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Denver/Boulder & Northern Colorado HMO Denver/Boulder Medicare Retiree Drug Subsidy

Formulary Listing

The following is a listing of the drugs on the Kaiser Permanente formulary for members enrolled in a Denver/Boulder HMO plan and Denver/Boulder Medicare Retiree Drug Subsidy (non-Part D). 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 limits 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 12 doses per prescription for 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, Felbatrol is restricted to Neurology and therefore a prescription for Felbatrol must be written by a neurologist. Drugs with restrictions are noted with a “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: * (asterisk) = A drug where at least one of the dosage forms is an injectable † (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 PA = A drug that requires specific medical criteria be met prior to being dispensed for the patient’s pharmacy benefit QL = A drug that has a quantity limit or is limited to a specific day supply R = A drug that is restricted to a specialist to prescribe RB = A drug that is restricted to certain benefit for coverage

Kaiser Permanente Commercial Formulary – December 2013

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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 Requirements/Limits ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA Brand BILTRICIDE Brand ANTI-INFECTIVE AGENTS ANTIBACTERIALS amoxicillin Generic/Brand † amoxicillin & potassium clavulanate Generic/Brand †

ampicillin Generic * AVELOX Brand * AZACTAM Brand * azithromycin Generic * bacitracin Generic bacitracin & polymyxin B Generic CAYSTON Brand * cefazolin sodium Generic * cefdinir Generic cefepime Generic * cefotaxime sodium Generic/Brand * † cefotetan Generic * CEFTAZIDIME Brand * ceftriaxone sodium Generic * cefuroxime axetil Generic/Brand † cefuroxime sodium Generic * cephalexin Generic CIPRODEX Brand ciprofloxacin hcl Generic/Brand * † clarithromycin Generic CLEOCIN Brand clindamycin hcl Generic/Brand † clindamycin palmitate hydrochloride Generic

clindamycin phosphate Generic/Brand * †

Kaiser Permanente Commercial Formulary – December 2013 - 2 -

Drug Name Drug Tier Requirements/Limits dicloxacillin sodium Generic doxycycline hyclate Generic/Brand * † doxycycline monohydrate Generic erythromycin base Generic/Brand † erythromycin ethylsuccinate Generic/Brand † erythromycin lactobionate Generic/Brand * † erythromycin sulfisoxazole Generic/Brand † FORTAZ Brand * GANTRISIN Brand gentamicin sulfate Generic * INVANZ Brand * levofloxacin Generic* minocycline hcl Generic neomycin sulfate Generic penicillin g potassium Generic * penicillin g procaine Generic * penicillin g sodium Generic * penicillin v potassium Generic piperacillin-tazobactam Generic/Brand * † PRIMAXIN I.M. Brand * streptomycin sulfate Generic * sulfamethoxazole-trimethoprim Generic * sulfasalazine Generic SUPRAX Brand TAZICEF Brand * tetracycline hcl Generic/Brand † TOBI Brand tobramycin sulfate Generic/Brand * † TROBICIN Brand * VANCOCIN ISO- OSMOTIC DEXTROSE Brand *

vancomycin hcl Generic/Brand * ZYVOX Brand * ANTI-INFECTIVE AGENTS ANTIFUNGALS AMBISOME Brand * amphotericin b Generic * ANCOBON Brand CANCIDAS Brand * fluconazole Generic * fluconazole in nacl Generic *


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Drug Name Drug Tier Requirements/Limits griseofulvin microsize Generic/Brand † griseofulvin ultramicrosize Generic ketoconazole Generic nystatin Generic voriconazole Generic/Brand * † ANTI-INFECTIVE AGENTS ANTIMYCOBACTERIALS dapsone Generic ethambutol hcl Generic isoniazid Generic pyrazinamide Generic rifampin Generic * ANTI-INFECTIVE AGENTS ANTIPROTOZOALS atovaquone-proguanil Generic chloroquine phosphate Generic DARAPRIM Brand hydroxychloroquine sulfate Generic mefloquine hcl Generic MEPRON Brand R metronidazole Generic * paromomycin sulfate Generic pentamidine isethionate Generic/Brand * † primaquine phosphate Generic ANTI-INFECTIVE AGENTS ANTIVIRALS abacavir Generic/Brand † acyclovir Generic * amantadine hcl Generic APTIVUS Brand ATRIPLA Brand R BARACLUDE Brand R COMBIVIR Brand COMPLERA Brand CRIXIVAN Brand CYTOVENE Generic/Brand * † didanosine Generic/Brand † EDURANT Brand EMTRIVA Brand EPIVIR Brand EPZICOM Brand


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Drug Name Drug Tier Requirements/Limits famciclovir Generic foscarnet sodium Generic * ganciclovir Generic/Brand * HEPSERA Brand R INCIVEK Brand * R, QL INTELENCE Brand INVIRASE Brand ISENTRESS Brand KALETRA Brand LEXIVA Brand nevirapine Generic/Brand † NORVIR Brand PEGASYS Brand * QL PREZISTA Brand RESCRIPTOR Brand REYATAZ Brand ribavirin Generic rimantadine hydrochloride Generic/Brand † SELZENTRY Brand stavudine Generic STRIBILD Brand SUSTIVA Brand SYNAGIS Brand * TAMIFLU Brand TRIZIVIR Brand TRUVADA Brand VALCYTE Brand VICTRELIS Brand * R, QL VIRACEPT Brand VIREAD Brand zidovudine Generic/Brand † ANTI-INFECTIVE AGENTS URINARY ANTI-INFECTIVES methenamine hippurate Generic nitrofurantoin macrocrystal Generic nitrofurantoin monohyd macro Generic PRIMSOL Brand/Generic trimethoprim Generic ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS cyproheptadine hcl Generic*


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Drug Name Drug Tier Requirements/Limits diphenhydramine hcl Generic * promethazine hcl Generic* ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE Brand * AFINITOR Brand R, QL anastrozole Generic R AVASTIN Brand * R bicalutamdie Generic R BICNU W/DILUENT ABSOLUTE ETHANOL Brand *

bleomycin sulfate Generic * carboplatin Generic * CEENU Brand R cisplatin Generic * cyclophosphamide Generic * cytarabine Generic * dacarbazine Generic * dactinomycin Generic * daunorubicin hcl Generic * docetaxel Generic * doxorubicin hcl Generic * ELSPAR Brand * EMCYT Brand R ERBITUX Brand * R etoposide Generic * R exemestane Generic R FEMARA Brand fludarabine phosphate Generic * fluorouracil Generic/Brand * † flutamide Generic GEMZAR Brand * GLEEVEC Brand R, QL HERCEPTIN Brand * HEXALEN Brand R hydroxyurea Generic idarubicin hcl Generic * ifosfamide Generic * ifosfamide & mesna Generic * INTRON-A Brand * R, QL INTRON-A W/DILUENT Brand * R, QL


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Drug Name Drug Tier Requirements/Limits LEUKERAN Brand R leuprolide acetate Generic/Brand * † LUPRON DEPOT Brand * LUPRON DEPOT-PED Brand * MATULANE Brand R megestrol acetate Generic melphalan Generic/Brand * † mercaptopurine Generic R methotrexate sodium Generic * mitomycin Generic * mitoxantrone hcl Generic * MUSTARGEN Brand * MYLERAN Brand R NEXAVAR Brand R, QL paclitaxel Generic * pentostatin Generic * RITUXAN Brand * SPRYCEL Brand R, QL SUTENT Brand R, QL TABLOID Brand R tamoxifen citrate Generic TARCEVA Brand R, QL TASIGNA Brand R, QL TEMODAR Brand R thiotepa Generic * topotecan Generic * TORISEL Brand * tretinoin Generic R TYKERB Brand R VIDAZA Brand * R vinblastine sulfate Generic * vincristine sulfate Generic * vinorelbine tartrate Generic * XELODA Brand R XTANDI Brand R ZELBORAF Brand R, QL ZOLADEX Brand * ZYTIGA Brand * QL AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS atropine sulfate Generic *


