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Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Southern Colorado Commercial HMO Formulary
The following is a listing of the drugs on the Kaiser Permanente Southern Colorado Commercial HMO formulary. This Formulary applies only to outpatient drugs provided to members for self administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The formulary does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the Drug Formulary. Kaiser Permanente has many brand and generic medications on the formulary. In most cases, a generic equivalent is used. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay.
How to use this Formulary document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters. Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-formulary drug. You can search the Formulary by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category. All dosage forms and strengths for a particular drug listed may not be formulary. Not all dosage forms of formulary drugs are covered under the prescription drug benefit. Some drugs are available in more than one dosage form (example: tablet and injectable).
Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. For example, budesonide (oral), a drug used for colitis, is restricted to physicians specialized in Gastroenterology.
Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit.
Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a certain quantity per copay. For example, the migraine medication Zomig
® is limited to
12 tablets per 30-day copay. Similar quantity limits exist for most migraine medications. In addition, other drugs are limited to a specific days supply. For example, Tarceva
® is limited to a 30-day supply.
In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment.
Restricted to Benefit: Some drugs are not covered unless the patient’s benefits specifically cover such medications. For example, Viagra
® and other drugs for sexual dysfunction are not covered
unless the patient’s benefits specifically cover them.
Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first.
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules. The following are examples of exception requests:
o Request to cover a drug that is not on our formulary o Request to waive coverage restrictions or limitations
Generally Kaiser Permanente will only approve requests for an exception if the alternative drugs included on the plan’s formulary, or existing utilization restrictions, would not be as effective in treating a condition or would cause adverse medical effects.
Key: * (asterisk) = A drug where at least one of the dosage forms is an injectable. Some patients have a specific self-injectable coinsurance. † (dagger) = Certain strengths or forms of the drug (e.g., tablet, gel, liquid) are only available as brand drugs and are subject to the brand cost share. MD = A drug that is required to be written by a physician specialized in the treatment of certain conditions. PA = A drug that requires specific medical criteria be met prior to dispensing for prescription benefit. QL = A drug that has a quantity limit or is limited to a specific day supply. RB = A drug that is restricted to a certain benefit for coverage. ST = A drug that requires another class of medications be attempted prior to dispensing for prescription benefit. This list of drugs should not be used to determine benefit issues such as prescription copay amounts. If you have questions about prescription benefits, please call Customer Service at 1-888-681-7878. The medications on this list are subject to change.
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
cyproheptadine hcl Generic
promethazine hcl Generic *
ANTIHISTAMINE DRUGS
SECOND GENERATION ANTIHISTAMINES
None
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ALBENZA Brand
BILTRICIDE Brand
STROMECTOL Brand
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
amoxicillin Generic
amoxicillin & potassium
clavulanate Generic/Brand †
ampicillin Generic/Brand †
AVELOX Brand
azithromycin Generic/Brand †
CAYSTON Brand PA
cefaclor Generic
cefadroxil Generic
cefdinir Generic
cefprozil Generic
cefuroxime axetil Generic/Brand †
cephalexin Generic
ciprofloxacin hcl Generic/Brand †
clarithromycin Generic
clindamycin hcl Generic/Brand †
dicloxacillin Generic
doxycycline Generic
erythromycin & sulfisoxazole Generic
erythromycin base Generic/Brand †
erythromycin ethylsuccinate Generic/Brand †
erythromycin stearate Brand
levofloxacin Generic
minocycline Generic
neomycin sulfate Generic/Brand †
NOROXIN Brand
penicillin V potassium Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
SPECTRACEF Brand
sulfadiazine Generic
sulfamethoxazole & trimethoprim Generic
sulfasalazine Generic
SUPRAX Brand
tetracycline Generic/Brand †
TOBI Neb, TOBI Podhaler Brand QL
VANCOCIN Brand QL
ZYVOX Brand * MD, PA, QL
ANTI-INFECTIVE AGENTS
ANTIFUNGALS
fluconazole Generic
griseofulvin ultramicrosize Generic
itraconazole Generic/Brand † PA
ketoconazole Generic
nystatin Generic/Brand †
terbinafine Generic
voriconazole Generic MD
ANTI-INFECTIVE AGENTS
ANTIMYCOBACTERIALS
DAPSONE Brand
ethambutol Generic
isoniazid Generic
MYCOBUTIN Brand
pyrazinamide Generic
rifampin Generic
ANTI-INFECTIVE AGENTS
ANTIVIRALS
Abacavir sulfate Generic
acyclovir Generic
APTIVUS Brand
ATRIPLA Brand
BARACLUDE Brand
COMBIVIR Brand
CRIXIVAN Brand
didanosine Generic/Brand †
EMTRIVA Brand
EPIVIR HBV Brand
EPZICOM Brand
famciclovir Generic
ganciclovir Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
HEPSERA Brand QL
INCIVEK Brand PA, QL
INFERGEN Brand * PA, QL
INTELENCE Brand
INVIRASE Brand
ISENTRESS Brand
KALETRA Brand
lamivudine Generic
LEXIVA Brand
nevirapine Generic
NORVIR Brand
PEGASYS Brand * PA, QL
PEG-INTRON Brand * PA, QL
PREZISTA Brand
RELENZA Brand QL
RESCRIPTOR Brand
REYATAZ Brand
ribavirin Generic/Brand † PA, QL
rimantadine Generic/Brand †
SELZENTRY Brand
stavudine Generic
SUSTIVA Brand
TAMIFLU Brand QL
TRIZIVIR Brand
TRUVADA Brand
TYZEKA Brand
VALCYTE Brand QL
VALTREX Brand
VIRACEPT Brand
VIREAD Brand
zidovudine Generic
ANTI-INFECTIVE AGENTS
ANTIPROTOZOALS
atovaquone/proguanil Generic
chloroquine phosphate Generic
DARAPRIM Brand
hydroxychloroquine sulfate Generic
mefloquine hcl Generic
metronidazole Generic
NEBUPENT Brand
paromomycin sulfate Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
primaquine phosphate Brand
YODOXIN Generic
ANTI-INFECTIVE AGENTS
URINARY ANTI-INFECTIVES
belladonna alkaloids,
methenamine, methylene blue &
phenyl salicylate
Generic
nitrofurantoin macrocrystals Generic/Brand †
nitrofurantoin monohydrate
macrocystals Generic
nitrofurantoin suspension Generic
trimethoprim Generic/Brand †
ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS
