Kaiser Permanente: Southern Colorado Commercial HMO Drug Formulary

Kaiser Permanente Southern Colorado Commercial HMO Formulary – December 2011

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Southern Colorado Commercial HMO Formulary

The following is a listing of the drugs on the Kaiser Permanente Southern Colorado Commercial HMO formulary. This Formulary applies only to outpatient drugs provided to members for self administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The formulary does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the Drug Formulary. Kaiser Permanente has many brand and generic medications on the formulary. In most cases, a generic equivalent is used. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay.

How to use this Formulary document Products available in a generic form are listed by their generic name in italics. With the exception of drugs where multiple branded products exist, medications only available as a brand name product are listed in all CAPITAL letters. Please remember that this list is subject to change and will be updated at least quarterly. Any product not found in this listing or in subsequent updates, will be considered a non-formulary drug. You can search the Formulary by using the index, by using the “Find” function in Adobe Reader, or by therapeutic drug category. All dosage forms and strengths for a particular drug listed may not be formulary. Not all dosage forms of formulary drugs are covered under the prescription drug benefit. Some drugs are available in more than one dosage form (example: tablet and injectable).

Restrictions on medication coverage: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Restricted to specialty: A drug that needs to be written by a physician specialized in the treatment of certain conditions for the drug to be covered under the patient’s pharmacy benefit. For example, Entocort EC

®, a drug used for colitis, is restricted to physicians specialized in Gastroenterology.

Prior authorization: Some drugs require specific medical criteria be met prior to dispensing the drug for the patient’s pharmacy benefit.

Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a certain quantity per copay. For example, the migraine medication Zomig

® is limited to

12 tablets per 30-day copay. Similar quantity limits exist for most migraine medications. In addition, other drugs are limited to a specific days supply. For example, Tarceva

® is limited to a 30-day supply.

In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment.

Restricted to Benefit: Some drugs are not covered unless the patient’s benefits specifically cover such medications. For example, Viagra

® and other drugs for sexual dysfunction are not covered

unless the patient’s benefits specifically cover them.

Step therapy: Some medications require a similar therapy be attempted first. For example, before lansoprazole can be dispensed, a drug such as omeprazole must be tried first.


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

o Request to cover a drug that is not on our formulary o Request to waive coverage restrictions or limitations

Generally Kaiser Permanente will only approve requests for an exception if the alternative drugs included on the plan’s formulary, or existing utilization restrictions, would not be as effective in treating a condition or would cause adverse medical effects.

Key: * (asterisk) = A drug where at least one of the dosage forms is an injectable. Some patients have a specific self-injectable coinsurance. † (dagger) = Certain strengths or forms of the drug (e.g., tablet, gel, liquid) are only available as brand drugs and are subject to the brand cost share. MD = A drug that is required to be written by a physician specialized in the treatment of certain conditions. PA = A drug that requires specific medical criteria be met prior to dispensing for prescription benefit. QL = A drug that has a quantity limit or is limited to a specific day supply. RB = A drug that is restricted to a certain benefit for coverage. ST = A drug that requires another class of medications be attempted prior to dispensing for prescription benefit. This list of drugs should not be used to determine benefit issues such as prescription copay amounts. If you have questions about prescription benefits, please call Customer Service at 1-888-681-7878. The medications on this list are subject to change.


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Drug Name Drug Tier Comments

ANTIHISTAMINE DRUGS

FIRST GENERATION ANTIHISTAMINES

cyproheptadine hcl Generic

promethazine hcl Generic *

ANTIHISTAMINE DRUGS

SECOND GENERATION ANTIHISTAMINES

None

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

ALBENZA Brand

BILTRICIDE Brand

mebendazole Brand

STROMECTOL Brand


ANTIBACTERIALS

amoxicillin Generic

amoxicillin & potassium

clavulanate Generic/Brand †

ampicillin Generic/Brand †

AVELOX Brand

azithromycin Generic/Brand †

cefaclor Generic

cefadroxil Generic

cefdinir Generic

cefprozil Generic

cefuroxime axetil Generic/Brand †

cephalexin Generic

ciprofloxacin hcl Generic/Brand †

clarithromycin Generic

clindamycin hcl Generic/Brand †

dicloxacillin Generic

doxycycline Generic

erythromycin & sulfisoxazole Generic

erythromycin base Generic/Brand †

erythromycin ethylsuccinate Generic/Brand †

erythromycin stearate Brand

HELIDAC Brand

levofloxacin Generic

minocycline Generic

neomycin sulfate Generic/Brand †


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NOROXIN Brand

penicillin V potassium Generic

SPECTRACEF Brand

sulfadiazine Generic

sulfamethoxazole & trimethoprim Generic

sulfasalazine Generic

SUPRAX Brand

tetracycline Generic/Brand †

TOBI NEB Brand

VANCOCIN Brand

ZYVOX Brand * MD, PA


ANTIFUNGALS

fluconazole Generic

GRIS-PEG Brand

itraconazole Generic/Brand † PA

ketoconazole Generic

nystatin Generic/Brand †

terbinafine Generic

VFEND Brand MD


ANTIMYCOBACTERIALS

DAPSONE Brand

ethambutol Generic

isoniazid Generic

MYCOBUTIN Brand

pyrazinamide Generic

rifampin Generic


ANTIVIRALS

acyclovir Generic

APTIVUS Brand

ATRIPLA Brand

BARACLUDE Brand

COMBIVIR Brand

CRIXIVAN Brand

didanosine Generic/Brand †

EMTRIVA Brand

EPIVIR Brand

EPIVIR HBV Brand

EPZICOM Brand


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famciclovir Generic

ganciclovir Generic QL

HEPSERA Brand

INFERGEN Brand * PA, QL

INTELENCE Brand

INVIRASE Brand

ISENTRESS Brand

KALETRA Brand

LEXIVA Brand

NORVIR Brand

PEGASYS Brand * PA, QL

PEG-INTRON Brand * PA, QL

PREZISTA Brand

RELENZA Brand QL

RESCRIPTOR Brand

REYATAZ Brand

ribavirin Generic/Brand † PA, QL

rimantadine Generic/Brand †

SELZENTRY Brand

stavudine Generic

SUSTIVA Brand

TAMIFLU Brand QL

TRIZIVIR Brand

TRUVADA Brand

TYZEKA Brand

VALCYTE Brand

VALTREX Brand

VIRACEPT Brand

VIRAMUNE Brand

VIREAD Brand

ZIAGEN Brand

zidovudine Generic


ANTIPROTOZOALS

atovaquone/proguanil Generic

chloroquine phosphate Generic

DARAPRIM Brand

hydroxychloroquine sulfate Generic

mefloquine hcl Generic

metronidazole Generic

NEBUPENT Brand


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paromomycin sulfate Generic

primaquine phosphate Brand

YODOXIN Generic


URINARY ANTI-INFECTIVES

belladonna alkaloids,

methenamine, methylene blue &

phenyl salicylate

Generic

nitrofurantoin macrocrystals Generic/Brand †

nitrofurantoin monohydrate

macrocystals Generic

nitrofurantoin suspension Generic

trimethoprim Generic/Brand †

ANTINEOPLASTIC AGENTS

ANTINEOPLASTIC AGENTS

AFINITOR Brand MD, QL

ALKERAN Brand *

anastrozole Generic

bicalutamide Generic

CEENU Brand

cyclophosphamide Brand

EMCYT Brand

etoposide Generic

exemestane Generic

flutamide Generic

GLEEVEC Brand QL

HEXALEN Brand

hydroxyurea Generic

INTRON-A Brand * PA, QL

IRESSA Brand

letrozole Generic

LEUKERAN Brand

leuprolide acetate Generic/Brand *† PA, QL

LYSODREN Brand

MATULANE Brand

megestrol acetate Generic

mercaptopurine Generic

methotrexate Generic/Brand *†

MYLERAN Brand

NEXAVAR Brand MD, QL

NILANDRON Brand


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SPRYCEL Brand QL

SUTENT Brand MD, QL

TABLOID Brand

tamoxifen citrate Generic

TARCEVA Brand QL

TARGRETIN Brand

TEMODAR Brand

tretinoin Generic

TYKERB Brand

XELODA Brand

ZOLINZA Brand

AUTONOMIC DRUGS

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS

ARICEPT Brand

ARICEPT ODT Brand

bethanechol chloride Generic

EVOXAC Brand

galantamine hbr Generic

galantamine hbr (extended

release) Generic

PROSTIGMIN Brand

pyridostigmine bromide Generic/Brand †

AUTONOMIC DRUGS

ANTICHOLINERGIC AGENTS

belladonna alkaloids &

phenobarbital Generic/Brand †

chlordiazepoxide & clidinium Generic

dicyclomine hcl Generic

DONNATAL EXTENTABS Brand

glycopyrrolate Generic

hyoscyamine sulfate Generic

ipratropium bromide (inhaled) Generic/Brand †

ipratropium bromide (nasal) Generic

SPIRIVA Brand QL

AUTONOMIC DRUGS

SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ADVAIR DISKUS Brand ST

ADVAIR HFA Brand ST

albuterol sulfate Generic/Brand †

COMBIVENT Brand

DULERA Brand


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epinephrine hcl Generic/Brand *† QL