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Drug Name Drug Tier Requirements/Limits ATROVENT HFA Brand benztropine mesylate Generic * clidinium / chlordiazepoxide Generic dicyclomine hcl Generic/Brand * † glycopyrrolate Generic * ipratropium bromide Generic propantheline bromide Generic scopolamine hydrobromide Generic/Brand * † SPIRIVA HANDIHALER Brand trihexyphenidyl hcl Generic AUTONOMIC DRUGS AUTONOMIC DRUGS, MISCELLANEOUS DIBENZYLINE Brand AUTONOMIC DRUGS PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride Generic donepezil hydrochloride Generic ENLON Brand * galantamine hydrobromide Generic MYTELASE Brand neostigmine methylsulfate Generic * pilocarpine hcl (oral) Generic/Brand † pyridostigmine bromide Generic/Brand † AUTONOMIC DRUGS SKELETAL MUSCLE RELAXANTS ANECTINE Brand * baclofen Generic cyclobenzaprine hcl Generic dantrolene sodium Generic/Brand * † methocarbamol Generic/Brand * † AUTONOMIC DRUGS SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS phentolamine mesylate Generic * AUTONOMIC DRUGS SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR DISKUS Brand albuterol Generic albuterol sulfate Generic COMBIVENT Brand COMBIVENT RESPIMAT Brand DULERA Brand


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Drug Name Drug Tier Requirements/Limits ephedrine sulfate (pressors) Generic * EPIPEN 2-PAK Brand * EPIPEN-JR 2-PAK Brand * FORADIL AEROLIZER Brand MAXAIR AUTOHALER Brand metaproterenol sulfate Generic phenylephrine hcl (pressors) Generic * SEREVENT DISKUS Brand terbutaline sulfate Generic * BLOOD FORMATION, COAGULATION, AND THROMBOSIS COAGULANTS AND ANTICOAGULANTS ABBOKINASE Brand * ACTIVASE Brand * AGGRENOX Brand aminocaproic acid Generic * anagrelide hcl Generic clopidogrel Generic dipyridamole Generic fondaparinux Generic * BRILINTA Brand enoxaparin sodium Generic * EFFIENT Brand heparin sodium (porcine) Generic * pentoxifylline Generic warfarin sodium Generic BLOOD FORMATION, COAGULATION AND THROMBOSIS HEMATOPOIETIC AGENTS NEUPOGEN Brand * R, QL PROCRIT Brand * QL BLOOD FORMATION, COAGULATION AND THROMBOSIS HEMOSTATICS HELIXATE FS Brand * HUMATE-P Brand * KOGENATE FS Brand * RECOMBINATE Brand * REFACTO Brand * BLOOD FORMATION, COAGULATION AND THROMBOSIS IRON PREPARATIONS DEXFERRUM Brand * INFED Brand * VENOFER Brand *


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Drug Name Drug Tier Requirements/Limits CARDIOVASCULAR DRUGS ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate Generic prazosin hcl Generic terazosin hcl Generic CARDIOVASCULAR DRUGS ANTILIPEMIC AGENTS cholestyramine Generic colestipol hcl Generic fenofibrate Generic gemfibrozil Generic LIPITOR Brand lovastatin Generic pravastatin sodium Generic simvastatin Generic CARDIOVASCULAR DRUGS BETA-ADRENERGIC BLOCKING AGENTS acebutolol Generic atenolol Generic/Brand * † carvedilol Generic labetalol hcl Generic * metoprolol succinate Generic metoprolol tartrate Generic * propranolol hcl Generic * sotalol hcl Generic CARDIOVASCULAR DRUGS CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besylate Generic diltiazem hcl Generic * nifedipine Generic nimodipine Generic verapamil hcl Generic * CARDIOVASCULAR DRUGS CARDIAC DRUGS amiodarone hcl Generic * digoxin Generic * disopyramide phosphate Generic/Brand † dopamine hcl Generic * flecainide acetate Generic lidocaine hcl (cardiac) Generic * procainamide hcl Generic *


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Drug Name Drug Tier Requirements/Limits propafenone hcl Generic quinidine gluconate Generic quinidine sulfate Generic TIKOSYN Brand R CARDIOVASCULAR DRUGS HYPOTENSIVE AGENTS acetazolamide Generic* clonidine hcl Generic hydralazine hcl Generic methazolamide Generic methyldopa Generic minoxidil Generic reserpine Generic CARDIOVASCULAR DRUGS RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS captopril Generic lisinopril Generic lisinopril & hydrochlorothiazide Generic losartan Generic losartan & hydrochlorothiazide Generic spironolactone Generic spironolactone & hydrochlorothiazide Generic

CARDIOVASCULAR DRUGS VASODILATING AGENTS ADCIRCA Brand R epoprostenol sodium Generic * isosorbide dinitrate Generic/Brand † isosorbide mononitrate Generic nitroglycerin Generic/Brand * † sildenafil citrate (pulmonary hypertention) Generic R

TRACLEER Brand R VENTAVIS Brand R CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS acetaminophen w/ codeine Generic butorphanol tartrate Generic * choline & mag salicylate Generic codeine phosphate Generic etodolac Generic


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Drug Name Drug Tier Requirements/Limits fentanyl transdermal system Generic fentanyl citrate Generic * flurbiprofen Generic hydrocodone-acetaminophen Generic hydromorphone hcl Generic * ibuprofen Generic * INDOCIN IV Brand * indomethacin Generic/Brand † ketorolac Generic * meloxicam Generic methadone hcl Generic morphine sulfate Generic/Brand * † nabumetone Generic naproxen Generic oxycodone hcl Generic oxycodone w/ acetaminophen Generic/Brand † salsalate Generic * SUBOXONE Brand R sufentanil citrate Generic * R sulindac Generic tramadol hcl Generic CENTRAL NERVOUS SYSTEM AGENTS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS amphetamine-dextroamphetamine Generic/Brand † dextroamphetamine sulfate Generic methylphenidate hcl Generic methylphenidate hcl extended Generic CENTRAL NERVOUS SYSTEM AGENTS ANTICONVULSANTS carbamazepine Generic/Brand † CELONTIN Brand divalproex sodium Generic divalproex sodium sprinkles Generic ethosuximide Generic FELBATOL Brand R felbamate Generic/Brand † gabapentin Generic lamotrigine Generic R levetiracetam Generic magnesium sulfate Generic *


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Drug Name Drug Tier Requirements/Limits MEBARAL Brand oxcarbazepine Generic † R phenobarbital Generic * phenytoin Generic/Brand † phenytoin sodium Generic * phenytoin sodium extended Generic primidone Generic topiramate Generic topiramate sprinkle Generic valproate sodium Generic * valproic acid Generic/Brand † zonisamide Generic R CENTRAL NERVOUS SYSTEM AGENTS ANTIMIGRAINE AGENTS butalbital & acetaminophen Generic butalbital, acetaminophen & caffeine Generic

butalbital, aspirin & caffeine Generic CAFERGOT Brand QL dihydroergotamine mesylate Generic/Brand * † ERGOMAR Brand QL naratriptan Generic* QL rizatriptan Generic* QL sumatriptan Generic* QL CENTRAL NERVOUS SYSTEM AGENTS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS buspirone hcl Generic droperidol Generic * R hydroxyzine hcl Generic * zolpidem tartrate Generic CENTRAL NERVOUS SYSTEM AGENTS BENZODIAZEPINES alprazolam Generic chlordiazepoxide Generic clonazepam Generic DIASTAT ACUDIAL Brand DIASTAT PEDIATRIC Brand diazepam Generic/Brand * † lorazepam Generic * midazolam Generic * oxazepam Generic/Brand †


