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Y0043_N00031430_Final06_C HPMS Approved Formulary File Submission 00022483 Version 13
Kaiser Permanente
2022 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 060122 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 June 1 2022 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 2022 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 titled 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 on how to request an exception You
2 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 2022 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2022 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 June 1 2022 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 59 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 see your Evidence of Coverage for more information
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 3
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 2022 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 2022 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 2022 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
4 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 5
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 2022 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 59 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg CIPRODEX) and generic drugs are listed in lower-case italics (eg amoxicillin) 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 2022 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
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 8 bull Kaiser Permanente 2022 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 azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP BICILLIN L-A SUSY cefaclor caps
Drug Name RequirementsLimits
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 intravenous 1gm 2gm 10gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 6gm HI
ceftazidime solr intravenous HI CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 750mg HI
cefuroxime sodium solr intravenous 15gm HI
cephalexin caps cephalexin susr cephalexin tabs chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w 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 2022 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
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 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 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
Drug Name RequirementsLimits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs erythromycin tbec FETROJA SOLR NDS 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 LYMEPAK 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
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium 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 10 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs 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 streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO suprax chew SYNERCID SOLR
Drug Name RequirementsLimits
targadox tabs MO tazicef solr injection HI tazicef solr intravenous 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
vancomycin hcl caps vancomycin hcl solr 250mg5ml vancomycin hcl solr intravenous 1gm 10gm 500mg HI
vancomycin hcl solr intravenous 5gm 750mg
XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ANTIFUNGALS AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS 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
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 2022 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS nystatin susp nystatin tabs 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 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 SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS
Drug Name RequirementsLimits
mefloquine hcl tabs metronidazole caps METRONIDAZOLE SOLN INTRAVENOUS 500mg100ml HI
metronidazole tabs nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs quinine sulfate caps NDS 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 APRETUDE SUER 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 DELSTRIGO TABS MO DESCOVY TABS 200-25mg MO DESCOVY TABS 120-15mg MO didanosine cpdr 200mg 250mg 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 12 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 PACK PANDS EPCLUSA TABS PANDS 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 LIVTENCITY TABS NDS lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO
Drug Name RequirementsLimits
maraviroc tabs 150mg 300mg MO MAVYRET PACK PANDS 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 oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEGASYS PROCLICK SOAJ 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN NDS PEGASYS SOSY NDS PEGINTRON KIT NDS PIFELTRO TABS MO 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
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 2022 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg MO sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS 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 PD TBSO MO TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEKLURY SOLN NDS VEKLURY SOLR NDS VEMLIDY TABS VIDEX EC CPDR 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
Drug Name RequirementsLimits
VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES 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 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg abiraterone acetate tabs 500mg NDS ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS NDS ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs arsenic trioxide soln NDS ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr
Drug Name RequirementsLimits
BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE SOLR BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS BESREMI SOSY NDS bexarotene caps NDS bicalutamide tabs 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 CAMCEVI PRSY CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR 50mg 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
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 2022 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
CYCLOPHOSPHAMIDE SOLN 2gm10ml 1gm5ml 500mg25ml
NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr 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 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 eulexin caps NDS
Drug Name RequirementsLimits
everolimus tabs 25mg 5mg 75mg 10mg NDS
everolimus tbso 2mg 3mg 5mg NDS EVOMELA SOLR NDS exemestane tabs EXKIVITY CAPS NDS FARYDAK CAPS 10mg 15mg 20mg LDNDS
FENSOLVI (6 MONTH) KIT 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 FYARRO SUSR 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 6000000unitml 10000000unitml
NDS
INTRON A SOLR 10000000unit 18000000unit 50000000unit 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 KIMMTRAK 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
lenalidomide caps 5mg 10mg 15mg 25mg NDS
Drug Name RequirementsLimits
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
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 TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA 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 2022 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
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 methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS nelarabine soln 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 120mg12ml 240mg24ml 40mg4ml
NDS
OPDUALAG SOLN NDS oxaliplatin soln oxaliplatin solr paclitaxel conc PACLITAXEL PROTEIN-BOUND PART SUSR 100 MG NDS
PADCEV SOLR 20mg 30mg NDS
Drug Name RequirementsLimits
paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEMFEXY SOLN 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 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
SCEMBLIX TABS 20mg 40mg NDS SIKLOS TABS NDS SOLTAMOX SOLN
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
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 05mg 075mg 1mg NDS
tamoxifen citrate tabs 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 TIVDAK SOLR 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 NDS
TRODELVY SOLR NDS
Drug Name RequirementsLimits
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 UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln 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
VONJO CAPS NDS VOTRIENT TABS NDS VYXEOS SUSR NDS WELIREG TABS 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
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 2022 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
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 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 ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO chlordiazepoxide-clidinium caps dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate oral soln MO glycopyrrolate pf sosy glycopyrrolate soln injection glycopyrrolate tabs 1mg 2mg MO
Drug Name RequirementsLimits
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 RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO varenicline tartrate misc MO varenicline tartrate tabs 05mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA FLEQSUVY SUSP NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs 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
Drug Name RequirementsLimits
albuterol sulfate er tb12 4mg 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcgact MONDS
albuterol sulfate nebu 0083 25mg05ml 063mg3ml 125mg3ml
PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY ipratropium-albuterol soln PAMO isoproterenol hcl soln LEVALBUTEROL HCL NEBU 125mg05ml 125mg3ml 031mg3ml 063mg3ml
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 SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS icatibant acetate 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 2022 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
OXBRYTA TABS NDS OXBRYTA TBSO NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS 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 BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln NDS enoxaparin sodium sosy 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
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 NDS LOVENOX SOSY 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg 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 SUSR NDS XARELTO TABS 25mg 10mg 15mg 20mg MO
HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
EPOGEN SOLN PANDS FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
PROCRIT SOLN 20000unitml 40000unitml PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RELEUKO SOLN 300mcgml 480mcg16ml NDS
RELEUKO SOSY 300mcg05ml 480mcg08ml NDS
RETACRIT SOLN 20000unitml PANDS RETACRIT SOLN PANDS TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS 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 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
Drug Name RequirementsLimits
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 150mg MO fenofibrate micronized caps 43mg 67mg 130mg 134mg 200mg
MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg 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
lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
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 SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 1gm MO BETA-ADRENERGIC BLOCKING 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 2022 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
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
ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
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
nadololbendroflumethiazide 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
Drug Name RequirementsLimits
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 cartia xt cp24 120mg 180mg 240mg 300mg MO
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 40mg 80mg 120mg MO
CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR SOLN MO CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln 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 lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy
Drug Name RequirementsLimits
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 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
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 2022 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
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
captopril-hydrochlorothiazide 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
quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
Drug Name RequirementsLimits
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO 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 dipyridamole tabs 25mg 50mg 75mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ascomp-codeine caps NDS benzhydrocodone-acetaminophen tabs NDS
bupap tabs 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 NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS dvorah tabs 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
Drug Name RequirementsLimits
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
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 hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd 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 NDS indomethacin caps indomethacin er cpcr indomethacin sodium solr ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lorcet hd tabs NDS lorcet plus 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln NDS meperidine hcl tabs 50mg NDS methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl tabs 5mg 10mg NDS MORPHINE SULFATE (CONCENTRATE) SOLN NDS
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 tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln 10mgml 20mgml NDS
nalfon tabs nalocet tabs NDS naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs
Drug Name RequirementsLimits
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 75-300mg 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 relafen ds tabs NDS SALSALATE TABS SUBSYS LIQD 1200mcg 1600mcg PANDS
sulindac tabs tencon tabs tolmetin sodium caps tolmetin sodium tabs
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 soln 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 tabs NDS vicodin es tabs NDS vicodin hp tabs NDS zebutal caps ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS amphetamine er suer NDS 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 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
evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS
Drug Name RequirementsLimits
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
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS procentra soln NDS relexxii tbcr NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
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
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 2022 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
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
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 EPRONTIA SOLN 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 lacosamide tabs 50mg 100mg 150mg 200mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
Drug Name RequirementsLimits
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
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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg 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 VALTOCO 15 MG DOSE LQPK VALTOCO 20 MG DOSE LQPK VALTOCO 5 MG DOSE LIQD vigabatrin pack LDNDS vigabatrin tabs NDS VIMPAT SOLN XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200mg NDS XCOPRI TBPK 14x125mg amp 14x25mg
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ PA AJOVY SOSY PA almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs
Drug Name RequirementsLimits
ergotamine-caffeine tabs FROVATRIPTAN SUCCINATE TABS
naratriptan hcl tabs NURTEC TBDP NDS QULIPTA TABS 10mg 30mg 60mg NDS
rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs UBRELVY TABS 50mg 100mg NDS zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl soln MO amantadine hcl tabs MO APOKYN SOCT NDS apomorphine hcl 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
EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg 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 2022 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
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
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
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 intensol conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS droperidol soln estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
Drug Name RequirementsLimits
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP PANDS 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 nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs seconal caps TEMAZEPAM CAPS 75mg 15mg 225mg 30mg 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS tetrabenazine tabs 125mg 25mg MO
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
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 1mg 2mg NDS
OCREVUS SOLN PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
Drug Name RequirementsLimits
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 ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS OPIATE ANTAGONISTS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
LUCEMYRA TABS NDS naloxone hcl liqd naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
VIVITROL SUSR NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg 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 2022 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
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 conc 30mgml 100mgml MO
chlorpromazine hcl soln chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
CITALOPRAM HYDROBROMIDE CAPS MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
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 HAFYERA SUSY INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 150mg 300mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
LITHIUM CARBONATE TABS MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
LYBALVI TABS NDS maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
Drug Name RequirementsLimits
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 susp MO paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps 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
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
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 2022 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
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 CAPS 150mg 200mg MO
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
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 MO trazodone hcl tabs 150mg 300mg 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
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 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 TRICITRATES SOLN AMMONIA DETOXICANTS carglumic acid tbso NDS constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN DEXTROSE SOLN INTRAVENOUS 5 10 HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE 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
Drug Name RequirementsLimits
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI furosemide tabs 20mg 40mg 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN tolvaptan tabs 15mg 30mg 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 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
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 2022 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate tabs MO CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
DEXTROSE-NACL SOLN INTRAVENOUS 25-045 5-02 5-045 5-09
HI
DEXTROSE-NACL SOLN INTRAVENOUS 10-02 10-045
HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 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 PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
Drug Name RequirementsLimits
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 10meq100ml 20meq100ml 40meq100ml 2meqml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN 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 ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME 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 38 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin oint bacitracin-polymyxin b oint bleph-10 soln chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin 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 paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln
Drug Name RequirementsLimits
sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ANTI-INFLAMMATORY AGENTS bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
CEQUA SOLN CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO cyclosporine emul MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO difluprednate emul MO flac oil 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
ILUVIEN IMPL ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint 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 2022 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
RESTASIS EMUL MO RESTASIS MULTIDOSE EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
VERKAZIA EMUL NDS YUTIQ IMPL ANTIALLERGIC AGENTS azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
betaxolol hcl soln MO bimatoprost soln MO brimonidine tartrate soln 015 02 MO
brinzolamide susp MO carteolol hcl soln MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
Drug Name RequirementsLimits
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO timolol maleate (once-daily) soln MO timolol maleate pf soln MO TIMOLOL MALEATE SOLG 025 05 MO
timolol maleate soln 025 05 MO
travoprost (bak free) 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 SUSVIMO (IMPLANT 1ST FILL) SOLN
SUSVIMO (IMPLANT REFILL) SOLN
TEPEZZA SOLR NDS VABYSMO SOLN LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lidocaine viscous hcl soln MO proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
balsalazide disodium caps MO colazal caps 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 OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS aprepitant caps PANDS dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl sosy ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy
Drug Name RequirementsLimits
SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS trimethobenzamide hcl caps PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc 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 famotidine (pf) soln 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 omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate 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 2022 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS 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 IBSRELA TABS NDS LIVMARLI SOLN NDS lubiprostone caps 8mcg 24mcg MO metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS TRULANCE TABS 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
Drug Name RequirementsLimits
clovique caps NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs deferasirox tbso deferiprone tabs 500mg 1000mg NDS
deferoxamine mesylate solr FERRIPROX SOLN LDNDS FERRIPROX TABS LDNDS FERRIPROX TWICE-A-DAY TABS NDS
penicillamine caps NDS penicillamine tabs NDS trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP ALKINDI SPRINKLE CPSP 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs 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 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp 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 10mg5ml 20mg5ml 25mg5ml 5mg5ml
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 SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TARPEYO CPDR NDS triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
danazol caps 50mg 100mg 200mg MO
Drug Name RequirementsLimits
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 405mg25gm 10mgact
MO
testosterone soln 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 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 enpresse-28 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 2022 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
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 jasmiel tabs MO JOLIVETTE 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
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
Drug Name RequirementsLimits
levora 01530 (28) 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 24 fe tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA 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 nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO nylia 135 tabs MO nylia 777 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 44 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 taysofy caps 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 wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135 (28) tabs MO
Drug Name RequirementsLimits
DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
AFREZZA POWD 90x8 UNIT amp 90x12 UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD 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 glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO HUMALOG KWIKPEN SOPN MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
JARDIANCE TABS 10mg 25mg MO KORLYM TABS LDNDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO metformin hcl er tb24 500mg 750mg 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 2022 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
OZEMPIC (2 MGDOSE) SOPN MO pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO tolazamide tabs 250mg 500mg MO tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
depo-estradiol oil dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
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 MO
Drug Name RequirementsLimits
006mg24hr 0075mg24hr 01mg24hr estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO fyavolv tabs MO jinteli tabs MO lopreeza tabs MO lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO prefest tabs MO PREMARIN SOLR raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PANDS CORTROPHIN GEL PANDS desmopressin ace spray refrig soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln desmopressin acetate tabs 01mg 02mg MO
SKYTROFA CART 3mg 36mg 43mg 52mg 63mg 76mg 91mg 11mg 133mg
NDS
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO 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 progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR NDS
Drug Name RequirementsLimits
EGRIFTA SV SOLR NDS GENOTROPIN CART 12mg PANDS GENOTROPIN MINIQUICK PRSY 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
HUMATROPE CART 6mg 12mg 24mg PANDS
HUMATROPE SOLR PANDS INCRELEX SOLN NDS LANREOTIDE ACETATE SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
octreotide acetate soln 50mcgml 100mcgml 200mcgml
octreotide acetate soln 500mcgml 1000mcgml
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 60mg02ml 90mg03ml 120mg05ml
NDS
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 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 2022 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 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 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
Drug Name RequirementsLimits
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 BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 70mg MO alendronate sodium tabs 5mg 10mg 35mg 40mg MO
EVENITY SOSY NDS IBANDRONATE SODIUM SOLN ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr 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 CIBINQO TABS 50mg 100mg 200mg NDS
CIMZIA KIT PANDS CIMZIA PREFILLED PSKT PANDS CIMZIA STARTER KIT PSKT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
INFLIXIMAB SOLR INTRAVENOUS HI
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 RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 15mg 30mg 45mg NDS
SIMPONI ARIA SOLN NDS
Drug Name RequirementsLimits
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 ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
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
ZORTRESS TABS PA MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BERINERT KIT INTRAVENOUS HI betaine powd NDS 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
Drug Name RequirementsLimits
CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENJAYMO SOLN 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 HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ONPATTRO SOLN NDS 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
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 PYRUKYND TABS 5mg 20mg 50mg NDS
PYRUKYND TAPER PACK TBPK NDS
RECORLEV TABS NDS REZUROCK TABS NDS
Drug Name RequirementsLimits
RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln 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 STERILE WATER FOR IRRIGATION SOLN
TAKHZYRO SOLN NDS TAKHZYRO SOSY NDS TAVNEOS CAPS NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR NDS tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VIJOICE TBPK NDS VILTEPSO SOLN NDS VOXZOGO SOLR 04mg 056mg 12mg NDS
VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS VYVGART SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg 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 2022 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 100mg067ml 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 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 ADVAIR HFA AERO 230-21mcgact MO
ADVAIR HFA AERO 45-21mcgact 115-21mcgact MO
Drug Name RequirementsLimits
ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS HI
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
DALIRESP TABS 250mcg 500mcg MO
FLOVENT HFA AERO MO fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PULMICORT FLEXHALER AEPB
SYMBICORT AERO TEZSPIRE SOSY NDS wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg 1000mcg 1200mcg 1400mcg 1600mcg
NDS
UPTRAVI TBPK NDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS HI
GAMUNEX-C SOLN INJECTION HI HYPERHEP B SOLN HYPERHEP B SOSY HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 1gm20ml 2gm20ml
HI
PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
VARIZIG SOLN TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP KINRIX SUSY QUADRACEL SUSP TDVAX SUSP
Drug Name RequirementsLimits
TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP BOOSTRIX SUSY 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 SOLN MENQUADFI SOLN MENVEO SOLR PEDIARIX SUSY PEDVAX HIB SUSP PENTACEL SUSR PREHEVBRIO SUSP PA PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TICOVAC SUSY TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN TYPHIM VI SOSY VAQTA SUSP VARIVAX INJ
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 2022 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint 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 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 clindamycin phosphate soln MO clindamycin phosphate swab MO clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn econazole nitrate crea ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA
Drug Name RequirementsLimits
gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham mafenide acetate pack malathion lotn metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea mupirocin oint naftifine hcl crea naftifine hcl gel neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ovide lotn oxiconazole nitrate crea permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 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
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
Drug Name RequirementsLimits
clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT 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 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
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO FLURANDRENOLIDE CREA 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 2022 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
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 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 prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO
Drug Name RequirementsLimits
psorcon crea MO RADIAURA CREA NDS texacort soln MO topicort crea 005 025 MO topicort gel MO topicort oint 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 VANOXIDE-HC LOTN WYNZORA CREA NDS ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
HYDROCORTISONE ACE-PRAMOXINE SUPP NDS
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 LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS 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
TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS 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
Drug Name RequirementsLimits
adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ADBRY SOSY NDS ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
azelaic acid gel MO AZELEX CREA MO 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
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA 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 KORSUVA SOLN NDS LACTIC ACID LOTN
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 2022 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
OPZELURA CREA 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 SHAM SALICYLIC ACID-CLEANSER KIT
SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SKYRIZI PEN SOAJ SKYRIZI SOSY STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
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 TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS
Drug Name RequirementsLimits
VECTICAL OINT MO XUREA CREA zenatane caps 10mg 20mg 30mg 40mg NDS
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 calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS
58 bull Kaiser Permanente 2018 Defined Standard Comprehensive Formulary
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 59
Index of Drugs
A abacavir sulfate soln 11 abacavir sulfate tabs 11 abacavir sulfate-lamivudine tabs 11 abacavir-lamivudine-zidovudine tabs 11 ABILIFY MAINTENA PRSY 300mg 400mg
32 ABILIFY MAINTENA SRER 300mg 400mg
32 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
abiraterone acetate tabs 250mg 14 abiraterone acetate tabs 500mg 14 ABRAXANE SUSR 14 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 56 acamprosate calcium tbec 25 acarbose tabs 25mg 50mg 100mg 44 accutane caps 10mg 20mg 30mg 40mg 56 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 26 acetaminophen-codeine soln 26 acetaminophen-codeine tabs 26 acetazolamide er cp12 39 acetazolamide sodium solr 39 acetazolamide tabs 125mg 250mg 39 ACETIC ACID SOLN 39 49 acetylcysteine soln 10 20 47 acitretin caps 10mg 175mg 25mg 56 ACTEMRA ACTPEN SOAJ 47 ACTEMRA SOSY 47 ACTHAR GEL 46 ACTHIB SOLR 52 ACTIMMUNE SOLN 49 acyclovir caps 11 acyclovir oint 53 acyclovir sodium soln intravenous 11 acyclovir susp 11
acyclovir tabs 400mg 800mg 11 ADACEL SUSP 52 ADAGEN SOLN 37 ADAKVEO SOLN 20 ADAPALENE CREA 56 adapalene gel 01 03 56 adapalene pads 56 adapalene soln 56 adapalene-benzoyl peroxide gel 56 ADAPALENE-BENZOYL PEROXIDE PADS
56 ADBRY SOSY 56 adderall tabs 28 adefovir dipivoxil tabs 11 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 51 adenosine soln 24 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 230-21mcgact 51 ADVAIR HFA AERO 45-21mcgact 115-
21mcgact 51 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 14 AFREZZA POWD 90x8 UNIT amp 90x12 UNIT
44 AJOVY SOAJ 30 AJOVY SOSY 30 ala-cort crea 1 25 54 albendazole tabs 8 albuterol sulfate er tb12 4mg 8mg 20 ALBUTEROL SULFATE HFA AERS
108mcgact 20 albuterol sulfate nebu 0083
25mg05ml 063mg3ml 125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 54 alclometasone dipropionate oint 54 ALCOHOL PREP PADS 35 ALDURAZYME SOLN 37 ALECENSA CAPS 14
60 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
alendronate sodium soln 47 alendronate sodium tabs 5mg 10mg
35mg 40mg 47 alendronate sodium tabs 70mg 47 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 41 ALKINDI SPRINKLE CPSP 1mg 2mg 5mg
41 allopurinol sodium solr 47 allopurinol tabs 100mg 300mg 47 allzital tabs 26 almotriptan malate tabs 30 alogliptin benzoate tabs 625mg 125mg
25mg 44 ALOGLIPTIN-METFORMIN HCL TABS 44 alogliptin-pioglitazone tabs 44 ALOSETRON HCL TABS 05mg 1mg 40 alprazolam er tb24 05mg 1mg 2mg 3mg
31 alprazolam intensol conc 31 alprazolam tabs 025mg 05mg 1mg 2mg
31 alprazolam tbdp 025mg 05mg 1mg 2mg
31 ALTACAINE SOLN 39 ALTAFRIN SOLN 39 altavera tabs 42 ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 51 alyacen 135 tabs 42 alyq tabs 25 amabelz tabs 45 amantadine hcl caps 30 amantadine hcl soln 30 amantadine hcl tabs 30 AMBISOME SUSR INTRAVENOUS 10 ambrisentan tabs 51 amcinonide crea 54 amcinonide lotn 54 amcinonide oint 54 amethia lo tabs 42 amethia tabs 42 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 36
amiloride-hydrochlorothiazide tabs 36 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 57 amiodarone hcl soln 24 amiodarone hcl tabs 100mg 200mg
400mg 24 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 33 amlodipine besy-benazepril hcl caps 23 amlodipine besylate tabs 25mg 5mg
10mg 23 amlodipine besylate-valsartan tabs 23 amlodipine-atorvastatin tabs 23 amlodipine-olmesartan tabs 23 amlodipine-valsartan-hctz tabs 23 ammonium lactate crea 56 ammonium lactate lotn 56 amnesteem caps 10mg 20mg 40mg 56 AMONDYS 45 SOLN 49 amoxapine tabs 25mg 50mg 100mg
150mg 33 amoxicill-clarithro-lansopraz misc 40 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8 amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 28 amphetamine sulfate tabs 5mg 10mg 28 amphetamine-dextroamphet er cp24 28 amphetamine-dextroamphetamine tabs 28 amphotericin b solr intravenous 10 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 42 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 55 anastrozole tabs 14
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 61
ANDRODERM PT24 2mg24hr 4mg24hr 42
antabuse tabs 250mg 500mg 25 anusol-hc crea 54 apap-caff-dihydrocodeine tabs 26 apexicon e crea 54 APLENZIN TB24 174mg 348mg 522mg 33 APOKYN SOCT 30 apomorphine hcl soct 30 apraclonidine hcl soln 39 aprepitant caps 40 APRETUDE SUER 11 apri tabs 42 APTIOM TABS 200mg 400mg 600mg
800mg 28 APTIVUS CAPS 11 APTIVUS SOLN 11 ARALAST NP SOLR INTRAVENOUS 51 aranelle tabs 42 ARANESP (ALBUMIN FREE) SOLN
60mcgml 100mcgml 200mcgml 21 ARANESP (ALBUMIN FREE) SOSY
60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 21
ARCALYST SOLR 49 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 49 ARIKAYCE SUSP 8 aripiprazole soln 33 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 33 aripiprazole tbdp 10mg 15mg 33 ARISTADA INITIO PRSY 33 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 33
armodafinil tabs 50mg 150mg 200mg 250mg 28
arsenic trioxide soln 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 49 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 52 ascomp-codeine caps 26 asenapine maleate subl 25mg 5mg 10mg
33
ashlyna tabs 42 ASMANEX HFA AERO 100mcgact
200mcgact 51 ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 48 ASTAGRAF XL CP24 05mg 1mg 48 atazanavir sulfate caps 150mg 200mg
300mg 11 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 31 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 22 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 39 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 32 aubra eq tabs 42 AUGMENTIN SUSR 8 AURYXIA TABS 36 AUSTEDO TABS 6mg 9mg 12mg 31 AVASTIN SOLN 14 AVC VAGINAL CREA 53 aviane tabs 42 AVITA CREA 56 AVITA GEL 56 AVONEX KIT 32 AVONEX PEN AJKT 32 AVONEX PREFILLED PSKT 32 AVSOLA SOLR 47 aygestin tabs 46 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 48 azathioprine sodium solr 48 azathioprine tabs 48 azelaic acid gel 56 azelastine hcl soln 005 01 015 39 azelastine-fluticasone susp 39 AZELEX CREA 56 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
62 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
B bacitracin oint 38 bacitracin solr 8 bacitracin-polymyxin b oint 38 bacitra-neomycin-polymyxin-hc oint 38 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 53 BAFIERTAM CPDR 32 balsalazide disodium caps 40 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 42 BANZEL SUSP 28 BANZEL TABS 200mg 400mg 28 BAQSIMI ONE PACK POWD 44 BAQSIMI TWO PACK POWD 44 BARACLUDE SOLN 11 BAVENCIO SOLN 14 BCG VACCINE SOLR 14 BD INSULIN SYR ULTRAFINE II MISC 35 BD INSULIN SYRINGE MISC 35 BD INSULIN SYRINGE UF MISC 35 BD PEN NEEDLE ORIGINAL UF MISC 35 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 32 BELEODAQ SOLR 14 BELRAPZO SOLN 14 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 14 BENDEKA SOLN 14 BENLYSTA SOAJ 48 BENLYSTA SOLR 48 BENLYSTA SOSY 48 BENZEPRO CREAMY WASH LIQD 53 BENZEPRO FOAMING CLOTHS MISC 53 benzhydrocodone-acetaminophen tabs 26 benzoyl perox-hydrocortisone lotn 54 BENZOYL PEROXIDE FORTE- HC LOTN
54 BENZOYL PEROXIDE GEL 53 benzoyl peroxide-erythromycin gel 53 benztropine mesylate soln 30 benztropine mesylate tabs 05mg 1mg
2mg 30 BEOVU SOLN 39 bepotastine besilate soln 39
BERINERT KIT INTRAVENOUS 49 beser lotn 54 BESPONSA SOLR 14 BESREMI SOSY 14 betaine powd 49 betamethasone dipropionate aug crea 54 betamethasone dipropionate aug gel 54 betamethasone dipropionate aug lotn 54 betamethasone dipropionate aug oint 54 betamethasone dipropionate crea 54 betamethasone dipropionate lotn 54 BETAMETHASONE DIPROPIONATE OINT
54 betamethasone sod phos amp acet susp 41 betamethasone valerate crea 54 betamethasone valerate foam 54 BETAMETHASONE VALERATE LOTN 54 BETAMETHASONE VALERATE OINT 54 BETASERON KIT 32 betaxolol hcl soln 39 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 19 bexarotene caps 14 BEXSERO SUSY 52 bicalutamide tabs 14 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICILLIN L-A SUSY 8 BIKTARVY TABS 11 bimatoprost soln 39 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23 bleomycin sulfate solr 14 bleph-10 soln 38 blephamide sop oint 38 BLEPHAMIDE SUSP 38 BLINCYTO SOLR 14 blisovi 24 fe tabs 42 blisovi fe 1530 tabs 42 BOOSTRIX SUSP 52 BOOSTRIX SUSY 52 BORTEZOMIB SOLR 14 bosentan tabs 51 BOSULIF TABS 100mg 400mg 500mg 14 BRAFTOVI CAPS 50mg 75mg 14 briellyn tabs 42 BRILINTA TABS 60mg 90mg 21
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 63
brimonidine tartrate soln 015 02 39 brinzolamide susp 39 BRIVIACT SOLN 28 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 28 bromfenac sodium (once-daily) soln 38 bromocriptine mesylate caps 30 bromocriptine mesylate tabs 30 BRONCHITOL CAPS 51 BROVANA NEBU 20 BRUKINSA CAPS 14 budesonide cpep 41 budesonide er tb24 41 budesonide susp 025mg2ml 05mg2ml
1mg2ml 51 bumetanide soln 36 bumetanide tabs 05mg 1mg 2mg 36 bupap tabs 26 bupivacaine hcl (pf) soln 49 bupivacaine hcl soln 49 BUPIVACAINE IN DEXTROSE SOLN 49 bupivacaine spinal soln 49 bupivacaine-epinephrine (pf) soln 49 bupivacaine-epinephrine soln 49 buprenorphine hcl subl 2mg 8mg 32 buprenorphine hcl-naloxone hcl film 32 buprenorphine hcl-naloxone hcl subl 32 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 32 bupropion hcl er (smoking det) tb12 33 bupropion hcl er (sr) tb12 100mg 150mg
200mg 33 bupropion hcl er (xl) tb24 150mg 300mg
450mg 33 bupropion hcl tabs 75mg 100mg 33 buspirone hcl tabs 5mg 10mg 31 buspirone hcl tabs 75mg 15mg 30mg 31 busulfan soln 14 butalbital-acetaminophen tabs 26 butalbital-apap-caff-cod caps 26 butalbital-apap-caffeine caps 26 butalbital-apap-caffeine tabs 26 butalbital-asa-caff-codeine caps 26 butalbital-aspirin-caffeine caps 26 butalbital-aspirin-caffeine tabs 26 butorphanol tartrate soln 26 BYLVAY (PELLETS) CPSP 200mcg
600mcg 41 BYLVAY CAPS 400mcg 1200mcg 41
C CABENUVA SUER 11 cabergoline tabs 30 CABLIVI KIT 21 CABOMETYX TABS 20mg 40mg 60mg 14 cafergot tabs 30 caffeine citrate soln 28 calcipotriene crea 56 calcipotriene oint 56 calcipotriene soln 56 calcipotriene-betameth diprop oint 54 calcipotriene-betameth diprop susp 54 calcitonin (salmon) soln 45 calcitrene oint 56 calcitriol caps 025mcg 05mcg 57 CALCITRIOL OINT 56 calcitriol soln 57 calcium acetate (phos binder) caps 37 calcium acetate tabs 37 CALCIUM GLUCONATE-NACL SOLN 37 CALQUENCE CAPS 14 CAMCEVI PRSY 14 camila tabs 42 camrese lo tabs 42 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 54 CAPLYTA CAPS 33 CAPRELSA TABS 100mg 300mg 14 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 25 CARAC CREA 56 carbamazepine chew 28 carbamazepine er cp12 100mg 200mg
300mg 28 carbamazepine er tb12 100mg 200mg
400mg 28 carbamazepine susp 28 carbamazepine tabs 28 carbidopa tabs 30 carbidopa-levodopa er tbcr 30 carbidopa-levodopa tabs 30 carbidopa-levodopa tbdp 30 carbidopa-levodopa-entacapone tabs 30 carbinoxamine maleate soln 13
64 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
carbinoxamine maleate tabs 13 carboplatin soln 14 carboprost tromethamine soln 45 CARDENE IV SOLN 23 carglumic acid tbso 35 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 14 CARNITOR SOLN 49 CARNITOR TABS 49 carteolol hcl soln 39 cartia xt cp24 120mg 180mg 240mg
300mg 23 carvedilol phosphate er cp24 10mg 20mg
40mg 80mg 23 carvedilol tabs 3125mg 625mg 125mg
25mg 23 caspofungin acetate solr intravenous 50mg
70mg 10 CAYSTON SOLR 51 caziant tabs 42 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 intravenous 1gm 2gm
10gm 8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 6gm 8 ceftazidime solr intravenous 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 750mg 8 cefuroxime sodium solr intravenous 15gm 8 celecoxib caps 26 CELONTIN CAPS 29 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 38 CERDELGA CAPS 37 CEREZYME SOLR 37 CEROVEL LOTN 56 cetirizine hcl soln 13 CEVIMELINE HCL CAPS 19 CHANTIX CONTINUING MONTH PAK
TABS 19 CHANTIX STARTING MONTH PAK TABS
19 CHANTIX TABS 05mg 1mg 19 CHEMET CAPS 41 chloramphenicol sod succinate solr 8 chlordiazepoxide hcl caps 5mg 10mg
25mg 31 chlordiazepoxide-amitriptyline tabs 33 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 38 chloroprocaine hcl (pf) soln 49 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 36 chlorothiazide tabs 250mg 500mg 36 chlorpromazine hcl conc 30mgml
100mgml 33 chlorpromazine hcl soln 33 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 33 chlorthalidone tabs 25mg 50mg 36 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 41 cholestyramine light pack 22 cholestyramine light powd 22 cholestyramine pack 22 cholestyramine powd 22 CHORIONIC GONADOTROPIN SOLR 45 CIBINQO TABS 50mg 100mg 200mg 47 ciclopirox gel 53 ciclopirox olamine crea 53
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 65
ciclopirox olamine susp 53 ciclopirox sham 53 ciclopirox soln 53 cidofovir soln 11 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 38 CIMDUO TABS 11 cimetidine hcl soln 40 cimetidine tabs 200mg 300mg 400mg
800mg 40 CIMZIA KIT 47 CIMZIA PREFILLED PSKT 47 CIMZIA STARTER KIT PSKT 47 cinacalcet hcl tabs 30mg 60mg 90mg 45 CINQAIR SOLN 51 CINRYZE SOLR INTRAVENOUS 49 CIPRODEX SUSP 38 ciprofloxacin hcl soln (ophth) 38 CIPROFLOXACIN HCL SOLN (OTIC) 38 ciprofloxacin hcl tabs 8 ciprofloxacin in d5w soln 8 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 38 cisplatin soln 14 CISPLATIN SOLR 50mg 14 CITALOPRAM HYDROBROMIDE CAPS 33 citalopram hydrobromide soln 33 citalopram hydrobromide tabs 10mg 20mg
40mg 33 citanest plain dental soln 49 cladribine soln 14 claravis caps 10mg 20mg 30mg 40mg 56 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 13 cleocin phosphate soln 9 cleocin solr 9 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
clindacin-p swab 53 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 53 clindamycin phosphate crea 53
clindamycin phosphate foam 53 clindamycin phosphate gel 53 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 53 clindamycin phosphate soln 9 53 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 53 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 36 clinisol sf soln intravenous 36 clobazam susp 29 clobazam tabs 10mg 20mg 29 clobetasol propionate crea 54 clobetasol propionate e crea 54 clobetasol propionate emulsion foam 54 clobetasol propionate foam 54 clobetasol propionate gel 54 clobetasol propionate liqd 54 clobetasol propionate lotn 54 clobetasol propionate oint 54 clobetasol propionate sham 54 clobetasol propionate soln 54 clocortolone pivalate crea 54 clocortolone pivalate pump crea 54 clofarabine soln 14 clomipramine hcl caps 25mg 50mg 75mg
33 clonazepam tabs 05mg 1mg 2mg 29 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 29 clonidine hcl (analgesia) soln 24
66 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
clonidine hcl er tb12 24 clonidine hcl tabs 01mg 02mg 03mg 24 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 24 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 31 clotrimazole crea 53 clotrimazole soln 53 clotrimazole troc 53 clotrimazole-betamethasone crea 53 clotrimazole-betamethasone lotn 53 clovique caps 41 clozapine tabs 25mg 50mg 100mg 200mg
33 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 33 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 26 colazal caps 40 COLCHICINE CAPS 47 colchicine tabs 47 colchicine-probenecid tabs 37 COLESEVELAM HCL PACK 22 colesevelam hcl tabs 22 colestipol hcl gran 22 colestipol hcl pack 22 colestipol hcl tabs 22 colistimethate sodium (cba) solr injection 9 colocort enem 54 COLY-MYCIN S SUSP 38 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 14 COMETRIQ (140 MG DAILY DOSE) KIT 14 COMETRIQ (60 MG DAILY DOSE) KIT 14 COMPLERA TABS 11 compro supp 33 CONSENSI TABS 23 constulose soln 35 COPIKTRA CAPS 15mg 25mg 14 CORDRAN TAPE 54 CORLANOR SOLN 24 CORLANOR TABS 5mg 75mg 24 cortisone acetate tabs 41 CORTISPORIN CREA 54 CORTISPORIN OINT 54 CORTROPHIN GEL 46 COSELA SOLR 49
COSENTYX (300 MG DOSE) SOSY 56 COSENTYX SENSOREADY (300 MG)
SOAJ 56 COSENTYX SENSOREADY PEN SOAJ 56 COSENTYX SOSY 75mg05ml 150mgml
56 COTELLIC TABS 14 CREON CPEP 37 CRESEMBA CAPS 10 CRESEMBA SOLR 10 CRIXIVAN CAPS 200mg 400mg 11 cromolyn sodium conc 51 cromolyn sodium nebu 51 cromolyn sodium soln 39 crotan lotn 53 cryselle-28 tabs 42 CRYSVITA SOLN 10mgml 20mgml
30mgml 49 CURITY GAUZE PADS 35 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 52
cyclafem 135 tabs 42 cyclafem 777 tabs 42 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 14 CYCLOPHOSPHAMIDE SOLN 2gm10ml
1gm5ml 500mg25ml 15 cyclophosphamide solr 15 cycloserine caps 11 cyclosporine caps 25mg 100mg 48 cyclosporine emul 38 cyclosporine modified caps 25mg 50mg
100mg 48 cyclosporine modified soln 48 cyclosporine soln 48 cyproheptadine hcl syrp 13 cyproheptadine hcl tabs 13 CYRAMZA SOLN 100mg10ml
500mg50ml 15 CYSTADANE POWD 49 CYSTADROPS SOLN 39 CYSTAGON CAPS 50mg 150mg 49 CYSTARAN SOLN 39 cytarabine (pf) soln 15 cytarabine soln 15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 67
CYTOGAM INJ 52
D dacarbazine solr 15 dactinomycin solr 15 dalfampridine er tb12 32 DALIRESP TABS 250mcg 500mcg 51 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 42 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 56 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 52 daptomycin solr intravenous 350mg 500mg
9 darifenacin hydrobromide er tb24 75mg
15mg 57 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 deblitane tabs 42 decadron tabs 5mg 75mg 41 decadron tabs 4mg 6mg 41 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 41 deferasirox tabs 41 deferasirox tbso 41 deferiprone tabs 500mg 1000mg 41 deferoxamine mesylate solr 41 DELSTRIGO TABS 11 deltasone tabs 41 delyla tabs 42 demeclocycline hcl tabs 9 DEMSER CAPS 22 depo-estradiol oil 45 DEPO-MEDROL SUSP 41 DEPO-PROVERA SUSP 400mgml 46 DEPO-SUBQ PROVERA 104 SUSY 46 depo-testosterone soln 100mgml
200mgml 42 DERMOTIC OIL 38 DESCOVY TABS 120-15mg 11 DESCOVY TABS 200-25mg 11
desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg 33
desloratadine tabs 13 desloratadine tbdp 13 desmopressin ace spray refrig soln 46 DESMOPRESSIN ACETATE SOLN 46 desmopressin acetate spray soln 46 desmopressin acetate tabs 01mg 02mg 46 desogestrel-ethinyl estradiol tabs 42 desonide crea 54 desonide gel 54 desonide lotn 54 desonide oint 54 desowen lotn 54 desoximetasone crea 005 025 54 desoximetasone gel 54 desoximetasone liqd 54 desoximetasone oint 005 025 54 desrx gel 54 DESVENLAFAXINE ER TB24 50mg
100mg 33 desvenlafaxine succinate er tb24 25mg
50mg 100mg 33 dexabliss tbpk 41 dexamethasone elix 41 dexamethasone intensol conc 41 dexamethasone sodium phosphate soln 38
41 dexamethasone soln 41 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 41 dexamethasone tbpk 41 dexchlorpheniramine maleate soln 13 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 28
dexmethylphenidate hcl tabs 25mg 5mg 10mg 28
dexpak 10 day tbpk 41 dexpak 13 day tbpk 41 dexpak 6 day tbpk 41 dexrazoxane hcl solr 49 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 28 dextroamphetamine sulfate soln 28 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 28 DEXTROSE IN LACTATED RINGERS
SOLN 37
68 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
DEXTROSE SOLN 36 DEXTROSE SOLN INTRAVENOUS 5
10 36 DEXTROSE-NACL SOLN INTRAVENOUS
10-02 10-045 37 DEXTROSE-NACL SOLN INTRAVENOUS
25-045 5-02 5-045 5-09 37 DIACOMIT CAPS 250mg 500mg 29 DIACOMIT PACK 250mg 500mg 29 DIASTAT ACUDIAL GEL 10mg 20mg 29 DIASTAT PEDIATRIC GEL 29 diazepam conc 31 diazepam gel 25mg 10mg 20mg 29 diazepam intensol conc 31 diazepam soln 5mg5ml 5mgml 31 diazepam tabs 2mg 5mg 10mg 31 diazoxide susp 44 diclofenac sodium er tb24 26 diclofenac sodium gel 1 3 54 diclofenac sodium soln 38 diclofenac sodium tbec 26 diclofenac-misoprostol tbec 26 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 11 DIFFERIN CREA 56 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 54 diflorasone diacetate oint 54 diflunisal tabs 26 difluprednate emul 38 digitek tabs 0125mg 025mg 24 digox tabs 24 digoxin soln 24 digoxin tabs 125mcg 250mcg 24 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 29 dilantin infatabs chew 29 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 23 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 23
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 23
diltiazem hcl er cp12 60mg 90mg 120mg 23
diltiazem hcl er cp24 120mg 180mg 240mg 23
diltiazem hcl soln 23 diltiazem hcl solr 23 diltiazem hcl tabs 30mg 60mg 90mg
120mg 23 dilt-xr cp24 120mg 180mg 240mg 23 dimenhydrinate soln 40 dimethyl fumarate cpdr 32 dimethyl fumarate starter pack misc 32 DIPENTUM CAPS 40 diphen elix 13 di-phen elix 13 diphenhydramine hcl elix 13 diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 40 diphenoxylate-atropine tabs 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 52 dipyridamole tabs 25mg 50mg 75mg 25 disopyramide phosphate caps 100mg
150mg 24 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 36 divalproex sodium csdr 29 divalproex sodium er tb24 250mg 500mg29 divalproex sodium tbec 125mg 250mg
500mg 29 dobutamine hcl soln 20 DOBUTAMINE IN D5W SOLN 20 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
24 dolishale tabs 42 donepezil hcl tabs 5mg 10mg 23mg 19 donepezil hcl tbdp 5mg 10mg 19 dopamine hcl soln 20 DOPAMINE IN D5W SOLN 20 DOPTELET TABS 21 dorzolamide hcl soln 39 dorzolamide hcl-timolol mal pf soln 39 dorzolamide hcl-timolol mal soln 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 69
dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 33 doxepin hcl conc 33 doxepin hcl crea 55 doxepin hcl tabs 3mg 6mg 33 doxercalciferol caps 05mcg 1mcg 25mcg
57 DOXERCALCIFEROL SOLN 57 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
150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 40 DRIZALMA SPRINKLE CSDR 33 dronabinol caps 25mg 5mg 10mg 40 droperidol soln 31 drospiren-eth estrad-levomefol tabs 42 drospirenone-ethinyl estradiol tabs 42 DROXIA CAPS 15 droxidopa caps 20 DUAKLIR PRESSAIR AEPB 19 DUEXIS TABS 26 duloxetine hcl cpep 20mg 30mg 40mg
60mg 33 DUPIXENT SOPN 200mg114ml
300mg2ml 51 DUPIXENT SOSY 100mg067ml
200mg114ml 300mg2ml 51 DURYSTA IMPL 39 dutasteride caps 47 dutasteride-tamsulosin hcl caps 47 dvorah tabs 26 dxevo 11-day tbpk 41
E ees 400 tabs 9 EASYGEL GEL 49 econazole nitrate crea 53 EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 46 EGRIFTA SV SOLR 46 ELAPRASE SOLN 37 ELELYSO SOLR 37 ELEPSIA XR TB24 1000mg 1500mg 29 eletriptan hydrobromide tabs 30 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 37 elixophyllin elix 57 ELLA TABS 42 ELLENCE SOLN 15 ELMIRON CAPS 49 eluryng ring 42 ELZONRIS SOLN 15 EMCYT CAPS 15 EMFLAZA SUSP 42 EMFLAZA TABS 6mg 18mg 30mg 36mg
42 EMPAVELI SOLN 49 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 30 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 25 enalaprilat inj 25 enalapril-hydrochlorothiazide tabs 25 ENBREL MINI SOCT 47 ENBREL SOLN 47 ENBREL SOLR 47 ENBREL SOSY 25mg05ml 50mgml 48 ENBREL SURECLICK SOAJ 48 ENDARI PACK 49 endocet tabs 26 ENDOMETRIN INST 46
70 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ENGERIX-B SUSP 10mcg05ml 20mcgml 52
ENHERTU SOLR 15 ENJAYMO SOLN 49 enoxaparin sodium soln 21 enoxaparin sodium sosy 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
enpresse-28 tabs 42 ENSPRYNG SOSY 49 ENSTILAR FOAM 54 entacapone tabs 30 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 25 ENTYVIO SOLR 41 enulose soln 35 ENVARSUS XR TB24 075mg 1mg 4mg48 EPCLUSA PACK 12 EPCLUSA TABS 12 EPIDIOLEX SOLN 29 epifoam foam 54 epinastine hcl soln 39 epinephrine (anaphylaxis) soln 20 epinephrine soaj 20 EPINEPHRINE SOSY 20 epirubicin hcl soln 15 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 25 EPOGEN SOLN 21 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 21 epoprostenol sodium solr 51 EPRONTIA SOLN 29 eprosartan mesylate tabs 25 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 33 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 30 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 43 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 53 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 53 erythromycin oint 38 erythromycin pads 53 erythromycin soln 53 erythromycin tbec 9 ESBRIET CAPS 51 ESBRIET TABS 267mg 801mg 51 escitalopram oxalate soln 33 escitalopram oxalate tabs 5mg 10mg
20mg 33 esgic caps 26 esgic tabs 26 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 40 esomeprazole magnesium pack 10mg
20mg 40mg 40 esomeprazole sodium solr 40 estarylla tabs 43 estazolam tabs 1mg 2mg 31 estrace crea 45 estrace tabs 05mg 1mg 2mg 45 estradiol crea 45 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
estradiol tabs 10mcg 05mg 1mg 2mg 45 estradiol valerate oil 45 estradiol-norethindrone acet tabs 45 ESTRING RING 45 eszopiclone tabs 1mg 2mg 3mg 31 ethacrynic acid tabs 36 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 29 ethosuximide soln 29 ethynodiol diac-eth estradiol tabs 43 etodolac caps 26
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 71
etodolac er tb24 26 etodolac tabs 26 etonogestrel-ethinyl estradiol ring 43 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 eulexin caps 15 EURAX CREA 53 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 46
evekeo tabs 5mg 10mg 28 EVENITY SOSY 47 everolimus tabs 025mg 48 everolimus tabs 05mg 075mg 1mg 48 everolimus tabs 25mg 5mg 75mg 10mg
15 everolimus tbso 2mg 3mg 5mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 22 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 49 exemestane tabs 15 EXKIVITY CAPS 15 EXONDYS 51 SOLN 500mg10ml
100mg2ml 49 EXSERVAN FILM 31 EXTAVIA KIT 32 EYLEA SOLN 39 EYLEA SOSY 39 ezetimibe tabs 22 ezetimibe-simvastatin tabs 22
F FABRAZYME SOLR 5mg 35mg 37 falmina tabs 43 famciclovir tabs 125mg 250mg 500mg 12 famotidine (pf) soln 40 famotidine premixed soln 40 famotidine soln 40 famotidine susr 40 famotidine tabs 20mg 40mg 40 FANAPT TABS 1mg 2mg 4mg 6mg 8mg
10mg 12mg 33 FANAPT TITRATION PACK TABS 33 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 51 FASENRA SOSY 51
fayosim tabs 43 febuxostat tabs 40mg 80mg 47 felbamate susp 29 felbamate tabs 400mg 600mg 29 felodipine er tb24 25mg 5mg 10mg 23 femynor tabs 43 fenofibrate caps 50mg 150mg 22 fenofibrate micronized caps 43mg 67mg
130mg 134mg 200mg 22 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 22 fenofibric acid cpdr 45mg 135mg 22 fenoprofen calcium caps 26 fenoprofen calcium tabs 26 fenortho caps 26 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 26 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 26
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 26
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 26
FERRIPROX SOLN 41 FERRIPROX TABS 41 FERRIPROX TWICE-A-DAY TABS 41 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
33 FETZIMA TITRATION C4PK 33 fexmid tabs 20 finasteride tabs 47 FINTEPLA SOLN 29 fioricet caps 26 fioricetcodeine caps 26 FIRDAPSE TABS 49 FIRMAGON (240 MG DOSE) SOLR 15 FIRMAGON SOLR 15 flac oil 38 flavoxate hcl tabs 57 FLEBOGAMMA DIF SOLN INTRAVENOUS
52 flecainide acetate tabs 50mg 100mg
150mg 24 FLEQSUVY SUSP 20 FLOVENT HFA AERO 51 floxuridine solr 15
72 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
fluconazole in sodium chloride soln intravenous 10
fluconazole susr 10 fluconazole tabs 10 flucytosine caps 250mg 500mg 10 fludarabine phosphate soln 15 fludarabine phosphate solr 15 fludrocortisone acetate tabs 42 flumazenil soln 31 flunisolide soln 38 fluocinolone acetonide body oil 54 fluocinolone acetonide crea 001 0025
54 fluocinolone acetonide oil 38 fluocinolone acetonide oint 54 fluocinolone acetonide scalp oil 54 fluocinolone acetonide soln 54 fluocinonide crea 54 fluocinonide emulsified base crea 54 FLUOCINONIDE GEL 54 fluocinonide oint 54 fluocinonide soln 54 FLUORITAB CHEW 025mg 05mg 1mg 49 FLUORITAB SOLN 49 fluorometholone susp 38 fluorouracil crea 5 56 fluorouracil crea 5 56 fluorouracil soln 15 56 fluorouracil soln 2 5 56 fluoxetine hcl (pmdd) tabs 10mg 20mg 33 fluoxetine hcl caps 10mg 20mg 40mg 33 fluoxetine hcl cpdr 33 fluoxetine hcl soln 33 fluoxetine hcl tabs 10mg 20mg 60mg 33 fluphenazine decanoate soln 33 fluphenazine hcl conc 33 fluphenazine hcl elix 33 fluphenazine hcl soln 33 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 34 FLURANDRENOLIDE CREA 54 flurandrenolide lotn 55 flurandrenolide oint 55 flurazepam hcl caps 15mg 30mg 31 flurbiprofen sodium soln 38 flurbiprofen tabs 26 flutamide caps 15 fluticasone propionate crea 55 fluticasone propionate lotn 55
fluticasone propionate oint 55 fluticasone propionate susp 38 fluticasone-salmeterol aepb 51 fluvastatin sodium caps 20mg 40mg 22 fluvastatin sodium er tb24 22 fluvoxamine maleate er cp24 100mg
150mg 34 fluvoxamine maleate tabs 25mg 50mg
100mg 34 FML FORTE SUSP 38 FML OINT 38 fomepizole soln 47 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 FORTEO SOPN 45 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 40 fosfomycin tromethamine pack 13 fosinopril sodium tabs 10mg 20mg 40mg
25 fosinopril sodium-hctz tabs 25 fosphenytoin sodium soln 29 FOTIVDA CAPS 089mg 134mg 15 FROVATRIPTAN SUCCINATE TABS 30 FULPHILA SOSY 21 fulvestrant soln 15 furosemide soln 8mgml 10mgml 36 furosemide soln injection 36 furosemide tabs 20mg 40mg 80mg 36 FUZEON SOLR 12 FYARRO SUSR 15 fyavolv tabs 45 FYCOMPA SUSP 29 FYCOMPA TABS 29
G gabapentin caps 100mg 400mg 29 gabapentin soln 29 gabapentin tabs 600mg 800mg 29 GALAFOLD CAPS 49 galantamine hydrobromide er cp24 8mg
16mg 24mg 19 galantamine hydrobromide soln 19 galantamine hydrobromide tabs 4mg 8mg
12mg 19 GAMASTAN INJ 52 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 48
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 73
GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm 52
GAMMAGARD SOLN INJECTION 52 GAMMAKED SOLN INJECTION 52 GAMMAPLEX SOLN INTRAVENOUS 52 GAMUNEX-C SOLN INJECTION 52 ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 52 GARDASIL 9 SUSY 52 gatifloxacin soln 38 GATTEX KIT 41 gavilyte-c solr 41 gavilyte-g solr 41 gavilyte-h kit 41 gavilyte-n with flavor pack solr 41 GAVRETO CAPS 15 GAZYVA SOLN 15 gemcitabine hcl soln 15 gemcitabine hcl solr 15 gemfibrozil tabs 22 gemmily caps 43 generlac soln 35 gengraf caps 25mg 50mg 100mg 48 gengraf soln 48 GENOTROPIN CART 12mg 46 GENOTROPIN MINIQUICK PRSY 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 46
gentak oint 38 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 53 gentamicin sulfate oint 53 gentamicin sulfate soln 9 38 gentamicin sulfate soln injection 9 GENVOYA TABS 12 gianvi tabs 43 GILENYA CAPS 025mg 05mg 32 GILOTRIF TABS 20mg 30mg 40mg 15 GIMOTI SOLN 41 GIVLAARI SOLN 49 GLASSIA SOLN INTRAVENOUS 51 glatopa sosy 20mgml 40mgml 32 glimepiride tabs 1mg 2mg 4mg 44 glipizide er tb24 25mg 5mg 10mg 44 glipizide tabs 5mg 10mg 44 glipizide-metformin hcl tabs 44 glucagon emergency kit 44
glyburide micronized tabs 15mg 3mg 6mg 44
glyburide tabs 125mg 25mg 5mg 44 glyburide-metformin tabs 44 glycate tabs 19 glycopyrrolate oral soln 19 glycopyrrolate pf sosy 19 glycopyrrolate soln injection 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 55 granisetron hcl soln 40 granisetron hcl tabs 40 GRANIX SOLN 480mcg16ml 300mcgml
21 GRANIX SOSY 300mcg05ml
480mcg08ml 21 GRASTEK SUBL 49 griseofulvin microsize susp 10 griseofulvin microsize tabs 10 griseofulvin ultramicrosize tabs 10 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 32 guanfacine hcl tabs 1mg 2mg 24 GUANIDINE HCL TABS 19 gynazole-1 crea 53
H HAEGARDA SOLR 2000unit 3000unit 49 hailey 24 fe tabs 43 halcinonide crea 55 halobetasol propionate crea 55 HALOBETASOL PROPIONATE FOAM 55 halobetasol propionate oint 55 haloperidol decanoate soln 34 haloperidol lactate conc 34 haloperidol lactate soln 34 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 34 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 52 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
HEPLISAV-B SOLN 52
74 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
HERCEPTIN HYLECTA SOLN 15 HERCEPTIN SOLR 150mg 440mg 15 HERZUMA SOLR 150mg 420mg 15 HETLIOZ CAPS 31 HETLIOZ LQ SUSP 31 HIBERIX SOLR 52 HUMALOG KWIKPEN SOPN 44 HUMALOG SOCT 44 HUMALOG SOLN 44 humatin caps 11 HUMATROPE CART 6mg 12mg 24mg 46 HUMATROPE SOLR 46 HUMIRA PEDIATRIC CROHNS START
PSKT 48 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 48 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 48 HUMIRA PEN-PEDIATRIC UC START
PNKT 48 HUMIRA PEN-PSUVADOL HS START
PNKT 48 HUMIRA PEN-PSORUVEIT STARTER
PNKT 48 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 48
HUMULIN 7030 KWIKPEN SUPN 44 HUMULIN 7030 SUSP 44 HUMULIN N KWIKPEN SUPN 44 HUMULIN N SUSP 44 HUMULIN R SOLN 44 HUMULIN R U-500 (CONCENTRATED)
SOLN 44 HUMULIN R U-500 KWIKPEN SOPN 44 hydralazine hcl soln 24 hydralazine hcl tabs 10mg 25mg 50mg
100mg 24 hydrochlorothiazide caps 36 hydrochlorothiazide tabs 125mg 25mg
50mg 36 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 26 hydrocodone-acetaminophen soln 26 hydrocodone-acetaminophen tabs 26 hydrocodone-ibuprofen tabs 26 hydrocortisone (perianal) crea 1 25 55 hydrocortisone ace-pramoxine crea 55
HYDROCORTISONE ACE-PRAMOXINE SUPP 55
hydrocortisone butyr lipo base crea 55 hydrocortisone butyrate crea 55 hydrocortisone butyrate lotn 55 HYDROCORTISONE BUTYRATE OINT 55 hydrocortisone butyrate soln 55 hydrocortisone crea 1 25 55 hydrocortisone enem 55 hydrocortisone lotn 55 hydrocortisone oint 1 25 55 hydrocortisone tabs 5mg 10mg 20mg 42 hydrocortisone valerate crea 55 hydrocortisone valerate oint 55 HYDROCORTISONE-ACETIC ACID SOLN
38 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 26 hydromorphone hcl liqd 26 hydromorphone hcl tabs 2mg 4mg 8mg 26 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 46 hydroxyprogesterone caproate soln 46 hydroxyurea caps 15 hydroxyzine hcl soln 31 hydroxyzine hcl syrp 31 hydroxyzine hcl tabs 31 hydroxyzine pamoate caps 31 HYPERHEP B SOLN 52 HYPERHEP B SOSY 52 HYPERRAB SD SOLN 52 HYQVIA KIT 52
I IBANDRONATE SODIUM SOLN 47 ibandronate sodium tabs 47 IBRANCE CAPS 75mg 100mg 125mg 15 IBRANCE TABS 75mg 100mg 125mg 15 IBSRELA TABS 41 ibu tabs 26 ibudone tabs 26 ibuprofen lysine soln 26 ibuprofen susp 26 ibuprofen tabs 26 ibutilide fumarate soln 24 icatibant acetate soln 20 iclevia tabs 43 ICLUSIG TABS 10mg 15mg 30mg 45mg
15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 75
icosapent ethyl caps 22 IDAMYCIN PFS SOLN 15 idarubicin hcl soln 15 IDHIFA TABS 50mg 100mg 15 ifosfamide soln 15 IFOSFAMIDE SOLR 16 ILARIS SOLN 26 ILUMYA SOSY 56 ILUVIEN IMPL 38 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 34 imipramine pamoate caps 75mg 100mg
125mg 150mg 34 imiquimod crea 375 5 56 IMIQUIMOD PUMP CREA 56 IMOGAM RABIES-HT SOLN 52 IMOVAX RABIES INJ 52 IMPAVIDO CAPS 11 INBRIJA CAPS 30 incassia tabs 43 INCRELEX SOLN 46 indapamide tabs 125mg 25mg 36 indocin supp 26 indomethacin caps 26 indomethacin er cpcr 26 indomethacin sodium solr 26 INFANRIX SUSP 52 INFLECTRA SOLR INTRAVENOUS 48 INFLIXIMAB SOLR INTRAVENOUS 48 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 32 INGREZZA CPPK 32 INLYTA TABS 1mg 5mg 16 INQOVI TABS 16 INREBIC CAPS 16 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 36 INTRON A SOLN 6000000unitml
10000000unitml 16 INTRON A SOLR 10000000unit
18000000unit 50000000unit 16 introvale tabs 43 INVEGA HAFYERA SUSY 34
INVEGA SUSTENNA SUSY 39mg025ml 34
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml 34
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml 34
INVIRASE CAPS 12 INVIRASE TABS 12 IOPIDINE SOLN 39 IPOL INJ 52 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 20 irbesartan tabs 75mg 150mg 300mg 25 irbesartan-hydrochlorothiazide tabs 25 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 20 isosorbide dinitrate er tbcr 25 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 25 isosorbide mononitrate er tb24 25 isosorbide mononitrate er tb24 30mg 60mg
25 isosorbide mononitrate tabs 10mg 20mg 25 isotretinoin caps 10mg 20mg 30mg 40mg
56 isradipine caps 25mg 5mg 23 ISTURISA TABS 1mg 5mg 10mg 49 itraconazole caps 10 ITRACONAZOLE SOLN 10 ivermectin crea 53 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 52
J JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16
76 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg 21
JARDIANCE TABS 10mg 25mg 44 jasmiel tabs 43 JEMPERLI SOLN 16 jinteli tabs 45 JOLIVETTE TABS 43 JULUCA TABS 12 junel 1530 tabs 43 junel 120 tabs 43 junel fe 1530 tabs 43 junel fe 120 tabs 43 junel fe 24 tabs 43 JUXTAPID CAPS 5mg 10mg 20mg 30mg
40mg 60mg 22 JYNARQUE TABS 15mg 30mg 36 JYNARQUE TBPK 36
K KADCYLA SOLR 100mg 160mg 16 kaitlib fe chew 43 KALYDECO PACK 25mg 50mg 75mg 51 KALYDECO TABS 51 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 37 kariva tabs 43 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ 37
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ 37
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS 37
KEDRAB SOLN 52 kelnor 135 tabs 43 kelnor 150 tabs 43 KENALOG SUSP 42 KEPIVANCE SOLR 56 KERALYT SHAM 56 KESIMPTA SOAJ 49 ketoconazole crea 53 ketoconazole foam 53 ketoconazole sham 53 ketoconazole tabs 10 ketodan foam 53 ketoprofen caps 26 ketoprofen er cp24 26 ketorolac tromethamine soln 26 38
ketorolac tromethamine soln 04 05 38 ketorolac tromethamine tabs 26 KEVEYIS TABS 49 KEVZARA SOAJ 150mg114ml
200mg114ml 48 KEVZARA SOSY 150mg114ml
200mg114ml 48 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 47 KHEDEZLA TB24 50mg 100mg 34 KIMMTRAK SOLN 16 KIMYRSA SOLR 9 KINERET SOSY 48 KINRIX SUSP 52 KINRIX SUSY 52 kionex susp 36 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KISQALI FEMARA(200 MG DOSE) TBPK
16 KITABIS PAK NEBU 51 KLISYRI OINT 56 KLOR-CON 10 TBCR 37 klor-con m15 tbcr 37 klor-con m20 tbcr 37 klor-con pack 37 klor-con sprinkle cpcr 8meq 10meq 37 KLOR-CON TBCR 37 KORLYM TABS 44 KORSUVA SOLN 56 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 35 K-TAB TBCR 37 kurvelo tabs 43 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 30 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 lacosamide tabs 50mg 100mg 150mg
200mg 29
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 77
LACRISERT INST 39 LACTATED RINGERS SOLN 37 49 LACTIC ACID LOTN 56 lactulose encephalopathy soln 35 lactulose pack 35 lactulose soln 35 LAMICTAL XR KIT 29 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 29 lamotrigine er tb24 25mg 50mg 100mg
200mg 250mg 300mg 29 lamotrigine kit 29 lamotrigine starter kit-blue kit 29 lamotrigine starter kit-green kit 29 lamotrigine starter kit-orange kit 29 lamotrigine tabs 25mg 100mg 150mg
200mg 29 lamotrigine tbdp 25mg 50mg 100mg
200mg 29 LANOXIN PEDIATRIC SOLN 24 LANREOTIDE ACETATE SOLN 46 lansoprazole cpdr 15mg 30mg 40 lansoprazole tbdd 15mg 30mg 40 lanthanum carbonate chew 500mg 750mg
1000mg 36 LANTUS SOLN 44 LANTUS SOLOSTAR SOPN 44 lapatinib ditosylate tabs 16 larin 1530 tabs 43 larin 120 tabs 43 larin fe 1530 tabs 43 larin fe 120 tabs 43 larissia tabs 43 LARTRUVO SOLN 190mg19ml
500mg50ml 16 latanoprost soln 39 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 34 LAYOLIS FE CHEW 43 LAZANDA SOLN 100mcgact 400mcgact
26 ledipasvir-sofosbuvir tabs 12 leena tabs 43 leflunomide tabs 10mg 20mg 48 LEMTRADA SOLN 32 lenalidomide caps 5mg 10mg 15mg 25mg
16
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 16 lessina tabs 43 letrozole tabs 16 leucovorin calcium soln 47 leucovorin calcium solr 47 leucovorin calcium tabs 5mg 10mg 15mg
25mg 47 LEUKERAN TABS 16 LEUKINE SOLR 21 leuprolide acetate kit 16 LEVALBUTEROL HCL NEBU
125mg05ml 125mg3ml 031mg3ml 063mg3ml 20
levalbuterol tartrate aero 20 levetiracetam er tb24 500mg 750mg 29 levetiracetam in nacl soln 29 levetiracetam soln 29 levetiracetam tabs 250mg 500mg 750mg
1000mg 29 levobunolol hcl soln 39 levocarnitine soln 49 LEVOCARNITINE TABS 49 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 38 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 47 levoleucovorin calcium solr 47 levonest tabs 43 levonorgest-eth est amp eth est tabs 43 levonorgest-eth estrad 91-day tabs 43 levonorgestrel-ethinyl estrad tabs 43 levonorg-eth estrad triphasic tabs 43 levora 01530 (28) tabs 43 levorphanol tartrate tabs 2mg 3mg 26 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
78 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEVOTHYROXINE SODIUM SOLR 47 LEVOTHYROXINE SODIUM TABS 25mcg
50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEXETTE FOAM 55 LEXIVA SUSP 12 LIALDA TBEC 40 LIBTAYO SOLN 16 lidocaine hcl (cardiac) pf sosy 24 lidocaine hcl (cardiac) sosy 24 lidocaine hcl (pf) soln 49 LIDOCAINE HCL CREA 55 lidocaine hcl lotn 55 lidocaine hcl soln 39 49 55 lidocaine hcl urethralmucosal gel 55 lidocaine hcl urethralmucosal prsy 55 LIDOCAINE IN D5W SOLN 24 lidocaine in dextrose soln 49 lidocaine oint 55 lidocaine ptch 55 lidocaine viscous hcl soln 40 lidocaine-epinephrine soln 49 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 55 LIDOCAINE-HYDROCORTISONE ACE KIT
55 lidocaine-prilocaine crea 55 lidocaine-tetracaine crea 55 LIDOCORT CREA 56 lidopin crea 56 LIDO-SORB LOTN 55 LIDOZION LOTN 56 lincomycin hcl soln 9 lindane sham 53 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 liothyronine sodium soln 47 liothyronine sodium tabs 5mcg 25mcg
50mcg 47 LIPODOX 50 INJ 16
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg 25
lisinopril-hydrochlorothiazide tabs 25 LITHIUM CARBONATE CAPS 150mg
300mg 600mg 34 lithium carbonate er tbcr 300mg 450mg 34 LITHIUM CARBONATE TABS 34 LITHIUM SOLN 34 LITHOSTAT TABS 35 LIVMARLI SOLN 41 LIVTENCITY TABS 12 loestrin 1530 (21) tabs 43 loestrin 120 (21) tabs 43 loestrin fe 1530 tabs 43 loestrin fe 120 tabs 43 LOKELMA PACK 5gm 10gm 36 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 16 loperamide hcl caps 40 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 45 lorazepam intensol conc 31 LORAZEPAM SOLN 4mgml 2mgml 31 lorazepam tabs 05mg 1mg 2mg 31 LORBRENA TABS 25mg 100mg 16 lorcet hd tabs 26 lorcet plus tabs 26 lorcet tabs 27 lortab elix 27 loryna tabs 43 losartan potassium tabs 25mg 50mg
100mg 25 losartan potassium-hctz tabs 25 LOTEMAX GEL 38 LOTEMAX SUSP 38 lovastatin tabs 10mg 20mg 40mg 22 LOVENOX SOLN 21 LOVENOX SOSY 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
low-ogestrel tabs 43 loxapine succinate caps 5mg 10mg 25mg
50mg 34 lubiprostone caps 8mcg 24mcg 41 LUCEMYRA TABS 32 LUCENTIS SOLN 03mg005ml
05mg005ml 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 79
LUCENTIS SOSY 03mg005ml 05mg005ml 39
LUDENT CHEW 025mg 05mg 1mg 49 LUMAKRAS TABS 16 LUMIGAN SOLN 39 LUMIZYME SOLR 37 LUMOXITI SOLR 16 LUPANETA PACK KIT 16 LUPKYNIS CAPS 48 LUPRON DEPOT (1-MONTH) KIT 16 LUPRON DEPOT (3-MONTH) KIT 16 LUPRON DEPOT (4-MONTH) KIT 16 LUPRON DEPOT (6-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 16 LUPRON DEPOT-PED (3-MONTH) KIT 16 lutera tabs 43 LYBALVI TABS 34 lyleq tabs 43 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 45
LYMEPAK TABS 9 LYNPARZA TABS 100mg 150mg 16 LYSODREN TABS 16 lyza tabs 43
M mafenide acetate pack 53 magnesium sulfate in d5w soln 37 magnesium sulfate soln 29 MAGNESIUM SULFATE SOLN INJECTION
50 29 MAKENA SOAJ 46 malathion lotn 53 MANNITOL SOLN 36 maprotiline hcl tabs 25mg 50mg 75mg 34 maraviroc tabs 150mg 300mg 12 MARGENZA SOLN 16 marlissa tabs 43 MARPLAN TABS 34 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 23 MAVENCLAD (10 TABS) TBPK 48 MAVENCLAD (4 TABS) TBPK 48 MAVENCLAD (5 TABS) TBPK 48
MAVENCLAD (6 TABS) TBPK 48 MAVENCLAD (7 TABS) TBPK 48 MAVENCLAD (8 TABS) TBPK 48 MAVENCLAD (9 TABS) TBPK 48 MAVYRET PACK 12 MAVYRET TABS 12 MAYZENT STARTER PACK TBPK 32 MAYZENT TABS 025mg 1mg 2mg 32 MENAPHOSMBHYO1 TABS 13 meclizine hcl tabs 40 meclofenamate sodium caps 27 MEDROL TABS 42 medroxyprogesterone acetate susp 46 medroxyprogesterone acetate susy 46 medroxyprogesterone acetate tabs 25mg
5mg 10mg 46 mefenamic acid caps 27 mefloquine hcl tabs 11 megestrol acetate susp 17 46 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 43 meloxicam tabs 27 melphalan hcl solr 17 memantine hcl er cp24 32 memantine hcl soln 32 memantine hcl tabs 5mg 10mg 32 MENACTRA SOLN 52 menest tabs 03mg 0625mg 125mg 45 MENQUADFI SOLN 52 MENVEO SOLR 52 meperidine hcl soln 27 meperidine hcl tabs 50mg 27 meprobamate tabs 31 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 43 mesalamine cpdr 40 mesalamine enem 40 mesalamine er cp24 40 mesalamine supp 40 mesalamine tbec 12gm 800mg 40 mesalamine-cleanser kit 40 mesna soln 49 MESNEX TABS 49 MESTINON SOLN 19 metadate er tbcr 28 metaproterenol sulfate syrp 20
80 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
metaproterenol sulfate tabs 10mg 20mg 20 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 44 metformin hcl tabs 500mg 850mg 1000mg
45 methadone hcl conc 27 methadone hcl intensol conc 27 methadone hcl tabs 5mg 10mg 27 methamphetamine hcl tabs 28 methazolamide tabs 25mg 50mg 39 methenamine hippurate tabs 13 METHENAMINE MANDELATE TABS 13 methergine tabs 45 methimazole tabs 5mg 10mg 47 methitest tabs 42 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 57 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 36 methyldopa tabs 250mg 500mg 24 methyldopa-hydrochlorothiazide tabs 24 methylergonovine maleate soln 45 methylergonovine maleate tabs 45 methylphenidate hcl chew 25mg 5mg
10mg 28 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 28 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 28 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 28
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 28
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 28
methylphenidate hcl soln 5mg5ml 10mg5ml 28
methylphenidate hcl tabs 5mg 10mg 20mg 28
methylprednisolone acetate susp 42 methylprednisolone sodium succ solr 42
methylprednisolone tabs 4mg 8mg 16mg 32mg 42
methylprednisolone tbpk 42 methyltestosterone caps 42 metoclopramide hcl soln 41 metoclopramide hcl tabs 5mg 10mg 41 metoclopramide hcl tbdp 5mg 10mg 41 metolazone tabs 25mg 5mg 10mg 36 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 23 metoprolol tartrate soct 23 metoprolol tartrate soln 23 metoprolol tartrate tabs 25mg 50mg
100mg 23 metoprolol tartrate tabs 375mg 75mg 23 metoprolol-hydrochlorothiazide tabs 23 metronidazole caps 11 metronidazole crea 53 metronidazole gel 53 metronidazole lotn 53 METRONIDAZOLE SOLN INTRAVENOUS
500mg100ml 11 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
24 mibelas 24 fe chew 43 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 53 miconazole-zinc oxide-petrolat oint 53 micort-hc crea 55 microgestin 1530 tabs 43 microgestin 120 tabs 43 microgestin 24 fe tabs 43 microgestin fe 1530 tabs 43 microgestin fe 120 tabs 43 midazolam hcl (pf) soln 31 midazolam hcl soln 31 midodrine hcl tabs 25mg 5mg 10mg 20 miglitol tabs 25mg 50mg 100mg 45 miglustat caps 38 mili tabs 43 millipred dp tbpk 42 millipred tabs 42 milrinone lactate in dextrose soln 24 milrinone lactate soln 24 mimvey lo tabs 45 mimvey tabs 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 81
minitran pt24 01mghr 02mghr 04mghr 06mghr 25
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 24 mirtazapine tabs 75mg 15mg 30mg
45mg 34 mirtazapine tbdp 15mg 30mg 45mg 34 misoprostol tabs 100mcg 200mcg 40 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 52 modafinil tabs 100mg 200mg 28 moexipril hcl tabs 75mg 15mg 25 molindone hcl tabs 5mg 10mg 25mg 34 mometasone furoate crea 55 mometasone furoate oint 55 mometasone furoate soln 55 mometasone furoate susp 38 MONJUVI SOLR 17 MONONESSA TABS 43 montelukast sodium chew 4mg 5mg 51 montelukast sodium pack 51 montelukast sodium tabs 51 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 27 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 27 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 27
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 27
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml 27
morphine sulfate tabs 15mg 30mg 27 moxifloxacin hcl (2x day) soln 38 moxifloxacin hcl in nacl soln intravenous 9 moxifloxacin hcl soln 38 moxifloxacin hcl tabs 9 MULPLETA TABS 21 MULTAQ TABS 24 mupirocin calcium crea 53 mupirocin oint 53 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17
MYALEPT SOLR 49 MYCAPSSA CPDR 46 mycophenolate mofetil caps 48 mycophenolate mofetil hcl solr 48 mycophenolate mofetil susr 48 mycophenolate mofetil tabs 49 mycophenolate sodium tbec 180mg 360mg
49 MYFEMBREE TABS 45 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 57 MYRBETRIQ TB24 25mg 50mg 57
N NABI-HB SOLN 52 nabumetone tabs 27 N-ACETYL-L-CYSTEINE CAPS 36 nadolol tabs 20mg 40mg 80mg 23 nadololbendroflumethiazide tabs 23 nadolol-bendroflumethiazide tabs 23 nafcillin sodium solr 9 nafcillin sodium solr injection 9 nafcillin sodium solr intravenous 9 NAFRINSE CHEW 49 NAFRINSE DROPS SOLN 49 naftifine hcl crea 53 naftifine hcl gel 53 NAGLAZYME SOLN 38 nalbuphine hcl soln 10mgml 20mgml 27 nalfon tabs 27 nalocet tabs 27 naloxone hcl liqd 32 naloxone hcl soaj 32 naloxone hcl soct 32 naloxone hcl soln 32 naloxone hcl sosy 32 naltrexone hcl tabs 32 naproxen sodium er tb24 27 naproxen sodium tabs 27 naproxen susp 27 naproxen tabs 27 naproxen tbec 27 naproxen-esomeprazole tbec 27 naratriptan hcl tabs 30 NARCAN LIQD 32 NATACYN SUSP 38 nateglinide tabs 60mg 120mg 45 NATPARA CART 25mcg 50mcg 75mcg
100mcg 45
82 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
NAYZILAM SOLN 29 necon 0535 (28) tabs 43 NECON 777 TABS 43 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 34 nelarabine soln 17 nembutal soln 31 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 38 neomycin-polymyxin b gu soln 53 neomycin-polymyxin-dexameth oint 38 neomycin-polymyxin-dexameth susp 39 neomycin-polymyxin-gramicidin soln 38 neomycin-polymyxin-hc soln 39 neomycin-polymyxin-hc susp 39 neo-polycin hc oint 38 neo-polycin oint 38 neo-synalar crea 55 NERLYNX TABS 17 NEULASTA ONPRO PSKT 21 NEULASTA SOSY 21 NEUPOGEN SOLN 480mcg16ml
300mcgml 21 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 21 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 38 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 22 niacor tabs 22 nicardipine hcl caps 20mg 30mg 23 NICARDIPINE HCL SOLN 23 NICOTROL INHA 19 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 43 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 49 nitro-bid oint 25
NITRO-DUR PT24 03mghr 08mghr 25 NITROFURANTOIN MACROCRYSTAL
CAPS 13 NITROFURANTOIN MONOHYD MACRO
CAPS 13 nitrofurantoin susp 13 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 25 nitroglycerin soln 25 nitroglycerin subl 03mg 04mg 06mg 25 nitropress soln 24 nitroprusside sodium soln 24 NITYR TABS 2mg 5mg 10mg 49 NIVESTYM SOLN 480mcg16ml
300mcgml 21 NIVESTYM SOSY 300mcg05ml
480mcg08ml 22 nizatidine caps 150mg 300mg 40 nizatidine soln 40 nolix crea 55 nolix lotn 55 nora-be tabs 43 norco tabs 27 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 46
norepinephrine bitartrate soln 20 norethin ace-eth estrad-fe caps 43 norethin ace-eth estrad-fe chew 43 norethin ace-eth estrad-fe tabs 43 norethindrone acetate tabs 46 norethindrone acet-ethinyl est tabs 43 norethindrone tabs 43 norethindrone-eth estradiol tabs 45 norethin-eth estradiol-fe chew 43 norgesic forte tabs 27 norgestimate-eth estradiol tabs 43 norgestim-eth estrad triphasic tabs 43 norlyroc tabs 43 NORPACE CR CP12 100mg 150mg 24 nortrel 0535 (28) tabs 43 nortrel 135 (21) tabs 43 nortrel 135 (28) tabs 43 nortrel 777 tabs 43 nortriptyline hcl caps 10mg 25mg 50mg
75mg 34 nortriptyline hcl soln 34 NORVIR CAPS 12 NORVIR PACK 12
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 83
NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 32 NOXAFIL SUSP 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 51 NUCALA SOLR 51 NUCALA SOSY 51 NUCYNTA ER TB12 200mg 250mg 27 NUCYNTA TABS 27 NUEDEXTA CAPS 32 NULIBRY SOLR 49 NULOJIX SOLR 49 NUPLAZID CAPS 34 NUPLAZID TABS 10mg 17mg 34 NURTEC TBDP 30 NUTRILIPID EMUL INTRAVENOUS 36 NUTROPIN AQ NUSPIN 10 SOPN 46 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 53 nylia 135 tabs 43 nylia 777 tabs 43 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 44 nystatin crea 53 nystatin oint 53 nystatin powd 53 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 55 nystatin-triamcinolone oint 55 nystop powd 53 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 41 ocella tabs 44 OCREVUS SOLN 32 OCTAGAM SOLN INTRAVENOUS
1gm20ml 2gm20ml 52 octreotide acetate soln 500mcgml
1000mcgml 46 octreotide acetate soln 50mcgml
100mcgml 200mcgml 46 ODACTRA SUBL 49 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 51
ofloxacin soln 38 ofloxacin tabs 10 ogestrel tabs 44 OGIVRI SOLR 17 olanzapine solr 34 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 34 olanzapine tbdp 5mg 10mg 15mg 20mg
34 olanzapine-fluoxetine hcl caps 34 olmesartan medoxomil tabs 5mg 20mg
40mg 25 olmesartan medoxomil-hctz tabs 25 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 39 OLUMIANT TABS 1mg 2mg 48 omega-3-acid ethyl esters caps 22 omeprazole cpdr 10mg 20mg 40mg 40 omeprazole-sodium bicarbonate caps 40 omeprazole-sodium bicarbonate pack 40 OMNITROPE SOCT 5mg15ml
10mg15ml 46 OMNITROPE SOLR 46 ondansetron hcl soln 40 ondansetron hcl sosy 40 ondansetron hcl tabs 4mg 8mg 24mg 40 ondansetron tbdp 4mg 8mg 40 ONIVYDE
INJ 17 ONPATTRO SOLN 50 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 OPDIVO SOLN 100mg10ml 120mg12ml
240mg24ml 40mg4ml 17 OPDUALAG SOLN 17 OPIUM TINC 40 OPZELURA CREA 57 ORACEA CPDR 57 oralone pste 55 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 48 ORENCIA SOLR 48 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 48 ORENITRAM TBCR 025mg 1mg 25mg
5mg 51 ORFADIN CAPS 50 ORFADIN SUSP 50 ORGOVYX TABS 45
84 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ORILISSA TABS 150mg 200mg 45 ORKAMBI PACK 51 ORKAMBI TABS 51 ORLADEYO CAPS 110mg 150mg 50 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 27 orphengesic forte tabs 27 orsythia tabs 44 ORTIKOS CP24 6mg 9mg 42 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 36 OTEZLA TABS 48 OTEZLA TBPK 48 ovide lotn 53 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 42 oxaprozin tabs 27 OXAYDO TABS 27 oxazepam caps 10mg 15mg 30mg 31 OXBRYTA TABS 21 OXBRYTA TBSO 21 oxcarbazepine susp 29 oxcarbazepine tabs 150mg 300mg 600mg
29 OXERVATE SOLN 39 oxiconazole nitrate crea 53 OXLUMO SOLN 50 OXTELLAR XR TB24 150mg 300mg
600mg 29 oxybutynin chloride er tb24 5mg 10mg
15mg 57 oxybutynin chloride syrp 57 oxybutynin chloride tabs 57 oxycodone hcl caps 27 oxycodone hcl conc 27 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxycodone hcl soln 27 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 27 oxycodone-acetaminophen soln 27
oxycodone-acetaminophen tabs 27 oxycodone-acetaminophen tabs 5-300mg
75-300mg 10-300mg 27 oxycodone-aspirin tabs 27 oxycodone-ibuprofen tabs 27 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 27 oxymorphone hcl tabs 5mg 10mg 27 OXYTOCIN SOLN 45 OZEMPIC (025 OR 05 MGDOSE) SOPN
45 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 45 OZEMPIC (2 MGDOSE) SOPN 45
P pacerone tabs 100mg 200mg 400mg 24 paclitaxel conc 17 PACLITAXEL PROTEIN-BOUND PART
SUSR 100 MG 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
50 PALFORZIA (120 MG DAILY DOSE) CSPK
50 PALFORZIA (160 MG DAILY DOSE) CSPK
50 PALFORZIA (20 MG DAILY DOSE) CSPK
50 PALFORZIA (200 MG DAILY DOSE) CSPK
50 PALFORZIA (240 MG DAILY DOSE) CSPK
50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK 50 PALFORZIA (300 MG TITRATION) PACK
50 PALFORZIA (40 MG DAILY DOSE) CSPK
50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
50 PALFORZIA INITIAL ESCALATION CSPK
50 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 34
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 85
palonosetron hcl soln 40 palonosetron hcl sosy 40 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 38 pamidronate disodium soln 47 pamidronate disodium solr 47 panlor tabs 27 PANRETIN GEL 56 pantoprazole sodium pack 40 PANTOPRAZOLE SODIUM SOLR 40 pantoprazole sodium tbec 20mg 40mg 40 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 52
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 57 PARICALCITOL SOLN 57 paroex soln 38 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 34 paroxetine hcl susp 34 paroxetine hcl tabs 10mg 20mg 34 paroxetine hcl tabs 30mg 40mg 34 paroxetine mesylate caps 34 paser pack 11 PEDIARIX SUSY 52 PEDVAX HIB SUSP 52 peg 3350electrolytes solr 41 peg 3350-kcl-na bicarb-nacl solr 41 peg-3350electrolytes solr 41 PEGANONE TABS 29 PEGASYS PROCLICK SOAJ
135mcg05ml 180mcg05ml 12 PEGASYS SOLN 12 PEGASYS SOSY 12 PEGINTRON KIT 12 PEG-PREP KIT 41 PEMAZYRE TABS 45mg 9mg 135mg 17 PEMFEXY SOLN 17 penicillamine caps 41 penicillamine tabs 41 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
PENTACEL SUSR 52 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 40 pentazocine-naloxone hcl tabs 27 pentobarbital sodium soln 31 pentoxifylline er tbcr 21 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 40 percocet tabs 27 perindopril erbumine tabs 2mg 4mg 8mg
25 periogard soln 38 PERJETA SOLN 17 permethrin crea 53 perphenazine tabs 2mg 4mg 8mg 16mg
34 perphenazine-amitriptyline tabs 34 PERSERIS PRSY 90mg 120mg 34 PEXEVA TABS 10mg 20mg 30mg 40mg
34 phenadoz supp 14 phenazo tabs 56 PHENAZOPYRIDINE HCL TABS 56 phenelzine sulfate tabs 34 phenergan soln 14 PHENOBARBITAL ELIX 31 PHENOBARBITAL SODIUM SOLN 31 PHENOBARBITAL TABS 31 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 20 PHENYLEPHRINE HCL SOLN 39 phenytek caps 200mg 300mg 29 phenytoin chew 29 phenytoin sodium extended caps 100mg
200mg 300mg 29 phenytoin sodium soln 29 phenytoin susp 29 PHESGO SOLN 17 PHOSLYRA SOLN 37 PHOSPHASAL TABS 13 PHOSPHOLINE IODIDE SOLR 39 phrenilin forte caps 27 PHYSIOLYTE SOLN 50 PHYSIOSOL IRRIGATION SOLN 50 PIFELTRO TABS 12 pilocarpine hcl soln 1 2 4 39 pilocarpine hcl tabs 5mg 75mg 19 pimecrolimus crea 57
86 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
pimozide tabs 1mg 2mg 34 pimtrea tabs 44 pindolol tabs 5mg 10mg 23 pioglitazone hcl tabs 15mg 30mg 45mg 45 pioglitazone hcl-glimepiride tabs 45 pioglitazone hcl-metformin hcl tabs 45 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 44 piroxicam caps 10mg 20mg 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN 32 PLEGRIDY SOSY 32 PLEGRIDY STARTER PACK SOPN 32 PLEGRIDY STARTER PACK SOSY 32 plenamine soln intravenous 36 podofilox soln 57 POLIVY SOLR 30mg 140mg 17 polocaine soln 50 polocaine-mpf soln 50 polycin oint 38 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 38 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 32 PONVORY TABS 32 portia-28 tabs 44 PORTRAZZA SOLN 17 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 35 POTASSIUM ACETATE SOLN 37 potassium chloride crys er tbcr 10meq
20meq 37 potassium chloride er cpcr 8meq 10meq 37 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 37 POTASSIUM CHLORIDE IN NACL SOLN
INTRAVENOUS 37 POTASSIUM CHLORIDE PACK 37 POTASSIUM CHLORIDE SOLN 10 20
37
potassium chloride soln intravenous 10meq100ml 20meq100ml 40meq100ml 2meqml 37
potassium citrate er tbcr 15meq 540mg 1080mg 35
POTASSIUM PHOSPHATES SOLN 37 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 37 POTELIGEO SOLN 17 PR BENZOYL PEROXIDE WASH LIQD 53 PRADAXA CAPS 75mg 110mg 150mg 21 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 31
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 31
PRAMOX GEL 56 prandin tabs 1mg 2mg 45 prasugrel hcl tabs 5mg 10mg 21 pravastatin sodium tabs 10mg 20mg
40mg 80mg 22 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22 PRED MILD SUSP 39 PRED-G SOP OINT 39 PRED-G SUSP 39 prednicarbate crea 55 prednicarbate oint 55 prednisolone acetate susp 39 prednisolone sodium phosphate soln 39 PREDNISOLONE SODIUM PHOSPHATE
SOLN 10mg5ml 20mg5ml 25mg5ml 5mg5ml 42
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 42
prednisolone soln 42 prednisone intensol conc 42 prednisone soln 42 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 42 prednisone tbpk 42 prefest tabs 45 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 29
pregabalin er tb24 825mg 165mg 330mg 27
pregabalin soln 29 PREHEVBRIO SUSP 52
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 87
PREMARIN SOLR 45 premasol soln intravenous 36 PRENATAL TABS 57 PRETOMANID TABS 11 prevalite pack 22 prevalite powd 22 previfem tabs 44 PREVYMIS SOLN 240mg12ml
480mg24ml 12 PREVYMIS TABS 240mg 480mg 12 PREZCOBIX TABS 12 PREZISTA SUSP 12 PREZISTA TABS 75mg 150mg 600mg
800mg 12 PRIFTIN TABS 11 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 29 primlev tabs 27 probenecid tabs 37 procainamide hcl soln 24 PROCALAMINE SOLN INTRAVENOUS 36 procentra soln 28 prochlorperazine edisylate soln 34 prochlorperazine maleate tabs 34 prochlorperazine supp 34 PROCRIT SOLN 20000unitml
40000unitml 22 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 22 proctofoam hc foam 56 procto-med hc crea 55 procto-pak crea 55 proctosol hc crea 55 proctozone-hc crea 55 PROCYSBI CPDR 25mg 75mg 50 PROCYSBI PACK 75mg 300mg 50 progesterone caps 100mg 200mg 46 progesterone oil 46 PROGRAF PACK 49 PROGRAF PACK 02mg 49 PROGRAF SOLN 49 prolate soln 27 prolate tabs 27 PROLEUKIN SOLR 17 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 24 propafenone hcl tabs 150mg 225mg
300mg 24 propantheline bromide tabs 19 proparacaine hcl soln 40 propranolol hcl er cp24 60mg 80mg
120mg 160mg 23 propranolol hcl soln 20mg5ml 40mg5ml 23 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 23 propranolol-hctz tabs 23 propylthiouracil tabs 47 PROQUAD SUSR 52 protriptyline hcl tabs 5mg 10mg 34 psorcon crea 55 PULMICORT FLEXHALER AEPB 51 PULMOZYME SOLN 38 PURIXAN SUSP 17 PYLERA CAPS 40 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 19 pyridostigmine bromide soln 19 pyridostigmine bromide tabs 30mg 60mg 19 pyrimethamine tabs 11 PYRUKYND TABS 5mg 20mg 50mg 50 PYRUKYND TAPER PACK TBPK 50
Q QDOLO SOLN 27 QINLOCK TABS 17 QUADRACEL SUSP 52 questran light powd 22 questran pack 22 questran powd 22 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 34 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 34 quinapril hcl tabs 5mg 10mg 20mg 40mg
25 quinapril-hydrochlorothiazide tabs 25 quinidine gluconate er tbcr 24 QUINIDINE GLUCONATE SOLN 24 quinidine sulfate tabs 200mg 300mg 24
88 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
quinine sulfate caps 11 QULIPTA TABS 10mg 30mg 60mg 30
R RABAVERT SUSR 52 rabeprazole sodium cpsp 40 rabeprazole sodium tbec 40 RADIAURA CREA 55 RADICAVA SOLN 32 raloxifene hcl tabs 45 ramelteon tabs 31 ramipril caps 125mg 25mg 5mg 10mg 25 ranolazine er tb12 500mg 1000mg 24 RAPIVAB SOLN 12 rasagiline mesylate tabs 05mg 1mg 31 RASUVO SOAJ 48 RAVICTI LIQD 35 RAYALDEE CPCR 57 REBETOL SOLN 12 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 32 REBIF REBIDOSE TITRATION PACK
SOAJ 32 REBIF SOSY 22mcg05ml 44mcg05ml 32 REBIF TITRATION PACK SOSY 32 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 44 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 52 RECORLEV TABS 50 RECTIV OINT 57 REGONOL SOLN 19 REGRANEX GEL 57 relafen ds tabs 27 RELENZA DISKHALER AEPB 12 RELEUKO SOLN 300mcgml
480mcg16ml 22 RELEUKO SOSY 300mcg05ml
480mcg08ml 22 relexxii tbcr 28 RELISTOR SOLN 8mg04ml 12mg06ml
41 RELISTOR TABS 41 reltone caps 200mg 400mg 41 REMICADE SOLR INTRAVENOUS 48 RENFLEXIS SOLR 48 repaglinide tabs 05mg 1mg 2mg 45 repaglinide-metformin hcl tabs 45
REPATHA SOSY 22 REPATHA SURECLICK SOAJ 22 RESCRIPTOR TABS 100mg 200mg 12 RESTASIS EMUL 39 RESTASIS MULTIDOSE EMUL 39 RETACRIT SOLN 22 RETACRIT SOLN 20000unitml 22 RETEVMO CAPS 40mg 80mg 17 RETIN-A CREA 0025 005 01 56 RETIN-A GEL 001 0025 56 RETIN-A MICRO GEL 004 01 56 RETIN-A MICRO PUMP GEL 004 01
56 RETISERT IMPL 39 RETROVIR SOLN 12 REVCOVI SOLN 38 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 17 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 34 REYATAZ PACK 12 REZUROCK TABS 50 RIABNI SOLN 100mg10ml 500mg50ml 17 ribasphere caps 12 ribasphere ribapak (1000 pack) tbpk 12 ribasphere ribapak (1200 pack) tbpk 12 ribasphere tabs 12 ribavirin caps 12 ribavirin solr 12 ribavirin tabs 13 RIDAURA CAPS 50 rifabutin caps 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 riluzole tabs 32 rimantadine hcl tabs 13 RIMSO-50 SOLN 50 RINGERS IRRIGATION SOLN 50 RINGERS SOLN 37 RINVOQ TB24 15mg 30mg 45mg 48 risedronate sodium tabs 5mg 30mg 35mg
150mg 47 risedronate sodium tbec 47 RISPERDAL CONSTA SRER 125mg
25mg 34 RISPERDAL CONSTA SRER 375mg
50mg 35
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 89
RISPERIDONE SOLN 35 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 35 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 35 ritonavir tabs 13 RITUXAN HYCELA SOLN 17 RITUXAN SOLN 17 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 44 rizatriptan benzoate tabs 30 rizatriptan benzoate tbdp 30 ROMIDEPSIN SOLN 17 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 31 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 31 ropivacaine hcl soln 50 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 22 ROTARIX SUSR 52 ROTATEQ SOLN 52 roweepra tabs 500mg 750mg 1000mg 29 roweepra xr tb24 500mg 750mg 29 ROZLYTREK CAPS 100mg 200mg 17 RUBRACA TABS 200mg 250mg 300mg 17 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 29 rufinamide tabs 200mg 400mg 29 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 17 RYBREVANT SOLN 17 ryclora soln 14 RYDAPT CAPS 17 RYLAZE SOLN 17 RYNODERM CREA 57 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 46 SAIZEN SOLR 5mg 88mg 46 SAIZENPREP SOLR 46 sajazir soln 21 SALEX SHAM 57 SALICYLIC ACID CREA 57
SALICYLIC ACID ER SOLN 57 SALICYLIC ACID FOAM 57 SALICYLIC ACID GEL 57 SALICYLIC ACID SHAM 57 SALICYLIC ACID-CLEANSER KIT 57 SALSALATE TABS 27 SANCUSO PTCH 40 SANDIMMUNE ORAL SOLN 100mgml 49 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 46 SANTYL OINT 57 SAPHNELO SOLN 49 SAPHRIS SUBL 25mg 5mg 10mg 35 sapropterin dihydrochloride pack 100mg
500mg 50 sapropterin dihydrochloride tabs 50 SARCLISA SOLN 500mg25ml 100mg5ml
17 SCEMBLIX TABS 20mg 40mg 17 scopolamine pt72 40 seconal caps 31 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 35 selegiline hcl caps 31 selegiline hcl tabs 31 selenium sulfide lotn 53 SELENIUM SULFIDE SHAM 53 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 13 SENSORCAINE SOLN 50 sensorcaineepinephrine soln 50 sensorcaine-mpf soln 50 sensorcaine-mpfepinephrine soln 50 SEREVENT DISKUS AEPB 20 SEROSTIM SOLR 4mg 5mg 6mg 46 SERTRALINE HCL CAPS 150mg 200mg
35 sertraline hcl conc 35 sertraline hcl tabs 25mg 50mg 100mg 35 setlakin tabs 44 sevelamer carbonate pack 08gm 24gm 36 sevelamer carbonate tabs 36 sevelamer hcl tabs 400mg 800mg 36 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 44 SHINGRIX SUSR 52 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 46
90 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
SIGNIFOR SOLN 03mgml 06mgml 09mgml 46
SIKLOS TABS 17 sildenafil citrate soln 25 sildenafil citrate susr 25 sildenafil citrate tabs 25 SILIQ SOSY 57 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 53 SIMPONI ARIA SOLN 48 SIMPONI SOAJ 50mg05ml 100mgml 48 SIMPONI SOSY 50mg05ml 100mgml 48 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 22 sirolimus soln 49 sirolimus tabs 05mg 1mg 2mg 49 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKYRIZI (150 MG DOSE) PSKT 57 SKYRIZI PEN SOAJ 57 SKYRIZI SOSY 57 SKYTROFA CART 3mg 36mg 43mg
52mg 63mg 76mg 91mg 11mg 133mg 46
sod benz-sod phenylacet soln 35 SODIUM ACETATE SOLN 35 SODIUM BICARBONATE SOLN 35 SODIUM CHLORIDE (PF) SOLN 37 SODIUM CHLORIDE SOLN 37 50 SODIUM CHLORIDE SOLN
INTRAVENOUS 045 09 3 5 37 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 50 SODIUM FLUORIDE SOLN 50 sodium phenylbutyrate powd 35 sodium phenylbutyrate tabs 35 SODIUM PHOSPHATES SOLN 37 sodium polystyrene sulfonate powd 36 sodium polystyrene sulfonate susp 36 sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 57 SOLTAMOX SOLN 17 SOLU-CORTEF SOLR 42 SOLU-MEDROL SOLR 42 SOMATULINE DEPOT SOLN 60mg02ml
90mg03ml 120mg05ml 46 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 46
sorine tabs 80mg 120mg 160mg 240mg 23
sotalol hcl (af) tabs 80mg 120mg 160mg 23 sotalol hcl tabs 80mg 120mg 160mg
240mg 23 SOTYLIZE SOLN 23 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 25 spironolactone-hctz tabs 25 SPRAVATO (56 MG DOSE) SOPK 35 SPRAVATO (84 MG DOSE) SOPK 35 sprintec 28 tabs 44 SPRITAM TB3D 250mg 500mg 750mg
1000mg 29 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 36 sronyx tabs 44 SSD CREA 53 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
57 STELARA SOSY 45mg05ml 90mgml 57 STERILE WATER FOR IRRIGATION SOLN
50 STIMATE SOLN 46 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18 STRENSIQ SOLN 18mg045ml
28mg07ml 80mg08ml 40mgml 38 streptomycin sulfate solr 10 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 20 SUBLOCADE SOSY 100mg05ml
300mg15ml 32 SUBSYS LIQD 1200mcg 1600mcg 27 subvenite starter kit-blue kit 29 subvenite starter kit-green kit 29 subvenite starter kit-orange kit 30 subvenite tabs 25mg 100mg 150mg
200mg 30 succinylcholine chloride soln 20 SUCRAID SOLN 38 sucralfate susp 40 sucralfate tabs 40
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 91
sulfacetamide sodium (acne) lotn 53 sulfacetamide sodium oint 38 sulfacetamide sodium soln 38 sulfacetamide-prednisolone soln 39 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 SULFAMYLON CREA 53 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 27 sumatriptan soln 30 sumatriptan succinate refill soct 30 sumatriptan succinate soaj 30 sumatriptan succinate soln 30 sumatriptan succinate sosy 30 sumatriptan succinate tabs 30 sunitinib malate caps 125mg 25mg
375mg 50mg 18 suprax chew 10 SUPREP BOWEL PREP KIT SOLN 41 SUSVIMO (IMPLANT 1ST FILL) SOLN 39 SUSVIMO (IMPLANT REFILL) SOLN 39 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 44 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 51 SYMDEKO TBPK 51 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 45 SYMLINPEN 60 SOPN 45 SYMPAZAN FILM 10mg 20mg 30 SYMPAZAN FILM 5mg 30 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 46 SYNDROS SOLN 40 SYNERCID SOLR 10 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 tacrolimus caps 05mg 1mg 5mg 49 TACROLIMUS OINT 01 003 57
tadalafil (pah) tabs 20mg 25 tadalafil tabs 25mg 5mg 25 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 50 TAKHZYRO SOSY 50 TALTZ SOAJ 57 TALTZ SOSY 57 TALZENNA CAPS 025mg 05mg 075mg
1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 47 taperdex 12-day tbpk 42 taperdex 6-day tbpk 42 taperdex 7-day tbpk 42 targadox tabs 10 TARGRETIN GEL 56 tarina 24 fe tabs 44 tarina fe 120 eq tabs 44 TARPEYO CPDR 42 TASIGNA CAPS 50mg 150mg 200mg 18 TAVALISSE TABS 100mg 150mg 22 TAVNEOS CAPS 50 taysofy caps 44 tazarotene crea 57 tazarotene foam 57 tazicef solr injection 10 tazicef solr intravenous 2gm 6gm 10 TAZORAC CREA 57 TAZORAC GEL 005 01 57 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 52 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TEFLARO SOLR INTRAVENOUS 10 TEGSEDI SOSY 50 telmisartan tabs 20mg 40mg 80mg 25 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 25 TEMAZEPAM CAPS 75mg 15mg 225mg
30mg 31 temsirolimus soln 18 tencon tabs 27 TENIPOSIDE SOLN 18 TENIVAC INJ 52 tenofovir disoproxil fumarate tabs 13
92 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TEPADINA SOLR 18 TEPEZZA SOLR 39 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 20 terbutaline sulfate tabs 25mg 5mg 20 terconazole crea 53 terconazole supp 53 TERIPARATIDE (RECOMBINANT) SOPN
46 testosterone cypionate soln 100mgml
200mgml 42 testosterone enanthate soln 42 testosterone gel 1 162
2025mg125gm 405mg25gm 10mgact 42
testosterone soln 42 tetrabenazine tabs 125mg 25mg 32 TETRACAINE HCL SOLN 40 tetracycline hcl caps 250mg 500mg 10 texacort soln 55 TEZSPIRE SOSY 51 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 57 theophylline er tb12 100mg 200mg
300mg 450mg 57 theophylline er tb24 400mg 600mg 57 theophylline soln 57 THIOLA EC TBEC 100mg 300mg 50 THIOLA TABS 50 thioridazine hcl tabs 10mg 25mg 50mg
100mg 35 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 35 THYROGEN SOLR 50 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
30 TIBSOVO TABS 18 TICOVAC SUSY 52 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 32 tilia fe tabs 44 timolol maleate (once-daily) soln 39 timolol maleate pf soln 39
TIMOLOL MALEATE SOLG 025 05 39 timolol maleate soln 025 05 39 timolol maleate tabs 5mg 10mg 20mg 23 tinidazole tabs 11 tiopronin tabs 50 TIS-U-SOL SOLN 50 TIVDAK SOLR 18 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 tizanidine hcl caps 20 tizanidine hcl tabs 20 TOBI PODHALER CAPS 51 TOBRADEX OINT 39 TOBRADEX ST SUSP 39 tobramycin nebu 300mg4ml 300mg5ml 51 tobramycin soln 38 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 39 TOBREX OINT 38 tofranil tabs 10mg 25mg 50mg 35 tolazamide tabs 250mg 500mg 45 tolbutamide tabs 45 tolcapone tabs 31 tolmetin sodium caps 27 tolmetin sodium tabs 27 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 57 tolterodine tartrate tabs 57 tolvaptan tabs 15mg 30mg 36 TOPEX TOPICAL ANESTHETIC AERO 56 topicort crea 005 025 55 topicort gel 55 topicort oint 55 topiramate cpsp 15mg 25mg 30 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 30 topiramate tabs 25mg 50mg 100mg
200mg 30 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
36 TPN ELECTROLYTES CONC
INTRAVENOUS 37 TRACLEER TBSO 51 TRADJENTA TABS 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 93
tramadol hcl er (biphasic) tb24 100mg 200mg 300mg 28
tramadol hcl er cp24 100mg 150mg 200mg 300mg 28
tramadol hcl er tb24 100mg 200mg 300mg 28
tramadol hcl soln 28 tramadol hcl tabs 50mg 100mg 28 tramadol-acetaminophen tabs 28 trandolapril tabs 1mg 2mg 4mg 25 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 21 tranexamic acid tabs 21 tranylcypromine sulfate tabs 35 TRAVASOL SOLN INTRAVENOUS 36 travoprost (bak free) soln 39 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 150mg 300mg 35 trazodone hcl tabs 50mg 100mg 35 TRECATOR TABS 11 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 57 TREMFYA SOSY 57 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 51 tretinoin caps 18 tretinoin crea 0025 005 01 56 tretinoin gel 001 0025 005 56 tretinoin microsphere gel 004 01 56 tretinoin microsphere pump gel 004
01 56 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 28 triamcinolone acetonide aers 55 triamcinolone acetonide crea 0025
01 05 55 triamcinolone acetonide lotn 0025 01
55 triamcinolone acetonide oint 0025
005 01 05 55 triamcinolone acetonide pste 55 triamcinolone acetonide susp 42 triamterene caps 50mg 100mg 36 triamterene-hctz caps 36 triamterene-hctz tabs 36 trianex oint 55 triazolam tabs 0125mg 025mg 31 TRICITRATES SOLN 35 triderm crea 01 05 55
trientine hcl caps 41 tri-estarylla tabs 44 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 35 trifluridine soln 38 trihexyphenidyl hcl soln 31 trihexyphenidyl hcl tabs 2mg 5mg 31 TRIKAFTA TBPK 51 tri-legest fe tabs 44 tri-lo-estarylla tabs 44 tri-lo-sprintec tabs 44 trilyte solr 41 trimethobenzamide hcl caps 40 TRIMETHOPRIM TABS 13 tri-mili tabs 44 trimipramine maleate caps 25mg 50mg
100mg 35 TRINESSA (28) TABS 44 TRINTELLIX TABS 5mg 10mg 20mg 35 tri-nymyo tabs 44 tri-previfem tabs 44 TRIPTODUR SRER 45 TRISENOX
SOLN 18 tri-sprintec tabs 44 tritocin oint 55 TRIUMEQ PD TBSO 13 TRIUMEQ TABS 13 trivora (28) tabs 44 tri-vylibra lo tabs 44 tri-vylibra tabs 44 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 30 TROPHAMINE SOLN INTRAVENOUS 36 trospium chloride er cp24 57 trospium chloride tabs 57 TRULANCE TABS 41 TRUMENBA SUSY 52 TRUSELTIQ (100MG DAILY DOSE) CPPK
18 TRUSELTIQ (125MG DAILY DOSE) CPPK
18 TRUSELTIQ (50MG DAILY DOSE) CPPK
18 TRUSELTIQ (75MG DAILY DOSE) CPPK
18
94 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 52 TYBOST TABS 13 tydemy tabs 44 tylenol with codeine 3 tabs 28 tylenol with codeine 4 tabs 28 TYMLOS SOPN 46 TYPHIM VI SOLN 52 TYPHIM VI SOSY 52 TYVASO REFILL SOLN 51 TYVASO STARTER SOLN 51
U UBRELVY TABS 50mg 100mg 30 UDENYCA SOSY 22 UKONIQ TABS 18 ULTOMIRIS SOLN 50 UMECTA MOUSSE FOAM 57 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
UNITUXIN SOLN 18 UPTRAVI SOLR 51 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 51
UPTRAVI TBPK 51 UREA CREA 39 57 UREA LOTN 40 57 UREA-C40 LOTN 57 urecholine tabs 5mg 10mg 25mg 50mg 20 uredeb crea 57 URETRON DS TABS 13 URIN DS TABS 13 ursodiol caps 200mg 400mg 41 ursodiol caps 300mg 41 ursodiol tabs 250mg 500mg 41 URYL TABS 13 USTELL CAPS 13 UTICAP CAPS 13 UTIRA-C TABS 13 UTRONA-C TABS 13
V VABYSMO SOLN 39 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 57 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 30 valproic acid caps 30 valproic acid soln 30 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
25 valsartan-hydrochlorothiazide tabs 25 VALTOCO 10 MG DOSE LIQD 30 VALTOCO 15 MG DOSE LQPK 30 VALTOCO 20 MG DOSE LQPK 30 VALTOCO 5 MG DOSE LIQD 30 vanatol lq soln 28 vancomycin hcl caps 10 vancomycin hcl solr 250mg5ml 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 vancomycin hcl solr intravenous 5gm
750mg 10 VANDAZOLE GEL 53 VANOXIDE-HC LOTN 55 VANTAS KIT 18 VAQTA SUSP 52 varenicline tartrate misc 19 varenicline tartrate tabs 05mg 1mg 19 VARIVAX INJ 52 VARIZIG SOLN 52 VASCEPA CAPS 1gm 22 VAXCHORA SUSR 53 vecamyl tabs 24 VECTICAL OINT 57 VEKLURY SOLN 13 VEKLURY SOLR 13 VELCADE SOLR 18 velivet tabs 44 VELPHORO CHEW 36 VELTASSA PACK 84gm 168gm 252gm
36 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 18 VENCLEXTA TABS 10mg 18 VENCLEXTA TABS 50mg 100mg 18
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 95
venlafaxine hcl er cp24 375mg 75mg 150mg 35
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg 35
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg 35
VENTAVIS SOLN 10mcgml 20mcgml 52 verapamil hcl er tbcr 120mg 180mg 240mg
24 verapamil hcl soln 24 verapamil hcl tabs 40mg 80mg 120mg 24 veripred 20 soln 42 VERKAZIA EMUL 39 VERSACLOZ SUSP 35 VERZENIO TABS 50mg 100mg 150mg
200mg 18 vestura tabs 44 VIBERZI TABS 75mg 100mg 41 vicodin es tabs 28 vicodin hp tabs 28 vicodin tabs 28 VICTOZA SOPN 45 VIDEX EC CPDR 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 44 vigabatrin pack 30 vigabatrin tabs 30 VIIBRYD STARTER PACK KIT 35 VIIBRYD TABS 10mg 20mg 40mg 35 VIJOICE TBPK 50 VILTEPSO SOLN 50 VIMIZIM SOLN 38 VIMPAT SOLN 30 vinblastine sulfate soln 18 vincasar pfs soln 18 vincristine sulfate soln 18 vinorelbine tartrate soln 18 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 47 VITRAKVI CAPS 25mg 100mg 18 VITRAKVI SOLN 18 VIVITROL SUSR 32 VIZIMPRO TABS 15mg 30mg 45mg 18 VOCABRIA TABS 13
VONJO CAPS 18 VORAXAZE SOLR 47 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 18 VOXZOGO SOLR 04mg 056mg 12mg 50 VPRIV SOLR 38 VRAYLAR CAPS 15mg 3mg 45mg 6mg
35 VRAYLAR CPPK 35 VUMERITY (STARTER) CPDR 50 VUMERITY CPDR 50 vyfemla tabs 44 vylibra tabs 44 VYNDAMAX CAPS 24 VYNDAQEL CAPS 24 VYONDYS 53 SOLN 50 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 28 VYVGART SOLN 50 VYXEOS SUSR 18
W WAKIX TABS 445mg 178mg 28 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 21 WATER FOR IRRIGATION STERILE
SOLN 50 WELIREG TABS 18 wixela inhub aepb 51 wymzya fe chew 44 WYNZORA CREA 55
X XALKORI CAPS 200mg 250mg 18 XARELTO STARTER PACK TBPK 21 XARELTO SUSR 21 XARELTO TABS 25mg 10mg 15mg
20mg 21 XATMEP SOLN 18 XCOPRI (250 MG DAILY DOSE) TBPK 30 XCOPRI (350 MG DAILY DOSE) TBPK 30 XCOPRI TABS 200mg 30 XCOPRI TABS 50mg 100mg 150mg 30 XCOPRI TBPK 30 XCOPRI TBPK 14x125mg amp 14x25mg 30
96 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
XELJANZ SOLN 48 XELJANZ TABS 5mg 10mg 48 XELJANZ XR TB24 11mg 22mg 48 XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 50 XERMELO TABS 40 XGEVA SOLN 47 XIFAXAN TABS 200mg 550mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 51 XOLAIR SOSY 75mg05ml 150mgml 51 XOSPATA TABS 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 18 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 18 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 XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 44 XUREA CREA 57 XURIDEN PACK 50 xylocaine dental soln 50 XYREM SOLN 32 XYWAV SOLN 32
Y YERVOY SOLN 19 YF-VAX INJ 53 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 39 yuvafem tabs 45
Z zafemy ptwk 44
zafirlukast tabs 10mg 20mg 51 zaleplon caps 5mg 10mg 31 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 44 zarontin soln 30 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 28 ZEJULA CAPS 19 ZELAPAR TBDP 31 ZELBORAF TABS 19 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
57 ZENPEP CPEP 38 zenzedi tabs 25mg 5mg 75mg 10mg
15mg 20mg 30mg 28 ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
32 ZEPOSIA CAPS 32 ZEPOSIA STARTER KIT CPPK 32 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERUVIA PTCH 56 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 51 ZIONODIL 100 LOTN 56 ZIONODIL LOTN 56 ziprasidone hcl caps 20mg 40mg 60mg
80mg 35 ziprasidone mesylate solr 35 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZOKINVY CAPS 50mg 75mg 50 zoledronic acid conc 47 zoledronic acid soln 47 ZOLINZA CAPS 19 zolmitriptan soln 30 zolmitriptan tabs 30 zolmitriptan tbdp 30 zolpidem tartrate er tbcr 625mg 125mg 31 zolpidem tartrate subl 175mg 35mg 31 zolpidem tartrate tabs 5mg 10mg 31 zonisamide caps 25mg 50mg 100mg 30 ZORBTIVE SOLR 46
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 97
ZORTRESS TABS 49 ZOSTAVAX SUSR 53 zovia 135 (28) tabs 44 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19
ZYKADIA TABS 19 ZYNLONTA SOLR 19 ZYPREXA RELPREVV SUSR 35 ZYTIGA TABS 19
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)
682896130 062022
This formulary was updated on 060122 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
kporgseniorrx Please recycle
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
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 June 1 2022 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 2022 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 titled 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 on how to request an exception You
2 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 2022 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2022 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 June 1 2022 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 59 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 see your Evidence of Coverage for more information
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 3
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 2022 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 2022 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 2022 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
4 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 5
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 2022 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 59 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg CIPRODEX) and generic drugs are listed in lower-case italics (eg amoxicillin) 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 2022 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
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 8 bull Kaiser Permanente 2022 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 azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP BICILLIN L-A SUSY cefaclor caps
Drug Name RequirementsLimits
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 intravenous 1gm 2gm 10gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 6gm HI
ceftazidime solr intravenous HI CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 750mg HI
cefuroxime sodium solr intravenous 15gm HI
cephalexin caps cephalexin susr cephalexin tabs chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w 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 2022 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
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 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 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
Drug Name RequirementsLimits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs erythromycin tbec FETROJA SOLR NDS 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 LYMEPAK 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
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium 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 10 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs 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 streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO suprax chew SYNERCID SOLR
Drug Name RequirementsLimits
targadox tabs MO tazicef solr injection HI tazicef solr intravenous 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
vancomycin hcl caps vancomycin hcl solr 250mg5ml vancomycin hcl solr intravenous 1gm 10gm 500mg HI
vancomycin hcl solr intravenous 5gm 750mg
XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ANTIFUNGALS AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS 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
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 2022 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS nystatin susp nystatin tabs 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 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 SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS
Drug Name RequirementsLimits
mefloquine hcl tabs metronidazole caps METRONIDAZOLE SOLN INTRAVENOUS 500mg100ml HI
metronidazole tabs nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs quinine sulfate caps NDS 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 APRETUDE SUER 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 DELSTRIGO TABS MO DESCOVY TABS 200-25mg MO DESCOVY TABS 120-15mg MO didanosine cpdr 200mg 250mg 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 12 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 PACK PANDS EPCLUSA TABS PANDS 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 LIVTENCITY TABS NDS lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO
Drug Name RequirementsLimits
maraviroc tabs 150mg 300mg MO MAVYRET PACK PANDS 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 oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEGASYS PROCLICK SOAJ 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN NDS PEGASYS SOSY NDS PEGINTRON KIT NDS PIFELTRO TABS MO 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
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 2022 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg MO sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS 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 PD TBSO MO TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEKLURY SOLN NDS VEKLURY SOLR NDS VEMLIDY TABS VIDEX EC CPDR 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
Drug Name RequirementsLimits
VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES 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 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg abiraterone acetate tabs 500mg NDS ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS NDS ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs arsenic trioxide soln NDS ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr
Drug Name RequirementsLimits
BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE SOLR BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS BESREMI SOSY NDS bexarotene caps NDS bicalutamide tabs 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 CAMCEVI PRSY CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR 50mg 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
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 2022 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
CYCLOPHOSPHAMIDE SOLN 2gm10ml 1gm5ml 500mg25ml
NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr 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 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 eulexin caps NDS
Drug Name RequirementsLimits
everolimus tabs 25mg 5mg 75mg 10mg NDS
everolimus tbso 2mg 3mg 5mg NDS EVOMELA SOLR NDS exemestane tabs EXKIVITY CAPS NDS FARYDAK CAPS 10mg 15mg 20mg LDNDS
FENSOLVI (6 MONTH) KIT 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 FYARRO SUSR 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 6000000unitml 10000000unitml
NDS
INTRON A SOLR 10000000unit 18000000unit 50000000unit 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 KIMMTRAK 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
lenalidomide caps 5mg 10mg 15mg 25mg NDS
Drug Name RequirementsLimits
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
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 TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA 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 2022 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
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 methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS nelarabine soln 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 120mg12ml 240mg24ml 40mg4ml
NDS
OPDUALAG SOLN NDS oxaliplatin soln oxaliplatin solr paclitaxel conc PACLITAXEL PROTEIN-BOUND PART SUSR 100 MG NDS
PADCEV SOLR 20mg 30mg NDS
Drug Name RequirementsLimits
paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEMFEXY SOLN 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 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
SCEMBLIX TABS 20mg 40mg NDS SIKLOS TABS NDS SOLTAMOX SOLN
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
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 05mg 075mg 1mg NDS
tamoxifen citrate tabs 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 TIVDAK SOLR 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 NDS
TRODELVY SOLR NDS
Drug Name RequirementsLimits
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 UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln 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
VONJO CAPS NDS VOTRIENT TABS NDS VYXEOS SUSR NDS WELIREG TABS 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
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 2022 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
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 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 ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO chlordiazepoxide-clidinium caps dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate oral soln MO glycopyrrolate pf sosy glycopyrrolate soln injection glycopyrrolate tabs 1mg 2mg MO
Drug Name RequirementsLimits
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 RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO varenicline tartrate misc MO varenicline tartrate tabs 05mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA FLEQSUVY SUSP NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs 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
Drug Name RequirementsLimits
albuterol sulfate er tb12 4mg 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcgact MONDS
albuterol sulfate nebu 0083 25mg05ml 063mg3ml 125mg3ml
PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY ipratropium-albuterol soln PAMO isoproterenol hcl soln LEVALBUTEROL HCL NEBU 125mg05ml 125mg3ml 031mg3ml 063mg3ml
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 SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS icatibant acetate 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 2022 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
OXBRYTA TABS NDS OXBRYTA TBSO NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS 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 BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln NDS enoxaparin sodium sosy 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
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 NDS LOVENOX SOSY 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg 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 SUSR NDS XARELTO TABS 25mg 10mg 15mg 20mg MO
HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
EPOGEN SOLN PANDS FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
PROCRIT SOLN 20000unitml 40000unitml PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RELEUKO SOLN 300mcgml 480mcg16ml NDS
RELEUKO SOSY 300mcg05ml 480mcg08ml NDS
RETACRIT SOLN 20000unitml PANDS RETACRIT SOLN PANDS TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS 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 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
Drug Name RequirementsLimits
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 150mg MO fenofibrate micronized caps 43mg 67mg 130mg 134mg 200mg
MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg 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
lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
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 SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 1gm MO BETA-ADRENERGIC BLOCKING 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 2022 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
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
ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
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
nadololbendroflumethiazide 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
Drug Name RequirementsLimits
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 cartia xt cp24 120mg 180mg 240mg 300mg MO
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 40mg 80mg 120mg MO
CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR SOLN MO CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln 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 lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy
Drug Name RequirementsLimits
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 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
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 2022 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
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
captopril-hydrochlorothiazide 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
quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
Drug Name RequirementsLimits
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO 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 dipyridamole tabs 25mg 50mg 75mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ascomp-codeine caps NDS benzhydrocodone-acetaminophen tabs NDS
bupap tabs 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 NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS dvorah tabs 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
Drug Name RequirementsLimits
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
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 hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd 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 NDS indomethacin caps indomethacin er cpcr indomethacin sodium solr ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lorcet hd tabs NDS lorcet plus 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln NDS meperidine hcl tabs 50mg NDS methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl tabs 5mg 10mg NDS MORPHINE SULFATE (CONCENTRATE) SOLN NDS
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 tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln 10mgml 20mgml NDS
nalfon tabs nalocet tabs NDS naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs
Drug Name RequirementsLimits
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 75-300mg 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 relafen ds tabs NDS SALSALATE TABS SUBSYS LIQD 1200mcg 1600mcg PANDS
sulindac tabs tencon tabs tolmetin sodium caps tolmetin sodium tabs
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 soln 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 tabs NDS vicodin es tabs NDS vicodin hp tabs NDS zebutal caps ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS amphetamine er suer NDS 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 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
evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS
Drug Name RequirementsLimits
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
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS procentra soln NDS relexxii tbcr NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
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
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 2022 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
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
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 EPRONTIA SOLN 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 lacosamide tabs 50mg 100mg 150mg 200mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
Drug Name RequirementsLimits
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
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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg 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 VALTOCO 15 MG DOSE LQPK VALTOCO 20 MG DOSE LQPK VALTOCO 5 MG DOSE LIQD vigabatrin pack LDNDS vigabatrin tabs NDS VIMPAT SOLN XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200mg NDS XCOPRI TBPK 14x125mg amp 14x25mg
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ PA AJOVY SOSY PA almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs
Drug Name RequirementsLimits
ergotamine-caffeine tabs FROVATRIPTAN SUCCINATE TABS
naratriptan hcl tabs NURTEC TBDP NDS QULIPTA TABS 10mg 30mg 60mg NDS
rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs UBRELVY TABS 50mg 100mg NDS zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl soln MO amantadine hcl tabs MO APOKYN SOCT NDS apomorphine hcl 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
EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg 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 2022 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
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
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
