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This document includes Kaiser Permanente of Georgia’s HMO formulary as of May 1, 2013. For an updated for- mulary, 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

Kaiser Permanente of Georgia HMO

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Page 1: Kaiser Permanente of Georgia HMO

This document includes Kaiser Permanente of Georgia’s HMO formulary as of May 1, 2013. For an updated for-

mulary, 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

Page 2: Kaiser Permanente of Georgia HMO

*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.*

Kaiser Permanente of Georgia HMO Formulary 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 May 1, 2013. 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 Agents.” If 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 23. 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

Page 3: Kaiser Permanente of Georgia HMO

*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.*

2 Kaiser Permanente of Georgia HMO Formulary

ingredients in the same amount as the 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.

Page 4: Kaiser Permanente of Georgia HMO

*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.*

Kaiser Permanente of Georgia HMO Formulary 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 statement from your physician supporting your request.

Page 5: Kaiser Permanente of Georgia HMO

*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.*

4 Kaiser Permanente of Georgia HMO Formulary

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.

Page 6: Kaiser Permanente of Georgia HMO

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

*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.*

Kaiser Permanente of Georgia HMO Formulary 5

Drug Name Drug Tier Restrictions

Antihistamine Drugs Antihistamine Drugs

cyproheptadine Generic promethazine Generic

Anti-infective Agents Anthelmintics

ALBENZA (albendazole) Brand Antibacterials

amoxicillin Generic amoxicillin & clavulanic acid Generic ampicillin Generic azithromycin Generic cefaclor Generic cefdinir Generic cefuroxime Generic cephalexin Generic ciprofloxacin Generic clarithromycin Generic clindamycin Generic clindamycin palmitate (solution) Generic dicloxacillin Generic doxycycline Generic erythromycin Generic erythromycin & sulfisoxazole Generic levofloxacin Generic minocycline Generic neomycin Generic penicillin V potassium Generic sulfadiazine Generic sulfamethoxazole & trimethoprim Generic sulfasalazine Generic tetracycline Generic ZYVOX (linezolid) Brand QL

Antifungals ANCOBON (flucytosine) Brand clotrimazole lozenge Generic fluconazole Generic QL griseofulvin Generic GRIS-PEG (griseofulvin) Brand itraconazole capsule Generic ketoconazole Generic nystatin Generic

Page 7: Kaiser Permanente of Georgia HMO

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

*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.*

6 Kaiser Permanente of Georgia HMO Formulary

Drug Name Drug Tier Restrictions SPORANOX (itraconazole) solution Brand

Antimycobacterials dapsone Generic ethambutol Generic isoniazid Generic MYCOBUTIN (rifabutin) Brand pyrazinamide Generic rifampin Generic

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

Antivirals abacavir tablet Generic QL acyclovir Generic APTIVUS (tipranavir) Brand QL ATRIPLA (efavirenz, emtricitabine, & tenofovir) Brand QL BARACLUDE (entecavir) Brand QL COMPLERA (rilpivirine, emtricitabine, & tenofovir) Brand QL CRIXIVAN (indinavir) Brand didanosine Generic QL EMTRIVA (emtricitabine) Brand QL EPIVIR (lamivudine & zidovudine) solution Brand QL EPZICOM (abacavir & lamivudine) Brand QL FUZEON (enfuvirtide) Brand QL HEPSERA (adefovirdipivoxil) Brand QL INTELENCE (etravirine) Brand QL INVIRASE (saquinavir) Brand QL ISENTRESS (raltegravir) Brand QL KALETRA (lopinavir & ritonavir) Brand QL lamivudine Generic QL lamivudine & zidovudine tablet Generic QL LEXIVA (fosamprenavir) Brand QL nevirapine tablet Generic QL NORVIR (ritonavir) Brand QL PEGASYS (peginterferon alfa-2a) Brand QL PEG-INTRON (peginterferon alfa-2b) Brand PREZISTA (darunavir) Brand QL RELENZA (zanamivir) Brand QL RESCRIPTOR (delavirdine) Brand QL

Page 8: Kaiser Permanente of Georgia HMO

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

*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.*

Kaiser Permanente of Georgia HMO Formulary 7

Drug Name Drug Tier Restrictions

REYATAZ (atazanavir) Brand QL ribavirin Generic rimantadine Generic QL SELZENTRY (maraviroc) Brand QL stavudine Generic QL SUSTIVA (efavirenz) Brand QL TAMIFLU (oseltamivir) Brand QL TRIZIVIR (abacavir, lamivudine, & zidovudine) Brand QL TRUVADA (emtricitabine & tenofovir) Brand QL VALCYTE (valganciclovir) Brand VIDEX (didanosine) suspension Brand QL VIRACEPT (nelfinavir) Brand QL VIRAMUNE (nevirapine) suspension Brand QL VIREAD (tenofovir) Brand QL ZIAGEN (abacavir) solution Brand QL zidovudine Generic QL

Urinary Anti-infectives nitrofurantoin macrocrystals Generic nitrofurantoin macrocrystals/monohydrate Generic trimethoprim Generic

Antineoplastic Agents Antineoplastic Agents

AFINITOR (everolimus) Brand ALKERAN (melphalan) Brand anastrozole Generic bicalutamide Generic CAPRELSA (vandetanib) Brand cyclophosphamide Generic DROXIA (hydroxyurea) Brand EMCYT (estramustine) Brand etoposide Generic flutamide Generic GLEEVEC (imatinibmesylate) Brand HYCAMTIN (topotecan) Brand hydroxyurea Generic INTRON-A (interferon alfa-2b vaccine) Brand letrozole Generic leucovorin calcium Generic LEUKERAN (chlorambucil) Brand LYSODREN (mitotane) Brand MATULANE (procarbazine) Brand megestrol Generic mercaptopurine Generic

Page 9: Kaiser Permanente of Georgia HMO

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

*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.*

8 Kaiser Permanente of Georgia HMO Formulary

Drug Name Drug Tier Restrictions methotrexate Generic MYLERAN (busulfan) Brand NEXAVAR (sorafenib) Brand REVLIMID (lenalidomide) Brand SPRYCEL (dasatinib) Brand SUTENT (sunitinib) Brand TABLOID (thoiguanine) Brand tamoxifen Generic TARCEVA (erlotinib) Brand TARGRETIN (bexarotene) Brand TASIGNA (nilotinib) Brand TEMODAR (temozolomide) Brand TREXALL (methotrexate) Brand TYKERB (lapatinib) Brand VOTRIENT (pazopanib) Brand XALKORI (crizotinib) Brand XELODA (capecitabine) Brand ZELBORAF (vemurafenib) Brand ZOLINZA (vorinostat) Brand ZYTIGA (abiraterone) Brand

Autonomic Drugs Anticholinergic Agents

atropine sulfate Generic ATROVENT HFA (ipratropium) Brand dicyclomine Generic glycopyrrolate Generic hyoscyamine Generic ipratropium bromide nasal Generic ipratropium bromide nebulizer Generic propantheline Generic SPIRIVA (tiotropium) Brand

Parasympathomimetic (Cholinergic) Agents bethanechol Generic donepezil Generic EXELON (rivastigmine) solution Brand galantamine IR, ER Generic MESTINON TIMESPAN (pyridostigmine sustained-release) Brand

neostigmine Generic pyridostigmine Generic rivastigmine capsule Generic

Skeletal Muscle Relaxants baclofen Generic

Page 10: Kaiser Permanente of Georgia HMO

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

*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.*

Kaiser Permanente of Georgia HMO Formulary 9

Drug Name Drug Tier Restrictions carisoprodol Generic chlorzoxazone Generic cyclobenzaprine Generic methocarbamol Generic tizanidine Generic