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Drug Name Drug Tier Requirements/Limits temazepam Generic triazolam Generic CENTRAL NERVOUS SYSTEM AGENTS CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS CAMPRAL Brand R carbidopa-levodopa Generic * COMTAN Brand NAMENDA Brand NAMENDA TITRATION PAK Brand pramipexole dihydrochloride Generic RILUTEK Brand ropinirole hydrochloride Generic selegiline hcl Generic R CENTRAL NERVOUS SYSTEM AGENTS OPIATE ANTAGONISTS naloxone hcl Generic * naltrexone hcl Generic R CENTRAL NERVOUS SYSTEM AGENTS PSYCHOTHERAPEUTIC AGENTS ABILIFY Brand amitriptyline hcl Generic bupropion hcl Generic chlorpromazine hcl Generic * citalopram hydrobromide Generic clomipramine hcl Generic clozapine Generic R desipramine hcl Generic doxepin hcl Generic fluoxetine hcl Generic fluphenazine decanoate Generic * fluphenazine hcl Generic * GEODON Brand haloperidol Generic haloperidol decanoate Generic * haloperidol lactate Generic * imipramine hcl Generic lithium carbonate Generic lithium citrate Generic loxapine succinate Generic mirtazapine Generic nefazodone hcl Generic


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Drug Name Drug Tier Requirements/Limits nortriptyline hcl Generic ORAP Brand paroxetine hcl Generic perphenazine Generic phenelzine sulfate Generic prochlorperazine edisylate Generic * prochlorperazine maleate Generic risperidone Generic/Brand † SEROQUEL Brand sertraline hcl Generic thioridazine hcl Generic thiothixene Generic tranylcypromine sulfate Generic trazodone hcl Generic trifluoperazine hcl Generic venlafaxine hcl Generic ZYPREXA Brand ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS citric acid monohydrate Generic potassium citrate (alkalinizer) Generic potassium citrate-citric acid Generic sodium acetate Generic * sodium bicarbonate Generic * sodium citrate & citric acid Generic ELECTROLYTIC, CALORIC, AND WATER BALANCE AMMONIA DETOXICANTS lactulose Generic ELECTROLYTIC, CALORIC, AND WATER BALANCE DIURETICS amiloride & hydrochlorothiazide Generic amiloride hcl Generic bumetanide Generic chlorothiazide Generic chlorthalidone Generic DYRENIUM Brand EDECRIN Brand * furosemide Generic * hydrochlorothiazide Generic metolazone Generic SODIUM EDECRIN Brand *


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Drug Name Drug Tier Requirements/Limits triamterene & hydrochlorothiazide Generic

ELECTROLYTIC, CALORIC, AND WATER BALANCE ION-REMOVING AGENTS RENAGEL Brand RENVELA Brand sodium polystyrene sulfonate Generic ELECTROLYTIC, CALORIC, AND WATER BALANCE IRRIGATING SOLUTIONS acetic acid Generic lactated ringer's (irrigation) Generic* ringer's irrigation Generic* sodium chloride (gu irrigant) Generic* water for irrigation, sterile Generic* ELECTROLYTIC, CALORIC, AND WATER BALANCE REPLACEMENT PREPARATIONS calcium chloride (dihydrate) Generic* calcium gluconate Generic* electrolyte concentrate solution Generic* ELIPHOS Brand K-PHOS Brand * PHOSLO Brand potassium phosphate dibasic monobasic w/sodium phosphate monobasic

Generic *

potassium acetate Generic * potassium chloride Generic/Brand * † potassium chloride microencapsulated crystals cr Generic

potassium phosphate dibasic Generic * sodium phosphate Generic* zinc (trace metals) Generic * ELECTROLYTIC, CALORIC, AND WATER BALANCE URICOSURIC AGENTS probenecid Generic ENZYMES ENZYMES ADAGEN Brand * PULMOZYME Brand ERECTILE DYSFUNCTION PHOSPHODIESTERACE-5 ENZYME INHIBITOR


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Drug Name Drug Tier Requirements/Limits CIALIS Brand RB LEVITRA Brand RB ERECTILE DYSFUNCTION PROSTAGLANDIN VASODILATORS alprostadil Generic/Brand * † RB EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES bacitracin-polymyxin b (ophth) Generic erythromycin (ophth) Generic gentamicin sulfate (ophth) Generic ofloxacin (ophth) Generic ofloxacin (otic) Generic polymyxin b-trimethoprim Generic sodium sulfacetamide & phenylephrine Generic

tobramycin sulfate (ophth) Generic/Brand † trifluridine Generic R ZYMAXID Brand EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFLAMMATORY AGENTS CIPRODEX Brand COLY-MYCIN S OTIC Brand dexamethasone sodium phosphate (ophth) Generic/Brand †

flunisolide (nasal) Generic fluorometholone (ophth) Generic/Brand † flurbiprofen sodium Generic fluticasone propionate (nasal) Generic LOTEMAX Brand MAXIDEX Brand neomycin-polymycin- dexamethasone Generic

neomycin-polymyxin- hydrocortisone (ophth) Generic

neomycin-polymyxin- hydrocortisone (otic) Generic

PRED-G Brand prednisolone acetate (ophth) Generic prednisolone sodium phosphate (ophth) Generic

RESTASIS Brand †


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Drug Name Drug Tier Requirements/Limits sulfacetamide sod-prednisolone Generic/Brand † VOLTAREN Brand EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTIALLERGIC AGENTS azelastine Generic cromolyn sodium (ophth) Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS EENT DRUGS, MISCELLANEOUS acetic acid (otic) Generic acetic acid-aluminum acetate Generic betaxolol hcl Generic brimonidine tartrate Generic CRESYLATE Brand dorzolamide Generic dorzolamide/timolol Generic EYLEA Brand* latanoprost Generic levobunolol hcl Generic LACRISERT Brand LUCENTIS Brand* MACUGEN Brand * PHOSPHOLINE IODIDE Brand pilocarpine hcl Generic/Brand † timolol maleate (ophth) Generic VISUDYNE Brand * EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS LOCAL ANESTHETICS benzocaine & antipyrine Generic lidocaine hcl (mouth-throat) Generic proparacaine hcl Generic tetracaine hcl (ophth) Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS MYDRIATICS atropine sulfate (ophthalmic) Generic CYCLOMYDRIL Brand cyclopentolate hcl Generic homatropine hbr Generic/Brand † ISOPTO HYOSCINE Brand tropicamide Generic EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS VASOCONSTRICTORS


