20 drug formulary - kaiser permanente...kaiser permanente will only cover fda-approved drugs used...

XB0001338-50-17

Effective October 2020

2020 Drug FormularyFor members covered through large employer groups with a 1- or 2-tier with additional specialty tier

in-network pharmacy benefit and no out-of-network pharmacy benefit

All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc.

Drug Formulary INTRODUCTION

What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost.

How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers.

How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs.

Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet.

How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage.

Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions.

Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/ formulary. Non-formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of the drug.

Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share.

http://www.ghc.org/

http://www.ghc.org/

The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 45 days prior to the effective date.

What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs?

Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name.

Step Therapy (ST) Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name.

Quantity Limit (QL) A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name.

High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy.

Drugs Limited to Select Pharmacies Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the www.kp.org/wa/formulary webpage.

Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are:

• Preferred blood glucose strips:

o One Touch Verio o One Touch Ultra

http://www.kp.org/wa/pharmacy/drug-formulary

o Prodigy – prior authorization required o Contour Next – prior authorization required

o Freestyle – prior authorization required

• Disposable insulin syringes and needles

• Lancing devices and lancets

Preferred blood glucose meters are covered only when filled through mail order pharmacy.

Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions.

To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy.

Address: Kaiser Permanente Mail Order Pharmacy

PO Box 34383 Seattle, WA 98124-1383

Phone: 800-245-RXRX (1-800-245-7979)

Fax: 206-630-7950, or toll-free 1-800-350-1683

Specialty Drugs Specialty drugs are high-cost drugs prescribed by a physician for the treatment of complex conditions. Some specialty products are dispensed from a preferred specialty pharmacy vendor.

Over-the-Counter (OTC) Drugs A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC drugs can be found in Appendix A. You may contact Member Service at 1-888-630- 4636 to find if you have OTC drug coverage.

Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the www.kp.org/wa/formulary webpage.

Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs.

If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your

provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non-preferred contraceptive will be covered in full.

Excluded Prescription Products for Medications that have Over-The- Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (Rhinocort Aqua), and fluticasone propionate nasal spray (Flonase). Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage.

How do I get additional information?

Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document. The most current drug formulary is available at www.kp.org/wa/formulary.

http://www.ghc.org/

http://www.ghc.org/

9

Table of Contents

Analgesics - Drugs for Pain and Inflammation ........................................................................ 11

Analgesics - Drugs for Pain .......................................................................................................... 11

Anesthetics ....................................................................................................................................... 12

Anti-Addiction / Substance Abuse Treatment Agents........................................................... 12

Antibacterials .................................................................................................................................... 12

Anticoagulants ................................................................................................................................. 13

Anticonvulsants - Drugs for Seizures ........................................................................................ 14

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia .............................. 14

Antidepressants ............................................................................................................................... 14

Antiemetics - Drugs for Nausea and Vomiting ........................................................................ 15

Antifungals ........................................................................................................................................ 15

Antigout Agents ............................................................................................................................... 15

Antimigraine Agents ....................................................................................................................... 16

Antimyasthenic Agents .................................................................................................................. 16

Antimycobacterials ......................................................................................................................... 16

Antineoplastics - Drugs for Cancer ............................................................................................ 16

Antiparasitics .................................................................................................................................... 17

Antiparkinson Agents ..................................................................................................................... 17

Antiplatelets ...................................................................................................................................... 17

Antipsychotics - Drugs for Mood Disorders ............................................................................ 17

Antivirals ............................................................................................................................................ 18

Anxiolytics - Drugs for Anxiety .................................................................................................... 19

Bipolar Agents - Drugs for Mood Disorders ............................................................................. 19

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......... 19

Cardiovascular Agents - Drugs for Heart and Circulation Conditions ............................. 19

Central Nervous System Agents - Drugs for Attention Deficit Disorder ......................... 22

Central Nervous System Agents - Drugs for Multiple Sclerosis......................................... 22

Central Nervous System Agents - Miscellaneous .................................................................. 22

Dental and Oral Agents - Drugs for Mouth and Throat Conditions ................................... 22

Dermatological Agents - Drugs for Skin Conditions ............................................................. 23

Diabetes - Antidiabetic Agents .................................................................................................... 25

Diabetes - Glucose Monitoring .................................................................................................... 25

Diabetes - Glycemic Agents ......................................................................................................... 26

Diabetes - Insulins ........................................................................................................................... 26

Electrolytes / Minerals / Metals / Vitamins ................................................................................ 27

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................. 28

10

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ............ 28

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment .......... 28

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ................... 29

Genitourinary Agents - Drugs for Prostate Conditions ......................................................... 29

Hormonal Agents - Adrenal .......................................................................................................... 29

Hormonal Agents - Men's Health ................................................................................................. 29

Hormonal Agents - Osteoporosis ............................................................................................... 30

Hormonal Agents - Pituitary ......................................................................................................... 30

Hormonal Agents - Sex Hormones and Birth Control ........................................................... 30

Hormonal Agents - Thyroid ........................................................................................................... 33

Immunological Agents - Drugs for Immune System Stimulation or Suppression ........ 33

Immunological Agents - Drugs for Vaccination ...................................................................... 33

Inflammatory Bowel Disease Agents ......................................................................................... 34

Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................. 34

Metabolic Bone Disease Agents - Other ................................................................................... 34

Miscellaneous Therapeutic Agents ............................................................................................ 34

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ........................ 35

Ophthalmic Agents - Drugs for Glaucoma ............................................................................... 36

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ......................................... 36

Otic Agents - Drugs for Ear Conditions ..................................................................................... 37

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ..................... 37

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions .............................................................................................................................................................. 37

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ................................... 38

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ................ 38

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ........................................ 38

Sleep Disorder Agents ................................................................................................................... 38

Index of Drugs .................................................................................................................................. 40

Effective Date: 10/01/2020 11

Drug Name Drug Tier

Notes

Analgesics - Drugs for Pain and Inflammation

celecoxib oral 1

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium oral 1

diflunisal oral 1

etodolac 1

flurbiprofen oral 1

ibu 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

indomethacin er 1

indomethacin oral capsule 25 mg, 50 mg

1

ketorolac tromethamine injection

1

ketorolac tromethamine intramuscular

1

meclofenamate sodium oral

1

meloxicam oral 1

nabumetone oral 1

naproxen oral 1

naproxen sodium oral tablet 275 mg, 550 mg

1

piroxicam oral 1

salsalate oral 1

sulindac oral 1

tolmetin sodium oral capsule

1

Analgesics - Drugs for Pain

acetaminophen-codeine 1 QL

acetaminophen-codeine #2

1 QL


1 QL


1 QL

Drug Name Drug Tier

Notes

butalbital-apap-caffeine oral tablet

1

butalbital-aspirin-caffeine 1

codeine sulfate 1 QL

endocet 1 QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1 PA; QL

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

1 QL

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

1 QL

hydromorphone hcl oral 1 QL

hydromorphone hcl rectal 1

levorphanol tartrate oral 1 PA; QL

lorcet 1 QL

lorcet hd 1 QL

methadone hcl intensol 1 PA; ST; QL

methadone hcl oral 1 PA; ST; QL

methadose oral tablet soluble

1 PA; ST; QL

morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml

1 QL

morphine sulfate er oral tablet extended release

1 PA; ST; QL

morphine sulfate oral 1 QL

morphine sulfate rectal 1

OXYCODONE HCL ER 2 PA; ST; QL

oxycodone hcl oral concentrate 100 mg/5ml

1 QL

oxycodone hcl oral solution

1 QL

oxycodone hcl oral tablet 1 QL


Drug Name Drug Tier

Notes

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1 QL

oxycodone-aspirin 1 QL

OXYCONTIN 2 PA; ST; QL

tramadol hcl ir 1 QL

tramadol-acetaminophen 1 QL

Anesthetics

glydo 1

lidocaine external patch 5 %

1

lidocaine hcl injection solution

1

lidocaine hcl urethral/mucosal

1

lidocaine-prilocaine 1

prilovix ultralite 1

prilovix ultralite plus 1

Anti-Addiction / Substance Abuse Treatment Agents

acamprosate calcium 1

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl sublingual tablet sublingual

1

bupropion hcl er (smoking det)

1

CHANTIX 2

CHANTIX CONTINUING MONTH PAK

2

CHANTIX STARTING MONTH PAK

2

disulfiram oral 1

naloxone hcl injection solution

1

naloxone hcl injection solution cartridge

1

naloxone hcl injection solution prefilled syringe

1

naltrexone hcl oral 1

Drug Name Drug Tier

Notes

NARCAN 1

NICORETTE MOUTH/THROAT GUM 2 MG

2 PA

nicotine polacrilex mouth/throat

2 PA

nicotine step 1 1 PA



VIVITROL 4 QL

Antibacterials

amoxicillin 1

amoxicillin-potassium clavulanate oral

1

ampicillin 1

ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 250 mg, 500 mg

1

avidoxy 1

azithromycin oral 1

BICILLIN L-A 2

cefadroxil 1

cefazolin sodium injection solution reconstituted 1 gm

1

cefdinir 1

cefixime 1

cefprozil 1

ceftazidime injection solution reconstituted 1 gm

1

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg

1

cefuroxime axetil 1

cephalexin oral capsule 250 mg, 500 mg

1

cephalexin oral suspension reconstituted

1


Drug Name Drug Tier

Notes

CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)

