Kaiser Permanente of Georgia HMO Formularyproviders.kaiserpermanente.org/info_assets/cpp_ga/...This document includes Kaiser Permanente of Georgia’s HMO formulary as of July 1, 2012.For

This document includes Kaiser Permanente of Georgia’s HMO formulary as of July 1, 2012. For an updated formulary, please visit our website at members.kp.org or call 1-888-865-5813, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users

should call 1-800-255-0056.

KAISER PERMANENTE OF GEORGIA

HMO FORMULARY

*All drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification, if needed.*

1

What is the Kaiser Permanente drug formulary? A formulary is a list of drugs determined to be safe and effective for our members by our Pharmacy and Therapeutics Committee. Use of formulary drugs enables Kaiser Permanente to provide optimal care to you and your family at reasonable costs. Kaiser Permanente continually updates the formulary throughout the year based on new medical evidence, considering the recommendations of appropriate physician experts.

Does the formulary ever change? Yes, Kaiser Permanente continually updates the formulary based on new medical evidence, considering the recommendations of appropriate physician experts and notifies our doctors, pharmacists, and other clinicians about any changes. If a change in the formulary affects any of your prescriptions, your doctor or pharmacist will let you know.

The enclosed formulary is current as of July 1, 2012. To get updated information about the drugs covered by Kaiser Permanente, please visit our website at members.kp.org or call Member Services at 1-888-865-5813, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call 1-800-255-0056.

How do I use the formulary? There are two easy ways to find your drug within the formulary:

Medical Condition The formulary begins on page 5. The drugs in this formulary are grouped into categories

depending on the type of medical condition that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular AgentsIf you know the medical condition your drug is used for, simply look for the category name in the list that begins on page 5. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you can look for the drug in the Index that begins on page 29. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find the drug. Next to the 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 the drug on the list. You may also use the search function on your computer to search for the medication by name.

What are generic drugs? Kaiser Permanente covers both brand-name drugs and generic drugs.

Brand-name drugs are drugs that are produced and sold under the original manufacturer’s brand name.

Generic drugs are produced and sold under their chemical names after the patent of the brand-name drug expires. Although the price is lower, the quality and effectiveness of generic drugs is the same as brand-name drugs. The Federal Food and Drug Administration (FDA) requires that generic drugs contain the same active ingredients in the same amount as the


2

brand-name drug. Kaiser Permanente pharmacies stock only generic drugs that have met the high standards of both the FDA and the experts in our quality assurance program.

Generic drugs are listed in lower-case italics (e.g., amoxicillin) within the formulary on page 5. If a drug is available as a generic, it is only listed with the generic name. Brand-name drugs are capitalized in the formulary (e.g., FLOVENT).

Generally, if a drug is available generically, the generic is on the formulary and the brand is not. Because all drug product strengths and package sizes of a formulary drug may not be included on the formulary, check with your Kaiser Permanente pharmacist for clarification.

How much will I pay for covered drugs? What you pay for covered drugs is determined by the outpatient prescription drug benefit outlined in your Evidence of Coverage. Some plans have a two tier closed formulary benefit and some plans have a three tier open formulary benefit.

Open formulary means your pharmacy benefit covers drugs that are on the formulary as well as others that are not. Open formulary benefits have a generic cost sharing requirement. This means that if you fill a brand name drug when a generic is available, that in addition to your standard copayment or coinsurance, you will also pay the difference in cost between the brand name and generic drug.

Coverage for prescription drugs is limited to drugs for which a prescription is required by

law. Coverage is also limited to drugs that are listed on the Kaiser Permanente drug formulary unless your benefit provides coverage for non-formulary (non-preferred) medications. Certain diabetic supplies do not require a prescription, but must still be listed in our formulary in order to be covered under the benefit.

Each prescription refill is provided on the same basis as the original prescription. Copayments are applied on a per prescription basis, for up to the lesser of the dispensing amount listed in the “Schedule of Benefits” or the standard prescription amount.

The standard prescription amount for the following items is:

· Migraine medications ― the smallest package size commercially available

· Ophthalmic and otic medications ― the smallest package size commercially available

· Oral and nasal inhalers ― the smallest standard package unit

Are there any other restrictions on coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

· Quantity Limits (QL): For certain drugs, Kaiser Permanente limits the amount of the drug that will be covered.

· Age Restriction (Age): For certain drugs, Kaiser Permanente limits coverage based on a designated age.


3

· Quality Restricted Medication (QRM): For certain drugs, Kaiser Permanente requires review and authorization prior to dispensing. Your Provider must obtain this review and authorization. The list of prescription drugs requiring review and authorization is subject to periodic review and modification by our Pharmacy and Therapeutics Committee.

You can find out if the drug has any additional requirements or limits by looking in the formulary that begins on page 5.

What if my drug is not on the formulary? If the drug is not on the formulary and your benefit does not provide non-formulary coverage, you have two options:

· You can contact Member Services at 1-888-865-5813, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call 1-800-255-0056 and ask Member Services for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered under the Kaiser Permanente formulary.

· You can request an exception for coverage of your non-formulary drug. There are several types of exception requests you can submit.

o You can request coverage for a drug, even though it is not on our formulary.

o You can request that we waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

What if I want or my doctor prescribes a non-formulary drug? · If you request a non-formulary drug and a

formulary alternative is available, you will be responsible for the full cost of that drug.

· If your drug benefit does not provide non-formulary coverage and your prescribing physician identified a clear medical reason to use a non-formulary rather than the similar formulary drug, such as an allergy to the formulary alternative, your physician may request an exception for coverage of a non-formulary drug. In that case your regular pharmacy copay would apply. Certain prescriptions require expert review before they can be dispensed.

Generally, Kaiser Permanente will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions have not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact your physician to initiate the request for exception process. When you are requesting a formulary or utilization restriction exception, you should submit a


4

statement from your physician supporting your request.

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 Kaiser Permanente, please call Member Services at 1-888-865-5813, Monday through Friday 7:00 a.m. to 7:00 p.m. TTY/TDD users should call 1-800-255-0056.

Or visit members.kp.org.

Kaiser Permanente of Georgia HMO Formulary QRM = Physician Review, QL = Quantity Limit; Age = Age Restriction


5

Drug Name Drug Tier Restrictions Analgesics

Non-Opioid Analgesics acetaminophen, isometheptene and dichloralphenazone Generic butalbital, acetaminophen and caffeine Generic butalbital, aspirin and caffeine Generic diclofenac Generic ELMIRON (pentosan polysulfate sodium) Brand etodolac Generic ibuprofen Generic indomethacin Generic meloxicam Generic nabumetone Generic naproxen Generic salsalate Generic sulindac Generic tolmetin Generic

Opioid Analgesics codeine and acetaminophen Generic codeine, caffeine, aspirin and butalbital Generic fentanyl Generic hydrocodone and acetaminophen Generic hydrocodone and homatropine Generic hydromorphone Generic meperidine Generic meperidine and promethazine Generic methadone Generic morphine Generic oxycodone and acetaminophen Generic oxycodone and aspirin Generic oxycodone immediate release Generic tramadol Generic

Anesthetics Anesthestics, miscellaneous

lidocaine and prilocaine cream Generic lidocaine hydrochloride viscous Generic lidocaine ointment Generic

Antibacterials Antibacterials, Others

bacitracin (ophthalmic ointment) Generic bacitracin and polmyxin B (ophthalmic ointment) Generic



6

Drug Name Drug Tier Restrictions bacitracin and neomycin and polymyxin B (ophthalmic ointment)

Generic

clindamycin Generic clindamycin palmitate (solution) Generic CORTISPORIN-TC (neomycin, colistin, hydrocortisone,and thonzonium)

Brand

metronidazole Generic NEODECADRON (neomycin and dexamethasone) Brand neomycin Generic neomycin and polymyxin B and dexamethasone Generic neomycin and polymyxin B and hydrocortisone Generic nitrofurantoin macrocrystals Generic nitrofurantoin macrocrystals/monohydrate Generic paromomycin Generic trimethoprim Generic trimethoprim and polymyxin B (ophthalmic solution) Generic ZYVOX (linezolid) Brand QL

Beta-Lactam, Cephalosporins cefaclor Generic cefdinir Generic cefuroxime Generic cephalexin Generic

Beta-Lactam, Penicillins amoxicillin Generic amoxicillin and clavulanic acid Generic ampicillin Generic dicloxacillin Generic penicillin V potassium Generic

Macrolides azithromycin Generic clarithromycin Generic erythromycin Generic

Quinolones ciprofloxacin Generic levofloxacin Generic ofloxacin (ophthalmic solution) Generic ZYMAR (gatifloxacin) Brand ZYMAXID (gatifloxacin) Generic

