Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Kaiser Permanente Colorado PPO/POS Preferred Product List
The following is a listing of the drugs on the Kaiser Permanente Southern Colorado PPO & Denver/Boulder PPO/POS preferred product listing. This product listing 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 listing 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 preferred product listing. Kaiser Permanente has many brand and generic medications on the preferred product listing. In most cases, a generic equivalent is used when available. Members will be notified when a generic equivalent is dispensed. 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. Kaiser Permanente may implement programs, such as a therapeutic interchange program, to promote safe and effective drug therapy. In these cases the prescribing provider and member are notified prior to a change occurring.
How to use this Preferred Product List 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-preferred drug. You can search the list 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. Some drugs are available in more than one dosage form (example: tablet and injectable). Not all dosage forms of drugs are covered under the prescription drug benefit. 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:
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.
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a specific days supply or quantity per copay. 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 individual prescription benefit specifically covers such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless the prescription benefit specifically covers 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.
Restricted to a specific age: Some medications may be restricted to a certain age or age range.
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 preferred product list 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 preferred product list, 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. (diamond) = A drug that is designated as a Specialty drug which may process at a Specialty tier of the individual prescription drug benefit, where applicable. † (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. AG = A drug that is restricted to a specific age range. NC = A drug that is specifically excluded under certain benefit plans. 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 Kaiser Permanente Member Services at 1-888-681-7878. The medications on this list are subject to change at any time throughout the year
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ALBENZA Brand
BILTRICIDE Brand
ivermectin Generic
MEBENDAZOLE Brand
ANTIBACTERIALS
amoxicillin Generic/Brand †
amoxicillin & pot clavulanate Generic/Brand †
ampicillin Generic/Brand †
azithromycin Generic/Brand †
CAYSTON Brand
cefaclor Generic/Brand †
cefadroxil Generic
cefdinir Generic
cefixime Generic
cefprozil Generic
cefuroxime axetil Generic/Brand †
cephalexin Generic
ciprofloxacin hcl Generic/Brand †
ciprofloxacin-ciprofloxacin hcl Generic
clarithromycin Generic
clindamycin hcl Generic
clindamycin palmitate hydrochloride Generic
dicloxacillin sodium Generic
doxycycline hyclate Generic
E.E.S. 400 Brand
ERYTHROCIN STEARATE Brand
erythromycin base Generic/Brand †
erythromycin-sulfisoxazole Generic
levofloxacin Generic
linezolid Generic/Brand * QL
minocycline hcl Generic
moxifloxacin hcl Generic
NEO-FRADIN Brand
NOROXIN Brand
PCE Brand
penicillin v potassium Generic
SPECTRACEF Brand
SULFADIAZINE Brand
sulfamethoxazole-trimethoprim Generic
sulfasalazine Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
SUPRAX Brand
TETRACYCLINE HCL Brand
TOBI Podhaler Brand QL
tobramycin neb Generic QL
vancomycin hcl Generic QL
ZYVOX Brand * QL
ANTIFUNGALS
fluconazole Generic
griseofulvin ultramicrosize Generic
itraconazole Generic/Brand †
ketoconazole Generic
nystatin Generic
nystatin (mouth-throat) Generic
terbinafine hcl Generic
voriconazole Generic
ANTIMYCOBACTERIALS
DAPSONE Brand
ethambutol hcl Generic
isoniazid Generic/Brand †
pyrazinamide Generic
rifabutin Generic
rifampin Generic
ANTIPROTOZOALS
atovaquone Generic
atovaquone-proguanil hcl Generic
chloroquine phosphate Generic
DARAPRIM Brand
hydroxychloroquine sulfate Generic
mefloquine hcl Generic
metronidazole Generic
NEBUPENT Brand
paromomycin sulfate Generic
PRIMAQUINE PHOSPHATE Brand
YODOXIN Brand
ANTIVIRALS
abacavir-lamivudine-zidovudine Generic
abacavir sulfate Generic/Brand †
acyclovir Generic
adefovir dipivoxil Generic QL
APTIVUS Brand
ATRIPLA Brand
BARACLUDE Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
CRIXIVAN Brand
didanosine Generic/Brand †
EMTRIVA Brand
entecavir Generic †
EPIVIR HBV Brand
EPZICOM Brand
famciclovir Generic
GANCICLOVIR Brand QL
HARVONI Brand QL
INFERGEN Brand * QL
INTELENCE Brand
INVIRASE Brand
ISENTRESS Brand
KALETRA Brand
lamivudine Generic/Brand †
lamivudine-zidovudine Generic
LEXIVA Brand
nevirapine Generic
NORVIR Brand
PEG-INTRON Brand * QL
PEGASYS Brand * QL
PREZISTA Brand
RELENZA DISKHALER Brand QL
RESCRIPTOR Brand
REYATAZ Brand
ribavirin (hepatitis c) Generic QL
rimantadine hydrochloride Generic
SELZENTRY Brand
SOVALDI Brand QL
stavudine Generic
SUSTIVA Brand
TAMIFLU Brand QL
TRUVADA Brand
TYZEKA Brand QL
valacyclovir hcl Generic
valganciclovir Generic QL
VICTRELIS Brand QL
VIRACEPT Brand
VIRAZOLE Brand QL
VIREAD Brand
zidovudine Generic
URINARY ANTI-INFECTIVES
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
methenamine-hyosc-methylene blue-sod phos-phenyl sal Generic
nitrofurantoin Generic
nitrofurantoin macrocrystal Generic/Brand †
nitrofurantoin monohyd macro Generic
PRIMSOL Brand
trimethoprim Generic
ANTIHISTAMINE DRUGS
ANTIHISTAMINE DRUGS
cyproheptadine hcl Generic
promethazine hcl Generic/Brand *†
ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS
AFINITOR Brand QL
ALKERAN Brand
anastrozole Generic
bicalutamide Generic
capecitabine Generic
CEENU Brand
CYCLOPHOSPHAMIDE Brand
ELIGARD Brand *
EMCYT Brand QL
ETOPOSIDE Brand
exemestane Generic
flutamide Generic
GLEEVEC Brand QL
HEXALEN Brand
hydroxyurea Generic
IMBRUVICA Brand QL
INTRON-A Brand * QL
IRESSA Brand QL
letrozole Generic
LEUKERAN Brand
leuprolide acetate Generic/Brand * †
LUPRON DEPOT Brand *
LUPRON DEPOT-PED Brand *
LYSODREN Brand QL
