Denver/Boulder, Northern Colorado & Southern Colorado ...€¦ · Kaiser Permanente has many brand name medications on the formulary. In many cases, a generic equivalent is used

Kaiser Permanente Healthcare Exchange Formulary – February 2014 - 1 -

Denver/Boulder, Northern Colorado & Southern Colorado Healthcare Exchange Formulary Listing

The following is a listing of the drugs on the Kaiser Permanente formulary for members enrolled in a Healthcare Exchange plan. Kaiser Permanente has many brand name medications on the formulary. In many 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 co-pay. 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). Drugs that have at least one dosage form as an injectable on formulary are noted with an asterisk (*). Drugs that have certain strengths or forms (e.g., tablet, gel capsule, liquid) that are only available as brand drugs are subject to the brand cost share.

Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limit the drug quantity that is

covered. We may also limit the amount of medication dispensed to a certain days supply. For example, Kaiser Permanente provides 18 doses per prescription for rizatriptan (generic Maxalt) and Tarceva is limited to a 30-day supply. Drugs with quantity limits are denoted with a “QL”. Additionally, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment.

Restricted to Specialists: In some cases, Kaiser Permanente may restrict drugs to be prescribed only by specialists to assure the safest care. For example, Felbatol is restricted to Neurology and therefore a prescription for Felbatol must be written by a neurologist. Drugs with restrictions are noted with an “R”.

Restricted to Benefit: Some drugs are covered under certain benefits for coverage. These drugs are noted with “RB”.

Medication Exception Process: Upon request, Kaiser Permanente may make an exception to our coverage rules. The following is an example of exception requests:

o Request to cover a drug that is not on our formulary Kaiser Permanente will cover non-formulary drugs only when it is medically necessary over any

formulary alternatives. Key: PA = Prior Authorization - A drug that requires specific medical criteria be met prior to being dispensed

for the patient’s pharmacy benefit QL = Quantity Limit - A drug that has a quantity limit or is limited to a specific day supply R = Restricted to Specialist - A drug that is restricted to a specialist to prescribe RB = Restricted to Benefit - A drug that is covered under a certain benefit * (asterisk) = Injectable = Drug Tier 4 † (dagger) = Drug is on Specialty Tier List (all forms) = Drug Tier 4

Specialty Drug Tier 4 may be any form of drug, such as oral, topical or injectable Drug Tier 4 may have a 30 day supply Quantity Limit (QL)

& (ampersand) = Indicates Multiple Dosage Forms 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 our Member Services department at 1-888-681-7878 (toll free). For the hearing or speech impaired: 1-800-521-4874 (toll free TTY). The medications on this list are subject to change.


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

ALBENZA Brand 2 Brand

BILTRICIDE Brand 2 Brand


ANTIBACTERIALS

amoxicillin Generic/Brand & 1, 2 Generic / Brand

amoxicillin & potassium clavulanate Generic/Brand & 1, 2 Generic / Brand

amoxicillin chewable Generic/Brand & 1, 2 Generic / Brand

ampicillin Generic/Brand * 1, 2, 4 Generic / Brand / Specialty Tier

AVELOX Brand * 4 Specialty Tier

AZACTAM Brand * 4 Specialty Tier

azithromycin Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

aztreonam Generic *& 1, 4 Generic / Specialty Tier

bacitracin Generic/Brand & 1, 2 Generic / Brand

bacitracin & polymyxin B Generic 1 Generic

BICILLIN L-A Brand * 4 Specialty Tier

CAYSTON Brand † QL 4 Specialty Tier

cefazolin sodium Generic *& 1, 4 Generic / Specialty Tier

cefdinir Generic 1 Generic

cefepime Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

cefotaxime sodium Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

cefotetan Generic *& 1, 4 Generic / Specialty Tier

ceftazidime Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

ceftriaxone sodium Generic *& 1, 4 Generic / Specialty Tier

cefuroxime axetil Generic/Brand & 1, 2 Generic / Brand

cefuroxime sodium Generic *& 1, 4 Generic / Specialty Tier

cephalexin Generic 1 Generic

ciprofloxacin hcl Generic/Brand & 1, 2 Generic / Brand

clarithromycin Generic 1 Generic

CLEOCIN Brand 2 Brand

clindamycin hcl Generic/Brand & 1, 2 Generic / Brand

clindamycin palmitate hcl Generic 1 Generic

clindamycin phosphate Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

dicloxacillin sodium Generic 1 Generic

doxycycline hyclate Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

doxycycline monohydrate Generic 1 Generic

erythromycin base Generic/Brand & 1, 2 Generic / Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

erythromycin ethylsuccinate Generic/Brand & 1, 2 Generic / Brand

erythromycin lactobionate Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

erythromycin sulfisoxazole Generic/Brand & 1, 2 Generic / Brand

FORTAZ Brand * 4 Specialty Tier

gentamicin sulfate Generic *& 1, 4 Generic / Specialty Tier

INVANZ Brand * 4 Specialty Tier

levofloxacin Generic *& 1, 4 Generic / Specialty Tier

minocycline hcl Generic 1 Generic

neomycin sulfate Generic 1 Generic

penicillin g potassium Generic *& 1, 4 Generic / Specialty Tier

penicillin g procaine Generic *& 1, 4 Generic / Specialty Tier

penicillin g sodium Generic *& 1, 4 Generic / Specialty Tier

penicillin v potassium Generic 1 Generic

piperacillin-tazobactam Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

PRIMAXIN Brand * 4 Specialty Tier

streptomycin sulfate Generic *& 1, 4 Generic / Specialty Tier

sulfamethoxazole-trimethoprim Generic *& 1, 4 Generic / Specialty Tier

sulfasalazine Generic 1 Generic

SUPRAX Brand 2 Brand

tetracycline hcl Generic/Brand & 1, 2 Generic / Brand

TOBI Brand † QL 4 Specialty Tier

tobramycin neb Generic † QL 4 Specialty Tier

tobramycin sulfate Generic/Brand *& 1, 2, 4 Generic /Brand / Specialty Tier

TROBICIN Brand * 4 Specialty Tier

VANCOCIN ISO-OSMOTIC

DEXTROSE Brand * 4 Specialty Tier

vancomycin hcl Brand †& QL 4 Specialty Tier

ZYVOX Brand † QL 4 Specialty Tier


ANTIFUNGALS

AMBISOME Brand * 4 Specialty Tier

amphotericin b Generic *& 1, 4 Generic / Specialty Tier

ANCOBON Brand 2 Brand

CANCIDAS Brand * 4 Specialty Tier

fluconazole Generic *& 1, 4 Generic / Specialty Tier

fluconazole in nacl Generic *& 1, 4 Generic / Specialty Tier

griseofulvin microsize Generic/Brand & 1, 2 Generic / Brand

griseofulvin ultramicrosize Generic 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

ketoconazole Generic 1 Generic

nystatin Generic/Brand & 1, 2 Generic / Brand

voriconazole Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier


ANTIMYCOBACTERIALS

dapsone Generic 1 Generic

ethambutol hcl Generic 1 Generic

isoniazid Generic 1 Generic

pyrazinamide Generic 1 Generic

rifampin Generic *& 1, 4 Generic / Specialty Tier


ANTIPROTOZOALS

atovaquone-proguanil Generic 1 Generic

chloroquine phosphate Generic 1 Generic

DARAPRIM Brand 2 Brand

hydroxychloroquine sulfate Generic 1 Generic

mefloquine hcl Generic 1 Generic

MEPRON Brand † QL 4 Specialty Tier

metronidazole Generic *& 1, 4 Generic / Specialty Tier

paromomycin sulfate Generic 1 Generic

pentamidine isethionate Brand * 4 Specialty Tier

primaquine phosphate Generic 1 Generic


ANTIVIRALS

abacavir Generic/Brand & 1, 2 Generic / Brand

acyclovir Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

amantadine hcl Generic 1 Generic

APTIVUS Brand †& 4 Specialty Tier

ATRIPLA Brand †

4 Specialty Tier

BARACLUDE Brand † R 4 Specialty Tier

COMPLERA Brand †

4 Specialty Tier

CRIXIVAN Brand 2 Brand

CYTOVENE Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

didanosine Generic/Brand & 1, 2 Generic / Brand

EDURANT Brand †

4 Specialty Tier

EMTRIVA Brand 2 Brand

EPIVIR Brand 2 Brand

EPZICOM Brand †

4 Specialty Tier


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

famciclovir Generic 1 Generic

foscarnet sodium Generic *& 1, 4 Generic / Specialty Tier

ganciclovir Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

HEPSERA Brand † QL, R 4 Specialty Tier

INCIVEK Brand † QL, R 4 Specialty Tier

INTELENCE Brand †

4 Specialty Tier

INVIRASE Brand †

4 Specialty Tier

ISENTRESS Brand †

4 Specialty Tier

KALETRA Brand †

4 Specialty Tier

lamivudine Generic 1 Generic

lamivudine/zidovudine Generic 1 Generic

LEXIVA Brand †

4 Specialty Tier

nevirapine Generic/Brand & 1, 2 Generic / Brand

NORVIR Brand †&

4 Specialty Tier

PEGASYS Brand † QL 4 Specialty Tier

PREZISTA Brand †&

4 Specialty Tier

RESCRIPTOR Brand

2 Brand

REYATAZ Brand †

4 Specialty Tier

ribavirin Generic

1 Generic

rimantadine hydrochloride Generic/Brand &

1, 2 Generic / Brand

SELZENTRY Brand †

4 Specialty Tier

stavudine Generic

1 Generic

STRIBILD Brand † 4 Specialty Tier

SUSTIVA Brand 2 Brand

SYNAGIS Brand * 4 Specialty Tier

TAMIFLU Brand 2 Brand

TRIZIVIR Brand †

4 Specialty Tier

TRUVADA Brand †

4 Specialty Tier

VALCYTE Brand † QL 4 Specialty Tier

VICTRELIS Brand † QL, R 4 Specialty Tier

VIRACEPT Brand †

4 Specialty Tier

VIREAD Brand †

4 Specialty Tier

zidovudine Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier


URINARY ANTI-INFECTIVES

methenamine hippurate Generic 1 Generic

nitrofurantoin macrocrystal Generic 1 Generic

nitrofurantoin monohyd macro Generic 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