Sulfonamide Related erythromycin-sulfisoxazole Generic sodium sulfacetamide and sulfur Generic



7

Drug Name Drug Tier Restrictions sulfacetamide Generic sulfadiazine Generic sulfamethoxazole and trimethoprim Generic

Tetracyclines doxycycline Generic minocycline Generic tetracycline Generic

Anticonvulsants Anticonvulsants, Other

phenobarbital Generic primidone Generic topiramate Generic SABRIL (vigabatrin) Brand QRM

Calcium Channel Modifying Agents ethosuximide Generic CELONTIN (methsuximide) Brand

GABA Augmenting Agents gabapentin Generic primidone Generic valproic acid and derivatives Generic

Glutamate Reducing Agents lamotrigine Generic

Sodium Channel Inhibitors carbamazepine Generic DILANTIN (phenytoin) Brand levetiracetam Generic levetiracetam extended-release Generic

Antidementia Agents Cholinesterase Inhibitors

COGNEX (tacrine) Brand donepezil hydrochloride Generic galantamine IR, ER Generic rivastigmine Generic

Glutamate Pathway Modifiers NAMENDA (memantine hydrochloride) Brand

Antidementia Agents, Other ergoloid mesylates Generic

Antidepressants Antidepressants, Other

bupropion IR, SR, XL Generic



8

Drug Name Drug Tier Restrictions mirtazapine Generic trazodone Generic

MAOIs phenelzine sulfate Generic tranylcypromine sulfate Generic

Reuptake Inhibitors amitriptyline Generic citalopram Generic clomipramine Generic desipramine Generic doxepin Generic fluoxetine Generic imipramine Generic nortriptyline Generic sertraline Generic venlafaxine Generic venlafaxine extended-release capsules Generic

Antiemetics Antiemetics, miscellaneous

chlorpromazine Generic dronabinol Generic hydroxyzine Generic ISOPTO HYOSCINE (scopolamine) (ophthalmic solution) Brand metoclopramide Generic ondansetron Generic perphenazine Generic prochlorperazine Generic promethazine Generic promethazine and codeine Generic promethazine and codeine and phenylephrine Generic

Antifungals Antifungals, Miscellaneous

ANCOBON (flucytosine) Brand clotrimazole lozenge Generic fluconazole Generic QL griseofulvin Generic itraconazole Generic ketoconazole Generic nystatin Generic nystatin and triamcinolone Generic



9

Drug Name Drug Tier Restrictions Antigout Agents

Antigout Agents, miscellaneous allopurinol Generic probenecid Generic

Anti-inflammatories Glucocorticoids

betamethasone Generic clobetasol Generic desonide Generic dexamethasone Generic FLOVENT (fluticasone) Brand fludrocortisone Generic flunisolide (nasal spray) Generic fluocinolone (solution) Generic fluocinonide Generic fluticasone (nasal spray) Generic hydrcortisone Generic MAXIDEX (dexamethasone) ophthalmic suspension Brand methylprednisolone Generic PRED-G (prednisolone) Brand prednisolone Generic prednisolone and sodium sulfacetamide Generic prednisone Generic PROCTOFOAM (hydrocortisone and pramoxine) Brand budesonide inhalation suspension Brand triamcinolone Generic

Non-Steroidals diclofenac Generic ELMIRON (pentosan polysulfate sodium) Brand etodolac Generic ibuprofen Generic indomethacin Generic meloxicam Generic nabumetone Generic naproxen Generic salsalate Generic sulindac Generic

Antimigraine Agents Abortive

CAFERGOT (ergotamine and caffeine) Brand



10

Drug Name Drug Tier Restrictions MIGRANAL (dihydroergotamine) Brand naratriptan Generic QL sumatriptan Generic QL

Prophylactic divalproex sodium Generic divalproex sodium ER Generic propranolol Generic

Antimycobacterials Antimycobacterials, other

dapsone Generic MYCOBUTIN (rifabutin) Brand

Antituberculars ethambutol Generic isoniazid Generic pyrazinamide Generic rifampin Generic

Antineoplastic Alkylating Agent

ALKERAN (melphalan) Brand cyclophosphamide Generic LEUKERAN (chlorambucil) Brand MATULANE (procarbazine) Brand MYLERAN (busulfan) Brand TEMODAR (temozolomide) Brand

Antimetabolites DROXIA (hydroxyurea) Brand fluorouracil Generic hydroxyurea Generic mercaptopurine Generic methotrexate Generic XELODA (capecitabine) Brand

Molecular Target Inhibitor GLEEVEC (imatinib mesylate) Brand SPRYCEL (dasatinib) Brand SUTENT (sunitinib) Brand tretinoin Generic TYKERB (lapatinib) Brand

Protective Agents leucovorin calcium Generic

Topoisomerase Inhibitors



11

Drug Name Drug Tier Restrictions etoposide Generic

Antineoplastic, miscellaneous TARGRETIN (bexarotene) Brand

Antiparasitics Antihelminths

ALBENZA (albendazole) Brand mebendazole Generic

Antiprotozoals DARAPRIM (pyrimethamine) Brand hydroxychloroquine Generic MEPRON (atovaquone) Brand PRIMAQUINE (primaquine) Brand

Pediculicides/Scabicides lindane Generic permethrin Generic

Antiparkinson Agents Antiparkinson Agent, other

benztropine mesylate Generic bromocriptine mesylate Generic selegiline Generic STALEVO (levodopa/carbidopa/entacapone) Brand trihexyphenidyl Generic

COMT Inhibitors COMTAN (entacapone) Brand

Dopamine Agonist amantadine Generic carbidopa-levodopa Generic pramipexole Generic ropinirole Generic

Antipsychotics Non-Phenothiazines

haloperidol Generic thiothixene Generic

Non-Phenothiazines/Atypicals ABILIFY (aripiprazole) Brand chlorpromazine Generic clozapine Generic fluphenazine Generic olanzapine Generic olanzapine ODT Generic



12

Drug Name Drug Tier Restrictions perphenazine Generic prochlorperazine Generic quetiapine Generic risperidone Generic trifluoperazine Generic ziprasidone Generic

Antivirals Anti-CMV Agents

VALCYTE (valganciclovir) Brand Antiherpetic Agents

acyclovir Generic Anti-HIV, CCR5 Antagonist

SELZENTRY (maraviroc) Brand Anti-HIV, Fusion Inhibitors

FUZEON (enfuvirtide) Brand Anti-HIV, Integrase Inhibitors

ISENTRESS (raltegravir) Brand Anti-HIV, NNRTI

INTELENCE (etravirine) Brand RESCRIPTOR (delavirdine) Brand SUSTIVA (efavirenz) Brand nevirapine tab Generic VIRAMUNE (nevirapine) suspension Brand

Anti-HIV, NRTI ATRIPLA (efavirenz, emtricitabine and tenofovir) Brand BARACLUDE (entecavir) Brand didanosine Generic EMTRIVA (emtricitabine) Brand EPZICOM (abacavir and lamivudine) Brand lamivudine Generic lamivudine and zidovudine Generic stavudine Generic TRIZIVIR (abacavir, lamivudine and zidovudine) Brand TRUVADA (emtricitabine and tenofovir) Brand VIDEX (didanosine delayed release) Brand VIREAD (tenofovir) Brand ZIAGEN (abacavir) Brand zidovudine Generic

Anti-HIV, Protease Inhibitors AGENERASE (amprenavir) Brand



13

Drug Name Drug Tier Restrictions APTIVUS (tipranavir) Brand CRIXIVAN (indinavir) Brand INVIRASE (saquinavir) Brand KALETRA (lopinavir and ritonavir) Brand LEXIVA (fosamprenavir) Brand NORVIR (ritonavir) Brand PREZISTA (darunavir) Brand REYATAZ (atazanavir) Brand VIRACEPT (nelfinavir) Brand

Antiinfluenza amantadine Generic FLUMADINE (rimantadine) Brand QL RELENZA (zanamivir) Brand QL TAMIFLU (oseltamivir) Brand QL

Antivirals, other HEPSERA (adefovir dipivoxil) Brand ribavirin Generic

Anxiolytics Antidepressants

doxepin Generic Anxiolytics, other

alprazolam Generic buspirone Generic chlordiazepoxide Generic clonazepam Generic clorazepate Generic diazepam Generic lorazepam Generic meprobamate Generic oxazepam Generic temazepam Generic

Autonomic Agents Parasympatholytics

atropine (ophthalmic solution) Generic belladonna and phenobarbital and ergotamine Generic dicyclomine Generic glycopyrrolate Generic hyoscyamine Generic ISOPTO HYOSCINE (scopolamine ophthalmic solution) Brand propantheline Generic