Sympatholytic (Adrenergic Blocking) Agents ergoloid mesylates Generic ergotamine & caffeine Generic MIGRANAL (dihydroergotamine) Brand tamsulosin Generic

Sympathomimetic (Adrenergic) Agents albuterol sulfate nebulizer solution Generic albuterol sulfate tablet, syrup Generic COMBIVENT RESPIMAT (ipratropium & albuterol) Brand EPIPEN (epinephrine) Brand EPIPEN JR (epinephrine) Brand ipratropium & albuterol nebulizer solution Generic PROAIR HFA (albuterol sulfate) Brand SEREVENT (salmeterol) Brand terbutaline Generic

Blood Formation, Coagulation, and Thrombosis Coagulants and Anticoagulants

AGGRENOX (aspirin & dipyridamole) Brand aminocaproic acid Generic anagrelide Generic cilostazol Generic clopidogrel Generic enoxaparin Generic pentoxifylline Generic warfarin sodium Generic

Hematopoietic Agents ARANESP (darbepoetinalfa) Brand LEUKINE (sargramostim) Brand NEUMEGA (oprelvekin) Brand NEUPOGEN (filgrastim) Brand PROCRIT (epoetinalfa) Brand

Cardiovascular Drugs α-Adrenergic Blocking Agents

doxazosin Generic prazosin Generic terazosin Generic

Antilipemic Agents atorvastatin Generic

Page 11: Kaiser Permanente of Georgia HMO

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

*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.*

10 Kaiser Permanente of Georgia HMO Formulary

Drug Name Drug Tier Restrictions cholestyramine resin Generic colestipol Generic fenofibrate Generic gemfibrozil Generic lovastatin Generic pravastatin Generic simvastatin Generic

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

Cardiac Drugs amiodarone Generic digoxin Generic disopyramide phosphate Generic flecainide Generic mexiletine Generic NORPACE CR (disopyramide phosphate controlled release) Brand

propafenone Generic quinidine Generic TIKOSYN (dofetilide) Brand

Hypotensive Agents clonidine Generic guanfacine Generic hydralazine Generic methyldopa Generic minoxidil Generic PROGLYCEM (diazoxide) Brand

Renin-Angiotensin-Aldosterone System Inhibitors benazepril Generic captopril Generic enalapril Generic lisinopril Generic lisinopril & hydrochlorothiazide Generic losartan Generic losartan & hydrochlorothiazide Generic ramipril Generic spironolactone Generic

Vasodilating Agents

Page 12: Kaiser Permanente of Georgia HMO

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

*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.*

Kaiser Permanente of Georgia HMO Formulary 11

Drug Name Drug Tier Restrictions dipyridamole Generic isosorbide dinitrate Generic isosorbide mononitrate Generic LETAIRIS (ambrisentan) Brand NITRO-BID (nitroglycerin) Brand nitroglycerin Generic NITROSTAT (nitroglycerin) Brand REMODULIN (trepostinil) Brand TRACLEER (bosentan) Brand

β-Adrenergic Blocking Agents acebutolol Generic atenolol Generic atenolol & chlorthalidone Generic bisoprolol Generic bisoprolol & hydrochlorothiazide Generic carvedilol Generic labetalol Generic metoprolol Generic metoprolol sustained release Generic nadolol Generic propranolol Generic sotalol Generic timolol Generic

Central Nervous System Agents Analgesics and Antipyretics

acetaminophen & codeine Generic acetaminophen, isometheptene, & dichloralphenazone Generic

buprenorphine Generic butalbital, acetaminophen, & caffeine Generic butalbital, acetaminophen, caffeine, & codeine Generic butalbital, aspirin, & caffeine Generic butalbital, aspirin, caffeine, & codeine Generic diclofenac Generic etodolac Generic fentanyl Generic QL hydrocodone & acetaminophen Generic hydromorphone Generic ibuprofen Generic indomethacin Generic meloxicam Generic meperidine Generic methadone Generic

Page 13: Kaiser Permanente of Georgia HMO

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

*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.*

12 Kaiser Permanente of Georgia HMO Formulary

Drug Name Drug Tier Restrictions morphine sulfate Generic morphine sulfate extended-release Generic nabumetone Generic naproxen Generic oxycodone & acetaminophen tablet Generic oxycodone & aspirin Generic oxycodone immediate release Generic ROXICET (oxycodone & acetaminophen) solution Brand salsalate Generic SUBOXONE (naloxone & buprenorphine) Brand QL sulindac Generic tolmetin Generic tramadol Generic

Anorexigenic Agents and Respiratory and Cerebral Stimulants amphetamine & dextroamphetamine Generic amphetamine & dextroamphetamine extended-release Generic

dextroamphetamine sulfate Generic QL methylphenidate Generic methylphenidate extended-release Generic QL

Anticonvulsants carbamazepine Generic carbamazepine extended-release Generic CELONTIN (methsuximide) Brand divalproex sodium Generic divalproex sodium ER Generic ethosuximide Generic gabapentin Generic lamotrigine Generic levetiracetam Generic levetiracetam extended-release Generic phenytoin Generic primidone Generic SABRIL (vigabatrin) Brand QRM topiramate Generic valproic acid & derivatives Generic

Antimigraine Agents naratriptan Generic QL sumatriptan Generic QL

Antiparkinsonian Agents amantadine Generic benztropinemesylate Generic bromocriptinemesylate Generic

Page 14: Kaiser Permanente of Georgia HMO

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

*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.*

Kaiser Permanente of Georgia HMO Formulary 13

Drug Name Drug Tier Restrictions cabergoline Generic carbidopa & levodopa Generic entacapone Generic pramipexole Generic ropinirole Generic selegiline Generic STALEVO (levodopa, carbidopa, & entacapone) Brand TASMAR (tolcapone) Brand trihexyphenidyl Generic

Anxiolytics, Sedatives, and Hypnotics alprazolam Generic buspirone Generic chlordiazepoxide Generic clonazepam Generic clorazepate Generic diazepam Generic hydroxyzine Generic lorazepam Generic meprobamate Generic oxazepam Generic phenobarbital Generic temazepam Generic zaleplon Generic zolpidem Generic

Central Nervous System Agents Miscellaneous NAMENDA (memantine hydrochloride) Brand RILUTEK (riluzole) Brand

Opiate Antagonists naltrexone hydrochloride Generic

Psychotherapeutic Agents ABILIFY (aripiprazole) Brand amitriptyline Generic bupropion IR, SR, XL Generic chlorpromazine Generic citalopram Generic clomipramine Generic clozapine Generic desipramine Generic doxepin Generic escitalopram Generic fluoxetine Generic fluphenazine Generic haloperidol Generic

Page 15: Kaiser Permanente of Georgia HMO

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

*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.*

14 Kaiser Permanente of Georgia HMO Formulary

Drug Name Drug Tier Restrictions imipramine Generic lithium Generic mirtazapine Generic nortriptyline Generic olanzapine Generic olanzapine ODT Generic paroxetine Generic perphenazine Generic phenelzine sulfate Generic prochlorperazine Generic quetiapine Generic risperidone Generic sertraline Generic thioridazine Generic thiothixene Generic tranylcypromine sulfate Generic trazodone Generic trifluoperazine Generic venlafaxine Generic venlafaxine extended-release capsules Generic ziprasidone Generic

Diabetic Supplies Diabetic Supplies

B-D INSUILIN SYRINGE (syringe w-ndl, disp.) Generic QL ONE TOUCH ULTRA 2 (blood glucose meter) Generic QL ONE TOUCH ULTRA TEST STRIPS Generic QL