PRIMSOL Brand 2 Brand

trimethoprim Generic 1 Generic

UROQID #2 Brand 2 Brand

ANTIHISTAMINE DRUGS

ANTIHISTAMINE DRUGS

cyproheptadine hcl Generic 1 Generic

diphenhydramine hcl Generic *& 1, 4 Generic / Specialty Tier

promethazine hcl Generic *& 1, 4 Generic / Specialty Tier

ANTINEOPLASTIC AGENTS

ANTINEOPLASTIC AGENTS

ABRAXANE Brand * 4 Specialty Tier

AFINITOR Brand † 4 Specialty Tier

anastrozole Generic

1 Generic

AVASTIN Brand * R 4 Specialty Tier

bicalutamide Generic R 1 Generic

BICNU W/DILUENT ABSOLUTE

ETHANOL Brand * 4 Specialty Tier

bleomycin sulfate Generic *& 1, 4 Generic / Specialty Tier

carboplatin Generic *& 1, 4 Generic / Specialty Tier

CEENU Brand R 2 Brand

cisplatin Generic *& 1, 4 Generic / Specialty Tier

cyclophosphamide Generic *& 1, 4 Generic / Specialty Tier

cytarabine Generic *& 1, 4 Generic / Specialty Tier

dacarbazine Generic *& 1, 4 Generic / Specialty Tier

dactinomycin Generic *& 1, 4 Generic / Specialty Tier

daunorubicin hcl Generic *& 1, 4 Generic / Specialty Tier

docetaxel Generic *& 1, 4 Generic / Specialty Tier

doxorubicin hcl Generic *& 1, 4 Generic / Specialty Tier

ELSPAR Brand * 4 Specialty Tier

EMCYT Brand † QL, R 4 Specialty Tier

ERBITUX Brand * R 4 Specialty Tier

etoposide Generic *& R 1, 4 Generic / Specialty Tier

exemestane Generic R 1 Generic

fludarabine phosphate Generic *& 1, 4 Generic / Specialty Tier

fluorouracil Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

flutamide Generic 1 Generic

GEMZAR Brand * 4 Specialty Tier

GLEEVEC Brand † QL, R 4 Specialty Tier


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

HERCEPTIN Brand * 4 Specialty Tier

HEXALEN Brand † R 4 Specialty Tier

hydroxyurea Generic 1 Generic

idarubicin hcl Generic *& 1, 4 Generic / Specialty Tier

ifosfamide Generic *& 1, 4 Generic / Specialty Tier

ifosfamide & mesna Generic *& 1, 4 Generic / Specialty Tier

INTRON-A Brand † QL, R 4 Specialty Tier

INTRON-A W/DILUENT Brand † QL, R 4 Specialty Tier

letrazole Generic 1 Generic

LEUKERAN Brand R 2 Brand

leuprolide acetate Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

LUPRON DEPOT Brand * 4 Specialty Tier

LUPRON DEPOT-PED Brand * 4 Specialty Tier

LYSODREN Brand * QL 4 Specialty Tier

MATULANE Brand † QL, R 4 Specialty Tier

megestrol acetate Generic 1 Generic

melphalan Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

mercaptopurine Generic R 1 Generic

methotrexate sodium Generic *& 1, 4 Generic / Specialty Tier

mitomycin Generic *& 1, 4 Generic / Specialty Tier

mitoxantrone hcl Generic *& 1, 4 Generic / Specialty Tier

MUSTARGEN Brand * 4 Specialty Tier

MYLERAN Brand R 2 Brand

NEXAVAR Brand † QL, R 4 Specialty Tier

paclitaxel Generic *& 1, 4 Generic / Specialty Tier

pentostatin Generic *& 1, 4 Generic / Specialty Tier

RITUXAN Brand * 4 Specialty Tier

SPRYCEL Brand † QL, R 4 Specialty Tier

SUTENT Brand † QL, R 4 Specialty Tier

TABLOID Brand R 2 Brand

tamoxifen citrate Generic 1 Generic

TARCEVA Brand † QL, R 4 Specialty Tier

TASIGNA Brand † QL, R 4 Specialty Tier

temozolomide Generic † QL, R 4 Specialty Tier

thiotepa Generic *& 1, 4 Generic / Specialty Tier

topotecan Generic *& 1, 4 Generic / Specialty Tier

TORISEL Brand * 4 Specialty Tier

TRETINOIN (CHEMOTHERAPY) Brand † QL, R 4 Specialty Tier


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

TYKERB Brand † QL, R 4 Specialty Tier

VIDAZA Brand * R 4 Specialty Tier

vinblastine sulfate Generic *& 1, 4 Generic / Specialty Tier

vincristine sulfate Generic *& 1, 4 Generic / Specialty Tier

vinorelbine tartrate Generic *& 1, 4 Generic / Specialty Tier

XELODA Brand R 2 Brand

XTANDI Brand † QL, R 4 Specialty Tier

ZELBORAF Brand † QL, R 4 Specialty Tier

ZOLADEX Brand * 4 Specialty Tier

ZYTIGA Brand † QL 4 Specialty Tier

AUTONOMIC DRUGS

ANTICHOLINERGIC AGENTS

atropine sulfate Generic *& 1, 4 Generic / Specialty Tier

ATROVENT HFA Brand 2 Brand

benztropine mesylate Generic *& 1, 4 Generic / Specialty Tier

clidinium / chlordiazepoxide Generic 1 Generic

dicyclomine hcl Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

glycopyrrolate Generic *& 1, 4 Generic / Specialty Tier

ipratropium bromide Generic 1 Generic

propantheline bromide Generic 1 Generic

TRANSDERM-SCOP DIS Brand 2 Brand

SPIRIVA HANDIHALER Brand 2 Brand

trihexyphenidyl hcl Generic 1 Generic

AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

CHANTIX Brand 2 Brand

DIBENZYLINE Brand 2 Brand

AUTONOMIC DRUGS

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS

bethanechol chloride Generic 1 Generic

donepezil hydrochloride Generic 1 Generic

ENLON Brand * 4 Specialty Tier

ergoloid mesylates Generic 1 Generic

galantamine hydrobromide Generic 1 Generic

MYTELASE Brand 2 Brand

neostigmine methylsulfate Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

pilocarpine hcl (oral) Generic/Brand & 1, 2 Generic / Brand

pyridostigmine bromide Generic/Brand & 1, 2 Generic / Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

AUTONOMIC DRUGS

SKELETAL MUSCLE RELAXANTS

ANECTINE Brand * 4 Specialty Tier

baclofen Generic 1 Generic

cyclobenzaprine hcl Generic 1 Generic

dantrolene sodium Generic *& 1, 4 Generic / Specialty Tier

methocarbamol Generic/Brand & 1, 2 Generic / Brand

AUTONOMIC DRUGS

SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS

phentolamine mesylate Generic *& 1, 4 Generic / Specialty Tier

AUTONOMIC DRUGS

SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ADVAIR DISKUS Brand 2 Brand

