabs 27 dxevo 11-day tbpk 45 DYANAVEL XR SUER 30 DYSPORT SOLR 300unit 500unit 54
E ees 400 tabs 9 EASYGEL GEL 54 econazole nitrate crea 58 EDARBYCLOR TABS 26 EDLUAR SUBL 5mg 10mg 33
78 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 51 EGRIFTA SV SOLR 51 ELAPRASE SOLN 40 ELELYSO SOLR 40 ELEPSIA XR TB24 1000mg 1500mg 31 ELESTRIN GEL 49 eletriptan hydrobromide tabs 32 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 40 elixophyllin elix 63 ELLA TABS 46 ELLENCE SOLN 15 ELMIRON CAPS 54 eluryng ring 46 ELZONRIS SOLN 15 EMBEDA CPCR 27 EMCYT CAPS 15 EMEND SUSR 43 EMFLAZA SUSP 45 EMFLAZA TABS 6mg 18mg 30mg 36mg
45 EMGALITY (300 MG DOSE) SOSY 32 EMGALITY SOAJ 32 EMGALITY SOSY 32 emoquette tabs 46 EMPAVELI SOLN 54 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 32 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 26 enalaprilat inj 26 enalapril-hydrochlorothiazide tabs 26 ENBREL MINI SOCT 52 ENBREL SOLN 52 ENBREL SOLR 52 ENBREL SOSY 25mg05ml 50mgml 52 ENBREL SURECLICK SOAJ 52 ENDARI PACK 54 endocet tabs 27
ENDOMETRIN INST 50 ENGERIX-B SUSP 10mcg05ml 20mcgml
57 ENHERTU SOLR 15 enoxaparin sodium soln 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
enpresse-28 tabs 46 enskyce tabs 46 ENSPRYNG SOSY 54 ENSTILAR FOAM 60 entacapone tabs 33 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 26 ENTYVIO SOLR 44 enulose soln 37 ENVARSUS XR TB24 075mg 1mg 4mg53 EPCLUSA TABS 12 EPIDIOLEX SOLN 31 EPIDUO FORTE GEL 62 epifoam foam 60 epinastine hcl soln 42 epinephrine (anaphylaxis) soln 21 epinephrine soaj 21 EPINEPHRINE SOSY 21 EPIPEN 2-PAK SOAJ 21 EPIPEN JR 2-PAK SOAJ 21 epirubicin hcl soln 15 epitol tabs 31 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 26 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 22
epoprostenol sodium solr 56 eprosartan mesylate tabs 26 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 35 ERAXIS SOLR INTRAVENOUS 50mg
100mg 11 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 32 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 79
ERTACZO CREA 58 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 58 ery-tab tbec 9 ERYTHROCIN LACTOBIONATE SOLR
INTRAVENOUS 9 erythrocin stearate tabs 9 erythromycin base cpep 9 erythromycin base tabs 9 erythromycin base tbec 9 erythromycin ethylsuccinate susr 9 erythromycin ethylsuccinate tabs 9 erythromycin gel 58 erythromycin oint 40 erythromycin pads 58 erythromycin soln 58 ESBRIET CAPS 56 ESBRIET TABS 267mg 801mg 56 escitalopram oxalate soln 35 escitalopram oxalate tabs 5mg 10mg
20mg 35 esgic caps 27 esgic tabs 27 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 43 esomeprazole magnesium pack 10mg
20mg 40mg 43 esomeprazole sodium solr 43 ESOMEPRAZOLE STRONTIUM CPDR 43 estarylla tabs 46 estazolam tabs 1mg 2mg 33 estrace crea 49 estrace tabs 05mg 1mg 2mg 49 estradiol crea 49 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 49
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
estradiol tabs 10mcg 05mg 1mg 2mg 49 estradiol valerate oil 49 estradiol-norethindrone acet tabs 49 ESTRING RING 49 eszopiclone tabs 1mg 2mg 3mg 33
ethacrynic acid tabs 38 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 31 ethosuximide soln 31 ethynodiol diac-eth estradiol tabs 46 etodolac caps 27 etodolac er tb24 27 etodolac tabs 27 etonogestrel-ethinyl estradiol ring 46 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 EURAX CREA 58 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
EVAMIST SOLN 49 evekeo tabs 5mg 10mg 30 EVENITY SOSY 52 everolimus tabs 025mg 53 everolimus tabs 05mg 075mg 53 everolimus tabs 25mg 5mg 75mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 23 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 54 EXELDERM CREA 58 EXELDERM SOLN 58 exemestane tabs 15 EXJADE TBSO 125mg 250mg 500mg 44 EXONDYS 51 SOLN 500mg10ml
100mg2ml 54 EXSERVAN FILM 34 EXTAVIA KIT 34 EYLEA SOLN 42 EYLEA SOSY 42 ezetimibe tabs 23 ezetimibe-simvastatin tabs 23
F FABIOR FOAM 62 FABRAZYME SOLR 5mg 35mg 40 falmina tabs 46 famciclovir tabs 125mg 250mg 500mg 12 famotidine premixed soln 43 famotidine soln 43 famotidine susr 43 famotidine tabs 20mg 40mg 43
80 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg 35
FANAPT TITRATION PACK TABS 35 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 55 FASENRA SOSY 55 FASLODEX SOLN 15 fayosim tabs 46 febuxostat tabs 40mg 80mg 52 felbamate susp 31 felbamate tabs 400mg 600mg 31 felodipine er tb24 25mg 5mg 10mg 24 femynor tabs 46 fenofibrate caps 50mg 134mg 150mg 23 fenofibrate micronized caps 43mg 67mg
130mg 200mg 23 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 23 fenofibric acid cpdr 45mg 135mg 23 FENOFIBRIC ACID TABS 35mg 105mg 23 fenoprofen calcium caps 27 fenoprofen calcium tabs 27 fenortho caps 27 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 27 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 27
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg 27
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 27
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 27
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg 27
FERRIPROX SOLN 44 FERRIPROX TABS 500mg 1000mg 44 FERRIPROX TWICE-A-DAY TABS 44 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
35 FETZIMA TITRATION C4PK 35 fexmid tabs 20 FIBRICOR TABS 23 FINACEA FOAM 62 finasteride tabs 52 FINTEPLA SOLN 31
fioricet caps 27 fioricetcodeine caps 27 FIRAZYR SOLN 21 FIRDAPSE TABS 54 FIRMAGON (240 MG DOSE) SOLR 16 FIRMAGON SOLR 16 FIRVANQ SOLR 9 flac oil 41 FLAREX SUSP 41 flavoxate hcl tabs 63 FLEBOGAMMA DIF SOLN INTRAVENOUS
5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml 57
flecainide acetate tabs 50mg 100mg 150mg 25
FLOLIPID SUSP 20mg5ml 40mg5ml 23 FLOVENT DISKUS AEPB 50mcgblist
100mcgblist 250mcgblist 56 FLOVENT HFA AERO 110mcgact
220mcgact 56 FLOVENT HFA AERO 44mcgact 56 floxuridine solr 16 fluconazole in sodium chloride soln
intravenous 11 fluconazole susr 11 fluconazole tabs 11 flucytosine caps 250mg 500mg 11 fludarabine phosphate soln 16 fludarabine phosphate solr 16 fludrocortisone acetate tabs 45 flumazenil soln 34 flunisolide soln 41 fluocinolone acetonide body oil 60 fluocinolone acetonide crea 001 0025
60 fluocinolone acetonide oil 41 fluocinolone acetonide oint 60 fluocinolone acetonide scalp oil 60 fluocinolone acetonide soln 60 fluocinonide crea 60 fluocinonide emulsified base crea 60 FLUOCINONIDE GEL 60 fluocinonide oint 60 fluocinonide soln 60 FLUORITAB CHEW 025mg 05mg 1mg 54 FLUORITAB SOLN 54 fluorometholone susp 41 fluorouracil crea 5 62
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 81
fluorouracil crea 5 62 fluorouracil soln 16 62 fluorouracil soln 2 5 62 fluoxetine hcl (pmdd) tabs 10mg 20mg 35 fluoxetine hcl caps 10mg 20mg 40mg 35 fluoxetine hcl cpdr 35 fluoxetine hcl soln 35 fluoxetine hcl tabs 10mg 20mg 60mg 36 fluphenazine decanoate soln 36 fluphenazine hcl conc 36 fluphenazine hcl elix 36 fluphenazine hcl soln 36 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 36 flurandrenolide crea 60 flurandrenolide lotn 60 flurandrenolide oint 60 flurazepam hcl caps 15mg 30mg 33 flurbiprofen sodium soln 41 flurbiprofen tabs 27 flutamide caps 16 fluticasone propionate crea 60 fluticasone propionate lotn 60 fluticasone propionate oint 60 fluticasone propionate susp 41 fluticasone-salmeterol aepb 56 fluvastatin sodium caps 20mg 40mg 23 fluvastatin sodium er tb24 23 fluvoxamine maleate er cp24 100mg
150mg 36 fluvoxamine maleate tabs 25mg 50mg
100mg 36 FML FORTE SUSP 41 FML OINT 41 fomepizole soln 52 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 formoterol fumarate nebu 21 FORTEO SOPN 50 FOSAMAX PLUS D TABS 52 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 43 fosfomycin tromethamine pack 14 fosinopril sodium tabs 10mg 20mg 40mg
26 fosinopril sodium-hctz tabs 26 fosphenytoin sodium soln 31 FOSRENOL PACK 750mg 1000mg 39
FOTIVDA CAPS 089mg 134mg 16 FREAMINE HBC SOLN INTRAVENOUS 38 frovatriptan succinate tabs 32 FULPHILA SOSY 22 fulvestrant soln 16 furosemide soln 8mgml 10mgml 38 furosemide soln injection 38 FUROSEMIDE TABS 40mg 80mg 20mg38 FUZEON SOLR 12 fyavolv tabs 49 FYCOMPA SUSP 31 FYCOMPA TABS 31
G gabapentin caps 100mg 400mg 31 gabapentin soln 31 gabapentin tabs 600mg 800mg 31 GALAFOLD CAPS 54 galantamine hydrobromide er cp24 8mg
16mg 24mg 20 galantamine hydrobromide soln 20 galantamine hydrobromide tabs 4mg 8mg
12mg 20 GAMASTAN INJ 57 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 53 GAMMAGARD SD LESS IGA SOLR
INTRAVENOUS 5gm 10gm 57 GAMMAGARD SOLN INJECTION 57 GAMMAKED SOLN INJECTION 57 GAMMAPLEX SOLN INTRAVENOUS
10gm100ml 20gm200ml 5gm50ml 57 GAMMAPLEX SOLN INTRAVENOUS
10gm200ml 57 GAMUNEX-C SOLN INJECTION
10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml 57
ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 57 GARDASIL 9 SUSY 57 gatifloxacin soln 40 GATTEX KIT 44 gavilyte-c solr 44 gavilyte-g solr 44 gavilyte-h kit 44 gavilyte-n with flavor pack solr 44 GAVRETO CAPS 16 GAZYVA SOLN 16
82 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
gemcitabine hcl soln 16 gemcitabine hcl solr 16 gemfibrozil tabs 23 gemmily caps 46 generlac soln 37 gengraf caps 25mg 50mg 100mg 53 gengraf soln 53 GENOTROPIN MINIQUICK SOLR 02mg 51 GENOTROPIN MINIQUICK SOLR 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 51
GENOTROPIN SOLR 5mg 12mg 51 gentak oint 40 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 58 gentamicin sulfate oint 58 gentamicin sulfate soln 9 40 gentamicin sulfate soln injection 9 GENVOYA TABS 12 GEODON SOLR 36 gianvi tabs 46 GILENYA CAPS 025mg 05mg 34 GILOTRIF TABS 20mg 30mg 40mg 16 GIMOTI SOLN 44 GIVLAARI SOLN 54 GLASSIA SOLN INTRAVENOUS 56 glatiramer acetate sosy 20mgml 40mgml
34 glatopa sosy 20mgml 40mgml 34 glimepiride tabs 1mg 2mg 4mg 48 glipizide er tb24 25mg 5mg 10mg 48 glipizide tabs 5mg 10mg 48 glipizide-metformin hcl tabs 48 GLOPERBA SOLN 52 GLUCAGEN HYPOKIT SOLR 48 glucagon emergency kit 48 glyburide micronized tabs 15mg 3mg 6mg
48 glyburide tabs 125mg 25mg 5mg 48 glyburide-metformin tabs 48 glycate tabs 19 glycopyrrolate pf sosy 19 glycopyrrolate soln 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 61 GLYXAMBI TABS 48 GOLYTELY SOLR 44 GONITRO PACK 26
granisetron hcl soln 43 granisetron hcl tabs 43 GRANIX SOLN 480mcg16ml 300mcgml
22 GRANIX SOSY 300mcg05ml
480mcg08ml 22 GRASTEK SUBL 54 griseofulvin microsize susp 11 griseofulvin microsize tabs 11 griseofulvin ultramicrosize tabs 11 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 34 guanfacine hcl tabs 1mg 2mg 25 GUANIDINE HCL TABS 20 gynazole-1 crea 58
H HAEGARDA SOLR 2000unit 3000unit 54 hailey 24 fe tabs 46 halcinonide crea 60 halobetasol propionate crea 60 HALOBETASOL PROPIONATE FOAM 60 halobetasol propionate oint 60 HALOG CREA 60 HALOG OINT 60 haloperidol decanoate soln 36 haloperidol lactate conc 36 haloperidol lactate soln 36 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 36 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 57 heparin (porcine) in nacl soln 21 HEPARIN SOD (PORCINE) IN D5W SOLN
21 heparin sodium (porcine) pf soln 21 heparin sodium (porcine) soln 1000unitml
5000unitml 10000unitml 20000unitml 21
HEPATAMINE SOLN INTRAVENOUS 38 HEPLISAV-B SOLN 57 HERCEPTIN HYLECTA SOLN 16 HERCEPTIN SOLR 150mg 440mg 16 HERZUMA SOLR 150mg 420mg 16 HETLIOZ CAPS 33 HETLIOZ LQ SUSP 33 HEXALEN CAPS 16 HIBERIX SOLR 57
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 83
HORIZANT TBCR 300mg 600mg 31 HUMALOG JUNIOR KWIKPEN SOPN 48 HUMALOG KWIKPEN SOPN 100unitml
200unitml 48 HUMALOG MIX 5050 KWIKPEN SUPN 48 HUMALOG MIX 5050 SUSP 48 HUMALOG MIX 7525 KWIKPEN SUPN 48 HUMALOG MIX 7525 SUSP 48 HUMALOG SOCT 48 HUMALOG SOLN 48 humatin caps 11 HUMATROPE SOLR 5mg 6mg 12mg
24mg 51 HUMIRA PEDIATRIC CROHNS START
PSKT 52 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 52 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 52 HUMIRA PEN-PEDIATRIC UC START
PNKT 52 HUMIRA PEN-PSUVADOL HS START
PNKT 52 HUMIRA PEN-PSORUVEIT STARTER
PNKT 52 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 52
HUMULIN 7030 KWIKPEN SUPN 48 HUMULIN 7030 SUSP 48 HUMULIN N KWIKPEN SUPN 48 HUMULIN N SUSP 48 HUMULIN R SOLN 48 HUMULIN R U-500 (CONCENTRATED)
SOLN 48 HUMULIN R U-500 KWIKPEN SOPN 48 hydralazine hcl soln 25 hydralazine hcl tabs 10mg 25mg 50mg
100mg 25 hydrochlorothiazide caps 38 hydrochlorothiazide tabs 125mg 25mg
50mg 38 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 27 hydrocodone-acetaminophen soln 27 hydrocodone-acetaminophen tabs 27 hydrocodone-ibuprofen tabs 27 hydrocortisone (perianal) crea 1 25 60 hydrocortisone ace-pramoxine crea 61
hydrocortisone butyr lipo base crea 60 hydrocortisone butyrate crea 60 hydrocortisone butyrate lotn 60 HYDROCORTISONE BUTYRATE OINT 60 hydrocortisone butyrate soln 60 hydrocortisone crea 1 25 60 hydrocortisone enem 60 hydrocortisone lotn 60 hydrocortisone oint 1 25 60 hydrocortisone tabs 5mg 10mg 20mg 45 hydrocortisone valerate crea 60 hydrocortisone valerate oint 60 HYDROCORTISONE-ACETIC ACID SOLN
41 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 28 hydromorphone hcl liqd 28 hydromorphone hcl pf soln 50mg5ml
10mgml 28 HYDROMORPHONE HCL SOLN 1mgml
2mgml 28 hydromorphone hcl tabs 2mg 4mg 8mg 28 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 50 hydroxyprogesterone caproate soln 50 hydroxyurea caps 16 hydroxyzine hcl soln 33 hydroxyzine hcl syrp 33 hydroxyzine hcl tabs 33 hydroxyzine pamoate caps 33 HYPERHEP B SOLN 57 HYPERRAB SD SOLN 57 HYQVIA KIT 57
I IBANDRONATE SODIUM SOLN 52 ibandronate sodium tabs 52 IBRANCE CAPS 75mg 100mg 125mg 16 IBRANCE TABS 75mg 100mg 125mg 16 ibu tabs 28 ibudone tabs 28 ibuprofen lysine soln 28 ibuprofen susp 28 ibuprofen tabs 28 ibutilide fumarate soln 25 icatibant acetate soln 21 iclevia tabs 46 ICLUSIG TABS 10mg 15mg 30mg 45mg
16
84 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
icosapent ethyl caps 23 IDAMYCIN PFS SOLN 16 idarubicin hcl soln 16 IDHIFA TABS 50mg 100mg 16 ifosfamide soln 16 IFOSFAMIDE SOLR 16 ILARIS SOLN 28 ILEVRO SUSP 41 ILUMYA SOSY 62 ILUVIEN IMPL 41 imatinib mesylate tabs 16 IMBRUVICA CAPS 70mg 140mg 16 IMBRUVICA TABS 140mg 280mg 420mg
560mg 16 IMFINZI SOLN 500mg10ml 120mg24ml
16 imipenem-cilastatin solr intravenous 9 imipramine hcl tabs 10mg 25mg 50mg 36 imipramine pamoate caps 75mg 100mg
125mg 150mg 36 imiquimod crea 375 5 62 IMIQUIMOD PUMP CREA 62 IMOGAM RABIES-HT SOLN 57 IMOVAX RABIES INJ 57 IMPAVIDO CAPS 11 IMVEXXY MAINTENANCE PACK INST
4mcg 10mcg 49 IMVEXXY STARTER PACK INST 4mcg
10mcg 49 INBRIJA CAPS 33 incassia tabs 46 INCRELEX SOLN 51 INCRUSE ELLIPTA AEPB 19 indapamide tabs 125mg 25mg 38 indocin supp 28 INDOCIN SUSP 28 indomethacin caps 28 INDOMETHACIN CAPS 20mg 28 indomethacin er cpcr 28 indomethacin sodium solr 28 INFANRIX SUSP 57 INFLECTRA SOLR INTRAVENOUS 52 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 34 INGREZZA CPPK 34 INLYTA TABS 1mg 5mg 16 INNOPRAN XL CP24 80mg 120mg 23 INQOVI TABS 16 INREBIC CAPS 16
INSULIN ASP PROT amp ASP FLEXPEN SUPN 48
INSULIN ASPART FLEXPEN SOPN 48 INSULIN ASPART PENFILL SOCT 48 INSULIN ASPART PROT amp ASPART SUSP
48 INSULIN ASPART SOLN 48 INSULIN LISPRO (1 UNIT DIAL) SOPN 48 INSULIN LISPRO SOLN 48 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 38 INTRALIPID EMUL INTRAVENOUS
20gm100ml 38 INTRAROSA INST 45 INTRON A SOLN 10muml 6000000unitml
16 INTRON A SOLR 10mu 18mu 50mu 16 introvale tabs 46 INVEGA SUSTENNA SUSY 39mg025ml
36 INVEGA SUSTENNA SUSY 78mg05ml
117mg075ml 234mg15ml 156mgml 36
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml 36
INVELTYS SUSP 41 INVIRASE CAPS 12 INVIRASE TABS 12 INVOKAMET TABS 48 INVOKAMET XR TB24 48 INVOKANA TABS 100mg 300mg 48 IONOSOL-MB IN D5W SOLN
INTRAVENOUS 39 IOPIDINE SOLN 42 IPOL INJ 57 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 21 irbesartan tabs 75mg 150mg 300mg 26 irbesartan-hydrochlorothiazide tabs 26 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isibloom tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 85
ISOLYTE-P IN D5W SOLN INTRAVENOUS 39
ISOLYTE-S SOLN INTRAVENOUS 39 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 21 isosorbide dinitrate er tbcr 26 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 26 isosorbide mononitrate er tb24 26 isosorbide mononitrate er tb24 30mg 60mg
26 isosorbide mononitrate tabs 10mg 20mg 26 isotretinoin caps 10mg 20mg 30mg 40mg
62 isradipine caps 25mg 5mg 24 ISTURISA TABS 1mg 5mg 10mg 54 itraconazole caps 11 ITRACONAZOLE SOLN 11 ivermectin crea 58 ivermectin lotn 58 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 57
J JADENU SPRINKLE PACK 90mg 180mg
360mg 44 JADENU TABS 90mg 360mg 44 JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16 jantoven tabs 1mg 2mg 25mg 3mg 4mg
5mg 6mg 75mg 10mg 21 JARDIANCE TABS 10mg 25mg 48 jasmiel tabs 46 JEMPERLI SOLN 16 JENTADUETO TABS 48 JENTADUETO XR TB24 48 jinteli tabs 49 JOLIVETTE TABS 46 juleber tabs 46 JULUCA TABS 12 junel 1530 tabs 46 junel 120 tabs 46 junel fe 1530 tabs 46 junel fe 120 tabs 46 junel fe 24 tabs 46
JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg 23
JYNARQUE TABS 15mg 30mg 39 JYNARQUE TBPK 39
K KADCYLA SOLR 100mg 160mg 16 KADIAN CP24 28 kaitlib fe chew 46 KALYDECO PACK 25mg 50mg 75mg 56 KALYDECO TABS 56 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 40 kariva tabs 46 KAZANO TABS 48 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-033 MEQ 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 40-5-09 MEQ 39 KCL-LACTATED RINGERS-D5W SOLN
INTRAVENOUS 39 KEDRAB SOLN 57 kelnor 135 tabs 46 kelnor 150 tabs 46 KENALOG SUSP 45 KEPIVANCE SOLR 61 keralyt sham 62 KESIMPTA SOAJ 54 ketoconazole crea 58 ketoconazole foam 58 ketoconazole sham 58 ketoconazole tabs 11 ketodan foam 58 ketoprofen caps 28 ketoprofen er cp24 28 ketorolac tromethamine soln 28 41 ketorolac tromethamine soln 04 05 41 ketorolac tromethamine tabs 28 KEVEYIS TABS 54 KEVZARA SOAJ 150mg114ml
200mg114ml 53 KEVZARA SOSY 150mg114ml
200mg114ml 53 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 52 KHEDEZLA TB24 50mg 100mg 36 KIMYRSA SOLR 9
86 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
KINERET SOSY 53 KINRIX SUSP 57 kionex susp 39 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (200 MG DOSE) TBPK
16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KITABIS PAK NEBU 56 KLISYRI OINT 62 KLOR-CON 10 TBCR 39 klor-con m10 tbcr 39 klor-con m15 tbcr 39 klor-con m20 tbcr 39 klor-con pack 39 klor-con sprinkle cpcr 8meq 10meq 39 KLOR-CON TBCR 39 KORLYM TABS 48 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 37 K-TAB TBCR 39 kurvelo tabs 46 KUVAN PACK 100mg 500mg 54 KUVAN TABS 54 KYNAMRO SOSY 23 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 33 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 LACRISERT INST 42 LACTATED RINGERS SOLN 39 54 LACTIC ACID LOTN 62 lactulose encephalopathy soln 37 lactulose pack 38 lactulose soln 38 LAMICTAL XR KIT 31 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 31
lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg 31
lamotrigine kit 31 lamotrigine starter kit-blue kit 31 lamotrigine starter kit-green kit 31 lamotrigine starter kit-orange kit 31 lamotrigine tabs 25mg 100mg 150mg
200mg 31 lamotrigine tbdp 25mg 50mg 100mg
200mg 31 LANOXIN PEDIATRIC SOLN 25 LANOXIN TABS 625mcg 25 lansoprazole cpdr 15mg 30mg 43 lansoprazole tbdd 15mg 30mg 43 lanthanum carbonate chew 500mg 750mg
1000mg 39 LANTUS SOLN 48 LANTUS SOLOSTAR SOPN 49 lapatinib ditosylate tabs 16 larin 1530 tabs 46 larin 120 tabs 46 larin fe 1530 tabs 46 larin fe 120 tabs 46 larissia tabs 46 LARTRUVO SOLN 190mg19ml
500mg50ml 16 LASTACAFT SOLN 42 latanoprost soln 42 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 36 LAYOLIS FE CHEW 46 LAZANDA SOLN 100mcgact 300mcgact
400mcgact 28 ledipasvir-sofosbuvir tabs 12 leena tabs 46 leflunomide tabs 10mg 20mg 53 LEMTRADA SOLN 34 LENVIMA (10 MG DAILY DOSE) CPPK 16 LENVIMA (12 MG DAILY DOSE) CPPK 16 LENVIMA (14 MG DAILY DOSE) CPPK 16 LENVIMA (18 MG DAILY DOSE) CPPK 16 LENVIMA (20 MG DAILY DOSE) CPPK 16 LENVIMA (24 MG DAILY DOSE) CPPK 16 LENVIMA (4 MG DAILY DOSE) CPPK 16 LENVIMA (8 MG DAILY DOSE) CPPK 17 lessina tabs 46 LETAIRIS TABS 5mg 10mg 56 letrozole tabs 17 leucovorin calcium soln 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 87
leucovorin calcium solr 52 leucovorin calcium tabs 5mg 10mg 15mg
25mg 52 LEUKERAN TABS 17 LEUKINE SOLR 22 leuprolide acetate kit 17 levalbuterol hcl nebu 125mg05ml
031mg3ml 063mg3ml 125mg3ml 21 levalbuterol tartrate aero 21 LEVEMIR FLEXTOUCH SOPN 49 LEVEMIR SOLN 49 levetiracetam er tb24 500mg 750mg 31 levetiracetam in nacl soln 31 levetiracetam soln 31 levetiracetam tabs 250mg 500mg 750mg
1000mg 31 levobunolol hcl soln 42 levocarnitine soln 54 LEVOCARNITINE TABS 54 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 40 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 52 levoleucovorin calcium solr 52 levonest tabs 46 levonorgest-eth est amp eth est tabs 47 levonorgest-eth estrad 91-day tabs 47 levonorgestrel-ethinyl estrad tabs 47 levonorg-eth estrad triphasic tabs 46 levora 01530 (28) tabs 47 levorphanol tartrate tabs 2mg 3mg 28 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEVOTHYROXINE SODIUM SOLR 51 levothyroxine sodium tabs 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEXETTE FOAM 60 LEXIVA SUSP 12 LIALDA TBEC 43 LIBTAYO SOLN 17 lidocaine hcl (cardiac) pf sosy 25 lidocaine hcl (cardiac) sosy 25 lidocaine hcl (pf) soln 54 LIDOCAINE HCL CREA 61 lidocaine hcl lotn 61 lidocaine hcl soln 42 54 61 lidocaine hcl urethralmucosal gel 61 lidocaine hcl urethralmucosal prsy 61 LIDOCAINE IN D5W SOLN 25 lidocaine in dextrose soln 54 lidocaine oint 61 lidocaine ptch 61 lidocaine viscous hcl soln 42 lidocaine-epinephrine soln 54 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 61 LIDOCAINE-HYDROCORTISONE ACE KIT
61 lidocaine-prilocaine crea 61 lidocaine-tetracaine crea 61 LIDOCORT CREA 61 lidopin crea 61 LIDO-SORB LOTN 61 LIDOZION LOTN 61 lincomycin hcl soln 9 lindane sham 58 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 LINZESS CAPS 72mcg 145mcg 290mcg
44 liothyronine sodium soln 51 liothyronine sodium tabs 5mcg 25mcg
50mcg 51 LIPODOX 50 INJ 17 lisinopril tabs 25mg 5mg 10mg 20mg
30mg 40mg 26 lisinopril-hydrochlorothiazide tabs 26 LITHIUM CARBONATE CAPS 300mg
150mg 600mg 36 lithium carbonate er tbcr 300mg 450mg 36 lithium carbonate tabs 36
88 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
LITHIUM SOLN 36 LITHOSTAT TABS 38 LIVALO TABS 1mg 2mg 4mg 23 LO LOESTRIN FE TABS 47 lodine tabs 28 loestrin 1530 (21) tabs 47 loestrin 120 (21) tabs 47 loestrin fe 1530 tabs 47 loestrin fe 120 tabs 47 LOKELMA PACK 5gm 10gm 39 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 17 loperamide hcl caps 43 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 49 lorazepam intensol conc 33 LORAZEPAM SOLN 4mgml 2mgml 33 lorazepam tabs 05mg 1mg 2mg 33 LORBRENA TABS 25mg 100mg 17 lorcet hd tabs 28 lorcet plus tabs 28 lorcet tabs 28 lortab elix 28 loryna tabs 47 lorzone tabs 375mg 750mg 20 losartan potassium tabs 25mg 50mg
100mg 26 losartan potassium-hctz tabs 26 LOTEMAX GEL 41 LOTEMAX OINT 41 LOTEMAX SUSP 41 loteprednol etabonate susp 41 lovastatin tabs 10mg 20mg 40mg 23 LOVENOX SOLN 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
low-ogestrel tabs 47 loxapine succinate caps 5mg 10mg 25mg
50mg 36 lubiprostone caps 8mcg 24mcg 44 LUCEMYRA TABS 34 LUCENTIS SOLN 03mg005ml
05mg005ml 42 LUCENTIS SOSY 03mg005ml
05mg005ml 42 LUDENT CHEW 025mg 05mg 1mg 54 LULICONAZOLE CREA 58 LUMAKRAS TABS 17
LUMIGAN SOLN 42 LUMIZYME SOLR 40 LUMOXITI SOLR 17 LUPANETA PACK KIT 17 LUPKYNIS CAPS 53 LUPRON DEPOT (1-MONTH) KIT 17 LUPRON DEPOT (3-MONTH) KIT 17 LUPRON DEPOT (4-MONTH) KIT 17 LUPRON DEPOT (6-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 17 LUPRON DEPOT-PED (3-MONTH) KIT 17 lutera tabs 47 LUZU CREA 58 lyleq tabs 47 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 50
LYNPARZA CAPS 17 LYNPARZA TABS 100mg 150mg 17 LYSODREN TABS 17 lyza tabs 47
M mafenide acetate pack 58 magnesium sulfate in d5w soln 39 magnesium sulfate soln 31 magnesium sulfate soln injection 50 31 MAGNESIUM SULFATE SOLN
INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml 31
MAKENA SOAJ 50 malathion lotn 58 MANNITOL SOLN 39 maprotiline hcl tabs 25mg 50mg 75mg 36 MARGENZA SOLN 17 marlissa tabs 47 MARPLAN TABS 36 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 24 MAVENCLAD (10 TABS) TBPK 53 MAVENCLAD (4 TABS) TBPK 53 MAVENCLAD (5 TABS) TBPK 53 MAVENCLAD (6 TABS) TBPK 53 MAVENCLAD (7 TABS) TBPK 53 MAVENCLAD (8 TABS) TBPK 53
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 89
MAVENCLAD (9 TABS) TBPK 53 MAVYRET TABS 12 MAXIDEX SUSP 41 MAYZENT STARTER PACK TBPK 34 MAYZENT TABS 025mg 2mg 34 MENAPHOSMBHYO1 TABS 14 meclizine hcl tabs 43 meclofenamate sodium caps 28 MEDROL TABS 45 medroxyprogesterone acetate susp 50 medroxyprogesterone acetate susy 50 medroxyprogesterone acetate tabs 25mg
5mg 10mg 50 mefenamic acid caps 28 mefloquine hcl tabs 11 megestrol acetate susp 17 50 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 47 meloxicam caps 28 meloxicam tabs 28 melphalan hcl solr 17 memantine hcl er cp24 34 memantine hcl soln 34 memantine hcl tabs 5mg 10mg 34 MENACTRA INJ 57 menest tabs 03mg 0625mg 125mg 50 MENOSTAR PTWK 50 MENQUADFI INJ 57 MENTAX CREA 58 MENVEO SOLR 57 meperidine hcl soln 50mg5ml 25mgml
50mgml 100mgml 28 meperidine hcl tabs 50mg 100mg 28 meprobamate tabs 33 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 47 mesalamine cpdr 43 mesalamine enem 43 mesalamine er cp24 43 mesalamine supp 43 mesalamine tbec 12gm 800mg 43 mesalamine-cleanser kit 43 mesna soln 54 MESNEX TABS 54 MESTINON SOLN 20 metadate er tbcr 30
metaproterenol sulfate syrp 21 metaproterenol sulfate tabs 10mg 20mg 21 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 49 metformin hcl tabs 500mg 850mg 1000mg
49 methadone hcl conc 28 methadone hcl intensol conc 28 methadone hcl soln 5mg5ml 10mg5ml
10mgml 28 methadone hcl tabs 5mg 10mg 28 methamphetamine hcl tabs 30 methazolamide tabs 25mg 50mg 42 methenamine hippurate tabs 14 METHENAMINE MANDELATE TABS 14 methergine tabs 50 methimazole tabs 5mg 10mg 51 methitest tabs 45 methocarbamol soln 20 methocarbamol tabs 20 methotrexate sodium (pf) soln 17 methotrexate sodium soln 17 methotrexate sodium solr 17 methotrexate tabs 17 methoxsalen rapid caps 62 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 39 methyldopa tabs 250mg 500mg 25 methyldopa-hydrochlorothiazide tabs 25 methylergonovine maleate soln 50 methylergonovine maleate tabs 50 methylphenidate hcl chew 25mg 5mg
10mg 30 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 30 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 30 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 30
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 30
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 30
methylphenidate hcl soln 5mg5ml 10mg5ml 30
90 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
methylphenidate hcl tabs 5mg 10mg 20mg 30
methylprednisolone acetate susp 45 methylprednisolone sodium succ solr 45 methylprednisolone tabs 4mg 8mg 16mg
32mg 45 methylprednisolone tbpk 45 methyltestosterone caps 45 metoclopramide hcl soln 44 metoclopramide hcl tabs 5mg 10mg 44 metoclopramide hcl tbdp 5mg 10mg 44 metolazone tabs 25mg 5mg 10mg 39 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 24 metoprolol tartrate soct 24 metoprolol tartrate soln 24 metoprolol tartrate tabs 25mg 50mg
100mg 24 metoprolol tartrate tabs 375mg 75mg 24 metoprolol-hydrochlorothiazide tabs 24 metronidazole caps 11 metronidazole crea 58 metronidazole gel 58 metronidazole in nacl soln 11 metronidazole in nacl soln intravenous 11 metronidazole lotn 58 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
25 mibelas 24 fe chew 47 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 58 miconazole-zinc oxide-petrolat oint 58 micort-hc crea 60 microgestin 1530 tabs 47 microgestin 120 tabs 47 microgestin fe 1530 tabs 47 microgestin fe 120 tabs 47 midazolam hcl (pf) soln 33 midazolam hcl soln 33 midazolam hcl syrp 33 midodrine hcl tabs 25mg 5mg 10mg 21 miglitol tabs 25mg 50mg 100mg 49 miglustat caps 40 mili tabs 47 millipred dp tbpk 45 millipred tabs 45
milrinone lactate in dextrose soln 25 milrinone lactate soln 25 mimvey lo tabs 50 mimvey tabs 50 minitran pt24 01mghr 02mghr 04mghr
06mghr 26 minocycline hcl caps 50mg 75mg 100mg 9 minocycline hcl er tb24 45mg 55mg 65mg
80mg 90mg 105mg 115mg 135mg 9 minocycline hcl tabs 50mg 75mg 100mg 9 minoxidil tabs 25mg 10mg 25 MIRCERA SOSY 30mcg03ml
50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml 22
mirtazapine tabs 75mg 15mg 30mg 45mg 36
mirtazapine tbdp 15mg 30mg 45mg 36 misoprostol tabs 100mcg 200mcg 43 MITIGARE CAPS 52 mitigo soln 28 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 57 modafinil tabs 100mg 200mg 30 moexipril hcl tabs 75mg 15mg 26 molindone hcl tabs 5mg 10mg 25mg 36 mometasone furoate crea 60 mometasone furoate oint 60 mometasone furoate soln 60 mometasone furoate susp 41 mondoxyne nl caps 75mg 100mg 9 MONJUVI SOLR 17 MONONESSA TABS 47 montelukast sodium chew 4mg 5mg 55 montelukast sodium pack 55 montelukast sodium tabs 55 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 28 morphine sulfate (pf) soln 4mgml 10mgml
28 MORPHINE SULFATE (PF) SOLN
INTRAVENOUS 28 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 28 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 28
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 91
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 28
MORPHINE SULFATE SOLN 28 MORPHINE SULFATE SOLN 10mg5ml
20mg5ml 28 MORPHINE SULFATE SOLN INJECTION
2mgml 4mgml 10mgml 28 MORPHINE SULFATE SOLN
INTRAVENOUS 28 morphine sulfate tabs 15mg 30mg 28 MOVANTIK TABS 125mg 25mg 44 MOXEZA SOLN 41 moxifloxacin hcl (2x day) soln 41 moxifloxacin hcl in nacl soln intravenous 10 moxifloxacin hcl soln 41 moxifloxacin hcl tabs 10 MULPLETA TABS 22 MULTAQ TABS 25 MULTIVITAMINFLUORIDE CHEW 63 MULTI-VITAMINFLUORIDE SOLN 63 MULTI-VITAMINFLUORIDEIRON SOLN
63 mupirocin calcium crea 58 mupirocin oint 59 MUSTARGEN SOLR 17 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17 MVC-FLUORIDE CHEW 64 MYALEPT SOLR 54 MYCAPSSA CPDR 51 mycophenolate mofetil caps 53 mycophenolate mofetil hcl solr 53 mycophenolate mofetil susr 53 mycophenolate mofetil tabs 53 mycophenolate sodium tbec 180mg 360mg
53 MYDAYIS CP24 30 MYFEMBREE TABS 50 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 62 MYRBETRIQ TB24 25mg 50mg 63 MYTESI TBEC 43
N NABI-HB SOLN 57 nabumetone tabs 28 N-ACETYL-L-CYSTEINE CAPS 38 nadolol tabs 20mg 40mg 80mg 24 nadolol-bendroflumethiazide tabs 24
nafcillin sodium solr 10 nafcillin sodium solr injection 10 nafcillin sodium solr intravenous 10 NAFRINSE CHEW 54 NAFRINSE DROPS SOLN 54 naftifine hcl crea 59 naftifine hcl gel 59 NAFTIN GEL 59 NAGLAZYME SOLN 40 nalbuphine hcl soln 28 nalfon tabs 28 nalocet tabs 28 naloxone hcl soaj 34 naloxone hcl soct 34 naloxone hcl soln 34 naloxone hcl sosy 34 naltrexone hcl tabs 35 NAMENDA XR TITRATION PACK CP24 34 NAPRELAN TB24 28 naproxen sodium er tb24 28 naproxen sodium tabs 28 naproxen susp 28 naproxen tabs 28 naproxen tbec 28 naproxen-esomeprazole tbec 28 naratriptan hcl tabs 32 NARCAN LIQD 35 NATACYN SUSP 41 NATAZIA TABS 47 nateglinide tabs 60mg 120mg 49 NATPARA CART 25mcg 50mcg 75mcg
100mcg 50 NATROBA SUSP 59 NAYZILAM SOLN 31 NEBUPENT SOLR 11 necon 0535 (28) tabs 47 NECON 777 TABS 47 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 36 nembutal soln 33 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 41 neomycin-polymyxin b gu soln 59 neomycin-polymyxin-dexameth oint 41 neomycin-polymyxin-dexameth susp 41 neomycin-polymyxin-gramicidin soln 41 neomycin-polymyxin-hc soln 41 neomycin-polymyxin-hc susp 41 neo-polycin hc oint 41
92 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
neo-polycin oint 41 neo-synalar crea 60 NEPHRAMINE SOLN INTRAVENOUS 38 NERLYNX TABS 17 NEULASTA ONPRO PSKT 22 NEULASTA SOSY 22 NEUPOGEN SOLN 480mcg16ml
300mcgml 22 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 22 NEVANAC SUSP 41 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 40 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 23 niacor tabs 23 nicardipine hcl caps 20mg 30mg 24 nicardipine hcl soln 24 NICOTROL INHA 20 NICOTROL NS SOLN 20 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 47 nilutamide tabs 17 nimodipine caps 24 NINLARO CAPS 23mg 3mg 4mg 17 nisoldipine er tb24 85mg 17mg 20mg
255mg 30mg 34mg 40mg 24 nitazoxanide tabs 11 nitisinone caps 2mg 5mg 10mg 54 nitro-bid oint 26 NITRO-DUR PT24 03mghr 08mghr 26 NITROFURANTOIN MACROCRYSTAL
CAPS 14 NITROFURANTOIN MONOHYD MACRO
CAPS 14 nitrofurantoin susp 14 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 26 nitroglycerin soln 26 nitroglycerin subl 03mg 04mg 06mg 26 nitropress soln 25 nitroprusside sodium soln 25 NITYR TABS 2mg 5mg 10mg 54
NIVESTYM SOLN 480mcg16ml 300mcgml 22
NIVESTYM SOSY 300mcg05ml 480mcg08ml 22
nizatidine caps 150mg 300mg 43 nizatidine soln 43 NOCDURNA SUBL 277mcg 553mcg 50 NOCTIVA EMUL 083mcg01ml
166mcg01ml 50 nolix crea 60 nolix lotn 60 nora-be tabs 47 norco tabs 28 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 51
norepinephrine bitartrate soln 21 norethin ace-eth estrad-fe caps 47 norethin ace-eth estrad-fe chew 47 norethin ace-eth estrad-fe tabs 47 norethindrone acetate tabs 50 norethindrone acet-ethinyl est tabs 47 norethindrone tabs 47 norethindrone-eth estradiol tabs 50 norethin-eth estradiol-fe chew 47 norgesic forte tabs 28 norgestimate-eth estradiol tabs 47 norgestim-eth estrad triphasic tabs 47 norlyroc tabs 47 NORMOSOL-M IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R SOLN INTRAVENOUS 39 NORPACE CR CP12 100mg 150mg 25 nortrel 0535 (28) tabs 47 nortrel 135 (21) tabs 47 nortrel 135 (28) tabs 47 nortrel 777 tabs 47 nortriptyline hcl caps 10mg 25mg 50mg
75mg 36 nortriptyline hcl soln 36 NORVIR CAPS 12 NORVIR PACK 12 NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 34 NOVAREL SOLR 5000unit 10000unit 50 NOVOLIN 7030 SUSP 49
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 93
NOVOLOG 7030 FLEXPEN RELION SUPN 49
NOVOLOG FLEXPEN RELION SOPN 49 NOVOLOG FLEXPEN SOPN 49 NOVOLOG MIX 7030 FLEXPEN SUPN 49 NOVOLOG MIX 7030 RELION SUSP 49 NOVOLOG MIX 7030 SUSP 49 NOVOLOG PENFILL SOCT 49 NOVOLOG RELION SOLN 49 NOVOLOG SOLN 49 NOXAFIL SUSP 11 NOXAFIL TBEC 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 55 NUCALA SOLR 55 NUCALA SOSY 55 NUCYNTA ER TB12 200mg 250mg 29 NUCYNTA ER TB12 50mg 100mg 150mg
29 NUCYNTA TABS 29 NUCYNTA TABS 50mg 75mg 29 NUEDEXTA CAPS 34 NULIBRY SOLR 54 NULOJIX SOLR 53 NUPLAZID CAPS 36 NUPLAZID TABS 10mg 17mg 36 NURTEC TBDP 32 NUTRILIPID EMUL INTRAVENOUS 38 NUTROPIN AQ NUSPIN 10 SOPN 51 NUTROPIN AQ NUSPIN 20 SOPN 51 NUTROPIN AQ NUSPIN 5 SOPN 51 NUVARING RING 47 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 59 nylia 777 tabs 47 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 47 nystatin crea 59 nystatin oint 59 nystatin powd 59 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 60 nystatin-triamcinolone oint 60 nystop powd 59 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 44 ocella tabs 47 OCREVUS SOLN 34 OCTAGAM SOLN INTRAVENOUS
5gm100ml 1gm20ml 2gm20ml 25gm500ml 57
octreotide acetate soln 51 ODACTRA SUBL 54 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 56 ofloxacin soln 41 ofloxacin tabs 10 ogestrel tabs 47 OGIVRI SOLR 17 okebo caps 10 olanzapine solr 36 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 36 olanzapine tbdp 5mg 10mg 15mg 20mg
36 olanzapine-fluoxetine hcl caps 36 olmesartan medoxomil tabs 5mg 20mg
40mg 26 olmesartan medoxomil-hctz tabs 26 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 42 OLUMIANT TABS 1mg 2mg 53 OLYSIO CAPS 12 OMECLAMOX-PAK MISC 43 omega-3-acid ethyl esters caps 23 omeprazole cpdr 10mg 20mg 40mg 43 omeprazole-sodium bicarbonate caps 43 omeprazole-sodium bicarbonate pack 44 OMNARIS SUSP 41 OMNIPOD STARTER KIT 37 OMNITROPE SOCT 5mg15ml
10mg15ml 51 OMNITROPE SOLR 51 ondansetron hcl soln 43 ondansetron hcl tabs 4mg 8mg 24mg 43 ondansetron tbdp 4mg 8mg 43 ONIVYDE INJ 17 ONPATTRO SOLN 54 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 ONZETRA XSAIL EXHP 32
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OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml 17
OPIUM TINC 43 ORACEA CPDR 62 ORALAIR SUBL 54 oralone pste 60 ORAVIG TABS 59 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 53 ORENCIA SOLR 53 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 53 ORENITRAM TBCR 0125mg 56 ORENITRAM TBCR 025mg 1mg 25mg
5mg 56 ORFADIN CAPS 54 ORFADIN SUSP 54 ORGOVYX TABS 50 ORIAHNN CPPK 50 ORILISSA TABS 150mg 200mg 50 ORKAMBI PACK 56 ORKAMBI TABS 56 ORLADEYO CAPS 110mg 150mg 54 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 29 orphengesic forte tabs 29 orsythia tabs 47 ORTIKOS CP24 6mg 9mg 45 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 39 OSMOPREP TABS 44 OSPHENA TABS 50 OTEZLA TABS 53 OTEZLA TBPK 53 OTOVEL SOLN 41 OTREXUP SOAJ 53 ovide lotn 59 OXACILLIN SODIUM IN DEXTROSE SOLN
INTRAVENOUS 10 oxacillin sodium solr injection 1gm 2gm 10 oxacillin sodium solr intravenous 10 oxaliplatin soln 17 oxaliplatin solr 17 oxandrolone tabs 45 oxandrolone tabs 25mg 45 oxaprozin tabs 29
OXAYDO TABS 29 oxazepam caps 10mg 15mg 30mg 33 OXBRYTA TABS 21 oxcarbazepine susp 31 oxcarbazepine tabs 150mg 300mg 600mg
31 OXERVATE SOLN 42 oxiconazole nitrate crea 59 OXISTAT LOTN 59 OXLUMO SOLN 54 OXTELLAR XR TB24 150mg 300mg
600mg 31 oxybutynin chloride er tb24 5mg 10mg
15mg 63 oxybutynin chloride syrp 63 oxybutynin chloride tabs 63 oxycodone hcl caps 29 oxycodone hcl conc 29 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxycodone hcl soln 29 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 29 oxycodone-acetaminophen soln 29 oxycodone-acetaminophen tabs 29 oxycodone-acetaminophen tabs 5-300mg
10-300mg 29 oxycodone-aspirin tabs 29 oxycodone-ibuprofen tabs 29 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 29 oxymorphone hcl tabs 5mg 10mg 29 OXYTOCIN SOLN 50 OZEMPIC (025 OR 05 MGDOSE) SOPN
49 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 49
P pacerone tabs 100mg 200mg 400mg 25 paclitaxel conc 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
54 PALFORZIA (120 MG DAILY DOSE) CSPK
54
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 95
PALFORZIA (160 MG DAILY DOSE) CSPK 54
PALFORZIA (20 MG DAILY DOSE) CSPK 54
PALFORZIA (200 MG DAILY DOSE) CSPK 54
PALFORZIA (240 MG DAILY DOSE) CSPK 55
PALFORZIA (3 MG DAILY DOSE) CSPK 55 PALFORZIA (300 MG MAINTENANCE)
PACK 55 PALFORZIA (300 MG TITRATION) PACK
55 PALFORZIA (40 MG DAILY DOSE) CSPK
55 PALFORZIA (6 MG DAILY DOSE) CSPK 55 PALFORZIA (80 MG DAILY DOSE) CSPK
55 PALFORZIA INITIAL ESCALATION CSPK
55 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 36 palonosetron hcl soln 43 palonosetron hcl sosy 43 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 40 pamidronate disodium soln 52 pamidronate disodium solr 52 PANCREAZE CPEP 40 PANDEL CREA 61 panlor tabs 29 PANRETIN GEL 61 pantoprazole sodium pack 44 PANTOPRAZOLE SODIUM SOLR 44 pantoprazole sodium tbec 20mg 40mg 44 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 57
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 64 PARICALCITOL SOLN 64 paroex soln 41 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 36 paroxetine hcl tabs 10mg 20mg 36 paroxetine hcl tabs 30mg 40mg 36 paroxetine mesylate caps 36 paser pack 11
PAXIL SUSP 36 PEDIARIX SUSP 57 PEDVAX HIB SUSP 57 peg 3350electrolytes solr 44 peg 3350-kcl-na bicarb-nacl solr 44 peg-3350electrolytes solr 44 PEGANONE TABS 31 PEGASYS PROCLICK SOLN
135mcg05ml 180mcg05ml 13 PEGASYS SOLN 180mcg05ml
180mcgml 13 PEGINTRON KIT 13 PEG-INTRON REDIPEN KIT 12 PEG-PREP KIT 44 PEMAZYRE TABS 45mg 9mg 135mg 17 penicillamine caps 45 penicillamine tabs 45 PENICILLIN G POT IN DEXTROSE SOLN
INTRAVENOUS 10 penicillin g potassium solr injection 10 penicillin g procaine susp 10 penicillin g sodium solr injection 10 penicillin v potassium solr 10 penicillin v potassium tabs 10 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 43 pentazocine-naloxone hcl tabs 29 pentobarbital sodium soln 33 pentoxifylline er tbcr 22 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 44 percocet tabs 29 perindopril erbumine tabs 2mg 4mg 8mg
26 periogard soln 41 PERJETA SOLN 17 permethrin crea 59 perphenazine tabs 2mg 4mg 8mg 16mg
36 perphenazine-amitriptyline tabs 36 PERSERIS PRSY 90mg 120mg 36 PERTZYE CPEP 40 PEXEVA TABS 10mg 20mg 30mg 40mg
36 phenadoz supp 14 phenazo tabs 61 PHENAZOPYRIDINE HCL TABS 61 phenelzine sulfate tabs 36
96 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
phenergan soln 14 PHENOBARBITAL ELIX 33 PHENOBARBITAL SODIUM SOLN 33 PHENOBARBITAL TABS 33 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 21 PHENYLEPHRINE HCL SOLN 42 phenytek caps 200mg 300mg 31 phenytoin chew 31 phenytoin sodium extended caps 100mg
200mg 300mg 31 phenytoin sodium soln 31 phenytoin susp 31 PHESGO SOLN 17 PHOSLYRA SOLN 39 PHOSPHASAL TABS 14 PHOSPHOLINE IODIDE SOLR 42 phrenilin forte caps 29 PHYSIOLYTE SOLN 55 PHYSIOSOL IRRIGATION SOLN 55 PIFELTRO TABS 13 pilocarpine hcl soln 1 2 4 42 pilocarpine hcl tabs 5mg 75mg 20 pimecrolimus crea 62 pimozide tabs 1mg 2mg 36 pimtrea tabs 47 pindolol tabs 5mg 10mg 24 pioglitazone hcl tabs 15mg 30mg 45mg 49 pioglitazone hcl-glimepiride tabs 49 pioglitazone hcl-metformin hcl tabs 49 piperacillin sod-tazobactam so solr 10 piperacillin sod-tazobactam so solr
intravenous 10 PIQRAY (200 MG DAILY DOSE) TBPK 17 PIQRAY (250 MG DAILY DOSE) TBPK 17 PIQRAY (300 MG DAILY DOSE) TBPK 17 pirmella 135 tabs 47 PIROXICAM CAPS 10mg 20mg 29 PLASMA-LYTE 148 SOLN INTRAVENOUS
39 PLASMA-LYTE A SOLN INTRAVENOUS 39 PLEGRIDY SOPN 13 PLEGRIDY SOSY 13 34 PLEGRIDY STARTER PACK SOPN 13 PLEGRIDY STARTER PACK SOSY 13 plenamine soln intravenous 38 PLENVU SOLR 44 podofilox soln 62 POLIVY SOLR 30mg 140mg 17
polocaine soln 55 polocaine-mpf soln 55 polycin oint 41 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 41 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 34 PONVORY TABS 34 portia-28 tabs 47 PORTRAZZA SOLN 17 POSACONAZOLE SUSP 11 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 37 POTASSIUM ACETATE SOLN 39 potassium chloride crys er tbcr 10meq
20meq 40 potassium chloride er cpcr 8meq 10meq 40 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 40 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 40 potassium chloride in nacl soln intravenous
40 potassium chloride pack 40 potassium chloride soln 10 20 40 POTASSIUM CHLORIDE SOLN
INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml 40
potassium citrate er tbcr 15meq 540mg 1080mg 37
POTASSIUM PHOSPHATES SOLN 40 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 40 POTELIGEO SOLN 18 PR BENZOYL PEROXIDE WASH LIQD 59 PRADAXA CAPS 110mg 150mg 22 PRADAXA CAPS 75mg 22 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 33
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 33
PRAMOX GEL 61 prandin tabs 1mg 2mg 49 prasugrel hcl tabs 5mg 10mg 22 pravastatin sodium tabs 10mg 20mg
40mg 80mg 23 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 97
PRED MILD SUSP 41 PRED-G SOP OINT 41 PRED-G SUSP 41 prednicarbate crea 61 prednicarbate oint 61 prednisolone acetate susp 41 prednisolone sodium phosphate soln 41 45 prednisolone sodium phosphate soln
5mg5ml 10mg5ml 20mg5ml 25mg5ml 45
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 45
prednisolone soln 45 prednisone intensol conc 45 prednisone soln 45 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 45 prednisone tbpk 45 prefest tabs 50 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 31
pregabalin er tb24 825mg 165mg 330mg 29
pregabalin soln 31 PREGNYL SOLR 50 PREMARIN SOLR 50 PREMARIN TABS 03mg 045mg
0625mg 09mg 125mg 50 premasol soln intravenous 38 PREMPHASE TABS 50 PREMPRO TABS 50 PRENATAL TABS 64 PRETOMANID TABS 11 prevalite pack 23 prevalite powd 23 previfem tabs 47 PREVYMIS SOLN 240mg12ml
480mg24ml 13 PREVYMIS TABS 240mg 480mg 13 PREZCOBIX TABS 13 PREZISTA SUSP 13 PREZISTA TABS 75mg 150mg 600mg
800mg 13 PRIFTIN TABS 11 PRILOSEC PACK 25mg 10mg 44 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 31 primlev tabs 29
PRIVIGEN SOLN INTRAVENOUS 57 PROAIR RESPICLICK AEPB 21 probenecid tabs 40 procainamide hcl soln 25 PROCALAMINE SOLN INTRAVENOUS 38 procentra soln 30 prochlorperazine edisylate soln 36 prochlorperazine maleate tabs 36 prochlorperazine supp 36 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 40000unitml 22
proctofoam hc foam 61 procto-med hc crea 61 procto-pak crea 61 proctosol hc crea 61 proctozone-hc crea 61 PROCYSBI CPDR 25mg 75mg 55 PROCYSBI PACK 75mg 300mg 55 progesterone caps 100mg 200mg 51 progesterone oil 51 PROGLYCEM SUSP 49 PROGRAF PACK 53 PROGRAF PACK 02mg 53 PROGRAF SOLN 53 PROLASTIN-C SOLN INTRAVENOUS 56 PROLASTIN-C SOLR INTRAVENOUS 56 prolate soln 29 prolate tabs 29 PROLENSA SOLN 41 PROLEUKIN SOLR 18 PROLIA SOSY 52 PROMACTA PACK 125mg 25mg 22 PROMACTA TABS 125mg 25mg 50mg
75mg 22 promethazine hcl soln 14 promethazine hcl supp 14 promethazine hcl syrp 14 promethazine hcl tabs 14 promethazine-phenylephrine syrp 14 promethegan supp 14 propafenone hcl er cp12 225mg 325mg
425mg 25 propafenone hcl tabs 150mg 225mg
300mg 25 propantheline bromide tabs 19 proparacaine hcl soln 43 propranolol hcl er cp24 60mg 80mg
120mg 160mg 24
98 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
propranolol hcl soln 20mg5ml 40mg5ml 24 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 24 propranolol-hctz tabs 24 propylthiouracil tabs 51 PROQUAD SUSR 58 PROSOL SOLN INTRAVENOUS 38 PROTONIX PACK 44 protriptyline hcl tabs 5mg 10mg 36 psorcon crea 61 PULMICORT FLEXHALER AEPB 45 PULMOZYME SOLN 40 PURIXAN SUSP 18 PYLERA CAPS 44 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 20 pyridostigmine bromide soln 20 pyridostigmine bromide tabs 30mg 60mg 20 pyrimethamine tabs 11
Q QBRELIS SOLN 26 QDOLO SOLN 29 QINLOCK TABS 18 QUADRACEL SUSP 57 questran light powd 23 questran pack 23 questran powd 23 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 36 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 37 QUILLICHEW ER CHER 20mg 30mg
40mg 30 QUILLIVANT XR SRER 30 quinapril hcl tabs 5mg 10mg 20mg 40mg
26 quinapril-hydrochlorothiazide tabs 26 quinidine gluconate er tbcr 25 QUINIDINE GLUCONATE SOLN 25 quinidine sulfate tabs 200mg 300mg 25 quinine sulfate caps 12
R RABAVERT SUSR 58 rabeprazole sodium cpsp 44 rabeprazole sodium tbec 44 RADICAVA SOLN 34
raloxifene hcl tabs 50 ramelteon tabs 33 ramipril caps 125mg 25mg 5mg 10mg 26 ranolazine er tb12 500mg 1000mg 25 RAPIVAB SOLN 13 rasagiline mesylate tabs 05mg 1mg 33 RASUVO SOAJ 53 RAVICTI LIQD 38 RAYALDEE CPCR 64 RAYOS TBEC 1mg 2mg 5mg 45 REBETOL SOLN 13 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 34 REBIF REBIDOSE TITRATION PACK
SOAJ 34 REBIF SOSY 22mcg05ml 44mcg05ml 34 REBIF TITRATION PACK SOSY 34 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 47 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 58 RECTIV OINT 62 REGONOL SOLN 20 REGRANEX GEL 62 relafen ds tabs 29 RELENZA DISKHALER AEPB 13 relexxii tbcr 30 RELISTOR SOLN 8mg04ml 12mg06ml
44 RELISTOR TABS 44 reltone caps 200mg 400mg 44 REMICADE SOLR INTRAVENOUS 53 RENFLEXIS SOLR 53 repaglinide tabs 05mg 1mg 2mg 49 repaglinide-metformin hcl tabs 49 REPATHA PUSHTRONEX SYSTEM SOCT
23 REPATHA SOSY 23 REPATHA SURECLICK SOAJ 23 RESCRIPTOR TABS 100mg 200mg 13 RESTASIS EMUL 41 RETACRIT SOLN 20000unit2ml
2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml 22
RETEVMO CAPS 40mg 80mg 18 RETIN-A CREA 0025 005 01 61 RETIN-A GEL 001 0025 61
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 99
RETIN-A MICRO GEL 004 01 61 RETIN-A MICRO PUMP GEL 61 RETIN-A MICRO PUMP GEL 004 01
61 RETIN-A MICRO PUMP GEL 008 61 RETISERT IMPL 41 RETROVIR SOLN 13 REVCOVI SOLN 40 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 18 revonto solr 20 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 37 REYATAZ PACK 13 REZUROCK TABS 55 RHOPRESSA SOLN 42 RIABNI SOLN 100mg10ml 500mg50ml 18 ribasphere caps 13 ribasphere ribapak (1000 pack) tbpk 13 ribasphere ribapak (1200 pack) tbpk 13 ribasphere tabs 13 ribavirin caps 13 ribavirin solr 13 ribavirin tabs 13 RIDAURA CAPS 55 RIFABUTIN CAPS 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 RIFATER TABS 11 riluzole tabs 34 rimantadine hcl tabs 13 RIMSO-50 SOLN 55 RINGERS IRRIGATION SOLN 55 RINGERS SOLN 40 RINVOQ TB24 53 risedronate sodium tabs 5mg 30mg 35mg
150mg 52 RISEDRONATE SODIUM TBEC 52 RISPERDAL CONSTA SRER 125mg
25mg 37 RISPERDAL CONSTA SRER 375mg
50mg 37 risperidone soln 37 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 37 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 37
ritonavir tabs 13 RITUXAN HYCELA SOLN 18 RITUXAN SOLN 18 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 47 rizatriptan benzoate tabs 32 rizatriptan benzoate tbdp 32 ROMIDEPSIN SOLN 18 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 33 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 33 ropivacaine hcl soln 55 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 23 ROTARIX SUSR 58 ROTATEQ SOLN 58 roweepra tabs 500mg 750mg 1000mg 31 roweepra xr tb24 500mg 750mg 31 ROXYBOND TABA 5mg 15mg 30mg 29 ROZEREM TABS 33 ROZLYTREK CAPS 100mg 200mg 18 RUBRACA TABS 200mg 250mg 300mg 18 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 31 rufinamide tabs 200mg 400mg 31 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 18 RUZURGI TABS 55 RYBREVANT SOLN 18 ryclora soln 14 RYDAPT CAPS 18 RYLAZE SOLN 18 RYNODERM CREA 62 RYTARY CPCR 33 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 51 SAIZEN SOLR 5mg 88mg 51 SAIZENPREP SOLR 51 sajazir soln 21 SALEX SHAM 62 SALICYLIC ACID CREA 62 SALICYLIC ACID ER SOLN 62
100 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
SALICYLIC ACID FOAM 62 SALICYLIC ACID GEL 62 SALICYLIC ACID LIQD 62 SALICYLIC ACID SHAM 62 SALICYLIC ACID WART REMOVER LIQD
62 SALICYLIC ACID-CLEANSER KIT 62 SALIMEZ CREA 62 SALSALATE TABS 29 SAMSCA TABS 15mg 39 SANCUSO PTCH 43 SANDIMMUNE ORAL SOLN 100mgml 53 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 51 SANTYL OINT 62 SAPHNELO SOLN 53 SAPHRIS SUBL 25mg 5mg 10mg 37 sapropterin dihydrochloride pack 100mg
500mg 55 sapropterin dihydrochloride tabs 55 SARCLISA SOLN 500mg25ml 100mg5ml
18 SAVELLA TABS 125mg 25mg 50mg
100mg 34 SAVELLA TITRATION PACK MISC 34 scopolamine pt72 43 seconal caps 33 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 37 selegiline hcl caps 33 selegiline hcl tabs 33 selenium sulfide lotn 59 SELENIUM SULFIDE SHAM 59 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 150mg
300mg 13 SEMPREX-D CAPS 14 SENSIPAR TABS 30mg 60mg 90mg 50 SENSORCAINE SOLN 55 sensorcaineepinephrine soln 55 sensorcaine-mpf soln 55 sensorcaine-mpfepinephrine soln 55 SEREVENT DISKUS AEPB 21 SEROSTIM SOLR 4mg 5mg 6mg 51 sertraline hcl conc 37 sertraline hcl tabs 25mg 50mg 100mg 37 setlakin tabs 47 sevelamer carbonate pack 08gm 24gm 39 sevelamer carbonate tabs 39
sevelamer hcl tabs 400mg 800mg 39 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 47 SHINGRIX SUSR 58 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 51 SIGNIFOR SOLN 03mgml 06mgml
09mgml 51 SIKLOS TABS 18 sildenafil citrate soln 26 sildenafil citrate susr 26 sildenafil citrate tabs 26 SILENOR TABS 37 SILIQ SOSY 62 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 59 SIMBRINZA SUSP 42 SIMPONI ARIA SOLN 53 SIMPONI SOAJ 50mg05ml 100mgml 53 SIMPONI SOSY 50mg05ml 100mgml 53 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 23 sirolimus soln 53 sirolimus tabs 05mg 1mg 2mg 53 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKLICE LOTN 59 SKYRIZI (150 MG DOSE) PSKT 62 SKYRIZI PEN SOAJ 63 SKYRIZI SOSY 63 sod benz-sod phenylacet soln 38 SODIUM ACETATE SOLN 37 SODIUM BICARBONATE SOLN 37 SODIUM CHLORIDE (PF) SOLN 40 SODIUM CHLORIDE SOLN 40 55 SODIUM CHLORIDE SOLN INJECTION 40 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 55 SODIUM FLUORIDE SOLN 55 SODIUM FLUORIDE TABS 55 SODIUM LACTATE SOLN INTRAVENOUS
37 sodium phenylbutyrate powd 38 sodium phenylbutyrate tabs 38 SODIUM PHOSPHATES SOLN 40 sodium polystyrene sulfonate powd 39 sodium polystyrene sulfonate susp 39 SODIUM SULFACETAMIDE SHAM 59
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 101
SODIUM SULFACETAMIDE WASH LIQD 59
sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 63 SOLIQUA SOPN 49 SOLOSEC PACK 12 soloxide tbec 10 SOLTAMOX SOLN 18 SOLU-CORTEF SOLR 45 SOLU-MEDROL SOLR 45 SOMATULINE DEPOT SOLN 51 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 51 SORILUX FOAM 63 sorine tabs 80mg 120mg 160mg 240mg
24 sotalol hcl (af) tabs 80mg 120mg 160mg 24 sotalol hcl tabs 80mg 120mg 160mg
240mg 24 SOTYLIZE SOLN 24 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPINOSAD SUSP 59 SPIRIVA HANDIHALER CAPS 19 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 26 spironolactone-hctz tabs 26 SPRAVATO (56 MG DOSE) SOPK 37 SPRAVATO (84 MG DOSE) SOPK 37 sprintec 28 tabs 47 SPRITAM TB3D 250mg 500mg 750mg
1000mg 31 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 39 sronyx tabs 47 SSD CREA 59 SSS 10-5 CREA 63 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
63 STELARA SOSY 45mg05ml 90mgml 63 STERILE WATER FOR IRRIGATION SOLN
55 STIMATE SOLN 50 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18
STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml 40
streptomycin sulfate solr 10 STRIANT MISC 46 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 21 SUBLOCADE SOSY 100mg05ml
300mg15ml 29 SUBSYS LIQD 100mcg 200mcg 400mcg
600mcg 800mcg 1200mcg 1600mcg 29 subvenite starter kit-blue kit 31 subvenite starter kit-green kit 31 subvenite starter kit-orange kit 31 subvenite tabs 25mg 100mg 150mg
200mg 31 succinylcholine chloride soln 20 SUCRAID SOLN 40 sucralfate susp 44 sucralfate tabs 44 sulfacetamide sodium (acne) lotn 59 SULFACETAMIDE SODIUM GEL 59 SULFACETAMIDE SODIUM LIQD 59 sulfacetamide sodium oint 41 sulfacetamide sodium soln 41 SULFACETAMIDE SODIUM-SULFUR
CREA 63 SULFACETAMIDE SODIUM-SULFUR
EMUL 63 SULFACETAMIDE SODIUM-SULFUR
LIQD 63 SULFACETAMIDE SODIUM-SULFUR
LOTN 63 SULFACETAMIDE SODIUM-SULFUR
PADS 63 SULFACETAMIDE SODIUM-SULFUR
SUSP 63 sulfacetamide-prednisolone soln 41 SULFACLEANSE 84 SUSP 63 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 sulfamez wash emul 63 SULFAMYLON CREA 59 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 29 sumatriptan soln 32
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sumatriptan succinate refill soct 32 sumatriptan succinate soaj 32 sumatriptan succinate soln 32 sumatriptan succinate sosy 32 sumatriptan succinate tabs 32 sunitinib malate caps 125mg 25mg
375mg 50mg 18 SUNOSI TABS 75mg 150mg 30 SUPRAX CAPS 10 suprax chew 10 suprax susr 100mg5ml 200mg5ml 10 SUPRAX SUSR 500 MG5ML 10 SUPREP BOWEL PREP KIT SOLN 44 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 47 SYLATRON KIT 18 SYLATRON KIT 600 MCG 18 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 56 SYMDEKO TBPK 56 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 49 SYMLINPEN 60 SOPN 49 SYMPAZAN FILM 10mg 20mg 32 SYMPAZAN FILM 5mg 31 SYMPROIC TABS 44 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 50 SYNDROS SOLN 43 SYNERCID SOLR 10 SYNJARDY TABS 49 SYNJARDY XR TB24 49 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 TACLONEX SUSP 61 tacrolimus caps 05mg 1mg 5mg 53 TACROLIMUS OINT 01 003 63 tadalafil (pah) tabs 20mg 26 tadalafil tabs 25mg 5mg 26 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 55 TALTZ SOAJ 63
TALTZ SOSY 63 TALZENNA CAPS 025mg 1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 51 taperdex 12-day tbpk 45 taperdex 6-day tbpk 45 taperdex 7-day tbpk 45 TARCEVA TABS 25mg 100mg 150mg 18 targadox tabs 10 TARGRETIN GEL 61 tarina 24 fe tabs 47 tarina fe 120 eq tabs 47 TASIGNA CAPS 50mg 150mg 200mg 18 tavaborole soln 59 TAVALISSE TABS 100mg 150mg 22 tazarotene crea 63 tazarotene foam 63 tazicef solr injection 1gm 2gm 6gm 10 TAZORAC CREA 63 TAZORAC GEL 005 01 63 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 57 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TECFIDERA CPDR 120mg 240mg 34 TECFIDERA MISC 34 TEFLARO SOLR INTRAVENOUS 400mg
600mg 10 TEGSEDI SOSY 55 TEKTURNA HCT TABS 26 telmisartan tabs 20mg 40mg 80mg 26 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 26 TEMAZEPAM CAPS 15mg 225mg 30mg
75mg 33 temsirolimus soln 18 tencon tabs 29 TENIPOSIDE SOLN 18 TENIVAC INJ 57 tenofovir disoproxil fumarate tabs 13 TEPADINA SOLR 18 TEPEZZA SOLR 42 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 21
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 103
terbutaline sulfate tabs 25mg 5mg 21 terconazole crea 59 terconazole supp 59 TERIPARATIDE (RECOMBINANT) SOPN
50 testosterone cypionate soln 100mgml
200mgml 46 testosterone enanthate soln 46 testosterone gel 1 162
2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact 46
testosterone soln 46 tetrabenazine tabs 125mg 25mg 34 TETRACAINE HCL SOLN 43 tetracycline hcl caps 250mg 500mg 10 texacort soln 61 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 63 theophylline er tb12 100mg 200mg
300mg 450mg 63 theophylline er tb24 400mg 600mg 63 theophylline soln 63 THIOLA EC TBEC 100mg 300mg 55 THIOLA TABS 55 thioridazine hcl tabs 10mg 25mg 50mg
100mg 37 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 37 THYROGEN SOLR 55 THYROLAR-1 TABS 51 THYROLAR-12 TABS 51 THYROLAR-14 TABS 51 THYROLAR-2 TABS 51 THYROLAR-3 TABS 51 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
32 TIBSOVO TABS 18 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 34 tilia fe tabs 47 timolol maleate pf soln 42 timolol maleate solg 025 05 42 timolol maleate soln 025 05 42 timolol maleate tabs 5mg 10mg 20mg 24 TIMOPTIC OCUDOSE SOLN 25 42
TIMOPTIC-XE SOLG 025 05 42 tinidazole tabs 12 tiopronin tabs 55 TIROSINT CAPS 13mcg 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
TIS-U-SOL SOLN 55 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 TIVORBEX CAPS 29 tizanidine hcl caps 20 21 tizanidine hcl tabs 20 TOBI PODHALER CAPS 56 TOBRADEX OINT 41 TOBRADEX ST SUSP 41 tobramycin nebu 300mg4ml 300mg5ml 56 tobramycin soln 41 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 42 TOBREX OINT 41 tofranil tabs 10mg 25mg 50mg 37 TOLAK CREA 63 tolazamide tabs 250mg 500mg 49 tolbutamide tabs 49 tolcapone tabs 33 tolmetin sodium caps 29 tolmetin sodium tabs 29 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 63 tolterodine tartrate tabs 63 TOLVAPTAN TABS 30mg 15mg 39 TOPEX TOPICAL ANESTHETIC AERO 61 topicort crea 005 025 61 topicort gel 61 topicort oint 61 topiramate cpsp 15mg 25mg 32 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 32 topiramate tabs 25mg 50mg 100mg
200mg 32 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
39 TOSYMRA SOLN 32
104 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
tovet foam 61 TPN ELECTROLYTES CONC
INTRAVENOUS 40 TRACLEER TABS 625mg 125mg 56 TRACLEER TBSO 56 TRADJENTA TABS 49 tramadol hcl er (biphasic) tb24 100mg
200mg 300mg 29 tramadol hcl er cp24 100mg 150mg
200mg 300mg 29 tramadol hcl er tb24 100mg 200mg 300mg
29 tramadol hcl tabs 50mg 100mg 29 tramadol-acetaminophen tabs 29 trandolapril tabs 1mg 2mg 4mg 26 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 22 tranexamic acid tabs 22 TRANSDERM SCOP (15 MG) PT72 43 tranylcypromine sulfate tabs 37 TRAVASOL SOLN INTRAVENOUS 38 TRAVATAN Z SOLN 42 travoprost (bak free) soln 42 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 37 trazodone hcl tabs 50mg 100mg 150mg 37 TRECATOR TABS 11 TRELEGY ELLIPTA AEPB 45 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 63 TREMFYA SOSY 63 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 56 tretinoin caps 18 tretinoin crea 0025 005 01 61 tretinoin gel 001 0025 005 61 tretinoin microsphere gel 004 01 61 tretinoin microsphere pump gel 004
01 62 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 29 triamcinolone acetonide aers 61 triamcinolone acetonide crea 0025
01 05 61 triamcinolone acetonide lotn 0025 01
61 triamcinolone acetonide oint 0025
005 01 05 61 triamcinolone acetonide pste 61
triamcinolone acetonide susp 45 triamterene caps 50mg 100mg 39 triamterene-hctz caps 39 triamterene-hctz tabs 39 trianex oint 61 triazolam tabs 0125mg 025mg 33 TRICITRATES SOLN 37 triderm crea 01 05 61 trientine hcl caps 45 tri-estarylla tabs 47 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 37 trifluridine soln 41 trihexyphenidyl hcl soln 33 trihexyphenidyl hcl tabs 2mg 5mg 33 TRIKAFTA TBPK 56 tri-legest fe tabs 47 tri-lo-estarylla tabs 47 tri-lo-sprintec tabs 47 trilyte solr 44 trimethobenzamide hcl caps 43 trimethoprim tabs 14 tri-mili tabs 47 trimipramine maleate caps 25mg 50mg
100mg 37 TRINESSA (28) TABS 47 TRINTELLIX TABS 5mg 10mg 20mg 37 tri-nymyo tabs 47 tri-previfem tabs 47 TRIPTODUR SRER 50 TRISENOX SOLN 18 TRISENOX SOLN 10mg10ml 18 tri-sprintec tabs 47 tritocin oint 61 TRIUMEQ TABS 13 TRI-VITAMINFLUORIDE SOLN 64 TRI-VITEFLUORIDE SOLN 64 trivora (28) tabs 47 tri-vylibra lo tabs 47 tri-vylibra tabs 47 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 32 TROPHAMINE SOLN INTRAVENOUS 38 trospium chloride er cp24 63 trospium chloride tabs 63 TRULANCE TABS 44 TRUMENBA SUSY 58
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 105
TRUSELTIQ (100MG DAILY DOSE) CPPK 18
TRUSELTIQ (125MG DAILY DOSE) CPPK 18
TRUSELTIQ (50MG DAILY DOSE) CPPK 18
TRUSELTIQ (75MG DAILY DOSE) CPPK 18
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 58 TYBOST TABS 13 tydemy tabs 47 TYKERB TABS 18 tylenol with codeine 3 tabs 29 tylenol with codeine 4 tabs 29 TYMLOS SOPN 50 TYPHIM VI SOLN 58 TYSABRI CONC INTRAVENOUS 34 TYVASO REFILL SOLN 56 TYVASO SOLN 56 TYVASO STARTER SOLN 56
U UBRELVY TABS 50mg 100mg 32 UCERIS FOAM 61 UDENYCA SOSY 22 UKONIQ TABS 18 ULORIC TABS 40mg 80mg 52 ULTOMIRIS SOLN 55 ULTRAVATE LOTN 61 UMECTA MOUSSE FOAM 63 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 52
UNITUXIN SOLN 18 UPLIZNA SOLN 53 UPTRAVI SOLR 56 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 56
UPTRAVI TBPK 57 UREA CREA 39 63 UREA LOTN 40 63 UREA-C40 LOTN 63 urecholine tabs 5mg 10mg 25mg 50mg 20
uredeb crea 63 URETRON DS TABS 14 URIN DS TABS 14 URSODIOL CAPS 200mg 400mg 44 ursodiol caps 300mg 44 ursodiol tabs 250mg 500mg 44 URYL TABS 14 USTELL CAPS 14 UTICAP CAPS 14 UTIRA-C TABS 14 UTRONA-C TABS 14
V VABOMERE SOLR INTRAVENOUS 10 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 63 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 32 valproic acid caps 32 valproic acid soln 32 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
26 valsartan-hydrochlorothiazide tabs 26 VALTOCO 10 MG DOSE LIQD 32 VALTOCO 15 MG DOSE LQPK 32 VALTOCO 20 MG DOSE LQPK 32 VALTOCO 5 MG DOSE LIQD 32 vanadom tabs 20 vanatol lq soln 29 vancomycin hcl caps 10 vancomycin hcl solr 10 VANCOMYCIN HCL SOLR 250 MG 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 VANDAZOLE GEL 59 VANOXIDE-HC LOTN 61 VANTAS KIT 19 VAQTA SUSP 58 VARIVAX INJ 58 VARIZIG SOLN 57 VARUBI (180 MG DOSE) TBPK 43 VASCEPA CAPS 05gm 1gm 23 VAXCHORA SUSR 58 vecamyl tabs 25 VECTICAL OINT 63 VELCADE SOLR 19 velivet tabs 47
106 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
VELPHORO CHEW 39 VELTASSA PACK 84gm 168gm 252gm
39 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 19 VENCLEXTA TABS 10mg 19 VENCLEXTA TABS 50mg 100mg 19 venlafaxine hcl er cp24 375mg 75mg
150mg 37 venlafaxine hcl er tb24 375mg 75mg
150mg 225mg 37 venlafaxine hcl tabs 25mg 375mg 50mg
75mg 100mg 37 VENTAVIS SOLN 10mcgml 20mcgml 57 VENTOLIN HFA AERS 21 VERAPAMIL HCL ER CP24 100mg
120mg 180mg 200mg 240mg 300mg 360mg 25
verapamil hcl er tbcr 120mg 180mg 240mg 25
verapamil hcl soln 25 verapamil hcl tabs 25 verapamil hcl tabs 80mg 120mg 25 VEREGEN OINT 63 VERELAN CP24 25 veripred 20 soln 45 VERSACLOZ SUSP 37 VERZENIO TABS 50mg 100mg 150mg
200mg 19 vestura tabs 47 VIBERZI TABS 75mg 100mg 44 VIBRAMYCIN SYRP 10 vicodin es tabs 29 vicodin hp tabs 29 vicodin tabs 29 VICTOZA SOPN 49 VIDEX EC CPDR 125mg 200mg 400mg 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 47 vigabatrin pack 32 vigabatrin tabs 32 vigadrone pack 32 VIIBRYD STARTER PACK KIT 37 VIIBRYD TABS 10mg 20mg 40mg 37 VILTEPSO SOLN 55 VIMIZIM SOLN 40 VIMPAT SOLN 32
VIMPAT TABS 32 vinblastine sulfate soln 19 vincasar pfs soln 19 vincristine sulfate soln 19 vinorelbine tartrate soln 19 VIOKACE TABS 40 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 52 VITAMINS ACD-FLUORIDE SOLN 64 VITRAKVI CAPS 25mg 100mg 19 VITRAKVI SOLN 19 VIVITROL SUSR 35 VIZIMPRO TABS 15mg 30mg 45mg 19 VOCABRIA TABS 13 VORAXAZE SOLR 52 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 19 VP-PNV-DHA CAPS 64 VPRIV SOLR 40 VRAYLAR CAPS 15mg 3mg 45mg 6mg
37 VRAYLAR CPPK 37 VUMERITY (STARTER) CPDR 55 VUMERITY CPDR 55 vyfemla tabs 47 vylibra tabs 47 VYNDAMAX CAPS 25 VYNDAQEL CAPS 25 VYONDYS 53 SOLN 55 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 30 VYVANSE CHEW 10mg 20mg 30mg
40mg 50mg 60mg 30 VYXEOS SUSR 19 VYZULTA SOLN 42
W WAKIX TABS 445mg 178mg 30 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 22 WATER FOR IRRIGATION STERILE
SOLN 55 wixela inhub aepb 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 107
wymzya fe chew 48 WYNZORA CREA 63
X XALKORI CAPS 200mg 250mg 19 XARELTO STARTER PACK TBPK 22 XARELTO TABS 25mg 10mg 15mg
20mg 22 XATMEP SOLN 19 XCOPRI (250 MG DAILY DOSE) TBPK 32 XCOPRI (350 MG DAILY DOSE) TBPK 32 XCOPRI TABS 200 MG 32 XCOPRI TABS 50mg 100mg 150mg 32 XCOPRI TBPK 32 XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
32 XELJANZ SOLN 53 XELJANZ TABS 5mg 10mg 53 XELJANZ XR TB24 11mg 22mg 53 XELPROS EMUL 42 XEMBIFY SOLN SUBCUTANEOUS
2gm10ml 4gm20ml 10gm50ml 1gm5ml 57
XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 55 XEOMIN SOLR 50unit 100unit 55 XEPI CREA 59 XERESE CREA 59 XERMELO TABS 43 XGEVA SOLN 52 XHANCE EXHU 42 XIFAXAN TABS 200mg 550mg 10 XIIDRA SOLN 42 XIMINO CP24 45mg 90mg 135mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 56 XOLAIR SOSY 75mg05ml 150mgml 56 XOSPATA TABS 19 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 19 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (40 MG TWICE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (60 MG ONCE WEEKLY) TBPK
20mg 60mg 19
XPOVIO (60 MG TWICE WEEKLY) TBPK 19
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg 19
XPOVIO (80 MG TWICE WEEKLY) TBPK 19
XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg 29
XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 48 XUREA CREA 63 XURIDEN PACK 55 xylocaine dental soln 55 XYOSTED SOAJ 50mg05ml 75mg05ml
100mg05ml 46 XYREM SOLN 34 XYWAV SOLN 34
Y YERVOY SOLN 19 YF-VAX INJ 58 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 42 yuvafem tabs 50
Z zafemy ptwk 48 zafirlukast tabs 10mg 20mg 55 zaleplon caps 5mg 10mg 33 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 48 zarontin soln 32 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 29 ZEJULA CAPS 19 ZELAPAR TBDP 33 ZELBORAF TABS 19 ZEMAIRA SOLR INTRAVENOUS 56 ZEMBRACE SYMTOUCH SOAJ 32 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
63 ZENPEP CPEP 40
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zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg 30
ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
34 ZEPOSIA CAPS 34 ZEPOSIA STARTER KIT CPPK 34 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERIT CAPS 15mg 20mg 30mg 40mg 13 ZERUVIA PTCH 61 ZETONNA AERS 42 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 55 ZINBRYTA SOSY 34 ZIONODIL 100 LOTN 61 ZIONODIL LOTN 61 ZIOPTAN SOLN 42 ziprasidone hcl caps 20mg 40mg 60mg
80mg 37 ziprasidone mesylate solr 37 ZIPSOR CAPS 29 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZIRGAN GEL 41 ZITHROMAX PACK 10 ZOKINVY CAPS 50mg 75mg 55 zoledronic acid conc 52 zoledronic acid soln 52
ZOLINZA CAPS 19 zolmitriptan soln 32 zolmitriptan tabs 32 zolmitriptan tbdp 32 zolpidem tartrate er tbcr 625mg 125mg 33 zolpidem tartrate subl 175mg 35mg 33 zolpidem tartrate tabs 5mg 10mg 33 ZOMACTON SOLR 51 ZOMACTON SOLR 5mg 51 ZOMIG SOLN 32 zonisamide caps 25mg 50mg 100mg 32 ZONTIVITY TABS 22 ZORBTIVE SOLR 51 ZORTRESS TABS 025mg 53 ZORTRESS TABS 05mg 075mg 1mg 53 ZORVOLEX CAPS 29 ZOSTAVAX SUSR 58 ZOSYN SOLN INTRAVENOUS 10 zovia 135e (28) tabs 48 ZUBSOLV SUBL 35 ZUPLENZ FILM 4mg 8mg 43 ZYCLARA PUMP CREA 63 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19 ZYKADIA TABS 19 ZYLET SUSP 42 ZYNLONTA SOLR 19 ZYPITAMAG TABS 1mg 2mg 4mg 23 ZYPREXA RELPREVV SUSR 37 ZYTIGA TABS 19 ZYVOX SOLN INTRAVENOUS 10
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Hmong Muajkwc pab txhais lus pub dawb rau koj
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tau cov kev pab txhais lus muab cov ntaub ntawv
txhais ua koj hom lus los yog ua lwm homTsuas hu
rau 1-800-464-4000 24 teev ib hnub twg 7 hnub ib
lim tiam twg (cov hnub caiv kaw) Cov neeg siv
TTY hu 711
Japanese 当院では言語支援を無料で年中無休
終日ご利用いただけます通訳サービス日本語
に翻訳された資料あるいは資料を別の書式でも
依頼できますお気軽に 1-800-464-4000 までお電話
ください (祭日を除き年中無休)TTYユーザー
は 711にお電話ください
Khmer ជនយភាសា គមានឥតអសថលៃដលអនកឡ ើយ 24
ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ អនកអាចឡសនើស ឡសវាអនកបកបរប សភារៈបដលបានបកបរបឡៅជាភាសាបមែរ ឬជាទរងផោសងឡទៀត រានបតទរសពទមកឡយើង តាមឡលម 1-800-464-4000 បាន 24 ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ (បទថលៃប ណោយ) អនកឡរបើ TTY ឡៅឡលម 711
Korean 요일 및 시간에 관계없이 언어 지원
서비스를 무료로 이용하실 수 있습니다 귀하는
통역 서비스 귀하의 언어로 번역된 자료 또는 대체
형식의 자료를 요청할 수 있습니다 요일 및 시간에
관계없이 1-800-464-4000번으로 전화하십시오
(공휴일 휴무) TTY 사용자 번호 711
Laotian ການຊວຍເຫ ອດານພາສາມໃຫໂດຍບ ເສຽຄາ
ແກທານ ຕະຫ ອດ 24 ຊ ວໂມງ 7 ວນຕ ອາທດ ທານ
ສາມາດຮອງຂ ຮບບ ລການນາຍພາສາ ໃຫແປເອກະ
ສານເປນພາສາຂອງທານ ຫ ໃນຮບແບບອ ນ ພຽງ
ແຕໂທຣຫາພວກເຮ າທ 1-800-464-4000 ຕະຫ ອດ 24
ຊ ວໂມງ 7 ວນຕ ອາທດ (ປດວນພກຕາງໆ) ຜໃຊສາຍ
TTY ໂທຣ 711
Navajo Saad bee aacutekaacutersquoarsquoayeed naacutehoacuteloacute trsquoaacuteaacute jiikrsquoeacute
naadiin doo bibąąrsquo diacuteiacutersquo aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute
damoo naacuteaacutedleehjiacute Atah halnersquoeacute aacutekaacutersquoadoolwołiacutegiacuteiacute joacutekiacute
trsquoaacuteadoo lersquoeacute trsquoaacuteaacute hoacutehazaadjiacute hadilyąąrsquogo eacuteiacute doodaiirsquo
naacuteaacutenaacute laacute ałrsquoąą aacutedaatrsquoehiacutegiacuteiacute bee haacutedadilyaarsquogo Kojiacute
hodiilnih 1-800-464-4000 naadiin doo bibąąrsquo diacuteiacutersquo
aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute damoo naacutersquoaacutedleehjiacute
(Dahodiyin biniiyeacute ersquoersquoaahgo eacuteiacute darsquodeelkaal)
TTY chodeeyooliacuteniacutegiacuteiacute kojiacute hodiilnih 711
Punjabi ਬਿਨ ਾ ਬਿਸੀ ਲ ਗਤ ਦ ਬਦਨ ਦ 24 ਘਟ ਹਫਤ ਦ 7 ਬਦਨ
ਦਭ ਸੀਆ ਸਵ ਵ ਾ ਤਹ ਡ ਲਈ ਉਪਲਿਧ ਹ ਤਸੀ ਇਿ ਦਭ ਸੀਏ ਦੀ
ਮਦਦ ਲਈ ਸਮਗਰੀਆਾ ਨ ਆਪਣੀ ਭ ਸ ਬਵਚ ਅਨਵ ਦ ਿਰਵ ਉਣ
ਲਈ ਜ ਾ ਬਿਸ ਵਖ ਫ ਰਮਟ ਬਵਚ ਪਰ ਪਤ ਿਰਨ ਲਈ ਿਨਤੀ ਿਰ ਸਿਦ
ਹ ਿਸ ਬਸਰਫ਼ ਸ ਨ 1-800-464-4000 ਤ ਬਦਨ ਦ 24 ਘਟ ਹਫ਼ਤ
ਦ 7 ਬਦਨ (ਛਟੀਆਾ ਵ ਲ ਬਦਨ ਿਦ ਰਬਹਦ ਹ) ਫ਼ਨ ਿਰ TTY ਦ
ਉਪਯਗ ਿਰਨ ਵ ਲ 711 lsquoਤ ਫ਼ਨ ਿਰਨ
Russian Мы бесплатно обеспечиваем Вас услугами
перевода 24 часа в сутки 7 дней в неделю Вы можете
воспользоваться помощью устного переводчика
запросить перевод материалов на свой язык или
запросить их в одном из альтернативных форматов
Просто позвоните нам по телефону 1-800-464-4000
который доступен 24 часа в сутки 7 дней в неделю
(кроме праздничных дней) Пользователи линии TTY
могут звонить по номеру 711
Spanish Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al diacutea 7 diacuteas a la semana
Puede solicitar los servicios de un inteacuterprete que los
materiales se traduzcan a su idioma o en formatos
alternativos Solo llame al 1-800-788-0616 24 horas al
diacutea 7 diacuteas a la semana (cerrado los diacuteas festivos) Los
usuarios de TTY deben llamar al 711
Tagalog May magagamit na tulong sa wika nang wala
kang babayaran 24 na oras bawat araw 7 araw bawat
linggo Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format Tawagan lamang
kami sa 1-800-464-4000 24 na oras bawat araw 7 araw
bawat linggo (sarado sa mga pista opisyal) Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711
Thai เรามบรการลามฟรส าหรบคณตลอด 24 ชวโมง
ทกวนตลอดชวโมงท าการของเราคณสามารถขอใหลาม
ชวยตอบค าถามของคณทเกยวกบความคมครองการดแล
สขภาพของเราและคณยงสามารถขอใหมการแปลเอกสา
รเปนภาษาทคณใชไดโดยไมมการคดคาบรการเพยงโทร
หาเราทหมายเลข 1-800-464-4000 ตลอด 24
ชวโมงทกวน (ปดใหบรการในวนหยดราชการ) ผใช TTY
โปรดโทรไปท 711
Vietnamese Dịch vụ thocircng dịch được cung cấp miễn
phiacute cho quyacute vị 24 giờ mỗi ngagravey 7 ngagravey trong tuần Quyacute
vị coacute thể yecircu cầu dịch vụ thocircng dịch tagravei liệu phiecircn dịch
ra ngocircn ngữ của quyacute vị hoặc tagravei liệu bằng nhiều higravenh
thức khaacutec Quyacute vị chỉ cần gọi cho chuacuteng tocirci tại số
1-800-464-4000 24 giờ mỗi ngagravey 7 ngagravey trong tuần
(trừ caacutec ngagravey lễ) Người dugraveng TTY xin gọi 711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
Provide no cost aids and services to people with disabilities to communicate effectively with us such as
diams Qualified sign language interpreters
diams Written information in other formats such as large print audio and accessible electronic formats
Provide no cost language services to people whose primary language is not English such as
diams Qualified interpreters
diams Information written in other languages
If you need these services call Member Services at 1-800-476-2167 (TTY 711)8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana Aurora CO 80014 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
61102709_CO
Multi-language Interpreter Services
English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-476-2167 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-476-2167 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-476-2167 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-476-2167 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-476-2167 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-476-2167 (TTY 711)번으로 전화해 주십시오
Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-800-476-2167 (телетайп 711)
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-476-2167(TTY711)までお電話にてご連絡ください
Amharic ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው 711)
German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-800-476-2167 (TTY 711)
French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-800-476-2167 (ATS 711)
Farsi
ی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ دیریبگ تماس (TTY 711) 2167-476-800-1 با باشد
Arabic
ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم )117- (رقم ھاتف الصم والبكم 7612-674-008-1
Yoruba AKIYESI Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o E pe ero ibanisoro yi 1-800-476-2167 (TTY 711)
Cushite-Oromo XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 1-800-476-2167 (TTY 711)
Nepali
धयान िदनहोस तपाइल नपाली बोलनहनछ भन तपाइको िनिमत भाषा सहायता सवाह िनःशलक पमा उपलबध छ फोन गनरहोस 1-800-476-2167 (िटिटवाइ 711)
KAH2711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
bull Provide no cost aids and services to people with disabilities to communicateeffectively with us such asdiams Qualified sign language interpretersdiams Written information in other formats such as large print audio and accessible
electronic formatsbull Provide no cost language services to people whose primary language is not English
such asdiams Qualified interpretersdiams Information written in other languages
If you need these services call Member Services at 1-800-805-2739 (TTY 711) 8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd Honolulu HI 96813 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Kaiser Permanente is an HMO plan with a Medicare contract Enrollment in Kaiser Permanente depends on contract renewal
H1230_2017MLI accepted
Multi-language Interpreter Services English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-805-2739 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-805-2739 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-805-2739 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-805-2739 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-805-2739 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-805-2739 (TTY 711)번으로 전화해 주십시오
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-805-2739(TTY711)までお電話にてご連絡ください
Lao
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 1-800-805-2739 (TTY 711)
Ilocano PAKDAAR Nu saritaem ti Ilocano ti serbisyo para ti baddang ti lengguahe nga awanan bayadna ket sidadaan para kenyam Awagan ti 1-800-805-2739 (TTY 711)
Samoan MO LOU SILAFIA Afai e te tautala Gagana faa Sāmoa o loo iai auaunaga fesoasoan e fai fua e leai se totogi mo oe Telefoni mai 1-800-805-2739 (TTY 711)
Marshallese LALE Ntildee kwōj kōnono Kajin Ṃajōḷ kwomarontilde bōk jerbal in jipantilde ilo kajin ṇe aṃ ejjeḷọk wōṇāān Kaalọk 1-800-805-2739 (TTY 711)
Trukese MEI AUCHEA Ika iei foosun fonuomw Foosun Chuuk iwe en mei tongeni omw kopwe angei aninisin chiakku ese kamo Kori 1-800-805-2739 (TTY 711)
Hawaiian E NĀNĀ MAI Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo loaʻa ke kōkua manuahi iā ʻoe E kelepona iā 1-800-805-2739 (TTY 711)
Pohnpeian Ni songen mwohmw ohte komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei Call 1-800-805-2739 (TTY 711)
Bisayan ATENSYON Kung nagsulti ka og Cebuano aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe nga walay bayad Tawag sa 1-800-805-2739 (TTY 711)
Tongan FAKATOKANGArsquoI Kapau lsquooku ke Lea-Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai atu ha tokoni tarsquoetotongi pea teke lava lsquoo marsquou ia Telefoni mai 1-800-805-2739 (TTY 711)
485236276 102021
This formulary was updated on 100121 For more recent information or other questions please contact the number for your Kaiser Permanente Region listed below seven days a week 8 am to 8 pm or visit kporgseniorrx
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Foundation Health Plan Inc 393 E Walnut St Pasadena CA 91188-8514 Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E Dakota Ave Denver CO 80247 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Foundation Health Plan Inc 711 Kapiolani Blvd Honolulu HI 96813 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
kporgseniorrx Please recycle
2 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
on how to request an exception You can find information in the section below entitled ldquoHow do I request an exception to the Kaiser Permanente Formularyrdquo
Changes that will not affect you if you are currently taking the drug
Generally if you are taking a drug on our 2021 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year You will not get direct notice this year about changes that do not affect you However on January 1 of the next year such changes would affect you and it is important to check the Drug List for the new benefit year for any changes to drugs
The enclosed formulary is current as of October 1 2021 To get updated information about the drugs covered by our plan please call us Contact information for your Kaiser Permanente Region appears on the front and back cover pages
In the event of a midyear non-maintenance formulary change we will provide details in the Medicare Part D Explanation of Benefits that we send you or Provision of Notice posted at kporgseniorrx
How do I use the formulary
There are two ways to find your drug within the formulary
Medical condition The formulary begins on page 6 The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat For example drugs used to treat a heart condition are listed under the category ldquoCardiovascular Drugsrdquo If you know what your drug is used for look for the category name in the list that begins on page 8 Then look under the category name for your drug Alphabetical listing
If you are not sure what category to look under you should look for your drug in the index that begins on page 66 The index provides an alphabetical list of all the drugs included in this document Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the index and find the name of your drug in the first column of the list What are generic drugs
Our plan covers both brand-name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug Generally generic drugs cost less than brand-name drugs Please see your Evidence of Coverage for more information
What are brand-name drugs
Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug When the patent on a brand-name drug expires other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices Please
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 3
see your Evidence of Coverage for more information
Are there any restrictions on my coverage
Some covered drugs may have additional requirements or limits on coverage These requirements and limits may include
bull Prior Authorization Our plan may require you or your network provider to get prior authorization for certain drugs This means that you will need to get approval from our plan before you fill your prescriptions If you donrsquot get approval we may not cover the drug
Note If your prescription has more than one refill remaining you can only get one refill at a time unless authorized because you will be away from our service area for an extended period of time For certain drugs we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive Also if there is a shortage in the marketplace we may fill your prescription for a limited quantity You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6 You can also get more information about the restrictions applied to specific covered drugs by visiting our website We have posted online a document that explains our prior authorization restriction You may also ask us to send you a copy Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages
You can ask us to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I request an exception to the Kaiser Permanente formularyrdquo for information about how to request an exception What if my drug is not on the formulary
If your drug is not included in this formulary (list of covered drugs) you should first check our Kaiser Permanente 2021 Comprehensive Formulary at kporgseniorrx or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region and confirm if your drug is covered If your Medicare Part D prescription drug is not on our Kaiser Permanente 2021 Comprehensive Formulary you have two options
bull You can ask your network provider to prescribe a similar drug that is included on our formulary
bull You can ask us to make an exception and cover your drug See the next section for information about how to request an exception
How do I request an exception to the Kaiser Permanente Formulary
You can ask us to make an exception to our coverage rules There are several types of exceptions that you can ask us to make
bull You can ask us to cover a drug even if it may not be in our Kaiser Permanente 2021 Comprehensive Formulary
4 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
bull You can ask us to waive coverage
restrictions or limits on your drug For example if your drug requires prior authorization you can ask us to waive the prior authorization requirement for your Part D drug
Generally we will only approve your request for an exception if the alternative drugs included on the planrsquos formulary or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception When you request a formulary or utilization restriction exception you should submit a statement from your network provider supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited (fast) exception if you or your network provider believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber
Please note You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare amp Medicaid Services (CMS) You cannot get an exception for drugs that are excluded under Medicare Part D Please refer to your Evidence of Coverage for more information about requesting exceptions including the appeals process What do I do before I can talk to my network provider about
changing my drugs or requesting an exception
In some cases you might be taking Medicare Part D drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your network provider to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your network provider to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan For each of your Part D drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide up to a maximum of a 30-day supply of medication After your first 30-day supply we may cover an additional refill as medically necessary After you have used these refills we will not pay for these drugs even if you have been a member of the plan less than 90 days
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug while you pursue a formulary exception
For current members with level of care changes if you enter into or are discharged from a hospital skilled nursing facility or long-term care facility to a different care setting or home this is what is known as a
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 5
level of care change When your level of care changes you may require an additional fill of your medication We will generally cover up to a one-month supply of your Part D drugs during this level of care transition period even if the drug is not on our Drug List
For more information
For more detailed information about your Kaiser Permanente prescription drug coverage please review your Evidence of Coverage and other plan materials If you have questions about our plan please call us Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048 Or visit httpwwwmedicaregov
6 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Kaiser Permanentersquos Formulary
The formulary below provides coverage information about the drugs covered by our plan If you have trouble finding your drug in the list turn to the index that begins on page 66 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg NEBUPENT) and generic drugs are listed in lower-case italics (eg ltamoxicillingt) The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number below Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy Northern CA ndash 1-888-218-6245 Monday through Friday 8 am to 8 pm Saturday 8 am to 6 pm and Sunday 9 am to 6 pm Southern CA ndash 1-866-206-2983 Monday through Friday 7 am to 7 pm Saturday 10 am to 2 pm
Colorado
Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday 8 am to 6 pm
Hawaii
Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday 800 am to 5 pm
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 7
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
8 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole tabs NDS emverm chew ivermectin tabs praziquantel tabs MO ANTIBACTERIALS amikacin sulfate soln amikacin sulfate soln injection HI amoxicillin caps amoxicillin chew amoxicillin susr amoxicillin tabs amoxicillin-pot clavulanate chew amoxicillin-pot clavulanate er tb12
amoxicillin-pot clavulanate susr amoxicillin-pot clavulanate tabs ampicillin caps ampicillin sodium solr ampicillin sodium solr injection 1gm 125mg HI
ampicillin sodium solr intravenous HI
ampicillin-sulbactam sodium solr ampicillin-sulbactam sodium solr injection HI
ampicillin-sulbactam sodium solr intravenous HI
ARIKAYCE SUSP PALDNDS AUGMENTIN SUSR AVYCAZ SOLR INTRAVENOUS HI AZITHROMYCIN PACK MO azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BAXDELA SOLR INTRAVENOUS HI
BAXDELA TABS MO
Drug Name RequirementsLimits
BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP cefaclor caps cefaclor er tb12 cefaclor susr cefadroxil caps cefadroxil susr cefadroxil tabs cefazolin sodium solr cefazolin sodium solr injection 1gm 10gm 500mg HI
cefdinir caps cefdinir susr cefepime hcl solr injection 1gm 2gm HI
cefixime caps cefixime susr cefotaxime sodium solr cefotetan disodium solr injection 1gm 2gm HI
cefoxitin sodium solr injection HI cefoxitin sodium solr intravenous 1gm 2gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 2gm 6gm HI
CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 75gm 750mg HI
cefuroxime sodium solr intravenous HI
cephalexin caps cephalexin susr cephalexin tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w soln ciprofloxacin in d5w soln intravenous HI
ciprofloxacin susr ciprofloxacin-ciproflox hcl er tb24 clarithromycin er tb24 clarithromycin susr clarithromycin tabs cleocin phosphate soln cleocin solr clindamycin hcl caps clindamycin palmitate hcl solr clindamycin phosphate in d5w soln intravenous HI
clindamycin phosphate soln clindamycin phosphate soln injection 300mg2ml 600mg4ml 900mg6ml
HI
colistimethate sodium (cba) solr injection HI
DALVANCE SOLR INTRAVENOUS HI
daptomycin solr intravenous 350mg 500mg HI
demeclocycline hcl tabs dicloxacillin sodium caps DIFICID SUSR NDS DIFICID TABS NDS DORYX MPC TBEC MO doxy 100 solr intravenous HI doxycycline hyclate caps 50mg 100mg MO
doxycycline hyclate tabs 20mg 75mg 100mg 150mg MO
doxycycline hyclate tbec 50mg 75mg 100mg 150mg 200mg MO
doxycycline monohydrate caps 50mg 75mg 100mg 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
Drug Name RequirementsLimits
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs FETROJA SOLR NDS FIRVANQ SOLR gentamicin in saline soln gentamicin in saline soln intravenous HI
gentamicin sulfate soln gentamicin sulfate soln injection HI imipenem-cilastatin solr intravenous HI
KIMYRSA SOLR NDS levofloxacin in d5w soln levofloxacin in d5w soln intravenous HI
levofloxacin soln levofloxacin soln intravenous HI levofloxacin tabs lincomycin hcl soln linezolid soln intravenous HI linezolid susr NDS linezolid tabs NDS meropenem solr intravenous 1gm 500mg HI
minocycline hcl caps 50mg 75mg 100mg MO
minocycline hcl er tb24 45mg 55mg 65mg 80mg 90mg 105mg 115mg 135mg
MO
minocycline hcl tabs 50mg 75mg 100mg MO
mondoxyne nl caps 75mg 100mg MO
morgidox caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 10 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium solr intravenous HI neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs okebo caps MO ORBACTIV SOLR NDS OXACILLIN SODIUM IN DEXTROSE SOLN INTRAVENOUS
HI
oxacillin sodium solr injection 1gm 2gm HI
oxacillin sodium solr intravenous HI PENICILLIN G POT IN DEXTROSE SOLN INTRAVENOUS
HI
penicillin g potassium solr injection HI
penicillin g procaine susp penicillin g sodium solr injection HI penicillin v potassium solr penicillin v potassium tabs piperacillin sod-tazobactam so solr
piperacillin sod-tazobactam so solr intravenous HI
polymyxin b sulfate solr injection HI RECARBRIO SOLR NDS SEYSARA TABS 60mg 100mg 150mg NDS
SIVEXTRO SOLR INTRAVENOUS HI
SIVEXTRO TABS NDS soloxide tbec MO streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
Drug Name RequirementsLimits
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO SUPRAX CAPS suprax chew suprax susr 100mg5ml 200mg5ml
SUPRAX SUSR 500 MG5ML SYNERCID SOLR targadox tabs MO tazicef solr injection 1gm 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS 400mg 600mg HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
VABOMERE SOLR INTRAVENOUS HI
vancomycin hcl caps vancomycin hcl solr VANCOMYCIN HCL SOLR 250 MG
vancomycin hcl solr intravenous 1gm 10gm 500mg HI
VIBRAMYCIN SYRP XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS XIMINO CP24 45mg 90mg 135mg MO
ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ZITHROMAX PACK MO ZOSYN SOLN INTRAVENOUS HI ZYVOX SOLN INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
ANTIFUNGALS ABELCET SUSP INTRAVENOUS HI
AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS ERAXIS SOLR INTRAVENOUS 50mg 100mg HI
fluconazole in sodium chloride soln intravenous HI
fluconazole susr fluconazole tabs flucytosine caps 250mg 500mg NDS griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs itraconazole caps ITRACONAZOLE SOLN MO ketoconazole tabs micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS NOXAFIL TBEC NDS nystatin susp nystatin tabs POSACONAZOLE SUSP NDS posaconazole tbec NDS terbinafine hcl tabs TOLSURA CAPS NDS voriconazole solr intravenous HI voriconazole susr voriconazole tabs ANTIMYCOBACTERIALS CAPASTAT SULFATE SOLR cycloserine caps dapsone tabs 25mg 100mg MO ethambutol hcl tabs 100mg 400mg MO
isoniazid soln
Drug Name RequirementsLimits
isoniazid syrp MO isoniazid tabs 100mg 300mg MO paser pack MO PRETOMANID TABS PRIFTIN TABS MO pyrazinamide tabs MO RIFABUTIN CAPS MO RIFADIN CAPS MO rifamate caps MO rifampin caps 150mg 300mg MO rifampin solr intravenous HI RIFATER TABS MO SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs BENZNIDAZOLE TABS 125mg 100mg MO
chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS DARAPRIM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS mefloquine hcl tabs metronidazole caps metronidazole in nacl soln metronidazole in nacl soln intravenous HI
metronidazole tabs NEBUPENT SOLR PA nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 12 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
quinine sulfate caps NDS SOLOSEC PACK tinidazole tabs ANTIVIRALS abacavir sulfate soln abacavir sulfate tabs MO abacavir sulfate-lamivudine tabs MO abacavir-lamivudine-zidovudine tabs MO
acyclovir caps MO acyclovir sodium soln intravenous HI
acyclovir susp MO acyclovir tabs 400mg 800mg MO adefovir dipivoxil tabs NDS APTIVUS CAPS MO APTIVUS SOLN MO atazanavir sulfate caps 150mg 200mg 300mg MO
BARACLUDE SOLN MO BIKTARVY TABS CABENUVA SUER cidofovir soln CIMDUO TABS MO COMPLERA TABS MO CRIXIVAN CAPS 200mg 400mg MO DAKLINZA TABS 30mg 60mg 90mg PANDS
DELSTRIGO TABS MO DESCOVY TABS MO didanosine cpdr 200mg 250mg 400mg MO
DOVATO TABS MO EDURANT TABS MO efavirenz caps 50mg 200mg MO efavirenz tabs MO efavirenz-emtricitab-tenofovir tabs MO
emtricitabine caps MO emtricitabine-tenofovir df tabs MO EMTRIVA SOLN MO entecavir tabs 05mg 1mg MO EPCLUSA TABS PANDS
Drug Name RequirementsLimits
EPIVIR HBV SOLN MO etravirine tabs 100mg 200mg MO EVOTAZ TABS MO famciclovir tabs 125mg 250mg 500mg MO
fosamprenavir calcium tabs MO FUZEON SOLR NDS ganciclovir sodium soln ganciclovir sodium solr GENVOYA TABS MO HARVONI PACK PANDS HARVONI TABS PANDS INTELENCE TABS 25mg MO INVIRASE CAPS MO INVIRASE TABS MO ISENTRESS CHEW 25mg 100mg MO
ISENTRESS HD TABS MO ISENTRESS PACK MO ISENTRESS TABS MO JULUCA TABS MO lamivudine soln MO lamivudine tabs 100mg 150mg 300mg MO
lamivudine-zidovudine tabs MO ledipasvir-sofosbuvir tabs PANDS LEXIVA SUSP MO lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO MAVYRET TABS PANDS nevirapine er tb24 100mg 400mg MO
nevirapine susp MO nevirapine tabs MO NORVIR CAPS MO NORVIR PACK MO NORVIR SOLN MO ODEFSEY TABS MO OLYSIO CAPS PANDS oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEG-INTRON REDIPEN KIT NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
PEGASYS PROCLICK SOLN 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN 180mcg05ml 180mcgml NDS
PEGINTRON KIT NDS PIFELTRO TABS MO PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
PREVYMIS SOLN 240mg12ml 480mg24ml NDS
PREVYMIS TABS 240mg 480mg NDS
PREZCOBIX TABS MO PREZISTA SUSP MO PREZISTA TABS 75mg 150mg 600mg 800mg MO
RAPIVAB SOLN NDS REBETOL SOLN MO RELENZA DISKHALER AEPB MO RESCRIPTOR TABS 100mg 200mg MO
RETROVIR SOLN MO REYATAZ PACK MO ribasphere caps MO ribasphere ribapak (1000 pack) tbpk MO
ribasphere ribapak (1200 pack) tbpk MO
ribasphere tabs MO ribavirin caps MO ribavirin solr ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg 150mg 300mg MO
sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS
Drug Name RequirementsLimits
SOVALDI TABS 200mg 400mg PANDS stavudine caps 15mg 20mg 30mg 40mg MO
STRIBILD TABS MO SYMFI LO TABS MO SYMFI TABS MO SYMTUZA TABS MO SYNAGIS SOLN 50mg05ml 100mgml NDS
tenofovir disoproxil fumarate tabs MO
TIVICAY PD TBSO MO TIVICAY TABS 10mg 25mg 50mg MO
TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEMLIDY TABS VIDEX EC CPDR 125mg 200mg 400mg MO
VIDEX SOLR 2gm 4gm MO VIEKIRA PAK TBPK PANDS VIEKIRA XR TB24 PANDS VIRACEPT TABS 250mg 625mg MO
VIREAD POWD MO VIREAD TABS 150mg MO VIREAD TABS 200mg 250mg MO VOCABRIA TABS MO VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS ZERIT CAPS 15mg 20mg 30mg 40mg MO
zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 14 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fosfomycin tromethamine pack MENAPHOSMBHYO1 TABS methenamine hippurate tabs METHENAMINE MANDELATE TABS
NITROFURANTOIN MACROCRYSTAL CAPS
NITROFURANTOIN MONOHYD MACRO CAPS
nitrofurantoin susp PHOSPHASAL TABS trimethoprim tabs MO URETRON DS TABS URIN DS TABS URYL TABS USTELL CAPS UTICAP CAPS UTIRA-C TABS UTRONA-C TABS ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate soln carbinoxamine maleate tabs cetirizine hcl soln CLARINEX SYRP CLARINEX-D 12 HOUR TB12 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln
Drug Name RequirementsLimits
promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs SEMPREX-D CAPS ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg 500mg NDS
ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS 25mg 5mg 75mg 10mg NDS
ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs ARRANON SOLN ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE INJ BELEODAQ SOLR NDS BELRAPZO SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS bexarotene caps NDS bicalutamide tabs BICNU SOLR bleomycin sulfate solr BLINCYTO SOLR NDS BORTEZOMIB SOLR BOSULIF TABS 100mg 400mg 500mg NDS
BRAFTOVI CAPS 50mg 75mg NDS BRUKINSA CAPS NDS busulfan soln CABOMETYX TABS 20mg 40mg 60mg NDS
CALQUENCE CAPS NDS CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR NDS cladribine soln clofarabine soln COMETRIQ (100 MG DAILY DOSE) KIT LDNDS
COMETRIQ (140 MG DAILY DOSE) KIT LDNDS
COMETRIQ (60 MG DAILY DOSE) KIT LDNDS
COPIKTRA CAPS 15mg 25mg NDS COTELLIC TABS NDS CYCLOPHOSPHAMIDE CAPS 25mg 50mg PA
CYCLOPHOSPHAMIDE SOLN 1gm5ml 500mg25ml NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr
Drug Name RequirementsLimits
dactinomycin solr DANYELZA SOLN NDS DARZALEX FASPRO SOLN NDS DARZALEX SOLN 400mg20ml 100mg5ml NDS
daunorubicin hcl soln DAURISMO TABS 25mg 100mg NDS decitabine solr DOCETAXEL (NON-ALCOHOL) SOLN 80mg4ml 160mg8ml 20mgml
NDS
docetaxel conc docetaxel soln doxorubicin hcl liposomal inj DOXORUBICIN HCL SOLN doxorubicin hcl solr DROXIA CAPS ELIGARD KIT ELLENCE SOLN ELZONRIS SOLN NDS EMCYT CAPS NDS EMPLICITI SOLR 300mg 400mg NDS
ENHERTU SOLR NDS epirubicin hcl soln ERBITUX SOLN ERIVEDGE CAPS NDS ERLEADA TABS NDS erlotinib hcl tabs 25mg 100mg 150mg NDS
ERWINASE SOLR NDS ERWINAZE SOLR NDS ETOPOPHOS SOLR NDS etoposide soln everolimus tabs 25mg 5mg 75mg NDS
EVOMELA SOLR NDS exemestane tabs FARYDAK CAPS 10mg 15mg 20mg LDNDS
FASLODEX SOLN NDS FENSOLVI (6 MONTH) KIT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 16 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
FIRMAGON (240 MG DOSE) SOLR
FIRMAGON SOLR floxuridine solr fludarabine phosphate soln fludarabine phosphate solr fluorouracil soln flutamide caps FOTIVDA CAPS 089mg 134mg NDS
fulvestrant soln NDS GAVRETO CAPS NDS GAZYVA SOLN NDS gemcitabine hcl soln gemcitabine hcl solr GILOTRIF TABS 20mg 30mg 40mg NDS
HERCEPTIN HYLECTA SOLN NDS HERCEPTIN SOLR 150mg 440mg NDS
HERZUMA SOLR 150mg 420mg NDS
HEXALEN CAPS NDS hydroxyurea caps IBRANCE CAPS 75mg 100mg 125mg NDS
IBRANCE TABS 75mg 100mg 125mg NDS
ICLUSIG TABS 10mg 15mg 30mg 45mg NDS
IDAMYCIN PFS SOLN idarubicin hcl soln IDHIFA TABS 50mg 100mg NDS ifosfamide soln IFOSFAMIDE SOLR imatinib mesylate tabs IMBRUVICA CAPS 70mg 140mg NDS
IMBRUVICA TABS 140mg 280mg 420mg 560mg NDS
IMFINZI SOLN 500mg10ml 120mg24ml NDS
INFUGEM SOLN NDS INLYTA TABS 1mg 5mg NDS
Drug Name RequirementsLimits
INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 10muml 6000000unitml NDS
INTRON A SOLR 10mu 18mu 50mu NDS
IRESSA TABS NDS irinotecan hcl soln IXEMPRA KIT SOLR NDS JAKAFI TABS 5mg 10mg 15mg 20mg 25mg NDS
JEMPERLI SOLN KADCYLA SOLR 100mg 160mg NDS KANJINTI SOLR 150mg 420mg NDS KEYTRUDA SOLN NDS KISQALI (200 MG DOSE) TBPK NDS KISQALI (400 MG DOSE) TBPK NDS KISQALI (600 MG DOSE) TBPK NDS KISQALI FEMARA (400 MG DOSE) TBPK NDS
KISQALI FEMARA (600 MG DOSE) TBPK NDS
KISQALI FEMARA (200 MG DOSE) TBPK NDS
KOSELUGO CAPS 10mg 25mg NDS KYPROLIS SOLR 10mg 30mg 60mg NDS
lapatinib ditosylate tabs NDS LARTRUVO SOLN 190mg19ml 500mg50ml NDS
LENVIMA (10 MG DAILY DOSE) CPPK LDNDS
LENVIMA (12 MG DAILY DOSE) CPPK LDNDS
LENVIMA (14 MG DAILY DOSE) CPPK LDNDS
LENVIMA (18 MG DAILY DOSE) CPPK LDNDS
LENVIMA (20 MG DAILY DOSE) CPPK LDNDS
LENVIMA (24 MG DAILY DOSE) CPPK LDNDS
LENVIMA (4 MG DAILY DOSE) CPPK LDNDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
LENVIMA (8 MG DAILY DOSE) CPPK LDNDS
letrozole tabs LEUKERAN TABS NDS leuprolide acetate kit LIBTAYO SOLN NDS LIPODOX 50 INJ LONSURF TABS NDS LORBRENA TABS 25mg 100mg NDS
LUMAKRAS TABS NDS LUMOXITI SOLR NDS LUPANETA PACK KIT LUPRON DEPOT (1-MONTH) KIT
LUPRON DEPOT (3-MONTH) KIT
LUPRON DEPOT (4-MONTH) KIT
LUPRON DEPOT (6-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT 75 MG
LUPRON DEPOT-PED (3-MONTH) KIT
LYNPARZA CAPS NDS LYNPARZA TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA SOLN NDS MARQIBO SUSP NDS MATULANE CAPS NDS megestrol acetate susp megestrol acetate tabs MEKINIST TABS 05mg 2mg NDS MEKTOVI TABS NDS melphalan hcl solr mercaptopurine tabs methotrexate sodium (pf) soln methotrexate sodium soln methotrexate sodium solr
Drug Name RequirementsLimits
methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS MUSTARGEN SOLR mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS NERLYNX TABS NDS NEXAVAR TABS NDS nilutamide tabs NINLARO CAPS 23mg 3mg 4mg NDS
NUBEQA TABS NDS ODOMZO CAPS NDS OGIVRI SOLR NDS ONIVYDE INJ NDS ONTRUZANT SOLR 150mg 420mg NDS
ONUREG TABS 200mg 300mg NDS OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml NDS
oxaliplatin soln oxaliplatin solr paclitaxel conc PADCEV SOLR 20mg 30mg NDS paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEPAXTO SOLR NDS PERJETA SOLN NDS PHESGO SOLN NDS PIQRAY (200 MG DAILY DOSE) TBPK NDS
PIQRAY (250 MG DAILY DOSE) TBPK NDS
PIQRAY (300 MG DAILY DOSE) TBPK NDS
POLIVY SOLR 30mg 140mg NDS POMALYST CAPS 1mg 2mg 3mg 4mg NDS
PORTRAZZA SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 18 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
POTELIGEO SOLN NDS PROLEUKIN SOLR NDS PURIXAN SUSP NDS QINLOCK TABS NDS RETEVMO CAPS 40mg 80mg NDS REVLIMID CAPS 25mg 5mg 10mg 15mg 20mg 25mg NDS
RIABNI SOLN 100mg10ml 500mg50ml NDS
RITUXAN HYCELA SOLN RITUXAN SOLN ROMIDEPSIN SOLN NDS ROZLYTREK CAPS 100mg 200mg NDS
RUBRACA TABS 200mg 250mg 300mg NDS
RUXIENCE SOLN 100mg10ml 500mg50ml NDS
RYBREVANT SOLN NDS RYDAPT CAPS NDS RYLAZE SOLN NDS SARCLISA SOLN 500mg25ml 100mg5ml NDS
SIKLOS TABS NDS SOLTAMOX SOLN SPRYCEL TABS 20mg 50mg 70mg 80mg 100mg 140mg NDS
STIVARGA TABS NDS sunitinib malate caps 125mg 25mg 375mg 50mg NDS
SUTENT CAPS 125mg 25mg 375mg 50mg NDS
SYLATRON KIT 600 MCG SYLATRON KIT SYLVANT SOLR 100mg 400mg NDS SYNRIBO SOLR NDS TABLOID TABS TABRECTA TABS 150mg 200mg NDS
TAFINLAR CAPS 50mg 75mg NDS TAGRISSO TABS 40mg 80mg NDS TALZENNA CAPS 025mg 1mg NDS tamoxifen citrate tabs
Drug Name RequirementsLimits
TARCEVA TABS 25mg 100mg 150mg NDS
TASIGNA CAPS 50mg 150mg 200mg NDS
TAZVERIK TABS NDS TECENTRIQ SOLN 840mg14ml 1200mg20ml NDS
temsirolimus soln TENIPOSIDE SOLN TEPADINA SOLR NDS TEPMETKO TABS NDS THALOMID CAPS 50mg 100mg 150mg 200mg NDS
thiotepa solr 15mg 100mg NDS TIBSOVO TABS NDS toposar soln TOPOTECAN HCL SOLN topotecan hcl solr toremifene citrate tabs NDS TRAZIMERA SOLR 150mg 420mg NDS
TRELSTAR MIXJECT SUSR tretinoin caps NDS trexall tabs 5mg 75mg 10mg 15mg PA
TRISENOX SOLN 10mg10ml NDS TRISENOX SOLN NDS TRODELVY SOLR NDS TRUSELTIQ (100MG DAILY DOSE) CPPK NDS
TRUSELTIQ (125MG DAILY DOSE) CPPK NDS
TRUSELTIQ (50MG DAILY DOSE) CPPK NDS
TRUSELTIQ (75MG DAILY DOSE) CPPK NDS
TRUXIMA SOLN 100mg10ml 500mg50ml NDS
TUKYSA TABS 50mg 150mg NDS TURALIO CAPS NDS TYKERB TABS NDS UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
VANTAS KIT VELCADE SOLR VENCLEXTA STARTING PACK TBPK NDS
VENCLEXTA TABS 10mg NDS VENCLEXTA TABS 50mg 100mg NDS
VERZENIO TABS 50mg 100mg 150mg 200mg NDS
vinblastine sulfate soln vincasar pfs soln vincristine sulfate soln vinorelbine tartrate soln VITRAKVI CAPS 25mg 100mg NDS VITRAKVI SOLN NDS VIZIMPRO TABS 15mg 30mg 45mg NDS
VOTRIENT TABS NDS VYXEOS SUSR NDS XALKORI CAPS 200mg 250mg NDS XATMEP SOLN PANDS XOSPATA TABS NDS XPOVIO (100 MG ONCE WEEKLY) TBPK 20mg 50mg NDS
XPOVIO (40 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (40 MG TWICE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (60 MG ONCE WEEKLY) TBPK 20mg 60mg NDS
XPOVIO (60 MG TWICE WEEKLY) TBPK NDS
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (80 MG TWICE WEEKLY) TBPK NDS
XTANDI CAPS NDS XTANDI TABS 40mg 80mg NDS YERVOY SOLN YONDELIS SOLR NDS YONSA TABS NDS ZALTRAP SOLN 100mg4ml 200mg8ml NDS
ZEJULA CAPS NDS
Drug Name RequirementsLimits
ZELBORAF TABS NDS ZEPZELCA SOLR NDS ZIRABEV SOLN 400mg16ml 100mg4ml NDS
ZOLINZA CAPS NDS ZYDELIG TABS 100mg 150mg NDS ZYKADIA CAPS NDS ZYKADIA TABS NDS ZYNLONTA SOLR NDS ZYTIGA TABS NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA AEPB MO ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO BEVESPI AEROSPHERE AERO MO chlordiazepoxide-clidinium caps CUVPOSA SOLN MO dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate pf sosy glycopyrrolate soln glycopyrrolate tabs 1mg 2mg MO INCRUSE ELLIPTA AEPB MO ipratropium bromide soln 002 PAMO ipratropium bromide soln 003 006 MO
LONHALA MAGNAIR REFILL KIT SOLN NDS
methscopolamine bromide tabs 25mg 5mg MO
propantheline bromide tabs MO SPIRIVA HANDIHALER CAPS MO SPIRIVA RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 20 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO NICOTROL NS SOLN MO PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride tabs 5mg 10mg 25mg 50mg MO
CEVIMELINE HCL CAPS MO donepezil hcl tabs 5mg 10mg 23mg MO
donepezil hcl tbdp 5mg 10mg MO galantamine hydrobromide er cp24 8mg 16mg 24mg MO
galantamine hydrobromide soln MO galantamine hydrobromide tabs 4mg 8mg 12mg MO
GUANIDINE HCL TABS MO MESTINON SOLN MO pilocarpine hcl tabs 5mg 75mg MO pyridostigmine bromide er tbcr MO pyridostigmine bromide soln MO pyridostigmine bromide tabs 30mg 60mg MO
REGONOL SOLN rivastigmine pt24 46mg24hr 95mg24hr 133mg24hr MO
rivastigmine tartrate caps 15mg 3mg 45mg 6mg MO
urecholine tabs 5mg 10mg 25mg 50mg MO
SKELETAL MUSCLE RELAXANTS baclofen soln baclofen tabs 5mg 10mg 20mg MO carisoprodol tabs 250mg 350mg PANDS carisoprodol-aspirin tabs PANDS carisoprodol-aspirin-codeine tabs PANDS
chlorzoxazone tabs 375mg 500mg 750mg NDS
Drug Name RequirementsLimits
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA lorzone tabs 375mg 750mg NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln revonto solr succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs vanadom tabs PANDS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl er tb24 MO dihydroergotamine mesylate soln NDS ergoloid mesylates tabs MO ergomar subl phenoxybenzamine hcl caps NDS silodosin caps 4mg 8mg MO tamsulosin hcl caps MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR HFA AERO MO albuterol sulfate er tb12 4mg 8mg MO
albuterol sulfate hfa aers MONDS albuterol sulfate nebu 0083 25mg05ml PAMO
albuterol sulfate nebu 063mg3ml 125mg3ml PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO ARCAPTA NEOHALER CAPS MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY EPIPEN 2-PAK SOAJ EPIPEN JR 2-PAK SOAJ formoterol fumarate nebu PAMO ipratropium-albuterol soln PAMO isoproterenol hcl soln levalbuterol hcl nebu 125mg05ml 031mg3ml 063mg3ml 125mg3ml
PAMO
levalbuterol tartrate aero MO metaproterenol sulfate syrp MO metaproterenol sulfate tabs 10mg 20mg MO
midodrine hcl tabs 25mg 5mg 10mg MO
norepinephrine bitartrate soln phenylephrine hcl soln PROAIR RESPICLICK AEPB MO SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
tizanidine hcl caps VENTOLIN HFA AERS MONDS BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS BERINERT KIT INTRAVENOUS HI FIRAZYR SOLN NDS icatibant acetate soln NDS OXBRYTA TABS NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS
Drug Name RequirementsLimits
COAGULANTS AND ANTICOAGULANTS aminocaproic acid soln MO aminocaproic acid tabs 500mg 1000mg MO
anagrelide hcl caps 05mg 1mg MO argatroban soln aspirin-dipyridamole er cp12 MO BEVYXXA CAPS 40mg 80mg MO BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
NDS
FRAGMIN SOLN 2500unit02ml 5000unit02ml 7500unit03ml 12500unit05ml 15000unit06ml 95000unit38ml 10000unitml 18000unt072ml
NDS
heparin (porcine) in nacl soln HEPARIN SOD (PORCINE) IN D5W SOLN
heparin sodium (porcine) pf soln PA heparin sodium (porcine) soln 1000unitml 5000unitml 10000unitml 20000unitml
PA
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg
MO
LOVENOX SOLN 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 22 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg PRADAXA CAPS 110mg 150mg MO
prasugrel hcl tabs 5mg 10mg MO tranexamic acid soln tranexamic acid tabs MO warfarin sodium tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 10mg
MO
XARELTO STARTER PACK TBPK MO
XARELTO TABS 25mg 10mg 15mg 20mg MO
ZONTIVITY TABS MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 25mcgml 40mcgml PANDS
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml
PANDS
FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MIRCERA SOSY 30mcg03ml 50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml
PA
MULPLETA TABS NDS
Drug Name RequirementsLimits
NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml NDS
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RETACRIT SOLN 20000unit2ml 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL TB24 4mg 8mg MO DEMSER CAPS NDS doxazosin mesylate tabs 1mg 2mg 4mg 8mg MO
metyrosine caps NDS prazosin hcl caps 1mg 2mg 5mg MO
terazosin hcl caps 1mg 2mg 5mg 10mg MO
ANTILIPEMIC AGENTS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
ALTOPREV TB24 20mg 40mg 60mg MO
ANTARA CAPS 30mg 90mg MO atorvastatin calcium tabs 10mg 20mg 40mg 80mg MO
cholestyramine light pack MO cholestyramine light powd MO cholestyramine pack MO cholestyramine powd MO colesevelam hcl pack MO colesevelam hcl tabs MO colestipol hcl gran MO colestipol hcl pack MO colestipol hcl tabs MO EVKEEZA SOLN 345mg23ml 1200mg8ml NDS
ezetimibe tabs MO ezetimibe-simvastatin tabs MO fenofibrate caps 50mg 134mg 150mg MO
fenofibrate micronized caps 43mg 67mg 130mg 200mg MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg MO
FENOFIBRIC ACID TABS 35mg 105mg MO
FIBRICOR TABS MO FLOLIPID SUSP 20mg5ml 40mg5ml MO
fluvastatin sodium caps 20mg 40mg MO
fluvastatin sodium er tb24 MO gemfibrozil tabs MO icosapent ethyl caps MO JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg PALDNDS
KYNAMRO SOSY PALDNDS LIVALO TABS 1mg 2mg 4mg MO lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
Drug Name RequirementsLimits
niacor tabs MO omega-3-acid ethyl esters caps MO pravastatin sodium tabs 10mg 20mg 40mg 80mg MO
prevalite pack MO prevalite powd MO questran light powd MO questran pack MO questran powd MO REPATHA PUSHTRONEX SYSTEM SOCT PANDS
REPATHA SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 05gm 1gm MO ZYPITAMAG TABS 1mg 2mg 4mg MO
BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl caps 200mg 400mg MO
atenolol tabs 25mg 50mg 100mg MO
atenolol-chlorthalidone tabs MO betaxolol hcl tabs 10mg 20mg MO bisoprolol fumarate tabs 5mg 10mg MO
bisoprolol-hydrochlorothiazide tabs MO
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg MO
carvedilol tabs 3125mg 625mg 125mg 25mg MO
DUTOPROL TB24 MO ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln INNOPRAN XL CP24 80mg 120mg MO
labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 24 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
metoprolol succinate er tb24 25mg 50mg 100mg 200mg MO
metoprolol tartrate soct metoprolol tartrate soln metoprolol tartrate tabs 25mg 50mg 100mg MO
metoprolol tartrate tabs 375mg 75mg MO
metoprolol-hydrochlorothiazide tabs MO
nadolol tabs 20mg 40mg 80mg MO nadolol-bendroflumethiazide tabs MO
pindolol tabs 5mg 10mg MO propranolol hcl er cp24 60mg 80mg 120mg 160mg MO
propranolol hcl soln 20mg5ml 40mg5ml MO
propranolol hcl tabs 10mg 20mg 40mg 60mg 80mg MO
propranolol-hctz tabs MO sorine tabs 80mg 120mg 160mg 240mg MO
sotalol hcl (af) tabs 80mg 120mg 160mg MO
sotalol hcl tabs 80mg 120mg 160mg 240mg MO
SOTYLIZE SOLN MO timolol maleate tabs 5mg 10mg 20mg MO
CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besy-benazepril hcl caps MO
amlodipine besylate tabs 25mg 5mg 10mg MO
amlodipine besylate-valsartan tabs MO
amlodipine-atorvastatin tabs MO amlodipine-olmesartan tabs MO amlodipine-valsartan-hctz tabs MO CARDENE IV SOLN CARDIZEM LA TB24 MO cartia xt cp24 120mg 180mg 240mg 300mg MO
Drug Name RequirementsLimits
CONSENSI TABS NDS dilt-xr cp24 120mg 180mg 240mg MO
diltiazem hcl er beads cp24 120mg 180mg 240mg 300mg 360mg 420mg
MO
DILTIAZEM HCL ER COATED BEADS CP24 120mg 180mg 240mg 300mg 360mg
MO
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg
MO
diltiazem hcl er cp12 60mg 90mg 120mg MO
diltiazem hcl er cp24 120mg 180mg 240mg MO
diltiazem hcl soln diltiazem hcl solr diltiazem hcl tabs 30mg 60mg 90mg 120mg MO
felodipine er tb24 25mg 5mg 10mg MO
isradipine caps 25mg 5mg MO matzim la tb24 180mg 240mg 300mg 360mg 420mg MO
nicardipine hcl caps 20mg 30mg MO nicardipine hcl soln nifedipine caps 10mg 20mg MO nifedipine er osmotic release tb24 30mg 60mg 90mg MO
nifedipine er tb24 30mg 60mg 90mg MO
nimodipine caps MO nisoldipine er tb24 85mg 17mg 20mg 255mg 30mg 34mg 40mg
MO
NYMALIZE SOLN 60mg20ml 6mgml NDS
olmesartan-amlodipine-hctz tabs MO taztia xt cp24 120mg 180mg 240mg 300mg 360mg MO
telmisartan-amlodipine tabs MO tiadylt er cp24 120mg 180mg 240mg 300mg 360mg 420mg MO
trandolapril-verapamil hcl er tbcr MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
VERAPAMIL HCL ER CP24 100mg 120mg 180mg 200mg 240mg 300mg 360mg
MO
verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 80mg 120mg MO verapamil hcl tabs MO VERELAN CP24 MO CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln inj DIGOXIN ORAL SOLN MO digoxin tabs 125mcg 250mcg MO disopyramide phosphate caps 100mg 150mg MO
dofetilide caps 125mcg 250mcg 500mcg MO
flecainide acetate tabs 50mg 100mg 150mg MO
ibutilide fumarate soln LANOXIN PEDIATRIC SOLN LANOXIN TABS 625mcg MO lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy LIDOCAINE IN D5W SOLN mexiletine hcl caps 150mg 200mg 250mg MO
milrinone lactate in dextrose soln milrinone lactate soln MULTAQ TABS NORPACE CR CP12 100mg 150mg MO
pacerone tabs 100mg 200mg 400mg MO
procainamide hcl soln
Drug Name RequirementsLimits
propafenone hcl er cp12 225mg 325mg 425mg MO
propafenone hcl tabs 150mg 225mg 300mg MO
quinidine gluconate er tbcr MO QUINIDINE GLUCONATE SOLN quinidine sulfate tabs 200mg 300mg MO
ranolazine er tb12 500mg 1000mg MO
VYNDAMAX CAPS NDS VYNDAQEL CAPS NDS HYPOTENSIVE AGENTS clonidine hcl (analgesia) soln clonidine hcl er tb12 MO clonidine hcl tabs 01mg 02mg 03mg MO
clonidine ptwk 01mg24hr 02mg24hr 03mg24hr MO
guanfacine hcl tabs 1mg 2mg MO hydralazine hcl soln hydralazine hcl tabs 10mg 25mg 50mg 100mg MO
methyldopa tabs 250mg 500mg MO methyldopa-hydrochlorothiazide tabs MO
minoxidil tabs 25mg 10mg MO nitropress soln nitroprusside sodium soln vecamyl tabs NDS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE TABS MO aliskiren fumarate tabs 150mg 300mg MO
benazepril hcl tabs 5mg 10mg 20mg 40mg MO
benazepril-hydrochlorothiazide tabs MO
candesartan cilexetil tabs 4mg 8mg 16mg 32mg MO
candesartan cilexetil-hctz tabs MO captopril tabs 125mg 25mg 50mg 100mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 26 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
captopril-hydrochlorothiazide tabs MO
CAROSPIR SUSP MO EDARBYCLOR TABS MO enalapril maleate tabs 25mg 5mg 10mg 20mg MO
enalapril-hydrochlorothiazide tabs MO
enalaprilat inj ENTRESTO TABS MO eplerenone tabs 25mg 50mg MO eprosartan mesylate tabs MO fosinopril sodium tabs 10mg 20mg 40mg MO
fosinopril sodium-hctz tabs MO irbesartan tabs 75mg 150mg 300mg MO
irbesartan-hydrochlorothiazide tabs MO
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg MO
lisinopril-hydrochlorothiazide tabs MO
losartan potassium tabs 25mg 50mg 100mg MO
losartan potassium-hctz tabs MO moexipril hcl tabs 75mg 15mg MO olmesartan medoxomil tabs 5mg 20mg 40mg MO
olmesartan medoxomil-hctz tabs MO perindopril erbumine tabs 2mg 4mg 8mg MO
QBRELIS SOLN MO quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO TEKTURNA HCT TABS MO
Drug Name RequirementsLimits
telmisartan tabs 20mg 40mg 80mg MO
telmisartan-hctz tabs MO trandolapril tabs 1mg 2mg 4mg MO valsartan tabs 40mg 80mg 160mg 320mg MO
valsartan-hydrochlorothiazide tabs MO
VASODILATING AGENTS alyq tabs PA BIDIL TABS MO dipyridamole tabs 25mg 50mg 75mg MO
GONITRO PACK MO isosorbide dinitrate er tbcr MO isosorbide dinitrate tabs 5mg 10mg 20mg 30mg MO
isosorbide mononitrate er tb24 30mg 60mg MO
isosorbide mononitrate er tb24 MO isosorbide mononitrate tabs 10mg 20mg MO
minitran pt24 01mghr 02mghr 04mghr 06mghr MO
nitro-bid oint MO NITRO-DUR PT24 03mghr 08mghr MO
nitroglycerin pt24 01mghr 02mghr 04mghr 06mghr MO
nitroglycerin soln MO nitroglycerin subl 03mg 04mg 06mg MO
sildenafil citrate soln PANDS sildenafil citrate susr PA sildenafil citrate tabs PAMO tadalafil (pah) tabs 20mg PA tadalafil tabs 25mg 5mg PA CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS acamprosate calcium tbec MO antabuse tabs 250mg 500mg MO disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
ABSTRAL SUBL 100mcg 200mcg 300mcg 400mcg 600mcg 800mcg
PANDS
acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ARYMO ER TBEA NDS ascomp-codeine caps NDS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
benzhydrocodone-acetaminophen tabs
bupap tabs buprenorphine hcl soln NDS buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
butalbital-acetaminophen caps NDS butalbital-acetaminophen tabs butalbital-apap-caff-cod caps NDS butalbital-apap-caffeine caps butalbital-apap-caffeine tabs butalbital-asa-caff-codeine caps NDS butalbital-aspirin-caffeine caps butalbital-aspirin-caffeine tabs butorphanol tartrate soln 1mgml 2mgml 10mgml NDS
BUTRANS PTWK NDS cataflam tabs NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
DEMEROL SOLN 25mg05ml 75mg15ml 100mg2ml 75mgml
PANDS
diclofenac potassium tabs diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs
Drug Name RequirementsLimits
DUEXIS TABS NDS DURAMORPH SOLN 05mgml 1mgml HINDS
dvorah tabs NDS EMBEDA CPCR NDS endocet tabs NDS esgic caps esgic tabs etodolac caps etodolac er tb24 etodolac tabs fenoprofen calcium caps fenoprofen calcium tabs fenortho caps fentanyl citrate (pf) soct NDS FENTANYL CITRATE (PF) SOLN 50mcgml 1000mcg20ml 2500mcg50ml
NDS
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fioricet caps fioricetcodeine caps NDS flurbiprofen tabs hydrocodone bitartrate er cp12 10mg 15mg 20mg 30mg 40mg 50mg
NDS
hydrocodone-acetaminophen soln NDS
hydrocodone-acetaminophen tabs NDS
hydrocodone-ibuprofen tabs NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 28 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd NDS hydromorphone hcl pf soln 50mg5ml 10mgml NDS
HYDROMORPHONE HCL SOLN 1mgml 2mgml NDS
hydromorphone hcl tabs 2mg 4mg 8mg NDS
ibu tabs ibudone tabs NDS ibuprofen lysine soln ibuprofen susp ibuprofen tabs ILARIS SOLN NDS indocin supp INDOCIN SUSP indomethacin caps INDOMETHACIN CAPS 20mg indomethacin er cpcr indomethacin sodium solr KADIAN CP24 NDS ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 300mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lodine tabs lorcet hd tabs NDS lorcet plus tabs NDS lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam caps meloxicam tabs meperidine hcl soln 50mg5ml 25mgml 50mgml 100mgml PANDS
meperidine hcl tabs 50mg 100mg NDS
Drug Name RequirementsLimits
methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl soln 5mg5ml 10mg5ml 10mgml NDS
methadone hcl tabs 5mg 10mg NDS mitigo soln MORPHINE SULFATE (CONCENTRATE) SOLN NDS
morphine sulfate (pf) soln 4mgml 10mgml NDS
MORPHINE SULFATE (PF) SOLN INTRAVENOUS HI
morphine sulfate er beads cp24 30mg 45mg 60mg 75mg 90mg 120mg
NDS
morphine sulfate er cp24 10mg 20mg 30mg 40mg 50mg 60mg 80mg 100mg
NDS
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg NDS
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml NDS
MORPHINE SULFATE SOLN HINDS MORPHINE SULFATE SOLN INJECTION 2mgml 4mgml 10mgml
HI
MORPHINE SULFATE SOLN INTRAVENOUS HI
morphine sulfate tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln nalfon tabs nalocet tabs NDS NAPRELAN TB24 naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
NUCYNTA ER TB12 50mg 100mg 150mg NDS
NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS 50mg 75mg NDS NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs oxaprozin tabs OXAYDO TABS NDS oxycodone hcl caps NDS oxycodone hcl conc NDS oxycodone hcl er t12a 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxycodone hcl soln NDS oxycodone hcl tabs 5mg 10mg 15mg 20mg 30mg NDS
oxycodone-acetaminophen soln NDS oxycodone-acetaminophen tabs NDS oxycodone-acetaminophen tabs 5-300mg 10-300mg NDS
oxycodone-aspirin tabs NDS oxycodone-ibuprofen tabs NDS OXYCONTIN T12A 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxymorphone hcl er tb12 5mg 75mg 10mg 15mg 20mg 30mg 40mg
NDS
oxymorphone hcl tabs 5mg 10mg NDS
panlor tabs NDS pentazocine-naloxone hcl tabs NDS percocet tabs NDS phrenilin forte caps PIROXICAM CAPS 10mg 20mg NDS pregabalin er tb24 825mg 165mg 330mg MO
primlev tabs NDS prolate soln NDS prolate tabs NDS QDOLO SOLN NDS
Drug Name RequirementsLimits
relafen ds tabs NDS ROXYBOND TABA 5mg 15mg 30mg NDS
SALSALATE TABS SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
SUBSYS LIQD 100mcg 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
sulindac tabs tencon tabs TIVORBEX CAPS tolmetin sodium caps tolmetin sodium tabs tramadol hcl er (biphasic) tb24 100mg 200mg 300mg NDS
tramadol hcl er cp24 100mg 150mg 200mg 300mg NDS
tramadol hcl er tb24 100mg 200mg 300mg NDS
tramadol hcl tabs 50mg 100mg NDS tramadol-acetaminophen tabs NDS trezix caps NDS tylenol with codeine 3 tabs NDS tylenol with codeine 4 tabs NDS vanatol lq soln vicodin es tabs NDS vicodin hp tabs NDS vicodin tabs NDS XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg NDS
zebutal caps ZIPSOR CAPS ZORVOLEX CAPS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS ADDERALL XR CP24 NDS ADZENYS ER SUER NDS ADZENYS XR-ODT TBED 31mg 63mg 94mg 125mg 157mg 188mg
NDS
amphetamine er suer NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 30 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
amphetamine sulfate tabs 5mg 10mg NDS
amphetamine-dextroamphet er cp24 NDS
amphetamine-dextroamphetamine tabs NDS
armodafinil tabs 50mg 150mg 200mg 250mg PA
caffeine citrate soln COTEMPLA XR-ODT TBED 86mg 173mg 259mg NDS
DAYTRANA PTCH 10mg9hr 15mg9hr 20mg9hr 30mg9hr NDS
dexmethylphenidate hcl er cp24 5mg 10mg 15mg 20mg 25mg 30mg 35mg 40mg
NDS
dexmethylphenidate hcl tabs 25mg 5mg 10mg NDS
dextroamphetamine sulfate er cp24 5mg 10mg 15mg NDS
dextroamphetamine sulfate soln NDS dextroamphetamine sulfate tabs 5mg 10mg 15mg 20mg 30mg NDS
DYANAVEL XR SUER NDS evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS methylphenidate hcl chew 25mg 5mg 10mg NDS
methylphenidate hcl er (cd) cpcr 10mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er (la) cp24 10mg 20mg 30mg 40mg 60mg
NDS
methylphenidate hcl er (xr) cp24 10mg 15mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg NDS
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg
NDS
methylphenidate hcl soln 5mg5ml 10mg5ml NDS
Drug Name RequirementsLimits
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS MYDAYIS CP24 NDS procentra soln NDS QUILLICHEW ER CHER 20mg 30mg 40mg NDS
QUILLIVANT XR SRER NDS relexxii tbcr NDS SUNOSI TABS 75mg 150mg NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
NDS
VYVANSE CHEW 10mg 20mg 30mg 40mg 50mg 60mg NDS
WAKIX TABS 445mg 178mg NDS zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg
NDS
ANTICONVULSANTS APTIOM TABS 200mg 400mg 600mg 800mg MO
BANZEL SUSP BANZEL TABS 200mg 400mg NDS BRIVIACT SOLN NDS BRIVIACT TABS 10mg 25mg 50mg 75mg 100mg NDS
carbamazepine chew MO carbamazepine er cp12 100mg 200mg 300mg MO
carbamazepine er tb12 100mg 200mg 400mg MO
carbamazepine susp MO carbamazepine tabs MO CELONTIN CAPS MO clobazam susp MO clobazam tabs 10mg 20mg MO clonazepam tabs 05mg 1mg 2mg NDS
clonazepam tbdp 0125mg 025mg 05mg 1mg 2mg NDS
DIACOMIT CAPS 250mg 500mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
DIACOMIT PACK 250mg 500mg NDS
DIASTAT ACUDIAL GEL 10mg 20mg NDS
DIASTAT PEDIATRIC GEL NDS diazepam gel 25mg 10mg 20mg NDS
dilantin caps 30mg 100mg MO dilantin infatabs chew MO divalproex sodium csdr MO divalproex sodium er tb24 250mg 500mg MO
divalproex sodium tbec 125mg 250mg 500mg MO
ELEPSIA XR TB24 1000mg 1500mg NDS
EPIDIOLEX SOLN PANDS epitol tabs MO ethosuximide caps MO ethosuximide soln MO felbamate susp MO felbamate tabs 400mg 600mg MO FINTEPLA SOLN NDS fosphenytoin sodium soln FYCOMPA SUSP NDS FYCOMPA TABS gabapentin caps 100mg 400mg MO gabapentin soln MO gabapentin tabs 600mg 800mg MO HORIZANT TBCR 300mg 600mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
lamotrigine kit MO lamotrigine starter kit-blue kit MO lamotrigine starter kit-green kit MO lamotrigine starter kit-orange kit MO lamotrigine tabs 25mg 100mg 150mg 200mg MO
lamotrigine tbdp 25mg 50mg 100mg 200mg MO
Drug Name RequirementsLimits
levetiracetam er tb24 500mg 750mg MO
levetiracetam in nacl soln levetiracetam soln MO levetiracetam tabs 250mg 500mg 750mg 1000mg MO
magnesium sulfate soln magnesium sulfate soln injection 50 HI
MAGNESIUM SULFATE SOLN INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml
HI
NAYZILAM SOLN NDS oxcarbazepine susp MO oxcarbazepine tabs 150mg 300mg 600mg MO
OXTELLAR XR TB24 150mg 300mg 600mg MO
PEGANONE TABS MO phenytek caps 200mg 300mg MO phenytoin chew MO phenytoin sodium extended caps 100mg 200mg 300mg MO
phenytoin sodium soln phenytoin susp MO pregabalin caps 25mg 50mg 75mg 100mg 150mg 200mg 225mg 300mg
MO
pregabalin soln MO primidone tabs 50mg 250mg MO roweepra tabs 500mg 750mg 1000mg MO
roweepra xr tb24 500mg 750mg MO rufinamide susp rufinamide tabs 200mg 400mg NDS SPRITAM TB3D 250mg 500mg 750mg 1000mg NDS
subvenite starter kit-blue kit MO subvenite starter kit-green kit MO subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 32 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
SYMPAZAN FILM 10mg 20mg tiagabine hcl tabs 2mg 4mg 12mg 16mg MO
topiramate cpsp 15mg 25mg MO topiramate er cs24 25mg 50mg 100mg 150mg 200mg MO
topiramate tabs 25mg 50mg 100mg 200mg MO
TROKENDI XR CP24 25mg 50mg 100mg 200mg MO
valproate sodium soln valproic acid caps MO valproic acid soln MO VALTOCO 10 MG DOSE LIQD NDS VALTOCO 15 MG DOSE LQPK NDS VALTOCO 20 MG DOSE LQPK NDS VALTOCO 5 MG DOSE LIQD NDS vigabatrin pack LDNDS vigabatrin tabs NDS vigadrone pack LDNDS VIMPAT SOLN VIMPAT TABS MO XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200 MG NDS XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ AJOVY SOSY almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs EMGALITY (300 MG DOSE) SOSY NDS
Drug Name RequirementsLimits
EMGALITY SOAJ EMGALITY SOSY ergotamine-caffeine tabs frovatriptan succinate tabs naratriptan hcl tabs NURTEC TBDP NDS ONZETRA XSAIL EXHP rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs TOSYMRA SOLN UBRELVY TABS 50mg 100mg NDS ZEMBRACE SYMTOUCH SOAJ zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ZOMIG SOLN ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl syrp MO amantadine hcl tabs MO APOKYN SOCT NDS benztropine mesylate soln benztropine mesylate tabs 05mg 1mg 2mg MO
bromocriptine mesylate caps MO bromocriptine mesylate tabs MO cabergoline tabs MO carbidopa tabs MO carbidopa-levodopa er tbcr MO carbidopa-levodopa tabs MO carbidopa-levodopa tbdp MO carbidopa-levodopa-entacapone tabs MO
DUOPA SUSP LD EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg NDS
pramipexole dihydrochloride er tb24 0375mg 075mg 15mg 225mg 3mg 375mg 45mg
MO
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg
MO
rasagiline mesylate tabs 05mg 1mg MO
ropinirole hcl er tb24 2mg 4mg 6mg 8mg 12mg MO
ropinirole hcl tabs 025mg 05mg 1mg 2mg 3mg 4mg 5mg
MO
RYTARY CPCR MO selegiline hcl caps MO selegiline hcl tabs MO tolcapone tabs MO trihexyphenidyl hcl soln MO trihexyphenidyl hcl tabs 2mg 5mg MO
ZELAPAR TBDP MO ANXIOLYTICS SEDATIVES AND HYPNOTICS alprazolam er tb24 05mg 1mg 2mg 3mg NDS
alprazolam intensol conc NDS alprazolam tabs 025mg 05mg 1mg 2mg NDS
alprazolam tbdp 025mg 05mg 1mg 2mg NDS
BELSOMRA TABS buspirone hcl tabs 5mg 10mg buspirone hcl tabs 75mg 15mg 30mg
chlordiazepoxide hcl caps 5mg 10mg 25mg NDS
clorazepate dipotassium tabs 375mg 75mg 15mg NDS
diazepam conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS
Drug Name RequirementsLimits
droperidol soln EDLUAR SUBL 5mg 10mg NDS estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP NDS hydroxyzine hcl soln hydroxyzine hcl syrp hydroxyzine hcl tabs hydroxyzine pamoate caps lorazepam intensol conc NDS LORAZEPAM SOLN 4mgml 2mgml NDS
lorazepam tabs 05mg 1mg 2mg NDS
meprobamate tabs midazolam hcl (pf) soln midazolam hcl soln midazolam hcl syrp nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs ROZEREM TABS seconal caps TEMAZEPAM CAPS 15mg 225mg 30mg 75mg NDS
triazolam tabs 0125mg 025mg NDS zaleplon caps 5mg 10mg NDS zolpidem tartrate er tbcr 625mg 125mg NDS
zolpidem tartrate subl 175mg 35mg NDS
zolpidem tartrate tabs 5mg 10mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 34 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS atomoxetine hcl caps 10mg 18mg 25mg 40mg 60mg 80mg 100mg
MO
AUSTEDO TABS 6mg 9mg 12mg LDNDS
EXSERVAN FILM NDS flumazenil soln guanfacine hcl er tb24 1mg 2mg 3mg 4mg MO
INGREZZA CAPS 40mg 60mg 80mg NDS
INGREZZA CPPK NDS memantine hcl er cp24 memantine hcl soln MO memantine hcl tabs 5mg 10mg MO NAMENDA XR TITRATION PACK CP24 MO
NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS SAVELLA TABS 125mg 25mg 50mg 100mg MO
SAVELLA TITRATION PACK MISC MO
tetrabenazine tabs 125mg 25mg NDS
TIGLUTIK SUSP NDS XYREM SOLN LDNDS XYWAV SOLN NDS MULTIPLE SCLEROSIS AGENTS AUBAGIO TABS 7mg 14mg PANDS AVONEX KIT NDS AVONEX PEN AJKT NDS AVONEX PREFILLED PSKT NDS BAFIERTAM CPDR NDS BETASERON KIT NDS dalfampridine er tb12 MO dimethyl fumarate cpdr dimethyl fumarate starter pack misc
Drug Name RequirementsLimits
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatiramer acetate sosy 20mgml 40mgml NDS
glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 2mg NDS OCREVUS SOLN PLEGRIDY SOSY NDS PONVORY STARTER PACK TBPK NDS
PONVORY TABS NDS REBIF REBIDOSE SOAJ 22mcg05ml 44mcg05ml NDS
REBIF REBIDOSE TITRATION PACK SOAJ NDS
REBIF SOSY 22mcg05ml 44mcg05ml NDS
REBIF TITRATION PACK SOSY NDS TECFIDERA CPDR 120mg 240mg NDS
TECFIDERA MISC NDS TYSABRI CONC INTRAVENOUS HI
ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS ZINBRYTA SOSY LDNDS OPIATE ANTAGONISTS BUNAVAIL FILM NDS buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
LUCEMYRA TABS NDS naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR NDS ZUBSOLV SUBL NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg NDS
ABILIFY MYCITE MAINTENANCE KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg NDS
amitriptyline hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
amoxapine tabs 25mg 50mg 100mg 150mg MO
APLENZIN TB24 174mg 348mg 522mg MO
aripiprazole soln MO aripiprazole tabs 2mg 5mg 10mg 15mg 20mg 30mg MO
aripiprazole tbdp 10mg 15mg MO ARISTADA INITIO PRSY NDS ARISTADA PRSY 441mg16ml 662mg24ml 882mg32ml 1064mg39ml
NDS
asenapine maleate subl 25mg 5mg 10mg MO
bupropion hcl er (smoking det) tb12 MO
bupropion hcl er (sr) tb12 100mg 150mg 200mg MO
bupropion hcl er (xl) tb24 150mg 300mg 450mg MO
bupropion hcl tabs 75mg 100mg MO CAPLYTA CAPS NDS chlordiazepoxide-amitriptyline tabs
chlorpromazine hcl soln
Drug Name RequirementsLimits
chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
clomipramine hcl caps 25mg 50mg 75mg MO
clozapine tabs 25mg 50mg 100mg 200mg NDS
clozapine tbdp 125mg 25mg 100mg 150mg 200mg NDS
compro supp MO desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
DESVENLAFAXINE ER TB24 50mg 100mg MO
desvenlafaxine succinate er tb24 25mg 50mg 100mg MO
doxepin hcl caps 10mg 25mg 50mg 75mg 100mg 150mg MO
doxepin hcl conc MO doxepin hcl tabs 3mg 6mg MO DRIZALMA SPRINKLE CSDR duloxetine hcl cpep 20mg 30mg 40mg 60mg MO
EQUETRO CP12 100mg 200mg 300mg MO
escitalopram oxalate soln MO escitalopram oxalate tabs 5mg 10mg 20mg MO
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg NDS
FANAPT TITRATION PACK TABS MO
FETZIMA CP24 20mg 40mg 80mg 120mg MO
FETZIMA TITRATION C4PK MO fluoxetine hcl (pmdd) tabs 10mg 20mg MO
fluoxetine hcl caps 10mg 20mg 40mg MO
fluoxetine hcl cpdr MO fluoxetine hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 36 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
GEODON SOLR haloperidol decanoate soln haloperidol lactate conc MO haloperidol lactate soln haloperidol tabs 05mg 1mg 2mg 5mg 10mg 20mg MO
imipramine hcl tabs 10mg 25mg 50mg MO
imipramine pamoate caps 75mg 100mg 125mg 150mg MO
INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 300mg 150mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
lithium carbonate tabs MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO
Drug Name RequirementsLimits
mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
nefazodone hcl tabs 50mg 100mg 150mg 200mg 250mg MO
nortriptyline hcl caps 10mg 25mg 50mg 75mg MO
nortriptyline hcl soln MO NUPLAZID CAPS NDS NUPLAZID TABS 10mg 17mg NDS olanzapine solr olanzapine tabs 25mg 5mg 75mg 10mg 15mg 20mg MO
olanzapine tbdp 5mg 10mg 15mg 20mg MO
olanzapine-fluoxetine hcl caps MO PALIPERIDONE ER TB24 15mg 3mg 6mg 9mg MO
paroxetine hcl er tb24 125mg 25mg 375mg MO
paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps MO PAXIL SUSP MO perphenazine tabs 2mg 4mg 8mg 16mg MO
perphenazine-amitriptyline tabs MO PERSERIS PRSY 90mg 120mg NDS PEXEVA TABS 10mg 20mg 30mg 40mg MO
phenelzine sulfate tabs MO pimozide tabs 1mg 2mg MO prochlorperazine edisylate soln prochlorperazine maleate tabs prochlorperazine supp MO protriptyline hcl tabs 5mg 10mg MO quetiapine fumarate er tb24 50mg 150mg 200mg 300mg 400mg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
quetiapine fumarate tabs 25mg 50mg 100mg 200mg 300mg 400mg
MO
REXULTI TABS 025mg 05mg 1mg 2mg 3mg 4mg NDS
RISPERDAL CONSTA SRER 125mg 25mg NDS
RISPERDAL CONSTA SRER 375mg 50mg NDS
risperidone soln MO risperidone tabs 025mg 05mg 1mg 2mg 3mg 4mg MO
risperidone tbdp 025mg 05mg 1mg 2mg 3mg 4mg MO
SAPHRIS SUBL 25mg 5mg 10mg NDS
SECUADO PT24 38mg24hr 57mg24hr 76mg24hr NDS
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
SILENOR TABS SPRAVATO (56 MG DOSE) SOPK NDS
SPRAVATO (84 MG DOSE) SOPK NDS
thioridazine hcl tabs 10mg 25mg 50mg 100mg MO
thiothixene caps 1mg 2mg 5mg 10mg MO