AFINITOR Brand MD, QL
ALKERAN Brand *
anastrozole Generic
bicalutamide Generic
CEENU Brand
cyclophosphamide Brand
EMCYT Brand QL
etoposide Generic
exemestane Generic
flutamide Generic
GLEEVEC Brand MD, QL
HEXALEN Brand
hydroxyurea Generic
INTRON-A Brand * PA, QL
IRESSA Brand QL
letrozole Generic
LEUKERAN Brand
leuprolide acetate Generic/Brand *† PA, QL
LYSODREN Brand QL
MATULANE Brand QL
megestrol acetate Generic
mercaptopurine Generic
methotrexate Generic/Brand *†
MYLERAN Brand
NEXAVAR Brand MD, QL
NILANDRON Brand
SPRYCEL Brand QL
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
SUTENT Brand MD, QL
TABLOID Brand
tamoxifen citrate Generic
TARCEVA Brand QL
TARGRETIN Brand QL
temozolomide Generic QL
tretinoin Generic QL
TYKERB Brand QL
VOTRIENT Brand QL
XELODA Brand
XTANDI Brand PA, QL
ZELBORAF Brand PA, QL
ZOLINZA Brand QL
ZYTIGA Brand PA, QL
AUTONOMIC DRUGS
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
ARICEPT Brand
ARICEPT ODT Brand
bethanechol chloride Generic
EVOXAC Brand
galantamine hbr Generic
galantamine hbr (extended
release) Generic
PROSTIGMIN Brand
pyridostigmine bromide Generic/Brand †
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
belladonna alkaloids &
phenobarbital Generic/Brand †
chlordiazepoxide & clidinium Generic
dicyclomine hcl Generic
DONNATAL EXTENTABS Brand
glycopyrrolate Generic
hyoscyamine sulfate Generic
ipratropium bromide (inhaled) Generic/Brand †
ipratropium bromide (nasal) Generic
SPIRIVA Brand QL
AUTONOMIC DRUGS
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ADVAIR DISKUS Brand ST
ADVAIR HFA Brand ST
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
albuterol sulfate Generic/Brand †
COMBIVENT RESPIMAT Brand
DULERA Brand
epinephrine hcl Generic/Brand *† QL
levalbuterol hcl solution Generic ST
MAXAIR AUTOHALER Brand
metaproterenol sulfate Generic/Brand †
midodrine hcl Generic
SEREVENT DISKUS Brand
terbutaline sulfate Generic
XOPENEX HFA Brand ST
AUTONOMIC DRUGS
SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS
DIBENZYLINE Brand
dihydroergotamine mesylate Generic/Brand *† QL
ERGOMAR Brand QL
tamsulosin hcl Generic
AUTONOMIC DRUGS
SKELETAL MUSCLE RELAXANTS
baclofen Generic
carisoprodol Generic
carisoprodol & aspirin Generic
cyclobenzaprine hcl Generic
dantrolene sodium Generic
methocarbamol Generic/Brand *†
tizanidine hcl Generic
AUTONOMIC DRUGS
AUTONOMIC DRUGS, MISCELLANEOUS
NICOTROL Brand PA, QL
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
ANTITHROMBOTIC AGENTS
anagrelide hcl Generic
BRILINTA Brand
cilostazol Generic
clopidogrel Generic
EFFIENT Brand * QL
fondaparinux Generic* QL
FRAGMIN Brand * QL
heparin sodium Generic/Brand *†
INNOHEP Brand * PA, QL
LOVENOX Brand * QL
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
warfarin sodium Generic
BLOOD FORMATION, COAGULATION AND THROMBOSIS
HEMATOPOIETIC AGENTS
EPOGEN Brand * PA, QL
LEUKINE Brand * PA, QL
NEULASTA Brand * PA, QL
PROCRIT Brand * PA, QL
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
HEMORRHEOLOGIC AGENTS
pentoxifylline Generic
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
ANTIHEMORRHAGIC AGENTS
aminocaproic acid Generic/Brand †
CARDIOVASCULAR DRUGS
CARDIAC DRUGS
amiodarone hcl Generic/Brand †
digoxin Generic/Brand †
disopyramide phosphate Generic/Brand †
flecainide acetate Generic
mexiletine hcl Generic
propafenone hcl Generic
quinidine gluconate Generic
quinidine sulfate Generic
TIKOSYN Brand
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
cholestyramine Generic
CRESTOR Brand
fenofibrate Generic
fenofibrate (micronized) Generic
gemfibrozil Generic
lovastatin Generic
NIASPAN Brand PA
pravastatin Generic
simvastatin Generic
CARDIOVASCULAR DRUGS
HYPOTENSIVE AGENTS
clonidine hcl Generic
guanfacine hcl Generic
hydralazine hcl Generic
methyldopa Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
reserpine Generic
CARDIOVASCULAR DRUGS
VASODILATING AGENTS
ADCIRCA Brand MD, QL
CAVERJECT Brand * QL, RB
CIALIS Brand QL, RB
dipyridamole Generic
EDEX Brand * QL, RB
isosorbide dinitrate Generic/Brand †
isosorbide mononitrate Generic
LETAIRIS Brand MD, QL
LEVITRA Brand QL, RB
MUSE Brand QL, RB
nitroglycerin Generic/Brand †
sildenafil citrate (REVATIO) Generic MD, QL
TRACLEER Brand MD, QL
VIAGRA Brand QL, RB
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate Generic
prazosin hcl Generic
terazosin hcl Generic
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl Generic
atenolol Generic
atenolol & chlorthalidone Generic
bisoprolol fumarate Generic
bisoprolol fumarate &
hydrochlorothiazide Generic
BYSTOLIC Brand
carvedilol Generic
COREG CR Brand
labetalol hcl Generic
metoprolol succinate Generic
metoprolol tartrate Generic
nadolol Generic
pindolol Generic
propranolol hcl Generic
sotalol hcl Generic
CARDIOVASCULAR DRUGS
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
CALCIUM-CHANNEL BLOCKING AGENTS
amlodipine besylate Generic
amlodipine besylate & benazepril
hcl Generic/Brand †
CARDENE SR Brand
diltiazem hcl Generic/Brand †
EXFORGE Brand ST
EXFORGE HCT Brand ST
felodipine Generic
isradipine Generic/Brand †
nifedipine Generic
TARKA Brand
verapamil hcl Generic
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
benazepril & hydrochlorothiazide Generic
benazepril hcl Generic
captopril Generic
captopril & hydrochlorothiazide Generic
DIOVAN Brand ST
enalapril maleate Generic
fosinopril sodium Generic
fosinopril sodium &
hydrochlorothiazide Generic
lisinopril Generic
lisinopril & hydrochlorothiazide Generic
losartan potassium Generic
losartan potassium &
hydrochlorothiazide Generic
moexipril & hydrochlorothiazide Generic
moexipril hcl Generic
quinapril & hydrochlorothiazide Generic
quinapril hcl Generic
ramipril Generic
spironolactone Generic
spironolactone &
hydrochlorothiazide Generic
valsartan & hydrochlorothiazide Generic ST
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
acetaminophen with codeine Generic
ACTIQ Brand MD, QL
buprenorphine HCl & naloxone
HCl Generic PA
butalbital, acetaminophen &
caffeine Generic
butalbital, acetaminophen,
caffeine & codeine Generic
butalbital, aspirin & caffeine Generic
butalbital, aspirin, caffeine &
codeine Generic
CELEBREX Brand QL, ST
choline magnesium trisalicylate Generic
diclofenac sodium Generic
etodolac Generic
fenoprofen calcium Generic/Brand †
fentanyl Generic QL
hydrocodone & acetaminophen Generic
hydromorphone hcl Generic/Brand †
ibuprofen Generic
indomethacin Generic/Brand †
ketoprofen Generic
ketorolac tromethamine Generic QL
meclofenamate sodium Generic
methadone hcl Generic QL
morphine sulfate Generic/Brand †
morphine sulfate (extended
release Generic QL
nabumetone Generic
naproxen Generic
naproxen sodium Generic
oxaprozin Generic
oxycodone & acetaminophen Generic
oxycodone & aspirin Generic
oxycodone hcl Generic
