Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Southern Colorado Commercial HMO Drug Formulary
The following is a listing of the drugs on the Southern Colorado Commercial HMO Drug 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 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 formulary. Kaiser Permanente has many brand and generic medications on the formulary. 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 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-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, budesonide (oral), generic for 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 specific days supply or quantity per copay. For example, Tarceva® is limited to a 30-day
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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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 Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits 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
ivermectin Generic
ANTI-INFECTIVE AGENTS
ANTIBACTERIALS
amoxicillin Generic
amoxicillin & potassium clavulanate Generic/Brand †
ampicillin Generic/Brand †
azithromycin Generic/Brand †
BACTOCILL/DEXTROSE Brand *
CAYSTON Brand PA
cefaclor Generic
cefadroxil Generic
cefdinir Generic
cefixime Generic
cefprozil Generic
CEFTRIAXONE SODIUM/DEXTROSE Brand *
cefuroxime axetil Generic/Brand †
cephalexin Generic
ciprofloxacin hcl Generic/Brand †
ciprofloxacin-ciprofloxacin hcl Generic
clarithromycin Generic
clindamycin hcl Generic/Brand †
dicloxacillin Generic
doxycycline Generic
doxycycline (monohydrate) Generic
erythromycin & sulfisoxazole Generic
erythromycin base Generic/Brand †
erythromycin ethylsuccinate Generic/Brand †
erythromycin stearate Brand
levofloxacin Generic
linezolid Brand * MD, PA, QL
minocycline Generic
moxifloxacin Generic
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Drug Name Drug Tier Requirements /
Limits neomycin sulfate Generic/Brand †
penicillin v potassium Generic
SPECTRACEF Brand
sulfadiazine Generic
sulfamethoxazole & trimethoprim Generic
sulfasalazine Generic
SUPRAX Brand
tetracycline Generic/Brand †
TOBI Podhaler Brand QL
tobramycin neb Generic QL
vancomycin Generic QL
ZYVOX Brand * MD, PA, QL
ANTI-INFECTIVE AGENTS
ANTIFUNGALS
fluconazole Generic
griseofulvin microsize Generic
griseofulvin ultramicrosize Generic
itraconazole Generic/Brand † MD
ketoconazole Generic
nystatin Generic/Brand †
terbinafine Generic
voriconazole Generic MD
ANTI-INFECTIVE AGENTS
ANTIMYCOBACTERIALS
DAPSONE Brand
ethambutol Generic
isoniazid Generic
pyrazinamide Generic
rifabutin Generic
rifampin Generic
ANTI-INFECTIVE AGENTS
ANTIVIRALS
abacavir sulfate-lamivudine-zidovudine Generic
abacavir sulfate Generic
acyclovir Generic
adefovir dipivoxil Generic QL
APTIVUS Brand
ATRIPLA Brand
BARACLUDE Brand
CRIXIVAN Brand
didanosine Generic/Brand †
EMTRIVA Brand
entecavir Generic †
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Drug Name Drug Tier Requirements /
Limits EPIVIR HBV Brand
EPZICOM Brand
famciclovir Generic
GANCYCLOVIR Brand QL
HARVONI Brand PA, QL
INTELENCE Brand
INVIRASE Brand
ISENTRESS Brand
KALETRA Brand
lamivudine Generic
lamivudine-zidovudine Generic
LEXIVA Brand
nevirapine Generic
NORVIR Brand
PEGASYS Brand * PA, QL
PEG-INTRON Brand * PA, QL
PREZISTA Brand
RELENZA Brand PA, QL
RESCRIPTOR Brand
REYATAZ Brand
ribavirin Generic PA, QL
rimantadine Generic/Brand †
SELZENTRY Brand
SOVALDI Brand PA, QL
stavudine Generic
SUSTIVA Brand
TAMIFLU Brand QL
TRUVADA Brand
TYZEKA Brand QL
valacyclovir Generic
valganciclovir Generic QL
VICTRELIS Brand PA, QL
VIRACEPT Brand
VIRAZOLE Brand PA, QL
VIREAD Brand
zidovudine Generic
ANTI-INFECTIVE AGENTS
ANTIPROTOZOALS
atovaquone/proguanil Generic
chloroquine phosphate Generic
DARAPRIM Brand
hydroxychloroquine sulfate Generic
mefloquine hcl Generic
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Drug Name Drug Tier Requirements /
Limits metronidazole Generic
NEBUPENT Brand
paromomycin sulfate Generic
PRIMAQUINE PHOSPHATE Brand
YODOXIN Generic
ANTI-INFECTIVE AGENTS
URINARY ANTI-INFECTIVES
belladonna alkaloids, methenamine,
methylene blue & phenyl salicylate Generic
methenamine hippurate Generic
methenamine mandelate 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
capecitabine Generic
CEENU Brand
CYCLOPHOSPHAMIDE Brand
ELIGARD Brand * PA
EMCYT Brand QL
ETOPOSIDE Brand
exemestane Generic
flutamide Generic
GLEEVEC Brand MD, QL
HEXALEN Brand
hydroxyurea Generic
IMBRUVICA Brand PA, QL
INTRON-A Brand * PA, QL
IRESSA Brand QL
letrozole Generic PA
LEUKERAN Brand
leuprolide acetate Generic/Brand *† PA
LUPRON DEPOT Brand * PA
LUPRON DEPOT-PED Brand * PA
LYSODREN Brand QL
MATULANE Brand QL
megestrol acetate Generic
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Drug Name Drug Tier Requirements /
Limits mercaptopurine Generic
methotrexate Generic/Brand *†
MYLERAN Brand
NEXAVAR Brand MD, QL
NILANDRON Brand
SPRYCEL Brand QL
SUTENT Brand MD, QL
TABLOID Brand
tamoxifen citrate Generic
TARCEVA Brand QL
TARGRETIN Brand QL
temozolomide Generic QL
tretinoin (chemo) Generic QL
TYKERB Brand QL
VOTRIENT Brand MD, QL
XTANDI Brand PA, QL
ZELBORAF Brand PA, QL
ZOLINZA Brand QL
ZYDELIG Brand PA, QL
ZYTIGA Brand PA, QL
AUTONOMIC DRUGS
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS
bethanechol chloride Generic
cevimeline hcl Generic
donepezil Generic
galantamine hbr Generic
galantamine hbr (extended release) Generic
pilocarpine hcl (oral) Generic
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 RESPIMAT Brand QL
AUTONOMIC DRUGS
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ADVAIR DISKUS Brand ST
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Drug Name Drug Tier Requirements /
Limits ADVAIR HFA Brand ST
albuterol sulfate Generic
COMBIVENT RESPIMAT Brand
DULERA Brand
ELIXOPHYLLIN Brand
epinephrine hcl Generic/Brand *† QL
ergoloid mesylates Generic
levalbuterol hcl solution Generic ST
metaproterenol sulfate Generic/Brand †
midodrine hcl Generic
SEREVENT DISKUS Brand
terbutaline sulfate Generic
VENTOLIN HFA Brand
XOPENEX HFA Brand ST
AUTONOMIC DRUGS
SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS
dihydroergotamine mesylate Generic/Brand *† QL
ERGOMAR Brand QL
phenoxybenzamine hcl Generic
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
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
ANTITHROMBOTIC AGENTS
anagrelide hcl Generic
BRILINTA Brand
cilostazol Generic
clopidogrel Generic
EFFIENT Brand * QL
fondaparinux Generic* QL
FRAGMIN Brand * QL
heparin sodium Generic/Brand *†
LOVENOX Brand * QL
PRADAXA Brand
warfarin sodium Generic
BLOOD FORMATION, COAGULATION AND THROMBOSIS
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Drug Name Drug Tier Requirements /
Limits HEMATOPOIETIC AGENTS
EPOGEN Brand * PA, QL
LEUKINE Brand * MD, QL
NEULASTA Brand * PA, QL
PROCRIT Brand * PA, QL
ZARXIO Brand * QL
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