tofranil tabs 10mg 25mg 50mg MO tranylcypromine sulfate tabs MO trazodone hcl tabs 50mg 100mg 150mg MO
trazodone hcl tabs MO trifluoperazine hcl tabs 1mg 2mg 5mg 10mg MO
trimipramine maleate caps 25mg 50mg 100mg MO
TRINTELLIX TABS 5mg 10mg 20mg MO
venlafaxine hcl er cp24 375mg 75mg 150mg MO
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg MO
Drug Name RequirementsLimits
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
VRAYLAR CAPS 15mg 3mg 45mg 6mg NDS
VRAYLAR CPPK NDS ziprasidone hcl caps 20mg 40mg 60mg 80mg MO
ziprasidone mesylate solr ZYPREXA RELPREVV SUSR DIABETIC SUPPLIES DIABETIC SUPPLIES ALCOHOL PREP PADS MO BD INSULIN SYR ULTRAFINE II MISC MO
BD INSULIN SYRINGE MISC MO BD INSULIN SYRINGE UF MISC MO
BD PEN NEEDLE ORIGINAL UF MISC MO
CURITY GAUZE PADS MO OMNIPOD STARTER KIT NDS ELECTROLYTIC CALORIC AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS POT amp SOD CIT-CIT AC SOLN potassium citrate er tbcr 15meq 540mg 1080mg MO
SODIUM ACETATE SOLN SODIUM BICARBONATE SOLN SODIUM LACTATE SOLN INTRAVENOUS HI
TRICITRATES SOLN AMMONIA DETOXICANTS CARBAGLU TABS LD constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 38 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lactulose pack MO lactulose soln MO LITHOSTAT TABS MO RAVICTI LIQD NDS sod benz-sod phenylacet soln sodium phenylbutyrate powd NDS sodium phenylbutyrate tabs NDS CALORIC AGENTS AMINOSYN-PF SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (27510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42525) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (525) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (525) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN dextrose soln intravenous 5 10 HI
Drug Name RequirementsLimits
FREAMINE HBC SOLN INTRAVENOUS HI
HEPATAMINE SOLN INTRAVENOUS HI
INTRALIPID EMUL INTRAVENOUS 20gm100ml HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NEPHRAMINE SOLN INTRAVENOUS HI
NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE SOLN INTRAVENOUS HI
PROSOL SOLN INTRAVENOUS HI TRAVASOL SOLN INTRAVENOUS HI
TROPHAMINE SOLN INTRAVENOUS HI
DIURETICS AMILORIDE HCL TABS MO amiloride-hydrochlorothiazide tabs MO
bumetanide soln bumetanide tabs 05mg 1mg 2mg MO
chlorothiazide sodium solr chlorothiazide tabs 250mg 500mg MO
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI FUROSEMIDE TABS 40mg 80mg 20mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN SAMSCA TABS 15mg NDS TOLVAPTAN TABS 30mg 15mg NDS torsemide tabs 5mg 10mg 20mg 100mg MO
triamterene caps 50mg 100mg MO triamterene-hctz caps MO triamterene-hctz tabs MO ION-REMOVING AGENTS AURYXIA TABS PAMONDS FOSRENOL PACK 750mg 1000mg NDS
kionex susp MO lanthanum carbonate chew 500mg 750mg 1000mg MO
LOKELMA PACK 5gm 10gm MO sevelamer carbonate pack 08gm 24gm MO
sevelamer carbonate tabs MO sevelamer hcl tabs 400mg 800mg MO
sodium polystyrene sulfonate powd MO
sodium polystyrene sulfonate susp MO
sps susp MO VELPHORO CHEW NDS VELTASSA PACK 84gm 168gm 252gm NDS
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate (phos binder) tabs MO
CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
Drug Name RequirementsLimits
DEXTROSE-NACL SOLN INTRAVENOUS HI
DEXTROSE 10NACL 02 DEXTROSE 10NACL 045 HI
DEXTROSE 5NACL 0225 HI IONOSOL-MB IN D5W SOLN INTRAVENOUS HI
ISOLYTE-P IN D5W SOLN INTRAVENOUS HI
ISOLYTE-S SOLN INTRAVENOUS HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-033 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 TBCR MO klor-con m10 tbcr MO klor-con m15 tbcr MO klor-con m20 tbcr MO klor-con pack MO klor-con sprinkle cpcr 8meq 10meq MO
KLOR-CON TBCR MO LACTATED RINGERS SOLN magnesium sulfate in d5w soln NORMOSOL-M IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R SOLN INTRAVENOUS HI
PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 40 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
POTASSIUM CHLORIDE ER TBCR 8meq 10meq 20meq MO
POTASSIUM CHLORIDE IN DEXTROSE SOLN INTRAVENOUS
HI
potassium chloride in nacl soln intravenous HI
potassium chloride pack MO potassium chloride soln 10 20 MO
POTASSIUM CHLORIDE SOLN INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN SODIUM CHLORIDE SOLN INJECTION HI
SODIUM CHLORIDE SOLN INTRAVENOUS 045 09 3 5
HI
SODIUM PHOSPHATES SOLN TPN ELECTROLYTES CONC INTRAVENOUS HI
URICOSURIC AGENTS colchicine-probenecid tabs MO probenecid tabs MO ENZYMES ENZYMES ADAGEN SOLN ALDURAZYME SOLN CERDELGA CAPS NDS CEREZYME SOLR NDS CREON CPEP MO ELAPRASE SOLN NDS
Drug Name RequirementsLimits
ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME SOLR NDS miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PANCREAZE CPEP MO PERTZYE CPEP MO PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VIOKACE TABS MO VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE SOLN bacitracin oint bacitracin-polymyxin b oint BESIVANCE SUSP bleph-10 soln CETRAXAL SOLN chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
CIPROFLOXACIN-FLUOCINOLONE PF SOLN
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
MOXEZA SOLN moxifloxacin hcl (2x day) soln moxifloxacin hcl soln NATACYN SUSP neo-polycin oint neomycin-bacitracin zn-polymyx oint
neomycin-polymyxin-gramicidin soln
ofloxacin soln OTOVEL SOLN paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ZIRGAN GEL ANTI-INFLAMMATORY AGENTS ACUVAIL SOLN MO ALREX SUSP MO bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
BROMSITE SOLN MO CEQUA SOLN CIPRO HC SUSP MO CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO DUREZOL EMUL MO flac oil MO
Drug Name RequirementsLimits
FLAREX SUSP MO flunisolide soln MO fluocinolone acetonide oil MO fluorometholone susp MO flurbiprofen sodium soln MO fluticasone propionate susp MO FML FORTE SUSP MO FML OINT MO HYDROCORTISONE-ACETIC ACID SOLN MO
ILEVRO SUSP MO ILUVIEN IMPL INVELTYS SUSP MO ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX OINT MO LOTEMAX SUSP MO loteprednol etabonate susp MO MAXIDEX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint MO
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO NEVANAC SUSP MO OMNARIS SUSP MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
PROLENSA SOLN MO RESTASIS EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 42 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tobramycin-dexamethasone susp MO
XHANCE EXHU MO XIIDRA SOLN YUTIQ IMPL ZETONNA AERS MO ZYLET SUSP MO ANTIALLERGIC AGENTS ALOCRIL SOLN MO ALOMIDE SOLN MO azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO LASTACAFT SOLN MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
ALPHAGAN P SOLN MO betaxolol hcl soln MO BETIMOL SOLN 025 05 MO BETOPTIC-S SUSP MO bimatoprost soln MO BRIMONIDINE TARTRATE SOLN 02 015 MO
brinzolamide susp MO carteolol hcl soln MO COMBIGAN SOLN MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO
Drug Name RequirementsLimits
methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO SIMBRINZA SUSP MO timolol maleate pf soln MO timolol maleate solg 025 05 MO
timolol maleate soln 025 05 MO
TIMOPTIC OCUDOSE SOLN 25 MO
TIMOPTIC-XE SOLG 025 05 MO
TRAVATAN Z SOLN MO travoprost (bak free) soln MO VYZULTA SOLN MO XELPROS EMUL MO ZIOPTAN SOLN MO EENT DRUGS MISCELLANEOUS ACETIC ACID SOLN MO ALTAFRIN SOLN apraclonidine hcl soln MO ATROPINE SULFATE SOLN MO BEOVU SOLN NDS CYSTADROPS SOLN NDS CYSTARAN SOLN EYLEA SOLN EYLEA SOSY IOPIDINE SOLN MO LACRISERT INST MO LUCENTIS SOLN 03mg005ml 05mg005ml NDS
LUCENTIS SOSY 03mg005ml 05mg005ml NDS
OXERVATE SOLN NDS PHENYLEPHRINE HCL SOLN RHOPRESSA SOLN TEPEZZA SOLR NDS LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl soln lidocaine viscous hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
APRISO CP24 MO balsalazide disodium caps MO colazal caps MO DELZICOL CPDR MO DIPENTUM CAPS NDS LIALDA TBEC MO mesalamine cpdr MO mesalamine enem MO mesalamine er cp24 MO mesalamine supp MO mesalamine tbec 12gm 800mg MO mesalamine-cleanser kit PENTASA CPCR 250mg 500mg MO
ANTIDIARRHEA AGENTS diphenoxylate-atropine liqd diphenoxylate-atropine tabs loperamide hcl caps MO MYTESI TBEC MO OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS AKYNZEO CAPS PA ANZEMET TABS 50mg 100mg PANDS aprepitant caps PANDS BONJESTA TBCR MO CESAMET CAPS PA dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
EMEND SUSR PANDS fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs
Drug Name RequirementsLimits
ondansetron hcl soln PA ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS TRANSDERM SCOP (15 MG) PT72
trimethobenzamide hcl caps PA VARUBI (180 MG DOSE) TBPK PANDS ZUPLENZ FILM 4mg 8mg PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc MO
CARAFATE SUSP MO cimetidine hcl soln MO cimetidine tabs 200mg 300mg 400mg 800mg MO
esomeprazole magnesium cpdr 20mg 40mg MO
esomeprazole magnesium pack 10mg 20mg 40mg MO
esomeprazole sodium solr ESOMEPRAZOLE STRONTIUM CPDR
famotidine premixed soln famotidine soln famotidine susr MO famotidine tabs 20mg 40mg MO lansoprazole cpdr 15mg 30mg MO lansoprazole tbdd 15mg 30mg MO misoprostol tabs 100mcg 200mcg MO
nizatidine caps 150mg 300mg MO nizatidine soln MO OMECLAMOX-PAK MISC MO omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 44 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PRILOSEC PACK 25mg 10mg MO PROTONIX PACK MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate tabs MO CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO GOLYTELY SOLR OSMOPREP TABS MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT PLENVU SOLR MO SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS AMITIZA CAPS 8mcg 24mcg MO BYLVAY (PELLETS) CPSP 200mcg 600mcg NDS
BYLVAY CAPS 400mcg 1200mcg NDS
CHOLBAM CAPS 50mg 250mg NDS ENTYVIO SOLR NDS GATTEX KIT PANDS GIMOTI SOLN NDS LINZESS CAPS 72mcg 145mcg 290mcg MO
lubiprostone caps 8mcg 24mcg MO
Drug Name RequirementsLimits
metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
MOVANTIK TABS 125mg 25mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS SYMPROIC TABS MO TRULANCE TABS MO ursodiol caps 300mg MO URSODIOL CAPS 200mg 400mg NDS
ursodiol tabs 250mg 500mg MO VIBERZI TABS 75mg 100mg NDS HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPS clovique caps NDS CUPRIMINE CAPS NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs 90mg 180mg 360mg NDS
deferasirox tbso 125mg NDS deferasirox tbso 250mg 500mg NDS deferiprone tabs NDS deferoxamine mesylate solr DEPEN TITRATABS TABS EXJADE TBSO 125mg 250mg 500mg NDS
FERRIPROX SOLN LDNDS FERRIPROX TABS 500mg 1000mg LDNDS
FERRIPROX TWICE-A-DAY TABS NDS
JADENU SPRINKLE PACK 90mg 180mg 360mg NDS
JADENU TABS 90mg 360mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
penicillamine caps penicillamine tabs trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP 05mg 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs MO decadron elix MO decadron tabs 5mg 75mg MO decadron tabs 4mg 6mg PAMO deltasone tabs PAMO DEPO-MEDROL SUSP dexabliss tbpk dexamethasone elix MO dexamethasone intensol conc MO dexamethasone sod phosphate pf soln
dexamethasone sodium phosphate soln
dexamethasone soln dexamethasone tabs 05mg 075mg 1mg 15mg 2mg 4mg 6mg
PAMO
dexamethasone tbpk MO dexpak 10 day tbpk MO dexpak 13 day tbpk MO dexpak 6 day tbpk MO dxevo 11-day tbpk EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
INTRAROSA INST KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp
Drug Name RequirementsLimits
methylprednisolone sodium succ solr
methylprednisolone tabs 4mg 8mg 16mg 32mg MO
methylprednisolone tbpk MO millipred dp tbpk millipred tabs MO ORTIKOS CP24 6mg 9mg NDS prednisolone sodium phosphate soln 5mg5ml 10mg5ml 20mg5ml 25mg5ml
MO
prednisolone sodium phosphate tbdp 10mg 15mg 30mg MO
prednisolone soln MO prednisone intensol conc PAMO prednisone soln PAMO prednisone tabs 1mg 25mg 5mg 10mg 20mg 50mg PAMO
prednisone tbpk PULMICORT FLEXHALER AEPB
RAYOS TBEC 1mg 2mg 5mg PAMO SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TRELEGY ELLIPTA AEPB MO triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
AVEED SOLN MO danazol caps 50mg 100mg 200mg MO
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs 25mg MO oxandrolone tabs MONDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 46 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
STRIANT MISC MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact
MO
testosterone soln MO XYOSTED SOAJ 50mg05ml 75mg05ml 100mg05ml MO
CONTRACEPTIVES altavera tabs MO alyacen 135 tabs MO amethia lo tabs MO amethia tabs MO apri tabs MO aranelle tabs MO ashlyna tabs MO aubra eq tabs MO aviane tabs MO balziva tabs MO blisovi 24 fe tabs MO blisovi fe 1530 tabs MO briellyn tabs MO camila tabs MO camrese lo tabs MO caziant tabs MO cryselle-28 tabs MO cyclafem 135 tabs MO cyclafem 777 tabs MO cyred eq tabs MO deblitane tabs MO delyla tabs MO desogestrel-ethinyl estradiol tabs MO dolishale tabs MO drospiren-eth estrad-levomefol tabs MO
drospirenone-ethinyl estradiol tabs MO
ELLA TABS MO eluryng ring MO emoquette tabs MO
Drug Name RequirementsLimits
enpresse-28 tabs MO enskyce tabs MO errin tabs MO estarylla tabs MO ethynodiol diac-eth estradiol tabs MO etonogestrel-ethinyl estradiol ring MO
falmina tabs MO fayosim tabs MO femynor tabs MO gemmily caps MO gianvi tabs MO hailey 24 fe tabs MO iclevia tabs MO incassia tabs MO introvale tabs MO isibloom tabs MO jasmiel tabs MO JOLIVETTE TABS MO juleber tabs MO junel 1530 tabs MO junel 120 tabs MO junel fe 1530 tabs MO junel fe 120 tabs MO junel fe 24 tabs MO kaitlib fe chew MO kariva tabs MO kelnor 135 tabs MO kelnor 150 tabs MO kurvelo tabs MO larin 1530 tabs MO larin 120 tabs MO larin fe 1530 tabs MO larin fe 120 tabs MO larissia tabs MO LAYOLIS FE CHEW MO leena tabs MO lessina tabs MO levonest tabs MO levonorg-eth estrad triphasic tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
levora 01530 (28) tabs MO LO LOESTRIN FE TABS MO loestrin 1530 (21) tabs MO loestrin 120 (21) tabs MO loestrin fe 1530 tabs MO loestrin fe 120 tabs MO loryna tabs MO low-ogestrel tabs MO lutera tabs MO lyleq tabs MO lyza tabs MO marlissa tabs MO melodetta 24 fe chew MO merzee caps MO mibelas 24 fe chew MO microgestin 1530 tabs MO microgestin 120 tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA TABS MO NATAZIA TABS MO necon 0535 (28) tabs MO NECON 777 TABS MO nikki tabs MO nora-be tabs MO norethin ace-eth estrad-fe caps MO norethin ace-eth estrad-fe chew MO norethin ace-eth estrad-fe tabs MO norethin-eth estradiol-fe chew MO norethindrone acet-ethinyl est tabs MO
norethindrone tabs MO norgestim-eth estrad triphasic tabs MO
norgestimate-eth estradiol tabs MO norlyroc tabs MO
Drug Name RequirementsLimits
nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO NUVARING RING MO nylia 777 tabs MO nymyo tabs MO ocella tabs MO ogestrel tabs MO orsythia tabs MO pimtrea tabs MO pirmella 135 tabs MO portia-28 tabs MO previfem tabs MO reclipsen tabs MO rivelsa tabs MO setlakin tabs MO sharobel tabs MO sprintec 28 tabs MO sronyx tabs MO syeda tabs MO tarina 24 fe tabs MO tarina fe 120 eq tabs MO tilia fe tabs MO tri-estarylla tabs MO tri-legest fe tabs MO tri-lo-estarylla tabs MO tri-lo-sprintec tabs MO tri-mili tabs MO tri-nymyo tabs MO tri-previfem tabs MO tri-sprintec tabs MO tri-vylibra lo tabs MO tri-vylibra tabs MO TRINESSA (28) TABS MO trivora (28) tabs MO tydemy tabs MO velivet tabs MO vestura tabs MO vienva tabs MO vyfemla tabs MO vylibra tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 48 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135e (28) tabs MO DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
ADMELOG SOLN MO ADMELOG SOLOSTAR SOPN MO AFREZZA POWD MO AFREZZA POWD 8 (90) amp 12 (90) UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO APIDRA SOLN PAMO APIDRA SOLOSTAR SOPN MO AVANDIA TABS 2mg 4mg MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD BYDUREON BCISE AUIJ BYDUREON PEN BYETTA 10 MCG PEN SOPN MO BYETTA 5 MCG PEN SOPN MO CYCLOSET TABS MO diazoxide susp glimepiride tabs 1mg 2mg 4mg MO glipizide er tb24 25mg 5mg 10mg MO
glipizide tabs 5mg 10mg MO glipizide-metformin hcl tabs MO GLUCAGEN HYPOKIT SOLR glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO GLYXAMBI TABS MO
Drug Name RequirementsLimits
HUMALOG JUNIOR KWIKPEN SOPN MO
HUMALOG KWIKPEN SOPN 100unitml 200unitml MO
HUMALOG MIX 5050 KWIKPEN SUPN MO
HUMALOG MIX 5050 SUSP MO HUMALOG MIX 7525 KWIKPEN SUPN MO
HUMALOG MIX 7525 SUSP MO HUMALOG SOCT MO HUMALOG SOLN PAMO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN PAMO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
INSULIN ASP PROT amp ASP FLEXPEN SUPN MO
INSULIN ASPART FLEXPEN SOPN MO
INSULIN ASPART PENFILL SOCT MO
INSULIN ASPART PROT amp ASPART SUSP MO
INSULIN ASPART SOLN PAMO INSULIN LISPRO (1 UNIT DIAL) SOPN MO
INSULIN LISPRO SOLN MO INVOKAMET TABS MO INVOKAMET XR TB24 MO INVOKANA TABS 100mg 300mg MO
JARDIANCE TABS 10mg 25mg MO JENTADUETO TABS MO JENTADUETO XR TB24 MO KAZANO TABS MO KORLYM TABS LDNDS LANTUS SOLN MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
LANTUS SOLOSTAR SOPN MO LEVEMIR FLEXTOUCH SOPN MO LEVEMIR SOLN MO metformin hcl er tb24 500mg 750mg MO
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO NOVOLIN 7030 SUSP MO NOVOLOG 7030 FLEXPEN RELION SUPN MO
NOVOLOG FLEXPEN RELION SOPN MO
NOVOLOG FLEXPEN SOPN MO NOVOLOG MIX 7030 FLEXPEN SUPN MO
NOVOLOG MIX 7030 RELION SUSP MO
NOVOLOG MIX 7030 SUSP MO NOVOLOG PENFILL SOCT MO NOVOLOG RELION SOLN PAMO NOVOLOG SOLN PAMO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO PROGLYCEM SUSP MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SOLIQUA SOPN MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO SYNJARDY TABS MO SYNJARDY XR TB24 MO tolazamide tabs 250mg 500mg MO
Drug Name RequirementsLimits
tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO ANGELIQ TABS MO CLIMARA PRO PTWK MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
COMBIPATCH PTTW MO DELESTROGEN OIL depo-estradiol oil DIVIGEL GEL MO dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
DUAVEE TABS MO ELESTRIN GEL MO estrace crea MO estrace tabs 05mg 1mg 2mg MO estradiol crea MO estradiol pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO EVAMIST SOLN MO fyavolv tabs MO IMVEXXY MAINTENANCE PACK INST 4mcg 10mcg MO
IMVEXXY STARTER PACK INST 4mcg 10mcg MO
jinteli tabs MO lopreeza tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 50 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
MENOSTAR PTWK MO mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO ORIAHNN CPPK NDS OSPHENA TABS MO prefest tabs MO PREMARIN SOLR PREMARIN TABS 03mg 045mg 0625mg 09mg 125mg
MO
PREMPHASE TABS MO PREMPRO TABS MO raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS NOVAREL SOLR 5000unit 10000unit PA
ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS PREGNYL SOLR PA TRIPTODUR SRER NDS OXYTOCICS carboprost tromethamine soln methergine tabs methylergonovine maleate soln methylergonovine maleate tabs OXYTOCIN SOLN PARATHYROID calcitonin (salmon) soln MO cinacalcet hcl tabs 30mg 60mg 90mg PANDS
FORTEO SOPN PANDS NATPARA CART 25mcg 50mcg 75mcg 100mcg LDNDS
Drug Name RequirementsLimits
SENSIPAR TABS 30mg 60mg 90mg PANDS
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PALDNDS DDAVP RHINAL TUBE SOLN MO desmopressin ace spray refrig soln MO
desmopressin acetate soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln DESMOPRESSIN ACETATE TABS 01mg 02mg MO
NOCDURNA SUBL 277mcg 553mcg MO
NOCTIVA EMUL 083mcg01ml 166mcg01ml MO
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO CRINONE GEL 4 8 PAMO DEPO-PROVERA SUSP 400mgml
DEPO-SUBQ PROVERA 104 SUSY
ENDOMETRIN INST PA hydroxyprogesterone caproate oil
hydroxyprogesterone caproate soln
MAKENA SOAJ NDS medroxyprogesterone acetate susp
medroxyprogesterone acetate susy
medroxyprogesterone acetate tabs 25mg 5mg 10mg MO
megestrol acetate susp MO norethindrone acetate tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS BYNFEZIA PEN SOPN NDS EGRIFTA SOLR NDS EGRIFTA SV SOLR NDS GENOTROPIN MINIQUICK SOLR 02mg PANDS
GENOTROPIN MINIQUICK SOLR 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
GENOTROPIN SOLR 5mg 12mg PANDS
HUMATROPE SOLR 5mg 6mg 12mg 24mg PANDS
INCRELEX SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
NUTROPIN AQ NUSPIN 20 SOPN PANDS
NUTROPIN AQ NUSPIN 5 SOPN PANDS
octreotide acetate soln OMNITROPE SOCT 5mg15ml 10mg15ml PANDS
OMNITROPE SOLR PANDS SAIZEN CLICKEASY SOLR PANDS SAIZEN SOLR 5mg 88mg PANDS SAIZENPREP SOLR PANDS SANDOSTATIN LAR DEPOT KIT 10mg 20mg 30mg NDS
SEROSTIM SOLR 4mg 5mg 6mg PANDS
SIGNIFOR LAR SRER 10mg 20mg 30mg 40mg 60mg NDS
SIGNIFOR SOLN 03mgml 06mgml 09mgml NDS
SOMATULINE DEPOT SOLN
Drug Name RequirementsLimits
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZOMACTON SOLR 5mg PANDS ZOMACTON SOLR PANDS ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVO-T TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVOTHYROXINE SODIUM SOLR
levothyroxine sodium tabs 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
liothyronine sodium soln liothyronine sodium tabs 5mcg 25mcg 50mcg MO
methimazole tabs 5mg 10mg MO propylthiouracil tabs MO tapazole tabs 5mg 10mg MO THYROLAR-1 TABS THYROLAR-12 TABS THYROLAR-14 TABS THYROLAR-2 TABS THYROLAR-3 TABS TIROSINT CAPS 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 52 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
137mcg 150mcg 175mcg 200mcg UNITHROID TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA REDUCTASE INHIBITORS dutasteride caps MO dutasteride-tamsulosin hcl caps MO finasteride tabs MO ANTIDOTES acetylcysteine soln 10 20 PAMO fomepizole soln KHAPZORY SOLR 175mg 300mg NDS
leucovorin calcium soln leucovorin calcium solr leucovorin calcium tabs 5mg 10mg 15mg 25mg MO
levoleucovorin calcium pf soln levoleucovorin calcium solr VISTOGARD PACK NDS VORAXAZE SOLR NDS ANTIGOUT AGENTS allopurinol sodium solr allopurinol tabs 100mg 300mg MO COLCHICINE CAPS MO colchicine tabs MO febuxostat tabs 40mg 80mg MO GLOPERBA SOLN MITIGARE CAPS MO ULORIC TABS 40mg 80mg MO BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 5mg 10mg 35mg 70mg MO
alendronate sodium tabs 40mg MO BINOSTO TBEF MO EVENITY SOSY NDS FOSAMAX PLUS D TABS MO IBANDRONATE SODIUM SOLN
Drug Name RequirementsLimits
ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr PROLIA SOSY risedronate sodium tabs 5mg 30mg 35mg 150mg MO
RISEDRONATE SODIUM TBEC MO XGEVA SOLN PANDS zoledronic acid conc zoledronic acid soln DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ACTPEN SOAJ NDS ACTEMRA SOSY NDS AVSOLA SOLR NDS CIMZIA KIT PANDS CIMZIA PREFILLED KIT PANDS CIMZIA STARTER KIT KIT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS ENBREL SOSY 25mg05ml 50mgml NDS
ENBREL SURECLICK SOAJ NDS HUMIRA PEDIATRIC CROHNS START PSKT NDS
HUMIRA PEN PNKT 40mg04ml 40mg08ml 80mg08ml
NDS
HUMIRA PEN-CDUCHS STARTER PNKT 40mg08ml 80mg08ml
NDS
HUMIRA PEN-PEDIATRIC UC START PNKT NDS
HUMIRA PEN-PSUVADOL HS START PNKT NDS
HUMIRA PEN-PSORUVEIT STARTER PNKT NDS
HUMIRA PSKT 10mg01ml 10mg02ml 20mg02ml 20mg04ml 40mg04ml 40mg08ml
NDS
INFLECTRA SOLR INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
KEVZARA SOAJ 150mg114ml 200mg114ml NDS
KEVZARA SOSY 150mg114ml 200mg114ml NDS
KINERET SOSY NDS leflunomide tabs 10mg 20mg MO OLUMIANT TABS 1mg 2mg NDS ORENCIA CLICKJECT SOAJ NDS ORENCIA SOLR NDS ORENCIA SOSY 50mg04ml 875mg07ml 125mgml NDS
OTEZLA TABS PANDS OTEZLA TBPK PANDS OTREXUP SOAJ RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 NDS SIMPONI ARIA SOLN NDS SIMPONI SOAJ 50mg05ml 100mgml NDS
SIMPONI SOSY 50mg05ml 100mgml NDS
XELJANZ SOLN NDS XELJANZ TABS 5mg 10mg NDS XELJANZ XR TB24 11mg 22mg NDS IMMUNE SUPPRESSANTS ASTAGRAF XL CP24 05mg 1mg PAMO
ASTAGRAF XL CP24 PA azasan tabs 75mg 100mg PAMO azathioprine sodium solr azathioprine tabs PAMO BENLYSTA SOAJ BENLYSTA SOLR BENLYSTA SOSY cyclosporine caps 25mg 100mg PAMO cyclosporine modified caps 25mg 50mg 100mg PAMO
cyclosporine modified soln PAMO cyclosporine soln PAMO
Drug Name RequirementsLimits
ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg PA GAMIFANT SOLN 50mg10ml 100mg20ml 10mg2ml NDS
gengraf caps 25mg 50mg 100mg PAMO
gengraf soln PAMO LUPKYNIS CAPS NDS MAVENCLAD (10 TABS) TBPK NDS MAVENCLAD (4 TABS) TBPK NDS MAVENCLAD (5 TABS) TBPK NDS MAVENCLAD (6 TABS) TBPK NDS MAVENCLAD (7 TABS) TBPK NDS MAVENCLAD (8 TABS) TBPK NDS MAVENCLAD (9 TABS) TBPK NDS mycophenolate mofetil caps PAMO mycophenolate mofetil hcl solr mycophenolate mofetil susr PAMO mycophenolate mofetil tabs PAMO mycophenolate sodium tbec 180mg 360mg PAMO
NULOJIX SOLR NDS PROGRAF PACK 02mg PA PROGRAF PACK PANDS PROGRAF SOLN PAMO SANDIMMUNE ORAL SOLN 100mgml PAMO
SAPHNELO SOLN NDS sirolimus soln PA sirolimus tabs 05mg 1mg 2mg PAMO tacrolimus caps 05mg 1mg 5mg PAMO
UPLIZNA SOLN ZORTRESS TABS 025mg PAMO ZORTRESS TABS 05mg 075mg 1mg PA
MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 54 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BOTOX SOLR 100unit 200unit PA bupivacaine hcl (pf) soln bupivacaine hcl soln BUPIVACAINE IN DEXTROSE SOLN
bupivacaine spinal soln bupivacaine-epinephrine (pf) soln
bupivacaine-epinephrine soln CARNITOR SOLN PAMO CARNITOR TABS PAMO chloroprocaine hcl (pf) soln CINRYZE SOLR INTRAVENOUS HI
citanest plain dental soln COSELA SOLR NDS CRYSVITA SOLN 10mgml 20mgml 30mgml NDS
CYSTADANE POWD LDNDS CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr DYSPORT SOLR 300unit 500unit PA
EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENSPRYNG SOSY NDS EVRYSDI SOLR NDS EXONDYS 51 SOLN 500mg10ml 100mg2ml NDS
FIRDAPSE TABS NDS FLUORITAB CHEW 025mg 05mg 1mg MO
FLUORITAB SOLN MO GALAFOLD CAPS NDS GIVLAARI SOLN NDS GRASTEK SUBL MO
Drug Name RequirementsLimits
HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS TABS NDS KUVAN PACK 100mg 500mg NDS KUVAN TABS NDS LACTATED RINGERS SOLN levocarnitine soln PAMO LEVOCARNITINE TABS PAMO lidocaine hcl (pf) soln lidocaine hcl soln lidocaine in dextrose soln lidocaine-epinephrine soln LUDENT CHEW 025mg 05mg 1mg MO
mesna soln MESNEX TABS NDS MYALEPT SOLR NDS NAFRINSE CHEW MO NAFRINSE DROPS SOLN MO nitisinone caps 2mg 5mg 10mg NDS NITYR TABS 2mg 5mg 10mg NDS NULIBRY SOLR NDS ODACTRA SUBL ONPATTRO SOLN NDS ORALAIR SUBL MO ORFADIN CAPS LDNDS ORFADIN SUSP LDNDS ORLADEYO CAPS 110mg 150mg NDS
OXLUMO SOLN PALFORZIA (12 MG DAILY DOSE) CSPK NDS
PALFORZIA (120 MG DAILY DOSE) CSPK NDS
PALFORZIA (160 MG DAILY DOSE) CSPK NDS
PALFORZIA (20 MG DAILY DOSE) CSPK NDS
PALFORZIA (200 MG DAILY DOSE) CSPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
PALFORZIA (240 MG DAILY DOSE) CSPK NDS
PALFORZIA (3 MG DAILY DOSE) CSPK NDS
PALFORZIA (300 MG MAINTENANCE) PACK NDS
PALFORZIA (300 MG TITRATION) PACK NDS
PALFORZIA (40 MG DAILY DOSE) CSPK NDS
PALFORZIA (6 MG DAILY DOSE) CSPK NDS
PALFORZIA (80 MG DAILY DOSE) CSPK NDS
PALFORZIA INITIAL ESCALATION CSPK NDS
PHYSIOLYTE SOLN PHYSIOSOL IRRIGATION SOLN
polocaine soln polocaine-mpf soln PROCYSBI CPDR 25mg 75mg NDS PROCYSBI PACK 75mg 300mg NDS REZUROCK TABS NDS RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln RUZURGI TABS NDS sapropterin dihydrochloride pack 100mg 500mg NDS
sapropterin dihydrochloride tabs NDS SENSORCAINE SOLN sensorcaine-mpf soln sensorcaine-mpfepinephrine soln
sensorcaineepinephrine soln SODIUM CHLORIDE SOLN MO SODIUM FLUORIDE CHEW 025mg 05mg 1mg MO
SODIUM FLUORIDE SOLN MO SODIUM FLUORIDE TABS MO STERILE WATER FOR IRRIGATION SOLN
Drug Name RequirementsLimits
TAKHZYRO SOLN NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VILTEPSO SOLN NDS VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR 50unit 100unit PA XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg NDS RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 200mg114ml 300mg2ml PANDS
FASENRA PEN SOAJ NDS FASENRA SOSY PA montelukast sodium chew 4mg 5mg MO
montelukast sodium pack MO montelukast sodium tabs MO NUCALA SOAJ PANDS NUCALA SOLR PANDS NUCALA SOSY PANDS zafirlukast tabs 10mg 20mg MO zileuton er tb12 NDS CYSTIC FIBROSIS BETHKIS NEBU PA
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 56 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CAYSTON SOLR LDNDS KALYDECO PACK 25mg 50mg 75mg PANDS
KALYDECO TABS PANDS KITABIS PAK NEBU PA ORKAMBI PACK NDS ORKAMBI TABS NDS SYMDEKO TBPK NDS TOBI PODHALER CAPS tobramycin nebu 300mg4ml 300mg5ml PA
TRIKAFTA TBPK LDNDS PULMONARY FIBROSIS ESBRIET CAPS PANDS ESBRIET TABS 267mg 801mg PANDS OFEV CAPS 100mg 150mg NDS RESPIRATORY AGENTS MISCELLANEOUS ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS 500mg 1000mg
HI
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact
MO
ASMANEX (120 METERED DOSES) AEPB MO
ASMANEX (30 METERED DOSES) AEPB 110mcginh MO
ASMANEX (30 METERED DOSES) AEPB MO
ASMANEX (60 METERED DOSES) AEPB MO
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
budesonide-formoterol fumarate aero
DALIRESP TABS 250mcg 500mcg MO
DULERA AERO MO
Drug Name RequirementsLimits
FLOVENT DISKUS AEPB 50mcgblist 100mcgblist 250mcgblist
MO
FLOVENT HFA AERO 44mcgact MO
FLOVENT HFA AERO 110mcgact 220mcgact MO
fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PROLASTIN-C SOLN INTRAVENOUS HI
PROLASTIN-C SOLR INTRAVENOUS HI
SYMBICORT AERO wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
ZEMAIRA SOLR INTRAVENOUS HI
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr LETAIRIS TABS 5mg 10mg NDS ORENITRAM TBCR 0125mg LDNDS ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TABS 625mg 125mg NDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
1000mcg 1200mcg 1400mcg 1600mcg UPTRAVI TBPK NDS VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS BIVIGAM SOLN 10gm100ml HI BIVIGAM SOLN 5gm50ml HI CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml
HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS 10gm200ml HI
GAMMAPLEX SOLN INTRAVENOUS 10gm100ml 20gm200ml 5gm50ml
HI
GAMUNEX-C SOLN INJECTION 10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml
HI
HYPERHEP B SOLN HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 5gm100ml HI
Drug Name RequirementsLimits
1gm20ml 2gm20ml 25gm500ml PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
PRIVIGEN SOLN INTRAVENOUS HI
VARIZIG SOLN XEMBIFY SOLN SUBCUTANEOUS 2gm10ml 4gm20ml 10gm50ml 1gm5ml
HI
TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP QUADRACEL SUSP TDVAX SUSP TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP DAPTACEL SUSP ENGERIX-B SUSP 10mcg05ml 20mcgml PA
GARDASIL 9 SUSP GARDASIL 9 SUSY HAVRIX SUSP HEPLISAV-B SOLN PA HIBERIX SOLR IMOVAX RABIES INJ INFANRIX SUSP IPOL INJ IXIARO SUSP M-M-R II SOLR MENACTRA INJ MENQUADFI INJ MENVEO SOLR PEDIARIX SUSP PEDVAX HIB SUSP
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 58 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN VAQTA SUSP VARIVAX INJ VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint AKTIPAK PACK MO AVC VAGINAL CREA BACTROBAN NASAL OINT BENZEPRO CREAMY WASH LIQD
BENZEPRO FOAMING CLOTHS MISC
BENZOYL PEROXIDE GEL NDS benzoyl peroxide-erythromycin gel MO
ciclopirox gel ciclopirox olamine crea ciclopirox olamine susp ciclopirox sham ciclopirox soln CLEOCIN SUPP clindacin-p swab MO clindamycin phos-benzoyl perox gel MO
clindamycin phosphate crea clindamycin phosphate foam MO clindamycin phosphate gel MO clindamycin phosphate lotn MO
Drug Name RequirementsLimits
clindamycin phosphate soln MO clindamycin phosphate swab MO CLINDESSE CREA clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn DENAVIR CREA econazole nitrate crea ERTACZO CREA ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA EXELDERM CREA EXELDERM SOLN gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ivermectin lotn ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham LULICONAZOLE CREA LUZU CREA mafenide acetate pack malathion lotn MENTAX CREA metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 59
Drug Name RequirementsLimits
mupirocin oint naftifine hcl crea naftifine hcl gel NAFTIN GEL NATROBA SUSP neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ORAVIG TABS ovide lotn oxiconazole nitrate crea OXISTAT LOTN permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SKLICE LOTN SODIUM SULFACETAMIDE SHAM
SODIUM SULFACETAMIDE WASH LIQD
SPINOSAD SUSP SSD CREA sulfacetamide sodium (acne) lotn MO SULFACETAMIDE SODIUM GEL
SULFACETAMIDE SODIUM LIQD
SULFAMYLON CREA tavaborole soln terconazole crea terconazole supp VANDAZOLE GEL XEPI CREA MO XERESE CREA ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) ala scalp lotn MO
Drug Name RequirementsLimits
ala-cort crea 1 25 MO alclometasone dipropionate crea MO alclometasone dipropionate oint MO amcinonide crea MO amcinonide lotn MO amcinonide oint MO anusol-hc crea MO apexicon e crea MO benzoyl perox-hydrocortisone lotn
BENZOYL PEROXIDE FORTE- HC LOTN NDS
beser lotn MO betamethasone dipropionate aug crea MO
betamethasone dipropionate aug gel MO
betamethasone dipropionate aug lotn MO
betamethasone dipropionate aug oint MO
betamethasone dipropionate crea MO
betamethasone dipropionate lotn MO BETAMETHASONE DIPROPIONATE OINT MO
betamethasone valerate crea MO betamethasone valerate foam MO BETAMETHASONE VALERATE LOTN MO
BETAMETHASONE VALERATE OINT MO
BRYHALI LOTN MO calcipotriene-betameth diprop oint MONDS
calcipotriene-betameth diprop susp NDS
CAPEX SHAM MO clobetasol propionate crea clobetasol propionate e crea MO clobetasol propionate emulsion foam
clobetasol propionate foam MO clobetasol propionate gel MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 60 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO CLOBEX SHAM MO CLOBEX SPRAY LIQD MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO clodan sham MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT MO DESONATE GEL MO desonide crea MO desonide gel MO desonide lotn MO desonide oint MO desowen lotn MO desoximetasone crea 005 025 MO
desoximetasone gel MO desoximetasone liqd MO desoximetasone oint 005 025 MO
desrx gel MO diclofenac sodium gel 1 3 MO diflorasone diacetate crea MO diflorasone diacetate oint MO DUOBRII LOTN MO ENSTILAR FOAM NDS epifoam foam fluocinolone acetonide body oil fluocinolone acetonide crea 001 0025 MO
fluocinolone acetonide oint MO fluocinolone acetonide scalp oil MO fluocinolone acetonide soln MO fluocinonide crea MO fluocinonide emulsified base crea MO
Drug Name RequirementsLimits
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO flurandrenolide crea MO flurandrenolide lotn MO flurandrenolide oint MO fluticasone propionate crea MO fluticasone propionate lotn MO fluticasone propionate oint MO halcinonide crea MO halobetasol propionate crea MO HALOBETASOL PROPIONATE FOAM NDS
halobetasol propionate oint MO HALOG CREA MO HALOG OINT MO hydrocortisone (perianal) crea 1 25 MO
hydrocortisone butyr lipo base crea
hydrocortisone butyrate crea MO hydrocortisone butyrate lotn MO HYDROCORTISONE BUTYRATE OINT MO
hydrocortisone butyrate soln MO hydrocortisone crea 1 25 MO hydrocortisone enem MO hydrocortisone lotn MO hydrocortisone oint 1 25 MO hydrocortisone valerate crea MO hydrocortisone valerate oint MO LEXETTE FOAM NDS micort-hc crea MO mometasone furoate crea MO mometasone furoate oint MO mometasone furoate soln MO neo-synalar crea MO nolix crea nolix lotn MO nystatin-triamcinolone crea MO nystatin-triamcinolone oint MO oralone pste MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 61
Drug Name RequirementsLimits
PANDEL CREA MO prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO psorcon crea MO TACLONEX SUSP NDS topicort crea 005 025 MO topicort gel MO topicort oint MO tovet foam MO triamcinolone acetonide aers MO triamcinolone acetonide crea 0025 01 05 MO
triamcinolone acetonide lotn 0025 01 MO
triamcinolone acetonide oint 0025 005 01 05 MO
triamcinolone acetonide pste MO trianex oint MO triderm crea 01 05 MO tritocin oint MO UCERIS FOAM MO ULTRAVATE LOTN NDS VANOXIDE-HC LOTN ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
LIDO-SORB LOTN LIDOCAINE HCL CREA lidocaine hcl lotn lidocaine hcl soln PA lidocaine hcl urethralmucosal gel MO
lidocaine hcl urethralmucosal prsy MO
lidocaine oint PAMO lidocaine ptch PAMO
Drug Name RequirementsLimits
LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea PA LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam texacort soln MO TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS ALTRENO LOTN PAMO AVITA CREA PAMO AVITA GEL PAMO KEPIVANCE SOLR NDS PANRETIN GEL NDS RETIN-A CREA 0025 005 01 PAMO
RETIN-A GEL 001 0025 PAMO RETIN-A MICRO GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 008 PAMO
RETIN-A MICRO PUMP GEL PANDS TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 62 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS ABSORICA CAPS 25mg 35mg NDS ABSORICA LD CAPS 8mg 16mg 24mg 32mg NDS
accutane caps 10mg 20mg 30mg 40mg NDS
acitretin caps 10mg 175mg 25mg NDS
ADAPALENE CREA MO adapalene gel 01 03 MO adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
AVAR CLEANSER EMUL AVAR-E EMOLLIENT CREA AVAR-E GREEN CREA azelaic acid gel MO AZELEX CREA MO BP 10-1 EMUL calcipotriene crea MO calcipotriene oint MO calcipotriene soln MO calcitrene oint MO CALCITRIOL OINT MO CARAC CREA CEROVEL LOTN claravis caps 10mg 20mg 30mg 40mg NDS
CONDYLOX GEL MO COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
Drug Name RequirementsLimits
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA MO DIFFERIN LOTN MO EPIDUO FORTE GEL MO FABIOR FOAM PAMO FINACEA FOAM MO fluorouracil crea 5 MO fluorouracil crea 5 fluorouracil soln 2 5 MO ILUMYA SOSY PA imiquimod crea 375 5 MO IMIQUIMOD PUMP CREA MO isotretinoin caps 10mg 20mg 30mg 40mg NDS
keralyt sham KLISYRI OINT NDS LACTIC ACID LOTN methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
ORACEA CPDR pimecrolimus crea MO podofilox soln MO RECTIV OINT MO REGRANEX GEL NDS RYNODERM CREA NDS SALEX SHAM SALICYLIC ACID CREA SALICYLIC ACID ER SOLN SALICYLIC ACID FOAM SALICYLIC ACID GEL SALICYLIC ACID LIQD SALICYLIC ACID SHAM SALICYLIC ACID WART REMOVER LIQD
SALICYLIC ACID-CLEANSER KIT
SALIMEZ CREA SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 63
Drug Name RequirementsLimits
SKYRIZI PEN SOAJ SKYRIZI SOSY SORILUX FOAM MO SSS 10-5 CREA STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
SULFACETAMIDE SODIUM-SULFUR CREA
SULFACETAMIDE SODIUM-SULFUR EMUL
SULFACETAMIDE SODIUM-SULFUR LIQD
SULFACETAMIDE SODIUM-SULFUR LOTN
SULFACETAMIDE SODIUM-SULFUR PADS
SULFACETAMIDE SODIUM-SULFUR SUSP
SULFACLEANSE 84 SUSP sulfamez wash emul TACROLIMUS OINT 01 003 MO
TALTZ SOAJ NDS TALTZ SOSY NDS tazarotene crea PAMO tazarotene foam PAMO TAZORAC CREA PAMO TAZORAC GEL 005 01 PAMO TOLAK CREA TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS VECTICAL OINT MO VEREGEN OINT MO WYNZORA CREA NDS XUREA CREA
Drug Name RequirementsLimits
zenatane caps 10mg 20mg 30mg 40mg NDS
ZYCLARA PUMP CREA MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline soln darifenacin hydrobromide er tb24 75mg 15mg MO
elixophyllin elix flavoxate hcl tabs MO MYRBETRIQ TB24 25mg 50mg MO oxybutynin chloride er tb24 5mg 10mg 15mg MO
oxybutynin chloride syrp MO oxybutynin chloride tabs MO solifenacin succinate tabs 5mg 10mg MO
theo-24 cp24 100mg 200mg 300mg 400mg MO
theophylline er tb12 100mg 200mg 300mg 450mg MO
theophylline er tb24 400mg 600mg MO
theophylline soln MO tolterodine tartrate er cp24 2mg 4mg MO
tolterodine tartrate tabs MO trospium chloride er cp24 MO trospium chloride tabs MO VITAMINS VITAMINS ADCF (05MGML) SOLN MO calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN MULTI-VITAMINFLUORIDEIRON SOLN
MO
MULTI-VITAMINFLUORIDE SOLN MO
MULTIVITAMINFLUORIDE CHEW MO
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Drug Name RequirementsLimits
MVC-FLUORIDE CHEW MO paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS TRI-VITAMINFLUORIDE SOLN MO TRI-VITEFLUORIDE SOLN MO VITAMINS ACD-FLUORIDE SOLN MO
VP-PNV-DHA CAPS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 65
The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not and
you need an urgent refill please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 6 or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number on page 6 NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
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Index of Drugs
A abacavir sulfate soln 12 abacavir sulfate tabs 12 abacavir sulfate-lamivudine tabs 12 abacavir-lamivudine-zidovudine tabs 12 ABELCET SUSP INTRAVENOUS 11 ABILIFY MAINTENA PRSY 300mg 400mg
35 ABILIFY MAINTENA SRER 300mg 400mg
35 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
abiraterone acetate tabs 250mg 500mg 14 ABRAXANE SUSR 14 ABSORICA CAPS 25mg 35mg 62 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 62 ABSTRAL SUBL 100mcg 200mcg
300mcg 400mcg 600mcg 800mcg 27 acamprosate calcium tbec 26 acarbose tabs 25mg 50mg 100mg 48 accutane caps 10mg 20mg 30mg 40mg 62 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 27 acetaminophen-codeine soln 27 acetaminophen-codeine tabs 27 acetazolamide er cp12 42 acetazolamide sodium solr 42 acetazolamide tabs 125mg 250mg 42 ACETIC ACID SOLN 42 53 acetylcysteine soln 10 20 52 acitretin caps 10mg 175mg 25mg 62 ACTEMRA ACTPEN SOAJ 52 ACTEMRA SOSY 52 ACTHAR GEL 50 ACTHIB SOLR 57 ACTIMMUNE SOLN 53 ACUVAIL SOLN 41
acyclovir caps 12 acyclovir oint 58 acyclovir sodium soln intravenous 12 acyclovir susp 12 acyclovir tabs 400mg 800mg 12 ADACEL SUSP 57 ADAGEN SOLN 40 ADAKVEO SOLN 21 ADAPALENE CREA 62 adapalene gel 01 03 62 adapalene pads 62 adapalene soln 62 adapalene-benzoyl peroxide gel 62 ADAPALENE-BENZOYL PEROXIDE PADS
62 ADCF (05MGML) SOLN 63 adderall tabs 29 ADDERALL XR CP24 29 adefovir dipivoxil tabs 12 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 56 adenosine soln 25 ADMELOG SOLN 48 ADMELOG SOLOSTAR SOPN 48 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 20 ADZENYS ER SUER 29 ADZENYS XR-ODT TBED 31mg 63mg
94mg 125mg 157mg 188mg 29 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 25mg 5mg 75mg 10mg
14 AFREZZA POWD 48 AFREZZA POWD 8 (90) amp 12 (90) UNIT 48 AJOVY SOAJ 32 AJOVY SOSY 32 AKTIPAK PACK 58 AKYNZEO CAPS 43 ala scalp lotn 59 ala-cort crea 1 25 59 albendazole tabs 8
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 67
albuterol sulfate er tb12 4mg 8mg 20 albuterol sulfate hfa aers 20 albuterol sulfate nebu 0083 25mg05ml
20 albuterol sulfate nebu 063mg3ml
125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 59 alclometasone dipropionate oint 59 ALCOHOL PREP PADS 37 ALDACTAZIDE TABS 25 ALDURAZYME SOLN 40 ALECENSA CAPS 14 alendronate sodium soln 52 alendronate sodium tabs 40mg 52 alendronate sodium tabs 5mg 10mg
35mg 70mg 52 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 05mg 1mg
2mg 5mg 45 allopurinol sodium solr 52 allopurinol tabs 100mg 300mg 52 allzital tabs 27 almotriptan malate tabs 32 ALOCRIL SOLN 42 alogliptin benzoate tabs 625mg 125mg
25mg 48 ALOGLIPTIN-METFORMIN HCL TABS 48 alogliptin-pioglitazone tabs 48 ALOMIDE SOLN 42 ALOSETRON HCL TABS 05mg 1mg 43 ALPHAGAN P SOLN 42 alprazolam er tb24 05mg 1mg 2mg 3mg
33 alprazolam intensol conc 33 alprazolam tabs 025mg 05mg 1mg 2mg
33 alprazolam tbdp 025mg 05mg 1mg 2mg
33 ALREX SUSP 41 ALTACAINE SOLN 42 ALTAFRIN SOLN 42 altavera tabs 46 ALTOPREV TB24 20mg 40mg 60mg 23 ALTRENO LOTN 61
ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 56 alyacen 135 tabs 46 alyq tabs 26 amabelz tabs 49 amantadine hcl caps 32 amantadine hcl syrp 32 amantadine hcl tabs 32 AMBISOME SUSR INTRAVENOUS 11 ambrisentan tabs 56 amcinonide crea 59 amcinonide lotn 59 amcinonide oint 59 amethia lo tabs 46 amethia tabs 46 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 38 amiloride-hydrochlorothiazide tabs 38 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 63 AMINOSYN-PF SOLN INTRAVENOUS 38 amiodarone hcl soln 25 amiodarone hcl tabs 100mg 200mg
400mg 25 AMITIZA CAPS 8mcg 24mcg 44 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 amlodipine besy-benazepril hcl caps 24 amlodipine besylate tabs 25mg 5mg
10mg 24 amlodipine besylate-valsartan tabs 24 amlodipine-atorvastatin tabs 24 amlodipine-olmesartan tabs 24 amlodipine-valsartan-hctz tabs 24 ammonium lactate crea 62 ammonium lactate lotn 62 amnesteem caps 10mg 20mg 40mg 62 AMONDYS 45 SOLN 53 amoxapine tabs 25mg 50mg 100mg
150mg 35 amoxicill-clarithro-lansopraz misc 43 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8
68 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 29 amphetamine sulfate tabs 5mg 10mg 30 amphetamine-dextroamphet er cp24 30 amphetamine-dextroamphetamine tabs 30 amphotericin b solr intravenous 11 ampicillin caps 8 ampicillin sodium solr 8 ampicillin sodium solr injection 1gm 125mg
8 ampicillin sodium solr intravenous 8 ampicillin-sulbactam sodium solr 8 ampicillin-sulbactam sodium solr injection 8 ampicillin-sulbactam sodium solr
intravenous 8 ANADROL-50 TABS 45 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 61 anastrozole tabs 14 ANDRODERM PT24 2mg24hr 4mg24hr
45 ANGELIQ TABS 49 ANORO ELLIPTA AEPB 19 antabuse tabs 250mg 500mg 26 ANTARA CAPS 30mg 90mg 23 anusol-hc crea 59 ANZEMET TABS 50mg 100mg 43 apap-caff-dihydrocodeine tabs 27 apexicon e crea 59 APIDRA SOLN 48 APIDRA SOLOSTAR SOPN 48 APLENZIN TB24 174mg 348mg 522mg 35 APOKYN SOCT 32 apraclonidine hcl soln 42 aprepitant caps 43 apri tabs 46 APRISO CP24 43 APTIOM TABS 200mg 400mg 600mg
800mg 30 APTIVUS CAPS 12 APTIVUS SOLN 12 ARALAST NP SOLR INTRAVENOUS
500mg 1000mg 56 aranelle tabs 46 ARANESP (ALBUMIN FREE) SOLN
25mcgml 40mcgml 22
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml 22
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml 22
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 22
ARCALYST SOLR 53 ARCAPTA NEOHALER CAPS 20 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 54 ARIKAYCE SUSP 8 aripiprazole soln 35 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 35 aripiprazole tbdp 10mg 15mg 35 ARISTADA INITIO PRSY 35 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 35
armodafinil tabs 50mg 150mg 200mg 250mg 30
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact 56
ARRANON SOLN 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 54 ARYMO ER TBEA 27 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 57 ascomp-codeine caps 27 asenapine maleate subl 25mg 5mg 10mg
35 ashlyna tabs 46 ASMANEX (120 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
110mcginh 56 ASMANEX (60 METERED DOSES) AEPB
56 ASMANEX HFA AERO 100mcgact
200mcgact 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 69
ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 53 ASTAGRAF XL CP24 05mg 1mg 53 atazanavir sulfate caps 150mg 200mg
300mg 12 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 34 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 23 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 42 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 34 aubra eq tabs 46 AUGMENTIN SUSR 8 AURYXIA TABS 39 AUSTEDO TABS 6mg 9mg 12mg 34 AVANDIA TABS 2mg 4mg 48 AVAR CLEANSER EMUL 62 AVAR-E EMOLLIENT CREA 62 AVAR-E GREEN CREA 62 AVASTIN SOLN 14 AVC VAGINAL CREA 58 AVEED SOLN 45 aviane tabs 46 AVITA CREA 61 AVITA GEL 61 AVONEX KIT 34 AVONEX PEN AJKT 34 AVONEX PREFILLED PSKT 34 AVSOLA SOLR 52 AVYCAZ SOLR INTRAVENOUS 8 aygestin tabs 50 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 53 AZASITE SOLN 40 azathioprine sodium solr 53 azathioprine tabs 53 azelaic acid gel 62 azelastine hcl soln 005 01 015 42 azelastine-fluticasone susp 42 AZELEX CREA 62
AZITHROMYCIN PACK 8 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
B bacitracin oint 40 bacitracin solr 8 bacitracin-polymyxin b oint 40 bacitra-neomycin-polymyxin-hc oint 41 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 58 BAFIERTAM CPDR 34 balsalazide disodium caps 43 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 46 BANZEL SUSP 30 BANZEL TABS 200mg 400mg 30 BAQSIMI ONE PACK POWD 48 BAQSIMI TWO PACK POWD 48 BARACLUDE SOLN 12 BAVENCIO SOLN 14 BAXDELA SOLR INTRAVENOUS 8 BAXDELA TABS 8 BCG VACCINE INJ 14 BD INSULIN SYR ULTRAFINE II MISC 37 BD INSULIN SYRINGE MISC 37 BD INSULIN SYRINGE UF MISC 37 BD PEN NEEDLE ORIGINAL UF MISC 37 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 27 BELEODAQ SOLR 14 BELRAPZO SOLN 14 BELSOMRA TABS 33 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 15 BENDEKA SOLN 15 BENLYSTA SOAJ 53 BENLYSTA SOLR 53 BENLYSTA SOSY 53 BENZEPRO CREAMY WASH LIQD 58 BENZEPRO FOAMING CLOTHS MISC 58 benzhydrocodone-acetaminophen tabs 27 BENZNIDAZOLE TABS 125mg 100mg 11 benzoyl perox-hydrocortisone lotn 59
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BENZOYL PEROXIDE FORTE- HC LOTN 59
BENZOYL PEROXIDE GEL 58 benzoyl peroxide-erythromycin gel 58 benztropine mesylate soln 32 benztropine mesylate tabs 05mg 1mg
2mg 32 BEOVU SOLN 42 bepotastine besilate soln 42 BERINERT KIT INTRAVENOUS 21 beser lotn 59 BESIVANCE SUSP 40 BESPONSA SOLR 15 betamethasone dipropionate aug crea 59 betamethasone dipropionate aug gel 59 betamethasone dipropionate aug lotn 59 betamethasone dipropionate aug oint 59 betamethasone dipropionate crea 59 betamethasone dipropionate lotn 59 BETAMETHASONE DIPROPIONATE OINT
59 betamethasone sod phos amp acet susp 45 betamethasone valerate crea 59 betamethasone valerate foam 59 BETAMETHASONE VALERATE LOTN 59 BETAMETHASONE VALERATE OINT 59 BETASERON KIT 34 betaxolol hcl soln 42 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 20 BETHKIS NEBU 55 BETIMOL SOLN 025 05 42 BETOPTIC-S SUSP 42 BEVESPI AEROSPHERE AERO 19 BEVYXXA CAPS 40mg 80mg 21 bexarotene caps 15 BEXSERO SUSY 57 bicalutamide tabs 15 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICNU SOLR 15 BIDIL TABS 26 BIKTARVY TABS 12 bimatoprost soln 42 BINOSTO TBEF 52 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23
BIVIGAM SOLN 10gm100ml 57 BIVIGAM SOLN 5gm50ml 57 bleomycin sulfate solr 15 bleph-10 soln 40 blephamide sop oint 41 BLEPHAMIDE SUSP 41 BLINCYTO SOLR 15 blisovi 24 fe tabs 46 blisovi fe 1530 tabs 46 BONJESTA TBCR 43 BOOSTRIX SUSP 57 BORTEZOMIB SOLR 15 bosentan tabs 56 BOSULIF TABS 100mg 400mg 500mg 15 BOTOX SOLR 100unit 200unit 54 BP 10-1 EMUL 62 BRAFTOVI CAPS 50mg 75mg 15 briellyn tabs 46 BRILINTA TABS 60mg 90mg 21 BRIMONIDINE TARTRATE SOLN 02
015 42 brinzolamide susp 42 BRIVIACT SOLN 30 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 30 bromfenac sodium (once-daily) soln 41 bromocriptine mesylate caps 32 bromocriptine mesylate tabs 32 BROMSITE SOLN 41 BRONCHITOL CAPS 56 BROVANA NEBU 20 BRUKINSA CAPS 15 BRYHALI LOTN 59 budesonide cpep 45 budesonide er tb24 45 budesonide susp 025mg2ml 05mg2ml
1mg2ml 56 budesonide-formoterol fumarate aero 56 bumetanide soln 38 bumetanide tabs 05mg 1mg 2mg 38 BUNAVAIL FILM 34 bupap tabs 27 bupivacaine hcl (pf) soln 54 bupivacaine hcl soln 54 BUPIVACAINE IN DEXTROSE SOLN 54 bupivacaine spinal soln 54 bupivacaine-epinephrine (pf) soln 54 bupivacaine-epinephrine soln 54 buprenorphine hcl soln 27
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 71
buprenorphine hcl subl 2mg 8mg 34 buprenorphine hcl-naloxone hcl film 34 buprenorphine hcl-naloxone hcl subl 34 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 27 bupropion hcl er (smoking det) tb12 35 bupropion hcl er (sr) tb12 100mg 150mg
200mg 35 bupropion hcl er (xl) tb24 150mg 300mg
450mg 35 bupropion hcl tabs 75mg 100mg 35 buspirone hcl tabs 5mg 10mg 33 buspirone hcl tabs 75mg 15mg 30mg 33 busulfan soln 15 butalbital-acetaminophen caps 27 butalbital-acetaminophen tabs 27 butalbital-apap-caff-cod caps 27 butalbital-apap-caffeine caps 27 butalbital-apap-caffeine tabs 27 butalbital-asa-caff-codeine caps 27 butalbital-aspirin-caffeine caps 27 butalbital-aspirin-caffeine tabs 27 butorphanol tartrate soln 1mgml 2mgml
10mgml 27 BUTRANS PTWK 27 BYDUREON BCISE AUIJ 48 BYDUREON PEN 48 BYETTA 10 MCG PEN SOPN 48 BYETTA 5 MCG PEN SOPN 48 BYLVAY (PELLETS) CPSP 200mcg
600mcg 44 BYLVAY CAPS 400mcg 1200mcg 44 BYNFEZIA PEN SOPN 51
C CABENUVA SUER 12 cabergoline tabs 32 CABLIVI KIT 22 CABOMETYX TABS 20mg 40mg 60mg 15 cafergot tabs 32 caffeine citrate soln 30 calcipotriene crea 62 calcipotriene oint 62 calcipotriene soln 62 calcipotriene-betameth diprop oint 59 calcipotriene-betameth diprop susp 59 calcitonin (salmon) soln 50 calcitrene oint 62 calcitriol caps 025mcg 05mcg 63
CALCITRIOL OINT 62 calcitriol soln 63 calcium acetate (phos binder) caps 39 calcium acetate (phos binder) tabs 39 CALCIUM GLUCONATE-NACL SOLN 39 CALQUENCE CAPS 15 camila tabs 46 camrese lo tabs 46 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 59 CAPLYTA CAPS 35 CAPRELSA TABS 100mg 300mg 15 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 26 CARAC CREA 62 CARAFATE SUSP 43 CARBAGLU TABS 37 carbamazepine chew 30 carbamazepine er cp12 100mg 200mg
300mg 30 carbamazepine er tb12 100mg 200mg
400mg 30 carbamazepine susp 30 carbamazepine tabs 30 carbidopa tabs 32 carbidopa-levodopa er tbcr 32 carbidopa-levodopa tabs 32 carbidopa-levodopa tbdp 32 carbidopa-levodopa-entacapone tabs 32 carbinoxamine maleate soln 14 carbinoxamine maleate tabs 14 carboplatin soln 15 carboprost tromethamine soln 50 CARDENE IV SOLN 24 CARDIZEM LA TB24 24 CARDURA XL TB24 4mg 8mg 22 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 15 CARNITOR SOLN 54 CARNITOR TABS 54 CAROSPIR SUSP 26 carteolol hcl soln 42
72 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
cartia xt cp24 120mg 180mg 240mg 300mg 24
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg 23
carvedilol tabs 3125mg 625mg 125mg 25mg 23
caspofungin acetate solr intravenous 50mg 70mg 11
cataflam tabs 27 CAYSTON SOLR 56 caziant tabs 46 cefaclor caps 8 cefaclor er tb12 8 cefaclor susr 8 cefadroxil caps 8 cefadroxil susr 8 cefadroxil tabs 8 cefazolin sodium solr 8 cefazolin sodium solr injection 1gm 10gm
500mg 8 cefdinir caps 8 cefdinir susr 8 cefepime hcl solr injection 1gm 2gm 8 cefixime caps 8 cefixime susr 8 cefotaxime sodium solr 8 cefotetan disodium solr injection 1gm 2gm 8 cefoxitin sodium solr injection 8 cefoxitin sodium solr intravenous 1gm 2gm
8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 2gm 6gm 8 CEFTIN SUSR 8 ceftriaxone sodium solr injection 1gm 2gm
250mg 500mg 8 ceftriaxone sodium solr intravenous 8 cefuroxime axetil tabs 8 cefuroxime sodium solr injection 75gm
750mg 8 cefuroxime sodium solr intravenous 8 celecoxib caps 27 CELONTIN CAPS 30 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 41
CERDELGA CAPS 40 CEREZYME SOLR 40 CEROVEL LOTN 62 CESAMET CAPS 43 cetirizine hcl soln 14 CETRAXAL SOLN 40 CEVIMELINE HCL CAPS 20 CHANTIX CONTINUING MONTH PAK
TABS 20 CHANTIX STARTING MONTH PAK TABS
20 CHANTIX TABS 05mg 1mg 20 CHEMET CAPS 44 chloramphenicol sod succinate solr 9 chlordiazepoxide hcl caps 5mg 10mg
25mg 33 chlordiazepoxide-amitriptyline tabs 35 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 40 chloroprocaine hcl (pf) soln 54 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 38 chlorothiazide tabs 250mg 500mg 38 chlorpromazine hcl soln 35 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 35 chlorthalidone tabs 25mg 50mg 38 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 44 cholestyramine light pack 23 cholestyramine light powd 23 cholestyramine pack 23 cholestyramine powd 23 CHORIONIC GONADOTROPIN SOLR 50 ciclopirox gel 58 ciclopirox olamine crea 58 ciclopirox olamine susp 58 ciclopirox sham 58 ciclopirox soln 58 cidofovir soln 12 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 40 CIMDUO TABS 12 cimetidine hcl soln 43 cimetidine tabs 200mg 300mg 400mg
800mg 43 CIMZIA KIT 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 73
CIMZIA PREFILLED KIT 52 CIMZIA STARTER KIT KIT 52 cinacalcet hcl tabs 30mg 60mg 90mg 50 CINQAIR SOLN 55 CINRYZE SOLR INTRAVENOUS 54 CIPRO HC SUSP 41 CIPRODEX SUSP 41 ciprofloxacin hcl soln (ophth) 40 CIPROFLOXACIN HCL SOLN (OTIC) 40 ciprofloxacin hcl tabs 9 ciprofloxacin in d5w soln 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 41 CIPROFLOXACIN-FLUOCINOLONE PF
SOLN 40 cisplatin soln 15 CISPLATIN SOLR 15 citalopram hydrobromide soln 35 citalopram hydrobromide tabs 10mg 20mg
40mg 35 citanest plain dental soln 54 cladribine soln 15 claravis caps 10mg 20mg 30mg 40mg 62 CLARINEX SYRP 14 CLARINEX-D 12 HOUR TB12 14 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 14 cleocin phosphate soln 9 cleocin solr 9 CLEOCIN SUPP 58 CLIMARA PRO PTWK 49 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
clindacin-p swab 58 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 58 clindamycin phosphate crea 58 clindamycin phosphate foam 58 clindamycin phosphate gel 58 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 58
clindamycin phosphate soln 9 58 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 58 CLINDESSE CREA 58 CLINIMIX EDEXTROSE (27510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42525) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (525) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (525) SOLN
INTRAVENOUS 38 clinisol sf soln intravenous 38 clobazam susp 30 clobazam tabs 10mg 20mg 30 clobetasol propionate crea 59 clobetasol propionate e crea 59 clobetasol propionate emulsion foam 59 clobetasol propionate foam 59 clobetasol propionate gel 59 clobetasol propionate liqd 60 clobetasol propionate lotn 60 clobetasol propionate oint 60 clobetasol propionate sham 60 clobetasol propionate soln 60 CLOBEX SHAM 60
74 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
CLOBEX SPRAY LIQD 60 clocortolone pivalate crea 60 clocortolone pivalate pump crea 60 clodan sham 60 clofarabine soln 15 clomipramine hcl caps 25mg 50mg 75mg
35 clonazepam tabs 05mg 1mg 2mg 30 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 30 clonidine hcl (analgesia) soln 25 clonidine hcl er tb12 25 clonidine hcl tabs 01mg 02mg 03mg 25 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 25 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 33 clotrimazole crea 58 clotrimazole soln 58 clotrimazole troc 58 clotrimazole-betamethasone crea 58 clotrimazole-betamethasone lotn 58 clovique caps 44 clozapine tabs 25mg 50mg 100mg 200mg
35 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 35 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 27 colazal caps 43 COLCHICINE CAPS 52 colchicine tabs 52 colchicine-probenecid tabs 40 colesevelam hcl pack 23 colesevelam hcl tabs 23 colestipol hcl gran 23 colestipol hcl pack 23 colestipol hcl tabs 23 colistimethate sodium (cba) solr injection 9 colocort enem 60 COLY-MYCIN S SUSP 41 COMBIGAN SOLN 42 COMBIPATCH PTTW 49 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 15 COMETRIQ (140 MG DAILY DOSE) KIT 15 COMETRIQ (60 MG DAILY DOSE) KIT 15
COMPLERA TABS 12 compro supp 35 CONDYLOX GEL 62 CONSENSI TABS 24 constulose soln 37 COPIKTRA CAPS 15mg 25mg 15 CORDRAN TAPE 60 CORLANOR TABS 5mg 75mg 25 cortisone acetate tabs 45 CORTISPORIN CREA 60 CORTISPORIN OINT 60 COSELA SOLR 54 COSENTYX (300 MG DOSE) SOSY 62 COSENTYX SENSOREADY (300 MG)
SOAJ 62 COSENTYX SENSOREADY PEN SOAJ 62 COSENTYX SOSY 75mg05ml 150mgml
62 COTELLIC TABS 15 COTEMPLA XR-ODT TBED 86mg
173mg 259mg 30 CREON CPEP 40 CRESEMBA CAPS 11 CRESEMBA SOLR 11 CRINONE GEL 4 8 50 CRIXIVAN CAPS 200mg 400mg 12 cromolyn sodium conc 55 cromolyn sodium nebu 55 cromolyn sodium soln 42 crotan lotn 58 cryselle-28 tabs 46 CRYSVITA SOLN 10mgml 20mgml
30mgml 54 CUPRIMINE CAPS 44 CURITY GAUZE PADS 37 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 57
CUVPOSA SOLN 19 cyclafem 135 tabs 46 cyclafem 777 tabs 46 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 15 CYCLOPHOSPHAMIDE SOLN 1gm5ml
500mg25ml 15 cyclophosphamide solr 15
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 75
cycloserine caps 11 CYCLOSET TABS 48 cyclosporine caps 25mg 100mg 53 cyclosporine modified caps 25mg 50mg
100mg 53 cyclosporine modified soln 53 cyclosporine soln 53 cyproheptadine hcl syrp 14 cyproheptadine hcl tabs 14 CYRAMZA SOLN 100mg10ml
500mg50ml 15 cyred eq tabs 46 CYSTADANE POWD 54 CYSTADROPS SOLN 42 CYSTAGON CAPS 50mg 150mg 54 CYSTARAN SOLN 42 cytarabine (pf) soln 15 cytarabine soln 15 CYTOGAM INJ 57
D dacarbazine solr 15 dactinomycin solr 15 DAKLINZA TABS 30mg 60mg 90mg 12 dalfampridine er tb12 34 DALIRESP TABS 250mcg 500mcg 56 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 45 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 62 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 57 daptomycin solr intravenous 350mg 500mg
9 DARAPRIM TABS 11 darifenacin hydrobromide er tb24 75mg
15mg 63 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 DAYTRANA PTCH 10mg9hr 15mg9hr
20mg9hr 30mg9hr 30 DDAVP RHINAL TUBE SOLN 50 deblitane tabs 46 decadron elix 45
decadron tabs 5mg 75mg 45 decadron tabs 4mg 6mg 45 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 44 deferasirox tabs 90mg 180mg 360mg 44 deferasirox tbso 125mg 44 deferasirox tbso 250mg 500mg 44 deferiprone tabs 44 deferoxamine mesylate solr 44 DELESTROGEN OIL 49 DELSTRIGO TABS 12 deltasone tabs 45 delyla tabs 46 DELZICOL CPDR 43 demeclocycline hcl tabs 9 DEMEROL SOLN 25mg05ml 75mg15ml
100mg2ml 75mgml 27 DEMSER CAPS 22 DENAVIR CREA 58 DEPEN TITRATABS TABS 44 depo-estradiol oil 49 DEPO-MEDROL SUSP 45 DEPO-PROVERA SUSP 400mgml 50 DEPO-SUBQ PROVERA 104 SUSY 50 depo-testosterone soln 100mgml
200mgml 45 DERMOTIC OIL 41 DESCOVY TABS 12 desipramine hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 desloratadine tabs 14 desloratadine tbdp 14 desmopressin ace spray refrig soln 50 desmopressin acetate
soln 50 DESMOPRESSIN ACETATE SOLN 50 desmopressin acetate spray soln 50 DESMOPRESSIN ACETATE TABS 01mg
02mg 50 desogestrel-ethinyl estradiol tabs 46 DESONATE GEL 60 desonide crea 60 desonide gel 60 desonide lotn 60 desonide oint 60 desowen lotn 60 desoximetasone crea 005 025 60 desoximetasone gel 60
76 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
desoximetasone liqd 60 desoximetasone oint 005 025 60 desrx gel 60 DESVENLAFAXINE ER TB24 50mg
100mg 35 desvenlafaxine succinate er tb24 25mg
50mg 100mg 35 dexabliss tbpk 45 dexamethasone elix 45 dexamethasone intensol conc 45 dexamethasone sod phosphate pf soln 45 dexamethasone sodium phosphate soln 41
45 dexamethasone soln 45 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 45 dexamethasone tbpk 45 dexchlorpheniramine maleate soln 14 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 30
dexmethylphenidate hcl tabs 25mg 5mg 10mg 30
dexpak 10 day tbpk 45 dexpak 13 day tbpk 45 dexpak 6 day tbpk 45 dexrazoxane hcl solr 54 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 30 dextroamphetamine sulfate soln 30 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 30 DEXTROSE 10NACL 02 39 DEXTROSE 5NACL 0225 39 DEXTROSE IN LACTATED RINGERS
SOLN 39 DEXTROSE SOLN 38 dextrose soln intravenous 5 10 38 DEXTROSE-NACL SOLN INTRAVENOUS
39 DIACOMIT CAPS 250mg 500mg 30 DIACOMIT PACK 250mg 500mg 31 DIASTAT ACUDIAL GEL 10mg 20mg 31 DIASTAT PEDIATRIC GEL 31 diazepam conc 33 diazepam gel 25mg 10mg 20mg 31 diazepam soln 5mg5ml 5mgml 33 diazepam tabs 2mg 5mg 10mg 33 diazoxide susp 48
diclofenac potassium tabs 27 diclofenac sodium er tb24 27 diclofenac sodium gel 1 3 60 diclofenac sodium soln 41 diclofenac sodium tbec 27 diclofenac-misoprostol tbec 27 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 12 DIFFERIN CREA 62 DIFFERIN LOTN 62 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 60 diflorasone diacetate oint 60 diflunisal tabs 27 digitek tabs 0125mg 025mg 25 digox tabs 25 DIGOXIN ORAL SOLN 25 digoxin soln inj 25 digoxin tabs 125mcg 250mcg 25 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 31 dilantin infatabs chew 31 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 24 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 24
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 24
diltiazem hcl er cp12 60mg 90mg 120mg 24
diltiazem hcl er cp24 120mg 180mg 240mg 24
diltiazem hcl soln 24 diltiazem hcl solr 24 diltiazem hcl tabs 30mg 60mg 90mg
120mg 24 dilt-xr cp24 120mg 180mg 240mg 24 dimenhydrinate soln 43 dimethyl fumarate cpdr 34 dimethyl fumarate starter pack misc 34 DIPENTUM CAPS 43 diphen elix 14 di-phen elix 14 diphenhydramine hcl elix 14
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 77
diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 43 diphenoxylate-atropine tabs 43 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 57 dipyridamole tabs 25mg 50mg 75mg 26 disopyramide phosphate caps 100mg
150mg 25 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 38 divalproex sodium csdr 31 divalproex sodium er tb24 250mg 500mg 31 divalproex sodium tbec 125mg 250mg
500mg 31 DIVIGEL GEL 49 dobutamine hcl soln 21 DOBUTAMINE IN D5W SOLN 21 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 160mg8ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
25 dolishale tabs 46 donepezil hcl tabs 5mg 10mg 23mg 20 donepezil hcl tbdp 5mg 10mg 20 dopamine hcl soln 21 DOPAMINE IN D5W SOLN 21 DOPTELET TABS 22 DORYX MPC TBEC 9 dorzolamide hcl soln 42 dorzolamide hcl-timolol mal pf soln 42 dorzolamide hcl-timolol mal soln 42 dotti pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 49
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 35 doxepin hcl conc 35 doxepin hcl crea 61 doxepin hcl tabs 3mg 6mg 35 doxercalciferol caps 05mcg 1mcg 25mcg
63 DOXERCALCIFEROL SOLN 63 doxorubicin hcl liposomal inj 15 DOXORUBICIN HCL SOLN 15
doxorubicin hcl solr 15 doxy 100 solr intravenous 9 doxycycline hyclate caps 50mg 100mg 9 doxycycline hyclate tabs 20mg 75mg
100mg 150mg 9 doxycycline hyclate tbec 50mg 75mg
100mg 150mg 200mg 9 doxycycline monohydrate caps 50mg
75mg 100mg 150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 43 DRIZALMA SPRINKLE CSDR 35 dronabinol caps 25mg 5mg 10mg 43 droperidol soln 33 drospiren-eth estrad-levomefol tabs 46 drospirenone-ethinyl estradiol tabs 46 DROXIA CAPS 15 droxidopa caps 21 DUAKLIR PRESSAIR AEPB 19 DUAVEE TABS 49 DUEXIS TABS 27 DULERA AERO 56 duloxetine hcl cpep 20mg 30mg 40mg
60mg 35 DUOBRII LOTN 60 DUOPA SUSP 32 DUPIXENT SOPN 200mg114ml
300mg2ml 55 DUPIXENT SOSY 200mg114ml
300mg2ml 55 DURAMORPH SOLN 05mgml 1mgml 27 DUREZOL EMUL 41 DURYSTA IMPL 42 dutasteride caps 52 dutasteride-tamsulosin hcl caps 52 DUTOPROL TB24 23 dvorah tabs 27 dxevo 11-day tbpk 45 DYANAVEL XR SUER 30 DYSPORT SOLR 300unit 500unit 54
E ees 400 tabs 9 EASYGEL GEL 54 econazole nitrate crea 58 EDARBYCLOR TABS 26 EDLUAR SUBL 5mg 10mg 33
78 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 51 EGRIFTA SV SOLR 51 ELAPRASE SOLN 40 ELELYSO SOLR 40 ELEPSIA XR TB24 1000mg 1500mg 31 ELESTRIN GEL 49 eletriptan hydrobromide tabs 32 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 40 elixophyllin elix 63 ELLA TABS 46 ELLENCE SOLN 15 ELMIRON CAPS 54 eluryng ring 46 ELZONRIS SOLN 15 EMBEDA CPCR 27 EMCYT CAPS 15 EMEND SUSR 43 EMFLAZA SUSP 45 EMFLAZA TABS 6mg 18mg 30mg 36mg
45 EMGALITY (300 MG DOSE) SOSY 32 EMGALITY SOAJ 32 EMGALITY SOSY 32 emoquette tabs 46 EMPAVELI SOLN 54 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 32 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 26 enalaprilat inj 26 enalapril-hydrochlorothiazide tabs 26 ENBREL MINI SOCT 52 ENBREL SOLN 52 ENBREL SOLR 52 ENBREL SOSY 25mg05ml 50mgml 52 ENBREL SURECLICK SOAJ 52 ENDARI PACK 54 endocet tabs 27
ENDOMETRIN INST 50 ENGERIX-B SUSP 10mcg05ml 20mcgml
57 ENHERTU SOLR 15 enoxaparin sodium soln 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
enpresse-28 tabs 46 enskyce tabs 46 ENSPRYNG SOSY 54 ENSTILAR FOAM 60 entacapone tabs 33 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 26 ENTYVIO SOLR 44 enulose soln 37 ENVARSUS XR TB24 075mg 1mg 4mg53 EPCLUSA TABS 12 EPIDIOLEX SOLN 31 EPIDUO FORTE GEL 62 epifoam foam 60 epinastine hcl soln 42 epinephrine (anaphylaxis) soln 21 epinephrine soaj 21 EPINEPHRINE SOSY 21 EPIPEN 2-PAK SOAJ 21 EPIPEN JR 2-PAK SOAJ 21 epirubicin hcl soln 15 epitol tabs 31 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 26 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 22
epoprostenol sodium solr 56 eprosartan mesylate tabs 26 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 35 ERAXIS SOLR INTRAVENOUS 50mg
100mg 11 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 32 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 79
ERTACZO CREA 58 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 58 ery-tab tbec 9 ERYTHROCIN LACTOBIONATE SOLR
INTRAVENOUS 9 erythrocin stearate tabs 9 erythromycin base cpep 9 erythromycin base tabs 9 erythromycin base tbec 9 erythromycin ethylsuccinate susr 9 erythromycin ethylsuccinate tabs 9 erythromycin gel 58 erythromycin oint 40 erythromycin pads 58 erythromycin soln 58 ESBRIET CAPS 56 ESBRIET TABS 267mg 801mg 56 escitalopram oxalate soln 35 escitalopram oxalate tabs 5mg 10mg
20mg 35 esgic caps 27 esgic tabs 27 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 43 esomeprazole magnesium pack 10mg
20mg 40mg 43 esomeprazole sodium solr 43 ESOMEPRAZOLE STRONTIUM CPDR 43 estarylla tabs 46 estazolam tabs 1mg 2mg 33 estrace crea 49 estrace tabs 05mg 1mg 2mg 49 estradiol crea 49 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 49
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
estradiol tabs 10mcg 05mg 1mg 2mg 49 estradiol valerate oil 49 estradiol-norethindrone acet tabs 49 ESTRING RING 49 eszopiclone tabs 1mg 2mg 3mg 33
ethacrynic acid tabs 38 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 31 ethosuximide soln 31 ethynodiol diac-eth estradiol tabs 46 etodolac caps 27 etodolac er tb24 27 etodolac tabs 27 etonogestrel-ethinyl estradiol ring 46 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 EURAX CREA 58 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
EVAMIST SOLN 49 evekeo tabs 5mg 10mg 30 EVENITY SOSY 52 everolimus tabs 025mg 53 everolimus tabs 05mg 075mg 53 everolimus tabs 25mg 5mg 75mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 23 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 54 EXELDERM CREA 58 EXELDERM SOLN 58 exemestane tabs 15 EXJADE TBSO 125mg 250mg 500mg 44 EXONDYS 51 SOLN 500mg10ml
100mg2ml 54 EXSERVAN FILM 34 EXTAVIA KIT 34 EYLEA SOLN 42 EYLEA SOSY 42 ezetimibe tabs 23 ezetimibe-simvastatin tabs 23
F FABIOR FOAM 62 FABRAZYME SOLR 5mg 35mg 40 falmina tabs 46 famciclovir tabs 125mg 250mg 500mg 12 famotidine premixed soln 43 famotidine soln 43 famotidine susr 43 famotidine tabs 20mg 40mg 43
80 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg 35
FANAPT TITRATION PACK TABS 35 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 55 FASENRA SOSY 55 FASLODEX SOLN 15 fayosim tabs 46 febuxostat tabs 40mg 80mg 52 felbamate susp 31 felbamate tabs 400mg 600mg 31 felodipine er tb24 25mg 5mg 10mg 24 femynor tabs 46 fenofibrate caps 50mg 134mg 150mg 23 fenofibrate micronized caps 43mg 67mg
130mg 200mg 23 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 23 fenofibric acid cpdr 45mg 135mg 23 FENOFIBRIC ACID TABS 35mg 105mg 23 fenoprofen calcium caps 27 fenoprofen calcium tabs 27 fenortho caps 27 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 27 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 27
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg 27
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 27
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 27
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg 27
FERRIPROX SOLN 44 FERRIPROX TABS 500mg 1000mg 44 FERRIPROX TWICE-A-DAY TABS 44 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
35 FETZIMA TITRATION C4PK 35 fexmid tabs 20 FIBRICOR TABS 23 FINACEA FOAM 62 finasteride tabs 52 FINTEPLA SOLN 31
fioricet caps 27 fioricetcodeine caps 27 FIRAZYR SOLN 21 FIRDAPSE TABS 54 FIRMAGON (240 MG DOSE) SOLR 16 FIRMAGON SOLR 16 FIRVANQ SOLR 9 flac oil 41 FLAREX SUSP 41 flavoxate hcl tabs 63 FLEBOGAMMA DIF SOLN INTRAVENOUS
5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml 57
flecainide acetate tabs 50mg 100mg 150mg 25
FLOLIPID SUSP 20mg5ml 40mg5ml 23 FLOVENT DISKUS AEPB 50mcgblist
100mcgblist 250mcgblist 56 FLOVENT HFA AERO 110mcgact
220mcgact 56 FLOVENT HFA AERO 44mcgact 56 floxuridine solr 16 fluconazole in sodium chloride soln
intravenous 11 fluconazole susr 11 fluconazole tabs 11 flucytosine caps 250mg 500mg 11 fludarabine phosphate soln 16 fludarabine phosphate solr 16 fludrocortisone acetate tabs 45 flumazenil soln 34 flunisolide soln 41 fluocinolone acetonide body oil 60 fluocinolone acetonide crea 001 0025
60 fluocinolone acetonide oil 41 fluocinolone acetonide oint 60 fluocinolone acetonide scalp oil 60 fluocinolone acetonide soln 60 fluocinonide crea 60 fluocinonide emulsified base crea 60 FLUOCINONIDE GEL 60 fluocinonide oint 60 fluocinonide soln 60 FLUORITAB CHEW 025mg 05mg 1mg 54 FLUORITAB SOLN 54 fluorometholone susp 41 fluorouracil crea 5 62
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fluorouracil crea 5 62 fluorouracil soln 16 62 fluorouracil soln 2 5 62 fluoxetine hcl (pmdd) tabs 10mg 20mg 35 fluoxetine hcl caps 10mg 20mg 40mg 35 fluoxetine hcl cpdr 35 fluoxetine hcl soln 35 fluoxetine hcl tabs 10mg 20mg 60mg 36 fluphenazine decanoate soln 36 fluphenazine hcl conc 36 fluphenazine hcl elix 36 fluphenazine hcl soln 36 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 36 flurandrenolide crea 60 flurandrenolide lotn 60 flurandrenolide oint 60 flurazepam hcl caps 15mg 30mg 33 flurbiprofen sodium soln 41 flurbiprofen tabs 27 flutamide caps 16 fluticasone propionate crea 60 fluticasone propionate lotn 60 fluticasone propionate oint 60 fluticasone propionate susp 41 fluticasone-salmeterol aepb 56 fluvastatin sodium caps 20mg 40mg 23 fluvastatin sodium er tb24 23 fluvoxamine maleate er cp24 100mg
150mg 36 fluvoxamine maleate tabs 25mg 50mg
100mg 36 FML FORTE SUSP 41 FML OINT 41 fomepizole soln 52 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 formoterol fumarate nebu 21 FORTEO SOPN 50 FOSAMAX PLUS D TABS 52 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 43 fosfomycin tromethamine pack 14 fosinopril sodium tabs 10mg 20mg 40mg
26 fosinopril sodium-hctz tabs 26 fosphenytoin sodium soln 31 FOSRENOL PACK 750mg 1000mg 39
FOTIVDA CAPS 089mg 134mg 16 FREAMINE HBC SOLN INTRAVENOUS 38 frovatriptan succinate tabs 32 FULPHILA SOSY 22 fulvestrant soln 16 furosemide soln 8mgml 10mgml 38 furosemide soln injection 38 FUROSEMIDE TABS 40mg 80mg 20mg38 FUZEON SOLR 12 fyavolv tabs 49 FYCOMPA SUSP 31 FYCOMPA TABS 31
G gabapentin caps 100mg 400mg 31 gabapentin soln 31 gabapentin tabs 600mg 800mg 31 GALAFOLD CAPS 54 galantamine hydrobromide er cp24 8mg
16mg 24mg 20 galantamine hydrobromide soln 20 galantamine hydrobromide tabs 4mg 8mg
12mg 20 GAMASTAN INJ 57 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 53 GAMMAGARD SD LESS IGA SOLR
INTRAVENOUS 5gm 10gm 57 GAMMAGARD SOLN INJECTION 57 GAMMAKED SOLN INJECTION 57 GAMMAPLEX SOLN INTRAVENOUS
10gm100ml 20gm200ml 5gm50ml 57 GAMMAPLEX SOLN INTRAVENOUS
10gm200ml 57 GAMUNEX-C SOLN INJECTION
10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml 57
ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 57 GARDASIL 9 SUSY 57 gatifloxacin soln 40 GATTEX KIT 44 gavilyte-c solr 44 gavilyte-g solr 44 gavilyte-h kit 44 gavilyte-n with flavor pack solr 44 GAVRETO CAPS 16 GAZYVA SOLN 16
82 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
gemcitabine hcl soln 16 gemcitabine hcl solr 16 gemfibrozil tabs 23 gemmily caps 46 generlac soln 37 gengraf caps 25mg 50mg 100mg 53 gengraf soln 53 GENOTROPIN MINIQUICK SOLR 02mg 51 GENOTROPIN MINIQUICK SOLR 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 51
GENOTROPIN SOLR 5mg 12mg 51 gentak oint 40 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 58 gentamicin sulfate oint 58 gentamicin sulfate soln 9 40 gentamicin sulfate soln injection 9 GENVOYA TABS 12 GEODON SOLR 36 gianvi tabs 46 GILENYA CAPS 025mg 05mg 34 GILOTRIF TABS 20mg 30mg 40mg 16 GIMOTI SOLN 44 GIVLAARI SOLN 54 GLASSIA SOLN INTRAVENOUS 56 glatiramer acetate sosy 20mgml 40mgml
34 glatopa sosy 20mgml 40mgml 34 glimepiride tabs 1mg 2mg 4mg 48 glipizide er tb24 25mg 5mg 10mg 48 glipizide tabs 5mg 10mg 48 glipizide-metformin hcl tabs 48 GLOPERBA SOLN 52 GLUCAGEN HYPOKIT SOLR 48 glucagon emergency kit 48 glyburide micronized tabs 15mg 3mg 6mg
48 glyburide tabs 125mg 25mg 5mg 48 glyburide-metformin tabs 48 glycate tabs 19 glycopyrrolate pf sosy 19 glycopyrrolate soln 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 61 GLYXAMBI TABS 48 GOLYTELY SOLR 44 GONITRO PACK 26
granisetron hcl soln 43 granisetron hcl tabs 43 GRANIX SOLN 480mcg16ml 300mcgml
22 GRANIX SOSY 300mcg05ml
480mcg08ml 22 GRASTEK SUBL 54 griseofulvin microsize susp 11 griseofulvin microsize tabs 11 griseofulvin ultramicrosize tabs 11 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 34 guanfacine hcl tabs 1mg 2mg 25 GUANIDINE HCL TABS 20 gynazole-1 crea 58
H HAEGARDA SOLR 2000unit 3000unit 54 hailey 24 fe tabs 46 halcinonide crea 60 halobetasol propionate crea 60 HALOBETASOL PROPIONATE FOAM 60 halobetasol propionate oint 60 HALOG CREA 60 HALOG OINT 60 haloperidol decanoate soln 36 haloperidol lactate conc 36 haloperidol lactate soln 36 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 36 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 57 heparin (porcine) in nacl soln 21 HEPARIN SOD (PORCINE) IN D5W SOLN
21 heparin sodium (porcine) pf soln 21 heparin sodium (porcine) soln 1000unitml
5000unitml 10000unitml 20000unitml 21
HEPATAMINE SOLN INTRAVENOUS 38 HEPLISAV-B SOLN 57 HERCEPTIN HYLECTA SOLN 16 HERCEPTIN SOLR 150mg 440mg 16 HERZUMA SOLR 150mg 420mg 16 HETLIOZ CAPS 33 HETLIOZ LQ SUSP 33 HEXALEN CAPS 16 HIBERIX SOLR 57
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 83
HORIZANT TBCR 300mg 600mg 31 HUMALOG JUNIOR KWIKPEN SOPN 48 HUMALOG KWIKPEN SOPN 100unitml
200unitml 48 HUMALOG MIX 5050 KWIKPEN SUPN 48 HUMALOG MIX 5050 SUSP 48 HUMALOG MIX 7525 KWIKPEN SUPN 48 HUMALOG MIX 7525 SUSP 48 HUMALOG SOCT 48 HUMALOG SOLN 48 humatin caps 11 HUMATROPE SOLR 5mg 6mg 12mg
24mg 51 HUMIRA PEDIATRIC CROHNS START
PSKT 52 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 52 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 52 HUMIRA PEN-PEDIATRIC UC START
PNKT 52 HUMIRA PEN-PSUVADOL HS START
PNKT 52 HUMIRA PEN-PSORUVEIT STARTER
PNKT 52 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 52
HUMULIN 7030 KWIKPEN SUPN 48 HUMULIN 7030 SUSP 48 HUMULIN N KWIKPEN SUPN 48 HUMULIN N SUSP 48 HUMULIN R SOLN 48 HUMULIN R U-500 (CONCENTRATED)
SOLN 48 HUMULIN R U-500 KWIKPEN SOPN 48 hydralazine hcl soln 25 hydralazine hcl tabs 10mg 25mg 50mg
100mg 25 hydrochlorothiazide caps 38 hydrochlorothiazide tabs 125mg 25mg
50mg 38 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 27 hydrocodone-acetaminophen soln 27 hydrocodone-acetaminophen tabs 27 hydrocodone-ibuprofen tabs 27 hydrocortisone (perianal) crea 1 25 60 hydrocortisone ace-pramoxine crea 61
hydrocortisone butyr lipo base crea 60 hydrocortisone butyrate crea 60 hydrocortisone butyrate lotn 60 HYDROCORTISONE BUTYRATE OINT 60 hydrocortisone butyrate soln 60 hydrocortisone crea 1 25 60 hydrocortisone enem 60 hydrocortisone lotn 60 hydrocortisone oint 1 25 60 hydrocortisone tabs 5mg 10mg 20mg 45 hydrocortisone valerate crea 60 hydrocortisone valerate oint 60 HYDROCORTISONE-ACETIC ACID SOLN
41 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 28 hydromorphone hcl liqd 28 hydromorphone hcl pf soln 50mg5ml
10mgml 28 HYDROMORPHONE HCL SOLN 1mgml
2mgml 28 hydromorphone hcl tabs 2mg 4mg 8mg 28 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 50 hydroxyprogesterone caproate soln 50 hydroxyurea caps 16 hydroxyzine hcl soln 33 hydroxyzine hcl syrp 33 hydroxyzine hcl tabs 33 hydroxyzine pamoate caps 33 HYPERHEP B SOLN 57 HYPERRAB SD SOLN 57 HYQVIA KIT 57
I IBANDRONATE SODIUM SOLN 52 ibandronate sodium tabs 52 IBRANCE CAPS 75mg 100mg 125mg 16 IBRANCE TABS 75mg 100mg 125mg 16 ibu tabs 28 ibudone tabs 28 ibuprofen lysine soln 28 ibuprofen susp 28 ibuprofen tabs 28 ibutilide fumarate soln 25 icatibant acetate soln 21 iclevia tabs 46 ICLUSIG TABS 10mg 15mg 30mg 45mg
16
84 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
icosapent ethyl caps 23 IDAMYCIN PFS SOLN 16 idarubicin hcl soln 16 IDHIFA TABS 50mg 100mg 16 ifosfamide soln 16 IFOSFAMIDE SOLR 16 ILARIS SOLN 28 ILEVRO SUSP 41 ILUMYA SOSY 62 ILUVIEN IMPL 41 imatinib mesylate tabs 16 IMBRUVICA CAPS 70mg 140mg 16 IMBRUVICA TABS 140mg 280mg 420mg
560mg 16 IMFINZI SOLN 500mg10ml 120mg24ml
16 imipenem-cilastatin solr intravenous 9 imipramine hcl tabs 10mg 25mg 50mg 36 imipramine pamoate caps 75mg 100mg
125mg 150mg 36 imiquimod crea 375 5 62 IMIQUIMOD PUMP CREA 62 IMOGAM RABIES-HT SOLN 57 IMOVAX RABIES INJ 57 IMPAVIDO CAPS 11 IMVEXXY MAINTENANCE PACK INST
4mcg 10mcg 49 IMVEXXY STARTER PACK INST 4mcg
10mcg 49 INBRIJA CAPS 33 incassia tabs 46 INCRELEX SOLN 51 INCRUSE ELLIPTA AEPB 19 indapamide tabs 125mg 25mg 38 indocin supp 28 INDOCIN SUSP 28 indomethacin caps 28 INDOMETHACIN CAPS 20mg 28 indomethacin er cpcr 28 indomethacin sodium solr 28 INFANRIX SUSP 57 INFLECTRA SOLR INTRAVENOUS 52 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 34 INGREZZA CPPK 34 INLYTA TABS 1mg 5mg 16 INNOPRAN XL CP24 80mg 120mg 23 INQOVI TABS 16 INREBIC CAPS 16
INSULIN ASP PROT amp ASP FLEXPEN SUPN 48
INSULIN ASPART FLEXPEN SOPN 48 INSULIN ASPART PENFILL SOCT 48 INSULIN ASPART PROT amp ASPART SUSP
48 INSULIN ASPART SOLN 48 INSULIN LISPRO (1 UNIT DIAL) SOPN 48 INSULIN LISPRO SOLN 48 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 38 INTRALIPID EMUL INTRAVENOUS
20gm100ml 38 INTRAROSA INST 45 INTRON A SOLN 10muml 6000000unitml
16 INTRON A SOLR 10mu 18mu 50mu 16 introvale tabs 46 INVEGA SUSTENNA SUSY 39mg025ml
36 INVEGA SUSTENNA SUSY 78mg05ml
117mg075ml 234mg15ml 156mgml 36
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml 36
INVELTYS SUSP 41 INVIRASE CAPS 12 INVIRASE TABS 12 INVOKAMET TABS 48 INVOKAMET XR TB24 48 INVOKANA TABS 100mg 300mg 48 IONOSOL-MB IN D5W SOLN
INTRAVENOUS 39 IOPIDINE SOLN 42 IPOL INJ 57 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 21 irbesartan tabs 75mg 150mg 300mg 26 irbesartan-hydrochlorothiazide tabs 26 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isibloom tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 85
ISOLYTE-P IN D5W SOLN INTRAVENOUS 39
ISOLYTE-S SOLN INTRAVENOUS 39 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 21 isosorbide dinitrate er tbcr 26 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 26 isosorbide mononitrate er tb24 26 isosorbide mononitrate er tb24 30mg 60mg
26 isosorbide mononitrate tabs 10mg 20mg 26 isotretinoin caps 10mg 20mg 30mg 40mg
62 isradipine caps 25mg 5mg 24 ISTURISA TABS 1mg 5mg 10mg 54 itraconazole caps 11 ITRACONAZOLE SOLN 11 ivermectin crea 58 ivermectin lotn 58 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 57
J JADENU SPRINKLE PACK 90mg 180mg
360mg 44 JADENU TABS 90mg 360mg 44 JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16 jantoven tabs 1mg 2mg 25mg 3mg 4mg
5mg 6mg 75mg 10mg 21 JARDIANCE TABS 10mg 25mg 48 jasmiel tabs 46 JEMPERLI SOLN 16 JENTADUETO TABS 48 JENTADUETO XR TB24 48 jinteli tabs 49 JOLIVETTE TABS 46 juleber tabs 46 JULUCA TABS 12 junel 1530 tabs 46 junel 120 tabs 46 junel fe 1530 tabs 46 junel fe 120 tabs 46 junel fe 24 tabs 46
JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg 23
JYNARQUE TABS 15mg 30mg 39 JYNARQUE TBPK 39
K KADCYLA SOLR 100mg 160mg 16 KADIAN CP24 28 kaitlib fe chew 46 KALYDECO PACK 25mg 50mg 75mg 56 KALYDECO TABS 56 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 40 kariva tabs 46 KAZANO TABS 48 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-033 MEQ 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 40-5-09 MEQ 39 KCL-LACTATED RINGERS-D5W SOLN
INTRAVENOUS 39 KEDRAB SOLN 57 kelnor 135 tabs 46 kelnor 150 tabs 46 KENALOG SUSP 45 KEPIVANCE SOLR 61 keralyt sham 62 KESIMPTA SOAJ 54 ketoconazole crea 58 ketoconazole foam 58 ketoconazole sham 58 ketoconazole tabs 11 ketodan foam 58 ketoprofen caps 28 ketoprofen er cp24 28 ketorolac tromethamine soln 28 41 ketorolac tromethamine soln 04 05 41 ketorolac tromethamine tabs 28 KEVEYIS TABS 54 KEVZARA SOAJ 150mg114ml
200mg114ml 53 KEVZARA SOSY 150mg114ml
200mg114ml 53 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 52 KHEDEZLA TB24 50mg 100mg 36 KIMYRSA SOLR 9
86 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
KINERET SOSY 53 KINRIX SUSP 57 kionex susp 39 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (200 MG DOSE) TBPK
16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KITABIS PAK NEBU 56 KLISYRI OINT 62 KLOR-CON 10 TBCR 39 klor-con m10 tbcr 39 klor-con m15 tbcr 39 klor-con m20 tbcr 39 klor-con pack 39 klor-con sprinkle cpcr 8meq 10meq 39 KLOR-CON TBCR 39 KORLYM TABS 48 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 37 K-TAB TBCR 39 kurvelo tabs 46 KUVAN PACK 100mg 500mg 54 KUVAN TABS 54 KYNAMRO SOSY 23 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 33 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 LACRISERT INST 42 LACTATED RINGERS SOLN 39 54 LACTIC ACID LOTN 62 lactulose encephalopathy soln 37 lactulose pack 38 lactulose soln 38 LAMICTAL XR KIT 31 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 31
lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg 31
lamotrigine kit 31 lamotrigine starter kit-blue kit 31 lamotrigine starter kit-green kit 31 lamotrigine starter kit-orange kit 31 lamotrigine tabs 25mg 100mg 150mg
200mg 31 lamotrigine tbdp 25mg 50mg 100mg
200mg 31 LANOXIN PEDIATRIC SOLN 25 LANOXIN TABS 625mcg 25 lansoprazole cpdr 15mg 30mg 43 lansoprazole tbdd 15mg 30mg 43 lanthanum carbonate chew 500mg 750mg
1000mg 39 LANTUS SOLN 48 LANTUS SOLOSTAR SOPN 49 lapatinib ditosylate tabs 16 larin 1530 tabs 46 larin 120 tabs 46 larin fe 1530 tabs 46 larin fe 120 tabs 46 larissia tabs 46 LARTRUVO SOLN 190mg19ml
500mg50ml 16 LASTACAFT SOLN 42 latanoprost soln 42 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 36 LAYOLIS FE CHEW 46 LAZANDA SOLN 100mcgact 300mcgact
400mcgact 28 ledipasvir-sofosbuvir tabs 12 leena tabs 46 leflunomide tabs 10mg 20mg 53 LEMTRADA SOLN 34 LENVIMA (10 MG DAILY DOSE) CPPK 16 LENVIMA (12 MG DAILY DOSE) CPPK 16 LENVIMA (14 MG DAILY DOSE) CPPK 16 LENVIMA (18 MG DAILY DOSE) CPPK 16 LENVIMA (20 MG DAILY DOSE) CPPK 16 LENVIMA (24 MG DAILY DOSE) CPPK 16 LENVIMA (4 MG DAILY DOSE) CPPK 16 LENVIMA (8 MG DAILY DOSE) CPPK 17 lessina tabs 46 LETAIRIS TABS 5mg 10mg 56 letrozole tabs 17 leucovorin calcium soln 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 87
leucovorin calcium solr 52 leucovorin calcium tabs 5mg 10mg 15mg
25mg 52 LEUKERAN TABS 17 LEUKINE SOLR 22 leuprolide acetate kit 17 levalbuterol hcl nebu 125mg05ml
031mg3ml 063mg3ml 125mg3ml 21 levalbuterol tartrate aero 21 LEVEMIR FLEXTOUCH SOPN 49 LEVEMIR SOLN 49 levetiracetam er tb24 500mg 750mg 31 levetiracetam in nacl soln 31 levetiracetam soln 31 levetiracetam tabs 250mg 500mg 750mg
1000mg 31 levobunolol hcl soln 42 levocarnitine soln 54 LEVOCARNITINE TABS 54 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 40 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 52 levoleucovorin calcium solr 52 levonest tabs 46 levonorgest-eth est amp eth est tabs 47 levonorgest-eth estrad 91-day tabs 47 levonorgestrel-ethinyl estrad tabs 47 levonorg-eth estrad triphasic tabs 46 levora 01530 (28) tabs 47 levorphanol tartrate tabs 2mg 3mg 28 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEVOTHYROXINE SODIUM SOLR 51 levothyroxine sodium tabs 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEXETTE FOAM 60 LEXIVA SUSP 12 LIALDA TBEC 43 LIBTAYO SOLN 17 lidocaine hcl (cardiac) pf sosy 25 lidocaine hcl (cardiac) sosy 25 lidocaine hcl (pf) soln 54 LIDOCAINE HCL CREA 61 lidocaine hcl lotn 61 lidocaine hcl soln 42 54 61 lidocaine hcl urethralmucosal gel 61 lidocaine hcl urethralmucosal prsy 61 LIDOCAINE IN D5W SOLN 25 lidocaine in dextrose soln 54 lidocaine oint 61 lidocaine ptch 61 lidocaine viscous hcl soln 42 lidocaine-epinephrine soln 54 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 61 LIDOCAINE-HYDROCORTISONE ACE KIT
61 lidocaine-prilocaine crea 61 lidocaine-tetracaine crea 61 LIDOCORT CREA 61 lidopin crea 61 LIDO-SORB LOTN 61 LIDOZION LOTN 61 lincomycin hcl soln 9 lindane sham 58 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 LINZESS CAPS 72mcg 145mcg 290mcg
44 liothyronine sodium soln 51 liothyronine sodium tabs 5mcg 25mcg
50mcg 51 LIPODOX 50 INJ 17 lisinopril tabs 25mg 5mg 10mg 20mg
30mg 40mg 26 lisinopril-hydrochlorothiazide tabs 26 LITHIUM CARBONATE CAPS 300mg
150mg 600mg 36 lithium carbonate er tbcr 300mg 450mg 36 lithium carbonate tabs 36
88 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
LITHIUM SOLN 36 LITHOSTAT TABS 38 LIVALO TABS 1mg 2mg 4mg 23 LO LOESTRIN FE TABS 47 lodine tabs 28 loestrin 1530 (21) tabs 47 loestrin 120 (21) tabs 47 loestrin fe 1530 tabs 47 loestrin fe 120 tabs 47 LOKELMA PACK 5gm 10gm 39 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 17 loperamide hcl caps 43 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 49 lorazepam intensol conc 33 LORAZEPAM SOLN 4mgml 2mgml 33 lorazepam tabs 05mg 1mg 2mg 33 LORBRENA TABS 25mg 100mg 17 lorcet hd tabs 28 lorcet plus tabs 28 lorcet tabs 28 lortab elix 28 loryna tabs 47 lorzone tabs 375mg 750mg 20 losartan potassium tabs 25mg 50mg
100mg 26 losartan potassium-hctz tabs 26 LOTEMAX GEL 41 LOTEMAX OINT 41 LOTEMAX SUSP 41 loteprednol etabonate susp 41 lovastatin tabs 10mg 20mg 40mg 23 LOVENOX SOLN 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
low-ogestrel tabs 47 loxapine succinate caps 5mg 10mg 25mg
50mg 36 lubiprostone caps 8mcg 24mcg 44 LUCEMYRA TABS 34 LUCENTIS SOLN 03mg005ml
05mg005ml 42 LUCENTIS SOSY 03mg005ml
05mg005ml 42 LUDENT CHEW 025mg 05mg 1mg 54 LULICONAZOLE CREA 58 LUMAKRAS TABS 17
LUMIGAN SOLN 42 LUMIZYME SOLR 40 LUMOXITI SOLR 17 LUPANETA PACK KIT 17 LUPKYNIS CAPS 53 LUPRON DEPOT (1-MONTH) KIT 17 LUPRON DEPOT (3-MONTH) KIT 17 LUPRON DEPOT (4-MONTH) KIT 17 LUPRON DEPOT (6-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 17 LUPRON DEPOT-PED (3-MONTH) KIT 17 lutera tabs 47 LUZU CREA 58 lyleq tabs 47 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 50
LYNPARZA CAPS 17 LYNPARZA TABS 100mg 150mg 17 LYSODREN TABS 17 lyza tabs 47
M mafenide acetate pack 58 magnesium sulfate in d5w soln 39 magnesium sulfate soln 31 magnesium sulfate soln injection 50 31 MAGNESIUM SULFATE SOLN
INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml 31
MAKENA SOAJ 50 malathion lotn 58 MANNITOL SOLN 39 maprotiline hcl tabs 25mg 50mg 75mg 36 MARGENZA SOLN 17 marlissa tabs 47 MARPLAN TABS 36 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 24 MAVENCLAD (10 TABS) TBPK 53 MAVENCLAD (4 TABS) TBPK 53 MAVENCLAD (5 TABS) TBPK 53 MAVENCLAD (6 TABS) TBPK 53 MAVENCLAD (7 TABS) TBPK 53 MAVENCLAD (8 TABS) TBPK 53
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 89
MAVENCLAD (9 TABS) TBPK 53 MAVYRET TABS 12 MAXIDEX SUSP 41 MAYZENT STARTER PACK TBPK 34 MAYZENT TABS 025mg 2mg 34 MENAPHOSMBHYO1 TABS 14 meclizine hcl tabs 43 meclofenamate sodium caps 28 MEDROL TABS 45 medroxyprogesterone acetate susp 50 medroxyprogesterone acetate susy 50 medroxyprogesterone acetate tabs 25mg
5mg 10mg 50 mefenamic acid caps 28 mefloquine hcl tabs 11 megestrol acetate susp 17 50 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 47 meloxicam caps 28 meloxicam tabs 28 melphalan hcl solr 17 memantine hcl er cp24 34 memantine hcl soln 34 memantine hcl tabs 5mg 10mg 34 MENACTRA INJ 57 menest tabs 03mg 0625mg 125mg 50 MENOSTAR PTWK 50 MENQUADFI INJ 57 MENTAX CREA 58 MENVEO SOLR 57 meperidine hcl soln 50mg5ml 25mgml
50mgml 100mgml 28 meperidine hcl tabs 50mg 100mg 28 meprobamate tabs 33 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 47 mesalamine cpdr 43 mesalamine enem 43 mesalamine er cp24 43 mesalamine supp 43 mesalamine tbec 12gm 800mg 43 mesalamine-cleanser kit 43 mesna soln 54 MESNEX TABS 54 MESTINON SOLN 20 metadate er tbcr 30
metaproterenol sulfate syrp 21 metaproterenol sulfate tabs 10mg 20mg 21 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 49 metformin hcl tabs 500mg 850mg 1000mg
49 methadone hcl conc 28 methadone hcl intensol conc 28 methadone hcl soln 5mg5ml 10mg5ml
10mgml 28 methadone hcl tabs 5mg 10mg 28 methamphetamine hcl tabs 30 methazolamide tabs 25mg 50mg 42 methenamine hippurate tabs 14 METHENAMINE MANDELATE TABS 14 methergine tabs 50 methimazole tabs 5mg 10mg 51 methitest tabs 45 methocarbamol soln 20 methocarbamol tabs 20 methotrexate sodium (pf) soln 17 methotrexate sodium soln 17 methotrexate sodium solr 17 methotrexate tabs 17 methoxsalen rapid caps 62 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 39 methyldopa tabs 250mg 500mg 25 methyldopa-hydrochlorothiazide tabs 25 methylergonovine maleate soln 50 methylergonovine maleate tabs 50 methylphenidate hcl chew 25mg 5mg
10mg 30 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 30 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 30 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 30
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 30
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 30
methylphenidate hcl soln 5mg5ml 10mg5ml 30
90 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
methylphenidate hcl tabs 5mg 10mg 20mg 30
methylprednisolone acetate susp 45 methylprednisolone sodium succ solr 45 methylprednisolone tabs 4mg 8mg 16mg
32mg 45 methylprednisolone tbpk 45 methyltestosterone caps 45 metoclopramide hcl soln 44 metoclopramide hcl tabs 5mg 10mg 44 metoclopramide hcl tbdp 5mg 10mg 44 metolazone tabs 25mg 5mg 10mg 39 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 24 metoprolol tartrate soct 24 metoprolol tartrate soln 24 metoprolol tartrate tabs 25mg 50mg
100mg 24 metoprolol tartrate tabs 375mg 75mg 24 metoprolol-hydrochlorothiazide tabs 24 metronidazole caps 11 metronidazole crea 58 metronidazole gel 58 metronidazole in nacl soln 11 metronidazole in nacl soln intravenous 11 metronidazole lotn 58 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
25 mibelas 24 fe chew 47 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 58 miconazole-zinc oxide-petrolat oint 58 micort-hc crea 60 microgestin 1530 tabs 47 microgestin 120 tabs 47 microgestin fe 1530 tabs 47 microgestin fe 120 tabs 47 midazolam hcl (pf) soln 33 midazolam hcl soln 33 midazolam hcl syrp 33 midodrine hcl tabs 25mg 5mg 10mg 21 miglitol tabs 25mg 50mg 100mg 49 miglustat caps 40 mili tabs 47 millipred dp tbpk 45 millipred tabs 45
milrinone lactate in dextrose soln 25 milrinone lactate soln 25 mimvey lo tabs 50 mimvey tabs 50 minitran pt24 01mghr 02mghr 04mghr
06mghr 26 minocycline hcl caps 50mg 75mg 100mg 9 minocycline hcl er tb24 45mg 55mg 65mg
80mg 90mg 105mg 115mg 135mg 9 minocycline hcl tabs 50mg 75mg 100mg 9 minoxidil tabs 25mg 10mg 25 MIRCERA SOSY 30mcg03ml
50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml 22
mirtazapine tabs 75mg 15mg 30mg 45mg 36
mirtazapine tbdp 15mg 30mg 45mg 36 misoprostol tabs 100mcg 200mcg 43 MITIGARE CAPS 52 mitigo soln 28 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 57 modafinil tabs 100mg 200mg 30 moexipril hcl tabs 75mg 15mg 26 molindone hcl tabs 5mg 10mg 25mg 36 mometasone furoate crea 60 mometasone furoate oint 60 mometasone furoate soln 60 mometasone furoate susp 41 mondoxyne nl caps 75mg 100mg 9 MONJUVI SOLR 17 MONONESSA TABS 47 montelukast sodium chew 4mg 5mg 55 montelukast sodium pack 55 montelukast sodium tabs 55 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 28 morphine sulfate (pf) soln 4mgml 10mgml
28 MORPHINE SULFATE (PF) SOLN
INTRAVENOUS 28 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 28 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 28
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 91
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 28
MORPHINE SULFATE SOLN 28 MORPHINE SULFATE SOLN 10mg5ml
20mg5ml 28 MORPHINE SULFATE SOLN INJECTION
2mgml 4mgml 10mgml 28 MORPHINE SULFATE SOLN
INTRAVENOUS 28 morphine sulfate tabs 15mg 30mg 28 MOVANTIK TABS 125mg 25mg 44 MOXEZA SOLN 41 moxifloxacin hcl (2x day) soln 41 moxifloxacin hcl in nacl soln intravenous 10 moxifloxacin hcl soln 41 moxifloxacin hcl tabs 10 MULPLETA TABS 22 MULTAQ TABS 25 MULTIVITAMINFLUORIDE CHEW 63 MULTI-VITAMINFLUORIDE SOLN 63 MULTI-VITAMINFLUORIDEIRON SOLN
63 mupirocin calcium crea 58 mupirocin oint 59 MUSTARGEN SOLR 17 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17 MVC-FLUORIDE CHEW 64 MYALEPT SOLR 54 MYCAPSSA CPDR 51 mycophenolate mofetil caps 53 mycophenolate mofetil hcl solr 53 mycophenolate mofetil susr 53 mycophenolate mofetil tabs 53 mycophenolate sodium tbec 180mg 360mg
53 MYDAYIS CP24 30 MYFEMBREE TABS 50 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 62 MYRBETRIQ TB24 25mg 50mg 63 MYTESI TBEC 43
N NABI-HB SOLN 57 nabumetone tabs 28 N-ACETYL-L-CYSTEINE CAPS 38 nadolol tabs 20mg 40mg 80mg 24 nadolol-bendroflumethiazide tabs 24
nafcillin sodium solr 10 nafcillin sodium solr injection 10 nafcillin sodium solr intravenous 10 NAFRINSE CHEW 54 NAFRINSE DROPS SOLN 54 naftifine hcl crea 59 naftifine hcl gel 59 NAFTIN GEL 59 NAGLAZYME SOLN 40 nalbuphine hcl soln 28 nalfon tabs 28 nalocet tabs 28 naloxone hcl soaj 34 naloxone hcl soct 34 naloxone hcl soln 34 naloxone hcl sosy 34 naltrexone hcl tabs 35 NAMENDA XR TITRATION PACK CP24 34 NAPRELAN TB24 28 naproxen sodium er tb24 28 naproxen sodium tabs 28 naproxen susp 28 naproxen tabs 28 naproxen tbec 28 naproxen-esomeprazole tbec 28 naratriptan hcl tabs 32 NARCAN LIQD 35 NATACYN SUSP 41 NATAZIA TABS 47 nateglinide tabs 60mg 120mg 49 NATPARA CART 25mcg 50mcg 75mcg
100mcg 50 NATROBA SUSP 59 NAYZILAM SOLN 31 NEBUPENT SOLR 11 necon 0535 (28) tabs 47 NECON 777 TABS 47 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 36 nembutal soln 33 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 41 neomycin-polymyxin b gu soln 59 neomycin-polymyxin-dexameth oint 41 neomycin-polymyxin-dexameth susp 41 neomycin-polymyxin-gramicidin soln 41 neomycin-polymyxin-hc soln 41 neomycin-polymyxin-hc susp 41 neo-polycin hc oint 41
92 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
neo-polycin oint 41 neo-synalar crea 60 NEPHRAMINE SOLN INTRAVENOUS 38 NERLYNX TABS 17 NEULASTA ONPRO PSKT 22 NEULASTA SOSY 22 NEUPOGEN SOLN 480mcg16ml
300mcgml 22 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 22 NEVANAC SUSP 41 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 40 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 23 niacor tabs 23 nicardipine hcl caps 20mg 30mg 24 nicardipine hcl soln 24 NICOTROL INHA 20 NICOTROL NS SOLN 20 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 47 nilutamide tabs 17 nimodipine caps 24 NINLARO CAPS 23mg 3mg 4mg 17 nisoldipine er tb24 85mg 17mg 20mg
255mg 30mg 34mg 40mg 24 nitazoxanide tabs 11 nitisinone caps 2mg 5mg 10mg 54 nitro-bid oint 26 NITRO-DUR PT24 03mghr 08mghr 26 NITROFURANTOIN MACROCRYSTAL
CAPS 14 NITROFURANTOIN MONOHYD MACRO
CAPS 14 nitrofurantoin susp 14 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 26 nitroglycerin soln 26 nitroglycerin subl 03mg 04mg 06mg 26 nitropress soln 25 nitroprusside sodium soln 25 NITYR TABS 2mg 5mg 10mg 54
NIVESTYM SOLN 480mcg16ml 300mcgml 22
NIVESTYM SOSY 300mcg05ml 480mcg08ml 22
nizatidine caps 150mg 300mg 43 nizatidine soln 43 NOCDURNA SUBL 277mcg 553mcg 50 NOCTIVA EMUL 083mcg01ml
166mcg01ml 50 nolix crea 60 nolix lotn 60 nora-be tabs 47 norco tabs 28 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 51
norepinephrine bitartrate soln 21 norethin ace-eth estrad-fe caps 47 norethin ace-eth estrad-fe chew 47 norethin ace-eth estrad-fe tabs 47 norethindrone acetate tabs 50 norethindrone acet-ethinyl est tabs 47 norethindrone tabs 47 norethindrone-eth estradiol tabs 50 norethin-eth estradiol-fe chew 47 norgesic forte tabs 28 norgestimate-eth estradiol tabs 47 norgestim-eth estrad triphasic tabs 47 norlyroc tabs 47 NORMOSOL-M IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R SOLN INTRAVENOUS 39 NORPACE CR CP12 100mg 150mg 25 nortrel 0535 (28) tabs 47 nortrel 135 (21) tabs 47 nortrel 135 (28) tabs 47 nortrel 777 tabs 47 nortriptyline hcl caps 10mg 25mg 50mg
75mg 36 nortriptyline hcl soln 36 NORVIR CAPS 12 NORVIR PACK 12 NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 34 NOVAREL SOLR 5000unit 10000unit 50 NOVOLIN 7030 SUSP 49
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 93
NOVOLOG 7030 FLEXPEN RELION SUPN 49
NOVOLOG FLEXPEN RELION SOPN 49 NOVOLOG FLEXPEN SOPN 49 NOVOLOG MIX 7030 FLEXPEN SUPN 49 NOVOLOG MIX 7030 RELION SUSP 49 NOVOLOG MIX 7030 SUSP 49 NOVOLOG PENFILL SOCT 49 NOVOLOG RELION SOLN 49 NOVOLOG SOLN 49 NOXAFIL SUSP 11 NOXAFIL TBEC 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 55 NUCALA SOLR 55 NUCALA SOSY 55 NUCYNTA ER TB12 200mg 250mg 29 NUCYNTA ER TB12 50mg 100mg 150mg
29 NUCYNTA TABS 29 NUCYNTA TABS 50mg 75mg 29 NUEDEXTA CAPS 34 NULIBRY SOLR 54 NULOJIX SOLR 53 NUPLAZID CAPS 36 NUPLAZID TABS 10mg 17mg 36 NURTEC TBDP 32 NUTRILIPID EMUL INTRAVENOUS 38 NUTROPIN AQ NUSPIN 10 SOPN 51 NUTROPIN AQ NUSPIN 20 SOPN 51 NUTROPIN AQ NUSPIN 5 SOPN 51 NUVARING RING 47 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 59 nylia 777 tabs 47 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 47 nystatin crea 59 nystatin oint 59 nystatin powd 59 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 60 nystatin-triamcinolone oint 60 nystop powd 59 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 44 ocella tabs 47 OCREVUS SOLN 34 OCTAGAM SOLN INTRAVENOUS
5gm100ml 1gm20ml 2gm20ml 25gm500ml 57
octreotide acetate soln 51 ODACTRA SUBL 54 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 56 ofloxacin soln 41 ofloxacin tabs 10 ogestrel tabs 47 OGIVRI SOLR 17 okebo caps 10 olanzapine solr 36 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 36 olanzapine tbdp 5mg 10mg 15mg 20mg
36 olanzapine-fluoxetine hcl caps 36 olmesartan medoxomil tabs 5mg 20mg
40mg 26 olmesartan medoxomil-hctz tabs 26 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 42 OLUMIANT TABS 1mg 2mg 53 OLYSIO CAPS 12 OMECLAMOX-PAK MISC 43 omega-3-acid ethyl esters caps 23 omeprazole cpdr 10mg 20mg 40mg 43 omeprazole-sodium bicarbonate caps 43 omeprazole-sodium bicarbonate pack 44 OMNARIS SUSP 41 OMNIPOD STARTER KIT 37 OMNITROPE SOCT 5mg15ml
10mg15ml 51 OMNITROPE SOLR 51 ondansetron hcl soln 43 ondansetron hcl tabs 4mg 8mg 24mg 43 ondansetron tbdp 4mg 8mg 43 ONIVYDE INJ 17 ONPATTRO SOLN 54 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 ONZETRA XSAIL EXHP 32
94 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml 17
OPIUM TINC 43 ORACEA CPDR 62 ORALAIR SUBL 54 oralone pste 60 ORAVIG TABS 59 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 53 ORENCIA SOLR 53 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 53 ORENITRAM TBCR 0125mg 56 ORENITRAM TBCR 025mg 1mg 25mg
5mg 56 ORFADIN CAPS 54 ORFADIN SUSP 54 ORGOVYX TABS 50 ORIAHNN CPPK 50 ORILISSA TABS 150mg 200mg 50 ORKAMBI PACK 56 ORKAMBI TABS 56 ORLADEYO CAPS 110mg 150mg 54 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 29 orphengesic forte tabs 29 orsythia tabs 47 ORTIKOS CP24 6mg 9mg 45 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 39 OSMOPREP TABS 44 OSPHENA TABS 50 OTEZLA TABS 53 OTEZLA TBPK 53 OTOVEL SOLN 41 OTREXUP SOAJ 53 ovide lotn 59 OXACILLIN SODIUM IN DEXTROSE SOLN
INTRAVENOUS 10 oxacillin sodium solr injection 1gm 2gm 10 oxacillin sodium solr intravenous 10 oxaliplatin soln 17 oxaliplatin solr 17 oxandrolone tabs 45 oxandrolone tabs 25mg 45 oxaprozin tabs 29
OXAYDO TABS 29 oxazepam caps 10mg 15mg 30mg 33 OXBRYTA TABS 21 oxcarbazepine susp 31 oxcarbazepine tabs 150mg 300mg 600mg
31 OXERVATE SOLN 42 oxiconazole nitrate crea 59 OXISTAT LOTN 59 OXLUMO SOLN 54 OXTELLAR XR TB24 150mg 300mg
600mg 31 oxybutynin chloride er tb24 5mg 10mg
15mg 63 oxybutynin chloride syrp 63 oxybutynin chloride tabs 63 oxycodone hcl caps 29 oxycodone hcl conc 29 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxycodone hcl soln 29 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 29 oxycodone-acetaminophen soln 29 oxycodone-acetaminophen tabs 29 oxycodone-acetaminophen tabs 5-300mg
10-300mg 29 oxycodone-aspirin tabs 29 oxycodone-ibuprofen tabs 29 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 29 oxymorphone hcl tabs 5mg 10mg 29 OXYTOCIN SOLN 50 OZEMPIC (025 OR 05 MGDOSE) SOPN
49 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 49
P pacerone tabs 100mg 200mg 400mg 25 paclitaxel conc 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
54 PALFORZIA (120 MG DAILY DOSE) CSPK
54
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 95
PALFORZIA (160 MG DAILY DOSE) CSPK 54
PALFORZIA (20 MG DAILY DOSE) CSPK 54
PALFORZIA (200 MG DAILY DOSE) CSPK 54
PALFORZIA (240 MG DAILY DOSE) CSPK 55
PALFORZIA (3 MG DAILY DOSE) CSPK 55 PALFORZIA (300 MG MAINTENANCE)
PACK 55 PALFORZIA (300 MG TITRATION) PACK
55 PALFORZIA (40 MG DAILY DOSE) CSPK
55 PALFORZIA (6 MG DAILY DOSE) CSPK 55 PALFORZIA (80 MG DAILY DOSE) CSPK
55 PALFORZIA INITIAL ESCALATION CSPK
55 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 36 palonosetron hcl soln 43 palonosetron hcl sosy 43 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 40 pamidronate disodium soln 52 pamidronate disodium solr 52 PANCREAZE CPEP 40 PANDEL CREA 61 panlor tabs 29 PANRETIN GEL 61 pantoprazole sodium pack 44 PANTOPRAZOLE SODIUM SOLR 44 pantoprazole sodium tbec 20mg 40mg 44 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 57
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 64 PARICALCITOL SOLN 64 paroex soln 41 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 36 paroxetine hcl tabs 10mg 20mg 36 paroxetine hcl tabs 30mg 40mg 36 paroxetine mesylate caps 36 paser pack 11
PAXIL SUSP 36 PEDIARIX SUSP 57 PEDVAX HIB SUSP 57 peg 3350electrolytes solr 44 peg 3350-kcl-na bicarb-nacl solr 44 peg-3350electrolytes solr 44 PEGANONE TABS 31 PEGASYS PROCLICK SOLN
135mcg05ml 180mcg05ml 13 PEGASYS SOLN 180mcg05ml
180mcgml 13 PEGINTRON KIT 13 PEG-INTRON REDIPEN KIT 12 PEG-PREP KIT 44 PEMAZYRE TABS 45mg 9mg 135mg 17 penicillamine caps 45 penicillamine tabs 45 PENICILLIN G POT IN DEXTROSE SOLN
INTRAVENOUS 10 penicillin g potassium solr injection 10 penicillin g procaine susp 10 penicillin g sodium solr injection 10 penicillin v potassium solr 10 penicillin v potassium tabs 10 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 43 pentazocine-naloxone hcl tabs 29 pentobarbital sodium soln 33 pentoxifylline er tbcr 22 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 44 percocet tabs 29 perindopril erbumine tabs 2mg 4mg 8mg
26 periogard soln 41 PERJETA SOLN 17 permethrin crea 59 perphenazine tabs 2mg 4mg 8mg 16mg
36 perphenazine-amitriptyline tabs 36 PERSERIS PRSY 90mg 120mg 36 PERTZYE CPEP 40 PEXEVA TABS 10mg 20mg 30mg 40mg
36 phenadoz supp 14 phenazo tabs 61 PHENAZOPYRIDINE HCL TABS 61 phenelzine sulfate tabs 36
96 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
phenergan soln 14 PHENOBARBITAL ELIX 33 PHENOBARBITAL SODIUM SOLN 33 PHENOBARBITAL TABS 33 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 21 PHENYLEPHRINE HCL SOLN 42 phenytek caps 200mg 300mg 31 phenytoin chew 31 phenytoin sodium extended caps 100mg
200mg 300mg 31 phenytoin sodium soln 31 phenytoin susp 31 PHESGO SOLN 17 PHOSLYRA SOLN 39 PHOSPHASAL TABS 14 PHOSPHOLINE IODIDE SOLR 42 phrenilin forte caps 29 PHYSIOLYTE SOLN 55 PHYSIOSOL IRRIGATION SOLN 55 PIFELTRO TABS 13 pilocarpine hcl soln 1 2 4 42 pilocarpine hcl tabs 5mg 75mg 20 pimecrolimus crea 62 pimozide tabs 1mg 2mg 36 pimtrea tabs 47 pindolol tabs 5mg 10mg 24 pioglitazone hcl tabs 15mg 30mg 45mg 49 pioglitazone hcl-glimepiride tabs 49 pioglitazone hcl-metformin hcl tabs 49 piperacillin sod-tazobactam so solr 10 piperacillin sod-tazobactam so solr
intravenous 10 PIQRAY (200 MG DAILY DOSE) TBPK 17 PIQRAY (250 MG DAILY DOSE) TBPK 17 PIQRAY (300 MG DAILY DOSE) TBPK 17 pirmella 135 tabs 47 PIROXICAM CAPS 10mg 20mg 29 PLASMA-LYTE 148 SOLN INTRAVENOUS
39 PLASMA-LYTE A SOLN INTRAVENOUS 39 PLEGRIDY SOPN 13 PLEGRIDY SOSY 13 34 PLEGRIDY STARTER PACK SOPN 13 PLEGRIDY STARTER PACK SOSY 13 plenamine soln intravenous 38 PLENVU SOLR 44 podofilox soln 62 POLIVY SOLR 30mg 140mg 17
polocaine soln 55 polocaine-mpf soln 55 polycin oint 41 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 41 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 34 PONVORY TABS 34 portia-28 tabs 47 PORTRAZZA SOLN 17 POSACONAZOLE SUSP 11 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 37 POTASSIUM ACETATE SOLN 39 potassium chloride crys er tbcr 10meq
20meq 40 potassium chloride er cpcr 8meq 10meq 40 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 40 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 40 potassium chloride in nacl soln intravenous
40 potassium chloride pack 40 potassium chloride soln 10 20 40 POTASSIUM CHLORIDE SOLN
INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml 40
potassium citrate er tbcr 15meq 540mg 1080mg 37
POTASSIUM PHOSPHATES SOLN 40 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 40 POTELIGEO SOLN 18 PR BENZOYL PEROXIDE WASH LIQD 59 PRADAXA CAPS 110mg 150mg 22 PRADAXA CAPS 75mg 22 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 33
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 33
PRAMOX GEL 61 prandin tabs 1mg 2mg 49 prasugrel hcl tabs 5mg 10mg 22 pravastatin sodium tabs 10mg 20mg
40mg 80mg 23 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 97
PRED MILD SUSP 41 PRED-G SOP OINT 41 PRED-G SUSP 41 prednicarbate crea 61 prednicarbate oint 61 prednisolone acetate susp 41 prednisolone sodium phosphate soln 41 45 prednisolone sodium phosphate soln
5mg5ml 10mg5ml 20mg5ml 25mg5ml 45
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 45
prednisolone soln 45 prednisone intensol conc 45 prednisone soln 45 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 45 prednisone tbpk 45 prefest tabs 50 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 31
pregabalin er tb24 825mg 165mg 330mg 29
pregabalin soln 31 PREGNYL SOLR 50 PREMARIN SOLR 50 PREMARIN TABS 03mg 045mg
0625mg 09mg 125mg 50 premasol soln intravenous 38 PREMPHASE TABS 50 PREMPRO TABS 50 PRENATAL TABS 64 PRETOMANID TABS 11 prevalite pack 23 prevalite powd 23 previfem tabs 47 PREVYMIS SOLN 240mg12ml
480mg24ml 13 PREVYMIS TABS 240mg 480mg 13 PREZCOBIX TABS 13 PREZISTA SUSP 13 PREZISTA TABS 75mg 150mg 600mg
800mg 13 PRIFTIN TABS 11 PRILOSEC PACK 25mg 10mg 44 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 31 primlev tabs 29
PRIVIGEN SOLN INTRAVENOUS 57 PROAIR RESPICLICK AEPB 21 probenecid tabs 40 procainamide hcl soln 25 PROCALAMINE SOLN INTRAVENOUS 38 procentra soln 30 prochlorperazine edisylate soln 36 prochlorperazine maleate tabs 36 prochlorperazine supp 36 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 40000unitml 22
proctofoam hc foam 61 procto-med hc crea 61 procto-pak crea 61 proctosol hc crea 61 proctozone-hc crea 61 PROCYSBI CPDR 25mg 75mg 55 PROCYSBI PACK 75mg 300mg 55 progesterone caps 100mg 200mg 51 progesterone oil 51 PROGLYCEM SUSP 49 PROGRAF PACK 53 PROGRAF PACK 02mg 53 PROGRAF SOLN 53 PROLASTIN-C SOLN INTRAVENOUS 56 PROLASTIN-C SOLR INTRAVENOUS 56 prolate soln 29 prolate tabs 29 PROLENSA SOLN 41 PROLEUKIN SOLR 18 PROLIA SOSY 52 PROMACTA PACK 125mg 25mg 22 PROMACTA TABS 125mg 25mg 50mg
75mg 22 promethazine hcl soln 14 promethazine hcl supp 14 promethazine hcl syrp 14 promethazine hcl tabs 14 promethazine-phenylephrine syrp 14 promethegan supp 14 propafenone hcl er cp12 225mg 325mg
425mg 25 propafenone hcl tabs 150mg 225mg
300mg 25 propantheline bromide tabs 19 proparacaine hcl soln 43 propranolol hcl er cp24 60mg 80mg
120mg 160mg 24
98 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
propranolol hcl soln 20mg5ml 40mg5ml 24 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 24 propranolol-hctz tabs 24 propylthiouracil tabs 51 PROQUAD SUSR 58 PROSOL SOLN INTRAVENOUS 38 PROTONIX PACK 44 protriptyline hcl tabs 5mg 10mg 36 psorcon crea 61 PULMICORT FLEXHALER AEPB 45 PULMOZYME SOLN 40 PURIXAN SUSP 18 PYLERA CAPS 44 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 20 pyridostigmine bromide soln 20 pyridostigmine bromide tabs 30mg 60mg 20 pyrimethamine tabs 11
Q QBRELIS SOLN 26 QDOLO SOLN 29 QINLOCK TABS 18 QUADRACEL SUSP 57 questran light powd 23 questran pack 23 questran powd 23 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 36 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 37 QUILLICHEW ER CHER 20mg 30mg
40mg 30 QUILLIVANT XR SRER 30 quinapril hcl tabs 5mg 10mg 20mg 40mg
26 quinapril-hydrochlorothiazide tabs 26 quinidine gluconate er tbcr 25 QUINIDINE GLUCONATE SOLN 25 quinidine sulfate tabs 200mg 300mg 25 quinine sulfate caps 12
R RABAVERT SUSR 58 rabeprazole sodium cpsp 44 rabeprazole sodium tbec 44 RADICAVA SOLN 34
raloxifene hcl tabs 50 ramelteon tabs 33 ramipril caps 125mg 25mg 5mg 10mg 26 ranolazine er tb12 500mg 1000mg 25 RAPIVAB SOLN 13 rasagiline mesylate tabs 05mg 1mg 33 RASUVO SOAJ 53 RAVICTI LIQD 38 RAYALDEE CPCR 64 RAYOS TBEC 1mg 2mg 5mg 45 REBETOL SOLN 13 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 34 REBIF REBIDOSE TITRATION PACK
SOAJ 34 REBIF SOSY 22mcg05ml 44mcg05ml 34 REBIF TITRATION PACK SOSY 34 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 47 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 58 RECTIV OINT 62 REGONOL SOLN 20 REGRANEX GEL 62 relafen ds tabs 29 RELENZA DISKHALER AEPB 13 relexxii tbcr 30 RELISTOR SOLN 8mg04ml 12mg06ml
44 RELISTOR TABS 44 reltone caps 200mg 400mg 44 REMICADE SOLR INTRAVENOUS 53 RENFLEXIS SOLR 53 repaglinide tabs 05mg 1mg 2mg 49 repaglinide-metformin hcl tabs 49 REPATHA PUSHTRONEX SYSTEM SOCT
23 REPATHA SOSY 23 REPATHA SURECLICK SOAJ 23 RESCRIPTOR TABS 100mg 200mg 13 RESTASIS EMUL 41 RETACRIT SOLN 20000unit2ml
2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml 22
RETEVMO CAPS 40mg 80mg 18 RETIN-A CREA 0025 005 01 61 RETIN-A GEL 001 0025 61
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 99
RETIN-A MICRO GEL 004 01 61 RETIN-A MICRO PUMP GEL 61 RETIN-A MICRO PUMP GEL 004 01
61 RETIN-A MICRO PUMP GEL 008 61 RETISERT IMPL 41 RETROVIR SOLN 13 REVCOVI SOLN 40 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 18 revonto solr 20 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 37 REYATAZ PACK 13 REZUROCK TABS 55 RHOPRESSA SOLN 42 RIABNI SOLN 100mg10ml 500mg50ml 18 ribasphere caps 13 ribasphere ribapak (1000 pack) tbpk 13 ribasphere ribapak (1200 pack) tbpk 13 ribasphere tabs 13 ribavirin caps 13 ribavirin solr 13 ribavirin tabs 13 RIDAURA CAPS 55 RIFABUTIN CAPS 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 RIFATER TABS 11 riluzole tabs 34 rimantadine hcl tabs 13 RIMSO-50 SOLN 55 RINGERS IRRIGATION SOLN 55 RINGERS SOLN 40 RINVOQ TB24 53 risedronate sodium tabs 5mg 30mg 35mg
150mg 52 RISEDRONATE SODIUM TBEC 52 RISPERDAL CONSTA SRER 125mg
25mg 37 RISPERDAL CONSTA SRER 375mg
50mg 37 risperidone soln 37 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 37 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 37
ritonavir tabs 13 RITUXAN HYCELA SOLN 18 RITUXAN SOLN 18 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 47 rizatriptan benzoate tabs 32 rizatriptan benzoate tbdp 32 ROMIDEPSIN SOLN 18 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 33 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 33 ropivacaine hcl soln 55 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 23 ROTARIX SUSR 58 ROTATEQ SOLN 58 roweepra tabs 500mg 750mg 1000mg 31 roweepra xr tb24 500mg 750mg 31 ROXYBOND TABA 5mg 15mg 30mg 29 ROZEREM TABS 33 ROZLYTREK CAPS 100mg 200mg 18 RUBRACA TABS 200mg 250mg 300mg 18 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 31 rufinamide tabs 200mg 400mg 31 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 18 RUZURGI TABS 55 RYBREVANT SOLN 18 ryclora soln 14 RYDAPT CAPS 18 RYLAZE SOLN 18 RYNODERM CREA 62 RYTARY CPCR 33 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 51 SAIZEN SOLR 5mg 88mg 51 SAIZENPREP SOLR 51 sajazir soln 21 SALEX SHAM 62 SALICYLIC ACID CREA 62 SALICYLIC ACID ER SOLN 62
100 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
SALICYLIC ACID FOAM 62 SALICYLIC ACID GEL 62 SALICYLIC ACID LIQD 62 SALICYLIC ACID SHAM 62 SALICYLIC ACID WART REMOVER LIQD
62 SALICYLIC ACID-CLEANSER KIT 62 SALIMEZ CREA 62 SALSALATE TABS 29 SAMSCA TABS 15mg 39 SANCUSO PTCH 43 SANDIMMUNE ORAL SOLN 100mgml 53 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 51 SANTYL OINT 62 SAPHNELO SOLN 53 SAPHRIS SUBL 25mg 5mg 10mg 37 sapropterin dihydrochloride pack 100mg
500mg 55 sapropterin dihydrochloride tabs 55 SARCLISA SOLN 500mg25ml 100mg5ml
18 SAVELLA TABS 125mg 25mg 50mg
100mg 34 SAVELLA TITRATION PACK MISC 34 scopolamine pt72 43 seconal caps 33 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 37 selegiline hcl caps 33 selegiline hcl tabs 33 selenium sulfide lotn 59 SELENIUM SULFIDE SHAM 59 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 150mg
300mg 13 SEMPREX-D CAPS 14 SENSIPAR TABS 30mg 60mg 90mg 50 SENSORCAINE SOLN 55 sensorcaineepinephrine soln 55 sensorcaine-mpf soln 55 sensorcaine-mpfepinephrine soln 55 SEREVENT DISKUS AEPB 21 SEROSTIM SOLR 4mg 5mg 6mg 51 sertraline hcl conc 37 sertraline hcl tabs 25mg 50mg 100mg 37 setlakin tabs 47 sevelamer carbonate pack 08gm 24gm 39 sevelamer carbonate tabs 39
sevelamer hcl tabs 400mg 800mg 39 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 47 SHINGRIX SUSR 58 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 51 SIGNIFOR SOLN 03mgml 06mgml
09mgml 51 SIKLOS TABS 18 sildenafil citrate soln 26 sildenafil citrate susr 26 sildenafil citrate tabs 26 SILENOR TABS 37 SILIQ SOSY 62 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 59 SIMBRINZA SUSP 42 SIMPONI ARIA SOLN 53 SIMPONI SOAJ 50mg05ml 100mgml 53 SIMPONI SOSY 50mg05ml 100mgml 53 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 23 sirolimus soln 53 sirolimus tabs 05mg 1mg 2mg 53 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKLICE LOTN 59 SKYRIZI (150 MG DOSE) PSKT 62 SKYRIZI PEN SOAJ 63 SKYRIZI SOSY 63 sod benz-sod phenylacet soln 38 SODIUM ACETATE SOLN 37 SODIUM BICARBONATE SOLN 37 SODIUM CHLORIDE (PF) SOLN 40 SODIUM CHLORIDE SOLN 40 55 SODIUM CHLORIDE SOLN INJECTION 40 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 55 SODIUM FLUORIDE SOLN 55 SODIUM FLUORIDE TABS 55 SODIUM LACTATE SOLN INTRAVENOUS
37 sodium phenylbutyrate powd 38 sodium phenylbutyrate tabs 38 SODIUM PHOSPHATES SOLN 40 sodium polystyrene sulfonate powd 39 sodium polystyrene sulfonate susp 39 SODIUM SULFACETAMIDE SHAM 59
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 101
SODIUM SULFACETAMIDE WASH LIQD 59
sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 63 SOLIQUA SOPN 49 SOLOSEC PACK 12 soloxide tbec 10 SOLTAMOX SOLN 18 SOLU-CORTEF SOLR 45 SOLU-MEDROL SOLR 45 SOMATULINE DEPOT SOLN 51 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 51 SORILUX FOAM 63 sorine tabs 80mg 120mg 160mg 240mg
24 sotalol hcl (af) tabs 80mg 120mg 160mg 24 sotalol hcl tabs 80mg 120mg 160mg
240mg 24 SOTYLIZE SOLN 24 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPINOSAD SUSP 59 SPIRIVA HANDIHALER CAPS 19 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 26 spironolactone-hctz tabs 26 SPRAVATO (56 MG DOSE) SOPK 37 SPRAVATO (84 MG DOSE) SOPK 37 sprintec 28 tabs 47 SPRITAM TB3D 250mg 500mg 750mg
1000mg 31 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 39 sronyx tabs 47 SSD CREA 59 SSS 10-5 CREA 63 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
63 STELARA SOSY 45mg05ml 90mgml 63 STERILE WATER FOR IRRIGATION SOLN
55 STIMATE SOLN 50 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18
STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml 40
streptomycin sulfate solr 10 STRIANT MISC 46 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 21 SUBLOCADE SOSY 100mg05ml
300mg15ml 29 SUBSYS LIQD 100mcg 200mcg 400mcg
600mcg 800mcg 1200mcg 1600mcg 29 subvenite starter kit-blue kit 31 subvenite starter kit-green kit 31 subvenite starter kit-orange kit 31 subvenite tabs 25mg 100mg 150mg
200mg 31 succinylcholine chloride soln 20 SUCRAID SOLN 40 sucralfate susp 44 sucralfate tabs 44 sulfacetamide sodium (acne) lotn 59 SULFACETAMIDE SODIUM GEL 59 SULFACETAMIDE SODIUM LIQD 59 sulfacetamide sodium oint 41 sulfacetamide sodium soln 41 SULFACETAMIDE SODIUM-SULFUR
CREA 63 SULFACETAMIDE SODIUM-SULFUR
EMUL 63 SULFACETAMIDE SODIUM-SULFUR
LIQD 63 SULFACETAMIDE SODIUM-SULFUR
LOTN 63 SULFACETAMIDE SODIUM-SULFUR
PADS 63 SULFACETAMIDE SODIUM-SULFUR
SUSP 63 sulfacetamide-prednisolone soln 41 SULFACLEANSE 84 SUSP 63 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 sulfamez wash emul 63 SULFAMYLON CREA 59 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 29 sumatriptan soln 32
102 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
sumatriptan succinate refill soct 32 sumatriptan succinate soaj 32 sumatriptan succinate soln 32 sumatriptan succinate sosy 32 sumatriptan succinate tabs 32 sunitinib malate caps 125mg 25mg
375mg 50mg 18 SUNOSI TABS 75mg 150mg 30 SUPRAX CAPS 10 suprax chew 10 suprax susr 100mg5ml 200mg5ml 10 SUPRAX SUSR 500 MG5ML 10 SUPREP BOWEL PREP KIT SOLN 44 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 47 SYLATRON KIT 18 SYLATRON KIT 600 MCG 18 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 56 SYMDEKO TBPK 56 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 49 SYMLINPEN 60 SOPN 49 SYMPAZAN FILM 10mg 20mg 32 SYMPAZAN FILM 5mg 31 SYMPROIC TABS 44 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 50 SYNDROS SOLN 43 SYNERCID SOLR 10 SYNJARDY TABS 49 SYNJARDY XR TB24 49 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 TACLONEX SUSP 61 tacrolimus caps 05mg 1mg 5mg 53 TACROLIMUS OINT 01 003 63 tadalafil (pah) tabs 20mg 26 tadalafil tabs 25mg 5mg 26 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 55 TALTZ SOAJ 63
TALTZ SOSY 63 TALZENNA CAPS 025mg 1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 51 taperdex 12-day tbpk 45 taperdex 6-day tbpk 45 taperdex 7-day tbpk 45 TARCEVA TABS 25mg 100mg 150mg 18 targadox tabs 10 TARGRETIN GEL 61 tarina 24 fe tabs 47 tarina fe 120 eq tabs 47 TASIGNA CAPS 50mg 150mg 200mg 18 tavaborole soln 59 TAVALISSE TABS 100mg 150mg 22 tazarotene crea 63 tazarotene foam 63 tazicef solr injection 1gm 2gm 6gm 10 TAZORAC CREA 63 TAZORAC GEL 005 01 63 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 57 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TECFIDERA CPDR 120mg 240mg 34 TECFIDERA MISC 34 TEFLARO SOLR INTRAVENOUS 400mg
600mg 10 TEGSEDI SOSY 55 TEKTURNA HCT TABS 26 telmisartan tabs 20mg 40mg 80mg 26 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 26 TEMAZEPAM CAPS 15mg 225mg 30mg
75mg 33 temsirolimus soln 18 tencon tabs 29 TENIPOSIDE SOLN 18 TENIVAC INJ 57 tenofovir disoproxil fumarate tabs 13 TEPADINA SOLR 18 TEPEZZA SOLR 42 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 21
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 103
terbutaline sulfate tabs 25mg 5mg 21 terconazole crea 59 terconazole supp 59 TERIPARATIDE (RECOMBINANT) SOPN
50 testosterone cypionate soln 100mgml
200mgml 46 testosterone enanthate soln 46 testosterone gel 1 162
2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact 46
testosterone soln 46 tetrabenazine tabs 125mg 25mg 34 TETRACAINE HCL SOLN 43 tetracycline hcl caps 250mg 500mg 10 texacort soln 61 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 63 theophylline er tb12 100mg 200mg
300mg 450mg 63 theophylline er tb24 400mg 600mg 63 theophylline soln 63 THIOLA EC TBEC 100mg 300mg 55 THIOLA TABS 55 thioridazine hcl tabs 10mg 25mg 50mg
100mg 37 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 37 THYROGEN SOLR 55 THYROLAR-1 TABS 51 THYROLAR-12 TABS 51 THYROLAR-14 TABS 51 THYROLAR-2 TABS 51 THYROLAR-3 TABS 51 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
32 TIBSOVO TABS 18 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 34 tilia fe tabs 47 timolol maleate pf soln 42 timolol maleate solg 025 05 42 timolol maleate soln 025 05 42 timolol maleate tabs 5mg 10mg 20mg 24 TIMOPTIC OCUDOSE SOLN 25 42
TIMOPTIC-XE SOLG 025 05 42 tinidazole tabs 12 tiopronin tabs 55 TIROSINT CAPS 13mcg 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
TIS-U-SOL SOLN 55 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 TIVORBEX CAPS 29 tizanidine hcl caps 20 21 tizanidine hcl tabs 20 TOBI PODHALER CAPS 56 TOBRADEX OINT 41 TOBRADEX ST SUSP 41 tobramycin nebu 300mg4ml 300mg5ml 56 tobramycin soln 41 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 42 TOBREX OINT 41 tofranil tabs 10mg 25mg 50mg 37 TOLAK CREA 63 tolazamide tabs 250mg 500mg 49 tolbutamide tabs 49 tolcapone tabs 33 tolmetin sodium caps 29 tolmetin sodium tabs 29 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 63 tolterodine tartrate tabs 63 TOLVAPTAN TABS 30mg 15mg 39 TOPEX TOPICAL ANESTHETIC AERO 61 topicort crea 005 025 61 topicort gel 61 topicort oint 61 topiramate cpsp 15mg 25mg 32 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 32 topiramate tabs 25mg 50mg 100mg
200mg 32 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
39 TOSYMRA SOLN 32
104 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
tovet foam 61 TPN ELECTROLYTES CONC
INTRAVENOUS 40 TRACLEER TABS 625mg 125mg 56 TRACLEER TBSO 56 TRADJENTA TABS 49 tramadol hcl er (biphasic) tb24 100mg
200mg 300mg 29 tramadol hcl er cp24 100mg 150mg
200mg 300mg 29 tramadol hcl er tb24 100mg 200mg 300mg
29 tramadol hcl tabs 50mg 100mg 29 tramadol-acetaminophen tabs 29 trandolapril tabs 1mg 2mg 4mg 26 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 22 tranexamic acid tabs 22 TRANSDERM SCOP (15 MG) PT72 43 tranylcypromine sulfate tabs 37 TRAVASOL SOLN INTRAVENOUS 38 TRAVATAN Z SOLN 42 travoprost (bak free) soln 42 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 37 trazodone hcl tabs 50mg 100mg 150mg 37 TRECATOR TABS 11 TRELEGY ELLIPTA AEPB 45 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 63 TREMFYA SOSY 63 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 56 tretinoin caps 18 tretinoin crea 0025 005 01 61 tretinoin gel 001 0025 005 61 tretinoin microsphere gel 004 01 61 tretinoin microsphere pump gel 004
01 62 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 29 triamcinolone acetonide aers 61 triamcinolone acetonide crea 0025
01 05 61 triamcinolone acetonide lotn 0025 01
61 triamcinolone acetonide oint 0025
005 01 05 61 triamcinolone acetonide pste 61
triamcinolone acetonide susp 45 triamterene caps 50mg 100mg 39 triamterene-hctz caps 39 triamterene-hctz tabs 39 trianex oint 61 triazolam tabs 0125mg 025mg 33 TRICITRATES SOLN 37 triderm crea 01 05 61 trientine hcl caps 45 tri-estarylla tabs 47 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 37 trifluridine soln 41 trihexyphenidyl hcl soln 33 trihexyphenidyl hcl tabs 2mg 5mg 33 TRIKAFTA TBPK 56 tri-legest fe tabs 47 tri-lo-estarylla tabs 47 tri-lo-sprintec tabs 47 trilyte solr 44 trimethobenzamide hcl caps 43 trimethoprim tabs 14 tri-mili tabs 47 trimipramine maleate caps 25mg 50mg
100mg 37 TRINESSA (28) TABS 47 TRINTELLIX TABS 5mg 10mg 20mg 37 tri-nymyo tabs 47 tri-previfem tabs 47 TRIPTODUR SRER 50 TRISENOX SOLN 18 TRISENOX SOLN 10mg10ml 18 tri-sprintec tabs 47 tritocin oint 61 TRIUMEQ TABS 13 TRI-VITAMINFLUORIDE SOLN 64 TRI-VITEFLUORIDE SOLN 64 trivora (28) tabs 47 tri-vylibra lo tabs 47 tri-vylibra tabs 47 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 32 TROPHAMINE SOLN INTRAVENOUS 38 trospium chloride er cp24 63 trospium chloride tabs 63 TRULANCE TABS 44 TRUMENBA SUSY 58
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 105
TRUSELTIQ (100MG DAILY DOSE) CPPK 18
TRUSELTIQ (125MG DAILY DOSE) CPPK 18
TRUSELTIQ (50MG DAILY DOSE) CPPK 18
TRUSELTIQ (75MG DAILY DOSE) CPPK 18
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 58 TYBOST TABS 13 tydemy tabs 47 TYKERB TABS 18 tylenol with codeine 3 tabs 29 tylenol with codeine 4 tabs 29 TYMLOS SOPN 50 TYPHIM VI SOLN 58 TYSABRI CONC INTRAVENOUS 34 TYVASO REFILL SOLN 56 TYVASO SOLN 56 TYVASO STARTER SOLN 56
U UBRELVY TABS 50mg 100mg 32 UCERIS FOAM 61 UDENYCA SOSY 22 UKONIQ TABS 18 ULORIC TABS 40mg 80mg 52 ULTOMIRIS SOLN 55 ULTRAVATE LOTN 61 UMECTA MOUSSE FOAM 63 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 52
UNITUXIN SOLN 18 UPLIZNA SOLN 53 UPTRAVI SOLR 56 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 56
UPTRAVI TBPK 57 UREA CREA 39 63 UREA LOTN 40 63 UREA-C40 LOTN 63 urecholine tabs 5mg 10mg 25mg 50mg 20
uredeb crea 63 URETRON DS TABS 14 URIN DS TABS 14 URSODIOL CAPS 200mg 400mg 44 ursodiol caps 300mg 44 ursodiol tabs 250mg 500mg 44 URYL TABS 14 USTELL CAPS 14 UTICAP CAPS 14 UTIRA-C TABS 14 UTRONA-C TABS 14
V VABOMERE SOLR INTRAVENOUS 10 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 63 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 32 valproic acid caps 32 valproic acid soln 32 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
26 valsartan-hydrochlorothiazide tabs 26 VALTOCO 10 MG DOSE LIQD 32 VALTOCO 15 MG DOSE LQPK 32 VALTOCO 20 MG DOSE LQPK 32 VALTOCO 5 MG DOSE LIQD 32 vanadom tabs 20 vanatol lq soln 29 vancomycin hcl caps 10 vancomycin hcl solr 10 VANCOMYCIN HCL SOLR 250 MG 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 VANDAZOLE GEL 59 VANOXIDE-HC LOTN 61 VANTAS KIT 19 VAQTA SUSP 58 VARIVAX INJ 58 VARIZIG SOLN 57 VARUBI (180 MG DOSE) TBPK 43 VASCEPA CAPS 05gm 1gm 23 VAXCHORA SUSR 58 vecamyl tabs 25 VECTICAL OINT 63 VELCADE SOLR 19 velivet tabs 47
106 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
VELPHORO CHEW 39 VELTASSA PACK 84gm 168gm 252gm
39 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 19 VENCLEXTA TABS 10mg 19 VENCLEXTA TABS 50mg 100mg 19 venlafaxine hcl er cp24 375mg 75mg
150mg 37 venlafaxine hcl er tb24 375mg 75mg
150mg 225mg 37 venlafaxine hcl tabs 25mg 375mg 50mg
75mg 100mg 37 VENTAVIS SOLN 10mcgml 20mcgml 57 VENTOLIN HFA AERS 21 VERAPAMIL HCL ER CP24 100mg
120mg 180mg 200mg 240mg 300mg 360mg 25
verapamil hcl er tbcr 120mg 180mg 240mg 25
verapamil hcl soln 25 verapamil hcl tabs 25 verapamil hcl tabs 80mg 120mg 25 VEREGEN OINT 63 VERELAN CP24 25 veripred 20 soln 45 VERSACLOZ SUSP 37 VERZENIO TABS 50mg 100mg 150mg
200mg 19 vestura tabs 47 VIBERZI TABS 75mg 100mg 44 VIBRAMYCIN SYRP 10 vicodin es tabs 29 vicodin hp tabs 29 vicodin tabs 29 VICTOZA SOPN 49 VIDEX EC CPDR 125mg 200mg 400mg 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 47 vigabatrin pack 32 vigabatrin tabs 32 vigadrone pack 32 VIIBRYD STARTER PACK KIT 37 VIIBRYD TABS 10mg 20mg 40mg 37 VILTEPSO SOLN 55 VIMIZIM SOLN 40 VIMPAT SOLN 32
VIMPAT TABS 32 vinblastine sulfate soln 19 vincasar pfs soln 19 vincristine sulfate soln 19 vinorelbine tartrate soln 19 VIOKACE TABS 40 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 52 VITAMINS ACD-FLUORIDE SOLN 64 VITRAKVI CAPS 25mg 100mg 19 VITRAKVI SOLN 19 VIVITROL SUSR 35 VIZIMPRO TABS 15mg 30mg 45mg 19 VOCABRIA TABS 13 VORAXAZE SOLR 52 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 19 VP-PNV-DHA CAPS 64 VPRIV SOLR 40 VRAYLAR CAPS 15mg 3mg 45mg 6mg
37 VRAYLAR CPPK 37 VUMERITY (STARTER) CPDR 55 VUMERITY CPDR 55 vyfemla tabs 47 vylibra tabs 47 VYNDAMAX CAPS 25 VYNDAQEL CAPS 25 VYONDYS 53 SOLN 55 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 30 VYVANSE CHEW 10mg 20mg 30mg
40mg 50mg 60mg 30 VYXEOS SUSR 19 VYZULTA SOLN 42
W WAKIX TABS 445mg 178mg 30 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 22 WATER FOR IRRIGATION STERILE
SOLN 55 wixela inhub aepb 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 107
wymzya fe chew 48 WYNZORA CREA 63
X XALKORI CAPS 200mg 250mg 19 XARELTO STARTER PACK TBPK 22 XARELTO TABS 25mg 10mg 15mg
20mg 22 XATMEP SOLN 19 XCOPRI (250 MG DAILY DOSE) TBPK 32 XCOPRI (350 MG DAILY DOSE) TBPK 32 XCOPRI TABS 200 MG 32 XCOPRI TABS 50mg 100mg 150mg 32 XCOPRI TBPK 32 XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
32 XELJANZ SOLN 53 XELJANZ TABS 5mg 10mg 53 XELJANZ XR TB24 11mg 22mg 53 XELPROS EMUL 42 XEMBIFY SOLN SUBCUTANEOUS
2gm10ml 4gm20ml 10gm50ml 1gm5ml 57
XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 55 XEOMIN SOLR 50unit 100unit 55 XEPI CREA 59 XERESE CREA 59 XERMELO TABS 43 XGEVA SOLN 52 XHANCE EXHU 42 XIFAXAN TABS 200mg 550mg 10 XIIDRA SOLN 42 XIMINO CP24 45mg 90mg 135mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 56 XOLAIR SOSY 75mg05ml 150mgml 56 XOSPATA TABS 19 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 19 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (40 MG TWICE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (60 MG ONCE WEEKLY) TBPK
20mg 60mg 19
XPOVIO (60 MG TWICE WEEKLY) TBPK 19
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg 19
XPOVIO (80 MG TWICE WEEKLY) TBPK 19
XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg 29
XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 48 XUREA CREA 63 XURIDEN PACK 55 xylocaine dental soln 55 XYOSTED SOAJ 50mg05ml 75mg05ml
100mg05ml 46 XYREM SOLN 34 XYWAV SOLN 34
Y YERVOY SOLN 19 YF-VAX INJ 58 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 42 yuvafem tabs 50
Z zafemy ptwk 48 zafirlukast tabs 10mg 20mg 55 zaleplon caps 5mg 10mg 33 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 48 zarontin soln 32 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 29 ZEJULA CAPS 19 ZELAPAR TBDP 33 ZELBORAF TABS 19 ZEMAIRA SOLR INTRAVENOUS 56 ZEMBRACE SYMTOUCH SOAJ 32 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
63 ZENPEP CPEP 40
108 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg 30
ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
34 ZEPOSIA CAPS 34 ZEPOSIA STARTER KIT CPPK 34 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERIT CAPS 15mg 20mg 30mg 40mg 13 ZERUVIA PTCH 61 ZETONNA AERS 42 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 55 ZINBRYTA SOSY 34 ZIONODIL 100 LOTN 61 ZIONODIL LOTN 61 ZIOPTAN SOLN 42 ziprasidone hcl caps 20mg 40mg 60mg
80mg 37 ziprasidone mesylate solr 37 ZIPSOR CAPS 29 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZIRGAN GEL 41 ZITHROMAX PACK 10 ZOKINVY CAPS 50mg 75mg 55 zoledronic acid conc 52 zoledronic acid soln 52
ZOLINZA CAPS 19 zolmitriptan soln 32 zolmitriptan tabs 32 zolmitriptan tbdp 32 zolpidem tartrate er tbcr 625mg 125mg 33 zolpidem tartrate subl 175mg 35mg 33 zolpidem tartrate tabs 5mg 10mg 33 ZOMACTON SOLR 51 ZOMACTON SOLR 5mg 51 ZOMIG SOLN 32 zonisamide caps 25mg 50mg 100mg 32 ZONTIVITY TABS 22 ZORBTIVE SOLR 51 ZORTRESS TABS 025mg 53 ZORTRESS TABS 05mg 075mg 1mg 53 ZORVOLEX CAPS 29 ZOSTAVAX SUSR 58 ZOSYN SOLN INTRAVENOUS 10 zovia 135e (28) tabs 48 ZUBSOLV SUBL 35 ZUPLENZ FILM 4mg 8mg 43 ZYCLARA PUMP CREA 63 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19 ZYKADIA TABS 19 ZYLET SUSP 42 ZYNLONTA SOLR 19 ZYPITAMAG TABS 1mg 2mg 4mg 23 ZYPREXA RELPREVV SUSR 37 ZYTIGA TABS 19 ZYVOX SOLN INTRAVENOUS 10
Nondiscrimination Notice
Kaiser Permanente does not discriminate on the basis of age race ethnicity color national origin
cultural background ancestry religion sex gender identity gender expression sexual orientation
marital status physical or mental disability source of payment genetic information citizenship
primary language or immigration status
Language assistance services are available from our Member Service Contact Center 24 hours a day
7 days a week (except closed holidays) Interpreter services including sign language are available at
no cost to you during all hours of operation Auxiliary aids and services for individuals with
disabilities are available at no cost to you during all hours of operation We can also provide you your