Electrolytic, Caloric and Water Balance Acidifying and Alkalinizing Agents

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

Ammonia Detoxicants lactulose Generic

Diuretics amiloride & hydrochlorothiazide Generic bumetanide Generic chlorthalidone Generic furosemide Generic hydrochlorothiazide Generic indapamide Generic metolazone Generic torsemide Generic triamterene & hydrochlorothiazide Generic

Ion-Removing Agents

Page 16: Kaiser Permanente of Georgia HMO

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

*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.*

Kaiser Permanente of Georgia HMO Formulary 15

Drug Name Drug Tier Restrictions RENVELA (sevelamer carbonate) Brand SPS (sodium polystyrene sulfonate) Brand

Replacement Products calcium acetate Generic ELIPHOS (calcium acetate) Brand K-PHOS (potassium acid phosphate) Brand PHOSLYRA (calcium acetate) Brand PHOSPHA NEUTRAL (potassium phosphate & sodium phosphate) Brand

potassium chloride Generic Uricosuric Agents

probenecid Generic Eye, Ear, Nose and Throat (EENT)

Anti-infectives aluminum acetate and acetic acid Generic bacitracin & polmyxin B (ophth) Generic bacitracin (ophth) Generic bacitracin, neomycin, & polymyxin B Generic chlorhexidine Generic erythromycin (ophth) Generic gentamicin sulfate (ophth) Generic NATACYN (natamycin) Brand neomycin, polymyxin B, & gramicidin Generic ofloxacin (ophth) Generic ofloxacin (otic) Generic sulfacetamide sodium (ophth) Generic tobramycin sulfate (ophth) solution Generic TOBREX (tobramycin) (ophth) ointment Brand trifluridine Generic trimethoprim & polymyxin B Generic ZYMAXID (gatifloxacin) Brand

Anti-inflammatory Agents bacitracin, neomycin, polymyxin B, & hydrocortisone (ophth) Generic

BLEPHAMIDE (sulfacetamide sodium & prednisolone) ointment, suspension Brand

CIPRODEX (dexamethasone & ciprofloxacin) Brand COLY-MYCIN S (neomycin, colistin, hydrocortisone, & thonzonium) Brand

dexamethasone sodium phosphate (ophth) Generic diclofenac sodium (ophth) Generic flunisolide (nasal) Generic fluoromethalone (ophth) Generic

Page 17: Kaiser Permanente of Georgia HMO

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

*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.*

16 Kaiser Permanente of Georgia HMO Formulary

Drug Name Drug Tier Restrictions fluticasone propionate (nasal) Generic ketorolac (ophth) Generic MAXIDEX (dexamethasone) Brand neomycin, polymyxin B, & dexamethasone Generic neomycin, polymyxin B, & hydrocortisone (ophth) Generic neomycin, polymyxin B, & hydrocortisone (otic) Generic PRED MILD (prednisolone acetate) Generic PRED-G (prednisolone & gentamicin) Brand prednisolone acetate (ophth) Generic RESTASIS (cyclosporine) Brand sulfacetamide sodium & prednisolone solution Generic TOBRADEX (tobramycin & dexamethasone) ointment Brand tobramycin & dexamethasone suspension Generic

Antiglaucoma Agents acetazolamide Generic betaxolol (ophth) Generic BETOPTIC S (betaxolol) Brand brimonidine Generic dorzolamide Generic dorzolamide & timolol Generic ISOPTO CARBACHOL (carbachol) Brand latanoprost Generic levobunolol Generic methazolamide Generic methazolamide Generic PHOSPHOLINE IODIDE (echothiophate) Brand pilocarpine (ophth) Generic timolol maleate (ophth) Generic

EENT Drugs, Miscellaneous IOPIDINE (apraclonidine) Brand

Local Anesthetics antipyrine & benzocaine Generic lidocaine (mouth-throat) Generic proparacaine Generic

Mydriatics ISOPTO HOMATROPINE (homatropine) Brand ISOPTO HYOSCINE (scopolamine) Brand

Gastrointestinal Drugs Anti-inflammatory Agents

balsalazide Generic CANASA (mesalamine) Brand LIALDA (mesalamine) Brand mesalamine enema Generic

Page 18: Kaiser Permanente of Georgia HMO

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

*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.*

Kaiser Permanente of Georgia HMO Formulary 17

Drug Name Drug Tier Restrictions PENTASA (mesalamine) Brand

Antidiarrheal Agents diphenoxylate & atropine Generic

Antiemetics dronabinol Generic ondansetron Generic EMEND (aprepitant) Brand

Antiulcer Agents and Acid Suppressants CARAFATE (sucralfate) suspension Brand cimetidine Generic misoprostol Generic ranitidine Generic sucralfate tablet Generic

Cathartics and Laxatives polyethylene glycol-electrolyte solution Generic

Digestants pancrelipase Generic ZENPEP (pancrelipase) Brand

GI Drug Miscellaneous clidinium & chlordiazepoxide Generic metoclopramide Generic phenobarbital & belladonna alkaloids Generic ursodiol Generic

Gold Compounds Gold Compounds

RIDAURA (auranofin) Brand Heavy Metal Antagonists

Heavy Metal Antagonists CUPRIMINE (penicillamine) Brand DEPEN (penicillamine) Brand EXJADE (deferasirox) Brand

Hormone and Synthetic Substitutes Adrenals

dexamethasone Generic fludrocortisone Generic hydrocortisone Generic methylprednisolone Generic prednisolone Generic prednisone Generic

Androgens ANDRODERM (testosterone) Brand ANDROID (methyltestosterone) Brand ANDROXY (fluoxymesterone) Brand

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*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.*

18 Kaiser Permanente of Georgia HMO Formulary

Drug Name Drug Tier Restrictions danazol Generic METHITEST (methyltestosterone) Brand testosterone cypionate Generic TESTRED (methyltestosterone) Brand

Contraceptives AVIANE (ethinyl estradiol & levonorgestrel) Generic QL BREVICON (ethinyl estradiol & norethindrone) Brand QL CRYSELLE (ethinyl estradiol & norgestrel) Generic QL ELLA (ulipristal) Brand ethinyl estradiol & ethynodioldiacetate Generic QL levonorgestrel tablet Generic Age LEVORA (ethinyl estradiol & levonorgestrel) Generic QL MICROGESTIN FE (ethinyl estradiol & norethindrone) Generic QL NECON (ethinyl estradiol & norethindrone) Generic QL NECON (mestranol & norethindrone) Generic QL PLAN B ONE STEP (levonorgestrel) Brand Age RECLIPSEN (ethinyl estradiol & desogestrel) Generic QL SPRINTEC (ethinyl estradiol & norgestimate) Generic QL TRI-NORINYL (ethinyl estradiol & norethindrone) Generic QL TRI-SPRINTEC (ethinyl estradiol & norgestimate) Generic QL TRIVORA (ethinyl estradiol & levonorgestrel) Generic QL

Diabetic Agents acarbose Generic pioglitazone Generic BYDUREON (exenatide extended-release) Brand QRM BYETTA (exenatide) Brand QRM glimepiride Generic glipizide Generic GLUCAGON (glucagon) Brand glyburide Generic HUMULIN 70/30 (insulin isophane & insulin regular) Brand HUMULIN-N (insulin isophane) Brand HUMULIN-R (insulin regular) Brand JANUMET (sitagliptin & metformin) Brand QRM JANUVIA (sitagliptin phosphate) Brand QRM JUVISYNC (sitagliptin & simvastatin) Brand QRM KOMBIGLYZE XR (saxagliptin & metformin extended-release) Brand QRM

metformin ER Generic metformin Generic ONGLYZA (saxagliptin) Brand QRM SYMLIN (pramlintide acetate) Brand QRM

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*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.*