MAXAIR AUTOHALER Brand

metaproterenol sulfate Generic/Brand †

midodrine hcl Generic

SEREVENT DISKUS Brand

terbutaline sulfate Generic

XOPENEX Brand ST

AUTONOMIC DRUGS

SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS

DIBENZYLINE Brand

dihydroergotamine mesylate Generic/Brand *† QL

ERGOMAR Brand QL

tamsulosin hcl Generic

AUTONOMIC DRUGS

SKELETAL MUSCLE RELAXANTS

baclofen Generic

carisoprodol Generic

carisoprodol & aspirin Generic

cyclobenzaprine hcl Generic

dantrolene sodium Generic

methocarbamol Generic/Brand *†

tizanidine hcl Generic

AUTONOMIC DRUGS

AUTONOMIC DRUGS, MISCELLANEOUS

NICOTROL Brand PA, QL

BLOOD FORMATION, COAGULATION, AND THROMBOSIS

ANTITHROMBOTIC AGENTS

anagrelide hcl Generic

cilostazol Generic

EFFIENT Brand * QL

fondaparinux Generic* QL

FRAGMIN Brand * QL

heparin sodium Generic/Brand *†

INNOHEP Brand * PA, QL

LOVENOX Brand * QL

PLAVIX Brand

warfarin sodium Generic

BLOOD FORMATION, COAGULATION AND THROMBOSIS

HEMATOPOIETIC AGENTS

EPOGEN Brand * PA, QL

LEUKINE Brand * PA, QL


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NEULASTA Brand * PA, QL

PROCRIT Brand * PA, QL


HEMORRHEOLOGIC AGENTS

pentoxifylline Generic


ANTIHEMORRHAGIC AGENTS

aminocaproic acid Generic/Brand †

CARDIOVASCULAR DRUGS

CARDIAC DRUGS

amiodarone hcl Generic/Brand †

digoxin Generic/Brand †

disopyramide phosphate Generic/Brand †

flecainide acetate Generic

mexiletine hcl Generic

propafenone hcl Generic

quinidine gluconate Generic

quinidine sulfate Generic

TIKOSYN Brand


ANTILIPEMIC AGENTS

cholestyramine Generic

CRESTOR Brand

fenofibrate Generic

fenofibrate (micronized) Generic

gemfibrozil Generic

lovastatin Generic

NIASPAN Brand

pravastatin Generic

simvastatin Generic

VYTORIN Brand

ZETIA Brand


HYPOTENSIVE AGENTS

clonidine hcl Generic

guanfacine hcl Generic

hydralazine hcl Generic

methyldopa Generic

reserpine Generic


VASODILATING AGENTS


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CAVERJECT Brand * QL, RB

CIALIS Brand QL, RB

dipyridamole Generic

EDEX Brand * QL, RB

isosorbide dinitrate Generic/Brand †

isosorbide mononitrate Generic

LETAIRIS Brand MD, QL

LEVITRA Brand QL, RB

MUSE Brand QL, RB

nitroglycerin Generic/Brand †

TRACLEER Brand MD, QL

VIAGRA Brand QL, RB


ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate Generic

prazosin hcl Generic

terazosin hcl Generic


BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl Generic

atenolol Generic

atenolol & chlorthalidone Generic

bisoprolol fumarate Generic

bisoprolol fumarate &

hydrochlorothiazide Generic

BYSTOLIC Brand

carvedilol Generic QL

COREG CR Brand

labetalol hcl Generic

metoprolol succinate Generic

metoprolol tartrate Generic

nadolol Generic

pindolol Generic

propranolol hcl Generic

sotalol hcl Generic


CALCIUM-CHANNEL BLOCKING AGENTS

amlodipine besylate Generic

amlodipine besylate & benazepril

hcl Generic/Brand †

CARDENE SR Brand


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diltiazem hcl Generic/Brand †

EXFORGE Brand ST

EXFORGE HCT Brand ST

felodipine Generic

isradipine Generic/Brand †

nifedipine Generic

TARKA Brand

verapamil hcl Generic


RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS

benazepril & hydrochlorothiazide Generic

benazepril hcl Generic

captopril Generic

captopril & hydrochlorothiazide Generic

DIOVAN Brand ST

DIOVAN HCT Brand ST

enalapril maleate Generic

fosinopril sodium Generic

fosinopril sodium &


lisinopril Generic

lisinopril & hydrochlorothiazide Generic

losartan potassium Generic

losartan potassium &


moexipril & hydrochlorothiazide Generic

moexipril hcl Generic

quinapril & hydrochlorothiazide Generic

quinapril hcl Generic

ramipril Generic

spironolactone Generic

spironolactone &


CENTRAL NERVOUS SYSTEM AGENTS

ANALGESICS AND ANTIPYRETICS

acetaminophen with codeine Generic

ACTIQ Brand MD, QL

butalbital, acetaminophen &

caffeine Generic


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butalbital, acetaminophen,

caffeine & codeine Generic

butalbital, aspirin & caffeine Generic

butalbital, aspirin, caffeine &

codeine Generic

CELEBREX Brand QL, ST

choline magnesium trisalicylate Generic

diclofenac sodium Generic

etodolac Generic

fenoprofen calcium Generic/Brand †

fentanyl Generic QL

FENTORA Brand MD, QL

hydrocodone & acetaminophen Generic

hydromorphone hcl Generic/Brand †

ibuprofen Generic

indomethacin Generic/Brand †

ketoprofen Generic

ketorolac tromethamine Generic QL

meclofenamate sodium Generic

methadone hcl Generic

morphine sulfate Generic/Brand †

morphine sulfate (extended

release) Generic

nabumetone Generic

naproxen Generic

naproxen sodium Generic

ONSOLIS Brand MD, QL

oxaprozin Generic

oxycodone & acetaminophen Generic

oxycodone & aspirin Generic

oxycodone hcl Generic

oxycodone hcl (extended release) Generic/Brand † QL

salsalate Generic

sulindac Generic

tramadol hcl Generic


OPIATE ANTAGONISTS

naltrexone hcl Generic


ANTICONVULSANTS

carbamazepine Generic


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carbamazepine (extended release) Generic/Brand †