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 intensol conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS droperidol soln estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
Drug Name RequirementsLimits
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP PANDS 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 nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs seconal caps TEMAZEPAM CAPS 75mg 15mg 225mg 30mg 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS tetrabenazine tabs 125mg 25mg MO
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
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 1mg 2mg NDS
OCREVUS SOLN PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
Drug Name RequirementsLimits
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 ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS OPIATE ANTAGONISTS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
LUCEMYRA TABS NDS naloxone hcl liqd naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
VIVITROL SUSR NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg 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 2022 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
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 conc 30mgml 100mgml MO
chlorpromazine hcl soln chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
CITALOPRAM HYDROBROMIDE CAPS MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
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 HAFYERA SUSY INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 150mg 300mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
LITHIUM CARBONATE TABS MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
LYBALVI TABS NDS maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
Drug Name RequirementsLimits
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 susp MO paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps 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
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
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 2022 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
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 CAPS 150mg 200mg MO
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
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 MO trazodone hcl tabs 150mg 300mg 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
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 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 TRICITRATES SOLN AMMONIA DETOXICANTS carglumic acid tbso NDS constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN DEXTROSE SOLN INTRAVENOUS 5 10 HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE 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
Drug Name RequirementsLimits
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI furosemide tabs 20mg 40mg 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN tolvaptan tabs 15mg 30mg 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 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
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 2022 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate tabs MO CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
DEXTROSE-NACL SOLN INTRAVENOUS 25-045 5-02 5-045 5-09
HI
DEXTROSE-NACL SOLN INTRAVENOUS 10-02 10-045
HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 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 PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
Drug Name RequirementsLimits
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 10meq100ml 20meq100ml 40meq100ml 2meqml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN 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 ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME 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 38 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin oint bacitracin-polymyxin b oint bleph-10 soln chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin 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 paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln
Drug Name RequirementsLimits
sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ANTI-INFLAMMATORY AGENTS bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
CEQUA SOLN CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO cyclosporine emul MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO difluprednate emul MO flac oil 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
ILUVIEN IMPL ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint 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 2022 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
RESTASIS EMUL MO RESTASIS MULTIDOSE EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
VERKAZIA EMUL NDS YUTIQ IMPL ANTIALLERGIC AGENTS azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
betaxolol hcl soln MO bimatoprost soln MO brimonidine tartrate soln 015 02 MO
brinzolamide susp MO carteolol hcl soln MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
Drug Name RequirementsLimits
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO timolol maleate (once-daily) soln MO timolol maleate pf soln MO TIMOLOL MALEATE SOLG 025 05 MO
timolol maleate soln 025 05 MO
travoprost (bak free) 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 SUSVIMO (IMPLANT 1ST FILL) SOLN
SUSVIMO (IMPLANT REFILL) SOLN
TEPEZZA SOLR NDS VABYSMO SOLN LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lidocaine viscous hcl soln MO proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
balsalazide disodium caps MO colazal caps 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 OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS aprepitant caps PANDS dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl sosy ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy
Drug Name RequirementsLimits
SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS trimethobenzamide hcl caps PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc 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 famotidine (pf) soln 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 omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate 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 2022 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS 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 IBSRELA TABS NDS LIVMARLI SOLN NDS lubiprostone caps 8mcg 24mcg MO metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS TRULANCE TABS 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
Drug Name RequirementsLimits
clovique caps NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs deferasirox tbso deferiprone tabs 500mg 1000mg NDS
deferoxamine mesylate solr FERRIPROX SOLN LDNDS FERRIPROX TABS LDNDS FERRIPROX TWICE-A-DAY TABS NDS
penicillamine caps NDS penicillamine tabs NDS trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP ALKINDI SPRINKLE CPSP 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs 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 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp 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 10mg5ml 20mg5ml 25mg5ml 5mg5ml
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 SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TARPEYO CPDR NDS triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
danazol caps 50mg 100mg 200mg MO
Drug Name RequirementsLimits
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 405mg25gm 10mgact
MO
testosterone soln 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 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 enpresse-28 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 2022 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
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 jasmiel tabs MO JOLIVETTE 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
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
Drug Name RequirementsLimits
levora 01530 (28) 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 24 fe tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA 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 nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO nylia 135 tabs MO nylia 777 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 44 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 taysofy caps 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 wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135 (28) tabs MO
Drug Name RequirementsLimits
DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
AFREZZA POWD 90x8 UNIT amp 90x12 UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD 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 glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO HUMALOG KWIKPEN SOPN MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
JARDIANCE TABS 10mg 25mg MO KORLYM TABS LDNDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO metformin hcl er tb24 500mg 750mg 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 2022 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
OZEMPIC (2 MGDOSE) SOPN MO pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO tolazamide tabs 250mg 500mg MO tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
depo-estradiol oil dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
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 MO
Drug Name RequirementsLimits
006mg24hr 0075mg24hr 01mg24hr estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO fyavolv tabs MO jinteli tabs MO lopreeza tabs MO lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO prefest tabs MO PREMARIN SOLR raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PANDS CORTROPHIN GEL PANDS desmopressin ace spray refrig soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln desmopressin acetate tabs 01mg 02mg MO
SKYTROFA CART 3mg 36mg 43mg 52mg 63mg 76mg 91mg 11mg 133mg
NDS
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO 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 progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR NDS
Drug Name RequirementsLimits
EGRIFTA SV SOLR NDS GENOTROPIN CART 12mg PANDS GENOTROPIN MINIQUICK PRSY 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
HUMATROPE CART 6mg 12mg 24mg PANDS
HUMATROPE SOLR PANDS INCRELEX SOLN NDS LANREOTIDE ACETATE SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
octreotide acetate soln 50mcgml 100mcgml 200mcgml
octreotide acetate soln 500mcgml 1000mcgml
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 60mg02ml 90mg03ml 120mg05ml
NDS
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 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 2022 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 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 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
Drug Name RequirementsLimits
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 BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 70mg MO alendronate sodium tabs 5mg 10mg 35mg 40mg MO
EVENITY SOSY NDS IBANDRONATE SODIUM SOLN ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr 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 CIBINQO TABS 50mg 100mg 200mg NDS
CIMZIA KIT PANDS CIMZIA PREFILLED PSKT PANDS CIMZIA STARTER KIT PSKT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
INFLIXIMAB SOLR INTRAVENOUS HI
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 RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 15mg 30mg 45mg NDS
SIMPONI ARIA SOLN NDS
Drug Name RequirementsLimits
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 ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
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
ZORTRESS TABS PA MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BERINERT KIT INTRAVENOUS HI betaine powd NDS 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
Drug Name RequirementsLimits
CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENJAYMO SOLN 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 HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ONPATTRO SOLN NDS 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
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 PYRUKYND TABS 5mg 20mg 50mg NDS
PYRUKYND TAPER PACK TBPK NDS
RECORLEV TABS NDS REZUROCK TABS NDS
Drug Name RequirementsLimits
RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln 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 STERILE WATER FOR IRRIGATION SOLN
TAKHZYRO SOLN NDS TAKHZYRO SOSY NDS TAVNEOS CAPS NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR NDS tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VIJOICE TBPK NDS VILTEPSO SOLN NDS VOXZOGO SOLR 04mg 056mg 12mg NDS
VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS VYVGART SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg 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 2022 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 100mg067ml 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 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 ADVAIR HFA AERO 230-21mcgact MO
ADVAIR HFA AERO 45-21mcgact 115-21mcgact MO
Drug Name RequirementsLimits
ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS HI
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
DALIRESP TABS 250mcg 500mcg MO
FLOVENT HFA AERO MO fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PULMICORT FLEXHALER AEPB
SYMBICORT AERO TEZSPIRE SOSY NDS wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg 1000mcg 1200mcg 1400mcg 1600mcg
NDS
UPTRAVI TBPK NDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS HI
GAMUNEX-C SOLN INJECTION HI HYPERHEP B SOLN HYPERHEP B SOSY HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 1gm20ml 2gm20ml
HI
PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
VARIZIG SOLN TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP KINRIX SUSY QUADRACEL SUSP TDVAX SUSP
Drug Name RequirementsLimits
TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP BOOSTRIX SUSY 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 SOLN MENQUADFI SOLN MENVEO SOLR PEDIARIX SUSY PEDVAX HIB SUSP PENTACEL SUSR PREHEVBRIO SUSP PA PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TICOVAC SUSY TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN TYPHIM VI SOSY VAQTA SUSP VARIVAX INJ
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 2022 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint 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 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 clindamycin phosphate soln MO clindamycin phosphate swab MO clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn econazole nitrate crea ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA
Drug Name RequirementsLimits
gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham mafenide acetate pack malathion lotn metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea mupirocin oint naftifine hcl crea naftifine hcl gel neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ovide lotn oxiconazole nitrate crea permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 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
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
Drug Name RequirementsLimits
clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT 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 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
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO FLURANDRENOLIDE CREA 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 2022 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
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 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 prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO
Drug Name RequirementsLimits
psorcon crea MO RADIAURA CREA NDS texacort soln MO topicort crea 005 025 MO topicort gel MO topicort oint 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 VANOXIDE-HC LOTN WYNZORA CREA NDS ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
HYDROCORTISONE ACE-PRAMOXINE SUPP NDS
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 LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS 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
TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS 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
Drug Name RequirementsLimits
adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ADBRY SOSY NDS ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
azelaic acid gel MO AZELEX CREA MO 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
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA 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 KORSUVA SOLN NDS LACTIC ACID LOTN
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 2022 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
OPZELURA CREA 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 SHAM SALICYLIC ACID-CLEANSER KIT
SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SKYRIZI PEN SOAJ SKYRIZI SOSY STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
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 TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS
Drug Name RequirementsLimits
VECTICAL OINT MO XUREA CREA zenatane caps 10mg 20mg 30mg 40mg NDS
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 calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS
58 bull Kaiser Permanente 2018 Defined Standard Comprehensive Formulary
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 59
Index of Drugs
A abacavir sulfate soln 11 abacavir sulfate tabs 11 abacavir sulfate-lamivudine tabs 11 abacavir-lamivudine-zidovudine tabs 11 ABILIFY MAINTENA PRSY 300mg 400mg
32 ABILIFY MAINTENA SRER 300mg 400mg
32 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
abiraterone acetate tabs 250mg 14 abiraterone acetate tabs 500mg 14 ABRAXANE SUSR 14 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 56 acamprosate calcium tbec 25 acarbose tabs 25mg 50mg 100mg 44 accutane caps 10mg 20mg 30mg 40mg 56 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 26 acetaminophen-codeine soln 26 acetaminophen-codeine tabs 26 acetazolamide er cp12 39 acetazolamide sodium solr 39 acetazolamide tabs 125mg 250mg 39 ACETIC ACID SOLN 39 49 acetylcysteine soln 10 20 47 acitretin caps 10mg 175mg 25mg 56 ACTEMRA ACTPEN SOAJ 47 ACTEMRA SOSY 47 ACTHAR GEL 46 ACTHIB SOLR 52 ACTIMMUNE SOLN 49 acyclovir caps 11 acyclovir oint 53 acyclovir sodium soln intravenous 11 acyclovir susp 11
acyclovir tabs 400mg 800mg 11 ADACEL SUSP 52 ADAGEN SOLN 37 ADAKVEO SOLN 20 ADAPALENE CREA 56 adapalene gel 01 03 56 adapalene pads 56 adapalene soln 56 adapalene-benzoyl peroxide gel 56 ADAPALENE-BENZOYL PEROXIDE PADS
56 ADBRY SOSY 56 adderall tabs 28 adefovir dipivoxil tabs 11 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 51 adenosine soln 24 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 230-21mcgact 51 ADVAIR HFA AERO 45-21mcgact 115-
21mcgact 51 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 14 AFREZZA POWD 90x8 UNIT amp 90x12 UNIT
44 AJOVY SOAJ 30 AJOVY SOSY 30 ala-cort crea 1 25 54 albendazole tabs 8 albuterol sulfate er tb12 4mg 8mg 20 ALBUTEROL SULFATE HFA AERS
108mcgact 20 albuterol sulfate nebu 0083
25mg05ml 063mg3ml 125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 54 alclometasone dipropionate oint 54 ALCOHOL PREP PADS 35 ALDURAZYME SOLN 37 ALECENSA CAPS 14
60 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
alendronate sodium soln 47 alendronate sodium tabs 5mg 10mg
35mg 40mg 47 alendronate sodium tabs 70mg 47 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 41 ALKINDI SPRINKLE CPSP 1mg 2mg 5mg
41 allopurinol sodium solr 47 allopurinol tabs 100mg 300mg 47 allzital tabs 26 almotriptan malate tabs 30 alogliptin benzoate tabs 625mg 125mg
25mg 44 ALOGLIPTIN-METFORMIN HCL TABS 44 alogliptin-pioglitazone tabs 44 ALOSETRON HCL TABS 05mg 1mg 40 alprazolam er tb24 05mg 1mg 2mg 3mg
31 alprazolam intensol conc 31 alprazolam tabs 025mg 05mg 1mg 2mg
31 alprazolam tbdp 025mg 05mg 1mg 2mg
31 ALTACAINE SOLN 39 ALTAFRIN SOLN 39 altavera tabs 42 ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 51 alyacen 135 tabs 42 alyq tabs 25 amabelz tabs 45 amantadine hcl caps 30 amantadine hcl soln 30 amantadine hcl tabs 30 AMBISOME SUSR INTRAVENOUS 10 ambrisentan tabs 51 amcinonide crea 54 amcinonide lotn 54 amcinonide oint 54 amethia lo tabs 42 amethia tabs 42 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 36
amiloride-hydrochlorothiazide tabs 36 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 57 amiodarone hcl soln 24 amiodarone hcl tabs 100mg 200mg
400mg 24 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 33 amlodipine besy-benazepril hcl caps 23 amlodipine besylate tabs 25mg 5mg
10mg 23 amlodipine besylate-valsartan tabs 23 amlodipine-atorvastatin tabs 23 amlodipine-olmesartan tabs 23 amlodipine-valsartan-hctz tabs 23 ammonium lactate crea 56 ammonium lactate lotn 56 amnesteem caps 10mg 20mg 40mg 56 AMONDYS 45 SOLN 49 amoxapine tabs 25mg 50mg 100mg
150mg 33 amoxicill-clarithro-lansopraz misc 40 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8 amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 28 amphetamine sulfate tabs 5mg 10mg 28 amphetamine-dextroamphet er cp24 28 amphetamine-dextroamphetamine tabs 28 amphotericin b solr intravenous 10 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 42 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 55 anastrozole tabs 14
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 61
ANDRODERM PT24 2mg24hr 4mg24hr 42
antabuse tabs 250mg 500mg 25 anusol-hc crea 54 apap-caff-dihydrocodeine tabs 26 apexicon e crea 54 APLENZIN TB24 174mg 348mg 522mg 33 APOKYN SOCT 30 apomorphine hcl soct 30 apraclonidine hcl soln 39 aprepitant caps 40 APRETUDE SUER 11 apri tabs 42 APTIOM TABS 200mg 400mg 600mg
800mg 28 APTIVUS CAPS 11 APTIVUS SOLN 11 ARALAST NP SOLR INTRAVENOUS 51 aranelle tabs 42 ARANESP (ALBUMIN FREE) SOLN
60mcgml 100mcgml 200mcgml 21 ARANESP (ALBUMIN FREE) SOSY
60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 21
ARCALYST SOLR 49 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 49 ARIKAYCE SUSP 8 aripiprazole soln 33 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 33 aripiprazole tbdp 10mg 15mg 33 ARISTADA INITIO PRSY 33 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 33
armodafinil tabs 50mg 150mg 200mg 250mg 28
arsenic trioxide soln 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 49 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 52 ascomp-codeine caps 26 asenapine maleate subl 25mg 5mg 10mg
33
ashlyna tabs 42 ASMANEX HFA AERO 100mcgact
200mcgact 51 ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 48 ASTAGRAF XL CP24 05mg 1mg 48 atazanavir sulfate caps 150mg 200mg
300mg 11 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 31 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 22 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 39 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 32 aubra eq tabs 42 AUGMENTIN SUSR 8 AURYXIA TABS 36 AUSTEDO TABS 6mg 9mg 12mg 31 AVASTIN SOLN 14 AVC VAGINAL CREA 53 aviane tabs 42 AVITA CREA 56 AVITA GEL 56 AVONEX KIT 32 AVONEX PEN AJKT 32 AVONEX PREFILLED PSKT 32 AVSOLA SOLR 47 aygestin tabs 46 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 48 azathioprine sodium solr 48 azathioprine tabs 48 azelaic acid gel 56 azelastine hcl soln 005 01 015 39 azelastine-fluticasone susp 39 AZELEX CREA 56 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
62 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
B bacitracin oint 38 bacitracin solr 8 bacitracin-polymyxin b oint 38 bacitra-neomycin-polymyxin-hc oint 38 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 53 BAFIERTAM CPDR 32 balsalazide disodium caps 40 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 42 BANZEL SUSP 28 BANZEL TABS 200mg 400mg 28 BAQSIMI ONE PACK POWD 44 BAQSIMI TWO PACK POWD 44 BARACLUDE SOLN 11 BAVENCIO SOLN 14 BCG VACCINE SOLR 14 BD INSULIN SYR ULTRAFINE II MISC 35 BD INSULIN SYRINGE MISC 35 BD INSULIN SYRINGE UF MISC 35 BD PEN NEEDLE ORIGINAL UF MISC 35 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 32 BELEODAQ SOLR 14 BELRAPZO SOLN 14 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 14 BENDEKA SOLN 14 BENLYSTA SOAJ 48 BENLYSTA SOLR 48 BENLYSTA SOSY 48 BENZEPRO CREAMY WASH LIQD 53 BENZEPRO FOAMING CLOTHS MISC 53 benzhydrocodone-acetaminophen tabs 26 benzoyl perox-hydrocortisone lotn 54 BENZOYL PEROXIDE FORTE- HC LOTN
54 BENZOYL PEROXIDE GEL 53 benzoyl peroxide-erythromycin gel 53 benztropine mesylate soln 30 benztropine mesylate tabs 05mg 1mg
2mg 30 BEOVU SOLN 39 bepotastine besilate soln 39
BERINERT KIT INTRAVENOUS 49 beser lotn 54 BESPONSA SOLR 14 BESREMI SOSY 14 betaine powd 49 betamethasone dipropionate aug crea 54 betamethasone dipropionate aug gel 54 betamethasone dipropionate aug lotn 54 betamethasone dipropionate aug oint 54 betamethasone dipropionate crea 54 betamethasone dipropionate lotn 54 BETAMETHASONE DIPROPIONATE OINT
54 betamethasone sod phos amp acet susp 41 betamethasone valerate crea 54 betamethasone valerate foam 54 BETAMETHASONE VALERATE LOTN 54 BETAMETHASONE VALERATE OINT 54 BETASERON KIT 32 betaxolol hcl soln 39 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 19 bexarotene caps 14 BEXSERO SUSY 52 bicalutamide tabs 14 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICILLIN L-A SUSY 8 BIKTARVY TABS 11 bimatoprost soln 39 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23 bleomycin sulfate solr 14 bleph-10 soln 38 blephamide sop oint 38 BLEPHAMIDE SUSP 38 BLINCYTO SOLR 14 blisovi 24 fe tabs 42 blisovi fe 1530 tabs 42 BOOSTRIX SUSP 52 BOOSTRIX SUSY 52 BORTEZOMIB SOLR 14 bosentan tabs 51 BOSULIF TABS 100mg 400mg 500mg 14 BRAFTOVI CAPS 50mg 75mg 14 briellyn tabs 42 BRILINTA TABS 60mg 90mg 21
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 63
brimonidine tartrate soln 015 02 39 brinzolamide susp 39 BRIVIACT SOLN 28 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 28 bromfenac sodium (once-daily) soln 38 bromocriptine mesylate caps 30 bromocriptine mesylate tabs 30 BRONCHITOL CAPS 51 BROVANA NEBU 20 BRUKINSA CAPS 14 budesonide cpep 41 budesonide er tb24 41 budesonide susp 025mg2ml 05mg2ml
1mg2ml 51 bumetanide soln 36 bumetanide tabs 05mg 1mg 2mg 36 bupap tabs 26 bupivacaine hcl (pf) soln 49 bupivacaine hcl soln 49 BUPIVACAINE IN DEXTROSE SOLN 49 bupivacaine spinal soln 49 bupivacaine-epinephrine (pf) soln 49 bupivacaine-epinephrine soln 49 buprenorphine hcl subl 2mg 8mg 32 buprenorphine hcl-naloxone hcl film 32 buprenorphine hcl-naloxone hcl subl 32 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 32 bupropion hcl er (smoking det) tb12 33 bupropion hcl er (sr) tb12 100mg 150mg
200mg 33 bupropion hcl er (xl) tb24 150mg 300mg
450mg 33 bupropion hcl tabs 75mg 100mg 33 buspirone hcl tabs 5mg 10mg 31 buspirone hcl tabs 75mg 15mg 30mg 31 busulfan soln 14 butalbital-acetaminophen tabs 26 butalbital-apap-caff-cod caps 26 butalbital-apap-caffeine caps 26 butalbital-apap-caffeine tabs 26 butalbital-asa-caff-codeine caps 26 butalbital-aspirin-caffeine caps 26 butalbital-aspirin-caffeine tabs 26 butorphanol tartrate soln 26 BYLVAY (PELLETS) CPSP 200mcg
600mcg 41 BYLVAY CAPS 400mcg 1200mcg 41
C CABENUVA SUER 11 cabergoline tabs 30 CABLIVI KIT 21 CABOMETYX TABS 20mg 40mg 60mg 14 cafergot tabs 30 caffeine citrate soln 28 calcipotriene crea 56 calcipotriene oint 56 calcipotriene soln 56 calcipotriene-betameth diprop oint 54 calcipotriene-betameth diprop susp 54 calcitonin (salmon) soln 45 calcitrene oint 56 calcitriol caps 025mcg 05mcg 57 CALCITRIOL OINT 56 calcitriol soln 57 calcium acetate (phos binder) caps 37 calcium acetate tabs 37 CALCIUM GLUCONATE-NACL SOLN 37 CALQUENCE CAPS 14 CAMCEVI PRSY 14 camila tabs 42 camrese lo tabs 42 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 54 CAPLYTA CAPS 33 CAPRELSA TABS 100mg 300mg 14 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 25 CARAC CREA 56 carbamazepine chew 28 carbamazepine er cp12 100mg 200mg
300mg 28 carbamazepine er tb12 100mg 200mg
400mg 28 carbamazepine susp 28 carbamazepine tabs 28 carbidopa tabs 30 carbidopa-levodopa er tbcr 30 carbidopa-levodopa tabs 30 carbidopa-levodopa tbdp 30 carbidopa-levodopa-entacapone tabs 30 carbinoxamine maleate soln 13
64 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
carbinoxamine maleate tabs 13 carboplatin soln 14 carboprost tromethamine soln 45 CARDENE IV SOLN 23 carglumic acid tbso 35 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 14 CARNITOR SOLN 49 CARNITOR TABS 49 carteolol hcl soln 39 cartia xt cp24 120mg 180mg 240mg
300mg 23 carvedilol phosphate er cp24 10mg 20mg
40mg 80mg 23 carvedilol tabs 3125mg 625mg 125mg
25mg 23 caspofungin acetate solr intravenous 50mg
70mg 10 CAYSTON SOLR 51 caziant tabs 42 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 intravenous 1gm 2gm
10gm 8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 6gm 8 ceftazidime solr intravenous 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 750mg 8 cefuroxime sodium solr intravenous 15gm 8 celecoxib caps 26 CELONTIN CAPS 29 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 38 CERDELGA CAPS 37 CEREZYME SOLR 37 CEROVEL LOTN 56 cetirizine hcl soln 13 CEVIMELINE HCL CAPS 19 CHANTIX CONTINUING MONTH PAK
TABS 19 CHANTIX STARTING MONTH PAK TABS
19 CHANTIX TABS 05mg 1mg 19 CHEMET CAPS 41 chloramphenicol sod succinate solr 8 chlordiazepoxide hcl caps 5mg 10mg
25mg 31 chlordiazepoxide-amitriptyline tabs 33 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 38 chloroprocaine hcl (pf) soln 49 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 36 chlorothiazide tabs 250mg 500mg 36 chlorpromazine hcl conc 30mgml
100mgml 33 chlorpromazine hcl soln 33 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 33 chlorthalidone tabs 25mg 50mg 36 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 41 cholestyramine light pack 22 cholestyramine light powd 22 cholestyramine pack 22 cholestyramine powd 22 CHORIONIC GONADOTROPIN SOLR 45 CIBINQO TABS 50mg 100mg 200mg 47 ciclopirox gel 53 ciclopirox olamine crea 53
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 65
ciclopirox olamine susp 53 ciclopirox sham 53 ciclopirox soln 53 cidofovir soln 11 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 38 CIMDUO TABS 11 cimetidine hcl soln 40 cimetidine tabs 200mg 300mg 400mg
800mg 40 CIMZIA KIT 47 CIMZIA PREFILLED PSKT 47 CIMZIA STARTER KIT PSKT 47 cinacalcet hcl tabs 30mg 60mg 90mg 45 CINQAIR SOLN 51 CINRYZE SOLR INTRAVENOUS 49 CIPRODEX SUSP 38 ciprofloxacin hcl soln (ophth) 38 CIPROFLOXACIN HCL SOLN (OTIC) 38 ciprofloxacin hcl tabs 8 ciprofloxacin in d5w soln 8 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 38 cisplatin soln 14 CISPLATIN SOLR 50mg 14 CITALOPRAM HYDROBROMIDE CAPS 33 citalopram hydrobromide soln 33 citalopram hydrobromide tabs 10mg 20mg
40mg 33 citanest plain dental soln 49 cladribine soln 14 claravis caps 10mg 20mg 30mg 40mg 56 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 13 cleocin phosphate soln 9 cleocin solr 9 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
clindacin-p swab 53 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 53 clindamycin phosphate crea 53
clindamycin phosphate foam 53 clindamycin phosphate gel 53 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 53 clindamycin phosphate soln 9 53 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 53 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 36 clinisol sf soln intravenous 36 clobazam susp 29 clobazam tabs 10mg 20mg 29 clobetasol propionate crea 54 clobetasol propionate e crea 54 clobetasol propionate emulsion foam 54 clobetasol propionate foam 54 clobetasol propionate gel 54 clobetasol propionate liqd 54 clobetasol propionate lotn 54 clobetasol propionate oint 54 clobetasol propionate sham 54 clobetasol propionate soln 54 clocortolone pivalate crea 54 clocortolone pivalate pump crea 54 clofarabine soln 14 clomipramine hcl caps 25mg 50mg 75mg
33 clonazepam tabs 05mg 1mg 2mg 29 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 29 clonidine hcl (analgesia) soln 24
66 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
clonidine hcl er tb12 24 clonidine hcl tabs 01mg 02mg 03mg 24 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 24 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 31 clotrimazole crea 53 clotrimazole soln 53 clotrimazole troc 53 clotrimazole-betamethasone crea 53 clotrimazole-betamethasone lotn 53 clovique caps 41 clozapine tabs 25mg 50mg 100mg 200mg
33 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 33 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 26 colazal caps 40 COLCHICINE CAPS 47 colchicine tabs 47 colchicine-probenecid tabs 37 COLESEVELAM HCL PACK 22 colesevelam hcl tabs 22 colestipol hcl gran 22 colestipol hcl pack 22 colestipol hcl tabs 22 colistimethate sodium (cba) solr injection 9 colocort enem 54 COLY-MYCIN S SUSP 38 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 14 COMETRIQ (140 MG DAILY DOSE) KIT 14 COMETRIQ (60 MG DAILY DOSE) KIT 14 COMPLERA TABS 11 compro supp 33 CONSENSI TABS 23 constulose soln 35 COPIKTRA CAPS 15mg 25mg 14 CORDRAN TAPE 54 CORLANOR SOLN 24 CORLANOR TABS 5mg 75mg 24 cortisone acetate tabs 41 CORTISPORIN CREA 54 CORTISPORIN OINT 54 CORTROPHIN GEL 46 COSELA SOLR 49
COSENTYX (300 MG DOSE) SOSY 56 COSENTYX SENSOREADY (300 MG)
SOAJ 56 COSENTYX SENSOREADY PEN SOAJ 56 COSENTYX SOSY 75mg05ml 150mgml
56 COTELLIC TABS 14 CREON CPEP 37 CRESEMBA CAPS 10 CRESEMBA SOLR 10 CRIXIVAN CAPS 200mg 400mg 11 cromolyn sodium conc 51 cromolyn sodium nebu 51 cromolyn sodium soln 39 crotan lotn 53 cryselle-28 tabs 42 CRYSVITA SOLN 10mgml 20mgml
30mgml 49 CURITY GAUZE PADS 35 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 52
cyclafem 135 tabs 42 cyclafem 777 tabs 42 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 14 CYCLOPHOSPHAMIDE SOLN 2gm10ml
1gm5ml 500mg25ml 15 cyclophosphamide solr 15 cycloserine caps 11 cyclosporine caps 25mg 100mg 48 cyclosporine emul 38 cyclosporine modified caps 25mg 50mg
100mg 48 cyclosporine modified soln 48 cyclosporine soln 48 cyproheptadine hcl syrp 13 cyproheptadine hcl tabs 13 CYRAMZA SOLN 100mg10ml
500mg50ml 15 CYSTADANE POWD 49 CYSTADROPS SOLN 39 CYSTAGON CAPS 50mg 150mg 49 CYSTARAN SOLN 39 cytarabine (pf) soln 15 cytarabine soln 15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 67
CYTOGAM INJ 52
D dacarbazine solr 15 dactinomycin solr 15 dalfampridine er tb12 32 DALIRESP TABS 250mcg 500mcg 51 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 42 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 56 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 52 daptomycin solr intravenous 350mg 500mg
9 darifenacin hydrobromide er tb24 75mg
15mg 57 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 deblitane tabs 42 decadron tabs 5mg 75mg 41 decadron tabs 4mg 6mg 41 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 41 deferasirox tabs 41 deferasirox tbso 41 deferiprone tabs 500mg 1000mg 41 deferoxamine mesylate solr 41 DELSTRIGO TABS 11 deltasone tabs 41 delyla tabs 42 demeclocycline hcl tabs 9 DEMSER CAPS 22 depo-estradiol oil 45 DEPO-MEDROL SUSP 41 DEPO-PROVERA SUSP 400mgml 46 DEPO-SUBQ PROVERA 104 SUSY 46 depo-testosterone soln 100mgml
200mgml 42 DERMOTIC OIL 38 DESCOVY TABS 120-15mg 11 DESCOVY TABS 200-25mg 11
desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg 33
desloratadine tabs 13 desloratadine tbdp 13 desmopressin ace spray refrig soln 46 DESMOPRESSIN ACETATE SOLN 46 desmopressin acetate spray soln 46 desmopressin acetate tabs 01mg 02mg 46 desogestrel-ethinyl estradiol tabs 42 desonide crea 54 desonide gel 54 desonide lotn 54 desonide oint 54 desowen lotn 54 desoximetasone crea 005 025 54 desoximetasone gel 54 desoximetasone liqd 54 desoximetasone oint 005 025 54 desrx gel 54 DESVENLAFAXINE ER TB24 50mg
100mg 33 desvenlafaxine succinate er tb24 25mg
50mg 100mg 33 dexabliss tbpk 41 dexamethasone elix 41 dexamethasone intensol conc 41 dexamethasone sodium phosphate soln 38
41 dexamethasone soln 41 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 41 dexamethasone tbpk 41 dexchlorpheniramine maleate soln 13 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 28
dexmethylphenidate hcl tabs 25mg 5mg 10mg 28
dexpak 10 day tbpk 41 dexpak 13 day tbpk 41 dexpak 6 day tbpk 41 dexrazoxane hcl solr 49 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 28 dextroamphetamine sulfate soln 28 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 28 DEXTROSE IN LACTATED RINGERS
SOLN 37
68 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
DEXTROSE SOLN 36 DEXTROSE SOLN INTRAVENOUS 5
10 36 DEXTROSE-NACL SOLN INTRAVENOUS
10-02 10-045 37 DEXTROSE-NACL SOLN INTRAVENOUS
25-045 5-02 5-045 5-09 37 DIACOMIT CAPS 250mg 500mg 29 DIACOMIT PACK 250mg 500mg 29 DIASTAT ACUDIAL GEL 10mg 20mg 29 DIASTAT PEDIATRIC GEL 29 diazepam conc 31 diazepam gel 25mg 10mg 20mg 29 diazepam intensol conc 31 diazepam soln 5mg5ml 5mgml 31 diazepam tabs 2mg 5mg 10mg 31 diazoxide susp 44 diclofenac sodium er tb24 26 diclofenac sodium gel 1 3 54 diclofenac sodium soln 38 diclofenac sodium tbec 26 diclofenac-misoprostol tbec 26 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 11 DIFFERIN CREA 56 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 54 diflorasone diacetate oint 54 diflunisal tabs 26 difluprednate emul 38 digitek tabs 0125mg 025mg 24 digox tabs 24 digoxin soln 24 digoxin tabs 125mcg 250mcg 24 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 29 dilantin infatabs chew 29 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 23 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 23
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 23
diltiazem hcl er cp12 60mg 90mg 120mg 23
diltiazem hcl er cp24 120mg 180mg 240mg 23
diltiazem hcl soln 23 diltiazem hcl solr 23 diltiazem hcl tabs 30mg 60mg 90mg
120mg 23 dilt-xr cp24 120mg 180mg 240mg 23 dimenhydrinate soln 40 dimethyl fumarate cpdr 32 dimethyl fumarate starter pack misc 32 DIPENTUM CAPS 40 diphen elix 13 di-phen elix 13 diphenhydramine hcl elix 13 diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 40 diphenoxylate-atropine tabs 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 52 dipyridamole tabs 25mg 50mg 75mg 25 disopyramide phosphate caps 100mg
150mg 24 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 36 divalproex sodium csdr 29 divalproex sodium er tb24 250mg 500mg29 divalproex sodium tbec 125mg 250mg
500mg 29 dobutamine hcl soln 20 DOBUTAMINE IN D5W SOLN 20 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
24 dolishale tabs 42 donepezil hcl tabs 5mg 10mg 23mg 19 donepezil hcl tbdp 5mg 10mg 19 dopamine hcl soln 20 DOPAMINE IN D5W SOLN 20 DOPTELET TABS 21 dorzolamide hcl soln 39 dorzolamide hcl-timolol mal pf soln 39 dorzolamide hcl-timolol mal soln 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 69
dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 33 doxepin hcl conc 33 doxepin hcl crea 55 doxepin hcl tabs 3mg 6mg 33 doxercalciferol caps 05mcg 1mcg 25mcg
57 DOXERCALCIFEROL SOLN 57 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
150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 40 DRIZALMA SPRINKLE CSDR 33 dronabinol caps 25mg 5mg 10mg 40 droperidol soln 31 drospiren-eth estrad-levomefol tabs 42 drospirenone-ethinyl estradiol tabs 42 DROXIA CAPS 15 droxidopa caps 20 DUAKLIR PRESSAIR AEPB 19 DUEXIS TABS 26 duloxetine hcl cpep 20mg 30mg 40mg
60mg 33 DUPIXENT SOPN 200mg114ml
300mg2ml 51 DUPIXENT SOSY 100mg067ml
200mg114ml 300mg2ml 51 DURYSTA IMPL 39 dutasteride caps 47 dutasteride-tamsulosin hcl caps 47 dvorah tabs 26 dxevo 11-day tbpk 41
E ees 400 tabs 9 EASYGEL GEL 49 econazole nitrate crea 53 EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 46 EGRIFTA SV SOLR 46 ELAPRASE SOLN 37 ELELYSO SOLR 37 ELEPSIA XR TB24 1000mg 1500mg 29 eletriptan hydrobromide tabs 30 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 37 elixophyllin elix 57 ELLA TABS 42 ELLENCE SOLN 15 ELMIRON CAPS 49 eluryng ring 42 ELZONRIS SOLN 15 EMCYT CAPS 15 EMFLAZA SUSP 42 EMFLAZA TABS 6mg 18mg 30mg 36mg
42 EMPAVELI SOLN 49 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 30 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 25 enalaprilat inj 25 enalapril-hydrochlorothiazide tabs 25 ENBREL MINI SOCT 47 ENBREL SOLN 47 ENBREL SOLR 47 ENBREL SOSY 25mg05ml 50mgml 48 ENBREL SURECLICK SOAJ 48 ENDARI PACK 49 endocet tabs 26 ENDOMETRIN INST 46
70 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ENGERIX-B SUSP 10mcg05ml 20mcgml 52
ENHERTU SOLR 15 ENJAYMO SOLN 49 enoxaparin sodium soln 21 enoxaparin sodium sosy 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
enpresse-28 tabs 42 ENSPRYNG SOSY 49 ENSTILAR FOAM 54 entacapone tabs 30 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 25 ENTYVIO SOLR 41 enulose soln 35 ENVARSUS XR TB24 075mg 1mg 4mg48 EPCLUSA PACK 12 EPCLUSA TABS 12 EPIDIOLEX SOLN 29 epifoam foam 54 epinastine hcl soln 39 epinephrine (anaphylaxis) soln 20 epinephrine soaj 20 EPINEPHRINE SOSY 20 epirubicin hcl soln 15 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 25 EPOGEN SOLN 21 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 21 epoprostenol sodium solr 51 EPRONTIA SOLN 29 eprosartan mesylate tabs 25 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 33 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 30 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 43 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 53 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 53 erythromycin oint 38 erythromycin pads 53 erythromycin soln 53 erythromycin tbec 9 ESBRIET CAPS 51 ESBRIET TABS 267mg 801mg 51 escitalopram oxalate soln 33 escitalopram oxalate tabs 5mg 10mg
20mg 33 esgic caps 26 esgic tabs 26 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 40 esomeprazole magnesium pack 10mg
20mg 40mg 40 esomeprazole sodium solr 40 estarylla tabs 43 estazolam tabs 1mg 2mg 31 estrace crea 45 estrace tabs 05mg 1mg 2mg 45 estradiol crea 45 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
estradiol tabs 10mcg 05mg 1mg 2mg 45 estradiol valerate oil 45 estradiol-norethindrone acet tabs 45 ESTRING RING 45 eszopiclone tabs 1mg 2mg 3mg 31 ethacrynic acid tabs 36 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 29 ethosuximide soln 29 ethynodiol diac-eth estradiol tabs 43 etodolac caps 26
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 71
etodolac er tb24 26 etodolac tabs 26 etonogestrel-ethinyl estradiol ring 43 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 eulexin caps 15 EURAX CREA 53 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 46
evekeo tabs 5mg 10mg 28 EVENITY SOSY 47 everolimus tabs 025mg 48 everolimus tabs 05mg 075mg 1mg 48 everolimus tabs 25mg 5mg 75mg 10mg
15 everolimus tbso 2mg 3mg 5mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 22 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 49 exemestane tabs 15 EXKIVITY CAPS 15 EXONDYS 51 SOLN 500mg10ml
100mg2ml 49 EXSERVAN FILM 31 EXTAVIA KIT 32 EYLEA SOLN 39 EYLEA SOSY 39 ezetimibe tabs 22 ezetimibe-simvastatin tabs 22
F FABRAZYME SOLR 5mg 35mg 37 falmina tabs 43 famciclovir tabs 125mg 250mg 500mg 12 famotidine (pf) soln 40 famotidine premixed soln 40 famotidine soln 40 famotidine susr 40 famotidine tabs 20mg 40mg 40 FANAPT TABS 1mg 2mg 4mg 6mg 8mg
10mg 12mg 33 FANAPT TITRATION PACK TABS 33 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 51 FASENRA SOSY 51
fayosim tabs 43 febuxostat tabs 40mg 80mg 47 felbamate susp 29 felbamate tabs 400mg 600mg 29 felodipine er tb24 25mg 5mg 10mg 23 femynor tabs 43 fenofibrate caps 50mg 150mg 22 fenofibrate micronized caps 43mg 67mg
130mg 134mg 200mg 22 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 22 fenofibric acid cpdr 45mg 135mg 22 fenoprofen calcium caps 26 fenoprofen calcium tabs 26 fenortho caps 26 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 26 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 26
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 26
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 26
FERRIPROX SOLN 41 FERRIPROX TABS 41 FERRIPROX TWICE-A-DAY TABS 41 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
33 FETZIMA TITRATION C4PK 33 fexmid tabs 20 finasteride tabs 47 FINTEPLA SOLN 29 fioricet caps 26 fioricetcodeine caps 26 FIRDAPSE TABS 49 FIRMAGON (240 MG DOSE) SOLR 15 FIRMAGON SOLR 15 flac oil 38 flavoxate hcl tabs 57 FLEBOGAMMA DIF SOLN INTRAVENOUS
52 flecainide acetate tabs 50mg 100mg
150mg 24 FLEQSUVY SUSP 20 FLOVENT HFA AERO 51 floxuridine solr 15
72 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
fluconazole in sodium chloride soln intravenous 10
fluconazole susr 10 fluconazole tabs 10 flucytosine caps 250mg 500mg 10 fludarabine phosphate soln 15 fludarabine phosphate solr 15 fludrocortisone acetate tabs 42 flumazenil soln 31 flunisolide soln 38 fluocinolone acetonide body oil 54 fluocinolone acetonide crea 001 0025
54 fluocinolone acetonide oil 38 fluocinolone acetonide oint 54 fluocinolone acetonide scalp oil 54 fluocinolone acetonide soln 54 fluocinonide crea 54 fluocinonide emulsified base crea 54 FLUOCINONIDE GEL 54 fluocinonide oint 54 fluocinonide soln 54 FLUORITAB CHEW 025mg 05mg 1mg 49 FLUORITAB SOLN 49 fluorometholone susp 38 fluorouracil crea 5 56 fluorouracil crea 5 56 fluorouracil soln 15 56 fluorouracil soln 2 5 56 fluoxetine hcl (pmdd) tabs 10mg 20mg 33 fluoxetine hcl caps 10mg 20mg 40mg 33 fluoxetine hcl cpdr 33 fluoxetine hcl soln 33 fluoxetine hcl tabs 10mg 20mg 60mg 33 fluphenazine decanoate soln 33 fluphenazine hcl conc 33 fluphenazine hcl elix 33 fluphenazine hcl soln 33 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 34 FLURANDRENOLIDE CREA 54 flurandrenolide lotn 55 flurandrenolide oint 55 flurazepam hcl caps 15mg 30mg 31 flurbiprofen sodium soln 38 flurbiprofen tabs 26 flutamide caps 15 fluticasone propionate crea 55 fluticasone propionate lotn 55
fluticasone propionate oint 55 fluticasone propionate susp 38 fluticasone-salmeterol aepb 51 fluvastatin sodium caps 20mg 40mg 22 fluvastatin sodium er tb24 22 fluvoxamine maleate er cp24 100mg
150mg 34 fluvoxamine maleate tabs 25mg 50mg
100mg 34 FML FORTE SUSP 38 FML OINT 38 fomepizole soln 47 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 FORTEO SOPN 45 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 40 fosfomycin tromethamine pack 13 fosinopril sodium tabs 10mg 20mg 40mg
25 fosinopril sodium-hctz tabs 25 fosphenytoin sodium soln 29 FOTIVDA CAPS 089mg 134mg 15 FROVATRIPTAN SUCCINATE TABS 30 FULPHILA SOSY 21 fulvestrant soln 15 furosemide soln 8mgml 10mgml 36 furosemide soln injection 36 furosemide tabs 20mg 40mg 80mg 36 FUZEON SOLR 12 FYARRO SUSR 15 fyavolv tabs 45 FYCOMPA SUSP 29 FYCOMPA TABS 29
G gabapentin caps 100mg 400mg 29 gabapentin soln 29 gabapentin tabs 600mg 800mg 29 GALAFOLD CAPS 49 galantamine hydrobromide er cp24 8mg
16mg 24mg 19 galantamine hydrobromide soln 19 galantamine hydrobromide tabs 4mg 8mg
12mg 19 GAMASTAN INJ 52 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 48
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 73
GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm 52
GAMMAGARD SOLN INJECTION 52 GAMMAKED SOLN INJECTION 52 GAMMAPLEX SOLN INTRAVENOUS 52 GAMUNEX-C SOLN INJECTION 52 ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 52 GARDASIL 9 SUSY 52 gatifloxacin soln 38 GATTEX KIT 41 gavilyte-c solr 41 gavilyte-g solr 41 gavilyte-h kit 41 gavilyte-n with flavor pack solr 41 GAVRETO CAPS 15 GAZYVA SOLN 15 gemcitabine hcl soln 15 gemcitabine hcl solr 15 gemfibrozil tabs 22 gemmily caps 43 generlac soln 35 gengraf caps 25mg 50mg 100mg 48 gengraf soln 48 GENOTROPIN CART 12mg 46 GENOTROPIN MINIQUICK PRSY 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 46
gentak oint 38 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 53 gentamicin sulfate oint 53 gentamicin sulfate soln 9 38 gentamicin sulfate soln injection 9 GENVOYA TABS 12 gianvi tabs 43 GILENYA CAPS 025mg 05mg 32 GILOTRIF TABS 20mg 30mg 40mg 15 GIMOTI SOLN 41 GIVLAARI SOLN 49 GLASSIA SOLN INTRAVENOUS 51 glatopa sosy 20mgml 40mgml 32 glimepiride tabs 1mg 2mg 4mg 44 glipizide er tb24 25mg 5mg 10mg 44 glipizide tabs 5mg 10mg 44 glipizide-metformin hcl tabs 44 glucagon emergency kit 44
glyburide micronized tabs 15mg 3mg 6mg 44
glyburide tabs 125mg 25mg 5mg 44 glyburide-metformin tabs 44 glycate tabs 19 glycopyrrolate oral soln 19 glycopyrrolate pf sosy 19 glycopyrrolate soln injection 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 55 granisetron hcl soln 40 granisetron hcl tabs 40 GRANIX SOLN 480mcg16ml 300mcgml
21 GRANIX SOSY 300mcg05ml
480mcg08ml 21 GRASTEK SUBL 49 griseofulvin microsize susp 10 griseofulvin microsize tabs 10 griseofulvin ultramicrosize tabs 10 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 32 guanfacine hcl tabs 1mg 2mg 24 GUANIDINE HCL TABS 19 gynazole-1 crea 53
H HAEGARDA SOLR 2000unit 3000unit 49 hailey 24 fe tabs 43 halcinonide crea 55 halobetasol propionate crea 55 HALOBETASOL PROPIONATE FOAM 55 halobetasol propionate oint 55 haloperidol decanoate soln 34 haloperidol lactate conc 34 haloperidol lactate soln 34 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 34 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 52 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
HEPLISAV-B SOLN 52
74 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
HERCEPTIN HYLECTA SOLN 15 HERCEPTIN SOLR 150mg 440mg 15 HERZUMA SOLR 150mg 420mg 15 HETLIOZ CAPS 31 HETLIOZ LQ SUSP 31 HIBERIX SOLR 52 HUMALOG KWIKPEN SOPN 44 HUMALOG SOCT 44 HUMALOG SOLN 44 humatin caps 11 HUMATROPE CART 6mg 12mg 24mg 46 HUMATROPE SOLR 46 HUMIRA PEDIATRIC CROHNS START
PSKT 48 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 48 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 48 HUMIRA PEN-PEDIATRIC UC START
PNKT 48 HUMIRA PEN-PSUVADOL HS START
PNKT 48 HUMIRA PEN-PSORUVEIT STARTER
PNKT 48 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 48
HUMULIN 7030 KWIKPEN SUPN 44 HUMULIN 7030 SUSP 44 HUMULIN N KWIKPEN SUPN 44 HUMULIN N SUSP 44 HUMULIN R SOLN 44 HUMULIN R U-500 (CONCENTRATED)
SOLN 44 HUMULIN R U-500 KWIKPEN SOPN 44 hydralazine hcl soln 24 hydralazine hcl tabs 10mg 25mg 50mg
100mg 24 hydrochlorothiazide caps 36 hydrochlorothiazide tabs 125mg 25mg
50mg 36 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 26 hydrocodone-acetaminophen soln 26 hydrocodone-acetaminophen tabs 26 hydrocodone-ibuprofen tabs 26 hydrocortisone (perianal) crea 1 25 55 hydrocortisone ace-pramoxine crea 55
HYDROCORTISONE ACE-PRAMOXINE SUPP 55
hydrocortisone butyr lipo base crea 55 hydrocortisone butyrate crea 55 hydrocortisone butyrate lotn 55 HYDROCORTISONE BUTYRATE OINT 55 hydrocortisone butyrate soln 55 hydrocortisone crea 1 25 55 hydrocortisone enem 55 hydrocortisone lotn 55 hydrocortisone oint 1 25 55 hydrocortisone tabs 5mg 10mg 20mg 42 hydrocortisone valerate crea 55 hydrocortisone valerate oint 55 HYDROCORTISONE-ACETIC ACID SOLN
38 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 26 hydromorphone hcl liqd 26 hydromorphone hcl tabs 2mg 4mg 8mg 26 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 46 hydroxyprogesterone caproate soln 46 hydroxyurea caps 15 hydroxyzine hcl soln 31 hydroxyzine hcl syrp 31 hydroxyzine hcl tabs 31 hydroxyzine pamoate caps 31 HYPERHEP B SOLN 52 HYPERHEP B SOSY 52 HYPERRAB SD SOLN 52 HYQVIA KIT 52
I IBANDRONATE SODIUM SOLN 47 ibandronate sodium tabs 47 IBRANCE CAPS 75mg 100mg 125mg 15 IBRANCE TABS 75mg 100mg 125mg 15 IBSRELA TABS 41 ibu tabs 26 ibudone tabs 26 ibuprofen lysine soln 26 ibuprofen susp 26 ibuprofen tabs 26 ibutilide fumarate soln 24 icatibant acetate soln 20 iclevia tabs 43 ICLUSIG TABS 10mg 15mg 30mg 45mg
15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 75
icosapent ethyl caps 22 IDAMYCIN PFS SOLN 15 idarubicin hcl soln 15 IDHIFA TABS 50mg 100mg 15 ifosfamide soln 15 IFOSFAMIDE SOLR 16 ILARIS SOLN 26 ILUMYA SOSY 56 ILUVIEN IMPL 38 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 34 imipramine pamoate caps 75mg 100mg
125mg 150mg 34 imiquimod crea 375 5 56 IMIQUIMOD PUMP CREA 56 IMOGAM RABIES-HT SOLN 52 IMOVAX RABIES INJ 52 IMPAVIDO CAPS 11 INBRIJA CAPS 30 incassia tabs 43 INCRELEX SOLN 46 indapamide tabs 125mg 25mg 36 indocin supp 26 indomethacin caps 26 indomethacin er cpcr 26 indomethacin sodium solr 26 INFANRIX SUSP 52 INFLECTRA SOLR INTRAVENOUS 48 INFLIXIMAB SOLR INTRAVENOUS 48 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 32 INGREZZA CPPK 32 INLYTA TABS 1mg 5mg 16 INQOVI TABS 16 INREBIC CAPS 16 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 36 INTRON A SOLN 6000000unitml
10000000unitml 16 INTRON A SOLR 10000000unit
18000000unit 50000000unit 16 introvale tabs 43 INVEGA HAFYERA SUSY 34
INVEGA SUSTENNA SUSY 39mg025ml 34
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml 34
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml 34
INVIRASE CAPS 12 INVIRASE TABS 12 IOPIDINE SOLN 39 IPOL INJ 52 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 20 irbesartan tabs 75mg 150mg 300mg 25 irbesartan-hydrochlorothiazide tabs 25 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 20 isosorbide dinitrate er tbcr 25 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 25 isosorbide mononitrate er tb24 25 isosorbide mononitrate er tb24 30mg 60mg
25 isosorbide mononitrate tabs 10mg 20mg 25 isotretinoin caps 10mg 20mg 30mg 40mg
56 isradipine caps 25mg 5mg 23 ISTURISA TABS 1mg 5mg 10mg 49 itraconazole caps 10 ITRACONAZOLE SOLN 10 ivermectin crea 53 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 52
J JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16
76 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg 21
JARDIANCE TABS 10mg 25mg 44 jasmiel tabs 43 JEMPERLI SOLN 16 jinteli tabs 45 JOLIVETTE TABS 43 JULUCA TABS 12 junel 1530 tabs 43 junel 120 tabs 43 junel fe 1530 tabs 43 junel fe 120 tabs 43 junel fe 24 tabs 43 JUXTAPID CAPS 5mg 10mg 20mg 30mg
40mg 60mg 22 JYNARQUE TABS 15mg 30mg 36 JYNARQUE TBPK 36
K KADCYLA SOLR 100mg 160mg 16 kaitlib fe chew 43 KALYDECO PACK 25mg 50mg 75mg 51 KALYDECO TABS 51 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 37 kariva tabs 43 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ 37
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ 37
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS 37
KEDRAB SOLN 52 kelnor 135 tabs 43 kelnor 150 tabs 43 KENALOG SUSP 42 KEPIVANCE SOLR 56 KERALYT SHAM 56 KESIMPTA SOAJ 49 ketoconazole crea 53 ketoconazole foam 53 ketoconazole sham 53 ketoconazole tabs 10 ketodan foam 53 ketoprofen caps 26 ketoprofen er cp24 26 ketorolac tromethamine soln 26 38
ketorolac tromethamine soln 04 05 38 ketorolac tromethamine tabs 26 KEVEYIS TABS 49 KEVZARA SOAJ 150mg114ml
200mg114ml 48 KEVZARA SOSY 150mg114ml
200mg114ml 48 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 47 KHEDEZLA TB24 50mg 100mg 34 KIMMTRAK SOLN 16 KIMYRSA SOLR 9 KINERET SOSY 48 KINRIX SUSP 52 KINRIX SUSY 52 kionex susp 36 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KISQALI FEMARA(200 MG DOSE) TBPK
16 KITABIS PAK NEBU 51 KLISYRI OINT 56 KLOR-CON 10 TBCR 37 klor-con m15 tbcr 37 klor-con m20 tbcr 37 klor-con pack 37 klor-con sprinkle cpcr 8meq 10meq 37 KLOR-CON TBCR 37 KORLYM TABS 44 KORSUVA SOLN 56 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 35 K-TAB TBCR 37 kurvelo tabs 43 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 30 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 lacosamide tabs 50mg 100mg 150mg
200mg 29
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 77
LACRISERT INST 39 LACTATED RINGERS SOLN 37 49 LACTIC ACID LOTN 56 lactulose encephalopathy soln 35 lactulose pack 35 lactulose soln 35 LAMICTAL XR KIT 29 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 29 lamotrigine er tb24 25mg 50mg 100mg
200mg 250mg 300mg 29 lamotrigine kit 29 lamotrigine starter kit-blue kit 29 lamotrigine starter kit-green kit 29 lamotrigine starter kit-orange kit 29 lamotrigine tabs 25mg 100mg 150mg
200mg 29 lamotrigine tbdp 25mg 50mg 100mg
200mg 29 LANOXIN PEDIATRIC SOLN 24 LANREOTIDE ACETATE SOLN 46 lansoprazole cpdr 15mg 30mg 40 lansoprazole tbdd 15mg 30mg 40 lanthanum carbonate chew 500mg 750mg
1000mg 36 LANTUS SOLN 44 LANTUS SOLOSTAR SOPN 44 lapatinib ditosylate tabs 16 larin 1530 tabs 43 larin 120 tabs 43 larin fe 1530 tabs 43 larin fe 120 tabs 43 larissia tabs 43 LARTRUVO SOLN 190mg19ml
500mg50ml 16 latanoprost soln 39 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 34 LAYOLIS FE CHEW 43 LAZANDA SOLN 100mcgact 400mcgact
26 ledipasvir-sofosbuvir tabs 12 leena tabs 43 leflunomide tabs 10mg 20mg 48 LEMTRADA SOLN 32 lenalidomide caps 5mg 10mg 15mg 25mg
16
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 16 lessina tabs 43 letrozole tabs 16 leucovorin calcium soln 47 leucovorin calcium solr 47 leucovorin calcium tabs 5mg 10mg 15mg
25mg 47 LEUKERAN TABS 16 LEUKINE SOLR 21 leuprolide acetate kit 16 LEVALBUTEROL HCL NEBU
125mg05ml 125mg3ml 031mg3ml 063mg3ml 20
levalbuterol tartrate aero 20 levetiracetam er tb24 500mg 750mg 29 levetiracetam in nacl soln 29 levetiracetam soln 29 levetiracetam tabs 250mg 500mg 750mg
1000mg 29 levobunolol hcl soln 39 levocarnitine soln 49 LEVOCARNITINE TABS 49 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 38 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 47 levoleucovorin calcium solr 47 levonest tabs 43 levonorgest-eth est amp eth est tabs 43 levonorgest-eth estrad 91-day tabs 43 levonorgestrel-ethinyl estrad tabs 43 levonorg-eth estrad triphasic tabs 43 levora 01530 (28) tabs 43 levorphanol tartrate tabs 2mg 3mg 26 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
78 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEVOTHYROXINE SODIUM SOLR 47 LEVOTHYROXINE SODIUM TABS 25mcg
50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEXETTE FOAM 55 LEXIVA SUSP 12 LIALDA TBEC 40 LIBTAYO SOLN 16 lidocaine hcl (cardiac) pf sosy 24 lidocaine hcl (cardiac) sosy 24 lidocaine hcl (pf) soln 49 LIDOCAINE HCL CREA 55 lidocaine hcl lotn 55 lidocaine hcl soln 39 49 55 lidocaine hcl urethralmucosal gel 55 lidocaine hcl urethralmucosal prsy 55 LIDOCAINE IN D5W SOLN 24 lidocaine in dextrose soln 49 lidocaine oint 55 lidocaine ptch 55 lidocaine viscous hcl soln 40 lidocaine-epinephrine soln 49 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 55 LIDOCAINE-HYDROCORTISONE ACE KIT
55 lidocaine-prilocaine crea 55 lidocaine-tetracaine crea 55 LIDOCORT CREA 56 lidopin crea 56 LIDO-SORB LOTN 55 LIDOZION LOTN 56 lincomycin hcl soln 9 lindane sham 53 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 liothyronine sodium soln 47 liothyronine sodium tabs 5mcg 25mcg
50mcg 47 LIPODOX 50 INJ 16
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg 25
lisinopril-hydrochlorothiazide tabs 25 LITHIUM CARBONATE CAPS 150mg
300mg 600mg 34 lithium carbonate er tbcr 300mg 450mg 34 LITHIUM CARBONATE TABS 34 LITHIUM SOLN 34 LITHOSTAT TABS 35 LIVMARLI SOLN 41 LIVTENCITY TABS 12 loestrin 1530 (21) tabs 43 loestrin 120 (21) tabs 43 loestrin fe 1530 tabs 43 loestrin fe 120 tabs 43 LOKELMA PACK 5gm 10gm 36 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 16 loperamide hcl caps 40 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 45 lorazepam intensol conc 31 LORAZEPAM SOLN 4mgml 2mgml 31 lorazepam tabs 05mg 1mg 2mg 31 LORBRENA TABS 25mg 100mg 16 lorcet hd tabs 26 lorcet plus tabs 26 lorcet tabs 27 lortab elix 27 loryna tabs 43 losartan potassium tabs 25mg 50mg
100mg 25 losartan potassium-hctz tabs 25 LOTEMAX GEL 38 LOTEMAX SUSP 38 lovastatin tabs 10mg 20mg 40mg 22 LOVENOX SOLN 21 LOVENOX SOSY 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
low-ogestrel tabs 43 loxapine succinate caps 5mg 10mg 25mg
50mg 34 lubiprostone caps 8mcg 24mcg 41 LUCEMYRA TABS 32 LUCENTIS SOLN 03mg005ml
05mg005ml 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 79
LUCENTIS SOSY 03mg005ml 05mg005ml 39
LUDENT CHEW 025mg 05mg 1mg 49 LUMAKRAS TABS 16 LUMIGAN SOLN 39 LUMIZYME SOLR 37 LUMOXITI SOLR 16 LUPANETA PACK KIT 16 LUPKYNIS CAPS 48 LUPRON DEPOT (1-MONTH) KIT 16 LUPRON DEPOT (3-MONTH) KIT 16 LUPRON DEPOT (4-MONTH) KIT 16 LUPRON DEPOT (6-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 16 LUPRON DEPOT-PED (3-MONTH) KIT 16 lutera tabs 43 LYBALVI TABS 34 lyleq tabs 43 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 45
LYMEPAK TABS 9 LYNPARZA TABS 100mg 150mg 16 LYSODREN TABS 16 lyza tabs 43
M mafenide acetate pack 53 magnesium sulfate in d5w soln 37 magnesium sulfate soln 29 MAGNESIUM SULFATE SOLN INJECTION
50 29 MAKENA SOAJ 46 malathion lotn 53 MANNITOL SOLN 36 maprotiline hcl tabs 25mg 50mg 75mg 34 maraviroc tabs 150mg 300mg 12 MARGENZA SOLN 16 marlissa tabs 43 MARPLAN TABS 34 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 23 MAVENCLAD (10 TABS) TBPK 48 MAVENCLAD (4 TABS) TBPK 48 MAVENCLAD (5 TABS) TBPK 48
MAVENCLAD (6 TABS) TBPK 48 MAVENCLAD (7 TABS) TBPK 48 MAVENCLAD (8 TABS) TBPK 48 MAVENCLAD (9 TABS) TBPK 48 MAVYRET PACK 12 MAVYRET TABS 12 MAYZENT STARTER PACK TBPK 32 MAYZENT TABS 025mg 1mg 2mg 32 MENAPHOSMBHYO1 TABS 13 meclizine hcl tabs 40 meclofenamate sodium caps 27 MEDROL TABS 42 medroxyprogesterone acetate susp 46 medroxyprogesterone acetate susy 46 medroxyprogesterone acetate tabs 25mg
5mg 10mg 46 mefenamic acid caps 27 mefloquine hcl tabs 11 megestrol acetate susp 17 46 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 43 meloxicam tabs 27 melphalan hcl solr 17 memantine hcl er cp24 32 memantine hcl soln 32 memantine hcl tabs 5mg 10mg 32 MENACTRA SOLN 52 menest tabs 03mg 0625mg 125mg 45 MENQUADFI SOLN 52 MENVEO SOLR 52 meperidine hcl soln 27 meperidine hcl tabs 50mg 27 meprobamate tabs 31 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 43 mesalamine cpdr 40 mesalamine enem 40 mesalamine er cp24 40 mesalamine supp 40 mesalamine tbec 12gm 800mg 40 mesalamine-cleanser kit 40 mesna soln 49 MESNEX TABS 49 MESTINON SOLN 19 metadate er tbcr 28 metaproterenol sulfate syrp 20
80 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
metaproterenol sulfate tabs 10mg 20mg 20 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 44 metformin hcl tabs 500mg 850mg 1000mg
45 methadone hcl conc 27 methadone hcl intensol conc 27 methadone hcl tabs 5mg 10mg 27 methamphetamine hcl tabs 28 methazolamide tabs 25mg 50mg 39 methenamine hippurate tabs 13 METHENAMINE MANDELATE TABS 13 methergine tabs 45 methimazole tabs 5mg 10mg 47 methitest tabs 42 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 57 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 36 methyldopa tabs 250mg 500mg 24 methyldopa-hydrochlorothiazide tabs 24 methylergonovine maleate soln 45 methylergonovine maleate tabs 45 methylphenidate hcl chew 25mg 5mg
10mg 28 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 28 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 28 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 28
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 28
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 28
methylphenidate hcl soln 5mg5ml 10mg5ml 28
methylphenidate hcl tabs 5mg 10mg 20mg 28
methylprednisolone acetate susp 42 methylprednisolone sodium succ solr 42
methylprednisolone tabs 4mg 8mg 16mg 32mg 42
methylprednisolone tbpk 42 methyltestosterone caps 42 metoclopramide hcl soln 41 metoclopramide hcl tabs 5mg 10mg 41 metoclopramide hcl tbdp 5mg 10mg 41 metolazone tabs 25mg 5mg 10mg 36 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 23 metoprolol tartrate soct 23 metoprolol tartrate soln 23 metoprolol tartrate tabs 25mg 50mg
100mg 23 metoprolol tartrate tabs 375mg 75mg 23 metoprolol-hydrochlorothiazide tabs 23 metronidazole caps 11 metronidazole crea 53 metronidazole gel 53 metronidazole lotn 53 METRONIDAZOLE SOLN INTRAVENOUS
500mg100ml 11 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
24 mibelas 24 fe chew 43 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 53 miconazole-zinc oxide-petrolat oint 53 micort-hc crea 55 microgestin 1530 tabs 43 microgestin 120 tabs 43 microgestin 24 fe tabs 43 microgestin fe 1530 tabs 43 microgestin fe 120 tabs 43 midazolam hcl (pf) soln 31 midazolam hcl soln 31 midodrine hcl tabs 25mg 5mg 10mg 20 miglitol tabs 25mg 50mg 100mg 45 miglustat caps 38 mili tabs 43 millipred dp tbpk 42 millipred tabs 42 milrinone lactate in dextrose soln 24 milrinone lactate soln 24 mimvey lo tabs 45 mimvey tabs 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 81
minitran pt24 01mghr 02mghr 04mghr 06mghr 25
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 24 mirtazapine tabs 75mg 15mg 30mg
45mg 34 mirtazapine tbdp 15mg 30mg 45mg 34 misoprostol tabs 100mcg 200mcg 40 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 52 modafinil tabs 100mg 200mg 28 moexipril hcl tabs 75mg 15mg 25 molindone hcl tabs 5mg 10mg 25mg 34 mometasone furoate crea 55 mometasone furoate oint 55 mometasone furoate soln 55 mometasone furoate susp 38 MONJUVI SOLR 17 MONONESSA TABS 43 montelukast sodium chew 4mg 5mg 51 montelukast sodium pack 51 montelukast sodium tabs 51 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 27 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 27 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 27
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 27
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml 27
morphine sulfate tabs 15mg 30mg 27 moxifloxacin hcl (2x day) soln 38 moxifloxacin hcl in nacl soln intravenous 9 moxifloxacin hcl soln 38 moxifloxacin hcl tabs 9 MULPLETA TABS 21 MULTAQ TABS 24 mupirocin calcium crea 53 mupirocin oint 53 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17
MYALEPT SOLR 49 MYCAPSSA CPDR 46 mycophenolate mofetil caps 48 mycophenolate mofetil hcl solr 48 mycophenolate mofetil susr 48 mycophenolate mofetil tabs 49 mycophenolate sodium tbec 180mg 360mg
49 MYFEMBREE TABS 45 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 57 MYRBETRIQ TB24 25mg 50mg 57
N NABI-HB SOLN 52 nabumetone tabs 27 N-ACETYL-L-CYSTEINE CAPS 36 nadolol tabs 20mg 40mg 80mg 23 nadololbendroflumethiazide tabs 23 nadolol-bendroflumethiazide tabs 23 nafcillin sodium solr 9 nafcillin sodium solr injection 9 nafcillin sodium solr intravenous 9 NAFRINSE CHEW 49 NAFRINSE DROPS SOLN 49 naftifine hcl crea 53 naftifine hcl gel 53 NAGLAZYME SOLN 38 nalbuphine hcl soln 10mgml 20mgml 27 nalfon tabs 27 nalocet tabs 27 naloxone hcl liqd 32 naloxone hcl soaj 32 naloxone hcl soct 32 naloxone hcl soln 32 naloxone hcl sosy 32 naltrexone hcl tabs 32 naproxen sodium er tb24 27 naproxen sodium tabs 27 naproxen susp 27 naproxen tabs 27 naproxen tbec 27 naproxen-esomeprazole tbec 27 naratriptan hcl tabs 30 NARCAN LIQD 32 NATACYN SUSP 38 nateglinide tabs 60mg 120mg 45 NATPARA CART 25mcg 50mcg 75mcg
100mcg 45
82 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
NAYZILAM SOLN 29 necon 0535 (28) tabs 43 NECON 777 TABS 43 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 34 nelarabine soln 17 nembutal soln 31 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 38 neomycin-polymyxin b gu soln 53 neomycin-polymyxin-dexameth oint 38 neomycin-polymyxin-dexameth susp 39 neomycin-polymyxin-gramicidin soln 38 neomycin-polymyxin-hc soln 39 neomycin-polymyxin-hc susp 39 neo-polycin hc oint 38 neo-polycin oint 38 neo-synalar crea 55 NERLYNX TABS 17 NEULASTA ONPRO PSKT 21 NEULASTA SOSY 21 NEUPOGEN SOLN 480mcg16ml
300mcgml 21 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 21 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 38 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 22 niacor tabs 22 nicardipine hcl caps 20mg 30mg 23 NICARDIPINE HCL SOLN 23 NICOTROL INHA 19 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 43 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 49 nitro-bid oint 25
NITRO-DUR PT24 03mghr 08mghr 25 NITROFURANTOIN MACROCRYSTAL
CAPS 13 NITROFURANTOIN MONOHYD MACRO
CAPS 13 nitrofurantoin susp 13 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 25 nitroglycerin soln 25 nitroglycerin subl 03mg 04mg 06mg 25 nitropress soln 24 nitroprusside sodium soln 24 NITYR TABS 2mg 5mg 10mg 49 NIVESTYM SOLN 480mcg16ml
300mcgml 21 NIVESTYM SOSY 300mcg05ml
480mcg08ml 22 nizatidine caps 150mg 300mg 40 nizatidine soln 40 nolix crea 55 nolix lotn 55 nora-be tabs 43 norco tabs 27 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 46
norepinephrine bitartrate soln 20 norethin ace-eth estrad-fe caps 43 norethin ace-eth estrad-fe chew 43 norethin ace-eth estrad-fe tabs 43 norethindrone acetate tabs 46 norethindrone acet-ethinyl est tabs 43 norethindrone tabs 43 norethindrone-eth estradiol tabs 45 norethin-eth estradiol-fe chew 43 norgesic forte tabs 27 norgestimate-eth estradiol tabs 43 norgestim-eth estrad triphasic tabs 43 norlyroc tabs 43 NORPACE CR CP12 100mg 150mg 24 nortrel 0535 (28) tabs 43 nortrel 135 (21) tabs 43 nortrel 135 (28) tabs 43 nortrel 777 tabs 43 nortriptyline hcl caps 10mg 25mg 50mg
75mg 34 nortriptyline hcl soln 34 NORVIR CAPS 12 NORVIR PACK 12
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 83
NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 32 NOXAFIL SUSP 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 51 NUCALA SOLR 51 NUCALA SOSY 51 NUCYNTA ER TB12 200mg 250mg 27 NUCYNTA TABS 27 NUEDEXTA CAPS 32 NULIBRY SOLR 49 NULOJIX SOLR 49 NUPLAZID CAPS 34 NUPLAZID TABS 10mg 17mg 34 NURTEC TBDP 30 NUTRILIPID EMUL INTRAVENOUS 36 NUTROPIN AQ NUSPIN 10 SOPN 46 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 53 nylia 135 tabs 43 nylia 777 tabs 43 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 44 nystatin crea 53 nystatin oint 53 nystatin powd 53 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 55 nystatin-triamcinolone oint 55 nystop powd 53 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 41 ocella tabs 44 OCREVUS SOLN 32 OCTAGAM SOLN INTRAVENOUS
1gm20ml 2gm20ml 52 octreotide acetate soln 500mcgml
1000mcgml 46 octreotide acetate soln 50mcgml
100mcgml 200mcgml 46 ODACTRA SUBL 49 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 51
ofloxacin soln 38 ofloxacin tabs 10 ogestrel tabs 44 OGIVRI SOLR 17 olanzapine solr 34 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 34 olanzapine tbdp 5mg 10mg 15mg 20mg
34 olanzapine-fluoxetine hcl caps 34 olmesartan medoxomil tabs 5mg 20mg
40mg 25 olmesartan medoxomil-hctz tabs 25 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 39 OLUMIANT TABS 1mg 2mg 48 omega-3-acid ethyl esters caps 22 omeprazole cpdr 10mg 20mg 40mg 40 omeprazole-sodium bicarbonate caps 40 omeprazole-sodium bicarbonate pack 40 OMNITROPE SOCT 5mg15ml
10mg15ml 46 OMNITROPE SOLR 46 ondansetron hcl soln 40 ondansetron hcl sosy 40 ondansetron hcl tabs 4mg 8mg 24mg 40 ondansetron tbdp 4mg 8mg 40 ONIVYDE
INJ 17 ONPATTRO SOLN 50 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 OPDIVO SOLN 100mg10ml 120mg12ml
240mg24ml 40mg4ml 17 OPDUALAG SOLN 17 OPIUM TINC 40 OPZELURA CREA 57 ORACEA CPDR 57 oralone pste 55 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 48 ORENCIA SOLR 48 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 48 ORENITRAM TBCR 025mg 1mg 25mg
5mg 51 ORFADIN CAPS 50 ORFADIN SUSP 50 ORGOVYX TABS 45
84 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ORILISSA TABS 150mg 200mg 45 ORKAMBI PACK 51 ORKAMBI TABS 51 ORLADEYO CAPS 110mg 150mg 50 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 27 orphengesic forte tabs 27 orsythia tabs 44 ORTIKOS CP24 6mg 9mg 42 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 36 OTEZLA TABS 48 OTEZLA TBPK 48 ovide lotn 53 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 42 oxaprozin tabs 27 OXAYDO TABS 27 oxazepam caps 10mg 15mg 30mg 31 OXBRYTA TABS 21 OXBRYTA TBSO 21 oxcarbazepine susp 29 oxcarbazepine tabs 150mg 300mg 600mg
29 OXERVATE SOLN 39 oxiconazole nitrate crea 53 OXLUMO SOLN 50 OXTELLAR XR TB24 150mg 300mg
600mg 29 oxybutynin chloride er tb24 5mg 10mg
15mg 57 oxybutynin chloride syrp 57 oxybutynin chloride tabs 57 oxycodone hcl caps 27 oxycodone hcl conc 27 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxycodone hcl soln 27 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 27 oxycodone-acetaminophen soln 27
oxycodone-acetaminophen tabs 27 oxycodone-acetaminophen tabs 5-300mg
75-300mg 10-300mg 27 oxycodone-aspirin tabs 27 oxycodone-ibuprofen tabs 27 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 27 oxymorphone hcl tabs 5mg 10mg 27 OXYTOCIN SOLN 45 OZEMPIC (025 OR 05 MGDOSE) SOPN
45 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 45 OZEMPIC (2 MGDOSE) SOPN 45
P pacerone tabs 100mg 200mg 400mg 24 paclitaxel conc 17 PACLITAXEL PROTEIN-BOUND PART
SUSR 100 MG 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
50 PALFORZIA (120 MG DAILY DOSE) CSPK
50 PALFORZIA (160 MG DAILY DOSE) CSPK
50 PALFORZIA (20 MG DAILY DOSE) CSPK
50 PALFORZIA (200 MG DAILY DOSE) CSPK
50 PALFORZIA (240 MG DAILY DOSE) CSPK
50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK 50 PALFORZIA (300 MG TITRATION) PACK
50 PALFORZIA (40 MG DAILY DOSE) CSPK
50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
50 PALFORZIA INITIAL ESCALATION CSPK
50 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 34
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 85
palonosetron hcl soln 40 palonosetron hcl sosy 40 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 38 pamidronate disodium soln 47 pamidronate disodium solr 47 panlor tabs 27 PANRETIN GEL 56 pantoprazole sodium pack 40 PANTOPRAZOLE SODIUM SOLR 40 pantoprazole sodium tbec 20mg 40mg 40 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 52
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 57 PARICALCITOL SOLN 57 paroex soln 38 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 34 paroxetine hcl susp 34 paroxetine hcl tabs 10mg 20mg 34 paroxetine hcl tabs 30mg 40mg 34 paroxetine mesylate caps 34 paser pack 11 PEDIARIX SUSY 52 PEDVAX HIB SUSP 52 peg 3350electrolytes solr 41 peg 3350-kcl-na bicarb-nacl solr 41 peg-3350electrolytes solr 41 PEGANONE TABS 29 PEGASYS PROCLICK SOAJ
135mcg05ml 180mcg05ml 12 PEGASYS SOLN 12 PEGASYS SOSY 12 PEGINTRON KIT 12 PEG-PREP KIT 41 PEMAZYRE TABS 45mg 9mg 135mg 17 PEMFEXY SOLN 17 penicillamine caps 41 penicillamine tabs 41 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
PENTACEL SUSR 52 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 40 pentazocine-naloxone hcl tabs 27 pentobarbital sodium soln 31 pentoxifylline er tbcr 21 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 40 percocet tabs 27 perindopril erbumine tabs 2mg 4mg 8mg
25 periogard soln 38 PERJETA SOLN 17 permethrin crea 53 perphenazine tabs 2mg 4mg 8mg 16mg
34 perphenazine-amitriptyline tabs 34 PERSERIS PRSY 90mg 120mg 34 PEXEVA TABS 10mg 20mg 30mg 40mg
34 phenadoz supp 14 phenazo tabs 56 PHENAZOPYRIDINE HCL TABS 56 phenelzine sulfate tabs 34 phenergan soln 14 PHENOBARBITAL ELIX 31 PHENOBARBITAL SODIUM SOLN 31 PHENOBARBITAL TABS 31 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 20 PHENYLEPHRINE HCL SOLN 39 phenytek caps 200mg 300mg 29 phenytoin chew 29 phenytoin sodium extended caps 100mg
200mg 300mg 29 phenytoin sodium soln 29 phenytoin susp 29 PHESGO SOLN 17 PHOSLYRA SOLN 37 PHOSPHASAL TABS 13 PHOSPHOLINE IODIDE SOLR 39 phrenilin forte caps 27 PHYSIOLYTE SOLN 50 PHYSIOSOL IRRIGATION SOLN 50 PIFELTRO TABS 12 pilocarpine hcl soln 1 2 4 39 pilocarpine hcl tabs 5mg 75mg 19 pimecrolimus crea 57
86 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
pimozide tabs 1mg 2mg 34 pimtrea tabs 44 pindolol tabs 5mg 10mg 23 pioglitazone hcl tabs 15mg 30mg 45mg 45 pioglitazone hcl-glimepiride tabs 45 pioglitazone hcl-metformin hcl tabs 45 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 44 piroxicam caps 10mg 20mg 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN 32 PLEGRIDY SOSY 32 PLEGRIDY STARTER PACK SOPN 32 PLEGRIDY STARTER PACK SOSY 32 plenamine soln intravenous 36 podofilox soln 57 POLIVY SOLR 30mg 140mg 17 polocaine soln 50 polocaine-mpf soln 50 polycin oint 38 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 38 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 32 PONVORY TABS 32 portia-28 tabs 44 PORTRAZZA SOLN 17 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 35 POTASSIUM ACETATE SOLN 37 potassium chloride crys er tbcr 10meq
20meq 37 potassium chloride er cpcr 8meq 10meq 37 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 37 POTASSIUM CHLORIDE IN NACL SOLN
INTRAVENOUS 37 POTASSIUM CHLORIDE PACK 37 POTASSIUM CHLORIDE SOLN 10 20
37
potassium chloride soln intravenous 10meq100ml 20meq100ml 40meq100ml 2meqml 37
potassium citrate er tbcr 15meq 540mg 1080mg 35
POTASSIUM PHOSPHATES SOLN 37 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 37 POTELIGEO SOLN 17 PR BENZOYL PEROXIDE WASH LIQD 53 PRADAXA CAPS 75mg 110mg 150mg 21 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 31
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 31
PRAMOX GEL 56 prandin tabs 1mg 2mg 45 prasugrel hcl tabs 5mg 10mg 21 pravastatin sodium tabs 10mg 20mg
40mg 80mg 22 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22 PRED MILD SUSP 39 PRED-G SOP OINT 39 PRED-G SUSP 39 prednicarbate crea 55 prednicarbate oint 55 prednisolone acetate susp 39 prednisolone sodium phosphate soln 39 PREDNISOLONE SODIUM PHOSPHATE
SOLN 10mg5ml 20mg5ml 25mg5ml 5mg5ml 42
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 42
prednisolone soln 42 prednisone intensol conc 42 prednisone soln 42 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 42 prednisone tbpk 42 prefest tabs 45 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 29
pregabalin er tb24 825mg 165mg 330mg 27
pregabalin soln 29 PREHEVBRIO SUSP 52
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 87
PREMARIN SOLR 45 premasol soln intravenous 36 PRENATAL TABS 57 PRETOMANID TABS 11 prevalite pack 22 prevalite powd 22 previfem tabs 44 PREVYMIS SOLN 240mg12ml
480mg24ml 12 PREVYMIS TABS 240mg 480mg 12 PREZCOBIX TABS 12 PREZISTA SUSP 12 PREZISTA TABS 75mg 150mg 600mg
800mg 12 PRIFTIN TABS 11 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 29 primlev tabs 27 probenecid tabs 37 procainamide hcl soln 24 PROCALAMINE SOLN INTRAVENOUS 36 procentra soln 28 prochlorperazine edisylate soln 34 prochlorperazine maleate tabs 34 prochlorperazine supp 34 PROCRIT SOLN 20000unitml
40000unitml 22 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 22 proctofoam hc foam 56 procto-med hc crea 55 procto-pak crea 55 proctosol hc crea 55 proctozone-hc crea 55 PROCYSBI CPDR 25mg 75mg 50 PROCYSBI PACK 75mg 300mg 50 progesterone caps 100mg 200mg 46 progesterone oil 46 PROGRAF PACK 49 PROGRAF PACK 02mg 49 PROGRAF SOLN 49 prolate soln 27 prolate tabs 27 PROLEUKIN SOLR 17 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 24 propafenone hcl tabs 150mg 225mg
300mg 24 propantheline bromide tabs 19 proparacaine hcl soln 40 propranolol hcl er cp24 60mg 80mg
120mg 160mg 23 propranolol hcl soln 20mg5ml 40mg5ml 23 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 23 propranolol-hctz tabs 23 propylthiouracil tabs 47 PROQUAD SUSR 52 protriptyline hcl tabs 5mg 10mg 34 psorcon crea 55 PULMICORT FLEXHALER AEPB 51 PULMOZYME SOLN 38 PURIXAN SUSP 17 PYLERA CAPS 40 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 19 pyridostigmine bromide soln 19 pyridostigmine bromide tabs 30mg 60mg 19 pyrimethamine tabs 11 PYRUKYND TABS 5mg 20mg 50mg 50 PYRUKYND TAPER PACK TBPK 50
Q QDOLO SOLN 27 QINLOCK TABS 17 QUADRACEL SUSP 52 questran light powd 22 questran pack 22 questran powd 22 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 34 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 34 quinapril hcl tabs 5mg 10mg 20mg 40mg
25 quinapril-hydrochlorothiazide tabs 25 quinidine gluconate er tbcr 24 QUINIDINE GLUCONATE SOLN 24 quinidine sulfate tabs 200mg 300mg 24
88 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
quinine sulfate caps 11 QULIPTA TABS 10mg 30mg 60mg 30
R RABAVERT SUSR 52 rabeprazole sodium cpsp 40 rabeprazole sodium tbec 40 RADIAURA CREA 55 RADICAVA SOLN 32 raloxifene hcl tabs 45 ramelteon tabs 31 ramipril caps 125mg 25mg 5mg 10mg 25 ranolazine er tb12 500mg 1000mg 24 RAPIVAB SOLN 12 rasagiline mesylate tabs 05mg 1mg 31 RASUVO SOAJ 48 RAVICTI LIQD 35 RAYALDEE CPCR 57 REBETOL SOLN 12 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 32 REBIF REBIDOSE TITRATION PACK
SOAJ 32 REBIF SOSY 22mcg05ml 44mcg05ml 32 REBIF TITRATION PACK SOSY 32 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 44 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 52 RECORLEV TABS 50 RECTIV OINT 57 REGONOL SOLN 19 REGRANEX GEL 57 relafen ds tabs 27 RELENZA DISKHALER AEPB 12 RELEUKO SOLN 300mcgml
480mcg16ml 22 RELEUKO SOSY 300mcg05ml
480mcg08ml 22 relexxii tbcr 28 RELISTOR SOLN 8mg04ml 12mg06ml
41 RELISTOR TABS 41 reltone caps 200mg 400mg 41 REMICADE SOLR INTRAVENOUS 48 RENFLEXIS SOLR 48 repaglinide tabs 05mg 1mg 2mg 45 repaglinide-metformin hcl tabs 45
REPATHA SOSY 22 REPATHA SURECLICK SOAJ 22 RESCRIPTOR TABS 100mg 200mg 12 RESTASIS EMUL 39 RESTASIS MULTIDOSE EMUL 39 RETACRIT SOLN 22 RETACRIT SOLN 20000unitml 22 RETEVMO CAPS 40mg 80mg 17 RETIN-A CREA 0025 005 01 56 RETIN-A GEL 001 0025 56 RETIN-A MICRO GEL 004 01 56 RETIN-A MICRO PUMP GEL 004 01
56 RETISERT IMPL 39 RETROVIR SOLN 12 REVCOVI SOLN 38 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 17 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 34 REYATAZ PACK 12 REZUROCK TABS 50 RIABNI SOLN 100mg10ml 500mg50ml 17 ribasphere caps 12 ribasphere ribapak (1000 pack) tbpk 12 ribasphere ribapak (1200 pack) tbpk 12 ribasphere tabs 12 ribavirin caps 12 ribavirin solr 12 ribavirin tabs 13 RIDAURA CAPS 50 rifabutin caps 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 riluzole tabs 32 rimantadine hcl tabs 13 RIMSO-50 SOLN 50 RINGERS IRRIGATION SOLN 50 RINGERS SOLN 37 RINVOQ TB24 15mg 30mg 45mg 48 risedronate sodium tabs 5mg 30mg 35mg
150mg 47 risedronate sodium tbec 47 RISPERDAL CONSTA SRER 125mg
25mg 34 RISPERDAL CONSTA SRER 375mg
50mg 35
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 89
RISPERIDONE SOLN 35 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 35 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 35 ritonavir tabs 13 RITUXAN HYCELA SOLN 17 RITUXAN SOLN 17 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 44 rizatriptan benzoate tabs 30 rizatriptan benzoate tbdp 30 ROMIDEPSIN SOLN 17 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 31 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 31 ropivacaine hcl soln 50 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 22 ROTARIX SUSR 52 ROTATEQ SOLN 52 roweepra tabs 500mg 750mg 1000mg 29 roweepra xr tb24 500mg 750mg 29 ROZLYTREK CAPS 100mg 200mg 17 RUBRACA TABS 200mg 250mg 300mg 17 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 29 rufinamide tabs 200mg 400mg 29 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 17 RYBREVANT SOLN 17 ryclora soln 14 RYDAPT CAPS 17 RYLAZE SOLN 17 RYNODERM CREA 57 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 46 SAIZEN SOLR 5mg 88mg 46 SAIZENPREP SOLR 46 sajazir soln 21 SALEX SHAM 57 SALICYLIC ACID CREA 57
SALICYLIC ACID ER SOLN 57 SALICYLIC ACID FOAM 57 SALICYLIC ACID GEL 57 SALICYLIC ACID SHAM 57 SALICYLIC ACID-CLEANSER KIT 57 SALSALATE TABS 27 SANCUSO PTCH 40 SANDIMMUNE ORAL SOLN 100mgml 49 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 46 SANTYL OINT 57 SAPHNELO SOLN 49 SAPHRIS SUBL 25mg 5mg 10mg 35 sapropterin dihydrochloride pack 100mg
500mg 50 sapropterin dihydrochloride tabs 50 SARCLISA SOLN 500mg25ml 100mg5ml
17 SCEMBLIX TABS 20mg 40mg 17 scopolamine pt72 40 seconal caps 31 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 35 selegiline hcl caps 31 selegiline hcl tabs 31 selenium sulfide lotn 53 SELENIUM SULFIDE SHAM 53 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 13 SENSORCAINE SOLN 50 sensorcaineepinephrine soln 50 sensorcaine-mpf soln 50 sensorcaine-mpfepinephrine soln 50 SEREVENT DISKUS AEPB 20 SEROSTIM SOLR 4mg 5mg 6mg 46 SERTRALINE HCL CAPS 150mg 200mg
35 sertraline hcl conc 35 sertraline hcl tabs 25mg 50mg 100mg 35 setlakin tabs 44 sevelamer carbonate pack 08gm 24gm 36 sevelamer carbonate tabs 36 sevelamer hcl tabs 400mg 800mg 36 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 44 SHINGRIX SUSR 52 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 46
90 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
SIGNIFOR SOLN 03mgml 06mgml 09mgml 46
SIKLOS TABS 17 sildenafil citrate soln 25 sildenafil citrate susr 25 sildenafil citrate tabs 25 SILIQ SOSY 57 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 53 SIMPONI ARIA SOLN 48 SIMPONI SOAJ 50mg05ml 100mgml 48 SIMPONI SOSY 50mg05ml 100mgml 48 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 22 sirolimus soln 49 sirolimus tabs 05mg 1mg 2mg 49 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKYRIZI (150 MG DOSE) PSKT 57 SKYRIZI PEN SOAJ 57 SKYRIZI SOSY 57 SKYTROFA CART 3mg 36mg 43mg
52mg 63mg 76mg 91mg 11mg 133mg 46
sod benz-sod phenylacet soln 35 SODIUM ACETATE SOLN 35 SODIUM BICARBONATE SOLN 35 SODIUM CHLORIDE (PF) SOLN 37 SODIUM CHLORIDE SOLN 37 50 SODIUM CHLORIDE SOLN
INTRAVENOUS 045 09 3 5 37 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 50 SODIUM FLUORIDE SOLN 50 sodium phenylbutyrate powd 35 sodium phenylbutyrate tabs 35 SODIUM PHOSPHATES SOLN 37 sodium polystyrene sulfonate powd 36 sodium polystyrene sulfonate susp 36 sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 57 SOLTAMOX SOLN 17 SOLU-CORTEF SOLR 42 SOLU-MEDROL SOLR 42 SOMATULINE DEPOT SOLN 60mg02ml
90mg03ml 120mg05ml 46 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 46
sorine tabs 80mg 120mg 160mg 240mg 23
sotalol hcl (af) tabs 80mg 120mg 160mg 23 sotalol hcl tabs 80mg 120mg 160mg
240mg 23 SOTYLIZE SOLN 23 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 25 spironolactone-hctz tabs 25 SPRAVATO (56 MG DOSE) SOPK 35 SPRAVATO (84 MG DOSE) SOPK 35 sprintec 28 tabs 44 SPRITAM TB3D 250mg 500mg 750mg
1000mg 29 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 36 sronyx tabs 44 SSD CREA 53 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
57 STELARA SOSY 45mg05ml 90mgml 57 STERILE WATER FOR IRRIGATION SOLN
50 STIMATE SOLN 46 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18 STRENSIQ SOLN 18mg045ml
28mg07ml 80mg08ml 40mgml 38 streptomycin sulfate solr 10 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 20 SUBLOCADE SOSY 100mg05ml
300mg15ml 32 SUBSYS LIQD 1200mcg 1600mcg 27 subvenite starter kit-blue kit 29 subvenite starter kit-green kit 29 subvenite starter kit-orange kit 30 subvenite tabs 25mg 100mg 150mg
200mg 30 succinylcholine chloride soln 20 SUCRAID SOLN 38 sucralfate susp 40 sucralfate tabs 40
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 91
sulfacetamide sodium (acne) lotn 53 sulfacetamide sodium oint 38 sulfacetamide sodium soln 38 sulfacetamide-prednisolone soln 39 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 SULFAMYLON CREA 53 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 27 sumatriptan soln 30 sumatriptan succinate refill soct 30 sumatriptan succinate soaj 30 sumatriptan succinate soln 30 sumatriptan succinate sosy 30 sumatriptan succinate tabs 30 sunitinib malate caps 125mg 25mg
375mg 50mg 18 suprax chew 10 SUPREP BOWEL PREP KIT SOLN 41 SUSVIMO (IMPLANT 1ST FILL) SOLN 39 SUSVIMO (IMPLANT REFILL) SOLN 39 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 44 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 51 SYMDEKO TBPK 51 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 45 SYMLINPEN 60 SOPN 45 SYMPAZAN FILM 10mg 20mg 30 SYMPAZAN FILM 5mg 30 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 46 SYNDROS SOLN 40 SYNERCID SOLR 10 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 tacrolimus caps 05mg 1mg 5mg 49 TACROLIMUS OINT 01 003 57
tadalafil (pah) tabs 20mg 25 tadalafil tabs 25mg 5mg 25 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 50 TAKHZYRO SOSY 50 TALTZ SOAJ 57 TALTZ SOSY 57 TALZENNA CAPS 025mg 05mg 075mg
1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 47 taperdex 12-day tbpk 42 taperdex 6-day tbpk 42 taperdex 7-day tbpk 42 targadox tabs 10 TARGRETIN GEL 56 tarina 24 fe tabs 44 tarina fe 120 eq tabs 44 TARPEYO CPDR 42 TASIGNA CAPS 50mg 150mg 200mg 18 TAVALISSE TABS 100mg 150mg 22 TAVNEOS CAPS 50 taysofy caps 44 tazarotene crea 57 tazarotene foam 57 tazicef solr injection 10 tazicef solr intravenous 2gm 6gm 10 TAZORAC CREA 57 TAZORAC GEL 005 01 57 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 52 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TEFLARO SOLR INTRAVENOUS 10 TEGSEDI SOSY 50 telmisartan tabs 20mg 40mg 80mg 25 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 25 TEMAZEPAM CAPS 75mg 15mg 225mg
30mg 31 temsirolimus soln 18 tencon tabs 27 TENIPOSIDE SOLN 18 TENIVAC INJ 52 tenofovir disoproxil fumarate tabs 13
92 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TEPADINA SOLR 18 TEPEZZA SOLR 39 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 20 terbutaline sulfate tabs 25mg 5mg 20 terconazole crea 53 terconazole supp 53 TERIPARATIDE (RECOMBINANT) SOPN
46 testosterone cypionate soln 100mgml
200mgml 42 testosterone enanthate soln 42 testosterone gel 1 162
2025mg125gm 405mg25gm 10mgact 42
testosterone soln 42 tetrabenazine tabs 125mg 25mg 32 TETRACAINE HCL SOLN 40 tetracycline hcl caps 250mg 500mg 10 texacort soln 55 TEZSPIRE SOSY 51 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 57 theophylline er tb12 100mg 200mg
300mg 450mg 57 theophylline er tb24 400mg 600mg 57 theophylline soln 57 THIOLA EC TBEC 100mg 300mg 50 THIOLA TABS 50 thioridazine hcl tabs 10mg 25mg 50mg
100mg 35 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 35 THYROGEN SOLR 50 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
30 TIBSOVO TABS 18 TICOVAC SUSY 52 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 32 tilia fe tabs 44 timolol maleate (once-daily) soln 39 timolol maleate pf soln 39
TIMOLOL MALEATE SOLG 025 05 39 timolol maleate soln 025 05 39 timolol maleate tabs 5mg 10mg 20mg 23 tinidazole tabs 11 tiopronin tabs 50 TIS-U-SOL SOLN 50 TIVDAK SOLR 18 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 tizanidine hcl caps 20 tizanidine hcl tabs 20 TOBI PODHALER CAPS 51 TOBRADEX OINT 39 TOBRADEX ST SUSP 39 tobramycin nebu 300mg4ml 300mg5ml 51 tobramycin soln 38 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 39 TOBREX OINT 38 tofranil tabs 10mg 25mg 50mg 35 tolazamide tabs 250mg 500mg 45 tolbutamide tabs 45 tolcapone tabs 31 tolmetin sodium caps 27 tolmetin sodium tabs 27 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 57 tolterodine tartrate tabs 57 tolvaptan tabs 15mg 30mg 36 TOPEX TOPICAL ANESTHETIC AERO 56 topicort crea 005 025 55 topicort gel 55 topicort oint 55 topiramate cpsp 15mg 25mg 30 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 30 topiramate tabs 25mg 50mg 100mg
200mg 30 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
36 TPN ELECTROLYTES CONC
INTRAVENOUS 37 TRACLEER TBSO 51 TRADJENTA TABS 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 93
tramadol hcl er (biphasic) tb24 100mg 200mg 300mg 28
tramadol hcl er cp24 100mg 150mg 200mg 300mg 28
tramadol hcl er tb24 100mg 200mg 300mg 28
tramadol hcl soln 28 tramadol hcl tabs 50mg 100mg 28 tramadol-acetaminophen tabs 28 trandolapril tabs 1mg 2mg 4mg 25 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 21 tranexamic acid tabs 21 tranylcypromine sulfate tabs 35 TRAVASOL SOLN INTRAVENOUS 36 travoprost (bak free) soln 39 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 150mg 300mg 35 trazodone hcl tabs 50mg 100mg 35 TRECATOR TABS 11 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 57 TREMFYA SOSY 57 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 51 tretinoin caps 18 tretinoin crea 0025 005 01 56 tretinoin gel 001 0025 005 56 tretinoin microsphere gel 004 01 56 tretinoin microsphere pump gel 004
01 56 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 28 triamcinolone acetonide aers 55 triamcinolone acetonide crea 0025
01 05 55 triamcinolone acetonide lotn 0025 01
55 triamcinolone acetonide oint 0025
005 01 05 55 triamcinolone acetonide pste 55 triamcinolone acetonide susp 42 triamterene caps 50mg 100mg 36 triamterene-hctz caps 36 triamterene-hctz tabs 36 trianex oint 55 triazolam tabs 0125mg 025mg 31 TRICITRATES SOLN 35 triderm crea 01 05 55
trientine hcl caps 41 tri-estarylla tabs 44 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 35 trifluridine soln 38 trihexyphenidyl hcl soln 31 trihexyphenidyl hcl tabs 2mg 5mg 31 TRIKAFTA TBPK 51 tri-legest fe tabs 44 tri-lo-estarylla tabs 44 tri-lo-sprintec tabs 44 trilyte solr 41 trimethobenzamide hcl caps 40 TRIMETHOPRIM TABS 13 tri-mili tabs 44 trimipramine maleate caps 25mg 50mg
100mg 35 TRINESSA (28) TABS 44 TRINTELLIX TABS 5mg 10mg 20mg 35 tri-nymyo tabs 44 tri-previfem tabs 44 TRIPTODUR SRER 45 TRISENOX
SOLN 18 tri-sprintec tabs 44 tritocin oint 55 TRIUMEQ PD TBSO 13 TRIUMEQ TABS 13 trivora (28) tabs 44 tri-vylibra lo tabs 44 tri-vylibra tabs 44 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 30 TROPHAMINE SOLN INTRAVENOUS 36 trospium chloride er cp24 57 trospium chloride tabs 57 TRULANCE TABS 41 TRUMENBA SUSY 52 TRUSELTIQ (100MG DAILY DOSE) CPPK
18 TRUSELTIQ (125MG DAILY DOSE) CPPK
18 TRUSELTIQ (50MG DAILY DOSE) CPPK
18 TRUSELTIQ (75MG DAILY DOSE) CPPK
18
94 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 52 TYBOST TABS 13 tydemy tabs 44 tylenol with codeine 3 tabs 28 tylenol with codeine 4 tabs 28 TYMLOS SOPN 46 TYPHIM VI SOLN 52 TYPHIM VI SOSY 52 TYVASO REFILL SOLN 51 TYVASO STARTER SOLN 51
U UBRELVY TABS 50mg 100mg 30 UDENYCA SOSY 22 UKONIQ TABS 18 ULTOMIRIS SOLN 50 UMECTA MOUSSE FOAM 57 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
UNITUXIN SOLN 18 UPTRAVI SOLR 51 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 51
UPTRAVI TBPK 51 UREA CREA 39 57 UREA LOTN 40 57 UREA-C40 LOTN 57 urecholine tabs 5mg 10mg 25mg 50mg 20 uredeb crea 57 URETRON DS TABS 13 URIN DS TABS 13 ursodiol caps 200mg 400mg 41 ursodiol caps 300mg 41 ursodiol tabs 250mg 500mg 41 URYL TABS 13 USTELL CAPS 13 UTICAP CAPS 13 UTIRA-C TABS 13 UTRONA-C TABS 13
V VABYSMO SOLN 39 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 57 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 30 valproic acid caps 30 valproic acid soln 30 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
25 valsartan-hydrochlorothiazide tabs 25 VALTOCO 10 MG DOSE LIQD 30 VALTOCO 15 MG DOSE LQPK 30 VALTOCO 20 MG DOSE LQPK 30 VALTOCO 5 MG DOSE LIQD 30 vanatol lq soln 28 vancomycin hcl caps 10 vancomycin hcl solr 250mg5ml 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 vancomycin hcl solr intravenous 5gm
750mg 10 VANDAZOLE GEL 53 VANOXIDE-HC LOTN 55 VANTAS KIT 18 VAQTA SUSP 52 varenicline tartrate misc 19 varenicline tartrate tabs 05mg 1mg 19 VARIVAX INJ 52 VARIZIG SOLN 52 VASCEPA CAPS 1gm 22 VAXCHORA SUSR 53 vecamyl tabs 24 VECTICAL OINT 57 VEKLURY SOLN 13 VEKLURY SOLR 13 VELCADE SOLR 18 velivet tabs 44 VELPHORO CHEW 36 VELTASSA PACK 84gm 168gm 252gm
36 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 18 VENCLEXTA TABS 10mg 18 VENCLEXTA TABS 50mg 100mg 18
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 95
venlafaxine hcl er cp24 375mg 75mg 150mg 35
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg 35
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg 35
VENTAVIS SOLN 10mcgml 20mcgml 52 verapamil hcl er tbcr 120mg 180mg 240mg
24 verapamil hcl soln 24 verapamil hcl tabs 40mg 80mg 120mg 24 veripred 20 soln 42 VERKAZIA EMUL 39 VERSACLOZ SUSP 35 VERZENIO TABS 50mg 100mg 150mg
200mg 18 vestura tabs 44 VIBERZI TABS 75mg 100mg 41 vicodin es tabs 28 vicodin hp tabs 28 vicodin tabs 28 VICTOZA SOPN 45 VIDEX EC CPDR 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 44 vigabatrin pack 30 vigabatrin tabs 30 VIIBRYD STARTER PACK KIT 35 VIIBRYD TABS 10mg 20mg 40mg 35 VIJOICE TBPK 50 VILTEPSO SOLN 50 VIMIZIM SOLN 38 VIMPAT SOLN 30 vinblastine sulfate soln 18 vincasar pfs soln 18 vincristine sulfate soln 18 vinorelbine tartrate soln 18 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 47 VITRAKVI CAPS 25mg 100mg 18 VITRAKVI SOLN 18 VIVITROL SUSR 32 VIZIMPRO TABS 15mg 30mg 45mg 18 VOCABRIA TABS 13
VONJO CAPS 18 VORAXAZE SOLR 47 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 18 VOXZOGO SOLR 04mg 056mg 12mg 50 VPRIV SOLR 38 VRAYLAR CAPS 15mg 3mg 45mg 6mg
35 VRAYLAR CPPK 35 VUMERITY (STARTER) CPDR 50 VUMERITY CPDR 50 vyfemla tabs 44 vylibra tabs 44 VYNDAMAX CAPS 24 VYNDAQEL CAPS 24 VYONDYS 53 SOLN 50 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 28 VYVGART SOLN 50 VYXEOS SUSR 18
W WAKIX TABS 445mg 178mg 28 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 21 WATER FOR IRRIGATION STERILE
SOLN 50 WELIREG TABS 18 wixela inhub aepb 51 wymzya fe chew 44 WYNZORA CREA 55
X XALKORI CAPS 200mg 250mg 18 XARELTO STARTER PACK TBPK 21 XARELTO SUSR 21 XARELTO TABS 25mg 10mg 15mg
20mg 21 XATMEP SOLN 18 XCOPRI (250 MG DAILY DOSE) TBPK 30 XCOPRI (350 MG DAILY DOSE) TBPK 30 XCOPRI TABS 200mg 30 XCOPRI TABS 50mg 100mg 150mg 30 XCOPRI TBPK 30 XCOPRI TBPK 14x125mg amp 14x25mg 30
96 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
XELJANZ SOLN 48 XELJANZ TABS 5mg 10mg 48 XELJANZ XR TB24 11mg 22mg 48 XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 50 XERMELO TABS 40 XGEVA SOLN 47 XIFAXAN TABS 200mg 550mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 51 XOLAIR SOSY 75mg05ml 150mgml 51 XOSPATA TABS 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 18 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 18 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 XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 44 XUREA CREA 57 XURIDEN PACK 50 xylocaine dental soln 50 XYREM SOLN 32 XYWAV SOLN 32
Y YERVOY SOLN 19 YF-VAX INJ 53 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 39 yuvafem tabs 45
Z zafemy ptwk 44
zafirlukast tabs 10mg 20mg 51 zaleplon caps 5mg 10mg 31 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 44 zarontin soln 30 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 28 ZEJULA CAPS 19 ZELAPAR TBDP 31 ZELBORAF TABS 19 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
57 ZENPEP CPEP 38 zenzedi tabs 25mg 5mg 75mg 10mg
15mg 20mg 30mg 28 ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
32 ZEPOSIA CAPS 32 ZEPOSIA STARTER KIT CPPK 32 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERUVIA PTCH 56 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 51 ZIONODIL 100 LOTN 56 ZIONODIL LOTN 56 ziprasidone hcl caps 20mg 40mg 60mg
80mg 35 ziprasidone mesylate solr 35 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZOKINVY CAPS 50mg 75mg 50 zoledronic acid conc 47 zoledronic acid soln 47 ZOLINZA CAPS 19 zolmitriptan soln 30 zolmitriptan tabs 30 zolmitriptan tbdp 30 zolpidem tartrate er tbcr 625mg 125mg 31 zolpidem tartrate subl 175mg 35mg 31 zolpidem tartrate tabs 5mg 10mg 31 zonisamide caps 25mg 50mg 100mg 30 ZORBTIVE SOLR 46
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 97
ZORTRESS TABS 49 ZOSTAVAX SUSR 53 zovia 135 (28) tabs 44 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19
ZYKADIA TABS 19 ZYNLONTA SOLR 19 ZYPREXA RELPREVV SUSR 35 ZYTIGA TABS 19
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with a Member Services representative for the dispute-resolution options that apply to you
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
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)
682896130 062022
This formulary was updated on 060122 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
kporgseniorrx Please recycle
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
Kaiser Permanente 2022 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 titled 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 on how to request an exception You
2 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 2022 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2022 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 June 1 2022 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 59 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 see your Evidence of Coverage for more information
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 3
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 2022 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 2022 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 2022 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
4 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 5
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 2022 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 59 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg CIPRODEX) and generic drugs are listed in lower-case italics (eg amoxicillin) 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 2022 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
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 8 bull Kaiser Permanente 2022 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 azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP BICILLIN L-A SUSY cefaclor caps
Drug Name RequirementsLimits
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 intravenous 1gm 2gm 10gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 6gm HI
ceftazidime solr intravenous HI CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 750mg HI
cefuroxime sodium solr intravenous 15gm HI
cephalexin caps cephalexin susr cephalexin tabs chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w 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 2022 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
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 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 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
Drug Name RequirementsLimits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs erythromycin tbec FETROJA SOLR NDS 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 LYMEPAK 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
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium 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 10 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs 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 streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO suprax chew SYNERCID SOLR
Drug Name RequirementsLimits
targadox tabs MO tazicef solr injection HI tazicef solr intravenous 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
vancomycin hcl caps vancomycin hcl solr 250mg5ml vancomycin hcl solr intravenous 1gm 10gm 500mg HI
vancomycin hcl solr intravenous 5gm 750mg
XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ANTIFUNGALS AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS 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
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 2022 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS nystatin susp nystatin tabs 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 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 SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS
Drug Name RequirementsLimits
mefloquine hcl tabs metronidazole caps METRONIDAZOLE SOLN INTRAVENOUS 500mg100ml HI
metronidazole tabs nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs quinine sulfate caps NDS 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 APRETUDE SUER 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 DELSTRIGO TABS MO DESCOVY TABS 200-25mg MO DESCOVY TABS 120-15mg MO didanosine cpdr 200mg 250mg 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 12 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 PACK PANDS EPCLUSA TABS PANDS 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 LIVTENCITY TABS NDS lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO
Drug Name RequirementsLimits
maraviroc tabs 150mg 300mg MO MAVYRET PACK PANDS 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 oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEGASYS PROCLICK SOAJ 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN NDS PEGASYS SOSY NDS PEGINTRON KIT NDS PIFELTRO TABS MO 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
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 2022 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg MO sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS 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 PD TBSO MO TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEKLURY SOLN NDS VEKLURY SOLR NDS VEMLIDY TABS VIDEX EC CPDR 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
Drug Name RequirementsLimits
VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES 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 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg abiraterone acetate tabs 500mg NDS ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS NDS ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs arsenic trioxide soln NDS ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr
Drug Name RequirementsLimits
BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE SOLR BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS BESREMI SOSY NDS bexarotene caps NDS bicalutamide tabs 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 CAMCEVI PRSY CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR 50mg 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
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 2022 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
CYCLOPHOSPHAMIDE SOLN 2gm10ml 1gm5ml 500mg25ml
NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr 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 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 eulexin caps NDS
Drug Name RequirementsLimits
everolimus tabs 25mg 5mg 75mg 10mg NDS
everolimus tbso 2mg 3mg 5mg NDS EVOMELA SOLR NDS exemestane tabs EXKIVITY CAPS NDS FARYDAK CAPS 10mg 15mg 20mg LDNDS
FENSOLVI (6 MONTH) KIT 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 FYARRO SUSR 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 6000000unitml 10000000unitml
NDS
INTRON A SOLR 10000000unit 18000000unit 50000000unit 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 KIMMTRAK 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
lenalidomide caps 5mg 10mg 15mg 25mg NDS
Drug Name RequirementsLimits
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
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 TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA 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 2022 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
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 methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS nelarabine soln 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 120mg12ml 240mg24ml 40mg4ml
NDS
OPDUALAG SOLN NDS oxaliplatin soln oxaliplatin solr paclitaxel conc PACLITAXEL PROTEIN-BOUND PART SUSR 100 MG NDS
PADCEV SOLR 20mg 30mg NDS
Drug Name RequirementsLimits
paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEMFEXY SOLN 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 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
SCEMBLIX TABS 20mg 40mg NDS SIKLOS TABS NDS SOLTAMOX SOLN
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
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 05mg 075mg 1mg NDS
tamoxifen citrate tabs 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 TIVDAK SOLR 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 NDS
TRODELVY SOLR NDS
Drug Name RequirementsLimits
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 UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln 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
VONJO CAPS NDS VOTRIENT TABS NDS VYXEOS SUSR NDS WELIREG TABS 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
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 2022 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
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 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 ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO chlordiazepoxide-clidinium caps dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate oral soln MO glycopyrrolate pf sosy glycopyrrolate soln injection glycopyrrolate tabs 1mg 2mg MO
Drug Name RequirementsLimits
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 RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO varenicline tartrate misc MO varenicline tartrate tabs 05mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA FLEQSUVY SUSP NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs 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
Drug Name RequirementsLimits
albuterol sulfate er tb12 4mg 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcgact MONDS
albuterol sulfate nebu 0083 25mg05ml 063mg3ml 125mg3ml
PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY ipratropium-albuterol soln PAMO isoproterenol hcl soln LEVALBUTEROL HCL NEBU 125mg05ml 125mg3ml 031mg3ml 063mg3ml
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 SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS icatibant acetate 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 2022 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
OXBRYTA TABS NDS OXBRYTA TBSO NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS 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 BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln NDS enoxaparin sodium sosy 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
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 NDS LOVENOX SOSY 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg 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 SUSR NDS XARELTO TABS 25mg 10mg 15mg 20mg MO
HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
EPOGEN SOLN PANDS FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
PROCRIT SOLN 20000unitml 40000unitml PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RELEUKO SOLN 300mcgml 480mcg16ml NDS
RELEUKO SOSY 300mcg05ml 480mcg08ml NDS
RETACRIT SOLN 20000unitml PANDS RETACRIT SOLN PANDS TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS 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 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
Drug Name RequirementsLimits
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 150mg MO fenofibrate micronized caps 43mg 67mg 130mg 134mg 200mg
MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg 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
lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
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 SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 1gm MO BETA-ADRENERGIC BLOCKING 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 2022 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
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
ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
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
nadololbendroflumethiazide 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
Drug Name RequirementsLimits
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 cartia xt cp24 120mg 180mg 240mg 300mg MO
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 40mg 80mg 120mg MO
CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR SOLN MO CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln 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 lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy
Drug Name RequirementsLimits
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 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
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 2022 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
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
captopril-hydrochlorothiazide 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
quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
Drug Name RequirementsLimits
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO 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 dipyridamole tabs 25mg 50mg 75mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ascomp-codeine caps NDS benzhydrocodone-acetaminophen tabs NDS
bupap tabs 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 NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS dvorah tabs 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
Drug Name RequirementsLimits
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
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 hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd 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 NDS indomethacin caps indomethacin er cpcr indomethacin sodium solr ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lorcet hd tabs NDS lorcet plus 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln NDS meperidine hcl tabs 50mg NDS methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl tabs 5mg 10mg NDS MORPHINE SULFATE (CONCENTRATE) SOLN NDS
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 tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln 10mgml 20mgml NDS
nalfon tabs nalocet tabs NDS naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs
Drug Name RequirementsLimits
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 75-300mg 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 relafen ds tabs NDS SALSALATE TABS SUBSYS LIQD 1200mcg 1600mcg PANDS
sulindac tabs tencon tabs tolmetin sodium caps tolmetin sodium tabs
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 soln 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 tabs NDS vicodin es tabs NDS vicodin hp tabs NDS zebutal caps ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS amphetamine er suer NDS 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 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
evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS
Drug Name RequirementsLimits
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
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS procentra soln NDS relexxii tbcr NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
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
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 2022 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
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
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 EPRONTIA SOLN 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 lacosamide tabs 50mg 100mg 150mg 200mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
Drug Name RequirementsLimits
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
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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg 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 VALTOCO 15 MG DOSE LQPK VALTOCO 20 MG DOSE LQPK VALTOCO 5 MG DOSE LIQD vigabatrin pack LDNDS vigabatrin tabs NDS VIMPAT SOLN XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200mg NDS XCOPRI TBPK 14x125mg amp 14x25mg
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ PA AJOVY SOSY PA almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs
Drug Name RequirementsLimits
ergotamine-caffeine tabs FROVATRIPTAN SUCCINATE TABS
naratriptan hcl tabs NURTEC TBDP NDS QULIPTA TABS 10mg 30mg 60mg NDS
rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs UBRELVY TABS 50mg 100mg NDS zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl soln MO amantadine hcl tabs MO APOKYN SOCT NDS apomorphine hcl 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
EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg 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 2022 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
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
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
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 intensol conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS droperidol soln estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
Drug Name RequirementsLimits
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP PANDS 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 nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs seconal caps TEMAZEPAM CAPS 75mg 15mg 225mg 30mg 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS tetrabenazine tabs 125mg 25mg MO
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
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 1mg 2mg NDS
OCREVUS SOLN PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
Drug Name RequirementsLimits
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 ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS OPIATE ANTAGONISTS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
LUCEMYRA TABS NDS naloxone hcl liqd naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
VIVITROL SUSR NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg 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 2022 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
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 conc 30mgml 100mgml MO
chlorpromazine hcl soln chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
CITALOPRAM HYDROBROMIDE CAPS MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
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 HAFYERA SUSY INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 150mg 300mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
LITHIUM CARBONATE TABS MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
LYBALVI TABS NDS maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
Drug Name RequirementsLimits
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 susp MO paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps 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
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
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 2022 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
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 CAPS 150mg 200mg MO
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
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 MO trazodone hcl tabs 150mg 300mg 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
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 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 TRICITRATES SOLN AMMONIA DETOXICANTS carglumic acid tbso NDS constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN DEXTROSE SOLN INTRAVENOUS 5 10 HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE 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
Drug Name RequirementsLimits
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI furosemide tabs 20mg 40mg 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN tolvaptan tabs 15mg 30mg 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 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
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 2022 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate tabs MO CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
DEXTROSE-NACL SOLN INTRAVENOUS 25-045 5-02 5-045 5-09
HI
DEXTROSE-NACL SOLN INTRAVENOUS 10-02 10-045
HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 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 PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
Drug Name RequirementsLimits
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 10meq100ml 20meq100ml 40meq100ml 2meqml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN 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 ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME 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 38 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin oint bacitracin-polymyxin b oint bleph-10 soln chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin 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 paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln
Drug Name RequirementsLimits
sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ANTI-INFLAMMATORY AGENTS bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
CEQUA SOLN CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO cyclosporine emul MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO difluprednate emul MO flac oil 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
ILUVIEN IMPL ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint 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 2022 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
RESTASIS EMUL MO RESTASIS MULTIDOSE EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
VERKAZIA EMUL NDS YUTIQ IMPL ANTIALLERGIC AGENTS azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
betaxolol hcl soln MO bimatoprost soln MO brimonidine tartrate soln 015 02 MO
brinzolamide susp MO carteolol hcl soln MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
Drug Name RequirementsLimits
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO timolol maleate (once-daily) soln MO timolol maleate pf soln MO TIMOLOL MALEATE SOLG 025 05 MO
timolol maleate soln 025 05 MO
travoprost (bak free) 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 SUSVIMO (IMPLANT 1ST FILL) SOLN
SUSVIMO (IMPLANT REFILL) SOLN
TEPEZZA SOLR NDS VABYSMO SOLN LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lidocaine viscous hcl soln MO proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
balsalazide disodium caps MO colazal caps 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 OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS aprepitant caps PANDS dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl sosy ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy
Drug Name RequirementsLimits
SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS trimethobenzamide hcl caps PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc 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 famotidine (pf) soln 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 omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate 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 2022 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS 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 IBSRELA TABS NDS LIVMARLI SOLN NDS lubiprostone caps 8mcg 24mcg MO metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS TRULANCE TABS 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
Drug Name RequirementsLimits
clovique caps NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs deferasirox tbso deferiprone tabs 500mg 1000mg NDS
deferoxamine mesylate solr FERRIPROX SOLN LDNDS FERRIPROX TABS LDNDS FERRIPROX TWICE-A-DAY TABS NDS
penicillamine caps NDS penicillamine tabs NDS trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP ALKINDI SPRINKLE CPSP 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs 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 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp 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 10mg5ml 20mg5ml 25mg5ml 5mg5ml
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 SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TARPEYO CPDR NDS triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
danazol caps 50mg 100mg 200mg MO
Drug Name RequirementsLimits
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 405mg25gm 10mgact
MO
testosterone soln 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 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 enpresse-28 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 2022 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
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 jasmiel tabs MO JOLIVETTE 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
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
Drug Name RequirementsLimits
levora 01530 (28) 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 24 fe tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA 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 nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO nylia 135 tabs MO nylia 777 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 44 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 taysofy caps 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 wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135 (28) tabs MO
Drug Name RequirementsLimits
DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
AFREZZA POWD 90x8 UNIT amp 90x12 UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD 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 glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO HUMALOG KWIKPEN SOPN MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
JARDIANCE TABS 10mg 25mg MO KORLYM TABS LDNDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO metformin hcl er tb24 500mg 750mg 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 2022 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
OZEMPIC (2 MGDOSE) SOPN MO pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO tolazamide tabs 250mg 500mg MO tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
depo-estradiol oil dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
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 MO
Drug Name RequirementsLimits
006mg24hr 0075mg24hr 01mg24hr estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO fyavolv tabs MO jinteli tabs MO lopreeza tabs MO lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO prefest tabs MO PREMARIN SOLR raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PANDS CORTROPHIN GEL PANDS desmopressin ace spray refrig soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln desmopressin acetate tabs 01mg 02mg MO
SKYTROFA CART 3mg 36mg 43mg 52mg 63mg 76mg 91mg 11mg 133mg
NDS
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO 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 progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR NDS
Drug Name RequirementsLimits
EGRIFTA SV SOLR NDS GENOTROPIN CART 12mg PANDS GENOTROPIN MINIQUICK PRSY 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
HUMATROPE CART 6mg 12mg 24mg PANDS
HUMATROPE SOLR PANDS INCRELEX SOLN NDS LANREOTIDE ACETATE SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
octreotide acetate soln 50mcgml 100mcgml 200mcgml
octreotide acetate soln 500mcgml 1000mcgml
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 60mg02ml 90mg03ml 120mg05ml
NDS
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 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 2022 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 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 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
Drug Name RequirementsLimits
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 BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 70mg MO alendronate sodium tabs 5mg 10mg 35mg 40mg MO
EVENITY SOSY NDS IBANDRONATE SODIUM SOLN ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr 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 CIBINQO TABS 50mg 100mg 200mg NDS
CIMZIA KIT PANDS CIMZIA PREFILLED PSKT PANDS CIMZIA STARTER KIT PSKT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
INFLIXIMAB SOLR INTRAVENOUS HI
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 RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 15mg 30mg 45mg NDS
SIMPONI ARIA SOLN NDS
Drug Name RequirementsLimits
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 ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
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
ZORTRESS TABS PA MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BERINERT KIT INTRAVENOUS HI betaine powd NDS 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
Drug Name RequirementsLimits
CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENJAYMO SOLN 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 HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ONPATTRO SOLN NDS 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
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 PYRUKYND TABS 5mg 20mg 50mg NDS
PYRUKYND TAPER PACK TBPK NDS
RECORLEV TABS NDS REZUROCK TABS NDS
Drug Name RequirementsLimits
RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln 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 STERILE WATER FOR IRRIGATION SOLN
TAKHZYRO SOLN NDS TAKHZYRO SOSY NDS TAVNEOS CAPS NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR NDS tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VIJOICE TBPK NDS VILTEPSO SOLN NDS VOXZOGO SOLR 04mg 056mg 12mg NDS
VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS VYVGART SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg 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 2022 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 100mg067ml 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 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 ADVAIR HFA AERO 230-21mcgact MO
ADVAIR HFA AERO 45-21mcgact 115-21mcgact MO
Drug Name RequirementsLimits
ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS HI
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
DALIRESP TABS 250mcg 500mcg MO
FLOVENT HFA AERO MO fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PULMICORT FLEXHALER AEPB
SYMBICORT AERO TEZSPIRE SOSY NDS wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg 1000mcg 1200mcg 1400mcg 1600mcg
NDS
UPTRAVI TBPK NDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS HI
GAMUNEX-C SOLN INJECTION HI HYPERHEP B SOLN HYPERHEP B SOSY HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 1gm20ml 2gm20ml
HI
PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
VARIZIG SOLN TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP KINRIX SUSY QUADRACEL SUSP TDVAX SUSP
Drug Name RequirementsLimits
TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP BOOSTRIX SUSY 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 SOLN MENQUADFI SOLN MENVEO SOLR PEDIARIX SUSY PEDVAX HIB SUSP PENTACEL SUSR PREHEVBRIO SUSP PA PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TICOVAC SUSY TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN TYPHIM VI SOSY VAQTA SUSP VARIVAX INJ
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 2022 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint 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 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 clindamycin phosphate soln MO clindamycin phosphate swab MO clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn econazole nitrate crea ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA
Drug Name RequirementsLimits
gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham mafenide acetate pack malathion lotn metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea mupirocin oint naftifine hcl crea naftifine hcl gel neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ovide lotn oxiconazole nitrate crea permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 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
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
Drug Name RequirementsLimits
clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT 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 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
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO FLURANDRENOLIDE CREA 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 2022 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
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 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 prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO
Drug Name RequirementsLimits
psorcon crea MO RADIAURA CREA NDS texacort soln MO topicort crea 005 025 MO topicort gel MO topicort oint 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 VANOXIDE-HC LOTN WYNZORA CREA NDS ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
HYDROCORTISONE ACE-PRAMOXINE SUPP NDS
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 LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS 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
TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS 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