Kaiser Permanente of Georgia HMO Formulary 19

Drug Name Drug Tier Restrictions

TRADJENTA (linagliptin) Brand QRM VICTOZA (liraglutide) Brand QRM

Estrogens and Antiestrogens estradiol Generic estradiol patch Generic ESTRING (estradiol) Brand estrogens & methyltestosterone Generic estropipate Generic EVISTA (raloxifene) Brand PREMARIN (conjugated estrogen)(vaginal cream) Brand VAGIFEM (estradiol) (vaginal tablets) Brand

Gonadotropins SYNAREL (nafarelin) Brand

Parathyroid calcitonin Generic

Pituitary ACTHAR (corticotropin) Brand QRM desmopressin Generic

Progestins medroxyprogesterone acetate tablet Generic NORA-BE (norethindrone) Generic

Somatotropin Agonists and Antagonists GENTROPIN (somatropin) Brand QRM HUMATROPE (somatropin) Brand QRM NORDITROPIN (somatropin) Brand QRM NUTROPIN AQ (somatropin) Brand QRM OMNITROPE (somatropin) Brand QRM SAIZEN (somatropin) Brand QRM SEROSTIM (somatropin) Brand QRM ZORBTIVE (somatropin) Brand QRM

Thyroid and Antithyroid Agents levothyroxine Generic liothyronine Generic methimazole Generic propylthiouracil Generic

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents

acetylcysteine Generic ACTIMMUNE (interferon gamma-1b) Brand alendronate Generic allopurinol Generic AMPYRA (dalfampridine) Brand QRM AVONEX (interferon beta-1a) Brand

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20 Kaiser Permanente of Georgia HMO Formulary

Drug Name Drug Tier Restrictions

azathioprine Generic COPAXONE (glatiramer) Brand cyclosporine Generic disulfiram Generic ELMIRON (pentosanpolysulfate sodium) Brand ENBREL (etanercept) Brand etidronate Generic EXTAVIA (interferon beta-1b) Brand finasteride Generic FIRAZYR (icatibant) Brand QRM fluoride sodium Generic GEL-KAM (stannous fluoride) Brand GILENYA (fingolimod) Brand QRM HUMIRA (adalimumab) Brand KALYDECO (ivacaftor) Brand QRM leflunomide Generic MESNEX (mesna) Brand methylergonovine maleate Generic mycophenolate mofetil Generic MYFORTIC (mycophentolate sodium) Brand ORENCIA (abatacept) Brand RAPAMUNE (sirolimus) Generic REBIF (interferon beta-1a) Brand SENSIPAR (cinacalcet) Brand tacrolimus Generic THALOMID (thalidomide) Brand

Respiratory Tract Agents Antitussives

benzonatate Generic guaifenesin & codeine Generic guaifenesin, pseudoephedrine, & codeine Generic hydrocodone & homatropine Generic promethazine & codeine Generic promethazine, phenylephrine, & codeine Generic

Anti-Inflammatory Agents cromolyn sodium Generic montelukast Generic

Mucolytic Agents PULMOZYME (dornasealfa) Brand

Respiratory Tract Agents, Miscellaneous ASMANEX (mometasone) Brand budesonide inhalation suspension Brand

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Kaiser Permanente of Georgia HMO Formulary 21

Drug Name Drug Tier Restrictions FLOVENT (fluticasone) Brand QVAR (beclomethasone) Brand

Skin and Mucous Membrane Agents Anti-infectives (Skin and Mucous Membranes)

clindamycin phosphate Generic erythromycin Generic erythromycin & benzoyl peroxide Generic iodoquinol & hydrocortisone Generic ketoconazole (topical) Generic lindane Generic metronidazole (topical) Generic mupirocin Generic nystatin (topical) Generic permethrin Generic selenium sulfide Generic silver sulfadiazine Generic

Anti-inflammatory Agents (Skin and Mucous Membrane) alclometasone dipropionate Generic betamethasone valerate Generic betamethasone dipropionate Generic betamethasone dipropionate augmented Generic clobetasol Generic clobetasol propionate Generic desonide Generic fluocinolone Generic fluocinonide Generic halobetasol propionate Generic hydrocortisone (topical) Generic hydrocortisone butyrate Generic mometasone furoate Generic nystatin & triamcinolone Generic triamcinolone acetonide (topical) Generic

Antipruritics and Local Anesthetics lidocaine (topical) Generic lidocaine & prilocaine Generic pramoxine & hydrocortisone cream Generic PROCTOFOAM (pramoxine & hydrocortisone) Brand

Astringents HYPERCARE (aluminum chloride hexahydrate) Brand

Cell Stimulants and Proliferants

tretinoin (topical) Generic Limited to age ≤35

Keratolytic Agents

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*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.*

22 Kaiser Permanente of Georgia HMO Formulary

Drug Name Drug Tier Restrictions sulfur & sulfacetamide sodium cleanser Generic sulfur & sulfacetamide sodium lotion Generic urea Generic

Keratoplastic Agents DRITHO-CREME (anthralin) Brand DRITHO-SCALP (anthralin) Brand

Skin and Mucous Membrane Agents Miscellaneous 8-MOP (methoxsalen) Brand calcipotriene Generic CONDYLOX (podofilox) Brand ELIDEL (pimecrolimus) Brand FLUOROPLEX (fluorouracil) Brand fluorouracil (topical) Generic imiquimod Generic isotretinoin Generic OXSORALEN-ULTRA (methoxsalen) Brand REGRANEX (becaplermin) Brand SANTYL (collagenase) Brand VECTICAL (calcitriol) Brand

Smooth Muscle Relaxants Smooth Muscle Relaxants

aminophylline Generic oxybutynin Generic oxybutynin XL Generic OXYTROL (oxybutynin) Brand theophylline Generic

Vitamins Vitamins

calcitriol Generic ergocalciferol Generic MEPHYTON (phytonadione) Brand

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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.*

Kaiser Permanente of Georgia HMO Formulary 23

Index of Drugs

8

8-MOP (methoxsalen).............................................................. 22

A

abacavir ....................................................................................... 6 abacavir tablet ............................................................................ 6 ABILIFY (aripiprazole) .............................................................. 13 acarbose ................................................................................... 18 acebutolol ................................................................................. 11 acetaminophen & codeine ..................................................... 11 acetaminophen, isometheptene, & dichloralphenazone ... 11 acetazolamide .......................................................................... 16 acetylcysteine ........................................................................... 19 ACTHAR (corticotropin) .......................................................... 19 ACTIMMUNE (interferon gamma-1b) ................................... 19 acyclovir ...................................................................................... 6 AFINITOR (everolimus) ............................................................. 7 AGGRENOX (aspirin & dipyridamole) .................................... 9 ALBENZA (albendazole) ........................................................... 5 albuterol sulfate nebulizer solution ......................................... 9 albuterol sulfate tablet, syrup .................................................. 9 alclometasone dipropionate .................................................. 21 alendronate .............................................................................. 19 ALKERAN (melphalan ............................................................... 7 ALKERAN (melphalan) .............................................................. 7 allopurinol ................................................................................. 19 alprazolam ................................................................................ 13 aluminum acetate and acetic acid ......................................... 15 amantadine ............................................................................... 12 amiloride & hydrochlorothiazide ........................................... 14 aminocaproic acid ..................................................................... 9 aminophylline ........................................................................... 22 amiodarone .............................................................................. 10 amitriptyline .............................................................................. 13 amlodipine ................................................................................ 10 amoxicillin ............................................................................... 2, 5 amoxicillin & clavulanic acid ..................................................... 5 amphetamine & dextroamphetamine ................................... 12 amphetamine & dextroamphetamine extended-release ... 12 ampicillin ..................................................................................... 5 AMPYRA (dalfampridine) ........................................................ 19 anagrelide ................................................................................... 9 anastrozole ................................................................................. 7 ANCOBON (flucytosine) ........................................................... 5 ANDRODERM (testosterone) ................................................. 17 ANDROID (methyltestosterone) ............................................ 17 ANDROXY (fluoxymesterone) ................................................ 17

antipyrine & benzocaine ......................................................... 16 APTIVUS (tipranavir) .................................................................. 6 ARANESP (darbepoetin alfa) .................................................... 9 ASMANEX (mometasone) ...................................................... 20 atenolol ..................................................................................... 11 atenolol & chlorthalidone ....................................................... 11 atorvastatin ................................................................................. 9 ATRIPLA (efavirenz, emtricitabine, & tenofovir) ..................... 6 atropine sulfate .......................................................................... 8 ATROVENT HFA (ipratropium) ................................................ 8 AVONEX (interferon beta-1a) ................................................. 19 azathioprine .............................................................................. 19 azithromycin ............................................................................... 5