oxycodone hcl (extended release) Generic/Brand † QL
salsalate Generic
sulindac Generic
tramadol hcl Generic
CENTRAL NERVOUS SYSTEM AGENTS
OPIATE ANTAGONISTS
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
naltrexone hcl Generic
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
carbamazepine Generic
carbamazepine (extended release) Generic/Brand †
CELONTIN Brand
clonazepam Generic
divalproex sodium Generic
divalproex sodium (extended
release) Generic
ethosuximide Generic
felbamate Brand MD
gabapentin Generic/Brand †
GABITRIL Brand
lamotrigine Generic QL
levetiracetam Generic
oxcarbazepine Generic
phenytoin Generic/Brand †
phenytoin sodium (extended
release) Generic/Brand †
primidone Generic
topiramate Generic
valproic acid Generic
zonisamide Generic MD
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ABILIFY Brand MD, QL
ABILIFY DISCMELT Brand MD, QL
amitriptyline hcl Generic
amoxapine Brand
bupropion hcl Generic
chlordiazepoxide & amitriptyline Generic
chlorpromazine hcl Generic
citalopram hydrobromide Generic QL
clomipramine hcl Generic
desipramine hcl Generic
doxepin hcl Generic
escitalopram oxalate Generic ST, QL
fluoxetine hcl Generic
fluphenazine hcl Generic
fluvoxamine maleate Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
haloperidol Generic
imipramine hcl Generic
imipramine pamoate Generic/Brand †
loxapine succinate Generic
maprotiline hcl Generic
mirtazapine Generic
MOBAN Brand
NARDIL Brand
NEFAZODONE HCL Brand MD
nortriptyline hcl Generic
olanzapine Generic MD, QL
olanzapine ODT Generic MD, QL
paroxetine hcl Generic
paroxetine hcl (extended release) Generic/Brand † QL
perphenazine Generic
prochlorperazine maleate Generic
protriptyline hcl Generic MD
quetiapine fumarate Generic MD, QL
risperidone Generic MD, QL
sertraline hcl Generic
thioridazine hcl Generic
thiothixene Generic/Brand †
tranylcypromine sulfate Generic
trazodone hcl Generic
trifluoperazine hcl Generic
trimipramine maleate Generic/Brand † MD
venlafaxine hcl Generic
venlafaxine hcl (extended release) Generic/Brand †
ziprasidone hcl Generic MD, QL
CENTRAL NERVOUS SYSTEM AGENTS
ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL
STIMULANTS, MISCELLANEOUS
ADDERALL XR Generic QL
amphetamine &
dextroamphetamine Generic QL
dexmethylphenidate hcl Generic QL
dextroamphetamine sulfate Generic QL
FOCALIN XR Brand QL
methylphenidate hcl Generic QLnsop
methylphenidate hcl (extended
release) Generic/Brand † QL
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
modafinil Generic PA, QL
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
alprazolam Generic
buspirone hcl Generic QL (7.5mg, 30mg)
chlordiazepoxide hcl Generic
clorazepate dipotassium Generic
diazepam Generic/Brand *†
estazolam Generic
flurazepam hcl Generic
hydroxyzine hcl Generic
hydroxyzine pamoate Generic
lorazepam Generic
oxazepam Generic
phenobarbital Generic
temazepam Generic/Brand †
triazolam Generic
zaleplon Generic QL
zolpidem tartrate Generic QL
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS
lithium carbonate Generic/Brand †
lithium carbonate (extended
release) Generic/Brand †
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
ergotamine tartrate & caffeine Generic QL
naratriptan Generic QL, ST
rizatriptan Generic QL, ST
sumatriptan succinate Generic/Brand *† QL
zolmitriptan Generic QL, ST
zolmitriptan ODT Generic QL, ST
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
amantadine hcl Generic
APOKYN Brand * PA, QL
benztropine mesylate Generic
bromocriptine mesylate Generic
cabergoline Generic MD
carbidopa & levodopa Generic
carbidopa & levodopa (extended Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
release)
entacapone Generic
pramipexole dihydrochloride Generic
ropinirole hcl Generic
selegiline hcl Generic
trihexyphenidyl hcl Generic
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS
riluzole Generic MD, QL
SAVELLA Brand QL
DEVICES
DEVICES
ORTHO DIAPHRAGM ALL-
FLEX KITs 65, 70, 75 AND 80 Brand
ORTHO DIAPHRAGM COIL
SPRING KITs 50, 100 AND 105 Brand
ORTHO DIAPHRAGM FLAT
SPRING KITs 55, 60, 65, 70, 75,
80, 85, 90, and 95
Brand
WIDE-SEAL SILICONE
DIAPHRAGM KITs 60, 65, 70,
75, 80, 85, 90, and 95
Brand
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ALKALINIZING AGENTS
potassium and sodium citrates
with citric acid Brand
potassium citrate Generic
sodium citrate & citric acid Generic
ELECTROLYTIC, CALORIC, AND WATER BALANCE
AMMONIA DETOXICANTS
lactulose Generic
ELECTROLYTIC, CALORIC, AND WATER BALANCE
REPLACEMENT PREPARATIONS
calcium acetate (phosphate
binder) Generic/Brand †
potassium bicarbonate &
potassium chloride Generic/Brand †
potassium chloride Generic/Brand †
ELECTROLYTIC, CALORIC AND WATER BALANCE
ION-REMOVING AGENTS
RENAGEL Brand
RENVELA Brand
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
RENVELA PAK Brand
sodium polystyrene sulfonate Generic
ELECTROLYTIC, CALORIC AND WATER BALANCE
DIURETICS
bumetanide Generic
chlorthalidone Generic
furosemide Generic
hydrochlorothiazide Generic
indapamide Generic
metolazone Generic
torsemide Generic
triamterene &
hydrochlorothiazide Generic
ELECTROLYTIC, CALORIC, AND WATER BALANCE
URICOSURIC AGENTS
COLCRYS Brand
probenecid Generic
probenecid & colchicine Generic
ENZYMES
ENZYMES
PULMOZYME Brand QL
RESPIRATORY TRACT AGENTS
ANTITUSSIVES
benzonatate Generic
guaifenesin & codeine Generic
hydrocodone & homatropine Generic
TUSSIONEX Brand
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORY AGENTS
cromolyn sodium Generic/Brand †
montelukast sodium Generic
montelukast sodium(packets) Generic ST, QL
zafirlukast Generic
RESPIRATORY TRACT AGENTS
RESPIRATORY TRACT AGENTS, MISCELLANEOUS
sodium chloride for nebulization Generic
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTIALLERGIC AGENTS
ALAMAST Brand
ALOCRIL (ophthalmic) Brand QL
ALOMIDE (ophthalmic) Brand
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
ASTELIN Brand
azelastine hcl (ophthalmic) Generic/Brand †
cromolyn sodium (ophthalmic) Generic
PATANOL Brand QL, ST
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTI-INFECTIVES
bacitracin & polymyxin B
(ophthalmic) Generic
bacitracin (ophthalmic) Brand
chlorhexidine gluconate (dental) Generic
ciprofloxacin hcl (ophthalmic) Generic
erythromycin (ophthalmic) Generic
gatifloxacin (ophthalmic) Generic MD
gentamicin sulfate (ophthalmic) Generic
neomycin, bacitracin & polymyxin
B (ophthalmic) Generic
ofloxacin (ophthalmic) Generic
ofloxacin (otic) Generic
polymyxin B & trimethoprim Generic
sulfacetamide sodium
(ophthalmic) Generic/Brand †
tobramycin sulfate (ophthalmic) Generic/Brand †
trifluridine (ophth) Generic
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTI-INFLAMMATORY AGENTS
BLEPHAMIDE (ophthalmic) Brand
BLEPHAMIDE S.O.P. Brand
CIPRO HC (otic) Brand
CIPRODEX Brand