2

ciprofloxacin hcl oral 1

clarithromycin oral 1

clindamycin hcl oral 1

clindamycin palmitate hcl 1

clindamycin phosphate injection solution 300 mg/2ml

1

clindamycin phosphate vaginal

1

dicloxacillin sodium 1

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 mg

1

doxycycline monohydrate oral capsule

1

doxycycline monohydrate oral tablet

1

FIRVANQ 2

gentamicin sulfate external

1

gentamicin sulfate injection solution 40 mg/ml

1

levofloxacin oral 1

linezolid oral suspension reconstituted

1 QL

linezolid oral tablet 1

methenamine hippurate 1

metronidazole oral tablet 1

metronidazole vaginal 1

minocycline hcl oral capsule

1

mondoxyne nl 1

morgidox oral 1

moxifloxacin hcl oral 1

mupirocin calcium 1

Drug Name Drug Tier

Notes

mupirocin external 1

neomycin sulfate oral 1

nitrofurantoin 1

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

penicillin v potassium 1

PRIMSOL 2

silver sulfadiazine external

1

SIVEXTRO ORAL 4 QL

ssd 1

sulfamethoxazole-trimethoprim oral

1

sulfatrim pediatric 1

SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML

2

tazicef injection solution reconstituted 1 gm

1

trimethoprim oral 1

vancomycin hcl oral solution reconstituted

1

vandazole 1

Anticoagulants

enoxaparin sodium 1 QL

fondaparinux sodium 4 QL

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 5000 unit/ml

1

heparin sodium (porcine) pf

1

jantoven 1

LOVENOX 1 QL

PRADAXA 2

warfarin sodium oral 1

XARELTO 2 PA


Drug Name Drug Tier

Notes

XARELTO STARTER PACK

2 PA

Anticonvulsants - Drugs for Seizures

carbamazepine er 1

carbamazepine oral 1

CELONTIN 2

DIASTAT PEDIATRIC 1

diazepam rectal 1

DILANTIN ORAL CAPSULE 30 MG

2

divalproex sodium er 1

divalproex sodium oral 1

epitol 1

ethosuximide oral 1

gabapentin oral 1

lamotrigine oral tablet 1

lamotrigine oral tablet chewable

1

levetiracetam er 1

levetiracetam oral 1

oxcarbazepine 1

phenobarbital oral 1

phenobarbital sodium injection solution 130 mg/ml

1

phenytoin infatabs 1

phenytoin oral 1

phenytoin sodium extended oral capsule 100 mg

1

phenytoin sodium injection

1

primidone oral 1 QL

roweepra 1

roweepra xr 1

subvenite 1

topiramate oral 1

valproic acid oral 1

VALTOCO 10 MG DOSE 2

Drug Name Drug Tier

Notes



VALTOCO 5 MG DOSE 2

zonisamide oral 1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

donepezil hcl oral tablet 10 mg, 5 mg

1

galantamine hydrobromide

1

galantamine hydrobromide er

1

memantine hcl oral tablet 10 mg, 5 mg

1

rivastigmine tartrate 1

Antidepressants

amitriptyline hcl oral 1

amoxapine 1

bupropion hcl er (sr) 1

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1

bupropion hcl oral 1

citalopram hydrobromide 1

clomipramine hcl oral 1

desipramine hcl oral 1

doxepin hcl oral capsule 1

doxepin hcl oral concentrate

1

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

1

escitalopram oxalate 1

fluoxetine hcl oral capsule 1

fluoxetine hcl oral solution 1

fluvoxamine maleate 1

imipramine hcl oral 1

maprotiline hcl 1

mirtazapine oral 1


Drug Name Drug Tier

Notes

nortriptyline hcl oral 1

paroxetine hcl 1

PAXIL ORAL SUSPENSION

2

perphenazine-amitriptyline

1

phenelzine sulfate oral 1

protriptyline hcl 1

sertraline hcl oral 1

tranylcypromine sulfate 1

trazodone hcl oral 1

venlafaxine hcl 1

venlafaxine hcl er oral capsule extended release 24 hour

1

Antiemetics - Drugs for Nausea and Vomiting

aprepitant oral capsule 125 mg, 80 & 125 mg, 80 mg

1

compro 1

dimenhydrinate injection 1

dronabinol 1

metoclopramide hcl injection

1

metoclopramide hcl oral solution

1

metoclopramide hcl oral tablet

1

ondansetron hcl injection 1

ondansetron hcl oral 1

ondansetron odt 1

perphenazine oral 1

prochlorperazine 1

prochlorperazine edisylate injection

1

prochlorperazine maleate oral

1

Antifungals

ciclodan 1

Drug Name Drug Tier

Notes

ciclopirox external gel 1

ciclopirox external solution

1

ciclopirox olamine external

1

clotrimazole mouth/throat 1

clotrimazole-betamethasone

1

CRESEMBA ORAL 4 PA; QL

fluconazole oral 1

flucytosine oral 4 QL

griseofulvin microsize oral 1

griseofulvin ultramicrosize 1

itraconazole oral 1 PA

ketoconazole external cream

1

ketoconazole external shampoo

1

ketoconazole oral 1

nyamyc 1

nystatin external 1

nystatin mouth/throat 1

nystatin oral 1

nystatin-triamcinolone 1

nystop 1

terbinafine hcl oral 1

voriconazole oral 1 PA

Antigout Agents

allopurinol oral 1

COLCHICINE ORAL CAPSULE

1

colchicine tablet 0.6 mg oral

1

COLCHICINE TABLET 0.6 MG ORAL (authorized generic)