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Drug Name Drug Tier Requirements/Limits ADRENALIN Brand * phenylephrine hcl (ophth) Generic GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS balsalazide Generic mesalamine Generic/Brand † GASTROINTESTINAL DRUGS ANTIDIARRHEA AGENTS diphenoxylate w/ atropine Generic paregoric Generic GASTROINTESTINAL DRUGS ANTIEMETICS dimenhydrinate Generic * dronabinol Generic EMEND Brand ondansetron Generic * ondansetron hcl Generic * prochlorperazine Generic * SCOPACE Brand TRANSDERM-SCOP Brand GASTROINTESTINAL DRUGS ANTIULCER AGENTS AND ACID SUPPRESSANTS cimetidine hcl Generic famotidine Generic * famotidine in nacl Generic * misoprostol Generic omeprazole Generic pantoprazole Generic ranitidine hcl Generic * sucralfate Generic GASTROINTESTINAL DRUGS DIGESTANTS CREON Brand PANCRELIPASE Brand ZENPEP Brand GASTROINTESTINAL DRUGS GI DRUGS, MISCELLANEOUS metoclopramide hcl Generic * peg 3350-kcl-sod bicarb-sod chloride-sod sulfate Generic

ursodiol Generic/Brand †


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Drug Name Drug Tier Requirements/Limits GOLD COMPOUNDS GOLD COMPOUNDS MYOCHRYSINE Brand * RIDAURA Brand HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET Brand CUPRIMINE Brand deferoxamine mesylate Generic * EXJADE Brand R pysostigmine salicylate Generic * HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ARISTOSPAN INTRA- ARTICULAR Brand *

ARISTOSPAN INTRALESIONAL Brand *

ASMANEX 120 METERED DOSES Brand

ASMANEX 60 METERED DOSES Brand

betamethasone acetate- betamethasone sodium phosphate Generic *

Budesonide Respules Generic cortisone acetate Generic dexamethasone Generic/Brand * † dexamethasone sodium phosphate Generic * ENTOCORT EC Brand FLOVENT HFA Brand fludrocortisone acetate Generic hydrocortisone Generic/Brand * † KENALOG-10 Brand * KENALOG-40 Brand * methylprednisolone Generic * methylprednisolone acetate Generic * methylprednisolone sod succ Generic * prednisolone Generic prednisone Generic QVAR Brand SOLU-CORTEF Brand * HORMONES AND SYNTHETIC SUBSTITUTES


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Drug Name Drug Tier Requirements/Limits ANDROGENS ANDRODERM Brand danazol Generic FIRST-TESTOSTERONE Brand * METHITEST Brand TESTOSTERONE Brand * testosterone cypionate Generic * TESTRED Brand HORMONES AND SYNTHETIC SUBSTITUTES CONTRACEPTIVES desogestrel-ethinyl estradiol Generic ethynodiol diacet & eth estrad Generic levonorgestrel & eth estradiol Generic levonorgestrel-eth estradiol (triphasic) Generic

norethindrone Generic norethin acet & estrad-fe Generic norethindrone & mestranol Generic/Brand † norethindrone & eth estradiol Generic/Brand † norethindrone acet & eth estra Generic norethindrone-eth estradiol (triphasic) Generic/Brand †

norgestimate-ethinyl estradiol Generic norgestimate-ethinyl estradiol (triphasic) Generic

HORMONES AND SYNTHETIC SUBSTITUTES DIABETIC AGENTS acarbose Generic glimepiride Generic glipizide Generic GLUCAGON EMERGENCY KIT Brand *

HUMALOG Brand * humulin 70/30 Generic * humulin n Generic * humulin r Generic * HUMULIN R U-500 (CONCENTRATED) Brand *

LANTUS Brand * PA metformin hcl Generic/Brand † tolbutamide Generic


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Drug Name Drug Tier Requirements/Limits HORMONES AND SYNTHETIC SUBSTITUTES ESTROGENS AND ANTIESTROGENS clomiphene citrate Generic RB DEPO-ESTRADIOL Brand * estradiol Generic/Brand * † estrogens with methyltestosterone Generic ESTRING Brand estropipate Generic EVISTA Brand NEXPLANON Brand * R PREMARIN INJECTION Brand * PREMARIN W/APPLICATOR Brand VAGIFEM Brand HORMONES AND SYNTHETIC SUBSTITUTES FOLLICLE STIMULATING HORMONES / LUTENIZING HORMONES BRAVELLE Brand * RB MENOPUR Brand * RB HORMONES AND SYNTHETIC SUBSTITUTES GONADOTROPINS chorionic gonadotropin Generic * RB FACTREL Brand * SYNAREL Brand HORMONES AND SYNTHETIC SUBSTITUTES PARATHYROID calcitonin (salmon) Generic/Brand * † HORMONES AND SYNTHETIC SUBSTITUTES PITUITARY ACTHAR HP Brand * PA desmopressin acetate Generic desmopressin acetate refrigerated Generic desmopressin acetate spray Generic desmopressin acetate spray refrigerated Generic

vasopressin Generic * HORMONES AND SYNTHETIC SUBSTITUTES PROGESTINS DEPO-PROVERA Brand * medroxyprogesterone acetate Generic * medroxyprogesterone acetate (contraceptive) Generic/Brand * †

norethindrone acetate Generic


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Drug Name Drug Tier Requirements/Limits progesterone Generic HORMONES AND SYNTHETIC SUBSTITUTES SOMATOTROPIN AGONISTS AND ANTAGONISTS OMNITROPE PREFILLED CARTRIDGE Brand PA

HORMONES AND SYNTHETIC SUBSTITUTES THYROID AND ANTITHYROID AGENTS levothyroxine sodium Generic liothyronine sodium Generic methimazole Generic potassium iodide Generic propylthiouracil Generic thyroid Generic INTRAVENOUS SOLUTIONS DEXTROSE dextrose 5% in water Generic * dextrose 5% in nacl 0.2% Generic * dextrose 5% in nacl 0.45% Generic * dextrose 5% in nacl 0.9% Generic * dextrose 10% in water Generic * dextrose 5% in lactated ringer’s Generic * INTRAVENOUS SOLUTIONS MISCELLANEOUS sterile water Generic * ringer’s injection Generic * lactated ringer’s Generic * sodium bicarbonate Generic * mannitol injection Generic * INTRAVENOUS SOLUTIONS NUTRITIONAL PRODUCTS amino acid solutions Generic * dextrose high concentration in water Generic *

INTRALIPID Brand * LIPOSYN III Brand * INTRAVENOUS SOLUTIONS SODIUM CHLORIDE (NACL, SALINE) nacl 0.45%, ½ normal saline Generic * nacl 0.9%, normal saline Generic * nacl 3% Generic * nacl 5% Generic *


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Drug Name Drug Tier Requirements/Limits IRRIGATION SOLUTIONS IRRIGATION SOLUTIONS sterile water Generic * sodium chloride 0.9% Generic * lactated ringer’s Generic * ringer’s irrigation Generic * acetic acid 0.25% Generic irrigation solution G Generic glycine 1.5% Generic sorbitol urologic 3% Generic * MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine Generic alendronate sodium Generic/Brand † allopurinol Generic ARALAST Brand * AVONEX Brand * R, QL azathioprine Generic BOTOX Brand * bromocriptine mesylate Generic bupivacaine hcl Generic * bupivacaine w/ epinephrine Generic* cabergoline Generic CEREZYME Brand * COLCRYS Brand COPAXONE Brand * R, QL cyclosporine modified Generic DIDRONEL Brand disulfiram Generic/Brand † ELMIRON Brand ENBREL Brand * R, QL ENBREL SURECLICK Brand * R, QL ETHYOL Brand * EXTAVIA Generic R, QL finasteride Generic FIRAZYR Brand * R, QL HUMIRA Brand * R, QL ketamine hcl Generic * KINERET Brand * R, QL leflunomide Generic R leucovorin calcium Generic *