B

bacitracin & polmyxin B (ophth)............................................. 15 bacitracin (ophth) ..................................................................... 15 bacitracin, neomycin, & polymyxin B .................................... 15 bacitracin, neomycin, polymyxin B, & hydrocortisone

(ophth) .................................................................................. 15 baclofen ...................................................................................... 8 balsalazide ................................................................................ 16 BARACLUDE (entecavir) ........................................................... 6 B-D INSUILIN SYRINGE (syringe w-ndl, disp.) ..................... 14 benazepril ................................................................................. 10 benzonatate ............................................................................. 20 benztropine mesylate .............................................................. 12 betamethasone ........................................................................ 21 betamethasone dipropionate ................................................ 21 betamethasone dipropionate augmented ........................... 21 betaxolol ................................................................................... 16 betaxolol (ophth) ..................................................................... 16 bethanechol ............................................................................... 8 BETOPTIC S (betaxolol) .......................................................... 16 bicalutamide ............................................................................... 7 bisoprolol .................................................................................. 11 bisoprolol & hydrochlorothiazide .......................................... 11 BLEPHAMIDE (sulfacetamide sodium & prednisolone)

ointment, suspension ......................................................... 15 brimonidine .............................................................................. 16 bromocriptine mesylate .......................................................... 12 budesonide inhalation suspension ........................................ 20 bumetanide .............................................................................. 14 buprenorphine ................................................................... 11, 12 bupropion ................................................................................. 13 bupropion IR, SR, XL ............................................................... 13 buspirone .................................................................................. 13 butalbital, acetaminophen, & caffeine .................................. 11

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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.*

24 Kaiser Permanente of Georgia HMO Formulary

butalbital, acetaminophen, caffeine, & codeine.................. 11 butalbital, aspirin, & caffeine .................................................. 11 butalbital, aspirin, caffeine, & codeine ................................. 11 BYDUREON (exenatide extended-release) .......................... 18 BYETTA (exenatide) ................................................................. 18

C

cabergoline............................................................................... 12 calcipotriene ............................................................................. 22 calcitonin ................................................................................... 19 calcitriol ..................................................................................... 22 calcium acetate ........................................................................ 15 CANASA (mesalamine) ........................................................... 16 CAPRELSA (vandetanib) ........................................................... 7 captopril .................................................................................... 10 carbamazepine ......................................................................... 12 carbamazepine extended-release ......................................... 12 carbidopa & levodopa ............................................................ 13 carisoprodol ............................................................................... 8 carvedilol................................................................................... 11 cefaclor ........................................................................................ 5 cefdinir ........................................................................................ 5 cefuroxime .................................................................................. 5 CELONTIN (methsuximide) .................................................... 12 cephalexin .................................................................................. 5 chlordiazepoxide ............................................................... 13, 17 chlorhexidine ............................................................................ 15 chlorpromazine ........................................................................ 13 chlorthalidone .................................................................... 11, 14 chlorzoxazone ............................................................................ 9 cholestyramine resin .................................................................. 9 cilostazol ..................................................................................... 9 cimetidine ................................................................................. 17 CIPRODEX (dexamethasone &ciprofloxacin) ....................... 15 ciprofloxacin ......................................................................... 5, 15 citalopram ................................................................................. 13 clarithromycin ............................................................................. 5 clidinium & chlordiazepoxide................................................. 17 clindamycin ........................................................................... 5, 21 clindamycin palmitate (solution) .............................................. 5 clindamycin phosphate ........................................................... 21 clobetasol ................................................................................. 21 clomipramine ........................................................................... 13 clonazepam .............................................................................. 13 clonidine ................................................................................... 10 clopidogrel ................................................................................. 9 clorazepate ............................................................................... 13 clotrimazole lozenge ................................................................. 5 clozapine ................................................................................... 13 colestipol .................................................................................. 10

COLY-MYCIN S (neomycin, colistin, hydrocortisone, & thonzonium) ......................................................................... 15

COMBIVENT RESPIMAT (ipratropium & albuterol) .............. 9 COMPLERA (rilpivirine, emtricitabine, & tenofovir)............... 6 CONDYLOX (podofilox).......................................................... 22 COPAXONE (glatiramer) ........................................................ 20 CRIXIVAN (indinavir) .................................................................. 6 cromolyn sodium ..................................................................... 20 CRYSELLE (ethinyl estradiol & norgestrel)............................ 18 CUPRIMINE (penicillamine) .................................................... 17 cyclobenzaprine ......................................................................... 9 cyclophosphamide .................................................................... 7 cyclosporine ....................................................................... 16, 20 cyproheptadine .......................................................................... 5

D

danazol ...................................................................................... 17 dapsone ...................................................................................... 6 DARAPRIM (pyrimethamine) .................................................... 6 DEPEN (penicillamine) ............................................................ 17 desipramine .............................................................................. 13 desmopressin ........................................................................... 19 desonide ................................................................................... 21 dexamethasone ........................................................... 15, 16, 17 dexamethasone sodium phosphate (ophth) ........................ 15 dextroamphetamine sulfate ................................................... 12 diazepam .................................................................................. 13 diclofenac ........................................................................... 11, 15 diclofenac sodium (ophth) ...................................................... 15 dicloxacillin ................................................................................. 5 dicyclomine ................................................................................ 8 didanosine .............................................................................. 6, 7 digoxin ...................................................................................... 10 diltiazem .................................................................................... 10 diphenoxylate & atropine ....................................................... 17 diphenoxylate and atropine ................................................... 17 dipyridamole ........................................................................ 9, 10 disopyramide phosphate ........................................................ 10 disulfiram .................................................................................. 20 divalproex sodium ................................................................... 12 divalproex sodium ER ............................................................. 12 donepezil .................................................................................... 8 dorzolamide ............................................................................. 16 dorzolamide & timolol ............................................................ 16 doxazosin .................................................................................... 9 doxepin ..................................................................................... 13 doxycycline ................................................................................. 5 DRITHO-CREME (anthralin) .................................................... 22 DRITHO-SCALP (anthralin) ..................................................... 22 dronabinol ................................................................................ 17

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Kaiser Permanente of Georgia HMO Formulary

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Kaiser Permanente of Georgia HMO Formulary 25

DROXIA (hydroxyurea) .............................................................. 7