Drug Name RequirementsLimits
adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ADBRY SOSY NDS ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
azelaic acid gel MO AZELEX CREA MO 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
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA 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 KORSUVA SOLN NDS LACTIC ACID LOTN
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 2022 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
OPZELURA CREA 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 SHAM SALICYLIC ACID-CLEANSER KIT
SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SKYRIZI PEN SOAJ SKYRIZI SOSY STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
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 TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS
Drug Name RequirementsLimits
VECTICAL OINT MO XUREA CREA zenatane caps 10mg 20mg 30mg 40mg NDS
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 calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS
58 bull Kaiser Permanente 2018 Defined Standard Comprehensive Formulary
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 59
Index of Drugs
A abacavir sulfate soln 11 abacavir sulfate tabs 11 abacavir sulfate-lamivudine tabs 11 abacavir-lamivudine-zidovudine tabs 11 ABILIFY MAINTENA PRSY 300mg 400mg
32 ABILIFY MAINTENA SRER 300mg 400mg
32 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
abiraterone acetate tabs 250mg 14 abiraterone acetate tabs 500mg 14 ABRAXANE SUSR 14 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 56 acamprosate calcium tbec 25 acarbose tabs 25mg 50mg 100mg 44 accutane caps 10mg 20mg 30mg 40mg 56 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 26 acetaminophen-codeine soln 26 acetaminophen-codeine tabs 26 acetazolamide er cp12 39 acetazolamide sodium solr 39 acetazolamide tabs 125mg 250mg 39 ACETIC ACID SOLN 39 49 acetylcysteine soln 10 20 47 acitretin caps 10mg 175mg 25mg 56 ACTEMRA ACTPEN SOAJ 47 ACTEMRA SOSY 47 ACTHAR GEL 46 ACTHIB SOLR 52 ACTIMMUNE SOLN 49 acyclovir caps 11 acyclovir oint 53 acyclovir sodium soln intravenous 11 acyclovir susp 11
acyclovir tabs 400mg 800mg 11 ADACEL SUSP 52 ADAGEN SOLN 37 ADAKVEO SOLN 20 ADAPALENE CREA 56 adapalene gel 01 03 56 adapalene pads 56 adapalene soln 56 adapalene-benzoyl peroxide gel 56 ADAPALENE-BENZOYL PEROXIDE PADS
56 ADBRY SOSY 56 adderall tabs 28 adefovir dipivoxil tabs 11 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 51 adenosine soln 24 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 230-21mcgact 51 ADVAIR HFA AERO 45-21mcgact 115-
21mcgact 51 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 14 AFREZZA POWD 90x8 UNIT amp 90x12 UNIT
44 AJOVY SOAJ 30 AJOVY SOSY 30 ala-cort crea 1 25 54 albendazole tabs 8 albuterol sulfate er tb12 4mg 8mg 20 ALBUTEROL SULFATE HFA AERS
108mcgact 20 albuterol sulfate nebu 0083
25mg05ml 063mg3ml 125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 54 alclometasone dipropionate oint 54 ALCOHOL PREP PADS 35 ALDURAZYME SOLN 37 ALECENSA CAPS 14
60 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
alendronate sodium soln 47 alendronate sodium tabs 5mg 10mg
35mg 40mg 47 alendronate sodium tabs 70mg 47 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 41 ALKINDI SPRINKLE CPSP 1mg 2mg 5mg
41 allopurinol sodium solr 47 allopurinol tabs 100mg 300mg 47 allzital tabs 26 almotriptan malate tabs 30 alogliptin benzoate tabs 625mg 125mg
25mg 44 ALOGLIPTIN-METFORMIN HCL TABS 44 alogliptin-pioglitazone tabs 44 ALOSETRON HCL TABS 05mg 1mg 40 alprazolam er tb24 05mg 1mg 2mg 3mg
31 alprazolam intensol conc 31 alprazolam tabs 025mg 05mg 1mg 2mg
31 alprazolam tbdp 025mg 05mg 1mg 2mg
31 ALTACAINE SOLN 39 ALTAFRIN SOLN 39 altavera tabs 42 ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 51 alyacen 135 tabs 42 alyq tabs 25 amabelz tabs 45 amantadine hcl caps 30 amantadine hcl soln 30 amantadine hcl tabs 30 AMBISOME SUSR INTRAVENOUS 10 ambrisentan tabs 51 amcinonide crea 54 amcinonide lotn 54 amcinonide oint 54 amethia lo tabs 42 amethia tabs 42 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 36
amiloride-hydrochlorothiazide tabs 36 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 57 amiodarone hcl soln 24 amiodarone hcl tabs 100mg 200mg
400mg 24 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 33 amlodipine besy-benazepril hcl caps 23 amlodipine besylate tabs 25mg 5mg
10mg 23 amlodipine besylate-valsartan tabs 23 amlodipine-atorvastatin tabs 23 amlodipine-olmesartan tabs 23 amlodipine-valsartan-hctz tabs 23 ammonium lactate crea 56 ammonium lactate lotn 56 amnesteem caps 10mg 20mg 40mg 56 AMONDYS 45 SOLN 49 amoxapine tabs 25mg 50mg 100mg
150mg 33 amoxicill-clarithro-lansopraz misc 40 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8 amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 28 amphetamine sulfate tabs 5mg 10mg 28 amphetamine-dextroamphet er cp24 28 amphetamine-dextroamphetamine tabs 28 amphotericin b solr intravenous 10 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 42 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 55 anastrozole tabs 14
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 61
ANDRODERM PT24 2mg24hr 4mg24hr 42
antabuse tabs 250mg 500mg 25 anusol-hc crea 54 apap-caff-dihydrocodeine tabs 26 apexicon e crea 54 APLENZIN TB24 174mg 348mg 522mg 33 APOKYN SOCT 30 apomorphine hcl soct 30 apraclonidine hcl soln 39 aprepitant caps 40 APRETUDE SUER 11 apri tabs 42 APTIOM TABS 200mg 400mg 600mg
800mg 28 APTIVUS CAPS 11 APTIVUS SOLN 11 ARALAST NP SOLR INTRAVENOUS 51 aranelle tabs 42 ARANESP (ALBUMIN FREE) SOLN
60mcgml 100mcgml 200mcgml 21 ARANESP (ALBUMIN FREE) SOSY
60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 21
ARCALYST SOLR 49 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 49 ARIKAYCE SUSP 8 aripiprazole soln 33 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 33 aripiprazole tbdp 10mg 15mg 33 ARISTADA INITIO PRSY 33 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 33
armodafinil tabs 50mg 150mg 200mg 250mg 28
arsenic trioxide soln 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 49 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 52 ascomp-codeine caps 26 asenapine maleate subl 25mg 5mg 10mg
33
ashlyna tabs 42 ASMANEX HFA AERO 100mcgact
200mcgact 51 ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 48 ASTAGRAF XL CP24 05mg 1mg 48 atazanavir sulfate caps 150mg 200mg
300mg 11 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 31 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 22 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 39 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 32 aubra eq tabs 42 AUGMENTIN SUSR 8 AURYXIA TABS 36 AUSTEDO TABS 6mg 9mg 12mg 31 AVASTIN SOLN 14 AVC VAGINAL CREA 53 aviane tabs 42 AVITA CREA 56 AVITA GEL 56 AVONEX KIT 32 AVONEX PEN AJKT 32 AVONEX PREFILLED PSKT 32 AVSOLA SOLR 47 aygestin tabs 46 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 48 azathioprine sodium solr 48 azathioprine tabs 48 azelaic acid gel 56 azelastine hcl soln 005 01 015 39 azelastine-fluticasone susp 39 AZELEX CREA 56 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
62 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
B bacitracin oint 38 bacitracin solr 8 bacitracin-polymyxin b oint 38 bacitra-neomycin-polymyxin-hc oint 38 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 53 BAFIERTAM CPDR 32 balsalazide disodium caps 40 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 42 BANZEL SUSP 28 BANZEL TABS 200mg 400mg 28 BAQSIMI ONE PACK POWD 44 BAQSIMI TWO PACK POWD 44 BARACLUDE SOLN 11 BAVENCIO SOLN 14 BCG VACCINE SOLR 14 BD INSULIN SYR ULTRAFINE II MISC 35 BD INSULIN SYRINGE MISC 35 BD INSULIN SYRINGE UF MISC 35 BD PEN NEEDLE ORIGINAL UF MISC 35 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 32 BELEODAQ SOLR 14 BELRAPZO SOLN 14 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 14 BENDEKA SOLN 14 BENLYSTA SOAJ 48 BENLYSTA SOLR 48 BENLYSTA SOSY 48 BENZEPRO CREAMY WASH LIQD 53 BENZEPRO FOAMING CLOTHS MISC 53 benzhydrocodone-acetaminophen tabs 26 benzoyl perox-hydrocortisone lotn 54 BENZOYL PEROXIDE FORTE- HC LOTN
54 BENZOYL PEROXIDE GEL 53 benzoyl peroxide-erythromycin gel 53 benztropine mesylate soln 30 benztropine mesylate tabs 05mg 1mg
2mg 30 BEOVU SOLN 39 bepotastine besilate soln 39
BERINERT KIT INTRAVENOUS 49 beser lotn 54 BESPONSA SOLR 14 BESREMI SOSY 14 betaine powd 49 betamethasone dipropionate aug crea 54 betamethasone dipropionate aug gel 54 betamethasone dipropionate aug lotn 54 betamethasone dipropionate aug oint 54 betamethasone dipropionate crea 54 betamethasone dipropionate lotn 54 BETAMETHASONE DIPROPIONATE OINT
54 betamethasone sod phos amp acet susp 41 betamethasone valerate crea 54 betamethasone valerate foam 54 BETAMETHASONE VALERATE LOTN 54 BETAMETHASONE VALERATE OINT 54 BETASERON KIT 32 betaxolol hcl soln 39 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 19 bexarotene caps 14 BEXSERO SUSY 52 bicalutamide tabs 14 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICILLIN L-A SUSY 8 BIKTARVY TABS 11 bimatoprost soln 39 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23 bleomycin sulfate solr 14 bleph-10 soln 38 blephamide sop oint 38 BLEPHAMIDE SUSP 38 BLINCYTO SOLR 14 blisovi 24 fe tabs 42 blisovi fe 1530 tabs 42 BOOSTRIX SUSP 52 BOOSTRIX SUSY 52 BORTEZOMIB SOLR 14 bosentan tabs 51 BOSULIF TABS 100mg 400mg 500mg 14 BRAFTOVI CAPS 50mg 75mg 14 briellyn tabs 42 BRILINTA TABS 60mg 90mg 21
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 63
brimonidine tartrate soln 015 02 39 brinzolamide susp 39 BRIVIACT SOLN 28 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 28 bromfenac sodium (once-daily) soln 38 bromocriptine mesylate caps 30 bromocriptine mesylate tabs 30 BRONCHITOL CAPS 51 BROVANA NEBU 20 BRUKINSA CAPS 14 budesonide cpep 41 budesonide er tb24 41 budesonide susp 025mg2ml 05mg2ml
1mg2ml 51 bumetanide soln 36 bumetanide tabs 05mg 1mg 2mg 36 bupap tabs 26 bupivacaine hcl (pf) soln 49 bupivacaine hcl soln 49 BUPIVACAINE IN DEXTROSE SOLN 49 bupivacaine spinal soln 49 bupivacaine-epinephrine (pf) soln 49 bupivacaine-epinephrine soln 49 buprenorphine hcl subl 2mg 8mg 32 buprenorphine hcl-naloxone hcl film 32 buprenorphine hcl-naloxone hcl subl 32 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 32 bupropion hcl er (smoking det) tb12 33 bupropion hcl er (sr) tb12 100mg 150mg
200mg 33 bupropion hcl er (xl) tb24 150mg 300mg
450mg 33 bupropion hcl tabs 75mg 100mg 33 buspirone hcl tabs 5mg 10mg 31 buspirone hcl tabs 75mg 15mg 30mg 31 busulfan soln 14 butalbital-acetaminophen tabs 26 butalbital-apap-caff-cod caps 26 butalbital-apap-caffeine caps 26 butalbital-apap-caffeine tabs 26 butalbital-asa-caff-codeine caps 26 butalbital-aspirin-caffeine caps 26 butalbital-aspirin-caffeine tabs 26 butorphanol tartrate soln 26 BYLVAY (PELLETS) CPSP 200mcg
600mcg 41 BYLVAY CAPS 400mcg 1200mcg 41
C CABENUVA SUER 11 cabergoline tabs 30 CABLIVI KIT 21 CABOMETYX TABS 20mg 40mg 60mg 14 cafergot tabs 30 caffeine citrate soln 28 calcipotriene crea 56 calcipotriene oint 56 calcipotriene soln 56 calcipotriene-betameth diprop oint 54 calcipotriene-betameth diprop susp 54 calcitonin (salmon) soln 45 calcitrene oint 56 calcitriol caps 025mcg 05mcg 57 CALCITRIOL OINT 56 calcitriol soln 57 calcium acetate (phos binder) caps 37 calcium acetate tabs 37 CALCIUM GLUCONATE-NACL SOLN 37 CALQUENCE CAPS 14 CAMCEVI PRSY 14 camila tabs 42 camrese lo tabs 42 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 54 CAPLYTA CAPS 33 CAPRELSA TABS 100mg 300mg 14 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 25 CARAC CREA 56 carbamazepine chew 28 carbamazepine er cp12 100mg 200mg
300mg 28 carbamazepine er tb12 100mg 200mg
400mg 28 carbamazepine susp 28 carbamazepine tabs 28 carbidopa tabs 30 carbidopa-levodopa er tbcr 30 carbidopa-levodopa tabs 30 carbidopa-levodopa tbdp 30 carbidopa-levodopa-entacapone tabs 30 carbinoxamine maleate soln 13
64 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
carbinoxamine maleate tabs 13 carboplatin soln 14 carboprost tromethamine soln 45 CARDENE IV SOLN 23 carglumic acid tbso 35 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 14 CARNITOR SOLN 49 CARNITOR TABS 49 carteolol hcl soln 39 cartia xt cp24 120mg 180mg 240mg
300mg 23 carvedilol phosphate er cp24 10mg 20mg
40mg 80mg 23 carvedilol tabs 3125mg 625mg 125mg
25mg 23 caspofungin acetate solr intravenous 50mg
70mg 10 CAYSTON SOLR 51 caziant tabs 42 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 intravenous 1gm 2gm
10gm 8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 6gm 8 ceftazidime solr intravenous 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 750mg 8 cefuroxime sodium solr intravenous 15gm 8 celecoxib caps 26 CELONTIN CAPS 29 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 38 CERDELGA CAPS 37 CEREZYME SOLR 37 CEROVEL LOTN 56 cetirizine hcl soln 13 CEVIMELINE HCL CAPS 19 CHANTIX CONTINUING MONTH PAK
TABS 19 CHANTIX STARTING MONTH PAK TABS
19 CHANTIX TABS 05mg 1mg 19 CHEMET CAPS 41 chloramphenicol sod succinate solr 8 chlordiazepoxide hcl caps 5mg 10mg
25mg 31 chlordiazepoxide-amitriptyline tabs 33 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 38 chloroprocaine hcl (pf) soln 49 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 36 chlorothiazide tabs 250mg 500mg 36 chlorpromazine hcl conc 30mgml
100mgml 33 chlorpromazine hcl soln 33 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 33 chlorthalidone tabs 25mg 50mg 36 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 41 cholestyramine light pack 22 cholestyramine light powd 22 cholestyramine pack 22 cholestyramine powd 22 CHORIONIC GONADOTROPIN SOLR 45 CIBINQO TABS 50mg 100mg 200mg 47 ciclopirox gel 53 ciclopirox olamine crea 53
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 65
ciclopirox olamine susp 53 ciclopirox sham 53 ciclopirox soln 53 cidofovir soln 11 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 38 CIMDUO TABS 11 cimetidine hcl soln 40 cimetidine tabs 200mg 300mg 400mg
800mg 40 CIMZIA KIT 47 CIMZIA PREFILLED PSKT 47 CIMZIA STARTER KIT PSKT 47 cinacalcet hcl tabs 30mg 60mg 90mg 45 CINQAIR SOLN 51 CINRYZE SOLR INTRAVENOUS 49 CIPRODEX SUSP 38 ciprofloxacin hcl soln (ophth) 38 CIPROFLOXACIN HCL SOLN (OTIC) 38 ciprofloxacin hcl tabs 8 ciprofloxacin in d5w soln 8 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 38 cisplatin soln 14 CISPLATIN SOLR 50mg 14 CITALOPRAM HYDROBROMIDE CAPS 33 citalopram hydrobromide soln 33 citalopram hydrobromide tabs 10mg 20mg
40mg 33 citanest plain dental soln 49 cladribine soln 14 claravis caps 10mg 20mg 30mg 40mg 56 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 13 cleocin phosphate soln 9 cleocin solr 9 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
clindacin-p swab 53 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 53 clindamycin phosphate crea 53
clindamycin phosphate foam 53 clindamycin phosphate gel 53 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 53 clindamycin phosphate soln 9 53 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 53 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 36 clinisol sf soln intravenous 36 clobazam susp 29 clobazam tabs 10mg 20mg 29 clobetasol propionate crea 54 clobetasol propionate e crea 54 clobetasol propionate emulsion foam 54 clobetasol propionate foam 54 clobetasol propionate gel 54 clobetasol propionate liqd 54 clobetasol propionate lotn 54 clobetasol propionate oint 54 clobetasol propionate sham 54 clobetasol propionate soln 54 clocortolone pivalate crea 54 clocortolone pivalate pump crea 54 clofarabine soln 14 clomipramine hcl caps 25mg 50mg 75mg
33 clonazepam tabs 05mg 1mg 2mg 29 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 29 clonidine hcl (analgesia) soln 24
66 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
clonidine hcl er tb12 24 clonidine hcl tabs 01mg 02mg 03mg 24 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 24 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 31 clotrimazole crea 53 clotrimazole soln 53 clotrimazole troc 53 clotrimazole-betamethasone crea 53 clotrimazole-betamethasone lotn 53 clovique caps 41 clozapine tabs 25mg 50mg 100mg 200mg
33 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 33 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 26 colazal caps 40 COLCHICINE CAPS 47 colchicine tabs 47 colchicine-probenecid tabs 37 COLESEVELAM HCL PACK 22 colesevelam hcl tabs 22 colestipol hcl gran 22 colestipol hcl pack 22 colestipol hcl tabs 22 colistimethate sodium (cba) solr injection 9 colocort enem 54 COLY-MYCIN S SUSP 38 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 14 COMETRIQ (140 MG DAILY DOSE) KIT 14 COMETRIQ (60 MG DAILY DOSE) KIT 14 COMPLERA TABS 11 compro supp 33 CONSENSI TABS 23 constulose soln 35 COPIKTRA CAPS 15mg 25mg 14 CORDRAN TAPE 54 CORLANOR SOLN 24 CORLANOR TABS 5mg 75mg 24 cortisone acetate tabs 41 CORTISPORIN CREA 54 CORTISPORIN OINT 54 CORTROPHIN GEL 46 COSELA SOLR 49
COSENTYX (300 MG DOSE) SOSY 56 COSENTYX SENSOREADY (300 MG)
SOAJ 56 COSENTYX SENSOREADY PEN SOAJ 56 COSENTYX SOSY 75mg05ml 150mgml
56 COTELLIC TABS 14 CREON CPEP 37 CRESEMBA CAPS 10 CRESEMBA SOLR 10 CRIXIVAN CAPS 200mg 400mg 11 cromolyn sodium conc 51 cromolyn sodium nebu 51 cromolyn sodium soln 39 crotan lotn 53 cryselle-28 tabs 42 CRYSVITA SOLN 10mgml 20mgml
30mgml 49 CURITY GAUZE PADS 35 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 52
cyclafem 135 tabs 42 cyclafem 777 tabs 42 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 14 CYCLOPHOSPHAMIDE SOLN 2gm10ml
1gm5ml 500mg25ml 15 cyclophosphamide solr 15 cycloserine caps 11 cyclosporine caps 25mg 100mg 48 cyclosporine emul 38 cyclosporine modified caps 25mg 50mg
100mg 48 cyclosporine modified soln 48 cyclosporine soln 48 cyproheptadine hcl syrp 13 cyproheptadine hcl tabs 13 CYRAMZA SOLN 100mg10ml
500mg50ml 15 CYSTADANE POWD 49 CYSTADROPS SOLN 39 CYSTAGON CAPS 50mg 150mg 49 CYSTARAN SOLN 39 cytarabine (pf) soln 15 cytarabine soln 15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 67
CYTOGAM INJ 52
D dacarbazine solr 15 dactinomycin solr 15 dalfampridine er tb12 32 DALIRESP TABS 250mcg 500mcg 51 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 42 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 56 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 52 daptomycin solr intravenous 350mg 500mg
9 darifenacin hydrobromide er tb24 75mg
15mg 57 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 deblitane tabs 42 decadron tabs 5mg 75mg 41 decadron tabs 4mg 6mg 41 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 41 deferasirox tabs 41 deferasirox tbso 41 deferiprone tabs 500mg 1000mg 41 deferoxamine mesylate solr 41 DELSTRIGO TABS 11 deltasone tabs 41 delyla tabs 42 demeclocycline hcl tabs 9 DEMSER CAPS 22 depo-estradiol oil 45 DEPO-MEDROL SUSP 41 DEPO-PROVERA SUSP 400mgml 46 DEPO-SUBQ PROVERA 104 SUSY 46 depo-testosterone soln 100mgml
200mgml 42 DERMOTIC OIL 38 DESCOVY TABS 120-15mg 11 DESCOVY TABS 200-25mg 11
desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg 33
desloratadine tabs 13 desloratadine tbdp 13 desmopressin ace spray refrig soln 46 DESMOPRESSIN ACETATE SOLN 46 desmopressin acetate spray soln 46 desmopressin acetate tabs 01mg 02mg 46 desogestrel-ethinyl estradiol tabs 42 desonide crea 54 desonide gel 54 desonide lotn 54 desonide oint 54 desowen lotn 54 desoximetasone crea 005 025 54 desoximetasone gel 54 desoximetasone liqd 54 desoximetasone oint 005 025 54 desrx gel 54 DESVENLAFAXINE ER TB24 50mg
100mg 33 desvenlafaxine succinate er tb24 25mg
50mg 100mg 33 dexabliss tbpk 41 dexamethasone elix 41 dexamethasone intensol conc 41 dexamethasone sodium phosphate soln 38
41 dexamethasone soln 41 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 41 dexamethasone tbpk 41 dexchlorpheniramine maleate soln 13 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 28
dexmethylphenidate hcl tabs 25mg 5mg 10mg 28
dexpak 10 day tbpk 41 dexpak 13 day tbpk 41 dexpak 6 day tbpk 41 dexrazoxane hcl solr 49 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 28 dextroamphetamine sulfate soln 28 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 28 DEXTROSE IN LACTATED RINGERS
SOLN 37
68 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
DEXTROSE SOLN 36 DEXTROSE SOLN INTRAVENOUS 5
10 36 DEXTROSE-NACL SOLN INTRAVENOUS
10-02 10-045 37 DEXTROSE-NACL SOLN INTRAVENOUS
25-045 5-02 5-045 5-09 37 DIACOMIT CAPS 250mg 500mg 29 DIACOMIT PACK 250mg 500mg 29 DIASTAT ACUDIAL GEL 10mg 20mg 29 DIASTAT PEDIATRIC GEL 29 diazepam conc 31 diazepam gel 25mg 10mg 20mg 29 diazepam intensol conc 31 diazepam soln 5mg5ml 5mgml 31 diazepam tabs 2mg 5mg 10mg 31 diazoxide susp 44 diclofenac sodium er tb24 26 diclofenac sodium gel 1 3 54 diclofenac sodium soln 38 diclofenac sodium tbec 26 diclofenac-misoprostol tbec 26 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 11 DIFFERIN CREA 56 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 54 diflorasone diacetate oint 54 diflunisal tabs 26 difluprednate emul 38 digitek tabs 0125mg 025mg 24 digox tabs 24 digoxin soln 24 digoxin tabs 125mcg 250mcg 24 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 29 dilantin infatabs chew 29 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 23 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 23
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 23
diltiazem hcl er cp12 60mg 90mg 120mg 23
diltiazem hcl er cp24 120mg 180mg 240mg 23
diltiazem hcl soln 23 diltiazem hcl solr 23 diltiazem hcl tabs 30mg 60mg 90mg
120mg 23 dilt-xr cp24 120mg 180mg 240mg 23 dimenhydrinate soln 40 dimethyl fumarate cpdr 32 dimethyl fumarate starter pack misc 32 DIPENTUM CAPS 40 diphen elix 13 di-phen elix 13 diphenhydramine hcl elix 13 diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 40 diphenoxylate-atropine tabs 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 52 dipyridamole tabs 25mg 50mg 75mg 25 disopyramide phosphate caps 100mg
150mg 24 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 36 divalproex sodium csdr 29 divalproex sodium er tb24 250mg 500mg29 divalproex sodium tbec 125mg 250mg
500mg 29 dobutamine hcl soln 20 DOBUTAMINE IN D5W SOLN 20 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
24 dolishale tabs 42 donepezil hcl tabs 5mg 10mg 23mg 19 donepezil hcl tbdp 5mg 10mg 19 dopamine hcl soln 20 DOPAMINE IN D5W SOLN 20 DOPTELET TABS 21 dorzolamide hcl soln 39 dorzolamide hcl-timolol mal pf soln 39 dorzolamide hcl-timolol mal soln 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 69
dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 33 doxepin hcl conc 33 doxepin hcl crea 55 doxepin hcl tabs 3mg 6mg 33 doxercalciferol caps 05mcg 1mcg 25mcg
57 DOXERCALCIFEROL SOLN 57 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
150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 40 DRIZALMA SPRINKLE CSDR 33 dronabinol caps 25mg 5mg 10mg 40 droperidol soln 31 drospiren-eth estrad-levomefol tabs 42 drospirenone-ethinyl estradiol tabs 42 DROXIA CAPS 15 droxidopa caps 20 DUAKLIR PRESSAIR AEPB 19 DUEXIS TABS 26 duloxetine hcl cpep 20mg 30mg 40mg
60mg 33 DUPIXENT SOPN 200mg114ml
300mg2ml 51 DUPIXENT SOSY 100mg067ml
200mg114ml 300mg2ml 51 DURYSTA IMPL 39 dutasteride caps 47 dutasteride-tamsulosin hcl caps 47 dvorah tabs 26 dxevo 11-day tbpk 41
E ees 400 tabs 9 EASYGEL GEL 49 econazole nitrate crea 53 EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 46 EGRIFTA SV SOLR 46 ELAPRASE SOLN 37 ELELYSO SOLR 37 ELEPSIA XR TB24 1000mg 1500mg 29 eletriptan hydrobromide tabs 30 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 37 elixophyllin elix 57 ELLA TABS 42 ELLENCE SOLN 15 ELMIRON CAPS 49 eluryng ring 42 ELZONRIS SOLN 15 EMCYT CAPS 15 EMFLAZA SUSP 42 EMFLAZA TABS 6mg 18mg 30mg 36mg
42 EMPAVELI SOLN 49 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 30 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 25 enalaprilat inj 25 enalapril-hydrochlorothiazide tabs 25 ENBREL MINI SOCT 47 ENBREL SOLN 47 ENBREL SOLR 47 ENBREL SOSY 25mg05ml 50mgml 48 ENBREL SURECLICK SOAJ 48 ENDARI PACK 49 endocet tabs 26 ENDOMETRIN INST 46
70 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ENGERIX-B SUSP 10mcg05ml 20mcgml 52
ENHERTU SOLR 15 ENJAYMO SOLN 49 enoxaparin sodium soln 21 enoxaparin sodium sosy 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
enpresse-28 tabs 42 ENSPRYNG SOSY 49 ENSTILAR FOAM 54 entacapone tabs 30 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 25 ENTYVIO SOLR 41 enulose soln 35 ENVARSUS XR TB24 075mg 1mg 4mg48 EPCLUSA PACK 12 EPCLUSA TABS 12 EPIDIOLEX SOLN 29 epifoam foam 54 epinastine hcl soln 39 epinephrine (anaphylaxis) soln 20 epinephrine soaj 20 EPINEPHRINE SOSY 20 epirubicin hcl soln 15 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 25 EPOGEN SOLN 21 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 21 epoprostenol sodium solr 51 EPRONTIA SOLN 29 eprosartan mesylate tabs 25 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 33 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 30 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 43 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 53 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 53 erythromycin oint 38 erythromycin pads 53 erythromycin soln 53 erythromycin tbec 9 ESBRIET CAPS 51 ESBRIET TABS 267mg 801mg 51 escitalopram oxalate soln 33 escitalopram oxalate tabs 5mg 10mg
20mg 33 esgic caps 26 esgic tabs 26 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 40 esomeprazole magnesium pack 10mg
20mg 40mg 40 esomeprazole sodium solr 40 estarylla tabs 43 estazolam tabs 1mg 2mg 31 estrace crea 45 estrace tabs 05mg 1mg 2mg 45 estradiol crea 45 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
estradiol tabs 10mcg 05mg 1mg 2mg 45 estradiol valerate oil 45 estradiol-norethindrone acet tabs 45 ESTRING RING 45 eszopiclone tabs 1mg 2mg 3mg 31 ethacrynic acid tabs 36 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 29 ethosuximide soln 29 ethynodiol diac-eth estradiol tabs 43 etodolac caps 26
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 71
etodolac er tb24 26 etodolac tabs 26 etonogestrel-ethinyl estradiol ring 43 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 eulexin caps 15 EURAX CREA 53 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 46
evekeo tabs 5mg 10mg 28 EVENITY SOSY 47 everolimus tabs 025mg 48 everolimus tabs 05mg 075mg 1mg 48 everolimus tabs 25mg 5mg 75mg 10mg
15 everolimus tbso 2mg 3mg 5mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 22 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 49 exemestane tabs 15 EXKIVITY CAPS 15 EXONDYS 51 SOLN 500mg10ml
100mg2ml 49 EXSERVAN FILM 31 EXTAVIA KIT 32 EYLEA SOLN 39 EYLEA SOSY 39 ezetimibe tabs 22 ezetimibe-simvastatin tabs 22
F FABRAZYME SOLR 5mg 35mg 37 falmina tabs 43 famciclovir tabs 125mg 250mg 500mg 12 famotidine (pf) soln 40 famotidine premixed soln 40 famotidine soln 40 famotidine susr 40 famotidine tabs 20mg 40mg 40 FANAPT TABS 1mg 2mg 4mg 6mg 8mg
10mg 12mg 33 FANAPT TITRATION PACK TABS 33 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 51 FASENRA SOSY 51
fayosim tabs 43 febuxostat tabs 40mg 80mg 47 felbamate susp 29 felbamate tabs 400mg 600mg 29 felodipine er tb24 25mg 5mg 10mg 23 femynor tabs 43 fenofibrate caps 50mg 150mg 22 fenofibrate micronized caps 43mg 67mg
130mg 134mg 200mg 22 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 22 fenofibric acid cpdr 45mg 135mg 22 fenoprofen calcium caps 26 fenoprofen calcium tabs 26 fenortho caps 26 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 26 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 26
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 26
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 26
FERRIPROX SOLN 41 FERRIPROX TABS 41 FERRIPROX TWICE-A-DAY TABS 41 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
33 FETZIMA TITRATION C4PK 33 fexmid tabs 20 finasteride tabs 47 FINTEPLA SOLN 29 fioricet caps 26 fioricetcodeine caps 26 FIRDAPSE TABS 49 FIRMAGON (240 MG DOSE) SOLR 15 FIRMAGON SOLR 15 flac oil 38 flavoxate hcl tabs 57 FLEBOGAMMA DIF SOLN INTRAVENOUS
52 flecainide acetate tabs 50mg 100mg
150mg 24 FLEQSUVY SUSP 20 FLOVENT HFA AERO 51 floxuridine solr 15
72 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
fluconazole in sodium chloride soln intravenous 10
fluconazole susr 10 fluconazole tabs 10 flucytosine caps 250mg 500mg 10 fludarabine phosphate soln 15 fludarabine phosphate solr 15 fludrocortisone acetate tabs 42 flumazenil soln 31 flunisolide soln 38 fluocinolone acetonide body oil 54 fluocinolone acetonide crea 001 0025
54 fluocinolone acetonide oil 38 fluocinolone acetonide oint 54 fluocinolone acetonide scalp oil 54 fluocinolone acetonide soln 54 fluocinonide crea 54 fluocinonide emulsified base crea 54 FLUOCINONIDE GEL 54 fluocinonide oint 54 fluocinonide soln 54 FLUORITAB CHEW 025mg 05mg 1mg 49 FLUORITAB SOLN 49 fluorometholone susp 38 fluorouracil crea 5 56 fluorouracil crea 5 56 fluorouracil soln 15 56 fluorouracil soln 2 5 56 fluoxetine hcl (pmdd) tabs 10mg 20mg 33 fluoxetine hcl caps 10mg 20mg 40mg 33 fluoxetine hcl cpdr 33 fluoxetine hcl soln 33 fluoxetine hcl tabs 10mg 20mg 60mg 33 fluphenazine decanoate soln 33 fluphenazine hcl conc 33 fluphenazine hcl elix 33 fluphenazine hcl soln 33 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 34 FLURANDRENOLIDE CREA 54 flurandrenolide lotn 55 flurandrenolide oint 55 flurazepam hcl caps 15mg 30mg 31 flurbiprofen sodium soln 38 flurbiprofen tabs 26 flutamide caps 15 fluticasone propionate crea 55 fluticasone propionate lotn 55
fluticasone propionate oint 55 fluticasone propionate susp 38 fluticasone-salmeterol aepb 51 fluvastatin sodium caps 20mg 40mg 22 fluvastatin sodium er tb24 22 fluvoxamine maleate er cp24 100mg
150mg 34 fluvoxamine maleate tabs 25mg 50mg
100mg 34 FML FORTE SUSP 38 FML OINT 38 fomepizole soln 47 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 FORTEO SOPN 45 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 40 fosfomycin tromethamine pack 13 fosinopril sodium tabs 10mg 20mg 40mg
25 fosinopril sodium-hctz tabs 25 fosphenytoin sodium soln 29 FOTIVDA CAPS 089mg 134mg 15 FROVATRIPTAN SUCCINATE TABS 30 FULPHILA SOSY 21 fulvestrant soln 15 furosemide soln 8mgml 10mgml 36 furosemide soln injection 36 furosemide tabs 20mg 40mg 80mg 36 FUZEON SOLR 12 FYARRO SUSR 15 fyavolv tabs 45 FYCOMPA SUSP 29 FYCOMPA TABS 29
G gabapentin caps 100mg 400mg 29 gabapentin soln 29 gabapentin tabs 600mg 800mg 29 GALAFOLD CAPS 49 galantamine hydrobromide er cp24 8mg
16mg 24mg 19 galantamine hydrobromide soln 19 galantamine hydrobromide tabs 4mg 8mg
12mg 19 GAMASTAN INJ 52 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 48
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 73
GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm 52
GAMMAGARD SOLN INJECTION 52 GAMMAKED SOLN INJECTION 52 GAMMAPLEX SOLN INTRAVENOUS 52 GAMUNEX-C SOLN INJECTION 52 ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 52 GARDASIL 9 SUSY 52 gatifloxacin soln 38 GATTEX KIT 41 gavilyte-c solr 41 gavilyte-g solr 41 gavilyte-h kit 41 gavilyte-n with flavor pack solr 41 GAVRETO CAPS 15 GAZYVA SOLN 15 gemcitabine hcl soln 15 gemcitabine hcl solr 15 gemfibrozil tabs 22 gemmily caps 43 generlac soln 35 gengraf caps 25mg 50mg 100mg 48 gengraf soln 48 GENOTROPIN CART 12mg 46 GENOTROPIN MINIQUICK PRSY 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 46
gentak oint 38 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 53 gentamicin sulfate oint 53 gentamicin sulfate soln 9 38 gentamicin sulfate soln injection 9 GENVOYA TABS 12 gianvi tabs 43 GILENYA CAPS 025mg 05mg 32 GILOTRIF TABS 20mg 30mg 40mg 15 GIMOTI SOLN 41 GIVLAARI SOLN 49 GLASSIA SOLN INTRAVENOUS 51 glatopa sosy 20mgml 40mgml 32 glimepiride tabs 1mg 2mg 4mg 44 glipizide er tb24 25mg 5mg 10mg 44 glipizide tabs 5mg 10mg 44 glipizide-metformin hcl tabs 44 glucagon emergency kit 44
glyburide micronized tabs 15mg 3mg 6mg 44
glyburide tabs 125mg 25mg 5mg 44 glyburide-metformin tabs 44 glycate tabs 19 glycopyrrolate oral soln 19 glycopyrrolate pf sosy 19 glycopyrrolate soln injection 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 55 granisetron hcl soln 40 granisetron hcl tabs 40 GRANIX SOLN 480mcg16ml 300mcgml
21 GRANIX SOSY 300mcg05ml
480mcg08ml 21 GRASTEK SUBL 49 griseofulvin microsize susp 10 griseofulvin microsize tabs 10 griseofulvin ultramicrosize tabs 10 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 32 guanfacine hcl tabs 1mg 2mg 24 GUANIDINE HCL TABS 19 gynazole-1 crea 53
H HAEGARDA SOLR 2000unit 3000unit 49 hailey 24 fe tabs 43 halcinonide crea 55 halobetasol propionate crea 55 HALOBETASOL PROPIONATE FOAM 55 halobetasol propionate oint 55 haloperidol decanoate soln 34 haloperidol lactate conc 34 haloperidol lactate soln 34 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 34 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 52 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
HEPLISAV-B SOLN 52
74 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
HERCEPTIN HYLECTA SOLN 15 HERCEPTIN SOLR 150mg 440mg 15 HERZUMA SOLR 150mg 420mg 15 HETLIOZ CAPS 31 HETLIOZ LQ SUSP 31 HIBERIX SOLR 52 HUMALOG KWIKPEN SOPN 44 HUMALOG SOCT 44 HUMALOG SOLN 44 humatin caps 11 HUMATROPE CART 6mg 12mg 24mg 46 HUMATROPE SOLR 46 HUMIRA PEDIATRIC CROHNS START
PSKT 48 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 48 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 48 HUMIRA PEN-PEDIATRIC UC START
PNKT 48 HUMIRA PEN-PSUVADOL HS START
PNKT 48 HUMIRA PEN-PSORUVEIT STARTER
PNKT 48 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 48
HUMULIN 7030 KWIKPEN SUPN 44 HUMULIN 7030 SUSP 44 HUMULIN N KWIKPEN SUPN 44 HUMULIN N SUSP 44 HUMULIN R SOLN 44 HUMULIN R U-500 (CONCENTRATED)
SOLN 44 HUMULIN R U-500 KWIKPEN SOPN 44 hydralazine hcl soln 24 hydralazine hcl tabs 10mg 25mg 50mg
100mg 24 hydrochlorothiazide caps 36 hydrochlorothiazide tabs 125mg 25mg
50mg 36 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 26 hydrocodone-acetaminophen soln 26 hydrocodone-acetaminophen tabs 26 hydrocodone-ibuprofen tabs 26 hydrocortisone (perianal) crea 1 25 55 hydrocortisone ace-pramoxine crea 55
HYDROCORTISONE ACE-PRAMOXINE SUPP 55
hydrocortisone butyr lipo base crea 55 hydrocortisone butyrate crea 55 hydrocortisone butyrate lotn 55 HYDROCORTISONE BUTYRATE OINT 55 hydrocortisone butyrate soln 55 hydrocortisone crea 1 25 55 hydrocortisone enem 55 hydrocortisone lotn 55 hydrocortisone oint 1 25 55 hydrocortisone tabs 5mg 10mg 20mg 42 hydrocortisone valerate crea 55 hydrocortisone valerate oint 55 HYDROCORTISONE-ACETIC ACID SOLN
38 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 26 hydromorphone hcl liqd 26 hydromorphone hcl tabs 2mg 4mg 8mg 26 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 46 hydroxyprogesterone caproate soln 46 hydroxyurea caps 15 hydroxyzine hcl soln 31 hydroxyzine hcl syrp 31 hydroxyzine hcl tabs 31 hydroxyzine pamoate caps 31 HYPERHEP B SOLN 52 HYPERHEP B SOSY 52 HYPERRAB SD SOLN 52 HYQVIA KIT 52
I IBANDRONATE SODIUM SOLN 47 ibandronate sodium tabs 47 IBRANCE CAPS 75mg 100mg 125mg 15 IBRANCE TABS 75mg 100mg 125mg 15 IBSRELA TABS 41 ibu tabs 26 ibudone tabs 26 ibuprofen lysine soln 26 ibuprofen susp 26 ibuprofen tabs 26 ibutilide fumarate soln 24 icatibant acetate soln 20 iclevia tabs 43 ICLUSIG TABS 10mg 15mg 30mg 45mg
15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 75
icosapent ethyl caps 22 IDAMYCIN PFS SOLN 15 idarubicin hcl soln 15 IDHIFA TABS 50mg 100mg 15 ifosfamide soln 15 IFOSFAMIDE SOLR 16 ILARIS SOLN 26 ILUMYA SOSY 56 ILUVIEN IMPL 38 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 34 imipramine pamoate caps 75mg 100mg
125mg 150mg 34 imiquimod crea 375 5 56 IMIQUIMOD PUMP CREA 56 IMOGAM RABIES-HT SOLN 52 IMOVAX RABIES INJ 52 IMPAVIDO CAPS 11 INBRIJA CAPS 30 incassia tabs 43 INCRELEX SOLN 46 indapamide tabs 125mg 25mg 36 indocin supp 26 indomethacin caps 26 indomethacin er cpcr 26 indomethacin sodium solr 26 INFANRIX SUSP 52 INFLECTRA SOLR INTRAVENOUS 48 INFLIXIMAB SOLR INTRAVENOUS 48 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 32 INGREZZA CPPK 32 INLYTA TABS 1mg 5mg 16 INQOVI TABS 16 INREBIC CAPS 16 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 36 INTRON A SOLN 6000000unitml
10000000unitml 16 INTRON A SOLR 10000000unit
18000000unit 50000000unit 16 introvale tabs 43 INVEGA HAFYERA SUSY 34
INVEGA SUSTENNA SUSY 39mg025ml 34
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml 34
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml 34
INVIRASE CAPS 12 INVIRASE TABS 12 IOPIDINE SOLN 39 IPOL INJ 52 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 20 irbesartan tabs 75mg 150mg 300mg 25 irbesartan-hydrochlorothiazide tabs 25 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 20 isosorbide dinitrate er tbcr 25 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 25 isosorbide mononitrate er tb24 25 isosorbide mononitrate er tb24 30mg 60mg
25 isosorbide mononitrate tabs 10mg 20mg 25 isotretinoin caps 10mg 20mg 30mg 40mg
56 isradipine caps 25mg 5mg 23 ISTURISA TABS 1mg 5mg 10mg 49 itraconazole caps 10 ITRACONAZOLE SOLN 10 ivermectin crea 53 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 52
J JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16
76 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg 21
JARDIANCE TABS 10mg 25mg 44 jasmiel tabs 43 JEMPERLI SOLN 16 jinteli tabs 45 JOLIVETTE TABS 43 JULUCA TABS 12 junel 1530 tabs 43 junel 120 tabs 43 junel fe 1530 tabs 43 junel fe 120 tabs 43 junel fe 24 tabs 43 JUXTAPID CAPS 5mg 10mg 20mg 30mg
40mg 60mg 22 JYNARQUE TABS 15mg 30mg 36 JYNARQUE TBPK 36
K KADCYLA SOLR 100mg 160mg 16 kaitlib fe chew 43 KALYDECO PACK 25mg 50mg 75mg 51 KALYDECO TABS 51 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 37 kariva tabs 43 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ 37
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ 37
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS 37
KEDRAB SOLN 52 kelnor 135 tabs 43 kelnor 150 tabs 43 KENALOG SUSP 42 KEPIVANCE SOLR 56 KERALYT SHAM 56 KESIMPTA SOAJ 49 ketoconazole crea 53 ketoconazole foam 53 ketoconazole sham 53 ketoconazole tabs 10 ketodan foam 53 ketoprofen caps 26 ketoprofen er cp24 26 ketorolac tromethamine soln 26 38
ketorolac tromethamine soln 04 05 38 ketorolac tromethamine tabs 26 KEVEYIS TABS 49 KEVZARA SOAJ 150mg114ml
200mg114ml 48 KEVZARA SOSY 150mg114ml
200mg114ml 48 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 47 KHEDEZLA TB24 50mg 100mg 34 KIMMTRAK SOLN 16 KIMYRSA SOLR 9 KINERET SOSY 48 KINRIX SUSP 52 KINRIX SUSY 52 kionex susp 36 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KISQALI FEMARA(200 MG DOSE) TBPK
16 KITABIS PAK NEBU 51 KLISYRI OINT 56 KLOR-CON 10 TBCR 37 klor-con m15 tbcr 37 klor-con m20 tbcr 37 klor-con pack 37 klor-con sprinkle cpcr 8meq 10meq 37 KLOR-CON TBCR 37 KORLYM TABS 44 KORSUVA SOLN 56 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 35 K-TAB TBCR 37 kurvelo tabs 43 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 30 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 lacosamide tabs 50mg 100mg 150mg
200mg 29
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 77
LACRISERT INST 39 LACTATED RINGERS SOLN 37 49 LACTIC ACID LOTN 56 lactulose encephalopathy soln 35 lactulose pack 35 lactulose soln 35 LAMICTAL XR KIT 29 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 29 lamotrigine er tb24 25mg 50mg 100mg
200mg 250mg 300mg 29 lamotrigine kit 29 lamotrigine starter kit-blue kit 29 lamotrigine starter kit-green kit 29 lamotrigine starter kit-orange kit 29 lamotrigine tabs 25mg 100mg 150mg
200mg 29 lamotrigine tbdp 25mg 50mg 100mg
200mg 29 LANOXIN PEDIATRIC SOLN 24 LANREOTIDE ACETATE SOLN 46 lansoprazole cpdr 15mg 30mg 40 lansoprazole tbdd 15mg 30mg 40 lanthanum carbonate chew 500mg 750mg
1000mg 36 LANTUS SOLN 44 LANTUS SOLOSTAR SOPN 44 lapatinib ditosylate tabs 16 larin 1530 tabs 43 larin 120 tabs 43 larin fe 1530 tabs 43 larin fe 120 tabs 43 larissia tabs 43 LARTRUVO SOLN 190mg19ml
500mg50ml 16 latanoprost soln 39 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 34 LAYOLIS FE CHEW 43 LAZANDA SOLN 100mcgact 400mcgact
26 ledipasvir-sofosbuvir tabs 12 leena tabs 43 leflunomide tabs 10mg 20mg 48 LEMTRADA SOLN 32 lenalidomide caps 5mg 10mg 15mg 25mg
16
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 16 lessina tabs 43 letrozole tabs 16 leucovorin calcium soln 47 leucovorin calcium solr 47 leucovorin calcium tabs 5mg 10mg 15mg
25mg 47 LEUKERAN TABS 16 LEUKINE SOLR 21 leuprolide acetate kit 16 LEVALBUTEROL HCL NEBU
125mg05ml 125mg3ml 031mg3ml 063mg3ml 20
levalbuterol tartrate aero 20 levetiracetam er tb24 500mg 750mg 29 levetiracetam in nacl soln 29 levetiracetam soln 29 levetiracetam tabs 250mg 500mg 750mg
1000mg 29 levobunolol hcl soln 39 levocarnitine soln 49 LEVOCARNITINE TABS 49 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 38 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 47 levoleucovorin calcium solr 47 levonest tabs 43 levonorgest-eth est amp eth est tabs 43 levonorgest-eth estrad 91-day tabs 43 levonorgestrel-ethinyl estrad tabs 43 levonorg-eth estrad triphasic tabs 43 levora 01530 (28) tabs 43 levorphanol tartrate tabs 2mg 3mg 26 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
78 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEVOTHYROXINE SODIUM SOLR 47 LEVOTHYROXINE SODIUM TABS 25mcg
50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEXETTE FOAM 55 LEXIVA SUSP 12 LIALDA TBEC 40 LIBTAYO SOLN 16 lidocaine hcl (cardiac) pf sosy 24 lidocaine hcl (cardiac) sosy 24 lidocaine hcl (pf) soln 49 LIDOCAINE HCL CREA 55 lidocaine hcl lotn 55 lidocaine hcl soln 39 49 55 lidocaine hcl urethralmucosal gel 55 lidocaine hcl urethralmucosal prsy 55 LIDOCAINE IN D5W SOLN 24 lidocaine in dextrose soln 49 lidocaine oint 55 lidocaine ptch 55 lidocaine viscous hcl soln 40 lidocaine-epinephrine soln 49 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 55 LIDOCAINE-HYDROCORTISONE ACE KIT
55 lidocaine-prilocaine crea 55 lidocaine-tetracaine crea 55 LIDOCORT CREA 56 lidopin crea 56 LIDO-SORB LOTN 55 LIDOZION LOTN 56 lincomycin hcl soln 9 lindane sham 53 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 liothyronine sodium soln 47 liothyronine sodium tabs 5mcg 25mcg
50mcg 47 LIPODOX 50 INJ 16
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg 25
lisinopril-hydrochlorothiazide tabs 25 LITHIUM CARBONATE CAPS 150mg
300mg 600mg 34 lithium carbonate er tbcr 300mg 450mg 34 LITHIUM CARBONATE TABS 34 LITHIUM SOLN 34 LITHOSTAT TABS 35 LIVMARLI SOLN 41 LIVTENCITY TABS 12 loestrin 1530 (21) tabs 43 loestrin 120 (21) tabs 43 loestrin fe 1530 tabs 43 loestrin fe 120 tabs 43 LOKELMA PACK 5gm 10gm 36 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 16 loperamide hcl caps 40 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 45 lorazepam intensol conc 31 LORAZEPAM SOLN 4mgml 2mgml 31 lorazepam tabs 05mg 1mg 2mg 31 LORBRENA TABS 25mg 100mg 16 lorcet hd tabs 26 lorcet plus tabs 26 lorcet tabs 27 lortab elix 27 loryna tabs 43 losartan potassium tabs 25mg 50mg
100mg 25 losartan potassium-hctz tabs 25 LOTEMAX GEL 38 LOTEMAX SUSP 38 lovastatin tabs 10mg 20mg 40mg 22 LOVENOX SOLN 21 LOVENOX SOSY 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
low-ogestrel tabs 43 loxapine succinate caps 5mg 10mg 25mg
50mg 34 lubiprostone caps 8mcg 24mcg 41 LUCEMYRA TABS 32 LUCENTIS SOLN 03mg005ml
05mg005ml 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 79
LUCENTIS SOSY 03mg005ml 05mg005ml 39
LUDENT CHEW 025mg 05mg 1mg 49 LUMAKRAS TABS 16 LUMIGAN SOLN 39 LUMIZYME SOLR 37 LUMOXITI SOLR 16 LUPANETA PACK KIT 16 LUPKYNIS CAPS 48 LUPRON DEPOT (1-MONTH) KIT 16 LUPRON DEPOT (3-MONTH) KIT 16 LUPRON DEPOT (4-MONTH) KIT 16 LUPRON DEPOT (6-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 16 LUPRON DEPOT-PED (3-MONTH) KIT 16 lutera tabs 43 LYBALVI TABS 34 lyleq tabs 43 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 45
LYMEPAK TABS 9 LYNPARZA TABS 100mg 150mg 16 LYSODREN TABS 16 lyza tabs 43
M mafenide acetate pack 53 magnesium sulfate in d5w soln 37 magnesium sulfate soln 29 MAGNESIUM SULFATE SOLN INJECTION
50 29 MAKENA SOAJ 46 malathion lotn 53 MANNITOL SOLN 36 maprotiline hcl tabs 25mg 50mg 75mg 34 maraviroc tabs 150mg 300mg 12 MARGENZA SOLN 16 marlissa tabs 43 MARPLAN TABS 34 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 23 MAVENCLAD (10 TABS) TBPK 48 MAVENCLAD (4 TABS) TBPK 48 MAVENCLAD (5 TABS) TBPK 48
MAVENCLAD (6 TABS) TBPK 48 MAVENCLAD (7 TABS) TBPK 48 MAVENCLAD (8 TABS) TBPK 48 MAVENCLAD (9 TABS) TBPK 48 MAVYRET PACK 12 MAVYRET TABS 12 MAYZENT STARTER PACK TBPK 32 MAYZENT TABS 025mg 1mg 2mg 32 MENAPHOSMBHYO1 TABS 13 meclizine hcl tabs 40 meclofenamate sodium caps 27 MEDROL TABS 42 medroxyprogesterone acetate susp 46 medroxyprogesterone acetate susy 46 medroxyprogesterone acetate tabs 25mg
5mg 10mg 46 mefenamic acid caps 27 mefloquine hcl tabs 11 megestrol acetate susp 17 46 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 43 meloxicam tabs 27 melphalan hcl solr 17 memantine hcl er cp24 32 memantine hcl soln 32 memantine hcl tabs 5mg 10mg 32 MENACTRA SOLN 52 menest tabs 03mg 0625mg 125mg 45 MENQUADFI SOLN 52 MENVEO SOLR 52 meperidine hcl soln 27 meperidine hcl tabs 50mg 27 meprobamate tabs 31 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 43 mesalamine cpdr 40 mesalamine enem 40 mesalamine er cp24 40 mesalamine supp 40 mesalamine tbec 12gm 800mg 40 mesalamine-cleanser kit 40 mesna soln 49 MESNEX TABS 49 MESTINON SOLN 19 metadate er tbcr 28 metaproterenol sulfate syrp 20
80 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
metaproterenol sulfate tabs 10mg 20mg 20 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 44 metformin hcl tabs 500mg 850mg 1000mg
45 methadone hcl conc 27 methadone hcl intensol conc 27 methadone hcl tabs 5mg 10mg 27 methamphetamine hcl tabs 28 methazolamide tabs 25mg 50mg 39 methenamine hippurate tabs 13 METHENAMINE MANDELATE TABS 13 methergine tabs 45 methimazole tabs 5mg 10mg 47 methitest tabs 42 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 57 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 36 methyldopa tabs 250mg 500mg 24 methyldopa-hydrochlorothiazide tabs 24 methylergonovine maleate soln 45 methylergonovine maleate tabs 45 methylphenidate hcl chew 25mg 5mg
10mg 28 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 28 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 28 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 28
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 28
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 28
methylphenidate hcl soln 5mg5ml 10mg5ml 28
methylphenidate hcl tabs 5mg 10mg 20mg 28
methylprednisolone acetate susp 42 methylprednisolone sodium succ solr 42
methylprednisolone tabs 4mg 8mg 16mg 32mg 42
methylprednisolone tbpk 42 methyltestosterone caps 42 metoclopramide hcl soln 41 metoclopramide hcl tabs 5mg 10mg 41 metoclopramide hcl tbdp 5mg 10mg 41 metolazone tabs 25mg 5mg 10mg 36 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 23 metoprolol tartrate soct 23 metoprolol tartrate soln 23 metoprolol tartrate tabs 25mg 50mg
100mg 23 metoprolol tartrate tabs 375mg 75mg 23 metoprolol-hydrochlorothiazide tabs 23 metronidazole caps 11 metronidazole crea 53 metronidazole gel 53 metronidazole lotn 53 METRONIDAZOLE SOLN INTRAVENOUS
500mg100ml 11 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
24 mibelas 24 fe chew 43 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 53 miconazole-zinc oxide-petrolat oint 53 micort-hc crea 55 microgestin 1530 tabs 43 microgestin 120 tabs 43 microgestin 24 fe tabs 43 microgestin fe 1530 tabs 43 microgestin fe 120 tabs 43 midazolam hcl (pf) soln 31 midazolam hcl soln 31 midodrine hcl tabs 25mg 5mg 10mg 20 miglitol tabs 25mg 50mg 100mg 45 miglustat caps 38 mili tabs 43 millipred dp tbpk 42 millipred tabs 42 milrinone lactate in dextrose soln 24 milrinone lactate soln 24 mimvey lo tabs 45 mimvey tabs 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 81
minitran pt24 01mghr 02mghr 04mghr 06mghr 25
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 24 mirtazapine tabs 75mg 15mg 30mg
45mg 34 mirtazapine tbdp 15mg 30mg 45mg 34 misoprostol tabs 100mcg 200mcg 40 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 52 modafinil tabs 100mg 200mg 28 moexipril hcl tabs 75mg 15mg 25 molindone hcl tabs 5mg 10mg 25mg 34 mometasone furoate crea 55 mometasone furoate oint 55 mometasone furoate soln 55 mometasone furoate susp 38 MONJUVI SOLR 17 MONONESSA TABS 43 montelukast sodium chew 4mg 5mg 51 montelukast sodium pack 51 montelukast sodium tabs 51 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 27 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 27 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 27
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 27
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml 27
morphine sulfate tabs 15mg 30mg 27 moxifloxacin hcl (2x day) soln 38 moxifloxacin hcl in nacl soln intravenous 9 moxifloxacin hcl soln 38 moxifloxacin hcl tabs 9 MULPLETA TABS 21 MULTAQ TABS 24 mupirocin calcium crea 53 mupirocin oint 53 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17
MYALEPT SOLR 49 MYCAPSSA CPDR 46 mycophenolate mofetil caps 48 mycophenolate mofetil hcl solr 48 mycophenolate mofetil susr 48 mycophenolate mofetil tabs 49 mycophenolate sodium tbec 180mg 360mg
49 MYFEMBREE TABS 45 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 57 MYRBETRIQ TB24 25mg 50mg 57
N NABI-HB SOLN 52 nabumetone tabs 27 N-ACETYL-L-CYSTEINE CAPS 36 nadolol tabs 20mg 40mg 80mg 23 nadololbendroflumethiazide tabs 23 nadolol-bendroflumethiazide tabs 23 nafcillin sodium solr 9 nafcillin sodium solr injection 9 nafcillin sodium solr intravenous 9 NAFRINSE CHEW 49 NAFRINSE DROPS SOLN 49 naftifine hcl crea 53 naftifine hcl gel 53 NAGLAZYME SOLN 38 nalbuphine hcl soln 10mgml 20mgml 27 nalfon tabs 27 nalocet tabs 27 naloxone hcl liqd 32 naloxone hcl soaj 32 naloxone hcl soct 32 naloxone hcl soln 32 naloxone hcl sosy 32 naltrexone hcl tabs 32 naproxen sodium er tb24 27 naproxen sodium tabs 27 naproxen susp 27 naproxen tabs 27 naproxen tbec 27 naproxen-esomeprazole tbec 27 naratriptan hcl tabs 30 NARCAN LIQD 32 NATACYN SUSP 38 nateglinide tabs 60mg 120mg 45 NATPARA CART 25mcg 50mcg 75mcg
100mcg 45
82 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
NAYZILAM SOLN 29 necon 0535 (28) tabs 43 NECON 777 TABS 43 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 34 nelarabine soln 17 nembutal soln 31 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 38 neomycin-polymyxin b gu soln 53 neomycin-polymyxin-dexameth oint 38 neomycin-polymyxin-dexameth susp 39 neomycin-polymyxin-gramicidin soln 38 neomycin-polymyxin-hc soln 39 neomycin-polymyxin-hc susp 39 neo-polycin hc oint 38 neo-polycin oint 38 neo-synalar crea 55 NERLYNX TABS 17 NEULASTA ONPRO PSKT 21 NEULASTA SOSY 21 NEUPOGEN SOLN 480mcg16ml
300mcgml 21 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 21 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 38 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 22 niacor tabs 22 nicardipine hcl caps 20mg 30mg 23 NICARDIPINE HCL SOLN 23 NICOTROL INHA 19 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 43 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 49 nitro-bid oint 25
NITRO-DUR PT24 03mghr 08mghr 25 NITROFURANTOIN MACROCRYSTAL
CAPS 13 NITROFURANTOIN MONOHYD MACRO
CAPS 13 nitrofurantoin susp 13 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 25 nitroglycerin soln 25 nitroglycerin subl 03mg 04mg 06mg 25 nitropress soln 24 nitroprusside sodium soln 24 NITYR TABS 2mg 5mg 10mg 49 NIVESTYM SOLN 480mcg16ml
300mcgml 21 NIVESTYM SOSY 300mcg05ml
480mcg08ml 22 nizatidine caps 150mg 300mg 40 nizatidine soln 40 nolix crea 55 nolix lotn 55 nora-be tabs 43 norco tabs 27 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 46
norepinephrine bitartrate soln 20 norethin ace-eth estrad-fe caps 43 norethin ace-eth estrad-fe chew 43 norethin ace-eth estrad-fe tabs 43 norethindrone acetate tabs 46 norethindrone acet-ethinyl est tabs 43 norethindrone tabs 43 norethindrone-eth estradiol tabs 45 norethin-eth estradiol-fe chew 43 norgesic forte tabs 27 norgestimate-eth estradiol tabs 43 norgestim-eth estrad triphasic tabs 43 norlyroc tabs 43 NORPACE CR CP12 100mg 150mg 24 nortrel 0535 (28) tabs 43 nortrel 135 (21) tabs 43 nortrel 135 (28) tabs 43 nortrel 777 tabs 43 nortriptyline hcl caps 10mg 25mg 50mg
75mg 34 nortriptyline hcl soln 34 NORVIR CAPS 12 NORVIR PACK 12
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 83
NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 32 NOXAFIL SUSP 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 51 NUCALA SOLR 51 NUCALA SOSY 51 NUCYNTA ER TB12 200mg 250mg 27 NUCYNTA TABS 27 NUEDEXTA CAPS 32 NULIBRY SOLR 49 NULOJIX SOLR 49 NUPLAZID CAPS 34 NUPLAZID TABS 10mg 17mg 34 NURTEC TBDP 30 NUTRILIPID EMUL INTRAVENOUS 36 NUTROPIN AQ NUSPIN 10 SOPN 46 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 53 nylia 135 tabs 43 nylia 777 tabs 43 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 44 nystatin crea 53 nystatin oint 53 nystatin powd 53 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 55 nystatin-triamcinolone oint 55 nystop powd 53 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 41 ocella tabs 44 OCREVUS SOLN 32 OCTAGAM SOLN INTRAVENOUS
1gm20ml 2gm20ml 52 octreotide acetate soln 500mcgml
1000mcgml 46 octreotide acetate soln 50mcgml
100mcgml 200mcgml 46 ODACTRA SUBL 49 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 51
ofloxacin soln 38 ofloxacin tabs 10 ogestrel tabs 44 OGIVRI SOLR 17 olanzapine solr 34 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 34 olanzapine tbdp 5mg 10mg 15mg 20mg
34 olanzapine-fluoxetine hcl caps 34 olmesartan medoxomil tabs 5mg 20mg
40mg 25 olmesartan medoxomil-hctz tabs 25 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 39 OLUMIANT TABS 1mg 2mg 48 omega-3-acid ethyl esters caps 22 omeprazole cpdr 10mg 20mg 40mg 40 omeprazole-sodium bicarbonate caps 40 omeprazole-sodium bicarbonate pack 40 OMNITROPE SOCT 5mg15ml
10mg15ml 46 OMNITROPE SOLR 46 ondansetron hcl soln 40 ondansetron hcl sosy 40 ondansetron hcl tabs 4mg 8mg 24mg 40 ondansetron tbdp 4mg 8mg 40 ONIVYDE
INJ 17 ONPATTRO SOLN 50 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 OPDIVO SOLN 100mg10ml 120mg12ml
240mg24ml 40mg4ml 17 OPDUALAG SOLN 17 OPIUM TINC 40 OPZELURA CREA 57 ORACEA CPDR 57 oralone pste 55 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 48 ORENCIA SOLR 48 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 48 ORENITRAM TBCR 025mg 1mg 25mg
5mg 51 ORFADIN CAPS 50 ORFADIN SUSP 50 ORGOVYX TABS 45
84 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ORILISSA TABS 150mg 200mg 45 ORKAMBI PACK 51 ORKAMBI TABS 51 ORLADEYO CAPS 110mg 150mg 50 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 27 orphengesic forte tabs 27 orsythia tabs 44 ORTIKOS CP24 6mg 9mg 42 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 36 OTEZLA TABS 48 OTEZLA TBPK 48 ovide lotn 53 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 42 oxaprozin tabs 27 OXAYDO TABS 27 oxazepam caps 10mg 15mg 30mg 31 OXBRYTA TABS 21 OXBRYTA TBSO 21 oxcarbazepine susp 29 oxcarbazepine tabs 150mg 300mg 600mg
29 OXERVATE SOLN 39 oxiconazole nitrate crea 53 OXLUMO SOLN 50 OXTELLAR XR TB24 150mg 300mg
600mg 29 oxybutynin chloride er tb24 5mg 10mg
15mg 57 oxybutynin chloride syrp 57 oxybutynin chloride tabs 57 oxycodone hcl caps 27 oxycodone hcl conc 27 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxycodone hcl soln 27 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 27 oxycodone-acetaminophen soln 27
oxycodone-acetaminophen tabs 27 oxycodone-acetaminophen tabs 5-300mg
75-300mg 10-300mg 27 oxycodone-aspirin tabs 27 oxycodone-ibuprofen tabs 27 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 27 oxymorphone hcl tabs 5mg 10mg 27 OXYTOCIN SOLN 45 OZEMPIC (025 OR 05 MGDOSE) SOPN
45 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 45 OZEMPIC (2 MGDOSE) SOPN 45
P pacerone tabs 100mg 200mg 400mg 24 paclitaxel conc 17 PACLITAXEL PROTEIN-BOUND PART
SUSR 100 MG 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
50 PALFORZIA (120 MG DAILY DOSE) CSPK
50 PALFORZIA (160 MG DAILY DOSE) CSPK
50 PALFORZIA (20 MG DAILY DOSE) CSPK
50 PALFORZIA (200 MG DAILY DOSE) CSPK
50 PALFORZIA (240 MG DAILY DOSE) CSPK
50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK 50 PALFORZIA (300 MG TITRATION) PACK
50 PALFORZIA (40 MG DAILY DOSE) CSPK
50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
50 PALFORZIA INITIAL ESCALATION CSPK
50 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 34
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 85
palonosetron hcl soln 40 palonosetron hcl sosy 40 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 38 pamidronate disodium soln 47 pamidronate disodium solr 47 panlor tabs 27 PANRETIN GEL 56 pantoprazole sodium pack 40 PANTOPRAZOLE SODIUM SOLR 40 pantoprazole sodium tbec 20mg 40mg 40 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 52
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 57 PARICALCITOL SOLN 57 paroex soln 38 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 34 paroxetine hcl susp 34 paroxetine hcl tabs 10mg 20mg 34 paroxetine hcl tabs 30mg 40mg 34 paroxetine mesylate caps 34 paser pack 11 PEDIARIX SUSY 52 PEDVAX HIB SUSP 52 peg 3350electrolytes solr 41 peg 3350-kcl-na bicarb-nacl solr 41 peg-3350electrolytes solr 41 PEGANONE TABS 29 PEGASYS PROCLICK SOAJ
135mcg05ml 180mcg05ml 12 PEGASYS SOLN 12 PEGASYS SOSY 12 PEGINTRON KIT 12 PEG-PREP KIT 41 PEMAZYRE TABS 45mg 9mg 135mg 17 PEMFEXY SOLN 17 penicillamine caps 41 penicillamine tabs 41 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
PENTACEL SUSR 52 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 40 pentazocine-naloxone hcl tabs 27 pentobarbital sodium soln 31 pentoxifylline er tbcr 21 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 40 percocet tabs 27 perindopril erbumine tabs 2mg 4mg 8mg
25 periogard soln 38 PERJETA SOLN 17 permethrin crea 53 perphenazine tabs 2mg 4mg 8mg 16mg
34 perphenazine-amitriptyline tabs 34 PERSERIS PRSY 90mg 120mg 34 PEXEVA TABS 10mg 20mg 30mg 40mg
34 phenadoz supp 14 phenazo tabs 56 PHENAZOPYRIDINE HCL TABS 56 phenelzine sulfate tabs 34 phenergan soln 14 PHENOBARBITAL ELIX 31 PHENOBARBITAL SODIUM SOLN 31 PHENOBARBITAL TABS 31 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 20 PHENYLEPHRINE HCL SOLN 39 phenytek caps 200mg 300mg 29 phenytoin chew 29 phenytoin sodium extended caps 100mg
200mg 300mg 29 phenytoin sodium soln 29 phenytoin susp 29 PHESGO SOLN 17 PHOSLYRA SOLN 37 PHOSPHASAL TABS 13 PHOSPHOLINE IODIDE SOLR 39 phrenilin forte caps 27 PHYSIOLYTE SOLN 50 PHYSIOSOL IRRIGATION SOLN 50 PIFELTRO TABS 12 pilocarpine hcl soln 1 2 4 39 pilocarpine hcl tabs 5mg 75mg 19 pimecrolimus crea 57
86 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
pimozide tabs 1mg 2mg 34 pimtrea tabs 44 pindolol tabs 5mg 10mg 23 pioglitazone hcl tabs 15mg 30mg 45mg 45 pioglitazone hcl-glimepiride tabs 45 pioglitazone hcl-metformin hcl tabs 45 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 44 piroxicam caps 10mg 20mg 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN 32 PLEGRIDY SOSY 32 PLEGRIDY STARTER PACK SOPN 32 PLEGRIDY STARTER PACK SOSY 32 plenamine soln intravenous 36 podofilox soln 57 POLIVY SOLR 30mg 140mg 17 polocaine soln 50 polocaine-mpf soln 50 polycin oint 38 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 38 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 32 PONVORY TABS 32 portia-28 tabs 44 PORTRAZZA SOLN 17 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 35 POTASSIUM ACETATE SOLN 37 potassium chloride crys er tbcr 10meq
20meq 37 potassium chloride er cpcr 8meq 10meq 37 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 37 POTASSIUM CHLORIDE IN NACL SOLN
INTRAVENOUS 37 POTASSIUM CHLORIDE PACK 37 POTASSIUM CHLORIDE SOLN 10 20
37
potassium chloride soln intravenous 10meq100ml 20meq100ml 40meq100ml 2meqml 37
potassium citrate er tbcr 15meq 540mg 1080mg 35
POTASSIUM PHOSPHATES SOLN 37 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 37 POTELIGEO SOLN 17 PR BENZOYL PEROXIDE WASH LIQD 53 PRADAXA CAPS 75mg 110mg 150mg 21 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 31
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 31
PRAMOX GEL 56 prandin tabs 1mg 2mg 45 prasugrel hcl tabs 5mg 10mg 21 pravastatin sodium tabs 10mg 20mg
40mg 80mg 22 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22 PRED MILD SUSP 39 PRED-G SOP OINT 39 PRED-G SUSP 39 prednicarbate crea 55 prednicarbate oint 55 prednisolone acetate susp 39 prednisolone sodium phosphate soln 39 PREDNISOLONE SODIUM PHOSPHATE
SOLN 10mg5ml 20mg5ml 25mg5ml 5mg5ml 42
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 42
prednisolone soln 42 prednisone intensol conc 42 prednisone soln 42 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 42 prednisone tbpk 42 prefest tabs 45 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 29
pregabalin er tb24 825mg 165mg 330mg 27
pregabalin soln 29 PREHEVBRIO SUSP 52
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 87
PREMARIN SOLR 45 premasol soln intravenous 36 PRENATAL TABS 57 PRETOMANID TABS 11 prevalite pack 22 prevalite powd 22 previfem tabs 44 PREVYMIS SOLN 240mg12ml
480mg24ml 12 PREVYMIS TABS 240mg 480mg 12 PREZCOBIX TABS 12 PREZISTA SUSP 12 PREZISTA TABS 75mg 150mg 600mg
800mg 12 PRIFTIN TABS 11 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 29 primlev tabs 27 probenecid tabs 37 procainamide hcl soln 24 PROCALAMINE SOLN INTRAVENOUS 36 procentra soln 28 prochlorperazine edisylate soln 34 prochlorperazine maleate tabs 34 prochlorperazine supp 34 PROCRIT SOLN 20000unitml
40000unitml 22 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 22 proctofoam hc foam 56 procto-med hc crea 55 procto-pak crea 55 proctosol hc crea 55 proctozone-hc crea 55 PROCYSBI CPDR 25mg 75mg 50 PROCYSBI PACK 75mg 300mg 50 progesterone caps 100mg 200mg 46 progesterone oil 46 PROGRAF PACK 49 PROGRAF PACK 02mg 49 PROGRAF SOLN 49 prolate soln 27 prolate tabs 27 PROLEUKIN SOLR 17 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 24 propafenone hcl tabs 150mg 225mg
300mg 24 propantheline bromide tabs 19 proparacaine hcl soln 40 propranolol hcl er cp24 60mg 80mg
120mg 160mg 23 propranolol hcl soln 20mg5ml 40mg5ml 23 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 23 propranolol-hctz tabs 23 propylthiouracil tabs 47 PROQUAD SUSR 52 protriptyline hcl tabs 5mg 10mg 34 psorcon crea 55 PULMICORT FLEXHALER AEPB 51 PULMOZYME SOLN 38 PURIXAN SUSP 17 PYLERA CAPS 40 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 19 pyridostigmine bromide soln 19 pyridostigmine bromide tabs 30mg 60mg 19 pyrimethamine tabs 11 PYRUKYND TABS 5mg 20mg 50mg 50 PYRUKYND TAPER PACK TBPK 50
Q QDOLO SOLN 27 QINLOCK TABS 17 QUADRACEL SUSP 52 questran light powd 22 questran pack 22 questran powd 22 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 34 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 34 quinapril hcl tabs 5mg 10mg 20mg 40mg
25 quinapril-hydrochlorothiazide tabs 25 quinidine gluconate er tbcr 24 QUINIDINE GLUCONATE SOLN 24 quinidine sulfate tabs 200mg 300mg 24
88 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
quinine sulfate caps 11 QULIPTA TABS 10mg 30mg 60mg 30
R RABAVERT SUSR 52 rabeprazole sodium cpsp 40 rabeprazole sodium tbec 40 RADIAURA CREA 55 RADICAVA SOLN 32 raloxifene hcl tabs 45 ramelteon tabs 31 ramipril caps 125mg 25mg 5mg 10mg 25 ranolazine er tb12 500mg 1000mg 24 RAPIVAB SOLN 12 rasagiline mesylate tabs 05mg 1mg 31 RASUVO SOAJ 48 RAVICTI LIQD 35 RAYALDEE CPCR 57 REBETOL SOLN 12 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 32 REBIF REBIDOSE TITRATION PACK
SOAJ 32 REBIF SOSY 22mcg05ml 44mcg05ml 32 REBIF TITRATION PACK SOSY 32 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 44 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 52 RECORLEV TABS 50 RECTIV OINT 57 REGONOL SOLN 19 REGRANEX GEL 57 relafen ds tabs 27 RELENZA DISKHALER AEPB 12 RELEUKO SOLN 300mcgml
480mcg16ml 22 RELEUKO SOSY 300mcg05ml
480mcg08ml 22 relexxii tbcr 28 RELISTOR SOLN 8mg04ml 12mg06ml
41 RELISTOR TABS 41 reltone caps 200mg 400mg 41 REMICADE SOLR INTRAVENOUS 48 RENFLEXIS SOLR 48 repaglinide tabs 05mg 1mg 2mg 45 repaglinide-metformin hcl tabs 45
REPATHA SOSY 22 REPATHA SURECLICK SOAJ 22 RESCRIPTOR TABS 100mg 200mg 12 RESTASIS EMUL 39 RESTASIS MULTIDOSE EMUL 39 RETACRIT SOLN 22 RETACRIT SOLN 20000unitml 22 RETEVMO CAPS 40mg 80mg 17 RETIN-A CREA 0025 005 01 56 RETIN-A GEL 001 0025 56 RETIN-A MICRO GEL 004 01 56 RETIN-A MICRO PUMP GEL 004 01
56 RETISERT IMPL 39 RETROVIR SOLN 12 REVCOVI SOLN 38 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 17 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 34 REYATAZ PACK 12 REZUROCK TABS 50 RIABNI SOLN 100mg10ml 500mg50ml 17 ribasphere caps 12 ribasphere ribapak (1000 pack) tbpk 12 ribasphere ribapak (1200 pack) tbpk 12 ribasphere tabs 12 ribavirin caps 12 ribavirin solr 12 ribavirin tabs 13 RIDAURA CAPS 50 rifabutin caps 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 riluzole tabs 32 rimantadine hcl tabs 13 RIMSO-50 SOLN 50 RINGERS IRRIGATION SOLN 50 RINGERS SOLN 37 RINVOQ TB24 15mg 30mg 45mg 48 risedronate sodium tabs 5mg 30mg 35mg
150mg 47 risedronate sodium tbec 47 RISPERDAL CONSTA SRER 125mg
25mg 34 RISPERDAL CONSTA SRER 375mg
50mg 35
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 89
RISPERIDONE SOLN 35 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 35 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 35 ritonavir tabs 13 RITUXAN HYCELA SOLN 17 RITUXAN SOLN 17 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 44 rizatriptan benzoate tabs 30 rizatriptan benzoate tbdp 30 ROMIDEPSIN SOLN 17 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 31 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 31 ropivacaine hcl soln 50 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 22 ROTARIX SUSR 52 ROTATEQ SOLN 52 roweepra tabs 500mg 750mg 1000mg 29 roweepra xr tb24 500mg 750mg 29 ROZLYTREK CAPS 100mg 200mg 17 RUBRACA TABS 200mg 250mg 300mg 17 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 29 rufinamide tabs 200mg 400mg 29 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 17 RYBREVANT SOLN 17 ryclora soln 14 RYDAPT CAPS 17 RYLAZE SOLN 17 RYNODERM CREA 57 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 46 SAIZEN SOLR 5mg 88mg 46 SAIZENPREP SOLR 46 sajazir soln 21 SALEX SHAM 57 SALICYLIC ACID CREA 57
SALICYLIC ACID ER SOLN 57 SALICYLIC ACID FOAM 57 SALICYLIC ACID GEL 57 SALICYLIC ACID SHAM 57 SALICYLIC ACID-CLEANSER KIT 57 SALSALATE TABS 27 SANCUSO PTCH 40 SANDIMMUNE ORAL SOLN 100mgml 49 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 46 SANTYL OINT 57 SAPHNELO SOLN 49 SAPHRIS SUBL 25mg 5mg 10mg 35 sapropterin dihydrochloride pack 100mg
500mg 50 sapropterin dihydrochloride tabs 50 SARCLISA SOLN 500mg25ml 100mg5ml
17 SCEMBLIX TABS 20mg 40mg 17 scopolamine pt72 40 seconal caps 31 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 35 selegiline hcl caps 31 selegiline hcl tabs 31 selenium sulfide lotn 53 SELENIUM SULFIDE SHAM 53 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 13 SENSORCAINE SOLN 50 sensorcaineepinephrine soln 50 sensorcaine-mpf soln 50 sensorcaine-mpfepinephrine soln 50 SEREVENT DISKUS AEPB 20 SEROSTIM SOLR 4mg 5mg 6mg 46 SERTRALINE HCL CAPS 150mg 200mg
35 sertraline hcl conc 35 sertraline hcl tabs 25mg 50mg 100mg 35 setlakin tabs 44 sevelamer carbonate pack 08gm 24gm 36 sevelamer carbonate tabs 36 sevelamer hcl tabs 400mg 800mg 36 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 44 SHINGRIX SUSR 52 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 46
90 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
SIGNIFOR SOLN 03mgml 06mgml 09mgml 46
SIKLOS TABS 17 sildenafil citrate soln 25 sildenafil citrate susr 25 sildenafil citrate tabs 25 SILIQ SOSY 57 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 53 SIMPONI ARIA SOLN 48 SIMPONI SOAJ 50mg05ml 100mgml 48 SIMPONI SOSY 50mg05ml 100mgml 48 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 22 sirolimus soln 49 sirolimus tabs 05mg 1mg 2mg 49 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKYRIZI (150 MG DOSE) PSKT 57 SKYRIZI PEN SOAJ 57 SKYRIZI SOSY 57 SKYTROFA CART 3mg 36mg 43mg
52mg 63mg 76mg 91mg 11mg 133mg 46
sod benz-sod phenylacet soln 35 SODIUM ACETATE SOLN 35 SODIUM BICARBONATE SOLN 35 SODIUM CHLORIDE (PF) SOLN 37 SODIUM CHLORIDE SOLN 37 50 SODIUM CHLORIDE SOLN
INTRAVENOUS 045 09 3 5 37 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 50 SODIUM FLUORIDE SOLN 50 sodium phenylbutyrate powd 35 sodium phenylbutyrate tabs 35 SODIUM PHOSPHATES SOLN 37 sodium polystyrene sulfonate powd 36 sodium polystyrene sulfonate susp 36 sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 57 SOLTAMOX SOLN 17 SOLU-CORTEF SOLR 42 SOLU-MEDROL SOLR 42 SOMATULINE DEPOT SOLN 60mg02ml
90mg03ml 120mg05ml 46 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 46
sorine tabs 80mg 120mg 160mg 240mg 23
sotalol hcl (af) tabs 80mg 120mg 160mg 23 sotalol hcl tabs 80mg 120mg 160mg
240mg 23 SOTYLIZE SOLN 23 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 25 spironolactone-hctz tabs 25 SPRAVATO (56 MG DOSE) SOPK 35 SPRAVATO (84 MG DOSE) SOPK 35 sprintec 28 tabs 44 SPRITAM TB3D 250mg 500mg 750mg
1000mg 29 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 36 sronyx tabs 44 SSD CREA 53 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
57 STELARA SOSY 45mg05ml 90mgml 57 STERILE WATER FOR IRRIGATION SOLN
50 STIMATE SOLN 46 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18 STRENSIQ SOLN 18mg045ml
28mg07ml 80mg08ml 40mgml 38 streptomycin sulfate solr 10 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 20 SUBLOCADE SOSY 100mg05ml
300mg15ml 32 SUBSYS LIQD 1200mcg 1600mcg 27 subvenite starter kit-blue kit 29 subvenite starter kit-green kit 29 subvenite starter kit-orange kit 30 subvenite tabs 25mg 100mg 150mg
200mg 30 succinylcholine chloride soln 20 SUCRAID SOLN 38 sucralfate susp 40 sucralfate tabs 40
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 91
sulfacetamide sodium (acne) lotn 53 sulfacetamide sodium oint 38 sulfacetamide sodium soln 38 sulfacetamide-prednisolone soln 39 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 SULFAMYLON CREA 53 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 27 sumatriptan soln 30 sumatriptan succinate refill soct 30 sumatriptan succinate soaj 30 sumatriptan succinate soln 30 sumatriptan succinate sosy 30 sumatriptan succinate tabs 30 sunitinib malate caps 125mg 25mg
375mg 50mg 18 suprax chew 10 SUPREP BOWEL PREP KIT SOLN 41 SUSVIMO (IMPLANT 1ST FILL) SOLN 39 SUSVIMO (IMPLANT REFILL) SOLN 39 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 44 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 51 SYMDEKO TBPK 51 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 45 SYMLINPEN 60 SOPN 45 SYMPAZAN FILM 10mg 20mg 30 SYMPAZAN FILM 5mg 30 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 46 SYNDROS SOLN 40 SYNERCID SOLR 10 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 tacrolimus caps 05mg 1mg 5mg 49 TACROLIMUS OINT 01 003 57
tadalafil (pah) tabs 20mg 25 tadalafil tabs 25mg 5mg 25 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 50 TAKHZYRO SOSY 50 TALTZ SOAJ 57 TALTZ SOSY 57 TALZENNA CAPS 025mg 05mg 075mg
1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 47 taperdex 12-day tbpk 42 taperdex 6-day tbpk 42 taperdex 7-day tbpk 42 targadox tabs 10 TARGRETIN GEL 56 tarina 24 fe tabs 44 tarina fe 120 eq tabs 44 TARPEYO CPDR 42 TASIGNA CAPS 50mg 150mg 200mg 18 TAVALISSE TABS 100mg 150mg 22 TAVNEOS CAPS 50 taysofy caps 44 tazarotene crea 57 tazarotene foam 57 tazicef solr injection 10 tazicef solr intravenous 2gm 6gm 10 TAZORAC CREA 57 TAZORAC GEL 005 01 57 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 52 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TEFLARO SOLR INTRAVENOUS 10 TEGSEDI SOSY 50 telmisartan tabs 20mg 40mg 80mg 25 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 25 TEMAZEPAM CAPS 75mg 15mg 225mg
30mg 31 temsirolimus soln 18 tencon tabs 27 TENIPOSIDE SOLN 18 TENIVAC INJ 52 tenofovir disoproxil fumarate tabs 13
92 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TEPADINA SOLR 18 TEPEZZA SOLR 39 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 20 terbutaline sulfate tabs 25mg 5mg 20 terconazole crea 53 terconazole supp 53 TERIPARATIDE (RECOMBINANT) SOPN
46 testosterone cypionate soln 100mgml
200mgml 42 testosterone enanthate soln 42 testosterone gel 1 162
2025mg125gm 405mg25gm 10mgact 42
testosterone soln 42 tetrabenazine tabs 125mg 25mg 32 TETRACAINE HCL SOLN 40 tetracycline hcl caps 250mg 500mg 10 texacort soln 55 TEZSPIRE SOSY 51 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 57 theophylline er tb12 100mg 200mg
300mg 450mg 57 theophylline er tb24 400mg 600mg 57 theophylline soln 57 THIOLA EC TBEC 100mg 300mg 50 THIOLA TABS 50 thioridazine hcl tabs 10mg 25mg 50mg
100mg 35 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 35 THYROGEN SOLR 50 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
30 TIBSOVO TABS 18 TICOVAC SUSY 52 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 32 tilia fe tabs 44 timolol maleate (once-daily) soln 39 timolol maleate pf soln 39
TIMOLOL MALEATE SOLG 025 05 39 timolol maleate soln 025 05 39 timolol maleate tabs 5mg 10mg 20mg 23 tinidazole tabs 11 tiopronin tabs 50 TIS-U-SOL SOLN 50 TIVDAK SOLR 18 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 tizanidine hcl caps 20 tizanidine hcl tabs 20 TOBI PODHALER CAPS 51 TOBRADEX OINT 39 TOBRADEX ST SUSP 39 tobramycin nebu 300mg4ml 300mg5ml 51 tobramycin soln 38 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 39 TOBREX OINT 38 tofranil tabs 10mg 25mg 50mg 35 tolazamide tabs 250mg 500mg 45 tolbutamide tabs 45 tolcapone tabs 31 tolmetin sodium caps 27 tolmetin sodium tabs 27 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 57 tolterodine tartrate tabs 57 tolvaptan tabs 15mg 30mg 36 TOPEX TOPICAL ANESTHETIC AERO 56 topicort crea 005 025 55 topicort gel 55 topicort oint 55 topiramate cpsp 15mg 25mg 30 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 30 topiramate tabs 25mg 50mg 100mg
200mg 30 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
36 TPN ELECTROLYTES CONC
INTRAVENOUS 37 TRACLEER TBSO 51 TRADJENTA TABS 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 93
tramadol hcl er (biphasic) tb24 100mg 200mg 300mg 28
tramadol hcl er cp24 100mg 150mg 200mg 300mg 28
tramadol hcl er tb24 100mg 200mg 300mg 28
tramadol hcl soln 28 tramadol hcl tabs 50mg 100mg 28 tramadol-acetaminophen tabs 28 trandolapril tabs 1mg 2mg 4mg 25 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 21 tranexamic acid tabs 21 tranylcypromine sulfate tabs 35 TRAVASOL SOLN INTRAVENOUS 36 travoprost (bak free) soln 39 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 150mg 300mg 35 trazodone hcl tabs 50mg 100mg 35 TRECATOR TABS 11 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 57 TREMFYA SOSY 57 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 51 tretinoin caps 18 tretinoin crea 0025 005 01 56 tretinoin gel 001 0025 005 56 tretinoin microsphere gel 004 01 56 tretinoin microsphere pump gel 004
01 56 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 28 triamcinolone acetonide aers 55 triamcinolone acetonide crea 0025
01 05 55 triamcinolone acetonide lotn 0025 01
55 triamcinolone acetonide oint 0025
005 01 05 55 triamcinolone acetonide pste 55 triamcinolone acetonide susp 42 triamterene caps 50mg 100mg 36 triamterene-hctz caps 36 triamterene-hctz tabs 36 trianex oint 55 triazolam tabs 0125mg 025mg 31 TRICITRATES SOLN 35 triderm crea 01 05 55
trientine hcl caps 41 tri-estarylla tabs 44 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 35 trifluridine soln 38 trihexyphenidyl hcl soln 31 trihexyphenidyl hcl tabs 2mg 5mg 31 TRIKAFTA TBPK 51 tri-legest fe tabs 44 tri-lo-estarylla tabs 44 tri-lo-sprintec tabs 44 trilyte solr 41 trimethobenzamide hcl caps 40 TRIMETHOPRIM TABS 13 tri-mili tabs 44 trimipramine maleate caps 25mg 50mg
100mg 35 TRINESSA (28) TABS 44 TRINTELLIX TABS 5mg 10mg 20mg 35 tri-nymyo tabs 44 tri-previfem tabs 44 TRIPTODUR SRER 45 TRISENOX
SOLN 18 tri-sprintec tabs 44 tritocin oint 55 TRIUMEQ PD TBSO 13 TRIUMEQ TABS 13 trivora (28) tabs 44 tri-vylibra lo tabs 44 tri-vylibra tabs 44 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 30 TROPHAMINE SOLN INTRAVENOUS 36 trospium chloride er cp24 57 trospium chloride tabs 57 TRULANCE TABS 41 TRUMENBA SUSY 52 TRUSELTIQ (100MG DAILY DOSE) CPPK
18 TRUSELTIQ (125MG DAILY DOSE) CPPK
18 TRUSELTIQ (50MG DAILY DOSE) CPPK
18 TRUSELTIQ (75MG DAILY DOSE) CPPK
18
94 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 52 TYBOST TABS 13 tydemy tabs 44 tylenol with codeine 3 tabs 28 tylenol with codeine 4 tabs 28 TYMLOS SOPN 46 TYPHIM VI SOLN 52 TYPHIM VI SOSY 52 TYVASO REFILL SOLN 51 TYVASO STARTER SOLN 51
U UBRELVY TABS 50mg 100mg 30 UDENYCA SOSY 22 UKONIQ TABS 18 ULTOMIRIS SOLN 50 UMECTA MOUSSE FOAM 57 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
UNITUXIN SOLN 18 UPTRAVI SOLR 51 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 51
UPTRAVI TBPK 51 UREA CREA 39 57 UREA LOTN 40 57 UREA-C40 LOTN 57 urecholine tabs 5mg 10mg 25mg 50mg 20 uredeb crea 57 URETRON DS TABS 13 URIN DS TABS 13 ursodiol caps 200mg 400mg 41 ursodiol caps 300mg 41 ursodiol tabs 250mg 500mg 41 URYL TABS 13 USTELL CAPS 13 UTICAP CAPS 13 UTIRA-C TABS 13 UTRONA-C TABS 13
V VABYSMO SOLN 39 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 57 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 30 valproic acid caps 30 valproic acid soln 30 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
25 valsartan-hydrochlorothiazide tabs 25 VALTOCO 10 MG DOSE LIQD 30 VALTOCO 15 MG DOSE LQPK 30 VALTOCO 20 MG DOSE LQPK 30 VALTOCO 5 MG DOSE LIQD 30 vanatol lq soln 28 vancomycin hcl caps 10 vancomycin hcl solr 250mg5ml 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 vancomycin hcl solr intravenous 5gm
750mg 10 VANDAZOLE GEL 53 VANOXIDE-HC LOTN 55 VANTAS KIT 18 VAQTA SUSP 52 varenicline tartrate misc 19 varenicline tartrate tabs 05mg 1mg 19 VARIVAX INJ 52 VARIZIG SOLN 52 VASCEPA CAPS 1gm 22 VAXCHORA SUSR 53 vecamyl tabs 24 VECTICAL OINT 57 VEKLURY SOLN 13 VEKLURY SOLR 13 VELCADE SOLR 18 velivet tabs 44 VELPHORO CHEW 36 VELTASSA PACK 84gm 168gm 252gm
36 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 18 VENCLEXTA TABS 10mg 18 VENCLEXTA TABS 50mg 100mg 18
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 95
venlafaxine hcl er cp24 375mg 75mg 150mg 35
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg 35
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg 35
VENTAVIS SOLN 10mcgml 20mcgml 52 verapamil hcl er tbcr 120mg 180mg 240mg
24 verapamil hcl soln 24 verapamil hcl tabs 40mg 80mg 120mg 24 veripred 20 soln 42 VERKAZIA EMUL 39 VERSACLOZ SUSP 35 VERZENIO TABS 50mg 100mg 150mg
200mg 18 vestura tabs 44 VIBERZI TABS 75mg 100mg 41 vicodin es tabs 28 vicodin hp tabs 28 vicodin tabs 28 VICTOZA SOPN 45 VIDEX EC CPDR 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 44 vigabatrin pack 30 vigabatrin tabs 30 VIIBRYD STARTER PACK KIT 35 VIIBRYD TABS 10mg 20mg 40mg 35 VIJOICE TBPK 50 VILTEPSO SOLN 50 VIMIZIM SOLN 38 VIMPAT SOLN 30 vinblastine sulfate soln 18 vincasar pfs soln 18 vincristine sulfate soln 18 vinorelbine tartrate soln 18 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 47 VITRAKVI CAPS 25mg 100mg 18 VITRAKVI SOLN 18 VIVITROL SUSR 32 VIZIMPRO TABS 15mg 30mg 45mg 18 VOCABRIA TABS 13
VONJO CAPS 18 VORAXAZE SOLR 47 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 18 VOXZOGO SOLR 04mg 056mg 12mg 50 VPRIV SOLR 38 VRAYLAR CAPS 15mg 3mg 45mg 6mg
35 VRAYLAR CPPK 35 VUMERITY (STARTER) CPDR 50 VUMERITY CPDR 50 vyfemla tabs 44 vylibra tabs 44 VYNDAMAX CAPS 24 VYNDAQEL CAPS 24 VYONDYS 53 SOLN 50 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 28 VYVGART SOLN 50 VYXEOS SUSR 18
W WAKIX TABS 445mg 178mg 28 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 21 WATER FOR IRRIGATION STERILE
SOLN 50 WELIREG TABS 18 wixela inhub aepb 51 wymzya fe chew 44 WYNZORA CREA 55
X XALKORI CAPS 200mg 250mg 18 XARELTO STARTER PACK TBPK 21 XARELTO SUSR 21 XARELTO TABS 25mg 10mg 15mg
20mg 21 XATMEP SOLN 18 XCOPRI (250 MG DAILY DOSE) TBPK 30 XCOPRI (350 MG DAILY DOSE) TBPK 30 XCOPRI TABS 200mg 30 XCOPRI TABS 50mg 100mg 150mg 30 XCOPRI TBPK 30 XCOPRI TBPK 14x125mg amp 14x25mg 30
96 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
XELJANZ SOLN 48 XELJANZ TABS 5mg 10mg 48 XELJANZ XR TB24 11mg 22mg 48 XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 50 XERMELO TABS 40 XGEVA SOLN 47 XIFAXAN TABS 200mg 550mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 51 XOLAIR SOSY 75mg05ml 150mgml 51 XOSPATA TABS 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 18 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 18 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 XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 44 XUREA CREA 57 XURIDEN PACK 50 xylocaine dental soln 50 XYREM SOLN 32 XYWAV SOLN 32
Y YERVOY SOLN 19 YF-VAX INJ 53 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 39 yuvafem tabs 45
Z zafemy ptwk 44
zafirlukast tabs 10mg 20mg 51 zaleplon caps 5mg 10mg 31 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 44 zarontin soln 30 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 28 ZEJULA CAPS 19 ZELAPAR TBDP 31 ZELBORAF TABS 19 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
57 ZENPEP CPEP 38 zenzedi tabs 25mg 5mg 75mg 10mg
15mg 20mg 30mg 28 ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
32 ZEPOSIA CAPS 32 ZEPOSIA STARTER KIT CPPK 32 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERUVIA PTCH 56 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 51 ZIONODIL 100 LOTN 56 ZIONODIL LOTN 56 ziprasidone hcl caps 20mg 40mg 60mg
80mg 35 ziprasidone mesylate solr 35 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZOKINVY CAPS 50mg 75mg 50 zoledronic acid conc 47 zoledronic acid soln 47 ZOLINZA CAPS 19 zolmitriptan soln 30 zolmitriptan tabs 30 zolmitriptan tbdp 30 zolpidem tartrate er tbcr 625mg 125mg 31 zolpidem tartrate subl 175mg 35mg 31 zolpidem tartrate tabs 5mg 10mg 31 zonisamide caps 25mg 50mg 100mg 30 ZORBTIVE SOLR 46
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 97
ZORTRESS TABS 49 ZOSTAVAX SUSR 53 zovia 135 (28) tabs 44 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19
ZYKADIA TABS 19 ZYNLONTA SOLR 19 ZYPREXA RELPREVV SUSR 35 ZYTIGA TABS 19
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)
682896130 062022
This formulary was updated on 060122 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
kporgseniorrx Please recycle
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
2 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 2022 formulary that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2022 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 June 1 2022 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 59 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 see your Evidence of Coverage for more information
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 3
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 2022 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 2022 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 2022 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
4 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 5
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 2022 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 59 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg CIPRODEX) and generic drugs are listed in lower-case italics (eg amoxicillin) 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 2022 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
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 8 bull Kaiser Permanente 2022 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 azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP BICILLIN L-A SUSY cefaclor caps
Drug Name RequirementsLimits
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 intravenous 1gm 2gm 10gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 6gm HI
ceftazidime solr intravenous HI CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 750mg HI
cefuroxime sodium solr intravenous 15gm HI
cephalexin caps cephalexin susr cephalexin tabs chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w 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 2022 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
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 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 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
Drug Name RequirementsLimits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs erythromycin tbec FETROJA SOLR NDS 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 LYMEPAK 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
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium 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 10 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs 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 streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO suprax chew SYNERCID SOLR
Drug Name RequirementsLimits
targadox tabs MO tazicef solr injection HI tazicef solr intravenous 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
vancomycin hcl caps vancomycin hcl solr 250mg5ml vancomycin hcl solr intravenous 1gm 10gm 500mg HI
vancomycin hcl solr intravenous 5gm 750mg
XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ANTIFUNGALS AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS 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
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 2022 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS nystatin susp nystatin tabs 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 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 SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS
Drug Name RequirementsLimits
mefloquine hcl tabs metronidazole caps METRONIDAZOLE SOLN INTRAVENOUS 500mg100ml HI
metronidazole tabs nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs quinine sulfate caps NDS 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 APRETUDE SUER 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 DELSTRIGO TABS MO DESCOVY TABS 200-25mg MO DESCOVY TABS 120-15mg MO didanosine cpdr 200mg 250mg 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 12 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 PACK PANDS EPCLUSA TABS PANDS 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 LIVTENCITY TABS NDS lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO
Drug Name RequirementsLimits
maraviroc tabs 150mg 300mg MO MAVYRET PACK PANDS 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 oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEGASYS PROCLICK SOAJ 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN NDS PEGASYS SOSY NDS PEGINTRON KIT NDS PIFELTRO TABS MO 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
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 2022 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg MO sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS 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 PD TBSO MO TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEKLURY SOLN NDS VEKLURY SOLR NDS VEMLIDY TABS VIDEX EC CPDR 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
Drug Name RequirementsLimits
VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES 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 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg abiraterone acetate tabs 500mg NDS ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS NDS ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs arsenic trioxide soln NDS ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr
Drug Name RequirementsLimits
BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE SOLR BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS BESREMI SOSY NDS bexarotene caps NDS bicalutamide tabs 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 CAMCEVI PRSY CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR 50mg 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
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 2022 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
CYCLOPHOSPHAMIDE SOLN 2gm10ml 1gm5ml 500mg25ml
NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr 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 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 eulexin caps NDS
Drug Name RequirementsLimits
everolimus tabs 25mg 5mg 75mg 10mg NDS
everolimus tbso 2mg 3mg 5mg NDS EVOMELA SOLR NDS exemestane tabs EXKIVITY CAPS NDS FARYDAK CAPS 10mg 15mg 20mg LDNDS
FENSOLVI (6 MONTH) KIT 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 FYARRO SUSR 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 6000000unitml 10000000unitml
NDS
INTRON A SOLR 10000000unit 18000000unit 50000000unit 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 KIMMTRAK 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
lenalidomide caps 5mg 10mg 15mg 25mg NDS
Drug Name RequirementsLimits
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
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 TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA 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 2022 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
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 methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS nelarabine soln 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 120mg12ml 240mg24ml 40mg4ml
NDS
OPDUALAG SOLN NDS oxaliplatin soln oxaliplatin solr paclitaxel conc PACLITAXEL PROTEIN-BOUND PART SUSR 100 MG NDS
PADCEV SOLR 20mg 30mg NDS
Drug Name RequirementsLimits
paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEMFEXY SOLN 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 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
SCEMBLIX TABS 20mg 40mg NDS SIKLOS TABS NDS SOLTAMOX SOLN
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
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 05mg 075mg 1mg NDS
tamoxifen citrate tabs 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 TIVDAK SOLR 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 NDS
TRODELVY SOLR NDS
Drug Name RequirementsLimits
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 UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln 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
VONJO CAPS NDS VOTRIENT TABS NDS VYXEOS SUSR NDS WELIREG TABS 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
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 2022 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
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 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 ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO chlordiazepoxide-clidinium caps dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate oral soln MO glycopyrrolate pf sosy glycopyrrolate soln injection glycopyrrolate tabs 1mg 2mg MO
Drug Name RequirementsLimits
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 RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO varenicline tartrate misc MO varenicline tartrate tabs 05mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA FLEQSUVY SUSP NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs 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
Drug Name RequirementsLimits
albuterol sulfate er tb12 4mg 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcgact MONDS
albuterol sulfate nebu 0083 25mg05ml 063mg3ml 125mg3ml
PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY ipratropium-albuterol soln PAMO isoproterenol hcl soln LEVALBUTEROL HCL NEBU 125mg05ml 125mg3ml 031mg3ml 063mg3ml
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 SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS icatibant acetate 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 2022 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
OXBRYTA TABS NDS OXBRYTA TBSO NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS 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 BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln NDS enoxaparin sodium sosy 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
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 NDS LOVENOX SOSY 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg 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 SUSR NDS XARELTO TABS 25mg 10mg 15mg 20mg MO
HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
EPOGEN SOLN PANDS FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
PROCRIT SOLN 20000unitml 40000unitml PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RELEUKO SOLN 300mcgml 480mcg16ml NDS
RELEUKO SOSY 300mcg05ml 480mcg08ml NDS
RETACRIT SOLN 20000unitml PANDS RETACRIT SOLN PANDS TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS 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 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
Drug Name RequirementsLimits
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 150mg MO fenofibrate micronized caps 43mg 67mg 130mg 134mg 200mg
MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg 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
lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
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 SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 1gm MO BETA-ADRENERGIC BLOCKING 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 2022 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
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
ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
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
nadololbendroflumethiazide 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
Drug Name RequirementsLimits
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 cartia xt cp24 120mg 180mg 240mg 300mg MO
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 40mg 80mg 120mg MO
CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR SOLN MO CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln 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 lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy
Drug Name RequirementsLimits
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 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
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 2022 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
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
captopril-hydrochlorothiazide 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
quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
Drug Name RequirementsLimits
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO 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 dipyridamole tabs 25mg 50mg 75mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ascomp-codeine caps NDS benzhydrocodone-acetaminophen tabs NDS
bupap tabs 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 NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS dvorah tabs 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
Drug Name RequirementsLimits
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
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 hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd 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 NDS indomethacin caps indomethacin er cpcr indomethacin sodium solr ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lorcet hd tabs NDS lorcet plus 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln NDS meperidine hcl tabs 50mg NDS methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl tabs 5mg 10mg NDS MORPHINE SULFATE (CONCENTRATE) SOLN NDS
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 tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln 10mgml 20mgml NDS
nalfon tabs nalocet tabs NDS naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs
Drug Name RequirementsLimits
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 75-300mg 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 relafen ds tabs NDS SALSALATE TABS SUBSYS LIQD 1200mcg 1600mcg PANDS
sulindac tabs tencon tabs tolmetin sodium caps tolmetin sodium tabs
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 soln 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 tabs NDS vicodin es tabs NDS vicodin hp tabs NDS zebutal caps ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS amphetamine er suer NDS 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 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
evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS
Drug Name RequirementsLimits
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
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS procentra soln NDS relexxii tbcr NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
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
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 2022 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
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
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 EPRONTIA SOLN 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 lacosamide tabs 50mg 100mg 150mg 200mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
Drug Name RequirementsLimits
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
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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg 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 VALTOCO 15 MG DOSE LQPK VALTOCO 20 MG DOSE LQPK VALTOCO 5 MG DOSE LIQD vigabatrin pack LDNDS vigabatrin tabs NDS VIMPAT SOLN XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200mg NDS XCOPRI TBPK 14x125mg amp 14x25mg
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ PA AJOVY SOSY PA almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs
Drug Name RequirementsLimits
ergotamine-caffeine tabs FROVATRIPTAN SUCCINATE TABS
naratriptan hcl tabs NURTEC TBDP NDS QULIPTA TABS 10mg 30mg 60mg NDS
rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs UBRELVY TABS 50mg 100mg NDS zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl soln MO amantadine hcl tabs MO APOKYN SOCT NDS apomorphine hcl 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
EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg 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 2022 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
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
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
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 intensol conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS droperidol soln estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
Drug Name RequirementsLimits
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP PANDS 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 nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs seconal caps TEMAZEPAM CAPS 75mg 15mg 225mg 30mg 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS tetrabenazine tabs 125mg 25mg MO
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
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 1mg 2mg NDS
OCREVUS SOLN PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
Drug Name RequirementsLimits
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 ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS OPIATE ANTAGONISTS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
LUCEMYRA TABS NDS naloxone hcl liqd naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
VIVITROL SUSR NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg 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 2022 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
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 conc 30mgml 100mgml MO
chlorpromazine hcl soln chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
CITALOPRAM HYDROBROMIDE CAPS MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
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 HAFYERA SUSY INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 150mg 300mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
LITHIUM CARBONATE TABS MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
LYBALVI TABS NDS maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
Drug Name RequirementsLimits
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 susp MO paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps 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
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
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 2022 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
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 CAPS 150mg 200mg MO
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
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 MO trazodone hcl tabs 150mg 300mg 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
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 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 TRICITRATES SOLN AMMONIA DETOXICANTS carglumic acid tbso NDS constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN DEXTROSE SOLN INTRAVENOUS 5 10 HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE 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
Drug Name RequirementsLimits
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI furosemide tabs 20mg 40mg 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN tolvaptan tabs 15mg 30mg 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 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
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 2022 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate tabs MO CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
DEXTROSE-NACL SOLN INTRAVENOUS 25-045 5-02 5-045 5-09
HI
DEXTROSE-NACL SOLN INTRAVENOUS 10-02 10-045
HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 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 PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
Drug Name RequirementsLimits
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 10meq100ml 20meq100ml 40meq100ml 2meqml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN 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 ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME 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 38 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin oint bacitracin-polymyxin b oint bleph-10 soln chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin 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 paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln
Drug Name RequirementsLimits
sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ANTI-INFLAMMATORY AGENTS bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
CEQUA SOLN CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO cyclosporine emul MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO difluprednate emul MO flac oil 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
ILUVIEN IMPL ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint 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 2022 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
RESTASIS EMUL MO RESTASIS MULTIDOSE EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
VERKAZIA EMUL NDS YUTIQ IMPL ANTIALLERGIC AGENTS azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
betaxolol hcl soln MO bimatoprost soln MO brimonidine tartrate soln 015 02 MO
brinzolamide susp MO carteolol hcl soln MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
Drug Name RequirementsLimits
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO timolol maleate (once-daily) soln MO timolol maleate pf soln MO TIMOLOL MALEATE SOLG 025 05 MO
timolol maleate soln 025 05 MO
travoprost (bak free) 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 SUSVIMO (IMPLANT 1ST FILL) SOLN
SUSVIMO (IMPLANT REFILL) SOLN
TEPEZZA SOLR NDS VABYSMO SOLN LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lidocaine viscous hcl soln MO proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
balsalazide disodium caps MO colazal caps 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 OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS aprepitant caps PANDS dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl sosy ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy
Drug Name RequirementsLimits
SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS trimethobenzamide hcl caps PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc 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 famotidine (pf) soln 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 omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate 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 2022 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS 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 IBSRELA TABS NDS LIVMARLI SOLN NDS lubiprostone caps 8mcg 24mcg MO metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS TRULANCE TABS 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
Drug Name RequirementsLimits
clovique caps NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs deferasirox tbso deferiprone tabs 500mg 1000mg NDS
deferoxamine mesylate solr FERRIPROX SOLN LDNDS FERRIPROX TABS LDNDS FERRIPROX TWICE-A-DAY TABS NDS
penicillamine caps NDS penicillamine tabs NDS trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP ALKINDI SPRINKLE CPSP 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs 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 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp 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 10mg5ml 20mg5ml 25mg5ml 5mg5ml
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 SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TARPEYO CPDR NDS triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
danazol caps 50mg 100mg 200mg MO
Drug Name RequirementsLimits
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 405mg25gm 10mgact
MO
testosterone soln 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 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 enpresse-28 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 2022 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
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 jasmiel tabs MO JOLIVETTE 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
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
Drug Name RequirementsLimits
levora 01530 (28) 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 24 fe tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA 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 nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO nylia 135 tabs MO nylia 777 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 44 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 taysofy caps 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 wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135 (28) tabs MO
Drug Name RequirementsLimits
DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
AFREZZA POWD 90x8 UNIT amp 90x12 UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD 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 glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO HUMALOG KWIKPEN SOPN MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
JARDIANCE TABS 10mg 25mg MO KORLYM TABS LDNDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO metformin hcl er tb24 500mg 750mg 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 2022 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
OZEMPIC (2 MGDOSE) SOPN MO pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO tolazamide tabs 250mg 500mg MO tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
depo-estradiol oil dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
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 MO
Drug Name RequirementsLimits
006mg24hr 0075mg24hr 01mg24hr estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO fyavolv tabs MO jinteli tabs MO lopreeza tabs MO lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO prefest tabs MO PREMARIN SOLR raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PANDS CORTROPHIN GEL PANDS desmopressin ace spray refrig soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln desmopressin acetate tabs 01mg 02mg MO
SKYTROFA CART 3mg 36mg 43mg 52mg 63mg 76mg 91mg 11mg 133mg
NDS
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO 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 progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR NDS
Drug Name RequirementsLimits
EGRIFTA SV SOLR NDS GENOTROPIN CART 12mg PANDS GENOTROPIN MINIQUICK PRSY 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
HUMATROPE CART 6mg 12mg 24mg PANDS
HUMATROPE SOLR PANDS INCRELEX SOLN NDS LANREOTIDE ACETATE SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
octreotide acetate soln 50mcgml 100mcgml 200mcgml
octreotide acetate soln 500mcgml 1000mcgml
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 60mg02ml 90mg03ml 120mg05ml
NDS
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 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 2022 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 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 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
Drug Name RequirementsLimits
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 BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 70mg MO alendronate sodium tabs 5mg 10mg 35mg 40mg MO
EVENITY SOSY NDS IBANDRONATE SODIUM SOLN ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr 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 CIBINQO TABS 50mg 100mg 200mg NDS
CIMZIA KIT PANDS CIMZIA PREFILLED PSKT PANDS CIMZIA STARTER KIT PSKT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
INFLIXIMAB SOLR INTRAVENOUS HI
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 RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 15mg 30mg 45mg NDS
SIMPONI ARIA SOLN NDS
Drug Name RequirementsLimits
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 ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
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
ZORTRESS TABS PA MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BERINERT KIT INTRAVENOUS HI betaine powd NDS 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
Drug Name RequirementsLimits
CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENJAYMO SOLN 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 HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ONPATTRO SOLN NDS 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
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 PYRUKYND TABS 5mg 20mg 50mg NDS
PYRUKYND TAPER PACK TBPK NDS
RECORLEV TABS NDS REZUROCK TABS NDS
Drug Name RequirementsLimits
RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln 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 STERILE WATER FOR IRRIGATION SOLN
TAKHZYRO SOLN NDS TAKHZYRO SOSY NDS TAVNEOS CAPS NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR NDS tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VIJOICE TBPK NDS VILTEPSO SOLN NDS VOXZOGO SOLR 04mg 056mg 12mg NDS
VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS VYVGART SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg 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 2022 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 100mg067ml 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 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 ADVAIR HFA AERO 230-21mcgact MO
ADVAIR HFA AERO 45-21mcgact 115-21mcgact MO
Drug Name RequirementsLimits
ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS HI
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
DALIRESP TABS 250mcg 500mcg MO
FLOVENT HFA AERO MO fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PULMICORT FLEXHALER AEPB
SYMBICORT AERO TEZSPIRE SOSY NDS wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg 1000mcg 1200mcg 1400mcg 1600mcg
NDS
UPTRAVI TBPK NDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS HI
GAMUNEX-C SOLN INJECTION HI HYPERHEP B SOLN HYPERHEP B SOSY HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 1gm20ml 2gm20ml
HI
PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
VARIZIG SOLN TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP KINRIX SUSY QUADRACEL SUSP TDVAX SUSP
Drug Name RequirementsLimits
TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP BOOSTRIX SUSY 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 SOLN MENQUADFI SOLN MENVEO SOLR PEDIARIX SUSY PEDVAX HIB SUSP PENTACEL SUSR PREHEVBRIO SUSP PA PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TICOVAC SUSY TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN TYPHIM VI SOSY VAQTA SUSP VARIVAX INJ
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 2022 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint 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 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 clindamycin phosphate soln MO clindamycin phosphate swab MO clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn econazole nitrate crea ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA
Drug Name RequirementsLimits
gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham mafenide acetate pack malathion lotn metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea mupirocin oint naftifine hcl crea naftifine hcl gel neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ovide lotn oxiconazole nitrate crea permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 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
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
Drug Name RequirementsLimits
clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT 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 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
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO FLURANDRENOLIDE CREA 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 2022 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
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 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 prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO
Drug Name RequirementsLimits
psorcon crea MO RADIAURA CREA NDS texacort soln MO topicort crea 005 025 MO topicort gel MO topicort oint 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 VANOXIDE-HC LOTN WYNZORA CREA NDS ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
HYDROCORTISONE ACE-PRAMOXINE SUPP NDS
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 LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS 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
TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS 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
Drug Name RequirementsLimits
adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ADBRY SOSY NDS ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
azelaic acid gel MO AZELEX CREA MO 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
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA 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 KORSUVA SOLN NDS LACTIC ACID LOTN
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 2022 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
OPZELURA CREA 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 SHAM SALICYLIC ACID-CLEANSER KIT
SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SKYRIZI PEN SOAJ SKYRIZI SOSY STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
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 TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS
Drug Name RequirementsLimits
VECTICAL OINT MO XUREA CREA zenatane caps 10mg 20mg 30mg 40mg NDS
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 calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS
58 bull Kaiser Permanente 2018 Defined Standard Comprehensive Formulary
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 59
Index of Drugs
A abacavir sulfate soln 11 abacavir sulfate tabs 11 abacavir sulfate-lamivudine tabs 11 abacavir-lamivudine-zidovudine tabs 11 ABILIFY MAINTENA PRSY 300mg 400mg
32 ABILIFY MAINTENA SRER 300mg 400mg
32 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
abiraterone acetate tabs 250mg 14 abiraterone acetate tabs 500mg 14 ABRAXANE SUSR 14 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 56 acamprosate calcium tbec 25 acarbose tabs 25mg 50mg 100mg 44 accutane caps 10mg 20mg 30mg 40mg 56 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 26 acetaminophen-codeine soln 26 acetaminophen-codeine tabs 26 acetazolamide er cp12 39 acetazolamide sodium solr 39 acetazolamide tabs 125mg 250mg 39 ACETIC ACID SOLN 39 49 acetylcysteine soln 10 20 47 acitretin caps 10mg 175mg 25mg 56 ACTEMRA ACTPEN SOAJ 47 ACTEMRA SOSY 47 ACTHAR GEL 46 ACTHIB SOLR 52 ACTIMMUNE SOLN 49 acyclovir caps 11 acyclovir oint 53 acyclovir sodium soln intravenous 11 acyclovir susp 11
acyclovir tabs 400mg 800mg 11 ADACEL SUSP 52 ADAGEN SOLN 37 ADAKVEO SOLN 20 ADAPALENE CREA 56 adapalene gel 01 03 56 adapalene pads 56 adapalene soln 56 adapalene-benzoyl peroxide gel 56 ADAPALENE-BENZOYL PEROXIDE PADS
56 ADBRY SOSY 56 adderall tabs 28 adefovir dipivoxil tabs 11 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 51 adenosine soln 24 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 230-21mcgact 51 ADVAIR HFA AERO 45-21mcgact 115-
21mcgact 51 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 14 AFREZZA POWD 90x8 UNIT amp 90x12 UNIT
44 AJOVY SOAJ 30 AJOVY SOSY 30 ala-cort crea 1 25 54 albendazole tabs 8 albuterol sulfate er tb12 4mg 8mg 20 ALBUTEROL SULFATE HFA AERS
108mcgact 20 albuterol sulfate nebu 0083
25mg05ml 063mg3ml 125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 54 alclometasone dipropionate oint 54 ALCOHOL PREP PADS 35 ALDURAZYME SOLN 37 ALECENSA CAPS 14
60 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
alendronate sodium soln 47 alendronate sodium tabs 5mg 10mg
35mg 40mg 47 alendronate sodium tabs 70mg 47 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 41 ALKINDI SPRINKLE CPSP 1mg 2mg 5mg
41 allopurinol sodium solr 47 allopurinol tabs 100mg 300mg 47 allzital tabs 26 almotriptan malate tabs 30 alogliptin benzoate tabs 625mg 125mg
25mg 44 ALOGLIPTIN-METFORMIN HCL TABS 44 alogliptin-pioglitazone tabs 44 ALOSETRON HCL TABS 05mg 1mg 40 alprazolam er tb24 05mg 1mg 2mg 3mg
31 alprazolam intensol conc 31 alprazolam tabs 025mg 05mg 1mg 2mg
31 alprazolam tbdp 025mg 05mg 1mg 2mg
31 ALTACAINE SOLN 39 ALTAFRIN SOLN 39 altavera tabs 42 ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 51 alyacen 135 tabs 42 alyq tabs 25 amabelz tabs 45 amantadine hcl caps 30 amantadine hcl soln 30 amantadine hcl tabs 30 AMBISOME SUSR INTRAVENOUS 10 ambrisentan tabs 51 amcinonide crea 54 amcinonide lotn 54 amcinonide oint 54 amethia lo tabs 42 amethia tabs 42 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 36
amiloride-hydrochlorothiazide tabs 36 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 57 amiodarone hcl soln 24 amiodarone hcl tabs 100mg 200mg
400mg 24 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 33 amlodipine besy-benazepril hcl caps 23 amlodipine besylate tabs 25mg 5mg
10mg 23 amlodipine besylate-valsartan tabs 23 amlodipine-atorvastatin tabs 23 amlodipine-olmesartan tabs 23 amlodipine-valsartan-hctz tabs 23 ammonium lactate crea 56 ammonium lactate lotn 56 amnesteem caps 10mg 20mg 40mg 56 AMONDYS 45 SOLN 49 amoxapine tabs 25mg 50mg 100mg
150mg 33 amoxicill-clarithro-lansopraz misc 40 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8 amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 28 amphetamine sulfate tabs 5mg 10mg 28 amphetamine-dextroamphet er cp24 28 amphetamine-dextroamphetamine tabs 28 amphotericin b solr intravenous 10 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 42 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 55 anastrozole tabs 14
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 61
ANDRODERM PT24 2mg24hr 4mg24hr 42
antabuse tabs 250mg 500mg 25 anusol-hc crea 54 apap-caff-dihydrocodeine tabs 26 apexicon e crea 54 APLENZIN TB24 174mg 348mg 522mg 33 APOKYN SOCT 30 apomorphine hcl soct 30 apraclonidine hcl soln 39 aprepitant caps 40 APRETUDE SUER 11 apri tabs 42 APTIOM TABS 200mg 400mg 600mg
800mg 28 APTIVUS CAPS 11 APTIVUS SOLN 11 ARALAST NP SOLR INTRAVENOUS 51 aranelle tabs 42 ARANESP (ALBUMIN FREE) SOLN
60mcgml 100mcgml 200mcgml 21 ARANESP (ALBUMIN FREE) SOSY
60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 21
ARCALYST SOLR 49 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 49 ARIKAYCE SUSP 8 aripiprazole soln 33 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 33 aripiprazole tbdp 10mg 15mg 33 ARISTADA INITIO PRSY 33 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 33
armodafinil tabs 50mg 150mg 200mg 250mg 28
arsenic trioxide soln 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 49 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 52 ascomp-codeine caps 26 asenapine maleate subl 25mg 5mg 10mg
33
ashlyna tabs 42 ASMANEX HFA AERO 100mcgact
200mcgact 51 ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 48 ASTAGRAF XL CP24 05mg 1mg 48 atazanavir sulfate caps 150mg 200mg
300mg 11 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 31 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 22 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 39 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 32 aubra eq tabs 42 AUGMENTIN SUSR 8 AURYXIA TABS 36 AUSTEDO TABS 6mg 9mg 12mg 31 AVASTIN SOLN 14 AVC VAGINAL CREA 53 aviane tabs 42 AVITA CREA 56 AVITA GEL 56 AVONEX KIT 32 AVONEX PEN AJKT 32 AVONEX PREFILLED PSKT 32 AVSOLA SOLR 47 aygestin tabs 46 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 48 azathioprine sodium solr 48 azathioprine tabs 48 azelaic acid gel 56 azelastine hcl soln 005 01 015 39 azelastine-fluticasone susp 39 AZELEX CREA 56 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
62 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
B bacitracin oint 38 bacitracin solr 8 bacitracin-polymyxin b oint 38 bacitra-neomycin-polymyxin-hc oint 38 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 53 BAFIERTAM CPDR 32 balsalazide disodium caps 40 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 42 BANZEL SUSP 28 BANZEL TABS 200mg 400mg 28 BAQSIMI ONE PACK POWD 44 BAQSIMI TWO PACK POWD 44 BARACLUDE SOLN 11 BAVENCIO SOLN 14 BCG VACCINE SOLR 14 BD INSULIN SYR ULTRAFINE II MISC 35 BD INSULIN SYRINGE MISC 35 BD INSULIN SYRINGE UF MISC 35 BD PEN NEEDLE ORIGINAL UF MISC 35 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 32 BELEODAQ SOLR 14 BELRAPZO SOLN 14 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 14 BENDEKA SOLN 14 BENLYSTA SOAJ 48 BENLYSTA SOLR 48 BENLYSTA SOSY 48 BENZEPRO CREAMY WASH LIQD 53 BENZEPRO FOAMING CLOTHS MISC 53 benzhydrocodone-acetaminophen tabs 26 benzoyl perox-hydrocortisone lotn 54 BENZOYL PEROXIDE FORTE- HC LOTN
54 BENZOYL PEROXIDE GEL 53 benzoyl peroxide-erythromycin gel 53 benztropine mesylate soln 30 benztropine mesylate tabs 05mg 1mg
2mg 30 BEOVU SOLN 39 bepotastine besilate soln 39
BERINERT KIT INTRAVENOUS 49 beser lotn 54 BESPONSA SOLR 14 BESREMI SOSY 14 betaine powd 49 betamethasone dipropionate aug crea 54 betamethasone dipropionate aug gel 54 betamethasone dipropionate aug lotn 54 betamethasone dipropionate aug oint 54 betamethasone dipropionate crea 54 betamethasone dipropionate lotn 54 BETAMETHASONE DIPROPIONATE OINT
54 betamethasone sod phos amp acet susp 41 betamethasone valerate crea 54 betamethasone valerate foam 54 BETAMETHASONE VALERATE LOTN 54 BETAMETHASONE VALERATE OINT 54 BETASERON KIT 32 betaxolol hcl soln 39 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 19 bexarotene caps 14 BEXSERO SUSY 52 bicalutamide tabs 14 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICILLIN L-A SUSY 8 BIKTARVY TABS 11 bimatoprost soln 39 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23 bleomycin sulfate solr 14 bleph-10 soln 38 blephamide sop oint 38 BLEPHAMIDE SUSP 38 BLINCYTO SOLR 14 blisovi 24 fe tabs 42 blisovi fe 1530 tabs 42 BOOSTRIX SUSP 52 BOOSTRIX SUSY 52 BORTEZOMIB SOLR 14 bosentan tabs 51 BOSULIF TABS 100mg 400mg 500mg 14 BRAFTOVI CAPS 50mg 75mg 14 briellyn tabs 42 BRILINTA TABS 60mg 90mg 21
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 63
brimonidine tartrate soln 015 02 39 brinzolamide susp 39 BRIVIACT SOLN 28 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 28 bromfenac sodium (once-daily) soln 38 bromocriptine mesylate caps 30 bromocriptine mesylate tabs 30 BRONCHITOL CAPS 51 BROVANA NEBU 20 BRUKINSA CAPS 14 budesonide cpep 41 budesonide er tb24 41 budesonide susp 025mg2ml 05mg2ml
1mg2ml 51 bumetanide soln 36 bumetanide tabs 05mg 1mg 2mg 36 bupap tabs 26 bupivacaine hcl (pf) soln 49 bupivacaine hcl soln 49 BUPIVACAINE IN DEXTROSE SOLN 49 bupivacaine spinal soln 49 bupivacaine-epinephrine (pf) soln 49 bupivacaine-epinephrine soln 49 buprenorphine hcl subl 2mg 8mg 32 buprenorphine hcl-naloxone hcl film 32 buprenorphine hcl-naloxone hcl subl 32 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 32 bupropion hcl er (smoking det) tb12 33 bupropion hcl er (sr) tb12 100mg 150mg
200mg 33 bupropion hcl er (xl) tb24 150mg 300mg
450mg 33 bupropion hcl tabs 75mg 100mg 33 buspirone hcl tabs 5mg 10mg 31 buspirone hcl tabs 75mg 15mg 30mg 31 busulfan soln 14 butalbital-acetaminophen tabs 26 butalbital-apap-caff-cod caps 26 butalbital-apap-caffeine caps 26 butalbital-apap-caffeine tabs 26 butalbital-asa-caff-codeine caps 26 butalbital-aspirin-caffeine caps 26 butalbital-aspirin-caffeine tabs 26 butorphanol tartrate soln 26 BYLVAY (PELLETS) CPSP 200mcg
600mcg 41 BYLVAY CAPS 400mcg 1200mcg 41
C CABENUVA SUER 11 cabergoline tabs 30 CABLIVI KIT 21 CABOMETYX TABS 20mg 40mg 60mg 14 cafergot tabs 30 caffeine citrate soln 28 calcipotriene crea 56 calcipotriene oint 56 calcipotriene soln 56 calcipotriene-betameth diprop oint 54 calcipotriene-betameth diprop susp 54 calcitonin (salmon) soln 45 calcitrene oint 56 calcitriol caps 025mcg 05mcg 57 CALCITRIOL OINT 56 calcitriol soln 57 calcium acetate (phos binder) caps 37 calcium acetate tabs 37 CALCIUM GLUCONATE-NACL SOLN 37 CALQUENCE CAPS 14 CAMCEVI PRSY 14 camila tabs 42 camrese lo tabs 42 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 54 CAPLYTA CAPS 33 CAPRELSA TABS 100mg 300mg 14 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 25 CARAC CREA 56 carbamazepine chew 28 carbamazepine er cp12 100mg 200mg
300mg 28 carbamazepine er tb12 100mg 200mg
400mg 28 carbamazepine susp 28 carbamazepine tabs 28 carbidopa tabs 30 carbidopa-levodopa er tbcr 30 carbidopa-levodopa tabs 30 carbidopa-levodopa tbdp 30 carbidopa-levodopa-entacapone tabs 30 carbinoxamine maleate soln 13
64 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
carbinoxamine maleate tabs 13 carboplatin soln 14 carboprost tromethamine soln 45 CARDENE IV SOLN 23 carglumic acid tbso 35 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 14 CARNITOR SOLN 49 CARNITOR TABS 49 carteolol hcl soln 39 cartia xt cp24 120mg 180mg 240mg
300mg 23 carvedilol phosphate er cp24 10mg 20mg
40mg 80mg 23 carvedilol tabs 3125mg 625mg 125mg
25mg 23 caspofungin acetate solr intravenous 50mg
70mg 10 CAYSTON SOLR 51 caziant tabs 42 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 intravenous 1gm 2gm
10gm 8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 6gm 8 ceftazidime solr intravenous 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 750mg 8 cefuroxime sodium solr intravenous 15gm 8 celecoxib caps 26 CELONTIN CAPS 29 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 38 CERDELGA CAPS 37 CEREZYME SOLR 37 CEROVEL LOTN 56 cetirizine hcl soln 13 CEVIMELINE HCL CAPS 19 CHANTIX CONTINUING MONTH PAK
TABS 19 CHANTIX STARTING MONTH PAK TABS
19 CHANTIX TABS 05mg 1mg 19 CHEMET CAPS 41 chloramphenicol sod succinate solr 8 chlordiazepoxide hcl caps 5mg 10mg
25mg 31 chlordiazepoxide-amitriptyline tabs 33 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 38 chloroprocaine hcl (pf) soln 49 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 36 chlorothiazide tabs 250mg 500mg 36 chlorpromazine hcl conc 30mgml
100mgml 33 chlorpromazine hcl soln 33 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 33 chlorthalidone tabs 25mg 50mg 36 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 41 cholestyramine light pack 22 cholestyramine light powd 22 cholestyramine pack 22 cholestyramine powd 22 CHORIONIC GONADOTROPIN SOLR 45 CIBINQO TABS 50mg 100mg 200mg 47 ciclopirox gel 53 ciclopirox olamine crea 53
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 65
ciclopirox olamine susp 53 ciclopirox sham 53 ciclopirox soln 53 cidofovir soln 11 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 38 CIMDUO TABS 11 cimetidine hcl soln 40 cimetidine tabs 200mg 300mg 400mg
800mg 40 CIMZIA KIT 47 CIMZIA PREFILLED PSKT 47 CIMZIA STARTER KIT PSKT 47 cinacalcet hcl tabs 30mg 60mg 90mg 45 CINQAIR SOLN 51 CINRYZE SOLR INTRAVENOUS 49 CIPRODEX SUSP 38 ciprofloxacin hcl soln (ophth) 38 CIPROFLOXACIN HCL SOLN (OTIC) 38 ciprofloxacin hcl tabs 8 ciprofloxacin in d5w soln 8 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 38 cisplatin soln 14 CISPLATIN SOLR 50mg 14 CITALOPRAM HYDROBROMIDE CAPS 33 citalopram hydrobromide soln 33 citalopram hydrobromide tabs 10mg 20mg
40mg 33 citanest plain dental soln 49 cladribine soln 14 claravis caps 10mg 20mg 30mg 40mg 56 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 13 cleocin phosphate soln 9 cleocin solr 9 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
clindacin-p swab 53 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 53 clindamycin phosphate crea 53
clindamycin phosphate foam 53 clindamycin phosphate gel 53 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 53 clindamycin phosphate soln 9 53 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 53 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 36 clinisol sf soln intravenous 36 clobazam susp 29 clobazam tabs 10mg 20mg 29 clobetasol propionate crea 54 clobetasol propionate e crea 54 clobetasol propionate emulsion foam 54 clobetasol propionate foam 54 clobetasol propionate gel 54 clobetasol propionate liqd 54 clobetasol propionate lotn 54 clobetasol propionate oint 54 clobetasol propionate sham 54 clobetasol propionate soln 54 clocortolone pivalate crea 54 clocortolone pivalate pump crea 54 clofarabine soln 14 clomipramine hcl caps 25mg 50mg 75mg
33 clonazepam tabs 05mg 1mg 2mg 29 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 29 clonidine hcl (analgesia) soln 24
66 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
clonidine hcl er tb12 24 clonidine hcl tabs 01mg 02mg 03mg 24 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 24 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 31 clotrimazole crea 53 clotrimazole soln 53 clotrimazole troc 53 clotrimazole-betamethasone crea 53 clotrimazole-betamethasone lotn 53 clovique caps 41 clozapine tabs 25mg 50mg 100mg 200mg
33 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 33 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 26 colazal caps 40 COLCHICINE CAPS 47 colchicine tabs 47 colchicine-probenecid tabs 37 COLESEVELAM HCL PACK 22 colesevelam hcl tabs 22 colestipol hcl gran 22 colestipol hcl pack 22 colestipol hcl tabs 22 colistimethate sodium (cba) solr injection 9 colocort enem 54 COLY-MYCIN S SUSP 38 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 14 COMETRIQ (140 MG DAILY DOSE) KIT 14 COMETRIQ (60 MG DAILY DOSE) KIT 14 COMPLERA TABS 11 compro supp 33 CONSENSI TABS 23 constulose soln 35 COPIKTRA CAPS 15mg 25mg 14 CORDRAN TAPE 54 CORLANOR SOLN 24 CORLANOR TABS 5mg 75mg 24 cortisone acetate tabs 41 CORTISPORIN CREA 54 CORTISPORIN OINT 54 CORTROPHIN GEL 46 COSELA SOLR 49