Parasympathomimetic



14

Drug Name Drug Tier Restrictions MESTINON TIMESPAN (pyridostigmine sustained-release) Brand pyridostigmine Generic

Sympatholytics acebutolol Generic atenolol Generic betaxolol Generic BETOPTIC S (betaxolol) Brand bisoprolol Generic carvedilol Generic labetalol Generic metoprolol Generic metoprolol sustained release Generic nadolol Generic prazosin Generic propranolol Generic sotalol Generic terazosin Generic timolol Generic

Sympathomimetics ALBUTEROL SULFATE (salbutamol) Brand clonidine Generic methyldopa Generic phenylephrine (ophthalmic solution) Generic

Bipolar Agents Bipolar Agents, miscellaneous

divalproex sodium Generic divalproex sodium ER Generic lithium Generic valproic acid and derivatives Generic

Blood Glucose Regulators Antidiabetic Agents, Alphaglucosidase Inhibitors

acarbose Generic Antidiabetic Agents, Amylinomimetics

SYMLIN (pramlintide acetate) Brand QRM Antidiabetic Agents, Antihypoglycemics

GLUCAGON (glucagon) Brand PROGLYCEM (diazoxide) Brand

Antidiabetic Agents, Biguanides metformin ER Generic metformin hcl Generic

Antidiabetic Agents, DPP-4 Inhibitors



15

Drug Name Drug Tier Restrictions JANUMET (sitagliptin/metformin) Brand QRM JANUVIA (sitagliptin phosphate) Brand QRM JUVISYNC (sitagliptin/simvastatin) Brand QRM KOMBIGLYZE XR (saxagliptin/metformin extended-release)

Brand QRM

ONGLYZA (saxagliptin) Brand QRM Antidiabetic Agents, Incretin Mimetics

BYDUREON (exenatide extended-release) Brand QRM BYETTA (exenatide) Brand QRM TRADJENTA (linagliptin) Brand QRM VICTOZA (liraglutide) Brand QRM

Antidiabetic Agents, Sulfonylureas glipizide Generic glyburide Generic

Antidiabetic Agents, Thiazolidinediones ACTOS (pioglitazone) Brand

Blood Sugar Diagnostics ONE TOUCH ULTRA TEST STRIPS Generic QL

Diabetic Supplies ONE TOUCH ULTRA 2 (blood glucose meter) Generic QL

Insulins NOVOLIN 70/30 Generic NOVOLIN-N (insulin isophane (human)) Generic NOVOLIN-R (insulin regular) Generic

Syringes & Accessories B-D INSUILIN SYRINGE (syringe w-ndl, disp.) Generic QL

Blood Products/Modifiers/Volume Expanders Anti-Coagulants

enoxaparin Generic warfarin sodium Generic XARELTO (rivaroxaban) Brand QRM

Blood Formation Products ARANESP (darbepoetin alfa) Brand LEUKINE (sargramostim) Brand NEUMEGA (oprelvekin) Brand NEUPOGEN (filgrastim) Brand PROCRIT (epoetin alfa) Brand

Blood, Other anagrelide Generic

Coagulants aminocaproic acid Generic



16

Drug Name Drug Tier Restrictions desmopressin Generic MEPHYTON (phytonadione) Brand

Hemorrheologic Agents pentoxifylline Generic

Iron Overload Products EXJADE (deferasirox) Brand

Platelet Aggregation Inhibitors AGGRENOX (aspirin and dipyridamole) Brand cilostazol Generic dipyridamole Generic clopidogrel Generic

Cardiovascular Agents Alpha-Adrenergic Agonists

clonidine Generic guanfacine Generic methlydopa Generic phenylephrine Generic

Alpha-Adrenergic Blocking Agents doxazosin Generic prazosin Generic terazosin Generic

Anti-Arrhythmics acebutolol Generic amiodarone Generic diltiazem Generic disopyramide phosphate Generic flecainide Generic lidocaine Generic mexiletine Generic NORPACE CR (disopyramide phosphate sustained release)

Brand

procainamide Generic propafenone Generic propranolol Generic quinidine Generic sotalol Generic TIKOSYN (dofetilide) Brand verapamil Generic

Beta-Adrenergic Blocking Agents acebutolol Generic atenolol Generic



17

Drug Name Drug Tier Restrictions atenolol/chlorthalidone Generic betaxolol Generic bisoprolol Generic bisoprolol and hydrochlorothiazide Generic carvedilol Generic labetalol Generic metoprolol Generic metoprolol sustained release Generic nadolol Generic propranolol Generic sotalol Generic timolol Generic

Calcium Channel Blocking Agents amlodipine Generic diltiazem Generic felodipine Generic nifedipine Generic nimodipine Generic QL verapamil Generic

Direct Cardiac Inotropics digoxin Generic

Diuretics acetazolamide Generic amiloride/hydrochlorothiazide Generic bumetanide Generic chlorthalidone Generic furosemide Generic hydrochlorothiazide Generic indapamide Generic methazolamide Generic metolazone Generic spironolactone Generic triamterene and hydrochlorothiazide Generic

Dyslipidemics atorvastatin Generic cholestyramine resin Generic colestipol Generic fenofibrate Generic gemfibrozil Generic lovastatin Generic pravastatin Generic



18

Drug Name Drug Tier Restrictions simvastatin Generic

Renin-Angiotension-Aldosterone System Inhibitors benazepril Generic captopril Generic enalapril Generic lisinopril Generic lisinopril and hydrochlorothiazide Generic losartan Generic losartan and hydrochlorothiazide Generic ramipril Generic spironolactone Generic

Vasodilators hydralazine Generic isosorbide dinitrate Generic isosorbide mononitrate Generic minoxidil Generic nitroglycerin Generic REMODULIN (trepostinil) Brand

Central Nervous System Agents Amphetamines

amphetamine and dextroamphetamine Generic amphetamine and dextroamphetamine extended-release Generic dextroamphetamine sulfate Generic

Non-Amphetamines methylphenidate extended-release Generic methylphenidate Generic RILUTEK (riluzole) Brand

Contraceptive Devices ALL FLEX (diaphragm) Brand PARAGARD (intrauterine) Brand

Dental and Oral Agents Dental and Oral Agents

chlorhexidine Generic doxycycline Generic minocycline Generic triamcinolone Generic

Dermatologic Agents Dermatologic Anesthetics

lidocaine ointment Generic PRAMOSONE (pramoxine and hydrocortisone) Brand

Dermatologic Antibacterials



19

Drug Name Drug Tier Restrictions clindamycin phosphate Generic erythromycin Generic erythromycin and benzoyl peroxide Generic metronidazole Generic mupirocin Generic silver sulfadiazine Generic

Dermatologic Antifungal iodoquinol and hydrocortisone Generic ketoconazole Generic nystatin Generic nystatin and triamcinolone Generic

Dermatologic Antiinflammatories betamethasone Generic clobetasol Generic desonide Generic fluocinolone solution Generic hydrocortisone Generic mometasone furoate Generic triamcinolone Generic

Dermatologic Antipruritic betamethasone Generic clobetasol Generic desonide Generic doxepin Generic fluocinolone Generic hydrocortisone Generic PROCTOFOAM (hydrocortisone and pramoxine) Brand triamcinolone Generic

Dermatologic Antivirals acyclovir Generic

Dermatologic Keratolytics CONDYLOX (podofilox) Brand DRITHOCREME (anthralin) Brand sulfacetamide sodium w/ sulfur lotion Generic sulfacetamide sodium w/ sulfur wash Generic urea Generic

Dermatologic Mitotic Inhibitors selenium sulfide Generic

Dermatologic Other aluminum chloride hexahydrate Generic

Dermatologic Photochemotherapy Agents



20

Drug Name Drug Tier Restrictions OXSORALEN (methoxsalen) Brand TRISORALEN (trioxsalen) Brand

Dermatologic Retinoids isotretinoin Generic

tretinoin Generic Limited to age

</=35 Dermatologic Tar Derivatives

coal tar Generic DRITHO-SCALP (anthralin) Brand

Dermatologic Vitamin-D Analog SANTYL (collagenase) Brand VECTICAL (calcitriol) Brand

Dermatologic Wound Care Agents papain and urea Generic REGRANEX (becaplermin) Brand

Deterrents/Replacements Alcohol Deterrents

disulfiram Generic Electrolyte, Caloric and Water Balance

Alkalinizing Agents potassium citrate Generic sod/potass/k cit/sodium cit/ca Generic

Ion Removing Agents RENVELA (sevelamer carbonate) Brand sodium polystyrene sulfonate Generic