albuterol Generic 1 Generic

albuterol sulfate Generic 1 Generic

COMBIVENT Brand 2 Brand

COMBIVENT RESPIMAT Brand 2 Brand

DULERA Brand 2 Brand

ephedrine sulfate (pressors) Generic *& 1, 4 Generic / Specialty Tier

EPIPEN 2-PAK Brand * 4 Specialty Tier

EPIPEN-JR 2-PAK Brand * 4 Specialty Tier

FORADIL AEROLIZER Brand 2 Brand

MAXAIR AUTOHALER Brand 2 Brand

metaproterenol sulfate Generic 1 Generic

norepinephrine bitartrate Generic *& 1, 4 Generic / Specialty Tier

phenylephrine hcl (pressors) Generic *& 1, 4 Generic / Specialty Tier

PROAIR Brand 2 Brand

SEREVENT DISKUS Brand 2 Brand

terbutaline sulfate Generic *& 1, 4 Generic / Specialty Tier

BLOOD FORMATION, COAGULATION, AND THROMBOSIS

COAGULANTS AND ANTICOAGULANTS

ABBOKINASE Brand * 4 Specialty Tier

ACTIVASE Brand * 4 Specialty Tier

AGGRENOX Brand 2 Brand

aminocaproic acid Generic *& 1, 4 Generic / Specialty Tier

anagrelide hcl Generic 1 Generic

BENEFIX Brand * 4 Specialty Tier

BRILINTA Brand 2 Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

CATHFLO ACTIVASE Brand * 4 Specialty Tier

clopidogrel Generic 1 Generic

dipyridamole Generic 1 Generic

EFFIENT Brand 2 Brand

enoxaparin sodium Generic † QL 4 Specialty Tier

fondaparinux Generic † QL 4 Specialty Tier

heparin sodium (porcine) Generic *& 1, 4 Generic / Specialty Tier

MONOCLATE-P Brand * 4 Specialty Tier

pentoxifylline Generic 1 Generic

PRADAXA Brand 2 Brand

PROFILNINE SD Brand † QL 4 Specialty Tier

PROTAMINE SULFATE Brand * 4 Specialty Tier

THROMBIN-JMI Brand * 4 Specialty Tier

warfarin sodium Generic 1 Generic


HEMATOPOIETIC AGENTS

NEUPOGEN Brand † QL 4 Specialty Tier

PROCRIT Brand † QL 4 Specialty Tier


HEMOSTATICS

ADVATE Brand * 4 Specialty Tier

HELIXATE FS Brand * 4 Specialty Tier

HUMATE-P Brand * 4 Specialty Tier

KOGENATE FS Brand * 4 Specialty Tier

RECOMBINATE Brand * 4 Specialty Tier

REFACTO Brand * 4 Specialty Tier

tranexamic acid Generic * 4 Specialty Tier


IRON PREPARATIONS

INFED Brand * 4 Specialty Tier

VENOFER Brand * 4 Specialty Tier

CARDIOVASCULAR DRUGS

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate Generic 1 Generic

prazosin hcl Generic 1 Generic

terazosin hcl Generic 1 Generic


ANTILIPEMIC AGENTS


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

atorvastatin Generic 1 Generic

cholestyramine Generic 1 Generic

colestipol hcl Generic 1 Generic

fenofibrate Generic 1 Generic

gemfibrozil Generic 1 Generic

lovastatin Generic 1 Generic

pravastatin sodium Generic 1 Generic

simvastatin Generic 1 Generic


BETA-ADRENERGIC BLOCKING AGENTS

acebutolol Generic 1 Generic

atenolol Generic 1 Generic

carvedilol Generic 1 Generic

labetalol hcl Generic *& 1, 4 Generic / Specialty Tier

metoprolol succinate Generic 1 Generic

metoprolol tartrate Generic *& 1, 4 Generic / Specialty Tier

propranolol hcl Generic *& 1, 4 Generic / Specialty Tier

sotalol hcl Generic 1 Generic


CALCIUM-CHANNEL BLOCKING AGENTS

amlodipine besylate Generic 1 Generic

diltiazem hcl Generic *& 1, 4 Generic / Specialty Tier

nifedipine Generic 1 Generic

nimodipine Generic 1 Generic

verapamil hcl Generic *& 1, 4 Generic / Specialty Tier


CARDIAC DRUGS

adenosine Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

amiodarone hcl Generic *& 1, 4 Generic / Specialty Tier

digoxin Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

disopyramide phosphate Generic/Brand & 1, 2 Generic / Brand

dopamine hcl Generic *& 1, 4 Generic / Specialty Tier

flecainide acetate Generic 1 Generic

lidocaine hcl (cardiac) Generic *& 1, 4 Generic / Specialty Tier

procainamide hcl Generic *& 1, 4 Generic / Specialty Tier

propafenone hcl Generic 1 Generic

quinidine gluconate Generic 1 Generic

quinidine sulfate Generic 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

TIKOSYN Brand R 2 Brand


HYPOTENSIVE AGENTS

acetazolamide Generic *& 1, 4 Generic / Specialty Tier

clonidine hcl Generic 1 Generic

hydralazine hcl Generic 1 Generic

methazolamide Generic 1 Generic

methyldopa Generic 1 Generic

minoxidil Generic 1 Generic

reserpine Generic 1 Generic


RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS

captopril Generic 1 Generic

lisinopril Generic 1 Generic

lisinopril & hydrochlorothiazide Generic 1 Generic

losartan Generic 1 Generic

losartan & hydrochlorothiazide Generic 1 Generic

spironolactone Generic 1 Generic

spironolactone &

hydrochlorothiazide Generic 1 Generic


VASODILATING AGENTS

ADCIRCA Brand R 2 Brand

epoprostenol sodium Generic *& 1, 4 Generic / Specialty Tier

isosorbide dinitrate Generic/Brand & 1, 2 Generic / Brand

isosorbide mononitrate Generic 1 Generic

nitroglycerin Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

sildenafil citrate (pulmonary

hypertention) Generic R 1 Generic

TRACLEER Brand † QL, R 4 Specialty Tier

VENTAVIS Brand † QL, R 4 Specialty Tier

CENTRAL NERVOUS SYSTEM AGENTS

ANALGESICS AND ANTIPYRETICS

acetaminophen w/ codeine Generic 1 Generic

buprenorphine hcl Generic *& 1, 4 Generic / Specialty Tier

buprenorphine hcl/naloxone Generic *& R 1, 4 Generic / Specialty Tier

butorphanol tartrate Generic *& R 1, 4 Generic / Specialty Tier

choline & mag salicylate Generic 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

codeine phosphate Generic 1 Generic

etodolac Generic 1 Generic

fentanyl citrate Generic *& 1, 4 Generic / Specialty Tier

fentanyl transdermal system Generic QL 1 Generic

hydrocodone-acetaminophen Generic 1 Generic

hydromorphone hcl Generic *& 1, 4 Generic / Specialty Tier

ibuprofen Generic *& 1, 4 Generic / Specialty Tier

INDOCIN IV Brand * 4 Specialty Tier

indomethacin Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

ketorolac Generic *& 1, 4 Generic / Specialty Tier

meloxicam Generic 1 Generic

methadone hcl Generic QL 1 Generic

morphine sulfate Generic/Brand *& QL 1, 2, 4 Generic / Brand / Specialty Tier

nabumetone Generic 1 Generic

naproxen Generic 1 Generic

oxycodone hcl Generic 1 Generic

oxycodone w/ acetaminophen Generic/Brand & 1, 2 Generic / Brand

salsalate Generic 1 Generic

sufentanil citrate Generic *& R 1, 4 Generic / Specialty Tier

sulindac Generic 1 Generic

tramadol hcl Generic 1 Generic


ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS

amphetamine-dextroamphetamine Generic/Brand & 1, 2 Generic / Brand

dextroamphetamine sulfate Generic 1 Generic

methylphenidate hcl Generic 1 Generic

methylphenidate hcl er Generic 1 Generic


ANTICONVULSANTS

carbamazepine Generic/Brand & 1, 2 Generic / Brand

CELONTIN Brand 2 Brand

divalproex sodium Generic 1 Generic

divalproex sodium sprinkles Generic 1 Generic

ethosuximide Generic 1 Generic

felbamate Generic/Brand & 1, 2 Generic / Brand

FELBATOL Brand † R 4 Specialty Tier

gabapentin Generic 1 Generic

lamotrigine Generic

1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

levetiracetam Generic 1 Generic

magnesium sulfate Generic *& 1, 4 Generic / Specialty Tier

MEBARAL Brand 2 Brand

oxcarbazepine Generic/Brand & 1, 2 Generic / Brand

phenobarbital Generic *& 1, 4 Generic / Specialty Tier

phenytoin Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

phenytoin sodium Generic *& 1, 4 Generic / Specialty Tier

phenytoin sodium extended Generic 1 Generic

primidone Generic 1 Generic

topiramate Generic 1 Generic

topiramate sprinkle Generic 1 Generic

valproate sodium Generic *& 1, 4 Generic / Specialty Tier

valproic acid Generic/Brand & 1, 2 Generic / Brand

zonisamide Generic

1 Generic


ANTIMIGRAINE AGENTS

butalbital & acetaminophen Generic 1 Generic

butalbital, acetaminophen &

caffeine Generic 1 Generic

butalbital, aspirin & caffeine Generic 1 Generic

CAFERGOT Brand QL 2 Brand

dihydroergotamine mesylate Brand *& QL 2,4 Brand / Specialty Tier

ERGOMAR Brand QL 2 Brand

MIGERGOT Brand QL 2 Brand

naratriptan Generic *& QL 1, 4 Generic / Specialty Tier

rizatriptan Generic *& QL 1, 4 Generic / Specialty Tier

sumatriptan Generic *& QL 1, 4 Generic / Specialty Tier


ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

buspirone hcl Generic 1 Generic

droperidol Generic *& R 1, 4 Generic / Specialty Tier

hydroxyzine hcl Generic *& 1, 4 Generic / Specialty Tier

mephobarbital Generic 1 Generic

zolpidem tartrate Generic 1 Generic


BENZODIAZEPINES

alprazolam Generic 1 Generic

chlordiazepoxide Generic 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

clonazepam Generic 1 Generic

DIASTAT ACUDIAL Brand 2 Brand

DIASTAT PEDIATRIC Brand 2 Brand

diazepam Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

lorazepam Generic *& 1, 4 Generic / Specialty Tier

midazolam Generic *& 1, 4 Generic / Specialty Tier

oxazepam Generic 1 Generic

temazepam Generic 1 Generic

triazolam Generic 1 Generic


CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS

atracurium besylate Generic *& 1, 4 Generic / Specialty Tier

CAMPRAL Brand R 2 Brand

carbidopa-levodopa Generic *& 1, 4 Generic / Specialty Tier

COMTAN Brand 2 Brand

entacapone Generic 1 Generic

NAMENDA Brand 2 Brand

NAMENDA TITRATION PAK Brand 2 Brand

pramipexole dihydrochloride Generic 1 Generic

riluzole Generic

4 Generic

rocuronium bromide Generic *& 1, 4 Generic / Specialty Tier

ropinirole hydrochloride Generic 1 Generic

SAVELLA Brand PA 4 Specialty Tier

selegiline hcl Generic

1 Generic

vecuronium bromide Generic *& 1, 4 Generic / Specialty Tier


OPIATE ANTAGONISTS

naloxone hcl Generic *& 1, 4 Generic / Specialty Tier

naltrexone hcl Generic R 1 Generic


PSYCHOTHERAPEUTIC AGENTS

ABILIFY Brand * 4 Specialty Tier

amitriptyline hcl Generic 1 Generic

bupropion hcl Generic 1 Generic

chlorpromazine hcl Generic *& 1, 4 Generic / Specialty Tier

citalopram hydrobromide Generic 1 Generic

clomipramine hcl Generic 1 Generic

clozapine Generic QL, R 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

desipramine hcl Generic 1 Generic

doxepin hcl Generic 1 Generic

fluoxetine hcl Generic 1 Generic

fluphenazine decanoate Generic *& 1, 4 Generic / Specialty Tier

fluphenazine hcl Generic *& 1, 4 Generic / Specialty Tier

haloperidol Generic 1 Generic

haloperidol decanoate Generic *& 1, 4 Generic / Specialty Tier

haloperidol lactate Generic *& 1, 4 Generic / Specialty Tier

imipramine hcl Generic 1 Generic

lithium carbonate Generic/Brand & 1, 2 Generic / Brand

loxapine succinate Generic 1 Generic

mirtazapine Generic 1 Generic

nefazodone hcl Generic 1 Generic

nortriptyline hcl Generic 1 Generic

olanzapine Generic 1 Generic

ORAP Brand 2 Brand

paroxetine hcl Generic 1 Generic

perphenazine Generic 1 Generic

phenelzine sulfate Generic 1 Generic

prochlorperazine edisylate Generic *& 1, 4 Generic / Specialty Tier

prochlorperazine maleate Generic 1 Generic

quetiapine fumarate Generic 1 Generic

risperidone Generic/Brand & 1, 2 Generic / Brand

sertraline hcl Generic 1 Generic

thioridazine hcl Generic 1 Generic

thiothixene Generic 1 Generic

tranylcypromine sulfate Generic 1 Generic

trazodone hcl Generic 1 Generic

trifluoperazine hcl Generic 1 Generic

venlafaxine hcl Generic 1 Generic

ziprasidone hcl Generic 1 Generic

ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AND ALKALINIZING AGENTS

citric acid/sodium citrate sol Generic 1 Generic

CYTRA-3 Brand 2 Brand

CYTRA-K Brand 2 Brand

potassium citrate (alkalinizer) Generic 1 Generic

potassium citrate-citric acid Generic 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