COSENTYX (300 MG DOSE) SOSY 56 COSENTYX SENSOREADY (300 MG)
SOAJ 56 COSENTYX SENSOREADY PEN SOAJ 56 COSENTYX SOSY 75mg05ml 150mgml
56 COTELLIC TABS 14 CREON CPEP 37 CRESEMBA CAPS 10 CRESEMBA SOLR 10 CRIXIVAN CAPS 200mg 400mg 11 cromolyn sodium conc 51 cromolyn sodium nebu 51 cromolyn sodium soln 39 crotan lotn 53 cryselle-28 tabs 42 CRYSVITA SOLN 10mgml 20mgml
30mgml 49 CURITY GAUZE PADS 35 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 52
cyclafem 135 tabs 42 cyclafem 777 tabs 42 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 14 CYCLOPHOSPHAMIDE SOLN 2gm10ml
1gm5ml 500mg25ml 15 cyclophosphamide solr 15 cycloserine caps 11 cyclosporine caps 25mg 100mg 48 cyclosporine emul 38 cyclosporine modified caps 25mg 50mg
100mg 48 cyclosporine modified soln 48 cyclosporine soln 48 cyproheptadine hcl syrp 13 cyproheptadine hcl tabs 13 CYRAMZA SOLN 100mg10ml
500mg50ml 15 CYSTADANE POWD 49 CYSTADROPS SOLN 39 CYSTAGON CAPS 50mg 150mg 49 CYSTARAN SOLN 39 cytarabine (pf) soln 15 cytarabine soln 15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 67
CYTOGAM INJ 52
D dacarbazine solr 15 dactinomycin solr 15 dalfampridine er tb12 32 DALIRESP TABS 250mcg 500mcg 51 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 42 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 56 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 52 daptomycin solr intravenous 350mg 500mg
9 darifenacin hydrobromide er tb24 75mg
15mg 57 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 deblitane tabs 42 decadron tabs 5mg 75mg 41 decadron tabs 4mg 6mg 41 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 41 deferasirox tabs 41 deferasirox tbso 41 deferiprone tabs 500mg 1000mg 41 deferoxamine mesylate solr 41 DELSTRIGO TABS 11 deltasone tabs 41 delyla tabs 42 demeclocycline hcl tabs 9 DEMSER CAPS 22 depo-estradiol oil 45 DEPO-MEDROL SUSP 41 DEPO-PROVERA SUSP 400mgml 46 DEPO-SUBQ PROVERA 104 SUSY 46 depo-testosterone soln 100mgml
200mgml 42 DERMOTIC OIL 38 DESCOVY TABS 120-15mg 11 DESCOVY TABS 200-25mg 11
desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg 33
desloratadine tabs 13 desloratadine tbdp 13 desmopressin ace spray refrig soln 46 DESMOPRESSIN ACETATE SOLN 46 desmopressin acetate spray soln 46 desmopressin acetate tabs 01mg 02mg 46 desogestrel-ethinyl estradiol tabs 42 desonide crea 54 desonide gel 54 desonide lotn 54 desonide oint 54 desowen lotn 54 desoximetasone crea 005 025 54 desoximetasone gel 54 desoximetasone liqd 54 desoximetasone oint 005 025 54 desrx gel 54 DESVENLAFAXINE ER TB24 50mg
100mg 33 desvenlafaxine succinate er tb24 25mg
50mg 100mg 33 dexabliss tbpk 41 dexamethasone elix 41 dexamethasone intensol conc 41 dexamethasone sodium phosphate soln 38
41 dexamethasone soln 41 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 41 dexamethasone tbpk 41 dexchlorpheniramine maleate soln 13 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 28
dexmethylphenidate hcl tabs 25mg 5mg 10mg 28
dexpak 10 day tbpk 41 dexpak 13 day tbpk 41 dexpak 6 day tbpk 41 dexrazoxane hcl solr 49 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 28 dextroamphetamine sulfate soln 28 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 28 DEXTROSE IN LACTATED RINGERS
SOLN 37
68 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
DEXTROSE SOLN 36 DEXTROSE SOLN INTRAVENOUS 5
10 36 DEXTROSE-NACL SOLN INTRAVENOUS
10-02 10-045 37 DEXTROSE-NACL SOLN INTRAVENOUS
25-045 5-02 5-045 5-09 37 DIACOMIT CAPS 250mg 500mg 29 DIACOMIT PACK 250mg 500mg 29 DIASTAT ACUDIAL GEL 10mg 20mg 29 DIASTAT PEDIATRIC GEL 29 diazepam conc 31 diazepam gel 25mg 10mg 20mg 29 diazepam intensol conc 31 diazepam soln 5mg5ml 5mgml 31 diazepam tabs 2mg 5mg 10mg 31 diazoxide susp 44 diclofenac sodium er tb24 26 diclofenac sodium gel 1 3 54 diclofenac sodium soln 38 diclofenac sodium tbec 26 diclofenac-misoprostol tbec 26 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 11 DIFFERIN CREA 56 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 54 diflorasone diacetate oint 54 diflunisal tabs 26 difluprednate emul 38 digitek tabs 0125mg 025mg 24 digox tabs 24 digoxin soln 24 digoxin tabs 125mcg 250mcg 24 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 29 dilantin infatabs chew 29 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 23 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 23
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 23
diltiazem hcl er cp12 60mg 90mg 120mg 23
diltiazem hcl er cp24 120mg 180mg 240mg 23
diltiazem hcl soln 23 diltiazem hcl solr 23 diltiazem hcl tabs 30mg 60mg 90mg
120mg 23 dilt-xr cp24 120mg 180mg 240mg 23 dimenhydrinate soln 40 dimethyl fumarate cpdr 32 dimethyl fumarate starter pack misc 32 DIPENTUM CAPS 40 diphen elix 13 di-phen elix 13 diphenhydramine hcl elix 13 diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 40 diphenoxylate-atropine tabs 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 52 dipyridamole tabs 25mg 50mg 75mg 25 disopyramide phosphate caps 100mg
150mg 24 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 36 divalproex sodium csdr 29 divalproex sodium er tb24 250mg 500mg29 divalproex sodium tbec 125mg 250mg
500mg 29 dobutamine hcl soln 20 DOBUTAMINE IN D5W SOLN 20 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
24 dolishale tabs 42 donepezil hcl tabs 5mg 10mg 23mg 19 donepezil hcl tbdp 5mg 10mg 19 dopamine hcl soln 20 DOPAMINE IN D5W SOLN 20 DOPTELET TABS 21 dorzolamide hcl soln 39 dorzolamide hcl-timolol mal pf soln 39 dorzolamide hcl-timolol mal soln 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 69
dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 33 doxepin hcl conc 33 doxepin hcl crea 55 doxepin hcl tabs 3mg 6mg 33 doxercalciferol caps 05mcg 1mcg 25mcg
57 DOXERCALCIFEROL SOLN 57 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
150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 40 DRIZALMA SPRINKLE CSDR 33 dronabinol caps 25mg 5mg 10mg 40 droperidol soln 31 drospiren-eth estrad-levomefol tabs 42 drospirenone-ethinyl estradiol tabs 42 DROXIA CAPS 15 droxidopa caps 20 DUAKLIR PRESSAIR AEPB 19 DUEXIS TABS 26 duloxetine hcl cpep 20mg 30mg 40mg
60mg 33 DUPIXENT SOPN 200mg114ml
300mg2ml 51 DUPIXENT SOSY 100mg067ml
200mg114ml 300mg2ml 51 DURYSTA IMPL 39 dutasteride caps 47 dutasteride-tamsulosin hcl caps 47 dvorah tabs 26 dxevo 11-day tbpk 41
E ees 400 tabs 9 EASYGEL GEL 49 econazole nitrate crea 53 EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 46 EGRIFTA SV SOLR 46 ELAPRASE SOLN 37 ELELYSO SOLR 37 ELEPSIA XR TB24 1000mg 1500mg 29 eletriptan hydrobromide tabs 30 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 37 elixophyllin elix 57 ELLA TABS 42 ELLENCE SOLN 15 ELMIRON CAPS 49 eluryng ring 42 ELZONRIS SOLN 15 EMCYT CAPS 15 EMFLAZA SUSP 42 EMFLAZA TABS 6mg 18mg 30mg 36mg
42 EMPAVELI SOLN 49 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 30 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 25 enalaprilat inj 25 enalapril-hydrochlorothiazide tabs 25 ENBREL MINI SOCT 47 ENBREL SOLN 47 ENBREL SOLR 47 ENBREL SOSY 25mg05ml 50mgml 48 ENBREL SURECLICK SOAJ 48 ENDARI PACK 49 endocet tabs 26 ENDOMETRIN INST 46
70 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ENGERIX-B SUSP 10mcg05ml 20mcgml 52
ENHERTU SOLR 15 ENJAYMO SOLN 49 enoxaparin sodium soln 21 enoxaparin sodium sosy 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
enpresse-28 tabs 42 ENSPRYNG SOSY 49 ENSTILAR FOAM 54 entacapone tabs 30 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 25 ENTYVIO SOLR 41 enulose soln 35 ENVARSUS XR TB24 075mg 1mg 4mg48 EPCLUSA PACK 12 EPCLUSA TABS 12 EPIDIOLEX SOLN 29 epifoam foam 54 epinastine hcl soln 39 epinephrine (anaphylaxis) soln 20 epinephrine soaj 20 EPINEPHRINE SOSY 20 epirubicin hcl soln 15 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 25 EPOGEN SOLN 21 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 21 epoprostenol sodium solr 51 EPRONTIA SOLN 29 eprosartan mesylate tabs 25 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 33 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 30 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 43 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 53 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 53 erythromycin oint 38 erythromycin pads 53 erythromycin soln 53 erythromycin tbec 9 ESBRIET CAPS 51 ESBRIET TABS 267mg 801mg 51 escitalopram oxalate soln 33 escitalopram oxalate tabs 5mg 10mg
20mg 33 esgic caps 26 esgic tabs 26 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 40 esomeprazole magnesium pack 10mg
20mg 40mg 40 esomeprazole sodium solr 40 estarylla tabs 43 estazolam tabs 1mg 2mg 31 estrace crea 45 estrace tabs 05mg 1mg 2mg 45 estradiol crea 45 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
estradiol tabs 10mcg 05mg 1mg 2mg 45 estradiol valerate oil 45 estradiol-norethindrone acet tabs 45 ESTRING RING 45 eszopiclone tabs 1mg 2mg 3mg 31 ethacrynic acid tabs 36 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 29 ethosuximide soln 29 ethynodiol diac-eth estradiol tabs 43 etodolac caps 26
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 71
etodolac er tb24 26 etodolac tabs 26 etonogestrel-ethinyl estradiol ring 43 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 eulexin caps 15 EURAX CREA 53 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 46
evekeo tabs 5mg 10mg 28 EVENITY SOSY 47 everolimus tabs 025mg 48 everolimus tabs 05mg 075mg 1mg 48 everolimus tabs 25mg 5mg 75mg 10mg
15 everolimus tbso 2mg 3mg 5mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 22 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 49 exemestane tabs 15 EXKIVITY CAPS 15 EXONDYS 51 SOLN 500mg10ml
100mg2ml 49 EXSERVAN FILM 31 EXTAVIA KIT 32 EYLEA SOLN 39 EYLEA SOSY 39 ezetimibe tabs 22 ezetimibe-simvastatin tabs 22
F FABRAZYME SOLR 5mg 35mg 37 falmina tabs 43 famciclovir tabs 125mg 250mg 500mg 12 famotidine (pf) soln 40 famotidine premixed soln 40 famotidine soln 40 famotidine susr 40 famotidine tabs 20mg 40mg 40 FANAPT TABS 1mg 2mg 4mg 6mg 8mg
10mg 12mg 33 FANAPT TITRATION PACK TABS 33 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 51 FASENRA SOSY 51
fayosim tabs 43 febuxostat tabs 40mg 80mg 47 felbamate susp 29 felbamate tabs 400mg 600mg 29 felodipine er tb24 25mg 5mg 10mg 23 femynor tabs 43 fenofibrate caps 50mg 150mg 22 fenofibrate micronized caps 43mg 67mg
130mg 134mg 200mg 22 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 22 fenofibric acid cpdr 45mg 135mg 22 fenoprofen calcium caps 26 fenoprofen calcium tabs 26 fenortho caps 26 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 26 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 26
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 26
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 26
FERRIPROX SOLN 41 FERRIPROX TABS 41 FERRIPROX TWICE-A-DAY TABS 41 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
33 FETZIMA TITRATION C4PK 33 fexmid tabs 20 finasteride tabs 47 FINTEPLA SOLN 29 fioricet caps 26 fioricetcodeine caps 26 FIRDAPSE TABS 49 FIRMAGON (240 MG DOSE) SOLR 15 FIRMAGON SOLR 15 flac oil 38 flavoxate hcl tabs 57 FLEBOGAMMA DIF SOLN INTRAVENOUS
52 flecainide acetate tabs 50mg 100mg
150mg 24 FLEQSUVY SUSP 20 FLOVENT HFA AERO 51 floxuridine solr 15
72 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
fluconazole in sodium chloride soln intravenous 10
fluconazole susr 10 fluconazole tabs 10 flucytosine caps 250mg 500mg 10 fludarabine phosphate soln 15 fludarabine phosphate solr 15 fludrocortisone acetate tabs 42 flumazenil soln 31 flunisolide soln 38 fluocinolone acetonide body oil 54 fluocinolone acetonide crea 001 0025
54 fluocinolone acetonide oil 38 fluocinolone acetonide oint 54 fluocinolone acetonide scalp oil 54 fluocinolone acetonide soln 54 fluocinonide crea 54 fluocinonide emulsified base crea 54 FLUOCINONIDE GEL 54 fluocinonide oint 54 fluocinonide soln 54 FLUORITAB CHEW 025mg 05mg 1mg 49 FLUORITAB SOLN 49 fluorometholone susp 38 fluorouracil crea 5 56 fluorouracil crea 5 56 fluorouracil soln 15 56 fluorouracil soln 2 5 56 fluoxetine hcl (pmdd) tabs 10mg 20mg 33 fluoxetine hcl caps 10mg 20mg 40mg 33 fluoxetine hcl cpdr 33 fluoxetine hcl soln 33 fluoxetine hcl tabs 10mg 20mg 60mg 33 fluphenazine decanoate soln 33 fluphenazine hcl conc 33 fluphenazine hcl elix 33 fluphenazine hcl soln 33 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 34 FLURANDRENOLIDE CREA 54 flurandrenolide lotn 55 flurandrenolide oint 55 flurazepam hcl caps 15mg 30mg 31 flurbiprofen sodium soln 38 flurbiprofen tabs 26 flutamide caps 15 fluticasone propionate crea 55 fluticasone propionate lotn 55
fluticasone propionate oint 55 fluticasone propionate susp 38 fluticasone-salmeterol aepb 51 fluvastatin sodium caps 20mg 40mg 22 fluvastatin sodium er tb24 22 fluvoxamine maleate er cp24 100mg
150mg 34 fluvoxamine maleate tabs 25mg 50mg
100mg 34 FML FORTE SUSP 38 FML OINT 38 fomepizole soln 47 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 FORTEO SOPN 45 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 40 fosfomycin tromethamine pack 13 fosinopril sodium tabs 10mg 20mg 40mg
25 fosinopril sodium-hctz tabs 25 fosphenytoin sodium soln 29 FOTIVDA CAPS 089mg 134mg 15 FROVATRIPTAN SUCCINATE TABS 30 FULPHILA SOSY 21 fulvestrant soln 15 furosemide soln 8mgml 10mgml 36 furosemide soln injection 36 furosemide tabs 20mg 40mg 80mg 36 FUZEON SOLR 12 FYARRO SUSR 15 fyavolv tabs 45 FYCOMPA SUSP 29 FYCOMPA TABS 29
G gabapentin caps 100mg 400mg 29 gabapentin soln 29 gabapentin tabs 600mg 800mg 29 GALAFOLD CAPS 49 galantamine hydrobromide er cp24 8mg
16mg 24mg 19 galantamine hydrobromide soln 19 galantamine hydrobromide tabs 4mg 8mg
12mg 19 GAMASTAN INJ 52 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 48
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 73
GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm 52
GAMMAGARD SOLN INJECTION 52 GAMMAKED SOLN INJECTION 52 GAMMAPLEX SOLN INTRAVENOUS 52 GAMUNEX-C SOLN INJECTION 52 ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 52 GARDASIL 9 SUSY 52 gatifloxacin soln 38 GATTEX KIT 41 gavilyte-c solr 41 gavilyte-g solr 41 gavilyte-h kit 41 gavilyte-n with flavor pack solr 41 GAVRETO CAPS 15 GAZYVA SOLN 15 gemcitabine hcl soln 15 gemcitabine hcl solr 15 gemfibrozil tabs 22 gemmily caps 43 generlac soln 35 gengraf caps 25mg 50mg 100mg 48 gengraf soln 48 GENOTROPIN CART 12mg 46 GENOTROPIN MINIQUICK PRSY 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 46
gentak oint 38 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 53 gentamicin sulfate oint 53 gentamicin sulfate soln 9 38 gentamicin sulfate soln injection 9 GENVOYA TABS 12 gianvi tabs 43 GILENYA CAPS 025mg 05mg 32 GILOTRIF TABS 20mg 30mg 40mg 15 GIMOTI SOLN 41 GIVLAARI SOLN 49 GLASSIA SOLN INTRAVENOUS 51 glatopa sosy 20mgml 40mgml 32 glimepiride tabs 1mg 2mg 4mg 44 glipizide er tb24 25mg 5mg 10mg 44 glipizide tabs 5mg 10mg 44 glipizide-metformin hcl tabs 44 glucagon emergency kit 44
glyburide micronized tabs 15mg 3mg 6mg 44
glyburide tabs 125mg 25mg 5mg 44 glyburide-metformin tabs 44 glycate tabs 19 glycopyrrolate oral soln 19 glycopyrrolate pf sosy 19 glycopyrrolate soln injection 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 55 granisetron hcl soln 40 granisetron hcl tabs 40 GRANIX SOLN 480mcg16ml 300mcgml
21 GRANIX SOSY 300mcg05ml
480mcg08ml 21 GRASTEK SUBL 49 griseofulvin microsize susp 10 griseofulvin microsize tabs 10 griseofulvin ultramicrosize tabs 10 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 32 guanfacine hcl tabs 1mg 2mg 24 GUANIDINE HCL TABS 19 gynazole-1 crea 53
H HAEGARDA SOLR 2000unit 3000unit 49 hailey 24 fe tabs 43 halcinonide crea 55 halobetasol propionate crea 55 HALOBETASOL PROPIONATE FOAM 55 halobetasol propionate oint 55 haloperidol decanoate soln 34 haloperidol lactate conc 34 haloperidol lactate soln 34 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 34 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 52 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
HEPLISAV-B SOLN 52
74 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
HERCEPTIN HYLECTA SOLN 15 HERCEPTIN SOLR 150mg 440mg 15 HERZUMA SOLR 150mg 420mg 15 HETLIOZ CAPS 31 HETLIOZ LQ SUSP 31 HIBERIX SOLR 52 HUMALOG KWIKPEN SOPN 44 HUMALOG SOCT 44 HUMALOG SOLN 44 humatin caps 11 HUMATROPE CART 6mg 12mg 24mg 46 HUMATROPE SOLR 46 HUMIRA PEDIATRIC CROHNS START
PSKT 48 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 48 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 48 HUMIRA PEN-PEDIATRIC UC START
PNKT 48 HUMIRA PEN-PSUVADOL HS START
PNKT 48 HUMIRA PEN-PSORUVEIT STARTER
PNKT 48 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 48
HUMULIN 7030 KWIKPEN SUPN 44 HUMULIN 7030 SUSP 44 HUMULIN N KWIKPEN SUPN 44 HUMULIN N SUSP 44 HUMULIN R SOLN 44 HUMULIN R U-500 (CONCENTRATED)
SOLN 44 HUMULIN R U-500 KWIKPEN SOPN 44 hydralazine hcl soln 24 hydralazine hcl tabs 10mg 25mg 50mg
100mg 24 hydrochlorothiazide caps 36 hydrochlorothiazide tabs 125mg 25mg
50mg 36 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 26 hydrocodone-acetaminophen soln 26 hydrocodone-acetaminophen tabs 26 hydrocodone-ibuprofen tabs 26 hydrocortisone (perianal) crea 1 25 55 hydrocortisone ace-pramoxine crea 55
HYDROCORTISONE ACE-PRAMOXINE SUPP 55
hydrocortisone butyr lipo base crea 55 hydrocortisone butyrate crea 55 hydrocortisone butyrate lotn 55 HYDROCORTISONE BUTYRATE OINT 55 hydrocortisone butyrate soln 55 hydrocortisone crea 1 25 55 hydrocortisone enem 55 hydrocortisone lotn 55 hydrocortisone oint 1 25 55 hydrocortisone tabs 5mg 10mg 20mg 42 hydrocortisone valerate crea 55 hydrocortisone valerate oint 55 HYDROCORTISONE-ACETIC ACID SOLN
38 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 26 hydromorphone hcl liqd 26 hydromorphone hcl tabs 2mg 4mg 8mg 26 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 46 hydroxyprogesterone caproate soln 46 hydroxyurea caps 15 hydroxyzine hcl soln 31 hydroxyzine hcl syrp 31 hydroxyzine hcl tabs 31 hydroxyzine pamoate caps 31 HYPERHEP B SOLN 52 HYPERHEP B SOSY 52 HYPERRAB SD SOLN 52 HYQVIA KIT 52
I IBANDRONATE SODIUM SOLN 47 ibandronate sodium tabs 47 IBRANCE CAPS 75mg 100mg 125mg 15 IBRANCE TABS 75mg 100mg 125mg 15 IBSRELA TABS 41 ibu tabs 26 ibudone tabs 26 ibuprofen lysine soln 26 ibuprofen susp 26 ibuprofen tabs 26 ibutilide fumarate soln 24 icatibant acetate soln 20 iclevia tabs 43 ICLUSIG TABS 10mg 15mg 30mg 45mg
15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 75
icosapent ethyl caps 22 IDAMYCIN PFS SOLN 15 idarubicin hcl soln 15 IDHIFA TABS 50mg 100mg 15 ifosfamide soln 15 IFOSFAMIDE SOLR 16 ILARIS SOLN 26 ILUMYA SOSY 56 ILUVIEN IMPL 38 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 34 imipramine pamoate caps 75mg 100mg
125mg 150mg 34 imiquimod crea 375 5 56 IMIQUIMOD PUMP CREA 56 IMOGAM RABIES-HT SOLN 52 IMOVAX RABIES INJ 52 IMPAVIDO CAPS 11 INBRIJA CAPS 30 incassia tabs 43 INCRELEX SOLN 46 indapamide tabs 125mg 25mg 36 indocin supp 26 indomethacin caps 26 indomethacin er cpcr 26 indomethacin sodium solr 26 INFANRIX SUSP 52 INFLECTRA SOLR INTRAVENOUS 48 INFLIXIMAB SOLR INTRAVENOUS 48 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 32 INGREZZA CPPK 32 INLYTA TABS 1mg 5mg 16 INQOVI TABS 16 INREBIC CAPS 16 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 36 INTRON A SOLN 6000000unitml
10000000unitml 16 INTRON A SOLR 10000000unit
18000000unit 50000000unit 16 introvale tabs 43 INVEGA HAFYERA SUSY 34
INVEGA SUSTENNA SUSY 39mg025ml 34
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml 34
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml 34
INVIRASE CAPS 12 INVIRASE TABS 12 IOPIDINE SOLN 39 IPOL INJ 52 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 20 irbesartan tabs 75mg 150mg 300mg 25 irbesartan-hydrochlorothiazide tabs 25 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 20 isosorbide dinitrate er tbcr 25 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 25 isosorbide mononitrate er tb24 25 isosorbide mononitrate er tb24 30mg 60mg
25 isosorbide mononitrate tabs 10mg 20mg 25 isotretinoin caps 10mg 20mg 30mg 40mg
56 isradipine caps 25mg 5mg 23 ISTURISA TABS 1mg 5mg 10mg 49 itraconazole caps 10 ITRACONAZOLE SOLN 10 ivermectin crea 53 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 52
J JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16
76 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg 21
JARDIANCE TABS 10mg 25mg 44 jasmiel tabs 43 JEMPERLI SOLN 16 jinteli tabs 45 JOLIVETTE TABS 43 JULUCA TABS 12 junel 1530 tabs 43 junel 120 tabs 43 junel fe 1530 tabs 43 junel fe 120 tabs 43 junel fe 24 tabs 43 JUXTAPID CAPS 5mg 10mg 20mg 30mg
40mg 60mg 22 JYNARQUE TABS 15mg 30mg 36 JYNARQUE TBPK 36
K KADCYLA SOLR 100mg 160mg 16 kaitlib fe chew 43 KALYDECO PACK 25mg 50mg 75mg 51 KALYDECO TABS 51 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 37 kariva tabs 43 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ 37
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ 37
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS 37
KEDRAB SOLN 52 kelnor 135 tabs 43 kelnor 150 tabs 43 KENALOG SUSP 42 KEPIVANCE SOLR 56 KERALYT SHAM 56 KESIMPTA SOAJ 49 ketoconazole crea 53 ketoconazole foam 53 ketoconazole sham 53 ketoconazole tabs 10 ketodan foam 53 ketoprofen caps 26 ketoprofen er cp24 26 ketorolac tromethamine soln 26 38
ketorolac tromethamine soln 04 05 38 ketorolac tromethamine tabs 26 KEVEYIS TABS 49 KEVZARA SOAJ 150mg114ml
200mg114ml 48 KEVZARA SOSY 150mg114ml
200mg114ml 48 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 47 KHEDEZLA TB24 50mg 100mg 34 KIMMTRAK SOLN 16 KIMYRSA SOLR 9 KINERET SOSY 48 KINRIX SUSP 52 KINRIX SUSY 52 kionex susp 36 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KISQALI FEMARA(200 MG DOSE) TBPK
16 KITABIS PAK NEBU 51 KLISYRI OINT 56 KLOR-CON 10 TBCR 37 klor-con m15 tbcr 37 klor-con m20 tbcr 37 klor-con pack 37 klor-con sprinkle cpcr 8meq 10meq 37 KLOR-CON TBCR 37 KORLYM TABS 44 KORSUVA SOLN 56 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 35 K-TAB TBCR 37 kurvelo tabs 43 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 30 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 lacosamide tabs 50mg 100mg 150mg
200mg 29
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 77
LACRISERT INST 39 LACTATED RINGERS SOLN 37 49 LACTIC ACID LOTN 56 lactulose encephalopathy soln 35 lactulose pack 35 lactulose soln 35 LAMICTAL XR KIT 29 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 29 lamotrigine er tb24 25mg 50mg 100mg
200mg 250mg 300mg 29 lamotrigine kit 29 lamotrigine starter kit-blue kit 29 lamotrigine starter kit-green kit 29 lamotrigine starter kit-orange kit 29 lamotrigine tabs 25mg 100mg 150mg
200mg 29 lamotrigine tbdp 25mg 50mg 100mg
200mg 29 LANOXIN PEDIATRIC SOLN 24 LANREOTIDE ACETATE SOLN 46 lansoprazole cpdr 15mg 30mg 40 lansoprazole tbdd 15mg 30mg 40 lanthanum carbonate chew 500mg 750mg
1000mg 36 LANTUS SOLN 44 LANTUS SOLOSTAR SOPN 44 lapatinib ditosylate tabs 16 larin 1530 tabs 43 larin 120 tabs 43 larin fe 1530 tabs 43 larin fe 120 tabs 43 larissia tabs 43 LARTRUVO SOLN 190mg19ml
500mg50ml 16 latanoprost soln 39 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 34 LAYOLIS FE CHEW 43 LAZANDA SOLN 100mcgact 400mcgact
26 ledipasvir-sofosbuvir tabs 12 leena tabs 43 leflunomide tabs 10mg 20mg 48 LEMTRADA SOLN 32 lenalidomide caps 5mg 10mg 15mg 25mg
16
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 16 lessina tabs 43 letrozole tabs 16 leucovorin calcium soln 47 leucovorin calcium solr 47 leucovorin calcium tabs 5mg 10mg 15mg
25mg 47 LEUKERAN TABS 16 LEUKINE SOLR 21 leuprolide acetate kit 16 LEVALBUTEROL HCL NEBU
125mg05ml 125mg3ml 031mg3ml 063mg3ml 20
levalbuterol tartrate aero 20 levetiracetam er tb24 500mg 750mg 29 levetiracetam in nacl soln 29 levetiracetam soln 29 levetiracetam tabs 250mg 500mg 750mg
1000mg 29 levobunolol hcl soln 39 levocarnitine soln 49 LEVOCARNITINE TABS 49 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 38 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 47 levoleucovorin calcium solr 47 levonest tabs 43 levonorgest-eth est amp eth est tabs 43 levonorgest-eth estrad 91-day tabs 43 levonorgestrel-ethinyl estrad tabs 43 levonorg-eth estrad triphasic tabs 43 levora 01530 (28) tabs 43 levorphanol tartrate tabs 2mg 3mg 26 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
78 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEVOTHYROXINE SODIUM SOLR 47 LEVOTHYROXINE SODIUM TABS 25mcg
50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEXETTE FOAM 55 LEXIVA SUSP 12 LIALDA TBEC 40 LIBTAYO SOLN 16 lidocaine hcl (cardiac) pf sosy 24 lidocaine hcl (cardiac) sosy 24 lidocaine hcl (pf) soln 49 LIDOCAINE HCL CREA 55 lidocaine hcl lotn 55 lidocaine hcl soln 39 49 55 lidocaine hcl urethralmucosal gel 55 lidocaine hcl urethralmucosal prsy 55 LIDOCAINE IN D5W SOLN 24 lidocaine in dextrose soln 49 lidocaine oint 55 lidocaine ptch 55 lidocaine viscous hcl soln 40 lidocaine-epinephrine soln 49 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 55 LIDOCAINE-HYDROCORTISONE ACE KIT
55 lidocaine-prilocaine crea 55 lidocaine-tetracaine crea 55 LIDOCORT CREA 56 lidopin crea 56 LIDO-SORB LOTN 55 LIDOZION LOTN 56 lincomycin hcl soln 9 lindane sham 53 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 liothyronine sodium soln 47 liothyronine sodium tabs 5mcg 25mcg
50mcg 47 LIPODOX 50 INJ 16
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg 25
lisinopril-hydrochlorothiazide tabs 25 LITHIUM CARBONATE CAPS 150mg
300mg 600mg 34 lithium carbonate er tbcr 300mg 450mg 34 LITHIUM CARBONATE TABS 34 LITHIUM SOLN 34 LITHOSTAT TABS 35 LIVMARLI SOLN 41 LIVTENCITY TABS 12 loestrin 1530 (21) tabs 43 loestrin 120 (21) tabs 43 loestrin fe 1530 tabs 43 loestrin fe 120 tabs 43 LOKELMA PACK 5gm 10gm 36 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 16 loperamide hcl caps 40 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 45 lorazepam intensol conc 31 LORAZEPAM SOLN 4mgml 2mgml 31 lorazepam tabs 05mg 1mg 2mg 31 LORBRENA TABS 25mg 100mg 16 lorcet hd tabs 26 lorcet plus tabs 26 lorcet tabs 27 lortab elix 27 loryna tabs 43 losartan potassium tabs 25mg 50mg
100mg 25 losartan potassium-hctz tabs 25 LOTEMAX GEL 38 LOTEMAX SUSP 38 lovastatin tabs 10mg 20mg 40mg 22 LOVENOX SOLN 21 LOVENOX SOSY 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
low-ogestrel tabs 43 loxapine succinate caps 5mg 10mg 25mg
50mg 34 lubiprostone caps 8mcg 24mcg 41 LUCEMYRA TABS 32 LUCENTIS SOLN 03mg005ml
05mg005ml 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 79
LUCENTIS SOSY 03mg005ml 05mg005ml 39
LUDENT CHEW 025mg 05mg 1mg 49 LUMAKRAS TABS 16 LUMIGAN SOLN 39 LUMIZYME SOLR 37 LUMOXITI SOLR 16 LUPANETA PACK KIT 16 LUPKYNIS CAPS 48 LUPRON DEPOT (1-MONTH) KIT 16 LUPRON DEPOT (3-MONTH) KIT 16 LUPRON DEPOT (4-MONTH) KIT 16 LUPRON DEPOT (6-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 16 LUPRON DEPOT-PED (3-MONTH) KIT 16 lutera tabs 43 LYBALVI TABS 34 lyleq tabs 43 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 45
LYMEPAK TABS 9 LYNPARZA TABS 100mg 150mg 16 LYSODREN TABS 16 lyza tabs 43
M mafenide acetate pack 53 magnesium sulfate in d5w soln 37 magnesium sulfate soln 29 MAGNESIUM SULFATE SOLN INJECTION
50 29 MAKENA SOAJ 46 malathion lotn 53 MANNITOL SOLN 36 maprotiline hcl tabs 25mg 50mg 75mg 34 maraviroc tabs 150mg 300mg 12 MARGENZA SOLN 16 marlissa tabs 43 MARPLAN TABS 34 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 23 MAVENCLAD (10 TABS) TBPK 48 MAVENCLAD (4 TABS) TBPK 48 MAVENCLAD (5 TABS) TBPK 48
MAVENCLAD (6 TABS) TBPK 48 MAVENCLAD (7 TABS) TBPK 48 MAVENCLAD (8 TABS) TBPK 48 MAVENCLAD (9 TABS) TBPK 48 MAVYRET PACK 12 MAVYRET TABS 12 MAYZENT STARTER PACK TBPK 32 MAYZENT TABS 025mg 1mg 2mg 32 MENAPHOSMBHYO1 TABS 13 meclizine hcl tabs 40 meclofenamate sodium caps 27 MEDROL TABS 42 medroxyprogesterone acetate susp 46 medroxyprogesterone acetate susy 46 medroxyprogesterone acetate tabs 25mg
5mg 10mg 46 mefenamic acid caps 27 mefloquine hcl tabs 11 megestrol acetate susp 17 46 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 43 meloxicam tabs 27 melphalan hcl solr 17 memantine hcl er cp24 32 memantine hcl soln 32 memantine hcl tabs 5mg 10mg 32 MENACTRA SOLN 52 menest tabs 03mg 0625mg 125mg 45 MENQUADFI SOLN 52 MENVEO SOLR 52 meperidine hcl soln 27 meperidine hcl tabs 50mg 27 meprobamate tabs 31 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 43 mesalamine cpdr 40 mesalamine enem 40 mesalamine er cp24 40 mesalamine supp 40 mesalamine tbec 12gm 800mg 40 mesalamine-cleanser kit 40 mesna soln 49 MESNEX TABS 49 MESTINON SOLN 19 metadate er tbcr 28 metaproterenol sulfate syrp 20
80 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
metaproterenol sulfate tabs 10mg 20mg 20 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 44 metformin hcl tabs 500mg 850mg 1000mg
45 methadone hcl conc 27 methadone hcl intensol conc 27 methadone hcl tabs 5mg 10mg 27 methamphetamine hcl tabs 28 methazolamide tabs 25mg 50mg 39 methenamine hippurate tabs 13 METHENAMINE MANDELATE TABS 13 methergine tabs 45 methimazole tabs 5mg 10mg 47 methitest tabs 42 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 57 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 36 methyldopa tabs 250mg 500mg 24 methyldopa-hydrochlorothiazide tabs 24 methylergonovine maleate soln 45 methylergonovine maleate tabs 45 methylphenidate hcl chew 25mg 5mg
10mg 28 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 28 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 28 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 28
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 28
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 28
methylphenidate hcl soln 5mg5ml 10mg5ml 28
methylphenidate hcl tabs 5mg 10mg 20mg 28
methylprednisolone acetate susp 42 methylprednisolone sodium succ solr 42
methylprednisolone tabs 4mg 8mg 16mg 32mg 42
methylprednisolone tbpk 42 methyltestosterone caps 42 metoclopramide hcl soln 41 metoclopramide hcl tabs 5mg 10mg 41 metoclopramide hcl tbdp 5mg 10mg 41 metolazone tabs 25mg 5mg 10mg 36 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 23 metoprolol tartrate soct 23 metoprolol tartrate soln 23 metoprolol tartrate tabs 25mg 50mg
100mg 23 metoprolol tartrate tabs 375mg 75mg 23 metoprolol-hydrochlorothiazide tabs 23 metronidazole caps 11 metronidazole crea 53 metronidazole gel 53 metronidazole lotn 53 METRONIDAZOLE SOLN INTRAVENOUS
500mg100ml 11 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
24 mibelas 24 fe chew 43 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 53 miconazole-zinc oxide-petrolat oint 53 micort-hc crea 55 microgestin 1530 tabs 43 microgestin 120 tabs 43 microgestin 24 fe tabs 43 microgestin fe 1530 tabs 43 microgestin fe 120 tabs 43 midazolam hcl (pf) soln 31 midazolam hcl soln 31 midodrine hcl tabs 25mg 5mg 10mg 20 miglitol tabs 25mg 50mg 100mg 45 miglustat caps 38 mili tabs 43 millipred dp tbpk 42 millipred tabs 42 milrinone lactate in dextrose soln 24 milrinone lactate soln 24 mimvey lo tabs 45 mimvey tabs 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 81
minitran pt24 01mghr 02mghr 04mghr 06mghr 25
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 24 mirtazapine tabs 75mg 15mg 30mg
45mg 34 mirtazapine tbdp 15mg 30mg 45mg 34 misoprostol tabs 100mcg 200mcg 40 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 52 modafinil tabs 100mg 200mg 28 moexipril hcl tabs 75mg 15mg 25 molindone hcl tabs 5mg 10mg 25mg 34 mometasone furoate crea 55 mometasone furoate oint 55 mometasone furoate soln 55 mometasone furoate susp 38 MONJUVI SOLR 17 MONONESSA TABS 43 montelukast sodium chew 4mg 5mg 51 montelukast sodium pack 51 montelukast sodium tabs 51 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 27 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 27 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 27
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 27
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml 27
morphine sulfate tabs 15mg 30mg 27 moxifloxacin hcl (2x day) soln 38 moxifloxacin hcl in nacl soln intravenous 9 moxifloxacin hcl soln 38 moxifloxacin hcl tabs 9 MULPLETA TABS 21 MULTAQ TABS 24 mupirocin calcium crea 53 mupirocin oint 53 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17
MYALEPT SOLR 49 MYCAPSSA CPDR 46 mycophenolate mofetil caps 48 mycophenolate mofetil hcl solr 48 mycophenolate mofetil susr 48 mycophenolate mofetil tabs 49 mycophenolate sodium tbec 180mg 360mg
49 MYFEMBREE TABS 45 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 57 MYRBETRIQ TB24 25mg 50mg 57
N NABI-HB SOLN 52 nabumetone tabs 27 N-ACETYL-L-CYSTEINE CAPS 36 nadolol tabs 20mg 40mg 80mg 23 nadololbendroflumethiazide tabs 23 nadolol-bendroflumethiazide tabs 23 nafcillin sodium solr 9 nafcillin sodium solr injection 9 nafcillin sodium solr intravenous 9 NAFRINSE CHEW 49 NAFRINSE DROPS SOLN 49 naftifine hcl crea 53 naftifine hcl gel 53 NAGLAZYME SOLN 38 nalbuphine hcl soln 10mgml 20mgml 27 nalfon tabs 27 nalocet tabs 27 naloxone hcl liqd 32 naloxone hcl soaj 32 naloxone hcl soct 32 naloxone hcl soln 32 naloxone hcl sosy 32 naltrexone hcl tabs 32 naproxen sodium er tb24 27 naproxen sodium tabs 27 naproxen susp 27 naproxen tabs 27 naproxen tbec 27 naproxen-esomeprazole tbec 27 naratriptan hcl tabs 30 NARCAN LIQD 32 NATACYN SUSP 38 nateglinide tabs 60mg 120mg 45 NATPARA CART 25mcg 50mcg 75mcg
100mcg 45
82 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
NAYZILAM SOLN 29 necon 0535 (28) tabs 43 NECON 777 TABS 43 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 34 nelarabine soln 17 nembutal soln 31 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 38 neomycin-polymyxin b gu soln 53 neomycin-polymyxin-dexameth oint 38 neomycin-polymyxin-dexameth susp 39 neomycin-polymyxin-gramicidin soln 38 neomycin-polymyxin-hc soln 39 neomycin-polymyxin-hc susp 39 neo-polycin hc oint 38 neo-polycin oint 38 neo-synalar crea 55 NERLYNX TABS 17 NEULASTA ONPRO PSKT 21 NEULASTA SOSY 21 NEUPOGEN SOLN 480mcg16ml
300mcgml 21 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 21 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 38 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 22 niacor tabs 22 nicardipine hcl caps 20mg 30mg 23 NICARDIPINE HCL SOLN 23 NICOTROL INHA 19 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 43 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 49 nitro-bid oint 25
NITRO-DUR PT24 03mghr 08mghr 25 NITROFURANTOIN MACROCRYSTAL
CAPS 13 NITROFURANTOIN MONOHYD MACRO
CAPS 13 nitrofurantoin susp 13 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 25 nitroglycerin soln 25 nitroglycerin subl 03mg 04mg 06mg 25 nitropress soln 24 nitroprusside sodium soln 24 NITYR TABS 2mg 5mg 10mg 49 NIVESTYM SOLN 480mcg16ml
300mcgml 21 NIVESTYM SOSY 300mcg05ml
480mcg08ml 22 nizatidine caps 150mg 300mg 40 nizatidine soln 40 nolix crea 55 nolix lotn 55 nora-be tabs 43 norco tabs 27 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 46
norepinephrine bitartrate soln 20 norethin ace-eth estrad-fe caps 43 norethin ace-eth estrad-fe chew 43 norethin ace-eth estrad-fe tabs 43 norethindrone acetate tabs 46 norethindrone acet-ethinyl est tabs 43 norethindrone tabs 43 norethindrone-eth estradiol tabs 45 norethin-eth estradiol-fe chew 43 norgesic forte tabs 27 norgestimate-eth estradiol tabs 43 norgestim-eth estrad triphasic tabs 43 norlyroc tabs 43 NORPACE CR CP12 100mg 150mg 24 nortrel 0535 (28) tabs 43 nortrel 135 (21) tabs 43 nortrel 135 (28) tabs 43 nortrel 777 tabs 43 nortriptyline hcl caps 10mg 25mg 50mg
75mg 34 nortriptyline hcl soln 34 NORVIR CAPS 12 NORVIR PACK 12
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 83
NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 32 NOXAFIL SUSP 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 51 NUCALA SOLR 51 NUCALA SOSY 51 NUCYNTA ER TB12 200mg 250mg 27 NUCYNTA TABS 27 NUEDEXTA CAPS 32 NULIBRY SOLR 49 NULOJIX SOLR 49 NUPLAZID CAPS 34 NUPLAZID TABS 10mg 17mg 34 NURTEC TBDP 30 NUTRILIPID EMUL INTRAVENOUS 36 NUTROPIN AQ NUSPIN 10 SOPN 46 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 53 nylia 135 tabs 43 nylia 777 tabs 43 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 44 nystatin crea 53 nystatin oint 53 nystatin powd 53 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 55 nystatin-triamcinolone oint 55 nystop powd 53 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 41 ocella tabs 44 OCREVUS SOLN 32 OCTAGAM SOLN INTRAVENOUS
1gm20ml 2gm20ml 52 octreotide acetate soln 500mcgml
1000mcgml 46 octreotide acetate soln 50mcgml
100mcgml 200mcgml 46 ODACTRA SUBL 49 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 51
ofloxacin soln 38 ofloxacin tabs 10 ogestrel tabs 44 OGIVRI SOLR 17 olanzapine solr 34 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 34 olanzapine tbdp 5mg 10mg 15mg 20mg
34 olanzapine-fluoxetine hcl caps 34 olmesartan medoxomil tabs 5mg 20mg
40mg 25 olmesartan medoxomil-hctz tabs 25 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 39 OLUMIANT TABS 1mg 2mg 48 omega-3-acid ethyl esters caps 22 omeprazole cpdr 10mg 20mg 40mg 40 omeprazole-sodium bicarbonate caps 40 omeprazole-sodium bicarbonate pack 40 OMNITROPE SOCT 5mg15ml
10mg15ml 46 OMNITROPE SOLR 46 ondansetron hcl soln 40 ondansetron hcl sosy 40 ondansetron hcl tabs 4mg 8mg 24mg 40 ondansetron tbdp 4mg 8mg 40 ONIVYDE
INJ 17 ONPATTRO SOLN 50 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 OPDIVO SOLN 100mg10ml 120mg12ml
240mg24ml 40mg4ml 17 OPDUALAG SOLN 17 OPIUM TINC 40 OPZELURA CREA 57 ORACEA CPDR 57 oralone pste 55 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 48 ORENCIA SOLR 48 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 48 ORENITRAM TBCR 025mg 1mg 25mg
5mg 51 ORFADIN CAPS 50 ORFADIN SUSP 50 ORGOVYX TABS 45
84 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ORILISSA TABS 150mg 200mg 45 ORKAMBI PACK 51 ORKAMBI TABS 51 ORLADEYO CAPS 110mg 150mg 50 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 27 orphengesic forte tabs 27 orsythia tabs 44 ORTIKOS CP24 6mg 9mg 42 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 36 OTEZLA TABS 48 OTEZLA TBPK 48 ovide lotn 53 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 42 oxaprozin tabs 27 OXAYDO TABS 27 oxazepam caps 10mg 15mg 30mg 31 OXBRYTA TABS 21 OXBRYTA TBSO 21 oxcarbazepine susp 29 oxcarbazepine tabs 150mg 300mg 600mg
29 OXERVATE SOLN 39 oxiconazole nitrate crea 53 OXLUMO SOLN 50 OXTELLAR XR TB24 150mg 300mg
600mg 29 oxybutynin chloride er tb24 5mg 10mg
15mg 57 oxybutynin chloride syrp 57 oxybutynin chloride tabs 57 oxycodone hcl caps 27 oxycodone hcl conc 27 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxycodone hcl soln 27 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 27 oxycodone-acetaminophen soln 27
oxycodone-acetaminophen tabs 27 oxycodone-acetaminophen tabs 5-300mg
75-300mg 10-300mg 27 oxycodone-aspirin tabs 27 oxycodone-ibuprofen tabs 27 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 27 oxymorphone hcl tabs 5mg 10mg 27 OXYTOCIN SOLN 45 OZEMPIC (025 OR 05 MGDOSE) SOPN
45 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 45 OZEMPIC (2 MGDOSE) SOPN 45
P pacerone tabs 100mg 200mg 400mg 24 paclitaxel conc 17 PACLITAXEL PROTEIN-BOUND PART
SUSR 100 MG 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
50 PALFORZIA (120 MG DAILY DOSE) CSPK
50 PALFORZIA (160 MG DAILY DOSE) CSPK
50 PALFORZIA (20 MG DAILY DOSE) CSPK
50 PALFORZIA (200 MG DAILY DOSE) CSPK
50 PALFORZIA (240 MG DAILY DOSE) CSPK
50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK 50 PALFORZIA (300 MG TITRATION) PACK
50 PALFORZIA (40 MG DAILY DOSE) CSPK
50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
50 PALFORZIA INITIAL ESCALATION CSPK
50 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 34
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 85
palonosetron hcl soln 40 palonosetron hcl sosy 40 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 38 pamidronate disodium soln 47 pamidronate disodium solr 47 panlor tabs 27 PANRETIN GEL 56 pantoprazole sodium pack 40 PANTOPRAZOLE SODIUM SOLR 40 pantoprazole sodium tbec 20mg 40mg 40 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 52
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 57 PARICALCITOL SOLN 57 paroex soln 38 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 34 paroxetine hcl susp 34 paroxetine hcl tabs 10mg 20mg 34 paroxetine hcl tabs 30mg 40mg 34 paroxetine mesylate caps 34 paser pack 11 PEDIARIX SUSY 52 PEDVAX HIB SUSP 52 peg 3350electrolytes solr 41 peg 3350-kcl-na bicarb-nacl solr 41 peg-3350electrolytes solr 41 PEGANONE TABS 29 PEGASYS PROCLICK SOAJ
135mcg05ml 180mcg05ml 12 PEGASYS SOLN 12 PEGASYS SOSY 12 PEGINTRON KIT 12 PEG-PREP KIT 41 PEMAZYRE TABS 45mg 9mg 135mg 17 PEMFEXY SOLN 17 penicillamine caps 41 penicillamine tabs 41 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
PENTACEL SUSR 52 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 40 pentazocine-naloxone hcl tabs 27 pentobarbital sodium soln 31 pentoxifylline er tbcr 21 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 40 percocet tabs 27 perindopril erbumine tabs 2mg 4mg 8mg
25 periogard soln 38 PERJETA SOLN 17 permethrin crea 53 perphenazine tabs 2mg 4mg 8mg 16mg
34 perphenazine-amitriptyline tabs 34 PERSERIS PRSY 90mg 120mg 34 PEXEVA TABS 10mg 20mg 30mg 40mg
34 phenadoz supp 14 phenazo tabs 56 PHENAZOPYRIDINE HCL TABS 56 phenelzine sulfate tabs 34 phenergan soln 14 PHENOBARBITAL ELIX 31 PHENOBARBITAL SODIUM SOLN 31 PHENOBARBITAL TABS 31 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 20 PHENYLEPHRINE HCL SOLN 39 phenytek caps 200mg 300mg 29 phenytoin chew 29 phenytoin sodium extended caps 100mg
200mg 300mg 29 phenytoin sodium soln 29 phenytoin susp 29 PHESGO SOLN 17 PHOSLYRA SOLN 37 PHOSPHASAL TABS 13 PHOSPHOLINE IODIDE SOLR 39 phrenilin forte caps 27 PHYSIOLYTE SOLN 50 PHYSIOSOL IRRIGATION SOLN 50 PIFELTRO TABS 12 pilocarpine hcl soln 1 2 4 39 pilocarpine hcl tabs 5mg 75mg 19 pimecrolimus crea 57
86 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
pimozide tabs 1mg 2mg 34 pimtrea tabs 44 pindolol tabs 5mg 10mg 23 pioglitazone hcl tabs 15mg 30mg 45mg 45 pioglitazone hcl-glimepiride tabs 45 pioglitazone hcl-metformin hcl tabs 45 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 44 piroxicam caps 10mg 20mg 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN 32 PLEGRIDY SOSY 32 PLEGRIDY STARTER PACK SOPN 32 PLEGRIDY STARTER PACK SOSY 32 plenamine soln intravenous 36 podofilox soln 57 POLIVY SOLR 30mg 140mg 17 polocaine soln 50 polocaine-mpf soln 50 polycin oint 38 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 38 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 32 PONVORY TABS 32 portia-28 tabs 44 PORTRAZZA SOLN 17 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 35 POTASSIUM ACETATE SOLN 37 potassium chloride crys er tbcr 10meq
20meq 37 potassium chloride er cpcr 8meq 10meq 37 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 37 POTASSIUM CHLORIDE IN NACL SOLN
INTRAVENOUS 37 POTASSIUM CHLORIDE PACK 37 POTASSIUM CHLORIDE SOLN 10 20
37
potassium chloride soln intravenous 10meq100ml 20meq100ml 40meq100ml 2meqml 37
potassium citrate er tbcr 15meq 540mg 1080mg 35
POTASSIUM PHOSPHATES SOLN 37 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 37 POTELIGEO SOLN 17 PR BENZOYL PEROXIDE WASH LIQD 53 PRADAXA CAPS 75mg 110mg 150mg 21 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 31
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 31
PRAMOX GEL 56 prandin tabs 1mg 2mg 45 prasugrel hcl tabs 5mg 10mg 21 pravastatin sodium tabs 10mg 20mg
40mg 80mg 22 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22 PRED MILD SUSP 39 PRED-G SOP OINT 39 PRED-G SUSP 39 prednicarbate crea 55 prednicarbate oint 55 prednisolone acetate susp 39 prednisolone sodium phosphate soln 39 PREDNISOLONE SODIUM PHOSPHATE
SOLN 10mg5ml 20mg5ml 25mg5ml 5mg5ml 42
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 42
prednisolone soln 42 prednisone intensol conc 42 prednisone soln 42 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 42 prednisone tbpk 42 prefest tabs 45 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 29
pregabalin er tb24 825mg 165mg 330mg 27
pregabalin soln 29 PREHEVBRIO SUSP 52
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 87
PREMARIN SOLR 45 premasol soln intravenous 36 PRENATAL TABS 57 PRETOMANID TABS 11 prevalite pack 22 prevalite powd 22 previfem tabs 44 PREVYMIS SOLN 240mg12ml
480mg24ml 12 PREVYMIS TABS 240mg 480mg 12 PREZCOBIX TABS 12 PREZISTA SUSP 12 PREZISTA TABS 75mg 150mg 600mg
800mg 12 PRIFTIN TABS 11 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 29 primlev tabs 27 probenecid tabs 37 procainamide hcl soln 24 PROCALAMINE SOLN INTRAVENOUS 36 procentra soln 28 prochlorperazine edisylate soln 34 prochlorperazine maleate tabs 34 prochlorperazine supp 34 PROCRIT SOLN 20000unitml
40000unitml 22 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 22 proctofoam hc foam 56 procto-med hc crea 55 procto-pak crea 55 proctosol hc crea 55 proctozone-hc crea 55 PROCYSBI CPDR 25mg 75mg 50 PROCYSBI PACK 75mg 300mg 50 progesterone caps 100mg 200mg 46 progesterone oil 46 PROGRAF PACK 49 PROGRAF PACK 02mg 49 PROGRAF SOLN 49 prolate soln 27 prolate tabs 27 PROLEUKIN SOLR 17 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 24 propafenone hcl tabs 150mg 225mg
300mg 24 propantheline bromide tabs 19 proparacaine hcl soln 40 propranolol hcl er cp24 60mg 80mg
120mg 160mg 23 propranolol hcl soln 20mg5ml 40mg5ml 23 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 23 propranolol-hctz tabs 23 propylthiouracil tabs 47 PROQUAD SUSR 52 protriptyline hcl tabs 5mg 10mg 34 psorcon crea 55 PULMICORT FLEXHALER AEPB 51 PULMOZYME SOLN 38 PURIXAN SUSP 17 PYLERA CAPS 40 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 19 pyridostigmine bromide soln 19 pyridostigmine bromide tabs 30mg 60mg 19 pyrimethamine tabs 11 PYRUKYND TABS 5mg 20mg 50mg 50 PYRUKYND TAPER PACK TBPK 50
Q QDOLO SOLN 27 QINLOCK TABS 17 QUADRACEL SUSP 52 questran light powd 22 questran pack 22 questran powd 22 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 34 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 34 quinapril hcl tabs 5mg 10mg 20mg 40mg
25 quinapril-hydrochlorothiazide tabs 25 quinidine gluconate er tbcr 24 QUINIDINE GLUCONATE SOLN 24 quinidine sulfate tabs 200mg 300mg 24
88 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
quinine sulfate caps 11 QULIPTA TABS 10mg 30mg 60mg 30
R RABAVERT SUSR 52 rabeprazole sodium cpsp 40 rabeprazole sodium tbec 40 RADIAURA CREA 55 RADICAVA SOLN 32 raloxifene hcl tabs 45 ramelteon tabs 31 ramipril caps 125mg 25mg 5mg 10mg 25 ranolazine er tb12 500mg 1000mg 24 RAPIVAB SOLN 12 rasagiline mesylate tabs 05mg 1mg 31 RASUVO SOAJ 48 RAVICTI LIQD 35 RAYALDEE CPCR 57 REBETOL SOLN 12 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 32 REBIF REBIDOSE TITRATION PACK
SOAJ 32 REBIF SOSY 22mcg05ml 44mcg05ml 32 REBIF TITRATION PACK SOSY 32 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 44 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 52 RECORLEV TABS 50 RECTIV OINT 57 REGONOL SOLN 19 REGRANEX GEL 57 relafen ds tabs 27 RELENZA DISKHALER AEPB 12 RELEUKO SOLN 300mcgml
480mcg16ml 22 RELEUKO SOSY 300mcg05ml
480mcg08ml 22 relexxii tbcr 28 RELISTOR SOLN 8mg04ml 12mg06ml
41 RELISTOR TABS 41 reltone caps 200mg 400mg 41 REMICADE SOLR INTRAVENOUS 48 RENFLEXIS SOLR 48 repaglinide tabs 05mg 1mg 2mg 45 repaglinide-metformin hcl tabs 45
REPATHA SOSY 22 REPATHA SURECLICK SOAJ 22 RESCRIPTOR TABS 100mg 200mg 12 RESTASIS EMUL 39 RESTASIS MULTIDOSE EMUL 39 RETACRIT SOLN 22 RETACRIT SOLN 20000unitml 22 RETEVMO CAPS 40mg 80mg 17 RETIN-A CREA 0025 005 01 56 RETIN-A GEL 001 0025 56 RETIN-A MICRO GEL 004 01 56 RETIN-A MICRO PUMP GEL 004 01
56 RETISERT IMPL 39 RETROVIR SOLN 12 REVCOVI SOLN 38 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 17 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 34 REYATAZ PACK 12 REZUROCK TABS 50 RIABNI SOLN 100mg10ml 500mg50ml 17 ribasphere caps 12 ribasphere ribapak (1000 pack) tbpk 12 ribasphere ribapak (1200 pack) tbpk 12 ribasphere tabs 12 ribavirin caps 12 ribavirin solr 12 ribavirin tabs 13 RIDAURA CAPS 50 rifabutin caps 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 riluzole tabs 32 rimantadine hcl tabs 13 RIMSO-50 SOLN 50 RINGERS IRRIGATION SOLN 50 RINGERS SOLN 37 RINVOQ TB24 15mg 30mg 45mg 48 risedronate sodium tabs 5mg 30mg 35mg
150mg 47 risedronate sodium tbec 47 RISPERDAL CONSTA SRER 125mg
25mg 34 RISPERDAL CONSTA SRER 375mg
50mg 35
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 89
RISPERIDONE SOLN 35 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 35 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 35 ritonavir tabs 13 RITUXAN HYCELA SOLN 17 RITUXAN SOLN 17 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 44 rizatriptan benzoate tabs 30 rizatriptan benzoate tbdp 30 ROMIDEPSIN SOLN 17 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 31 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 31 ropivacaine hcl soln 50 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 22 ROTARIX SUSR 52 ROTATEQ SOLN 52 roweepra tabs 500mg 750mg 1000mg 29 roweepra xr tb24 500mg 750mg 29 ROZLYTREK CAPS 100mg 200mg 17 RUBRACA TABS 200mg 250mg 300mg 17 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 29 rufinamide tabs 200mg 400mg 29 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 17 RYBREVANT SOLN 17 ryclora soln 14 RYDAPT CAPS 17 RYLAZE SOLN 17 RYNODERM CREA 57 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 46 SAIZEN SOLR 5mg 88mg 46 SAIZENPREP SOLR 46 sajazir soln 21 SALEX SHAM 57 SALICYLIC ACID CREA 57
SALICYLIC ACID ER SOLN 57 SALICYLIC ACID FOAM 57 SALICYLIC ACID GEL 57 SALICYLIC ACID SHAM 57 SALICYLIC ACID-CLEANSER KIT 57 SALSALATE TABS 27 SANCUSO PTCH 40 SANDIMMUNE ORAL SOLN 100mgml 49 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 46 SANTYL OINT 57 SAPHNELO SOLN 49 SAPHRIS SUBL 25mg 5mg 10mg 35 sapropterin dihydrochloride pack 100mg
500mg 50 sapropterin dihydrochloride tabs 50 SARCLISA SOLN 500mg25ml 100mg5ml
17 SCEMBLIX TABS 20mg 40mg 17 scopolamine pt72 40 seconal caps 31 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 35 selegiline hcl caps 31 selegiline hcl tabs 31 selenium sulfide lotn 53 SELENIUM SULFIDE SHAM 53 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 13 SENSORCAINE SOLN 50 sensorcaineepinephrine soln 50 sensorcaine-mpf soln 50 sensorcaine-mpfepinephrine soln 50 SEREVENT DISKUS AEPB 20 SEROSTIM SOLR 4mg 5mg 6mg 46 SERTRALINE HCL CAPS 150mg 200mg
35 sertraline hcl conc 35 sertraline hcl tabs 25mg 50mg 100mg 35 setlakin tabs 44 sevelamer carbonate pack 08gm 24gm 36 sevelamer carbonate tabs 36 sevelamer hcl tabs 400mg 800mg 36 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 44 SHINGRIX SUSR 52 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 46
90 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
SIGNIFOR SOLN 03mgml 06mgml 09mgml 46
SIKLOS TABS 17 sildenafil citrate soln 25 sildenafil citrate susr 25 sildenafil citrate tabs 25 SILIQ SOSY 57 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 53 SIMPONI ARIA SOLN 48 SIMPONI SOAJ 50mg05ml 100mgml 48 SIMPONI SOSY 50mg05ml 100mgml 48 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 22 sirolimus soln 49 sirolimus tabs 05mg 1mg 2mg 49 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKYRIZI (150 MG DOSE) PSKT 57 SKYRIZI PEN SOAJ 57 SKYRIZI SOSY 57 SKYTROFA CART 3mg 36mg 43mg
52mg 63mg 76mg 91mg 11mg 133mg 46
sod benz-sod phenylacet soln 35 SODIUM ACETATE SOLN 35 SODIUM BICARBONATE SOLN 35 SODIUM CHLORIDE (PF) SOLN 37 SODIUM CHLORIDE SOLN 37 50 SODIUM CHLORIDE SOLN
INTRAVENOUS 045 09 3 5 37 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 50 SODIUM FLUORIDE SOLN 50 sodium phenylbutyrate powd 35 sodium phenylbutyrate tabs 35 SODIUM PHOSPHATES SOLN 37 sodium polystyrene sulfonate powd 36 sodium polystyrene sulfonate susp 36 sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 57 SOLTAMOX SOLN 17 SOLU-CORTEF SOLR 42 SOLU-MEDROL SOLR 42 SOMATULINE DEPOT SOLN 60mg02ml
90mg03ml 120mg05ml 46 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 46
sorine tabs 80mg 120mg 160mg 240mg 23
sotalol hcl (af) tabs 80mg 120mg 160mg 23 sotalol hcl tabs 80mg 120mg 160mg
240mg 23 SOTYLIZE SOLN 23 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 25 spironolactone-hctz tabs 25 SPRAVATO (56 MG DOSE) SOPK 35 SPRAVATO (84 MG DOSE) SOPK 35 sprintec 28 tabs 44 SPRITAM TB3D 250mg 500mg 750mg
1000mg 29 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 36 sronyx tabs 44 SSD CREA 53 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
57 STELARA SOSY 45mg05ml 90mgml 57 STERILE WATER FOR IRRIGATION SOLN
50 STIMATE SOLN 46 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18 STRENSIQ SOLN 18mg045ml
28mg07ml 80mg08ml 40mgml 38 streptomycin sulfate solr 10 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 20 SUBLOCADE SOSY 100mg05ml
300mg15ml 32 SUBSYS LIQD 1200mcg 1600mcg 27 subvenite starter kit-blue kit 29 subvenite starter kit-green kit 29 subvenite starter kit-orange kit 30 subvenite tabs 25mg 100mg 150mg
200mg 30 succinylcholine chloride soln 20 SUCRAID SOLN 38 sucralfate susp 40 sucralfate tabs 40
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 91
sulfacetamide sodium (acne) lotn 53 sulfacetamide sodium oint 38 sulfacetamide sodium soln 38 sulfacetamide-prednisolone soln 39 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 SULFAMYLON CREA 53 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 27 sumatriptan soln 30 sumatriptan succinate refill soct 30 sumatriptan succinate soaj 30 sumatriptan succinate soln 30 sumatriptan succinate sosy 30 sumatriptan succinate tabs 30 sunitinib malate caps 125mg 25mg
375mg 50mg 18 suprax chew 10 SUPREP BOWEL PREP KIT SOLN 41 SUSVIMO (IMPLANT 1ST FILL) SOLN 39 SUSVIMO (IMPLANT REFILL) SOLN 39 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 44 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 51 SYMDEKO TBPK 51 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 45 SYMLINPEN 60 SOPN 45 SYMPAZAN FILM 10mg 20mg 30 SYMPAZAN FILM 5mg 30 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 46 SYNDROS SOLN 40 SYNERCID SOLR 10 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 tacrolimus caps 05mg 1mg 5mg 49 TACROLIMUS OINT 01 003 57
tadalafil (pah) tabs 20mg 25 tadalafil tabs 25mg 5mg 25 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 50 TAKHZYRO SOSY 50 TALTZ SOAJ 57 TALTZ SOSY 57 TALZENNA CAPS 025mg 05mg 075mg
1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 47 taperdex 12-day tbpk 42 taperdex 6-day tbpk 42 taperdex 7-day tbpk 42 targadox tabs 10 TARGRETIN GEL 56 tarina 24 fe tabs 44 tarina fe 120 eq tabs 44 TARPEYO CPDR 42 TASIGNA CAPS 50mg 150mg 200mg 18 TAVALISSE TABS 100mg 150mg 22 TAVNEOS CAPS 50 taysofy caps 44 tazarotene crea 57 tazarotene foam 57 tazicef solr injection 10 tazicef solr intravenous 2gm 6gm 10 TAZORAC CREA 57 TAZORAC GEL 005 01 57 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 52 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TEFLARO SOLR INTRAVENOUS 10 TEGSEDI SOSY 50 telmisartan tabs 20mg 40mg 80mg 25 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 25 TEMAZEPAM CAPS 75mg 15mg 225mg
30mg 31 temsirolimus soln 18 tencon tabs 27 TENIPOSIDE SOLN 18 TENIVAC INJ 52 tenofovir disoproxil fumarate tabs 13
92 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TEPADINA SOLR 18 TEPEZZA SOLR 39 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 20 terbutaline sulfate tabs 25mg 5mg 20 terconazole crea 53 terconazole supp 53 TERIPARATIDE (RECOMBINANT) SOPN
46 testosterone cypionate soln 100mgml
200mgml 42 testosterone enanthate soln 42 testosterone gel 1 162
2025mg125gm 405mg25gm 10mgact 42
testosterone soln 42 tetrabenazine tabs 125mg 25mg 32 TETRACAINE HCL SOLN 40 tetracycline hcl caps 250mg 500mg 10 texacort soln 55 TEZSPIRE SOSY 51 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 57 theophylline er tb12 100mg 200mg
300mg 450mg 57 theophylline er tb24 400mg 600mg 57 theophylline soln 57 THIOLA EC TBEC 100mg 300mg 50 THIOLA TABS 50 thioridazine hcl tabs 10mg 25mg 50mg
100mg 35 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 35 THYROGEN SOLR 50 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
30 TIBSOVO TABS 18 TICOVAC SUSY 52 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 32 tilia fe tabs 44 timolol maleate (once-daily) soln 39 timolol maleate pf soln 39
TIMOLOL MALEATE SOLG 025 05 39 timolol maleate soln 025 05 39 timolol maleate tabs 5mg 10mg 20mg 23 tinidazole tabs 11 tiopronin tabs 50 TIS-U-SOL SOLN 50 TIVDAK SOLR 18 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 tizanidine hcl caps 20 tizanidine hcl tabs 20 TOBI PODHALER CAPS 51 TOBRADEX OINT 39 TOBRADEX ST SUSP 39 tobramycin nebu 300mg4ml 300mg5ml 51 tobramycin soln 38 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 39 TOBREX OINT 38 tofranil tabs 10mg 25mg 50mg 35 tolazamide tabs 250mg 500mg 45 tolbutamide tabs 45 tolcapone tabs 31 tolmetin sodium caps 27 tolmetin sodium tabs 27 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 57 tolterodine tartrate tabs 57 tolvaptan tabs 15mg 30mg 36 TOPEX TOPICAL ANESTHETIC AERO 56 topicort crea 005 025 55 topicort gel 55 topicort oint 55 topiramate cpsp 15mg 25mg 30 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 30 topiramate tabs 25mg 50mg 100mg
200mg 30 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
36 TPN ELECTROLYTES CONC
INTRAVENOUS 37 TRACLEER TBSO 51 TRADJENTA TABS 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 93
tramadol hcl er (biphasic) tb24 100mg 200mg 300mg 28
tramadol hcl er cp24 100mg 150mg 200mg 300mg 28
tramadol hcl er tb24 100mg 200mg 300mg 28
tramadol hcl soln 28 tramadol hcl tabs 50mg 100mg 28 tramadol-acetaminophen tabs 28 trandolapril tabs 1mg 2mg 4mg 25 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 21 tranexamic acid tabs 21 tranylcypromine sulfate tabs 35 TRAVASOL SOLN INTRAVENOUS 36 travoprost (bak free) soln 39 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 150mg 300mg 35 trazodone hcl tabs 50mg 100mg 35 TRECATOR TABS 11 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 57 TREMFYA SOSY 57 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 51 tretinoin caps 18 tretinoin crea 0025 005 01 56 tretinoin gel 001 0025 005 56 tretinoin microsphere gel 004 01 56 tretinoin microsphere pump gel 004
01 56 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 28 triamcinolone acetonide aers 55 triamcinolone acetonide crea 0025
01 05 55 triamcinolone acetonide lotn 0025 01
55 triamcinolone acetonide oint 0025
005 01 05 55 triamcinolone acetonide pste 55 triamcinolone acetonide susp 42 triamterene caps 50mg 100mg 36 triamterene-hctz caps 36 triamterene-hctz tabs 36 trianex oint 55 triazolam tabs 0125mg 025mg 31 TRICITRATES SOLN 35 triderm crea 01 05 55
trientine hcl caps 41 tri-estarylla tabs 44 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 35 trifluridine soln 38 trihexyphenidyl hcl soln 31 trihexyphenidyl hcl tabs 2mg 5mg 31 TRIKAFTA TBPK 51 tri-legest fe tabs 44 tri-lo-estarylla tabs 44 tri-lo-sprintec tabs 44 trilyte solr 41 trimethobenzamide hcl caps 40 TRIMETHOPRIM TABS 13 tri-mili tabs 44 trimipramine maleate caps 25mg 50mg
100mg 35 TRINESSA (28) TABS 44 TRINTELLIX TABS 5mg 10mg 20mg 35 tri-nymyo tabs 44 tri-previfem tabs 44 TRIPTODUR SRER 45 TRISENOX
SOLN 18 tri-sprintec tabs 44 tritocin oint 55 TRIUMEQ PD TBSO 13 TRIUMEQ TABS 13 trivora (28) tabs 44 tri-vylibra lo tabs 44 tri-vylibra tabs 44 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 30 TROPHAMINE SOLN INTRAVENOUS 36 trospium chloride er cp24 57 trospium chloride tabs 57 TRULANCE TABS 41 TRUMENBA SUSY 52 TRUSELTIQ (100MG DAILY DOSE) CPPK
18 TRUSELTIQ (125MG DAILY DOSE) CPPK
18 TRUSELTIQ (50MG DAILY DOSE) CPPK
18 TRUSELTIQ (75MG DAILY DOSE) CPPK
18
94 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 52 TYBOST TABS 13 tydemy tabs 44 tylenol with codeine 3 tabs 28 tylenol with codeine 4 tabs 28 TYMLOS SOPN 46 TYPHIM VI SOLN 52 TYPHIM VI SOSY 52 TYVASO REFILL SOLN 51 TYVASO STARTER SOLN 51
U UBRELVY TABS 50mg 100mg 30 UDENYCA SOSY 22 UKONIQ TABS 18 ULTOMIRIS SOLN 50 UMECTA MOUSSE FOAM 57 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
UNITUXIN SOLN 18 UPTRAVI SOLR 51 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 51
UPTRAVI TBPK 51 UREA CREA 39 57 UREA LOTN 40 57 UREA-C40 LOTN 57 urecholine tabs 5mg 10mg 25mg 50mg 20 uredeb crea 57 URETRON DS TABS 13 URIN DS TABS 13 ursodiol caps 200mg 400mg 41 ursodiol caps 300mg 41 ursodiol tabs 250mg 500mg 41 URYL TABS 13 USTELL CAPS 13 UTICAP CAPS 13 UTIRA-C TABS 13 UTRONA-C TABS 13
V VABYSMO SOLN 39 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 57 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 30 valproic acid caps 30 valproic acid soln 30 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
25 valsartan-hydrochlorothiazide tabs 25 VALTOCO 10 MG DOSE LIQD 30 VALTOCO 15 MG DOSE LQPK 30 VALTOCO 20 MG DOSE LQPK 30 VALTOCO 5 MG DOSE LIQD 30 vanatol lq soln 28 vancomycin hcl caps 10 vancomycin hcl solr 250mg5ml 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 vancomycin hcl solr intravenous 5gm
750mg 10 VANDAZOLE GEL 53 VANOXIDE-HC LOTN 55 VANTAS KIT 18 VAQTA SUSP 52 varenicline tartrate misc 19 varenicline tartrate tabs 05mg 1mg 19 VARIVAX INJ 52 VARIZIG SOLN 52 VASCEPA CAPS 1gm 22 VAXCHORA SUSR 53 vecamyl tabs 24 VECTICAL OINT 57 VEKLURY SOLN 13 VEKLURY SOLR 13 VELCADE SOLR 18 velivet tabs 44 VELPHORO CHEW 36 VELTASSA PACK 84gm 168gm 252gm
36 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 18 VENCLEXTA TABS 10mg 18 VENCLEXTA TABS 50mg 100mg 18
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 95
venlafaxine hcl er cp24 375mg 75mg 150mg 35
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg 35
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg 35
VENTAVIS SOLN 10mcgml 20mcgml 52 verapamil hcl er tbcr 120mg 180mg 240mg
24 verapamil hcl soln 24 verapamil hcl tabs 40mg 80mg 120mg 24 veripred 20 soln 42 VERKAZIA EMUL 39 VERSACLOZ SUSP 35 VERZENIO TABS 50mg 100mg 150mg
200mg 18 vestura tabs 44 VIBERZI TABS 75mg 100mg 41 vicodin es tabs 28 vicodin hp tabs 28 vicodin tabs 28 VICTOZA SOPN 45 VIDEX EC CPDR 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 44 vigabatrin pack 30 vigabatrin tabs 30 VIIBRYD STARTER PACK KIT 35 VIIBRYD TABS 10mg 20mg 40mg 35 VIJOICE TBPK 50 VILTEPSO SOLN 50 VIMIZIM SOLN 38 VIMPAT SOLN 30 vinblastine sulfate soln 18 vincasar pfs soln 18 vincristine sulfate soln 18 vinorelbine tartrate soln 18 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 47 VITRAKVI CAPS 25mg 100mg 18 VITRAKVI SOLN 18 VIVITROL SUSR 32 VIZIMPRO TABS 15mg 30mg 45mg 18 VOCABRIA TABS 13
VONJO CAPS 18 VORAXAZE SOLR 47 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 18 VOXZOGO SOLR 04mg 056mg 12mg 50 VPRIV SOLR 38 VRAYLAR CAPS 15mg 3mg 45mg 6mg
35 VRAYLAR CPPK 35 VUMERITY (STARTER) CPDR 50 VUMERITY CPDR 50 vyfemla tabs 44 vylibra tabs 44 VYNDAMAX CAPS 24 VYNDAQEL CAPS 24 VYONDYS 53 SOLN 50 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 28 VYVGART SOLN 50 VYXEOS SUSR 18
W WAKIX TABS 445mg 178mg 28 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 21 WATER FOR IRRIGATION STERILE
SOLN 50 WELIREG TABS 18 wixela inhub aepb 51 wymzya fe chew 44 WYNZORA CREA 55
X XALKORI CAPS 200mg 250mg 18 XARELTO STARTER PACK TBPK 21 XARELTO SUSR 21 XARELTO TABS 25mg 10mg 15mg
20mg 21 XATMEP SOLN 18 XCOPRI (250 MG DAILY DOSE) TBPK 30 XCOPRI (350 MG DAILY DOSE) TBPK 30 XCOPRI TABS 200mg 30 XCOPRI TABS 50mg 100mg 150mg 30 XCOPRI TBPK 30 XCOPRI TBPK 14x125mg amp 14x25mg 30
96 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
XELJANZ SOLN 48 XELJANZ TABS 5mg 10mg 48 XELJANZ XR TB24 11mg 22mg 48 XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 50 XERMELO TABS 40 XGEVA SOLN 47 XIFAXAN TABS 200mg 550mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 51 XOLAIR SOSY 75mg05ml 150mgml 51 XOSPATA TABS 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 18 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 18 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 XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 44 XUREA CREA 57 XURIDEN PACK 50 xylocaine dental soln 50 XYREM SOLN 32 XYWAV SOLN 32
Y YERVOY SOLN 19 YF-VAX INJ 53 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 39 yuvafem tabs 45
Z zafemy ptwk 44
zafirlukast tabs 10mg 20mg 51 zaleplon caps 5mg 10mg 31 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 44 zarontin soln 30 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 28 ZEJULA CAPS 19 ZELAPAR TBDP 31 ZELBORAF TABS 19 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
57 ZENPEP CPEP 38 zenzedi tabs 25mg 5mg 75mg 10mg
15mg 20mg 30mg 28 ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
32 ZEPOSIA CAPS 32 ZEPOSIA STARTER KIT CPPK 32 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERUVIA PTCH 56 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 51 ZIONODIL 100 LOTN 56 ZIONODIL LOTN 56 ziprasidone hcl caps 20mg 40mg 60mg
80mg 35 ziprasidone mesylate solr 35 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZOKINVY CAPS 50mg 75mg 50 zoledronic acid conc 47 zoledronic acid soln 47 ZOLINZA CAPS 19 zolmitriptan soln 30 zolmitriptan tabs 30 zolmitriptan tbdp 30 zolpidem tartrate er tbcr 625mg 125mg 31 zolpidem tartrate subl 175mg 35mg 31 zolpidem tartrate tabs 5mg 10mg 31 zonisamide caps 25mg 50mg 100mg 30 ZORBTIVE SOLR 46
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 97
ZORTRESS TABS 49 ZOSTAVAX SUSR 53 zovia 135 (28) tabs 44 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19
ZYKADIA TABS 19 ZYNLONTA SOLR 19 ZYPREXA RELPREVV SUSR 35 ZYTIGA TABS 19
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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)
682896130 062022
This formulary was updated on 060122 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
kporgseniorrx Please recycle
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 3
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 2022 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 2022 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 2022 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
4 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 5
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 2022 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 59 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg CIPRODEX) and generic drugs are listed in lower-case italics (eg amoxicillin) 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 2022 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
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 8 bull Kaiser Permanente 2022 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 azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP BICILLIN L-A SUSY cefaclor caps
Drug Name RequirementsLimits
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 intravenous 1gm 2gm 10gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 6gm HI
ceftazidime solr intravenous HI CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 750mg HI
cefuroxime sodium solr intravenous 15gm HI
cephalexin caps cephalexin susr cephalexin tabs chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w 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 2022 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
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 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 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
Drug Name RequirementsLimits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs erythromycin tbec FETROJA SOLR NDS 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 LYMEPAK 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
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium 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 10 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs 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 streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO suprax chew SYNERCID SOLR
Drug Name RequirementsLimits
targadox tabs MO tazicef solr injection HI tazicef solr intravenous 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
vancomycin hcl caps vancomycin hcl solr 250mg5ml vancomycin hcl solr intravenous 1gm 10gm 500mg HI
vancomycin hcl solr intravenous 5gm 750mg
XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ANTIFUNGALS AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS 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
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 2022 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS nystatin susp nystatin tabs 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 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 SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS
Drug Name RequirementsLimits
mefloquine hcl tabs metronidazole caps METRONIDAZOLE SOLN INTRAVENOUS 500mg100ml HI
metronidazole tabs nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs quinine sulfate caps NDS 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 APRETUDE SUER 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 DELSTRIGO TABS MO DESCOVY TABS 200-25mg MO DESCOVY TABS 120-15mg MO didanosine cpdr 200mg 250mg 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 12 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 PACK PANDS EPCLUSA TABS PANDS 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 LIVTENCITY TABS NDS lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO
Drug Name RequirementsLimits
maraviroc tabs 150mg 300mg MO MAVYRET PACK PANDS 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 oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEGASYS PROCLICK SOAJ 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN NDS PEGASYS SOSY NDS PEGINTRON KIT NDS PIFELTRO TABS MO 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
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 2022 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg MO sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS 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 PD TBSO MO TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEKLURY SOLN NDS VEKLURY SOLR NDS VEMLIDY TABS VIDEX EC CPDR 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
Drug Name RequirementsLimits
VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES 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 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg abiraterone acetate tabs 500mg NDS ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS NDS ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs arsenic trioxide soln NDS ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr
Drug Name RequirementsLimits
BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE SOLR BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS BESREMI SOSY NDS bexarotene caps NDS bicalutamide tabs 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 CAMCEVI PRSY CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR 50mg 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
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 2022 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
CYCLOPHOSPHAMIDE SOLN 2gm10ml 1gm5ml 500mg25ml
NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr 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 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 eulexin caps NDS
Drug Name RequirementsLimits
everolimus tabs 25mg 5mg 75mg 10mg NDS
everolimus tbso 2mg 3mg 5mg NDS EVOMELA SOLR NDS exemestane tabs EXKIVITY CAPS NDS FARYDAK CAPS 10mg 15mg 20mg LDNDS
FENSOLVI (6 MONTH) KIT 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 FYARRO SUSR 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 6000000unitml 10000000unitml
NDS
INTRON A SOLR 10000000unit 18000000unit 50000000unit 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 KIMMTRAK 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
lenalidomide caps 5mg 10mg 15mg 25mg NDS
Drug Name RequirementsLimits
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
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 TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA 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 2022 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
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 methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS nelarabine soln 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 120mg12ml 240mg24ml 40mg4ml
NDS
OPDUALAG SOLN NDS oxaliplatin soln oxaliplatin solr paclitaxel conc PACLITAXEL PROTEIN-BOUND PART SUSR 100 MG NDS
PADCEV SOLR 20mg 30mg NDS
Drug Name RequirementsLimits
paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEMFEXY SOLN 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 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
SCEMBLIX TABS 20mg 40mg NDS SIKLOS TABS NDS SOLTAMOX SOLN
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
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 05mg 075mg 1mg NDS
tamoxifen citrate tabs 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 TIVDAK SOLR 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 NDS
TRODELVY SOLR NDS
Drug Name RequirementsLimits
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 UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln 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
VONJO CAPS NDS VOTRIENT TABS NDS VYXEOS SUSR NDS WELIREG TABS 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
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 2022 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
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 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 ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO chlordiazepoxide-clidinium caps dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate oral soln MO glycopyrrolate pf sosy glycopyrrolate soln injection glycopyrrolate tabs 1mg 2mg MO
Drug Name RequirementsLimits
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 RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO varenicline tartrate misc MO varenicline tartrate tabs 05mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA FLEQSUVY SUSP NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs 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
Drug Name RequirementsLimits
albuterol sulfate er tb12 4mg 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcgact MONDS
albuterol sulfate nebu 0083 25mg05ml 063mg3ml 125mg3ml
PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY ipratropium-albuterol soln PAMO isoproterenol hcl soln LEVALBUTEROL HCL NEBU 125mg05ml 125mg3ml 031mg3ml 063mg3ml
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 SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS icatibant acetate 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 2022 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
OXBRYTA TABS NDS OXBRYTA TBSO NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS 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 BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln NDS enoxaparin sodium sosy 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
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 NDS LOVENOX SOSY 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg 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 SUSR NDS XARELTO TABS 25mg 10mg 15mg 20mg MO
HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
EPOGEN SOLN PANDS FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
PROCRIT SOLN 20000unitml 40000unitml PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RELEUKO SOLN 300mcgml 480mcg16ml NDS
RELEUKO SOSY 300mcg05ml 480mcg08ml NDS
RETACRIT SOLN 20000unitml PANDS RETACRIT SOLN PANDS TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS 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 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
Drug Name RequirementsLimits
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 150mg MO fenofibrate micronized caps 43mg 67mg 130mg 134mg 200mg
MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg 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
lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
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 SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 1gm MO BETA-ADRENERGIC BLOCKING 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 2022 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
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
ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
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
nadololbendroflumethiazide 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
Drug Name RequirementsLimits
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 cartia xt cp24 120mg 180mg 240mg 300mg MO
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 40mg 80mg 120mg MO
CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR SOLN MO CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln 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 lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy
Drug Name RequirementsLimits
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 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
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 2022 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
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
captopril-hydrochlorothiazide 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
quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
Drug Name RequirementsLimits
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO 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 dipyridamole tabs 25mg 50mg 75mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ascomp-codeine caps NDS benzhydrocodone-acetaminophen tabs NDS
bupap tabs 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 NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS dvorah tabs 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
Drug Name RequirementsLimits
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
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 hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd 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 NDS indomethacin caps indomethacin er cpcr indomethacin sodium solr ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lorcet hd tabs NDS lorcet plus 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln NDS meperidine hcl tabs 50mg NDS methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl tabs 5mg 10mg NDS MORPHINE SULFATE (CONCENTRATE) SOLN NDS
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 tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln 10mgml 20mgml NDS
nalfon tabs nalocet tabs NDS naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs
Drug Name RequirementsLimits
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 75-300mg 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 relafen ds tabs NDS SALSALATE TABS SUBSYS LIQD 1200mcg 1600mcg PANDS
sulindac tabs tencon tabs tolmetin sodium caps tolmetin sodium tabs
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 soln 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 tabs NDS vicodin es tabs NDS vicodin hp tabs NDS zebutal caps ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS amphetamine er suer NDS 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 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
evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS
Drug Name RequirementsLimits
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
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS procentra soln NDS relexxii tbcr NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
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
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 2022 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
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
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 EPRONTIA SOLN 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 lacosamide tabs 50mg 100mg 150mg 200mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
Drug Name RequirementsLimits
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
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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg 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 VALTOCO 15 MG DOSE LQPK VALTOCO 20 MG DOSE LQPK VALTOCO 5 MG DOSE LIQD vigabatrin pack LDNDS vigabatrin tabs NDS VIMPAT SOLN XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200mg NDS XCOPRI TBPK 14x125mg amp 14x25mg
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ PA AJOVY SOSY PA almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs
Drug Name RequirementsLimits
ergotamine-caffeine tabs FROVATRIPTAN SUCCINATE TABS
naratriptan hcl tabs NURTEC TBDP NDS QULIPTA TABS 10mg 30mg 60mg NDS
rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs UBRELVY TABS 50mg 100mg NDS zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl soln MO amantadine hcl tabs MO APOKYN SOCT NDS apomorphine hcl 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
EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg 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 2022 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
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
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
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 intensol conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS droperidol soln estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
Drug Name RequirementsLimits
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP PANDS 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 nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs seconal caps TEMAZEPAM CAPS 75mg 15mg 225mg 30mg 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS tetrabenazine tabs 125mg 25mg MO
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
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 1mg 2mg NDS
OCREVUS SOLN PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
Drug Name RequirementsLimits
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 ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS OPIATE ANTAGONISTS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
LUCEMYRA TABS NDS naloxone hcl liqd naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
VIVITROL SUSR NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg 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 2022 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
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 conc 30mgml 100mgml MO
chlorpromazine hcl soln chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
CITALOPRAM HYDROBROMIDE CAPS MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
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 HAFYERA SUSY INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 150mg 300mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
LITHIUM CARBONATE TABS MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
LYBALVI TABS NDS maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
Drug Name RequirementsLimits
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 susp MO paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps 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
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
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 2022 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
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 CAPS 150mg 200mg MO
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
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 MO trazodone hcl tabs 150mg 300mg 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
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 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 TRICITRATES SOLN AMMONIA DETOXICANTS carglumic acid tbso NDS constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN DEXTROSE SOLN INTRAVENOUS 5 10 HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE 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
Drug Name RequirementsLimits
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI furosemide tabs 20mg 40mg 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN tolvaptan tabs 15mg 30mg 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 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
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 2022 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate tabs MO CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
DEXTROSE-NACL SOLN INTRAVENOUS 25-045 5-02 5-045 5-09
HI
DEXTROSE-NACL SOLN INTRAVENOUS 10-02 10-045
HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 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 PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
Drug Name RequirementsLimits
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 10meq100ml 20meq100ml 40meq100ml 2meqml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN 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 ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME 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 38 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin oint bacitracin-polymyxin b oint bleph-10 soln chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin 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 paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln
Drug Name RequirementsLimits
sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ANTI-INFLAMMATORY AGENTS bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
CEQUA SOLN CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO cyclosporine emul MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO difluprednate emul MO flac oil 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
ILUVIEN IMPL ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint 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 2022 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
RESTASIS EMUL MO RESTASIS MULTIDOSE EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
VERKAZIA EMUL NDS YUTIQ IMPL ANTIALLERGIC AGENTS azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
betaxolol hcl soln MO bimatoprost soln MO brimonidine tartrate soln 015 02 MO
brinzolamide susp MO carteolol hcl soln MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
Drug Name RequirementsLimits
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO timolol maleate (once-daily) soln MO timolol maleate pf soln MO TIMOLOL MALEATE SOLG 025 05 MO
timolol maleate soln 025 05 MO
travoprost (bak free) 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 SUSVIMO (IMPLANT 1ST FILL) SOLN
SUSVIMO (IMPLANT REFILL) SOLN
TEPEZZA SOLR NDS VABYSMO SOLN LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lidocaine viscous hcl soln MO proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
balsalazide disodium caps MO colazal caps 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 OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS aprepitant caps PANDS dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl sosy ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy
Drug Name RequirementsLimits
SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS trimethobenzamide hcl caps PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc 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 famotidine (pf) soln 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 omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate 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 2022 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS 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 IBSRELA TABS NDS LIVMARLI SOLN NDS lubiprostone caps 8mcg 24mcg MO metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS TRULANCE TABS 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
Drug Name RequirementsLimits
clovique caps NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs deferasirox tbso deferiprone tabs 500mg 1000mg NDS
deferoxamine mesylate solr FERRIPROX SOLN LDNDS FERRIPROX TABS LDNDS FERRIPROX TWICE-A-DAY TABS NDS
penicillamine caps NDS penicillamine tabs NDS trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP ALKINDI SPRINKLE CPSP 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs 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 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp 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 10mg5ml 20mg5ml 25mg5ml 5mg5ml
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 SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TARPEYO CPDR NDS triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
danazol caps 50mg 100mg 200mg MO
Drug Name RequirementsLimits
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 405mg25gm 10mgact
MO
testosterone soln 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 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 enpresse-28 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 2022 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
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 jasmiel tabs MO JOLIVETTE 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
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
Drug Name RequirementsLimits
levora 01530 (28) 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 24 fe tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA 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 nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO nylia 135 tabs MO nylia 777 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 44 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 taysofy caps 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 wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135 (28) tabs MO
Drug Name RequirementsLimits
DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
AFREZZA POWD 90x8 UNIT amp 90x12 UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD 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 glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO HUMALOG KWIKPEN SOPN MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
JARDIANCE TABS 10mg 25mg MO KORLYM TABS LDNDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO metformin hcl er tb24 500mg 750mg 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 2022 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
OZEMPIC (2 MGDOSE) SOPN MO pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO tolazamide tabs 250mg 500mg MO tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
depo-estradiol oil dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
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 MO
Drug Name RequirementsLimits
006mg24hr 0075mg24hr 01mg24hr estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO fyavolv tabs MO jinteli tabs MO lopreeza tabs MO lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO prefest tabs MO PREMARIN SOLR raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PANDS CORTROPHIN GEL PANDS desmopressin ace spray refrig soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln desmopressin acetate tabs 01mg 02mg MO
SKYTROFA CART 3mg 36mg 43mg 52mg 63mg 76mg 91mg 11mg 133mg
NDS
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO 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 progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR NDS
Drug Name RequirementsLimits
EGRIFTA SV SOLR NDS GENOTROPIN CART 12mg PANDS GENOTROPIN MINIQUICK PRSY 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
HUMATROPE CART 6mg 12mg 24mg PANDS
HUMATROPE SOLR PANDS INCRELEX SOLN NDS LANREOTIDE ACETATE SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
octreotide acetate soln 50mcgml 100mcgml 200mcgml
octreotide acetate soln 500mcgml 1000mcgml
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 60mg02ml 90mg03ml 120mg05ml
NDS
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 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 2022 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 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 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
Drug Name RequirementsLimits
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 BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 70mg MO alendronate sodium tabs 5mg 10mg 35mg 40mg MO
EVENITY SOSY NDS IBANDRONATE SODIUM SOLN ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr 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 CIBINQO TABS 50mg 100mg 200mg NDS
CIMZIA KIT PANDS CIMZIA PREFILLED PSKT PANDS CIMZIA STARTER KIT PSKT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
INFLIXIMAB SOLR INTRAVENOUS HI
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 RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 15mg 30mg 45mg NDS
SIMPONI ARIA SOLN NDS
Drug Name RequirementsLimits
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 ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
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
ZORTRESS TABS PA MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BERINERT KIT INTRAVENOUS HI betaine powd NDS 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
Drug Name RequirementsLimits
CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENJAYMO SOLN 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 HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ONPATTRO SOLN NDS 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
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 PYRUKYND TABS 5mg 20mg 50mg NDS
PYRUKYND TAPER PACK TBPK NDS
RECORLEV TABS NDS REZUROCK TABS NDS
Drug Name RequirementsLimits
RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln 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 STERILE WATER FOR IRRIGATION SOLN
TAKHZYRO SOLN NDS TAKHZYRO SOSY NDS TAVNEOS CAPS NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR NDS tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VIJOICE TBPK NDS VILTEPSO SOLN NDS VOXZOGO SOLR 04mg 056mg 12mg NDS
VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS VYVGART SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg 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 2022 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 100mg067ml 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 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 ADVAIR HFA AERO 230-21mcgact MO
ADVAIR HFA AERO 45-21mcgact 115-21mcgact MO
Drug Name RequirementsLimits
ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS HI
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
DALIRESP TABS 250mcg 500mcg MO
FLOVENT HFA AERO MO fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PULMICORT FLEXHALER AEPB
SYMBICORT AERO TEZSPIRE SOSY NDS wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg 1000mcg 1200mcg 1400mcg 1600mcg
NDS
UPTRAVI TBPK NDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS HI
GAMUNEX-C SOLN INJECTION HI HYPERHEP B SOLN HYPERHEP B SOSY HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 1gm20ml 2gm20ml
HI
PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
VARIZIG SOLN TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP KINRIX SUSY QUADRACEL SUSP TDVAX SUSP
Drug Name RequirementsLimits
TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP BOOSTRIX SUSY 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 SOLN MENQUADFI SOLN MENVEO SOLR PEDIARIX SUSY PEDVAX HIB SUSP PENTACEL SUSR PREHEVBRIO SUSP PA PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TICOVAC SUSY TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN TYPHIM VI SOSY VAQTA SUSP VARIVAX INJ
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 2022 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint 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 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 clindamycin phosphate soln MO clindamycin phosphate swab MO clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn econazole nitrate crea ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA
Drug Name RequirementsLimits
gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham mafenide acetate pack malathion lotn metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea mupirocin oint naftifine hcl crea naftifine hcl gel neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ovide lotn oxiconazole nitrate crea permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 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
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
Drug Name RequirementsLimits
clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT 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 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
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO FLURANDRENOLIDE CREA 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 2022 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
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 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 prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO
Drug Name RequirementsLimits
psorcon crea MO RADIAURA CREA NDS texacort soln MO topicort crea 005 025 MO topicort gel MO topicort oint 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 VANOXIDE-HC LOTN WYNZORA CREA NDS ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
HYDROCORTISONE ACE-PRAMOXINE SUPP NDS
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 LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS 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
TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS 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
Drug Name RequirementsLimits
adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ADBRY SOSY NDS ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
azelaic acid gel MO AZELEX CREA MO 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
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA 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 KORSUVA SOLN NDS LACTIC ACID LOTN
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 2022 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
OPZELURA CREA 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 SHAM SALICYLIC ACID-CLEANSER KIT
SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SKYRIZI PEN SOAJ SKYRIZI SOSY STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
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 TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS
Drug Name RequirementsLimits
VECTICAL OINT MO XUREA CREA zenatane caps 10mg 20mg 30mg 40mg NDS
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 calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS
58 bull Kaiser Permanente 2018 Defined Standard Comprehensive Formulary
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 59
Index of Drugs
A abacavir sulfate soln 11 abacavir sulfate tabs 11 abacavir sulfate-lamivudine tabs 11 abacavir-lamivudine-zidovudine tabs 11 ABILIFY MAINTENA PRSY 300mg 400mg
32 ABILIFY MAINTENA SRER 300mg 400mg
32 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
abiraterone acetate tabs 250mg 14 abiraterone acetate tabs 500mg 14 ABRAXANE SUSR 14 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 56 acamprosate calcium tbec 25 acarbose tabs 25mg 50mg 100mg 44 accutane caps 10mg 20mg 30mg 40mg 56 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 26 acetaminophen-codeine soln 26 acetaminophen-codeine tabs 26 acetazolamide er cp12 39 acetazolamide sodium solr 39 acetazolamide tabs 125mg 250mg 39 ACETIC ACID SOLN 39 49 acetylcysteine soln 10 20 47 acitretin caps 10mg 175mg 25mg 56 ACTEMRA ACTPEN SOAJ 47 ACTEMRA SOSY 47 ACTHAR GEL 46 ACTHIB SOLR 52 ACTIMMUNE SOLN 49 acyclovir caps 11 acyclovir oint 53 acyclovir sodium soln intravenous 11 acyclovir susp 11
acyclovir tabs 400mg 800mg 11 ADACEL SUSP 52 ADAGEN SOLN 37 ADAKVEO SOLN 20 ADAPALENE CREA 56 adapalene gel 01 03 56 adapalene pads 56 adapalene soln 56 adapalene-benzoyl peroxide gel 56 ADAPALENE-BENZOYL PEROXIDE PADS
56 ADBRY SOSY 56 adderall tabs 28 adefovir dipivoxil tabs 11 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 51 adenosine soln 24 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 230-21mcgact 51 ADVAIR HFA AERO 45-21mcgact 115-
21mcgact 51 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 14 AFREZZA POWD 90x8 UNIT amp 90x12 UNIT
44 AJOVY SOAJ 30 AJOVY SOSY 30 ala-cort crea 1 25 54 albendazole tabs 8 albuterol sulfate er tb12 4mg 8mg 20 ALBUTEROL SULFATE HFA AERS
108mcgact 20 albuterol sulfate nebu 0083
25mg05ml 063mg3ml 125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 54 alclometasone dipropionate oint 54 ALCOHOL PREP PADS 35 ALDURAZYME SOLN 37 ALECENSA CAPS 14
60 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
alendronate sodium soln 47 alendronate sodium tabs 5mg 10mg
35mg 40mg 47 alendronate sodium tabs 70mg 47 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 41 ALKINDI SPRINKLE CPSP 1mg 2mg 5mg
41 allopurinol sodium solr 47 allopurinol tabs 100mg 300mg 47 allzital tabs 26 almotriptan malate tabs 30 alogliptin benzoate tabs 625mg 125mg
25mg 44 ALOGLIPTIN-METFORMIN HCL TABS 44 alogliptin-pioglitazone tabs 44 ALOSETRON HCL TABS 05mg 1mg 40 alprazolam er tb24 05mg 1mg 2mg 3mg
31 alprazolam intensol conc 31 alprazolam tabs 025mg 05mg 1mg 2mg
31 alprazolam tbdp 025mg 05mg 1mg 2mg
31 ALTACAINE SOLN 39 ALTAFRIN SOLN 39 altavera tabs 42 ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 51 alyacen 135 tabs 42 alyq tabs 25 amabelz tabs 45 amantadine hcl caps 30 amantadine hcl soln 30 amantadine hcl tabs 30 AMBISOME SUSR INTRAVENOUS 10 ambrisentan tabs 51 amcinonide crea 54 amcinonide lotn 54 amcinonide oint 54 amethia lo tabs 42 amethia tabs 42 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 36
amiloride-hydrochlorothiazide tabs 36 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 57 amiodarone hcl soln 24 amiodarone hcl tabs 100mg 200mg
400mg 24 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 33 amlodipine besy-benazepril hcl caps 23 amlodipine besylate tabs 25mg 5mg
10mg 23 amlodipine besylate-valsartan tabs 23 amlodipine-atorvastatin tabs 23 amlodipine-olmesartan tabs 23 amlodipine-valsartan-hctz tabs 23 ammonium lactate crea 56 ammonium lactate lotn 56 amnesteem caps 10mg 20mg 40mg 56 AMONDYS 45 SOLN 49 amoxapine tabs 25mg 50mg 100mg
150mg 33 amoxicill-clarithro-lansopraz misc 40 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8 amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 28 amphetamine sulfate tabs 5mg 10mg 28 amphetamine-dextroamphet er cp24 28 amphetamine-dextroamphetamine tabs 28 amphotericin b solr intravenous 10 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 42 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 55 anastrozole tabs 14
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 61
ANDRODERM PT24 2mg24hr 4mg24hr 42
antabuse tabs 250mg 500mg 25 anusol-hc crea 54 apap-caff-dihydrocodeine tabs 26 apexicon e crea 54 APLENZIN TB24 174mg 348mg 522mg 33 APOKYN SOCT 30 apomorphine hcl soct 30 apraclonidine hcl soln 39 aprepitant caps 40 APRETUDE SUER 11 apri tabs 42 APTIOM TABS 200mg 400mg 600mg
800mg 28 APTIVUS CAPS 11 APTIVUS SOLN 11 ARALAST NP SOLR INTRAVENOUS 51 aranelle tabs 42 ARANESP (ALBUMIN FREE) SOLN
60mcgml 100mcgml 200mcgml 21 ARANESP (ALBUMIN FREE) SOSY
60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 21
ARCALYST SOLR 49 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 49 ARIKAYCE SUSP 8 aripiprazole soln 33 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 33 aripiprazole tbdp 10mg 15mg 33 ARISTADA INITIO PRSY 33 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 33
armodafinil tabs 50mg 150mg 200mg 250mg 28
arsenic trioxide soln 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 49 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 52 ascomp-codeine caps 26 asenapine maleate subl 25mg 5mg 10mg
33
ashlyna tabs 42 ASMANEX HFA AERO 100mcgact
200mcgact 51 ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 48 ASTAGRAF XL CP24 05mg 1mg 48 atazanavir sulfate caps 150mg 200mg
300mg 11 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 31 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 22 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 39 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 32 aubra eq tabs 42 AUGMENTIN SUSR 8 AURYXIA TABS 36 AUSTEDO TABS 6mg 9mg 12mg 31 AVASTIN SOLN 14 AVC VAGINAL CREA 53 aviane tabs 42 AVITA CREA 56 AVITA GEL 56 AVONEX KIT 32 AVONEX PEN AJKT 32 AVONEX PREFILLED PSKT 32 AVSOLA SOLR 47 aygestin tabs 46 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 48 azathioprine sodium solr 48 azathioprine tabs 48 azelaic acid gel 56 azelastine hcl soln 005 01 015 39 azelastine-fluticasone susp 39 AZELEX CREA 56 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
62 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
B bacitracin oint 38 bacitracin solr 8 bacitracin-polymyxin b oint 38 bacitra-neomycin-polymyxin-hc oint 38 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 53 BAFIERTAM CPDR 32 balsalazide disodium caps 40 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 42 BANZEL SUSP 28 BANZEL TABS 200mg 400mg 28 BAQSIMI ONE PACK POWD 44 BAQSIMI TWO PACK POWD 44 BARACLUDE SOLN 11 BAVENCIO SOLN 14 BCG VACCINE SOLR 14 BD INSULIN SYR ULTRAFINE II MISC 35 BD INSULIN SYRINGE MISC 35 BD INSULIN SYRINGE UF MISC 35 BD PEN NEEDLE ORIGINAL UF MISC 35 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 32 BELEODAQ SOLR 14 BELRAPZO SOLN 14 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 14 BENDEKA SOLN 14 BENLYSTA SOAJ 48 BENLYSTA SOLR 48 BENLYSTA SOSY 48 BENZEPRO CREAMY WASH LIQD 53 BENZEPRO FOAMING CLOTHS MISC 53 benzhydrocodone-acetaminophen tabs 26 benzoyl perox-hydrocortisone lotn 54 BENZOYL PEROXIDE FORTE- HC LOTN
54 BENZOYL PEROXIDE GEL 53 benzoyl peroxide-erythromycin gel 53 benztropine mesylate soln 30 benztropine mesylate tabs 05mg 1mg
2mg 30 BEOVU SOLN 39 bepotastine besilate soln 39
BERINERT KIT INTRAVENOUS 49 beser lotn 54 BESPONSA SOLR 14 BESREMI SOSY 14 betaine powd 49 betamethasone dipropionate aug crea 54 betamethasone dipropionate aug gel 54 betamethasone dipropionate aug lotn 54 betamethasone dipropionate aug oint 54 betamethasone dipropionate crea 54 betamethasone dipropionate lotn 54 BETAMETHASONE DIPROPIONATE OINT
54 betamethasone sod phos amp acet susp 41 betamethasone valerate crea 54 betamethasone valerate foam 54 BETAMETHASONE VALERATE LOTN 54 BETAMETHASONE VALERATE OINT 54 BETASERON KIT 32 betaxolol hcl soln 39 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 19 bexarotene caps 14 BEXSERO SUSY 52 bicalutamide tabs 14 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICILLIN L-A SUSY 8 BIKTARVY TABS 11 bimatoprost soln 39 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23 bleomycin sulfate solr 14 bleph-10 soln 38 blephamide sop oint 38 BLEPHAMIDE SUSP 38 BLINCYTO SOLR 14 blisovi 24 fe tabs 42 blisovi fe 1530 tabs 42 BOOSTRIX SUSP 52 BOOSTRIX SUSY 52 BORTEZOMIB SOLR 14 bosentan tabs 51 BOSULIF TABS 100mg 400mg 500mg 14 BRAFTOVI CAPS 50mg 75mg 14 briellyn tabs 42 BRILINTA TABS 60mg 90mg 21
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 63
brimonidine tartrate soln 015 02 39 brinzolamide susp 39 BRIVIACT SOLN 28 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 28 bromfenac sodium (once-daily) soln 38 bromocriptine mesylate caps 30 bromocriptine mesylate tabs 30 BRONCHITOL CAPS 51 BROVANA NEBU 20 BRUKINSA CAPS 14 budesonide cpep 41 budesonide er tb24 41 budesonide susp 025mg2ml 05mg2ml
1mg2ml 51 bumetanide soln 36 bumetanide tabs 05mg 1mg 2mg 36 bupap tabs 26 bupivacaine hcl (pf) soln 49 bupivacaine hcl soln 49 BUPIVACAINE IN DEXTROSE SOLN 49 bupivacaine spinal soln 49 bupivacaine-epinephrine (pf) soln 49 bupivacaine-epinephrine soln 49 buprenorphine hcl subl 2mg 8mg 32 buprenorphine hcl-naloxone hcl film 32 buprenorphine hcl-naloxone hcl subl 32 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 32 bupropion hcl er (smoking det) tb12 33 bupropion hcl er (sr) tb12 100mg 150mg
200mg 33 bupropion hcl er (xl) tb24 150mg 300mg
450mg 33 bupropion hcl tabs 75mg 100mg 33 buspirone hcl tabs 5mg 10mg 31 buspirone hcl tabs 75mg 15mg 30mg 31 busulfan soln 14 butalbital-acetaminophen tabs 26 butalbital-apap-caff-cod caps 26 butalbital-apap-caffeine caps 26 butalbital-apap-caffeine tabs 26 butalbital-asa-caff-codeine caps 26 butalbital-aspirin-caffeine caps 26 butalbital-aspirin-caffeine tabs 26 butorphanol tartrate soln 26 BYLVAY (PELLETS) CPSP 200mcg
600mcg 41 BYLVAY CAPS 400mcg 1200mcg 41
C CABENUVA SUER 11 cabergoline tabs 30 CABLIVI KIT 21 CABOMETYX TABS 20mg 40mg 60mg 14 cafergot tabs 30 caffeine citrate soln 28 calcipotriene crea 56 calcipotriene oint 56 calcipotriene soln 56 calcipotriene-betameth diprop oint 54 calcipotriene-betameth diprop susp 54 calcitonin (salmon) soln 45 calcitrene oint 56 calcitriol caps 025mcg 05mcg 57 CALCITRIOL OINT 56 calcitriol soln 57 calcium acetate (phos binder) caps 37 calcium acetate tabs 37 CALCIUM GLUCONATE-NACL SOLN 37 CALQUENCE CAPS 14 CAMCEVI PRSY 14 camila tabs 42 camrese lo tabs 42 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 54 CAPLYTA CAPS 33 CAPRELSA TABS 100mg 300mg 14 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 25 CARAC CREA 56 carbamazepine chew 28 carbamazepine er cp12 100mg 200mg
300mg 28 carbamazepine er tb12 100mg 200mg
400mg 28 carbamazepine susp 28 carbamazepine tabs 28 carbidopa tabs 30 carbidopa-levodopa er tbcr 30 carbidopa-levodopa tabs 30 carbidopa-levodopa tbdp 30 carbidopa-levodopa-entacapone tabs 30 carbinoxamine maleate soln 13
64 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
carbinoxamine maleate tabs 13 carboplatin soln 14 carboprost tromethamine soln 45 CARDENE IV SOLN 23 carglumic acid tbso 35 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 14 CARNITOR SOLN 49 CARNITOR TABS 49 carteolol hcl soln 39 cartia xt cp24 120mg 180mg 240mg
300mg 23 carvedilol phosphate er cp24 10mg 20mg
40mg 80mg 23 carvedilol tabs 3125mg 625mg 125mg
25mg 23 caspofungin acetate solr intravenous 50mg
70mg 10 CAYSTON SOLR 51 caziant tabs 42 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 intravenous 1gm 2gm
10gm 8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 6gm 8 ceftazidime solr intravenous 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 750mg 8 cefuroxime sodium solr intravenous 15gm 8 celecoxib caps 26 CELONTIN CAPS 29 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 38 CERDELGA CAPS 37 CEREZYME SOLR 37 CEROVEL LOTN 56 cetirizine hcl soln 13 CEVIMELINE HCL CAPS 19 CHANTIX CONTINUING MONTH PAK
TABS 19 CHANTIX STARTING MONTH PAK TABS
19 CHANTIX TABS 05mg 1mg 19 CHEMET CAPS 41 chloramphenicol sod succinate solr 8 chlordiazepoxide hcl caps 5mg 10mg
25mg 31 chlordiazepoxide-amitriptyline tabs 33 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 38 chloroprocaine hcl (pf) soln 49 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 36 chlorothiazide tabs 250mg 500mg 36 chlorpromazine hcl conc 30mgml
100mgml 33 chlorpromazine hcl soln 33 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 33 chlorthalidone tabs 25mg 50mg 36 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 41 cholestyramine light pack 22 cholestyramine light powd 22 cholestyramine pack 22 cholestyramine powd 22 CHORIONIC GONADOTROPIN SOLR 45 CIBINQO TABS 50mg 100mg 200mg 47 ciclopirox gel 53 ciclopirox olamine crea 53
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 65
ciclopirox olamine susp 53 ciclopirox sham 53 ciclopirox soln 53 cidofovir soln 11 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 38 CIMDUO TABS 11 cimetidine hcl soln 40 cimetidine tabs 200mg 300mg 400mg
800mg 40 CIMZIA KIT 47 CIMZIA PREFILLED PSKT 47 CIMZIA STARTER KIT PSKT 47 cinacalcet hcl tabs 30mg 60mg 90mg 45 CINQAIR SOLN 51 CINRYZE SOLR INTRAVENOUS 49 CIPRODEX SUSP 38 ciprofloxacin hcl soln (ophth) 38 CIPROFLOXACIN HCL SOLN (OTIC) 38 ciprofloxacin hcl tabs 8 ciprofloxacin in d5w soln 8 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 38 cisplatin soln 14 CISPLATIN SOLR 50mg 14 CITALOPRAM HYDROBROMIDE CAPS 33 citalopram hydrobromide soln 33 citalopram hydrobromide tabs 10mg 20mg
40mg 33 citanest plain dental soln 49 cladribine soln 14 claravis caps 10mg 20mg 30mg 40mg 56 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 13 cleocin phosphate soln 9 cleocin solr 9 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
clindacin-p swab 53 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 53 clindamycin phosphate crea 53
clindamycin phosphate foam 53 clindamycin phosphate gel 53 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 53 clindamycin phosphate soln 9 53 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 53 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 36 clinisol sf soln intravenous 36 clobazam susp 29 clobazam tabs 10mg 20mg 29 clobetasol propionate crea 54 clobetasol propionate e crea 54 clobetasol propionate emulsion foam 54 clobetasol propionate foam 54 clobetasol propionate gel 54 clobetasol propionate liqd 54 clobetasol propionate lotn 54 clobetasol propionate oint 54 clobetasol propionate sham 54 clobetasol propionate soln 54 clocortolone pivalate crea 54 clocortolone pivalate pump crea 54 clofarabine soln 14 clomipramine hcl caps 25mg 50mg 75mg
33 clonazepam tabs 05mg 1mg 2mg 29 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 29 clonidine hcl (analgesia) soln 24
66 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
clonidine hcl er tb12 24 clonidine hcl tabs 01mg 02mg 03mg 24 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 24 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 31 clotrimazole crea 53 clotrimazole soln 53 clotrimazole troc 53 clotrimazole-betamethasone crea 53 clotrimazole-betamethasone lotn 53 clovique caps 41 clozapine tabs 25mg 50mg 100mg 200mg
33 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 33 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 26 colazal caps 40 COLCHICINE CAPS 47 colchicine tabs 47 colchicine-probenecid tabs 37 COLESEVELAM HCL PACK 22 colesevelam hcl tabs 22 colestipol hcl gran 22 colestipol hcl pack 22 colestipol hcl tabs 22 colistimethate sodium (cba) solr injection 9 colocort enem 54 COLY-MYCIN S SUSP 38 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 14 COMETRIQ (140 MG DAILY DOSE) KIT 14 COMETRIQ (60 MG DAILY DOSE) KIT 14 COMPLERA TABS 11 compro supp 33 CONSENSI TABS 23 constulose soln 35 COPIKTRA CAPS 15mg 25mg 14 CORDRAN TAPE 54 CORLANOR SOLN 24 CORLANOR TABS 5mg 75mg 24 cortisone acetate tabs 41 CORTISPORIN CREA 54 CORTISPORIN OINT 54 CORTROPHIN GEL 46 COSELA SOLR 49
COSENTYX (300 MG DOSE) SOSY 56 COSENTYX SENSOREADY (300 MG)
SOAJ 56 COSENTYX SENSOREADY PEN SOAJ 56 COSENTYX SOSY 75mg05ml 150mgml
56 COTELLIC TABS 14 CREON CPEP 37 CRESEMBA CAPS 10 CRESEMBA SOLR 10 CRIXIVAN CAPS 200mg 400mg 11 cromolyn sodium conc 51 cromolyn sodium nebu 51 cromolyn sodium soln 39 crotan lotn 53 cryselle-28 tabs 42 CRYSVITA SOLN 10mgml 20mgml
30mgml 49 CURITY GAUZE PADS 35 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 52
cyclafem 135 tabs 42 cyclafem 777 tabs 42 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 14 CYCLOPHOSPHAMIDE SOLN 2gm10ml
1gm5ml 500mg25ml 15 cyclophosphamide solr 15 cycloserine caps 11 cyclosporine caps 25mg 100mg 48 cyclosporine emul 38 cyclosporine modified caps 25mg 50mg
100mg 48 cyclosporine modified soln 48 cyclosporine soln 48 cyproheptadine hcl syrp 13 cyproheptadine hcl tabs 13 CYRAMZA SOLN 100mg10ml
500mg50ml 15 CYSTADANE POWD 49 CYSTADROPS SOLN 39 CYSTAGON CAPS 50mg 150mg 49 CYSTARAN SOLN 39 cytarabine (pf) soln 15 cytarabine soln 15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 67
CYTOGAM INJ 52
D dacarbazine solr 15 dactinomycin solr 15 dalfampridine er tb12 32 DALIRESP TABS 250mcg 500mcg 51 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 42 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 56 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 52 daptomycin solr intravenous 350mg 500mg
9 darifenacin hydrobromide er tb24 75mg
15mg 57 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 deblitane tabs 42 decadron tabs 5mg 75mg 41 decadron tabs 4mg 6mg 41 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 41 deferasirox tabs 41 deferasirox tbso 41 deferiprone tabs 500mg 1000mg 41 deferoxamine mesylate solr 41 DELSTRIGO TABS 11 deltasone tabs 41 delyla tabs 42 demeclocycline hcl tabs 9 DEMSER CAPS 22 depo-estradiol oil 45 DEPO-MEDROL SUSP 41 DEPO-PROVERA SUSP 400mgml 46 DEPO-SUBQ PROVERA 104 SUSY 46 depo-testosterone soln 100mgml
200mgml 42 DERMOTIC OIL 38 DESCOVY TABS 120-15mg 11 DESCOVY TABS 200-25mg 11
desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg 33
desloratadine tabs 13 desloratadine tbdp 13 desmopressin ace spray refrig soln 46 DESMOPRESSIN ACETATE SOLN 46 desmopressin acetate spray soln 46 desmopressin acetate tabs 01mg 02mg 46 desogestrel-ethinyl estradiol tabs 42 desonide crea 54 desonide gel 54 desonide lotn 54 desonide oint 54 desowen lotn 54 desoximetasone crea 005 025 54 desoximetasone gel 54 desoximetasone liqd 54 desoximetasone oint 005 025 54 desrx gel 54 DESVENLAFAXINE ER TB24 50mg
100mg 33 desvenlafaxine succinate er tb24 25mg
50mg 100mg 33 dexabliss tbpk 41 dexamethasone elix 41 dexamethasone intensol conc 41 dexamethasone sodium phosphate soln 38
41 dexamethasone soln 41 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 41 dexamethasone tbpk 41 dexchlorpheniramine maleate soln 13 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 28
dexmethylphenidate hcl tabs 25mg 5mg 10mg 28
dexpak 10 day tbpk 41 dexpak 13 day tbpk 41 dexpak 6 day tbpk 41 dexrazoxane hcl solr 49 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 28 dextroamphetamine sulfate soln 28 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 28 DEXTROSE IN LACTATED RINGERS
SOLN 37
68 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
DEXTROSE SOLN 36 DEXTROSE SOLN INTRAVENOUS 5
10 36 DEXTROSE-NACL SOLN INTRAVENOUS
10-02 10-045 37 DEXTROSE-NACL SOLN INTRAVENOUS
25-045 5-02 5-045 5-09 37 DIACOMIT CAPS 250mg 500mg 29 DIACOMIT PACK 250mg 500mg 29 DIASTAT ACUDIAL GEL 10mg 20mg 29 DIASTAT PEDIATRIC GEL 29 diazepam conc 31 diazepam gel 25mg 10mg 20mg 29 diazepam intensol conc 31 diazepam soln 5mg5ml 5mgml 31 diazepam tabs 2mg 5mg 10mg 31 diazoxide susp 44 diclofenac sodium er tb24 26 diclofenac sodium gel 1 3 54 diclofenac sodium soln 38 diclofenac sodium tbec 26 diclofenac-misoprostol tbec 26 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 11 DIFFERIN CREA 56 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 54 diflorasone diacetate oint 54 diflunisal tabs 26 difluprednate emul 38 digitek tabs 0125mg 025mg 24 digox tabs 24 digoxin soln 24 digoxin tabs 125mcg 250mcg 24 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 29 dilantin infatabs chew 29 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 23 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 23
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 23
diltiazem hcl er cp12 60mg 90mg 120mg 23
diltiazem hcl er cp24 120mg 180mg 240mg 23
diltiazem hcl soln 23 diltiazem hcl solr 23 diltiazem hcl tabs 30mg 60mg 90mg
120mg 23 dilt-xr cp24 120mg 180mg 240mg 23 dimenhydrinate soln 40 dimethyl fumarate cpdr 32 dimethyl fumarate starter pack misc 32 DIPENTUM CAPS 40 diphen elix 13 di-phen elix 13 diphenhydramine hcl elix 13 diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 40 diphenoxylate-atropine tabs 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 52 dipyridamole tabs 25mg 50mg 75mg 25 disopyramide phosphate caps 100mg
150mg 24 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 36 divalproex sodium csdr 29 divalproex sodium er tb24 250mg 500mg29 divalproex sodium tbec 125mg 250mg
500mg 29 dobutamine hcl soln 20 DOBUTAMINE IN D5W SOLN 20 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
24 dolishale tabs 42 donepezil hcl tabs 5mg 10mg 23mg 19 donepezil hcl tbdp 5mg 10mg 19 dopamine hcl soln 20 DOPAMINE IN D5W SOLN 20 DOPTELET TABS 21 dorzolamide hcl soln 39 dorzolamide hcl-timolol mal pf soln 39 dorzolamide hcl-timolol mal soln 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 69
dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 33 doxepin hcl conc 33 doxepin hcl crea 55 doxepin hcl tabs 3mg 6mg 33 doxercalciferol caps 05mcg 1mcg 25mcg
57 DOXERCALCIFEROL SOLN 57 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
150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 40 DRIZALMA SPRINKLE CSDR 33 dronabinol caps 25mg 5mg 10mg 40 droperidol soln 31 drospiren-eth estrad-levomefol tabs 42 drospirenone-ethinyl estradiol tabs 42 DROXIA CAPS 15 droxidopa caps 20 DUAKLIR PRESSAIR AEPB 19 DUEXIS TABS 26 duloxetine hcl cpep 20mg 30mg 40mg
60mg 33 DUPIXENT SOPN 200mg114ml
300mg2ml 51 DUPIXENT SOSY 100mg067ml
200mg114ml 300mg2ml 51 DURYSTA IMPL 39 dutasteride caps 47 dutasteride-tamsulosin hcl caps 47 dvorah tabs 26 dxevo 11-day tbpk 41
E ees 400 tabs 9 EASYGEL GEL 49 econazole nitrate crea 53 EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 46 EGRIFTA SV SOLR 46 ELAPRASE SOLN 37 ELELYSO SOLR 37 ELEPSIA XR TB24 1000mg 1500mg 29 eletriptan hydrobromide tabs 30 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 37 elixophyllin elix 57 ELLA TABS 42 ELLENCE SOLN 15 ELMIRON CAPS 49 eluryng ring 42 ELZONRIS SOLN 15 EMCYT CAPS 15 EMFLAZA SUSP 42 EMFLAZA TABS 6mg 18mg 30mg 36mg
42 EMPAVELI SOLN 49 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 30 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 25 enalaprilat inj 25 enalapril-hydrochlorothiazide tabs 25 ENBREL MINI SOCT 47 ENBREL SOLN 47 ENBREL SOLR 47 ENBREL SOSY 25mg05ml 50mgml 48 ENBREL SURECLICK SOAJ 48 ENDARI PACK 49 endocet tabs 26 ENDOMETRIN INST 46
70 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ENGERIX-B SUSP 10mcg05ml 20mcgml 52
ENHERTU SOLR 15 ENJAYMO SOLN 49 enoxaparin sodium soln 21 enoxaparin sodium sosy 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
enpresse-28 tabs 42 ENSPRYNG SOSY 49 ENSTILAR FOAM 54 entacapone tabs 30 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 25 ENTYVIO SOLR 41 enulose soln 35 ENVARSUS XR TB24 075mg 1mg 4mg48 EPCLUSA PACK 12 EPCLUSA TABS 12 EPIDIOLEX SOLN 29 epifoam foam 54 epinastine hcl soln 39 epinephrine (anaphylaxis) soln 20 epinephrine soaj 20 EPINEPHRINE SOSY 20 epirubicin hcl soln 15 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 25 EPOGEN SOLN 21 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 21 epoprostenol sodium solr 51 EPRONTIA SOLN 29 eprosartan mesylate tabs 25 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 33 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 30 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 43 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 53 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 53 erythromycin oint 38 erythromycin pads 53 erythromycin soln 53 erythromycin tbec 9 ESBRIET CAPS 51 ESBRIET TABS 267mg 801mg 51 escitalopram oxalate soln 33 escitalopram oxalate tabs 5mg 10mg
20mg 33 esgic caps 26 esgic tabs 26 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 40 esomeprazole magnesium pack 10mg
20mg 40mg 40 esomeprazole sodium solr 40 estarylla tabs 43 estazolam tabs 1mg 2mg 31 estrace crea 45 estrace tabs 05mg 1mg 2mg 45 estradiol crea 45 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
estradiol tabs 10mcg 05mg 1mg 2mg 45 estradiol valerate oil 45 estradiol-norethindrone acet tabs 45 ESTRING RING 45 eszopiclone tabs 1mg 2mg 3mg 31 ethacrynic acid tabs 36 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 29 ethosuximide soln 29 ethynodiol diac-eth estradiol tabs 43 etodolac caps 26
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 71
etodolac er tb24 26 etodolac tabs 26 etonogestrel-ethinyl estradiol ring 43 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 eulexin caps 15 EURAX CREA 53 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 46
evekeo tabs 5mg 10mg 28 EVENITY SOSY 47 everolimus tabs 025mg 48 everolimus tabs 05mg 075mg 1mg 48 everolimus tabs 25mg 5mg 75mg 10mg
15 everolimus tbso 2mg 3mg 5mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 22 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 49 exemestane tabs 15 EXKIVITY CAPS 15 EXONDYS 51 SOLN 500mg10ml
100mg2ml 49 EXSERVAN FILM 31 EXTAVIA KIT 32 EYLEA SOLN 39 EYLEA SOSY 39 ezetimibe tabs 22 ezetimibe-simvastatin tabs 22
F FABRAZYME SOLR 5mg 35mg 37 falmina tabs 43 famciclovir tabs 125mg 250mg 500mg 12 famotidine (pf) soln 40 famotidine premixed soln 40 famotidine soln 40 famotidine susr 40 famotidine tabs 20mg 40mg 40 FANAPT TABS 1mg 2mg 4mg 6mg 8mg
10mg 12mg 33 FANAPT TITRATION PACK TABS 33 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 51 FASENRA SOSY 51
fayosim tabs 43 febuxostat tabs 40mg 80mg 47 felbamate susp 29 felbamate tabs 400mg 600mg 29 felodipine er tb24 25mg 5mg 10mg 23 femynor tabs 43 fenofibrate caps 50mg 150mg 22 fenofibrate micronized caps 43mg 67mg
130mg 134mg 200mg 22 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 22 fenofibric acid cpdr 45mg 135mg 22 fenoprofen calcium caps 26 fenoprofen calcium tabs 26 fenortho caps 26 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 26 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 26
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 26
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 26
FERRIPROX SOLN 41 FERRIPROX TABS 41 FERRIPROX TWICE-A-DAY TABS 41 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
33 FETZIMA TITRATION C4PK 33 fexmid tabs 20 finasteride tabs 47 FINTEPLA SOLN 29 fioricet caps 26 fioricetcodeine caps 26 FIRDAPSE TABS 49 FIRMAGON (240 MG DOSE) SOLR 15 FIRMAGON SOLR 15 flac oil 38 flavoxate hcl tabs 57 FLEBOGAMMA DIF SOLN INTRAVENOUS
52 flecainide acetate tabs 50mg 100mg
150mg 24 FLEQSUVY SUSP 20 FLOVENT HFA AERO 51 floxuridine solr 15
72 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
fluconazole in sodium chloride soln intravenous 10
fluconazole susr 10 fluconazole tabs 10 flucytosine caps 250mg 500mg 10 fludarabine phosphate soln 15 fludarabine phosphate solr 15 fludrocortisone acetate tabs 42 flumazenil soln 31 flunisolide soln 38 fluocinolone acetonide body oil 54 fluocinolone acetonide crea 001 0025
54 fluocinolone acetonide oil 38 fluocinolone acetonide oint 54 fluocinolone acetonide scalp oil 54 fluocinolone acetonide soln 54 fluocinonide crea 54 fluocinonide emulsified base crea 54 FLUOCINONIDE GEL 54 fluocinonide oint 54 fluocinonide soln 54 FLUORITAB CHEW 025mg 05mg 1mg 49 FLUORITAB SOLN 49 fluorometholone susp 38 fluorouracil crea 5 56 fluorouracil crea 5 56 fluorouracil soln 15 56 fluorouracil soln 2 5 56 fluoxetine hcl (pmdd) tabs 10mg 20mg 33 fluoxetine hcl caps 10mg 20mg 40mg 33 fluoxetine hcl cpdr 33 fluoxetine hcl soln 33 fluoxetine hcl tabs 10mg 20mg 60mg 33 fluphenazine decanoate soln 33 fluphenazine hcl conc 33 fluphenazine hcl elix 33 fluphenazine hcl soln 33 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 34 FLURANDRENOLIDE CREA 54 flurandrenolide lotn 55 flurandrenolide oint 55 flurazepam hcl caps 15mg 30mg 31 flurbiprofen sodium soln 38 flurbiprofen tabs 26 flutamide caps 15 fluticasone propionate crea 55 fluticasone propionate lotn 55
fluticasone propionate oint 55 fluticasone propionate susp 38 fluticasone-salmeterol aepb 51 fluvastatin sodium caps 20mg 40mg 22 fluvastatin sodium er tb24 22 fluvoxamine maleate er cp24 100mg
150mg 34 fluvoxamine maleate tabs 25mg 50mg
100mg 34 FML FORTE SUSP 38 FML OINT 38 fomepizole soln 47 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 FORTEO SOPN 45 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 40 fosfomycin tromethamine pack 13 fosinopril sodium tabs 10mg 20mg 40mg
25 fosinopril sodium-hctz tabs 25 fosphenytoin sodium soln 29 FOTIVDA CAPS 089mg 134mg 15 FROVATRIPTAN SUCCINATE TABS 30 FULPHILA SOSY 21 fulvestrant soln 15 furosemide soln 8mgml 10mgml 36 furosemide soln injection 36 furosemide tabs 20mg 40mg 80mg 36 FUZEON SOLR 12 FYARRO SUSR 15 fyavolv tabs 45 FYCOMPA SUSP 29 FYCOMPA TABS 29
G gabapentin caps 100mg 400mg 29 gabapentin soln 29 gabapentin tabs 600mg 800mg 29 GALAFOLD CAPS 49 galantamine hydrobromide er cp24 8mg
16mg 24mg 19 galantamine hydrobromide soln 19 galantamine hydrobromide tabs 4mg 8mg
12mg 19 GAMASTAN INJ 52 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 48
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 73
GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm 52
GAMMAGARD SOLN INJECTION 52 GAMMAKED SOLN INJECTION 52 GAMMAPLEX SOLN INTRAVENOUS 52 GAMUNEX-C SOLN INJECTION 52 ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 52 GARDASIL 9 SUSY 52 gatifloxacin soln 38 GATTEX KIT 41 gavilyte-c solr 41 gavilyte-g solr 41 gavilyte-h kit 41 gavilyte-n with flavor pack solr 41 GAVRETO CAPS 15 GAZYVA SOLN 15 gemcitabine hcl soln 15 gemcitabine hcl solr 15 gemfibrozil tabs 22 gemmily caps 43 generlac soln 35 gengraf caps 25mg 50mg 100mg 48 gengraf soln 48 GENOTROPIN CART 12mg 46 GENOTROPIN MINIQUICK PRSY 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 46
gentak oint 38 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 53 gentamicin sulfate oint 53 gentamicin sulfate soln 9 38 gentamicin sulfate soln injection 9 GENVOYA TABS 12 gianvi tabs 43 GILENYA CAPS 025mg 05mg 32 GILOTRIF TABS 20mg 30mg 40mg 15 GIMOTI SOLN 41 GIVLAARI SOLN 49 GLASSIA SOLN INTRAVENOUS 51 glatopa sosy 20mgml 40mgml 32 glimepiride tabs 1mg 2mg 4mg 44 glipizide er tb24 25mg 5mg 10mg 44 glipizide tabs 5mg 10mg 44 glipizide-metformin hcl tabs 44 glucagon emergency kit 44
glyburide micronized tabs 15mg 3mg 6mg 44
glyburide tabs 125mg 25mg 5mg 44 glyburide-metformin tabs 44 glycate tabs 19 glycopyrrolate oral soln 19 glycopyrrolate pf sosy 19 glycopyrrolate soln injection 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 55 granisetron hcl soln 40 granisetron hcl tabs 40 GRANIX SOLN 480mcg16ml 300mcgml
21 GRANIX SOSY 300mcg05ml
480mcg08ml 21 GRASTEK SUBL 49 griseofulvin microsize susp 10 griseofulvin microsize tabs 10 griseofulvin ultramicrosize tabs 10 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 32 guanfacine hcl tabs 1mg 2mg 24 GUANIDINE HCL TABS 19 gynazole-1 crea 53
H HAEGARDA SOLR 2000unit 3000unit 49 hailey 24 fe tabs 43 halcinonide crea 55 halobetasol propionate crea 55 HALOBETASOL PROPIONATE FOAM 55 halobetasol propionate oint 55 haloperidol decanoate soln 34 haloperidol lactate conc 34 haloperidol lactate soln 34 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 34 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 52 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
HEPLISAV-B SOLN 52
74 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
HERCEPTIN HYLECTA SOLN 15 HERCEPTIN SOLR 150mg 440mg 15 HERZUMA SOLR 150mg 420mg 15 HETLIOZ CAPS 31 HETLIOZ LQ SUSP 31 HIBERIX SOLR 52 HUMALOG KWIKPEN SOPN 44 HUMALOG SOCT 44 HUMALOG SOLN 44 humatin caps 11 HUMATROPE CART 6mg 12mg 24mg 46 HUMATROPE SOLR 46 HUMIRA PEDIATRIC CROHNS START
PSKT 48 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 48 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 48 HUMIRA PEN-PEDIATRIC UC START
PNKT 48 HUMIRA PEN-PSUVADOL HS START
PNKT 48 HUMIRA PEN-PSORUVEIT STARTER
PNKT 48 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 48
HUMULIN 7030 KWIKPEN SUPN 44 HUMULIN 7030 SUSP 44 HUMULIN N KWIKPEN SUPN 44 HUMULIN N SUSP 44 HUMULIN R SOLN 44 HUMULIN R U-500 (CONCENTRATED)
SOLN 44 HUMULIN R U-500 KWIKPEN SOPN 44 hydralazine hcl soln 24 hydralazine hcl tabs 10mg 25mg 50mg
100mg 24 hydrochlorothiazide caps 36 hydrochlorothiazide tabs 125mg 25mg