COLY-MYCIN-S (otic) Brand
diclofenac sodium (ophthalmic) Generic
FLAREX Brand
flunisolide (nasal) Generic
fluorometholone (ophthalmic) Generic
flurbiprofen sodium (ophthalmic) Generic
fluticasone propionate (nasal) Generic
FML FORTE Brand
hydrocortisone & acetic acid
(otic) Generic
ketorolac tromethamine
(ophthalmic) Generic/Brand †
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
NASONEX Brand
neomycin, polymyxin, bacitracin
& hydrocortisone (ophthalmic) Generic/Brand †
neomycin, polymyxin &
dexamethasone (ophthalmic) Generic
neomycin, polymyxin &
hydrocortisone (ophthalmic) Brand
neomycin, polymyxin &
hydrocortisone (otic) Generic
POLY-PRED (ophthalmic) Brand
PRED-G (ophthalmic) Brand
PRED-G S.O.P. (ophthalmic) Brand
prednisolone acetate (ophthalmic) Generic/Brand †
prednisolone sodium phosphate
(ophthalmic) Generic
sulfacetamide sodium &
prednisolone sodium phosphate
(ophthalmic)
Generic
tobramycin sulfate &
dexamethasone (ophth) Generic/Brand †
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
LOCAL ANESTHETICS
antipyrine, benzocaine &
polycosanol Generic/Brand
benzocaine & antipyrine (otic) Generic
lidocaine hcl (mouth-throat) Generic
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
MYDRIATICS
atropine sulfate (ophthalmic) Generic
tropicamide (ophthalmic) Generic
EYE, EAR, NOSE AND THROAT (EENT) PREPARATION
ANTIGLAUCOMA AGENTS
acetazolamide Generic
AZOPT (ophthalmic) Brand
betaxolol hcl (ophthalmic) Brand
BETIMOL Brand
BETOPTIC-S (ophthalmic) Brand
brimonidine tartrate Generic/Brand †
carteolol hcl (ophthalmic) Generic
dorzolamide hcl & timolol maleate
(ophthalmic) Generic
dorzolamide hcl (ophthalmic) Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
latanoprost Generic
levobunolol hcl (ophthalmic) Generic
methazolamide Generic
metipranolol (ophthalmic) Generic
PHOSPHOLINE IODIDE
(ophthalmic) Brand
pilocarpine hcl (ophthalmic) Generic
timolol maleate (ophthalmic) Generic
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EENT DRUGS, MISCELLANEOUS
acetic acid & aluminum acetate Generic
acetic acid (otic) Generic
GASTROINTESTINAL DRUGS
ANTIDIARRHEA AGENTS
diphenoxylate & atropine Generic
GASTROINTESTINAL DRUGS
CATHARTICS AND LAXATIVES
polyethylene glycol 3350,
potassium chloride, sodium
bicarbonate, sodium chloride &
sodium sulfate
Generic/Brand †
polyethylene glycol 3350,
potassium chloride, sodium
bicarbonate & sodium chloride
Generic
GASTROINTESTINAL DRUGS
CHOLELITHOLYTIC AGENTS
ursodiol Generic
GASTROINTESTINAL DRUGS
DIGESTANTS
amylase 12,000 units; lipase 4,000
units; protease 12,000 units Generic/Brand †
amylase 16,600 units; lipase 5,000
units; protease 18,750 units Generic/Brand †
amylase 20,000 units; lipase 4,500
units; protease 25,000 units Generic/Brand †
amylase 27,000 units; lipase
5,000 units; protease 17,000
units
Generic/Brand †
amylase 30,000 units; lipase
10,000 units; protease 30,000
units
Generic/Brand †
amylase 30,000 units; lipase 8,000 Generic/Brand †
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
units; protease 30,000 units
amylase 33,200 units; lipase
10,000 units; protease 37,500
units
Generic/Brand †
amylase 48,000 units; lipase
16,000 units; protease 48,000
units
Generic/Brand †
amylase 55,000 units; lipase
10,000 units; protease 34,000
units
Generic/Brand †
amylase 56,000 units; lipase
20,000 units; protease 44,000
units
Generic/Brand †
amylase 60,000 units; lipase
16,000 units; protease 60,000
units
Generic/Brand †
amylase 66,400 units; lipase
20,000 units; protease 75,000
units
Generic/Brand †
amylase 82,000 units; lipase
15,000 units; protease 51,000
units
Generic/Brand †
amylase 109,000 units; lipase
20,000 units; protease 68,000
units
Generic/Brand †
GASTROINTESTINAL DRUGS
ANTIEMETICS
ANTIVERT Brand
EMEND Brand MD, QL
ondansetron hcl Generic QL
GASTROINTESTINAL DRUGS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
famotidine Generic
misoprostol Generic
omeprazole Generic
pantoprazole sodium Generic
ranitidine hcl Generic
sucralfate Generic/Brand †
GASTROINTESTINAL DRUGS
PROKINETIC AGENTS
metoclopramide hcl Generic
GASTROINTESTINAL DRUGS
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
ANTI-INFLAMMATORY AGENTS
APRISO Brand
balsalazide Generic
LIALDA Brand
sulfasalazine Generic
GOLD COMPOUNDS
GOLD COMPOUNDS
RIDAURA Brand
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
CUPRIMINE Brand
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
ASMANEX Brand
budesonide (oral) Generic MD, QL
budesonide (nebulized) Generic
CELESTONE Brand
cortisone acetate Generic
dexamethasone Generic
FLOVENT DISKUS Brand
FLOVENT HFA Brand
fludrocortisone acetate Generic
hydrocortisone Generic
methylprednisolone Generic/Brand †
prednisolone Generic
prednisolone sodium phosphate Generic
prednisone Generic/Brand †
PULMICORT FLEXHALER Brand
QVAR Brand
HORMONES AND SYNTHETIC SUBSTITUTES
ANDROGENS
ANDRODERM Brand PA, QL
ANDROGEL 1% PUMP Brand PA, QL
ANDROXY Brand QL
AXIRON Brand PA, QL
danazol Generic
DELATESTRYL Brand * PA
fluoxymesterone Generic/Brand †
METHITEST Brand
testosterone Generic/Brand *† PA, QL
testosterone cypionate Brand/Generic *† PA, QL
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
HORMONES AND SYNTHETIC SUBSTITUTES
CONTRACEPTIVES Possible Brands
desogestrel & ethinyl estradiol
(monophasic) Generic/Brand †
APRI, DESOGEN,
KARIVA,
MIRCETTE,
ORTHO-CEPT
desogestrel & ethinyl estradiol
(triphasic) Generic
CESIA, CYCLESSA,
VELIVET
drospirenone & ethinyl estradiol Brand YASMIN
ethynodiol diacetate & ethinyl
estradiol Generic
KELNOR, ZOVIA
1/35E, ZOVIA 1/50E
levonorgestrel & ethinyl estradio
(monophasic)l Generic/Brand †
LESSINA,
NORDETTE,
PORTIA
levonorgestrel & ethinyl estradiol
(91-day) Generic/Brand †
JOLESSA,
SEASONIQUE
levonorgestrel & ethinyl estradiol
(triphasic) Generic
ENPRESSE,
TRIVORA
levonorgestrel (emergency oral
contraceptive) Generic/Brand †
norethindrone & ethinyl estradiol
(biphasic) Brand NECON 10/11
norethindrone & ethinyl estradiol
(monophasic) Generic/Brand †
MODICON,
NORTREL 0.5/35,
NORTREL 1/35,
ORTHO-NOVUM
1/35
norethindrone & ethinyl estradiol
(triphasic) Generic/Brand †
NECON 7/7/7,
NORTREL 7/7/7,
ORTHO-NOVUM
7/7/7, TRI-
NORINYL
norethindrone & mestranol Generic/Brand †
NECON 1/50,
ORTHO-NOVUM
1/50
norethindrone (contraceptive) Generic/Brand †
NOR-QD, NORA-
BE, ORTHO-
MICRONOR
norethindrone acetate & ethinyl
estradiol Generic/Brand †
LOESTRIN 1/20,
MICROGESTIN
1/20, LOESTRIN
1.5/30,
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
MICROGESTIN
1.5/30
norethindrone acetate, estradiol,
& iron Generic/Brand †
LOESTRIN FE 1/20,
MICROGESTIN FE
1/20, LOESTRIN FE
1.5/30,
MICROGESTIN FE
1.5/30
norgestimate & ethinyl estradiol
(monophasic) Generic/Brand †
PREVIFEM,
SPRINTEC, ORTHO-
CYCLEN
norgestimate & ethinyl estradiol