HEMORRHEOLOGIC AGENTS
pentoxifylline Generic
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
ANTIHEMORRHAGIC AGENTS
aminocaproic acid Generic/Brand †
CARDIOVASCULAR DRUGS
CARDIAC DRUGS
amiodarone hcl Generic/Brand †
digoxin Generic/Brand †
disopyramide phosphate Generic/Brand †
flecainide acetate Generic
mexiletine hcl Generic
propafenone hcl Generic
quinidine gluconate Generic
quinidine sulfate Generic
TIKOSYN Brand
CARDIOVASCULAR DRUGS
ANTILIPEMIC AGENTS
atorvastatin calcium Generic
cholestyramine Generic
cholestyramine light Generic
colestipol Generic
CRESTOR Brand
fenofibrate Generic
fenofibrate (micronized) Generic
gemfibrozil Generic
lovastatin Generic
NIASPAN Brand PA
pravastatin Generic
simvastatin Generic
CARDIOVASCULAR DRUGS
HYPOTENSIVE AGENTS
clonidine hcl Generic
guanfacine hcl Generic
hydralazine hcl Generic
methyldopa Generic
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Drug Name Drug Tier Requirements /
Limits minoxidil Generic
RESERPINE Brand
CARDIOVASCULAR DRUGS
VASODILATING AGENTS
ADCIRCA Brand MD, QL
alprostadil Generic * PA, QL, RB
CAVERJECT Brand * PA, QL, RB
CIALIS Brand PA, QL, RB
dipyridamole Generic
EDEX Brand * PA, QL, RB
isosorbide dinitrate Generic/Brand †
isosorbide mononitrate Generic
LETAIRIS Brand MD, QL
LEVITRA Brand PA, QL, RB
MUSE Brand PA, QL, RB
nitroglycerin Generic/Brand †
OSPHENA Brand PA, QL, RB
sildenafil citrate (pulmonary hypertension) Generic MD
TRACLEER Brand MD, QL
VIAGRA Brand PA, QL, RB
CARDIOVASCULAR DRUGS
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate Generic
prazosin hcl Generic
terazosin hcl Generic
CARDIOVASCULAR DRUGS
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl Generic
atenolol Generic
atenolol & chlorthalidone Generic
bisoprolol fumarate Generic
bisoprolol fumarate & hydrochlorothiazide Generic
BYSTOLIC Brand
carvedilol Generic
COREG CR Brand
labetalol hcl Generic
metoprolol succinate Generic
metoprolol tartrate Generic
nadolol Generic
pindolol Generic
propranolol hcl Generic
sotalol hcl Generic
CARDIOVASCULAR DRUGS
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Drug Name Drug Tier Requirements /
Limits CALCIUM-CHANNEL BLOCKING AGENTS
amlodipine besylate Generic
amlodipine besylate & benazepril hcl Generic
amlodipine besylate & valsartan Generic ST
CARDENE SR Brand
diltiazem hcl Generic/Brand †
diltiazem hcl coated beads Generic
diltiazem hcl extended release beads Generic
EXFORGE HCT Brand ST
felodipine Generic
isradipine Generic/Brand †
nifedipine Generic
nimodipined Generic
TARKA Brand
verapamil hcl Generic
CARDIOVASCULAR DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
benazepril & hydrochlorothiazide Generic
benazepril hcl Generic
captopril Generic
CAPTOPRIL & HYDROCHLOROTHIAZIE Brand
enalapril maleate Generic
fosinopril sodium Generic
fosinopril sodium & hydrochlorothiazide Generic
lisinopril Generic
lisinopril & hydrochlorothiazide Generic
losartan potassium Generic
losartan potassium & hydrochlorothiazide Generic
moexipril & hydrochlorothiazide Generic
moexipril hcl Generic
quinapril & hydrochlorothiazide Generic
quinapril hcl Generic
ramipril Generic
spironolactone Generic
spironolactone & hydrochlorothiazide Generic
valsartan Generic ST
valsartan & hydrochlorothiazide Generic ST
CENTRAL NERVOUS SYSTEM AGENTS
ANALGESICS AND ANTIPYRETICS
acetaminophen with codeine Generic
buprenorphine HCl & naloxone HCl Generic/Brand † PA, QL
butalbital & acetaminophen Generic
butalbital, acetaminophen & caffeine Generic
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Drug Name Drug Tier Requirements /
Limits butalbital, acetaminophen, caffeine & codeine Generic
butalbital, aspirin & caffeine Generic
butalbital, aspirin, caffeine & codeine Generic
celecoxib Generic QL, ST
choline magnesium trisalicylate Generic
diclofenac sodium Generic
etodolac Generic
fenoprofen calcium Generic/Brand †
fentanyl Generic MD, PA, QL
fentanyl citrate Generic MD, PA, QL
hydrocodone & acetaminophen Generic QL
hydromorphone hcl Generic/Brand † QL
ibuprofen Generic
indomethacin Generic/Brand †
ketoprofen Generic
KETOPROFEN (extended release) Brand
ketorolac tromethamine Generic QL
meclofenamate sodium Generic
meloxicam Generic
methadone hcl Generic QL
morphine sulfate Generic/Brand † QL
morphine sulfate (extended release) Generic QL
nabumetone Generic
naproxen Generic
naproxen sodium Generic
oxaprozin Generic
oxycodone & acetaminophen Generic QL
oxycodone & aspirin Generic QL
oxycodone hcl Generic QL
salsalate Generic
sulindac Generic
tramadol hcl Generic
CENTRAL NERVOUS SYSTEM AGENTS
OPIATE ANTAGONISTS
naltrexone hcl Generic
CENTRAL NERVOUS SYSTEM AGENTS
ANTICONVULSANTS
carbamazepine Generic
carbamazepine (extended release) Generic
CELONTIN Brand
clonazepam Generic
divalproex sodium Generic
divalproex sodium (extended release) Generic
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Drug Name Drug Tier Requirements /
Limits ethosuximide Generic
felbamate Brand MD
gabapentin Generic/Brand †
lamotrigine Generic QL
levetiracetam Generic
oxcarbazepine Generic
phenytoin Generic/Brand †
phenytoin sodium (extended release) Generic/Brand †
primidone Generic
tiagabine Generic
topiramate Generic
valproate sodium Generic
valproic acid Generic
zonisamide Generic MD
CENTRAL NERVOUS SYSTEM AGENTS
PSYCHOTHERAPEUTIC AGENTS
ABILIFY Brand MD, QL
ABILIFY DISCMELT Brand MD, QL
amitriptyline hcl Generic
AMOXAPINE Brand
aripiprazole Generic MD, QL
bupropion hcl Generic
bupropion hcl (smoking deterrent) Generic
bupropion hcl xl Generic QL
chlordiazepoxide & amitriptyline Generic
chlorpromazine hcl Generic
citalopram hydrobromide Generic QL
clomipramine hcl Generic
clozapine Generic MD, QL
desipramine hcl Generic
doxepin hcl Generic
duloxetine hcl Generic
escitalopram oxalate Generic QL, ST
fluoxetine hcl Generic
fluoxetine hcl weekly Generic QL
fluphenazine hcl Generic
fluvoxamine maleate Generic
haloperidol Generic
haloperidol lactate Generic
imipramine hcl Generic
imipramine pamoate Generic/Brand †
loxapine succinate Generic
maprotiline hcl Generic
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Drug Name Drug Tier Requirements /
Limits mirtazapine Generic
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
phenelzine sulfate Generic
prochlorperazine maleate Generic
protriptyline hcl Generic MD
quetiapine fumarate Generic MD, QL
risperidone Generic MD, QL
sertraline hcl Generic
SURMONTIL Brand MD
thioridazine hcl Generic
thiothixene Generic/Brand †
tranylcypromine sulfate Generic
trazodone hcl Generic QL
trifluoperazine hcl Generic
venlafaxine hcl Generic
venlafaxine hcl (extended release) Generic/Brand †
ziprasidone hcl Generic MD, QL
CENTRAL NERVOUS SYSTEM AGENTS
ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL
STIMULANTS, MISCELLANEOUS
amphetamine & dextroamphetamine Generic QL
dexmethylphenidate hcl Generic QL
dextroamphetamine sulfate Generic QL
methylphenidate hcl Generic QL