Enzyme Replacements/Modifiers Enzyme Replacements/Modifiers, other

PANCREAZE (pancrelipase) Brand ZENPEP (pancrelipase) Brand

Gastrointestinal Agents Antispasmodics, Gastrointestinal

clidinium and chlordiazepoxide Generic dicyclomine Generic hyoscyamine Generic phenobarbital and belladonna alkaloids Generic propantheline Generic

H2 Blocking Agents cimetidine Generic ranitidine Generic

Gastrointestinal Agents, other COLYTE (polyethylene glycol-electrolyte solution) Brand



21

Drug Name Drug Tier Restrictions diphenoxylate and atropine Generic HELICOBACTER PYLORI TREATMENT PACK Brand lactulose Generic ursodiol Generic

Protectants misoprosto Generic sucralfate Generic

Genitourinary Agents Antispasmodics, Urinary

hyoscyamine Generic oxybutynin Generic oxybutynin XL Generic OXYTROL (oxybutynin) Brand propantheline Generic

Benign Prostatic Hypertrophy Agents finasteride Generic terazosin Generic

Spasmodics, Urinary bethanechol Generic

Hormonal Agents, Stimulant/Replacement/Modifying Adrenal

betamethasone Generic budesonide inhalation suspension Generic clobetasol Generic desonide Generic dexamethasone Generic FLOVENT (fluticasone) Brand fluocinolone Generic fluocinonide Generic hydrocortisone Generic methylprednisolone Generic PRED-G (prednisolone and gentamicin) Brand prednisolone and sodium sulfacetamide Generic prednisone Generic triamcinolone Generic triamcinolone acetonide Generic

Growth Hormones GENTROPIN (somatropin) Brand QRM HUMATROPE (somatropin) Brand QRM NORDITROPIN (somatropin) Brand QRM NUTROPIN AQ (somatropin) Brand QRM



22

Drug Name Drug Tier Restrictions OMNITROPE (somatropin) Brand QRM SAIZEN (somatropin) Brand QRM SEROSTIM (somatropin) Brand QRM ZORBTIVE (somatropin) Brand QRM

Parathyroid/Metabolic Bone Disease Agents alendronate Generic calcitonin Generic etidronate Generic

Pituitary ACTHAR (corticotropin) Brand QRM bromocriptine mesylate Generic desmopressin Generic

Prostaglandins misoprostol Generic

Sex Hormones/Modifier ANDRODERM (testosterone) Brand AVIANE (ethinyl estradiol and levonorgestrel) Generic CLIMARA (estradiol) Generic danazol Generic ELLA (ulipristal) Brand estradiol Generic estrogens and methyltestosterone Generic estropipate Generic ethinyl estradiol and ethynodiol diacetate Generic EVISTA (raloxifene) Brand fluoxymesterone Generic IMPLANON (etonogestrel) Brand LEVORA (ethinyl estradiol and levonorgestrel) Generic medroxyprogesterone Generic megestrol Generic methyltestosterone Generic MICROGESTIN FE (ethinyl estradiol and norethindrone) Generic NECON (ethinyl estradiol and norethindrone) Generic NECON (mestranol and norethindrone) Generic NORA-BE (norethindrone) Generic PLAN B (levonorgestrel) Brand Age PREMARIN (conjugated estrogen)(vaginal cream) Brand RECLIPSEN (ethinyl estradiol and desogestrel) Generic SPRINTEC (ethinyl estradiol and norgestimate) Generic testosterone cypionate Generic TRI-NORINYL (ethinyl estradiol and norethindrone) Generic



23

Drug Name Drug Tier Restrictions TRI-SPRINTEC (ethinyl estradiol and norgestimate) Generic TRIVORA (ethinyl estradiol and levonorgestrel) Generic VAGIFEM (estradiol) (vaginal tablets) Brand

Thyroid levothyroxine Generic liothyronin Generic SENSIPAR (cinacalcet) Brand

Hormonal Agents, Suppressant Adrenal

LYSODREN (mitotane) Brand Pituitary

bromocriptine mesylate Generic cabergoline Generic SYNAREL (nafarelin) Brand

Sex Hormones/Modifiers anastrazole Generic bicalutamide Generic EMCYT (estramustine) Brand FEMARA (letrozole) Brand finasteride Generic flutamide Generic tamoxifen Generic

Thyroid methimazole Generic propylthiouracil Generic

Immunological Agents Immune Stimulants

ACTIMMUNE (interferon gamma-1b) Brand AVONEX (interferon beta-1a) Brand EXTAVIA (interferon beta-1b) Generic INTRON-A (interferon alfa-2b vaccine) Brand PEGASYS (peginterferon alfa 2a) Brand PEG-INTRON (peginterferon alfa-2b) Brand REBIF (interferon beta-1a) Brand

Immune Suppressants azathioprine Generic CUPRIMINE (penicillamine) Brand cyclosporine Generic DEPEN (penicillamine) Brand ENBREL (etanercept) Brand GILENYA (fingolimod) Brand QRM



24

Drug Name Drug Tier Restrictions HUMIRA (adalimumab) Brand methotrexate Generic mycophenolate mofeti) Generic MYFORTIC (mycophenolic acid) Brand RAPAMUNE (sirolimus) Brand tacrolimus Generic

Immunomodulator COPAXONE (glatiramer) Brand ELIDEL (pimecrolimus) Brand imiquimod Generic leflunomide Generic RIDAURA (auranofin) Brand tacrolimus Generic THALOMID (thalidomide) Brand

Inflammatory Bowel Glucorticoids

dexamethasone Generic hydrocortisone Generic methylprednisolone Generic prednisolone Generic prednisone Generic triamcinolone Generic

Salicylates ASACOL (mesalamine) Brand balsalazide Generic CANASA (mesalamine) Brand mesalamine enema Generic PENTASA (mesalamine) Brand

Sulfonamides sulfasalazine Generic

Miscellaneous Agents AMPYRA (dalfampridine) Brand QRM FIRAZYR (icatibant) Brand QRM KALYDECO (ivacaftor) Brand QRM

Ophthalmic Agents Ophthalmics, Antibacterial

bacitracin Generic bacitracin and neomycin and polymyxin B Generic bacitracin and neomycin and polymyxin B and hydrocortisone

Generic

bacitracin and polymyxin B Generic



25

Drug Name Drug Tier Restrictions erythromycin Generic gentamicin Generic neomycin and polymyxin and gramicidin Generic ofloxacin Generic sodium sulfacetamide Generic TOBRADEX (tobramycin and dexamethasone) ointment Brand tobramycin and dexamethasone suspension Generic tobramycin solution Generic TOBREX (tobramycin) solution Brand trimethoprim and polymyxin B (ophthalmic solution) Generic ZYMAXID (gatifloxacin) Brand

Ophthalmics, Antifungal NATACYN (natamycin) Brand

Ophthalmics, Antiglaucoma Agents acetazolamide Generic betaxolol Generic brimonidine Generic dipivefrin Generic dorzolamide Generic dorzolamide/timolol Generic IOPIDINE (apraclonidine) Brand ISOPTO-CARBACHOL (carbachol) Brand latanoprost Generic levobunolol Generic methazolamide Generic PHOSPHOLINE IODIDE (echothiophate) Brand pilocarpine Generic timolol Generic

Ophthalmics, Anti-inflammatories dexamethasone ophthalmic solution Generic diclofenac Generic fluoromethalone Generic ketorolac Generic MAXIDEX (dexamethasone) ophthalmic suspension Brand PRED-G (prednisolone and gentamicin) Brand

Ophthalmics, Antivirals trifluridine Generic

Ophthalmics, Other cyclopentolate Generic ISOPTO HOMATROPINE (homatropine) Brand proparacaine Generic



26

Drug Name Drug Tier Restrictions RESTASIS (cyclosporine) Brand

Otic Agents Otic, Antibacterials

acetic acid Generic ofloxacin Generic neomycin and polymyxin B and hydrocortisone Generic PRED-G (prednisolone and gentamicin) Brand tobramycin and dexamethasone Generic

Otic, Anti-inflammatories antipyrine and benzocaine Generic CIPRODEX (dexamethasone and ciprofloxacin) Brand dexamethasone Generic neomycin and polymyxin B and hydrocortisone Generic

Otic, Other aluminum acetate and acetic acid Generic

Respiratory Tract Medications Antihistamines

cyproheptadine Generic hydroxyzine Generic promethazine Generic promethazine and codeine Generic promethazine and codeine and phenylephrine Generic

Bronchodilators, Anticholinergic COMBIVENT (ipratropium and albuterol) Brand ipratropium bromide Generic SPIRIVA (tiotropium) Brand

Bronchodilators, Anti-inflammatories ASMANEX (mometasone) Brand dexamethasone Generic FLOVENT (fluticasone) Brand budesonide inhalation suspension Brand QVAR (beclomethasone) Brand