2

colchicine-probenecid 1

COLCRYS 2

probenecid 1


Drug Name Drug Tier

Notes

Antimigraine Agents

dihydroergotamine mesylate injection

1 QL

dihydroergotamine mesylate nasal

4

ERGOMAR 2

ergotamine-caffeine 1

MIGERGOT 2

naratriptan hcl 1

rizatriptan benzoate 1

sumatriptan nasal 1

sumatriptan succinate oral

1

sumatriptan succinate refill

1

sumatriptan succinate subcutaneous

1

zolmitriptan oral 1

Antimyasthenic Agents

MESTINON ORAL SOLUTION

2

pyridostigmine bromide er 1

pyridostigmine bromide oral

1

Antimycobacterials

dapsone oral 1

ethambutol hcl oral 1

isoniazid oral 1

MYAMBUTOL 2

PRIFTIN 2

pyrazinamide oral 1

rifabutin 1

rifampin oral 1

Antineoplastics - Drugs for Cancer

abiraterone acetate 1 QL

AFINITOR DISPERZ 2 PA; QL

AFINITOR ORAL TABLET 10 MG

2 PA; QL

anastrozole oral 1

Drug Name Drug Tier

Notes

bicalutamide 1

capecitabine 1 QL

COTELLIC 2 PA; QL

cyclophosphamide oral 1

DROXIA 2

erlotinib hcl 1 PA

etoposide oral 1 QL

everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg

1 PA; QL

exemestane 1

flutamide 1

GILOTRIF 2 PA; QL

GLEOSTINE 2

hydroxyurea oral 1

imatinib mesylate 1 QL

IMBRUVICA ORAL CAPSULE

2 PA; QL

IMBRUVICA ORAL TABLET 140 MG, 420 MG, 560 MG

2 PA; QL

IRESSA 2 PA; QL

letrozole oral 1

leucovorin calcium oral 1

LEUKERAN 2

MATULANE 2 QL

MEKINIST 2 PA; QL

melphalan 1 QL

mercaptopurine oral 1

mesna 1

MESNEX ORAL 2

MYLERAN 2 QL

NEXAVAR 2 PA

REVLIMID 2 PA; QL

RYDAPT 2 PA; QL

SPRYCEL 2 PA; QL

STIVARGA 2 PA

SUTENT 2 PA; QL

TABLOID 2

TAFINLAR 2 PA; QL


Drug Name Drug Tier

Notes

TAGRISSO 2 PA; QL

tamoxifen citrate oral 1

temozolomide 1 QL

THALOMID 2 PA; QL

tretinoin oral 1 QL

TYKERB 2 PA; QL

VENCLEXTA 2 PA; QL

VENCLEXTA STARTING PACK

2 PA; QL

VOTRIENT 2 PA; QL

XTANDI 2 PA; QL

ZELBORAF 2 PA

ZYDELIG 2 PA; QL

ZYTIGA ORAL TABLET 500 MG

2 QL

Antiparasitics

albendazole oral 1

ALINIA 2

atovaquone oral 4

chloroquine phosphate oral

1

hydroxychloroquine sulfate oral

1

KRINTAFEL 2

permethrin external 1

praziquantel oral 1

primaquine phosphate 1

pyrimethamine oral 4 PA; QL

Antiparkinson Agents

amantadine hcl oral 1

benztropine mesylate 1

bromocriptine mesylate oral

1

carbidopa oral 1

carbidopa-levodopa er 1

carbidopa-levodopa oral tablet

1

carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg

1

Drug Name Drug Tier

Notes

carbidopa-levodopa-entacapone

1

DUOPA 4 PA

entacapone 1

pramipexole dihydrochloride

1

rasagiline mesylate oral 1 PA

ropinirole hcl 1

selegiline hcl oral 1

trihexyphenidyl hcl 1

Antiplatelets

aspirin-dipyridamole er 1

BRILINTA 2

cilostazol 1

clopidogrel bisulfate oral 1

dipyridamole oral 1

prasugrel hcl 1

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA 4 QL

aripiprazole oral solution 1

aripiprazole oral tablet 1

ARISTADA 4 QL

ARISTADA INITIO 4 QL

chlorpromazine hcl injection

1

chlorpromazine hcl oral 1

clozapine oral tablet 1

fluphenazine decanoate injection

1

fluphenazine hcl 1

haloperidol decanoate intramuscular

1

haloperidol lactate 1

haloperidol oral 1

INVEGA SUSTENNA 4

INVEGA TRINZA 4 QL

loxapine succinate 1

olanzapine 1


Drug Name Drug Tier

Notes

PERSERIS 4

pimozide 1

quetiapine fumarate 1

quetiapine fumarate er 1

RISPERDAL CONSTA 2

risperidone oral solution 1

risperidone oral tablet 1

thiothixene 1

trifluoperazine hcl 1

ziprasidone hcl 1

ZYPREXA RELPREVV 2

Antivirals

abacavir sulfate 1

abacavir sulfate-lamivudine

1 QL

abacavir-lamivudine-zidovudine

4 QL

acyclovir oral 1

adefovir dipivoxil 1 QL

APTIVUS ORAL CAPSULE

4 QL

atazanavir sulfate 1 QL

ATRIPLA 4 QL

BARACLUDE ORAL SOLUTION

4 QL

BIKTARVY 4 QL

CIMDUO 4 QL

COMPLERA 4 PA; QL

CRIXIVAN 2

DESCOVY 4 QL

didanosine 1

DOVATO 4 QL

EDURANT 2

efavirenz 1

EMTRIVA 2

entecavir 1 QL

EPCLUSA 4 PA; QL

Drug Name Drug Tier

Notes

EPIVIR HBV ORAL SOLUTION

2

fosamprenavir calcium 4 QL

GENVOYA 4

HARVONI 4 PA; QL

INTELENCE 2

INTRON A 2 QL

INVIRASE 2

ISENTRESS HD 2

ISENTRESS ORAL TABLET

2

ISENTRESS ORAL TABLET CHEWABLE

2

JULUCA 4 QL

KALETRA ORAL TABLET 2

lamivudine 1

lamivudine-zidovudine 1

LEDIPASVIR-SOFOSBUVIR

4 PA; QL

LEXIVA ORAL SUSPENSION

4 QL

lopinavir-ritonavir 1

nevirapine er 1

nevirapine oral tablet 1

NORVIR ORAL PACKET 2

NORVIR ORAL SOLUTION

2

ODEFSEY 4 QL

oseltamivir phosphate oral

1

PEGASYS 4 QL

PEGASYS PROCLICK 4 QL

PEGINTRON 4 QL

PREVYMIS ORAL 4 PA; QL

PREZCOBIX 2 QL

PREZISTA 2

RELENZA DISKHALER 2

REYATAZ ORAL PACKET

2

ribavirin oral 1 QL


Drug Name Drug Tier

Notes

rimantadine hcl 1

ritonavir 1

SELZENTRY ORAL SOLUTION

4 QL

SELZENTRY ORAL TABLET 150 MG, 300 MG

4 QL

SELZENTRY ORAL TABLET 25 MG, 75 MG

4

SOFOSBUVIR-VELPATASVIR

4 PA; QL

stavudine 1

STRIBILD 4 PA; QL

SYMFI 1

SYMFI LO 1

SYMTUZA 4 QL

TAMIFLU 2

TEMIXYS 4 QL

tenofovir disoproxil fumarate

1

TIVICAY 2

TIVICAY PD 2

TRIUMEQ 4 QL

TRUVADA 4 QL

TYBOST 2 PA

valacyclovir hcl oral 1

valganciclovir hcl 4 QL

VIRACEPT 2

VIREAD ORAL POWDER 2

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2

VOSEVI 4 PA; QL

zidovudine 1

Anxiolytics - Drugs for Anxiety

alprazolam er 1

alprazolam oral tablet 1

alprazolam xr 1

buspirone hcl oral 1

Drug Name Drug Tier

Notes

chlordiazepoxide hcl 1

clonazepam oral 1

clorazepate dipotassium 1

diazepam injection 1

diazepam intramuscular 1

diazepam oral solution 1

diazepam oral tablet 1

hydroxyzine hcl oral 1

hydroxyzine pamoate oral 1

lorazepam injection solution 2 mg/ml

1

lorazepam intensol 1

lorazepam oral concentrate 2 mg/ml

1

lorazepam oral tablet 1

midazolam hcl (pf) injection solution 10 mg/2ml, 5 mg/ml

1

midazolam hcl injection solution 10 mg/2ml, 5 mg/ml

1

oxazepam 1

triazolam 1

Bipolar Agents - Drugs for Mood Disorders

lithium 1

lithium carbonate er 1

lithium carbonate oral 1

Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders

anagrelide hcl 1

EPOGEN 2 PA

HEMLIBRA 4 PA; QL

LEUKINE 2

NEUPOGEN 4 QL

PROCRIT 2 PA

tranexamic acid oral 1 QL

ZARXIO 4 QL

Cardiovascular Agents - Drugs for Heart and Circulation Conditions


Drug Name Drug Tier

Notes

acebutolol hcl oral 1

ALDACTAZIDE ORAL TABLET 50-50 MG

2

alprostadil injection 1

amiloride hcl oral 1

amiloride-hydrochlorothiazide

1

amiodarone hcl oral tablet 200 mg

1

amlodipine besylate oral 1

amlodipine besylate-benazepril hcl

1

amlodipine-olmesartan 1

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral 1

benazepril hcl oral 1

benazepril-hydrochlorothiazide

1

betaxolol hcl oral 1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

captopril oral 1

captopril-hydrochlorothiazide

1

cartia xt 1

carvedilol 1

chlorthalidone 1

cholestyramine light packets

1

cholestyramine oral packets

1

clonidine 1

clonidine hcl oral 1

colestipol hcl 1

digitek 1

digox 1

Drug Name Drug Tier

Notes

digoxin injection 1

digoxin oral 1

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

1

diltiazem hcl er oral capsule extended release 12 hour

1

diltiazem hcl oral 1

dilt-xr 1

disopyramide phosphate 1

DIURIL 2

doxazosin mesylate oral 1

enalapril maleate oral 1

enalapril-hydrochlorothiazide

1

ENTRESTO 2 PA

epinephrine pf 1

eplerenone 1

ethacrynic acid 1 PA

ezetimibe 1

ezetimibe-simvastatin 1

felodipine er 1

fenofibrate micronized 1

fenofibrate oral capsule 134 mg, 200 mg, 67 mg

1

fenofibrate oral tablet 160 mg, 54 mg

1

fenofibric acid oral tablet 1

flecainide acetate 1

fosinopril sodium 1

fosinopril sodium-hctz 1

furosemide injection 1

furosemide oral 1

gemfibrozil oral 1

guanfacine hcl 1

hydralazine hcl oral 1


Drug Name Drug Tier

Notes

hydrochlorothiazide oral 1

indapamide 1

irbesartan 1

irbesartan-hydrochlorothiazide

1

isosorbide dinitrate 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

isradipine 1

labetalol hcl oral 1

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

losartan potassium oral 1

losartan potassium-hctz 1

lovastatin 1

methyldopa 1

metolazone 1

metoprolol succinate er 1

metoprolol tartrate oral 1

metoprolol-hydrochlorothiazide

1

mexiletine hcl oral 1

midodrine hcl 1

minitran 1

minoxidil oral 1

moexipril hcl 1

nadolol oral 1

nicardipine hcl oral 1

nifedipine er 1

nifedipine er osmotic release

1

nifedipine oral 1

nimodipine oral 1

NITRO-BID 2

Drug Name Drug Tier

Notes

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

2

nitroglycerin sublingual 1

nitroglycerin transdermal 1

nitro-time oral capsule extended release 9 mg

1

NORPACE CR 2

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

pacerone oral tablet 200 mg

1

papaverine hcl injection 1

pentoxifylline er 1

perindopril erbumine 1

phenoxybenzamine hcl oral

4

phentolamine mesylate injection

1

pindolol 1

pravastatin sodium 1

prazosin hcl oral 1

prevalite 1

procainamide hcl injection 1

propafenone hcl 1

propranolol hcl er 1

propranolol hcl oral 1

propranolol-hctz 1

quinapril hcl 1

quinapril-hydrochlorothiazide

1

quinidine gluconate er 1

quinidine sulfate 1

ramipril 1

RECTIV 2

rosuvastatin calcium 1

simvastatin oral 1


Drug Name Drug Tier

Notes

sorine 1

sotalol hcl (af) 1

sotalol hcl oral 1

spironolactone oral 1

spironolactone-hctz 1

timolol maleate oral 1

torsemide 1

trandolapril 1

triamterene oral 1

triamterene-hctz 1

valsartan 1

valsartan-hydrochlorothiazide

1

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

1

verapamil hcl er oral tablet extended release

1

verapamil hcl oral 1

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL XR 1 QL

amphetamine-dextroamphetamine

1

amphetamine-dextroamphetamine er

1 QL

atomoxetine hcl 1

dexmethylphenidate hcl 1

dextroamphetamine sulfate er

1 QL

dextroamphetamine sulfate oral tablet

1

guanfacine hcl er 1

metadate er 1 QL

methylphenidate hcl er 1 QL

methylphenidate hcl er (cd)