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Drug Name Drug Tier Requirements/Limits levocarnitine (metabolic modifiers) Generic *

lidocaine hcl (local anesth.) Generic * mesna Generic * mycophenolate mofetil Generic/Brand † OCTREOTIDE ACETATE Brand/Generic * ORENCIA Brand * R pamidronate disodium Generic * RAPAMUNE Brand REBIF Brand * R, QL REMICADE Brand * R REVLIMID Brand R, QL RIMSO-50 Brand * SANDIMMUNE Brand SENSIPAR Brand SORIATANE Brand R tacrolimus Generic/Brand * † tamsulosin Generic THALOMID Brand R THIOLA Brand VPRIV Brand * ZEMAIRA Brand * ZOMETA Brand * OXYTOCICS OXYTOCICS methylergonovine maleate Generic * HEMABATE Brand * oxytocin Generic * RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS cromolyn sodium Generic/Brand † montelukast sodium Generic RESPIRATORY TRACT AGENTS RESPIRATORY AGENTS, MISCELLANEOUS acetylcysteine Generic benzonatate Generic guaifenesin / codeine Generic hydrocodone / chlorpheniramine Generic hydrocodone / homatropine Generic ipratropium bromide (nasal) Generic LETAIRIS Brand R


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Drug Name Drug Tier Requirements/Limits sodium chloride (inhalant) Generic sterile water Generic SERUMS, TOXOIDS, AND VACCINES SERUMS GAMUNEX-C Brand * HYPERRHO S/D Brand * HYPERTET S/D Brand * immune globulin (human) iv Brand * IMOGAM RABIES-HT Brand * NABI-HB Brand * RESPIGAM Brand * VARIZIG Brand * RHOPHYLAC Brand * SERUMS, TOXOIDS, AND VACCINES TOXOIDS ADACEL Brand * DECAVAC Brand * DIPTHERIA/TETANUS TOXOID PEDIATRIC Brand *

INFANRIX Brand * SERUMS, TOXOIDS, AND VACCINES VACCINES ACTHIB Brand * ATTENUVAX Brand * GARDASIL Brand * HAVRIX Brand * HIBERIX Brand * IMOVAX RABIES (H.D.C.V.) Brand * IPOL INACTIVATED IPV Brand * MENACTRA Brand * MENOMUNE-A/C/Y/W-135 Brand * MERUVAX II W/DILUENT 10 DOSE Brand *

MUMPSVAX W/DILUENT 10 DOSE Brand *

PEDIARIX Brand * PEDVAX HIB Brand * PREVNAR 13 Brand * PROQUAD Brand * RABAVERT Brand * RECOMBIVAX HB Brand *


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Drug Name Drug Tier Requirements/Limits ROTARIX Brand * ROTATEQ Brand * THERACYS Brand * TICE BCG Brand * VAQTA Brand * VARIVAX Brand * ZOSTAVAX Brand * SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) BACTROBAN NASAL Brand benzoyl peroxide-erythromycin gel Generic

ciclopirox olamine Generic clindamycin phosphate (topical) Generic/Brand † clindamycin phosphate vaginal Generic/Brand † clotrimazole troche Generic erythromycin (acne aid) Generic/Brand † gentamicin sulfate (topical) Generic iodoquinol / hydrocortisone Generic ketoconazole (topical) Generic metronidazole (topical) Generic metronidazole vaginal Generic mupirocin Generic/Brand † nystatin Brand permethrin Generic selenium sulfide Generic silver sulfadiazine Generic terbinafine hcl Generic SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) alclometasone dipropionate Generic ANALPRAM-HC Brand aug betamethasone dipropionate Generic betamethasone dipropionate (topical) Generic

betamethasone valerate Generic CARMOL-HC Brand clotrimazole-betamethasone Generic clobetasol propionate Generic CORDRAN TAPE Brand desonide Generic


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Drug Name Drug Tier Requirements/Limits fluocinolone acetonide Generic fluocinonide Generic fluocinonide emulsified base Generic halobetasol Generic hydrocortisone (intrarectal) Generic hydrocortisone (rectal) Generic/Brand † hydrocortisone (topical) Generic/Brand † hydrocortisone butyrate Generic/ Brand † LOCOID LIPOCREAM Brand mometasone furoate Generic nystatin-triamcinolone Generic PROCTOFOAM-HC Brand SKIN AND MUCOUS MEMBRANE AGENTS CELL STIMULANTS AND PROLIFERANTS tretinoin Generic R SKIN AND MUCOUS MEMBRANE AGENTS SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS 8-MOP CAPSULE Brand aluminum chloride Generic/Brand † AZELEX Brand R calcipotriene Generic DIFFERIN Brand DRITHO-SCALP Brand FINACEA Brand fluorouracil (topical) Generic/Brand † imiquimod Generic R isotretinoin Generic R lidocaine Generic/Brand † lidocaine hcl Generic* lidocaine-prilocaine Generic OXSORALEN ULTRA Brand para-aminobenzoic acid Generic PHISOHEX Brand podofilox Generic/Brand † PROTOPIC Brand R PSORIATEC Brand SANTYL Brand sulfacetamide sodium Generic TAZORAC Brand R trypsin, balsam peru & castor oil Generic


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Drug Name Drug Tier Requirements/Limits VECTICAL Brand XERAC AC Brand SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS oxybutynin chloride Generic/Brand † OXYTROL Brand theophylline Generic/Brand † VITAMINS VITAMINS AQUASOL A Brand * calcitriol Generic cyanocobalamin Generic * DRISDOL Brand folic acid Generic * phytonadione Generic * pyridoxine Generic * thiamine Generic * INDEX OF DRUGS Kaiser Permanente Commercial Comprehensive Formulary Index

8 8-MOP 28

A ABBOKINASE 9 ABILIFY 14 ABRAXANE 6 acarbose 21 acebutolol 10 ACETADOTE 24 acetaminophen w/ codeine 11 acetazolamide 11 acetic acid 16, 18 acetic acid (otic) 18 acetic acid 0.25% 24 acetic acid-aluminum acetate 18 acetylcysteine 25 ACTHAR HP 22 ACTHIB 26 ACTIVASE 9 acyclovir 4 ADACEL 26 ADAGEN 16 ADCIRCA 11 ADRENALIN 19

ADVAIR DISKUS 8 AFINITOR 6 AGGRENOX 9 ALBENZA 2 albuterol 8 albuterol sulfate 8 alclometasone dipropionate 27 alendronate sodium 24 allopurinol 24 alprazolam 13 alprostadil 17 aluminum chloride 28 amantadine hcl 4 AMBISOME 3 amiloride & hydrochlorothiazide 15 amiloride hcl 15 amino acid solutions 23 aminocaproic acid 9 amiodarone hcl 10 amitriptyline hcl 14 amlodipine besylate 10 amoxicillin 2 amoxicillin & potassium clavulanate 2 amphetamine-dextroamphetamine 12 amphotericin b 3 ampicillin 2 anagrelide hcl 9 ANALPRAM-HC 27


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anastrozole 6 ANCOBON 3 ANDRODERM 21 ANECTINE 8 APTIVUS 4 AQUASOL A 29 ARALAST 24 ARISTOSPAN INTRA-ARTICULAR 20 ARISTOSPAN INTRALESIONAL 20 ASMANEX 120 METERED DOSES 20 ASMANEX 60 METERED DOSES 20 atenolol 10 atovaquone-proguanil 4 ATRIPLA 4 atropine sulfate 7, 18 atropine sulfate (ophthalmic) 18 ATROVENT HFA 8 ATTENUVAX 26 aug betamethasone dipropionate 27 avacavir 4 AVASTIN 6 AVELOX 2 AVONEX 24 AZACTAM 2 azathioprine 24 azelastine 18 azelastine 18 AZELEX 28 azithromycin 2