sodium acetate Generic *& 1, 4 Generic / Specialty Tier

sodium bicarbonate Generic *& 1, 4 Generic / Specialty Tier

sodium citrate & citric acid Generic 1 Generic


AMMONIA DETOXICANTS

lactulose Generic 1 Generic


DIURETICS

amiloride & hydrochlorothiazide Generic 1 Generic

amiloride hcl Generic 1 Generic

bumetanide Generic 1 Generic

chlorothiazide Generic 1 Generic

chlorthalidone Generic 1 Generic

DYRENIUM Brand 2 Brand

EDECRIN Brand 2 Brand

furosemide Generic *& 1, 4 Generic / Specialty Tier

hydrochlorothiazide Generic 1 Generic

metolazone Generic 1 Generic

triamterene & hydrochlorothiazide Generic 1 Generic


ION-REMOVING AGENTS

RENVELA Brand 2 Brand

sodium polystyrene sulfonate Generic 1 Generic


IRRIGATING SOLUTIONS

lactated ringer's (irrigation) Generic 1 Generic

ringer's irrigation Generic 1 Generic

sodium chloride (gu irrigant) Generic 1 Generic

water for irrigation, sterile Generic *& 1, 4 Generic / Specialty Tier


REPLACEMENT PREPARATIONS

calcium chloride (dihydrate) Generic *& 1, 4 Generic / Specialty Tier

calcium gluconate Generic *& 1, 4 Generic / Specialty Tier

electrolyte concentrate solution Generic *& 1, 4 Generic / Specialty Tier

ELIPHOS Brand 2 Brand

K-PHOS Brand 2 Brand

PHOSLO Brand 2 Brand

potassium acetate Generic *& 1, 4 Generic / Specialty Tier


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

potassium chloride Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

potassium chloride

microencapsulated crystals cr Generic 1 Generic

potassium phosphate dibasic Generic *& 1, 4 Generic / Specialty Tier

potassium phosphate dibasic

monobasic w/sodium phosphate

monobasic

Generic *& 1, 4 Generic / Specialty Tier

sodium phosphate Generic *& 1, 4 Generic / Specialty Tier

zinc (trace metals) Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier


URICOSURIC AGENTS

probenecid Generic 1 Generic

ENZYMES

ENZYMES

ADAGEN Brand *

4 Specialty Tier

PULMOZYME Brand † QL 4 Specialty Tier

ERECTILE DYSFUNCTION

PHOSPHODIESTERACE-5 ENZYME INHIBITOR

CIALIS Brand QL, RB 2 Brand

LEVITRA Brand QL, RB 2 Brand

VIAGRA Brand QL, RB 2 Brand

ERECTILE DYSFUNCTION

PROSTAGLANDIN VASODILATORS

CAVERJECT Brand * RB 2, 4 Brand / Specialty Tier

EDEX Brand * RB 2, 4 Brand / Specialty Tier

MUSE Brand RB 2 Brand

EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS

ANTI-INFECTIVES

bacitracin-polymyxin b (ophth) Generic 1 Generic

erythromycin (ophth) Generic 1 Generic

gentamicin sulfate (ophth) Generic 1 Generic

nystatin Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

ofloxacin (ophth) Generic 1 Generic

ofloxacin (otic) Generic 1 Generic

polymyxin b-trimethoprim Generic 1 Generic

sodium sulfacetamide &

phenylephrine Generic 1 Generic

tobramycin sulfate (ophth) Generic/Brand & 1, 2 Generic / Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

trifluridine Generic

1 Generic

ZYMAXID Brand 2 Brand


ANTI-INFLAMMATORY AGENTS

CIPRODEX Brand 2 Brand

COLY-MYCIN S OTIC Brand 2 Brand

CORTISPORIN-TC SUS-TC OTIC Brand 2 Brand

dexamethasone sodium phosphate

(ophth) Generic/Brand & 1, 2 Generic / Brand

diclofenac sodium (ophth) Generic 1 Generic

flunisolide (nasal) Generic 1 Generic

fluorometholone (ophth) Generic/Brand & 1, 2 Generic / Brand

flurbiprofen sodium Generic 1 Generic

fluticasone propionate (nasal) Generic 1 Generic

FML FORTE SUS Brand 2 Brand

FML OINT Brand 2 Brand

LOTEMAX Brand 2 Brand

neomycin-polymycin-dexamethasone Generic 1 Generic

neomycin-polymyxin-hydrocortisone

(ophth) Generic 1 Generic

neomycin-polymyxin-hydrocortisone

(otic) Generic 1 Generic

PRED-G Brand 2 Brand

prednisolone acetate (ophth) Generic 1 Generic

prednisolone sodium phosphate

(ophth) Generic 1 Generic

RESTASIS Brand 2 Brand

sulfacetamide sod-prednisolone Generic/Brand & 1, 2 Generic / Brand


ANTIALLERGIC AGENTS

azelastine Generic 1 Generic

cromolyn sodium (ophth) Generic 1 Generic


EENT DRUGS, MISCELLANEOUS

acetic acid (otic) Generic 1 Generic

acetic acid-aluminum acetate Generic 1 Generic

betaxolol hcl Generic 1 Generic

brimonidine tartrate Generic 1 Generic

CRESYLATE Brand 2 Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

dorzolamide Generic 1 Generic

dorzolamide/timolol Generic 1 Generic

EYLEA Brand * 4 Specialty Tier

fluorescein sodium Generic 1 Generic

fluorescein/proparacaine Generic 1 Generic

HEALON GV Brand * 4 Specialty Tier

LACRISERT Brand 2 Brand

latanoprost Generic 1 Generic

levobunolol hcl Generic 1 Generic

LUCENTIS Brand * 4 Specialty Tier

MACUGEN Brand * 4 Specialty Tier

ophthalmic irrigation - intraocular Generic 1 Generic

PHOSPHOLINE IODIDE Brand 2 Brand

pilocarpine hcl Generic/Brand & 1, 2 Generic / Brand

timolol maleate (ophth) Generic 1 Generic

VISUDYNE Brand * 4 Specialty Tier


LOCAL ANESTHETICS

benzocaine & antipyrine Generic 1 Generic

lidocaine hcl (mouth-throat) Generic 1 Generic

proparacaine hcl Generic 1 Generic

tetracaine hcl (ophth) Generic 1 Generic


MYDRIATICS

atropine sulfate (ophthalmic) Generic 1 Generic

CYCLOMYDRIL Brand 2 Brand

cyclopentolate hcl Generic 1 Generic

ISOPTO HOMATROPINE Brand 2 Brand

ISOPTO HOMATROPINE Brand 2 Brand

ISOPTO HYOSCINE Brand 2 Brand

tropicamide Generic 1 Generic


VASOCONSTRICTORS

ADRENALIN Brand * 4 Specialty Tier

phenylephrine hcl (ophth) Generic 1 Generic

GASTROINTESTINAL DRUGS


balsalazide Generic 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

LIALDA Brand 2 Brand

mesalamine Generic/Brand & 1, 2 Generic / Brand


ANTIDIARRHEA AGENTS

diphenoxylate w/ atropine Generic 1 Generic

paregoric Generic 1 Generic


ANTIEMETICS

dimenhydrinate Generic *& 1, 4 Generic / Specialty Tier

dronabinol Generic 1 Generic

EMEND Brand 2 Brand

ondansetron Generic *& 1, 4 Generic / Specialty Tier

ondansetron hcl Generic *& 1, 4 Generic / Specialty Tier

prochlorperazine Generic *& 1, 4 Generic / Specialty Tier

SCOPACE Brand 2 Brand

TRANSDERM-SCOP Brand 2 Brand


ANTIULCER AGENTS AND ACID SUPPRESSANTS

cimetidine hcl Generic 1 Generic

famotidine Generic *& 1, 4 Generic / Specialty Tier

famotidine in nacl Generic *& 1, 4 Generic / Specialty Tier

misoprostol Generic 1 Generic

omeprazole Generic 1 Generic

pantoprazole Generic 1 Generic

ranitidine hcl Generic *& 1, 4 Generic / Specialty Tier

sucralfate Generic 1 Generic


DIGESTANTS

CREON Brand 2 Brand

PANCRELIPASE Brand 2 Brand

VIOKASE Brand 2 Brand

ZENPEP Brand 2 Brand


GI DRUGS, MISCELLANEOUS

LINZESS Brand PA 2 Brand

metoclopramide hcl Generic *& 1, 4 Generic / Specialty Tier

peg 3350-kcl-sod bicarb-sod

chloride-sod sulfate Generic 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

ursodiol Generic 1 Generic

GOLD COMPOUNDS

GOLD COMPOUNDS

RIDAURA Brand 2 Brand

HEAVY METAL ANTAGONISTS

HEAVY METAL ANTAGONISTS

CHEMET Brand 2 Brand

CUPRIMINE Brand 2 Brand

deferoxamine mesylate Generic *& 1, 4 Generic / Specialty Tier

EXJADE Brand † QL, R 4 Specialty Tier

flumazenil Generic *& 1, 4 Generic / Specialty Tier

PHYSOSTIGMINE SALICYLATE Brand * 4 Specialty Tier

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

ARISTOSPAN INTRA-

ARTICULAR Brand * 4 Specialty Tier

ARISTOSPAN INTRALESIONAL Brand * 4 Specialty Tier

ASMANEX 120 METERED

DOSES Brand 2 Brand

ASMANEX 60 METERED DOSES Brand 2 Brand

betamethasone acetate-

betamethasone sodium phosphate Generic *& 1, 4 Generic / Specialty Tier

budesonide Generic 1 Generic

cortisone acetate Generic 1 Generic

dexamethasone Generic *& 1, 4 Generic / Specialty Tier

dexamethasone sodium phosphate Generic *& 1, 4 Generic / Specialty Tier

FLOVENT HFA Brand 2 Brand

fludrocortisone acetate Generic 1 Generic

hydrocortisone Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

hydrocortisone sod succinate Generic *& 1, 4 Generic / Specialty Tier

KENALOG-10 Brand * 4 Specialty Tier

KENALOG-40 Brand * 4 Specialty Tier

methylprednisolone Generic *& 1, 4 Generic / Specialty Tier

methylprednisolone acetate Generic *& 1, 4 Generic / Specialty Tier

methylprednisolone sod succ Generic *& 1, 4 Generic / Specialty Tier

prednisolone Generic 1 Generic

prednisone Generic 1 Generic

QVAR Brand 2 Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

SOLU-CORTEF Brand * 4 Specialty Tier

triamcinolone acetonide Generic/Brand & 1, 2 Generic / Brand


ANDROGENS

ANADROL-50 Brand 2 Brand

ANDRODERM Brand 2 Brand

ANDROID Brand 2 Brand

danazol Generic 1 Generic

FIRST-TESTOSTERONE Brand * 4 Specialty Tier

METHITEST Brand 2 Brand

testosterone cypionate Generic *& 1, 4 Generic / Specialty Tier

TESTRED Brand 2 Brand


CONTRACEPTIVES

desogestrel-ethinyl estradiol Generic 1 Generic

ethynodiol diacet & eth estrad Generic 1 Generic

levonorgestrel & eth estradiol Generic 1 Generic

levonorgestrel-eth estradiol

(triphasic) Generic 1 Generic

norethin acet & estrad-fe Generic 1 Generic

norethindrone Generic 1 Generic

norethindrone & eth estradiol Generic/Brand & 1, 2 Generic / Brand

norethindrone & mestranol Generic/Brand & 1, 2, 4 Generic / Brand / Specialty Tier