(triphasic) Generic/Brand †
ORTHO TRI-
CYCLEN, TRI-
PREVIFEM, TRI-
SPRINTEC
norgestrel & ethinyl estradiol Generic/Brand †
CRYSELLE,
LO/OVRAL, LOW-
OGESTREL,
OGESTREL
NUVARING Brand PA, QL
ORTHO EVRA Brand PA, QL
HORMONES AND SYNTHETIC SUBSTITUTES
ESTROGENS AND ESTROGEN AGONISTS-ANTAGONISTS
COMBIPATCH Brand
esterified estrogens &
methyltestosterone Generic
ESTRACE VAGINAL Brand
estradiol (oral) Generic/Brand † estradiol tablet,
ESTRACE
estradiol (transdermal) Generic/Brand †
ALORA, CLIMARA,
ESTRADIOL,
VIVELLE-DOT
estropipate Generic
EVISTA Brand
FEMHRT Brand
PREMARIN Brand
PREMPHASE Brand
PREMPRO Brand
VAGIFEM Brand
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
acarbose Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
glimepiride Generic
glipizide Generic
glipizide (extended release) Generic
glyburide Generic
glyburide & metformin hcl Generic
HUMALOG Brand
HUMALOG KWIKPEN Brand PA
HUMALOG MIX 50/50 Brand
HUMALOG MIX 50/50 PEN Brand PA
HUMALOG MIX 75/25 Brand
HUMALOG MIX 75/25 PEN Brand PA
HUMULIN R U-500 Brand
insulin isophane & regular
(human) pen Brand PA
insulin isophane & regular
(human) Brand
insulin isophane (human) Brand
insulin isophane (human) pen Brand PA
insulin regular (human) Brand
LANTUS Brand
LANTUS FOR OPTICLIK Brand PA
LANTUS SOLOSTAR Brand PA
LEVEMIR Brand
LEVEMIR FLEXPEN Brand PA
metformin hcl Generic
metformin hcl (extended release) Generic
NOVOLOG Brand
NOVOLOG FLEXPEN Brand PA
NOVOLOG MIX 70/30
FLEXPEN Brand PA
NOVOLOG MIX 70/30 Brand
pioglitazone hcl Generic
tolazamide Generic
tolbutamide Generic
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIHYPOGLYCEMIC AGENTS
glucagon hcl Brand †
HORMONES AND SYNTHETIC SUBSTITUTES
PARATHYROID
calcitonin (salmon) Generic QL
FORTEO Brand * PA, QL
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
HORMONES AND SYNTHETIC SUBSTITUTES
PITUITARY
ACTHAR HP Brand * PA, QL
desmopressin acetate Generic *
HORMONES AND SYNTHETIC SUBSTITUTES
SOMATROPIN AGONISTS AND ANTAGONISTS
OMNITROPE Brand * PA, QL
HORMONES AND SYNTHETIC SUBSTITUTES
PROGESTINS
medroxyprogesterone acetate Generic
norethindrone acetate Generic
progesterone, micronized Generic RB
HORMONES AND SYNTHETIC SUBSTITUTES
THYROID AND ANTITHYROID AGENTS
ARMOUR THYROID Brand
levothyroxine sodium Generic/Brand †
liothyronine Generic
methimazole Generic
propylthiouracil Generic
SSKI Brand
thyroid Generic/Brand †
THYROLAR Brand
OXYTOCICS
OXYTOCICS
ERGOTRATE MALEATE Brand
methylergonovine Generic
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)
AVC Brand
BACTROBAN Brand
BACTROBAN NASAL Brand
benzoyl peroxide & erythromycin Generic
ciclopirox olamine Generic
clindamycin phosphate (topical) Generic
clindamycin phosphate (vaginal) Generic
clotrimazole Generic
clotrimazole & betamethasone
dipropionate Generic
clotrimazole (topical) Generic
erythromycin (topical) Generic
EURAX Brand
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
EXELDERM Brand
gentamicin sulfate (topical) Generic
ketoconazole (topical) Generic
lindane Generic
metronidazole (topical) Generic/Brand † MD
metronidazole (vaginal) Generic
miconazole nitrate Brand
mupirocin (topical) Generic
NAFTIN Brand
nystatin (topical) Generic
permethrin Generic
selenium sulfide Generic
silver sulfadiazine Generic
sulfacetamide sodium (topical) Generic
ZOVIRAX Brand
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)
APEXICON E Brand
augmented betamethasone
dipropionate Generic
betamethasone dipropionate
(topical) Generic
betamethasone valerate Generic
clobetasol propionate Generic
clobetasol propionate emollient
base Generic
CLODERM Brand
CORDRAN Brand
CORTIFOAM Brand
CORTISPORIN Brand
desonide Generic
desoximetasone Generic
diflorasone diacetate Generic
fluocinolone acetonide Brand
fluocinonide Generic
fluocinonide emulsified base Generic
fluticasone propionate Generic/Brand †
halobetasol propionate Generic
hydrocortisone (intrarectal) Generic
hydrocortisone (rectal) Generic
hydrocortisone (topical) Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
hydrocortisone acetate (rectal) Generic
hydrocortisone valerate Generic
KENALOG Brand
mometasone furoate Generic
nystatin & triamcinolone Generic
pramoxine & hydrocortisone Brand
triamcinolone acetonide (mouth) Generic
triamcinolone acetonide (topical) Generic
SKIN AND MUCOUS MEMBRANE AGENTS
ANTIPRURITICS AND LOCAL ANESTHETICS
hydrocortisone acetate &
pramoxine Generic/Brand †
lidocaine hcl Generic
phenazopyridine hcl Generic
SKIN AND MUCOUS MEMBRANE AGENTS
CELL STIMULANTS AND PROLIFERANTS
tretinoin Generic PA, QL
SKIN AND MUCOUS MEMBRANE AGENTS
PIGMENTING AND DEPIGMENTING AGENTS
OXSORALEN Brand
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS
adapalene Generic MD
aluminum chloride Generic
AMEVIVE Brand * PA, QL
calcipotriene Generic/Brand †
calcitriol (topical) Generic ST
DRITHO-CREME Brand
DRITHO-SCALP Brand
ELIDEL Brand MD, QL
FINACEA Brand MD
fluorouracil (topical) Generic/Brand †
imiquimod Generic
isotretinoin Generic
podofilox Generic/Brand †
PROTOPIC Brand MD
REGRANEX Brand PA, QL
TARGRETIN Brand
TAZORAC Brand QL
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
DETROL LA Brand
flavoxate hcl Generic
oxybutynin chloride Generic
oxybutynin chloride (extended
release) Generic
tolterodine tartrate Generic
SMOOTH MUSCLE RELAXANTS
RESPIRATORY SMOOTH MUSCLE RELAXANTS
aminophylline Generic
theophylline Generic/Brand †
VITAMINS
VITAMIN B COMPLEX
folic acid Generic
VITAMINS
VITAMIN D
calcitriol Generic
ergocalciferol Generic
VITAMINS
VITAMIN K ACTIVITY
MEPHYTON Brand
VITAMINS
PRENATAL VITAMINS
prenatal vitamin with docusate,
ferrous fumarate, & folic acid Generic
prenatal vitamin with docusate,
iron carbonyl, & folic acid Generic
prenatal vitamin with ferrous
fumarate & folic acid Generic/Brand †
prenatal vitamin with iron
polysaccharide complex & folic
acid
Generic
prenatal vitamin with minerals,
iron, & folic acid Brand
prenatal vitamin with selenium,
ferrous fumarate, & folic acid Generic
prenatal vitamin without vitamin
a, with iron carbonyl, docusate, &
folic acid
Generic
VITAMINS
PEDIATRIC MULTIVITAMINS
pediatric multivitamins with
fluoride Generic/Brand †
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
pediatric vitamins A, C, D, with
fluoride Generic/Brand †
MISCELLANEOUS THERAPEUTIC AGENTS
ALCOHOL DETERRENTS
disulfiram Generic
MISCELLANEOUS THERAPEUTIC AGENTS
5-ALPHA-REDUCTASE INHIBITORS
finasteride Generic MD
MISCELLANEOUS THERAPEUTIC AGENTS
ANTIDOTES
acetylcysteine Generic
leucovorin calcium Generic/Brand *†
MISCELLANEOUS THERAPEUTIC AGENTS
ANTIGOUT AGENTS
allopurinol Generic
COLCRYS Brand
MISCELLANEOUS THERAPEUTIC AGENTS
BIOLOGIC RESPONSE MODIFIERS
COPAXONE Brand * MD, QL
REBIF Brand * MD, QL
REVLIMID Brand QL
THALOMID Brand QL
MISCELLANEOUS THERAPEUTIC AGENTS
BONE RESORPTION INHIBITORS