1 QL

Drug Name Drug Tier

Notes

methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg

1 PA; ST; QL

methylphenidate hcl oral tablet

1

relexxii 1 QL

zenzedi oral tablet 10 mg, 5 mg

1

Central Nervous System Agents - Drugs for Multiple Sclerosis

AVONEX PEN 4 PA; QL

AVONEX PREFILLED 4 PA; QL

AVONEX VIAL INTRAMUSCULAR KIT INTRAMUSCULAR KIT 30 MCG

4 PA; QL

EXTAVIA 4 QL

GILENYA 4 PA; QL

glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml

4 QL

glatopa subcutaneous solution prefilled syringe 20 mg/ml

4 QL

REBIF 4 PA; QL

REBIF REBIDOSE 4 PA; QL

REBIF REBIDOSE TITRATION PACK

4 PA; QL

REBIF TITRATION PACK 4 PA; QL

Central Nervous System Agents - Miscellaneous

caffeine citrate oral 1

pregabalin oral 1 QL

riluzole 1 QL

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

chlorhexidine gluconate mouth/throat

1

lidocaine viscous hcl 1

oralone 1

paroex 1

periogard 1


Drug Name Drug Tier

Notes

pilocarpine hcl oral tablet 5 mg

1

triamcinolone acetonide mouth/throat

1

Dermatological Agents - Drugs for Skin Conditions

acitretin 1 QL

adapalene external cream 1

adapalene external gel 1

ala-cort external cream 2.5 %

1

alclometasone dipropionate

1

AMELUZ 2 QL

amnesteem 1

avar cleanser 1

avita 1

AZELEX 2

benzoyl peroxide-erythromycin

1

betamethasone dipropionate aug

1

betamethasone dipropionate external

1

betamethasone valerate external

1

calcipotriene external cream

1

calcipotriene external ointment

1

calcipotriene external solution

1

calcitrene 1

calcitriol external 1

CAPEX 2

CARAC 2

claravis 1

clindacin etz external swab

1

clindacin-p 1

Drug Name Drug Tier

Notes

clindamycin phosphate-benzoyl peroxide external gel 1-5 %

1

clindamycin phosphate external gel

1

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

clobetasol prop emollient base

1

clobetasol propionate e 1

clobetasol propionate external cream

1

clobetasol propionate external gel

1

clobetasol propionate external lotion

1

clobetasol propionate external ointment

1

clobetasol propionate external solution

1

CONDYLOX 2

CORDRAN EXTERNAL TAPE

2

CORTISPORIN EXTERNAL OINTMENT

2

desonide external cream 1

desonide external lotion 1

desonide external ointment

1

desoximetasone external cream

1

desoximetasone external gel

1

desoximetasone external ointment

1

DIFFERIN EXTERNAL CREAM

1

DIFFERIN EXTERNAL LOTION

2


Drug Name Drug Tier

Notes

DRYSOL 2

ELIDEL 1

erythromycin external 1

FINACEA EXTERNAL FOAM

2

fluocinolone acetonide body

1

fluocinolone acetonide external

1

fluocinolone acetonide scalp

1

fluocinonide emulsified base

1

fluocinonide external cream 0.05 %

1

fluocinonide external gel 1

fluocinonide external ointment

1

fluocinonide external solution

1

FLUOROPLEX 2

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

1

fluorouracil external solution

1

fluticasone propionate external cream

1

halobetasol propionate external cream

1

halobetasol propionate external ointment

1

hydrocortisone ace-pramoxine external cream 2.5-1 %

1

hydrocortisone butyrate external cream

1

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

Drug Name Drug Tier

Notes

hydrocortisone external cream 2.5 %

1

hydrocortisone external lotion 2.5 %

1

hydrocortisone external ointment 1 %, 2.5 %

1

hydrocortisone valerate 1

imiquimod external 1

isotretinoin oral 1

LEVULAN KERASTICK 2 QL

methoxsalen rapid 4 QL

metronidazole external cream

1

metronidazole external gel 0.75 %

1

mometasone furoate external

1

myorisan 1

PICATO 2 QL

pimecrolimus cream 1 % external

1

PIMECROLIMUS CREAM 1 % EXTERNAL

2

podofilox external 1

PRAMOSONE EXTERNAL CREAM 1-1 %

2

PRAMOSONE EXTERNAL LOTION

2

RETIN-A 1

RETIN-A MICRO GEL 0.04 %, 0.1 %

1

RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %

1

rosadan external cream 1

rosadan external gel 1

SANTYL 2

selenium sulfide external lotion

1

sodium sulfacetamide 1


Drug Name Drug Tier

Notes

sulfacetamide sodium (acne)

1

sulfacetamide sodium-sulfur external emulsion

1

sulfacetamide sodium-sulfur external lotion 10-5 %

1

sulfacetamide-sulfur in urea

1

synalar external cream 1

synalar external ointment 1

tacrolimus external ointment

1

tazarotene external 1

TAZORAC EXTERNAL CREAM 0.05 %

2

TAZORAC EXTERNAL CREAM 0.1 %

1

TAZORAC EXTERNAL GEL

2

tretinoin external cream 1

tretinoin external gel 0.01 %, 0.025 %

1

tretinoin microsphere 1

tretinoin microsphere pump

1

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

triderm 1

urea external cream 40 % 1

uremez-40 1

VECTICAL 1

zenatane 1

Diabetes - Antidiabetic Agents

acarbose oral 1

glimepiride 1

Drug Name Drug Tier

Notes

glipizide er 1

glipizide ir 1

glipizide xl 1

glyburide oral 1

JARDIANCE 2 PA; QL

metformin hcl er 1

metformin hcl ir 1

RIOMET 2

tolbutamide 1

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA IN VITRO

1

ACCU-CHEK COMPACT PLUS CONTROL

1

ACCU-CHEK FASTCLIX LANCET KIT

1

ACCU-CHEK GUIDE CONTROL

1

ACCU-CHEK MULTICLIX LANCET DEVICE KIT

1

ACCU-CHEK SMARTVIEW CONTROL

1

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

1

AGAMATRIX CONTROL LEVEL 2

1

AGAMATRIX CONTROL LEVEL 4

1

AUTOLET LANCING DEVICE

1

CARETOUCH CONTROL SOL LEVEL 2

1

CARETOUCH LANCING/EJECTOR

1

CONTOUR CONTROL 1

CONTOUR NEXT CONTROL

1

CONTOUR NEXT TEST 1 PA; QL

DIATHRIVE GLUCOSE CONTROL SOLN

1

DIATHRIVE LANCING DEVICE

1


Drug Name Drug Tier

Notes

EASY TRAK II CONTROL 1

EASYMAX 15 LEVEL 2-3 CONTROL

1

EASYMAX CONTROL 1

EASYMAX CONTROL NORMAL/HIGH

1

EMBRACE TALK GLUCOSE CONTROL

1

FORTISCARE CONTROL 1

FREESTYLE TEST 1 PA; QL

GENTEEL LANCING KIT (BLUE)

1

GOJJI CONTROL 1

GOJJI LANCING DEVICE/CLEAR CAP

1

LANCETS 1

LANCETS KIT 1

MICROLET NEXT LANCING DEVICE

1

ONETOUCH DELICA LANCING DEV

1

ONETOUCH DELICA PLUS LANCING

1

ONETOUCH ULTRA 1 QL

ONETOUCH VERIO IN VITRO SOLUTION HIGH

1

ONETOUCH VERIO TEST STRIPS

1 QL

SURESTEP PRO HIGH GLUCOSE

1

SURESTEP PRO LOW GLUCOSE

1

SURESTEP PRO NORMAL GLUCOSE

1

TRUE METRIX LEVEL 1 1



UNISTRIP CONTROL IN VITRO SOLUTION LOW

1

VIVAGUARD INO CONTROL SOLUTION

1

Drug Name Drug Tier

Notes

VIVAGUARD LANCING DEVICE

1

Diabetes - Glycemic Agents

BAQSIMI ONE PACK 2

BAQSIMI TWO PACK 2

diazoxide oral 1

GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT INJECTION KIT

2

PROGLYCEM 2

Diabetes - Insulins

BD AUTOSHIELD DUO PEN NEEDLES

1

BD ULTRA-FINE INSULIN SYRINGES

1

BD ULTRA-FINE PEN NEEDLES

1

BD VEO INSULIN SYR U/F 1/2UNIT

1

HUMALOG KWIKPEN 2

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMALOG VIAL 2

HUMULIN 70/30 KWIKPEN

1

HUMULIN 70/30 VIAL 1

HUMULIN N KWIKPEN 1

HUMULIN N VIAL 1

HUMULIN R U-500 KWIKPEN

1

HUMULIN R U-500 VIAL 1

HUMULIN R VIAL 1

INSULIN LISPRO 2

INSULIN LISPRO (1 UNIT DIAL)

2

INSULIN PEN NEEDLES 1


Drug Name Drug Tier

Notes

INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G 0.3 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

1

LANTUS SOLOSTAR 2 PA

LANTUS U-100 VIAL 2 PA

LEVEMIR U-100 FLEXTOUCH

2 PA

LEVEMIR U-100 VIAL 2 PA

MAXICOMFORT SYR 27G X 1/2"