norethindrone acet & eth estra Generic 1 Generic

norethindrone-eth estradiol

(triphasic) Generic/Brand & 1, 2, 4 Generic / Brand / Specialty Tier

norgestimate-ethinyl estradiol Generic 1 Generic

norgestimate-ethinyl estradiol

(triphasic) Generic 1 Generic


DIABETIC AGENTS

acarbose Generic 1 Generic

glimepiride Generic 1 Generic

glipizide Generic 1 Generic

GLUCAGON EMERGENCY KIT Brand * 4 Specialty Tier

HUMALOG Brand 2 Brand

HUMULIN 70/30 Brand 2 Brand

HUMULIN N Brand 2 Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

HUMULIN R Brand 2 Brand

HUMULIN R U-500

(CONCENTRATED) Brand 2 Brand

LANTUS Brand PA 2 Brand

metformin hcl Generic/Brand & 1, 2 Generic / Brand

tolbutamide Generic 1 Generic


ESTROGENS AND ANTIESTROGENS

clomiphene citrate Generic RB 1 Generic

DEPO-ESTRADIOL Brand * 4 Specialty Tier

estradiol Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

ESTRING Brand 2 Brand

estrogens with methyltestosterone Generic 1 Generic

estropipate Generic 1 Generic

EVISTA Brand 2 Brand

PREMARIN INJECTION Brand * 4 Specialty Tier

PREMARIN W/APPLICATOR Brand 2 Brand

VAGIFEM Brand 2 Brand


FOLLICLE STIMULATING HORMONES / LUTENIZING HORMONES

BRAVELLE Brand * RB 2, 4 Brand / Specialty Tier

MENOPUR Brand * RB 2, 4 Brand / Specialty Tier


GONADOTROPINS

chorionic gonadotropin Generic *& 1, 4 Generic / Specialty Tier

FACTREL Brand * 4 Specialty Tier

SYNAREL Brand 2 Brand


PARATHYROID

calcitonin (salmon) Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier


PITUITARY

ACTHAR HP Brand † PA, QL 4 Specialty Tier

desmopressin acetate Generic *& 1, 4 Generic / Specialty Tier

desmopressin acetate refrigerated Generic 1 Generic

desmopressin acetate spray Generic 1 Generic

vasopressin Generic *& 1, 4 Generic / Specialty Tier



Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

PROGESTINS

DEPO-PROVERA Brand * 4 Specialty Tier

medroxyprogesterone acetate Generic *& 1, 4 Generic / Specialty Tier

medroxyprogesterone acetate

(contraceptive) Brand * 4 Specialty Tier

norethindrone acetate Generic 1 Generic

progesterone Generic *& 1, 4 Generic / Specialty Tier


SOMATOTROPIN AGONISTS AND ANTAGONISTS

OMNITROPE 5MG Brand * PA 4 Specialty Tier

OMNITROPE 10MG Brand * PA 4 Specialty Tier


THYROID AND ANTITHYROID AGENTS

levothyroxine sodium Generic 1 Generic

liothyronine sodium Generic 1 Generic

methimazole Generic 1 Generic

potassium iodide Generic 1 Generic

propylthiouracil Generic 1 Generic

thyroid Generic/Brand & 1, 2 Generic / Brand

INTRAVENOUS SOLUTIONS

DEXTROSE

dextrose 10% in water Generic *& 1, 4 Generic / Specialty Tier

dextrose 5% in lactated ringer’s Generic *& 1, 4 Generic / Specialty Tier

dextrose 5% in nacl 0.2% Generic *& 1, 4 Generic / Specialty Tier



dextrose 5% in water Generic *& 1, 4 Generic / Specialty Tier


MISCELLANEOUS

BACTERIOSTATIC WATER FOR

INJECTION/BENZYL ALCOHOL

INJ BENZ ALC

Brand * 4 Specialty Tier

lactated ringer’s Generic *& 1, 4 Generic / Specialty Tier

mannitol injection Generic *& 1, 4 Generic / Specialty Tier

ringer’s injection Generic *& 1, 4 Generic / Specialty Tier

sodium bicarbonate Generic *& 1, 4 Generic / Specialty Tier

sterile water Generic *& 1, 4 Generic / Specialty Tier



Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

NUTRITIONAL PRODUCTS

amino acid solutions Generic *& 1, 4 Generic / Specialty Tier

dextrose high concentration in water Generic *& 1, 4 Generic / Specialty Tier

INTRALIPID Brand * 4 Specialty Tier

LIPOSYN III Brand * 4 Specialty Tier


SODIUM CHLORIDE (NACL, SALINE)

nacl 0.45%, ½ normal saline Generic *& 1, 4 Generic / Specialty Tier

nacl 0.9%, normal saline Generic *& 1, 4 Generic / Specialty Tier

nacl 3% Generic *& 1, 4 Generic / Specialty Tier

nacl 5% Generic *& 1, 4 Generic / Specialty Tier

IRRIGATION SOLUTIONS

IRRIGATION SOLUTIONS

cosyntropin Generic *& 1, 4 Generic / Specialty Tier

irrigation solution G Generic 1 Generic

lactated ringer’s Generic 1 Generic

ringer’s irrigation Generic *& 1, 4 Generic / Specialty Tier

sodium chloride 0.9% Generic *& 1, 4 Generic / Specialty Tier

sorbitol urologic 3% Generic *& 1, 4 Generic / Specialty Tier

sterile water Generic 1 Generic

MISCELLANEOUS THERAPEUTIC AGENTS

MISCELLANEOUS THERAPEUTIC AGENTS

acitretin Generic 1 Generic

acetylcysteine Generic 1 Generic

alendronate sodium Generic 1 Generic

allopurinol Generic 1 Generic

amifostine Generic *& 1, 4 Generic / Specialty Tier

AMPHADASE Brand * 4 Specialty Tier

ARALAST Brand * 4 Specialty Tier

AVONEX Brand † QL, R 4 Specialty Tier

azathioprine Generic 1 Generic

BOTOX Brand * 4 Specialty Tier

bromocriptine mesylate Generic 1 Generic

bupivacaine hcl Generic *& 1, 4 Generic / Specialty Tier

bupivacaine w/ epinephrine Generic *& 1, 4 Generic / Specialty Tier

buproprion hcl (smoking deterrent) Generic 1 Generic

cabergoline Generic 1 Generic

CELLCEPT SUS Brand 2 Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

CEREZYME Brand † QL 4 Specialty Tier

COLCRYS Brand 2 Brand

COPAXONE Brand † QL, R 4 Specialty Tier

cyclosporine modified Generic 1 Generic

disulfiram Generic/Brand & 1, 2 Generic / Brand

ELMIRON Brand 2 Brand

ENBREL Brand † QL, R 4 Specialty Tier

ENBREL SURECLICK Brand † QL, R 4 Specialty Tier

etidronate disodium Generic 1 Generic

EXTAVIA Brand † QL, R 4 Specialty Tier

finasteride Generic 1 Generic

FIRAZYR Brand † QL, R 4 Specialty Tier

GELFILM ENVELOPE Brand 2 Brand

GELFOAM SPONGE Brand 2 Brand

HUMIRA Brand † QL, R 4 Specialty Tier

ketamine hcl Generic *& 1, 4 Generic / Specialty Tier

KINERET Brand † QL, R 4 Specialty Tier

leflunomide Generic

1 Generic

leucovorin calcium Generic *& 1, 4 Generic / Specialty Tier

levocarnitine (metabolic modifiers) Generic *& 1, 4 Generic / Specialty Tier

lidocaine hcl (local anesth.) Generic *& 1, 4 Generic / Specialty Tier

mesna Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

METOPIRONE Brand 2 Brand

mycophenolate mofetil Generic/Brand & 1, 2 Generic / Brand

octreotide acetate Generic † QL 4 Specialty Tier

ORENCIA Brand † QL, R 4 Specialty Tier

pamidronate disodium Generic *& 1, 4 Generic / Specialty Tier

propofol Generic *& 1, 4 Generic / Specialty Tier

PROVOCHOLINE Brand 2 Brand

RAPAMUNE Brand †

4 Specialty Tier

REBIF Brand † QL, R 4 Specialty Tier

REMICADE Brand * R 4 Specialty Tier

REVLIMID Brand † QL, R 4 Specialty Tier

RIMSO-50 Brand * 4 Specialty Tier

SANDIMMUNE Brand 2 Brand

SENSIPAR Brand † QL 4 Specialty Tier

sevoflurane Generic 1 Generic

SUPRANE Brand 2 Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

tacrolimus Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

tamsulosin Generic 1 Generic

THALOMID Brand † QL, R 4 Specialty Tier

THIOLA Brand 2 Brand

TRAVASOL Brand * 4 Specialty Tier

VPRIV Brand * QL 4 Specialty Tier

ZEMAIRA Brand * 4 Specialty Tier

ZOMETA Brand * 4 Specialty Tier

OXYTOCICS

OXYTOCICS

HEMABATE Brand * 4 Specialty Tier

methylergonovine maleate Generic *& 1, 4 Generic / Specialty Tier

oxytocin Generic *& 1, 4 Generic / Specialty Tier

RESPIRATORY TRACT AGENTS


cromolyn sodium Generic/Brand & 1, 2 Generic / Brand

montelukast sodium Generic 1 Generic

RESPIRATORY TRACT AGENTS

RESPIRATORY AGENTS, MISCELLANEOUS

acetylcysteine Generic 1 Generic

benzonatate Generic 1 Generic

guaifenesin / codeine Generic 1 Generic

hydrocodone / chlorpheniramine Generic 1 Generic

hydrocodone / homatropine Generic 1 Generic

ipratropium bromide (nasal) Generic 1 Generic

LETAIRIS Brand † QL, R 4 Specialty Tier

sodium chloride (inhalant) Generic 1 Generic

sterile water Generic 1 Generic

SERUMS, TOXOIDS, AND VACCINES

SERUMS

GAMUNEX-C Brand * 4 Specialty Tier

SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)