alendronate sodium Generic
etidronate disodium Generic/Brand †
FOSAMAX PLUS D Brand
MISCELLANEOUS THERAPEUTIC AGENTS
CARIOSTATIC AGENTS
sodium fluoride Generic
MISCELLANEOUS THERAPEUTIC AGENTS
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS
ENBREL Brand * MD, QL
HUMIRA Brand * MD, QL
leflunomide Generic PA
MISCELLANEOUS THERAPEUTIC AGENTS
IMMUNOSUPPRESSIVE AGENTS
azathioprine Generic
cyclosporine modified (for
microemulsion) Generic/Brand †
mycophenolate mofetil Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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Drug Name Drug Tier Comments
MYFORTIC Brand
RAPAMUNE Brand
SANDIMMUNE Brand
tacrolimus Generic
MISCELLANEOUS THERAPEUTIC AGENTS
PROTECTIVE AGENTS
ELMIRON Brand
MISCELLANEOUS THERAPEUTIC AGENTS
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
FIRAZYR Brand * QL
levocarnitine Generic/Brand †
yohimbine hcl Generic RB
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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INDEX OF DRUGS
Kaiser Permanente Southern Colorado
Commercial HMO Comprehensive Formulary Index
A
abacavir sulfate 4
ABILIFY 13
ABILIFY DISCMELT 13
acarbose 24
acebutolol hcl 10
acetaminophen with codeine 12
acetazolamide 19
acetic acid & aluminum acetate 20
acetic acid (otic) 20
acetylcysteine 30
ACTHAR HP 26
ACTIQ 12
acyclovir 4
adapalene 28
ADCIRCA 10
ADDERALL XR 14
ADVAIR DISKUS 7
ADVAIR HFA 7
AFINITOR 6
ALAMAST 17
ALBENZA 3
albuterol sulfate 8
alendronate sodium 30
ALKERAN 6
allopurinol 30
ALOCRIL (ophthalmic) 17
ALOMIDE (ophthalmic) 17
ALORA 24
alprazolam 15
aluminum chloride 28
amantadine hcl 15
AMEVIVE 28
aminocaproic acid 9
aminophylline 29
amiodarone hcl 9
amitriptyline hcl 13
amlodipine besylate 11
amlodipine besylate & benazepril hcl 11
amoxapine 13
amoxicillin 3
amoxicillin & potassium 3
amphetamine & dextroamphetamine 14
ampicillin 3
amylase 109,000 units; lipase 20,000 units; protease
68,000 units 21
amylase 12,000 units; lipase 4,000 units; protease 12,000
units 20
amylase 16,600 units; lipase 5,000 units; protease 18,750
units 20, 21
amylase 20,000 units; lipase 4,500 units; protease 25,000
units 20
amylase 27,000 units; lipase 5,000 units; protease 17,000
units 20
amylase 30,000 units; lipase 10,000 units; protease 30,000
units 20
amylase 30,000 units; lipase 8,000 units; protease 30,000
units 20
amylase 33,200 units; lipase 10,000 units; protease 37,500
units 21
amylase 48,000 units; lipase 16,000 units; protease 48,000
units 21
amylase 55,000 units; lipase 10,000 units; protease 34,000
units 21
amylase 56,000 units; lipase 20,000 units; protease 44,000
units 21
amylase 60,000 units; lipase 16,000 units; protease 60,000
units 21
amylase 82,000 units; lipase 15,000 units; protease 51,000
units 21
anagrelide hcl 8
anastrozole 6
ANDRODERM 22
ANDROGEL 1% PUMP 22
ANDROXY 22
antipyrine, benzocaine & polycosanol 19
ANTIVERT 21
APEXICON E 27
APOKYN 15
APRI 23
APRISO 22
APTIVUS 4
ARICEPT 7
ARICEPT ODT 7
ARMOUR THYROID 26
ASMANEX 22
ASTELIN 18
atenolol 10
atenolol & chlorthalidone 10
atovaquone/proguanil 5
ATRIPLA 4
atropine sulfate (ophthalmic) 19
augmented betamethasone dipropionate 27
AVC 26
AVELOX 3
AXIRON 22
azathioprine 30
azelastine hcl (ophthalmic) 18
azithromycin 3
AZOPT (ophthalmic) 19
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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B
bacitracin & polymyxin B (ophthalmic) 18
bacitracin (ophthalmic) 18
baclofen 8
BACTROBAN 26
BACTROBAN NASAL 26
balsalazide 22
BARACLUDE 4
belladonna alkaloids & phenobarbital 7
belladonna alkaloids, 6
benazepril & hydrochlorothiazide 11
benazepril hcl 11
benzocaine & antipyrine (otic) 19
benzonatate 17
benzoyl peroxide & erythromycin 26
benztropine mesylate 15
betamethasone dipropionate (topical) 27
betamethasone valerate 27
betaxolol hcl (ophthalmic) 19
bethanechol chloride 7
BETIMOL 19
BETOPTIC-S (ophthalmic) 19
bicalutamide 6
BILTRICIDE 3
bisoprolol fumarate 10
bisoprolol fumarate & hydrochlorothiazide 10
BLEPHAMIDE (ophthalmic) 18
BLEPHAMIDE S.O.P. 18
BRILINTA 8
brimonidine tartrate 19
bromocriptine mesylate 15
budesonide (nebulized) 22
budesonide (oral) 22
bumetanide 17
buprenorphine HCl & naloxone HCL 12
bupropion hcl 13
buspirone hcl 15
butalbital, acetaminophen & caffeine 12
butalbital, acetaminophen, caffeine & codeine 12
butalbital, aspirin & caffeine 12
butalbital, aspirin, caffeine & codeine 12
BYSTOLIC 10
C
cabergoline 15
calcipotriene 28
calcitonin (salmon) 25
calcitriol 29
calcitriol (topical) 28
calcium acetate (phosphate binde)r 16
captopril 11
captopril & hydrochlorothiazide 11
carbamazepine 13
carbamazepine (extended release) 13
carbidopa & levodopa 15
carbidopa & levodopa (extended release) 15
CARDENE SR 11
carisoprodol 8
carisoprodol & aspirin 8
carteolol hcl (ophthalmic) 19
carvedilol 10
CAVERJECT 10
CAYSTON 3
CEENU 6
cefaclor 3
cefadroxil 3
cefdinir 3
cefprozil 3
cefuroxime axetil 3
CELEBREX 12
CELESTONE 22
CELONTIN 13
cephalexin 3
CESIA 23
chlordiazepoxide & amitriptyline 13
chlordiazepoxide & clidinium 7
chlordiazepoxide hcl 15
chlorhexidine gluconate (dental) 18
chloroquine phosphate 5
chlorpromazine hcl 13
chlorthalidone 17
cholestyramine 9
choline magnesium trisalicylate 12
CIALIS 10
ciclopirox olamine 26
cilostazol 8
CIPRO HC (otic) 18
CIPRODEX 18
ciprofloxacin hcl 3
ciprofloxacin hcl (ophthalmic) 18
citalopram hydrobromide 13
clarithromycin 3
CLIMARA 24
clindamycin hcl 3
clindamycin phosphate (topical) 26
clindamycin phosphate (vaginal) 26
clobetasol propionate 27
clobetasol propionate emollient base 27
CLODERM 27
clomipramine hcl 13
clonazepam 13
clonidine hcl 9
clopidogrel 8
clorazepate dipotassium 15
clotrimazole 26
clotrimazole & betamethasone dipropionate 26
clotrimazole (topical) 26
COLCRYS 17, 30
COLY-MYCIN-S (otic) 18
COMBIPATCH 24
COMBIVENT RESPIMAT 8
COMBIVIR 4
COPAXONE 30
CORDRAN 27
COREG CR 10
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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CORTIFOAM 27
cortisone acetate 22
CORTISPORIN 27
CRESTOR 9
CRIXIVAN 4
cromolyn sodium 17
cromolyn sodium (ophthalmic) 18
CRYSELLE 24
CUPRIMINE 22
CYCLESSA 23
cyclobenzaprine hcl 8
cyclophosphamide 6
cyclosporine modified (for microemulsion) 30
cyproheptadine hcl 3
D
danazol 22
dantrolene sodium 8
dapsone 4
DARAPRIM 5
DELATESTRYL 22
desipramine hcl 13
desmopressin acetate 26
DESOGEN 23
desogestrel & ethinyl estradiol (monophasic) 23
desogestrel & ethinyl estradiol (triphasic) 23
desonide 27
desoximetasone 27
DETROL LA 29
dexamethasone 22
dexmethylphenidate hcl 14
dextroamphetamine sulfate 14
diazepam 15
DIBENZYLINE 8
diclofenac sodium 12
diclofenac sodium (ophthalmic) 18
dicloxacillin 3
dicyclomine hcl 7
didanosine 4
diflorasone diacetate 27
digoxin 9
dihydroergotamine mesylate 8