MATULANE Brand QL
megestrol acetate Generic
melphalan hcl Generic *
mercaptopurine Generic
methotrexate sodium Generic/Brand †
MYLERAN Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
NEXAVAR Brand QL
NILANDRON Brand
PURIXAN Brand
RHEUMATREX Brand
SPRYCEL Brand QL
SUTENT Brand QL
TABLOID Brand
tamoxifen citrate Generic
TARCEVA Brand QL
TARGRETIN Brand QL
temozolomide Generic QL
tretinoin (chemotherapy) Generic QL
TYKERB Brand QL
VOTRIENT Brand QL
XTANDI Brand QL
ZELBORAF Brand QL
ZOLINZA Brand QL
ZYDELIG Brand QL
ZYTIGA Brand QL
AUTONOMIC DRUGS
ANTICHOLINERGIC AGENTS
ATROVENT HFA Brand
clidinium & chlordiazepoxide Generic
dicyclomine hcl Generic/Brand †
DONNATAL Brand
glycopyrrolate Generic
hyoscyamine sulfate Generic
ipratropium bromide Generic
ipratropium bromide (nasal) Generic
SPIRIVA RESPIMAT Brand
AUTONOMIC DRUGS, MISCELLANEOUS
phenoxybenzamine hcl Generic
tamsulosin hcl Generic
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
bethanechol chloride Generic
cevimeline hcl Generic
donepezil hydrochloride Generic
galantamine hydrobromide Generic
PROSTIGMIN Brand
pyridostigmine bromide Generic/Brand †
SKELETAL MUSCLE RELAXANTS
baclofen Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
carisoprodol Generic
carisoprodol w/ aspirin Generic
cyclobenzaprine hcl Generic
dantrolene sodium Generic
methocarbamol Generic/Brand *†
tizanidine hcl Generic
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ADRENALIN Brand * QL
ADVAIR DISKUS Brand
albuterol sulfate Generic/Brand †
COMBIVENT Brand
COMBIVENT RESPIMAT Brand
epinephrine hcl Generic *
levalbuterol hcl Generic
METAPROTERENOL SULFATE Brand
midodrine hcl Generic
SEREVENT DISKUS Brand
terbutaline sulfate Generic
XOPENEX HFA Brand
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
ANTITHROMBOTIC AGENTS
anagrelide hcl Generic
cilostazol Generic
clopidogrel bisulfate Generic
EFFIENT Brand
fondaparinux sodium Generic/Brand * QL
FRAGMIN Brand * QL
heparin sod (porcine) in d5w Generic *
heparin sodium (porcine) Generic/Brand *
heparin sodium (porcine) lock flush Generic/Brand *
INNOHEP Brand * QL
LOVENOX Brand * QL
COAGULANTS AND ANTICOAGULANTS
aminocaproic acid Generic/Brand †
BRILINTA Brand
pentoxifylline Generic
warfarin sodium Generic
HEMATOPOIETIC AGENTS
EPOGEN Brand * QL
LEUKINE Brand * QL
NEULASTA Brand * QL
PROCRIT Brand * QL
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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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
ANTILIPEMIC AGENTS
cholestyramine Generic
cholestyramine light Generic
CRESTOR Brand
fenofibrate Generic
fenofibrate micronized Generic
gemfibrozil Generic
lovastatin Generic
NIASPAN Brand
pravastatin sodium Generic
simvastatin Generic
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl Generic
atenolol Generic
atenolol & chlorthalidone Generic
bisoprolol & hydrochlorothiazide Generic
bisoprolol fumarate Generic
BYSTOLIC Brand
carvedilol Generic
COREG CR Brand
labetalol hcl Generic
metoprolol succinate Generic
metoprolol tartrate Generic
nadolol Generic
pindolol Generic
propranolol hcl Generic
sotalol hcl Generic
CALCIUM-CHANNEL BLOCKING AGENTS
amlodipine besylate Generic
amlodipine besylate-benazepril hcl Generic
CARDENE SR Brand
diltiazem hcl Generic
diltiazem hcl coated beads Generic
diltiazem hcl extended release beads Generic
DYNACIRC CR Brand
EXFORGE Brand
EXFORGE HCT Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
felodipine Generic
ISRADIPINE Brand
nifedipine Generic
TARKA Brand
verapamil hcl Generic/Brand †
CARDIAC DRUGS
amiodarone hcl Generic
digoxin Generic/Brand †
disopyramide phosphate Generic/Brand †
flecainide acetate Generic
mexiletine hcl Generic
propafenone hcl Generic
quinidine gluconate Generic
quinidine sulfate Generic/Brand †
TIKOSYN Brand
HYPOTENSIVE AGENTS
clonidine hcl Generic
guanfacine hcl Generic
hydralazine hcl Generic
methazolamide Generic
methyldopa Generic
RESERPINE Brand
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
benazepril & hydrochlorothiazide Generic
benazepril hcl Generic
captopril Generic
CAPTOPRIL/HYDROCHLOROTHIAZIDE Brand
enalapril maleate Generic
fosinopril sodium Generic
fosinopril sodium & hydrochlorothiazide Generic
lisinopril Generic
lisinopril & hydrochlorothiazide Generic
losartan potassium Generic
losartan potassium & hydrochlorothiazide Generic
moexipril hcl Generic
moexipril-hydrochlorothiazide Generic
quinapril hcl Generic
quinapril-hydrochlorothiazide Generic
ramipril Generic
spironolactone Generic
spironolactone & hydrochlorothiazide Generic
valsartan Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
valsartan-hydrochlorothiazide Generic
VASODILATING AGENTS
alprostadil Generic * QL, RB
CAVERJECT Brand * QL, RB
CIALIS Brand QL, RB
dipyridamole Generic
isosorbide dinitrate Generic/Brand †
isosorbide mononitrate Generic
LETAIRIS Brand QL, RB
LEVITRA Brand QL, RB
MUSE Brand QL, RB
nitroglycerin Generic/Brand †
sildenafil citrate (pulmonary hypertension) Generic
TRACLEER Brand QL
VIAGRA Brand QL, RB
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
acetaminophen w/ codeine Generic
buprenorphine hcl-naloxone hcl dihydrate Generic/Brand † QL
butalbital-acetaminophen-caffeine Generic
butalbital-acetaminophen-caffeine w/ codeine Generic
butalbital-aspirin-caffeine w/cod Generic
BUTALBITAL/ASPIRIN/CAFFEINE Brand
celecoxib Generic QL
choline & mag salicylate Generic
diclofenac sodium Generic
etodolac Generic
FENOPROFEN CALCIUM Brand
fentanyl Generic QL
fentanyl citrate Generic QL
hydromorphone hcl Generic/Brand † QL
ibuprofen Generic
indomethacin Generic/Brand †
KETOPROFEN (extended release) Brand
ketorolac tromethamine Generic QL
MECLOFENAMATE SODIUM Brand
methadone hcl Generic QL
morphine sulfate Generic/Brand † QL
morphine sulfate (extended release) Generic/Brand † QL
nabumetone Generic
naproxen Generic
naproxen sodium Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
oxaprozin Generic
oxycodone hcl Generic/Brand † QL
oxycodone w/ acetaminophen Generic QL
oxycodone-aspirin Generic QL
salsalate Generic
sulindac Generic
tramadol hcl Generic
ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS
amphetamine-dextroamphetamine Generic/Brand † QL
dexmethylphenidate hcl Generic/Brand † QL
dextroamphetamine sulfate Generic QL
methylphenidate hcl Generic/Brand † QL