family and friends with any special assistance needed to access our facilities and services You may
request materials translated in your language at no cost to you You may also request these materials in
large text or in other formats to accommodate your needs at no cost to you For more information call
1-800-464-4000 (TTY 711)
A grievance is any expression of dissatisfaction expressed by you or your authorized representative
through the grievance process For example if you believe that we have discriminated against you you
can file a grievance Please refer to your Evidence of Coverage or Certificate of Insurance or speak
with a Member Services representative for the dispute-resolution options that apply to you
You may submit a grievance in the following ways
bull By phone Call member services at 1-800-464-4000 (TTY 711) 24 hours a day
7 days a week (except closed holidays)
bull By mail Call us at 1-800-464-4000 (TTY 711) and ask to have a form sent to you
bull In person Fill out a Complaint or Benefit ClaimRequest form at a member services office
located at a Plan Facility (go to your provider directory at kporgfacilities for addresses)
bull Online Use the online form on our website at kporg
Please call our Member Service Contact Center if you need help submitting a grievance
The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to
discrimination on the basis of race color national origin sex age or disability You may also
contact the Kaiser Permanente Civil Rights Coordinator directly at
Northern California
Civil RightsADA Coordinator
1800 Harrison St
16th Floor
Oakland CA 94612
Southern California
Civil RightsADA Coordinator
SCAL Compliance and Privacy
393 East Walnut St
Pasadena CA 91188
You can also file a civil rights complaint with the US Department of Health and Human Services
Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available
at ocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human
Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201
1-800-368-1019 1-800-537-7697 (TTY) Complaint forms are available at
hhsgovocrofficefileindexhtml
Language Assistance Services
English Language assistance
is available at no cost to you
24 hours a day 7 days a week
You can request interpreter
services materials translated
into your language or in
alternative formats Just call us
at 1-800-464-4000 24 hours a
day 7 days a week (closed
holidays) TTY users call 711
Arabic مجانا على مدار الساعة كافة متوفرة لك خدمات الترجمة الفورية
أيام الأسبوع بإمكانك طلب خدمة الترجمة الفورية أو ترجمة وثائق للغتك أو
4000-464-800-1 لصيغ أخرى ما عليك سوى الاتصال بنا على الرقم
لمستخدمي خدمة على مدار الساعة كافة أيام الأسبوع )مغلق أيام العطلات(
(711الرقم ) الهاتف النصي يرجي الاتصال على
Armenian Ձեզ կարող է անվճար օգնություն
տրամադրվել լեզվի հարցում` օրը 24 ժամ շաբաթը
7 օր Դուք կարող եք պահանջել բանավոր
թարգմանչի ծառայություններ Ձեր լեզվով
թարգմանված կամ այլընտրանքային ձևաչափով
պատրաստված նյութեր Պարզապես զանգահարեք
մեզ` 1-800-464-4000 հեռախոսահամարով` օրը
24 ժամ` շաբաթը 7 օր (տոն օրերին փակ է) TTY-ից
օգտվողները պետք է զանգահարեն 711
Chinese 您每週 7天每天 24小時均可獲得免費語
言協助您可以申請口譯服務要求將資料翻譯成
您所用語言或轉換為其他格式我們每週 7天
每天 24小時均歡迎您打電話 1-800-757-7585 前來聯
絡(節假日 休息)聽障及語障專線 (TTY) 使用者
請撥 711
Farsi بدون روز هفته 7ساعت شبانروز و 24در زبانی خدمات
مترجم خدمات شما می توانید برای استهزینه در اختیار شما اخذ
صورتهای دیگر به زبان شما و یا به جزوات ترجمهشفاهی
روز هفته 7ساعت شبانروز و 24 کافیست در درخواست کنید
4000-464-800-1)به استثنای روزهای تعطیل( با ما به شماره
تماس بگیرند 711با شماره TTYتماس بگیرید کاربران
Hindi बिना किसी लागत ि दभाबिया सवाए कदन ि 24 घट
सपताह ि सातो कदन उपलबध ह आप एि दभाबिय िी सवाओ
ि बलए बिना किसी लागत ि सामबियो िो अपनी भािा म
अनवाद िरवान ि बलए या विबपपि परारपो ि बलए अनरोध
िर सित ह िस िवल हम 1-800-464-4000 पर कदन ि 24
घट सपताह ि सातो कदन (छटटियो वाल कदन िद रहता ह) िॉल
िर TTY उपयोगिताा 711 पर िॉल िर
Hmong Muajkwc pab txhais lus pub dawb rau koj
24 teev ib hnub twg 7 hnub ib lim tiam twg Koj thov
tau cov kev pab txhais lus muab cov ntaub ntawv
txhais ua koj hom lus los yog ua lwm homTsuas hu
rau 1-800-464-4000 24 teev ib hnub twg 7 hnub ib
lim tiam twg (cov hnub caiv kaw) Cov neeg siv
TTY hu 711
Japanese 当院では言語支援を無料で年中無休
終日ご利用いただけます通訳サービス日本語
に翻訳された資料あるいは資料を別の書式でも
依頼できますお気軽に 1-800-464-4000 までお電話
ください (祭日を除き年中無休)TTYユーザー
は 711にお電話ください
Khmer ជនយភាសា គមានឥតអសថលៃដលអនកឡ ើយ 24
ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ អនកអាចឡសនើស ឡសវាអនកបកបរប សភារៈបដលបានបកបរបឡៅជាភាសាបមែរ ឬជាទរងផោសងឡទៀត រានបតទរសពទមកឡយើង តាមឡលម 1-800-464-4000 បាន 24 ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ (បទថលៃប ណោយ) អនកឡរបើ TTY ឡៅឡលម 711
Korean 요일 및 시간에 관계없이 언어 지원
서비스를 무료로 이용하실 수 있습니다 귀하는
통역 서비스 귀하의 언어로 번역된 자료 또는 대체
형식의 자료를 요청할 수 있습니다 요일 및 시간에
관계없이 1-800-464-4000번으로 전화하십시오
(공휴일 휴무) TTY 사용자 번호 711
Laotian ການຊວຍເຫ ອດານພາສາມໃຫໂດຍບ ເສຽຄາ
ແກທານ ຕະຫ ອດ 24 ຊ ວໂມງ 7 ວນຕ ອາທດ ທານ
ສາມາດຮອງຂ ຮບບ ລການນາຍພາສາ ໃຫແປເອກະ
ສານເປນພາສາຂອງທານ ຫ ໃນຮບແບບອ ນ ພຽງ
ແຕໂທຣຫາພວກເຮ າທ 1-800-464-4000 ຕະຫ ອດ 24
ຊ ວໂມງ 7 ວນຕ ອາທດ (ປດວນພກຕາງໆ) ຜໃຊສາຍ
TTY ໂທຣ 711
Navajo Saad bee aacutekaacutersquoarsquoayeed naacutehoacuteloacute trsquoaacuteaacute jiikrsquoeacute
naadiin doo bibąąrsquo diacuteiacutersquo aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute
damoo naacuteaacutedleehjiacute Atah halnersquoeacute aacutekaacutersquoadoolwołiacutegiacuteiacute joacutekiacute
trsquoaacuteadoo lersquoeacute trsquoaacuteaacute hoacutehazaadjiacute hadilyąąrsquogo eacuteiacute doodaiirsquo
naacuteaacutenaacute laacute ałrsquoąą aacutedaatrsquoehiacutegiacuteiacute bee haacutedadilyaarsquogo Kojiacute
hodiilnih 1-800-464-4000 naadiin doo bibąąrsquo diacuteiacutersquo
aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute damoo naacutersquoaacutedleehjiacute
(Dahodiyin biniiyeacute ersquoersquoaahgo eacuteiacute darsquodeelkaal)
TTY chodeeyooliacuteniacutegiacuteiacute kojiacute hodiilnih 711
Punjabi ਬਿਨ ਾ ਬਿਸੀ ਲ ਗਤ ਦ ਬਦਨ ਦ 24 ਘਟ ਹਫਤ ਦ 7 ਬਦਨ
ਦਭ ਸੀਆ ਸਵ ਵ ਾ ਤਹ ਡ ਲਈ ਉਪਲਿਧ ਹ ਤਸੀ ਇਿ ਦਭ ਸੀਏ ਦੀ
ਮਦਦ ਲਈ ਸਮਗਰੀਆਾ ਨ ਆਪਣੀ ਭ ਸ ਬਵਚ ਅਨਵ ਦ ਿਰਵ ਉਣ
ਲਈ ਜ ਾ ਬਿਸ ਵਖ ਫ ਰਮਟ ਬਵਚ ਪਰ ਪਤ ਿਰਨ ਲਈ ਿਨਤੀ ਿਰ ਸਿਦ
ਹ ਿਸ ਬਸਰਫ਼ ਸ ਨ 1-800-464-4000 ਤ ਬਦਨ ਦ 24 ਘਟ ਹਫ਼ਤ
ਦ 7 ਬਦਨ (ਛਟੀਆਾ ਵ ਲ ਬਦਨ ਿਦ ਰਬਹਦ ਹ) ਫ਼ਨ ਿਰ TTY ਦ
ਉਪਯਗ ਿਰਨ ਵ ਲ 711 lsquoਤ ਫ਼ਨ ਿਰਨ
Russian Мы бесплатно обеспечиваем Вас услугами
перевода 24 часа в сутки 7 дней в неделю Вы можете
воспользоваться помощью устного переводчика
запросить перевод материалов на свой язык или
запросить их в одном из альтернативных форматов
Просто позвоните нам по телефону 1-800-464-4000
который доступен 24 часа в сутки 7 дней в неделю
(кроме праздничных дней) Пользователи линии TTY
могут звонить по номеру 711
Spanish Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al diacutea 7 diacuteas a la semana
Puede solicitar los servicios de un inteacuterprete que los
materiales se traduzcan a su idioma o en formatos
alternativos Solo llame al 1-800-788-0616 24 horas al
diacutea 7 diacuteas a la semana (cerrado los diacuteas festivos) Los
usuarios de TTY deben llamar al 711
Tagalog May magagamit na tulong sa wika nang wala
kang babayaran 24 na oras bawat araw 7 araw bawat
linggo Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format Tawagan lamang
kami sa 1-800-464-4000 24 na oras bawat araw 7 araw
bawat linggo (sarado sa mga pista opisyal) Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711
Thai เรามบรการลามฟรส าหรบคณตลอด 24 ชวโมง
ทกวนตลอดชวโมงท าการของเราคณสามารถขอใหลาม
ชวยตอบค าถามของคณทเกยวกบความคมครองการดแล
สขภาพของเราและคณยงสามารถขอใหมการแปลเอกสา
รเปนภาษาทคณใชไดโดยไมมการคดคาบรการเพยงโทร
หาเราทหมายเลข 1-800-464-4000 ตลอด 24
ชวโมงทกวน (ปดใหบรการในวนหยดราชการ) ผใช TTY
โปรดโทรไปท 711
Vietnamese Dịch vụ thocircng dịch được cung cấp miễn
phiacute cho quyacute vị 24 giờ mỗi ngagravey 7 ngagravey trong tuần Quyacute
vị coacute thể yecircu cầu dịch vụ thocircng dịch tagravei liệu phiecircn dịch
ra ngocircn ngữ của quyacute vị hoặc tagravei liệu bằng nhiều higravenh
thức khaacutec Quyacute vị chỉ cần gọi cho chuacuteng tocirci tại số
1-800-464-4000 24 giờ mỗi ngagravey 7 ngagravey trong tuần
(trừ caacutec ngagravey lễ) Người dugraveng TTY xin gọi 711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
Provide no cost aids and services to people with disabilities to communicate effectively with us such as
diams Qualified sign language interpreters
diams Written information in other formats such as large print audio and accessible electronic formats
Provide no cost language services to people whose primary language is not English such as
diams Qualified interpreters
diams Information written in other languages
If you need these services call Member Services at 1-800-476-2167 (TTY 711)8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana Aurora CO 80014 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
61102709_CO
Multi-language Interpreter Services
English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-476-2167 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-476-2167 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-476-2167 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-476-2167 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-476-2167 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-476-2167 (TTY 711)번으로 전화해 주십시오
Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-800-476-2167 (телетайп 711)
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-476-2167(TTY711)までお電話にてご連絡ください
Amharic ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው 711)
German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-800-476-2167 (TTY 711)
French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-800-476-2167 (ATS 711)
Farsi
ی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ دیریبگ تماس (TTY 711) 2167-476-800-1 با باشد
Arabic
ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم )117- (رقم ھاتف الصم والبكم 7612-674-008-1
Yoruba AKIYESI Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o E pe ero ibanisoro yi 1-800-476-2167 (TTY 711)
Cushite-Oromo XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 1-800-476-2167 (TTY 711)
Nepali
धयान िदनहोस तपाइल नपाली बोलनहनछ भन तपाइको िनिमत भाषा सहायता सवाह िनःशलक पमा उपलबध छ फोन गनरहोस 1-800-476-2167 (िटिटवाइ 711)
KAH2711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
bull Provide no cost aids and services to people with disabilities to communicateeffectively with us such asdiams Qualified sign language interpretersdiams Written information in other formats such as large print audio and accessible
electronic formatsbull Provide no cost language services to people whose primary language is not English
such asdiams Qualified interpretersdiams Information written in other languages
If you need these services call Member Services at 1-800-805-2739 (TTY 711) 8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd Honolulu HI 96813 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Kaiser Permanente is an HMO plan with a Medicare contract Enrollment in Kaiser Permanente depends on contract renewal
H1230_2017MLI accepted
Multi-language Interpreter Services English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-805-2739 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-805-2739 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-805-2739 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-805-2739 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-805-2739 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-805-2739 (TTY 711)번으로 전화해 주십시오
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-805-2739(TTY711)までお電話にてご連絡ください
Lao
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 1-800-805-2739 (TTY 711)
Ilocano PAKDAAR Nu saritaem ti Ilocano ti serbisyo para ti baddang ti lengguahe nga awanan bayadna ket sidadaan para kenyam Awagan ti 1-800-805-2739 (TTY 711)
Samoan MO LOU SILAFIA Afai e te tautala Gagana faa Sāmoa o loo iai auaunaga fesoasoan e fai fua e leai se totogi mo oe Telefoni mai 1-800-805-2739 (TTY 711)
Marshallese LALE Ntildee kwōj kōnono Kajin Ṃajōḷ kwomarontilde bōk jerbal in jipantilde ilo kajin ṇe aṃ ejjeḷọk wōṇāān Kaalọk 1-800-805-2739 (TTY 711)
Trukese MEI AUCHEA Ika iei foosun fonuomw Foosun Chuuk iwe en mei tongeni omw kopwe angei aninisin chiakku ese kamo Kori 1-800-805-2739 (TTY 711)
Hawaiian E NĀNĀ MAI Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo loaʻa ke kōkua manuahi iā ʻoe E kelepona iā 1-800-805-2739 (TTY 711)
Pohnpeian Ni songen mwohmw ohte komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei Call 1-800-805-2739 (TTY 711)
Bisayan ATENSYON Kung nagsulti ka og Cebuano aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe nga walay bayad Tawag sa 1-800-805-2739 (TTY 711)
Tongan FAKATOKANGArsquoI Kapau lsquooku ke Lea-Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai atu ha tokoni tarsquoetotongi pea teke lava lsquoo marsquou ia Telefoni mai 1-800-805-2739 (TTY 711)
485236276 102021
This formulary was updated on 100121 For more recent information or other questions please contact the number for your Kaiser Permanente Region listed below seven days a week 8 am to 8 pm or visit kporgseniorrx
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Foundation Health Plan Inc 393 E Walnut St Pasadena CA 91188-8514 Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E Dakota Ave Denver CO 80247 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Foundation Health Plan Inc 711 Kapiolani Blvd Honolulu HI 96813 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
kporgseniorrx Please recycle
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 3
see your Evidence of Coverage for more information
Are there any restrictions on my coverage
Some covered drugs may have additional requirements or limits on coverage These requirements and limits may include
bull Prior Authorization Our plan may require you or your network provider to get prior authorization for certain drugs This means that you will need to get approval from our plan before you fill your prescriptions If you donrsquot get approval we may not cover the drug
Note If your prescription has more than one refill remaining you can only get one refill at a time unless authorized because you will be away from our service area for an extended period of time For certain drugs we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive Also if there is a shortage in the marketplace we may fill your prescription for a limited quantity You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6 You can also get more information about the restrictions applied to specific covered drugs by visiting our website We have posted online a document that explains our prior authorization restriction You may also ask us to send you a copy Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages
You can ask us to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I request an exception to the Kaiser Permanente formularyrdquo for information about how to request an exception What if my drug is not on the formulary
If your drug is not included in this formulary (list of covered drugs) you should first check our Kaiser Permanente 2021 Comprehensive Formulary at kporgseniorrx or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region and confirm if your drug is covered If your Medicare Part D prescription drug is not on our Kaiser Permanente 2021 Comprehensive Formulary you have two options
bull You can ask your network provider to prescribe a similar drug that is included on our formulary
bull You can ask us to make an exception and cover your drug See the next section for information about how to request an exception
How do I request an exception to the Kaiser Permanente Formulary
You can ask us to make an exception to our coverage rules There are several types of exceptions that you can ask us to make
bull You can ask us to cover a drug even if it may not be in our Kaiser Permanente 2021 Comprehensive Formulary
4 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
bull You can ask us to waive coverage
restrictions or limits on your drug For example if your drug requires prior authorization you can ask us to waive the prior authorization requirement for your Part D drug
Generally we will only approve your request for an exception if the alternative drugs included on the planrsquos formulary or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception When you request a formulary or utilization restriction exception you should submit a statement from your network provider supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited (fast) exception if you or your network provider believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber
Please note You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare amp Medicaid Services (CMS) You cannot get an exception for drugs that are excluded under Medicare Part D Please refer to your Evidence of Coverage for more information about requesting exceptions including the appeals process What do I do before I can talk to my network provider about
changing my drugs or requesting an exception
In some cases you might be taking Medicare Part D drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your network provider to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your network provider to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan For each of your Part D drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide up to a maximum of a 30-day supply of medication After your first 30-day supply we may cover an additional refill as medically necessary After you have used these refills we will not pay for these drugs even if you have been a member of the plan less than 90 days
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug while you pursue a formulary exception
For current members with level of care changes if you enter into or are discharged from a hospital skilled nursing facility or long-term care facility to a different care setting or home this is what is known as a
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 5
level of care change When your level of care changes you may require an additional fill of your medication We will generally cover up to a one-month supply of your Part D drugs during this level of care transition period even if the drug is not on our Drug List
For more information
For more detailed information about your Kaiser Permanente prescription drug coverage please review your Evidence of Coverage and other plan materials If you have questions about our plan please call us Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048 Or visit httpwwwmedicaregov
6 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Kaiser Permanentersquos Formulary
The formulary below provides coverage information about the drugs covered by our plan If you have trouble finding your drug in the list turn to the index that begins on page 66 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg NEBUPENT) and generic drugs are listed in lower-case italics (eg ltamoxicillingt) The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number below Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy Northern CA ndash 1-888-218-6245 Monday through Friday 8 am to 8 pm Saturday 8 am to 6 pm and Sunday 9 am to 6 pm Southern CA ndash 1-866-206-2983 Monday through Friday 7 am to 7 pm Saturday 10 am to 2 pm
Colorado
Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday 8 am to 6 pm
Hawaii
Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday 800 am to 5 pm
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 7
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
8 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole tabs NDS emverm chew ivermectin tabs praziquantel tabs MO ANTIBACTERIALS amikacin sulfate soln amikacin sulfate soln injection HI amoxicillin caps amoxicillin chew amoxicillin susr amoxicillin tabs amoxicillin-pot clavulanate chew amoxicillin-pot clavulanate er tb12
amoxicillin-pot clavulanate susr amoxicillin-pot clavulanate tabs ampicillin caps ampicillin sodium solr ampicillin sodium solr injection 1gm 125mg HI
ampicillin sodium solr intravenous HI
ampicillin-sulbactam sodium solr ampicillin-sulbactam sodium solr injection HI
ampicillin-sulbactam sodium solr intravenous HI
ARIKAYCE SUSP PALDNDS AUGMENTIN SUSR AVYCAZ SOLR INTRAVENOUS HI AZITHROMYCIN PACK MO azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BAXDELA SOLR INTRAVENOUS HI
BAXDELA TABS MO
Drug Name RequirementsLimits
BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP cefaclor caps cefaclor er tb12 cefaclor susr cefadroxil caps cefadroxil susr cefadroxil tabs cefazolin sodium solr cefazolin sodium solr injection 1gm 10gm 500mg HI
cefdinir caps cefdinir susr cefepime hcl solr injection 1gm 2gm HI
cefixime caps cefixime susr cefotaxime sodium solr cefotetan disodium solr injection 1gm 2gm HI
cefoxitin sodium solr injection HI cefoxitin sodium solr intravenous 1gm 2gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 2gm 6gm HI
CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 75gm 750mg HI
cefuroxime sodium solr intravenous HI
cephalexin caps cephalexin susr cephalexin tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w soln ciprofloxacin in d5w soln intravenous HI
ciprofloxacin susr ciprofloxacin-ciproflox hcl er tb24 clarithromycin er tb24 clarithromycin susr clarithromycin tabs cleocin phosphate soln cleocin solr clindamycin hcl caps clindamycin palmitate hcl solr clindamycin phosphate in d5w soln intravenous HI
clindamycin phosphate soln clindamycin phosphate soln injection 300mg2ml 600mg4ml 900mg6ml
HI
colistimethate sodium (cba) solr injection HI
DALVANCE SOLR INTRAVENOUS HI
daptomycin solr intravenous 350mg 500mg HI
demeclocycline hcl tabs dicloxacillin sodium caps DIFICID SUSR NDS DIFICID TABS NDS DORYX MPC TBEC MO doxy 100 solr intravenous HI doxycycline hyclate caps 50mg 100mg MO
doxycycline hyclate tabs 20mg 75mg 100mg 150mg MO
doxycycline hyclate tbec 50mg 75mg 100mg 150mg 200mg MO
doxycycline monohydrate caps 50mg 75mg 100mg 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
Drug Name RequirementsLimits
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs FETROJA SOLR NDS FIRVANQ SOLR gentamicin in saline soln gentamicin in saline soln intravenous HI
gentamicin sulfate soln gentamicin sulfate soln injection HI imipenem-cilastatin solr intravenous HI
KIMYRSA SOLR NDS levofloxacin in d5w soln levofloxacin in d5w soln intravenous HI
levofloxacin soln levofloxacin soln intravenous HI levofloxacin tabs lincomycin hcl soln linezolid soln intravenous HI linezolid susr NDS linezolid tabs NDS meropenem solr intravenous 1gm 500mg HI
minocycline hcl caps 50mg 75mg 100mg MO
minocycline hcl er tb24 45mg 55mg 65mg 80mg 90mg 105mg 115mg 135mg
MO
minocycline hcl tabs 50mg 75mg 100mg MO
mondoxyne nl caps 75mg 100mg MO
morgidox caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 10 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium solr intravenous HI neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs okebo caps MO ORBACTIV SOLR NDS OXACILLIN SODIUM IN DEXTROSE SOLN INTRAVENOUS
HI
oxacillin sodium solr injection 1gm 2gm HI
oxacillin sodium solr intravenous HI PENICILLIN G POT IN DEXTROSE SOLN INTRAVENOUS
HI
penicillin g potassium solr injection HI
penicillin g procaine susp penicillin g sodium solr injection HI penicillin v potassium solr penicillin v potassium tabs piperacillin sod-tazobactam so solr
piperacillin sod-tazobactam so solr intravenous HI
polymyxin b sulfate solr injection HI RECARBRIO SOLR NDS SEYSARA TABS 60mg 100mg 150mg NDS
SIVEXTRO SOLR INTRAVENOUS HI
SIVEXTRO TABS NDS soloxide tbec MO streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
Drug Name RequirementsLimits
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO SUPRAX CAPS suprax chew suprax susr 100mg5ml 200mg5ml
SUPRAX SUSR 500 MG5ML SYNERCID SOLR targadox tabs MO tazicef solr injection 1gm 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS 400mg 600mg HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
VABOMERE SOLR INTRAVENOUS HI
vancomycin hcl caps vancomycin hcl solr VANCOMYCIN HCL SOLR 250 MG
vancomycin hcl solr intravenous 1gm 10gm 500mg HI
VIBRAMYCIN SYRP XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS XIMINO CP24 45mg 90mg 135mg MO
ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ZITHROMAX PACK MO ZOSYN SOLN INTRAVENOUS HI ZYVOX SOLN INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
ANTIFUNGALS ABELCET SUSP INTRAVENOUS HI
AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS ERAXIS SOLR INTRAVENOUS 50mg 100mg HI
fluconazole in sodium chloride soln intravenous HI
fluconazole susr fluconazole tabs flucytosine caps 250mg 500mg NDS griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs itraconazole caps ITRACONAZOLE SOLN MO ketoconazole tabs micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS NOXAFIL TBEC NDS nystatin susp nystatin tabs POSACONAZOLE SUSP NDS posaconazole tbec NDS terbinafine hcl tabs TOLSURA CAPS NDS voriconazole solr intravenous HI voriconazole susr voriconazole tabs ANTIMYCOBACTERIALS CAPASTAT SULFATE SOLR cycloserine caps dapsone tabs 25mg 100mg MO ethambutol hcl tabs 100mg 400mg MO
isoniazid soln
Drug Name RequirementsLimits
isoniazid syrp MO isoniazid tabs 100mg 300mg MO paser pack MO PRETOMANID TABS PRIFTIN TABS MO pyrazinamide tabs MO RIFABUTIN CAPS MO RIFADIN CAPS MO rifamate caps MO rifampin caps 150mg 300mg MO rifampin solr intravenous HI RIFATER TABS MO SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs BENZNIDAZOLE TABS 125mg 100mg MO
chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS DARAPRIM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS mefloquine hcl tabs metronidazole caps metronidazole in nacl soln metronidazole in nacl soln intravenous HI
metronidazole tabs NEBUPENT SOLR PA nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 12 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
quinine sulfate caps NDS SOLOSEC PACK tinidazole tabs ANTIVIRALS abacavir sulfate soln abacavir sulfate tabs MO abacavir sulfate-lamivudine tabs MO abacavir-lamivudine-zidovudine tabs MO
acyclovir caps MO acyclovir sodium soln intravenous HI
acyclovir susp MO acyclovir tabs 400mg 800mg MO adefovir dipivoxil tabs NDS APTIVUS CAPS MO APTIVUS SOLN MO atazanavir sulfate caps 150mg 200mg 300mg MO
BARACLUDE SOLN MO BIKTARVY TABS CABENUVA SUER cidofovir soln CIMDUO TABS MO COMPLERA TABS MO CRIXIVAN CAPS 200mg 400mg MO DAKLINZA TABS 30mg 60mg 90mg PANDS
DELSTRIGO TABS MO DESCOVY TABS MO didanosine cpdr 200mg 250mg 400mg MO
DOVATO TABS MO EDURANT TABS MO efavirenz caps 50mg 200mg MO efavirenz tabs MO efavirenz-emtricitab-tenofovir tabs MO
emtricitabine caps MO emtricitabine-tenofovir df tabs MO EMTRIVA SOLN MO entecavir tabs 05mg 1mg MO EPCLUSA TABS PANDS
Drug Name RequirementsLimits
EPIVIR HBV SOLN MO etravirine tabs 100mg 200mg MO EVOTAZ TABS MO famciclovir tabs 125mg 250mg 500mg MO
fosamprenavir calcium tabs MO FUZEON SOLR NDS ganciclovir sodium soln ganciclovir sodium solr GENVOYA TABS MO HARVONI PACK PANDS HARVONI TABS PANDS INTELENCE TABS 25mg MO INVIRASE CAPS MO INVIRASE TABS MO ISENTRESS CHEW 25mg 100mg MO
ISENTRESS HD TABS MO ISENTRESS PACK MO ISENTRESS TABS MO JULUCA TABS MO lamivudine soln MO lamivudine tabs 100mg 150mg 300mg MO
lamivudine-zidovudine tabs MO ledipasvir-sofosbuvir tabs PANDS LEXIVA SUSP MO lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO MAVYRET TABS PANDS nevirapine er tb24 100mg 400mg MO
nevirapine susp MO nevirapine tabs MO NORVIR CAPS MO NORVIR PACK MO NORVIR SOLN MO ODEFSEY TABS MO OLYSIO CAPS PANDS oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEG-INTRON REDIPEN KIT NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
PEGASYS PROCLICK SOLN 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN 180mcg05ml 180mcgml NDS
PEGINTRON KIT NDS PIFELTRO TABS MO PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
PREVYMIS SOLN 240mg12ml 480mg24ml NDS
PREVYMIS TABS 240mg 480mg NDS
PREZCOBIX TABS MO PREZISTA SUSP MO PREZISTA TABS 75mg 150mg 600mg 800mg MO
RAPIVAB SOLN NDS REBETOL SOLN MO RELENZA DISKHALER AEPB MO RESCRIPTOR TABS 100mg 200mg MO
RETROVIR SOLN MO REYATAZ PACK MO ribasphere caps MO ribasphere ribapak (1000 pack) tbpk MO
ribasphere ribapak (1200 pack) tbpk MO
ribasphere tabs MO ribavirin caps MO ribavirin solr ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg 150mg 300mg MO
sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS
Drug Name RequirementsLimits
SOVALDI TABS 200mg 400mg PANDS stavudine caps 15mg 20mg 30mg 40mg MO
STRIBILD TABS MO SYMFI LO TABS MO SYMFI TABS MO SYMTUZA TABS MO SYNAGIS SOLN 50mg05ml 100mgml NDS
tenofovir disoproxil fumarate tabs MO
TIVICAY PD TBSO MO TIVICAY TABS 10mg 25mg 50mg MO
TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEMLIDY TABS VIDEX EC CPDR 125mg 200mg 400mg MO
VIDEX SOLR 2gm 4gm MO VIEKIRA PAK TBPK PANDS VIEKIRA XR TB24 PANDS VIRACEPT TABS 250mg 625mg MO
VIREAD POWD MO VIREAD TABS 150mg MO VIREAD TABS 200mg 250mg MO VOCABRIA TABS MO VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS ZERIT CAPS 15mg 20mg 30mg 40mg MO
zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 14 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fosfomycin tromethamine pack MENAPHOSMBHYO1 TABS methenamine hippurate tabs METHENAMINE MANDELATE TABS
NITROFURANTOIN MACROCRYSTAL CAPS
NITROFURANTOIN MONOHYD MACRO CAPS
nitrofurantoin susp PHOSPHASAL TABS trimethoprim tabs MO URETRON DS TABS URIN DS TABS URYL TABS USTELL CAPS UTICAP CAPS UTIRA-C TABS UTRONA-C TABS ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate soln carbinoxamine maleate tabs cetirizine hcl soln CLARINEX SYRP CLARINEX-D 12 HOUR TB12 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln
Drug Name RequirementsLimits
promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs SEMPREX-D CAPS ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg 500mg NDS
ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS 25mg 5mg 75mg 10mg NDS
ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs ARRANON SOLN ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE INJ BELEODAQ SOLR NDS BELRAPZO SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS bexarotene caps NDS bicalutamide tabs BICNU SOLR bleomycin sulfate solr BLINCYTO SOLR NDS BORTEZOMIB SOLR BOSULIF TABS 100mg 400mg 500mg NDS
BRAFTOVI CAPS 50mg 75mg NDS BRUKINSA CAPS NDS busulfan soln CABOMETYX TABS 20mg 40mg 60mg NDS
CALQUENCE CAPS NDS CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR NDS cladribine soln clofarabine soln COMETRIQ (100 MG DAILY DOSE) KIT LDNDS
COMETRIQ (140 MG DAILY DOSE) KIT LDNDS
COMETRIQ (60 MG DAILY DOSE) KIT LDNDS
COPIKTRA CAPS 15mg 25mg NDS COTELLIC TABS NDS CYCLOPHOSPHAMIDE CAPS 25mg 50mg PA
CYCLOPHOSPHAMIDE SOLN 1gm5ml 500mg25ml NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr
Drug Name RequirementsLimits
dactinomycin solr DANYELZA SOLN NDS DARZALEX FASPRO SOLN NDS DARZALEX SOLN 400mg20ml 100mg5ml NDS
daunorubicin hcl soln DAURISMO TABS 25mg 100mg NDS decitabine solr DOCETAXEL (NON-ALCOHOL) SOLN 80mg4ml 160mg8ml 20mgml
NDS
docetaxel conc docetaxel soln doxorubicin hcl liposomal inj DOXORUBICIN HCL SOLN doxorubicin hcl solr DROXIA CAPS ELIGARD KIT ELLENCE SOLN ELZONRIS SOLN NDS EMCYT CAPS NDS EMPLICITI SOLR 300mg 400mg NDS
ENHERTU SOLR NDS epirubicin hcl soln ERBITUX SOLN ERIVEDGE CAPS NDS ERLEADA TABS NDS erlotinib hcl tabs 25mg 100mg 150mg NDS
ERWINASE SOLR NDS ERWINAZE SOLR NDS ETOPOPHOS SOLR NDS etoposide soln everolimus tabs 25mg 5mg 75mg NDS
EVOMELA SOLR NDS exemestane tabs FARYDAK CAPS 10mg 15mg 20mg LDNDS
FASLODEX SOLN NDS FENSOLVI (6 MONTH) KIT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 16 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
FIRMAGON (240 MG DOSE) SOLR
FIRMAGON SOLR floxuridine solr fludarabine phosphate soln fludarabine phosphate solr fluorouracil soln flutamide caps FOTIVDA CAPS 089mg 134mg NDS
fulvestrant soln NDS GAVRETO CAPS NDS GAZYVA SOLN NDS gemcitabine hcl soln gemcitabine hcl solr GILOTRIF TABS 20mg 30mg 40mg NDS
HERCEPTIN HYLECTA SOLN NDS HERCEPTIN SOLR 150mg 440mg NDS
HERZUMA SOLR 150mg 420mg NDS
HEXALEN CAPS NDS hydroxyurea caps IBRANCE CAPS 75mg 100mg 125mg NDS
IBRANCE TABS 75mg 100mg 125mg NDS
ICLUSIG TABS 10mg 15mg 30mg 45mg NDS
IDAMYCIN PFS SOLN idarubicin hcl soln IDHIFA TABS 50mg 100mg NDS ifosfamide soln IFOSFAMIDE SOLR imatinib mesylate tabs IMBRUVICA CAPS 70mg 140mg NDS
IMBRUVICA TABS 140mg 280mg 420mg 560mg NDS
IMFINZI SOLN 500mg10ml 120mg24ml NDS
INFUGEM SOLN NDS INLYTA TABS 1mg 5mg NDS
Drug Name RequirementsLimits
INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 10muml 6000000unitml NDS
INTRON A SOLR 10mu 18mu 50mu NDS
IRESSA TABS NDS irinotecan hcl soln IXEMPRA KIT SOLR NDS JAKAFI TABS 5mg 10mg 15mg 20mg 25mg NDS
JEMPERLI SOLN KADCYLA SOLR 100mg 160mg NDS KANJINTI SOLR 150mg 420mg NDS KEYTRUDA SOLN NDS KISQALI (200 MG DOSE) TBPK NDS KISQALI (400 MG DOSE) TBPK NDS KISQALI (600 MG DOSE) TBPK NDS KISQALI FEMARA (400 MG DOSE) TBPK NDS
KISQALI FEMARA (600 MG DOSE) TBPK NDS
KISQALI FEMARA (200 MG DOSE) TBPK NDS
KOSELUGO CAPS 10mg 25mg NDS KYPROLIS SOLR 10mg 30mg 60mg NDS
lapatinib ditosylate tabs NDS LARTRUVO SOLN 190mg19ml 500mg50ml NDS
LENVIMA (10 MG DAILY DOSE) CPPK LDNDS
LENVIMA (12 MG DAILY DOSE) CPPK LDNDS
LENVIMA (14 MG DAILY DOSE) CPPK LDNDS
LENVIMA (18 MG DAILY DOSE) CPPK LDNDS
LENVIMA (20 MG DAILY DOSE) CPPK LDNDS
LENVIMA (24 MG DAILY DOSE) CPPK LDNDS
LENVIMA (4 MG DAILY DOSE) CPPK LDNDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
LENVIMA (8 MG DAILY DOSE) CPPK LDNDS
letrozole tabs LEUKERAN TABS NDS leuprolide acetate kit LIBTAYO SOLN NDS LIPODOX 50 INJ LONSURF TABS NDS LORBRENA TABS 25mg 100mg NDS
LUMAKRAS TABS NDS LUMOXITI SOLR NDS LUPANETA PACK KIT LUPRON DEPOT (1-MONTH) KIT
LUPRON DEPOT (3-MONTH) KIT
LUPRON DEPOT (4-MONTH) KIT
LUPRON DEPOT (6-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT 75 MG
LUPRON DEPOT-PED (3-MONTH) KIT
LYNPARZA CAPS NDS LYNPARZA TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA SOLN NDS MARQIBO SUSP NDS MATULANE CAPS NDS megestrol acetate susp megestrol acetate tabs MEKINIST TABS 05mg 2mg NDS MEKTOVI TABS NDS melphalan hcl solr mercaptopurine tabs methotrexate sodium (pf) soln methotrexate sodium soln methotrexate sodium solr
Drug Name RequirementsLimits
methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS MUSTARGEN SOLR mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS NERLYNX TABS NDS NEXAVAR TABS NDS nilutamide tabs NINLARO CAPS 23mg 3mg 4mg NDS
NUBEQA TABS NDS ODOMZO CAPS NDS OGIVRI SOLR NDS ONIVYDE INJ NDS ONTRUZANT SOLR 150mg 420mg NDS
ONUREG TABS 200mg 300mg NDS OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml NDS
oxaliplatin soln oxaliplatin solr paclitaxel conc PADCEV SOLR 20mg 30mg NDS paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEPAXTO SOLR NDS PERJETA SOLN NDS PHESGO SOLN NDS PIQRAY (200 MG DAILY DOSE) TBPK NDS
PIQRAY (250 MG DAILY DOSE) TBPK NDS
PIQRAY (300 MG DAILY DOSE) TBPK NDS
POLIVY SOLR 30mg 140mg NDS POMALYST CAPS 1mg 2mg 3mg 4mg NDS
PORTRAZZA SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 18 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
POTELIGEO SOLN NDS PROLEUKIN SOLR NDS PURIXAN SUSP NDS QINLOCK TABS NDS RETEVMO CAPS 40mg 80mg NDS REVLIMID CAPS 25mg 5mg 10mg 15mg 20mg 25mg NDS
RIABNI SOLN 100mg10ml 500mg50ml NDS
RITUXAN HYCELA SOLN RITUXAN SOLN ROMIDEPSIN SOLN NDS ROZLYTREK CAPS 100mg 200mg NDS
RUBRACA TABS 200mg 250mg 300mg NDS
RUXIENCE SOLN 100mg10ml 500mg50ml NDS
RYBREVANT SOLN NDS RYDAPT CAPS NDS RYLAZE SOLN NDS SARCLISA SOLN 500mg25ml 100mg5ml NDS
SIKLOS TABS NDS SOLTAMOX SOLN SPRYCEL TABS 20mg 50mg 70mg 80mg 100mg 140mg NDS
STIVARGA TABS NDS sunitinib malate caps 125mg 25mg 375mg 50mg NDS
SUTENT CAPS 125mg 25mg 375mg 50mg NDS
SYLATRON KIT 600 MCG SYLATRON KIT SYLVANT SOLR 100mg 400mg NDS SYNRIBO SOLR NDS TABLOID TABS TABRECTA TABS 150mg 200mg NDS
TAFINLAR CAPS 50mg 75mg NDS TAGRISSO TABS 40mg 80mg NDS TALZENNA CAPS 025mg 1mg NDS tamoxifen citrate tabs
Drug Name RequirementsLimits
TARCEVA TABS 25mg 100mg 150mg NDS
TASIGNA CAPS 50mg 150mg 200mg NDS
TAZVERIK TABS NDS TECENTRIQ SOLN 840mg14ml 1200mg20ml NDS
temsirolimus soln TENIPOSIDE SOLN TEPADINA SOLR NDS TEPMETKO TABS NDS THALOMID CAPS 50mg 100mg 150mg 200mg NDS
thiotepa solr 15mg 100mg NDS TIBSOVO TABS NDS toposar soln TOPOTECAN HCL SOLN topotecan hcl solr toremifene citrate tabs NDS TRAZIMERA SOLR 150mg 420mg NDS
TRELSTAR MIXJECT SUSR tretinoin caps NDS trexall tabs 5mg 75mg 10mg 15mg PA
TRISENOX SOLN 10mg10ml NDS TRISENOX SOLN NDS TRODELVY SOLR NDS TRUSELTIQ (100MG DAILY DOSE) CPPK NDS
TRUSELTIQ (125MG DAILY DOSE) CPPK NDS
TRUSELTIQ (50MG DAILY DOSE) CPPK NDS
TRUSELTIQ (75MG DAILY DOSE) CPPK NDS
TRUXIMA SOLN 100mg10ml 500mg50ml NDS
TUKYSA TABS 50mg 150mg NDS TURALIO CAPS NDS TYKERB TABS NDS UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
VANTAS KIT VELCADE SOLR VENCLEXTA STARTING PACK TBPK NDS
VENCLEXTA TABS 10mg NDS VENCLEXTA TABS 50mg 100mg NDS
VERZENIO TABS 50mg 100mg 150mg 200mg NDS
vinblastine sulfate soln vincasar pfs soln vincristine sulfate soln vinorelbine tartrate soln VITRAKVI CAPS 25mg 100mg NDS VITRAKVI SOLN NDS VIZIMPRO TABS 15mg 30mg 45mg NDS
VOTRIENT TABS NDS VYXEOS SUSR NDS XALKORI CAPS 200mg 250mg NDS XATMEP SOLN PANDS XOSPATA TABS NDS XPOVIO (100 MG ONCE WEEKLY) TBPK 20mg 50mg NDS
XPOVIO (40 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (40 MG TWICE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (60 MG ONCE WEEKLY) TBPK 20mg 60mg NDS
XPOVIO (60 MG TWICE WEEKLY) TBPK NDS
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (80 MG TWICE WEEKLY) TBPK NDS
XTANDI CAPS NDS XTANDI TABS 40mg 80mg NDS YERVOY SOLN YONDELIS SOLR NDS YONSA TABS NDS ZALTRAP SOLN 100mg4ml 200mg8ml NDS
ZEJULA CAPS NDS
Drug Name RequirementsLimits
ZELBORAF TABS NDS ZEPZELCA SOLR NDS ZIRABEV SOLN 400mg16ml 100mg4ml NDS
ZOLINZA CAPS NDS ZYDELIG TABS 100mg 150mg NDS ZYKADIA CAPS NDS ZYKADIA TABS NDS ZYNLONTA SOLR NDS ZYTIGA TABS NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA AEPB MO ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO BEVESPI AEROSPHERE AERO MO chlordiazepoxide-clidinium caps CUVPOSA SOLN MO dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate pf sosy glycopyrrolate soln glycopyrrolate tabs 1mg 2mg MO INCRUSE ELLIPTA AEPB MO ipratropium bromide soln 002 PAMO ipratropium bromide soln 003 006 MO
LONHALA MAGNAIR REFILL KIT SOLN NDS
methscopolamine bromide tabs 25mg 5mg MO
propantheline bromide tabs MO SPIRIVA HANDIHALER CAPS MO SPIRIVA RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 20 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO NICOTROL NS SOLN MO PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride tabs 5mg 10mg 25mg 50mg MO
CEVIMELINE HCL CAPS MO donepezil hcl tabs 5mg 10mg 23mg MO
donepezil hcl tbdp 5mg 10mg MO galantamine hydrobromide er cp24 8mg 16mg 24mg MO
galantamine hydrobromide soln MO galantamine hydrobromide tabs 4mg 8mg 12mg MO
GUANIDINE HCL TABS MO MESTINON SOLN MO pilocarpine hcl tabs 5mg 75mg MO pyridostigmine bromide er tbcr MO pyridostigmine bromide soln MO pyridostigmine bromide tabs 30mg 60mg MO
REGONOL SOLN rivastigmine pt24 46mg24hr 95mg24hr 133mg24hr MO
rivastigmine tartrate caps 15mg 3mg 45mg 6mg MO
urecholine tabs 5mg 10mg 25mg 50mg MO
SKELETAL MUSCLE RELAXANTS baclofen soln baclofen tabs 5mg 10mg 20mg MO carisoprodol tabs 250mg 350mg PANDS carisoprodol-aspirin tabs PANDS carisoprodol-aspirin-codeine tabs PANDS
chlorzoxazone tabs 375mg 500mg 750mg NDS
Drug Name RequirementsLimits
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA lorzone tabs 375mg 750mg NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln revonto solr succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs vanadom tabs PANDS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl er tb24 MO dihydroergotamine mesylate soln NDS ergoloid mesylates tabs MO ergomar subl phenoxybenzamine hcl caps NDS silodosin caps 4mg 8mg MO tamsulosin hcl caps MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR HFA AERO MO albuterol sulfate er tb12 4mg 8mg MO
albuterol sulfate hfa aers MONDS albuterol sulfate nebu 0083 25mg05ml PAMO
albuterol sulfate nebu 063mg3ml 125mg3ml PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO ARCAPTA NEOHALER CAPS MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY EPIPEN 2-PAK SOAJ EPIPEN JR 2-PAK SOAJ formoterol fumarate nebu PAMO ipratropium-albuterol soln PAMO isoproterenol hcl soln levalbuterol hcl nebu 125mg05ml 031mg3ml 063mg3ml 125mg3ml
PAMO
levalbuterol tartrate aero MO metaproterenol sulfate syrp MO metaproterenol sulfate tabs 10mg 20mg MO
midodrine hcl tabs 25mg 5mg 10mg MO
norepinephrine bitartrate soln phenylephrine hcl soln PROAIR RESPICLICK AEPB MO SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
tizanidine hcl caps VENTOLIN HFA AERS MONDS BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS BERINERT KIT INTRAVENOUS HI FIRAZYR SOLN NDS icatibant acetate soln NDS OXBRYTA TABS NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS
Drug Name RequirementsLimits
COAGULANTS AND ANTICOAGULANTS aminocaproic acid soln MO aminocaproic acid tabs 500mg 1000mg MO
anagrelide hcl caps 05mg 1mg MO argatroban soln aspirin-dipyridamole er cp12 MO BEVYXXA CAPS 40mg 80mg MO BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
NDS
FRAGMIN SOLN 2500unit02ml 5000unit02ml 7500unit03ml 12500unit05ml 15000unit06ml 95000unit38ml 10000unitml 18000unt072ml
NDS
heparin (porcine) in nacl soln HEPARIN SOD (PORCINE) IN D5W SOLN
heparin sodium (porcine) pf soln PA heparin sodium (porcine) soln 1000unitml 5000unitml 10000unitml 20000unitml
PA
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg
MO
LOVENOX SOLN 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 22 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg PRADAXA CAPS 110mg 150mg MO
prasugrel hcl tabs 5mg 10mg MO tranexamic acid soln tranexamic acid tabs MO warfarin sodium tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 10mg
MO
XARELTO STARTER PACK TBPK MO
XARELTO TABS 25mg 10mg 15mg 20mg MO
ZONTIVITY TABS MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 25mcgml 40mcgml PANDS
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml
PANDS
FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MIRCERA SOSY 30mcg03ml 50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml
PA
MULPLETA TABS NDS
Drug Name RequirementsLimits
NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml NDS
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RETACRIT SOLN 20000unit2ml 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL TB24 4mg 8mg MO DEMSER CAPS NDS doxazosin mesylate tabs 1mg 2mg 4mg 8mg MO
metyrosine caps NDS prazosin hcl caps 1mg 2mg 5mg MO
terazosin hcl caps 1mg 2mg 5mg 10mg MO
ANTILIPEMIC AGENTS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
ALTOPREV TB24 20mg 40mg 60mg MO
ANTARA CAPS 30mg 90mg MO atorvastatin calcium tabs 10mg 20mg 40mg 80mg MO
cholestyramine light pack MO cholestyramine light powd MO cholestyramine pack MO cholestyramine powd MO colesevelam hcl pack MO colesevelam hcl tabs MO colestipol hcl gran MO colestipol hcl pack MO colestipol hcl tabs MO EVKEEZA SOLN 345mg23ml 1200mg8ml NDS
ezetimibe tabs MO ezetimibe-simvastatin tabs MO fenofibrate caps 50mg 134mg 150mg MO
fenofibrate micronized caps 43mg 67mg 130mg 200mg MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg MO
FENOFIBRIC ACID TABS 35mg 105mg MO
FIBRICOR TABS MO FLOLIPID SUSP 20mg5ml 40mg5ml MO
fluvastatin sodium caps 20mg 40mg MO
fluvastatin sodium er tb24 MO gemfibrozil tabs MO icosapent ethyl caps MO JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg PALDNDS
KYNAMRO SOSY PALDNDS LIVALO TABS 1mg 2mg 4mg MO lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
Drug Name RequirementsLimits
niacor tabs MO omega-3-acid ethyl esters caps MO pravastatin sodium tabs 10mg 20mg 40mg 80mg MO
prevalite pack MO prevalite powd MO questran light powd MO questran pack MO questran powd MO REPATHA PUSHTRONEX SYSTEM SOCT PANDS
REPATHA SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 05gm 1gm MO ZYPITAMAG TABS 1mg 2mg 4mg MO
BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl caps 200mg 400mg MO
atenolol tabs 25mg 50mg 100mg MO
atenolol-chlorthalidone tabs MO betaxolol hcl tabs 10mg 20mg MO bisoprolol fumarate tabs 5mg 10mg MO
bisoprolol-hydrochlorothiazide tabs MO
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg MO
carvedilol tabs 3125mg 625mg 125mg 25mg MO
DUTOPROL TB24 MO ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln INNOPRAN XL CP24 80mg 120mg MO
labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 24 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
metoprolol succinate er tb24 25mg 50mg 100mg 200mg MO
metoprolol tartrate soct metoprolol tartrate soln metoprolol tartrate tabs 25mg 50mg 100mg MO
metoprolol tartrate tabs 375mg 75mg MO
metoprolol-hydrochlorothiazide tabs MO
nadolol tabs 20mg 40mg 80mg MO nadolol-bendroflumethiazide tabs MO
pindolol tabs 5mg 10mg MO propranolol hcl er cp24 60mg 80mg 120mg 160mg MO
propranolol hcl soln 20mg5ml 40mg5ml MO
propranolol hcl tabs 10mg 20mg 40mg 60mg 80mg MO
propranolol-hctz tabs MO sorine tabs 80mg 120mg 160mg 240mg MO
sotalol hcl (af) tabs 80mg 120mg 160mg MO
sotalol hcl tabs 80mg 120mg 160mg 240mg MO
SOTYLIZE SOLN MO timolol maleate tabs 5mg 10mg 20mg MO
CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besy-benazepril hcl caps MO
amlodipine besylate tabs 25mg 5mg 10mg MO
amlodipine besylate-valsartan tabs MO
amlodipine-atorvastatin tabs MO amlodipine-olmesartan tabs MO amlodipine-valsartan-hctz tabs MO CARDENE IV SOLN CARDIZEM LA TB24 MO cartia xt cp24 120mg 180mg 240mg 300mg MO
Drug Name RequirementsLimits
CONSENSI TABS NDS dilt-xr cp24 120mg 180mg 240mg MO
diltiazem hcl er beads cp24 120mg 180mg 240mg 300mg 360mg 420mg
MO
DILTIAZEM HCL ER COATED BEADS CP24 120mg 180mg 240mg 300mg 360mg
MO
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg
MO
diltiazem hcl er cp12 60mg 90mg 120mg MO
diltiazem hcl er cp24 120mg 180mg 240mg MO
diltiazem hcl soln diltiazem hcl solr diltiazem hcl tabs 30mg 60mg 90mg 120mg MO
felodipine er tb24 25mg 5mg 10mg MO
isradipine caps 25mg 5mg MO matzim la tb24 180mg 240mg 300mg 360mg 420mg MO
nicardipine hcl caps 20mg 30mg MO nicardipine hcl soln nifedipine caps 10mg 20mg MO nifedipine er osmotic release tb24 30mg 60mg 90mg MO
nifedipine er tb24 30mg 60mg 90mg MO
nimodipine caps MO nisoldipine er tb24 85mg 17mg 20mg 255mg 30mg 34mg 40mg
MO
NYMALIZE SOLN 60mg20ml 6mgml NDS
olmesartan-amlodipine-hctz tabs MO taztia xt cp24 120mg 180mg 240mg 300mg 360mg MO
telmisartan-amlodipine tabs MO tiadylt er cp24 120mg 180mg 240mg 300mg 360mg 420mg MO
trandolapril-verapamil hcl er tbcr MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
VERAPAMIL HCL ER CP24 100mg 120mg 180mg 200mg 240mg 300mg 360mg
MO
verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 80mg 120mg MO verapamil hcl tabs MO VERELAN CP24 MO CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln inj DIGOXIN ORAL SOLN MO digoxin tabs 125mcg 250mcg MO disopyramide phosphate caps 100mg 150mg MO
dofetilide caps 125mcg 250mcg 500mcg MO
flecainide acetate tabs 50mg 100mg 150mg MO
ibutilide fumarate soln LANOXIN PEDIATRIC SOLN LANOXIN TABS 625mcg MO lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy LIDOCAINE IN D5W SOLN mexiletine hcl caps 150mg 200mg 250mg MO
milrinone lactate in dextrose soln milrinone lactate soln MULTAQ TABS NORPACE CR CP12 100mg 150mg MO
pacerone tabs 100mg 200mg 400mg MO
procainamide hcl soln
Drug Name RequirementsLimits
propafenone hcl er cp12 225mg 325mg 425mg MO
propafenone hcl tabs 150mg 225mg 300mg MO
quinidine gluconate er tbcr MO QUINIDINE GLUCONATE SOLN quinidine sulfate tabs 200mg 300mg MO
ranolazine er tb12 500mg 1000mg MO
VYNDAMAX CAPS NDS VYNDAQEL CAPS NDS HYPOTENSIVE AGENTS clonidine hcl (analgesia) soln clonidine hcl er tb12 MO clonidine hcl tabs 01mg 02mg 03mg MO
clonidine ptwk 01mg24hr 02mg24hr 03mg24hr MO
guanfacine hcl tabs 1mg 2mg MO hydralazine hcl soln hydralazine hcl tabs 10mg 25mg 50mg 100mg MO
methyldopa tabs 250mg 500mg MO methyldopa-hydrochlorothiazide tabs MO
minoxidil tabs 25mg 10mg MO nitropress soln nitroprusside sodium soln vecamyl tabs NDS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE TABS MO aliskiren fumarate tabs 150mg 300mg MO
benazepril hcl tabs 5mg 10mg 20mg 40mg MO
benazepril-hydrochlorothiazide tabs MO
candesartan cilexetil tabs 4mg 8mg 16mg 32mg MO
candesartan cilexetil-hctz tabs MO captopril tabs 125mg 25mg 50mg 100mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 26 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
captopril-hydrochlorothiazide tabs MO
CAROSPIR SUSP MO EDARBYCLOR TABS MO enalapril maleate tabs 25mg 5mg 10mg 20mg MO
enalapril-hydrochlorothiazide tabs MO
enalaprilat inj ENTRESTO TABS MO eplerenone tabs 25mg 50mg MO eprosartan mesylate tabs MO fosinopril sodium tabs 10mg 20mg 40mg MO
fosinopril sodium-hctz tabs MO irbesartan tabs 75mg 150mg 300mg MO
irbesartan-hydrochlorothiazide tabs MO
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg MO
lisinopril-hydrochlorothiazide tabs MO
losartan potassium tabs 25mg 50mg 100mg MO
losartan potassium-hctz tabs MO moexipril hcl tabs 75mg 15mg MO olmesartan medoxomil tabs 5mg 20mg 40mg MO
olmesartan medoxomil-hctz tabs MO perindopril erbumine tabs 2mg 4mg 8mg MO
QBRELIS SOLN MO quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO TEKTURNA HCT TABS MO
Drug Name RequirementsLimits
telmisartan tabs 20mg 40mg 80mg MO
telmisartan-hctz tabs MO trandolapril tabs 1mg 2mg 4mg MO valsartan tabs 40mg 80mg 160mg 320mg MO
valsartan-hydrochlorothiazide tabs MO
VASODILATING AGENTS alyq tabs PA BIDIL TABS MO dipyridamole tabs 25mg 50mg 75mg MO
GONITRO PACK MO isosorbide dinitrate er tbcr MO isosorbide dinitrate tabs 5mg 10mg 20mg 30mg MO
isosorbide mononitrate er tb24 30mg 60mg MO
isosorbide mononitrate er tb24 MO isosorbide mononitrate tabs 10mg 20mg MO
minitran pt24 01mghr 02mghr 04mghr 06mghr MO
nitro-bid oint MO NITRO-DUR PT24 03mghr 08mghr MO
nitroglycerin pt24 01mghr 02mghr 04mghr 06mghr MO
nitroglycerin soln MO nitroglycerin subl 03mg 04mg 06mg MO
sildenafil citrate soln PANDS sildenafil citrate susr PA sildenafil citrate tabs PAMO tadalafil (pah) tabs 20mg PA tadalafil tabs 25mg 5mg PA CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS acamprosate calcium tbec MO antabuse tabs 250mg 500mg MO disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
ABSTRAL SUBL 100mcg 200mcg 300mcg 400mcg 600mcg 800mcg
PANDS
acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ARYMO ER TBEA NDS ascomp-codeine caps NDS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
benzhydrocodone-acetaminophen tabs
bupap tabs buprenorphine hcl soln NDS buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
butalbital-acetaminophen caps NDS butalbital-acetaminophen tabs butalbital-apap-caff-cod caps NDS butalbital-apap-caffeine caps butalbital-apap-caffeine tabs butalbital-asa-caff-codeine caps NDS butalbital-aspirin-caffeine caps butalbital-aspirin-caffeine tabs butorphanol tartrate soln 1mgml 2mgml 10mgml NDS
BUTRANS PTWK NDS cataflam tabs NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
DEMEROL SOLN 25mg05ml 75mg15ml 100mg2ml 75mgml
PANDS
diclofenac potassium tabs diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs
Drug Name RequirementsLimits
DUEXIS TABS NDS DURAMORPH SOLN 05mgml 1mgml HINDS
dvorah tabs NDS EMBEDA CPCR NDS endocet tabs NDS esgic caps esgic tabs etodolac caps etodolac er tb24 etodolac tabs fenoprofen calcium caps fenoprofen calcium tabs fenortho caps fentanyl citrate (pf) soct NDS FENTANYL CITRATE (PF) SOLN 50mcgml 1000mcg20ml 2500mcg50ml
NDS
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fioricet caps fioricetcodeine caps NDS flurbiprofen tabs hydrocodone bitartrate er cp12 10mg 15mg 20mg 30mg 40mg 50mg
NDS
hydrocodone-acetaminophen soln NDS
hydrocodone-acetaminophen tabs NDS
hydrocodone-ibuprofen tabs NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 28 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd NDS hydromorphone hcl pf soln 50mg5ml 10mgml NDS
HYDROMORPHONE HCL SOLN 1mgml 2mgml NDS
hydromorphone hcl tabs 2mg 4mg 8mg NDS
ibu tabs ibudone tabs NDS ibuprofen lysine soln ibuprofen susp ibuprofen tabs ILARIS SOLN NDS indocin supp INDOCIN SUSP indomethacin caps INDOMETHACIN CAPS 20mg indomethacin er cpcr indomethacin sodium solr KADIAN CP24 NDS ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 300mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lodine tabs lorcet hd tabs NDS lorcet plus tabs NDS lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam caps meloxicam tabs meperidine hcl soln 50mg5ml 25mgml 50mgml 100mgml PANDS
meperidine hcl tabs 50mg 100mg NDS
Drug Name RequirementsLimits
methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl soln 5mg5ml 10mg5ml 10mgml NDS
methadone hcl tabs 5mg 10mg NDS mitigo soln MORPHINE SULFATE (CONCENTRATE) SOLN NDS
morphine sulfate (pf) soln 4mgml 10mgml NDS
MORPHINE SULFATE (PF) SOLN INTRAVENOUS HI
morphine sulfate er beads cp24 30mg 45mg 60mg 75mg 90mg 120mg
NDS
morphine sulfate er cp24 10mg 20mg 30mg 40mg 50mg 60mg 80mg 100mg
NDS
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg NDS
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml NDS
MORPHINE SULFATE SOLN HINDS MORPHINE SULFATE SOLN INJECTION 2mgml 4mgml 10mgml
HI
MORPHINE SULFATE SOLN INTRAVENOUS HI
morphine sulfate tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln nalfon tabs nalocet tabs NDS NAPRELAN TB24 naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
NUCYNTA ER TB12 50mg 100mg 150mg NDS
NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS 50mg 75mg NDS NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs oxaprozin tabs OXAYDO TABS NDS oxycodone hcl caps NDS oxycodone hcl conc NDS oxycodone hcl er t12a 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxycodone hcl soln NDS oxycodone hcl tabs 5mg 10mg 15mg 20mg 30mg NDS
oxycodone-acetaminophen soln NDS oxycodone-acetaminophen tabs NDS oxycodone-acetaminophen tabs 5-300mg 10-300mg NDS
oxycodone-aspirin tabs NDS oxycodone-ibuprofen tabs NDS OXYCONTIN T12A 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxymorphone hcl er tb12 5mg 75mg 10mg 15mg 20mg 30mg 40mg
NDS
oxymorphone hcl tabs 5mg 10mg NDS
panlor tabs NDS pentazocine-naloxone hcl tabs NDS percocet tabs NDS phrenilin forte caps PIROXICAM CAPS 10mg 20mg NDS pregabalin er tb24 825mg 165mg 330mg MO
primlev tabs NDS prolate soln NDS prolate tabs NDS QDOLO SOLN NDS
Drug Name RequirementsLimits
relafen ds tabs NDS ROXYBOND TABA 5mg 15mg 30mg NDS
SALSALATE TABS SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
SUBSYS LIQD 100mcg 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
sulindac tabs tencon tabs TIVORBEX CAPS tolmetin sodium caps tolmetin sodium tabs tramadol hcl er (biphasic) tb24 100mg 200mg 300mg NDS
tramadol hcl er cp24 100mg 150mg 200mg 300mg NDS
tramadol hcl er tb24 100mg 200mg 300mg NDS
tramadol hcl tabs 50mg 100mg NDS tramadol-acetaminophen tabs NDS trezix caps NDS tylenol with codeine 3 tabs NDS tylenol with codeine 4 tabs NDS vanatol lq soln vicodin es tabs NDS vicodin hp tabs NDS vicodin tabs NDS XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg NDS
zebutal caps ZIPSOR CAPS ZORVOLEX CAPS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS ADDERALL XR CP24 NDS ADZENYS ER SUER NDS ADZENYS XR-ODT TBED 31mg 63mg 94mg 125mg 157mg 188mg
NDS
amphetamine er suer NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 30 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
amphetamine sulfate tabs 5mg 10mg NDS
amphetamine-dextroamphet er cp24 NDS
amphetamine-dextroamphetamine tabs NDS
armodafinil tabs 50mg 150mg 200mg 250mg PA
caffeine citrate soln COTEMPLA XR-ODT TBED 86mg 173mg 259mg NDS
DAYTRANA PTCH 10mg9hr 15mg9hr 20mg9hr 30mg9hr NDS
dexmethylphenidate hcl er cp24 5mg 10mg 15mg 20mg 25mg 30mg 35mg 40mg
NDS
dexmethylphenidate hcl tabs 25mg 5mg 10mg NDS
dextroamphetamine sulfate er cp24 5mg 10mg 15mg NDS
dextroamphetamine sulfate soln NDS dextroamphetamine sulfate tabs 5mg 10mg 15mg 20mg 30mg NDS
DYANAVEL XR SUER NDS evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS methylphenidate hcl chew 25mg 5mg 10mg NDS
methylphenidate hcl er (cd) cpcr 10mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er (la) cp24 10mg 20mg 30mg 40mg 60mg
NDS
methylphenidate hcl er (xr) cp24 10mg 15mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg NDS
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg
NDS
methylphenidate hcl soln 5mg5ml 10mg5ml NDS
Drug Name RequirementsLimits
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS MYDAYIS CP24 NDS procentra soln NDS QUILLICHEW ER CHER 20mg 30mg 40mg NDS
QUILLIVANT XR SRER NDS relexxii tbcr NDS SUNOSI TABS 75mg 150mg NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
NDS
VYVANSE CHEW 10mg 20mg 30mg 40mg 50mg 60mg NDS
WAKIX TABS 445mg 178mg NDS zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg
NDS
ANTICONVULSANTS APTIOM TABS 200mg 400mg 600mg 800mg MO
BANZEL SUSP BANZEL TABS 200mg 400mg NDS BRIVIACT SOLN NDS BRIVIACT TABS 10mg 25mg 50mg 75mg 100mg NDS
carbamazepine chew MO carbamazepine er cp12 100mg 200mg 300mg MO
carbamazepine er tb12 100mg 200mg 400mg MO
carbamazepine susp MO carbamazepine tabs MO CELONTIN CAPS MO clobazam susp MO clobazam tabs 10mg 20mg MO clonazepam tabs 05mg 1mg 2mg NDS
clonazepam tbdp 0125mg 025mg 05mg 1mg 2mg NDS
DIACOMIT CAPS 250mg 500mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
DIACOMIT PACK 250mg 500mg NDS
DIASTAT ACUDIAL GEL 10mg 20mg NDS
DIASTAT PEDIATRIC GEL NDS diazepam gel 25mg 10mg 20mg NDS
dilantin caps 30mg 100mg MO dilantin infatabs chew MO divalproex sodium csdr MO divalproex sodium er tb24 250mg 500mg MO
divalproex sodium tbec 125mg 250mg 500mg MO
ELEPSIA XR TB24 1000mg 1500mg NDS
EPIDIOLEX SOLN PANDS epitol tabs MO ethosuximide caps MO ethosuximide soln MO felbamate susp MO felbamate tabs 400mg 600mg MO FINTEPLA SOLN NDS fosphenytoin sodium soln FYCOMPA SUSP NDS FYCOMPA TABS gabapentin caps 100mg 400mg MO gabapentin soln MO gabapentin tabs 600mg 800mg MO HORIZANT TBCR 300mg 600mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
lamotrigine kit MO lamotrigine starter kit-blue kit MO lamotrigine starter kit-green kit MO lamotrigine starter kit-orange kit MO lamotrigine tabs 25mg 100mg 150mg 200mg MO
lamotrigine tbdp 25mg 50mg 100mg 200mg MO
Drug Name RequirementsLimits
levetiracetam er tb24 500mg 750mg MO
levetiracetam in nacl soln levetiracetam soln MO levetiracetam tabs 250mg 500mg 750mg 1000mg MO
magnesium sulfate soln magnesium sulfate soln injection 50 HI
MAGNESIUM SULFATE SOLN INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml
HI
NAYZILAM SOLN NDS oxcarbazepine susp MO oxcarbazepine tabs 150mg 300mg 600mg MO
OXTELLAR XR TB24 150mg 300mg 600mg MO
PEGANONE TABS MO phenytek caps 200mg 300mg MO phenytoin chew MO phenytoin sodium extended caps 100mg 200mg 300mg MO
phenytoin sodium soln phenytoin susp MO pregabalin caps 25mg 50mg 75mg 100mg 150mg 200mg 225mg 300mg
MO
pregabalin soln MO primidone tabs 50mg 250mg MO roweepra tabs 500mg 750mg 1000mg MO
roweepra xr tb24 500mg 750mg MO rufinamide susp rufinamide tabs 200mg 400mg NDS SPRITAM TB3D 250mg 500mg 750mg 1000mg NDS
subvenite starter kit-blue kit MO subvenite starter kit-green kit MO subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 32 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
SYMPAZAN FILM 10mg 20mg tiagabine hcl tabs 2mg 4mg 12mg 16mg MO
topiramate cpsp 15mg 25mg MO topiramate er cs24 25mg 50mg 100mg 150mg 200mg MO
topiramate tabs 25mg 50mg 100mg 200mg MO
TROKENDI XR CP24 25mg 50mg 100mg 200mg MO
valproate sodium soln valproic acid caps MO valproic acid soln MO VALTOCO 10 MG DOSE LIQD NDS VALTOCO 15 MG DOSE LQPK NDS VALTOCO 20 MG DOSE LQPK NDS VALTOCO 5 MG DOSE LIQD NDS vigabatrin pack LDNDS vigabatrin tabs NDS vigadrone pack LDNDS VIMPAT SOLN VIMPAT TABS MO XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200 MG NDS XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ AJOVY SOSY almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs EMGALITY (300 MG DOSE) SOSY NDS
Drug Name RequirementsLimits
EMGALITY SOAJ EMGALITY SOSY ergotamine-caffeine tabs frovatriptan succinate tabs naratriptan hcl tabs NURTEC TBDP NDS ONZETRA XSAIL EXHP rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs TOSYMRA SOLN UBRELVY TABS 50mg 100mg NDS ZEMBRACE SYMTOUCH SOAJ zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ZOMIG SOLN ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl syrp MO amantadine hcl tabs MO APOKYN SOCT NDS benztropine mesylate soln benztropine mesylate tabs 05mg 1mg 2mg MO
bromocriptine mesylate caps MO bromocriptine mesylate tabs MO cabergoline tabs MO carbidopa tabs MO carbidopa-levodopa er tbcr MO carbidopa-levodopa tabs MO carbidopa-levodopa tbdp MO carbidopa-levodopa-entacapone tabs MO
DUOPA SUSP LD EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg NDS
pramipexole dihydrochloride er tb24 0375mg 075mg 15mg 225mg 3mg 375mg 45mg
MO
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg
MO
rasagiline mesylate tabs 05mg 1mg MO
ropinirole hcl er tb24 2mg 4mg 6mg 8mg 12mg MO
ropinirole hcl tabs 025mg 05mg 1mg 2mg 3mg 4mg 5mg
MO
RYTARY CPCR MO selegiline hcl caps MO selegiline hcl tabs MO tolcapone tabs MO trihexyphenidyl hcl soln MO trihexyphenidyl hcl tabs 2mg 5mg MO
ZELAPAR TBDP MO ANXIOLYTICS SEDATIVES AND HYPNOTICS alprazolam er tb24 05mg 1mg 2mg 3mg NDS
alprazolam intensol conc NDS alprazolam tabs 025mg 05mg 1mg 2mg NDS
alprazolam tbdp 025mg 05mg 1mg 2mg NDS
BELSOMRA TABS buspirone hcl tabs 5mg 10mg buspirone hcl tabs 75mg 15mg 30mg
chlordiazepoxide hcl caps 5mg 10mg 25mg NDS
clorazepate dipotassium tabs 375mg 75mg 15mg NDS
diazepam conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS
Drug Name RequirementsLimits
droperidol soln EDLUAR SUBL 5mg 10mg NDS estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP NDS hydroxyzine hcl soln hydroxyzine hcl syrp hydroxyzine hcl tabs hydroxyzine pamoate caps lorazepam intensol conc NDS LORAZEPAM SOLN 4mgml 2mgml NDS
lorazepam tabs 05mg 1mg 2mg NDS
meprobamate tabs midazolam hcl (pf) soln midazolam hcl soln midazolam hcl syrp nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs ROZEREM TABS seconal caps TEMAZEPAM CAPS 15mg 225mg 30mg 75mg NDS
triazolam tabs 0125mg 025mg NDS zaleplon caps 5mg 10mg NDS zolpidem tartrate er tbcr 625mg 125mg NDS
zolpidem tartrate subl 175mg 35mg NDS
zolpidem tartrate tabs 5mg 10mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 34 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS atomoxetine hcl caps 10mg 18mg 25mg 40mg 60mg 80mg 100mg
MO
AUSTEDO TABS 6mg 9mg 12mg LDNDS
EXSERVAN FILM NDS flumazenil soln guanfacine hcl er tb24 1mg 2mg 3mg 4mg MO
INGREZZA CAPS 40mg 60mg 80mg NDS
INGREZZA CPPK NDS memantine hcl er cp24 memantine hcl soln MO memantine hcl tabs 5mg 10mg MO NAMENDA XR TITRATION PACK CP24 MO
NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS SAVELLA TABS 125mg 25mg 50mg 100mg MO
SAVELLA TITRATION PACK MISC MO
tetrabenazine tabs 125mg 25mg NDS
TIGLUTIK SUSP NDS XYREM SOLN LDNDS XYWAV SOLN NDS MULTIPLE SCLEROSIS AGENTS AUBAGIO TABS 7mg 14mg PANDS AVONEX KIT NDS AVONEX PEN AJKT NDS AVONEX PREFILLED PSKT NDS BAFIERTAM CPDR NDS BETASERON KIT NDS dalfampridine er tb12 MO dimethyl fumarate cpdr dimethyl fumarate starter pack misc
Drug Name RequirementsLimits
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatiramer acetate sosy 20mgml 40mgml NDS
glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 2mg NDS OCREVUS SOLN PLEGRIDY SOSY NDS PONVORY STARTER PACK TBPK NDS
PONVORY TABS NDS REBIF REBIDOSE SOAJ 22mcg05ml 44mcg05ml NDS
REBIF REBIDOSE TITRATION PACK SOAJ NDS
REBIF SOSY 22mcg05ml 44mcg05ml NDS
REBIF TITRATION PACK SOSY NDS TECFIDERA CPDR 120mg 240mg NDS
TECFIDERA MISC NDS TYSABRI CONC INTRAVENOUS HI
ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS ZINBRYTA SOSY LDNDS OPIATE ANTAGONISTS BUNAVAIL FILM NDS buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
LUCEMYRA TABS NDS naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR NDS ZUBSOLV SUBL NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg NDS
ABILIFY MYCITE MAINTENANCE KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg NDS
amitriptyline hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
amoxapine tabs 25mg 50mg 100mg 150mg MO
APLENZIN TB24 174mg 348mg 522mg MO
aripiprazole soln MO aripiprazole tabs 2mg 5mg 10mg 15mg 20mg 30mg MO
aripiprazole tbdp 10mg 15mg MO ARISTADA INITIO PRSY NDS ARISTADA PRSY 441mg16ml 662mg24ml 882mg32ml 1064mg39ml
NDS
asenapine maleate subl 25mg 5mg 10mg MO
bupropion hcl er (smoking det) tb12 MO
bupropion hcl er (sr) tb12 100mg 150mg 200mg MO
bupropion hcl er (xl) tb24 150mg 300mg 450mg MO
bupropion hcl tabs 75mg 100mg MO CAPLYTA CAPS NDS chlordiazepoxide-amitriptyline tabs
chlorpromazine hcl soln
Drug Name RequirementsLimits
chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
clomipramine hcl caps 25mg 50mg 75mg MO
clozapine tabs 25mg 50mg 100mg 200mg NDS
clozapine tbdp 125mg 25mg 100mg 150mg 200mg NDS
compro supp MO desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
DESVENLAFAXINE ER TB24 50mg 100mg MO
desvenlafaxine succinate er tb24 25mg 50mg 100mg MO
doxepin hcl caps 10mg 25mg 50mg 75mg 100mg 150mg MO
doxepin hcl conc MO doxepin hcl tabs 3mg 6mg MO DRIZALMA SPRINKLE CSDR duloxetine hcl cpep 20mg 30mg 40mg 60mg MO
EQUETRO CP12 100mg 200mg 300mg MO
escitalopram oxalate soln MO escitalopram oxalate tabs 5mg 10mg 20mg MO
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg NDS
FANAPT TITRATION PACK TABS MO
FETZIMA CP24 20mg 40mg 80mg 120mg MO
FETZIMA TITRATION C4PK MO fluoxetine hcl (pmdd) tabs 10mg 20mg MO
fluoxetine hcl caps 10mg 20mg 40mg MO
fluoxetine hcl cpdr MO fluoxetine hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 36 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
GEODON SOLR haloperidol decanoate soln haloperidol lactate conc MO haloperidol lactate soln haloperidol tabs 05mg 1mg 2mg 5mg 10mg 20mg MO
imipramine hcl tabs 10mg 25mg 50mg MO
imipramine pamoate caps 75mg 100mg 125mg 150mg MO
INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 300mg 150mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
lithium carbonate tabs MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO
Drug Name RequirementsLimits
mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
nefazodone hcl tabs 50mg 100mg 150mg 200mg 250mg MO
nortriptyline hcl caps 10mg 25mg 50mg 75mg MO
nortriptyline hcl soln MO NUPLAZID CAPS NDS NUPLAZID TABS 10mg 17mg NDS olanzapine solr olanzapine tabs 25mg 5mg 75mg 10mg 15mg 20mg MO
olanzapine tbdp 5mg 10mg 15mg 20mg MO
olanzapine-fluoxetine hcl caps MO PALIPERIDONE ER TB24 15mg 3mg 6mg 9mg MO
paroxetine hcl er tb24 125mg 25mg 375mg MO
paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps MO PAXIL SUSP MO perphenazine tabs 2mg 4mg 8mg 16mg MO
perphenazine-amitriptyline tabs MO PERSERIS PRSY 90mg 120mg NDS PEXEVA TABS 10mg 20mg 30mg 40mg MO
phenelzine sulfate tabs MO pimozide tabs 1mg 2mg MO prochlorperazine edisylate soln prochlorperazine maleate tabs prochlorperazine supp MO protriptyline hcl tabs 5mg 10mg MO quetiapine fumarate er tb24 50mg 150mg 200mg 300mg 400mg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
quetiapine fumarate tabs 25mg 50mg 100mg 200mg 300mg 400mg
MO
REXULTI TABS 025mg 05mg 1mg 2mg 3mg 4mg NDS
RISPERDAL CONSTA SRER 125mg 25mg NDS
RISPERDAL CONSTA SRER 375mg 50mg NDS
risperidone soln MO risperidone tabs 025mg 05mg 1mg 2mg 3mg 4mg MO
risperidone tbdp 025mg 05mg 1mg 2mg 3mg 4mg MO
SAPHRIS SUBL 25mg 5mg 10mg NDS
SECUADO PT24 38mg24hr 57mg24hr 76mg24hr NDS
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
SILENOR TABS SPRAVATO (56 MG DOSE) SOPK NDS
SPRAVATO (84 MG DOSE) SOPK NDS
thioridazine hcl tabs 10mg 25mg 50mg 100mg MO
thiothixene caps 1mg 2mg 5mg 10mg MO
tofranil tabs 10mg 25mg 50mg MO tranylcypromine sulfate tabs MO trazodone hcl tabs 50mg 100mg 150mg MO
trazodone hcl tabs MO trifluoperazine hcl tabs 1mg 2mg 5mg 10mg MO
trimipramine maleate caps 25mg 50mg 100mg MO
TRINTELLIX TABS 5mg 10mg 20mg MO
venlafaxine hcl er cp24 375mg 75mg 150mg MO
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg MO
Drug Name RequirementsLimits
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
VRAYLAR CAPS 15mg 3mg 45mg 6mg NDS
VRAYLAR CPPK NDS ziprasidone hcl caps 20mg 40mg 60mg 80mg MO
ziprasidone mesylate solr ZYPREXA RELPREVV SUSR DIABETIC SUPPLIES DIABETIC SUPPLIES ALCOHOL PREP PADS MO BD INSULIN SYR ULTRAFINE II MISC MO
BD INSULIN SYRINGE MISC MO BD INSULIN SYRINGE UF MISC MO
BD PEN NEEDLE ORIGINAL UF MISC MO
CURITY GAUZE PADS MO OMNIPOD STARTER KIT NDS ELECTROLYTIC CALORIC AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS POT amp SOD CIT-CIT AC SOLN potassium citrate er tbcr 15meq 540mg 1080mg MO
SODIUM ACETATE SOLN SODIUM BICARBONATE SOLN SODIUM LACTATE SOLN INTRAVENOUS HI
TRICITRATES SOLN AMMONIA DETOXICANTS CARBAGLU TABS LD constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 38 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lactulose pack MO lactulose soln MO LITHOSTAT TABS MO RAVICTI LIQD NDS sod benz-sod phenylacet soln sodium phenylbutyrate powd NDS sodium phenylbutyrate tabs NDS CALORIC AGENTS AMINOSYN-PF SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (27510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42525) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (525) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (525) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN dextrose soln intravenous 5 10 HI
Drug Name RequirementsLimits
FREAMINE HBC SOLN INTRAVENOUS HI
HEPATAMINE SOLN INTRAVENOUS HI
INTRALIPID EMUL INTRAVENOUS 20gm100ml HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NEPHRAMINE SOLN INTRAVENOUS HI
NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE SOLN INTRAVENOUS HI
PROSOL SOLN INTRAVENOUS HI TRAVASOL SOLN INTRAVENOUS HI
TROPHAMINE SOLN INTRAVENOUS HI
DIURETICS AMILORIDE HCL TABS MO amiloride-hydrochlorothiazide tabs MO
bumetanide soln bumetanide tabs 05mg 1mg 2mg MO
chlorothiazide sodium solr chlorothiazide tabs 250mg 500mg MO
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI FUROSEMIDE TABS 40mg 80mg 20mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN SAMSCA TABS 15mg NDS TOLVAPTAN TABS 30mg 15mg NDS torsemide tabs 5mg 10mg 20mg 100mg MO
triamterene caps 50mg 100mg MO triamterene-hctz caps MO triamterene-hctz tabs MO ION-REMOVING AGENTS AURYXIA TABS PAMONDS FOSRENOL PACK 750mg 1000mg NDS
kionex susp MO lanthanum carbonate chew 500mg 750mg 1000mg MO
LOKELMA PACK 5gm 10gm MO sevelamer carbonate pack 08gm 24gm MO
sevelamer carbonate tabs MO sevelamer hcl tabs 400mg 800mg MO
sodium polystyrene sulfonate powd MO
sodium polystyrene sulfonate susp MO
sps susp MO VELPHORO CHEW NDS VELTASSA PACK 84gm 168gm 252gm NDS
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate (phos binder) tabs MO
CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
Drug Name RequirementsLimits
DEXTROSE-NACL SOLN INTRAVENOUS HI
DEXTROSE 10NACL 02 DEXTROSE 10NACL 045 HI
DEXTROSE 5NACL 0225 HI IONOSOL-MB IN D5W SOLN INTRAVENOUS HI
ISOLYTE-P IN D5W SOLN INTRAVENOUS HI
ISOLYTE-S SOLN INTRAVENOUS HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-033 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 TBCR MO klor-con m10 tbcr MO klor-con m15 tbcr MO klor-con m20 tbcr MO klor-con pack MO klor-con sprinkle cpcr 8meq 10meq MO
KLOR-CON TBCR MO LACTATED RINGERS SOLN magnesium sulfate in d5w soln NORMOSOL-M IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R SOLN INTRAVENOUS HI
PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 40 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
POTASSIUM CHLORIDE ER TBCR 8meq 10meq 20meq MO
POTASSIUM CHLORIDE IN DEXTROSE SOLN INTRAVENOUS
HI
potassium chloride in nacl soln intravenous HI
potassium chloride pack MO potassium chloride soln 10 20 MO
POTASSIUM CHLORIDE SOLN INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN SODIUM CHLORIDE SOLN INJECTION HI
SODIUM CHLORIDE SOLN INTRAVENOUS 045 09 3 5
HI
SODIUM PHOSPHATES SOLN TPN ELECTROLYTES CONC INTRAVENOUS HI
URICOSURIC AGENTS colchicine-probenecid tabs MO probenecid tabs MO ENZYMES ENZYMES ADAGEN SOLN ALDURAZYME SOLN CERDELGA CAPS NDS CEREZYME SOLR NDS CREON CPEP MO ELAPRASE SOLN NDS
Drug Name RequirementsLimits
ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME SOLR NDS miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PANCREAZE CPEP MO PERTZYE CPEP MO PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VIOKACE TABS MO VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE SOLN bacitracin oint bacitracin-polymyxin b oint BESIVANCE SUSP bleph-10 soln CETRAXAL SOLN chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
CIPROFLOXACIN-FLUOCINOLONE PF SOLN
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
MOXEZA SOLN moxifloxacin hcl (2x day) soln moxifloxacin hcl soln NATACYN SUSP neo-polycin oint neomycin-bacitracin zn-polymyx oint
neomycin-polymyxin-gramicidin soln
ofloxacin soln OTOVEL SOLN paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ZIRGAN GEL ANTI-INFLAMMATORY AGENTS ACUVAIL SOLN MO ALREX SUSP MO bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
BROMSITE SOLN MO CEQUA SOLN CIPRO HC SUSP MO CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO DUREZOL EMUL MO flac oil MO
Drug Name RequirementsLimits
FLAREX SUSP MO flunisolide soln MO fluocinolone acetonide oil MO fluorometholone susp MO flurbiprofen sodium soln MO fluticasone propionate susp MO FML FORTE SUSP MO FML OINT MO HYDROCORTISONE-ACETIC ACID SOLN MO
ILEVRO SUSP MO ILUVIEN IMPL INVELTYS SUSP MO ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX OINT MO LOTEMAX SUSP MO loteprednol etabonate susp MO MAXIDEX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint MO
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO NEVANAC SUSP MO OMNARIS SUSP MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
PROLENSA SOLN MO RESTASIS EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 42 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tobramycin-dexamethasone susp MO
XHANCE EXHU MO XIIDRA SOLN YUTIQ IMPL ZETONNA AERS MO ZYLET SUSP MO ANTIALLERGIC AGENTS ALOCRIL SOLN MO ALOMIDE SOLN MO azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO LASTACAFT SOLN MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
ALPHAGAN P SOLN MO betaxolol hcl soln MO BETIMOL SOLN 025 05 MO BETOPTIC-S SUSP MO bimatoprost soln MO BRIMONIDINE TARTRATE SOLN 02 015 MO
brinzolamide susp MO carteolol hcl soln MO COMBIGAN SOLN MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO
Drug Name RequirementsLimits
methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO SIMBRINZA SUSP MO timolol maleate pf soln MO timolol maleate solg 025 05 MO
timolol maleate soln 025 05 MO
TIMOPTIC OCUDOSE SOLN 25 MO
TIMOPTIC-XE SOLG 025 05 MO
TRAVATAN Z SOLN MO travoprost (bak free) soln MO VYZULTA SOLN MO XELPROS EMUL MO ZIOPTAN SOLN MO EENT DRUGS MISCELLANEOUS ACETIC ACID SOLN MO ALTAFRIN SOLN apraclonidine hcl soln MO ATROPINE SULFATE SOLN MO BEOVU SOLN NDS CYSTADROPS SOLN NDS CYSTARAN SOLN EYLEA SOLN EYLEA SOSY IOPIDINE SOLN MO LACRISERT INST MO LUCENTIS SOLN 03mg005ml 05mg005ml NDS
LUCENTIS SOSY 03mg005ml 05mg005ml NDS
OXERVATE SOLN NDS PHENYLEPHRINE HCL SOLN RHOPRESSA SOLN TEPEZZA SOLR NDS LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl soln lidocaine viscous hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
APRISO CP24 MO balsalazide disodium caps MO colazal caps MO DELZICOL CPDR MO DIPENTUM CAPS NDS LIALDA TBEC MO mesalamine cpdr MO mesalamine enem MO mesalamine er cp24 MO mesalamine supp MO mesalamine tbec 12gm 800mg MO mesalamine-cleanser kit PENTASA CPCR 250mg 500mg MO
ANTIDIARRHEA AGENTS diphenoxylate-atropine liqd diphenoxylate-atropine tabs loperamide hcl caps MO MYTESI TBEC MO OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS AKYNZEO CAPS PA ANZEMET TABS 50mg 100mg PANDS aprepitant caps PANDS BONJESTA TBCR MO CESAMET CAPS PA dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
EMEND SUSR PANDS fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs
Drug Name RequirementsLimits
ondansetron hcl soln PA ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS TRANSDERM SCOP (15 MG) PT72
trimethobenzamide hcl caps PA VARUBI (180 MG DOSE) TBPK PANDS ZUPLENZ FILM 4mg 8mg PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc MO
CARAFATE SUSP MO cimetidine hcl soln MO cimetidine tabs 200mg 300mg 400mg 800mg MO
esomeprazole magnesium cpdr 20mg 40mg MO
esomeprazole magnesium pack 10mg 20mg 40mg MO
esomeprazole sodium solr ESOMEPRAZOLE STRONTIUM CPDR
famotidine premixed soln famotidine soln famotidine susr MO famotidine tabs 20mg 40mg MO lansoprazole cpdr 15mg 30mg MO lansoprazole tbdd 15mg 30mg MO misoprostol tabs 100mcg 200mcg MO
nizatidine caps 150mg 300mg MO nizatidine soln MO OMECLAMOX-PAK MISC MO omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 44 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PRILOSEC PACK 25mg 10mg MO PROTONIX PACK MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate tabs MO CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO GOLYTELY SOLR OSMOPREP TABS MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT PLENVU SOLR MO SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS AMITIZA CAPS 8mcg 24mcg MO BYLVAY (PELLETS) CPSP 200mcg 600mcg NDS
BYLVAY CAPS 400mcg 1200mcg NDS
CHOLBAM CAPS 50mg 250mg NDS ENTYVIO SOLR NDS GATTEX KIT PANDS GIMOTI SOLN NDS LINZESS CAPS 72mcg 145mcg 290mcg MO
lubiprostone caps 8mcg 24mcg MO
Drug Name RequirementsLimits
metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
MOVANTIK TABS 125mg 25mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS SYMPROIC TABS MO TRULANCE TABS MO ursodiol caps 300mg MO URSODIOL CAPS 200mg 400mg NDS
ursodiol tabs 250mg 500mg MO VIBERZI TABS 75mg 100mg NDS HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPS clovique caps NDS CUPRIMINE CAPS NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs 90mg 180mg 360mg NDS
deferasirox tbso 125mg NDS deferasirox tbso 250mg 500mg NDS deferiprone tabs NDS deferoxamine mesylate solr DEPEN TITRATABS TABS EXJADE TBSO 125mg 250mg 500mg NDS
FERRIPROX SOLN LDNDS FERRIPROX TABS 500mg 1000mg LDNDS
FERRIPROX TWICE-A-DAY TABS NDS
JADENU SPRINKLE PACK 90mg 180mg 360mg NDS
JADENU TABS 90mg 360mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
penicillamine caps penicillamine tabs trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP 05mg 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs MO decadron elix MO decadron tabs 5mg 75mg MO decadron tabs 4mg 6mg PAMO deltasone tabs PAMO DEPO-MEDROL SUSP dexabliss tbpk dexamethasone elix MO dexamethasone intensol conc MO dexamethasone sod phosphate pf soln
dexamethasone sodium phosphate soln
dexamethasone soln dexamethasone tabs 05mg 075mg 1mg 15mg 2mg 4mg 6mg
PAMO
dexamethasone tbpk MO dexpak 10 day tbpk MO dexpak 13 day tbpk MO dexpak 6 day tbpk MO dxevo 11-day tbpk EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
INTRAROSA INST KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp
Drug Name RequirementsLimits
methylprednisolone sodium succ solr
methylprednisolone tabs 4mg 8mg 16mg 32mg MO
methylprednisolone tbpk MO millipred dp tbpk millipred tabs MO ORTIKOS CP24 6mg 9mg NDS prednisolone sodium phosphate soln 5mg5ml 10mg5ml 20mg5ml 25mg5ml
MO
prednisolone sodium phosphate tbdp 10mg 15mg 30mg MO
prednisolone soln MO prednisone intensol conc PAMO prednisone soln PAMO prednisone tabs 1mg 25mg 5mg 10mg 20mg 50mg PAMO
prednisone tbpk PULMICORT FLEXHALER AEPB
RAYOS TBEC 1mg 2mg 5mg PAMO SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TRELEGY ELLIPTA AEPB MO triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
AVEED SOLN MO danazol caps 50mg 100mg 200mg MO
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs 25mg MO oxandrolone tabs MONDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 46 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
STRIANT MISC MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact
MO
testosterone soln MO XYOSTED SOAJ 50mg05ml 75mg05ml 100mg05ml MO
CONTRACEPTIVES altavera tabs MO alyacen 135 tabs MO amethia lo tabs MO amethia tabs MO apri tabs MO aranelle tabs MO ashlyna tabs MO aubra eq tabs MO aviane tabs MO balziva tabs MO blisovi 24 fe tabs MO blisovi fe 1530 tabs MO briellyn tabs MO camila tabs MO camrese lo tabs MO caziant tabs MO cryselle-28 tabs MO cyclafem 135 tabs MO cyclafem 777 tabs MO cyred eq tabs MO deblitane tabs MO delyla tabs MO desogestrel-ethinyl estradiol tabs MO dolishale tabs MO drospiren-eth estrad-levomefol tabs MO
drospirenone-ethinyl estradiol tabs MO
ELLA TABS MO eluryng ring MO emoquette tabs MO
Drug Name RequirementsLimits
enpresse-28 tabs MO enskyce tabs MO errin tabs MO estarylla tabs MO ethynodiol diac-eth estradiol tabs MO etonogestrel-ethinyl estradiol ring MO
falmina tabs MO fayosim tabs MO femynor tabs MO gemmily caps MO gianvi tabs MO hailey 24 fe tabs MO iclevia tabs MO incassia tabs MO introvale tabs MO isibloom tabs MO jasmiel tabs MO JOLIVETTE TABS MO juleber tabs MO junel 1530 tabs MO junel 120 tabs MO junel fe 1530 tabs MO junel fe 120 tabs MO junel fe 24 tabs MO kaitlib fe chew MO kariva tabs MO kelnor 135 tabs MO kelnor 150 tabs MO kurvelo tabs MO larin 1530 tabs MO larin 120 tabs MO larin fe 1530 tabs MO larin fe 120 tabs MO larissia tabs MO LAYOLIS FE CHEW MO leena tabs MO lessina tabs MO levonest tabs MO levonorg-eth estrad triphasic tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
levora 01530 (28) tabs MO LO LOESTRIN FE TABS MO loestrin 1530 (21) tabs MO loestrin 120 (21) tabs MO loestrin fe 1530 tabs MO loestrin fe 120 tabs MO loryna tabs MO low-ogestrel tabs MO lutera tabs MO lyleq tabs MO lyza tabs MO marlissa tabs MO melodetta 24 fe chew MO merzee caps MO mibelas 24 fe chew MO microgestin 1530 tabs MO microgestin 120 tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA TABS MO NATAZIA TABS MO necon 0535 (28) tabs MO NECON 777 TABS MO nikki tabs MO nora-be tabs MO norethin ace-eth estrad-fe caps MO norethin ace-eth estrad-fe chew MO norethin ace-eth estrad-fe tabs MO norethin-eth estradiol-fe chew MO norethindrone acet-ethinyl est tabs MO
norethindrone tabs MO norgestim-eth estrad triphasic tabs MO
norgestimate-eth estradiol tabs MO norlyroc tabs MO
Drug Name RequirementsLimits
nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO NUVARING RING MO nylia 777 tabs MO nymyo tabs MO ocella tabs MO ogestrel tabs MO orsythia tabs MO pimtrea tabs MO pirmella 135 tabs MO portia-28 tabs MO previfem tabs MO reclipsen tabs MO rivelsa tabs MO setlakin tabs MO sharobel tabs MO sprintec 28 tabs MO sronyx tabs MO syeda tabs MO tarina 24 fe tabs MO tarina fe 120 eq tabs MO tilia fe tabs MO tri-estarylla tabs MO tri-legest fe tabs MO tri-lo-estarylla tabs MO tri-lo-sprintec tabs MO tri-mili tabs MO tri-nymyo tabs MO tri-previfem tabs MO tri-sprintec tabs MO tri-vylibra lo tabs MO tri-vylibra tabs MO TRINESSA (28) TABS MO trivora (28) tabs MO tydemy tabs MO velivet tabs MO vestura tabs MO vienva tabs MO vyfemla tabs MO vylibra tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 48 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135e (28) tabs MO DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
ADMELOG SOLN MO ADMELOG SOLOSTAR SOPN MO AFREZZA POWD MO AFREZZA POWD 8 (90) amp 12 (90) UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO APIDRA SOLN PAMO APIDRA SOLOSTAR SOPN MO AVANDIA TABS 2mg 4mg MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD BYDUREON BCISE AUIJ BYDUREON PEN BYETTA 10 MCG PEN SOPN MO BYETTA 5 MCG PEN SOPN MO CYCLOSET TABS MO diazoxide susp glimepiride tabs 1mg 2mg 4mg MO glipizide er tb24 25mg 5mg 10mg MO
glipizide tabs 5mg 10mg MO glipizide-metformin hcl tabs MO GLUCAGEN HYPOKIT SOLR glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO GLYXAMBI TABS MO
Drug Name RequirementsLimits
HUMALOG JUNIOR KWIKPEN SOPN MO
HUMALOG KWIKPEN SOPN 100unitml 200unitml MO
HUMALOG MIX 5050 KWIKPEN SUPN MO
HUMALOG MIX 5050 SUSP MO HUMALOG MIX 7525 KWIKPEN SUPN MO
HUMALOG MIX 7525 SUSP MO HUMALOG SOCT MO HUMALOG SOLN PAMO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN PAMO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
INSULIN ASP PROT amp ASP FLEXPEN SUPN MO
INSULIN ASPART FLEXPEN SOPN MO
INSULIN ASPART PENFILL SOCT MO
INSULIN ASPART PROT amp ASPART SUSP MO
INSULIN ASPART SOLN PAMO INSULIN LISPRO (1 UNIT DIAL) SOPN MO
INSULIN LISPRO SOLN MO INVOKAMET TABS MO INVOKAMET XR TB24 MO INVOKANA TABS 100mg 300mg MO
JARDIANCE TABS 10mg 25mg MO JENTADUETO TABS MO JENTADUETO XR TB24 MO KAZANO TABS MO KORLYM TABS LDNDS LANTUS SOLN MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
LANTUS SOLOSTAR SOPN MO LEVEMIR FLEXTOUCH SOPN MO LEVEMIR SOLN MO metformin hcl er tb24 500mg 750mg MO
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO NOVOLIN 7030 SUSP MO NOVOLOG 7030 FLEXPEN RELION SUPN MO
NOVOLOG FLEXPEN RELION SOPN MO
NOVOLOG FLEXPEN SOPN MO NOVOLOG MIX 7030 FLEXPEN SUPN MO
NOVOLOG MIX 7030 RELION SUSP MO
NOVOLOG MIX 7030 SUSP MO NOVOLOG PENFILL SOCT MO NOVOLOG RELION SOLN PAMO NOVOLOG SOLN PAMO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO PROGLYCEM SUSP MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SOLIQUA SOPN MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO SYNJARDY TABS MO SYNJARDY XR TB24 MO tolazamide tabs 250mg 500mg MO
Drug Name RequirementsLimits
tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO ANGELIQ TABS MO CLIMARA PRO PTWK MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
COMBIPATCH PTTW MO DELESTROGEN OIL depo-estradiol oil DIVIGEL GEL MO dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
DUAVEE TABS MO ELESTRIN GEL MO estrace crea MO estrace tabs 05mg 1mg 2mg MO estradiol crea MO estradiol pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO EVAMIST SOLN MO fyavolv tabs MO IMVEXXY MAINTENANCE PACK INST 4mcg 10mcg MO
IMVEXXY STARTER PACK INST 4mcg 10mcg MO
jinteli tabs MO lopreeza tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 50 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
MENOSTAR PTWK MO mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO ORIAHNN CPPK NDS OSPHENA TABS MO prefest tabs MO PREMARIN SOLR PREMARIN TABS 03mg 045mg 0625mg 09mg 125mg
MO
PREMPHASE TABS MO PREMPRO TABS MO raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS NOVAREL SOLR 5000unit 10000unit PA
ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS PREGNYL SOLR PA TRIPTODUR SRER NDS OXYTOCICS carboprost tromethamine soln methergine tabs methylergonovine maleate soln methylergonovine maleate tabs OXYTOCIN SOLN PARATHYROID calcitonin (salmon) soln MO cinacalcet hcl tabs 30mg 60mg 90mg PANDS
FORTEO SOPN PANDS NATPARA CART 25mcg 50mcg 75mcg 100mcg LDNDS
Drug Name RequirementsLimits
SENSIPAR TABS 30mg 60mg 90mg PANDS
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PALDNDS DDAVP RHINAL TUBE SOLN MO desmopressin ace spray refrig soln MO
desmopressin acetate soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln DESMOPRESSIN ACETATE TABS 01mg 02mg MO
NOCDURNA SUBL 277mcg 553mcg MO
NOCTIVA EMUL 083mcg01ml 166mcg01ml MO
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO CRINONE GEL 4 8 PAMO DEPO-PROVERA SUSP 400mgml
DEPO-SUBQ PROVERA 104 SUSY
ENDOMETRIN INST PA hydroxyprogesterone caproate oil
hydroxyprogesterone caproate soln
MAKENA SOAJ NDS medroxyprogesterone acetate susp
medroxyprogesterone acetate susy
medroxyprogesterone acetate tabs 25mg 5mg 10mg MO
megestrol acetate susp MO norethindrone acetate tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS BYNFEZIA PEN SOPN NDS EGRIFTA SOLR NDS EGRIFTA SV SOLR NDS GENOTROPIN MINIQUICK SOLR 02mg PANDS
GENOTROPIN MINIQUICK SOLR 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
GENOTROPIN SOLR 5mg 12mg PANDS
HUMATROPE SOLR 5mg 6mg 12mg 24mg PANDS
INCRELEX SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
NUTROPIN AQ NUSPIN 20 SOPN PANDS
NUTROPIN AQ NUSPIN 5 SOPN PANDS
octreotide acetate soln OMNITROPE SOCT 5mg15ml 10mg15ml PANDS
OMNITROPE SOLR PANDS SAIZEN CLICKEASY SOLR PANDS SAIZEN SOLR 5mg 88mg PANDS SAIZENPREP SOLR PANDS SANDOSTATIN LAR DEPOT KIT 10mg 20mg 30mg NDS
SEROSTIM SOLR 4mg 5mg 6mg PANDS
SIGNIFOR LAR SRER 10mg 20mg 30mg 40mg 60mg NDS
SIGNIFOR SOLN 03mgml 06mgml 09mgml NDS
SOMATULINE DEPOT SOLN
Drug Name RequirementsLimits
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZOMACTON SOLR 5mg PANDS ZOMACTON SOLR PANDS ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVO-T TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVOTHYROXINE SODIUM SOLR
levothyroxine sodium tabs 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
liothyronine sodium soln liothyronine sodium tabs 5mcg 25mcg 50mcg MO
methimazole tabs 5mg 10mg MO propylthiouracil tabs MO tapazole tabs 5mg 10mg MO THYROLAR-1 TABS THYROLAR-12 TABS THYROLAR-14 TABS THYROLAR-2 TABS THYROLAR-3 TABS TIROSINT CAPS 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 52 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
137mcg 150mcg 175mcg 200mcg UNITHROID TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA REDUCTASE INHIBITORS dutasteride caps MO dutasteride-tamsulosin hcl caps MO finasteride tabs MO ANTIDOTES acetylcysteine soln 10 20 PAMO fomepizole soln KHAPZORY SOLR 175mg 300mg NDS
leucovorin calcium soln leucovorin calcium solr leucovorin calcium tabs 5mg 10mg 15mg 25mg MO
levoleucovorin calcium pf soln levoleucovorin calcium solr VISTOGARD PACK NDS VORAXAZE SOLR NDS ANTIGOUT AGENTS allopurinol sodium solr allopurinol tabs 100mg 300mg MO COLCHICINE CAPS MO colchicine tabs MO febuxostat tabs 40mg 80mg MO GLOPERBA SOLN MITIGARE CAPS MO ULORIC TABS 40mg 80mg MO BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 5mg 10mg 35mg 70mg MO
alendronate sodium tabs 40mg MO BINOSTO TBEF MO EVENITY SOSY NDS FOSAMAX PLUS D TABS MO IBANDRONATE SODIUM SOLN
Drug Name RequirementsLimits
ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr PROLIA SOSY risedronate sodium tabs 5mg 30mg 35mg 150mg MO
RISEDRONATE SODIUM TBEC MO XGEVA SOLN PANDS zoledronic acid conc zoledronic acid soln DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ACTPEN SOAJ NDS ACTEMRA SOSY NDS AVSOLA SOLR NDS CIMZIA KIT PANDS CIMZIA PREFILLED KIT PANDS CIMZIA STARTER KIT KIT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS ENBREL SOSY 25mg05ml 50mgml NDS
ENBREL SURECLICK SOAJ NDS HUMIRA PEDIATRIC CROHNS START PSKT NDS
HUMIRA PEN PNKT 40mg04ml 40mg08ml 80mg08ml
NDS
HUMIRA PEN-CDUCHS STARTER PNKT 40mg08ml 80mg08ml
NDS
HUMIRA PEN-PEDIATRIC UC START PNKT NDS
HUMIRA PEN-PSUVADOL HS START PNKT NDS
HUMIRA PEN-PSORUVEIT STARTER PNKT NDS
HUMIRA PSKT 10mg01ml 10mg02ml 20mg02ml 20mg04ml 40mg04ml 40mg08ml
NDS
INFLECTRA SOLR INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
KEVZARA SOAJ 150mg114ml 200mg114ml NDS
KEVZARA SOSY 150mg114ml 200mg114ml NDS
KINERET SOSY NDS leflunomide tabs 10mg 20mg MO OLUMIANT TABS 1mg 2mg NDS ORENCIA CLICKJECT SOAJ NDS ORENCIA SOLR NDS ORENCIA SOSY 50mg04ml 875mg07ml 125mgml NDS
OTEZLA TABS PANDS OTEZLA TBPK PANDS OTREXUP SOAJ RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 NDS SIMPONI ARIA SOLN NDS SIMPONI SOAJ 50mg05ml 100mgml NDS
SIMPONI SOSY 50mg05ml 100mgml NDS
XELJANZ SOLN NDS XELJANZ TABS 5mg 10mg NDS XELJANZ XR TB24 11mg 22mg NDS IMMUNE SUPPRESSANTS ASTAGRAF XL CP24 05mg 1mg PAMO
ASTAGRAF XL CP24 PA azasan tabs 75mg 100mg PAMO azathioprine sodium solr azathioprine tabs PAMO BENLYSTA SOAJ BENLYSTA SOLR BENLYSTA SOSY cyclosporine caps 25mg 100mg PAMO cyclosporine modified caps 25mg 50mg 100mg PAMO
cyclosporine modified soln PAMO cyclosporine soln PAMO
Drug Name RequirementsLimits
ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg PA GAMIFANT SOLN 50mg10ml 100mg20ml 10mg2ml NDS
gengraf caps 25mg 50mg 100mg PAMO
gengraf soln PAMO LUPKYNIS CAPS NDS MAVENCLAD (10 TABS) TBPK NDS MAVENCLAD (4 TABS) TBPK NDS MAVENCLAD (5 TABS) TBPK NDS MAVENCLAD (6 TABS) TBPK NDS MAVENCLAD (7 TABS) TBPK NDS MAVENCLAD (8 TABS) TBPK NDS MAVENCLAD (9 TABS) TBPK NDS mycophenolate mofetil caps PAMO mycophenolate mofetil hcl solr mycophenolate mofetil susr PAMO mycophenolate mofetil tabs PAMO mycophenolate sodium tbec 180mg 360mg PAMO
NULOJIX SOLR NDS PROGRAF PACK 02mg PA PROGRAF PACK PANDS PROGRAF SOLN PAMO SANDIMMUNE ORAL SOLN 100mgml PAMO
SAPHNELO SOLN NDS sirolimus soln PA sirolimus tabs 05mg 1mg 2mg PAMO tacrolimus caps 05mg 1mg 5mg PAMO
UPLIZNA SOLN ZORTRESS TABS 025mg PAMO ZORTRESS TABS 05mg 075mg 1mg PA
MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 54 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BOTOX SOLR 100unit 200unit PA bupivacaine hcl (pf) soln bupivacaine hcl soln BUPIVACAINE IN DEXTROSE SOLN
bupivacaine spinal soln bupivacaine-epinephrine (pf) soln
bupivacaine-epinephrine soln CARNITOR SOLN PAMO CARNITOR TABS PAMO chloroprocaine hcl (pf) soln CINRYZE SOLR INTRAVENOUS HI
citanest plain dental soln COSELA SOLR NDS CRYSVITA SOLN 10mgml 20mgml 30mgml NDS
CYSTADANE POWD LDNDS CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr DYSPORT SOLR 300unit 500unit PA
EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENSPRYNG SOSY NDS EVRYSDI SOLR NDS EXONDYS 51 SOLN 500mg10ml 100mg2ml NDS
FIRDAPSE TABS NDS FLUORITAB CHEW 025mg 05mg 1mg MO
FLUORITAB SOLN MO GALAFOLD CAPS NDS GIVLAARI SOLN NDS GRASTEK SUBL MO
Drug Name RequirementsLimits
HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS TABS NDS KUVAN PACK 100mg 500mg NDS KUVAN TABS NDS LACTATED RINGERS SOLN levocarnitine soln PAMO LEVOCARNITINE TABS PAMO lidocaine hcl (pf) soln lidocaine hcl soln lidocaine in dextrose soln lidocaine-epinephrine soln LUDENT CHEW 025mg 05mg 1mg MO
mesna soln MESNEX TABS NDS MYALEPT SOLR NDS NAFRINSE CHEW MO NAFRINSE DROPS SOLN MO nitisinone caps 2mg 5mg 10mg NDS NITYR TABS 2mg 5mg 10mg NDS NULIBRY SOLR NDS ODACTRA SUBL ONPATTRO SOLN NDS ORALAIR SUBL MO ORFADIN CAPS LDNDS ORFADIN SUSP LDNDS ORLADEYO CAPS 110mg 150mg NDS
OXLUMO SOLN PALFORZIA (12 MG DAILY DOSE) CSPK NDS
PALFORZIA (120 MG DAILY DOSE) CSPK NDS
PALFORZIA (160 MG DAILY DOSE) CSPK NDS
PALFORZIA (20 MG DAILY DOSE) CSPK NDS
PALFORZIA (200 MG DAILY DOSE) CSPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
PALFORZIA (240 MG DAILY DOSE) CSPK NDS
PALFORZIA (3 MG DAILY DOSE) CSPK NDS
PALFORZIA (300 MG MAINTENANCE) PACK NDS
PALFORZIA (300 MG TITRATION) PACK NDS
PALFORZIA (40 MG DAILY DOSE) CSPK NDS
PALFORZIA (6 MG DAILY DOSE) CSPK NDS
PALFORZIA (80 MG DAILY DOSE) CSPK NDS
PALFORZIA INITIAL ESCALATION CSPK NDS
PHYSIOLYTE SOLN PHYSIOSOL IRRIGATION SOLN
polocaine soln polocaine-mpf soln PROCYSBI CPDR 25mg 75mg NDS PROCYSBI PACK 75mg 300mg NDS REZUROCK TABS NDS RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln RUZURGI TABS NDS sapropterin dihydrochloride pack 100mg 500mg NDS
sapropterin dihydrochloride tabs NDS SENSORCAINE SOLN sensorcaine-mpf soln sensorcaine-mpfepinephrine soln
sensorcaineepinephrine soln SODIUM CHLORIDE SOLN MO SODIUM FLUORIDE CHEW 025mg 05mg 1mg MO
SODIUM FLUORIDE SOLN MO SODIUM FLUORIDE TABS MO STERILE WATER FOR IRRIGATION SOLN
Drug Name RequirementsLimits
TAKHZYRO SOLN NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VILTEPSO SOLN NDS VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR 50unit 100unit PA XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg NDS RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 200mg114ml 300mg2ml PANDS
FASENRA PEN SOAJ NDS FASENRA SOSY PA montelukast sodium chew 4mg 5mg MO
montelukast sodium pack MO montelukast sodium tabs MO NUCALA SOAJ PANDS NUCALA SOLR PANDS NUCALA SOSY PANDS zafirlukast tabs 10mg 20mg MO zileuton er tb12 NDS CYSTIC FIBROSIS BETHKIS NEBU PA
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 56 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CAYSTON SOLR LDNDS KALYDECO PACK 25mg 50mg 75mg PANDS
KALYDECO TABS PANDS KITABIS PAK NEBU PA ORKAMBI PACK NDS ORKAMBI TABS NDS SYMDEKO TBPK NDS TOBI PODHALER CAPS tobramycin nebu 300mg4ml 300mg5ml PA
TRIKAFTA TBPK LDNDS PULMONARY FIBROSIS ESBRIET CAPS PANDS ESBRIET TABS 267mg 801mg PANDS OFEV CAPS 100mg 150mg NDS RESPIRATORY AGENTS MISCELLANEOUS ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS 500mg 1000mg
HI
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact
MO
ASMANEX (120 METERED DOSES) AEPB MO
ASMANEX (30 METERED DOSES) AEPB 110mcginh MO
ASMANEX (30 METERED DOSES) AEPB MO
ASMANEX (60 METERED DOSES) AEPB MO
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
budesonide-formoterol fumarate aero
DALIRESP TABS 250mcg 500mcg MO
DULERA AERO MO
Drug Name RequirementsLimits
FLOVENT DISKUS AEPB 50mcgblist 100mcgblist 250mcgblist
MO
FLOVENT HFA AERO 44mcgact MO
FLOVENT HFA AERO 110mcgact 220mcgact MO
fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PROLASTIN-C SOLN INTRAVENOUS HI
PROLASTIN-C SOLR INTRAVENOUS HI
SYMBICORT AERO wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
ZEMAIRA SOLR INTRAVENOUS HI
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr LETAIRIS TABS 5mg 10mg NDS ORENITRAM TBCR 0125mg LDNDS ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TABS 625mg 125mg NDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
1000mcg 1200mcg 1400mcg 1600mcg UPTRAVI TBPK NDS VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS BIVIGAM SOLN 10gm100ml HI BIVIGAM SOLN 5gm50ml HI CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml
HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS 10gm200ml HI
GAMMAPLEX SOLN INTRAVENOUS 10gm100ml 20gm200ml 5gm50ml
HI
GAMUNEX-C SOLN INJECTION 10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml
HI
HYPERHEP B SOLN HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 5gm100ml HI
Drug Name RequirementsLimits
1gm20ml 2gm20ml 25gm500ml PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
PRIVIGEN SOLN INTRAVENOUS HI
VARIZIG SOLN XEMBIFY SOLN SUBCUTANEOUS 2gm10ml 4gm20ml 10gm50ml 1gm5ml
HI
TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP QUADRACEL SUSP TDVAX SUSP TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP DAPTACEL SUSP ENGERIX-B SUSP 10mcg05ml 20mcgml PA
GARDASIL 9 SUSP GARDASIL 9 SUSY HAVRIX SUSP HEPLISAV-B SOLN PA HIBERIX SOLR IMOVAX RABIES INJ INFANRIX SUSP IPOL INJ IXIARO SUSP M-M-R II SOLR MENACTRA INJ MENQUADFI INJ MENVEO SOLR PEDIARIX SUSP PEDVAX HIB SUSP
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 58 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN VAQTA SUSP VARIVAX INJ VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint AKTIPAK PACK MO AVC VAGINAL CREA BACTROBAN NASAL OINT BENZEPRO CREAMY WASH LIQD
BENZEPRO FOAMING CLOTHS MISC
BENZOYL PEROXIDE GEL NDS benzoyl peroxide-erythromycin gel MO
ciclopirox gel ciclopirox olamine crea ciclopirox olamine susp ciclopirox sham ciclopirox soln CLEOCIN SUPP clindacin-p swab MO clindamycin phos-benzoyl perox gel MO
clindamycin phosphate crea clindamycin phosphate foam MO clindamycin phosphate gel MO clindamycin phosphate lotn MO
Drug Name RequirementsLimits
clindamycin phosphate soln MO clindamycin phosphate swab MO CLINDESSE CREA clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn DENAVIR CREA econazole nitrate crea ERTACZO CREA ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA EXELDERM CREA EXELDERM SOLN gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ivermectin lotn ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham LULICONAZOLE CREA LUZU CREA mafenide acetate pack malathion lotn MENTAX CREA metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 59
Drug Name RequirementsLimits
mupirocin oint naftifine hcl crea naftifine hcl gel NAFTIN GEL NATROBA SUSP neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ORAVIG TABS ovide lotn oxiconazole nitrate crea OXISTAT LOTN permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SKLICE LOTN SODIUM SULFACETAMIDE SHAM
SODIUM SULFACETAMIDE WASH LIQD
SPINOSAD SUSP SSD CREA sulfacetamide sodium (acne) lotn MO SULFACETAMIDE SODIUM GEL
SULFACETAMIDE SODIUM LIQD
SULFAMYLON CREA tavaborole soln terconazole crea terconazole supp VANDAZOLE GEL XEPI CREA MO XERESE CREA ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) ala scalp lotn MO
Drug Name RequirementsLimits
ala-cort crea 1 25 MO alclometasone dipropionate crea MO alclometasone dipropionate oint MO amcinonide crea MO amcinonide lotn MO amcinonide oint MO anusol-hc crea MO apexicon e crea MO benzoyl perox-hydrocortisone lotn
BENZOYL PEROXIDE FORTE- HC LOTN NDS
beser lotn MO betamethasone dipropionate aug crea MO
betamethasone dipropionate aug gel MO
betamethasone dipropionate aug lotn MO
betamethasone dipropionate aug oint MO
betamethasone dipropionate crea MO
betamethasone dipropionate lotn MO BETAMETHASONE DIPROPIONATE OINT MO
betamethasone valerate crea MO betamethasone valerate foam MO BETAMETHASONE VALERATE LOTN MO
BETAMETHASONE VALERATE OINT MO
BRYHALI LOTN MO calcipotriene-betameth diprop oint MONDS
calcipotriene-betameth diprop susp NDS
CAPEX SHAM MO clobetasol propionate crea clobetasol propionate e crea MO clobetasol propionate emulsion foam
clobetasol propionate foam MO clobetasol propionate gel MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 60 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO CLOBEX SHAM MO CLOBEX SPRAY LIQD MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO clodan sham MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT MO DESONATE GEL MO desonide crea MO desonide gel MO desonide lotn MO desonide oint MO desowen lotn MO desoximetasone crea 005 025 MO
desoximetasone gel MO desoximetasone liqd MO desoximetasone oint 005 025 MO
desrx gel MO diclofenac sodium gel 1 3 MO diflorasone diacetate crea MO diflorasone diacetate oint MO DUOBRII LOTN MO ENSTILAR FOAM NDS epifoam foam fluocinolone acetonide body oil fluocinolone acetonide crea 001 0025 MO
fluocinolone acetonide oint MO fluocinolone acetonide scalp oil MO fluocinolone acetonide soln MO fluocinonide crea MO fluocinonide emulsified base crea MO
Drug Name RequirementsLimits
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO flurandrenolide crea MO flurandrenolide lotn MO flurandrenolide oint MO fluticasone propionate crea MO fluticasone propionate lotn MO fluticasone propionate oint MO halcinonide crea MO halobetasol propionate crea MO HALOBETASOL PROPIONATE FOAM NDS
halobetasol propionate oint MO HALOG CREA MO HALOG OINT MO hydrocortisone (perianal) crea 1 25 MO
hydrocortisone butyr lipo base crea
hydrocortisone butyrate crea MO hydrocortisone butyrate lotn MO HYDROCORTISONE BUTYRATE OINT MO
hydrocortisone butyrate soln MO hydrocortisone crea 1 25 MO hydrocortisone enem MO hydrocortisone lotn MO hydrocortisone oint 1 25 MO hydrocortisone valerate crea MO hydrocortisone valerate oint MO LEXETTE FOAM NDS micort-hc crea MO mometasone furoate crea MO mometasone furoate oint MO mometasone furoate soln MO neo-synalar crea MO nolix crea nolix lotn MO nystatin-triamcinolone crea MO nystatin-triamcinolone oint MO oralone pste MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 61
Drug Name RequirementsLimits
PANDEL CREA MO prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO psorcon crea MO TACLONEX SUSP NDS topicort crea 005 025 MO topicort gel MO topicort oint MO tovet foam MO triamcinolone acetonide aers MO triamcinolone acetonide crea 0025 01 05 MO
triamcinolone acetonide lotn 0025 01 MO
triamcinolone acetonide oint 0025 005 01 05 MO
triamcinolone acetonide pste MO trianex oint MO triderm crea 01 05 MO tritocin oint MO UCERIS FOAM MO ULTRAVATE LOTN NDS VANOXIDE-HC LOTN ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
LIDO-SORB LOTN LIDOCAINE HCL CREA lidocaine hcl lotn lidocaine hcl soln PA lidocaine hcl urethralmucosal gel MO
lidocaine hcl urethralmucosal prsy MO
lidocaine oint PAMO lidocaine ptch PAMO
Drug Name RequirementsLimits
LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea PA LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam texacort soln MO TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS ALTRENO LOTN PAMO AVITA CREA PAMO AVITA GEL PAMO KEPIVANCE SOLR NDS PANRETIN GEL NDS RETIN-A CREA 0025 005 01 PAMO
RETIN-A GEL 001 0025 PAMO RETIN-A MICRO GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 008 PAMO
RETIN-A MICRO PUMP GEL PANDS TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 62 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS ABSORICA CAPS 25mg 35mg NDS ABSORICA LD CAPS 8mg 16mg 24mg 32mg NDS
accutane caps 10mg 20mg 30mg 40mg NDS
acitretin caps 10mg 175mg 25mg NDS
ADAPALENE CREA MO adapalene gel 01 03 MO adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
AVAR CLEANSER EMUL AVAR-E EMOLLIENT CREA AVAR-E GREEN CREA azelaic acid gel MO AZELEX CREA MO BP 10-1 EMUL calcipotriene crea MO calcipotriene oint MO calcipotriene soln MO calcitrene oint MO CALCITRIOL OINT MO CARAC CREA CEROVEL LOTN claravis caps 10mg 20mg 30mg 40mg NDS
CONDYLOX GEL MO COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
Drug Name RequirementsLimits
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA MO DIFFERIN LOTN MO EPIDUO FORTE GEL MO FABIOR FOAM PAMO FINACEA FOAM MO fluorouracil crea 5 MO fluorouracil crea 5 fluorouracil soln 2 5 MO ILUMYA SOSY PA imiquimod crea 375 5 MO IMIQUIMOD PUMP CREA MO isotretinoin caps 10mg 20mg 30mg 40mg NDS
keralyt sham KLISYRI OINT NDS LACTIC ACID LOTN methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
ORACEA CPDR pimecrolimus crea MO podofilox soln MO RECTIV OINT MO REGRANEX GEL NDS RYNODERM CREA NDS SALEX SHAM SALICYLIC ACID CREA SALICYLIC ACID ER SOLN SALICYLIC ACID FOAM SALICYLIC ACID GEL SALICYLIC ACID LIQD SALICYLIC ACID SHAM SALICYLIC ACID WART REMOVER LIQD
SALICYLIC ACID-CLEANSER KIT
SALIMEZ CREA SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 63
Drug Name RequirementsLimits
SKYRIZI PEN SOAJ SKYRIZI SOSY SORILUX FOAM MO SSS 10-5 CREA STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
SULFACETAMIDE SODIUM-SULFUR CREA
SULFACETAMIDE SODIUM-SULFUR EMUL
SULFACETAMIDE SODIUM-SULFUR LIQD
SULFACETAMIDE SODIUM-SULFUR LOTN
SULFACETAMIDE SODIUM-SULFUR PADS
SULFACETAMIDE SODIUM-SULFUR SUSP
SULFACLEANSE 84 SUSP sulfamez wash emul TACROLIMUS OINT 01 003 MO
TALTZ SOAJ NDS TALTZ SOSY NDS tazarotene crea PAMO tazarotene foam PAMO TAZORAC CREA PAMO TAZORAC GEL 005 01 PAMO TOLAK CREA TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS VECTICAL OINT MO VEREGEN OINT MO WYNZORA CREA NDS XUREA CREA
Drug Name RequirementsLimits
zenatane caps 10mg 20mg 30mg 40mg NDS
ZYCLARA PUMP CREA MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline soln darifenacin hydrobromide er tb24 75mg 15mg MO
elixophyllin elix flavoxate hcl tabs MO MYRBETRIQ TB24 25mg 50mg MO oxybutynin chloride er tb24 5mg 10mg 15mg MO
oxybutynin chloride syrp MO oxybutynin chloride tabs MO solifenacin succinate tabs 5mg 10mg MO
theo-24 cp24 100mg 200mg 300mg 400mg MO
theophylline er tb12 100mg 200mg 300mg 450mg MO
theophylline er tb24 400mg 600mg MO
theophylline soln MO tolterodine tartrate er cp24 2mg 4mg MO
tolterodine tartrate tabs MO trospium chloride er cp24 MO trospium chloride tabs MO VITAMINS VITAMINS ADCF (05MGML) SOLN MO calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN MULTI-VITAMINFLUORIDEIRON SOLN
MO
MULTI-VITAMINFLUORIDE SOLN MO
MULTIVITAMINFLUORIDE CHEW MO
64 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
MVC-FLUORIDE CHEW MO paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS TRI-VITAMINFLUORIDE SOLN MO TRI-VITEFLUORIDE SOLN MO VITAMINS ACD-FLUORIDE SOLN MO
VP-PNV-DHA CAPS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 65
The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not and
you need an urgent refill please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 6 or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number on page 6 NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
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Index of Drugs
A abacavir sulfate soln 12 abacavir sulfate tabs 12 abacavir sulfate-lamivudine tabs 12 abacavir-lamivudine-zidovudine tabs 12 ABELCET SUSP INTRAVENOUS 11 ABILIFY MAINTENA PRSY 300mg 400mg
35 ABILIFY MAINTENA SRER 300mg 400mg
35 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
abiraterone acetate tabs 250mg 500mg 14 ABRAXANE SUSR 14 ABSORICA CAPS 25mg 35mg 62 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 62 ABSTRAL SUBL 100mcg 200mcg
300mcg 400mcg 600mcg 800mcg 27 acamprosate calcium tbec 26 acarbose tabs 25mg 50mg 100mg 48 accutane caps 10mg 20mg 30mg 40mg 62 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 27 acetaminophen-codeine soln 27 acetaminophen-codeine tabs 27 acetazolamide er cp12 42 acetazolamide sodium solr 42 acetazolamide tabs 125mg 250mg 42 ACETIC ACID SOLN 42 53 acetylcysteine soln 10 20 52 acitretin caps 10mg 175mg 25mg 62 ACTEMRA ACTPEN SOAJ 52 ACTEMRA SOSY 52 ACTHAR GEL 50 ACTHIB SOLR 57 ACTIMMUNE SOLN 53 ACUVAIL SOLN 41
acyclovir caps 12 acyclovir oint 58 acyclovir sodium soln intravenous 12 acyclovir susp 12 acyclovir tabs 400mg 800mg 12 ADACEL SUSP 57 ADAGEN SOLN 40 ADAKVEO SOLN 21 ADAPALENE CREA 62 adapalene gel 01 03 62 adapalene pads 62 adapalene soln 62 adapalene-benzoyl peroxide gel 62 ADAPALENE-BENZOYL PEROXIDE PADS
62 ADCF (05MGML) SOLN 63 adderall tabs 29 ADDERALL XR CP24 29 adefovir dipivoxil tabs 12 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 56 adenosine soln 25 ADMELOG SOLN 48 ADMELOG SOLOSTAR SOPN 48 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 20 ADZENYS ER SUER 29 ADZENYS XR-ODT TBED 31mg 63mg
94mg 125mg 157mg 188mg 29 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 25mg 5mg 75mg 10mg
14 AFREZZA POWD 48 AFREZZA POWD 8 (90) amp 12 (90) UNIT 48 AJOVY SOAJ 32 AJOVY SOSY 32 AKTIPAK PACK 58 AKYNZEO CAPS 43 ala scalp lotn 59 ala-cort crea 1 25 59 albendazole tabs 8
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albuterol sulfate er tb12 4mg 8mg 20 albuterol sulfate hfa aers 20 albuterol sulfate nebu 0083 25mg05ml
20 albuterol sulfate nebu 063mg3ml
125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 59 alclometasone dipropionate oint 59 ALCOHOL PREP PADS 37 ALDACTAZIDE TABS 25 ALDURAZYME SOLN 40 ALECENSA CAPS 14 alendronate sodium soln 52 alendronate sodium tabs 40mg 52 alendronate sodium tabs 5mg 10mg
35mg 70mg 52 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 05mg 1mg
2mg 5mg 45 allopurinol sodium solr 52 allopurinol tabs 100mg 300mg 52 allzital tabs 27 almotriptan malate tabs 32 ALOCRIL SOLN 42 alogliptin benzoate tabs 625mg 125mg
25mg 48 ALOGLIPTIN-METFORMIN HCL TABS 48 alogliptin-pioglitazone tabs 48 ALOMIDE SOLN 42 ALOSETRON HCL TABS 05mg 1mg 43 ALPHAGAN P SOLN 42 alprazolam er tb24 05mg 1mg 2mg 3mg
33 alprazolam intensol conc 33 alprazolam tabs 025mg 05mg 1mg 2mg
33 alprazolam tbdp 025mg 05mg 1mg 2mg
33 ALREX SUSP 41 ALTACAINE SOLN 42 ALTAFRIN SOLN 42 altavera tabs 46 ALTOPREV TB24 20mg 40mg 60mg 23 ALTRENO LOTN 61
ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 56 alyacen 135 tabs 46 alyq tabs 26 amabelz tabs 49 amantadine hcl caps 32 amantadine hcl syrp 32 amantadine hcl tabs 32 AMBISOME SUSR INTRAVENOUS 11 ambrisentan tabs 56 amcinonide crea 59 amcinonide lotn 59 amcinonide oint 59 amethia lo tabs 46 amethia tabs 46 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 38 amiloride-hydrochlorothiazide tabs 38 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 63 AMINOSYN-PF SOLN INTRAVENOUS 38 amiodarone hcl soln 25 amiodarone hcl tabs 100mg 200mg
400mg 25 AMITIZA CAPS 8mcg 24mcg 44 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 amlodipine besy-benazepril hcl caps 24 amlodipine besylate tabs 25mg 5mg
10mg 24 amlodipine besylate-valsartan tabs 24 amlodipine-atorvastatin tabs 24 amlodipine-olmesartan tabs 24 amlodipine-valsartan-hctz tabs 24 ammonium lactate crea 62 ammonium lactate lotn 62 amnesteem caps 10mg 20mg 40mg 62 AMONDYS 45 SOLN 53 amoxapine tabs 25mg 50mg 100mg
150mg 35 amoxicill-clarithro-lansopraz misc 43 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8
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amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 29 amphetamine sulfate tabs 5mg 10mg 30 amphetamine-dextroamphet er cp24 30 amphetamine-dextroamphetamine tabs 30 amphotericin b solr intravenous 11 ampicillin caps 8 ampicillin sodium solr 8 ampicillin sodium solr injection 1gm 125mg
8 ampicillin sodium solr intravenous 8 ampicillin-sulbactam sodium solr 8 ampicillin-sulbactam sodium solr injection 8 ampicillin-sulbactam sodium solr
intravenous 8 ANADROL-50 TABS 45 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 61 anastrozole tabs 14 ANDRODERM PT24 2mg24hr 4mg24hr
45 ANGELIQ TABS 49 ANORO ELLIPTA AEPB 19 antabuse tabs 250mg 500mg 26 ANTARA CAPS 30mg 90mg 23 anusol-hc crea 59 ANZEMET TABS 50mg 100mg 43 apap-caff-dihydrocodeine tabs 27 apexicon e crea 59 APIDRA SOLN 48 APIDRA SOLOSTAR SOPN 48 APLENZIN TB24 174mg 348mg 522mg 35 APOKYN SOCT 32 apraclonidine hcl soln 42 aprepitant caps 43 apri tabs 46 APRISO CP24 43 APTIOM TABS 200mg 400mg 600mg
800mg 30 APTIVUS CAPS 12 APTIVUS SOLN 12 ARALAST NP SOLR INTRAVENOUS
500mg 1000mg 56 aranelle tabs 46 ARANESP (ALBUMIN FREE) SOLN
25mcgml 40mcgml 22
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml 22
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml 22
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 22
ARCALYST SOLR 53 ARCAPTA NEOHALER CAPS 20 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 54 ARIKAYCE SUSP 8 aripiprazole soln 35 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 35 aripiprazole tbdp 10mg 15mg 35 ARISTADA INITIO PRSY 35 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 35
armodafinil tabs 50mg 150mg 200mg 250mg 30
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact 56
ARRANON SOLN 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 54 ARYMO ER TBEA 27 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 57 ascomp-codeine caps 27 asenapine maleate subl 25mg 5mg 10mg
35 ashlyna tabs 46 ASMANEX (120 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
110mcginh 56 ASMANEX (60 METERED DOSES) AEPB
56 ASMANEX HFA AERO 100mcgact
200mcgact 56
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ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 53 ASTAGRAF XL CP24 05mg 1mg 53 atazanavir sulfate caps 150mg 200mg
300mg 12 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 34 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 23 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 42 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 34 aubra eq tabs 46 AUGMENTIN SUSR 8 AURYXIA TABS 39 AUSTEDO TABS 6mg 9mg 12mg 34 AVANDIA TABS 2mg 4mg 48 AVAR CLEANSER EMUL 62 AVAR-E EMOLLIENT CREA 62 AVAR-E GREEN CREA 62 AVASTIN SOLN 14 AVC VAGINAL CREA 58 AVEED SOLN 45 aviane tabs 46 AVITA CREA 61 AVITA GEL 61 AVONEX KIT 34 AVONEX PEN AJKT 34 AVONEX PREFILLED PSKT 34 AVSOLA SOLR 52 AVYCAZ SOLR INTRAVENOUS 8 aygestin tabs 50 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 53 AZASITE SOLN 40 azathioprine sodium solr 53 azathioprine tabs 53 azelaic acid gel 62 azelastine hcl soln 005 01 015 42 azelastine-fluticasone susp 42 AZELEX CREA 62
AZITHROMYCIN PACK 8 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
B bacitracin oint 40 bacitracin solr 8 bacitracin-polymyxin b oint 40 bacitra-neomycin-polymyxin-hc oint 41 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 58 BAFIERTAM CPDR 34 balsalazide disodium caps 43 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 46 BANZEL SUSP 30 BANZEL TABS 200mg 400mg 30 BAQSIMI ONE PACK POWD 48 BAQSIMI TWO PACK POWD 48 BARACLUDE SOLN 12 BAVENCIO SOLN 14 BAXDELA SOLR INTRAVENOUS 8 BAXDELA TABS 8 BCG VACCINE INJ 14 BD INSULIN SYR ULTRAFINE II MISC 37 BD INSULIN SYRINGE MISC 37 BD INSULIN SYRINGE UF MISC 37 BD PEN NEEDLE ORIGINAL UF MISC 37 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 27 BELEODAQ SOLR 14 BELRAPZO SOLN 14 BELSOMRA TABS 33 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 15 BENDEKA SOLN 15 BENLYSTA SOAJ 53 BENLYSTA SOLR 53 BENLYSTA SOSY 53 BENZEPRO CREAMY WASH LIQD 58 BENZEPRO FOAMING CLOTHS MISC 58 benzhydrocodone-acetaminophen tabs 27 BENZNIDAZOLE TABS 125mg 100mg 11 benzoyl perox-hydrocortisone lotn 59
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BENZOYL PEROXIDE FORTE- HC LOTN 59
BENZOYL PEROXIDE GEL 58 benzoyl peroxide-erythromycin gel 58 benztropine mesylate soln 32 benztropine mesylate tabs 05mg 1mg
2mg 32 BEOVU SOLN 42 bepotastine besilate soln 42 BERINERT KIT INTRAVENOUS 21 beser lotn 59 BESIVANCE SUSP 40 BESPONSA SOLR 15 betamethasone dipropionate aug crea 59 betamethasone dipropionate aug gel 59 betamethasone dipropionate aug lotn 59 betamethasone dipropionate aug oint 59 betamethasone dipropionate crea 59 betamethasone dipropionate lotn 59 BETAMETHASONE DIPROPIONATE OINT
59 betamethasone sod phos amp acet susp 45 betamethasone valerate crea 59 betamethasone valerate foam 59 BETAMETHASONE VALERATE LOTN 59 BETAMETHASONE VALERATE OINT 59 BETASERON KIT 34 betaxolol hcl soln 42 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 20 BETHKIS NEBU 55 BETIMOL SOLN 025 05 42 BETOPTIC-S SUSP 42 BEVESPI AEROSPHERE AERO 19 BEVYXXA CAPS 40mg 80mg 21 bexarotene caps 15 BEXSERO SUSY 57 bicalutamide tabs 15 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICNU SOLR 15 BIDIL TABS 26 BIKTARVY TABS 12 bimatoprost soln 42 BINOSTO TBEF 52 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23
BIVIGAM SOLN 10gm100ml 57 BIVIGAM SOLN 5gm50ml 57 bleomycin sulfate solr 15 bleph-10 soln 40 blephamide sop oint 41 BLEPHAMIDE SUSP 41 BLINCYTO SOLR 15 blisovi 24 fe tabs 46 blisovi fe 1530 tabs 46 BONJESTA TBCR 43 BOOSTRIX SUSP 57 BORTEZOMIB SOLR 15 bosentan tabs 56 BOSULIF TABS 100mg 400mg 500mg 15 BOTOX SOLR 100unit 200unit 54 BP 10-1 EMUL 62 BRAFTOVI CAPS 50mg 75mg 15 briellyn tabs 46 BRILINTA TABS 60mg 90mg 21 BRIMONIDINE TARTRATE SOLN 02
015 42 brinzolamide susp 42 BRIVIACT SOLN 30 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 30 bromfenac sodium (once-daily) soln 41 bromocriptine mesylate caps 32 bromocriptine mesylate tabs 32 BROMSITE SOLN 41 BRONCHITOL CAPS 56 BROVANA NEBU 20 BRUKINSA CAPS 15 BRYHALI LOTN 59 budesonide cpep 45 budesonide er tb24 45 budesonide susp 025mg2ml 05mg2ml
1mg2ml 56 budesonide-formoterol fumarate aero 56 bumetanide soln 38 bumetanide tabs 05mg 1mg 2mg 38 BUNAVAIL FILM 34 bupap tabs 27 bupivacaine hcl (pf) soln 54 bupivacaine hcl soln 54 BUPIVACAINE IN DEXTROSE SOLN 54 bupivacaine spinal soln 54 bupivacaine-epinephrine (pf) soln 54 bupivacaine-epinephrine soln 54 buprenorphine hcl soln 27
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buprenorphine hcl subl 2mg 8mg 34 buprenorphine hcl-naloxone hcl film 34 buprenorphine hcl-naloxone hcl subl 34 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 27 bupropion hcl er (smoking det) tb12 35 bupropion hcl er (sr) tb12 100mg 150mg
200mg 35 bupropion hcl er (xl) tb24 150mg 300mg
450mg 35 bupropion hcl tabs 75mg 100mg 35 buspirone hcl tabs 5mg 10mg 33 buspirone hcl tabs 75mg 15mg 30mg 33 busulfan soln 15 butalbital-acetaminophen caps 27 butalbital-acetaminophen tabs 27 butalbital-apap-caff-cod caps 27 butalbital-apap-caffeine caps 27 butalbital-apap-caffeine tabs 27 butalbital-asa-caff-codeine caps 27 butalbital-aspirin-caffeine caps 27 butalbital-aspirin-caffeine tabs 27 butorphanol tartrate soln 1mgml 2mgml
10mgml 27 BUTRANS PTWK 27 BYDUREON BCISE AUIJ 48 BYDUREON PEN 48 BYETTA 10 MCG PEN SOPN 48 BYETTA 5 MCG PEN SOPN 48 BYLVAY (PELLETS) CPSP 200mcg
600mcg 44 BYLVAY CAPS 400mcg 1200mcg 44 BYNFEZIA PEN SOPN 51
C CABENUVA SUER 12 cabergoline tabs 32 CABLIVI KIT 22 CABOMETYX TABS 20mg 40mg 60mg 15 cafergot tabs 32 caffeine citrate soln 30 calcipotriene crea 62 calcipotriene oint 62 calcipotriene soln 62 calcipotriene-betameth diprop oint 59 calcipotriene-betameth diprop susp 59 calcitonin (salmon) soln 50 calcitrene oint 62 calcitriol caps 025mcg 05mcg 63
CALCITRIOL OINT 62 calcitriol soln 63 calcium acetate (phos binder) caps 39 calcium acetate (phos binder) tabs 39 CALCIUM GLUCONATE-NACL SOLN 39 CALQUENCE CAPS 15 camila tabs 46 camrese lo tabs 46 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 59 CAPLYTA CAPS 35 CAPRELSA TABS 100mg 300mg 15 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 26 CARAC CREA 62 CARAFATE SUSP 43 CARBAGLU TABS 37 carbamazepine chew 30 carbamazepine er cp12 100mg 200mg
300mg 30 carbamazepine er tb12 100mg 200mg
400mg 30 carbamazepine susp 30 carbamazepine tabs 30 carbidopa tabs 32 carbidopa-levodopa er tbcr 32 carbidopa-levodopa tabs 32 carbidopa-levodopa tbdp 32 carbidopa-levodopa-entacapone tabs 32 carbinoxamine maleate soln 14 carbinoxamine maleate tabs 14 carboplatin soln 15 carboprost tromethamine soln 50 CARDENE IV SOLN 24 CARDIZEM LA TB24 24 CARDURA XL TB24 4mg 8mg 22 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 15 CARNITOR SOLN 54 CARNITOR TABS 54 CAROSPIR SUSP 26 carteolol hcl soln 42
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cartia xt cp24 120mg 180mg 240mg 300mg 24
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg 23
carvedilol tabs 3125mg 625mg 125mg 25mg 23
caspofungin acetate solr intravenous 50mg 70mg 11
cataflam tabs 27 CAYSTON SOLR 56 caziant tabs 46 cefaclor caps 8 cefaclor er tb12 8 cefaclor susr 8 cefadroxil caps 8 cefadroxil susr 8 cefadroxil tabs 8 cefazolin sodium solr 8 cefazolin sodium solr injection 1gm 10gm
500mg 8 cefdinir caps 8 cefdinir susr 8 cefepime hcl solr injection 1gm 2gm 8 cefixime caps 8 cefixime susr 8 cefotaxime sodium solr 8 cefotetan disodium solr injection 1gm 2gm 8 cefoxitin sodium solr injection 8 cefoxitin sodium solr intravenous 1gm 2gm
8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 2gm 6gm 8 CEFTIN SUSR 8 ceftriaxone sodium solr injection 1gm 2gm
250mg 500mg 8 ceftriaxone sodium solr intravenous 8 cefuroxime axetil tabs 8 cefuroxime sodium solr injection 75gm
750mg 8 cefuroxime sodium solr intravenous 8 celecoxib caps 27 CELONTIN CAPS 30 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 41
CERDELGA CAPS 40 CEREZYME SOLR 40 CEROVEL LOTN 62 CESAMET CAPS 43 cetirizine hcl soln 14 CETRAXAL SOLN 40 CEVIMELINE HCL CAPS 20 CHANTIX CONTINUING MONTH PAK
TABS 20 CHANTIX STARTING MONTH PAK TABS
20 CHANTIX TABS 05mg 1mg 20 CHEMET CAPS 44 chloramphenicol sod succinate solr 9 chlordiazepoxide hcl caps 5mg 10mg
25mg 33 chlordiazepoxide-amitriptyline tabs 35 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 40 chloroprocaine hcl (pf) soln 54 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 38 chlorothiazide tabs 250mg 500mg 38 chlorpromazine hcl soln 35 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 35 chlorthalidone tabs 25mg 50mg 38 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 44 cholestyramine light pack 23 cholestyramine light powd 23 cholestyramine pack 23 cholestyramine powd 23 CHORIONIC GONADOTROPIN SOLR 50 ciclopirox gel 58 ciclopirox olamine crea 58 ciclopirox olamine susp 58 ciclopirox sham 58 ciclopirox soln 58 cidofovir soln 12 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 40 CIMDUO TABS 12 cimetidine hcl soln 43 cimetidine tabs 200mg 300mg 400mg
800mg 43 CIMZIA KIT 52
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CIMZIA PREFILLED KIT 52 CIMZIA STARTER KIT KIT 52 cinacalcet hcl tabs 30mg 60mg 90mg 50 CINQAIR SOLN 55 CINRYZE SOLR INTRAVENOUS 54 CIPRO HC SUSP 41 CIPRODEX SUSP 41 ciprofloxacin hcl soln (ophth) 40 CIPROFLOXACIN HCL SOLN (OTIC) 40 ciprofloxacin hcl tabs 9 ciprofloxacin in d5w soln 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 41 CIPROFLOXACIN-FLUOCINOLONE PF
SOLN 40 cisplatin soln 15 CISPLATIN SOLR 15 citalopram hydrobromide soln 35 citalopram hydrobromide tabs 10mg 20mg
40mg 35 citanest plain dental soln 54 cladribine soln 15 claravis caps 10mg 20mg 30mg 40mg 62 CLARINEX SYRP 14 CLARINEX-D 12 HOUR TB12 14 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 14 cleocin phosphate soln 9 cleocin solr 9 CLEOCIN SUPP 58 CLIMARA PRO PTWK 49 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
clindacin-p swab 58 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 58 clindamycin phosphate crea 58 clindamycin phosphate foam 58 clindamycin phosphate gel 58 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 58
clindamycin phosphate soln 9 58 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 58 CLINDESSE CREA 58 CLINIMIX EDEXTROSE (27510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42525) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (525) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (525) SOLN
INTRAVENOUS 38 clinisol sf soln intravenous 38 clobazam susp 30 clobazam tabs 10mg 20mg 30 clobetasol propionate crea 59 clobetasol propionate e crea 59 clobetasol propionate emulsion foam 59 clobetasol propionate foam 59 clobetasol propionate gel 59 clobetasol propionate liqd 60 clobetasol propionate lotn 60 clobetasol propionate oint 60 clobetasol propionate sham 60 clobetasol propionate soln 60 CLOBEX SHAM 60
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CLOBEX SPRAY LIQD 60 clocortolone pivalate crea 60 clocortolone pivalate pump crea 60 clodan sham 60 clofarabine soln 15 clomipramine hcl caps 25mg 50mg 75mg
35 clonazepam tabs 05mg 1mg 2mg 30 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 30 clonidine hcl (analgesia) soln 25 clonidine hcl er tb12 25 clonidine hcl tabs 01mg 02mg 03mg 25 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 25 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 33 clotrimazole crea 58 clotrimazole soln 58 clotrimazole troc 58 clotrimazole-betamethasone crea 58 clotrimazole-betamethasone lotn 58 clovique caps 44 clozapine tabs 25mg 50mg 100mg 200mg
35 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 35 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 27 colazal caps 43 COLCHICINE CAPS 52 colchicine tabs 52 colchicine-probenecid tabs 40 colesevelam hcl pack 23 colesevelam hcl tabs 23 colestipol hcl gran 23 colestipol hcl pack 23 colestipol hcl tabs 23 colistimethate sodium (cba) solr injection 9 colocort enem 60 COLY-MYCIN S SUSP 41 COMBIGAN SOLN 42 COMBIPATCH PTTW 49 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 15 COMETRIQ (140 MG DAILY DOSE) KIT 15 COMETRIQ (60 MG DAILY DOSE) KIT 15
COMPLERA TABS 12 compro supp 35 CONDYLOX GEL 62 CONSENSI TABS 24 constulose soln 37 COPIKTRA CAPS 15mg 25mg 15 CORDRAN TAPE 60 CORLANOR TABS 5mg 75mg 25 cortisone acetate tabs 45 CORTISPORIN CREA 60 CORTISPORIN OINT 60 COSELA SOLR 54 COSENTYX (300 MG DOSE) SOSY 62 COSENTYX SENSOREADY (300 MG)
SOAJ 62 COSENTYX SENSOREADY PEN SOAJ 62 COSENTYX SOSY 75mg05ml 150mgml
62 COTELLIC TABS 15 COTEMPLA XR-ODT TBED 86mg
173mg 259mg 30 CREON CPEP 40 CRESEMBA CAPS 11 CRESEMBA SOLR 11 CRINONE GEL 4 8 50 CRIXIVAN CAPS 200mg 400mg 12 cromolyn sodium conc 55 cromolyn sodium nebu 55 cromolyn sodium soln 42 crotan lotn 58 cryselle-28 tabs 46 CRYSVITA SOLN 10mgml 20mgml
30mgml 54 CUPRIMINE CAPS 44 CURITY GAUZE PADS 37 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 57
CUVPOSA SOLN 19 cyclafem 135 tabs 46 cyclafem 777 tabs 46 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 15 CYCLOPHOSPHAMIDE SOLN 1gm5ml
500mg25ml 15 cyclophosphamide solr 15
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 75
cycloserine caps 11 CYCLOSET TABS 48 cyclosporine caps 25mg 100mg 53 cyclosporine modified caps 25mg 50mg
100mg 53 cyclosporine modified soln 53 cyclosporine soln 53 cyproheptadine hcl syrp 14 cyproheptadine hcl tabs 14 CYRAMZA SOLN 100mg10ml
500mg50ml 15 cyred eq tabs 46 CYSTADANE POWD 54 CYSTADROPS SOLN 42 CYSTAGON CAPS 50mg 150mg 54 CYSTARAN SOLN 42 cytarabine (pf) soln 15 cytarabine soln 15 CYTOGAM INJ 57
D dacarbazine solr 15 dactinomycin solr 15 DAKLINZA TABS 30mg 60mg 90mg 12 dalfampridine er tb12 34 DALIRESP TABS 250mcg 500mcg 56 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 45 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 62 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 57 daptomycin solr intravenous 350mg 500mg
9 DARAPRIM TABS 11 darifenacin hydrobromide er tb24 75mg
15mg 63 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 DAYTRANA PTCH 10mg9hr 15mg9hr
20mg9hr 30mg9hr 30 DDAVP RHINAL TUBE SOLN 50 deblitane tabs 46 decadron elix 45
decadron tabs 5mg 75mg 45 decadron tabs 4mg 6mg 45 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 44 deferasirox tabs 90mg 180mg 360mg 44 deferasirox tbso 125mg 44 deferasirox tbso 250mg 500mg 44 deferiprone tabs 44 deferoxamine mesylate solr 44 DELESTROGEN OIL 49 DELSTRIGO TABS 12 deltasone tabs 45 delyla tabs 46 DELZICOL CPDR 43 demeclocycline hcl tabs 9 DEMEROL SOLN 25mg05ml 75mg15ml
100mg2ml 75mgml 27 DEMSER CAPS 22 DENAVIR CREA 58 DEPEN TITRATABS TABS 44 depo-estradiol oil 49 DEPO-MEDROL SUSP 45 DEPO-PROVERA SUSP 400mgml 50 DEPO-SUBQ PROVERA 104 SUSY 50 depo-testosterone soln 100mgml
200mgml 45 DERMOTIC OIL 41 DESCOVY TABS 12 desipramine hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 desloratadine tabs 14 desloratadine tbdp 14 desmopressin ace spray refrig soln 50 desmopressin acetate
soln 50 DESMOPRESSIN ACETATE SOLN 50 desmopressin acetate spray soln 50 DESMOPRESSIN ACETATE TABS 01mg
02mg 50 desogestrel-ethinyl estradiol tabs 46 DESONATE GEL 60 desonide crea 60 desonide gel 60 desonide lotn 60 desonide oint 60 desowen lotn 60 desoximetasone crea 005 025 60 desoximetasone gel 60
76 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
desoximetasone liqd 60 desoximetasone oint 005 025 60 desrx gel 60 DESVENLAFAXINE ER TB24 50mg
100mg 35 desvenlafaxine succinate er tb24 25mg
50mg 100mg 35 dexabliss tbpk 45 dexamethasone elix 45 dexamethasone intensol conc 45 dexamethasone sod phosphate pf soln 45 dexamethasone sodium phosphate soln 41
45 dexamethasone soln 45 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 45 dexamethasone tbpk 45 dexchlorpheniramine maleate soln 14 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 30
dexmethylphenidate hcl tabs 25mg 5mg 10mg 30
dexpak 10 day tbpk 45 dexpak 13 day tbpk 45 dexpak 6 day tbpk 45 dexrazoxane hcl solr 54 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 30 dextroamphetamine sulfate soln 30 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 30 DEXTROSE 10NACL 02 39 DEXTROSE 5NACL 0225 39 DEXTROSE IN LACTATED RINGERS
SOLN 39 DEXTROSE SOLN 38 dextrose soln intravenous 5 10 38 DEXTROSE-NACL SOLN INTRAVENOUS
39 DIACOMIT CAPS 250mg 500mg 30 DIACOMIT PACK 250mg 500mg 31 DIASTAT ACUDIAL GEL 10mg 20mg 31 DIASTAT PEDIATRIC GEL 31 diazepam conc 33 diazepam gel 25mg 10mg 20mg 31 diazepam soln 5mg5ml 5mgml 33 diazepam tabs 2mg 5mg 10mg 33 diazoxide susp 48
diclofenac potassium tabs 27 diclofenac sodium er tb24 27 diclofenac sodium gel 1 3 60 diclofenac sodium soln 41 diclofenac sodium tbec 27 diclofenac-misoprostol tbec 27 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 12 DIFFERIN CREA 62 DIFFERIN LOTN 62 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 60 diflorasone diacetate oint 60 diflunisal tabs 27 digitek tabs 0125mg 025mg 25 digox tabs 25 DIGOXIN ORAL SOLN 25 digoxin soln inj 25 digoxin tabs 125mcg 250mcg 25 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 31 dilantin infatabs chew 31 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 24 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 24
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 24
diltiazem hcl er cp12 60mg 90mg 120mg 24
diltiazem hcl er cp24 120mg 180mg 240mg 24
diltiazem hcl soln 24 diltiazem hcl solr 24 diltiazem hcl tabs 30mg 60mg 90mg
120mg 24 dilt-xr cp24 120mg 180mg 240mg 24 dimenhydrinate soln 43 dimethyl fumarate cpdr 34 dimethyl fumarate starter pack misc 34 DIPENTUM CAPS 43 diphen elix 14 di-phen elix 14 diphenhydramine hcl elix 14
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 77
diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 43 diphenoxylate-atropine tabs 43 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 57 dipyridamole tabs 25mg 50mg 75mg 26 disopyramide phosphate caps 100mg
150mg 25 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 38 divalproex sodium csdr 31 divalproex sodium er tb24 250mg 500mg 31 divalproex sodium tbec 125mg 250mg
500mg 31 DIVIGEL GEL 49 dobutamine hcl soln 21 DOBUTAMINE IN D5W SOLN 21 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 160mg8ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
25 dolishale tabs 46 donepezil hcl tabs 5mg 10mg 23mg 20 donepezil hcl tbdp 5mg 10mg 20 dopamine hcl soln 21 DOPAMINE IN D5W SOLN 21 DOPTELET TABS 22 DORYX MPC TBEC 9 dorzolamide hcl soln 42 dorzolamide hcl-timolol mal pf soln 42 dorzolamide hcl-timolol mal soln 42 dotti pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 49
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 35 doxepin hcl conc 35 doxepin hcl crea 61 doxepin hcl tabs 3mg 6mg 35 doxercalciferol caps 05mcg 1mcg 25mcg
63 DOXERCALCIFEROL SOLN 63 doxorubicin hcl liposomal inj 15 DOXORUBICIN HCL SOLN 15
doxorubicin hcl solr 15 doxy 100 solr intravenous 9 doxycycline hyclate caps 50mg 100mg 9 doxycycline hyclate tabs 20mg 75mg
100mg 150mg 9 doxycycline hyclate tbec 50mg 75mg
100mg 150mg 200mg 9 doxycycline monohydrate caps 50mg
75mg 100mg 150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 43 DRIZALMA SPRINKLE CSDR 35 dronabinol caps 25mg 5mg 10mg 43 droperidol soln 33 drospiren-eth estrad-levomefol tabs 46 drospirenone-ethinyl estradiol tabs 46 DROXIA CAPS 15 droxidopa caps 21 DUAKLIR PRESSAIR AEPB 19 DUAVEE TABS 49 DUEXIS TABS 27 DULERA AERO 56 duloxetine hcl cpep 20mg 30mg 40mg
60mg 35 DUOBRII LOTN 60 DUOPA SUSP 32 DUPIXENT SOPN 200mg114ml
300mg2ml 55 DUPIXENT SOSY 200mg114ml
300mg2ml 55 DURAMORPH SOLN 05mgml 1mgml 27 DUREZOL EMUL 41 DURYSTA IMPL 42 dutasteride caps 52 dutasteride-tamsulosin hcl caps 52 DUTOPROL TB24 23 dvorah tabs 27 dxevo 11-day tbpk 45 DYANAVEL XR SUER 30 DYSPORT SOLR 300unit 500unit 54
E ees 400 tabs 9 EASYGEL GEL 54 econazole nitrate crea 58 EDARBYCLOR TABS 26 EDLUAR SUBL 5mg 10mg 33
78 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 51 EGRIFTA SV SOLR 51 ELAPRASE SOLN 40 ELELYSO SOLR 40 ELEPSIA XR TB24 1000mg 1500mg 31 ELESTRIN GEL 49 eletriptan hydrobromide tabs 32 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 40 elixophyllin elix 63 ELLA TABS 46 ELLENCE SOLN 15 ELMIRON CAPS 54 eluryng ring 46 ELZONRIS SOLN 15 EMBEDA CPCR 27 EMCYT CAPS 15 EMEND SUSR 43 EMFLAZA SUSP 45 EMFLAZA TABS 6mg 18mg 30mg 36mg
45 EMGALITY (300 MG DOSE) SOSY 32 EMGALITY SOAJ 32 EMGALITY SOSY 32 emoquette tabs 46 EMPAVELI SOLN 54 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 32 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 26 enalaprilat inj 26 enalapril-hydrochlorothiazide tabs 26 ENBREL MINI SOCT 52 ENBREL SOLN 52 ENBREL SOLR 52 ENBREL SOSY 25mg05ml 50mgml 52 ENBREL SURECLICK SOAJ 52 ENDARI PACK 54 endocet tabs 27