diltiazem hcl 11
DIOVAN 11
diphenoxylate & atropine 20
dipyridamole 10
disopyramide phosphate 9
disulfiram 30
divalproex sodium 13
divalproex sodium (extended release) 13
DONNATAL EXTENTABS 7
dorzolamide hcl & timolol maleate (ophthalmic) 19
dorzolamide hcl (ophthalmic) 19
doxazosin mesylate 10
doxepin hcl 13
doxycycline 3
DRITHO-CREME 28
drospirenone & ethinyl estradiol 23
DULERA 8
E
EDEX 10
EFFIENT 8
ELIDEL 28
ELMIRON 31
EMCYT 6
EMEND 21
EMTRIVA 4
enalapril maleate 11
ENBREL 30
ENPRESSE 23
entacapone 16
epinephrine hcl 8
EPIVIR HBV 4
EPOGEN 9
EPZICOM 4
ergocalciferol 29
ERGOMAR 8
ergotamine tartrate & caffeine 15
ERGOTRATE MALEATE 26
erythromycin (ophthalmic) 18
erythromycin (topical) 26
erythromycin base 3
erythromycin ethylsuccinate 3
erythromycin stearate 3
erythromycin sulfisoxazole 3
escitalopram oxalate 13
estazolam 15
esterified estrogens & methyltestosterone 24
ESTRACE 24
ESTRACE VAGINAL 24
ESTRADIOL 24
estradiol (oral) 24
estradiol (transdermal) 24
estropipate 24
ethambutol 4
ethosuximide 13
ethynodiol diacetate & ethinyl estradiol 23
etidronate disodium 30
etodolac 12
etoposide 6
EURAX 26
EVISTA 24
EVOXAC 7
EXELDERM 27
exemestane 6
EXFORGE 11
EXFORGE HCT 11
F
famciclovir 4
famotidine 21
felbamate 13
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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felodipine 11
FEMHRT 24
fenofibrate 9
fenofibrate (micronized) 9
fenoprofen calcium 12
fentanyl 12
fexofenadine hcl 3
FINACEA 28
finasteride 30
FIRAZYR 31
FLAREX 18
flavoxate hcl 29
flecainide acetate 9
FLOVENT DISKUS 22
FLOVENT HFA 22
fluconazole 4
fludrocortisone acetate 22
flunisolide (nasal) 18
fluocinolone acetonide 27
fluocinonide 27
fluocinonide emulsified base 27
fluorometholone (ophthalmic) 18
fluorouracil (topical) 28
fluoxetine hcl 13
fluoxymesterone 22
fluphenazine hcl 13
flurazepam hcl 15
flurbiprofen sodium (ophthalmic) 18
flutamide 6
fluticasone propionate 27
fluticasone propionate (nasal) 18
fluvoxamine maleate 13
FML FORTE 18
FOCALIN XR 14
folic acid 29
fondaparinux 8
FORTEO 25
FOSAMAX PLUS D 30
fosinopril sodium 11
fosinopril sodium & hydrochlorothiazide 11
FRAGMIN 8
furosemide 17
G
gabapentin 13
GABITRIL 13
galantamine hbr 7
galantamine hbr (extended release) 7
ganciclovir 4
gatifloxacin (ophthalmic) 18
gemfibrozil 9
gentamicin sulfate (ophthalmic) 18
gentamicin sulfate (topical) 27
GLEEVEC 6
glimepiride 25
glipizide 25
glucagon hcl 25
glyburide 25
glyburide & metformin hcl 25
glycopyrrolate 7
griseofulvin ultramicrosize 4
guaifenesin & codeine 17
guanfacine hcl 9
H
halobetasol propionate 27
haloperidol 14
heparin sodium 8
HEPSERA 5
HEXALEN 6
HUMALOG 25
HUMALOG KWIKPEN 25
HUMALOG MIX 50/50 25
HUMALOG MIX 50/50 PEN 25
HUMALOG MIX 75/25 25
HUMALOG MIX 75/25 PEN 25
HUMIRA 30
HUMULIN R U-500 25
hydralazine hcl 9
hydrochlorothiazide 17
hydrocodone & acetaminophen 12
hydrocortisone 22
hydrocortisone & acetic acid (otic) 18
hydrocortisone (intrarectal) 27
hydrocortisone (rectal) 27
hydrocortisone (topical) 27
hydrocortisone acetate & pramoxine 28
hydrocortisone acetate (rectal) 28
hydrocortisone valerate 28
hydromorphone hcl 12
hydroxychloroquine sulfate 5
hydroxyurea 6
hydroxyzine hcl 15
hydroxyzine pamoate 15
hyoscyamine sulfate 7
I
ibuprofen 12
imipramine hcl 14
imipramine pamoate 14
imiquomod 28
INCIVEK 5
indapamide 17
indomethacin 12
INFERGEN 5
INNOHEP 8
insulin isophane & regular (human) 25
insulin isophane & regular (human) pen 25
insulin isophane (human) 25
insulin isophane (human) pen 25
insulin regular (human) 25
INTELENCE 5
INTRON-A 6
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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INVIRASE 5
ipratropium bromide (inhaled 7
ipratropium bromide (nasal) 7
IRESSA 6
ISENTRESS 5
isoniazid 4
isosorbide dinitrate 10
isosorbide mononitrate 10
isotretinoin 28
isradipine 11
itraconazole 4
J
JOLESSA 23
K
KALETRA 5
KARIVA 23
KELNOR 23
KENALOG 28
ketoconazole 4, 27
ketoprofen 12
ketorolac tromethamine 12
ketorolac tromethamine (ophthalmic)) 18
L
labetalol hcl 10
lactulose 16
lamivudine 5
lamotrigine 13
LANTUS 25
LANTUS FOR OPTICLIK 25
LANTUS SOLOSTAR 25
latanoprost 20
leflunomide 30
LESSINA 23
LETAIRIS 10
letrozole 6
leucovorin calcium 30
LEUKERAN 6
LEUKINE 9
leuprolide acetate 6
levalbuterol hcl solution 8
LEVEMIR 25
LEVEMIR FLEXPEN 25
levetiracetam 13
LEVITRA 10
levobunolol hcl (ophthalmic) 20
levocarnitine 31
levofloxacin 3
levonorgestrel & ethinyl estradiol (91-day) 23
levonorgestrel & ethinyl estradiol (monophasic) 23
levonorgestrel & ethinyl estradiol (triphasic) 23
levonorgestrel (emergency oral contraceptive 23
levothyroxine sodium 26
LEXIVA 5
LIALDA 22
lidocaine hcl 28
lidocaine hcl (mouth-throat) 19
lindane 27
liothyronine 26
lisinopril 11
lisinopril & hydrochlorothiazide 11
lithium carbonate 15
lithium carbonate (extended release) 15
LO/OVRAL 24
LOESTRIN 1.5/30 23
LOESTRIN 1/20 23
LOESTRIN FE 1.5/30 24
LOESTRIN FE 1/20 24
lorazepam 15
losartan potassium 11
losartan potassium & hydrochlorothiazide 11
lovastatin 9
LOVENOX 8
LOW-OGESTREL 24
loxapine succinate 14
LYSODREN 6
M
maprotiline hcl 14
MATULANE 6
MAXAIR AUTOHALER 8
meclofenamate sodium 12
medroxyprogesterone acetate 26
mefloquine hcl 5
megestrol acetate 6
MEPHYTON 29
mercaptopurine 6
metaproterenol sulfate 8
metformin hcl 25
metformin hcl (extended release) 25
methadone hcl 12
methazolamide 20
methimazole 26
METHITEST 22
methocarbamol 8
methotrexate 6
methyldopa 9
methylergonovine 26
methylphenidate hcl 14
methylphenidate hcl (extended release) 14
methylprednisolone 22
metipranolol (ophthalmic) 20
metoclopramide hcl 21
metolazone 17
metoprolol succinate 10
metoprolol tartrate 10
metronidazole 5
metronidazole (topical) 27
metronidazole (vaginal) 27
mexiletine hcl 9
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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miconazole nitrate 27
MICROGESTIN 1.5/30 23
MICROGESTIN 1/20 23
MICROGESTIN FE 1.5/30 24
MICROGESTIN FE 1/20 24
midodrine hcl 8
minocycline 3
MIRCETTE 23
mirtazapine 14
misoprostol 21
MOBAN 14
modafinil 15
MODICON 23
moexipril & hydrochlorothiazide 11
moexipril hcl 11
mometasone furoate 28
montelukast sodium 17
montelukast sodium(packets) 17
morphine sulfate 12
mupirocin (topical) 27
MUSE 10
MYCOBUTIN 4
mycophenolate mofetil 30
MYFORTIC 31
MYLERAN 6
N
nabumetone 12
nadolol 10
NAFTIN 27
naltrexone hcl 13
naproxen 12
naproxen sodium 12
naratriptan 15
NARDIL 14
NASONEX 19
NEBUPENT 5
NECON 1/50 23
NECON 10/11 23
NECON 7/7/7 23
NEFAZODONE HCL 14
neomycin sulfate 3
neomycin, bacitracin & polymyxin B (ophthalmic) 18
neomycin, polymyxin & dexamethasone (ophthalmic) 19
neomycin, polymyxin & hydrocortisone (ophthalmic) 19
neomycin, polymyxin & hydrocortisone (otic) 19
neomycin, polymyxin, bacitracin & hydrocortisone
(ophthalmic) 19