BACTROBAN NASAL Brand 2 Brand

BENZAMYCIN PAK GEL PAK Brand 2 Brand

benzoyl peroxide-erythromycin gel Generic 1 Generic

ciclopirox olamine Generic 1 Generic

clindamycin phosphate (topical) Generic/Brand & 1, 2 Generic / Brand


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

clindamycin phosphate vaginal Generic/Brand & 1, 2 Generic / Brand

clotrimazole troche Generic 1 Generic

erythromycin (acne aid) Generic/Brand & 1, 2 Generic / Brand

gentamicin sulfate (topical) Generic 1 Generic

iodoquinol / hydrocortisone Generic 1 Generic

ketoconazole (topical) Generic 1 Generic

metronidazole (topical) Generic 1 Generic

metronidazole vaginal Generic 1 Generic

mupirocin Generic/Brand & 1, 2 Generic / Brand

nystatin Generic/Brand & 1, 2 Generic / Brand

permethrin Generic 1 Generic

selenium sulfide Generic 1 Generic

silver sulfadiazine Generic 1 Generic

terbinafine hcl Generic 1 Generic


ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)

alclometasone dipropionate Generic 1 Generic

aug betamethasone dipropionate Generic 1 Generic

betamethasone dipropionate

(topical) Generic 1 Generic

betamethasone valerate Generic 1 Generic

clobetasol propionate Generic 1 Generic

clotrimazole w/ betamethasone Generic 1 Generic

CORDRAN TAPE Brand 2 Brand

desonide Generic 1 Generic

fluocinolone acetonide Generic 1 Generic

fluocinonide Generic 1 Generic

fluocinonide emulsified base Generic 1 Generic

halobetasol Generic 1 Generic

hydrocortisone (intrarectal) Generic 1 Generic

hydrocortisone (rectal) Generic/Brand & 1, 2 Generic / Brand

hydrocortisone (topical) Generic/Brand & 1, 2 Generic / Brand

hydrocortisone butyrate Generic/Brand & 1, 2 Generic / Brand

LOCOID LIPOCREAM Brand 2 Brand

mometasone furoate Generic 1 Generic

nystatin-triamcinolone Generic 1 Generic

PROCTOFOAM-HC Brand 2 Brand

urea-hc acetate Generic 1 Generic


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier


CELL STIMULANTS AND PROLIFERANTS

DIFFERIN Brand 2 Brand

tretinoin Generic 1 Generic


SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS

8-MOP Brand 2 Brand

aluminum chloride Generic/Brand & 1, 2 Generic / Brand

AZELEX Brand

2 Brand

calcipotriene Generic 1 Generic

DRITHO-CREAM HP Brand 2 Brand

DRITHO-SCALP Brand 2 Brand

ETHYL CHLORIDE/MIST AER Brand 2 Brand

FINACEA Brand 2 Brand

fluorouracil (topical) Generic/Brand & 1, 2 Generic / Brand

imiquimod Generic

1 Generic

isotretinoin Generic R 1 Generic

lidocaine Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

lidocaine hcl Generic *& 1, 4 Generic / Specialty Tier

lidocaine-prilocaine Generic 1 Generic

OXSORALEN ULTRA Brand 2 Brand

para-aminobenzoic acid Generic 1 Generic

PHISOHEX Brand 2 Brand

podofilox Generic/Brand & 1, 2 Generic / Brand

PROTOPIC Brand R 2 Brand

SANTYL Brand 2 Brand

sulfacetamide sodium Generic 1 Generic

TAZORAC Brand R 2 Brand

trypsin, balsam peru & castor oil Generic 1 Generic

VECTICAL Brand 2 Brand

SMOOTH MUSCLE RELAXANTS

SMOOTH MUSCLE RELAXANTS

oxybutynin chloride Generic 1 Generic

OXYTROL Brand 2 Brand

theophylline Generic/Brand & 1, 2 Generic / Brand

VITAMINS

VITAMINS

AQUASOL A Brand * 4 Specialty Tier


Drug Name Drug Tier

Require

ments /

Limits

Drug

Tier

Number

Name of Drug Tier

calcitriol Generic 1 Generic

cyanocobalamin Generic *& 1, 4 Generic / Specialty Tier

ergocalciferol Generic 1 Generic

folic acid Generic *& 1, 4 Generic / Specialty Tier

phytonadione Generic/Brand *& 1, 2, 4 Generic / Brand / Specialty Tier

potassium aminobenzoate Generic/Brand & 1, 2 Generic / Brand

pyridoxine Generic *& 1, 4 Generic / Specialty Tier

thiamine Generic *& 1, 4 Generic / Specialty Tier


INDEX 8

8-MOP 30

A

abacavir 4 ABBOKINASE 9 ABILIFY 15 ABRAXANE 6 acarbose 23 acebutolol 11 acetaminophen w/ codeine 12 acetazolamide 12 acetic acid (otic) 19 acetic acid-aluminum acetate 19 acetylcysteine 26, 28 ACTHAR HP 24 ACTIVASE 9 acyclovir 4 ADAGEN 18 ADCIRCA 12 adenosine 11 ADRENALIN 20 ADVAIR DISKUS 9 ADVATE 10 AFINITOR 6 AGGRENOX 9 ALBENZA 2–31 albuterol 9 albuterol sulfate 9 alclometasone dipropionate 29 alendronate sodium 26 allopurinol 26 alprazolam 14 aluminum chloride 30 amantadine hcl 4 AMBISOME 3 amifostine 26 amiloride & hydrochlorothiazide 17 amiloride hcl 17 amino acid solutions 26 aminocaproic acid 9 amiodarone hcl 11 amitriptyline hcl 15 amlodipine besylate 11 amoxicillin 2 amoxicillin & potassium clavulanate 2 amoxicillin chewable 2 AMPHADASE 26 amphetamine-dextroamphetamine 13

amphotericin b 3 ampicillin 2 ANADROL-50 23 anagrelide hcl 9 anastrozole 6 ANCOBON 3 ANDRODERM 23 ANDROID 23 ANECTINE 9 ANTHELMINTICS 2 ANTIBACTERIALS 2 ANTI-INFECTIVE AGENTS 2–3, 2, 3, 4, 5 APTIVUS 4 AQUASOL A 30 ARALAST 26 ARISTOSPAN INTRA-ARTICULAR 22 ARISTOSPAN INTRALESIONAL 22 ASMANEX 120 METERED DOSES 22 ASMANEX 60 METERED DOSES 22 atenolol 11 atorvastatin 11 atovaquone-proguanil 4 atracurium besylate 15 ATRIPLA 4 atropine sulfate 8, 20 atropine sulfate (ophthalmic) 20 ATROVENT HFA 8 aug betamethasone dipropionate 29 AVASTIN 6 AVELOX 2–31 AVONEX 26 AZACTAM 2 azathioprine 26 azelastine 19 AZELEX 30 azithromycin 2 aztreonam 2

B

bacitracin 2, 18 bacitracin & polymyxin B 2 bacitracin-polymyxin b (ophth) 18 baclofen 9 BACTERIOSTATIC WATER FOR INJECTION/BENZYL ALCOHOL

INJ BENZ ALC 25 BACTROBAN NASAL 28 balsalazide 20 BARACLUDE 4 BENEFIX 9 BENZAMYCIN PAK GEL PAK 28 benzocaine & antipyrine 20 benzonatate 28 benzoyl peroxide-erythromycin gel 28 benztropine mesylate 8


betamethasone acetate-betamethasone sodium phosphate 22 betamethasone dipropionate (topical) 29 betamethasone valerate 29 betaxolol hcl 19 bethanechol chloride 8 bicalutamide 6 BICILLIN L-A 2 BICNU W/DILUENT ABSOLUTE ETHANOL 6 BILTRICIDE 2 bleomycin sulfate 6 BOTOX 26 BRAVELLE 24 BRILINTA 9 brimonidine tartrate 19 bromocriptine mesylate 26 Budesonide 22 bumetanide 17 bupivacaine hcl 26 bupivacaine w/ epinephrine 26 buprenorphine hcl 12 buprenorphine hcl/naloxone 12 bupropion hcl 15 buproprion hcl (smoking deterrent) 26 buspirone hcl 14 butalbital & acetaminophen 14 butalbital, acetaminophen & caffeine 14 butalbital, aspirin & caffeine 14 butorphanol tartrate 12