Bronchodilators, Sympathomimetic albuterol Generic epinephrine Generic epinephrine injection auto injector Generic metaproterenol Generic SEREVENT (salmeterol) Brand terbutaline Generic

Bronchodilators, Xanthines aminophylline Generic



27

Drug Name Drug Tier Restrictions theophylline Generic

Mast Cell Stabilizers cromolyn sodium Generic

Mucolytics acetylcysteine Generic PULMOZYME (dornase alfa) Brand

Respiratory Tract Agents, other benzonatate Generic codeine and guaIfenesin Generic FLOLAN (epoprostenol) Brand guaifensin and pseudoephedrine and codeine Generic TRACLEER (bosentan) Brand

Sedative/Hypnotic Sedative/Hypnotic, miscellaneous

chloral hydrate Generic zaleplon Generic zolpidem Generic

Skeletal Muscle Relaxants Skeletal Muscle Relaxants, miscellaneous

baclofen Generic carisoprodol Generic chlorzoxazone Generic cyclobenzaprine hydrochloride Generic methocarbamol Generic tizanidine Generic

Therapeutic Nutrients/Mineral Electrolytes Electrolyte Minerals

ELIPHOS (calcium acetate) Brand fluoride sodium Generic FLUORITAB (fluoride) Brand FLURA-DROP (fluoride) Brand PHOSLO (calcium acetate) Brand PHOSLYRA (calcium acetate) Brand PHOSPHA (potassium phosphate dibasic and monobasic) Brand potassium acid phosphate Generic potassium chloride Generic potassium phosphate and sodium phosphate Generic

Vitamin/ Vitamin Analog calcitriol Generic ergocalciferol Generic

Toxocologic Agents



28

Drug Name Drug Tier Restrictions Opioid Antagonist

buprenorphine Generic naltrexone hydrochloride Generic SUBOXONE (naloxone and buprenorphine) Brand

Uterine-active Agents METHERGINE (methylergonovine maleate) Brand

Kaiser Permanente of Georgia HMO Formulary

29

Index of Drugs

A

ABILIFY (aripiprazole) ................................................................. 11 acarbose ..................................................................................... 14 acebutolol ............................................................................. 14, 16 acetaminophen, isometheptene and dichloralphenazone............ 5 acetazolamide ...................................................................... 17, 25 acetic acid .................................................................................. 26 acetic acid and hydrocortisone ................................................... 26 acetylcysteine ............................................................................. 27 ACTHAR (corticotropin) .............................................................. 22 ACTIMMUNE (interferon gamma-1b) ......................................... 23 ACTOS (pioglitazone) .................................................................. 15 acyclovir ............................................................................... 12, 19 AGENERASE (amprenavir) .......................................................... 12 AGGRENOX (aspirin and dipyridamole) ...................................... 16 ALBENZA (albendazole) .............................................................. 11 albuterol ..................................................................................... 26 ALBUTEROL SULFATE (salbutamol) ............................................ 14 alendronate ................................................................................ 22 ALKERAN (melphalan) ................................................................ 10 ALL FLEX (diaphragm) ................................................................. 18 allopurinol .................................................................................... 9 alprazolam ................................................................................. 13 aluminum acetate and acetic acid ............................................. 26 aluminum chloride hexahydrate ................................................. 19 amantadine .......................................................................... 11, 13 amiloride/hydrochlorothiazide ................................................... 17 aminocaproic acid ...................................................................... 15 aminophylline ............................................................................. 26 amiodarone ................................................................................ 16 amitriptyline ................................................................................. 8 amlodipine.................................................................................. 17 amoxicillin ................................................................................ 2, 6 amoxicillin and clavulanic acid ..................................................... 6 amphetamine and dextroamphetamine .................................... 18 amphetamine and dextroamphetamine extended release ........ 18 ampicillin ...................................................................................... 6 AMPYRA (dalfampridine) ............................................................ 24 anagrelide .................................................................................. 15 anastrazole ................................................................................. 23 ANCOBON (flucytosine) ................................................................ 8 ANDRODERM (testosterone) ...................................................... 22 antipyrine and benzocaine ......................................................... 26 APTIVUS (tipranavir) ................................................................... 13 ARANESP (darbepoetin alfa)....................................................... 15 ASACOL (mesalamine) ................................................................ 24 ASMANEX (mometasone) ........................................................... 26 atenolol .......................................................................... 14, 16, 17

atenolol/chlorthalidone .............................................................. 17 atorvastatin ................................................................................ 17 ATRIPLA (efavirenz, emtricitabine and tenofovir) ....................... 12 atropine ...................................................................................... 13 atropine (ophthalmic solution) ................................................... 13 AVIANE (ethinyl estradiol and levonorgestrel) ........................... 22 AVONEX (interferon beta-1a) ..................................................... 23 azathioprine ............................................................................... 23 azithromycin ................................................................................. 6

B

bacitracin............................................................................ 5, 6, 24 bacitracin (ophthalmic ointment) ................................................. 5 bacitracin and polmyxin B ........................................................... 5 bacitracin and polmyxin B (ophthalmic ointment) ...................... 5 bacitracin and neomycin and polymyxin B ............................. 6, 24 bacitracin and neomycin and polymyxin B (ophthalmic ointment)

................................................................................................. 6 bacitracin and neomycin and polymyxin B and Hydrocortisone . 24 bacitracin and polymycin B ........................................................ 24 bacitracin and polymyxin B ........................................................ 24 bacitracin and polymyxin B and neomycin ................................. 24 baclofen ...................................................................................... 27 balsalazide .................................................................................. 24 BARACLUDE (entecavir) .............................................................. 12 B-D INSUILIN SYRINGE (syringe w-ndl, disp.) .............................. 15 belladonna and phenobarbital and ergotamine ......................... 13 benazepril ................................................................................... 18 Benign Prostatic Hypertrophy Agents ........................................ 21 benzonatate ............................................................................... 27 benztropine mesylate ................................................................. 11 betamethasone ................................................................ 9, 19, 21 betaxolol ......................................................................... 14, 17, 25 bethanechol ................................................................................ 21 BETOPTIC S (betaxolol) ............................................................... 14 bicalutamide ............................................................................... 23 bisoprolol .............................................................................. 14, 17 bisoprolol and hydrochlorothiazide ............................................ 17 brimonidine ................................................................................ 25 bromocriptine ............................................................................. 23 bromocriptine mesylate ................................................. 11, 22, 23 budesonide inhalation suspension ................................... 9, 21, 26 bumetanide ................................................................................ 17 buprenorphine ............................................................................ 28 bupropion ..................................................................................... 7 bupropion IR, SR, XL...................................................................... 7 buspirone .................................................................................... 13 butalbital, acetaminophen and caffeine ...................................... 5


30

butalbital, aspirin and caffeine ..................................................... 5 BYDUREON (exenatide extended-release) .................................. 15 BYETTA (exenatide) .................................................................... 15

C

cabergoline ................................................................................. 23 CAFERGOT (ergotamine and caffeine) .......................................... 9 calcitonin .................................................................................... 22 calcitriol ................................................................................ 20, 27 CANASA (mesalamine) ............................................................... 24 captopril ..................................................................................... 18 carbamazepine ............................................................................. 7 carbidopa-levodopa ................................................................... 11 carisoprodol ................................................................................ 27 carvedilol .............................................................................. 14, 17 cefaclor ......................................................................................... 6 cefdinir ......................................................................................... 6 cefuroxime .................................................................................... 6 CELONTIN (methsuximide) ........................................................... 7 cephalexin .................................................................................... 6 chloral hydrate ........................................................................... 27 chlordiazepoxide .................................................................. 13, 20 chlorhexidine .............................................................................. 18 chlorpromazine....................................................................... 8, 11 chlorthalidone ............................................................................ 17 chlorzoxazone ............................................................................. 27 cholestyramine resin .................................................................. 17 cilostazol ..................................................................................... 16 cimetidine ................................................................................... 20 CIPRODEX (dexamethasone and ciprofloxacin) .......................... 26 ciprofloxacin ........................................................................... 6, 26 citalopram .................................................................................... 8 clarithromycin .............................................................................. 6 clidinium and chlordiazepoxide .................................................. 20 CLIMARA (estradiol) ................................................................... 22 clindamycin ............................................................................ 6, 19 clindamycin palmitate (solution) .................................................. 6 clindamycin phosphate ............................................................... 19 clobetasol ......................................................................... 9, 19, 21 clomipramine ............................................................................... 8 clonazepam ................................................................................ 13 clonidine ............................................................................... 14, 16 clopidogrel .................................................................................. 16 clorazepate ................................................................................. 13 clotrimazole .................................................................................. 8 clotrimazole lozenge..................................................................... 8 clozapine .................................................................................... 11 coal tar ....................................................................................... 20 codeine and acetaminophen ........................................................ 5 codeine and guafenesin" ............................................................ 27

codeine and guaIfenesin ............................................................. 27 codeine, caffeine, aspirin and butalbital ...................................... 5 COGNEX (tacrine) ......................................................................... 7 colestipol .................................................................................... 17 COLYTE (polyethylene glycol-electrolyte solution) ...................... 20 COMBIVENT (ipratropium and albuterol) ................................... 26 COMTAN (entacapone) .............................................................. 11 CONDYLOX (podofilox) ............................................................... 19 COPAXONE (glatiramer) ............................................................. 24 CORTISPORIN-TC (neomycin, colistin, hydrocortisone,and

thonzonium) ............................................................................ 6 CRIXIVAN (indinavir) ................................................................... 13 cromolyn sodium ........................................................................ 27 CUPRIMINE (penicillamine) ........................................................ 23 cyclobenzaprine hydrochloride ................................................... 27 cyclopentolate ............................................................................ 25 cyclophosphamide ...................................................................... 10 cyclosporine .......................................................................... 23, 26 cyproheptadine .......................................................................... 26