methylphenidate hcl (extended release) Generic/Brand † QL
modafinil Generic PA, QL
phentermine Generic QL, RB
QSYMIA Brand PA, QL, RB
CENTRAL NERVOUS SYSTEM AGENTS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
alprazolam Generic
buspirone hcl Generic QL (7.5mg, 30mg)
chlordiazepoxide hcl Generic
clorazepate dipotassium Generic
diazepam Generic/Brand *†
estazolam Generic
flurazepam hcl Generic
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Drug Name Drug Tier Requirements /
Limits hydroxyzine hcl Generic
hydroxyzine pamoate Generic
lorazepam Generic
oxazepam Generic
phenobarbital Generic
temazepam Generic/Brand † MD
triazolam Generic
zaleplon Generic QL
zolpidem tartrate Generic QL
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS
lithium carbonate Generic/Brand †
lithium carbonate (extended release) Generic/Brand †
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMIGRAINE AGENTS
CAFERGOT Brand QL
naratriptan Generic QL, ST
rizatriptan Generic QL, ST
sumatriptan succinate Generic/Brand *† QL
zolmitriptan Generic/Brand QL, ST
zolmitriptan ODT Generic QL, ST
CENTRAL NERVOUS SYSTEM AGENTS
ANTIPARKINSONIAN AGENTS
amantadine hcl Generic
APOKYN Brand * MD, QL
benztropine mesylate Generic
bromocriptine mesylate Generic
cabergoline Generic MD
carbidopa & levodopa Generic
carbidopa & levodopa (extended release) Generic
entacapone Generic
pramipexole dihydrochloride Generic
ropinirole hcl Generic
selegiline hcl Generic
trihexyphenidyl hcl Generic
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS
acamprosate calcium Generic
riluzole Generic MD
NARCAN Brand
nemantine hcl Generic
pramipexole dihydrochloride Generic
selegiline hcl Generic
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Drug Name Drug Tier Requirements /
Limits SAVELLA Brand QL
ELECTROLYTIC, CALORIC AND WATER BALANCE
ALKALINIZING AGENTS
potassium & sodium citrates w/ citric acid Generic
potassium citrate Generic
potassium citrate-citric acid Generic
sodium citrate & citric acid Generic
ELECTROLYTIC, CALORIC AND WATER BALANCE
AMMONIA DETOXICANTS
lactulose Generic
ELECTROLYTIC, CALORIC AND WATER BALANCE
DIURETICS
amiloride & hydrochlorothiazide Generic
amiloride Generic
bumetanide Generic
chlorothiazide Generic
chlorthalidone Generic
furosemide Generic
hydrochlorothiazide Generic
indapamide Generic
metolazone Generic
torsemide Generic
triamterene & hydrochlorothiazide Generic
ELECTROLYTIC, CALORIC AND WATER BALANCE
ION-REMOVING AGENTS
RENAGEL Brand
RENVELA Brand
RENVELA PAK Brand
sodium polystyrene sulfonate Generic
ELECTROLYTIC, CALORIC AND WATER BALANCE
IRRIGATING SOLUTIONS
lactated ringer’s (irrigation)) Generic
ringer’s (irrigation) Generic
sodium chloride (gu irrigant) Generic
water for irrigation (sterile) Generic
ELECTROLYTIC, CALORIC AND WATER BALANCE
REPLACEMENT PREPARATIONS
ADDAMEL N Brand *
calcium acetate (phosphate binder) Generic/Brand †
potassium bicarb & potassium chloride Generic/Brand †
potassium chloride Generic
pot phosphate monobasic w/ sod phosphate dibasic & monobasic Generic
zinc sulfate Generic
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Drug Name Drug Tier Requirements /
Limits ELECTROLYTIC, CALORIC AND WATER BALANCE
URICOSURIC AGENTS
colchicine Generic
probenecid Generic
probenecid & colchicine Generic
ENZYMES
ENZYMES
PULMOZYME Brand QL
RESPIRATORY TRACT AGENTS
ANTITUSSIVES
benzonatate Generic
guaifenesin & codeine Generic
hydrocodone & homatropine Generic QL
hydrocodone polistirex & chlorpheniramine polistirex Generic QL
RESPIRATORY TRACT AGENTS
RESPIRATORY TRACT ANTI-INFLAMMATORY AGENTS
cromolyn sodium Generic/Brand †
montelukast sodium Generic
montelukast sodium (packets) Generic QL, ST
STRIVERDI RESPIMAT
zafirlukast Generic
RESPIRATORY TRACT AGENTS
RESPIRATORY TRACT AGENTS, MISCELLANEOUS
sodium chloride for nebulization Generic
EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS
EENT ANTI-ALLERGIC AGENTS
ALAMAST Brand
ALOCRIL (ophthalmic) Brand QL
ALOMIDE (ophthalmic) Brand
azelastine hcl spray Generic
azelastine hcl (ophthalmic) Generic/Brand †
cromolyn sodium (ophthalmic) Generic
PATANOL Brand QL, ST
EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS
EENT ANTI-INFECTIVES
bacitracin & polymyxin B (ophthalmic) Generic
bacitracin (ophthalmic) Brand
chlorhexidine gluconate (dental) Generic
ciprofloxacin hcl (ophthalmic) Generic
dexamthasone sod phosphate (ophthalmic) Generic
erythromycin (ophthalmic) Generic
gatifloxacin (ophthalmic) Generic MD
gentamicin sulfate (ophthalmic) Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits neomycin, bacitracin & polymyxin B (ophth) Generic
neomycin, polymyxin & dexamethasone (ophth) Generic
ofloxacin (ophthalmic) Generic
ofloxacin (otic) Generic
polymyxin B & trimethoprim Generic
sulfacetamide sodium (ophthalmic) Generic/Brand †
tobramycin sulfate (ophthalmic) Generic/Brand †
trifluridine (ophthalmic) Generic
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
EENT ANTI-INFLAMMATORY AGENTS
BLEPHAMIDE (ophthalmic) Brand
BLEPHAMIDE S.O.P. Brand
CIPRO HC (otic) Brand
CIPRODEX Brand
COLY-MYCIN-S (otic) Brand
diclofenac sodium (ophthalmic) Generic
FLAREX Brand
flunisolide (nasal) Generic
fluorometholone (ophthalmic) Generic
flurbiprofen sodium (ophthalmic) Generic
fluticasone propionate (nasal) Generic
FML FORTE Brand
hydrocortisone & acetic acid (otic) Generic
ketorolac tromethamine (ophthalmic) Generic/Brand †
NASONEX Brand
neomycin, polymyxin, bacitracin
& hydrocortisone (ophthalmic) Generic/Brand †
neomycin, polymyxin &
dexamethasone (ophthalmic) Generic
NEOMYCIN, POLYMYXIN &
DEXAMETHASONE (ophthalmic) Brand
neomycin, polymyxin &
hydrocortisone (otic) Generic
PRED-G (ophthalmic) Brand
PRED-G S.O.P. (ophthalmic) Brand
prednisolone acetate (ophthalmic) Generic/Brand †
prednisolone sodium phosphate (ophth) Generic
sulfacetamide sodium &
prednisolone sodium phosphate (ophth) Generic
tobramycin sulfate & dexamethasone (ophth) Generic/Brand †
EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS
EENT ANTIGLAUCOMA AGENTS
acetazolamide Generic
AZOPT (ophthalmic) Brand
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits betaxolol hcl (ophthalmic) Generic/Brand †
BETIMOL Brand
brimonidine tartrate Generic/Brand †
carteolol hcl (ophthalmic) Generic
dorzolamide hcl & timolol maleate (ophth) Generic
dorzolamide hcl (ophthalmic) Generic
latanoprost Generic
levobunolol hcl (ophthalmic) Generic
methazolamide Generic
METIPRANOLOL (ophthalmic) Brand
PHOSPHOLINE IODIDE (ophthalmic) Brand
pilocarpine hcl (ophthalmic) Generic
timolol maleate (ophthalmic) Generic
EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS
EENT DRUGS, MISCELLANEOUS
acetic acid & aluminum acetate Generic
acetic acid (otic) Generic
fluorescein sodium Generic
fluorescein w/ benoxinate Generic
fluorescein w/ proparacaine Generic
ophthalmic irrigation Generic
phenylephrine (ophth) Generic
EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS
EENT LOCAL ANESTHETICS
antipyrine, benzocaine & polycosanol Generic/Brand
benzocaine & antipyrine (otic) Generic
lidocaine hcl (mouth-throat) Generic
proparacaine Generic
tetracaine hcl (ophth) Generic
EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS
EENT MYDRIATICS
atropine sulfate (ophthalmic) Generic
cyclopentolate hcl (ophthalmic) Generic
tropicamide (ophthalmic) Generic
GASTROINTESTINAL DRUGS
ANTIDIARRHEA AGENTS
diphenoxylate & atropine Generic
GASTROINTESTINAL DRUGS
CATHARTICS AND LAXATIVES
polyethylene glycol 3350,
potassium chloride, sodium
bicarbonate, sodium chloride &
sodium sulfate
Generic/Brand †
polyethylene glycol 3350, Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits potassium chloride, sodium
bicarbonate & sodium chloride
GASTROINTESTINAL DRUGS
CHOLELITHOLYTIC AGENTS
ursodiol Generic/Brand †
GASTROINTESTINAL DRUGS
DIGESTANTS
amylase 27,000 units; lipase
5,000 units; protease 17,000 units Generic/Brand †
amylase 55,000 units; lipase
10,000 units; protease 34,000 units Generic/Brand †
amylase 82,000 units; lipase
15,000 units; protease 51,000 units Generic/Brand †
amylase 109,000 units; lipase
20,000 units; protease 68,000 units Generic/Brand †
GASTROINTESTINAL DRUGS
ANTIEMETICS
ANTIVERT Brand
dronabinol Generic QL
EMEND Brand MD, QL
ondansetron hcl Generic QL
GASTROINTESTINAL DRUGS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
cimetidine hcl Generic
famotidine Generic
misoprostol Generic
omeprazole Generic
pantoprazole sodium Generic
PREVACID SOLUTAB Brand ST
ranitidine hcl Generic
sucralfate Generic/Brand †
GASTROINTESTINAL DRUGS
PROKINETIC AGENTS
metoclopramide hcl Generic
GASTROINTESTINAL DRUGS
GI ANTI-INFLAMMATORY AGENTS
APRISO Brand
balsalazine disodium Generic
LIALDA Brand
mesalamine Generic
sulfasalazine Generic
GOLD COMPOUNDS
GOLD COMPOUNDS
RIDAURA Brand
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
CUPRIMINE Brand PA, QL
DEPEN Brand QL
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
ASMANEX Brand
ASMANEX HFA Brand
budesonide (oral) Generic MD, QL
budesonide (nebulized) Generic
CORTISONE ACETATE Brand
dexamethazone Generic/Brand
FLOVENT DISKUS Brand
FLOVENT HFA Brand
fludrocortisone acetate Generic
hydrocortisone Generic
methylprednisolone Generic/Brand †
prednisolone Generic
prednisolone sodium phosphate Generic
prednisone Generic/Brand †
PULMICORT FLEXHALER Brand
QVAR Brand
HORMONES AND SYNTHETIC SUBSTITUTES
ANDROGENS
ANDRODERM Brand PA, QL
ANDROXY Brand QL
AXIRON Brand PA, QL
danazol Generic
METHITEST Brand
testosterone Generic/Brand *† PA, QL
testosterone cypionate Generic/Brand *† PA, QL
testosterone enanthate Brand/Generic *† PA, QL
HORMONES AND SYNTHETIC SUBSTITUTES
CONTRACEPTIVES Possible Brands
desogestrel & ethinyl estradiol (monophasic) Generic/Brand †
APRI,
DESOGEN,
KARIVA,
MIRCETTE,
ORTHO-CEPT
desogestrel & ethinyl estradiol (triphasic) Generic
CESIA,
CYCLESSA,
VELIVET
drospirenone & ethinyl estradiol Brand YASMIN
ELLA Brand
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits
ethynodiol diacetate & ethinyl estradiol Generic
KELNOR,
ZOVIA 1/35E,
ZOVIA 1/50E
levonorgestrel & ethinyl estradiol (91-day) Generic/Brand † JOLESSA,
SEASONIQUE
levonorgestrel & ethinyl estradiol (monophasic) Generic/Brand †
LESSINA,
NORDETTE,
PORTIA
levonorgestrel & ethinyl estradiol (triphasic) Generic ENPRESSE,
TRIVORA
levonorgestrel (emergency oral contraceptive) Generic/Brand † AG
norethindrone & ethinyl estradiol (biphasic) Brand NECON 10/11
norethindrone & ethinyl estradiol (monophasic) Generic/Brand †
MODICON,
NORTREL 0.5/35,
NORTREL 1/35,
ORTHO-NOVUM
1/35
norethindrone & ethinyl estradiol (triphasic) Generic/Brand †
NECON 7/7/7,
NORTREL 7/7/7,
ORTHO-NOVUM
7/7/7,
TRI-NORINYL
norethindrone & mestranol Generic/Brand †
NECON 1/50,
ORTHO-NOVUM
1/50
norethindrone (contraceptive) Generic/Brand †
NOR-QD,
NORA-BE,
ORTHO-
MICRONOR
norethindrone acetate & ethinyl estradiol Generic/Brand †
LOESTRIN 1/20,
MICROGESTIN
1/20,
LOESTRIN 1.5/30,
MICROGESTIN
1.5/30
norethindrone acetate, estradiol & iron Generic/Brand †
LOESTRIN FE 1/20,
MICROGESTIN FE
1/20,
LOESTRIN FE
1.5/30,
MICROGESTIN FE
1.5/30
norgestimate & ethinyl estradiol (monophasic) Generic/Brand †
PREVIFEM,
SPRINTEC,
ORTHO-CYCLEN
norgestimate & ethinyl estradiol (triphasic) Generic/Brand †
ORTHO TRI-
CYCLEN,
TRI-PREVIFEM,
TRI-SPRINTEC
norgestrel & ethinyl estradiol Generic/Brand † CRYSELLE,
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits LO/OVRAL,
LOW-OGESTREL,
OGESTREL
NUVARING Brand PA, QL
PLAN B Brand AG
XULANE Brand PA, QL
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIDIABETIC AGENTS
acarbose Generic
glimepiride Generic
glipizide Generic
glipizide (extended release) Generic
glyburide Generic
glyburide & metformin hcl Generic
HUMALOG Brand PA
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 SOLOSTAR Brand PA
LEVEMIR Brand
LEVEMIR FLEXTOUCH Brand PA
metformin hcl Generic
metformin hcl (extended release) Generic
NOVOLOG Brand
NOVOLOG FLEXPEN Brand PA
NOVOLOG MIX 70/30 FLEXPEN Brand PA
NOVOLOG MIX 70/30 Brand
pioglitazone hcl Generic
tolazamide Generic
TOLBUTAMIDE Brand
HORMONES AND SYNTHETIC SUBSTITUTES
ANTIHYPOGLYCEMIC AGENTS
GLUCAGON HCL Brand † QL
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits HORMONES AND SYNTHETIC SUBSTITUTES
ESTROGENS AND ESTROGEN AGONISTS-ANTAGONISTS
COMBIPATCH Brand
clomiphene citrate Generic PA, RB
esterified estrogens & methyltestosterone Generic
ESTRACE VAGINAL Brand
estradiol (oral) Generic/Brand †
estradiol (transdermal) Generic/Brand † QL
estradiol valerate Generic *
estropipate Generic
FEMHRT LOW DOSE Brand
PREMARIN Brand
PREMPHASE Brand
PREMPRO Brand
raloxifene Generic
VAGIFEM Brand
HORMONES AND SYNTHETIC SUBSTITUTES
GONADOTROPINS
BRAVELLE Brand * PA. RB
chorionic gonadotropin Generic * PA. RB FOLLISTIM AQ Brand * PA. RB GONAL-F Brand * PA. RB MENOPUR Brand * PA. RB OVIDREL Brand * PA. RB
HORMONES AND SYNTHETIC SUBSTITUTES
PARATHYROID
calcitonin (salmon) Generic QL
FORTEO Brand * PA, QL
HORMONES AND SYNTHETIC SUBSTITUTES
PITUITARY
ACTHAR HP Brand * PA, QL
desmopressin acetate Generic *
HORMONES AND SYNTHETIC SUBSTITUTES
SOMATROPIN AGONISTS AND ANTAGONISTS
OMNITROPE Brand * PA, QL
HORMONES AND SYNTHETIC SUBSTITUTES
PROGESTINS
medroxyprogesterone acetate Generic
norethindrone acetate Generic
progesterone, micronized Generic PA, RB
HORMONES AND SYNTHETIC SUBSTITUTES
THYROID AND ANTITHYROID AGENTS
levothyroxine sodium Generic/Brand †
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits liothyronine Generic
methimazole Generic
propylthiouracil Generic
SSKI Brand
thyroid Generic/Brand †
THYROLAR Brand
MISCELLANEOUS THERAPEUTIC AGENTS
5-ALPHA-REDUCTASE INHIBITORS
finasteride Generic MD
MISCELLANEOUS THERAPEUTIC AGENTS
ALCOHOL DETERRENTS
disulfiram Generic
MISCELLANEOUS THERAPEUTIC AGENTS
ANTIDOTES
acetylcysteine Generic
leucovorin calcium Generic/Brand *†
MISCELLANEOUS THERAPEUTIC AGENTS