CELONTIN Brand

clonazepam Generic

divalproex sodium Generic

divalproex sodium (extended

release) Generic

ethosuximide Generic

felbamate Brand MD

gabapentin Generic/Brand †

GABITRIL Brand

lamotrigine Generic QL

levetiracetam Generic

oxcarbazepine Generic

phenytoin Generic/Brand †

phenytoin sodium (extended

release) Generic/Brand †

primidone Generic

topiramate Generic

valproic acid Generic

zonisamide Generic MD


PSYCHOTHERAPEUTIC AGENTS

ABILIFY Brand MD, QL

ABILIFY DISCMELT Brand MD, QL

amitriptyline hcl Generic

amoxapine Brand

bupropion hcl Generic

chlordiazepoxide & amitriptyline Generic

chlorpromazine hcl Generic

citalopram hydrobromide Generic

clomipramine hcl Generic

desipramine hcl Generic

doxepin hcl Generic

fluoxetine hcl Generic/Brand †

fluphenazine hcl Generic

fluvoxamine maleate Generic

GEODON Brand MD, QL

haloperidol Generic

imipramine hcl Generic

imipramine pamoate Generic/Brand †

LEXAPRO Brand ST, QL


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loxapine succinate Generic

maprotiline hcl Generic

mirtazapine Generic

MOBAN Brand

NARDIL Brand

NEFAZODONE HCL Brand MD

nortriptyline hcl Generic

olanzapine Generic MD, QL

olanzapine ODT Generic MD, QL

paroxetine hcl Generic

paroxetine hcl (extended release) Generic/Brand † QL

perphenazine Generic

prochlorperazine maleate Generic

protriptyline hcl Generic MD

risperidone Generic MD, QL

SEROQUEL Brand MD, QL

sertraline hcl Generic

thioridazine hcl Generic

thiothixene Generic/Brand †

tranylcypromine sulfate Generic

trazodone hcl Generic

trifluoperazine hcl Generic

trimipramine maleate Generic/Brand † MD

venlafaxine hcl Generic

venlafaxine hcl (extended release) Generic/Brand †


ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL

STIMULANTS, MISCELLANEOUS

ADDERALL XR Generic QL

amphetamine &

dextroamphetamine Generic

dexmethylphenidate hcl Generic

dextroamphetamine sulfate Generic

FOCALIN XR Brand QL

methylphenidate hcl Generic

methylphenidate hcl (extended

release) Generic/Brand † PA, QL

PROVIGIL Brand QL


ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

alprazolam Generic


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buspirone hcl Generic/Brand † QL

CHLORAL HYDRATE Brand

chlordiazepoxide hcl Generic

clorazepate dipotassium Generic

diazepam Generic/Brand *†

estazolam Generic

flurazepam hcl Generic

hydroxyzine hcl Generic

hydroxyzine pamoate Generic

lorazepam Generic

oxazepam Generic

phenobarbital Generic

temazepam Generic/Brand †

triazolam Generic

zaleplon Generic QL

zolpidem tartrate Generic QL


ANTIMANIC AGENTS

lithium carbonate Generic/Brand †

lithium carbonate (extended

release) Generic/Brand †


ANTIMIGRAINE AGENTS

ergotamine tartrate & caffeine Generic QL

FROVA Brand QL

sumatriptan succinate Generic/Brand *† QL

ZOMIG Brand QL

ZOMIG ZMT Brand QL


ANTIPARKINSONIAN AGENTS

amantadine hcl Generic

APOKYN Brand * PA, QL

benztropine mesylate Generic

bromocriptine mesylate Generic

cabergoline Generic MD

carbidopa & levodopa Generic

carbidopa & levodopa (extended

release) Generic

COMTAN Brand

pramipexole dihydrochloride Generic

ropinirole hcl Generic


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selegiline hcl Generic

trihexyphenidyl hcl Generic


CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS

RILUTEK Brand MD

SAVELLA Brand QL

DEVICES

DEVICES

ORTHO DIAPHRAGM ALL-

FLEX KITs 65, 70, 75 AND 80 Brand

ORTHO DIAPHRAGM COIL

SPRING KITs 50, 100 AND 105 Brand

ORTHO DIAPHRAGM FLAT

SPRING KITs 55, 60, 65, 70, 75,

80, 85, 90, and 95

Brand

WIDE-SEAL SILICONE

DIAPHRAGM KITs 60, 65, 70,

75, 80, 85, 90, and 95

Brand

ELECTROLYTIC, CALORIC, AND WATER BALANCE

ALKALINIZING AGENTS

potassium and sodium citrates

with citric acid Brand

potassium citrate Generic

sodium citrate & citric acid Generic


AMMONIA DETOXICANTS

lactulose Generic


REPLACEMENT PREPARATIONS

calcium acetate (phosphate

binder) Generic/Brand †

potassium bicarbonate &

potassium chloride Generic/Brand †

potassium chloride Generic/Brand †

ELECTROLYTIC, CALORIC AND WATER BALANCE

ION-REMOVING AGENTS

RENAGEL Brand

RENVELA Brand

RENVELA PAK Brand

sodium polystyrene sulfonate Generic

ELECTROLYTIC, CALORIC AND WATER BALANCE


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DIURETICS

bumetanide Generic

chlorthalidone Generic

furosemide Generic


indapamide Generic

metolazone Generic

torsemide Generic

triamterene &



URICOSURIC AGENTS

probenecid Generic

probenecid & colchicine Generic

ENZYMES

ENZYMES

PULMOZYME Brand

RESPIRATORY TRACT AGENTS

ANTITUSSIVES

benzonatate Generic

guaifenesin & codeine Generic

hydrocodone & homatropine Generic

TUSSIONEX Brand


ANTI-INFLAMMATORY AGENTS

cromolyn sodium Generic/Brand †

SINGULAIR Brand QL, ST

zafirlukast Generic


RESPIRATORY TRACT AGENTS, MISCELLANEOUS

sodium chloride for nebulization Generic

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

ANTIALLERGIC AGENTS

ALAMAST Brand

ALOCRIL (ophthalmic) Brand QL

ALOMIDE (ophthalmic) Brand

ASTELIN Brand

azelastine hcl (ophthalmic) Generic/Brand †

cromolyn sodium (ophthalmic) Generic

PATANOL Brand QL, ST



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ANTI-INFECTIVES

bacitracin & polymyxin B

(ophthalmic) Generic

bacitracin (ophthalmic) Brand

chlorhexidine gluconate (dental) Generic

ciprofloxacin hcl (ophthalmic) Generic

erythromycin (ophthalmic) Generic

gentamicin sulfate (ophthalmic) Generic

neomycin, bacitracin & polymyxin

B (ophthalmic) Generic

ofloxacin (ophthalmic) Generic

ofloxacin (otic) Generic

polymyxin B & trimethoprim Generic

sulfacetamide sodium

(ophthalmic) Generic/Brand †

tobramycin sulfate (ophthalmic) Generic/Brand †

trifluridine (ophth) Generic

ZYMAXID Brand MD



BLEPHAMIDE (ophthalmic) Brand

BLEPHAMIDE S.O.P. Brand

CIPRO HC (otic) Brand

CIPRODEX Brand

COLY-MYCIN-S (otic) Brand

diclofenac sodium (ophthalmic) Generic

FLAREX Brand

flunisolide (nasal) Generic

fluorometholone (ophthalmic) Generic

flurbiprofen sodium (ophthalmic) Generic

fluticasone propionate (nasal) Generic

FML FORTE Brand

hydrocortisone & acetic acid

(otic) Generic

ketorolac tromethamine


NASONEX Brand

neomycin, polymyxin, bacitracin

& hydrocortisone (ophthalmic) Generic/Brand †

neomycin, polymyxin &

dexamethasone (ophthalmic) Generic


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hydrocortisone (ophthalmic) Brand


hydrocortisone (otic) Generic

POLY-PRED (ophthalmic) Brand

PRED-G (ophthalmic) Brand

PRED-G S.O.P. (ophthalmic) Brand

prednisolone acetate (ophthalmic) Generic/Brand †

prednisolone sodium phosphate


sulfacetamide sodium &

prednisolone sodium phosphate

(ophthalmic)