E

ELIDEL (pimecrolimus) ............................................................ 22 ELIPHOS (calcium acetate) ..................................................... 15 ELLA (ulipristal) ......................................................................... 18 EMCYT (estramustine) ............................................................... 7 EMEND (aprepitant) ................................................................ 17 EMTRIVA (emtricitabine) ........................................................... 6 enalapril .................................................................................... 10 ENBREL (etanercept) ............................................................... 20 enoxaparin .................................................................................. 9 entacapone ............................................................................... 13 epinephrine injection auto injector ......................................... 9 EPIPEN (epinephrine) ................................................................ 9 EPIPEN JR (epinephrine) ........................................................... 9 EPIVIR (lamivudine & zidovudine) solution ............................. 6 EPZICOM (abacavir & lamivudine) .......................................... 6 ergocalciferol ........................................................................... 22 ergoloid mesylates .................................................................... 9 ergotamine & caffeine .............................................................. 9 erythromycin ................................................................... 5, 15, 21 erythromycin & benzoyl peroxide ......................................... 21 erythromycin & sulfisoxazole .................................................... 5 erythromycin (ophth) ............................................................... 15 escitalopram ............................................................................. 13 estradiol .............................................................................. 18, 19 estradiol patch ......................................................................... 19 ESTRING (estradiol) ................................................................. 19 estrogens & methyltestosterone ........................................... 19 estropipate ............................................................................... 19 ethambutol ................................................................................. 6 ethinyl estradiol & ethynodioldiacetate ................................ 18 ethosuximide ............................................................................ 12 etidronate ................................................................................. 20 etodolac .................................................................................... 11 etoposide .................................................................................... 7 EVISTA (raloxifene) .................................................................. 19 EXELON (rivastigmine) solution ............................................... 8 EXJADE (deferasirox) .............................................................. 17 EXTAVIA (interferon beta-1b) ................................................. 20

F

felodipine .................................................................................. 10 fenofibrate ................................................................................ 10 fentanyl...................................................................................... 11 finasteride ................................................................................. 20 FIRAZYR (icatibant) .................................................................. 20

flecainide .................................................................................. 10 FLOVENT (fluticasone) ............................................................ 20 fluconazole ................................................................................. 5 fludrocortisone ......................................................................... 17 flunisolide (nasal) ..................................................................... 15 fluocinolone .............................................................................. 21 fluocinonide .............................................................................. 21 fluoride sodium ........................................................................ 20 fluoromethalone (ophth) ......................................................... 15 FLUOROPLEX (fluorouracil) .................................................... 22 fluorouracil (topical) ................................................................. 22 fluoxetine .................................................................................. 13 fluphenazine ............................................................................. 13 flutamide ..................................................................................... 7 fluticasone propionate (nasal) ................................................ 15 furosemide ................................................................................ 14 FUZEON (enfuvirtide) ................................................................ 6

G

gabapentin ............................................................................... 12 galantamine IR, ER ..................................................................... 8 GEL-KAM (stannous fluoride) ................................................. 20 gemfibrozil ................................................................................ 10 gentamicin sulfate (ophth) ...................................................... 15 GENTROPIN (somatropin) ...................................................... 19 GILENYA (fingolimod) ............................................................. 20 GLEEVEC (imatinib mesylate) .................................................. 7 glimepiride ............................................................................... 18 glipizide..................................................................................... 18 GLUCAGON (glucagon) ......................................................... 18 glyburide ................................................................................... 18 glycopyrrolate ............................................................................ 8 griseofulvin ................................................................................. 5 GRIS-PEG (griseofulvin)............................................................. 5 guaifenesin & codeine ............................................................ 20 guaifenesin, pseudoephedrine, & codeine .......................... 20 guanfacine ................................................................................ 10

H

halobetasol propionate .......................................................... 21 haloperidol ............................................................................... 13 HEPSERA (adefovir dipivoxil) ................................................... 6 HEPSERA (adefovirdipivoxil) .................................................... 6 HUMATROPE (somatropin) .................................................... 19 HUMIRA (adalimumab) ........................................................... 20 HUMULIN 70/30 (insulin isophane & insulin regular) .......... 18 HUMULIN-N (insulin isophane) .............................................. 18 HUMULIN-R (insulin regular) .................................................. 18

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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.*

26 Kaiser Permanente of Georgia HMO Formulary

HYCAMTIN (topotecan) ............................................................ 7 hydralazine ................................................................................ 10 hydrochlorothiazide..................................................... 10, 11, 14 hydrocodone & acetaminophen ............................................ 11 hydrocodone & homatropine ................................................ 20 hydrocortisone ....................................................... 15, 16, 17, 21 hydrocortisone (topical) .......................................................... 21 hydrocortisone butyrate ......................................................... 21 hydromorphone ....................................................................... 11 hydroxychloroquine ................................................................... 6 hydroxyurea ................................................................................ 7 hydroxyzine ............................................................................... 13 hyoscyamine ............................................................................... 8 HYPERCARE (aluminum chloride hexahydrate) ................... 21

I

ibuprofen .................................................................................. 11 imipramine ................................................................................ 13 imiquimod ................................................................................ 22 indapamide .............................................................................. 14 indomethacin ........................................................................... 11 INTELENCE (etravirine) ............................................................. 6 INTRON-A (interferon alfa-2b vaccine) ................................... 7 INVIRASE (saquinavir) ................................................................ 6 iodoquinol & hydrocortisone ................................................. 21 IOPIDINE (apraclonidine) ....................................................... 16 ipratropium & albuterol nebulizer solution ............................ 9 ipratropium bromide nasal ....................................................... 8 ipratropium bromide nebulizer ................................................ 8 ISENTRESS (raltegravir) ............................................................. 6 isoniazid ...................................................................................... 6 ISOPTO CARBACHOL (carbachol) ........................................ 16 ISOPTO HOMATROPINE (homatropine) ............................. 16 ISOPTO HYOSCINE (scopolamine) ....................................... 16 isosorbide dinitrate ................................................................. 11 isosorbide mononitrate........................................................... 11 isotretinoin ................................................................................ 22 itraconazole capsule .................................................................. 5

J

JANUMET (sitagliptin & metformin) ...................................... 18 JANUVIA (sitagliptin phosphate) ........................................... 18 JUVISYNC (sitagliptin & simvastatin) ..................................... 18

K

KALETRA (lopinavir & ritonavir)................................................ 6 KALYDECO (ivacaftor) ............................................................. 20

ketoconazole ........................................................................ 5, 21 ketoconazole (topical) ............................................................. 21 ketorolac (ophth) ...................................................................... 16 KOMBIGLYZE XR (saxagliptin & metformin extended-

release) ................................................................................. 18 K-PHOS (potassium acid phosphate) .................................... 15

L

labetalol .................................................................................... 11 lactulose .................................................................................... 14 lamivudine .............................................................................. 6, 7 lamivudine & zidovudine tablet ............................................... 6 lamotrigine ............................................................................... 12 latanoprost ............................................................................... 16 leflunomide............................................................................... 20 LETAIRIS (ambrisentan) ........................................................... 11 letrozole ...................................................................................... 7 leucovorin calcium ..................................................................... 7 LEUKERAN (chlorambucil) ........................................................ 7 LEUKINE (sargramostim) ........................................................... 9 levetiracetam ............................................................................ 12 levetiracetam extended-release ............................................ 12 levobunolol ............................................................................... 16 levofloxacin ................................................................................. 5 levonorgestrel tablet ............................................................... 18 levothyroxine ............................................................................ 19 LEXIVA (fosamprenavir) ............................................................. 6 LIALDA (mesalamine) .............................................................. 16 lidocaine & prilocaine ............................................................. 21 lidocaine (mouth-throat) ......................................................... 16 lidocaine (topical) .................................................................... 21 lidocaine hcl (mouth-throat) ................................................... 16 lindane ...................................................................................... 21 liothyronine ............................................................................... 19 lisinopril ..................................................................................... 10 lisinopril & hydrochlorothiazide ............................................. 10 lithium........................................................................................ 14 lorazepam ................................................................................. 13 losartan...................................................................................... 10 losartan & hydrochlorothiazide .............................................. 10 lovastatin ................................................................................... 10 LYSODREN (mitotane) .............................................................. 7