ANTIGOUT AGENTS
allopurinol Generic
colchicine Generic
MISCELLANEOUS THERAPEUTIC AGENTS
BIOLOGIC RESPONSE MODIFIERS
GLATOPA Generic * MD, QL
REBIF Brand * MD, QL
REVLIMID Brand QL
THALOMID Brand QL
MISCELLANEOUS THERAPEUTIC AGENTS
BONE RESORPTION INHIBITORS
alendronate sodium Generic
ETIDRONATE DISODIUM Brand
FOSAMAX PLUS D Brand
MISCELLANEOUS THERAPEUTIC AGENTS
CARIOSTATIC AGENTS
sodium fluoride Generic
MISCELLANEOUS THERAPEUTIC AGENTS
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS
ENBREL Brand * MD, QL
HUMIRA Brand * MD, QL
leflunomide Generic MD
MISCELLANEOUS THERAPEUTIC AGENTS
IMMUNOSUPPRESSIVE AGENTS
azathioprine Generic
cyclosporine Generic/Brand †
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits cyclosporine modified (for microemulsion) Generic/Brand †
mycophenolate mofetil Generic
mycophenolate sodium Generic
RAPAMUNE Brand
tacrolimus Generic
sirolimus Generic
MISCELLANEOUS THERAPEUTIC AGENTS
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
acitretin Generic
CYSTAGON Brand PA
FIRAZYR Brand * QL
KINERET Brand * QL
levocarnitine Generic/Brand †
lidocaine-prilocaine Generic
MISCELLANEOUS THERAPEUTIC AGENTS
PROTECTIVE AGENTS
ELMIRON Brand
OXYTOCICS
OXYTOCICS
methylergonovine Generic
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)
acyclovir Generic
AVC Brand
BACTROBAN NASAL Brand
benzoyl peroxide & erythromycin Generic
ciclopirox Generic
ciclopiroxolamine 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
GENTAMICIN SULFATE (topical) Brand
ketoconazole (topical) Generic
lindane Generic
metronidazole (topical) Generic/Brand † MD
metronidazole (vaginal) Generic
MICONAZOLE 3 Brand
mupirocin (topical) Generic
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits NAFTIN Brand
nystatin (topical) Generic
permethrin Generic
selenium sulfide Generic
silver sulfadiazine Generic
sulfacetamide sodium (topical) Generic
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)
alclometasone dipropionate Generic
APEXICON E Brand
augmented betamethasone dipropionate Generic
betamethasone dipropionate (topical) Generic
betamethasone valerate Generic
clobetasol propionate Generic MD
clobetasol propionate emollient base Generic MD
CLODERM Brand
CORDRAN Brand
CORTIFOAM Brand
CORTISPORIN Brand
desonide Generic
desoximetasone Generic
diflorasone diacetate Generic
EPIFOAM Brand
fluocinolone acetonide Generic
fluocinonide Generic
fluocinonide emulsified base Generic
fluticasone propionate Generic/Brand †
halobetasol propionate Generic
hydrocortisone butyrate Generic
hydrocortisone butyrate hydrophilic lipo base Generic
hydrocortisone (intrarectal) Generic
hydrocortisone (rectal) Generic
hydrocortisone (topical) Generic
hydrocortisone acetate (rectal) Generic
hydrocortisone valerate Generic
iodoquinol-hc Generic
KENALOG Brand
mometasone furoate Generic
nystatin & triamcinolone Generic
triamcinolone acetonide (mouth) Generic
triamcinolone acetonide (topical) Generic
SKIN AND MUCOUS MEMBRANE AGENTS
ANTIPRURITICS AND LOCAL ANESTHETICS
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits hydrocortisone acetate & pramoxine Generic/Brand †
lidocaine hcl Generic ST
phenazopyridine hcl Generic
SKIN AND MUCOUS MEMBRANE AGENTS
CELL STIMULANTS AND PROLIFERANTS
tretinoin Generic AG, QL
SKIN AND MUCOUS MEMBRANE AGENTS
PIGMENTING AND DEPIGMENTING AGENTS
OXSORALEN Brand
SKIN AND MUCOUS MEMBRANE AGENTS
SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS
adapalene Generic MD
aluminum chloride Generic
AMEVIVE Brand * PA, QL
calcipotriene Generic/Brand †
DRITHO-CREME HP Brand
ELIDEL Brand MD, PA, QL
FINACEA Brand MD
fluorouracil (topical) Generic/Brand †
imiquimod Generic
isotretinoin Generic QL
podofilox Generic/Brand †
REGRANEX Brand PA, QL
tacrolimus (topical) Generic MD
TARGRETIN Brand QL
TAZORAC Brand QL
VECTICAL (topical) Brand ST
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
RESPIRATORY SMOOTH MUSCLE RELAXANTS
AMINOPHYLLINE Brand
theophylline Generic/Brand †
VITAMINS
VITAMIN B COMPLEX
folic acid Generic
VITAMINS
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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Drug Name Drug Tier Requirements /
Limits VITAMIN D
calcitriol Generic
ergocalciferol Generic
VITAMINS
VITAMIN K ACTIVITY
MEPHYTON Brand
VITAMINS
PRENATAL VITAMINS
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
VITAMINS
PEDIATRIC MULTIVITAMINS
pediatric multivitamins with fluoride Generic/Brand †
pediatric vitamins A, C, D, with fluoride Generic/Brand †
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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INDEX OF DRUGS
Kaiser Permanente Southern Colorado
Commercial HMO Comprehensive Formulary Index
5
5-ALPHA-REDUCTASE INHIBITORS 25
A
abacavir sulfate 4
abacavir sulfate-lamivudine-zidovudine 4
ABILIFY 13
ABILIFY DISCMELT 13
acamprosate calcium 15
acarbose 23
acebutolol hcl 10
acetaminophen with codeine 11
acetazolamide 18
acetic acid & aluminum acetate 19
acetic acid (otic) 19
acetylcysteine 25
acitretin 26
ACTHAR HP 24
acyclovir 4, 26
adapalene 28
ADCIRCA 10
ADDAMEL N 16
adefovir dipivoxil 4
adenovir dipivoxil 4
ADRENALS 21
ADVAIR DISKUS 7
ADVAIR HFA 8
AFINITOR 6
ALAMAST 17
ALBENZA 3
albuterol sulfate 8
alclometasone dipropionate 27
ALCOHOL DETERRENTS 25
alendronate sodium 25
ALKALINIZING AGENTS 16
ALKERAN 6
allopurinol 25
ALOCRIL (ophthalmic) 17
ALOMIDE (ophthalmic) 17
ALPHA-ADRENERGIC BLOCKING AGENTS 10
alprazolam 14
alprostadil 10
aluminum chloride 28
amantadine hcl 15
AMEVIVE 28
amiloride 16
amiloride & hydrochlorothiazide 16
aminocaproic acid 9
AMINOPHYLLINE 28
amiodarone hcl 9
amitriptyline hcl 13
amlodipine besylate 11
amlodipine besylate & benazepril hcl 11
amlodipine besylate & valsartan 11
AMMONIA DETOXICANTS 16
AMOXAPINE 13
amoxicillin 3
amoxicillin & potassium 3
amphetamine & dextroamphetamine 14
ampicillin 3
amylase 109,000 units; lipase 20,000 units; protease
68,000 units 20
amylase 27,000 units; lipase 5,000 units; protease 17,000
units 20
amylase 55,000 units; lipase 10,000 units; protease 34,000
units 20
amylase 82,000 units; lipase 15,000 units; protease 51,000
units 20
anagrelide hcl 8
ANALGESICS AND ANTIPYRETICS 11
anastrozole 6
ANDRODERM 21
ANDROGENS 21
ANDROXY 21
ANOREXIGENIC AGENTS AND RESPIRATORY
AND CEREBRAL 14
ANTHELMINTICS 3
ANTIALLERGIC AGENTS 17
ANTIBACTERIALS 3
ANTICHOLINERGIC AGENTS 7
ANTICONVULSANTS 12
ANTIDIARRHEA AGENTS 19
ANTIDOTES 25
ANTIEMETICS 20
ANTIFUNGALS 4
ANTIGOUT AGENTS 25
ANTIHEMORRHAGIC AGENTS 9
ANTIHISTAMINE DRUGS 3
ANTIHYPOGLYCEMIC AGENTS 23
ANTI-INFECTIVE AGENTS 3, 4, 5, 6
ANTI-INFECTIVES (SKIN AND MUCOUS
MEMBRANE) 26
ANTI-INFLAMMATORY AGENTS (SKIN AND
MUCOUS MEMBRANE) 27
ANTILIPEMIC AGENTS 9
ANTIMANIC AGENTS 15
ANTIMIGRAINE AGENTS 15
ANTIMYCOBACTERIALS 4
ANTINEOPLASTIC AGENTS 6
ANTIPARKINSONIAN AGENTS 15
ANTIPROTOZOALS 5
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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ANTIPRURITICS AND LOCAL ANESTHETICS 27