Generic

tobramycin sulfate &

dexamethasone (ophth) Generic/Brand †


LOCAL ANESTHETICS

antipyrine, benzocaine &

polycosanol Generic/Brand

benzocaine & antipyrine (otic) Generic

lidocaine hcl (mouth-throat) Generic


MYDRIATICS

atropine sulfate (ophthalmic) Generic

tropicamide (ophthalmic) Generic

EYE, EAR, NOSE AND THROAT (EENT) PREPARATION

ANTIGLAUCOMA AGENTS

acetazolamide Generic

AZOPT (ophthalmic) Brand

betaxolol hcl (ophthalmic) Brand

BETIMOL Brand

BETOPTIC-S (ophthalmic) Brand

brimonidine tartrate Generic/Brand †

carteolol hcl (ophthalmic) Generic

dorzolamide hcl & timolol maleate


dorzolamide hcl (ophthalmic) Generic

ISOPTO CARBACHOL


latanoprost Generic

levobunolol hcl (ophthalmic) Generic


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LUMIGAN Brand

methazolamide Generic

metipranolol (ophthalmic) Generic

PHOSPHOLINE IODIDE

(ophthalmic) Brand

pilocarpine hcl (ophthalmic) Generic

timolol maleate (ophthalmic) Generic


EENT DRUGS, MISCELLANEOUS

acetic acid & aluminum acetate Generic

acetic acid (otic) Generic

GASTROINTESTINAL DRUGS

ANTIDIARRHEA AGENTS

diphenoxylate & atropine Generic


CATHARTICS AND LAXATIVES

polyethylene glycol 3350,

potassium chloride, sodium

bicarbonate, sodium chloride &

sodium sulfate

Generic/Brand †

polyethylene glycol 3350,

potassium chloride, sodium

bicarbonate & sodium chloride

Generic


CHOLELITHOLYTIC AGENTS

ursodiol Generic


DIGESTANTS

amylase 12,000 units; lipase 4,000

units; protease 12,000 units Generic/Brand †





amylase 27,000 units; lipase

5,000 units; protease 17,000

units

Generic/Brand †



units

Generic/Brand †




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units

Generic/Brand †



units

Generic/Brand †



units

Generic/Brand †



units

Generic/Brand †



units

Generic/Brand †



units

Generic/Brand †



units

Generic/Brand †



units

Generic/Brand †


ANTIEMETICS

ANTIVERT Brand

EMEND Brand MD, QL

ondansetron hcl Generic QL


ANTIULCER AGENTS AND ACID SUPPRESSANTS

famotidine Generic

lansoprazole Generic/Brand † ST

lansoprazole ODT Generic/Brand † ST

misoprostol Generic

omeprazole Generic

pantoprazole sodium Generic

ranitidine hcl Generic

sucralfate Generic/Brand †


PROKINETIC AGENTS

metoclopramide hcl Generic


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ASACOL Brand

DIPENTUM Brand

PENTASA Brand

GOLD COMPOUNDS

GOLD COMPOUNDS

RIDAURA Brand

HEAVY METAL ANTAGONISTS

HEAVY METAL ANTAGONISTS

CUPRIMINE Brand

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

ASMANEX Brand

budesonide (oral) Generic MD, QL

budesonide (nebulized) Generic

CELESTONE Brand

cortisone acetate Generic

dexamethasone Generic

FLOVENT DISKUS Brand

FLOVENT HFA Brand

fludrocortisone acetate Generic

hydrocortisone Generic

methylprednisolone Generic/Brand †

prednisolone Generic

prednisolone sodium phosphate Generic

prednisone Generic/Brand †

PULMICORT FLEXHALER Brand

QVAR Brand


ANDROGENS

ANDRODERM Brand PA

ANDROGEL Brand PA

danazol Generic

DELATESTRYL Brand * PA

fluoxymesterone Generic/Brand †

METHITEST Brand

testosterone Generic/Brand *† PA

testosterone cypionate Brand/Generic *† PA


CONTRACEPTIVES Possible Brands


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desogestrel & ethinyl estradiol

(monophasic) Generic/Brand †

APRI, DESOGEN,

KARIVA,

MIRCETTE,

ORTHO-CEPT

desogestrel & ethinyl estradiol

(triphasic) Generic

CESIA, CYCLESSA,

VELIVET

drospirenone & ethinyl estradiol Brand YASMIN

ethynodiol diacetate & ethinyl

estradiol Generic

KELNOR, ZOVIA

1/35E, ZOVIA 1/50E

levonorgestrel & ethinyl estradio

(monophasic)l Generic/Brand †

LESSINA,

NORDETTE,

PORTIA

levonorgestrel & ethinyl estradiol

(91-day) Generic/Brand †

JOLESSA,

SEASONIQUE

levonorgestrel & ethinyl estradiol

(triphasic) Generic

ENPRESSE,

TRIVORA

levonorgestrel (emergency oral

contraceptive) Generic/Brand †

norethindrone & ethinyl estradiol

(biphasic) Brand NECON 10/11



MODICON,

NORTREL 0.5/35,

NORTREL 1/35,

ORTHO-NOVUM

1/35


(triphasic) Generic/Brand †

NECON 7/7/7,

NORTREL 7/7/7,

ORTHO-NOVUM

7/7/7, TRI-

NORINYL

norethindrone & mestranol Generic/Brand †

NECON 1/50,

ORTHO-NOVUM

1/50

norethindrone (contraceptive) Generic/Brand †

NOR-QD, NORA-

BE, ORTHO-

MICRONOR

norethindrone acetate & ethinyl

estradiol Generic/Brand †

LOESTRIN 1/20,

MICROGESTIN

1/20, LOESTRIN

1.5/30,

MICROGESTIN

1.5/30


- 24 -


norethindrone acetate, estradiol,

& iron Generic/Brand †

LOESTRIN FE 1/20,

MICROGESTIN FE

1/20, LOESTRIN FE

1.5/30,

MICROGESTIN FE

1.5/30

norgestimate & ethinyl estradiol


PREVIFEM,

SPRINTEC, ORTHO-

CYCLEN

norgestimate & ethinyl estradiol

(triphasic) Generic/Brand †

ORTHO TRI-

CYCLEN, TRI-

PREVIFEM, TRI-

SPRINTEC

norgestrel & ethinyl estradiol Generic/Brand †

CRYSELLE,

LO/OVRAL, LOW-

OGESTREL,

OGESTREL

NUVARING Brand ST, QL

ORTHO EVRA Brand ST, QL


ESTROGENS AND ESTROGEN AGONISTS-ANTAGONISTS

COMBIPATCH Brand

esterified estrogens &

methyltestosterone Generic

ESTRACE VAGINAL Brand

estradiol (oral) Generic/Brand † estradiol tablet,

ESTRACE

estradiol (transdermal) Generic/Brand †

ALORA, CLIMARA,

ESTRADIOL,

VIVELLE-DOT

estropipate Generic

EVISTA Brand

FEMHRT Brand

PREMARIN Brand

PREMPHASE Brand

PREMPRO Brand

VAGIFEM Brand


ANTIDIABETIC AGENTS

acarbose Generic

ACTOS Brand

glimepiride Generic


- 25 -


glipizide Generic

glipizide (extended release) Generic

glyburide Generic

glyburide & metformin hcl Generic

HUMALOG Brand

HUMALOG KWIKPEN Brand PA

HUMALOG MIX 50/50 Brand

HUMALOG MIX 50/50 PEN Brand PA

HUMALOG MIX 75/25 Brand

HUMALOG MIX 75/25 PEN Brand PA

HUMULIN R U-500 Brand

insulin isophane & regular

(human) pen Brand PA

insulin isophane & regular

(human) Brand

insulin isophane (human) Brand

insulin isophane (human) pen Brand PA

insulin regular (human) Brand

LANTUS Brand

LANTUS FOR OPTICLIK Brand PA

LANTUS SOLOSTAR Brand PA

LEVEMIR Brand

LEVEMIR FLEXPEN Brand PA

metformin hcl Generic

metformin hcl (extended release) Generic

NOVOLOG Brand

NOVOLOG FLEXPEN Brand PA

NOVOLOG MIX 70/30

FLEXPEN Brand PA

NOVOLOG MIX 70/30 Brand

tolazamide Generic

tolbutamide Generic


ANTIHYPOGLYCEMIC AGENTS

glucagon hcl Brand †


PARATHYROID

calcitonin (salmon) Generic QL

FORTEO Brand * PA, QL


PITUITARY


- 26 -


ACTHAR HP Brand * QL

desmopressin acetate Generic *


SOMATROPIN AGONISTS AND ANTAGONISTS

NORDITROPIN Brand * PA, QL

OMNITROPE Brand * PA, QL


PROGESTINS

medroxyprogesterone acetate Generic

norethindrone acetate Generic

PROMETRIUM Brand RB


THYROID AND ANTITHYROID AGENTS

ARMOUR THYROID Brand

levothyroxine sodium Generic/Brand †

liothyronine Generic

methimazole Generic

propylthiouracil Generic

SSKI Brand

thyroid Generic/Brand †

THYROLAR Brand

OXYTOCICS

OXYTOCICS

ERGOTRATE MALEATE Brand

methylergonovine Generic

SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)