D

danazol ....................................................................................... 22 dapsone ...................................................................................... 10 DARAPRIM (pyrimethamine) ...................................................... 11 DEPEN (penicillamine) ................................................................ 23 desipramine .................................................................................. 8 desmopressin........................................................................ 16, 22 desonide ........................................................................... 9, 19, 21 dexamethasone ................................................ 6, 9, 21, 24, 25, 26 dexamethasone ophthalmic solution ......................................... 25 dextroamphetamine sulfate ....................................................... 18 diazepam .................................................................................... 13 diclofenac ........................................................................... 5, 9, 25 dicloxacillin ................................................................................... 6 dicyclomine ........................................................................... 13, 20 didanosine .................................................................................. 12 digoxin ........................................................................................ 17 DILANTIN (phenytoin .................................................................... 7 diltiazem ............................................................................... 16, 17 diphenoxylate and atropine ....................................................... 21 dipivefrin .................................................................................... 25 dipiverin ...................................................................................... 25 dipyridamole .............................................................................. 16 disopyramide phosphate ............................................................ 16 disulfiram ................................................................................... 20 divalproex sodium ................................................................ 10, 14 divalproex sodium ER ........................................................... 10, 14 donepezil hydrochloride ............................................................... 7 dorzolamide................................................................................ 25 dorzolamide/timolol ................................................................... 25


31

doxazosin .................................................................................... 16 doxepin ............................................................................. 8, 13, 19 doxycycline ............................................................................. 7, 18 DRITHOCREME (anthralin ........................................................... 19 DRITHOCREME (anthralin) ......................................................... 19 DRITHO-SCALP (anthralin) .......................................................... 20 dronabinol .................................................................................... 8 DROXIA (hydroxyurea) ................................................................ 10

E

ELIDEL (pimecrolimus) ................................................................ 24 ELIPHOS (calcium acetate) ......................................................... 27 ELLA (ulipristal) ........................................................................... 22 ELMIRON (pentosan ................................................................. 5, 9 ELMIRON (pentosan polysulfate sodium) ................................. 5, 9 EMCYT (estramustine) ................................................................ 23 EMTRIVA (emtricitabine) ............................................................ 12 enalapril ..................................................................................... 18 ENBREL (etanercept) .................................................................. 23 enoxaparin ................................................................................. 15 epinephrine ................................................................................ 26 epinephrine injection auto injector............................................. 26 EPZICOM (abacavir and lamivudine) .......................................... 12 ergocalciferol .............................................................................. 27 ergoloid mesylates ....................................................................... 7 erythromycin .................................................................... 6, 19, 25 erythromycin and benzoyl peroxide ........................................... 19 erythromycin-sulfisoxazole ........................................................... 6 estradiol ............................................................................... 22, 23 estrogens and methyltestosterone ............................................. 22 estropipate ................................................................................. 22 ethambutol ................................................................................. 10 ethinyl estradiol and ethynodiol diacetate ................................. 22 ethinyl estradiol and levonorgestrel ..................................... 22, 23 ethinyl estradiol and norethindrone ........................................... 22 ethinyl estradiol and norgestimate ...................................... 22, 23 ethosuximide ................................................................................ 7 etidronate ................................................................................... 22 etodolac .................................................................................... 5, 9 etoposide .................................................................................... 11 EVISTA (raloxifene) ..................................................................... 22 EXJADE (deferasirox) .................................................................. 16 EXTAVIA (interferon beta-1b) ..................................................... 23

F

felodipine .................................................................................... 17 FEMARA (letrozole) .................................................................... 23 fenofibrate.................................................................................. 17

fentanyl ........................................................................................ 5 finasteride ............................................................................ 21, 23 FIRAZYR (icatibant) ..................................................................... 24 flecainide .................................................................................... 16 FLOLAN (epoprostenol)............................................................... 27 FLOVENT (fluticasone) ...................................................... 9, 21, 26 fluconazole ................................................................................... 8 fludrocortisone ............................................................................. 9 FLUMADINE (rimantadine) ......................................................... 13 flunisolide (nasal spray) ................................................................ 9 fluocinolone ...................................................................... 9, 19, 21 fluocinolone (solution) .................................................................. 9 fluocinolone solution .................................................................. 19 fluocinonide ............................................................................ 9, 21 fluoride sodium........................................................................... 27 FLUORITAB (fluoride) .................................................................. 27 fluoromethalone ......................................................................... 25 fluorouracil ................................................................................. 10 fluoxetine...................................................................................... 8 fluoxymesterone ......................................................................... 22 fluphenazine ............................................................................... 11 FLURA-DROP (fluoride) ............................................................... 27 flutamide .................................................................................... 23 fluticasone (nasal spray) .............................................................. 9 furosemide ................................................................................. 17 FUZEON (enfuvirtide).................................................................. 12

G

gabapentin ................................................................................... 7 galantamine IR, ER ....................................................................... 7 gemfibrozil ................................................................................. 17 gentamicin...................................................................... 21, 25, 26 GENTROPIN (somatropin)........................................................... 21 GILENYA (fingolimod) ................................................................. 23 GLEEVEC (imatinib mesylate) ..................................................... 10 glipizide ...................................................................................... 15 GLUCAGON (glucagon) ............................................................... 14 glyburide .................................................................................... 15 glycopyrrolate ............................................................................ 13 griseofulvin ................................................................................... 8 guaifensin and pseudoephedrine and codeine ........................... 27 guanfacine .................................................................................. 16

H

haloperidol ................................................................................. 11 HELICOBACTER PYLORI TREATMENT PACK ................................. 21 HEPSERA (adefovir dipivoxil) ...................................................... 13 HUMATROPE (somatropin) ........................................................ 21


32

HUMIRA (adalimumab) .............................................................. 24 hydralazine ................................................................................. 18 hydrcortisone................................................................................ 9 hydrochlorothiazide .............................................................. 17, 18 hydrocodone and acetaminophen ................................................ 5 hydrocodone and homatropine .................................................... 5 hydrocortisone ........................................... 6, 9, 18, 19, 21, 24, 26 hydromorphone ............................................................................ 5 hydroxychloroquine .................................................................... 11 hydroxyurea ............................................................................... 10 hydroxyzine ............................................................................ 8, 26 hyoscyamine ................................................................... 13, 20, 21

I

ibuprofen .................................................................................. 5, 9 imipramine ................................................................................... 8 imiquimod .................................................................................. 24 IMPLANON (etonogestrel) .......................................................... 22 indapamide ................................................................................ 17 indomethacin ........................................................................... 5, 9 INTELENCE (etravirine) ............................................................... 12 INTRON-A (interferon alfa-2b vaccine) ....................................... 23 INVIRASE (saquinavir) ................................................................. 13 iodoquinol and hydrocortisone ................................................... 19 IOPIDINE (apraclonidine) ............................................................ 25 ipratropium bromide .................................................................. 26 ISENTRESS (raltegravir) .............................................................. 12 isoniazid ..................................................................................... 10 ISOPTO HOMATROPINE (homatropine) ...................................... 25 ISOPTO HYOSCINE (scopolamine ophthalmic solution) .............. 13 ISOPTO HYOSCINE (scopolamine) (ophthalmic solution) .............. 8 ISOPTO-CARBACHOL (carbachol) ............................................... 25 isosorbide dinitrate..................................................................... 18 isosorbide mononitrate .............................................................. 18 isotretinoin ................................................................................. 20 itraconazole .................................................................................. 8

J

JANUMET (sitagliptin/metformin) .............................................. 15 JANUVIA (sitagliptin phosphate) ................................................ 15 JUVISYNC (sitagliptin/simvastatin) ............................................. 15