modafinil Generic QL
ANTICONVULSANTS
carbamazepine Generic
carbamazepine (extended release) Generic
CELONTIN Brand
clonazepam Generic
divalproex sodium Generic
divalproex sodium (extended release) Generic
ethosuximide Generic
felbamate Generic
gabapentin Generic
lamotrigine Generic QL
levetiracetam Generic
lithium carbonate Generic
oxcarbazepine Generic/Brand †
phenytoin Generic/Brand †
phenytoin sodium extended Generic/Brand †
primidone Generic
tiagabine hcl Generic/Brand †
topiramate Generic
valproate sodium Generic
valproic acid Generic
zonisamide Generic
ANTIMIGRAINE AGENTS
CAFERGOT Brand QL
dihydroergotamine mesylate Generic/Brand *† QL
ERGOMAR Brand QL
naratriptan hcl Generic QL
rizatriptan benzoate Generic QL
SUMATRIPTAN Brand QL
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
sumatriptan succinate Generic * QL
zolmitriptan Generic/Brand † QL
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
alprazolam Generic
buspirone hcl Generic QL
CHLORAL HYDRATE Brand
chlordiazepoxide hcl Generic
clorazepate dipotassium Generic
diazepam Generic *
estazolam Generic
flurazepam hcl Generic
hydroxyzine hcl Generic
hydroxyzine pamoate Generic/Brand †
lorazepam Generic
oxazepam Generic
phenobarbital Generic/Brand †
temazepam Generic
triazolam Generic
zaleplon Generic QL
zolpidem tartrate Generic QL
CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS
amantadine hcl Generic
APOKYN Brand * QL
benztropine mesylate Generic
bromocriptine mesylate Generic
cabergoline Generic
carbidopa-levodopa Generic
carbidopa-levodopa (extended release) Generic
entacapone Generic
pramipexole dihydrochloride Generic
riluzole Generic
ropinirole hydrochloride Generic
SAVELLA Brand QL
selegiline hcl Generic
trihexyphenidyl hcl Generic
OPIATE ANTAGONISTS
naltrexone hcl Generic
PSYCHOTHERAPEUTIC AGENTS
ABILIFY Brand QL
amitriptyline hcl Generic
AMOXAPINE Brand
aripiprazole Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
bupropion hcl Generic QL
bupropion hcl (smoking deterrent) Generic
CHLORDIAZEPOXIDE/AMITRIPTYLINE Brand
chlorpromazine hcl Generic
citalopram hydrobromide Generic QL
clomipramine hcl Generic
desipramine hcl Generic
doxepin hcl Generic/Brand †
escitalopram oxalate Generic QL
fluoxetine hcl Generic QL
fluphenazine hcl Generic/Brand †
fluvoxamine maleate Generic
haloperidol Generic
haloperidol lactate Generic
imipramine hcl Generic
imipramine pamoate Generic
lithium carbonate Generic
loxapine succinate Generic
MAPROTILINE HCL Brand
mirtazapine Generic
nefazodone hcl Generic/Brand †
nortriptyline hcl Generic/Brand †
olanzapine Generic QL
olanzapine odt Generic QL
paroxetine hcl Generic/Brand † QL
perphenazine Generic
phenelzine sulfate Generic
prochlorperazine Generic
prochlorperazine maleate Generic
protriptyline hcl Generic
quetiapine fumarate Generic QL
risperidone Generic QL
sertraline hcl Generic
SURMONTIL Brand
thioridazine hcl Generic
thiothixene Generic/Brand †
tranylcypromine sulfate Generic
trazodone hcl Generic
trifluoperazine hcl Generic
venlafaxine hcl Generic/Brand †
ziprasidone hcl Generic QL
DEVICES
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Drug Name Drug Tier Requirements/Limits
DEVICES
ASSESS FULL RANGE PEAK FLOW METER Brand
NORDIPEN 5 INJECTION DEVICE Brand
DIABETIC SUPPLIES
DIABETIC SUPPLIES
ACCU-CHEK COMPACT PLUS CARE KIT Brand
ACCU-CHEK COMPACT TEST DRUM Brand QL
ACETEST Brand
ADVOCATE DUO/TALKING Brand
AUTOLET PLATFORMS Brand
BD AUTOSHIELD 29G X 3/16" Brand
BD INSULIN SYRINGE LUER-LOK/U-100/1ML Brand
BD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X 1/2" Brand
BD SYRINGE LUER-LOK/1ML Brand
CARTRIDGE IR 1200 Brand
CHEMSTRIP 2 LN STRIPS Brand
CHEMSTRIP UGK Brand
CHEMSTRIP-MICRAL Brand
CLINISTIX Brand
CLINITEST Brand
DUO-CARE CONTROL SOLUTION Brand
FREESTYLE LANCETS Brand
FREESTYLE NAVIGATOR SENSOR KIT Brand
GLUCOLET 2 AUTOMATIC LANCING DEVICE Brand
INSULIN PUMP IR1250 BLUE Brand
NEEDLE-FREE INSULIN SYRINGE A Brand
NOVOPEN 3 PENMATE Brand
PRECISION XTRA Brand
SIDEKICK BLOOD GLUCOSE SYSTEM Brand
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ACIDIFYING AND ALKALINIZING AGENTS
POTASSIUM CITRATE Brand
potassium & sodium citrates w/ citric acid Generic
sodium citrate & citric acid Generic/Brand †
AMMONIA DETOXICANTS
lactulose Generic
lactulose (encephalopathy) Generic
DIURETICS
bumetanide Generic
CHLORTHALIDONE Brand
furosemide Generic
SODIUM EDECRIN Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
hydrochlorothiazide Generic
indapamide Generic
metolazone Generic
torsemide Generic
triamterene & hydrochlorothiazide Generic
ION-REMOVING AGENTS
RENAGEL Brand
RENVELA Brand
sodium polystyrene sulfonate Generic/Brand †
REPLACEMENT PREPARATIONS
calcium acetate (phosphate binder) Generic
potassium bicarb & chloride Generic
potassium chloride Generic/Brand †
potassium chloride microencapsulated crystals cr Generic
URICOSURIC AGENTS
colchicine Generic
colchicine w/ probenecid Generic
probenecid Generic
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ANTI-INFECTIVES
BACITRACIN Brand
bacitracin-polymyxin b (ophth) Generic
chlorhexidine gluconate (mouth-throat) Generic
ciprofloxacin hcl (ophth) Generic
erythromycin (ophth) Generic
gatifloxacin (ophth) Generic
gentamicin sulfate (ophth) Generic
neomycin-bacitracinzn-polymyxin Generic
ofloxacin (ophth) Generic
ofloxacin (otic) Generic
polymyxin b-trimethoprim Generic
sulfacetamide sodium (ophth) Generic
tobramycin (ophth) Generic/Brand †
trifluridine Generic
ANTI-INFLAMMATORY AGENTS
bacitracin-poly-neomycin-hc Generic
BLEPHAMIDE (ophthalmic) Brand
BLEPHAMIDE S.O.P. Brand
CIPRO HC Brand
CIPRODEX Brand
COLY-MYCIN S Brand
diclofenac sodium (ophth) Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
FLAREX Brand
FLUNISOLIDE (nasal) Brand
fluorometholone (ophth) Generic/Brand †
flurbiprofen sodium Generic
fluticasone propionate (nasal) Generic
FML FORTE Brand
ketorolac tromethamine (ophth) Generic
NASONEX Brand
neomycin-polymy-dexameth Generic
neomycin-polymyxin-hc (otic) Generic
POLY-PRED Brand
PRED-G Brand
prednisolone acetate (ophth) Generic/Brand †
PREDNISOLONE SODIUM PHOSPHATE Brand
sulfacetamide sod-prednisolone Generic/Brand †
tobramycin-dexamethasone Generic/Brand †
ANTIALLERGIC AGENTS
ALAMAST Brand
ALOCRIL Brand QL
ALOMIDE Brand
azelastine hcl Generic
azelastine hcl (ophth) Generic