C

cabergoline 26 CAFERGOT 14 calcipotriene 30 calcitonin (salmon) 24 calcitriol 31 calcium chloride (dihydrate) 17 calcium gluconate 17 CAMPRAL 15 CANCIDAS 3 captopril 12 carbamazepine 13 carbidopa-levodopa 15 carboplatin 6 carvedilol 11 CATHFLO ACTIVASE 10 CAVERJECT 18 CAYSTON 2 CEENU 6 cefazolin sodium 2 cefdinir 2 cefepime 2 cefotaxime sodium 2 cefotetan 2 ceftazidime 2

ceftriaxone sodium 2 cefuroxime axetil 2 cefuroxime sodium 2 CELLCEPT SUS 26 CELONTIN 13 cephalexin 2 CEREZYME 27 CHANTIX 8 CHEMET 22 chlordiazepoxide 14 chloroquine phosphate 4 chlorothiazide 17 chlorpromazine hcl 15 chlorthalidone 17 cholestyramine 11 choline & mag salicylate 12 chorionic gonadotropin 24 CIALIS 18 ciclopirox olamine 28 cimetidine hcl 21 CIPRODEX 19 ciprofloxacin hcl 2 cisplatin 6 citalopram hydrobromide 15 citric acid/sodium citrate sol 16 clarithromycin 2 CLEOCIN 2 clidinium / chlordiazepoxide 8 clindamycin hcl 2 clindamycin palmitate hydrochloride 2 clindamycin phosphate 2, 28, 29 clindamycin phosphate (topical) 28 clindamycin phosphate vaginal 29 clobetasol propionate 29 clomiphene citrate 24 clomipramine hcl 15 clonazepam 15 clonidine hcl 12 clopidogrel 10 clotrimazole troche 29 clotrimazole w/ betamethasone 29 clozapine 15 codeine phosphate 13 COLCRYS 27 colestipol hcl 11 COLY-MYCIN S OTIC 19 COMBIVENT 9 COMBIVENT RESPIMAT 9 COMPLERA 4 COMTAN 15 COPAXONE 27 CORDRAN TAPE 29 cortisone acetate 22 CORTISPORIN-TC SUS-TC OTIC 19


cosyntropin 26 CREON 21 CRESYLATE 19 CRIXIVAN 4 cromolyn sodium 19, 28 cromolyn sodium (ophth) 19 CUPRIMINE 22 cyanocobalamin 31 cyclobenzaprine hcl 9 CYCLOMYDRIL 20 cyclopentolate hcl 20 cyclophosphamide 6 cyclosporine modified 27 cyproheptadine hcl 6 cytarabine 6 CYTOVENE 4 CYTRA-3 16 CYTRA-K 16

D

dacarbazine 6 dactinomycin 6 danazol 23 dantrolene sodium 9 dapsone 4 DARAPRIM 4 daunorubicin hcl 6 deferoxamine mesylate 22 DEPO-ESTRADIOL 24 DEPO-PROVERA 25 desipramine hcl 16 desmopressin acetate 24 desmopressin acetate refrigerated 24 desmopressin acetate spray 24 desogestrel-ethinyl estradiol 23 desonide 29 dexamethasone 19, 22 dexamethasone sodium phosphate 19, 22 dexamethasone sodium phosphate (ophth) 19 dextroamphetamine sulfate 13 dextrose 10% in water 25 dextrose 5% in lactated ringer’s 25 dextrose 5% in nacl 0.2% 25 dextrose 5% in nacl 0.45% 25 dextrose 5% in nacl 0.9% 25 dextrose 5% in water 25 dextrose high concentration in water 26 DIASTAT ACUDIAL 15 DIASTAT PEDIATRIC 15 diazepam 15 DIBENZYLINE 8 diclofenac sodium (ophth) 19 dicloxacillin sodium 2 dicyclomine hcl 8

didanosine 4 DIFFERIN 30 digoxin 11 dihydroergotamine mesylate 14 diltiazem hcl 11 dimenhydrinate 21 diphenhydramine hcl 6 diphenoxylate w/ atropine 21 dipyridamole 10 disopyramide phosphate 11 disulfiram 27 divalproex sodium 13 divalproex sodium sprinkles 13 docetaxel 6 donepezil hydrochloride 8 dopamine hcl 11 dorzolamide 20 dorzolamide/timolol 20 doxazosin mesylate 10 doxepin hcl 16 doxorubicin hcl 6 doxycycline hyclate 2 doxycycline monohydrate 2 DRITHO-CREAM HP 30 DRITHO-SCALP 30 dronabinol 21 droperidol 14 Drug Name 2–31 DULERA 9 DYRENIUM 17

E

EDECRIN 17 EDEX 18 EDURANT 4 EFFIENT 10 electrolyte concentrate solution 17 ELIPHOS 17 ELMIRON 27 ELSPAR 6 EMCYT 6 EMEND 21 EMTRIVA 4 ENBREL 27 ENBREL SURECLICK 27 ENLON 8 enoxaparin sodium 10 entacapone 15 ephedrine sulfate (pressors) 9 EPIPEN 2-PAK 9 EPIPEN-JR 2-PAK 9 EPIVIR 4 epoprostenol sodium 12 EPZICOM 4


ERBITUX 6 ergocalciferol 31 ergoloid mesylates 8 ERGOMAR 14 erythromycin (acne aid) 29 erythromycin (ophth) 18 erythromycin base 2 erythromycin ethylsuccinate 3 erythromycin lactobionate 3 erythromycin sulfisoxazole 3 estradiol 24 ESTRING 24 estrogens with methyltestosterone 24 estropipate 24 ethambutol hcl 4 ethosuximide 13 ETHYL CHLORIDE/MIST AER MIST 30 ethynodiol diacet & eth estrad 23 etidronate disodium 27 etodolac 13 etoposide 6 EVISTA 24 exemestane 6 EXJADE 22 EXTAVIA 27 EYLEA 20

F

FACTREL 24 famciclovir 5 famotidine 21 famotidine in nacl 21 felbamate 13 FELBATOL 13 fenofibrate 11 fentanyl citrate 13 fentanyl transdermal system 13 FINACEA 30 finasteride 27 FIRAZYR 27 FIRST-TESTOSTERONE 23 flecainide acetate 11 FLOVENT HFA 22 fluconazole 3 fluconazole in nacl 3 fludarabine phosphate 6 fludrocortisone acetate 22 flumazenil 22 flunisolide (nasal) 19 fluocinolone acetonide 29 fluocinonide 29 fluocinonide emulsified base 29 fluorescein sodium 20 fluorescein/proparacaine 20

fluorometholone (ophth) 19 fluorouracil 6, 30 fluorouracil (topical) 30 fluoxetine hcl 16 fluphenazine decanoate 16 fluphenazine hcl 16 flurbiprofen sodium 19 flutamide 6 fluticasone propionate (nasal) 19 FML FORTE SUS 19 FML OINT 19 folic acid 31 fondaparinux 10 FORADIL AEROLIZER 9 FORTAZ 3 foscarnet sodium 5 furosemide 17

G

gabapentin 13 galantamine hydrobromide 8 GAMUNEX-C 28 ganciclovir 5 GELFILM ENVELOPE 27 GELFOAM SPONGE 27 gemfibrozil 11 GEMZAR 6 gentamicin sulfate 3, 18, 29 gentamicin sulfate (ophth) 18 gentamicin sulfate (topical) 29 GLEEVEC 6 glimepiride 23 glipizide 23 GLUCAGON EMERGENCY KIT 23 glycopyrrolate 8 griseofulvin microsize 3 griseofulvin ultramicrosize 3 guaifenesin / codeine 28

H

halobetasol 29 haloperidol 16 haloperidol decanoate 16 haloperidol lactate 16 HEALON GV 20 HELIXATE FS 10 HEMABATE 28 heparin sodium (porcine) 10 HEPSERA 5 HERCEPTIN 7 HEXALEN 7 HUMALOG 23 HUMATE-P 10 HUMIRA 27


HUMULIN 70/30 23 HUMULIN N 23 HUMULIN R 24 HUMULIN R U-500 (CONCENTRATED) 24 hydralazine hcl 12 hydrochlorothiazide 17 hydrocodone / chlorpheniramine 28 hydrocodone / homatropine 28 hydrocodone-acetaminophen 13 hydrocortisone 22, 29 hydrocortisone (intrarectal) 29 hydrocortisone (rectal) 29 hydrocortisone (topical) 29 hydrocortisone butyrate 29 hydrocortisone sod succinate 22 hydromorphone hcl 13 hydroxychloroquine sulfate 4 hydroxyurea 7 hydroxyzine hcl 14

I

ibuprofen 13 idarubicin hcl 7 ifosfamide 7 ifosfamide & mesna 7 imipramine hcl 16 imiquimod 30 INCIVEK 5 INDOCIN IV 13 indomethacin 13 INFED 10 INTELENCE 5 INTRALIPID 26 INTRON-A 7 INTRON-A W/DILUENT 7 INVANZ 3 INVIRASE 5 iodoquinol / hydrocortisone 29 ipratropium bromide 8, 28 ipratropium bromide (nasal) 28 irrigation solution G 26 ISENTRESS 5 isoniazid 4 ISOPTO HOMATROPINE 20 ISOPTO HYOSCINE 20 isosorbide dinitrate 12 isosorbide mononitrate 12 isotretinoin 30

K

KALETRA 5 KENALOG-10 22 KENALOG-40 22 ketamine hcl 27

ketoconazole 4, 29 ketoconazole (topical) 29 ketorolac 13 KINERET 27 KOGENATE FS 10 K-PHOS 17

L

labetalol hcl 11 LACRISERT 20 lactated ringer’s 25, 26 lactated ringer's (irrigation) 17 lactulose 17 lamivudine 5 lamivudine/zidovudine 5 lamotrigine 13 LANTUS 24 latanoprost 20 leflunomide 27 LETAIRIS 28 letrazole 7 leucovorin calcium 27 LEUKERAN 7 leuprolide acetate 7 levetiracetam 14 LEVITRA 18 levobunolol hcl 20 levocarnitine (metabolic modifiers) 27 levofloxacin 3 levonorgestrel & eth estradiol 23 levonorgestrel-eth estradiol (triphasic) 23 levothyroxine sodium 25 LEXIVA 5 LIALDA 21 lidocaine 11, 20, 27, 30 lidocaine hcl 11, 20, 27, 30 lidocaine hcl (cardiac) 11 lidocaine hcl (local anesth.) 27 lidocaine hcl (mouth-throat) 20 lidocaine-prilocaine 30 LINZESS 21 liothyronine sodium 25 LIPOSYN III 26 lisinopril 12 lisinopril & hydrochlorothiazide 12 lithium carbonate 16 LOCOID LIPOCREAM 29 lorazepam 15 losartan 12 losartan & hydrochlorothiazide 12 LOTEMAX 19 lovastatin 11 loxapine succinate 16 LUCENTIS 20