50mg 36 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 26 hydrocodone-acetaminophen soln 26 hydrocodone-acetaminophen tabs 26 hydrocodone-ibuprofen tabs 26 hydrocortisone (perianal) crea 1 25 55 hydrocortisone ace-pramoxine crea 55
HYDROCORTISONE ACE-PRAMOXINE SUPP 55
hydrocortisone butyr lipo base crea 55 hydrocortisone butyrate crea 55 hydrocortisone butyrate lotn 55 HYDROCORTISONE BUTYRATE OINT 55 hydrocortisone butyrate soln 55 hydrocortisone crea 1 25 55 hydrocortisone enem 55 hydrocortisone lotn 55 hydrocortisone oint 1 25 55 hydrocortisone tabs 5mg 10mg 20mg 42 hydrocortisone valerate crea 55 hydrocortisone valerate oint 55 HYDROCORTISONE-ACETIC ACID SOLN
38 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 26 hydromorphone hcl liqd 26 hydromorphone hcl tabs 2mg 4mg 8mg 26 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 46 hydroxyprogesterone caproate soln 46 hydroxyurea caps 15 hydroxyzine hcl soln 31 hydroxyzine hcl syrp 31 hydroxyzine hcl tabs 31 hydroxyzine pamoate caps 31 HYPERHEP B SOLN 52 HYPERHEP B SOSY 52 HYPERRAB SD SOLN 52 HYQVIA KIT 52
I IBANDRONATE SODIUM SOLN 47 ibandronate sodium tabs 47 IBRANCE CAPS 75mg 100mg 125mg 15 IBRANCE TABS 75mg 100mg 125mg 15 IBSRELA TABS 41 ibu tabs 26 ibudone tabs 26 ibuprofen lysine soln 26 ibuprofen susp 26 ibuprofen tabs 26 ibutilide fumarate soln 24 icatibant acetate soln 20 iclevia tabs 43 ICLUSIG TABS 10mg 15mg 30mg 45mg
15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 75
icosapent ethyl caps 22 IDAMYCIN PFS SOLN 15 idarubicin hcl soln 15 IDHIFA TABS 50mg 100mg 15 ifosfamide soln 15 IFOSFAMIDE SOLR 16 ILARIS SOLN 26 ILUMYA SOSY 56 ILUVIEN IMPL 38 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 34 imipramine pamoate caps 75mg 100mg
125mg 150mg 34 imiquimod crea 375 5 56 IMIQUIMOD PUMP CREA 56 IMOGAM RABIES-HT SOLN 52 IMOVAX RABIES INJ 52 IMPAVIDO CAPS 11 INBRIJA CAPS 30 incassia tabs 43 INCRELEX SOLN 46 indapamide tabs 125mg 25mg 36 indocin supp 26 indomethacin caps 26 indomethacin er cpcr 26 indomethacin sodium solr 26 INFANRIX SUSP 52 INFLECTRA SOLR INTRAVENOUS 48 INFLIXIMAB SOLR INTRAVENOUS 48 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 32 INGREZZA CPPK 32 INLYTA TABS 1mg 5mg 16 INQOVI TABS 16 INREBIC CAPS 16 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 36 INTRON A SOLN 6000000unitml
10000000unitml 16 INTRON A SOLR 10000000unit
18000000unit 50000000unit 16 introvale tabs 43 INVEGA HAFYERA SUSY 34
INVEGA SUSTENNA SUSY 39mg025ml 34
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml 34
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml 34
INVIRASE CAPS 12 INVIRASE TABS 12 IOPIDINE SOLN 39 IPOL INJ 52 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 20 irbesartan tabs 75mg 150mg 300mg 25 irbesartan-hydrochlorothiazide tabs 25 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 20 isosorbide dinitrate er tbcr 25 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 25 isosorbide mononitrate er tb24 25 isosorbide mononitrate er tb24 30mg 60mg
25 isosorbide mononitrate tabs 10mg 20mg 25 isotretinoin caps 10mg 20mg 30mg 40mg
56 isradipine caps 25mg 5mg 23 ISTURISA TABS 1mg 5mg 10mg 49 itraconazole caps 10 ITRACONAZOLE SOLN 10 ivermectin crea 53 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 52
J JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16
76 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg 21
JARDIANCE TABS 10mg 25mg 44 jasmiel tabs 43 JEMPERLI SOLN 16 jinteli tabs 45 JOLIVETTE TABS 43 JULUCA TABS 12 junel 1530 tabs 43 junel 120 tabs 43 junel fe 1530 tabs 43 junel fe 120 tabs 43 junel fe 24 tabs 43 JUXTAPID CAPS 5mg 10mg 20mg 30mg
40mg 60mg 22 JYNARQUE TABS 15mg 30mg 36 JYNARQUE TBPK 36
K KADCYLA SOLR 100mg 160mg 16 kaitlib fe chew 43 KALYDECO PACK 25mg 50mg 75mg 51 KALYDECO TABS 51 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 37 kariva tabs 43 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ 37
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ 37
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS 37
KEDRAB SOLN 52 kelnor 135 tabs 43 kelnor 150 tabs 43 KENALOG SUSP 42 KEPIVANCE SOLR 56 KERALYT SHAM 56 KESIMPTA SOAJ 49 ketoconazole crea 53 ketoconazole foam 53 ketoconazole sham 53 ketoconazole tabs 10 ketodan foam 53 ketoprofen caps 26 ketoprofen er cp24 26 ketorolac tromethamine soln 26 38
ketorolac tromethamine soln 04 05 38 ketorolac tromethamine tabs 26 KEVEYIS TABS 49 KEVZARA SOAJ 150mg114ml
200mg114ml 48 KEVZARA SOSY 150mg114ml
200mg114ml 48 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 47 KHEDEZLA TB24 50mg 100mg 34 KIMMTRAK SOLN 16 KIMYRSA SOLR 9 KINERET SOSY 48 KINRIX SUSP 52 KINRIX SUSY 52 kionex susp 36 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KISQALI FEMARA(200 MG DOSE) TBPK
16 KITABIS PAK NEBU 51 KLISYRI OINT 56 KLOR-CON 10 TBCR 37 klor-con m15 tbcr 37 klor-con m20 tbcr 37 klor-con pack 37 klor-con sprinkle cpcr 8meq 10meq 37 KLOR-CON TBCR 37 KORLYM TABS 44 KORSUVA SOLN 56 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 35 K-TAB TBCR 37 kurvelo tabs 43 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 30 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 lacosamide tabs 50mg 100mg 150mg
200mg 29
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 77
LACRISERT INST 39 LACTATED RINGERS SOLN 37 49 LACTIC ACID LOTN 56 lactulose encephalopathy soln 35 lactulose pack 35 lactulose soln 35 LAMICTAL XR KIT 29 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 29 lamotrigine er tb24 25mg 50mg 100mg
200mg 250mg 300mg 29 lamotrigine kit 29 lamotrigine starter kit-blue kit 29 lamotrigine starter kit-green kit 29 lamotrigine starter kit-orange kit 29 lamotrigine tabs 25mg 100mg 150mg
200mg 29 lamotrigine tbdp 25mg 50mg 100mg
200mg 29 LANOXIN PEDIATRIC SOLN 24 LANREOTIDE ACETATE SOLN 46 lansoprazole cpdr 15mg 30mg 40 lansoprazole tbdd 15mg 30mg 40 lanthanum carbonate chew 500mg 750mg
1000mg 36 LANTUS SOLN 44 LANTUS SOLOSTAR SOPN 44 lapatinib ditosylate tabs 16 larin 1530 tabs 43 larin 120 tabs 43 larin fe 1530 tabs 43 larin fe 120 tabs 43 larissia tabs 43 LARTRUVO SOLN 190mg19ml
500mg50ml 16 latanoprost soln 39 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 34 LAYOLIS FE CHEW 43 LAZANDA SOLN 100mcgact 400mcgact
26 ledipasvir-sofosbuvir tabs 12 leena tabs 43 leflunomide tabs 10mg 20mg 48 LEMTRADA SOLN 32 lenalidomide caps 5mg 10mg 15mg 25mg
16
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 16 lessina tabs 43 letrozole tabs 16 leucovorin calcium soln 47 leucovorin calcium solr 47 leucovorin calcium tabs 5mg 10mg 15mg
25mg 47 LEUKERAN TABS 16 LEUKINE SOLR 21 leuprolide acetate kit 16 LEVALBUTEROL HCL NEBU
125mg05ml 125mg3ml 031mg3ml 063mg3ml 20
levalbuterol tartrate aero 20 levetiracetam er tb24 500mg 750mg 29 levetiracetam in nacl soln 29 levetiracetam soln 29 levetiracetam tabs 250mg 500mg 750mg
1000mg 29 levobunolol hcl soln 39 levocarnitine soln 49 LEVOCARNITINE TABS 49 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 38 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 47 levoleucovorin calcium solr 47 levonest tabs 43 levonorgest-eth est amp eth est tabs 43 levonorgest-eth estrad 91-day tabs 43 levonorgestrel-ethinyl estrad tabs 43 levonorg-eth estrad triphasic tabs 43 levora 01530 (28) tabs 43 levorphanol tartrate tabs 2mg 3mg 26 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
78 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEVOTHYROXINE SODIUM SOLR 47 LEVOTHYROXINE SODIUM TABS 25mcg
50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEXETTE FOAM 55 LEXIVA SUSP 12 LIALDA TBEC 40 LIBTAYO SOLN 16 lidocaine hcl (cardiac) pf sosy 24 lidocaine hcl (cardiac) sosy 24 lidocaine hcl (pf) soln 49 LIDOCAINE HCL CREA 55 lidocaine hcl lotn 55 lidocaine hcl soln 39 49 55 lidocaine hcl urethralmucosal gel 55 lidocaine hcl urethralmucosal prsy 55 LIDOCAINE IN D5W SOLN 24 lidocaine in dextrose soln 49 lidocaine oint 55 lidocaine ptch 55 lidocaine viscous hcl soln 40 lidocaine-epinephrine soln 49 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 55 LIDOCAINE-HYDROCORTISONE ACE KIT
55 lidocaine-prilocaine crea 55 lidocaine-tetracaine crea 55 LIDOCORT CREA 56 lidopin crea 56 LIDO-SORB LOTN 55 LIDOZION LOTN 56 lincomycin hcl soln 9 lindane sham 53 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 liothyronine sodium soln 47 liothyronine sodium tabs 5mcg 25mcg
50mcg 47 LIPODOX 50 INJ 16
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg 25
lisinopril-hydrochlorothiazide tabs 25 LITHIUM CARBONATE CAPS 150mg
300mg 600mg 34 lithium carbonate er tbcr 300mg 450mg 34 LITHIUM CARBONATE TABS 34 LITHIUM SOLN 34 LITHOSTAT TABS 35 LIVMARLI SOLN 41 LIVTENCITY TABS 12 loestrin 1530 (21) tabs 43 loestrin 120 (21) tabs 43 loestrin fe 1530 tabs 43 loestrin fe 120 tabs 43 LOKELMA PACK 5gm 10gm 36 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 16 loperamide hcl caps 40 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 45 lorazepam intensol conc 31 LORAZEPAM SOLN 4mgml 2mgml 31 lorazepam tabs 05mg 1mg 2mg 31 LORBRENA TABS 25mg 100mg 16 lorcet hd tabs 26 lorcet plus tabs 26 lorcet tabs 27 lortab elix 27 loryna tabs 43 losartan potassium tabs 25mg 50mg
100mg 25 losartan potassium-hctz tabs 25 LOTEMAX GEL 38 LOTEMAX SUSP 38 lovastatin tabs 10mg 20mg 40mg 22 LOVENOX SOLN 21 LOVENOX SOSY 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
low-ogestrel tabs 43 loxapine succinate caps 5mg 10mg 25mg
50mg 34 lubiprostone caps 8mcg 24mcg 41 LUCEMYRA TABS 32 LUCENTIS SOLN 03mg005ml
05mg005ml 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 79
LUCENTIS SOSY 03mg005ml 05mg005ml 39
LUDENT CHEW 025mg 05mg 1mg 49 LUMAKRAS TABS 16 LUMIGAN SOLN 39 LUMIZYME SOLR 37 LUMOXITI SOLR 16 LUPANETA PACK KIT 16 LUPKYNIS CAPS 48 LUPRON DEPOT (1-MONTH) KIT 16 LUPRON DEPOT (3-MONTH) KIT 16 LUPRON DEPOT (4-MONTH) KIT 16 LUPRON DEPOT (6-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 16 LUPRON DEPOT-PED (3-MONTH) KIT 16 lutera tabs 43 LYBALVI TABS 34 lyleq tabs 43 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 45
LYMEPAK TABS 9 LYNPARZA TABS 100mg 150mg 16 LYSODREN TABS 16 lyza tabs 43
M mafenide acetate pack 53 magnesium sulfate in d5w soln 37 magnesium sulfate soln 29 MAGNESIUM SULFATE SOLN INJECTION
50 29 MAKENA SOAJ 46 malathion lotn 53 MANNITOL SOLN 36 maprotiline hcl tabs 25mg 50mg 75mg 34 maraviroc tabs 150mg 300mg 12 MARGENZA SOLN 16 marlissa tabs 43 MARPLAN TABS 34 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 23 MAVENCLAD (10 TABS) TBPK 48 MAVENCLAD (4 TABS) TBPK 48 MAVENCLAD (5 TABS) TBPK 48
MAVENCLAD (6 TABS) TBPK 48 MAVENCLAD (7 TABS) TBPK 48 MAVENCLAD (8 TABS) TBPK 48 MAVENCLAD (9 TABS) TBPK 48 MAVYRET PACK 12 MAVYRET TABS 12 MAYZENT STARTER PACK TBPK 32 MAYZENT TABS 025mg 1mg 2mg 32 MENAPHOSMBHYO1 TABS 13 meclizine hcl tabs 40 meclofenamate sodium caps 27 MEDROL TABS 42 medroxyprogesterone acetate susp 46 medroxyprogesterone acetate susy 46 medroxyprogesterone acetate tabs 25mg
5mg 10mg 46 mefenamic acid caps 27 mefloquine hcl tabs 11 megestrol acetate susp 17 46 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 43 meloxicam tabs 27 melphalan hcl solr 17 memantine hcl er cp24 32 memantine hcl soln 32 memantine hcl tabs 5mg 10mg 32 MENACTRA SOLN 52 menest tabs 03mg 0625mg 125mg 45 MENQUADFI SOLN 52 MENVEO SOLR 52 meperidine hcl soln 27 meperidine hcl tabs 50mg 27 meprobamate tabs 31 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 43 mesalamine cpdr 40 mesalamine enem 40 mesalamine er cp24 40 mesalamine supp 40 mesalamine tbec 12gm 800mg 40 mesalamine-cleanser kit 40 mesna soln 49 MESNEX TABS 49 MESTINON SOLN 19 metadate er tbcr 28 metaproterenol sulfate syrp 20
80 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
metaproterenol sulfate tabs 10mg 20mg 20 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 44 metformin hcl tabs 500mg 850mg 1000mg
45 methadone hcl conc 27 methadone hcl intensol conc 27 methadone hcl tabs 5mg 10mg 27 methamphetamine hcl tabs 28 methazolamide tabs 25mg 50mg 39 methenamine hippurate tabs 13 METHENAMINE MANDELATE TABS 13 methergine tabs 45 methimazole tabs 5mg 10mg 47 methitest tabs 42 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 57 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 36 methyldopa tabs 250mg 500mg 24 methyldopa-hydrochlorothiazide tabs 24 methylergonovine maleate soln 45 methylergonovine maleate tabs 45 methylphenidate hcl chew 25mg 5mg
10mg 28 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 28 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 28 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 28
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 28
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 28
methylphenidate hcl soln 5mg5ml 10mg5ml 28
methylphenidate hcl tabs 5mg 10mg 20mg 28
methylprednisolone acetate susp 42 methylprednisolone sodium succ solr 42
methylprednisolone tabs 4mg 8mg 16mg 32mg 42
methylprednisolone tbpk 42 methyltestosterone caps 42 metoclopramide hcl soln 41 metoclopramide hcl tabs 5mg 10mg 41 metoclopramide hcl tbdp 5mg 10mg 41 metolazone tabs 25mg 5mg 10mg 36 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 23 metoprolol tartrate soct 23 metoprolol tartrate soln 23 metoprolol tartrate tabs 25mg 50mg
100mg 23 metoprolol tartrate tabs 375mg 75mg 23 metoprolol-hydrochlorothiazide tabs 23 metronidazole caps 11 metronidazole crea 53 metronidazole gel 53 metronidazole lotn 53 METRONIDAZOLE SOLN INTRAVENOUS
500mg100ml 11 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
24 mibelas 24 fe chew 43 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 53 miconazole-zinc oxide-petrolat oint 53 micort-hc crea 55 microgestin 1530 tabs 43 microgestin 120 tabs 43 microgestin 24 fe tabs 43 microgestin fe 1530 tabs 43 microgestin fe 120 tabs 43 midazolam hcl (pf) soln 31 midazolam hcl soln 31 midodrine hcl tabs 25mg 5mg 10mg 20 miglitol tabs 25mg 50mg 100mg 45 miglustat caps 38 mili tabs 43 millipred dp tbpk 42 millipred tabs 42 milrinone lactate in dextrose soln 24 milrinone lactate soln 24 mimvey lo tabs 45 mimvey tabs 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 81
minitran pt24 01mghr 02mghr 04mghr 06mghr 25
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 24 mirtazapine tabs 75mg 15mg 30mg
45mg 34 mirtazapine tbdp 15mg 30mg 45mg 34 misoprostol tabs 100mcg 200mcg 40 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 52 modafinil tabs 100mg 200mg 28 moexipril hcl tabs 75mg 15mg 25 molindone hcl tabs 5mg 10mg 25mg 34 mometasone furoate crea 55 mometasone furoate oint 55 mometasone furoate soln 55 mometasone furoate susp 38 MONJUVI SOLR 17 MONONESSA TABS 43 montelukast sodium chew 4mg 5mg 51 montelukast sodium pack 51 montelukast sodium tabs 51 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 27 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 27 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 27
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 27
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml 27
morphine sulfate tabs 15mg 30mg 27 moxifloxacin hcl (2x day) soln 38 moxifloxacin hcl in nacl soln intravenous 9 moxifloxacin hcl soln 38 moxifloxacin hcl tabs 9 MULPLETA TABS 21 MULTAQ TABS 24 mupirocin calcium crea 53 mupirocin oint 53 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17
MYALEPT SOLR 49 MYCAPSSA CPDR 46 mycophenolate mofetil caps 48 mycophenolate mofetil hcl solr 48 mycophenolate mofetil susr 48 mycophenolate mofetil tabs 49 mycophenolate sodium tbec 180mg 360mg
49 MYFEMBREE TABS 45 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 57 MYRBETRIQ TB24 25mg 50mg 57
N NABI-HB SOLN 52 nabumetone tabs 27 N-ACETYL-L-CYSTEINE CAPS 36 nadolol tabs 20mg 40mg 80mg 23 nadololbendroflumethiazide tabs 23 nadolol-bendroflumethiazide tabs 23 nafcillin sodium solr 9 nafcillin sodium solr injection 9 nafcillin sodium solr intravenous 9 NAFRINSE CHEW 49 NAFRINSE DROPS SOLN 49 naftifine hcl crea 53 naftifine hcl gel 53 NAGLAZYME SOLN 38 nalbuphine hcl soln 10mgml 20mgml 27 nalfon tabs 27 nalocet tabs 27 naloxone hcl liqd 32 naloxone hcl soaj 32 naloxone hcl soct 32 naloxone hcl soln 32 naloxone hcl sosy 32 naltrexone hcl tabs 32 naproxen sodium er tb24 27 naproxen sodium tabs 27 naproxen susp 27 naproxen tabs 27 naproxen tbec 27 naproxen-esomeprazole tbec 27 naratriptan hcl tabs 30 NARCAN LIQD 32 NATACYN SUSP 38 nateglinide tabs 60mg 120mg 45 NATPARA CART 25mcg 50mcg 75mcg
100mcg 45
82 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
NAYZILAM SOLN 29 necon 0535 (28) tabs 43 NECON 777 TABS 43 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 34 nelarabine soln 17 nembutal soln 31 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 38 neomycin-polymyxin b gu soln 53 neomycin-polymyxin-dexameth oint 38 neomycin-polymyxin-dexameth susp 39 neomycin-polymyxin-gramicidin soln 38 neomycin-polymyxin-hc soln 39 neomycin-polymyxin-hc susp 39 neo-polycin hc oint 38 neo-polycin oint 38 neo-synalar crea 55 NERLYNX TABS 17 NEULASTA ONPRO PSKT 21 NEULASTA SOSY 21 NEUPOGEN SOLN 480mcg16ml
300mcgml 21 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 21 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 38 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 22 niacor tabs 22 nicardipine hcl caps 20mg 30mg 23 NICARDIPINE HCL SOLN 23 NICOTROL INHA 19 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 43 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 49 nitro-bid oint 25
NITRO-DUR PT24 03mghr 08mghr 25 NITROFURANTOIN MACROCRYSTAL
CAPS 13 NITROFURANTOIN MONOHYD MACRO
CAPS 13 nitrofurantoin susp 13 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 25 nitroglycerin soln 25 nitroglycerin subl 03mg 04mg 06mg 25 nitropress soln 24 nitroprusside sodium soln 24 NITYR TABS 2mg 5mg 10mg 49 NIVESTYM SOLN 480mcg16ml
300mcgml 21 NIVESTYM SOSY 300mcg05ml
480mcg08ml 22 nizatidine caps 150mg 300mg 40 nizatidine soln 40 nolix crea 55 nolix lotn 55 nora-be tabs 43 norco tabs 27 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 46
norepinephrine bitartrate soln 20 norethin ace-eth estrad-fe caps 43 norethin ace-eth estrad-fe chew 43 norethin ace-eth estrad-fe tabs 43 norethindrone acetate tabs 46 norethindrone acet-ethinyl est tabs 43 norethindrone tabs 43 norethindrone-eth estradiol tabs 45 norethin-eth estradiol-fe chew 43 norgesic forte tabs 27 norgestimate-eth estradiol tabs 43 norgestim-eth estrad triphasic tabs 43 norlyroc tabs 43 NORPACE CR CP12 100mg 150mg 24 nortrel 0535 (28) tabs 43 nortrel 135 (21) tabs 43 nortrel 135 (28) tabs 43 nortrel 777 tabs 43 nortriptyline hcl caps 10mg 25mg 50mg
75mg 34 nortriptyline hcl soln 34 NORVIR CAPS 12 NORVIR PACK 12
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 83
NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 32 NOXAFIL SUSP 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 51 NUCALA SOLR 51 NUCALA SOSY 51 NUCYNTA ER TB12 200mg 250mg 27 NUCYNTA TABS 27 NUEDEXTA CAPS 32 NULIBRY SOLR 49 NULOJIX SOLR 49 NUPLAZID CAPS 34 NUPLAZID TABS 10mg 17mg 34 NURTEC TBDP 30 NUTRILIPID EMUL INTRAVENOUS 36 NUTROPIN AQ NUSPIN 10 SOPN 46 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 53 nylia 135 tabs 43 nylia 777 tabs 43 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 44 nystatin crea 53 nystatin oint 53 nystatin powd 53 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 55 nystatin-triamcinolone oint 55 nystop powd 53 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 41 ocella tabs 44 OCREVUS SOLN 32 OCTAGAM SOLN INTRAVENOUS
1gm20ml 2gm20ml 52 octreotide acetate soln 500mcgml
1000mcgml 46 octreotide acetate soln 50mcgml
100mcgml 200mcgml 46 ODACTRA SUBL 49 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 51
ofloxacin soln 38 ofloxacin tabs 10 ogestrel tabs 44 OGIVRI SOLR 17 olanzapine solr 34 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 34 olanzapine tbdp 5mg 10mg 15mg 20mg
34 olanzapine-fluoxetine hcl caps 34 olmesartan medoxomil tabs 5mg 20mg
40mg 25 olmesartan medoxomil-hctz tabs 25 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 39 OLUMIANT TABS 1mg 2mg 48 omega-3-acid ethyl esters caps 22 omeprazole cpdr 10mg 20mg 40mg 40 omeprazole-sodium bicarbonate caps 40 omeprazole-sodium bicarbonate pack 40 OMNITROPE SOCT 5mg15ml
10mg15ml 46 OMNITROPE SOLR 46 ondansetron hcl soln 40 ondansetron hcl sosy 40 ondansetron hcl tabs 4mg 8mg 24mg 40 ondansetron tbdp 4mg 8mg 40 ONIVYDE
INJ 17 ONPATTRO SOLN 50 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 OPDIVO SOLN 100mg10ml 120mg12ml
240mg24ml 40mg4ml 17 OPDUALAG SOLN 17 OPIUM TINC 40 OPZELURA CREA 57 ORACEA CPDR 57 oralone pste 55 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 48 ORENCIA SOLR 48 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 48 ORENITRAM TBCR 025mg 1mg 25mg
5mg 51 ORFADIN CAPS 50 ORFADIN SUSP 50 ORGOVYX TABS 45
84 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ORILISSA TABS 150mg 200mg 45 ORKAMBI PACK 51 ORKAMBI TABS 51 ORLADEYO CAPS 110mg 150mg 50 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 27 orphengesic forte tabs 27 orsythia tabs 44 ORTIKOS CP24 6mg 9mg 42 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 36 OTEZLA TABS 48 OTEZLA TBPK 48 ovide lotn 53 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 42 oxaprozin tabs 27 OXAYDO TABS 27 oxazepam caps 10mg 15mg 30mg 31 OXBRYTA TABS 21 OXBRYTA TBSO 21 oxcarbazepine susp 29 oxcarbazepine tabs 150mg 300mg 600mg
29 OXERVATE SOLN 39 oxiconazole nitrate crea 53 OXLUMO SOLN 50 OXTELLAR XR TB24 150mg 300mg
600mg 29 oxybutynin chloride er tb24 5mg 10mg
15mg 57 oxybutynin chloride syrp 57 oxybutynin chloride tabs 57 oxycodone hcl caps 27 oxycodone hcl conc 27 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxycodone hcl soln 27 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 27 oxycodone-acetaminophen soln 27
oxycodone-acetaminophen tabs 27 oxycodone-acetaminophen tabs 5-300mg
75-300mg 10-300mg 27 oxycodone-aspirin tabs 27 oxycodone-ibuprofen tabs 27 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 27 oxymorphone hcl tabs 5mg 10mg 27 OXYTOCIN SOLN 45 OZEMPIC (025 OR 05 MGDOSE) SOPN
45 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 45 OZEMPIC (2 MGDOSE) SOPN 45
P pacerone tabs 100mg 200mg 400mg 24 paclitaxel conc 17 PACLITAXEL PROTEIN-BOUND PART
SUSR 100 MG 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
50 PALFORZIA (120 MG DAILY DOSE) CSPK
50 PALFORZIA (160 MG DAILY DOSE) CSPK
50 PALFORZIA (20 MG DAILY DOSE) CSPK
50 PALFORZIA (200 MG DAILY DOSE) CSPK
50 PALFORZIA (240 MG DAILY DOSE) CSPK
50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK 50 PALFORZIA (300 MG TITRATION) PACK
50 PALFORZIA (40 MG DAILY DOSE) CSPK
50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
50 PALFORZIA INITIAL ESCALATION CSPK
50 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 34
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 85
palonosetron hcl soln 40 palonosetron hcl sosy 40 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 38 pamidronate disodium soln 47 pamidronate disodium solr 47 panlor tabs 27 PANRETIN GEL 56 pantoprazole sodium pack 40 PANTOPRAZOLE SODIUM SOLR 40 pantoprazole sodium tbec 20mg 40mg 40 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 52
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 57 PARICALCITOL SOLN 57 paroex soln 38 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 34 paroxetine hcl susp 34 paroxetine hcl tabs 10mg 20mg 34 paroxetine hcl tabs 30mg 40mg 34 paroxetine mesylate caps 34 paser pack 11 PEDIARIX SUSY 52 PEDVAX HIB SUSP 52 peg 3350electrolytes solr 41 peg 3350-kcl-na bicarb-nacl solr 41 peg-3350electrolytes solr 41 PEGANONE TABS 29 PEGASYS PROCLICK SOAJ
135mcg05ml 180mcg05ml 12 PEGASYS SOLN 12 PEGASYS SOSY 12 PEGINTRON KIT 12 PEG-PREP KIT 41 PEMAZYRE TABS 45mg 9mg 135mg 17 PEMFEXY SOLN 17 penicillamine caps 41 penicillamine tabs 41 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
PENTACEL SUSR 52 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 40 pentazocine-naloxone hcl tabs 27 pentobarbital sodium soln 31 pentoxifylline er tbcr 21 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 40 percocet tabs 27 perindopril erbumine tabs 2mg 4mg 8mg
25 periogard soln 38 PERJETA SOLN 17 permethrin crea 53 perphenazine tabs 2mg 4mg 8mg 16mg
34 perphenazine-amitriptyline tabs 34 PERSERIS PRSY 90mg 120mg 34 PEXEVA TABS 10mg 20mg 30mg 40mg
34 phenadoz supp 14 phenazo tabs 56 PHENAZOPYRIDINE HCL TABS 56 phenelzine sulfate tabs 34 phenergan soln 14 PHENOBARBITAL ELIX 31 PHENOBARBITAL SODIUM SOLN 31 PHENOBARBITAL TABS 31 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 20 PHENYLEPHRINE HCL SOLN 39 phenytek caps 200mg 300mg 29 phenytoin chew 29 phenytoin sodium extended caps 100mg
200mg 300mg 29 phenytoin sodium soln 29 phenytoin susp 29 PHESGO SOLN 17 PHOSLYRA SOLN 37 PHOSPHASAL TABS 13 PHOSPHOLINE IODIDE SOLR 39 phrenilin forte caps 27 PHYSIOLYTE SOLN 50 PHYSIOSOL IRRIGATION SOLN 50 PIFELTRO TABS 12 pilocarpine hcl soln 1 2 4 39 pilocarpine hcl tabs 5mg 75mg 19 pimecrolimus crea 57
86 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
pimozide tabs 1mg 2mg 34 pimtrea tabs 44 pindolol tabs 5mg 10mg 23 pioglitazone hcl tabs 15mg 30mg 45mg 45 pioglitazone hcl-glimepiride tabs 45 pioglitazone hcl-metformin hcl tabs 45 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 44 piroxicam caps 10mg 20mg 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN 32 PLEGRIDY SOSY 32 PLEGRIDY STARTER PACK SOPN 32 PLEGRIDY STARTER PACK SOSY 32 plenamine soln intravenous 36 podofilox soln 57 POLIVY SOLR 30mg 140mg 17 polocaine soln 50 polocaine-mpf soln 50 polycin oint 38 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 38 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 32 PONVORY TABS 32 portia-28 tabs 44 PORTRAZZA SOLN 17 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 35 POTASSIUM ACETATE SOLN 37 potassium chloride crys er tbcr 10meq
20meq 37 potassium chloride er cpcr 8meq 10meq 37 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 37 POTASSIUM CHLORIDE IN NACL SOLN
INTRAVENOUS 37 POTASSIUM CHLORIDE PACK 37 POTASSIUM CHLORIDE SOLN 10 20
37
potassium chloride soln intravenous 10meq100ml 20meq100ml 40meq100ml 2meqml 37
potassium citrate er tbcr 15meq 540mg 1080mg 35
POTASSIUM PHOSPHATES SOLN 37 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 37 POTELIGEO SOLN 17 PR BENZOYL PEROXIDE WASH LIQD 53 PRADAXA CAPS 75mg 110mg 150mg 21 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 31
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 31
PRAMOX GEL 56 prandin tabs 1mg 2mg 45 prasugrel hcl tabs 5mg 10mg 21 pravastatin sodium tabs 10mg 20mg
40mg 80mg 22 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22 PRED MILD SUSP 39 PRED-G SOP OINT 39 PRED-G SUSP 39 prednicarbate crea 55 prednicarbate oint 55 prednisolone acetate susp 39 prednisolone sodium phosphate soln 39 PREDNISOLONE SODIUM PHOSPHATE
SOLN 10mg5ml 20mg5ml 25mg5ml 5mg5ml 42
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 42
prednisolone soln 42 prednisone intensol conc 42 prednisone soln 42 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 42 prednisone tbpk 42 prefest tabs 45 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 29
pregabalin er tb24 825mg 165mg 330mg 27
pregabalin soln 29 PREHEVBRIO SUSP 52
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 87
PREMARIN SOLR 45 premasol soln intravenous 36 PRENATAL TABS 57 PRETOMANID TABS 11 prevalite pack 22 prevalite powd 22 previfem tabs 44 PREVYMIS SOLN 240mg12ml
480mg24ml 12 PREVYMIS TABS 240mg 480mg 12 PREZCOBIX TABS 12 PREZISTA SUSP 12 PREZISTA TABS 75mg 150mg 600mg
800mg 12 PRIFTIN TABS 11 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 29 primlev tabs 27 probenecid tabs 37 procainamide hcl soln 24 PROCALAMINE SOLN INTRAVENOUS 36 procentra soln 28 prochlorperazine edisylate soln 34 prochlorperazine maleate tabs 34 prochlorperazine supp 34 PROCRIT SOLN 20000unitml
40000unitml 22 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 22 proctofoam hc foam 56 procto-med hc crea 55 procto-pak crea 55 proctosol hc crea 55 proctozone-hc crea 55 PROCYSBI CPDR 25mg 75mg 50 PROCYSBI PACK 75mg 300mg 50 progesterone caps 100mg 200mg 46 progesterone oil 46 PROGRAF PACK 49 PROGRAF PACK 02mg 49 PROGRAF SOLN 49 prolate soln 27 prolate tabs 27 PROLEUKIN SOLR 17 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 24 propafenone hcl tabs 150mg 225mg
300mg 24 propantheline bromide tabs 19 proparacaine hcl soln 40 propranolol hcl er cp24 60mg 80mg
120mg 160mg 23 propranolol hcl soln 20mg5ml 40mg5ml 23 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 23 propranolol-hctz tabs 23 propylthiouracil tabs 47 PROQUAD SUSR 52 protriptyline hcl tabs 5mg 10mg 34 psorcon crea 55 PULMICORT FLEXHALER AEPB 51 PULMOZYME SOLN 38 PURIXAN SUSP 17 PYLERA CAPS 40 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 19 pyridostigmine bromide soln 19 pyridostigmine bromide tabs 30mg 60mg 19 pyrimethamine tabs 11 PYRUKYND TABS 5mg 20mg 50mg 50 PYRUKYND TAPER PACK TBPK 50
Q QDOLO SOLN 27 QINLOCK TABS 17 QUADRACEL SUSP 52 questran light powd 22 questran pack 22 questran powd 22 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 34 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 34 quinapril hcl tabs 5mg 10mg 20mg 40mg
25 quinapril-hydrochlorothiazide tabs 25 quinidine gluconate er tbcr 24 QUINIDINE GLUCONATE SOLN 24 quinidine sulfate tabs 200mg 300mg 24
88 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
quinine sulfate caps 11 QULIPTA TABS 10mg 30mg 60mg 30
R RABAVERT SUSR 52 rabeprazole sodium cpsp 40 rabeprazole sodium tbec 40 RADIAURA CREA 55 RADICAVA SOLN 32 raloxifene hcl tabs 45 ramelteon tabs 31 ramipril caps 125mg 25mg 5mg 10mg 25 ranolazine er tb12 500mg 1000mg 24 RAPIVAB SOLN 12 rasagiline mesylate tabs 05mg 1mg 31 RASUVO SOAJ 48 RAVICTI LIQD 35 RAYALDEE CPCR 57 REBETOL SOLN 12 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 32 REBIF REBIDOSE TITRATION PACK
SOAJ 32 REBIF SOSY 22mcg05ml 44mcg05ml 32 REBIF TITRATION PACK SOSY 32 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 44 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 52 RECORLEV TABS 50 RECTIV OINT 57 REGONOL SOLN 19 REGRANEX GEL 57 relafen ds tabs 27 RELENZA DISKHALER AEPB 12 RELEUKO SOLN 300mcgml
480mcg16ml 22 RELEUKO SOSY 300mcg05ml
480mcg08ml 22 relexxii tbcr 28 RELISTOR SOLN 8mg04ml 12mg06ml
41 RELISTOR TABS 41 reltone caps 200mg 400mg 41 REMICADE SOLR INTRAVENOUS 48 RENFLEXIS SOLR 48 repaglinide tabs 05mg 1mg 2mg 45 repaglinide-metformin hcl tabs 45
REPATHA SOSY 22 REPATHA SURECLICK SOAJ 22 RESCRIPTOR TABS 100mg 200mg 12 RESTASIS EMUL 39 RESTASIS MULTIDOSE EMUL 39 RETACRIT SOLN 22 RETACRIT SOLN 20000unitml 22 RETEVMO CAPS 40mg 80mg 17 RETIN-A CREA 0025 005 01 56 RETIN-A GEL 001 0025 56 RETIN-A MICRO GEL 004 01 56 RETIN-A MICRO PUMP GEL 004 01
56 RETISERT IMPL 39 RETROVIR SOLN 12 REVCOVI SOLN 38 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 17 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 34 REYATAZ PACK 12 REZUROCK TABS 50 RIABNI SOLN 100mg10ml 500mg50ml 17 ribasphere caps 12 ribasphere ribapak (1000 pack) tbpk 12 ribasphere ribapak (1200 pack) tbpk 12 ribasphere tabs 12 ribavirin caps 12 ribavirin solr 12 ribavirin tabs 13 RIDAURA CAPS 50 rifabutin caps 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 riluzole tabs 32 rimantadine hcl tabs 13 RIMSO-50 SOLN 50 RINGERS IRRIGATION SOLN 50 RINGERS SOLN 37 RINVOQ TB24 15mg 30mg 45mg 48 risedronate sodium tabs 5mg 30mg 35mg
150mg 47 risedronate sodium tbec 47 RISPERDAL CONSTA SRER 125mg
25mg 34 RISPERDAL CONSTA SRER 375mg
50mg 35
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 89
RISPERIDONE SOLN 35 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 35 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 35 ritonavir tabs 13 RITUXAN HYCELA SOLN 17 RITUXAN SOLN 17 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 44 rizatriptan benzoate tabs 30 rizatriptan benzoate tbdp 30 ROMIDEPSIN SOLN 17 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 31 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 31 ropivacaine hcl soln 50 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 22 ROTARIX SUSR 52 ROTATEQ SOLN 52 roweepra tabs 500mg 750mg 1000mg 29 roweepra xr tb24 500mg 750mg 29 ROZLYTREK CAPS 100mg 200mg 17 RUBRACA TABS 200mg 250mg 300mg 17 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 29 rufinamide tabs 200mg 400mg 29 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 17 RYBREVANT SOLN 17 ryclora soln 14 RYDAPT CAPS 17 RYLAZE SOLN 17 RYNODERM CREA 57 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 46 SAIZEN SOLR 5mg 88mg 46 SAIZENPREP SOLR 46 sajazir soln 21 SALEX SHAM 57 SALICYLIC ACID CREA 57
SALICYLIC ACID ER SOLN 57 SALICYLIC ACID FOAM 57 SALICYLIC ACID GEL 57 SALICYLIC ACID SHAM 57 SALICYLIC ACID-CLEANSER KIT 57 SALSALATE TABS 27 SANCUSO PTCH 40 SANDIMMUNE ORAL SOLN 100mgml 49 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 46 SANTYL OINT 57 SAPHNELO SOLN 49 SAPHRIS SUBL 25mg 5mg 10mg 35 sapropterin dihydrochloride pack 100mg
500mg 50 sapropterin dihydrochloride tabs 50 SARCLISA SOLN 500mg25ml 100mg5ml
17 SCEMBLIX TABS 20mg 40mg 17 scopolamine pt72 40 seconal caps 31 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 35 selegiline hcl caps 31 selegiline hcl tabs 31 selenium sulfide lotn 53 SELENIUM SULFIDE SHAM 53 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 13 SENSORCAINE SOLN 50 sensorcaineepinephrine soln 50 sensorcaine-mpf soln 50 sensorcaine-mpfepinephrine soln 50 SEREVENT DISKUS AEPB 20 SEROSTIM SOLR 4mg 5mg 6mg 46 SERTRALINE HCL CAPS 150mg 200mg
35 sertraline hcl conc 35 sertraline hcl tabs 25mg 50mg 100mg 35 setlakin tabs 44 sevelamer carbonate pack 08gm 24gm 36 sevelamer carbonate tabs 36 sevelamer hcl tabs 400mg 800mg 36 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 44 SHINGRIX SUSR 52 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 46
90 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
SIGNIFOR SOLN 03mgml 06mgml 09mgml 46
SIKLOS TABS 17 sildenafil citrate soln 25 sildenafil citrate susr 25 sildenafil citrate tabs 25 SILIQ SOSY 57 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 53 SIMPONI ARIA SOLN 48 SIMPONI SOAJ 50mg05ml 100mgml 48 SIMPONI SOSY 50mg05ml 100mgml 48 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 22 sirolimus soln 49 sirolimus tabs 05mg 1mg 2mg 49 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKYRIZI (150 MG DOSE) PSKT 57 SKYRIZI PEN SOAJ 57 SKYRIZI SOSY 57 SKYTROFA CART 3mg 36mg 43mg
52mg 63mg 76mg 91mg 11mg 133mg 46
sod benz-sod phenylacet soln 35 SODIUM ACETATE SOLN 35 SODIUM BICARBONATE SOLN 35 SODIUM CHLORIDE (PF) SOLN 37 SODIUM CHLORIDE SOLN 37 50 SODIUM CHLORIDE SOLN
INTRAVENOUS 045 09 3 5 37 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 50 SODIUM FLUORIDE SOLN 50 sodium phenylbutyrate powd 35 sodium phenylbutyrate tabs 35 SODIUM PHOSPHATES SOLN 37 sodium polystyrene sulfonate powd 36 sodium polystyrene sulfonate susp 36 sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 57 SOLTAMOX SOLN 17 SOLU-CORTEF SOLR 42 SOLU-MEDROL SOLR 42 SOMATULINE DEPOT SOLN 60mg02ml
90mg03ml 120mg05ml 46 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 46
sorine tabs 80mg 120mg 160mg 240mg 23
sotalol hcl (af) tabs 80mg 120mg 160mg 23 sotalol hcl tabs 80mg 120mg 160mg
240mg 23 SOTYLIZE SOLN 23 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 25 spironolactone-hctz tabs 25 SPRAVATO (56 MG DOSE) SOPK 35 SPRAVATO (84 MG DOSE) SOPK 35 sprintec 28 tabs 44 SPRITAM TB3D 250mg 500mg 750mg
1000mg 29 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 36 sronyx tabs 44 SSD CREA 53 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
57 STELARA SOSY 45mg05ml 90mgml 57 STERILE WATER FOR IRRIGATION SOLN
50 STIMATE SOLN 46 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18 STRENSIQ SOLN 18mg045ml
28mg07ml 80mg08ml 40mgml 38 streptomycin sulfate solr 10 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 20 SUBLOCADE SOSY 100mg05ml
300mg15ml 32 SUBSYS LIQD 1200mcg 1600mcg 27 subvenite starter kit-blue kit 29 subvenite starter kit-green kit 29 subvenite starter kit-orange kit 30 subvenite tabs 25mg 100mg 150mg
200mg 30 succinylcholine chloride soln 20 SUCRAID SOLN 38 sucralfate susp 40 sucralfate tabs 40
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 91
sulfacetamide sodium (acne) lotn 53 sulfacetamide sodium oint 38 sulfacetamide sodium soln 38 sulfacetamide-prednisolone soln 39 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 SULFAMYLON CREA 53 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 27 sumatriptan soln 30 sumatriptan succinate refill soct 30 sumatriptan succinate soaj 30 sumatriptan succinate soln 30 sumatriptan succinate sosy 30 sumatriptan succinate tabs 30 sunitinib malate caps 125mg 25mg
375mg 50mg 18 suprax chew 10 SUPREP BOWEL PREP KIT SOLN 41 SUSVIMO (IMPLANT 1ST FILL) SOLN 39 SUSVIMO (IMPLANT REFILL) SOLN 39 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 44 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 51 SYMDEKO TBPK 51 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 45 SYMLINPEN 60 SOPN 45 SYMPAZAN FILM 10mg 20mg 30 SYMPAZAN FILM 5mg 30 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 46 SYNDROS SOLN 40 SYNERCID SOLR 10 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 tacrolimus caps 05mg 1mg 5mg 49 TACROLIMUS OINT 01 003 57
tadalafil (pah) tabs 20mg 25 tadalafil tabs 25mg 5mg 25 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 50 TAKHZYRO SOSY 50 TALTZ SOAJ 57 TALTZ SOSY 57 TALZENNA CAPS 025mg 05mg 075mg
1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 47 taperdex 12-day tbpk 42 taperdex 6-day tbpk 42 taperdex 7-day tbpk 42 targadox tabs 10 TARGRETIN GEL 56 tarina 24 fe tabs 44 tarina fe 120 eq tabs 44 TARPEYO CPDR 42 TASIGNA CAPS 50mg 150mg 200mg 18 TAVALISSE TABS 100mg 150mg 22 TAVNEOS CAPS 50 taysofy caps 44 tazarotene crea 57 tazarotene foam 57 tazicef solr injection 10 tazicef solr intravenous 2gm 6gm 10 TAZORAC CREA 57 TAZORAC GEL 005 01 57 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 52 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TEFLARO SOLR INTRAVENOUS 10 TEGSEDI SOSY 50 telmisartan tabs 20mg 40mg 80mg 25 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 25 TEMAZEPAM CAPS 75mg 15mg 225mg
30mg 31 temsirolimus soln 18 tencon tabs 27 TENIPOSIDE SOLN 18 TENIVAC INJ 52 tenofovir disoproxil fumarate tabs 13
92 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TEPADINA SOLR 18 TEPEZZA SOLR 39 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 20 terbutaline sulfate tabs 25mg 5mg 20 terconazole crea 53 terconazole supp 53 TERIPARATIDE (RECOMBINANT) SOPN
46 testosterone cypionate soln 100mgml
200mgml 42 testosterone enanthate soln 42 testosterone gel 1 162
2025mg125gm 405mg25gm 10mgact 42
testosterone soln 42 tetrabenazine tabs 125mg 25mg 32 TETRACAINE HCL SOLN 40 tetracycline hcl caps 250mg 500mg 10 texacort soln 55 TEZSPIRE SOSY 51 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 57 theophylline er tb12 100mg 200mg
300mg 450mg 57 theophylline er tb24 400mg 600mg 57 theophylline soln 57 THIOLA EC TBEC 100mg 300mg 50 THIOLA TABS 50 thioridazine hcl tabs 10mg 25mg 50mg
100mg 35 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 35 THYROGEN SOLR 50 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
30 TIBSOVO TABS 18 TICOVAC SUSY 52 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 32 tilia fe tabs 44 timolol maleate (once-daily) soln 39 timolol maleate pf soln 39
TIMOLOL MALEATE SOLG 025 05 39 timolol maleate soln 025 05 39 timolol maleate tabs 5mg 10mg 20mg 23 tinidazole tabs 11 tiopronin tabs 50 TIS-U-SOL SOLN 50 TIVDAK SOLR 18 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 tizanidine hcl caps 20 tizanidine hcl tabs 20 TOBI PODHALER CAPS 51 TOBRADEX OINT 39 TOBRADEX ST SUSP 39 tobramycin nebu 300mg4ml 300mg5ml 51 tobramycin soln 38 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 39 TOBREX OINT 38 tofranil tabs 10mg 25mg 50mg 35 tolazamide tabs 250mg 500mg 45 tolbutamide tabs 45 tolcapone tabs 31 tolmetin sodium caps 27 tolmetin sodium tabs 27 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 57 tolterodine tartrate tabs 57 tolvaptan tabs 15mg 30mg 36 TOPEX TOPICAL ANESTHETIC AERO 56 topicort crea 005 025 55 topicort gel 55 topicort oint 55 topiramate cpsp 15mg 25mg 30 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 30 topiramate tabs 25mg 50mg 100mg
200mg 30 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
36 TPN ELECTROLYTES CONC
INTRAVENOUS 37 TRACLEER TBSO 51 TRADJENTA TABS 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 93
tramadol hcl er (biphasic) tb24 100mg 200mg 300mg 28
tramadol hcl er cp24 100mg 150mg 200mg 300mg 28
tramadol hcl er tb24 100mg 200mg 300mg 28
tramadol hcl soln 28 tramadol hcl tabs 50mg 100mg 28 tramadol-acetaminophen tabs 28 trandolapril tabs 1mg 2mg 4mg 25 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 21 tranexamic acid tabs 21 tranylcypromine sulfate tabs 35 TRAVASOL SOLN INTRAVENOUS 36 travoprost (bak free) soln 39 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 150mg 300mg 35 trazodone hcl tabs 50mg 100mg 35 TRECATOR TABS 11 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 57 TREMFYA SOSY 57 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 51 tretinoin caps 18 tretinoin crea 0025 005 01 56 tretinoin gel 001 0025 005 56 tretinoin microsphere gel 004 01 56 tretinoin microsphere pump gel 004
01 56 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 28 triamcinolone acetonide aers 55 triamcinolone acetonide crea 0025
01 05 55 triamcinolone acetonide lotn 0025 01
55 triamcinolone acetonide oint 0025
005 01 05 55 triamcinolone acetonide pste 55 triamcinolone acetonide susp 42 triamterene caps 50mg 100mg 36 triamterene-hctz caps 36 triamterene-hctz tabs 36 trianex oint 55 triazolam tabs 0125mg 025mg 31 TRICITRATES SOLN 35 triderm crea 01 05 55
trientine hcl caps 41 tri-estarylla tabs 44 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 35 trifluridine soln 38 trihexyphenidyl hcl soln 31 trihexyphenidyl hcl tabs 2mg 5mg 31 TRIKAFTA TBPK 51 tri-legest fe tabs 44 tri-lo-estarylla tabs 44 tri-lo-sprintec tabs 44 trilyte solr 41 trimethobenzamide hcl caps 40 TRIMETHOPRIM TABS 13 tri-mili tabs 44 trimipramine maleate caps 25mg 50mg
100mg 35 TRINESSA (28) TABS 44 TRINTELLIX TABS 5mg 10mg 20mg 35 tri-nymyo tabs 44 tri-previfem tabs 44 TRIPTODUR SRER 45 TRISENOX
SOLN 18 tri-sprintec tabs 44 tritocin oint 55 TRIUMEQ PD TBSO 13 TRIUMEQ TABS 13 trivora (28) tabs 44 tri-vylibra lo tabs 44 tri-vylibra tabs 44 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 30 TROPHAMINE SOLN INTRAVENOUS 36 trospium chloride er cp24 57 trospium chloride tabs 57 TRULANCE TABS 41 TRUMENBA SUSY 52 TRUSELTIQ (100MG DAILY DOSE) CPPK
18 TRUSELTIQ (125MG DAILY DOSE) CPPK
18 TRUSELTIQ (50MG DAILY DOSE) CPPK
18 TRUSELTIQ (75MG DAILY DOSE) CPPK
18
94 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 52 TYBOST TABS 13 tydemy tabs 44 tylenol with codeine 3 tabs 28 tylenol with codeine 4 tabs 28 TYMLOS SOPN 46 TYPHIM VI SOLN 52 TYPHIM VI SOSY 52 TYVASO REFILL SOLN 51 TYVASO STARTER SOLN 51
U UBRELVY TABS 50mg 100mg 30 UDENYCA SOSY 22 UKONIQ TABS 18 ULTOMIRIS SOLN 50 UMECTA MOUSSE FOAM 57 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
UNITUXIN SOLN 18 UPTRAVI SOLR 51 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 51
UPTRAVI TBPK 51 UREA CREA 39 57 UREA LOTN 40 57 UREA-C40 LOTN 57 urecholine tabs 5mg 10mg 25mg 50mg 20 uredeb crea 57 URETRON DS TABS 13 URIN DS TABS 13 ursodiol caps 200mg 400mg 41 ursodiol caps 300mg 41 ursodiol tabs 250mg 500mg 41 URYL TABS 13 USTELL CAPS 13 UTICAP CAPS 13 UTIRA-C TABS 13 UTRONA-C TABS 13
V VABYSMO SOLN 39 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 57 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 30 valproic acid caps 30 valproic acid soln 30 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
25 valsartan-hydrochlorothiazide tabs 25 VALTOCO 10 MG DOSE LIQD 30 VALTOCO 15 MG DOSE LQPK 30 VALTOCO 20 MG DOSE LQPK 30 VALTOCO 5 MG DOSE LIQD 30 vanatol lq soln 28 vancomycin hcl caps 10 vancomycin hcl solr 250mg5ml 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 vancomycin hcl solr intravenous 5gm
750mg 10 VANDAZOLE GEL 53 VANOXIDE-HC LOTN 55 VANTAS KIT 18 VAQTA SUSP 52 varenicline tartrate misc 19 varenicline tartrate tabs 05mg 1mg 19 VARIVAX INJ 52 VARIZIG SOLN 52 VASCEPA CAPS 1gm 22 VAXCHORA SUSR 53 vecamyl tabs 24 VECTICAL OINT 57 VEKLURY SOLN 13 VEKLURY SOLR 13 VELCADE SOLR 18 velivet tabs 44 VELPHORO CHEW 36 VELTASSA PACK 84gm 168gm 252gm
36 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 18 VENCLEXTA TABS 10mg 18 VENCLEXTA TABS 50mg 100mg 18
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 95
venlafaxine hcl er cp24 375mg 75mg 150mg 35
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg 35
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg 35
VENTAVIS SOLN 10mcgml 20mcgml 52 verapamil hcl er tbcr 120mg 180mg 240mg
24 verapamil hcl soln 24 verapamil hcl tabs 40mg 80mg 120mg 24 veripred 20 soln 42 VERKAZIA EMUL 39 VERSACLOZ SUSP 35 VERZENIO TABS 50mg 100mg 150mg
200mg 18 vestura tabs 44 VIBERZI TABS 75mg 100mg 41 vicodin es tabs 28 vicodin hp tabs 28 vicodin tabs 28 VICTOZA SOPN 45 VIDEX EC CPDR 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 44 vigabatrin pack 30 vigabatrin tabs 30 VIIBRYD STARTER PACK KIT 35 VIIBRYD TABS 10mg 20mg 40mg 35 VIJOICE TBPK 50 VILTEPSO SOLN 50 VIMIZIM SOLN 38 VIMPAT SOLN 30 vinblastine sulfate soln 18 vincasar pfs soln 18 vincristine sulfate soln 18 vinorelbine tartrate soln 18 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 47 VITRAKVI CAPS 25mg 100mg 18 VITRAKVI SOLN 18 VIVITROL SUSR 32 VIZIMPRO TABS 15mg 30mg 45mg 18 VOCABRIA TABS 13
VONJO CAPS 18 VORAXAZE SOLR 47 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 18 VOXZOGO SOLR 04mg 056mg 12mg 50 VPRIV SOLR 38 VRAYLAR CAPS 15mg 3mg 45mg 6mg
35 VRAYLAR CPPK 35 VUMERITY (STARTER) CPDR 50 VUMERITY CPDR 50 vyfemla tabs 44 vylibra tabs 44 VYNDAMAX CAPS 24 VYNDAQEL CAPS 24 VYONDYS 53 SOLN 50 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 28 VYVGART SOLN 50 VYXEOS SUSR 18
W WAKIX TABS 445mg 178mg 28 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 21 WATER FOR IRRIGATION STERILE
SOLN 50 WELIREG TABS 18 wixela inhub aepb 51 wymzya fe chew 44 WYNZORA CREA 55
X XALKORI CAPS 200mg 250mg 18 XARELTO STARTER PACK TBPK 21 XARELTO SUSR 21 XARELTO TABS 25mg 10mg 15mg
20mg 21 XATMEP SOLN 18 XCOPRI (250 MG DAILY DOSE) TBPK 30 XCOPRI (350 MG DAILY DOSE) TBPK 30 XCOPRI TABS 200mg 30 XCOPRI TABS 50mg 100mg 150mg 30 XCOPRI TBPK 30 XCOPRI TBPK 14x125mg amp 14x25mg 30
96 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
XELJANZ SOLN 48 XELJANZ TABS 5mg 10mg 48 XELJANZ XR TB24 11mg 22mg 48 XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 50 XERMELO TABS 40 XGEVA SOLN 47 XIFAXAN TABS 200mg 550mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 51 XOLAIR SOSY 75mg05ml 150mgml 51 XOSPATA TABS 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 18 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 18 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 XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 44 XUREA CREA 57 XURIDEN PACK 50 xylocaine dental soln 50 XYREM SOLN 32 XYWAV SOLN 32
Y YERVOY SOLN 19 YF-VAX INJ 53 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 39 yuvafem tabs 45
Z zafemy ptwk 44
zafirlukast tabs 10mg 20mg 51 zaleplon caps 5mg 10mg 31 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 44 zarontin soln 30 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 28 ZEJULA CAPS 19 ZELAPAR TBDP 31 ZELBORAF TABS 19 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
57 ZENPEP CPEP 38 zenzedi tabs 25mg 5mg 75mg 10mg
15mg 20mg 30mg 28 ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
32 ZEPOSIA CAPS 32 ZEPOSIA STARTER KIT CPPK 32 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERUVIA PTCH 56 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 51 ZIONODIL 100 LOTN 56 ZIONODIL LOTN 56 ziprasidone hcl caps 20mg 40mg 60mg
80mg 35 ziprasidone mesylate solr 35 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZOKINVY CAPS 50mg 75mg 50 zoledronic acid conc 47 zoledronic acid soln 47 ZOLINZA CAPS 19 zolmitriptan soln 30 zolmitriptan tabs 30 zolmitriptan tbdp 30 zolpidem tartrate er tbcr 625mg 125mg 31 zolpidem tartrate subl 175mg 35mg 31 zolpidem tartrate tabs 5mg 10mg 31 zonisamide caps 25mg 50mg 100mg 30 ZORBTIVE SOLR 46
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 97
ZORTRESS TABS 49 ZOSTAVAX SUSR 53 zovia 135 (28) tabs 44 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19
ZYKADIA TABS 19 ZYNLONTA SOLR 19 ZYPREXA RELPREVV SUSR 35 ZYTIGA TABS 19
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)
682896130 062022
This formulary was updated on 060122 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
kporgseniorrx Please recycle
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
4 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
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 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 5
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 2022 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 59 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg CIPRODEX) and generic drugs are listed in lower-case italics (eg amoxicillin) 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 2022 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
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 8 bull Kaiser Permanente 2022 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 azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP BICILLIN L-A SUSY cefaclor caps
Drug Name RequirementsLimits
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 intravenous 1gm 2gm 10gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 6gm HI
ceftazidime solr intravenous HI CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 750mg HI
cefuroxime sodium solr intravenous 15gm HI
cephalexin caps cephalexin susr cephalexin tabs chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w 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 2022 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
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 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 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
Drug Name RequirementsLimits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs erythromycin tbec FETROJA SOLR NDS 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 LYMEPAK 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
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium 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 10 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs 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 streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO suprax chew SYNERCID SOLR
Drug Name RequirementsLimits
targadox tabs MO tazicef solr injection HI tazicef solr intravenous 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
vancomycin hcl caps vancomycin hcl solr 250mg5ml vancomycin hcl solr intravenous 1gm 10gm 500mg HI
vancomycin hcl solr intravenous 5gm 750mg
XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ANTIFUNGALS AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS 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
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 2022 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS nystatin susp nystatin tabs 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 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 SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS
Drug Name RequirementsLimits
mefloquine hcl tabs metronidazole caps METRONIDAZOLE SOLN INTRAVENOUS 500mg100ml HI
metronidazole tabs nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs quinine sulfate caps NDS 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 APRETUDE SUER 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 DELSTRIGO TABS MO DESCOVY TABS 200-25mg MO DESCOVY TABS 120-15mg MO didanosine cpdr 200mg 250mg 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 12 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 PACK PANDS EPCLUSA TABS PANDS 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 LIVTENCITY TABS NDS lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO
Drug Name RequirementsLimits
maraviroc tabs 150mg 300mg MO MAVYRET PACK PANDS 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 oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEGASYS PROCLICK SOAJ 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN NDS PEGASYS SOSY NDS PEGINTRON KIT NDS PIFELTRO TABS MO 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
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 2022 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg MO sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS 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 PD TBSO MO TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEKLURY SOLN NDS VEKLURY SOLR NDS VEMLIDY TABS VIDEX EC CPDR 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
Drug Name RequirementsLimits
VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES 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 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg abiraterone acetate tabs 500mg NDS ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS NDS ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs arsenic trioxide soln NDS ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr
Drug Name RequirementsLimits
BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE SOLR BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS BESREMI SOSY NDS bexarotene caps NDS bicalutamide tabs 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 CAMCEVI PRSY CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR 50mg 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
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 2022 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
CYCLOPHOSPHAMIDE SOLN 2gm10ml 1gm5ml 500mg25ml
NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr 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 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 eulexin caps NDS
Drug Name RequirementsLimits
everolimus tabs 25mg 5mg 75mg 10mg NDS
everolimus tbso 2mg 3mg 5mg NDS EVOMELA SOLR NDS exemestane tabs EXKIVITY CAPS NDS FARYDAK CAPS 10mg 15mg 20mg LDNDS
FENSOLVI (6 MONTH) KIT 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 FYARRO SUSR 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 6000000unitml 10000000unitml
NDS
INTRON A SOLR 10000000unit 18000000unit 50000000unit 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 KIMMTRAK 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
lenalidomide caps 5mg 10mg 15mg 25mg NDS
Drug Name RequirementsLimits
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
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 TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA 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 2022 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
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 methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS nelarabine soln 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 120mg12ml 240mg24ml 40mg4ml
NDS
OPDUALAG SOLN NDS oxaliplatin soln oxaliplatin solr paclitaxel conc PACLITAXEL PROTEIN-BOUND PART SUSR 100 MG NDS
PADCEV SOLR 20mg 30mg NDS
Drug Name RequirementsLimits
paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEMFEXY SOLN 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 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
SCEMBLIX TABS 20mg 40mg NDS SIKLOS TABS NDS SOLTAMOX SOLN
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
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 05mg 075mg 1mg NDS
tamoxifen citrate tabs 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 TIVDAK SOLR 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 NDS
TRODELVY SOLR NDS
Drug Name RequirementsLimits
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 UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln 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
VONJO CAPS NDS VOTRIENT TABS NDS VYXEOS SUSR NDS WELIREG TABS 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
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 2022 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
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 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 ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO chlordiazepoxide-clidinium caps dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate oral soln MO glycopyrrolate pf sosy glycopyrrolate soln injection glycopyrrolate tabs 1mg 2mg MO
Drug Name RequirementsLimits
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 RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO varenicline tartrate misc MO varenicline tartrate tabs 05mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA FLEQSUVY SUSP NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs 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
Drug Name RequirementsLimits
albuterol sulfate er tb12 4mg 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcgact MONDS
albuterol sulfate nebu 0083 25mg05ml 063mg3ml 125mg3ml
PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY ipratropium-albuterol soln PAMO isoproterenol hcl soln LEVALBUTEROL HCL NEBU 125mg05ml 125mg3ml 031mg3ml 063mg3ml
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 SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS icatibant acetate 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 2022 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
OXBRYTA TABS NDS OXBRYTA TBSO NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS 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 BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln NDS enoxaparin sodium sosy 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
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 NDS LOVENOX SOSY 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg 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 SUSR NDS XARELTO TABS 25mg 10mg 15mg 20mg MO
HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
EPOGEN SOLN PANDS FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
PROCRIT SOLN 20000unitml 40000unitml PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RELEUKO SOLN 300mcgml 480mcg16ml NDS
RELEUKO SOSY 300mcg05ml 480mcg08ml NDS
RETACRIT SOLN 20000unitml PANDS RETACRIT SOLN PANDS TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS 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 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
Drug Name RequirementsLimits
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 150mg MO fenofibrate micronized caps 43mg 67mg 130mg 134mg 200mg
MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg 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
lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
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 SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 1gm MO BETA-ADRENERGIC BLOCKING 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 2022 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
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
ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
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
nadololbendroflumethiazide 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
Drug Name RequirementsLimits
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 cartia xt cp24 120mg 180mg 240mg 300mg MO
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 40mg 80mg 120mg MO
CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR SOLN MO CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln 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 lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy
Drug Name RequirementsLimits
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 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
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 2022 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
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
captopril-hydrochlorothiazide 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
quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
Drug Name RequirementsLimits
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO 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 dipyridamole tabs 25mg 50mg 75mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ascomp-codeine caps NDS benzhydrocodone-acetaminophen tabs NDS
bupap tabs 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 NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS dvorah tabs 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
Drug Name RequirementsLimits
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
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 hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd 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 NDS indomethacin caps indomethacin er cpcr indomethacin sodium solr ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lorcet hd tabs NDS lorcet plus 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln NDS meperidine hcl tabs 50mg NDS methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl tabs 5mg 10mg NDS MORPHINE SULFATE (CONCENTRATE) SOLN NDS
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 tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln 10mgml 20mgml NDS
nalfon tabs nalocet tabs NDS naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs
Drug Name RequirementsLimits
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 75-300mg 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 relafen ds tabs NDS SALSALATE TABS SUBSYS LIQD 1200mcg 1600mcg PANDS
sulindac tabs tencon tabs tolmetin sodium caps tolmetin sodium tabs
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 soln 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 tabs NDS vicodin es tabs NDS vicodin hp tabs NDS zebutal caps ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS amphetamine er suer NDS 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 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
evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS
Drug Name RequirementsLimits
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
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS procentra soln NDS relexxii tbcr NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
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
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 2022 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
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
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 EPRONTIA SOLN 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 lacosamide tabs 50mg 100mg 150mg 200mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
Drug Name RequirementsLimits
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
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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg 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 VALTOCO 15 MG DOSE LQPK VALTOCO 20 MG DOSE LQPK VALTOCO 5 MG DOSE LIQD vigabatrin pack LDNDS vigabatrin tabs NDS VIMPAT SOLN XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200mg NDS XCOPRI TBPK 14x125mg amp 14x25mg
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ PA AJOVY SOSY PA almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs
Drug Name RequirementsLimits
ergotamine-caffeine tabs FROVATRIPTAN SUCCINATE TABS
naratriptan hcl tabs NURTEC TBDP NDS QULIPTA TABS 10mg 30mg 60mg NDS
rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs UBRELVY TABS 50mg 100mg NDS zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl soln MO amantadine hcl tabs MO APOKYN SOCT NDS apomorphine hcl 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
EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg 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 2022 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
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
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
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 intensol conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS droperidol soln estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
Drug Name RequirementsLimits
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP PANDS 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 nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs seconal caps TEMAZEPAM CAPS 75mg 15mg 225mg 30mg 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS tetrabenazine tabs 125mg 25mg MO
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
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 1mg 2mg NDS
OCREVUS SOLN PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
Drug Name RequirementsLimits
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 ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS OPIATE ANTAGONISTS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
LUCEMYRA TABS NDS naloxone hcl liqd naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
VIVITROL SUSR NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg 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 2022 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
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 conc 30mgml 100mgml MO
chlorpromazine hcl soln chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
CITALOPRAM HYDROBROMIDE CAPS MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
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 HAFYERA SUSY INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 150mg 300mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
LITHIUM CARBONATE TABS MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
LYBALVI TABS NDS maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
Drug Name RequirementsLimits
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 susp MO paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps 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
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
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 2022 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
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 CAPS 150mg 200mg MO
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
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 MO trazodone hcl tabs 150mg 300mg 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
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 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 TRICITRATES SOLN AMMONIA DETOXICANTS carglumic acid tbso NDS constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN DEXTROSE SOLN INTRAVENOUS 5 10 HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE 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
Drug Name RequirementsLimits
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI furosemide tabs 20mg 40mg 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN tolvaptan tabs 15mg 30mg 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 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
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 2022 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate tabs MO CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
DEXTROSE-NACL SOLN INTRAVENOUS 25-045 5-02 5-045 5-09
HI
DEXTROSE-NACL SOLN INTRAVENOUS 10-02 10-045
HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 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 PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
Drug Name RequirementsLimits
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 10meq100ml 20meq100ml 40meq100ml 2meqml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN 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 ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME 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 38 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin oint bacitracin-polymyxin b oint bleph-10 soln chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin 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 paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln
Drug Name RequirementsLimits
sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ANTI-INFLAMMATORY AGENTS bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
CEQUA SOLN CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO cyclosporine emul MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO difluprednate emul MO flac oil 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
ILUVIEN IMPL ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint 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 2022 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
RESTASIS EMUL MO RESTASIS MULTIDOSE EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
VERKAZIA EMUL NDS YUTIQ IMPL ANTIALLERGIC AGENTS azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
betaxolol hcl soln MO bimatoprost soln MO brimonidine tartrate soln 015 02 MO
brinzolamide susp MO carteolol hcl soln MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
Drug Name RequirementsLimits
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO timolol maleate (once-daily) soln MO timolol maleate pf soln MO TIMOLOL MALEATE SOLG 025 05 MO
timolol maleate soln 025 05 MO
travoprost (bak free) 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 SUSVIMO (IMPLANT 1ST FILL) SOLN
SUSVIMO (IMPLANT REFILL) SOLN
TEPEZZA SOLR NDS VABYSMO SOLN LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lidocaine viscous hcl soln MO proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
balsalazide disodium caps MO colazal caps 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 OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS aprepitant caps PANDS dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl sosy ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy
Drug Name RequirementsLimits
SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS trimethobenzamide hcl caps PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc 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 famotidine (pf) soln 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 omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate 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 2022 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS 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 IBSRELA TABS NDS LIVMARLI SOLN NDS lubiprostone caps 8mcg 24mcg MO metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS TRULANCE TABS 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
Drug Name RequirementsLimits
clovique caps NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs deferasirox tbso deferiprone tabs 500mg 1000mg NDS
deferoxamine mesylate solr FERRIPROX SOLN LDNDS FERRIPROX TABS LDNDS FERRIPROX TWICE-A-DAY TABS NDS
penicillamine caps NDS penicillamine tabs NDS trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP ALKINDI SPRINKLE CPSP 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs 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 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp 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 10mg5ml 20mg5ml 25mg5ml 5mg5ml
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 SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TARPEYO CPDR NDS triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
danazol caps 50mg 100mg 200mg MO
Drug Name RequirementsLimits
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 405mg25gm 10mgact
MO
testosterone soln 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 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 enpresse-28 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 2022 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
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 jasmiel tabs MO JOLIVETTE 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
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
Drug Name RequirementsLimits
levora 01530 (28) 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 24 fe tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA 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 nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO nylia 135 tabs MO nylia 777 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 44 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 taysofy caps 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 wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135 (28) tabs MO
Drug Name RequirementsLimits
DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
AFREZZA POWD 90x8 UNIT amp 90x12 UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD 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 glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO HUMALOG KWIKPEN SOPN MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
JARDIANCE TABS 10mg 25mg MO KORLYM TABS LDNDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO metformin hcl er tb24 500mg 750mg 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 2022 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
OZEMPIC (2 MGDOSE) SOPN MO pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO tolazamide tabs 250mg 500mg MO tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
depo-estradiol oil dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
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 MO
Drug Name RequirementsLimits
006mg24hr 0075mg24hr 01mg24hr estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO fyavolv tabs MO jinteli tabs MO lopreeza tabs MO lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO prefest tabs MO PREMARIN SOLR raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PANDS CORTROPHIN GEL PANDS desmopressin ace spray refrig soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln desmopressin acetate tabs 01mg 02mg MO
SKYTROFA CART 3mg 36mg 43mg 52mg 63mg 76mg 91mg 11mg 133mg
NDS
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO 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 progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR NDS
Drug Name RequirementsLimits
EGRIFTA SV SOLR NDS GENOTROPIN CART 12mg PANDS GENOTROPIN MINIQUICK PRSY 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
HUMATROPE CART 6mg 12mg 24mg PANDS
HUMATROPE SOLR PANDS INCRELEX SOLN NDS LANREOTIDE ACETATE SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
octreotide acetate soln 50mcgml 100mcgml 200mcgml
octreotide acetate soln 500mcgml 1000mcgml
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 60mg02ml 90mg03ml 120mg05ml
NDS
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 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 2022 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 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 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
Drug Name RequirementsLimits
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 BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 70mg MO alendronate sodium tabs 5mg 10mg 35mg 40mg MO
EVENITY SOSY NDS IBANDRONATE SODIUM SOLN ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr 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 CIBINQO TABS 50mg 100mg 200mg NDS
CIMZIA KIT PANDS CIMZIA PREFILLED PSKT PANDS CIMZIA STARTER KIT PSKT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
INFLIXIMAB SOLR INTRAVENOUS HI
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 RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 15mg 30mg 45mg NDS
SIMPONI ARIA SOLN NDS
Drug Name RequirementsLimits
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 ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
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
ZORTRESS TABS PA MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BERINERT KIT INTRAVENOUS HI betaine powd NDS 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
Drug Name RequirementsLimits
CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENJAYMO SOLN 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 HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ONPATTRO SOLN NDS 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
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 PYRUKYND TABS 5mg 20mg 50mg NDS
PYRUKYND TAPER PACK TBPK NDS
RECORLEV TABS NDS REZUROCK TABS NDS
Drug Name RequirementsLimits
RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln 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 STERILE WATER FOR IRRIGATION SOLN
TAKHZYRO SOLN NDS TAKHZYRO SOSY NDS TAVNEOS CAPS NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR NDS tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VIJOICE TBPK NDS VILTEPSO SOLN NDS VOXZOGO SOLR 04mg 056mg 12mg NDS
VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS VYVGART SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg 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 2022 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 100mg067ml 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 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 ADVAIR HFA AERO 230-21mcgact MO
ADVAIR HFA AERO 45-21mcgact 115-21mcgact MO
Drug Name RequirementsLimits
ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS HI
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
DALIRESP TABS 250mcg 500mcg MO
FLOVENT HFA AERO MO fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PULMICORT FLEXHALER AEPB
SYMBICORT AERO TEZSPIRE SOSY NDS wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg 1000mcg 1200mcg 1400mcg 1600mcg
NDS
UPTRAVI TBPK NDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS HI
GAMUNEX-C SOLN INJECTION HI HYPERHEP B SOLN HYPERHEP B SOSY HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 1gm20ml 2gm20ml
HI
PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
VARIZIG SOLN TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP KINRIX SUSY QUADRACEL SUSP TDVAX SUSP
Drug Name RequirementsLimits
TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP BOOSTRIX SUSY 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 SOLN MENQUADFI SOLN MENVEO SOLR PEDIARIX SUSY PEDVAX HIB SUSP PENTACEL SUSR PREHEVBRIO SUSP PA PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TICOVAC SUSY TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN TYPHIM VI SOSY VAQTA SUSP VARIVAX INJ
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 2022 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint 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 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 clindamycin phosphate soln MO clindamycin phosphate swab MO clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn econazole nitrate crea ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA
Drug Name RequirementsLimits
gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham mafenide acetate pack malathion lotn metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea mupirocin oint naftifine hcl crea naftifine hcl gel neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ovide lotn oxiconazole nitrate crea permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 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
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
Drug Name RequirementsLimits
clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT 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 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
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO FLURANDRENOLIDE CREA 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 2022 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
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 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 prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO
Drug Name RequirementsLimits
psorcon crea MO RADIAURA CREA NDS texacort soln MO topicort crea 005 025 MO topicort gel MO topicort oint 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 VANOXIDE-HC LOTN WYNZORA CREA NDS ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
HYDROCORTISONE ACE-PRAMOXINE SUPP NDS
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 LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS 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
TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS 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
Drug Name RequirementsLimits
adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ADBRY SOSY NDS ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
azelaic acid gel MO AZELEX CREA MO 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
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA 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 KORSUVA SOLN NDS LACTIC ACID LOTN
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 2022 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
OPZELURA CREA 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 SHAM SALICYLIC ACID-CLEANSER KIT
SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SKYRIZI PEN SOAJ SKYRIZI SOSY STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
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 TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS
Drug Name RequirementsLimits
VECTICAL OINT MO XUREA CREA zenatane caps 10mg 20mg 30mg 40mg NDS
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 calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS
58 bull Kaiser Permanente 2018 Defined Standard Comprehensive Formulary
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 59
Index of Drugs
A abacavir sulfate soln 11 abacavir sulfate tabs 11 abacavir sulfate-lamivudine tabs 11 abacavir-lamivudine-zidovudine tabs 11 ABILIFY MAINTENA PRSY 300mg 400mg
32 ABILIFY MAINTENA SRER 300mg 400mg
32 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
abiraterone acetate tabs 250mg 14 abiraterone acetate tabs 500mg 14 ABRAXANE SUSR 14 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 56 acamprosate calcium tbec 25 acarbose tabs 25mg 50mg 100mg 44 accutane caps 10mg 20mg 30mg 40mg 56 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 26 acetaminophen-codeine soln 26 acetaminophen-codeine tabs 26 acetazolamide er cp12 39 acetazolamide sodium solr 39 acetazolamide tabs 125mg 250mg 39 ACETIC ACID SOLN 39 49 acetylcysteine soln 10 20 47 acitretin caps 10mg 175mg 25mg 56 ACTEMRA ACTPEN SOAJ 47 ACTEMRA SOSY 47 ACTHAR GEL 46 ACTHIB SOLR 52 ACTIMMUNE SOLN 49 acyclovir caps 11 acyclovir oint 53 acyclovir sodium soln intravenous 11 acyclovir susp 11
acyclovir tabs 400mg 800mg 11 ADACEL SUSP 52 ADAGEN SOLN 37 ADAKVEO SOLN 20 ADAPALENE CREA 56 adapalene gel 01 03 56 adapalene pads 56 adapalene soln 56 adapalene-benzoyl peroxide gel 56 ADAPALENE-BENZOYL PEROXIDE PADS
56 ADBRY SOSY 56 adderall tabs 28 adefovir dipivoxil tabs 11 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 51 adenosine soln 24 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 230-21mcgact 51 ADVAIR HFA AERO 45-21mcgact 115-
21mcgact 51 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 14 AFREZZA POWD 90x8 UNIT amp 90x12 UNIT
44 AJOVY SOAJ 30 AJOVY SOSY 30 ala-cort crea 1 25 54 albendazole tabs 8 albuterol sulfate er tb12 4mg 8mg 20 ALBUTEROL SULFATE HFA AERS
108mcgact 20 albuterol sulfate nebu 0083
25mg05ml 063mg3ml 125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 54 alclometasone dipropionate oint 54 ALCOHOL PREP PADS 35 ALDURAZYME SOLN 37 ALECENSA CAPS 14
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alendronate sodium soln 47 alendronate sodium tabs 5mg 10mg
35mg 40mg 47 alendronate sodium tabs 70mg 47 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 41 ALKINDI SPRINKLE CPSP 1mg 2mg 5mg
41 allopurinol sodium solr 47 allopurinol tabs 100mg 300mg 47 allzital tabs 26 almotriptan malate tabs 30 alogliptin benzoate tabs 625mg 125mg
25mg 44 ALOGLIPTIN-METFORMIN HCL TABS 44 alogliptin-pioglitazone tabs 44 ALOSETRON HCL TABS 05mg 1mg 40 alprazolam er tb24 05mg 1mg 2mg 3mg
31 alprazolam intensol conc 31 alprazolam tabs 025mg 05mg 1mg 2mg
31 alprazolam tbdp 025mg 05mg 1mg 2mg
31 ALTACAINE SOLN 39 ALTAFRIN SOLN 39 altavera tabs 42 ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 51 alyacen 135 tabs 42 alyq tabs 25 amabelz tabs 45 amantadine hcl caps 30 amantadine hcl soln 30 amantadine hcl tabs 30 AMBISOME SUSR INTRAVENOUS 10 ambrisentan tabs 51 amcinonide crea 54 amcinonide lotn 54 amcinonide oint 54 amethia lo tabs 42 amethia tabs 42 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 36
amiloride-hydrochlorothiazide tabs 36 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 57 amiodarone hcl soln 24 amiodarone hcl tabs 100mg 200mg
400mg 24 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 33 amlodipine besy-benazepril hcl caps 23 amlodipine besylate tabs 25mg 5mg
10mg 23 amlodipine besylate-valsartan tabs 23 amlodipine-atorvastatin tabs 23 amlodipine-olmesartan tabs 23 amlodipine-valsartan-hctz tabs 23 ammonium lactate crea 56 ammonium lactate lotn 56 amnesteem caps 10mg 20mg 40mg 56 AMONDYS 45 SOLN 49 amoxapine tabs 25mg 50mg 100mg
150mg 33 amoxicill-clarithro-lansopraz misc 40 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8 amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 28 amphetamine sulfate tabs 5mg 10mg 28 amphetamine-dextroamphet er cp24 28 amphetamine-dextroamphetamine tabs 28 amphotericin b solr intravenous 10 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 42 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 55 anastrozole tabs 14
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 61
ANDRODERM PT24 2mg24hr 4mg24hr 42
antabuse tabs 250mg 500mg 25 anusol-hc crea 54 apap-caff-dihydrocodeine tabs 26 apexicon e crea 54 APLENZIN TB24 174mg 348mg 522mg 33 APOKYN SOCT 30 apomorphine hcl soct 30 apraclonidine hcl soln 39 aprepitant caps 40 APRETUDE SUER 11 apri tabs 42 APTIOM TABS 200mg 400mg 600mg
800mg 28 APTIVUS CAPS 11 APTIVUS SOLN 11 ARALAST NP SOLR INTRAVENOUS 51 aranelle tabs 42 ARANESP (ALBUMIN FREE) SOLN
60mcgml 100mcgml 200mcgml 21 ARANESP (ALBUMIN FREE) SOSY
60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 21
ARCALYST SOLR 49 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 49 ARIKAYCE SUSP 8 aripiprazole soln 33 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 33 aripiprazole tbdp 10mg 15mg 33 ARISTADA INITIO PRSY 33 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 33
armodafinil tabs 50mg 150mg 200mg 250mg 28
arsenic trioxide soln 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 49 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 52 ascomp-codeine caps 26 asenapine maleate subl 25mg 5mg 10mg
33
ashlyna tabs 42 ASMANEX HFA AERO 100mcgact
200mcgact 51 ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 48 ASTAGRAF XL CP24 05mg 1mg 48 atazanavir sulfate caps 150mg 200mg
300mg 11 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 31 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 22 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 39 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 32 aubra eq tabs 42 AUGMENTIN SUSR 8 AURYXIA TABS 36 AUSTEDO TABS 6mg 9mg 12mg 31 AVASTIN SOLN 14 AVC VAGINAL CREA 53 aviane tabs 42 AVITA CREA 56 AVITA GEL 56 AVONEX KIT 32 AVONEX PEN AJKT 32 AVONEX PREFILLED PSKT 32 AVSOLA SOLR 47 aygestin tabs 46 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 48 azathioprine sodium solr 48 azathioprine tabs 48 azelaic acid gel 56 azelastine hcl soln 005 01 015 39 azelastine-fluticasone susp 39 AZELEX CREA 56 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
62 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
B bacitracin oint 38 bacitracin solr 8 bacitracin-polymyxin b oint 38 bacitra-neomycin-polymyxin-hc oint 38 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 53 BAFIERTAM CPDR 32 balsalazide disodium caps 40 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 42 BANZEL SUSP 28 BANZEL TABS 200mg 400mg 28 BAQSIMI ONE PACK POWD 44 BAQSIMI TWO PACK POWD 44 BARACLUDE SOLN 11 BAVENCIO SOLN 14 BCG VACCINE SOLR 14 BD INSULIN SYR ULTRAFINE II MISC 35 BD INSULIN SYRINGE MISC 35 BD INSULIN SYRINGE UF MISC 35 BD PEN NEEDLE ORIGINAL UF MISC 35 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 32 BELEODAQ SOLR 14 BELRAPZO SOLN 14 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 14 BENDEKA SOLN 14 BENLYSTA SOAJ 48 BENLYSTA SOLR 48 BENLYSTA SOSY 48 BENZEPRO CREAMY WASH LIQD 53 BENZEPRO FOAMING CLOTHS MISC 53 benzhydrocodone-acetaminophen tabs 26 benzoyl perox-hydrocortisone lotn 54 BENZOYL PEROXIDE FORTE- HC LOTN
54 BENZOYL PEROXIDE GEL 53 benzoyl peroxide-erythromycin gel 53 benztropine mesylate soln 30 benztropine mesylate tabs 05mg 1mg
2mg 30 BEOVU SOLN 39 bepotastine besilate soln 39
BERINERT KIT INTRAVENOUS 49 beser lotn 54 BESPONSA SOLR 14 BESREMI SOSY 14 betaine powd 49 betamethasone dipropionate aug crea 54 betamethasone dipropionate aug gel 54 betamethasone dipropionate aug lotn 54 betamethasone dipropionate aug oint 54 betamethasone dipropionate crea 54 betamethasone dipropionate lotn 54 BETAMETHASONE DIPROPIONATE OINT
54 betamethasone sod phos amp acet susp 41 betamethasone valerate crea 54 betamethasone valerate foam 54 BETAMETHASONE VALERATE LOTN 54 BETAMETHASONE VALERATE OINT 54 BETASERON KIT 32 betaxolol hcl soln 39 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 19 bexarotene caps 14 BEXSERO SUSY 52 bicalutamide tabs 14 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICILLIN L-A SUSY 8 BIKTARVY TABS 11 bimatoprost soln 39 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23 bleomycin sulfate solr 14 bleph-10 soln 38 blephamide sop oint 38 BLEPHAMIDE SUSP 38 BLINCYTO SOLR 14 blisovi 24 fe tabs 42 blisovi fe 1530 tabs 42 BOOSTRIX SUSP 52 BOOSTRIX SUSY 52 BORTEZOMIB SOLR 14 bosentan tabs 51 BOSULIF TABS 100mg 400mg 500mg 14 BRAFTOVI CAPS 50mg 75mg 14 briellyn tabs 42 BRILINTA TABS 60mg 90mg 21
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 63
brimonidine tartrate soln 015 02 39 brinzolamide susp 39 BRIVIACT SOLN 28 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 28 bromfenac sodium (once-daily) soln 38 bromocriptine mesylate caps 30 bromocriptine mesylate tabs 30 BRONCHITOL CAPS 51 BROVANA NEBU 20 BRUKINSA CAPS 14 budesonide cpep 41 budesonide er tb24 41 budesonide susp 025mg2ml 05mg2ml
1mg2ml 51 bumetanide soln 36 bumetanide tabs 05mg 1mg 2mg 36 bupap tabs 26 bupivacaine hcl (pf) soln 49 bupivacaine hcl soln 49 BUPIVACAINE IN DEXTROSE SOLN 49 bupivacaine spinal soln 49 bupivacaine-epinephrine (pf) soln 49 bupivacaine-epinephrine soln 49 buprenorphine hcl subl 2mg 8mg 32 buprenorphine hcl-naloxone hcl film 32 buprenorphine hcl-naloxone hcl subl 32 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 32 bupropion hcl er (smoking det) tb12 33 bupropion hcl er (sr) tb12 100mg 150mg
200mg 33 bupropion hcl er (xl) tb24 150mg 300mg
450mg 33 bupropion hcl tabs 75mg 100mg 33 buspirone hcl tabs 5mg 10mg 31 buspirone hcl tabs 75mg 15mg 30mg 31 busulfan soln 14 butalbital-acetaminophen tabs 26 butalbital-apap-caff-cod caps 26 butalbital-apap-caffeine caps 26 butalbital-apap-caffeine tabs 26 butalbital-asa-caff-codeine caps 26 butalbital-aspirin-caffeine caps 26 butalbital-aspirin-caffeine tabs 26 butorphanol tartrate soln 26 BYLVAY (PELLETS) CPSP 200mcg
600mcg 41 BYLVAY CAPS 400mcg 1200mcg 41
C CABENUVA SUER 11 cabergoline tabs 30 CABLIVI KIT 21 CABOMETYX TABS 20mg 40mg 60mg 14 cafergot tabs 30 caffeine citrate soln 28 calcipotriene crea 56 calcipotriene oint 56 calcipotriene soln 56 calcipotriene-betameth diprop oint 54 calcipotriene-betameth diprop susp 54 calcitonin (salmon) soln 45 calcitrene oint 56 calcitriol caps 025mcg 05mcg 57 CALCITRIOL OINT 56 calcitriol soln 57 calcium acetate (phos binder) caps 37 calcium acetate tabs 37 CALCIUM GLUCONATE-NACL SOLN 37 CALQUENCE CAPS 14 CAMCEVI PRSY 14 camila tabs 42 camrese lo tabs 42 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 54 CAPLYTA CAPS 33 CAPRELSA TABS 100mg 300mg 14 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 25 CARAC CREA 56 carbamazepine chew 28 carbamazepine er cp12 100mg 200mg
300mg 28 carbamazepine er tb12 100mg 200mg
400mg 28 carbamazepine susp 28 carbamazepine tabs 28 carbidopa tabs 30 carbidopa-levodopa er tbcr 30 carbidopa-levodopa tabs 30 carbidopa-levodopa tbdp 30 carbidopa-levodopa-entacapone tabs 30 carbinoxamine maleate soln 13
64 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
carbinoxamine maleate tabs 13 carboplatin soln 14 carboprost tromethamine soln 45 CARDENE IV SOLN 23 carglumic acid tbso 35 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 14 CARNITOR SOLN 49 CARNITOR TABS 49 carteolol hcl soln 39 cartia xt cp24 120mg 180mg 240mg
300mg 23 carvedilol phosphate er cp24 10mg 20mg
40mg 80mg 23 carvedilol tabs 3125mg 625mg 125mg
25mg 23 caspofungin acetate solr intravenous 50mg
70mg 10 CAYSTON SOLR 51 caziant tabs 42 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 intravenous 1gm 2gm
10gm 8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 6gm 8 ceftazidime solr intravenous 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 750mg 8 cefuroxime sodium solr intravenous 15gm 8 celecoxib caps 26 CELONTIN CAPS 29 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 38 CERDELGA CAPS 37 CEREZYME SOLR 37 CEROVEL LOTN 56 cetirizine hcl soln 13 CEVIMELINE HCL CAPS 19 CHANTIX CONTINUING MONTH PAK
TABS 19 CHANTIX STARTING MONTH PAK TABS
19 CHANTIX TABS 05mg 1mg 19 CHEMET CAPS 41 chloramphenicol sod succinate solr 8 chlordiazepoxide hcl caps 5mg 10mg
25mg 31 chlordiazepoxide-amitriptyline tabs 33 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 38 chloroprocaine hcl (pf) soln 49 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 36 chlorothiazide tabs 250mg 500mg 36 chlorpromazine hcl conc 30mgml
100mgml 33 chlorpromazine hcl soln 33 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 33 chlorthalidone tabs 25mg 50mg 36 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 41 cholestyramine light pack 22 cholestyramine light powd 22 cholestyramine pack 22 cholestyramine powd 22 CHORIONIC GONADOTROPIN SOLR 45 CIBINQO TABS 50mg 100mg 200mg 47 ciclopirox gel 53 ciclopirox olamine crea 53
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 65
ciclopirox olamine susp 53 ciclopirox sham 53 ciclopirox soln 53 cidofovir soln 11 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 38 CIMDUO TABS 11 cimetidine hcl soln 40 cimetidine tabs 200mg 300mg 400mg
800mg 40 CIMZIA KIT 47 CIMZIA PREFILLED PSKT 47 CIMZIA STARTER KIT PSKT 47 cinacalcet hcl tabs 30mg 60mg 90mg 45 CINQAIR SOLN 51 CINRYZE SOLR INTRAVENOUS 49 CIPRODEX SUSP 38 ciprofloxacin hcl soln (ophth) 38 CIPROFLOXACIN HCL SOLN (OTIC) 38 ciprofloxacin hcl tabs 8 ciprofloxacin in d5w soln 8 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 38 cisplatin soln 14 CISPLATIN SOLR 50mg 14 CITALOPRAM HYDROBROMIDE CAPS 33 citalopram hydrobromide soln 33 citalopram hydrobromide tabs 10mg 20mg
40mg 33 citanest plain dental soln 49 cladribine soln 14 claravis caps 10mg 20mg 30mg 40mg 56 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 13 cleocin phosphate soln 9 cleocin solr 9 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
clindacin-p swab 53 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 53 clindamycin phosphate crea 53
clindamycin phosphate foam 53 clindamycin phosphate gel 53 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 53 clindamycin phosphate soln 9 53 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 53 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 36 clinisol sf soln intravenous 36 clobazam susp 29 clobazam tabs 10mg 20mg 29 clobetasol propionate crea 54 clobetasol propionate e crea 54 clobetasol propionate emulsion foam 54 clobetasol propionate foam 54 clobetasol propionate gel 54 clobetasol propionate liqd 54 clobetasol propionate lotn 54 clobetasol propionate oint 54 clobetasol propionate sham 54 clobetasol propionate soln 54 clocortolone pivalate crea 54 clocortolone pivalate pump crea 54 clofarabine soln 14 clomipramine hcl caps 25mg 50mg 75mg
33 clonazepam tabs 05mg 1mg 2mg 29 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 29 clonidine hcl (analgesia) soln 24
66 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
clonidine hcl er tb12 24 clonidine hcl tabs 01mg 02mg 03mg 24 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 24 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 31 clotrimazole crea 53 clotrimazole soln 53 clotrimazole troc 53 clotrimazole-betamethasone crea 53 clotrimazole-betamethasone lotn 53 clovique caps 41 clozapine tabs 25mg 50mg 100mg 200mg
33 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 33 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 26 colazal caps 40 COLCHICINE CAPS 47 colchicine tabs 47 colchicine-probenecid tabs 37 COLESEVELAM HCL PACK 22 colesevelam hcl tabs 22 colestipol hcl gran 22 colestipol hcl pack 22 colestipol hcl tabs 22 colistimethate sodium (cba) solr injection 9 colocort enem 54 COLY-MYCIN S SUSP 38 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 14 COMETRIQ (140 MG DAILY DOSE) KIT 14 COMETRIQ (60 MG DAILY DOSE) KIT 14 COMPLERA TABS 11 compro supp 33 CONSENSI TABS 23 constulose soln 35 COPIKTRA CAPS 15mg 25mg 14 CORDRAN TAPE 54 CORLANOR SOLN 24 CORLANOR TABS 5mg 75mg 24 cortisone acetate tabs 41 CORTISPORIN CREA 54 CORTISPORIN OINT 54 CORTROPHIN GEL 46 COSELA SOLR 49
COSENTYX (300 MG DOSE) SOSY 56 COSENTYX SENSOREADY (300 MG)
SOAJ 56 COSENTYX SENSOREADY PEN SOAJ 56 COSENTYX SOSY 75mg05ml 150mgml
56 COTELLIC TABS 14 CREON CPEP 37 CRESEMBA CAPS 10 CRESEMBA SOLR 10 CRIXIVAN CAPS 200mg 400mg 11 cromolyn sodium conc 51 cromolyn sodium nebu 51 cromolyn sodium soln 39 crotan lotn 53 cryselle-28 tabs 42 CRYSVITA SOLN 10mgml 20mgml
30mgml 49 CURITY GAUZE PADS 35 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 52
cyclafem 135 tabs 42 cyclafem 777 tabs 42 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 14 CYCLOPHOSPHAMIDE SOLN 2gm10ml
1gm5ml 500mg25ml 15 cyclophosphamide solr 15 cycloserine caps 11 cyclosporine caps 25mg 100mg 48 cyclosporine emul 38 cyclosporine modified caps 25mg 50mg
100mg 48 cyclosporine modified soln 48 cyclosporine soln 48 cyproheptadine hcl syrp 13 cyproheptadine hcl tabs 13 CYRAMZA SOLN 100mg10ml
500mg50ml 15 CYSTADANE POWD 49 CYSTADROPS SOLN 39 CYSTAGON CAPS 50mg 150mg 49 CYSTARAN SOLN 39 cytarabine (pf) soln 15 cytarabine soln 15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 67
CYTOGAM INJ 52
D dacarbazine solr 15 dactinomycin solr 15 dalfampridine er tb12 32 DALIRESP TABS 250mcg 500mcg 51 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 42 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 56 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 52 daptomycin solr intravenous 350mg 500mg
9 darifenacin hydrobromide er tb24 75mg
15mg 57 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 deblitane tabs 42 decadron tabs 5mg 75mg 41 decadron tabs 4mg 6mg 41 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 41 deferasirox tabs 41 deferasirox tbso 41 deferiprone tabs 500mg 1000mg 41 deferoxamine mesylate solr 41 DELSTRIGO TABS 11 deltasone tabs 41 delyla tabs 42 demeclocycline hcl tabs 9 DEMSER CAPS 22 depo-estradiol oil 45 DEPO-MEDROL SUSP 41 DEPO-PROVERA SUSP 400mgml 46 DEPO-SUBQ PROVERA 104 SUSY 46 depo-testosterone soln 100mgml
200mgml 42 DERMOTIC OIL 38 DESCOVY TABS 120-15mg 11 DESCOVY TABS 200-25mg 11
desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg 33
desloratadine tabs 13 desloratadine tbdp 13 desmopressin ace spray refrig soln 46 DESMOPRESSIN ACETATE SOLN 46 desmopressin acetate spray soln 46 desmopressin acetate tabs 01mg 02mg 46 desogestrel-ethinyl estradiol tabs 42 desonide crea 54 desonide gel 54 desonide lotn 54 desonide oint 54 desowen lotn 54 desoximetasone crea 005 025 54 desoximetasone gel 54 desoximetasone liqd 54 desoximetasone oint 005 025 54 desrx gel 54 DESVENLAFAXINE ER TB24 50mg
100mg 33 desvenlafaxine succinate er tb24 25mg
50mg 100mg 33 dexabliss tbpk 41 dexamethasone elix 41 dexamethasone intensol conc 41 dexamethasone sodium phosphate soln 38
41 dexamethasone soln 41 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 41 dexamethasone tbpk 41 dexchlorpheniramine maleate soln 13 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 28
dexmethylphenidate hcl tabs 25mg 5mg 10mg 28
dexpak 10 day tbpk 41 dexpak 13 day tbpk 41 dexpak 6 day tbpk 41 dexrazoxane hcl solr 49 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 28 dextroamphetamine sulfate soln 28 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 28 DEXTROSE IN LACTATED RINGERS
SOLN 37
68 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
DEXTROSE SOLN 36 DEXTROSE SOLN INTRAVENOUS 5
10 36 DEXTROSE-NACL SOLN INTRAVENOUS
10-02 10-045 37 DEXTROSE-NACL SOLN INTRAVENOUS
25-045 5-02 5-045 5-09 37 DIACOMIT CAPS 250mg 500mg 29 DIACOMIT PACK 250mg 500mg 29 DIASTAT ACUDIAL GEL 10mg 20mg 29 DIASTAT PEDIATRIC GEL 29 diazepam conc 31 diazepam gel 25mg 10mg 20mg 29 diazepam intensol conc 31 diazepam soln 5mg5ml 5mgml 31 diazepam tabs 2mg 5mg 10mg 31 diazoxide susp 44 diclofenac sodium er tb24 26 diclofenac sodium gel 1 3 54 diclofenac sodium soln 38 diclofenac sodium tbec 26 diclofenac-misoprostol tbec 26 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 11 DIFFERIN CREA 56 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 54 diflorasone diacetate oint 54 diflunisal tabs 26 difluprednate emul 38 digitek tabs 0125mg 025mg 24 digox tabs 24 digoxin soln 24 digoxin tabs 125mcg 250mcg 24 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 29 dilantin infatabs chew 29 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 23 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 23
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 23
diltiazem hcl er cp12 60mg 90mg 120mg 23
diltiazem hcl er cp24 120mg 180mg 240mg 23
diltiazem hcl soln 23 diltiazem hcl solr 23 diltiazem hcl tabs 30mg 60mg 90mg
120mg 23 dilt-xr cp24 120mg 180mg 240mg 23 dimenhydrinate soln 40 dimethyl fumarate cpdr 32 dimethyl fumarate starter pack misc 32 DIPENTUM CAPS 40 diphen elix 13 di-phen elix 13 diphenhydramine hcl elix 13 diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 40 diphenoxylate-atropine tabs 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 52 dipyridamole tabs 25mg 50mg 75mg 25 disopyramide phosphate caps 100mg
150mg 24 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 36 divalproex sodium csdr 29 divalproex sodium er tb24 250mg 500mg29 divalproex sodium tbec 125mg 250mg
500mg 29 dobutamine hcl soln 20 DOBUTAMINE IN D5W SOLN 20 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
24 dolishale tabs 42 donepezil hcl tabs 5mg 10mg 23mg 19 donepezil hcl tbdp 5mg 10mg 19 dopamine hcl soln 20 DOPAMINE IN D5W SOLN 20 DOPTELET TABS 21 dorzolamide hcl soln 39 dorzolamide hcl-timolol mal pf soln 39 dorzolamide hcl-timolol mal soln 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 69
dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 33 doxepin hcl conc 33 doxepin hcl crea 55 doxepin hcl tabs 3mg 6mg 33 doxercalciferol caps 05mcg 1mcg 25mcg
57 DOXERCALCIFEROL SOLN 57 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
150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 40 DRIZALMA SPRINKLE CSDR 33 dronabinol caps 25mg 5mg 10mg 40 droperidol soln 31 drospiren-eth estrad-levomefol tabs 42 drospirenone-ethinyl estradiol tabs 42 DROXIA CAPS 15 droxidopa caps 20 DUAKLIR PRESSAIR AEPB 19 DUEXIS TABS 26 duloxetine hcl cpep 20mg 30mg 40mg
60mg 33 DUPIXENT SOPN 200mg114ml
300mg2ml 51 DUPIXENT SOSY 100mg067ml
200mg114ml 300mg2ml 51 DURYSTA IMPL 39 dutasteride caps 47 dutasteride-tamsulosin hcl caps 47 dvorah tabs 26 dxevo 11-day tbpk 41
E ees 400 tabs 9 EASYGEL GEL 49 econazole nitrate crea 53 EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 46 EGRIFTA SV SOLR 46 ELAPRASE SOLN 37 ELELYSO SOLR 37 ELEPSIA XR TB24 1000mg 1500mg 29 eletriptan hydrobromide tabs 30 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 37 elixophyllin elix 57 ELLA TABS 42 ELLENCE SOLN 15 ELMIRON CAPS 49 eluryng ring 42 ELZONRIS SOLN 15 EMCYT CAPS 15 EMFLAZA SUSP 42 EMFLAZA TABS 6mg 18mg 30mg 36mg
42 EMPAVELI SOLN 49 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 30 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 25 enalaprilat inj 25 enalapril-hydrochlorothiazide tabs 25 ENBREL MINI SOCT 47 ENBREL SOLN 47 ENBREL SOLR 47 ENBREL SOSY 25mg05ml 50mgml 48 ENBREL SURECLICK SOAJ 48 ENDARI PACK 49 endocet tabs 26 ENDOMETRIN INST 46
70 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ENGERIX-B SUSP 10mcg05ml 20mcgml 52
ENHERTU SOLR 15 ENJAYMO SOLN 49 enoxaparin sodium soln 21 enoxaparin sodium sosy 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
enpresse-28 tabs 42 ENSPRYNG SOSY 49 ENSTILAR FOAM 54 entacapone tabs 30 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 25 ENTYVIO SOLR 41 enulose soln 35 ENVARSUS XR TB24 075mg 1mg 4mg48 EPCLUSA PACK 12 EPCLUSA TABS 12 EPIDIOLEX SOLN 29 epifoam foam 54 epinastine hcl soln 39 epinephrine (anaphylaxis) soln 20 epinephrine soaj 20 EPINEPHRINE SOSY 20 epirubicin hcl soln 15 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 25 EPOGEN SOLN 21 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 21 epoprostenol sodium solr 51 EPRONTIA SOLN 29 eprosartan mesylate tabs 25 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 33 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 30 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 43 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 53 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 53 erythromycin oint 38 erythromycin pads 53 erythromycin soln 53 erythromycin tbec 9 ESBRIET CAPS 51 ESBRIET TABS 267mg 801mg 51 escitalopram oxalate soln 33 escitalopram oxalate tabs 5mg 10mg
20mg 33 esgic caps 26 esgic tabs 26 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 40 esomeprazole magnesium pack 10mg
20mg 40mg 40 esomeprazole sodium solr 40 estarylla tabs 43 estazolam tabs 1mg 2mg 31 estrace crea 45 estrace tabs 05mg 1mg 2mg 45 estradiol crea 45 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
estradiol tabs 10mcg 05mg 1mg 2mg 45 estradiol valerate oil 45 estradiol-norethindrone acet tabs 45 ESTRING RING 45 eszopiclone tabs 1mg 2mg 3mg 31 ethacrynic acid tabs 36 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 29 ethosuximide soln 29 ethynodiol diac-eth estradiol tabs 43 etodolac caps 26
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 71
etodolac er tb24 26 etodolac tabs 26 etonogestrel-ethinyl estradiol ring 43 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 eulexin caps 15 EURAX CREA 53 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 46
evekeo tabs 5mg 10mg 28 EVENITY SOSY 47 everolimus tabs 025mg 48 everolimus tabs 05mg 075mg 1mg 48 everolimus tabs 25mg 5mg 75mg 10mg
15 everolimus tbso 2mg 3mg 5mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 22 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 49 exemestane tabs 15 EXKIVITY CAPS 15 EXONDYS 51 SOLN 500mg10ml
100mg2ml 49 EXSERVAN FILM 31 EXTAVIA KIT 32 EYLEA SOLN 39 EYLEA SOSY 39 ezetimibe tabs 22 ezetimibe-simvastatin tabs 22
F FABRAZYME SOLR 5mg 35mg 37 falmina tabs 43 famciclovir tabs 125mg 250mg 500mg 12 famotidine (pf) soln 40 famotidine premixed soln 40 famotidine soln 40 famotidine susr 40 famotidine tabs 20mg 40mg 40 FANAPT TABS 1mg 2mg 4mg 6mg 8mg
10mg 12mg 33 FANAPT TITRATION PACK TABS 33 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 51 FASENRA SOSY 51
fayosim tabs 43 febuxostat tabs 40mg 80mg 47 felbamate susp 29 felbamate tabs 400mg 600mg 29 felodipine er tb24 25mg 5mg 10mg 23 femynor tabs 43 fenofibrate caps 50mg 150mg 22 fenofibrate micronized caps 43mg 67mg
130mg 134mg 200mg 22 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 22 fenofibric acid cpdr 45mg 135mg 22 fenoprofen calcium caps 26 fenoprofen calcium tabs 26 fenortho caps 26 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 26 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 26
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 26
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 26
FERRIPROX SOLN 41 FERRIPROX TABS 41 FERRIPROX TWICE-A-DAY TABS 41 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
33 FETZIMA TITRATION C4PK 33 fexmid tabs 20 finasteride tabs 47 FINTEPLA SOLN 29 fioricet caps 26 fioricetcodeine caps 26 FIRDAPSE TABS 49 FIRMAGON (240 MG DOSE) SOLR 15 FIRMAGON SOLR 15 flac oil 38 flavoxate hcl tabs 57 FLEBOGAMMA DIF SOLN INTRAVENOUS
52 flecainide acetate tabs 50mg 100mg
150mg 24 FLEQSUVY SUSP 20 FLOVENT HFA AERO 51 floxuridine solr 15
72 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
fluconazole in sodium chloride soln intravenous 10
fluconazole susr 10 fluconazole tabs 10 flucytosine caps 250mg 500mg 10 fludarabine phosphate soln 15 fludarabine phosphate solr 15 fludrocortisone acetate tabs 42 flumazenil soln 31 flunisolide soln 38 fluocinolone acetonide body oil 54 fluocinolone acetonide crea 001 0025
54 fluocinolone acetonide oil 38 fluocinolone acetonide oint 54 fluocinolone acetonide scalp oil 54 fluocinolone acetonide soln 54 fluocinonide crea 54 fluocinonide emulsified base crea 54 FLUOCINONIDE GEL 54 fluocinonide oint 54 fluocinonide soln 54 FLUORITAB CHEW 025mg 05mg 1mg 49 FLUORITAB SOLN 49 fluorometholone susp 38 fluorouracil crea 5 56 fluorouracil crea 5 56 fluorouracil soln 15 56 fluorouracil soln 2 5 56 fluoxetine hcl (pmdd) tabs 10mg 20mg 33 fluoxetine hcl caps 10mg 20mg 40mg 33 fluoxetine hcl cpdr 33 fluoxetine hcl soln 33 fluoxetine hcl tabs 10mg 20mg 60mg 33 fluphenazine decanoate soln 33 fluphenazine hcl conc 33 fluphenazine hcl elix 33 fluphenazine hcl soln 33 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 34 FLURANDRENOLIDE CREA 54 flurandrenolide lotn 55 flurandrenolide oint 55 flurazepam hcl caps 15mg 30mg 31 flurbiprofen sodium soln 38 flurbiprofen tabs 26 flutamide caps 15 fluticasone propionate crea 55 fluticasone propionate lotn 55
fluticasone propionate oint 55 fluticasone propionate susp 38 fluticasone-salmeterol aepb 51 fluvastatin sodium caps 20mg 40mg 22 fluvastatin sodium er tb24 22 fluvoxamine maleate er cp24 100mg
150mg 34 fluvoxamine maleate tabs 25mg 50mg
100mg 34 FML FORTE SUSP 38 FML OINT 38 fomepizole soln 47 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 FORTEO SOPN 45 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 40 fosfomycin tromethamine pack 13 fosinopril sodium tabs 10mg 20mg 40mg
25 fosinopril sodium-hctz tabs 25 fosphenytoin sodium soln 29 FOTIVDA CAPS 089mg 134mg 15 FROVATRIPTAN SUCCINATE TABS 30 FULPHILA SOSY 21 fulvestrant soln 15 furosemide soln 8mgml 10mgml 36 furosemide soln injection 36 furosemide tabs 20mg 40mg 80mg 36 FUZEON SOLR 12 FYARRO SUSR 15 fyavolv tabs 45 FYCOMPA SUSP 29 FYCOMPA TABS 29
G gabapentin caps 100mg 400mg 29 gabapentin soln 29 gabapentin tabs 600mg 800mg 29 GALAFOLD CAPS 49 galantamine hydrobromide er cp24 8mg
16mg 24mg 19 galantamine hydrobromide soln 19 galantamine hydrobromide tabs 4mg 8mg
12mg 19 GAMASTAN INJ 52 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 48
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 73
GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm 52
GAMMAGARD SOLN INJECTION 52 GAMMAKED SOLN INJECTION 52 GAMMAPLEX SOLN INTRAVENOUS 52 GAMUNEX-C SOLN INJECTION 52 ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 52 GARDASIL 9 SUSY 52 gatifloxacin soln 38 GATTEX KIT 41 gavilyte-c solr 41 gavilyte-g solr 41 gavilyte-h kit 41 gavilyte-n with flavor pack solr 41 GAVRETO CAPS 15 GAZYVA SOLN 15 gemcitabine hcl soln 15 gemcitabine hcl solr 15 gemfibrozil tabs 22 gemmily caps 43 generlac soln 35 gengraf caps 25mg 50mg 100mg 48 gengraf soln 48 GENOTROPIN CART 12mg 46 GENOTROPIN MINIQUICK PRSY 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 46
gentak oint 38 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 53 gentamicin sulfate oint 53 gentamicin sulfate soln 9 38 gentamicin sulfate soln injection 9 GENVOYA TABS 12 gianvi tabs 43 GILENYA CAPS 025mg 05mg 32 GILOTRIF TABS 20mg 30mg 40mg 15 GIMOTI SOLN 41 GIVLAARI SOLN 49 GLASSIA SOLN INTRAVENOUS 51 glatopa sosy 20mgml 40mgml 32 glimepiride tabs 1mg 2mg 4mg 44 glipizide er tb24 25mg 5mg 10mg 44 glipizide tabs 5mg 10mg 44 glipizide-metformin hcl tabs 44 glucagon emergency kit 44
glyburide micronized tabs 15mg 3mg 6mg 44
glyburide tabs 125mg 25mg 5mg 44 glyburide-metformin tabs 44 glycate tabs 19 glycopyrrolate oral soln 19 glycopyrrolate pf sosy 19 glycopyrrolate soln injection 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 55 granisetron hcl soln 40 granisetron hcl tabs 40 GRANIX SOLN 480mcg16ml 300mcgml
21 GRANIX SOSY 300mcg05ml
480mcg08ml 21 GRASTEK SUBL 49 griseofulvin microsize susp 10 griseofulvin microsize tabs 10 griseofulvin ultramicrosize tabs 10 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 32 guanfacine hcl tabs 1mg 2mg 24 GUANIDINE HCL TABS 19 gynazole-1 crea 53
H HAEGARDA SOLR 2000unit 3000unit 49 hailey 24 fe tabs 43 halcinonide crea 55 halobetasol propionate crea 55 HALOBETASOL PROPIONATE FOAM 55 halobetasol propionate oint 55 haloperidol decanoate soln 34 haloperidol lactate conc 34 haloperidol lactate soln 34 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 34 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 52 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
HEPLISAV-B SOLN 52
74 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
HERCEPTIN HYLECTA SOLN 15 HERCEPTIN SOLR 150mg 440mg 15 HERZUMA SOLR 150mg 420mg 15 HETLIOZ CAPS 31 HETLIOZ LQ SUSP 31 HIBERIX SOLR 52 HUMALOG KWIKPEN SOPN 44 HUMALOG SOCT 44 HUMALOG SOLN 44 humatin caps 11 HUMATROPE CART 6mg 12mg 24mg 46 HUMATROPE SOLR 46 HUMIRA PEDIATRIC CROHNS START
PSKT 48 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 48 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 48 HUMIRA PEN-PEDIATRIC UC START
PNKT 48 HUMIRA PEN-PSUVADOL HS START
PNKT 48 HUMIRA PEN-PSORUVEIT STARTER
PNKT 48 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 48
HUMULIN 7030 KWIKPEN SUPN 44 HUMULIN 7030 SUSP 44 HUMULIN N KWIKPEN SUPN 44 HUMULIN N SUSP 44 HUMULIN R SOLN 44 HUMULIN R U-500 (CONCENTRATED)
SOLN 44 HUMULIN R U-500 KWIKPEN SOPN 44 hydralazine hcl soln 24 hydralazine hcl tabs 10mg 25mg 50mg
100mg 24 hydrochlorothiazide caps 36 hydrochlorothiazide tabs 125mg 25mg
50mg 36 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 26 hydrocodone-acetaminophen soln 26 hydrocodone-acetaminophen tabs 26 hydrocodone-ibuprofen tabs 26 hydrocortisone (perianal) crea 1 25 55 hydrocortisone ace-pramoxine crea 55
HYDROCORTISONE ACE-PRAMOXINE SUPP 55
hydrocortisone butyr lipo base crea 55 hydrocortisone butyrate crea 55 hydrocortisone butyrate lotn 55 HYDROCORTISONE BUTYRATE OINT 55 hydrocortisone butyrate soln 55 hydrocortisone crea 1 25 55 hydrocortisone enem 55 hydrocortisone lotn 55 hydrocortisone oint 1 25 55 hydrocortisone tabs 5mg 10mg 20mg 42 hydrocortisone valerate crea 55 hydrocortisone valerate oint 55 HYDROCORTISONE-ACETIC ACID SOLN
38 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 26 hydromorphone hcl liqd 26 hydromorphone hcl tabs 2mg 4mg 8mg 26 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 46 hydroxyprogesterone caproate soln 46 hydroxyurea caps 15 hydroxyzine hcl soln 31 hydroxyzine hcl syrp 31 hydroxyzine hcl tabs 31 hydroxyzine pamoate caps 31 HYPERHEP B SOLN 52 HYPERHEP B SOSY 52 HYPERRAB SD SOLN 52 HYQVIA KIT 52
I IBANDRONATE SODIUM SOLN 47 ibandronate sodium tabs 47 IBRANCE CAPS 75mg 100mg 125mg 15 IBRANCE TABS 75mg 100mg 125mg 15 IBSRELA TABS 41 ibu tabs 26 ibudone tabs 26 ibuprofen lysine soln 26 ibuprofen susp 26 ibuprofen tabs 26 ibutilide fumarate soln 24 icatibant acetate soln 20 iclevia tabs 43 ICLUSIG TABS 10mg 15mg 30mg 45mg
15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 75
icosapent ethyl caps 22 IDAMYCIN PFS SOLN 15 idarubicin hcl soln 15 IDHIFA TABS 50mg 100mg 15 ifosfamide soln 15 IFOSFAMIDE SOLR 16 ILARIS SOLN 26 ILUMYA SOSY 56 ILUVIEN IMPL 38 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 34 imipramine pamoate caps 75mg 100mg
125mg 150mg 34 imiquimod crea 375 5 56 IMIQUIMOD PUMP CREA 56 IMOGAM RABIES-HT SOLN 52 IMOVAX RABIES INJ 52 IMPAVIDO CAPS 11 INBRIJA CAPS 30 incassia tabs 43 INCRELEX SOLN 46 indapamide tabs 125mg 25mg 36 indocin supp 26 indomethacin caps 26 indomethacin er cpcr 26 indomethacin sodium solr 26 INFANRIX SUSP 52 INFLECTRA SOLR INTRAVENOUS 48 INFLIXIMAB SOLR INTRAVENOUS 48 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 32 INGREZZA CPPK 32 INLYTA TABS 1mg 5mg 16 INQOVI TABS 16 INREBIC CAPS 16 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 36 INTRON A SOLN 6000000unitml
10000000unitml 16 INTRON A SOLR 10000000unit
18000000unit 50000000unit 16 introvale tabs 43 INVEGA HAFYERA SUSY 34
INVEGA SUSTENNA SUSY 39mg025ml 34
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml 34
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml 34
INVIRASE CAPS 12 INVIRASE TABS 12 IOPIDINE SOLN 39 IPOL INJ 52 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 20 irbesartan tabs 75mg 150mg 300mg 25 irbesartan-hydrochlorothiazide tabs 25 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 20 isosorbide dinitrate er tbcr 25 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 25 isosorbide mononitrate er tb24 25 isosorbide mononitrate er tb24 30mg 60mg
25 isosorbide mononitrate tabs 10mg 20mg 25 isotretinoin caps 10mg 20mg 30mg 40mg
56 isradipine caps 25mg 5mg 23 ISTURISA TABS 1mg 5mg 10mg 49 itraconazole caps 10 ITRACONAZOLE SOLN 10 ivermectin crea 53 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 52
J JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16
76 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg 21
JARDIANCE TABS 10mg 25mg 44 jasmiel tabs 43 JEMPERLI SOLN 16 jinteli tabs 45 JOLIVETTE TABS 43 JULUCA TABS 12 junel 1530 tabs 43 junel 120 tabs 43 junel fe 1530 tabs 43 junel fe 120 tabs 43 junel fe 24 tabs 43 JUXTAPID CAPS 5mg 10mg 20mg 30mg
40mg 60mg 22 JYNARQUE TABS 15mg 30mg 36 JYNARQUE TBPK 36
K KADCYLA SOLR 100mg 160mg 16 kaitlib fe chew 43 KALYDECO PACK 25mg 50mg 75mg 51 KALYDECO TABS 51 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 37 kariva tabs 43 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ 37
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ 37
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS 37
KEDRAB SOLN 52 kelnor 135 tabs 43 kelnor 150 tabs 43 KENALOG SUSP 42 KEPIVANCE SOLR 56 KERALYT SHAM 56 KESIMPTA SOAJ 49 ketoconazole crea 53 ketoconazole foam 53 ketoconazole sham 53 ketoconazole tabs 10 ketodan foam 53 ketoprofen caps 26 ketoprofen er cp24 26 ketorolac tromethamine soln 26 38
ketorolac tromethamine soln 04 05 38 ketorolac tromethamine tabs 26 KEVEYIS TABS 49 KEVZARA SOAJ 150mg114ml
200mg114ml 48 KEVZARA SOSY 150mg114ml
200mg114ml 48 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 47 KHEDEZLA TB24 50mg 100mg 34 KIMMTRAK SOLN 16 KIMYRSA SOLR 9 KINERET SOSY 48 KINRIX SUSP 52 KINRIX SUSY 52 kionex susp 36 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KISQALI FEMARA(200 MG DOSE) TBPK
16 KITABIS PAK NEBU 51 KLISYRI OINT 56 KLOR-CON 10 TBCR 37 klor-con m15 tbcr 37 klor-con m20 tbcr 37 klor-con pack 37 klor-con sprinkle cpcr 8meq 10meq 37 KLOR-CON TBCR 37 KORLYM TABS 44 KORSUVA SOLN 56 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 35 K-TAB TBCR 37 kurvelo tabs 43 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 30 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 lacosamide tabs 50mg 100mg 150mg
200mg 29
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 77
LACRISERT INST 39 LACTATED RINGERS SOLN 37 49 LACTIC ACID LOTN 56 lactulose encephalopathy soln 35 lactulose pack 35 lactulose soln 35 LAMICTAL XR KIT 29 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 29 lamotrigine er tb24 25mg 50mg 100mg
200mg 250mg 300mg 29 lamotrigine kit 29 lamotrigine starter kit-blue kit 29 lamotrigine starter kit-green kit 29 lamotrigine starter kit-orange kit 29 lamotrigine tabs 25mg 100mg 150mg
200mg 29 lamotrigine tbdp 25mg 50mg 100mg
200mg 29 LANOXIN PEDIATRIC SOLN 24 LANREOTIDE ACETATE SOLN 46 lansoprazole cpdr 15mg 30mg 40 lansoprazole tbdd 15mg 30mg 40 lanthanum carbonate chew 500mg 750mg
1000mg 36 LANTUS SOLN 44 LANTUS SOLOSTAR SOPN 44 lapatinib ditosylate tabs 16 larin 1530 tabs 43 larin 120 tabs 43 larin fe 1530 tabs 43 larin fe 120 tabs 43 larissia tabs 43 LARTRUVO SOLN 190mg19ml
500mg50ml 16 latanoprost soln 39 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 34 LAYOLIS FE CHEW 43 LAZANDA SOLN 100mcgact 400mcgact
26 ledipasvir-sofosbuvir tabs 12 leena tabs 43 leflunomide tabs 10mg 20mg 48 LEMTRADA SOLN 32 lenalidomide caps 5mg 10mg 15mg 25mg
16
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 16 lessina tabs 43 letrozole tabs 16 leucovorin calcium soln 47 leucovorin calcium solr 47 leucovorin calcium tabs 5mg 10mg 15mg
25mg 47 LEUKERAN TABS 16 LEUKINE SOLR 21 leuprolide acetate kit 16 LEVALBUTEROL HCL NEBU
125mg05ml 125mg3ml 031mg3ml 063mg3ml 20
levalbuterol tartrate aero 20 levetiracetam er tb24 500mg 750mg 29 levetiracetam in nacl soln 29 levetiracetam soln 29 levetiracetam tabs 250mg 500mg 750mg
1000mg 29 levobunolol hcl soln 39 levocarnitine soln 49 LEVOCARNITINE TABS 49 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 38 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 47 levoleucovorin calcium solr 47 levonest tabs 43 levonorgest-eth est amp eth est tabs 43 levonorgest-eth estrad 91-day tabs 43 levonorgestrel-ethinyl estrad tabs 43 levonorg-eth estrad triphasic tabs 43 levora 01530 (28) tabs 43 levorphanol tartrate tabs 2mg 3mg 26 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
78 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEVOTHYROXINE SODIUM SOLR 47 LEVOTHYROXINE SODIUM TABS 25mcg
50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEXETTE FOAM 55 LEXIVA SUSP 12 LIALDA TBEC 40 LIBTAYO SOLN 16 lidocaine hcl (cardiac) pf sosy 24 lidocaine hcl (cardiac) sosy 24 lidocaine hcl (pf) soln 49 LIDOCAINE HCL CREA 55 lidocaine hcl lotn 55 lidocaine hcl soln 39 49 55 lidocaine hcl urethralmucosal gel 55 lidocaine hcl urethralmucosal prsy 55 LIDOCAINE IN D5W SOLN 24 lidocaine in dextrose soln 49 lidocaine oint 55 lidocaine ptch 55 lidocaine viscous hcl soln 40 lidocaine-epinephrine soln 49 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 55 LIDOCAINE-HYDROCORTISONE ACE KIT
55 lidocaine-prilocaine crea 55 lidocaine-tetracaine crea 55 LIDOCORT CREA 56 lidopin crea 56 LIDO-SORB LOTN 55 LIDOZION LOTN 56 lincomycin hcl soln 9 lindane sham 53 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 liothyronine sodium soln 47 liothyronine sodium tabs 5mcg 25mcg
50mcg 47 LIPODOX 50 INJ 16
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg 25
lisinopril-hydrochlorothiazide tabs 25 LITHIUM CARBONATE CAPS 150mg
300mg 600mg 34 lithium carbonate er tbcr 300mg 450mg 34 LITHIUM CARBONATE TABS 34 LITHIUM SOLN 34 LITHOSTAT TABS 35 LIVMARLI SOLN 41 LIVTENCITY TABS 12 loestrin 1530 (21) tabs 43 loestrin 120 (21) tabs 43 loestrin fe 1530 tabs 43 loestrin fe 120 tabs 43 LOKELMA PACK 5gm 10gm 36 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 16 loperamide hcl caps 40 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 45 lorazepam intensol conc 31 LORAZEPAM SOLN 4mgml 2mgml 31 lorazepam tabs 05mg 1mg 2mg 31 LORBRENA TABS 25mg 100mg 16 lorcet hd tabs 26 lorcet plus tabs 26 lorcet tabs 27 lortab elix 27 loryna tabs 43 losartan potassium tabs 25mg 50mg
100mg 25 losartan potassium-hctz tabs 25 LOTEMAX GEL 38 LOTEMAX SUSP 38 lovastatin tabs 10mg 20mg 40mg 22 LOVENOX SOLN 21 LOVENOX SOSY 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
low-ogestrel tabs 43 loxapine succinate caps 5mg 10mg 25mg
50mg 34 lubiprostone caps 8mcg 24mcg 41 LUCEMYRA TABS 32 LUCENTIS SOLN 03mg005ml
05mg005ml 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 79
LUCENTIS SOSY 03mg005ml 05mg005ml 39
LUDENT CHEW 025mg 05mg 1mg 49 LUMAKRAS TABS 16 LUMIGAN SOLN 39 LUMIZYME SOLR 37 LUMOXITI SOLR 16 LUPANETA PACK KIT 16 LUPKYNIS CAPS 48 LUPRON DEPOT (1-MONTH) KIT 16 LUPRON DEPOT (3-MONTH) KIT 16 LUPRON DEPOT (4-MONTH) KIT 16 LUPRON DEPOT (6-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 16 LUPRON DEPOT-PED (3-MONTH) KIT 16 lutera tabs 43 LYBALVI TABS 34 lyleq tabs 43 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 45
LYMEPAK TABS 9 LYNPARZA TABS 100mg 150mg 16 LYSODREN TABS 16 lyza tabs 43
M mafenide acetate pack 53 magnesium sulfate in d5w soln 37 magnesium sulfate soln 29 MAGNESIUM SULFATE SOLN INJECTION
50 29 MAKENA SOAJ 46 malathion lotn 53 MANNITOL SOLN 36 maprotiline hcl tabs 25mg 50mg 75mg 34 maraviroc tabs 150mg 300mg 12 MARGENZA SOLN 16 marlissa tabs 43 MARPLAN TABS 34 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 23 MAVENCLAD (10 TABS) TBPK 48 MAVENCLAD (4 TABS) TBPK 48 MAVENCLAD (5 TABS) TBPK 48
MAVENCLAD (6 TABS) TBPK 48 MAVENCLAD (7 TABS) TBPK 48 MAVENCLAD (8 TABS) TBPK 48 MAVENCLAD (9 TABS) TBPK 48 MAVYRET PACK 12 MAVYRET TABS 12 MAYZENT STARTER PACK TBPK 32 MAYZENT TABS 025mg 1mg 2mg 32 MENAPHOSMBHYO1 TABS 13 meclizine hcl tabs 40 meclofenamate sodium caps 27 MEDROL TABS 42 medroxyprogesterone acetate susp 46 medroxyprogesterone acetate susy 46 medroxyprogesterone acetate tabs 25mg
5mg 10mg 46 mefenamic acid caps 27 mefloquine hcl tabs 11 megestrol acetate susp 17 46 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 43 meloxicam tabs 27 melphalan hcl solr 17 memantine hcl er cp24 32 memantine hcl soln 32 memantine hcl tabs 5mg 10mg 32 MENACTRA SOLN 52 menest tabs 03mg 0625mg 125mg 45 MENQUADFI SOLN 52 MENVEO SOLR 52 meperidine hcl soln 27 meperidine hcl tabs 50mg 27 meprobamate tabs 31 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 43 mesalamine cpdr 40 mesalamine enem 40 mesalamine er cp24 40 mesalamine supp 40 mesalamine tbec 12gm 800mg 40 mesalamine-cleanser kit 40 mesna soln 49 MESNEX TABS 49 MESTINON SOLN 19 metadate er tbcr 28 metaproterenol sulfate syrp 20
80 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
metaproterenol sulfate tabs 10mg 20mg 20 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 44 metformin hcl tabs 500mg 850mg 1000mg
45 methadone hcl conc 27 methadone hcl intensol conc 27 methadone hcl tabs 5mg 10mg 27 methamphetamine hcl tabs 28 methazolamide tabs 25mg 50mg 39 methenamine hippurate tabs 13 METHENAMINE MANDELATE TABS 13 methergine tabs 45 methimazole tabs 5mg 10mg 47 methitest tabs 42 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 57 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 36 methyldopa tabs 250mg 500mg 24 methyldopa-hydrochlorothiazide tabs 24 methylergonovine maleate soln 45 methylergonovine maleate tabs 45 methylphenidate hcl chew 25mg 5mg
10mg 28 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 28 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 28 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 28
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 28
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 28
methylphenidate hcl soln 5mg5ml 10mg5ml 28
methylphenidate hcl tabs 5mg 10mg 20mg 28
methylprednisolone acetate susp 42 methylprednisolone sodium succ solr 42
methylprednisolone tabs 4mg 8mg 16mg 32mg 42
methylprednisolone tbpk 42 methyltestosterone caps 42 metoclopramide hcl soln 41 metoclopramide hcl tabs 5mg 10mg 41 metoclopramide hcl tbdp 5mg 10mg 41 metolazone tabs 25mg 5mg 10mg 36 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 23 metoprolol tartrate soct 23 metoprolol tartrate soln 23 metoprolol tartrate tabs 25mg 50mg
100mg 23 metoprolol tartrate tabs 375mg 75mg 23 metoprolol-hydrochlorothiazide tabs 23 metronidazole caps 11 metronidazole crea 53 metronidazole gel 53 metronidazole lotn 53 METRONIDAZOLE SOLN INTRAVENOUS
500mg100ml 11 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
24 mibelas 24 fe chew 43 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 53 miconazole-zinc oxide-petrolat oint 53 micort-hc crea 55 microgestin 1530 tabs 43 microgestin 120 tabs 43 microgestin 24 fe tabs 43 microgestin fe 1530 tabs 43 microgestin fe 120 tabs 43 midazolam hcl (pf) soln 31 midazolam hcl soln 31 midodrine hcl tabs 25mg 5mg 10mg 20 miglitol tabs 25mg 50mg 100mg 45 miglustat caps 38 mili tabs 43 millipred dp tbpk 42 millipred tabs 42 milrinone lactate in dextrose soln 24 milrinone lactate soln 24 mimvey lo tabs 45 mimvey tabs 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 81
minitran pt24 01mghr 02mghr 04mghr 06mghr 25
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 24 mirtazapine tabs 75mg 15mg 30mg
45mg 34 mirtazapine tbdp 15mg 30mg 45mg 34 misoprostol tabs 100mcg 200mcg 40 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 52 modafinil tabs 100mg 200mg 28 moexipril hcl tabs 75mg 15mg 25 molindone hcl tabs 5mg 10mg 25mg 34 mometasone furoate crea 55 mometasone furoate oint 55 mometasone furoate soln 55 mometasone furoate susp 38 MONJUVI SOLR 17 MONONESSA TABS 43 montelukast sodium chew 4mg 5mg 51 montelukast sodium pack 51 montelukast sodium tabs 51 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 27 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 27 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 27
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 27
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml 27
morphine sulfate tabs 15mg 30mg 27 moxifloxacin hcl (2x day) soln 38 moxifloxacin hcl in nacl soln intravenous 9 moxifloxacin hcl soln 38 moxifloxacin hcl tabs 9 MULPLETA TABS 21 MULTAQ TABS 24 mupirocin calcium crea 53 mupirocin oint 53 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17
MYALEPT SOLR 49 MYCAPSSA CPDR 46 mycophenolate mofetil caps 48 mycophenolate mofetil hcl solr 48 mycophenolate mofetil susr 48 mycophenolate mofetil tabs 49 mycophenolate sodium tbec 180mg 360mg
49 MYFEMBREE TABS 45 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 57 MYRBETRIQ TB24 25mg 50mg 57
N NABI-HB SOLN 52 nabumetone tabs 27 N-ACETYL-L-CYSTEINE CAPS 36 nadolol tabs 20mg 40mg 80mg 23 nadololbendroflumethiazide tabs 23 nadolol-bendroflumethiazide tabs 23 nafcillin sodium solr 9 nafcillin sodium solr injection 9 nafcillin sodium solr intravenous 9 NAFRINSE CHEW 49 NAFRINSE DROPS SOLN 49 naftifine hcl crea 53 naftifine hcl gel 53 NAGLAZYME SOLN 38 nalbuphine hcl soln 10mgml 20mgml 27 nalfon tabs 27 nalocet tabs 27 naloxone hcl liqd 32 naloxone hcl soaj 32 naloxone hcl soct 32 naloxone hcl soln 32 naloxone hcl sosy 32 naltrexone hcl tabs 32 naproxen sodium er tb24 27 naproxen sodium tabs 27 naproxen susp 27 naproxen tabs 27 naproxen tbec 27 naproxen-esomeprazole tbec 27 naratriptan hcl tabs 30 NARCAN LIQD 32 NATACYN SUSP 38 nateglinide tabs 60mg 120mg 45 NATPARA CART 25mcg 50mcg 75mcg
100mcg 45
82 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
NAYZILAM SOLN 29 necon 0535 (28) tabs 43 NECON 777 TABS 43 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 34 nelarabine soln 17 nembutal soln 31 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 38 neomycin-polymyxin b gu soln 53 neomycin-polymyxin-dexameth oint 38 neomycin-polymyxin-dexameth susp 39 neomycin-polymyxin-gramicidin soln 38 neomycin-polymyxin-hc soln 39 neomycin-polymyxin-hc susp 39 neo-polycin hc oint 38 neo-polycin oint 38 neo-synalar crea 55 NERLYNX TABS 17 NEULASTA ONPRO PSKT 21 NEULASTA SOSY 21 NEUPOGEN SOLN 480mcg16ml
300mcgml 21 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 21 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 38 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 22 niacor tabs 22 nicardipine hcl caps 20mg 30mg 23 NICARDIPINE HCL SOLN 23 NICOTROL INHA 19 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 43 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 49 nitro-bid oint 25