cromolyn sodium (ophth) Generic
PATANOL Brand QL
ANTIGLAUCOMA AGENTS
acetazolamide Generic/Brand †
AZOPT Brand QL
betaxolol hcl (ophth) Generic/Brand †
BETIMOL Brand
brimonidine tartrate Generic/Brand †
carteolol hcl (ophth) Generic
dorzolamide hcl Generic
dorzolamide hcl-timolol maleate Generic
latanoprost Generic
levobunolol hcl Generic/Brand †
methazolamide Generic
METIPRANOLOL Brand
PHOSPHOLINE IODIDE Brand
pilocarpine hcl Generic
timolol maleate (ophth) Generic
EENT DRUGS, MISCELLANEOUS
acetic acid (otic) Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
ACETIC ACID/ALUMINUM ACETATE Brand
hydrocortisone w/acetic acid Generic
LOCAL ANESTHETICS
antipyrine-benzocaine Generic
antipyrine, benzocaine & polycosanol Generic/Brand
lidocaine hcl (mouth-throat) Generic
MYDRIATICS
atropine sulfate (ophthalmic) Generic
dipivefrin hcl Generic
tropicamide Generic
GASTROINTESTINAL DRUGS
ANTI-INFLAMMATORY AGENTS
APRISO Brand
LIALDA Brand
sulfasalazine Generic
ANTIEMETICS
ANTIVERT Brand
EMEND Brand QL
ondansetron Generic QL
ondansetron hcl Generic QL
ANTIULCER AGENTS AND ACID SUPPRESSANTS
famotidine Generic
misoprostol Generic
omeprazole Generic
pantoprazole sodium Generic
PREVACID SOLUTAB Brand
ranitidine hcl Generic
sucralfate Generic/Brand †
DIGESTANTS
ZENPEP Brand
GI DRUGS, MISCELLANEOUS
diphenoxylate w/ atropine Generic/Brand †
metoclopramide hcl Generic
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate Generic/Brand †
peg 3350-potassium chloride-sod bicarbonate-sod chloride Generic
ursodiol Generic/Brand †
GOLD COMPOUNDS
GOLD COMPOUNDS
RIDAURA Brand
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
CUPRIMINE Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
ASMANEX 120 METERED DOSES Brand
budesonide Generic QL
budesonide (inhalation) Generic/Brand †
CELESTONE Brand
CORTISONE ACETATE Brand
DEXAMETHASONE Brand
FLOVENT DISKUS Brand
FLOVENT HFA Brand
fludrocortisone acetate Generic
hydrocortisone Generic
methylprednisolone Generic/Brand †
prednisolone Generic
prednisolone sodium phosphate Generic
prednisone Generic/Brand †
QVAR Brand
ANDROGENS
ANDRODERM Brand
ANDROXY Brand QL
danazol Generic
METHITEST Brand
testosterone Generic QL
testosterone cypionate Generic * QL
testosterone enanthate Generic * QL
CONTRACEPTIVES
desogestrel & ethinyl estradiol Generic
desogestrel-ethinyl estradiol (biphasic) Generic
desogestrel-ethinyl estradiol (triphasic) Generic
drospirenone-ethinyl estradiol Generic
ELLA Brand
ethynodiol diacet & ethinyl estradiol Generic/Brand †
levonorgestrel & ethinyl estradiol Generic
levonorgestrel-ethinyl estradiol (91-day) Generic
levonorgestrel-ethinyl estradiol (triphasic) Generic
NECON 1/50-28 Brand
NECON 10/11-28 Brand
norethin acet & ethinyl estradiol-fe Generic
norethindrone & ethinyl estradiol Generic
norethindrone (contraceptive) Generic
norethindrone acet & ethinyl estradiol Generic
norethindrone-ethinyl estradiol (triphasic) Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
- 20 -
Drug Name Drug Tier Requirements/Limits
norgestimate-ethinyl estradiol Generic
norgestimate-ethinyl estradiol (triphasic) Generic/Brand †
norgestrel & ethinyl estradiol Generic/Brand †
NUVARING Brand QL
PLAN B Brand
XULANE Brand QL
DIABETIC AGENTS
acarbose Generic
glimepiride Generic
glipizide Generic
glipizide (extended release) Generic
GLUCAGEN Brand *
GLUCAGON EMERGENCY KIT Brand *
glyburide Generic
glyburide-metformin Generic
HUMALOG Brand
HUMALOG MIX 50/50 Brand
HUMULIN N Brand
HUMULIN R Brand
LANTUS Brand
LANTUS SOLOSTAR Brand
LEVEMIR Brand
LEVEMIR FLEXTOUCH Brand
metformin hcl Generic
metformin hcl (extended release) Generic
NOVOLOG Brand
NOVOLOG MIX 70/30 Brand
pioglitazone hcl Generic
tolazamide Generic/Brand †
TOLBUTAMIDE Brand
ESTROGENS AND ANTIESTROGENS
COMBIPATCH Brand
esterified estrogens & methyltestosterone Generic
ESTRACE VAGINAL Brand
estradiol (oral) Generic/Brand †
estradiol (transdermal) Generic/Brand † QL
estropipate Generic/Brand †
FEMHRT LOW DOSE Brand
PREMARIN Brand
PREMPHASE Brand
raloxifene hcl Generic
VAGIFEM Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
GONADOTROPINS
BRAVELLE Brand * RB
chorionic gonadotropin Generic * RB
clomiphene citrate Generic RB
FOLLISTIM AQ Brand * RB
GONAL-F Brand * RB
MENOPUR Brand * RB
OVIDREL Brand * RB
PARATHYROID
calcitonin (salmon) Generic QL
FORTEO Brand * QL
PITUITARY
ACTHAR HP Brand * QL
desmopressin acetate Generic *
desmopressin acetate refrigerated Generic
desmopressin acetate spray Generic
desmopressin acetate spray refrigerated Generic
PROGESTINS
medroxyprogesterone acetate Generic
norethindrone acetate Generic
progesterone micronized Generic RB
SOMATOTROPIN AGONISTS AND ANTAGONISTS
OMNITROPE Brand * NC, QL
THYROID AND ANTITHYROID AGENTS
levothyroxine sodium Generic
liothyronine sodium Generic
methimazole Generic
propylthiouracil Generic
SSKI Brand
thyroid Generic/Brand †
THYROLAR Brand
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
acetylcysteine Generic
ADCIRCA Brand QL
alendronate sodium Generic/Brand †
allopurinol Generic
azathioprine Generic
cyclosporine modified (for microemulsion) Generic/Brand †
CYSTAGON Brand
disulfiram Generic/Brand †
ELMIRON Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
ENBREL Brand * QL
ETIDRONATE DISODIUM Brand
finasteride Generic
FIRAZYR Brand * QL
FOSAMAX PLUS D Brand
GLATOPA Generic * QL
HUMIRA Brand * QL
leflunomide Generic
leucovorin calcium Generic/Brand *†
levocarnitine (metabolic modifiers) Generic/Brand †
mycophenolate mofetil Generic
mycophenolate sodium Generic
RAPAMUNE Brand
REBIF Brand * QL
REVLIMID Brand QL
SANDIMMUNE Brand
sirolimus Generic
sodium fluoride Generic/Brand †
sodium fluoride (dental) Generic
tacrolimus Generic
THALOMID Brand QL
OXYTOCICS
OXYTOCICS
ERGOTRATE MALEATE Brand
methylergonovine maleate Generic
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORY AGENTS
cromolyn sodium Generic
montelukast sodium Generic QL
montelukast sodium (granules) Generic QL
STRIVERDI RESPIMAT Brand
zafirlukast Generic
ANTITUSSIVES
benzonatate Generic
guaifenesin-codeine Generic/Brand †
hydrocodone polistirex-chlorpheniramine polistirex Generic QL
hydrocodone w/ homatropine Generic QL
RESPIRATORY AGENTS, MISCELLANEOUS
DULERA Brand
ELIXOPHYLLIN Brand
PULMOZYME Brand QL
sodium chloride (inhalant) Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