antipyrine, benzocaine & polycosanol 19
ANTITHROMBOTIC AGENTS 8
ANTITUSSIVES 17
ANTIULCER AGENTS AND ACID SUPPRESSANTS
20
ANTIVERT 20
ANTIVIRALS 4
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS 14
APEXICON E 27
APOKYN 15
APRI 21
APRISO 20
APTIVUS 4
aripiprazole 13
ASMANEX 21
ASMANEX HFA 21
atenolol 10
atenolol & chlorthalidone 10
atorvastatin calcium 9
atovaquone/proguanil 5
ATRIPLA 4
atropine sulfate (ophthalmic) 19
augmented betamethasone dipropionate 27
AUTONOMIC DRUGS 7, 8
AVC 26
AXIRON 21
azathioprine 25
azelastine hcl (ophthalmic) 17
azelastine hcl spray 17
azithromycin 3
AZOPT (ophthalmic) 18
B
bacitracin & polymyxin B (ophthalmic) 17
bacitracin (ophthalmic) 17
baclofen 8
BACTOCILL/DEXTROSE 3
BACTROBAN NASAL 26
balsalazine disodium 20
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
BETA-ADRENERGIC BLOCKING AGENTS 10
betamethasone dipropionate (topical) 27
betamethasone valerate 27
betaxolol hcl (ophthalmic) 19
bethanechol chloride 7
BETIMOL 19
bicalutamide 6
BILTRICIDE 3
BIOLOGIC RESPONSE MODIFIERS 25
bisoprolol fumarate 10
bisoprolol fumarate & hydrochlorothiazide 10
BLEPHAMIDE (ophthalmic) 18
BLEPHAMIDE S.O.P. 18
BLOOD FORMATION, COAGULATION AND
THROMBOSIS 8
BLOOD FORMATION, COAGULATION, AND
THROMBOSIS 8, 9
BONE RESORPTION INHIBITORS 25
BRAVELLE 24
BRILINTA 8
brimonidine tartrate 19
bromocriptine mesylate 15
budesonide (nebulized) 21
budesonide (oral) 21
bumetanide 16
buprenorphine HCl & naloxone HCL 11
bupropion hcl 13
bupropion hcl (smoking deterrent) 13
bupropion hcl xl 13
buspirone hcl 14
butalbital & acetaminophen 11
butalbital, acetaminophen & caffeine 11
butalbital, acetaminophen, caffeine & codeine 12
butalbital, aspirin & caffeine 12
butalbital, aspirin, caffeine & codeine 12
BYSTOLIC 10
C
cabergoline 15
CAFERGOT 15
calcipotriene 28
calcitonin (salmon) 24
calcitriol 29
calcium acetate (phosphate binde)r 16
CALCIUM-CHANNEL BLOCKING AGENTS 11
capecitabine 6
captopril 11
CAPTOPRIL & HYDROCHLOROTHIAZIE 11
carbamazepine 12
carbamazepine (extended release) 12
carbidopa & levodopa 15
carbidopa & levodopa (extended release) 15
CARDENE SR 11
CARDIAC DRUGS 9
CARDIOVASCULAR DRUGS 9, 10, 11
CARIOSTATIC AGENTS 25
carisoprodol 8
carisoprodol & aspirin 8
carteolol hcl (ophthalmic) 19
carvedilol 10
CATHARTICS AND LAXATIVES 19
CAVERJECT 10
CAYSTON 3
CEENU 6
cefaclor 3
cefadroxil 3
cefdinir 3
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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cefixime 3
cefprozil 3
CEFTRIAXONE SODIUM/DEXTROSE 3
cefuroxime axetil 3
celecoxib 12
CELL STIMULANTS AND PROLIFERANTS 28
CELONTIN 12
CENTRAL NERVOUS SYSTEM AGENTS 11, 12, 13,
14, 15
CENTRAL NERVOUS SYSTEM AGENTS,
MISCELLANEOUS 15
cephalexin 3
CESIA 21
cevimeline hcl 7
chlordiazepoxide & amitriptyline 13
chlordiazepoxide & clidinium 7
chlordiazepoxide hcl 14
chlorhexidine gluconate (dental) 17
chloroquine phosphate 5
chlorothiazide 16
chlorpromazine hcl 13
chlorthalidone 16
CHOLELITHOLYTIC AGENTS 20
cholestyramine 9
cholestyramine light 9
choline magnesium trisalicylate 12
chorionic gonadotropin 24
CIALIS 10
ciclopiroxolamine 26
cilostazol 8
cimetidine hcl 20
CIPRO HC (otic) 18
CIPRODEX 18
ciprofloxacin hcl 3
ciprofloxacin hcl (ophthalmic) 17
ciprofloxacin-ciprofloxacin hcl 3
citalopram hydrobromide 13
clarithromycin 3
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 12
clonidine hcl 9
clopidogrel 8
clorazepate dipotassium 14
clotrimazole 26
clotrimazole & betamethasone dipropionate 26
clotrimazole (topical) 26
clozapine 13
colchicine 17, 25
colestipol 9
COLY-MYCIN-S (otic) 18
COMBIPATCH 24
COMBIVENT RESPIMAT 8
CONTRACEPTIVES 21
CORDRAN 27
COREG CR 10
CORTIFOAM 27
CORTISONE ACETATE 21
CORTISPORIN 27
CRESTOR 9
CRIXIVAN 4
cromolyn sodium 17
cromolyn sodium (ophthalmic) 17
CRYSELLE 22
CUPRIMINE 21
CYCLESSA 21
cyclobenzaprine hcl 8
cyclopentolate hcl (ophthalmic) 19
cyclophosphamide 6
cyclosporine 25
cyclosporine modified (for microemulsion) 26
cyproheptadine hcl 3
CYSTAGON 26
D
danazol 21
dantrolene sodium 8
dapsone 4
DARAPRIM 5
DEPEN 21
desipramine hcl 13
desmopressin acetate 24
DESOGEN 21
desogestrel & ethinyl estradiol (monophasic) 21
desogestrel & ethinyl estradiol (triphasic) 21
desonide 27
desoximetasone 27
dexamethasone 21
dexamthasone sod phosphate (ophthalmic) 17
dexmethylphenidate hcl 14
dextroamphetamine sulfate 14
diazepam 14
diclofenac sodium 12
diclofenac sodium (ophthalmic) 18
dicloxacillin 3
dicyclomine hcl 7
didanosine 4
diflorasone diacetate 27
DIGESTANTS 20
digoxin 9
dihydroergotamine mesylate 8
diltiazem hcl 11
diltiazem hcl coated beads 11
diltiazem hcl extended release beads 11
diphenoxylate & atropine 19
dipyridamole 10
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS
25
disopyramide phosphate 9
disulfiram 25
DIURETICS 16
divalproex sodium 12
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divalproex sodium (extended release) 12
donepezil 7
DONNATAL EXTENTABS 7
dorzolamide hcl & timolol maleate (ophthalmic) 19
dorzolamide hcl (ophthalmic) 19
doxazosin mesylate 10
doxepin hcl 13
doxycycline 3
doxycycline (monohydrate) 3
DRITHO-CREME HP 28
dronabinol 20
drospirenone & ethinyl estradiol 21
DULERA 8
duloxetine 13
E
EDEX 10
EENT ANTIGLAUCOMA AGENTS 18
EENT ANTI-INFECTIVES 17
EENT ANTI-INFLAMMATORY AGENTS 18
EENT DRUGS, MISCELLANEOUS 19
EENT MYDRIATICS 19
EFFIENT 8
ELECTROLYTIC, CALORIC AND WATER
BALANCE 16, 17
ELIDEL 28
ELIGARD 6
ELIXOPHYLLIN 8
ELLA 21
ELMIRON 26
EMCYT 6
EMEND 20
EMTRIVA 4
enalapril maleate 11
ENBREL 25
ENPRESSE 22
entacapone 15
ENZYMES 17
epinephrine hcl 8
EPIVIR HBV 5
EPOGEN 9
EPZICOM 5
ergocalciferol 29
ergoloid mesylates 8
ERGOMAR 8
erythromycin (ophthalmic) 17
erythromycin (topical) 26
erythromycin base 3
erythromycin ethylsuccinate 3
erythromycin stearate 3
erythromycin sulfisoxazole 3
escitalopram oxalate 13
estazolam 14
esterified estrogens & methyltestosterone 24
ESTRACE VAGINAL 24
estradiol (oral) 24
estradiol (transdermal) 24
estradiol valerate 24
ESTROGENS AND ESTROGEN AGONISTS-
ANTAGONISTS 24
estropipate 24
ethambutol 4
ethosuximide 13
ethynodiol diacetate & ethinyl estradiol 22
etidronate disodium 25
etodolac 12
etoposide 6
EURAX 26
EXELDERM 26
exemestane 6
EXFORGE HCT 11
EYE, EAR, NOSE AND THROAT (EENT)
PREPARATIONS 17
EYE, EAR, NOSE, AND THROAT (EENT)
PREPARATIONS 17, 18, 19
F
famciclovir 4, 5
famotidine 20
felbamate 13
felodipine 11
FEMHRT 24
FEMHRT LOW DOSE 24
fenofibrate 9
fenofibrate (micronized) 9
fenoprofen calcium 12
fentanyl 12
fentanyl citrate 12
FINACEA 28
finasteride 25
FIRAZYR 26
FIRST GENERATION ANTIHISTAMINES 3
FLAREX 18
flavoxate hcl 28
flecainide acetate 9
FLOVENT DISKUS 21
FLOVENT HFA 21
fluconazole 4
fludrocortisone acetate 21
flunisolide (nasal) 18
fluocinolone acetonide 27
fluocinonide 27
fluocinonide emulsified base 27
fluorescein sodium 19
fluorescein w/ benoxinate 19
fluorescein w/ proparacaine 19
fluorometholone (ophthalmic) 18
fluorouracil (topical) 28