1

NOVOFINE AUTOCOVER PEN NEEDLE

1

NOVOFINE PEN NEEDLE

1

NOVOFINE PLUS PEN NEEDLE

1

NOVOTWIST PEN NEEDLE

1

Electrolytes / Minerals / Metals / Vitamins

argyle sterile saline 1

CARNITOR ORAL 1

CARNITOR SF 1

curity sterile saline 1

cyanocobalamin injection solution 1000 mcg/ml

1

cytra k crystals 1

ergocalciferol oral capsule 1

fluoritab oral tablet chewable 0.55 (0.25 f) mg, 2.2 (1 f) mg

1

FLURA-DROPS 2

Drug Name Drug Tier

Notes

folic acid injection 1

folic acid oral tablet 1 mg 1

kionex 1

klor-con 1

klor-con 10 1

klor-con m10 1

KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL

1

KLOR-CON M15 TABLET EXTENDED RELEASE 15 MEQ ORAL

2

klor-con m20 1

klor-con sprinkle 1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ

1

K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ, 8 MEQ

2

levocarnitine oral solution 1

levocarnitine oral tablet 1

levocarnitine sf 1

ludent oral tablet chewable 0.55 (0.25 f) mg

1

MEPHYTON 1

nafrinse 1

ORACIT 2

phospha 250 neutral 1

phosphorous 1

phospho-trin 250 neutral 1

phytonadione injection 1

phytonadione oral 1

potassium chloride crys er 1

potassium chloride er 1

potassium chloride oral 1

potassium citrate er 1

potassium citrate-citric acid

1


Drug Name Drug Tier

Notes

sod citrate-citric acid 1

sodium chloride (pf) 1

sodium chloride irrigation 1

sodium fluoride oral solution

1

sodium fluoride oral tablet 1.1 (0.5 f) mg

1

sodium fluoride oral tablet chewable

1

sodium polystyrene sulfonate oral

1

sps 1

taron-crystals 1

tricitrates 1

virt-phos 250 neutral 1

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1

vitamin k1 injection 1

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

CARAFATE ORAL SUSPENSION

1

cimetidine hcl 1

cimetidine oral 1

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg, 40 mg

1

lansoprazole oral capsule delayed release

1

misoprostol oral 1

omeprazole oral capsule delayed release

1

pantoprazole sodium oral tablet delayed release

1

rabeprazole sodium oral tablet delayed release

1 PA; ST

sucralfate oral 1

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

Drug Name Drug Tier

Notes

belladonna alkaloids-opium

1

chlordiazepoxide-clidinium

1

constulose 1

dicyclomine hcl oral 1

diphenoxylate-atropine 1

enulose 1

gavilyte-c 1

gavilyte-g 1

gavilyte-n with flavor pack 1

generlac 1

glycopyrrolate injection solution

1

glycopyrrolate oral tablet 1 mg, 2 mg

1

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

2

HELIDAC THERAPY 2

lactulose encephalopathy 1

lactulose oral solution 1

loperamide hcl oral capsule

1

MOVIPREP 2

opium 1

peg 3350-kcl-na bicarb-nacl

1

peg-3350/electrolytes 1

propantheline bromide oral

1

PYLERA 2

RELISTOR SUBCUTANEOUS

2

trilyte 1

ursodiol oral 1

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

CERDELGA 4 PA; QL


Drug Name Drug Tier

Notes

CREON 2

CYSTAGON 2 PA

ZENPEP 2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

acetic acid irrigation 1

bethanechol chloride oral 1

calcium acetate (phos binder)

1

calcium acetate oral tablet 667 mg

1

CERVIDIL 2

darifenacin hydrobromide er

1

ELMIRON 2

flavoxate hcl 1

oxybutynin chloride er 1

oxybutynin chloride oral 1

penicillamine oral tablet 4 PA; QL

PENTOSAN POLYSULFATE SODIUM ORAL

2

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

PREPIDIL 2

PROSTIN E2 2

sevelamer carbonate 1

sevelamer hcl 1

solifenacin succinate 1

tolterodine tartrate 1

tolterodine tartrate er 1

trospium chloride 1

trospium chloride er 1

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

dutasteride oral 1

Drug Name Drug Tier

Notes

finasteride oral tablet 5 mg

1

tamsulosin hcl 1

terazosin hcl 1

Hormonal Agents - Adrenal

CORTEF ORAL TABLET 5 MG

2

cortisone acetate oral 1

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

2

dexamethasone intensol 2

dexamethasone oral elixir 1

dexamethasone oral solution

1

dexamethasone oral tablet

1

dexamethasone sod phosphate pf injection solution

1

dexamethasone sodium phosphate injection

1

fludrocortisone acetate oral

1

hydrocortisone oral 1

MEDROL ORAL TABLET 2 MG

2

methylprednisolone oral 1

methylprednisolone sodium succ injection solution reconstituted 125 mg

1

prednisolone oral solution 1

prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

1

prednisone oral 1

SOLU-CORTEF 2

Hormonal Agents - Men's Health

danazol oral 1


Drug Name Drug Tier

Notes

DEPO-TESTOSTERONE (brand testosterone cypionate intramuscular)

1 PA

TESTOSTERONE CYPIONATE INJECTION

1 PA

testosterone cypionate intramuscular

1 PA

testosterone enanthate intramuscular

1 PA

testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)

1 PA; QL

Hormonal Agents - Osteoporosis

raloxifene hcl 1

Hormonal Agents - Pituitary

ACTHAR 4 PA; QL

cabergoline 1

desmopressin ace spray refrig

1

desmopressin acetate injection

1

desmopressin acetate oral

1

desmopressin acetate spray

1

leuprolide acetate injection

1

LUPRON DEPOT (1-MONTH)

2

LUPRON DEPOT (3-MONTH)

2

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2

LUPRON DEPOT-PED (1-MONTH)

2

LUPRON DEPOT-PED (3-MONTH)

2

Drug Name Drug Tier

Notes

octreotide acetate 1

OMNITROPE 4 PA; QL

SANDOSTATIN LAR DEPOT

2 QL

STIMATE 2

Hormonal Agents - Sex Hormones and Birth Control

afirmelle 1

altavera 1

alyacen 1/35 1

alyacen 7/7/7 1

apri 1

aranelle 1

aubra 1

aubra eq 1

aurovela 1.5/30 1

aurovela 1/20 1

aurovela fe 1.5/30 1

aurovela fe 1/20 1

aviane 1

ayuna 1

balziva 1

blisovi fe 1.5/30 1

blisovi fe 1/20 1

briellyn 1

camila 1

caziant 1

chateal 1

chateal eq 1

CLIMARA 1

cryselle-28 1

cyclafem 1/35 1

cyclafem 7/7/7 1

cyred 1

cyred eq 1

dasetta 1/35 1

dasetta 7/7/7 1


Drug Name Drug Tier

Notes

deblitane 1

DELESTROGEN 2

delyla 1

DEPO-ESTRADIOL 2

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

1

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

1

elinest 1

ELLA 2

eluryng 1

emoquette 1

enpresse-28 1

enskyce 1

errin 1

estarylla 1

estradiol oral 1

estradiol transdermal patch weekly

1

estradiol vaginal 1

estradiol valerate intramuscular

1

ESTRING 2

ethynodiol diac-eth estradiol

1

etonogestrel-ethinyl estradiol

1

falmina 1

FEMRING 2

femynor 1

hailey 1.5/30 1

hailey fe 1.5/30 1

hailey fe 1/20 1

heather 1

hydroxyprogesterone caproate intramuscular oil

4

incassia 1

Drug Name Drug Tier

Notes

isibloom 1

jencycla 1

juleber 1

junel 1.5/30 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

kalliga 1

kelnor 1/35 1

kelnor 1/50 1

kurvelo 1

larin 1.5/30 1

larin 1/20 1

larin fe 1.5/30 1

larin fe 1/20 1

larissia 1

leena 1

lessina 1

levonest 1

levonorgestrel 1

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

1

levonorg-eth estrad triphasic

1

levora 0.15/30 (28) 1

lillow 1

low-ogestrel 1

lutera 1

lyza 1

MAKENA SUBCUTANEOUS

4 QL

marlissa 1

medroxyprogesterone acetate intramuscular

1

medroxyprogesterone acetate oral

1


Drug Name Drug Tier

Notes

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

1

megestrol acetate oral tablet

1

microgestin 1.5/30 1

microgestin 1/20 1

microgestin fe 1.5/30 1

microgestin fe 1/20 1

mili 1

MIRENA (52 MG) 2

mono-linyah 1

necon 0.5/35 (28) 1

nora-be 1

norethin ace-eth estrad-fe oral tablet

1

norethindrone acetate oral

1

norethindrone acet-ethinyl est

1

norethindrone oral 1

norgestimate-eth estradiol 1

norgestimate-ethinyl estradiol triphasic

1

norlyda 1

norlyroc 1

nortrel 0.5/35 (28) 1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

nortrel 7/7/7 1

ocella 1

orsythia 1

PARAGARD INTRAUTERINE COPPER

2

philith 1

pirmella 1/35 1

pirmella 7/7/7 1

portia-28 1

Drug Name Drug Tier

Notes

PREMARIN VAGINAL 2

preventeza 1

previfem 1

progesterone intramuscular

1

progesterone micronized oral

1

reclipsen 1

sharobel 1

SKYLA 2

sprintec 28 1

sronyx 1

syeda 1

tarina fe 1/20 1

tarina fe 1/20 eq 1

tri femynor 1

tri-estarylla 1

tri-linyah 1

tri-lo-estarylla 1

tri-lo-marzia 1

tri-lo-mili 1

tri-lo-sprintec 1

tri-mili 1

tri-previfem 1

tri-sprintec 1

trivora (28) 1

tri-vylibra 1

tri-vylibra lo 1

tulana 1

velivet 1

vienva 1

vyfemla 1

vylibra 1

wera 1

xulane 1

yuvafem 1

zarah 1


Drug Name Drug Tier

Notes

zovia 1/35e (28) 1

zumandimine 1

Hormonal Agents - Thyroid

levothyroxine sodium oral 1

liothyronine sodium oral 1

methimazole oral 1

propylthiouracil oral 1

Immunological Agents - Drugs for Immune System Stimulation or Suppression

azathioprine oral 1

BERINERT 4 PA; QL

COSENTYX (300 MG DOSE)

4 PA; QL

COSENTYX 150 MG/ML 4 PA; QL

COSENTYX SENSOREADY (300 MG)