- 23 -
Drug Name Drug Tier Requirements/Limits
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)
acyclovir topical Generic
AVC Brand
BACTROBAN NASAL Brand
benzoyl peroxide-erythromycin Generic/Brand †
ciclopirox Generic
ciclopiroxolamine Generic
clindamycin phosphate (topical) Generic
clindamycin phosphate vaginal Generic
clotrimazole Generic
clotrimazole (topical) Generic
clotrimazole w/ betamethasone Generic
erythromycin (acne aid) Generic
EURAX Brand
EXELDERM Brand
GENTAMICIN SULFATE Brand
ketoconazole (topical) Generic
lindane Generic
metronidazole (topical) Generic/Brand †
metronidazole vaginal Generic
MICONAZOLE 3 Brand
mupirocin Generic
NAFTIN Brand
nystatin (topical) Generic
NYSTATIN VAGINAL Brand
permethrin Generic
selenium sulfide Generic
silver sulfadiazine Generic
sulfacetamide sodium (acne) Generic
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)
APEXICON E Brand
betamethasone dipropionate (topical) Generic
betamethasone dipropionate augmented Generic
betamethasone valerate Generic
clobetasol propionate Generic
clobetasol propionate emollient base Generic
CLODERM Brand
CORDRAN Brand
CORTIFOAM Brand
CORTISPORIN Brand
desonide Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
desoximetasone Generic
diflorasone diacetate Generic/Brand †
EPIFOAM Brand
fluocinolone acetonide Generic
fluocinonide Generic
fluocinonide emulsified base Generic
fluticasone propionate Generic/Brand †
halobetasol propionate Generic
hydrocortisone (intrarectal) Generic
hydrocortisone (rectal) Generic
hydrocortisone (topical) Generic
hydrocortisone valerate Generic
KENALOG Brand
mometasone furoate Generic
nystatin-triamcinolone Generic
triamcinolone acetonide (mouth) Generic
triamcinolone acetonide (topical) Generic/Brand †
ANTIPRURITICS AND LOCAL ANESTHETICS
hydrocortisone acetate (rectal) Generic
hydrocortisone acetate w/ pramoxine Generic/Brand †
lidocaine Generic
lidocaine hcl Generic
phenazopyridine hcl Generic
CELL STIMULANTS AND PROLIFERANTS
tretinoin Generic/Brand † QL
SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS
adapalene Generic/Brand †
aluminum chloride Generic
AMEVIVE Brand * QL
calcipotriene Generic
DRITHO-CREME HP Brand
DRITHO-SCALP Brand
ELIDEL Brand QL
FINACEA Brand
fluorouracil (topical) Generic
imiquimod Generic
isotretinoin Generic/Brand † QL
mupirocin calcium (topical) Generic
OXSORALEN Brand
podofilox Generic/Brand †
REGRANEX Brand QL
tacrolimus (topical) Generic
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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Drug Name Drug Tier Requirements/Limits
TARGRETIN Brand QL
TAZORAC Brand QL
VECTICAL Brand
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
flavoxate hcl Generic
oxybutynin chloride Generic
oxybutynin chloride (extended release) Generic
tolterodine tartrate Generic
tolterodine tartrate (extended release) Generic
trospium chloride Generic
SMOOTH MUSCLE RELAXANTS
AMINOPHYLLINE Brand
theophylline Generic
VITAMINS
VITAMIN B COMPLEX
folic acid Generic
VITAMIN D
calcitriol Generic/Brand †
ergocalciferol Generic
VITAMIN K ACTIVITY
MEPHYTON Brand
VITAMINS
pediatric multivitamins w/fl Generic
pediatric vitamins acd w/ fluoride Generic
PRENATAL VITAMIN WITH DOCUSATE, FERROUS FUMARATE
& FOLIC ACID Brand
PRENATAL VITAMIN WITH DOCUSATE, IRON CARBONYL &
FOLIC ACID Brand
PRENATAL VITAMIN WITH FERROUS FUMARATE & FOLIC
ACID Brand
PRENATAL VITAMIN WITH IRON CARBONYL & FOLIC ACID Brand
PRENATAL VITAMIN WITH MINERALS, IRON & FOLIC ACID Brand
PRENATAL VITAMIN WITH SELENIUM, FERROUS FUMARATE
& FOLIC ACID Brand
PRENATAL VITAMIN WITHOUT VITAMIN A, WITH IRON
CARBONYL, DOCUSATE & FOLIC ACID Brand
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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INDEX OF DRUGS
Kaiser Permanente Southern Colorado
Commercial PPO Comprehensive Formulary Index
A
abacavir sulfate, 4 abacavir-lamivudine-zidovudine, 4 ABILIFY, 13 acarbose, 20 ACCU-CHEK COMPACT PLUS CARE KIT, 15 ACCU-CHEK COMPACT TEST DRUM, 15 acebutolol hcl, 9 acetaminophen w/ codeine, 11 acetazolamide, 17 ACETEST, 15 acetic acid (otic), 17 ACETIC ACID/ALUMINUM ACETATE, 18 acetylcysteine, 21 ACIDIFYING AND ALKALINIZING AGENTS, 15 ACTHAR HP, 21 acyclovir, 4 acyclovir topical, 23 adapalene, 24 ADCIRCA, 21 adefovir dipivoxil, 4 ADRENALIN, 8 ADRENALS, 19 ADVAIR DISKUS, 8 ADVOCATE DUO/TALKING, 15 AFINITOR, 6 ALAMAST, 17 ALBENZA, 3 albuterol sulfate, 8 alendronate sodium, 21 ALKERAN, 6 allopurinol, 21 ALOCRIL, 17 ALOMIDE, 17 ALPHA-ADRENERGIC BLOCKING AGENTS, 9 alprazolam, 13 alprostadil, 11 aluminum chloride, 24 amantadine hcl, 13 AMEVIVE, 24 aminocaproic acid, 8 AMINOPHYLLINE, 25 amiodarone hcl, 10 amitriptyline hcl, 13 amlodipine besylate, 9
amlodipine besylate-benazepril hcl, 9 AMMONIA DETOXICANTS, 15 AMOXAPINE, 13 amoxicillin, 3 amoxicillin & pot clavulanate, 3 amphetamine-dextroamphetamine, 12 ampicillin, 3 anagrelide hcl, 8 ANALGESICS AND ANTIPYRETICS, 11 anastrozole, 6 ANDRODERM, 19 ANDROGENS, 19 ANDROXY, 19 ANOREXIGENIC AGENTS AND RESPIRATORY AND
CEREBRAL STIMULANTS, 12 ANTHELMINTICS, 3 ANTIALLERGIC AGENTS, 17 ANTIBACTERIALS, 3 ANTICHOLINERGIC AGENTS, 7 ANTICONVULSANTS, 12 ANTIEMETICS, 18 ANTIFUNGALS, 4 ANTIGLAUCOMA AGENTS, 17 ANTIHISTAMINE DRUGS, 6 ANTI-INFECTIVE AGENTS, 3 ANTI-INFECTIVES, 16 ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE), 23 ANTI-INFLAMMATORY AGENTS, 16, 18, 22 ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS
MEMBRANE), 23 ANTILIPEMIC AGENTS, 9 ANTIMIGRAINE AGENTS, 12 ANTIMYCOBACTERIALS, 4 ANTINEOPLASTIC AGENTS, 6 ANTIPROTOZOALS, 4 ANTIPRURITICS AND LOCAL ANESTHETICS, 24 antipyrine, benzocaine & polycosanol, 18 antipyrine-benzocaine, 18 ANTITHROMBOTIC AGENTS, 8 ANTITUSSIVES, 22 ANTIULCER AGENTS AND ACID SUPPRESSANTS, 18 ANTIVERT, 18 ANTIVIRALS, 4 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS, 13 APEXICON E, 23 APOKYN, 13 APRISO, 18
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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APTIVUS, 4 aripiprazole, 13 ASMANEX 120 METERED DOSES, 19 ASSESS FULL RANGE PEAK FLOW METER, 15 atenolol, 9 atenolol & chlorthalidone, 9 atovaquone-proguanil hcl, 4 ATRIPLA, 4 atropine sulfate (ophthalmic), 18 ATROVENT HFA, 7 AUTOLET PLATFORMS, 15 AUTONOMIC DRUGS, 7 AVC, 23 azathioprine, 21 azelastine hcl, 17 azelastine hcl (ophth), 17 azithromycin, 3 AZOPT, 17