fluoxetine hcl 13
fluphenazine hcl 13
flurazepam hcl 14
flurbiprofen sodium (ophthalmic) 18
flutamide 6
fluticasone propionate 27
fluticasone propionate (nasal) 18
fluvoxamine maleate 13
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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FML FORTE 18
folic acid 28
FOLLISTIM AQ 24
fondaparinux 8
FORTEO 24
FOSAMAX PLUS D 25
fosinopril sodium 11
fosinopril sodium & hydrochlorothiazide 11
FRAGMIN 8
furosemide 16
G
gabapentin 13
galantamine hbr 7
galantamine hbr (extended release) 7
GANCYCLOVIR 5
GASTROINTESTINAL DRUGS 19, 20
gatifloxacin (ophthalmic) 17
gemfibrozil 9
GENITOURINARY SMOOTH MUSCLE
RELAXANTS 28
GENTAMICIN SULFATE 26
gentamicin sulfate (ophthalmic) 17
GENTAMICIN SULFATE (topical) 26
GI ANTI-INFLAMMATORY AGENTS 20
GLATOPA 25
GLEEVEC 6
glimepiride 23
glipizide 23
glipizide (extended release) 23
GLUCAGON HCL 23
glyburide 23
glyburide & metformin hcl 23
glycopyrrolate 7
GOLD COMPOUNDS 20
GONADOTROPINS 24
GONAL-F 24
griseofulvin ultramicrosize 4
guaifenesin & codeine 17
guanfacine hcl 9
H
halobetasol propionate 27
haloperidol 13
haloperidol lactate 13
HARVONI 5
HEAVY METAL ANTAGONISTS 21
HEMATOPOIETIC AGENTS 9
HEMORRHEOLOGIC AGENTS 9
heparin sodium 8
HEXALEN 6
HORMONES AND SYNTHETIC SUBSTITUTES 21,
23, 24
HUMALOG 23
HUMALOG KWIKPEN 23
HUMALOG MIX 50/50 23
HUMALOG MIX 50/50 PEN 23
HUMALOG MIX 75/25 23
HUMALOG MIX 75/25 PEN 23
HUMIRA 25
HUMULIN R U-500 23
hydralazine hcl 9
hydrochlorothiazide 16
hydrocodone & acetaminophen 12
hydrocodone & homatropine 17
hydrocodone polistirex & chlorpheniramine polistirex 17
hydrocortisone 21
hydrocortisone & acetic acid (otic) 18
hydrocortisone (intrarectal) 27
hydrocortisone (rectal) 27
hydrocortisone (topical) 27
hydrocortisone acetate & pramoxine 28
hydrocortisone acetate (rectal) 27
hydrocortisone butyrate 27
hydrocortisone butyrate hydrophilic lipo base 27
hydrocortisone valerate 27
hydromorphone hcl 12
hydroxychloroquine sulfate 5
hydroxyurea 6
hydroxyzine hcl 15
hydroxyzine pamoate 15
hyoscyamine sulfate 7
HYPOTENSIVE AGENTS 9
I
ibuprofen 12
IMBRUVICA 6
imipramine hcl 13
imipramine pamoate 13
imiquomod 28
IMMUNOSUPPRESSIVE AGENTS 25
indapamide 16
indomethacin 12
INSULIN ISOPHANE & 23
INSULIN ISOPHANE (HUMAN) 23
INSULIN REGULAR (HUMAN) 23
INTELENCE 5
INTRON-A 6
INVIRASE 5
iodoquinol-hc 27
ION-REMOVING AGENTS 16
ipratropium bromide (inhaled 7
ipratropium bromide (nasal) 7
IRESSA 6
ISENTRESS 5
isoniazid 4
isosorbide dinitrate 10
isosorbide mononitrate 10
isotretinoin 28
isradipine 11
itraconazole 4
ivermectin 3
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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J
JOLESSA 22
K
KALETRA 5
KARIVA 21
KELNOR 22
KENALOG 27
ketoconazole 4, 26
ketoprofen 12
ketoprofen (extended release) 12
ketorolac tromethamine 12
ketorolac tromethamine (ophthalmic)) 18
KINERET 26
L
labetalol hcl 10
lactated ringer’s (irrigation) 16
lactulose 16
lamivudine 5
lamivudine-zidovudine 5
lamotrigine 13
LANTUS 23
LANTUS SOLOSTAR 23
latanoprost 19
leflunomide 25
LESSINA 22
LETAIRIS 10
letrozole 6
leucovorin calcium 25
LEUKERAN 6
LEUKINE 9
leuprolide acetate 6
levalbuterol hcl solution 8
LEVEMIR 23
LEVEMIR FLEXTOUCH 23
levetiracetam 13
LEVITRA 10
levobunolol hcl (ophthalmic) 19
levocarnitine 26
levofloxacin 3
levonorgestrel & ethinyl estradiol (91-day) 22
levonorgestrel & ethinyl estradiol (monophasic) 22
levonorgestrel & ethinyl estradiol (triphasic) 22
levonorgestrel (emergency oral contraceptive 22
levothyroxine sodium 24
LEXIVA 5
LIALDA 20
lidocaine hcl 28
lidocaine hcl (mouth-throat) 19
lidocaine-prilocaine 26
lindane 26
linezolid 3
liothyronine 25
lisinopril 11
lisinopril & hydrochlorothiazide 11
lithium carbonate 15
lithium carbonate (extended release) 15
LO/OVRAL 23
LOCAL ANESTHETICS 19
LOESTRIN 1.5/30 22
LOESTRIN 1/20 22
LOESTRIN FE 1.5/30 22
LOESTRIN FE 1/20 22
lorazepam 15
losartan potassium 11
losartan potassium & hydrochlorothiazide 11
lovastatin 9
LOVENOX 8
LOW-OGESTREL 23
loxapine succinate 13
LUPRON DEPOT 6
LUPRON DEPOT-PED 6
LYSODREN 6
M
maprotiline hcl 13
MATULANE 6
meclofenamate sodium 12
medroxyprogesterone acetate 24
mefloquine hcl 5
megestrol acetate 6
meloxicam 12
MENOPUR 24
MEPHYTON 29
mercaptopurine 7
mesalamine 20
metaproterenol sulfate 8
metformin hcl 23
metformin hcl (extended release) 23
methadone hcl 12
methazolamide 19
methenamine hippurate 6
methenamine mandelate 6
methimazole 25
METHITEST 21
methocarbamol 8
methotrexate 7
methyldopa 9
methylergonovine 26
methylphenidate hcl 14
methylphenidate hcl (extended release) 14
methylprednisolone 21
metipranolol (ophthalmic) 19
metoclopramide hcl 20
metolazone 16
metoprolol succinate 10
metoprolol tartrate 10
metronidazole 6
metronidazole (topical) 26
metronidazole (vaginal) 26
mexiletine hcl 9
MICONAZOLE 3 26
miconazole nitrate 26
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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MICROGESTIN 1.5/30 22
MICROGESTIN 1/20 22
MICROGESTIN FE 1.5/30 22
MICROGESTIN FE 1/20 22
midodrine hcl 8
minocycline 3
minoxidil 10
MIRCETTE 21
mirtazapine 14
MISCELLANEOUS THERAPEUTIC AGENTS 25, 26
misoprostol 20
modafinil 14
MODICON 22
moexipril & hydrochlorothiazide 11
moexipril hcl 11
mometasone furoate 27
montelukast sodium 17
montelukast sodium(packets) 17
morphine sulfate 12
morphine sulfate (extended release) 12
moxifloxacin 3
mupirocin (topical) 26
MUSE 10
mycophenolate mofetil 26
mycophenolate sodium 26
MYLERAN 7
N
nabumetone 12
nadolol 10
NAFTIN 27
naltrexone hcl 12
naproxen 12
naproxen sodium 12
naratriptan 15
NARCAN 15
NASONEX 18
NEBUPENT 6
NECON 1/50 22
NECON 10/11 22
NECON 7/7/7 22
NEFAZODONE HCL 14
nemantine hcl 15
neomycin sulfate 4
neomycin, bacitracin & polymyxin B (ophthalmic) 18
NEOMYCIN, POLYMYXIN & 18
neomycin, polymyxin & dexamethasone (ophth) 18
neomycin, polymyxin & dexamethasone (ophthalmic) 18
neomycin, polymyxin & hydrocortisone (otic) 18
neomycin, polymyxin, bacitracin & hydrocortisone
(ophthalmic) 18
NEULASTA 9
nevirapine 5
NEXAVAR 7
NIASPAN 9
nifedipine 11
NILANDRON 7
nimodipine 11
nitrofurantoin macrocrystals 6
nitrofurantoin monohydrate macrocystals 6
nitrofurantoin suspension 6
nitroglycerin 10
NORA-BE 22
NORDETTE 22
norethindrone & ethinyl estradiol (biphasic) 22
norethindrone & ethinyl estradiol (monophasic) 22
norethindrone & ethinyl estradiol (triphasic) 22
norethindrone & mestranol 22
norethindrone (contraceptive) 22
norethindrone acetate 24
norethindrone acetate & ethinyl estradiol 22
norethindrone acetate, estradiol, & iron 22
norgestimate & ethinyl estradiol (monophasic) 22
norgestimate & ethinyl estradiol (triphasic) 22
norgestrel & ethinyl estradiol 22
NOR-QD 22
NORTREL 0.5/35 22
NORTREL 1/35, 22
NORTREL 7/7/7 22
nortriptyline hcl 14
NORVIR 5
NOVOLOG 23
NOVOLOG FLEXPEN 23
NOVOLOG MIX 70/30 23
NOVOLOG MIX 70/30 FLEXPEN 23
NUVARING 23
nystatin 4
nystatin & triamcinolone 27
nystatin (topical) 27
O