NEULASTA 9
nevirapine 5
NEXAVAR 6
NIASPAN 9
NICOTROL 8
nifedipine 11
NILANDRON 6
nitrofurantoin macrocrystals 6
nitrofurantoin monohydrate macrocystals 6
nitroglycerin 10
NORA-BE 23
NORDETTE 23
norethindrone & ethinyl estradiol (biphasic) 23
norethindrone & ethinyl estradiol (monophasic) 23
norethindrone & ethinyl estradiol (triphasic) 23
norethindrone & mestranol 23
norethindrone (contraceptive) 23
norethindrone acetate 26
norethindrone acetate & ethinyl estradiol 23
norethindrone acetate, estradiol, & iron 24
norgestimate & ethinyl estradiol (monophasic) 24
norgestimate & ethinyl estradiol (triphasic) 24
norgestrel & ethinyl estradiol 24
NOROXIN 3
NOR-QD 23
NORTREL 0.5/35 23
NORTREL 1/35, 23
NORTREL 7/7/7 23
nortriptyline hcl 14
NORVIR 5
NOVOLOG 25
NOVOLOG FLEXPEN 25
NOVOLOG MIX 70/30 25
NOVOLOG MIX 70/30 FLEXPEN 25
NUVARING 24
nystatin 4
nystatin & triamcinolone 28
nystatin (topical) 27
O
ofloxacin (ophthalmic) 18
ofloxacin (otic) 18
OGESTREL 24
olanzapin 14
olanzapine ODT 14
omeprazole 21
OMNITROPE 26
ondansetron hcl 21
ORTHO DIAPHRAGM ALL-FLEX KITs 55, 60, 65, 70,
75, 80, 85, 90, 95 16
ORTHO DIAPHRAGM COIL SPRING KITs 50, 100
AND 105 16
ORTHO DIAPHRAGM FLAT SPRING KITs 55, 60, 65,
70, 75, 80, 85, 90, and 95 16
ORTHO EVRA 24
ORTHO TRI-CYCLEN 24
ORTHO-CEPT 23
ORTHO-CYCLEN 24
ORTHO-MICRONOR 23
ORTHO-NOVUM 1/35 23
ORTHO-NOVUM 1/50 23
ORTHO-NOVUM 7/7/7 23
oxaprozin 12
oxazepam 15
oxcarbazepine 13
OXSORALEN 28
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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oxybutynin chloride 29
oxybutynin chloride (extended release) 29
oxycodone & acetaminophen 12
oxycodone & aspirin 12
oxycodone hcl 12
oxycodone hcl (extended release) 12
P
pantoprazole sodium 21
paromomycin sulfate 5
paroxetine hcl 14
paroxetine hcl (extended release) 14
PATANOL 18
pediatric multivitamins with fluoride 29
pediatric vitamins A, C, D, with fluoride 30
PEGASYS 5
PEG-INTRON 5
penicillin V potassium 3
pentoxifylline 9
permethrin 27
perphenazine 14
phenazopyridine hcl 28
phenobarbital 15
phenytoin 13
phenytoin sodium (extended release) 13
PHOSPHOLINE IODIDE (ophthalmic) 20
pilocarpine hcl (ophthalmic) 20
pindolol 10
pioglitazone hcl 25
podofilox 28
polyethylene glycol 3350, 20
polyethylene glycol 3350, potassium chloride, sodium
bicarbonate & sodium chloride 20
polymyxin B & trimethoprim 18
POLY-PRED (ophthalmic) 19
PORTIA 23
potassium and sodium citrates with citric acid 16
potassium bicarbonate & potassium chloride 16
potassium chloride 16
potassium citrate 16
pramipexole dihydrochloride 16
pramoxine & hydrocortisone 28
pravastatin 9
prazosin hcl 10
PRED-G (ophthalmic) 19
PRED-G S.O.P. (ophthalmic) 19
prednisolone 22
prednisolone acetate (ophthalmic) 19
prednisolone sodium phosphate 22
prednisolone sodium phosphate (ophthalmic) 19
prednisone 22
PREMARIN 24
PREMPHASE 24
PREMPRO 24
prenatal vitamin with docusate, ferrous fumarate, & folic
acid 29
prenatal vitamin with docusate, iron carbonyl, & folic acid
29
prenatal vitamin with ferrous fumarate & folic acid 29
prenatal vitamin with iron polysaccharide complex & folic
acid 29
prenatal vitamin with minerals, iron, & folic acid 29
prenatal vitamin with selenium, ferrous fumarate, & folic
acid 29
prenatal vitamin without vitamin a, with iron carbonyl,
docusate, & folic acid 29
PREVIFEM 24
PREZISTA 5
primaquine phosphate 6
primidone 13
probenecid 17
probenecid & colchicine 17
prochlorperazine maleate 14
PROCRIT 9
progesterone, micronized 26
promethazine hcl 3
propafenone hcl 9
propranolol hcl 10
propylthiouracil 26
PROSTIGMIN 7
PROTOPIC 28
protriptyline hcl 14
PULMICORT FLEXHALER 22
PULMOZYME 17
pyrazinamide 4
pyridostigmine bromide 7
Q
quetiapine fumarate 14
quinapril & hydrochlorothiazide 11
quinapril hcl 11
quinidine gluconate 9
quinidine sulfate 9
QVAR 22
R
ramipril 11
ranitidine hcl 21
RAPAMUNE 31
REBIF 30
REGRANEX 28
RELENZA 5
RENAGEL 16
RENVELA 16
RENVELA PAK 17
RESCRIPTOR 5
reserpine 10
REVLIMID 30
REYATAZ 5
ribavirin 5
RIDAURA 22
rifampin 4
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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riluzole 16
rimantadine 5
risperidone 14
rizatriptan 15
ropinirole hcl 16
S
salsalate 12
SANDIMMUNE 31
SAVELLA 16
SEASONIQUE 23
selegiline hcl 16
selenium sulfide 27
SELZENTRY 5
SEREVENT DISKUS 8
sertraline hcl 14
sildenafil citrate (REVATIO) 10
silver sulfadiazine 27
simvastatin 9
sodium chloride for nebulization 17
sodium citrate & citric acid 16
sodium fluoride 30
sodium polystyrene sulfonate 17
sotalol hcl 10
SPECTRACEF 4
SPIRIVA 7
spironolactone 11
spironolactone & hydrochlorothiazide 11
SPRINTEC 24
SPRYCEL 6
SSKI 26
stavudine 5
STROMECTOL 3
sucralfate 21
sulfacetamide sodium & prednisolone sodium phosphate
(ophthalmic) 19
sulfacetamide sodium (ophthalmic) 18
sulfacetamide sodium (topical) 27
sulfadiazine 4
sulfamethoxazole & trimethoprim 4
sulfasalazine 4, 22
sulindac 12
sumatriptan succinate 15
SUPRAX 4
SUSTIVA 5
SUTENT 7
T
TABLOID 7
tacrolimus 31
TAMIFLU 5
tamoxifen citrate 7
tamsulosin hcl 8
TARCEVA 7
TARGRETIN 7, 28
TARKA 11
TAZORAC 28
temazepam 15
temozolomide 7
terazosin hcl 10
terbinafine 4
terbutaline sulfate 8
testosterone 22
testosterone cypionate 22
tetracycline 4
THALOMID 30
theophylline 29
thioridazine hcl 14
thiothixene 14
thyroid 26
THYROLAR 26
TIKOSYN 9
timolol maleate (ophthalmic) 20
tizanidine hcl 8
TOBI Neb, TOBI Podhaler 4
tobramycin sulfate & dexamethasone (ophth) 19
tobramycin sulfate (ophthalmic) 18
tolazamide 25
tolbutamide 25
tolterodine tartrate 29
topiramate 13
torsemide 17
TRACLEER 10
tramadol hcl 12
tranylcypromine sulfate 14
trazodone hcl 14
tretinoin 7, 28
triamcinolone acetonide (mouth) 28
triamcinolone acetonide (topical) 28
triamterene & hydrochlorothiazide 17
triazolam 15
trifluoperazine hcl 14
trifluridine (ophth) 18
trihexyphenidyl hcl 16
trimethoprim 6
trimipramine maleate 14
TRI-NORINYL 23
TRI-PREVIFEM 24
TRI-SPRINTEC 24
TRIVORA 23
TRIZIVIR 5
tropicamide (ophthalmic) 19
TRUVADA 5
TUSSIONEX 17
TYKERB 7
TYZEKA 5
U
ursodiol 20
V
VAGIFEM 24
Kaiser Permanente Southern Colorado Commercial HMO Formulary (3/3/2014)
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VALCYTE 5
valproic acid 13
valsartan & hydrochlorothiazide 11
VALTREX 5
VANCOCIN 4
VELIVET 23
venlafaxine hcl 14
venlafaxine hcl (extended release) 14
verapamil hcl 11
VIAGRA 10
VIRACEPT 5
VIREAD 5
VIVELLE-DOT 24
voriconazole 4
VOTRIENT 7
W
warfarin sodium 9
WIDE-SEAL SILICONE DIAPHRAGM KITs 60, 65, 70,
75, 80, 85, 90, and 95 16
X
XELODA 7
XOPENEX HFA 8
XTANDI 7
Y
YASMIN 23
YODOXIN 6
yohimbine hcl 31
Z
zafirlukast 17
zaleplon 15
ZELBORAF 7
zidovudine 5
ziprasidone hcl 14
ZOLINZA 7
zolmitriptan 15
zolmitriptan ODT 15
zolpidem tartrate 15
zonisamide 13
ZOVIA 1/35E 23
ZOVIA 1/50E 23
ZOVIRAX 27
ZYTIGA 7
ZYVOX 4