B
BACITRACIN, 16 bacitracin-polymyxin b (ophth), 16 bacitracin-poly-neomycin-hc, 16 baclofen, 7 BACTROBAN NASAL, 23 BARACLUDE, 4 BD AUTOSHIELD 29G X 3/16", 15 BD INSULIN SYRINGE LUER-LOK/U-100/1ML, 15 BD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X
1/2", 15 BD SYRINGE LUER-LOK/1ML, 15 benazepril & hydrochlorothiazide, 10 benazepril hcl, 10 benzonatate, 22 benzoyl peroxide-erythromycin, 23 benztropine mesylate, 13 BETA-ADRENERGIC BLOCKING AGENTS, 9 betamethasone dipropionate (topical), 23 betamethasone dipropionate augmented, 23 betamethasone valerate, 23 betaxolol hcl (ophth), 17 bethanechol chloride, 7 BETIMOL, 17 bicalutamide, 6 BILTRICIDE, 3 bisoprolol & hydrochlorothiazide, 9 bisoprolol fumarate, 9 BLEPHAMIDE (ophthalmic), 16 BLEPHAMIDE S.O.P., 16 BLOOD FORMATION, COAGULATION, AND THROMBOSIS,
8 BRAVELLE, 21
BRILINTA, 8 brimonidine tartrate, 17 bromocriptine mesylate, 13 budesonide, 19 budesonide (inhalation), 19 bumetanide, 15 buprenorphine hcl-naloxone hcl dihydrate, 11 bupropion hcl, 14 bupropion hcl (smoking deterrent), 14 buspirone hcl, 13 BUTALBITAL/ASPIRIN/CAFFEINE, 11 butalbital-acetaminophen-caffeine, 11 butalbital-acetaminophen-caffeine w/ codeine, 11 butalbital-aspirin-caffeine w/cod, 11 BYSTOLIC, 9
C
cabergoline, 13 CAFERGOT, 12 calcipotriene, 24 calcitonin (salmon), 21 calcitriol, 25 calcium acetate (phosphate binder, 16 CALCIUM-CHANNEL BLOCKING AGENTS, 9 capecitabine, 6 captopril, 10 CAPTOPRIL/HYDROCHLOROTHIAZIDE, 10 carbamazepine, 12 carbamazepine (extended release), 12 carbidopa-levodopa, 13 carbidopa-levodopa (extended release), 13 CARDENE SR, 9 CARDIAC DRUGS, 10 CARDIOVASCULAR DRUGS, 9 carisoprodol, 8 carisoprodol w/ aspirin, 8 carteolol hcl (ophth), 17 CARTRIDGE IR 1200, 15 carvedilol, 9 CAVERJECT, 11 CAYSTON, 3 CEENU, 6 cefaclor, 3 cefadroxil, 3 cefdinir, 3 cefixime, 3 cefprozil, 3 cefuroxime axetil, 3 celecoxib, 11 CELESTONE, 19 CELL STIMULANTS AND PROLIFERANTS, 24 CELONTIN, 12
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
- 28 -
CENTRAL NERVOUS SYSTEM AGENTS, 11 CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS,
13 cephalexin, 3 cevimeline hcl, 7 CHEMSTRIP 2 LN STRIPS, 15 CHEMSTRIP UGK, 15 CHEMSTRIP-MICRAL, 15 CHLORAL HYDRATE, 13 chlordiazepoxide hcl, 13 CHLORDIAZEPOXIDE/AMITRIPTYLINE, 14 chlorhexidine gluconate (mouth-throat), 16 chloroquine phosphate, 4 chlorpromazine hcl, 14 CHLORTHALIDONE, 15 cholestyramine, 9 cholestyramine light, 9 choline & mag salicylate, 11 chorionic gonadotropin, 21 CIALIS, 11 ciclopirox, 23 ciclopiroxolamine, 23 cilostazol, 8 CIPRO HC, 16 CIPRODEX, 16 ciprofloxacin hcl, 3 ciprofloxacin hcl (ophth), 16 citalopram hydrobromide, 14 clarithromycin, 3 clidinium & chlordiazepoxide, 7 clindamycin hcl, 3 clindamycin palmitate hydrochloride, 3 clindamycin phosphate (topical), 23 clindamycin phosphate vaginal, 23 CLINISTIX, 15 CLINITEST, 15 clobetasol propionate, 23 clobetasol propionate emollient base, 23 CLODERM, 23 clomiphene citrate, 21 clomipramine hcl, 14 clonazepam, 12 clonidine hcl, 10 clopidogrel bisulfate, 8 clorazepate dipotassium, 13 clotrimazole, 23 clotrimazole (topical), 23 clotrimazole w/ betamethasone, 23 COAGULANTS AND ANTICOAGULANTS, 8 colchicine, 16 colchicine w/ probenecid, 16 COLY-MYCIN S, 16 COMBIPATCH, 20 COMBIVENT, 8
COMBIVENT RESPIMAT, 8 COMTAN, 13 CONTRACEPTIVES, 19 CORDRAN, 23 COREG CR, 9 CORTIFOAM, 23 CORTISONE ACETATE, 19 CORTISPORIN, 23 CRESTOR, 9 CRIXIVAN, 5 cromolyn sodium, 22 cromolyn sodium (ophth), 17 CUPRIMINE, 18 cyclobenzaprine hcl, 8 CYCLOPHOSPHAMIDE, 6 cyclosporine modified (for microemulsion), 21 cyproheptadine hcl, 6 CYSTAGON, 21
D
danazol, 19 dantrolene sodium, 8 DAPSONE, 4 DARAPRIM, 4 desipramine hcl, 14 desmopressin acetate, 21 desmopressin acetate refrigerated, 21 desmopressin acetate spray, 21 desmopressin acetate spray refrigerated, 21 desogestrel & ethinyl estradiol, 19 desogestrel-ethinyl estradiol (biphasic), 19 desogestrel-ethinyl estradiol (triphasic), 19 desonide, 23 desoximetasone, 24 DEVICES, 14 DEXAMETHASONE, 19 dexmethylphenidate hcl, 12 dextroamphetamine sulfate, 12 DIABETIC AGENTS, 20 DIABETIC SUPPLIES, 15 diazepam, 13 diclofenac sodium, 11 diclofenac sodium (ophth), 16 dicloxacillin sodium, 3 dicyclomine hcl, 7 didanosine, 5 diflorasone diacetate, 24 DIGESTANTS, 18 digoxin, 10 dihydroergotamine mesylate, 12 diltiazem hcl, 9 diltiazem hcl coated beads, 9
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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diltiazem hcl extended release beads, 9 diphenoxylate w/ atropine, 18 dipivefrin hcl, 18 dipyridamole, 11 disopyramide phosphate, 10 disulfiram, 21 DIURETICS, 15 divalproex sodium, 12 divalproex sodium (extended release), 12 donepezil hydrochloride, 7 DONNATAL, 7 dorzolamide hcl, 17 dorzolamide hcl-timolol maleate, 17 doxazosin mesylate, 9 doxepin hcl, 14 doxycycline hyclate, 3 DRITHO-CREME HP, 24 DRITHO-SCALP, 24 drospirenone-ethinyl estradiol, 19 DULERA, 22 DUO-CARE CONTROL SOLUTION, 15 DYNACIRC CR, 9
E
E.E.S. 400, 3 EENT DRUGS, MISCELLANEOUS, 17 EFFIENT, 8 ELECTROLYTIC, CALORIC, AND WATER BALANCE, 15 ELIDEL, 24 ELIGARD, 6 ELIXOPHYLLIN, 22 ELLA, 19 ELMIRON, 21 EMCYT, 6 EMEND, 18 EMTRIVA, 5 enalapril maleate, 10 ENBREL, 22 entacapone, 13 EPIFOAM, 24 epinephrine hcl, 8 EPIVIR HBV, 5 EPOGEN, 8 EPZICOM, 5 ergocalciferol, 25 ERGOMAR, 12 ERGOTRATE MALEATE, 22 ERYTHROCIN STEARATE, 3 erythromycin (acne aid), 23 erythromycin (ophth), 16 erythromycin base, 3 erythromycin-sulfisoxazole, 3
escitalopram oxalate, 14 estazolam, 13 esterified estrogens & methyltestosterone, 20 ESTRACE VAGINAL, 20 estradiol, 20 estradiol (oral), 20 estradiol (transdermal, 20 ESTROGENS AND ANTIESTROGENS, 20 estropipate, 20 ethambutol hcl, 4 ethosuximide, 12 ethynodiol diacet & ethinyl estradiol, 19 ETIDRONATE DISODIUM, 22 etodolac, 11 ETOPOSIDE, 6 EURAX, 23 EXELDERM, 23 exemestane, 6 EXFORGE, 9 EXFORGE HCT, 9 EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS, 16
F
famciclovir, 5 famotidine, 18 felbamate, 12 felodipine, 10 FEMHRT LOW DOSE, 20 fenofibrate, 9 fenofibrate micronized, 9 FENOPROFEN CALCIUM, 11 fentanyl, 11 fentanyl citrate, 11 FINACEA, 24 finasteride, 22 FIRAZYR, 22 FLAREX, 17 flavoxate hcl, 25 flecainide acetate, 10 FLOVENT DISKUS, 19 FLOVENT HFA, 19 fluconazole, 4 fludrocortisone acetate, 19 FLUNISOLIDE, 17 fluocinolone acetonide, 24 fluocinonide, 24 fluocinonide emulsified base, 24 fluorometholone (ophth), 17 fluorouracil (topical), 24 fluoxetine hcl, 14 fluphenazine hcl, 14 flurazepam hcl, 13