NITRO-DUR PT24 03mghr 08mghr 25 NITROFURANTOIN MACROCRYSTAL
CAPS 13 NITROFURANTOIN MONOHYD MACRO
CAPS 13 nitrofurantoin susp 13 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 25 nitroglycerin soln 25 nitroglycerin subl 03mg 04mg 06mg 25 nitropress soln 24 nitroprusside sodium soln 24 NITYR TABS 2mg 5mg 10mg 49 NIVESTYM SOLN 480mcg16ml
300mcgml 21 NIVESTYM SOSY 300mcg05ml
480mcg08ml 22 nizatidine caps 150mg 300mg 40 nizatidine soln 40 nolix crea 55 nolix lotn 55 nora-be tabs 43 norco tabs 27 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 46
norepinephrine bitartrate soln 20 norethin ace-eth estrad-fe caps 43 norethin ace-eth estrad-fe chew 43 norethin ace-eth estrad-fe tabs 43 norethindrone acetate tabs 46 norethindrone acet-ethinyl est tabs 43 norethindrone tabs 43 norethindrone-eth estradiol tabs 45 norethin-eth estradiol-fe chew 43 norgesic forte tabs 27 norgestimate-eth estradiol tabs 43 norgestim-eth estrad triphasic tabs 43 norlyroc tabs 43 NORPACE CR CP12 100mg 150mg 24 nortrel 0535 (28) tabs 43 nortrel 135 (21) tabs 43 nortrel 135 (28) tabs 43 nortrel 777 tabs 43 nortriptyline hcl caps 10mg 25mg 50mg
75mg 34 nortriptyline hcl soln 34 NORVIR CAPS 12 NORVIR PACK 12
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 83
NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 32 NOXAFIL SUSP 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 51 NUCALA SOLR 51 NUCALA SOSY 51 NUCYNTA ER TB12 200mg 250mg 27 NUCYNTA TABS 27 NUEDEXTA CAPS 32 NULIBRY SOLR 49 NULOJIX SOLR 49 NUPLAZID CAPS 34 NUPLAZID TABS 10mg 17mg 34 NURTEC TBDP 30 NUTRILIPID EMUL INTRAVENOUS 36 NUTROPIN AQ NUSPIN 10 SOPN 46 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 53 nylia 135 tabs 43 nylia 777 tabs 43 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 44 nystatin crea 53 nystatin oint 53 nystatin powd 53 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 55 nystatin-triamcinolone oint 55 nystop powd 53 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 41 ocella tabs 44 OCREVUS SOLN 32 OCTAGAM SOLN INTRAVENOUS
1gm20ml 2gm20ml 52 octreotide acetate soln 500mcgml
1000mcgml 46 octreotide acetate soln 50mcgml
100mcgml 200mcgml 46 ODACTRA SUBL 49 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 51
ofloxacin soln 38 ofloxacin tabs 10 ogestrel tabs 44 OGIVRI SOLR 17 olanzapine solr 34 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 34 olanzapine tbdp 5mg 10mg 15mg 20mg
34 olanzapine-fluoxetine hcl caps 34 olmesartan medoxomil tabs 5mg 20mg
40mg 25 olmesartan medoxomil-hctz tabs 25 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 39 OLUMIANT TABS 1mg 2mg 48 omega-3-acid ethyl esters caps 22 omeprazole cpdr 10mg 20mg 40mg 40 omeprazole-sodium bicarbonate caps 40 omeprazole-sodium bicarbonate pack 40 OMNITROPE SOCT 5mg15ml
10mg15ml 46 OMNITROPE SOLR 46 ondansetron hcl soln 40 ondansetron hcl sosy 40 ondansetron hcl tabs 4mg 8mg 24mg 40 ondansetron tbdp 4mg 8mg 40 ONIVYDE
INJ 17 ONPATTRO SOLN 50 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 OPDIVO SOLN 100mg10ml 120mg12ml
240mg24ml 40mg4ml 17 OPDUALAG SOLN 17 OPIUM TINC 40 OPZELURA CREA 57 ORACEA CPDR 57 oralone pste 55 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 48 ORENCIA SOLR 48 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 48 ORENITRAM TBCR 025mg 1mg 25mg
5mg 51 ORFADIN CAPS 50 ORFADIN SUSP 50 ORGOVYX TABS 45
84 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ORILISSA TABS 150mg 200mg 45 ORKAMBI PACK 51 ORKAMBI TABS 51 ORLADEYO CAPS 110mg 150mg 50 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 27 orphengesic forte tabs 27 orsythia tabs 44 ORTIKOS CP24 6mg 9mg 42 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 36 OTEZLA TABS 48 OTEZLA TBPK 48 ovide lotn 53 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 42 oxaprozin tabs 27 OXAYDO TABS 27 oxazepam caps 10mg 15mg 30mg 31 OXBRYTA TABS 21 OXBRYTA TBSO 21 oxcarbazepine susp 29 oxcarbazepine tabs 150mg 300mg 600mg
29 OXERVATE SOLN 39 oxiconazole nitrate crea 53 OXLUMO SOLN 50 OXTELLAR XR TB24 150mg 300mg
600mg 29 oxybutynin chloride er tb24 5mg 10mg
15mg 57 oxybutynin chloride syrp 57 oxybutynin chloride tabs 57 oxycodone hcl caps 27 oxycodone hcl conc 27 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxycodone hcl soln 27 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 27 oxycodone-acetaminophen soln 27
oxycodone-acetaminophen tabs 27 oxycodone-acetaminophen tabs 5-300mg
75-300mg 10-300mg 27 oxycodone-aspirin tabs 27 oxycodone-ibuprofen tabs 27 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 27 oxymorphone hcl tabs 5mg 10mg 27 OXYTOCIN SOLN 45 OZEMPIC (025 OR 05 MGDOSE) SOPN
45 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 45 OZEMPIC (2 MGDOSE) SOPN 45
P pacerone tabs 100mg 200mg 400mg 24 paclitaxel conc 17 PACLITAXEL PROTEIN-BOUND PART
SUSR 100 MG 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
50 PALFORZIA (120 MG DAILY DOSE) CSPK
50 PALFORZIA (160 MG DAILY DOSE) CSPK
50 PALFORZIA (20 MG DAILY DOSE) CSPK
50 PALFORZIA (200 MG DAILY DOSE) CSPK
50 PALFORZIA (240 MG DAILY DOSE) CSPK
50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK 50 PALFORZIA (300 MG TITRATION) PACK
50 PALFORZIA (40 MG DAILY DOSE) CSPK
50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
50 PALFORZIA INITIAL ESCALATION CSPK
50 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 34
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 85
palonosetron hcl soln 40 palonosetron hcl sosy 40 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 38 pamidronate disodium soln 47 pamidronate disodium solr 47 panlor tabs 27 PANRETIN GEL 56 pantoprazole sodium pack 40 PANTOPRAZOLE SODIUM SOLR 40 pantoprazole sodium tbec 20mg 40mg 40 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 52
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 57 PARICALCITOL SOLN 57 paroex soln 38 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 34 paroxetine hcl susp 34 paroxetine hcl tabs 10mg 20mg 34 paroxetine hcl tabs 30mg 40mg 34 paroxetine mesylate caps 34 paser pack 11 PEDIARIX SUSY 52 PEDVAX HIB SUSP 52 peg 3350electrolytes solr 41 peg 3350-kcl-na bicarb-nacl solr 41 peg-3350electrolytes solr 41 PEGANONE TABS 29 PEGASYS PROCLICK SOAJ
135mcg05ml 180mcg05ml 12 PEGASYS SOLN 12 PEGASYS SOSY 12 PEGINTRON KIT 12 PEG-PREP KIT 41 PEMAZYRE TABS 45mg 9mg 135mg 17 PEMFEXY SOLN 17 penicillamine caps 41 penicillamine tabs 41 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
PENTACEL SUSR 52 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 40 pentazocine-naloxone hcl tabs 27 pentobarbital sodium soln 31 pentoxifylline er tbcr 21 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 40 percocet tabs 27 perindopril erbumine tabs 2mg 4mg 8mg
25 periogard soln 38 PERJETA SOLN 17 permethrin crea 53 perphenazine tabs 2mg 4mg 8mg 16mg
34 perphenazine-amitriptyline tabs 34 PERSERIS PRSY 90mg 120mg 34 PEXEVA TABS 10mg 20mg 30mg 40mg
34 phenadoz supp 14 phenazo tabs 56 PHENAZOPYRIDINE HCL TABS 56 phenelzine sulfate tabs 34 phenergan soln 14 PHENOBARBITAL ELIX 31 PHENOBARBITAL SODIUM SOLN 31 PHENOBARBITAL TABS 31 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 20 PHENYLEPHRINE HCL SOLN 39 phenytek caps 200mg 300mg 29 phenytoin chew 29 phenytoin sodium extended caps 100mg
200mg 300mg 29 phenytoin sodium soln 29 phenytoin susp 29 PHESGO SOLN 17 PHOSLYRA SOLN 37 PHOSPHASAL TABS 13 PHOSPHOLINE IODIDE SOLR 39 phrenilin forte caps 27 PHYSIOLYTE SOLN 50 PHYSIOSOL IRRIGATION SOLN 50 PIFELTRO TABS 12 pilocarpine hcl soln 1 2 4 39 pilocarpine hcl tabs 5mg 75mg 19 pimecrolimus crea 57
86 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
pimozide tabs 1mg 2mg 34 pimtrea tabs 44 pindolol tabs 5mg 10mg 23 pioglitazone hcl tabs 15mg 30mg 45mg 45 pioglitazone hcl-glimepiride tabs 45 pioglitazone hcl-metformin hcl tabs 45 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 44 piroxicam caps 10mg 20mg 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN 32 PLEGRIDY SOSY 32 PLEGRIDY STARTER PACK SOPN 32 PLEGRIDY STARTER PACK SOSY 32 plenamine soln intravenous 36 podofilox soln 57 POLIVY SOLR 30mg 140mg 17 polocaine soln 50 polocaine-mpf soln 50 polycin oint 38 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 38 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 32 PONVORY TABS 32 portia-28 tabs 44 PORTRAZZA SOLN 17 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 35 POTASSIUM ACETATE SOLN 37 potassium chloride crys er tbcr 10meq
20meq 37 potassium chloride er cpcr 8meq 10meq 37 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 37 POTASSIUM CHLORIDE IN NACL SOLN
INTRAVENOUS 37 POTASSIUM CHLORIDE PACK 37 POTASSIUM CHLORIDE SOLN 10 20
37
potassium chloride soln intravenous 10meq100ml 20meq100ml 40meq100ml 2meqml 37
potassium citrate er tbcr 15meq 540mg 1080mg 35
POTASSIUM PHOSPHATES SOLN 37 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 37 POTELIGEO SOLN 17 PR BENZOYL PEROXIDE WASH LIQD 53 PRADAXA CAPS 75mg 110mg 150mg 21 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 31
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 31
PRAMOX GEL 56 prandin tabs 1mg 2mg 45 prasugrel hcl tabs 5mg 10mg 21 pravastatin sodium tabs 10mg 20mg
40mg 80mg 22 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22 PRED MILD SUSP 39 PRED-G SOP OINT 39 PRED-G SUSP 39 prednicarbate crea 55 prednicarbate oint 55 prednisolone acetate susp 39 prednisolone sodium phosphate soln 39 PREDNISOLONE SODIUM PHOSPHATE
SOLN 10mg5ml 20mg5ml 25mg5ml 5mg5ml 42
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 42
prednisolone soln 42 prednisone intensol conc 42 prednisone soln 42 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 42 prednisone tbpk 42 prefest tabs 45 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 29
pregabalin er tb24 825mg 165mg 330mg 27
pregabalin soln 29 PREHEVBRIO SUSP 52
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 87
PREMARIN SOLR 45 premasol soln intravenous 36 PRENATAL TABS 57 PRETOMANID TABS 11 prevalite pack 22 prevalite powd 22 previfem tabs 44 PREVYMIS SOLN 240mg12ml
480mg24ml 12 PREVYMIS TABS 240mg 480mg 12 PREZCOBIX TABS 12 PREZISTA SUSP 12 PREZISTA TABS 75mg 150mg 600mg
800mg 12 PRIFTIN TABS 11 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 29 primlev tabs 27 probenecid tabs 37 procainamide hcl soln 24 PROCALAMINE SOLN INTRAVENOUS 36 procentra soln 28 prochlorperazine edisylate soln 34 prochlorperazine maleate tabs 34 prochlorperazine supp 34 PROCRIT SOLN 20000unitml
40000unitml 22 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 22 proctofoam hc foam 56 procto-med hc crea 55 procto-pak crea 55 proctosol hc crea 55 proctozone-hc crea 55 PROCYSBI CPDR 25mg 75mg 50 PROCYSBI PACK 75mg 300mg 50 progesterone caps 100mg 200mg 46 progesterone oil 46 PROGRAF PACK 49 PROGRAF PACK 02mg 49 PROGRAF SOLN 49 prolate soln 27 prolate tabs 27 PROLEUKIN SOLR 17 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 24 propafenone hcl tabs 150mg 225mg
300mg 24 propantheline bromide tabs 19 proparacaine hcl soln 40 propranolol hcl er cp24 60mg 80mg
120mg 160mg 23 propranolol hcl soln 20mg5ml 40mg5ml 23 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 23 propranolol-hctz tabs 23 propylthiouracil tabs 47 PROQUAD SUSR 52 protriptyline hcl tabs 5mg 10mg 34 psorcon crea 55 PULMICORT FLEXHALER AEPB 51 PULMOZYME SOLN 38 PURIXAN SUSP 17 PYLERA CAPS 40 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 19 pyridostigmine bromide soln 19 pyridostigmine bromide tabs 30mg 60mg 19 pyrimethamine tabs 11 PYRUKYND TABS 5mg 20mg 50mg 50 PYRUKYND TAPER PACK TBPK 50
Q QDOLO SOLN 27 QINLOCK TABS 17 QUADRACEL SUSP 52 questran light powd 22 questran pack 22 questran powd 22 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 34 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 34 quinapril hcl tabs 5mg 10mg 20mg 40mg
25 quinapril-hydrochlorothiazide tabs 25 quinidine gluconate er tbcr 24 QUINIDINE GLUCONATE SOLN 24 quinidine sulfate tabs 200mg 300mg 24
88 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
quinine sulfate caps 11 QULIPTA TABS 10mg 30mg 60mg 30
R RABAVERT SUSR 52 rabeprazole sodium cpsp 40 rabeprazole sodium tbec 40 RADIAURA CREA 55 RADICAVA SOLN 32 raloxifene hcl tabs 45 ramelteon tabs 31 ramipril caps 125mg 25mg 5mg 10mg 25 ranolazine er tb12 500mg 1000mg 24 RAPIVAB SOLN 12 rasagiline mesylate tabs 05mg 1mg 31 RASUVO SOAJ 48 RAVICTI LIQD 35 RAYALDEE CPCR 57 REBETOL SOLN 12 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 32 REBIF REBIDOSE TITRATION PACK
SOAJ 32 REBIF SOSY 22mcg05ml 44mcg05ml 32 REBIF TITRATION PACK SOSY 32 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 44 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 52 RECORLEV TABS 50 RECTIV OINT 57 REGONOL SOLN 19 REGRANEX GEL 57 relafen ds tabs 27 RELENZA DISKHALER AEPB 12 RELEUKO SOLN 300mcgml
480mcg16ml 22 RELEUKO SOSY 300mcg05ml
480mcg08ml 22 relexxii tbcr 28 RELISTOR SOLN 8mg04ml 12mg06ml
41 RELISTOR TABS 41 reltone caps 200mg 400mg 41 REMICADE SOLR INTRAVENOUS 48 RENFLEXIS SOLR 48 repaglinide tabs 05mg 1mg 2mg 45 repaglinide-metformin hcl tabs 45
REPATHA SOSY 22 REPATHA SURECLICK SOAJ 22 RESCRIPTOR TABS 100mg 200mg 12 RESTASIS EMUL 39 RESTASIS MULTIDOSE EMUL 39 RETACRIT SOLN 22 RETACRIT SOLN 20000unitml 22 RETEVMO CAPS 40mg 80mg 17 RETIN-A CREA 0025 005 01 56 RETIN-A GEL 001 0025 56 RETIN-A MICRO GEL 004 01 56 RETIN-A MICRO PUMP GEL 004 01
56 RETISERT IMPL 39 RETROVIR SOLN 12 REVCOVI SOLN 38 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 17 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 34 REYATAZ PACK 12 REZUROCK TABS 50 RIABNI SOLN 100mg10ml 500mg50ml 17 ribasphere caps 12 ribasphere ribapak (1000 pack) tbpk 12 ribasphere ribapak (1200 pack) tbpk 12 ribasphere tabs 12 ribavirin caps 12 ribavirin solr 12 ribavirin tabs 13 RIDAURA CAPS 50 rifabutin caps 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 riluzole tabs 32 rimantadine hcl tabs 13 RIMSO-50 SOLN 50 RINGERS IRRIGATION SOLN 50 RINGERS SOLN 37 RINVOQ TB24 15mg 30mg 45mg 48 risedronate sodium tabs 5mg 30mg 35mg
150mg 47 risedronate sodium tbec 47 RISPERDAL CONSTA SRER 125mg
25mg 34 RISPERDAL CONSTA SRER 375mg
50mg 35
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 89
RISPERIDONE SOLN 35 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 35 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 35 ritonavir tabs 13 RITUXAN HYCELA SOLN 17 RITUXAN SOLN 17 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 44 rizatriptan benzoate tabs 30 rizatriptan benzoate tbdp 30 ROMIDEPSIN SOLN 17 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 31 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 31 ropivacaine hcl soln 50 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 22 ROTARIX SUSR 52 ROTATEQ SOLN 52 roweepra tabs 500mg 750mg 1000mg 29 roweepra xr tb24 500mg 750mg 29 ROZLYTREK CAPS 100mg 200mg 17 RUBRACA TABS 200mg 250mg 300mg 17 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 29 rufinamide tabs 200mg 400mg 29 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 17 RYBREVANT SOLN 17 ryclora soln 14 RYDAPT CAPS 17 RYLAZE SOLN 17 RYNODERM CREA 57 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 46 SAIZEN SOLR 5mg 88mg 46 SAIZENPREP SOLR 46 sajazir soln 21 SALEX SHAM 57 SALICYLIC ACID CREA 57
SALICYLIC ACID ER SOLN 57 SALICYLIC ACID FOAM 57 SALICYLIC ACID GEL 57 SALICYLIC ACID SHAM 57 SALICYLIC ACID-CLEANSER KIT 57 SALSALATE TABS 27 SANCUSO PTCH 40 SANDIMMUNE ORAL SOLN 100mgml 49 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 46 SANTYL OINT 57 SAPHNELO SOLN 49 SAPHRIS SUBL 25mg 5mg 10mg 35 sapropterin dihydrochloride pack 100mg
500mg 50 sapropterin dihydrochloride tabs 50 SARCLISA SOLN 500mg25ml 100mg5ml
17 SCEMBLIX TABS 20mg 40mg 17 scopolamine pt72 40 seconal caps 31 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 35 selegiline hcl caps 31 selegiline hcl tabs 31 selenium sulfide lotn 53 SELENIUM SULFIDE SHAM 53 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 13 SENSORCAINE SOLN 50 sensorcaineepinephrine soln 50 sensorcaine-mpf soln 50 sensorcaine-mpfepinephrine soln 50 SEREVENT DISKUS AEPB 20 SEROSTIM SOLR 4mg 5mg 6mg 46 SERTRALINE HCL CAPS 150mg 200mg
35 sertraline hcl conc 35 sertraline hcl tabs 25mg 50mg 100mg 35 setlakin tabs 44 sevelamer carbonate pack 08gm 24gm 36 sevelamer carbonate tabs 36 sevelamer hcl tabs 400mg 800mg 36 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 44 SHINGRIX SUSR 52 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 46
90 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
SIGNIFOR SOLN 03mgml 06mgml 09mgml 46
SIKLOS TABS 17 sildenafil citrate soln 25 sildenafil citrate susr 25 sildenafil citrate tabs 25 SILIQ SOSY 57 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 53 SIMPONI ARIA SOLN 48 SIMPONI SOAJ 50mg05ml 100mgml 48 SIMPONI SOSY 50mg05ml 100mgml 48 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 22 sirolimus soln 49 sirolimus tabs 05mg 1mg 2mg 49 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKYRIZI (150 MG DOSE) PSKT 57 SKYRIZI PEN SOAJ 57 SKYRIZI SOSY 57 SKYTROFA CART 3mg 36mg 43mg
52mg 63mg 76mg 91mg 11mg 133mg 46
sod benz-sod phenylacet soln 35 SODIUM ACETATE SOLN 35 SODIUM BICARBONATE SOLN 35 SODIUM CHLORIDE (PF) SOLN 37 SODIUM CHLORIDE SOLN 37 50 SODIUM CHLORIDE SOLN
INTRAVENOUS 045 09 3 5 37 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 50 SODIUM FLUORIDE SOLN 50 sodium phenylbutyrate powd 35 sodium phenylbutyrate tabs 35 SODIUM PHOSPHATES SOLN 37 sodium polystyrene sulfonate powd 36 sodium polystyrene sulfonate susp 36 sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 57 SOLTAMOX SOLN 17 SOLU-CORTEF SOLR 42 SOLU-MEDROL SOLR 42 SOMATULINE DEPOT SOLN 60mg02ml
90mg03ml 120mg05ml 46 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 46
sorine tabs 80mg 120mg 160mg 240mg 23
sotalol hcl (af) tabs 80mg 120mg 160mg 23 sotalol hcl tabs 80mg 120mg 160mg
240mg 23 SOTYLIZE SOLN 23 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 25 spironolactone-hctz tabs 25 SPRAVATO (56 MG DOSE) SOPK 35 SPRAVATO (84 MG DOSE) SOPK 35 sprintec 28 tabs 44 SPRITAM TB3D 250mg 500mg 750mg
1000mg 29 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 36 sronyx tabs 44 SSD CREA 53 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
57 STELARA SOSY 45mg05ml 90mgml 57 STERILE WATER FOR IRRIGATION SOLN
50 STIMATE SOLN 46 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18 STRENSIQ SOLN 18mg045ml
28mg07ml 80mg08ml 40mgml 38 streptomycin sulfate solr 10 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 20 SUBLOCADE SOSY 100mg05ml
300mg15ml 32 SUBSYS LIQD 1200mcg 1600mcg 27 subvenite starter kit-blue kit 29 subvenite starter kit-green kit 29 subvenite starter kit-orange kit 30 subvenite tabs 25mg 100mg 150mg
200mg 30 succinylcholine chloride soln 20 SUCRAID SOLN 38 sucralfate susp 40 sucralfate tabs 40
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 91
sulfacetamide sodium (acne) lotn 53 sulfacetamide sodium oint 38 sulfacetamide sodium soln 38 sulfacetamide-prednisolone soln 39 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 SULFAMYLON CREA 53 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 27 sumatriptan soln 30 sumatriptan succinate refill soct 30 sumatriptan succinate soaj 30 sumatriptan succinate soln 30 sumatriptan succinate sosy 30 sumatriptan succinate tabs 30 sunitinib malate caps 125mg 25mg
375mg 50mg 18 suprax chew 10 SUPREP BOWEL PREP KIT SOLN 41 SUSVIMO (IMPLANT 1ST FILL) SOLN 39 SUSVIMO (IMPLANT REFILL) SOLN 39 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 44 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 51 SYMDEKO TBPK 51 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 45 SYMLINPEN 60 SOPN 45 SYMPAZAN FILM 10mg 20mg 30 SYMPAZAN FILM 5mg 30 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 46 SYNDROS SOLN 40 SYNERCID SOLR 10 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 tacrolimus caps 05mg 1mg 5mg 49 TACROLIMUS OINT 01 003 57
tadalafil (pah) tabs 20mg 25 tadalafil tabs 25mg 5mg 25 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 50 TAKHZYRO SOSY 50 TALTZ SOAJ 57 TALTZ SOSY 57 TALZENNA CAPS 025mg 05mg 075mg
1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 47 taperdex 12-day tbpk 42 taperdex 6-day tbpk 42 taperdex 7-day tbpk 42 targadox tabs 10 TARGRETIN GEL 56 tarina 24 fe tabs 44 tarina fe 120 eq tabs 44 TARPEYO CPDR 42 TASIGNA CAPS 50mg 150mg 200mg 18 TAVALISSE TABS 100mg 150mg 22 TAVNEOS CAPS 50 taysofy caps 44 tazarotene crea 57 tazarotene foam 57 tazicef solr injection 10 tazicef solr intravenous 2gm 6gm 10 TAZORAC CREA 57 TAZORAC GEL 005 01 57 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 52 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TEFLARO SOLR INTRAVENOUS 10 TEGSEDI SOSY 50 telmisartan tabs 20mg 40mg 80mg 25 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 25 TEMAZEPAM CAPS 75mg 15mg 225mg
30mg 31 temsirolimus soln 18 tencon tabs 27 TENIPOSIDE SOLN 18 TENIVAC INJ 52 tenofovir disoproxil fumarate tabs 13
92 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TEPADINA SOLR 18 TEPEZZA SOLR 39 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 20 terbutaline sulfate tabs 25mg 5mg 20 terconazole crea 53 terconazole supp 53 TERIPARATIDE (RECOMBINANT) SOPN
46 testosterone cypionate soln 100mgml
200mgml 42 testosterone enanthate soln 42 testosterone gel 1 162
2025mg125gm 405mg25gm 10mgact 42
testosterone soln 42 tetrabenazine tabs 125mg 25mg 32 TETRACAINE HCL SOLN 40 tetracycline hcl caps 250mg 500mg 10 texacort soln 55 TEZSPIRE SOSY 51 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 57 theophylline er tb12 100mg 200mg
300mg 450mg 57 theophylline er tb24 400mg 600mg 57 theophylline soln 57 THIOLA EC TBEC 100mg 300mg 50 THIOLA TABS 50 thioridazine hcl tabs 10mg 25mg 50mg
100mg 35 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 35 THYROGEN SOLR 50 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
30 TIBSOVO TABS 18 TICOVAC SUSY 52 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 32 tilia fe tabs 44 timolol maleate (once-daily) soln 39 timolol maleate pf soln 39
TIMOLOL MALEATE SOLG 025 05 39 timolol maleate soln 025 05 39 timolol maleate tabs 5mg 10mg 20mg 23 tinidazole tabs 11 tiopronin tabs 50 TIS-U-SOL SOLN 50 TIVDAK SOLR 18 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 tizanidine hcl caps 20 tizanidine hcl tabs 20 TOBI PODHALER CAPS 51 TOBRADEX OINT 39 TOBRADEX ST SUSP 39 tobramycin nebu 300mg4ml 300mg5ml 51 tobramycin soln 38 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 39 TOBREX OINT 38 tofranil tabs 10mg 25mg 50mg 35 tolazamide tabs 250mg 500mg 45 tolbutamide tabs 45 tolcapone tabs 31 tolmetin sodium caps 27 tolmetin sodium tabs 27 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 57 tolterodine tartrate tabs 57 tolvaptan tabs 15mg 30mg 36 TOPEX TOPICAL ANESTHETIC AERO 56 topicort crea 005 025 55 topicort gel 55 topicort oint 55 topiramate cpsp 15mg 25mg 30 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 30 topiramate tabs 25mg 50mg 100mg
200mg 30 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
36 TPN ELECTROLYTES CONC
INTRAVENOUS 37 TRACLEER TBSO 51 TRADJENTA TABS 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 93
tramadol hcl er (biphasic) tb24 100mg 200mg 300mg 28
tramadol hcl er cp24 100mg 150mg 200mg 300mg 28
tramadol hcl er tb24 100mg 200mg 300mg 28
tramadol hcl soln 28 tramadol hcl tabs 50mg 100mg 28 tramadol-acetaminophen tabs 28 trandolapril tabs 1mg 2mg 4mg 25 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 21 tranexamic acid tabs 21 tranylcypromine sulfate tabs 35 TRAVASOL SOLN INTRAVENOUS 36 travoprost (bak free) soln 39 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 150mg 300mg 35 trazodone hcl tabs 50mg 100mg 35 TRECATOR TABS 11 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 57 TREMFYA SOSY 57 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 51 tretinoin caps 18 tretinoin crea 0025 005 01 56 tretinoin gel 001 0025 005 56 tretinoin microsphere gel 004 01 56 tretinoin microsphere pump gel 004
01 56 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 28 triamcinolone acetonide aers 55 triamcinolone acetonide crea 0025
01 05 55 triamcinolone acetonide lotn 0025 01
55 triamcinolone acetonide oint 0025
005 01 05 55 triamcinolone acetonide pste 55 triamcinolone acetonide susp 42 triamterene caps 50mg 100mg 36 triamterene-hctz caps 36 triamterene-hctz tabs 36 trianex oint 55 triazolam tabs 0125mg 025mg 31 TRICITRATES SOLN 35 triderm crea 01 05 55
trientine hcl caps 41 tri-estarylla tabs 44 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 35 trifluridine soln 38 trihexyphenidyl hcl soln 31 trihexyphenidyl hcl tabs 2mg 5mg 31 TRIKAFTA TBPK 51 tri-legest fe tabs 44 tri-lo-estarylla tabs 44 tri-lo-sprintec tabs 44 trilyte solr 41 trimethobenzamide hcl caps 40 TRIMETHOPRIM TABS 13 tri-mili tabs 44 trimipramine maleate caps 25mg 50mg
100mg 35 TRINESSA (28) TABS 44 TRINTELLIX TABS 5mg 10mg 20mg 35 tri-nymyo tabs 44 tri-previfem tabs 44 TRIPTODUR SRER 45 TRISENOX
SOLN 18 tri-sprintec tabs 44 tritocin oint 55 TRIUMEQ PD TBSO 13 TRIUMEQ TABS 13 trivora (28) tabs 44 tri-vylibra lo tabs 44 tri-vylibra tabs 44 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 30 TROPHAMINE SOLN INTRAVENOUS 36 trospium chloride er cp24 57 trospium chloride tabs 57 TRULANCE TABS 41 TRUMENBA SUSY 52 TRUSELTIQ (100MG DAILY DOSE) CPPK
18 TRUSELTIQ (125MG DAILY DOSE) CPPK
18 TRUSELTIQ (50MG DAILY DOSE) CPPK
18 TRUSELTIQ (75MG DAILY DOSE) CPPK
18
94 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 52 TYBOST TABS 13 tydemy tabs 44 tylenol with codeine 3 tabs 28 tylenol with codeine 4 tabs 28 TYMLOS SOPN 46 TYPHIM VI SOLN 52 TYPHIM VI SOSY 52 TYVASO REFILL SOLN 51 TYVASO STARTER SOLN 51
U UBRELVY TABS 50mg 100mg 30 UDENYCA SOSY 22 UKONIQ TABS 18 ULTOMIRIS SOLN 50 UMECTA MOUSSE FOAM 57 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
UNITUXIN SOLN 18 UPTRAVI SOLR 51 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 51
UPTRAVI TBPK 51 UREA CREA 39 57 UREA LOTN 40 57 UREA-C40 LOTN 57 urecholine tabs 5mg 10mg 25mg 50mg 20 uredeb crea 57 URETRON DS TABS 13 URIN DS TABS 13 ursodiol caps 200mg 400mg 41 ursodiol caps 300mg 41 ursodiol tabs 250mg 500mg 41 URYL TABS 13 USTELL CAPS 13 UTICAP CAPS 13 UTIRA-C TABS 13 UTRONA-C TABS 13
V VABYSMO SOLN 39 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 57 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 30 valproic acid caps 30 valproic acid soln 30 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
25 valsartan-hydrochlorothiazide tabs 25 VALTOCO 10 MG DOSE LIQD 30 VALTOCO 15 MG DOSE LQPK 30 VALTOCO 20 MG DOSE LQPK 30 VALTOCO 5 MG DOSE LIQD 30 vanatol lq soln 28 vancomycin hcl caps 10 vancomycin hcl solr 250mg5ml 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 vancomycin hcl solr intravenous 5gm
750mg 10 VANDAZOLE GEL 53 VANOXIDE-HC LOTN 55 VANTAS KIT 18 VAQTA SUSP 52 varenicline tartrate misc 19 varenicline tartrate tabs 05mg 1mg 19 VARIVAX INJ 52 VARIZIG SOLN 52 VASCEPA CAPS 1gm 22 VAXCHORA SUSR 53 vecamyl tabs 24 VECTICAL OINT 57 VEKLURY SOLN 13 VEKLURY SOLR 13 VELCADE SOLR 18 velivet tabs 44 VELPHORO CHEW 36 VELTASSA PACK 84gm 168gm 252gm
36 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 18 VENCLEXTA TABS 10mg 18 VENCLEXTA TABS 50mg 100mg 18
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 95
venlafaxine hcl er cp24 375mg 75mg 150mg 35
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg 35
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg 35
VENTAVIS SOLN 10mcgml 20mcgml 52 verapamil hcl er tbcr 120mg 180mg 240mg
24 verapamil hcl soln 24 verapamil hcl tabs 40mg 80mg 120mg 24 veripred 20 soln 42 VERKAZIA EMUL 39 VERSACLOZ SUSP 35 VERZENIO TABS 50mg 100mg 150mg
200mg 18 vestura tabs 44 VIBERZI TABS 75mg 100mg 41 vicodin es tabs 28 vicodin hp tabs 28 vicodin tabs 28 VICTOZA SOPN 45 VIDEX EC CPDR 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 44 vigabatrin pack 30 vigabatrin tabs 30 VIIBRYD STARTER PACK KIT 35 VIIBRYD TABS 10mg 20mg 40mg 35 VIJOICE TBPK 50 VILTEPSO SOLN 50 VIMIZIM SOLN 38 VIMPAT SOLN 30 vinblastine sulfate soln 18 vincasar pfs soln 18 vincristine sulfate soln 18 vinorelbine tartrate soln 18 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 47 VITRAKVI CAPS 25mg 100mg 18 VITRAKVI SOLN 18 VIVITROL SUSR 32 VIZIMPRO TABS 15mg 30mg 45mg 18 VOCABRIA TABS 13
VONJO CAPS 18 VORAXAZE SOLR 47 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 18 VOXZOGO SOLR 04mg 056mg 12mg 50 VPRIV SOLR 38 VRAYLAR CAPS 15mg 3mg 45mg 6mg
35 VRAYLAR CPPK 35 VUMERITY (STARTER) CPDR 50 VUMERITY CPDR 50 vyfemla tabs 44 vylibra tabs 44 VYNDAMAX CAPS 24 VYNDAQEL CAPS 24 VYONDYS 53 SOLN 50 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 28 VYVGART SOLN 50 VYXEOS SUSR 18
W WAKIX TABS 445mg 178mg 28 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 21 WATER FOR IRRIGATION STERILE
SOLN 50 WELIREG TABS 18 wixela inhub aepb 51 wymzya fe chew 44 WYNZORA CREA 55
X XALKORI CAPS 200mg 250mg 18 XARELTO STARTER PACK TBPK 21 XARELTO SUSR 21 XARELTO TABS 25mg 10mg 15mg
20mg 21 XATMEP SOLN 18 XCOPRI (250 MG DAILY DOSE) TBPK 30 XCOPRI (350 MG DAILY DOSE) TBPK 30 XCOPRI TABS 200mg 30 XCOPRI TABS 50mg 100mg 150mg 30 XCOPRI TBPK 30 XCOPRI TBPK 14x125mg amp 14x25mg 30
96 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
XELJANZ SOLN 48 XELJANZ TABS 5mg 10mg 48 XELJANZ XR TB24 11mg 22mg 48 XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 50 XERMELO TABS 40 XGEVA SOLN 47 XIFAXAN TABS 200mg 550mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 51 XOLAIR SOSY 75mg05ml 150mgml 51 XOSPATA TABS 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 18 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 18 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 XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 44 XUREA CREA 57 XURIDEN PACK 50 xylocaine dental soln 50 XYREM SOLN 32 XYWAV SOLN 32
Y YERVOY SOLN 19 YF-VAX INJ 53 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 39 yuvafem tabs 45
Z zafemy ptwk 44
zafirlukast tabs 10mg 20mg 51 zaleplon caps 5mg 10mg 31 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 44 zarontin soln 30 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 28 ZEJULA CAPS 19 ZELAPAR TBDP 31 ZELBORAF TABS 19 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
57 ZENPEP CPEP 38 zenzedi tabs 25mg 5mg 75mg 10mg
15mg 20mg 30mg 28 ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
32 ZEPOSIA CAPS 32 ZEPOSIA STARTER KIT CPPK 32 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERUVIA PTCH 56 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 51 ZIONODIL 100 LOTN 56 ZIONODIL LOTN 56 ziprasidone hcl caps 20mg 40mg 60mg
80mg 35 ziprasidone mesylate solr 35 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZOKINVY CAPS 50mg 75mg 50 zoledronic acid conc 47 zoledronic acid soln 47 ZOLINZA CAPS 19 zolmitriptan soln 30 zolmitriptan tabs 30 zolmitriptan tbdp 30 zolpidem tartrate er tbcr 625mg 125mg 31 zolpidem tartrate subl 175mg 35mg 31 zolpidem tartrate tabs 5mg 10mg 31 zonisamide caps 25mg 50mg 100mg 30 ZORBTIVE SOLR 46
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 97
ZORTRESS TABS 49 ZOSTAVAX SUSR 53 zovia 135 (28) tabs 44 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19
ZYKADIA TABS 19 ZYNLONTA SOLR 19 ZYPREXA RELPREVV SUSR 35 ZYTIGA TABS 19
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)
682896130 062022
This formulary was updated on 060122 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
kporgseniorrx Please recycle
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 5
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 2022 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 59 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg CIPRODEX) and generic drugs are listed in lower-case italics (eg amoxicillin) 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 2022 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
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 8 bull Kaiser Permanente 2022 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 azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP BICILLIN L-A SUSY cefaclor caps
Drug Name RequirementsLimits
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 intravenous 1gm 2gm 10gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 6gm HI
ceftazidime solr intravenous HI CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 750mg HI
cefuroxime sodium solr intravenous 15gm HI
cephalexin caps cephalexin susr cephalexin tabs chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w 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 2022 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
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 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 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
Drug Name RequirementsLimits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs erythromycin tbec FETROJA SOLR NDS 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 LYMEPAK 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
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium 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 10 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs 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 streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO suprax chew SYNERCID SOLR
Drug Name RequirementsLimits
targadox tabs MO tazicef solr injection HI tazicef solr intravenous 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
vancomycin hcl caps vancomycin hcl solr 250mg5ml vancomycin hcl solr intravenous 1gm 10gm 500mg HI
vancomycin hcl solr intravenous 5gm 750mg
XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ANTIFUNGALS AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS 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
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 2022 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS nystatin susp nystatin tabs 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 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 SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS
Drug Name RequirementsLimits
mefloquine hcl tabs metronidazole caps METRONIDAZOLE SOLN INTRAVENOUS 500mg100ml HI
metronidazole tabs nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs quinine sulfate caps NDS 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 APRETUDE SUER 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 DELSTRIGO TABS MO DESCOVY TABS 200-25mg MO DESCOVY TABS 120-15mg MO didanosine cpdr 200mg 250mg 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 12 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 PACK PANDS EPCLUSA TABS PANDS 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 LIVTENCITY TABS NDS lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO
Drug Name RequirementsLimits
maraviroc tabs 150mg 300mg MO MAVYRET PACK PANDS 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 oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEGASYS PROCLICK SOAJ 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN NDS PEGASYS SOSY NDS PEGINTRON KIT NDS PIFELTRO TABS MO 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
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 2022 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg MO sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS 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 PD TBSO MO TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEKLURY SOLN NDS VEKLURY SOLR NDS VEMLIDY TABS VIDEX EC CPDR 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
Drug Name RequirementsLimits
VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES 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 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg abiraterone acetate tabs 500mg NDS ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS NDS ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs arsenic trioxide soln NDS ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr
Drug Name RequirementsLimits
BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE SOLR BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS BESREMI SOSY NDS bexarotene caps NDS bicalutamide tabs 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 CAMCEVI PRSY CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR 50mg 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
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 2022 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
CYCLOPHOSPHAMIDE SOLN 2gm10ml 1gm5ml 500mg25ml
NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr 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 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 eulexin caps NDS
Drug Name RequirementsLimits
everolimus tabs 25mg 5mg 75mg 10mg NDS
everolimus tbso 2mg 3mg 5mg NDS EVOMELA SOLR NDS exemestane tabs EXKIVITY CAPS NDS FARYDAK CAPS 10mg 15mg 20mg LDNDS
FENSOLVI (6 MONTH) KIT 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 FYARRO SUSR 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 6000000unitml 10000000unitml
NDS
INTRON A SOLR 10000000unit 18000000unit 50000000unit 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 KIMMTRAK 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
lenalidomide caps 5mg 10mg 15mg 25mg NDS
Drug Name RequirementsLimits
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
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 TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA 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 2022 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
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 methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS nelarabine soln 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 120mg12ml 240mg24ml 40mg4ml
NDS
OPDUALAG SOLN NDS oxaliplatin soln oxaliplatin solr paclitaxel conc PACLITAXEL PROTEIN-BOUND PART SUSR 100 MG NDS
PADCEV SOLR 20mg 30mg NDS
Drug Name RequirementsLimits
paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEMFEXY SOLN 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 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
SCEMBLIX TABS 20mg 40mg NDS SIKLOS TABS NDS SOLTAMOX SOLN
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
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 05mg 075mg 1mg NDS
tamoxifen citrate tabs 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 TIVDAK SOLR 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 NDS
TRODELVY SOLR NDS
Drug Name RequirementsLimits
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 UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln 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
VONJO CAPS NDS VOTRIENT TABS NDS VYXEOS SUSR NDS WELIREG TABS 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
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 2022 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
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 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 ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO chlordiazepoxide-clidinium caps dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate oral soln MO glycopyrrolate pf sosy glycopyrrolate soln injection glycopyrrolate tabs 1mg 2mg MO
Drug Name RequirementsLimits
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 RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO varenicline tartrate misc MO varenicline tartrate tabs 05mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA FLEQSUVY SUSP NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs 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
Drug Name RequirementsLimits
albuterol sulfate er tb12 4mg 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcgact MONDS
albuterol sulfate nebu 0083 25mg05ml 063mg3ml 125mg3ml
PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY ipratropium-albuterol soln PAMO isoproterenol hcl soln LEVALBUTEROL HCL NEBU 125mg05ml 125mg3ml 031mg3ml 063mg3ml
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 SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS icatibant acetate 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 2022 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
OXBRYTA TABS NDS OXBRYTA TBSO NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS 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 BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln NDS enoxaparin sodium sosy 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
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 NDS LOVENOX SOSY 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg 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 SUSR NDS XARELTO TABS 25mg 10mg 15mg 20mg MO
HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
EPOGEN SOLN PANDS FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
PROCRIT SOLN 20000unitml 40000unitml PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RELEUKO SOLN 300mcgml 480mcg16ml NDS
RELEUKO SOSY 300mcg05ml 480mcg08ml NDS
RETACRIT SOLN 20000unitml PANDS RETACRIT SOLN PANDS TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS 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 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
Drug Name RequirementsLimits
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 150mg MO fenofibrate micronized caps 43mg 67mg 130mg 134mg 200mg
MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg 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
lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
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 SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 1gm MO BETA-ADRENERGIC BLOCKING 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 2022 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
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
ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
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
nadololbendroflumethiazide 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
Drug Name RequirementsLimits
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 cartia xt cp24 120mg 180mg 240mg 300mg MO
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 40mg 80mg 120mg MO
CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR SOLN MO CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln 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 lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy
Drug Name RequirementsLimits
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 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
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 2022 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
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
captopril-hydrochlorothiazide 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
quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
Drug Name RequirementsLimits
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO 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 dipyridamole tabs 25mg 50mg 75mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ascomp-codeine caps NDS benzhydrocodone-acetaminophen tabs NDS
bupap tabs 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 NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS dvorah tabs 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
Drug Name RequirementsLimits
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
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 hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd 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 NDS indomethacin caps indomethacin er cpcr indomethacin sodium solr ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lorcet hd tabs NDS lorcet plus 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln NDS meperidine hcl tabs 50mg NDS methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl tabs 5mg 10mg NDS MORPHINE SULFATE (CONCENTRATE) SOLN NDS
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 tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln 10mgml 20mgml NDS
nalfon tabs nalocet tabs NDS naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs
Drug Name RequirementsLimits
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 75-300mg 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 relafen ds tabs NDS SALSALATE TABS SUBSYS LIQD 1200mcg 1600mcg PANDS
sulindac tabs tencon tabs tolmetin sodium caps tolmetin sodium tabs
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 soln 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 tabs NDS vicodin es tabs NDS vicodin hp tabs NDS zebutal caps ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS amphetamine er suer NDS 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 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
evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS
Drug Name RequirementsLimits
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
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS procentra soln NDS relexxii tbcr NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
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
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 2022 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
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
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 EPRONTIA SOLN 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 lacosamide tabs 50mg 100mg 150mg 200mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
Drug Name RequirementsLimits
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
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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg 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 VALTOCO 15 MG DOSE LQPK VALTOCO 20 MG DOSE LQPK VALTOCO 5 MG DOSE LIQD vigabatrin pack LDNDS vigabatrin tabs NDS VIMPAT SOLN XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200mg NDS XCOPRI TBPK 14x125mg amp 14x25mg
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ PA AJOVY SOSY PA almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs
Drug Name RequirementsLimits
ergotamine-caffeine tabs FROVATRIPTAN SUCCINATE TABS
naratriptan hcl tabs NURTEC TBDP NDS QULIPTA TABS 10mg 30mg 60mg NDS
rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs UBRELVY TABS 50mg 100mg NDS zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl soln MO amantadine hcl tabs MO APOKYN SOCT NDS apomorphine hcl 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
EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg 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 2022 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
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
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
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 intensol conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS droperidol soln estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
Drug Name RequirementsLimits
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP PANDS 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 nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs seconal caps TEMAZEPAM CAPS 75mg 15mg 225mg 30mg 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS tetrabenazine tabs 125mg 25mg MO
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
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 1mg 2mg NDS
OCREVUS SOLN PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
Drug Name RequirementsLimits
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 ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS OPIATE ANTAGONISTS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
LUCEMYRA TABS NDS naloxone hcl liqd naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
VIVITROL SUSR NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg 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 2022 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
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 conc 30mgml 100mgml MO
chlorpromazine hcl soln chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
CITALOPRAM HYDROBROMIDE CAPS MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
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 HAFYERA SUSY INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 150mg 300mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
LITHIUM CARBONATE TABS MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
LYBALVI TABS NDS maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
Drug Name RequirementsLimits
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 susp MO paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps 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
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
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 2022 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
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 CAPS 150mg 200mg MO
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
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 MO trazodone hcl tabs 150mg 300mg 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
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 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 TRICITRATES SOLN AMMONIA DETOXICANTS carglumic acid tbso NDS constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN DEXTROSE SOLN INTRAVENOUS 5 10 HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE 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
Drug Name RequirementsLimits
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI furosemide tabs 20mg 40mg 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN tolvaptan tabs 15mg 30mg 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 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
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 2022 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate tabs MO CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
DEXTROSE-NACL SOLN INTRAVENOUS 25-045 5-02 5-045 5-09
HI
DEXTROSE-NACL SOLN INTRAVENOUS 10-02 10-045
HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 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 PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
Drug Name RequirementsLimits
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 10meq100ml 20meq100ml 40meq100ml 2meqml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN 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 ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME 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 38 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin oint bacitracin-polymyxin b oint bleph-10 soln chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin 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 paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln
Drug Name RequirementsLimits
sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ANTI-INFLAMMATORY AGENTS bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
CEQUA SOLN CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO cyclosporine emul MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO difluprednate emul MO flac oil 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
ILUVIEN IMPL ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint 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 2022 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
RESTASIS EMUL MO RESTASIS MULTIDOSE EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
VERKAZIA EMUL NDS YUTIQ IMPL ANTIALLERGIC AGENTS azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
betaxolol hcl soln MO bimatoprost soln MO brimonidine tartrate soln 015 02 MO
brinzolamide susp MO carteolol hcl soln MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
Drug Name RequirementsLimits
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO timolol maleate (once-daily) soln MO timolol maleate pf soln MO TIMOLOL MALEATE SOLG 025 05 MO
timolol maleate soln 025 05 MO
travoprost (bak free) 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 SUSVIMO (IMPLANT 1ST FILL) SOLN
SUSVIMO (IMPLANT REFILL) SOLN
TEPEZZA SOLR NDS VABYSMO SOLN LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lidocaine viscous hcl soln MO proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
balsalazide disodium caps MO colazal caps 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 OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS aprepitant caps PANDS dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl sosy ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy
Drug Name RequirementsLimits
SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS trimethobenzamide hcl caps PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc 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 famotidine (pf) soln 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 omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate 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 2022 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS 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 IBSRELA TABS NDS LIVMARLI SOLN NDS lubiprostone caps 8mcg 24mcg MO metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS TRULANCE TABS 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
Drug Name RequirementsLimits
clovique caps NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs deferasirox tbso deferiprone tabs 500mg 1000mg NDS
deferoxamine mesylate solr FERRIPROX SOLN LDNDS FERRIPROX TABS LDNDS FERRIPROX TWICE-A-DAY TABS NDS
penicillamine caps NDS penicillamine tabs NDS trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP ALKINDI SPRINKLE CPSP 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs 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 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp 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 10mg5ml 20mg5ml 25mg5ml 5mg5ml
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 SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TARPEYO CPDR NDS triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
danazol caps 50mg 100mg 200mg MO
Drug Name RequirementsLimits
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 405mg25gm 10mgact
MO
testosterone soln 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 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 enpresse-28 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 2022 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
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 jasmiel tabs MO JOLIVETTE 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
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
Drug Name RequirementsLimits
levora 01530 (28) 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 24 fe tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA 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 nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO nylia 135 tabs MO nylia 777 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 44 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 taysofy caps 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 wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135 (28) tabs MO
Drug Name RequirementsLimits
DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
AFREZZA POWD 90x8 UNIT amp 90x12 UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD 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 glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO HUMALOG KWIKPEN SOPN MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
JARDIANCE TABS 10mg 25mg MO KORLYM TABS LDNDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO metformin hcl er tb24 500mg 750mg 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 2022 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
OZEMPIC (2 MGDOSE) SOPN MO pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO tolazamide tabs 250mg 500mg MO tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
depo-estradiol oil dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
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 MO
Drug Name RequirementsLimits
006mg24hr 0075mg24hr 01mg24hr estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO fyavolv tabs MO jinteli tabs MO lopreeza tabs MO lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO prefest tabs MO PREMARIN SOLR raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PANDS CORTROPHIN GEL PANDS desmopressin ace spray refrig soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln desmopressin acetate tabs 01mg 02mg MO
SKYTROFA CART 3mg 36mg 43mg 52mg 63mg 76mg 91mg 11mg 133mg
NDS
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO 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 progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR NDS
Drug Name RequirementsLimits
EGRIFTA SV SOLR NDS GENOTROPIN CART 12mg PANDS GENOTROPIN MINIQUICK PRSY 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
HUMATROPE CART 6mg 12mg 24mg PANDS
HUMATROPE SOLR PANDS INCRELEX SOLN NDS LANREOTIDE ACETATE SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
octreotide acetate soln 50mcgml 100mcgml 200mcgml
octreotide acetate soln 500mcgml 1000mcgml
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 60mg02ml 90mg03ml 120mg05ml
NDS
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 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 2022 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 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 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
Drug Name RequirementsLimits
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 BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 70mg MO alendronate sodium tabs 5mg 10mg 35mg 40mg MO
EVENITY SOSY NDS IBANDRONATE SODIUM SOLN ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr 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 CIBINQO TABS 50mg 100mg 200mg NDS
CIMZIA KIT PANDS CIMZIA PREFILLED PSKT PANDS CIMZIA STARTER KIT PSKT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
INFLIXIMAB SOLR INTRAVENOUS HI
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 RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 15mg 30mg 45mg NDS
SIMPONI ARIA SOLN NDS
Drug Name RequirementsLimits
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 ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
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
ZORTRESS TABS PA MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BERINERT KIT INTRAVENOUS HI betaine powd NDS 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
Drug Name RequirementsLimits
CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENJAYMO SOLN 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 HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ONPATTRO SOLN NDS 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
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 PYRUKYND TABS 5mg 20mg 50mg NDS
PYRUKYND TAPER PACK TBPK NDS
RECORLEV TABS NDS REZUROCK TABS NDS
Drug Name RequirementsLimits
RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln 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 STERILE WATER FOR IRRIGATION SOLN
TAKHZYRO SOLN NDS TAKHZYRO SOSY NDS TAVNEOS CAPS NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR NDS tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VIJOICE TBPK NDS VILTEPSO SOLN NDS VOXZOGO SOLR 04mg 056mg 12mg NDS
VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS VYVGART SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg 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 2022 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 100mg067ml 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 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 ADVAIR HFA AERO 230-21mcgact MO
ADVAIR HFA AERO 45-21mcgact 115-21mcgact MO
Drug Name RequirementsLimits
ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS HI
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
DALIRESP TABS 250mcg 500mcg MO
FLOVENT HFA AERO MO fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PULMICORT FLEXHALER AEPB
SYMBICORT AERO TEZSPIRE SOSY NDS wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg 1000mcg 1200mcg 1400mcg 1600mcg
NDS
UPTRAVI TBPK NDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS HI
GAMUNEX-C SOLN INJECTION HI HYPERHEP B SOLN HYPERHEP B SOSY HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 1gm20ml 2gm20ml
HI
PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
VARIZIG SOLN TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP KINRIX SUSY QUADRACEL SUSP TDVAX SUSP
Drug Name RequirementsLimits
TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP BOOSTRIX SUSY 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 SOLN MENQUADFI SOLN MENVEO SOLR PEDIARIX SUSY PEDVAX HIB SUSP PENTACEL SUSR PREHEVBRIO SUSP PA PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TICOVAC SUSY TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN TYPHIM VI SOSY VAQTA SUSP VARIVAX INJ
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 2022 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint 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 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 clindamycin phosphate soln MO clindamycin phosphate swab MO clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn econazole nitrate crea ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA
Drug Name RequirementsLimits
gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham mafenide acetate pack malathion lotn metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea mupirocin oint naftifine hcl crea naftifine hcl gel neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ovide lotn oxiconazole nitrate crea permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 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
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
Drug Name RequirementsLimits
clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT 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 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
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO FLURANDRENOLIDE CREA 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 2022 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
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 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 prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO
Drug Name RequirementsLimits
psorcon crea MO RADIAURA CREA NDS texacort soln MO topicort crea 005 025 MO topicort gel MO topicort oint 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 VANOXIDE-HC LOTN WYNZORA CREA NDS ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
HYDROCORTISONE ACE-PRAMOXINE SUPP NDS
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 LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS 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
TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS 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
Drug Name RequirementsLimits
adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ADBRY SOSY NDS ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
azelaic acid gel MO AZELEX CREA MO 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
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA 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 KORSUVA SOLN NDS LACTIC ACID LOTN
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 2022 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
OPZELURA CREA 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 SHAM SALICYLIC ACID-CLEANSER KIT
SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SKYRIZI PEN SOAJ SKYRIZI SOSY STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
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 TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS
Drug Name RequirementsLimits
VECTICAL OINT MO XUREA CREA zenatane caps 10mg 20mg 30mg 40mg NDS
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 calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS
58 bull Kaiser Permanente 2018 Defined Standard Comprehensive Formulary
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 59
Index of Drugs
A abacavir sulfate soln 11 abacavir sulfate tabs 11 abacavir sulfate-lamivudine tabs 11 abacavir-lamivudine-zidovudine tabs 11 ABILIFY MAINTENA PRSY 300mg 400mg
32 ABILIFY MAINTENA SRER 300mg 400mg
32 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
abiraterone acetate tabs 250mg 14 abiraterone acetate tabs 500mg 14 ABRAXANE SUSR 14 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 56 acamprosate calcium tbec 25 acarbose tabs 25mg 50mg 100mg 44 accutane caps 10mg 20mg 30mg 40mg 56 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 26 acetaminophen-codeine soln 26 acetaminophen-codeine tabs 26 acetazolamide er cp12 39 acetazolamide sodium solr 39 acetazolamide tabs 125mg 250mg 39 ACETIC ACID SOLN 39 49 acetylcysteine soln 10 20 47 acitretin caps 10mg 175mg 25mg 56 ACTEMRA ACTPEN SOAJ 47 ACTEMRA SOSY 47 ACTHAR GEL 46 ACTHIB SOLR 52 ACTIMMUNE SOLN 49 acyclovir caps 11 acyclovir oint 53 acyclovir sodium soln intravenous 11 acyclovir susp 11
acyclovir tabs 400mg 800mg 11 ADACEL SUSP 52 ADAGEN SOLN 37 ADAKVEO SOLN 20 ADAPALENE CREA 56 adapalene gel 01 03 56 adapalene pads 56 adapalene soln 56 adapalene-benzoyl peroxide gel 56 ADAPALENE-BENZOYL PEROXIDE PADS
56 ADBRY SOSY 56 adderall tabs 28 adefovir dipivoxil tabs 11 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 51 adenosine soln 24 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 230-21mcgact 51 ADVAIR HFA AERO 45-21mcgact 115-
21mcgact 51 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 14 AFREZZA POWD 90x8 UNIT amp 90x12 UNIT
44 AJOVY SOAJ 30 AJOVY SOSY 30 ala-cort crea 1 25 54 albendazole tabs 8 albuterol sulfate er tb12 4mg 8mg 20 ALBUTEROL SULFATE HFA AERS
108mcgact 20 albuterol sulfate nebu 0083
25mg05ml 063mg3ml 125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 54 alclometasone dipropionate oint 54 ALCOHOL PREP PADS 35 ALDURAZYME SOLN 37 ALECENSA CAPS 14
60 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
alendronate sodium soln 47 alendronate sodium tabs 5mg 10mg
35mg 40mg 47 alendronate sodium tabs 70mg 47 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 41 ALKINDI SPRINKLE CPSP 1mg 2mg 5mg
41 allopurinol sodium solr 47 allopurinol tabs 100mg 300mg 47 allzital tabs 26 almotriptan malate tabs 30 alogliptin benzoate tabs 625mg 125mg
25mg 44 ALOGLIPTIN-METFORMIN HCL TABS 44 alogliptin-pioglitazone tabs 44 ALOSETRON HCL TABS 05mg 1mg 40 alprazolam er tb24 05mg 1mg 2mg 3mg
31 alprazolam intensol conc 31 alprazolam tabs 025mg 05mg 1mg 2mg
31 alprazolam tbdp 025mg 05mg 1mg 2mg
31 ALTACAINE SOLN 39 ALTAFRIN SOLN 39 altavera tabs 42 ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 51 alyacen 135 tabs 42 alyq tabs 25 amabelz tabs 45 amantadine hcl caps 30 amantadine hcl soln 30 amantadine hcl tabs 30 AMBISOME SUSR INTRAVENOUS 10 ambrisentan tabs 51 amcinonide crea 54 amcinonide lotn 54 amcinonide oint 54 amethia lo tabs 42 amethia tabs 42 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 36
amiloride-hydrochlorothiazide tabs 36 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 57 amiodarone hcl soln 24 amiodarone hcl tabs 100mg 200mg
400mg 24 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 33 amlodipine besy-benazepril hcl caps 23 amlodipine besylate tabs 25mg 5mg
10mg 23 amlodipine besylate-valsartan tabs 23 amlodipine-atorvastatin tabs 23 amlodipine-olmesartan tabs 23 amlodipine-valsartan-hctz tabs 23 ammonium lactate crea 56 ammonium lactate lotn 56 amnesteem caps 10mg 20mg 40mg 56 AMONDYS 45 SOLN 49 amoxapine tabs 25mg 50mg 100mg
150mg 33 amoxicill-clarithro-lansopraz misc 40 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8 amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 28 amphetamine sulfate tabs 5mg 10mg 28 amphetamine-dextroamphet er cp24 28 amphetamine-dextroamphetamine tabs 28 amphotericin b solr intravenous 10 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 42 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 55 anastrozole tabs 14
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 61
ANDRODERM PT24 2mg24hr 4mg24hr 42
antabuse tabs 250mg 500mg 25 anusol-hc crea 54 apap-caff-dihydrocodeine tabs 26 apexicon e crea 54 APLENZIN TB24 174mg 348mg 522mg 33 APOKYN SOCT 30 apomorphine hcl soct 30 apraclonidine hcl soln 39 aprepitant caps 40 APRETUDE SUER 11 apri tabs 42 APTIOM TABS 200mg 400mg 600mg
800mg 28 APTIVUS CAPS 11 APTIVUS SOLN 11 ARALAST NP SOLR INTRAVENOUS 51 aranelle tabs 42 ARANESP (ALBUMIN FREE) SOLN
60mcgml 100mcgml 200mcgml 21 ARANESP (ALBUMIN FREE) SOSY
60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 21
ARCALYST SOLR 49 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 49 ARIKAYCE SUSP 8 aripiprazole soln 33 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 33 aripiprazole tbdp 10mg 15mg 33 ARISTADA INITIO PRSY 33 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 33
armodafinil tabs 50mg 150mg 200mg 250mg 28
arsenic trioxide soln 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 49 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 52 ascomp-codeine caps 26 asenapine maleate subl 25mg 5mg 10mg
33
ashlyna tabs 42 ASMANEX HFA AERO 100mcgact
200mcgact 51 ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 48 ASTAGRAF XL CP24 05mg 1mg 48 atazanavir sulfate caps 150mg 200mg
300mg 11 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 31 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 22 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 39 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 32 aubra eq tabs 42 AUGMENTIN SUSR 8 AURYXIA TABS 36 AUSTEDO TABS 6mg 9mg 12mg 31 AVASTIN SOLN 14 AVC VAGINAL CREA 53 aviane tabs 42 AVITA CREA 56 AVITA GEL 56 AVONEX KIT 32 AVONEX PEN AJKT 32 AVONEX PREFILLED PSKT 32 AVSOLA SOLR 47 aygestin tabs 46 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 48 azathioprine sodium solr 48 azathioprine tabs 48 azelaic acid gel 56 azelastine hcl soln 005 01 015 39 azelastine-fluticasone susp 39 AZELEX CREA 56 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
62 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
B bacitracin oint 38 bacitracin solr 8 bacitracin-polymyxin b oint 38 bacitra-neomycin-polymyxin-hc oint 38 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 53 BAFIERTAM CPDR 32 balsalazide disodium caps 40 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 42 BANZEL SUSP 28 BANZEL TABS 200mg 400mg 28 BAQSIMI ONE PACK POWD 44 BAQSIMI TWO PACK POWD 44 BARACLUDE SOLN 11 BAVENCIO SOLN 14 BCG VACCINE SOLR 14 BD INSULIN SYR ULTRAFINE II MISC 35 BD INSULIN SYRINGE MISC 35 BD INSULIN SYRINGE UF MISC 35 BD PEN NEEDLE ORIGINAL UF MISC 35 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 32 BELEODAQ SOLR 14 BELRAPZO SOLN 14 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 14 BENDEKA SOLN 14 BENLYSTA SOAJ 48 BENLYSTA SOLR 48 BENLYSTA SOSY 48 BENZEPRO CREAMY WASH LIQD 53 BENZEPRO FOAMING CLOTHS MISC 53 benzhydrocodone-acetaminophen tabs 26 benzoyl perox-hydrocortisone lotn 54 BENZOYL PEROXIDE FORTE- HC LOTN
54 BENZOYL PEROXIDE GEL 53 benzoyl peroxide-erythromycin gel 53 benztropine mesylate soln 30 benztropine mesylate tabs 05mg 1mg
2mg 30 BEOVU SOLN 39 bepotastine besilate soln 39
BERINERT KIT INTRAVENOUS 49 beser lotn 54 BESPONSA SOLR 14 BESREMI SOSY 14 betaine powd 49 betamethasone dipropionate aug crea 54 betamethasone dipropionate aug gel 54 betamethasone dipropionate aug lotn 54 betamethasone dipropionate aug oint 54 betamethasone dipropionate crea 54 betamethasone dipropionate lotn 54 BETAMETHASONE DIPROPIONATE OINT
54 betamethasone sod phos amp acet susp 41 betamethasone valerate crea 54 betamethasone valerate foam 54 BETAMETHASONE VALERATE LOTN 54 BETAMETHASONE VALERATE OINT 54 BETASERON KIT 32 betaxolol hcl soln 39 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 19 bexarotene caps 14 BEXSERO SUSY 52 bicalutamide tabs 14 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICILLIN L-A SUSY 8 BIKTARVY TABS 11 bimatoprost soln 39 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23 bleomycin sulfate solr 14 bleph-10 soln 38 blephamide sop oint 38 BLEPHAMIDE SUSP 38 BLINCYTO SOLR 14 blisovi 24 fe tabs 42 blisovi fe 1530 tabs 42 BOOSTRIX SUSP 52 BOOSTRIX SUSY 52 BORTEZOMIB SOLR 14 bosentan tabs 51 BOSULIF TABS 100mg 400mg 500mg 14 BRAFTOVI CAPS 50mg 75mg 14 briellyn tabs 42 BRILINTA TABS 60mg 90mg 21
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 63
brimonidine tartrate soln 015 02 39 brinzolamide susp 39 BRIVIACT SOLN 28 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 28 bromfenac sodium (once-daily) soln 38 bromocriptine mesylate caps 30 bromocriptine mesylate tabs 30 BRONCHITOL CAPS 51 BROVANA NEBU 20 BRUKINSA CAPS 14 budesonide cpep 41 budesonide er tb24 41 budesonide susp 025mg2ml 05mg2ml
1mg2ml 51 bumetanide soln 36 bumetanide tabs 05mg 1mg 2mg 36 bupap tabs 26 bupivacaine hcl (pf) soln 49 bupivacaine hcl soln 49 BUPIVACAINE IN DEXTROSE SOLN 49 bupivacaine spinal soln 49 bupivacaine-epinephrine (pf) soln 49 bupivacaine-epinephrine soln 49 buprenorphine hcl subl 2mg 8mg 32 buprenorphine hcl-naloxone hcl film 32 buprenorphine hcl-naloxone hcl subl 32 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 32 bupropion hcl er (smoking det) tb12 33 bupropion hcl er (sr) tb12 100mg 150mg
200mg 33 bupropion hcl er (xl) tb24 150mg 300mg
450mg 33 bupropion hcl tabs 75mg 100mg 33 buspirone hcl tabs 5mg 10mg 31 buspirone hcl tabs 75mg 15mg 30mg 31 busulfan soln 14 butalbital-acetaminophen tabs 26 butalbital-apap-caff-cod caps 26 butalbital-apap-caffeine caps 26 butalbital-apap-caffeine tabs 26 butalbital-asa-caff-codeine caps 26 butalbital-aspirin-caffeine caps 26 butalbital-aspirin-caffeine tabs 26 butorphanol tartrate soln 26 BYLVAY (PELLETS) CPSP 200mcg
600mcg 41 BYLVAY CAPS 400mcg 1200mcg 41
C CABENUVA SUER 11 cabergoline tabs 30 CABLIVI KIT 21 CABOMETYX TABS 20mg 40mg 60mg 14 cafergot tabs 30 caffeine citrate soln 28 calcipotriene crea 56 calcipotriene oint 56 calcipotriene soln 56 calcipotriene-betameth diprop oint 54 calcipotriene-betameth diprop susp 54 calcitonin (salmon) soln 45 calcitrene oint 56 calcitriol caps 025mcg 05mcg 57 CALCITRIOL OINT 56 calcitriol soln 57 calcium acetate (phos binder) caps 37 calcium acetate tabs 37 CALCIUM GLUCONATE-NACL SOLN 37 CALQUENCE CAPS 14 CAMCEVI PRSY 14 camila tabs 42 camrese lo tabs 42 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 54 CAPLYTA CAPS 33 CAPRELSA TABS 100mg 300mg 14 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 25 CARAC CREA 56 carbamazepine chew 28 carbamazepine er cp12 100mg 200mg
300mg 28 carbamazepine er tb12 100mg 200mg
400mg 28 carbamazepine susp 28 carbamazepine tabs 28 carbidopa tabs 30 carbidopa-levodopa er tbcr 30 carbidopa-levodopa tabs 30 carbidopa-levodopa tbdp 30 carbidopa-levodopa-entacapone tabs 30 carbinoxamine maleate soln 13
64 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
carbinoxamine maleate tabs 13 carboplatin soln 14 carboprost tromethamine soln 45 CARDENE IV SOLN 23 carglumic acid tbso 35 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 14 CARNITOR SOLN 49 CARNITOR TABS 49 carteolol hcl soln 39 cartia xt cp24 120mg 180mg 240mg
300mg 23 carvedilol phosphate er cp24 10mg 20mg
40mg 80mg 23 carvedilol tabs 3125mg 625mg 125mg
25mg 23 caspofungin acetate solr intravenous 50mg
70mg 10 CAYSTON SOLR 51 caziant tabs 42 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 intravenous 1gm 2gm
10gm 8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 6gm 8 ceftazidime solr intravenous 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 750mg 8 cefuroxime sodium solr intravenous 15gm 8 celecoxib caps 26 CELONTIN CAPS 29 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 38 CERDELGA CAPS 37 CEREZYME SOLR 37 CEROVEL LOTN 56 cetirizine hcl soln 13 CEVIMELINE HCL CAPS 19 CHANTIX CONTINUING MONTH PAK
TABS 19 CHANTIX STARTING MONTH PAK TABS
19 CHANTIX TABS 05mg 1mg 19 CHEMET CAPS 41 chloramphenicol sod succinate solr 8 chlordiazepoxide hcl caps 5mg 10mg
25mg 31 chlordiazepoxide-amitriptyline tabs 33 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 38 chloroprocaine hcl (pf) soln 49 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 36 chlorothiazide tabs 250mg 500mg 36 chlorpromazine hcl conc 30mgml
100mgml 33 chlorpromazine hcl soln 33 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 33 chlorthalidone tabs 25mg 50mg 36 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 41 cholestyramine light pack 22 cholestyramine light powd 22 cholestyramine pack 22 cholestyramine powd 22 CHORIONIC GONADOTROPIN SOLR 45 CIBINQO TABS 50mg 100mg 200mg 47 ciclopirox gel 53 ciclopirox olamine crea 53
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 65
ciclopirox olamine susp 53 ciclopirox sham 53 ciclopirox soln 53 cidofovir soln 11 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 38 CIMDUO TABS 11 cimetidine hcl soln 40 cimetidine tabs 200mg 300mg 400mg
800mg 40 CIMZIA KIT 47 CIMZIA PREFILLED PSKT 47 CIMZIA STARTER KIT PSKT 47 cinacalcet hcl tabs 30mg 60mg 90mg 45 CINQAIR SOLN 51 CINRYZE SOLR INTRAVENOUS 49 CIPRODEX SUSP 38 ciprofloxacin hcl soln (ophth) 38 CIPROFLOXACIN HCL SOLN (OTIC) 38 ciprofloxacin hcl tabs 8 ciprofloxacin in d5w soln 8 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 38 cisplatin soln 14 CISPLATIN SOLR 50mg 14 CITALOPRAM HYDROBROMIDE CAPS 33 citalopram hydrobromide soln 33 citalopram hydrobromide tabs 10mg 20mg
40mg 33 citanest plain dental soln 49 cladribine soln 14 claravis caps 10mg 20mg 30mg 40mg 56 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 13 cleocin phosphate soln 9 cleocin solr 9 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
clindacin-p swab 53 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 53 clindamycin phosphate crea 53
clindamycin phosphate foam 53 clindamycin phosphate gel 53 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 53 clindamycin phosphate soln 9 53 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 53 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 36 clinisol sf soln intravenous 36 clobazam susp 29 clobazam tabs 10mg 20mg 29 clobetasol propionate crea 54 clobetasol propionate e crea 54 clobetasol propionate emulsion foam 54 clobetasol propionate foam 54 clobetasol propionate gel 54 clobetasol propionate liqd 54 clobetasol propionate lotn 54 clobetasol propionate oint 54 clobetasol propionate sham 54 clobetasol propionate soln 54 clocortolone pivalate crea 54 clocortolone pivalate pump crea 54 clofarabine soln 14 clomipramine hcl caps 25mg 50mg 75mg
33 clonazepam tabs 05mg 1mg 2mg 29 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 29 clonidine hcl (analgesia) soln 24
66 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
clonidine hcl er tb12 24 clonidine hcl tabs 01mg 02mg 03mg 24 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 24 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 31 clotrimazole crea 53 clotrimazole soln 53 clotrimazole troc 53 clotrimazole-betamethasone crea 53 clotrimazole-betamethasone lotn 53 clovique caps 41 clozapine tabs 25mg 50mg 100mg 200mg
33 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 33 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 26 colazal caps 40 COLCHICINE CAPS 47 colchicine tabs 47 colchicine-probenecid tabs 37 COLESEVELAM HCL PACK 22 colesevelam hcl tabs 22 colestipol hcl gran 22 colestipol hcl pack 22 colestipol hcl tabs 22 colistimethate sodium (cba) solr injection 9 colocort enem 54 COLY-MYCIN S SUSP 38 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 14 COMETRIQ (140 MG DAILY DOSE) KIT 14 COMETRIQ (60 MG DAILY DOSE) KIT 14 COMPLERA TABS 11 compro supp 33 CONSENSI TABS 23 constulose soln 35 COPIKTRA CAPS 15mg 25mg 14 CORDRAN TAPE 54 CORLANOR SOLN 24 CORLANOR TABS 5mg 75mg 24 cortisone acetate tabs 41 CORTISPORIN CREA 54 CORTISPORIN OINT 54 CORTROPHIN GEL 46 COSELA SOLR 49
COSENTYX (300 MG DOSE) SOSY 56 COSENTYX SENSOREADY (300 MG)
SOAJ 56 COSENTYX SENSOREADY PEN SOAJ 56 COSENTYX SOSY 75mg05ml 150mgml
56 COTELLIC TABS 14 CREON CPEP 37 CRESEMBA CAPS 10 CRESEMBA SOLR 10 CRIXIVAN CAPS 200mg 400mg 11 cromolyn sodium conc 51 cromolyn sodium nebu 51 cromolyn sodium soln 39 crotan lotn 53 cryselle-28 tabs 42 CRYSVITA SOLN 10mgml 20mgml
30mgml 49 CURITY GAUZE PADS 35 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 52
cyclafem 135 tabs 42 cyclafem 777 tabs 42 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 14 CYCLOPHOSPHAMIDE SOLN 2gm10ml
1gm5ml 500mg25ml 15 cyclophosphamide solr 15 cycloserine caps 11 cyclosporine caps 25mg 100mg 48 cyclosporine emul 38 cyclosporine modified caps 25mg 50mg
100mg 48 cyclosporine modified soln 48 cyclosporine soln 48 cyproheptadine hcl syrp 13 cyproheptadine hcl tabs 13 CYRAMZA SOLN 100mg10ml
500mg50ml 15 CYSTADANE POWD 49 CYSTADROPS SOLN 39 CYSTAGON CAPS 50mg 150mg 49 CYSTARAN SOLN 39 cytarabine (pf) soln 15 cytarabine soln 15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 67
CYTOGAM INJ 52
D dacarbazine solr 15 dactinomycin solr 15 dalfampridine er tb12 32 DALIRESP TABS 250mcg 500mcg 51 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 42 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 56 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 52 daptomycin solr intravenous 350mg 500mg
9 darifenacin hydrobromide er tb24 75mg
15mg 57 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 deblitane tabs 42 decadron tabs 5mg 75mg 41 decadron tabs 4mg 6mg 41 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 41 deferasirox tabs 41 deferasirox tbso 41 deferiprone tabs 500mg 1000mg 41 deferoxamine mesylate solr 41 DELSTRIGO TABS 11 deltasone tabs 41 delyla tabs 42 demeclocycline hcl tabs 9 DEMSER CAPS 22 depo-estradiol oil 45 DEPO-MEDROL SUSP 41 DEPO-PROVERA SUSP 400mgml 46 DEPO-SUBQ PROVERA 104 SUSY 46 depo-testosterone soln 100mgml
200mgml 42 DERMOTIC OIL 38 DESCOVY TABS 120-15mg 11 DESCOVY TABS 200-25mg 11
desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg 33
desloratadine tabs 13 desloratadine tbdp 13 desmopressin ace spray refrig soln 46 DESMOPRESSIN ACETATE SOLN 46 desmopressin acetate spray soln 46 desmopressin acetate tabs 01mg 02mg 46 desogestrel-ethinyl estradiol tabs 42 desonide crea 54 desonide gel 54 desonide lotn 54 desonide oint 54 desowen lotn 54 desoximetasone crea 005 025 54 desoximetasone gel 54 desoximetasone liqd 54 desoximetasone oint 005 025 54 desrx gel 54 DESVENLAFAXINE ER TB24 50mg
100mg 33 desvenlafaxine succinate er tb24 25mg
50mg 100mg 33 dexabliss tbpk 41 dexamethasone elix 41 dexamethasone intensol conc 41 dexamethasone sodium phosphate soln 38
41 dexamethasone soln 41 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 41 dexamethasone tbpk 41 dexchlorpheniramine maleate soln 13 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 28
dexmethylphenidate hcl tabs 25mg 5mg 10mg 28
dexpak 10 day tbpk 41 dexpak 13 day tbpk 41 dexpak 6 day tbpk 41 dexrazoxane hcl solr 49 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 28 dextroamphetamine sulfate soln 28 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 28 DEXTROSE IN LACTATED RINGERS
SOLN 37
68 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
DEXTROSE SOLN 36 DEXTROSE SOLN INTRAVENOUS 5
10 36 DEXTROSE-NACL SOLN INTRAVENOUS
10-02 10-045 37 DEXTROSE-NACL SOLN INTRAVENOUS
25-045 5-02 5-045 5-09 37 DIACOMIT CAPS 250mg 500mg 29 DIACOMIT PACK 250mg 500mg 29 DIASTAT ACUDIAL GEL 10mg 20mg 29 DIASTAT PEDIATRIC GEL 29 diazepam conc 31 diazepam gel 25mg 10mg 20mg 29 diazepam intensol conc 31 diazepam soln 5mg5ml 5mgml 31 diazepam tabs 2mg 5mg 10mg 31 diazoxide susp 44 diclofenac sodium er tb24 26 diclofenac sodium gel 1 3 54 diclofenac sodium soln 38 diclofenac sodium tbec 26 diclofenac-misoprostol tbec 26 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 11 DIFFERIN CREA 56 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 54 diflorasone diacetate oint 54 diflunisal tabs 26 difluprednate emul 38 digitek tabs 0125mg 025mg 24 digox tabs 24 digoxin soln 24 digoxin tabs 125mcg 250mcg 24 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 29 dilantin infatabs chew 29 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 23 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 23
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 23
diltiazem hcl er cp12 60mg 90mg 120mg 23
diltiazem hcl er cp24 120mg 180mg 240mg 23
diltiazem hcl soln 23 diltiazem hcl solr 23 diltiazem hcl tabs 30mg 60mg 90mg
120mg 23 dilt-xr cp24 120mg 180mg 240mg 23 dimenhydrinate soln 40 dimethyl fumarate cpdr 32 dimethyl fumarate starter pack misc 32 DIPENTUM CAPS 40 diphen elix 13 di-phen elix 13 diphenhydramine hcl elix 13 diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 40 diphenoxylate-atropine tabs 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 52 dipyridamole tabs 25mg 50mg 75mg 25 disopyramide phosphate caps 100mg
150mg 24 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 36 divalproex sodium csdr 29 divalproex sodium er tb24 250mg 500mg29 divalproex sodium tbec 125mg 250mg
500mg 29 dobutamine hcl soln 20 DOBUTAMINE IN D5W SOLN 20 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
24 dolishale tabs 42 donepezil hcl tabs 5mg 10mg 23mg 19 donepezil hcl tbdp 5mg 10mg 19 dopamine hcl soln 20 DOPAMINE IN D5W SOLN 20 DOPTELET TABS 21 dorzolamide hcl soln 39 dorzolamide hcl-timolol mal pf soln 39 dorzolamide hcl-timolol mal soln 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 69
dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 33 doxepin hcl conc 33 doxepin hcl crea 55 doxepin hcl tabs 3mg 6mg 33 doxercalciferol caps 05mcg 1mcg 25mcg
57 DOXERCALCIFEROL SOLN 57 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
150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 40 DRIZALMA SPRINKLE CSDR 33 dronabinol caps 25mg 5mg 10mg 40 droperidol soln 31 drospiren-eth estrad-levomefol tabs 42 drospirenone-ethinyl estradiol tabs 42 DROXIA CAPS 15 droxidopa caps 20 DUAKLIR PRESSAIR AEPB 19 DUEXIS TABS 26 duloxetine hcl cpep 20mg 30mg 40mg
60mg 33 DUPIXENT SOPN 200mg114ml
300mg2ml 51 DUPIXENT SOSY 100mg067ml
200mg114ml 300mg2ml 51 DURYSTA IMPL 39 dutasteride caps 47 dutasteride-tamsulosin hcl caps 47 dvorah tabs 26 dxevo 11-day tbpk 41
E ees 400 tabs 9 EASYGEL GEL 49 econazole nitrate crea 53 EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 46 EGRIFTA SV SOLR 46 ELAPRASE SOLN 37 ELELYSO SOLR 37 ELEPSIA XR TB24 1000mg 1500mg 29 eletriptan hydrobromide tabs 30 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 37 elixophyllin elix 57 ELLA TABS 42 ELLENCE SOLN 15 ELMIRON CAPS 49 eluryng ring 42 ELZONRIS SOLN 15 EMCYT CAPS 15 EMFLAZA SUSP 42 EMFLAZA TABS 6mg 18mg 30mg 36mg
42 EMPAVELI SOLN 49 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 30 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 25 enalaprilat inj 25 enalapril-hydrochlorothiazide tabs 25 ENBREL MINI SOCT 47 ENBREL SOLN 47 ENBREL SOLR 47 ENBREL SOSY 25mg05ml 50mgml 48 ENBREL SURECLICK SOAJ 48 ENDARI PACK 49 endocet tabs 26 ENDOMETRIN INST 46
70 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ENGERIX-B SUSP 10mcg05ml 20mcgml 52
ENHERTU SOLR 15 ENJAYMO SOLN 49 enoxaparin sodium soln 21 enoxaparin sodium sosy 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
enpresse-28 tabs 42 ENSPRYNG SOSY 49 ENSTILAR FOAM 54 entacapone tabs 30 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 25 ENTYVIO SOLR 41 enulose soln 35 ENVARSUS XR TB24 075mg 1mg 4mg48 EPCLUSA PACK 12 EPCLUSA TABS 12 EPIDIOLEX SOLN 29 epifoam foam 54 epinastine hcl soln 39 epinephrine (anaphylaxis) soln 20 epinephrine soaj 20 EPINEPHRINE SOSY 20 epirubicin hcl soln 15 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 25 EPOGEN SOLN 21 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 21 epoprostenol sodium solr 51 EPRONTIA SOLN 29 eprosartan mesylate tabs 25 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 33 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 30 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 43 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 53 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 53 erythromycin oint 38 erythromycin pads 53 erythromycin soln 53 erythromycin tbec 9 ESBRIET CAPS 51 ESBRIET TABS 267mg 801mg 51 escitalopram oxalate soln 33 escitalopram oxalate tabs 5mg 10mg
20mg 33 esgic caps 26 esgic tabs 26 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 40 esomeprazole magnesium pack 10mg
20mg 40mg 40 esomeprazole sodium solr 40 estarylla tabs 43 estazolam tabs 1mg 2mg 31 estrace crea 45 estrace tabs 05mg 1mg 2mg 45 estradiol crea 45 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
estradiol tabs 10mcg 05mg 1mg 2mg 45 estradiol valerate oil 45 estradiol-norethindrone acet tabs 45 ESTRING RING 45 eszopiclone tabs 1mg 2mg 3mg 31 ethacrynic acid tabs 36 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 29 ethosuximide soln 29 ethynodiol diac-eth estradiol tabs 43 etodolac caps 26
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 71
etodolac er tb24 26 etodolac tabs 26 etonogestrel-ethinyl estradiol ring 43 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 eulexin caps 15 EURAX CREA 53 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 46
evekeo tabs 5mg 10mg 28 EVENITY SOSY 47 everolimus tabs 025mg 48 everolimus tabs 05mg 075mg 1mg 48 everolimus tabs 25mg 5mg 75mg 10mg
15 everolimus tbso 2mg 3mg 5mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 22 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 49 exemestane tabs 15 EXKIVITY CAPS 15 EXONDYS 51 SOLN 500mg10ml
100mg2ml 49 EXSERVAN FILM 31 EXTAVIA KIT 32 EYLEA SOLN 39 EYLEA SOSY 39 ezetimibe tabs 22 ezetimibe-simvastatin tabs 22
F FABRAZYME SOLR 5mg 35mg 37 falmina tabs 43 famciclovir tabs 125mg 250mg 500mg 12 famotidine (pf) soln 40 famotidine premixed soln 40 famotidine soln 40 famotidine susr 40 famotidine tabs 20mg 40mg 40 FANAPT TABS 1mg 2mg 4mg 6mg 8mg
10mg 12mg 33 FANAPT TITRATION PACK TABS 33 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 51 FASENRA SOSY 51
fayosim tabs 43 febuxostat tabs 40mg 80mg 47 felbamate susp 29 felbamate tabs 400mg 600mg 29 felodipine er tb24 25mg 5mg 10mg 23 femynor tabs 43 fenofibrate caps 50mg 150mg 22 fenofibrate micronized caps 43mg 67mg
130mg 134mg 200mg 22 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 22 fenofibric acid cpdr 45mg 135mg 22 fenoprofen calcium caps 26 fenoprofen calcium tabs 26 fenortho caps 26 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 26 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 26
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 26
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 26
FERRIPROX SOLN 41 FERRIPROX TABS 41 FERRIPROX TWICE-A-DAY TABS 41 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
33 FETZIMA TITRATION C4PK 33 fexmid tabs 20 finasteride tabs 47 FINTEPLA SOLN 29 fioricet caps 26 fioricetcodeine caps 26 FIRDAPSE TABS 49 FIRMAGON (240 MG DOSE) SOLR 15 FIRMAGON SOLR 15 flac oil 38 flavoxate hcl tabs 57 FLEBOGAMMA DIF SOLN INTRAVENOUS
52 flecainide acetate tabs 50mg 100mg
150mg 24 FLEQSUVY SUSP 20 FLOVENT HFA AERO 51 floxuridine solr 15
72 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
fluconazole in sodium chloride soln intravenous 10
fluconazole susr 10 fluconazole tabs 10 flucytosine caps 250mg 500mg 10 fludarabine phosphate soln 15 fludarabine phosphate solr 15 fludrocortisone acetate tabs 42 flumazenil soln 31 flunisolide soln 38 fluocinolone acetonide body oil 54 fluocinolone acetonide crea 001 0025
54 fluocinolone acetonide oil 38 fluocinolone acetonide oint 54 fluocinolone acetonide scalp oil 54 fluocinolone acetonide soln 54 fluocinonide crea 54 fluocinonide emulsified base crea 54 FLUOCINONIDE GEL 54 fluocinonide oint 54 fluocinonide soln 54 FLUORITAB CHEW 025mg 05mg 1mg 49 FLUORITAB SOLN 49 fluorometholone susp 38 fluorouracil crea 5 56 fluorouracil crea 5 56 fluorouracil soln 15 56 fluorouracil soln 2 5 56 fluoxetine hcl (pmdd) tabs 10mg 20mg 33 fluoxetine hcl caps 10mg 20mg 40mg 33 fluoxetine hcl cpdr 33 fluoxetine hcl soln 33 fluoxetine hcl tabs 10mg 20mg 60mg 33 fluphenazine decanoate soln 33 fluphenazine hcl conc 33 fluphenazine hcl elix 33 fluphenazine hcl soln 33 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 34 FLURANDRENOLIDE CREA 54 flurandrenolide lotn 55 flurandrenolide oint 55 flurazepam hcl caps 15mg 30mg 31 flurbiprofen sodium soln 38 flurbiprofen tabs 26 flutamide caps 15 fluticasone propionate crea 55 fluticasone propionate lotn 55
fluticasone propionate oint 55 fluticasone propionate susp 38 fluticasone-salmeterol aepb 51 fluvastatin sodium caps 20mg 40mg 22 fluvastatin sodium er tb24 22 fluvoxamine maleate er cp24 100mg
150mg 34 fluvoxamine maleate tabs 25mg 50mg
100mg 34 FML FORTE SUSP 38 FML OINT 38 fomepizole soln 47 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 FORTEO SOPN 45 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 40 fosfomycin tromethamine pack 13 fosinopril sodium tabs 10mg 20mg 40mg
25 fosinopril sodium-hctz tabs 25 fosphenytoin sodium soln 29 FOTIVDA CAPS 089mg 134mg 15 FROVATRIPTAN SUCCINATE TABS 30 FULPHILA SOSY 21 fulvestrant soln 15 furosemide soln 8mgml 10mgml 36 furosemide soln injection 36 furosemide tabs 20mg 40mg 80mg 36 FUZEON SOLR 12 FYARRO SUSR 15 fyavolv tabs 45 FYCOMPA SUSP 29 FYCOMPA TABS 29
G gabapentin caps 100mg 400mg 29 gabapentin soln 29 gabapentin tabs 600mg 800mg 29 GALAFOLD CAPS 49 galantamine hydrobromide er cp24 8mg
16mg 24mg 19 galantamine hydrobromide soln 19 galantamine hydrobromide tabs 4mg 8mg
12mg 19 GAMASTAN INJ 52 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 48
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 73
GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm 52
GAMMAGARD SOLN INJECTION 52 GAMMAKED SOLN INJECTION 52 GAMMAPLEX SOLN INTRAVENOUS 52 GAMUNEX-C SOLN INJECTION 52 ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 52 GARDASIL 9 SUSY 52 gatifloxacin soln 38 GATTEX KIT 41 gavilyte-c solr 41 gavilyte-g solr 41 gavilyte-h kit 41 gavilyte-n with flavor pack solr 41 GAVRETO CAPS 15 GAZYVA SOLN 15 gemcitabine hcl soln 15 gemcitabine hcl solr 15 gemfibrozil tabs 22 gemmily caps 43 generlac soln 35 gengraf caps 25mg 50mg 100mg 48 gengraf soln 48 GENOTROPIN CART 12mg 46 GENOTROPIN MINIQUICK PRSY 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 46
gentak oint 38 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 53 gentamicin sulfate oint 53 gentamicin sulfate soln 9 38 gentamicin sulfate soln injection 9 GENVOYA TABS 12 gianvi tabs 43 GILENYA CAPS 025mg 05mg 32 GILOTRIF TABS 20mg 30mg 40mg 15 GIMOTI SOLN 41 GIVLAARI SOLN 49 GLASSIA SOLN INTRAVENOUS 51 glatopa sosy 20mgml 40mgml 32 glimepiride tabs 1mg 2mg 4mg 44 glipizide er tb24 25mg 5mg 10mg 44 glipizide tabs 5mg 10mg 44 glipizide-metformin hcl tabs 44 glucagon emergency kit 44
glyburide micronized tabs 15mg 3mg 6mg 44
glyburide tabs 125mg 25mg 5mg 44 glyburide-metformin tabs 44 glycate tabs 19 glycopyrrolate oral soln 19 glycopyrrolate pf sosy 19 glycopyrrolate soln injection 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 55 granisetron hcl soln 40 granisetron hcl tabs 40 GRANIX SOLN 480mcg16ml 300mcgml
21 GRANIX SOSY 300mcg05ml
480mcg08ml 21 GRASTEK SUBL 49 griseofulvin microsize susp 10 griseofulvin microsize tabs 10 griseofulvin ultramicrosize tabs 10 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 32 guanfacine hcl tabs 1mg 2mg 24 GUANIDINE HCL TABS 19 gynazole-1 crea 53
H HAEGARDA SOLR 2000unit 3000unit 49 hailey 24 fe tabs 43 halcinonide crea 55 halobetasol propionate crea 55 HALOBETASOL PROPIONATE FOAM 55 halobetasol propionate oint 55 haloperidol decanoate soln 34 haloperidol lactate conc 34 haloperidol lactate soln 34 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 34 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 52 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
HEPLISAV-B SOLN 52
74 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
HERCEPTIN HYLECTA SOLN 15 HERCEPTIN SOLR 150mg 440mg 15 HERZUMA SOLR 150mg 420mg 15 HETLIOZ CAPS 31 HETLIOZ LQ SUSP 31 HIBERIX SOLR 52 HUMALOG KWIKPEN SOPN 44 HUMALOG SOCT 44 HUMALOG SOLN 44 humatin caps 11 HUMATROPE CART 6mg 12mg 24mg 46 HUMATROPE SOLR 46 HUMIRA PEDIATRIC CROHNS START
PSKT 48 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 48 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 48 HUMIRA PEN-PEDIATRIC UC START
PNKT 48 HUMIRA PEN-PSUVADOL HS START
PNKT 48 HUMIRA PEN-PSORUVEIT STARTER
PNKT 48 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 48
HUMULIN 7030 KWIKPEN SUPN 44 HUMULIN 7030 SUSP 44 HUMULIN N KWIKPEN SUPN 44 HUMULIN N SUSP 44 HUMULIN R SOLN 44 HUMULIN R U-500 (CONCENTRATED)
SOLN 44 HUMULIN R U-500 KWIKPEN SOPN 44 hydralazine hcl soln 24 hydralazine hcl tabs 10mg 25mg 50mg
100mg 24 hydrochlorothiazide caps 36 hydrochlorothiazide tabs 125mg 25mg
50mg 36 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 26 hydrocodone-acetaminophen soln 26 hydrocodone-acetaminophen tabs 26 hydrocodone-ibuprofen tabs 26 hydrocortisone (perianal) crea 1 25 55 hydrocortisone ace-pramoxine crea 55
HYDROCORTISONE ACE-PRAMOXINE SUPP 55
hydrocortisone butyr lipo base crea 55 hydrocortisone butyrate crea 55 hydrocortisone butyrate lotn 55 HYDROCORTISONE BUTYRATE OINT 55 hydrocortisone butyrate soln 55 hydrocortisone crea 1 25 55 hydrocortisone enem 55 hydrocortisone lotn 55 hydrocortisone oint 1 25 55 hydrocortisone tabs 5mg 10mg 20mg 42 hydrocortisone valerate crea 55 hydrocortisone valerate oint 55 HYDROCORTISONE-ACETIC ACID SOLN
38 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 26 hydromorphone hcl liqd 26 hydromorphone hcl tabs 2mg 4mg 8mg 26 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 46 hydroxyprogesterone caproate soln 46 hydroxyurea caps 15 hydroxyzine hcl soln 31 hydroxyzine hcl syrp 31 hydroxyzine hcl tabs 31 hydroxyzine pamoate caps 31 HYPERHEP B SOLN 52 HYPERHEP B SOSY 52 HYPERRAB SD SOLN 52 HYQVIA KIT 52
I IBANDRONATE SODIUM SOLN 47 ibandronate sodium tabs 47 IBRANCE CAPS 75mg 100mg 125mg 15 IBRANCE TABS 75mg 100mg 125mg 15 IBSRELA TABS 41 ibu tabs 26 ibudone tabs 26 ibuprofen lysine soln 26 ibuprofen susp 26 ibuprofen tabs 26 ibutilide fumarate soln 24 icatibant acetate soln 20 iclevia tabs 43 ICLUSIG TABS 10mg 15mg 30mg 45mg
15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 75
icosapent ethyl caps 22 IDAMYCIN PFS SOLN 15 idarubicin hcl soln 15 IDHIFA TABS 50mg 100mg 15 ifosfamide soln 15 IFOSFAMIDE SOLR 16 ILARIS SOLN 26 ILUMYA SOSY 56 ILUVIEN IMPL 38 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 34 imipramine pamoate caps 75mg 100mg
125mg 150mg 34 imiquimod crea 375 5 56 IMIQUIMOD PUMP CREA 56 IMOGAM RABIES-HT SOLN 52 IMOVAX RABIES INJ 52 IMPAVIDO CAPS 11 INBRIJA CAPS 30 incassia tabs 43 INCRELEX SOLN 46 indapamide tabs 125mg 25mg 36 indocin supp 26 indomethacin caps 26 indomethacin er cpcr 26 indomethacin sodium solr 26 INFANRIX SUSP 52 INFLECTRA SOLR INTRAVENOUS 48 INFLIXIMAB SOLR INTRAVENOUS 48 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 32 INGREZZA CPPK 32 INLYTA TABS 1mg 5mg 16 INQOVI TABS 16 INREBIC CAPS 16 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 36 INTRON A SOLN 6000000unitml
10000000unitml 16 INTRON A SOLR 10000000unit
18000000unit 50000000unit 16 introvale tabs 43 INVEGA HAFYERA SUSY 34
INVEGA SUSTENNA SUSY 39mg025ml 34
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml 34
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml 34
INVIRASE CAPS 12 INVIRASE TABS 12 IOPIDINE SOLN 39 IPOL INJ 52 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 20 irbesartan tabs 75mg 150mg 300mg 25 irbesartan-hydrochlorothiazide tabs 25 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 20 isosorbide dinitrate er tbcr 25 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 25 isosorbide mononitrate er tb24 25 isosorbide mononitrate er tb24 30mg 60mg
25 isosorbide mononitrate tabs 10mg 20mg 25 isotretinoin caps 10mg 20mg 30mg 40mg
56 isradipine caps 25mg 5mg 23 ISTURISA TABS 1mg 5mg 10mg 49 itraconazole caps 10 ITRACONAZOLE SOLN 10 ivermectin crea 53 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 52
J JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16
76 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg 21
JARDIANCE TABS 10mg 25mg 44 jasmiel tabs 43 JEMPERLI SOLN 16 jinteli tabs 45 JOLIVETTE TABS 43 JULUCA TABS 12 junel 1530 tabs 43 junel 120 tabs 43 junel fe 1530 tabs 43 junel fe 120 tabs 43 junel fe 24 tabs 43 JUXTAPID CAPS 5mg 10mg 20mg 30mg
40mg 60mg 22 JYNARQUE TABS 15mg 30mg 36 JYNARQUE TBPK 36
K KADCYLA SOLR 100mg 160mg 16 kaitlib fe chew 43 KALYDECO PACK 25mg 50mg 75mg 51 KALYDECO TABS 51 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 37 kariva tabs 43 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ 37
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ 37
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS 37
KEDRAB SOLN 52 kelnor 135 tabs 43 kelnor 150 tabs 43 KENALOG SUSP 42 KEPIVANCE SOLR 56 KERALYT SHAM 56 KESIMPTA SOAJ 49 ketoconazole crea 53 ketoconazole foam 53 ketoconazole sham 53 ketoconazole tabs 10 ketodan foam 53 ketoprofen caps 26 ketoprofen er cp24 26 ketorolac tromethamine soln 26 38
ketorolac tromethamine soln 04 05 38 ketorolac tromethamine tabs 26 KEVEYIS TABS 49 KEVZARA SOAJ 150mg114ml
200mg114ml 48 KEVZARA SOSY 150mg114ml
200mg114ml 48 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 47 KHEDEZLA TB24 50mg 100mg 34 KIMMTRAK SOLN 16 KIMYRSA SOLR 9 KINERET SOSY 48 KINRIX SUSP 52 KINRIX SUSY 52 kionex susp 36 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KISQALI FEMARA(200 MG DOSE) TBPK
16 KITABIS PAK NEBU 51 KLISYRI OINT 56 KLOR-CON 10 TBCR 37 klor-con m15 tbcr 37 klor-con m20 tbcr 37 klor-con pack 37 klor-con sprinkle cpcr 8meq 10meq 37 KLOR-CON TBCR 37 KORLYM TABS 44 KORSUVA SOLN 56 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 35 K-TAB TBCR 37 kurvelo tabs 43 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 30 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 lacosamide tabs 50mg 100mg 150mg
200mg 29
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 77
LACRISERT INST 39 LACTATED RINGERS SOLN 37 49 LACTIC ACID LOTN 56 lactulose encephalopathy soln 35 lactulose pack 35 lactulose soln 35 LAMICTAL XR KIT 29 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 29 lamotrigine er tb24 25mg 50mg 100mg
200mg 250mg 300mg 29 lamotrigine kit 29 lamotrigine starter kit-blue kit 29 lamotrigine starter kit-green kit 29 lamotrigine starter kit-orange kit 29 lamotrigine tabs 25mg 100mg 150mg
200mg 29 lamotrigine tbdp 25mg 50mg 100mg
200mg 29 LANOXIN PEDIATRIC SOLN 24 LANREOTIDE ACETATE SOLN 46 lansoprazole cpdr 15mg 30mg 40 lansoprazole tbdd 15mg 30mg 40 lanthanum carbonate chew 500mg 750mg
1000mg 36 LANTUS SOLN 44 LANTUS SOLOSTAR SOPN 44 lapatinib ditosylate tabs 16 larin 1530 tabs 43 larin 120 tabs 43 larin fe 1530 tabs 43 larin fe 120 tabs 43 larissia tabs 43 LARTRUVO SOLN 190mg19ml
500mg50ml 16 latanoprost soln 39 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 34 LAYOLIS FE CHEW 43 LAZANDA SOLN 100mcgact 400mcgact
26 ledipasvir-sofosbuvir tabs 12 leena tabs 43 leflunomide tabs 10mg 20mg 48 LEMTRADA SOLN 32 lenalidomide caps 5mg 10mg 15mg 25mg
16
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 16 lessina tabs 43 letrozole tabs 16 leucovorin calcium soln 47 leucovorin calcium solr 47 leucovorin calcium tabs 5mg 10mg 15mg
25mg 47 LEUKERAN TABS 16 LEUKINE SOLR 21 leuprolide acetate kit 16 LEVALBUTEROL HCL NEBU
125mg05ml 125mg3ml 031mg3ml 063mg3ml 20
levalbuterol tartrate aero 20 levetiracetam er tb24 500mg 750mg 29 levetiracetam in nacl soln 29 levetiracetam soln 29 levetiracetam tabs 250mg 500mg 750mg
1000mg 29 levobunolol hcl soln 39 levocarnitine soln 49 LEVOCARNITINE TABS 49 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 38 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 47 levoleucovorin calcium solr 47 levonest tabs 43 levonorgest-eth est amp eth est tabs 43 levonorgest-eth estrad 91-day tabs 43 levonorgestrel-ethinyl estrad tabs 43 levonorg-eth estrad triphasic tabs 43 levora 01530 (28) tabs 43 levorphanol tartrate tabs 2mg 3mg 26 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
78 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEVOTHYROXINE SODIUM SOLR 47 LEVOTHYROXINE SODIUM TABS 25mcg
50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEXETTE FOAM 55 LEXIVA SUSP 12 LIALDA TBEC 40 LIBTAYO SOLN 16 lidocaine hcl (cardiac) pf sosy 24 lidocaine hcl (cardiac) sosy 24 lidocaine hcl (pf) soln 49 LIDOCAINE HCL CREA 55 lidocaine hcl lotn 55 lidocaine hcl soln 39 49 55 lidocaine hcl urethralmucosal gel 55 lidocaine hcl urethralmucosal prsy 55 LIDOCAINE IN D5W SOLN 24 lidocaine in dextrose soln 49 lidocaine oint 55 lidocaine ptch 55 lidocaine viscous hcl soln 40 lidocaine-epinephrine soln 49 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 55 LIDOCAINE-HYDROCORTISONE ACE KIT
55 lidocaine-prilocaine crea 55 lidocaine-tetracaine crea 55 LIDOCORT CREA 56 lidopin crea 56 LIDO-SORB LOTN 55 LIDOZION LOTN 56 lincomycin hcl soln 9 lindane sham 53 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 liothyronine sodium soln 47 liothyronine sodium tabs 5mcg 25mcg
50mcg 47 LIPODOX 50 INJ 16
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg 25
lisinopril-hydrochlorothiazide tabs 25 LITHIUM CARBONATE CAPS 150mg
300mg 600mg 34 lithium carbonate er tbcr 300mg 450mg 34 LITHIUM CARBONATE TABS 34 LITHIUM SOLN 34 LITHOSTAT TABS 35 LIVMARLI SOLN 41 LIVTENCITY TABS 12 loestrin 1530 (21) tabs 43 loestrin 120 (21) tabs 43 loestrin fe 1530 tabs 43 loestrin fe 120 tabs 43 LOKELMA PACK 5gm 10gm 36 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 16 loperamide hcl caps 40 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 45 lorazepam intensol conc 31 LORAZEPAM SOLN 4mgml 2mgml 31 lorazepam tabs 05mg 1mg 2mg 31 LORBRENA TABS 25mg 100mg 16 lorcet hd tabs 26 lorcet plus tabs 26 lorcet tabs 27 lortab elix 27 loryna tabs 43 losartan potassium tabs 25mg 50mg
100mg 25 losartan potassium-hctz tabs 25 LOTEMAX GEL 38 LOTEMAX SUSP 38 lovastatin tabs 10mg 20mg 40mg 22 LOVENOX SOLN 21 LOVENOX SOSY 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
low-ogestrel tabs 43 loxapine succinate caps 5mg 10mg 25mg
50mg 34 lubiprostone caps 8mcg 24mcg 41 LUCEMYRA TABS 32 LUCENTIS SOLN 03mg005ml
05mg005ml 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 79
LUCENTIS SOSY 03mg005ml 05mg005ml 39
LUDENT CHEW 025mg 05mg 1mg 49 LUMAKRAS TABS 16 LUMIGAN SOLN 39 LUMIZYME SOLR 37 LUMOXITI SOLR 16 LUPANETA PACK KIT 16 LUPKYNIS CAPS 48 LUPRON DEPOT (1-MONTH) KIT 16 LUPRON DEPOT (3-MONTH) KIT 16 LUPRON DEPOT (4-MONTH) KIT 16 LUPRON DEPOT (6-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 16 LUPRON DEPOT-PED (3-MONTH) KIT 16 lutera tabs 43 LYBALVI TABS 34 lyleq tabs 43 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 45
LYMEPAK TABS 9 LYNPARZA TABS 100mg 150mg 16 LYSODREN TABS 16 lyza tabs 43
M mafenide acetate pack 53 magnesium sulfate in d5w soln 37 magnesium sulfate soln 29 MAGNESIUM SULFATE SOLN INJECTION
50 29 MAKENA SOAJ 46 malathion lotn 53 MANNITOL SOLN 36 maprotiline hcl tabs 25mg 50mg 75mg 34 maraviroc tabs 150mg 300mg 12 MARGENZA SOLN 16 marlissa tabs 43 MARPLAN TABS 34 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 23 MAVENCLAD (10 TABS) TBPK 48 MAVENCLAD (4 TABS) TBPK 48 MAVENCLAD (5 TABS) TBPK 48
MAVENCLAD (6 TABS) TBPK 48 MAVENCLAD (7 TABS) TBPK 48 MAVENCLAD (8 TABS) TBPK 48 MAVENCLAD (9 TABS) TBPK 48 MAVYRET PACK 12 MAVYRET TABS 12 MAYZENT STARTER PACK TBPK 32 MAYZENT TABS 025mg 1mg 2mg 32 MENAPHOSMBHYO1 TABS 13 meclizine hcl tabs 40 meclofenamate sodium caps 27 MEDROL TABS 42 medroxyprogesterone acetate susp 46 medroxyprogesterone acetate susy 46 medroxyprogesterone acetate tabs 25mg
5mg 10mg 46 mefenamic acid caps 27 mefloquine hcl tabs 11 megestrol acetate susp 17 46 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 43 meloxicam tabs 27 melphalan hcl solr 17 memantine hcl er cp24 32 memantine hcl soln 32 memantine hcl tabs 5mg 10mg 32 MENACTRA SOLN 52 menest tabs 03mg 0625mg 125mg 45 MENQUADFI SOLN 52 MENVEO SOLR 52 meperidine hcl soln 27 meperidine hcl tabs 50mg 27 meprobamate tabs 31 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 43 mesalamine cpdr 40 mesalamine enem 40 mesalamine er cp24 40 mesalamine supp 40 mesalamine tbec 12gm 800mg 40 mesalamine-cleanser kit 40 mesna soln 49 MESNEX TABS 49 MESTINON SOLN 19 metadate er tbcr 28 metaproterenol sulfate syrp 20
80 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
metaproterenol sulfate tabs 10mg 20mg 20 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 44 metformin hcl tabs 500mg 850mg 1000mg
45 methadone hcl conc 27 methadone hcl intensol conc 27 methadone hcl tabs 5mg 10mg 27 methamphetamine hcl tabs 28 methazolamide tabs 25mg 50mg 39 methenamine hippurate tabs 13 METHENAMINE MANDELATE TABS 13 methergine tabs 45 methimazole tabs 5mg 10mg 47 methitest tabs 42 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 57 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 36 methyldopa tabs 250mg 500mg 24 methyldopa-hydrochlorothiazide tabs 24 methylergonovine maleate soln 45 methylergonovine maleate tabs 45 methylphenidate hcl chew 25mg 5mg
10mg 28 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 28 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 28 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 28
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 28
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 28
methylphenidate hcl soln 5mg5ml 10mg5ml 28
methylphenidate hcl tabs 5mg 10mg 20mg 28
methylprednisolone acetate susp 42 methylprednisolone sodium succ solr 42
methylprednisolone tabs 4mg 8mg 16mg 32mg 42
methylprednisolone tbpk 42 methyltestosterone caps 42 metoclopramide hcl soln 41 metoclopramide hcl tabs 5mg 10mg 41 metoclopramide hcl tbdp 5mg 10mg 41 metolazone tabs 25mg 5mg 10mg 36 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 23 metoprolol tartrate soct 23 metoprolol tartrate soln 23 metoprolol tartrate tabs 25mg 50mg
100mg 23 metoprolol tartrate tabs 375mg 75mg 23 metoprolol-hydrochlorothiazide tabs 23 metronidazole caps 11 metronidazole crea 53 metronidazole gel 53 metronidazole lotn 53 METRONIDAZOLE SOLN INTRAVENOUS
500mg100ml 11 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
24 mibelas 24 fe chew 43 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 53 miconazole-zinc oxide-petrolat oint 53 micort-hc crea 55 microgestin 1530 tabs 43 microgestin 120 tabs 43 microgestin 24 fe tabs 43 microgestin fe 1530 tabs 43 microgestin fe 120 tabs 43 midazolam hcl (pf) soln 31 midazolam hcl soln 31 midodrine hcl tabs 25mg 5mg 10mg 20 miglitol tabs 25mg 50mg 100mg 45 miglustat caps 38 mili tabs 43 millipred dp tbpk 42 millipred tabs 42 milrinone lactate in dextrose soln 24 milrinone lactate soln 24 mimvey lo tabs 45 mimvey tabs 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 81
minitran pt24 01mghr 02mghr 04mghr 06mghr 25
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 24 mirtazapine tabs 75mg 15mg 30mg
45mg 34 mirtazapine tbdp 15mg 30mg 45mg 34 misoprostol tabs 100mcg 200mcg 40 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 52 modafinil tabs 100mg 200mg 28 moexipril hcl tabs 75mg 15mg 25 molindone hcl tabs 5mg 10mg 25mg 34 mometasone furoate crea 55 mometasone furoate oint 55 mometasone furoate soln 55 mometasone furoate susp 38 MONJUVI SOLR 17 MONONESSA TABS 43 montelukast sodium chew 4mg 5mg 51 montelukast sodium pack 51 montelukast sodium tabs 51 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 27 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 27 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 27
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 27
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml 27
morphine sulfate tabs 15mg 30mg 27 moxifloxacin hcl (2x day) soln 38 moxifloxacin hcl in nacl soln intravenous 9 moxifloxacin hcl soln 38 moxifloxacin hcl tabs 9 MULPLETA TABS 21 MULTAQ TABS 24 mupirocin calcium crea 53 mupirocin oint 53 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17
MYALEPT SOLR 49 MYCAPSSA CPDR 46 mycophenolate mofetil caps 48 mycophenolate mofetil hcl solr 48 mycophenolate mofetil susr 48 mycophenolate mofetil tabs 49 mycophenolate sodium tbec 180mg 360mg
49 MYFEMBREE TABS 45 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 57 MYRBETRIQ TB24 25mg 50mg 57
N NABI-HB SOLN 52 nabumetone tabs 27 N-ACETYL-L-CYSTEINE CAPS 36 nadolol tabs 20mg 40mg 80mg 23 nadololbendroflumethiazide tabs 23 nadolol-bendroflumethiazide tabs 23 nafcillin sodium solr 9 nafcillin sodium solr injection 9 nafcillin sodium solr intravenous 9 NAFRINSE CHEW 49 NAFRINSE DROPS SOLN 49 naftifine hcl crea 53 naftifine hcl gel 53 NAGLAZYME SOLN 38 nalbuphine hcl soln 10mgml 20mgml 27 nalfon tabs 27 nalocet tabs 27 naloxone hcl liqd 32 naloxone hcl soaj 32 naloxone hcl soct 32 naloxone hcl soln 32 naloxone hcl sosy 32 naltrexone hcl tabs 32 naproxen sodium er tb24 27 naproxen sodium tabs 27 naproxen susp 27 naproxen tabs 27 naproxen tbec 27 naproxen-esomeprazole tbec 27 naratriptan hcl tabs 30 NARCAN LIQD 32 NATACYN SUSP 38 nateglinide tabs 60mg 120mg 45 NATPARA CART 25mcg 50mcg 75mcg
100mcg 45
82 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
NAYZILAM SOLN 29 necon 0535 (28) tabs 43 NECON 777 TABS 43 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 34 nelarabine soln 17 nembutal soln 31 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 38 neomycin-polymyxin b gu soln 53 neomycin-polymyxin-dexameth oint 38 neomycin-polymyxin-dexameth susp 39 neomycin-polymyxin-gramicidin soln 38 neomycin-polymyxin-hc soln 39 neomycin-polymyxin-hc susp 39 neo-polycin hc oint 38 neo-polycin oint 38 neo-synalar crea 55 NERLYNX TABS 17 NEULASTA ONPRO PSKT 21 NEULASTA SOSY 21 NEUPOGEN SOLN 480mcg16ml
300mcgml 21 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 21 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 38 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 22 niacor tabs 22 nicardipine hcl caps 20mg 30mg 23 NICARDIPINE HCL SOLN 23 NICOTROL INHA 19 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 43 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 49 nitro-bid oint 25
NITRO-DUR PT24 03mghr 08mghr 25 NITROFURANTOIN MACROCRYSTAL
CAPS 13 NITROFURANTOIN MONOHYD MACRO
CAPS 13 nitrofurantoin susp 13 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 25 nitroglycerin soln 25 nitroglycerin subl 03mg 04mg 06mg 25 nitropress soln 24 nitroprusside sodium soln 24 NITYR TABS 2mg 5mg 10mg 49 NIVESTYM SOLN 480mcg16ml
300mcgml 21 NIVESTYM SOSY 300mcg05ml
480mcg08ml 22 nizatidine caps 150mg 300mg 40 nizatidine soln 40 nolix crea 55 nolix lotn 55 nora-be tabs 43 norco tabs 27 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 46
norepinephrine bitartrate soln 20 norethin ace-eth estrad-fe caps 43 norethin ace-eth estrad-fe chew 43 norethin ace-eth estrad-fe tabs 43 norethindrone acetate tabs 46 norethindrone acet-ethinyl est tabs 43 norethindrone tabs 43 norethindrone-eth estradiol tabs 45 norethin-eth estradiol-fe chew 43 norgesic forte tabs 27 norgestimate-eth estradiol tabs 43 norgestim-eth estrad triphasic tabs 43 norlyroc tabs 43 NORPACE CR CP12 100mg 150mg 24 nortrel 0535 (28) tabs 43 nortrel 135 (21) tabs 43 nortrel 135 (28) tabs 43 nortrel 777 tabs 43 nortriptyline hcl caps 10mg 25mg 50mg
75mg 34 nortriptyline hcl soln 34 NORVIR CAPS 12 NORVIR PACK 12
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 83
NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 32 NOXAFIL SUSP 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 51 NUCALA SOLR 51 NUCALA SOSY 51 NUCYNTA ER TB12 200mg 250mg 27 NUCYNTA TABS 27 NUEDEXTA CAPS 32 NULIBRY SOLR 49 NULOJIX SOLR 49 NUPLAZID CAPS 34 NUPLAZID TABS 10mg 17mg 34 NURTEC TBDP 30 NUTRILIPID EMUL INTRAVENOUS 36 NUTROPIN AQ NUSPIN 10 SOPN 46 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 53 nylia 135 tabs 43 nylia 777 tabs 43 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 44 nystatin crea 53 nystatin oint 53 nystatin powd 53 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 55 nystatin-triamcinolone oint 55 nystop powd 53 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 41 ocella tabs 44 OCREVUS SOLN 32 OCTAGAM SOLN INTRAVENOUS
1gm20ml 2gm20ml 52 octreotide acetate soln 500mcgml
1000mcgml 46 octreotide acetate soln 50mcgml
100mcgml 200mcgml 46 ODACTRA SUBL 49 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 51
ofloxacin soln 38 ofloxacin tabs 10 ogestrel tabs 44 OGIVRI SOLR 17 olanzapine solr 34 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 34 olanzapine tbdp 5mg 10mg 15mg 20mg
34 olanzapine-fluoxetine hcl caps 34 olmesartan medoxomil tabs 5mg 20mg
40mg 25 olmesartan medoxomil-hctz tabs 25 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 39 OLUMIANT TABS 1mg 2mg 48 omega-3-acid ethyl esters caps 22 omeprazole cpdr 10mg 20mg 40mg 40 omeprazole-sodium bicarbonate caps 40 omeprazole-sodium bicarbonate pack 40 OMNITROPE SOCT 5mg15ml
10mg15ml 46 OMNITROPE SOLR 46 ondansetron hcl soln 40 ondansetron hcl sosy 40 ondansetron hcl tabs 4mg 8mg 24mg 40 ondansetron tbdp 4mg 8mg 40 ONIVYDE
INJ 17 ONPATTRO SOLN 50 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 OPDIVO SOLN 100mg10ml 120mg12ml
240mg24ml 40mg4ml 17 OPDUALAG SOLN 17 OPIUM TINC 40 OPZELURA CREA 57 ORACEA CPDR 57 oralone pste 55 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 48 ORENCIA SOLR 48 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 48 ORENITRAM TBCR 025mg 1mg 25mg
5mg 51 ORFADIN CAPS 50 ORFADIN SUSP 50 ORGOVYX TABS 45
84 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ORILISSA TABS 150mg 200mg 45 ORKAMBI PACK 51 ORKAMBI TABS 51 ORLADEYO CAPS 110mg 150mg 50 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 27 orphengesic forte tabs 27 orsythia tabs 44 ORTIKOS CP24 6mg 9mg 42 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 36 OTEZLA TABS 48 OTEZLA TBPK 48 ovide lotn 53 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 42 oxaprozin tabs 27 OXAYDO TABS 27 oxazepam caps 10mg 15mg 30mg 31 OXBRYTA TABS 21 OXBRYTA TBSO 21 oxcarbazepine susp 29 oxcarbazepine tabs 150mg 300mg 600mg
29 OXERVATE SOLN 39 oxiconazole nitrate crea 53 OXLUMO SOLN 50 OXTELLAR XR TB24 150mg 300mg
600mg 29 oxybutynin chloride er tb24 5mg 10mg
15mg 57 oxybutynin chloride syrp 57 oxybutynin chloride tabs 57 oxycodone hcl caps 27 oxycodone hcl conc 27 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxycodone hcl soln 27 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 27 oxycodone-acetaminophen soln 27
oxycodone-acetaminophen tabs 27 oxycodone-acetaminophen tabs 5-300mg
75-300mg 10-300mg 27 oxycodone-aspirin tabs 27 oxycodone-ibuprofen tabs 27 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 27 oxymorphone hcl tabs 5mg 10mg 27 OXYTOCIN SOLN 45 OZEMPIC (025 OR 05 MGDOSE) SOPN
45 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 45 OZEMPIC (2 MGDOSE) SOPN 45
P pacerone tabs 100mg 200mg 400mg 24 paclitaxel conc 17 PACLITAXEL PROTEIN-BOUND PART
SUSR 100 MG 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
50 PALFORZIA (120 MG DAILY DOSE) CSPK
50 PALFORZIA (160 MG DAILY DOSE) CSPK
50 PALFORZIA (20 MG DAILY DOSE) CSPK
50 PALFORZIA (200 MG DAILY DOSE) CSPK
50 PALFORZIA (240 MG DAILY DOSE) CSPK
50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK 50 PALFORZIA (300 MG TITRATION) PACK
50 PALFORZIA (40 MG DAILY DOSE) CSPK
50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
50 PALFORZIA INITIAL ESCALATION CSPK
50 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 34
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 85
palonosetron hcl soln 40 palonosetron hcl sosy 40 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 38 pamidronate disodium soln 47 pamidronate disodium solr 47 panlor tabs 27 PANRETIN GEL 56 pantoprazole sodium pack 40 PANTOPRAZOLE SODIUM SOLR 40 pantoprazole sodium tbec 20mg 40mg 40 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 52
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 57 PARICALCITOL SOLN 57 paroex soln 38 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 34 paroxetine hcl susp 34 paroxetine hcl tabs 10mg 20mg 34 paroxetine hcl tabs 30mg 40mg 34 paroxetine mesylate caps 34 paser pack 11 PEDIARIX SUSY 52 PEDVAX HIB SUSP 52 peg 3350electrolytes solr 41 peg 3350-kcl-na bicarb-nacl solr 41 peg-3350electrolytes solr 41 PEGANONE TABS 29 PEGASYS PROCLICK SOAJ
135mcg05ml 180mcg05ml 12 PEGASYS SOLN 12 PEGASYS SOSY 12 PEGINTRON KIT 12 PEG-PREP KIT 41 PEMAZYRE TABS 45mg 9mg 135mg 17 PEMFEXY SOLN 17 penicillamine caps 41 penicillamine tabs 41 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
PENTACEL SUSR 52 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 40 pentazocine-naloxone hcl tabs 27 pentobarbital sodium soln 31 pentoxifylline er tbcr 21 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 40 percocet tabs 27 perindopril erbumine tabs 2mg 4mg 8mg
25 periogard soln 38 PERJETA SOLN 17 permethrin crea 53 perphenazine tabs 2mg 4mg 8mg 16mg
34 perphenazine-amitriptyline tabs 34 PERSERIS PRSY 90mg 120mg 34 PEXEVA TABS 10mg 20mg 30mg 40mg
34 phenadoz supp 14 phenazo tabs 56 PHENAZOPYRIDINE HCL TABS 56 phenelzine sulfate tabs 34 phenergan soln 14 PHENOBARBITAL ELIX 31 PHENOBARBITAL SODIUM SOLN 31 PHENOBARBITAL TABS 31 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 20 PHENYLEPHRINE HCL SOLN 39 phenytek caps 200mg 300mg 29 phenytoin chew 29 phenytoin sodium extended caps 100mg
200mg 300mg 29 phenytoin sodium soln 29 phenytoin susp 29 PHESGO SOLN 17 PHOSLYRA SOLN 37 PHOSPHASAL TABS 13 PHOSPHOLINE IODIDE SOLR 39 phrenilin forte caps 27 PHYSIOLYTE SOLN 50 PHYSIOSOL IRRIGATION SOLN 50 PIFELTRO TABS 12 pilocarpine hcl soln 1 2 4 39 pilocarpine hcl tabs 5mg 75mg 19 pimecrolimus crea 57
86 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
pimozide tabs 1mg 2mg 34 pimtrea tabs 44 pindolol tabs 5mg 10mg 23 pioglitazone hcl tabs 15mg 30mg 45mg 45 pioglitazone hcl-glimepiride tabs 45 pioglitazone hcl-metformin hcl tabs 45 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 44 piroxicam caps 10mg 20mg 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN 32 PLEGRIDY SOSY 32 PLEGRIDY STARTER PACK SOPN 32 PLEGRIDY STARTER PACK SOSY 32 plenamine soln intravenous 36 podofilox soln 57 POLIVY SOLR 30mg 140mg 17 polocaine soln 50 polocaine-mpf soln 50 polycin oint 38 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 38 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 32 PONVORY TABS 32 portia-28 tabs 44 PORTRAZZA SOLN 17 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 35 POTASSIUM ACETATE SOLN 37 potassium chloride crys er tbcr 10meq
20meq 37 potassium chloride er cpcr 8meq 10meq 37 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 37 POTASSIUM CHLORIDE IN NACL SOLN
INTRAVENOUS 37 POTASSIUM CHLORIDE PACK 37 POTASSIUM CHLORIDE SOLN 10 20
37
potassium chloride soln intravenous 10meq100ml 20meq100ml 40meq100ml 2meqml 37
potassium citrate er tbcr 15meq 540mg 1080mg 35
POTASSIUM PHOSPHATES SOLN 37 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 37 POTELIGEO SOLN 17 PR BENZOYL PEROXIDE WASH LIQD 53 PRADAXA CAPS 75mg 110mg 150mg 21 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 31
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 31
PRAMOX GEL 56 prandin tabs 1mg 2mg 45 prasugrel hcl tabs 5mg 10mg 21 pravastatin sodium tabs 10mg 20mg
40mg 80mg 22 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22 PRED MILD SUSP 39 PRED-G SOP OINT 39 PRED-G SUSP 39 prednicarbate crea 55 prednicarbate oint 55 prednisolone acetate susp 39 prednisolone sodium phosphate soln 39 PREDNISOLONE SODIUM PHOSPHATE
SOLN 10mg5ml 20mg5ml 25mg5ml 5mg5ml 42
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 42
prednisolone soln 42 prednisone intensol conc 42 prednisone soln 42 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 42 prednisone tbpk 42 prefest tabs 45 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 29
pregabalin er tb24 825mg 165mg 330mg 27
pregabalin soln 29 PREHEVBRIO SUSP 52
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 87
PREMARIN SOLR 45 premasol soln intravenous 36 PRENATAL TABS 57 PRETOMANID TABS 11 prevalite pack 22 prevalite powd 22 previfem tabs 44 PREVYMIS SOLN 240mg12ml
480mg24ml 12 PREVYMIS TABS 240mg 480mg 12 PREZCOBIX TABS 12 PREZISTA SUSP 12 PREZISTA TABS 75mg 150mg 600mg
800mg 12 PRIFTIN TABS 11 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 29 primlev tabs 27 probenecid tabs 37 procainamide hcl soln 24 PROCALAMINE SOLN INTRAVENOUS 36 procentra soln 28 prochlorperazine edisylate soln 34 prochlorperazine maleate tabs 34 prochlorperazine supp 34 PROCRIT SOLN 20000unitml
40000unitml 22 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 22 proctofoam hc foam 56 procto-med hc crea 55 procto-pak crea 55 proctosol hc crea 55 proctozone-hc crea 55 PROCYSBI CPDR 25mg 75mg 50 PROCYSBI PACK 75mg 300mg 50 progesterone caps 100mg 200mg 46 progesterone oil 46 PROGRAF PACK 49 PROGRAF PACK 02mg 49 PROGRAF SOLN 49 prolate soln 27 prolate tabs 27 PROLEUKIN SOLR 17 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 24 propafenone hcl tabs 150mg 225mg
300mg 24 propantheline bromide tabs 19 proparacaine hcl soln 40 propranolol hcl er cp24 60mg 80mg
120mg 160mg 23 propranolol hcl soln 20mg5ml 40mg5ml 23 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 23 propranolol-hctz tabs 23 propylthiouracil tabs 47 PROQUAD SUSR 52 protriptyline hcl tabs 5mg 10mg 34 psorcon crea 55 PULMICORT FLEXHALER AEPB 51 PULMOZYME SOLN 38 PURIXAN SUSP 17 PYLERA CAPS 40 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 19 pyridostigmine bromide soln 19 pyridostigmine bromide tabs 30mg 60mg 19 pyrimethamine tabs 11 PYRUKYND TABS 5mg 20mg 50mg 50 PYRUKYND TAPER PACK TBPK 50
Q QDOLO SOLN 27 QINLOCK TABS 17 QUADRACEL SUSP 52 questran light powd 22 questran pack 22 questran powd 22 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 34 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 34 quinapril hcl tabs 5mg 10mg 20mg 40mg
25 quinapril-hydrochlorothiazide tabs 25 quinidine gluconate er tbcr 24 QUINIDINE GLUCONATE SOLN 24 quinidine sulfate tabs 200mg 300mg 24
88 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
quinine sulfate caps 11 QULIPTA TABS 10mg 30mg 60mg 30
R RABAVERT SUSR 52 rabeprazole sodium cpsp 40 rabeprazole sodium tbec 40 RADIAURA CREA 55 RADICAVA SOLN 32 raloxifene hcl tabs 45 ramelteon tabs 31 ramipril caps 125mg 25mg 5mg 10mg 25 ranolazine er tb12 500mg 1000mg 24 RAPIVAB SOLN 12 rasagiline mesylate tabs 05mg 1mg 31 RASUVO SOAJ 48 RAVICTI LIQD 35 RAYALDEE CPCR 57 REBETOL SOLN 12 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 32 REBIF REBIDOSE TITRATION PACK
SOAJ 32 REBIF SOSY 22mcg05ml 44mcg05ml 32 REBIF TITRATION PACK SOSY 32 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 44 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 52 RECORLEV TABS 50 RECTIV OINT 57 REGONOL SOLN 19 REGRANEX GEL 57 relafen ds tabs 27 RELENZA DISKHALER AEPB 12 RELEUKO SOLN 300mcgml
480mcg16ml 22 RELEUKO SOSY 300mcg05ml
480mcg08ml 22 relexxii tbcr 28 RELISTOR SOLN 8mg04ml 12mg06ml
41 RELISTOR TABS 41 reltone caps 200mg 400mg 41 REMICADE SOLR INTRAVENOUS 48 RENFLEXIS SOLR 48 repaglinide tabs 05mg 1mg 2mg 45 repaglinide-metformin hcl tabs 45
REPATHA SOSY 22 REPATHA SURECLICK SOAJ 22 RESCRIPTOR TABS 100mg 200mg 12 RESTASIS EMUL 39 RESTASIS MULTIDOSE EMUL 39 RETACRIT SOLN 22 RETACRIT SOLN 20000unitml 22 RETEVMO CAPS 40mg 80mg 17 RETIN-A CREA 0025 005 01 56 RETIN-A GEL 001 0025 56 RETIN-A MICRO GEL 004 01 56 RETIN-A MICRO PUMP GEL 004 01
56 RETISERT IMPL 39 RETROVIR SOLN 12 REVCOVI SOLN 38 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 17 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 34 REYATAZ PACK 12 REZUROCK TABS 50 RIABNI SOLN 100mg10ml 500mg50ml 17 ribasphere caps 12 ribasphere ribapak (1000 pack) tbpk 12 ribasphere ribapak (1200 pack) tbpk 12 ribasphere tabs 12 ribavirin caps 12 ribavirin solr 12 ribavirin tabs 13 RIDAURA CAPS 50 rifabutin caps 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 riluzole tabs 32 rimantadine hcl tabs 13 RIMSO-50 SOLN 50 RINGERS IRRIGATION SOLN 50 RINGERS SOLN 37 RINVOQ TB24 15mg 30mg 45mg 48 risedronate sodium tabs 5mg 30mg 35mg
150mg 47 risedronate sodium tbec 47 RISPERDAL CONSTA SRER 125mg
25mg 34 RISPERDAL CONSTA SRER 375mg
50mg 35
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 89
RISPERIDONE SOLN 35 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 35 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 35 ritonavir tabs 13 RITUXAN HYCELA SOLN 17 RITUXAN SOLN 17 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 44 rizatriptan benzoate tabs 30 rizatriptan benzoate tbdp 30 ROMIDEPSIN SOLN 17 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 31 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 31 ropivacaine hcl soln 50 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 22 ROTARIX SUSR 52 ROTATEQ SOLN 52 roweepra tabs 500mg 750mg 1000mg 29 roweepra xr tb24 500mg 750mg 29 ROZLYTREK CAPS 100mg 200mg 17 RUBRACA TABS 200mg 250mg 300mg 17 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 29 rufinamide tabs 200mg 400mg 29 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 17 RYBREVANT SOLN 17 ryclora soln 14 RYDAPT CAPS 17 RYLAZE SOLN 17 RYNODERM CREA 57 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 46 SAIZEN SOLR 5mg 88mg 46 SAIZENPREP SOLR 46 sajazir soln 21 SALEX SHAM 57 SALICYLIC ACID CREA 57
SALICYLIC ACID ER SOLN 57 SALICYLIC ACID FOAM 57 SALICYLIC ACID GEL 57 SALICYLIC ACID SHAM 57 SALICYLIC ACID-CLEANSER KIT 57 SALSALATE TABS 27 SANCUSO PTCH 40 SANDIMMUNE ORAL SOLN 100mgml 49 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 46 SANTYL OINT 57 SAPHNELO SOLN 49 SAPHRIS SUBL 25mg 5mg 10mg 35 sapropterin dihydrochloride pack 100mg
500mg 50 sapropterin dihydrochloride tabs 50 SARCLISA SOLN 500mg25ml 100mg5ml
17 SCEMBLIX TABS 20mg 40mg 17 scopolamine pt72 40 seconal caps 31 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 35 selegiline hcl caps 31 selegiline hcl tabs 31 selenium sulfide lotn 53 SELENIUM SULFIDE SHAM 53 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 13 SENSORCAINE SOLN 50 sensorcaineepinephrine soln 50 sensorcaine-mpf soln 50 sensorcaine-mpfepinephrine soln 50 SEREVENT DISKUS AEPB 20 SEROSTIM SOLR 4mg 5mg 6mg 46 SERTRALINE HCL CAPS 150mg 200mg
35 sertraline hcl conc 35 sertraline hcl tabs 25mg 50mg 100mg 35 setlakin tabs 44 sevelamer carbonate pack 08gm 24gm 36 sevelamer carbonate tabs 36 sevelamer hcl tabs 400mg 800mg 36 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 44 SHINGRIX SUSR 52 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 46
90 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
SIGNIFOR SOLN 03mgml 06mgml 09mgml 46
SIKLOS TABS 17 sildenafil citrate soln 25 sildenafil citrate susr 25 sildenafil citrate tabs 25 SILIQ SOSY 57 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 53 SIMPONI ARIA SOLN 48 SIMPONI SOAJ 50mg05ml 100mgml 48 SIMPONI SOSY 50mg05ml 100mgml 48 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 22 sirolimus soln 49 sirolimus tabs 05mg 1mg 2mg 49 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKYRIZI (150 MG DOSE) PSKT 57 SKYRIZI PEN SOAJ 57 SKYRIZI SOSY 57 SKYTROFA CART 3mg 36mg 43mg
52mg 63mg 76mg 91mg 11mg 133mg 46
sod benz-sod phenylacet soln 35 SODIUM ACETATE SOLN 35 SODIUM BICARBONATE SOLN 35 SODIUM CHLORIDE (PF) SOLN 37 SODIUM CHLORIDE SOLN 37 50 SODIUM CHLORIDE SOLN