4 PA; QL

COSENTYX SENSOREADY PEN

4 PA; QL

CUVITRU 4 PA; QL

cyclosporine modified 1

cyclosporine oral 1

ENBREL 4 PA; QL

ENBREL MINI 4 PA; QL

ENBREL SURECLICK 4 PA; QL

gengraf 1

HIZENTRA 4 PA; QL

HUMIRA 4 PA; QL

HUMIRA PEDIATRIC CROHNS START

4 PA; QL

HUMIRA PEN 4 PA; QL

HUMIRA PEN-CD/UC/HS STARTER

4 PA; QL

HUMIRA PEN-PS/UV/ADOL HS START

4 PA; QL

HYPERHEP B S/D 2

HYQVIA 4 PA; QL

icatibant acetate 4 QL

leflunomide oral 1

methotrexate oral 1

Drug Name Drug Tier

Notes

methotrexate sodium 1

methotrexate sodium (pf) 1

mycophenolate mofetil 1

mycophenolate sodium 1

NABI-HB 2

ORENCIA CLICKJECT 4 PA; QL

ORENCIA SUBCUTANEOUS

4 PA; QL

OTEZLA 4 PA; QL

RASUVO 2

RIDAURA 4 QL

sirolimus oral tablet 1

STELARA SUBCUTANEOUS

4 PA; QL

tacrolimus oral 1

TREMFYA 4 PA; QL

XELJANZ 4 PA; QL

XELJANZ XR 4 PA; QL

Immunological Agents - Drugs for Vaccination

ACTHIB 2

ADACEL 2

AFLURIA QUADRIVALENT

1

BEXSERO 2

BOOSTRIX 2

DAPTACEL 2

DIPHTHERIA-TETANUS TOXOIDS DT

2

ENGERIX-B 2

FLUAD 1

FLUARIX QUADRIVALENT

1

FLUBLOK QUADRIVALENT

1

FLUCELVAX QUADRIVALENT

1

FLULAVAL QUADRIVALENT

1


Drug Name Drug Tier

Notes

FLUMIST QUADRIVALENT

1

FLUZONE HIGH-DOSE QUADRIVALENT

1

FLUZONE QUADRIVALENT

1

GARDASIL 9 2

HAVRIX 2

HEPLISAV-B 2

HIBERIX 2

INFANRIX 2

IPOL 2

KINRIX 2

MENACTRA 2

MENVEO 2

M-M-R II 2

PEDIARIX 2

PEDVAX HIB 2

PENTACEL 2

PNEUMOVAX 23 2

PREVNAR 13 2

PROQUAD 2

QUADRACEL 2

RECOMBIVAX HB 2

ROTARIX 2

ROTATEQ 2

SHINGRIX 2

TDVAX 2

TENIVAC 2

TETANUS-DIPHTHERIA TOXOIDS TD

2

TRUMENBA 2

VAQTA INTRAMUSCULAR SUSPENSION 50 UNIT/ML

2

VARIVAX 2

Inflammatory Bowel Disease Agents

Drug Name Drug Tier

Notes

balsalazide disodium 1

CORTIFOAM 2

hydrocortisone (perianal) external cream 2.5 %

1

hydrocortisone rectal 1

LIALDA 1 PA; ST

mesalamine oral tablet delayed release 1.2 gm

1 PA; ST

mesalamine rectal 1

PENTASA 2 PA; ST

PROCTOFOAM HC 2

procto-med hc 1

proctosol hc 1

proctozone-hc 1

sulfasalazine oral 1

Metabolic Bone Disease Agents - Drugs for Osteoporosis

alendronate sodium 1

ibandronate sodium oral 1

risedronate sodium oral tablet

1 PA; ST

Metabolic Bone Disease Agents - Other

calcitriol oral 1

cinacalcet hcl 1 PA

Miscellaneous Therapeutic Agents

ALCOHOL PREP PADS PAD

1

ALCOHOL PREP PADS PAD 70 %

1

BREATHE EASE LARGE 2

BREATHE EASE MEDIUM

2

BREATHE EASE SMALL 2

BREATHERITE 2

CAYA 2

CLEVER CHOICE HOLDING CHAMBER

2

COMPACT SPACE CHAMBER/LG MASK

2


Drug Name Drug Tier

Notes

COMPACT SPACE CHAMBER/MED MASK

2

COMPACT SPACE CHAMBER/SM MASK

2

deferoxamine mesylate injection solution reconstituted 500 mg

1

EASIVENT 2

FEMCAP 2

FLEXICHAMBER ADULT MASK/SMALL

2

FLEXICHAMBER CHILD MASK/LARGE

2

FLEXICHAMBER CHILD MASK/SMALL

2

GLUCAGEN DIAGNOSTIC

2

GLUCAGON HCL (DIAGNOSTIC)

2

MASK VORTEX 2

methergine 1

methylergonovine maleate

1

MICROCHAMBER DEVICE

2

NOZIN NASAL SANITIZER POPSWAB

1

PANDA MASK LARGE 2

PANDA MASK MEDIUM 2

PANDA MASK SMALL 2

PEDIATRIC PANDA MASK

2

pocket spacer 2

PRO COMFORT SPACER ADULT

2

PRO COMFORT SPACER CHILD

2

PRO COMFORT SPACER INFANT

2

PROCARE SPACER/ADULT MASK

2

PROCARE SPACER/CHILD MASK

2

Drug Name Drug Tier

Notes

WIDE-SEAL DIAPHRAGM 60

2


2


2


2


2


2


2


2

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

ACULAR 2

ALOMIDE 2

azelastine hcl ophthalmic 1

bacitracin ophthalmic 1

CILOXAN OPHTHALMIC OINTMENT

2

ciprofloxacin hcl ophthalmic

1

cromolyn sodium ophthalmic

1

dexamethasone sodium phosphate ophthalmic

1

diclofenac sodium ophthalmic

1

DUREZOL 2

erythromycin ophthalmic 1

fluorometholone 1

flurbiprofen sodium 1

FML 2

FML FORTE 2

gatifloxacin ophthalmic 1

gentak 1

gentamicin sulfate ophthalmic

1


Drug Name Drug Tier

Notes

ketorolac tromethamine ophthalmic

1

moxifloxacin hcl (2x day) 1

moxifloxacin hcl ophthalmic

1

NATACYN 2

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic solution 0.1 %

1

PRED MILD 2

prednisolone acetate ophthalmic

1

prednisolone acetate p-f 1

sulfacetamide sodium ophthalmic

1

tobramycin ophthalmic 1

TOBREX OPHTHALMIC OINTMENT

2

trifluridine 1

VIGAMOX 2

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er 1

acetazolamide oral 1

AZOPT 2

betaxolol hcl ophthalmic 1

BETOPTIC-S 2

bimatoprost ophthalmic 1

brimonidine tartrate ophthalmic solution 0.2 %

1

carteolol hcl 1

dorzolamide hcl ophthalmic

1

dorzolamide hcl-timolol mal

1

latanoprost ophthalmic 1

levobunolol hcl 1

LUMIGAN 2

methazolamide oral 1

pilocarpine hcl ophthalmic 1

Drug Name Drug Tier

Notes

timolol maleate ophthalmic gel forming solution

1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

1

travoprost (bak free) 1

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-poly-bac 1

altafrin 1

atropine sulfate ophthalmic ointment

1

ATROPINE SULFATE OPHTHALMIC SOLUTION 0.01 %

1

atropine sulfate ophthalmic solution 1 %

1

bacitracin-polymyxin b ophthalmic

1

bacitra-neomycin-polymyxin-hc

1

BLEPHAMIDE 2

BLEPHAMIDE S.O.P. 2

cyclopentolate hcl ophthalmic

1

CYCLOSPORINE IN KLARITY

2 PA

homatropaire 1

ISOPTO ATROPINE 2

LACRISERT 2

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

neomycin-polymyxin-gramicidin

1

neo-polycin hc 1

phenylephrine hcl ophthalmic

1

polycin 1


Drug Name Drug Tier

Notes

polymyxin b-trimethoprim 1

PRED-G 2

PRED-G S.O.P. 2

RESTASIS 2 PA

RESTASIS MULTIDOSE 2 PA

sulfacetamide-prednisolone ophthalmic solution

1

TOBRADEX OPHTHALMIC OINTMENT

2

tobramycin-dexamethasone

1

XIIDRA 2 PA

Otic Agents - Drugs for Ear Conditions

acetic acid otic 1

CIPRO HC 2

CIPRODEX 2

ciprofloxacin-dexamethasone

1

neomycin-polymyxin-hc otic

1

ofloxacin otic 1

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

azelastine hcl nasal 1

benzonatate oral capsule 100 mg, 200 mg

1

carbinoxamine maleate 1

clemastine fumarate oral tablet 2.68 mg

1

cyproheptadine hcl oral 1

desloratadine 1

diphenhydramine hcl injection

1

flunisolide nasal 1

hydrocodone-homatropine

1

hydromet 1

ipratropium bromide nasal 1

Drug Name Drug Tier

Notes

levocetirizine dihydrochloride oral

1

nebusal inhalation nebulization solution 3 %

1

promethazine hcl oral 1

promethazine hcl rectal 1

promethazine-dm 1

promethazine-phenylephrine

1

promethegan 1

pulmosal 1

ryvent 1

sodium chloride inhalation nebulization solution 0.9 %, 3 %, 7 %

1

SSKI 2

SURVANTA 2

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

acetylcysteine inhalation 1

ADVAIR DISKUS 1

ADVAIR HFA 2

albuterol sulfate hfa 1 QL

albuterol sulfate inhalation 1

albuterol sulfate oral 1

ALVESCO 2

ASMANEX (120 METERED DOSES)