B bacitracin 2, 17 bacitracin & polymyxin B 2 bacitracin-polymyxin b (ophth) 17 baclofen 8 BACTROBAN 27 BACTROBAN NASAL 27 balsalazide 19 BARACLUDE 4 benzocaine & antipyrine 18 benzonatate 25 benzoyl peroxide-erythromycin 27 benztropine mesylate 8 betamethasone acetate 20 betamethasone dipropionate (topical) 27 betamethasone sodium phosphate 20 betamethasone valerate 27 betaxolol hcl 18 bethanechol chloride 8 bicalutamide 6 BICNU W/DILUENT ABSOLUTE ETHANOL 6 BILTRICIDE 2 bleomycin sulfate 6 BOTOX 24 BRAVELLE 22 BRILINTA 9 brimonidine tartrate 18

bromocriptine mesylate 24 budesonide respules 20 bumetanide 15 bupivacaine hcl 24 bupivacaine w/ epinephrine 24 bupropion hcl 14 buspirone hcl 13 butalbital & acetaminophen 13 butalbital, acetaminophen & caffeine 13 butalbital, aspirin & caffeine 13 butorphanol tartrate 11

C cabergoline 24 CAFERGOT 13 calcipotriene 28 calcitonin (salmon) 22 calcitriol 29 calcium chloride (dihydrate) 16 calcium gluconate 16 CAMPRAL 14 CANCIDAS 3 captopril 11 carbamazepine 12 carbidopa-levodopa 14 carboplatin 6 CARMOL-HC 27 carvedilol 10 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 CELONTIN 12 cephalexin 2 CEREZYME 24 CHEMET 20 chlordiazepoxide 13 chloroquine phosphate 4 chlorothiazide 15 chlorpromazine hcl 14 chlorthalidone 15 cholestyramine 10 choline & mag salicylate 11 chorionic gonadotropin 22 CIALIS 17 ciclopirox olamine 27 cimetidine hcl 19 CIPRODEX 2, 17 ciprofloxacin hcl 2 cisplatin 6


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citalopram hydrobromide 14 citric acid monohydrate 15 clarithromycin 2 CLEOCIN 2 clidinium / chlordiazepoxide 8 clindamycin hcl 2 clindamycin palmitate hydrochloride 2 clindamycin phosphate 2, 27 clindamycin phosphate (topical) 27 clindamycin phosphate vaginal 27 clobetasol propionate 27 clomiphene citrate 22 clomipramine hcl 14 clonazepam 13 clonidine hcl 11 clopidogrel 9 clotrimazole 27 clotrimazole-betamethasone 27 clozapine 14 codeine phosphate 11 COLCRYS 24 colestipol hcl 10 COLY-MYCIN S OTIC 17 COMBIVENT 8 COMBIVENT RESPIMAT 8 COMBIVIR 4 COMPLERA 4 COMTAN 14 COPAXONE 24 CORDRAN 27 CORDRAN TAPE 27 cortisone acetate 20 CREON 19 CRESYLATE 18 CRIXIVAN 4 cromolyn sodium 18, 25 cromolyn sodium (ophth) 18 CUPRIMINE 20 cyanocobalamin 29 cyclobenzaprine hcl 8 CYCLOMYDRIL 18 cyclopentolate hcl 18 cyclophosphamide 6 cyclosporine modified 24 cyproheptadine hcl 5 cytarabine 6 CYTOVENE 4

D dacarbazine 6 dactinomycin 6 danazol 21 dantrolene sodium 8 dapsone 4 DARAPRIM 4 daunorubicin hcl 6 DECAVAC 26

deferoxamine mesylate 20 DEPO-ESTRADIOL 22 DEPO-PROVERA 22 desipramine hcl 14 desmopressin acetate 22 desmopressin acetate refrigerated 22 desmopressin acetate spray 22 desmopressin acetate spray refrigerated 22 desogestrel-ethinyl estradiol 21 desonide 27 dexamethasone 17, 20 dexamethasone sodium phosphate 17, 20 dexamethasone sodium phosphate (ophth) 17 DEXFERRUM 9 dextroamphetamine sulfate 12 dextrose 10% in water 23 dextrose 5% in lactated ringer’s 23 dextrose 5% in nacl 0.2% 23 dextrose 5% in nacl 0.45% 23 dextrose 5% in nacl 0.9% 23 dextrose 5% in water 23 dextrose high concentration 23 DIASTAT ACUDIAL 13 DIASTAT PEDIATRIC 13 diazepam 13 DIBENZYLINE 8 dicloxacillin sodium 3 dicyclomine hcl 8 didanosine 4 DIDRONEL 24 DIFFERIN 28 digoxin 10 dihydroergotamine mesylate 13 diltiazem hcl 10 dimenhydrinate 19 diphenhydramine hcl 6 diphenoxylate w/ atropine 19 DIPTHERIA/TETANUS TOXOID PEDIATRIC 26 dipyridamole 9 disopyramide phosphate 10 disulfiram 24 divalproex sodium 12 divalproex sodium sprinkles 12 docetaxel 6 donepezil hydrochloride 8 dopamine hcl 10 dorzolamide 18 dorzolamide/timolol 18 doxazosin mesylate 10 doxepin hcl 14 doxorubicin hcl 6 doxycycline hyclate 3 doxycycline monohydrate 3 DRISDOL 29 DRITHO-SCALP 28 dronabinol 19 droperidol 13 DULERA 8


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DYRENIUM 15

E EDECRIN 15 EDURANT 4 EFFIENT 9 electrolyte-2 in invert sugar 16 ELIPHOS 16 ELMIRON 24 ELSPAR 6 EMCYT 6 EMEND 19 EMTRIVA 4 ENBREL 24 ENBREL SURECLICK 24 ENLON 8 enoxaparin sodium ) 9 ENTOCORT EC 20 ephedrine sulfate (pressors) 9 EPIPEN 2-PAK 9 EPIPEN-JR 2-PAK 9 EPIVIR 4 epoprostenol sodium 11 EPZICOM 4 ERBITUX 6 ERGOMAR 13 erythromycin (acne aid 27 erythromycin (ophth) 17 erythromycin base 3 erythromycin ethylsuccinate 3 erythromycin lactobionate 3 erythromycin sulfisoxazole 3 estradiol 21, 22 ESTRING 22 estrogens with methyltestosterone 22 estropipate 22 ethambutol hcl 4 ethosuximide 12 ethynodiol diacet & eth estrad 21 ETHYOL 24 etodolac 11 etoposide 6 EVISTA 22 exemestane 6 EXJADE 20 EXTAVIA 24 EYLEA 18

F FACTREL 22 famciclovir 5 famotidine 19 famotidine in nacl 19 felbamate 12 FELBATOL 12 FEMARA 6

fenofibrate 10 fentanyl 12 fentanyl citrate 12 fentanyl transdermal system 12 FINACEA 28 finasteride 24 FIRAZYR 24 FIRST-TESTOSTERONE 21 flecainide acetate 10 FLOVENT HFA 20 fluconazole 3 fluconazole in nacl 3 fludarabine phosphate 6 fludrocortisone acetate 20 flunisolide (nasal) 17 fluocinolone acetonide 28 fluocinonide 28 fluocinonide emulsified base 28 fluorometholone (ophth) 17 fluorouracil 6, 28 fluorouracil (topical) 28 fluoxetine hcl 14 fluphenazine decanoate 14 fluphenazine hcl 14 flurbiprofen 12, 17 flurbiprofen sodium 17 flutamide 6 fluticasone propionate 17 fluticasone propionate (nasal) 17 folic acid 29 fondaparinux 9 FORADIL AEROLIZER 9 FORTAZ 3 foscarnet sodium 5 furosemide 15