LUPRON DEPOT 7 LUPRON DEPOT-PED 7 LYSODREN 7

M

MACUGEN 20 magnesium sulfate 14 mannitol injection 25 MATULANE 7 MAXAIR AUTOHALER 9 MEBARAL 14 medroxyprogesterone acetate 25 medroxyprogesterone acetate (contraceptive) 25 mefloquine hcl 4 megestrol acetate 7 meloxicam 13 melphalan 7 MENOPUR 24 mephobarbital 14 MEPRON 4 mercaptopurine 7 mesalamine 21 mesna 27 metaproterenol sulfate 9 metformin hcl 24 methadone hcl 13 methazolamide 12 methenamine hippurate 5 methimazole 25 METHITEST 23 methocarbamol 9 methotrexate sodium 7 methyldopa 12 methylergonovine maleate 28 methylphenidate hcl 13 methylphenidate hcl extended 13 methylprednisolone 22 methylprednisolone acetate 22 methylprednisolone sod succ 22 metoclopramide hcl 21 metolazone 17 METOPIRONE 27 metoprolol succinate 11 metoprolol tartrate 11 metronidazole 4, 29 metronidazole (topical) 29 metronidazole vaginal 29 midazolam 15 MIGERGOT 14 minocycline hcl 3 minoxidil 12 mirtazapine 16 misoprostol 21 mitomycin 7

mitoxantrone hcl 7 mometasone furoate 29 MONOCLATE-P 10 montelukast sodium 28 morphine sulfate 13 mupirocin 29 MUSE 18 MUSTARGEN 7 mycophenolate mofetil 27 MYLERAN 7 MYTELASE 8

N

nabumetone 13 nacl 0.45%, ½ normal saline 26 nacl 0.9%, normal saline 26 nacl 3% 26 nacl 5% 26 naloxone hcl 15 naltrexone hcl 15 NAMENDA 15 NAMENDA TITRATION PAK 15 naproxen 13 naratriptan 14 nefazodone hcl 16 neomycin sulfate 3 neomycin-polymycin-dexamethasone 19 neomycin-polymyxin-hydrocortisone (ophth) 19 neomycin-polymyxin-hydrocortisone (otic) 19 neostigmine methylsulfate 8 NEUPOGEN 10 nevirapine 5 NEXAVAR 7 nifedipine 11 nimodipine 11 nitrofurantoin macrocrystal 5 nitrofurantoin monohyd macro 5 nitroglycerin 12 norepinephrine bitartrate 9 norethin acet & estrad-fe 23 norethindrone 23, 25 norethindrone & eth estradiol 23 norethindrone & mestranol 23 norethindrone acet & eth estra 23 norethindrone acetate 25 norethindrone-eth estradiol (triphasic) 23 norgestimate-ethinyl estradiol 23 norgestimate-ethinyl estradiol (triphasic) 23 nortriptyline hcl 16 NORVIR 5 nystatin 4, 18, 29 nystatin-triamcinolone 29


O

octreotide acetate 27 ofloxacin (ophth) 18 ofloxacin (otic) 18 olanzapine 16 omeprazole 21 OMNITROPE 10MG 25 OMNITROPE 5MG 25 ondansetron 21 ondansetron hcl 21 ophthalmic irrigation sol - intraocular 20 ORAP 16 ORENCIA 27 oxazepam 15 oxcarbazepine 14 OXSORALEN ULTRA 30 oxybutynin chloride 30 oxycodone hcl 13 oxycodone w/ acetaminophen 13 oxytocin 28 OXYTROL 30

P

paclitaxel 7 pamidronate disodium 27 PANCRELIPASE 21 pantoprazole 21 para-aminobenzoic acid 30 paregoric 21 paromomycin sulfate 4 paroxetine hcl 16 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 21 PEGASYS 5 penicillin g potassium 3 penicillin g procaine 3 penicillin g sodium 3 penicillin v potassium 3 pentamidine isethionate 4 pentostatin 7 pentoxifylline 10 permethrin 29 perphenazine 16 phenelzine sulfate 16 phenobarbital 14 phentolamine mesylate 9 phenylephrine hcl (ophth) 20 phenylephrine hcl (pressors) 9 phenytoin 14 phenytoin sodium 14 phenytoin sodium extended 14 PHISOHEX 30 PHOSLO 17 PHOSPHOLINE IODIDE 20 PHYSOSTIGMINE SALICYLATE 22

phytonadione 31 pilocarpine hcl 8, 20 pilocarpine hcl (oral) 8 piperacillin-tazobactam 3 podofilox 30 polymyxin b-trimethoprim 18 potassium acetate 17 potassium aminobenzoate 31 potassium chloride 18 potassium chloride microencapsulated crystals cr 18 potassium citrate (alkalinizer) 16 potassium citrate-citric acid 16 potassium iodide 25 potassium phosphate dibasic 18 potassium phosphate dibasic monobasic w/sodium phosphate

monobasic 18 PRADAXA 10 pramipexole dihydrochloride 15 pravastatin sodium 11 prazosin hcl 10 PRED-G 19 prednisolone 19, 22 prednisolone acetate (ophth) 19 prednisolone sodium phosphate (ophth) 19 prednisone 22 PREMARIN INJECTION 24 PREMARIN W/APPLICATOR 24 PREZISTA 5 primaquine phosphate 4 PRIMAXIN 3 primidone 14 PRIMSOL 6 PROAIR 9 probenecid 18 procainamide hcl 11 prochlorperazine 16, 21 prochlorperazine edisylate 16 prochlorperazine maleate 16 PROCRIT 10 PROCTOFOAM-HC 29 PROFILNINE SD 10 progesterone 25 promethazine hcl 6 propafenone hcl 11 propantheline bromide 8 proparacaine hcl 20 propofol 27 propranolol hcl 11 propylthiouracil 25 PROTAMINE SULFATE 10 PROTOPIC 30 PROVOCHOLINE 27 PULMOZYME 18 pyrazinamide 4


pyridostigmine bromide 8 pyridoxine 31

Q

quetiapine fumarate 16 quinidine gluconate 11 quinidine sulfate 11 QVAR 22

R

ranitidine hcl 21 RAPAMUNE 27 REBIF 27 RECOMBINATE 10 REFACTO 10 REMICADE 27 RENVELA 17 RESCRIPTOR 5 reserpine 12 RESTASIS 19 REVLIMID 27 REYATAZ 5 ribavirin 5 RIDAURA 22 rifampin 4 riluzole 15 rimantadine hydrochloride 5 RIMSO-50 27 risperidone 16 RITUXAN 7 rizatriptan 1, 14 rocuronium bromide 15 ropinirole hydrochloride 15

S

salsalate 13 SANDIMMUNE 27 SANTYL 30 SAVELLA 15 SCOPACE 21 selegiline hcl 15 selenium sulfide 29 SELZENTRY 5 SENSIPAR 27 SEREVENT DISKUS 9 sertraline hcl 16 sevoflurane 27 sildenafil citrate (pulmonary hypertention) 12 silver sulfadiazine 29 simvastatin 11 sodium acetate 17 sodium bicarbonate 17, 25 sodium chloride (gu irrigant) 17 sodium chloride (inhalant) 28

sodium chloride 0.9% 26 sodium citrate & citric acid 17 sodium phosphate 18 sodium polystyrene sulfonate 17 sodium sulfacetamide & phenylephrine 18 SOLU-CORTEF 23 sorbitol urologic 3% 26 SORIATANE 26 sotalol hcl 11 SPIRIVA HANDIHALER 8 spironolactone 12 spironolactone & hydrochlorothiazide 12 SPRYCEL 7 stavudine 5 sterile water 25, 26, 28 streptomycin sulfate 3 STRIBILD 5 sucralfate 21 sufentanil citrate 13 sulfacetamide sodium 30 sulfacetamide sod-prednisolone 19 sulfamethoxazole-trimethoprim 3 sulfasalazine 3 sulindac 13 sumatriptan 14 SUPRANE 27 SUPRAX 3 SUSTIVA 5 SUTENT 7 SYNAGIS 5 SYNAREL 24

T

TABLOID 7 tacrolimus 28 TAMIFLU 5 tamoxifen citrate 7 tamsulosin 28 TARCEVA 7 TASIGNA 7 TAZORAC 30 temazepam 15 temozolomide 7 terazosin hcl 10 terbinafine hcl 29 terbutaline sulfate 9 testosterone cypionate 23 TESTRED 23 tetracaine hcl (ophth) 20 tetracycline 3 tetracycline hcl 3 THALOMID 28 theophylline 30 thiamine 31


THIOLA 28 thioridazine hcl 16 thiotepa 7 thiothixene 16 THROMBIN-JMI 10 thyroid 25 TIKOSYN 12 timolol maleate (ophth) 20 TOBI 3 tobramycin sulfate 3, 18 tobramycin sulfate (ophth) 18 tolbutamide 24 topiramate 14 topiramate sprinkle 14 topotecan 7 TORISEL 7 TRACLEER 12 tramadol hcl 13 tranexamic acid 10 TRANSDERM-SCOP 8, 21 tranylcypromine sulfate 16 TRAVASOL 28 trazodone hcl 16 tretinoin 30 TRETINOIN (CHEMOTHERAPY) 7 triamcinolone acetonide 23 triamterene & hydrochlorothiazide 17 triazolam 15 trifluoperazine hcl 16 trifluridine 19 trihexyphenidyl hcl 8 trimethoprim 3, 6 TRIZIVIR 5 TROBICIN 3 tropicamide 20 TRUVADA 5 trypsin, balsam peru & castor oil 30 TYKERB 8

U

urea-hc acetate 29 UROQID #2 6 ursodiol 22

V

VAGIFEM 24 VALCYTE 5

valproate sodium 14 valproic acid 14 VANCOCIN ISO-OSMOTIC DEXTROSE 3 vancomycin hcl 3 vasopressin 24 VECTICAL 30 vecuronium bromide 15 venlafaxine hcl 16 VENOFER 10 VENTAVIS 12 verapamil hcl 11 VIAGRA 18 VICTRELIS 5 VIDAZA 8 vinblastine sulfate 8 vincristine sulfate 8 vinorelbine tartrate 8 VIOKASE 21 VIRACEPT 5 VIREAD 5 VISUDYNE 20 voriconazole 4 VPRIV 28

W

warfarin sodium 10 water for irrigation, sterile 17

X

XELODA 8 XTANDI 8

Z

ZELBORAF 8 ZEMAIRA 28 ZENPEP 21 zidovudine 5 zinc (trace metals) 18 ziprasidone hcl 16 ZOLADEX 8 zolpidem tartrate 14 ZOMETA 28 zonisamide 14 ZYMAXID 19 ZYTIGA 8 ZYVOX 3

Documents

Denver/Boulder, Northern Colorado & Southern Colorado ...€¦ · Kaiser Permanente has many brand name medications on the formulary. In many cases, a generic equivalent is used