2 PA; ST


2 PA; ST


2 PA; ST


2 PA; ST


2 PA; ST

ASMANEX HFA 2 PA; ST

ATROVENT HFA 2

budesonide inhalation 1


Drug Name Drug Tier

Notes

COMBIVENT RESPIMAT 2

cromolyn sodium inhalation

1

epinephrine injection solution auto-injector

1

ESBRIET 4 PA; QL

FLOVENT DISKUS 2 PA

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT

2 PA

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT

2

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1

ipratropium bromide inhalation

1

ipratropium-albuterol 1

metaproterenol sulfate oral

1

montelukast sodium oral 1

OFEV 4 PA; QL

SEREVENT DISKUS 2 PA; ST

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT

2 PA; ST

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

2

STIOLTO RESPIMAT 2

STRIVERDI RESPIMAT 2 PA

terbutaline sulfate oral 1

theophylline 1

theophylline er 1

VENTOLIN HFA 1 QL

Drug Name Drug Tier

Notes

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

PULMOZYME 2

tobramycin inhalation 4 PA; QL

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ambrisentan 1 PA; QL

bosentan 1 PA; QL

OPSUMIT 4 PA; QL

sildenafil citrate oral tablet 20 mg

4 PA

TYVASO 2 PA; QL

TYVASO REFILL 2 PA; QL

TYVASO STARTER 2 PA; QL

UPTRAVI 4 PA; QL

VENTAVIS 4 PA; QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

baclofen oral 1

cyclobenzaprine hcl oral tablet 10 mg, 5 mg

1 QL

dantrolene sodium oral 1

methocarbamol injection 1

methocarbamol oral 1 QL

orphenadrine citrate er 1 QL

tizanidine hcl oral tablet 1

Sleep Disorder Agents

eszopiclone 1

flurazepam hcl 1

modafinil 1

SECONAL 2

temazepam oral capsule 15 mg, 30 mg, 7.5 mg

1

zaleplon 1

zolpidem tartrate oral 1

40

Index of Drugs

A abacavir sulfate ............... 18 abacavir sulfate-lamivudine

.................................... 18 abacavir-lamivudine-

zidovudine ................... 18 ABILIFY MAINTENA ........ 17 abiraterone acetate.......... 16 acamprosate calcium ....... 12 acarbose ......................... 25 ACCU-CHEK AVIVA

DEVICE ....................... 25 ACCU-CHEK COMPACT

PLUS CONTROL ......... 25 ACCU-CHEK FASTCLIX

LANCET KIT ................ 25 ACCU-CHEK GUIDE

CONTROL ................... 25 ACCU-CHEK MULTICLIX

LANCET DEVICE KIT .. 25 ACCU-CHEK SMARTVIEW

CONTROL ................... 25 ACCU-CHEK SOFTCLIX

LANCET DEVICE KIT .. 25 acebutolol hcl .................. 20 acetaminophen-codeine .. 11 acetaminophen-codeine #2

.................................... 11 acetaminophen-codeine #3

.................................... 11 acetaminophen-codeine #4

.................................... 11 acetazolamide ................. 36 acetazolamide er ............. 36 acetic acid ................. 28, 36 acetylcysteine .................. 37 acitretin ............................ 23 ACTHAR ......................... 29 ACTHIB ........................... 33 ACULAR .......................... 35 acyclovir .......................... 18 ADACEL .......................... 33 adapalene ....................... 23 ADDERALL XR ............... 22 adefovir dipivoxil .............. 18 ADVAIR DISKUS ............. 37 ADVAIR HFA ................... 37 AFINITOR ....................... 16 AFINITOR DISPERZ ....... 16 afirmelle ........................... 30 AFLURIA QUADRIVALENT

.................................... 33

AGAMATRIX CONTROL LEVEL 2 ...................... 25

AGAMATRIX CONTROL LEVEL 4 ...................... 25

ak-poly-bac...................... 36 ala-cort ............................ 23 albendazole ..................... 17 albuterol sulfate ............... 37 albuterol sulfate hfa ......... 37 alclometasone dipropionate

.................................... 23 ALCOHOL PREP PADS .. 34 ALDACTAZIDE ............... 20 alendronate sodium ......... 34 alfuzosin hcl er ................ 29 ALINIA ............................. 17 allopurinol ........................ 15 ALOMIDE ........................ 35 alprazolam....................... 19 alprazolam er .................. 19 alprazolam xr ................... 19 alprostadil ........................ 20 altafrin ............................. 36 altavera ........................... 30 ALVESCO ....................... 37 alyacen 1/35 .................... 30 alyacen 7/7/7 ................... 30 amantadine hcl ................ 17 ambrisentan .................... 38 AMELUZ ......................... 23 amiloride hcl .................... 20 amiloride-

hydrochlorothiazide ..... 20 amiodarone hcl ................ 20 amitriptyline hcl ............... 14 amlodipine besylate ......... 20 amlodipine besylate-

benazepril hcl .............. 20 amlodipine-olmesartan .... 20 amnesteem ..................... 23 amoxapine....................... 14 amoxicillin ....................... 12 amoxicillin-potassium

clavulanate .................. 12 amphetamine-

dextroamphetamine ..... 22 amphetamine-

dextroamphetamine er . 22 ampicillin ......................... 12 ampicillin sodium ............. 12 anagrelide hcl .................. 19 anastrozole...................... 16 aprepitant ........................ 15

apri .................................. 30 APTIVUS......................... 18 aranelle ........................... 30 argyle sterile saline ......... 27 aripiprazole ..................... 17 ARISTADA ...................... 17 ARISTADA INITIO ........... 17 ASMANEX (120 METERED

DOSES) ...................... 37 ASMANEX (14 METERED




DOSES) ...................... 37 ASMANEX HFA .............. 37 aspirin-dipyridamole er .... 17 atazanavir sulfate ............ 18 atenolol ........................... 20 atenolol-chlorthalidone .... 20 atomoxetine hcl ............... 22 atorvastatin calcium ........ 20 atovaquone ..................... 17 ATRIPLA ......................... 18 atropine sulfate ............... 36 ATROPINE SULFATE ..... 36 ATROVENT HFA ............ 37 aubra ............................... 30 aubra eq .......................... 30 aurovela 1.5/30 ............... 30 aurovela 1/20 .................. 30 aurovela fe 1.5/30 ........... 30 aurovela fe 1/20 .............. 30 AUTOLET LANCING

DEVICE ....................... 25 avar cleanser .................. 23 aviane ............................. 30 avidoxy ............................ 12 avita ................................ 23 AVONEX PEN ................. 22 AVONEX PREFILLED ..... 22 AVONEX VIAL

INTRAMUSCULAR KIT .................................... 22

ayuna .............................. 30 azathioprine .................... 32 azelastine hcl ............ 35, 37 AZELEX .......................... 23 azithromycin .................... 12 AZOPT ............................ 36

41

B bacitracin ......................... 35 bacitracin-polymyxin b ..... 36 bacitra-neomycin-

polymyxin-hc ............... 36 baclofen ........................... 38 balsalazide disodium ....... 34 balziva ............................. 30 BAQSIMI ONE PACK ...... 26 BAQSIMI TWO PACK ..... 26 BARACLUDE .................. 18 BD AUTOSHIELD DUO

PEN NEEDLES ........... 26 BD ULTRA-FINE INSULIN

SYRINGES .................. 26 BD ULTRA-FINE PEN

NEEDLES .................... 26 BD VEO INSULIN SYR U/F

1/2UNIT ....................... 26 belladonna alkaloids-opium

.................................... 28 benazepril hcl .................. 20 benazepril-

hydrochlorothiazide ..... 20 benzonatate .................... 37 benzoyl peroxide-

erythromycin ................ 23 benztropine mesylate ...... 17 BERINERT ...................... 32 betamethasone

dipropionate ................. 23 betamethasone

dipropionate aug .......... 23 betamethasone valerate .. 23 betaxolol hcl .............. 20, 36 bethanechol chloride ....... 28 BETOPTIC-S ................... 36 BEXSERO ....................... 33 bicalutamide .................... 16 BICILLIN L-A ................... 12 BIKTARVY ...................... 18 bimatoprost ..................... 36 bisoprolol fumarate .......... 20 bisoprolol-

hydrochlorothiazide ..... 20 BLEPHAMIDE ................. 36 BLEPHAMIDE S.O.P. ...... 36 blisovi fe 1.5/30 ............... 30 blisovi fe 1/20 .................. 30 BOOSTRIX ...................... 33 bosentan ......................... 38 BREATHE EASE LARGE 34 BREATHE EASE MEDIUM

.................................... 34 BREATHE EASE SMALL 34

BREATHERITE ............... 34 briellyn ............................. 30 BRILINTA ........................ 17 brimonidine tartrate ......... 36 bromocriptine mesylate ... 17 budesonide...................... 37 bumetanide ..................... 20 buprenorphine hcl............ 12 buprenorphine hcl-naloxone

hcl ............................... 12 bupropion hcl ................... 14 bupropion hcl er (smoking

det) .............................. 12 bupropion hcl er (sr) ........ 14 bupropion hcl er (xl) ......... 14 buspirone hcl ................... 19 butalbital-apap-caffeine ... 11 butalbital-aspirin-caffeine . 11 C cabergoline...................... 29 caffeine citrate ................. 22 calcipotriene .................... 23 calcitrene ......................... 23 calcitriol ..................... 23, 34 calcium acetate ............... 28 calcium acetate (phos

binder) ......................... 28 camila .............................. 30 capecitabine .................... 16 CAPEX ............................ 23 captopril .......................... 20 captopril-

hydrochlorothiazide ..... 20 CARAC ........................... 23 CARAFATE ..................... 28 carbamazepine ................ 14 carbamazepine er............ 14 carbidopa ........................ 17 carbidopa-levodopa ......... 17 carbidopa-levodopa er ..... 17 carbidopa-levodopa-

entacapone ................. 17 carbinoxamine maleate ... 37 CARETOUCH CONTROL

SOL LEVEL 2 .............. 25 CARETOUCH

LANCING/EJECTOR ... 25 CARNITOR ..................... 27 CARNITOR SF ................ 27 carteolol hcl ..................... 36 cartia xt ........................... 20 carvedilol ......................... 20 CAYA .............................. 34 caziant ............................. 30 cefadroxil ......................... 12

cefazolin sodium ............. 12 cefdinir ............................ 12 cefixime ........................... 12 cefprozil .......................... 12 ceftazidime ...................... 12 ceftriaxone sodium .......... 12 cefuroxime axetil ............. 12 celecoxib ......................... 11 CELONTIN ...................... 14 cephalexin ....................... 12 CERDELGA .................... 28 CERVIDIL ....................... 28 CHANTIX ........................ 12 CHANTIX CONTINUING