ENDOMETRIN INST 50 ENGERIX-B SUSP 10mcg05ml 20mcgml
57 ENHERTU SOLR 15 enoxaparin sodium soln 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
enpresse-28 tabs 46 enskyce tabs 46 ENSPRYNG SOSY 54 ENSTILAR FOAM 60 entacapone tabs 33 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 26 ENTYVIO SOLR 44 enulose soln 37 ENVARSUS XR TB24 075mg 1mg 4mg53 EPCLUSA TABS 12 EPIDIOLEX SOLN 31 EPIDUO FORTE GEL 62 epifoam foam 60 epinastine hcl soln 42 epinephrine (anaphylaxis) soln 21 epinephrine soaj 21 EPINEPHRINE SOSY 21 EPIPEN 2-PAK SOAJ 21 EPIPEN JR 2-PAK SOAJ 21 epirubicin hcl soln 15 epitol tabs 31 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 26 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 22
epoprostenol sodium solr 56 eprosartan mesylate tabs 26 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 35 ERAXIS SOLR INTRAVENOUS 50mg
100mg 11 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 32 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 79
ERTACZO CREA 58 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 58 ery-tab tbec 9 ERYTHROCIN LACTOBIONATE SOLR
INTRAVENOUS 9 erythrocin stearate tabs 9 erythromycin base cpep 9 erythromycin base tabs 9 erythromycin base tbec 9 erythromycin ethylsuccinate susr 9 erythromycin ethylsuccinate tabs 9 erythromycin gel 58 erythromycin oint 40 erythromycin pads 58 erythromycin soln 58 ESBRIET CAPS 56 ESBRIET TABS 267mg 801mg 56 escitalopram oxalate soln 35 escitalopram oxalate tabs 5mg 10mg
20mg 35 esgic caps 27 esgic tabs 27 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 43 esomeprazole magnesium pack 10mg
20mg 40mg 43 esomeprazole sodium solr 43 ESOMEPRAZOLE STRONTIUM CPDR 43 estarylla tabs 46 estazolam tabs 1mg 2mg 33 estrace crea 49 estrace tabs 05mg 1mg 2mg 49 estradiol crea 49 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 49
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
estradiol tabs 10mcg 05mg 1mg 2mg 49 estradiol valerate oil 49 estradiol-norethindrone acet tabs 49 ESTRING RING 49 eszopiclone tabs 1mg 2mg 3mg 33
ethacrynic acid tabs 38 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 31 ethosuximide soln 31 ethynodiol diac-eth estradiol tabs 46 etodolac caps 27 etodolac er tb24 27 etodolac tabs 27 etonogestrel-ethinyl estradiol ring 46 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 EURAX CREA 58 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
EVAMIST SOLN 49 evekeo tabs 5mg 10mg 30 EVENITY SOSY 52 everolimus tabs 025mg 53 everolimus tabs 05mg 075mg 53 everolimus tabs 25mg 5mg 75mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 23 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 54 EXELDERM CREA 58 EXELDERM SOLN 58 exemestane tabs 15 EXJADE TBSO 125mg 250mg 500mg 44 EXONDYS 51 SOLN 500mg10ml
100mg2ml 54 EXSERVAN FILM 34 EXTAVIA KIT 34 EYLEA SOLN 42 EYLEA SOSY 42 ezetimibe tabs 23 ezetimibe-simvastatin tabs 23
F FABIOR FOAM 62 FABRAZYME SOLR 5mg 35mg 40 falmina tabs 46 famciclovir tabs 125mg 250mg 500mg 12 famotidine premixed soln 43 famotidine soln 43 famotidine susr 43 famotidine tabs 20mg 40mg 43
80 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg 35
FANAPT TITRATION PACK TABS 35 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 55 FASENRA SOSY 55 FASLODEX SOLN 15 fayosim tabs 46 febuxostat tabs 40mg 80mg 52 felbamate susp 31 felbamate tabs 400mg 600mg 31 felodipine er tb24 25mg 5mg 10mg 24 femynor tabs 46 fenofibrate caps 50mg 134mg 150mg 23 fenofibrate micronized caps 43mg 67mg
130mg 200mg 23 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 23 fenofibric acid cpdr 45mg 135mg 23 FENOFIBRIC ACID TABS 35mg 105mg 23 fenoprofen calcium caps 27 fenoprofen calcium tabs 27 fenortho caps 27 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 27 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 27
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg 27
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 27
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 27
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg 27
FERRIPROX SOLN 44 FERRIPROX TABS 500mg 1000mg 44 FERRIPROX TWICE-A-DAY TABS 44 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
35 FETZIMA TITRATION C4PK 35 fexmid tabs 20 FIBRICOR TABS 23 FINACEA FOAM 62 finasteride tabs 52 FINTEPLA SOLN 31
fioricet caps 27 fioricetcodeine caps 27 FIRAZYR SOLN 21 FIRDAPSE TABS 54 FIRMAGON (240 MG DOSE) SOLR 16 FIRMAGON SOLR 16 FIRVANQ SOLR 9 flac oil 41 FLAREX SUSP 41 flavoxate hcl tabs 63 FLEBOGAMMA DIF SOLN INTRAVENOUS
5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml 57
flecainide acetate tabs 50mg 100mg 150mg 25
FLOLIPID SUSP 20mg5ml 40mg5ml 23 FLOVENT DISKUS AEPB 50mcgblist
100mcgblist 250mcgblist 56 FLOVENT HFA AERO 110mcgact
220mcgact 56 FLOVENT HFA AERO 44mcgact 56 floxuridine solr 16 fluconazole in sodium chloride soln
intravenous 11 fluconazole susr 11 fluconazole tabs 11 flucytosine caps 250mg 500mg 11 fludarabine phosphate soln 16 fludarabine phosphate solr 16 fludrocortisone acetate tabs 45 flumazenil soln 34 flunisolide soln 41 fluocinolone acetonide body oil 60 fluocinolone acetonide crea 001 0025
60 fluocinolone acetonide oil 41 fluocinolone acetonide oint 60 fluocinolone acetonide scalp oil 60 fluocinolone acetonide soln 60 fluocinonide crea 60 fluocinonide emulsified base crea 60 FLUOCINONIDE GEL 60 fluocinonide oint 60 fluocinonide soln 60 FLUORITAB CHEW 025mg 05mg 1mg 54 FLUORITAB SOLN 54 fluorometholone susp 41 fluorouracil crea 5 62
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 81
fluorouracil crea 5 62 fluorouracil soln 16 62 fluorouracil soln 2 5 62 fluoxetine hcl (pmdd) tabs 10mg 20mg 35 fluoxetine hcl caps 10mg 20mg 40mg 35 fluoxetine hcl cpdr 35 fluoxetine hcl soln 35 fluoxetine hcl tabs 10mg 20mg 60mg 36 fluphenazine decanoate soln 36 fluphenazine hcl conc 36 fluphenazine hcl elix 36 fluphenazine hcl soln 36 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 36 flurandrenolide crea 60 flurandrenolide lotn 60 flurandrenolide oint 60 flurazepam hcl caps 15mg 30mg 33 flurbiprofen sodium soln 41 flurbiprofen tabs 27 flutamide caps 16 fluticasone propionate crea 60 fluticasone propionate lotn 60 fluticasone propionate oint 60 fluticasone propionate susp 41 fluticasone-salmeterol aepb 56 fluvastatin sodium caps 20mg 40mg 23 fluvastatin sodium er tb24 23 fluvoxamine maleate er cp24 100mg
150mg 36 fluvoxamine maleate tabs 25mg 50mg
100mg 36 FML FORTE SUSP 41 FML OINT 41 fomepizole soln 52 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 formoterol fumarate nebu 21 FORTEO SOPN 50 FOSAMAX PLUS D TABS 52 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 43 fosfomycin tromethamine pack 14 fosinopril sodium tabs 10mg 20mg 40mg
26 fosinopril sodium-hctz tabs 26 fosphenytoin sodium soln 31 FOSRENOL PACK 750mg 1000mg 39
FOTIVDA CAPS 089mg 134mg 16 FREAMINE HBC SOLN INTRAVENOUS 38 frovatriptan succinate tabs 32 FULPHILA SOSY 22 fulvestrant soln 16 furosemide soln 8mgml 10mgml 38 furosemide soln injection 38 FUROSEMIDE TABS 40mg 80mg 20mg38 FUZEON SOLR 12 fyavolv tabs 49 FYCOMPA SUSP 31 FYCOMPA TABS 31
G gabapentin caps 100mg 400mg 31 gabapentin soln 31 gabapentin tabs 600mg 800mg 31 GALAFOLD CAPS 54 galantamine hydrobromide er cp24 8mg
16mg 24mg 20 galantamine hydrobromide soln 20 galantamine hydrobromide tabs 4mg 8mg
12mg 20 GAMASTAN INJ 57 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 53 GAMMAGARD SD LESS IGA SOLR
INTRAVENOUS 5gm 10gm 57 GAMMAGARD SOLN INJECTION 57 GAMMAKED SOLN INJECTION 57 GAMMAPLEX SOLN INTRAVENOUS
10gm100ml 20gm200ml 5gm50ml 57 GAMMAPLEX SOLN INTRAVENOUS
10gm200ml 57 GAMUNEX-C SOLN INJECTION
10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml 57
ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 57 GARDASIL 9 SUSY 57 gatifloxacin soln 40 GATTEX KIT 44 gavilyte-c solr 44 gavilyte-g solr 44 gavilyte-h kit 44 gavilyte-n with flavor pack solr 44 GAVRETO CAPS 16 GAZYVA SOLN 16
82 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
gemcitabine hcl soln 16 gemcitabine hcl solr 16 gemfibrozil tabs 23 gemmily caps 46 generlac soln 37 gengraf caps 25mg 50mg 100mg 53 gengraf soln 53 GENOTROPIN MINIQUICK SOLR 02mg 51 GENOTROPIN MINIQUICK SOLR 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 51
GENOTROPIN SOLR 5mg 12mg 51 gentak oint 40 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 58 gentamicin sulfate oint 58 gentamicin sulfate soln 9 40 gentamicin sulfate soln injection 9 GENVOYA TABS 12 GEODON SOLR 36 gianvi tabs 46 GILENYA CAPS 025mg 05mg 34 GILOTRIF TABS 20mg 30mg 40mg 16 GIMOTI SOLN 44 GIVLAARI SOLN 54 GLASSIA SOLN INTRAVENOUS 56 glatiramer acetate sosy 20mgml 40mgml
34 glatopa sosy 20mgml 40mgml 34 glimepiride tabs 1mg 2mg 4mg 48 glipizide er tb24 25mg 5mg 10mg 48 glipizide tabs 5mg 10mg 48 glipizide-metformin hcl tabs 48 GLOPERBA SOLN 52 GLUCAGEN HYPOKIT SOLR 48 glucagon emergency kit 48 glyburide micronized tabs 15mg 3mg 6mg
48 glyburide tabs 125mg 25mg 5mg 48 glyburide-metformin tabs 48 glycate tabs 19 glycopyrrolate pf sosy 19 glycopyrrolate soln 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 61 GLYXAMBI TABS 48 GOLYTELY SOLR 44 GONITRO PACK 26
granisetron hcl soln 43 granisetron hcl tabs 43 GRANIX SOLN 480mcg16ml 300mcgml
22 GRANIX SOSY 300mcg05ml
480mcg08ml 22 GRASTEK SUBL 54 griseofulvin microsize susp 11 griseofulvin microsize tabs 11 griseofulvin ultramicrosize tabs 11 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 34 guanfacine hcl tabs 1mg 2mg 25 GUANIDINE HCL TABS 20 gynazole-1 crea 58
H HAEGARDA SOLR 2000unit 3000unit 54 hailey 24 fe tabs 46 halcinonide crea 60 halobetasol propionate crea 60 HALOBETASOL PROPIONATE FOAM 60 halobetasol propionate oint 60 HALOG CREA 60 HALOG OINT 60 haloperidol decanoate soln 36 haloperidol lactate conc 36 haloperidol lactate soln 36 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 36 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 57 heparin (porcine) in nacl soln 21 HEPARIN SOD (PORCINE) IN D5W SOLN
21 heparin sodium (porcine) pf soln 21 heparin sodium (porcine) soln 1000unitml
5000unitml 10000unitml 20000unitml 21
HEPATAMINE SOLN INTRAVENOUS 38 HEPLISAV-B SOLN 57 HERCEPTIN HYLECTA SOLN 16 HERCEPTIN SOLR 150mg 440mg 16 HERZUMA SOLR 150mg 420mg 16 HETLIOZ CAPS 33 HETLIOZ LQ SUSP 33 HEXALEN CAPS 16 HIBERIX SOLR 57
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 83
HORIZANT TBCR 300mg 600mg 31 HUMALOG JUNIOR KWIKPEN SOPN 48 HUMALOG KWIKPEN SOPN 100unitml
200unitml 48 HUMALOG MIX 5050 KWIKPEN SUPN 48 HUMALOG MIX 5050 SUSP 48 HUMALOG MIX 7525 KWIKPEN SUPN 48 HUMALOG MIX 7525 SUSP 48 HUMALOG SOCT 48 HUMALOG SOLN 48 humatin caps 11 HUMATROPE SOLR 5mg 6mg 12mg
24mg 51 HUMIRA PEDIATRIC CROHNS START
PSKT 52 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 52 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 52 HUMIRA PEN-PEDIATRIC UC START
PNKT 52 HUMIRA PEN-PSUVADOL HS START
PNKT 52 HUMIRA PEN-PSORUVEIT STARTER
PNKT 52 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 52
HUMULIN 7030 KWIKPEN SUPN 48 HUMULIN 7030 SUSP 48 HUMULIN N KWIKPEN SUPN 48 HUMULIN N SUSP 48 HUMULIN R SOLN 48 HUMULIN R U-500 (CONCENTRATED)
SOLN 48 HUMULIN R U-500 KWIKPEN SOPN 48 hydralazine hcl soln 25 hydralazine hcl tabs 10mg 25mg 50mg
100mg 25 hydrochlorothiazide caps 38 hydrochlorothiazide tabs 125mg 25mg
50mg 38 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 27 hydrocodone-acetaminophen soln 27 hydrocodone-acetaminophen tabs 27 hydrocodone-ibuprofen tabs 27 hydrocortisone (perianal) crea 1 25 60 hydrocortisone ace-pramoxine crea 61
hydrocortisone butyr lipo base crea 60 hydrocortisone butyrate crea 60 hydrocortisone butyrate lotn 60 HYDROCORTISONE BUTYRATE OINT 60 hydrocortisone butyrate soln 60 hydrocortisone crea 1 25 60 hydrocortisone enem 60 hydrocortisone lotn 60 hydrocortisone oint 1 25 60 hydrocortisone tabs 5mg 10mg 20mg 45 hydrocortisone valerate crea 60 hydrocortisone valerate oint 60 HYDROCORTISONE-ACETIC ACID SOLN
41 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 28 hydromorphone hcl liqd 28 hydromorphone hcl pf soln 50mg5ml
10mgml 28 HYDROMORPHONE HCL SOLN 1mgml
2mgml 28 hydromorphone hcl tabs 2mg 4mg 8mg 28 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 50 hydroxyprogesterone caproate soln 50 hydroxyurea caps 16 hydroxyzine hcl soln 33 hydroxyzine hcl syrp 33 hydroxyzine hcl tabs 33 hydroxyzine pamoate caps 33 HYPERHEP B SOLN 57 HYPERRAB SD SOLN 57 HYQVIA KIT 57
I IBANDRONATE SODIUM SOLN 52 ibandronate sodium tabs 52 IBRANCE CAPS 75mg 100mg 125mg 16 IBRANCE TABS 75mg 100mg 125mg 16 ibu tabs 28 ibudone tabs 28 ibuprofen lysine soln 28 ibuprofen susp 28 ibuprofen tabs 28 ibutilide fumarate soln 25 icatibant acetate soln 21 iclevia tabs 46 ICLUSIG TABS 10mg 15mg 30mg 45mg
16
84 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
icosapent ethyl caps 23 IDAMYCIN PFS SOLN 16 idarubicin hcl soln 16 IDHIFA TABS 50mg 100mg 16 ifosfamide soln 16 IFOSFAMIDE SOLR 16 ILARIS SOLN 28 ILEVRO SUSP 41 ILUMYA SOSY 62 ILUVIEN IMPL 41 imatinib mesylate tabs 16 IMBRUVICA CAPS 70mg 140mg 16 IMBRUVICA TABS 140mg 280mg 420mg
560mg 16 IMFINZI SOLN 500mg10ml 120mg24ml
16 imipenem-cilastatin solr intravenous 9 imipramine hcl tabs 10mg 25mg 50mg 36 imipramine pamoate caps 75mg 100mg
125mg 150mg 36 imiquimod crea 375 5 62 IMIQUIMOD PUMP CREA 62 IMOGAM RABIES-HT SOLN 57 IMOVAX RABIES INJ 57 IMPAVIDO CAPS 11 IMVEXXY MAINTENANCE PACK INST
4mcg 10mcg 49 IMVEXXY STARTER PACK INST 4mcg
10mcg 49 INBRIJA CAPS 33 incassia tabs 46 INCRELEX SOLN 51 INCRUSE ELLIPTA AEPB 19 indapamide tabs 125mg 25mg 38 indocin supp 28 INDOCIN SUSP 28 indomethacin caps 28 INDOMETHACIN CAPS 20mg 28 indomethacin er cpcr 28 indomethacin sodium solr 28 INFANRIX SUSP 57 INFLECTRA SOLR INTRAVENOUS 52 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 34 INGREZZA CPPK 34 INLYTA TABS 1mg 5mg 16 INNOPRAN XL CP24 80mg 120mg 23 INQOVI TABS 16 INREBIC CAPS 16
INSULIN ASP PROT amp ASP FLEXPEN SUPN 48
INSULIN ASPART FLEXPEN SOPN 48 INSULIN ASPART PENFILL SOCT 48 INSULIN ASPART PROT amp ASPART SUSP
48 INSULIN ASPART SOLN 48 INSULIN LISPRO (1 UNIT DIAL) SOPN 48 INSULIN LISPRO SOLN 48 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 38 INTRALIPID EMUL INTRAVENOUS
20gm100ml 38 INTRAROSA INST 45 INTRON A SOLN 10muml 6000000unitml
16 INTRON A SOLR 10mu 18mu 50mu 16 introvale tabs 46 INVEGA SUSTENNA SUSY 39mg025ml
36 INVEGA SUSTENNA SUSY 78mg05ml
117mg075ml 234mg15ml 156mgml 36
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml 36
INVELTYS SUSP 41 INVIRASE CAPS 12 INVIRASE TABS 12 INVOKAMET TABS 48 INVOKAMET XR TB24 48 INVOKANA TABS 100mg 300mg 48 IONOSOL-MB IN D5W SOLN
INTRAVENOUS 39 IOPIDINE SOLN 42 IPOL INJ 57 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 21 irbesartan tabs 75mg 150mg 300mg 26 irbesartan-hydrochlorothiazide tabs 26 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isibloom tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 85
ISOLYTE-P IN D5W SOLN INTRAVENOUS 39
ISOLYTE-S SOLN INTRAVENOUS 39 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 21 isosorbide dinitrate er tbcr 26 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 26 isosorbide mononitrate er tb24 26 isosorbide mononitrate er tb24 30mg 60mg
26 isosorbide mononitrate tabs 10mg 20mg 26 isotretinoin caps 10mg 20mg 30mg 40mg
62 isradipine caps 25mg 5mg 24 ISTURISA TABS 1mg 5mg 10mg 54 itraconazole caps 11 ITRACONAZOLE SOLN 11 ivermectin crea 58 ivermectin lotn 58 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 57
J JADENU SPRINKLE PACK 90mg 180mg
360mg 44 JADENU TABS 90mg 360mg 44 JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16 jantoven tabs 1mg 2mg 25mg 3mg 4mg
5mg 6mg 75mg 10mg 21 JARDIANCE TABS 10mg 25mg 48 jasmiel tabs 46 JEMPERLI SOLN 16 JENTADUETO TABS 48 JENTADUETO XR TB24 48 jinteli tabs 49 JOLIVETTE TABS 46 juleber tabs 46 JULUCA TABS 12 junel 1530 tabs 46 junel 120 tabs 46 junel fe 1530 tabs 46 junel fe 120 tabs 46 junel fe 24 tabs 46
JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg 23
JYNARQUE TABS 15mg 30mg 39 JYNARQUE TBPK 39
K KADCYLA SOLR 100mg 160mg 16 KADIAN CP24 28 kaitlib fe chew 46 KALYDECO PACK 25mg 50mg 75mg 56 KALYDECO TABS 56 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 40 kariva tabs 46 KAZANO TABS 48 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-033 MEQ 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 40-5-09 MEQ 39 KCL-LACTATED RINGERS-D5W SOLN
INTRAVENOUS 39 KEDRAB SOLN 57 kelnor 135 tabs 46 kelnor 150 tabs 46 KENALOG SUSP 45 KEPIVANCE SOLR 61 keralyt sham 62 KESIMPTA SOAJ 54 ketoconazole crea 58 ketoconazole foam 58 ketoconazole sham 58 ketoconazole tabs 11 ketodan foam 58 ketoprofen caps 28 ketoprofen er cp24 28 ketorolac tromethamine soln 28 41 ketorolac tromethamine soln 04 05 41 ketorolac tromethamine tabs 28 KEVEYIS TABS 54 KEVZARA SOAJ 150mg114ml
200mg114ml 53 KEVZARA SOSY 150mg114ml
200mg114ml 53 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 52 KHEDEZLA TB24 50mg 100mg 36 KIMYRSA SOLR 9
86 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
KINERET SOSY 53 KINRIX SUSP 57 kionex susp 39 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (200 MG DOSE) TBPK
16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KITABIS PAK NEBU 56 KLISYRI OINT 62 KLOR-CON 10 TBCR 39 klor-con m10 tbcr 39 klor-con m15 tbcr 39 klor-con m20 tbcr 39 klor-con pack 39 klor-con sprinkle cpcr 8meq 10meq 39 KLOR-CON TBCR 39 KORLYM TABS 48 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 37 K-TAB TBCR 39 kurvelo tabs 46 KUVAN PACK 100mg 500mg 54 KUVAN TABS 54 KYNAMRO SOSY 23 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 33 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 LACRISERT INST 42 LACTATED RINGERS SOLN 39 54 LACTIC ACID LOTN 62 lactulose encephalopathy soln 37 lactulose pack 38 lactulose soln 38 LAMICTAL XR KIT 31 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 31
lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg 31
lamotrigine kit 31 lamotrigine starter kit-blue kit 31 lamotrigine starter kit-green kit 31 lamotrigine starter kit-orange kit 31 lamotrigine tabs 25mg 100mg 150mg
200mg 31 lamotrigine tbdp 25mg 50mg 100mg
200mg 31 LANOXIN PEDIATRIC SOLN 25 LANOXIN TABS 625mcg 25 lansoprazole cpdr 15mg 30mg 43 lansoprazole tbdd 15mg 30mg 43 lanthanum carbonate chew 500mg 750mg
1000mg 39 LANTUS SOLN 48 LANTUS SOLOSTAR SOPN 49 lapatinib ditosylate tabs 16 larin 1530 tabs 46 larin 120 tabs 46 larin fe 1530 tabs 46 larin fe 120 tabs 46 larissia tabs 46 LARTRUVO SOLN 190mg19ml
500mg50ml 16 LASTACAFT SOLN 42 latanoprost soln 42 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 36 LAYOLIS FE CHEW 46 LAZANDA SOLN 100mcgact 300mcgact
400mcgact 28 ledipasvir-sofosbuvir tabs 12 leena tabs 46 leflunomide tabs 10mg 20mg 53 LEMTRADA SOLN 34 LENVIMA (10 MG DAILY DOSE) CPPK 16 LENVIMA (12 MG DAILY DOSE) CPPK 16 LENVIMA (14 MG DAILY DOSE) CPPK 16 LENVIMA (18 MG DAILY DOSE) CPPK 16 LENVIMA (20 MG DAILY DOSE) CPPK 16 LENVIMA (24 MG DAILY DOSE) CPPK 16 LENVIMA (4 MG DAILY DOSE) CPPK 16 LENVIMA (8 MG DAILY DOSE) CPPK 17 lessina tabs 46 LETAIRIS TABS 5mg 10mg 56 letrozole tabs 17 leucovorin calcium soln 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 87
leucovorin calcium solr 52 leucovorin calcium tabs 5mg 10mg 15mg
25mg 52 LEUKERAN TABS 17 LEUKINE SOLR 22 leuprolide acetate kit 17 levalbuterol hcl nebu 125mg05ml
031mg3ml 063mg3ml 125mg3ml 21 levalbuterol tartrate aero 21 LEVEMIR FLEXTOUCH SOPN 49 LEVEMIR SOLN 49 levetiracetam er tb24 500mg 750mg 31 levetiracetam in nacl soln 31 levetiracetam soln 31 levetiracetam tabs 250mg 500mg 750mg
1000mg 31 levobunolol hcl soln 42 levocarnitine soln 54 LEVOCARNITINE TABS 54 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 40 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 52 levoleucovorin calcium solr 52 levonest tabs 46 levonorgest-eth est amp eth est tabs 47 levonorgest-eth estrad 91-day tabs 47 levonorgestrel-ethinyl estrad tabs 47 levonorg-eth estrad triphasic tabs 46 levora 01530 (28) tabs 47 levorphanol tartrate tabs 2mg 3mg 28 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEVOTHYROXINE SODIUM SOLR 51 levothyroxine sodium tabs 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEXETTE FOAM 60 LEXIVA SUSP 12 LIALDA TBEC 43 LIBTAYO SOLN 17 lidocaine hcl (cardiac) pf sosy 25 lidocaine hcl (cardiac) sosy 25 lidocaine hcl (pf) soln 54 LIDOCAINE HCL CREA 61 lidocaine hcl lotn 61 lidocaine hcl soln 42 54 61 lidocaine hcl urethralmucosal gel 61 lidocaine hcl urethralmucosal prsy 61 LIDOCAINE IN D5W SOLN 25 lidocaine in dextrose soln 54 lidocaine oint 61 lidocaine ptch 61 lidocaine viscous hcl soln 42 lidocaine-epinephrine soln 54 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 61 LIDOCAINE-HYDROCORTISONE ACE KIT
61 lidocaine-prilocaine crea 61 lidocaine-tetracaine crea 61 LIDOCORT CREA 61 lidopin crea 61 LIDO-SORB LOTN 61 LIDOZION LOTN 61 lincomycin hcl soln 9 lindane sham 58 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 LINZESS CAPS 72mcg 145mcg 290mcg
44 liothyronine sodium soln 51 liothyronine sodium tabs 5mcg 25mcg
50mcg 51 LIPODOX 50 INJ 17 lisinopril tabs 25mg 5mg 10mg 20mg
30mg 40mg 26 lisinopril-hydrochlorothiazide tabs 26 LITHIUM CARBONATE CAPS 300mg
150mg 600mg 36 lithium carbonate er tbcr 300mg 450mg 36 lithium carbonate tabs 36
88 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
LITHIUM SOLN 36 LITHOSTAT TABS 38 LIVALO TABS 1mg 2mg 4mg 23 LO LOESTRIN FE TABS 47 lodine tabs 28 loestrin 1530 (21) tabs 47 loestrin 120 (21) tabs 47 loestrin fe 1530 tabs 47 loestrin fe 120 tabs 47 LOKELMA PACK 5gm 10gm 39 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 17 loperamide hcl caps 43 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 49 lorazepam intensol conc 33 LORAZEPAM SOLN 4mgml 2mgml 33 lorazepam tabs 05mg 1mg 2mg 33 LORBRENA TABS 25mg 100mg 17 lorcet hd tabs 28 lorcet plus tabs 28 lorcet tabs 28 lortab elix 28 loryna tabs 47 lorzone tabs 375mg 750mg 20 losartan potassium tabs 25mg 50mg
100mg 26 losartan potassium-hctz tabs 26 LOTEMAX GEL 41 LOTEMAX OINT 41 LOTEMAX SUSP 41 loteprednol etabonate susp 41 lovastatin tabs 10mg 20mg 40mg 23 LOVENOX SOLN 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
low-ogestrel tabs 47 loxapine succinate caps 5mg 10mg 25mg
50mg 36 lubiprostone caps 8mcg 24mcg 44 LUCEMYRA TABS 34 LUCENTIS SOLN 03mg005ml
05mg005ml 42 LUCENTIS SOSY 03mg005ml
05mg005ml 42 LUDENT CHEW 025mg 05mg 1mg 54 LULICONAZOLE CREA 58 LUMAKRAS TABS 17
LUMIGAN SOLN 42 LUMIZYME SOLR 40 LUMOXITI SOLR 17 LUPANETA PACK KIT 17 LUPKYNIS CAPS 53 LUPRON DEPOT (1-MONTH) KIT 17 LUPRON DEPOT (3-MONTH) KIT 17 LUPRON DEPOT (4-MONTH) KIT 17 LUPRON DEPOT (6-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 17 LUPRON DEPOT-PED (3-MONTH) KIT 17 lutera tabs 47 LUZU CREA 58 lyleq tabs 47 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 50
LYNPARZA CAPS 17 LYNPARZA TABS 100mg 150mg 17 LYSODREN TABS 17 lyza tabs 47
M mafenide acetate pack 58 magnesium sulfate in d5w soln 39 magnesium sulfate soln 31 magnesium sulfate soln injection 50 31 MAGNESIUM SULFATE SOLN
INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml 31
MAKENA SOAJ 50 malathion lotn 58 MANNITOL SOLN 39 maprotiline hcl tabs 25mg 50mg 75mg 36 MARGENZA SOLN 17 marlissa tabs 47 MARPLAN TABS 36 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 24 MAVENCLAD (10 TABS) TBPK 53 MAVENCLAD (4 TABS) TBPK 53 MAVENCLAD (5 TABS) TBPK 53 MAVENCLAD (6 TABS) TBPK 53 MAVENCLAD (7 TABS) TBPK 53 MAVENCLAD (8 TABS) TBPK 53
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 89
MAVENCLAD (9 TABS) TBPK 53 MAVYRET TABS 12 MAXIDEX SUSP 41 MAYZENT STARTER PACK TBPK 34 MAYZENT TABS 025mg 2mg 34 MENAPHOSMBHYO1 TABS 14 meclizine hcl tabs 43 meclofenamate sodium caps 28 MEDROL TABS 45 medroxyprogesterone acetate susp 50 medroxyprogesterone acetate susy 50 medroxyprogesterone acetate tabs 25mg
5mg 10mg 50 mefenamic acid caps 28 mefloquine hcl tabs 11 megestrol acetate susp 17 50 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 47 meloxicam caps 28 meloxicam tabs 28 melphalan hcl solr 17 memantine hcl er cp24 34 memantine hcl soln 34 memantine hcl tabs 5mg 10mg 34 MENACTRA INJ 57 menest tabs 03mg 0625mg 125mg 50 MENOSTAR PTWK 50 MENQUADFI INJ 57 MENTAX CREA 58 MENVEO SOLR 57 meperidine hcl soln 50mg5ml 25mgml
50mgml 100mgml 28 meperidine hcl tabs 50mg 100mg 28 meprobamate tabs 33 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 47 mesalamine cpdr 43 mesalamine enem 43 mesalamine er cp24 43 mesalamine supp 43 mesalamine tbec 12gm 800mg 43 mesalamine-cleanser kit 43 mesna soln 54 MESNEX TABS 54 MESTINON SOLN 20 metadate er tbcr 30
metaproterenol sulfate syrp 21 metaproterenol sulfate tabs 10mg 20mg 21 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 49 metformin hcl tabs 500mg 850mg 1000mg
49 methadone hcl conc 28 methadone hcl intensol conc 28 methadone hcl soln 5mg5ml 10mg5ml
10mgml 28 methadone hcl tabs 5mg 10mg 28 methamphetamine hcl tabs 30 methazolamide tabs 25mg 50mg 42 methenamine hippurate tabs 14 METHENAMINE MANDELATE TABS 14 methergine tabs 50 methimazole tabs 5mg 10mg 51 methitest tabs 45 methocarbamol soln 20 methocarbamol tabs 20 methotrexate sodium (pf) soln 17 methotrexate sodium soln 17 methotrexate sodium solr 17 methotrexate tabs 17 methoxsalen rapid caps 62 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 39 methyldopa tabs 250mg 500mg 25 methyldopa-hydrochlorothiazide tabs 25 methylergonovine maleate soln 50 methylergonovine maleate tabs 50 methylphenidate hcl chew 25mg 5mg
10mg 30 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 30 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 30 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 30
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 30
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 30
methylphenidate hcl soln 5mg5ml 10mg5ml 30
90 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
methylphenidate hcl tabs 5mg 10mg 20mg 30
methylprednisolone acetate susp 45 methylprednisolone sodium succ solr 45 methylprednisolone tabs 4mg 8mg 16mg
32mg 45 methylprednisolone tbpk 45 methyltestosterone caps 45 metoclopramide hcl soln 44 metoclopramide hcl tabs 5mg 10mg 44 metoclopramide hcl tbdp 5mg 10mg 44 metolazone tabs 25mg 5mg 10mg 39 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 24 metoprolol tartrate soct 24 metoprolol tartrate soln 24 metoprolol tartrate tabs 25mg 50mg
100mg 24 metoprolol tartrate tabs 375mg 75mg 24 metoprolol-hydrochlorothiazide tabs 24 metronidazole caps 11 metronidazole crea 58 metronidazole gel 58 metronidazole in nacl soln 11 metronidazole in nacl soln intravenous 11 metronidazole lotn 58 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
25 mibelas 24 fe chew 47 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 58 miconazole-zinc oxide-petrolat oint 58 micort-hc crea 60 microgestin 1530 tabs 47 microgestin 120 tabs 47 microgestin fe 1530 tabs 47 microgestin fe 120 tabs 47 midazolam hcl (pf) soln 33 midazolam hcl soln 33 midazolam hcl syrp 33 midodrine hcl tabs 25mg 5mg 10mg 21 miglitol tabs 25mg 50mg 100mg 49 miglustat caps 40 mili tabs 47 millipred dp tbpk 45 millipred tabs 45
milrinone lactate in dextrose soln 25 milrinone lactate soln 25 mimvey lo tabs 50 mimvey tabs 50 minitran pt24 01mghr 02mghr 04mghr
06mghr 26 minocycline hcl caps 50mg 75mg 100mg 9 minocycline hcl er tb24 45mg 55mg 65mg
80mg 90mg 105mg 115mg 135mg 9 minocycline hcl tabs 50mg 75mg 100mg 9 minoxidil tabs 25mg 10mg 25 MIRCERA SOSY 30mcg03ml
50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml 22
mirtazapine tabs 75mg 15mg 30mg 45mg 36
mirtazapine tbdp 15mg 30mg 45mg 36 misoprostol tabs 100mcg 200mcg 43 MITIGARE CAPS 52 mitigo soln 28 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 57 modafinil tabs 100mg 200mg 30 moexipril hcl tabs 75mg 15mg 26 molindone hcl tabs 5mg 10mg 25mg 36 mometasone furoate crea 60 mometasone furoate oint 60 mometasone furoate soln 60 mometasone furoate susp 41 mondoxyne nl caps 75mg 100mg 9 MONJUVI SOLR 17 MONONESSA TABS 47 montelukast sodium chew 4mg 5mg 55 montelukast sodium pack 55 montelukast sodium tabs 55 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 28 morphine sulfate (pf) soln 4mgml 10mgml
28 MORPHINE SULFATE (PF) SOLN
INTRAVENOUS 28 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 28 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 28
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 91
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 28
MORPHINE SULFATE SOLN 28 MORPHINE SULFATE SOLN 10mg5ml
20mg5ml 28 MORPHINE SULFATE SOLN INJECTION
2mgml 4mgml 10mgml 28 MORPHINE SULFATE SOLN
INTRAVENOUS 28 morphine sulfate tabs 15mg 30mg 28 MOVANTIK TABS 125mg 25mg 44 MOXEZA SOLN 41 moxifloxacin hcl (2x day) soln 41 moxifloxacin hcl in nacl soln intravenous 10 moxifloxacin hcl soln 41 moxifloxacin hcl tabs 10 MULPLETA TABS 22 MULTAQ TABS 25 MULTIVITAMINFLUORIDE CHEW 63 MULTI-VITAMINFLUORIDE SOLN 63 MULTI-VITAMINFLUORIDEIRON SOLN
63 mupirocin calcium crea 58 mupirocin oint 59 MUSTARGEN SOLR 17 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17 MVC-FLUORIDE CHEW 64 MYALEPT SOLR 54 MYCAPSSA CPDR 51 mycophenolate mofetil caps 53 mycophenolate mofetil hcl solr 53 mycophenolate mofetil susr 53 mycophenolate mofetil tabs 53 mycophenolate sodium tbec 180mg 360mg
53 MYDAYIS CP24 30 MYFEMBREE TABS 50 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 62 MYRBETRIQ TB24 25mg 50mg 63 MYTESI TBEC 43
N NABI-HB SOLN 57 nabumetone tabs 28 N-ACETYL-L-CYSTEINE CAPS 38 nadolol tabs 20mg 40mg 80mg 24 nadolol-bendroflumethiazide tabs 24
nafcillin sodium solr 10 nafcillin sodium solr injection 10 nafcillin sodium solr intravenous 10 NAFRINSE CHEW 54 NAFRINSE DROPS SOLN 54 naftifine hcl crea 59 naftifine hcl gel 59 NAFTIN GEL 59 NAGLAZYME SOLN 40 nalbuphine hcl soln 28 nalfon tabs 28 nalocet tabs 28 naloxone hcl soaj 34 naloxone hcl soct 34 naloxone hcl soln 34 naloxone hcl sosy 34 naltrexone hcl tabs 35 NAMENDA XR TITRATION PACK CP24 34 NAPRELAN TB24 28 naproxen sodium er tb24 28 naproxen sodium tabs 28 naproxen susp 28 naproxen tabs 28 naproxen tbec 28 naproxen-esomeprazole tbec 28 naratriptan hcl tabs 32 NARCAN LIQD 35 NATACYN SUSP 41 NATAZIA TABS 47 nateglinide tabs 60mg 120mg 49 NATPARA CART 25mcg 50mcg 75mcg
100mcg 50 NATROBA SUSP 59 NAYZILAM SOLN 31 NEBUPENT SOLR 11 necon 0535 (28) tabs 47 NECON 777 TABS 47 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 36 nembutal soln 33 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 41 neomycin-polymyxin b gu soln 59 neomycin-polymyxin-dexameth oint 41 neomycin-polymyxin-dexameth susp 41 neomycin-polymyxin-gramicidin soln 41 neomycin-polymyxin-hc soln 41 neomycin-polymyxin-hc susp 41 neo-polycin hc oint 41
92 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
neo-polycin oint 41 neo-synalar crea 60 NEPHRAMINE SOLN INTRAVENOUS 38 NERLYNX TABS 17 NEULASTA ONPRO PSKT 22 NEULASTA SOSY 22 NEUPOGEN SOLN 480mcg16ml
300mcgml 22 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 22 NEVANAC SUSP 41 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 40 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 23 niacor tabs 23 nicardipine hcl caps 20mg 30mg 24 nicardipine hcl soln 24 NICOTROL INHA 20 NICOTROL NS SOLN 20 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 47 nilutamide tabs 17 nimodipine caps 24 NINLARO CAPS 23mg 3mg 4mg 17 nisoldipine er tb24 85mg 17mg 20mg
255mg 30mg 34mg 40mg 24 nitazoxanide tabs 11 nitisinone caps 2mg 5mg 10mg 54 nitro-bid oint 26 NITRO-DUR PT24 03mghr 08mghr 26 NITROFURANTOIN MACROCRYSTAL
CAPS 14 NITROFURANTOIN MONOHYD MACRO
CAPS 14 nitrofurantoin susp 14 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 26 nitroglycerin soln 26 nitroglycerin subl 03mg 04mg 06mg 26 nitropress soln 25 nitroprusside sodium soln 25 NITYR TABS 2mg 5mg 10mg 54
NIVESTYM SOLN 480mcg16ml 300mcgml 22
NIVESTYM SOSY 300mcg05ml 480mcg08ml 22
nizatidine caps 150mg 300mg 43 nizatidine soln 43 NOCDURNA SUBL 277mcg 553mcg 50 NOCTIVA EMUL 083mcg01ml
166mcg01ml 50 nolix crea 60 nolix lotn 60 nora-be tabs 47 norco tabs 28 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 51
norepinephrine bitartrate soln 21 norethin ace-eth estrad-fe caps 47 norethin ace-eth estrad-fe chew 47 norethin ace-eth estrad-fe tabs 47 norethindrone acetate tabs 50 norethindrone acet-ethinyl est tabs 47 norethindrone tabs 47 norethindrone-eth estradiol tabs 50 norethin-eth estradiol-fe chew 47 norgesic forte tabs 28 norgestimate-eth estradiol tabs 47 norgestim-eth estrad triphasic tabs 47 norlyroc tabs 47 NORMOSOL-M IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R SOLN INTRAVENOUS 39 NORPACE CR CP12 100mg 150mg 25 nortrel 0535 (28) tabs 47 nortrel 135 (21) tabs 47 nortrel 135 (28) tabs 47 nortrel 777 tabs 47 nortriptyline hcl caps 10mg 25mg 50mg
75mg 36 nortriptyline hcl soln 36 NORVIR CAPS 12 NORVIR PACK 12 NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 34 NOVAREL SOLR 5000unit 10000unit 50 NOVOLIN 7030 SUSP 49
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 93
NOVOLOG 7030 FLEXPEN RELION SUPN 49
NOVOLOG FLEXPEN RELION SOPN 49 NOVOLOG FLEXPEN SOPN 49 NOVOLOG MIX 7030 FLEXPEN SUPN 49 NOVOLOG MIX 7030 RELION SUSP 49 NOVOLOG MIX 7030 SUSP 49 NOVOLOG PENFILL SOCT 49 NOVOLOG RELION SOLN 49 NOVOLOG SOLN 49 NOXAFIL SUSP 11 NOXAFIL TBEC 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 55 NUCALA SOLR 55 NUCALA SOSY 55 NUCYNTA ER TB12 200mg 250mg 29 NUCYNTA ER TB12 50mg 100mg 150mg
29 NUCYNTA TABS 29 NUCYNTA TABS 50mg 75mg 29 NUEDEXTA CAPS 34 NULIBRY SOLR 54 NULOJIX SOLR 53 NUPLAZID CAPS 36 NUPLAZID TABS 10mg 17mg 36 NURTEC TBDP 32 NUTRILIPID EMUL INTRAVENOUS 38 NUTROPIN AQ NUSPIN 10 SOPN 51 NUTROPIN AQ NUSPIN 20 SOPN 51 NUTROPIN AQ NUSPIN 5 SOPN 51 NUVARING RING 47 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 59 nylia 777 tabs 47 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 47 nystatin crea 59 nystatin oint 59 nystatin powd 59 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 60 nystatin-triamcinolone oint 60 nystop powd 59 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 44 ocella tabs 47 OCREVUS SOLN 34 OCTAGAM SOLN INTRAVENOUS
5gm100ml 1gm20ml 2gm20ml 25gm500ml 57
octreotide acetate soln 51 ODACTRA SUBL 54 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 56 ofloxacin soln 41 ofloxacin tabs 10 ogestrel tabs 47 OGIVRI SOLR 17 okebo caps 10 olanzapine solr 36 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 36 olanzapine tbdp 5mg 10mg 15mg 20mg
36 olanzapine-fluoxetine hcl caps 36 olmesartan medoxomil tabs 5mg 20mg
40mg 26 olmesartan medoxomil-hctz tabs 26 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 42 OLUMIANT TABS 1mg 2mg 53 OLYSIO CAPS 12 OMECLAMOX-PAK MISC 43 omega-3-acid ethyl esters caps 23 omeprazole cpdr 10mg 20mg 40mg 43 omeprazole-sodium bicarbonate caps 43 omeprazole-sodium bicarbonate pack 44 OMNARIS SUSP 41 OMNIPOD STARTER KIT 37 OMNITROPE SOCT 5mg15ml
10mg15ml 51 OMNITROPE SOLR 51 ondansetron hcl soln 43 ondansetron hcl tabs 4mg 8mg 24mg 43 ondansetron tbdp 4mg 8mg 43 ONIVYDE INJ 17 ONPATTRO SOLN 54 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 ONZETRA XSAIL EXHP 32
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OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml 17
OPIUM TINC 43 ORACEA CPDR 62 ORALAIR SUBL 54 oralone pste 60 ORAVIG TABS 59 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 53 ORENCIA SOLR 53 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 53 ORENITRAM TBCR 0125mg 56 ORENITRAM TBCR 025mg 1mg 25mg
5mg 56 ORFADIN CAPS 54 ORFADIN SUSP 54 ORGOVYX TABS 50 ORIAHNN CPPK 50 ORILISSA TABS 150mg 200mg 50 ORKAMBI PACK 56 ORKAMBI TABS 56 ORLADEYO CAPS 110mg 150mg 54 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 29 orphengesic forte tabs 29 orsythia tabs 47 ORTIKOS CP24 6mg 9mg 45 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 39 OSMOPREP TABS 44 OSPHENA TABS 50 OTEZLA TABS 53 OTEZLA TBPK 53 OTOVEL SOLN 41 OTREXUP SOAJ 53 ovide lotn 59 OXACILLIN SODIUM IN DEXTROSE SOLN
INTRAVENOUS 10 oxacillin sodium solr injection 1gm 2gm 10 oxacillin sodium solr intravenous 10 oxaliplatin soln 17 oxaliplatin solr 17 oxandrolone tabs 45 oxandrolone tabs 25mg 45 oxaprozin tabs 29
OXAYDO TABS 29 oxazepam caps 10mg 15mg 30mg 33 OXBRYTA TABS 21 oxcarbazepine susp 31 oxcarbazepine tabs 150mg 300mg 600mg
31 OXERVATE SOLN 42 oxiconazole nitrate crea 59 OXISTAT LOTN 59 OXLUMO SOLN 54 OXTELLAR XR TB24 150mg 300mg
600mg 31 oxybutynin chloride er tb24 5mg 10mg
15mg 63 oxybutynin chloride syrp 63 oxybutynin chloride tabs 63 oxycodone hcl caps 29 oxycodone hcl conc 29 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxycodone hcl soln 29 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 29 oxycodone-acetaminophen soln 29 oxycodone-acetaminophen tabs 29 oxycodone-acetaminophen tabs 5-300mg
10-300mg 29 oxycodone-aspirin tabs 29 oxycodone-ibuprofen tabs 29 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 29 oxymorphone hcl tabs 5mg 10mg 29 OXYTOCIN SOLN 50 OZEMPIC (025 OR 05 MGDOSE) SOPN
49 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 49
P pacerone tabs 100mg 200mg 400mg 25 paclitaxel conc 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
54 PALFORZIA (120 MG DAILY DOSE) CSPK
54
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 95
PALFORZIA (160 MG DAILY DOSE) CSPK 54
PALFORZIA (20 MG DAILY DOSE) CSPK 54
PALFORZIA (200 MG DAILY DOSE) CSPK 54
PALFORZIA (240 MG DAILY DOSE) CSPK 55
PALFORZIA (3 MG DAILY DOSE) CSPK 55 PALFORZIA (300 MG MAINTENANCE)
PACK 55 PALFORZIA (300 MG TITRATION) PACK
55 PALFORZIA (40 MG DAILY DOSE) CSPK
55 PALFORZIA (6 MG DAILY DOSE) CSPK 55 PALFORZIA (80 MG DAILY DOSE) CSPK
55 PALFORZIA INITIAL ESCALATION CSPK
55 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 36 palonosetron hcl soln 43 palonosetron hcl sosy 43 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 40 pamidronate disodium soln 52 pamidronate disodium solr 52 PANCREAZE CPEP 40 PANDEL CREA 61 panlor tabs 29 PANRETIN GEL 61 pantoprazole sodium pack 44 PANTOPRAZOLE SODIUM SOLR 44 pantoprazole sodium tbec 20mg 40mg 44 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 57
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 64 PARICALCITOL SOLN 64 paroex soln 41 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 36 paroxetine hcl tabs 10mg 20mg 36 paroxetine hcl tabs 30mg 40mg 36 paroxetine mesylate caps 36 paser pack 11
PAXIL SUSP 36 PEDIARIX SUSP 57 PEDVAX HIB SUSP 57 peg 3350electrolytes solr 44 peg 3350-kcl-na bicarb-nacl solr 44 peg-3350electrolytes solr 44 PEGANONE TABS 31 PEGASYS PROCLICK SOLN
135mcg05ml 180mcg05ml 13 PEGASYS SOLN 180mcg05ml
180mcgml 13 PEGINTRON KIT 13 PEG-INTRON REDIPEN KIT 12 PEG-PREP KIT 44 PEMAZYRE TABS 45mg 9mg 135mg 17 penicillamine caps 45 penicillamine tabs 45 PENICILLIN G POT IN DEXTROSE SOLN
INTRAVENOUS 10 penicillin g potassium solr injection 10 penicillin g procaine susp 10 penicillin g sodium solr injection 10 penicillin v potassium solr 10 penicillin v potassium tabs 10 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 43 pentazocine-naloxone hcl tabs 29 pentobarbital sodium soln 33 pentoxifylline er tbcr 22 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 44 percocet tabs 29 perindopril erbumine tabs 2mg 4mg 8mg
26 periogard soln 41 PERJETA SOLN 17 permethrin crea 59 perphenazine tabs 2mg 4mg 8mg 16mg
36 perphenazine-amitriptyline tabs 36 PERSERIS PRSY 90mg 120mg 36 PERTZYE CPEP 40 PEXEVA TABS 10mg 20mg 30mg 40mg
36 phenadoz supp 14 phenazo tabs 61 PHENAZOPYRIDINE HCL TABS 61 phenelzine sulfate tabs 36
96 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
phenergan soln 14 PHENOBARBITAL ELIX 33 PHENOBARBITAL SODIUM SOLN 33 PHENOBARBITAL TABS 33 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 21 PHENYLEPHRINE HCL SOLN 42 phenytek caps 200mg 300mg 31 phenytoin chew 31 phenytoin sodium extended caps 100mg
200mg 300mg 31 phenytoin sodium soln 31 phenytoin susp 31 PHESGO SOLN 17 PHOSLYRA SOLN 39 PHOSPHASAL TABS 14 PHOSPHOLINE IODIDE SOLR 42 phrenilin forte caps 29 PHYSIOLYTE SOLN 55 PHYSIOSOL IRRIGATION SOLN 55 PIFELTRO TABS 13 pilocarpine hcl soln 1 2 4 42 pilocarpine hcl tabs 5mg 75mg 20 pimecrolimus crea 62 pimozide tabs 1mg 2mg 36 pimtrea tabs 47 pindolol tabs 5mg 10mg 24 pioglitazone hcl tabs 15mg 30mg 45mg 49 pioglitazone hcl-glimepiride tabs 49 pioglitazone hcl-metformin hcl tabs 49 piperacillin sod-tazobactam so solr 10 piperacillin sod-tazobactam so solr
intravenous 10 PIQRAY (200 MG DAILY DOSE) TBPK 17 PIQRAY (250 MG DAILY DOSE) TBPK 17 PIQRAY (300 MG DAILY DOSE) TBPK 17 pirmella 135 tabs 47 PIROXICAM CAPS 10mg 20mg 29 PLASMA-LYTE 148 SOLN INTRAVENOUS
39 PLASMA-LYTE A SOLN INTRAVENOUS 39 PLEGRIDY SOPN 13 PLEGRIDY SOSY 13 34 PLEGRIDY STARTER PACK SOPN 13 PLEGRIDY STARTER PACK SOSY 13 plenamine soln intravenous 38 PLENVU SOLR 44 podofilox soln 62 POLIVY SOLR 30mg 140mg 17
polocaine soln 55 polocaine-mpf soln 55 polycin oint 41 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 41 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 34 PONVORY TABS 34 portia-28 tabs 47 PORTRAZZA SOLN 17 POSACONAZOLE SUSP 11 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 37 POTASSIUM ACETATE SOLN 39 potassium chloride crys er tbcr 10meq
20meq 40 potassium chloride er cpcr 8meq 10meq 40 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 40 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 40 potassium chloride in nacl soln intravenous
40 potassium chloride pack 40 potassium chloride soln 10 20 40 POTASSIUM CHLORIDE SOLN
INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml 40
potassium citrate er tbcr 15meq 540mg 1080mg 37
POTASSIUM PHOSPHATES SOLN 40 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 40 POTELIGEO SOLN 18 PR BENZOYL PEROXIDE WASH LIQD 59 PRADAXA CAPS 110mg 150mg 22 PRADAXA CAPS 75mg 22 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 33
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 33
PRAMOX GEL 61 prandin tabs 1mg 2mg 49 prasugrel hcl tabs 5mg 10mg 22 pravastatin sodium tabs 10mg 20mg
40mg 80mg 23 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 97
PRED MILD SUSP 41 PRED-G SOP OINT 41 PRED-G SUSP 41 prednicarbate crea 61 prednicarbate oint 61 prednisolone acetate susp 41 prednisolone sodium phosphate soln 41 45 prednisolone sodium phosphate soln
5mg5ml 10mg5ml 20mg5ml 25mg5ml 45
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 45
prednisolone soln 45 prednisone intensol conc 45 prednisone soln 45 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 45 prednisone tbpk 45 prefest tabs 50 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 31
pregabalin er tb24 825mg 165mg 330mg 29
pregabalin soln 31 PREGNYL SOLR 50 PREMARIN SOLR 50 PREMARIN TABS 03mg 045mg
0625mg 09mg 125mg 50 premasol soln intravenous 38 PREMPHASE TABS 50 PREMPRO TABS 50 PRENATAL TABS 64 PRETOMANID TABS 11 prevalite pack 23 prevalite powd 23 previfem tabs 47 PREVYMIS SOLN 240mg12ml
480mg24ml 13 PREVYMIS TABS 240mg 480mg 13 PREZCOBIX TABS 13 PREZISTA SUSP 13 PREZISTA TABS 75mg 150mg 600mg
800mg 13 PRIFTIN TABS 11 PRILOSEC PACK 25mg 10mg 44 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 31 primlev tabs 29
PRIVIGEN SOLN INTRAVENOUS 57 PROAIR RESPICLICK AEPB 21 probenecid tabs 40 procainamide hcl soln 25 PROCALAMINE SOLN INTRAVENOUS 38 procentra soln 30 prochlorperazine edisylate soln 36 prochlorperazine maleate tabs 36 prochlorperazine supp 36 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 40000unitml 22
proctofoam hc foam 61 procto-med hc crea 61 procto-pak crea 61 proctosol hc crea 61 proctozone-hc crea 61 PROCYSBI CPDR 25mg 75mg 55 PROCYSBI PACK 75mg 300mg 55 progesterone caps 100mg 200mg 51 progesterone oil 51 PROGLYCEM SUSP 49 PROGRAF PACK 53 PROGRAF PACK 02mg 53 PROGRAF SOLN 53 PROLASTIN-C SOLN INTRAVENOUS 56 PROLASTIN-C SOLR INTRAVENOUS 56 prolate soln 29 prolate tabs 29 PROLENSA SOLN 41 PROLEUKIN SOLR 18 PROLIA SOSY 52 PROMACTA PACK 125mg 25mg 22 PROMACTA TABS 125mg 25mg 50mg
75mg 22 promethazine hcl soln 14 promethazine hcl supp 14 promethazine hcl syrp 14 promethazine hcl tabs 14 promethazine-phenylephrine syrp 14 promethegan supp 14 propafenone hcl er cp12 225mg 325mg
425mg 25 propafenone hcl tabs 150mg 225mg
300mg 25 propantheline bromide tabs 19 proparacaine hcl soln 43 propranolol hcl er cp24 60mg 80mg
120mg 160mg 24
98 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
propranolol hcl soln 20mg5ml 40mg5ml 24 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 24 propranolol-hctz tabs 24 propylthiouracil tabs 51 PROQUAD SUSR 58 PROSOL SOLN INTRAVENOUS 38 PROTONIX PACK 44 protriptyline hcl tabs 5mg 10mg 36 psorcon crea 61 PULMICORT FLEXHALER AEPB 45 PULMOZYME SOLN 40 PURIXAN SUSP 18 PYLERA CAPS 44 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 20 pyridostigmine bromide soln 20 pyridostigmine bromide tabs 30mg 60mg 20 pyrimethamine tabs 11
Q QBRELIS SOLN 26 QDOLO SOLN 29 QINLOCK TABS 18 QUADRACEL SUSP 57 questran light powd 23 questran pack 23 questran powd 23 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 36 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 37 QUILLICHEW ER CHER 20mg 30mg
40mg 30 QUILLIVANT XR SRER 30 quinapril hcl tabs 5mg 10mg 20mg 40mg
26 quinapril-hydrochlorothiazide tabs 26 quinidine gluconate er tbcr 25 QUINIDINE GLUCONATE SOLN 25 quinidine sulfate tabs 200mg 300mg 25 quinine sulfate caps 12
R RABAVERT SUSR 58 rabeprazole sodium cpsp 44 rabeprazole sodium tbec 44 RADICAVA SOLN 34
raloxifene hcl tabs 50 ramelteon tabs 33 ramipril caps 125mg 25mg 5mg 10mg 26 ranolazine er tb12 500mg 1000mg 25 RAPIVAB SOLN 13 rasagiline mesylate tabs 05mg 1mg 33 RASUVO SOAJ 53 RAVICTI LIQD 38 RAYALDEE CPCR 64 RAYOS TBEC 1mg 2mg 5mg 45 REBETOL SOLN 13 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 34 REBIF REBIDOSE TITRATION PACK
SOAJ 34 REBIF SOSY 22mcg05ml 44mcg05ml 34 REBIF TITRATION PACK SOSY 34 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 47 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 58 RECTIV OINT 62 REGONOL SOLN 20 REGRANEX GEL 62 relafen ds tabs 29 RELENZA DISKHALER AEPB 13 relexxii tbcr 30 RELISTOR SOLN 8mg04ml 12mg06ml
44 RELISTOR TABS 44 reltone caps 200mg 400mg 44 REMICADE SOLR INTRAVENOUS 53 RENFLEXIS SOLR 53 repaglinide tabs 05mg 1mg 2mg 49 repaglinide-metformin hcl tabs 49 REPATHA PUSHTRONEX SYSTEM SOCT
23 REPATHA SOSY 23 REPATHA SURECLICK SOAJ 23 RESCRIPTOR TABS 100mg 200mg 13 RESTASIS EMUL 41 RETACRIT SOLN 20000unit2ml
2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml 22
RETEVMO CAPS 40mg 80mg 18 RETIN-A CREA 0025 005 01 61 RETIN-A GEL 001 0025 61
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 99
RETIN-A MICRO GEL 004 01 61 RETIN-A MICRO PUMP GEL 61 RETIN-A MICRO PUMP GEL 004 01
61 RETIN-A MICRO PUMP GEL 008 61 RETISERT IMPL 41 RETROVIR SOLN 13 REVCOVI SOLN 40 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 18 revonto solr 20 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 37 REYATAZ PACK 13 REZUROCK TABS 55 RHOPRESSA SOLN 42 RIABNI SOLN 100mg10ml 500mg50ml 18 ribasphere caps 13 ribasphere ribapak (1000 pack) tbpk 13 ribasphere ribapak (1200 pack) tbpk 13 ribasphere tabs 13 ribavirin caps 13 ribavirin solr 13 ribavirin tabs 13 RIDAURA CAPS 55 RIFABUTIN CAPS 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 RIFATER TABS 11 riluzole tabs 34 rimantadine hcl tabs 13 RIMSO-50 SOLN 55 RINGERS IRRIGATION SOLN 55 RINGERS SOLN 40 RINVOQ TB24 53 risedronate sodium tabs 5mg 30mg 35mg
150mg 52 RISEDRONATE SODIUM TBEC 52 RISPERDAL CONSTA SRER 125mg
25mg 37 RISPERDAL CONSTA SRER 375mg
50mg 37 risperidone soln 37 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 37 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 37
ritonavir tabs 13 RITUXAN HYCELA SOLN 18 RITUXAN SOLN 18 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 47 rizatriptan benzoate tabs 32 rizatriptan benzoate tbdp 32 ROMIDEPSIN SOLN 18 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 33 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 33 ropivacaine hcl soln 55 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 23 ROTARIX SUSR 58 ROTATEQ SOLN 58 roweepra tabs 500mg 750mg 1000mg 31 roweepra xr tb24 500mg 750mg 31 ROXYBOND TABA 5mg 15mg 30mg 29 ROZEREM TABS 33 ROZLYTREK CAPS 100mg 200mg 18 RUBRACA TABS 200mg 250mg 300mg 18 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 31 rufinamide tabs 200mg 400mg 31 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 18 RUZURGI TABS 55 RYBREVANT SOLN 18 ryclora soln 14 RYDAPT CAPS 18 RYLAZE SOLN 18 RYNODERM CREA 62 RYTARY CPCR 33 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 51 SAIZEN SOLR 5mg 88mg 51 SAIZENPREP SOLR 51 sajazir soln 21 SALEX SHAM 62 SALICYLIC ACID CREA 62 SALICYLIC ACID ER SOLN 62
100 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
SALICYLIC ACID FOAM 62 SALICYLIC ACID GEL 62 SALICYLIC ACID LIQD 62 SALICYLIC ACID SHAM 62 SALICYLIC ACID WART REMOVER LIQD
62 SALICYLIC ACID-CLEANSER KIT 62 SALIMEZ CREA 62 SALSALATE TABS 29 SAMSCA TABS 15mg 39 SANCUSO PTCH 43 SANDIMMUNE ORAL SOLN 100mgml 53 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 51 SANTYL OINT 62 SAPHNELO SOLN 53 SAPHRIS SUBL 25mg 5mg 10mg 37 sapropterin dihydrochloride pack 100mg
500mg 55 sapropterin dihydrochloride tabs 55 SARCLISA SOLN 500mg25ml 100mg5ml
18 SAVELLA TABS 125mg 25mg 50mg
100mg 34 SAVELLA TITRATION PACK MISC 34 scopolamine pt72 43 seconal caps 33 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 37 selegiline hcl caps 33 selegiline hcl tabs 33 selenium sulfide lotn 59 SELENIUM SULFIDE SHAM 59 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 150mg
300mg 13 SEMPREX-D CAPS 14 SENSIPAR TABS 30mg 60mg 90mg 50 SENSORCAINE SOLN 55 sensorcaineepinephrine soln 55 sensorcaine-mpf soln 55 sensorcaine-mpfepinephrine soln 55 SEREVENT DISKUS AEPB 21 SEROSTIM SOLR 4mg 5mg 6mg 51 sertraline hcl conc 37 sertraline hcl tabs 25mg 50mg 100mg 37 setlakin tabs 47 sevelamer carbonate pack 08gm 24gm 39 sevelamer carbonate tabs 39
sevelamer hcl tabs 400mg 800mg 39 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 47 SHINGRIX SUSR 58 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 51 SIGNIFOR SOLN 03mgml 06mgml
09mgml 51 SIKLOS TABS 18 sildenafil citrate soln 26 sildenafil citrate susr 26 sildenafil citrate tabs 26 SILENOR TABS 37 SILIQ SOSY 62 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 59 SIMBRINZA SUSP 42 SIMPONI ARIA SOLN 53 SIMPONI SOAJ 50mg05ml 100mgml 53 SIMPONI SOSY 50mg05ml 100mgml 53 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 23 sirolimus soln 53 sirolimus tabs 05mg 1mg 2mg 53 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKLICE LOTN 59 SKYRIZI (150 MG DOSE) PSKT 62 SKYRIZI PEN SOAJ 63 SKYRIZI SOSY 63 sod benz-sod phenylacet soln 38 SODIUM ACETATE SOLN 37 SODIUM BICARBONATE SOLN 37 SODIUM CHLORIDE (PF) SOLN 40 SODIUM CHLORIDE SOLN 40 55 SODIUM CHLORIDE SOLN INJECTION 40 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 55 SODIUM FLUORIDE SOLN 55 SODIUM FLUORIDE TABS 55 SODIUM LACTATE SOLN INTRAVENOUS
37 sodium phenylbutyrate powd 38 sodium phenylbutyrate tabs 38 SODIUM PHOSPHATES SOLN 40 sodium polystyrene sulfonate powd 39 sodium polystyrene sulfonate susp 39 SODIUM SULFACETAMIDE SHAM 59
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 101
SODIUM SULFACETAMIDE WASH LIQD 59
sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 63 SOLIQUA SOPN 49 SOLOSEC PACK 12 soloxide tbec 10 SOLTAMOX SOLN 18 SOLU-CORTEF SOLR 45 SOLU-MEDROL SOLR 45 SOMATULINE DEPOT SOLN 51 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 51 SORILUX FOAM 63 sorine tabs 80mg 120mg 160mg 240mg
24 sotalol hcl (af) tabs 80mg 120mg 160mg 24 sotalol hcl tabs 80mg 120mg 160mg
240mg 24 SOTYLIZE SOLN 24 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPINOSAD SUSP 59 SPIRIVA HANDIHALER CAPS 19 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 26 spironolactone-hctz tabs 26 SPRAVATO (56 MG DOSE) SOPK 37 SPRAVATO (84 MG DOSE) SOPK 37 sprintec 28 tabs 47 SPRITAM TB3D 250mg 500mg 750mg
1000mg 31 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 39 sronyx tabs 47 SSD CREA 59 SSS 10-5 CREA 63 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
63 STELARA SOSY 45mg05ml 90mgml 63 STERILE WATER FOR IRRIGATION SOLN
55 STIMATE SOLN 50 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18
STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml 40
streptomycin sulfate solr 10 STRIANT MISC 46 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 21 SUBLOCADE SOSY 100mg05ml
300mg15ml 29 SUBSYS LIQD 100mcg 200mcg 400mcg
600mcg 800mcg 1200mcg 1600mcg 29 subvenite starter kit-blue kit 31 subvenite starter kit-green kit 31 subvenite starter kit-orange kit 31 subvenite tabs 25mg 100mg 150mg
200mg 31 succinylcholine chloride soln 20 SUCRAID SOLN 40 sucralfate susp 44 sucralfate tabs 44 sulfacetamide sodium (acne) lotn 59 SULFACETAMIDE SODIUM GEL 59 SULFACETAMIDE SODIUM LIQD 59 sulfacetamide sodium oint 41 sulfacetamide sodium soln 41 SULFACETAMIDE SODIUM-SULFUR
CREA 63 SULFACETAMIDE SODIUM-SULFUR
EMUL 63 SULFACETAMIDE SODIUM-SULFUR
LIQD 63 SULFACETAMIDE SODIUM-SULFUR
LOTN 63 SULFACETAMIDE SODIUM-SULFUR
PADS 63 SULFACETAMIDE SODIUM-SULFUR
SUSP 63 sulfacetamide-prednisolone soln 41 SULFACLEANSE 84 SUSP 63 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 sulfamez wash emul 63 SULFAMYLON CREA 59 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 29 sumatriptan soln 32
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sumatriptan succinate refill soct 32 sumatriptan succinate soaj 32 sumatriptan succinate soln 32 sumatriptan succinate sosy 32 sumatriptan succinate tabs 32 sunitinib malate caps 125mg 25mg
375mg 50mg 18 SUNOSI TABS 75mg 150mg 30 SUPRAX CAPS 10 suprax chew 10 suprax susr 100mg5ml 200mg5ml 10 SUPRAX SUSR 500 MG5ML 10 SUPREP BOWEL PREP KIT SOLN 44 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 47 SYLATRON KIT 18 SYLATRON KIT 600 MCG 18 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 56 SYMDEKO TBPK 56 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 49 SYMLINPEN 60 SOPN 49 SYMPAZAN FILM 10mg 20mg 32 SYMPAZAN FILM 5mg 31 SYMPROIC TABS 44 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 50 SYNDROS SOLN 43 SYNERCID SOLR 10 SYNJARDY TABS 49 SYNJARDY XR TB24 49 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 TACLONEX SUSP 61 tacrolimus caps 05mg 1mg 5mg 53 TACROLIMUS OINT 01 003 63 tadalafil (pah) tabs 20mg 26 tadalafil tabs 25mg 5mg 26 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 55 TALTZ SOAJ 63
TALTZ SOSY 63 TALZENNA CAPS 025mg 1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 51 taperdex 12-day tbpk 45 taperdex 6-day tbpk 45 taperdex 7-day tbpk 45 TARCEVA TABS 25mg 100mg 150mg 18 targadox tabs 10 TARGRETIN GEL 61 tarina 24 fe tabs 47 tarina fe 120 eq tabs 47 TASIGNA CAPS 50mg 150mg 200mg 18 tavaborole soln 59 TAVALISSE TABS 100mg 150mg 22 tazarotene crea 63 tazarotene foam 63 tazicef solr injection 1gm 2gm 6gm 10 TAZORAC CREA 63 TAZORAC GEL 005 01 63 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 57 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TECFIDERA CPDR 120mg 240mg 34 TECFIDERA MISC 34 TEFLARO SOLR INTRAVENOUS 400mg
600mg 10 TEGSEDI SOSY 55 TEKTURNA HCT TABS 26 telmisartan tabs 20mg 40mg 80mg 26 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 26 TEMAZEPAM CAPS 15mg 225mg 30mg
75mg 33 temsirolimus soln 18 tencon tabs 29 TENIPOSIDE SOLN 18 TENIVAC INJ 57 tenofovir disoproxil fumarate tabs 13 TEPADINA SOLR 18 TEPEZZA SOLR 42 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 21
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 103
terbutaline sulfate tabs 25mg 5mg 21 terconazole crea 59 terconazole supp 59 TERIPARATIDE (RECOMBINANT) SOPN
50 testosterone cypionate soln 100mgml
200mgml 46 testosterone enanthate soln 46 testosterone gel 1 162
2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact 46
testosterone soln 46 tetrabenazine tabs 125mg 25mg 34 TETRACAINE HCL SOLN 43 tetracycline hcl caps 250mg 500mg 10 texacort soln 61 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 63 theophylline er tb12 100mg 200mg
300mg 450mg 63 theophylline er tb24 400mg 600mg 63 theophylline soln 63 THIOLA EC TBEC 100mg 300mg 55 THIOLA TABS 55 thioridazine hcl tabs 10mg 25mg 50mg
100mg 37 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 37 THYROGEN SOLR 55 THYROLAR-1 TABS 51 THYROLAR-12 TABS 51 THYROLAR-14 TABS 51 THYROLAR-2 TABS 51 THYROLAR-3 TABS 51 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
32 TIBSOVO TABS 18 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 34 tilia fe tabs 47 timolol maleate pf soln 42 timolol maleate solg 025 05 42 timolol maleate soln 025 05 42 timolol maleate tabs 5mg 10mg 20mg 24 TIMOPTIC OCUDOSE SOLN 25 42
TIMOPTIC-XE SOLG 025 05 42 tinidazole tabs 12 tiopronin tabs 55 TIROSINT CAPS 13mcg 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
TIS-U-SOL SOLN 55 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 TIVORBEX CAPS 29 tizanidine hcl caps 20 21 tizanidine hcl tabs 20 TOBI PODHALER CAPS 56 TOBRADEX OINT 41 TOBRADEX ST SUSP 41 tobramycin nebu 300mg4ml 300mg5ml 56 tobramycin soln 41 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 42 TOBREX OINT 41 tofranil tabs 10mg 25mg 50mg 37 TOLAK CREA 63 tolazamide tabs 250mg 500mg 49 tolbutamide tabs 49 tolcapone tabs 33 tolmetin sodium caps 29 tolmetin sodium tabs 29 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 63 tolterodine tartrate tabs 63 TOLVAPTAN TABS 30mg 15mg 39 TOPEX TOPICAL ANESTHETIC AERO 61 topicort crea 005 025 61 topicort gel 61 topicort oint 61 topiramate cpsp 15mg 25mg 32 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 32 topiramate tabs 25mg 50mg 100mg
200mg 32 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
39 TOSYMRA SOLN 32
104 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
tovet foam 61 TPN ELECTROLYTES CONC
INTRAVENOUS 40 TRACLEER TABS 625mg 125mg 56 TRACLEER TBSO 56 TRADJENTA TABS 49 tramadol hcl er (biphasic) tb24 100mg
200mg 300mg 29 tramadol hcl er cp24 100mg 150mg
200mg 300mg 29 tramadol hcl er tb24 100mg 200mg 300mg
29 tramadol hcl tabs 50mg 100mg 29 tramadol-acetaminophen tabs 29 trandolapril tabs 1mg 2mg 4mg 26 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 22 tranexamic acid tabs 22 TRANSDERM SCOP (15 MG) PT72 43 tranylcypromine sulfate tabs 37 TRAVASOL SOLN INTRAVENOUS 38 TRAVATAN Z SOLN 42 travoprost (bak free) soln 42 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 37 trazodone hcl tabs 50mg 100mg 150mg 37 TRECATOR TABS 11 TRELEGY ELLIPTA AEPB 45 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 63 TREMFYA SOSY 63 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 56 tretinoin caps 18 tretinoin crea 0025 005 01 61 tretinoin gel 001 0025 005 61 tretinoin microsphere gel 004 01 61 tretinoin microsphere pump gel 004
01 62 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 29 triamcinolone acetonide aers 61 triamcinolone acetonide crea 0025
01 05 61 triamcinolone acetonide lotn 0025 01
61 triamcinolone acetonide oint 0025
005 01 05 61 triamcinolone acetonide pste 61
triamcinolone acetonide susp 45 triamterene caps 50mg 100mg 39 triamterene-hctz caps 39 triamterene-hctz tabs 39 trianex oint 61 triazolam tabs 0125mg 025mg 33 TRICITRATES SOLN 37 triderm crea 01 05 61 trientine hcl caps 45 tri-estarylla tabs 47 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 37 trifluridine soln 41 trihexyphenidyl hcl soln 33 trihexyphenidyl hcl tabs 2mg 5mg 33 TRIKAFTA TBPK 56 tri-legest fe tabs 47 tri-lo-estarylla tabs 47 tri-lo-sprintec tabs 47 trilyte solr 44 trimethobenzamide hcl caps 43 trimethoprim tabs 14 tri-mili tabs 47 trimipramine maleate caps 25mg 50mg
100mg 37 TRINESSA (28) TABS 47 TRINTELLIX TABS 5mg 10mg 20mg 37 tri-nymyo tabs 47 tri-previfem tabs 47 TRIPTODUR SRER 50 TRISENOX SOLN 18 TRISENOX SOLN 10mg10ml 18 tri-sprintec tabs 47 tritocin oint 61 TRIUMEQ TABS 13 TRI-VITAMINFLUORIDE SOLN 64 TRI-VITEFLUORIDE SOLN 64 trivora (28) tabs 47 tri-vylibra lo tabs 47 tri-vylibra tabs 47 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 32 TROPHAMINE SOLN INTRAVENOUS 38 trospium chloride er cp24 63 trospium chloride tabs 63 TRULANCE TABS 44 TRUMENBA SUSY 58
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 105
TRUSELTIQ (100MG DAILY DOSE) CPPK 18
TRUSELTIQ (125MG DAILY DOSE) CPPK 18
TRUSELTIQ (50MG DAILY DOSE) CPPK 18
TRUSELTIQ (75MG DAILY DOSE) CPPK 18
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 58 TYBOST TABS 13 tydemy tabs 47 TYKERB TABS 18 tylenol with codeine 3 tabs 29 tylenol with codeine 4 tabs 29 TYMLOS SOPN 50 TYPHIM VI SOLN 58 TYSABRI CONC INTRAVENOUS 34 TYVASO REFILL SOLN 56 TYVASO SOLN 56 TYVASO STARTER SOLN 56
U UBRELVY TABS 50mg 100mg 32 UCERIS FOAM 61 UDENYCA SOSY 22 UKONIQ TABS 18 ULORIC TABS 40mg 80mg 52 ULTOMIRIS SOLN 55 ULTRAVATE LOTN 61 UMECTA MOUSSE FOAM 63 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 52
UNITUXIN SOLN 18 UPLIZNA SOLN 53 UPTRAVI SOLR 56 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 56
UPTRAVI TBPK 57 UREA CREA 39 63 UREA LOTN 40 63 UREA-C40 LOTN 63 urecholine tabs 5mg 10mg 25mg 50mg 20
uredeb crea 63 URETRON DS TABS 14 URIN DS TABS 14 URSODIOL CAPS 200mg 400mg 44 ursodiol caps 300mg 44 ursodiol tabs 250mg 500mg 44 URYL TABS 14 USTELL CAPS 14 UTICAP CAPS 14 UTIRA-C TABS 14 UTRONA-C TABS 14
V VABOMERE SOLR INTRAVENOUS 10 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 63 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 32 valproic acid caps 32 valproic acid soln 32 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
26 valsartan-hydrochlorothiazide tabs 26 VALTOCO 10 MG DOSE LIQD 32 VALTOCO 15 MG DOSE LQPK 32 VALTOCO 20 MG DOSE LQPK 32 VALTOCO 5 MG DOSE LIQD 32 vanadom tabs 20 vanatol lq soln 29 vancomycin hcl caps 10 vancomycin hcl solr 10 VANCOMYCIN HCL SOLR 250 MG 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 VANDAZOLE GEL 59 VANOXIDE-HC LOTN 61 VANTAS KIT 19 VAQTA SUSP 58 VARIVAX INJ 58 VARIZIG SOLN 57 VARUBI (180 MG DOSE) TBPK 43 VASCEPA CAPS 05gm 1gm 23 VAXCHORA SUSR 58 vecamyl tabs 25 VECTICAL OINT 63 VELCADE SOLR 19 velivet tabs 47
106 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
VELPHORO CHEW 39 VELTASSA PACK 84gm 168gm 252gm
39 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 19 VENCLEXTA TABS 10mg 19 VENCLEXTA TABS 50mg 100mg 19 venlafaxine hcl er cp24 375mg 75mg
150mg 37 venlafaxine hcl er tb24 375mg 75mg
150mg 225mg 37 venlafaxine hcl tabs 25mg 375mg 50mg
75mg 100mg 37 VENTAVIS SOLN 10mcgml 20mcgml 57 VENTOLIN HFA AERS 21 VERAPAMIL HCL ER CP24 100mg
120mg 180mg 200mg 240mg 300mg 360mg 25
verapamil hcl er tbcr 120mg 180mg 240mg 25
verapamil hcl soln 25 verapamil hcl tabs 25 verapamil hcl tabs 80mg 120mg 25 VEREGEN OINT 63 VERELAN CP24 25 veripred 20 soln 45 VERSACLOZ SUSP 37 VERZENIO TABS 50mg 100mg 150mg
200mg 19 vestura tabs 47 VIBERZI TABS 75mg 100mg 44 VIBRAMYCIN SYRP 10 vicodin es tabs 29 vicodin hp tabs 29 vicodin tabs 29 VICTOZA SOPN 49 VIDEX EC CPDR 125mg 200mg 400mg 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 47 vigabatrin pack 32 vigabatrin tabs 32 vigadrone pack 32 VIIBRYD STARTER PACK KIT 37 VIIBRYD TABS 10mg 20mg 40mg 37 VILTEPSO SOLN 55 VIMIZIM SOLN 40 VIMPAT SOLN 32
VIMPAT TABS 32 vinblastine sulfate soln 19 vincasar pfs soln 19 vincristine sulfate soln 19 vinorelbine tartrate soln 19 VIOKACE TABS 40 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 52 VITAMINS ACD-FLUORIDE SOLN 64 VITRAKVI CAPS 25mg 100mg 19 VITRAKVI SOLN 19 VIVITROL SUSR 35 VIZIMPRO TABS 15mg 30mg 45mg 19 VOCABRIA TABS 13 VORAXAZE SOLR 52 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 19 VP-PNV-DHA CAPS 64 VPRIV SOLR 40 VRAYLAR CAPS 15mg 3mg 45mg 6mg
37 VRAYLAR CPPK 37 VUMERITY (STARTER) CPDR 55 VUMERITY CPDR 55 vyfemla tabs 47 vylibra tabs 47 VYNDAMAX CAPS 25 VYNDAQEL CAPS 25 VYONDYS 53 SOLN 55 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 30 VYVANSE CHEW 10mg 20mg 30mg
40mg 50mg 60mg 30 VYXEOS SUSR 19 VYZULTA SOLN 42
W WAKIX TABS 445mg 178mg 30 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 22 WATER FOR IRRIGATION STERILE
SOLN 55 wixela inhub aepb 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 107
wymzya fe chew 48 WYNZORA CREA 63
X XALKORI CAPS 200mg 250mg 19 XARELTO STARTER PACK TBPK 22 XARELTO TABS 25mg 10mg 15mg
20mg 22 XATMEP SOLN 19 XCOPRI (250 MG DAILY DOSE) TBPK 32 XCOPRI (350 MG DAILY DOSE) TBPK 32 XCOPRI TABS 200 MG 32 XCOPRI TABS 50mg 100mg 150mg 32 XCOPRI TBPK 32 XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
32 XELJANZ SOLN 53 XELJANZ TABS 5mg 10mg 53 XELJANZ XR TB24 11mg 22mg 53 XELPROS EMUL 42 XEMBIFY SOLN SUBCUTANEOUS
2gm10ml 4gm20ml 10gm50ml 1gm5ml 57
XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 55 XEOMIN SOLR 50unit 100unit 55 XEPI CREA 59 XERESE CREA 59 XERMELO TABS 43 XGEVA SOLN 52 XHANCE EXHU 42 XIFAXAN TABS 200mg 550mg 10 XIIDRA SOLN 42 XIMINO CP24 45mg 90mg 135mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 56 XOLAIR SOSY 75mg05ml 150mgml 56 XOSPATA TABS 19 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 19 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (40 MG TWICE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (60 MG ONCE WEEKLY) TBPK
20mg 60mg 19
XPOVIO (60 MG TWICE WEEKLY) TBPK 19
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg 19
XPOVIO (80 MG TWICE WEEKLY) TBPK 19
XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg 29
XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 48 XUREA CREA 63 XURIDEN PACK 55 xylocaine dental soln 55 XYOSTED SOAJ 50mg05ml 75mg05ml
100mg05ml 46 XYREM SOLN 34 XYWAV SOLN 34
Y YERVOY SOLN 19 YF-VAX INJ 58 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 42 yuvafem tabs 50
Z zafemy ptwk 48 zafirlukast tabs 10mg 20mg 55 zaleplon caps 5mg 10mg 33 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 48 zarontin soln 32 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 29 ZEJULA CAPS 19 ZELAPAR TBDP 33 ZELBORAF TABS 19 ZEMAIRA SOLR INTRAVENOUS 56 ZEMBRACE SYMTOUCH SOAJ 32 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
63 ZENPEP CPEP 40
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zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg 30
ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
34 ZEPOSIA CAPS 34 ZEPOSIA STARTER KIT CPPK 34 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERIT CAPS 15mg 20mg 30mg 40mg 13 ZERUVIA PTCH 61 ZETONNA AERS 42 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 55 ZINBRYTA SOSY 34 ZIONODIL 100 LOTN 61 ZIONODIL LOTN 61 ZIOPTAN SOLN 42 ziprasidone hcl caps 20mg 40mg 60mg
80mg 37 ziprasidone mesylate solr 37 ZIPSOR CAPS 29 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZIRGAN GEL 41 ZITHROMAX PACK 10 ZOKINVY CAPS 50mg 75mg 55 zoledronic acid conc 52 zoledronic acid soln 52
ZOLINZA CAPS 19 zolmitriptan soln 32 zolmitriptan tabs 32 zolmitriptan tbdp 32 zolpidem tartrate er tbcr 625mg 125mg 33 zolpidem tartrate subl 175mg 35mg 33 zolpidem tartrate tabs 5mg 10mg 33 ZOMACTON SOLR 51 ZOMACTON SOLR 5mg 51 ZOMIG SOLN 32 zonisamide caps 25mg 50mg 100mg 32 ZONTIVITY TABS 22 ZORBTIVE SOLR 51 ZORTRESS TABS 025mg 53 ZORTRESS TABS 05mg 075mg 1mg 53 ZORVOLEX CAPS 29 ZOSTAVAX SUSR 58 ZOSYN SOLN INTRAVENOUS 10 zovia 135e (28) tabs 48 ZUBSOLV SUBL 35 ZUPLENZ FILM 4mg 8mg 43 ZYCLARA PUMP CREA 63 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19 ZYKADIA TABS 19 ZYLET SUSP 42 ZYNLONTA SOLR 19 ZYPITAMAG TABS 1mg 2mg 4mg 23 ZYPREXA RELPREVV SUSR 37 ZYTIGA TABS 19 ZYVOX SOLN INTRAVENOUS 10
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Hmong Muajkwc pab txhais lus pub dawb rau koj
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tau cov kev pab txhais lus muab cov ntaub ntawv
txhais ua koj hom lus los yog ua lwm homTsuas hu
rau 1-800-464-4000 24 teev ib hnub twg 7 hnub ib
lim tiam twg (cov hnub caiv kaw) Cov neeg siv
TTY hu 711
Japanese 当院では言語支援を無料で年中無休
終日ご利用いただけます通訳サービス日本語
に翻訳された資料あるいは資料を別の書式でも
依頼できますお気軽に 1-800-464-4000 までお電話
ください (祭日を除き年中無休)TTYユーザー
は 711にお電話ください
Khmer ជនយភាសា គមានឥតអសថលៃដលអនកឡ ើយ 24
ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ អនកអាចឡសនើស ឡសវាអនកបកបរប សភារៈបដលបានបកបរបឡៅជាភាសាបមែរ ឬជាទរងផោសងឡទៀត រានបតទរសពទមកឡយើង តាមឡលម 1-800-464-4000 បាន 24 ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ (បទថលៃប ណោយ) អនកឡរបើ TTY ឡៅឡលម 711
Korean 요일 및 시간에 관계없이 언어 지원
서비스를 무료로 이용하실 수 있습니다 귀하는
통역 서비스 귀하의 언어로 번역된 자료 또는 대체
형식의 자료를 요청할 수 있습니다 요일 및 시간에
관계없이 1-800-464-4000번으로 전화하십시오
(공휴일 휴무) TTY 사용자 번호 711
Laotian ການຊວຍເຫ ອດານພາສາມໃຫໂດຍບ ເສຽຄາ
ແກທານ ຕະຫ ອດ 24 ຊ ວໂມງ 7 ວນຕ ອາທດ ທານ
ສາມາດຮອງຂ ຮບບ ລການນາຍພາສາ ໃຫແປເອກະ
ສານເປນພາສາຂອງທານ ຫ ໃນຮບແບບອ ນ ພຽງ
ແຕໂທຣຫາພວກເຮ າທ 1-800-464-4000 ຕະຫ ອດ 24
ຊ ວໂມງ 7 ວນຕ ອາທດ (ປດວນພກຕາງໆ) ຜໃຊສາຍ
TTY ໂທຣ 711
Navajo Saad bee aacutekaacutersquoarsquoayeed naacutehoacuteloacute trsquoaacuteaacute jiikrsquoeacute
naadiin doo bibąąrsquo diacuteiacutersquo aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute
damoo naacuteaacutedleehjiacute Atah halnersquoeacute aacutekaacutersquoadoolwołiacutegiacuteiacute joacutekiacute
trsquoaacuteadoo lersquoeacute trsquoaacuteaacute hoacutehazaadjiacute hadilyąąrsquogo eacuteiacute doodaiirsquo
naacuteaacutenaacute laacute ałrsquoąą aacutedaatrsquoehiacutegiacuteiacute bee haacutedadilyaarsquogo Kojiacute
hodiilnih 1-800-464-4000 naadiin doo bibąąrsquo diacuteiacutersquo
aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute damoo naacutersquoaacutedleehjiacute
(Dahodiyin biniiyeacute ersquoersquoaahgo eacuteiacute darsquodeelkaal)
TTY chodeeyooliacuteniacutegiacuteiacute kojiacute hodiilnih 711
Punjabi ਬਿਨ ਾ ਬਿਸੀ ਲ ਗਤ ਦ ਬਦਨ ਦ 24 ਘਟ ਹਫਤ ਦ 7 ਬਦਨ
ਦਭ ਸੀਆ ਸਵ ਵ ਾ ਤਹ ਡ ਲਈ ਉਪਲਿਧ ਹ ਤਸੀ ਇਿ ਦਭ ਸੀਏ ਦੀ
ਮਦਦ ਲਈ ਸਮਗਰੀਆਾ ਨ ਆਪਣੀ ਭ ਸ ਬਵਚ ਅਨਵ ਦ ਿਰਵ ਉਣ
ਲਈ ਜ ਾ ਬਿਸ ਵਖ ਫ ਰਮਟ ਬਵਚ ਪਰ ਪਤ ਿਰਨ ਲਈ ਿਨਤੀ ਿਰ ਸਿਦ
ਹ ਿਸ ਬਸਰਫ਼ ਸ ਨ 1-800-464-4000 ਤ ਬਦਨ ਦ 24 ਘਟ ਹਫ਼ਤ
ਦ 7 ਬਦਨ (ਛਟੀਆਾ ਵ ਲ ਬਦਨ ਿਦ ਰਬਹਦ ਹ) ਫ਼ਨ ਿਰ TTY ਦ
ਉਪਯਗ ਿਰਨ ਵ ਲ 711 lsquoਤ ਫ਼ਨ ਿਰਨ
Russian Мы бесплатно обеспечиваем Вас услугами
перевода 24 часа в сутки 7 дней в неделю Вы можете
воспользоваться помощью устного переводчика
запросить перевод материалов на свой язык или
запросить их в одном из альтернативных форматов
Просто позвоните нам по телефону 1-800-464-4000
который доступен 24 часа в сутки 7 дней в неделю
(кроме праздничных дней) Пользователи линии TTY
могут звонить по номеру 711
Spanish Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al diacutea 7 diacuteas a la semana
Puede solicitar los servicios de un inteacuterprete que los
materiales se traduzcan a su idioma o en formatos
alternativos Solo llame al 1-800-788-0616 24 horas al
diacutea 7 diacuteas a la semana (cerrado los diacuteas festivos) Los
usuarios de TTY deben llamar al 711
Tagalog May magagamit na tulong sa wika nang wala
kang babayaran 24 na oras bawat araw 7 araw bawat
linggo Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format Tawagan lamang
kami sa 1-800-464-4000 24 na oras bawat araw 7 araw
bawat linggo (sarado sa mga pista opisyal) Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711
Thai เรามบรการลามฟรส าหรบคณตลอด 24 ชวโมง
ทกวนตลอดชวโมงท าการของเราคณสามารถขอใหลาม
ชวยตอบค าถามของคณทเกยวกบความคมครองการดแล
สขภาพของเราและคณยงสามารถขอใหมการแปลเอกสา
รเปนภาษาทคณใชไดโดยไมมการคดคาบรการเพยงโทร
หาเราทหมายเลข 1-800-464-4000 ตลอด 24
ชวโมงทกวน (ปดใหบรการในวนหยดราชการ) ผใช TTY
โปรดโทรไปท 711
Vietnamese Dịch vụ thocircng dịch được cung cấp miễn
phiacute cho quyacute vị 24 giờ mỗi ngagravey 7 ngagravey trong tuần Quyacute
vị coacute thể yecircu cầu dịch vụ thocircng dịch tagravei liệu phiecircn dịch
ra ngocircn ngữ của quyacute vị hoặc tagravei liệu bằng nhiều higravenh
thức khaacutec Quyacute vị chỉ cần gọi cho chuacuteng tocirci tại số
1-800-464-4000 24 giờ mỗi ngagravey 7 ngagravey trong tuần
(trừ caacutec ngagravey lễ) Người dugraveng TTY xin gọi 711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
Provide no cost aids and services to people with disabilities to communicate effectively with us such as
diams Qualified sign language interpreters
diams Written information in other formats such as large print audio and accessible electronic formats
Provide no cost language services to people whose primary language is not English such as
diams Qualified interpreters
diams Information written in other languages
If you need these services call Member Services at 1-800-476-2167 (TTY 711)8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana Aurora CO 80014 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
61102709_CO
Multi-language Interpreter Services
English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-476-2167 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-476-2167 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-476-2167 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-476-2167 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-476-2167 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-476-2167 (TTY 711)번으로 전화해 주십시오
Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-800-476-2167 (телетайп 711)
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-476-2167(TTY711)までお電話にてご連絡ください
Amharic ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው 711)
German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-800-476-2167 (TTY 711)
French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-800-476-2167 (ATS 711)
Farsi
ی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ دیریبگ تماس (TTY 711) 2167-476-800-1 با باشد
Arabic
ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم )117- (رقم ھاتف الصم والبكم 7612-674-008-1
Yoruba AKIYESI Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o E pe ero ibanisoro yi 1-800-476-2167 (TTY 711)
Cushite-Oromo XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 1-800-476-2167 (TTY 711)
Nepali
धयान िदनहोस तपाइल नपाली बोलनहनछ भन तपाइको िनिमत भाषा सहायता सवाह िनःशलक पमा उपलबध छ फोन गनरहोस 1-800-476-2167 (िटिटवाइ 711)
KAH2711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
bull Provide no cost aids and services to people with disabilities to communicateeffectively with us such asdiams Qualified sign language interpretersdiams Written information in other formats such as large print audio and accessible
electronic formatsbull Provide no cost language services to people whose primary language is not English
such asdiams Qualified interpretersdiams Information written in other languages
If you need these services call Member Services at 1-800-805-2739 (TTY 711) 8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd Honolulu HI 96813 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Kaiser Permanente is an HMO plan with a Medicare contract Enrollment in Kaiser Permanente depends on contract renewal
H1230_2017MLI accepted
Multi-language Interpreter Services English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-805-2739 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-805-2739 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-805-2739 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-805-2739 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-805-2739 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-805-2739 (TTY 711)번으로 전화해 주십시오
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-805-2739(TTY711)までお電話にてご連絡ください
Lao
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 1-800-805-2739 (TTY 711)
Ilocano PAKDAAR Nu saritaem ti Ilocano ti serbisyo para ti baddang ti lengguahe nga awanan bayadna ket sidadaan para kenyam Awagan ti 1-800-805-2739 (TTY 711)
Samoan MO LOU SILAFIA Afai e te tautala Gagana faa Sāmoa o loo iai auaunaga fesoasoan e fai fua e leai se totogi mo oe Telefoni mai 1-800-805-2739 (TTY 711)
Marshallese LALE Ntildee kwōj kōnono Kajin Ṃajōḷ kwomarontilde bōk jerbal in jipantilde ilo kajin ṇe aṃ ejjeḷọk wōṇāān Kaalọk 1-800-805-2739 (TTY 711)
Trukese MEI AUCHEA Ika iei foosun fonuomw Foosun Chuuk iwe en mei tongeni omw kopwe angei aninisin chiakku ese kamo Kori 1-800-805-2739 (TTY 711)
Hawaiian E NĀNĀ MAI Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo loaʻa ke kōkua manuahi iā ʻoe E kelepona iā 1-800-805-2739 (TTY 711)
Pohnpeian Ni songen mwohmw ohte komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei Call 1-800-805-2739 (TTY 711)
Bisayan ATENSYON Kung nagsulti ka og Cebuano aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe nga walay bayad Tawag sa 1-800-805-2739 (TTY 711)
Tongan FAKATOKANGArsquoI Kapau lsquooku ke Lea-Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai atu ha tokoni tarsquoetotongi pea teke lava lsquoo marsquou ia Telefoni mai 1-800-805-2739 (TTY 711)
485236276 102021
This formulary was updated on 100121 For more recent information or other questions please contact the number for your Kaiser Permanente Region listed below seven days a week 8 am to 8 pm or visit kporgseniorrx
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Foundation Health Plan Inc 393 E Walnut St Pasadena CA 91188-8514 Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E Dakota Ave Denver CO 80247 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Foundation Health Plan Inc 711 Kapiolani Blvd Honolulu HI 96813 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
kporgseniorrx Please recycle
4 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
bull You can ask us to waive coverage
restrictions or limits on your drug For example if your drug requires prior authorization you can ask us to waive the prior authorization requirement for your Part D drug
Generally we will only approve your request for an exception if the alternative drugs included on the planrsquos formulary or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception When you request a formulary or utilization restriction exception you should submit a statement from your network provider supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited (fast) exception if you or your network provider believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber
Please note You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare amp Medicaid Services (CMS) You cannot get an exception for drugs that are excluded under Medicare Part D Please refer to your Evidence of Coverage for more information about requesting exceptions including the appeals process What do I do before I can talk to my network provider about
changing my drugs or requesting an exception
In some cases you might be taking Medicare Part D drugs that are not on our formulary Or you may be taking a drug that is on our formulary but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your network provider to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take While you talk to your network provider to determine the right course of action for you we may cover your drug in certain cases during the first 90 days you are a member of our plan For each of your Part D drugs that is not on our formulary or if your ability to get your drugs is limited we will cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide up to a maximum of a 30-day supply of medication After your first 30-day supply we may cover an additional refill as medically necessary After you have used these refills we will not pay for these drugs even if you have been a member of the plan less than 90 days
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug while you pursue a formulary exception
For current members with level of care changes if you enter into or are discharged from a hospital skilled nursing facility or long-term care facility to a different care setting or home this is what is known as a
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 5
level of care change When your level of care changes you may require an additional fill of your medication We will generally cover up to a one-month supply of your Part D drugs during this level of care transition period even if the drug is not on our Drug List
For more information
For more detailed information about your Kaiser Permanente prescription drug coverage please review your Evidence of Coverage and other plan materials If you have questions about our plan please call us Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048 Or visit httpwwwmedicaregov
6 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Kaiser Permanentersquos Formulary
The formulary below provides coverage information about the drugs covered by our plan If you have trouble finding your drug in the list turn to the index that begins on page 66 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg NEBUPENT) and generic drugs are listed in lower-case italics (eg ltamoxicillingt) The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number below Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy Northern CA ndash 1-888-218-6245 Monday through Friday 8 am to 8 pm Saturday 8 am to 6 pm and Sunday 9 am to 6 pm Southern CA ndash 1-866-206-2983 Monday through Friday 7 am to 7 pm Saturday 10 am to 2 pm
Colorado
Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday 8 am to 6 pm
Hawaii
Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday 800 am to 5 pm
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 7
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
8 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole tabs NDS emverm chew ivermectin tabs praziquantel tabs MO ANTIBACTERIALS amikacin sulfate soln amikacin sulfate soln injection HI amoxicillin caps amoxicillin chew amoxicillin susr amoxicillin tabs amoxicillin-pot clavulanate chew amoxicillin-pot clavulanate er tb12
amoxicillin-pot clavulanate susr amoxicillin-pot clavulanate tabs ampicillin caps ampicillin sodium solr ampicillin sodium solr injection 1gm 125mg HI
ampicillin sodium solr intravenous HI
ampicillin-sulbactam sodium solr ampicillin-sulbactam sodium solr injection HI
ampicillin-sulbactam sodium solr intravenous HI
ARIKAYCE SUSP PALDNDS AUGMENTIN SUSR AVYCAZ SOLR INTRAVENOUS HI AZITHROMYCIN PACK MO azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BAXDELA SOLR INTRAVENOUS HI
BAXDELA TABS MO
Drug Name RequirementsLimits
BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP cefaclor caps cefaclor er tb12 cefaclor susr cefadroxil caps cefadroxil susr cefadroxil tabs cefazolin sodium solr cefazolin sodium solr injection 1gm 10gm 500mg HI
cefdinir caps cefdinir susr cefepime hcl solr injection 1gm 2gm HI
cefixime caps cefixime susr cefotaxime sodium solr cefotetan disodium solr injection 1gm 2gm HI
cefoxitin sodium solr injection HI cefoxitin sodium solr intravenous 1gm 2gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 2gm 6gm HI
CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 75gm 750mg HI
cefuroxime sodium solr intravenous HI
cephalexin caps cephalexin susr cephalexin tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w soln ciprofloxacin in d5w soln intravenous HI
ciprofloxacin susr ciprofloxacin-ciproflox hcl er tb24 clarithromycin er tb24 clarithromycin susr clarithromycin tabs cleocin phosphate soln cleocin solr clindamycin hcl caps clindamycin palmitate hcl solr clindamycin phosphate in d5w soln intravenous HI
clindamycin phosphate soln clindamycin phosphate soln injection 300mg2ml 600mg4ml 900mg6ml
HI
colistimethate sodium (cba) solr injection HI
DALVANCE SOLR INTRAVENOUS HI
daptomycin solr intravenous 350mg 500mg HI
demeclocycline hcl tabs dicloxacillin sodium caps DIFICID SUSR NDS DIFICID TABS NDS DORYX MPC TBEC MO doxy 100 solr intravenous HI doxycycline hyclate caps 50mg 100mg MO
doxycycline hyclate tabs 20mg 75mg 100mg 150mg MO
doxycycline hyclate tbec 50mg 75mg 100mg 150mg 200mg MO
doxycycline monohydrate caps 50mg 75mg 100mg 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
Drug Name RequirementsLimits
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs FETROJA SOLR NDS FIRVANQ SOLR gentamicin in saline soln gentamicin in saline soln intravenous HI
gentamicin sulfate soln gentamicin sulfate soln injection HI imipenem-cilastatin solr intravenous HI
KIMYRSA SOLR NDS levofloxacin in d5w soln levofloxacin in d5w soln intravenous HI
levofloxacin soln levofloxacin soln intravenous HI levofloxacin tabs lincomycin hcl soln linezolid soln intravenous HI linezolid susr NDS linezolid tabs NDS meropenem solr intravenous 1gm 500mg HI
minocycline hcl caps 50mg 75mg 100mg MO
minocycline hcl er tb24 45mg 55mg 65mg 80mg 90mg 105mg 115mg 135mg
MO
minocycline hcl tabs 50mg 75mg 100mg MO
mondoxyne nl caps 75mg 100mg MO
morgidox caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 10 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium solr intravenous HI neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs okebo caps MO ORBACTIV SOLR NDS OXACILLIN SODIUM IN DEXTROSE SOLN INTRAVENOUS
HI
oxacillin sodium solr injection 1gm 2gm HI
oxacillin sodium solr intravenous HI PENICILLIN G POT IN DEXTROSE SOLN INTRAVENOUS
HI
penicillin g potassium solr injection HI
penicillin g procaine susp penicillin g sodium solr injection HI penicillin v potassium solr penicillin v potassium tabs piperacillin sod-tazobactam so solr
piperacillin sod-tazobactam so solr intravenous HI
polymyxin b sulfate solr injection HI RECARBRIO SOLR NDS SEYSARA TABS 60mg 100mg 150mg NDS
SIVEXTRO SOLR INTRAVENOUS HI
SIVEXTRO TABS NDS soloxide tbec MO streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
Drug Name RequirementsLimits
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO SUPRAX CAPS suprax chew suprax susr 100mg5ml 200mg5ml
SUPRAX SUSR 500 MG5ML SYNERCID SOLR targadox tabs MO tazicef solr injection 1gm 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS 400mg 600mg HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
VABOMERE SOLR INTRAVENOUS HI
vancomycin hcl caps vancomycin hcl solr VANCOMYCIN HCL SOLR 250 MG
vancomycin hcl solr intravenous 1gm 10gm 500mg HI
VIBRAMYCIN SYRP XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS XIMINO CP24 45mg 90mg 135mg MO
ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ZITHROMAX PACK MO ZOSYN SOLN INTRAVENOUS HI ZYVOX SOLN INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
ANTIFUNGALS ABELCET SUSP INTRAVENOUS HI
AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS ERAXIS SOLR INTRAVENOUS 50mg 100mg HI
fluconazole in sodium chloride soln intravenous HI
fluconazole susr fluconazole tabs flucytosine caps 250mg 500mg NDS griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs itraconazole caps ITRACONAZOLE SOLN MO ketoconazole tabs micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS NOXAFIL TBEC NDS nystatin susp nystatin tabs POSACONAZOLE SUSP NDS posaconazole tbec NDS terbinafine hcl tabs TOLSURA CAPS NDS voriconazole solr intravenous HI voriconazole susr voriconazole tabs ANTIMYCOBACTERIALS CAPASTAT SULFATE SOLR cycloserine caps dapsone tabs 25mg 100mg MO ethambutol hcl tabs 100mg 400mg MO
isoniazid soln
Drug Name RequirementsLimits
isoniazid syrp MO isoniazid tabs 100mg 300mg MO paser pack MO PRETOMANID TABS PRIFTIN TABS MO pyrazinamide tabs MO RIFABUTIN CAPS MO RIFADIN CAPS MO rifamate caps MO rifampin caps 150mg 300mg MO rifampin solr intravenous HI RIFATER TABS MO SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs BENZNIDAZOLE TABS 125mg 100mg MO
chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS DARAPRIM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS mefloquine hcl tabs metronidazole caps metronidazole in nacl soln metronidazole in nacl soln intravenous HI
metronidazole tabs NEBUPENT SOLR PA nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 12 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
quinine sulfate caps NDS SOLOSEC PACK tinidazole tabs ANTIVIRALS abacavir sulfate soln abacavir sulfate tabs MO abacavir sulfate-lamivudine tabs MO abacavir-lamivudine-zidovudine tabs MO
acyclovir caps MO acyclovir sodium soln intravenous HI
acyclovir susp MO acyclovir tabs 400mg 800mg MO adefovir dipivoxil tabs NDS APTIVUS CAPS MO APTIVUS SOLN MO atazanavir sulfate caps 150mg 200mg 300mg MO
BARACLUDE SOLN MO BIKTARVY TABS CABENUVA SUER cidofovir soln CIMDUO TABS MO COMPLERA TABS MO CRIXIVAN CAPS 200mg 400mg MO DAKLINZA TABS 30mg 60mg 90mg PANDS
DELSTRIGO TABS MO DESCOVY TABS MO didanosine cpdr 200mg 250mg 400mg MO
DOVATO TABS MO EDURANT TABS MO efavirenz caps 50mg 200mg MO efavirenz tabs MO efavirenz-emtricitab-tenofovir tabs MO
emtricitabine caps MO emtricitabine-tenofovir df tabs MO EMTRIVA SOLN MO entecavir tabs 05mg 1mg MO EPCLUSA TABS PANDS
Drug Name RequirementsLimits
EPIVIR HBV SOLN MO etravirine tabs 100mg 200mg MO EVOTAZ TABS MO famciclovir tabs 125mg 250mg 500mg MO
fosamprenavir calcium tabs MO FUZEON SOLR NDS ganciclovir sodium soln ganciclovir sodium solr GENVOYA TABS MO HARVONI PACK PANDS HARVONI TABS PANDS INTELENCE TABS 25mg MO INVIRASE CAPS MO INVIRASE TABS MO ISENTRESS CHEW 25mg 100mg MO
ISENTRESS HD TABS MO ISENTRESS PACK MO ISENTRESS TABS MO JULUCA TABS MO lamivudine soln MO lamivudine tabs 100mg 150mg 300mg MO
lamivudine-zidovudine tabs MO ledipasvir-sofosbuvir tabs PANDS LEXIVA SUSP MO lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO MAVYRET TABS PANDS nevirapine er tb24 100mg 400mg MO
nevirapine susp MO nevirapine tabs MO NORVIR CAPS MO NORVIR PACK MO NORVIR SOLN MO ODEFSEY TABS MO OLYSIO CAPS PANDS oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEG-INTRON REDIPEN KIT NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
PEGASYS PROCLICK SOLN 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN 180mcg05ml 180mcgml NDS
PEGINTRON KIT NDS PIFELTRO TABS MO PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
PREVYMIS SOLN 240mg12ml 480mg24ml NDS
PREVYMIS TABS 240mg 480mg NDS
PREZCOBIX TABS MO PREZISTA SUSP MO PREZISTA TABS 75mg 150mg 600mg 800mg MO
RAPIVAB SOLN NDS REBETOL SOLN MO RELENZA DISKHALER AEPB MO RESCRIPTOR TABS 100mg 200mg MO
RETROVIR SOLN MO REYATAZ PACK MO ribasphere caps MO ribasphere ribapak (1000 pack) tbpk MO
ribasphere ribapak (1200 pack) tbpk MO
ribasphere tabs MO ribavirin caps MO ribavirin solr ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg 150mg 300mg MO
sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS
Drug Name RequirementsLimits
SOVALDI TABS 200mg 400mg PANDS stavudine caps 15mg 20mg 30mg 40mg MO
STRIBILD TABS MO SYMFI LO TABS MO SYMFI TABS MO SYMTUZA TABS MO SYNAGIS SOLN 50mg05ml 100mgml NDS
tenofovir disoproxil fumarate tabs MO
TIVICAY PD TBSO MO TIVICAY TABS 10mg 25mg 50mg MO
TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEMLIDY TABS VIDEX EC CPDR 125mg 200mg 400mg MO
VIDEX SOLR 2gm 4gm MO VIEKIRA PAK TBPK PANDS VIEKIRA XR TB24 PANDS VIRACEPT TABS 250mg 625mg MO
VIREAD POWD MO VIREAD TABS 150mg MO VIREAD TABS 200mg 250mg MO VOCABRIA TABS MO VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS ZERIT CAPS 15mg 20mg 30mg 40mg MO
zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 14 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fosfomycin tromethamine pack MENAPHOSMBHYO1 TABS methenamine hippurate tabs METHENAMINE MANDELATE TABS
NITROFURANTOIN MACROCRYSTAL CAPS
NITROFURANTOIN MONOHYD MACRO CAPS
nitrofurantoin susp PHOSPHASAL TABS trimethoprim tabs MO URETRON DS TABS URIN DS TABS URYL TABS USTELL CAPS UTICAP CAPS UTIRA-C TABS UTRONA-C TABS ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate soln carbinoxamine maleate tabs cetirizine hcl soln CLARINEX SYRP CLARINEX-D 12 HOUR TB12 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln
Drug Name RequirementsLimits
promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs SEMPREX-D CAPS ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg 500mg NDS
ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS 25mg 5mg 75mg 10mg NDS
ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs ARRANON SOLN ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE INJ BELEODAQ SOLR NDS BELRAPZO SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS bexarotene caps NDS bicalutamide tabs BICNU SOLR bleomycin sulfate solr BLINCYTO SOLR NDS BORTEZOMIB SOLR BOSULIF TABS 100mg 400mg 500mg NDS
BRAFTOVI CAPS 50mg 75mg NDS BRUKINSA CAPS NDS busulfan soln CABOMETYX TABS 20mg 40mg 60mg NDS
CALQUENCE CAPS NDS CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR NDS cladribine soln clofarabine soln COMETRIQ (100 MG DAILY DOSE) KIT LDNDS
COMETRIQ (140 MG DAILY DOSE) KIT LDNDS
COMETRIQ (60 MG DAILY DOSE) KIT LDNDS
COPIKTRA CAPS 15mg 25mg NDS COTELLIC TABS NDS CYCLOPHOSPHAMIDE CAPS 25mg 50mg PA
CYCLOPHOSPHAMIDE SOLN 1gm5ml 500mg25ml NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr
Drug Name RequirementsLimits
dactinomycin solr DANYELZA SOLN NDS DARZALEX FASPRO SOLN NDS DARZALEX SOLN 400mg20ml 100mg5ml NDS
daunorubicin hcl soln DAURISMO TABS 25mg 100mg NDS decitabine solr DOCETAXEL (NON-ALCOHOL) SOLN 80mg4ml 160mg8ml 20mgml
NDS
docetaxel conc docetaxel soln doxorubicin hcl liposomal inj DOXORUBICIN HCL SOLN doxorubicin hcl solr DROXIA CAPS ELIGARD KIT ELLENCE SOLN ELZONRIS SOLN NDS EMCYT CAPS NDS EMPLICITI SOLR 300mg 400mg NDS
ENHERTU SOLR NDS epirubicin hcl soln ERBITUX SOLN ERIVEDGE CAPS NDS ERLEADA TABS NDS erlotinib hcl tabs 25mg 100mg 150mg NDS
ERWINASE SOLR NDS ERWINAZE SOLR NDS ETOPOPHOS SOLR NDS etoposide soln everolimus tabs 25mg 5mg 75mg NDS
EVOMELA SOLR NDS exemestane tabs FARYDAK CAPS 10mg 15mg 20mg LDNDS
FASLODEX SOLN NDS FENSOLVI (6 MONTH) KIT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 16 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
FIRMAGON (240 MG DOSE) SOLR
FIRMAGON SOLR floxuridine solr fludarabine phosphate soln fludarabine phosphate solr fluorouracil soln flutamide caps FOTIVDA CAPS 089mg 134mg NDS
fulvestrant soln NDS GAVRETO CAPS NDS GAZYVA SOLN NDS gemcitabine hcl soln gemcitabine hcl solr GILOTRIF TABS 20mg 30mg 40mg NDS
HERCEPTIN HYLECTA SOLN NDS HERCEPTIN SOLR 150mg 440mg NDS
HERZUMA SOLR 150mg 420mg NDS
HEXALEN CAPS NDS hydroxyurea caps IBRANCE CAPS 75mg 100mg 125mg NDS
IBRANCE TABS 75mg 100mg 125mg NDS
ICLUSIG TABS 10mg 15mg 30mg 45mg NDS
IDAMYCIN PFS SOLN idarubicin hcl soln IDHIFA TABS 50mg 100mg NDS ifosfamide soln IFOSFAMIDE SOLR imatinib mesylate tabs IMBRUVICA CAPS 70mg 140mg NDS
IMBRUVICA TABS 140mg 280mg 420mg 560mg NDS
IMFINZI SOLN 500mg10ml 120mg24ml NDS
INFUGEM SOLN NDS INLYTA TABS 1mg 5mg NDS
Drug Name RequirementsLimits
INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 10muml 6000000unitml NDS
INTRON A SOLR 10mu 18mu 50mu NDS
IRESSA TABS NDS irinotecan hcl soln IXEMPRA KIT SOLR NDS JAKAFI TABS 5mg 10mg 15mg 20mg 25mg NDS
JEMPERLI SOLN KADCYLA SOLR 100mg 160mg NDS KANJINTI SOLR 150mg 420mg NDS KEYTRUDA SOLN NDS KISQALI (200 MG DOSE) TBPK NDS KISQALI (400 MG DOSE) TBPK NDS KISQALI (600 MG DOSE) TBPK NDS KISQALI FEMARA (400 MG DOSE) TBPK NDS
KISQALI FEMARA (600 MG DOSE) TBPK NDS
KISQALI FEMARA (200 MG DOSE) TBPK NDS
KOSELUGO CAPS 10mg 25mg NDS KYPROLIS SOLR 10mg 30mg 60mg NDS
lapatinib ditosylate tabs NDS LARTRUVO SOLN 190mg19ml 500mg50ml NDS
LENVIMA (10 MG DAILY DOSE) CPPK LDNDS
LENVIMA (12 MG DAILY DOSE) CPPK LDNDS
LENVIMA (14 MG DAILY DOSE) CPPK LDNDS
LENVIMA (18 MG DAILY DOSE) CPPK LDNDS
LENVIMA (20 MG DAILY DOSE) CPPK LDNDS
LENVIMA (24 MG DAILY DOSE) CPPK LDNDS
LENVIMA (4 MG DAILY DOSE) CPPK LDNDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
LENVIMA (8 MG DAILY DOSE) CPPK LDNDS
letrozole tabs LEUKERAN TABS NDS leuprolide acetate kit LIBTAYO SOLN NDS LIPODOX 50 INJ LONSURF TABS NDS LORBRENA TABS 25mg 100mg NDS
LUMAKRAS TABS NDS LUMOXITI SOLR NDS LUPANETA PACK KIT LUPRON DEPOT (1-MONTH) KIT
LUPRON DEPOT (3-MONTH) KIT
LUPRON DEPOT (4-MONTH) KIT
LUPRON DEPOT (6-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT 75 MG
LUPRON DEPOT-PED (3-MONTH) KIT
LYNPARZA CAPS NDS LYNPARZA TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA SOLN NDS MARQIBO SUSP NDS MATULANE CAPS NDS megestrol acetate susp megestrol acetate tabs MEKINIST TABS 05mg 2mg NDS MEKTOVI TABS NDS melphalan hcl solr mercaptopurine tabs methotrexate sodium (pf) soln methotrexate sodium soln methotrexate sodium solr
Drug Name RequirementsLimits
methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS MUSTARGEN SOLR mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS NERLYNX TABS NDS NEXAVAR TABS NDS nilutamide tabs NINLARO CAPS 23mg 3mg 4mg NDS
NUBEQA TABS NDS ODOMZO CAPS NDS OGIVRI SOLR NDS ONIVYDE INJ NDS ONTRUZANT SOLR 150mg 420mg NDS
ONUREG TABS 200mg 300mg NDS OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml NDS
oxaliplatin soln oxaliplatin solr paclitaxel conc PADCEV SOLR 20mg 30mg NDS paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEPAXTO SOLR NDS PERJETA SOLN NDS PHESGO SOLN NDS PIQRAY (200 MG DAILY DOSE) TBPK NDS
PIQRAY (250 MG DAILY DOSE) TBPK NDS
PIQRAY (300 MG DAILY DOSE) TBPK NDS
POLIVY SOLR 30mg 140mg NDS POMALYST CAPS 1mg 2mg 3mg 4mg NDS
PORTRAZZA SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 18 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
POTELIGEO SOLN NDS PROLEUKIN SOLR NDS PURIXAN SUSP NDS QINLOCK TABS NDS RETEVMO CAPS 40mg 80mg NDS REVLIMID CAPS 25mg 5mg 10mg 15mg 20mg 25mg NDS
RIABNI SOLN 100mg10ml 500mg50ml NDS
RITUXAN HYCELA SOLN RITUXAN SOLN ROMIDEPSIN SOLN NDS ROZLYTREK CAPS 100mg 200mg NDS
RUBRACA TABS 200mg 250mg 300mg NDS
RUXIENCE SOLN 100mg10ml 500mg50ml NDS
RYBREVANT SOLN NDS RYDAPT CAPS NDS RYLAZE SOLN NDS SARCLISA SOLN 500mg25ml 100mg5ml NDS
SIKLOS TABS NDS SOLTAMOX SOLN SPRYCEL TABS 20mg 50mg 70mg 80mg 100mg 140mg NDS
STIVARGA TABS NDS sunitinib malate caps 125mg 25mg 375mg 50mg NDS
SUTENT CAPS 125mg 25mg 375mg 50mg NDS
SYLATRON KIT 600 MCG SYLATRON KIT SYLVANT SOLR 100mg 400mg NDS SYNRIBO SOLR NDS TABLOID TABS TABRECTA TABS 150mg 200mg NDS
TAFINLAR CAPS 50mg 75mg NDS TAGRISSO TABS 40mg 80mg NDS TALZENNA CAPS 025mg 1mg NDS tamoxifen citrate tabs
Drug Name RequirementsLimits
TARCEVA TABS 25mg 100mg 150mg NDS
TASIGNA CAPS 50mg 150mg 200mg NDS
TAZVERIK TABS NDS TECENTRIQ SOLN 840mg14ml 1200mg20ml NDS
temsirolimus soln TENIPOSIDE SOLN TEPADINA SOLR NDS TEPMETKO TABS NDS THALOMID CAPS 50mg 100mg 150mg 200mg NDS
thiotepa solr 15mg 100mg NDS TIBSOVO TABS NDS toposar soln TOPOTECAN HCL SOLN topotecan hcl solr toremifene citrate tabs NDS TRAZIMERA SOLR 150mg 420mg NDS
TRELSTAR MIXJECT SUSR tretinoin caps NDS trexall tabs 5mg 75mg 10mg 15mg PA
TRISENOX SOLN 10mg10ml NDS TRISENOX SOLN NDS TRODELVY SOLR NDS TRUSELTIQ (100MG DAILY DOSE) CPPK NDS
TRUSELTIQ (125MG DAILY DOSE) CPPK NDS
TRUSELTIQ (50MG DAILY DOSE) CPPK NDS
TRUSELTIQ (75MG DAILY DOSE) CPPK NDS
TRUXIMA SOLN 100mg10ml 500mg50ml NDS
TUKYSA TABS 50mg 150mg NDS TURALIO CAPS NDS TYKERB TABS NDS UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
VANTAS KIT VELCADE SOLR VENCLEXTA STARTING PACK TBPK NDS
VENCLEXTA TABS 10mg NDS VENCLEXTA TABS 50mg 100mg NDS
VERZENIO TABS 50mg 100mg 150mg 200mg NDS
vinblastine sulfate soln vincasar pfs soln vincristine sulfate soln vinorelbine tartrate soln VITRAKVI CAPS 25mg 100mg NDS VITRAKVI SOLN NDS VIZIMPRO TABS 15mg 30mg 45mg NDS
VOTRIENT TABS NDS VYXEOS SUSR NDS XALKORI CAPS 200mg 250mg NDS XATMEP SOLN PANDS XOSPATA TABS NDS XPOVIO (100 MG ONCE WEEKLY) TBPK 20mg 50mg NDS
XPOVIO (40 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (40 MG TWICE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (60 MG ONCE WEEKLY) TBPK 20mg 60mg NDS
XPOVIO (60 MG TWICE WEEKLY) TBPK NDS
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (80 MG TWICE WEEKLY) TBPK NDS
XTANDI CAPS NDS XTANDI TABS 40mg 80mg NDS YERVOY SOLN YONDELIS SOLR NDS YONSA TABS NDS ZALTRAP SOLN 100mg4ml 200mg8ml NDS
ZEJULA CAPS NDS
Drug Name RequirementsLimits
ZELBORAF TABS NDS ZEPZELCA SOLR NDS ZIRABEV SOLN 400mg16ml 100mg4ml NDS
ZOLINZA CAPS NDS ZYDELIG TABS 100mg 150mg NDS ZYKADIA CAPS NDS ZYKADIA TABS NDS ZYNLONTA SOLR NDS ZYTIGA TABS NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA AEPB MO ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO BEVESPI AEROSPHERE AERO MO chlordiazepoxide-clidinium caps CUVPOSA SOLN MO dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate pf sosy glycopyrrolate soln glycopyrrolate tabs 1mg 2mg MO INCRUSE ELLIPTA AEPB MO ipratropium bromide soln 002 PAMO ipratropium bromide soln 003 006 MO
LONHALA MAGNAIR REFILL KIT SOLN NDS
methscopolamine bromide tabs 25mg 5mg MO
propantheline bromide tabs MO SPIRIVA HANDIHALER CAPS MO SPIRIVA RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 20 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO NICOTROL NS SOLN MO PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride tabs 5mg 10mg 25mg 50mg MO
CEVIMELINE HCL CAPS MO donepezil hcl tabs 5mg 10mg 23mg MO
donepezil hcl tbdp 5mg 10mg MO galantamine hydrobromide er cp24 8mg 16mg 24mg MO
galantamine hydrobromide soln MO galantamine hydrobromide tabs 4mg 8mg 12mg MO
GUANIDINE HCL TABS MO MESTINON SOLN MO pilocarpine hcl tabs 5mg 75mg MO pyridostigmine bromide er tbcr MO pyridostigmine bromide soln MO pyridostigmine bromide tabs 30mg 60mg MO
REGONOL SOLN rivastigmine pt24 46mg24hr 95mg24hr 133mg24hr MO
rivastigmine tartrate caps 15mg 3mg 45mg 6mg MO
urecholine tabs 5mg 10mg 25mg 50mg MO
SKELETAL MUSCLE RELAXANTS baclofen soln baclofen tabs 5mg 10mg 20mg MO carisoprodol tabs 250mg 350mg PANDS carisoprodol-aspirin tabs PANDS carisoprodol-aspirin-codeine tabs PANDS
chlorzoxazone tabs 375mg 500mg 750mg NDS
Drug Name RequirementsLimits
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA lorzone tabs 375mg 750mg NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln revonto solr succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs vanadom tabs PANDS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl er tb24 MO dihydroergotamine mesylate soln NDS ergoloid mesylates tabs MO ergomar subl phenoxybenzamine hcl caps NDS silodosin caps 4mg 8mg MO tamsulosin hcl caps MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR HFA AERO MO albuterol sulfate er tb12 4mg 8mg MO
albuterol sulfate hfa aers MONDS albuterol sulfate nebu 0083 25mg05ml PAMO
albuterol sulfate nebu 063mg3ml 125mg3ml PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO ARCAPTA NEOHALER CAPS MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY EPIPEN 2-PAK SOAJ EPIPEN JR 2-PAK SOAJ formoterol fumarate nebu PAMO ipratropium-albuterol soln PAMO isoproterenol hcl soln levalbuterol hcl nebu 125mg05ml 031mg3ml 063mg3ml 125mg3ml
PAMO
levalbuterol tartrate aero MO metaproterenol sulfate syrp MO metaproterenol sulfate tabs 10mg 20mg MO
midodrine hcl tabs 25mg 5mg 10mg MO
norepinephrine bitartrate soln phenylephrine hcl soln PROAIR RESPICLICK AEPB MO SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
tizanidine hcl caps VENTOLIN HFA AERS MONDS BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS BERINERT KIT INTRAVENOUS HI FIRAZYR SOLN NDS icatibant acetate soln NDS OXBRYTA TABS NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS
Drug Name RequirementsLimits
COAGULANTS AND ANTICOAGULANTS aminocaproic acid soln MO aminocaproic acid tabs 500mg 1000mg MO
anagrelide hcl caps 05mg 1mg MO argatroban soln aspirin-dipyridamole er cp12 MO BEVYXXA CAPS 40mg 80mg MO BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
NDS
FRAGMIN SOLN 2500unit02ml 5000unit02ml 7500unit03ml 12500unit05ml 15000unit06ml 95000unit38ml 10000unitml 18000unt072ml
NDS
heparin (porcine) in nacl soln HEPARIN SOD (PORCINE) IN D5W SOLN
heparin sodium (porcine) pf soln PA heparin sodium (porcine) soln 1000unitml 5000unitml 10000unitml 20000unitml
PA
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg
MO
LOVENOX SOLN 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 22 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg PRADAXA CAPS 110mg 150mg MO
prasugrel hcl tabs 5mg 10mg MO tranexamic acid soln tranexamic acid tabs MO warfarin sodium tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 10mg
MO
XARELTO STARTER PACK TBPK MO
XARELTO TABS 25mg 10mg 15mg 20mg MO
ZONTIVITY TABS MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 25mcgml 40mcgml PANDS
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml
PANDS
FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MIRCERA SOSY 30mcg03ml 50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml
PA
MULPLETA TABS NDS
Drug Name RequirementsLimits
NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml NDS
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RETACRIT SOLN 20000unit2ml 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL TB24 4mg 8mg MO DEMSER CAPS NDS doxazosin mesylate tabs 1mg 2mg 4mg 8mg MO
metyrosine caps NDS prazosin hcl caps 1mg 2mg 5mg MO
terazosin hcl caps 1mg 2mg 5mg 10mg MO
ANTILIPEMIC AGENTS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
ALTOPREV TB24 20mg 40mg 60mg MO
ANTARA CAPS 30mg 90mg MO atorvastatin calcium tabs 10mg 20mg 40mg 80mg MO
cholestyramine light pack MO cholestyramine light powd MO cholestyramine pack MO cholestyramine powd MO colesevelam hcl pack MO colesevelam hcl tabs MO colestipol hcl gran MO colestipol hcl pack MO colestipol hcl tabs MO EVKEEZA SOLN 345mg23ml 1200mg8ml NDS
ezetimibe tabs MO ezetimibe-simvastatin tabs MO fenofibrate caps 50mg 134mg 150mg MO
fenofibrate micronized caps 43mg 67mg 130mg 200mg MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg MO
FENOFIBRIC ACID TABS 35mg 105mg MO
FIBRICOR TABS MO FLOLIPID SUSP 20mg5ml 40mg5ml MO
fluvastatin sodium caps 20mg 40mg MO
fluvastatin sodium er tb24 MO gemfibrozil tabs MO icosapent ethyl caps MO JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg PALDNDS
KYNAMRO SOSY PALDNDS LIVALO TABS 1mg 2mg 4mg MO lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
Drug Name RequirementsLimits
niacor tabs MO omega-3-acid ethyl esters caps MO pravastatin sodium tabs 10mg 20mg 40mg 80mg MO
prevalite pack MO prevalite powd MO questran light powd MO questran pack MO questran powd MO REPATHA PUSHTRONEX SYSTEM SOCT PANDS
REPATHA SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 05gm 1gm MO ZYPITAMAG TABS 1mg 2mg 4mg MO
BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl caps 200mg 400mg MO
atenolol tabs 25mg 50mg 100mg MO
atenolol-chlorthalidone tabs MO betaxolol hcl tabs 10mg 20mg MO bisoprolol fumarate tabs 5mg 10mg MO
bisoprolol-hydrochlorothiazide tabs MO
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg MO
carvedilol tabs 3125mg 625mg 125mg 25mg MO
DUTOPROL TB24 MO ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln INNOPRAN XL CP24 80mg 120mg MO
labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 24 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
metoprolol succinate er tb24 25mg 50mg 100mg 200mg MO
metoprolol tartrate soct metoprolol tartrate soln metoprolol tartrate tabs 25mg 50mg 100mg MO
metoprolol tartrate tabs 375mg 75mg MO
metoprolol-hydrochlorothiazide tabs MO
nadolol tabs 20mg 40mg 80mg MO nadolol-bendroflumethiazide tabs MO
pindolol tabs 5mg 10mg MO propranolol hcl er cp24 60mg 80mg 120mg 160mg MO
propranolol hcl soln 20mg5ml 40mg5ml MO
propranolol hcl tabs 10mg 20mg 40mg 60mg 80mg MO
propranolol-hctz tabs MO sorine tabs 80mg 120mg 160mg 240mg MO
sotalol hcl (af) tabs 80mg 120mg 160mg MO
sotalol hcl tabs 80mg 120mg 160mg 240mg MO
SOTYLIZE SOLN MO timolol maleate tabs 5mg 10mg 20mg MO
CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besy-benazepril hcl caps MO
amlodipine besylate tabs 25mg 5mg 10mg MO
amlodipine besylate-valsartan tabs MO
amlodipine-atorvastatin tabs MO amlodipine-olmesartan tabs MO amlodipine-valsartan-hctz tabs MO CARDENE IV SOLN CARDIZEM LA TB24 MO cartia xt cp24 120mg 180mg 240mg 300mg MO
Drug Name RequirementsLimits
CONSENSI TABS NDS dilt-xr cp24 120mg 180mg 240mg MO
diltiazem hcl er beads cp24 120mg 180mg 240mg 300mg 360mg 420mg
MO
DILTIAZEM HCL ER COATED BEADS CP24 120mg 180mg 240mg 300mg 360mg
MO
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg
MO
diltiazem hcl er cp12 60mg 90mg 120mg MO
diltiazem hcl er cp24 120mg 180mg 240mg MO
diltiazem hcl soln diltiazem hcl solr diltiazem hcl tabs 30mg 60mg 90mg 120mg MO
felodipine er tb24 25mg 5mg 10mg MO
isradipine caps 25mg 5mg MO matzim la tb24 180mg 240mg 300mg 360mg 420mg MO
nicardipine hcl caps 20mg 30mg MO nicardipine hcl soln nifedipine caps 10mg 20mg MO nifedipine er osmotic release tb24 30mg 60mg 90mg MO
nifedipine er tb24 30mg 60mg 90mg MO
nimodipine caps MO nisoldipine er tb24 85mg 17mg 20mg 255mg 30mg 34mg 40mg
MO
NYMALIZE SOLN 60mg20ml 6mgml NDS
olmesartan-amlodipine-hctz tabs MO taztia xt cp24 120mg 180mg 240mg 300mg 360mg MO
telmisartan-amlodipine tabs MO tiadylt er cp24 120mg 180mg 240mg 300mg 360mg 420mg MO
trandolapril-verapamil hcl er tbcr MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
VERAPAMIL HCL ER CP24 100mg 120mg 180mg 200mg 240mg 300mg 360mg
MO
verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 80mg 120mg MO verapamil hcl tabs MO VERELAN CP24 MO CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln inj DIGOXIN ORAL SOLN MO digoxin tabs 125mcg 250mcg MO disopyramide phosphate caps 100mg 150mg MO
dofetilide caps 125mcg 250mcg 500mcg MO
flecainide acetate tabs 50mg 100mg 150mg MO
ibutilide fumarate soln LANOXIN PEDIATRIC SOLN LANOXIN TABS 625mcg MO lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy LIDOCAINE IN D5W SOLN mexiletine hcl caps 150mg 200mg 250mg MO
milrinone lactate in dextrose soln milrinone lactate soln MULTAQ TABS NORPACE CR CP12 100mg 150mg MO
pacerone tabs 100mg 200mg 400mg MO
procainamide hcl soln
Drug Name RequirementsLimits
propafenone hcl er cp12 225mg 325mg 425mg MO
propafenone hcl tabs 150mg 225mg 300mg MO
quinidine gluconate er tbcr MO QUINIDINE GLUCONATE SOLN quinidine sulfate tabs 200mg 300mg MO
ranolazine er tb12 500mg 1000mg MO
VYNDAMAX CAPS NDS VYNDAQEL CAPS NDS HYPOTENSIVE AGENTS clonidine hcl (analgesia) soln clonidine hcl er tb12 MO clonidine hcl tabs 01mg 02mg 03mg MO
clonidine ptwk 01mg24hr 02mg24hr 03mg24hr MO
guanfacine hcl tabs 1mg 2mg MO hydralazine hcl soln hydralazine hcl tabs 10mg 25mg 50mg 100mg MO
methyldopa tabs 250mg 500mg MO methyldopa-hydrochlorothiazide tabs MO
minoxidil tabs 25mg 10mg MO nitropress soln nitroprusside sodium soln vecamyl tabs NDS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE TABS MO aliskiren fumarate tabs 150mg 300mg MO
benazepril hcl tabs 5mg 10mg 20mg 40mg MO
benazepril-hydrochlorothiazide tabs MO
candesartan cilexetil tabs 4mg 8mg 16mg 32mg MO
candesartan cilexetil-hctz tabs MO captopril tabs 125mg 25mg 50mg 100mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 26 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
captopril-hydrochlorothiazide tabs MO
CAROSPIR SUSP MO EDARBYCLOR TABS MO enalapril maleate tabs 25mg 5mg 10mg 20mg MO
enalapril-hydrochlorothiazide tabs MO
enalaprilat inj ENTRESTO TABS MO eplerenone tabs 25mg 50mg MO eprosartan mesylate tabs MO fosinopril sodium tabs 10mg 20mg 40mg MO
fosinopril sodium-hctz tabs MO irbesartan tabs 75mg 150mg 300mg MO
irbesartan-hydrochlorothiazide tabs MO
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg MO
lisinopril-hydrochlorothiazide tabs MO
losartan potassium tabs 25mg 50mg 100mg MO
losartan potassium-hctz tabs MO moexipril hcl tabs 75mg 15mg MO olmesartan medoxomil tabs 5mg 20mg 40mg MO
olmesartan medoxomil-hctz tabs MO perindopril erbumine tabs 2mg 4mg 8mg MO
QBRELIS SOLN MO quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO TEKTURNA HCT TABS MO
Drug Name RequirementsLimits
telmisartan tabs 20mg 40mg 80mg MO
telmisartan-hctz tabs MO trandolapril tabs 1mg 2mg 4mg MO valsartan tabs 40mg 80mg 160mg 320mg MO
valsartan-hydrochlorothiazide tabs MO
VASODILATING AGENTS alyq tabs PA BIDIL TABS MO dipyridamole tabs 25mg 50mg 75mg MO
GONITRO PACK MO isosorbide dinitrate er tbcr MO isosorbide dinitrate tabs 5mg 10mg 20mg 30mg MO
isosorbide mononitrate er tb24 30mg 60mg MO
isosorbide mononitrate er tb24 MO isosorbide mononitrate tabs 10mg 20mg MO
minitran pt24 01mghr 02mghr 04mghr 06mghr MO
nitro-bid oint MO NITRO-DUR PT24 03mghr 08mghr MO
nitroglycerin pt24 01mghr 02mghr 04mghr 06mghr MO
nitroglycerin soln MO nitroglycerin subl 03mg 04mg 06mg MO
sildenafil citrate soln PANDS sildenafil citrate susr PA sildenafil citrate tabs PAMO tadalafil (pah) tabs 20mg PA tadalafil tabs 25mg 5mg PA CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS acamprosate calcium tbec MO antabuse tabs 250mg 500mg MO disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
ABSTRAL SUBL 100mcg 200mcg 300mcg 400mcg 600mcg 800mcg
PANDS
acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ARYMO ER TBEA NDS ascomp-codeine caps NDS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
benzhydrocodone-acetaminophen tabs
bupap tabs buprenorphine hcl soln NDS buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
butalbital-acetaminophen caps NDS butalbital-acetaminophen tabs butalbital-apap-caff-cod caps NDS butalbital-apap-caffeine caps butalbital-apap-caffeine tabs butalbital-asa-caff-codeine caps NDS butalbital-aspirin-caffeine caps butalbital-aspirin-caffeine tabs butorphanol tartrate soln 1mgml 2mgml 10mgml NDS
BUTRANS PTWK NDS cataflam tabs NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
DEMEROL SOLN 25mg05ml 75mg15ml 100mg2ml 75mgml
PANDS
diclofenac potassium tabs diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs
Drug Name RequirementsLimits
DUEXIS TABS NDS DURAMORPH SOLN 05mgml 1mgml HINDS
dvorah tabs NDS EMBEDA CPCR NDS endocet tabs NDS esgic caps esgic tabs etodolac caps etodolac er tb24 etodolac tabs fenoprofen calcium caps fenoprofen calcium tabs fenortho caps fentanyl citrate (pf) soct NDS FENTANYL CITRATE (PF) SOLN 50mcgml 1000mcg20ml 2500mcg50ml
NDS
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fioricet caps fioricetcodeine caps NDS flurbiprofen tabs hydrocodone bitartrate er cp12 10mg 15mg 20mg 30mg 40mg 50mg
NDS
hydrocodone-acetaminophen soln NDS
hydrocodone-acetaminophen tabs NDS
hydrocodone-ibuprofen tabs NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 28 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd NDS hydromorphone hcl pf soln 50mg5ml 10mgml NDS
HYDROMORPHONE HCL SOLN 1mgml 2mgml NDS
hydromorphone hcl tabs 2mg 4mg 8mg NDS
ibu tabs ibudone tabs NDS ibuprofen lysine soln ibuprofen susp ibuprofen tabs ILARIS SOLN NDS indocin supp INDOCIN SUSP indomethacin caps INDOMETHACIN CAPS 20mg indomethacin er cpcr indomethacin sodium solr KADIAN CP24 NDS ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 300mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lodine tabs lorcet hd tabs NDS lorcet plus tabs NDS lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam caps meloxicam tabs meperidine hcl soln 50mg5ml 25mgml 50mgml 100mgml PANDS
meperidine hcl tabs 50mg 100mg NDS
Drug Name RequirementsLimits
methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl soln 5mg5ml 10mg5ml 10mgml NDS
methadone hcl tabs 5mg 10mg NDS mitigo soln MORPHINE SULFATE (CONCENTRATE) SOLN NDS
morphine sulfate (pf) soln 4mgml 10mgml NDS
MORPHINE SULFATE (PF) SOLN INTRAVENOUS HI
morphine sulfate er beads cp24 30mg 45mg 60mg 75mg 90mg 120mg
NDS
morphine sulfate er cp24 10mg 20mg 30mg 40mg 50mg 60mg 80mg 100mg
NDS
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg NDS
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml NDS
MORPHINE SULFATE SOLN HINDS MORPHINE SULFATE SOLN INJECTION 2mgml 4mgml 10mgml
HI
MORPHINE SULFATE SOLN INTRAVENOUS HI
morphine sulfate tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln nalfon tabs nalocet tabs NDS NAPRELAN TB24 naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
NUCYNTA ER TB12 50mg 100mg 150mg NDS
NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS 50mg 75mg NDS NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs oxaprozin tabs OXAYDO TABS NDS oxycodone hcl caps NDS oxycodone hcl conc NDS oxycodone hcl er t12a 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxycodone hcl soln NDS oxycodone hcl tabs 5mg 10mg 15mg 20mg 30mg NDS
oxycodone-acetaminophen soln NDS oxycodone-acetaminophen tabs NDS oxycodone-acetaminophen tabs 5-300mg 10-300mg NDS
oxycodone-aspirin tabs NDS oxycodone-ibuprofen tabs NDS OXYCONTIN T12A 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxymorphone hcl er tb12 5mg 75mg 10mg 15mg 20mg 30mg 40mg
NDS
oxymorphone hcl tabs 5mg 10mg NDS
panlor tabs NDS pentazocine-naloxone hcl tabs NDS percocet tabs NDS phrenilin forte caps PIROXICAM CAPS 10mg 20mg NDS pregabalin er tb24 825mg 165mg 330mg MO
primlev tabs NDS prolate soln NDS prolate tabs NDS QDOLO SOLN NDS
Drug Name RequirementsLimits
relafen ds tabs NDS ROXYBOND TABA 5mg 15mg 30mg NDS
SALSALATE TABS SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
SUBSYS LIQD 100mcg 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
sulindac tabs tencon tabs TIVORBEX CAPS tolmetin sodium caps tolmetin sodium tabs tramadol hcl er (biphasic) tb24 100mg 200mg 300mg NDS
tramadol hcl er cp24 100mg 150mg 200mg 300mg NDS
tramadol hcl er tb24 100mg 200mg 300mg NDS
tramadol hcl tabs 50mg 100mg NDS tramadol-acetaminophen tabs NDS trezix caps NDS tylenol with codeine 3 tabs NDS tylenol with codeine 4 tabs NDS vanatol lq soln vicodin es tabs NDS vicodin hp tabs NDS vicodin tabs NDS XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg NDS
zebutal caps ZIPSOR CAPS ZORVOLEX CAPS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS ADDERALL XR CP24 NDS ADZENYS ER SUER NDS ADZENYS XR-ODT TBED 31mg 63mg 94mg 125mg 157mg 188mg
NDS
amphetamine er suer NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 30 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
amphetamine sulfate tabs 5mg 10mg NDS
amphetamine-dextroamphet er cp24 NDS
amphetamine-dextroamphetamine tabs NDS
armodafinil tabs 50mg 150mg 200mg 250mg PA
caffeine citrate soln COTEMPLA XR-ODT TBED 86mg 173mg 259mg NDS
DAYTRANA PTCH 10mg9hr 15mg9hr 20mg9hr 30mg9hr NDS
dexmethylphenidate hcl er cp24 5mg 10mg 15mg 20mg 25mg 30mg 35mg 40mg
NDS
dexmethylphenidate hcl tabs 25mg 5mg 10mg NDS
dextroamphetamine sulfate er cp24 5mg 10mg 15mg NDS
dextroamphetamine sulfate soln NDS dextroamphetamine sulfate tabs 5mg 10mg 15mg 20mg 30mg NDS
DYANAVEL XR SUER NDS evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS methylphenidate hcl chew 25mg 5mg 10mg NDS
methylphenidate hcl er (cd) cpcr 10mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er (la) cp24 10mg 20mg 30mg 40mg 60mg
NDS
methylphenidate hcl er (xr) cp24 10mg 15mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg NDS
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg
NDS
methylphenidate hcl soln 5mg5ml 10mg5ml NDS
Drug Name RequirementsLimits
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS MYDAYIS CP24 NDS procentra soln NDS QUILLICHEW ER CHER 20mg 30mg 40mg NDS
QUILLIVANT XR SRER NDS relexxii tbcr NDS SUNOSI TABS 75mg 150mg NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
NDS
VYVANSE CHEW 10mg 20mg 30mg 40mg 50mg 60mg NDS
WAKIX TABS 445mg 178mg NDS zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg
NDS
ANTICONVULSANTS APTIOM TABS 200mg 400mg 600mg 800mg MO
BANZEL SUSP BANZEL TABS 200mg 400mg NDS BRIVIACT SOLN NDS BRIVIACT TABS 10mg 25mg 50mg 75mg 100mg NDS
carbamazepine chew MO carbamazepine er cp12 100mg 200mg 300mg MO
carbamazepine er tb12 100mg 200mg 400mg MO
carbamazepine susp MO carbamazepine tabs MO CELONTIN CAPS MO clobazam susp MO clobazam tabs 10mg 20mg MO clonazepam tabs 05mg 1mg 2mg NDS
clonazepam tbdp 0125mg 025mg 05mg 1mg 2mg NDS
DIACOMIT CAPS 250mg 500mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
DIACOMIT PACK 250mg 500mg NDS
DIASTAT ACUDIAL GEL 10mg 20mg NDS
DIASTAT PEDIATRIC GEL NDS diazepam gel 25mg 10mg 20mg NDS
dilantin caps 30mg 100mg MO dilantin infatabs chew MO divalproex sodium csdr MO divalproex sodium er tb24 250mg 500mg MO
divalproex sodium tbec 125mg 250mg 500mg MO
ELEPSIA XR TB24 1000mg 1500mg NDS
EPIDIOLEX SOLN PANDS epitol tabs MO ethosuximide caps MO ethosuximide soln MO felbamate susp MO felbamate tabs 400mg 600mg MO FINTEPLA SOLN NDS fosphenytoin sodium soln FYCOMPA SUSP NDS FYCOMPA TABS gabapentin caps 100mg 400mg MO gabapentin soln MO gabapentin tabs 600mg 800mg MO HORIZANT TBCR 300mg 600mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
lamotrigine kit MO lamotrigine starter kit-blue kit MO lamotrigine starter kit-green kit MO lamotrigine starter kit-orange kit MO lamotrigine tabs 25mg 100mg 150mg 200mg MO
lamotrigine tbdp 25mg 50mg 100mg 200mg MO
Drug Name RequirementsLimits
levetiracetam er tb24 500mg 750mg MO
levetiracetam in nacl soln levetiracetam soln MO levetiracetam tabs 250mg 500mg 750mg 1000mg MO
magnesium sulfate soln magnesium sulfate soln injection 50 HI
MAGNESIUM SULFATE SOLN INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml
HI
NAYZILAM SOLN NDS oxcarbazepine susp MO oxcarbazepine tabs 150mg 300mg 600mg MO
OXTELLAR XR TB24 150mg 300mg 600mg MO
PEGANONE TABS MO phenytek caps 200mg 300mg MO phenytoin chew MO phenytoin sodium extended caps 100mg 200mg 300mg MO
phenytoin sodium soln phenytoin susp MO pregabalin caps 25mg 50mg 75mg 100mg 150mg 200mg 225mg 300mg
MO
pregabalin soln MO primidone tabs 50mg 250mg MO roweepra tabs 500mg 750mg 1000mg MO
roweepra xr tb24 500mg 750mg MO rufinamide susp rufinamide tabs 200mg 400mg NDS SPRITAM TB3D 250mg 500mg 750mg 1000mg NDS
subvenite starter kit-blue kit MO subvenite starter kit-green kit MO subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 32 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
SYMPAZAN FILM 10mg 20mg tiagabine hcl tabs 2mg 4mg 12mg 16mg MO
topiramate cpsp 15mg 25mg MO topiramate er cs24 25mg 50mg 100mg 150mg 200mg MO
topiramate tabs 25mg 50mg 100mg 200mg MO
TROKENDI XR CP24 25mg 50mg 100mg 200mg MO
valproate sodium soln valproic acid caps MO valproic acid soln MO VALTOCO 10 MG DOSE LIQD NDS VALTOCO 15 MG DOSE LQPK NDS VALTOCO 20 MG DOSE LQPK NDS VALTOCO 5 MG DOSE LIQD NDS vigabatrin pack LDNDS vigabatrin tabs NDS vigadrone pack LDNDS VIMPAT SOLN VIMPAT TABS MO XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200 MG NDS XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ AJOVY SOSY almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs EMGALITY (300 MG DOSE) SOSY NDS
Drug Name RequirementsLimits
EMGALITY SOAJ EMGALITY SOSY ergotamine-caffeine tabs frovatriptan succinate tabs naratriptan hcl tabs NURTEC TBDP NDS ONZETRA XSAIL EXHP rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs TOSYMRA SOLN UBRELVY TABS 50mg 100mg NDS ZEMBRACE SYMTOUCH SOAJ zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ZOMIG SOLN ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl syrp MO amantadine hcl tabs MO APOKYN SOCT NDS benztropine mesylate soln benztropine mesylate tabs 05mg 1mg 2mg MO
bromocriptine mesylate caps MO bromocriptine mesylate tabs MO cabergoline tabs MO carbidopa tabs MO carbidopa-levodopa er tbcr MO carbidopa-levodopa tabs MO carbidopa-levodopa tbdp MO carbidopa-levodopa-entacapone tabs MO
DUOPA SUSP LD EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg NDS
pramipexole dihydrochloride er tb24 0375mg 075mg 15mg 225mg 3mg 375mg 45mg
MO
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg
MO
rasagiline mesylate tabs 05mg 1mg MO
ropinirole hcl er tb24 2mg 4mg 6mg 8mg 12mg MO
ropinirole hcl tabs 025mg 05mg 1mg 2mg 3mg 4mg 5mg
MO
RYTARY CPCR MO selegiline hcl caps MO selegiline hcl tabs MO tolcapone tabs MO trihexyphenidyl hcl soln MO trihexyphenidyl hcl tabs 2mg 5mg MO
ZELAPAR TBDP MO ANXIOLYTICS SEDATIVES AND HYPNOTICS alprazolam er tb24 05mg 1mg 2mg 3mg NDS
alprazolam intensol conc NDS alprazolam tabs 025mg 05mg 1mg 2mg NDS
alprazolam tbdp 025mg 05mg 1mg 2mg NDS
BELSOMRA TABS buspirone hcl tabs 5mg 10mg buspirone hcl tabs 75mg 15mg 30mg
chlordiazepoxide hcl caps 5mg 10mg 25mg NDS
clorazepate dipotassium tabs 375mg 75mg 15mg NDS
diazepam conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS
Drug Name RequirementsLimits
droperidol soln EDLUAR SUBL 5mg 10mg NDS estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP NDS hydroxyzine hcl soln hydroxyzine hcl syrp hydroxyzine hcl tabs hydroxyzine pamoate caps lorazepam intensol conc NDS LORAZEPAM SOLN 4mgml 2mgml NDS
lorazepam tabs 05mg 1mg 2mg NDS
meprobamate tabs midazolam hcl (pf) soln midazolam hcl soln midazolam hcl syrp nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs ROZEREM TABS seconal caps TEMAZEPAM CAPS 15mg 225mg 30mg 75mg NDS
triazolam tabs 0125mg 025mg NDS zaleplon caps 5mg 10mg NDS zolpidem tartrate er tbcr 625mg 125mg NDS
zolpidem tartrate subl 175mg 35mg NDS
zolpidem tartrate tabs 5mg 10mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 34 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS atomoxetine hcl caps 10mg 18mg 25mg 40mg 60mg 80mg 100mg
MO
AUSTEDO TABS 6mg 9mg 12mg LDNDS
EXSERVAN FILM NDS flumazenil soln guanfacine hcl er tb24 1mg 2mg 3mg 4mg MO
INGREZZA CAPS 40mg 60mg 80mg NDS
INGREZZA CPPK NDS memantine hcl er cp24 memantine hcl soln MO memantine hcl tabs 5mg 10mg MO NAMENDA XR TITRATION PACK CP24 MO
NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS SAVELLA TABS 125mg 25mg 50mg 100mg MO
SAVELLA TITRATION PACK MISC MO
tetrabenazine tabs 125mg 25mg NDS
TIGLUTIK SUSP NDS XYREM SOLN LDNDS XYWAV SOLN NDS MULTIPLE SCLEROSIS AGENTS AUBAGIO TABS 7mg 14mg PANDS AVONEX KIT NDS AVONEX PEN AJKT NDS AVONEX PREFILLED PSKT NDS BAFIERTAM CPDR NDS BETASERON KIT NDS dalfampridine er tb12 MO dimethyl fumarate cpdr dimethyl fumarate starter pack misc
Drug Name RequirementsLimits
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatiramer acetate sosy 20mgml 40mgml NDS
glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 2mg NDS OCREVUS SOLN PLEGRIDY SOSY NDS PONVORY STARTER PACK TBPK NDS
PONVORY TABS NDS REBIF REBIDOSE SOAJ 22mcg05ml 44mcg05ml NDS
REBIF REBIDOSE TITRATION PACK SOAJ NDS
REBIF SOSY 22mcg05ml 44mcg05ml NDS
REBIF TITRATION PACK SOSY NDS TECFIDERA CPDR 120mg 240mg NDS
TECFIDERA MISC NDS TYSABRI CONC INTRAVENOUS HI
ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS ZINBRYTA SOSY LDNDS OPIATE ANTAGONISTS BUNAVAIL FILM NDS buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
LUCEMYRA TABS NDS naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR NDS ZUBSOLV SUBL NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg NDS
ABILIFY MYCITE MAINTENANCE KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg NDS
amitriptyline hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
amoxapine tabs 25mg 50mg 100mg 150mg MO
APLENZIN TB24 174mg 348mg 522mg MO
aripiprazole soln MO aripiprazole tabs 2mg 5mg 10mg 15mg 20mg 30mg MO
aripiprazole tbdp 10mg 15mg MO ARISTADA INITIO PRSY NDS ARISTADA PRSY 441mg16ml 662mg24ml 882mg32ml 1064mg39ml
NDS
asenapine maleate subl 25mg 5mg 10mg MO
bupropion hcl er (smoking det) tb12 MO
bupropion hcl er (sr) tb12 100mg 150mg 200mg MO
bupropion hcl er (xl) tb24 150mg 300mg 450mg MO
bupropion hcl tabs 75mg 100mg MO CAPLYTA CAPS NDS chlordiazepoxide-amitriptyline tabs
chlorpromazine hcl soln
Drug Name RequirementsLimits
chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
clomipramine hcl caps 25mg 50mg 75mg MO
clozapine tabs 25mg 50mg 100mg 200mg NDS
clozapine tbdp 125mg 25mg 100mg 150mg 200mg NDS
compro supp MO desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
DESVENLAFAXINE ER TB24 50mg 100mg MO
desvenlafaxine succinate er tb24 25mg 50mg 100mg MO
doxepin hcl caps 10mg 25mg 50mg 75mg 100mg 150mg MO
doxepin hcl conc MO doxepin hcl tabs 3mg 6mg MO DRIZALMA SPRINKLE CSDR duloxetine hcl cpep 20mg 30mg 40mg 60mg MO
EQUETRO CP12 100mg 200mg 300mg MO
escitalopram oxalate soln MO escitalopram oxalate tabs 5mg 10mg 20mg MO
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg NDS
FANAPT TITRATION PACK TABS MO
FETZIMA CP24 20mg 40mg 80mg 120mg MO
FETZIMA TITRATION C4PK MO fluoxetine hcl (pmdd) tabs 10mg 20mg MO
fluoxetine hcl caps 10mg 20mg 40mg MO
fluoxetine hcl cpdr MO fluoxetine hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 36 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
GEODON SOLR haloperidol decanoate soln haloperidol lactate conc MO haloperidol lactate soln haloperidol tabs 05mg 1mg 2mg 5mg 10mg 20mg MO
imipramine hcl tabs 10mg 25mg 50mg MO
imipramine pamoate caps 75mg 100mg 125mg 150mg MO
INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 300mg 150mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
lithium carbonate tabs MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO
Drug Name RequirementsLimits
mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
nefazodone hcl tabs 50mg 100mg 150mg 200mg 250mg MO
nortriptyline hcl caps 10mg 25mg 50mg 75mg MO
nortriptyline hcl soln MO NUPLAZID CAPS NDS NUPLAZID TABS 10mg 17mg NDS olanzapine solr olanzapine tabs 25mg 5mg 75mg 10mg 15mg 20mg MO
olanzapine tbdp 5mg 10mg 15mg 20mg MO
olanzapine-fluoxetine hcl caps MO PALIPERIDONE ER TB24 15mg 3mg 6mg 9mg MO
paroxetine hcl er tb24 125mg 25mg 375mg MO
paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps MO PAXIL SUSP MO perphenazine tabs 2mg 4mg 8mg 16mg MO
perphenazine-amitriptyline tabs MO PERSERIS PRSY 90mg 120mg NDS PEXEVA TABS 10mg 20mg 30mg 40mg MO
phenelzine sulfate tabs MO pimozide tabs 1mg 2mg MO prochlorperazine edisylate soln prochlorperazine maleate tabs prochlorperazine supp MO protriptyline hcl tabs 5mg 10mg MO quetiapine fumarate er tb24 50mg 150mg 200mg 300mg 400mg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
quetiapine fumarate tabs 25mg 50mg 100mg 200mg 300mg 400mg
MO
REXULTI TABS 025mg 05mg 1mg 2mg 3mg 4mg NDS
RISPERDAL CONSTA SRER 125mg 25mg NDS
RISPERDAL CONSTA SRER 375mg 50mg NDS
risperidone soln MO risperidone tabs 025mg 05mg 1mg 2mg 3mg 4mg MO
risperidone tbdp 025mg 05mg 1mg 2mg 3mg 4mg MO
SAPHRIS SUBL 25mg 5mg 10mg NDS
SECUADO PT24 38mg24hr 57mg24hr 76mg24hr NDS
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
SILENOR TABS SPRAVATO (56 MG DOSE) SOPK NDS
SPRAVATO (84 MG DOSE) SOPK NDS
thioridazine hcl tabs 10mg 25mg 50mg 100mg MO
thiothixene caps 1mg 2mg 5mg 10mg MO
tofranil tabs 10mg 25mg 50mg MO tranylcypromine sulfate tabs MO trazodone hcl tabs 50mg 100mg 150mg MO
trazodone hcl tabs MO trifluoperazine hcl tabs 1mg 2mg 5mg 10mg MO
trimipramine maleate caps 25mg 50mg 100mg MO
TRINTELLIX TABS 5mg 10mg 20mg MO
venlafaxine hcl er cp24 375mg 75mg 150mg MO
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg MO
Drug Name RequirementsLimits
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
VRAYLAR CAPS 15mg 3mg 45mg 6mg NDS
VRAYLAR CPPK NDS ziprasidone hcl caps 20mg 40mg 60mg 80mg MO
ziprasidone mesylate solr ZYPREXA RELPREVV SUSR DIABETIC SUPPLIES DIABETIC SUPPLIES ALCOHOL PREP PADS MO BD INSULIN SYR ULTRAFINE II MISC MO
BD INSULIN SYRINGE MISC MO BD INSULIN SYRINGE UF MISC MO
BD PEN NEEDLE ORIGINAL UF MISC MO
CURITY GAUZE PADS MO OMNIPOD STARTER KIT NDS ELECTROLYTIC CALORIC AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS POT amp SOD CIT-CIT AC SOLN potassium citrate er tbcr 15meq 540mg 1080mg MO
SODIUM ACETATE SOLN SODIUM BICARBONATE SOLN SODIUM LACTATE SOLN INTRAVENOUS HI
TRICITRATES SOLN AMMONIA DETOXICANTS CARBAGLU TABS LD constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 38 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lactulose pack MO lactulose soln MO LITHOSTAT TABS MO RAVICTI LIQD NDS sod benz-sod phenylacet soln sodium phenylbutyrate powd NDS sodium phenylbutyrate tabs NDS CALORIC AGENTS AMINOSYN-PF SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (27510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42525) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (525) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (525) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN dextrose soln intravenous 5 10 HI
Drug Name RequirementsLimits
FREAMINE HBC SOLN INTRAVENOUS HI
HEPATAMINE SOLN INTRAVENOUS HI
INTRALIPID EMUL INTRAVENOUS 20gm100ml HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NEPHRAMINE SOLN INTRAVENOUS HI
NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE SOLN INTRAVENOUS HI
PROSOL SOLN INTRAVENOUS HI TRAVASOL SOLN INTRAVENOUS HI
TROPHAMINE SOLN INTRAVENOUS HI
DIURETICS AMILORIDE HCL TABS MO amiloride-hydrochlorothiazide tabs MO
bumetanide soln bumetanide tabs 05mg 1mg 2mg MO
chlorothiazide sodium solr chlorothiazide tabs 250mg 500mg MO
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI FUROSEMIDE TABS 40mg 80mg 20mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN SAMSCA TABS 15mg NDS TOLVAPTAN TABS 30mg 15mg NDS torsemide tabs 5mg 10mg 20mg 100mg MO
triamterene caps 50mg 100mg MO triamterene-hctz caps MO triamterene-hctz tabs MO ION-REMOVING AGENTS AURYXIA TABS PAMONDS FOSRENOL PACK 750mg 1000mg NDS
kionex susp MO lanthanum carbonate chew 500mg 750mg 1000mg MO
LOKELMA PACK 5gm 10gm MO sevelamer carbonate pack 08gm 24gm MO
sevelamer carbonate tabs MO sevelamer hcl tabs 400mg 800mg MO
sodium polystyrene sulfonate powd MO
sodium polystyrene sulfonate susp MO
sps susp MO VELPHORO CHEW NDS VELTASSA PACK 84gm 168gm 252gm NDS
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate (phos binder) tabs MO
CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
Drug Name RequirementsLimits
DEXTROSE-NACL SOLN INTRAVENOUS HI
DEXTROSE 10NACL 02 DEXTROSE 10NACL 045 HI
DEXTROSE 5NACL 0225 HI IONOSOL-MB IN D5W SOLN INTRAVENOUS HI
ISOLYTE-P IN D5W SOLN INTRAVENOUS HI
ISOLYTE-S SOLN INTRAVENOUS HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-033 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 TBCR MO klor-con m10 tbcr MO klor-con m15 tbcr MO klor-con m20 tbcr MO klor-con pack MO klor-con sprinkle cpcr 8meq 10meq MO
KLOR-CON TBCR MO LACTATED RINGERS SOLN magnesium sulfate in d5w soln NORMOSOL-M IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R SOLN INTRAVENOUS HI
PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 40 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
POTASSIUM CHLORIDE ER TBCR 8meq 10meq 20meq MO
POTASSIUM CHLORIDE IN DEXTROSE SOLN INTRAVENOUS
HI
potassium chloride in nacl soln intravenous HI
potassium chloride pack MO potassium chloride soln 10 20 MO
POTASSIUM CHLORIDE SOLN INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN SODIUM CHLORIDE SOLN INJECTION HI
SODIUM CHLORIDE SOLN INTRAVENOUS 045 09 3 5
HI
SODIUM PHOSPHATES SOLN TPN ELECTROLYTES CONC INTRAVENOUS HI
URICOSURIC AGENTS colchicine-probenecid tabs MO probenecid tabs MO ENZYMES ENZYMES ADAGEN SOLN ALDURAZYME SOLN CERDELGA CAPS NDS CEREZYME SOLR NDS CREON CPEP MO ELAPRASE SOLN NDS
Drug Name RequirementsLimits
ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME SOLR NDS miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PANCREAZE CPEP MO PERTZYE CPEP MO PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VIOKACE TABS MO VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE SOLN bacitracin oint bacitracin-polymyxin b oint BESIVANCE SUSP bleph-10 soln CETRAXAL SOLN chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
CIPROFLOXACIN-FLUOCINOLONE PF SOLN
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
MOXEZA SOLN moxifloxacin hcl (2x day) soln moxifloxacin hcl soln NATACYN SUSP neo-polycin oint neomycin-bacitracin zn-polymyx oint
neomycin-polymyxin-gramicidin soln
ofloxacin soln OTOVEL SOLN paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ZIRGAN GEL ANTI-INFLAMMATORY AGENTS ACUVAIL SOLN MO ALREX SUSP MO bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
BROMSITE SOLN MO CEQUA SOLN CIPRO HC SUSP MO CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO DUREZOL EMUL MO flac oil MO