K

KALETRA (lopinavir and ritonavir) .............................................. 13 KALYDECO (ivacaftor) ................................................................. 24 ketoconazole .......................................................................... 8, 19 ketorolac .................................................................................... 25

KOMBIGLYZE XR (saxagliptin/metformin extended-release) ...... 15

L

labetalol ............................................................................... 14, 17 lactulose ..................................................................................... 21 lamivudine .................................................................................. 12 lamivudine and zidovudine ......................................................... 12 lamotrigine ................................................................................... 7 latanoprost ................................................................................. 25 leflunomide ................................................................................ 24 leucovorin calcium ...................................................................... 10 LEUKERAN (chlorambucil) .......................................................... 10 LEUKINE (sargramostim) ............................................................ 15 levetiracetam ............................................................................... 7 levetiracetam extended-release ................................................... 7 levobunolol ................................................................................. 25 levofloxacin .................................................................................. 6 LEVORA (ethinyl estradiol and levonorgestrel) ........................... 22 levothyroxine .............................................................................. 23 LEXIVA (fosamprenavir) .............................................................. 13 lidocaine ........................................................................... 5, 16, 18 lidocaine and prilocaine ............................................................... 5 lidocaine and prilocaine cream..................................................... 5 lidocaine hydrochloride (local anesthetic) .................................... 5 lidocaine hydrochloride viscous .................................................... 5 lidocaine ointment.................................................................. 5, 18 lindane ........................................................................................ 11 liothyronine ................................................................................ 23 lisinopril ...................................................................................... 18 lisinopril and hydrochlorothiazide .............................................. 18 lithium ........................................................................................ 14 lorazepam .................................................................................. 13 losartan ...................................................................................... 18 losartan and hydrochlorothiazide .............................................. 18 lovastatin .................................................................................... 17 LYSODREN (mitotane) ................................................................ 23

M

MATULANE (procarbazine) ......................................................... 10 MAXIDEX (dexamethasone) ophthalmic suspension .............. 9, 25 mebendazole .............................................................................. 11 medroxyprogesterone ................................................................ 22 megestrol ................................................................................... 22 meloxicam ................................................................................ 5, 9 meperidine ................................................................................... 5 meperidine and promethazine ..................................................... 5 MEPHYTON (phytonadione ........................................................ 16 meprobamate ............................................................................. 13


33

MEPRON (atovaquone) .............................................................. 11 mercaptopurine .......................................................................... 10 mesalamine enema .................................................................... 24 MESTINON TIMESPAN (pyridostigmine sustained-release) ........ 14 metaproterenol .......................................................................... 26 metformin ER ............................................................................. 14 metformin hcl ............................................................................. 14 methadone ................................................................................... 5 methazolamide ..................................................................... 17, 25 METHERGINE (methylergonovine maleate) ............................... 28 methimazole ............................................................................... 23 methlydopa ................................................................................ 16 methlyprednisolone .................................................................... 21 methocarbamol .......................................................................... 27 methotrexate........................................................................ 10, 24 methyldopa ................................................................................ 14 methylphenidate ........................................................................ 18 methylphenidate extended-release ............................................ 18 methylprednisolone .......................................................... 9, 21, 24 methyltestosterone .................................................................... 22 metoclopramide ........................................................................... 8 metolazone ................................................................................. 17 metoprolol ............................................................................ 14, 17 metoprolol sustained release ............................................... 14, 17 metronidazole ........................................................................ 6, 19 mexiletine ................................................................................... 16 MICROGESTIN FE (ethinyl estradiol and norethindrone) ............ 22 MIGRANAL (dihydroergotamine) ................................................ 10 minocycline ............................................................................. 7, 18 minoxidil ..................................................................................... 18 mirtazapine .................................................................................. 8 misoprostol ........................................................................... 21, 22 mitotane ..................................................................................... 23 mometasone furoate ................................................................. 19 morphine ...................................................................................... 5 mupirocin ................................................................................... 19 MYCOBUTIN (rifabutin) .............................................................. 10 mycophenolate mofetil .............................................................. 24 MYFORTIC (mycophenolic acid) .................................................. 24 MYLERAN (busulfan) .................................................................. 10

N

nabumetone ............................................................................. 5, 9 nadolol ................................................................................. 14, 17 naltrexone hydrochloride ........................................................... 28 NAMENDA (memantine hydrochloride)........................................ 7 naproxen .................................................................................. 5, 9 naratriptan ................................................................................. 10 NATACYN (natamycin) ................................................................ 25 NECON (ethinyl estradiol and norethindrone) ............................ 22

NECON (mestranol and norethindrone) ..................................... 22 NEODECADRON (neomycin and dexamethasone) ........................ 6 neomycin .................................................................... 6, 24, 25, 26 neomycin and polymyxin and gramicidin ................................... 25 neomycin and polymyxin and hydrocortisone ............................ 26 neomycin and polymyxin B and dexamethasone ......................... 6 neomycin and polymyxin B and hydrocortisone ............... 6, 24, 26 neomycin and polynyxin B and hydrocortisone ............................ 6 NEUMEGA (oprelvekin) .............................................................. 15 NEUPOGEN (filgrastim) .............................................................. 15 nevirapine tab............................................................................. 12 nifedipine .................................................................................... 17 nimodipine.................................................................................. 17 nitrofurantoin macrocrystals ........................................................ 6 nitrofurantoin macrocrystals/monohydrate................................. 6 nitroglycerin ............................................................................... 18 NORA-BE (norethindrone) .......................................................... 22 NORDITROPIN (somatropin) ....................................................... 21 norethindrone............................................................................. 22 NORPACE CR (disopyramide phosphate sustained release) ....... 16 nortriptyline .................................................................................. 8 NORVIR (ritonavir) ...................................................................... 13 NOVOLIN 70/30 .......................................................................... 15 NOVOLIN-N (insulin isophane (human)) ..................................... 15 NOVOLIN-R (insulin regular) ....................................................... 15 NUTROPIN AQ (somatropin) ....................................................... 21 nystatin .................................................................................. 8, 19 nystatin and triamcinolone .................................................... 8, 19

O

ofloxacin ........................................................................... 6, 25, 26 ofloxacin (ophthalmic solution) .................................................... 6 olanzapine .................................................................................. 11 olanzapine ODT .......................................................................... 11 OMNITROPE (somatropin) .......................................................... 22 ondansetron ................................................................................. 8 ONE TOUCH ULTRA 2 (blood glucose meter) .............................. 15 ONE TOUCH ULTRA TEST STRIPS ................................................ 15 ONGLYZA (saxagliptin) ............................................................... 15 oxazepam ................................................................................... 13 OXSORALEN (methoxsalen) ........................................................ 20 oxybutynin .................................................................................. 21 oxybutynin XL ............................................................................. 21 oxycodone and acetaminophen ................................................... 5 oxycodone and aspirin .................................................................. 5 oxycodone immediate release ...................................................... 5 OXYTROL (oxybutynin) ................................................................ 21


34

P

PANCREAZE (pancrelipase) ......................................................... 20 papain and urea ......................................................................... 20 PARAGARD (intrauterine) ........................................................... 18 paromomycin ............................................................................... 6 PEGASYS (peginterferon alfa 2a) ................................................ 23 PEG-INTRON (peginterferon alfa-2b) ......................................... 23 penicillin V potassium ................................................................... 6 PENTASA (mesalamine) .............................................................. 24 pentoxifylline .............................................................................. 16 permethrin.................................................................................. 11 perphenazine .......................................................................... 8, 12 phenelzine sulfate ........................................................................ 8 phenobarbital ................................................................... 7, 13, 20 phenobarbital and belladonna alkaloids .................................... 20 phenylephrine ............................................................. 8, 14, 16, 26 phenylephrine (ophthalmic solution) .......................................... 14 phenytoin ..................................................................................... 7 PHOSLO (calcium acetate) .......................................................... 27 PHOSLYRA (calcium acetate) ...................................................... 27 PHOSPHA (potassium phosphate dibasic and monobasic) ......... 27 PHOSPHOLINE IODIDE (echothiophate)...................................... 25 pilocarpine .................................................................................. 25 PLAN B (levonorgestrel) .............................................................. 22 potassium acid phosphate .......................................................... 27 potassium chloride ..................................................................... 27 potassium citrate........................................................................ 20 potassium phosphate and sodium phosphate ............................ 27 pramipexole................................................................................ 11 PRAMOSONE (pramoxine and hydrocortisone ........................... 18 pravastatin ................................................................................. 17 prazosin ................................................................................ 14, 16 PRED-G (prednisolone and gentamicin) ......................... 21, 25, 26 prednisolone ......................................................... 9, 21, 24, 25, 26 prednisolone and gentamicin ..................................................... 21 prednisolone and sodium sulfacetamide ................................ 9, 21 prednisone ........................................................................ 9, 21, 24 PREMARIN (conjugated estrogen)(vaginal cream) ..................... 22 PREZISTA (darunavir) .................................................................. 13 PRIMAQUINE (primaquine) ........................................................ 11 primidone ..................................................................................... 7 probenecid .................................................................................... 9 procainamide ............................................................................. 16 prochlorperazine .................................................................... 8, 12 PROCRIT (epoetin alfa) ............................................................... 15 PROCTOFOAM (hydrocortisone and pramoxine) .................... 9, 19 PROGLYCEM (diazoxide) ............................................................. 14 promethazine ..................................................................... 5, 8, 26 promethazine and codeine ..................................................... 8, 26 promethazine and codeine and phenylephrine ...................... 8, 26

propafenone ............................................................................... 16 propantheline ................................................................. 13, 20, 21 proparacaine .............................................................................. 25 propranolol ............................................................... 10, 14, 16, 17 propylthiouracil .......................................................................... 23 PULMOZYME (dornase alfa) ....................................................... 27 pyrazinamide .............................................................................. 10 pyridostigmine ............................................................................ 14