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
- 30 -
flurbiprofen sodium, 17 flutamide, 6 fluticasone propionate, 24 fluticasone propionate (nasal), 17 fluvoxamine maleate, 14 FML FORTE, 17 folic acid, 25 FOLLISTIM AQ, 21 fondaparinux sodium, 8 FORTEO, 21 FOSAMAX PLUS D, 22 fosinopril sodium, 10 fosinopril sodium & hydrochlorothiazide, 10 FRAGMIN, 8 FREESTYLE LANCETS, 15 FREESTYLE NAVIGATOR SENSOR KIT, 15 furosemide, 15
G
gabapentin, 12 galantamine hydrobromide, 7 GANCICLOVIR, 5 GASTROINTESTINAL DRUGS, 18 gatifloxacin (ophth), 16 gemfibrozil, 9 GENITOURINARY SMOOTH MUSCLE RELAXANTS, 25 GENTAMICIN SULFATE, 23 gentamicin sulfate (ophth), 16 GI DRUGS, MISCELLANEOUS, 18 GLATOPA, 22 GLEEVEC, 6 glimepiride, 20 glipizide, 20 glipizide (extended release), 20 GLUCAGEN, 20 GLUCAGON EMERGENCY KIT, 20 GLUCOLET 2 AUTOMATIC LANCING DEVICE, 15 glyburide, 20 glyburide-metformin, 20 glycopyrrolate, 7 GOLD COMPOUNDS, 18 GONADOTROPINS, 21 GONAL-F, 21 griseofulvin ultramicrosize, 4 guaifenesin-codeine, 22 guanfacine hcl, 10
H
halobetasol propionate, 24 haloperidol, 14 haloperidol lactate, 14
HARVONI, 5 HEAVY METAL ANTAGONISTS, 18 HEMATOPOIETIC AGENTS, 8 heparin sod (porcine) in d5w, 8 heparin sodium (porcine), 8 heparin sodium (porcine) lock flush, 8 HEXALEN, 6 HORMONES AND SYNTHETIC SUBSTITUTES, 19 HUMALOG, 20 HUMALOG MIX 50/50, 20 HUMIRA, 22 HUMULIN N, 20 HUMULIN R, 20 hydralazine hcl, 10 hydrochlorothiazide, 16 hydrocodone polistirex-chlorpheniramine polistirex, 22 hydrocodone w/ homatropine, 22 hydrocortisone, 19 hydrocortisone (intrarectal), 24 hydrocortisone (rectal), 24 hydrocortisone (topical), 24 hydrocortisone acetate (rectal), 24 hydrocortisone acetate w/ pramoxine, 24 hydrocortisone valerate, 24 hydrocortisone w/acetic acid, 18 hydromorphone hcl, 11 hydroxychloroquine sulfate, 4 hydroxyurea, 6 hydroxyzine hcl, 13 hydroxyzine pamoate, 13 hyoscyamine sulfate, 7 HYPOTENSIVE AGENTS, 10
I
ibuprofen, 11 imipramine hcl, 14 imipramine pamoate, 14 imiquimod, 24 indapamide, 16 indomethacin, 11 INFERGEN, 5 INNOHEP, 8 INSULIN PUMP IR1250 BLUE, 15 INTELENCE, 5 INTRON-A, 6 INVIRASE, 5 ION-REMOVING AGENTS, 16 ipratropium bromide, 7 ipratropium bromide (nasal), 7 IRESSA, 6 ISENTRESS, 5 isoniazid, 4
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
- 31 -
isosorbide dinitrate, 11 isosorbide mononitrate, 11 isotretinoin, 24 ISRADIPINE, 10 itraconazole, 4 ivermectin, 3
K
KALETRA, 5 KENALOG, 24 ketoconazole, 4 ketoconazole (topical), 23 KETOPROFEN ER, 11 ketorolac tromethamine, 11 ketorolac tromethamine (ophth), 17
L
labetalol hcl, 9 lactulose, 15 lactulose (encephalopathy), 15 lamivudine, 5 lamotrigine, 12 LANTUS, 20 LANTUS SOLOSTAR, 20 latanoprost, 17 leflunomide, 22 LETAIRIS, 11 letrozole, 6 leucovorin calcium, 22 LEUKERAN, 6 LEUKINE, 8 leuprolide acetate, 6 levalbuterol hcl, 8 LEVEMIR, 20 LEVEMIR FLEXTOUCH, 20 levetiracetam, 12 LEVITRA, 11 levobunolol hcl, 17 levocarnitine (metabolic modifiers), 22 levofloxacin, 3 levonorgestrel & ethinyl estradiol, 19 levonorgestrel-ethinyl estradiol (91-day), 19 levonorgestrel-ethinyl estradiol (triphasic), 19 levothyroxine sodium, 21 LEXIVA, 5 LIALDA, 18 lidocaine, 24 lidocaine hcl, 24 lidocaine hcl (mouth-throat), 18 lindane, 23 linezolid, 3
liothyronine sodium, 21 lisinopril, 10 lisinopril & hydrochlorothiazide, 10 lithium carbonate, 12, 14 LOCAL ANESTHETICS, 18 lorazepam, 13 losartan potassium, 10 losartan potassium & hydrochlorothiazide, 10 lovastatin, 9 LOVENOX, 8 loxapine succinate, 14 LUPRON DEPOT, 6 LUPRON DEPOT-PED, 6 LYSODREN, 6
M
MAPROTILINE HCL, 14 MATULANE, 6 MEBENDAZOLE, 3 MECLOFENAMATE SODIUM, 11 medroxyprogesterone acetate, 21 mefloquine hcl, 4 megestrol acetate, 6 melphalan hcl, 6 MENOPUR, 21 MEPHYTON, 25 mercaptopurine, 6 METAPROTERENOL SULFATE, 8 metformin hcl, 20 metformin hcl (extended release), 20 methadone hcl, 11 methazolamide, 10, 17 methenamine-hyosc-methylene blue-sod phos-phenyl sal, 6 methimazole, 21 METHITEST, 19 methocarbamol, 8 methotrexate sodium, 6 methyldopa, 10 methylergonovine maleate, 22 methylphenidate hcl, 12 methylprednisolone, 19 METIPRANOLOL, 17 metoclopramide hcl, 18 metolazone, 16 metoprolol succinate, 9 metoprolol tartrate, 9 metronidazole, 4 metronidazole (topical), 23 metronidazole vaginal, 23 mexiletine hcl, 10 MICONAZOLE, 23 midodrine hcl, 8
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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minocycline hcl, 3 mirtazapine, 14 MISCELLANEOUS THERAPEUTIC AGENTS, 21 misoprostol, 18 modafinil, 12 moexipril hcl, 10 moexipril-hydrochlorothiazide, 10 mometasone furoate, 24 montelukast sodium, 22 montelukast sodium (granules), 22 morphine sulfate, 11 morphine sulfate (extended release), 11 moxifloxacin hcl, 3 mupirocin, 23 mupirocin calcium (topical), 24 MUSE, 11 mycophenolate mofetil, 22 MYDRIATICS, 18 MYLERAN, 6
N
nabumetone, 11 nadolol, 9 NAFTIN, 23 naltrexone hcl, 13 naproxen, 11 naproxen sodium, 11 naratriptan hcl, 12 NASONEX, 17 NEBUPENT, 4 NECON 1/50-28, 19 NECON 10/11-28, 19 NEEDLE-FREE INSULIN SYRINGE A, 15 nefazodone hcl, 14 NEO-FRADIN, 3 neomycin-bacitracinzn-polymyxin, 16 neomycin-polymy-dexameth, 17 neomycin-polymyxin-hc (otic), 17 NEULASTA, 8 nevirapine, 5 NEXAVAR, 7 NIASPAN, 9 nifedipine, 10 NILANDRON, 7 nitrofurantoin, 6 nitrofurantoin macrocrystal, 6 nitrofurantoin monohyd macro, 6 nitroglycerin, 11 NORDIPEN 5 INJECTION DEVICE, 15 norethin acet & ethinyl estradiol-fe, 19 norethindrone & ethinyl estradiol, 19 norethindrone (contraceptive), 19
norethindrone acet & ethinyl estradiol, 19 norethindrone acetate, 21 norethindrone-ethinyl estradiol (triphasic), 19 norgestimate-ethinyl estradiol, 20 norgestimate-ethinyl estradiol (triphasic), 20 norgestrel & ethinyl estradiol, 20 NOROXIN, 3 nortriptyline hcl, 14 NORVIR, 5 NOVOLOG, 20 NOVOLOG MIX 70/30, 20 NOVOPEN 3 PENMATE, 15 NUVARING, 20 nystatin, 4 nystatin (mouth-throat), 4 nystatin (topical), 23 NYSTATIN VAGINAL, 23 nystatin-triamcinolone, 24
O