AVC Brand

BACTROBAN Brand

BACTROBAN NASAL Brand

benzoyl peroxide & erythromycin Generic

ciclopirox olamine Generic

clindamycin phosphate (topical) Generic

clindamycin phosphate (vaginal) Generic

clotrimazole Generic

clotrimazole & betamethasone

dipropionate Generic

clotrimazole (topical) Generic

erythromycin (topical) Generic

EURAX Brand

EXELDERM Brand


- 27 -


gentamicin sulfate (topical) Generic

ketoconazole (topical) Generic

lindane Generic

metronidazole (topical) Generic/Brand † MD

metronidazole (vaginal) Generic

miconazole nitrate Brand

mupirocin (topical) Generic

NAFTIN Brand

nystatin (topical) Generic

nystatin (vaginal) Brand

permethrin Generic

selenium sulfide Generic

silver sulfadiazine Generic

sulfacetamide sodium (topical) Generic

ZOVIRAX Brand


ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)

APEXICON E Brand

augmented betamethasone

dipropionate Generic

betamethasone dipropionate

(topical) Generic

betamethasone valerate Generic

clobetasol propionate Generic

clobetasol propionate emollient

base Generic

CLODERM Brand

CORDRAN Brand

CORTIFOAM Brand

CORTISPORIN Brand

desonide Generic

desoximetasone Generic

diflorasone diacetate Generic

fluocinolone acetonide Brand

fluocinonide Generic

fluocinonide emulsified base Generic

fluticasone propionate Generic/Brand †

halobetasol propionate Generic

hydrocortisone (intrarectal) Generic

hydrocortisone (rectal) Generic

hydrocortisone (topical) Generic


- 28 -


hydrocortisone acetate (rectal) Generic

hydrocortisone valerate Generic

KENALOG Brand

mometasone furoate Generic

nystatin & triamcinolone Generic

pramoxine & hydrocortisone Brand

triamcinolone acetonide (mouth) Generic

triamcinolone acetonide (topical) Generic


ANTIPRURITICS AND LOCAL ANESTHETICS

hydrocortisone acetate &

pramoxine Generic/Brand †

lidocaine hcl Generic

phenazopyridine hcl Generic


CELL STIMULANTS AND PROLIFERANTS

RETIN-A MICRO Brand PA, QL

tretinoin Generic PA, QL


PIGMENTING AND DEPIGMENTING AGENTS

OXSORALEN Brand


SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS

aluminum chloride Generic

AMEVIVE Brand * PA, QL

calcipotriene Generic/Brand †

DIFFERIN Brand MD

DRITHO-CREME Brand

DRITHO-SCALP Brand

ELIDEL Brand MD, QL

FINACEA Brand MD

fluorouracil (topical) Generic/Brand †

imiquimod Generic

isotretinoin Generic

podofilox Generic/Brand †

PROTOPIC Brand MD

REGRANEX Brand PA, QL

TARGRETIN Brand

TAZORAC Brand QL

SMOOTH MUSCLE RELAXANTS

GENITOURINARY SMOOTH MUSCLE RELAXANTS


- 29 -


DETROL Brand

DETROL LA Brand

flavoxate hcl Generic

oxybutynin chloride Generic

oxybutynin chloride (extended

release) Generic

SMOOTH MUSCLE RELAXANTS

RESPIRATORY SMOOTH MUSCLE RELAXANTS

aminophylline Generic

theophylline Generic/Brand †

VITAMINS

VITAMIN B COMPLEX

folic acid Generic

VITAMINS

VITAMIN D

calcitriol Generic

ergocalciferol Generic

VITAMINS

VITAMIN K ACTIVITY

MEPHYTON Brand

VITAMINS

PRENATAL VITAMINS

prenatal vitamin with docusate,

ferrous fumarate, & folic acid Generic

prenatal vitamin with docusate,

iron carbonyl, & folic acid Generic

prenatal vitamin with ferrous

fumarate & folic acid Generic/Brand †

prenatal vitamin with iron

polysaccharide complex & folic

acid

Generic

prenatal vitamin with minerals,

iron, & folic acid Brand

prenatal vitamin with selenium,

ferrous fumarate, & folic acid Generic

prenatal vitamin without vitamin

a, with iron carbonyl, docusate, &

folic acid

Generic

VITAMINS

PEDIATRIC MULTIVITAMINS

pediatric multivitamins with Generic/Brand †


- 30 -


fluoride

pediatric vitamins A, C, D, with

fluoride Generic/Brand †

MISCELLANEOUS THERAPEUTIC AGENTS

ALCOHOL DETERRENTS

disulfiram Generic


5-ALPHA-REDUCTASE INHIBITORS

finasteride Generic MD, ST


ANTIDOTES

acetylcysteine Generic

leucovorin calcium Generic/Brand *†


ANTIGOUT AGENTS

allopurinol Generic

colchicine Generic


BIOLOGIC RESPONSE MODIFIERS

COPAXONE Brand * MD, PA, QL

REBIF Brand * MD, PA, QL

REVLIMID Brand QL

THALOMID Brand QL


BONE RESORPTION INHIBITORS

alendronate sodium Generic

etidronate disodium Generic/Brand †

FOSAMAX PLUS D Brand


CARIOSTATIC AGENTS

sodium fluoride Generic


DISEASE-MODIFYING ANTIRHEUMATIC DRUGS

ENBREL Brand * MD, QL

HUMIRA Brand * MD, QL

KINERET Brand * PA, QL

leflunomide Generic PA


IMMUNOSUPPRESSIVE AGENTS

azathioprine Generic

cyclosporine modified (for Generic/Brand †


- 31 -


microemulsion)