INTRAVENOUS 045 09 3 5 37 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 50 SODIUM FLUORIDE SOLN 50 sodium phenylbutyrate powd 35 sodium phenylbutyrate tabs 35 SODIUM PHOSPHATES SOLN 37 sodium polystyrene sulfonate powd 36 sodium polystyrene sulfonate susp 36 sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 57 SOLTAMOX SOLN 17 SOLU-CORTEF SOLR 42 SOLU-MEDROL SOLR 42 SOMATULINE DEPOT SOLN 60mg02ml
90mg03ml 120mg05ml 46 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 46
sorine tabs 80mg 120mg 160mg 240mg 23
sotalol hcl (af) tabs 80mg 120mg 160mg 23 sotalol hcl tabs 80mg 120mg 160mg
240mg 23 SOTYLIZE SOLN 23 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 25 spironolactone-hctz tabs 25 SPRAVATO (56 MG DOSE) SOPK 35 SPRAVATO (84 MG DOSE) SOPK 35 sprintec 28 tabs 44 SPRITAM TB3D 250mg 500mg 750mg
1000mg 29 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 36 sronyx tabs 44 SSD CREA 53 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
57 STELARA SOSY 45mg05ml 90mgml 57 STERILE WATER FOR IRRIGATION SOLN
50 STIMATE SOLN 46 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18 STRENSIQ SOLN 18mg045ml
28mg07ml 80mg08ml 40mgml 38 streptomycin sulfate solr 10 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 20 SUBLOCADE SOSY 100mg05ml
300mg15ml 32 SUBSYS LIQD 1200mcg 1600mcg 27 subvenite starter kit-blue kit 29 subvenite starter kit-green kit 29 subvenite starter kit-orange kit 30 subvenite tabs 25mg 100mg 150mg
200mg 30 succinylcholine chloride soln 20 SUCRAID SOLN 38 sucralfate susp 40 sucralfate tabs 40
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 91
sulfacetamide sodium (acne) lotn 53 sulfacetamide sodium oint 38 sulfacetamide sodium soln 38 sulfacetamide-prednisolone soln 39 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 SULFAMYLON CREA 53 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 27 sumatriptan soln 30 sumatriptan succinate refill soct 30 sumatriptan succinate soaj 30 sumatriptan succinate soln 30 sumatriptan succinate sosy 30 sumatriptan succinate tabs 30 sunitinib malate caps 125mg 25mg
375mg 50mg 18 suprax chew 10 SUPREP BOWEL PREP KIT SOLN 41 SUSVIMO (IMPLANT 1ST FILL) SOLN 39 SUSVIMO (IMPLANT REFILL) SOLN 39 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 44 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 51 SYMDEKO TBPK 51 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 45 SYMLINPEN 60 SOPN 45 SYMPAZAN FILM 10mg 20mg 30 SYMPAZAN FILM 5mg 30 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 46 SYNDROS SOLN 40 SYNERCID SOLR 10 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 tacrolimus caps 05mg 1mg 5mg 49 TACROLIMUS OINT 01 003 57
tadalafil (pah) tabs 20mg 25 tadalafil tabs 25mg 5mg 25 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 50 TAKHZYRO SOSY 50 TALTZ SOAJ 57 TALTZ SOSY 57 TALZENNA CAPS 025mg 05mg 075mg
1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 47 taperdex 12-day tbpk 42 taperdex 6-day tbpk 42 taperdex 7-day tbpk 42 targadox tabs 10 TARGRETIN GEL 56 tarina 24 fe tabs 44 tarina fe 120 eq tabs 44 TARPEYO CPDR 42 TASIGNA CAPS 50mg 150mg 200mg 18 TAVALISSE TABS 100mg 150mg 22 TAVNEOS CAPS 50 taysofy caps 44 tazarotene crea 57 tazarotene foam 57 tazicef solr injection 10 tazicef solr intravenous 2gm 6gm 10 TAZORAC CREA 57 TAZORAC GEL 005 01 57 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 52 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TEFLARO SOLR INTRAVENOUS 10 TEGSEDI SOSY 50 telmisartan tabs 20mg 40mg 80mg 25 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 25 TEMAZEPAM CAPS 75mg 15mg 225mg
30mg 31 temsirolimus soln 18 tencon tabs 27 TENIPOSIDE SOLN 18 TENIVAC INJ 52 tenofovir disoproxil fumarate tabs 13
92 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TEPADINA SOLR 18 TEPEZZA SOLR 39 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 20 terbutaline sulfate tabs 25mg 5mg 20 terconazole crea 53 terconazole supp 53 TERIPARATIDE (RECOMBINANT) SOPN
46 testosterone cypionate soln 100mgml
200mgml 42 testosterone enanthate soln 42 testosterone gel 1 162
2025mg125gm 405mg25gm 10mgact 42
testosterone soln 42 tetrabenazine tabs 125mg 25mg 32 TETRACAINE HCL SOLN 40 tetracycline hcl caps 250mg 500mg 10 texacort soln 55 TEZSPIRE SOSY 51 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 57 theophylline er tb12 100mg 200mg
300mg 450mg 57 theophylline er tb24 400mg 600mg 57 theophylline soln 57 THIOLA EC TBEC 100mg 300mg 50 THIOLA TABS 50 thioridazine hcl tabs 10mg 25mg 50mg
100mg 35 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 35 THYROGEN SOLR 50 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
30 TIBSOVO TABS 18 TICOVAC SUSY 52 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 32 tilia fe tabs 44 timolol maleate (once-daily) soln 39 timolol maleate pf soln 39
TIMOLOL MALEATE SOLG 025 05 39 timolol maleate soln 025 05 39 timolol maleate tabs 5mg 10mg 20mg 23 tinidazole tabs 11 tiopronin tabs 50 TIS-U-SOL SOLN 50 TIVDAK SOLR 18 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 tizanidine hcl caps 20 tizanidine hcl tabs 20 TOBI PODHALER CAPS 51 TOBRADEX OINT 39 TOBRADEX ST SUSP 39 tobramycin nebu 300mg4ml 300mg5ml 51 tobramycin soln 38 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 39 TOBREX OINT 38 tofranil tabs 10mg 25mg 50mg 35 tolazamide tabs 250mg 500mg 45 tolbutamide tabs 45 tolcapone tabs 31 tolmetin sodium caps 27 tolmetin sodium tabs 27 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 57 tolterodine tartrate tabs 57 tolvaptan tabs 15mg 30mg 36 TOPEX TOPICAL ANESTHETIC AERO 56 topicort crea 005 025 55 topicort gel 55 topicort oint 55 topiramate cpsp 15mg 25mg 30 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 30 topiramate tabs 25mg 50mg 100mg
200mg 30 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
36 TPN ELECTROLYTES CONC
INTRAVENOUS 37 TRACLEER TBSO 51 TRADJENTA TABS 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 93
tramadol hcl er (biphasic) tb24 100mg 200mg 300mg 28
tramadol hcl er cp24 100mg 150mg 200mg 300mg 28
tramadol hcl er tb24 100mg 200mg 300mg 28
tramadol hcl soln 28 tramadol hcl tabs 50mg 100mg 28 tramadol-acetaminophen tabs 28 trandolapril tabs 1mg 2mg 4mg 25 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 21 tranexamic acid tabs 21 tranylcypromine sulfate tabs 35 TRAVASOL SOLN INTRAVENOUS 36 travoprost (bak free) soln 39 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 150mg 300mg 35 trazodone hcl tabs 50mg 100mg 35 TRECATOR TABS 11 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 57 TREMFYA SOSY 57 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 51 tretinoin caps 18 tretinoin crea 0025 005 01 56 tretinoin gel 001 0025 005 56 tretinoin microsphere gel 004 01 56 tretinoin microsphere pump gel 004
01 56 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 28 triamcinolone acetonide aers 55 triamcinolone acetonide crea 0025
01 05 55 triamcinolone acetonide lotn 0025 01
55 triamcinolone acetonide oint 0025
005 01 05 55 triamcinolone acetonide pste 55 triamcinolone acetonide susp 42 triamterene caps 50mg 100mg 36 triamterene-hctz caps 36 triamterene-hctz tabs 36 trianex oint 55 triazolam tabs 0125mg 025mg 31 TRICITRATES SOLN 35 triderm crea 01 05 55
trientine hcl caps 41 tri-estarylla tabs 44 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 35 trifluridine soln 38 trihexyphenidyl hcl soln 31 trihexyphenidyl hcl tabs 2mg 5mg 31 TRIKAFTA TBPK 51 tri-legest fe tabs 44 tri-lo-estarylla tabs 44 tri-lo-sprintec tabs 44 trilyte solr 41 trimethobenzamide hcl caps 40 TRIMETHOPRIM TABS 13 tri-mili tabs 44 trimipramine maleate caps 25mg 50mg
100mg 35 TRINESSA (28) TABS 44 TRINTELLIX TABS 5mg 10mg 20mg 35 tri-nymyo tabs 44 tri-previfem tabs 44 TRIPTODUR SRER 45 TRISENOX
SOLN 18 tri-sprintec tabs 44 tritocin oint 55 TRIUMEQ PD TBSO 13 TRIUMEQ TABS 13 trivora (28) tabs 44 tri-vylibra lo tabs 44 tri-vylibra tabs 44 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 30 TROPHAMINE SOLN INTRAVENOUS 36 trospium chloride er cp24 57 trospium chloride tabs 57 TRULANCE TABS 41 TRUMENBA SUSY 52 TRUSELTIQ (100MG DAILY DOSE) CPPK
18 TRUSELTIQ (125MG DAILY DOSE) CPPK
18 TRUSELTIQ (50MG DAILY DOSE) CPPK
18 TRUSELTIQ (75MG DAILY DOSE) CPPK
18
94 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 52 TYBOST TABS 13 tydemy tabs 44 tylenol with codeine 3 tabs 28 tylenol with codeine 4 tabs 28 TYMLOS SOPN 46 TYPHIM VI SOLN 52 TYPHIM VI SOSY 52 TYVASO REFILL SOLN 51 TYVASO STARTER SOLN 51
U UBRELVY TABS 50mg 100mg 30 UDENYCA SOSY 22 UKONIQ TABS 18 ULTOMIRIS SOLN 50 UMECTA MOUSSE FOAM 57 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
UNITUXIN SOLN 18 UPTRAVI SOLR 51 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 51
UPTRAVI TBPK 51 UREA CREA 39 57 UREA LOTN 40 57 UREA-C40 LOTN 57 urecholine tabs 5mg 10mg 25mg 50mg 20 uredeb crea 57 URETRON DS TABS 13 URIN DS TABS 13 ursodiol caps 200mg 400mg 41 ursodiol caps 300mg 41 ursodiol tabs 250mg 500mg 41 URYL TABS 13 USTELL CAPS 13 UTICAP CAPS 13 UTIRA-C TABS 13 UTRONA-C TABS 13
V VABYSMO SOLN 39 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 57 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 30 valproic acid caps 30 valproic acid soln 30 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
25 valsartan-hydrochlorothiazide tabs 25 VALTOCO 10 MG DOSE LIQD 30 VALTOCO 15 MG DOSE LQPK 30 VALTOCO 20 MG DOSE LQPK 30 VALTOCO 5 MG DOSE LIQD 30 vanatol lq soln 28 vancomycin hcl caps 10 vancomycin hcl solr 250mg5ml 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 vancomycin hcl solr intravenous 5gm
750mg 10 VANDAZOLE GEL 53 VANOXIDE-HC LOTN 55 VANTAS KIT 18 VAQTA SUSP 52 varenicline tartrate misc 19 varenicline tartrate tabs 05mg 1mg 19 VARIVAX INJ 52 VARIZIG SOLN 52 VASCEPA CAPS 1gm 22 VAXCHORA SUSR 53 vecamyl tabs 24 VECTICAL OINT 57 VEKLURY SOLN 13 VEKLURY SOLR 13 VELCADE SOLR 18 velivet tabs 44 VELPHORO CHEW 36 VELTASSA PACK 84gm 168gm 252gm
36 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 18 VENCLEXTA TABS 10mg 18 VENCLEXTA TABS 50mg 100mg 18
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 95
venlafaxine hcl er cp24 375mg 75mg 150mg 35
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg 35
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg 35
VENTAVIS SOLN 10mcgml 20mcgml 52 verapamil hcl er tbcr 120mg 180mg 240mg
24 verapamil hcl soln 24 verapamil hcl tabs 40mg 80mg 120mg 24 veripred 20 soln 42 VERKAZIA EMUL 39 VERSACLOZ SUSP 35 VERZENIO TABS 50mg 100mg 150mg
200mg 18 vestura tabs 44 VIBERZI TABS 75mg 100mg 41 vicodin es tabs 28 vicodin hp tabs 28 vicodin tabs 28 VICTOZA SOPN 45 VIDEX EC CPDR 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 44 vigabatrin pack 30 vigabatrin tabs 30 VIIBRYD STARTER PACK KIT 35 VIIBRYD TABS 10mg 20mg 40mg 35 VIJOICE TBPK 50 VILTEPSO SOLN 50 VIMIZIM SOLN 38 VIMPAT SOLN 30 vinblastine sulfate soln 18 vincasar pfs soln 18 vincristine sulfate soln 18 vinorelbine tartrate soln 18 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 47 VITRAKVI CAPS 25mg 100mg 18 VITRAKVI SOLN 18 VIVITROL SUSR 32 VIZIMPRO TABS 15mg 30mg 45mg 18 VOCABRIA TABS 13
VONJO CAPS 18 VORAXAZE SOLR 47 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 18 VOXZOGO SOLR 04mg 056mg 12mg 50 VPRIV SOLR 38 VRAYLAR CAPS 15mg 3mg 45mg 6mg
35 VRAYLAR CPPK 35 VUMERITY (STARTER) CPDR 50 VUMERITY CPDR 50 vyfemla tabs 44 vylibra tabs 44 VYNDAMAX CAPS 24 VYNDAQEL CAPS 24 VYONDYS 53 SOLN 50 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 28 VYVGART SOLN 50 VYXEOS SUSR 18
W WAKIX TABS 445mg 178mg 28 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 21 WATER FOR IRRIGATION STERILE
SOLN 50 WELIREG TABS 18 wixela inhub aepb 51 wymzya fe chew 44 WYNZORA CREA 55
X XALKORI CAPS 200mg 250mg 18 XARELTO STARTER PACK TBPK 21 XARELTO SUSR 21 XARELTO TABS 25mg 10mg 15mg
20mg 21 XATMEP SOLN 18 XCOPRI (250 MG DAILY DOSE) TBPK 30 XCOPRI (350 MG DAILY DOSE) TBPK 30 XCOPRI TABS 200mg 30 XCOPRI TABS 50mg 100mg 150mg 30 XCOPRI TBPK 30 XCOPRI TBPK 14x125mg amp 14x25mg 30
96 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
XELJANZ SOLN 48 XELJANZ TABS 5mg 10mg 48 XELJANZ XR TB24 11mg 22mg 48 XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 50 XERMELO TABS 40 XGEVA SOLN 47 XIFAXAN TABS 200mg 550mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 51 XOLAIR SOSY 75mg05ml 150mgml 51 XOSPATA TABS 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 18 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 18 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 XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 44 XUREA CREA 57 XURIDEN PACK 50 xylocaine dental soln 50 XYREM SOLN 32 XYWAV SOLN 32
Y YERVOY SOLN 19 YF-VAX INJ 53 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 39 yuvafem tabs 45
Z zafemy ptwk 44
zafirlukast tabs 10mg 20mg 51 zaleplon caps 5mg 10mg 31 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 44 zarontin soln 30 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 28 ZEJULA CAPS 19 ZELAPAR TBDP 31 ZELBORAF TABS 19 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
57 ZENPEP CPEP 38 zenzedi tabs 25mg 5mg 75mg 10mg
15mg 20mg 30mg 28 ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
32 ZEPOSIA CAPS 32 ZEPOSIA STARTER KIT CPPK 32 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERUVIA PTCH 56 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 51 ZIONODIL 100 LOTN 56 ZIONODIL LOTN 56 ziprasidone hcl caps 20mg 40mg 60mg
80mg 35 ziprasidone mesylate solr 35 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZOKINVY CAPS 50mg 75mg 50 zoledronic acid conc 47 zoledronic acid soln 47 ZOLINZA CAPS 19 zolmitriptan soln 30 zolmitriptan tabs 30 zolmitriptan tbdp 30 zolpidem tartrate er tbcr 625mg 125mg 31 zolpidem tartrate subl 175mg 35mg 31 zolpidem tartrate tabs 5mg 10mg 31 zonisamide caps 25mg 50mg 100mg 30 ZORBTIVE SOLR 46
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 97
ZORTRESS TABS 49 ZOSTAVAX SUSR 53 zovia 135 (28) tabs 44 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19
ZYKADIA TABS 19 ZYNLONTA SOLR 19 ZYPREXA RELPREVV SUSR 35 ZYTIGA TABS 19
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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
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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
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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
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(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)
682896130 062022
This formulary was updated on 060122 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
kporgseniorrx Please recycle
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
6 bull Kaiser Permanente 2022 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 59 The first column of the chart lists the drug name Brand-name drugs are capitalized (eg CIPRODEX) and generic drugs are listed in lower-case italics (eg amoxicillin) 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 2022 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
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 8 bull Kaiser Permanente 2022 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 azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP BICILLIN L-A SUSY cefaclor caps
Drug Name RequirementsLimits
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 intravenous 1gm 2gm 10gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 6gm HI
ceftazidime solr intravenous HI CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 750mg HI
cefuroxime sodium solr intravenous 15gm HI
cephalexin caps cephalexin susr cephalexin tabs chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w 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 2022 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
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 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 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
Drug Name RequirementsLimits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs erythromycin tbec FETROJA SOLR NDS 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 LYMEPAK 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
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium 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 10 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs 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 streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO suprax chew SYNERCID SOLR
Drug Name RequirementsLimits
targadox tabs MO tazicef solr injection HI tazicef solr intravenous 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
vancomycin hcl caps vancomycin hcl solr 250mg5ml vancomycin hcl solr intravenous 1gm 10gm 500mg HI
vancomycin hcl solr intravenous 5gm 750mg
XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ANTIFUNGALS AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS 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
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 2022 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS nystatin susp nystatin tabs 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 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 SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS
Drug Name RequirementsLimits
mefloquine hcl tabs metronidazole caps METRONIDAZOLE SOLN INTRAVENOUS 500mg100ml HI
metronidazole tabs nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs quinine sulfate caps NDS 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 APRETUDE SUER 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 DELSTRIGO TABS MO DESCOVY TABS 200-25mg MO DESCOVY TABS 120-15mg MO didanosine cpdr 200mg 250mg 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 12 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 PACK PANDS EPCLUSA TABS PANDS 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 LIVTENCITY TABS NDS lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO
Drug Name RequirementsLimits
maraviroc tabs 150mg 300mg MO MAVYRET PACK PANDS 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 oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEGASYS PROCLICK SOAJ 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN NDS PEGASYS SOSY NDS PEGINTRON KIT NDS PIFELTRO TABS MO 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
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 2022 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg MO sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS 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 PD TBSO MO TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEKLURY SOLN NDS VEKLURY SOLR NDS VEMLIDY TABS VIDEX EC CPDR 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
Drug Name RequirementsLimits
VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES 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 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg abiraterone acetate tabs 500mg NDS ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS NDS ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs arsenic trioxide soln NDS ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr
Drug Name RequirementsLimits
BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE SOLR BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS BESREMI SOSY NDS bexarotene caps NDS bicalutamide tabs 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 CAMCEVI PRSY CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR 50mg 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
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 2022 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
CYCLOPHOSPHAMIDE SOLN 2gm10ml 1gm5ml 500mg25ml
NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr 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 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 eulexin caps NDS
Drug Name RequirementsLimits
everolimus tabs 25mg 5mg 75mg 10mg NDS
everolimus tbso 2mg 3mg 5mg NDS EVOMELA SOLR NDS exemestane tabs EXKIVITY CAPS NDS FARYDAK CAPS 10mg 15mg 20mg LDNDS
FENSOLVI (6 MONTH) KIT 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 FYARRO SUSR 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 6000000unitml 10000000unitml
NDS
INTRON A SOLR 10000000unit 18000000unit 50000000unit 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 KIMMTRAK 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
lenalidomide caps 5mg 10mg 15mg 25mg NDS
Drug Name RequirementsLimits
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
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 TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA 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 2022 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
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 methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS nelarabine soln 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 120mg12ml 240mg24ml 40mg4ml
NDS
OPDUALAG SOLN NDS oxaliplatin soln oxaliplatin solr paclitaxel conc PACLITAXEL PROTEIN-BOUND PART SUSR 100 MG NDS
PADCEV SOLR 20mg 30mg NDS
Drug Name RequirementsLimits
paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEMFEXY SOLN 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 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
SCEMBLIX TABS 20mg 40mg NDS SIKLOS TABS NDS SOLTAMOX SOLN
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
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 05mg 075mg 1mg NDS
tamoxifen citrate tabs 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 TIVDAK SOLR 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 NDS
TRODELVY SOLR NDS
Drug Name RequirementsLimits
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 UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln 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
VONJO CAPS NDS VOTRIENT TABS NDS VYXEOS SUSR NDS WELIREG TABS 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
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 2022 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
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 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 ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO chlordiazepoxide-clidinium caps dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate oral soln MO glycopyrrolate pf sosy glycopyrrolate soln injection glycopyrrolate tabs 1mg 2mg MO
Drug Name RequirementsLimits
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 RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO varenicline tartrate misc MO varenicline tartrate tabs 05mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA FLEQSUVY SUSP NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs 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
Drug Name RequirementsLimits
albuterol sulfate er tb12 4mg 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcgact MONDS
albuterol sulfate nebu 0083 25mg05ml 063mg3ml 125mg3ml
PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY ipratropium-albuterol soln PAMO isoproterenol hcl soln LEVALBUTEROL HCL NEBU 125mg05ml 125mg3ml 031mg3ml 063mg3ml
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 SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS icatibant acetate 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 2022 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
OXBRYTA TABS NDS OXBRYTA TBSO NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS 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 BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln NDS enoxaparin sodium sosy 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
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 NDS LOVENOX SOSY 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg 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 SUSR NDS XARELTO TABS 25mg 10mg 15mg 20mg MO
HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
EPOGEN SOLN PANDS FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
PROCRIT SOLN 20000unitml 40000unitml PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RELEUKO SOLN 300mcgml 480mcg16ml NDS
RELEUKO SOSY 300mcg05ml 480mcg08ml NDS
RETACRIT SOLN 20000unitml PANDS RETACRIT SOLN PANDS TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS 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 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
Drug Name RequirementsLimits
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 150mg MO fenofibrate micronized caps 43mg 67mg 130mg 134mg 200mg
MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg 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
lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
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 SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 1gm MO BETA-ADRENERGIC BLOCKING 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 2022 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
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
ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
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
nadololbendroflumethiazide 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
Drug Name RequirementsLimits
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 cartia xt cp24 120mg 180mg 240mg 300mg MO
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 40mg 80mg 120mg MO
CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR SOLN MO CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln 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 lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy
Drug Name RequirementsLimits
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 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
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 2022 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
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
captopril-hydrochlorothiazide 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
quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
Drug Name RequirementsLimits
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO 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 dipyridamole tabs 25mg 50mg 75mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ascomp-codeine caps NDS benzhydrocodone-acetaminophen tabs NDS
bupap tabs 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 NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS dvorah tabs 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
Drug Name RequirementsLimits
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
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 hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd 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 NDS indomethacin caps indomethacin er cpcr indomethacin sodium solr ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lorcet hd tabs NDS lorcet plus 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln NDS meperidine hcl tabs 50mg NDS methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl tabs 5mg 10mg NDS MORPHINE SULFATE (CONCENTRATE) SOLN NDS
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 tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln 10mgml 20mgml NDS
nalfon tabs nalocet tabs NDS naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs
Drug Name RequirementsLimits
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 75-300mg 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 relafen ds tabs NDS SALSALATE TABS SUBSYS LIQD 1200mcg 1600mcg PANDS
sulindac tabs tencon tabs tolmetin sodium caps tolmetin sodium tabs
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 soln 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 tabs NDS vicodin es tabs NDS vicodin hp tabs NDS zebutal caps ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS amphetamine er suer NDS 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 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
evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS
Drug Name RequirementsLimits
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
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS procentra soln NDS relexxii tbcr NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
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
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 2022 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
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
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 EPRONTIA SOLN 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 lacosamide tabs 50mg 100mg 150mg 200mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
Drug Name RequirementsLimits
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
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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg 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 VALTOCO 15 MG DOSE LQPK VALTOCO 20 MG DOSE LQPK VALTOCO 5 MG DOSE LIQD vigabatrin pack LDNDS vigabatrin tabs NDS VIMPAT SOLN XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200mg NDS XCOPRI TBPK 14x125mg amp 14x25mg
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ PA AJOVY SOSY PA almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs
Drug Name RequirementsLimits
ergotamine-caffeine tabs FROVATRIPTAN SUCCINATE TABS
naratriptan hcl tabs NURTEC TBDP NDS QULIPTA TABS 10mg 30mg 60mg NDS
rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs UBRELVY TABS 50mg 100mg NDS zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl soln MO amantadine hcl tabs MO APOKYN SOCT NDS apomorphine hcl 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
EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg 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 2022 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
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
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
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 intensol conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS droperidol soln estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
Drug Name RequirementsLimits
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP PANDS 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 nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs seconal caps TEMAZEPAM CAPS 75mg 15mg 225mg 30mg 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS tetrabenazine tabs 125mg 25mg MO
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
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 1mg 2mg NDS
OCREVUS SOLN PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
Drug Name RequirementsLimits
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 ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS OPIATE ANTAGONISTS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
LUCEMYRA TABS NDS naloxone hcl liqd naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
VIVITROL SUSR NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg 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 2022 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
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 conc 30mgml 100mgml MO
chlorpromazine hcl soln chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
CITALOPRAM HYDROBROMIDE CAPS MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
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 HAFYERA SUSY INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 150mg 300mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
LITHIUM CARBONATE TABS MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
LYBALVI TABS NDS maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
Drug Name RequirementsLimits
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 susp MO paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps 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
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
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 2022 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
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 CAPS 150mg 200mg MO
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
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 MO trazodone hcl tabs 150mg 300mg 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
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 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 TRICITRATES SOLN AMMONIA DETOXICANTS carglumic acid tbso NDS constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN DEXTROSE SOLN INTRAVENOUS 5 10 HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE 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
Drug Name RequirementsLimits
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI furosemide tabs 20mg 40mg 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN tolvaptan tabs 15mg 30mg 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 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
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 2022 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate tabs MO CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
DEXTROSE-NACL SOLN INTRAVENOUS 25-045 5-02 5-045 5-09
HI
DEXTROSE-NACL SOLN INTRAVENOUS 10-02 10-045
HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 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 PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
Drug Name RequirementsLimits
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 10meq100ml 20meq100ml 40meq100ml 2meqml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN 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 ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME 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 38 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin oint bacitracin-polymyxin b oint bleph-10 soln chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin 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 paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln
Drug Name RequirementsLimits
sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ANTI-INFLAMMATORY AGENTS bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
CEQUA SOLN CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO cyclosporine emul MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO difluprednate emul MO flac oil 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
ILUVIEN IMPL ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint 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 2022 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
RESTASIS EMUL MO RESTASIS MULTIDOSE EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
VERKAZIA EMUL NDS YUTIQ IMPL ANTIALLERGIC AGENTS azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
betaxolol hcl soln MO bimatoprost soln MO brimonidine tartrate soln 015 02 MO
brinzolamide susp MO carteolol hcl soln MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
Drug Name RequirementsLimits
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO timolol maleate (once-daily) soln MO timolol maleate pf soln MO TIMOLOL MALEATE SOLG 025 05 MO
timolol maleate soln 025 05 MO
travoprost (bak free) 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 SUSVIMO (IMPLANT 1ST FILL) SOLN
SUSVIMO (IMPLANT REFILL) SOLN
TEPEZZA SOLR NDS VABYSMO SOLN LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lidocaine viscous hcl soln MO proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
balsalazide disodium caps MO colazal caps 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 OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS aprepitant caps PANDS dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl sosy ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy
Drug Name RequirementsLimits
SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS trimethobenzamide hcl caps PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc 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 famotidine (pf) soln 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 omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate 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 2022 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS 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 IBSRELA TABS NDS LIVMARLI SOLN NDS lubiprostone caps 8mcg 24mcg MO metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS TRULANCE TABS 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
Drug Name RequirementsLimits
clovique caps NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs deferasirox tbso deferiprone tabs 500mg 1000mg NDS
deferoxamine mesylate solr FERRIPROX SOLN LDNDS FERRIPROX TABS LDNDS FERRIPROX TWICE-A-DAY TABS NDS
penicillamine caps NDS penicillamine tabs NDS trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP ALKINDI SPRINKLE CPSP 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs 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 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp 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 10mg5ml 20mg5ml 25mg5ml 5mg5ml
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 SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TARPEYO CPDR NDS triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
danazol caps 50mg 100mg 200mg MO
Drug Name RequirementsLimits
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 405mg25gm 10mgact
MO
testosterone soln 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 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 enpresse-28 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 2022 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
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 jasmiel tabs MO JOLIVETTE 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
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
Drug Name RequirementsLimits
levora 01530 (28) 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 24 fe tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA 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 nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO nylia 135 tabs MO nylia 777 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 44 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 taysofy caps 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 wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135 (28) tabs MO
Drug Name RequirementsLimits
DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
AFREZZA POWD 90x8 UNIT amp 90x12 UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD 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 glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO HUMALOG KWIKPEN SOPN MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
JARDIANCE TABS 10mg 25mg MO KORLYM TABS LDNDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO metformin hcl er tb24 500mg 750mg 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 2022 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
OZEMPIC (2 MGDOSE) SOPN MO pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO tolazamide tabs 250mg 500mg MO tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
depo-estradiol oil dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
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 MO
Drug Name RequirementsLimits
006mg24hr 0075mg24hr 01mg24hr estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO fyavolv tabs MO jinteli tabs MO lopreeza tabs MO lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO prefest tabs MO PREMARIN SOLR raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PANDS CORTROPHIN GEL PANDS desmopressin ace spray refrig soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln desmopressin acetate tabs 01mg 02mg MO
SKYTROFA CART 3mg 36mg 43mg 52mg 63mg 76mg 91mg 11mg 133mg
NDS
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO 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 progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR NDS
Drug Name RequirementsLimits
EGRIFTA SV SOLR NDS GENOTROPIN CART 12mg PANDS GENOTROPIN MINIQUICK PRSY 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
HUMATROPE CART 6mg 12mg 24mg PANDS
HUMATROPE SOLR PANDS INCRELEX SOLN NDS LANREOTIDE ACETATE SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
octreotide acetate soln 50mcgml 100mcgml 200mcgml
octreotide acetate soln 500mcgml 1000mcgml
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 60mg02ml 90mg03ml 120mg05ml
NDS
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 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 2022 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 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 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
Drug Name RequirementsLimits
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 BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 70mg MO alendronate sodium tabs 5mg 10mg 35mg 40mg MO
EVENITY SOSY NDS IBANDRONATE SODIUM SOLN ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr 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 CIBINQO TABS 50mg 100mg 200mg NDS
CIMZIA KIT PANDS CIMZIA PREFILLED PSKT PANDS CIMZIA STARTER KIT PSKT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
INFLIXIMAB SOLR INTRAVENOUS HI
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 RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 15mg 30mg 45mg NDS
SIMPONI ARIA SOLN NDS
Drug Name RequirementsLimits
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 ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
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
ZORTRESS TABS PA MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BERINERT KIT INTRAVENOUS HI betaine powd NDS 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
Drug Name RequirementsLimits
CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENJAYMO SOLN 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 HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ONPATTRO SOLN NDS 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
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 PYRUKYND TABS 5mg 20mg 50mg NDS
PYRUKYND TAPER PACK TBPK NDS
RECORLEV TABS NDS REZUROCK TABS NDS
Drug Name RequirementsLimits
RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln 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 STERILE WATER FOR IRRIGATION SOLN
TAKHZYRO SOLN NDS TAKHZYRO SOSY NDS TAVNEOS CAPS NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR NDS tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VIJOICE TBPK NDS VILTEPSO SOLN NDS VOXZOGO SOLR 04mg 056mg 12mg NDS
VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS VYVGART SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg 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 2022 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 100mg067ml 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 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 ADVAIR HFA AERO 230-21mcgact MO
ADVAIR HFA AERO 45-21mcgact 115-21mcgact MO
Drug Name RequirementsLimits
ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS HI
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
DALIRESP TABS 250mcg 500mcg MO
FLOVENT HFA AERO MO fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PULMICORT FLEXHALER AEPB
SYMBICORT AERO TEZSPIRE SOSY NDS wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg 1000mcg 1200mcg 1400mcg 1600mcg
NDS
UPTRAVI TBPK NDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS HI
GAMUNEX-C SOLN INJECTION HI HYPERHEP B SOLN HYPERHEP B SOSY HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 1gm20ml 2gm20ml
HI
PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
VARIZIG SOLN TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP KINRIX SUSY QUADRACEL SUSP TDVAX SUSP
Drug Name RequirementsLimits
TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP BOOSTRIX SUSY 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 SOLN MENQUADFI SOLN MENVEO SOLR PEDIARIX SUSY PEDVAX HIB SUSP PENTACEL SUSR PREHEVBRIO SUSP PA PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TICOVAC SUSY TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN TYPHIM VI SOSY VAQTA SUSP VARIVAX INJ
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 2022 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint 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 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 clindamycin phosphate soln MO clindamycin phosphate swab MO clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn econazole nitrate crea ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA
Drug Name RequirementsLimits
gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham mafenide acetate pack malathion lotn metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea mupirocin oint naftifine hcl crea naftifine hcl gel neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ovide lotn oxiconazole nitrate crea permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 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
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
Drug Name RequirementsLimits
clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT 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 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
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO FLURANDRENOLIDE CREA 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 2022 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
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 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 prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO
Drug Name RequirementsLimits
psorcon crea MO RADIAURA CREA NDS texacort soln MO topicort crea 005 025 MO topicort gel MO topicort oint 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 VANOXIDE-HC LOTN WYNZORA CREA NDS ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
HYDROCORTISONE ACE-PRAMOXINE SUPP NDS
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 LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS 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
TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS 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
Drug Name RequirementsLimits
adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ADBRY SOSY NDS ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
azelaic acid gel MO AZELEX CREA MO 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
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA 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 KORSUVA SOLN NDS LACTIC ACID LOTN
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 2022 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
OPZELURA CREA 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 SHAM SALICYLIC ACID-CLEANSER KIT
SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SKYRIZI PEN SOAJ SKYRIZI SOSY STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
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 TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS
Drug Name RequirementsLimits
VECTICAL OINT MO XUREA CREA zenatane caps 10mg 20mg 30mg 40mg NDS
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 calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS
58 bull Kaiser Permanente 2018 Defined Standard Comprehensive Formulary
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 59
Index of Drugs
A abacavir sulfate soln 11 abacavir sulfate tabs 11 abacavir sulfate-lamivudine tabs 11 abacavir-lamivudine-zidovudine tabs 11 ABILIFY MAINTENA PRSY 300mg 400mg
32 ABILIFY MAINTENA SRER 300mg 400mg
32 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
abiraterone acetate tabs 250mg 14 abiraterone acetate tabs 500mg 14 ABRAXANE SUSR 14 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 56 acamprosate calcium tbec 25 acarbose tabs 25mg 50mg 100mg 44 accutane caps 10mg 20mg 30mg 40mg 56 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 26 acetaminophen-codeine soln 26 acetaminophen-codeine tabs 26 acetazolamide er cp12 39 acetazolamide sodium solr 39 acetazolamide tabs 125mg 250mg 39 ACETIC ACID SOLN 39 49 acetylcysteine soln 10 20 47 acitretin caps 10mg 175mg 25mg 56 ACTEMRA ACTPEN SOAJ 47 ACTEMRA SOSY 47 ACTHAR GEL 46 ACTHIB SOLR 52 ACTIMMUNE SOLN 49 acyclovir caps 11 acyclovir oint 53 acyclovir sodium soln intravenous 11 acyclovir susp 11
acyclovir tabs 400mg 800mg 11 ADACEL SUSP 52 ADAGEN SOLN 37 ADAKVEO SOLN 20 ADAPALENE CREA 56 adapalene gel 01 03 56 adapalene pads 56 adapalene soln 56 adapalene-benzoyl peroxide gel 56 ADAPALENE-BENZOYL PEROXIDE PADS
56 ADBRY SOSY 56 adderall tabs 28 adefovir dipivoxil tabs 11 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 51 adenosine soln 24 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 230-21mcgact 51 ADVAIR HFA AERO 45-21mcgact 115-
21mcgact 51 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 14 AFREZZA POWD 90x8 UNIT amp 90x12 UNIT
44 AJOVY SOAJ 30 AJOVY SOSY 30 ala-cort crea 1 25 54 albendazole tabs 8 albuterol sulfate er tb12 4mg 8mg 20 ALBUTEROL SULFATE HFA AERS
108mcgact 20 albuterol sulfate nebu 0083
25mg05ml 063mg3ml 125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 54 alclometasone dipropionate oint 54 ALCOHOL PREP PADS 35 ALDURAZYME SOLN 37 ALECENSA CAPS 14
60 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
alendronate sodium soln 47 alendronate sodium tabs 5mg 10mg
35mg 40mg 47 alendronate sodium tabs 70mg 47 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 41 ALKINDI SPRINKLE CPSP 1mg 2mg 5mg
41 allopurinol sodium solr 47 allopurinol tabs 100mg 300mg 47 allzital tabs 26 almotriptan malate tabs 30 alogliptin benzoate tabs 625mg 125mg
25mg 44 ALOGLIPTIN-METFORMIN HCL TABS 44 alogliptin-pioglitazone tabs 44 ALOSETRON HCL TABS 05mg 1mg 40 alprazolam er tb24 05mg 1mg 2mg 3mg
31 alprazolam intensol conc 31 alprazolam tabs 025mg 05mg 1mg 2mg
31 alprazolam tbdp 025mg 05mg 1mg 2mg
31 ALTACAINE SOLN 39 ALTAFRIN SOLN 39 altavera tabs 42 ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 51 alyacen 135 tabs 42 alyq tabs 25 amabelz tabs 45 amantadine hcl caps 30 amantadine hcl soln 30 amantadine hcl tabs 30 AMBISOME SUSR INTRAVENOUS 10 ambrisentan tabs 51 amcinonide crea 54 amcinonide lotn 54 amcinonide oint 54 amethia lo tabs 42 amethia tabs 42 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 36
amiloride-hydrochlorothiazide tabs 36 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 57 amiodarone hcl soln 24 amiodarone hcl tabs 100mg 200mg
400mg 24 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 33 amlodipine besy-benazepril hcl caps 23 amlodipine besylate tabs 25mg 5mg
10mg 23 amlodipine besylate-valsartan tabs 23 amlodipine-atorvastatin tabs 23 amlodipine-olmesartan tabs 23 amlodipine-valsartan-hctz tabs 23 ammonium lactate crea 56 ammonium lactate lotn 56 amnesteem caps 10mg 20mg 40mg 56 AMONDYS 45 SOLN 49 amoxapine tabs 25mg 50mg 100mg
150mg 33 amoxicill-clarithro-lansopraz misc 40 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8 amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 28 amphetamine sulfate tabs 5mg 10mg 28 amphetamine-dextroamphet er cp24 28 amphetamine-dextroamphetamine tabs 28 amphotericin b solr intravenous 10 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 42 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 55 anastrozole tabs 14
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 61
ANDRODERM PT24 2mg24hr 4mg24hr 42
antabuse tabs 250mg 500mg 25 anusol-hc crea 54 apap-caff-dihydrocodeine tabs 26 apexicon e crea 54 APLENZIN TB24 174mg 348mg 522mg 33 APOKYN SOCT 30 apomorphine hcl soct 30 apraclonidine hcl soln 39 aprepitant caps 40 APRETUDE SUER 11 apri tabs 42 APTIOM TABS 200mg 400mg 600mg
800mg 28 APTIVUS CAPS 11 APTIVUS SOLN 11 ARALAST NP SOLR INTRAVENOUS 51 aranelle tabs 42 ARANESP (ALBUMIN FREE) SOLN
60mcgml 100mcgml 200mcgml 21 ARANESP (ALBUMIN FREE) SOSY
60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 21
ARCALYST SOLR 49 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 49 ARIKAYCE SUSP 8 aripiprazole soln 33 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 33 aripiprazole tbdp 10mg 15mg 33 ARISTADA INITIO PRSY 33 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 33
armodafinil tabs 50mg 150mg 200mg 250mg 28
arsenic trioxide soln 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 49 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 52 ascomp-codeine caps 26 asenapine maleate subl 25mg 5mg 10mg
33
ashlyna tabs 42 ASMANEX HFA AERO 100mcgact
200mcgact 51 ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 48 ASTAGRAF XL CP24 05mg 1mg 48 atazanavir sulfate caps 150mg 200mg
300mg 11 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 31 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 22 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 39 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 32 aubra eq tabs 42 AUGMENTIN SUSR 8 AURYXIA TABS 36 AUSTEDO TABS 6mg 9mg 12mg 31 AVASTIN SOLN 14 AVC VAGINAL CREA 53 aviane tabs 42 AVITA CREA 56 AVITA GEL 56 AVONEX KIT 32 AVONEX PEN AJKT 32 AVONEX PREFILLED PSKT 32 AVSOLA SOLR 47 aygestin tabs 46 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 48 azathioprine sodium solr 48 azathioprine tabs 48 azelaic acid gel 56 azelastine hcl soln 005 01 015 39 azelastine-fluticasone susp 39 AZELEX CREA 56 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
62 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
B bacitracin oint 38 bacitracin solr 8 bacitracin-polymyxin b oint 38 bacitra-neomycin-polymyxin-hc oint 38 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 53 BAFIERTAM CPDR 32 balsalazide disodium caps 40 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 42 BANZEL SUSP 28 BANZEL TABS 200mg 400mg 28 BAQSIMI ONE PACK POWD 44 BAQSIMI TWO PACK POWD 44 BARACLUDE SOLN 11 BAVENCIO SOLN 14 BCG VACCINE SOLR 14 BD INSULIN SYR ULTRAFINE II MISC 35 BD INSULIN SYRINGE MISC 35 BD INSULIN SYRINGE UF MISC 35 BD PEN NEEDLE ORIGINAL UF MISC 35 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 32 BELEODAQ SOLR 14 BELRAPZO SOLN 14 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 14 BENDEKA SOLN 14 BENLYSTA SOAJ 48 BENLYSTA SOLR 48 BENLYSTA SOSY 48 BENZEPRO CREAMY WASH LIQD 53 BENZEPRO FOAMING CLOTHS MISC 53 benzhydrocodone-acetaminophen tabs 26 benzoyl perox-hydrocortisone lotn 54 BENZOYL PEROXIDE FORTE- HC LOTN
54 BENZOYL PEROXIDE GEL 53 benzoyl peroxide-erythromycin gel 53 benztropine mesylate soln 30 benztropine mesylate tabs 05mg 1mg
2mg 30 BEOVU SOLN 39 bepotastine besilate soln 39
BERINERT KIT INTRAVENOUS 49 beser lotn 54 BESPONSA SOLR 14 BESREMI SOSY 14 betaine powd 49 betamethasone dipropionate aug crea 54 betamethasone dipropionate aug gel 54 betamethasone dipropionate aug lotn 54 betamethasone dipropionate aug oint 54 betamethasone dipropionate crea 54 betamethasone dipropionate lotn 54 BETAMETHASONE DIPROPIONATE OINT
54 betamethasone sod phos amp acet susp 41 betamethasone valerate crea 54 betamethasone valerate foam 54 BETAMETHASONE VALERATE LOTN 54 BETAMETHASONE VALERATE OINT 54 BETASERON KIT 32 betaxolol hcl soln 39 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 19 bexarotene caps 14 BEXSERO SUSY 52 bicalutamide tabs 14 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICILLIN L-A SUSY 8 BIKTARVY TABS 11 bimatoprost soln 39 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23 bleomycin sulfate solr 14 bleph-10 soln 38 blephamide sop oint 38 BLEPHAMIDE SUSP 38 BLINCYTO SOLR 14 blisovi 24 fe tabs 42 blisovi fe 1530 tabs 42 BOOSTRIX SUSP 52 BOOSTRIX SUSY 52 BORTEZOMIB SOLR 14 bosentan tabs 51 BOSULIF TABS 100mg 400mg 500mg 14 BRAFTOVI CAPS 50mg 75mg 14 briellyn tabs 42 BRILINTA TABS 60mg 90mg 21
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 63
brimonidine tartrate soln 015 02 39 brinzolamide susp 39 BRIVIACT SOLN 28 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 28 bromfenac sodium (once-daily) soln 38 bromocriptine mesylate caps 30 bromocriptine mesylate tabs 30 BRONCHITOL CAPS 51 BROVANA NEBU 20 BRUKINSA CAPS 14 budesonide cpep 41 budesonide er tb24 41 budesonide susp 025mg2ml 05mg2ml
1mg2ml 51 bumetanide soln 36 bumetanide tabs 05mg 1mg 2mg 36 bupap tabs 26 bupivacaine hcl (pf) soln 49 bupivacaine hcl soln 49 BUPIVACAINE IN DEXTROSE SOLN 49 bupivacaine spinal soln 49 bupivacaine-epinephrine (pf) soln 49 bupivacaine-epinephrine soln 49 buprenorphine hcl subl 2mg 8mg 32 buprenorphine hcl-naloxone hcl film 32 buprenorphine hcl-naloxone hcl subl 32 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 32 bupropion hcl er (smoking det) tb12 33 bupropion hcl er (sr) tb12 100mg 150mg
200mg 33 bupropion hcl er (xl) tb24 150mg 300mg
450mg 33 bupropion hcl tabs 75mg 100mg 33 buspirone hcl tabs 5mg 10mg 31 buspirone hcl tabs 75mg 15mg 30mg 31 busulfan soln 14 butalbital-acetaminophen tabs 26 butalbital-apap-caff-cod caps 26 butalbital-apap-caffeine caps 26 butalbital-apap-caffeine tabs 26 butalbital-asa-caff-codeine caps 26 butalbital-aspirin-caffeine caps 26 butalbital-aspirin-caffeine tabs 26 butorphanol tartrate soln 26 BYLVAY (PELLETS) CPSP 200mcg
600mcg 41 BYLVAY CAPS 400mcg 1200mcg 41
C CABENUVA SUER 11 cabergoline tabs 30 CABLIVI KIT 21 CABOMETYX TABS 20mg 40mg 60mg 14 cafergot tabs 30 caffeine citrate soln 28 calcipotriene crea 56 calcipotriene oint 56 calcipotriene soln 56 calcipotriene-betameth diprop oint 54 calcipotriene-betameth diprop susp 54 calcitonin (salmon) soln 45 calcitrene oint 56 calcitriol caps 025mcg 05mcg 57 CALCITRIOL OINT 56 calcitriol soln 57 calcium acetate (phos binder) caps 37 calcium acetate tabs 37 CALCIUM GLUCONATE-NACL SOLN 37 CALQUENCE CAPS 14 CAMCEVI PRSY 14 camila tabs 42 camrese lo tabs 42 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 54 CAPLYTA CAPS 33 CAPRELSA TABS 100mg 300mg 14 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 25 CARAC CREA 56 carbamazepine chew 28 carbamazepine er cp12 100mg 200mg
300mg 28 carbamazepine er tb12 100mg 200mg
400mg 28 carbamazepine susp 28 carbamazepine tabs 28 carbidopa tabs 30 carbidopa-levodopa er tbcr 30 carbidopa-levodopa tabs 30 carbidopa-levodopa tbdp 30 carbidopa-levodopa-entacapone tabs 30 carbinoxamine maleate soln 13
64 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
carbinoxamine maleate tabs 13 carboplatin soln 14 carboprost tromethamine soln 45 CARDENE IV SOLN 23 carglumic acid tbso 35 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 14 CARNITOR SOLN 49 CARNITOR TABS 49 carteolol hcl soln 39 cartia xt cp24 120mg 180mg 240mg
300mg 23 carvedilol phosphate er cp24 10mg 20mg
40mg 80mg 23 carvedilol tabs 3125mg 625mg 125mg
25mg 23 caspofungin acetate solr intravenous 50mg
70mg 10 CAYSTON SOLR 51 caziant tabs 42 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 intravenous 1gm 2gm
10gm 8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 6gm 8 ceftazidime solr intravenous 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 750mg 8 cefuroxime sodium solr intravenous 15gm 8 celecoxib caps 26 CELONTIN CAPS 29 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 38 CERDELGA CAPS 37 CEREZYME SOLR 37 CEROVEL LOTN 56 cetirizine hcl soln 13 CEVIMELINE HCL CAPS 19 CHANTIX CONTINUING MONTH PAK
TABS 19 CHANTIX STARTING MONTH PAK TABS
19 CHANTIX TABS 05mg 1mg 19 CHEMET CAPS 41 chloramphenicol sod succinate solr 8 chlordiazepoxide hcl caps 5mg 10mg
25mg 31 chlordiazepoxide-amitriptyline tabs 33 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 38 chloroprocaine hcl (pf) soln 49 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 36 chlorothiazide tabs 250mg 500mg 36 chlorpromazine hcl conc 30mgml
100mgml 33 chlorpromazine hcl soln 33 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 33 chlorthalidone tabs 25mg 50mg 36 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 41 cholestyramine light pack 22 cholestyramine light powd 22 cholestyramine pack 22 cholestyramine powd 22 CHORIONIC GONADOTROPIN SOLR 45 CIBINQO TABS 50mg 100mg 200mg 47 ciclopirox gel 53 ciclopirox olamine crea 53
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 65
ciclopirox olamine susp 53 ciclopirox sham 53 ciclopirox soln 53 cidofovir soln 11 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 38 CIMDUO TABS 11 cimetidine hcl soln 40 cimetidine tabs 200mg 300mg 400mg
800mg 40 CIMZIA KIT 47 CIMZIA PREFILLED PSKT 47 CIMZIA STARTER KIT PSKT 47 cinacalcet hcl tabs 30mg 60mg 90mg 45 CINQAIR SOLN 51 CINRYZE SOLR INTRAVENOUS 49 CIPRODEX SUSP 38 ciprofloxacin hcl soln (ophth) 38 CIPROFLOXACIN HCL SOLN (OTIC) 38 ciprofloxacin hcl tabs 8 ciprofloxacin in d5w soln 8 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 38 cisplatin soln 14 CISPLATIN SOLR 50mg 14 CITALOPRAM HYDROBROMIDE CAPS 33 citalopram hydrobromide soln 33 citalopram hydrobromide tabs 10mg 20mg
40mg 33 citanest plain dental soln 49 cladribine soln 14 claravis caps 10mg 20mg 30mg 40mg 56 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 13 cleocin phosphate soln 9 cleocin solr 9 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
clindacin-p swab 53 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 53 clindamycin phosphate crea 53
clindamycin phosphate foam 53 clindamycin phosphate gel 53 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 53 clindamycin phosphate soln 9 53 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 53 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 36 clinisol sf soln intravenous 36 clobazam susp 29 clobazam tabs 10mg 20mg 29 clobetasol propionate crea 54 clobetasol propionate e crea 54 clobetasol propionate emulsion foam 54 clobetasol propionate foam 54 clobetasol propionate gel 54 clobetasol propionate liqd 54 clobetasol propionate lotn 54 clobetasol propionate oint 54 clobetasol propionate sham 54 clobetasol propionate soln 54 clocortolone pivalate crea 54 clocortolone pivalate pump crea 54 clofarabine soln 14 clomipramine hcl caps 25mg 50mg 75mg
33 clonazepam tabs 05mg 1mg 2mg 29 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 29 clonidine hcl (analgesia) soln 24
66 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
clonidine hcl er tb12 24 clonidine hcl tabs 01mg 02mg 03mg 24 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 24 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 31 clotrimazole crea 53 clotrimazole soln 53 clotrimazole troc 53 clotrimazole-betamethasone crea 53 clotrimazole-betamethasone lotn 53 clovique caps 41 clozapine tabs 25mg 50mg 100mg 200mg
33 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 33 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 26 colazal caps 40 COLCHICINE CAPS 47 colchicine tabs 47 colchicine-probenecid tabs 37 COLESEVELAM HCL PACK 22 colesevelam hcl tabs 22 colestipol hcl gran 22 colestipol hcl pack 22 colestipol hcl tabs 22 colistimethate sodium (cba) solr injection 9 colocort enem 54 COLY-MYCIN S SUSP 38 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 14 COMETRIQ (140 MG DAILY DOSE) KIT 14 COMETRIQ (60 MG DAILY DOSE) KIT 14 COMPLERA TABS 11 compro supp 33 CONSENSI TABS 23 constulose soln 35 COPIKTRA CAPS 15mg 25mg 14 CORDRAN TAPE 54 CORLANOR SOLN 24 CORLANOR TABS 5mg 75mg 24 cortisone acetate tabs 41 CORTISPORIN CREA 54 CORTISPORIN OINT 54 CORTROPHIN GEL 46 COSELA SOLR 49
COSENTYX (300 MG DOSE) SOSY 56 COSENTYX SENSOREADY (300 MG)
SOAJ 56 COSENTYX SENSOREADY PEN SOAJ 56 COSENTYX SOSY 75mg05ml 150mgml
56 COTELLIC TABS 14 CREON CPEP 37 CRESEMBA CAPS 10 CRESEMBA SOLR 10 CRIXIVAN CAPS 200mg 400mg 11 cromolyn sodium conc 51 cromolyn sodium nebu 51 cromolyn sodium soln 39 crotan lotn 53 cryselle-28 tabs 42 CRYSVITA SOLN 10mgml 20mgml
30mgml 49 CURITY GAUZE PADS 35 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 52
cyclafem 135 tabs 42 cyclafem 777 tabs 42 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 14 CYCLOPHOSPHAMIDE SOLN 2gm10ml
1gm5ml 500mg25ml 15 cyclophosphamide solr 15 cycloserine caps 11 cyclosporine caps 25mg 100mg 48 cyclosporine emul 38 cyclosporine modified caps 25mg 50mg
100mg 48 cyclosporine modified soln 48 cyclosporine soln 48 cyproheptadine hcl syrp 13 cyproheptadine hcl tabs 13 CYRAMZA SOLN 100mg10ml
500mg50ml 15 CYSTADANE POWD 49 CYSTADROPS SOLN 39 CYSTAGON CAPS 50mg 150mg 49 CYSTARAN SOLN 39 cytarabine (pf) soln 15 cytarabine soln 15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 67
CYTOGAM INJ 52
D dacarbazine solr 15 dactinomycin solr 15 dalfampridine er tb12 32 DALIRESP TABS 250mcg 500mcg 51 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 42 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 56 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 52 daptomycin solr intravenous 350mg 500mg
9 darifenacin hydrobromide er tb24 75mg
15mg 57 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 deblitane tabs 42 decadron tabs 5mg 75mg 41 decadron tabs 4mg 6mg 41 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 41 deferasirox tabs 41 deferasirox tbso 41 deferiprone tabs 500mg 1000mg 41 deferoxamine mesylate solr 41 DELSTRIGO TABS 11 deltasone tabs 41 delyla tabs 42 demeclocycline hcl tabs 9 DEMSER CAPS 22 depo-estradiol oil 45 DEPO-MEDROL SUSP 41 DEPO-PROVERA SUSP 400mgml 46 DEPO-SUBQ PROVERA 104 SUSY 46 depo-testosterone soln 100mgml
200mgml 42 DERMOTIC OIL 38 DESCOVY TABS 120-15mg 11 DESCOVY TABS 200-25mg 11
desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg 33
desloratadine tabs 13 desloratadine tbdp 13 desmopressin ace spray refrig soln 46 DESMOPRESSIN ACETATE SOLN 46 desmopressin acetate spray soln 46 desmopressin acetate tabs 01mg 02mg 46 desogestrel-ethinyl estradiol tabs 42 desonide crea 54 desonide gel 54 desonide lotn 54 desonide oint 54 desowen lotn 54 desoximetasone crea 005 025 54 desoximetasone gel 54 desoximetasone liqd 54 desoximetasone oint 005 025 54 desrx gel 54 DESVENLAFAXINE ER TB24 50mg
100mg 33 desvenlafaxine succinate er tb24 25mg
50mg 100mg 33 dexabliss tbpk 41 dexamethasone elix 41 dexamethasone intensol conc 41 dexamethasone sodium phosphate soln 38
41 dexamethasone soln 41 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 41 dexamethasone tbpk 41 dexchlorpheniramine maleate soln 13 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 28
dexmethylphenidate hcl tabs 25mg 5mg 10mg 28
dexpak 10 day tbpk 41 dexpak 13 day tbpk 41 dexpak 6 day tbpk 41 dexrazoxane hcl solr 49 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 28 dextroamphetamine sulfate soln 28 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 28 DEXTROSE IN LACTATED RINGERS
SOLN 37
68 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
DEXTROSE SOLN 36 DEXTROSE SOLN INTRAVENOUS 5
10 36 DEXTROSE-NACL SOLN INTRAVENOUS
10-02 10-045 37 DEXTROSE-NACL SOLN INTRAVENOUS
25-045 5-02 5-045 5-09 37 DIACOMIT CAPS 250mg 500mg 29 DIACOMIT PACK 250mg 500mg 29 DIASTAT ACUDIAL GEL 10mg 20mg 29 DIASTAT PEDIATRIC GEL 29 diazepam conc 31 diazepam gel 25mg 10mg 20mg 29 diazepam intensol conc 31 diazepam soln 5mg5ml 5mgml 31 diazepam tabs 2mg 5mg 10mg 31 diazoxide susp 44 diclofenac sodium er tb24 26 diclofenac sodium gel 1 3 54 diclofenac sodium soln 38 diclofenac sodium tbec 26 diclofenac-misoprostol tbec 26 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 11 DIFFERIN CREA 56 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 54 diflorasone diacetate oint 54 diflunisal tabs 26 difluprednate emul 38 digitek tabs 0125mg 025mg 24 digox tabs 24 digoxin soln 24 digoxin tabs 125mcg 250mcg 24 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 29 dilantin infatabs chew 29 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 23 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 23
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 23
diltiazem hcl er cp12 60mg 90mg 120mg 23
diltiazem hcl er cp24 120mg 180mg 240mg 23
diltiazem hcl soln 23 diltiazem hcl solr 23 diltiazem hcl tabs 30mg 60mg 90mg
120mg 23 dilt-xr cp24 120mg 180mg 240mg 23 dimenhydrinate soln 40 dimethyl fumarate cpdr 32 dimethyl fumarate starter pack misc 32 DIPENTUM CAPS 40 diphen elix 13 di-phen elix 13 diphenhydramine hcl elix 13 diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 40 diphenoxylate-atropine tabs 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 52 dipyridamole tabs 25mg 50mg 75mg 25 disopyramide phosphate caps 100mg
150mg 24 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 36 divalproex sodium csdr 29 divalproex sodium er tb24 250mg 500mg29 divalproex sodium tbec 125mg 250mg
500mg 29 dobutamine hcl soln 20 DOBUTAMINE IN D5W SOLN 20 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
24 dolishale tabs 42 donepezil hcl tabs 5mg 10mg 23mg 19 donepezil hcl tbdp 5mg 10mg 19 dopamine hcl soln 20 DOPAMINE IN D5W SOLN 20 DOPTELET TABS 21 dorzolamide hcl soln 39 dorzolamide hcl-timolol mal pf soln 39 dorzolamide hcl-timolol mal soln 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 69
dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 33 doxepin hcl conc 33 doxepin hcl crea 55 doxepin hcl tabs 3mg 6mg 33 doxercalciferol caps 05mcg 1mcg 25mcg
57 DOXERCALCIFEROL SOLN 57 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
150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 40 DRIZALMA SPRINKLE CSDR 33 dronabinol caps 25mg 5mg 10mg 40 droperidol soln 31 drospiren-eth estrad-levomefol tabs 42 drospirenone-ethinyl estradiol tabs 42 DROXIA CAPS 15 droxidopa caps 20 DUAKLIR PRESSAIR AEPB 19 DUEXIS TABS 26 duloxetine hcl cpep 20mg 30mg 40mg
60mg 33 DUPIXENT SOPN 200mg114ml
300mg2ml 51 DUPIXENT SOSY 100mg067ml
200mg114ml 300mg2ml 51 DURYSTA IMPL 39 dutasteride caps 47 dutasteride-tamsulosin hcl caps 47 dvorah tabs 26 dxevo 11-day tbpk 41
E ees 400 tabs 9 EASYGEL GEL 49 econazole nitrate crea 53 EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 46 EGRIFTA SV SOLR 46 ELAPRASE SOLN 37 ELELYSO SOLR 37 ELEPSIA XR TB24 1000mg 1500mg 29 eletriptan hydrobromide tabs 30 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 37 elixophyllin elix 57 ELLA TABS 42 ELLENCE SOLN 15 ELMIRON CAPS 49 eluryng ring 42 ELZONRIS SOLN 15 EMCYT CAPS 15 EMFLAZA SUSP 42 EMFLAZA TABS 6mg 18mg 30mg 36mg
42 EMPAVELI SOLN 49 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 30 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 25 enalaprilat inj 25 enalapril-hydrochlorothiazide tabs 25 ENBREL MINI SOCT 47 ENBREL SOLN 47 ENBREL SOLR 47 ENBREL SOSY 25mg05ml 50mgml 48 ENBREL SURECLICK SOAJ 48 ENDARI PACK 49 endocet tabs 26 ENDOMETRIN INST 46
70 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ENGERIX-B SUSP 10mcg05ml 20mcgml 52
ENHERTU SOLR 15 ENJAYMO SOLN 49 enoxaparin sodium soln 21 enoxaparin sodium sosy 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
enpresse-28 tabs 42 ENSPRYNG SOSY 49 ENSTILAR FOAM 54 entacapone tabs 30 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 25 ENTYVIO SOLR 41 enulose soln 35 ENVARSUS XR TB24 075mg 1mg 4mg48 EPCLUSA PACK 12 EPCLUSA TABS 12 EPIDIOLEX SOLN 29 epifoam foam 54 epinastine hcl soln 39 epinephrine (anaphylaxis) soln 20 epinephrine soaj 20 EPINEPHRINE SOSY 20 epirubicin hcl soln 15 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 25 EPOGEN SOLN 21 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 21 epoprostenol sodium solr 51 EPRONTIA SOLN 29 eprosartan mesylate tabs 25 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 33 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 30 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 43 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 53 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 53 erythromycin oint 38 erythromycin pads 53 erythromycin soln 53 erythromycin tbec 9 ESBRIET CAPS 51 ESBRIET TABS 267mg 801mg 51 escitalopram oxalate soln 33 escitalopram oxalate tabs 5mg 10mg
20mg 33 esgic caps 26 esgic tabs 26 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 40 esomeprazole magnesium pack 10mg
20mg 40mg 40 esomeprazole sodium solr 40 estarylla tabs 43 estazolam tabs 1mg 2mg 31 estrace crea 45 estrace tabs 05mg 1mg 2mg 45 estradiol crea 45 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
estradiol tabs 10mcg 05mg 1mg 2mg 45 estradiol valerate oil 45 estradiol-norethindrone acet tabs 45 ESTRING RING 45 eszopiclone tabs 1mg 2mg 3mg 31 ethacrynic acid tabs 36 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 29 ethosuximide soln 29 ethynodiol diac-eth estradiol tabs 43 etodolac caps 26
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 71
etodolac er tb24 26 etodolac tabs 26 etonogestrel-ethinyl estradiol ring 43 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 eulexin caps 15 EURAX CREA 53 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 46
evekeo tabs 5mg 10mg 28 EVENITY SOSY 47 everolimus tabs 025mg 48 everolimus tabs 05mg 075mg 1mg 48 everolimus tabs 25mg 5mg 75mg 10mg
15 everolimus tbso 2mg 3mg 5mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 22 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 49 exemestane tabs 15 EXKIVITY CAPS 15 EXONDYS 51 SOLN 500mg10ml
100mg2ml 49 EXSERVAN FILM 31 EXTAVIA KIT 32 EYLEA SOLN 39 EYLEA SOSY 39 ezetimibe tabs 22 ezetimibe-simvastatin tabs 22
F FABRAZYME SOLR 5mg 35mg 37 falmina tabs 43 famciclovir tabs 125mg 250mg 500mg 12 famotidine (pf) soln 40 famotidine premixed soln 40 famotidine soln 40 famotidine susr 40 famotidine tabs 20mg 40mg 40 FANAPT TABS 1mg 2mg 4mg 6mg 8mg
10mg 12mg 33 FANAPT TITRATION PACK TABS 33 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 51 FASENRA SOSY 51
fayosim tabs 43 febuxostat tabs 40mg 80mg 47 felbamate susp 29 felbamate tabs 400mg 600mg 29 felodipine er tb24 25mg 5mg 10mg 23 femynor tabs 43 fenofibrate caps 50mg 150mg 22 fenofibrate micronized caps 43mg 67mg
130mg 134mg 200mg 22 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 22 fenofibric acid cpdr 45mg 135mg 22 fenoprofen calcium caps 26 fenoprofen calcium tabs 26 fenortho caps 26 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 26 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 26
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 26
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 26
FERRIPROX SOLN 41 FERRIPROX TABS 41 FERRIPROX TWICE-A-DAY TABS 41 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
33 FETZIMA TITRATION C4PK 33 fexmid tabs 20 finasteride tabs 47 FINTEPLA SOLN 29 fioricet caps 26 fioricetcodeine caps 26 FIRDAPSE TABS 49 FIRMAGON (240 MG DOSE) SOLR 15 FIRMAGON SOLR 15 flac oil 38 flavoxate hcl tabs 57 FLEBOGAMMA DIF SOLN INTRAVENOUS
52 flecainide acetate tabs 50mg 100mg
150mg 24 FLEQSUVY SUSP 20 FLOVENT HFA AERO 51 floxuridine solr 15
72 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
fluconazole in sodium chloride soln intravenous 10
fluconazole susr 10 fluconazole tabs 10 flucytosine caps 250mg 500mg 10 fludarabine phosphate soln 15 fludarabine phosphate solr 15 fludrocortisone acetate tabs 42 flumazenil soln 31 flunisolide soln 38 fluocinolone acetonide body oil 54 fluocinolone acetonide crea 001 0025
54 fluocinolone acetonide oil 38 fluocinolone acetonide oint 54 fluocinolone acetonide scalp oil 54 fluocinolone acetonide soln 54 fluocinonide crea 54 fluocinonide emulsified base crea 54 FLUOCINONIDE GEL 54 fluocinonide oint 54 fluocinonide soln 54 FLUORITAB CHEW 025mg 05mg 1mg 49 FLUORITAB SOLN 49 fluorometholone susp 38 fluorouracil crea 5 56 fluorouracil crea 5 56 fluorouracil soln 15 56 fluorouracil soln 2 5 56 fluoxetine hcl (pmdd) tabs 10mg 20mg 33 fluoxetine hcl caps 10mg 20mg 40mg 33 fluoxetine hcl cpdr 33 fluoxetine hcl soln 33 fluoxetine hcl tabs 10mg 20mg 60mg 33 fluphenazine decanoate soln 33 fluphenazine hcl conc 33 fluphenazine hcl elix 33 fluphenazine hcl soln 33 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 34 FLURANDRENOLIDE CREA 54 flurandrenolide lotn 55 flurandrenolide oint 55 flurazepam hcl caps 15mg 30mg 31 flurbiprofen sodium soln 38 flurbiprofen tabs 26 flutamide caps 15 fluticasone propionate crea 55 fluticasone propionate lotn 55
fluticasone propionate oint 55 fluticasone propionate susp 38 fluticasone-salmeterol aepb 51 fluvastatin sodium caps 20mg 40mg 22 fluvastatin sodium er tb24 22 fluvoxamine maleate er cp24 100mg
150mg 34 fluvoxamine maleate tabs 25mg 50mg
100mg 34 FML FORTE SUSP 38 FML OINT 38 fomepizole soln 47 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 FORTEO SOPN 45 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 40 fosfomycin tromethamine pack 13 fosinopril sodium tabs 10mg 20mg 40mg
25 fosinopril sodium-hctz tabs 25 fosphenytoin sodium soln 29 FOTIVDA CAPS 089mg 134mg 15 FROVATRIPTAN SUCCINATE TABS 30 FULPHILA SOSY 21 fulvestrant soln 15 furosemide soln 8mgml 10mgml 36 furosemide soln injection 36 furosemide tabs 20mg 40mg 80mg 36 FUZEON SOLR 12 FYARRO SUSR 15 fyavolv tabs 45 FYCOMPA SUSP 29 FYCOMPA TABS 29
G gabapentin caps 100mg 400mg 29 gabapentin soln 29 gabapentin tabs 600mg 800mg 29 GALAFOLD CAPS 49 galantamine hydrobromide er cp24 8mg
16mg 24mg 19 galantamine hydrobromide soln 19 galantamine hydrobromide tabs 4mg 8mg
12mg 19 GAMASTAN INJ 52 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 48
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 73
GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm 52
GAMMAGARD SOLN INJECTION 52 GAMMAKED SOLN INJECTION 52 GAMMAPLEX SOLN INTRAVENOUS 52 GAMUNEX-C SOLN INJECTION 52 ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 52 GARDASIL 9 SUSY 52 gatifloxacin soln 38 GATTEX KIT 41 gavilyte-c solr 41 gavilyte-g solr 41 gavilyte-h kit 41 gavilyte-n with flavor pack solr 41 GAVRETO CAPS 15 GAZYVA SOLN 15 gemcitabine hcl soln 15 gemcitabine hcl solr 15 gemfibrozil tabs 22 gemmily caps 43 generlac soln 35 gengraf caps 25mg 50mg 100mg 48 gengraf soln 48 GENOTROPIN CART 12mg 46 GENOTROPIN MINIQUICK PRSY 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 46
gentak oint 38 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 53 gentamicin sulfate oint 53 gentamicin sulfate soln 9 38 gentamicin sulfate soln injection 9 GENVOYA TABS 12 gianvi tabs 43 GILENYA CAPS 025mg 05mg 32 GILOTRIF TABS 20mg 30mg 40mg 15 GIMOTI SOLN 41 GIVLAARI SOLN 49 GLASSIA SOLN INTRAVENOUS 51 glatopa sosy 20mgml 40mgml 32 glimepiride tabs 1mg 2mg 4mg 44 glipizide er tb24 25mg 5mg 10mg 44 glipizide tabs 5mg 10mg 44 glipizide-metformin hcl tabs 44 glucagon emergency kit 44
glyburide micronized tabs 15mg 3mg 6mg 44
glyburide tabs 125mg 25mg 5mg 44 glyburide-metformin tabs 44 glycate tabs 19 glycopyrrolate oral soln 19 glycopyrrolate pf sosy 19 glycopyrrolate soln injection 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 55 granisetron hcl soln 40 granisetron hcl tabs 40 GRANIX SOLN 480mcg16ml 300mcgml
21 GRANIX SOSY 300mcg05ml
480mcg08ml 21 GRASTEK SUBL 49 griseofulvin microsize susp 10 griseofulvin microsize tabs 10 griseofulvin ultramicrosize tabs 10 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 32 guanfacine hcl tabs 1mg 2mg 24 GUANIDINE HCL TABS 19 gynazole-1 crea 53
H HAEGARDA SOLR 2000unit 3000unit 49 hailey 24 fe tabs 43 halcinonide crea 55 halobetasol propionate crea 55 HALOBETASOL PROPIONATE FOAM 55 halobetasol propionate oint 55 haloperidol decanoate soln 34 haloperidol lactate conc 34 haloperidol lactate soln 34 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 34 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 52 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
HEPLISAV-B SOLN 52
74 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
HERCEPTIN HYLECTA SOLN 15 HERCEPTIN SOLR 150mg 440mg 15 HERZUMA SOLR 150mg 420mg 15 HETLIOZ CAPS 31 HETLIOZ LQ SUSP 31 HIBERIX SOLR 52 HUMALOG KWIKPEN SOPN 44 HUMALOG SOCT 44 HUMALOG SOLN 44 humatin caps 11 HUMATROPE CART 6mg 12mg 24mg 46 HUMATROPE SOLR 46 HUMIRA PEDIATRIC CROHNS START
PSKT 48 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 48 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 48 HUMIRA PEN-PEDIATRIC UC START
PNKT 48 HUMIRA PEN-PSUVADOL HS START
PNKT 48 HUMIRA PEN-PSORUVEIT STARTER
PNKT 48 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 48
HUMULIN 7030 KWIKPEN SUPN 44 HUMULIN 7030 SUSP 44 HUMULIN N KWIKPEN SUPN 44 HUMULIN N SUSP 44 HUMULIN R SOLN 44 HUMULIN R U-500 (CONCENTRATED)
SOLN 44 HUMULIN R U-500 KWIKPEN SOPN 44 hydralazine hcl soln 24 hydralazine hcl tabs 10mg 25mg 50mg
100mg 24 hydrochlorothiazide caps 36 hydrochlorothiazide tabs 125mg 25mg
50mg 36 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 26 hydrocodone-acetaminophen soln 26 hydrocodone-acetaminophen tabs 26 hydrocodone-ibuprofen tabs 26 hydrocortisone (perianal) crea 1 25 55 hydrocortisone ace-pramoxine crea 55
HYDROCORTISONE ACE-PRAMOXINE SUPP 55
hydrocortisone butyr lipo base crea 55 hydrocortisone butyrate crea 55 hydrocortisone butyrate lotn 55 HYDROCORTISONE BUTYRATE OINT 55 hydrocortisone butyrate soln 55 hydrocortisone crea 1 25 55 hydrocortisone enem 55 hydrocortisone lotn 55 hydrocortisone oint 1 25 55 hydrocortisone tabs 5mg 10mg 20mg 42 hydrocortisone valerate crea 55 hydrocortisone valerate oint 55 HYDROCORTISONE-ACETIC ACID SOLN
38 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 26 hydromorphone hcl liqd 26 hydromorphone hcl tabs 2mg 4mg 8mg 26 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 46 hydroxyprogesterone caproate soln 46 hydroxyurea caps 15 hydroxyzine hcl soln 31 hydroxyzine hcl syrp 31 hydroxyzine hcl tabs 31 hydroxyzine pamoate caps 31 HYPERHEP B SOLN 52 HYPERHEP B SOSY 52 HYPERRAB SD SOLN 52 HYQVIA KIT 52
I IBANDRONATE SODIUM SOLN 47 ibandronate sodium tabs 47 IBRANCE CAPS 75mg 100mg 125mg 15 IBRANCE TABS 75mg 100mg 125mg 15 IBSRELA TABS 41 ibu tabs 26 ibudone tabs 26 ibuprofen lysine soln 26 ibuprofen susp 26 ibuprofen tabs 26 ibutilide fumarate soln 24 icatibant acetate soln 20 iclevia tabs 43 ICLUSIG TABS 10mg 15mg 30mg 45mg
15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 75
icosapent ethyl caps 22 IDAMYCIN PFS SOLN 15 idarubicin hcl soln 15 IDHIFA TABS 50mg 100mg 15 ifosfamide soln 15 IFOSFAMIDE SOLR 16 ILARIS SOLN 26 ILUMYA SOSY 56 ILUVIEN IMPL 38 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 34 imipramine pamoate caps 75mg 100mg
125mg 150mg 34 imiquimod crea 375 5 56 IMIQUIMOD PUMP CREA 56 IMOGAM RABIES-HT SOLN 52 IMOVAX RABIES INJ 52 IMPAVIDO CAPS 11 INBRIJA CAPS 30 incassia tabs 43 INCRELEX SOLN 46 indapamide tabs 125mg 25mg 36 indocin supp 26 indomethacin caps 26 indomethacin er cpcr 26 indomethacin sodium solr 26 INFANRIX SUSP 52 INFLECTRA SOLR INTRAVENOUS 48 INFLIXIMAB SOLR INTRAVENOUS 48 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 32 INGREZZA CPPK 32 INLYTA TABS 1mg 5mg 16 INQOVI TABS 16 INREBIC CAPS 16 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 36 INTRON A SOLN 6000000unitml
10000000unitml 16 INTRON A SOLR 10000000unit
18000000unit 50000000unit 16 introvale tabs 43 INVEGA HAFYERA SUSY 34
INVEGA SUSTENNA SUSY 39mg025ml 34
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml 34
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml 34
INVIRASE CAPS 12 INVIRASE TABS 12 IOPIDINE SOLN 39 IPOL INJ 52 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 20 irbesartan tabs 75mg 150mg 300mg 25 irbesartan-hydrochlorothiazide tabs 25 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 20 isosorbide dinitrate er tbcr 25 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 25 isosorbide mononitrate er tb24 25 isosorbide mononitrate er tb24 30mg 60mg
25 isosorbide mononitrate tabs 10mg 20mg 25 isotretinoin caps 10mg 20mg 30mg 40mg
56 isradipine caps 25mg 5mg 23 ISTURISA TABS 1mg 5mg 10mg 49 itraconazole caps 10 ITRACONAZOLE SOLN 10 ivermectin crea 53 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 52
J JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16
76 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg 21
JARDIANCE TABS 10mg 25mg 44 jasmiel tabs 43 JEMPERLI SOLN 16 jinteli tabs 45 JOLIVETTE TABS 43 JULUCA TABS 12 junel 1530 tabs 43 junel 120 tabs 43 junel fe 1530 tabs 43 junel fe 120 tabs 43 junel fe 24 tabs 43 JUXTAPID CAPS 5mg 10mg 20mg 30mg
40mg 60mg 22 JYNARQUE TABS 15mg 30mg 36 JYNARQUE TBPK 36
K KADCYLA SOLR 100mg 160mg 16 kaitlib fe chew 43 KALYDECO PACK 25mg 50mg 75mg 51 KALYDECO TABS 51 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 37 kariva tabs 43 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ 37
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ 37
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS 37
KEDRAB SOLN 52 kelnor 135 tabs 43 kelnor 150 tabs 43 KENALOG SUSP 42 KEPIVANCE SOLR 56 KERALYT SHAM 56 KESIMPTA SOAJ 49 ketoconazole crea 53 ketoconazole foam 53 ketoconazole sham 53 ketoconazole tabs 10 ketodan foam 53 ketoprofen caps 26 ketoprofen er cp24 26 ketorolac tromethamine soln 26 38
ketorolac tromethamine soln 04 05 38 ketorolac tromethamine tabs 26 KEVEYIS TABS 49 KEVZARA SOAJ 150mg114ml
200mg114ml 48 KEVZARA SOSY 150mg114ml
200mg114ml 48 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 47 KHEDEZLA TB24 50mg 100mg 34 KIMMTRAK SOLN 16 KIMYRSA SOLR 9 KINERET SOSY 48 KINRIX SUSP 52 KINRIX SUSY 52 kionex susp 36 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KISQALI FEMARA(200 MG DOSE) TBPK
16 KITABIS PAK NEBU 51 KLISYRI OINT 56 KLOR-CON 10 TBCR 37 klor-con m15 tbcr 37 klor-con m20 tbcr 37 klor-con pack 37 klor-con sprinkle cpcr 8meq 10meq 37 KLOR-CON TBCR 37 KORLYM TABS 44 KORSUVA SOLN 56 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 35 K-TAB TBCR 37 kurvelo tabs 43 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 30 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 lacosamide tabs 50mg 100mg 150mg
200mg 29
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 77
LACRISERT INST 39 LACTATED RINGERS SOLN 37 49 LACTIC ACID LOTN 56 lactulose encephalopathy soln 35 lactulose pack 35 lactulose soln 35 LAMICTAL XR KIT 29 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 29 lamotrigine er tb24 25mg 50mg 100mg
200mg 250mg 300mg 29 lamotrigine kit 29 lamotrigine starter kit-blue kit 29 lamotrigine starter kit-green kit 29 lamotrigine starter kit-orange kit 29 lamotrigine tabs 25mg 100mg 150mg
200mg 29 lamotrigine tbdp 25mg 50mg 100mg
200mg 29 LANOXIN PEDIATRIC SOLN 24 LANREOTIDE ACETATE SOLN 46 lansoprazole cpdr 15mg 30mg 40 lansoprazole tbdd 15mg 30mg 40 lanthanum carbonate chew 500mg 750mg
1000mg 36 LANTUS SOLN 44 LANTUS SOLOSTAR SOPN 44 lapatinib ditosylate tabs 16 larin 1530 tabs 43 larin 120 tabs 43 larin fe 1530 tabs 43 larin fe 120 tabs 43 larissia tabs 43 LARTRUVO SOLN 190mg19ml
500mg50ml 16 latanoprost soln 39 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 34 LAYOLIS FE CHEW 43 LAZANDA SOLN 100mcgact 400mcgact
26 ledipasvir-sofosbuvir tabs 12 leena tabs 43 leflunomide tabs 10mg 20mg 48 LEMTRADA SOLN 32 lenalidomide caps 5mg 10mg 15mg 25mg
16
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 16 lessina tabs 43 letrozole tabs 16 leucovorin calcium soln 47 leucovorin calcium solr 47 leucovorin calcium tabs 5mg 10mg 15mg
25mg 47 LEUKERAN TABS 16 LEUKINE SOLR 21 leuprolide acetate kit 16 LEVALBUTEROL HCL NEBU
125mg05ml 125mg3ml 031mg3ml 063mg3ml 20
levalbuterol tartrate aero 20 levetiracetam er tb24 500mg 750mg 29 levetiracetam in nacl soln 29 levetiracetam soln 29 levetiracetam tabs 250mg 500mg 750mg
1000mg 29 levobunolol hcl soln 39 levocarnitine soln 49 LEVOCARNITINE TABS 49 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 38 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 47 levoleucovorin calcium solr 47 levonest tabs 43 levonorgest-eth est amp eth est tabs 43 levonorgest-eth estrad 91-day tabs 43 levonorgestrel-ethinyl estrad tabs 43 levonorg-eth estrad triphasic tabs 43 levora 01530 (28) tabs 43 levorphanol tartrate tabs 2mg 3mg 26 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
78 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEVOTHYROXINE SODIUM SOLR 47 LEVOTHYROXINE SODIUM TABS 25mcg
50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEXETTE FOAM 55 LEXIVA SUSP 12 LIALDA TBEC 40 LIBTAYO SOLN 16 lidocaine hcl (cardiac) pf sosy 24 lidocaine hcl (cardiac) sosy 24 lidocaine hcl (pf) soln 49 LIDOCAINE HCL CREA 55 lidocaine hcl lotn 55 lidocaine hcl soln 39 49 55 lidocaine hcl urethralmucosal gel 55 lidocaine hcl urethralmucosal prsy 55 LIDOCAINE IN D5W SOLN 24 lidocaine in dextrose soln 49 lidocaine oint 55 lidocaine ptch 55 lidocaine viscous hcl soln 40 lidocaine-epinephrine soln 49 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 55 LIDOCAINE-HYDROCORTISONE ACE KIT
55 lidocaine-prilocaine crea 55 lidocaine-tetracaine crea 55 LIDOCORT CREA 56 lidopin crea 56 LIDO-SORB LOTN 55 LIDOZION LOTN 56 lincomycin hcl soln 9 lindane sham 53 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 liothyronine sodium soln 47 liothyronine sodium tabs 5mcg 25mcg
50mcg 47 LIPODOX 50 INJ 16
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg 25
lisinopril-hydrochlorothiazide tabs 25 LITHIUM CARBONATE CAPS 150mg
300mg 600mg 34 lithium carbonate er tbcr 300mg 450mg 34 LITHIUM CARBONATE TABS 34 LITHIUM SOLN 34 LITHOSTAT TABS 35 LIVMARLI SOLN 41 LIVTENCITY TABS 12 loestrin 1530 (21) tabs 43 loestrin 120 (21) tabs 43 loestrin fe 1530 tabs 43 loestrin fe 120 tabs 43 LOKELMA PACK 5gm 10gm 36 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 16 loperamide hcl caps 40 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 45 lorazepam intensol conc 31 LORAZEPAM SOLN 4mgml 2mgml 31 lorazepam tabs 05mg 1mg 2mg 31 LORBRENA TABS 25mg 100mg 16 lorcet hd tabs 26 lorcet plus tabs 26 lorcet tabs 27 lortab elix 27 loryna tabs 43 losartan potassium tabs 25mg 50mg
100mg 25 losartan potassium-hctz tabs 25 LOTEMAX GEL 38 LOTEMAX SUSP 38 lovastatin tabs 10mg 20mg 40mg 22 LOVENOX SOLN 21 LOVENOX SOSY 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
low-ogestrel tabs 43 loxapine succinate caps 5mg 10mg 25mg
50mg 34 lubiprostone caps 8mcg 24mcg 41 LUCEMYRA TABS 32 LUCENTIS SOLN 03mg005ml
05mg005ml 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 79
LUCENTIS SOSY 03mg005ml 05mg005ml 39
LUDENT CHEW 025mg 05mg 1mg 49 LUMAKRAS TABS 16 LUMIGAN SOLN 39 LUMIZYME SOLR 37 LUMOXITI SOLR 16 LUPANETA PACK KIT 16 LUPKYNIS CAPS 48 LUPRON DEPOT (1-MONTH) KIT 16 LUPRON DEPOT (3-MONTH) KIT 16 LUPRON DEPOT (4-MONTH) KIT 16 LUPRON DEPOT (6-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 16 LUPRON DEPOT-PED (3-MONTH) KIT 16 lutera tabs 43 LYBALVI TABS 34 lyleq tabs 43 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 45
LYMEPAK TABS 9 LYNPARZA TABS 100mg 150mg 16 LYSODREN TABS 16 lyza tabs 43
M mafenide acetate pack 53 magnesium sulfate in d5w soln 37 magnesium sulfate soln 29 MAGNESIUM SULFATE SOLN INJECTION
50 29 MAKENA SOAJ 46 malathion lotn 53 MANNITOL SOLN 36 maprotiline hcl tabs 25mg 50mg 75mg 34 maraviroc tabs 150mg 300mg 12 MARGENZA SOLN 16 marlissa tabs 43 MARPLAN TABS 34 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 23 MAVENCLAD (10 TABS) TBPK 48 MAVENCLAD (4 TABS) TBPK 48 MAVENCLAD (5 TABS) TBPK 48
MAVENCLAD (6 TABS) TBPK 48 MAVENCLAD (7 TABS) TBPK 48 MAVENCLAD (8 TABS) TBPK 48 MAVENCLAD (9 TABS) TBPK 48 MAVYRET PACK 12 MAVYRET TABS 12 MAYZENT STARTER PACK TBPK 32 MAYZENT TABS 025mg 1mg 2mg 32 MENAPHOSMBHYO1 TABS 13 meclizine hcl tabs 40 meclofenamate sodium caps 27 MEDROL TABS 42 medroxyprogesterone acetate susp 46 medroxyprogesterone acetate susy 46 medroxyprogesterone acetate tabs 25mg
5mg 10mg 46 mefenamic acid caps 27 mefloquine hcl tabs 11 megestrol acetate susp 17 46 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 43 meloxicam tabs 27 melphalan hcl solr 17 memantine hcl er cp24 32 memantine hcl soln 32 memantine hcl tabs 5mg 10mg 32 MENACTRA SOLN 52 menest tabs 03mg 0625mg 125mg 45 MENQUADFI SOLN 52 MENVEO SOLR 52 meperidine hcl soln 27 meperidine hcl tabs 50mg 27 meprobamate tabs 31 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 43 mesalamine cpdr 40 mesalamine enem 40 mesalamine er cp24 40 mesalamine supp 40 mesalamine tbec 12gm 800mg 40 mesalamine-cleanser kit 40 mesna soln 49 MESNEX TABS 49 MESTINON SOLN 19 metadate er tbcr 28 metaproterenol sulfate syrp 20
80 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
metaproterenol sulfate tabs 10mg 20mg 20 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 44 metformin hcl tabs 500mg 850mg 1000mg
45 methadone hcl conc 27 methadone hcl intensol conc 27 methadone hcl tabs 5mg 10mg 27 methamphetamine hcl tabs 28 methazolamide tabs 25mg 50mg 39 methenamine hippurate tabs 13 METHENAMINE MANDELATE TABS 13 methergine tabs 45 methimazole tabs 5mg 10mg 47 methitest tabs 42 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 57 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 36 methyldopa tabs 250mg 500mg 24 methyldopa-hydrochlorothiazide tabs 24 methylergonovine maleate soln 45 methylergonovine maleate tabs 45 methylphenidate hcl chew 25mg 5mg
10mg 28 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 28 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 28 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 28
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 28
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 28
methylphenidate hcl soln 5mg5ml 10mg5ml 28
methylphenidate hcl tabs 5mg 10mg 20mg 28
methylprednisolone acetate susp 42 methylprednisolone sodium succ solr 42
methylprednisolone tabs 4mg 8mg 16mg 32mg 42
methylprednisolone tbpk 42 methyltestosterone caps 42 metoclopramide hcl soln 41 metoclopramide hcl tabs 5mg 10mg 41 metoclopramide hcl tbdp 5mg 10mg 41 metolazone tabs 25mg 5mg 10mg 36 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 23 metoprolol tartrate soct 23 metoprolol tartrate soln 23 metoprolol tartrate tabs 25mg 50mg
100mg 23 metoprolol tartrate tabs 375mg 75mg 23 metoprolol-hydrochlorothiazide tabs 23 metronidazole caps 11 metronidazole crea 53 metronidazole gel 53 metronidazole lotn 53 METRONIDAZOLE SOLN INTRAVENOUS
500mg100ml 11 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
24 mibelas 24 fe chew 43 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 53 miconazole-zinc oxide-petrolat oint 53 micort-hc crea 55 microgestin 1530 tabs 43 microgestin 120 tabs 43 microgestin 24 fe tabs 43 microgestin fe 1530 tabs 43 microgestin fe 120 tabs 43 midazolam hcl (pf) soln 31 midazolam hcl soln 31 midodrine hcl tabs 25mg 5mg 10mg 20 miglitol tabs 25mg 50mg 100mg 45 miglustat caps 38 mili tabs 43 millipred dp tbpk 42 millipred tabs 42 milrinone lactate in dextrose soln 24 milrinone lactate soln 24 mimvey lo tabs 45 mimvey tabs 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 81
minitran pt24 01mghr 02mghr 04mghr 06mghr 25
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 24 mirtazapine tabs 75mg 15mg 30mg
45mg 34 mirtazapine tbdp 15mg 30mg 45mg 34 misoprostol tabs 100mcg 200mcg 40 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 52 modafinil tabs 100mg 200mg 28 moexipril hcl tabs 75mg 15mg 25 molindone hcl tabs 5mg 10mg 25mg 34 mometasone furoate crea 55 mometasone furoate oint 55 mometasone furoate soln 55 mometasone furoate susp 38 MONJUVI SOLR 17 MONONESSA TABS 43 montelukast sodium chew 4mg 5mg 51 montelukast sodium pack 51 montelukast sodium tabs 51 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 27 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 27 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 27
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 27
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml 27
morphine sulfate tabs 15mg 30mg 27 moxifloxacin hcl (2x day) soln 38 moxifloxacin hcl in nacl soln intravenous 9 moxifloxacin hcl soln 38 moxifloxacin hcl tabs 9 MULPLETA TABS 21 MULTAQ TABS 24 mupirocin calcium crea 53 mupirocin oint 53 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17
MYALEPT SOLR 49 MYCAPSSA CPDR 46 mycophenolate mofetil caps 48 mycophenolate mofetil hcl solr 48 mycophenolate mofetil susr 48 mycophenolate mofetil tabs 49 mycophenolate sodium tbec 180mg 360mg
49 MYFEMBREE TABS 45 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 57 MYRBETRIQ TB24 25mg 50mg 57
N NABI-HB SOLN 52 nabumetone tabs 27 N-ACETYL-L-CYSTEINE CAPS 36 nadolol tabs 20mg 40mg 80mg 23 nadololbendroflumethiazide tabs 23 nadolol-bendroflumethiazide tabs 23 nafcillin sodium solr 9 nafcillin sodium solr injection 9 nafcillin sodium solr intravenous 9 NAFRINSE CHEW 49 NAFRINSE DROPS SOLN 49 naftifine hcl crea 53 naftifine hcl gel 53 NAGLAZYME SOLN 38 nalbuphine hcl soln 10mgml 20mgml 27 nalfon tabs 27 nalocet tabs 27 naloxone hcl liqd 32 naloxone hcl soaj 32 naloxone hcl soct 32 naloxone hcl soln 32 naloxone hcl sosy 32 naltrexone hcl tabs 32 naproxen sodium er tb24 27 naproxen sodium tabs 27 naproxen susp 27 naproxen tabs 27 naproxen tbec 27 naproxen-esomeprazole tbec 27 naratriptan hcl tabs 30 NARCAN LIQD 32 NATACYN SUSP 38 nateglinide tabs 60mg 120mg 45 NATPARA CART 25mcg 50mcg 75mcg
100mcg 45
82 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
NAYZILAM SOLN 29 necon 0535 (28) tabs 43 NECON 777 TABS 43 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 34 nelarabine soln 17 nembutal soln 31 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 38 neomycin-polymyxin b gu soln 53 neomycin-polymyxin-dexameth oint 38 neomycin-polymyxin-dexameth susp 39 neomycin-polymyxin-gramicidin soln 38 neomycin-polymyxin-hc soln 39 neomycin-polymyxin-hc susp 39 neo-polycin hc oint 38 neo-polycin oint 38 neo-synalar crea 55 NERLYNX TABS 17 NEULASTA ONPRO PSKT 21 NEULASTA SOSY 21 NEUPOGEN SOLN 480mcg16ml
300mcgml 21 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 21 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 38 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 22 niacor tabs 22 nicardipine hcl caps 20mg 30mg 23 NICARDIPINE HCL SOLN 23 NICOTROL INHA 19 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 43 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 49 nitro-bid oint 25
NITRO-DUR PT24 03mghr 08mghr 25 NITROFURANTOIN MACROCRYSTAL
CAPS 13 NITROFURANTOIN MONOHYD MACRO
CAPS 13 nitrofurantoin susp 13 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 25 nitroglycerin soln 25 nitroglycerin subl 03mg 04mg 06mg 25 nitropress soln 24 nitroprusside sodium soln 24 NITYR TABS 2mg 5mg 10mg 49 NIVESTYM SOLN 480mcg16ml
300mcgml 21 NIVESTYM SOSY 300mcg05ml
480mcg08ml 22 nizatidine caps 150mg 300mg 40 nizatidine soln 40 nolix crea 55 nolix lotn 55 nora-be tabs 43 norco tabs 27 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 46
norepinephrine bitartrate soln 20 norethin ace-eth estrad-fe caps 43 norethin ace-eth estrad-fe chew 43 norethin ace-eth estrad-fe tabs 43 norethindrone acetate tabs 46 norethindrone acet-ethinyl est tabs 43 norethindrone tabs 43 norethindrone-eth estradiol tabs 45 norethin-eth estradiol-fe chew 43 norgesic forte tabs 27 norgestimate-eth estradiol tabs 43 norgestim-eth estrad triphasic tabs 43 norlyroc tabs 43 NORPACE CR CP12 100mg 150mg 24 nortrel 0535 (28) tabs 43 nortrel 135 (21) tabs 43 nortrel 135 (28) tabs 43 nortrel 777 tabs 43 nortriptyline hcl caps 10mg 25mg 50mg
75mg 34 nortriptyline hcl soln 34 NORVIR CAPS 12 NORVIR PACK 12
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 83
NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 32 NOXAFIL SUSP 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 51 NUCALA SOLR 51 NUCALA SOSY 51 NUCYNTA ER TB12 200mg 250mg 27 NUCYNTA TABS 27 NUEDEXTA CAPS 32 NULIBRY SOLR 49 NULOJIX SOLR 49 NUPLAZID CAPS 34 NUPLAZID TABS 10mg 17mg 34 NURTEC TBDP 30 NUTRILIPID EMUL INTRAVENOUS 36 NUTROPIN AQ NUSPIN 10 SOPN 46 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 53 nylia 135 tabs 43 nylia 777 tabs 43 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 44 nystatin crea 53 nystatin oint 53 nystatin powd 53 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 55 nystatin-triamcinolone oint 55 nystop powd 53 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 41 ocella tabs 44 OCREVUS SOLN 32 OCTAGAM SOLN INTRAVENOUS
1gm20ml 2gm20ml 52 octreotide acetate soln 500mcgml
1000mcgml 46 octreotide acetate soln 50mcgml
100mcgml 200mcgml 46 ODACTRA SUBL 49 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 51
ofloxacin soln 38 ofloxacin tabs 10 ogestrel tabs 44 OGIVRI SOLR 17 olanzapine solr 34 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 34 olanzapine tbdp 5mg 10mg 15mg 20mg
34 olanzapine-fluoxetine hcl caps 34 olmesartan medoxomil tabs 5mg 20mg
40mg 25 olmesartan medoxomil-hctz tabs 25 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 39 OLUMIANT TABS 1mg 2mg 48 omega-3-acid ethyl esters caps 22 omeprazole cpdr 10mg 20mg 40mg 40 omeprazole-sodium bicarbonate caps 40 omeprazole-sodium bicarbonate pack 40 OMNITROPE SOCT 5mg15ml
10mg15ml 46 OMNITROPE SOLR 46 ondansetron hcl soln 40 ondansetron hcl sosy 40 ondansetron hcl tabs 4mg 8mg 24mg 40 ondansetron tbdp 4mg 8mg 40 ONIVYDE
INJ 17 ONPATTRO SOLN 50 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 OPDIVO SOLN 100mg10ml 120mg12ml
240mg24ml 40mg4ml 17 OPDUALAG SOLN 17 OPIUM TINC 40 OPZELURA CREA 57 ORACEA CPDR 57 oralone pste 55 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 48 ORENCIA SOLR 48 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 48 ORENITRAM TBCR 025mg 1mg 25mg
5mg 51 ORFADIN CAPS 50 ORFADIN SUSP 50 ORGOVYX TABS 45
84 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ORILISSA TABS 150mg 200mg 45 ORKAMBI PACK 51 ORKAMBI TABS 51 ORLADEYO CAPS 110mg 150mg 50 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 27 orphengesic forte tabs 27 orsythia tabs 44 ORTIKOS CP24 6mg 9mg 42 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 36 OTEZLA TABS 48 OTEZLA TBPK 48 ovide lotn 53 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 42 oxaprozin tabs 27 OXAYDO TABS 27 oxazepam caps 10mg 15mg 30mg 31 OXBRYTA TABS 21 OXBRYTA TBSO 21 oxcarbazepine susp 29 oxcarbazepine tabs 150mg 300mg 600mg
29 OXERVATE SOLN 39 oxiconazole nitrate crea 53 OXLUMO SOLN 50 OXTELLAR XR TB24 150mg 300mg
600mg 29 oxybutynin chloride er tb24 5mg 10mg
15mg 57 oxybutynin chloride syrp 57 oxybutynin chloride tabs 57 oxycodone hcl caps 27 oxycodone hcl conc 27 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxycodone hcl soln 27 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 27 oxycodone-acetaminophen soln 27
oxycodone-acetaminophen tabs 27 oxycodone-acetaminophen tabs 5-300mg
75-300mg 10-300mg 27 oxycodone-aspirin tabs 27 oxycodone-ibuprofen tabs 27 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 27 oxymorphone hcl tabs 5mg 10mg 27 OXYTOCIN SOLN 45 OZEMPIC (025 OR 05 MGDOSE) SOPN
45 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 45 OZEMPIC (2 MGDOSE) SOPN 45
P pacerone tabs 100mg 200mg 400mg 24 paclitaxel conc 17 PACLITAXEL PROTEIN-BOUND PART
SUSR 100 MG 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
50 PALFORZIA (120 MG DAILY DOSE) CSPK
50 PALFORZIA (160 MG DAILY DOSE) CSPK
50 PALFORZIA (20 MG DAILY DOSE) CSPK
50 PALFORZIA (200 MG DAILY DOSE) CSPK
50 PALFORZIA (240 MG DAILY DOSE) CSPK
50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK 50 PALFORZIA (300 MG TITRATION) PACK
50 PALFORZIA (40 MG DAILY DOSE) CSPK
50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
50 PALFORZIA INITIAL ESCALATION CSPK
50 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 34
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 85
palonosetron hcl soln 40 palonosetron hcl sosy 40 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 38 pamidronate disodium soln 47 pamidronate disodium solr 47 panlor tabs 27 PANRETIN GEL 56 pantoprazole sodium pack 40 PANTOPRAZOLE SODIUM SOLR 40 pantoprazole sodium tbec 20mg 40mg 40 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 52
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 57 PARICALCITOL SOLN 57 paroex soln 38 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 34 paroxetine hcl susp 34 paroxetine hcl tabs 10mg 20mg 34 paroxetine hcl tabs 30mg 40mg 34 paroxetine mesylate caps 34 paser pack 11 PEDIARIX SUSY 52 PEDVAX HIB SUSP 52 peg 3350electrolytes solr 41 peg 3350-kcl-na bicarb-nacl solr 41 peg-3350electrolytes solr 41 PEGANONE TABS 29 PEGASYS PROCLICK SOAJ
135mcg05ml 180mcg05ml 12 PEGASYS SOLN 12 PEGASYS SOSY 12 PEGINTRON KIT 12 PEG-PREP KIT 41 PEMAZYRE TABS 45mg 9mg 135mg 17 PEMFEXY SOLN 17 penicillamine caps 41 penicillamine tabs 41 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
PENTACEL SUSR 52 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 40 pentazocine-naloxone hcl tabs 27 pentobarbital sodium soln 31 pentoxifylline er tbcr 21 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 40 percocet tabs 27 perindopril erbumine tabs 2mg 4mg 8mg
25 periogard soln 38 PERJETA SOLN 17 permethrin crea 53 perphenazine tabs 2mg 4mg 8mg 16mg
34 perphenazine-amitriptyline tabs 34 PERSERIS PRSY 90mg 120mg 34 PEXEVA TABS 10mg 20mg 30mg 40mg
34 phenadoz supp 14 phenazo tabs 56 PHENAZOPYRIDINE HCL TABS 56 phenelzine sulfate tabs 34 phenergan soln 14 PHENOBARBITAL ELIX 31 PHENOBARBITAL SODIUM SOLN 31 PHENOBARBITAL TABS 31 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 20 PHENYLEPHRINE HCL SOLN 39 phenytek caps 200mg 300mg 29 phenytoin chew 29 phenytoin sodium extended caps 100mg
200mg 300mg 29 phenytoin sodium soln 29 phenytoin susp 29 PHESGO SOLN 17 PHOSLYRA SOLN 37 PHOSPHASAL TABS 13 PHOSPHOLINE IODIDE SOLR 39 phrenilin forte caps 27 PHYSIOLYTE SOLN 50 PHYSIOSOL IRRIGATION SOLN 50 PIFELTRO TABS 12 pilocarpine hcl soln 1 2 4 39 pilocarpine hcl tabs 5mg 75mg 19 pimecrolimus crea 57
86 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
pimozide tabs 1mg 2mg 34 pimtrea tabs 44 pindolol tabs 5mg 10mg 23 pioglitazone hcl tabs 15mg 30mg 45mg 45 pioglitazone hcl-glimepiride tabs 45 pioglitazone hcl-metformin hcl tabs 45 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 44 piroxicam caps 10mg 20mg 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN 32 PLEGRIDY SOSY 32 PLEGRIDY STARTER PACK SOPN 32 PLEGRIDY STARTER PACK SOSY 32 plenamine soln intravenous 36 podofilox soln 57 POLIVY SOLR 30mg 140mg 17 polocaine soln 50 polocaine-mpf soln 50 polycin oint 38 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 38 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 32 PONVORY TABS 32 portia-28 tabs 44 PORTRAZZA SOLN 17 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 35 POTASSIUM ACETATE SOLN 37 potassium chloride crys er tbcr 10meq
20meq 37 potassium chloride er cpcr 8meq 10meq 37 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 37 POTASSIUM CHLORIDE IN NACL SOLN
INTRAVENOUS 37 POTASSIUM CHLORIDE PACK 37 POTASSIUM CHLORIDE SOLN 10 20
37
potassium chloride soln intravenous 10meq100ml 20meq100ml 40meq100ml 2meqml 37
potassium citrate er tbcr 15meq 540mg 1080mg 35
POTASSIUM PHOSPHATES SOLN 37 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 37 POTELIGEO SOLN 17 PR BENZOYL PEROXIDE WASH LIQD 53 PRADAXA CAPS 75mg 110mg 150mg 21 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 31
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 31
PRAMOX GEL 56 prandin tabs 1mg 2mg 45 prasugrel hcl tabs 5mg 10mg 21 pravastatin sodium tabs 10mg 20mg
40mg 80mg 22 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22 PRED MILD SUSP 39 PRED-G SOP OINT 39 PRED-G SUSP 39 prednicarbate crea 55 prednicarbate oint 55 prednisolone acetate susp 39 prednisolone sodium phosphate soln 39 PREDNISOLONE SODIUM PHOSPHATE
SOLN 10mg5ml 20mg5ml 25mg5ml 5mg5ml 42
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 42
prednisolone soln 42 prednisone intensol conc 42 prednisone soln 42 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 42 prednisone tbpk 42 prefest tabs 45 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 29
pregabalin er tb24 825mg 165mg 330mg 27
pregabalin soln 29 PREHEVBRIO SUSP 52
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 87
PREMARIN SOLR 45 premasol soln intravenous 36 PRENATAL TABS 57 PRETOMANID TABS 11 prevalite pack 22 prevalite powd 22 previfem tabs 44 PREVYMIS SOLN 240mg12ml
480mg24ml 12 PREVYMIS TABS 240mg 480mg 12 PREZCOBIX TABS 12 PREZISTA SUSP 12 PREZISTA TABS 75mg 150mg 600mg
800mg 12 PRIFTIN TABS 11 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 29 primlev tabs 27 probenecid tabs 37 procainamide hcl soln 24 PROCALAMINE SOLN INTRAVENOUS 36 procentra soln 28 prochlorperazine edisylate soln 34 prochlorperazine maleate tabs 34 prochlorperazine supp 34 PROCRIT SOLN 20000unitml
40000unitml 22 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 22 proctofoam hc foam 56 procto-med hc crea 55 procto-pak crea 55 proctosol hc crea 55 proctozone-hc crea 55 PROCYSBI CPDR 25mg 75mg 50 PROCYSBI PACK 75mg 300mg 50 progesterone caps 100mg 200mg 46 progesterone oil 46 PROGRAF PACK 49 PROGRAF PACK 02mg 49 PROGRAF SOLN 49 prolate soln 27 prolate tabs 27 PROLEUKIN SOLR 17 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 24 propafenone hcl tabs 150mg 225mg
300mg 24 propantheline bromide tabs 19 proparacaine hcl soln 40 propranolol hcl er cp24 60mg 80mg
120mg 160mg 23 propranolol hcl soln 20mg5ml 40mg5ml 23 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 23 propranolol-hctz tabs 23 propylthiouracil tabs 47 PROQUAD SUSR 52 protriptyline hcl tabs 5mg 10mg 34 psorcon crea 55 PULMICORT FLEXHALER AEPB 51 PULMOZYME SOLN 38 PURIXAN SUSP 17 PYLERA CAPS 40 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 19 pyridostigmine bromide soln 19 pyridostigmine bromide tabs 30mg 60mg 19 pyrimethamine tabs 11 PYRUKYND TABS 5mg 20mg 50mg 50 PYRUKYND TAPER PACK TBPK 50
Q QDOLO SOLN 27 QINLOCK TABS 17 QUADRACEL SUSP 52 questran light powd 22 questran pack 22 questran powd 22 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 34 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 34 quinapril hcl tabs 5mg 10mg 20mg 40mg
25 quinapril-hydrochlorothiazide tabs 25 quinidine gluconate er tbcr 24 QUINIDINE GLUCONATE SOLN 24 quinidine sulfate tabs 200mg 300mg 24
88 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
quinine sulfate caps 11 QULIPTA TABS 10mg 30mg 60mg 30
R RABAVERT SUSR 52 rabeprazole sodium cpsp 40 rabeprazole sodium tbec 40 RADIAURA CREA 55 RADICAVA SOLN 32 raloxifene hcl tabs 45 ramelteon tabs 31 ramipril caps 125mg 25mg 5mg 10mg 25 ranolazine er tb12 500mg 1000mg 24 RAPIVAB SOLN 12 rasagiline mesylate tabs 05mg 1mg 31 RASUVO SOAJ 48 RAVICTI LIQD 35 RAYALDEE CPCR 57 REBETOL SOLN 12 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 32 REBIF REBIDOSE TITRATION PACK
SOAJ 32 REBIF SOSY 22mcg05ml 44mcg05ml 32 REBIF TITRATION PACK SOSY 32 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 44 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 52 RECORLEV TABS 50 RECTIV OINT 57 REGONOL SOLN 19 REGRANEX GEL 57 relafen ds tabs 27 RELENZA DISKHALER AEPB 12 RELEUKO SOLN 300mcgml
480mcg16ml 22 RELEUKO SOSY 300mcg05ml
480mcg08ml 22 relexxii tbcr 28 RELISTOR SOLN 8mg04ml 12mg06ml
41 RELISTOR TABS 41 reltone caps 200mg 400mg 41 REMICADE SOLR INTRAVENOUS 48 RENFLEXIS SOLR 48 repaglinide tabs 05mg 1mg 2mg 45 repaglinide-metformin hcl tabs 45
REPATHA SOSY 22 REPATHA SURECLICK SOAJ 22 RESCRIPTOR TABS 100mg 200mg 12 RESTASIS EMUL 39 RESTASIS MULTIDOSE EMUL 39 RETACRIT SOLN 22 RETACRIT SOLN 20000unitml 22 RETEVMO CAPS 40mg 80mg 17 RETIN-A CREA 0025 005 01 56 RETIN-A GEL 001 0025 56 RETIN-A MICRO GEL 004 01 56 RETIN-A MICRO PUMP GEL 004 01
56 RETISERT IMPL 39 RETROVIR SOLN 12 REVCOVI SOLN 38 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 17 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 34 REYATAZ PACK 12 REZUROCK TABS 50 RIABNI SOLN 100mg10ml 500mg50ml 17 ribasphere caps 12 ribasphere ribapak (1000 pack) tbpk 12 ribasphere ribapak (1200 pack) tbpk 12 ribasphere tabs 12 ribavirin caps 12 ribavirin solr 12 ribavirin tabs 13 RIDAURA CAPS 50 rifabutin caps 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 riluzole tabs 32 rimantadine hcl tabs 13 RIMSO-50 SOLN 50 RINGERS IRRIGATION SOLN 50 RINGERS SOLN 37 RINVOQ TB24 15mg 30mg 45mg 48 risedronate sodium tabs 5mg 30mg 35mg
150mg 47 risedronate sodium tbec 47 RISPERDAL CONSTA SRER 125mg
25mg 34 RISPERDAL CONSTA SRER 375mg
50mg 35
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 89
RISPERIDONE SOLN 35 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 35 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 35 ritonavir tabs 13 RITUXAN HYCELA SOLN 17 RITUXAN SOLN 17 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 44 rizatriptan benzoate tabs 30 rizatriptan benzoate tbdp 30 ROMIDEPSIN SOLN 17 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 31 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 31 ropivacaine hcl soln 50 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 22 ROTARIX SUSR 52 ROTATEQ SOLN 52 roweepra tabs 500mg 750mg 1000mg 29 roweepra xr tb24 500mg 750mg 29 ROZLYTREK CAPS 100mg 200mg 17 RUBRACA TABS 200mg 250mg 300mg 17 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 29 rufinamide tabs 200mg 400mg 29 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 17 RYBREVANT SOLN 17 ryclora soln 14 RYDAPT CAPS 17 RYLAZE SOLN 17 RYNODERM CREA 57 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 46 SAIZEN SOLR 5mg 88mg 46 SAIZENPREP SOLR 46 sajazir soln 21 SALEX SHAM 57 SALICYLIC ACID CREA 57
SALICYLIC ACID ER SOLN 57 SALICYLIC ACID FOAM 57 SALICYLIC ACID GEL 57 SALICYLIC ACID SHAM 57 SALICYLIC ACID-CLEANSER KIT 57 SALSALATE TABS 27 SANCUSO PTCH 40 SANDIMMUNE ORAL SOLN 100mgml 49 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 46 SANTYL OINT 57 SAPHNELO SOLN 49 SAPHRIS SUBL 25mg 5mg 10mg 35 sapropterin dihydrochloride pack 100mg
500mg 50 sapropterin dihydrochloride tabs 50 SARCLISA SOLN 500mg25ml 100mg5ml
17 SCEMBLIX TABS 20mg 40mg 17 scopolamine pt72 40 seconal caps 31 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 35 selegiline hcl caps 31 selegiline hcl tabs 31 selenium sulfide lotn 53 SELENIUM SULFIDE SHAM 53 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 13 SENSORCAINE SOLN 50 sensorcaineepinephrine soln 50 sensorcaine-mpf soln 50 sensorcaine-mpfepinephrine soln 50 SEREVENT DISKUS AEPB 20 SEROSTIM SOLR 4mg 5mg 6mg 46 SERTRALINE HCL CAPS 150mg 200mg
35 sertraline hcl conc 35 sertraline hcl tabs 25mg 50mg 100mg 35 setlakin tabs 44 sevelamer carbonate pack 08gm 24gm 36 sevelamer carbonate tabs 36 sevelamer hcl tabs 400mg 800mg 36 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 44 SHINGRIX SUSR 52 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 46
90 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
SIGNIFOR SOLN 03mgml 06mgml 09mgml 46
SIKLOS TABS 17 sildenafil citrate soln 25 sildenafil citrate susr 25 sildenafil citrate tabs 25 SILIQ SOSY 57 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 53 SIMPONI ARIA SOLN 48 SIMPONI SOAJ 50mg05ml 100mgml 48 SIMPONI SOSY 50mg05ml 100mgml 48 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 22 sirolimus soln 49 sirolimus tabs 05mg 1mg 2mg 49 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKYRIZI (150 MG DOSE) PSKT 57 SKYRIZI PEN SOAJ 57 SKYRIZI SOSY 57 SKYTROFA CART 3mg 36mg 43mg
52mg 63mg 76mg 91mg 11mg 133mg 46
sod benz-sod phenylacet soln 35 SODIUM ACETATE SOLN 35 SODIUM BICARBONATE SOLN 35 SODIUM CHLORIDE (PF) SOLN 37 SODIUM CHLORIDE SOLN 37 50 SODIUM CHLORIDE SOLN
INTRAVENOUS 045 09 3 5 37 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 50 SODIUM FLUORIDE SOLN 50 sodium phenylbutyrate powd 35 sodium phenylbutyrate tabs 35 SODIUM PHOSPHATES SOLN 37 sodium polystyrene sulfonate powd 36 sodium polystyrene sulfonate susp 36 sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 57 SOLTAMOX SOLN 17 SOLU-CORTEF SOLR 42 SOLU-MEDROL SOLR 42 SOMATULINE DEPOT SOLN 60mg02ml
90mg03ml 120mg05ml 46 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 46
sorine tabs 80mg 120mg 160mg 240mg 23
sotalol hcl (af) tabs 80mg 120mg 160mg 23 sotalol hcl tabs 80mg 120mg 160mg
240mg 23 SOTYLIZE SOLN 23 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 25 spironolactone-hctz tabs 25 SPRAVATO (56 MG DOSE) SOPK 35 SPRAVATO (84 MG DOSE) SOPK 35 sprintec 28 tabs 44 SPRITAM TB3D 250mg 500mg 750mg
1000mg 29 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 36 sronyx tabs 44 SSD CREA 53 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
57 STELARA SOSY 45mg05ml 90mgml 57 STERILE WATER FOR IRRIGATION SOLN
50 STIMATE SOLN 46 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18 STRENSIQ SOLN 18mg045ml
28mg07ml 80mg08ml 40mgml 38 streptomycin sulfate solr 10 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 20 SUBLOCADE SOSY 100mg05ml
300mg15ml 32 SUBSYS LIQD 1200mcg 1600mcg 27 subvenite starter kit-blue kit 29 subvenite starter kit-green kit 29 subvenite starter kit-orange kit 30 subvenite tabs 25mg 100mg 150mg
200mg 30 succinylcholine chloride soln 20 SUCRAID SOLN 38 sucralfate susp 40 sucralfate tabs 40
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 91
sulfacetamide sodium (acne) lotn 53 sulfacetamide sodium oint 38 sulfacetamide sodium soln 38 sulfacetamide-prednisolone soln 39 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 SULFAMYLON CREA 53 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 27 sumatriptan soln 30 sumatriptan succinate refill soct 30 sumatriptan succinate soaj 30 sumatriptan succinate soln 30 sumatriptan succinate sosy 30 sumatriptan succinate tabs 30 sunitinib malate caps 125mg 25mg
375mg 50mg 18 suprax chew 10 SUPREP BOWEL PREP KIT SOLN 41 SUSVIMO (IMPLANT 1ST FILL) SOLN 39 SUSVIMO (IMPLANT REFILL) SOLN 39 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 44 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 51 SYMDEKO TBPK 51 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 45 SYMLINPEN 60 SOPN 45 SYMPAZAN FILM 10mg 20mg 30 SYMPAZAN FILM 5mg 30 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 46 SYNDROS SOLN 40 SYNERCID SOLR 10 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 tacrolimus caps 05mg 1mg 5mg 49 TACROLIMUS OINT 01 003 57
tadalafil (pah) tabs 20mg 25 tadalafil tabs 25mg 5mg 25 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 50 TAKHZYRO SOSY 50 TALTZ SOAJ 57 TALTZ SOSY 57 TALZENNA CAPS 025mg 05mg 075mg
1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 47 taperdex 12-day tbpk 42 taperdex 6-day tbpk 42 taperdex 7-day tbpk 42 targadox tabs 10 TARGRETIN GEL 56 tarina 24 fe tabs 44 tarina fe 120 eq tabs 44 TARPEYO CPDR 42 TASIGNA CAPS 50mg 150mg 200mg 18 TAVALISSE TABS 100mg 150mg 22 TAVNEOS CAPS 50 taysofy caps 44 tazarotene crea 57 tazarotene foam 57 tazicef solr injection 10 tazicef solr intravenous 2gm 6gm 10 TAZORAC CREA 57 TAZORAC GEL 005 01 57 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 52 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TEFLARO SOLR INTRAVENOUS 10 TEGSEDI SOSY 50 telmisartan tabs 20mg 40mg 80mg 25 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 25 TEMAZEPAM CAPS 75mg 15mg 225mg
30mg 31 temsirolimus soln 18 tencon tabs 27 TENIPOSIDE SOLN 18 TENIVAC INJ 52 tenofovir disoproxil fumarate tabs 13
92 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TEPADINA SOLR 18 TEPEZZA SOLR 39 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 20 terbutaline sulfate tabs 25mg 5mg 20 terconazole crea 53 terconazole supp 53 TERIPARATIDE (RECOMBINANT) SOPN
46 testosterone cypionate soln 100mgml
200mgml 42 testosterone enanthate soln 42 testosterone gel 1 162
2025mg125gm 405mg25gm 10mgact 42
testosterone soln 42 tetrabenazine tabs 125mg 25mg 32 TETRACAINE HCL SOLN 40 tetracycline hcl caps 250mg 500mg 10 texacort soln 55 TEZSPIRE SOSY 51 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 57 theophylline er tb12 100mg 200mg
300mg 450mg 57 theophylline er tb24 400mg 600mg 57 theophylline soln 57 THIOLA EC TBEC 100mg 300mg 50 THIOLA TABS 50 thioridazine hcl tabs 10mg 25mg 50mg
100mg 35 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 35 THYROGEN SOLR 50 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
30 TIBSOVO TABS 18 TICOVAC SUSY 52 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 32 tilia fe tabs 44 timolol maleate (once-daily) soln 39 timolol maleate pf soln 39
TIMOLOL MALEATE SOLG 025 05 39 timolol maleate soln 025 05 39 timolol maleate tabs 5mg 10mg 20mg 23 tinidazole tabs 11 tiopronin tabs 50 TIS-U-SOL SOLN 50 TIVDAK SOLR 18 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 tizanidine hcl caps 20 tizanidine hcl tabs 20 TOBI PODHALER CAPS 51 TOBRADEX OINT 39 TOBRADEX ST SUSP 39 tobramycin nebu 300mg4ml 300mg5ml 51 tobramycin soln 38 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 39 TOBREX OINT 38 tofranil tabs 10mg 25mg 50mg 35 tolazamide tabs 250mg 500mg 45 tolbutamide tabs 45 tolcapone tabs 31 tolmetin sodium caps 27 tolmetin sodium tabs 27 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 57 tolterodine tartrate tabs 57 tolvaptan tabs 15mg 30mg 36 TOPEX TOPICAL ANESTHETIC AERO 56 topicort crea 005 025 55 topicort gel 55 topicort oint 55 topiramate cpsp 15mg 25mg 30 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 30 topiramate tabs 25mg 50mg 100mg
200mg 30 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
36 TPN ELECTROLYTES CONC
INTRAVENOUS 37 TRACLEER TBSO 51 TRADJENTA TABS 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 93
tramadol hcl er (biphasic) tb24 100mg 200mg 300mg 28
tramadol hcl er cp24 100mg 150mg 200mg 300mg 28
tramadol hcl er tb24 100mg 200mg 300mg 28
tramadol hcl soln 28 tramadol hcl tabs 50mg 100mg 28 tramadol-acetaminophen tabs 28 trandolapril tabs 1mg 2mg 4mg 25 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 21 tranexamic acid tabs 21 tranylcypromine sulfate tabs 35 TRAVASOL SOLN INTRAVENOUS 36 travoprost (bak free) soln 39 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 150mg 300mg 35 trazodone hcl tabs 50mg 100mg 35 TRECATOR TABS 11 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 57 TREMFYA SOSY 57 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 51 tretinoin caps 18 tretinoin crea 0025 005 01 56 tretinoin gel 001 0025 005 56 tretinoin microsphere gel 004 01 56 tretinoin microsphere pump gel 004
01 56 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 28 triamcinolone acetonide aers 55 triamcinolone acetonide crea 0025
01 05 55 triamcinolone acetonide lotn 0025 01
55 triamcinolone acetonide oint 0025
005 01 05 55 triamcinolone acetonide pste 55 triamcinolone acetonide susp 42 triamterene caps 50mg 100mg 36 triamterene-hctz caps 36 triamterene-hctz tabs 36 trianex oint 55 triazolam tabs 0125mg 025mg 31 TRICITRATES SOLN 35 triderm crea 01 05 55
trientine hcl caps 41 tri-estarylla tabs 44 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 35 trifluridine soln 38 trihexyphenidyl hcl soln 31 trihexyphenidyl hcl tabs 2mg 5mg 31 TRIKAFTA TBPK 51 tri-legest fe tabs 44 tri-lo-estarylla tabs 44 tri-lo-sprintec tabs 44 trilyte solr 41 trimethobenzamide hcl caps 40 TRIMETHOPRIM TABS 13 tri-mili tabs 44 trimipramine maleate caps 25mg 50mg
100mg 35 TRINESSA (28) TABS 44 TRINTELLIX TABS 5mg 10mg 20mg 35 tri-nymyo tabs 44 tri-previfem tabs 44 TRIPTODUR SRER 45 TRISENOX
SOLN 18 tri-sprintec tabs 44 tritocin oint 55 TRIUMEQ PD TBSO 13 TRIUMEQ TABS 13 trivora (28) tabs 44 tri-vylibra lo tabs 44 tri-vylibra tabs 44 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 30 TROPHAMINE SOLN INTRAVENOUS 36 trospium chloride er cp24 57 trospium chloride tabs 57 TRULANCE TABS 41 TRUMENBA SUSY 52 TRUSELTIQ (100MG DAILY DOSE) CPPK
18 TRUSELTIQ (125MG DAILY DOSE) CPPK
18 TRUSELTIQ (50MG DAILY DOSE) CPPK
18 TRUSELTIQ (75MG DAILY DOSE) CPPK
18
94 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 52 TYBOST TABS 13 tydemy tabs 44 tylenol with codeine 3 tabs 28 tylenol with codeine 4 tabs 28 TYMLOS SOPN 46 TYPHIM VI SOLN 52 TYPHIM VI SOSY 52 TYVASO REFILL SOLN 51 TYVASO STARTER SOLN 51
U UBRELVY TABS 50mg 100mg 30 UDENYCA SOSY 22 UKONIQ TABS 18 ULTOMIRIS SOLN 50 UMECTA MOUSSE FOAM 57 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
UNITUXIN SOLN 18 UPTRAVI SOLR 51 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 51
UPTRAVI TBPK 51 UREA CREA 39 57 UREA LOTN 40 57 UREA-C40 LOTN 57 urecholine tabs 5mg 10mg 25mg 50mg 20 uredeb crea 57 URETRON DS TABS 13 URIN DS TABS 13 ursodiol caps 200mg 400mg 41 ursodiol caps 300mg 41 ursodiol tabs 250mg 500mg 41 URYL TABS 13 USTELL CAPS 13 UTICAP CAPS 13 UTIRA-C TABS 13 UTRONA-C TABS 13
V VABYSMO SOLN 39 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 57 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 30 valproic acid caps 30 valproic acid soln 30 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
25 valsartan-hydrochlorothiazide tabs 25 VALTOCO 10 MG DOSE LIQD 30 VALTOCO 15 MG DOSE LQPK 30 VALTOCO 20 MG DOSE LQPK 30 VALTOCO 5 MG DOSE LIQD 30 vanatol lq soln 28 vancomycin hcl caps 10 vancomycin hcl solr 250mg5ml 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 vancomycin hcl solr intravenous 5gm
750mg 10 VANDAZOLE GEL 53 VANOXIDE-HC LOTN 55 VANTAS KIT 18 VAQTA SUSP 52 varenicline tartrate misc 19 varenicline tartrate tabs 05mg 1mg 19 VARIVAX INJ 52 VARIZIG SOLN 52 VASCEPA CAPS 1gm 22 VAXCHORA SUSR 53 vecamyl tabs 24 VECTICAL OINT 57 VEKLURY SOLN 13 VEKLURY SOLR 13 VELCADE SOLR 18 velivet tabs 44 VELPHORO CHEW 36 VELTASSA PACK 84gm 168gm 252gm
36 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 18 VENCLEXTA TABS 10mg 18 VENCLEXTA TABS 50mg 100mg 18
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 95
venlafaxine hcl er cp24 375mg 75mg 150mg 35
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg 35
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg 35
VENTAVIS SOLN 10mcgml 20mcgml 52 verapamil hcl er tbcr 120mg 180mg 240mg
24 verapamil hcl soln 24 verapamil hcl tabs 40mg 80mg 120mg 24 veripred 20 soln 42 VERKAZIA EMUL 39 VERSACLOZ SUSP 35 VERZENIO TABS 50mg 100mg 150mg
200mg 18 vestura tabs 44 VIBERZI TABS 75mg 100mg 41 vicodin es tabs 28 vicodin hp tabs 28 vicodin tabs 28 VICTOZA SOPN 45 VIDEX EC CPDR 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 44 vigabatrin pack 30 vigabatrin tabs 30 VIIBRYD STARTER PACK KIT 35 VIIBRYD TABS 10mg 20mg 40mg 35 VIJOICE TBPK 50 VILTEPSO SOLN 50 VIMIZIM SOLN 38 VIMPAT SOLN 30 vinblastine sulfate soln 18 vincasar pfs soln 18 vincristine sulfate soln 18 vinorelbine tartrate soln 18 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 47 VITRAKVI CAPS 25mg 100mg 18 VITRAKVI SOLN 18 VIVITROL SUSR 32 VIZIMPRO TABS 15mg 30mg 45mg 18 VOCABRIA TABS 13
VONJO CAPS 18 VORAXAZE SOLR 47 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 18 VOXZOGO SOLR 04mg 056mg 12mg 50 VPRIV SOLR 38 VRAYLAR CAPS 15mg 3mg 45mg 6mg
35 VRAYLAR CPPK 35 VUMERITY (STARTER) CPDR 50 VUMERITY CPDR 50 vyfemla tabs 44 vylibra tabs 44 VYNDAMAX CAPS 24 VYNDAQEL CAPS 24 VYONDYS 53 SOLN 50 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 28 VYVGART SOLN 50 VYXEOS SUSR 18
W WAKIX TABS 445mg 178mg 28 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 21 WATER FOR IRRIGATION STERILE
SOLN 50 WELIREG TABS 18 wixela inhub aepb 51 wymzya fe chew 44 WYNZORA CREA 55
X XALKORI CAPS 200mg 250mg 18 XARELTO STARTER PACK TBPK 21 XARELTO SUSR 21 XARELTO TABS 25mg 10mg 15mg
20mg 21 XATMEP SOLN 18 XCOPRI (250 MG DAILY DOSE) TBPK 30 XCOPRI (350 MG DAILY DOSE) TBPK 30 XCOPRI TABS 200mg 30 XCOPRI TABS 50mg 100mg 150mg 30 XCOPRI TBPK 30 XCOPRI TBPK 14x125mg amp 14x25mg 30
96 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
XELJANZ SOLN 48 XELJANZ TABS 5mg 10mg 48 XELJANZ XR TB24 11mg 22mg 48 XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 50 XERMELO TABS 40 XGEVA SOLN 47 XIFAXAN TABS 200mg 550mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 51 XOLAIR SOSY 75mg05ml 150mgml 51 XOSPATA TABS 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 18 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 18 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 XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 44 XUREA CREA 57 XURIDEN PACK 50 xylocaine dental soln 50 XYREM SOLN 32 XYWAV SOLN 32
Y YERVOY SOLN 19 YF-VAX INJ 53 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 39 yuvafem tabs 45
Z zafemy ptwk 44
zafirlukast tabs 10mg 20mg 51 zaleplon caps 5mg 10mg 31 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 44 zarontin soln 30 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 28 ZEJULA CAPS 19 ZELAPAR TBDP 31 ZELBORAF TABS 19 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
57 ZENPEP CPEP 38 zenzedi tabs 25mg 5mg 75mg 10mg
15mg 20mg 30mg 28 ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
32 ZEPOSIA CAPS 32 ZEPOSIA STARTER KIT CPPK 32 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERUVIA PTCH 56 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 51 ZIONODIL 100 LOTN 56 ZIONODIL LOTN 56 ziprasidone hcl caps 20mg 40mg 60mg
80mg 35 ziprasidone mesylate solr 35 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZOKINVY CAPS 50mg 75mg 50 zoledronic acid conc 47 zoledronic acid soln 47 ZOLINZA CAPS 19 zolmitriptan soln 30 zolmitriptan tabs 30 zolmitriptan tbdp 30 zolpidem tartrate er tbcr 625mg 125mg 31 zolpidem tartrate subl 175mg 35mg 31 zolpidem tartrate tabs 5mg 10mg 31 zonisamide caps 25mg 50mg 100mg 30 ZORBTIVE SOLR 46
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 97
ZORTRESS TABS 49 ZOSTAVAX SUSR 53 zovia 135 (28) tabs 44 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19
ZYKADIA TABS 19 ZYNLONTA SOLR 19 ZYPREXA RELPREVV SUSR 35 ZYTIGA TABS 19
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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
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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)
682896130 062022
This formulary was updated on 060122 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
kporgseniorrx Please recycle
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
Kaiser Permanente 2022 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
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table 8 bull Kaiser Permanente 2022 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 azithromycin solr intravenous HI azithromycin susr 100mg5ml 200mg5ml MO
azithromycin tabs 250mg 500mg 600mg MO
aztreonam solr injection HI bacitracin solr BICILLIN C-R 900300 SUSP BICILLIN C-R SUSP BICILLIN L-A SUSP BICILLIN L-A SUSY cefaclor caps
Drug Name RequirementsLimits
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 intravenous 1gm 2gm 10gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm 6gm HI
ceftazidime solr intravenous HI CEFTIN SUSR ceftriaxone sodium solr injection 1gm 2gm 250mg 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 750mg HI
cefuroxime sodium solr intravenous 15gm HI
cephalexin caps cephalexin susr cephalexin tabs chloramphenicol sod succinate solr
ciprofloxacin hcl tabs ciprofloxacin in d5w 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 2022 Defined Standard Comprehensive Formulary bull 9
Drug Name RequirementsLimits
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 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 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg 75mg 100mg 150mg MO
ees 400 tabs ertapenem sodium solr injection HI ery-tab tbec ERYTHROCIN LACTOBIONATE SOLR INTRAVENOUS HI
Drug Name RequirementsLimits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs erythromycin tbec FETROJA SOLR NDS 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 LYMEPAK 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
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium 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 10 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
neomycin sulfate tabs NUZYRA SOLR HINDS NUZYRA TABS NDS ofloxacin tabs 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 streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim soln
sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SULFATRIM PEDIATRIC SUSP MO suprax chew SYNERCID SOLR
Drug Name RequirementsLimits
targadox tabs MO tazicef solr injection HI tazicef solr intravenous 2gm 6gm HI
TEFLARO SOLR INTRAVENOUS HI
tetracycline hcl caps 250mg 500mg MO
TIGECYCLINE SOLR INTRAVENOUS HI
tobramycin sulfate soln injection 80mg2ml 10mgml HI
vancomycin hcl caps vancomycin hcl solr 250mg5ml vancomycin hcl solr intravenous 1gm 10gm 500mg HI
vancomycin hcl solr intravenous 5gm 750mg
XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ANTIFUNGALS AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI caspofungin acetate solr intravenous 50mg 70mg HI
CRESEMBA CAPS NDS CRESEMBA SOLR NDS 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
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 2022 Defined Standard Comprehensive Formulary bull 11
Drug Name RequirementsLimits