Drug Name RequirementsLimits
FLAREX SUSP MO flunisolide soln MO fluocinolone acetonide oil MO fluorometholone susp MO flurbiprofen sodium soln MO fluticasone propionate susp MO FML FORTE SUSP MO FML OINT MO HYDROCORTISONE-ACETIC ACID SOLN MO
ILEVRO SUSP MO ILUVIEN IMPL INVELTYS SUSP MO ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX OINT MO LOTEMAX SUSP MO loteprednol etabonate susp MO MAXIDEX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint MO
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO NEVANAC SUSP MO OMNARIS SUSP MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
PROLENSA SOLN MO RESTASIS EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 42 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tobramycin-dexamethasone susp MO
XHANCE EXHU MO XIIDRA SOLN YUTIQ IMPL ZETONNA AERS MO ZYLET SUSP MO ANTIALLERGIC AGENTS ALOCRIL SOLN MO ALOMIDE SOLN MO azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO LASTACAFT SOLN MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
ALPHAGAN P SOLN MO betaxolol hcl soln MO BETIMOL SOLN 025 05 MO BETOPTIC-S SUSP MO bimatoprost soln MO BRIMONIDINE TARTRATE SOLN 02 015 MO
brinzolamide susp MO carteolol hcl soln MO COMBIGAN SOLN MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO
Drug Name RequirementsLimits
methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO SIMBRINZA SUSP MO timolol maleate pf soln MO timolol maleate solg 025 05 MO
timolol maleate soln 025 05 MO
TIMOPTIC OCUDOSE SOLN 25 MO
TIMOPTIC-XE SOLG 025 05 MO
TRAVATAN Z SOLN MO travoprost (bak free) soln MO VYZULTA SOLN MO XELPROS EMUL MO ZIOPTAN SOLN MO EENT DRUGS MISCELLANEOUS ACETIC ACID SOLN MO ALTAFRIN SOLN apraclonidine hcl soln MO ATROPINE SULFATE SOLN MO BEOVU SOLN NDS CYSTADROPS SOLN NDS CYSTARAN SOLN EYLEA SOLN EYLEA SOSY IOPIDINE SOLN MO LACRISERT INST MO LUCENTIS SOLN 03mg005ml 05mg005ml NDS
LUCENTIS SOSY 03mg005ml 05mg005ml NDS
OXERVATE SOLN NDS PHENYLEPHRINE HCL SOLN RHOPRESSA SOLN TEPEZZA SOLR NDS LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl soln lidocaine viscous hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
APRISO CP24 MO balsalazide disodium caps MO colazal caps MO DELZICOL CPDR MO DIPENTUM CAPS NDS LIALDA TBEC MO mesalamine cpdr MO mesalamine enem MO mesalamine er cp24 MO mesalamine supp MO mesalamine tbec 12gm 800mg MO mesalamine-cleanser kit PENTASA CPCR 250mg 500mg MO
ANTIDIARRHEA AGENTS diphenoxylate-atropine liqd diphenoxylate-atropine tabs loperamide hcl caps MO MYTESI TBEC MO OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS AKYNZEO CAPS PA ANZEMET TABS 50mg 100mg PANDS aprepitant caps PANDS BONJESTA TBCR MO CESAMET CAPS PA dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
EMEND SUSR PANDS fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs
Drug Name RequirementsLimits
ondansetron hcl soln PA ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS TRANSDERM SCOP (15 MG) PT72
trimethobenzamide hcl caps PA VARUBI (180 MG DOSE) TBPK PANDS ZUPLENZ FILM 4mg 8mg PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc MO
CARAFATE SUSP MO cimetidine hcl soln MO cimetidine tabs 200mg 300mg 400mg 800mg MO
esomeprazole magnesium cpdr 20mg 40mg MO
esomeprazole magnesium pack 10mg 20mg 40mg MO
esomeprazole sodium solr ESOMEPRAZOLE STRONTIUM CPDR
famotidine premixed soln famotidine soln famotidine susr MO famotidine tabs 20mg 40mg MO lansoprazole cpdr 15mg 30mg MO lansoprazole tbdd 15mg 30mg MO misoprostol tabs 100mcg 200mcg MO
nizatidine caps 150mg 300mg MO nizatidine soln MO OMECLAMOX-PAK MISC MO omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 44 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PRILOSEC PACK 25mg 10mg MO PROTONIX PACK MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate tabs MO CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO GOLYTELY SOLR OSMOPREP TABS MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT PLENVU SOLR MO SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS AMITIZA CAPS 8mcg 24mcg MO BYLVAY (PELLETS) CPSP 200mcg 600mcg NDS
BYLVAY CAPS 400mcg 1200mcg NDS
CHOLBAM CAPS 50mg 250mg NDS ENTYVIO SOLR NDS GATTEX KIT PANDS GIMOTI SOLN NDS LINZESS CAPS 72mcg 145mcg 290mcg MO
lubiprostone caps 8mcg 24mcg MO
Drug Name RequirementsLimits
metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
MOVANTIK TABS 125mg 25mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS SYMPROIC TABS MO TRULANCE TABS MO ursodiol caps 300mg MO URSODIOL CAPS 200mg 400mg NDS
ursodiol tabs 250mg 500mg MO VIBERZI TABS 75mg 100mg NDS HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPS clovique caps NDS CUPRIMINE CAPS NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs 90mg 180mg 360mg NDS
deferasirox tbso 125mg NDS deferasirox tbso 250mg 500mg NDS deferiprone tabs NDS deferoxamine mesylate solr DEPEN TITRATABS TABS EXJADE TBSO 125mg 250mg 500mg NDS
FERRIPROX SOLN LDNDS FERRIPROX TABS 500mg 1000mg LDNDS
FERRIPROX TWICE-A-DAY TABS NDS
JADENU SPRINKLE PACK 90mg 180mg 360mg NDS
JADENU TABS 90mg 360mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
penicillamine caps penicillamine tabs trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP 05mg 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs MO decadron elix MO decadron tabs 5mg 75mg MO decadron tabs 4mg 6mg PAMO deltasone tabs PAMO DEPO-MEDROL SUSP dexabliss tbpk dexamethasone elix MO dexamethasone intensol conc MO dexamethasone sod phosphate pf soln
dexamethasone sodium phosphate soln
dexamethasone soln dexamethasone tabs 05mg 075mg 1mg 15mg 2mg 4mg 6mg
PAMO
dexamethasone tbpk MO dexpak 10 day tbpk MO dexpak 13 day tbpk MO dexpak 6 day tbpk MO dxevo 11-day tbpk EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
INTRAROSA INST KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp
Drug Name RequirementsLimits
methylprednisolone sodium succ solr
methylprednisolone tabs 4mg 8mg 16mg 32mg MO
methylprednisolone tbpk MO millipred dp tbpk millipred tabs MO ORTIKOS CP24 6mg 9mg NDS prednisolone sodium phosphate soln 5mg5ml 10mg5ml 20mg5ml 25mg5ml
MO
prednisolone sodium phosphate tbdp 10mg 15mg 30mg MO
prednisolone soln MO prednisone intensol conc PAMO prednisone soln PAMO prednisone tabs 1mg 25mg 5mg 10mg 20mg 50mg PAMO
prednisone tbpk PULMICORT FLEXHALER AEPB
RAYOS TBEC 1mg 2mg 5mg PAMO SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TRELEGY ELLIPTA AEPB MO triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
AVEED SOLN MO danazol caps 50mg 100mg 200mg MO
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs 25mg MO oxandrolone tabs MONDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 46 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
STRIANT MISC MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact
MO
testosterone soln MO XYOSTED SOAJ 50mg05ml 75mg05ml 100mg05ml MO
CONTRACEPTIVES altavera tabs MO alyacen 135 tabs MO amethia lo tabs MO amethia tabs MO apri tabs MO aranelle tabs MO ashlyna tabs MO aubra eq tabs MO aviane tabs MO balziva tabs MO blisovi 24 fe tabs MO blisovi fe 1530 tabs MO briellyn tabs MO camila tabs MO camrese lo tabs MO caziant tabs MO cryselle-28 tabs MO cyclafem 135 tabs MO cyclafem 777 tabs MO cyred eq tabs MO deblitane tabs MO delyla tabs MO desogestrel-ethinyl estradiol tabs MO dolishale tabs MO drospiren-eth estrad-levomefol tabs MO
drospirenone-ethinyl estradiol tabs MO
ELLA TABS MO eluryng ring MO emoquette tabs MO
Drug Name RequirementsLimits
enpresse-28 tabs MO enskyce tabs MO errin tabs MO estarylla tabs MO ethynodiol diac-eth estradiol tabs MO etonogestrel-ethinyl estradiol ring MO
falmina tabs MO fayosim tabs MO femynor tabs MO gemmily caps MO gianvi tabs MO hailey 24 fe tabs MO iclevia tabs MO incassia tabs MO introvale tabs MO isibloom tabs MO jasmiel tabs MO JOLIVETTE TABS MO juleber tabs MO junel 1530 tabs MO junel 120 tabs MO junel fe 1530 tabs MO junel fe 120 tabs MO junel fe 24 tabs MO kaitlib fe chew MO kariva tabs MO kelnor 135 tabs MO kelnor 150 tabs MO kurvelo tabs MO larin 1530 tabs MO larin 120 tabs MO larin fe 1530 tabs MO larin fe 120 tabs MO larissia tabs MO LAYOLIS FE CHEW MO leena tabs MO lessina tabs MO levonest tabs MO levonorg-eth estrad triphasic tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
levora 01530 (28) tabs MO LO LOESTRIN FE TABS MO loestrin 1530 (21) tabs MO loestrin 120 (21) tabs MO loestrin fe 1530 tabs MO loestrin fe 120 tabs MO loryna tabs MO low-ogestrel tabs MO lutera tabs MO lyleq tabs MO lyza tabs MO marlissa tabs MO melodetta 24 fe chew MO merzee caps MO mibelas 24 fe chew MO microgestin 1530 tabs MO microgestin 120 tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA TABS MO NATAZIA TABS MO necon 0535 (28) tabs MO NECON 777 TABS MO nikki tabs MO nora-be tabs MO norethin ace-eth estrad-fe caps MO norethin ace-eth estrad-fe chew MO norethin ace-eth estrad-fe tabs MO norethin-eth estradiol-fe chew MO norethindrone acet-ethinyl est tabs MO
norethindrone tabs MO norgestim-eth estrad triphasic tabs MO
norgestimate-eth estradiol tabs MO norlyroc tabs MO
Drug Name RequirementsLimits
nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO NUVARING RING MO nylia 777 tabs MO nymyo tabs MO ocella tabs MO ogestrel tabs MO orsythia tabs MO pimtrea tabs MO pirmella 135 tabs MO portia-28 tabs MO previfem tabs MO reclipsen tabs MO rivelsa tabs MO setlakin tabs MO sharobel tabs MO sprintec 28 tabs MO sronyx tabs MO syeda tabs MO tarina 24 fe tabs MO tarina fe 120 eq tabs MO tilia fe tabs MO tri-estarylla tabs MO tri-legest fe tabs MO tri-lo-estarylla tabs MO tri-lo-sprintec tabs MO tri-mili tabs MO tri-nymyo tabs MO tri-previfem tabs MO tri-sprintec tabs MO tri-vylibra lo tabs MO tri-vylibra tabs MO TRINESSA (28) TABS MO trivora (28) tabs MO tydemy tabs MO velivet tabs MO vestura tabs MO vienva tabs MO vyfemla tabs MO vylibra tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 48 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135e (28) tabs MO DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
ADMELOG SOLN MO ADMELOG SOLOSTAR SOPN MO AFREZZA POWD MO AFREZZA POWD 8 (90) amp 12 (90) UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO APIDRA SOLN PAMO APIDRA SOLOSTAR SOPN MO AVANDIA TABS 2mg 4mg MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD BYDUREON BCISE AUIJ BYDUREON PEN BYETTA 10 MCG PEN SOPN MO BYETTA 5 MCG PEN SOPN MO CYCLOSET TABS MO diazoxide susp glimepiride tabs 1mg 2mg 4mg MO glipizide er tb24 25mg 5mg 10mg MO
glipizide tabs 5mg 10mg MO glipizide-metformin hcl tabs MO GLUCAGEN HYPOKIT SOLR glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO GLYXAMBI TABS MO
Drug Name RequirementsLimits
HUMALOG JUNIOR KWIKPEN SOPN MO
HUMALOG KWIKPEN SOPN 100unitml 200unitml MO
HUMALOG MIX 5050 KWIKPEN SUPN MO
HUMALOG MIX 5050 SUSP MO HUMALOG MIX 7525 KWIKPEN SUPN MO
HUMALOG MIX 7525 SUSP MO HUMALOG SOCT MO HUMALOG SOLN PAMO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN PAMO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
INSULIN ASP PROT amp ASP FLEXPEN SUPN MO
INSULIN ASPART FLEXPEN SOPN MO
INSULIN ASPART PENFILL SOCT MO
INSULIN ASPART PROT amp ASPART SUSP MO
INSULIN ASPART SOLN PAMO INSULIN LISPRO (1 UNIT DIAL) SOPN MO
INSULIN LISPRO SOLN MO INVOKAMET TABS MO INVOKAMET XR TB24 MO INVOKANA TABS 100mg 300mg MO
JARDIANCE TABS 10mg 25mg MO JENTADUETO TABS MO JENTADUETO XR TB24 MO KAZANO TABS MO KORLYM TABS LDNDS LANTUS SOLN MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
LANTUS SOLOSTAR SOPN MO LEVEMIR FLEXTOUCH SOPN MO LEVEMIR SOLN MO metformin hcl er tb24 500mg 750mg MO
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO NOVOLIN 7030 SUSP MO NOVOLOG 7030 FLEXPEN RELION SUPN MO
NOVOLOG FLEXPEN RELION SOPN MO
NOVOLOG FLEXPEN SOPN MO NOVOLOG MIX 7030 FLEXPEN SUPN MO
NOVOLOG MIX 7030 RELION SUSP MO
NOVOLOG MIX 7030 SUSP MO NOVOLOG PENFILL SOCT MO NOVOLOG RELION SOLN PAMO NOVOLOG SOLN PAMO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO PROGLYCEM SUSP MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SOLIQUA SOPN MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO SYNJARDY TABS MO SYNJARDY XR TB24 MO tolazamide tabs 250mg 500mg MO
Drug Name RequirementsLimits
tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO ANGELIQ TABS MO CLIMARA PRO PTWK MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
COMBIPATCH PTTW MO DELESTROGEN OIL depo-estradiol oil DIVIGEL GEL MO dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
DUAVEE TABS MO ELESTRIN GEL MO estrace crea MO estrace tabs 05mg 1mg 2mg MO estradiol crea MO estradiol pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO EVAMIST SOLN MO fyavolv tabs MO IMVEXXY MAINTENANCE PACK INST 4mcg 10mcg MO
IMVEXXY STARTER PACK INST 4mcg 10mcg MO
jinteli tabs MO lopreeza tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 50 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
MENOSTAR PTWK MO mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO ORIAHNN CPPK NDS OSPHENA TABS MO prefest tabs MO PREMARIN SOLR PREMARIN TABS 03mg 045mg 0625mg 09mg 125mg
MO
PREMPHASE TABS MO PREMPRO TABS MO raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS NOVAREL SOLR 5000unit 10000unit PA
ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS PREGNYL SOLR PA TRIPTODUR SRER NDS OXYTOCICS carboprost tromethamine soln methergine tabs methylergonovine maleate soln methylergonovine maleate tabs OXYTOCIN SOLN PARATHYROID calcitonin (salmon) soln MO cinacalcet hcl tabs 30mg 60mg 90mg PANDS
FORTEO SOPN PANDS NATPARA CART 25mcg 50mcg 75mcg 100mcg LDNDS
Drug Name RequirementsLimits
SENSIPAR TABS 30mg 60mg 90mg PANDS
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PALDNDS DDAVP RHINAL TUBE SOLN MO desmopressin ace spray refrig soln MO
desmopressin acetate soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln DESMOPRESSIN ACETATE TABS 01mg 02mg MO
NOCDURNA SUBL 277mcg 553mcg MO
NOCTIVA EMUL 083mcg01ml 166mcg01ml MO
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO CRINONE GEL 4 8 PAMO DEPO-PROVERA SUSP 400mgml
DEPO-SUBQ PROVERA 104 SUSY
ENDOMETRIN INST PA hydroxyprogesterone caproate oil
hydroxyprogesterone caproate soln
MAKENA SOAJ NDS medroxyprogesterone acetate susp
medroxyprogesterone acetate susy
medroxyprogesterone acetate tabs 25mg 5mg 10mg MO
megestrol acetate susp MO norethindrone acetate tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS BYNFEZIA PEN SOPN NDS EGRIFTA SOLR NDS EGRIFTA SV SOLR NDS GENOTROPIN MINIQUICK SOLR 02mg PANDS
GENOTROPIN MINIQUICK SOLR 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
GENOTROPIN SOLR 5mg 12mg PANDS
HUMATROPE SOLR 5mg 6mg 12mg 24mg PANDS
INCRELEX SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
NUTROPIN AQ NUSPIN 20 SOPN PANDS
NUTROPIN AQ NUSPIN 5 SOPN PANDS
octreotide acetate soln OMNITROPE SOCT 5mg15ml 10mg15ml PANDS
OMNITROPE SOLR PANDS SAIZEN CLICKEASY SOLR PANDS SAIZEN SOLR 5mg 88mg PANDS SAIZENPREP SOLR PANDS SANDOSTATIN LAR DEPOT KIT 10mg 20mg 30mg NDS
SEROSTIM SOLR 4mg 5mg 6mg PANDS
SIGNIFOR LAR SRER 10mg 20mg 30mg 40mg 60mg NDS
SIGNIFOR SOLN 03mgml 06mgml 09mgml NDS
SOMATULINE DEPOT SOLN
Drug Name RequirementsLimits
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZOMACTON SOLR 5mg PANDS ZOMACTON SOLR PANDS ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVO-T TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVOTHYROXINE SODIUM SOLR
levothyroxine sodium tabs 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
liothyronine sodium soln liothyronine sodium tabs 5mcg 25mcg 50mcg MO
methimazole tabs 5mg 10mg MO propylthiouracil tabs MO tapazole tabs 5mg 10mg MO THYROLAR-1 TABS THYROLAR-12 TABS THYROLAR-14 TABS THYROLAR-2 TABS THYROLAR-3 TABS TIROSINT CAPS 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 52 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
137mcg 150mcg 175mcg 200mcg UNITHROID TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA REDUCTASE INHIBITORS dutasteride caps MO dutasteride-tamsulosin hcl caps MO finasteride tabs MO ANTIDOTES acetylcysteine soln 10 20 PAMO fomepizole soln KHAPZORY SOLR 175mg 300mg NDS
leucovorin calcium soln leucovorin calcium solr leucovorin calcium tabs 5mg 10mg 15mg 25mg MO
levoleucovorin calcium pf soln levoleucovorin calcium solr VISTOGARD PACK NDS VORAXAZE SOLR NDS ANTIGOUT AGENTS allopurinol sodium solr allopurinol tabs 100mg 300mg MO COLCHICINE CAPS MO colchicine tabs MO febuxostat tabs 40mg 80mg MO GLOPERBA SOLN MITIGARE CAPS MO ULORIC TABS 40mg 80mg MO BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 5mg 10mg 35mg 70mg MO
alendronate sodium tabs 40mg MO BINOSTO TBEF MO EVENITY SOSY NDS FOSAMAX PLUS D TABS MO IBANDRONATE SODIUM SOLN
Drug Name RequirementsLimits
ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr PROLIA SOSY risedronate sodium tabs 5mg 30mg 35mg 150mg MO
RISEDRONATE SODIUM TBEC MO XGEVA SOLN PANDS zoledronic acid conc zoledronic acid soln DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ACTPEN SOAJ NDS ACTEMRA SOSY NDS AVSOLA SOLR NDS CIMZIA KIT PANDS CIMZIA PREFILLED KIT PANDS CIMZIA STARTER KIT KIT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS ENBREL SOSY 25mg05ml 50mgml NDS
ENBREL SURECLICK SOAJ NDS HUMIRA PEDIATRIC CROHNS START PSKT NDS
HUMIRA PEN PNKT 40mg04ml 40mg08ml 80mg08ml
NDS
HUMIRA PEN-CDUCHS STARTER PNKT 40mg08ml 80mg08ml
NDS
HUMIRA PEN-PEDIATRIC UC START PNKT NDS
HUMIRA PEN-PSUVADOL HS START PNKT NDS
HUMIRA PEN-PSORUVEIT STARTER PNKT NDS
HUMIRA PSKT 10mg01ml 10mg02ml 20mg02ml 20mg04ml 40mg04ml 40mg08ml
NDS
INFLECTRA SOLR INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
KEVZARA SOAJ 150mg114ml 200mg114ml NDS
KEVZARA SOSY 150mg114ml 200mg114ml NDS
KINERET SOSY NDS leflunomide tabs 10mg 20mg MO OLUMIANT TABS 1mg 2mg NDS ORENCIA CLICKJECT SOAJ NDS ORENCIA SOLR NDS ORENCIA SOSY 50mg04ml 875mg07ml 125mgml NDS
OTEZLA TABS PANDS OTEZLA TBPK PANDS OTREXUP SOAJ RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 NDS SIMPONI ARIA SOLN NDS SIMPONI SOAJ 50mg05ml 100mgml NDS
SIMPONI SOSY 50mg05ml 100mgml NDS
XELJANZ SOLN NDS XELJANZ TABS 5mg 10mg NDS XELJANZ XR TB24 11mg 22mg NDS IMMUNE SUPPRESSANTS ASTAGRAF XL CP24 05mg 1mg PAMO
ASTAGRAF XL CP24 PA azasan tabs 75mg 100mg PAMO azathioprine sodium solr azathioprine tabs PAMO BENLYSTA SOAJ BENLYSTA SOLR BENLYSTA SOSY cyclosporine caps 25mg 100mg PAMO cyclosporine modified caps 25mg 50mg 100mg PAMO
cyclosporine modified soln PAMO cyclosporine soln PAMO
Drug Name RequirementsLimits
ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg PA GAMIFANT SOLN 50mg10ml 100mg20ml 10mg2ml NDS
gengraf caps 25mg 50mg 100mg PAMO
gengraf soln PAMO LUPKYNIS CAPS NDS MAVENCLAD (10 TABS) TBPK NDS MAVENCLAD (4 TABS) TBPK NDS MAVENCLAD (5 TABS) TBPK NDS MAVENCLAD (6 TABS) TBPK NDS MAVENCLAD (7 TABS) TBPK NDS MAVENCLAD (8 TABS) TBPK NDS MAVENCLAD (9 TABS) TBPK NDS mycophenolate mofetil caps PAMO mycophenolate mofetil hcl solr mycophenolate mofetil susr PAMO mycophenolate mofetil tabs PAMO mycophenolate sodium tbec 180mg 360mg PAMO
NULOJIX SOLR NDS PROGRAF PACK 02mg PA PROGRAF PACK PANDS PROGRAF SOLN PAMO SANDIMMUNE ORAL SOLN 100mgml PAMO
SAPHNELO SOLN NDS sirolimus soln PA sirolimus tabs 05mg 1mg 2mg PAMO tacrolimus caps 05mg 1mg 5mg PAMO
UPLIZNA SOLN ZORTRESS TABS 025mg PAMO ZORTRESS TABS 05mg 075mg 1mg PA
MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 54 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BOTOX SOLR 100unit 200unit PA bupivacaine hcl (pf) soln bupivacaine hcl soln BUPIVACAINE IN DEXTROSE SOLN
bupivacaine spinal soln bupivacaine-epinephrine (pf) soln
bupivacaine-epinephrine soln CARNITOR SOLN PAMO CARNITOR TABS PAMO chloroprocaine hcl (pf) soln CINRYZE SOLR INTRAVENOUS HI
citanest plain dental soln COSELA SOLR NDS CRYSVITA SOLN 10mgml 20mgml 30mgml NDS
CYSTADANE POWD LDNDS CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr DYSPORT SOLR 300unit 500unit PA
EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENSPRYNG SOSY NDS EVRYSDI SOLR NDS EXONDYS 51 SOLN 500mg10ml 100mg2ml NDS
FIRDAPSE TABS NDS FLUORITAB CHEW 025mg 05mg 1mg MO
FLUORITAB SOLN MO GALAFOLD CAPS NDS GIVLAARI SOLN NDS GRASTEK SUBL MO
Drug Name RequirementsLimits
HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS TABS NDS KUVAN PACK 100mg 500mg NDS KUVAN TABS NDS LACTATED RINGERS SOLN levocarnitine soln PAMO LEVOCARNITINE TABS PAMO lidocaine hcl (pf) soln lidocaine hcl soln lidocaine in dextrose soln lidocaine-epinephrine soln LUDENT CHEW 025mg 05mg 1mg MO
mesna soln MESNEX TABS NDS MYALEPT SOLR NDS NAFRINSE CHEW MO NAFRINSE DROPS SOLN MO nitisinone caps 2mg 5mg 10mg NDS NITYR TABS 2mg 5mg 10mg NDS NULIBRY SOLR NDS ODACTRA SUBL ONPATTRO SOLN NDS ORALAIR SUBL MO ORFADIN CAPS LDNDS ORFADIN SUSP LDNDS ORLADEYO CAPS 110mg 150mg NDS
OXLUMO SOLN PALFORZIA (12 MG DAILY DOSE) CSPK NDS
PALFORZIA (120 MG DAILY DOSE) CSPK NDS
PALFORZIA (160 MG DAILY DOSE) CSPK NDS
PALFORZIA (20 MG DAILY DOSE) CSPK NDS
PALFORZIA (200 MG DAILY DOSE) CSPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
PALFORZIA (240 MG DAILY DOSE) CSPK NDS
PALFORZIA (3 MG DAILY DOSE) CSPK NDS
PALFORZIA (300 MG MAINTENANCE) PACK NDS
PALFORZIA (300 MG TITRATION) PACK NDS
PALFORZIA (40 MG DAILY DOSE) CSPK NDS
PALFORZIA (6 MG DAILY DOSE) CSPK NDS
PALFORZIA (80 MG DAILY DOSE) CSPK NDS
PALFORZIA INITIAL ESCALATION CSPK NDS
PHYSIOLYTE SOLN PHYSIOSOL IRRIGATION SOLN
polocaine soln polocaine-mpf soln PROCYSBI CPDR 25mg 75mg NDS PROCYSBI PACK 75mg 300mg NDS REZUROCK TABS NDS RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln RUZURGI TABS NDS sapropterin dihydrochloride pack 100mg 500mg NDS
sapropterin dihydrochloride tabs NDS SENSORCAINE SOLN sensorcaine-mpf soln sensorcaine-mpfepinephrine soln
sensorcaineepinephrine soln SODIUM CHLORIDE SOLN MO SODIUM FLUORIDE CHEW 025mg 05mg 1mg MO
SODIUM FLUORIDE SOLN MO SODIUM FLUORIDE TABS MO STERILE WATER FOR IRRIGATION SOLN
Drug Name RequirementsLimits
TAKHZYRO SOLN NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VILTEPSO SOLN NDS VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR 50unit 100unit PA XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg NDS RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 200mg114ml 300mg2ml PANDS
FASENRA PEN SOAJ NDS FASENRA SOSY PA montelukast sodium chew 4mg 5mg MO
montelukast sodium pack MO montelukast sodium tabs MO NUCALA SOAJ PANDS NUCALA SOLR PANDS NUCALA SOSY PANDS zafirlukast tabs 10mg 20mg MO zileuton er tb12 NDS CYSTIC FIBROSIS BETHKIS NEBU PA
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 56 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CAYSTON SOLR LDNDS KALYDECO PACK 25mg 50mg 75mg PANDS
KALYDECO TABS PANDS KITABIS PAK NEBU PA ORKAMBI PACK NDS ORKAMBI TABS NDS SYMDEKO TBPK NDS TOBI PODHALER CAPS tobramycin nebu 300mg4ml 300mg5ml PA
TRIKAFTA TBPK LDNDS PULMONARY FIBROSIS ESBRIET CAPS PANDS ESBRIET TABS 267mg 801mg PANDS OFEV CAPS 100mg 150mg NDS RESPIRATORY AGENTS MISCELLANEOUS ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS 500mg 1000mg
HI
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact
MO
ASMANEX (120 METERED DOSES) AEPB MO
ASMANEX (30 METERED DOSES) AEPB 110mcginh MO
ASMANEX (30 METERED DOSES) AEPB MO
ASMANEX (60 METERED DOSES) AEPB MO
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
budesonide-formoterol fumarate aero
DALIRESP TABS 250mcg 500mcg MO
DULERA AERO MO
Drug Name RequirementsLimits
FLOVENT DISKUS AEPB 50mcgblist 100mcgblist 250mcgblist
MO
FLOVENT HFA AERO 44mcgact MO
FLOVENT HFA AERO 110mcgact 220mcgact MO
fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PROLASTIN-C SOLN INTRAVENOUS HI
PROLASTIN-C SOLR INTRAVENOUS HI
SYMBICORT AERO wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
ZEMAIRA SOLR INTRAVENOUS HI
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr LETAIRIS TABS 5mg 10mg NDS ORENITRAM TBCR 0125mg LDNDS ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TABS 625mg 125mg NDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
1000mcg 1200mcg 1400mcg 1600mcg UPTRAVI TBPK NDS VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS BIVIGAM SOLN 10gm100ml HI BIVIGAM SOLN 5gm50ml HI CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml
HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS 10gm200ml HI
GAMMAPLEX SOLN INTRAVENOUS 10gm100ml 20gm200ml 5gm50ml
HI
GAMUNEX-C SOLN INJECTION 10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml
HI
HYPERHEP B SOLN HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 5gm100ml HI
Drug Name RequirementsLimits
1gm20ml 2gm20ml 25gm500ml PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
PRIVIGEN SOLN INTRAVENOUS HI
VARIZIG SOLN XEMBIFY SOLN SUBCUTANEOUS 2gm10ml 4gm20ml 10gm50ml 1gm5ml
HI
TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP QUADRACEL SUSP TDVAX SUSP TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP DAPTACEL SUSP ENGERIX-B SUSP 10mcg05ml 20mcgml PA
GARDASIL 9 SUSP GARDASIL 9 SUSY HAVRIX SUSP HEPLISAV-B SOLN PA HIBERIX SOLR IMOVAX RABIES INJ INFANRIX SUSP IPOL INJ IXIARO SUSP M-M-R II SOLR MENACTRA INJ MENQUADFI INJ MENVEO SOLR PEDIARIX SUSP PEDVAX HIB SUSP
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 58 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN VAQTA SUSP VARIVAX INJ VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint AKTIPAK PACK MO AVC VAGINAL CREA BACTROBAN NASAL OINT BENZEPRO CREAMY WASH LIQD
BENZEPRO FOAMING CLOTHS MISC
BENZOYL PEROXIDE GEL NDS benzoyl peroxide-erythromycin gel MO
ciclopirox gel ciclopirox olamine crea ciclopirox olamine susp ciclopirox sham ciclopirox soln CLEOCIN SUPP clindacin-p swab MO clindamycin phos-benzoyl perox gel MO
clindamycin phosphate crea clindamycin phosphate foam MO clindamycin phosphate gel MO clindamycin phosphate lotn MO
Drug Name RequirementsLimits
clindamycin phosphate soln MO clindamycin phosphate swab MO CLINDESSE CREA clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn DENAVIR CREA econazole nitrate crea ERTACZO CREA ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA EXELDERM CREA EXELDERM SOLN gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ivermectin lotn ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham LULICONAZOLE CREA LUZU CREA mafenide acetate pack malathion lotn MENTAX CREA metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 59
Drug Name RequirementsLimits
mupirocin oint naftifine hcl crea naftifine hcl gel NAFTIN GEL NATROBA SUSP neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ORAVIG TABS ovide lotn oxiconazole nitrate crea OXISTAT LOTN permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SKLICE LOTN SODIUM SULFACETAMIDE SHAM
SODIUM SULFACETAMIDE WASH LIQD
SPINOSAD SUSP SSD CREA sulfacetamide sodium (acne) lotn MO SULFACETAMIDE SODIUM GEL
SULFACETAMIDE SODIUM LIQD
SULFAMYLON CREA tavaborole soln terconazole crea terconazole supp VANDAZOLE GEL XEPI CREA MO XERESE CREA ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) ala scalp lotn MO
Drug Name RequirementsLimits
ala-cort crea 1 25 MO alclometasone dipropionate crea MO alclometasone dipropionate oint MO amcinonide crea MO amcinonide lotn MO amcinonide oint MO anusol-hc crea MO apexicon e crea MO benzoyl perox-hydrocortisone lotn
BENZOYL PEROXIDE FORTE- HC LOTN NDS
beser lotn MO betamethasone dipropionate aug crea MO
betamethasone dipropionate aug gel MO
betamethasone dipropionate aug lotn MO
betamethasone dipropionate aug oint MO
betamethasone dipropionate crea MO
betamethasone dipropionate lotn MO BETAMETHASONE DIPROPIONATE OINT MO
betamethasone valerate crea MO betamethasone valerate foam MO BETAMETHASONE VALERATE LOTN MO
BETAMETHASONE VALERATE OINT MO
BRYHALI LOTN MO calcipotriene-betameth diprop oint MONDS
calcipotriene-betameth diprop susp NDS
CAPEX SHAM MO clobetasol propionate crea clobetasol propionate e crea MO clobetasol propionate emulsion foam
clobetasol propionate foam MO clobetasol propionate gel MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 60 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO CLOBEX SHAM MO CLOBEX SPRAY LIQD MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO clodan sham MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT MO DESONATE GEL MO desonide crea MO desonide gel MO desonide lotn MO desonide oint MO desowen lotn MO desoximetasone crea 005 025 MO
desoximetasone gel MO desoximetasone liqd MO desoximetasone oint 005 025 MO
desrx gel MO diclofenac sodium gel 1 3 MO diflorasone diacetate crea MO diflorasone diacetate oint MO DUOBRII LOTN MO ENSTILAR FOAM NDS epifoam foam fluocinolone acetonide body oil fluocinolone acetonide crea 001 0025 MO
fluocinolone acetonide oint MO fluocinolone acetonide scalp oil MO fluocinolone acetonide soln MO fluocinonide crea MO fluocinonide emulsified base crea MO
Drug Name RequirementsLimits
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO flurandrenolide crea MO flurandrenolide lotn MO flurandrenolide oint MO fluticasone propionate crea MO fluticasone propionate lotn MO fluticasone propionate oint MO halcinonide crea MO halobetasol propionate crea MO HALOBETASOL PROPIONATE FOAM NDS
halobetasol propionate oint MO HALOG CREA MO HALOG OINT MO hydrocortisone (perianal) crea 1 25 MO
hydrocortisone butyr lipo base crea
hydrocortisone butyrate crea MO hydrocortisone butyrate lotn MO HYDROCORTISONE BUTYRATE OINT MO
hydrocortisone butyrate soln MO hydrocortisone crea 1 25 MO hydrocortisone enem MO hydrocortisone lotn MO hydrocortisone oint 1 25 MO hydrocortisone valerate crea MO hydrocortisone valerate oint MO LEXETTE FOAM NDS micort-hc crea MO mometasone furoate crea MO mometasone furoate oint MO mometasone furoate soln MO neo-synalar crea MO nolix crea nolix lotn MO nystatin-triamcinolone crea MO nystatin-triamcinolone oint MO oralone pste MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 61
Drug Name RequirementsLimits
PANDEL CREA MO prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO psorcon crea MO TACLONEX SUSP NDS topicort crea 005 025 MO topicort gel MO topicort oint MO tovet foam MO triamcinolone acetonide aers MO triamcinolone acetonide crea 0025 01 05 MO
triamcinolone acetonide lotn 0025 01 MO
triamcinolone acetonide oint 0025 005 01 05 MO
triamcinolone acetonide pste MO trianex oint MO triderm crea 01 05 MO tritocin oint MO UCERIS FOAM MO ULTRAVATE LOTN NDS VANOXIDE-HC LOTN ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
LIDO-SORB LOTN LIDOCAINE HCL CREA lidocaine hcl lotn lidocaine hcl soln PA lidocaine hcl urethralmucosal gel MO
lidocaine hcl urethralmucosal prsy MO
lidocaine oint PAMO lidocaine ptch PAMO
Drug Name RequirementsLimits
LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea PA LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam texacort soln MO TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS ALTRENO LOTN PAMO AVITA CREA PAMO AVITA GEL PAMO KEPIVANCE SOLR NDS PANRETIN GEL NDS RETIN-A CREA 0025 005 01 PAMO
RETIN-A GEL 001 0025 PAMO RETIN-A MICRO GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 008 PAMO
RETIN-A MICRO PUMP GEL PANDS TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 62 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS ABSORICA CAPS 25mg 35mg NDS ABSORICA LD CAPS 8mg 16mg 24mg 32mg NDS
accutane caps 10mg 20mg 30mg 40mg NDS
acitretin caps 10mg 175mg 25mg NDS
ADAPALENE CREA MO adapalene gel 01 03 MO adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
AVAR CLEANSER EMUL AVAR-E EMOLLIENT CREA AVAR-E GREEN CREA azelaic acid gel MO AZELEX CREA MO BP 10-1 EMUL calcipotriene crea MO calcipotriene oint MO calcipotriene soln MO calcitrene oint MO CALCITRIOL OINT MO CARAC CREA CEROVEL LOTN claravis caps 10mg 20mg 30mg 40mg NDS
CONDYLOX GEL MO COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
Drug Name RequirementsLimits
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA MO DIFFERIN LOTN MO EPIDUO FORTE GEL MO FABIOR FOAM PAMO FINACEA FOAM MO fluorouracil crea 5 MO fluorouracil crea 5 fluorouracil soln 2 5 MO ILUMYA SOSY PA imiquimod crea 375 5 MO IMIQUIMOD PUMP CREA MO isotretinoin caps 10mg 20mg 30mg 40mg NDS
keralyt sham KLISYRI OINT NDS LACTIC ACID LOTN methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
ORACEA CPDR pimecrolimus crea MO podofilox soln MO RECTIV OINT MO REGRANEX GEL NDS RYNODERM CREA NDS SALEX SHAM SALICYLIC ACID CREA SALICYLIC ACID ER SOLN SALICYLIC ACID FOAM SALICYLIC ACID GEL SALICYLIC ACID LIQD SALICYLIC ACID SHAM SALICYLIC ACID WART REMOVER LIQD
SALICYLIC ACID-CLEANSER KIT
SALIMEZ CREA SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 63
Drug Name RequirementsLimits
SKYRIZI PEN SOAJ SKYRIZI SOSY SORILUX FOAM MO SSS 10-5 CREA STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
SULFACETAMIDE SODIUM-SULFUR CREA
SULFACETAMIDE SODIUM-SULFUR EMUL
SULFACETAMIDE SODIUM-SULFUR LIQD
SULFACETAMIDE SODIUM-SULFUR LOTN
SULFACETAMIDE SODIUM-SULFUR PADS
SULFACETAMIDE SODIUM-SULFUR SUSP
SULFACLEANSE 84 SUSP sulfamez wash emul TACROLIMUS OINT 01 003 MO
TALTZ SOAJ NDS TALTZ SOSY NDS tazarotene crea PAMO tazarotene foam PAMO TAZORAC CREA PAMO TAZORAC GEL 005 01 PAMO TOLAK CREA TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS VECTICAL OINT MO VEREGEN OINT MO WYNZORA CREA NDS XUREA CREA
Drug Name RequirementsLimits
zenatane caps 10mg 20mg 30mg 40mg NDS
ZYCLARA PUMP CREA MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline soln darifenacin hydrobromide er tb24 75mg 15mg MO
elixophyllin elix flavoxate hcl tabs MO MYRBETRIQ TB24 25mg 50mg MO oxybutynin chloride er tb24 5mg 10mg 15mg MO
oxybutynin chloride syrp MO oxybutynin chloride tabs MO solifenacin succinate tabs 5mg 10mg MO
theo-24 cp24 100mg 200mg 300mg 400mg MO
theophylline er tb12 100mg 200mg 300mg 450mg MO
theophylline er tb24 400mg 600mg MO
theophylline soln MO tolterodine tartrate er cp24 2mg 4mg MO
tolterodine tartrate tabs MO trospium chloride er cp24 MO trospium chloride tabs MO VITAMINS VITAMINS ADCF (05MGML) SOLN MO calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN MULTI-VITAMINFLUORIDEIRON SOLN
MO
MULTI-VITAMINFLUORIDE SOLN MO
MULTIVITAMINFLUORIDE CHEW MO
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Drug Name RequirementsLimits
MVC-FLUORIDE CHEW MO paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS TRI-VITAMINFLUORIDE SOLN MO TRI-VITEFLUORIDE SOLN MO VITAMINS ACD-FLUORIDE SOLN MO
VP-PNV-DHA CAPS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 65
The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not and
you need an urgent refill please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 6 or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number on page 6 NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
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Index of Drugs
A abacavir sulfate soln 12 abacavir sulfate tabs 12 abacavir sulfate-lamivudine tabs 12 abacavir-lamivudine-zidovudine tabs 12 ABELCET SUSP INTRAVENOUS 11 ABILIFY MAINTENA PRSY 300mg 400mg
35 ABILIFY MAINTENA SRER 300mg 400mg
35 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
abiraterone acetate tabs 250mg 500mg 14 ABRAXANE SUSR 14 ABSORICA CAPS 25mg 35mg 62 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 62 ABSTRAL SUBL 100mcg 200mcg
300mcg 400mcg 600mcg 800mcg 27 acamprosate calcium tbec 26 acarbose tabs 25mg 50mg 100mg 48 accutane caps 10mg 20mg 30mg 40mg 62 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 27 acetaminophen-codeine soln 27 acetaminophen-codeine tabs 27 acetazolamide er cp12 42 acetazolamide sodium solr 42 acetazolamide tabs 125mg 250mg 42 ACETIC ACID SOLN 42 53 acetylcysteine soln 10 20 52 acitretin caps 10mg 175mg 25mg 62 ACTEMRA ACTPEN SOAJ 52 ACTEMRA SOSY 52 ACTHAR GEL 50 ACTHIB SOLR 57 ACTIMMUNE SOLN 53 ACUVAIL SOLN 41
acyclovir caps 12 acyclovir oint 58 acyclovir sodium soln intravenous 12 acyclovir susp 12 acyclovir tabs 400mg 800mg 12 ADACEL SUSP 57 ADAGEN SOLN 40 ADAKVEO SOLN 21 ADAPALENE CREA 62 adapalene gel 01 03 62 adapalene pads 62 adapalene soln 62 adapalene-benzoyl peroxide gel 62 ADAPALENE-BENZOYL PEROXIDE PADS
62 ADCF (05MGML) SOLN 63 adderall tabs 29 ADDERALL XR CP24 29 adefovir dipivoxil tabs 12 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 56 adenosine soln 25 ADMELOG SOLN 48 ADMELOG SOLOSTAR SOPN 48 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 20 ADZENYS ER SUER 29 ADZENYS XR-ODT TBED 31mg 63mg
94mg 125mg 157mg 188mg 29 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 25mg 5mg 75mg 10mg
14 AFREZZA POWD 48 AFREZZA POWD 8 (90) amp 12 (90) UNIT 48 AJOVY SOAJ 32 AJOVY SOSY 32 AKTIPAK PACK 58 AKYNZEO CAPS 43 ala scalp lotn 59 ala-cort crea 1 25 59 albendazole tabs 8
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albuterol sulfate er tb12 4mg 8mg 20 albuterol sulfate hfa aers 20 albuterol sulfate nebu 0083 25mg05ml
20 albuterol sulfate nebu 063mg3ml
125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 59 alclometasone dipropionate oint 59 ALCOHOL PREP PADS 37 ALDACTAZIDE TABS 25 ALDURAZYME SOLN 40 ALECENSA CAPS 14 alendronate sodium soln 52 alendronate sodium tabs 40mg 52 alendronate sodium tabs 5mg 10mg
35mg 70mg 52 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 05mg 1mg
2mg 5mg 45 allopurinol sodium solr 52 allopurinol tabs 100mg 300mg 52 allzital tabs 27 almotriptan malate tabs 32 ALOCRIL SOLN 42 alogliptin benzoate tabs 625mg 125mg
25mg 48 ALOGLIPTIN-METFORMIN HCL TABS 48 alogliptin-pioglitazone tabs 48 ALOMIDE SOLN 42 ALOSETRON HCL TABS 05mg 1mg 43 ALPHAGAN P SOLN 42 alprazolam er tb24 05mg 1mg 2mg 3mg
33 alprazolam intensol conc 33 alprazolam tabs 025mg 05mg 1mg 2mg
33 alprazolam tbdp 025mg 05mg 1mg 2mg
33 ALREX SUSP 41 ALTACAINE SOLN 42 ALTAFRIN SOLN 42 altavera tabs 46 ALTOPREV TB24 20mg 40mg 60mg 23 ALTRENO LOTN 61
ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 56 alyacen 135 tabs 46 alyq tabs 26 amabelz tabs 49 amantadine hcl caps 32 amantadine hcl syrp 32 amantadine hcl tabs 32 AMBISOME SUSR INTRAVENOUS 11 ambrisentan tabs 56 amcinonide crea 59 amcinonide lotn 59 amcinonide oint 59 amethia lo tabs 46 amethia tabs 46 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 38 amiloride-hydrochlorothiazide tabs 38 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 63 AMINOSYN-PF SOLN INTRAVENOUS 38 amiodarone hcl soln 25 amiodarone hcl tabs 100mg 200mg
400mg 25 AMITIZA CAPS 8mcg 24mcg 44 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 amlodipine besy-benazepril hcl caps 24 amlodipine besylate tabs 25mg 5mg
10mg 24 amlodipine besylate-valsartan tabs 24 amlodipine-atorvastatin tabs 24 amlodipine-olmesartan tabs 24 amlodipine-valsartan-hctz tabs 24 ammonium lactate crea 62 ammonium lactate lotn 62 amnesteem caps 10mg 20mg 40mg 62 AMONDYS 45 SOLN 53 amoxapine tabs 25mg 50mg 100mg
150mg 35 amoxicill-clarithro-lansopraz misc 43 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8
68 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 29 amphetamine sulfate tabs 5mg 10mg 30 amphetamine-dextroamphet er cp24 30 amphetamine-dextroamphetamine tabs 30 amphotericin b solr intravenous 11 ampicillin caps 8 ampicillin sodium solr 8 ampicillin sodium solr injection 1gm 125mg
8 ampicillin sodium solr intravenous 8 ampicillin-sulbactam sodium solr 8 ampicillin-sulbactam sodium solr injection 8 ampicillin-sulbactam sodium solr
intravenous 8 ANADROL-50 TABS 45 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 61 anastrozole tabs 14 ANDRODERM PT24 2mg24hr 4mg24hr
45 ANGELIQ TABS 49 ANORO ELLIPTA AEPB 19 antabuse tabs 250mg 500mg 26 ANTARA CAPS 30mg 90mg 23 anusol-hc crea 59 ANZEMET TABS 50mg 100mg 43 apap-caff-dihydrocodeine tabs 27 apexicon e crea 59 APIDRA SOLN 48 APIDRA SOLOSTAR SOPN 48 APLENZIN TB24 174mg 348mg 522mg 35 APOKYN SOCT 32 apraclonidine hcl soln 42 aprepitant caps 43 apri tabs 46 APRISO CP24 43 APTIOM TABS 200mg 400mg 600mg
800mg 30 APTIVUS CAPS 12 APTIVUS SOLN 12 ARALAST NP SOLR INTRAVENOUS
500mg 1000mg 56 aranelle tabs 46 ARANESP (ALBUMIN FREE) SOLN
25mcgml 40mcgml 22
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml 22
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml 22
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 22
ARCALYST SOLR 53 ARCAPTA NEOHALER CAPS 20 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 54 ARIKAYCE SUSP 8 aripiprazole soln 35 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 35 aripiprazole tbdp 10mg 15mg 35 ARISTADA INITIO PRSY 35 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 35
armodafinil tabs 50mg 150mg 200mg 250mg 30
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact 56
ARRANON SOLN 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 54 ARYMO ER TBEA 27 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 57 ascomp-codeine caps 27 asenapine maleate subl 25mg 5mg 10mg
35 ashlyna tabs 46 ASMANEX (120 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
110mcginh 56 ASMANEX (60 METERED DOSES) AEPB
56 ASMANEX HFA AERO 100mcgact
200mcgact 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 69
ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 53 ASTAGRAF XL CP24 05mg 1mg 53 atazanavir sulfate caps 150mg 200mg
300mg 12 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 34 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 23 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 42 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 34 aubra eq tabs 46 AUGMENTIN SUSR 8 AURYXIA TABS 39 AUSTEDO TABS 6mg 9mg 12mg 34 AVANDIA TABS 2mg 4mg 48 AVAR CLEANSER EMUL 62 AVAR-E EMOLLIENT CREA 62 AVAR-E GREEN CREA 62 AVASTIN SOLN 14 AVC VAGINAL CREA 58 AVEED SOLN 45 aviane tabs 46 AVITA CREA 61 AVITA GEL 61 AVONEX KIT 34 AVONEX PEN AJKT 34 AVONEX PREFILLED PSKT 34 AVSOLA SOLR 52 AVYCAZ SOLR INTRAVENOUS 8 aygestin tabs 50 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 53 AZASITE SOLN 40 azathioprine sodium solr 53 azathioprine tabs 53 azelaic acid gel 62 azelastine hcl soln 005 01 015 42 azelastine-fluticasone susp 42 AZELEX CREA 62
AZITHROMYCIN PACK 8 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
B bacitracin oint 40 bacitracin solr 8 bacitracin-polymyxin b oint 40 bacitra-neomycin-polymyxin-hc oint 41 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 58 BAFIERTAM CPDR 34 balsalazide disodium caps 43 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 46 BANZEL SUSP 30 BANZEL TABS 200mg 400mg 30 BAQSIMI ONE PACK POWD 48 BAQSIMI TWO PACK POWD 48 BARACLUDE SOLN 12 BAVENCIO SOLN 14 BAXDELA SOLR INTRAVENOUS 8 BAXDELA TABS 8 BCG VACCINE INJ 14 BD INSULIN SYR ULTRAFINE II MISC 37 BD INSULIN SYRINGE MISC 37 BD INSULIN SYRINGE UF MISC 37 BD PEN NEEDLE ORIGINAL UF MISC 37 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 27 BELEODAQ SOLR 14 BELRAPZO SOLN 14 BELSOMRA TABS 33 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 15 BENDEKA SOLN 15 BENLYSTA SOAJ 53 BENLYSTA SOLR 53 BENLYSTA SOSY 53 BENZEPRO CREAMY WASH LIQD 58 BENZEPRO FOAMING CLOTHS MISC 58 benzhydrocodone-acetaminophen tabs 27 BENZNIDAZOLE TABS 125mg 100mg 11 benzoyl perox-hydrocortisone lotn 59
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BENZOYL PEROXIDE FORTE- HC LOTN 59
BENZOYL PEROXIDE GEL 58 benzoyl peroxide-erythromycin gel 58 benztropine mesylate soln 32 benztropine mesylate tabs 05mg 1mg
2mg 32 BEOVU SOLN 42 bepotastine besilate soln 42 BERINERT KIT INTRAVENOUS 21 beser lotn 59 BESIVANCE SUSP 40 BESPONSA SOLR 15 betamethasone dipropionate aug crea 59 betamethasone dipropionate aug gel 59 betamethasone dipropionate aug lotn 59 betamethasone dipropionate aug oint 59 betamethasone dipropionate crea 59 betamethasone dipropionate lotn 59 BETAMETHASONE DIPROPIONATE OINT
59 betamethasone sod phos amp acet susp 45 betamethasone valerate crea 59 betamethasone valerate foam 59 BETAMETHASONE VALERATE LOTN 59 BETAMETHASONE VALERATE OINT 59 BETASERON KIT 34 betaxolol hcl soln 42 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 20 BETHKIS NEBU 55 BETIMOL SOLN 025 05 42 BETOPTIC-S SUSP 42 BEVESPI AEROSPHERE AERO 19 BEVYXXA CAPS 40mg 80mg 21 bexarotene caps 15 BEXSERO SUSY 57 bicalutamide tabs 15 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICNU SOLR 15 BIDIL TABS 26 BIKTARVY TABS 12 bimatoprost soln 42 BINOSTO TBEF 52 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23
BIVIGAM SOLN 10gm100ml 57 BIVIGAM SOLN 5gm50ml 57 bleomycin sulfate solr 15 bleph-10 soln 40 blephamide sop oint 41 BLEPHAMIDE SUSP 41 BLINCYTO SOLR 15 blisovi 24 fe tabs 46 blisovi fe 1530 tabs 46 BONJESTA TBCR 43 BOOSTRIX SUSP 57 BORTEZOMIB SOLR 15 bosentan tabs 56 BOSULIF TABS 100mg 400mg 500mg 15 BOTOX SOLR 100unit 200unit 54 BP 10-1 EMUL 62 BRAFTOVI CAPS 50mg 75mg 15 briellyn tabs 46 BRILINTA TABS 60mg 90mg 21 BRIMONIDINE TARTRATE SOLN 02
015 42 brinzolamide susp 42 BRIVIACT SOLN 30 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 30 bromfenac sodium (once-daily) soln 41 bromocriptine mesylate caps 32 bromocriptine mesylate tabs 32 BROMSITE SOLN 41 BRONCHITOL CAPS 56 BROVANA NEBU 20 BRUKINSA CAPS 15 BRYHALI LOTN 59 budesonide cpep 45 budesonide er tb24 45 budesonide susp 025mg2ml 05mg2ml
1mg2ml 56 budesonide-formoterol fumarate aero 56 bumetanide soln 38 bumetanide tabs 05mg 1mg 2mg 38 BUNAVAIL FILM 34 bupap tabs 27 bupivacaine hcl (pf) soln 54 bupivacaine hcl soln 54 BUPIVACAINE IN DEXTROSE SOLN 54 bupivacaine spinal soln 54 bupivacaine-epinephrine (pf) soln 54 bupivacaine-epinephrine soln 54 buprenorphine hcl soln 27
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 71
buprenorphine hcl subl 2mg 8mg 34 buprenorphine hcl-naloxone hcl film 34 buprenorphine hcl-naloxone hcl subl 34 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 27 bupropion hcl er (smoking det) tb12 35 bupropion hcl er (sr) tb12 100mg 150mg
200mg 35 bupropion hcl er (xl) tb24 150mg 300mg
450mg 35 bupropion hcl tabs 75mg 100mg 35 buspirone hcl tabs 5mg 10mg 33 buspirone hcl tabs 75mg 15mg 30mg 33 busulfan soln 15 butalbital-acetaminophen caps 27 butalbital-acetaminophen tabs 27 butalbital-apap-caff-cod caps 27 butalbital-apap-caffeine caps 27 butalbital-apap-caffeine tabs 27 butalbital-asa-caff-codeine caps 27 butalbital-aspirin-caffeine caps 27 butalbital-aspirin-caffeine tabs 27 butorphanol tartrate soln 1mgml 2mgml
10mgml 27 BUTRANS PTWK 27 BYDUREON BCISE AUIJ 48 BYDUREON PEN 48 BYETTA 10 MCG PEN SOPN 48 BYETTA 5 MCG PEN SOPN 48 BYLVAY (PELLETS) CPSP 200mcg
600mcg 44 BYLVAY CAPS 400mcg 1200mcg 44 BYNFEZIA PEN SOPN 51
C CABENUVA SUER 12 cabergoline tabs 32 CABLIVI KIT 22 CABOMETYX TABS 20mg 40mg 60mg 15 cafergot tabs 32 caffeine citrate soln 30 calcipotriene crea 62 calcipotriene oint 62 calcipotriene soln 62 calcipotriene-betameth diprop oint 59 calcipotriene-betameth diprop susp 59 calcitonin (salmon) soln 50 calcitrene oint 62 calcitriol caps 025mcg 05mcg 63
CALCITRIOL OINT 62 calcitriol soln 63 calcium acetate (phos binder) caps 39 calcium acetate (phos binder) tabs 39 CALCIUM GLUCONATE-NACL SOLN 39 CALQUENCE CAPS 15 camila tabs 46 camrese lo tabs 46 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 59 CAPLYTA CAPS 35 CAPRELSA TABS 100mg 300mg 15 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 26 CARAC CREA 62 CARAFATE SUSP 43 CARBAGLU TABS 37 carbamazepine chew 30 carbamazepine er cp12 100mg 200mg
300mg 30 carbamazepine er tb12 100mg 200mg
400mg 30 carbamazepine susp 30 carbamazepine tabs 30 carbidopa tabs 32 carbidopa-levodopa er tbcr 32 carbidopa-levodopa tabs 32 carbidopa-levodopa tbdp 32 carbidopa-levodopa-entacapone tabs 32 carbinoxamine maleate soln 14 carbinoxamine maleate tabs 14 carboplatin soln 15 carboprost tromethamine soln 50 CARDENE IV SOLN 24 CARDIZEM LA TB24 24 CARDURA XL TB24 4mg 8mg 22 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 15 CARNITOR SOLN 54 CARNITOR TABS 54 CAROSPIR SUSP 26 carteolol hcl soln 42
72 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
cartia xt cp24 120mg 180mg 240mg 300mg 24
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg 23
carvedilol tabs 3125mg 625mg 125mg 25mg 23
caspofungin acetate solr intravenous 50mg 70mg 11
cataflam tabs 27 CAYSTON SOLR 56 caziant tabs 46 cefaclor caps 8 cefaclor er tb12 8 cefaclor susr 8 cefadroxil caps 8 cefadroxil susr 8 cefadroxil tabs 8 cefazolin sodium solr 8 cefazolin sodium solr injection 1gm 10gm
500mg 8 cefdinir caps 8 cefdinir susr 8 cefepime hcl solr injection 1gm 2gm 8 cefixime caps 8 cefixime susr 8 cefotaxime sodium solr 8 cefotetan disodium solr injection 1gm 2gm 8 cefoxitin sodium solr injection 8 cefoxitin sodium solr intravenous 1gm 2gm
8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 2gm 6gm 8 CEFTIN SUSR 8 ceftriaxone sodium solr injection 1gm 2gm
250mg 500mg 8 ceftriaxone sodium solr intravenous 8 cefuroxime axetil tabs 8 cefuroxime sodium solr injection 75gm
750mg 8 cefuroxime sodium solr intravenous 8 celecoxib caps 27 CELONTIN CAPS 30 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 41
CERDELGA CAPS 40 CEREZYME SOLR 40 CEROVEL LOTN 62 CESAMET CAPS 43 cetirizine hcl soln 14 CETRAXAL SOLN 40 CEVIMELINE HCL CAPS 20 CHANTIX CONTINUING MONTH PAK
TABS 20 CHANTIX STARTING MONTH PAK TABS
20 CHANTIX TABS 05mg 1mg 20 CHEMET CAPS 44 chloramphenicol sod succinate solr 9 chlordiazepoxide hcl caps 5mg 10mg
25mg 33 chlordiazepoxide-amitriptyline tabs 35 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 40 chloroprocaine hcl (pf) soln 54 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 38 chlorothiazide tabs 250mg 500mg 38 chlorpromazine hcl soln 35 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 35 chlorthalidone tabs 25mg 50mg 38 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 44 cholestyramine light pack 23 cholestyramine light powd 23 cholestyramine pack 23 cholestyramine powd 23 CHORIONIC GONADOTROPIN SOLR 50 ciclopirox gel 58 ciclopirox olamine crea 58 ciclopirox olamine susp 58 ciclopirox sham 58 ciclopirox soln 58 cidofovir soln 12 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 40 CIMDUO TABS 12 cimetidine hcl soln 43 cimetidine tabs 200mg 300mg 400mg
800mg 43 CIMZIA KIT 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 73
CIMZIA PREFILLED KIT 52 CIMZIA STARTER KIT KIT 52 cinacalcet hcl tabs 30mg 60mg 90mg 50 CINQAIR SOLN 55 CINRYZE SOLR INTRAVENOUS 54 CIPRO HC SUSP 41 CIPRODEX SUSP 41 ciprofloxacin hcl soln (ophth) 40 CIPROFLOXACIN HCL SOLN (OTIC) 40 ciprofloxacin hcl tabs 9 ciprofloxacin in d5w soln 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 41 CIPROFLOXACIN-FLUOCINOLONE PF
SOLN 40 cisplatin soln 15 CISPLATIN SOLR 15 citalopram hydrobromide soln 35 citalopram hydrobromide tabs 10mg 20mg
40mg 35 citanest plain dental soln 54 cladribine soln 15 claravis caps 10mg 20mg 30mg 40mg 62 CLARINEX SYRP 14 CLARINEX-D 12 HOUR TB12 14 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 14 cleocin phosphate soln 9 cleocin solr 9 CLEOCIN SUPP 58 CLIMARA PRO PTWK 49 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
clindacin-p swab 58 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 58 clindamycin phosphate crea 58 clindamycin phosphate foam 58 clindamycin phosphate gel 58 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 58
clindamycin phosphate soln 9 58 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 58 CLINDESSE CREA 58 CLINIMIX EDEXTROSE (27510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42525) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (525) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (525) SOLN
INTRAVENOUS 38 clinisol sf soln intravenous 38 clobazam susp 30 clobazam tabs 10mg 20mg 30 clobetasol propionate crea 59 clobetasol propionate e crea 59 clobetasol propionate emulsion foam 59 clobetasol propionate foam 59 clobetasol propionate gel 59 clobetasol propionate liqd 60 clobetasol propionate lotn 60 clobetasol propionate oint 60 clobetasol propionate sham 60 clobetasol propionate soln 60 CLOBEX SHAM 60
74 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
CLOBEX SPRAY LIQD 60 clocortolone pivalate crea 60 clocortolone pivalate pump crea 60 clodan sham 60 clofarabine soln 15 clomipramine hcl caps 25mg 50mg 75mg
35 clonazepam tabs 05mg 1mg 2mg 30 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 30 clonidine hcl (analgesia) soln 25 clonidine hcl er tb12 25 clonidine hcl tabs 01mg 02mg 03mg 25 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 25 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 33 clotrimazole crea 58 clotrimazole soln 58 clotrimazole troc 58 clotrimazole-betamethasone crea 58 clotrimazole-betamethasone lotn 58 clovique caps 44 clozapine tabs 25mg 50mg 100mg 200mg
35 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 35 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 27 colazal caps 43 COLCHICINE CAPS 52 colchicine tabs 52 colchicine-probenecid tabs 40 colesevelam hcl pack 23 colesevelam hcl tabs 23 colestipol hcl gran 23 colestipol hcl pack 23 colestipol hcl tabs 23 colistimethate sodium (cba) solr injection 9 colocort enem 60 COLY-MYCIN S SUSP 41 COMBIGAN SOLN 42 COMBIPATCH PTTW 49 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 15 COMETRIQ (140 MG DAILY DOSE) KIT 15 COMETRIQ (60 MG DAILY DOSE) KIT 15
COMPLERA TABS 12 compro supp 35 CONDYLOX GEL 62 CONSENSI TABS 24 constulose soln 37 COPIKTRA CAPS 15mg 25mg 15 CORDRAN TAPE 60 CORLANOR TABS 5mg 75mg 25 cortisone acetate tabs 45 CORTISPORIN CREA 60 CORTISPORIN OINT 60 COSELA SOLR 54 COSENTYX (300 MG DOSE) SOSY 62 COSENTYX SENSOREADY (300 MG)
SOAJ 62 COSENTYX SENSOREADY PEN SOAJ 62 COSENTYX SOSY 75mg05ml 150mgml
62 COTELLIC TABS 15 COTEMPLA XR-ODT TBED 86mg
173mg 259mg 30 CREON CPEP 40 CRESEMBA CAPS 11 CRESEMBA SOLR 11 CRINONE GEL 4 8 50 CRIXIVAN CAPS 200mg 400mg 12 cromolyn sodium conc 55 cromolyn sodium nebu 55 cromolyn sodium soln 42 crotan lotn 58 cryselle-28 tabs 46 CRYSVITA SOLN 10mgml 20mgml
30mgml 54 CUPRIMINE CAPS 44 CURITY GAUZE PADS 37 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 57
CUVPOSA SOLN 19 cyclafem 135 tabs 46 cyclafem 777 tabs 46 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 15 CYCLOPHOSPHAMIDE SOLN 1gm5ml
500mg25ml 15 cyclophosphamide solr 15
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 75
cycloserine caps 11 CYCLOSET TABS 48 cyclosporine caps 25mg 100mg 53 cyclosporine modified caps 25mg 50mg
100mg 53 cyclosporine modified soln 53 cyclosporine soln 53 cyproheptadine hcl syrp 14 cyproheptadine hcl tabs 14 CYRAMZA SOLN 100mg10ml
500mg50ml 15 cyred eq tabs 46 CYSTADANE POWD 54 CYSTADROPS SOLN 42 CYSTAGON CAPS 50mg 150mg 54 CYSTARAN SOLN 42 cytarabine (pf) soln 15 cytarabine soln 15 CYTOGAM INJ 57
D dacarbazine solr 15 dactinomycin solr 15 DAKLINZA TABS 30mg 60mg 90mg 12 dalfampridine er tb12 34 DALIRESP TABS 250mcg 500mcg 56 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 45 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 62 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 57 daptomycin solr intravenous 350mg 500mg
9 DARAPRIM TABS 11 darifenacin hydrobromide er tb24 75mg
15mg 63 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 DAYTRANA PTCH 10mg9hr 15mg9hr
20mg9hr 30mg9hr 30 DDAVP RHINAL TUBE SOLN 50 deblitane tabs 46 decadron elix 45
decadron tabs 5mg 75mg 45 decadron tabs 4mg 6mg 45 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 44 deferasirox tabs 90mg 180mg 360mg 44 deferasirox tbso 125mg 44 deferasirox tbso 250mg 500mg 44 deferiprone tabs 44 deferoxamine mesylate solr 44 DELESTROGEN OIL 49 DELSTRIGO TABS 12 deltasone tabs 45 delyla tabs 46 DELZICOL CPDR 43 demeclocycline hcl tabs 9 DEMEROL SOLN 25mg05ml 75mg15ml
100mg2ml 75mgml 27 DEMSER CAPS 22 DENAVIR CREA 58 DEPEN TITRATABS TABS 44 depo-estradiol oil 49 DEPO-MEDROL SUSP 45 DEPO-PROVERA SUSP 400mgml 50 DEPO-SUBQ PROVERA 104 SUSY 50 depo-testosterone soln 100mgml
200mgml 45 DERMOTIC OIL 41 DESCOVY TABS 12 desipramine hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 desloratadine tabs 14 desloratadine tbdp 14 desmopressin ace spray refrig soln 50 desmopressin acetate
soln 50 DESMOPRESSIN ACETATE SOLN 50 desmopressin acetate spray soln 50 DESMOPRESSIN ACETATE TABS 01mg
02mg 50 desogestrel-ethinyl estradiol tabs 46 DESONATE GEL 60 desonide crea 60 desonide gel 60 desonide lotn 60 desonide oint 60 desowen lotn 60 desoximetasone crea 005 025 60 desoximetasone gel 60
76 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
desoximetasone liqd 60 desoximetasone oint 005 025 60 desrx gel 60 DESVENLAFAXINE ER TB24 50mg
100mg 35 desvenlafaxine succinate er tb24 25mg
50mg 100mg 35 dexabliss tbpk 45 dexamethasone elix 45 dexamethasone intensol conc 45 dexamethasone sod phosphate pf soln 45 dexamethasone sodium phosphate soln 41
45 dexamethasone soln 45 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 45 dexamethasone tbpk 45 dexchlorpheniramine maleate soln 14 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 30
dexmethylphenidate hcl tabs 25mg 5mg 10mg 30
dexpak 10 day tbpk 45 dexpak 13 day tbpk 45 dexpak 6 day tbpk 45 dexrazoxane hcl solr 54 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 30 dextroamphetamine sulfate soln 30 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 30 DEXTROSE 10NACL 02 39 DEXTROSE 5NACL 0225 39 DEXTROSE IN LACTATED RINGERS
SOLN 39 DEXTROSE SOLN 38 dextrose soln intravenous 5 10 38 DEXTROSE-NACL SOLN INTRAVENOUS
39 DIACOMIT CAPS 250mg 500mg 30 DIACOMIT PACK 250mg 500mg 31 DIASTAT ACUDIAL GEL 10mg 20mg 31 DIASTAT PEDIATRIC GEL 31 diazepam conc 33 diazepam gel 25mg 10mg 20mg 31 diazepam soln 5mg5ml 5mgml 33 diazepam tabs 2mg 5mg 10mg 33 diazoxide susp 48
diclofenac potassium tabs 27 diclofenac sodium er tb24 27 diclofenac sodium gel 1 3 60 diclofenac sodium soln 41 diclofenac sodium tbec 27 diclofenac-misoprostol tbec 27 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 12 DIFFERIN CREA 62 DIFFERIN LOTN 62 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 60 diflorasone diacetate oint 60 diflunisal tabs 27 digitek tabs 0125mg 025mg 25 digox tabs 25 DIGOXIN ORAL SOLN 25 digoxin soln inj 25 digoxin tabs 125mcg 250mcg 25 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 31 dilantin infatabs chew 31 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 24 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 24
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 24
diltiazem hcl er cp12 60mg 90mg 120mg 24
diltiazem hcl er cp24 120mg 180mg 240mg 24
diltiazem hcl soln 24 diltiazem hcl solr 24 diltiazem hcl tabs 30mg 60mg 90mg
120mg 24 dilt-xr cp24 120mg 180mg 240mg 24 dimenhydrinate soln 43 dimethyl fumarate cpdr 34 dimethyl fumarate starter pack misc 34 DIPENTUM CAPS 43 diphen elix 14 di-phen elix 14 diphenhydramine hcl elix 14
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 77
diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 43 diphenoxylate-atropine tabs 43 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 57 dipyridamole tabs 25mg 50mg 75mg 26 disopyramide phosphate caps 100mg
150mg 25 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 38 divalproex sodium csdr 31 divalproex sodium er tb24 250mg 500mg 31 divalproex sodium tbec 125mg 250mg
500mg 31 DIVIGEL GEL 49 dobutamine hcl soln 21 DOBUTAMINE IN D5W SOLN 21 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 160mg8ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
25 dolishale tabs 46 donepezil hcl tabs 5mg 10mg 23mg 20 donepezil hcl tbdp 5mg 10mg 20 dopamine hcl soln 21 DOPAMINE IN D5W SOLN 21 DOPTELET TABS 22 DORYX MPC TBEC 9 dorzolamide hcl soln 42 dorzolamide hcl-timolol mal pf soln 42 dorzolamide hcl-timolol mal soln 42 dotti pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 49
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 35 doxepin hcl conc 35 doxepin hcl crea 61 doxepin hcl tabs 3mg 6mg 35 doxercalciferol caps 05mcg 1mcg 25mcg
63 DOXERCALCIFEROL SOLN 63 doxorubicin hcl liposomal inj 15 DOXORUBICIN HCL SOLN 15
doxorubicin hcl solr 15 doxy 100 solr intravenous 9 doxycycline hyclate caps 50mg 100mg 9 doxycycline hyclate tabs 20mg 75mg
100mg 150mg 9 doxycycline hyclate tbec 50mg 75mg
100mg 150mg 200mg 9 doxycycline monohydrate caps 50mg
75mg 100mg 150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 43 DRIZALMA SPRINKLE CSDR 35 dronabinol caps 25mg 5mg 10mg 43 droperidol soln 33 drospiren-eth estrad-levomefol tabs 46 drospirenone-ethinyl estradiol tabs 46 DROXIA CAPS 15 droxidopa caps 21 DUAKLIR PRESSAIR AEPB 19 DUAVEE TABS 49 DUEXIS TABS 27 DULERA AERO 56 duloxetine hcl cpep 20mg 30mg 40mg
60mg 35 DUOBRII LOTN 60 DUOPA SUSP 32 DUPIXENT SOPN 200mg114ml
300mg2ml 55 DUPIXENT SOSY 200mg114ml
300mg2ml 55 DURAMORPH SOLN 05mgml 1mgml 27 DUREZOL EMUL 41 DURYSTA IMPL 42 dutasteride caps 52 dutasteride-tamsulosin hcl caps 52 DUTOPROL TB24 23 dvorah tabs 27 dxevo 11-day tbpk 45 DYANAVEL XR SUER 30 DYSPORT SOLR 300unit 500unit 54
E ees 400 tabs 9 EASYGEL GEL 54 econazole nitrate crea 58 EDARBYCLOR TABS 26 EDLUAR SUBL 5mg 10mg 33
78 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 51 EGRIFTA SV SOLR 51 ELAPRASE SOLN 40 ELELYSO SOLR 40 ELEPSIA XR TB24 1000mg 1500mg 31 ELESTRIN GEL 49 eletriptan hydrobromide tabs 32 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 40 elixophyllin elix 63 ELLA TABS 46 ELLENCE SOLN 15 ELMIRON CAPS 54 eluryng ring 46 ELZONRIS SOLN 15 EMBEDA CPCR 27 EMCYT CAPS 15 EMEND SUSR 43 EMFLAZA SUSP 45 EMFLAZA TABS 6mg 18mg 30mg 36mg
45 EMGALITY (300 MG DOSE) SOSY 32 EMGALITY SOAJ 32 EMGALITY SOSY 32 emoquette tabs 46 EMPAVELI SOLN 54 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 32 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 26 enalaprilat inj 26 enalapril-hydrochlorothiazide tabs 26 ENBREL MINI SOCT 52 ENBREL SOLN 52 ENBREL SOLR 52 ENBREL SOSY 25mg05ml 50mgml 52 ENBREL SURECLICK SOAJ 52 ENDARI PACK 54 endocet tabs 27
ENDOMETRIN INST 50 ENGERIX-B SUSP 10mcg05ml 20mcgml
57 ENHERTU SOLR 15 enoxaparin sodium soln 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
enpresse-28 tabs 46 enskyce tabs 46 ENSPRYNG SOSY 54 ENSTILAR FOAM 60 entacapone tabs 33 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 26 ENTYVIO SOLR 44 enulose soln 37 ENVARSUS XR TB24 075mg 1mg 4mg53 EPCLUSA TABS 12 EPIDIOLEX SOLN 31 EPIDUO FORTE GEL 62 epifoam foam 60 epinastine hcl soln 42 epinephrine (anaphylaxis) soln 21 epinephrine soaj 21 EPINEPHRINE SOSY 21 EPIPEN 2-PAK SOAJ 21 EPIPEN JR 2-PAK SOAJ 21 epirubicin hcl soln 15 epitol tabs 31 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 26 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 22
epoprostenol sodium solr 56 eprosartan mesylate tabs 26 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 35 ERAXIS SOLR INTRAVENOUS 50mg
100mg 11 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 32 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 79
ERTACZO CREA 58 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 58 ery-tab tbec 9 ERYTHROCIN LACTOBIONATE SOLR
INTRAVENOUS 9 erythrocin stearate tabs 9 erythromycin base cpep 9 erythromycin base tabs 9 erythromycin base tbec 9 erythromycin ethylsuccinate susr 9 erythromycin ethylsuccinate tabs 9 erythromycin gel 58 erythromycin oint 40 erythromycin pads 58 erythromycin soln 58 ESBRIET CAPS 56 ESBRIET TABS 267mg 801mg 56 escitalopram oxalate soln 35 escitalopram oxalate tabs 5mg 10mg
20mg 35 esgic caps 27 esgic tabs 27 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 43 esomeprazole magnesium pack 10mg
20mg 40mg 43 esomeprazole sodium solr 43 ESOMEPRAZOLE STRONTIUM CPDR 43 estarylla tabs 46 estazolam tabs 1mg 2mg 33 estrace crea 49 estrace tabs 05mg 1mg 2mg 49 estradiol crea 49 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 49
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
estradiol tabs 10mcg 05mg 1mg 2mg 49 estradiol valerate oil 49 estradiol-norethindrone acet tabs 49 ESTRING RING 49 eszopiclone tabs 1mg 2mg 3mg 33
ethacrynic acid tabs 38 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 31 ethosuximide soln 31 ethynodiol diac-eth estradiol tabs 46 etodolac caps 27 etodolac er tb24 27 etodolac tabs 27 etonogestrel-ethinyl estradiol ring 46 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 EURAX CREA 58 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
EVAMIST SOLN 49 evekeo tabs 5mg 10mg 30 EVENITY SOSY 52 everolimus tabs 025mg 53 everolimus tabs 05mg 075mg 53 everolimus tabs 25mg 5mg 75mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 23 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 54 EXELDERM CREA 58 EXELDERM SOLN 58 exemestane tabs 15 EXJADE TBSO 125mg 250mg 500mg 44 EXONDYS 51 SOLN 500mg10ml
100mg2ml 54 EXSERVAN FILM 34 EXTAVIA KIT 34 EYLEA SOLN 42 EYLEA SOSY 42 ezetimibe tabs 23 ezetimibe-simvastatin tabs 23
F FABIOR FOAM 62 FABRAZYME SOLR 5mg 35mg 40 falmina tabs 46 famciclovir tabs 125mg 250mg 500mg 12 famotidine premixed soln 43 famotidine soln 43 famotidine susr 43 famotidine tabs 20mg 40mg 43
80 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg 35
FANAPT TITRATION PACK TABS 35 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 55 FASENRA SOSY 55 FASLODEX SOLN 15 fayosim tabs 46 febuxostat tabs 40mg 80mg 52 felbamate susp 31 felbamate tabs 400mg 600mg 31 felodipine er tb24 25mg 5mg 10mg 24 femynor tabs 46 fenofibrate caps 50mg 134mg 150mg 23 fenofibrate micronized caps 43mg 67mg
130mg 200mg 23 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 23 fenofibric acid cpdr 45mg 135mg 23 FENOFIBRIC ACID TABS 35mg 105mg 23 fenoprofen calcium caps 27 fenoprofen calcium tabs 27 fenortho caps 27 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 27 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 27
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg 27
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 27
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 27
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg 27
FERRIPROX SOLN 44 FERRIPROX TABS 500mg 1000mg 44 FERRIPROX TWICE-A-DAY TABS 44 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
35 FETZIMA TITRATION C4PK 35 fexmid tabs 20 FIBRICOR TABS 23 FINACEA FOAM 62 finasteride tabs 52 FINTEPLA SOLN 31
fioricet caps 27 fioricetcodeine caps 27 FIRAZYR SOLN 21 FIRDAPSE TABS 54 FIRMAGON (240 MG DOSE) SOLR 16 FIRMAGON SOLR 16 FIRVANQ SOLR 9 flac oil 41 FLAREX SUSP 41 flavoxate hcl tabs 63 FLEBOGAMMA DIF SOLN INTRAVENOUS
5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml 57
flecainide acetate tabs 50mg 100mg 150mg 25
FLOLIPID SUSP 20mg5ml 40mg5ml 23 FLOVENT DISKUS AEPB 50mcgblist
100mcgblist 250mcgblist 56 FLOVENT HFA AERO 110mcgact
220mcgact 56 FLOVENT HFA AERO 44mcgact 56 floxuridine solr 16 fluconazole in sodium chloride soln
intravenous 11 fluconazole susr 11 fluconazole tabs 11 flucytosine caps 250mg 500mg 11 fludarabine phosphate soln 16 fludarabine phosphate solr 16 fludrocortisone acetate tabs 45 flumazenil soln 34 flunisolide soln 41 fluocinolone acetonide body oil 60 fluocinolone acetonide crea 001 0025
60 fluocinolone acetonide oil 41 fluocinolone acetonide oint 60 fluocinolone acetonide scalp oil 60 fluocinolone acetonide soln 60 fluocinonide crea 60 fluocinonide emulsified base crea 60 FLUOCINONIDE GEL 60 fluocinonide oint 60 fluocinonide soln 60 FLUORITAB CHEW 025mg 05mg 1mg 54 FLUORITAB SOLN 54 fluorometholone susp 41 fluorouracil crea 5 62
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fluorouracil crea 5 62 fluorouracil soln 16 62 fluorouracil soln 2 5 62 fluoxetine hcl (pmdd) tabs 10mg 20mg 35 fluoxetine hcl caps 10mg 20mg 40mg 35 fluoxetine hcl cpdr 35 fluoxetine hcl soln 35 fluoxetine hcl tabs 10mg 20mg 60mg 36 fluphenazine decanoate soln 36 fluphenazine hcl conc 36 fluphenazine hcl elix 36 fluphenazine hcl soln 36 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 36 flurandrenolide crea 60 flurandrenolide lotn 60 flurandrenolide oint 60 flurazepam hcl caps 15mg 30mg 33 flurbiprofen sodium soln 41 flurbiprofen tabs 27 flutamide caps 16 fluticasone propionate crea 60 fluticasone propionate lotn 60 fluticasone propionate oint 60 fluticasone propionate susp 41 fluticasone-salmeterol aepb 56 fluvastatin sodium caps 20mg 40mg 23 fluvastatin sodium er tb24 23 fluvoxamine maleate er cp24 100mg
150mg 36 fluvoxamine maleate tabs 25mg 50mg
100mg 36 FML FORTE SUSP 41 FML OINT 41 fomepizole soln 52 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 formoterol fumarate nebu 21 FORTEO SOPN 50 FOSAMAX PLUS D TABS 52 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 43 fosfomycin tromethamine pack 14 fosinopril sodium tabs 10mg 20mg 40mg
26 fosinopril sodium-hctz tabs 26 fosphenytoin sodium soln 31 FOSRENOL PACK 750mg 1000mg 39
FOTIVDA CAPS 089mg 134mg 16 FREAMINE HBC SOLN INTRAVENOUS 38 frovatriptan succinate tabs 32 FULPHILA SOSY 22 fulvestrant soln 16 furosemide soln 8mgml 10mgml 38 furosemide soln injection 38 FUROSEMIDE TABS 40mg 80mg 20mg38 FUZEON SOLR 12 fyavolv tabs 49 FYCOMPA SUSP 31 FYCOMPA TABS 31
G gabapentin caps 100mg 400mg 31 gabapentin soln 31 gabapentin tabs 600mg 800mg 31 GALAFOLD CAPS 54 galantamine hydrobromide er cp24 8mg
16mg 24mg 20 galantamine hydrobromide soln 20 galantamine hydrobromide tabs 4mg 8mg
12mg 20 GAMASTAN INJ 57 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 53 GAMMAGARD SD LESS IGA SOLR
INTRAVENOUS 5gm 10gm 57 GAMMAGARD SOLN INJECTION 57 GAMMAKED SOLN INJECTION 57 GAMMAPLEX SOLN INTRAVENOUS
10gm100ml 20gm200ml 5gm50ml 57 GAMMAPLEX SOLN INTRAVENOUS
10gm200ml 57 GAMUNEX-C SOLN INJECTION
10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml 57
ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 57 GARDASIL 9 SUSY 57 gatifloxacin soln 40 GATTEX KIT 44 gavilyte-c solr 44 gavilyte-g solr 44 gavilyte-h kit 44 gavilyte-n with flavor pack solr 44 GAVRETO CAPS 16 GAZYVA SOLN 16
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gemcitabine hcl soln 16 gemcitabine hcl solr 16 gemfibrozil tabs 23 gemmily caps 46 generlac soln 37 gengraf caps 25mg 50mg 100mg 53 gengraf soln 53 GENOTROPIN MINIQUICK SOLR 02mg 51 GENOTROPIN MINIQUICK SOLR 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 51
GENOTROPIN SOLR 5mg 12mg 51 gentak oint 40 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 58 gentamicin sulfate oint 58 gentamicin sulfate soln 9 40 gentamicin sulfate soln injection 9 GENVOYA TABS 12 GEODON SOLR 36 gianvi tabs 46 GILENYA CAPS 025mg 05mg 34 GILOTRIF TABS 20mg 30mg 40mg 16 GIMOTI SOLN 44 GIVLAARI SOLN 54 GLASSIA SOLN INTRAVENOUS 56 glatiramer acetate sosy 20mgml 40mgml
34 glatopa sosy 20mgml 40mgml 34 glimepiride tabs 1mg 2mg 4mg 48 glipizide er tb24 25mg 5mg 10mg 48 glipizide tabs 5mg 10mg 48 glipizide-metformin hcl tabs 48 GLOPERBA SOLN 52 GLUCAGEN HYPOKIT SOLR 48 glucagon emergency kit 48 glyburide micronized tabs 15mg 3mg 6mg
48 glyburide tabs 125mg 25mg 5mg 48 glyburide-metformin tabs 48 glycate tabs 19 glycopyrrolate pf sosy 19 glycopyrrolate soln 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 61 GLYXAMBI TABS 48 GOLYTELY SOLR 44 GONITRO PACK 26
granisetron hcl soln 43 granisetron hcl tabs 43 GRANIX SOLN 480mcg16ml 300mcgml
22 GRANIX SOSY 300mcg05ml
480mcg08ml 22 GRASTEK SUBL 54 griseofulvin microsize susp 11 griseofulvin microsize tabs 11 griseofulvin ultramicrosize tabs 11 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 34 guanfacine hcl tabs 1mg 2mg 25 GUANIDINE HCL TABS 20 gynazole-1 crea 58
H HAEGARDA SOLR 2000unit 3000unit 54 hailey 24 fe tabs 46 halcinonide crea 60 halobetasol propionate crea 60 HALOBETASOL PROPIONATE FOAM 60 halobetasol propionate oint 60 HALOG CREA 60 HALOG OINT 60 haloperidol decanoate soln 36 haloperidol lactate conc 36 haloperidol lactate soln 36 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 36 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 57 heparin (porcine) in nacl soln 21 HEPARIN SOD (PORCINE) IN D5W SOLN
21 heparin sodium (porcine) pf soln 21 heparin sodium (porcine) soln 1000unitml
5000unitml 10000unitml 20000unitml 21
HEPATAMINE SOLN INTRAVENOUS 38 HEPLISAV-B SOLN 57 HERCEPTIN HYLECTA SOLN 16 HERCEPTIN SOLR 150mg 440mg 16 HERZUMA SOLR 150mg 420mg 16 HETLIOZ CAPS 33 HETLIOZ LQ SUSP 33 HEXALEN CAPS 16 HIBERIX SOLR 57
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HORIZANT TBCR 300mg 600mg 31 HUMALOG JUNIOR KWIKPEN SOPN 48 HUMALOG KWIKPEN SOPN 100unitml
200unitml 48 HUMALOG MIX 5050 KWIKPEN SUPN 48 HUMALOG MIX 5050 SUSP 48 HUMALOG MIX 7525 KWIKPEN SUPN 48 HUMALOG MIX 7525 SUSP 48 HUMALOG SOCT 48 HUMALOG SOLN 48 humatin caps 11 HUMATROPE SOLR 5mg 6mg 12mg
24mg 51 HUMIRA PEDIATRIC CROHNS START
PSKT 52 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 52 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 52 HUMIRA PEN-PEDIATRIC UC START
PNKT 52 HUMIRA PEN-PSUVADOL HS START
PNKT 52 HUMIRA PEN-PSORUVEIT STARTER
PNKT 52 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 52
HUMULIN 7030 KWIKPEN SUPN 48 HUMULIN 7030 SUSP 48 HUMULIN N KWIKPEN SUPN 48 HUMULIN N SUSP 48 HUMULIN R SOLN 48 HUMULIN R U-500 (CONCENTRATED)
SOLN 48 HUMULIN R U-500 KWIKPEN SOPN 48 hydralazine hcl soln 25 hydralazine hcl tabs 10mg 25mg 50mg
100mg 25 hydrochlorothiazide caps 38 hydrochlorothiazide tabs 125mg 25mg
50mg 38 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 27 hydrocodone-acetaminophen soln 27 hydrocodone-acetaminophen tabs 27 hydrocodone-ibuprofen tabs 27 hydrocortisone (perianal) crea 1 25 60 hydrocortisone ace-pramoxine crea 61
hydrocortisone butyr lipo base crea 60 hydrocortisone butyrate crea 60 hydrocortisone butyrate lotn 60 HYDROCORTISONE BUTYRATE OINT 60 hydrocortisone butyrate soln 60 hydrocortisone crea 1 25 60 hydrocortisone enem 60 hydrocortisone lotn 60 hydrocortisone oint 1 25 60 hydrocortisone tabs 5mg 10mg 20mg 45 hydrocortisone valerate crea 60 hydrocortisone valerate oint 60 HYDROCORTISONE-ACETIC ACID SOLN
41 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 28 hydromorphone hcl liqd 28 hydromorphone hcl pf soln 50mg5ml
10mgml 28 HYDROMORPHONE HCL SOLN 1mgml
2mgml 28 hydromorphone hcl tabs 2mg 4mg 8mg 28 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 50 hydroxyprogesterone caproate soln 50 hydroxyurea caps 16 hydroxyzine hcl soln 33 hydroxyzine hcl syrp 33 hydroxyzine hcl tabs 33 hydroxyzine pamoate caps 33 HYPERHEP B SOLN 57 HYPERRAB SD SOLN 57 HYQVIA KIT 57
I IBANDRONATE SODIUM SOLN 52 ibandronate sodium tabs 52 IBRANCE CAPS 75mg 100mg 125mg 16 IBRANCE TABS 75mg 100mg 125mg 16 ibu tabs 28 ibudone tabs 28 ibuprofen lysine soln 28 ibuprofen susp 28 ibuprofen tabs 28 ibutilide fumarate soln 25 icatibant acetate soln 21 iclevia tabs 46 ICLUSIG TABS 10mg 15mg 30mg 45mg
16
84 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
icosapent ethyl caps 23 IDAMYCIN PFS SOLN 16 idarubicin hcl soln 16 IDHIFA TABS 50mg 100mg 16 ifosfamide soln 16 IFOSFAMIDE SOLR 16 ILARIS SOLN 28 ILEVRO SUSP 41 ILUMYA SOSY 62 ILUVIEN IMPL 41 imatinib mesylate tabs 16 IMBRUVICA CAPS 70mg 140mg 16 IMBRUVICA TABS 140mg 280mg 420mg
560mg 16 IMFINZI SOLN 500mg10ml 120mg24ml
16 imipenem-cilastatin solr intravenous 9 imipramine hcl tabs 10mg 25mg 50mg 36 imipramine pamoate caps 75mg 100mg
125mg 150mg 36 imiquimod crea 375 5 62 IMIQUIMOD PUMP CREA 62 IMOGAM RABIES-HT SOLN 57 IMOVAX RABIES INJ 57 IMPAVIDO CAPS 11 IMVEXXY MAINTENANCE PACK INST
4mcg 10mcg 49 IMVEXXY STARTER PACK INST 4mcg
10mcg 49 INBRIJA CAPS 33 incassia tabs 46 INCRELEX SOLN 51 INCRUSE ELLIPTA AEPB 19 indapamide tabs 125mg 25mg 38 indocin supp 28 INDOCIN SUSP 28 indomethacin caps 28 INDOMETHACIN CAPS 20mg 28 indomethacin er cpcr 28 indomethacin sodium solr 28 INFANRIX SUSP 57 INFLECTRA SOLR INTRAVENOUS 52 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 34 INGREZZA CPPK 34 INLYTA TABS 1mg 5mg 16 INNOPRAN XL CP24 80mg 120mg 23 INQOVI TABS 16 INREBIC CAPS 16
INSULIN ASP PROT amp ASP FLEXPEN SUPN 48
INSULIN ASPART FLEXPEN SOPN 48 INSULIN ASPART PENFILL SOCT 48 INSULIN ASPART PROT amp ASPART SUSP
48 INSULIN ASPART SOLN 48 INSULIN LISPRO (1 UNIT DIAL) SOPN 48 INSULIN LISPRO SOLN 48 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 38 INTRALIPID EMUL INTRAVENOUS
20gm100ml 38 INTRAROSA INST 45 INTRON A SOLN 10muml 6000000unitml
16 INTRON A SOLR 10mu 18mu 50mu 16 introvale tabs 46 INVEGA SUSTENNA SUSY 39mg025ml
36 INVEGA SUSTENNA SUSY 78mg05ml
117mg075ml 234mg15ml 156mgml 36
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml 36
INVELTYS SUSP 41 INVIRASE CAPS 12 INVIRASE TABS 12 INVOKAMET TABS 48 INVOKAMET XR TB24 48 INVOKANA TABS 100mg 300mg 48 IONOSOL-MB IN D5W SOLN
INTRAVENOUS 39 IOPIDINE SOLN 42 IPOL INJ 57 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 21 irbesartan tabs 75mg 150mg 300mg 26 irbesartan-hydrochlorothiazide tabs 26 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isibloom tabs 46
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ISOLYTE-P IN D5W SOLN INTRAVENOUS 39
ISOLYTE-S SOLN INTRAVENOUS 39 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 21 isosorbide dinitrate er tbcr 26 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 26 isosorbide mononitrate er tb24 26 isosorbide mononitrate er tb24 30mg 60mg
26 isosorbide mononitrate tabs 10mg 20mg 26 isotretinoin caps 10mg 20mg 30mg 40mg
62 isradipine caps 25mg 5mg 24 ISTURISA TABS 1mg 5mg 10mg 54 itraconazole caps 11 ITRACONAZOLE SOLN 11 ivermectin crea 58 ivermectin lotn 58 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 57
J JADENU SPRINKLE PACK 90mg 180mg
360mg 44 JADENU TABS 90mg 360mg 44 JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16 jantoven tabs 1mg 2mg 25mg 3mg 4mg
5mg 6mg 75mg 10mg 21 JARDIANCE TABS 10mg 25mg 48 jasmiel tabs 46 JEMPERLI SOLN 16 JENTADUETO TABS 48 JENTADUETO XR TB24 48 jinteli tabs 49 JOLIVETTE TABS 46 juleber tabs 46 JULUCA TABS 12 junel 1530 tabs 46 junel 120 tabs 46 junel fe 1530 tabs 46 junel fe 120 tabs 46 junel fe 24 tabs 46
JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg 23
JYNARQUE TABS 15mg 30mg 39 JYNARQUE TBPK 39
K KADCYLA SOLR 100mg 160mg 16 KADIAN CP24 28 kaitlib fe chew 46 KALYDECO PACK 25mg 50mg 75mg 56 KALYDECO TABS 56 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 40 kariva tabs 46 KAZANO TABS 48 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-033 MEQ 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 40-5-09 MEQ 39 KCL-LACTATED RINGERS-D5W SOLN
INTRAVENOUS 39 KEDRAB SOLN 57 kelnor 135 tabs 46 kelnor 150 tabs 46 KENALOG SUSP 45 KEPIVANCE SOLR 61 keralyt sham 62 KESIMPTA SOAJ 54 ketoconazole crea 58 ketoconazole foam 58 ketoconazole sham 58 ketoconazole tabs 11 ketodan foam 58 ketoprofen caps 28 ketoprofen er cp24 28 ketorolac tromethamine soln 28 41 ketorolac tromethamine soln 04 05 41 ketorolac tromethamine tabs 28 KEVEYIS TABS 54 KEVZARA SOAJ 150mg114ml
200mg114ml 53 KEVZARA SOSY 150mg114ml
200mg114ml 53 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 52 KHEDEZLA TB24 50mg 100mg 36 KIMYRSA SOLR 9
86 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
KINERET SOSY 53 KINRIX SUSP 57 kionex susp 39 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (200 MG DOSE) TBPK
16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KITABIS PAK NEBU 56 KLISYRI OINT 62 KLOR-CON 10 TBCR 39 klor-con m10 tbcr 39 klor-con m15 tbcr 39 klor-con m20 tbcr 39 klor-con pack 39 klor-con sprinkle cpcr 8meq 10meq 39 KLOR-CON TBCR 39 KORLYM TABS 48 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 37 K-TAB TBCR 39 kurvelo tabs 46 KUVAN PACK 100mg 500mg 54 KUVAN TABS 54 KYNAMRO SOSY 23 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 33 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 LACRISERT INST 42 LACTATED RINGERS SOLN 39 54 LACTIC ACID LOTN 62 lactulose encephalopathy soln 37 lactulose pack 38 lactulose soln 38 LAMICTAL XR KIT 31 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 31
lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg 31
lamotrigine kit 31 lamotrigine starter kit-blue kit 31 lamotrigine starter kit-green kit 31 lamotrigine starter kit-orange kit 31 lamotrigine tabs 25mg 100mg 150mg
200mg 31 lamotrigine tbdp 25mg 50mg 100mg
200mg 31 LANOXIN PEDIATRIC SOLN 25 LANOXIN TABS 625mcg 25 lansoprazole cpdr 15mg 30mg 43 lansoprazole tbdd 15mg 30mg 43 lanthanum carbonate chew 500mg 750mg
1000mg 39 LANTUS SOLN 48 LANTUS SOLOSTAR SOPN 49 lapatinib ditosylate tabs 16 larin 1530 tabs 46 larin 120 tabs 46 larin fe 1530 tabs 46 larin fe 120 tabs 46 larissia tabs 46 LARTRUVO SOLN 190mg19ml
500mg50ml 16 LASTACAFT SOLN 42 latanoprost soln 42 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 36 LAYOLIS FE CHEW 46 LAZANDA SOLN 100mcgact 300mcgact
400mcgact 28 ledipasvir-sofosbuvir tabs 12 leena tabs 46 leflunomide tabs 10mg 20mg 53 LEMTRADA SOLN 34 LENVIMA (10 MG DAILY DOSE) CPPK 16 LENVIMA (12 MG DAILY DOSE) CPPK 16 LENVIMA (14 MG DAILY DOSE) CPPK 16 LENVIMA (18 MG DAILY DOSE) CPPK 16 LENVIMA (20 MG DAILY DOSE) CPPK 16 LENVIMA (24 MG DAILY DOSE) CPPK 16 LENVIMA (4 MG DAILY DOSE) CPPK 16 LENVIMA (8 MG DAILY DOSE) CPPK 17 lessina tabs 46 LETAIRIS TABS 5mg 10mg 56 letrozole tabs 17 leucovorin calcium soln 52
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leucovorin calcium solr 52 leucovorin calcium tabs 5mg 10mg 15mg
25mg 52 LEUKERAN TABS 17 LEUKINE SOLR 22 leuprolide acetate kit 17 levalbuterol hcl nebu 125mg05ml
031mg3ml 063mg3ml 125mg3ml 21 levalbuterol tartrate aero 21 LEVEMIR FLEXTOUCH SOPN 49 LEVEMIR SOLN 49 levetiracetam er tb24 500mg 750mg 31 levetiracetam in nacl soln 31 levetiracetam soln 31 levetiracetam tabs 250mg 500mg 750mg
1000mg 31 levobunolol hcl soln 42 levocarnitine soln 54 LEVOCARNITINE TABS 54 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 40 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 52 levoleucovorin calcium solr 52 levonest tabs 46 levonorgest-eth est amp eth est tabs 47 levonorgest-eth estrad 91-day tabs 47 levonorgestrel-ethinyl estrad tabs 47 levonorg-eth estrad triphasic tabs 46 levora 01530 (28) tabs 47 levorphanol tartrate tabs 2mg 3mg 28 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEVOTHYROXINE SODIUM SOLR 51 levothyroxine sodium tabs 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEXETTE FOAM 60 LEXIVA SUSP 12 LIALDA TBEC 43 LIBTAYO SOLN 17 lidocaine hcl (cardiac) pf sosy 25 lidocaine hcl (cardiac) sosy 25 lidocaine hcl (pf) soln 54 LIDOCAINE HCL CREA 61 lidocaine hcl lotn 61 lidocaine hcl soln 42 54 61 lidocaine hcl urethralmucosal gel 61 lidocaine hcl urethralmucosal prsy 61 LIDOCAINE IN D5W SOLN 25 lidocaine in dextrose soln 54 lidocaine oint 61 lidocaine ptch 61 lidocaine viscous hcl soln 42 lidocaine-epinephrine soln 54 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 61 LIDOCAINE-HYDROCORTISONE ACE KIT
61 lidocaine-prilocaine crea 61 lidocaine-tetracaine crea 61 LIDOCORT CREA 61 lidopin crea 61 LIDO-SORB LOTN 61 LIDOZION LOTN 61 lincomycin hcl soln 9 lindane sham 58 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 LINZESS CAPS 72mcg 145mcg 290mcg
44 liothyronine sodium soln 51 liothyronine sodium tabs 5mcg 25mcg
50mcg 51 LIPODOX 50 INJ 17 lisinopril tabs 25mg 5mg 10mg 20mg
30mg 40mg 26 lisinopril-hydrochlorothiazide tabs 26 LITHIUM CARBONATE CAPS 300mg
150mg 600mg 36 lithium carbonate er tbcr 300mg 450mg 36 lithium carbonate tabs 36
88 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
LITHIUM SOLN 36 LITHOSTAT TABS 38 LIVALO TABS 1mg 2mg 4mg 23 LO LOESTRIN FE TABS 47 lodine tabs 28 loestrin 1530 (21) tabs 47 loestrin 120 (21) tabs 47 loestrin fe 1530 tabs 47 loestrin fe 120 tabs 47 LOKELMA PACK 5gm 10gm 39 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 17 loperamide hcl caps 43 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 49 lorazepam intensol conc 33 LORAZEPAM SOLN 4mgml 2mgml 33 lorazepam tabs 05mg 1mg 2mg 33 LORBRENA TABS 25mg 100mg 17 lorcet hd tabs 28 lorcet plus tabs 28 lorcet tabs 28 lortab elix 28 loryna tabs 47 lorzone tabs 375mg 750mg 20 losartan potassium tabs 25mg 50mg
100mg 26 losartan potassium-hctz tabs 26 LOTEMAX GEL 41 LOTEMAX OINT 41 LOTEMAX SUSP 41 loteprednol etabonate susp 41 lovastatin tabs 10mg 20mg 40mg 23 LOVENOX SOLN 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
low-ogestrel tabs 47 loxapine succinate caps 5mg 10mg 25mg
50mg 36 lubiprostone caps 8mcg 24mcg 44 LUCEMYRA TABS 34 LUCENTIS SOLN 03mg005ml
05mg005ml 42 LUCENTIS SOSY 03mg005ml
05mg005ml 42 LUDENT CHEW 025mg 05mg 1mg 54 LULICONAZOLE CREA 58 LUMAKRAS TABS 17
LUMIGAN SOLN 42 LUMIZYME SOLR 40 LUMOXITI SOLR 17 LUPANETA PACK KIT 17 LUPKYNIS CAPS 53 LUPRON DEPOT (1-MONTH) KIT 17 LUPRON DEPOT (3-MONTH) KIT 17 LUPRON DEPOT (4-MONTH) KIT 17 LUPRON DEPOT (6-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 17 LUPRON DEPOT-PED (3-MONTH) KIT 17 lutera tabs 47 LUZU CREA 58 lyleq tabs 47 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 50
LYNPARZA CAPS 17 LYNPARZA TABS 100mg 150mg 17 LYSODREN TABS 17 lyza tabs 47
M mafenide acetate pack 58 magnesium sulfate in d5w soln 39 magnesium sulfate soln 31 magnesium sulfate soln injection 50 31 MAGNESIUM SULFATE SOLN
INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml 31
MAKENA SOAJ 50 malathion lotn 58 MANNITOL SOLN 39 maprotiline hcl tabs 25mg 50mg 75mg 36 MARGENZA SOLN 17 marlissa tabs 47 MARPLAN TABS 36 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 24 MAVENCLAD (10 TABS) TBPK 53 MAVENCLAD (4 TABS) TBPK 53 MAVENCLAD (5 TABS) TBPK 53 MAVENCLAD (6 TABS) TBPK 53 MAVENCLAD (7 TABS) TBPK 53 MAVENCLAD (8 TABS) TBPK 53
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 89
MAVENCLAD (9 TABS) TBPK 53 MAVYRET TABS 12 MAXIDEX SUSP 41 MAYZENT STARTER PACK TBPK 34 MAYZENT TABS 025mg 2mg 34 MENAPHOSMBHYO1 TABS 14 meclizine hcl tabs 43 meclofenamate sodium caps 28 MEDROL TABS 45 medroxyprogesterone acetate susp 50 medroxyprogesterone acetate susy 50 medroxyprogesterone acetate tabs 25mg
5mg 10mg 50 mefenamic acid caps 28 mefloquine hcl tabs 11 megestrol acetate susp 17 50 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 47 meloxicam caps 28 meloxicam tabs 28 melphalan hcl solr 17 memantine hcl er cp24 34 memantine hcl soln 34 memantine hcl tabs 5mg 10mg 34 MENACTRA INJ 57 menest tabs 03mg 0625mg 125mg 50 MENOSTAR PTWK 50 MENQUADFI INJ 57 MENTAX CREA 58 MENVEO SOLR 57 meperidine hcl soln 50mg5ml 25mgml
50mgml 100mgml 28 meperidine hcl tabs 50mg 100mg 28 meprobamate tabs 33 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 47 mesalamine cpdr 43 mesalamine enem 43 mesalamine er cp24 43 mesalamine supp 43 mesalamine tbec 12gm 800mg 43 mesalamine-cleanser kit 43 mesna soln 54 MESNEX TABS 54 MESTINON SOLN 20 metadate er tbcr 30
metaproterenol sulfate syrp 21 metaproterenol sulfate tabs 10mg 20mg 21 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 49 metformin hcl tabs 500mg 850mg 1000mg
49 methadone hcl conc 28 methadone hcl intensol conc 28 methadone hcl soln 5mg5ml 10mg5ml
10mgml 28 methadone hcl tabs 5mg 10mg 28 methamphetamine hcl tabs 30 methazolamide tabs 25mg 50mg 42 methenamine hippurate tabs 14 METHENAMINE MANDELATE TABS 14 methergine tabs 50 methimazole tabs 5mg 10mg 51 methitest tabs 45 methocarbamol soln 20 methocarbamol tabs 20 methotrexate sodium (pf) soln 17 methotrexate sodium soln 17 methotrexate sodium solr 17 methotrexate tabs 17 methoxsalen rapid caps 62 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 39 methyldopa tabs 250mg 500mg 25 methyldopa-hydrochlorothiazide tabs 25 methylergonovine maleate soln 50 methylergonovine maleate tabs 50 methylphenidate hcl chew 25mg 5mg
10mg 30 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 30 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 30 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 30
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 30
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 30
methylphenidate hcl soln 5mg5ml 10mg5ml 30
90 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
methylphenidate hcl tabs 5mg 10mg 20mg 30
methylprednisolone acetate susp 45 methylprednisolone sodium succ solr 45 methylprednisolone tabs 4mg 8mg 16mg
32mg 45 methylprednisolone tbpk 45 methyltestosterone caps 45 metoclopramide hcl soln 44 metoclopramide hcl tabs 5mg 10mg 44 metoclopramide hcl tbdp 5mg 10mg 44 metolazone tabs 25mg 5mg 10mg 39 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 24 metoprolol tartrate soct 24 metoprolol tartrate soln 24 metoprolol tartrate tabs 25mg 50mg
100mg 24 metoprolol tartrate tabs 375mg 75mg 24 metoprolol-hydrochlorothiazide tabs 24 metronidazole caps 11 metronidazole crea 58 metronidazole gel 58 metronidazole in nacl soln 11 metronidazole in nacl soln intravenous 11 metronidazole lotn 58 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
25 mibelas 24 fe chew 47 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 58 miconazole-zinc oxide-petrolat oint 58 micort-hc crea 60 microgestin 1530 tabs 47 microgestin 120 tabs 47 microgestin fe 1530 tabs 47 microgestin fe 120 tabs 47 midazolam hcl (pf) soln 33 midazolam hcl soln 33 midazolam hcl syrp 33 midodrine hcl tabs 25mg 5mg 10mg 21 miglitol tabs 25mg 50mg 100mg 49 miglustat caps 40 mili tabs 47 millipred dp tbpk 45 millipred tabs 45
milrinone lactate in dextrose soln 25 milrinone lactate soln 25 mimvey lo tabs 50 mimvey tabs 50 minitran pt24 01mghr 02mghr 04mghr
06mghr 26 minocycline hcl caps 50mg 75mg 100mg 9 minocycline hcl er tb24 45mg 55mg 65mg
80mg 90mg 105mg 115mg 135mg 9 minocycline hcl tabs 50mg 75mg 100mg 9 minoxidil tabs 25mg 10mg 25 MIRCERA SOSY 30mcg03ml
50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml 22
mirtazapine tabs 75mg 15mg 30mg 45mg 36
mirtazapine tbdp 15mg 30mg 45mg 36 misoprostol tabs 100mcg 200mcg 43 MITIGARE CAPS 52 mitigo soln 28 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 57 modafinil tabs 100mg 200mg 30 moexipril hcl tabs 75mg 15mg 26 molindone hcl tabs 5mg 10mg 25mg 36 mometasone furoate crea 60 mometasone furoate oint 60 mometasone furoate soln 60 mometasone furoate susp 41 mondoxyne nl caps 75mg 100mg 9 MONJUVI SOLR 17 MONONESSA TABS 47 montelukast sodium chew 4mg 5mg 55 montelukast sodium pack 55 montelukast sodium tabs 55 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 28 morphine sulfate (pf) soln 4mgml 10mgml
28 MORPHINE SULFATE (PF) SOLN
INTRAVENOUS 28 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 28 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 28
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 91
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 28
MORPHINE SULFATE SOLN 28 MORPHINE SULFATE SOLN 10mg5ml
20mg5ml 28 MORPHINE SULFATE SOLN INJECTION
2mgml 4mgml 10mgml 28 MORPHINE SULFATE SOLN
INTRAVENOUS 28 morphine sulfate tabs 15mg 30mg 28 MOVANTIK TABS 125mg 25mg 44 MOXEZA SOLN 41 moxifloxacin hcl (2x day) soln 41 moxifloxacin hcl in nacl soln intravenous 10 moxifloxacin hcl soln 41 moxifloxacin hcl tabs 10 MULPLETA TABS 22 MULTAQ TABS 25 MULTIVITAMINFLUORIDE CHEW 63 MULTI-VITAMINFLUORIDE SOLN 63 MULTI-VITAMINFLUORIDEIRON SOLN
63 mupirocin calcium crea 58 mupirocin oint 59 MUSTARGEN SOLR 17 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17 MVC-FLUORIDE CHEW 64 MYALEPT SOLR 54 MYCAPSSA CPDR 51 mycophenolate mofetil caps 53 mycophenolate mofetil hcl solr 53 mycophenolate mofetil susr 53 mycophenolate mofetil tabs 53 mycophenolate sodium tbec 180mg 360mg
53 MYDAYIS CP24 30 MYFEMBREE TABS 50 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 62 MYRBETRIQ TB24 25mg 50mg 63 MYTESI TBEC 43
N NABI-HB SOLN 57 nabumetone tabs 28 N-ACETYL-L-CYSTEINE CAPS 38 nadolol tabs 20mg 40mg 80mg 24 nadolol-bendroflumethiazide tabs 24
nafcillin sodium solr 10 nafcillin sodium solr injection 10 nafcillin sodium solr intravenous 10 NAFRINSE CHEW 54 NAFRINSE DROPS SOLN 54 naftifine hcl crea 59 naftifine hcl gel 59 NAFTIN GEL 59 NAGLAZYME SOLN 40 nalbuphine hcl soln 28 nalfon tabs 28 nalocet tabs 28 naloxone hcl soaj 34 naloxone hcl soct 34 naloxone hcl soln 34 naloxone hcl sosy 34 naltrexone hcl tabs 35 NAMENDA XR TITRATION PACK CP24 34 NAPRELAN TB24 28 naproxen sodium er tb24 28 naproxen sodium tabs 28 naproxen susp 28 naproxen tabs 28 naproxen tbec 28 naproxen-esomeprazole tbec 28 naratriptan hcl tabs 32 NARCAN LIQD 35 NATACYN SUSP 41 NATAZIA TABS 47 nateglinide tabs 60mg 120mg 49 NATPARA CART 25mcg 50mcg 75mcg
100mcg 50 NATROBA SUSP 59 NAYZILAM SOLN 31 NEBUPENT SOLR 11 necon 0535 (28) tabs 47 NECON 777 TABS 47 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 36 nembutal soln 33 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 41 neomycin-polymyxin b gu soln 59 neomycin-polymyxin-dexameth oint 41 neomycin-polymyxin-dexameth susp 41 neomycin-polymyxin-gramicidin soln 41 neomycin-polymyxin-hc soln 41 neomycin-polymyxin-hc susp 41 neo-polycin hc oint 41
92 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
neo-polycin oint 41 neo-synalar crea 60 NEPHRAMINE SOLN INTRAVENOUS 38 NERLYNX TABS 17 NEULASTA ONPRO PSKT 22 NEULASTA SOSY 22 NEUPOGEN SOLN 480mcg16ml
300mcgml 22 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 22 NEVANAC SUSP 41 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 40 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 23 niacor tabs 23 nicardipine hcl caps 20mg 30mg 24 nicardipine hcl soln 24 NICOTROL INHA 20 NICOTROL NS SOLN 20 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 47 nilutamide tabs 17 nimodipine caps 24 NINLARO CAPS 23mg 3mg 4mg 17 nisoldipine er tb24 85mg 17mg 20mg
255mg 30mg 34mg 40mg 24 nitazoxanide tabs 11 nitisinone caps 2mg 5mg 10mg 54 nitro-bid oint 26 NITRO-DUR PT24 03mghr 08mghr 26 NITROFURANTOIN MACROCRYSTAL
CAPS 14 NITROFURANTOIN MONOHYD MACRO
CAPS 14 nitrofurantoin susp 14 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 26 nitroglycerin soln 26 nitroglycerin subl 03mg 04mg 06mg 26 nitropress soln 25 nitroprusside sodium soln 25 NITYR TABS 2mg 5mg 10mg 54
NIVESTYM SOLN 480mcg16ml 300mcgml 22
NIVESTYM SOSY 300mcg05ml 480mcg08ml 22
nizatidine caps 150mg 300mg 43 nizatidine soln 43 NOCDURNA SUBL 277mcg 553mcg 50 NOCTIVA EMUL 083mcg01ml
166mcg01ml 50 nolix crea 60 nolix lotn 60 nora-be tabs 47 norco tabs 28 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 51
norepinephrine bitartrate soln 21 norethin ace-eth estrad-fe caps 47 norethin ace-eth estrad-fe chew 47 norethin ace-eth estrad-fe tabs 47 norethindrone acetate tabs 50 norethindrone acet-ethinyl est tabs 47 norethindrone tabs 47 norethindrone-eth estradiol tabs 50 norethin-eth estradiol-fe chew 47 norgesic forte tabs 28 norgestimate-eth estradiol tabs 47 norgestim-eth estrad triphasic tabs 47 norlyroc tabs 47 NORMOSOL-M IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R SOLN INTRAVENOUS 39 NORPACE CR CP12 100mg 150mg 25 nortrel 0535 (28) tabs 47 nortrel 135 (21) tabs 47 nortrel 135 (28) tabs 47 nortrel 777 tabs 47 nortriptyline hcl caps 10mg 25mg 50mg
75mg 36 nortriptyline hcl soln 36 NORVIR CAPS 12 NORVIR PACK 12 NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 34 NOVAREL SOLR 5000unit 10000unit 50 NOVOLIN 7030 SUSP 49
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 93
NOVOLOG 7030 FLEXPEN RELION SUPN 49
NOVOLOG FLEXPEN RELION SOPN 49 NOVOLOG FLEXPEN SOPN 49 NOVOLOG MIX 7030 FLEXPEN SUPN 49 NOVOLOG MIX 7030 RELION SUSP 49 NOVOLOG MIX 7030 SUSP 49 NOVOLOG PENFILL SOCT 49 NOVOLOG RELION SOLN 49 NOVOLOG SOLN 49 NOXAFIL SUSP 11 NOXAFIL TBEC 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 55 NUCALA SOLR 55 NUCALA SOSY 55 NUCYNTA ER TB12 200mg 250mg 29 NUCYNTA ER TB12 50mg 100mg 150mg
29 NUCYNTA TABS 29 NUCYNTA TABS 50mg 75mg 29 NUEDEXTA CAPS 34 NULIBRY SOLR 54 NULOJIX SOLR 53 NUPLAZID CAPS 36 NUPLAZID TABS 10mg 17mg 36 NURTEC TBDP 32 NUTRILIPID EMUL INTRAVENOUS 38 NUTROPIN AQ NUSPIN 10 SOPN 51 NUTROPIN AQ NUSPIN 20 SOPN 51 NUTROPIN AQ NUSPIN 5 SOPN 51 NUVARING RING 47 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 59 nylia 777 tabs 47 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 47 nystatin crea 59 nystatin oint 59 nystatin powd 59 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 60 nystatin-triamcinolone oint 60 nystop powd 59 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 44 ocella tabs 47 OCREVUS SOLN 34 OCTAGAM SOLN INTRAVENOUS
5gm100ml 1gm20ml 2gm20ml 25gm500ml 57
octreotide acetate soln 51 ODACTRA SUBL 54 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 56 ofloxacin soln 41 ofloxacin tabs 10 ogestrel tabs 47 OGIVRI SOLR 17 okebo caps 10 olanzapine solr 36 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 36 olanzapine tbdp 5mg 10mg 15mg 20mg
36 olanzapine-fluoxetine hcl caps 36 olmesartan medoxomil tabs 5mg 20mg
40mg 26 olmesartan medoxomil-hctz tabs 26 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 42 OLUMIANT TABS 1mg 2mg 53 OLYSIO CAPS 12 OMECLAMOX-PAK MISC 43 omega-3-acid ethyl esters caps 23 omeprazole cpdr 10mg 20mg 40mg 43 omeprazole-sodium bicarbonate caps 43 omeprazole-sodium bicarbonate pack 44 OMNARIS SUSP 41 OMNIPOD STARTER KIT 37 OMNITROPE SOCT 5mg15ml
10mg15ml 51 OMNITROPE SOLR 51 ondansetron hcl soln 43 ondansetron hcl tabs 4mg 8mg 24mg 43 ondansetron tbdp 4mg 8mg 43 ONIVYDE INJ 17 ONPATTRO SOLN 54 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 ONZETRA XSAIL EXHP 32
94 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml 17
OPIUM TINC 43 ORACEA CPDR 62 ORALAIR SUBL 54 oralone pste 60 ORAVIG TABS 59 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 53 ORENCIA SOLR 53 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 53 ORENITRAM TBCR 0125mg 56 ORENITRAM TBCR 025mg 1mg 25mg
5mg 56 ORFADIN CAPS 54 ORFADIN SUSP 54 ORGOVYX TABS 50 ORIAHNN CPPK 50 ORILISSA TABS 150mg 200mg 50 ORKAMBI PACK 56 ORKAMBI TABS 56 ORLADEYO CAPS 110mg 150mg 54 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 29 orphengesic forte tabs 29 orsythia tabs 47 ORTIKOS CP24 6mg 9mg 45 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 39 OSMOPREP TABS 44 OSPHENA TABS 50 OTEZLA TABS 53 OTEZLA TBPK 53 OTOVEL SOLN 41 OTREXUP SOAJ 53 ovide lotn 59 OXACILLIN SODIUM IN DEXTROSE SOLN
INTRAVENOUS 10 oxacillin sodium solr injection 1gm 2gm 10 oxacillin sodium solr intravenous 10 oxaliplatin soln 17 oxaliplatin solr 17 oxandrolone tabs 45 oxandrolone tabs 25mg 45 oxaprozin tabs 29
OXAYDO TABS 29 oxazepam caps 10mg 15mg 30mg 33 OXBRYTA TABS 21 oxcarbazepine susp 31 oxcarbazepine tabs 150mg 300mg 600mg
31 OXERVATE SOLN 42 oxiconazole nitrate crea 59 OXISTAT LOTN 59 OXLUMO SOLN 54 OXTELLAR XR TB24 150mg 300mg
600mg 31 oxybutynin chloride er tb24 5mg 10mg
15mg 63 oxybutynin chloride syrp 63 oxybutynin chloride tabs 63 oxycodone hcl caps 29 oxycodone hcl conc 29 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxycodone hcl soln 29 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 29 oxycodone-acetaminophen soln 29 oxycodone-acetaminophen tabs 29 oxycodone-acetaminophen tabs 5-300mg
10-300mg 29 oxycodone-aspirin tabs 29 oxycodone-ibuprofen tabs 29 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 29 oxymorphone hcl tabs 5mg 10mg 29 OXYTOCIN SOLN 50 OZEMPIC (025 OR 05 MGDOSE) SOPN
49 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 49
P pacerone tabs 100mg 200mg 400mg 25 paclitaxel conc 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
54 PALFORZIA (120 MG DAILY DOSE) CSPK
54
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 95
PALFORZIA (160 MG DAILY DOSE) CSPK 54
PALFORZIA (20 MG DAILY DOSE) CSPK 54
PALFORZIA (200 MG DAILY DOSE) CSPK 54
PALFORZIA (240 MG DAILY DOSE) CSPK 55
PALFORZIA (3 MG DAILY DOSE) CSPK 55 PALFORZIA (300 MG MAINTENANCE)
PACK 55 PALFORZIA (300 MG TITRATION) PACK
55 PALFORZIA (40 MG DAILY DOSE) CSPK
55 PALFORZIA (6 MG DAILY DOSE) CSPK 55 PALFORZIA (80 MG DAILY DOSE) CSPK
55 PALFORZIA INITIAL ESCALATION CSPK
55 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 36 palonosetron hcl soln 43 palonosetron hcl sosy 43 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 40 pamidronate disodium soln 52 pamidronate disodium solr 52 PANCREAZE CPEP 40 PANDEL CREA 61 panlor tabs 29 PANRETIN GEL 61 pantoprazole sodium pack 44 PANTOPRAZOLE SODIUM SOLR 44 pantoprazole sodium tbec 20mg 40mg 44 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 57
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 64 PARICALCITOL SOLN 64 paroex soln 41 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 36 paroxetine hcl tabs 10mg 20mg 36 paroxetine hcl tabs 30mg 40mg 36 paroxetine mesylate caps 36 paser pack 11
PAXIL SUSP 36 PEDIARIX SUSP 57 PEDVAX HIB SUSP 57 peg 3350electrolytes solr 44 peg 3350-kcl-na bicarb-nacl solr 44 peg-3350electrolytes solr 44 PEGANONE TABS 31 PEGASYS PROCLICK SOLN
135mcg05ml 180mcg05ml 13 PEGASYS SOLN 180mcg05ml
180mcgml 13 PEGINTRON KIT 13 PEG-INTRON REDIPEN KIT 12 PEG-PREP KIT 44 PEMAZYRE TABS 45mg 9mg 135mg 17 penicillamine caps 45 penicillamine tabs 45 PENICILLIN G POT IN DEXTROSE SOLN
INTRAVENOUS 10 penicillin g potassium solr injection 10 penicillin g procaine susp 10 penicillin g sodium solr injection 10 penicillin v potassium solr 10 penicillin v potassium tabs 10 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 43 pentazocine-naloxone hcl tabs 29 pentobarbital sodium soln 33 pentoxifylline er tbcr 22 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 44 percocet tabs 29 perindopril erbumine tabs 2mg 4mg 8mg
26 periogard soln 41 PERJETA SOLN 17 permethrin crea 59 perphenazine tabs 2mg 4mg 8mg 16mg
36 perphenazine-amitriptyline tabs 36 PERSERIS PRSY 90mg 120mg 36 PERTZYE CPEP 40 PEXEVA TABS 10mg 20mg 30mg 40mg
36 phenadoz supp 14 phenazo tabs 61 PHENAZOPYRIDINE HCL TABS 61 phenelzine sulfate tabs 36
96 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
phenergan soln 14 PHENOBARBITAL ELIX 33 PHENOBARBITAL SODIUM SOLN 33 PHENOBARBITAL TABS 33 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 21 PHENYLEPHRINE HCL SOLN 42 phenytek caps 200mg 300mg 31 phenytoin chew 31 phenytoin sodium extended caps 100mg
200mg 300mg 31 phenytoin sodium soln 31 phenytoin susp 31 PHESGO SOLN 17 PHOSLYRA SOLN 39 PHOSPHASAL TABS 14 PHOSPHOLINE IODIDE SOLR 42 phrenilin forte caps 29 PHYSIOLYTE SOLN 55 PHYSIOSOL IRRIGATION SOLN 55 PIFELTRO TABS 13 pilocarpine hcl soln 1 2 4 42 pilocarpine hcl tabs 5mg 75mg 20 pimecrolimus crea 62 pimozide tabs 1mg 2mg 36 pimtrea tabs 47 pindolol tabs 5mg 10mg 24 pioglitazone hcl tabs 15mg 30mg 45mg 49 pioglitazone hcl-glimepiride tabs 49 pioglitazone hcl-metformin hcl tabs 49 piperacillin sod-tazobactam so solr 10 piperacillin sod-tazobactam so solr
intravenous 10 PIQRAY (200 MG DAILY DOSE) TBPK 17 PIQRAY (250 MG DAILY DOSE) TBPK 17 PIQRAY (300 MG DAILY DOSE) TBPK 17 pirmella 135 tabs 47 PIROXICAM CAPS 10mg 20mg 29 PLASMA-LYTE 148 SOLN INTRAVENOUS
39 PLASMA-LYTE A SOLN INTRAVENOUS 39 PLEGRIDY SOPN 13 PLEGRIDY SOSY 13 34 PLEGRIDY STARTER PACK SOPN 13 PLEGRIDY STARTER PACK SOSY 13 plenamine soln intravenous 38 PLENVU SOLR 44 podofilox soln 62 POLIVY SOLR 30mg 140mg 17
polocaine soln 55 polocaine-mpf soln 55 polycin oint 41 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 41 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 34 PONVORY TABS 34 portia-28 tabs 47 PORTRAZZA SOLN 17 POSACONAZOLE SUSP 11 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 37 POTASSIUM ACETATE SOLN 39 potassium chloride crys er tbcr 10meq
20meq 40 potassium chloride er cpcr 8meq 10meq 40 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 40 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 40 potassium chloride in nacl soln intravenous
40 potassium chloride pack 40 potassium chloride soln 10 20 40 POTASSIUM CHLORIDE SOLN
INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml 40
potassium citrate er tbcr 15meq 540mg 1080mg 37
POTASSIUM PHOSPHATES SOLN 40 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 40 POTELIGEO SOLN 18 PR BENZOYL PEROXIDE WASH LIQD 59 PRADAXA CAPS 110mg 150mg 22 PRADAXA CAPS 75mg 22 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 33
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 33
PRAMOX GEL 61 prandin tabs 1mg 2mg 49 prasugrel hcl tabs 5mg 10mg 22 pravastatin sodium tabs 10mg 20mg
40mg 80mg 23 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 97
PRED MILD SUSP 41 PRED-G SOP OINT 41 PRED-G SUSP 41 prednicarbate crea 61 prednicarbate oint 61 prednisolone acetate susp 41 prednisolone sodium phosphate soln 41 45 prednisolone sodium phosphate soln
5mg5ml 10mg5ml 20mg5ml 25mg5ml 45
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 45
prednisolone soln 45 prednisone intensol conc 45 prednisone soln 45 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 45 prednisone tbpk 45 prefest tabs 50 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 31
pregabalin er tb24 825mg 165mg 330mg 29
pregabalin soln 31 PREGNYL SOLR 50 PREMARIN SOLR 50 PREMARIN TABS 03mg 045mg
0625mg 09mg 125mg 50 premasol soln intravenous 38 PREMPHASE TABS 50 PREMPRO TABS 50 PRENATAL TABS 64 PRETOMANID TABS 11 prevalite pack 23 prevalite powd 23 previfem tabs 47 PREVYMIS SOLN 240mg12ml
480mg24ml 13 PREVYMIS TABS 240mg 480mg 13 PREZCOBIX TABS 13 PREZISTA SUSP 13 PREZISTA TABS 75mg 150mg 600mg
800mg 13 PRIFTIN TABS 11 PRILOSEC PACK 25mg 10mg 44 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 31 primlev tabs 29
PRIVIGEN SOLN INTRAVENOUS 57 PROAIR RESPICLICK AEPB 21 probenecid tabs 40 procainamide hcl soln 25 PROCALAMINE SOLN INTRAVENOUS 38 procentra soln 30 prochlorperazine edisylate soln 36 prochlorperazine maleate tabs 36 prochlorperazine supp 36 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 40000unitml 22
proctofoam hc foam 61 procto-med hc crea 61 procto-pak crea 61 proctosol hc crea 61 proctozone-hc crea 61 PROCYSBI CPDR 25mg 75mg 55 PROCYSBI PACK 75mg 300mg 55 progesterone caps 100mg 200mg 51 progesterone oil 51 PROGLYCEM SUSP 49 PROGRAF PACK 53 PROGRAF PACK 02mg 53 PROGRAF SOLN 53 PROLASTIN-C SOLN INTRAVENOUS 56 PROLASTIN-C SOLR INTRAVENOUS 56 prolate soln 29 prolate tabs 29 PROLENSA SOLN 41 PROLEUKIN SOLR 18 PROLIA SOSY 52 PROMACTA PACK 125mg 25mg 22 PROMACTA TABS 125mg 25mg 50mg
75mg 22 promethazine hcl soln 14 promethazine hcl supp 14 promethazine hcl syrp 14 promethazine hcl tabs 14 promethazine-phenylephrine syrp 14 promethegan supp 14 propafenone hcl er cp12 225mg 325mg
425mg 25 propafenone hcl tabs 150mg 225mg
300mg 25 propantheline bromide tabs 19 proparacaine hcl soln 43 propranolol hcl er cp24 60mg 80mg
120mg 160mg 24
98 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
propranolol hcl soln 20mg5ml 40mg5ml 24 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 24 propranolol-hctz tabs 24 propylthiouracil tabs 51 PROQUAD SUSR 58 PROSOL SOLN INTRAVENOUS 38 PROTONIX PACK 44 protriptyline hcl tabs 5mg 10mg 36 psorcon crea 61 PULMICORT FLEXHALER AEPB 45 PULMOZYME SOLN 40 PURIXAN SUSP 18 PYLERA CAPS 44 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 20 pyridostigmine bromide soln 20 pyridostigmine bromide tabs 30mg 60mg 20 pyrimethamine tabs 11
Q QBRELIS SOLN 26 QDOLO SOLN 29 QINLOCK TABS 18 QUADRACEL SUSP 57 questran light powd 23 questran pack 23 questran powd 23 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 36 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 37 QUILLICHEW ER CHER 20mg 30mg
40mg 30 QUILLIVANT XR SRER 30 quinapril hcl tabs 5mg 10mg 20mg 40mg
26 quinapril-hydrochlorothiazide tabs 26 quinidine gluconate er tbcr 25 QUINIDINE GLUCONATE SOLN 25 quinidine sulfate tabs 200mg 300mg 25 quinine sulfate caps 12
R RABAVERT SUSR 58 rabeprazole sodium cpsp 44 rabeprazole sodium tbec 44 RADICAVA SOLN 34
raloxifene hcl tabs 50 ramelteon tabs 33 ramipril caps 125mg 25mg 5mg 10mg 26 ranolazine er tb12 500mg 1000mg 25 RAPIVAB SOLN 13 rasagiline mesylate tabs 05mg 1mg 33 RASUVO SOAJ 53 RAVICTI LIQD 38 RAYALDEE CPCR 64 RAYOS TBEC 1mg 2mg 5mg 45 REBETOL SOLN 13 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 34 REBIF REBIDOSE TITRATION PACK
SOAJ 34 REBIF SOSY 22mcg05ml 44mcg05ml 34 REBIF TITRATION PACK SOSY 34 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 47 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 58 RECTIV OINT 62 REGONOL SOLN 20 REGRANEX GEL 62 relafen ds tabs 29 RELENZA DISKHALER AEPB 13 relexxii tbcr 30 RELISTOR SOLN 8mg04ml 12mg06ml
44 RELISTOR TABS 44 reltone caps 200mg 400mg 44 REMICADE SOLR INTRAVENOUS 53 RENFLEXIS SOLR 53 repaglinide tabs 05mg 1mg 2mg 49 repaglinide-metformin hcl tabs 49 REPATHA PUSHTRONEX SYSTEM SOCT
23 REPATHA SOSY 23 REPATHA SURECLICK SOAJ 23 RESCRIPTOR TABS 100mg 200mg 13 RESTASIS EMUL 41 RETACRIT SOLN 20000unit2ml
2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml 22
RETEVMO CAPS 40mg 80mg 18 RETIN-A CREA 0025 005 01 61 RETIN-A GEL 001 0025 61
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 99
RETIN-A MICRO GEL 004 01 61 RETIN-A MICRO PUMP GEL 61 RETIN-A MICRO PUMP GEL 004 01
61 RETIN-A MICRO PUMP GEL 008 61 RETISERT IMPL 41 RETROVIR SOLN 13 REVCOVI SOLN 40 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 18 revonto solr 20 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 37 REYATAZ PACK 13 REZUROCK TABS 55 RHOPRESSA SOLN 42 RIABNI SOLN 100mg10ml 500mg50ml 18 ribasphere caps 13 ribasphere ribapak (1000 pack) tbpk 13 ribasphere ribapak (1200 pack) tbpk 13 ribasphere tabs 13 ribavirin caps 13 ribavirin solr 13 ribavirin tabs 13 RIDAURA CAPS 55 RIFABUTIN CAPS 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 RIFATER TABS 11 riluzole tabs 34 rimantadine hcl tabs 13 RIMSO-50 SOLN 55 RINGERS IRRIGATION SOLN 55 RINGERS SOLN 40 RINVOQ TB24 53 risedronate sodium tabs 5mg 30mg 35mg
150mg 52 RISEDRONATE SODIUM TBEC 52 RISPERDAL CONSTA SRER 125mg
25mg 37 RISPERDAL CONSTA SRER 375mg
50mg 37 risperidone soln 37 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 37 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 37
ritonavir tabs 13 RITUXAN HYCELA SOLN 18 RITUXAN SOLN 18 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 47 rizatriptan benzoate tabs 32 rizatriptan benzoate tbdp 32 ROMIDEPSIN SOLN 18 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 33 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 33 ropivacaine hcl soln 55 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 23 ROTARIX SUSR 58 ROTATEQ SOLN 58 roweepra tabs 500mg 750mg 1000mg 31 roweepra xr tb24 500mg 750mg 31 ROXYBOND TABA 5mg 15mg 30mg 29 ROZEREM TABS 33 ROZLYTREK CAPS 100mg 200mg 18 RUBRACA TABS 200mg 250mg 300mg 18 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 31 rufinamide tabs 200mg 400mg 31 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 18 RUZURGI TABS 55 RYBREVANT SOLN 18 ryclora soln 14 RYDAPT CAPS 18 RYLAZE SOLN 18 RYNODERM CREA 62 RYTARY CPCR 33 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 51 SAIZEN SOLR 5mg 88mg 51 SAIZENPREP SOLR 51 sajazir soln 21 SALEX SHAM 62 SALICYLIC ACID CREA 62 SALICYLIC ACID ER SOLN 62
100 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
SALICYLIC ACID FOAM 62 SALICYLIC ACID GEL 62 SALICYLIC ACID LIQD 62 SALICYLIC ACID SHAM 62 SALICYLIC ACID WART REMOVER LIQD
62 SALICYLIC ACID-CLEANSER KIT 62 SALIMEZ CREA 62 SALSALATE TABS 29 SAMSCA TABS 15mg 39 SANCUSO PTCH 43 SANDIMMUNE ORAL SOLN 100mgml 53 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 51 SANTYL OINT 62 SAPHNELO SOLN 53 SAPHRIS SUBL 25mg 5mg 10mg 37 sapropterin dihydrochloride pack 100mg
500mg 55 sapropterin dihydrochloride tabs 55 SARCLISA SOLN 500mg25ml 100mg5ml
18 SAVELLA TABS 125mg 25mg 50mg
100mg 34 SAVELLA TITRATION PACK MISC 34 scopolamine pt72 43 seconal caps 33 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 37 selegiline hcl caps 33 selegiline hcl tabs 33 selenium sulfide lotn 59 SELENIUM SULFIDE SHAM 59 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 150mg
300mg 13 SEMPREX-D CAPS 14 SENSIPAR TABS 30mg 60mg 90mg 50 SENSORCAINE SOLN 55 sensorcaineepinephrine soln 55 sensorcaine-mpf soln 55 sensorcaine-mpfepinephrine soln 55 SEREVENT DISKUS AEPB 21 SEROSTIM SOLR 4mg 5mg 6mg 51 sertraline hcl conc 37 sertraline hcl tabs 25mg 50mg 100mg 37 setlakin tabs 47 sevelamer carbonate pack 08gm 24gm 39 sevelamer carbonate tabs 39
sevelamer hcl tabs 400mg 800mg 39 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 47 SHINGRIX SUSR 58 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 51 SIGNIFOR SOLN 03mgml 06mgml
09mgml 51 SIKLOS TABS 18 sildenafil citrate soln 26 sildenafil citrate susr 26 sildenafil citrate tabs 26 SILENOR TABS 37 SILIQ SOSY 62 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 59 SIMBRINZA SUSP 42 SIMPONI ARIA SOLN 53 SIMPONI SOAJ 50mg05ml 100mgml 53 SIMPONI SOSY 50mg05ml 100mgml 53 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 23 sirolimus soln 53 sirolimus tabs 05mg 1mg 2mg 53 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKLICE LOTN 59 SKYRIZI (150 MG DOSE) PSKT 62 SKYRIZI PEN SOAJ 63 SKYRIZI SOSY 63 sod benz-sod phenylacet soln 38 SODIUM ACETATE SOLN 37 SODIUM BICARBONATE SOLN 37 SODIUM CHLORIDE (PF) SOLN 40 SODIUM CHLORIDE SOLN 40 55 SODIUM CHLORIDE SOLN INJECTION 40 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 55 SODIUM FLUORIDE SOLN 55 SODIUM FLUORIDE TABS 55 SODIUM LACTATE SOLN INTRAVENOUS
37 sodium phenylbutyrate powd 38 sodium phenylbutyrate tabs 38 SODIUM PHOSPHATES SOLN 40 sodium polystyrene sulfonate powd 39 sodium polystyrene sulfonate susp 39 SODIUM SULFACETAMIDE SHAM 59
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 101
SODIUM SULFACETAMIDE WASH LIQD 59
sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 63 SOLIQUA SOPN 49 SOLOSEC PACK 12 soloxide tbec 10 SOLTAMOX SOLN 18 SOLU-CORTEF SOLR 45 SOLU-MEDROL SOLR 45 SOMATULINE DEPOT SOLN 51 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 51 SORILUX FOAM 63 sorine tabs 80mg 120mg 160mg 240mg
24 sotalol hcl (af) tabs 80mg 120mg 160mg 24 sotalol hcl tabs 80mg 120mg 160mg
240mg 24 SOTYLIZE SOLN 24 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPINOSAD SUSP 59 SPIRIVA HANDIHALER CAPS 19 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 26 spironolactone-hctz tabs 26 SPRAVATO (56 MG DOSE) SOPK 37 SPRAVATO (84 MG DOSE) SOPK 37 sprintec 28 tabs 47 SPRITAM TB3D 250mg 500mg 750mg
1000mg 31 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 39 sronyx tabs 47 SSD CREA 59 SSS 10-5 CREA 63 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
63 STELARA SOSY 45mg05ml 90mgml 63 STERILE WATER FOR IRRIGATION SOLN
55 STIMATE SOLN 50 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18
STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml 40
streptomycin sulfate solr 10 STRIANT MISC 46 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 21 SUBLOCADE SOSY 100mg05ml
300mg15ml 29 SUBSYS LIQD 100mcg 200mcg 400mcg
600mcg 800mcg 1200mcg 1600mcg 29 subvenite starter kit-blue kit 31 subvenite starter kit-green kit 31 subvenite starter kit-orange kit 31 subvenite tabs 25mg 100mg 150mg
200mg 31 succinylcholine chloride soln 20 SUCRAID SOLN 40 sucralfate susp 44 sucralfate tabs 44 sulfacetamide sodium (acne) lotn 59 SULFACETAMIDE SODIUM GEL 59 SULFACETAMIDE SODIUM LIQD 59 sulfacetamide sodium oint 41 sulfacetamide sodium soln 41 SULFACETAMIDE SODIUM-SULFUR
CREA 63 SULFACETAMIDE SODIUM-SULFUR
EMUL 63 SULFACETAMIDE SODIUM-SULFUR
LIQD 63 SULFACETAMIDE SODIUM-SULFUR
LOTN 63 SULFACETAMIDE SODIUM-SULFUR
PADS 63 SULFACETAMIDE SODIUM-SULFUR
SUSP 63 sulfacetamide-prednisolone soln 41 SULFACLEANSE 84 SUSP 63 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 sulfamez wash emul 63 SULFAMYLON CREA 59 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 29 sumatriptan soln 32
102 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
sumatriptan succinate refill soct 32 sumatriptan succinate soaj 32 sumatriptan succinate soln 32 sumatriptan succinate sosy 32 sumatriptan succinate tabs 32 sunitinib malate caps 125mg 25mg
375mg 50mg 18 SUNOSI TABS 75mg 150mg 30 SUPRAX CAPS 10 suprax chew 10 suprax susr 100mg5ml 200mg5ml 10 SUPRAX SUSR 500 MG5ML 10 SUPREP BOWEL PREP KIT SOLN 44 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 47 SYLATRON KIT 18 SYLATRON KIT 600 MCG 18 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 56 SYMDEKO TBPK 56 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 49 SYMLINPEN 60 SOPN 49 SYMPAZAN FILM 10mg 20mg 32 SYMPAZAN FILM 5mg 31 SYMPROIC TABS 44 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 50 SYNDROS SOLN 43 SYNERCID SOLR 10 SYNJARDY TABS 49 SYNJARDY XR TB24 49 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 TACLONEX SUSP 61 tacrolimus caps 05mg 1mg 5mg 53 TACROLIMUS OINT 01 003 63 tadalafil (pah) tabs 20mg 26 tadalafil tabs 25mg 5mg 26 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 55 TALTZ SOAJ 63
TALTZ SOSY 63 TALZENNA CAPS 025mg 1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 51 taperdex 12-day tbpk 45 taperdex 6-day tbpk 45 taperdex 7-day tbpk 45 TARCEVA TABS 25mg 100mg 150mg 18 targadox tabs 10 TARGRETIN GEL 61 tarina 24 fe tabs 47 tarina fe 120 eq tabs 47 TASIGNA CAPS 50mg 150mg 200mg 18 tavaborole soln 59 TAVALISSE TABS 100mg 150mg 22 tazarotene crea 63 tazarotene foam 63 tazicef solr injection 1gm 2gm 6gm 10 TAZORAC CREA 63 TAZORAC GEL 005 01 63 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 57 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TECFIDERA CPDR 120mg 240mg 34 TECFIDERA MISC 34 TEFLARO SOLR INTRAVENOUS 400mg
600mg 10 TEGSEDI SOSY 55 TEKTURNA HCT TABS 26 telmisartan tabs 20mg 40mg 80mg 26 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 26 TEMAZEPAM CAPS 15mg 225mg 30mg
75mg 33 temsirolimus soln 18 tencon tabs 29 TENIPOSIDE SOLN 18 TENIVAC INJ 57 tenofovir disoproxil fumarate tabs 13 TEPADINA SOLR 18 TEPEZZA SOLR 42 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 21
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 103
terbutaline sulfate tabs 25mg 5mg 21 terconazole crea 59 terconazole supp 59 TERIPARATIDE (RECOMBINANT) SOPN
50 testosterone cypionate soln 100mgml
200mgml 46 testosterone enanthate soln 46 testosterone gel 1 162
2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact 46
testosterone soln 46 tetrabenazine tabs 125mg 25mg 34 TETRACAINE HCL SOLN 43 tetracycline hcl caps 250mg 500mg 10 texacort soln 61 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 63 theophylline er tb12 100mg 200mg
300mg 450mg 63 theophylline er tb24 400mg 600mg 63 theophylline soln 63 THIOLA EC TBEC 100mg 300mg 55 THIOLA TABS 55 thioridazine hcl tabs 10mg 25mg 50mg
100mg 37 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 37 THYROGEN SOLR 55 THYROLAR-1 TABS 51 THYROLAR-12 TABS 51 THYROLAR-14 TABS 51 THYROLAR-2 TABS 51 THYROLAR-3 TABS 51 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
32 TIBSOVO TABS 18 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 34 tilia fe tabs 47 timolol maleate pf soln 42 timolol maleate solg 025 05 42 timolol maleate soln 025 05 42 timolol maleate tabs 5mg 10mg 20mg 24 TIMOPTIC OCUDOSE SOLN 25 42
TIMOPTIC-XE SOLG 025 05 42 tinidazole tabs 12 tiopronin tabs 55 TIROSINT CAPS 13mcg 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
TIS-U-SOL SOLN 55 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 TIVORBEX CAPS 29 tizanidine hcl caps 20 21 tizanidine hcl tabs 20 TOBI PODHALER CAPS 56 TOBRADEX OINT 41 TOBRADEX ST SUSP 41 tobramycin nebu 300mg4ml 300mg5ml 56 tobramycin soln 41 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 42 TOBREX OINT 41 tofranil tabs 10mg 25mg 50mg 37 TOLAK CREA 63 tolazamide tabs 250mg 500mg 49 tolbutamide tabs 49 tolcapone tabs 33 tolmetin sodium caps 29 tolmetin sodium tabs 29 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 63 tolterodine tartrate tabs 63 TOLVAPTAN TABS 30mg 15mg 39 TOPEX TOPICAL ANESTHETIC AERO 61 topicort crea 005 025 61 topicort gel 61 topicort oint 61 topiramate cpsp 15mg 25mg 32 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 32 topiramate tabs 25mg 50mg 100mg
200mg 32 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
39 TOSYMRA SOLN 32
104 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
tovet foam 61 TPN ELECTROLYTES CONC
INTRAVENOUS 40 TRACLEER TABS 625mg 125mg 56 TRACLEER TBSO 56 TRADJENTA TABS 49 tramadol hcl er (biphasic) tb24 100mg
200mg 300mg 29 tramadol hcl er cp24 100mg 150mg
200mg 300mg 29 tramadol hcl er tb24 100mg 200mg 300mg
29 tramadol hcl tabs 50mg 100mg 29 tramadol-acetaminophen tabs 29 trandolapril tabs 1mg 2mg 4mg 26 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 22 tranexamic acid tabs 22 TRANSDERM SCOP (15 MG) PT72 43 tranylcypromine sulfate tabs 37 TRAVASOL SOLN INTRAVENOUS 38 TRAVATAN Z SOLN 42 travoprost (bak free) soln 42 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 37 trazodone hcl tabs 50mg 100mg 150mg 37 TRECATOR TABS 11 TRELEGY ELLIPTA AEPB 45 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 63 TREMFYA SOSY 63 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 56 tretinoin caps 18 tretinoin crea 0025 005 01 61 tretinoin gel 001 0025 005 61 tretinoin microsphere gel 004 01 61 tretinoin microsphere pump gel 004
01 62 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 29 triamcinolone acetonide aers 61 triamcinolone acetonide crea 0025
01 05 61 triamcinolone acetonide lotn 0025 01
61 triamcinolone acetonide oint 0025
005 01 05 61 triamcinolone acetonide pste 61
triamcinolone acetonide susp 45 triamterene caps 50mg 100mg 39 triamterene-hctz caps 39 triamterene-hctz tabs 39 trianex oint 61 triazolam tabs 0125mg 025mg 33 TRICITRATES SOLN 37 triderm crea 01 05 61 trientine hcl caps 45 tri-estarylla tabs 47 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 37 trifluridine soln 41 trihexyphenidyl hcl soln 33 trihexyphenidyl hcl tabs 2mg 5mg 33 TRIKAFTA TBPK 56 tri-legest fe tabs 47 tri-lo-estarylla tabs 47 tri-lo-sprintec tabs 47 trilyte solr 44 trimethobenzamide hcl caps 43 trimethoprim tabs 14 tri-mili tabs 47 trimipramine maleate caps 25mg 50mg
100mg 37 TRINESSA (28) TABS 47 TRINTELLIX TABS 5mg 10mg 20mg 37 tri-nymyo tabs 47 tri-previfem tabs 47 TRIPTODUR SRER 50 TRISENOX SOLN 18 TRISENOX SOLN 10mg10ml 18 tri-sprintec tabs 47 tritocin oint 61 TRIUMEQ TABS 13 TRI-VITAMINFLUORIDE SOLN 64 TRI-VITEFLUORIDE SOLN 64 trivora (28) tabs 47 tri-vylibra lo tabs 47 tri-vylibra tabs 47 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 32 TROPHAMINE SOLN INTRAVENOUS 38 trospium chloride er cp24 63 trospium chloride tabs 63 TRULANCE TABS 44 TRUMENBA SUSY 58
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 105
TRUSELTIQ (100MG DAILY DOSE) CPPK 18
TRUSELTIQ (125MG DAILY DOSE) CPPK 18
TRUSELTIQ (50MG DAILY DOSE) CPPK 18
TRUSELTIQ (75MG DAILY DOSE) CPPK 18
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 58 TYBOST TABS 13 tydemy tabs 47 TYKERB TABS 18 tylenol with codeine 3 tabs 29 tylenol with codeine 4 tabs 29 TYMLOS SOPN 50 TYPHIM VI SOLN 58 TYSABRI CONC INTRAVENOUS 34 TYVASO REFILL SOLN 56 TYVASO SOLN 56 TYVASO STARTER SOLN 56
U UBRELVY TABS 50mg 100mg 32 UCERIS FOAM 61 UDENYCA SOSY 22 UKONIQ TABS 18 ULORIC TABS 40mg 80mg 52 ULTOMIRIS SOLN 55 ULTRAVATE LOTN 61 UMECTA MOUSSE FOAM 63 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 52
UNITUXIN SOLN 18 UPLIZNA SOLN 53 UPTRAVI SOLR 56 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 56
UPTRAVI TBPK 57 UREA CREA 39 63 UREA LOTN 40 63 UREA-C40 LOTN 63 urecholine tabs 5mg 10mg 25mg 50mg 20
uredeb crea 63 URETRON DS TABS 14 URIN DS TABS 14 URSODIOL CAPS 200mg 400mg 44 ursodiol caps 300mg 44 ursodiol tabs 250mg 500mg 44 URYL TABS 14 USTELL CAPS 14 UTICAP CAPS 14 UTIRA-C TABS 14 UTRONA-C TABS 14
V VABOMERE SOLR INTRAVENOUS 10 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 63 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 32 valproic acid caps 32 valproic acid soln 32 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
26 valsartan-hydrochlorothiazide tabs 26 VALTOCO 10 MG DOSE LIQD 32 VALTOCO 15 MG DOSE LQPK 32 VALTOCO 20 MG DOSE LQPK 32 VALTOCO 5 MG DOSE LIQD 32 vanadom tabs 20 vanatol lq soln 29 vancomycin hcl caps 10 vancomycin hcl solr 10 VANCOMYCIN HCL SOLR 250 MG 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 VANDAZOLE GEL 59 VANOXIDE-HC LOTN 61 VANTAS KIT 19 VAQTA SUSP 58 VARIVAX INJ 58 VARIZIG SOLN 57 VARUBI (180 MG DOSE) TBPK 43 VASCEPA CAPS 05gm 1gm 23 VAXCHORA SUSR 58 vecamyl tabs 25 VECTICAL OINT 63 VELCADE SOLR 19 velivet tabs 47
106 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
VELPHORO CHEW 39 VELTASSA PACK 84gm 168gm 252gm
39 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 19 VENCLEXTA TABS 10mg 19 VENCLEXTA TABS 50mg 100mg 19 venlafaxine hcl er cp24 375mg 75mg
150mg 37 venlafaxine hcl er tb24 375mg 75mg
150mg 225mg 37 venlafaxine hcl tabs 25mg 375mg 50mg
75mg 100mg 37 VENTAVIS SOLN 10mcgml 20mcgml 57 VENTOLIN HFA AERS 21 VERAPAMIL HCL ER CP24 100mg
120mg 180mg 200mg 240mg 300mg 360mg 25
verapamil hcl er tbcr 120mg 180mg 240mg 25
verapamil hcl soln 25 verapamil hcl tabs 25 verapamil hcl tabs 80mg 120mg 25 VEREGEN OINT 63 VERELAN CP24 25 veripred 20 soln 45 VERSACLOZ SUSP 37 VERZENIO TABS 50mg 100mg 150mg
200mg 19 vestura tabs 47 VIBERZI TABS 75mg 100mg 44 VIBRAMYCIN SYRP 10 vicodin es tabs 29 vicodin hp tabs 29 vicodin tabs 29 VICTOZA SOPN 49 VIDEX EC CPDR 125mg 200mg 400mg 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 47 vigabatrin pack 32 vigabatrin tabs 32 vigadrone pack 32 VIIBRYD STARTER PACK KIT 37 VIIBRYD TABS 10mg 20mg 40mg 37 VILTEPSO SOLN 55 VIMIZIM SOLN 40 VIMPAT SOLN 32
VIMPAT TABS 32 vinblastine sulfate soln 19 vincasar pfs soln 19 vincristine sulfate soln 19 vinorelbine tartrate soln 19 VIOKACE TABS 40 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 52 VITAMINS ACD-FLUORIDE SOLN 64 VITRAKVI CAPS 25mg 100mg 19 VITRAKVI SOLN 19 VIVITROL SUSR 35 VIZIMPRO TABS 15mg 30mg 45mg 19 VOCABRIA TABS 13 VORAXAZE SOLR 52 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 19 VP-PNV-DHA CAPS 64 VPRIV SOLR 40 VRAYLAR CAPS 15mg 3mg 45mg 6mg
37 VRAYLAR CPPK 37 VUMERITY (STARTER) CPDR 55 VUMERITY CPDR 55 vyfemla tabs 47 vylibra tabs 47 VYNDAMAX CAPS 25 VYNDAQEL CAPS 25 VYONDYS 53 SOLN 55 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 30 VYVANSE CHEW 10mg 20mg 30mg
40mg 50mg 60mg 30 VYXEOS SUSR 19 VYZULTA SOLN 42
W WAKIX TABS 445mg 178mg 30 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 22 WATER FOR IRRIGATION STERILE
SOLN 55 wixela inhub aepb 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 107
wymzya fe chew 48 WYNZORA CREA 63
X XALKORI CAPS 200mg 250mg 19 XARELTO STARTER PACK TBPK 22 XARELTO TABS 25mg 10mg 15mg
20mg 22 XATMEP SOLN 19 XCOPRI (250 MG DAILY DOSE) TBPK 32 XCOPRI (350 MG DAILY DOSE) TBPK 32 XCOPRI TABS 200 MG 32 XCOPRI TABS 50mg 100mg 150mg 32 XCOPRI TBPK 32 XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
32 XELJANZ SOLN 53 XELJANZ TABS 5mg 10mg 53 XELJANZ XR TB24 11mg 22mg 53 XELPROS EMUL 42 XEMBIFY SOLN SUBCUTANEOUS
2gm10ml 4gm20ml 10gm50ml 1gm5ml 57
XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 55 XEOMIN SOLR 50unit 100unit 55 XEPI CREA 59 XERESE CREA 59 XERMELO TABS 43 XGEVA SOLN 52 XHANCE EXHU 42 XIFAXAN TABS 200mg 550mg 10 XIIDRA SOLN 42 XIMINO CP24 45mg 90mg 135mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 56 XOLAIR SOSY 75mg05ml 150mgml 56 XOSPATA TABS 19 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 19 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (40 MG TWICE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (60 MG ONCE WEEKLY) TBPK
20mg 60mg 19
XPOVIO (60 MG TWICE WEEKLY) TBPK 19
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg 19
XPOVIO (80 MG TWICE WEEKLY) TBPK 19
XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg 29
XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 48 XUREA CREA 63 XURIDEN PACK 55 xylocaine dental soln 55 XYOSTED SOAJ 50mg05ml 75mg05ml
100mg05ml 46 XYREM SOLN 34 XYWAV SOLN 34
Y YERVOY SOLN 19 YF-VAX INJ 58 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 42 yuvafem tabs 50
Z zafemy ptwk 48 zafirlukast tabs 10mg 20mg 55 zaleplon caps 5mg 10mg 33 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 48 zarontin soln 32 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 29 ZEJULA CAPS 19 ZELAPAR TBDP 33 ZELBORAF TABS 19 ZEMAIRA SOLR INTRAVENOUS 56 ZEMBRACE SYMTOUCH SOAJ 32 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
63 ZENPEP CPEP 40
108 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg 30
ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
34 ZEPOSIA CAPS 34 ZEPOSIA STARTER KIT CPPK 34 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERIT CAPS 15mg 20mg 30mg 40mg 13 ZERUVIA PTCH 61 ZETONNA AERS 42 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 55 ZINBRYTA SOSY 34 ZIONODIL 100 LOTN 61 ZIONODIL LOTN 61 ZIOPTAN SOLN 42 ziprasidone hcl caps 20mg 40mg 60mg
80mg 37 ziprasidone mesylate solr 37 ZIPSOR CAPS 29 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZIRGAN GEL 41 ZITHROMAX PACK 10 ZOKINVY CAPS 50mg 75mg 55 zoledronic acid conc 52 zoledronic acid soln 52
ZOLINZA CAPS 19 zolmitriptan soln 32 zolmitriptan tabs 32 zolmitriptan tbdp 32 zolpidem tartrate er tbcr 625mg 125mg 33 zolpidem tartrate subl 175mg 35mg 33 zolpidem tartrate tabs 5mg 10mg 33 ZOMACTON SOLR 51 ZOMACTON SOLR 5mg 51 ZOMIG SOLN 32 zonisamide caps 25mg 50mg 100mg 32 ZONTIVITY TABS 22 ZORBTIVE SOLR 51 ZORTRESS TABS 025mg 53 ZORTRESS TABS 05mg 075mg 1mg 53 ZORVOLEX CAPS 29 ZOSTAVAX SUSR 58 ZOSYN SOLN INTRAVENOUS 10 zovia 135e (28) tabs 48 ZUBSOLV SUBL 35 ZUPLENZ FILM 4mg 8mg 43 ZYCLARA PUMP CREA 63 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19 ZYKADIA TABS 19 ZYLET SUSP 42 ZYNLONTA SOLR 19 ZYPITAMAG TABS 1mg 2mg 4mg 23 ZYPREXA RELPREVV SUSR 37 ZYTIGA TABS 19 ZYVOX SOLN INTRAVENOUS 10
Nondiscrimination Notice
Kaiser Permanente does not discriminate on the basis of age race ethnicity color national origin
cultural background ancestry religion sex gender identity gender expression sexual orientation
marital status physical or mental disability source of payment genetic information citizenship
primary language or immigration status
Language assistance services are available from our Member Service Contact Center 24 hours a day
7 days a week (except closed holidays) Interpreter services including sign language are available at
no cost to you during all hours of operation Auxiliary aids and services for individuals with
disabilities are available at no cost to you during all hours of operation We can also provide you your
family and friends with any special assistance needed to access our facilities and services You may
request materials translated in your language at no cost to you You may also request these materials in
large text or in other formats to accommodate your needs at no cost to you For more information call
1-800-464-4000 (TTY 711)
A grievance is any expression of dissatisfaction expressed by you or your authorized representative
through the grievance process For example if you believe that we have discriminated against you you
can file a grievance Please refer to your Evidence of Coverage or Certificate of Insurance or speak
with a Member Services representative for the dispute-resolution options that apply to you
You may submit a grievance in the following ways
bull By phone Call member services at 1-800-464-4000 (TTY 711) 24 hours a day
7 days a week (except closed holidays)
bull By mail Call us at 1-800-464-4000 (TTY 711) and ask to have a form sent to you
bull In person Fill out a Complaint or Benefit ClaimRequest form at a member services office
located at a Plan Facility (go to your provider directory at kporgfacilities for addresses)
bull Online Use the online form on our website at kporg
Please call our Member Service Contact Center if you need help submitting a grievance
The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to
discrimination on the basis of race color national origin sex age or disability You may also
contact the Kaiser Permanente Civil Rights Coordinator directly at
Northern California
Civil RightsADA Coordinator
1800 Harrison St
16th Floor
Oakland CA 94612
Southern California
Civil RightsADA Coordinator
SCAL Compliance and Privacy
393 East Walnut St
Pasadena CA 91188
You can also file a civil rights complaint with the US Department of Health and Human Services
Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available
at ocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human
Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201
1-800-368-1019 1-800-537-7697 (TTY) Complaint forms are available at
hhsgovocrofficefileindexhtml
Language Assistance Services
English Language assistance
is available at no cost to you
24 hours a day 7 days a week
You can request interpreter
services materials translated
into your language or in
alternative formats Just call us
at 1-800-464-4000 24 hours a
day 7 days a week (closed
holidays) TTY users call 711
Arabic مجانا على مدار الساعة كافة متوفرة لك خدمات الترجمة الفورية
أيام الأسبوع بإمكانك طلب خدمة الترجمة الفورية أو ترجمة وثائق للغتك أو
4000-464-800-1 لصيغ أخرى ما عليك سوى الاتصال بنا على الرقم
لمستخدمي خدمة على مدار الساعة كافة أيام الأسبوع )مغلق أيام العطلات(
(711الرقم ) الهاتف النصي يرجي الاتصال على
Armenian Ձեզ կարող է անվճար օգնություն
տրամադրվել լեզվի հարցում` օրը 24 ժամ շաբաթը
7 օր Դուք կարող եք պահանջել բանավոր
թարգմանչի ծառայություններ Ձեր լեզվով
թարգմանված կամ այլընտրանքային ձևաչափով
պատրաստված նյութեր Պարզապես զանգահարեք
մեզ` 1-800-464-4000 հեռախոսահամարով` օրը
24 ժամ` շաբաթը 7 օր (տոն օրերին փակ է) TTY-ից
օգտվողները պետք է զանգահարեն 711
Chinese 您每週 7天每天 24小時均可獲得免費語
言協助您可以申請口譯服務要求將資料翻譯成
您所用語言或轉換為其他格式我們每週 7天
每天 24小時均歡迎您打電話 1-800-757-7585 前來聯
絡(節假日 休息)聽障及語障專線 (TTY) 使用者
請撥 711
Farsi بدون روز هفته 7ساعت شبانروز و 24در زبانی خدمات
مترجم خدمات شما می توانید برای استهزینه در اختیار شما اخذ
صورتهای دیگر به زبان شما و یا به جزوات ترجمهشفاهی
روز هفته 7ساعت شبانروز و 24 کافیست در درخواست کنید
4000-464-800-1)به استثنای روزهای تعطیل( با ما به شماره
تماس بگیرند 711با شماره TTYتماس بگیرید کاربران
Hindi बिना किसी लागत ि दभाबिया सवाए कदन ि 24 घट
सपताह ि सातो कदन उपलबध ह आप एि दभाबिय िी सवाओ
ि बलए बिना किसी लागत ि सामबियो िो अपनी भािा म
अनवाद िरवान ि बलए या विबपपि परारपो ि बलए अनरोध
िर सित ह िस िवल हम 1-800-464-4000 पर कदन ि 24
घट सपताह ि सातो कदन (छटटियो वाल कदन िद रहता ह) िॉल
िर TTY उपयोगिताा 711 पर िॉल िर
Hmong Muajkwc pab txhais lus pub dawb rau koj
24 teev ib hnub twg 7 hnub ib lim tiam twg Koj thov
tau cov kev pab txhais lus muab cov ntaub ntawv
txhais ua koj hom lus los yog ua lwm homTsuas hu
rau 1-800-464-4000 24 teev ib hnub twg 7 hnub ib
lim tiam twg (cov hnub caiv kaw) Cov neeg siv
TTY hu 711
Japanese 当院では言語支援を無料で年中無休
終日ご利用いただけます通訳サービス日本語
に翻訳された資料あるいは資料を別の書式でも
依頼できますお気軽に 1-800-464-4000 までお電話
ください (祭日を除き年中無休)TTYユーザー
は 711にお電話ください
Khmer ជនយភាសា គមានឥតអសថលៃដលអនកឡ ើយ 24
ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ អនកអាចឡសនើស ឡសវាអនកបកបរប សភារៈបដលបានបកបរបឡៅជាភាសាបមែរ ឬជាទរងផោសងឡទៀត រានបតទរសពទមកឡយើង តាមឡលម 1-800-464-4000 បាន 24 ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ (បទថលៃប ណោយ) អនកឡរបើ TTY ឡៅឡលម 711
Korean 요일 및 시간에 관계없이 언어 지원
서비스를 무료로 이용하실 수 있습니다 귀하는
통역 서비스 귀하의 언어로 번역된 자료 또는 대체
형식의 자료를 요청할 수 있습니다 요일 및 시간에
관계없이 1-800-464-4000번으로 전화하십시오
(공휴일 휴무) TTY 사용자 번호 711
Laotian ການຊວຍເຫ ອດານພາສາມໃຫໂດຍບ ເສຽຄາ
ແກທານ ຕະຫ ອດ 24 ຊ ວໂມງ 7 ວນຕ ອາທດ ທານ
ສາມາດຮອງຂ ຮບບ ລການນາຍພາສາ ໃຫແປເອກະ
ສານເປນພາສາຂອງທານ ຫ ໃນຮບແບບອ ນ ພຽງ
ແຕໂທຣຫາພວກເຮ າທ 1-800-464-4000 ຕະຫ ອດ 24
ຊ ວໂມງ 7 ວນຕ ອາທດ (ປດວນພກຕາງໆ) ຜໃຊສາຍ
TTY ໂທຣ 711
Navajo Saad bee aacutekaacutersquoarsquoayeed naacutehoacuteloacute trsquoaacuteaacute jiikrsquoeacute
naadiin doo bibąąrsquo diacuteiacutersquo aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute
damoo naacuteaacutedleehjiacute Atah halnersquoeacute aacutekaacutersquoadoolwołiacutegiacuteiacute joacutekiacute
trsquoaacuteadoo lersquoeacute trsquoaacuteaacute hoacutehazaadjiacute hadilyąąrsquogo eacuteiacute doodaiirsquo