mycophenolate mofetil Generic

MYFORTIC Brand

RAPAMUNE Brand

SANDIMMUNE Brand

tacrolimus Generic


PROTECTIVE AGENTS

ELMIRON Brand


OTHER MISCELLANEOUS THERAPEUTIC AGENTS

levocarnitine Generic/Brand †

yohimbine hcl Generic RB


- 32 -

INDEX OF DRUGS

Kaiser Permanente 2011 Southern Colorado

Commercial HMO Comprehensive Formulary Index

A

ABILIFY 13

ABILIFY DISCMELT 13

acarbose 24

acebutolol hcl 10

acetaminophen with codeine 11

acetazolamide 19

acetic acid & aluminum acetate 20

acetic acid (otic) 20

acetylcysteine 30

ACTHAR HP 26

ACTIQ 11

ACTOS 24

acyclovir 4

ADDERALL XR 14

ADVAIR DISKUS 7

ADVAIR HFA 7

AFINITOR 6

ALAMAST 17

ALBENZA 3

albuterol sulfate 7

alendronate sodium 30

ALKERAN 6

allopurinol 30

ALOCRIL (ophthalmic) 17

ALOMIDE (ophthalmic) 17

ALORA 24

alprazolam 14

aluminum chloride 28

amantadine hcl 15

AMEVIVE 28

aminocaproic acid 9

aminophylline 29

amiodarone hcl 9

amitriptyline hcl 13

amlodipine besylate 10

amlodipine besylate & benazepril hcl 10

amoxapine 13

amoxicillin 3

amoxicillin & potassium 3

amphetamine & dextroamphetamine 14

ampicillin 3

amylase 109,000 units; lipase 20,000 units; protease

68,000 units 21

amylase 12,000 units; lipase 4,000 units; protease 12,000

units 20


units 20, 21


units 20


units 20


units 20


units 20


units 21


units 21


units 21


units 21


units 21


units 21

anagrelide hcl 8

anastrozole 6

ANDRODERM 22

ANDROGEL 22

antipyrine, benzocaine & polycosanol 19

ANTIVERT 21

APEXICON E 27

APOKYN 15

APRI 23

APTIVUS 4

ARICEPT 7

ARICEPT ODT 7

ARMOUR THYROID 26

ASACOL 22

ASMANEX 22

ASTELIN 17

atenolol 10

atenolol & chlorthalidone 10

atovaquone/proguanil 5

ATRIPLA 4

atropine sulfate (ophthalmic) 19

augmented betamethasone dipropionate 27

AVC 26

AVELOX 3

azathioprine 30

azelastine hcl (ophthalmic) 17

azithromycin 3

AZOPT (ophthalmic) 19

B

bacitracin & polymyxin B (ophthalmic) 18

bacitracin (ophthalmic) 18

baclofen 8

BACTROBAN 26


- 33 -

BACTROBAN NASAL 26

BARACLUDE 4

belladonna alkaloids & phenobarbital 7

belladonna alkaloids, 6

benazepril & hydrochlorothiazide 11

benazepril hcl 11

benzocaine & antipyrine (otic) 19

benzonatate 17

benzoyl peroxide & erythromycin 26

benztropine mesylate 15

betamethasone dipropionate (topical) 27

betamethasone valerate 27

betaxolol hcl (ophthalmic) 19

bethanechol chloride 7

BETIMOL 19

BETOPTIC-S (ophthalmic) 19

bicalutamide 6

BILTRICIDE 3

bisoprolol fumarate 10

bisoprolol fumarate & hydrochlorothiazide 10

BLEPHAMIDE (ophthalmic) 18

BLEPHAMIDE S.O.P. 18

brimonidine tartrate 19

bromocriptine mesylate 15

budesonide (nebulized) 22

budesonide (oral) 22

bumetanide 17

bupropion hcl 13

buspirone hcl 15

butalbital, acetaminophen & caffeine 11

butalbital, acetaminophen, caffeine & codeine 12

butalbital, aspirin & caffeine 12

butalbital, aspirin, caffeine & codeine 12

BYSTOLIC 10

C

cabergoline 15

calcipotriene 28

calcitonin (salmon) 25

calcitriol 29

calcium acetate (phosphate binde)r 16

captopril 11

captopril & hydrochlorothiazide 11

carbamazepine 12

carbamazepine (extended release) 13

carbidopa & levodopa 15

carbidopa & levodopa (extended release) 15

CARDENE SR 10

carisoprodol 8

carisoprodol & aspirin 8

carteolol hcl (ophthalmic) 19

carvedilol 10

CAVERJECT 10

CEENU 6

cefaclor 3

cefadroxil 3

cefdinir 3

cefprozil 3

cefuroxime axetil 3

CELEBREX 12

CELESTONE 22

CELONTIN 13

cephalexin 3

CESIA 23

CHLORAL HYDRATE 15

chlordiazepoxide & amitriptyline 13

chlordiazepoxide & clidinium 7

chlordiazepoxide hcl 15

chlorhexidine gluconate (dental) 18

chloroquine phosphate 5

chlorpromazine hcl 13

chlorthalidone 17

cholestyramine 9

choline magnesium trisalicylate 12

CIALIS 10

ciclopirox olamine 26

cilostazol 8

CIPRO HC (otic) 18

CIPRODEX 18

ciprofloxacin hcl 3

ciprofloxacin hcl (ophthalmic) 18

citalopram hydrobromide 13

clarithromycin 3

CLIMARA 24

clindamycin hcl 3

clindamycin phosphate (topical) 26

clindamycin phosphate (vaginal) 26

clobetasol propionate 27

clobetasol propionate emollient base 27

CLODERM 27

clomipramine hcl 13

clonazepam 13

clonidine hcl 9

clorazepate dipotassium 15

clotrimazole 26

clotrimazole & betamethasone dipropionate 26

clotrimazole (topical) 26

colchicine 30

COLY-MYCIN-S (otic) 18

COMBIPATCH 24

COMBIVENT 7

COMBIVIR 4

COMTAN 15

COPAXONE 30

CORDRAN 27

COREG CR 10

CORTIFOAM 27

cortisone acetate 22

CORTISPORIN 27

CRESTOR 9

CRIXIVAN 4

cromolyn sodium 17

cromolyn sodium (ophthalmic) 17

CRYSELLE 24

CUPRIMINE 22


- 34 -

CYCLESSA 23

cyclobenzaprine hcl 8

cyclophosphamide 6

cyclosporine modified (for microemulsion) 30

cyproheptadine hcl 3

D

danazol 22

dantrolene sodium 8

dapsone 4

DARAPRIM 5

DELATESTRYL 22

desipramine hcl 13

desmopressin acetate 26

DESOGEN 23

desogestrel & ethinyl estradiol (monophasic) 23

desogestrel & ethinyl estradiol (triphasic) 23

desonide 27

desoximetasone 27

DETROL 29

DETROL LA 29

dexamethasone 22

dexmethylphenidate hcl 14

dextroamphetamine sulfate 14

diazepam 15

DIBENZYLINE 8

diclofenac sodium 12

diclofenac sodium (ophthalmic) 18

dicloxacillin 3

dicyclomine hcl 7

didanosine 4

DIFFERIN 28

diflorasone diacetate 27

digoxin 9

dihydroergotamine mesylate 8

diltiazem hcl 11

DIOVAN 11

DIOVAN HCT 11

DIPENTUM 22

diphenoxylate & atropine 20

dipyridamole 10

disopyramide phosphate 9

disulfiram 30

divalproex sodium 13

divalproex sodium (extended release) 13

DONNATAL EXTENTABS 7

dorzolamide hcl & timolol maleate (ophthalmic) 19

dorzolamide hcl (ophthalmic) 19

doxazosin mesylate 10

doxepin hcl 13

doxycycline 3

DRITHO-CREME 28

drospirenone & ethinyl estradiol 23

DULERA 7

E

EDEX 10

EFFIENT 8

ELIDEL 28

ELMIRON 31

EMCYT 6

EMEND 21

EMTRIVA 4

enalapril maleate 11

ENBREL 30

ENPRESSE 23

epinephrine hcl 8

EPIVIR 4

EPIVIR HBV 4

EPOGEN 8

EPZICOM 4

ergocalciferol 29

ERGOMAR 8

ergotamine tartrate & caffeine 15

ERGOTRATE MALEATE 26

erythromycin (ophthalmic) 18

erythromycin (topical) 26

erythromycin base 3

erythromycin ethylsuccinate 3

erythromycin stearate 3

erythromycin sulfisoxazole 3

estazolam 15

esterified estrogens & methyltestosterone 24

ESTRACE 24

ESTRACE VAGINAL 24

ESTRADIOL 24

estradiol (oral) 24

estradiol (transdermal) 24

estropipate 24

ethambutol 4

ethosuximide 13