M

MATULANE (procarbazine) ...................................................... 7 MAXIDEX (dexamethasone) ................................................... 16 medroxyprogesterone acetate tablet ................................... 19 megestrol .................................................................................... 7

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Kaiser Permanente of Georgia HMO Formulary

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Kaiser Permanente of Georgia HMO Formulary 27

meloxicam ................................................................................ 11 meperidine ............................................................................... 11 MEPHYTON (phytonadione) .................................................. 22 meprobamate .......................................................................... 13 MEPRON (atovaquone) ............................................................. 6 mercaptopurine ......................................................................... 7 mesalamine enema ................................................................. 16 MESNEX (mesna) ..................................................................... 20 MESTINON TIMESPAN (pyridostigmine sustained-release)8 metformin ................................................................................. 18 metformin ER............................................................................ 18 methadone ............................................................................... 11 methazolamide ........................................................................ 16 methimazole ............................................................................. 19 METHITEST (methyltestosterone) ......................................... 18 methocarbamol .......................................................................... 9 methotrexate .......................................................................... 7, 8 methyldopa .............................................................................. 10 methylergonovine maleate .................................................... 20 methylphenidate ...................................................................... 12 methylphenidate extended-release ...................................... 12 methylprednisolone ................................................................ 17 metoclopramide ...................................................................... 17 metolazone ............................................................................... 14 metoprolol ................................................................................ 11 metoprolol sustained release ................................................. 11 metronidazole ...................................................................... 6, 21 metronidazole (topical) ........................................................... 21 mexiletine ................................................................................. 10 MIGRANAL (dihydroergotamine) ............................................ 9 minocycline ................................................................................. 5 minoxidil ................................................................................... 10 mirtazapine ............................................................................... 14 misoprostol ............................................................................... 17 mometasone furoate ............................................................... 21 montelukast .............................................................................. 20 morphine sulfate ................................................................ 11, 12 morphine sulfate extended-release ...................................... 12 mupirocin .................................................................................. 21 MYCOBUTIN (rifabutin) ............................................................ 6 mycophenolate mofetil ........................................................... 20 MYFORTIC (mycophentolate sodium) .................................. 20 MYLERAN (busulfan) ................................................................. 8

N

nabumetone ............................................................................. 12 nadolol ...................................................................................... 11 naltrexone hydrochloride ....................................................... 13 NAMENDA (memantine hydrochloride) ............................... 13 naproxen ................................................................................... 12

naratriptan ................................................................................ 12 NATACYN (natamycin) ............................................................ 15 NECON (ethinyl estradiol & norethindrone) ........................ 18 NECON (mestranol & norethindrone) .................................. 18 neomycin ........................................................................ 5, 15, 16 neomycin, polymyxin B, & dexamethasone ......................... 16 neomycin, polymyxin B, & gramicidin ................................... 15 neomycin, polymyxin B, & hydrocortisone (ophth) ....... 15, 16 neomycin, polymyxin B, & hydrocortisone (otic) ................. 16 neostigmine ................................................................................ 8 NEUMEGA (oprelvekin) ............................................................ 9 NEUPOGEN (filgrastim) ............................................................ 9 nevirapine tablet ........................................................................ 6 NEXAVAR (sorafenib) ................................................................ 8 nifedipine .................................................................................. 10 nimodipine ............................................................................... 10 NITRO-BID (nitroglycerin) ....................................................... 11 nitrofurantoin macrocrystals ..................................................... 7 nitrofurantoin macrocrystals/monohydrate ............................ 7 nitroglycerin .............................................................................. 11 NITROSTAT (nitroglycerin) ..................................................... 11 NORA-BE (norethindrone) ...................................................... 19 NORDITROPIN (somatropin) ................................................. 19 norethindrone .......................................................................... 19 NORPACE CR (disopyramide phosphate controlled

release) ................................................................................. 10 nortriptyline .............................................................................. 14 NORVIR (ritonavir) ...................................................................... 6 NUTROPIN AQ (somatropin) ................................................. 19 nystatin .................................................................................. 5, 21 nystatin & triamcinolone ......................................................... 21 nystatin (topical) ....................................................................... 21

O

ofloxacin (ophth) ...................................................................... 15 ofloxacin (otic) .......................................................................... 15 olanzapine ................................................................................ 14 olanzapine ODT ....................................................................... 14 OMNITROPE (somatropin) ..................................................... 19 ondansetron ............................................................................. 17 ONE TOUCH ULTRA 2 (blood glucose meter) .................... 14 ONE TOUCH ULTRA TEST STRIPS ....................................... 14 ONGLYZA (saxagliptin) ........................................................... 18 ORENCIA (abatacept) ............................................................. 20 oxazepam ................................................................................. 13 OXSORALEN-ULTRA (methoxsalen) ..................................... 22 oxybutynin ................................................................................ 22 oxybutynin XL ........................................................................... 22 oxycodone & acetaminophen tablet..................................... 12 oxycodone & aspirin ................................................................ 12

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28 Kaiser Permanente of Georgia HMO Formulary

oxycodone immediate release............................................... 12 OXYTROL (oxybutynin) ........................................................... 22

P

pancrelipase ............................................................................. 17 paromomycin ............................................................................. 6 paroxetine ................................................................................. 14 PEGASYS (peginterferon alfa-2a) ............................................ 6 PEG-INTRON (peginterferon alfa-2b) ..................................... 6 penicillin V potassium ............................................................... 5 PENTASA (mesalamine) .......................................................... 16 pentoxifylline .............................................................................. 9 permethrin ................................................................................ 21 perphenazine ........................................................................... 14 phenelzine sulfate .................................................................... 14 phenobarbital ..................................................................... 13, 17 phenobarbital & belladonna alkaloids .................................. 17 phenytoin .................................................................................. 12 PHOSLYRA (calcium acetate) ................................................. 15 PHOSPHA NEUTRAL (potassium phosphate & sodium

phosphate) ........................................................................... 15 PHOSPHOLINE IODIDE (echothiophate) ............................. 16 pilocarpine (ophth) .................................................................. 16 pioglitazone .............................................................................. 18 PLAN B ONE STEP (levonorgestrel) ...................................... 18 polyethylene glycol-electrolyte solution ............................... 17 polymyxin b-trimethoprim ...................................................... 15 potassium chloride .................................................................. 15 potassium citrate ..................................................................... 14 pramipexole ............................................................................. 13 pramoxine & hydrocortisone cream ...................................... 21 pravastatin ................................................................................ 10 prazosin ....................................................................................... 9 PRED MILD (prednisolone acetate) ....................................... 16 PRED-G (prednisolone & gentamicin) ................................... 16 prednisolone ................................................................ 15, 16, 17 prednisolone acetate (ophth) ................................................. 16 prednisone................................................................................ 17 PREMARIN (conjugated estrogen)(vaginal cream) .............. 19 PREZISTA (darunavir) ................................................................. 6 PRIMAQUINE (primaquine) ...................................................... 6 primidone ................................................................................. 12 PROAIR HFA (albuterol sulfate) ............................................... 9 probenecid ............................................................................... 15 prochlorperazine ...................................................................... 14 PROCRIT (epoetin alfa) ............................................................. 9 PROCTOFOAM (pramoxine & hydrocortisone)................... 21 PROGLYCEM (diazoxide) ........................................................ 10 promethazine ....................................................................... 5, 20 promethazine & codeine ........................................................ 20

promethazine, phenylephrine, & codeine ............................ 20 propafenone ............................................................................. 10 propantheline ............................................................................. 8 proparacaine ............................................................................ 16 propranolol ............................................................................... 11 propylthiouracil ........................................................................ 19 PULMOZYME (dornase alfa) ................................................... 20 pyrazinamide .............................................................................. 6 pyridostigmine ........................................................................... 8