naacuteaacutenaacute laacute ałrsquoąą aacutedaatrsquoehiacutegiacuteiacute bee haacutedadilyaarsquogo Kojiacute
hodiilnih 1-800-464-4000 naadiin doo bibąąrsquo diacuteiacutersquo
aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute damoo naacutersquoaacutedleehjiacute
(Dahodiyin biniiyeacute ersquoersquoaahgo eacuteiacute darsquodeelkaal)
TTY chodeeyooliacuteniacutegiacuteiacute kojiacute hodiilnih 711
Punjabi ਬਿਨ ਾ ਬਿਸੀ ਲ ਗਤ ਦ ਬਦਨ ਦ 24 ਘਟ ਹਫਤ ਦ 7 ਬਦਨ
ਦਭ ਸੀਆ ਸਵ ਵ ਾ ਤਹ ਡ ਲਈ ਉਪਲਿਧ ਹ ਤਸੀ ਇਿ ਦਭ ਸੀਏ ਦੀ
ਮਦਦ ਲਈ ਸਮਗਰੀਆਾ ਨ ਆਪਣੀ ਭ ਸ ਬਵਚ ਅਨਵ ਦ ਿਰਵ ਉਣ
ਲਈ ਜ ਾ ਬਿਸ ਵਖ ਫ ਰਮਟ ਬਵਚ ਪਰ ਪਤ ਿਰਨ ਲਈ ਿਨਤੀ ਿਰ ਸਿਦ
ਹ ਿਸ ਬਸਰਫ਼ ਸ ਨ 1-800-464-4000 ਤ ਬਦਨ ਦ 24 ਘਟ ਹਫ਼ਤ
ਦ 7 ਬਦਨ (ਛਟੀਆਾ ਵ ਲ ਬਦਨ ਿਦ ਰਬਹਦ ਹ) ਫ਼ਨ ਿਰ TTY ਦ
ਉਪਯਗ ਿਰਨ ਵ ਲ 711 lsquoਤ ਫ਼ਨ ਿਰਨ
Russian Мы бесплатно обеспечиваем Вас услугами
перевода 24 часа в сутки 7 дней в неделю Вы можете
воспользоваться помощью устного переводчика
запросить перевод материалов на свой язык или
запросить их в одном из альтернативных форматов
Просто позвоните нам по телефону 1-800-464-4000
который доступен 24 часа в сутки 7 дней в неделю
(кроме праздничных дней) Пользователи линии TTY
могут звонить по номеру 711
Spanish Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al diacutea 7 diacuteas a la semana
Puede solicitar los servicios de un inteacuterprete que los
materiales se traduzcan a su idioma o en formatos
alternativos Solo llame al 1-800-788-0616 24 horas al
diacutea 7 diacuteas a la semana (cerrado los diacuteas festivos) Los
usuarios de TTY deben llamar al 711
Tagalog May magagamit na tulong sa wika nang wala
kang babayaran 24 na oras bawat araw 7 araw bawat
linggo Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format Tawagan lamang
kami sa 1-800-464-4000 24 na oras bawat araw 7 araw
bawat linggo (sarado sa mga pista opisyal) Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711
Thai เรามบรการลามฟรส าหรบคณตลอด 24 ชวโมง
ทกวนตลอดชวโมงท าการของเราคณสามารถขอใหลาม
ชวยตอบค าถามของคณทเกยวกบความคมครองการดแล
สขภาพของเราและคณยงสามารถขอใหมการแปลเอกสา
รเปนภาษาทคณใชไดโดยไมมการคดคาบรการเพยงโทร
หาเราทหมายเลข 1-800-464-4000 ตลอด 24
ชวโมงทกวน (ปดใหบรการในวนหยดราชการ) ผใช TTY
โปรดโทรไปท 711
Vietnamese Dịch vụ thocircng dịch được cung cấp miễn
phiacute cho quyacute vị 24 giờ mỗi ngagravey 7 ngagravey trong tuần Quyacute
vị coacute thể yecircu cầu dịch vụ thocircng dịch tagravei liệu phiecircn dịch
ra ngocircn ngữ của quyacute vị hoặc tagravei liệu bằng nhiều higravenh
thức khaacutec Quyacute vị chỉ cần gọi cho chuacuteng tocirci tại số
1-800-464-4000 24 giờ mỗi ngagravey 7 ngagravey trong tuần
(trừ caacutec ngagravey lễ) Người dugraveng TTY xin gọi 711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
Provide no cost aids and services to people with disabilities to communicate effectively with us such as
diams Qualified sign language interpreters
diams Written information in other formats such as large print audio and accessible electronic formats
Provide no cost language services to people whose primary language is not English such as
diams Qualified interpreters
diams Information written in other languages
If you need these services call Member Services at 1-800-476-2167 (TTY 711)8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana Aurora CO 80014 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
61102709_CO
Multi-language Interpreter Services
English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-476-2167 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-476-2167 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-476-2167 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-476-2167 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-476-2167 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-476-2167 (TTY 711)번으로 전화해 주십시오
Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-800-476-2167 (телетайп 711)
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-476-2167(TTY711)までお電話にてご連絡ください
Amharic ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው 711)
German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-800-476-2167 (TTY 711)
French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-800-476-2167 (ATS 711)
Farsi
ی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ دیریبگ تماس (TTY 711) 2167-476-800-1 با باشد
Arabic
ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم )117- (رقم ھاتف الصم والبكم 7612-674-008-1
Yoruba AKIYESI Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o E pe ero ibanisoro yi 1-800-476-2167 (TTY 711)
Cushite-Oromo XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 1-800-476-2167 (TTY 711)
Nepali
धयान िदनहोस तपाइल नपाली बोलनहनछ भन तपाइको िनिमत भाषा सहायता सवाह िनःशलक पमा उपलबध छ फोन गनरहोस 1-800-476-2167 (िटिटवाइ 711)
KAH2711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
bull Provide no cost aids and services to people with disabilities to communicateeffectively with us such asdiams Qualified sign language interpretersdiams Written information in other formats such as large print audio and accessible
electronic formatsbull Provide no cost language services to people whose primary language is not English
such asdiams Qualified interpretersdiams Information written in other languages
If you need these services call Member Services at 1-800-805-2739 (TTY 711) 8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd Honolulu HI 96813 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Kaiser Permanente is an HMO plan with a Medicare contract Enrollment in Kaiser Permanente depends on contract renewal
H1230_2017MLI accepted
Multi-language Interpreter Services English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-805-2739 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-805-2739 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-805-2739 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-805-2739 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-805-2739 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-805-2739 (TTY 711)번으로 전화해 주십시오
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-805-2739(TTY711)までお電話にてご連絡ください
Lao
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 1-800-805-2739 (TTY 711)
Ilocano PAKDAAR Nu saritaem ti Ilocano ti serbisyo para ti baddang ti lengguahe nga awanan bayadna ket sidadaan para kenyam Awagan ti 1-800-805-2739 (TTY 711)
Samoan MO LOU SILAFIA Afai e te tautala Gagana faa Sāmoa o loo iai auaunaga fesoasoan e fai fua e leai se totogi mo oe Telefoni mai 1-800-805-2739 (TTY 711)
Marshallese LALE Ntildee kwōj kōnono Kajin Ṃajōḷ kwomarontilde bōk jerbal in jipantilde ilo kajin ṇe aṃ ejjeḷọk wōṇāān Kaalọk 1-800-805-2739 (TTY 711)
Trukese MEI AUCHEA Ika iei foosun fonuomw Foosun Chuuk iwe en mei tongeni omw kopwe angei aninisin chiakku ese kamo Kori 1-800-805-2739 (TTY 711)
Hawaiian E NĀNĀ MAI Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo loaʻa ke kōkua manuahi iā ʻoe E kelepona iā 1-800-805-2739 (TTY 711)
Pohnpeian Ni songen mwohmw ohte komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei Call 1-800-805-2739 (TTY 711)
Bisayan ATENSYON Kung nagsulti ka og Cebuano aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe nga walay bayad Tawag sa 1-800-805-2739 (TTY 711)
Tongan FAKATOKANGArsquoI Kapau lsquooku ke Lea-Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai atu ha tokoni tarsquoetotongi pea teke lava lsquoo marsquou ia Telefoni mai 1-800-805-2739 (TTY 711)
485236276 102021
This formulary was updated on 100121 For more recent information or other questions please contact the number for your Kaiser Permanente Region listed below seven days a week 8 am to 8 pm or visit kporgseniorrx
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Foundation Health Plan Inc 393 E Walnut St Pasadena CA 91188-8514 Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E Dakota Ave Denver CO 80247 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Foundation Health Plan Inc 711 Kapiolani Blvd Honolulu HI 96813 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
kporgseniorrx Please recycle
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 5
level of care change When your level of care changes you may require an additional fill of your medication We will generally cover up to a one-month supply of your Part D drugs during this level of care transition period even if the drug is not on our Drug List
For more information
For more detailed information about your Kaiser Permanente prescription drug coverage please review your Evidence of Coverage and other plan materials If you have questions about our plan please call us Contact information for your Kaiser Permanente Region along with the date we last updated the formulary appears on the front and back cover pages If you have general questions about Medicare prescription drug coverage please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day7 days a week TTY users should call 1-877-486-2048 Or visit httpwwwmedicaregov
6 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Kaiser Permanentersquos Formulary
The formulary below provides coverage information about the drugs covered by our plan If you have trouble finding your drug in the list turn to the index that begins on page 66 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg NEBUPENT) and generic drugs are listed in lower-case italics (eg ltamoxicillingt) The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number below Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy Northern CA ndash 1-888-218-6245 Monday through Friday 8 am to 8 pm Saturday 8 am to 6 pm and Sunday 9 am to 6 pm Southern CA ndash 1-866-206-2983 Monday through Friday 7 am to 7 pm Saturday 10 am to 2 pm
Colorado
Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday 8 am to 6 pm
Hawaii
Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday 800 am to 5 pm
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 7
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
8 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole tabs NDS emverm chew ivermectin tabs praziquantel tabs MO ANTIBACTERIALS amikacin sulfate soln amikacin sulfate soln injection HI amoxicillin caps amoxicillin chew amoxicillin susr amoxicillin tabs amoxicillin-pot clavulanate chew amoxicillin-pot clavulanate er tb12
amoxicillin-pot clavulanate susr amoxicillin-pot clavulanate tabs ampicillin caps ampicillin sodium solr ampicillin sodium solr injection 1gm 125mg HI
ampicillin sodium solr intravenous HI
ampicillin-sulbactam sodium solr ampicillin-sulbactam sodium solr injection HI
ampicillin-sulbactam sodium solr intravenous HI
ARIKAYCE SUSP PALDNDS AUGMENTIN SUSR AVYCAZ SOLR INTRAVENOUS HI AZITHROMYCIN PACK MO azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BAXDELA SOLR INTRAVENOUS HI
BAXDELA TABS MO
Drug Name RequirementsLimits
BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP cefaclor caps cefaclor er tb12 cefaclor susr cefadroxil caps cefadroxil susr cefadroxil tabs cefazolin sodium solr cefazolin sodium solr injection 1gm 10gm 500mg HI
cefdinir caps cefdinir susr cefepime hcl solr injection 1gm 2gm HI
cefixime caps cefixime susr cefotaxime sodium solr cefotetan disodium solr injection 1gm 2gm HI
cefoxitin sodium solr injection HI cefoxitin sodium solr intravenous 1gm 2gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 2gm 6gm HI
CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 75gm 750mg HI
cefuroxime sodium solr intravenous HI
cephalexin caps cephalexin susr cephalexin tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w soln ciprofloxacin in d5w soln intravenous HI
ciprofloxacin susr ciprofloxacin-ciproflox hcl er tb24 clarithromycin er tb24 clarithromycin susr clarithromycin tabs cleocin phosphate soln cleocin solr clindamycin hcl caps clindamycin palmitate hcl solr clindamycin phosphate in d5w soln intravenous HI
clindamycin phosphate soln clindamycin phosphate soln injection 300mg2ml 600mg4ml 900mg6ml
HI
colistimethate sodium (cba) solr injection HI
DALVANCE SOLR INTRAVENOUS HI
daptomycin solr intravenous 350mg 500mg HI
demeclocycline hcl tabs dicloxacillin sodium caps DIFICID SUSR NDS DIFICID TABS NDS DORYX MPC TBEC MO doxy 100 solr intravenous HI doxycycline hyclate caps 50mg 100mg MO
doxycycline hyclate tabs 20mg 75mg 100mg 150mg MO
doxycycline hyclate tbec 50mg 75mg 100mg 150mg 200mg MO
doxycycline monohydrate caps 50mg 75mg 100mg 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
Drug Name RequirementsLimits
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs FETROJA SOLR NDS FIRVANQ SOLR gentamicin in saline soln gentamicin in saline soln intravenous HI
gentamicin sulfate soln gentamicin sulfate soln injection HI imipenem-cilastatin solr intravenous HI
KIMYRSA SOLR NDS levofloxacin in d5w soln levofloxacin in d5w soln intravenous HI
levofloxacin soln levofloxacin soln intravenous HI levofloxacin tabs lincomycin hcl soln linezolid soln intravenous HI linezolid susr NDS linezolid tabs NDS meropenem solr intravenous 1gm 500mg HI
minocycline hcl caps 50mg 75mg 100mg MO
minocycline hcl er tb24 45mg 55mg 65mg 80mg 90mg 105mg 115mg 135mg
MO
minocycline hcl tabs 50mg 75mg 100mg MO
mondoxyne nl caps 75mg 100mg MO
morgidox caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 10 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium solr intravenous HI neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs okebo caps MO ORBACTIV SOLR NDS OXACILLIN SODIUM IN DEXTROSE SOLN INTRAVENOUS
HI
oxacillin sodium solr injection 1gm 2gm HI
oxacillin sodium solr intravenous HI PENICILLIN G POT IN DEXTROSE SOLN INTRAVENOUS
HI
penicillin g potassium solr injection HI
penicillin g procaine susp penicillin g sodium solr injection HI penicillin v potassium solr penicillin v potassium tabs piperacillin sod-tazobactam so solr
piperacillin sod-tazobactam so solr intravenous HI
polymyxin b sulfate solr injection HI RECARBRIO SOLR NDS SEYSARA TABS 60mg 100mg 150mg NDS
SIVEXTRO SOLR INTRAVENOUS HI
SIVEXTRO TABS NDS soloxide tbec MO streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
Drug Name RequirementsLimits
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO SUPRAX CAPS suprax chew suprax susr 100mg5ml 200mg5ml
SUPRAX SUSR 500 MG5ML SYNERCID SOLR targadox tabs MO tazicef solr injection 1gm 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS 400mg 600mg HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
VABOMERE SOLR INTRAVENOUS HI
vancomycin hcl caps vancomycin hcl solr VANCOMYCIN HCL SOLR 250 MG
vancomycin hcl solr intravenous 1gm 10gm 500mg HI
VIBRAMYCIN SYRP XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS XIMINO CP24 45mg 90mg 135mg MO
ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ZITHROMAX PACK MO ZOSYN SOLN INTRAVENOUS HI ZYVOX SOLN INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
ANTIFUNGALS ABELCET SUSP INTRAVENOUS HI
AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS ERAXIS SOLR INTRAVENOUS 50mg 100mg HI
fluconazole in sodium chloride soln intravenous HI
fluconazole susr fluconazole tabs flucytosine caps 250mg 500mg NDS griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs itraconazole caps ITRACONAZOLE SOLN MO ketoconazole tabs micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS NOXAFIL TBEC NDS nystatin susp nystatin tabs POSACONAZOLE SUSP NDS posaconazole tbec NDS terbinafine hcl tabs TOLSURA CAPS NDS voriconazole solr intravenous HI voriconazole susr voriconazole tabs ANTIMYCOBACTERIALS CAPASTAT SULFATE SOLR cycloserine caps dapsone tabs 25mg 100mg MO ethambutol hcl tabs 100mg 400mg MO
isoniazid soln
Drug Name RequirementsLimits
isoniazid syrp MO isoniazid tabs 100mg 300mg MO paser pack MO PRETOMANID TABS PRIFTIN TABS MO pyrazinamide tabs MO RIFABUTIN CAPS MO RIFADIN CAPS MO rifamate caps MO rifampin caps 150mg 300mg MO rifampin solr intravenous HI RIFATER TABS MO SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs BENZNIDAZOLE TABS 125mg 100mg MO
chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS DARAPRIM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS mefloquine hcl tabs metronidazole caps metronidazole in nacl soln metronidazole in nacl soln intravenous HI
metronidazole tabs NEBUPENT SOLR PA nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 12 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
quinine sulfate caps NDS SOLOSEC PACK tinidazole tabs ANTIVIRALS abacavir sulfate soln abacavir sulfate tabs MO abacavir sulfate-lamivudine tabs MO abacavir-lamivudine-zidovudine tabs MO
acyclovir caps MO acyclovir sodium soln intravenous HI
acyclovir susp MO acyclovir tabs 400mg 800mg MO adefovir dipivoxil tabs NDS APTIVUS CAPS MO APTIVUS SOLN MO atazanavir sulfate caps 150mg 200mg 300mg MO
BARACLUDE SOLN MO BIKTARVY TABS CABENUVA SUER cidofovir soln CIMDUO TABS MO COMPLERA TABS MO CRIXIVAN CAPS 200mg 400mg MO DAKLINZA TABS 30mg 60mg 90mg PANDS
DELSTRIGO TABS MO DESCOVY TABS MO didanosine cpdr 200mg 250mg 400mg MO
DOVATO TABS MO EDURANT TABS MO efavirenz caps 50mg 200mg MO efavirenz tabs MO efavirenz-emtricitab-tenofovir tabs MO
emtricitabine caps MO emtricitabine-tenofovir df tabs MO EMTRIVA SOLN MO entecavir tabs 05mg 1mg MO EPCLUSA TABS PANDS
Drug Name RequirementsLimits
EPIVIR HBV SOLN MO etravirine tabs 100mg 200mg MO EVOTAZ TABS MO famciclovir tabs 125mg 250mg 500mg MO
fosamprenavir calcium tabs MO FUZEON SOLR NDS ganciclovir sodium soln ganciclovir sodium solr GENVOYA TABS MO HARVONI PACK PANDS HARVONI TABS PANDS INTELENCE TABS 25mg MO INVIRASE CAPS MO INVIRASE TABS MO ISENTRESS CHEW 25mg 100mg MO
ISENTRESS HD TABS MO ISENTRESS PACK MO ISENTRESS TABS MO JULUCA TABS MO lamivudine soln MO lamivudine tabs 100mg 150mg 300mg MO
lamivudine-zidovudine tabs MO ledipasvir-sofosbuvir tabs PANDS LEXIVA SUSP MO lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO MAVYRET TABS PANDS nevirapine er tb24 100mg 400mg MO
nevirapine susp MO nevirapine tabs MO NORVIR CAPS MO NORVIR PACK MO NORVIR SOLN MO ODEFSEY TABS MO OLYSIO CAPS PANDS oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEG-INTRON REDIPEN KIT NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
PEGASYS PROCLICK SOLN 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN 180mcg05ml 180mcgml NDS
PEGINTRON KIT NDS PIFELTRO TABS MO PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
PREVYMIS SOLN 240mg12ml 480mg24ml NDS
PREVYMIS TABS 240mg 480mg NDS
PREZCOBIX TABS MO PREZISTA SUSP MO PREZISTA TABS 75mg 150mg 600mg 800mg MO
RAPIVAB SOLN NDS REBETOL SOLN MO RELENZA DISKHALER AEPB MO RESCRIPTOR TABS 100mg 200mg MO
RETROVIR SOLN MO REYATAZ PACK MO ribasphere caps MO ribasphere ribapak (1000 pack) tbpk MO
ribasphere ribapak (1200 pack) tbpk MO
ribasphere tabs MO ribavirin caps MO ribavirin solr ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg 150mg 300mg MO
sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS
Drug Name RequirementsLimits
SOVALDI TABS 200mg 400mg PANDS stavudine caps 15mg 20mg 30mg 40mg MO
STRIBILD TABS MO SYMFI LO TABS MO SYMFI TABS MO SYMTUZA TABS MO SYNAGIS SOLN 50mg05ml 100mgml NDS
tenofovir disoproxil fumarate tabs MO
TIVICAY PD TBSO MO TIVICAY TABS 10mg 25mg 50mg MO
TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEMLIDY TABS VIDEX EC CPDR 125mg 200mg 400mg MO
VIDEX SOLR 2gm 4gm MO VIEKIRA PAK TBPK PANDS VIEKIRA XR TB24 PANDS VIRACEPT TABS 250mg 625mg MO
VIREAD POWD MO VIREAD TABS 150mg MO VIREAD TABS 200mg 250mg MO VOCABRIA TABS MO VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS ZERIT CAPS 15mg 20mg 30mg 40mg MO
zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 14 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fosfomycin tromethamine pack MENAPHOSMBHYO1 TABS methenamine hippurate tabs METHENAMINE MANDELATE TABS
NITROFURANTOIN MACROCRYSTAL CAPS
NITROFURANTOIN MONOHYD MACRO CAPS
nitrofurantoin susp PHOSPHASAL TABS trimethoprim tabs MO URETRON DS TABS URIN DS TABS URYL TABS USTELL CAPS UTICAP CAPS UTIRA-C TABS UTRONA-C TABS ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate soln carbinoxamine maleate tabs cetirizine hcl soln CLARINEX SYRP CLARINEX-D 12 HOUR TB12 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln
Drug Name RequirementsLimits
promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs SEMPREX-D CAPS ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg 500mg NDS
ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS 25mg 5mg 75mg 10mg NDS
ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs ARRANON SOLN ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE INJ BELEODAQ SOLR NDS BELRAPZO SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS bexarotene caps NDS bicalutamide tabs BICNU SOLR bleomycin sulfate solr BLINCYTO SOLR NDS BORTEZOMIB SOLR BOSULIF TABS 100mg 400mg 500mg NDS
BRAFTOVI CAPS 50mg 75mg NDS BRUKINSA CAPS NDS busulfan soln CABOMETYX TABS 20mg 40mg 60mg NDS
CALQUENCE CAPS NDS CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR NDS cladribine soln clofarabine soln COMETRIQ (100 MG DAILY DOSE) KIT LDNDS
COMETRIQ (140 MG DAILY DOSE) KIT LDNDS
COMETRIQ (60 MG DAILY DOSE) KIT LDNDS
COPIKTRA CAPS 15mg 25mg NDS COTELLIC TABS NDS CYCLOPHOSPHAMIDE CAPS 25mg 50mg PA
CYCLOPHOSPHAMIDE SOLN 1gm5ml 500mg25ml NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr
Drug Name RequirementsLimits
dactinomycin solr DANYELZA SOLN NDS DARZALEX FASPRO SOLN NDS DARZALEX SOLN 400mg20ml 100mg5ml NDS
daunorubicin hcl soln DAURISMO TABS 25mg 100mg NDS decitabine solr DOCETAXEL (NON-ALCOHOL) SOLN 80mg4ml 160mg8ml 20mgml
NDS
docetaxel conc docetaxel soln doxorubicin hcl liposomal inj DOXORUBICIN HCL SOLN doxorubicin hcl solr DROXIA CAPS ELIGARD KIT ELLENCE SOLN ELZONRIS SOLN NDS EMCYT CAPS NDS EMPLICITI SOLR 300mg 400mg NDS
ENHERTU SOLR NDS epirubicin hcl soln ERBITUX SOLN ERIVEDGE CAPS NDS ERLEADA TABS NDS erlotinib hcl tabs 25mg 100mg 150mg NDS
ERWINASE SOLR NDS ERWINAZE SOLR NDS ETOPOPHOS SOLR NDS etoposide soln everolimus tabs 25mg 5mg 75mg NDS
EVOMELA SOLR NDS exemestane tabs FARYDAK CAPS 10mg 15mg 20mg LDNDS
FASLODEX SOLN NDS FENSOLVI (6 MONTH) KIT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 16 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
FIRMAGON (240 MG DOSE) SOLR
FIRMAGON SOLR floxuridine solr fludarabine phosphate soln fludarabine phosphate solr fluorouracil soln flutamide caps FOTIVDA CAPS 089mg 134mg NDS
fulvestrant soln NDS GAVRETO CAPS NDS GAZYVA SOLN NDS gemcitabine hcl soln gemcitabine hcl solr GILOTRIF TABS 20mg 30mg 40mg NDS
HERCEPTIN HYLECTA SOLN NDS HERCEPTIN SOLR 150mg 440mg NDS
HERZUMA SOLR 150mg 420mg NDS
HEXALEN CAPS NDS hydroxyurea caps IBRANCE CAPS 75mg 100mg 125mg NDS
IBRANCE TABS 75mg 100mg 125mg NDS
ICLUSIG TABS 10mg 15mg 30mg 45mg NDS
IDAMYCIN PFS SOLN idarubicin hcl soln IDHIFA TABS 50mg 100mg NDS ifosfamide soln IFOSFAMIDE SOLR imatinib mesylate tabs IMBRUVICA CAPS 70mg 140mg NDS
IMBRUVICA TABS 140mg 280mg 420mg 560mg NDS
IMFINZI SOLN 500mg10ml 120mg24ml NDS
INFUGEM SOLN NDS INLYTA TABS 1mg 5mg NDS
Drug Name RequirementsLimits
INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 10muml 6000000unitml NDS
INTRON A SOLR 10mu 18mu 50mu NDS
IRESSA TABS NDS irinotecan hcl soln IXEMPRA KIT SOLR NDS JAKAFI TABS 5mg 10mg 15mg 20mg 25mg NDS
JEMPERLI SOLN KADCYLA SOLR 100mg 160mg NDS KANJINTI SOLR 150mg 420mg NDS KEYTRUDA SOLN NDS KISQALI (200 MG DOSE) TBPK NDS KISQALI (400 MG DOSE) TBPK NDS KISQALI (600 MG DOSE) TBPK NDS KISQALI FEMARA (400 MG DOSE) TBPK NDS
KISQALI FEMARA (600 MG DOSE) TBPK NDS
KISQALI FEMARA (200 MG DOSE) TBPK NDS
KOSELUGO CAPS 10mg 25mg NDS KYPROLIS SOLR 10mg 30mg 60mg NDS
lapatinib ditosylate tabs NDS LARTRUVO SOLN 190mg19ml 500mg50ml NDS
LENVIMA (10 MG DAILY DOSE) CPPK LDNDS
LENVIMA (12 MG DAILY DOSE) CPPK LDNDS
LENVIMA (14 MG DAILY DOSE) CPPK LDNDS
LENVIMA (18 MG DAILY DOSE) CPPK LDNDS
LENVIMA (20 MG DAILY DOSE) CPPK LDNDS
LENVIMA (24 MG DAILY DOSE) CPPK LDNDS
LENVIMA (4 MG DAILY DOSE) CPPK LDNDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
LENVIMA (8 MG DAILY DOSE) CPPK LDNDS
letrozole tabs LEUKERAN TABS NDS leuprolide acetate kit LIBTAYO SOLN NDS LIPODOX 50 INJ LONSURF TABS NDS LORBRENA TABS 25mg 100mg NDS
LUMAKRAS TABS NDS LUMOXITI SOLR NDS LUPANETA PACK KIT LUPRON DEPOT (1-MONTH) KIT
LUPRON DEPOT (3-MONTH) KIT
LUPRON DEPOT (4-MONTH) KIT
LUPRON DEPOT (6-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT 75 MG
LUPRON DEPOT-PED (3-MONTH) KIT
LYNPARZA CAPS NDS LYNPARZA TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA SOLN NDS MARQIBO SUSP NDS MATULANE CAPS NDS megestrol acetate susp megestrol acetate tabs MEKINIST TABS 05mg 2mg NDS MEKTOVI TABS NDS melphalan hcl solr mercaptopurine tabs methotrexate sodium (pf) soln methotrexate sodium soln methotrexate sodium solr
Drug Name RequirementsLimits
methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS MUSTARGEN SOLR mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS NERLYNX TABS NDS NEXAVAR TABS NDS nilutamide tabs NINLARO CAPS 23mg 3mg 4mg NDS
NUBEQA TABS NDS ODOMZO CAPS NDS OGIVRI SOLR NDS ONIVYDE INJ NDS ONTRUZANT SOLR 150mg 420mg NDS
ONUREG TABS 200mg 300mg NDS OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml NDS
oxaliplatin soln oxaliplatin solr paclitaxel conc PADCEV SOLR 20mg 30mg NDS paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEPAXTO SOLR NDS PERJETA SOLN NDS PHESGO SOLN NDS PIQRAY (200 MG DAILY DOSE) TBPK NDS
PIQRAY (250 MG DAILY DOSE) TBPK NDS
PIQRAY (300 MG DAILY DOSE) TBPK NDS
POLIVY SOLR 30mg 140mg NDS POMALYST CAPS 1mg 2mg 3mg 4mg NDS
PORTRAZZA SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 18 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
POTELIGEO SOLN NDS PROLEUKIN SOLR NDS PURIXAN SUSP NDS QINLOCK TABS NDS RETEVMO CAPS 40mg 80mg NDS REVLIMID CAPS 25mg 5mg 10mg 15mg 20mg 25mg NDS
RIABNI SOLN 100mg10ml 500mg50ml NDS
RITUXAN HYCELA SOLN RITUXAN SOLN ROMIDEPSIN SOLN NDS ROZLYTREK CAPS 100mg 200mg NDS
RUBRACA TABS 200mg 250mg 300mg NDS
RUXIENCE SOLN 100mg10ml 500mg50ml NDS
RYBREVANT SOLN NDS RYDAPT CAPS NDS RYLAZE SOLN NDS SARCLISA SOLN 500mg25ml 100mg5ml NDS
SIKLOS TABS NDS SOLTAMOX SOLN SPRYCEL TABS 20mg 50mg 70mg 80mg 100mg 140mg NDS
STIVARGA TABS NDS sunitinib malate caps 125mg 25mg 375mg 50mg NDS
SUTENT CAPS 125mg 25mg 375mg 50mg NDS
SYLATRON KIT 600 MCG SYLATRON KIT SYLVANT SOLR 100mg 400mg NDS SYNRIBO SOLR NDS TABLOID TABS TABRECTA TABS 150mg 200mg NDS
TAFINLAR CAPS 50mg 75mg NDS TAGRISSO TABS 40mg 80mg NDS TALZENNA CAPS 025mg 1mg NDS tamoxifen citrate tabs
Drug Name RequirementsLimits
TARCEVA TABS 25mg 100mg 150mg NDS
TASIGNA CAPS 50mg 150mg 200mg NDS
TAZVERIK TABS NDS TECENTRIQ SOLN 840mg14ml 1200mg20ml NDS
temsirolimus soln TENIPOSIDE SOLN TEPADINA SOLR NDS TEPMETKO TABS NDS THALOMID CAPS 50mg 100mg 150mg 200mg NDS
thiotepa solr 15mg 100mg NDS TIBSOVO TABS NDS toposar soln TOPOTECAN HCL SOLN topotecan hcl solr toremifene citrate tabs NDS TRAZIMERA SOLR 150mg 420mg NDS
TRELSTAR MIXJECT SUSR tretinoin caps NDS trexall tabs 5mg 75mg 10mg 15mg PA
TRISENOX SOLN 10mg10ml NDS TRISENOX SOLN NDS TRODELVY SOLR NDS TRUSELTIQ (100MG DAILY DOSE) CPPK NDS
TRUSELTIQ (125MG DAILY DOSE) CPPK NDS
TRUSELTIQ (50MG DAILY DOSE) CPPK NDS
TRUSELTIQ (75MG DAILY DOSE) CPPK NDS
TRUXIMA SOLN 100mg10ml 500mg50ml NDS
TUKYSA TABS 50mg 150mg NDS TURALIO CAPS NDS TYKERB TABS NDS UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
VANTAS KIT VELCADE SOLR VENCLEXTA STARTING PACK TBPK NDS
VENCLEXTA TABS 10mg NDS VENCLEXTA TABS 50mg 100mg NDS
VERZENIO TABS 50mg 100mg 150mg 200mg NDS
vinblastine sulfate soln vincasar pfs soln vincristine sulfate soln vinorelbine tartrate soln VITRAKVI CAPS 25mg 100mg NDS VITRAKVI SOLN NDS VIZIMPRO TABS 15mg 30mg 45mg NDS
VOTRIENT TABS NDS VYXEOS SUSR NDS XALKORI CAPS 200mg 250mg NDS XATMEP SOLN PANDS XOSPATA TABS NDS XPOVIO (100 MG ONCE WEEKLY) TBPK 20mg 50mg NDS
XPOVIO (40 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (40 MG TWICE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (60 MG ONCE WEEKLY) TBPK 20mg 60mg NDS
XPOVIO (60 MG TWICE WEEKLY) TBPK NDS
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (80 MG TWICE WEEKLY) TBPK NDS
XTANDI CAPS NDS XTANDI TABS 40mg 80mg NDS YERVOY SOLN YONDELIS SOLR NDS YONSA TABS NDS ZALTRAP SOLN 100mg4ml 200mg8ml NDS
ZEJULA CAPS NDS
Drug Name RequirementsLimits
ZELBORAF TABS NDS ZEPZELCA SOLR NDS ZIRABEV SOLN 400mg16ml 100mg4ml NDS
ZOLINZA CAPS NDS ZYDELIG TABS 100mg 150mg NDS ZYKADIA CAPS NDS ZYKADIA TABS NDS ZYNLONTA SOLR NDS ZYTIGA TABS NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA AEPB MO ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO BEVESPI AEROSPHERE AERO MO chlordiazepoxide-clidinium caps CUVPOSA SOLN MO dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate pf sosy glycopyrrolate soln glycopyrrolate tabs 1mg 2mg MO INCRUSE ELLIPTA AEPB MO ipratropium bromide soln 002 PAMO ipratropium bromide soln 003 006 MO
LONHALA MAGNAIR REFILL KIT SOLN NDS
methscopolamine bromide tabs 25mg 5mg MO
propantheline bromide tabs MO SPIRIVA HANDIHALER CAPS MO SPIRIVA RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 20 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO NICOTROL NS SOLN MO PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride tabs 5mg 10mg 25mg 50mg MO
CEVIMELINE HCL CAPS MO donepezil hcl tabs 5mg 10mg 23mg MO
donepezil hcl tbdp 5mg 10mg MO galantamine hydrobromide er cp24 8mg 16mg 24mg MO
galantamine hydrobromide soln MO galantamine hydrobromide tabs 4mg 8mg 12mg MO
GUANIDINE HCL TABS MO MESTINON SOLN MO pilocarpine hcl tabs 5mg 75mg MO pyridostigmine bromide er tbcr MO pyridostigmine bromide soln MO pyridostigmine bromide tabs 30mg 60mg MO
REGONOL SOLN rivastigmine pt24 46mg24hr 95mg24hr 133mg24hr MO
rivastigmine tartrate caps 15mg 3mg 45mg 6mg MO
urecholine tabs 5mg 10mg 25mg 50mg MO
SKELETAL MUSCLE RELAXANTS baclofen soln baclofen tabs 5mg 10mg 20mg MO carisoprodol tabs 250mg 350mg PANDS carisoprodol-aspirin tabs PANDS carisoprodol-aspirin-codeine tabs PANDS
chlorzoxazone tabs 375mg 500mg 750mg NDS
Drug Name RequirementsLimits
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA lorzone tabs 375mg 750mg NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln revonto solr succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs vanadom tabs PANDS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl er tb24 MO dihydroergotamine mesylate soln NDS ergoloid mesylates tabs MO ergomar subl phenoxybenzamine hcl caps NDS silodosin caps 4mg 8mg MO tamsulosin hcl caps MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR HFA AERO MO albuterol sulfate er tb12 4mg 8mg MO
albuterol sulfate hfa aers MONDS albuterol sulfate nebu 0083 25mg05ml PAMO
albuterol sulfate nebu 063mg3ml 125mg3ml PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO ARCAPTA NEOHALER CAPS MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY EPIPEN 2-PAK SOAJ EPIPEN JR 2-PAK SOAJ formoterol fumarate nebu PAMO ipratropium-albuterol soln PAMO isoproterenol hcl soln levalbuterol hcl nebu 125mg05ml 031mg3ml 063mg3ml 125mg3ml
PAMO
levalbuterol tartrate aero MO metaproterenol sulfate syrp MO metaproterenol sulfate tabs 10mg 20mg MO
midodrine hcl tabs 25mg 5mg 10mg MO
norepinephrine bitartrate soln phenylephrine hcl soln PROAIR RESPICLICK AEPB MO SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
tizanidine hcl caps VENTOLIN HFA AERS MONDS BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS BERINERT KIT INTRAVENOUS HI FIRAZYR SOLN NDS icatibant acetate soln NDS OXBRYTA TABS NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS
Drug Name RequirementsLimits
COAGULANTS AND ANTICOAGULANTS aminocaproic acid soln MO aminocaproic acid tabs 500mg 1000mg MO
anagrelide hcl caps 05mg 1mg MO argatroban soln aspirin-dipyridamole er cp12 MO BEVYXXA CAPS 40mg 80mg MO BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
NDS
FRAGMIN SOLN 2500unit02ml 5000unit02ml 7500unit03ml 12500unit05ml 15000unit06ml 95000unit38ml 10000unitml 18000unt072ml
NDS
heparin (porcine) in nacl soln HEPARIN SOD (PORCINE) IN D5W SOLN
heparin sodium (porcine) pf soln PA heparin sodium (porcine) soln 1000unitml 5000unitml 10000unitml 20000unitml
PA
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg
MO
LOVENOX SOLN 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 22 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg PRADAXA CAPS 110mg 150mg MO
prasugrel hcl tabs 5mg 10mg MO tranexamic acid soln tranexamic acid tabs MO warfarin sodium tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 10mg
MO
XARELTO STARTER PACK TBPK MO
XARELTO TABS 25mg 10mg 15mg 20mg MO
ZONTIVITY TABS MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 25mcgml 40mcgml PANDS
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml
PANDS
FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MIRCERA SOSY 30mcg03ml 50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml
PA
MULPLETA TABS NDS
Drug Name RequirementsLimits
NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml NDS
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RETACRIT SOLN 20000unit2ml 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL TB24 4mg 8mg MO DEMSER CAPS NDS doxazosin mesylate tabs 1mg 2mg 4mg 8mg MO
metyrosine caps NDS prazosin hcl caps 1mg 2mg 5mg MO
terazosin hcl caps 1mg 2mg 5mg 10mg MO
ANTILIPEMIC AGENTS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
ALTOPREV TB24 20mg 40mg 60mg MO
ANTARA CAPS 30mg 90mg MO atorvastatin calcium tabs 10mg 20mg 40mg 80mg MO
cholestyramine light pack MO cholestyramine light powd MO cholestyramine pack MO cholestyramine powd MO colesevelam hcl pack MO colesevelam hcl tabs MO colestipol hcl gran MO colestipol hcl pack MO colestipol hcl tabs MO EVKEEZA SOLN 345mg23ml 1200mg8ml NDS
ezetimibe tabs MO ezetimibe-simvastatin tabs MO fenofibrate caps 50mg 134mg 150mg MO
fenofibrate micronized caps 43mg 67mg 130mg 200mg MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg MO
FENOFIBRIC ACID TABS 35mg 105mg MO
FIBRICOR TABS MO FLOLIPID SUSP 20mg5ml 40mg5ml MO
fluvastatin sodium caps 20mg 40mg MO
fluvastatin sodium er tb24 MO gemfibrozil tabs MO icosapent ethyl caps MO JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg PALDNDS
KYNAMRO SOSY PALDNDS LIVALO TABS 1mg 2mg 4mg MO lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
Drug Name RequirementsLimits
niacor tabs MO omega-3-acid ethyl esters caps MO pravastatin sodium tabs 10mg 20mg 40mg 80mg MO
prevalite pack MO prevalite powd MO questran light powd MO questran pack MO questran powd MO REPATHA PUSHTRONEX SYSTEM SOCT PANDS
REPATHA SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 05gm 1gm MO ZYPITAMAG TABS 1mg 2mg 4mg MO
BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl caps 200mg 400mg MO
atenolol tabs 25mg 50mg 100mg MO
atenolol-chlorthalidone tabs MO betaxolol hcl tabs 10mg 20mg MO bisoprolol fumarate tabs 5mg 10mg MO
bisoprolol-hydrochlorothiazide tabs MO
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg MO
carvedilol tabs 3125mg 625mg 125mg 25mg MO
DUTOPROL TB24 MO ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln INNOPRAN XL CP24 80mg 120mg MO
labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 24 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
metoprolol succinate er tb24 25mg 50mg 100mg 200mg MO
metoprolol tartrate soct metoprolol tartrate soln metoprolol tartrate tabs 25mg 50mg 100mg MO
metoprolol tartrate tabs 375mg 75mg MO
metoprolol-hydrochlorothiazide tabs MO
nadolol tabs 20mg 40mg 80mg MO nadolol-bendroflumethiazide tabs MO
pindolol tabs 5mg 10mg MO propranolol hcl er cp24 60mg 80mg 120mg 160mg MO
propranolol hcl soln 20mg5ml 40mg5ml MO
propranolol hcl tabs 10mg 20mg 40mg 60mg 80mg MO
propranolol-hctz tabs MO sorine tabs 80mg 120mg 160mg 240mg MO
sotalol hcl (af) tabs 80mg 120mg 160mg MO
sotalol hcl tabs 80mg 120mg 160mg 240mg MO
SOTYLIZE SOLN MO timolol maleate tabs 5mg 10mg 20mg MO
CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besy-benazepril hcl caps MO
amlodipine besylate tabs 25mg 5mg 10mg MO
amlodipine besylate-valsartan tabs MO
amlodipine-atorvastatin tabs MO amlodipine-olmesartan tabs MO amlodipine-valsartan-hctz tabs MO CARDENE IV SOLN CARDIZEM LA TB24 MO cartia xt cp24 120mg 180mg 240mg 300mg MO
Drug Name RequirementsLimits
CONSENSI TABS NDS dilt-xr cp24 120mg 180mg 240mg MO
diltiazem hcl er beads cp24 120mg 180mg 240mg 300mg 360mg 420mg
MO
DILTIAZEM HCL ER COATED BEADS CP24 120mg 180mg 240mg 300mg 360mg
MO
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg
MO
diltiazem hcl er cp12 60mg 90mg 120mg MO
diltiazem hcl er cp24 120mg 180mg 240mg MO
diltiazem hcl soln diltiazem hcl solr diltiazem hcl tabs 30mg 60mg 90mg 120mg MO
felodipine er tb24 25mg 5mg 10mg MO
isradipine caps 25mg 5mg MO matzim la tb24 180mg 240mg 300mg 360mg 420mg MO
nicardipine hcl caps 20mg 30mg MO nicardipine hcl soln nifedipine caps 10mg 20mg MO nifedipine er osmotic release tb24 30mg 60mg 90mg MO
nifedipine er tb24 30mg 60mg 90mg MO
nimodipine caps MO nisoldipine er tb24 85mg 17mg 20mg 255mg 30mg 34mg 40mg
MO
NYMALIZE SOLN 60mg20ml 6mgml NDS
olmesartan-amlodipine-hctz tabs MO taztia xt cp24 120mg 180mg 240mg 300mg 360mg MO
telmisartan-amlodipine tabs MO tiadylt er cp24 120mg 180mg 240mg 300mg 360mg 420mg MO
trandolapril-verapamil hcl er tbcr MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
VERAPAMIL HCL ER CP24 100mg 120mg 180mg 200mg 240mg 300mg 360mg
MO
verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 80mg 120mg MO verapamil hcl tabs MO VERELAN CP24 MO CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln inj DIGOXIN ORAL SOLN MO digoxin tabs 125mcg 250mcg MO disopyramide phosphate caps 100mg 150mg MO
dofetilide caps 125mcg 250mcg 500mcg MO
flecainide acetate tabs 50mg 100mg 150mg MO
ibutilide fumarate soln LANOXIN PEDIATRIC SOLN LANOXIN TABS 625mcg MO lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy LIDOCAINE IN D5W SOLN mexiletine hcl caps 150mg 200mg 250mg MO
milrinone lactate in dextrose soln milrinone lactate soln MULTAQ TABS NORPACE CR CP12 100mg 150mg MO
pacerone tabs 100mg 200mg 400mg MO
procainamide hcl soln
Drug Name RequirementsLimits
propafenone hcl er cp12 225mg 325mg 425mg MO
propafenone hcl tabs 150mg 225mg 300mg MO
quinidine gluconate er tbcr MO QUINIDINE GLUCONATE SOLN quinidine sulfate tabs 200mg 300mg MO
ranolazine er tb12 500mg 1000mg MO
VYNDAMAX CAPS NDS VYNDAQEL CAPS NDS HYPOTENSIVE AGENTS clonidine hcl (analgesia) soln clonidine hcl er tb12 MO clonidine hcl tabs 01mg 02mg 03mg MO
clonidine ptwk 01mg24hr 02mg24hr 03mg24hr MO
guanfacine hcl tabs 1mg 2mg MO hydralazine hcl soln hydralazine hcl tabs 10mg 25mg 50mg 100mg MO
methyldopa tabs 250mg 500mg MO methyldopa-hydrochlorothiazide tabs MO
minoxidil tabs 25mg 10mg MO nitropress soln nitroprusside sodium soln vecamyl tabs NDS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE TABS MO aliskiren fumarate tabs 150mg 300mg MO
benazepril hcl tabs 5mg 10mg 20mg 40mg MO
benazepril-hydrochlorothiazide tabs MO
candesartan cilexetil tabs 4mg 8mg 16mg 32mg MO
candesartan cilexetil-hctz tabs MO captopril tabs 125mg 25mg 50mg 100mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 26 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
captopril-hydrochlorothiazide tabs MO
CAROSPIR SUSP MO EDARBYCLOR TABS MO enalapril maleate tabs 25mg 5mg 10mg 20mg MO
enalapril-hydrochlorothiazide tabs MO
enalaprilat inj ENTRESTO TABS MO eplerenone tabs 25mg 50mg MO eprosartan mesylate tabs MO fosinopril sodium tabs 10mg 20mg 40mg MO
fosinopril sodium-hctz tabs MO irbesartan tabs 75mg 150mg 300mg MO
irbesartan-hydrochlorothiazide tabs MO
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg MO
lisinopril-hydrochlorothiazide tabs MO
losartan potassium tabs 25mg 50mg 100mg MO
losartan potassium-hctz tabs MO moexipril hcl tabs 75mg 15mg MO olmesartan medoxomil tabs 5mg 20mg 40mg MO
olmesartan medoxomil-hctz tabs MO perindopril erbumine tabs 2mg 4mg 8mg MO
QBRELIS SOLN MO quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO TEKTURNA HCT TABS MO
Drug Name RequirementsLimits
telmisartan tabs 20mg 40mg 80mg MO
telmisartan-hctz tabs MO trandolapril tabs 1mg 2mg 4mg MO valsartan tabs 40mg 80mg 160mg 320mg MO
valsartan-hydrochlorothiazide tabs MO
VASODILATING AGENTS alyq tabs PA BIDIL TABS MO dipyridamole tabs 25mg 50mg 75mg MO
GONITRO PACK MO isosorbide dinitrate er tbcr MO isosorbide dinitrate tabs 5mg 10mg 20mg 30mg MO
isosorbide mononitrate er tb24 30mg 60mg MO
isosorbide mononitrate er tb24 MO isosorbide mononitrate tabs 10mg 20mg MO
minitran pt24 01mghr 02mghr 04mghr 06mghr MO
nitro-bid oint MO NITRO-DUR PT24 03mghr 08mghr MO
nitroglycerin pt24 01mghr 02mghr 04mghr 06mghr MO
nitroglycerin soln MO nitroglycerin subl 03mg 04mg 06mg MO
sildenafil citrate soln PANDS sildenafil citrate susr PA sildenafil citrate tabs PAMO tadalafil (pah) tabs 20mg PA tadalafil tabs 25mg 5mg PA CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS acamprosate calcium tbec MO antabuse tabs 250mg 500mg MO disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
ABSTRAL SUBL 100mcg 200mcg 300mcg 400mcg 600mcg 800mcg
PANDS
acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ARYMO ER TBEA NDS ascomp-codeine caps NDS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
benzhydrocodone-acetaminophen tabs
bupap tabs buprenorphine hcl soln NDS buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
butalbital-acetaminophen caps NDS butalbital-acetaminophen tabs butalbital-apap-caff-cod caps NDS butalbital-apap-caffeine caps butalbital-apap-caffeine tabs butalbital-asa-caff-codeine caps NDS butalbital-aspirin-caffeine caps butalbital-aspirin-caffeine tabs butorphanol tartrate soln 1mgml 2mgml 10mgml NDS
BUTRANS PTWK NDS cataflam tabs NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
DEMEROL SOLN 25mg05ml 75mg15ml 100mg2ml 75mgml
PANDS
diclofenac potassium tabs diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs
Drug Name RequirementsLimits
DUEXIS TABS NDS DURAMORPH SOLN 05mgml 1mgml HINDS
dvorah tabs NDS EMBEDA CPCR NDS endocet tabs NDS esgic caps esgic tabs etodolac caps etodolac er tb24 etodolac tabs fenoprofen calcium caps fenoprofen calcium tabs fenortho caps fentanyl citrate (pf) soct NDS FENTANYL CITRATE (PF) SOLN 50mcgml 1000mcg20ml 2500mcg50ml
NDS
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fioricet caps fioricetcodeine caps NDS flurbiprofen tabs hydrocodone bitartrate er cp12 10mg 15mg 20mg 30mg 40mg 50mg
NDS
hydrocodone-acetaminophen soln NDS
hydrocodone-acetaminophen tabs NDS
hydrocodone-ibuprofen tabs NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 28 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd NDS hydromorphone hcl pf soln 50mg5ml 10mgml NDS
HYDROMORPHONE HCL SOLN 1mgml 2mgml NDS
hydromorphone hcl tabs 2mg 4mg 8mg NDS
ibu tabs ibudone tabs NDS ibuprofen lysine soln ibuprofen susp ibuprofen tabs ILARIS SOLN NDS indocin supp INDOCIN SUSP indomethacin caps INDOMETHACIN CAPS 20mg indomethacin er cpcr indomethacin sodium solr KADIAN CP24 NDS ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 300mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lodine tabs lorcet hd tabs NDS lorcet plus tabs NDS lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam caps meloxicam tabs meperidine hcl soln 50mg5ml 25mgml 50mgml 100mgml PANDS
meperidine hcl tabs 50mg 100mg NDS
Drug Name RequirementsLimits
methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl soln 5mg5ml 10mg5ml 10mgml NDS
methadone hcl tabs 5mg 10mg NDS mitigo soln MORPHINE SULFATE (CONCENTRATE) SOLN NDS
morphine sulfate (pf) soln 4mgml 10mgml NDS
MORPHINE SULFATE (PF) SOLN INTRAVENOUS HI
morphine sulfate er beads cp24 30mg 45mg 60mg 75mg 90mg 120mg
NDS
morphine sulfate er cp24 10mg 20mg 30mg 40mg 50mg 60mg 80mg 100mg
NDS
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg NDS
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml NDS
MORPHINE SULFATE SOLN HINDS MORPHINE SULFATE SOLN INJECTION 2mgml 4mgml 10mgml
HI
MORPHINE SULFATE SOLN INTRAVENOUS HI
morphine sulfate tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln nalfon tabs nalocet tabs NDS NAPRELAN TB24 naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
NUCYNTA ER TB12 50mg 100mg 150mg NDS
NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS 50mg 75mg NDS NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs oxaprozin tabs OXAYDO TABS NDS oxycodone hcl caps NDS oxycodone hcl conc NDS oxycodone hcl er t12a 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxycodone hcl soln NDS oxycodone hcl tabs 5mg 10mg 15mg 20mg 30mg NDS
oxycodone-acetaminophen soln NDS oxycodone-acetaminophen tabs NDS oxycodone-acetaminophen tabs 5-300mg 10-300mg NDS
oxycodone-aspirin tabs NDS oxycodone-ibuprofen tabs NDS OXYCONTIN T12A 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxymorphone hcl er tb12 5mg 75mg 10mg 15mg 20mg 30mg 40mg
NDS
oxymorphone hcl tabs 5mg 10mg NDS
panlor tabs NDS pentazocine-naloxone hcl tabs NDS percocet tabs NDS phrenilin forte caps PIROXICAM CAPS 10mg 20mg NDS pregabalin er tb24 825mg 165mg 330mg MO
primlev tabs NDS prolate soln NDS prolate tabs NDS QDOLO SOLN NDS
Drug Name RequirementsLimits
relafen ds tabs NDS ROXYBOND TABA 5mg 15mg 30mg NDS
SALSALATE TABS SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
SUBSYS LIQD 100mcg 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
sulindac tabs tencon tabs TIVORBEX CAPS tolmetin sodium caps tolmetin sodium tabs tramadol hcl er (biphasic) tb24 100mg 200mg 300mg NDS
tramadol hcl er cp24 100mg 150mg 200mg 300mg NDS
tramadol hcl er tb24 100mg 200mg 300mg NDS
tramadol hcl tabs 50mg 100mg NDS tramadol-acetaminophen tabs NDS trezix caps NDS tylenol with codeine 3 tabs NDS tylenol with codeine 4 tabs NDS vanatol lq soln vicodin es tabs NDS vicodin hp tabs NDS vicodin tabs NDS XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg NDS
zebutal caps ZIPSOR CAPS ZORVOLEX CAPS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS ADDERALL XR CP24 NDS ADZENYS ER SUER NDS ADZENYS XR-ODT TBED 31mg 63mg 94mg 125mg 157mg 188mg
NDS
amphetamine er suer NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 30 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
amphetamine sulfate tabs 5mg 10mg NDS
amphetamine-dextroamphet er cp24 NDS
amphetamine-dextroamphetamine tabs NDS
armodafinil tabs 50mg 150mg 200mg 250mg PA
caffeine citrate soln COTEMPLA XR-ODT TBED 86mg 173mg 259mg NDS
DAYTRANA PTCH 10mg9hr 15mg9hr 20mg9hr 30mg9hr NDS
dexmethylphenidate hcl er cp24 5mg 10mg 15mg 20mg 25mg 30mg 35mg 40mg
NDS
dexmethylphenidate hcl tabs 25mg 5mg 10mg NDS
dextroamphetamine sulfate er cp24 5mg 10mg 15mg NDS
dextroamphetamine sulfate soln NDS dextroamphetamine sulfate tabs 5mg 10mg 15mg 20mg 30mg NDS
DYANAVEL XR SUER NDS evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS methylphenidate hcl chew 25mg 5mg 10mg NDS
methylphenidate hcl er (cd) cpcr 10mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er (la) cp24 10mg 20mg 30mg 40mg 60mg
NDS
methylphenidate hcl er (xr) cp24 10mg 15mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg NDS
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg
NDS
methylphenidate hcl soln 5mg5ml 10mg5ml NDS
Drug Name RequirementsLimits
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS MYDAYIS CP24 NDS procentra soln NDS QUILLICHEW ER CHER 20mg 30mg 40mg NDS
QUILLIVANT XR SRER NDS relexxii tbcr NDS SUNOSI TABS 75mg 150mg NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
NDS
VYVANSE CHEW 10mg 20mg 30mg 40mg 50mg 60mg NDS
WAKIX TABS 445mg 178mg NDS zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg
NDS
ANTICONVULSANTS APTIOM TABS 200mg 400mg 600mg 800mg MO
BANZEL SUSP BANZEL TABS 200mg 400mg NDS BRIVIACT SOLN NDS BRIVIACT TABS 10mg 25mg 50mg 75mg 100mg NDS
carbamazepine chew MO carbamazepine er cp12 100mg 200mg 300mg MO
carbamazepine er tb12 100mg 200mg 400mg MO
carbamazepine susp MO carbamazepine tabs MO CELONTIN CAPS MO clobazam susp MO clobazam tabs 10mg 20mg MO clonazepam tabs 05mg 1mg 2mg NDS
clonazepam tbdp 0125mg 025mg 05mg 1mg 2mg NDS
DIACOMIT CAPS 250mg 500mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
DIACOMIT PACK 250mg 500mg NDS
DIASTAT ACUDIAL GEL 10mg 20mg NDS
DIASTAT PEDIATRIC GEL NDS diazepam gel 25mg 10mg 20mg NDS
dilantin caps 30mg 100mg MO dilantin infatabs chew MO divalproex sodium csdr MO divalproex sodium er tb24 250mg 500mg MO
divalproex sodium tbec 125mg 250mg 500mg MO
ELEPSIA XR TB24 1000mg 1500mg NDS
EPIDIOLEX SOLN PANDS epitol tabs MO ethosuximide caps MO ethosuximide soln MO felbamate susp MO felbamate tabs 400mg 600mg MO FINTEPLA SOLN NDS fosphenytoin sodium soln FYCOMPA SUSP NDS FYCOMPA TABS gabapentin caps 100mg 400mg MO gabapentin soln MO gabapentin tabs 600mg 800mg MO HORIZANT TBCR 300mg 600mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
lamotrigine kit MO lamotrigine starter kit-blue kit MO lamotrigine starter kit-green kit MO lamotrigine starter kit-orange kit MO lamotrigine tabs 25mg 100mg 150mg 200mg MO
lamotrigine tbdp 25mg 50mg 100mg 200mg MO
Drug Name RequirementsLimits
levetiracetam er tb24 500mg 750mg MO
levetiracetam in nacl soln levetiracetam soln MO levetiracetam tabs 250mg 500mg 750mg 1000mg MO
magnesium sulfate soln magnesium sulfate soln injection 50 HI
MAGNESIUM SULFATE SOLN INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml
HI
NAYZILAM SOLN NDS oxcarbazepine susp MO oxcarbazepine tabs 150mg 300mg 600mg MO
OXTELLAR XR TB24 150mg 300mg 600mg MO
PEGANONE TABS MO phenytek caps 200mg 300mg MO phenytoin chew MO phenytoin sodium extended caps 100mg 200mg 300mg MO
phenytoin sodium soln phenytoin susp MO pregabalin caps 25mg 50mg 75mg 100mg 150mg 200mg 225mg 300mg
MO
pregabalin soln MO primidone tabs 50mg 250mg MO roweepra tabs 500mg 750mg 1000mg MO
roweepra xr tb24 500mg 750mg MO rufinamide susp rufinamide tabs 200mg 400mg NDS SPRITAM TB3D 250mg 500mg 750mg 1000mg NDS
subvenite starter kit-blue kit MO subvenite starter kit-green kit MO subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 32 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
SYMPAZAN FILM 10mg 20mg tiagabine hcl tabs 2mg 4mg 12mg 16mg MO
topiramate cpsp 15mg 25mg MO topiramate er cs24 25mg 50mg 100mg 150mg 200mg MO
topiramate tabs 25mg 50mg 100mg 200mg MO
TROKENDI XR CP24 25mg 50mg 100mg 200mg MO
valproate sodium soln valproic acid caps MO valproic acid soln MO VALTOCO 10 MG DOSE LIQD NDS VALTOCO 15 MG DOSE LQPK NDS VALTOCO 20 MG DOSE LQPK NDS VALTOCO 5 MG DOSE LIQD NDS vigabatrin pack LDNDS vigabatrin tabs NDS vigadrone pack LDNDS VIMPAT SOLN VIMPAT TABS MO XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200 MG NDS XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ AJOVY SOSY almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs EMGALITY (300 MG DOSE) SOSY NDS
Drug Name RequirementsLimits
EMGALITY SOAJ EMGALITY SOSY ergotamine-caffeine tabs frovatriptan succinate tabs naratriptan hcl tabs NURTEC TBDP NDS ONZETRA XSAIL EXHP rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs TOSYMRA SOLN UBRELVY TABS 50mg 100mg NDS ZEMBRACE SYMTOUCH SOAJ zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ZOMIG SOLN ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl syrp MO amantadine hcl tabs MO APOKYN SOCT NDS benztropine mesylate soln benztropine mesylate tabs 05mg 1mg 2mg MO
bromocriptine mesylate caps MO bromocriptine mesylate tabs MO cabergoline tabs MO carbidopa tabs MO carbidopa-levodopa er tbcr MO carbidopa-levodopa tabs MO carbidopa-levodopa tbdp MO carbidopa-levodopa-entacapone tabs MO
DUOPA SUSP LD EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg NDS
pramipexole dihydrochloride er tb24 0375mg 075mg 15mg 225mg 3mg 375mg 45mg
MO
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg
MO
rasagiline mesylate tabs 05mg 1mg MO
ropinirole hcl er tb24 2mg 4mg 6mg 8mg 12mg MO
ropinirole hcl tabs 025mg 05mg 1mg 2mg 3mg 4mg 5mg
MO
RYTARY CPCR MO selegiline hcl caps MO selegiline hcl tabs MO tolcapone tabs MO trihexyphenidyl hcl soln MO trihexyphenidyl hcl tabs 2mg 5mg MO
ZELAPAR TBDP MO ANXIOLYTICS SEDATIVES AND HYPNOTICS alprazolam er tb24 05mg 1mg 2mg 3mg NDS
alprazolam intensol conc NDS alprazolam tabs 025mg 05mg 1mg 2mg NDS
alprazolam tbdp 025mg 05mg 1mg 2mg NDS
BELSOMRA TABS buspirone hcl tabs 5mg 10mg buspirone hcl tabs 75mg 15mg 30mg
chlordiazepoxide hcl caps 5mg 10mg 25mg NDS
clorazepate dipotassium tabs 375mg 75mg 15mg NDS
diazepam conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS
Drug Name RequirementsLimits
droperidol soln EDLUAR SUBL 5mg 10mg NDS estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP NDS hydroxyzine hcl soln hydroxyzine hcl syrp hydroxyzine hcl tabs hydroxyzine pamoate caps lorazepam intensol conc NDS LORAZEPAM SOLN 4mgml 2mgml NDS
lorazepam tabs 05mg 1mg 2mg NDS
meprobamate tabs midazolam hcl (pf) soln midazolam hcl soln midazolam hcl syrp nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs ROZEREM TABS seconal caps TEMAZEPAM CAPS 15mg 225mg 30mg 75mg NDS
triazolam tabs 0125mg 025mg NDS zaleplon caps 5mg 10mg NDS zolpidem tartrate er tbcr 625mg 125mg NDS
zolpidem tartrate subl 175mg 35mg NDS
zolpidem tartrate tabs 5mg 10mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 34 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS atomoxetine hcl caps 10mg 18mg 25mg 40mg 60mg 80mg 100mg
MO
AUSTEDO TABS 6mg 9mg 12mg LDNDS
EXSERVAN FILM NDS flumazenil soln guanfacine hcl er tb24 1mg 2mg 3mg 4mg MO
INGREZZA CAPS 40mg 60mg 80mg NDS
INGREZZA CPPK NDS memantine hcl er cp24 memantine hcl soln MO memantine hcl tabs 5mg 10mg MO NAMENDA XR TITRATION PACK CP24 MO
NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS SAVELLA TABS 125mg 25mg 50mg 100mg MO
SAVELLA TITRATION PACK MISC MO
tetrabenazine tabs 125mg 25mg NDS
TIGLUTIK SUSP NDS XYREM SOLN LDNDS XYWAV SOLN NDS MULTIPLE SCLEROSIS AGENTS AUBAGIO TABS 7mg 14mg PANDS AVONEX KIT NDS AVONEX PEN AJKT NDS AVONEX PREFILLED PSKT NDS BAFIERTAM CPDR NDS BETASERON KIT NDS dalfampridine er tb12 MO dimethyl fumarate cpdr dimethyl fumarate starter pack misc
Drug Name RequirementsLimits
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatiramer acetate sosy 20mgml 40mgml NDS
glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 2mg NDS OCREVUS SOLN PLEGRIDY SOSY NDS PONVORY STARTER PACK TBPK NDS
PONVORY TABS NDS REBIF REBIDOSE SOAJ 22mcg05ml 44mcg05ml NDS
REBIF REBIDOSE TITRATION PACK SOAJ NDS
REBIF SOSY 22mcg05ml 44mcg05ml NDS
REBIF TITRATION PACK SOSY NDS TECFIDERA CPDR 120mg 240mg NDS
TECFIDERA MISC NDS TYSABRI CONC INTRAVENOUS HI
ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS ZINBRYTA SOSY LDNDS OPIATE ANTAGONISTS BUNAVAIL FILM NDS buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
LUCEMYRA TABS NDS naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR NDS ZUBSOLV SUBL NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg NDS
ABILIFY MYCITE MAINTENANCE KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg NDS
amitriptyline hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
amoxapine tabs 25mg 50mg 100mg 150mg MO
APLENZIN TB24 174mg 348mg 522mg MO
aripiprazole soln MO aripiprazole tabs 2mg 5mg 10mg 15mg 20mg 30mg MO
aripiprazole tbdp 10mg 15mg MO ARISTADA INITIO PRSY NDS ARISTADA PRSY 441mg16ml 662mg24ml 882mg32ml 1064mg39ml
NDS
asenapine maleate subl 25mg 5mg 10mg MO
bupropion hcl er (smoking det) tb12 MO
bupropion hcl er (sr) tb12 100mg 150mg 200mg MO
bupropion hcl er (xl) tb24 150mg 300mg 450mg MO
bupropion hcl tabs 75mg 100mg MO CAPLYTA CAPS NDS chlordiazepoxide-amitriptyline tabs
chlorpromazine hcl soln
Drug Name RequirementsLimits
chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
clomipramine hcl caps 25mg 50mg 75mg MO
clozapine tabs 25mg 50mg 100mg 200mg NDS
clozapine tbdp 125mg 25mg 100mg 150mg 200mg NDS
compro supp MO desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
DESVENLAFAXINE ER TB24 50mg 100mg MO
desvenlafaxine succinate er tb24 25mg 50mg 100mg MO
doxepin hcl caps 10mg 25mg 50mg 75mg 100mg 150mg MO
doxepin hcl conc MO doxepin hcl tabs 3mg 6mg MO DRIZALMA SPRINKLE CSDR duloxetine hcl cpep 20mg 30mg 40mg 60mg MO
EQUETRO CP12 100mg 200mg 300mg MO
escitalopram oxalate soln MO escitalopram oxalate tabs 5mg 10mg 20mg MO
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg NDS
FANAPT TITRATION PACK TABS MO
FETZIMA CP24 20mg 40mg 80mg 120mg MO
FETZIMA TITRATION C4PK MO fluoxetine hcl (pmdd) tabs 10mg 20mg MO
fluoxetine hcl caps 10mg 20mg 40mg MO
fluoxetine hcl cpdr MO fluoxetine hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 36 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
GEODON SOLR haloperidol decanoate soln haloperidol lactate conc MO haloperidol lactate soln haloperidol tabs 05mg 1mg 2mg 5mg 10mg 20mg MO
imipramine hcl tabs 10mg 25mg 50mg MO
imipramine pamoate caps 75mg 100mg 125mg 150mg MO
INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 300mg 150mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
lithium carbonate tabs MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO
Drug Name RequirementsLimits
mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
nefazodone hcl tabs 50mg 100mg 150mg 200mg 250mg MO
nortriptyline hcl caps 10mg 25mg 50mg 75mg MO
nortriptyline hcl soln MO NUPLAZID CAPS NDS NUPLAZID TABS 10mg 17mg NDS olanzapine solr olanzapine tabs 25mg 5mg 75mg 10mg 15mg 20mg MO
olanzapine tbdp 5mg 10mg 15mg 20mg MO
olanzapine-fluoxetine hcl caps MO PALIPERIDONE ER TB24 15mg 3mg 6mg 9mg MO
paroxetine hcl er tb24 125mg 25mg 375mg MO
paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps MO PAXIL SUSP MO perphenazine tabs 2mg 4mg 8mg 16mg MO
perphenazine-amitriptyline tabs MO PERSERIS PRSY 90mg 120mg NDS PEXEVA TABS 10mg 20mg 30mg 40mg MO
phenelzine sulfate tabs MO pimozide tabs 1mg 2mg MO prochlorperazine edisylate soln prochlorperazine maleate tabs prochlorperazine supp MO protriptyline hcl tabs 5mg 10mg MO quetiapine fumarate er tb24 50mg 150mg 200mg 300mg 400mg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
quetiapine fumarate tabs 25mg 50mg 100mg 200mg 300mg 400mg
MO
REXULTI TABS 025mg 05mg 1mg 2mg 3mg 4mg NDS
RISPERDAL CONSTA SRER 125mg 25mg NDS
RISPERDAL CONSTA SRER 375mg 50mg NDS
risperidone soln MO risperidone tabs 025mg 05mg 1mg 2mg 3mg 4mg MO
risperidone tbdp 025mg 05mg 1mg 2mg 3mg 4mg MO
SAPHRIS SUBL 25mg 5mg 10mg NDS
SECUADO PT24 38mg24hr 57mg24hr 76mg24hr NDS
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
SILENOR TABS SPRAVATO (56 MG DOSE) SOPK NDS
SPRAVATO (84 MG DOSE) SOPK NDS
thioridazine hcl tabs 10mg 25mg 50mg 100mg MO
thiothixene caps 1mg 2mg 5mg 10mg MO
tofranil tabs 10mg 25mg 50mg MO tranylcypromine sulfate tabs MO trazodone hcl tabs 50mg 100mg 150mg MO
trazodone hcl tabs MO trifluoperazine hcl tabs 1mg 2mg 5mg 10mg MO
trimipramine maleate caps 25mg 50mg 100mg MO
TRINTELLIX TABS 5mg 10mg 20mg MO
venlafaxine hcl er cp24 375mg 75mg 150mg MO
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg MO
Drug Name RequirementsLimits
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
VRAYLAR CAPS 15mg 3mg 45mg 6mg NDS
VRAYLAR CPPK NDS ziprasidone hcl caps 20mg 40mg 60mg 80mg MO
ziprasidone mesylate solr ZYPREXA RELPREVV SUSR DIABETIC SUPPLIES DIABETIC SUPPLIES ALCOHOL PREP PADS MO BD INSULIN SYR ULTRAFINE II MISC MO
BD INSULIN SYRINGE MISC MO BD INSULIN SYRINGE UF MISC MO
BD PEN NEEDLE ORIGINAL UF MISC MO
CURITY GAUZE PADS MO OMNIPOD STARTER KIT NDS ELECTROLYTIC CALORIC AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS POT amp SOD CIT-CIT AC SOLN potassium citrate er tbcr 15meq 540mg 1080mg MO
SODIUM ACETATE SOLN SODIUM BICARBONATE SOLN SODIUM LACTATE SOLN INTRAVENOUS HI
TRICITRATES SOLN AMMONIA DETOXICANTS CARBAGLU TABS LD constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 38 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lactulose pack MO lactulose soln MO LITHOSTAT TABS MO RAVICTI LIQD NDS sod benz-sod phenylacet soln sodium phenylbutyrate powd NDS sodium phenylbutyrate tabs NDS CALORIC AGENTS AMINOSYN-PF SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (27510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42525) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (525) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (525) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN dextrose soln intravenous 5 10 HI
Drug Name RequirementsLimits
FREAMINE HBC SOLN INTRAVENOUS HI
HEPATAMINE SOLN INTRAVENOUS HI
INTRALIPID EMUL INTRAVENOUS 20gm100ml HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NEPHRAMINE SOLN INTRAVENOUS HI
NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE SOLN INTRAVENOUS HI
PROSOL SOLN INTRAVENOUS HI TRAVASOL SOLN INTRAVENOUS HI
TROPHAMINE SOLN INTRAVENOUS HI
DIURETICS AMILORIDE HCL TABS MO amiloride-hydrochlorothiazide tabs MO
bumetanide soln bumetanide tabs 05mg 1mg 2mg MO
chlorothiazide sodium solr chlorothiazide tabs 250mg 500mg MO
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI FUROSEMIDE TABS 40mg 80mg 20mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN SAMSCA TABS 15mg NDS TOLVAPTAN TABS 30mg 15mg NDS torsemide tabs 5mg 10mg 20mg 100mg MO
triamterene caps 50mg 100mg MO triamterene-hctz caps MO triamterene-hctz tabs MO ION-REMOVING AGENTS AURYXIA TABS PAMONDS FOSRENOL PACK 750mg 1000mg NDS
kionex susp MO lanthanum carbonate chew 500mg 750mg 1000mg MO
LOKELMA PACK 5gm 10gm MO sevelamer carbonate pack 08gm 24gm MO
sevelamer carbonate tabs MO sevelamer hcl tabs 400mg 800mg MO
sodium polystyrene sulfonate powd MO
sodium polystyrene sulfonate susp MO
sps susp MO VELPHORO CHEW NDS VELTASSA PACK 84gm 168gm 252gm NDS
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate (phos binder) tabs MO
CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
Drug Name RequirementsLimits
DEXTROSE-NACL SOLN INTRAVENOUS HI
DEXTROSE 10NACL 02 DEXTROSE 10NACL 045 HI
DEXTROSE 5NACL 0225 HI IONOSOL-MB IN D5W SOLN INTRAVENOUS HI
ISOLYTE-P IN D5W SOLN INTRAVENOUS HI
ISOLYTE-S SOLN INTRAVENOUS HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-033 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 TBCR MO klor-con m10 tbcr MO klor-con m15 tbcr MO klor-con m20 tbcr MO klor-con pack MO klor-con sprinkle cpcr 8meq 10meq MO
KLOR-CON TBCR MO LACTATED RINGERS SOLN magnesium sulfate in d5w soln NORMOSOL-M IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R SOLN INTRAVENOUS HI
PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 40 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
POTASSIUM CHLORIDE ER TBCR 8meq 10meq 20meq MO
POTASSIUM CHLORIDE IN DEXTROSE SOLN INTRAVENOUS
HI
potassium chloride in nacl soln intravenous HI
potassium chloride pack MO potassium chloride soln 10 20 MO
POTASSIUM CHLORIDE SOLN INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN SODIUM CHLORIDE SOLN INJECTION HI
SODIUM CHLORIDE SOLN INTRAVENOUS 045 09 3 5
HI
SODIUM PHOSPHATES SOLN TPN ELECTROLYTES CONC INTRAVENOUS HI
URICOSURIC AGENTS colchicine-probenecid tabs MO probenecid tabs MO ENZYMES ENZYMES ADAGEN SOLN ALDURAZYME SOLN CERDELGA CAPS NDS CEREZYME SOLR NDS CREON CPEP MO ELAPRASE SOLN NDS
Drug Name RequirementsLimits
ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME SOLR NDS miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PANCREAZE CPEP MO PERTZYE CPEP MO PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VIOKACE TABS MO VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE SOLN bacitracin oint bacitracin-polymyxin b oint BESIVANCE SUSP bleph-10 soln CETRAXAL SOLN chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
CIPROFLOXACIN-FLUOCINOLONE PF SOLN
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
MOXEZA SOLN moxifloxacin hcl (2x day) soln moxifloxacin hcl soln NATACYN SUSP neo-polycin oint neomycin-bacitracin zn-polymyx oint
neomycin-polymyxin-gramicidin soln
ofloxacin soln OTOVEL SOLN paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ZIRGAN GEL ANTI-INFLAMMATORY AGENTS ACUVAIL SOLN MO ALREX SUSP MO bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
BROMSITE SOLN MO CEQUA SOLN CIPRO HC SUSP MO CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO DUREZOL EMUL MO flac oil MO
Drug Name RequirementsLimits
FLAREX SUSP MO flunisolide soln MO fluocinolone acetonide oil MO fluorometholone susp MO flurbiprofen sodium soln MO fluticasone propionate susp MO FML FORTE SUSP MO FML OINT MO HYDROCORTISONE-ACETIC ACID SOLN MO
ILEVRO SUSP MO ILUVIEN IMPL INVELTYS SUSP MO ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX OINT MO LOTEMAX SUSP MO loteprednol etabonate susp MO MAXIDEX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint MO
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO NEVANAC SUSP MO OMNARIS SUSP MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
PROLENSA SOLN MO RESTASIS EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 42 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tobramycin-dexamethasone susp MO
XHANCE EXHU MO XIIDRA SOLN YUTIQ IMPL ZETONNA AERS MO ZYLET SUSP MO ANTIALLERGIC AGENTS ALOCRIL SOLN MO ALOMIDE SOLN MO azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO LASTACAFT SOLN MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
ALPHAGAN P SOLN MO betaxolol hcl soln MO BETIMOL SOLN 025 05 MO BETOPTIC-S SUSP MO bimatoprost soln MO BRIMONIDINE TARTRATE SOLN 02 015 MO
brinzolamide susp MO carteolol hcl soln MO COMBIGAN SOLN MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO
Drug Name RequirementsLimits
methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO SIMBRINZA SUSP MO timolol maleate pf soln MO timolol maleate solg 025 05 MO
timolol maleate soln 025 05 MO
TIMOPTIC OCUDOSE SOLN 25 MO
TIMOPTIC-XE SOLG 025 05 MO
TRAVATAN Z SOLN MO travoprost (bak free) soln MO VYZULTA SOLN MO XELPROS EMUL MO ZIOPTAN SOLN MO EENT DRUGS MISCELLANEOUS ACETIC ACID SOLN MO ALTAFRIN SOLN apraclonidine hcl soln MO ATROPINE SULFATE SOLN MO BEOVU SOLN NDS CYSTADROPS SOLN NDS CYSTARAN SOLN EYLEA SOLN EYLEA SOSY IOPIDINE SOLN MO LACRISERT INST MO LUCENTIS SOLN 03mg005ml 05mg005ml NDS
LUCENTIS SOSY 03mg005ml 05mg005ml NDS
OXERVATE SOLN NDS PHENYLEPHRINE HCL SOLN RHOPRESSA SOLN TEPEZZA SOLR NDS LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl soln lidocaine viscous hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
APRISO CP24 MO balsalazide disodium caps MO colazal caps MO DELZICOL CPDR MO DIPENTUM CAPS NDS LIALDA TBEC MO mesalamine cpdr MO mesalamine enem MO mesalamine er cp24 MO mesalamine supp MO mesalamine tbec 12gm 800mg MO mesalamine-cleanser kit PENTASA CPCR 250mg 500mg MO
ANTIDIARRHEA AGENTS diphenoxylate-atropine liqd diphenoxylate-atropine tabs loperamide hcl caps MO MYTESI TBEC MO OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS AKYNZEO CAPS PA ANZEMET TABS 50mg 100mg PANDS aprepitant caps PANDS BONJESTA TBCR MO CESAMET CAPS PA dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
EMEND SUSR PANDS fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs
Drug Name RequirementsLimits
ondansetron hcl soln PA ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS TRANSDERM SCOP (15 MG) PT72
trimethobenzamide hcl caps PA VARUBI (180 MG DOSE) TBPK PANDS ZUPLENZ FILM 4mg 8mg PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc MO
CARAFATE SUSP MO cimetidine hcl soln MO cimetidine tabs 200mg 300mg 400mg 800mg MO
esomeprazole magnesium cpdr 20mg 40mg MO
esomeprazole magnesium pack 10mg 20mg 40mg MO
esomeprazole sodium solr ESOMEPRAZOLE STRONTIUM CPDR
famotidine premixed soln famotidine soln famotidine susr MO famotidine tabs 20mg 40mg MO lansoprazole cpdr 15mg 30mg MO lansoprazole tbdd 15mg 30mg MO misoprostol tabs 100mcg 200mcg MO
nizatidine caps 150mg 300mg MO nizatidine soln MO OMECLAMOX-PAK MISC MO omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 44 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PRILOSEC PACK 25mg 10mg MO PROTONIX PACK MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate tabs MO CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO GOLYTELY SOLR OSMOPREP TABS MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT PLENVU SOLR MO SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS AMITIZA CAPS 8mcg 24mcg MO BYLVAY (PELLETS) CPSP 200mcg 600mcg NDS
BYLVAY CAPS 400mcg 1200mcg NDS
CHOLBAM CAPS 50mg 250mg NDS ENTYVIO SOLR NDS GATTEX KIT PANDS GIMOTI SOLN NDS LINZESS CAPS 72mcg 145mcg 290mcg MO
lubiprostone caps 8mcg 24mcg MO
Drug Name RequirementsLimits
metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
MOVANTIK TABS 125mg 25mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS SYMPROIC TABS MO TRULANCE TABS MO ursodiol caps 300mg MO URSODIOL CAPS 200mg 400mg NDS
ursodiol tabs 250mg 500mg MO VIBERZI TABS 75mg 100mg NDS HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPS clovique caps NDS CUPRIMINE CAPS NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs 90mg 180mg 360mg NDS
deferasirox tbso 125mg NDS deferasirox tbso 250mg 500mg NDS deferiprone tabs NDS deferoxamine mesylate solr DEPEN TITRATABS TABS EXJADE TBSO 125mg 250mg 500mg NDS
FERRIPROX SOLN LDNDS FERRIPROX TABS 500mg 1000mg LDNDS
FERRIPROX TWICE-A-DAY TABS NDS
JADENU SPRINKLE PACK 90mg 180mg 360mg NDS
JADENU TABS 90mg 360mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
penicillamine caps penicillamine tabs trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP 05mg 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs MO decadron elix MO decadron tabs 5mg 75mg MO decadron tabs 4mg 6mg PAMO deltasone tabs PAMO DEPO-MEDROL SUSP dexabliss tbpk dexamethasone elix MO dexamethasone intensol conc MO dexamethasone sod phosphate pf soln
dexamethasone sodium phosphate soln
dexamethasone soln dexamethasone tabs 05mg 075mg 1mg 15mg 2mg 4mg 6mg
PAMO
dexamethasone tbpk MO dexpak 10 day tbpk MO dexpak 13 day tbpk MO dexpak 6 day tbpk MO dxevo 11-day tbpk EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
INTRAROSA INST KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp
Drug Name RequirementsLimits
methylprednisolone sodium succ solr
methylprednisolone tabs 4mg 8mg 16mg 32mg MO
methylprednisolone tbpk MO millipred dp tbpk millipred tabs MO ORTIKOS CP24 6mg 9mg NDS prednisolone sodium phosphate soln 5mg5ml 10mg5ml 20mg5ml 25mg5ml
MO
prednisolone sodium phosphate tbdp 10mg 15mg 30mg MO
prednisolone soln MO prednisone intensol conc PAMO prednisone soln PAMO prednisone tabs 1mg 25mg 5mg 10mg 20mg 50mg PAMO
prednisone tbpk PULMICORT FLEXHALER AEPB
RAYOS TBEC 1mg 2mg 5mg PAMO SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TRELEGY ELLIPTA AEPB MO triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
AVEED SOLN MO danazol caps 50mg 100mg 200mg MO
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs 25mg MO oxandrolone tabs MONDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 46 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
STRIANT MISC MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact
MO
testosterone soln MO XYOSTED SOAJ 50mg05ml 75mg05ml 100mg05ml MO
CONTRACEPTIVES altavera tabs MO alyacen 135 tabs MO amethia lo tabs MO amethia tabs MO apri tabs MO aranelle tabs MO ashlyna tabs MO aubra eq tabs MO aviane tabs MO balziva tabs MO blisovi 24 fe tabs MO blisovi fe 1530 tabs MO briellyn tabs MO camila tabs MO camrese lo tabs MO caziant tabs MO cryselle-28 tabs MO cyclafem 135 tabs MO cyclafem 777 tabs MO cyred eq tabs MO deblitane tabs MO delyla tabs MO desogestrel-ethinyl estradiol tabs MO dolishale tabs MO drospiren-eth estrad-levomefol tabs MO
drospirenone-ethinyl estradiol tabs MO
ELLA TABS MO eluryng ring MO emoquette tabs MO
Drug Name RequirementsLimits
enpresse-28 tabs MO enskyce tabs MO errin tabs MO estarylla tabs MO ethynodiol diac-eth estradiol tabs MO etonogestrel-ethinyl estradiol ring MO
falmina tabs MO fayosim tabs MO femynor tabs MO gemmily caps MO gianvi tabs MO hailey 24 fe tabs MO iclevia tabs MO incassia tabs MO introvale tabs MO isibloom tabs MO jasmiel tabs MO JOLIVETTE TABS MO juleber tabs MO junel 1530 tabs MO junel 120 tabs MO junel fe 1530 tabs MO junel fe 120 tabs MO junel fe 24 tabs MO kaitlib fe chew MO kariva tabs MO kelnor 135 tabs MO kelnor 150 tabs MO kurvelo tabs MO larin 1530 tabs MO larin 120 tabs MO larin fe 1530 tabs MO larin fe 120 tabs MO larissia tabs MO LAYOLIS FE CHEW MO leena tabs MO lessina tabs MO levonest tabs MO levonorg-eth estrad triphasic tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
levora 01530 (28) tabs MO LO LOESTRIN FE TABS MO loestrin 1530 (21) tabs MO loestrin 120 (21) tabs MO loestrin fe 1530 tabs MO loestrin fe 120 tabs MO loryna tabs MO low-ogestrel tabs MO lutera tabs MO lyleq tabs MO lyza tabs MO marlissa tabs MO melodetta 24 fe chew MO merzee caps MO mibelas 24 fe chew MO microgestin 1530 tabs MO microgestin 120 tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA TABS MO NATAZIA TABS MO necon 0535 (28) tabs MO NECON 777 TABS MO nikki tabs MO nora-be tabs MO norethin ace-eth estrad-fe caps MO norethin ace-eth estrad-fe chew MO norethin ace-eth estrad-fe tabs MO norethin-eth estradiol-fe chew MO norethindrone acet-ethinyl est tabs MO
norethindrone tabs MO norgestim-eth estrad triphasic tabs MO
norgestimate-eth estradiol tabs MO norlyroc tabs MO
Drug Name RequirementsLimits
nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO NUVARING RING MO nylia 777 tabs MO nymyo tabs MO ocella tabs MO ogestrel tabs MO orsythia tabs MO pimtrea tabs MO pirmella 135 tabs MO portia-28 tabs MO previfem tabs MO reclipsen tabs MO rivelsa tabs MO setlakin tabs MO sharobel tabs MO sprintec 28 tabs MO sronyx tabs MO syeda tabs MO tarina 24 fe tabs MO tarina fe 120 eq tabs MO tilia fe tabs MO tri-estarylla tabs MO tri-legest fe tabs MO tri-lo-estarylla tabs MO tri-lo-sprintec tabs MO tri-mili tabs MO tri-nymyo tabs MO tri-previfem tabs MO tri-sprintec tabs MO tri-vylibra lo tabs MO tri-vylibra tabs MO TRINESSA (28) TABS MO trivora (28) tabs MO tydemy tabs MO velivet tabs MO vestura tabs MO vienva tabs MO vyfemla tabs MO vylibra tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 48 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135e (28) tabs MO DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
ADMELOG SOLN MO ADMELOG SOLOSTAR SOPN MO AFREZZA POWD MO AFREZZA POWD 8 (90) amp 12 (90) UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO APIDRA SOLN PAMO APIDRA SOLOSTAR SOPN MO AVANDIA TABS 2mg 4mg MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD BYDUREON BCISE AUIJ BYDUREON PEN BYETTA 10 MCG PEN SOPN MO BYETTA 5 MCG PEN SOPN MO CYCLOSET TABS MO diazoxide susp glimepiride tabs 1mg 2mg 4mg MO glipizide er tb24 25mg 5mg 10mg MO
glipizide tabs 5mg 10mg MO glipizide-metformin hcl tabs MO GLUCAGEN HYPOKIT SOLR glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO GLYXAMBI TABS MO
Drug Name RequirementsLimits
HUMALOG JUNIOR KWIKPEN SOPN MO
HUMALOG KWIKPEN SOPN 100unitml 200unitml MO
HUMALOG MIX 5050 KWIKPEN SUPN MO
HUMALOG MIX 5050 SUSP MO HUMALOG MIX 7525 KWIKPEN SUPN MO
HUMALOG MIX 7525 SUSP MO HUMALOG SOCT MO HUMALOG SOLN PAMO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN PAMO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
INSULIN ASP PROT amp ASP FLEXPEN SUPN MO
INSULIN ASPART FLEXPEN SOPN MO
INSULIN ASPART PENFILL SOCT MO
INSULIN ASPART PROT amp ASPART SUSP MO
INSULIN ASPART SOLN PAMO INSULIN LISPRO (1 UNIT DIAL) SOPN MO
INSULIN LISPRO SOLN MO INVOKAMET TABS MO INVOKAMET XR TB24 MO INVOKANA TABS 100mg 300mg MO
JARDIANCE TABS 10mg 25mg MO JENTADUETO TABS MO JENTADUETO XR TB24 MO KAZANO TABS MO KORLYM TABS LDNDS LANTUS SOLN MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
LANTUS SOLOSTAR SOPN MO LEVEMIR FLEXTOUCH SOPN MO LEVEMIR SOLN MO metformin hcl er tb24 500mg 750mg MO
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO NOVOLIN 7030 SUSP MO NOVOLOG 7030 FLEXPEN RELION SUPN MO
NOVOLOG FLEXPEN RELION SOPN MO
NOVOLOG FLEXPEN SOPN MO NOVOLOG MIX 7030 FLEXPEN SUPN MO
NOVOLOG MIX 7030 RELION SUSP MO
NOVOLOG MIX 7030 SUSP MO NOVOLOG PENFILL SOCT MO NOVOLOG RELION SOLN PAMO NOVOLOG SOLN PAMO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO PROGLYCEM SUSP MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SOLIQUA SOPN MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO SYNJARDY TABS MO SYNJARDY XR TB24 MO tolazamide tabs 250mg 500mg MO
Drug Name RequirementsLimits
tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO ANGELIQ TABS MO CLIMARA PRO PTWK MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
COMBIPATCH PTTW MO DELESTROGEN OIL depo-estradiol oil DIVIGEL GEL MO dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
DUAVEE TABS MO ELESTRIN GEL MO estrace crea MO estrace tabs 05mg 1mg 2mg MO estradiol crea MO estradiol pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO EVAMIST SOLN MO fyavolv tabs MO IMVEXXY MAINTENANCE PACK INST 4mcg 10mcg MO
IMVEXXY STARTER PACK INST 4mcg 10mcg MO
jinteli tabs MO lopreeza tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 50 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
MENOSTAR PTWK MO mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO ORIAHNN CPPK NDS OSPHENA TABS MO prefest tabs MO PREMARIN SOLR PREMARIN TABS 03mg 045mg 0625mg 09mg 125mg
MO
PREMPHASE TABS MO PREMPRO TABS MO raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS NOVAREL SOLR 5000unit 10000unit PA
ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS PREGNYL SOLR PA TRIPTODUR SRER NDS OXYTOCICS carboprost tromethamine soln methergine tabs methylergonovine maleate soln methylergonovine maleate tabs OXYTOCIN SOLN PARATHYROID calcitonin (salmon) soln MO cinacalcet hcl tabs 30mg 60mg 90mg PANDS
FORTEO SOPN PANDS NATPARA CART 25mcg 50mcg 75mcg 100mcg LDNDS
Drug Name RequirementsLimits
SENSIPAR TABS 30mg 60mg 90mg PANDS
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PALDNDS DDAVP RHINAL TUBE SOLN MO desmopressin ace spray refrig soln MO
desmopressin acetate soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln DESMOPRESSIN ACETATE TABS 01mg 02mg MO
NOCDURNA SUBL 277mcg 553mcg MO
NOCTIVA EMUL 083mcg01ml 166mcg01ml MO
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO CRINONE GEL 4 8 PAMO DEPO-PROVERA SUSP 400mgml
DEPO-SUBQ PROVERA 104 SUSY
ENDOMETRIN INST PA hydroxyprogesterone caproate oil
hydroxyprogesterone caproate soln
MAKENA SOAJ NDS medroxyprogesterone acetate susp
medroxyprogesterone acetate susy
medroxyprogesterone acetate tabs 25mg 5mg 10mg MO
megestrol acetate susp MO norethindrone acetate tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS BYNFEZIA PEN SOPN NDS EGRIFTA SOLR NDS EGRIFTA SV SOLR NDS GENOTROPIN MINIQUICK SOLR 02mg PANDS
GENOTROPIN MINIQUICK SOLR 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
GENOTROPIN SOLR 5mg 12mg PANDS
HUMATROPE SOLR 5mg 6mg 12mg 24mg PANDS
INCRELEX SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
NUTROPIN AQ NUSPIN 20 SOPN PANDS
NUTROPIN AQ NUSPIN 5 SOPN PANDS
octreotide acetate soln OMNITROPE SOCT 5mg15ml 10mg15ml PANDS
OMNITROPE SOLR PANDS SAIZEN CLICKEASY SOLR PANDS SAIZEN SOLR 5mg 88mg PANDS SAIZENPREP SOLR PANDS SANDOSTATIN LAR DEPOT KIT 10mg 20mg 30mg NDS
SEROSTIM SOLR 4mg 5mg 6mg PANDS
SIGNIFOR LAR SRER 10mg 20mg 30mg 40mg 60mg NDS
SIGNIFOR SOLN 03mgml 06mgml 09mgml NDS
SOMATULINE DEPOT SOLN
Drug Name RequirementsLimits
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZOMACTON SOLR 5mg PANDS ZOMACTON SOLR PANDS ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVO-T TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVOTHYROXINE SODIUM SOLR
levothyroxine sodium tabs 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
liothyronine sodium soln liothyronine sodium tabs 5mcg 25mcg 50mcg MO
methimazole tabs 5mg 10mg MO propylthiouracil tabs MO tapazole tabs 5mg 10mg MO THYROLAR-1 TABS THYROLAR-12 TABS THYROLAR-14 TABS THYROLAR-2 TABS THYROLAR-3 TABS TIROSINT CAPS 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 52 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
137mcg 150mcg 175mcg 200mcg UNITHROID TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA REDUCTASE INHIBITORS dutasteride caps MO dutasteride-tamsulosin hcl caps MO finasteride tabs MO ANTIDOTES acetylcysteine soln 10 20 PAMO fomepizole soln KHAPZORY SOLR 175mg 300mg NDS
leucovorin calcium soln leucovorin calcium solr leucovorin calcium tabs 5mg 10mg 15mg 25mg MO
levoleucovorin calcium pf soln levoleucovorin calcium solr VISTOGARD PACK NDS VORAXAZE SOLR NDS ANTIGOUT AGENTS allopurinol sodium solr allopurinol tabs 100mg 300mg MO COLCHICINE CAPS MO colchicine tabs MO febuxostat tabs 40mg 80mg MO GLOPERBA SOLN MITIGARE CAPS MO ULORIC TABS 40mg 80mg MO BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 5mg 10mg 35mg 70mg MO
alendronate sodium tabs 40mg MO BINOSTO TBEF MO EVENITY SOSY NDS FOSAMAX PLUS D TABS MO IBANDRONATE SODIUM SOLN
Drug Name RequirementsLimits
ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr PROLIA SOSY risedronate sodium tabs 5mg 30mg 35mg 150mg MO
RISEDRONATE SODIUM TBEC MO XGEVA SOLN PANDS zoledronic acid conc zoledronic acid soln DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ACTPEN SOAJ NDS ACTEMRA SOSY NDS AVSOLA SOLR NDS CIMZIA KIT PANDS CIMZIA PREFILLED KIT PANDS CIMZIA STARTER KIT KIT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS ENBREL SOSY 25mg05ml 50mgml NDS
ENBREL SURECLICK SOAJ NDS HUMIRA PEDIATRIC CROHNS START PSKT NDS
HUMIRA PEN PNKT 40mg04ml 40mg08ml 80mg08ml
NDS
HUMIRA PEN-CDUCHS STARTER PNKT 40mg08ml 80mg08ml
NDS
HUMIRA PEN-PEDIATRIC UC START PNKT NDS
HUMIRA PEN-PSUVADOL HS START PNKT NDS
HUMIRA PEN-PSORUVEIT STARTER PNKT NDS
HUMIRA PSKT 10mg01ml 10mg02ml 20mg02ml 20mg04ml 40mg04ml 40mg08ml
NDS
INFLECTRA SOLR INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
KEVZARA SOAJ 150mg114ml 200mg114ml NDS
KEVZARA SOSY 150mg114ml 200mg114ml NDS
KINERET SOSY NDS leflunomide tabs 10mg 20mg MO OLUMIANT TABS 1mg 2mg NDS ORENCIA CLICKJECT SOAJ NDS ORENCIA SOLR NDS ORENCIA SOSY 50mg04ml 875mg07ml 125mgml NDS
OTEZLA TABS PANDS OTEZLA TBPK PANDS OTREXUP SOAJ RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 NDS SIMPONI ARIA SOLN NDS SIMPONI SOAJ 50mg05ml 100mgml NDS
SIMPONI SOSY 50mg05ml 100mgml NDS
XELJANZ SOLN NDS XELJANZ TABS 5mg 10mg NDS XELJANZ XR TB24 11mg 22mg NDS IMMUNE SUPPRESSANTS ASTAGRAF XL CP24 05mg 1mg PAMO
ASTAGRAF XL CP24 PA azasan tabs 75mg 100mg PAMO azathioprine sodium solr azathioprine tabs PAMO BENLYSTA SOAJ BENLYSTA SOLR BENLYSTA SOSY cyclosporine caps 25mg 100mg PAMO cyclosporine modified caps 25mg 50mg 100mg PAMO
cyclosporine modified soln PAMO cyclosporine soln PAMO
Drug Name RequirementsLimits
ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg PA GAMIFANT SOLN 50mg10ml 100mg20ml 10mg2ml NDS
gengraf caps 25mg 50mg 100mg PAMO
gengraf soln PAMO LUPKYNIS CAPS NDS MAVENCLAD (10 TABS) TBPK NDS MAVENCLAD (4 TABS) TBPK NDS MAVENCLAD (5 TABS) TBPK NDS MAVENCLAD (6 TABS) TBPK NDS MAVENCLAD (7 TABS) TBPK NDS MAVENCLAD (8 TABS) TBPK NDS MAVENCLAD (9 TABS) TBPK NDS mycophenolate mofetil caps PAMO mycophenolate mofetil hcl solr mycophenolate mofetil susr PAMO mycophenolate mofetil tabs PAMO mycophenolate sodium tbec 180mg 360mg PAMO
NULOJIX SOLR NDS PROGRAF PACK 02mg PA PROGRAF PACK PANDS PROGRAF SOLN PAMO SANDIMMUNE ORAL SOLN 100mgml PAMO
SAPHNELO SOLN NDS sirolimus soln PA sirolimus tabs 05mg 1mg 2mg PAMO tacrolimus caps 05mg 1mg 5mg PAMO
UPLIZNA SOLN ZORTRESS TABS 025mg PAMO ZORTRESS TABS 05mg 075mg 1mg PA
MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 54 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BOTOX SOLR 100unit 200unit PA bupivacaine hcl (pf) soln bupivacaine hcl soln BUPIVACAINE IN DEXTROSE SOLN
bupivacaine spinal soln bupivacaine-epinephrine (pf) soln
bupivacaine-epinephrine soln CARNITOR SOLN PAMO CARNITOR TABS PAMO chloroprocaine hcl (pf) soln CINRYZE SOLR INTRAVENOUS HI
citanest plain dental soln COSELA SOLR NDS CRYSVITA SOLN 10mgml 20mgml 30mgml NDS
CYSTADANE POWD LDNDS CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr DYSPORT SOLR 300unit 500unit PA
EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENSPRYNG SOSY NDS EVRYSDI SOLR NDS EXONDYS 51 SOLN 500mg10ml 100mg2ml NDS
FIRDAPSE TABS NDS FLUORITAB CHEW 025mg 05mg 1mg MO
FLUORITAB SOLN MO GALAFOLD CAPS NDS GIVLAARI SOLN NDS GRASTEK SUBL MO
Drug Name RequirementsLimits
HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS TABS NDS KUVAN PACK 100mg 500mg NDS KUVAN TABS NDS LACTATED RINGERS SOLN levocarnitine soln PAMO LEVOCARNITINE TABS PAMO lidocaine hcl (pf) soln lidocaine hcl soln lidocaine in dextrose soln lidocaine-epinephrine soln LUDENT CHEW 025mg 05mg 1mg MO
mesna soln MESNEX TABS NDS MYALEPT SOLR NDS NAFRINSE CHEW MO NAFRINSE DROPS SOLN MO nitisinone caps 2mg 5mg 10mg NDS NITYR TABS 2mg 5mg 10mg NDS NULIBRY SOLR NDS ODACTRA SUBL ONPATTRO SOLN NDS ORALAIR SUBL MO ORFADIN CAPS LDNDS ORFADIN SUSP LDNDS ORLADEYO CAPS 110mg 150mg NDS
OXLUMO SOLN PALFORZIA (12 MG DAILY DOSE) CSPK NDS
PALFORZIA (120 MG DAILY DOSE) CSPK NDS
PALFORZIA (160 MG DAILY DOSE) CSPK NDS
PALFORZIA (20 MG DAILY DOSE) CSPK NDS
PALFORZIA (200 MG DAILY DOSE) CSPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
PALFORZIA (240 MG DAILY DOSE) CSPK NDS
PALFORZIA (3 MG DAILY DOSE) CSPK NDS
PALFORZIA (300 MG MAINTENANCE) PACK NDS
PALFORZIA (300 MG TITRATION) PACK NDS
PALFORZIA (40 MG DAILY DOSE) CSPK NDS
PALFORZIA (6 MG DAILY DOSE) CSPK NDS
PALFORZIA (80 MG DAILY DOSE) CSPK NDS
PALFORZIA INITIAL ESCALATION CSPK NDS
PHYSIOLYTE SOLN PHYSIOSOL IRRIGATION SOLN
polocaine soln polocaine-mpf soln PROCYSBI CPDR 25mg 75mg NDS PROCYSBI PACK 75mg 300mg NDS REZUROCK TABS NDS RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln RUZURGI TABS NDS sapropterin dihydrochloride pack 100mg 500mg NDS
sapropterin dihydrochloride tabs NDS SENSORCAINE SOLN sensorcaine-mpf soln sensorcaine-mpfepinephrine soln
sensorcaineepinephrine soln SODIUM CHLORIDE SOLN MO SODIUM FLUORIDE CHEW 025mg 05mg 1mg MO
SODIUM FLUORIDE SOLN MO SODIUM FLUORIDE TABS MO STERILE WATER FOR IRRIGATION SOLN
Drug Name RequirementsLimits
TAKHZYRO SOLN NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VILTEPSO SOLN NDS VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR 50unit 100unit PA XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg NDS RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 200mg114ml 300mg2ml PANDS
FASENRA PEN SOAJ NDS FASENRA SOSY PA montelukast sodium chew 4mg 5mg MO
montelukast sodium pack MO montelukast sodium tabs MO NUCALA SOAJ PANDS NUCALA SOLR PANDS NUCALA SOSY PANDS zafirlukast tabs 10mg 20mg MO zileuton er tb12 NDS CYSTIC FIBROSIS BETHKIS NEBU PA
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 56 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CAYSTON SOLR LDNDS KALYDECO PACK 25mg 50mg 75mg PANDS
KALYDECO TABS PANDS KITABIS PAK NEBU PA ORKAMBI PACK NDS ORKAMBI TABS NDS SYMDEKO TBPK NDS TOBI PODHALER CAPS tobramycin nebu 300mg4ml 300mg5ml PA
TRIKAFTA TBPK LDNDS PULMONARY FIBROSIS ESBRIET CAPS PANDS ESBRIET TABS 267mg 801mg PANDS OFEV CAPS 100mg 150mg NDS RESPIRATORY AGENTS MISCELLANEOUS ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS 500mg 1000mg
HI
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact
MO
ASMANEX (120 METERED DOSES) AEPB MO
ASMANEX (30 METERED DOSES) AEPB 110mcginh MO
ASMANEX (30 METERED DOSES) AEPB MO
ASMANEX (60 METERED DOSES) AEPB MO
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
budesonide-formoterol fumarate aero
DALIRESP TABS 250mcg 500mcg MO
DULERA AERO MO
Drug Name RequirementsLimits
FLOVENT DISKUS AEPB 50mcgblist 100mcgblist 250mcgblist
MO
FLOVENT HFA AERO 44mcgact MO
FLOVENT HFA AERO 110mcgact 220mcgact MO
fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PROLASTIN-C SOLN INTRAVENOUS HI
PROLASTIN-C SOLR INTRAVENOUS HI
SYMBICORT AERO wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
ZEMAIRA SOLR INTRAVENOUS HI
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr LETAIRIS TABS 5mg 10mg NDS ORENITRAM TBCR 0125mg LDNDS ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TABS 625mg 125mg NDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
1000mcg 1200mcg 1400mcg 1600mcg UPTRAVI TBPK NDS VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS BIVIGAM SOLN 10gm100ml HI BIVIGAM SOLN 5gm50ml HI CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml
HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS 10gm200ml HI
GAMMAPLEX SOLN INTRAVENOUS 10gm100ml 20gm200ml 5gm50ml
HI
GAMUNEX-C SOLN INJECTION 10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml
HI
HYPERHEP B SOLN HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 5gm100ml HI
Drug Name RequirementsLimits
1gm20ml 2gm20ml 25gm500ml PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
PRIVIGEN SOLN INTRAVENOUS HI
VARIZIG SOLN XEMBIFY SOLN SUBCUTANEOUS 2gm10ml 4gm20ml 10gm50ml 1gm5ml
HI
TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP QUADRACEL SUSP TDVAX SUSP TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP DAPTACEL SUSP ENGERIX-B SUSP 10mcg05ml 20mcgml PA
GARDASIL 9 SUSP GARDASIL 9 SUSY HAVRIX SUSP HEPLISAV-B SOLN PA HIBERIX SOLR IMOVAX RABIES INJ INFANRIX SUSP IPOL INJ IXIARO SUSP M-M-R II SOLR MENACTRA INJ MENQUADFI INJ MENVEO SOLR PEDIARIX SUSP PEDVAX HIB SUSP
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 58 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN VAQTA SUSP VARIVAX INJ VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint AKTIPAK PACK MO AVC VAGINAL CREA BACTROBAN NASAL OINT BENZEPRO CREAMY WASH LIQD
BENZEPRO FOAMING CLOTHS MISC
BENZOYL PEROXIDE GEL NDS benzoyl peroxide-erythromycin gel MO
ciclopirox gel ciclopirox olamine crea ciclopirox olamine susp ciclopirox sham ciclopirox soln CLEOCIN SUPP clindacin-p swab MO clindamycin phos-benzoyl perox gel MO
clindamycin phosphate crea clindamycin phosphate foam MO clindamycin phosphate gel MO clindamycin phosphate lotn MO
Drug Name RequirementsLimits
clindamycin phosphate soln MO clindamycin phosphate swab MO CLINDESSE CREA clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn DENAVIR CREA econazole nitrate crea ERTACZO CREA ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA EXELDERM CREA EXELDERM SOLN gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ivermectin lotn ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham LULICONAZOLE CREA LUZU CREA mafenide acetate pack malathion lotn MENTAX CREA metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 59
Drug Name RequirementsLimits
mupirocin oint naftifine hcl crea naftifine hcl gel NAFTIN GEL NATROBA SUSP neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ORAVIG TABS ovide lotn oxiconazole nitrate crea OXISTAT LOTN permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SKLICE LOTN SODIUM SULFACETAMIDE SHAM
SODIUM SULFACETAMIDE WASH LIQD
SPINOSAD SUSP SSD CREA sulfacetamide sodium (acne) lotn MO SULFACETAMIDE SODIUM GEL
SULFACETAMIDE SODIUM LIQD
SULFAMYLON CREA tavaborole soln terconazole crea terconazole supp VANDAZOLE GEL XEPI CREA MO XERESE CREA ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) ala scalp lotn MO
Drug Name RequirementsLimits
ala-cort crea 1 25 MO alclometasone dipropionate crea MO alclometasone dipropionate oint MO amcinonide crea MO amcinonide lotn MO amcinonide oint MO anusol-hc crea MO apexicon e crea MO benzoyl perox-hydrocortisone lotn
BENZOYL PEROXIDE FORTE- HC LOTN NDS
beser lotn MO betamethasone dipropionate aug crea MO
betamethasone dipropionate aug gel MO
betamethasone dipropionate aug lotn MO
betamethasone dipropionate aug oint MO
betamethasone dipropionate crea MO
betamethasone dipropionate lotn MO BETAMETHASONE DIPROPIONATE OINT MO
betamethasone valerate crea MO betamethasone valerate foam MO BETAMETHASONE VALERATE LOTN MO
BETAMETHASONE VALERATE OINT MO
BRYHALI LOTN MO calcipotriene-betameth diprop oint MONDS
calcipotriene-betameth diprop susp NDS
CAPEX SHAM MO clobetasol propionate crea clobetasol propionate e crea MO clobetasol propionate emulsion foam
clobetasol propionate foam MO clobetasol propionate gel MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 60 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO CLOBEX SHAM MO CLOBEX SPRAY LIQD MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO clodan sham MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT MO DESONATE GEL MO desonide crea MO desonide gel MO desonide lotn MO desonide oint MO desowen lotn MO desoximetasone crea 005 025 MO
desoximetasone gel MO desoximetasone liqd MO desoximetasone oint 005 025 MO
desrx gel MO diclofenac sodium gel 1 3 MO diflorasone diacetate crea MO diflorasone diacetate oint MO DUOBRII LOTN MO ENSTILAR FOAM NDS epifoam foam fluocinolone acetonide body oil fluocinolone acetonide crea 001 0025 MO
fluocinolone acetonide oint MO fluocinolone acetonide scalp oil MO fluocinolone acetonide soln MO fluocinonide crea MO fluocinonide emulsified base crea MO
Drug Name RequirementsLimits
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO flurandrenolide crea MO flurandrenolide lotn MO flurandrenolide oint MO fluticasone propionate crea MO fluticasone propionate lotn MO fluticasone propionate oint MO halcinonide crea MO halobetasol propionate crea MO HALOBETASOL PROPIONATE FOAM NDS
halobetasol propionate oint MO HALOG CREA MO HALOG OINT MO hydrocortisone (perianal) crea 1 25 MO
hydrocortisone butyr lipo base crea
hydrocortisone butyrate crea MO hydrocortisone butyrate lotn MO HYDROCORTISONE BUTYRATE OINT MO
hydrocortisone butyrate soln MO hydrocortisone crea 1 25 MO hydrocortisone enem MO hydrocortisone lotn MO hydrocortisone oint 1 25 MO hydrocortisone valerate crea MO hydrocortisone valerate oint MO LEXETTE FOAM NDS micort-hc crea MO mometasone furoate crea MO mometasone furoate oint MO mometasone furoate soln MO neo-synalar crea MO nolix crea nolix lotn MO nystatin-triamcinolone crea MO nystatin-triamcinolone oint MO oralone pste MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 61
Drug Name RequirementsLimits
PANDEL CREA MO prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO psorcon crea MO TACLONEX SUSP NDS topicort crea 005 025 MO topicort gel MO topicort oint MO tovet foam MO triamcinolone acetonide aers MO triamcinolone acetonide crea 0025 01 05 MO
triamcinolone acetonide lotn 0025 01 MO
triamcinolone acetonide oint 0025 005 01 05 MO
triamcinolone acetonide pste MO trianex oint MO triderm crea 01 05 MO tritocin oint MO UCERIS FOAM MO ULTRAVATE LOTN NDS VANOXIDE-HC LOTN ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
LIDO-SORB LOTN LIDOCAINE HCL CREA lidocaine hcl lotn lidocaine hcl soln PA lidocaine hcl urethralmucosal gel MO
lidocaine hcl urethralmucosal prsy MO
lidocaine oint PAMO lidocaine ptch PAMO
Drug Name RequirementsLimits
LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea PA LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam texacort soln MO TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS ALTRENO LOTN PAMO AVITA CREA PAMO AVITA GEL PAMO KEPIVANCE SOLR NDS PANRETIN GEL NDS RETIN-A CREA 0025 005 01 PAMO
RETIN-A GEL 001 0025 PAMO RETIN-A MICRO GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 008 PAMO
RETIN-A MICRO PUMP GEL PANDS TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 62 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS ABSORICA CAPS 25mg 35mg NDS ABSORICA LD CAPS 8mg 16mg 24mg 32mg NDS
accutane caps 10mg 20mg 30mg 40mg NDS
acitretin caps 10mg 175mg 25mg NDS
ADAPALENE CREA MO adapalene gel 01 03 MO adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
AVAR CLEANSER EMUL AVAR-E EMOLLIENT CREA AVAR-E GREEN CREA azelaic acid gel MO AZELEX CREA MO BP 10-1 EMUL calcipotriene crea MO calcipotriene oint MO calcipotriene soln MO calcitrene oint MO CALCITRIOL OINT MO CARAC CREA CEROVEL LOTN claravis caps 10mg 20mg 30mg 40mg NDS
CONDYLOX GEL MO COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
Drug Name RequirementsLimits
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA MO DIFFERIN LOTN MO EPIDUO FORTE GEL MO FABIOR FOAM PAMO FINACEA FOAM MO fluorouracil crea 5 MO fluorouracil crea 5 fluorouracil soln 2 5 MO ILUMYA SOSY PA imiquimod crea 375 5 MO IMIQUIMOD PUMP CREA MO isotretinoin caps 10mg 20mg 30mg 40mg NDS
keralyt sham KLISYRI OINT NDS LACTIC ACID LOTN methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
ORACEA CPDR pimecrolimus crea MO podofilox soln MO RECTIV OINT MO REGRANEX GEL NDS RYNODERM CREA NDS SALEX SHAM SALICYLIC ACID CREA SALICYLIC ACID ER SOLN SALICYLIC ACID FOAM SALICYLIC ACID GEL SALICYLIC ACID LIQD SALICYLIC ACID SHAM SALICYLIC ACID WART REMOVER LIQD
SALICYLIC ACID-CLEANSER KIT
SALIMEZ CREA SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 63
Drug Name RequirementsLimits
SKYRIZI PEN SOAJ SKYRIZI SOSY SORILUX FOAM MO SSS 10-5 CREA STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
SULFACETAMIDE SODIUM-SULFUR CREA
SULFACETAMIDE SODIUM-SULFUR EMUL
SULFACETAMIDE SODIUM-SULFUR LIQD
SULFACETAMIDE SODIUM-SULFUR LOTN
SULFACETAMIDE SODIUM-SULFUR PADS
SULFACETAMIDE SODIUM-SULFUR SUSP
SULFACLEANSE 84 SUSP sulfamez wash emul TACROLIMUS OINT 01 003 MO
TALTZ SOAJ NDS TALTZ SOSY NDS tazarotene crea PAMO tazarotene foam PAMO TAZORAC CREA PAMO TAZORAC GEL 005 01 PAMO TOLAK CREA TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS VECTICAL OINT MO VEREGEN OINT MO WYNZORA CREA NDS XUREA CREA
Drug Name RequirementsLimits
zenatane caps 10mg 20mg 30mg 40mg NDS
ZYCLARA PUMP CREA MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline soln darifenacin hydrobromide er tb24 75mg 15mg MO
elixophyllin elix flavoxate hcl tabs MO MYRBETRIQ TB24 25mg 50mg MO oxybutynin chloride er tb24 5mg 10mg 15mg MO
oxybutynin chloride syrp MO oxybutynin chloride tabs MO solifenacin succinate tabs 5mg 10mg MO
theo-24 cp24 100mg 200mg 300mg 400mg MO
theophylline er tb12 100mg 200mg 300mg 450mg MO
theophylline er tb24 400mg 600mg MO
theophylline soln MO tolterodine tartrate er cp24 2mg 4mg MO
tolterodine tartrate tabs MO trospium chloride er cp24 MO trospium chloride tabs MO VITAMINS VITAMINS ADCF (05MGML) SOLN MO calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN MULTI-VITAMINFLUORIDEIRON SOLN
MO
MULTI-VITAMINFLUORIDE SOLN MO
MULTIVITAMINFLUORIDE CHEW MO
64 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
MVC-FLUORIDE CHEW MO paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS TRI-VITAMINFLUORIDE SOLN MO TRI-VITEFLUORIDE SOLN MO VITAMINS ACD-FLUORIDE SOLN MO
VP-PNV-DHA CAPS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 65
The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not and
you need an urgent refill please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 6 or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number on page 6 NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
66 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Index of Drugs
A abacavir sulfate soln 12 abacavir sulfate tabs 12 abacavir sulfate-lamivudine tabs 12 abacavir-lamivudine-zidovudine tabs 12 ABELCET SUSP INTRAVENOUS 11 ABILIFY MAINTENA PRSY 300mg 400mg
35 ABILIFY MAINTENA SRER 300mg 400mg
35 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
abiraterone acetate tabs 250mg 500mg 14 ABRAXANE SUSR 14 ABSORICA CAPS 25mg 35mg 62 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 62 ABSTRAL SUBL 100mcg 200mcg
300mcg 400mcg 600mcg 800mcg 27 acamprosate calcium tbec 26 acarbose tabs 25mg 50mg 100mg 48 accutane caps 10mg 20mg 30mg 40mg 62 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 27 acetaminophen-codeine soln 27 acetaminophen-codeine tabs 27 acetazolamide er cp12 42 acetazolamide sodium solr 42 acetazolamide tabs 125mg 250mg 42 ACETIC ACID SOLN 42 53 acetylcysteine soln 10 20 52 acitretin caps 10mg 175mg 25mg 62 ACTEMRA ACTPEN SOAJ 52 ACTEMRA SOSY 52 ACTHAR GEL 50 ACTHIB SOLR 57 ACTIMMUNE SOLN 53 ACUVAIL SOLN 41
acyclovir caps 12 acyclovir oint 58 acyclovir sodium soln intravenous 12 acyclovir susp 12 acyclovir tabs 400mg 800mg 12 ADACEL SUSP 57 ADAGEN SOLN 40 ADAKVEO SOLN 21 ADAPALENE CREA 62 adapalene gel 01 03 62 adapalene pads 62 adapalene soln 62 adapalene-benzoyl peroxide gel 62 ADAPALENE-BENZOYL PEROXIDE PADS
62 ADCF (05MGML) SOLN 63 adderall tabs 29 ADDERALL XR CP24 29 adefovir dipivoxil tabs 12 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 56 adenosine soln 25 ADMELOG SOLN 48 ADMELOG SOLOSTAR SOPN 48 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 20 ADZENYS ER SUER 29 ADZENYS XR-ODT TBED 31mg 63mg
94mg 125mg 157mg 188mg 29 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 25mg 5mg 75mg 10mg
14 AFREZZA POWD 48 AFREZZA POWD 8 (90) amp 12 (90) UNIT 48 AJOVY SOAJ 32 AJOVY SOSY 32 AKTIPAK PACK 58 AKYNZEO CAPS 43 ala scalp lotn 59 ala-cort crea 1 25 59 albendazole tabs 8
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 67
albuterol sulfate er tb12 4mg 8mg 20 albuterol sulfate hfa aers 20 albuterol sulfate nebu 0083 25mg05ml
20 albuterol sulfate nebu 063mg3ml
125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 59 alclometasone dipropionate oint 59 ALCOHOL PREP PADS 37 ALDACTAZIDE TABS 25 ALDURAZYME SOLN 40 ALECENSA CAPS 14 alendronate sodium soln 52 alendronate sodium tabs 40mg 52 alendronate sodium tabs 5mg 10mg
35mg 70mg 52 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 05mg 1mg
2mg 5mg 45 allopurinol sodium solr 52 allopurinol tabs 100mg 300mg 52 allzital tabs 27 almotriptan malate tabs 32 ALOCRIL SOLN 42 alogliptin benzoate tabs 625mg 125mg
25mg 48 ALOGLIPTIN-METFORMIN HCL TABS 48 alogliptin-pioglitazone tabs 48 ALOMIDE SOLN 42 ALOSETRON HCL TABS 05mg 1mg 43 ALPHAGAN P SOLN 42 alprazolam er tb24 05mg 1mg 2mg 3mg
33 alprazolam intensol conc 33 alprazolam tabs 025mg 05mg 1mg 2mg
33 alprazolam tbdp 025mg 05mg 1mg 2mg
33 ALREX SUSP 41 ALTACAINE SOLN 42 ALTAFRIN SOLN 42 altavera tabs 46 ALTOPREV TB24 20mg 40mg 60mg 23 ALTRENO LOTN 61
ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 56 alyacen 135 tabs 46 alyq tabs 26 amabelz tabs 49 amantadine hcl caps 32 amantadine hcl syrp 32 amantadine hcl tabs 32 AMBISOME SUSR INTRAVENOUS 11 ambrisentan tabs 56 amcinonide crea 59 amcinonide lotn 59 amcinonide oint 59 amethia lo tabs 46 amethia tabs 46 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 38 amiloride-hydrochlorothiazide tabs 38 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 63 AMINOSYN-PF SOLN INTRAVENOUS 38 amiodarone hcl soln 25 amiodarone hcl tabs 100mg 200mg
400mg 25 AMITIZA CAPS 8mcg 24mcg 44 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 amlodipine besy-benazepril hcl caps 24 amlodipine besylate tabs 25mg 5mg
10mg 24 amlodipine besylate-valsartan tabs 24 amlodipine-atorvastatin tabs 24 amlodipine-olmesartan tabs 24 amlodipine-valsartan-hctz tabs 24 ammonium lactate crea 62 ammonium lactate lotn 62 amnesteem caps 10mg 20mg 40mg 62 AMONDYS 45 SOLN 53 amoxapine tabs 25mg 50mg 100mg
150mg 35 amoxicill-clarithro-lansopraz misc 43 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8
68 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 29 amphetamine sulfate tabs 5mg 10mg 30 amphetamine-dextroamphet er cp24 30 amphetamine-dextroamphetamine tabs 30 amphotericin b solr intravenous 11 ampicillin caps 8 ampicillin sodium solr 8 ampicillin sodium solr injection 1gm 125mg
8 ampicillin sodium solr intravenous 8 ampicillin-sulbactam sodium solr 8 ampicillin-sulbactam sodium solr injection 8 ampicillin-sulbactam sodium solr
intravenous 8 ANADROL-50 TABS 45 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 61 anastrozole tabs 14 ANDRODERM PT24 2mg24hr 4mg24hr
45 ANGELIQ TABS 49 ANORO ELLIPTA AEPB 19 antabuse tabs 250mg 500mg 26 ANTARA CAPS 30mg 90mg 23 anusol-hc crea 59 ANZEMET TABS 50mg 100mg 43 apap-caff-dihydrocodeine tabs 27 apexicon e crea 59 APIDRA SOLN 48 APIDRA SOLOSTAR SOPN 48 APLENZIN TB24 174mg 348mg 522mg 35 APOKYN SOCT 32 apraclonidine hcl soln 42 aprepitant caps 43 apri tabs 46 APRISO CP24 43 APTIOM TABS 200mg 400mg 600mg
800mg 30 APTIVUS CAPS 12 APTIVUS SOLN 12 ARALAST NP SOLR INTRAVENOUS
500mg 1000mg 56 aranelle tabs 46 ARANESP (ALBUMIN FREE) SOLN
25mcgml 40mcgml 22
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml 22
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml 22
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 22
ARCALYST SOLR 53 ARCAPTA NEOHALER CAPS 20 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 54 ARIKAYCE SUSP 8 aripiprazole soln 35 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 35 aripiprazole tbdp 10mg 15mg 35 ARISTADA INITIO PRSY 35 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 35
armodafinil tabs 50mg 150mg 200mg 250mg 30
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact 56
ARRANON SOLN 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 54 ARYMO ER TBEA 27 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 57 ascomp-codeine caps 27 asenapine maleate subl 25mg 5mg 10mg
35 ashlyna tabs 46 ASMANEX (120 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
110mcginh 56 ASMANEX (60 METERED DOSES) AEPB
56 ASMANEX HFA AERO 100mcgact
200mcgact 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 69
ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 53 ASTAGRAF XL CP24 05mg 1mg 53 atazanavir sulfate caps 150mg 200mg
300mg 12 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 34 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 23 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 42 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 34 aubra eq tabs 46 AUGMENTIN SUSR 8 AURYXIA TABS 39 AUSTEDO TABS 6mg 9mg 12mg 34 AVANDIA TABS 2mg 4mg 48 AVAR CLEANSER EMUL 62 AVAR-E EMOLLIENT CREA 62 AVAR-E GREEN CREA 62 AVASTIN SOLN 14 AVC VAGINAL CREA 58 AVEED SOLN 45 aviane tabs 46 AVITA CREA 61 AVITA GEL 61 AVONEX KIT 34 AVONEX PEN AJKT 34 AVONEX PREFILLED PSKT 34 AVSOLA SOLR 52 AVYCAZ SOLR INTRAVENOUS 8 aygestin tabs 50 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 53 AZASITE SOLN 40 azathioprine sodium solr 53 azathioprine tabs 53 azelaic acid gel 62 azelastine hcl soln 005 01 015 42 azelastine-fluticasone susp 42 AZELEX CREA 62
AZITHROMYCIN PACK 8 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
B bacitracin oint 40 bacitracin solr 8 bacitracin-polymyxin b oint 40 bacitra-neomycin-polymyxin-hc oint 41 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 58 BAFIERTAM CPDR 34 balsalazide disodium caps 43 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 46 BANZEL SUSP 30 BANZEL TABS 200mg 400mg 30 BAQSIMI ONE PACK POWD 48 BAQSIMI TWO PACK POWD 48 BARACLUDE SOLN 12 BAVENCIO SOLN 14 BAXDELA SOLR INTRAVENOUS 8 BAXDELA TABS 8 BCG VACCINE INJ 14 BD INSULIN SYR ULTRAFINE II MISC 37 BD INSULIN SYRINGE MISC 37 BD INSULIN SYRINGE UF MISC 37 BD PEN NEEDLE ORIGINAL UF MISC 37 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 27 BELEODAQ SOLR 14 BELRAPZO SOLN 14 BELSOMRA TABS 33 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 15 BENDEKA SOLN 15 BENLYSTA SOAJ 53 BENLYSTA SOLR 53 BENLYSTA SOSY 53 BENZEPRO CREAMY WASH LIQD 58 BENZEPRO FOAMING CLOTHS MISC 58 benzhydrocodone-acetaminophen tabs 27 BENZNIDAZOLE TABS 125mg 100mg 11 benzoyl perox-hydrocortisone lotn 59
70 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
BENZOYL PEROXIDE FORTE- HC LOTN 59
BENZOYL PEROXIDE GEL 58 benzoyl peroxide-erythromycin gel 58 benztropine mesylate soln 32 benztropine mesylate tabs 05mg 1mg
2mg 32 BEOVU SOLN 42 bepotastine besilate soln 42 BERINERT KIT INTRAVENOUS 21 beser lotn 59 BESIVANCE SUSP 40 BESPONSA SOLR 15 betamethasone dipropionate aug crea 59 betamethasone dipropionate aug gel 59 betamethasone dipropionate aug lotn 59 betamethasone dipropionate aug oint 59 betamethasone dipropionate crea 59 betamethasone dipropionate lotn 59 BETAMETHASONE DIPROPIONATE OINT
59 betamethasone sod phos amp acet susp 45 betamethasone valerate crea 59 betamethasone valerate foam 59 BETAMETHASONE VALERATE LOTN 59 BETAMETHASONE VALERATE OINT 59 BETASERON KIT 34 betaxolol hcl soln 42 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 20 BETHKIS NEBU 55 BETIMOL SOLN 025 05 42 BETOPTIC-S SUSP 42 BEVESPI AEROSPHERE AERO 19 BEVYXXA CAPS 40mg 80mg 21 bexarotene caps 15 BEXSERO SUSY 57 bicalutamide tabs 15 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICNU SOLR 15 BIDIL TABS 26 BIKTARVY TABS 12 bimatoprost soln 42 BINOSTO TBEF 52 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23
BIVIGAM SOLN 10gm100ml 57 BIVIGAM SOLN 5gm50ml 57 bleomycin sulfate solr 15 bleph-10 soln 40 blephamide sop oint 41 BLEPHAMIDE SUSP 41 BLINCYTO SOLR 15 blisovi 24 fe tabs 46 blisovi fe 1530 tabs 46 BONJESTA TBCR 43 BOOSTRIX SUSP 57 BORTEZOMIB SOLR 15 bosentan tabs 56 BOSULIF TABS 100mg 400mg 500mg 15 BOTOX SOLR 100unit 200unit 54 BP 10-1 EMUL 62 BRAFTOVI CAPS 50mg 75mg 15 briellyn tabs 46 BRILINTA TABS 60mg 90mg 21 BRIMONIDINE TARTRATE SOLN 02
015 42 brinzolamide susp 42 BRIVIACT SOLN 30 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 30 bromfenac sodium (once-daily) soln 41 bromocriptine mesylate caps 32 bromocriptine mesylate tabs 32 BROMSITE SOLN 41 BRONCHITOL CAPS 56 BROVANA NEBU 20 BRUKINSA CAPS 15 BRYHALI LOTN 59 budesonide cpep 45 budesonide er tb24 45 budesonide susp 025mg2ml 05mg2ml
1mg2ml 56 budesonide-formoterol fumarate aero 56 bumetanide soln 38 bumetanide tabs 05mg 1mg 2mg 38 BUNAVAIL FILM 34 bupap tabs 27 bupivacaine hcl (pf) soln 54 bupivacaine hcl soln 54 BUPIVACAINE IN DEXTROSE SOLN 54 bupivacaine spinal soln 54 bupivacaine-epinephrine (pf) soln 54 bupivacaine-epinephrine soln 54 buprenorphine hcl soln 27
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 71
buprenorphine hcl subl 2mg 8mg 34 buprenorphine hcl-naloxone hcl film 34 buprenorphine hcl-naloxone hcl subl 34 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 27 bupropion hcl er (smoking det) tb12 35 bupropion hcl er (sr) tb12 100mg 150mg
200mg 35 bupropion hcl er (xl) tb24 150mg 300mg
450mg 35 bupropion hcl tabs 75mg 100mg 35 buspirone hcl tabs 5mg 10mg 33 buspirone hcl tabs 75mg 15mg 30mg 33 busulfan soln 15 butalbital-acetaminophen caps 27 butalbital-acetaminophen tabs 27 butalbital-apap-caff-cod caps 27 butalbital-apap-caffeine caps 27 butalbital-apap-caffeine tabs 27 butalbital-asa-caff-codeine caps 27 butalbital-aspirin-caffeine caps 27 butalbital-aspirin-caffeine tabs 27 butorphanol tartrate soln 1mgml 2mgml
10mgml 27 BUTRANS PTWK 27 BYDUREON BCISE AUIJ 48 BYDUREON PEN 48 BYETTA 10 MCG PEN SOPN 48 BYETTA 5 MCG PEN SOPN 48 BYLVAY (PELLETS) CPSP 200mcg
600mcg 44 BYLVAY CAPS 400mcg 1200mcg 44 BYNFEZIA PEN SOPN 51
C CABENUVA SUER 12 cabergoline tabs 32 CABLIVI KIT 22 CABOMETYX TABS 20mg 40mg 60mg 15 cafergot tabs 32 caffeine citrate soln 30 calcipotriene crea 62 calcipotriene oint 62 calcipotriene soln 62 calcipotriene-betameth diprop oint 59 calcipotriene-betameth diprop susp 59 calcitonin (salmon) soln 50 calcitrene oint 62 calcitriol caps 025mcg 05mcg 63
CALCITRIOL OINT 62 calcitriol soln 63 calcium acetate (phos binder) caps 39 calcium acetate (phos binder) tabs 39 CALCIUM GLUCONATE-NACL SOLN 39 CALQUENCE CAPS 15 camila tabs 46 camrese lo tabs 46 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 59 CAPLYTA CAPS 35 CAPRELSA TABS 100mg 300mg 15 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 26 CARAC CREA 62 CARAFATE SUSP 43 CARBAGLU TABS 37 carbamazepine chew 30 carbamazepine er cp12 100mg 200mg
300mg 30 carbamazepine er tb12 100mg 200mg
400mg 30 carbamazepine susp 30 carbamazepine tabs 30 carbidopa tabs 32 carbidopa-levodopa er tbcr 32 carbidopa-levodopa tabs 32 carbidopa-levodopa tbdp 32 carbidopa-levodopa-entacapone tabs 32 carbinoxamine maleate soln 14 carbinoxamine maleate tabs 14 carboplatin soln 15 carboprost tromethamine soln 50 CARDENE IV SOLN 24 CARDIZEM LA TB24 24 CARDURA XL TB24 4mg 8mg 22 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 15 CARNITOR SOLN 54 CARNITOR TABS 54 CAROSPIR SUSP 26 carteolol hcl soln 42
72 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
cartia xt cp24 120mg 180mg 240mg 300mg 24
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg 23
carvedilol tabs 3125mg 625mg 125mg 25mg 23
caspofungin acetate solr intravenous 50mg 70mg 11
cataflam tabs 27 CAYSTON SOLR 56 caziant tabs 46 cefaclor caps 8 cefaclor er tb12 8 cefaclor susr 8 cefadroxil caps 8 cefadroxil susr 8 cefadroxil tabs 8 cefazolin sodium solr 8 cefazolin sodium solr injection 1gm 10gm
500mg 8 cefdinir caps 8 cefdinir susr 8 cefepime hcl solr injection 1gm 2gm 8 cefixime caps 8 cefixime susr 8 cefotaxime sodium solr 8 cefotetan disodium solr injection 1gm 2gm 8 cefoxitin sodium solr injection 8 cefoxitin sodium solr intravenous 1gm 2gm
8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 2gm 6gm 8 CEFTIN SUSR 8 ceftriaxone sodium solr injection 1gm 2gm
250mg 500mg 8 ceftriaxone sodium solr intravenous 8 cefuroxime axetil tabs 8 cefuroxime sodium solr injection 75gm
750mg 8 cefuroxime sodium solr intravenous 8 celecoxib caps 27 CELONTIN CAPS 30 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 41
CERDELGA CAPS 40 CEREZYME SOLR 40 CEROVEL LOTN 62 CESAMET CAPS 43 cetirizine hcl soln 14 CETRAXAL SOLN 40 CEVIMELINE HCL CAPS 20 CHANTIX CONTINUING MONTH PAK
TABS 20 CHANTIX STARTING MONTH PAK TABS
20 CHANTIX TABS 05mg 1mg 20 CHEMET CAPS 44 chloramphenicol sod succinate solr 9 chlordiazepoxide hcl caps 5mg 10mg
25mg 33 chlordiazepoxide-amitriptyline tabs 35 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 40 chloroprocaine hcl (pf) soln 54 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 38 chlorothiazide tabs 250mg 500mg 38 chlorpromazine hcl soln 35 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 35 chlorthalidone tabs 25mg 50mg 38 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 44 cholestyramine light pack 23 cholestyramine light powd 23 cholestyramine pack 23 cholestyramine powd 23 CHORIONIC GONADOTROPIN SOLR 50 ciclopirox gel 58 ciclopirox olamine crea 58 ciclopirox olamine susp 58 ciclopirox sham 58 ciclopirox soln 58 cidofovir soln 12 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 40 CIMDUO TABS 12 cimetidine hcl soln 43 cimetidine tabs 200mg 300mg 400mg
800mg 43 CIMZIA KIT 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 73
CIMZIA PREFILLED KIT 52 CIMZIA STARTER KIT KIT 52 cinacalcet hcl tabs 30mg 60mg 90mg 50 CINQAIR SOLN 55 CINRYZE SOLR INTRAVENOUS 54 CIPRO HC SUSP 41 CIPRODEX SUSP 41 ciprofloxacin hcl soln (ophth) 40 CIPROFLOXACIN HCL SOLN (OTIC) 40 ciprofloxacin hcl tabs 9 ciprofloxacin in d5w soln 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 41 CIPROFLOXACIN-FLUOCINOLONE PF
SOLN 40 cisplatin soln 15 CISPLATIN SOLR 15 citalopram hydrobromide soln 35 citalopram hydrobromide tabs 10mg 20mg
40mg 35 citanest plain dental soln 54 cladribine soln 15 claravis caps 10mg 20mg 30mg 40mg 62 CLARINEX SYRP 14 CLARINEX-D 12 HOUR TB12 14 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 14 cleocin phosphate soln 9 cleocin solr 9 CLEOCIN SUPP 58 CLIMARA PRO PTWK 49 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
clindacin-p swab 58 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 58 clindamycin phosphate crea 58 clindamycin phosphate foam 58 clindamycin phosphate gel 58 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 58
clindamycin phosphate soln 9 58 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 58 CLINDESSE CREA 58 CLINIMIX EDEXTROSE (27510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42525) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (525) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (525) SOLN
INTRAVENOUS 38 clinisol sf soln intravenous 38 clobazam susp 30 clobazam tabs 10mg 20mg 30 clobetasol propionate crea 59 clobetasol propionate e crea 59 clobetasol propionate emulsion foam 59 clobetasol propionate foam 59 clobetasol propionate gel 59 clobetasol propionate liqd 60 clobetasol propionate lotn 60 clobetasol propionate oint 60 clobetasol propionate sham 60 clobetasol propionate soln 60 CLOBEX SHAM 60
74 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
CLOBEX SPRAY LIQD 60 clocortolone pivalate crea 60 clocortolone pivalate pump crea 60 clodan sham 60 clofarabine soln 15 clomipramine hcl caps 25mg 50mg 75mg
35 clonazepam tabs 05mg 1mg 2mg 30 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 30 clonidine hcl (analgesia) soln 25 clonidine hcl er tb12 25 clonidine hcl tabs 01mg 02mg 03mg 25 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 25 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 33 clotrimazole crea 58 clotrimazole soln 58 clotrimazole troc 58 clotrimazole-betamethasone crea 58 clotrimazole-betamethasone lotn 58 clovique caps 44 clozapine tabs 25mg 50mg 100mg 200mg
35 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 35 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 27 colazal caps 43 COLCHICINE CAPS 52 colchicine tabs 52 colchicine-probenecid tabs 40 colesevelam hcl pack 23 colesevelam hcl tabs 23 colestipol hcl gran 23 colestipol hcl pack 23 colestipol hcl tabs 23 colistimethate sodium (cba) solr injection 9 colocort enem 60 COLY-MYCIN S SUSP 41 COMBIGAN SOLN 42 COMBIPATCH PTTW 49 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 15 COMETRIQ (140 MG DAILY DOSE) KIT 15 COMETRIQ (60 MG DAILY DOSE) KIT 15
COMPLERA TABS 12 compro supp 35 CONDYLOX GEL 62 CONSENSI TABS 24 constulose soln 37 COPIKTRA CAPS 15mg 25mg 15 CORDRAN TAPE 60 CORLANOR TABS 5mg 75mg 25 cortisone acetate tabs 45 CORTISPORIN CREA 60 CORTISPORIN OINT 60 COSELA SOLR 54 COSENTYX (300 MG DOSE) SOSY 62 COSENTYX SENSOREADY (300 MG)
SOAJ 62 COSENTYX SENSOREADY PEN SOAJ 62 COSENTYX SOSY 75mg05ml 150mgml
62 COTELLIC TABS 15 COTEMPLA XR-ODT TBED 86mg
173mg 259mg 30 CREON CPEP 40 CRESEMBA CAPS 11 CRESEMBA SOLR 11 CRINONE GEL 4 8 50 CRIXIVAN CAPS 200mg 400mg 12 cromolyn sodium conc 55 cromolyn sodium nebu 55 cromolyn sodium soln 42 crotan lotn 58 cryselle-28 tabs 46 CRYSVITA SOLN 10mgml 20mgml
30mgml 54 CUPRIMINE CAPS 44 CURITY GAUZE PADS 37 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 57
CUVPOSA SOLN 19 cyclafem 135 tabs 46 cyclafem 777 tabs 46 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 15 CYCLOPHOSPHAMIDE SOLN 1gm5ml
500mg25ml 15 cyclophosphamide solr 15
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 75
cycloserine caps 11 CYCLOSET TABS 48 cyclosporine caps 25mg 100mg 53 cyclosporine modified caps 25mg 50mg
100mg 53 cyclosporine modified soln 53 cyclosporine soln 53 cyproheptadine hcl syrp 14 cyproheptadine hcl tabs 14 CYRAMZA SOLN 100mg10ml
500mg50ml 15 cyred eq tabs 46 CYSTADANE POWD 54 CYSTADROPS SOLN 42 CYSTAGON CAPS 50mg 150mg 54 CYSTARAN SOLN 42 cytarabine (pf) soln 15 cytarabine soln 15 CYTOGAM INJ 57
D dacarbazine solr 15 dactinomycin solr 15 DAKLINZA TABS 30mg 60mg 90mg 12 dalfampridine er tb12 34 DALIRESP TABS 250mcg 500mcg 56 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 45 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 62 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 57 daptomycin solr intravenous 350mg 500mg
9 DARAPRIM TABS 11 darifenacin hydrobromide er tb24 75mg
15mg 63 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 DAYTRANA PTCH 10mg9hr 15mg9hr
20mg9hr 30mg9hr 30 DDAVP RHINAL TUBE SOLN 50 deblitane tabs 46 decadron elix 45
decadron tabs 5mg 75mg 45 decadron tabs 4mg 6mg 45 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 44 deferasirox tabs 90mg 180mg 360mg 44 deferasirox tbso 125mg 44 deferasirox tbso 250mg 500mg 44 deferiprone tabs 44 deferoxamine mesylate solr 44 DELESTROGEN OIL 49 DELSTRIGO TABS 12 deltasone tabs 45 delyla tabs 46 DELZICOL CPDR 43 demeclocycline hcl tabs 9 DEMEROL SOLN 25mg05ml 75mg15ml
100mg2ml 75mgml 27 DEMSER CAPS 22 DENAVIR CREA 58 DEPEN TITRATABS TABS 44 depo-estradiol oil 49 DEPO-MEDROL SUSP 45 DEPO-PROVERA SUSP 400mgml 50 DEPO-SUBQ PROVERA 104 SUSY 50 depo-testosterone soln 100mgml
200mgml 45 DERMOTIC OIL 41 DESCOVY TABS 12 desipramine hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 desloratadine tabs 14 desloratadine tbdp 14 desmopressin ace spray refrig soln 50 desmopressin acetate
soln 50 DESMOPRESSIN ACETATE SOLN 50 desmopressin acetate spray soln 50 DESMOPRESSIN ACETATE TABS 01mg
02mg 50 desogestrel-ethinyl estradiol tabs 46 DESONATE GEL 60 desonide crea 60 desonide gel 60 desonide lotn 60 desonide oint 60 desowen lotn 60 desoximetasone crea 005 025 60 desoximetasone gel 60
76 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
desoximetasone liqd 60 desoximetasone oint 005 025 60 desrx gel 60 DESVENLAFAXINE ER TB24 50mg
100mg 35 desvenlafaxine succinate er tb24 25mg
50mg 100mg 35 dexabliss tbpk 45 dexamethasone elix 45 dexamethasone intensol conc 45 dexamethasone sod phosphate pf soln 45 dexamethasone sodium phosphate soln 41
45 dexamethasone soln 45 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 45 dexamethasone tbpk 45 dexchlorpheniramine maleate soln 14 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 30
dexmethylphenidate hcl tabs 25mg 5mg 10mg 30
dexpak 10 day tbpk 45 dexpak 13 day tbpk 45 dexpak 6 day tbpk 45 dexrazoxane hcl solr 54 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 30 dextroamphetamine sulfate soln 30 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 30 DEXTROSE 10NACL 02 39 DEXTROSE 5NACL 0225 39 DEXTROSE IN LACTATED RINGERS
SOLN 39 DEXTROSE SOLN 38 dextrose soln intravenous 5 10 38 DEXTROSE-NACL SOLN INTRAVENOUS
39 DIACOMIT CAPS 250mg 500mg 30 DIACOMIT PACK 250mg 500mg 31 DIASTAT ACUDIAL GEL 10mg 20mg 31 DIASTAT PEDIATRIC GEL 31 diazepam conc 33 diazepam gel 25mg 10mg 20mg 31 diazepam soln 5mg5ml 5mgml 33 diazepam tabs 2mg 5mg 10mg 33 diazoxide susp 48
diclofenac potassium tabs 27 diclofenac sodium er tb24 27 diclofenac sodium gel 1 3 60 diclofenac sodium soln 41 diclofenac sodium tbec 27 diclofenac-misoprostol tbec 27 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 12 DIFFERIN CREA 62 DIFFERIN LOTN 62 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 60 diflorasone diacetate oint 60 diflunisal tabs 27 digitek tabs 0125mg 025mg 25 digox tabs 25 DIGOXIN ORAL SOLN 25 digoxin soln inj 25 digoxin tabs 125mcg 250mcg 25 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 31 dilantin infatabs chew 31 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 24 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 24
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 24
diltiazem hcl er cp12 60mg 90mg 120mg 24
diltiazem hcl er cp24 120mg 180mg 240mg 24
diltiazem hcl soln 24 diltiazem hcl solr 24 diltiazem hcl tabs 30mg 60mg 90mg
120mg 24 dilt-xr cp24 120mg 180mg 240mg 24 dimenhydrinate soln 43 dimethyl fumarate cpdr 34 dimethyl fumarate starter pack misc 34 DIPENTUM CAPS 43 diphen elix 14 di-phen elix 14 diphenhydramine hcl elix 14
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 77
diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 43 diphenoxylate-atropine tabs 43 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 57 dipyridamole tabs 25mg 50mg 75mg 26 disopyramide phosphate caps 100mg
150mg 25 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 38 divalproex sodium csdr 31 divalproex sodium er tb24 250mg 500mg 31 divalproex sodium tbec 125mg 250mg
500mg 31 DIVIGEL GEL 49 dobutamine hcl soln 21 DOBUTAMINE IN D5W SOLN 21 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 160mg8ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
25 dolishale tabs 46 donepezil hcl tabs 5mg 10mg 23mg 20 donepezil hcl tbdp 5mg 10mg 20 dopamine hcl soln 21 DOPAMINE IN D5W SOLN 21 DOPTELET TABS 22 DORYX MPC TBEC 9 dorzolamide hcl soln 42 dorzolamide hcl-timolol mal pf soln 42 dorzolamide hcl-timolol mal soln 42 dotti pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 49
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 35 doxepin hcl conc 35 doxepin hcl crea 61 doxepin hcl tabs 3mg 6mg 35 doxercalciferol caps 05mcg 1mcg 25mcg
63 DOXERCALCIFEROL SOLN 63 doxorubicin hcl liposomal inj 15 DOXORUBICIN HCL SOLN 15
doxorubicin hcl solr 15 doxy 100 solr intravenous 9 doxycycline hyclate caps 50mg 100mg 9 doxycycline hyclate tabs 20mg 75mg
100mg 150mg 9 doxycycline hyclate tbec 50mg 75mg
100mg 150mg 200mg 9 doxycycline monohydrate caps 50mg
75mg 100mg 150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 43 DRIZALMA SPRINKLE CSDR 35 dronabinol caps 25mg 5mg 10mg 43 droperidol soln 33 drospiren-eth estrad-levomefol tabs 46 drospirenone-ethinyl estradiol tabs 46 DROXIA CAPS 15 droxidopa caps 21 DUAKLIR PRESSAIR AEPB 19 DUAVEE TABS 49 DUEXIS TABS 27 DULERA AERO 56 duloxetine hcl cpep 20mg 30mg 40mg
60mg 35 DUOBRII LOTN 60 DUOPA SUSP 32 DUPIXENT SOPN 200mg114ml
300mg2ml 55 DUPIXENT SOSY 200mg114ml
300mg2ml 55 DURAMORPH SOLN 05mgml 1mgml 27 DUREZOL EMUL 41 DURYSTA IMPL 42 dutasteride caps 52 dutasteride-tamsulosin hcl caps 52 DUTOPROL TB24 23 dvorah tabs 27 dxevo 11-day tbpk 45 DYANAVEL XR SUER 30 DYSPORT SOLR 300unit 500unit 54
E ees 400 tabs 9 EASYGEL GEL 54 econazole nitrate crea 58 EDARBYCLOR TABS 26 EDLUAR SUBL 5mg 10mg 33
78 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 51 EGRIFTA SV SOLR 51 ELAPRASE SOLN 40 ELELYSO SOLR 40 ELEPSIA XR TB24 1000mg 1500mg 31 ELESTRIN GEL 49 eletriptan hydrobromide tabs 32 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 40 elixophyllin elix 63 ELLA TABS 46 ELLENCE SOLN 15 ELMIRON CAPS 54 eluryng ring 46 ELZONRIS SOLN 15 EMBEDA CPCR 27 EMCYT CAPS 15 EMEND SUSR 43 EMFLAZA SUSP 45 EMFLAZA TABS 6mg 18mg 30mg 36mg
45 EMGALITY (300 MG DOSE) SOSY 32 EMGALITY SOAJ 32 EMGALITY SOSY 32 emoquette tabs 46 EMPAVELI SOLN 54 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 32 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 26 enalaprilat inj 26 enalapril-hydrochlorothiazide tabs 26 ENBREL MINI SOCT 52 ENBREL SOLN 52 ENBREL SOLR 52 ENBREL SOSY 25mg05ml 50mgml 52 ENBREL SURECLICK SOAJ 52 ENDARI PACK 54 endocet tabs 27
ENDOMETRIN INST 50 ENGERIX-B SUSP 10mcg05ml 20mcgml
57 ENHERTU SOLR 15 enoxaparin sodium soln 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
enpresse-28 tabs 46 enskyce tabs 46 ENSPRYNG SOSY 54 ENSTILAR FOAM 60 entacapone tabs 33 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 26 ENTYVIO SOLR 44 enulose soln 37 ENVARSUS XR TB24 075mg 1mg 4mg53 EPCLUSA TABS 12 EPIDIOLEX SOLN 31 EPIDUO FORTE GEL 62 epifoam foam 60 epinastine hcl soln 42 epinephrine (anaphylaxis) soln 21 epinephrine soaj 21 EPINEPHRINE SOSY 21 EPIPEN 2-PAK SOAJ 21 EPIPEN JR 2-PAK SOAJ 21 epirubicin hcl soln 15 epitol tabs 31 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 26 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 22
epoprostenol sodium solr 56 eprosartan mesylate tabs 26 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 35 ERAXIS SOLR INTRAVENOUS 50mg
100mg 11 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 32 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 79
ERTACZO CREA 58 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 58 ery-tab tbec 9 ERYTHROCIN LACTOBIONATE SOLR
INTRAVENOUS 9 erythrocin stearate tabs 9 erythromycin base cpep 9 erythromycin base tabs 9 erythromycin base tbec 9 erythromycin ethylsuccinate susr 9 erythromycin ethylsuccinate tabs 9 erythromycin gel 58 erythromycin oint 40 erythromycin pads 58 erythromycin soln 58 ESBRIET CAPS 56 ESBRIET TABS 267mg 801mg 56 escitalopram oxalate soln 35 escitalopram oxalate tabs 5mg 10mg
20mg 35 esgic caps 27 esgic tabs 27 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 43 esomeprazole magnesium pack 10mg
20mg 40mg 43 esomeprazole sodium solr 43 ESOMEPRAZOLE STRONTIUM CPDR 43 estarylla tabs 46 estazolam tabs 1mg 2mg 33 estrace crea 49 estrace tabs 05mg 1mg 2mg 49 estradiol crea 49 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 49
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
estradiol tabs 10mcg 05mg 1mg 2mg 49 estradiol valerate oil 49 estradiol-norethindrone acet tabs 49 ESTRING RING 49 eszopiclone tabs 1mg 2mg 3mg 33
ethacrynic acid tabs 38 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 31 ethosuximide soln 31 ethynodiol diac-eth estradiol tabs 46 etodolac caps 27 etodolac er tb24 27 etodolac tabs 27 etonogestrel-ethinyl estradiol ring 46 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 EURAX CREA 58 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
EVAMIST SOLN 49 evekeo tabs 5mg 10mg 30 EVENITY SOSY 52 everolimus tabs 025mg 53 everolimus tabs 05mg 075mg 53 everolimus tabs 25mg 5mg 75mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 23 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 54 EXELDERM CREA 58 EXELDERM SOLN 58 exemestane tabs 15 EXJADE TBSO 125mg 250mg 500mg 44 EXONDYS 51 SOLN 500mg10ml
100mg2ml 54 EXSERVAN FILM 34 EXTAVIA KIT 34 EYLEA SOLN 42 EYLEA SOSY 42 ezetimibe tabs 23 ezetimibe-simvastatin tabs 23
F FABIOR FOAM 62 FABRAZYME SOLR 5mg 35mg 40 falmina tabs 46 famciclovir tabs 125mg 250mg 500mg 12 famotidine premixed soln 43 famotidine soln 43 famotidine susr 43 famotidine tabs 20mg 40mg 43
80 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg 35
FANAPT TITRATION PACK TABS 35 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 55 FASENRA SOSY 55 FASLODEX SOLN 15 fayosim tabs 46 febuxostat tabs 40mg 80mg 52 felbamate susp 31 felbamate tabs 400mg 600mg 31 felodipine er tb24 25mg 5mg 10mg 24 femynor tabs 46 fenofibrate caps 50mg 134mg 150mg 23 fenofibrate micronized caps 43mg 67mg
130mg 200mg 23 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 23 fenofibric acid cpdr 45mg 135mg 23 FENOFIBRIC ACID TABS 35mg 105mg 23 fenoprofen calcium caps 27 fenoprofen calcium tabs 27 fenortho caps 27 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 27 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 27
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg 27
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 27
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 27
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg 27
FERRIPROX SOLN 44 FERRIPROX TABS 500mg 1000mg 44 FERRIPROX TWICE-A-DAY TABS 44 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
35 FETZIMA TITRATION C4PK 35 fexmid tabs 20 FIBRICOR TABS 23 FINACEA FOAM 62 finasteride tabs 52 FINTEPLA SOLN 31
fioricet caps 27 fioricetcodeine caps 27 FIRAZYR SOLN 21 FIRDAPSE TABS 54 FIRMAGON (240 MG DOSE) SOLR 16 FIRMAGON SOLR 16 FIRVANQ SOLR 9 flac oil 41 FLAREX SUSP 41 flavoxate hcl tabs 63 FLEBOGAMMA DIF SOLN INTRAVENOUS
5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml 57
flecainide acetate tabs 50mg 100mg 150mg 25
FLOLIPID SUSP 20mg5ml 40mg5ml 23 FLOVENT DISKUS AEPB 50mcgblist
100mcgblist 250mcgblist 56 FLOVENT HFA AERO 110mcgact
220mcgact 56 FLOVENT HFA AERO 44mcgact 56 floxuridine solr 16 fluconazole in sodium chloride soln
intravenous 11 fluconazole susr 11 fluconazole tabs 11 flucytosine caps 250mg 500mg 11 fludarabine phosphate soln 16 fludarabine phosphate solr 16 fludrocortisone acetate tabs 45 flumazenil soln 34 flunisolide soln 41 fluocinolone acetonide body oil 60 fluocinolone acetonide crea 001 0025
60 fluocinolone acetonide oil 41 fluocinolone acetonide oint 60 fluocinolone acetonide scalp oil 60 fluocinolone acetonide soln 60 fluocinonide crea 60 fluocinonide emulsified base crea 60 FLUOCINONIDE GEL 60 fluocinonide oint 60 fluocinonide soln 60 FLUORITAB CHEW 025mg 05mg 1mg 54 FLUORITAB SOLN 54 fluorometholone susp 41 fluorouracil crea 5 62
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 81
fluorouracil crea 5 62 fluorouracil soln 16 62 fluorouracil soln 2 5 62 fluoxetine hcl (pmdd) tabs 10mg 20mg 35 fluoxetine hcl caps 10mg 20mg 40mg 35 fluoxetine hcl cpdr 35 fluoxetine hcl soln 35 fluoxetine hcl tabs 10mg 20mg 60mg 36 fluphenazine decanoate soln 36 fluphenazine hcl conc 36 fluphenazine hcl elix 36 fluphenazine hcl soln 36 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 36 flurandrenolide crea 60 flurandrenolide lotn 60 flurandrenolide oint 60 flurazepam hcl caps 15mg 30mg 33 flurbiprofen sodium soln 41 flurbiprofen tabs 27 flutamide caps 16 fluticasone propionate crea 60 fluticasone propionate lotn 60 fluticasone propionate oint 60 fluticasone propionate susp 41 fluticasone-salmeterol aepb 56 fluvastatin sodium caps 20mg 40mg 23 fluvastatin sodium er tb24 23 fluvoxamine maleate er cp24 100mg
150mg 36 fluvoxamine maleate tabs 25mg 50mg
100mg 36 FML FORTE SUSP 41 FML OINT 41 fomepizole soln 52 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 formoterol fumarate nebu 21 FORTEO SOPN 50 FOSAMAX PLUS D TABS 52 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 43 fosfomycin tromethamine pack 14 fosinopril sodium tabs 10mg 20mg 40mg
26 fosinopril sodium-hctz tabs 26 fosphenytoin sodium soln 31 FOSRENOL PACK 750mg 1000mg 39
FOTIVDA CAPS 089mg 134mg 16 FREAMINE HBC SOLN INTRAVENOUS 38 frovatriptan succinate tabs 32 FULPHILA SOSY 22 fulvestrant soln 16 furosemide soln 8mgml 10mgml 38 furosemide soln injection 38 FUROSEMIDE TABS 40mg 80mg 20mg38 FUZEON SOLR 12 fyavolv tabs 49 FYCOMPA SUSP 31 FYCOMPA TABS 31
G gabapentin caps 100mg 400mg 31 gabapentin soln 31 gabapentin tabs 600mg 800mg 31 GALAFOLD CAPS 54 galantamine hydrobromide er cp24 8mg
16mg 24mg 20 galantamine hydrobromide soln 20 galantamine hydrobromide tabs 4mg 8mg
12mg 20 GAMASTAN INJ 57 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 53 GAMMAGARD SD LESS IGA SOLR
INTRAVENOUS 5gm 10gm 57 GAMMAGARD SOLN INJECTION 57 GAMMAKED SOLN INJECTION 57 GAMMAPLEX SOLN INTRAVENOUS
10gm100ml 20gm200ml 5gm50ml 57 GAMMAPLEX SOLN INTRAVENOUS
10gm200ml 57 GAMUNEX-C SOLN INJECTION
10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml 57
ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 57 GARDASIL 9 SUSY 57 gatifloxacin soln 40 GATTEX KIT 44 gavilyte-c solr 44 gavilyte-g solr 44 gavilyte-h kit 44 gavilyte-n with flavor pack solr 44 GAVRETO CAPS 16 GAZYVA SOLN 16
82 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
gemcitabine hcl soln 16 gemcitabine hcl solr 16 gemfibrozil tabs 23 gemmily caps 46 generlac soln 37 gengraf caps 25mg 50mg 100mg 53 gengraf soln 53 GENOTROPIN MINIQUICK SOLR 02mg 51 GENOTROPIN MINIQUICK SOLR 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 51
GENOTROPIN SOLR 5mg 12mg 51 gentak oint 40 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 58 gentamicin sulfate oint 58 gentamicin sulfate soln 9 40 gentamicin sulfate soln injection 9 GENVOYA TABS 12 GEODON SOLR 36 gianvi tabs 46 GILENYA CAPS 025mg 05mg 34 GILOTRIF TABS 20mg 30mg 40mg 16 GIMOTI SOLN 44 GIVLAARI SOLN 54 GLASSIA SOLN INTRAVENOUS 56 glatiramer acetate sosy 20mgml 40mgml
34 glatopa sosy 20mgml 40mgml 34 glimepiride tabs 1mg 2mg 4mg 48 glipizide er tb24 25mg 5mg 10mg 48 glipizide tabs 5mg 10mg 48 glipizide-metformin hcl tabs 48 GLOPERBA SOLN 52 GLUCAGEN HYPOKIT SOLR 48 glucagon emergency kit 48 glyburide micronized tabs 15mg 3mg 6mg
48 glyburide tabs 125mg 25mg 5mg 48 glyburide-metformin tabs 48 glycate tabs 19 glycopyrrolate pf sosy 19 glycopyrrolate soln 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 61 GLYXAMBI TABS 48 GOLYTELY SOLR 44 GONITRO PACK 26
granisetron hcl soln 43 granisetron hcl tabs 43 GRANIX SOLN 480mcg16ml 300mcgml
22 GRANIX SOSY 300mcg05ml
480mcg08ml 22 GRASTEK SUBL 54 griseofulvin microsize susp 11 griseofulvin microsize tabs 11 griseofulvin ultramicrosize tabs 11 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 34 guanfacine hcl tabs 1mg 2mg 25 GUANIDINE HCL TABS 20 gynazole-1 crea 58