Q

quetiapine .................................................................................. 12 quinidine ..................................................................................... 16 QVAR (beclomethasone) ............................................................ 26

R

ramipril ....................................................................................... 18 ranitidine .................................................................................... 20 RAPAMUNE (sirolimus) ............................................................... 24 REBIF (interferon beta-1a) .......................................................... 23 RECLIPSEN (ethinyl estradiol and desogestrel) ........................... 22 REGRANEX (becaplermin) ........................................................... 20 RELENZA (zanamivir) .................................................................. 13 REMODULIN (trepostinil) ............................................................ 18 RENVELA (sevelamer carbonate) ................................................ 20 RESCRIPTOR (delavirdine) ........................................................... 12 RESTASIS (cyclosporine) .............................................................. 26 REYATAZ (atazanavir .................................................................. 13 REYATAZ (atazanavir) ................................................................. 13 ribavirin ...................................................................................... 13 RIDAURA (auranofin) .................................................................. 24 rifampin ...................................................................................... 10 RILUTEK (riluzole) ....................................................................... 18 risperidone ................................................................................. 12 rivastigmine .................................................................................. 7 ropinirole .................................................................................... 11

S

SABRIL (vigabatrin) ....................................................................... 7 SAIZEN (somatropin) .................................................................. 22 salsalate ................................................................................... 5, 9 SANTYL (collagenase) ................................................................. 20 selegiline..................................................................................... 11 selenium sulfide .......................................................................... 19 SELZENTRY (maraviroc) .............................................................. 12 SENSIPAR (cinacalcet)................................................................. 23 SEREVENT (salmeterol) ............................................................... 26 SEROSTIM (somatropin) ............................................................. 22


35

sertraline ...................................................................................... 8 silver sulfadiazine ....................................................................... 19 simvastatin ........................................................................... 15, 18 sod/potass/k cit/sodium cit/ca ................................................... 20 sodium polystyrene sulfonate..................................................... 20 sodium sulfacetamide .................................................. 6, 9, 21, 25 sodium sulfacetamide and sulfur ................................................. 6 sotalol ............................................................................. 14, 16, 17 Spasmodics, Urinary ................................................................... 21 SPIRIVA (tiotropium) ................................................................... 26 spironolactone ...................................................................... 17, 18 SPRINTEC (ethinyl estradiol and norgestimate) .................... 22, 23 SPRYCEL (dasatinib) .................................................................... 10 STALEVO (levodopa/carbidopa/entacapone .............................. 11 STALEVO (levodopa/carbidopa/entacapone) ............................. 11 stavudine .................................................................................... 12 SUBOXONE (naloxone and buprenorphine) ................................ 28 sucralfate ................................................................................... 21 sulfacetamide ..................................................... 6, 7, 9, 19, 21, 25 sulfacetamide sodium w/ sulfur lotion ....................................... 19 sulfacetamide sodium w/ sulfur wash ........................................ 19 sulfadiazine ............................................................................ 7, 19 sulfamethoxazole and trimethoprim ............................................ 7 sulfasalazine ............................................................................... 24 sulindac .................................................................................... 5, 9 sumatriptan ................................................................................ 10 SUSTIVA (efavirenz) .................................................................... 12 SUTENT (sunitinib) ...................................................................... 10 SYMLIN (pramlintide acetate) .................................................... 14 SYNAREL (nafarelin) ................................................................... 23

T

tacrolimus................................................................................... 24 TAMIFLU (oseltamivir) ................................................................ 13 tamoxifen ................................................................................... 23 TARGRETIN (bexarotene) ............................................................ 11 tebutaline ................................................................................... 26 temazepam ................................................................................ 13 TEMODAR (temozolomide) ......................................................... 10 terazosin ......................................................................... 14, 16, 21 terbutaline .................................................................................. 26 testosterone cypionate ............................................................... 22 tetracycline ................................................................................... 7 THALOMID (thalidomide) ........................................................... 24 theophylline ................................................................................ 27 thiothixene ................................................................................. 11 TIKOSYN (dofetilide) ................................................................... 16 timolol ............................................................................ 14, 17, 25 tizanidine .................................................................................... 27 TOBRADEX (tobramycin and dexamethasone) ointment ........... 25

tobramycin ................................................................................. 25 tobramycin and dexamethasone .......................................... 25, 26 tobramycin and dexamethasone suspension ............................. 25 tobramycin solution.................................................................... 25 TOBREX (tobramycin) solution ................................................... 25 tolmetin ........................................................................................ 5 topiramate ................................................................................... 7 TRACLEER (bosentan) ................................................................. 27 TRADJENTA (linagliptin) ............................................................. 15 tramadol ....................................................................................... 5 tranylcypromine sulfate ............................................................... 8 trazodone ..................................................................................... 8 tretinoin ................................................................................ 10, 20 triamcinolone ................................................... 8, 9, 18, 19, 21, 24 triamcinolone acetonide ............................................................. 21 triamterene and hydrochlorothiazide ......................................... 17 trifluoperazine ............................................................................ 12 trifluridine ................................................................................... 25 trihexyphenidyl ........................................................................... 11 trimethoprim ...................................................................... 6, 7, 25 trimethoprim and polymyxin B (ophthalmic solution) ............ 6, 25 TRI-NORINYL (ethinyl estradiol and norethindrone) ................... 22 TRISORALEN (trioxsalen) ............................................................ 20 TRI-SPRINTEC (ethinyl estradiol and norgestimate) ................... 23 TRIVORA (ethinyl estradiol and levonorgestrel) ......................... 23 TRIZIVIR (abacavir and lamivudine and zidovudine) ................... 12 TRUVADA (emtricitabine and tenofovir) ..................................... 12 TYKERB (lapatinib) ...................................................................... 10

U

urea ...................................................................................... 19, 20 ursodiol ....................................................................................... 21

V

VAGIFEM (estradiol) (vaginal tablets) ........................................ 23 VALCYTE (valganciclovir) ............................................................ 12 valproic acid ................................................................................. 7 valproic acid and derivatives .................................................. 7, 14 VECTICAL (calcitriol) ................................................................... 20 venlafaxine ................................................................................... 8 venlafaxine extended-release capsules ........................................ 8 verapamil ............................................................................. 16, 17 VICTOZA (liraglutide) .................................................................. 15 VIDEX (didanosine delayed release) ........................................... 12 VIRACEPT (nelfinavir) ................................................................. 13 VIRAMUNE (nevirapine) ............................................................. 12 VIRAMUNE (nevirapine) suspension .......................................... 12 VIREAD (tenofovir) ...................................................................... 12


36

W

warfarin sodium ......................................................................... 15

X

XARELTO (rivaroxaban) .............................................................. 15 XELODA (capecitabine) ............................................................... 10

Z

zaleplon ...................................................................................... 27

ZENPEP (pancrelipase)................................................................ 20 ZIAGEN (abacavir) ...................................................................... 12 zidovudine .................................................................................. 12 ziprasidone ................................................................................. 12 zolpidem ..................................................................................... 27 ZORBTIVE (somatropin) .............................................................. 22 ZYMAR (gatifloxacin) .................................................................... 6 ZYMAXID (gatifloxacin) .......................................................... 6, 25 ZYVOX (linezolid) .......................................................................... 6

Documents

Kaiser Permanente of Georgia HMO Formularyproviders.kaiserpermanente.org/info_assets/cpp_ga/...This document includes Kaiser Permanente of Georgia’s HMO formulary as of July 1, 2012.For