G gabapentin 12 galantamine hydrobromide 8 GAMUNEX-C 26 ganciclovir 5 GANTRISIN 3 GARDASIL 26 gemfibrozil 10 GEMZAR 6 gentamicin sulfate 3, 17, 27 gentamicin sulfate (ophth) 17 gentamicin sulfate (topical) 27 GEODON 14 GLEEVEC 6 glimepiride 21 glipizide 21 GLUCAGON EMERGENCY KIT 21 glycine 1.5% 24 glycopyrrolate 8 griseofulvin microsize 4 griseofulvin ultramicrosize 4


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guaifenesin / codeine 25

H halobetasol 28 haloperidol 14 haloperidol decanoate 14 haloperidol lactate 14 HAVRIX 26 HELIXATE FS 9 HEMABATE 25 heparin sodium (porcine) 9 HEPSERA 5 HERCEPTIN 6 HEXALEN 6 HIBERIX 26 homatropine hbr 18 HUMALOG 21 HUMATE-P 9 HUMIRA 24 humulin 70/30 21 humulin n 21 humulin r 21 HUMULIN R U-500 (CONCENTRATED) 21 hydralazine hcl 11 hydrochlorothiazide 11, 15, 16 hydrocodone / chlorpheniramine 25 hydrocodone / homatropine 25 hydrocodone-acetaminophen 12 hydrocortisone 20, 28 hydrocortisone (intrarectal) 28 hydrocortisone (rectal) 28 hydrocortisone (topical) 28 hydrocortisone butyrate 28 hydromorphone hcl 12 hydroxychloroquine sulfate 4 hydroxyurea 6 hydroxyzine hcl 13 HYPERRHO S/D 26 HYPERTET S/D 26

I ibuprofen 12 idarubicin hcl 6 ifosfamide 6 ifosfamide & mesna 6 imipramine hcl 14 imiquimod 28 immune globulin (human) iv 26 IMOGAM RABIES-HT 26 IMOVAX RABIES (H.D.C.V.) 26 INCIVEK 5 INDOCIN IV 12 indomethacin 12 INFANRIX 26 INFED 9 INTELENCE 5

INTRALIPID 23 INTRON-A 6 INTRON-A W/DILUENT 6 INVANZ 3 INVIRASE 5 iodoquinol / hydrocortisone 27 IPOL INACTIVATED IPV 26 ipratropium bromide 8, 25 ipratropium bromide (nasal) 25 irrigation solution G 24 ISENTRESS 5 isoniazid 4 ISOPTO HYOSCINE 18 isosorbide dinitrate 11 isosorbide mononitrate 11 isotretinoin 28

K KALETRA 5 KENALOG-10 20 KENALOG-40 20 ketamine hcl 24 ketoconazole 4, 27 ketoconazole (topical) 27 ketorolac 12 KINERET 24 KOGENATE FS 9 K-PHOS 16

L labetalol hcl 10 LACRISERT 18 lactated ringer’s 23, 24 lactated ringer's 16 lactated ringer's (irrigation) 16 lactulose 15 lamotrigine 12 LANTUS 21 latanoprost 18 leflunomide 24 LETAIRIS 25 leucovorin calcium 24 LEUKERAN 7 LEUPROLIDE ACETATE 7 levetiracetam 12 LEVITRA 17 levobunolol hcl 18 levocarnitine (metabolic modifiers) 25 levofloxacin 3 levonorgestrel & eth estradiol 21 levonorgestrel-eth estradiol (triphasic) 21 levothyroxine sodium 23 LEXIVA 5 lidocaine 10, 18, 25, 28 lidocaine hcl 10, 18, 25, 28 lidocaine hcl (cardiac) 10


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lidocaine hcl (local anesth.) 25 lidocaine hcl (mouth-throat) 18 lidocaine-prilocaine 28 liothyronine sodium 23 LIPITOR 10 LIPOSYN 23 LIPOSYN III 23 lisinopril 11 lisinopril & hydrochlorothiazide 11 lithium carbonate 14 lithium citrate 14 LOCOID LIPOCREAM 28 lorazepam 13 losartan 11 losartan & hydrochlorothiazide 11 LOTEMAX 17 lovastatin 10 loxapine succinate 14 LUCENTIS 18 LUPRON DEPOT 7 LUPRON DEPOT-PED 7

M MACUGEN 18 magnesium sulfate 12 mannitol injection 23 MATULANE 7 MAXAIR AUTOHALER 9 MAXIDEX 17 MEBARAL 13 medroxyprogesterone acetate 22 medroxyprogesterone acetate (contraceptive) 22 mefloquine hcl 4 megestrol acetate 7 meloxicam 12 melphalan 7 MENACTRA 26 MENOMUNE-A/C/Y/W-135 26 MENOPUR 22 MEPRON 4 mercaptopurine 7 MERUVAX II W/DILUENT 10 DOSE 26 mesalamine 19 mesna 6, 25 metaproterenol sulfate 9 metformin hcl 21 methadone hcl 12 methazolamide 11 methenamine hippurate 5 methimazole 23 METHITEST 21 methocarbamol 8 methotrexate sodium 7 methyldopa 11 methylgonovine maleate 25 methylphenidate hcl 12 methylphenidate hcl extended 12

methylprednisolone 20 methylprednisolone acetate 20 methylprednisolone sod succ 20 metoclopramide hcl 19 metolazone 15 metoprolol succinate 10 metoprolol tartrate 10 metronidazole 4, 27 metronidazole (topical) 27 metronidazole vaginal 27 midazolam 13 minocycline hcl 3 minoxidil 11 mirtazapine 14 misoprostol 19 mitomycin 7 mitoxantrone hcl 7 mometasone furoate 28 montelukast sodium 25 morphine sulfate 12 MUMPSVAX W/DILUENT 10 DOSE 26 mupirocin 27 MUSTARGEN 7 mycophenolate mofetil 25 MYLERAN 7 MYOCHRYSINE 20 MYTELASE 8

N NABI-HB 26 nabumetone 12 nacl 0.45%, ½ normal saline 23 nacl 0.9%, normal saline 23 nacl 3% 23 nacl 5% 23 naloxone hcl 14 naltrexone hcl 14 NAMENDA 14 NAMENDA TITRATION PAK 14 naproxen 12 naratriptan 13 nefazodone hcl 14 neomycin sulfate 3 neomycin-polymycin-dexamethasone 17 neomycin-polymyxin-hydrocortisone (ophth) 17 neomycin-polymyxin-hydrocortisone (otic) 17 neostigmine methylsulfate 8 NEUPOGEN 9 nevirapine 5 NEXAVAR 7 NEXPLANON 22 nifedipine 10 NIMODIPINE 10 nitrofurantoin macrocrystal 5 nitrofurantoin monohyd macro 5 nitroglycerin 11 norethin acet & estrad-fe 21


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norethindrone & eth estradiol 21 norethindrone & mestranol 21 norethindrone acet & eth estra 21 norethindrone acetate 22 norethindrone-eth estradiol (triphasic) 21 norgestimate-ethinyl estradiol 21 norgestimate-ethinyl estradiol (triphasic) 21 nortriptyline hcl 15 NORVIR 5 nystatin 4, 28 NYSTATIN 27 nystatin-triamcinolone 28

O OCTREOTIDE ACETATE 25 ofloxacin (ophth) 17 ofloxacin (otic) 17 omeprazole 19 OMNITROPE PREFILLED CARTRIDGE 23 ondansetron 19 ondansetron hcl 19 ORAP 15 ORENCIA 25 oxazepam 13 oxcarbazepine 13 OXSORALEN ULTRA 28 oxybutynin chloride 29 oxycodone hcl 12 oxycodone w/ acetaminophen 12 oxytocin 25 OXYTROL 29