H HAEGARDA SOLR 2000unit 3000unit 54 hailey 24 fe tabs 46 halcinonide crea 60 halobetasol propionate crea 60 HALOBETASOL PROPIONATE FOAM 60 halobetasol propionate oint 60 HALOG CREA 60 HALOG OINT 60 haloperidol decanoate soln 36 haloperidol lactate conc 36 haloperidol lactate soln 36 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 36 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 57 heparin (porcine) in nacl soln 21 HEPARIN SOD (PORCINE) IN D5W SOLN
21 heparin sodium (porcine) pf soln 21 heparin sodium (porcine) soln 1000unitml
5000unitml 10000unitml 20000unitml 21
HEPATAMINE SOLN INTRAVENOUS 38 HEPLISAV-B SOLN 57 HERCEPTIN HYLECTA SOLN 16 HERCEPTIN SOLR 150mg 440mg 16 HERZUMA SOLR 150mg 420mg 16 HETLIOZ CAPS 33 HETLIOZ LQ SUSP 33 HEXALEN CAPS 16 HIBERIX SOLR 57
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 83
HORIZANT TBCR 300mg 600mg 31 HUMALOG JUNIOR KWIKPEN SOPN 48 HUMALOG KWIKPEN SOPN 100unitml
200unitml 48 HUMALOG MIX 5050 KWIKPEN SUPN 48 HUMALOG MIX 5050 SUSP 48 HUMALOG MIX 7525 KWIKPEN SUPN 48 HUMALOG MIX 7525 SUSP 48 HUMALOG SOCT 48 HUMALOG SOLN 48 humatin caps 11 HUMATROPE SOLR 5mg 6mg 12mg
24mg 51 HUMIRA PEDIATRIC CROHNS START
PSKT 52 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 52 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 52 HUMIRA PEN-PEDIATRIC UC START
PNKT 52 HUMIRA PEN-PSUVADOL HS START
PNKT 52 HUMIRA PEN-PSORUVEIT STARTER
PNKT 52 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 52
HUMULIN 7030 KWIKPEN SUPN 48 HUMULIN 7030 SUSP 48 HUMULIN N KWIKPEN SUPN 48 HUMULIN N SUSP 48 HUMULIN R SOLN 48 HUMULIN R U-500 (CONCENTRATED)
SOLN 48 HUMULIN R U-500 KWIKPEN SOPN 48 hydralazine hcl soln 25 hydralazine hcl tabs 10mg 25mg 50mg
100mg 25 hydrochlorothiazide caps 38 hydrochlorothiazide tabs 125mg 25mg
50mg 38 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 27 hydrocodone-acetaminophen soln 27 hydrocodone-acetaminophen tabs 27 hydrocodone-ibuprofen tabs 27 hydrocortisone (perianal) crea 1 25 60 hydrocortisone ace-pramoxine crea 61
hydrocortisone butyr lipo base crea 60 hydrocortisone butyrate crea 60 hydrocortisone butyrate lotn 60 HYDROCORTISONE BUTYRATE OINT 60 hydrocortisone butyrate soln 60 hydrocortisone crea 1 25 60 hydrocortisone enem 60 hydrocortisone lotn 60 hydrocortisone oint 1 25 60 hydrocortisone tabs 5mg 10mg 20mg 45 hydrocortisone valerate crea 60 hydrocortisone valerate oint 60 HYDROCORTISONE-ACETIC ACID SOLN
41 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 28 hydromorphone hcl liqd 28 hydromorphone hcl pf soln 50mg5ml
10mgml 28 HYDROMORPHONE HCL SOLN 1mgml
2mgml 28 hydromorphone hcl tabs 2mg 4mg 8mg 28 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 50 hydroxyprogesterone caproate soln 50 hydroxyurea caps 16 hydroxyzine hcl soln 33 hydroxyzine hcl syrp 33 hydroxyzine hcl tabs 33 hydroxyzine pamoate caps 33 HYPERHEP B SOLN 57 HYPERRAB SD SOLN 57 HYQVIA KIT 57
I IBANDRONATE SODIUM SOLN 52 ibandronate sodium tabs 52 IBRANCE CAPS 75mg 100mg 125mg 16 IBRANCE TABS 75mg 100mg 125mg 16 ibu tabs 28 ibudone tabs 28 ibuprofen lysine soln 28 ibuprofen susp 28 ibuprofen tabs 28 ibutilide fumarate soln 25 icatibant acetate soln 21 iclevia tabs 46 ICLUSIG TABS 10mg 15mg 30mg 45mg
16
84 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
icosapent ethyl caps 23 IDAMYCIN PFS SOLN 16 idarubicin hcl soln 16 IDHIFA TABS 50mg 100mg 16 ifosfamide soln 16 IFOSFAMIDE SOLR 16 ILARIS SOLN 28 ILEVRO SUSP 41 ILUMYA SOSY 62 ILUVIEN IMPL 41 imatinib mesylate tabs 16 IMBRUVICA CAPS 70mg 140mg 16 IMBRUVICA TABS 140mg 280mg 420mg
560mg 16 IMFINZI SOLN 500mg10ml 120mg24ml
16 imipenem-cilastatin solr intravenous 9 imipramine hcl tabs 10mg 25mg 50mg 36 imipramine pamoate caps 75mg 100mg
125mg 150mg 36 imiquimod crea 375 5 62 IMIQUIMOD PUMP CREA 62 IMOGAM RABIES-HT SOLN 57 IMOVAX RABIES INJ 57 IMPAVIDO CAPS 11 IMVEXXY MAINTENANCE PACK INST
4mcg 10mcg 49 IMVEXXY STARTER PACK INST 4mcg
10mcg 49 INBRIJA CAPS 33 incassia tabs 46 INCRELEX SOLN 51 INCRUSE ELLIPTA AEPB 19 indapamide tabs 125mg 25mg 38 indocin supp 28 INDOCIN SUSP 28 indomethacin caps 28 INDOMETHACIN CAPS 20mg 28 indomethacin er cpcr 28 indomethacin sodium solr 28 INFANRIX SUSP 57 INFLECTRA SOLR INTRAVENOUS 52 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 34 INGREZZA CPPK 34 INLYTA TABS 1mg 5mg 16 INNOPRAN XL CP24 80mg 120mg 23 INQOVI TABS 16 INREBIC CAPS 16
INSULIN ASP PROT amp ASP FLEXPEN SUPN 48
INSULIN ASPART FLEXPEN SOPN 48 INSULIN ASPART PENFILL SOCT 48 INSULIN ASPART PROT amp ASPART SUSP
48 INSULIN ASPART SOLN 48 INSULIN LISPRO (1 UNIT DIAL) SOPN 48 INSULIN LISPRO SOLN 48 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 38 INTRALIPID EMUL INTRAVENOUS
20gm100ml 38 INTRAROSA INST 45 INTRON A SOLN 10muml 6000000unitml
16 INTRON A SOLR 10mu 18mu 50mu 16 introvale tabs 46 INVEGA SUSTENNA SUSY 39mg025ml
36 INVEGA SUSTENNA SUSY 78mg05ml
117mg075ml 234mg15ml 156mgml 36
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml 36
INVELTYS SUSP 41 INVIRASE CAPS 12 INVIRASE TABS 12 INVOKAMET TABS 48 INVOKAMET XR TB24 48 INVOKANA TABS 100mg 300mg 48 IONOSOL-MB IN D5W SOLN
INTRAVENOUS 39 IOPIDINE SOLN 42 IPOL INJ 57 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 21 irbesartan tabs 75mg 150mg 300mg 26 irbesartan-hydrochlorothiazide tabs 26 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isibloom tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 85
ISOLYTE-P IN D5W SOLN INTRAVENOUS 39
ISOLYTE-S SOLN INTRAVENOUS 39 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 21 isosorbide dinitrate er tbcr 26 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 26 isosorbide mononitrate er tb24 26 isosorbide mononitrate er tb24 30mg 60mg
26 isosorbide mononitrate tabs 10mg 20mg 26 isotretinoin caps 10mg 20mg 30mg 40mg
62 isradipine caps 25mg 5mg 24 ISTURISA TABS 1mg 5mg 10mg 54 itraconazole caps 11 ITRACONAZOLE SOLN 11 ivermectin crea 58 ivermectin lotn 58 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 57
J JADENU SPRINKLE PACK 90mg 180mg
360mg 44 JADENU TABS 90mg 360mg 44 JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16 jantoven tabs 1mg 2mg 25mg 3mg 4mg
5mg 6mg 75mg 10mg 21 JARDIANCE TABS 10mg 25mg 48 jasmiel tabs 46 JEMPERLI SOLN 16 JENTADUETO TABS 48 JENTADUETO XR TB24 48 jinteli tabs 49 JOLIVETTE TABS 46 juleber tabs 46 JULUCA TABS 12 junel 1530 tabs 46 junel 120 tabs 46 junel fe 1530 tabs 46 junel fe 120 tabs 46 junel fe 24 tabs 46
JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg 23
JYNARQUE TABS 15mg 30mg 39 JYNARQUE TBPK 39
K KADCYLA SOLR 100mg 160mg 16 KADIAN CP24 28 kaitlib fe chew 46 KALYDECO PACK 25mg 50mg 75mg 56 KALYDECO TABS 56 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 40 kariva tabs 46 KAZANO TABS 48 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-033 MEQ 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 40-5-09 MEQ 39 KCL-LACTATED RINGERS-D5W SOLN
INTRAVENOUS 39 KEDRAB SOLN 57 kelnor 135 tabs 46 kelnor 150 tabs 46 KENALOG SUSP 45 KEPIVANCE SOLR 61 keralyt sham 62 KESIMPTA SOAJ 54 ketoconazole crea 58 ketoconazole foam 58 ketoconazole sham 58 ketoconazole tabs 11 ketodan foam 58 ketoprofen caps 28 ketoprofen er cp24 28 ketorolac tromethamine soln 28 41 ketorolac tromethamine soln 04 05 41 ketorolac tromethamine tabs 28 KEVEYIS TABS 54 KEVZARA SOAJ 150mg114ml
200mg114ml 53 KEVZARA SOSY 150mg114ml
200mg114ml 53 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 52 KHEDEZLA TB24 50mg 100mg 36 KIMYRSA SOLR 9
86 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
KINERET SOSY 53 KINRIX SUSP 57 kionex susp 39 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (200 MG DOSE) TBPK
16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KITABIS PAK NEBU 56 KLISYRI OINT 62 KLOR-CON 10 TBCR 39 klor-con m10 tbcr 39 klor-con m15 tbcr 39 klor-con m20 tbcr 39 klor-con pack 39 klor-con sprinkle cpcr 8meq 10meq 39 KLOR-CON TBCR 39 KORLYM TABS 48 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 37 K-TAB TBCR 39 kurvelo tabs 46 KUVAN PACK 100mg 500mg 54 KUVAN TABS 54 KYNAMRO SOSY 23 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 33 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 LACRISERT INST 42 LACTATED RINGERS SOLN 39 54 LACTIC ACID LOTN 62 lactulose encephalopathy soln 37 lactulose pack 38 lactulose soln 38 LAMICTAL XR KIT 31 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 31
lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg 31
lamotrigine kit 31 lamotrigine starter kit-blue kit 31 lamotrigine starter kit-green kit 31 lamotrigine starter kit-orange kit 31 lamotrigine tabs 25mg 100mg 150mg
200mg 31 lamotrigine tbdp 25mg 50mg 100mg
200mg 31 LANOXIN PEDIATRIC SOLN 25 LANOXIN TABS 625mcg 25 lansoprazole cpdr 15mg 30mg 43 lansoprazole tbdd 15mg 30mg 43 lanthanum carbonate chew 500mg 750mg
1000mg 39 LANTUS SOLN 48 LANTUS SOLOSTAR SOPN 49 lapatinib ditosylate tabs 16 larin 1530 tabs 46 larin 120 tabs 46 larin fe 1530 tabs 46 larin fe 120 tabs 46 larissia tabs 46 LARTRUVO SOLN 190mg19ml
500mg50ml 16 LASTACAFT SOLN 42 latanoprost soln 42 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 36 LAYOLIS FE CHEW 46 LAZANDA SOLN 100mcgact 300mcgact
400mcgact 28 ledipasvir-sofosbuvir tabs 12 leena tabs 46 leflunomide tabs 10mg 20mg 53 LEMTRADA SOLN 34 LENVIMA (10 MG DAILY DOSE) CPPK 16 LENVIMA (12 MG DAILY DOSE) CPPK 16 LENVIMA (14 MG DAILY DOSE) CPPK 16 LENVIMA (18 MG DAILY DOSE) CPPK 16 LENVIMA (20 MG DAILY DOSE) CPPK 16 LENVIMA (24 MG DAILY DOSE) CPPK 16 LENVIMA (4 MG DAILY DOSE) CPPK 16 LENVIMA (8 MG DAILY DOSE) CPPK 17 lessina tabs 46 LETAIRIS TABS 5mg 10mg 56 letrozole tabs 17 leucovorin calcium soln 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 87
leucovorin calcium solr 52 leucovorin calcium tabs 5mg 10mg 15mg
25mg 52 LEUKERAN TABS 17 LEUKINE SOLR 22 leuprolide acetate kit 17 levalbuterol hcl nebu 125mg05ml
031mg3ml 063mg3ml 125mg3ml 21 levalbuterol tartrate aero 21 LEVEMIR FLEXTOUCH SOPN 49 LEVEMIR SOLN 49 levetiracetam er tb24 500mg 750mg 31 levetiracetam in nacl soln 31 levetiracetam soln 31 levetiracetam tabs 250mg 500mg 750mg
1000mg 31 levobunolol hcl soln 42 levocarnitine soln 54 LEVOCARNITINE TABS 54 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 40 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 52 levoleucovorin calcium solr 52 levonest tabs 46 levonorgest-eth est amp eth est tabs 47 levonorgest-eth estrad 91-day tabs 47 levonorgestrel-ethinyl estrad tabs 47 levonorg-eth estrad triphasic tabs 46 levora 01530 (28) tabs 47 levorphanol tartrate tabs 2mg 3mg 28 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEVOTHYROXINE SODIUM SOLR 51 levothyroxine sodium tabs 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEXETTE FOAM 60 LEXIVA SUSP 12 LIALDA TBEC 43 LIBTAYO SOLN 17 lidocaine hcl (cardiac) pf sosy 25 lidocaine hcl (cardiac) sosy 25 lidocaine hcl (pf) soln 54 LIDOCAINE HCL CREA 61 lidocaine hcl lotn 61 lidocaine hcl soln 42 54 61 lidocaine hcl urethralmucosal gel 61 lidocaine hcl urethralmucosal prsy 61 LIDOCAINE IN D5W SOLN 25 lidocaine in dextrose soln 54 lidocaine oint 61 lidocaine ptch 61 lidocaine viscous hcl soln 42 lidocaine-epinephrine soln 54 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 61 LIDOCAINE-HYDROCORTISONE ACE KIT
61 lidocaine-prilocaine crea 61 lidocaine-tetracaine crea 61 LIDOCORT CREA 61 lidopin crea 61 LIDO-SORB LOTN 61 LIDOZION LOTN 61 lincomycin hcl soln 9 lindane sham 58 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 LINZESS CAPS 72mcg 145mcg 290mcg
44 liothyronine sodium soln 51 liothyronine sodium tabs 5mcg 25mcg
50mcg 51 LIPODOX 50 INJ 17 lisinopril tabs 25mg 5mg 10mg 20mg
30mg 40mg 26 lisinopril-hydrochlorothiazide tabs 26 LITHIUM CARBONATE CAPS 300mg
150mg 600mg 36 lithium carbonate er tbcr 300mg 450mg 36 lithium carbonate tabs 36
88 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
LITHIUM SOLN 36 LITHOSTAT TABS 38 LIVALO TABS 1mg 2mg 4mg 23 LO LOESTRIN FE TABS 47 lodine tabs 28 loestrin 1530 (21) tabs 47 loestrin 120 (21) tabs 47 loestrin fe 1530 tabs 47 loestrin fe 120 tabs 47 LOKELMA PACK 5gm 10gm 39 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 17 loperamide hcl caps 43 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 49 lorazepam intensol conc 33 LORAZEPAM SOLN 4mgml 2mgml 33 lorazepam tabs 05mg 1mg 2mg 33 LORBRENA TABS 25mg 100mg 17 lorcet hd tabs 28 lorcet plus tabs 28 lorcet tabs 28 lortab elix 28 loryna tabs 47 lorzone tabs 375mg 750mg 20 losartan potassium tabs 25mg 50mg
100mg 26 losartan potassium-hctz tabs 26 LOTEMAX GEL 41 LOTEMAX OINT 41 LOTEMAX SUSP 41 loteprednol etabonate susp 41 lovastatin tabs 10mg 20mg 40mg 23 LOVENOX SOLN 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
low-ogestrel tabs 47 loxapine succinate caps 5mg 10mg 25mg
50mg 36 lubiprostone caps 8mcg 24mcg 44 LUCEMYRA TABS 34 LUCENTIS SOLN 03mg005ml
05mg005ml 42 LUCENTIS SOSY 03mg005ml
05mg005ml 42 LUDENT CHEW 025mg 05mg 1mg 54 LULICONAZOLE CREA 58 LUMAKRAS TABS 17
LUMIGAN SOLN 42 LUMIZYME SOLR 40 LUMOXITI SOLR 17 LUPANETA PACK KIT 17 LUPKYNIS CAPS 53 LUPRON DEPOT (1-MONTH) KIT 17 LUPRON DEPOT (3-MONTH) KIT 17 LUPRON DEPOT (4-MONTH) KIT 17 LUPRON DEPOT (6-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 17 LUPRON DEPOT-PED (3-MONTH) KIT 17 lutera tabs 47 LUZU CREA 58 lyleq tabs 47 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 50
LYNPARZA CAPS 17 LYNPARZA TABS 100mg 150mg 17 LYSODREN TABS 17 lyza tabs 47
M mafenide acetate pack 58 magnesium sulfate in d5w soln 39 magnesium sulfate soln 31 magnesium sulfate soln injection 50 31 MAGNESIUM SULFATE SOLN
INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml 31
MAKENA SOAJ 50 malathion lotn 58 MANNITOL SOLN 39 maprotiline hcl tabs 25mg 50mg 75mg 36 MARGENZA SOLN 17 marlissa tabs 47 MARPLAN TABS 36 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 24 MAVENCLAD (10 TABS) TBPK 53 MAVENCLAD (4 TABS) TBPK 53 MAVENCLAD (5 TABS) TBPK 53 MAVENCLAD (6 TABS) TBPK 53 MAVENCLAD (7 TABS) TBPK 53 MAVENCLAD (8 TABS) TBPK 53
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 89
MAVENCLAD (9 TABS) TBPK 53 MAVYRET TABS 12 MAXIDEX SUSP 41 MAYZENT STARTER PACK TBPK 34 MAYZENT TABS 025mg 2mg 34 MENAPHOSMBHYO1 TABS 14 meclizine hcl tabs 43 meclofenamate sodium caps 28 MEDROL TABS 45 medroxyprogesterone acetate susp 50 medroxyprogesterone acetate susy 50 medroxyprogesterone acetate tabs 25mg
5mg 10mg 50 mefenamic acid caps 28 mefloquine hcl tabs 11 megestrol acetate susp 17 50 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 47 meloxicam caps 28 meloxicam tabs 28 melphalan hcl solr 17 memantine hcl er cp24 34 memantine hcl soln 34 memantine hcl tabs 5mg 10mg 34 MENACTRA INJ 57 menest tabs 03mg 0625mg 125mg 50 MENOSTAR PTWK 50 MENQUADFI INJ 57 MENTAX CREA 58 MENVEO SOLR 57 meperidine hcl soln 50mg5ml 25mgml
50mgml 100mgml 28 meperidine hcl tabs 50mg 100mg 28 meprobamate tabs 33 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 47 mesalamine cpdr 43 mesalamine enem 43 mesalamine er cp24 43 mesalamine supp 43 mesalamine tbec 12gm 800mg 43 mesalamine-cleanser kit 43 mesna soln 54 MESNEX TABS 54 MESTINON SOLN 20 metadate er tbcr 30
metaproterenol sulfate syrp 21 metaproterenol sulfate tabs 10mg 20mg 21 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 49 metformin hcl tabs 500mg 850mg 1000mg
49 methadone hcl conc 28 methadone hcl intensol conc 28 methadone hcl soln 5mg5ml 10mg5ml
10mgml 28 methadone hcl tabs 5mg 10mg 28 methamphetamine hcl tabs 30 methazolamide tabs 25mg 50mg 42 methenamine hippurate tabs 14 METHENAMINE MANDELATE TABS 14 methergine tabs 50 methimazole tabs 5mg 10mg 51 methitest tabs 45 methocarbamol soln 20 methocarbamol tabs 20 methotrexate sodium (pf) soln 17 methotrexate sodium soln 17 methotrexate sodium solr 17 methotrexate tabs 17 methoxsalen rapid caps 62 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 39 methyldopa tabs 250mg 500mg 25 methyldopa-hydrochlorothiazide tabs 25 methylergonovine maleate soln 50 methylergonovine maleate tabs 50 methylphenidate hcl chew 25mg 5mg
10mg 30 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 30 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 30 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 30
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 30
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 30
methylphenidate hcl soln 5mg5ml 10mg5ml 30
90 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
methylphenidate hcl tabs 5mg 10mg 20mg 30
methylprednisolone acetate susp 45 methylprednisolone sodium succ solr 45 methylprednisolone tabs 4mg 8mg 16mg
32mg 45 methylprednisolone tbpk 45 methyltestosterone caps 45 metoclopramide hcl soln 44 metoclopramide hcl tabs 5mg 10mg 44 metoclopramide hcl tbdp 5mg 10mg 44 metolazone tabs 25mg 5mg 10mg 39 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 24 metoprolol tartrate soct 24 metoprolol tartrate soln 24 metoprolol tartrate tabs 25mg 50mg
100mg 24 metoprolol tartrate tabs 375mg 75mg 24 metoprolol-hydrochlorothiazide tabs 24 metronidazole caps 11 metronidazole crea 58 metronidazole gel 58 metronidazole in nacl soln 11 metronidazole in nacl soln intravenous 11 metronidazole lotn 58 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
25 mibelas 24 fe chew 47 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 58 miconazole-zinc oxide-petrolat oint 58 micort-hc crea 60 microgestin 1530 tabs 47 microgestin 120 tabs 47 microgestin fe 1530 tabs 47 microgestin fe 120 tabs 47 midazolam hcl (pf) soln 33 midazolam hcl soln 33 midazolam hcl syrp 33 midodrine hcl tabs 25mg 5mg 10mg 21 miglitol tabs 25mg 50mg 100mg 49 miglustat caps 40 mili tabs 47 millipred dp tbpk 45 millipred tabs 45
milrinone lactate in dextrose soln 25 milrinone lactate soln 25 mimvey lo tabs 50 mimvey tabs 50 minitran pt24 01mghr 02mghr 04mghr
06mghr 26 minocycline hcl caps 50mg 75mg 100mg 9 minocycline hcl er tb24 45mg 55mg 65mg
80mg 90mg 105mg 115mg 135mg 9 minocycline hcl tabs 50mg 75mg 100mg 9 minoxidil tabs 25mg 10mg 25 MIRCERA SOSY 30mcg03ml
50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml 22
mirtazapine tabs 75mg 15mg 30mg 45mg 36
mirtazapine tbdp 15mg 30mg 45mg 36 misoprostol tabs 100mcg 200mcg 43 MITIGARE CAPS 52 mitigo soln 28 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 57 modafinil tabs 100mg 200mg 30 moexipril hcl tabs 75mg 15mg 26 molindone hcl tabs 5mg 10mg 25mg 36 mometasone furoate crea 60 mometasone furoate oint 60 mometasone furoate soln 60 mometasone furoate susp 41 mondoxyne nl caps 75mg 100mg 9 MONJUVI SOLR 17 MONONESSA TABS 47 montelukast sodium chew 4mg 5mg 55 montelukast sodium pack 55 montelukast sodium tabs 55 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 28 morphine sulfate (pf) soln 4mgml 10mgml
28 MORPHINE SULFATE (PF) SOLN
INTRAVENOUS 28 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 28 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 28
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 91
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 28
MORPHINE SULFATE SOLN 28 MORPHINE SULFATE SOLN 10mg5ml
20mg5ml 28 MORPHINE SULFATE SOLN INJECTION
2mgml 4mgml 10mgml 28 MORPHINE SULFATE SOLN
INTRAVENOUS 28 morphine sulfate tabs 15mg 30mg 28 MOVANTIK TABS 125mg 25mg 44 MOXEZA SOLN 41 moxifloxacin hcl (2x day) soln 41 moxifloxacin hcl in nacl soln intravenous 10 moxifloxacin hcl soln 41 moxifloxacin hcl tabs 10 MULPLETA TABS 22 MULTAQ TABS 25 MULTIVITAMINFLUORIDE CHEW 63 MULTI-VITAMINFLUORIDE SOLN 63 MULTI-VITAMINFLUORIDEIRON SOLN
63 mupirocin calcium crea 58 mupirocin oint 59 MUSTARGEN SOLR 17 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17 MVC-FLUORIDE CHEW 64 MYALEPT SOLR 54 MYCAPSSA CPDR 51 mycophenolate mofetil caps 53 mycophenolate mofetil hcl solr 53 mycophenolate mofetil susr 53 mycophenolate mofetil tabs 53 mycophenolate sodium tbec 180mg 360mg
53 MYDAYIS CP24 30 MYFEMBREE TABS 50 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 62 MYRBETRIQ TB24 25mg 50mg 63 MYTESI TBEC 43
N NABI-HB SOLN 57 nabumetone tabs 28 N-ACETYL-L-CYSTEINE CAPS 38 nadolol tabs 20mg 40mg 80mg 24 nadolol-bendroflumethiazide tabs 24
nafcillin sodium solr 10 nafcillin sodium solr injection 10 nafcillin sodium solr intravenous 10 NAFRINSE CHEW 54 NAFRINSE DROPS SOLN 54 naftifine hcl crea 59 naftifine hcl gel 59 NAFTIN GEL 59 NAGLAZYME SOLN 40 nalbuphine hcl soln 28 nalfon tabs 28 nalocet tabs 28 naloxone hcl soaj 34 naloxone hcl soct 34 naloxone hcl soln 34 naloxone hcl sosy 34 naltrexone hcl tabs 35 NAMENDA XR TITRATION PACK CP24 34 NAPRELAN TB24 28 naproxen sodium er tb24 28 naproxen sodium tabs 28 naproxen susp 28 naproxen tabs 28 naproxen tbec 28 naproxen-esomeprazole tbec 28 naratriptan hcl tabs 32 NARCAN LIQD 35 NATACYN SUSP 41 NATAZIA TABS 47 nateglinide tabs 60mg 120mg 49 NATPARA CART 25mcg 50mcg 75mcg
100mcg 50 NATROBA SUSP 59 NAYZILAM SOLN 31 NEBUPENT SOLR 11 necon 0535 (28) tabs 47 NECON 777 TABS 47 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 36 nembutal soln 33 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 41 neomycin-polymyxin b gu soln 59 neomycin-polymyxin-dexameth oint 41 neomycin-polymyxin-dexameth susp 41 neomycin-polymyxin-gramicidin soln 41 neomycin-polymyxin-hc soln 41 neomycin-polymyxin-hc susp 41 neo-polycin hc oint 41
92 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
neo-polycin oint 41 neo-synalar crea 60 NEPHRAMINE SOLN INTRAVENOUS 38 NERLYNX TABS 17 NEULASTA ONPRO PSKT 22 NEULASTA SOSY 22 NEUPOGEN SOLN 480mcg16ml
300mcgml 22 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 22 NEVANAC SUSP 41 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 40 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 23 niacor tabs 23 nicardipine hcl caps 20mg 30mg 24 nicardipine hcl soln 24 NICOTROL INHA 20 NICOTROL NS SOLN 20 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 47 nilutamide tabs 17 nimodipine caps 24 NINLARO CAPS 23mg 3mg 4mg 17 nisoldipine er tb24 85mg 17mg 20mg
255mg 30mg 34mg 40mg 24 nitazoxanide tabs 11 nitisinone caps 2mg 5mg 10mg 54 nitro-bid oint 26 NITRO-DUR PT24 03mghr 08mghr 26 NITROFURANTOIN MACROCRYSTAL
CAPS 14 NITROFURANTOIN MONOHYD MACRO
CAPS 14 nitrofurantoin susp 14 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 26 nitroglycerin soln 26 nitroglycerin subl 03mg 04mg 06mg 26 nitropress soln 25 nitroprusside sodium soln 25 NITYR TABS 2mg 5mg 10mg 54
NIVESTYM SOLN 480mcg16ml 300mcgml 22
NIVESTYM SOSY 300mcg05ml 480mcg08ml 22
nizatidine caps 150mg 300mg 43 nizatidine soln 43 NOCDURNA SUBL 277mcg 553mcg 50 NOCTIVA EMUL 083mcg01ml
166mcg01ml 50 nolix crea 60 nolix lotn 60 nora-be tabs 47 norco tabs 28 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 51
norepinephrine bitartrate soln 21 norethin ace-eth estrad-fe caps 47 norethin ace-eth estrad-fe chew 47 norethin ace-eth estrad-fe tabs 47 norethindrone acetate tabs 50 norethindrone acet-ethinyl est tabs 47 norethindrone tabs 47 norethindrone-eth estradiol tabs 50 norethin-eth estradiol-fe chew 47 norgesic forte tabs 28 norgestimate-eth estradiol tabs 47 norgestim-eth estrad triphasic tabs 47 norlyroc tabs 47 NORMOSOL-M IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R SOLN INTRAVENOUS 39 NORPACE CR CP12 100mg 150mg 25 nortrel 0535 (28) tabs 47 nortrel 135 (21) tabs 47 nortrel 135 (28) tabs 47 nortrel 777 tabs 47 nortriptyline hcl caps 10mg 25mg 50mg
75mg 36 nortriptyline hcl soln 36 NORVIR CAPS 12 NORVIR PACK 12 NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 34 NOVAREL SOLR 5000unit 10000unit 50 NOVOLIN 7030 SUSP 49
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 93
NOVOLOG 7030 FLEXPEN RELION SUPN 49
NOVOLOG FLEXPEN RELION SOPN 49 NOVOLOG FLEXPEN SOPN 49 NOVOLOG MIX 7030 FLEXPEN SUPN 49 NOVOLOG MIX 7030 RELION SUSP 49 NOVOLOG MIX 7030 SUSP 49 NOVOLOG PENFILL SOCT 49 NOVOLOG RELION SOLN 49 NOVOLOG SOLN 49 NOXAFIL SUSP 11 NOXAFIL TBEC 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 55 NUCALA SOLR 55 NUCALA SOSY 55 NUCYNTA ER TB12 200mg 250mg 29 NUCYNTA ER TB12 50mg 100mg 150mg
29 NUCYNTA TABS 29 NUCYNTA TABS 50mg 75mg 29 NUEDEXTA CAPS 34 NULIBRY SOLR 54 NULOJIX SOLR 53 NUPLAZID CAPS 36 NUPLAZID TABS 10mg 17mg 36 NURTEC TBDP 32 NUTRILIPID EMUL INTRAVENOUS 38 NUTROPIN AQ NUSPIN 10 SOPN 51 NUTROPIN AQ NUSPIN 20 SOPN 51 NUTROPIN AQ NUSPIN 5 SOPN 51 NUVARING RING 47 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 59 nylia 777 tabs 47 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 47 nystatin crea 59 nystatin oint 59 nystatin powd 59 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 60 nystatin-triamcinolone oint 60 nystop powd 59 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 44 ocella tabs 47 OCREVUS SOLN 34 OCTAGAM SOLN INTRAVENOUS
5gm100ml 1gm20ml 2gm20ml 25gm500ml 57
octreotide acetate soln 51 ODACTRA SUBL 54 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 56 ofloxacin soln 41 ofloxacin tabs 10 ogestrel tabs 47 OGIVRI SOLR 17 okebo caps 10 olanzapine solr 36 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 36 olanzapine tbdp 5mg 10mg 15mg 20mg
36 olanzapine-fluoxetine hcl caps 36 olmesartan medoxomil tabs 5mg 20mg
40mg 26 olmesartan medoxomil-hctz tabs 26 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 42 OLUMIANT TABS 1mg 2mg 53 OLYSIO CAPS 12 OMECLAMOX-PAK MISC 43 omega-3-acid ethyl esters caps 23 omeprazole cpdr 10mg 20mg 40mg 43 omeprazole-sodium bicarbonate caps 43 omeprazole-sodium bicarbonate pack 44 OMNARIS SUSP 41 OMNIPOD STARTER KIT 37 OMNITROPE SOCT 5mg15ml
10mg15ml 51 OMNITROPE SOLR 51 ondansetron hcl soln 43 ondansetron hcl tabs 4mg 8mg 24mg 43 ondansetron tbdp 4mg 8mg 43 ONIVYDE INJ 17 ONPATTRO SOLN 54 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 ONZETRA XSAIL EXHP 32
94 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml 17
OPIUM TINC 43 ORACEA CPDR 62 ORALAIR SUBL 54 oralone pste 60 ORAVIG TABS 59 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 53 ORENCIA SOLR 53 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 53 ORENITRAM TBCR 0125mg 56 ORENITRAM TBCR 025mg 1mg 25mg
5mg 56 ORFADIN CAPS 54 ORFADIN SUSP 54 ORGOVYX TABS 50 ORIAHNN CPPK 50 ORILISSA TABS 150mg 200mg 50 ORKAMBI PACK 56 ORKAMBI TABS 56 ORLADEYO CAPS 110mg 150mg 54 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 29 orphengesic forte tabs 29 orsythia tabs 47 ORTIKOS CP24 6mg 9mg 45 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 39 OSMOPREP TABS 44 OSPHENA TABS 50 OTEZLA TABS 53 OTEZLA TBPK 53 OTOVEL SOLN 41 OTREXUP SOAJ 53 ovide lotn 59 OXACILLIN SODIUM IN DEXTROSE SOLN
INTRAVENOUS 10 oxacillin sodium solr injection 1gm 2gm 10 oxacillin sodium solr intravenous 10 oxaliplatin soln 17 oxaliplatin solr 17 oxandrolone tabs 45 oxandrolone tabs 25mg 45 oxaprozin tabs 29
OXAYDO TABS 29 oxazepam caps 10mg 15mg 30mg 33 OXBRYTA TABS 21 oxcarbazepine susp 31 oxcarbazepine tabs 150mg 300mg 600mg
31 OXERVATE SOLN 42 oxiconazole nitrate crea 59 OXISTAT LOTN 59 OXLUMO SOLN 54 OXTELLAR XR TB24 150mg 300mg
600mg 31 oxybutynin chloride er tb24 5mg 10mg
15mg 63 oxybutynin chloride syrp 63 oxybutynin chloride tabs 63 oxycodone hcl caps 29 oxycodone hcl conc 29 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxycodone hcl soln 29 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 29 oxycodone-acetaminophen soln 29 oxycodone-acetaminophen tabs 29 oxycodone-acetaminophen tabs 5-300mg
10-300mg 29 oxycodone-aspirin tabs 29 oxycodone-ibuprofen tabs 29 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 29 oxymorphone hcl tabs 5mg 10mg 29 OXYTOCIN SOLN 50 OZEMPIC (025 OR 05 MGDOSE) SOPN
49 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 49
P pacerone tabs 100mg 200mg 400mg 25 paclitaxel conc 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
54 PALFORZIA (120 MG DAILY DOSE) CSPK
54
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 95
PALFORZIA (160 MG DAILY DOSE) CSPK 54
PALFORZIA (20 MG DAILY DOSE) CSPK 54
PALFORZIA (200 MG DAILY DOSE) CSPK 54
PALFORZIA (240 MG DAILY DOSE) CSPK 55
PALFORZIA (3 MG DAILY DOSE) CSPK 55 PALFORZIA (300 MG MAINTENANCE)
PACK 55 PALFORZIA (300 MG TITRATION) PACK
55 PALFORZIA (40 MG DAILY DOSE) CSPK
55 PALFORZIA (6 MG DAILY DOSE) CSPK 55 PALFORZIA (80 MG DAILY DOSE) CSPK
55 PALFORZIA INITIAL ESCALATION CSPK
55 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 36 palonosetron hcl soln 43 palonosetron hcl sosy 43 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 40 pamidronate disodium soln 52 pamidronate disodium solr 52 PANCREAZE CPEP 40 PANDEL CREA 61 panlor tabs 29 PANRETIN GEL 61 pantoprazole sodium pack 44 PANTOPRAZOLE SODIUM SOLR 44 pantoprazole sodium tbec 20mg 40mg 44 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 57
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 64 PARICALCITOL SOLN 64 paroex soln 41 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 36 paroxetine hcl tabs 10mg 20mg 36 paroxetine hcl tabs 30mg 40mg 36 paroxetine mesylate caps 36 paser pack 11
PAXIL SUSP 36 PEDIARIX SUSP 57 PEDVAX HIB SUSP 57 peg 3350electrolytes solr 44 peg 3350-kcl-na bicarb-nacl solr 44 peg-3350electrolytes solr 44 PEGANONE TABS 31 PEGASYS PROCLICK SOLN
135mcg05ml 180mcg05ml 13 PEGASYS SOLN 180mcg05ml
180mcgml 13 PEGINTRON KIT 13 PEG-INTRON REDIPEN KIT 12 PEG-PREP KIT 44 PEMAZYRE TABS 45mg 9mg 135mg 17 penicillamine caps 45 penicillamine tabs 45 PENICILLIN G POT IN DEXTROSE SOLN
INTRAVENOUS 10 penicillin g potassium solr injection 10 penicillin g procaine susp 10 penicillin g sodium solr injection 10 penicillin v potassium solr 10 penicillin v potassium tabs 10 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 43 pentazocine-naloxone hcl tabs 29 pentobarbital sodium soln 33 pentoxifylline er tbcr 22 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 44 percocet tabs 29 perindopril erbumine tabs 2mg 4mg 8mg
26 periogard soln 41 PERJETA SOLN 17 permethrin crea 59 perphenazine tabs 2mg 4mg 8mg 16mg
36 perphenazine-amitriptyline tabs 36 PERSERIS PRSY 90mg 120mg 36 PERTZYE CPEP 40 PEXEVA TABS 10mg 20mg 30mg 40mg
36 phenadoz supp 14 phenazo tabs 61 PHENAZOPYRIDINE HCL TABS 61 phenelzine sulfate tabs 36
96 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
phenergan soln 14 PHENOBARBITAL ELIX 33 PHENOBARBITAL SODIUM SOLN 33 PHENOBARBITAL TABS 33 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 21 PHENYLEPHRINE HCL SOLN 42 phenytek caps 200mg 300mg 31 phenytoin chew 31 phenytoin sodium extended caps 100mg
200mg 300mg 31 phenytoin sodium soln 31 phenytoin susp 31 PHESGO SOLN 17 PHOSLYRA SOLN 39 PHOSPHASAL TABS 14 PHOSPHOLINE IODIDE SOLR 42 phrenilin forte caps 29 PHYSIOLYTE SOLN 55 PHYSIOSOL IRRIGATION SOLN 55 PIFELTRO TABS 13 pilocarpine hcl soln 1 2 4 42 pilocarpine hcl tabs 5mg 75mg 20 pimecrolimus crea 62 pimozide tabs 1mg 2mg 36 pimtrea tabs 47 pindolol tabs 5mg 10mg 24 pioglitazone hcl tabs 15mg 30mg 45mg 49 pioglitazone hcl-glimepiride tabs 49 pioglitazone hcl-metformin hcl tabs 49 piperacillin sod-tazobactam so solr 10 piperacillin sod-tazobactam so solr
intravenous 10 PIQRAY (200 MG DAILY DOSE) TBPK 17 PIQRAY (250 MG DAILY DOSE) TBPK 17 PIQRAY (300 MG DAILY DOSE) TBPK 17 pirmella 135 tabs 47 PIROXICAM CAPS 10mg 20mg 29 PLASMA-LYTE 148 SOLN INTRAVENOUS
39 PLASMA-LYTE A SOLN INTRAVENOUS 39 PLEGRIDY SOPN 13 PLEGRIDY SOSY 13 34 PLEGRIDY STARTER PACK SOPN 13 PLEGRIDY STARTER PACK SOSY 13 plenamine soln intravenous 38 PLENVU SOLR 44 podofilox soln 62 POLIVY SOLR 30mg 140mg 17
polocaine soln 55 polocaine-mpf soln 55 polycin oint 41 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 41 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 34 PONVORY TABS 34 portia-28 tabs 47 PORTRAZZA SOLN 17 POSACONAZOLE SUSP 11 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 37 POTASSIUM ACETATE SOLN 39 potassium chloride crys er tbcr 10meq
20meq 40 potassium chloride er cpcr 8meq 10meq 40 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 40 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 40 potassium chloride in nacl soln intravenous
40 potassium chloride pack 40 potassium chloride soln 10 20 40 POTASSIUM CHLORIDE SOLN
INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml 40
potassium citrate er tbcr 15meq 540mg 1080mg 37
POTASSIUM PHOSPHATES SOLN 40 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 40 POTELIGEO SOLN 18 PR BENZOYL PEROXIDE WASH LIQD 59 PRADAXA CAPS 110mg 150mg 22 PRADAXA CAPS 75mg 22 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 33
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 33
PRAMOX GEL 61 prandin tabs 1mg 2mg 49 prasugrel hcl tabs 5mg 10mg 22 pravastatin sodium tabs 10mg 20mg
40mg 80mg 23 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 97
PRED MILD SUSP 41 PRED-G SOP OINT 41 PRED-G SUSP 41 prednicarbate crea 61 prednicarbate oint 61 prednisolone acetate susp 41 prednisolone sodium phosphate soln 41 45 prednisolone sodium phosphate soln
5mg5ml 10mg5ml 20mg5ml 25mg5ml 45
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 45
prednisolone soln 45 prednisone intensol conc 45 prednisone soln 45 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 45 prednisone tbpk 45 prefest tabs 50 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 31
pregabalin er tb24 825mg 165mg 330mg 29
pregabalin soln 31 PREGNYL SOLR 50 PREMARIN SOLR 50 PREMARIN TABS 03mg 045mg
0625mg 09mg 125mg 50 premasol soln intravenous 38 PREMPHASE TABS 50 PREMPRO TABS 50 PRENATAL TABS 64 PRETOMANID TABS 11 prevalite pack 23 prevalite powd 23 previfem tabs 47 PREVYMIS SOLN 240mg12ml
480mg24ml 13 PREVYMIS TABS 240mg 480mg 13 PREZCOBIX TABS 13 PREZISTA SUSP 13 PREZISTA TABS 75mg 150mg 600mg
800mg 13 PRIFTIN TABS 11 PRILOSEC PACK 25mg 10mg 44 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 31 primlev tabs 29
PRIVIGEN SOLN INTRAVENOUS 57 PROAIR RESPICLICK AEPB 21 probenecid tabs 40 procainamide hcl soln 25 PROCALAMINE SOLN INTRAVENOUS 38 procentra soln 30 prochlorperazine edisylate soln 36 prochlorperazine maleate tabs 36 prochlorperazine supp 36 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 40000unitml 22
proctofoam hc foam 61 procto-med hc crea 61 procto-pak crea 61 proctosol hc crea 61 proctozone-hc crea 61 PROCYSBI CPDR 25mg 75mg 55 PROCYSBI PACK 75mg 300mg 55 progesterone caps 100mg 200mg 51 progesterone oil 51 PROGLYCEM SUSP 49 PROGRAF PACK 53 PROGRAF PACK 02mg 53 PROGRAF SOLN 53 PROLASTIN-C SOLN INTRAVENOUS 56 PROLASTIN-C SOLR INTRAVENOUS 56 prolate soln 29 prolate tabs 29 PROLENSA SOLN 41 PROLEUKIN SOLR 18 PROLIA SOSY 52 PROMACTA PACK 125mg 25mg 22 PROMACTA TABS 125mg 25mg 50mg
75mg 22 promethazine hcl soln 14 promethazine hcl supp 14 promethazine hcl syrp 14 promethazine hcl tabs 14 promethazine-phenylephrine syrp 14 promethegan supp 14 propafenone hcl er cp12 225mg 325mg
425mg 25 propafenone hcl tabs 150mg 225mg
300mg 25 propantheline bromide tabs 19 proparacaine hcl soln 43 propranolol hcl er cp24 60mg 80mg
120mg 160mg 24
98 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
propranolol hcl soln 20mg5ml 40mg5ml 24 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 24 propranolol-hctz tabs 24 propylthiouracil tabs 51 PROQUAD SUSR 58 PROSOL SOLN INTRAVENOUS 38 PROTONIX PACK 44 protriptyline hcl tabs 5mg 10mg 36 psorcon crea 61 PULMICORT FLEXHALER AEPB 45 PULMOZYME SOLN 40 PURIXAN SUSP 18 PYLERA CAPS 44 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 20 pyridostigmine bromide soln 20 pyridostigmine bromide tabs 30mg 60mg 20 pyrimethamine tabs 11
Q QBRELIS SOLN 26 QDOLO SOLN 29 QINLOCK TABS 18 QUADRACEL SUSP 57 questran light powd 23 questran pack 23 questran powd 23 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 36 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 37 QUILLICHEW ER CHER 20mg 30mg
40mg 30 QUILLIVANT XR SRER 30 quinapril hcl tabs 5mg 10mg 20mg 40mg
26 quinapril-hydrochlorothiazide tabs 26 quinidine gluconate er tbcr 25 QUINIDINE GLUCONATE SOLN 25 quinidine sulfate tabs 200mg 300mg 25 quinine sulfate caps 12
R RABAVERT SUSR 58 rabeprazole sodium cpsp 44 rabeprazole sodium tbec 44 RADICAVA SOLN 34
raloxifene hcl tabs 50 ramelteon tabs 33 ramipril caps 125mg 25mg 5mg 10mg 26 ranolazine er tb12 500mg 1000mg 25 RAPIVAB SOLN 13 rasagiline mesylate tabs 05mg 1mg 33 RASUVO SOAJ 53 RAVICTI LIQD 38 RAYALDEE CPCR 64 RAYOS TBEC 1mg 2mg 5mg 45 REBETOL SOLN 13 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 34 REBIF REBIDOSE TITRATION PACK
SOAJ 34 REBIF SOSY 22mcg05ml 44mcg05ml 34 REBIF TITRATION PACK SOSY 34 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 47 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 58 RECTIV OINT 62 REGONOL SOLN 20 REGRANEX GEL 62 relafen ds tabs 29 RELENZA DISKHALER AEPB 13 relexxii tbcr 30 RELISTOR SOLN 8mg04ml 12mg06ml
44 RELISTOR TABS 44 reltone caps 200mg 400mg 44 REMICADE SOLR INTRAVENOUS 53 RENFLEXIS SOLR 53 repaglinide tabs 05mg 1mg 2mg 49 repaglinide-metformin hcl tabs 49 REPATHA PUSHTRONEX SYSTEM SOCT
23 REPATHA SOSY 23 REPATHA SURECLICK SOAJ 23 RESCRIPTOR TABS 100mg 200mg 13 RESTASIS EMUL 41 RETACRIT SOLN 20000unit2ml
2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml 22
RETEVMO CAPS 40mg 80mg 18 RETIN-A CREA 0025 005 01 61 RETIN-A GEL 001 0025 61
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RETIN-A MICRO GEL 004 01 61 RETIN-A MICRO PUMP GEL 61 RETIN-A MICRO PUMP GEL 004 01
61 RETIN-A MICRO PUMP GEL 008 61 RETISERT IMPL 41 RETROVIR SOLN 13 REVCOVI SOLN 40 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 18 revonto solr 20 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 37 REYATAZ PACK 13 REZUROCK TABS 55 RHOPRESSA SOLN 42 RIABNI SOLN 100mg10ml 500mg50ml 18 ribasphere caps 13 ribasphere ribapak (1000 pack) tbpk 13 ribasphere ribapak (1200 pack) tbpk 13 ribasphere tabs 13 ribavirin caps 13 ribavirin solr 13 ribavirin tabs 13 RIDAURA CAPS 55 RIFABUTIN CAPS 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 RIFATER TABS 11 riluzole tabs 34 rimantadine hcl tabs 13 RIMSO-50 SOLN 55 RINGERS IRRIGATION SOLN 55 RINGERS SOLN 40 RINVOQ TB24 53 risedronate sodium tabs 5mg 30mg 35mg
150mg 52 RISEDRONATE SODIUM TBEC 52 RISPERDAL CONSTA SRER 125mg
25mg 37 RISPERDAL CONSTA SRER 375mg
50mg 37 risperidone soln 37 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 37 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 37
ritonavir tabs 13 RITUXAN HYCELA SOLN 18 RITUXAN SOLN 18 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 47 rizatriptan benzoate tabs 32 rizatriptan benzoate tbdp 32 ROMIDEPSIN SOLN 18 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 33 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 33 ropivacaine hcl soln 55 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 23 ROTARIX SUSR 58 ROTATEQ SOLN 58 roweepra tabs 500mg 750mg 1000mg 31 roweepra xr tb24 500mg 750mg 31 ROXYBOND TABA 5mg 15mg 30mg 29 ROZEREM TABS 33 ROZLYTREK CAPS 100mg 200mg 18 RUBRACA TABS 200mg 250mg 300mg 18 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 31 rufinamide tabs 200mg 400mg 31 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 18 RUZURGI TABS 55 RYBREVANT SOLN 18 ryclora soln 14 RYDAPT CAPS 18 RYLAZE SOLN 18 RYNODERM CREA 62 RYTARY CPCR 33 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 51 SAIZEN SOLR 5mg 88mg 51 SAIZENPREP SOLR 51 sajazir soln 21 SALEX SHAM 62 SALICYLIC ACID CREA 62 SALICYLIC ACID ER SOLN 62
100 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
SALICYLIC ACID FOAM 62 SALICYLIC ACID GEL 62 SALICYLIC ACID LIQD 62 SALICYLIC ACID SHAM 62 SALICYLIC ACID WART REMOVER LIQD
62 SALICYLIC ACID-CLEANSER KIT 62 SALIMEZ CREA 62 SALSALATE TABS 29 SAMSCA TABS 15mg 39 SANCUSO PTCH 43 SANDIMMUNE ORAL SOLN 100mgml 53 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 51 SANTYL OINT 62 SAPHNELO SOLN 53 SAPHRIS SUBL 25mg 5mg 10mg 37 sapropterin dihydrochloride pack 100mg
500mg 55 sapropterin dihydrochloride tabs 55 SARCLISA SOLN 500mg25ml 100mg5ml
18 SAVELLA TABS 125mg 25mg 50mg
100mg 34 SAVELLA TITRATION PACK MISC 34 scopolamine pt72 43 seconal caps 33 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 37 selegiline hcl caps 33 selegiline hcl tabs 33 selenium sulfide lotn 59 SELENIUM SULFIDE SHAM 59 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 150mg
300mg 13 SEMPREX-D CAPS 14 SENSIPAR TABS 30mg 60mg 90mg 50 SENSORCAINE SOLN 55 sensorcaineepinephrine soln 55 sensorcaine-mpf soln 55 sensorcaine-mpfepinephrine soln 55 SEREVENT DISKUS AEPB 21 SEROSTIM SOLR 4mg 5mg 6mg 51 sertraline hcl conc 37 sertraline hcl tabs 25mg 50mg 100mg 37 setlakin tabs 47 sevelamer carbonate pack 08gm 24gm 39 sevelamer carbonate tabs 39
sevelamer hcl tabs 400mg 800mg 39 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 47 SHINGRIX SUSR 58 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 51 SIGNIFOR SOLN 03mgml 06mgml
09mgml 51 SIKLOS TABS 18 sildenafil citrate soln 26 sildenafil citrate susr 26 sildenafil citrate tabs 26 SILENOR TABS 37 SILIQ SOSY 62 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 59 SIMBRINZA SUSP 42 SIMPONI ARIA SOLN 53 SIMPONI SOAJ 50mg05ml 100mgml 53 SIMPONI SOSY 50mg05ml 100mgml 53 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 23 sirolimus soln 53 sirolimus tabs 05mg 1mg 2mg 53 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKLICE LOTN 59 SKYRIZI (150 MG DOSE) PSKT 62 SKYRIZI PEN SOAJ 63 SKYRIZI SOSY 63 sod benz-sod phenylacet soln 38 SODIUM ACETATE SOLN 37 SODIUM BICARBONATE SOLN 37 SODIUM CHLORIDE (PF) SOLN 40 SODIUM CHLORIDE SOLN 40 55 SODIUM CHLORIDE SOLN INJECTION 40 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 55 SODIUM FLUORIDE SOLN 55 SODIUM FLUORIDE TABS 55 SODIUM LACTATE SOLN INTRAVENOUS
37 sodium phenylbutyrate powd 38 sodium phenylbutyrate tabs 38 SODIUM PHOSPHATES SOLN 40 sodium polystyrene sulfonate powd 39 sodium polystyrene sulfonate susp 39 SODIUM SULFACETAMIDE SHAM 59
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 101
SODIUM SULFACETAMIDE WASH LIQD 59
sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 63 SOLIQUA SOPN 49 SOLOSEC PACK 12 soloxide tbec 10 SOLTAMOX SOLN 18 SOLU-CORTEF SOLR 45 SOLU-MEDROL SOLR 45 SOMATULINE DEPOT SOLN 51 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 51 SORILUX FOAM 63 sorine tabs 80mg 120mg 160mg 240mg
24 sotalol hcl (af) tabs 80mg 120mg 160mg 24 sotalol hcl tabs 80mg 120mg 160mg
240mg 24 SOTYLIZE SOLN 24 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPINOSAD SUSP 59 SPIRIVA HANDIHALER CAPS 19 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 26 spironolactone-hctz tabs 26 SPRAVATO (56 MG DOSE) SOPK 37 SPRAVATO (84 MG DOSE) SOPK 37 sprintec 28 tabs 47 SPRITAM TB3D 250mg 500mg 750mg
1000mg 31 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 39 sronyx tabs 47 SSD CREA 59 SSS 10-5 CREA 63 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
63 STELARA SOSY 45mg05ml 90mgml 63 STERILE WATER FOR IRRIGATION SOLN
55 STIMATE SOLN 50 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18
STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml 40
streptomycin sulfate solr 10 STRIANT MISC 46 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 21 SUBLOCADE SOSY 100mg05ml
300mg15ml 29 SUBSYS LIQD 100mcg 200mcg 400mcg
600mcg 800mcg 1200mcg 1600mcg 29 subvenite starter kit-blue kit 31 subvenite starter kit-green kit 31 subvenite starter kit-orange kit 31 subvenite tabs 25mg 100mg 150mg
200mg 31 succinylcholine chloride soln 20 SUCRAID SOLN 40 sucralfate susp 44 sucralfate tabs 44 sulfacetamide sodium (acne) lotn 59 SULFACETAMIDE SODIUM GEL 59 SULFACETAMIDE SODIUM LIQD 59 sulfacetamide sodium oint 41 sulfacetamide sodium soln 41 SULFACETAMIDE SODIUM-SULFUR
CREA 63 SULFACETAMIDE SODIUM-SULFUR
EMUL 63 SULFACETAMIDE SODIUM-SULFUR
LIQD 63 SULFACETAMIDE SODIUM-SULFUR
LOTN 63 SULFACETAMIDE SODIUM-SULFUR
PADS 63 SULFACETAMIDE SODIUM-SULFUR
SUSP 63 sulfacetamide-prednisolone soln 41 SULFACLEANSE 84 SUSP 63 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 sulfamez wash emul 63 SULFAMYLON CREA 59 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 29 sumatriptan soln 32
102 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
sumatriptan succinate refill soct 32 sumatriptan succinate soaj 32 sumatriptan succinate soln 32 sumatriptan succinate sosy 32 sumatriptan succinate tabs 32 sunitinib malate caps 125mg 25mg
375mg 50mg 18 SUNOSI TABS 75mg 150mg 30 SUPRAX CAPS 10 suprax chew 10 suprax susr 100mg5ml 200mg5ml 10 SUPRAX SUSR 500 MG5ML 10 SUPREP BOWEL PREP KIT SOLN 44 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 47 SYLATRON KIT 18 SYLATRON KIT 600 MCG 18 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 56 SYMDEKO TBPK 56 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 49 SYMLINPEN 60 SOPN 49 SYMPAZAN FILM 10mg 20mg 32 SYMPAZAN FILM 5mg 31 SYMPROIC TABS 44 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 50 SYNDROS SOLN 43 SYNERCID SOLR 10 SYNJARDY TABS 49 SYNJARDY XR TB24 49 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 TACLONEX SUSP 61 tacrolimus caps 05mg 1mg 5mg 53 TACROLIMUS OINT 01 003 63 tadalafil (pah) tabs 20mg 26 tadalafil tabs 25mg 5mg 26 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 55 TALTZ SOAJ 63
TALTZ SOSY 63 TALZENNA CAPS 025mg 1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 51 taperdex 12-day tbpk 45 taperdex 6-day tbpk 45 taperdex 7-day tbpk 45 TARCEVA TABS 25mg 100mg 150mg 18 targadox tabs 10 TARGRETIN GEL 61 tarina 24 fe tabs 47 tarina fe 120 eq tabs 47 TASIGNA CAPS 50mg 150mg 200mg 18 tavaborole soln 59 TAVALISSE TABS 100mg 150mg 22 tazarotene crea 63 tazarotene foam 63 tazicef solr injection 1gm 2gm 6gm 10 TAZORAC CREA 63 TAZORAC GEL 005 01 63 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 57 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TECFIDERA CPDR 120mg 240mg 34 TECFIDERA MISC 34 TEFLARO SOLR INTRAVENOUS 400mg
600mg 10 TEGSEDI SOSY 55 TEKTURNA HCT TABS 26 telmisartan tabs 20mg 40mg 80mg 26 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 26 TEMAZEPAM CAPS 15mg 225mg 30mg
75mg 33 temsirolimus soln 18 tencon tabs 29 TENIPOSIDE SOLN 18 TENIVAC INJ 57 tenofovir disoproxil fumarate tabs 13 TEPADINA SOLR 18 TEPEZZA SOLR 42 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 21
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 103
terbutaline sulfate tabs 25mg 5mg 21 terconazole crea 59 terconazole supp 59 TERIPARATIDE (RECOMBINANT) SOPN
50 testosterone cypionate soln 100mgml
200mgml 46 testosterone enanthate soln 46 testosterone gel 1 162
2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact 46
testosterone soln 46 tetrabenazine tabs 125mg 25mg 34 TETRACAINE HCL SOLN 43 tetracycline hcl caps 250mg 500mg 10 texacort soln 61 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 63 theophylline er tb12 100mg 200mg
300mg 450mg 63 theophylline er tb24 400mg 600mg 63 theophylline soln 63 THIOLA EC TBEC 100mg 300mg 55 THIOLA TABS 55 thioridazine hcl tabs 10mg 25mg 50mg
100mg 37 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 37 THYROGEN SOLR 55 THYROLAR-1 TABS 51 THYROLAR-12 TABS 51 THYROLAR-14 TABS 51 THYROLAR-2 TABS 51 THYROLAR-3 TABS 51 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
32 TIBSOVO TABS 18 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 34 tilia fe tabs 47 timolol maleate pf soln 42 timolol maleate solg 025 05 42 timolol maleate soln 025 05 42 timolol maleate tabs 5mg 10mg 20mg 24 TIMOPTIC OCUDOSE SOLN 25 42
TIMOPTIC-XE SOLG 025 05 42 tinidazole tabs 12 tiopronin tabs 55 TIROSINT CAPS 13mcg 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
TIS-U-SOL SOLN 55 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 TIVORBEX CAPS 29 tizanidine hcl caps 20 21 tizanidine hcl tabs 20 TOBI PODHALER CAPS 56 TOBRADEX OINT 41 TOBRADEX ST SUSP 41 tobramycin nebu 300mg4ml 300mg5ml 56 tobramycin soln 41 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 42 TOBREX OINT 41 tofranil tabs 10mg 25mg 50mg 37 TOLAK CREA 63 tolazamide tabs 250mg 500mg 49 tolbutamide tabs 49 tolcapone tabs 33 tolmetin sodium caps 29 tolmetin sodium tabs 29 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 63 tolterodine tartrate tabs 63 TOLVAPTAN TABS 30mg 15mg 39 TOPEX TOPICAL ANESTHETIC AERO 61 topicort crea 005 025 61 topicort gel 61 topicort oint 61 topiramate cpsp 15mg 25mg 32 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 32 topiramate tabs 25mg 50mg 100mg
200mg 32 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
39 TOSYMRA SOLN 32
104 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
tovet foam 61 TPN ELECTROLYTES CONC
INTRAVENOUS 40 TRACLEER TABS 625mg 125mg 56 TRACLEER TBSO 56 TRADJENTA TABS 49 tramadol hcl er (biphasic) tb24 100mg
200mg 300mg 29 tramadol hcl er cp24 100mg 150mg
200mg 300mg 29 tramadol hcl er tb24 100mg 200mg 300mg
29 tramadol hcl tabs 50mg 100mg 29 tramadol-acetaminophen tabs 29 trandolapril tabs 1mg 2mg 4mg 26 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 22 tranexamic acid tabs 22 TRANSDERM SCOP (15 MG) PT72 43 tranylcypromine sulfate tabs 37 TRAVASOL SOLN INTRAVENOUS 38 TRAVATAN Z SOLN 42 travoprost (bak free) soln 42 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 37 trazodone hcl tabs 50mg 100mg 150mg 37 TRECATOR TABS 11 TRELEGY ELLIPTA AEPB 45 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 63 TREMFYA SOSY 63 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 56 tretinoin caps 18 tretinoin crea 0025 005 01 61 tretinoin gel 001 0025 005 61 tretinoin microsphere gel 004 01 61 tretinoin microsphere pump gel 004
01 62 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 29 triamcinolone acetonide aers 61 triamcinolone acetonide crea 0025
01 05 61 triamcinolone acetonide lotn 0025 01
61 triamcinolone acetonide oint 0025
005 01 05 61 triamcinolone acetonide pste 61
triamcinolone acetonide susp 45 triamterene caps 50mg 100mg 39 triamterene-hctz caps 39 triamterene-hctz tabs 39 trianex oint 61 triazolam tabs 0125mg 025mg 33 TRICITRATES SOLN 37 triderm crea 01 05 61 trientine hcl caps 45 tri-estarylla tabs 47 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 37 trifluridine soln 41 trihexyphenidyl hcl soln 33 trihexyphenidyl hcl tabs 2mg 5mg 33 TRIKAFTA TBPK 56 tri-legest fe tabs 47 tri-lo-estarylla tabs 47 tri-lo-sprintec tabs 47 trilyte solr 44 trimethobenzamide hcl caps 43 trimethoprim tabs 14 tri-mili tabs 47 trimipramine maleate caps 25mg 50mg
100mg 37 TRINESSA (28) TABS 47 TRINTELLIX TABS 5mg 10mg 20mg 37 tri-nymyo tabs 47 tri-previfem tabs 47 TRIPTODUR SRER 50 TRISENOX SOLN 18 TRISENOX SOLN 10mg10ml 18 tri-sprintec tabs 47 tritocin oint 61 TRIUMEQ TABS 13 TRI-VITAMINFLUORIDE SOLN 64 TRI-VITEFLUORIDE SOLN 64 trivora (28) tabs 47 tri-vylibra lo tabs 47 tri-vylibra tabs 47 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 32 TROPHAMINE SOLN INTRAVENOUS 38 trospium chloride er cp24 63 trospium chloride tabs 63 TRULANCE TABS 44 TRUMENBA SUSY 58
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 105
TRUSELTIQ (100MG DAILY DOSE) CPPK 18
TRUSELTIQ (125MG DAILY DOSE) CPPK 18
TRUSELTIQ (50MG DAILY DOSE) CPPK 18
TRUSELTIQ (75MG DAILY DOSE) CPPK 18
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 58 TYBOST TABS 13 tydemy tabs 47 TYKERB TABS 18 tylenol with codeine 3 tabs 29 tylenol with codeine 4 tabs 29 TYMLOS SOPN 50 TYPHIM VI SOLN 58 TYSABRI CONC INTRAVENOUS 34 TYVASO REFILL SOLN 56 TYVASO SOLN 56 TYVASO STARTER SOLN 56
U UBRELVY TABS 50mg 100mg 32 UCERIS FOAM 61 UDENYCA SOSY 22 UKONIQ TABS 18 ULORIC TABS 40mg 80mg 52 ULTOMIRIS SOLN 55 ULTRAVATE LOTN 61 UMECTA MOUSSE FOAM 63 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 52
UNITUXIN SOLN 18 UPLIZNA SOLN 53 UPTRAVI SOLR 56 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 56
UPTRAVI TBPK 57 UREA CREA 39 63 UREA LOTN 40 63 UREA-C40 LOTN 63 urecholine tabs 5mg 10mg 25mg 50mg 20
uredeb crea 63 URETRON DS TABS 14 URIN DS TABS 14 URSODIOL CAPS 200mg 400mg 44 ursodiol caps 300mg 44 ursodiol tabs 250mg 500mg 44 URYL TABS 14 USTELL CAPS 14 UTICAP CAPS 14 UTIRA-C TABS 14 UTRONA-C TABS 14
V VABOMERE SOLR INTRAVENOUS 10 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 63 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 32 valproic acid caps 32 valproic acid soln 32 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
26 valsartan-hydrochlorothiazide tabs 26 VALTOCO 10 MG DOSE LIQD 32 VALTOCO 15 MG DOSE LQPK 32 VALTOCO 20 MG DOSE LQPK 32 VALTOCO 5 MG DOSE LIQD 32 vanadom tabs 20 vanatol lq soln 29 vancomycin hcl caps 10 vancomycin hcl solr 10 VANCOMYCIN HCL SOLR 250 MG 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 VANDAZOLE GEL 59 VANOXIDE-HC LOTN 61 VANTAS KIT 19 VAQTA SUSP 58 VARIVAX INJ 58 VARIZIG SOLN 57 VARUBI (180 MG DOSE) TBPK 43 VASCEPA CAPS 05gm 1gm 23 VAXCHORA SUSR 58 vecamyl tabs 25 VECTICAL OINT 63 VELCADE SOLR 19 velivet tabs 47
106 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
VELPHORO CHEW 39 VELTASSA PACK 84gm 168gm 252gm
39 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 19 VENCLEXTA TABS 10mg 19 VENCLEXTA TABS 50mg 100mg 19 venlafaxine hcl er cp24 375mg 75mg
150mg 37 venlafaxine hcl er tb24 375mg 75mg
150mg 225mg 37 venlafaxine hcl tabs 25mg 375mg 50mg
75mg 100mg 37 VENTAVIS SOLN 10mcgml 20mcgml 57 VENTOLIN HFA AERS 21 VERAPAMIL HCL ER CP24 100mg
120mg 180mg 200mg 240mg 300mg 360mg 25
verapamil hcl er tbcr 120mg 180mg 240mg 25
verapamil hcl soln 25 verapamil hcl tabs 25 verapamil hcl tabs 80mg 120mg 25 VEREGEN OINT 63 VERELAN CP24 25 veripred 20 soln 45 VERSACLOZ SUSP 37 VERZENIO TABS 50mg 100mg 150mg
200mg 19 vestura tabs 47 VIBERZI TABS 75mg 100mg 44 VIBRAMYCIN SYRP 10 vicodin es tabs 29 vicodin hp tabs 29 vicodin tabs 29 VICTOZA SOPN 49 VIDEX EC CPDR 125mg 200mg 400mg 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 47 vigabatrin pack 32 vigabatrin tabs 32 vigadrone pack 32 VIIBRYD STARTER PACK KIT 37 VIIBRYD TABS 10mg 20mg 40mg 37 VILTEPSO SOLN 55 VIMIZIM SOLN 40 VIMPAT SOLN 32
VIMPAT TABS 32 vinblastine sulfate soln 19 vincasar pfs soln 19 vincristine sulfate soln 19 vinorelbine tartrate soln 19 VIOKACE TABS 40 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 52 VITAMINS ACD-FLUORIDE SOLN 64 VITRAKVI CAPS 25mg 100mg 19 VITRAKVI SOLN 19 VIVITROL SUSR 35 VIZIMPRO TABS 15mg 30mg 45mg 19 VOCABRIA TABS 13 VORAXAZE SOLR 52 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 19 VP-PNV-DHA CAPS 64 VPRIV SOLR 40 VRAYLAR CAPS 15mg 3mg 45mg 6mg
37 VRAYLAR CPPK 37 VUMERITY (STARTER) CPDR 55 VUMERITY CPDR 55 vyfemla tabs 47 vylibra tabs 47 VYNDAMAX CAPS 25 VYNDAQEL CAPS 25 VYONDYS 53 SOLN 55 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 30 VYVANSE CHEW 10mg 20mg 30mg
40mg 50mg 60mg 30 VYXEOS SUSR 19 VYZULTA SOLN 42
W WAKIX TABS 445mg 178mg 30 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 22 WATER FOR IRRIGATION STERILE
SOLN 55 wixela inhub aepb 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 107
wymzya fe chew 48 WYNZORA CREA 63
X XALKORI CAPS 200mg 250mg 19 XARELTO STARTER PACK TBPK 22 XARELTO TABS 25mg 10mg 15mg
20mg 22 XATMEP SOLN 19 XCOPRI (250 MG DAILY DOSE) TBPK 32 XCOPRI (350 MG DAILY DOSE) TBPK 32 XCOPRI TABS 200 MG 32 XCOPRI TABS 50mg 100mg 150mg 32 XCOPRI TBPK 32 XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
32 XELJANZ SOLN 53 XELJANZ TABS 5mg 10mg 53 XELJANZ XR TB24 11mg 22mg 53 XELPROS EMUL 42 XEMBIFY SOLN SUBCUTANEOUS
2gm10ml 4gm20ml 10gm50ml 1gm5ml 57
XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 55 XEOMIN SOLR 50unit 100unit 55 XEPI CREA 59 XERESE CREA 59 XERMELO TABS 43 XGEVA SOLN 52 XHANCE EXHU 42 XIFAXAN TABS 200mg 550mg 10 XIIDRA SOLN 42 XIMINO CP24 45mg 90mg 135mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 56 XOLAIR SOSY 75mg05ml 150mgml 56 XOSPATA TABS 19 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 19 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (40 MG TWICE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (60 MG ONCE WEEKLY) TBPK
20mg 60mg 19
XPOVIO (60 MG TWICE WEEKLY) TBPK 19
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg 19
XPOVIO (80 MG TWICE WEEKLY) TBPK 19
XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg 29
XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 48 XUREA CREA 63 XURIDEN PACK 55 xylocaine dental soln 55 XYOSTED SOAJ 50mg05ml 75mg05ml
100mg05ml 46 XYREM SOLN 34 XYWAV SOLN 34
Y YERVOY SOLN 19 YF-VAX INJ 58 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 42 yuvafem tabs 50
Z zafemy ptwk 48 zafirlukast tabs 10mg 20mg 55 zaleplon caps 5mg 10mg 33 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 48 zarontin soln 32 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 29 ZEJULA CAPS 19 ZELAPAR TBDP 33 ZELBORAF TABS 19 ZEMAIRA SOLR INTRAVENOUS 56 ZEMBRACE SYMTOUCH SOAJ 32 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
63 ZENPEP CPEP 40
108 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg 30
ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
34 ZEPOSIA CAPS 34 ZEPOSIA STARTER KIT CPPK 34 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERIT CAPS 15mg 20mg 30mg 40mg 13 ZERUVIA PTCH 61 ZETONNA AERS 42 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 55 ZINBRYTA SOSY 34 ZIONODIL 100 LOTN 61 ZIONODIL LOTN 61 ZIOPTAN SOLN 42 ziprasidone hcl caps 20mg 40mg 60mg
80mg 37 ziprasidone mesylate solr 37 ZIPSOR CAPS 29 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZIRGAN GEL 41 ZITHROMAX PACK 10 ZOKINVY CAPS 50mg 75mg 55 zoledronic acid conc 52 zoledronic acid soln 52
ZOLINZA CAPS 19 zolmitriptan soln 32 zolmitriptan tabs 32 zolmitriptan tbdp 32 zolpidem tartrate er tbcr 625mg 125mg 33 zolpidem tartrate subl 175mg 35mg 33 zolpidem tartrate tabs 5mg 10mg 33 ZOMACTON SOLR 51 ZOMACTON SOLR 5mg 51 ZOMIG SOLN 32 zonisamide caps 25mg 50mg 100mg 32 ZONTIVITY TABS 22 ZORBTIVE SOLR 51 ZORTRESS TABS 025mg 53 ZORTRESS TABS 05mg 075mg 1mg 53 ZORVOLEX CAPS 29 ZOSTAVAX SUSR 58 ZOSYN SOLN INTRAVENOUS 10 zovia 135e (28) tabs 48 ZUBSOLV SUBL 35 ZUPLENZ FILM 4mg 8mg 43 ZYCLARA PUMP CREA 63 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19 ZYKADIA TABS 19 ZYLET SUSP 42 ZYNLONTA SOLR 19 ZYPITAMAG TABS 1mg 2mg 4mg 23 ZYPREXA RELPREVV SUSR 37 ZYTIGA TABS 19 ZYVOX SOLN INTRAVENOUS 10
Nondiscrimination Notice
Kaiser Permanente does not discriminate on the basis of age race ethnicity color national origin
cultural background ancestry religion sex gender identity gender expression sexual orientation
marital status physical or mental disability source of payment genetic information citizenship
primary language or immigration status
Language assistance services are available from our Member Service Contact Center 24 hours a day
7 days a week (except closed holidays) Interpreter services including sign language are available at
no cost to you during all hours of operation Auxiliary aids and services for individuals with
disabilities are available at no cost to you during all hours of operation We can also provide you your
family and friends with any special assistance needed to access our facilities and services You may
request materials translated in your language at no cost to you You may also request these materials in
large text or in other formats to accommodate your needs at no cost to you For more information call
1-800-464-4000 (TTY 711)
A grievance is any expression of dissatisfaction expressed by you or your authorized representative
through the grievance process For example if you believe that we have discriminated against you you
can file a grievance Please refer to your Evidence of Coverage or Certificate of Insurance or speak
with a Member Services representative for the dispute-resolution options that apply to you
You may submit a grievance in the following ways
bull By phone Call member services at 1-800-464-4000 (TTY 711) 24 hours a day
7 days a week (except closed holidays)
bull By mail Call us at 1-800-464-4000 (TTY 711) and ask to have a form sent to you
bull In person Fill out a Complaint or Benefit ClaimRequest form at a member services office
located at a Plan Facility (go to your provider directory at kporgfacilities for addresses)
bull Online Use the online form on our website at kporg
Please call our Member Service Contact Center if you need help submitting a grievance
The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to
discrimination on the basis of race color national origin sex age or disability You may also
contact the Kaiser Permanente Civil Rights Coordinator directly at
Northern California
Civil RightsADA Coordinator
1800 Harrison St
16th Floor
Oakland CA 94612
Southern California
Civil RightsADA Coordinator
SCAL Compliance and Privacy
393 East Walnut St
Pasadena CA 91188
You can also file a civil rights complaint with the US Department of Health and Human Services
Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available
at ocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human
Services 200 Independence Ave SW Room 509F HHH Building Washington DC 20201
1-800-368-1019 1-800-537-7697 (TTY) Complaint forms are available at
hhsgovocrofficefileindexhtml
Language Assistance Services
English Language assistance
is available at no cost to you
24 hours a day 7 days a week
You can request interpreter
services materials translated
into your language or in
alternative formats Just call us
at 1-800-464-4000 24 hours a
day 7 days a week (closed
holidays) TTY users call 711
Arabic مجانا على مدار الساعة كافة متوفرة لك خدمات الترجمة الفورية
أيام الأسبوع بإمكانك طلب خدمة الترجمة الفورية أو ترجمة وثائق للغتك أو
4000-464-800-1 لصيغ أخرى ما عليك سوى الاتصال بنا على الرقم
لمستخدمي خدمة على مدار الساعة كافة أيام الأسبوع )مغلق أيام العطلات(
(711الرقم ) الهاتف النصي يرجي الاتصال على
Armenian Ձեզ կարող է անվճար օգնություն
տրամադրվել լեզվի հարցում` օրը 24 ժամ շաբաթը
7 օր Դուք կարող եք պահանջել բանավոր
թարգմանչի ծառայություններ Ձեր լեզվով
թարգմանված կամ այլընտրանքային ձևաչափով
պատրաստված նյութեր Պարզապես զանգահարեք
մեզ` 1-800-464-4000 հեռախոսահամարով` օրը
24 ժամ` շաբաթը 7 օր (տոն օրերին փակ է) TTY-ից
օգտվողները պետք է զանգահարեն 711
Chinese 您每週 7天每天 24小時均可獲得免費語
言協助您可以申請口譯服務要求將資料翻譯成
您所用語言或轉換為其他格式我們每週 7天
每天 24小時均歡迎您打電話 1-800-757-7585 前來聯
絡(節假日 休息)聽障及語障專線 (TTY) 使用者
請撥 711
Farsi بدون روز هفته 7ساعت شبانروز و 24در زبانی خدمات
مترجم خدمات شما می توانید برای استهزینه در اختیار شما اخذ
صورتهای دیگر به زبان شما و یا به جزوات ترجمهشفاهی
روز هفته 7ساعت شبانروز و 24 کافیست در درخواست کنید
4000-464-800-1)به استثنای روزهای تعطیل( با ما به شماره
تماس بگیرند 711با شماره TTYتماس بگیرید کاربران
Hindi बिना किसी लागत ि दभाबिया सवाए कदन ि 24 घट
सपताह ि सातो कदन उपलबध ह आप एि दभाबिय िी सवाओ
ि बलए बिना किसी लागत ि सामबियो िो अपनी भािा म
अनवाद िरवान ि बलए या विबपपि परारपो ि बलए अनरोध
िर सित ह िस िवल हम 1-800-464-4000 पर कदन ि 24
घट सपताह ि सातो कदन (छटटियो वाल कदन िद रहता ह) िॉल
िर TTY उपयोगिताा 711 पर िॉल िर
Hmong Muajkwc pab txhais lus pub dawb rau koj
24 teev ib hnub twg 7 hnub ib lim tiam twg Koj thov
tau cov kev pab txhais lus muab cov ntaub ntawv
txhais ua koj hom lus los yog ua lwm homTsuas hu
rau 1-800-464-4000 24 teev ib hnub twg 7 hnub ib
lim tiam twg (cov hnub caiv kaw) Cov neeg siv
TTY hu 711
Japanese 当院では言語支援を無料で年中無休
終日ご利用いただけます通訳サービス日本語
に翻訳された資料あるいは資料を別の書式でも
依頼できますお気軽に 1-800-464-4000 までお電話
ください (祭日を除き年中無休)TTYユーザー
は 711にお電話ください
Khmer ជនយភាសា គមានឥតអសថលៃដលអនកឡ ើយ 24
ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ អនកអាចឡសនើស ឡសវាអនកបកបរប សភារៈបដលបានបកបរបឡៅជាភាសាបមែរ ឬជាទរងផោសងឡទៀត រានបតទរសពទមកឡយើង តាមឡលម 1-800-464-4000 បាន 24 ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ (បទថលៃប ណោយ) អនកឡរបើ TTY ឡៅឡលម 711
Korean 요일 및 시간에 관계없이 언어 지원
서비스를 무료로 이용하실 수 있습니다 귀하는
통역 서비스 귀하의 언어로 번역된 자료 또는 대체
형식의 자료를 요청할 수 있습니다 요일 및 시간에
관계없이 1-800-464-4000번으로 전화하십시오
(공휴일 휴무) TTY 사용자 번호 711
Laotian ການຊວຍເຫ ອດານພາສາມໃຫໂດຍບ ເສຽຄາ
ແກທານ ຕະຫ ອດ 24 ຊ ວໂມງ 7 ວນຕ ອາທດ ທານ
ສາມາດຮອງຂ ຮບບ ລການນາຍພາສາ ໃຫແປເອກະ
ສານເປນພາສາຂອງທານ ຫ ໃນຮບແບບອ ນ ພຽງ
ແຕໂທຣຫາພວກເຮ າທ 1-800-464-4000 ຕະຫ ອດ 24
ຊ ວໂມງ 7 ວນຕ ອາທດ (ປດວນພກຕາງໆ) ຜໃຊສາຍ
TTY ໂທຣ 711
Navajo Saad bee aacutekaacutersquoarsquoayeed naacutehoacuteloacute trsquoaacuteaacute jiikrsquoeacute
naadiin doo bibąąrsquo diacuteiacutersquo aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute
damoo naacuteaacutedleehjiacute Atah halnersquoeacute aacutekaacutersquoadoolwołiacutegiacuteiacute joacutekiacute
trsquoaacuteadoo lersquoeacute trsquoaacuteaacute hoacutehazaadjiacute hadilyąąrsquogo eacuteiacute doodaiirsquo
naacuteaacutenaacute laacute ałrsquoąą aacutedaatrsquoehiacutegiacuteiacute bee haacutedadilyaarsquogo Kojiacute
hodiilnih 1-800-464-4000 naadiin doo bibąąrsquo diacuteiacutersquo
aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute damoo naacutersquoaacutedleehjiacute
(Dahodiyin biniiyeacute ersquoersquoaahgo eacuteiacute darsquodeelkaal)
TTY chodeeyooliacuteniacutegiacuteiacute kojiacute hodiilnih 711
Punjabi ਬਿਨ ਾ ਬਿਸੀ ਲ ਗਤ ਦ ਬਦਨ ਦ 24 ਘਟ ਹਫਤ ਦ 7 ਬਦਨ
ਦਭ ਸੀਆ ਸਵ ਵ ਾ ਤਹ ਡ ਲਈ ਉਪਲਿਧ ਹ ਤਸੀ ਇਿ ਦਭ ਸੀਏ ਦੀ
ਮਦਦ ਲਈ ਸਮਗਰੀਆਾ ਨ ਆਪਣੀ ਭ ਸ ਬਵਚ ਅਨਵ ਦ ਿਰਵ ਉਣ
ਲਈ ਜ ਾ ਬਿਸ ਵਖ ਫ ਰਮਟ ਬਵਚ ਪਰ ਪਤ ਿਰਨ ਲਈ ਿਨਤੀ ਿਰ ਸਿਦ
ਹ ਿਸ ਬਸਰਫ਼ ਸ ਨ 1-800-464-4000 ਤ ਬਦਨ ਦ 24 ਘਟ ਹਫ਼ਤ
ਦ 7 ਬਦਨ (ਛਟੀਆਾ ਵ ਲ ਬਦਨ ਿਦ ਰਬਹਦ ਹ) ਫ਼ਨ ਿਰ TTY ਦ
ਉਪਯਗ ਿਰਨ ਵ ਲ 711 lsquoਤ ਫ਼ਨ ਿਰਨ
Russian Мы бесплатно обеспечиваем Вас услугами
перевода 24 часа в сутки 7 дней в неделю Вы можете
воспользоваться помощью устного переводчика
запросить перевод материалов на свой язык или
запросить их в одном из альтернативных форматов
Просто позвоните нам по телефону 1-800-464-4000
который доступен 24 часа в сутки 7 дней в неделю
(кроме праздничных дней) Пользователи линии TTY
могут звонить по номеру 711
Spanish Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al diacutea 7 diacuteas a la semana
Puede solicitar los servicios de un inteacuterprete que los
materiales se traduzcan a su idioma o en formatos
alternativos Solo llame al 1-800-788-0616 24 horas al
diacutea 7 diacuteas a la semana (cerrado los diacuteas festivos) Los
usuarios de TTY deben llamar al 711
Tagalog May magagamit na tulong sa wika nang wala
kang babayaran 24 na oras bawat araw 7 araw bawat
linggo Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format Tawagan lamang
kami sa 1-800-464-4000 24 na oras bawat araw 7 araw
bawat linggo (sarado sa mga pista opisyal) Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711
Thai เรามบรการลามฟรส าหรบคณตลอด 24 ชวโมง
ทกวนตลอดชวโมงท าการของเราคณสามารถขอใหลาม
ชวยตอบค าถามของคณทเกยวกบความคมครองการดแล
สขภาพของเราและคณยงสามารถขอใหมการแปลเอกสา
รเปนภาษาทคณใชไดโดยไมมการคดคาบรการเพยงโทร
หาเราทหมายเลข 1-800-464-4000 ตลอด 24
ชวโมงทกวน (ปดใหบรการในวนหยดราชการ) ผใช TTY
โปรดโทรไปท 711
Vietnamese Dịch vụ thocircng dịch được cung cấp miễn
phiacute cho quyacute vị 24 giờ mỗi ngagravey 7 ngagravey trong tuần Quyacute
vị coacute thể yecircu cầu dịch vụ thocircng dịch tagravei liệu phiecircn dịch
ra ngocircn ngữ của quyacute vị hoặc tagravei liệu bằng nhiều higravenh
thức khaacutec Quyacute vị chỉ cần gọi cho chuacuteng tocirci tại số
1-800-464-4000 24 giờ mỗi ngagravey 7 ngagravey trong tuần
(trừ caacutec ngagravey lễ) Người dugraveng TTY xin gọi 711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
Provide no cost aids and services to people with disabilities to communicate effectively with us such as
diams Qualified sign language interpreters
diams Written information in other formats such as large print audio and accessible electronic formats
Provide no cost language services to people whose primary language is not English such as
diams Qualified interpreters
diams Information written in other languages
If you need these services call Member Services at 1-800-476-2167 (TTY 711)8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana Aurora CO 80014 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
61102709_CO
Multi-language Interpreter Services
English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-476-2167 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-476-2167 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-476-2167 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-476-2167 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-476-2167 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-476-2167 (TTY 711)번으로 전화해 주십시오
Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-800-476-2167 (телетайп 711)
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-476-2167(TTY711)までお電話にてご連絡ください
Amharic ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው 711)
German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-800-476-2167 (TTY 711)
French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-800-476-2167 (ATS 711)
Farsi
ی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ دیریبگ تماس (TTY 711) 2167-476-800-1 با باشد
Arabic
ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم )117- (رقم ھاتف الصم والبكم 7612-674-008-1
Yoruba AKIYESI Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o E pe ero ibanisoro yi 1-800-476-2167 (TTY 711)
Cushite-Oromo XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 1-800-476-2167 (TTY 711)
Nepali
धयान िदनहोस तपाइल नपाली बोलनहनछ भन तपाइको िनिमत भाषा सहायता सवाह िनःशलक पमा उपलबध छ फोन गनरहोस 1-800-476-2167 (िटिटवाइ 711)
KAH2711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
bull Provide no cost aids and services to people with disabilities to communicateeffectively with us such asdiams Qualified sign language interpretersdiams Written information in other formats such as large print audio and accessible
electronic formatsbull Provide no cost language services to people whose primary language is not English
such asdiams Qualified interpretersdiams Information written in other languages
If you need these services call Member Services at 1-800-805-2739 (TTY 711) 8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd Honolulu HI 96813 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Kaiser Permanente is an HMO plan with a Medicare contract Enrollment in Kaiser Permanente depends on contract renewal
H1230_2017MLI accepted
Multi-language Interpreter Services English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-805-2739 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-805-2739 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-805-2739 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-805-2739 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-805-2739 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-805-2739 (TTY 711)번으로 전화해 주십시오
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-805-2739(TTY711)までお電話にてご連絡ください
Lao
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 1-800-805-2739 (TTY 711)
Ilocano PAKDAAR Nu saritaem ti Ilocano ti serbisyo para ti baddang ti lengguahe nga awanan bayadna ket sidadaan para kenyam Awagan ti 1-800-805-2739 (TTY 711)
Samoan MO LOU SILAFIA Afai e te tautala Gagana faa Sāmoa o loo iai auaunaga fesoasoan e fai fua e leai se totogi mo oe Telefoni mai 1-800-805-2739 (TTY 711)
Marshallese LALE Ntildee kwōj kōnono Kajin Ṃajōḷ kwomarontilde bōk jerbal in jipantilde ilo kajin ṇe aṃ ejjeḷọk wōṇāān Kaalọk 1-800-805-2739 (TTY 711)
Trukese MEI AUCHEA Ika iei foosun fonuomw Foosun Chuuk iwe en mei tongeni omw kopwe angei aninisin chiakku ese kamo Kori 1-800-805-2739 (TTY 711)
Hawaiian E NĀNĀ MAI Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo loaʻa ke kōkua manuahi iā ʻoe E kelepona iā 1-800-805-2739 (TTY 711)
Pohnpeian Ni songen mwohmw ohte komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei Call 1-800-805-2739 (TTY 711)
Bisayan ATENSYON Kung nagsulti ka og Cebuano aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe nga walay bayad Tawag sa 1-800-805-2739 (TTY 711)
Tongan FAKATOKANGArsquoI Kapau lsquooku ke Lea-Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai atu ha tokoni tarsquoetotongi pea teke lava lsquoo marsquou ia Telefoni mai 1-800-805-2739 (TTY 711)
485236276 102021
This formulary was updated on 100121 For more recent information or other questions please contact the number for your Kaiser Permanente Region listed below seven days a week 8 am to 8 pm or visit kporgseniorrx
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Foundation Health Plan Inc 393 E Walnut St Pasadena CA 91188-8514 Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E Dakota Ave Denver CO 80247 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Foundation Health Plan Inc 711 Kapiolani Blvd Honolulu HI 96813 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
kporgseniorrx Please recycle
6 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Kaiser Permanentersquos Formulary
The formulary below provides coverage information about the drugs covered by our plan If you have trouble finding your drug in the list turn to the index that begins on page 66 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg NEBUPENT) and generic drugs are listed in lower-case italics (eg ltamoxicillingt) The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number below Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy Northern CA ndash 1-888-218-6245 Monday through Friday 8 am to 8 pm Saturday 8 am to 6 pm and Sunday 9 am to 6 pm Southern CA ndash 1-866-206-2983 Monday through Friday 7 am to 7 pm Saturday 10 am to 2 pm
Colorado
Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday 8 am to 6 pm
Hawaii
Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday 800 am to 5 pm
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 7
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
8 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole tabs NDS emverm chew ivermectin tabs praziquantel tabs MO ANTIBACTERIALS amikacin sulfate soln amikacin sulfate soln injection HI amoxicillin caps amoxicillin chew amoxicillin susr amoxicillin tabs amoxicillin-pot clavulanate chew amoxicillin-pot clavulanate er tb12
amoxicillin-pot clavulanate susr amoxicillin-pot clavulanate tabs ampicillin caps ampicillin sodium solr ampicillin sodium solr injection 1gm 125mg HI
ampicillin sodium solr intravenous HI
ampicillin-sulbactam sodium solr ampicillin-sulbactam sodium solr injection HI
ampicillin-sulbactam sodium solr intravenous HI
ARIKAYCE SUSP PALDNDS AUGMENTIN SUSR AVYCAZ SOLR INTRAVENOUS HI AZITHROMYCIN PACK MO azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BAXDELA SOLR INTRAVENOUS HI
BAXDELA TABS MO
Drug Name RequirementsLimits
BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP cefaclor caps cefaclor er tb12 cefaclor susr cefadroxil caps cefadroxil susr cefadroxil tabs cefazolin sodium solr cefazolin sodium solr injection 1gm 10gm 500mg HI
cefdinir caps cefdinir susr cefepime hcl solr injection 1gm 2gm HI
cefixime caps cefixime susr cefotaxime sodium solr cefotetan disodium solr injection 1gm 2gm HI
cefoxitin sodium solr injection HI cefoxitin sodium solr intravenous 1gm 2gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 2gm 6gm HI
CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 75gm 750mg HI
cefuroxime sodium solr intravenous HI
cephalexin caps cephalexin susr cephalexin tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w soln ciprofloxacin in d5w soln intravenous HI
ciprofloxacin susr ciprofloxacin-ciproflox hcl er tb24 clarithromycin er tb24 clarithromycin susr clarithromycin tabs cleocin phosphate soln cleocin solr clindamycin hcl caps clindamycin palmitate hcl solr clindamycin phosphate in d5w soln intravenous HI
clindamycin phosphate soln clindamycin phosphate soln injection 300mg2ml 600mg4ml 900mg6ml
HI
colistimethate sodium (cba) solr injection HI
DALVANCE SOLR INTRAVENOUS HI
daptomycin solr intravenous 350mg 500mg HI
demeclocycline hcl tabs dicloxacillin sodium caps DIFICID SUSR NDS DIFICID TABS NDS DORYX MPC TBEC MO doxy 100 solr intravenous HI doxycycline hyclate caps 50mg 100mg MO
doxycycline hyclate tabs 20mg 75mg 100mg 150mg MO
doxycycline hyclate tbec 50mg 75mg 100mg 150mg 200mg MO
doxycycline monohydrate caps 50mg 75mg 100mg 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
Drug Name RequirementsLimits
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs FETROJA SOLR NDS FIRVANQ SOLR gentamicin in saline soln gentamicin in saline soln intravenous HI
gentamicin sulfate soln gentamicin sulfate soln injection HI imipenem-cilastatin solr intravenous HI
KIMYRSA SOLR NDS levofloxacin in d5w soln levofloxacin in d5w soln intravenous HI
levofloxacin soln levofloxacin soln intravenous HI levofloxacin tabs lincomycin hcl soln linezolid soln intravenous HI linezolid susr NDS linezolid tabs NDS meropenem solr intravenous 1gm 500mg HI
minocycline hcl caps 50mg 75mg 100mg MO
minocycline hcl er tb24 45mg 55mg 65mg 80mg 90mg 105mg 115mg 135mg
MO
minocycline hcl tabs 50mg 75mg 100mg MO
mondoxyne nl caps 75mg 100mg MO
morgidox caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 10 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium solr intravenous HI neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs okebo caps MO ORBACTIV SOLR NDS OXACILLIN SODIUM IN DEXTROSE SOLN INTRAVENOUS
HI
oxacillin sodium solr injection 1gm 2gm HI
oxacillin sodium solr intravenous HI PENICILLIN G POT IN DEXTROSE SOLN INTRAVENOUS
HI
penicillin g potassium solr injection HI
penicillin g procaine susp penicillin g sodium solr injection HI penicillin v potassium solr penicillin v potassium tabs piperacillin sod-tazobactam so solr
piperacillin sod-tazobactam so solr intravenous HI
polymyxin b sulfate solr injection HI RECARBRIO SOLR NDS SEYSARA TABS 60mg 100mg 150mg NDS
SIVEXTRO SOLR INTRAVENOUS HI
SIVEXTRO TABS NDS soloxide tbec MO streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
Drug Name RequirementsLimits
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO SUPRAX CAPS suprax chew suprax susr 100mg5ml 200mg5ml
SUPRAX SUSR 500 MG5ML SYNERCID SOLR targadox tabs MO tazicef solr injection 1gm 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS 400mg 600mg HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
VABOMERE SOLR INTRAVENOUS HI
vancomycin hcl caps vancomycin hcl solr VANCOMYCIN HCL SOLR 250 MG
vancomycin hcl solr intravenous 1gm 10gm 500mg HI
VIBRAMYCIN SYRP XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS XIMINO CP24 45mg 90mg 135mg MO
ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ZITHROMAX PACK MO ZOSYN SOLN INTRAVENOUS HI ZYVOX SOLN INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
ANTIFUNGALS ABELCET SUSP INTRAVENOUS HI
AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS ERAXIS SOLR INTRAVENOUS 50mg 100mg HI
fluconazole in sodium chloride soln intravenous HI
fluconazole susr fluconazole tabs flucytosine caps 250mg 500mg NDS griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs itraconazole caps ITRACONAZOLE SOLN MO ketoconazole tabs micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS NOXAFIL TBEC NDS nystatin susp nystatin tabs POSACONAZOLE SUSP NDS posaconazole tbec NDS terbinafine hcl tabs TOLSURA CAPS NDS voriconazole solr intravenous HI voriconazole susr voriconazole tabs ANTIMYCOBACTERIALS CAPASTAT SULFATE SOLR cycloserine caps dapsone tabs 25mg 100mg MO ethambutol hcl tabs 100mg 400mg MO
isoniazid soln
Drug Name RequirementsLimits
isoniazid syrp MO isoniazid tabs 100mg 300mg MO paser pack MO PRETOMANID TABS PRIFTIN TABS MO pyrazinamide tabs MO RIFABUTIN CAPS MO RIFADIN CAPS MO rifamate caps MO rifampin caps 150mg 300mg MO rifampin solr intravenous HI RIFATER TABS MO SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs BENZNIDAZOLE TABS 125mg 100mg MO
chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS DARAPRIM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS mefloquine hcl tabs metronidazole caps metronidazole in nacl soln metronidazole in nacl soln intravenous HI
metronidazole tabs NEBUPENT SOLR PA nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 12 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
quinine sulfate caps NDS SOLOSEC PACK tinidazole tabs ANTIVIRALS abacavir sulfate soln abacavir sulfate tabs MO abacavir sulfate-lamivudine tabs MO abacavir-lamivudine-zidovudine tabs MO
acyclovir caps MO acyclovir sodium soln intravenous HI
acyclovir susp MO acyclovir tabs 400mg 800mg MO adefovir dipivoxil tabs NDS APTIVUS CAPS MO APTIVUS SOLN MO atazanavir sulfate caps 150mg 200mg 300mg MO
BARACLUDE SOLN MO BIKTARVY TABS CABENUVA SUER cidofovir soln CIMDUO TABS MO COMPLERA TABS MO CRIXIVAN CAPS 200mg 400mg MO DAKLINZA TABS 30mg 60mg 90mg PANDS
DELSTRIGO TABS MO DESCOVY TABS MO didanosine cpdr 200mg 250mg 400mg MO
DOVATO TABS MO EDURANT TABS MO efavirenz caps 50mg 200mg MO efavirenz tabs MO efavirenz-emtricitab-tenofovir tabs MO
emtricitabine caps MO emtricitabine-tenofovir df tabs MO EMTRIVA SOLN MO entecavir tabs 05mg 1mg MO EPCLUSA TABS PANDS
Drug Name RequirementsLimits
EPIVIR HBV SOLN MO etravirine tabs 100mg 200mg MO EVOTAZ TABS MO famciclovir tabs 125mg 250mg 500mg MO
fosamprenavir calcium tabs MO FUZEON SOLR NDS ganciclovir sodium soln ganciclovir sodium solr GENVOYA TABS MO HARVONI PACK PANDS HARVONI TABS PANDS INTELENCE TABS 25mg MO INVIRASE CAPS MO INVIRASE TABS MO ISENTRESS CHEW 25mg 100mg MO
ISENTRESS HD TABS MO ISENTRESS PACK MO ISENTRESS TABS MO JULUCA TABS MO lamivudine soln MO lamivudine tabs 100mg 150mg 300mg MO
lamivudine-zidovudine tabs MO ledipasvir-sofosbuvir tabs PANDS LEXIVA SUSP MO lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO MAVYRET TABS PANDS nevirapine er tb24 100mg 400mg MO
nevirapine susp MO nevirapine tabs MO NORVIR CAPS MO NORVIR PACK MO NORVIR SOLN MO ODEFSEY TABS MO OLYSIO CAPS PANDS oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEG-INTRON REDIPEN KIT NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
PEGASYS PROCLICK SOLN 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN 180mcg05ml 180mcgml NDS
PEGINTRON KIT NDS PIFELTRO TABS MO PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
PREVYMIS SOLN 240mg12ml 480mg24ml NDS
PREVYMIS TABS 240mg 480mg NDS
PREZCOBIX TABS MO PREZISTA SUSP MO PREZISTA TABS 75mg 150mg 600mg 800mg MO
RAPIVAB SOLN NDS REBETOL SOLN MO RELENZA DISKHALER AEPB MO RESCRIPTOR TABS 100mg 200mg MO
RETROVIR SOLN MO REYATAZ PACK MO ribasphere caps MO ribasphere ribapak (1000 pack) tbpk MO
ribasphere ribapak (1200 pack) tbpk MO
ribasphere tabs MO ribavirin caps MO ribavirin solr ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg 150mg 300mg MO
sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS
Drug Name RequirementsLimits
SOVALDI TABS 200mg 400mg PANDS stavudine caps 15mg 20mg 30mg 40mg MO
STRIBILD TABS MO SYMFI LO TABS MO SYMFI TABS MO SYMTUZA TABS MO SYNAGIS SOLN 50mg05ml 100mgml NDS
tenofovir disoproxil fumarate tabs MO
TIVICAY PD TBSO MO TIVICAY TABS 10mg 25mg 50mg MO
TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEMLIDY TABS VIDEX EC CPDR 125mg 200mg 400mg MO
VIDEX SOLR 2gm 4gm MO VIEKIRA PAK TBPK PANDS VIEKIRA XR TB24 PANDS VIRACEPT TABS 250mg 625mg MO
VIREAD POWD MO VIREAD TABS 150mg MO VIREAD TABS 200mg 250mg MO VOCABRIA TABS MO VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS ZERIT CAPS 15mg 20mg 30mg 40mg MO
zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 14 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fosfomycin tromethamine pack MENAPHOSMBHYO1 TABS methenamine hippurate tabs METHENAMINE MANDELATE TABS
NITROFURANTOIN MACROCRYSTAL CAPS
NITROFURANTOIN MONOHYD MACRO CAPS
nitrofurantoin susp PHOSPHASAL TABS trimethoprim tabs MO URETRON DS TABS URIN DS TABS URYL TABS USTELL CAPS UTICAP CAPS UTIRA-C TABS UTRONA-C TABS ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate soln carbinoxamine maleate tabs cetirizine hcl soln CLARINEX SYRP CLARINEX-D 12 HOUR TB12 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln
Drug Name RequirementsLimits
promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs SEMPREX-D CAPS ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg 500mg NDS
ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS 25mg 5mg 75mg 10mg NDS
ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs ARRANON SOLN ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE INJ BELEODAQ SOLR NDS BELRAPZO SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS bexarotene caps NDS bicalutamide tabs BICNU SOLR bleomycin sulfate solr BLINCYTO SOLR NDS BORTEZOMIB SOLR BOSULIF TABS 100mg 400mg 500mg NDS
BRAFTOVI CAPS 50mg 75mg NDS BRUKINSA CAPS NDS busulfan soln CABOMETYX TABS 20mg 40mg 60mg NDS
CALQUENCE CAPS NDS CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR NDS cladribine soln clofarabine soln COMETRIQ (100 MG DAILY DOSE) KIT LDNDS
COMETRIQ (140 MG DAILY DOSE) KIT LDNDS
COMETRIQ (60 MG DAILY DOSE) KIT LDNDS
COPIKTRA CAPS 15mg 25mg NDS COTELLIC TABS NDS CYCLOPHOSPHAMIDE CAPS 25mg 50mg PA
CYCLOPHOSPHAMIDE SOLN 1gm5ml 500mg25ml NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr
Drug Name RequirementsLimits
dactinomycin solr DANYELZA SOLN NDS DARZALEX FASPRO SOLN NDS DARZALEX SOLN 400mg20ml 100mg5ml NDS
daunorubicin hcl soln DAURISMO TABS 25mg 100mg NDS decitabine solr DOCETAXEL (NON-ALCOHOL) SOLN 80mg4ml 160mg8ml 20mgml
NDS
docetaxel conc docetaxel soln doxorubicin hcl liposomal inj DOXORUBICIN HCL SOLN doxorubicin hcl solr DROXIA CAPS ELIGARD KIT ELLENCE SOLN ELZONRIS SOLN NDS EMCYT CAPS NDS EMPLICITI SOLR 300mg 400mg NDS
ENHERTU SOLR NDS epirubicin hcl soln ERBITUX SOLN ERIVEDGE CAPS NDS ERLEADA TABS NDS erlotinib hcl tabs 25mg 100mg 150mg NDS
ERWINASE SOLR NDS ERWINAZE SOLR NDS ETOPOPHOS SOLR NDS etoposide soln everolimus tabs 25mg 5mg 75mg NDS
EVOMELA SOLR NDS exemestane tabs FARYDAK CAPS 10mg 15mg 20mg LDNDS
FASLODEX SOLN NDS FENSOLVI (6 MONTH) KIT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 16 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
FIRMAGON (240 MG DOSE) SOLR
FIRMAGON SOLR floxuridine solr fludarabine phosphate soln fludarabine phosphate solr fluorouracil soln flutamide caps FOTIVDA CAPS 089mg 134mg NDS
fulvestrant soln NDS GAVRETO CAPS NDS GAZYVA SOLN NDS gemcitabine hcl soln gemcitabine hcl solr GILOTRIF TABS 20mg 30mg 40mg NDS
HERCEPTIN HYLECTA SOLN NDS HERCEPTIN SOLR 150mg 440mg NDS
HERZUMA SOLR 150mg 420mg NDS
HEXALEN CAPS NDS hydroxyurea caps IBRANCE CAPS 75mg 100mg 125mg NDS
IBRANCE TABS 75mg 100mg 125mg NDS
ICLUSIG TABS 10mg 15mg 30mg 45mg NDS
IDAMYCIN PFS SOLN idarubicin hcl soln IDHIFA TABS 50mg 100mg NDS ifosfamide soln IFOSFAMIDE SOLR imatinib mesylate tabs IMBRUVICA CAPS 70mg 140mg NDS
IMBRUVICA TABS 140mg 280mg 420mg 560mg NDS
IMFINZI SOLN 500mg10ml 120mg24ml NDS
INFUGEM SOLN NDS INLYTA TABS 1mg 5mg NDS
Drug Name RequirementsLimits
INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 10muml 6000000unitml NDS
INTRON A SOLR 10mu 18mu 50mu NDS
IRESSA TABS NDS irinotecan hcl soln IXEMPRA KIT SOLR NDS JAKAFI TABS 5mg 10mg 15mg 20mg 25mg NDS
JEMPERLI SOLN KADCYLA SOLR 100mg 160mg NDS KANJINTI SOLR 150mg 420mg NDS KEYTRUDA SOLN NDS KISQALI (200 MG DOSE) TBPK NDS KISQALI (400 MG DOSE) TBPK NDS KISQALI (600 MG DOSE) TBPK NDS KISQALI FEMARA (400 MG DOSE) TBPK NDS
KISQALI FEMARA (600 MG DOSE) TBPK NDS
KISQALI FEMARA (200 MG DOSE) TBPK NDS
KOSELUGO CAPS 10mg 25mg NDS KYPROLIS SOLR 10mg 30mg 60mg NDS
lapatinib ditosylate tabs NDS LARTRUVO SOLN 190mg19ml 500mg50ml NDS
LENVIMA (10 MG DAILY DOSE) CPPK LDNDS
LENVIMA (12 MG DAILY DOSE) CPPK LDNDS
LENVIMA (14 MG DAILY DOSE) CPPK LDNDS
LENVIMA (18 MG DAILY DOSE) CPPK LDNDS
LENVIMA (20 MG DAILY DOSE) CPPK LDNDS
LENVIMA (24 MG DAILY DOSE) CPPK LDNDS
LENVIMA (4 MG DAILY DOSE) CPPK LDNDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
LENVIMA (8 MG DAILY DOSE) CPPK LDNDS
letrozole tabs LEUKERAN TABS NDS leuprolide acetate kit LIBTAYO SOLN NDS LIPODOX 50 INJ LONSURF TABS NDS LORBRENA TABS 25mg 100mg NDS
LUMAKRAS TABS NDS LUMOXITI SOLR NDS LUPANETA PACK KIT LUPRON DEPOT (1-MONTH) KIT
LUPRON DEPOT (3-MONTH) KIT
LUPRON DEPOT (4-MONTH) KIT
LUPRON DEPOT (6-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT 75 MG
LUPRON DEPOT-PED (3-MONTH) KIT
LYNPARZA CAPS NDS LYNPARZA TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA SOLN NDS MARQIBO SUSP NDS MATULANE CAPS NDS megestrol acetate susp megestrol acetate tabs MEKINIST TABS 05mg 2mg NDS MEKTOVI TABS NDS melphalan hcl solr mercaptopurine tabs methotrexate sodium (pf) soln methotrexate sodium soln methotrexate sodium solr
Drug Name RequirementsLimits
methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS MUSTARGEN SOLR mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS NERLYNX TABS NDS NEXAVAR TABS NDS nilutamide tabs NINLARO CAPS 23mg 3mg 4mg NDS
NUBEQA TABS NDS ODOMZO CAPS NDS OGIVRI SOLR NDS ONIVYDE INJ NDS ONTRUZANT SOLR 150mg 420mg NDS
ONUREG TABS 200mg 300mg NDS OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml NDS
oxaliplatin soln oxaliplatin solr paclitaxel conc PADCEV SOLR 20mg 30mg NDS paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEPAXTO SOLR NDS PERJETA SOLN NDS PHESGO SOLN NDS PIQRAY (200 MG DAILY DOSE) TBPK NDS
PIQRAY (250 MG DAILY DOSE) TBPK NDS
PIQRAY (300 MG DAILY DOSE) TBPK NDS
POLIVY SOLR 30mg 140mg NDS POMALYST CAPS 1mg 2mg 3mg 4mg NDS
PORTRAZZA SOLN NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 18 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
POTELIGEO SOLN NDS PROLEUKIN SOLR NDS PURIXAN SUSP NDS QINLOCK TABS NDS RETEVMO CAPS 40mg 80mg NDS REVLIMID CAPS 25mg 5mg 10mg 15mg 20mg 25mg NDS
RIABNI SOLN 100mg10ml 500mg50ml NDS
RITUXAN HYCELA SOLN RITUXAN SOLN ROMIDEPSIN SOLN NDS ROZLYTREK CAPS 100mg 200mg NDS
RUBRACA TABS 200mg 250mg 300mg NDS
RUXIENCE SOLN 100mg10ml 500mg50ml NDS
RYBREVANT SOLN NDS RYDAPT CAPS NDS RYLAZE SOLN NDS SARCLISA SOLN 500mg25ml 100mg5ml NDS
SIKLOS TABS NDS SOLTAMOX SOLN SPRYCEL TABS 20mg 50mg 70mg 80mg 100mg 140mg NDS
STIVARGA TABS NDS sunitinib malate caps 125mg 25mg 375mg 50mg NDS
SUTENT CAPS 125mg 25mg 375mg 50mg NDS
SYLATRON KIT 600 MCG SYLATRON KIT SYLVANT SOLR 100mg 400mg NDS SYNRIBO SOLR NDS TABLOID TABS TABRECTA TABS 150mg 200mg NDS
TAFINLAR CAPS 50mg 75mg NDS TAGRISSO TABS 40mg 80mg NDS TALZENNA CAPS 025mg 1mg NDS tamoxifen citrate tabs
Drug Name RequirementsLimits
TARCEVA TABS 25mg 100mg 150mg NDS
TASIGNA CAPS 50mg 150mg 200mg NDS
TAZVERIK TABS NDS TECENTRIQ SOLN 840mg14ml 1200mg20ml NDS
temsirolimus soln TENIPOSIDE SOLN TEPADINA SOLR NDS TEPMETKO TABS NDS THALOMID CAPS 50mg 100mg 150mg 200mg NDS
thiotepa solr 15mg 100mg NDS TIBSOVO TABS NDS toposar soln TOPOTECAN HCL SOLN topotecan hcl solr toremifene citrate tabs NDS TRAZIMERA SOLR 150mg 420mg NDS
TRELSTAR MIXJECT SUSR tretinoin caps NDS trexall tabs 5mg 75mg 10mg 15mg PA
TRISENOX SOLN 10mg10ml NDS TRISENOX SOLN NDS TRODELVY SOLR NDS TRUSELTIQ (100MG DAILY DOSE) CPPK NDS
TRUSELTIQ (125MG DAILY DOSE) CPPK NDS
TRUSELTIQ (50MG DAILY DOSE) CPPK NDS
TRUSELTIQ (75MG DAILY DOSE) CPPK NDS
TRUXIMA SOLN 100mg10ml 500mg50ml NDS
TUKYSA TABS 50mg 150mg NDS TURALIO CAPS NDS TYKERB TABS NDS UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
VANTAS KIT VELCADE SOLR VENCLEXTA STARTING PACK TBPK NDS
VENCLEXTA TABS 10mg NDS VENCLEXTA TABS 50mg 100mg NDS
VERZENIO TABS 50mg 100mg 150mg 200mg NDS
vinblastine sulfate soln vincasar pfs soln vincristine sulfate soln vinorelbine tartrate soln VITRAKVI CAPS 25mg 100mg NDS VITRAKVI SOLN NDS VIZIMPRO TABS 15mg 30mg 45mg NDS
VOTRIENT TABS NDS VYXEOS SUSR NDS XALKORI CAPS 200mg 250mg NDS XATMEP SOLN PANDS XOSPATA TABS NDS XPOVIO (100 MG ONCE WEEKLY) TBPK 20mg 50mg NDS
XPOVIO (40 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (40 MG TWICE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (60 MG ONCE WEEKLY) TBPK 20mg 60mg NDS
XPOVIO (60 MG TWICE WEEKLY) TBPK NDS
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg NDS
XPOVIO (80 MG TWICE WEEKLY) TBPK NDS
XTANDI CAPS NDS XTANDI TABS 40mg 80mg NDS YERVOY SOLN YONDELIS SOLR NDS YONSA TABS NDS ZALTRAP SOLN 100mg4ml 200mg8ml NDS
ZEJULA CAPS NDS
Drug Name RequirementsLimits
ZELBORAF TABS NDS ZEPZELCA SOLR NDS ZIRABEV SOLN 400mg16ml 100mg4ml NDS
ZOLINZA CAPS NDS ZYDELIG TABS 100mg 150mg NDS ZYKADIA CAPS NDS ZYKADIA TABS NDS ZYNLONTA SOLR NDS ZYTIGA TABS NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA AEPB MO ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO BEVESPI AEROSPHERE AERO MO chlordiazepoxide-clidinium caps CUVPOSA SOLN MO dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate pf sosy glycopyrrolate soln glycopyrrolate tabs 1mg 2mg MO INCRUSE ELLIPTA AEPB MO ipratropium bromide soln 002 PAMO ipratropium bromide soln 003 006 MO
LONHALA MAGNAIR REFILL KIT SOLN NDS
methscopolamine bromide tabs 25mg 5mg MO
propantheline bromide tabs MO SPIRIVA HANDIHALER CAPS MO SPIRIVA RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 20 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO NICOTROL NS SOLN MO PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride tabs 5mg 10mg 25mg 50mg MO
CEVIMELINE HCL CAPS MO donepezil hcl tabs 5mg 10mg 23mg MO
donepezil hcl tbdp 5mg 10mg MO galantamine hydrobromide er cp24 8mg 16mg 24mg MO
galantamine hydrobromide soln MO galantamine hydrobromide tabs 4mg 8mg 12mg MO
GUANIDINE HCL TABS MO MESTINON SOLN MO pilocarpine hcl tabs 5mg 75mg MO pyridostigmine bromide er tbcr MO pyridostigmine bromide soln MO pyridostigmine bromide tabs 30mg 60mg MO
REGONOL SOLN rivastigmine pt24 46mg24hr 95mg24hr 133mg24hr MO
rivastigmine tartrate caps 15mg 3mg 45mg 6mg MO
urecholine tabs 5mg 10mg 25mg 50mg MO
SKELETAL MUSCLE RELAXANTS baclofen soln baclofen tabs 5mg 10mg 20mg MO carisoprodol tabs 250mg 350mg PANDS carisoprodol-aspirin tabs PANDS carisoprodol-aspirin-codeine tabs PANDS
chlorzoxazone tabs 375mg 500mg 750mg NDS
Drug Name RequirementsLimits
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA lorzone tabs 375mg 750mg NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln revonto solr succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs vanadom tabs PANDS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl er tb24 MO dihydroergotamine mesylate soln NDS ergoloid mesylates tabs MO ergomar subl phenoxybenzamine hcl caps NDS silodosin caps 4mg 8mg MO tamsulosin hcl caps MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR HFA AERO MO albuterol sulfate er tb12 4mg 8mg MO
albuterol sulfate hfa aers MONDS albuterol sulfate nebu 0083 25mg05ml PAMO
albuterol sulfate nebu 063mg3ml 125mg3ml PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO ARCAPTA NEOHALER CAPS MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY EPIPEN 2-PAK SOAJ EPIPEN JR 2-PAK SOAJ formoterol fumarate nebu PAMO ipratropium-albuterol soln PAMO isoproterenol hcl soln levalbuterol hcl nebu 125mg05ml 031mg3ml 063mg3ml 125mg3ml
PAMO
levalbuterol tartrate aero MO metaproterenol sulfate syrp MO metaproterenol sulfate tabs 10mg 20mg MO
midodrine hcl tabs 25mg 5mg 10mg MO
norepinephrine bitartrate soln phenylephrine hcl soln PROAIR RESPICLICK AEPB MO SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
tizanidine hcl caps VENTOLIN HFA AERS MONDS BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS BERINERT KIT INTRAVENOUS HI FIRAZYR SOLN NDS icatibant acetate soln NDS OXBRYTA TABS NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS
Drug Name RequirementsLimits
COAGULANTS AND ANTICOAGULANTS aminocaproic acid soln MO aminocaproic acid tabs 500mg 1000mg MO
anagrelide hcl caps 05mg 1mg MO argatroban soln aspirin-dipyridamole er cp12 MO BEVYXXA CAPS 40mg 80mg MO BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
NDS
FRAGMIN SOLN 2500unit02ml 5000unit02ml 7500unit03ml 12500unit05ml 15000unit06ml 95000unit38ml 10000unitml 18000unt072ml
NDS
heparin (porcine) in nacl soln HEPARIN SOD (PORCINE) IN D5W SOLN
heparin sodium (porcine) pf soln PA heparin sodium (porcine) soln 1000unitml 5000unitml 10000unitml 20000unitml
PA
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg
MO
LOVENOX SOLN 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 22 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg PRADAXA CAPS 110mg 150mg MO
prasugrel hcl tabs 5mg 10mg MO tranexamic acid soln tranexamic acid tabs MO warfarin sodium tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 10mg
MO
XARELTO STARTER PACK TBPK MO
XARELTO TABS 25mg 10mg 15mg 20mg MO
ZONTIVITY TABS MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 25mcgml 40mcgml PANDS
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml
PANDS
FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MIRCERA SOSY 30mcg03ml 50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml
PA
MULPLETA TABS NDS
Drug Name RequirementsLimits
NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml NDS
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RETACRIT SOLN 20000unit2ml 2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml
PANDS
TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL TB24 4mg 8mg MO DEMSER CAPS NDS doxazosin mesylate tabs 1mg 2mg 4mg 8mg MO
metyrosine caps NDS prazosin hcl caps 1mg 2mg 5mg MO
terazosin hcl caps 1mg 2mg 5mg 10mg MO
ANTILIPEMIC AGENTS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
ALTOPREV TB24 20mg 40mg 60mg MO
ANTARA CAPS 30mg 90mg MO atorvastatin calcium tabs 10mg 20mg 40mg 80mg MO
cholestyramine light pack MO cholestyramine light powd MO cholestyramine pack MO cholestyramine powd MO colesevelam hcl pack MO colesevelam hcl tabs MO colestipol hcl gran MO colestipol hcl pack MO colestipol hcl tabs MO EVKEEZA SOLN 345mg23ml 1200mg8ml NDS
ezetimibe tabs MO ezetimibe-simvastatin tabs MO fenofibrate caps 50mg 134mg 150mg MO
fenofibrate micronized caps 43mg 67mg 130mg 200mg MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg MO
FENOFIBRIC ACID TABS 35mg 105mg MO
FIBRICOR TABS MO FLOLIPID SUSP 20mg5ml 40mg5ml MO
fluvastatin sodium caps 20mg 40mg MO
fluvastatin sodium er tb24 MO gemfibrozil tabs MO icosapent ethyl caps MO JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg PALDNDS
KYNAMRO SOSY PALDNDS LIVALO TABS 1mg 2mg 4mg MO lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
Drug Name RequirementsLimits
niacor tabs MO omega-3-acid ethyl esters caps MO pravastatin sodium tabs 10mg 20mg 40mg 80mg MO
prevalite pack MO prevalite powd MO questran light powd MO questran pack MO questran powd MO REPATHA PUSHTRONEX SYSTEM SOCT PANDS
REPATHA SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 05gm 1gm MO ZYPITAMAG TABS 1mg 2mg 4mg MO
BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl caps 200mg 400mg MO
atenolol tabs 25mg 50mg 100mg MO
atenolol-chlorthalidone tabs MO betaxolol hcl tabs 10mg 20mg MO bisoprolol fumarate tabs 5mg 10mg MO
bisoprolol-hydrochlorothiazide tabs MO
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg MO
carvedilol tabs 3125mg 625mg 125mg 25mg MO
DUTOPROL TB24 MO ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln INNOPRAN XL CP24 80mg 120mg MO
labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 24 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
metoprolol succinate er tb24 25mg 50mg 100mg 200mg MO
metoprolol tartrate soct metoprolol tartrate soln metoprolol tartrate tabs 25mg 50mg 100mg MO
metoprolol tartrate tabs 375mg 75mg MO
metoprolol-hydrochlorothiazide tabs MO
nadolol tabs 20mg 40mg 80mg MO nadolol-bendroflumethiazide tabs MO
pindolol tabs 5mg 10mg MO propranolol hcl er cp24 60mg 80mg 120mg 160mg MO
propranolol hcl soln 20mg5ml 40mg5ml MO
propranolol hcl tabs 10mg 20mg 40mg 60mg 80mg MO
propranolol-hctz tabs MO sorine tabs 80mg 120mg 160mg 240mg MO
sotalol hcl (af) tabs 80mg 120mg 160mg MO
sotalol hcl tabs 80mg 120mg 160mg 240mg MO
SOTYLIZE SOLN MO timolol maleate tabs 5mg 10mg 20mg MO
CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besy-benazepril hcl caps MO
amlodipine besylate tabs 25mg 5mg 10mg MO
amlodipine besylate-valsartan tabs MO
amlodipine-atorvastatin tabs MO amlodipine-olmesartan tabs MO amlodipine-valsartan-hctz tabs MO CARDENE IV SOLN CARDIZEM LA TB24 MO cartia xt cp24 120mg 180mg 240mg 300mg MO
Drug Name RequirementsLimits
CONSENSI TABS NDS dilt-xr cp24 120mg 180mg 240mg MO
diltiazem hcl er beads cp24 120mg 180mg 240mg 300mg 360mg 420mg
MO
DILTIAZEM HCL ER COATED BEADS CP24 120mg 180mg 240mg 300mg 360mg
MO
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg
MO
diltiazem hcl er cp12 60mg 90mg 120mg MO
diltiazem hcl er cp24 120mg 180mg 240mg MO
diltiazem hcl soln diltiazem hcl solr diltiazem hcl tabs 30mg 60mg 90mg 120mg MO
felodipine er tb24 25mg 5mg 10mg MO
isradipine caps 25mg 5mg MO matzim la tb24 180mg 240mg 300mg 360mg 420mg MO
nicardipine hcl caps 20mg 30mg MO nicardipine hcl soln nifedipine caps 10mg 20mg MO nifedipine er osmotic release tb24 30mg 60mg 90mg MO
nifedipine er tb24 30mg 60mg 90mg MO
nimodipine caps MO nisoldipine er tb24 85mg 17mg 20mg 255mg 30mg 34mg 40mg
MO
NYMALIZE SOLN 60mg20ml 6mgml NDS
olmesartan-amlodipine-hctz tabs MO taztia xt cp24 120mg 180mg 240mg 300mg 360mg MO
telmisartan-amlodipine tabs MO tiadylt er cp24 120mg 180mg 240mg 300mg 360mg 420mg MO
trandolapril-verapamil hcl er tbcr MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
VERAPAMIL HCL ER CP24 100mg 120mg 180mg 200mg 240mg 300mg 360mg
MO
verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 80mg 120mg MO verapamil hcl tabs MO VERELAN CP24 MO CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln inj DIGOXIN ORAL SOLN MO digoxin tabs 125mcg 250mcg MO disopyramide phosphate caps 100mg 150mg MO
dofetilide caps 125mcg 250mcg 500mcg MO
flecainide acetate tabs 50mg 100mg 150mg MO
ibutilide fumarate soln LANOXIN PEDIATRIC SOLN LANOXIN TABS 625mcg MO lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy LIDOCAINE IN D5W SOLN mexiletine hcl caps 150mg 200mg 250mg MO
milrinone lactate in dextrose soln milrinone lactate soln MULTAQ TABS NORPACE CR CP12 100mg 150mg MO
pacerone tabs 100mg 200mg 400mg MO
procainamide hcl soln
Drug Name RequirementsLimits
propafenone hcl er cp12 225mg 325mg 425mg MO
propafenone hcl tabs 150mg 225mg 300mg MO
quinidine gluconate er tbcr MO QUINIDINE GLUCONATE SOLN quinidine sulfate tabs 200mg 300mg MO
ranolazine er tb12 500mg 1000mg MO
VYNDAMAX CAPS NDS VYNDAQEL CAPS NDS HYPOTENSIVE AGENTS clonidine hcl (analgesia) soln clonidine hcl er tb12 MO clonidine hcl tabs 01mg 02mg 03mg MO
clonidine ptwk 01mg24hr 02mg24hr 03mg24hr MO
guanfacine hcl tabs 1mg 2mg MO hydralazine hcl soln hydralazine hcl tabs 10mg 25mg 50mg 100mg MO
methyldopa tabs 250mg 500mg MO methyldopa-hydrochlorothiazide tabs MO
minoxidil tabs 25mg 10mg MO nitropress soln nitroprusside sodium soln vecamyl tabs NDS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE TABS MO aliskiren fumarate tabs 150mg 300mg MO
benazepril hcl tabs 5mg 10mg 20mg 40mg MO
benazepril-hydrochlorothiazide tabs MO
candesartan cilexetil tabs 4mg 8mg 16mg 32mg MO
candesartan cilexetil-hctz tabs MO captopril tabs 125mg 25mg 50mg 100mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 26 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
captopril-hydrochlorothiazide tabs MO
CAROSPIR SUSP MO EDARBYCLOR TABS MO enalapril maleate tabs 25mg 5mg 10mg 20mg MO
enalapril-hydrochlorothiazide tabs MO
enalaprilat inj ENTRESTO TABS MO eplerenone tabs 25mg 50mg MO eprosartan mesylate tabs MO fosinopril sodium tabs 10mg 20mg 40mg MO
fosinopril sodium-hctz tabs MO irbesartan tabs 75mg 150mg 300mg MO
irbesartan-hydrochlorothiazide tabs MO
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg MO
lisinopril-hydrochlorothiazide tabs MO
losartan potassium tabs 25mg 50mg 100mg MO
losartan potassium-hctz tabs MO moexipril hcl tabs 75mg 15mg MO olmesartan medoxomil tabs 5mg 20mg 40mg MO
olmesartan medoxomil-hctz tabs MO perindopril erbumine tabs 2mg 4mg 8mg MO
QBRELIS SOLN MO quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO TEKTURNA HCT TABS MO
Drug Name RequirementsLimits
telmisartan tabs 20mg 40mg 80mg MO
telmisartan-hctz tabs MO trandolapril tabs 1mg 2mg 4mg MO valsartan tabs 40mg 80mg 160mg 320mg MO
valsartan-hydrochlorothiazide tabs MO
VASODILATING AGENTS alyq tabs PA BIDIL TABS MO dipyridamole tabs 25mg 50mg 75mg MO
GONITRO PACK MO isosorbide dinitrate er tbcr MO isosorbide dinitrate tabs 5mg 10mg 20mg 30mg MO
isosorbide mononitrate er tb24 30mg 60mg MO
isosorbide mononitrate er tb24 MO isosorbide mononitrate tabs 10mg 20mg MO
minitran pt24 01mghr 02mghr 04mghr 06mghr MO
nitro-bid oint MO NITRO-DUR PT24 03mghr 08mghr MO
nitroglycerin pt24 01mghr 02mghr 04mghr 06mghr MO
nitroglycerin soln MO nitroglycerin subl 03mg 04mg 06mg MO
sildenafil citrate soln PANDS sildenafil citrate susr PA sildenafil citrate tabs PAMO tadalafil (pah) tabs 20mg PA tadalafil tabs 25mg 5mg PA CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS acamprosate calcium tbec MO antabuse tabs 250mg 500mg MO disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
ABSTRAL SUBL 100mcg 200mcg 300mcg 400mcg 600mcg 800mcg
PANDS
acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ARYMO ER TBEA NDS ascomp-codeine caps NDS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
benzhydrocodone-acetaminophen tabs
bupap tabs buprenorphine hcl soln NDS buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
butalbital-acetaminophen caps NDS butalbital-acetaminophen tabs butalbital-apap-caff-cod caps NDS butalbital-apap-caffeine caps butalbital-apap-caffeine tabs butalbital-asa-caff-codeine caps NDS butalbital-aspirin-caffeine caps butalbital-aspirin-caffeine tabs butorphanol tartrate soln 1mgml 2mgml 10mgml NDS
BUTRANS PTWK NDS cataflam tabs NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
DEMEROL SOLN 25mg05ml 75mg15ml 100mg2ml 75mgml
PANDS
diclofenac potassium tabs diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs
Drug Name RequirementsLimits
DUEXIS TABS NDS DURAMORPH SOLN 05mgml 1mgml HINDS
dvorah tabs NDS EMBEDA CPCR NDS endocet tabs NDS esgic caps esgic tabs etodolac caps etodolac er tb24 etodolac tabs fenoprofen calcium caps fenoprofen calcium tabs fenortho caps fentanyl citrate (pf) soct NDS FENTANYL CITRATE (PF) SOLN 50mcgml 1000mcg20ml 2500mcg50ml
NDS
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fioricet caps fioricetcodeine caps NDS flurbiprofen tabs hydrocodone bitartrate er cp12 10mg 15mg 20mg 30mg 40mg 50mg
NDS
hydrocodone-acetaminophen soln NDS
hydrocodone-acetaminophen tabs NDS
hydrocodone-ibuprofen tabs NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 28 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd NDS hydromorphone hcl pf soln 50mg5ml 10mgml NDS
HYDROMORPHONE HCL SOLN 1mgml 2mgml NDS
hydromorphone hcl tabs 2mg 4mg 8mg NDS
ibu tabs ibudone tabs NDS ibuprofen lysine soln ibuprofen susp ibuprofen tabs ILARIS SOLN NDS indocin supp INDOCIN SUSP indomethacin caps INDOMETHACIN CAPS 20mg indomethacin er cpcr indomethacin sodium solr KADIAN CP24 NDS ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 300mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lodine tabs lorcet hd tabs NDS lorcet plus tabs NDS lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam caps meloxicam tabs meperidine hcl soln 50mg5ml 25mgml 50mgml 100mgml PANDS
meperidine hcl tabs 50mg 100mg NDS
Drug Name RequirementsLimits
methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl soln 5mg5ml 10mg5ml 10mgml NDS
methadone hcl tabs 5mg 10mg NDS mitigo soln MORPHINE SULFATE (CONCENTRATE) SOLN NDS
morphine sulfate (pf) soln 4mgml 10mgml NDS
MORPHINE SULFATE (PF) SOLN INTRAVENOUS HI
morphine sulfate er beads cp24 30mg 45mg 60mg 75mg 90mg 120mg
NDS
morphine sulfate er cp24 10mg 20mg 30mg 40mg 50mg 60mg 80mg 100mg
NDS
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg NDS
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml NDS
MORPHINE SULFATE SOLN HINDS MORPHINE SULFATE SOLN INJECTION 2mgml 4mgml 10mgml
HI
MORPHINE SULFATE SOLN INTRAVENOUS HI
morphine sulfate tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln nalfon tabs nalocet tabs NDS NAPRELAN TB24 naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
NUCYNTA ER TB12 50mg 100mg 150mg NDS
NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS 50mg 75mg NDS NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs oxaprozin tabs OXAYDO TABS NDS oxycodone hcl caps NDS oxycodone hcl conc NDS oxycodone hcl er t12a 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxycodone hcl soln NDS oxycodone hcl tabs 5mg 10mg 15mg 20mg 30mg NDS
oxycodone-acetaminophen soln NDS oxycodone-acetaminophen tabs NDS oxycodone-acetaminophen tabs 5-300mg 10-300mg NDS
oxycodone-aspirin tabs NDS oxycodone-ibuprofen tabs NDS OXYCONTIN T12A 10mg 15mg 20mg 30mg 40mg 60mg 80mg
NDS
oxymorphone hcl er tb12 5mg 75mg 10mg 15mg 20mg 30mg 40mg
NDS
oxymorphone hcl tabs 5mg 10mg NDS
panlor tabs NDS pentazocine-naloxone hcl tabs NDS percocet tabs NDS phrenilin forte caps PIROXICAM CAPS 10mg 20mg NDS pregabalin er tb24 825mg 165mg 330mg MO
primlev tabs NDS prolate soln NDS prolate tabs NDS QDOLO SOLN NDS
Drug Name RequirementsLimits
relafen ds tabs NDS ROXYBOND TABA 5mg 15mg 30mg NDS
SALSALATE TABS SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
SUBSYS LIQD 100mcg 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg
PANDS
sulindac tabs tencon tabs TIVORBEX CAPS tolmetin sodium caps tolmetin sodium tabs tramadol hcl er (biphasic) tb24 100mg 200mg 300mg NDS
tramadol hcl er cp24 100mg 150mg 200mg 300mg NDS
tramadol hcl er tb24 100mg 200mg 300mg NDS
tramadol hcl tabs 50mg 100mg NDS tramadol-acetaminophen tabs NDS trezix caps NDS tylenol with codeine 3 tabs NDS tylenol with codeine 4 tabs NDS vanatol lq soln vicodin es tabs NDS vicodin hp tabs NDS vicodin tabs NDS XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg NDS
zebutal caps ZIPSOR CAPS ZORVOLEX CAPS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS ADDERALL XR CP24 NDS ADZENYS ER SUER NDS ADZENYS XR-ODT TBED 31mg 63mg 94mg 125mg 157mg 188mg
NDS
amphetamine er suer NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 30 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
amphetamine sulfate tabs 5mg 10mg NDS
amphetamine-dextroamphet er cp24 NDS
amphetamine-dextroamphetamine tabs NDS
armodafinil tabs 50mg 150mg 200mg 250mg PA
caffeine citrate soln COTEMPLA XR-ODT TBED 86mg 173mg 259mg NDS
DAYTRANA PTCH 10mg9hr 15mg9hr 20mg9hr 30mg9hr NDS
dexmethylphenidate hcl er cp24 5mg 10mg 15mg 20mg 25mg 30mg 35mg 40mg
NDS
dexmethylphenidate hcl tabs 25mg 5mg 10mg NDS
dextroamphetamine sulfate er cp24 5mg 10mg 15mg NDS
dextroamphetamine sulfate soln NDS dextroamphetamine sulfate tabs 5mg 10mg 15mg 20mg 30mg NDS
DYANAVEL XR SUER NDS evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS methylphenidate hcl chew 25mg 5mg 10mg NDS
methylphenidate hcl er (cd) cpcr 10mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er (la) cp24 10mg 20mg 30mg 40mg 60mg
NDS
methylphenidate hcl er (xr) cp24 10mg 15mg 20mg 30mg 40mg 50mg 60mg
NDS
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg NDS
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg
NDS
methylphenidate hcl soln 5mg5ml 10mg5ml NDS
Drug Name RequirementsLimits
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS MYDAYIS CP24 NDS procentra soln NDS QUILLICHEW ER CHER 20mg 30mg 40mg NDS
QUILLIVANT XR SRER NDS relexxii tbcr NDS SUNOSI TABS 75mg 150mg NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
NDS
VYVANSE CHEW 10mg 20mg 30mg 40mg 50mg 60mg NDS
WAKIX TABS 445mg 178mg NDS zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg
NDS
ANTICONVULSANTS APTIOM TABS 200mg 400mg 600mg 800mg MO
BANZEL SUSP BANZEL TABS 200mg 400mg NDS BRIVIACT SOLN NDS BRIVIACT TABS 10mg 25mg 50mg 75mg 100mg NDS
carbamazepine chew MO carbamazepine er cp12 100mg 200mg 300mg MO
carbamazepine er tb12 100mg 200mg 400mg MO
carbamazepine susp MO carbamazepine tabs MO CELONTIN CAPS MO clobazam susp MO clobazam tabs 10mg 20mg MO clonazepam tabs 05mg 1mg 2mg NDS
clonazepam tbdp 0125mg 025mg 05mg 1mg 2mg NDS
DIACOMIT CAPS 250mg 500mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
DIACOMIT PACK 250mg 500mg NDS
DIASTAT ACUDIAL GEL 10mg 20mg NDS
DIASTAT PEDIATRIC GEL NDS diazepam gel 25mg 10mg 20mg NDS
dilantin caps 30mg 100mg MO dilantin infatabs chew MO divalproex sodium csdr MO divalproex sodium er tb24 250mg 500mg MO
divalproex sodium tbec 125mg 250mg 500mg MO
ELEPSIA XR TB24 1000mg 1500mg NDS
EPIDIOLEX SOLN PANDS epitol tabs MO ethosuximide caps MO ethosuximide soln MO felbamate susp MO felbamate tabs 400mg 600mg MO FINTEPLA SOLN NDS fosphenytoin sodium soln FYCOMPA SUSP NDS FYCOMPA TABS gabapentin caps 100mg 400mg MO gabapentin soln MO gabapentin tabs 600mg 800mg MO HORIZANT TBCR 300mg 600mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
lamotrigine kit MO lamotrigine starter kit-blue kit MO lamotrigine starter kit-green kit MO lamotrigine starter kit-orange kit MO lamotrigine tabs 25mg 100mg 150mg 200mg MO
lamotrigine tbdp 25mg 50mg 100mg 200mg MO
Drug Name RequirementsLimits
levetiracetam er tb24 500mg 750mg MO
levetiracetam in nacl soln levetiracetam soln MO levetiracetam tabs 250mg 500mg 750mg 1000mg MO
magnesium sulfate soln magnesium sulfate soln injection 50 HI
MAGNESIUM SULFATE SOLN INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml
HI
NAYZILAM SOLN NDS oxcarbazepine susp MO oxcarbazepine tabs 150mg 300mg 600mg MO
OXTELLAR XR TB24 150mg 300mg 600mg MO
PEGANONE TABS MO phenytek caps 200mg 300mg MO phenytoin chew MO phenytoin sodium extended caps 100mg 200mg 300mg MO
phenytoin sodium soln phenytoin susp MO pregabalin caps 25mg 50mg 75mg 100mg 150mg 200mg 225mg 300mg
MO
pregabalin soln MO primidone tabs 50mg 250mg MO roweepra tabs 500mg 750mg 1000mg MO
roweepra xr tb24 500mg 750mg MO rufinamide susp rufinamide tabs 200mg 400mg NDS SPRITAM TB3D 250mg 500mg 750mg 1000mg NDS
subvenite starter kit-blue kit MO subvenite starter kit-green kit MO subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 32 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
SYMPAZAN FILM 10mg 20mg tiagabine hcl tabs 2mg 4mg 12mg 16mg MO
topiramate cpsp 15mg 25mg MO topiramate er cs24 25mg 50mg 100mg 150mg 200mg MO
topiramate tabs 25mg 50mg 100mg 200mg MO
TROKENDI XR CP24 25mg 50mg 100mg 200mg MO
valproate sodium soln valproic acid caps MO valproic acid soln MO VALTOCO 10 MG DOSE LIQD NDS VALTOCO 15 MG DOSE LQPK NDS VALTOCO 20 MG DOSE LQPK NDS VALTOCO 5 MG DOSE LIQD NDS vigabatrin pack LDNDS vigabatrin tabs NDS vigadrone pack LDNDS VIMPAT SOLN VIMPAT TABS MO XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200 MG NDS XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ AJOVY SOSY almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs EMGALITY (300 MG DOSE) SOSY NDS
Drug Name RequirementsLimits
EMGALITY SOAJ EMGALITY SOSY ergotamine-caffeine tabs frovatriptan succinate tabs naratriptan hcl tabs NURTEC TBDP NDS ONZETRA XSAIL EXHP rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs TOSYMRA SOLN UBRELVY TABS 50mg 100mg NDS ZEMBRACE SYMTOUCH SOAJ zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ZOMIG SOLN ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl syrp MO amantadine hcl tabs MO APOKYN SOCT NDS benztropine mesylate soln benztropine mesylate tabs 05mg 1mg 2mg MO
bromocriptine mesylate caps MO bromocriptine mesylate tabs MO cabergoline tabs MO carbidopa tabs MO carbidopa-levodopa er tbcr MO carbidopa-levodopa tabs MO carbidopa-levodopa tbdp MO carbidopa-levodopa-entacapone tabs MO
DUOPA SUSP LD EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg NDS
pramipexole dihydrochloride er tb24 0375mg 075mg 15mg 225mg 3mg 375mg 45mg
MO
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg
MO
rasagiline mesylate tabs 05mg 1mg MO
ropinirole hcl er tb24 2mg 4mg 6mg 8mg 12mg MO
ropinirole hcl tabs 025mg 05mg 1mg 2mg 3mg 4mg 5mg
MO
RYTARY CPCR MO selegiline hcl caps MO selegiline hcl tabs MO tolcapone tabs MO trihexyphenidyl hcl soln MO trihexyphenidyl hcl tabs 2mg 5mg MO
ZELAPAR TBDP MO ANXIOLYTICS SEDATIVES AND HYPNOTICS alprazolam er tb24 05mg 1mg 2mg 3mg NDS
alprazolam intensol conc NDS alprazolam tabs 025mg 05mg 1mg 2mg NDS
alprazolam tbdp 025mg 05mg 1mg 2mg NDS
BELSOMRA TABS buspirone hcl tabs 5mg 10mg buspirone hcl tabs 75mg 15mg 30mg
chlordiazepoxide hcl caps 5mg 10mg 25mg NDS
clorazepate dipotassium tabs 375mg 75mg 15mg NDS
diazepam conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS
Drug Name RequirementsLimits
droperidol soln EDLUAR SUBL 5mg 10mg NDS estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP NDS hydroxyzine hcl soln hydroxyzine hcl syrp hydroxyzine hcl tabs hydroxyzine pamoate caps lorazepam intensol conc NDS LORAZEPAM SOLN 4mgml 2mgml NDS
lorazepam tabs 05mg 1mg 2mg NDS
meprobamate tabs midazolam hcl (pf) soln midazolam hcl soln midazolam hcl syrp nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs ROZEREM TABS seconal caps TEMAZEPAM CAPS 15mg 225mg 30mg 75mg NDS
triazolam tabs 0125mg 025mg NDS zaleplon caps 5mg 10mg NDS zolpidem tartrate er tbcr 625mg 125mg NDS
zolpidem tartrate subl 175mg 35mg NDS
zolpidem tartrate tabs 5mg 10mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 34 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CENTRAL NERVOUS SYSTEM AGENTS MISCELLANEOUS atomoxetine hcl caps 10mg 18mg 25mg 40mg 60mg 80mg 100mg
MO
AUSTEDO TABS 6mg 9mg 12mg LDNDS
EXSERVAN FILM NDS flumazenil soln guanfacine hcl er tb24 1mg 2mg 3mg 4mg MO
INGREZZA CAPS 40mg 60mg 80mg NDS
INGREZZA CPPK NDS memantine hcl er cp24 memantine hcl soln MO memantine hcl tabs 5mg 10mg MO NAMENDA XR TITRATION PACK CP24 MO
NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS SAVELLA TABS 125mg 25mg 50mg 100mg MO
SAVELLA TITRATION PACK MISC MO
tetrabenazine tabs 125mg 25mg NDS
TIGLUTIK SUSP NDS XYREM SOLN LDNDS XYWAV SOLN NDS MULTIPLE SCLEROSIS AGENTS AUBAGIO TABS 7mg 14mg PANDS AVONEX KIT NDS AVONEX PEN AJKT NDS AVONEX PREFILLED PSKT NDS BAFIERTAM CPDR NDS BETASERON KIT NDS dalfampridine er tb12 MO dimethyl fumarate cpdr dimethyl fumarate starter pack misc
Drug Name RequirementsLimits
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatiramer acetate sosy 20mgml 40mgml NDS
glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 2mg NDS OCREVUS SOLN PLEGRIDY SOSY NDS PONVORY STARTER PACK TBPK NDS
PONVORY TABS NDS REBIF REBIDOSE SOAJ 22mcg05ml 44mcg05ml NDS
REBIF REBIDOSE TITRATION PACK SOAJ NDS
REBIF SOSY 22mcg05ml 44mcg05ml NDS
REBIF TITRATION PACK SOSY NDS TECFIDERA CPDR 120mg 240mg NDS
TECFIDERA MISC NDS TYSABRI CONC INTRAVENOUS HI
ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS ZINBRYTA SOSY LDNDS OPIATE ANTAGONISTS BUNAVAIL FILM NDS buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
LUCEMYRA TABS NDS naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
naltrexone hcl tabs NARCAN LIQD VIVITROL SUSR NDS ZUBSOLV SUBL NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg NDS
ABILIFY MYCITE MAINTENANCE KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg
NDS
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg NDS
amitriptyline hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
amoxapine tabs 25mg 50mg 100mg 150mg MO
APLENZIN TB24 174mg 348mg 522mg MO
aripiprazole soln MO aripiprazole tabs 2mg 5mg 10mg 15mg 20mg 30mg MO
aripiprazole tbdp 10mg 15mg MO ARISTADA INITIO PRSY NDS ARISTADA PRSY 441mg16ml 662mg24ml 882mg32ml 1064mg39ml
NDS
asenapine maleate subl 25mg 5mg 10mg MO
bupropion hcl er (smoking det) tb12 MO
bupropion hcl er (sr) tb12 100mg 150mg 200mg MO
bupropion hcl er (xl) tb24 150mg 300mg 450mg MO
bupropion hcl tabs 75mg 100mg MO CAPLYTA CAPS NDS chlordiazepoxide-amitriptyline tabs
chlorpromazine hcl soln
Drug Name RequirementsLimits
chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
clomipramine hcl caps 25mg 50mg 75mg MO
clozapine tabs 25mg 50mg 100mg 200mg NDS
clozapine tbdp 125mg 25mg 100mg 150mg 200mg NDS
compro supp MO desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg
MO
DESVENLAFAXINE ER TB24 50mg 100mg MO
desvenlafaxine succinate er tb24 25mg 50mg 100mg MO
doxepin hcl caps 10mg 25mg 50mg 75mg 100mg 150mg MO
doxepin hcl conc MO doxepin hcl tabs 3mg 6mg MO DRIZALMA SPRINKLE CSDR duloxetine hcl cpep 20mg 30mg 40mg 60mg MO
EQUETRO CP12 100mg 200mg 300mg MO
escitalopram oxalate soln MO escitalopram oxalate tabs 5mg 10mg 20mg MO
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg NDS
FANAPT TITRATION PACK TABS MO
FETZIMA CP24 20mg 40mg 80mg 120mg MO
FETZIMA TITRATION C4PK MO fluoxetine hcl (pmdd) tabs 10mg 20mg MO
fluoxetine hcl caps 10mg 20mg 40mg MO
fluoxetine hcl cpdr MO fluoxetine hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 36 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
GEODON SOLR haloperidol decanoate soln haloperidol lactate conc MO haloperidol lactate soln haloperidol tabs 05mg 1mg 2mg 5mg 10mg 20mg MO
imipramine hcl tabs 10mg 25mg 50mg MO
imipramine pamoate caps 75mg 100mg 125mg 150mg MO
INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 300mg 150mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
lithium carbonate tabs MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO
Drug Name RequirementsLimits
mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
nefazodone hcl tabs 50mg 100mg 150mg 200mg 250mg MO
nortriptyline hcl caps 10mg 25mg 50mg 75mg MO
nortriptyline hcl soln MO NUPLAZID CAPS NDS NUPLAZID TABS 10mg 17mg NDS olanzapine solr olanzapine tabs 25mg 5mg 75mg 10mg 15mg 20mg MO
olanzapine tbdp 5mg 10mg 15mg 20mg MO
olanzapine-fluoxetine hcl caps MO PALIPERIDONE ER TB24 15mg 3mg 6mg 9mg MO
paroxetine hcl er tb24 125mg 25mg 375mg MO
paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps MO PAXIL SUSP MO perphenazine tabs 2mg 4mg 8mg 16mg MO
perphenazine-amitriptyline tabs MO PERSERIS PRSY 90mg 120mg NDS PEXEVA TABS 10mg 20mg 30mg 40mg MO
phenelzine sulfate tabs MO pimozide tabs 1mg 2mg MO prochlorperazine edisylate soln prochlorperazine maleate tabs prochlorperazine supp MO protriptyline hcl tabs 5mg 10mg MO quetiapine fumarate er tb24 50mg 150mg 200mg 300mg 400mg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
quetiapine fumarate tabs 25mg 50mg 100mg 200mg 300mg 400mg
MO
REXULTI TABS 025mg 05mg 1mg 2mg 3mg 4mg NDS
RISPERDAL CONSTA SRER 125mg 25mg NDS
RISPERDAL CONSTA SRER 375mg 50mg NDS
risperidone soln MO risperidone tabs 025mg 05mg 1mg 2mg 3mg 4mg MO
risperidone tbdp 025mg 05mg 1mg 2mg 3mg 4mg MO
SAPHRIS SUBL 25mg 5mg 10mg NDS
SECUADO PT24 38mg24hr 57mg24hr 76mg24hr NDS
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
SILENOR TABS SPRAVATO (56 MG DOSE) SOPK NDS
SPRAVATO (84 MG DOSE) SOPK NDS
thioridazine hcl tabs 10mg 25mg 50mg 100mg MO
thiothixene caps 1mg 2mg 5mg 10mg MO
tofranil tabs 10mg 25mg 50mg MO tranylcypromine sulfate tabs MO trazodone hcl tabs 50mg 100mg 150mg MO
trazodone hcl tabs MO trifluoperazine hcl tabs 1mg 2mg 5mg 10mg MO
trimipramine maleate caps 25mg 50mg 100mg MO
TRINTELLIX TABS 5mg 10mg 20mg MO
venlafaxine hcl er cp24 375mg 75mg 150mg MO
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg MO
Drug Name RequirementsLimits
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
VRAYLAR CAPS 15mg 3mg 45mg 6mg NDS
VRAYLAR CPPK NDS ziprasidone hcl caps 20mg 40mg 60mg 80mg MO
ziprasidone mesylate solr ZYPREXA RELPREVV SUSR DIABETIC SUPPLIES DIABETIC SUPPLIES ALCOHOL PREP PADS MO BD INSULIN SYR ULTRAFINE II MISC MO
BD INSULIN SYRINGE MISC MO BD INSULIN SYRINGE UF MISC MO
BD PEN NEEDLE ORIGINAL UF MISC MO
CURITY GAUZE PADS MO OMNIPOD STARTER KIT NDS ELECTROLYTIC CALORIC AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS POT amp SOD CIT-CIT AC SOLN potassium citrate er tbcr 15meq 540mg 1080mg MO
SODIUM ACETATE SOLN SODIUM BICARBONATE SOLN SODIUM LACTATE SOLN INTRAVENOUS HI
TRICITRATES SOLN AMMONIA DETOXICANTS CARBAGLU TABS LD constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 38 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lactulose pack MO lactulose soln MO LITHOSTAT TABS MO RAVICTI LIQD NDS sod benz-sod phenylacet soln sodium phenylbutyrate powd NDS sodium phenylbutyrate tabs NDS CALORIC AGENTS AMINOSYN-PF SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (27510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42525) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (525) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (525) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN dextrose soln intravenous 5 10 HI
Drug Name RequirementsLimits
FREAMINE HBC SOLN INTRAVENOUS HI
HEPATAMINE SOLN INTRAVENOUS HI
INTRALIPID EMUL INTRAVENOUS 20gm100ml HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NEPHRAMINE SOLN INTRAVENOUS HI
NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE SOLN INTRAVENOUS HI
PROSOL SOLN INTRAVENOUS HI TRAVASOL SOLN INTRAVENOUS HI
TROPHAMINE SOLN INTRAVENOUS HI
DIURETICS AMILORIDE HCL TABS MO amiloride-hydrochlorothiazide tabs MO
bumetanide soln bumetanide tabs 05mg 1mg 2mg MO
chlorothiazide sodium solr chlorothiazide tabs 250mg 500mg MO
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI FUROSEMIDE TABS 40mg 80mg 20mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN SAMSCA TABS 15mg NDS TOLVAPTAN TABS 30mg 15mg NDS torsemide tabs 5mg 10mg 20mg 100mg MO
triamterene caps 50mg 100mg MO triamterene-hctz caps MO triamterene-hctz tabs MO ION-REMOVING AGENTS AURYXIA TABS PAMONDS FOSRENOL PACK 750mg 1000mg NDS
kionex susp MO lanthanum carbonate chew 500mg 750mg 1000mg MO
LOKELMA PACK 5gm 10gm MO sevelamer carbonate pack 08gm 24gm MO
sevelamer carbonate tabs MO sevelamer hcl tabs 400mg 800mg MO
sodium polystyrene sulfonate powd MO
sodium polystyrene sulfonate susp MO
sps susp MO VELPHORO CHEW NDS VELTASSA PACK 84gm 168gm 252gm NDS
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate (phos binder) tabs MO
CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
Drug Name RequirementsLimits
DEXTROSE-NACL SOLN INTRAVENOUS HI
DEXTROSE 10NACL 02 DEXTROSE 10NACL 045 HI
DEXTROSE 5NACL 0225 HI IONOSOL-MB IN D5W SOLN INTRAVENOUS HI
ISOLYTE-P IN D5W SOLN INTRAVENOUS HI
ISOLYTE-S SOLN INTRAVENOUS HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-033 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 TBCR MO klor-con m10 tbcr MO klor-con m15 tbcr MO klor-con m20 tbcr MO klor-con pack MO klor-con sprinkle cpcr 8meq 10meq MO
KLOR-CON TBCR MO LACTATED RINGERS SOLN magnesium sulfate in d5w soln NORMOSOL-M IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R SOLN INTRAVENOUS HI
PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 40 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
POTASSIUM CHLORIDE ER TBCR 8meq 10meq 20meq MO
POTASSIUM CHLORIDE IN DEXTROSE SOLN INTRAVENOUS
HI
potassium chloride in nacl soln intravenous HI
potassium chloride pack MO potassium chloride soln 10 20 MO
POTASSIUM CHLORIDE SOLN INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN SODIUM CHLORIDE SOLN INJECTION HI
SODIUM CHLORIDE SOLN INTRAVENOUS 045 09 3 5
HI
SODIUM PHOSPHATES SOLN TPN ELECTROLYTES CONC INTRAVENOUS HI
URICOSURIC AGENTS colchicine-probenecid tabs MO probenecid tabs MO ENZYMES ENZYMES ADAGEN SOLN ALDURAZYME SOLN CERDELGA CAPS NDS CEREZYME SOLR NDS CREON CPEP MO ELAPRASE SOLN NDS
Drug Name RequirementsLimits
ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME SOLR NDS miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PANCREAZE CPEP MO PERTZYE CPEP MO PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VIOKACE TABS MO VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE SOLN bacitracin oint bacitracin-polymyxin b oint BESIVANCE SUSP bleph-10 soln CETRAXAL SOLN chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
CIPROFLOXACIN-FLUOCINOLONE PF SOLN
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin soln
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
MOXEZA SOLN moxifloxacin hcl (2x day) soln moxifloxacin hcl soln NATACYN SUSP neo-polycin oint neomycin-bacitracin zn-polymyx oint
neomycin-polymyxin-gramicidin soln
ofloxacin soln OTOVEL SOLN paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ZIRGAN GEL ANTI-INFLAMMATORY AGENTS ACUVAIL SOLN MO ALREX SUSP MO bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
BROMSITE SOLN MO CEQUA SOLN CIPRO HC SUSP MO CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO DUREZOL EMUL MO flac oil MO
Drug Name RequirementsLimits
FLAREX SUSP MO flunisolide soln MO fluocinolone acetonide oil MO fluorometholone susp MO flurbiprofen sodium soln MO fluticasone propionate susp MO FML FORTE SUSP MO FML OINT MO HYDROCORTISONE-ACETIC ACID SOLN MO
ILEVRO SUSP MO ILUVIEN IMPL INVELTYS SUSP MO ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX OINT MO LOTEMAX SUSP MO loteprednol etabonate susp MO MAXIDEX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint MO
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO NEVANAC SUSP MO OMNARIS SUSP MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
PROLENSA SOLN MO RESTASIS EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 42 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tobramycin-dexamethasone susp MO
XHANCE EXHU MO XIIDRA SOLN YUTIQ IMPL ZETONNA AERS MO ZYLET SUSP MO ANTIALLERGIC AGENTS ALOCRIL SOLN MO ALOMIDE SOLN MO azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO LASTACAFT SOLN MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
ALPHAGAN P SOLN MO betaxolol hcl soln MO BETIMOL SOLN 025 05 MO BETOPTIC-S SUSP MO bimatoprost soln MO BRIMONIDINE TARTRATE SOLN 02 015 MO
brinzolamide susp MO carteolol hcl soln MO COMBIGAN SOLN MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO
Drug Name RequirementsLimits
methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO SIMBRINZA SUSP MO timolol maleate pf soln MO timolol maleate solg 025 05 MO
timolol maleate soln 025 05 MO
TIMOPTIC OCUDOSE SOLN 25 MO
TIMOPTIC-XE SOLG 025 05 MO
TRAVATAN Z SOLN MO travoprost (bak free) soln MO VYZULTA SOLN MO XELPROS EMUL MO ZIOPTAN SOLN MO EENT DRUGS MISCELLANEOUS ACETIC ACID SOLN MO ALTAFRIN SOLN apraclonidine hcl soln MO ATROPINE SULFATE SOLN MO BEOVU SOLN NDS CYSTADROPS SOLN NDS CYSTARAN SOLN EYLEA SOLN EYLEA SOSY IOPIDINE SOLN MO LACRISERT INST MO LUCENTIS SOLN 03mg005ml 05mg005ml NDS
LUCENTIS SOSY 03mg005ml 05mg005ml NDS
OXERVATE SOLN NDS PHENYLEPHRINE HCL SOLN RHOPRESSA SOLN TEPEZZA SOLR NDS LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl soln lidocaine viscous hcl soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
APRISO CP24 MO balsalazide disodium caps MO colazal caps MO DELZICOL CPDR MO DIPENTUM CAPS NDS LIALDA TBEC MO mesalamine cpdr MO mesalamine enem MO mesalamine er cp24 MO mesalamine supp MO mesalamine tbec 12gm 800mg MO mesalamine-cleanser kit PENTASA CPCR 250mg 500mg MO
ANTIDIARRHEA AGENTS diphenoxylate-atropine liqd diphenoxylate-atropine tabs loperamide hcl caps MO MYTESI TBEC MO OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS AKYNZEO CAPS PA ANZEMET TABS 50mg 100mg PANDS aprepitant caps PANDS BONJESTA TBCR MO CESAMET CAPS PA dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
EMEND SUSR PANDS fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs
Drug Name RequirementsLimits
ondansetron hcl soln PA ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS TRANSDERM SCOP (15 MG) PT72
trimethobenzamide hcl caps PA VARUBI (180 MG DOSE) TBPK PANDS ZUPLENZ FILM 4mg 8mg PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc MO
CARAFATE SUSP MO cimetidine hcl soln MO cimetidine tabs 200mg 300mg 400mg 800mg MO
esomeprazole magnesium cpdr 20mg 40mg MO
esomeprazole magnesium pack 10mg 20mg 40mg MO
esomeprazole sodium solr ESOMEPRAZOLE STRONTIUM CPDR
famotidine premixed soln famotidine soln famotidine susr MO famotidine tabs 20mg 40mg MO lansoprazole cpdr 15mg 30mg MO lansoprazole tbdd 15mg 30mg MO misoprostol tabs 100mcg 200mcg MO
nizatidine caps 150mg 300mg MO nizatidine soln MO OMECLAMOX-PAK MISC MO omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 44 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PRILOSEC PACK 25mg 10mg MO PROTONIX PACK MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate tabs MO CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO GOLYTELY SOLR OSMOPREP TABS MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT PLENVU SOLR MO SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS AMITIZA CAPS 8mcg 24mcg MO BYLVAY (PELLETS) CPSP 200mcg 600mcg NDS
BYLVAY CAPS 400mcg 1200mcg NDS
CHOLBAM CAPS 50mg 250mg NDS ENTYVIO SOLR NDS GATTEX KIT PANDS GIMOTI SOLN NDS LINZESS CAPS 72mcg 145mcg 290mcg MO
lubiprostone caps 8mcg 24mcg MO
Drug Name RequirementsLimits
metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
MOVANTIK TABS 125mg 25mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS SYMPROIC TABS MO TRULANCE TABS MO ursodiol caps 300mg MO URSODIOL CAPS 200mg 400mg NDS
ursodiol tabs 250mg 500mg MO VIBERZI TABS 75mg 100mg NDS HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPS clovique caps NDS CUPRIMINE CAPS NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs 90mg 180mg 360mg NDS
deferasirox tbso 125mg NDS deferasirox tbso 250mg 500mg NDS deferiprone tabs NDS deferoxamine mesylate solr DEPEN TITRATABS TABS EXJADE TBSO 125mg 250mg 500mg NDS
FERRIPROX SOLN LDNDS FERRIPROX TABS 500mg 1000mg LDNDS
FERRIPROX TWICE-A-DAY TABS NDS
JADENU SPRINKLE PACK 90mg 180mg 360mg NDS
JADENU TABS 90mg 360mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
penicillamine caps penicillamine tabs trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP 05mg 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs MO decadron elix MO decadron tabs 5mg 75mg MO decadron tabs 4mg 6mg PAMO deltasone tabs PAMO DEPO-MEDROL SUSP dexabliss tbpk dexamethasone elix MO dexamethasone intensol conc MO dexamethasone sod phosphate pf soln
dexamethasone sodium phosphate soln
dexamethasone soln dexamethasone tabs 05mg 075mg 1mg 15mg 2mg 4mg 6mg
PAMO
dexamethasone tbpk MO dexpak 10 day tbpk MO dexpak 13 day tbpk MO dexpak 6 day tbpk MO dxevo 11-day tbpk EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
INTRAROSA INST KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp
Drug Name RequirementsLimits
methylprednisolone sodium succ solr
methylprednisolone tabs 4mg 8mg 16mg 32mg MO
methylprednisolone tbpk MO millipred dp tbpk millipred tabs MO ORTIKOS CP24 6mg 9mg NDS prednisolone sodium phosphate soln 5mg5ml 10mg5ml 20mg5ml 25mg5ml
MO
prednisolone sodium phosphate tbdp 10mg 15mg 30mg MO
prednisolone soln MO prednisone intensol conc PAMO prednisone soln PAMO prednisone tabs 1mg 25mg 5mg 10mg 20mg 50mg PAMO
prednisone tbpk PULMICORT FLEXHALER AEPB
RAYOS TBEC 1mg 2mg 5mg PAMO SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TRELEGY ELLIPTA AEPB MO triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
AVEED SOLN MO danazol caps 50mg 100mg 200mg MO
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs 25mg MO oxandrolone tabs MONDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 46 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
STRIANT MISC MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact
MO
testosterone soln MO XYOSTED SOAJ 50mg05ml 75mg05ml 100mg05ml MO
CONTRACEPTIVES altavera tabs MO alyacen 135 tabs MO amethia lo tabs MO amethia tabs MO apri tabs MO aranelle tabs MO ashlyna tabs MO aubra eq tabs MO aviane tabs MO balziva tabs MO blisovi 24 fe tabs MO blisovi fe 1530 tabs MO briellyn tabs MO camila tabs MO camrese lo tabs MO caziant tabs MO cryselle-28 tabs MO cyclafem 135 tabs MO cyclafem 777 tabs MO cyred eq tabs MO deblitane tabs MO delyla tabs MO desogestrel-ethinyl estradiol tabs MO dolishale tabs MO drospiren-eth estrad-levomefol tabs MO
drospirenone-ethinyl estradiol tabs MO
ELLA TABS MO eluryng ring MO emoquette tabs MO
Drug Name RequirementsLimits
enpresse-28 tabs MO enskyce tabs MO errin tabs MO estarylla tabs MO ethynodiol diac-eth estradiol tabs MO etonogestrel-ethinyl estradiol ring MO