ethynodiol diacetate & ethinyl estradiol 23

etidronate disodium 30

etodolac 12

etoposide 6

EURAX 26

EVISTA 24

EVOXAC 7

EXELDERM 26

exemestane 6

EXFORGE 11

EXFORGE HCT 11

F

famciclovir 5

famotidine 21

felbamate 13

felodipine 11

FEMHRT 24

fenofibrate 9

fenofibrate (micronized) 9


- 35 -

fenoprofen calcium 12

fentanyl 12

FENTORA 12

fexofenadine hcl 3

FINACEA 28

finasteride 30

FLAREX 18

flavoxate hcl 29

flecainide acetate 9

FLOVENT DISKUS 22

FLOVENT HFA 22

fluconazole 4

fludrocortisone acetate 22

flunisolide (nasal) 18

fluocinolone acetonide 27

fluocinonide 27

fluocinonide emulsified base 27

fluorometholone (ophthalmic) 18

fluorouracil (topical) 28

fluoxetine hcl 13

fluoxymesterone 22

fluphenazine hcl 13

flurazepam hcl 15

flurbiprofen sodium (ophthalmic) 18

flutamide 6

fluticasone propionate 27

fluticasone propionate (nasal) 18

fluvoxamine maleate 13

FML FORTE 18

FOCALIN XR 14

folic acid 29

fondaparinux 8

FORTEO 25

FOSAMAX PLUS D 30

fosinopril sodium 11

fosinopril sodium & hydrochlorothiazide 11

FRAGMIN 8

FROVA 15

furosemide 17

G

gabapentin 13

GABITRIL 13

galantamine hbr 7

galantamine hbr (extended release) 7

ganciclovir 5

gemfibrozil 9

gentamicin sulfate (ophthalmic) 18

gentamicin sulfate (topical) 27

GEODON 13

GLEEVEC 6

glimepiride 24

glipizide 25

glucagon hcl 25

glyburide 25

glyburide & metformin hcl 25

glycopyrrolate 7

GRIS-PEG 4

guaifenesin & codeine 17

guanfacine hcl 9

H

halobetasol propionate 27

haloperidol 13

HELIDAC 3

heparin sodium 8

HEPSERA 5

HEXALEN 6

HUMALOG 25

HUMALOG KWIKPEN 25

HUMALOG MIX 50/50 25

HUMALOG MIX 50/50 PEN 25

HUMALOG MIX 75/25 25

HUMALOG MIX 75/25 PEN 25

HUMIRA 30

HUMULIN R U-500 25

hydralazine hcl 9

hydrochlorothiazide 17

hydrocodone & acetaminophen 12

hydrocortisone 22

hydrocortisone & acetic acid (otic) 18

hydrocortisone (intrarectal) 27

hydrocortisone (rectal) 27

hydrocortisone (topical) 27

hydrocortisone acetate & pramoxine 28

hydrocortisone acetate (rectal) 28

hydrocortisone valerate 28

hydromorphone hcl 12

hydroxychloroquine sulfate 5

hydroxyurea 6

hydroxyzine hcl 15

hydroxyzine pamoate 15

hyoscyamine sulfate 7

I

ibuprofen 12

imipramine hcl 13

imipramine pamoate 13

imiquomod 28

indapamide 17

indomethacin 12

INFERGEN 5

INNOHEP 8

insulin isophane & regular (human) 25

insulin isophane & regular (human) pen 25

insulin isophane (human) 25

insulin isophane (human) pen 25

insulin regular (human) 25

INTELENCE 5

INTRON-A 6

INVIRASE 5

ipratropium bromide (inhaled 7

ipratropium bromide (nasal) 7


- 36 -

IRESSA 6

ISENTRESS 5

isoniazid 4

ISOPTO CARBACHOL (ophthalmic) 19

isosorbide dinitrate 10

isosorbide mononitrate 10

isotretinoin 28

isradipine 11

itraconazole 4

J

JOLESSA 23

K

KALETRA 5

KARIVA 23

KELNOR 23

KENALOG 28

ketoconazole 4, 27

ketoprofen 12

ketorolac tromethamine 12

ketorolac tromethamine (ophthalmic)) 18

KINERET 30

L

labetalol hcl 10

lactulose 16

lamotrigine 13

lansoprazole 21

lansoprazole ODT 21

LANTUS 25

LANTUS FOR OPTICLIK 25

LANTUS SOLOSTAR 25

latanoprost 19

leflunomide 30

LESSINA 23

LETAIRIS 10

letrozole 6

leucovorin calcium 30

LEUKERAN 6

LEUKINE 8

leuprolide acetate 6

LEVEMIR 25

LEVEMIR FLEXPEN 25

levetiracetam 13

LEVITRA 10

levobunolol hcl (ophthalmic) 19

levocarnitine 31

levofloxacin 3

levonorgestrel & ethinyl estradiol (91-day) 23

levonorgestrel & ethinyl estradiol (monophasic) 23

levonorgestrel & ethinyl estradiol (triphasic) 23

levonorgestrel (emergency oral contraceptive 23

levothyroxine sodium 26

LEXAPRO 13

LEXIVA 5

lidocaine hcl 28

lidocaine hcl (mouth-throat) 19

lindane 27

liothyronine 26

lisinopril 11

lisinopril & hydrochlorothiazide 11

lithium carbonate 15

lithium carbonate (extended release) 15

LO/OVRAL 24

LOESTRIN 1.5/30 23

LOESTRIN 1/20 23

LOESTRIN FE 1.5/30 24

LOESTRIN FE 1/20 24

lorazepam 15

losartan potassium 11

losartan potassium & hydrochlorothiazide 11

lovastatin 9

LOVENOX 8

LOW-OGESTREL 24

loxapine succinate 14

LUMIGAN 20

LYSODREN 6

M

maprotiline hcl 14

MATULANE 6

MAXAIR AUTOHALER 8

mebendazole 3

meclofenamate sodium 12

medroxyprogesterone acetate 26

mefloquine hcl 5

megestrol acetate 6

MEPHYTON 29

mercaptopurine 6

metaproterenol sulfate 8

metformin hcl 25

metformin hcl (extended release) 25

methadone hcl 12

methazolamide 20

methimazole 26

METHITEST 22

methocarbamol 8

methotrexate 6

methyldopa 9

methylergonovine 26

methylphenidate hcl 14

methylphenidate hcl (extended release) 14

methylprednisolone 22

metipranolol (ophthalmic) 20

metoclopramide hcl 21

metolazone 17

metoprolol succinate 10

metoprolol tartrate 10

metronidazole 5

metronidazole (topical) 27

metronidazole (vaginal) 27


- 37 -

mexiletine hcl 9

miconazole nitrate 27

MICROGESTIN 1.5/30 23

MICROGESTIN 1/20 23

MICROGESTIN FE 1.5/30 24

MICROGESTIN FE 1/20 24

midodrine hcl 8

minocycline 3

MIRCETTE 23

mirtazapine 14

misoprostol 21

MOBAN 14

MODICON 23

moexipril & hydrochlorothiazide 11

moexipril hcl 11

mometasone furoate 28

morphine sulfate 12

morphine sulfate (extended release) 12

mupirocin (topical) 27

MUSE 10

MYCOBUTIN 4

mycophenolate mofetil 31

MYFORTIC 31

MYLERAN 6

N

nabumetone 12

nadolol 10

NAFTIN 27

naltrexone hcl 12

naproxen 12

naproxen sodium 12

NARDIL 14

NASONEX 18

NEBUPENT 5

NECON 1/50 23

NECON 10/11 23

NECON 7/7/7 23

NEFAZODONE HCL 14

neomycin sulfate 3

neomycin, bacitracin & polymyxin B (ophthalmic) 18

neomycin, polymyxin & dexamethasone (ophthalmic) 18

neomycin, polymyxin & hydrocortisone (ophthalmic) 19

neomycin, polymyxin & hydrocortisone (otic) 19

neomycin, polymyxin, bacitracin & hydrocortisone

(ophthalmic) 18

NEULASTA 9

NEXAVAR 6

NIASPAN 9

NICOTROL 8

nifedipine 11

NILANDRON 6

nitrofurantoin macrocrystals 6

nitrofurantoin monohydrate macrocystals 6

nitroglycerin 10

NORA-BE 23

NORDETTE 23

NORDITROPIN 26

norethindrone & ethinyl estradiol (biphasic) 23

norethindrone & ethinyl estradiol (monophasic) 23

norethindrone & ethinyl estradiol (triphasic) 23

norethindrone & mestranol 23

norethindrone (contraceptive) 23

norethindrone acetate 26

norethindrone acetate & ethinyl estradiol 23

norethindrone acetate, estradiol, & iron 24

norgestimate & ethinyl estradiol (monophasic) 24

norgestimate & ethinyl estradiol (triphasic) 24