micafungin sodium solr intravenous 50mg 100mg HI
NOXAFIL SUSP NDS nystatin susp nystatin tabs 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 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 SIRTURO TABS 20mg 100mg NDS TRECATOR TABS MO ANTIPROTOZOALS ARTESUNATE SOLR NDS atovaquone susp NDS atovaquone-proguanil hcl tabs chloroquine phosphate tabs 250mg 500mg NDS
COARTEM TABS humatin caps hydroxychloroquine sulfate tabs MONDS IMPAVIDO CAPS NDS KRINTAFEL TABS
Drug Name RequirementsLimits
mefloquine hcl tabs metronidazole caps METRONIDAZOLE SOLN INTRAVENOUS 500mg100ml HI
metronidazole tabs nitazoxanide tabs paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj PRIMAQUINE PHOSPHATE TABS
pyrimethamine tabs quinine sulfate caps NDS 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 APRETUDE SUER 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 DELSTRIGO TABS MO DESCOVY TABS 200-25mg MO DESCOVY TABS 120-15mg MO didanosine cpdr 200mg 250mg 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 12 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 PACK PANDS EPCLUSA TABS PANDS 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 LIVTENCITY TABS NDS lopinavir-ritonavir soln MO lopinavir-ritonavir tabs MO
Drug Name RequirementsLimits
maraviroc tabs 150mg 300mg MO MAVYRET PACK PANDS 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 oseltamivir phosphate caps 30mg 45mg 75mg MO
oseltamivir phosphate susr MO PEGASYS PROCLICK SOAJ 135mcg05ml 180mcg05ml NDS
PEGASYS SOLN NDS PEGASYS SOSY NDS PEGINTRON KIT NDS PIFELTRO TABS MO 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
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 2022 Defined Standard Comprehensive Formulary bull 13
Drug Name RequirementsLimits
ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO RUKOBIA TB12 SELZENTRY SOLN MO SELZENTRY TABS 25mg 75mg MO sofosbuvir-velpatasvir tabs PANDS SOVALDI PACK 150mg 200mg PANDS 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 PD TBSO MO TRIUMEQ TABS MO TRIZIVIR TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm 500mg MO
valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEKLURY SOLN NDS VEKLURY SOLR NDS VEMLIDY TABS VIDEX EC CPDR 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
Drug Name RequirementsLimits
VOSEVI TABS PANDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PANDS zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES 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 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
di-phen elix diphen elix diphenhydramine hcl elix
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
diphenhydramine hcl soln levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp phenergan soln promethazine hcl soln promethazine hcl supp promethazine hcl syrp promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs 250mg abiraterone acetate tabs 500mg NDS ABRAXANE SUSR adriamycin soln adriamycin solr adrucil soln AFINITOR DISPERZ TBSO 2mg 3mg 5mg NDS
AFINITOR TABS NDS ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg 90mg 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs arsenic trioxide soln NDS ARZERRA CONC 1000mg50ml 100mg5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 25mg 50mg 100mg 200mg 300mg NDS
azacitidine susr
Drug Name RequirementsLimits
BALVERSA TABS 3mg 4mg 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE SOLR BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS BESREMI SOSY NDS bexarotene caps NDS bicalutamide tabs 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 CAMCEVI PRSY CAPRELSA TABS 100mg 300mg LDNDS
carboplatin soln carmustine solr cisplatin soln CISPLATIN SOLR 50mg 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
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 2022 Defined Standard Comprehensive Formulary bull 15
Drug Name RequirementsLimits
CYCLOPHOSPHAMIDE SOLN 2gm10ml 1gm5ml 500mg25ml
NDS
cyclophosphamide solr CYRAMZA SOLN 100mg10ml 500mg50ml NDS
cytarabine (pf) soln cytarabine soln dacarbazine solr 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 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 eulexin caps NDS
Drug Name RequirementsLimits
everolimus tabs 25mg 5mg 75mg 10mg NDS
everolimus tbso 2mg 3mg 5mg NDS EVOMELA SOLR NDS exemestane tabs EXKIVITY CAPS NDS FARYDAK CAPS 10mg 15mg 20mg LDNDS
FENSOLVI (6 MONTH) KIT 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 FYARRO SUSR 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 INQOVI TABS NDS INREBIC CAPS NDS INTRON A SOLN 6000000unitml 10000000unitml
NDS
INTRON A SOLR 10000000unit 18000000unit 50000000unit 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 KIMMTRAK 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
lenalidomide caps 5mg 10mg 15mg 25mg NDS
Drug Name RequirementsLimits
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
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 TABS 100mg 150mg NDS
LYSODREN TABS NDS MARGENZA 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 2022 Defined Standard Comprehensive Formulary bull 17
Drug Name RequirementsLimits
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 methotrexate tabs PA mitomycin solr mitoxantrone hcl conc MONJUVI SOLR NDS mutamycin solr MVASI SOLN 400mg16ml 100mg4ml NDS
MYLOTARG SOLR NDS nelarabine soln 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 120mg12ml 240mg24ml 40mg4ml
NDS
OPDUALAG SOLN NDS oxaliplatin soln oxaliplatin solr paclitaxel conc PACLITAXEL PROTEIN-BOUND PART SUSR 100 MG NDS
PADCEV SOLR 20mg 30mg NDS
Drug Name RequirementsLimits
paraplatin soln PEMAZYRE TABS 45mg 9mg 135mg NDS
PEMFEXY SOLN 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 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
SCEMBLIX TABS 20mg 40mg NDS SIKLOS TABS NDS SOLTAMOX SOLN
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
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 05mg 075mg 1mg NDS
tamoxifen citrate tabs 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 TIVDAK SOLR 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 NDS
TRODELVY SOLR NDS
Drug Name RequirementsLimits
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 UKONIQ TABS NDS UNITUXIN SOLN NDS valrubicin soln 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
VONJO CAPS NDS VOTRIENT TABS NDS VYXEOS SUSR NDS WELIREG TABS 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
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 2022 Defined Standard Comprehensive Formulary bull 19
Drug Name RequirementsLimits
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 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 ATROPINE SULFATE SOLN ATROPINE SULFATE SOSY ATROVENT HFA AERS MO chlordiazepoxide-clidinium caps dicyclomine hcl caps MO dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycate tabs glycopyrrolate oral soln MO glycopyrrolate pf sosy glycopyrrolate soln injection glycopyrrolate tabs 1mg 2mg MO
Drug Name RequirementsLimits
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 RESPIMAT AERS 25mcgact MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO YUPELRI SOLN PANDS AUTONOMIC DRUGS MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS 05mg 1mg MO NICOTROL INHA MO varenicline tartrate misc MO varenicline tartrate tabs 05mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
cyclobenzaprine hcl er cp24 15mg 30mg PA
cyclobenzaprine hcl tabs 5mg 75mg 10mg PA
dantrolene sodium caps dantrolene sodium solr fexmid tabs PA FLEQSUVY SUSP NDS metaxall tabs metaxalone tabs methocarbamol soln methocarbamol tabs orphenadrine citrate er tb12 orphenadrine citrate soln succinylcholine chloride soln tizanidine hcl caps tizanidine hcl tabs 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
Drug Name RequirementsLimits
albuterol sulfate er tb12 4mg 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcgact MONDS
albuterol sulfate nebu 0083 25mg05ml 063mg3ml 125mg3ml
PAMO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg 4mg MO arformoterol tartrate nebu PAMONDS BROVANA NEBU PAMONDS COMBIVENT RESPIMAT AERS MO dobutamine hcl soln DOBUTAMINE IN D5W SOLN dopamine hcl soln DOPAMINE IN D5W SOLN droxidopa caps epinephrine (anaphylaxis) soln epinephrine soaj EPINEPHRINE SOSY ipratropium-albuterol soln PAMO isoproterenol hcl soln LEVALBUTEROL HCL NEBU 125mg05ml 125mg3ml 031mg3ml 063mg3ml
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 SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate soln terbutaline sulfate tabs 25mg 5mg MO
BLOOD FORMATION COAGULATION AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS icatibant acetate 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 2022 Defined Standard Comprehensive Formulary bull 21
Drug Name RequirementsLimits
OXBRYTA TABS NDS OXBRYTA TBSO NDS RUCONEST SOLR INTRAVENOUS HI
sajazir soln NDS 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 BRILINTA TABS 60mg 90mg MO cilostazol tabs 50mg 100mg MO clopidogrel bisulfate tabs 75mg 300mg MO
ELIQUIS TABS MO enoxaparin sodium soln NDS enoxaparin sodium sosy 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
eptifibatide soln fondaparinux sodium soln 25mg05ml NDS
fondaparinux sodium soln 5mg04ml 75mg06ml 10mg08ml
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 NDS LOVENOX SOSY 30mg03ml 40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml
NDS
Drug Name RequirementsLimits
pentoxifylline er tbcr MO PRADAXA CAPS 75mg 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 SUSR NDS XARELTO TABS 25mg 10mg 15mg 20mg MO
HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 60mcgml 100mcgml 200mcgml
PANDS
ARANESP (ALBUMIN FREE) SOSY 60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml
PANDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
EPOGEN SOLN PANDS FULPHILA SOSY NDS GRANIX SOLN 480mcg16ml 300mcgml NDS
GRANIX SOSY 300mcg05ml 480mcg08ml NDS
LEUKINE SOLR NDS MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg16ml 300mcgml NDS
NEUPOGEN SOSY 300mcg05ml 480mcg08ml NDS
NIVESTYM SOLN 480mcg16ml 300mcgml 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
NIVESTYM SOSY 300mcg05ml 480mcg08ml NDS
NPLATE SOLR NDS NYVEPRIA SOSY NDS PROCRIT SOLN 2000unitml 3000unitml 4000unitml 10000unitml
PANDS
PROCRIT SOLN 20000unitml 40000unitml PANDS
PROMACTA PACK 125mg 25mg NDS
PROMACTA TABS 125mg 25mg 50mg 75mg NDS
REBLOZYL SOLR 25mg 75mg NDS RELEUKO SOLN 300mcgml 480mcg16ml NDS
RELEUKO SOSY 300mcg05ml 480mcg08ml NDS
RETACRIT SOLN 20000unitml PANDS RETACRIT SOLN PANDS TAVALISSE TABS 100mg 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg05ml 480mcg08ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS 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 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
Drug Name RequirementsLimits
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 150mg MO fenofibrate micronized caps 43mg 67mg 130mg 134mg 200mg
MO
fenofibrate tabs 40mg 48mg 54mg 120mg 145mg 160mg MO
fenofibric acid cpdr 45mg 135mg 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
lovastatin tabs 10mg 20mg 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg 750mg 1000mg MO
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 SOSY PANDS REPATHA SURECLICK SOAJ PANDS rosuvastatin calcium tabs 5mg 10mg 20mg 40mg MO
simvastatin tabs 5mg 10mg 20mg 40mg 80mg MO
VASCEPA CAPS 1gm MO BETA-ADRENERGIC BLOCKING 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 2022 Defined Standard Comprehensive Formulary bull 23
Drug Name RequirementsLimits
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
ESMOLOL HCL SOLN esmolol hcl-sodium chloride soln labetalol hcl soln labetalol hcl tabs 100mg 200mg 300mg MO
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
nadololbendroflumethiazide 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
Drug Name RequirementsLimits
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 cartia xt cp24 120mg 180mg 240mg 300mg MO
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 verapamil hcl er tbcr 120mg 180mg 240mg MO
verapamil hcl soln verapamil hcl tabs 40mg 80mg 120mg MO
CARDIAC DRUGS adenosine soln amiodarone hcl soln amiodarone hcl tabs 100mg 200mg 400mg MO
CORLANOR SOLN MO CORLANOR TABS 5mg 75mg MO digitek tabs 0125mg 025mg MO digox tabs digoxin soln 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 lidocaine hcl (cardiac) pf sosy lidocaine hcl (cardiac) sosy
Drug Name RequirementsLimits
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 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
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 2022 Defined Standard Comprehensive Formulary bull 25
Drug Name RequirementsLimits
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
captopril-hydrochlorothiazide 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
quinapril hcl tabs 5mg 10mg 20mg 40mg MO
quinapril-hydrochlorothiazide tabs MO
Drug Name RequirementsLimits
ramipril caps 125mg 25mg 5mg 10mg MO
spironolactone tabs 25mg 50mg 100mg MO
spironolactone-hctz tabs MO 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 dipyridamole tabs 25mg 50mg 75mg 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
disulfiram tabs 250mg 500mg MO ANALGESICS AND ANTIPYRETICS acetaminophen-codeine 3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS allzital tabs apap-caff-dihydrocodeine tabs NDS ascomp-codeine caps NDS benzhydrocodone-acetaminophen tabs NDS
bupap tabs 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 NDS celecoxib caps CODEINE SULFATE TABS 15mg 30mg 60mg NDS
diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS dvorah tabs 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
Drug Name RequirementsLimits
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg
PANDS
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr
NDS
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 hydromorphone hcl er tb24 8mg 12mg 16mg 32mg NDS
hydromorphone hcl liqd 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 NDS indomethacin caps indomethacin er cpcr indomethacin sodium solr ketoprofen caps ketoprofen er cp24 ketorolac tromethamine soln ketorolac tromethamine tabs LAZANDA SOLN 100mcgact 400mcgact PANDS
levorphanol tartrate tabs 2mg 3mg NDS
lorcet hd tabs NDS lorcet plus 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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 27
Drug Name RequirementsLimits
lorcet tabs NDS lortab elix NDS meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln NDS meperidine hcl tabs 50mg NDS methadone hcl conc NDS methadone hcl intensol conc NDS methadone hcl tabs 5mg 10mg NDS MORPHINE SULFATE (CONCENTRATE) SOLN NDS
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 tabs 15mg 30mg NDS
nabumetone tabs nalbuphine hcl soln 10mgml 20mgml NDS
nalfon tabs nalocet tabs NDS naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen tbec naproxen-esomeprazole tbec NDS norco tabs NDS norgesic forte tabs NUCYNTA ER TB12 200mg 250mg NDS
NUCYNTA TABS NDS orphenadrine-aspirin-caffeine tabs
orphengesic forte tabs
Drug Name RequirementsLimits
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 75-300mg 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 relafen ds tabs NDS SALSALATE TABS SUBSYS LIQD 1200mcg 1600mcg PANDS
sulindac tabs tencon tabs tolmetin sodium caps tolmetin sodium tabs
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 soln 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 tabs NDS vicodin es tabs NDS vicodin hp tabs NDS zebutal caps ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS amphetamine er suer NDS 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 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
evekeo tabs 5mg 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PANDS
Drug Name RequirementsLimits
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
methylphenidate hcl tabs 5mg 10mg 20mg NDS
modafinil tabs 100mg 200mg PANDS procentra soln NDS relexxii tbcr NDS VYVANSE CAPS 10mg 20mg 30mg 40mg 50mg 60mg 70mg
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
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 2022 Defined Standard Comprehensive Formulary bull 29
Drug Name RequirementsLimits
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
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 EPRONTIA SOLN 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 lacosamide tabs 50mg 100mg 150mg 200mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg 25mg MO lamotrigine er tb24 25mg 50mg 100mg 200mg 250mg 300mg MO
Drug Name RequirementsLimits
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
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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
subvenite starter kit-orange kit MO subvenite tabs 25mg 100mg 150mg 200mg MO
SYMPAZAN FILM 5mg 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 VALTOCO 15 MG DOSE LQPK VALTOCO 20 MG DOSE LQPK VALTOCO 5 MG DOSE LIQD vigabatrin pack LDNDS vigabatrin tabs NDS VIMPAT SOLN XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg 100mg 150mg
XCOPRI TABS 200mg NDS XCOPRI TBPK 14x125mg amp 14x25mg
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg 50mg 100mg MO
ANTIMIGRAINE AGENTS AJOVY SOAJ PA AJOVY SOSY PA almotriptan malate tabs cafergot tabs eletriptan hydrobromide tabs
Drug Name RequirementsLimits
ergotamine-caffeine tabs FROVATRIPTAN SUCCINATE TABS
naratriptan hcl tabs NURTEC TBDP NDS QULIPTA TABS 10mg 30mg 60mg NDS
rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs UBRELVY TABS 50mg 100mg NDS zolmitriptan soln zolmitriptan tabs zolmitriptan tbdp ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl soln MO amantadine hcl tabs MO APOKYN SOCT NDS apomorphine hcl 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
EMSAM PT24 6mg24hr 9mg24hr 12mg24hr NDS
entacapone tabs MO INBRIJA CAPS NDS KYNMOBI FILM 10mg 15mg 20mg 25mg 30mg 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 2022 Defined Standard Comprehensive Formulary bull 31
Drug Name RequirementsLimits
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
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
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 intensol conc NDS diazepam soln 5mg5ml 5mgml NDS diazepam tabs 2mg 5mg 10mg NDS droperidol soln estazolam tabs 1mg 2mg NDS eszopiclone tabs 1mg 2mg 3mg NDS flurazepam hcl caps 15mg 30mg NDS
Drug Name RequirementsLimits
HETLIOZ CAPS PANDS HETLIOZ LQ SUSP PANDS 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 nembutal soln oxazepam caps 10mg 15mg 30mg NDS
pentobarbital sodium soln PHENOBARBITAL ELIX PHENOBARBITAL SODIUM SOLN
PHENOBARBITAL TABS ramelteon tabs seconal caps TEMAZEPAM CAPS 75mg 15mg 225mg 30mg 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
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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 NOURIANZ TABS 20mg 40mg NDS NUEDEXTA CAPS PANDS RADICAVA SOLN NDS riluzole tabs MONDS tetrabenazine tabs 125mg 25mg MO
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
EXTAVIA KIT NDS GILENYA CAPS 025mg 05mg NDS glatopa sosy 20mgml 40mgml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS 025mg 1mg 2mg NDS
OCREVUS SOLN PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
Drug Name RequirementsLimits
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 ZEPOSIA 7-DAY STARTER PACK CPPK NDS
ZEPOSIA CAPS NDS ZEPOSIA STARTER KIT CPPK NDS OPIATE ANTAGONISTS BELBUCA FILM 75mcg 150mcg 300mcg 450mcg 600mcg 750mcg 900mcg
NDS
buprenorphine hcl subl 2mg 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
buprenorphine ptwk 5mcghr 75mcghr 10mcghr 15mcghr 20mcghr
NDS
LUCEMYRA TABS NDS naloxone hcl liqd naloxone hcl soaj NDS naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg05ml 300mg15ml NDS
VIVITROL SUSR NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg 400mg NDS
ABILIFY MAINTENA SRER 300mg 400mg 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 2022 Defined Standard Comprehensive Formulary bull 33
Drug Name RequirementsLimits
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 conc 30mgml 100mgml MO
chlorpromazine hcl soln chlorpromazine hcl tabs 10mg 25mg 50mg 100mg 200mg MO
CITALOPRAM HYDROBROMIDE CAPS MO
citalopram hydrobromide soln MO citalopram hydrobromide tabs 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 fluoxetine hcl tabs 10mg 20mg 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO fluphenazine hcl elix MO fluphenazine hcl soln
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
fluphenazine hcl tabs 1mg 25mg 5mg 10mg MO
fluvoxamine maleate er cp24 100mg 150mg MO
fluvoxamine maleate tabs 25mg 50mg 100mg MO
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 HAFYERA SUSY INVEGA SUSTENNA SUSY 39mg025ml NDS
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml
NDS
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml
NDS
KHEDEZLA TB24 50mg 100mg MO LATUDA TABS 20mg 40mg 60mg 80mg 120mg NDS
LITHIUM CARBONATE CAPS 150mg 300mg 600mg MO
lithium carbonate er tbcr 300mg 450mg MO
LITHIUM CARBONATE TABS MO LITHIUM SOLN MO loxapine succinate caps 5mg 10mg 25mg 50mg MO
LYBALVI TABS NDS maprotiline hcl tabs 25mg 50mg 75mg MO
MARPLAN TABS MO mirtazapine tabs 75mg 15mg 30mg 45mg MO
mirtazapine tbdp 15mg 30mg 45mg MO
molindone hcl tabs 5mg 10mg 25mg MO
Drug Name RequirementsLimits
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 susp MO paroxetine hcl tabs 10mg 20mg MO paroxetine hcl tabs 30mg 40mg MO paroxetine mesylate caps 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
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
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 2022 Defined Standard Comprehensive Formulary bull 35
Drug Name RequirementsLimits
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 CAPS 150mg 200mg MO
sertraline hcl conc MO sertraline hcl tabs 25mg 50mg 100mg MO
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 MO trazodone hcl tabs 150mg 300mg 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
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg 20mg 40mg MO
Drug Name RequirementsLimits
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 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 TRICITRATES SOLN AMMONIA DETOXICANTS carglumic acid tbso NDS constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm 20gm MO lactulose encephalopathy soln MO 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
CLINIMIX EDEXTROSE (2755) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIX EDEXTROSE (520) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (42510) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (4255) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (515) SOLN INTRAVENOUS HI
CLINIMIXDEXTROSE (520) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI DEXTROSE SOLN DEXTROSE SOLN INTRAVENOUS 5 10 HI
INTRALIPID EMUL INTRAVENOUS HI
N-ACETYL-L-CYSTEINE CAPS MO NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI PROCALAMINE 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
Drug Name RequirementsLimits
chlorthalidone tabs 25mg 50mg MO DIURIL SUSP MO ethacrynic acid tabs MO furosemide soln 8mgml 10mgml MO
furosemide soln injection HI furosemide tabs 20mg 40mg 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 125mg 25mg 50mg MO
indapamide tabs 125mg 25mg MO JYNARQUE TABS 15mg 30mg NDS JYNARQUE TBPK NDS MANNITOL SOLN methyclothiazide tabs MO metolazone tabs 25mg 5mg 10mg MO
OSMITROL SOLN tolvaptan tabs 15mg 30mg 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 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
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 2022 Defined Standard Comprehensive Formulary bull 37
Drug Name RequirementsLimits
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate tabs MO CALCIUM GLUCONATE-NACL SOLN
DEXTROSE IN LACTATED RINGERS SOLN
DEXTROSE-NACL SOLN INTRAVENOUS 25-045 5-02 5-045 5-09
HI
DEXTROSE-NACL SOLN INTRAVENOUS 10-02 10-045
HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ
HI
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ
HI
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 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 PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
POTASSIUM ACETATE SOLN potassium chloride crys er tbcr 10meq 20meq MO
potassium chloride er cpcr 8meq 10meq MO
Drug Name RequirementsLimits
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 10meq100ml 20meq100ml 40meq100ml 2meqml
HI
POTASSIUM PHOSPHATES SOLN
POTASSIUM PHOSPHATES(66 MEQ K) SOLN
RINGERS SOLN SODIUM CHLORIDE (PF) SOLN SODIUM CHLORIDE SOLN 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 ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg 35mg NDS KANUMA SOLN NDS LUMIZYME 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 38 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
miglustat caps NDS NAGLAZYME SOLN NDS NEXVIAZYME SOLR NDS PALYNZIQ SOSY 25mg05ml 10mg05ml 20mgml NDS
PULMOZYME SOLN PANDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg045ml 28mg07ml 80mg08ml 40mgml
LDNDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VPRIV SOLR NDS ZENPEP CPEP MO EYE EAR NOSE AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin oint bacitracin-polymyxin b oint bleph-10 soln chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin 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 paroex soln periogard soln polycin oint polymyxin b-trimethoprim soln
Drug Name RequirementsLimits
sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ANTI-INFLAMMATORY AGENTS bacitra-neomycin-polymyxin-hc oint MO
blephamide sop oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
CEQUA SOLN CIPRODEX SUSP MO ciprofloxacin-dexamethasone susp MO
COLY-MYCIN S SUSP MO cyclosporine emul MO DERMOTIC OIL MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO difluprednate emul MO flac oil 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
ILUVIEN IMPL ketorolac tromethamine soln 04 05 MO
LOTEMAX GEL MO LOTEMAX SUSP MO mometasone furoate susp MO neo-polycin hc oint MO neomycin-polymyxin-dexameth oint 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 2022 Defined Standard Comprehensive Formulary bull 39
Drug Name RequirementsLimits
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO PRED MILD SUSP MO PRED-G SOP OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
RESTASIS EMUL MO RESTASIS MULTIDOSE EMUL MO RETISERT IMPL sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
VERKAZIA EMUL NDS YUTIQ IMPL ANTIALLERGIC AGENTS azelastine hcl soln 005 01 015 MO
azelastine-fluticasone susp MO bepotastine besilate soln MO cromolyn sodium soln MO epinastine hcl soln MO olopatadine hcl soln 01 02 06 MO
ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide sodium solr acetazolamide tabs 125mg 250mg MO
betaxolol hcl soln MO bimatoprost soln MO brimonidine tartrate soln 015 02 MO
brinzolamide susp MO carteolol hcl soln MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
Drug Name RequirementsLimits
dorzolamide hcl-timolol mal soln MO DURYSTA IMPL NDS latanoprost soln MO levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1 2 4 MO timolol maleate (once-daily) soln MO timolol maleate pf soln MO TIMOLOL MALEATE SOLG 025 05 MO
timolol maleate soln 025 05 MO
travoprost (bak free) 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 SUSVIMO (IMPLANT 1ST FILL) SOLN
SUSVIMO (IMPLANT REFILL) SOLN
TEPEZZA SOLR NDS VABYSMO SOLN LOCAL ANESTHETICS ALTACAINE SOLN lidocaine hcl 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
lidocaine viscous hcl soln MO proparacaine hcl soln MO TETRACAINE HCL SOLN GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS ALOSETRON HCL TABS 05mg 1mg NDS
balsalazide disodium caps MO colazal caps 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 OPIUM TINC XERMELO TABS LDNDS ANTIEMETICS aprepitant caps PANDS dimenhydrinate soln doxylamine-pyridoxine tbec MO dronabinol caps 25mg 5mg 10mg PA
fosaprepitant dimeglumine solr granisetron hcl soln granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl sosy ondansetron hcl tabs 4mg 8mg 24mg PA
ondansetron tbdp 4mg 8mg PA palonosetron hcl soln palonosetron hcl sosy
Drug Name RequirementsLimits
SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PANDS trimethobenzamide hcl caps PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc 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 famotidine (pf) soln 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 omeprazole cpdr 10mg 20mg 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium pack MO PANTOPRAZOLE SODIUM SOLR
pantoprazole sodium tbec 20mg 40mg MO
pepcid tabs 20mg 40mg MO PYLERA CAPS MONDS rabeprazole sodium cpsp rabeprazole sodium tbec MO sucralfate susp MO sucralfate 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 2022 Defined Standard Comprehensive Formulary bull 41
Drug Name RequirementsLimits
CATHARTICS AND LAXATIVES gavilyte-c solr MO gavilyte-g solr MO gavilyte-h kit gavilyte-n with flavor pack solr MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350electrolytes solr MO peg-3350electrolytes solr MO PEG-PREP KIT SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS MISCELLANEOUS 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 IBSRELA TABS NDS LIVMARLI SOLN NDS lubiprostone caps 8mcg 24mcg MO metoclopramide hcl soln MO metoclopramide hcl tabs 5mg 10mg MO
metoclopramide hcl tbdp 5mg 10mg MO
OCALIVA TABS 5mg 10mg LDNDS RELISTOR SOLN 8mg04ml 12mg06ml NDS
RELISTOR TABS NDS reltone caps 200mg 400mg NDS TRULANCE TABS 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
Drug Name RequirementsLimits
clovique caps NDS deferasirox granules pack 90mg 180mg 360mg NDS
deferasirox tabs deferasirox tbso deferiprone tabs 500mg 1000mg NDS
deferoxamine mesylate solr FERRIPROX SOLN LDNDS FERRIPROX TABS LDNDS FERRIPROX TWICE-A-DAY TABS NDS
penicillamine caps NDS penicillamine tabs NDS trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ALKINDI SPRINKLE CPSP ALKINDI SPRINKLE CPSP 1mg 2mg 5mg NDS
betamethasone sod phos amp acet susp
budesonide cpep MO budesonide er tb24 NDS cortisone acetate tabs 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 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
EMFLAZA SUSP LDNDS EMFLAZA TABS 6mg 18mg 30mg 36mg LDNDS
fludrocortisone acetate tabs MO hydrocortisone tabs 5mg 10mg 20mg MO
KENALOG SUSP MEDROL TABS MO methylprednisolone acetate susp 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 10mg5ml 20mg5ml 25mg5ml 5mg5ml
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 SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TARPEYO CPDR NDS triamcinolone acetonide susp veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg24hr 4mg24hr MO
danazol caps 50mg 100mg 200mg MO
Drug Name RequirementsLimits
depo-testosterone soln 100mgml 200mgml MO
methitest tabs MO methyltestosterone caps MO oxandrolone tabs MO testosterone cypionate soln 100mgml 200mgml MO
testosterone enanthate soln MO testosterone gel 1 162 2025mg125gm 405mg25gm 10mgact
MO
testosterone soln 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 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 enpresse-28 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 2022 Defined Standard Comprehensive Formulary bull 43
Drug Name RequirementsLimits
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 jasmiel tabs MO JOLIVETTE 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
levonorgest-eth est amp eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
levonorgestrel-ethinyl estrad tabs MO
Drug Name RequirementsLimits
levora 01530 (28) 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 24 fe tabs MO microgestin fe 1530 tabs MO microgestin fe 120 tabs MO mili tabs MO MONONESSA 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 nortrel 0535 (28) tabs MO nortrel 135 (21) tabs MO nortrel 135 (28) tabs MO nortrel 777 tabs MO nylia 135 tabs MO nylia 777 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 44 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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 taysofy caps 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 wymzya fe chew MO xulane ptwk MO zafemy ptwk MO zarah tabs MO zovia 135 (28) tabs MO
Drug Name RequirementsLimits
DIABETIC AGENTS acarbose tabs 25mg 50mg 100mg MO
AFREZZA POWD 90x8 UNIT amp 90x12 UNIT NDS
alogliptin benzoate tabs 625mg 125mg 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO BAQSIMI ONE PACK POWD BAQSIMI TWO PACK POWD 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 glucagon emergency kit glyburide micronized tabs 15mg 3mg 6mg MO
glyburide tabs 125mg 25mg 5mg MO
glyburide-metformin tabs MO HUMALOG KWIKPEN SOPN MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 7030 KWIKPEN SUPN MO
HUMULIN 7030 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
JARDIANCE TABS 10mg 25mg MO KORLYM TABS LDNDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO metformin hcl er tb24 500mg 750mg 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 2022 Defined Standard Comprehensive Formulary bull 45
Drug Name RequirementsLimits
metformin hcl tabs 500mg 850mg 1000mg MO
miglitol tabs 25mg 50mg 100mg MO
nateglinide tabs 60mg 120mg MO OZEMPIC (025 OR 05 MGDOSE) SOPN MO
OZEMPIC (1 MGDOSE) SOPN 2mg15ml 4mg3ml MO
OZEMPIC (2 MGDOSE) SOPN MO pioglitazone hcl tabs 15mg 30mg 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg 2mg MO repaglinide tabs 05mg 1mg 2mg MO
repaglinide-metformin hcl tabs MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO tolazamide tabs 250mg 500mg MO tolbutamide tabs MO TRADJENTA TABS MO VICTOZA SOPN MO ESTROGENS AND ANTIESTROGENS amabelz tabs MO CLIMARA PTWK 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr
MO
depo-estradiol oil dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
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 MO
Drug Name RequirementsLimits
006mg24hr 0075mg24hr 01mg24hr estradiol tabs 10mcg 05mg 1mg 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO ESTRING RING MO fyavolv tabs MO jinteli tabs MO lopreeza tabs MO lyllana pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr
MO
menest tabs 03mg 0625mg 125mg MO
mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO prefest tabs MO PREMARIN SOLR raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
MYFEMBREE TABS NDS ORGOVYX TABS NDS ORILISSA TABS 150mg 200mg NDS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
TERIPARATIDE (RECOMBINANT) SOPN PANDS
TYMLOS SOPN NDS PITUITARY ACTHAR GEL PANDS CORTROPHIN GEL PANDS desmopressin ace spray refrig soln MO
DESMOPRESSIN ACETATE SOLN
desmopressin acetate spray soln desmopressin acetate tabs 01mg 02mg MO
SKYTROFA CART 3mg 36mg 43mg 52mg 63mg 76mg 91mg 11mg 133mg
NDS
STIMATE SOLN MO SYNAREL SOLN MO PROGESTINS aygestin tabs MO 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 progesterone caps 100mg 200mg MO
progesterone oil SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR NDS
Drug Name RequirementsLimits
EGRIFTA SV SOLR NDS GENOTROPIN CART 12mg PANDS GENOTROPIN MINIQUICK PRSY 04mg 06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg
PANDS
HUMATROPE CART 6mg 12mg 24mg PANDS
HUMATROPE SOLR PANDS INCRELEX SOLN NDS LANREOTIDE ACETATE SOLN NDS MYCAPSSA CPDR NDS NORDITROPIN FLEXPRO SOPN 5mg15ml 10mg15ml 15mg15ml 30mg3ml
PANDS
NUTROPIN AQ NUSPIN 10 SOPN PANDS
octreotide acetate soln 50mcgml 100mcgml 200mcgml
octreotide acetate soln 500mcgml 1000mcgml
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 60mg02ml 90mg03ml 120mg05ml
NDS
SOMAVERT SOLR 10mg 15mg 20mg 25mg 30mg LDNDS
ZORBTIVE SOLR PANDS THYROID AND ANTITHYROID AGENTS EUTHYROX TABS 25mcg 50mcg 75mcg 88mcg 100mcg 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 2022 Defined Standard Comprehensive Formulary bull 47
Drug Name RequirementsLimits
112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 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 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
Drug Name RequirementsLimits
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 BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 70mg MO alendronate sodium tabs 5mg 10mg 35mg 40mg MO
EVENITY SOSY NDS IBANDRONATE SODIUM SOLN ibandronate sodium tabs PAMO pamidronate disodium soln pamidronate disodium solr 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 CIBINQO TABS 50mg 100mg 200mg NDS
CIMZIA KIT PANDS CIMZIA PREFILLED PSKT PANDS CIMZIA STARTER KIT PSKT PA ENBREL MINI SOCT NDS ENBREL SOLN NDS ENBREL SOLR PANDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
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
INFLIXIMAB SOLR INTRAVENOUS HI
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 RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 15mg 30mg 45mg NDS
SIMPONI ARIA SOLN NDS
Drug Name RequirementsLimits
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 ENVARSUS XR TB24 075mg 1mg 4mg PAMO
everolimus tabs 025mg PAMO everolimus tabs 05mg 075mg 1mg 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
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 2022 Defined Standard Comprehensive Formulary bull 49
Drug Name RequirementsLimits
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
ZORTRESS TABS PA MISCELLANEOUS THERAPEUTIC AGENTS ACETIC ACID SOLN ACTIMMUNE SOLN AMONDYS 45 SOLN NDS ARCALYST SOLR NDS ARGYLE STERILE WATER SOLN
ARTICADENT DENTAL SOCT BERINERT KIT INTRAVENOUS HI betaine powd NDS 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
Drug Name RequirementsLimits
CYSTAGON CAPS 50mg 150mg LDNDS
dexrazoxane hcl solr EASYGEL GEL ELMIRON CAPS EMPAVELI SOLN NDS ENDARI PACK NDS ENJAYMO SOLN 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 HAEGARDA SOLR 2000unit 3000unit NDS
ISTURISA TABS 1mg 5mg 10mg NDS
KESIMPTA SOAJ NDS KEVEYIS 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
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ONPATTRO SOLN NDS 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
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 PYRUKYND TABS 5mg 20mg 50mg NDS
PYRUKYND TAPER PACK TBPK NDS
RECORLEV TABS NDS REZUROCK TABS NDS
Drug Name RequirementsLimits
RIDAURA CAPS MO RIMSO-50 SOLN RINGERS IRRIGATION SOLN ropivacaine hcl soln 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 STERILE WATER FOR IRRIGATION SOLN
TAKHZYRO SOLN NDS TAKHZYRO SOSY NDS TAVNEOS CAPS NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg 300mg NDS
THIOLA TABS NDS THYROGEN SOLR NDS tiopronin tabs NDS TIS-U-SOL SOLN ULTOMIRIS SOLN VIJOICE TBPK NDS VILTEPSO SOLN NDS VOXZOGO SOLR 04mg 056mg 12mg NDS
VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS VYVGART SOLN NDS WATER FOR IRRIGATION STERILE SOLN
XEOMIN SOLR PANDS XURIDEN PACK NDS xylocaine dental soln ZOKINVY CAPS 50mg 75mg 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 2022 Defined Standard Comprehensive Formulary bull 51
Drug Name RequirementsLimits
RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PAMO DUPIXENT SOPN 200mg114ml 300mg2ml PANDS
DUPIXENT SOSY 100mg067ml 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 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 ADVAIR HFA AERO 230-21mcgact MO
ADVAIR HFA AERO 45-21mcgact 115-21mcgact MO
Drug Name RequirementsLimits
ALVESCO AERS 80mcgact 160mcgact MO
ARALAST NP SOLR INTRAVENOUS HI
ASMANEX HFA AERO 100mcgact 200mcgact MO
BRONCHITOL CAPS NDS budesonide susp 025mg2ml 05mg2ml 1mg2ml PAMO
DALIRESP TABS 250mcg 500mcg MO
FLOVENT HFA AERO MO fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PULMICORT FLEXHALER AEPB
SYMBICORT AERO TEZSPIRE SOSY NDS wixela inhub aepb XOLAIR SOLR PANDS XOLAIR SOSY 75mg05ml 150mgml PANDS
VASODILATING AGENTS ADEMPAS TABS 05mg 1mg 15mg 2mg 25mg PANDS
ambrisentan tabs bosentan tabs epoprostenol sodium solr ORENITRAM TBCR 025mg 1mg 25mg 5mg LDNDS
TRACLEER TBSO NDS treprostinil soln 20mg20ml 50mg20ml 100mg20ml 200mg20ml
PALDNDS
TYVASO REFILL SOLN PALD TYVASO STARTER SOLN PALD UPTRAVI SOLR NDS UPTRAVI TABS 200mcg 400mcg 600mcg 800mcg 1000mcg 1200mcg 1400mcg 1600mcg
NDS
UPTRAVI TBPK NDS
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
VENTAVIS SOLN 10mcgml 20mcgml PALDNDS
SERUMS TOXOIDS AND VACCINES SERUMS ASCENIV SOLN NDS CUTAQUIG SOLN 165gm10ml 2gm12ml 33gm20ml 4gm24ml 8gm48ml 1gm6ml
PANDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS HI
GAMASTAN INJ PA GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS HI
GAMUNEX-C SOLN INJECTION HI HYPERHEP B SOLN HYPERHEP B SOSY HYPERRAB SD SOLN HYQVIA KIT PANDS IMOGAM RABIES-HT SOLN KEDRAB SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 1gm20ml 2gm20ml
HI
PANZYGA SOLN INTRAVENOUS 10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml
HI
VARIZIG SOLN TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP KINRIX SUSY QUADRACEL SUSP TDVAX SUSP
Drug Name RequirementsLimits
TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP BOOSTRIX SUSY 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 SOLN MENQUADFI SOLN MENVEO SOLR PEDIARIX SUSY PEDVAX HIB SUSP PENTACEL SUSR PREHEVBRIO SUSP PA PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg05ml 10mcgml 40mcgml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TICOVAC SUSY TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN TYPHIM VI SOSY VAQTA SUSP VARIVAX INJ
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 2022 Defined Standard Comprehensive Formulary bull 53
Drug Name RequirementsLimits
VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint 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 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 clindamycin phosphate soln MO clindamycin phosphate swab MO clotrimazole crea clotrimazole soln clotrimazole troc clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn crotan lotn econazole nitrate crea ery pads MO erythromycin gel MO erythromycin pads MO erythromycin soln MO EURAX CREA
Drug Name RequirementsLimits
gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea ketoconazole crea ketoconazole foam ketoconazole sham ketodan foam lindane sham mafenide acetate pack malathion lotn metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp miconazole-zinc oxide-petrolat oint
mupirocin calcium crea mupirocin oint naftifine hcl crea naftifine hcl gel neomycin-polymyxin b gu soln nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ovide lotn oxiconazole nitrate crea permethrin crea PR BENZOYL PEROXIDE WASH LIQD
selenium sulfide lotn SELENIUM SULFIDE SHAM SILVER SULFADIAZINE CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL
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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) 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
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
Drug Name RequirementsLimits
clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT 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 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
FLUOCINONIDE GEL MO fluocinonide oint MO fluocinonide soln MO FLURANDRENOLIDE CREA 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 2022 Defined Standard Comprehensive Formulary bull 55
Drug Name RequirementsLimits
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 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 prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO proctosol hc crea MO proctozone-hc crea MO
Drug Name RequirementsLimits
psorcon crea MO RADIAURA CREA NDS texacort soln MO topicort crea 005 025 MO topicort gel MO topicort oint 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 VANOXIDE-HC LOTN WYNZORA CREA NDS ANTIPRURITICS AND LOCAL ANESTHETICS ANA-LEX KIT doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
HYDROCORTISONE ACE-PRAMOXINE SUPP NDS
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 LIDOCAINE-HYDROCORT (PERIANAL) CREA
LIDOCAINE-HYDROCORTISONE ACE KIT
lidocaine-prilocaine crea PAMO lidocaine-tetracaine crea 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 2022 Defined Standard Comprehensive Formulary
Drug Name RequirementsLimits
LIDOCORT CREA lidopin crea LIDOZION LOTN phenazo tabs PHENAZOPYRIDINE HCL TABS
PRAMOX GEL proctofoam hc foam TOPEX TOPICAL ANESTHETIC AERO
ZERUVIA PTCH ZIONODIL 100 LOTN ZIONODIL LOTN CELL STIMULANTS AND PROLIFERANTS 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
TARGRETIN GEL PANDS tretinoin crea 0025 005 01 PAMO
tretinoin gel 001 0025 005 PAMO
tretinoin microsphere gel 004 01 PAMO
tretinoin microsphere pump gel 004 01 PAMO
SKIN AND MUCOUS MEMBRANE AGENTS MISCELLANEOUS 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
Drug Name RequirementsLimits
adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ADAPALENE-BENZOYL PEROXIDE PADS NDS
ADBRY SOSY NDS ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg 20mg 40mg NDS
azelaic acid gel MO AZELEX CREA MO 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
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY 75mg05ml 150mgml NDS
DAPSONE GEL 75 5 MO DIFFERIN CREA 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 KORSUVA SOLN NDS LACTIC ACID LOTN
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 2022 Defined Standard Comprehensive Formulary bull 57
Drug Name RequirementsLimits
methoxsalen rapid caps MO myorisan caps 10mg 20mg 30mg 40mg NDS
OPZELURA CREA 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 SHAM SALICYLIC ACID-CLEANSER KIT
SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SKYRIZI PEN SOAJ SKYRIZI SOSY STELARA SOLN 45mg05ml 130mg26ml PA
STELARA SOSY 45mg05ml 90mgml PA
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 TREMFYA SOPN TREMFYA SOSY UMECTA MOUSSE FOAM UREA CREA 39 UREA LOTN 40 UREA-C40 LOTN uredeb crea VALCHLOR GEL NDS
Drug Name RequirementsLimits
VECTICAL OINT MO XUREA CREA zenatane caps 10mg 20mg 30mg 40mg NDS
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 calcitriol caps 025mcg 05mcg PAMO calcitriol soln PAMO doxercalciferol caps 05mcg 1mcg 25mcg PAMO
DOXERCALCIFEROL SOLN paricalcitol caps 1mcg 2mcg 4mcg PAMO
PARICALCITOL SOLN PRENATAL TABS MO RAYALDEE CPCR NDS
58 bull Kaiser Permanente 2018 Defined Standard Comprehensive Formulary
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
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 59
Index of Drugs
A abacavir sulfate soln 11 abacavir sulfate tabs 11 abacavir sulfate-lamivudine tabs 11 abacavir-lamivudine-zidovudine tabs 11 ABILIFY MAINTENA PRSY 300mg 400mg
32 ABILIFY MAINTENA SRER 300mg 400mg
32 ABILIFY MYCITE MAINTENANCE KIT
TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE STARTER KIT TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
ABILIFY MYCITE TABS 2mg 5mg 10mg 15mg 20mg 30mg 33
abiraterone acetate tabs 250mg 14 abiraterone acetate tabs 500mg 14 ABRAXANE SUSR 14 ABSORICA LD CAPS 8mg 16mg 24mg
32mg 56 acamprosate calcium tbec 25 acarbose tabs 25mg 50mg 100mg 44 accutane caps 10mg 20mg 30mg 40mg 56 acebutolol hcl caps 200mg 400mg 23 acetaminophen-codeine 3 tabs 26 acetaminophen-codeine soln 26 acetaminophen-codeine tabs 26 acetazolamide er cp12 39 acetazolamide sodium solr 39 acetazolamide tabs 125mg 250mg 39 ACETIC ACID SOLN 39 49 acetylcysteine soln 10 20 47 acitretin caps 10mg 175mg 25mg 56 ACTEMRA ACTPEN SOAJ 47 ACTEMRA SOSY 47 ACTHAR GEL 46 ACTHIB SOLR 52 ACTIMMUNE SOLN 49 acyclovir caps 11 acyclovir oint 53 acyclovir sodium soln intravenous 11 acyclovir susp 11
acyclovir tabs 400mg 800mg 11 ADACEL SUSP 52 ADAGEN SOLN 37 ADAKVEO SOLN 20 ADAPALENE CREA 56 adapalene gel 01 03 56 adapalene pads 56 adapalene soln 56 adapalene-benzoyl peroxide gel 56 ADAPALENE-BENZOYL PEROXIDE PADS
56 ADBRY SOSY 56 adderall tabs 28 adefovir dipivoxil tabs 11 ADEMPAS TABS 05mg 1mg 15mg 2mg
25mg 51 adenosine soln 24 adriamycin soln 14 adriamycin solr 14 adrucil soln 14 ADVAIR HFA AERO 230-21mcgact 51 ADVAIR HFA AERO 45-21mcgact 115-
21mcgact 51 AFINITOR DISPERZ TBSO 2mg 3mg 5mg
14 AFINITOR TABS 14 AFREZZA POWD 90x8 UNIT amp 90x12 UNIT
44 AJOVY SOAJ 30 AJOVY SOSY 30 ala-cort crea 1 25 54 albendazole tabs 8 albuterol sulfate er tb12 4mg 8mg 20 ALBUTEROL SULFATE HFA AERS
108mcgact 20 albuterol sulfate nebu 0083
25mg05ml 063mg3ml 125mg3ml 20 albuterol sulfate syrp 20 albuterol sulfate tabs 2mg 4mg 20 alclometasone dipropionate crea 54 alclometasone dipropionate oint 54 ALCOHOL PREP PADS 35 ALDURAZYME SOLN 37 ALECENSA CAPS 14
60 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
alendronate sodium soln 47 alendronate sodium tabs 5mg 10mg
35mg 40mg 47 alendronate sodium tabs 70mg 47 alfuzosin hcl er tb24 20 ALIMTA SOLR 14 ALIQOPA SOLR 14 aliskiren fumarate tabs 150mg 300mg 25 ALKINDI SPRINKLE CPSP 41 ALKINDI SPRINKLE CPSP 1mg 2mg 5mg
41 allopurinol sodium solr 47 allopurinol tabs 100mg 300mg 47 allzital tabs 26 almotriptan malate tabs 30 alogliptin benzoate tabs 625mg 125mg
25mg 44 ALOGLIPTIN-METFORMIN HCL TABS 44 alogliptin-pioglitazone tabs 44 ALOSETRON HCL TABS 05mg 1mg 40 alprazolam er tb24 05mg 1mg 2mg 3mg
31 alprazolam intensol conc 31 alprazolam tabs 025mg 05mg 1mg 2mg
31 alprazolam tbdp 025mg 05mg 1mg 2mg
31 ALTACAINE SOLN 39 ALTAFRIN SOLN 39 altavera tabs 42 ALUNBRIG TABS 30mg 90mg 180mg 14 ALUNBRIG TBPK 14 ALVESCO AERS 80mcgact 160mcgact 51 alyacen 135 tabs 42 alyq tabs 25 amabelz tabs 45 amantadine hcl caps 30 amantadine hcl soln 30 amantadine hcl tabs 30 AMBISOME SUSR INTRAVENOUS 10 ambrisentan tabs 51 amcinonide crea 54 amcinonide lotn 54 amcinonide oint 54 amethia lo tabs 42 amethia tabs 42 amikacin sulfate soln 8 amikacin sulfate soln injection 8 AMILORIDE HCL TABS 36
amiloride-hydrochlorothiazide tabs 36 aminocaproic acid soln 21 aminocaproic acid tabs 500mg 1000mg 21 aminophylline soln 57 amiodarone hcl soln 24 amiodarone hcl tabs 100mg 200mg
400mg 24 amitriptyline hcl tabs 10mg 25mg 50mg
75mg 100mg 150mg 33 amlodipine besy-benazepril hcl caps 23 amlodipine besylate tabs 25mg 5mg
10mg 23 amlodipine besylate-valsartan tabs 23 amlodipine-atorvastatin tabs 23 amlodipine-olmesartan tabs 23 amlodipine-valsartan-hctz tabs 23 ammonium lactate crea 56 ammonium lactate lotn 56 amnesteem caps 10mg 20mg 40mg 56 AMONDYS 45 SOLN 49 amoxapine tabs 25mg 50mg 100mg
150mg 33 amoxicill-clarithro-lansopraz misc 40 amoxicillin caps 8 amoxicillin chew 8 amoxicillin susr 8 amoxicillin tabs 8 amoxicillin-pot clavulanate chew 8 amoxicillin-pot clavulanate er tb12 8 amoxicillin-pot clavulanate susr 8 amoxicillin-pot clavulanate tabs 8 amphetamine er suer 28 amphetamine sulfate tabs 5mg 10mg 28 amphetamine-dextroamphet er cp24 28 amphetamine-dextroamphetamine tabs 28 amphotericin b solr intravenous 10 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 42 anagrelide hcl caps 05mg 1mg 21 ANA-LEX KIT 55 anastrozole tabs 14
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 61
ANDRODERM PT24 2mg24hr 4mg24hr 42
antabuse tabs 250mg 500mg 25 anusol-hc crea 54 apap-caff-dihydrocodeine tabs 26 apexicon e crea 54 APLENZIN TB24 174mg 348mg 522mg 33 APOKYN SOCT 30 apomorphine hcl soct 30 apraclonidine hcl soln 39 aprepitant caps 40 APRETUDE SUER 11 apri tabs 42 APTIOM TABS 200mg 400mg 600mg
800mg 28 APTIVUS CAPS 11 APTIVUS SOLN 11 ARALAST NP SOLR INTRAVENOUS 51 aranelle tabs 42 ARANESP (ALBUMIN FREE) SOLN
60mcgml 100mcgml 200mcgml 21 ARANESP (ALBUMIN FREE) SOSY
60mcg03ml 150mcg03ml 200mcg04ml 100mcg05ml 300mcg06ml 500mcgml 21
ARCALYST SOLR 49 arformoterol tartrate nebu 20 argatroban soln 21 ARGYLE STERILE WATER SOLN 49 ARIKAYCE SUSP 8 aripiprazole soln 33 aripiprazole tabs 2mg 5mg 10mg 15mg
20mg 30mg 33 aripiprazole tbdp 10mg 15mg 33 ARISTADA INITIO PRSY 33 ARISTADA PRSY 441mg16ml
662mg24ml 882mg32ml 1064mg39ml 33
armodafinil tabs 50mg 150mg 200mg 250mg 28
arsenic trioxide soln 14 ARTESUNATE SOLR 11 ARTICADENT DENTAL SOCT 49 ARZERRA CONC 1000mg50ml
100mg5ml 14 ASCENIV SOLN 52 ascomp-codeine caps 26 asenapine maleate subl 25mg 5mg 10mg
33
ashlyna tabs 42 ASMANEX HFA AERO 100mcgact
200mcgact 51 ASPARLAS SOLN 14 aspirin-dipyridamole er cp12 21 ASTAGRAF XL CP24 48 ASTAGRAF XL CP24 05mg 1mg 48 atazanavir sulfate caps 150mg 200mg
300mg 11 atenolol tabs 25mg 50mg 100mg 23 atenolol-chlorthalidone tabs 23 atomoxetine hcl caps 10mg 18mg 25mg
40mg 60mg 80mg 100mg 31 atorvastatin calcium tabs 10mg 20mg
40mg 80mg 22 atovaquone susp 11 atovaquone-proguanil hcl tabs 11 ATROPINE SULFATE SOLN 19 39 ATROPINE SULFATE SOSY 19 ATROVENT HFA AERS 19 AUBAGIO TABS 7mg 14mg 32 aubra eq tabs 42 AUGMENTIN SUSR 8 AURYXIA TABS 36 AUSTEDO TABS 6mg 9mg 12mg 31 AVASTIN SOLN 14 AVC VAGINAL CREA 53 aviane tabs 42 AVITA CREA 56 AVITA GEL 56 AVONEX KIT 32 AVONEX PEN AJKT 32 AVONEX PREFILLED PSKT 32 AVSOLA SOLR 47 aygestin tabs 46 AYVAKIT TABS 25mg 50mg 100mg
200mg 300mg 14 azacitidine susr 14 azasan tabs 75mg 100mg 48 azathioprine sodium solr 48 azathioprine tabs 48 azelaic acid gel 56 azelastine hcl soln 005 01 015 39 azelastine-fluticasone susp 39 AZELEX CREA 56 azithromycin solr intravenous 8 azithromycin susr 100mg5ml 200mg5ml 8 azithromycin tabs 250mg 500mg 600mg 8 aztreonam solr injection 8
62 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
B bacitracin oint 38 bacitracin solr 8 bacitracin-polymyxin b oint 38 bacitra-neomycin-polymyxin-hc oint 38 baclofen soln 20 baclofen tabs 5mg 10mg 20mg 20 BACTROBAN NASAL OINT 53 BAFIERTAM CPDR 32 balsalazide disodium caps 40 BALVERSA TABS 3mg 4mg 5mg 14 balziva tabs 42 BANZEL SUSP 28 BANZEL TABS 200mg 400mg 28 BAQSIMI ONE PACK POWD 44 BAQSIMI TWO PACK POWD 44 BARACLUDE SOLN 11 BAVENCIO SOLN 14 BCG VACCINE SOLR 14 BD INSULIN SYR ULTRAFINE II MISC 35 BD INSULIN SYRINGE MISC 35 BD INSULIN SYRINGE UF MISC 35 BD PEN NEEDLE ORIGINAL UF MISC 35 BELBUCA FILM 75mcg 150mcg 300mcg
450mcg 600mcg 750mcg 900mcg 32 BELEODAQ SOLR 14 BELRAPZO SOLN 14 benazepril hcl tabs 5mg 10mg 20mg
40mg 25 benazepril-hydrochlorothiazide tabs 25 BENDAMUSTINE HCL SOLN 14 BENDEKA SOLN 14 BENLYSTA SOAJ 48 BENLYSTA SOLR 48 BENLYSTA SOSY 48 BENZEPRO CREAMY WASH LIQD 53 BENZEPRO FOAMING CLOTHS MISC 53 benzhydrocodone-acetaminophen tabs 26 benzoyl perox-hydrocortisone lotn 54 BENZOYL PEROXIDE FORTE- HC LOTN
54 BENZOYL PEROXIDE GEL 53 benzoyl peroxide-erythromycin gel 53 benztropine mesylate soln 30 benztropine mesylate tabs 05mg 1mg
2mg 30 BEOVU SOLN 39 bepotastine besilate soln 39
BERINERT KIT INTRAVENOUS 49 beser lotn 54 BESPONSA SOLR 14 BESREMI SOSY 14 betaine powd 49 betamethasone dipropionate aug crea 54 betamethasone dipropionate aug gel 54 betamethasone dipropionate aug lotn 54 betamethasone dipropionate aug oint 54 betamethasone dipropionate crea 54 betamethasone dipropionate lotn 54 BETAMETHASONE DIPROPIONATE OINT
54 betamethasone sod phos amp acet susp 41 betamethasone valerate crea 54 betamethasone valerate foam 54 BETAMETHASONE VALERATE LOTN 54 BETAMETHASONE VALERATE OINT 54 BETASERON KIT 32 betaxolol hcl soln 39 betaxolol hcl tabs 10mg 20mg 23 bethanechol chloride tabs 5mg 10mg
25mg 50mg 19 bexarotene caps 14 BEXSERO SUSY 52 bicalutamide tabs 14 BICILLIN C-R 900300 SUSP 8 BICILLIN C-R SUSP 8 BICILLIN L-A SUSP 8 BICILLIN L-A SUSY 8 BIKTARVY TABS 11 bimatoprost soln 39 bisoprolol fumarate tabs 5mg 10mg 23 bisoprolol-hydrochlorothiazide tabs 23 bleomycin sulfate solr 14 bleph-10 soln 38 blephamide sop oint 38 BLEPHAMIDE SUSP 38 BLINCYTO SOLR 14 blisovi 24 fe tabs 42 blisovi fe 1530 tabs 42 BOOSTRIX SUSP 52 BOOSTRIX SUSY 52 BORTEZOMIB SOLR 14 bosentan tabs 51 BOSULIF TABS 100mg 400mg 500mg 14 BRAFTOVI CAPS 50mg 75mg 14 briellyn tabs 42 BRILINTA TABS 60mg 90mg 21
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 63
brimonidine tartrate soln 015 02 39 brinzolamide susp 39 BRIVIACT SOLN 28 BRIVIACT TABS 10mg 25mg 50mg
75mg 100mg 28 bromfenac sodium (once-daily) soln 38 bromocriptine mesylate caps 30 bromocriptine mesylate tabs 30 BRONCHITOL CAPS 51 BROVANA NEBU 20 BRUKINSA CAPS 14 budesonide cpep 41 budesonide er tb24 41 budesonide susp 025mg2ml 05mg2ml
1mg2ml 51 bumetanide soln 36 bumetanide tabs 05mg 1mg 2mg 36 bupap tabs 26 bupivacaine hcl (pf) soln 49 bupivacaine hcl soln 49 BUPIVACAINE IN DEXTROSE SOLN 49 bupivacaine spinal soln 49 bupivacaine-epinephrine (pf) soln 49 bupivacaine-epinephrine soln 49 buprenorphine hcl subl 2mg 8mg 32 buprenorphine hcl-naloxone hcl film 32 buprenorphine hcl-naloxone hcl subl 32 buprenorphine ptwk 5mcghr 75mcghr
10mcghr 15mcghr 20mcghr 32 bupropion hcl er (smoking det) tb12 33 bupropion hcl er (sr) tb12 100mg 150mg
200mg 33 bupropion hcl er (xl) tb24 150mg 300mg
450mg 33 bupropion hcl tabs 75mg 100mg 33 buspirone hcl tabs 5mg 10mg 31 buspirone hcl tabs 75mg 15mg 30mg 31 busulfan soln 14 butalbital-acetaminophen tabs 26 butalbital-apap-caff-cod caps 26 butalbital-apap-caffeine caps 26 butalbital-apap-caffeine tabs 26 butalbital-asa-caff-codeine caps 26 butalbital-aspirin-caffeine caps 26 butalbital-aspirin-caffeine tabs 26 butorphanol tartrate soln 26 BYLVAY (PELLETS) CPSP 200mcg
600mcg 41 BYLVAY CAPS 400mcg 1200mcg 41
C CABENUVA SUER 11 cabergoline tabs 30 CABLIVI KIT 21 CABOMETYX TABS 20mg 40mg 60mg 14 cafergot tabs 30 caffeine citrate soln 28 calcipotriene crea 56 calcipotriene oint 56 calcipotriene soln 56 calcipotriene-betameth diprop oint 54 calcipotriene-betameth diprop susp 54 calcitonin (salmon) soln 45 calcitrene oint 56 calcitriol caps 025mcg 05mcg 57 CALCITRIOL OINT 56 calcitriol soln 57 calcium acetate (phos binder) caps 37 calcium acetate tabs 37 CALCIUM GLUCONATE-NACL SOLN 37 CALQUENCE CAPS 14 CAMCEVI PRSY 14 camila tabs 42 camrese lo tabs 42 candesartan cilexetil tabs 4mg 8mg 16mg
32mg 25 candesartan cilexetil-hctz tabs 25 CAPASTAT SULFATE SOLR 11 CAPEX SHAM 54 CAPLYTA CAPS 33 CAPRELSA TABS 100mg 300mg 14 captopril tabs 125mg 25mg 50mg 100mg
25 captopril-hydrochlorothiazide tabs 25 CARAC CREA 56 carbamazepine chew 28 carbamazepine er cp12 100mg 200mg
300mg 28 carbamazepine er tb12 100mg 200mg
400mg 28 carbamazepine susp 28 carbamazepine tabs 28 carbidopa tabs 30 carbidopa-levodopa er tbcr 30 carbidopa-levodopa tabs 30 carbidopa-levodopa tbdp 30 carbidopa-levodopa-entacapone tabs 30 carbinoxamine maleate soln 13
64 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
carbinoxamine maleate tabs 13 carboplatin soln 14 carboprost tromethamine soln 45 CARDENE IV SOLN 23 carglumic acid tbso 35 carisoprodol tabs 250mg 350mg 20 carisoprodol-aspirin tabs 20 carisoprodol-aspirin-codeine tabs 20 carmustine solr 14 CARNITOR SOLN 49 CARNITOR TABS 49 carteolol hcl soln 39 cartia xt cp24 120mg 180mg 240mg
300mg 23 carvedilol phosphate er cp24 10mg 20mg
40mg 80mg 23 carvedilol tabs 3125mg 625mg 125mg
25mg 23 caspofungin acetate solr intravenous 50mg
70mg 10 CAYSTON SOLR 51 caziant tabs 42 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 intravenous 1gm 2gm
10gm 8 cefpodoxime proxetil susr 8 cefpodoxime proxetil tabs 8 cefprozil susr 8 cefprozil tabs 8 ceftazidime solr injection 1gm 6gm 8 ceftazidime solr intravenous 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 750mg 8 cefuroxime sodium solr intravenous 15gm 8 celecoxib caps 26 CELONTIN CAPS 29 cephalexin caps 8 cephalexin susr 8 cephalexin tabs 8 CEQUA SOLN 38 CERDELGA CAPS 37 CEREZYME SOLR 37 CEROVEL LOTN 56 cetirizine hcl soln 13 CEVIMELINE HCL CAPS 19 CHANTIX CONTINUING MONTH PAK
TABS 19 CHANTIX STARTING MONTH PAK TABS
19 CHANTIX TABS 05mg 1mg 19 CHEMET CAPS 41 chloramphenicol sod succinate solr 8 chlordiazepoxide hcl caps 5mg 10mg
25mg 31 chlordiazepoxide-amitriptyline tabs 33 chlordiazepoxide-clidinium caps 19 chlorhexidine gluconate soln 38 chloroprocaine hcl (pf) soln 49 chloroquine phosphate tabs 250mg 500mg
11 chlorothiazide sodium solr 36 chlorothiazide tabs 250mg 500mg 36 chlorpromazine hcl conc 30mgml
100mgml 33 chlorpromazine hcl soln 33 chlorpromazine hcl tabs 10mg 25mg
50mg 100mg 200mg 33 chlorthalidone tabs 25mg 50mg 36 chlorzoxazone tabs 375mg 500mg 750mg
20 CHOLBAM CAPS 50mg 250mg 41 cholestyramine light pack 22 cholestyramine light powd 22 cholestyramine pack 22 cholestyramine powd 22 CHORIONIC GONADOTROPIN SOLR 45 CIBINQO TABS 50mg 100mg 200mg 47 ciclopirox gel 53 ciclopirox olamine crea 53
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 65
ciclopirox olamine susp 53 ciclopirox sham 53 ciclopirox soln 53 cidofovir soln 11 cilostazol tabs 50mg 100mg 21 CILOXAN OINT 38 CIMDUO TABS 11 cimetidine hcl soln 40 cimetidine tabs 200mg 300mg 400mg
800mg 40 CIMZIA KIT 47 CIMZIA PREFILLED PSKT 47 CIMZIA STARTER KIT PSKT 47 cinacalcet hcl tabs 30mg 60mg 90mg 45 CINQAIR SOLN 51 CINRYZE SOLR INTRAVENOUS 49 CIPRODEX SUSP 38 ciprofloxacin hcl soln (ophth) 38 CIPROFLOXACIN HCL SOLN (OTIC) 38 ciprofloxacin hcl tabs 8 ciprofloxacin in d5w soln 8 9 ciprofloxacin in d5w soln intravenous 9 ciprofloxacin susr 9 ciprofloxacin-ciproflox hcl er tb24 9 ciprofloxacin-dexamethasone susp 38 cisplatin soln 14 CISPLATIN SOLR 50mg 14 CITALOPRAM HYDROBROMIDE CAPS 33 citalopram hydrobromide soln 33 citalopram hydrobromide tabs 10mg 20mg
40mg 33 citanest plain dental soln 49 cladribine soln 14 claravis caps 10mg 20mg 30mg 40mg 56 clarithromycin er tb24 9 clarithromycin susr 9 clarithromycin tabs 9 clemastine fumarate tabs 13 cleocin phosphate soln 9 cleocin solr 9 CLIMARA PTWK 375mcg24hr
0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
clindacin-p swab 53 clindamycin hcl caps 9 clindamycin palmitate hcl solr 9 clindamycin phos-benzoyl perox gel 53 clindamycin phosphate crea 53
clindamycin phosphate foam 53 clindamycin phosphate gel 53 clindamycin phosphate in d5w soln
intravenous 9 clindamycin phosphate lotn 53 clindamycin phosphate soln 9 53 clindamycin phosphate soln injection
300mg2ml 600mg4ml 900mg6ml 9 clindamycin phosphate swab 53 CLINIMIX EDEXTROSE (2755) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIX EDEXTROSE (520) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (42510) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (4255) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (515) SOLN
INTRAVENOUS 36 CLINIMIXDEXTROSE (520) SOLN
INTRAVENOUS 36 clinisol sf soln intravenous 36 clobazam susp 29 clobazam tabs 10mg 20mg 29 clobetasol propionate crea 54 clobetasol propionate e crea 54 clobetasol propionate emulsion foam 54 clobetasol propionate foam 54 clobetasol propionate gel 54 clobetasol propionate liqd 54 clobetasol propionate lotn 54 clobetasol propionate oint 54 clobetasol propionate sham 54 clobetasol propionate soln 54 clocortolone pivalate crea 54 clocortolone pivalate pump crea 54 clofarabine soln 14 clomipramine hcl caps 25mg 50mg 75mg
33 clonazepam tabs 05mg 1mg 2mg 29 clonazepam tbdp 0125mg 025mg 05mg
1mg 2mg 29 clonidine hcl (analgesia) soln 24
66 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
clonidine hcl er tb12 24 clonidine hcl tabs 01mg 02mg 03mg 24 clonidine ptwk 01mg24hr 02mg24hr
03mg24hr 24 clopidogrel bisulfate tabs 75mg 300mg 21 clorazepate dipotassium tabs 375mg
75mg 15mg 31 clotrimazole crea 53 clotrimazole soln 53 clotrimazole troc 53 clotrimazole-betamethasone crea 53 clotrimazole-betamethasone lotn 53 clovique caps 41 clozapine tabs 25mg 50mg 100mg 200mg
33 clozapine tbdp 125mg 25mg 100mg
150mg 200mg 33 COARTEM TABS 11 CODEINE SULFATE TABS 15mg 30mg
60mg 26 colazal caps 40 COLCHICINE CAPS 47 colchicine tabs 47 colchicine-probenecid tabs 37 COLESEVELAM HCL PACK 22 colesevelam hcl tabs 22 colestipol hcl gran 22 colestipol hcl pack 22 colestipol hcl tabs 22 colistimethate sodium (cba) solr injection 9 colocort enem 54 COLY-MYCIN S SUSP 38 COMBIVENT RESPIMAT AERS 20 COMETRIQ (100 MG DAILY DOSE) KIT 14 COMETRIQ (140 MG DAILY DOSE) KIT 14 COMETRIQ (60 MG DAILY DOSE) KIT 14 COMPLERA TABS 11 compro supp 33 CONSENSI TABS 23 constulose soln 35 COPIKTRA CAPS 15mg 25mg 14 CORDRAN TAPE 54 CORLANOR SOLN 24 CORLANOR TABS 5mg 75mg 24 cortisone acetate tabs 41 CORTISPORIN CREA 54 CORTISPORIN OINT 54 CORTROPHIN GEL 46 COSELA SOLR 49
COSENTYX (300 MG DOSE) SOSY 56 COSENTYX SENSOREADY (300 MG)
SOAJ 56 COSENTYX SENSOREADY PEN SOAJ 56 COSENTYX SOSY 75mg05ml 150mgml
56 COTELLIC TABS 14 CREON CPEP 37 CRESEMBA CAPS 10 CRESEMBA SOLR 10 CRIXIVAN CAPS 200mg 400mg 11 cromolyn sodium conc 51 cromolyn sodium nebu 51 cromolyn sodium soln 39 crotan lotn 53 cryselle-28 tabs 42 CRYSVITA SOLN 10mgml 20mgml
30mgml 49 CURITY GAUZE PADS 35 CUTAQUIG SOLN 165gm10ml 2gm12ml
33gm20ml 4gm24ml 8gm48ml 1gm6ml 52
cyclafem 135 tabs 42 cyclafem 777 tabs 42 cyclobenzaprine hcl er cp24 15mg 30mg 20 cyclobenzaprine hcl tabs 5mg 75mg
10mg 20 CYCLOPHOSPHAMIDE CAPS 25mg
50mg 14 CYCLOPHOSPHAMIDE SOLN 2gm10ml
1gm5ml 500mg25ml 15 cyclophosphamide solr 15 cycloserine caps 11 cyclosporine caps 25mg 100mg 48 cyclosporine emul 38 cyclosporine modified caps 25mg 50mg
100mg 48 cyclosporine modified soln 48 cyclosporine soln 48 cyproheptadine hcl syrp 13 cyproheptadine hcl tabs 13 CYRAMZA SOLN 100mg10ml
500mg50ml 15 CYSTADANE POWD 49 CYSTADROPS SOLN 39 CYSTAGON CAPS 50mg 150mg 49 CYSTARAN SOLN 39 cytarabine (pf) soln 15 cytarabine soln 15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 67
CYTOGAM INJ 52
D dacarbazine solr 15 dactinomycin solr 15 dalfampridine er tb12 32 DALIRESP TABS 250mcg 500mcg 51 DALVANCE SOLR INTRAVENOUS 9 danazol caps 50mg 100mg 200mg 42 dantrolene sodium caps 20 dantrolene sodium solr 20 DANYELZA SOLN 15 DAPSONE GEL 75 5 56 dapsone tabs 25mg 100mg 11 DAPTACEL SUSP 52 daptomycin solr intravenous 350mg 500mg
9 darifenacin hydrobromide er tb24 75mg
15mg 57 DARZALEX FASPRO SOLN 15 DARZALEX SOLN 400mg20ml 100mg5ml
15 daunorubicin hcl soln 15 DAURISMO TABS 25mg 100mg 15 deblitane tabs 42 decadron tabs 5mg 75mg 41 decadron tabs 4mg 6mg 41 decitabine solr 15 deferasirox granules pack 90mg 180mg
360mg 41 deferasirox tabs 41 deferasirox tbso 41 deferiprone tabs 500mg 1000mg 41 deferoxamine mesylate solr 41 DELSTRIGO TABS 11 deltasone tabs 41 delyla tabs 42 demeclocycline hcl tabs 9 DEMSER CAPS 22 depo-estradiol oil 45 DEPO-MEDROL SUSP 41 DEPO-PROVERA SUSP 400mgml 46 DEPO-SUBQ PROVERA 104 SUSY 46 depo-testosterone soln 100mgml
200mgml 42 DERMOTIC OIL 38 DESCOVY TABS 120-15mg 11 DESCOVY TABS 200-25mg 11
desipramine hcl tabs 10mg 25mg 50mg 75mg 100mg 150mg 33
desloratadine tabs 13 desloratadine tbdp 13 desmopressin ace spray refrig soln 46 DESMOPRESSIN ACETATE SOLN 46 desmopressin acetate spray soln 46 desmopressin acetate tabs 01mg 02mg 46 desogestrel-ethinyl estradiol tabs 42 desonide crea 54 desonide gel 54 desonide lotn 54 desonide oint 54 desowen lotn 54 desoximetasone crea 005 025 54 desoximetasone gel 54 desoximetasone liqd 54 desoximetasone oint 005 025 54 desrx gel 54 DESVENLAFAXINE ER TB24 50mg
100mg 33 desvenlafaxine succinate er tb24 25mg
50mg 100mg 33 dexabliss tbpk 41 dexamethasone elix 41 dexamethasone intensol conc 41 dexamethasone sodium phosphate soln 38
41 dexamethasone soln 41 dexamethasone tabs 05mg 075mg 1mg
15mg 2mg 4mg 6mg 41 dexamethasone tbpk 41 dexchlorpheniramine maleate soln 13 dexmethylphenidate hcl er cp24 5mg
10mg 15mg 20mg 25mg 30mg 35mg 40mg 28
dexmethylphenidate hcl tabs 25mg 5mg 10mg 28
dexpak 10 day tbpk 41 dexpak 13 day tbpk 41 dexpak 6 day tbpk 41 dexrazoxane hcl solr 49 dextroamphetamine sulfate er cp24 5mg
10mg 15mg 28 dextroamphetamine sulfate soln 28 dextroamphetamine sulfate tabs 5mg
10mg 15mg 20mg 30mg 28 DEXTROSE IN LACTATED RINGERS
SOLN 37
68 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
DEXTROSE SOLN 36 DEXTROSE SOLN INTRAVENOUS 5
10 36 DEXTROSE-NACL SOLN INTRAVENOUS
10-02 10-045 37 DEXTROSE-NACL SOLN INTRAVENOUS
25-045 5-02 5-045 5-09 37 DIACOMIT CAPS 250mg 500mg 29 DIACOMIT PACK 250mg 500mg 29 DIASTAT ACUDIAL GEL 10mg 20mg 29 DIASTAT PEDIATRIC GEL 29 diazepam conc 31 diazepam gel 25mg 10mg 20mg 29 diazepam intensol conc 31 diazepam soln 5mg5ml 5mgml 31 diazepam tabs 2mg 5mg 10mg 31 diazoxide susp 44 diclofenac sodium er tb24 26 diclofenac sodium gel 1 3 54 diclofenac sodium soln 38 diclofenac sodium tbec 26 diclofenac-misoprostol tbec 26 dicloxacillin sodium caps 9 dicyclomine hcl caps 19 dicyclomine hcl soln 19 dicyclomine hcl tabs 19 didanosine cpdr 200mg 250mg 400mg 11 DIFFERIN CREA 56 DIFICID SUSR 9 DIFICID TABS 9 diflorasone diacetate crea 54 diflorasone diacetate oint 54 diflunisal tabs 26 difluprednate emul 38 digitek tabs 0125mg 025mg 24 digox tabs 24 digoxin soln 24 digoxin tabs 125mcg 250mcg 24 dihydroergotamine mesylate soln 20 dilantin caps 30mg 100mg 29 dilantin infatabs chew 29 diltiazem hcl er beads cp24 120mg 180mg
240mg 300mg 360mg 420mg 23 DILTIAZEM HCL ER COATED BEADS
CP24 120mg 180mg 240mg 300mg 360mg 23
diltiazem hcl er coated beads tb24 180mg 240mg 300mg 360mg 420mg 23
diltiazem hcl er cp12 60mg 90mg 120mg 23
diltiazem hcl er cp24 120mg 180mg 240mg 23
diltiazem hcl soln 23 diltiazem hcl solr 23 diltiazem hcl tabs 30mg 60mg 90mg
120mg 23 dilt-xr cp24 120mg 180mg 240mg 23 dimenhydrinate soln 40 dimethyl fumarate cpdr 32 dimethyl fumarate starter pack misc 32 DIPENTUM CAPS 40 diphen elix 13 di-phen elix 13 diphenhydramine hcl elix 13 diphenhydramine hcl soln 14 diphenoxylate-atropine liqd 40 diphenoxylate-atropine tabs 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP 52 dipyridamole tabs 25mg 50mg 75mg 25 disopyramide phosphate caps 100mg
150mg 24 disulfiram tabs 250mg 500mg 26 DIURIL SUSP 36 divalproex sodium csdr 29 divalproex sodium er tb24 250mg 500mg29 divalproex sodium tbec 125mg 250mg
500mg 29 dobutamine hcl soln 20 DOBUTAMINE IN D5W SOLN 20 DOCETAXEL (NON-ALCOHOL) SOLN
80mg4ml 20mgml 15 docetaxel conc 15 docetaxel soln 15 dofetilide caps 125mcg 250mcg 500mcg
24 dolishale tabs 42 donepezil hcl tabs 5mg 10mg 23mg 19 donepezil hcl tbdp 5mg 10mg 19 dopamine hcl soln 20 DOPAMINE IN D5W SOLN 20 DOPTELET TABS 21 dorzolamide hcl soln 39 dorzolamide hcl-timolol mal pf soln 39 dorzolamide hcl-timolol mal soln 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 69
dotti pttw 0025mg24hr 00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
DOVATO TABS 12 doxazosin mesylate tabs 1mg 2mg 4mg
8mg 22 doxepin hcl caps 10mg 25mg 50mg
75mg 100mg 150mg 33 doxepin hcl conc 33 doxepin hcl crea 55 doxepin hcl tabs 3mg 6mg 33 doxercalciferol caps 05mcg 1mcg 25mcg
57 DOXERCALCIFEROL SOLN 57 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
150mg 9 doxycycline monohydrate susr 9 doxycycline monohydrate tabs 50mg
75mg 100mg 150mg 9 doxylamine-pyridoxine tbec 40 DRIZALMA SPRINKLE CSDR 33 dronabinol caps 25mg 5mg 10mg 40 droperidol soln 31 drospiren-eth estrad-levomefol tabs 42 drospirenone-ethinyl estradiol tabs 42 DROXIA CAPS 15 droxidopa caps 20 DUAKLIR PRESSAIR AEPB 19 DUEXIS TABS 26 duloxetine hcl cpep 20mg 30mg 40mg
60mg 33 DUPIXENT SOPN 200mg114ml
300mg2ml 51 DUPIXENT SOSY 100mg067ml
200mg114ml 300mg2ml 51 DURYSTA IMPL 39 dutasteride caps 47 dutasteride-tamsulosin hcl caps 47 dvorah tabs 26 dxevo 11-day tbpk 41
E ees 400 tabs 9 EASYGEL GEL 49 econazole nitrate crea 53 EDURANT TABS 12 efavirenz caps 50mg 200mg 12 efavirenz tabs 12 efavirenz-emtricitab-tenofovir tabs 12 EGRIFTA SOLR 46 EGRIFTA SV SOLR 46 ELAPRASE SOLN 37 ELELYSO SOLR 37 ELEPSIA XR TB24 1000mg 1500mg 29 eletriptan hydrobromide tabs 30 ELIGARD KIT 15 ELIQUIS TABS 21 ELITEK SOLR 37 elixophyllin elix 57 ELLA TABS 42 ELLENCE SOLN 15 ELMIRON CAPS 49 eluryng ring 42 ELZONRIS SOLN 15 EMCYT CAPS 15 EMFLAZA SUSP 42 EMFLAZA TABS 6mg 18mg 30mg 36mg
42 EMPAVELI SOLN 49 EMPLICITI SOLR 300mg 400mg 15 EMSAM PT24 6mg24hr 9mg24hr
12mg24hr 30 emtricitabine caps 12 emtricitabine-tenofovir df tabs 12 EMTRIVA SOLN 12 emverm chew 8 enalapril maleate tabs 25mg 5mg 10mg
20mg 25 enalaprilat inj 25 enalapril-hydrochlorothiazide tabs 25 ENBREL MINI SOCT 47 ENBREL SOLN 47 ENBREL SOLR 47 ENBREL SOSY 25mg05ml 50mgml 48 ENBREL SURECLICK SOAJ 48 ENDARI PACK 49 endocet tabs 26 ENDOMETRIN INST 46
70 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ENGERIX-B SUSP 10mcg05ml 20mcgml 52
ENHERTU SOLR 15 ENJAYMO SOLN 49 enoxaparin sodium soln 21 enoxaparin sodium sosy 30mg03ml
40mg04ml 60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
enpresse-28 tabs 42 ENSPRYNG SOSY 49 ENSTILAR FOAM 54 entacapone tabs 30 entecavir tabs 05mg 1mg 12 ENTRESTO TABS 25 ENTYVIO SOLR 41 enulose soln 35 ENVARSUS XR TB24 075mg 1mg 4mg48 EPCLUSA PACK 12 EPCLUSA TABS 12 EPIDIOLEX SOLN 29 epifoam foam 54 epinastine hcl soln 39 epinephrine (anaphylaxis) soln 20 epinephrine soaj 20 EPINEPHRINE SOSY 20 epirubicin hcl soln 15 EPIVIR HBV SOLN 12 eplerenone tabs 25mg 50mg 25 EPOGEN SOLN 21 EPOGEN SOLN 2000unitml 3000unitml
4000unitml 10000unitml 21 epoprostenol sodium solr 51 EPRONTIA SOLN 29 eprosartan mesylate tabs 25 eptifibatide soln 21 EQUETRO CP12 100mg 200mg 300mg 33 ERBITUX SOLN 15 ergoloid mesylates tabs 20 ergomar subl 20 ergotamine-caffeine tabs 30 ERIVEDGE CAPS 15 ERLEADA TABS 15 erlotinib hcl tabs 25mg 100mg 150mg 15 errin tabs 43 ertapenem sodium solr injection 9 ERWINASE SOLR 15 ERWINAZE SOLR 15 ery pads 53 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 53 erythromycin oint 38 erythromycin pads 53 erythromycin soln 53 erythromycin tbec 9 ESBRIET CAPS 51 ESBRIET TABS 267mg 801mg 51 escitalopram oxalate soln 33 escitalopram oxalate tabs 5mg 10mg
20mg 33 esgic caps 26 esgic tabs 26 ESMOLOL HCL SOLN 23 esmolol hcl-sodium chloride soln 23 esomeprazole magnesium cpdr 20mg
40mg 40 esomeprazole magnesium pack 10mg
20mg 40mg 40 esomeprazole sodium solr 40 estarylla tabs 43 estazolam tabs 1mg 2mg 31 estrace crea 45 estrace tabs 05mg 1mg 2mg 45 estradiol crea 45 estradiol pttw 0025mg24hr
00375mg24hr 005mg24hr 0075mg24hr 01mg24hr 45
estradiol ptwk 375mcg24hr 0025mg24hr 005mg24hr 006mg24hr 0075mg24hr 01mg24hr 45
estradiol tabs 10mcg 05mg 1mg 2mg 45 estradiol valerate oil 45 estradiol-norethindrone acet tabs 45 ESTRING RING 45 eszopiclone tabs 1mg 2mg 3mg 31 ethacrynic acid tabs 36 ethambutol hcl tabs 100mg 400mg 11 ethosuximide caps 29 ethosuximide soln 29 ethynodiol diac-eth estradiol tabs 43 etodolac caps 26
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 71
etodolac er tb24 26 etodolac tabs 26 etonogestrel-ethinyl estradiol ring 43 ETOPOPHOS SOLR 15 etoposide soln 15 etravirine tabs 100mg 200mg 12 eulexin caps 15 EURAX CREA 53 EUTHYROX TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 46
evekeo tabs 5mg 10mg 28 EVENITY SOSY 47 everolimus tabs 025mg 48 everolimus tabs 05mg 075mg 1mg 48 everolimus tabs 25mg 5mg 75mg 10mg
15 everolimus tbso 2mg 3mg 5mg 15 EVKEEZA SOLN 345mg23ml
1200mg8ml 22 EVOMELA SOLR 15 EVOTAZ TABS 12 EVRYSDI SOLR 49 exemestane tabs 15 EXKIVITY CAPS 15 EXONDYS 51 SOLN 500mg10ml
100mg2ml 49 EXSERVAN FILM 31 EXTAVIA KIT 32 EYLEA SOLN 39 EYLEA SOSY 39 ezetimibe tabs 22 ezetimibe-simvastatin tabs 22
F FABRAZYME SOLR 5mg 35mg 37 falmina tabs 43 famciclovir tabs 125mg 250mg 500mg 12 famotidine (pf) soln 40 famotidine premixed soln 40 famotidine soln 40 famotidine susr 40 famotidine tabs 20mg 40mg 40 FANAPT TABS 1mg 2mg 4mg 6mg 8mg
10mg 12mg 33 FANAPT TITRATION PACK TABS 33 FARYDAK CAPS 10mg 15mg 20mg 15 FASENRA PEN SOAJ 51 FASENRA SOSY 51
fayosim tabs 43 febuxostat tabs 40mg 80mg 47 felbamate susp 29 felbamate tabs 400mg 600mg 29 felodipine er tb24 25mg 5mg 10mg 23 femynor tabs 43 fenofibrate caps 50mg 150mg 22 fenofibrate micronized caps 43mg 67mg
130mg 134mg 200mg 22 fenofibrate tabs 40mg 48mg 54mg
120mg 145mg 160mg 22 fenofibric acid cpdr 45mg 135mg 22 fenoprofen calcium caps 26 fenoprofen calcium tabs 26 fenortho caps 26 FENSOLVI (6 MONTH) KIT 15 fentanyl citrate (pf) soct 26 FENTANYL CITRATE (PF) SOLN
50mcgml 1000mcg20ml 2500mcg50ml 26
fentanyl citrate tabs 100mcg 200mcg 400mcg 600mcg 800mcg 26
fentanyl pt72 12mcghr 25mcghr 375mcghr 50mcghr 625mcghr 75mcghr 875mcghr 100mcghr 26
FERRIPROX SOLN 41 FERRIPROX TABS 41 FERRIPROX TWICE-A-DAY TABS 41 FETROJA SOLR 9 FETZIMA CP24 20mg 40mg 80mg 120mg
33 FETZIMA TITRATION C4PK 33 fexmid tabs 20 finasteride tabs 47 FINTEPLA SOLN 29 fioricet caps 26 fioricetcodeine caps 26 FIRDAPSE TABS 49 FIRMAGON (240 MG DOSE) SOLR 15 FIRMAGON SOLR 15 flac oil 38 flavoxate hcl tabs 57 FLEBOGAMMA DIF SOLN INTRAVENOUS
52 flecainide acetate tabs 50mg 100mg
150mg 24 FLEQSUVY SUSP 20 FLOVENT HFA AERO 51 floxuridine solr 15
72 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
fluconazole in sodium chloride soln intravenous 10
fluconazole susr 10 fluconazole tabs 10 flucytosine caps 250mg 500mg 10 fludarabine phosphate soln 15 fludarabine phosphate solr 15 fludrocortisone acetate tabs 42 flumazenil soln 31 flunisolide soln 38 fluocinolone acetonide body oil 54 fluocinolone acetonide crea 001 0025
54 fluocinolone acetonide oil 38 fluocinolone acetonide oint 54 fluocinolone acetonide scalp oil 54 fluocinolone acetonide soln 54 fluocinonide crea 54 fluocinonide emulsified base crea 54 FLUOCINONIDE GEL 54 fluocinonide oint 54 fluocinonide soln 54 FLUORITAB CHEW 025mg 05mg 1mg 49 FLUORITAB SOLN 49 fluorometholone susp 38 fluorouracil crea 5 56 fluorouracil crea 5 56 fluorouracil soln 15 56 fluorouracil soln 2 5 56 fluoxetine hcl (pmdd) tabs 10mg 20mg 33 fluoxetine hcl caps 10mg 20mg 40mg 33 fluoxetine hcl cpdr 33 fluoxetine hcl soln 33 fluoxetine hcl tabs 10mg 20mg 60mg 33 fluphenazine decanoate soln 33 fluphenazine hcl conc 33 fluphenazine hcl elix 33 fluphenazine hcl soln 33 fluphenazine hcl tabs 1mg 25mg 5mg
10mg 34 FLURANDRENOLIDE CREA 54 flurandrenolide lotn 55 flurandrenolide oint 55 flurazepam hcl caps 15mg 30mg 31 flurbiprofen sodium soln 38 flurbiprofen tabs 26 flutamide caps 15 fluticasone propionate crea 55 fluticasone propionate lotn 55
fluticasone propionate oint 55 fluticasone propionate susp 38 fluticasone-salmeterol aepb 51 fluvastatin sodium caps 20mg 40mg 22 fluvastatin sodium er tb24 22 fluvoxamine maleate er cp24 100mg
150mg 34 fluvoxamine maleate tabs 25mg 50mg
100mg 34 FML FORTE SUSP 38 FML OINT 38 fomepizole soln 47 fondaparinux sodium soln 25mg05ml 21 fondaparinux sodium soln 5mg04ml
75mg06ml 10mg08ml 21 FORTEO SOPN 45 fosamprenavir calcium tabs 12 fosaprepitant dimeglumine solr 40 fosfomycin tromethamine pack 13 fosinopril sodium tabs 10mg 20mg 40mg
25 fosinopril sodium-hctz tabs 25 fosphenytoin sodium soln 29 FOTIVDA CAPS 089mg 134mg 15 FROVATRIPTAN SUCCINATE TABS 30 FULPHILA SOSY 21 fulvestrant soln 15 furosemide soln 8mgml 10mgml 36 furosemide soln injection 36 furosemide tabs 20mg 40mg 80mg 36 FUZEON SOLR 12 FYARRO SUSR 15 fyavolv tabs 45 FYCOMPA SUSP 29 FYCOMPA TABS 29
G gabapentin caps 100mg 400mg 29 gabapentin soln 29 gabapentin tabs 600mg 800mg 29 GALAFOLD CAPS 49 galantamine hydrobromide er cp24 8mg
16mg 24mg 19 galantamine hydrobromide soln 19 galantamine hydrobromide tabs 4mg 8mg
12mg 19 GAMASTAN INJ 52 GAMIFANT SOLN 50mg10ml
100mg20ml 10mg2ml 48
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 73
GAMMAGARD SD LESS IGA SOLR INTRAVENOUS 5gm 10gm 52
GAMMAGARD SOLN INJECTION 52 GAMMAKED SOLN INJECTION 52 GAMMAPLEX SOLN INTRAVENOUS 52 GAMUNEX-C SOLN INJECTION 52 ganciclovir sodium soln 12 ganciclovir sodium solr 12 GARDASIL 9 SUSP 52 GARDASIL 9 SUSY 52 gatifloxacin soln 38 GATTEX KIT 41 gavilyte-c solr 41 gavilyte-g solr 41 gavilyte-h kit 41 gavilyte-n with flavor pack solr 41 GAVRETO CAPS 15 GAZYVA SOLN 15 gemcitabine hcl soln 15 gemcitabine hcl solr 15 gemfibrozil tabs 22 gemmily caps 43 generlac soln 35 gengraf caps 25mg 50mg 100mg 48 gengraf soln 48 GENOTROPIN CART 12mg 46 GENOTROPIN MINIQUICK PRSY 04mg
06mg 08mg 1mg 12mg 14mg 16mg 18mg 2mg 46
gentak oint 38 gentamicin in saline soln 9 gentamicin in saline soln intravenous 9 gentamicin sulfate crea 53 gentamicin sulfate oint 53 gentamicin sulfate soln 9 38 gentamicin sulfate soln injection 9 GENVOYA TABS 12 gianvi tabs 43 GILENYA CAPS 025mg 05mg 32 GILOTRIF TABS 20mg 30mg 40mg 15 GIMOTI SOLN 41 GIVLAARI SOLN 49 GLASSIA SOLN INTRAVENOUS 51 glatopa sosy 20mgml 40mgml 32 glimepiride tabs 1mg 2mg 4mg 44 glipizide er tb24 25mg 5mg 10mg 44 glipizide tabs 5mg 10mg 44 glipizide-metformin hcl tabs 44 glucagon emergency kit 44
glyburide micronized tabs 15mg 3mg 6mg 44
glyburide tabs 125mg 25mg 5mg 44 glyburide-metformin tabs 44 glycate tabs 19 glycopyrrolate oral soln 19 glycopyrrolate pf sosy 19 glycopyrrolate soln injection 19 glycopyrrolate tabs 1mg 2mg 19 glydo prsy 55 granisetron hcl soln 40 granisetron hcl tabs 40 GRANIX SOLN 480mcg16ml 300mcgml
21 GRANIX SOSY 300mcg05ml
480mcg08ml 21 GRASTEK SUBL 49 griseofulvin microsize susp 10 griseofulvin microsize tabs 10 griseofulvin ultramicrosize tabs 10 guanfacine hcl er tb24 1mg 2mg 3mg
4mg 32 guanfacine hcl tabs 1mg 2mg 24 GUANIDINE HCL TABS 19 gynazole-1 crea 53
H HAEGARDA SOLR 2000unit 3000unit 49 hailey 24 fe tabs 43 halcinonide crea 55 halobetasol propionate crea 55 HALOBETASOL PROPIONATE FOAM 55 halobetasol propionate oint 55 haloperidol decanoate soln 34 haloperidol lactate conc 34 haloperidol lactate soln 34 haloperidol tabs 05mg 1mg 2mg 5mg
10mg 20mg 34 HARVONI PACK 12 HARVONI TABS 12 HAVRIX SUSP 52 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
HEPLISAV-B SOLN 52
74 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
HERCEPTIN HYLECTA SOLN 15 HERCEPTIN SOLR 150mg 440mg 15 HERZUMA SOLR 150mg 420mg 15 HETLIOZ CAPS 31 HETLIOZ LQ SUSP 31 HIBERIX SOLR 52 HUMALOG KWIKPEN SOPN 44 HUMALOG SOCT 44 HUMALOG SOLN 44 humatin caps 11 HUMATROPE CART 6mg 12mg 24mg 46 HUMATROPE SOLR 46 HUMIRA PEDIATRIC CROHNS START
PSKT 48 HUMIRA PEN PNKT 40mg04ml
40mg08ml 80mg08ml 48 HUMIRA PEN-CDUCHS STARTER PNKT
40mg08ml 80mg08ml 48 HUMIRA PEN-PEDIATRIC UC START
PNKT 48 HUMIRA PEN-PSUVADOL HS START
PNKT 48 HUMIRA PEN-PSORUVEIT STARTER
PNKT 48 HUMIRA PSKT 10mg01ml 10mg02ml
20mg02ml 20mg04ml 40mg04ml 40mg08ml 48
HUMULIN 7030 KWIKPEN SUPN 44 HUMULIN 7030 SUSP 44 HUMULIN N KWIKPEN SUPN 44 HUMULIN N SUSP 44 HUMULIN R SOLN 44 HUMULIN R U-500 (CONCENTRATED)
SOLN 44 HUMULIN R U-500 KWIKPEN SOPN 44 hydralazine hcl soln 24 hydralazine hcl tabs 10mg 25mg 50mg
100mg 24 hydrochlorothiazide caps 36 hydrochlorothiazide tabs 125mg 25mg
50mg 36 hydrocodone bitartrate er cp12 10mg
15mg 20mg 30mg 40mg 50mg 26 hydrocodone-acetaminophen soln 26 hydrocodone-acetaminophen tabs 26 hydrocodone-ibuprofen tabs 26 hydrocortisone (perianal) crea 1 25 55 hydrocortisone ace-pramoxine crea 55
HYDROCORTISONE ACE-PRAMOXINE SUPP 55
hydrocortisone butyr lipo base crea 55 hydrocortisone butyrate crea 55 hydrocortisone butyrate lotn 55 HYDROCORTISONE BUTYRATE OINT 55 hydrocortisone butyrate soln 55 hydrocortisone crea 1 25 55 hydrocortisone enem 55 hydrocortisone lotn 55 hydrocortisone oint 1 25 55 hydrocortisone tabs 5mg 10mg 20mg 42 hydrocortisone valerate crea 55 hydrocortisone valerate oint 55 HYDROCORTISONE-ACETIC ACID SOLN
38 hydromorphone hcl er tb24 8mg 12mg
16mg 32mg 26 hydromorphone hcl liqd 26 hydromorphone hcl tabs 2mg 4mg 8mg 26 hydroxychloroquine sulfate tabs 11 hydroxyprogesterone caproate oil 46 hydroxyprogesterone caproate soln 46 hydroxyurea caps 15 hydroxyzine hcl soln 31 hydroxyzine hcl syrp 31 hydroxyzine hcl tabs 31 hydroxyzine pamoate caps 31 HYPERHEP B SOLN 52 HYPERHEP B SOSY 52 HYPERRAB SD SOLN 52 HYQVIA KIT 52
I IBANDRONATE SODIUM SOLN 47 ibandronate sodium tabs 47 IBRANCE CAPS 75mg 100mg 125mg 15 IBRANCE TABS 75mg 100mg 125mg 15 IBSRELA TABS 41 ibu tabs 26 ibudone tabs 26 ibuprofen lysine soln 26 ibuprofen susp 26 ibuprofen tabs 26 ibutilide fumarate soln 24 icatibant acetate soln 20 iclevia tabs 43 ICLUSIG TABS 10mg 15mg 30mg 45mg
15
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 75
icosapent ethyl caps 22 IDAMYCIN PFS SOLN 15 idarubicin hcl soln 15 IDHIFA TABS 50mg 100mg 15 ifosfamide soln 15 IFOSFAMIDE SOLR 16 ILARIS SOLN 26 ILUMYA SOSY 56 ILUVIEN IMPL 38 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 34 imipramine pamoate caps 75mg 100mg
125mg 150mg 34 imiquimod crea 375 5 56 IMIQUIMOD PUMP CREA 56 IMOGAM RABIES-HT SOLN 52 IMOVAX RABIES INJ 52 IMPAVIDO CAPS 11 INBRIJA CAPS 30 incassia tabs 43 INCRELEX SOLN 46 indapamide tabs 125mg 25mg 36 indocin supp 26 indomethacin caps 26 indomethacin er cpcr 26 indomethacin sodium solr 26 INFANRIX SUSP 52 INFLECTRA SOLR INTRAVENOUS 48 INFLIXIMAB SOLR INTRAVENOUS 48 INFUGEM SOLN 16 INGREZZA CAPS 40mg 60mg 80mg 32 INGREZZA CPPK 32 INLYTA TABS 1mg 5mg 16 INQOVI TABS 16 INREBIC CAPS 16 INTELENCE TABS 25mg 12 INTRALIPID EMUL INTRAVENOUS 36 INTRON A SOLN 6000000unitml
10000000unitml 16 INTRON A SOLR 10000000unit
18000000unit 50000000unit 16 introvale tabs 43 INVEGA HAFYERA SUSY 34
INVEGA SUSTENNA SUSY 39mg025ml 34
INVEGA SUSTENNA SUSY 78mg05ml 117mg075ml 234mg15ml 156mgml 34
INVEGA TRINZA SUSY 273mg088ml 410mg132ml 546mg175ml 819mg263ml 34
INVIRASE CAPS 12 INVIRASE TABS 12 IOPIDINE SOLN 39 IPOL INJ 52 ipratropium bromide soln 002 19 ipratropium bromide soln 003 006 19 ipratropium-albuterol soln 20 irbesartan tabs 75mg 150mg 300mg 25 irbesartan-hydrochlorothiazide tabs 25 IRESSA TABS 16 irinotecan hcl soln 16 ISENTRESS CHEW 25mg 100mg 12 ISENTRESS HD TABS 12 ISENTRESS PACK 12 ISENTRESS TABS 12 isoniazid soln 11 isoniazid syrp 11 isoniazid tabs 100mg 300mg 11 isoproterenol hcl soln 20 isosorbide dinitrate er tbcr 25 isosorbide dinitrate tabs 5mg 10mg 20mg
30mg 25 isosorbide mononitrate er tb24 25 isosorbide mononitrate er tb24 30mg 60mg
25 isosorbide mononitrate tabs 10mg 20mg 25 isotretinoin caps 10mg 20mg 30mg 40mg
56 isradipine caps 25mg 5mg 23 ISTURISA TABS 1mg 5mg 10mg 49 itraconazole caps 10 ITRACONAZOLE SOLN 10 ivermectin crea 53 ivermectin tabs 8 IXEMPRA KIT SOLR 16 IXIARO SUSP 52
J JAKAFI TABS 5mg 10mg 15mg 20mg
25mg 16
76 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
jantoven tabs 1mg 2mg 25mg 3mg 4mg 5mg 6mg 75mg 10mg 21
JARDIANCE TABS 10mg 25mg 44 jasmiel tabs 43 JEMPERLI SOLN 16 jinteli tabs 45 JOLIVETTE TABS 43 JULUCA TABS 12 junel 1530 tabs 43 junel 120 tabs 43 junel fe 1530 tabs 43 junel fe 120 tabs 43 junel fe 24 tabs 43 JUXTAPID CAPS 5mg 10mg 20mg 30mg
40mg 60mg 22 JYNARQUE TABS 15mg 30mg 36 JYNARQUE TBPK 36
K KADCYLA SOLR 100mg 160mg 16 kaitlib fe chew 43 KALYDECO PACK 25mg 50mg 75mg 51 KALYDECO TABS 51 KANJINTI SOLR 150mg 420mg 16 KANUMA SOLN 37 kariva tabs 43 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS 20-5-02 MEQ 10-5-045 MEQ 20-5-045 MEQ 30-5-045 MEQ 40-5-045 MEQ 20-5-09 MEQ 37
KCL IN DEXTROSE-NACL SOLN INTRAVENOUS 40-5-09 MEQ 37
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS 37
KEDRAB SOLN 52 kelnor 135 tabs 43 kelnor 150 tabs 43 KENALOG SUSP 42 KEPIVANCE SOLR 56 KERALYT SHAM 56 KESIMPTA SOAJ 49 ketoconazole crea 53 ketoconazole foam 53 ketoconazole sham 53 ketoconazole tabs 10 ketodan foam 53 ketoprofen caps 26 ketoprofen er cp24 26 ketorolac tromethamine soln 26 38
ketorolac tromethamine soln 04 05 38 ketorolac tromethamine tabs 26 KEVEYIS TABS 49 KEVZARA SOAJ 150mg114ml
200mg114ml 48 KEVZARA SOSY 150mg114ml
200mg114ml 48 KEYTRUDA SOLN 16 KHAPZORY SOLR 175mg 300mg 47 KHEDEZLA TB24 50mg 100mg 34 KIMMTRAK SOLN 16 KIMYRSA SOLR 9 KINERET SOSY 48 KINRIX SUSP 52 KINRIX SUSY 52 kionex susp 36 KISQALI (200 MG DOSE) TBPK 16 KISQALI (400 MG DOSE) TBPK 16 KISQALI (600 MG DOSE) TBPK 16 KISQALI FEMARA (400 MG DOSE) TBPK
16 KISQALI FEMARA (600 MG DOSE) TBPK
16 KISQALI FEMARA(200 MG DOSE) TBPK
16 KITABIS PAK NEBU 51 KLISYRI OINT 56 KLOR-CON 10 TBCR 37 klor-con m15 tbcr 37 klor-con m20 tbcr 37 klor-con pack 37 klor-con sprinkle cpcr 8meq 10meq 37 KLOR-CON TBCR 37 KORLYM TABS 44 KORSUVA SOLN 56 KOSELUGO CAPS 10mg 25mg 16 KRINTAFEL TABS 11 kristalose pack 10gm 20gm 35 K-TAB TBCR 37 kurvelo tabs 43 KYNMOBI FILM 10mg 15mg 20mg 25mg
30mg 30 KYPROLIS SOLR 10mg 30mg 60mg 16
L labetalol hcl soln 23 labetalol hcl tabs 100mg 200mg 300mg 23 lacosamide tabs 50mg 100mg 150mg
200mg 29
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 77
LACRISERT INST 39 LACTATED RINGERS SOLN 37 49 LACTIC ACID LOTN 56 lactulose encephalopathy soln 35 lactulose pack 35 lactulose soln 35 LAMICTAL XR KIT 29 lamivudine soln 12 lamivudine tabs 100mg 150mg 300mg 12 lamivudine-zidovudine tabs 12 lamotrigine chew 5mg 25mg 29 lamotrigine er tb24 25mg 50mg 100mg
200mg 250mg 300mg 29 lamotrigine kit 29 lamotrigine starter kit-blue kit 29 lamotrigine starter kit-green kit 29 lamotrigine starter kit-orange kit 29 lamotrigine tabs 25mg 100mg 150mg
200mg 29 lamotrigine tbdp 25mg 50mg 100mg
200mg 29 LANOXIN PEDIATRIC SOLN 24 LANREOTIDE ACETATE SOLN 46 lansoprazole cpdr 15mg 30mg 40 lansoprazole tbdd 15mg 30mg 40 lanthanum carbonate chew 500mg 750mg
1000mg 36 LANTUS SOLN 44 LANTUS SOLOSTAR SOPN 44 lapatinib ditosylate tabs 16 larin 1530 tabs 43 larin 120 tabs 43 larin fe 1530 tabs 43 larin fe 120 tabs 43 larissia tabs 43 LARTRUVO SOLN 190mg19ml
500mg50ml 16 latanoprost soln 39 LATUDA TABS 20mg 40mg 60mg 80mg
120mg 34 LAYOLIS FE CHEW 43 LAZANDA SOLN 100mcgact 400mcgact
26 ledipasvir-sofosbuvir tabs 12 leena tabs 43 leflunomide tabs 10mg 20mg 48 LEMTRADA SOLN 32 lenalidomide caps 5mg 10mg 15mg 25mg
16
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 16 lessina tabs 43 letrozole tabs 16 leucovorin calcium soln 47 leucovorin calcium solr 47 leucovorin calcium tabs 5mg 10mg 15mg
25mg 47 LEUKERAN TABS 16 LEUKINE SOLR 21 leuprolide acetate kit 16 LEVALBUTEROL HCL NEBU
125mg05ml 125mg3ml 031mg3ml 063mg3ml 20
levalbuterol tartrate aero 20 levetiracetam er tb24 500mg 750mg 29 levetiracetam in nacl soln 29 levetiracetam soln 29 levetiracetam tabs 250mg 500mg 750mg
1000mg 29 levobunolol hcl soln 39 levocarnitine soln 49 LEVOCARNITINE TABS 49 levocetirizine dihydrochloride soln 14 levocetirizine dihydrochloride tabs 14 levofloxacin in d5w soln 9 levofloxacin in d5w soln intravenous 9 levofloxacin soln 9 38 levofloxacin soln intravenous 9 levofloxacin tabs 9 levoleucovorin calcium pf soln 47 levoleucovorin calcium solr 47 levonest tabs 43 levonorgest-eth est amp eth est tabs 43 levonorgest-eth estrad 91-day tabs 43 levonorgestrel-ethinyl estrad tabs 43 levonorg-eth estrad triphasic tabs 43 levora 01530 (28) tabs 43 levorphanol tartrate tabs 2mg 3mg 26 LEVO-T TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
78 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
levothyroxine sodium caps 13mcg 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEVOTHYROXINE SODIUM SOLR 47 LEVOTHYROXINE SODIUM TABS 25mcg
50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
LEVOXYL TABS 25mcg 50mcg 75mcg 88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 47
LEXETTE FOAM 55 LEXIVA SUSP 12 LIALDA TBEC 40 LIBTAYO SOLN 16 lidocaine hcl (cardiac) pf sosy 24 lidocaine hcl (cardiac) sosy 24 lidocaine hcl (pf) soln 49 LIDOCAINE HCL CREA 55 lidocaine hcl lotn 55 lidocaine hcl soln 39 49 55 lidocaine hcl urethralmucosal gel 55 lidocaine hcl urethralmucosal prsy 55 LIDOCAINE IN D5W SOLN 24 lidocaine in dextrose soln 49 lidocaine oint 55 lidocaine ptch 55 lidocaine viscous hcl soln 40 lidocaine-epinephrine soln 49 LIDOCAINE-HYDROCORT (PERIANAL)
CREA 55 LIDOCAINE-HYDROCORTISONE ACE KIT
55 lidocaine-prilocaine crea 55 lidocaine-tetracaine crea 55 LIDOCORT CREA 56 lidopin crea 56 LIDO-SORB LOTN 55 LIDOZION LOTN 56 lincomycin hcl soln 9 lindane sham 53 linezolid soln intravenous 9 linezolid susr 9 linezolid tabs 9 liothyronine sodium soln 47 liothyronine sodium tabs 5mcg 25mcg
50mcg 47 LIPODOX 50 INJ 16
lisinopril tabs 25mg 5mg 10mg 20mg 30mg 40mg 25
lisinopril-hydrochlorothiazide tabs 25 LITHIUM CARBONATE CAPS 150mg
300mg 600mg 34 lithium carbonate er tbcr 300mg 450mg 34 LITHIUM CARBONATE TABS 34 LITHIUM SOLN 34 LITHOSTAT TABS 35 LIVMARLI SOLN 41 LIVTENCITY TABS 12 loestrin 1530 (21) tabs 43 loestrin 120 (21) tabs 43 loestrin fe 1530 tabs 43 loestrin fe 120 tabs 43 LOKELMA PACK 5gm 10gm 36 LONHALA MAGNAIR REFILL KIT SOLN 19 LONSURF TABS 16 loperamide hcl caps 40 lopinavir-ritonavir soln 12 lopinavir-ritonavir tabs 12 lopreeza tabs 45 lorazepam intensol conc 31 LORAZEPAM SOLN 4mgml 2mgml 31 lorazepam tabs 05mg 1mg 2mg 31 LORBRENA TABS 25mg 100mg 16 lorcet hd tabs 26 lorcet plus tabs 26 lorcet tabs 27 lortab elix 27 loryna tabs 43 losartan potassium tabs 25mg 50mg
100mg 25 losartan potassium-hctz tabs 25 LOTEMAX GEL 38 LOTEMAX SUSP 38 lovastatin tabs 10mg 20mg 40mg 22 LOVENOX SOLN 21 LOVENOX SOSY 30mg03ml 40mg04ml
60mg06ml 80mg08ml 120mg08ml 100mgml 150mgml 21
low-ogestrel tabs 43 loxapine succinate caps 5mg 10mg 25mg
50mg 34 lubiprostone caps 8mcg 24mcg 41 LUCEMYRA TABS 32 LUCENTIS SOLN 03mg005ml
05mg005ml 39
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 79
LUCENTIS SOSY 03mg005ml 05mg005ml 39
LUDENT CHEW 025mg 05mg 1mg 49 LUMAKRAS TABS 16 LUMIGAN SOLN 39 LUMIZYME SOLR 37 LUMOXITI SOLR 16 LUPANETA PACK KIT 16 LUPKYNIS CAPS 48 LUPRON DEPOT (1-MONTH) KIT 16 LUPRON DEPOT (3-MONTH) KIT 16 LUPRON DEPOT (4-MONTH) KIT 16 LUPRON DEPOT (6-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 16 LUPRON DEPOT-PED (1-MONTH) KIT 75
MG 16 LUPRON DEPOT-PED (3-MONTH) KIT 16 lutera tabs 43 LYBALVI TABS 34 lyleq tabs 43 lyllana pttw 0025mg24hr 00375mg24hr
005mg24hr 0075mg24hr 01mg24hr 45
LYMEPAK TABS 9 LYNPARZA TABS 100mg 150mg 16 LYSODREN TABS 16 lyza tabs 43
M mafenide acetate pack 53 magnesium sulfate in d5w soln 37 magnesium sulfate soln 29 MAGNESIUM SULFATE SOLN INJECTION
50 29 MAKENA SOAJ 46 malathion lotn 53 MANNITOL SOLN 36 maprotiline hcl tabs 25mg 50mg 75mg 34 maraviroc tabs 150mg 300mg 12 MARGENZA SOLN 16 marlissa tabs 43 MARPLAN TABS 34 MARQIBO SUSP 17 MATULANE CAPS 17 matzim la tb24 180mg 240mg 300mg
360mg 420mg 23 MAVENCLAD (10 TABS) TBPK 48 MAVENCLAD (4 TABS) TBPK 48 MAVENCLAD (5 TABS) TBPK 48
MAVENCLAD (6 TABS) TBPK 48 MAVENCLAD (7 TABS) TBPK 48 MAVENCLAD (8 TABS) TBPK 48 MAVENCLAD (9 TABS) TBPK 48 MAVYRET PACK 12 MAVYRET TABS 12 MAYZENT STARTER PACK TBPK 32 MAYZENT TABS 025mg 1mg 2mg 32 MENAPHOSMBHYO1 TABS 13 meclizine hcl tabs 40 meclofenamate sodium caps 27 MEDROL TABS 42 medroxyprogesterone acetate susp 46 medroxyprogesterone acetate susy 46 medroxyprogesterone acetate tabs 25mg
5mg 10mg 46 mefenamic acid caps 27 mefloquine hcl tabs 11 megestrol acetate susp 17 46 megestrol acetate tabs 17 MEKINIST TABS 05mg 2mg 17 MEKTOVI TABS 17 melodetta 24 fe chew 43 meloxicam tabs 27 melphalan hcl solr 17 memantine hcl er cp24 32 memantine hcl soln 32 memantine hcl tabs 5mg 10mg 32 MENACTRA SOLN 52 menest tabs 03mg 0625mg 125mg 45 MENQUADFI SOLN 52 MENVEO SOLR 52 meperidine hcl soln 27 meperidine hcl tabs 50mg 27 meprobamate tabs 31 mercaptopurine tabs 17 meropenem solr intravenous 1gm 500mg 9 merzee caps 43 mesalamine cpdr 40 mesalamine enem 40 mesalamine er cp24 40 mesalamine supp 40 mesalamine tbec 12gm 800mg 40 mesalamine-cleanser kit 40 mesna soln 49 MESNEX TABS 49 MESTINON SOLN 19 metadate er tbcr 28 metaproterenol sulfate syrp 20
80 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
metaproterenol sulfate tabs 10mg 20mg 20 metaxall tabs 20 metaxalone tabs 20 metformin hcl er tb24 500mg 750mg 44 metformin hcl tabs 500mg 850mg 1000mg
45 methadone hcl conc 27 methadone hcl intensol conc 27 methadone hcl tabs 5mg 10mg 27 methamphetamine hcl tabs 28 methazolamide tabs 25mg 50mg 39 methenamine hippurate tabs 13 METHENAMINE MANDELATE TABS 13 methergine tabs 45 methimazole tabs 5mg 10mg 47 methitest tabs 42 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 57 methscopolamine bromide tabs 25mg 5mg
19 methyclothiazide tabs 36 methyldopa tabs 250mg 500mg 24 methyldopa-hydrochlorothiazide tabs 24 methylergonovine maleate soln 45 methylergonovine maleate tabs 45 methylphenidate hcl chew 25mg 5mg
10mg 28 methylphenidate hcl er (cd) cpcr 10mg
20mg 30mg 40mg 50mg 60mg 28 methylphenidate hcl er (la) cp24 10mg
20mg 30mg 40mg 60mg 28 methylphenidate hcl er (xr) cp24 10mg
15mg 20mg 30mg 40mg 50mg 60mg 28
methylphenidate hcl er tb24 18mg 27mg 36mg 54mg 28
methylphenidate hcl er tbcr 10mg 18mg 20mg 27mg 36mg 54mg 72mg 28
methylphenidate hcl soln 5mg5ml 10mg5ml 28
methylphenidate hcl tabs 5mg 10mg 20mg 28
methylprednisolone acetate susp 42 methylprednisolone sodium succ solr 42
methylprednisolone tabs 4mg 8mg 16mg 32mg 42
methylprednisolone tbpk 42 methyltestosterone caps 42 metoclopramide hcl soln 41 metoclopramide hcl tabs 5mg 10mg 41 metoclopramide hcl tbdp 5mg 10mg 41 metolazone tabs 25mg 5mg 10mg 36 metoprolol succinate er tb24 25mg 50mg
100mg 200mg 23 metoprolol tartrate soct 23 metoprolol tartrate soln 23 metoprolol tartrate tabs 25mg 50mg
100mg 23 metoprolol tartrate tabs 375mg 75mg 23 metoprolol-hydrochlorothiazide tabs 23 metronidazole caps 11 metronidazole crea 53 metronidazole gel 53 metronidazole lotn 53 METRONIDAZOLE SOLN INTRAVENOUS
500mg100ml 11 metronidazole tabs 11 metyrosine caps 22 mexiletine hcl caps 150mg 200mg 250mg
24 mibelas 24 fe chew 43 micafungin sodium solr intravenous 50mg
100mg 11 miconazole 3 supp 53 miconazole-zinc oxide-petrolat oint 53 micort-hc crea 55 microgestin 1530 tabs 43 microgestin 120 tabs 43 microgestin 24 fe tabs 43 microgestin fe 1530 tabs 43 microgestin fe 120 tabs 43 midazolam hcl (pf) soln 31 midazolam hcl soln 31 midodrine hcl tabs 25mg 5mg 10mg 20 miglitol tabs 25mg 50mg 100mg 45 miglustat caps 38 mili tabs 43 millipred dp tbpk 42 millipred tabs 42 milrinone lactate in dextrose soln 24 milrinone lactate soln 24 mimvey lo tabs 45 mimvey tabs 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 81
minitran pt24 01mghr 02mghr 04mghr 06mghr 25
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 24 mirtazapine tabs 75mg 15mg 30mg
45mg 34 mirtazapine tbdp 15mg 30mg 45mg 34 misoprostol tabs 100mcg 200mcg 40 mitomycin solr 17 mitoxantrone hcl conc 17 M-M-R II SOLR 52 modafinil tabs 100mg 200mg 28 moexipril hcl tabs 75mg 15mg 25 molindone hcl tabs 5mg 10mg 25mg 34 mometasone furoate crea 55 mometasone furoate oint 55 mometasone furoate soln 55 mometasone furoate susp 38 MONJUVI SOLR 17 MONONESSA TABS 43 montelukast sodium chew 4mg 5mg 51 montelukast sodium pack 51 montelukast sodium tabs 51 morgidox caps 9 MORPHINE SULFATE (CONCENTRATE)
SOLN 27 morphine sulfate er beads cp24 30mg
45mg 60mg 75mg 90mg 120mg 27 morphine sulfate er cp24 10mg 20mg
30mg 40mg 50mg 60mg 80mg 100mg 27
morphine sulfate er tbcr 15mg 30mg 60mg 100mg 200mg 27
MORPHINE SULFATE SOLN 10mg5ml 20mg5ml 27
morphine sulfate tabs 15mg 30mg 27 moxifloxacin hcl (2x day) soln 38 moxifloxacin hcl in nacl soln intravenous 9 moxifloxacin hcl soln 38 moxifloxacin hcl tabs 9 MULPLETA TABS 21 MULTAQ TABS 24 mupirocin calcium crea 53 mupirocin oint 53 mutamycin solr 17 MVASI SOLN 400mg16ml 100mg4ml 17
MYALEPT SOLR 49 MYCAPSSA CPDR 46 mycophenolate mofetil caps 48 mycophenolate mofetil hcl solr 48 mycophenolate mofetil susr 48 mycophenolate mofetil tabs 49 mycophenolate sodium tbec 180mg 360mg
49 MYFEMBREE TABS 45 MYLOTARG SOLR 17 myorisan caps 10mg 20mg 30mg 40mg 57 MYRBETRIQ TB24 25mg 50mg 57
N NABI-HB SOLN 52 nabumetone tabs 27 N-ACETYL-L-CYSTEINE CAPS 36 nadolol tabs 20mg 40mg 80mg 23 nadololbendroflumethiazide tabs 23 nadolol-bendroflumethiazide tabs 23 nafcillin sodium solr 9 nafcillin sodium solr injection 9 nafcillin sodium solr intravenous 9 NAFRINSE CHEW 49 NAFRINSE DROPS SOLN 49 naftifine hcl crea 53 naftifine hcl gel 53 NAGLAZYME SOLN 38 nalbuphine hcl soln 10mgml 20mgml 27 nalfon tabs 27 nalocet tabs 27 naloxone hcl liqd 32 naloxone hcl soaj 32 naloxone hcl soct 32 naloxone hcl soln 32 naloxone hcl sosy 32 naltrexone hcl tabs 32 naproxen sodium er tb24 27 naproxen sodium tabs 27 naproxen susp 27 naproxen tabs 27 naproxen tbec 27 naproxen-esomeprazole tbec 27 naratriptan hcl tabs 30 NARCAN LIQD 32 NATACYN SUSP 38 nateglinide tabs 60mg 120mg 45 NATPARA CART 25mcg 50mcg 75mcg
100mcg 45
82 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
NAYZILAM SOLN 29 necon 0535 (28) tabs 43 NECON 777 TABS 43 nefazodone hcl tabs 50mg 100mg 150mg
200mg 250mg 34 nelarabine soln 17 nembutal soln 31 neomycin sulfate tabs 10 neomycin-bacitracin zn-polymyx oint 38 neomycin-polymyxin b gu soln 53 neomycin-polymyxin-dexameth oint 38 neomycin-polymyxin-dexameth susp 39 neomycin-polymyxin-gramicidin soln 38 neomycin-polymyxin-hc soln 39 neomycin-polymyxin-hc susp 39 neo-polycin hc oint 38 neo-polycin oint 38 neo-synalar crea 55 NERLYNX TABS 17 NEULASTA ONPRO PSKT 21 NEULASTA SOSY 21 NEUPOGEN SOLN 480mcg16ml
300mcgml 21 NEUPOGEN SOSY 300mcg05ml
480mcg08ml 21 nevirapine er tb24 100mg 400mg 12 nevirapine susp 12 nevirapine tabs 12 NEXAVAR TABS 17 NEXVIAZYME SOLR 38 niacin er (antihyperlipidemic) tbcr 500mg
750mg 1000mg 22 niacor tabs 22 nicardipine hcl caps 20mg 30mg 23 NICARDIPINE HCL SOLN 23 NICOTROL INHA 19 nifedipine caps 10mg 20mg 24 nifedipine er osmotic release tb24 30mg
60mg 90mg 24 nifedipine er tb24 30mg 60mg 90mg 24 nikki tabs 43 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 49 nitro-bid oint 25
NITRO-DUR PT24 03mghr 08mghr 25 NITROFURANTOIN MACROCRYSTAL
CAPS 13 NITROFURANTOIN MONOHYD MACRO
CAPS 13 nitrofurantoin susp 13 nitroglycerin pt24 01mghr 02mghr
04mghr 06mghr 25 nitroglycerin soln 25 nitroglycerin subl 03mg 04mg 06mg 25 nitropress soln 24 nitroprusside sodium soln 24 NITYR TABS 2mg 5mg 10mg 49 NIVESTYM SOLN 480mcg16ml
300mcgml 21 NIVESTYM SOSY 300mcg05ml
480mcg08ml 22 nizatidine caps 150mg 300mg 40 nizatidine soln 40 nolix crea 55 nolix lotn 55 nora-be tabs 43 norco tabs 27 NORDITROPIN FLEXPRO SOPN
5mg15ml 10mg15ml 15mg15ml 30mg3ml 46
norepinephrine bitartrate soln 20 norethin ace-eth estrad-fe caps 43 norethin ace-eth estrad-fe chew 43 norethin ace-eth estrad-fe tabs 43 norethindrone acetate tabs 46 norethindrone acet-ethinyl est tabs 43 norethindrone tabs 43 norethindrone-eth estradiol tabs 45 norethin-eth estradiol-fe chew 43 norgesic forte tabs 27 norgestimate-eth estradiol tabs 43 norgestim-eth estrad triphasic tabs 43 norlyroc tabs 43 NORPACE CR CP12 100mg 150mg 24 nortrel 0535 (28) tabs 43 nortrel 135 (21) tabs 43 nortrel 135 (28) tabs 43 nortrel 777 tabs 43 nortriptyline hcl caps 10mg 25mg 50mg
75mg 34 nortriptyline hcl soln 34 NORVIR CAPS 12 NORVIR PACK 12
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 83
NORVIR SOLN 12 NOURIANZ TABS 20mg 40mg 32 NOXAFIL SUSP 11 NPLATE SOLR 22 NUBEQA TABS 17 NUCALA SOAJ 51 NUCALA SOLR 51 NUCALA SOSY 51 NUCYNTA ER TB12 200mg 250mg 27 NUCYNTA TABS 27 NUEDEXTA CAPS 32 NULIBRY SOLR 49 NULOJIX SOLR 49 NUPLAZID CAPS 34 NUPLAZID TABS 10mg 17mg 34 NURTEC TBDP 30 NUTRILIPID EMUL INTRAVENOUS 36 NUTROPIN AQ NUSPIN 10 SOPN 46 NUZYRA SOLR 10 NUZYRA TABS 10 nyamyc powd 53 nylia 135 tabs 43 nylia 777 tabs 43 NYMALIZE SOLN 60mg20ml 6mgml 24 nymyo tabs 44 nystatin crea 53 nystatin oint 53 nystatin powd 53 nystatin susp 11 nystatin tabs 11 nystatin-triamcinolone crea 55 nystatin-triamcinolone oint 55 nystop powd 53 NYVEPRIA SOSY 22
O OCALIVA TABS 5mg 10mg 41 ocella tabs 44 OCREVUS SOLN 32 OCTAGAM SOLN INTRAVENOUS
1gm20ml 2gm20ml 52 octreotide acetate soln 500mcgml
1000mcgml 46 octreotide acetate soln 50mcgml
100mcgml 200mcgml 46 ODACTRA SUBL 49 ODEFSEY TABS 12 ODOMZO CAPS 17 OFEV CAPS 100mg 150mg 51
ofloxacin soln 38 ofloxacin tabs 10 ogestrel tabs 44 OGIVRI SOLR 17 olanzapine solr 34 olanzapine tabs 25mg 5mg 75mg 10mg
15mg 20mg 34 olanzapine tbdp 5mg 10mg 15mg 20mg
34 olanzapine-fluoxetine hcl caps 34 olmesartan medoxomil tabs 5mg 20mg
40mg 25 olmesartan medoxomil-hctz tabs 25 olmesartan-amlodipine-hctz tabs 24 olopatadine hcl soln 01 02 06 39 OLUMIANT TABS 1mg 2mg 48 omega-3-acid ethyl esters caps 22 omeprazole cpdr 10mg 20mg 40mg 40 omeprazole-sodium bicarbonate caps 40 omeprazole-sodium bicarbonate pack 40 OMNITROPE SOCT 5mg15ml
10mg15ml 46 OMNITROPE SOLR 46 ondansetron hcl soln 40 ondansetron hcl sosy 40 ondansetron hcl tabs 4mg 8mg 24mg 40 ondansetron tbdp 4mg 8mg 40 ONIVYDE
INJ 17 ONPATTRO SOLN 50 ONTRUZANT SOLR 150mg 420mg 17 ONUREG TABS 200mg 300mg 17 OPDIVO SOLN 100mg10ml 120mg12ml
240mg24ml 40mg4ml 17 OPDUALAG SOLN 17 OPIUM TINC 40 OPZELURA CREA 57 ORACEA CPDR 57 oralone pste 55 ORBACTIV SOLR 10 ORENCIA CLICKJECT SOAJ 48 ORENCIA SOLR 48 ORENCIA SOSY 50mg04ml
875mg07ml 125mgml 48 ORENITRAM TBCR 025mg 1mg 25mg
5mg 51 ORFADIN CAPS 50 ORFADIN SUSP 50 ORGOVYX TABS 45
84 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
ORILISSA TABS 150mg 200mg 45 ORKAMBI PACK 51 ORKAMBI TABS 51 ORLADEYO CAPS 110mg 150mg 50 orphenadrine citrate er tb12 20 orphenadrine citrate soln 20 orphenadrine-aspirin-caffeine tabs 27 orphengesic forte tabs 27 orsythia tabs 44 ORTIKOS CP24 6mg 9mg 42 oseltamivir phosphate caps 30mg 45mg
75mg 12 oseltamivir phosphate susr 12 OSMITROL SOLN 36 OTEZLA TABS 48 OTEZLA TBPK 48 ovide lotn 53 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 42 oxaprozin tabs 27 OXAYDO TABS 27 oxazepam caps 10mg 15mg 30mg 31 OXBRYTA TABS 21 OXBRYTA TBSO 21 oxcarbazepine susp 29 oxcarbazepine tabs 150mg 300mg 600mg
29 OXERVATE SOLN 39 oxiconazole nitrate crea 53 OXLUMO SOLN 50 OXTELLAR XR TB24 150mg 300mg
600mg 29 oxybutynin chloride er tb24 5mg 10mg
15mg 57 oxybutynin chloride syrp 57 oxybutynin chloride tabs 57 oxycodone hcl caps 27 oxycodone hcl conc 27 oxycodone hcl er t12a 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxycodone hcl soln 27 oxycodone hcl tabs 5mg 10mg 15mg
20mg 30mg 27 oxycodone-acetaminophen soln 27
oxycodone-acetaminophen tabs 27 oxycodone-acetaminophen tabs 5-300mg
75-300mg 10-300mg 27 oxycodone-aspirin tabs 27 oxycodone-ibuprofen tabs 27 OXYCONTIN T12A 10mg 15mg 20mg
30mg 40mg 60mg 80mg 27 oxymorphone hcl er tb12 5mg 75mg
10mg 15mg 20mg 30mg 40mg 27 oxymorphone hcl tabs 5mg 10mg 27 OXYTOCIN SOLN 45 OZEMPIC (025 OR 05 MGDOSE) SOPN
45 OZEMPIC (1 MGDOSE) SOPN 2mg15ml
4mg3ml 45 OZEMPIC (2 MGDOSE) SOPN 45
P pacerone tabs 100mg 200mg 400mg 24 paclitaxel conc 17 PACLITAXEL PROTEIN-BOUND PART
SUSR 100 MG 17 PADCEV SOLR 20mg 30mg 17 PALFORZIA (12 MG DAILY DOSE) CSPK
50 PALFORZIA (120 MG DAILY DOSE) CSPK
50 PALFORZIA (160 MG DAILY DOSE) CSPK
50 PALFORZIA (20 MG DAILY DOSE) CSPK
50 PALFORZIA (200 MG DAILY DOSE) CSPK
50 PALFORZIA (240 MG DAILY DOSE) CSPK
50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK 50 PALFORZIA (300 MG TITRATION) PACK
50 PALFORZIA (40 MG DAILY DOSE) CSPK
50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
50 PALFORZIA INITIAL ESCALATION CSPK
50 PALIPERIDONE ER TB24 15mg 3mg
6mg 9mg 34
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 85
palonosetron hcl soln 40 palonosetron hcl sosy 40 PALYNZIQ SOSY 25mg05ml
10mg05ml 20mgml 38 pamidronate disodium soln 47 pamidronate disodium solr 47 panlor tabs 27 PANRETIN GEL 56 pantoprazole sodium pack 40 PANTOPRAZOLE SODIUM SOLR 40 pantoprazole sodium tbec 20mg 40mg 40 PANZYGA SOLN INTRAVENOUS
10gm100ml 1gm10ml 20gm200ml 25gm25ml 30gm300ml 5gm50ml 52
paraplatin soln 17 paricalcitol caps 1mcg 2mcg 4mcg 57 PARICALCITOL SOLN 57 paroex soln 38 paromomycin sulfate caps 11 paroxetine hcl er tb24 125mg 25mg
375mg 34 paroxetine hcl susp 34 paroxetine hcl tabs 10mg 20mg 34 paroxetine hcl tabs 30mg 40mg 34 paroxetine mesylate caps 34 paser pack 11 PEDIARIX SUSY 52 PEDVAX HIB SUSP 52 peg 3350electrolytes solr 41 peg 3350-kcl-na bicarb-nacl solr 41 peg-3350electrolytes solr 41 PEGANONE TABS 29 PEGASYS PROCLICK SOAJ
135mcg05ml 180mcg05ml 12 PEGASYS SOLN 12 PEGASYS SOSY 12 PEGINTRON KIT 12 PEG-PREP KIT 41 PEMAZYRE TABS 45mg 9mg 135mg 17 PEMFEXY SOLN 17 penicillamine caps 41 penicillamine tabs 41 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
PENTACEL SUSR 52 pentamidine isethionate inh 11 pentamidine isethionate inj 11 PENTASA CPCR 250mg 500mg 40 pentazocine-naloxone hcl tabs 27 pentobarbital sodium soln 31 pentoxifylline er tbcr 21 PEPAXTO SOLR 17 pepcid tabs 20mg 40mg 40 percocet tabs 27 perindopril erbumine tabs 2mg 4mg 8mg
25 periogard soln 38 PERJETA SOLN 17 permethrin crea 53 perphenazine tabs 2mg 4mg 8mg 16mg
34 perphenazine-amitriptyline tabs 34 PERSERIS PRSY 90mg 120mg 34 PEXEVA TABS 10mg 20mg 30mg 40mg
34 phenadoz supp 14 phenazo tabs 56 PHENAZOPYRIDINE HCL TABS 56 phenelzine sulfate tabs 34 phenergan soln 14 PHENOBARBITAL ELIX 31 PHENOBARBITAL SODIUM SOLN 31 PHENOBARBITAL TABS 31 phenoxybenzamine hcl caps 20 phenylephrine hcl soln 20 PHENYLEPHRINE HCL SOLN 39 phenytek caps 200mg 300mg 29 phenytoin chew 29 phenytoin sodium extended caps 100mg
200mg 300mg 29 phenytoin sodium soln 29 phenytoin susp 29 PHESGO SOLN 17 PHOSLYRA SOLN 37 PHOSPHASAL TABS 13 PHOSPHOLINE IODIDE SOLR 39 phrenilin forte caps 27 PHYSIOLYTE SOLN 50 PHYSIOSOL IRRIGATION SOLN 50 PIFELTRO TABS 12 pilocarpine hcl soln 1 2 4 39 pilocarpine hcl tabs 5mg 75mg 19 pimecrolimus crea 57
86 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
pimozide tabs 1mg 2mg 34 pimtrea tabs 44 pindolol tabs 5mg 10mg 23 pioglitazone hcl tabs 15mg 30mg 45mg 45 pioglitazone hcl-glimepiride tabs 45 pioglitazone hcl-metformin hcl tabs 45 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 44 piroxicam caps 10mg 20mg 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN 32 PLEGRIDY SOSY 32 PLEGRIDY STARTER PACK SOPN 32 PLEGRIDY STARTER PACK SOSY 32 plenamine soln intravenous 36 podofilox soln 57 POLIVY SOLR 30mg 140mg 17 polocaine soln 50 polocaine-mpf soln 50 polycin oint 38 polymyxin b sulfate solr injection 10 polymyxin b-trimethoprim soln 38 POMALYST CAPS 1mg 2mg 3mg 4mg 17 PONVORY STARTER PACK TBPK 32 PONVORY TABS 32 portia-28 tabs 44 PORTRAZZA SOLN 17 posaconazole tbec 11 POT amp SOD CIT-CIT AC SOLN 35 POTASSIUM ACETATE SOLN 37 potassium chloride crys er tbcr 10meq
20meq 37 potassium chloride er cpcr 8meq 10meq 37 POTASSIUM CHLORIDE ER TBCR 8meq
10meq 20meq 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS 37 POTASSIUM CHLORIDE IN NACL SOLN
INTRAVENOUS 37 POTASSIUM CHLORIDE PACK 37 POTASSIUM CHLORIDE SOLN 10 20
37
potassium chloride soln intravenous 10meq100ml 20meq100ml 40meq100ml 2meqml 37
potassium citrate er tbcr 15meq 540mg 1080mg 35
POTASSIUM PHOSPHATES SOLN 37 POTASSIUM PHOSPHATES(66 MEQ K)
SOLN 37 POTELIGEO SOLN 17 PR BENZOYL PEROXIDE WASH LIQD 53 PRADAXA CAPS 75mg 110mg 150mg 21 pramipexole dihydrochloride er tb24
0375mg 075mg 15mg 225mg 3mg 375mg 45mg 31
pramipexole dihydrochloride tabs 0125mg 025mg 05mg 075mg 1mg 15mg 31
PRAMOX GEL 56 prandin tabs 1mg 2mg 45 prasugrel hcl tabs 5mg 10mg 21 pravastatin sodium tabs 10mg 20mg
40mg 80mg 22 praziquantel tabs 8 prazosin hcl caps 1mg 2mg 5mg 22 PRED MILD SUSP 39 PRED-G SOP OINT 39 PRED-G SUSP 39 prednicarbate crea 55 prednicarbate oint 55 prednisolone acetate susp 39 prednisolone sodium phosphate soln 39 PREDNISOLONE SODIUM PHOSPHATE
SOLN 10mg5ml 20mg5ml 25mg5ml 5mg5ml 42
prednisolone sodium phosphate tbdp 10mg 15mg 30mg 42
prednisolone soln 42 prednisone intensol conc 42 prednisone soln 42 prednisone tabs 1mg 25mg 5mg 10mg
20mg 50mg 42 prednisone tbpk 42 prefest tabs 45 pregabalin caps 25mg 50mg 75mg
100mg 150mg 200mg 225mg 300mg 29
pregabalin er tb24 825mg 165mg 330mg 27
pregabalin soln 29 PREHEVBRIO SUSP 52
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 87
PREMARIN SOLR 45 premasol soln intravenous 36 PRENATAL TABS 57 PRETOMANID TABS 11 prevalite pack 22 prevalite powd 22 previfem tabs 44 PREVYMIS SOLN 240mg12ml
480mg24ml 12 PREVYMIS TABS 240mg 480mg 12 PREZCOBIX TABS 12 PREZISTA SUSP 12 PREZISTA TABS 75mg 150mg 600mg
800mg 12 PRIFTIN TABS 11 PRIMAQUINE PHOSPHATE TABS 11 primidone tabs 50mg 250mg 29 primlev tabs 27 probenecid tabs 37 procainamide hcl soln 24 PROCALAMINE SOLN INTRAVENOUS 36 procentra soln 28 prochlorperazine edisylate soln 34 prochlorperazine maleate tabs 34 prochlorperazine supp 34 PROCRIT SOLN 20000unitml
40000unitml 22 PROCRIT SOLN 2000unitml 3000unitml
4000unitml 10000unitml 22 proctofoam hc foam 56 procto-med hc crea 55 procto-pak crea 55 proctosol hc crea 55 proctozone-hc crea 55 PROCYSBI CPDR 25mg 75mg 50 PROCYSBI PACK 75mg 300mg 50 progesterone caps 100mg 200mg 46 progesterone oil 46 PROGRAF PACK 49 PROGRAF PACK 02mg 49 PROGRAF SOLN 49 prolate soln 27 prolate tabs 27 PROLEUKIN SOLR 17 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 24 propafenone hcl tabs 150mg 225mg
300mg 24 propantheline bromide tabs 19 proparacaine hcl soln 40 propranolol hcl er cp24 60mg 80mg
120mg 160mg 23 propranolol hcl soln 20mg5ml 40mg5ml 23 propranolol hcl tabs 10mg 20mg 40mg
60mg 80mg 23 propranolol-hctz tabs 23 propylthiouracil tabs 47 PROQUAD SUSR 52 protriptyline hcl tabs 5mg 10mg 34 psorcon crea 55 PULMICORT FLEXHALER AEPB 51 PULMOZYME SOLN 38 PURIXAN SUSP 17 PYLERA CAPS 40 pyrazinamide tabs 11 pyridostigmine bromide er tbcr 19 pyridostigmine bromide soln 19 pyridostigmine bromide tabs 30mg 60mg 19 pyrimethamine tabs 11 PYRUKYND TABS 5mg 20mg 50mg 50 PYRUKYND TAPER PACK TBPK 50
Q QDOLO SOLN 27 QINLOCK TABS 17 QUADRACEL SUSP 52 questran light powd 22 questran pack 22 questran powd 22 quetiapine fumarate er tb24 50mg 150mg
200mg 300mg 400mg 34 quetiapine fumarate tabs 25mg 50mg
100mg 200mg 300mg 400mg 34 quinapril hcl tabs 5mg 10mg 20mg 40mg
25 quinapril-hydrochlorothiazide tabs 25 quinidine gluconate er tbcr 24 QUINIDINE GLUCONATE SOLN 24 quinidine sulfate tabs 200mg 300mg 24
88 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
quinine sulfate caps 11 QULIPTA TABS 10mg 30mg 60mg 30
R RABAVERT SUSR 52 rabeprazole sodium cpsp 40 rabeprazole sodium tbec 40 RADIAURA CREA 55 RADICAVA SOLN 32 raloxifene hcl tabs 45 ramelteon tabs 31 ramipril caps 125mg 25mg 5mg 10mg 25 ranolazine er tb12 500mg 1000mg 24 RAPIVAB SOLN 12 rasagiline mesylate tabs 05mg 1mg 31 RASUVO SOAJ 48 RAVICTI LIQD 35 RAYALDEE CPCR 57 REBETOL SOLN 12 REBIF REBIDOSE SOAJ 22mcg05ml
44mcg05ml 32 REBIF REBIDOSE TITRATION PACK
SOAJ 32 REBIF SOSY 22mcg05ml 44mcg05ml 32 REBIF TITRATION PACK SOSY 32 REBLOZYL SOLR 25mg 75mg 22 RECARBRIO SOLR 10 reclipsen tabs 44 RECOMBIVAX HB SUSP 5mcg05ml
10mcgml 40mcgml 52 RECORLEV TABS 50 RECTIV OINT 57 REGONOL SOLN 19 REGRANEX GEL 57 relafen ds tabs 27 RELENZA DISKHALER AEPB 12 RELEUKO SOLN 300mcgml
480mcg16ml 22 RELEUKO SOSY 300mcg05ml
480mcg08ml 22 relexxii tbcr 28 RELISTOR SOLN 8mg04ml 12mg06ml
41 RELISTOR TABS 41 reltone caps 200mg 400mg 41 REMICADE SOLR INTRAVENOUS 48 RENFLEXIS SOLR 48 repaglinide tabs 05mg 1mg 2mg 45 repaglinide-metformin hcl tabs 45
REPATHA SOSY 22 REPATHA SURECLICK SOAJ 22 RESCRIPTOR TABS 100mg 200mg 12 RESTASIS EMUL 39 RESTASIS MULTIDOSE EMUL 39 RETACRIT SOLN 22 RETACRIT SOLN 20000unitml 22 RETEVMO CAPS 40mg 80mg 17 RETIN-A CREA 0025 005 01 56 RETIN-A GEL 001 0025 56 RETIN-A MICRO GEL 004 01 56 RETIN-A MICRO PUMP GEL 004 01
56 RETISERT IMPL 39 RETROVIR SOLN 12 REVCOVI SOLN 38 REVLIMID CAPS 25mg 5mg 10mg
15mg 20mg 25mg 17 REXULTI TABS 025mg 05mg 1mg 2mg
3mg 4mg 34 REYATAZ PACK 12 REZUROCK TABS 50 RIABNI SOLN 100mg10ml 500mg50ml 17 ribasphere caps 12 ribasphere ribapak (1000 pack) tbpk 12 ribasphere ribapak (1200 pack) tbpk 12 ribasphere tabs 12 ribavirin caps 12 ribavirin solr 12 ribavirin tabs 13 RIDAURA CAPS 50 rifabutin caps 11 RIFADIN CAPS 11 rifamate caps 11 rifampin caps 150mg 300mg 11 rifampin solr intravenous 11 riluzole tabs 32 rimantadine hcl tabs 13 RIMSO-50 SOLN 50 RINGERS IRRIGATION SOLN 50 RINGERS SOLN 37 RINVOQ TB24 15mg 30mg 45mg 48 risedronate sodium tabs 5mg 30mg 35mg
150mg 47 risedronate sodium tbec 47 RISPERDAL CONSTA SRER 125mg
25mg 34 RISPERDAL CONSTA SRER 375mg
50mg 35
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 89
RISPERIDONE SOLN 35 risperidone tabs 025mg 05mg 1mg 2mg
3mg 4mg 35 risperidone tbdp 025mg 05mg 1mg 2mg
3mg 4mg 35 ritonavir tabs 13 RITUXAN HYCELA SOLN 17 RITUXAN SOLN 17 rivastigmine pt24 46mg24hr 95mg24hr
133mg24hr 20 rivastigmine tartrate caps 15mg 3mg
45mg 6mg 20 rivelsa tabs 44 rizatriptan benzoate tabs 30 rizatriptan benzoate tbdp 30 ROMIDEPSIN SOLN 17 ropinirole hcl er tb24 2mg 4mg 6mg 8mg
12mg 31 ropinirole hcl tabs 025mg 05mg 1mg
2mg 3mg 4mg 5mg 31 ropivacaine hcl soln 50 rosuvastatin calcium tabs 5mg 10mg
20mg 40mg 22 ROTARIX SUSR 52 ROTATEQ SOLN 52 roweepra tabs 500mg 750mg 1000mg 29 roweepra xr tb24 500mg 750mg 29 ROZLYTREK CAPS 100mg 200mg 17 RUBRACA TABS 200mg 250mg 300mg 17 RUCONEST SOLR INTRAVENOUS 21 rufinamide susp 29 rufinamide tabs 200mg 400mg 29 RUKOBIA TB12 13 RUXIENCE SOLN 100mg10ml
500mg50ml 17 RYBREVANT SOLN 17 ryclora soln 14 RYDAPT CAPS 17 RYLAZE SOLN 17 RYNODERM CREA 57 ryvent tabs 14
S SAIZEN CLICKEASY SOLR 46 SAIZEN SOLR 5mg 88mg 46 SAIZENPREP SOLR 46 sajazir soln 21 SALEX SHAM 57 SALICYLIC ACID CREA 57
SALICYLIC ACID ER SOLN 57 SALICYLIC ACID FOAM 57 SALICYLIC ACID GEL 57 SALICYLIC ACID SHAM 57 SALICYLIC ACID-CLEANSER KIT 57 SALSALATE TABS 27 SANCUSO PTCH 40 SANDIMMUNE ORAL SOLN 100mgml 49 SANDOSTATIN LAR DEPOT KIT 10mg
20mg 30mg 46 SANTYL OINT 57 SAPHNELO SOLN 49 SAPHRIS SUBL 25mg 5mg 10mg 35 sapropterin dihydrochloride pack 100mg
500mg 50 sapropterin dihydrochloride tabs 50 SARCLISA SOLN 500mg25ml 100mg5ml
17 SCEMBLIX TABS 20mg 40mg 17 scopolamine pt72 40 seconal caps 31 SECUADO PT24 38mg24hr 57mg24hr
76mg24hr 35 selegiline hcl caps 31 selegiline hcl tabs 31 selenium sulfide lotn 53 SELENIUM SULFIDE SHAM 53 SELZENTRY SOLN 13 SELZENTRY TABS 25mg 75mg 13 SENSORCAINE SOLN 50 sensorcaineepinephrine soln 50 sensorcaine-mpf soln 50 sensorcaine-mpfepinephrine soln 50 SEREVENT DISKUS AEPB 20 SEROSTIM SOLR 4mg 5mg 6mg 46 SERTRALINE HCL CAPS 150mg 200mg
35 sertraline hcl conc 35 sertraline hcl tabs 25mg 50mg 100mg 35 setlakin tabs 44 sevelamer carbonate pack 08gm 24gm 36 sevelamer carbonate tabs 36 sevelamer hcl tabs 400mg 800mg 36 SEYSARA TABS 60mg 100mg 150mg 10 sharobel tabs 44 SHINGRIX SUSR 52 SIGNIFOR LAR SRER 10mg 20mg 30mg
40mg 60mg 46
90 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
SIGNIFOR SOLN 03mgml 06mgml 09mgml 46
SIKLOS TABS 17 sildenafil citrate soln 25 sildenafil citrate susr 25 sildenafil citrate tabs 25 SILIQ SOSY 57 silodosin caps 4mg 8mg 20 SILVER SULFADIAZINE CREA 53 SIMPONI ARIA SOLN 48 SIMPONI SOAJ 50mg05ml 100mgml 48 SIMPONI SOSY 50mg05ml 100mgml 48 simvastatin tabs 5mg 10mg 20mg 40mg
80mg 22 sirolimus soln 49 sirolimus tabs 05mg 1mg 2mg 49 SIRTURO TABS 20mg 100mg 11 SIVEXTRO SOLR INTRAVENOUS 10 SIVEXTRO TABS 10 SKYRIZI (150 MG DOSE) PSKT 57 SKYRIZI PEN SOAJ 57 SKYRIZI SOSY 57 SKYTROFA CART 3mg 36mg 43mg
52mg 63mg 76mg 91mg 11mg 133mg 46
sod benz-sod phenylacet soln 35 SODIUM ACETATE SOLN 35 SODIUM BICARBONATE SOLN 35 SODIUM CHLORIDE (PF) SOLN 37 SODIUM CHLORIDE SOLN 37 50 SODIUM CHLORIDE SOLN
INTRAVENOUS 045 09 3 5 37 SODIUM FLUORIDE CHEW 025mg
05mg 1mg 50 SODIUM FLUORIDE SOLN 50 sodium phenylbutyrate powd 35 sodium phenylbutyrate tabs 35 SODIUM PHOSPHATES SOLN 37 sodium polystyrene sulfonate powd 36 sodium polystyrene sulfonate susp 36 sofosbuvir-velpatasvir tabs 13 solifenacin succinate tabs 5mg 10mg 57 SOLTAMOX SOLN 17 SOLU-CORTEF SOLR 42 SOLU-MEDROL SOLR 42 SOMATULINE DEPOT SOLN 60mg02ml
90mg03ml 120mg05ml 46 SOMAVERT SOLR 10mg 15mg 20mg
25mg 30mg 46
sorine tabs 80mg 120mg 160mg 240mg 23
sotalol hcl (af) tabs 80mg 120mg 160mg 23 sotalol hcl tabs 80mg 120mg 160mg
240mg 23 SOTYLIZE SOLN 23 SOVALDI PACK 150mg 200mg 13 SOVALDI TABS 200mg 400mg 13 SPIRIVA RESPIMAT AERS 19 SPIRIVA RESPIMAT AERS 25mcgact 19 spironolactone tabs 25mg 50mg 100mg 25 spironolactone-hctz tabs 25 SPRAVATO (56 MG DOSE) SOPK 35 SPRAVATO (84 MG DOSE) SOPK 35 sprintec 28 tabs 44 SPRITAM TB3D 250mg 500mg 750mg
1000mg 29 SPRYCEL TABS 20mg 50mg 70mg
80mg 100mg 140mg 18 sps susp 36 sronyx tabs 44 SSD CREA 53 stavudine caps 15mg 20mg 30mg 40mg
13 STELARA SOLN 45mg05ml 130mg26ml
57 STELARA SOSY 45mg05ml 90mgml 57 STERILE WATER FOR IRRIGATION SOLN
50 STIMATE SOLN 46 STIOLTO RESPIMAT AERS 19 STIVARGA TABS 18 STRENSIQ SOLN 18mg045ml
28mg07ml 80mg08ml 40mgml 38 streptomycin sulfate solr 10 STRIBILD TABS 13 STRIVERDI RESPIMAT AERS 20 SUBLOCADE SOSY 100mg05ml
300mg15ml 32 SUBSYS LIQD 1200mcg 1600mcg 27 subvenite starter kit-blue kit 29 subvenite starter kit-green kit 29 subvenite starter kit-orange kit 30 subvenite tabs 25mg 100mg 150mg
200mg 30 succinylcholine chloride soln 20 SUCRAID SOLN 38 sucralfate susp 40 sucralfate tabs 40
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 91
sulfacetamide sodium (acne) lotn 53 sulfacetamide sodium oint 38 sulfacetamide sodium soln 38 sulfacetamide-prednisolone soln 39 sulfadiazine tabs 10 sulfamethoxazole-trimethoprim soln 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tabs 10 SULFAMYLON CREA 53 sulfasalazine tabs 10 sulfasalazine tbec 10 SULFATRIM PEDIATRIC SUSP 10 sulindac tabs 27 sumatriptan soln 30 sumatriptan succinate refill soct 30 sumatriptan succinate soaj 30 sumatriptan succinate soln 30 sumatriptan succinate sosy 30 sumatriptan succinate tabs 30 sunitinib malate caps 125mg 25mg
375mg 50mg 18 suprax chew 10 SUPREP BOWEL PREP KIT SOLN 41 SUSVIMO (IMPLANT 1ST FILL) SOLN 39 SUSVIMO (IMPLANT REFILL) SOLN 39 SUTENT CAPS 125mg 25mg 375mg
50mg 18 syeda tabs 44 SYLVANT SOLR 100mg 400mg 18 SYMBICORT AERO 51 SYMDEKO TBPK 51 SYMFI LO TABS 13 SYMFI TABS 13 SYMLINPEN 120 SOPN 45 SYMLINPEN 60 SOPN 45 SYMPAZAN FILM 10mg 20mg 30 SYMPAZAN FILM 5mg 30 SYMTUZA TABS 13 SYNAGIS SOLN 50mg05ml 100mgml 13 SYNAREL SOLN 46 SYNDROS SOLN 40 SYNERCID SOLR 10 SYNRIBO SOLR 18
T TABLOID TABS 18 TABRECTA TABS 150mg 200mg 18 tacrolimus caps 05mg 1mg 5mg 49 TACROLIMUS OINT 01 003 57
tadalafil (pah) tabs 20mg 25 tadalafil tabs 25mg 5mg 25 TAFINLAR CAPS 50mg 75mg 18 TAGRISSO TABS 40mg 80mg 18 TAKHZYRO SOLN 50 TAKHZYRO SOSY 50 TALTZ SOAJ 57 TALTZ SOSY 57 TALZENNA CAPS 025mg 05mg 075mg
1mg 18 tamoxifen citrate tabs 18 tamsulosin hcl caps 20 tapazole tabs 5mg 10mg 47 taperdex 12-day tbpk 42 taperdex 6-day tbpk 42 taperdex 7-day tbpk 42 targadox tabs 10 TARGRETIN GEL 56 tarina 24 fe tabs 44 tarina fe 120 eq tabs 44 TARPEYO CPDR 42 TASIGNA CAPS 50mg 150mg 200mg 18 TAVALISSE TABS 100mg 150mg 22 TAVNEOS CAPS 50 taysofy caps 44 tazarotene crea 57 tazarotene foam 57 tazicef solr injection 10 tazicef solr intravenous 2gm 6gm 10 TAZORAC CREA 57 TAZORAC GEL 005 01 57 taztia xt cp24 120mg 180mg 240mg
300mg 360mg 24 TAZVERIK TABS 18 TDVAX SUSP 52 TECENTRIQ SOLN 840mg14ml
1200mg20ml 18 TEFLARO SOLR INTRAVENOUS 10 TEGSEDI SOSY 50 telmisartan tabs 20mg 40mg 80mg 25 telmisartan-amlodipine tabs 24 telmisartan-hctz tabs 25 TEMAZEPAM CAPS 75mg 15mg 225mg
30mg 31 temsirolimus soln 18 tencon tabs 27 TENIPOSIDE SOLN 18 TENIVAC INJ 52 tenofovir disoproxil fumarate tabs 13
92 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TEPADINA SOLR 18 TEPEZZA SOLR 39 TEPMETKO TABS 18 terazosin hcl caps 1mg 2mg 5mg 10mg 22 terbinafine hcl tabs 11 terbutaline sulfate soln 20 terbutaline sulfate tabs 25mg 5mg 20 terconazole crea 53 terconazole supp 53 TERIPARATIDE (RECOMBINANT) SOPN
46 testosterone cypionate soln 100mgml
200mgml 42 testosterone enanthate soln 42 testosterone gel 1 162
2025mg125gm 405mg25gm 10mgact 42
testosterone soln 42 tetrabenazine tabs 125mg 25mg 32 TETRACAINE HCL SOLN 40 tetracycline hcl caps 250mg 500mg 10 texacort soln 55 TEZSPIRE SOSY 51 THALOMID CAPS 50mg 100mg 150mg
200mg 18 theo-24 cp24 100mg 200mg 300mg
400mg 57 theophylline er tb12 100mg 200mg
300mg 450mg 57 theophylline er tb24 400mg 600mg 57 theophylline soln 57 THIOLA EC TBEC 100mg 300mg 50 THIOLA TABS 50 thioridazine hcl tabs 10mg 25mg 50mg
100mg 35 thiotepa solr 15mg 100mg 18 thiothixene caps 1mg 2mg 5mg 10mg 35 THYROGEN SOLR 50 tiadylt er cp24 120mg 180mg 240mg
300mg 360mg 420mg 24 tiagabine hcl tabs 2mg 4mg 12mg 16mg
30 TIBSOVO TABS 18 TICOVAC SUSY 52 TIGECYCLINE SOLR INTRAVENOUS 10 TIGLUTIK SUSP 32 tilia fe tabs 44 timolol maleate (once-daily) soln 39 timolol maleate pf soln 39
TIMOLOL MALEATE SOLG 025 05 39 timolol maleate soln 025 05 39 timolol maleate tabs 5mg 10mg 20mg 23 tinidazole tabs 11 tiopronin tabs 50 TIS-U-SOL SOLN 50 TIVDAK SOLR 18 TIVICAY PD TBSO 13 TIVICAY TABS 10mg 25mg 50mg 13 tizanidine hcl caps 20 tizanidine hcl tabs 20 TOBI PODHALER CAPS 51 TOBRADEX OINT 39 TOBRADEX ST SUSP 39 tobramycin nebu 300mg4ml 300mg5ml 51 tobramycin soln 38 tobramycin sulfate soln injection 80mg2ml
10mgml 10 tobramycin-dexamethasone susp 39 TOBREX OINT 38 tofranil tabs 10mg 25mg 50mg 35 tolazamide tabs 250mg 500mg 45 tolbutamide tabs 45 tolcapone tabs 31 tolmetin sodium caps 27 tolmetin sodium tabs 27 TOLSURA CAPS 11 tolterodine tartrate er cp24 2mg 4mg 57 tolterodine tartrate tabs 57 tolvaptan tabs 15mg 30mg 36 TOPEX TOPICAL ANESTHETIC AERO 56 topicort crea 005 025 55 topicort gel 55 topicort oint 55 topiramate cpsp 15mg 25mg 30 topiramate er cs24 25mg 50mg 100mg
150mg 200mg 30 topiramate tabs 25mg 50mg 100mg
200mg 30 toposar soln 18 TOPOTECAN HCL SOLN 18 topotecan hcl solr 18 toremifene citrate tabs 18 torsemide tabs 5mg 10mg 20mg 100mg
36 TPN ELECTROLYTES CONC
INTRAVENOUS 37 TRACLEER TBSO 51 TRADJENTA TABS 45
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 93
tramadol hcl er (biphasic) tb24 100mg 200mg 300mg 28
tramadol hcl er cp24 100mg 150mg 200mg 300mg 28
tramadol hcl er tb24 100mg 200mg 300mg 28
tramadol hcl soln 28 tramadol hcl tabs 50mg 100mg 28 tramadol-acetaminophen tabs 28 trandolapril tabs 1mg 2mg 4mg 25 trandolapril-verapamil hcl er tbcr 24 tranexamic acid soln 21 tranexamic acid tabs 21 tranylcypromine sulfate tabs 35 TRAVASOL SOLN INTRAVENOUS 36 travoprost (bak free) soln 39 TRAZIMERA SOLR 150mg 420mg 18 trazodone hcl tabs 150mg 300mg 35 trazodone hcl tabs 50mg 100mg 35 TRECATOR TABS 11 TRELSTAR MIXJECT SUSR 18 TREMFYA SOPN 57 TREMFYA SOSY 57 treprostinil soln 20mg20ml 50mg20ml
100mg20ml 200mg20ml 51 tretinoin caps 18 tretinoin crea 0025 005 01 56 tretinoin gel 001 0025 005 56 tretinoin microsphere gel 004 01 56 tretinoin microsphere pump gel 004
01 56 trexall tabs 5mg 75mg 10mg 15mg 18 trezix caps 28 triamcinolone acetonide aers 55 triamcinolone acetonide crea 0025
01 05 55 triamcinolone acetonide lotn 0025 01
55 triamcinolone acetonide oint 0025
005 01 05 55 triamcinolone acetonide pste 55 triamcinolone acetonide susp 42 triamterene caps 50mg 100mg 36 triamterene-hctz caps 36 triamterene-hctz tabs 36 trianex oint 55 triazolam tabs 0125mg 025mg 31 TRICITRATES SOLN 35 triderm crea 01 05 55
trientine hcl caps 41 tri-estarylla tabs 44 trifluoperazine hcl tabs 1mg 2mg 5mg
10mg 35 trifluridine soln 38 trihexyphenidyl hcl soln 31 trihexyphenidyl hcl tabs 2mg 5mg 31 TRIKAFTA TBPK 51 tri-legest fe tabs 44 tri-lo-estarylla tabs 44 tri-lo-sprintec tabs 44 trilyte solr 41 trimethobenzamide hcl caps 40 TRIMETHOPRIM TABS 13 tri-mili tabs 44 trimipramine maleate caps 25mg 50mg
100mg 35 TRINESSA (28) TABS 44 TRINTELLIX TABS 5mg 10mg 20mg 35 tri-nymyo tabs 44 tri-previfem tabs 44 TRIPTODUR SRER 45 TRISENOX
SOLN 18 tri-sprintec tabs 44 tritocin oint 55 TRIUMEQ PD TBSO 13 TRIUMEQ TABS 13 trivora (28) tabs 44 tri-vylibra lo tabs 44 tri-vylibra tabs 44 TRIZIVIR TABS 13 TRODELVY SOLR 18 TROKENDI XR CP24 25mg 50mg 100mg
200mg 30 TROPHAMINE SOLN INTRAVENOUS 36 trospium chloride er cp24 57 trospium chloride tabs 57 TRULANCE TABS 41 TRUMENBA SUSY 52 TRUSELTIQ (100MG DAILY DOSE) CPPK
18 TRUSELTIQ (125MG DAILY DOSE) CPPK
18 TRUSELTIQ (50MG DAILY DOSE) CPPK
18 TRUSELTIQ (75MG DAILY DOSE) CPPK
18
94 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
TRUXIMA SOLN 100mg10ml 500mg50ml 18
TUKYSA TABS 50mg 150mg 18 TURALIO CAPS 18 TWINRIX SUSY 52 TYBOST TABS 13 tydemy tabs 44 tylenol with codeine 3 tabs 28 tylenol with codeine 4 tabs 28 TYMLOS SOPN 46 TYPHIM VI SOLN 52 TYPHIM VI SOSY 52 TYVASO REFILL SOLN 51 TYVASO STARTER SOLN 51
U UBRELVY TABS 50mg 100mg 30 UDENYCA SOSY 22 UKONIQ TABS 18 ULTOMIRIS SOLN 50 UMECTA MOUSSE FOAM 57 UNITHROID TABS 25mcg 50mcg 75mcg
88mcg 100mcg 112mcg 125mcg 137mcg 150mcg 175mcg 200mcg 300mcg 47
UNITUXIN SOLN 18 UPTRAVI SOLR 51 UPTRAVI TABS 200mcg 400mcg 600mcg
800mcg 1000mcg 1200mcg 1400mcg 1600mcg 51
UPTRAVI TBPK 51 UREA CREA 39 57 UREA LOTN 40 57 UREA-C40 LOTN 57 urecholine tabs 5mg 10mg 25mg 50mg 20 uredeb crea 57 URETRON DS TABS 13 URIN DS TABS 13 ursodiol caps 200mg 400mg 41 ursodiol caps 300mg 41 ursodiol tabs 250mg 500mg 41 URYL TABS 13 USTELL CAPS 13 UTICAP CAPS 13 UTIRA-C TABS 13 UTRONA-C TABS 13
V VABYSMO SOLN 39 valacyclovir hcl tabs 1gm 500mg 13 VALCHLOR GEL 57 valganciclovir hcl solr 13 valganciclovir hcl tabs 13 valproate sodium soln 30 valproic acid caps 30 valproic acid soln 30 valrubicin soln 18 valsartan tabs 40mg 80mg 160mg 320mg
25 valsartan-hydrochlorothiazide tabs 25 VALTOCO 10 MG DOSE LIQD 30 VALTOCO 15 MG DOSE LQPK 30 VALTOCO 20 MG DOSE LQPK 30 VALTOCO 5 MG DOSE LIQD 30 vanatol lq soln 28 vancomycin hcl caps 10 vancomycin hcl solr 250mg5ml 10 vancomycin hcl solr intravenous 1gm
10gm 500mg 10 vancomycin hcl solr intravenous 5gm
750mg 10 VANDAZOLE GEL 53 VANOXIDE-HC LOTN 55 VANTAS KIT 18 VAQTA SUSP 52 varenicline tartrate misc 19 varenicline tartrate tabs 05mg 1mg 19 VARIVAX INJ 52 VARIZIG SOLN 52 VASCEPA CAPS 1gm 22 VAXCHORA SUSR 53 vecamyl tabs 24 VECTICAL OINT 57 VEKLURY SOLN 13 VEKLURY SOLR 13 VELCADE SOLR 18 velivet tabs 44 VELPHORO CHEW 36 VELTASSA PACK 84gm 168gm 252gm
36 VEMLIDY TABS 13 VENCLEXTA STARTING PACK TBPK 18 VENCLEXTA TABS 10mg 18 VENCLEXTA TABS 50mg 100mg 18
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 95
venlafaxine hcl er cp24 375mg 75mg 150mg 35
venlafaxine hcl er tb24 375mg 75mg 150mg 225mg 35
venlafaxine hcl tabs 25mg 375mg 50mg 75mg 100mg 35
VENTAVIS SOLN 10mcgml 20mcgml 52 verapamil hcl er tbcr 120mg 180mg 240mg
24 verapamil hcl soln 24 verapamil hcl tabs 40mg 80mg 120mg 24 veripred 20 soln 42 VERKAZIA EMUL 39 VERSACLOZ SUSP 35 VERZENIO TABS 50mg 100mg 150mg
200mg 18 vestura tabs 44 VIBERZI TABS 75mg 100mg 41 vicodin es tabs 28 vicodin hp tabs 28 vicodin tabs 28 VICTOZA SOPN 45 VIDEX EC CPDR 13 VIDEX SOLR 2gm 4gm 13 VIEKIRA PAK TBPK 13 VIEKIRA XR TB24 13 vienva tabs 44 vigabatrin pack 30 vigabatrin tabs 30 VIIBRYD STARTER PACK KIT 35 VIIBRYD TABS 10mg 20mg 40mg 35 VIJOICE TBPK 50 VILTEPSO SOLN 50 VIMIZIM SOLN 38 VIMPAT SOLN 30 vinblastine sulfate soln 18 vincasar pfs soln 18 vincristine sulfate soln 18 vinorelbine tartrate soln 18 VIRACEPT TABS 250mg 625mg 13 VIREAD POWD 13 VIREAD TABS 150mg 13 VIREAD TABS 200mg 250mg 13 VISTOGARD PACK 47 VITRAKVI CAPS 25mg 100mg 18 VITRAKVI SOLN 18 VIVITROL SUSR 32 VIZIMPRO TABS 15mg 30mg 45mg 18 VOCABRIA TABS 13
VONJO CAPS 18 VORAXAZE SOLR 47 voriconazole solr intravenous 11 voriconazole susr 11 voriconazole tabs 11 VOSEVI TABS 13 VOTRIENT TABS 18 VOXZOGO SOLR 04mg 056mg 12mg 50 VPRIV SOLR 38 VRAYLAR CAPS 15mg 3mg 45mg 6mg
35 VRAYLAR CPPK 35 VUMERITY (STARTER) CPDR 50 VUMERITY CPDR 50 vyfemla tabs 44 vylibra tabs 44 VYNDAMAX CAPS 24 VYNDAQEL CAPS 24 VYONDYS 53 SOLN 50 VYVANSE CAPS 10mg 20mg 30mg
40mg 50mg 60mg 70mg 28 VYVGART SOLN 50 VYXEOS SUSR 18
W WAKIX TABS 445mg 178mg 28 warfarin sodium tabs 1mg 2mg 25mg
3mg 4mg 5mg 6mg 10mg 21 WATER FOR IRRIGATION STERILE
SOLN 50 WELIREG TABS 18 wixela inhub aepb 51 wymzya fe chew 44 WYNZORA CREA 55
X XALKORI CAPS 200mg 250mg 18 XARELTO STARTER PACK TBPK 21 XARELTO SUSR 21 XARELTO TABS 25mg 10mg 15mg
20mg 21 XATMEP SOLN 18 XCOPRI (250 MG DAILY DOSE) TBPK 30 XCOPRI (350 MG DAILY DOSE) TBPK 30 XCOPRI TABS 200mg 30 XCOPRI TABS 50mg 100mg 150mg 30 XCOPRI TBPK 30 XCOPRI TBPK 14x125mg amp 14x25mg 30
96 bull Kaiser Permanente 2022 Defined Standard Comprehensive Formulary
XELJANZ SOLN 48 XELJANZ TABS 5mg 10mg 48 XELJANZ XR TB24 11mg 22mg 48 XENLETA SOLN 10 XENLETA TABS 10 XEOMIN SOLR 50 XERMELO TABS 40 XGEVA SOLN 47 XIFAXAN TABS 200mg 550mg 10 XOFLUZA (40 MG DOSE) TBPK 13 XOFLUZA (80 MG DOSE) TBPK 13 XOLAIR SOLR 51 XOLAIR SOSY 75mg05ml 150mgml 51 XOSPATA TABS 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
20mg 50mg 18 XPOVIO (40 MG ONCE WEEKLY) TBPK
20mg 40mg 18 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 XTANDI CAPS 19 XTANDI TABS 40mg 80mg 19 xulane ptwk 44 XUREA CREA 57 XURIDEN PACK 50 xylocaine dental soln 50 XYREM SOLN 32 XYWAV SOLN 32
Y YERVOY SOLN 19 YF-VAX INJ 53 YONDELIS SOLR 19 YONSA TABS 19 YUPELRI SOLN 19 YUTIQ IMPL 39 yuvafem tabs 45
Z zafemy ptwk 44
zafirlukast tabs 10mg 20mg 51 zaleplon caps 5mg 10mg 31 ZALTRAP SOLN 100mg4ml 200mg8ml 19 zarah tabs 44 zarontin soln 30 ZARXIO SOSY 300mcg05ml
480mcg08ml 22 zebutal caps 28 ZEJULA CAPS 19 ZELAPAR TBDP 31 ZELBORAF TABS 19 ZEMDRI SOLN INTRAVENOUS 10 zenatane caps 10mg 20mg 30mg 40mg
57 ZENPEP CPEP 38 zenzedi tabs 25mg 5mg 75mg 10mg
15mg 20mg 30mg 28 ZEPATIER TABS 13 ZEPOSIA 7-DAY STARTER PACK CPPK
32 ZEPOSIA CAPS 32 ZEPOSIA STARTER KIT CPPK 32 ZEPZELCA SOLR 19 ZERBAXA SOLR INTRAVENOUS 10 ZERUVIA PTCH 56 zidovudine caps 13 zidovudine syrp 13 zidovudine tabs 13 ZIEXTENZO SOSY 22 zileuton er tb12 51 ZIONODIL 100 LOTN 56 ZIONODIL LOTN 56 ziprasidone hcl caps 20mg 40mg 60mg
80mg 35 ziprasidone mesylate solr 35 ZIRABEV SOLN 400mg16ml 100mg4ml
19 ZOKINVY CAPS 50mg 75mg 50 zoledronic acid conc 47 zoledronic acid soln 47 ZOLINZA CAPS 19 zolmitriptan soln 30 zolmitriptan tabs 30 zolmitriptan tbdp 30 zolpidem tartrate er tbcr 625mg 125mg 31 zolpidem tartrate subl 175mg 35mg 31 zolpidem tartrate tabs 5mg 10mg 31 zonisamide caps 25mg 50mg 100mg 30 ZORBTIVE SOLR 46
Kaiser Permanente 2022 Defined Standard Comprehensive Formulary bull 97
ZORTRESS TABS 49 ZOSTAVAX SUSR 53 zovia 135 (28) tabs 44 ZYDELIG TABS 100mg 150mg 19 ZYKADIA CAPS 19
ZYKADIA TABS 19 ZYNLONTA SOLR 19 ZYPREXA RELPREVV SUSR 35 ZYTIGA TABS 19
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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)
682896130 062022
This formulary was updated on 060122 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
kporgseniorrx Please recycle
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