Q

quetiapine ................................................................................. 14 quinidine ................................................................................... 10 QVAR (beclomethasone) ........................................................ 21

R

ramipril ...................................................................................... 10 ranitidine ................................................................................... 17 RAPAMUNE (sirolimus) ........................................................... 20 REBIF (interferon beta-1a) ...................................................... 20 RECLIPSEN (ethinyl estradiol & desogestrel) ....................... 18 REGRANEX (becaplermin) ...................................................... 22 RELENZA (zanamivir) ................................................................. 6 REMODULIN (trepostinil)........................................................ 11 RENVELA (sevelamer carbonate) ........................................... 14 RESCRIPTOR (delavirdine) ........................................................ 6 RESTASIS (cyclosporine) ......................................................... 16 REVLIMID (lenalidomide) .......................................................... 8 REYATAZ (atazanavir) ................................................................ 6 ribavirin ....................................................................................... 7 RIDAURA (auranofin) ............................................................... 17 rifampin ....................................................................................... 6 RILUTEK (riluzole) ..................................................................... 13 rimantadine ................................................................................ 7 risperidone ............................................................................... 14 rivastigmine capsule .................................................................. 8 ropinirole .................................................................................. 13 ROXICET (oxycodone & acetaminophen) solution ............ 12

S

SABRIL (vigabatrin) .................................................................. 12 SAIZEN (somatropin) ............................................................... 19 salsalate..................................................................................... 12 SANTYL (collagenase) ............................................................. 22 selegiline ................................................................................... 13 selenium sulfide ....................................................................... 21 SELZENTRY (maraviroc) ............................................................ 7

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Kaiser Permanente of Georgia HMO Formulary

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Kaiser Permanente of Georgia HMO Formulary 29

SENSIPAR (cinacalcet) ............................................................. 20 SEREVENT (salmeterol) ............................................................. 9 SEROSTIM (somatropin) ......................................................... 19 sertraline ................................................................................... 14 silver sulfadiazine ..................................................................... 21 simvastatin .......................................................................... 10, 18 sod/potass/k cit/sodium cit/ca .............................................. 14 sotalol ........................................................................................ 11 SPIRIVA (tiotropium) .................................................................. 8 spironolactone ......................................................................... 10 SPORANOX (itraconazole) solution ........................................ 5 SPRINTEC (ethinyl estradiol & norgestimate) ...................... 18 SPRYCEL (dasatinib) .................................................................. 8 SPS (sodium polystyrene sulfonate) ...................................... 15 STALEVO (levodopa, carbidopa, & entacapone) ................ 13 stavudine ..................................................................................... 7 SUBOXONE (naloxone & buprenorphine) ........................... 12 sucralfate ................................................................................... 17 sulfacetamide sodium & prednisolone solution .................. 16 sulfacetamide sodium (ophth) ............................................... 15 sulfadiazine ........................................................................... 5, 21 sulfamethoxazole & trimethoprim ........................................... 5 sulfasalazine ................................................................................ 5 sulfur & sulfacetamide sodium cleanser ............................... 21 sulfur & sulfacetamide sodium lotion .................................... 22 sulindac ..................................................................................... 12 sumatriptan ............................................................................... 12 SUSTIVA (efavirenz) ................................................................... 7 SUTENT (sunitinib) ..................................................................... 8 SYMLIN (pramlintide acetate) ................................................ 18 SYNAREL (nafarelin) ................................................................ 19

T

TABLOID (thoiguanine) ............................................................. 8 tacrolimus ................................................................................. 20 TAMIFLU (oseltamivir) ............................................................... 7 tamoxifen .................................................................................... 8 tamsulosin ................................................................................... 9 TARCEVA (erlotinib) .................................................................. 8 TARGRETIN (bexarotene) ......................................................... 8 TASIGNA (nilotinib) ................................................................... 8 TASMAR (tolcapone) ............................................................... 13 temazepam ............................................................................... 13 TEMODAR (temozolomide)...................................................... 8 terazosin ...................................................................................... 9 terbutaline .................................................................................. 9 testosterone cypionate ........................................................... 18 TESTRED (methyltestosterone) .............................................. 18 tetracycline ................................................................................. 5 THALOMID (thalidomide) ....................................................... 20

theophylline .............................................................................. 22 thioridazine ............................................................................... 14 thiothixene ................................................................................ 14 TIKOSYN (dofetilide) ............................................................... 10 timolol ................................................................................. 11, 16 timolol maleate (ophth)........................................................... 16 tizanidine..................................................................................... 9 TOBRADEX (tobramycin & dexamethasone) ointment ...... 16 tobramycin & dexamethasone suspension .......................... 16 tobramycin sulfate (ophth) solution ....................................... 15 TOBREX (tobramycin) (ophth) ointment ............................... 15 tolmetin ..................................................................................... 12 topiramate ................................................................................ 12 torsemide .................................................................................. 14 TRACLEER (bosentan) ............................................................. 11 TRADJENTA (linagliptin)......................................................... 18 tramadol .................................................................................... 12 tranylcypromine sulfate ........................................................... 14 trazodone .................................................................................. 14 tretinoin ..................................................................................... 21 tretinoin (topical) ...................................................................... 21 TREXALL (methotrexate) ........................................................... 8 triamcinolone acetonide (topical) .......................................... 21 triamterene & hydrochlorothiazide ....................................... 14 trifluoperazine .......................................................................... 14 trifluridine.................................................................................. 15 trihexyphenidyl ......................................................................... 13 trimethoprim .................................................................... 5, 7, 15 trimethoprim & polymyxin B .................................................. 15 TRIZIVIR (abacavir, lamivudine, & zidovudine) ....................... 7 TRUVADA (emtricitabine & tenofovir) ..................................... 7 TYKERB (lapatinib) ..................................................................... 8

U

urea ............................................................................................ 22 ursodiol ..................................................................................... 17

V

VAGIFEM (estradiol) (vaginal tablets) ................................... 19 VALCYTE (valganciclovir) .......................................................... 7 valproic acid & derivatives ...................................................... 12 VECTICAL (calcitriol)................................................................ 22 venlafaxine ................................................................................ 14 venlafaxine extended-release capsules ................................ 14 verapamil .................................................................................. 10 VICTOZA (liraglutide) .............................................................. 19 VIRACEPT (nelfinavir) ................................................................ 7 VIRAMUNE (nevirapine) suspension ....................................... 7

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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.*

30 Kaiser Permanente of Georgia HMO Formulary

VIREAD (tenofovir) ..................................................................... 7 VOTRIENT (pazopanib) ............................................................. 8

W

warfarin sodium .......................................................................... 9

X

XALKORI (crizotinib) .................................................................. 8 XELODA (capecitabine) ............................................................ 8

Z

zaleplon ..................................................................................... 13 ZELBORAF (vemurafenib) ......................................................... 8 ZENPEP (pancrelipase) ............................................................ 17 ZIAGEN (abacavir) solution ...................................................... 7 zidovudine .............................................................................. 6, 7 ziprasidone ............................................................................... 14 ZOLINZA (vorinostat)................................................................. 8 zolpidem ................................................................................... 13 ZORBTIVE (somatropin) .......................................................... 19 ZYMAXID (gatifloxacin) ........................................................... 15 ZYTIGA (abiraterone) ................................................................ 8 ZYVOX (linezolid) ....................................................................... 5