ofloxacin (ophth), 16 ofloxacin (otic), 16 olanzapine, 14 olanzapine odt, 14 omeprazole, 18 OMNITROPE, 21 ondansetron, 18 ondansetron hcl, 18 OPIATE ANTAGONISTS, 13 OVIDREL, 21 oxaprozin, 12 oxazepam, 13 oxcarbazepine, 12 OXSORALEN, 24 oxybutynin chloride, 25 oxybutynin chloride (extended release), 25 oxycodone hcl, 12 oxycodone w/ acetaminophen, 12 oxycodone-aspirin, 12 OXYTOCICS, 22
P
pantoprazole sodium, 18 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS, 7 PARATHYROID, 21 paromomycin sulfate, 4 paroxetine hcl, 14 PATANOL, 17 PCE, 3 pediatric multivitamins w/fl, 25 pediatric vitamins acd w/ fluoride, 25
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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peg 3350-kcl-sod bicarb-sod chloride-sod sulfate, 18 peg 3350-potassium chloride-sod bicarbonate-sod chloride,
18 PEGASYS, 5 PEG-INTRON, 5 penicillin v potassium, 3 pentoxifylline, 8 permethrin, 23 perphenazine, 14 phenazopyridine hcl, 24 phenelzine sulfate, 14 phenobarbital, 13 phenoxybenzamine, 7 phenytoin, 12 phenytoin sodium extended, 12 PHOSPHOLINE IODIDE, 17 pilocarpine hcl, 17 pindolol, 9 pioglitazone hcl, 20 PITUITARY, 21 PLAN B, 20 podofilox, 24 polymyxin b-trimethoprim, 16 POLY-PRED, 17 potassium & sodium citrates w/ citric acid, 15 potassium bicarb & chloride, 16 potassium chloride, 16 potassium chloride microencapsulated crystals cr, 16 POTASSIUM CITRATE, 15 pramipexole dihydrochloride, 13 pravastatin sodium, 9 prazosin hcl, 9 PRECISION XTRA, 15 PRED-G, 17 prednisolone, 19 prednisolone acetate (ophth), 17 prednisolone sodium phosphate, 19 PREDNISOLONE SODIUM PHOSPHATE, 17 prednisone, 19 PREMARIN, 20 PREMPHASE, 20 PRENATAL VITAMIN WITH DOCUSATE, FERROUS
FUMARATE & FOLIC ACID, 25 PRENATAL VITAMIN WITH DOCUSATE, IRON CARBONYL &
FOLIC ACID, 25 PRENATAL VITAMIN WITH FERROUS FUMARATE & FOLIC
ACID, 25 PRENATAL VITAMIN WITH IRON CARBONYL & FOLIC ACID,
25 PRENATAL VITAMIN WITH MINERALS, IRON & FOLIC ACID,
25 PRENATAL VITAMIN WITH SELENIUM, FERROUS
FUMARATE & FOLIC ACID, 25
PRENATAL VITAMIN WITHOUT VITAMIN A, WITH IRON CARBONYL, DOCUSATE & FOLIC ACID, 25
PREVACID SOLUTAB, 18 PREZISTA, 5 PRIMAQUINE PHOSPHATE, 4 primidone, 12 PRIMSOL, 6 probenecid, 16 prochlorperazine, 14 prochlorperazine maleate, 14 PROCRIT, 8 progesterone micronized, 21 PROGESTINS, 21 promethazine hcl, 6 propafenone hcl, 10 propranolol hcl, 9 propylthiouracil, 21 PROSTIGMIN, 7 protriptyline hcl, 14 PSYCHOTHERAPEUTIC AGENTS, 13 PULMOZYME, 22 PURIXAN, 7 pyrazinamide, 4 pyridostigmine bromide, 7
Q
quetiapine fumarate, 14 quinapril hcl, 10 quinapril-hydrochlorothiazide, 10 quinidine gluconate, 10 quinidine sulfate, 10 QVAR, 19
R
raloxifene hcl, 20 ramipril, 10 ranitidine hcl, 18 RAPAMUNE, 22 REBIF, 22 REGRANEX, 24 RELENZA DISKHALER, 5 RENAGEL, 16 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
INHIBITORS, 10 RENVELA, 16 REPLACEMENT PREPARATIONS, 16 RESCRIPTOR, 5 RESERPINE, 10 RESPIRATORY AGENTS, MISCELLANEOUS, 22 RESPIRATORY TRACT AGENTS, 22 REVLIMID, 22
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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REYATAZ, 5 RHEUMATREX, 7 ribavirin (hepatitis c), 5 RIDAURA, 18 rifabutin, 4 rifampin, 4 riluzole, 13 rimantadine hydrochloride, 5 risperidone, 14 rizatriptan benzoate, 12 ropinirole hydrochloride, 13
S
salsalate, 12 SANDIMMUNE, 22 SAVELLA, 13 selegiline hcl, 13 selenium sulfide, 23 SELZENTRY, 5 SEREVENT DISKUS, 8 sertraline hcl, 14 SIDEKICK BLOOD GLUCOSE SYSTEM, 15 sildenafil citrate (pulmonary hypertension), 11 silver sulfadiazine, 23 simvastatin, 9 sirolimus, 22 SKELETAL MUSCLE RELAXANTS, 7 SKIN AND MUCOUS MEMBRANE AGENTS, 23 SKIN AND MUCOUS MEMBRANE AGENTS,
MISCELLANEOUS, 24 SMOOTH MUSCLE RELAXANTS, 25 sodium chloride (inhalant), 22 sodium citrate & citric acid, 15 SODIUM EDECRIN, 15 sodium fluoride, 22 sodium fluoride (dental), 22 sodium polystyrene sulfonate, 16 SOMATOTROPIN AGONISTS AND ANTAGONISTS, 21 sotalol hcl, 9 SOVALDI, 5 SPECTRACEF, 3 SPIRIVA RESPIMAT, 7 spironolactone, 10 spironolactone & hydrochlorothiazide, 10 SPRYCEL, 7 SSKI, 21 stavudine, 5 sucralfate, 18 sulfacetamide sodium (acne), 23 sulfacetamide sodium (ophth), 16 sulfacetamide sod-prednisolone, 17 SULFADIAZINE, 3
sulfamethoxazole-trimethoprim, 3 sulfasalazine, 3, 18 sulindac, 12 SUMATRIPTAN, 12 sumatriptan succinate, 13 SUPRAX, 4 SURMONTIL, 14 SUSTIVA, 5 SUTENT, 7 SYMPATHOMIMETIC (ADRENERGIC) AGENTS, 8
T
TABLOID, 7 tacrolimus, 22 tacrolimus (topical), 24 TAMIFLU, 5 tamoxifen citrate, 7 tamsulosin hcl, 7 TARCEVA, 7 TARGRETIN, 7, 25 TARKA, 10 TAZORAC, 25 temazepam, 13 temozolomide, 7 terazosin hcl, 9 terbinafine hcl, 4 terbutaline sulfate, 8 testosterone, 19 testosterone cypionate, 19 testosterone enanthate, 19 TETRACYCLINE HCL, 4 THALOMID, 22 theophylline, 25 thioridazine hcl, 14 thiothixene, 14 thyroid, 21 THYROID AND ANTITHYROID AGENTS, 21 THYROLAR, 21 THYROLAR-1, 21 tiagabine hcl, 12 TIKOSYN, 10 timolol maleate (ophth), 17 tizanidine hcl, 8 tobramycin, 4 tobramycin (ophth), 16 tobramycin-dexamethasone, 17 tolazamide, 20 TOLBUTAMIDE, 20 tolterodine tartrate, 25 tolterodine tartrate (extended release), 25 topiramate, 12 torsemide, 16
Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)
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TRACLEER, 11 tramadol hcl, 12 tranylcypromine sulfate, 14 trazodone hcl, 14 tretinoin, 24 tretinoin (chemotherapy), 7 triamcinolone acetonide (mouth), 24 triamcinolone acetonide (topical), 24 triamterene & hydrochlorothiazide, 16 triazolam, 13 trifluoperazine hcl, 14 trifluridine, 16 trihexyphenidyl hcl, 13 trimethoprim, 6 tropicamide, 18 trospium chloride, 25 TRUVADA, 5 TYKERB, 7 TYZEKA, 5
U
URICOSURIC AGENTS, 16 URINARY ANTI-INFECTIVES, 5 ursodiol, 18
V
VAGIFEM, 20 valacyclovir hcl, 5 valganciclovir, 5 valproate sodium, 12 valproic acid, 12 valsartan-hydrochlorothiazide, 10, 11 vancomycin hcl, 4 VASODILATING AGENTS, 11 VECTICAL, 25 venlafaxine hcl, 14 verapamil hcl, 10 VIAGRA, 11
VICTRELIS, 5 VIRACEPT, 5 VIRAZOLE, 5 VIREAD, 5 VITAMIN B COMPLEX, 25 VITAMIN D, 25 VITAMIN K ACTIVITY, 25 VITAMINS, 25 voriconazole, 4 VOTRIENT, 7
W
warfarin sodium, 8
X
XOPENEX HFA, 8 XTANDI, 7 XULANE, 20
Y
YODOXIN, 4
Z
zafirlukast, 22 zaleplon, 13 ZELBORAF, 7 ZENPEP, 18 zidovudine, 5 ziprasidone hcl, 14 ZOLINZA, 7 zolmitriptan, 13 zolpidem tartrate, 13 zonisamide, 12 ZYDELIG, 7 ZYTIGA, 7 ZYVOX, 4
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