norgestrel & ethinyl estradiol 24

NOROXIN 4

NOR-QD 23

NORTREL 0.5/35 23

NORTREL 1/35, 23

NORTREL 7/7/7 23

nortriptyline hcl 14

NORVIR 5

NOVOLOG 25

NOVOLOG FLEXPEN 25

NOVOLOG MIX 70/30 25

NOVOLOG MIX 70/30 FLEXPEN 25

NUVARING 24

nystatin 4

nystatin & triamcinolone 28

nystatin (topical) 27

nystatin (vaginal) 27

O

ofloxacin (ophthalmic) 18

ofloxacin (otic) 18

OGESTREL 24

olanzapin 14

olanzapine ODT 14

omeprazole 21

OMNITROPE 26

ondansetron hcl 21

ONSOLIS 12

ORTHO DIAPHRAGM ALL-FLEX KITs 55, 60, 65, 70,

75, 80, 85, 90, 95 16

ORTHO DIAPHRAGM COIL SPRING KITs 50, 100

AND 105 16

ORTHO DIAPHRAGM FLAT SPRING KITs 55, 60, 65,

70, 75, 80, 85, 90, and 95 16

ORTHO EVRA 24

ORTHO TRI-CYCLEN 24

ORTHO-CEPT 23

ORTHO-CYCLEN 24

ORTHO-MICRONOR 23

ORTHO-NOVUM 1/35 23

ORTHO-NOVUM 1/50 23

ORTHO-NOVUM 7/7/7 23

oxaprozin 12

oxazepam 15

oxcarbazepine 13

OXSORALEN 28


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oxybutynin chloride 29

oxybutynin chloride (extended release) 29

oxycodone & acetaminophen 12

oxycodone & aspirin 12

oxycodone hcl 12

oxycodone hcl (extended release) 12

P

pantoprazole sodium 21

paromomycin sulfate 6

paroxetine hcl 14

paroxetine hcl (extended release) 14

PATANOL 17

pediatric multivitamins with fluoride 29

pediatric vitamins A, C, D, with fluoride 30

PEGASYS 5

PEG-INTRON 5

penicillin V potassium 4

PENTASA 22

pentoxifylline 9

permethrin 27

perphenazine 14

phenazopyridine hcl 28

phenobarbital 15

phenytoin 13

phenytoin sodium (extended release) 13

PHOSPHOLINE IODIDE (ophthalmic) 20

pilocarpine hcl (ophthalmic) 20

pindolol 10

PLAVIX 8

podofilox 28

polyethylene glycol 3350, 20

polyethylene glycol 3350, potassium chloride, sodium

bicarbonate & sodium chloride 20

polymyxin B & trimethoprim 18

POLY-PRED (ophthalmic) 19

PORTIA 23

potassium and sodium citrates with citric acid 16

potassium bicarbonate & potassium chloride 16

potassium chloride 16

potassium citrate 16

pramipexole dihydrochloride 15

pramoxine & hydrocortisone 28

pravastatin 9

prazosin hcl 10

PRED-G (ophthalmic) 19

PRED-G S.O.P. (ophthalmic) 19

prednisolone 22

prednisolone acetate (ophthalmic) 19

prednisolone sodium phosphate 22

prednisolone sodium phosphate (ophthalmic) 19

prednisone 22

PREMARIN 24

PREMPHASE 24

PREMPRO 24

prenatal vitamin with docusate, ferrous fumarate, & folic

acid 29

prenatal vitamin with docusate, iron carbonyl, & folic acid

29

prenatal vitamin with ferrous fumarate & folic acid 29

prenatal vitamin with iron polysaccharide complex & folic

acid 29

prenatal vitamin with minerals, iron, & folic acid 29

prenatal vitamin with selenium, ferrous fumarate, & folic

acid 29

prenatal vitamin without vitamin a, with iron carbonyl,

docusate, & folic acid 29

PREVIFEM 24

PREZISTA 5

primaquine phosphate 6

primidone 13

probenecid 17

probenecid & colchicine 17

prochlorperazine maleate 14

PROCRIT 9

promethazine hcl 3

PROMETRIUM 26

propafenone hcl 9

propranolol hcl 10

propylthiouracil 26

PROSTIGMIN 7

PROTOPIC 28

protriptyline hcl 14

PROVIGIL 14

PULMICORT FLEXHALER 22

PULMOZYME 17

pyrazinamide 4

pyridostigmine bromide 7

Q

quinapril & hydrochlorothiazide 11

quinapril hcl 11

quinidine gluconate 9

quinidine sulfate 9

QVAR 22

R

ramipril 11

ranitidine hcl 21

RAPAMUNE 31

REBIF 30

REGRANEX 28

RELENZA 5

RENAGEL 16

RENVELA 16

RENVELA PAK 16

RESCRIPTOR 5

reserpine 9

RETIN-A MICRO 28

REVLIMID 30

REYATAZ 5

ribavirin 5

RIDAURA 22


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rifampin 4

RILUTEK 16

rimantadine 5

risperidone 14

ropinirole hcl 15

S

salsalate 12

SANDIMMUNE 31

SAVELLA 16

SEASONIQUE 23

selegiline hcl 16

selenium sulfide 27

SELZENTRY 5

SEREVENT DISKUS 8

SEROQUEL 14

sertraline hcl 14

silver sulfadiazine 27

simvastatin 9

SINGULAIR 17

sodium chloride for nebulization 17

sodium citrate & citric acid 16

sodium fluoride 30

sodium polystyrene sulfonate 16

sotalol hcl 10

SPECTRACEF 4

SPIRIVA 7

spironolactone 11

spironolactone & hydrochlorothiazide 11

SPRINTEC 24

SPRYCEL 7

SSKI 26

stavudine 5

STROMECTOL 3

sucralfate 21

sulfacetamide sodium & prednisolone sodium phosphate

(ophthalmic) 19

sulfacetamide sodium (ophthalmic) 18

sulfacetamide sodium (topical) 27

sulfadiazine 4

sulfamethoxazole & trimethoprim 4

sulfasalazine 4

sulindac 12

sumatriptan succinate 15

SUPRAX 4

SUSTIVA 5

SUTENT 7

T

TABLOID 7

tacrolimus 31

TAMIFLU 5

tamoxifen citrate 7

tamsulosin hcl 8

TARCEVA 7

TARGRETIN 7, 28

TARKA 11

TAZORAC 28

temazepam 15

TEMODAR 7

terazosin hcl 10

terbinafine 4

terbutaline sulfate 8

testosterone 22

testosterone cypionate 22

tetracycline 4

THALOMID 30

theophylline 29

thioridazine hcl 14

thiothixene 14

thyroid 26

THYROLAR 26

TIKOSYN 9

timolol maleate (ophthalmic) 20

tizanidine hcl 8

TOBI NEB 4

tobramycin sulfate & dexamethasone (ophth) 19

tobramycin sulfate (ophthalmic) 18

tolazamide 25

tolbutamide 25

topiramate 13

torsemide 17

TRACLEER 10

tramadol hcl 12

tranylcypromine sulfate 14

trazodone hcl 14

tretinoin 7, 28

triamcinolone acetonide (mouth) 28

triamcinolone acetonide (topical) 28

triamterene & hydrochlorothiazide 17

triazolam 15

trifluoperazine hcl 14

trifluridine (ophth) 18

trihexyphenidyl hcl 16

trimethoprim 6

trimipramine maleate 14

TRI-NORINYL 23

TRI-PREVIFEM 24

TRI-SPRINTEC 24

TRIVORA 23

TRIZIVIR 5

tropicamide (ophthalmic) 19

TRUVADA 5

TUSSIONEX 17

TYKERB 7

TYZEKA 5

U

ursodiol 20

V

VAGIFEM 24


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VALCYTE 5

valproic acid 13

VALTREX 5

VANCOCIN 4

VELIVET 23

venlafaxine hcl 14

venlafaxine hcl (extended release) 14

verapamil hcl 11

VFEND 4

VIAGRA 10

VIRACEPT 5

VIRAMUNE 5

VIREAD 5

VIVELLE-DOT 24

VYTORIN 9

W

warfarin sodium 8

WIDE-SEAL SILICONE DIAPHRAGM KITs 60, 65, 70,

75, 80, 85, 90, and 95 16

X

XELODA 7

XOPENEX 8

Y

YASMIN 23

YODOXIN 6

yohimbine hcl 31

Z

zafirlukast 17

zaleplon 15

ZETIA 9

ZIAGEN 5

zidovudine 5

ZOLINZA 7

zolpidem tartrate 15

ZOMIG 15

ZOMIG ZMT 15

zonisamide 13

ZOVIA 1/35E 23

ZOVIA 1/50E 23

ZOVIRAX 27

ZYMAXID 18

ZYVOX 4

Kaiser Permanente: Southern Colorado Commercial HMO Drug Formulary

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Transcript of Kaiser Permanente: Southern Colorado Commercial HMO Drug Formulary