P paclitaxel 7 pamidronate disodium 25 PANCRELIPASE 19 pantoprazole 19 para-aminobenzoic acid 28 paregoric 19 paromomycin sulfate 4 paroxetine hcl 15 PEDIARIX 26 PEDVAX HIB 26 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 19 PEGASYS 5 penicillin g potassium 3 penicillin g procaine 3 penicillin g sodium 3 penicillin v potassium 3 pentamidine isethionate 4 pentostatin 7 pentoxifylline 9 permethrin 27 perphenazine 15 phenelzine sulfate 15 phenobarbital 13

phentolamine mesylate 8 phenylephrine hcl (ophth) 19 phenylephrine hcl (pressors) 9 phenytoin 13 phenytoin sodium 13 phenytoin sodium extended 13 PHISOHEX 28 PHOSLO 16 PHOSPHOLINE IODIDE 18 physostigmine salicylate 20 phytonadione 29 pilocarpine hcl 8, 18 pilocarpine hcl (oral) 8 piperacillin-tazobactam 3 podofilox 28 polymyxin b-trimethoprim 17 potassium acetate 16 potassium chloride 16 potassium chloride microencapsulated crystals cr 16 potassium citrate (alkalinizer) 15 potassium citrate-citric acid 15 potassium iodide 23 potassium phosphate dibasic 16 potassium phosphate dibasic & monobasic w/ sodium

phosphate monobasic 16 pramipexole dihydrochloride 14 pravastatin sodium 10 prazosin hcl 10 PRED-G 17 prednisolone 17, 18, 20 prednisolone acetate (ophth) 17 prednisolone sodium phosphate 17 prednisolone sodium phosphate (ophth) 17 prednisone 20 PREMARIN INJECTION 22 PREMARIN W/APPLICATOR 22 PREVNAR 13 26 PREZISTA 5 PRIMAQUINE PHOSPHATE 4 PRIMAXIN I.M. 3 primidone 13 PRIMSOL 5 probenecid 16 procainamide hcl 10 prochlorperazine 15, 19 prochlorperazine edisylate 15 prochlorperazine maleate 15 PROCRIT 9 PROCTOFOAM-HC 28 progesterone 23 promethazine hcl 6 propafenone hcl 11 propantheline bromide 8 proparacaine hcl 18 propranolol hcl 10 propylthiouracil 23 PROQUAD 26 PROTOPIC 28


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PSORIATEC 28 PULMOZYME 16 pyrazinamide 4 pyridostigmine bromide 8 pyridoxine 29

Q quinidine gluconate 11 quinidine sulfate 11 QVAR 20

R RABAVERT 26 ranitidine hcl 19 RAPAMUNE 25 REBIF 25 RECOMBINATE 9 RECOMBIVAX HB 26 REFACTO 9 REMICADE 25 RENAGEL 16 RENVELA 16 RESCRIPTOR 5 RESERPINE 11 RESPIGAM 26 RESTASIS 17 REVLIMID 25 REYATAZ 5 RHOPHYLAC 26 ribavirin (hepatitis c) 5 RIDAURA 20 rifampin 4 RILUTEK 14 rimantadine hydrochloride 5 RIMSO-50 25 ringer’s injection 23 ringer’s irrigation 24 ringer's irrigation 16 risperidone 15 RITUXAN 7 rizatriptan 13 ropinirole hydrochloride 14 ROTARIX 27 ROTATEQ 27

S salsalate 12 SANDIMMUNE 25 SANTYL 28 SCOPACE 19 scopolamine hydrobromide 8 selegiline hcl 14 selenium sulfide 27 SELZENTRY 5 SENSIPAR 25

SEREVENT DISKUS 9 SEROQUEL 15 sertraline hcl 15 sildenafil citrate (pulmonary hypertention) 11 silver sulfadiazine 27 simvastatin 10 sodium acetate 15 sodium bicarbonate 15, 23 sodium chloride 16, 26 sodium chloride (gu irrigant) 16 sodium chloride (inhalant) 26 sodium chloride 0.9% 24 sodium citrate & citric acid 15 SODIUM EDECRIN 15 sodium phosphate 16, 17, 20 sodium polystyrene sulfonate 16 sodium sulfacetamide & phenylephrine 17 SOLU-CORTEF 20 sorbitol urologic 3% 24 SORIATANE 25 sotalol hcl 10 SPIRIVA HANDIHALER 8 spironolactone 11 spironolactone & hydrochlorothiazide 11 SPRYCEL 7 stavudine 5 sterile water 23, 24, 26 streptomycin sulfate 3 STRIBILD 5 SUBOXONE 12 sucralfate 19 sufentanil citrate 12 sulfacetamide sodium 28 sulfacetamide sod-prednisolone 18 sulfamethoxazole-trimethoprim 3 sulfasalazine 3 sulindac 12 sumatriptan 13 SUPRAX 3 SUSTIVA 5 SUTENT 7 SYNAGIS 5 SYNAREL 22

T TABLOID 7 tacrolimus 25 TAMIFLU 5 tamoxifen citrate 7 tamsulosin 25 TARCEVA 7 TASIGNA 7 TAZICEF 3 TAZORAC 28 temazepam 14 TEMODAR 7 terazosin hcl 10


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terbinafine hcl 27 terbutaline sulfate 9 TESTOSTERONE 21 testosterone cypionate 21 TESTRED 21 TETANUS TOXOID 26 tetracaine hcl (ophth) 18 tetracycline hcl 3 THALOMID 25 theophylline 29 THERACYS 27 thiamine 29 THIOLA 25 thioridazine hcl 15 thiotepa 7 thiothixene 15 thyroid 23 TICE BCG 27 TIKOSYN 11 timolol maleate 18 timolol maleate (ophth) 18 TOBI 3 tobramycin sulfate 3, 17 tobramycin sulfate (ophth) 17 TOLBUTAMIDE 21 topiramate 13 topiramate sprinkle 13 topotecan 7 TORISEL 7 TRACLEER 11 tramadol hcl 12 TRANSDERM-SCOP 19 tranylcypromine sulfate 15 trazodone hcl 15 tretinoin 7, 28 triamterene & hydrochlorothiazide 16 triazolam 14 trifluoperazine hcl 15 trifluridine 17 trihexyphenidyl hcl 8 trimethoprim 5, 17 TRIZIVIR 5 TROBICIN 3 tropicamide 18 TRUVADA 5 trypsin, balsam peru & castor 28 TYKERB 7

U ursodiol 19

V VAGIFEM 22

VALCYTE 5 valproate sodium 13 valproic acid 13 VANCOCIN ISO-OSMOTIC DEXTROSE 3 vancomycin hcl 3 VAQTA 27 VARIVAX 27 VARIZIG 26 vasopressin 22 VECTICAL 29 venlafaxine hcl 15 VENOFER 9 VENTAVIS 11 verapamil hcl 10 VICTRELIS 5 VIDAZA 7 VINBLASTINE SULFATE 7 vincristine sulfate 7 vinorelbine tartrate 7 VIRACEPT 5 VIREAD 5 VISUDYNE 18 VOLTAREN 18 voriconazole 4 VPRIV 25

W warfarin sodium 9 water for irrigation, sterile 16

X XELODA 7 XERAC AC 29 XTANDI 7

Z ZELBORAF 7 ZEMAIRA 25 ZENPEP 19 zidovudine 5 zinc (trace metals) 16 ZOLADEX 7 zolpidem tartrate 13 ZOMETA 25 zonisamide 13 ZOSTAVAX 27 ZYMAXID 17 ZYPREXA 15 ZYTIGA 7 ZYVOX 3


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