falmina tabs MO fayosim tabs MO femynor tabs MO gemmily caps MO gianvi tabs MO hailey 24 fe tabs MO iclevia tabs MO incassia tabs MO introvale tabs MO isibloom tabs MO jasmiel tabs MO JOLIVETTE TABS MO juleber tabs MO junel 1530 tabs MO junel 120 tabs MO junel fe 1530 tabs MO junel fe 120 tabs MO junel fe 24 tabs MO kaitlib fe chew MO kariva tabs MO kelnor 135 tabs MO kelnor 150 tabs MO kurvelo tabs MO larin 1530 tabs MO larin 120 tabs MO larin fe 1530 tabs MO larin fe 120 tabs MO larissia tabs MO LAYOLIS FE CHEW MO leena tabs MO lessina tabs MO levonest tabs MO levonorg-eth estrad triphasic tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
levora 01530 (28) tabs MO LO LOESTRIN FE TABS MO loestrin 1530 (21) tabs MO loestrin 120 (21) tabs MO loestrin fe 1530 tabs MO loestrin fe 120 tabs MO loryna tabs MO low-ogestrel tabs MO lutera tabs MO lyleq tabs MO lyza tabs MO marlissa tabs MO melodetta 24 fe chew MO merzee caps MO mibelas 24 fe chew MO microgestin 1530 tabs MO microgestin 120 tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA TABS MO NATAZIA TABS MO necon 0535 (28) tabs MO NECON 777 TABS MO nikki tabs MO nora-be tabs MO norethin ace-eth estrad-fe caps MO norethin ace-eth estrad-fe chew MO norethin ace-eth estrad-fe tabs MO norethin-eth estradiol-fe chew MO norethindrone acet-ethinyl est tabs MO
norethindrone tabs MO norgestim-eth estrad triphasic tabs MO
norgestimate-eth estradiol tabs MO norlyroc tabs MO
Drug Name RequirementsLimits
nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO NUVARING RING MO nylia 777 tabs MO nymyo tabs MO ocella tabs MO ogestrel tabs MO orsythia tabs MO pimtrea tabs MO pirmella 135 tabs MO portia-28 tabs MO previfem tabs MO reclipsen tabs MO rivelsa tabs MO setlakin tabs MO sharobel tabs MO sprintec 28 tabs MO sronyx tabs MO syeda tabs MO tarina 24 fe tabs MO tarina fe 120 eq tabs MO tilia fe tabs MO tri-estarylla tabs MO tri-legest fe tabs MO tri-lo-estarylla tabs MO tri-lo-sprintec tabs MO tri-mili tabs MO tri-nymyo tabs MO tri-previfem tabs MO tri-sprintec tabs MO tri-vylibra lo tabs MO tri-vylibra tabs MO TRINESSA (28) TABS MO trivora (28) tabs MO tydemy tabs MO velivet tabs MO vestura tabs MO vienva tabs MO vyfemla tabs MO vylibra tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 48 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135e (28) tabs MO DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
ADMELOG SOLN MO ADMELOG SOLOSTAR SOPN MO AFREZZA POWD MO AFREZZA POWD 8 (90) amp 12 (90) UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO APIDRA SOLN PAMO APIDRA SOLOSTAR SOPN MO AVANDIA TABS 2mg 4mg MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD BYDUREON BCISE AUIJ BYDUREON PEN BYETTA 10 MCG PEN SOPN MO BYETTA 5 MCG PEN SOPN MO CYCLOSET TABS MO diazoxide susp glimepiride tabs 1mg 2mg 4mg MO glipizide er tb24 25mg 5mg 10mg MO
glipizide tabs 5mg 10mg MO glipizide-metformin hcl tabs MO GLUCAGEN HYPOKIT SOLR glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO GLYXAMBI TABS MO
Drug Name RequirementsLimits
HUMALOG JUNIOR KWIKPEN SOPN MO
HUMALOG KWIKPEN SOPN 100unitml 200unitml MO
HUMALOG MIX 5050 KWIKPEN SUPN MO
HUMALOG MIX 5050 SUSP MO HUMALOG MIX 7525 KWIKPEN SUPN MO
HUMALOG MIX 7525 SUSP MO HUMALOG SOCT MO HUMALOG SOLN PAMO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN PAMO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
INSULIN ASP PROT amp ASP FLEXPEN SUPN MO
INSULIN ASPART FLEXPEN SOPN MO
INSULIN ASPART PENFILL SOCT MO
INSULIN ASPART PROT amp ASPART SUSP MO
INSULIN ASPART SOLN PAMO INSULIN LISPRO (1 UNIT DIAL) SOPN MO
INSULIN LISPRO SOLN MO INVOKAMET TABS MO INVOKAMET XR TB24 MO INVOKANA TABS 100mg 300mg MO
JARDIANCE TABS 10mg 25mg MO JENTADUETO TABS MO JENTADUETO XR TB24 MO KAZANO TABS MO KORLYM TABS LDNDS LANTUS SOLN MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
LANTUS SOLOSTAR SOPN MO LEVEMIR FLEXTOUCH SOPN MO LEVEMIR SOLN MO metformin hcl er tb24 500mg 750mg MO
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO NOVOLIN 7030 SUSP MO NOVOLOG 7030 FLEXPEN RELION SUPN MO
NOVOLOG FLEXPEN RELION SOPN MO
NOVOLOG FLEXPEN SOPN MO NOVOLOG MIX 7030 FLEXPEN SUPN MO
NOVOLOG MIX 7030 RELION SUSP MO
NOVOLOG MIX 7030 SUSP MO NOVOLOG PENFILL SOCT MO NOVOLOG RELION SOLN PAMO NOVOLOG SOLN PAMO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO PROGLYCEM SUSP MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SOLIQUA SOPN MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO SYNJARDY TABS MO SYNJARDY XR TB24 MO tolazamide tabs 250mg 500mg MO
Drug Name RequirementsLimits
tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO ANGELIQ TABS MO CLIMARA PRO PTWK MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
COMBIPATCH PTTW MO DELESTROGEN OIL depo-estradiol oil DIVIGEL GEL MO dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
DUAVEE TABS MO ELESTRIN GEL MO estrace crea MO estrace tabs 05mg 1mg 2mg MO estradiol crea MO estradiol pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO EVAMIST SOLN MO fyavolv tabs MO IMVEXXY MAINTENANCE PACK INST 4mcg 10mcg MO
IMVEXXY STARTER PACK INST 4mcg 10mcg MO
jinteli tabs MO lopreeza tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 50 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
MENOSTAR PTWK MO mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO ORIAHNN CPPK NDS OSPHENA TABS MO prefest tabs MO PREMARIN SOLR PREMARIN TABS 03mg 045mg 0625mg 09mg 125mg
MO
PREMPHASE TABS MO PREMPRO TABS MO raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS NOVAREL SOLR 5000unit 10000unit PA
ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS PREGNYL SOLR PA TRIPTODUR SRER NDS OXYTOCICS carboprost tromethamine soln methergine tabs methylergonovine maleate soln methylergonovine maleate tabs OXYTOCIN SOLN PARATHYROID calcitonin (salmon) soln MO cinacalcet hcl tabs 30mg 60mg 90mg PANDS
FORTEO SOPN PANDS NATPARA CART 25mcg 50mcg 75mcg 100mcg LDNDS
Drug Name RequirementsLimits
SENSIPAR TABS 30mg 60mg 90mg PANDS
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PALDNDS DDAVP RHINAL TUBE SOLN MO desmopressin ace spray refrig soln MO
desmopressin acetate soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln DESMOPRESSIN ACETATE TABS 01mg 02mg MO
NOCDURNA SUBL 277mcg 553mcg MO
NOCTIVA EMUL 083mcg01ml 166mcg01ml MO
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO CRINONE GEL 4 8 PAMO DEPO-PROVERA SUSP 400mgml
DEPO-SUBQ PROVERA 104 SUSY
ENDOMETRIN INST PA hydroxyprogesterone caproate oil
hydroxyprogesterone caproate soln
MAKENA SOAJ NDS medroxyprogesterone acetate susp
medroxyprogesterone acetate susy
medroxyprogesterone acetate tabs 25mg 5mg 10mg MO
megestrol acetate susp MO norethindrone acetate tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS BYNFEZIA PEN SOPN NDS EGRIFTA SOLR NDS EGRIFTA SV SOLR NDS GENOTROPIN MINIQUICK SOLR 02mg PANDS
GENOTROPIN MINIQUICK SOLR 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
GENOTROPIN SOLR 5mg 12mg PANDS
HUMATROPE SOLR 5mg 6mg 12mg 24mg PANDS
INCRELEX SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
NUTROPIN AQ NUSPIN 20 SOPN PANDS
NUTROPIN AQ NUSPIN 5 SOPN PANDS
octreotide acetate soln OMNITROPE SOCT 5mg15ml 10mg15ml PANDS
OMNITROPE SOLR PANDS SAIZEN CLICKEASY SOLR PANDS SAIZEN SOLR 5mg 88mg PANDS SAIZENPREP SOLR PANDS SANDOSTATIN LAR DEPOT KIT 10mg 20mg 30mg NDS
SEROSTIM SOLR 4mg 5mg 6mg PANDS
SIGNIFOR LAR SRER 10mg 20mg 30mg 40mg 60mg NDS
SIGNIFOR SOLN 03mgml 06mgml 09mgml NDS
SOMATULINE DEPOT SOLN
Drug Name RequirementsLimits
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZOMACTON SOLR 5mg PANDS ZOMACTON SOLR PANDS ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVO-T TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
LEVOTHYROXINE SODIUM SOLR
levothyroxine sodium tabs 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg
MO
liothyronine sodium soln liothyronine sodium tabs 5mcg 25mcg 50mcg MO
methimazole tabs 5mg 10mg MO propylthiouracil tabs MO tapazole tabs 5mg 10mg MO THYROLAR-1 TABS THYROLAR-12 TABS THYROLAR-14 TABS THYROLAR-2 TABS THYROLAR-3 TABS TIROSINT CAPS 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 52 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
137mcg 150mcg 175mcg 200mcg UNITHROID TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg
MO
MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA REDUCTASE INHIBITORS dutasteride caps MO dutasteride-tamsulosin hcl caps MO finasteride tabs MO ANTIDOTES acetylcysteine soln 10 20 PAMO fomepizole soln KHAPZORY SOLR 175mg 300mg NDS
leucovorin calcium soln leucovorin calcium solr leucovorin calcium tabs 5mg 10mg 15mg 25mg MO
levoleucovorin calcium pf soln levoleucovorin calcium solr VISTOGARD PACK NDS VORAXAZE SOLR NDS ANTIGOUT AGENTS allopurinol sodium solr allopurinol tabs 100mg 300mg MO COLCHICINE CAPS MO colchicine tabs MO febuxostat tabs 40mg 80mg MO GLOPERBA SOLN MITIGARE CAPS MO ULORIC TABS 40mg 80mg MO BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 5mg 10mg 35mg 70mg MO
alendronate sodium tabs 40mg MO BINOSTO TBEF MO EVENITY SOSY NDS FOSAMAX PLUS D TABS MO IBANDRONATE SODIUM SOLN
Drug Name RequirementsLimits
ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr PROLIA SOSY risedronate sodium tabs 5mg 30mg 35mg 150mg MO
RISEDRONATE SODIUM TBEC MO XGEVA SOLN PANDS zoledronic acid conc zoledronic acid soln DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ACTPEN SOAJ NDS ACTEMRA SOSY NDS AVSOLA SOLR NDS CIMZIA KIT PANDS CIMZIA PREFILLED KIT PANDS CIMZIA STARTER KIT KIT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS ENBREL SOSY 25mg05ml 50mgml NDS
ENBREL SURECLICK SOAJ NDS HUMIRA PEDIATRIC CROHNS START PSKT NDS
HUMIRA PEN PNKT 40mg04ml 40mg08ml 80mg08ml
NDS
HUMIRA PEN-CDUCHS STARTER PNKT 40mg08ml 80mg08ml
NDS
HUMIRA PEN-PEDIATRIC UC START PNKT NDS
HUMIRA PEN-PSUVADOL HS START PNKT NDS
HUMIRA PEN-PSORUVEIT STARTER PNKT NDS
HUMIRA PSKT 10mg01ml 10mg02ml 20mg02ml 20mg04ml 40mg04ml 40mg08ml
NDS
INFLECTRA SOLR INTRAVENOUS HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
KEVZARA SOAJ 150mg114ml 200mg114ml NDS
KEVZARA SOSY 150mg114ml 200mg114ml NDS
KINERET SOSY NDS leflunomide tabs 10mg 20mg MO OLUMIANT TABS 1mg 2mg NDS ORENCIA CLICKJECT SOAJ NDS ORENCIA SOLR NDS ORENCIA SOSY 50mg04ml 875mg07ml 125mgml NDS
OTEZLA TABS PANDS OTEZLA TBPK PANDS OTREXUP SOAJ RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 NDS SIMPONI ARIA SOLN NDS SIMPONI SOAJ 50mg05ml 100mgml NDS
SIMPONI SOSY 50mg05ml 100mgml NDS
XELJANZ SOLN NDS XELJANZ TABS 5mg 10mg NDS XELJANZ XR TB24 11mg 22mg NDS IMMUNE SUPPRESSANTS ASTAGRAF XL CP24 05mg 1mg PAMO
ASTAGRAF XL CP24 PA azasan tabs 75mg 100mg PAMO azathioprine sodium solr azathioprine tabs PAMO BENLYSTA SOAJ BENLYSTA SOLR BENLYSTA SOSY cyclosporine caps 25mg 100mg PAMO cyclosporine modified caps 25mg 50mg 100mg PAMO
cyclosporine modified soln PAMO cyclosporine soln PAMO
Drug Name RequirementsLimits
ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg PA GAMIFANT SOLN 50mg10ml 100mg20ml 10mg2ml NDS
gengraf caps 25mg 50mg 100mg PAMO
gengraf soln PAMO LUPKYNIS CAPS NDS MAVENCLAD (10 TABS) TBPK NDS MAVENCLAD (4 TABS) TBPK NDS MAVENCLAD (5 TABS) TBPK NDS MAVENCLAD (6 TABS) TBPK NDS MAVENCLAD (7 TABS) TBPK NDS MAVENCLAD (8 TABS) TBPK NDS MAVENCLAD (9 TABS) TBPK NDS mycophenolate mofetil caps PAMO mycophenolate mofetil hcl solr mycophenolate mofetil susr PAMO mycophenolate mofetil tabs PAMO mycophenolate sodium tbec 180mg 360mg PAMO
NULOJIX SOLR NDS PROGRAF PACK 02mg PA PROGRAF PACK PANDS PROGRAF SOLN PAMO SANDIMMUNE ORAL SOLN 100mgml PAMO
SAPHNELO SOLN NDS sirolimus soln PA sirolimus tabs 05mg 1mg 2mg PAMO tacrolimus caps 05mg 1mg 5mg PAMO
UPLIZNA SOLN ZORTRESS TABS 025mg PAMO ZORTRESS TABS 05mg 075mg 1mg PA
MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 54 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BOTOX SOLR 100unit 200unit PA bupivacaine hcl (pf) soln bupivacaine hcl soln BUPIVACAINE IN DEXTROSE SOLN
bupivacaine spinal soln bupivacaine-epinephrine (pf) soln
bupivacaine-epinephrine soln CARNITOR SOLN PAMO CARNITOR TABS PAMO chloroprocaine hcl (pf) soln CINRYZE SOLR INTRAVENOUS HI
citanest plain dental soln COSELA SOLR NDS CRYSVITA SOLN 10mgml 20mgml 30mgml NDS
CYSTADANE POWD LDNDS CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr DYSPORT SOLR 300unit 500unit PA
EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENSPRYNG SOSY NDS EVRYSDI SOLR NDS EXONDYS 51 SOLN 500mg10ml 100mg2ml NDS
FIRDAPSE TABS NDS FLUORITAB CHEW 025mg 05mg 1mg MO
FLUORITAB SOLN MO GALAFOLD CAPS NDS GIVLAARI SOLN NDS GRASTEK SUBL MO
Drug Name RequirementsLimits
HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS TABS NDS KUVAN PACK 100mg 500mg NDS KUVAN TABS NDS LACTATED RINGERS SOLN levocarnitine soln PAMO LEVOCARNITINE TABS PAMO lidocaine hcl (pf) soln lidocaine hcl soln lidocaine in dextrose soln lidocaine-epinephrine soln LUDENT CHEW 025mg 05mg 1mg MO
mesna soln MESNEX TABS NDS MYALEPT SOLR NDS NAFRINSE CHEW MO NAFRINSE DROPS SOLN MO nitisinone caps 2mg 5mg 10mg NDS NITYR TABS 2mg 5mg 10mg NDS NULIBRY SOLR NDS ODACTRA SUBL ONPATTRO SOLN NDS ORALAIR SUBL MO ORFADIN CAPS LDNDS ORFADIN SUSP LDNDS ORLADEYO CAPS 110mg 150mg NDS
OXLUMO SOLN PALFORZIA (12 MG DAILY DOSE) CSPK NDS
PALFORZIA (120 MG DAILY DOSE) CSPK NDS
PALFORZIA (160 MG DAILY DOSE) CSPK NDS
PALFORZIA (20 MG DAILY DOSE) CSPK NDS
PALFORZIA (200 MG DAILY DOSE) CSPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
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Drug Name RequirementsLimits
PALFORZIA (240 MG DAILY DOSE) CSPK NDS
PALFORZIA (3 MG DAILY DOSE) CSPK NDS
PALFORZIA (300 MG MAINTENANCE) PACK NDS
PALFORZIA (300 MG TITRATION) PACK NDS
PALFORZIA (40 MG DAILY DOSE) CSPK NDS
PALFORZIA (6 MG DAILY DOSE) CSPK NDS
PALFORZIA (80 MG DAILY DOSE) CSPK NDS
PALFORZIA INITIAL ESCALATION CSPK NDS
PHYSIOLYTE SOLN PHYSIOSOL IRRIGATION SOLN
polocaine soln polocaine-mpf soln PROCYSBI CPDR 25mg 75mg NDS PROCYSBI PACK 75mg 300mg NDS REZUROCK TABS NDS RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln RUZURGI TABS NDS sapropterin dihydrochloride pack 100mg 500mg NDS
sapropterin dihydrochloride tabs NDS SENSORCAINE SOLN sensorcaine-mpf soln sensorcaine-mpfepinephrine soln
sensorcaineepinephrine soln SODIUM CHLORIDE SOLN MO SODIUM FLUORIDE CHEW 025mg 05mg 1mg MO
SODIUM FLUORIDE SOLN MO SODIUM FLUORIDE TABS MO STERILE WATER FOR IRRIGATION SOLN
Drug Name RequirementsLimits
TAKHZYRO SOLN NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VILTEPSO SOLN NDS VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR 50unit 100unit PA XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg NDS RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 200mg114ml 300mg2ml PANDS
FASENRA PEN SOAJ NDS FASENRA SOSY PA montelukast sodium chew 4mg 5mg MO
montelukast sodium pack MO montelukast sodium tabs MO NUCALA SOAJ PANDS NUCALA SOLR PANDS NUCALA SOSY PANDS zafirlukast tabs 10mg 20mg MO zileuton er tb12 NDS CYSTIC FIBROSIS BETHKIS NEBU PA
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 56 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CAYSTON SOLR LDNDS KALYDECO PACK 25mg 50mg 75mg PANDS
KALYDECO TABS PANDS KITABIS PAK NEBU PA ORKAMBI PACK NDS ORKAMBI TABS NDS SYMDEKO TBPK NDS TOBI PODHALER CAPS tobramycin nebu 300mg4ml 300mg5ml PA
TRIKAFTA TBPK LDNDS PULMONARY FIBROSIS ESBRIET CAPS PANDS ESBRIET TABS 267mg 801mg PANDS OFEV CAPS 100mg 150mg NDS RESPIRATORY AGENTS MISCELLANEOUS ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS 500mg 1000mg
HI
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact
MO
ASMANEX (120 METERED DOSES) AEPB MO
ASMANEX (30 METERED DOSES) AEPB 110mcginh MO
ASMANEX (30 METERED DOSES) AEPB MO
ASMANEX (60 METERED DOSES) AEPB MO
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
budesonide-formoterol fumarate aero
DALIRESP TABS 250mcg 500mcg MO
DULERA AERO MO
Drug Name RequirementsLimits
FLOVENT DISKUS AEPB 50mcgblist 100mcgblist 250mcgblist
MO
FLOVENT HFA AERO 44mcgact MO
FLOVENT HFA AERO 110mcgact 220mcgact MO
fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PROLASTIN-C SOLN INTRAVENOUS HI
PROLASTIN-C SOLR INTRAVENOUS HI
SYMBICORT AERO wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
ZEMAIRA SOLR INTRAVENOUS HI
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr LETAIRIS TABS 5mg 10mg NDS ORENITRAM TBCR 0125mg LDNDS ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TABS 625mg 125mg NDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
1000mcg 1200mcg 1400mcg 1600mcg UPTRAVI TBPK NDS VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS BIVIGAM SOLN 10gm100ml HI BIVIGAM SOLN 5gm50ml HI CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml
HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS 10gm200ml HI
GAMMAPLEX SOLN INTRAVENOUS 10gm100ml 20gm200ml 5gm50ml
HI
GAMUNEX-C SOLN INJECTION 10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml
HI
HYPERHEP B SOLN HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 5gm100ml HI
Drug Name RequirementsLimits
1gm20ml 2gm20ml 25gm500ml PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
PRIVIGEN SOLN INTRAVENOUS HI
VARIZIG SOLN XEMBIFY SOLN SUBCUTANEOUS 2gm10ml 4gm20ml 10gm50ml 1gm5ml
HI
TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP QUADRACEL SUSP TDVAX SUSP TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP DAPTACEL SUSP ENGERIX-B SUSP 10mcg05ml 20mcgml PA
GARDASIL 9 SUSP GARDASIL 9 SUSY HAVRIX SUSP HEPLISAV-B SOLN PA HIBERIX SOLR IMOVAX RABIES INJ INFANRIX SUSP IPOL INJ IXIARO SUSP M-M-R II SOLR MENACTRA INJ MENQUADFI INJ MENVEO SOLR PEDIARIX SUSP PEDVAX HIB SUSP
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 58 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN VAQTA SUSP VARIVAX INJ VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint AKTIPAK PACK MO AVC VAGINAL CREA BACTROBAN NASAL OINT BENZEPRO CREAMY WASH LIQD
BENZEPRO FOAMING CLOTHS MISC
BENZOYL PEROXIDE GEL NDS benzoyl peroxide-erythromycin gel MO
ciclopirox gel ciclopirox olamine crea ciclopirox olamine susp ciclopirox sham ciclopirox soln CLEOCIN SUPP clindacin-p swab MO clindamycin phos-benzoyl perox gel MO
clindamycin phosphate crea clindamycin phosphate foam MO clindamycin phosphate gel MO clindamycin phosphate lotn MO
Drug Name RequirementsLimits
clindamycin phosphate soln MO clindamycin phosphate swab MO CLINDESSE CREA clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn DENAVIR CREA econazole nitrate crea ERTACZO CREA ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA EXELDERM CREA EXELDERM SOLN gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ivermectin lotn ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham LULICONAZOLE CREA LUZU CREA mafenide acetate pack malathion lotn MENTAX CREA metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
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Drug Name RequirementsLimits
mupirocin oint naftifine hcl crea naftifine hcl gel NAFTIN GEL NATROBA SUSP neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ORAVIG TABS ovide lotn oxiconazole nitrate crea OXISTAT LOTN permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SKLICE LOTN SODIUM SULFACETAMIDE SHAM
SODIUM SULFACETAMIDE WASH LIQD
SPINOSAD SUSP SSD CREA sulfacetamide sodium (acne) lotn MO SULFACETAMIDE SODIUM GEL
SULFACETAMIDE SODIUM LIQD
SULFAMYLON CREA tavaborole soln terconazole crea terconazole supp VANDAZOLE GEL XEPI CREA MO XERESE CREA ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) ala scalp lotn MO
Drug Name RequirementsLimits
ala-cort crea 1 25 MO alclometasone dipropionate crea MO alclometasone dipropionate oint MO amcinonide crea MO amcinonide lotn MO amcinonide oint MO anusol-hc crea MO apexicon e crea MO benzoyl perox-hydrocortisone lotn
BENZOYL PEROXIDE FORTE- HC LOTN NDS
beser lotn MO betamethasone dipropionate aug crea MO
betamethasone dipropionate aug gel MO
betamethasone dipropionate aug lotn MO
betamethasone dipropionate aug oint MO
betamethasone dipropionate crea MO
betamethasone dipropionate lotn MO BETAMETHASONE DIPROPIONATE OINT MO
betamethasone valerate crea MO betamethasone valerate foam MO BETAMETHASONE VALERATE LOTN MO
BETAMETHASONE VALERATE OINT MO
BRYHALI LOTN MO calcipotriene-betameth diprop oint MONDS
calcipotriene-betameth diprop susp NDS
CAPEX SHAM MO clobetasol propionate crea clobetasol propionate e crea MO clobetasol propionate emulsion foam
clobetasol propionate foam MO clobetasol propionate gel MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 60 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO CLOBEX SHAM MO CLOBEX SPRAY LIQD MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO clodan sham MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT MO DESONATE GEL MO desonide crea MO desonide gel MO desonide lotn MO desonide oint MO desowen lotn MO desoximetasone crea 005 025 MO
desoximetasone gel MO desoximetasone liqd MO desoximetasone oint 005 025 MO
desrx gel MO diclofenac sodium gel 1 3 MO diflorasone diacetate crea MO diflorasone diacetate oint MO DUOBRII LOTN MO ENSTILAR FOAM NDS epifoam foam fluocinolone acetonide body oil fluocinolone acetonide crea 001 0025 MO
fluocinolone acetonide oint MO fluocinolone acetonide scalp oil MO fluocinolone acetonide soln MO fluocinonide crea MO fluocinonide emulsified base crea MO
Drug Name RequirementsLimits
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO flurandrenolide crea MO flurandrenolide lotn MO flurandrenolide oint MO fluticasone propionate crea MO fluticasone propionate lotn MO fluticasone propionate oint MO halcinonide crea MO halobetasol propionate crea MO HALOBETASOL PROPIONATE FOAM NDS
halobetasol propionate oint MO HALOG CREA MO HALOG OINT MO hydrocortisone (perianal) crea 1 25 MO
hydrocortisone butyr lipo base crea
hydrocortisone butyrate crea MO hydrocortisone butyrate lotn MO HYDROCORTISONE BUTYRATE OINT MO
hydrocortisone butyrate soln MO hydrocortisone crea 1 25 MO hydrocortisone enem MO hydrocortisone lotn MO hydrocortisone oint 1 25 MO hydrocortisone valerate crea MO hydrocortisone valerate oint MO LEXETTE FOAM NDS micort-hc crea MO mometasone furoate crea MO mometasone furoate oint MO mometasone furoate soln MO neo-synalar crea MO nolix crea nolix lotn MO nystatin-triamcinolone crea MO nystatin-triamcinolone oint MO oralone pste MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 61
Drug Name RequirementsLimits
PANDEL CREA MO prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO psorcon crea MO TACLONEX SUSP NDS topicort crea 005 025 MO topicort gel MO topicort oint MO tovet foam MO triamcinolone acetonide aers MO triamcinolone acetonide crea 0025 01 05 MO
triamcinolone acetonide lotn 0025 01 MO
triamcinolone acetonide oint 0025 005 01 05 MO
triamcinolone acetonide pste MO trianex oint MO triderm crea 01 05 MO tritocin oint MO UCERIS FOAM MO ULTRAVATE LOTN NDS VANOXIDE-HC LOTN ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
LIDO-SORB LOTN LIDOCAINE HCL CREA lidocaine hcl lotn lidocaine hcl soln PA lidocaine hcl urethralmucosal gel MO
lidocaine hcl urethralmucosal prsy MO
lidocaine oint PAMO lidocaine ptch PAMO
Drug Name RequirementsLimits
LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea PA LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam texacort soln MO TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS ALTRENO LOTN PAMO AVITA CREA PAMO AVITA GEL PAMO KEPIVANCE SOLR NDS PANRETIN GEL NDS RETIN-A CREA 0025 005 01 PAMO
RETIN-A GEL 001 0025 PAMO RETIN-A MICRO GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 004 01 PAMO
RETIN-A MICRO PUMP GEL 008 PAMO
RETIN-A MICRO PUMP GEL PANDS TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 62 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS ABSORICA CAPS 25mg 35mg NDS ABSORICA LD CAPS 8mg 16mg 24mg 32mg NDS
accutane caps 10mg 20mg 30mg 40mg NDS
acitretin caps 10mg 175mg 25mg NDS
ADAPALENE CREA MO adapalene gel 01 03 MO adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
AVAR CLEANSER EMUL AVAR-E EMOLLIENT CREA AVAR-E GREEN CREA azelaic acid gel MO AZELEX CREA MO BP 10-1 EMUL calcipotriene crea MO calcipotriene oint MO calcipotriene soln MO calcitrene oint MO CALCITRIOL OINT MO CARAC CREA CEROVEL LOTN claravis caps 10mg 20mg 30mg 40mg NDS
CONDYLOX GEL MO COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
Drug Name RequirementsLimits
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA MO DIFFERIN LOTN MO EPIDUO FORTE GEL MO FABIOR FOAM PAMO FINACEA FOAM MO fluorouracil crea 5 MO fluorouracil crea 5 fluorouracil soln 2 5 MO ILUMYA SOSY PA imiquimod crea 375 5 MO IMIQUIMOD PUMP CREA MO isotretinoin caps 10mg 20mg 30mg 40mg NDS
keralyt sham KLISYRI OINT NDS LACTIC ACID LOTN methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
ORACEA CPDR pimecrolimus crea MO podofilox soln MO RECTIV OINT MO REGRANEX GEL NDS RYNODERM CREA NDS SALEX SHAM SALICYLIC ACID CREA SALICYLIC ACID ER SOLN SALICYLIC ACID FOAM SALICYLIC ACID GEL SALICYLIC ACID LIQD SALICYLIC ACID SHAM SALICYLIC ACID WART REMOVER LIQD
SALICYLIC ACID-CLEANSER KIT
SALIMEZ CREA SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 63
Drug Name RequirementsLimits
SKYRIZI PEN SOAJ SKYRIZI SOSY SORILUX FOAM MO SSS 10-5 CREA STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
SULFACETAMIDE SODIUM-SULFUR CREA
SULFACETAMIDE SODIUM-SULFUR EMUL
SULFACETAMIDE SODIUM-SULFUR LIQD
SULFACETAMIDE SODIUM-SULFUR LOTN
SULFACETAMIDE SODIUM-SULFUR PADS
SULFACETAMIDE SODIUM-SULFUR SUSP
SULFACLEANSE 84 SUSP sulfamez wash emul TACROLIMUS OINT 01 003 MO
TALTZ SOAJ NDS TALTZ SOSY NDS tazarotene crea PAMO tazarotene foam PAMO TAZORAC CREA PAMO TAZORAC GEL 005 01 PAMO TOLAK CREA TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS VECTICAL OINT MO VEREGEN OINT MO WYNZORA CREA NDS XUREA CREA
Drug Name RequirementsLimits
zenatane caps 10mg 20mg 30mg 40mg NDS
ZYCLARA PUMP CREA MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline soln darifenacin hydrobromide er tb24 75mg 15mg MO
elixophyllin elix flavoxate hcl tabs MO MYRBETRIQ TB24 25mg 50mg MO oxybutynin chloride er tb24 5mg 10mg 15mg MO
oxybutynin chloride syrp MO oxybutynin chloride tabs MO solifenacin succinate tabs 5mg 10mg MO
theo-24 cp24 100mg 200mg 300mg 400mg MO
theophylline er tb12 100mg 200mg 300mg 450mg MO
theophylline er tb24 400mg 600mg MO
theophylline soln MO tolterodine tartrate er cp24 2mg 4mg MO
tolterodine tartrate tabs MO trospium chloride er cp24 MO trospium chloride tabs MO VITAMINS VITAMINS ADCF (05MGML) SOLN MO calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN MULTI-VITAMINFLUORIDEIRON SOLN
MO
MULTI-VITAMINFLUORIDE SOLN MO
MULTIVITAMINFLUORIDE CHEW MO
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Drug Name RequirementsLimits
MVC-FLUORIDE CHEW MO paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS TRI-VITAMINFLUORIDE SOLN MO TRI-VITEFLUORIDE SOLN MO VITAMINS ACD-FLUORIDE SOLN MO
VP-PNV-DHA CAPS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 65
The information in the RequirementsLimits column tells you if our plan has any special requirements for coverage of your drug Certain strengths or forms of the drug may be subject to the utilization management codes listed below HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies For more information please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies For more information consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region MO = Mail-order drugs You may order prescription refills of certain medications through our mail-order service online at kporgrefill or by phone or mobile app which may lower your costs for a three-month supply Please contact us at least 5 days before your refills run out Generally you should receive them within 3 to 5 days If not and
you need an urgent refill please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 6 or the phone number on the prescription label for assistance Not all drugs can be mailed restrictions and limitations apply For more information please visit kporgseniorrx or call the appropriate regional phone number on page 6 NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (eg via infusion pump nebulizer or other Durable Medical Equipment device) where they are administered (at home or in a long-term care facility) and what medical condition they are administered for Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered
66 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
Index of Drugs
A abacavir sulfate soln 12 abacavir sulfate tabs 12 abacavir sulfate-lamivudine tabs 12 abacavir-lamivudine-zidovudine tabs 12 ABELCET SUSP INTRAVENOUS 11 ABILIFY MAINTENA PRSY 300mg 400mg
35 ABILIFY MAINTENA SRER 300mg 400mg
35 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 35
abiraterone acetate tabs 250mg 500mg 14 ABRAXANE SUSR 14 ABSORICA CAPS 25mg 35mg 62 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 62 ABSTRAL SUBL 100mcg 200mcg
300mcg 400mcg 600mcg 800mcg 27 acamprosate calcium tbec 26 acarbose tabs 25mg 50mg 100mg 48 accutane caps 10mg 20mg 30mg 40mg 62 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 27 acetaminophen-codeine soln 27 acetaminophen-codeine tabs 27 acetazolamide er cp12 42 acetazolamide sodium solr 42 acetazolamide tabs 125mg 250mg 42 ACETIC ACID SOLN 42 53 acetylcysteine soln 10 20 52 acitretin caps 10mg 175mg 25mg 62 ACTEMRA ACTPEN SOAJ 52 ACTEMRA SOSY 52 ACTHAR GEL 50 ACTHIB SOLR 57 ACTIMMUNE SOLN 53 ACUVAIL SOLN 41
acyclovir caps 12 acyclovir oint 58 acyclovir sodium soln intravenous 12 acyclovir susp 12 acyclovir tabs 400mg 800mg 12 ADACEL SUSP 57 ADAGEN SOLN 40 ADAKVEO SOLN 21 ADAPALENE CREA 62 adapalene gel 01 03 62 adapalene pads 62 adapalene soln 62 adapalene-benzoyl peroxide gel 62 ADAPALENE-BENZOYL PEROXIDE PADS
62 ADCF (05MGML) SOLN 63 adderall tabs 29 ADDERALL XR CP24 29 adefovir dipivoxil tabs 12 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 56 adenosine soln 25 ADMELOG SOLN 48 ADMELOG SOLOSTAR SOPN 48 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 20 ADZENYS ER SUER 29 ADZENYS XR-ODT TBED 31mg 63mg
94mg 125mg 157mg 188mg 29 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 25mg 5mg 75mg 10mg
14 AFREZZA POWD 48 AFREZZA POWD 8 (90) amp 12 (90) UNIT 48 AJOVY SOAJ 32 AJOVY SOSY 32 AKTIPAK PACK 58 AKYNZEO CAPS 43 ala scalp lotn 59 ala-cort crea 1 25 59 albendazole tabs 8
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 67
albuterol sulfate er tb12 4mg 8mg 20 albuterol sulfate hfa aers 20 albuterol sulfate nebu 0083 25mg05ml
20 albuterol sulfate nebu 063mg3ml
125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 59 alclometasone dipropionate oint 59 ALCOHOL PREP PADS 37 ALDACTAZIDE TABS 25 ALDURAZYME SOLN 40 ALECENSA CAPS 14 alendronate sodium soln 52 alendronate sodium tabs 40mg 52 alendronate sodium tabs 5mg 10mg
35mg 70mg 52 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 05mg 1mg
2mg 5mg 45 allopurinol sodium solr 52 allopurinol tabs 100mg 300mg 52 allzital tabs 27 almotriptan malate tabs 32 ALOCRIL SOLN 42 alogliptin benzoate tabs 625mg 125mg
25mg 48 ALOGLIPTIN-METFORMIN HCL TABS 48 alogliptin-pioglitazone tabs 48 ALOMIDE SOLN 42 ALOSETRON HCL TABS 05mg 1mg 43 ALPHAGAN P SOLN 42 alprazolam er tb24 05mg 1mg 2mg 3mg
33 alprazolam intensol conc 33 alprazolam tabs 025mg 05mg 1mg 2mg
33 alprazolam tbdp 025mg 05mg 1mg 2mg
33 ALREX SUSP 41 ALTACAINE SOLN 42 ALTAFRIN SOLN 42 altavera tabs 46 ALTOPREV TB24 20mg 40mg 60mg 23 ALTRENO LOTN 61
ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 56 alyacen 135 tabs 46 alyq tabs 26 amabelz tabs 49 amantadine hcl caps 32 amantadine hcl syrp 32 amantadine hcl tabs 32 AMBISOME SUSR INTRAVENOUS 11 ambrisentan tabs 56 amcinonide crea 59 amcinonide lotn 59 amcinonide oint 59 amethia lo tabs 46 amethia tabs 46 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 38 amiloride-hydrochlorothiazide tabs 38 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 63 AMINOSYN-PF SOLN INTRAVENOUS 38 amiodarone hcl soln 25 amiodarone hcl tabs 100mg 200mg
400mg 25 AMITIZA CAPS 8mcg 24mcg 44 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 amlodipine besy-benazepril hcl caps 24 amlodipine besylate tabs 25mg 5mg
10mg 24 amlodipine besylate-valsartan tabs 24 amlodipine-atorvastatin tabs 24 amlodipine-olmesartan tabs 24 amlodipine-valsartan-hctz tabs 24 ammonium lactate crea 62 ammonium lactate lotn 62 amnesteem caps 10mg 20mg 40mg 62 AMONDYS 45 SOLN 53 amoxapine tabs 25mg 50mg 100mg
150mg 35 amoxicill-clarithro-lansopraz misc 43 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8
68 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 29 amphetamine sulfate tabs 5mg 10mg 30 amphetamine-dextroamphet er cp24 30 amphetamine-dextroamphetamine tabs 30 amphotericin b solr intravenous 11 ampicillin caps 8 ampicillin sodium solr 8 ampicillin sodium solr injection 1gm 125mg
8 ampicillin sodium solr intravenous 8 ampicillin-sulbactam sodium solr 8 ampicillin-sulbactam sodium solr injection 8 ampicillin-sulbactam sodium solr
intravenous 8 ANADROL-50 TABS 45 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 61 anastrozole tabs 14 ANDRODERM PT24 2mg24hr 4mg24hr
45 ANGELIQ TABS 49 ANORO ELLIPTA AEPB 19 antabuse tabs 250mg 500mg 26 ANTARA CAPS 30mg 90mg 23 anusol-hc crea 59 ANZEMET TABS 50mg 100mg 43 apap-caff-dihydrocodeine tabs 27 apexicon e crea 59 APIDRA SOLN 48 APIDRA SOLOSTAR SOPN 48 APLENZIN TB24 174mg 348mg 522mg 35 APOKYN SOCT 32 apraclonidine hcl soln 42 aprepitant caps 43 apri tabs 46 APRISO CP24 43 APTIOM TABS 200mg 400mg 600mg
800mg 30 APTIVUS CAPS 12 APTIVUS SOLN 12 ARALAST NP SOLR INTRAVENOUS
500mg 1000mg 56 aranelle tabs 46 ARANESP (ALBUMIN FREE) SOLN
25mcgml 40mcgml 22
ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml 300mcgml 22
ARANESP (ALBUMIN FREE) SOSY 25mcg042ml 10mcg04ml 40mcg04ml 22
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 22
ARCALYST SOLR 53 ARCAPTA NEOHALER CAPS 20 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 54 ARIKAYCE SUSP 8 aripiprazole soln 35 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 35 aripiprazole tbdp 10mg 15mg 35 ARISTADA INITIO PRSY 35 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 35
armodafinil tabs 50mg 150mg 200mg 250mg 30
ARNUITY ELLIPTA AEPB 50mcgact 100mcgact 200mcgact 56
ARRANON SOLN 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 54 ARYMO ER TBEA 27 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 57 ascomp-codeine caps 27 asenapine maleate subl 25mg 5mg 10mg
35 ashlyna tabs 46 ASMANEX (120 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
56 ASMANEX (30 METERED DOSES) AEPB
110mcginh 56 ASMANEX (60 METERED DOSES) AEPB
56 ASMANEX HFA AERO 100mcgact
200mcgact 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 69
ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 53 ASTAGRAF XL CP24 05mg 1mg 53 atazanavir sulfate caps 150mg 200mg
300mg 12 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 34 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 23 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 42 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 34 aubra eq tabs 46 AUGMENTIN SUSR 8 AURYXIA TABS 39 AUSTEDO TABS 6mg 9mg 12mg 34 AVANDIA TABS 2mg 4mg 48 AVAR CLEANSER EMUL 62 AVAR-E EMOLLIENT CREA 62 AVAR-E GREEN CREA 62 AVASTIN SOLN 14 AVC VAGINAL CREA 58 AVEED SOLN 45 aviane tabs 46 AVITA CREA 61 AVITA GEL 61 AVONEX KIT 34 AVONEX PEN AJKT 34 AVONEX PREFILLED PSKT 34 AVSOLA SOLR 52 AVYCAZ SOLR INTRAVENOUS 8 aygestin tabs 50 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 53 AZASITE SOLN 40 azathioprine sodium solr 53 azathioprine tabs 53 azelaic acid gel 62 azelastine hcl soln 005 01 015 42 azelastine-fluticasone susp 42 AZELEX CREA 62
AZITHROMYCIN PACK 8 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
B bacitracin oint 40 bacitracin solr 8 bacitracin-polymyxin b oint 40 bacitra-neomycin-polymyxin-hc oint 41 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 58 BAFIERTAM CPDR 34 balsalazide disodium caps 43 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 46 BANZEL SUSP 30 BANZEL TABS 200mg 400mg 30 BAQSIMI ONE PACK POWD 48 BAQSIMI TWO PACK POWD 48 BARACLUDE SOLN 12 BAVENCIO SOLN 14 BAXDELA SOLR INTRAVENOUS 8 BAXDELA TABS 8 BCG VACCINE INJ 14 BD INSULIN SYR ULTRAFINE II MISC 37 BD INSULIN SYRINGE MISC 37 BD INSULIN SYRINGE UF MISC 37 BD PEN NEEDLE ORIGINAL UF MISC 37 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 27 BELEODAQ SOLR 14 BELRAPZO SOLN 14 BELSOMRA TABS 33 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 15 BENDEKA SOLN 15 BENLYSTA SOAJ 53 BENLYSTA SOLR 53 BENLYSTA SOSY 53 BENZEPRO CREAMY WASH LIQD 58 BENZEPRO FOAMING CLOTHS MISC 58 benzhydrocodone-acetaminophen tabs 27 BENZNIDAZOLE TABS 125mg 100mg 11 benzoyl perox-hydrocortisone lotn 59
70 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
BENZOYL PEROXIDE FORTE- HC LOTN 59
BENZOYL PEROXIDE GEL 58 benzoyl peroxide-erythromycin gel 58 benztropine mesylate soln 32 benztropine mesylate tabs 05mg 1mg
2mg 32 BEOVU SOLN 42 bepotastine besilate soln 42 BERINERT KIT INTRAVENOUS 21 beser lotn 59 BESIVANCE SUSP 40 BESPONSA SOLR 15 betamethasone dipropionate aug crea 59 betamethasone dipropionate aug gel 59 betamethasone dipropionate aug lotn 59 betamethasone dipropionate aug oint 59 betamethasone dipropionate crea 59 betamethasone dipropionate lotn 59 BETAMETHASONE DIPROPIONATE OINT
59 betamethasone sod phos amp acet susp 45 betamethasone valerate crea 59 betamethasone valerate foam 59 BETAMETHASONE VALERATE LOTN 59 BETAMETHASONE VALERATE OINT 59 BETASERON KIT 34 betaxolol hcl soln 42 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 20 BETHKIS NEBU 55 BETIMOL SOLN 025 05 42 BETOPTIC-S SUSP 42 BEVESPI AEROSPHERE AERO 19 BEVYXXA CAPS 40mg 80mg 21 bexarotene caps 15 BEXSERO SUSY 57 bicalutamide tabs 15 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICNU SOLR 15 BIDIL TABS 26 BIKTARVY TABS 12 bimatoprost soln 42 BINOSTO TBEF 52 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23
BIVIGAM SOLN 10gm100ml 57 BIVIGAM SOLN 5gm50ml 57 bleomycin sulfate solr 15 bleph-10 soln 40 blephamide sop oint 41 BLEPHAMIDE SUSP 41 BLINCYTO SOLR 15 blisovi 24 fe tabs 46 blisovi fe 1530 tabs 46 BONJESTA TBCR 43 BOOSTRIX SUSP 57 BORTEZOMIB SOLR 15 bosentan tabs 56 BOSULIF TABS 100mg 400mg 500mg 15 BOTOX SOLR 100unit 200unit 54 BP 10-1 EMUL 62 BRAFTOVI CAPS 50mg 75mg 15 briellyn tabs 46 BRILINTA TABS 60mg 90mg 21 BRIMONIDINE TARTRATE SOLN 02
015 42 brinzolamide susp 42 BRIVIACT SOLN 30 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 30 bromfenac sodium (once-daily) soln 41 bromocriptine mesylate caps 32 bromocriptine mesylate tabs 32 BROMSITE SOLN 41 BRONCHITOL CAPS 56 BROVANA NEBU 20 BRUKINSA CAPS 15 BRYHALI LOTN 59 budesonide cpep 45 budesonide er tb24 45 budesonide susp 025mg2ml 05mg2ml
1mg2ml 56 budesonide-formoterol fumarate aero 56 bumetanide soln 38 bumetanide tabs 05mg 1mg 2mg 38 BUNAVAIL FILM 34 bupap tabs 27 bupivacaine hcl (pf) soln 54 bupivacaine hcl soln 54 BUPIVACAINE IN DEXTROSE SOLN 54 bupivacaine spinal soln 54 bupivacaine-epinephrine (pf) soln 54 bupivacaine-epinephrine soln 54 buprenorphine hcl soln 27
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 71
buprenorphine hcl subl 2mg 8mg 34 buprenorphine hcl-naloxone hcl film 34 buprenorphine hcl-naloxone hcl subl 34 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 27 bupropion hcl er (smoking det) tb12 35 bupropion hcl er (sr) tb12 100mg 150mg
200mg 35 bupropion hcl er (xl) tb24 150mg 300mg
450mg 35 bupropion hcl tabs 75mg 100mg 35 buspirone hcl tabs 5mg 10mg 33 buspirone hcl tabs 75mg 15mg 30mg 33 busulfan soln 15 butalbital-acetaminophen caps 27 butalbital-acetaminophen tabs 27 butalbital-apap-caff-cod caps 27 butalbital-apap-caffeine caps 27 butalbital-apap-caffeine tabs 27 butalbital-asa-caff-codeine caps 27 butalbital-aspirin-caffeine caps 27 butalbital-aspirin-caffeine tabs 27 butorphanol tartrate soln 1mgml 2mgml
10mgml 27 BUTRANS PTWK 27 BYDUREON BCISE AUIJ 48 BYDUREON PEN 48 BYETTA 10 MCG PEN SOPN 48 BYETTA 5 MCG PEN SOPN 48 BYLVAY (PELLETS) CPSP 200mcg
600mcg 44 BYLVAY CAPS 400mcg 1200mcg 44 BYNFEZIA PEN SOPN 51
C CABENUVA SUER 12 cabergoline tabs 32 CABLIVI KIT 22 CABOMETYX TABS 20mg 40mg 60mg 15 cafergot tabs 32 caffeine citrate soln 30 calcipotriene crea 62 calcipotriene oint 62 calcipotriene soln 62 calcipotriene-betameth diprop oint 59 calcipotriene-betameth diprop susp 59 calcitonin (salmon) soln 50 calcitrene oint 62 calcitriol caps 025mcg 05mcg 63
CALCITRIOL OINT 62 calcitriol soln 63 calcium acetate (phos binder) caps 39 calcium acetate (phos binder) tabs 39 CALCIUM GLUCONATE-NACL SOLN 39 CALQUENCE CAPS 15 camila tabs 46 camrese lo tabs 46 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 59 CAPLYTA CAPS 35 CAPRELSA TABS 100mg 300mg 15 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 26 CARAC CREA 62 CARAFATE SUSP 43 CARBAGLU TABS 37 carbamazepine chew 30 carbamazepine er cp12 100mg 200mg
300mg 30 carbamazepine er tb12 100mg 200mg
400mg 30 carbamazepine susp 30 carbamazepine tabs 30 carbidopa tabs 32 carbidopa-levodopa er tbcr 32 carbidopa-levodopa tabs 32 carbidopa-levodopa tbdp 32 carbidopa-levodopa-entacapone tabs 32 carbinoxamine maleate soln 14 carbinoxamine maleate tabs 14 carboplatin soln 15 carboprost tromethamine soln 50 CARDENE IV SOLN 24 CARDIZEM LA TB24 24 CARDURA XL TB24 4mg 8mg 22 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 15 CARNITOR SOLN 54 CARNITOR TABS 54 CAROSPIR SUSP 26 carteolol hcl soln 42
72 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
cartia xt cp24 120mg 180mg 240mg 300mg 24
carvedilol phosphate er cp24 10mg 20mg 40mg 80mg 23
carvedilol tabs 3125mg 625mg 125mg 25mg 23
caspofungin acetate solr intravenous 50mg 70mg 11
cataflam tabs 27 CAYSTON SOLR 56 caziant tabs 46 cefaclor caps 8 cefaclor er tb12 8 cefaclor susr 8 cefadroxil caps 8 cefadroxil susr 8 cefadroxil tabs 8 cefazolin sodium solr 8 cefazolin sodium solr injection 1gm 10gm
500mg 8 cefdinir caps 8 cefdinir susr 8 cefepime hcl solr injection 1gm 2gm 8 cefixime caps 8 cefixime susr 8 cefotaxime sodium solr 8 cefotetan disodium solr injection 1gm 2gm 8 cefoxitin sodium solr injection 8 cefoxitin sodium solr intravenous 1gm 2gm
8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 2gm 6gm 8 CEFTIN SUSR 8 ceftriaxone sodium solr injection 1gm 2gm
250mg 500mg 8 ceftriaxone sodium solr intravenous 8 cefuroxime axetil tabs 8 cefuroxime sodium solr injection 75gm
750mg 8 cefuroxime sodium solr intravenous 8 celecoxib caps 27 CELONTIN CAPS 30 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 41
CERDELGA CAPS 40 CEREZYME SOLR 40 CEROVEL LOTN 62 CESAMET CAPS 43 cetirizine hcl soln 14 CETRAXAL SOLN 40 CEVIMELINE HCL CAPS 20 CHANTIX CONTINUING MONTH PAK
TABS 20 CHANTIX STARTING MONTH PAK TABS
20 CHANTIX TABS 05mg 1mg 20 CHEMET CAPS 44 chloramphenicol sod succinate solr 9 chlordiazepoxide hcl caps 5mg 10mg
25mg 33 chlordiazepoxide-amitriptyline tabs 35 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 40 chloroprocaine hcl (pf) soln 54 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 38 chlorothiazide tabs 250mg 500mg 38 chlorpromazine hcl soln 35 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 35 chlorthalidone tabs 25mg 50mg 38 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 44 cholestyramine light pack 23 cholestyramine light powd 23 cholestyramine pack 23 cholestyramine powd 23 CHORIONIC GONADOTROPIN SOLR 50 ciclopirox gel 58 ciclopirox olamine crea 58 ciclopirox olamine susp 58 ciclopirox sham 58 ciclopirox soln 58 cidofovir soln 12 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 40 CIMDUO TABS 12 cimetidine hcl soln 43 cimetidine tabs 200mg 300mg 400mg
800mg 43 CIMZIA KIT 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 73
CIMZIA PREFILLED KIT 52 CIMZIA STARTER KIT KIT 52 cinacalcet hcl tabs 30mg 60mg 90mg 50 CINQAIR SOLN 55 CINRYZE SOLR INTRAVENOUS 54 CIPRO HC SUSP 41 CIPRODEX SUSP 41 ciprofloxacin hcl soln (ophth) 40 CIPROFLOXACIN HCL SOLN (OTIC) 40 ciprofloxacin hcl tabs 9 ciprofloxacin in d5w soln 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 41 CIPROFLOXACIN-FLUOCINOLONE PF
SOLN 40 cisplatin soln 15 CISPLATIN SOLR 15 citalopram hydrobromide soln 35 citalopram hydrobromide tabs 10mg 20mg
40mg 35 citanest plain dental soln 54 cladribine soln 15 claravis caps 10mg 20mg 30mg 40mg 62 CLARINEX SYRP 14 CLARINEX-D 12 HOUR TB12 14 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 14 cleocin phosphate soln 9 cleocin solr 9 CLEOCIN SUPP 58 CLIMARA PRO PTWK 49 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
clindacin-p swab 58 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 58 clindamycin phosphate crea 58 clindamycin phosphate foam 58 clindamycin phosphate gel 58 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 58
clindamycin phosphate soln 9 58 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 58 CLINDESSE CREA 58 CLINIMIX EDEXTROSE (27510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (42525) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIX EDEXTROSE (525) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (2755) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (42520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 38 CLINIMIXDEXTROSE (525) SOLN
INTRAVENOUS 38 clinisol sf soln intravenous 38 clobazam susp 30 clobazam tabs 10mg 20mg 30 clobetasol propionate crea 59 clobetasol propionate e crea 59 clobetasol propionate emulsion foam 59 clobetasol propionate foam 59 clobetasol propionate gel 59 clobetasol propionate liqd 60 clobetasol propionate lotn 60 clobetasol propionate oint 60 clobetasol propionate sham 60 clobetasol propionate soln 60 CLOBEX SHAM 60
74 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
CLOBEX SPRAY LIQD 60 clocortolone pivalate crea 60 clocortolone pivalate pump crea 60 clodan sham 60 clofarabine soln 15 clomipramine hcl caps 25mg 50mg 75mg
35 clonazepam tabs 05mg 1mg 2mg 30 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 30 clonidine hcl (analgesia) soln 25 clonidine hcl er tb12 25 clonidine hcl tabs 01mg 02mg 03mg 25 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 25 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 33 clotrimazole crea 58 clotrimazole soln 58 clotrimazole troc 58 clotrimazole-betamethasone crea 58 clotrimazole-betamethasone lotn 58 clovique caps 44 clozapine tabs 25mg 50mg 100mg 200mg
35 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 35 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 27 colazal caps 43 COLCHICINE CAPS 52 colchicine tabs 52 colchicine-probenecid tabs 40 colesevelam hcl pack 23 colesevelam hcl tabs 23 colestipol hcl gran 23 colestipol hcl pack 23 colestipol hcl tabs 23 colistimethate sodium (cba) solr injection 9 colocort enem 60 COLY-MYCIN S SUSP 41 COMBIGAN SOLN 42 COMBIPATCH PTTW 49 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 15 COMETRIQ (140 MG DAILY DOSE) KIT 15 COMETRIQ (60 MG DAILY DOSE) KIT 15
COMPLERA TABS 12 compro supp 35 CONDYLOX GEL 62 CONSENSI TABS 24 constulose soln 37 COPIKTRA CAPS 15mg 25mg 15 CORDRAN TAPE 60 CORLANOR TABS 5mg 75mg 25 cortisone acetate tabs 45 CORTISPORIN CREA 60 CORTISPORIN OINT 60 COSELA SOLR 54 COSENTYX (300 MG DOSE) SOSY 62 COSENTYX SENSOREADY (300 MG)
SOAJ 62 COSENTYX SENSOREADY PEN SOAJ 62 COSENTYX SOSY 75mg05ml 150mgml
62 COTELLIC TABS 15 COTEMPLA XR-ODT TBED 86mg
173mg 259mg 30 CREON CPEP 40 CRESEMBA CAPS 11 CRESEMBA SOLR 11 CRINONE GEL 4 8 50 CRIXIVAN CAPS 200mg 400mg 12 cromolyn sodium conc 55 cromolyn sodium nebu 55 cromolyn sodium soln 42 crotan lotn 58 cryselle-28 tabs 46 CRYSVITA SOLN 10mgml 20mgml
30mgml 54 CUPRIMINE CAPS 44 CURITY GAUZE PADS 37 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 57
CUVPOSA SOLN 19 cyclafem 135 tabs 46 cyclafem 777 tabs 46 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 15 CYCLOPHOSPHAMIDE SOLN 1gm5ml
500mg25ml 15 cyclophosphamide solr 15
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 75
cycloserine caps 11 CYCLOSET TABS 48 cyclosporine caps 25mg 100mg 53 cyclosporine modified caps 25mg 50mg
100mg 53 cyclosporine modified soln 53 cyclosporine soln 53 cyproheptadine hcl syrp 14 cyproheptadine hcl tabs 14 CYRAMZA SOLN 100mg10ml
500mg50ml 15 cyred eq tabs 46 CYSTADANE POWD 54 CYSTADROPS SOLN 42 CYSTAGON CAPS 50mg 150mg 54 CYSTARAN SOLN 42 cytarabine (pf) soln 15 cytarabine soln 15 CYTOGAM INJ 57
D dacarbazine solr 15 dactinomycin solr 15 DAKLINZA TABS 30mg 60mg 90mg 12 dalfampridine er tb12 34 DALIRESP TABS 250mcg 500mcg 56 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 45 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 62 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 57 daptomycin solr intravenous 350mg 500mg
9 DARAPRIM TABS 11 darifenacin hydrobromide er tb24 75mg
15mg 63 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 DAYTRANA PTCH 10mg9hr 15mg9hr
20mg9hr 30mg9hr 30 DDAVP RHINAL TUBE SOLN 50 deblitane tabs 46 decadron elix 45
decadron tabs 5mg 75mg 45 decadron tabs 4mg 6mg 45 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 44 deferasirox tabs 90mg 180mg 360mg 44 deferasirox tbso 125mg 44 deferasirox tbso 250mg 500mg 44 deferiprone tabs 44 deferoxamine mesylate solr 44 DELESTROGEN OIL 49 DELSTRIGO TABS 12 deltasone tabs 45 delyla tabs 46 DELZICOL CPDR 43 demeclocycline hcl tabs 9 DEMEROL SOLN 25mg05ml 75mg15ml
100mg2ml 75mgml 27 DEMSER CAPS 22 DENAVIR CREA 58 DEPEN TITRATABS TABS 44 depo-estradiol oil 49 DEPO-MEDROL SUSP 45 DEPO-PROVERA SUSP 400mgml 50 DEPO-SUBQ PROVERA 104 SUSY 50 depo-testosterone soln 100mgml
200mgml 45 DERMOTIC OIL 41 DESCOVY TABS 12 desipramine hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 35 desloratadine tabs 14 desloratadine tbdp 14 desmopressin ace spray refrig soln 50 desmopressin acetate
soln 50 DESMOPRESSIN ACETATE SOLN 50 desmopressin acetate spray soln 50 DESMOPRESSIN ACETATE TABS 01mg
02mg 50 desogestrel-ethinyl estradiol tabs 46 DESONATE GEL 60 desonide crea 60 desonide gel 60 desonide lotn 60 desonide oint 60 desowen lotn 60 desoximetasone crea 005 025 60 desoximetasone gel 60
76 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
desoximetasone liqd 60 desoximetasone oint 005 025 60 desrx gel 60 DESVENLAFAXINE ER TB24 50mg
100mg 35 desvenlafaxine succinate er tb24 25mg
50mg 100mg 35 dexabliss tbpk 45 dexamethasone elix 45 dexamethasone intensol conc 45 dexamethasone sod phosphate pf soln 45 dexamethasone sodium phosphate soln 41
45 dexamethasone soln 45 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 45 dexamethasone tbpk 45 dexchlorpheniramine maleate soln 14 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 30
dexmethylphenidate hcl tabs 25mg 5mg 10mg 30
dexpak 10 day tbpk 45 dexpak 13 day tbpk 45 dexpak 6 day tbpk 45 dexrazoxane hcl solr 54 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 30 dextroamphetamine sulfate soln 30 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 30 DEXTROSE 10NACL 02 39 DEXTROSE 5NACL 0225 39 DEXTROSE IN LACTATED RINGERS
SOLN 39 DEXTROSE SOLN 38 dextrose soln intravenous 5 10 38 DEXTROSE-NACL SOLN INTRAVENOUS
39 DIACOMIT CAPS 250mg 500mg 30 DIACOMIT PACK 250mg 500mg 31 DIASTAT ACUDIAL GEL 10mg 20mg 31 DIASTAT PEDIATRIC GEL 31 diazepam conc 33 diazepam gel 25mg 10mg 20mg 31 diazepam soln 5mg5ml 5mgml 33 diazepam tabs 2mg 5mg 10mg 33 diazoxide susp 48
diclofenac potassium tabs 27 diclofenac sodium er tb24 27 diclofenac sodium gel 1 3 60 diclofenac sodium soln 41 diclofenac sodium tbec 27 diclofenac-misoprostol tbec 27 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 12 DIFFERIN CREA 62 DIFFERIN LOTN 62 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 60 diflorasone diacetate oint 60 diflunisal tabs 27 digitek tabs 0125mg 025mg 25 digox tabs 25 DIGOXIN ORAL SOLN 25 digoxin soln inj 25 digoxin tabs 125mcg 250mcg 25 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 31 dilantin infatabs chew 31 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 24 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 24
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 24
diltiazem hcl er cp12 60mg 90mg 120mg 24
diltiazem hcl er cp24 120mg 180mg 240mg 24
diltiazem hcl soln 24 diltiazem hcl solr 24 diltiazem hcl tabs 30mg 60mg 90mg
120mg 24 dilt-xr cp24 120mg 180mg 240mg 24 dimenhydrinate soln 43 dimethyl fumarate cpdr 34 dimethyl fumarate starter pack misc 34 DIPENTUM CAPS 43 diphen elix 14 di-phen elix 14 diphenhydramine hcl elix 14
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 77
diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 43 diphenoxylate-atropine tabs 43 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 57 dipyridamole tabs 25mg 50mg 75mg 26 disopyramide phosphate caps 100mg
150mg 25 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 38 divalproex sodium csdr 31 divalproex sodium er tb24 250mg 500mg 31 divalproex sodium tbec 125mg 250mg
500mg 31 DIVIGEL GEL 49 dobutamine hcl soln 21 DOBUTAMINE IN D5W SOLN 21 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 160mg8ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
25 dolishale tabs 46 donepezil hcl tabs 5mg 10mg 23mg 20 donepezil hcl tbdp 5mg 10mg 20 dopamine hcl soln 21 DOPAMINE IN D5W SOLN 21 DOPTELET TABS 22 DORYX MPC TBEC 9 dorzolamide hcl soln 42 dorzolamide hcl-timolol mal pf soln 42 dorzolamide hcl-timolol mal soln 42 dotti pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 49
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 35 doxepin hcl conc 35 doxepin hcl crea 61 doxepin hcl tabs 3mg 6mg 35 doxercalciferol caps 05mcg 1mcg 25mcg
63 DOXERCALCIFEROL SOLN 63 doxorubicin hcl liposomal inj 15 DOXORUBICIN HCL SOLN 15
doxorubicin hcl solr 15 doxy 100 solr intravenous 9 doxycycline hyclate caps 50mg 100mg 9 doxycycline hyclate tabs 20mg 75mg
100mg 150mg 9 doxycycline hyclate tbec 50mg 75mg
100mg 150mg 200mg 9 doxycycline monohydrate caps 50mg
75mg 100mg 150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 43 DRIZALMA SPRINKLE CSDR 35 dronabinol caps 25mg 5mg 10mg 43 droperidol soln 33 drospiren-eth estrad-levomefol tabs 46 drospirenone-ethinyl estradiol tabs 46 DROXIA CAPS 15 droxidopa caps 21 DUAKLIR PRESSAIR AEPB 19 DUAVEE TABS 49 DUEXIS TABS 27 DULERA AERO 56 duloxetine hcl cpep 20mg 30mg 40mg
60mg 35 DUOBRII LOTN 60 DUOPA SUSP 32 DUPIXENT SOPN 200mg114ml
300mg2ml 55 DUPIXENT SOSY 200mg114ml
300mg2ml 55 DURAMORPH SOLN 05mgml 1mgml 27 DUREZOL EMUL 41 DURYSTA IMPL 42 dutasteride caps 52 dutasteride-tamsulosin hcl caps 52 DUTOPROL TB24 23 dvorah tabs 27 dxevo 11-day tbpk 45 DYANAVEL XR SUER 30 DYSPORT SOLR 300unit 500unit 54
E ees 400 tabs 9 EASYGEL GEL 54 econazole nitrate crea 58 EDARBYCLOR TABS 26 EDLUAR SUBL 5mg 10mg 33
78 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 51 EGRIFTA SV SOLR 51 ELAPRASE SOLN 40 ELELYSO SOLR 40 ELEPSIA XR TB24 1000mg 1500mg 31 ELESTRIN GEL 49 eletriptan hydrobromide tabs 32 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 40 elixophyllin elix 63 ELLA TABS 46 ELLENCE SOLN 15 ELMIRON CAPS 54 eluryng ring 46 ELZONRIS SOLN 15 EMBEDA CPCR 27 EMCYT CAPS 15 EMEND SUSR 43 EMFLAZA SUSP 45 EMFLAZA TABS 6mg 18mg 30mg 36mg
45 EMGALITY (300 MG DOSE) SOSY 32 EMGALITY SOAJ 32 EMGALITY SOSY 32 emoquette tabs 46 EMPAVELI SOLN 54 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 32 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 26 enalaprilat inj 26 enalapril-hydrochlorothiazide tabs 26 ENBREL MINI SOCT 52 ENBREL SOLN 52 ENBREL SOLR 52 ENBREL SOSY 25mg05ml 50mgml 52 ENBREL SURECLICK SOAJ 52 ENDARI PACK 54 endocet tabs 27
ENDOMETRIN INST 50 ENGERIX-B SUSP 10mcg05ml 20mcgml
57 ENHERTU SOLR 15 enoxaparin sodium soln 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
enpresse-28 tabs 46 enskyce tabs 46 ENSPRYNG SOSY 54 ENSTILAR FOAM 60 entacapone tabs 33 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 26 ENTYVIO SOLR 44 enulose soln 37 ENVARSUS XR TB24 075mg 1mg 4mg53 EPCLUSA TABS 12 EPIDIOLEX SOLN 31 EPIDUO FORTE GEL 62 epifoam foam 60 epinastine hcl soln 42 epinephrine (anaphylaxis) soln 21 epinephrine soaj 21 EPINEPHRINE SOSY 21 EPIPEN 2-PAK SOAJ 21 EPIPEN JR 2-PAK SOAJ 21 epirubicin hcl soln 15 epitol tabs 31 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 26 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 22
epoprostenol sodium solr 56 eprosartan mesylate tabs 26 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 35 ERAXIS SOLR INTRAVENOUS 50mg
100mg 11 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 32 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 79
ERTACZO CREA 58 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 58 ery-tab tbec 9 ERYTHROCIN LACTOBIONATE SOLR
INTRAVENOUS 9 erythrocin stearate tabs 9 erythromycin base cpep 9 erythromycin base tabs 9 erythromycin base tbec 9 erythromycin ethylsuccinate susr 9 erythromycin ethylsuccinate tabs 9 erythromycin gel 58 erythromycin oint 40 erythromycin pads 58 erythromycin soln 58 ESBRIET CAPS 56 ESBRIET TABS 267mg 801mg 56 escitalopram oxalate soln 35 escitalopram oxalate tabs 5mg 10mg
20mg 35 esgic caps 27 esgic tabs 27 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 43 esomeprazole magnesium pack 10mg
20mg 40mg 43 esomeprazole sodium solr 43 ESOMEPRAZOLE STRONTIUM CPDR 43 estarylla tabs 46 estazolam tabs 1mg 2mg 33 estrace crea 49 estrace tabs 05mg 1mg 2mg 49 estradiol crea 49 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 49
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 49
estradiol tabs 10mcg 05mg 1mg 2mg 49 estradiol valerate oil 49 estradiol-norethindrone acet tabs 49 ESTRING RING 49 eszopiclone tabs 1mg 2mg 3mg 33
ethacrynic acid tabs 38 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 31 ethosuximide soln 31 ethynodiol diac-eth estradiol tabs 46 etodolac caps 27 etodolac er tb24 27 etodolac tabs 27 etonogestrel-ethinyl estradiol ring 46 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 EURAX CREA 58 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
EVAMIST SOLN 49 evekeo tabs 5mg 10mg 30 EVENITY SOSY 52 everolimus tabs 025mg 53 everolimus tabs 05mg 075mg 53 everolimus tabs 25mg 5mg 75mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 23 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 54 EXELDERM CREA 58 EXELDERM SOLN 58 exemestane tabs 15 EXJADE TBSO 125mg 250mg 500mg 44 EXONDYS 51 SOLN 500mg10ml
100mg2ml 54 EXSERVAN FILM 34 EXTAVIA KIT 34 EYLEA SOLN 42 EYLEA SOSY 42 ezetimibe tabs 23 ezetimibe-simvastatin tabs 23
F FABIOR FOAM 62 FABRAZYME SOLR 5mg 35mg 40 falmina tabs 46 famciclovir tabs 125mg 250mg 500mg 12 famotidine premixed soln 43 famotidine soln 43 famotidine susr 43 famotidine tabs 20mg 40mg 43
80 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
FANAPT TABS 1mg 2mg 4mg 6mg 8mg 10mg 12mg 35
FANAPT TITRATION PACK TABS 35 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 55 FASENRA SOSY 55 FASLODEX SOLN 15 fayosim tabs 46 febuxostat tabs 40mg 80mg 52 felbamate susp 31 felbamate tabs 400mg 600mg 31 felodipine er tb24 25mg 5mg 10mg 24 femynor tabs 46 fenofibrate caps 50mg 134mg 150mg 23 fenofibrate micronized caps 43mg 67mg
130mg 200mg 23 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 23 fenofibric acid cpdr 45mg 135mg 23 FENOFIBRIC ACID TABS 35mg 105mg 23 fenoprofen calcium caps 27 fenoprofen calcium tabs 27 fenortho caps 27 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 27 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 27
fentanyl citrate lpop 200mcg 400mcg 600mcg 800mcg 1200mcg 1600mcg 27
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 27
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 27
FENTORA TABS 100mcg 200mcg 400mcg 600mcg 800mcg 27
FERRIPROX SOLN 44 FERRIPROX TABS 500mg 1000mg 44 FERRIPROX TWICE-A-DAY TABS 44 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
35 FETZIMA TITRATION C4PK 35 fexmid tabs 20 FIBRICOR TABS 23 FINACEA FOAM 62 finasteride tabs 52 FINTEPLA SOLN 31
fioricet caps 27 fioricetcodeine caps 27 FIRAZYR SOLN 21 FIRDAPSE TABS 54 FIRMAGON (240 MG DOSE) SOLR 16 FIRMAGON SOLR 16 FIRVANQ SOLR 9 flac oil 41 FLAREX SUSP 41 flavoxate hcl tabs 63 FLEBOGAMMA DIF SOLN INTRAVENOUS
5gm100ml 10gm100ml 05gm10ml 10gm200ml 20gm200ml 20gm400ml 25gm50ml 5gm50ml 57
flecainide acetate tabs 50mg 100mg 150mg 25
FLOLIPID SUSP 20mg5ml 40mg5ml 23 FLOVENT DISKUS AEPB 50mcgblist
100mcgblist 250mcgblist 56 FLOVENT HFA AERO 110mcgact
220mcgact 56 FLOVENT HFA AERO 44mcgact 56 floxuridine solr 16 fluconazole in sodium chloride soln
intravenous 11 fluconazole susr 11 fluconazole tabs 11 flucytosine caps 250mg 500mg 11 fludarabine phosphate soln 16 fludarabine phosphate solr 16 fludrocortisone acetate tabs 45 flumazenil soln 34 flunisolide soln 41 fluocinolone acetonide body oil 60 fluocinolone acetonide crea 001 0025
60 fluocinolone acetonide oil 41 fluocinolone acetonide oint 60 fluocinolone acetonide scalp oil 60 fluocinolone acetonide soln 60 fluocinonide crea 60 fluocinonide emulsified base crea 60 FLUOCINONIDE GEL 60 fluocinonide oint 60 fluocinonide soln 60 FLUORITAB CHEW 025mg 05mg 1mg 54 FLUORITAB SOLN 54 fluorometholone susp 41 fluorouracil crea 5 62
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 81
fluorouracil crea 5 62 fluorouracil soln 16 62 fluorouracil soln 2 5 62 fluoxetine hcl (pmdd) tabs 10mg 20mg 35 fluoxetine hcl caps 10mg 20mg 40mg 35 fluoxetine hcl cpdr 35 fluoxetine hcl soln 35 fluoxetine hcl tabs 10mg 20mg 60mg 36 fluphenazine decanoate soln 36 fluphenazine hcl conc 36 fluphenazine hcl elix 36 fluphenazine hcl soln 36 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 36 flurandrenolide crea 60 flurandrenolide lotn 60 flurandrenolide oint 60 flurazepam hcl caps 15mg 30mg 33 flurbiprofen sodium soln 41 flurbiprofen tabs 27 flutamide caps 16 fluticasone propionate crea 60 fluticasone propionate lotn 60 fluticasone propionate oint 60 fluticasone propionate susp 41 fluticasone-salmeterol aepb 56 fluvastatin sodium caps 20mg 40mg 23 fluvastatin sodium er tb24 23 fluvoxamine maleate er cp24 100mg
150mg 36 fluvoxamine maleate tabs 25mg 50mg
100mg 36 FML FORTE SUSP 41 FML OINT 41 fomepizole soln 52 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 formoterol fumarate nebu 21 FORTEO SOPN 50 FOSAMAX PLUS D TABS 52 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 43 fosfomycin tromethamine pack 14 fosinopril sodium tabs 10mg 20mg 40mg
26 fosinopril sodium-hctz tabs 26 fosphenytoin sodium soln 31 FOSRENOL PACK 750mg 1000mg 39
FOTIVDA CAPS 089mg 134mg 16 FREAMINE HBC SOLN INTRAVENOUS 38 frovatriptan succinate tabs 32 FULPHILA SOSY 22 fulvestrant soln 16 furosemide soln 8mgml 10mgml 38 furosemide soln injection 38 FUROSEMIDE TABS 40mg 80mg 20mg38 FUZEON SOLR 12 fyavolv tabs 49 FYCOMPA SUSP 31 FYCOMPA TABS 31
G gabapentin caps 100mg 400mg 31 gabapentin soln 31 gabapentin tabs 600mg 800mg 31 GALAFOLD CAPS 54 galantamine hydrobromide er cp24 8mg
16mg 24mg 20 galantamine hydrobromide soln 20 galantamine hydrobromide tabs 4mg 8mg
12mg 20 GAMASTAN INJ 57 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 53 GAMMAGARD SD LESS IGA SOLR
INTRAVENOUS 5gm 10gm 57 GAMMAGARD SOLN INJECTION 57 GAMMAKED SOLN INJECTION 57 GAMMAPLEX SOLN INTRAVENOUS
10gm100ml 20gm200ml 5gm50ml 57 GAMMAPLEX SOLN INTRAVENOUS
10gm200ml 57 GAMUNEX-C SOLN INJECTION
10gm100ml 1gm10ml 20gm200ml 25gm25ml 5gm50ml 57
ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 57 GARDASIL 9 SUSY 57 gatifloxacin soln 40 GATTEX KIT 44 gavilyte-c solr 44 gavilyte-g solr 44 gavilyte-h kit 44 gavilyte-n with flavor pack solr 44 GAVRETO CAPS 16 GAZYVA SOLN 16
82 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
gemcitabine hcl soln 16 gemcitabine hcl solr 16 gemfibrozil tabs 23 gemmily caps 46 generlac soln 37 gengraf caps 25mg 50mg 100mg 53 gengraf soln 53 GENOTROPIN MINIQUICK SOLR 02mg 51 GENOTROPIN MINIQUICK SOLR 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 51
GENOTROPIN SOLR 5mg 12mg 51 gentak oint 40 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 58 gentamicin sulfate oint 58 gentamicin sulfate soln 9 40 gentamicin sulfate soln injection 9 GENVOYA TABS 12 GEODON SOLR 36 gianvi tabs 46 GILENYA CAPS 025mg 05mg 34 GILOTRIF TABS 20mg 30mg 40mg 16 GIMOTI SOLN 44 GIVLAARI SOLN 54 GLASSIA SOLN INTRAVENOUS 56 glatiramer acetate sosy 20mgml 40mgml
34 glatopa sosy 20mgml 40mgml 34 glimepiride tabs 1mg 2mg 4mg 48 glipizide er tb24 25mg 5mg 10mg 48 glipizide tabs 5mg 10mg 48 glipizide-metformin hcl tabs 48 GLOPERBA SOLN 52 GLUCAGEN HYPOKIT SOLR 48 glucagon emergency kit 48 glyburide micronized tabs 15mg 3mg 6mg
48 glyburide tabs 125mg 25mg 5mg 48 glyburide-metformin tabs 48 glycate tabs 19 glycopyrrolate pf sosy 19 glycopyrrolate soln 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 61 GLYXAMBI TABS 48 GOLYTELY SOLR 44 GONITRO PACK 26
granisetron hcl soln 43 granisetron hcl tabs 43 GRANIX SOLN 480mcg16ml 300mcgml
22 GRANIX SOSY 300mcg05ml
480mcg08ml 22 GRASTEK SUBL 54 griseofulvin microsize susp 11 griseofulvin microsize tabs 11 griseofulvin ultramicrosize tabs 11 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 34 guanfacine hcl tabs 1mg 2mg 25 GUANIDINE HCL TABS 20 gynazole-1 crea 58
H HAEGARDA SOLR 2000unit 3000unit 54 hailey 24 fe tabs 46 halcinonide crea 60 halobetasol propionate crea 60 HALOBETASOL PROPIONATE FOAM 60 halobetasol propionate oint 60 HALOG CREA 60 HALOG OINT 60 haloperidol decanoate soln 36 haloperidol lactate conc 36 haloperidol lactate soln 36 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 36 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 57 heparin (porcine) in nacl soln 21 HEPARIN SOD (PORCINE) IN D5W SOLN
21 heparin sodium (porcine) pf soln 21 heparin sodium (porcine) soln 1000unitml
5000unitml 10000unitml 20000unitml 21
HEPATAMINE SOLN INTRAVENOUS 38 HEPLISAV-B SOLN 57 HERCEPTIN HYLECTA SOLN 16 HERCEPTIN SOLR 150mg 440mg 16 HERZUMA SOLR 150mg 420mg 16 HETLIOZ CAPS 33 HETLIOZ LQ SUSP 33 HEXALEN CAPS 16 HIBERIX SOLR 57
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 83
HORIZANT TBCR 300mg 600mg 31 HUMALOG JUNIOR KWIKPEN SOPN 48 HUMALOG KWIKPEN SOPN 100unitml
200unitml 48 HUMALOG MIX 5050 KWIKPEN SUPN 48 HUMALOG MIX 5050 SUSP 48 HUMALOG MIX 7525 KWIKPEN SUPN 48 HUMALOG MIX 7525 SUSP 48 HUMALOG SOCT 48 HUMALOG SOLN 48 humatin caps 11 HUMATROPE SOLR 5mg 6mg 12mg
24mg 51 HUMIRA PEDIATRIC CROHNS START
PSKT 52 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 52 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 52 HUMIRA PEN-PEDIATRIC UC START
PNKT 52 HUMIRA PEN-PSUVADOL HS START
PNKT 52 HUMIRA PEN-PSORUVEIT STARTER
PNKT 52 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 52
HUMULIN 7030 KWIKPEN SUPN 48 HUMULIN 7030 SUSP 48 HUMULIN N KWIKPEN SUPN 48 HUMULIN N SUSP 48 HUMULIN R SOLN 48 HUMULIN R U-500 (CONCENTRATED)
SOLN 48 HUMULIN R U-500 KWIKPEN SOPN 48 hydralazine hcl soln 25 hydralazine hcl tabs 10mg 25mg 50mg
100mg 25 hydrochlorothiazide caps 38 hydrochlorothiazide tabs 125mg 25mg
50mg 38 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 27 hydrocodone-acetaminophen soln 27 hydrocodone-acetaminophen tabs 27 hydrocodone-ibuprofen tabs 27 hydrocortisone (perianal) crea 1 25 60 hydrocortisone ace-pramoxine crea 61
hydrocortisone butyr lipo base crea 60 hydrocortisone butyrate crea 60 hydrocortisone butyrate lotn 60 HYDROCORTISONE BUTYRATE OINT 60 hydrocortisone butyrate soln 60 hydrocortisone crea 1 25 60 hydrocortisone enem 60 hydrocortisone lotn 60 hydrocortisone oint 1 25 60 hydrocortisone tabs 5mg 10mg 20mg 45 hydrocortisone valerate crea 60 hydrocortisone valerate oint 60 HYDROCORTISONE-ACETIC ACID SOLN
41 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 28 hydromorphone hcl liqd 28 hydromorphone hcl pf soln 50mg5ml
10mgml 28 HYDROMORPHONE HCL SOLN 1mgml
2mgml 28 hydromorphone hcl tabs 2mg 4mg 8mg 28 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 50 hydroxyprogesterone caproate soln 50 hydroxyurea caps 16 hydroxyzine hcl soln 33 hydroxyzine hcl syrp 33 hydroxyzine hcl tabs 33 hydroxyzine pamoate caps 33 HYPERHEP B SOLN 57 HYPERRAB SD SOLN 57 HYQVIA KIT 57
I IBANDRONATE SODIUM SOLN 52 ibandronate sodium tabs 52 IBRANCE CAPS 75mg 100mg 125mg 16 IBRANCE TABS 75mg 100mg 125mg 16 ibu tabs 28 ibudone tabs 28 ibuprofen lysine soln 28 ibuprofen susp 28 ibuprofen tabs 28 ibutilide fumarate soln 25 icatibant acetate soln 21 iclevia tabs 46 ICLUSIG TABS 10mg 15mg 30mg 45mg
16
84 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
icosapent ethyl caps 23 IDAMYCIN PFS SOLN 16 idarubicin hcl soln 16 IDHIFA TABS 50mg 100mg 16 ifosfamide soln 16 IFOSFAMIDE SOLR 16 ILARIS SOLN 28 ILEVRO SUSP 41 ILUMYA SOSY 62 ILUVIEN IMPL 41 imatinib mesylate tabs 16 IMBRUVICA CAPS 70mg 140mg 16 IMBRUVICA TABS 140mg 280mg 420mg
560mg 16 IMFINZI SOLN 500mg10ml 120mg24ml
16 imipenem-cilastatin solr intravenous 9 imipramine hcl tabs 10mg 25mg 50mg 36 imipramine pamoate caps 75mg 100mg
125mg 150mg 36 imiquimod crea 375 5 62 IMIQUIMOD PUMP CREA 62 IMOGAM RABIES-HT SOLN 57 IMOVAX RABIES INJ 57 IMPAVIDO CAPS 11 IMVEXXY MAINTENANCE PACK INST
4mcg 10mcg 49 IMVEXXY STARTER PACK INST 4mcg
10mcg 49 INBRIJA CAPS 33 incassia tabs 46 INCRELEX SOLN 51 INCRUSE ELLIPTA AEPB 19 indapamide tabs 125mg 25mg 38 indocin supp 28 INDOCIN SUSP 28 indomethacin caps 28 INDOMETHACIN CAPS 20mg 28 indomethacin er cpcr 28 indomethacin sodium solr 28 INFANRIX SUSP 57 INFLECTRA SOLR INTRAVENOUS 52 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 34 INGREZZA CPPK 34 INLYTA TABS 1mg 5mg 16 INNOPRAN XL CP24 80mg 120mg 23 INQOVI TABS 16 INREBIC CAPS 16
INSULIN ASP PROT amp ASP FLEXPEN SUPN 48
INSULIN ASPART FLEXPEN SOPN 48 INSULIN ASPART PENFILL SOCT 48 INSULIN ASPART PROT amp ASPART SUSP
48 INSULIN ASPART SOLN 48 INSULIN LISPRO (1 UNIT DIAL) SOPN 48 INSULIN LISPRO SOLN 48 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 38 INTRALIPID EMUL INTRAVENOUS
20gm100ml 38 INTRAROSA INST 45 INTRON A SOLN 10muml 6000000unitml
16 INTRON A SOLR 10mu 18mu 50mu 16 introvale tabs 46 INVEGA SUSTENNA SUSY 39mg025ml
36 INVEGA SUSTENNA SUSY 78mg05ml
117mg075ml 234mg15ml 156mgml 36
INVEGA TRINZA SUSY 273mg0875ml 410mg1315ml 546mg175ml 819mg2625ml 36
INVELTYS SUSP 41 INVIRASE CAPS 12 INVIRASE TABS 12 INVOKAMET TABS 48 INVOKAMET XR TB24 48 INVOKANA TABS 100mg 300mg 48 IONOSOL-MB IN D5W SOLN
INTRAVENOUS 39 IOPIDINE SOLN 42 IPOL INJ 57 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 21 irbesartan tabs 75mg 150mg 300mg 26 irbesartan-hydrochlorothiazide tabs 26 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isibloom tabs 46
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 85
ISOLYTE-P IN D5W SOLN INTRAVENOUS 39
ISOLYTE-S SOLN INTRAVENOUS 39 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 21 isosorbide dinitrate er tbcr 26 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 26 isosorbide mononitrate er tb24 26 isosorbide mononitrate er tb24 30mg 60mg
26 isosorbide mononitrate tabs 10mg 20mg 26 isotretinoin caps 10mg 20mg 30mg 40mg
62 isradipine caps 25mg 5mg 24 ISTURISA TABS 1mg 5mg 10mg 54 itraconazole caps 11 ITRACONAZOLE SOLN 11 ivermectin crea 58 ivermectin lotn 58 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 57
J JADENU SPRINKLE PACK 90mg 180mg
360mg 44 JADENU TABS 90mg 360mg 44 JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16 jantoven tabs 1mg 2mg 25mg 3mg 4mg
5mg 6mg 75mg 10mg 21 JARDIANCE TABS 10mg 25mg 48 jasmiel tabs 46 JEMPERLI SOLN 16 JENTADUETO TABS 48 JENTADUETO XR TB24 48 jinteli tabs 49 JOLIVETTE TABS 46 juleber tabs 46 JULUCA TABS 12 junel 1530 tabs 46 junel 120 tabs 46 junel fe 1530 tabs 46 junel fe 120 tabs 46 junel fe 24 tabs 46
JUXTAPID CAPS 5mg 10mg 20mg 30mg 40mg 60mg 23
JYNARQUE TABS 15mg 30mg 39 JYNARQUE TBPK 39
K KADCYLA SOLR 100mg 160mg 16 KADIAN CP24 28 kaitlib fe chew 46 KALYDECO PACK 25mg 50mg 75mg 56 KALYDECO TABS 56 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 40 kariva tabs 46 KAZANO TABS 48 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-033 MEQ 39 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 40-5-09 MEQ 39 KCL-LACTATED RINGERS-D5W SOLN
INTRAVENOUS 39 KEDRAB SOLN 57 kelnor 135 tabs 46 kelnor 150 tabs 46 KENALOG SUSP 45 KEPIVANCE SOLR 61 keralyt sham 62 KESIMPTA SOAJ 54 ketoconazole crea 58 ketoconazole foam 58 ketoconazole sham 58 ketoconazole tabs 11 ketodan foam 58 ketoprofen caps 28 ketoprofen er cp24 28 ketorolac tromethamine soln 28 41 ketorolac tromethamine soln 04 05 41 ketorolac tromethamine tabs 28 KEVEYIS TABS 54 KEVZARA SOAJ 150mg114ml
200mg114ml 53 KEVZARA SOSY 150mg114ml
200mg114ml 53 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 52 KHEDEZLA TB24 50mg 100mg 36 KIMYRSA SOLR 9
86 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
KINERET SOSY 53 KINRIX SUSP 57 kionex susp 39 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (200 MG DOSE) TBPK
16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KITABIS PAK NEBU 56 KLISYRI OINT 62 KLOR-CON 10 TBCR 39 klor-con m10 tbcr 39 klor-con m15 tbcr 39 klor-con m20 tbcr 39 klor-con pack 39 klor-con sprinkle cpcr 8meq 10meq 39 KLOR-CON TBCR 39 KORLYM TABS 48 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 37 K-TAB TBCR 39 kurvelo tabs 46 KUVAN PACK 100mg 500mg 54 KUVAN TABS 54 KYNAMRO SOSY 23 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 33 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 LACRISERT INST 42 LACTATED RINGERS SOLN 39 54 LACTIC ACID LOTN 62 lactulose encephalopathy soln 37 lactulose pack 38 lactulose soln 38 LAMICTAL XR KIT 31 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 31
lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg 31
lamotrigine kit 31 lamotrigine starter kit-blue kit 31 lamotrigine starter kit-green kit 31 lamotrigine starter kit-orange kit 31 lamotrigine tabs 25mg 100mg 150mg
200mg 31 lamotrigine tbdp 25mg 50mg 100mg
200mg 31 LANOXIN PEDIATRIC SOLN 25 LANOXIN TABS 625mcg 25 lansoprazole cpdr 15mg 30mg 43 lansoprazole tbdd 15mg 30mg 43 lanthanum carbonate chew 500mg 750mg
1000mg 39 LANTUS SOLN 48 LANTUS SOLOSTAR SOPN 49 lapatinib ditosylate tabs 16 larin 1530 tabs 46 larin 120 tabs 46 larin fe 1530 tabs 46 larin fe 120 tabs 46 larissia tabs 46 LARTRUVO SOLN 190mg19ml
500mg50ml 16 LASTACAFT SOLN 42 latanoprost soln 42 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 36 LAYOLIS FE CHEW 46 LAZANDA SOLN 100mcgact 300mcgact
400mcgact 28 ledipasvir-sofosbuvir tabs 12 leena tabs 46 leflunomide tabs 10mg 20mg 53 LEMTRADA SOLN 34 LENVIMA (10 MG DAILY DOSE) CPPK 16 LENVIMA (12 MG DAILY DOSE) CPPK 16 LENVIMA (14 MG DAILY DOSE) CPPK 16 LENVIMA (18 MG DAILY DOSE) CPPK 16 LENVIMA (20 MG DAILY DOSE) CPPK 16 LENVIMA (24 MG DAILY DOSE) CPPK 16 LENVIMA (4 MG DAILY DOSE) CPPK 16 LENVIMA (8 MG DAILY DOSE) CPPK 17 lessina tabs 46 LETAIRIS TABS 5mg 10mg 56 letrozole tabs 17 leucovorin calcium soln 52
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 87
leucovorin calcium solr 52 leucovorin calcium tabs 5mg 10mg 15mg
25mg 52 LEUKERAN TABS 17 LEUKINE SOLR 22 leuprolide acetate kit 17 levalbuterol hcl nebu 125mg05ml
031mg3ml 063mg3ml 125mg3ml 21 levalbuterol tartrate aero 21 LEVEMIR FLEXTOUCH SOPN 49 LEVEMIR SOLN 49 levetiracetam er tb24 500mg 750mg 31 levetiracetam in nacl soln 31 levetiracetam soln 31 levetiracetam tabs 250mg 500mg 750mg
1000mg 31 levobunolol hcl soln 42 levocarnitine soln 54 LEVOCARNITINE TABS 54 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 40 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 52 levoleucovorin calcium solr 52 levonest tabs 46 levonorgest-eth est amp eth est tabs 47 levonorgest-eth estrad 91-day tabs 47 levonorgestrel-ethinyl estrad tabs 47 levonorg-eth estrad triphasic tabs 46 levora 01530 (28) tabs 47 levorphanol tartrate tabs 2mg 3mg 28 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEVOTHYROXINE SODIUM SOLR 51 levothyroxine sodium tabs 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 51
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
LEXETTE FOAM 60 LEXIVA SUSP 12 LIALDA TBEC 43 LIBTAYO SOLN 17 lidocaine hcl (cardiac) pf sosy 25 lidocaine hcl (cardiac) sosy 25 lidocaine hcl (pf) soln 54 LIDOCAINE HCL CREA 61 lidocaine hcl lotn 61 lidocaine hcl soln 42 54 61 lidocaine hcl urethralmucosal gel 61 lidocaine hcl urethralmucosal prsy 61 LIDOCAINE IN D5W SOLN 25 lidocaine in dextrose soln 54 lidocaine oint 61 lidocaine ptch 61 lidocaine viscous hcl soln 42 lidocaine-epinephrine soln 54 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 61 LIDOCAINE-HYDROCORTISONE ACE KIT
61 lidocaine-prilocaine crea 61 lidocaine-tetracaine crea 61 LIDOCORT CREA 61 lidopin crea 61 LIDO-SORB LOTN 61 LIDOZION LOTN 61 lincomycin hcl soln 9 lindane sham 58 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 LINZESS CAPS 72mcg 145mcg 290mcg
44 liothyronine sodium soln 51 liothyronine sodium tabs 5mcg 25mcg
50mcg 51 LIPODOX 50 INJ 17 lisinopril tabs 25mg 5mg 10mg 20mg
30mg 40mg 26 lisinopril-hydrochlorothiazide tabs 26 LITHIUM CARBONATE CAPS 300mg
150mg 600mg 36 lithium carbonate er tbcr 300mg 450mg 36 lithium carbonate tabs 36
88 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
LITHIUM SOLN 36 LITHOSTAT TABS 38 LIVALO TABS 1mg 2mg 4mg 23 LO LOESTRIN FE TABS 47 lodine tabs 28 loestrin 1530 (21) tabs 47 loestrin 120 (21) tabs 47 loestrin fe 1530 tabs 47 loestrin fe 120 tabs 47 LOKELMA PACK 5gm 10gm 39 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 17 loperamide hcl caps 43 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 49 lorazepam intensol conc 33 LORAZEPAM SOLN 4mgml 2mgml 33 lorazepam tabs 05mg 1mg 2mg 33 LORBRENA TABS 25mg 100mg 17 lorcet hd tabs 28 lorcet plus tabs 28 lorcet tabs 28 lortab elix 28 loryna tabs 47 lorzone tabs 375mg 750mg 20 losartan potassium tabs 25mg 50mg
100mg 26 losartan potassium-hctz tabs 26 LOTEMAX GEL 41 LOTEMAX OINT 41 LOTEMAX SUSP 41 loteprednol etabonate susp 41 lovastatin tabs 10mg 20mg 40mg 23 LOVENOX SOLN 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 300mg3ml 100mgml 150mgml 21
low-ogestrel tabs 47 loxapine succinate caps 5mg 10mg 25mg
50mg 36 lubiprostone caps 8mcg 24mcg 44 LUCEMYRA TABS 34 LUCENTIS SOLN 03mg005ml
05mg005ml 42 LUCENTIS SOSY 03mg005ml
05mg005ml 42 LUDENT CHEW 025mg 05mg 1mg 54 LULICONAZOLE CREA 58 LUMAKRAS TABS 17
LUMIGAN SOLN 42 LUMIZYME SOLR 40 LUMOXITI SOLR 17 LUPANETA PACK KIT 17 LUPKYNIS CAPS 53 LUPRON DEPOT (1-MONTH) KIT 17 LUPRON DEPOT (3-MONTH) KIT 17 LUPRON DEPOT (4-MONTH) KIT 17 LUPRON DEPOT (6-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 17 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 17 LUPRON DEPOT-PED (3-MONTH) KIT 17 lutera tabs 47 LUZU CREA 58 lyleq tabs 47 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 50
LYNPARZA CAPS 17 LYNPARZA TABS 100mg 150mg 17 LYSODREN TABS 17 lyza tabs 47
M mafenide acetate pack 58 magnesium sulfate in d5w soln 39 magnesium sulfate soln 31 magnesium sulfate soln injection 50 31 MAGNESIUM SULFATE SOLN
INTRAVENOUS 40gm1000ml 4gm100ml 20gm500ml 2gm50ml 31
MAKENA SOAJ 50 malathion lotn 58 MANNITOL SOLN 39 maprotiline hcl tabs 25mg 50mg 75mg 36 MARGENZA SOLN 17 marlissa tabs 47 MARPLAN TABS 36 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 24 MAVENCLAD (10 TABS) TBPK 53 MAVENCLAD (4 TABS) TBPK 53 MAVENCLAD (5 TABS) TBPK 53 MAVENCLAD (6 TABS) TBPK 53 MAVENCLAD (7 TABS) TBPK 53 MAVENCLAD (8 TABS) TBPK 53
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 89
MAVENCLAD (9 TABS) TBPK 53 MAVYRET TABS 12 MAXIDEX SUSP 41 MAYZENT STARTER PACK TBPK 34 MAYZENT TABS 025mg 2mg 34 MENAPHOSMBHYO1 TABS 14 meclizine hcl tabs 43 meclofenamate sodium caps 28 MEDROL TABS 45 medroxyprogesterone acetate susp 50 medroxyprogesterone acetate susy 50 medroxyprogesterone acetate tabs 25mg
5mg 10mg 50 mefenamic acid caps 28 mefloquine hcl tabs 11 megestrol acetate susp 17 50 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 47 meloxicam caps 28 meloxicam tabs 28 melphalan hcl solr 17 memantine hcl er cp24 34 memantine hcl soln 34 memantine hcl tabs 5mg 10mg 34 MENACTRA INJ 57 menest tabs 03mg 0625mg 125mg 50 MENOSTAR PTWK 50 MENQUADFI INJ 57 MENTAX CREA 58 MENVEO SOLR 57 meperidine hcl soln 50mg5ml 25mgml
50mgml 100mgml 28 meperidine hcl tabs 50mg 100mg 28 meprobamate tabs 33 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 47 mesalamine cpdr 43 mesalamine enem 43 mesalamine er cp24 43 mesalamine supp 43 mesalamine tbec 12gm 800mg 43 mesalamine-cleanser kit 43 mesna soln 54 MESNEX TABS 54 MESTINON SOLN 20 metadate er tbcr 30
metaproterenol sulfate syrp 21 metaproterenol sulfate tabs 10mg 20mg 21 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 49 metformin hcl tabs 500mg 850mg 1000mg
49 methadone hcl conc 28 methadone hcl intensol conc 28 methadone hcl soln 5mg5ml 10mg5ml
10mgml 28 methadone hcl tabs 5mg 10mg 28 methamphetamine hcl tabs 30 methazolamide tabs 25mg 50mg 42 methenamine hippurate tabs 14 METHENAMINE MANDELATE TABS 14 methergine tabs 50 methimazole tabs 5mg 10mg 51 methitest tabs 45 methocarbamol soln 20 methocarbamol tabs 20 methotrexate sodium (pf) soln 17 methotrexate sodium soln 17 methotrexate sodium solr 17 methotrexate tabs 17 methoxsalen rapid caps 62 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 39 methyldopa tabs 250mg 500mg 25 methyldopa-hydrochlorothiazide tabs 25 methylergonovine maleate soln 50 methylergonovine maleate tabs 50 methylphenidate hcl chew 25mg 5mg
10mg 30 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 30 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 30 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 30
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 30
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 30
methylphenidate hcl soln 5mg5ml 10mg5ml 30
90 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
methylphenidate hcl tabs 5mg 10mg 20mg 30
methylprednisolone acetate susp 45 methylprednisolone sodium succ solr 45 methylprednisolone tabs 4mg 8mg 16mg
32mg 45 methylprednisolone tbpk 45 methyltestosterone caps 45 metoclopramide hcl soln 44 metoclopramide hcl tabs 5mg 10mg 44 metoclopramide hcl tbdp 5mg 10mg 44 metolazone tabs 25mg 5mg 10mg 39 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 24 metoprolol tartrate soct 24 metoprolol tartrate soln 24 metoprolol tartrate tabs 25mg 50mg
100mg 24 metoprolol tartrate tabs 375mg 75mg 24 metoprolol-hydrochlorothiazide tabs 24 metronidazole caps 11 metronidazole crea 58 metronidazole gel 58 metronidazole in nacl soln 11 metronidazole in nacl soln intravenous 11 metronidazole lotn 58 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
25 mibelas 24 fe chew 47 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 58 miconazole-zinc oxide-petrolat oint 58 micort-hc crea 60 microgestin 1530 tabs 47 microgestin 120 tabs 47 microgestin fe 1530 tabs 47 microgestin fe 120 tabs 47 midazolam hcl (pf) soln 33 midazolam hcl soln 33 midazolam hcl syrp 33 midodrine hcl tabs 25mg 5mg 10mg 21 miglitol tabs 25mg 50mg 100mg 49 miglustat caps 40 mili tabs 47 millipred dp tbpk 45 millipred tabs 45
milrinone lactate in dextrose soln 25 milrinone lactate soln 25 mimvey lo tabs 50 mimvey tabs 50 minitran pt24 01mghr 02mghr 04mghr
06mghr 26 minocycline hcl caps 50mg 75mg 100mg 9 minocycline hcl er tb24 45mg 55mg 65mg
80mg 90mg 105mg 115mg 135mg 9 minocycline hcl tabs 50mg 75mg 100mg 9 minoxidil tabs 25mg 10mg 25 MIRCERA SOSY 30mcg03ml
50mcg03ml 75mcg03ml 100mcg03ml 150mcg03ml 200mcg03ml 22
mirtazapine tabs 75mg 15mg 30mg 45mg 36
mirtazapine tbdp 15mg 30mg 45mg 36 misoprostol tabs 100mcg 200mcg 43 MITIGARE CAPS 52 mitigo soln 28 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 57 modafinil tabs 100mg 200mg 30 moexipril hcl tabs 75mg 15mg 26 molindone hcl tabs 5mg 10mg 25mg 36 mometasone furoate crea 60 mometasone furoate oint 60 mometasone furoate soln 60 mometasone furoate susp 41 mondoxyne nl caps 75mg 100mg 9 MONJUVI SOLR 17 MONONESSA TABS 47 montelukast sodium chew 4mg 5mg 55 montelukast sodium pack 55 montelukast sodium tabs 55 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 28 morphine sulfate (pf) soln 4mgml 10mgml
28 MORPHINE SULFATE (PF) SOLN
INTRAVENOUS 28 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 28 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 28
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 91
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 28
MORPHINE SULFATE SOLN 28 MORPHINE SULFATE SOLN 10mg5ml
20mg5ml 28 MORPHINE SULFATE SOLN INJECTION
2mgml 4mgml 10mgml 28 MORPHINE SULFATE SOLN
INTRAVENOUS 28 morphine sulfate tabs 15mg 30mg 28 MOVANTIK TABS 125mg 25mg 44 MOXEZA SOLN 41 moxifloxacin hcl (2x day) soln 41 moxifloxacin hcl in nacl soln intravenous 10 moxifloxacin hcl soln 41 moxifloxacin hcl tabs 10 MULPLETA TABS 22 MULTAQ TABS 25 MULTIVITAMINFLUORIDE CHEW 63 MULTI-VITAMINFLUORIDE SOLN 63 MULTI-VITAMINFLUORIDEIRON SOLN
63 mupirocin calcium crea 58 mupirocin oint 59 MUSTARGEN SOLR 17 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17 MVC-FLUORIDE CHEW 64 MYALEPT SOLR 54 MYCAPSSA CPDR 51 mycophenolate mofetil caps 53 mycophenolate mofetil hcl solr 53 mycophenolate mofetil susr 53 mycophenolate mofetil tabs 53 mycophenolate sodium tbec 180mg 360mg
53 MYDAYIS CP24 30 MYFEMBREE TABS 50 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 62 MYRBETRIQ TB24 25mg 50mg 63 MYTESI TBEC 43
N NABI-HB SOLN 57 nabumetone tabs 28 N-ACETYL-L-CYSTEINE CAPS 38 nadolol tabs 20mg 40mg 80mg 24 nadolol-bendroflumethiazide tabs 24
nafcillin sodium solr 10 nafcillin sodium solr injection 10 nafcillin sodium solr intravenous 10 NAFRINSE CHEW 54 NAFRINSE DROPS SOLN 54 naftifine hcl crea 59 naftifine hcl gel 59 NAFTIN GEL 59 NAGLAZYME SOLN 40 nalbuphine hcl soln 28 nalfon tabs 28 nalocet tabs 28 naloxone hcl soaj 34 naloxone hcl soct 34 naloxone hcl soln 34 naloxone hcl sosy 34 naltrexone hcl tabs 35 NAMENDA XR TITRATION PACK CP24 34 NAPRELAN TB24 28 naproxen sodium er tb24 28 naproxen sodium tabs 28 naproxen susp 28 naproxen tabs 28 naproxen tbec 28 naproxen-esomeprazole tbec 28 naratriptan hcl tabs 32 NARCAN LIQD 35 NATACYN SUSP 41 NATAZIA TABS 47 nateglinide tabs 60mg 120mg 49 NATPARA CART 25mcg 50mcg 75mcg
100mcg 50 NATROBA SUSP 59 NAYZILAM SOLN 31 NEBUPENT SOLR 11 necon 0535 (28) tabs 47 NECON 777 TABS 47 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 36 nembutal soln 33 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 41 neomycin-polymyxin b gu soln 59 neomycin-polymyxin-dexameth oint 41 neomycin-polymyxin-dexameth susp 41 neomycin-polymyxin-gramicidin soln 41 neomycin-polymyxin-hc soln 41 neomycin-polymyxin-hc susp 41 neo-polycin hc oint 41
92 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
neo-polycin oint 41 neo-synalar crea 60 NEPHRAMINE SOLN INTRAVENOUS 38 NERLYNX TABS 17 NEULASTA ONPRO PSKT 22 NEULASTA SOSY 22 NEUPOGEN SOLN 480mcg16ml
300mcgml 22 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 22 NEVANAC SUSP 41 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 40 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 23 niacor tabs 23 nicardipine hcl caps 20mg 30mg 24 nicardipine hcl soln 24 NICOTROL INHA 20 NICOTROL NS SOLN 20 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 47 nilutamide tabs 17 nimodipine caps 24 NINLARO CAPS 23mg 3mg 4mg 17 nisoldipine er tb24 85mg 17mg 20mg
255mg 30mg 34mg 40mg 24 nitazoxanide tabs 11 nitisinone caps 2mg 5mg 10mg 54 nitro-bid oint 26 NITRO-DUR PT24 03mghr 08mghr 26 NITROFURANTOIN MACROCRYSTAL
CAPS 14 NITROFURANTOIN MONOHYD MACRO
CAPS 14 nitrofurantoin susp 14 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 26 nitroglycerin soln 26 nitroglycerin subl 03mg 04mg 06mg 26 nitropress soln 25 nitroprusside sodium soln 25 NITYR TABS 2mg 5mg 10mg 54
NIVESTYM SOLN 480mcg16ml 300mcgml 22
NIVESTYM SOSY 300mcg05ml 480mcg08ml 22
nizatidine caps 150mg 300mg 43 nizatidine soln 43 NOCDURNA SUBL 277mcg 553mcg 50 NOCTIVA EMUL 083mcg01ml
166mcg01ml 50 nolix crea 60 nolix lotn 60 nora-be tabs 47 norco tabs 28 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 51
norepinephrine bitartrate soln 21 norethin ace-eth estrad-fe caps 47 norethin ace-eth estrad-fe chew 47 norethin ace-eth estrad-fe tabs 47 norethindrone acetate tabs 50 norethindrone acet-ethinyl est tabs 47 norethindrone tabs 47 norethindrone-eth estradiol tabs 50 norethin-eth estradiol-fe chew 47 norgesic forte tabs 28 norgestimate-eth estradiol tabs 47 norgestim-eth estrad triphasic tabs 47 norlyroc tabs 47 NORMOSOL-M IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R IN D5W SOLN
INTRAVENOUS 39 NORMOSOL-R SOLN INTRAVENOUS 39 NORPACE CR CP12 100mg 150mg 25 nortrel 0535 (28) tabs 47 nortrel 135 (21) tabs 47 nortrel 135 (28) tabs 47 nortrel 777 tabs 47 nortriptyline hcl caps 10mg 25mg 50mg
75mg 36 nortriptyline hcl soln 36 NORVIR CAPS 12 NORVIR PACK 12 NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 34 NOVAREL SOLR 5000unit 10000unit 50 NOVOLIN 7030 SUSP 49
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 93
NOVOLOG 7030 FLEXPEN RELION SUPN 49
NOVOLOG FLEXPEN RELION SOPN 49 NOVOLOG FLEXPEN SOPN 49 NOVOLOG MIX 7030 FLEXPEN SUPN 49 NOVOLOG MIX 7030 RELION SUSP 49 NOVOLOG MIX 7030 SUSP 49 NOVOLOG PENFILL SOCT 49 NOVOLOG RELION SOLN 49 NOVOLOG SOLN 49 NOXAFIL SUSP 11 NOXAFIL TBEC 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 55 NUCALA SOLR 55 NUCALA SOSY 55 NUCYNTA ER TB12 200mg 250mg 29 NUCYNTA ER TB12 50mg 100mg 150mg
29 NUCYNTA TABS 29 NUCYNTA TABS 50mg 75mg 29 NUEDEXTA CAPS 34 NULIBRY SOLR 54 NULOJIX SOLR 53 NUPLAZID CAPS 36 NUPLAZID TABS 10mg 17mg 36 NURTEC TBDP 32 NUTRILIPID EMUL INTRAVENOUS 38 NUTROPIN AQ NUSPIN 10 SOPN 51 NUTROPIN AQ NUSPIN 20 SOPN 51 NUTROPIN AQ NUSPIN 5 SOPN 51 NUVARING RING 47 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 59 nylia 777 tabs 47 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 47 nystatin crea 59 nystatin oint 59 nystatin powd 59 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 60 nystatin-triamcinolone oint 60 nystop powd 59 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 44 ocella tabs 47 OCREVUS SOLN 34 OCTAGAM SOLN INTRAVENOUS
5gm100ml 1gm20ml 2gm20ml 25gm500ml 57
octreotide acetate soln 51 ODACTRA SUBL 54 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 56 ofloxacin soln 41 ofloxacin tabs 10 ogestrel tabs 47 OGIVRI SOLR 17 okebo caps 10 olanzapine solr 36 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 36 olanzapine tbdp 5mg 10mg 15mg 20mg
36 olanzapine-fluoxetine hcl caps 36 olmesartan medoxomil tabs 5mg 20mg
40mg 26 olmesartan medoxomil-hctz tabs 26 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 42 OLUMIANT TABS 1mg 2mg 53 OLYSIO CAPS 12 OMECLAMOX-PAK MISC 43 omega-3-acid ethyl esters caps 23 omeprazole cpdr 10mg 20mg 40mg 43 omeprazole-sodium bicarbonate caps 43 omeprazole-sodium bicarbonate pack 44 OMNARIS SUSP 41 OMNIPOD STARTER KIT 37 OMNITROPE SOCT 5mg15ml
10mg15ml 51 OMNITROPE SOLR 51 ondansetron hcl soln 43 ondansetron hcl tabs 4mg 8mg 24mg 43 ondansetron tbdp 4mg 8mg 43 ONIVYDE INJ 17 ONPATTRO SOLN 54 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 ONZETRA XSAIL EXHP 32
94 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
OPDIVO SOLN 100mg10ml 240mg24ml 40mg4ml 17
OPIUM TINC 43 ORACEA CPDR 62 ORALAIR SUBL 54 oralone pste 60 ORAVIG TABS 59 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 53 ORENCIA SOLR 53 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 53 ORENITRAM TBCR 0125mg 56 ORENITRAM TBCR 025mg 1mg 25mg
5mg 56 ORFADIN CAPS 54 ORFADIN SUSP 54 ORGOVYX TABS 50 ORIAHNN CPPK 50 ORILISSA TABS 150mg 200mg 50 ORKAMBI PACK 56 ORKAMBI TABS 56 ORLADEYO CAPS 110mg 150mg 54 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 29 orphengesic forte tabs 29 orsythia tabs 47 ORTIKOS CP24 6mg 9mg 45 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 39 OSMOPREP TABS 44 OSPHENA TABS 50 OTEZLA TABS 53 OTEZLA TBPK 53 OTOVEL SOLN 41 OTREXUP SOAJ 53 ovide lotn 59 OXACILLIN SODIUM IN DEXTROSE SOLN
INTRAVENOUS 10 oxacillin sodium solr injection 1gm 2gm 10 oxacillin sodium solr intravenous 10 oxaliplatin soln 17 oxaliplatin solr 17 oxandrolone tabs 45 oxandrolone tabs 25mg 45 oxaprozin tabs 29
OXAYDO TABS 29 oxazepam caps 10mg 15mg 30mg 33 OXBRYTA TABS 21 oxcarbazepine susp 31 oxcarbazepine tabs 150mg 300mg 600mg
31 OXERVATE SOLN 42 oxiconazole nitrate crea 59 OXISTAT LOTN 59 OXLUMO SOLN 54 OXTELLAR XR TB24 150mg 300mg
600mg 31 oxybutynin chloride er tb24 5mg 10mg
15mg 63 oxybutynin chloride syrp 63 oxybutynin chloride tabs 63 oxycodone hcl caps 29 oxycodone hcl conc 29 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxycodone hcl soln 29 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 29 oxycodone-acetaminophen soln 29 oxycodone-acetaminophen tabs 29 oxycodone-acetaminophen tabs 5-300mg
10-300mg 29 oxycodone-aspirin tabs 29 oxycodone-ibuprofen tabs 29 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 29 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 29 oxymorphone hcl tabs 5mg 10mg 29 OXYTOCIN SOLN 50 OZEMPIC (025 OR 05 MGDOSE) SOPN
49 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 49
P pacerone tabs 100mg 200mg 400mg 25 paclitaxel conc 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
54 PALFORZIA (120 MG DAILY DOSE) CSPK
54
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 95
PALFORZIA (160 MG DAILY DOSE) CSPK 54
PALFORZIA (20 MG DAILY DOSE) CSPK 54
PALFORZIA (200 MG DAILY DOSE) CSPK 54
PALFORZIA (240 MG DAILY DOSE) CSPK 55
PALFORZIA (3 MG DAILY DOSE) CSPK 55 PALFORZIA (300 MG MAINTENANCE)
PACK 55 PALFORZIA (300 MG TITRATION) PACK
55 PALFORZIA (40 MG DAILY DOSE) CSPK
55 PALFORZIA (6 MG DAILY DOSE) CSPK 55 PALFORZIA (80 MG DAILY DOSE) CSPK
55 PALFORZIA INITIAL ESCALATION CSPK
55 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 36 palonosetron hcl soln 43 palonosetron hcl sosy 43 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 40 pamidronate disodium soln 52 pamidronate disodium solr 52 PANCREAZE CPEP 40 PANDEL CREA 61 panlor tabs 29 PANRETIN GEL 61 pantoprazole sodium pack 44 PANTOPRAZOLE SODIUM SOLR 44 pantoprazole sodium tbec 20mg 40mg 44 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 57
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 64 PARICALCITOL SOLN 64 paroex soln 41 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 36 paroxetine hcl tabs 10mg 20mg 36 paroxetine hcl tabs 30mg 40mg 36 paroxetine mesylate caps 36 paser pack 11
PAXIL SUSP 36 PEDIARIX SUSP 57 PEDVAX HIB SUSP 57 peg 3350electrolytes solr 44 peg 3350-kcl-na bicarb-nacl solr 44 peg-3350electrolytes solr 44 PEGANONE TABS 31 PEGASYS PROCLICK SOLN
135mcg05ml 180mcg05ml 13 PEGASYS SOLN 180mcg05ml
180mcgml 13 PEGINTRON KIT 13 PEG-INTRON REDIPEN KIT 12 PEG-PREP KIT 44 PEMAZYRE TABS 45mg 9mg 135mg 17 penicillamine caps 45 penicillamine tabs 45 PENICILLIN G POT IN DEXTROSE SOLN
INTRAVENOUS 10 penicillin g potassium solr injection 10 penicillin g procaine susp 10 penicillin g sodium solr injection 10 penicillin v potassium solr 10 penicillin v potassium tabs 10 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 43 pentazocine-naloxone hcl tabs 29 pentobarbital sodium soln 33 pentoxifylline er tbcr 22 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 44 percocet tabs 29 perindopril erbumine tabs 2mg 4mg 8mg
26 periogard soln 41 PERJETA SOLN 17 permethrin crea 59 perphenazine tabs 2mg 4mg 8mg 16mg
36 perphenazine-amitriptyline tabs 36 PERSERIS PRSY 90mg 120mg 36 PERTZYE CPEP 40 PEXEVA TABS 10mg 20mg 30mg 40mg
36 phenadoz supp 14 phenazo tabs 61 PHENAZOPYRIDINE HCL TABS 61 phenelzine sulfate tabs 36
96 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
phenergan soln 14 PHENOBARBITAL ELIX 33 PHENOBARBITAL SODIUM SOLN 33 PHENOBARBITAL TABS 33 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 21 PHENYLEPHRINE HCL SOLN 42 phenytek caps 200mg 300mg 31 phenytoin chew 31 phenytoin sodium extended caps 100mg
200mg 300mg 31 phenytoin sodium soln 31 phenytoin susp 31 PHESGO SOLN 17 PHOSLYRA SOLN 39 PHOSPHASAL TABS 14 PHOSPHOLINE IODIDE SOLR 42 phrenilin forte caps 29 PHYSIOLYTE SOLN 55 PHYSIOSOL IRRIGATION SOLN 55 PIFELTRO TABS 13 pilocarpine hcl soln 1 2 4 42 pilocarpine hcl tabs 5mg 75mg 20 pimecrolimus crea 62 pimozide tabs 1mg 2mg 36 pimtrea tabs 47 pindolol tabs 5mg 10mg 24 pioglitazone hcl tabs 15mg 30mg 45mg 49 pioglitazone hcl-glimepiride tabs 49 pioglitazone hcl-metformin hcl tabs 49 piperacillin sod-tazobactam so solr 10 piperacillin sod-tazobactam so solr
intravenous 10 PIQRAY (200 MG DAILY DOSE) TBPK 17 PIQRAY (250 MG DAILY DOSE) TBPK 17 PIQRAY (300 MG DAILY DOSE) TBPK 17 pirmella 135 tabs 47 PIROXICAM CAPS 10mg 20mg 29 PLASMA-LYTE 148 SOLN INTRAVENOUS
39 PLASMA-LYTE A SOLN INTRAVENOUS 39 PLEGRIDY SOPN 13 PLEGRIDY SOSY 13 34 PLEGRIDY STARTER PACK SOPN 13 PLEGRIDY STARTER PACK SOSY 13 plenamine soln intravenous 38 PLENVU SOLR 44 podofilox soln 62 POLIVY SOLR 30mg 140mg 17
polocaine soln 55 polocaine-mpf soln 55 polycin oint 41 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 41 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 34 PONVORY TABS 34 portia-28 tabs 47 PORTRAZZA SOLN 17 POSACONAZOLE SUSP 11 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 37 POTASSIUM ACETATE SOLN 39 potassium chloride crys er tbcr 10meq
20meq 40 potassium chloride er cpcr 8meq 10meq 40 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 40 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 40 potassium chloride in nacl soln intravenous
40 potassium chloride pack 40 potassium chloride soln 10 20 40 POTASSIUM CHLORIDE SOLN
INTRAVENOUS 2meqml 10meq100ml 20meq100ml 40meq100ml 40
potassium citrate er tbcr 15meq 540mg 1080mg 37
POTASSIUM PHOSPHATES SOLN 40 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 40 POTELIGEO SOLN 18 PR BENZOYL PEROXIDE WASH LIQD 59 PRADAXA CAPS 110mg 150mg 22 PRADAXA CAPS 75mg 22 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 33
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 33
PRAMOX GEL 61 prandin tabs 1mg 2mg 49 prasugrel hcl tabs 5mg 10mg 22 pravastatin sodium tabs 10mg 20mg
40mg 80mg 23 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 97
PRED MILD SUSP 41 PRED-G SOP OINT 41 PRED-G SUSP 41 prednicarbate crea 61 prednicarbate oint 61 prednisolone acetate susp 41 prednisolone sodium phosphate soln 41 45 prednisolone sodium phosphate soln
5mg5ml 10mg5ml 20mg5ml 25mg5ml 45
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 45
prednisolone soln 45 prednisone intensol conc 45 prednisone soln 45 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 45 prednisone tbpk 45 prefest tabs 50 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 31
pregabalin er tb24 825mg 165mg 330mg 29
pregabalin soln 31 PREGNYL SOLR 50 PREMARIN SOLR 50 PREMARIN TABS 03mg 045mg
0625mg 09mg 125mg 50 premasol soln intravenous 38 PREMPHASE TABS 50 PREMPRO TABS 50 PRENATAL TABS 64 PRETOMANID TABS 11 prevalite pack 23 prevalite powd 23 previfem tabs 47 PREVYMIS SOLN 240mg12ml
480mg24ml 13 PREVYMIS TABS 240mg 480mg 13 PREZCOBIX TABS 13 PREZISTA SUSP 13 PREZISTA TABS 75mg 150mg 600mg
800mg 13 PRIFTIN TABS 11 PRILOSEC PACK 25mg 10mg 44 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 31 primlev tabs 29
PRIVIGEN SOLN INTRAVENOUS 57 PROAIR RESPICLICK AEPB 21 probenecid tabs 40 procainamide hcl soln 25 PROCALAMINE SOLN INTRAVENOUS 38 procentra soln 30 prochlorperazine edisylate soln 36 prochlorperazine maleate tabs 36 prochlorperazine supp 36 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 20000unitml 40000unitml 22
proctofoam hc foam 61 procto-med hc crea 61 procto-pak crea 61 proctosol hc crea 61 proctozone-hc crea 61 PROCYSBI CPDR 25mg 75mg 55 PROCYSBI PACK 75mg 300mg 55 progesterone caps 100mg 200mg 51 progesterone oil 51 PROGLYCEM SUSP 49 PROGRAF PACK 53 PROGRAF PACK 02mg 53 PROGRAF SOLN 53 PROLASTIN-C SOLN INTRAVENOUS 56 PROLASTIN-C SOLR INTRAVENOUS 56 prolate soln 29 prolate tabs 29 PROLENSA SOLN 41 PROLEUKIN SOLR 18 PROLIA SOSY 52 PROMACTA PACK 125mg 25mg 22 PROMACTA TABS 125mg 25mg 50mg
75mg 22 promethazine hcl soln 14 promethazine hcl supp 14 promethazine hcl syrp 14 promethazine hcl tabs 14 promethazine-phenylephrine syrp 14 promethegan supp 14 propafenone hcl er cp12 225mg 325mg
425mg 25 propafenone hcl tabs 150mg 225mg
300mg 25 propantheline bromide tabs 19 proparacaine hcl soln 43 propranolol hcl er cp24 60mg 80mg
120mg 160mg 24
98 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
propranolol hcl soln 20mg5ml 40mg5ml 24 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 24 propranolol-hctz tabs 24 propylthiouracil tabs 51 PROQUAD SUSR 58 PROSOL SOLN INTRAVENOUS 38 PROTONIX PACK 44 protriptyline hcl tabs 5mg 10mg 36 psorcon crea 61 PULMICORT FLEXHALER AEPB 45 PULMOZYME SOLN 40 PURIXAN SUSP 18 PYLERA CAPS 44 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 20 pyridostigmine bromide soln 20 pyridostigmine bromide tabs 30mg 60mg 20 pyrimethamine tabs 11
Q QBRELIS SOLN 26 QDOLO SOLN 29 QINLOCK TABS 18 QUADRACEL SUSP 57 questran light powd 23 questran pack 23 questran powd 23 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 36 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 37 QUILLICHEW ER CHER 20mg 30mg
40mg 30 QUILLIVANT XR SRER 30 quinapril hcl tabs 5mg 10mg 20mg 40mg
26 quinapril-hydrochlorothiazide tabs 26 quinidine gluconate er tbcr 25 QUINIDINE GLUCONATE SOLN 25 quinidine sulfate tabs 200mg 300mg 25 quinine sulfate caps 12
R RABAVERT SUSR 58 rabeprazole sodium cpsp 44 rabeprazole sodium tbec 44 RADICAVA SOLN 34
raloxifene hcl tabs 50 ramelteon tabs 33 ramipril caps 125mg 25mg 5mg 10mg 26 ranolazine er tb12 500mg 1000mg 25 RAPIVAB SOLN 13 rasagiline mesylate tabs 05mg 1mg 33 RASUVO SOAJ 53 RAVICTI LIQD 38 RAYALDEE CPCR 64 RAYOS TBEC 1mg 2mg 5mg 45 REBETOL SOLN 13 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 34 REBIF REBIDOSE TITRATION PACK
SOAJ 34 REBIF SOSY 22mcg05ml 44mcg05ml 34 REBIF TITRATION PACK SOSY 34 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 47 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 58 RECTIV OINT 62 REGONOL SOLN 20 REGRANEX GEL 62 relafen ds tabs 29 RELENZA DISKHALER AEPB 13 relexxii tbcr 30 RELISTOR SOLN 8mg04ml 12mg06ml
44 RELISTOR TABS 44 reltone caps 200mg 400mg 44 REMICADE SOLR INTRAVENOUS 53 RENFLEXIS SOLR 53 repaglinide tabs 05mg 1mg 2mg 49 repaglinide-metformin hcl tabs 49 REPATHA PUSHTRONEX SYSTEM SOCT
23 REPATHA SOSY 23 REPATHA SURECLICK SOAJ 23 RESCRIPTOR TABS 100mg 200mg 13 RESTASIS EMUL 41 RETACRIT SOLN 20000unit2ml
2000unitml 3000unitml 4000unitml 10000unitml 20000unitml 40000unitml 22
RETEVMO CAPS 40mg 80mg 18 RETIN-A CREA 0025 005 01 61 RETIN-A GEL 001 0025 61
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 99
RETIN-A MICRO GEL 004 01 61 RETIN-A MICRO PUMP GEL 61 RETIN-A MICRO PUMP GEL 004 01
61 RETIN-A MICRO PUMP GEL 008 61 RETISERT IMPL 41 RETROVIR SOLN 13 REVCOVI SOLN 40 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 18 revonto solr 20 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 37 REYATAZ PACK 13 REZUROCK TABS 55 RHOPRESSA SOLN 42 RIABNI SOLN 100mg10ml 500mg50ml 18 ribasphere caps 13 ribasphere ribapak (1000 pack) tbpk 13 ribasphere ribapak (1200 pack) tbpk 13 ribasphere tabs 13 ribavirin caps 13 ribavirin solr 13 ribavirin tabs 13 RIDAURA CAPS 55 RIFABUTIN CAPS 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 RIFATER TABS 11 riluzole tabs 34 rimantadine hcl tabs 13 RIMSO-50 SOLN 55 RINGERS IRRIGATION SOLN 55 RINGERS SOLN 40 RINVOQ TB24 53 risedronate sodium tabs 5mg 30mg 35mg
150mg 52 RISEDRONATE SODIUM TBEC 52 RISPERDAL CONSTA SRER 125mg
25mg 37 RISPERDAL CONSTA SRER 375mg
50mg 37 risperidone soln 37 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 37 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 37
ritonavir tabs 13 RITUXAN HYCELA SOLN 18 RITUXAN SOLN 18 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 47 rizatriptan benzoate tabs 32 rizatriptan benzoate tbdp 32 ROMIDEPSIN SOLN 18 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 33 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 33 ropivacaine hcl soln 55 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 23 ROTARIX SUSR 58 ROTATEQ SOLN 58 roweepra tabs 500mg 750mg 1000mg 31 roweepra xr tb24 500mg 750mg 31 ROXYBOND TABA 5mg 15mg 30mg 29 ROZEREM TABS 33 ROZLYTREK CAPS 100mg 200mg 18 RUBRACA TABS 200mg 250mg 300mg 18 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 31 rufinamide tabs 200mg 400mg 31 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 18 RUZURGI TABS 55 RYBREVANT SOLN 18 ryclora soln 14 RYDAPT CAPS 18 RYLAZE SOLN 18 RYNODERM CREA 62 RYTARY CPCR 33 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 51 SAIZEN SOLR 5mg 88mg 51 SAIZENPREP SOLR 51 sajazir soln 21 SALEX SHAM 62 SALICYLIC ACID CREA 62 SALICYLIC ACID ER SOLN 62
100 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
SALICYLIC ACID FOAM 62 SALICYLIC ACID GEL 62 SALICYLIC ACID LIQD 62 SALICYLIC ACID SHAM 62 SALICYLIC ACID WART REMOVER LIQD
62 SALICYLIC ACID-CLEANSER KIT 62 SALIMEZ CREA 62 SALSALATE TABS 29 SAMSCA TABS 15mg 39 SANCUSO PTCH 43 SANDIMMUNE ORAL SOLN 100mgml 53 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 51 SANTYL OINT 62 SAPHNELO SOLN 53 SAPHRIS SUBL 25mg 5mg 10mg 37 sapropterin dihydrochloride pack 100mg
500mg 55 sapropterin dihydrochloride tabs 55 SARCLISA SOLN 500mg25ml 100mg5ml
18 SAVELLA TABS 125mg 25mg 50mg
100mg 34 SAVELLA TITRATION PACK MISC 34 scopolamine pt72 43 seconal caps 33 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 37 selegiline hcl caps 33 selegiline hcl tabs 33 selenium sulfide lotn 59 SELENIUM SULFIDE SHAM 59 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 150mg
300mg 13 SEMPREX-D CAPS 14 SENSIPAR TABS 30mg 60mg 90mg 50 SENSORCAINE SOLN 55 sensorcaineepinephrine soln 55 sensorcaine-mpf soln 55 sensorcaine-mpfepinephrine soln 55 SEREVENT DISKUS AEPB 21 SEROSTIM SOLR 4mg 5mg 6mg 51 sertraline hcl conc 37 sertraline hcl tabs 25mg 50mg 100mg 37 setlakin tabs 47 sevelamer carbonate pack 08gm 24gm 39 sevelamer carbonate tabs 39
sevelamer hcl tabs 400mg 800mg 39 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 47 SHINGRIX SUSR 58 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 51 SIGNIFOR SOLN 03mgml 06mgml
09mgml 51 SIKLOS TABS 18 sildenafil citrate soln 26 sildenafil citrate susr 26 sildenafil citrate tabs 26 SILENOR TABS 37 SILIQ SOSY 62 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 59 SIMBRINZA SUSP 42 SIMPONI ARIA SOLN 53 SIMPONI SOAJ 50mg05ml 100mgml 53 SIMPONI SOSY 50mg05ml 100mgml 53 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 23 sirolimus soln 53 sirolimus tabs 05mg 1mg 2mg 53 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKLICE LOTN 59 SKYRIZI (150 MG DOSE) PSKT 62 SKYRIZI PEN SOAJ 63 SKYRIZI SOSY 63 sod benz-sod phenylacet soln 38 SODIUM ACETATE SOLN 37 SODIUM BICARBONATE SOLN 37 SODIUM CHLORIDE (PF) SOLN 40 SODIUM CHLORIDE SOLN 40 55 SODIUM CHLORIDE SOLN INJECTION 40 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 55 SODIUM FLUORIDE SOLN 55 SODIUM FLUORIDE TABS 55 SODIUM LACTATE SOLN INTRAVENOUS
37 sodium phenylbutyrate powd 38 sodium phenylbutyrate tabs 38 SODIUM PHOSPHATES SOLN 40 sodium polystyrene sulfonate powd 39 sodium polystyrene sulfonate susp 39 SODIUM SULFACETAMIDE SHAM 59
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 101
SODIUM SULFACETAMIDE WASH LIQD 59
sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 63 SOLIQUA SOPN 49 SOLOSEC PACK 12 soloxide tbec 10 SOLTAMOX SOLN 18 SOLU-CORTEF SOLR 45 SOLU-MEDROL SOLR 45 SOMATULINE DEPOT SOLN 51 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 51 SORILUX FOAM 63 sorine tabs 80mg 120mg 160mg 240mg
24 sotalol hcl (af) tabs 80mg 120mg 160mg 24 sotalol hcl tabs 80mg 120mg 160mg
240mg 24 SOTYLIZE SOLN 24 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPINOSAD SUSP 59 SPIRIVA HANDIHALER CAPS 19 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 26 spironolactone-hctz tabs 26 SPRAVATO (56 MG DOSE) SOPK 37 SPRAVATO (84 MG DOSE) SOPK 37 sprintec 28 tabs 47 SPRITAM TB3D 250mg 500mg 750mg
1000mg 31 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 39 sronyx tabs 47 SSD CREA 59 SSS 10-5 CREA 63 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
63 STELARA SOSY 45mg05ml 90mgml 63 STERILE WATER FOR IRRIGATION SOLN
55 STIMATE SOLN 50 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18
STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml 40
streptomycin sulfate solr 10 STRIANT MISC 46 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 21 SUBLOCADE SOSY 100mg05ml
300mg15ml 29 SUBSYS LIQD 100mcg 200mcg 400mcg
600mcg 800mcg 1200mcg 1600mcg 29 subvenite starter kit-blue kit 31 subvenite starter kit-green kit 31 subvenite starter kit-orange kit 31 subvenite tabs 25mg 100mg 150mg
200mg 31 succinylcholine chloride soln 20 SUCRAID SOLN 40 sucralfate susp 44 sucralfate tabs 44 sulfacetamide sodium (acne) lotn 59 SULFACETAMIDE SODIUM GEL 59 SULFACETAMIDE SODIUM LIQD 59 sulfacetamide sodium oint 41 sulfacetamide sodium soln 41 SULFACETAMIDE SODIUM-SULFUR
CREA 63 SULFACETAMIDE SODIUM-SULFUR
EMUL 63 SULFACETAMIDE SODIUM-SULFUR
LIQD 63 SULFACETAMIDE SODIUM-SULFUR
LOTN 63 SULFACETAMIDE SODIUM-SULFUR
PADS 63 SULFACETAMIDE SODIUM-SULFUR
SUSP 63 sulfacetamide-prednisolone soln 41 SULFACLEANSE 84 SUSP 63 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 sulfamez wash emul 63 SULFAMYLON CREA 59 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 29 sumatriptan soln 32
102 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
sumatriptan succinate refill soct 32 sumatriptan succinate soaj 32 sumatriptan succinate soln 32 sumatriptan succinate sosy 32 sumatriptan succinate tabs 32 sunitinib malate caps 125mg 25mg
375mg 50mg 18 SUNOSI TABS 75mg 150mg 30 SUPRAX CAPS 10 suprax chew 10 suprax susr 100mg5ml 200mg5ml 10 SUPRAX SUSR 500 MG5ML 10 SUPREP BOWEL PREP KIT SOLN 44 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 47 SYLATRON KIT 18 SYLATRON KIT 600 MCG 18 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 56 SYMDEKO TBPK 56 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 49 SYMLINPEN 60 SOPN 49 SYMPAZAN FILM 10mg 20mg 32 SYMPAZAN FILM 5mg 31 SYMPROIC TABS 44 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 50 SYNDROS SOLN 43 SYNERCID SOLR 10 SYNJARDY TABS 49 SYNJARDY XR TB24 49 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 TACLONEX SUSP 61 tacrolimus caps 05mg 1mg 5mg 53 TACROLIMUS OINT 01 003 63 tadalafil (pah) tabs 20mg 26 tadalafil tabs 25mg 5mg 26 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 55 TALTZ SOAJ 63
TALTZ SOSY 63 TALZENNA CAPS 025mg 1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 51 taperdex 12-day tbpk 45 taperdex 6-day tbpk 45 taperdex 7-day tbpk 45 TARCEVA TABS 25mg 100mg 150mg 18 targadox tabs 10 TARGRETIN GEL 61 tarina 24 fe tabs 47 tarina fe 120 eq tabs 47 TASIGNA CAPS 50mg 150mg 200mg 18 tavaborole soln 59 TAVALISSE TABS 100mg 150mg 22 tazarotene crea 63 tazarotene foam 63 tazicef solr injection 1gm 2gm 6gm 10 TAZORAC CREA 63 TAZORAC GEL 005 01 63 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 57 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TECFIDERA CPDR 120mg 240mg 34 TECFIDERA MISC 34 TEFLARO SOLR INTRAVENOUS 400mg
600mg 10 TEGSEDI SOSY 55 TEKTURNA HCT TABS 26 telmisartan tabs 20mg 40mg 80mg 26 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 26 TEMAZEPAM CAPS 15mg 225mg 30mg
75mg 33 temsirolimus soln 18 tencon tabs 29 TENIPOSIDE SOLN 18 TENIVAC INJ 57 tenofovir disoproxil fumarate tabs 13 TEPADINA SOLR 18 TEPEZZA SOLR 42 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 21
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 103
terbutaline sulfate tabs 25mg 5mg 21 terconazole crea 59 terconazole supp 59 TERIPARATIDE (RECOMBINANT) SOPN
50 testosterone cypionate soln 100mgml
200mgml 46 testosterone enanthate soln 46 testosterone gel 1 162
2025mg125gm 25mg25gm 405mg25gm 50mg5gm 10mgact 46
testosterone soln 46 tetrabenazine tabs 125mg 25mg 34 TETRACAINE HCL SOLN 43 tetracycline hcl caps 250mg 500mg 10 texacort soln 61 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 63 theophylline er tb12 100mg 200mg
300mg 450mg 63 theophylline er tb24 400mg 600mg 63 theophylline soln 63 THIOLA EC TBEC 100mg 300mg 55 THIOLA TABS 55 thioridazine hcl tabs 10mg 25mg 50mg
100mg 37 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 37 THYROGEN SOLR 55 THYROLAR-1 TABS 51 THYROLAR-12 TABS 51 THYROLAR-14 TABS 51 THYROLAR-2 TABS 51 THYROLAR-3 TABS 51 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
32 TIBSOVO TABS 18 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 34 tilia fe tabs 47 timolol maleate pf soln 42 timolol maleate solg 025 05 42 timolol maleate soln 025 05 42 timolol maleate tabs 5mg 10mg 20mg 24 TIMOPTIC OCUDOSE SOLN 25 42
TIMOPTIC-XE SOLG 025 05 42 tinidazole tabs 12 tiopronin tabs 55 TIROSINT CAPS 13mcg 25mcg 50mcg
75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 51
TIS-U-SOL SOLN 55 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 TIVORBEX CAPS 29 tizanidine hcl caps 20 21 tizanidine hcl tabs 20 TOBI PODHALER CAPS 56 TOBRADEX OINT 41 TOBRADEX ST SUSP 41 tobramycin nebu 300mg4ml 300mg5ml 56 tobramycin soln 41 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 42 TOBREX OINT 41 tofranil tabs 10mg 25mg 50mg 37 TOLAK CREA 63 tolazamide tabs 250mg 500mg 49 tolbutamide tabs 49 tolcapone tabs 33 tolmetin sodium caps 29 tolmetin sodium tabs 29 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 63 tolterodine tartrate tabs 63 TOLVAPTAN TABS 30mg 15mg 39 TOPEX TOPICAL ANESTHETIC AERO 61 topicort crea 005 025 61 topicort gel 61 topicort oint 61 topiramate cpsp 15mg 25mg 32 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 32 topiramate tabs 25mg 50mg 100mg
200mg 32 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
39 TOSYMRA SOLN 32
104 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
tovet foam 61 TPN ELECTROLYTES CONC
INTRAVENOUS 40 TRACLEER TABS 625mg 125mg 56 TRACLEER TBSO 56 TRADJENTA TABS 49 tramadol hcl er (biphasic) tb24 100mg
200mg 300mg 29 tramadol hcl er cp24 100mg 150mg
200mg 300mg 29 tramadol hcl er tb24 100mg 200mg 300mg
29 tramadol hcl tabs 50mg 100mg 29 tramadol-acetaminophen tabs 29 trandolapril tabs 1mg 2mg 4mg 26 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 22 tranexamic acid tabs 22 TRANSDERM SCOP (15 MG) PT72 43 tranylcypromine sulfate tabs 37 TRAVASOL SOLN INTRAVENOUS 38 TRAVATAN Z SOLN 42 travoprost (bak free) soln 42 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 37 trazodone hcl tabs 50mg 100mg 150mg 37 TRECATOR TABS 11 TRELEGY ELLIPTA AEPB 45 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 63 TREMFYA SOSY 63 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 56 tretinoin caps 18 tretinoin crea 0025 005 01 61 tretinoin gel 001 0025 005 61 tretinoin microsphere gel 004 01 61 tretinoin microsphere pump gel 004
01 62 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 29 triamcinolone acetonide aers 61 triamcinolone acetonide crea 0025
01 05 61 triamcinolone acetonide lotn 0025 01
61 triamcinolone acetonide oint 0025
005 01 05 61 triamcinolone acetonide pste 61
triamcinolone acetonide susp 45 triamterene caps 50mg 100mg 39 triamterene-hctz caps 39 triamterene-hctz tabs 39 trianex oint 61 triazolam tabs 0125mg 025mg 33 TRICITRATES SOLN 37 triderm crea 01 05 61 trientine hcl caps 45 tri-estarylla tabs 47 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 37 trifluridine soln 41 trihexyphenidyl hcl soln 33 trihexyphenidyl hcl tabs 2mg 5mg 33 TRIKAFTA TBPK 56 tri-legest fe tabs 47 tri-lo-estarylla tabs 47 tri-lo-sprintec tabs 47 trilyte solr 44 trimethobenzamide hcl caps 43 trimethoprim tabs 14 tri-mili tabs 47 trimipramine maleate caps 25mg 50mg
100mg 37 TRINESSA (28) TABS 47 TRINTELLIX TABS 5mg 10mg 20mg 37 tri-nymyo tabs 47 tri-previfem tabs 47 TRIPTODUR SRER 50 TRISENOX SOLN 18 TRISENOX SOLN 10mg10ml 18 tri-sprintec tabs 47 tritocin oint 61 TRIUMEQ TABS 13 TRI-VITAMINFLUORIDE SOLN 64 TRI-VITEFLUORIDE SOLN 64 trivora (28) tabs 47 tri-vylibra lo tabs 47 tri-vylibra tabs 47 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 32 TROPHAMINE SOLN INTRAVENOUS 38 trospium chloride er cp24 63 trospium chloride tabs 63 TRULANCE TABS 44 TRUMENBA SUSY 58
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 105
TRUSELTIQ (100MG DAILY DOSE) CPPK 18
TRUSELTIQ (125MG DAILY DOSE) CPPK 18
TRUSELTIQ (50MG DAILY DOSE) CPPK 18
TRUSELTIQ (75MG DAILY DOSE) CPPK 18
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 58 TYBOST TABS 13 tydemy tabs 47 TYKERB TABS 18 tylenol with codeine 3 tabs 29 tylenol with codeine 4 tabs 29 TYMLOS SOPN 50 TYPHIM VI SOLN 58 TYSABRI CONC INTRAVENOUS 34 TYVASO REFILL SOLN 56 TYVASO SOLN 56 TYVASO STARTER SOLN 56
U UBRELVY TABS 50mg 100mg 32 UCERIS FOAM 61 UDENYCA SOSY 22 UKONIQ TABS 18 ULORIC TABS 40mg 80mg 52 ULTOMIRIS SOLN 55 ULTRAVATE LOTN 61 UMECTA MOUSSE FOAM 63 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 52
UNITUXIN SOLN 18 UPLIZNA SOLN 53 UPTRAVI SOLR 56 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 56
UPTRAVI TBPK 57 UREA CREA 39 63 UREA LOTN 40 63 UREA-C40 LOTN 63 urecholine tabs 5mg 10mg 25mg 50mg 20
uredeb crea 63 URETRON DS TABS 14 URIN DS TABS 14 URSODIOL CAPS 200mg 400mg 44 ursodiol caps 300mg 44 ursodiol tabs 250mg 500mg 44 URYL TABS 14 USTELL CAPS 14 UTICAP CAPS 14 UTIRA-C TABS 14 UTRONA-C TABS 14
V VABOMERE SOLR INTRAVENOUS 10 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 63 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 32 valproic acid caps 32 valproic acid soln 32 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
26 valsartan-hydrochlorothiazide tabs 26 VALTOCO 10 MG DOSE LIQD 32 VALTOCO 15 MG DOSE LQPK 32 VALTOCO 20 MG DOSE LQPK 32 VALTOCO 5 MG DOSE LIQD 32 vanadom tabs 20 vanatol lq soln 29 vancomycin hcl caps 10 vancomycin hcl solr 10 VANCOMYCIN HCL SOLR 250 MG 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 VANDAZOLE GEL 59 VANOXIDE-HC LOTN 61 VANTAS KIT 19 VAQTA SUSP 58 VARIVAX INJ 58 VARIZIG SOLN 57 VARUBI (180 MG DOSE) TBPK 43 VASCEPA CAPS 05gm 1gm 23 VAXCHORA SUSR 58 vecamyl tabs 25 VECTICAL OINT 63 VELCADE SOLR 19 velivet tabs 47
106 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
VELPHORO CHEW 39 VELTASSA PACK 84gm 168gm 252gm
39 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 19 VENCLEXTA TABS 10mg 19 VENCLEXTA TABS 50mg 100mg 19 venlafaxine hcl er cp24 375mg 75mg
150mg 37 venlafaxine hcl er tb24 375mg 75mg
150mg 225mg 37 venlafaxine hcl tabs 25mg 375mg 50mg
75mg 100mg 37 VENTAVIS SOLN 10mcgml 20mcgml 57 VENTOLIN HFA AERS 21 VERAPAMIL HCL ER CP24 100mg
120mg 180mg 200mg 240mg 300mg 360mg 25
verapamil hcl er tbcr 120mg 180mg 240mg 25
verapamil hcl soln 25 verapamil hcl tabs 25 verapamil hcl tabs 80mg 120mg 25 VEREGEN OINT 63 VERELAN CP24 25 veripred 20 soln 45 VERSACLOZ SUSP 37 VERZENIO TABS 50mg 100mg 150mg
200mg 19 vestura tabs 47 VIBERZI TABS 75mg 100mg 44 VIBRAMYCIN SYRP 10 vicodin es tabs 29 vicodin hp tabs 29 vicodin tabs 29 VICTOZA SOPN 49 VIDEX EC CPDR 125mg 200mg 400mg 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 47 vigabatrin pack 32 vigabatrin tabs 32 vigadrone pack 32 VIIBRYD STARTER PACK KIT 37 VIIBRYD TABS 10mg 20mg 40mg 37 VILTEPSO SOLN 55 VIMIZIM SOLN 40 VIMPAT SOLN 32
VIMPAT TABS 32 vinblastine sulfate soln 19 vincasar pfs soln 19 vincristine sulfate soln 19 vinorelbine tartrate soln 19 VIOKACE TABS 40 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 52 VITAMINS ACD-FLUORIDE SOLN 64 VITRAKVI CAPS 25mg 100mg 19 VITRAKVI SOLN 19 VIVITROL SUSR 35 VIZIMPRO TABS 15mg 30mg 45mg 19 VOCABRIA TABS 13 VORAXAZE SOLR 52 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 19 VP-PNV-DHA CAPS 64 VPRIV SOLR 40 VRAYLAR CAPS 15mg 3mg 45mg 6mg
37 VRAYLAR CPPK 37 VUMERITY (STARTER) CPDR 55 VUMERITY CPDR 55 vyfemla tabs 47 vylibra tabs 47 VYNDAMAX CAPS 25 VYNDAQEL CAPS 25 VYONDYS 53 SOLN 55 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 30 VYVANSE CHEW 10mg 20mg 30mg
40mg 50mg 60mg 30 VYXEOS SUSR 19 VYZULTA SOLN 42
W WAKIX TABS 445mg 178mg 30 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 22 WATER FOR IRRIGATION STERILE
SOLN 55 wixela inhub aepb 56
Kaiser Permanente 2021 Defined Standard Comprehensive Formulary bull 107
wymzya fe chew 48 WYNZORA CREA 63
X XALKORI CAPS 200mg 250mg 19 XARELTO STARTER PACK TBPK 22 XARELTO TABS 25mg 10mg 15mg
20mg 22 XATMEP SOLN 19 XCOPRI (250 MG DAILY DOSE) TBPK 32 XCOPRI (350 MG DAILY DOSE) TBPK 32 XCOPRI TABS 200 MG 32 XCOPRI TABS 50mg 100mg 150mg 32 XCOPRI TBPK 32 XCOPRI TBPK 14 x 125 MG amp 14 X 25 MG
32 XELJANZ SOLN 53 XELJANZ TABS 5mg 10mg 53 XELJANZ XR TB24 11mg 22mg 53 XELPROS EMUL 42 XEMBIFY SOLN SUBCUTANEOUS
2gm10ml 4gm20ml 10gm50ml 1gm5ml 57
XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 55 XEOMIN SOLR 50unit 100unit 55 XEPI CREA 59 XERESE CREA 59 XERMELO TABS 43 XGEVA SOLN 52 XHANCE EXHU 42 XIFAXAN TABS 200mg 550mg 10 XIIDRA SOLN 42 XIMINO CP24 45mg 90mg 135mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 56 XOLAIR SOSY 75mg05ml 150mgml 56 XOSPATA TABS 19 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 19 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (40 MG TWICE WEEKLY) TBPK
20mg 40mg 19 XPOVIO (60 MG ONCE WEEKLY) TBPK
20mg 60mg 19
XPOVIO (60 MG TWICE WEEKLY) TBPK 19
XPOVIO (80 MG ONCE WEEKLY) TBPK 20mg 40mg 19
XPOVIO (80 MG TWICE WEEKLY) TBPK 19
XTAMPZA ER C12A 9mg 135mg 18mg 27mg 36mg 29
XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 48 XUREA CREA 63 XURIDEN PACK 55 xylocaine dental soln 55 XYOSTED SOAJ 50mg05ml 75mg05ml
100mg05ml 46 XYREM SOLN 34 XYWAV SOLN 34
Y YERVOY SOLN 19 YF-VAX INJ 58 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 42 yuvafem tabs 50
Z zafemy ptwk 48 zafirlukast tabs 10mg 20mg 55 zaleplon caps 5mg 10mg 33 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 48 zarontin soln 32 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 29 ZEJULA CAPS 19 ZELAPAR TBDP 33 ZELBORAF TABS 19 ZEMAIRA SOLR INTRAVENOUS 56 ZEMBRACE SYMTOUCH SOAJ 32 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
63 ZENPEP CPEP 40
108 bull Kaiser Permanente 2021 Defined Standard Comprehensive Formulary
zenzedi tabs 25mg 5mg 75mg 10mg 15mg 20mg 30mg 30
ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
34 ZEPOSIA CAPS 34 ZEPOSIA STARTER KIT CPPK 34 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERIT CAPS 15mg 20mg 30mg 40mg 13 ZERUVIA PTCH 61 ZETONNA AERS 42 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 55 ZINBRYTA SOSY 34 ZIONODIL 100 LOTN 61 ZIONODIL LOTN 61 ZIOPTAN SOLN 42 ziprasidone hcl caps 20mg 40mg 60mg
80mg 37 ziprasidone mesylate solr 37 ZIPSOR CAPS 29 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZIRGAN GEL 41 ZITHROMAX PACK 10 ZOKINVY CAPS 50mg 75mg 55 zoledronic acid conc 52 zoledronic acid soln 52
ZOLINZA CAPS 19 zolmitriptan soln 32 zolmitriptan tabs 32 zolmitriptan tbdp 32 zolpidem tartrate er tbcr 625mg 125mg 33 zolpidem tartrate subl 175mg 35mg 33 zolpidem tartrate tabs 5mg 10mg 33 ZOMACTON SOLR 51 ZOMACTON SOLR 5mg 51 ZOMIG SOLN 32 zonisamide caps 25mg 50mg 100mg 32 ZONTIVITY TABS 22 ZORBTIVE SOLR 51 ZORTRESS TABS 025mg 53 ZORTRESS TABS 05mg 075mg 1mg 53 ZORVOLEX CAPS 29 ZOSTAVAX SUSR 58 ZOSYN SOLN INTRAVENOUS 10 zovia 135e (28) tabs 48 ZUBSOLV SUBL 35 ZUPLENZ FILM 4mg 8mg 43 ZYCLARA PUMP CREA 63 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19 ZYKADIA TABS 19 ZYLET SUSP 42 ZYNLONTA SOLR 19 ZYPITAMAG TABS 1mg 2mg 4mg 23 ZYPREXA RELPREVV SUSR 37 ZYTIGA TABS 19 ZYVOX SOLN INTRAVENOUS 10
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You may submit a grievance in the following ways
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Civil RightsADA Coordinator
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16th Floor
Oakland CA 94612
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You can also file a civil rights complaint with the US Department of Health and Human Services
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services materials translated
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Arabic مجانا على مدار الساعة كافة متوفرة لك خدمات الترجمة الفورية
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տրամադրվել լեզվի հարցում` օրը 24 ժամ շաբաթը
7 օր Դուք կարող եք պահանջել բանավոր
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24 ժամ` շաբաթը 7 օր (տոն օրերին փակ է) TTY-ից
օգտվողները պետք է զանգահարեն 711
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言協助您可以申請口譯服務要求將資料翻譯成
您所用語言或轉換為其他格式我們每週 7天
每天 24小時均歡迎您打電話 1-800-757-7585 前來聯
絡(節假日 休息)聽障及語障專線 (TTY) 使用者
請撥 711
Farsi بدون روز هفته 7ساعت شبانروز و 24در زبانی خدمات
مترجم خدمات شما می توانید برای استهزینه در اختیار شما اخذ
صورتهای دیگر به زبان شما و یا به جزوات ترجمهشفاهی
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تماس بگیرند 711با شماره TTYتماس بگیرید کاربران
Hindi बिना किसी लागत ि दभाबिया सवाए कदन ि 24 घट
सपताह ि सातो कदन उपलबध ह आप एि दभाबिय िी सवाओ
ि बलए बिना किसी लागत ि सामबियो िो अपनी भािा म
अनवाद िरवान ि बलए या विबपपि परारपो ि बलए अनरोध
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घट सपताह ि सातो कदन (छटटियो वाल कदन िद रहता ह) िॉल
िर TTY उपयोगिताा 711 पर िॉल िर
Hmong Muajkwc pab txhais lus pub dawb rau koj
24 teev ib hnub twg 7 hnub ib lim tiam twg Koj thov
tau cov kev pab txhais lus muab cov ntaub ntawv
txhais ua koj hom lus los yog ua lwm homTsuas hu
rau 1-800-464-4000 24 teev ib hnub twg 7 hnub ib
lim tiam twg (cov hnub caiv kaw) Cov neeg siv
TTY hu 711
Japanese 当院では言語支援を無料で年中無休
終日ご利用いただけます通訳サービス日本語
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ください (祭日を除き年中無休)TTYユーザー
は 711にお電話ください
Khmer ជនយភាសា គមានឥតអសថលៃដលអនកឡ ើយ 24
ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ អនកអាចឡសនើស ឡសវាអនកបកបរប សភារៈបដលបានបកបរបឡៅជាភាសាបមែរ ឬជាទរងផោសងឡទៀត រានបតទរសពទមកឡយើង តាមឡលម 1-800-464-4000 បាន 24 ឡមា ោងមយថលៃ 7 ថលៃមយអាទតោយ (បទថលៃប ណោយ) អនកឡរបើ TTY ឡៅឡលម 711
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서비스를 무료로 이용하실 수 있습니다 귀하는
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형식의 자료를 요청할 수 있습니다 요일 및 시간에
관계없이 1-800-464-4000번으로 전화하십시오
(공휴일 휴무) TTY 사용자 번호 711
Laotian ການຊວຍເຫ ອດານພາສາມໃຫໂດຍບ ເສຽຄາ
ແກທານ ຕະຫ ອດ 24 ຊ ວໂມງ 7 ວນຕ ອາທດ ທານ
ສາມາດຮອງຂ ຮບບ ລການນາຍພາສາ ໃຫແປເອກະ
ສານເປນພາສາຂອງທານ ຫ ໃນຮບແບບອ ນ ພຽງ
ແຕໂທຣຫາພວກເຮ າທ 1-800-464-4000 ຕະຫ ອດ 24
ຊ ວໂມງ 7 ວນຕ ອາທດ (ປດວນພກຕາງໆ) ຜໃຊສາຍ
TTY ໂທຣ 711
Navajo Saad bee aacutekaacutersquoarsquoayeed naacutehoacuteloacute trsquoaacuteaacute jiikrsquoeacute
naadiin doo bibąąrsquo diacuteiacutersquo aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute
damoo naacuteaacutedleehjiacute Atah halnersquoeacute aacutekaacutersquoadoolwołiacutegiacuteiacute joacutekiacute
trsquoaacuteadoo lersquoeacute trsquoaacuteaacute hoacutehazaadjiacute hadilyąąrsquogo eacuteiacute doodaiirsquo
naacuteaacutenaacute laacute ałrsquoąą aacutedaatrsquoehiacutegiacuteiacute bee haacutedadilyaarsquogo Kojiacute
hodiilnih 1-800-464-4000 naadiin doo bibąąrsquo diacuteiacutersquo
aheacuteeacutersquoiikeed tsostsrsquoid yiskąąjiacute damoo naacutersquoaacutedleehjiacute
(Dahodiyin biniiyeacute ersquoersquoaahgo eacuteiacute darsquodeelkaal)
TTY chodeeyooliacuteniacutegiacuteiacute kojiacute hodiilnih 711
Punjabi ਬਿਨ ਾ ਬਿਸੀ ਲ ਗਤ ਦ ਬਦਨ ਦ 24 ਘਟ ਹਫਤ ਦ 7 ਬਦਨ
ਦਭ ਸੀਆ ਸਵ ਵ ਾ ਤਹ ਡ ਲਈ ਉਪਲਿਧ ਹ ਤਸੀ ਇਿ ਦਭ ਸੀਏ ਦੀ
ਮਦਦ ਲਈ ਸਮਗਰੀਆਾ ਨ ਆਪਣੀ ਭ ਸ ਬਵਚ ਅਨਵ ਦ ਿਰਵ ਉਣ
ਲਈ ਜ ਾ ਬਿਸ ਵਖ ਫ ਰਮਟ ਬਵਚ ਪਰ ਪਤ ਿਰਨ ਲਈ ਿਨਤੀ ਿਰ ਸਿਦ
ਹ ਿਸ ਬਸਰਫ਼ ਸ ਨ 1-800-464-4000 ਤ ਬਦਨ ਦ 24 ਘਟ ਹਫ਼ਤ
ਦ 7 ਬਦਨ (ਛਟੀਆਾ ਵ ਲ ਬਦਨ ਿਦ ਰਬਹਦ ਹ) ਫ਼ਨ ਿਰ TTY ਦ
ਉਪਯਗ ਿਰਨ ਵ ਲ 711 lsquoਤ ਫ਼ਨ ਿਰਨ
Russian Мы бесплатно обеспечиваем Вас услугами
перевода 24 часа в сутки 7 дней в неделю Вы можете
воспользоваться помощью устного переводчика
запросить перевод материалов на свой язык или
запросить их в одном из альтернативных форматов
Просто позвоните нам по телефону 1-800-464-4000
который доступен 24 часа в сутки 7 дней в неделю
(кроме праздничных дней) Пользователи линии TTY
могут звонить по номеру 711
Spanish Contamos con asistencia de idiomas sin costo
alguno para usted 24 horas al diacutea 7 diacuteas a la semana
Puede solicitar los servicios de un inteacuterprete que los
materiales se traduzcan a su idioma o en formatos
alternativos Solo llame al 1-800-788-0616 24 horas al
diacutea 7 diacuteas a la semana (cerrado los diacuteas festivos) Los
usuarios de TTY deben llamar al 711
Tagalog May magagamit na tulong sa wika nang wala
kang babayaran 24 na oras bawat araw 7 araw bawat
linggo Maaari kang humingi ng mga serbisyo ng
tagasalin sa wika mga babasahin na isinalin sa iyong
wika o sa mga alternatibong format Tawagan lamang
kami sa 1-800-464-4000 24 na oras bawat araw 7 araw
bawat linggo (sarado sa mga pista opisyal) Ang mga
gumagamit ng TTY ay maaaring tumawag sa 711
Thai เรามบรการลามฟรส าหรบคณตลอด 24 ชวโมง
ทกวนตลอดชวโมงท าการของเราคณสามารถขอใหลาม
ชวยตอบค าถามของคณทเกยวกบความคมครองการดแล
สขภาพของเราและคณยงสามารถขอใหมการแปลเอกสา
รเปนภาษาทคณใชไดโดยไมมการคดคาบรการเพยงโทร
หาเราทหมายเลข 1-800-464-4000 ตลอด 24
ชวโมงทกวน (ปดใหบรการในวนหยดราชการ) ผใช TTY
โปรดโทรไปท 711
Vietnamese Dịch vụ thocircng dịch được cung cấp miễn
phiacute cho quyacute vị 24 giờ mỗi ngagravey 7 ngagravey trong tuần Quyacute
vị coacute thể yecircu cầu dịch vụ thocircng dịch tagravei liệu phiecircn dịch
ra ngocircn ngữ của quyacute vị hoặc tagravei liệu bằng nhiều higravenh
thức khaacutec Quyacute vị chỉ cần gọi cho chuacuteng tocirci tại số
1-800-464-4000 24 giờ mỗi ngagravey 7 ngagravey trong tuần
(trừ caacutec ngagravey lễ) Người dugraveng TTY xin gọi 711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
Provide no cost aids and services to people with disabilities to communicate effectively with us such as
diams Qualified sign language interpreters
diams Written information in other formats such as large print audio and accessible electronic formats
Provide no cost language services to people whose primary language is not English such as
diams Qualified interpreters
diams Information written in other languages
If you need these services call Member Services at 1-800-476-2167 (TTY 711)8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana Aurora CO 80014 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
61102709_CO
Multi-language Interpreter Services
English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-476-2167 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-476-2167 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-476-2167 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-476-2167 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-476-2167 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-476-2167 (TTY 711)번으로 전화해 주십시오
Russian ВНИМАНИЕ Если вы говорите на русском языке то вам доступны бесплатные услуги перевода Звоните 1-800-476-2167 (телетайп 711)
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-476-2167(TTY711)までお電話にてご連絡ください
Amharic ማስታወሻ የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው 711)
German ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfuumlgung Rufnummer 1-800-476-2167 (TTY 711)
French ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le 1-800-476-2167 (ATS 711)
Farsi
ی م فراھم شمای برا گانیرا بصورتی زبان لاتیتسھ دیکنی م گفتگو فارسی زبان بھ اگر توجھ دیریبگ تماس (TTY 711) 2167-476-800-1 با باشد
Arabic
ملحوظة إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم )117- (رقم ھاتف الصم والبكم 7612-674-008-1
Yoruba AKIYESI Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o E pe ero ibanisoro yi 1-800-476-2167 (TTY 711)
Cushite-Oromo XIYYEEFFANNAA Afaan dubbattu Oroomiffa tajaajila gargaarsa afaanii kanfaltiidhaan ala ni argama Bilbilaa 1-800-476-2167 (TTY 711)
Nepali
धयान िदनहोस तपाइल नपाली बोलनहनछ भन तपाइको िनिमत भाषा सहायता सवाह िनःशलक पमा उपलबध छ फोन गनरहोस 1-800-476-2167 (िटिटवाइ 711)
KAH2711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Kaiser Permanente does not exclude people or treat them differently because of race color national origin age disability or sex We also
bull Provide no cost aids and services to people with disabilities to communicateeffectively with us such asdiams Qualified sign language interpretersdiams Written information in other formats such as large print audio and accessible
electronic formatsbull Provide no cost language services to people whose primary language is not English
such asdiams Qualified interpretersdiams Information written in other languages
If you need these services call Member Services at 1-800-805-2739 (TTY 711) 8 am to 8 pm seven days a week
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd Honolulu HI 96813 or calling Member Services at the number listed above You can file a grievance by mail or phone If you need help filing a grievance our Civil Rights Coordinator is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Kaiser Permanente is an HMO plan with a Medicare contract Enrollment in Kaiser Permanente depends on contract renewal
H1230_2017MLI accepted
Multi-language Interpreter Services English ATTENTION If you speak a language other than English language assistance services free of charge are available to you Call 1-800-805-2739 (TTY 711)
Spanish ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-805-2739 (TTY 711)
Chinese 注意如果您使用繁體中文您可以免費獲得語言援助服務請致電 1-800-805-2739 (TTY711)
Vietnamese CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-800-805-2739 (TTY 711)
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa 1-800-805-2739 (TTY 711)
Korean
주의 한국어를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수 있습니다
1-800-805-2739 (TTY 711)번으로 전화해 주십시오
Japanese 注意事項日本語を話される場合無料の言語支援をご利用いただけます1-800-805-2739(TTY711)までお電話にてご連絡ください
Lao
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ ການບ ລ ການຊວຍເຫອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມພອມໃຫທານ ໂທຣ 1-800-805-2739 (TTY 711)
Ilocano PAKDAAR Nu saritaem ti Ilocano ti serbisyo para ti baddang ti lengguahe nga awanan bayadna ket sidadaan para kenyam Awagan ti 1-800-805-2739 (TTY 711)
Samoan MO LOU SILAFIA Afai e te tautala Gagana faa Sāmoa o loo iai auaunaga fesoasoan e fai fua e leai se totogi mo oe Telefoni mai 1-800-805-2739 (TTY 711)
Marshallese LALE Ntildee kwōj kōnono Kajin Ṃajōḷ kwomarontilde bōk jerbal in jipantilde ilo kajin ṇe aṃ ejjeḷọk wōṇāān Kaalọk 1-800-805-2739 (TTY 711)
Trukese MEI AUCHEA Ika iei foosun fonuomw Foosun Chuuk iwe en mei tongeni omw kopwe angei aninisin chiakku ese kamo Kori 1-800-805-2739 (TTY 711)
Hawaiian E NĀNĀ MAI Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo loaʻa ke kōkua manuahi iā ʻoe E kelepona iā 1-800-805-2739 (TTY 711)
Pohnpeian Ni songen mwohmw ohte komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei Call 1-800-805-2739 (TTY 711)
Bisayan ATENSYON Kung nagsulti ka og Cebuano aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe nga walay bayad Tawag sa 1-800-805-2739 (TTY 711)
Tongan FAKATOKANGArsquoI Kapau lsquooku ke Lea-Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai atu ha tokoni tarsquoetotongi pea teke lava lsquoo marsquou ia Telefoni mai 1-800-805-2739 (TTY 711)
485236276 102021
This formulary was updated on 100121 For more recent information or other questions please contact the number for your Kaiser Permanente Region listed below seven days a week 8 am to 8 pm or visit kporgseniorrx
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Foundation Health Plan Inc 393 E Walnut St Pasadena CA 91188-8514 Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E Dakota Ave Denver CO 80247 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Foundation Health Plan Inc 711 Kapiolani Blvd Honolulu HI 96813 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
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