ofloxacin (ophthalmic) 18
ofloxacin (otic) 18
OGESTREL 23
olanzapine 14
olanzapine odt 14
omeprazole 20
OMNITROPE 24
ondansetron hcl 20
ophthalmic irrigation 19
OPIATE ANTAGONISTS 12
ORTHO TRI-CYCLEN 22
ORTHO-CEPT 21
ORTHO-CYCLEN 22
ORTHO-MICRONOR 22
ORTHO-NOVUM 1/35 22
ORTHO-NOVUM 1/50 22
ORTHO-NOVUM 7/7/7 22
OSPHENA 10
OTHER MISCELLANEOUS THERAPEUTIC
AGENTS 26
OVIDREL 24
oxaprozin 12
oxazepam 15
oxcarbazepine 13
OXSORALEN 28
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oxybutynin chloride 28
oxybutynin chloride (extended release) 28
oxycodone & acetaminophen 12
oxycodone & aspirin 12
oxycodone hcl 12
OXYTOCICS 26
P
pantoprazole sodium 20
PARASYMPATHOMIMETIC (CHOLINERGIC)
AGENTS 7
PARATHYROID 24
paromomycin sulfate 6
paroxetine hcl 14
paroxetine hcl (extended release) 14
PATANOL 17
PEDIATRIC MULTIVITAMINS 29
pediatric multivitamins with fluoride 29
pediatric vitamins A, C, D, with fluoride 29
PEGASYS 5
PEG-INTRON 5
penicillin V potassium 4
pentoxifylline 9
permethrin 27
perphenazine 14
phenazopyridine hcl 28
phenelzine 14
phenobarbital 15
phenoxybenzamine 8
phentermine 14
phenylephrine (ophth) 19
phenytoin 13
phenytoin sodium (extended release) 13
PHOSPHOLINE IODIDE (ophthalmic) 19
PIGMENTING AND DEPIGMENTING AGENTS 28
pilocarpine hcl (ophthalmic) 19
pilocarpine hcl (oral) 7
pindolol 10
pioglitazone hcl 23
PITUITARY 24
PLAN B 23
podofilox 28
polyethylene glycol 3350, 19
polyethylene glycol 3350, potassium chloride, sodium
bicarbonate & sodium chloride 19
polymyxin B & trimethoprim 18
PORTIA 22
pot phosphate monobasic w/ sod phosphate dibasic &
monobasic 16
potassium and sodium citrates with citric acid 16
potassium bicarbonate & potassium chloride 16
potassium chloride 16
potassium citrate 16
potassium citrate-citric acid 16
PRADAXA 8
pramipexole dihydrochloride 15
pramipexole dihydrochloride 15
PRAMOXINE-HC 27
pravastatin 9
prazosin hcl 10
PRED-G (ophthalmic) 18
PRED-G S.O.P. (ophthalmic) 18
prednisolone 21
prednisolone acetate (ophthalmic) 18
prednisolone sodium phosphate 21
prednisolone sodium phosphate (ophthalmic) 18
prednisone 21
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 CARBONYL &
FOLIC ACID 29
PRENATAL VITAMIN WITH MINERALS, IRON &
FOLIC ACID 29
PRENATAL VITAMIN WITH SELENIUM, FERROUS
FUMARATE & FOLIC ACID 29
PRENATAL VITAMINS 29
PREVACID SOLUTAB 20
PREVIFEM 22
PREZISTA 5
PRIMAQUINE PHOSPHATE 6
primidone 13
probenecid 17
probenecid & colchicine 17
prochlorperazine maleate 14
PROCRIT 9
progesterone, micronized 24
PROGESTINS 24
PROKINETIC AGENTS 20
promethazine hcl 3
propafenone hcl 9
proparacaine 19
propranolol hcl 10
propylthiouracil 25
PROTECTIVE AGENTS 26
protriptyline hcl 14
PSYCHOTHERAPEUTIC AGENTS 13
PULMICORT FLEXHALER 21
PULMOZYME 16, 17
pyrazinamide 4
pyridostigmine bromide 7
Q
QSYMIA 14
quetiapine fumarate 14
quinapril & hydrochlorothiazide 11
quinapril hcl 11
quinidine gluconate 9
quinidine sulfate 9
QVAR 21
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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R
raloxifene 24
ramipril 11
ranitidine hcl 20
RAPAMUNE 26
REBIF 25
REGRANEX 28
RELENZA 5
RENAGEL 16
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
INHIBITORS 11
RENVELA 16
RENVELA PAK 16
REPLACEMENT PREPARATIONS 16
RESCRIPTOR 5
reserpine 10
RESPIRATORY SMOOTH MUSCLE RELAXANTS28
RESPIRATORY TRACT AGENTS 17
RESPIRATORY TRACT AGENTS,
MISCELLANEOUS 17
RESPIRATORY TRACT ANTI-INFLAMMATORY
AGENTS 17
REVLIMID 25
REYATAZ 5
ribavirin 5
RIDAURA 20
rifabutin 4
rifampin 4
riluzole 15
rimantadine 5
ringer’s (irrigation) 16
risperidone 14
rizatriptan 15
ropinirole hcl 15
S
salsalate 12
SAVELLA 16
SEASONIQUE 22
SECOND GENERATION ANTIHISTAMINES 3
selegiline hcl 15
selenium sulfide 27
SELZENTRY 5
SEREVENT DISKUS 8
sertraline hcl 14
sildenafil citrate (REVATIO) 10
silver sulfadiazine 27
simvastatin 9
sirolimus 26
SKELETAL MUSCLE RELAXANTS 8
SKIN AND MUCOUS MEMBRANE AGENTS 26, 27,
28
SKIN AND MUCOUS MEMBRANE AGENTS,
MISCELLANEOUS 28
SMOOTH MUSCLE RELAXANTS 28
sodium chloride (gu irrigant) 16
sodium chloride for nebulization 17
sodium citrate & citric acid 16
sodium fluoride 25
sodium polystyrene sulfonate 16
SOMATROPIN AGONISTS AND ANTAGONISTS 24
sotalol hcl 10
SOVALDI 5
SPECTRACEF 4
SPIRIVA RESPIMAT 7
spironolactone 11
spironolactone & hydrochlorothiazide 11
SPRINTEC 22
SPRYCEL 7
SSKI 25
stavudine 5
STRIVERDI RESPIMAT 17
sucralfate 20
sulfacetamide sodium & prednisolone sodium phosphate
(ophthalmic) 18
sulfacetamide sodium (ophthalmic) 18
sulfacetamide sodium (topical) 27
sulfadiazine 4
sulfamethoxazole & trimethoprim 4
sulfasalazine 4, 20
sulindac 12
sumatriptan succinate 15
SUPRAX 4
SUSTIVA 5
SUTENT 7
SYMPATHOLYTIC (ADRENERGIC BLOCKING)
AGENTS 8
SYMPATHOMIMETIC (ADRENERGIC) AGENTS 7
T
TABLOID 7
tacrolimus 26
tacrolimus (topical) 28
TAMIFLU 5
tamoxifen citrate 7
tamsulosin hcl 8
TARCEVA 7
TARGRETIN 7, 28
TARKA 11
TAZORAC 28
temazepam 15
temozolomide 7
terazosin hcl 10
terbinafine 4
terbutaline sulfate 8
testosterone 21
testosterone cypionate 21
testosterone enanthate 21
tetracaine hcl (ophth) 19
tetracycline 4
THALOMID 25
theophylline 28
thioridazine hcl 14
thiothixene 14
thyroid 25
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THYROID AND ANTITHYROID AGENTS 24
THYROLAR 25
tiagabine 13
TIKOSYN 9
timolol maleate (ophthalmic) 19
tizanidine hcl 8
TOBI Podhaler 4
tobramycin neb 4
tobramycin sulfate & dexamethasone (ophth) 18
tobramycin sulfate (ophthalmic) 18
tolazamide 23
TOLBUTAMIDE 23
tolterodine tartrate 28
tolterodine tartrate (extended release) 28
topiramate 13
torsemide 16
TRACLEER 10
tramadol hcl 12
tranylcypromine sulfate 14
trazodone hcl 14
tretinoin 28
tretinoin (chemo) 7
triamcinolone acetonide (mouth) 27
triamcinolone acetonide (topical) 27
triamterene & hydrochlorothiazide 16
triazolam 15
trifluoperazine hcl 14
trifluridine (ophth) 18
trihexyphenidyl hcl 15
trimethoprim 6
TRI-NORINYL 22
TRI-PREVIFEM 22
TRI-SPRINTEC 22
TRIVORA 22
tropicamide (ophthalmic) 19
trospium chloride 28
TRUVADA 5
TYKERB 7
TYZEKA 5
U
URICOSURIC AGENTS 17
URINARY ANTI-INFECTIVES 6
ursodiol 20
V
VAGIFEM 24
valacyclovir 5
valganciclovir 5
valproic acid 13
valsartan 11
valsartan & hydrochlorothiazide 11
vancomycin 4
VASODILATING AGENTS 10
VECTICAL 28
VELIVET 21
venlafaxine hcl 14
venlafaxine hcl (extended release) 14
VENTOLIN HFA 8
verapamil hcl 11
VIAGRA 10
VICTRELIS 5
VIRACEPT 5
VIREAD 5
VITAMIN B COMPLEX 28
VITAMIN D 29
VITAMIN K ACTIVITY 29
VITAMINS 28, 29
voriconazole 4
VOTRIENT 7
W
warfarin sodium 8
water for irrigation (sterile) 16
X
XOPENEX HFA 8
XTANDI 7
XULANE 23
Y
YASMIN 21
YODOXIN 6
Z
zafirlukast 17
zaleplon 15
ZARXIO 9
ZELBORAF 7
zidovudine 5
zinc sulfate 16
ziprasidone hcl 14
ZOLINZA 7
zolmitriptan 15
zolmitriptan ODT 15
zolpidem tartrate 15
zonisamide 13
ZOVIA 1/35E 22
ZOVIA 1/50E 22
ZYDELIG 7
ZYTIGA 7
ZYVOX 4
Kaiser Permanente Southern Colorado Commercial HMO Formulary (April 5, 2016)
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