MONTH PAK ............... 12 CHANTIX STARTING

MONTH PAK ............... 12 chateal ............................ 30 chateal eq ....................... 30 chlordiazepoxide hcl ........ 19 chlordiazepoxide-clidinium

.................................... 28 chlorhexidine gluconate ... 22 chloroquine phosphate .... 17 chlorpromazine hcl .......... 17 chlorthalidone .................. 20 cholestyramine ................ 20 cholestyramine light ........ 20 ciclodan ........................... 15 ciclopirox ......................... 15 ciclopirox olamine ............ 15 cilostazol ......................... 17 CILOXAN ........................ 35 CIMDUO ......................... 18 cimetidine ........................ 28 cimetidine hcl .................. 28 cinacalcet hcl .................. 34 CIPRO ............................ 13 CIPRO HC ...................... 36 CIPRODEX ..................... 36 ciprofloxacin hcl......... 13, 35 ciprofloxacin-

dexamethasone ........... 37 citalopram hydrobromide . 14 claravis ............................ 23 clarithromycin .................. 13 clemastine fumarate ........ 37 CLEVER CHOICE

HOLDING CHAMBER . 34 CLIMARA ........................ 30 clindacin etz .................... 23 clindacin-p ....................... 23 clindamycin hcl ................ 13 clindamycin palmitate hcl 13

42

clindamycin phosphate ... 13, 23

clindamycin phosphate-benzoyl peroxide ......... 23

clobetasol prop emollient base ............................ 23

clobetasol propionate ...... 23 clobetasol propionate e ... 23 clomipramine hcl ............. 14 clonazepam ..................... 19 clonidine .......................... 20 clonidine hcl .................... 20 clopidogrel bisulfate ......... 17 clorazepate dipotassium .. 19 clotrimazole ..................... 15 clotrimazole-betamethasone

.................................... 15 clozapine ......................... 17 codeine sulfate ................ 11 colchicine ........................ 15 COLCHICINE .................. 15 colchicine-probenecid ...... 15 COLCRYS ....................... 15 colestipol hcl .................... 20 COMBIVENT RESPIMAT 37 COMPACT SPACE

CHAMBER/LG MASK .. 34 COMPACT SPACE

CHAMBER/MED MASK .................................... 34

COMPACT SPACE CHAMBER/SM MASK . 34

COMPLERA .................... 18 compro ............................ 15 CONDYLOX .................... 23 constulose ....................... 28 CONTOUR CONTROL .... 25 CONTOUR NEXT

CONTROL ................... 25 CONTOUR NEXT TEST .. 25 CORDRAN ...................... 23 CORTEF ......................... 29 CORTIFOAM ................... 34 cortisone acetate ............. 29 CORTISPORIN ............... 23 COSENTYX (300 MG

DOSE) ......................... 32 COSENTYX 150 MG/ML . 32 COSENTYX

SENSOREADY (300 MG) .................................... 32

COSENTYX SENSOREADY PEN ... 32

COTELLIC ....................... 16 CREON ........................... 28

CRESEMBA .................... 15 CRIXIVAN ....................... 18 cromolyn sodium ....... 35, 37 cryselle-28 ....................... 30 curity sterile saline ........... 27 CUVITRU ........................ 33 cyanocobalamin .............. 27 cyclafem 1/35 .................. 30 cyclafem 7/7/7 ................. 30 cyclobenzaprine hcl ......... 38 cyclopentolate hcl ............ 36 cyclophosphamide ........... 16 cyclosporine .................... 33 CYCLOSPORINE IN

KLARITY ..................... 36 cyclosporine modified ...... 33 cyproheptadine hcl .......... 37 cyred ............................... 30 cyred eq .......................... 30 CYSTAGON .................... 28 cytra k crystals ................ 27 D danazol ........................... 29 dantrolene sodium ........... 38 dapsone .......................... 16 DAPTACEL ..................... 33 darifenacin hydrobromide er

.................................... 28 dasetta 1/35 .................... 30 dasetta 7/7/7 ................... 30 deblitane ......................... 30 deferoxamine mesylate ... 34 DELESTROGEN ............. 30 delyla............................... 30 DEPO-ESTRADIOL ......... 30 DEPO-MEDROL ............. 29 DEPO-TESTOSTERONE 29 DESCOVY....................... 18 desipramine hcl ............... 14 desloratadine ................... 37 desmopressin ace spray

refrig ............................ 30 desmopressin acetate ..... 30 desmopressin acetate spray

.................................... 30 desogestrel-ethinyl estradiol

.................................... 30 desonide ......................... 23 desoximetasone .............. 23 dexamethasone ............... 29 dexamethasone intensol.. 29 dexamethasone sod

phosphate pf................ 29 dexamethasone sodium

phosphate ............. 29, 35

dexmethylphenidate hcl ... 22 dextroamphetamine sulfate

.................................... 22 dextroamphetamine sulfate

er ................................. 22 DIASTAT PEDIATRIC ..... 14 DIATHRIVE GLUCOSE

CONTROL SOLN ........ 25 DIATHRIVE LANCING

DEVICE ....................... 25 diazepam .................. 14, 19 diazoxide ......................... 26 diclofenac potassium ....... 11 diclofenac sodium ..... 11, 35 diclofenac sodium er ....... 11 dicloxacillin sodium ......... 13 dicyclomine hcl ................ 28 didanosine ....................... 18 DIFFERIN ....................... 23 diflunisal .......................... 11 digitek ............................. 20 digox ............................... 20 digoxin ............................ 20 dihydroergotamine mesylate

.................................... 16 DILANTIN........................ 14 diltiazem hcl .................... 20 diltiazem hcl er ................ 20 diltiazem hcl er coated

beads .......................... 20 dilt-xr ............................... 20 dimenhydrinate ............... 15 diphenhydramine hcl ....... 37 diphenoxylate-atropine .... 28 DIPHTHERIA-TETANUS

TOXOIDS DT .............. 33 dipyridamole .................... 17 disopyramide phosphate . 20 disulfiram......................... 12 DIURIL ............................ 20 divalproex sodium ........... 14 divalproex sodium er ....... 14 donepezil hcl ................... 14 dorzolamide hcl ............... 36 dorzolamide hcl-timolol mal

.................................... 36 DOVATO ......................... 18 doxazosin mesylate ......... 20 doxepin hcl ...................... 14 doxycycline hyclate ......... 13 doxycycline monohydrate 13 dronabinol ....................... 15 drospirenone-ethinyl

estradiol ...................... 30 DROXIA .......................... 16

43

DRYSOL ......................... 23 duloxetine hcl .................. 14 DUOPA ........................... 17 DUREZOL ....................... 35 dutasteride ...................... 29 E EASIVENT ...................... 34 EASY TRAK II CONTROL

.................................... 25 EASYMAX 15 LEVEL 2-3

CONTROL ................... 25 EASYMAX CONTROL ..... 25 EASYMAX CONTROL

NORMAL/HIGH ........... 25 EDURANT ....................... 18 efavirenz .......................... 18 ELIDEL ............................ 23 elinest .............................. 30 ELLA ............................... 30 ELMIRON ........................ 28 eluryng ............................ 30 EMBRACE TALK

GLUCOSE CONTROL . 25 emoquette ....................... 30 EMTRIVA ........................ 18 enalapril maleate ............. 20 enalapril-

hydrochlorothiazide ..... 20 ENBREL .......................... 33 ENBREL MINI ................. 33 ENBREL SURECLICK ..... 33 endocet ........................... 11 ENGERIX-B..................... 33 enoxaparin sodium .......... 13 enpresse-28 .................... 30 enskyce ........................... 30 entacapone ..................... 17 entecavir .......................... 18 ENTRESTO ..................... 20 enulose ............................ 28 EPCLUSA ....................... 18 epinephrine ..................... 37 epinephrine pf .................. 20 epitol ............................... 14 EPIVIR HBV .................... 18 eplerenone ...................... 20 EPOGEN ......................... 19 ergocalciferol ................... 27 ERGOMAR ...................... 16 ergotamine-caffeine ......... 16 erlotinib hcl ...................... 16 errin ................................. 31 erythromycin .............. 23, 35 ESBRIET ......................... 37 escitalopram oxalate ........ 14

estarylla ........................... 31 estradiol .......................... 31 estradiol valerate ............. 31 ESTRING ........................ 31 eszopiclone ..................... 38 ethacrynic acid ................ 20 ethambutol hcl ................. 16 ethosuximide ................... 14 ethynodiol diac-eth estradiol

.................................... 31 etodolac .......................... 11 etonogestrel-ethinyl

estradiol ....................... 31 etoposide ........................ 16 everolimus ....................... 16 exemestane ..................... 16 EXTAVIA ......................... 22 ezetimibe ......................... 20 ezetimibe-simvastatin ...... 20 F falmina ............................ 31 famotidine ....................... 28 felodipine er ..................... 20 FEMCAP ......................... 34 FEMRING ....................... 31 femynor ........................... 31 fenofibrate ....................... 20 fenofibrate micronized ..... 20 fenofibric acid .................. 20 fentanyl ........................... 11 FINACEA ........................ 23 finasteride ....................... 29 FIRVANQ ........................ 13 flavoxate hcl .................... 29 flecainide acetate ............ 20 FLEXICHAMBER ADULT

MASK/SMALL ............. 34 FLEXICHAMBER CHILD

MASK/LARGE ............. 34 FLEXICHAMBER CHILD

MASK/SMALL ............. 34 FLOVENT DISKUS ......... 37 FLOVENT HFA ............... 37 FLUAD ............................ 33 FLUARIX QUADRIVALENT

.................................... 33 FLUBLOK QUADRIVALENT

.................................... 33 FLUCELVAX

QUADRIVALENT ........ 33 fluconazole ...................... 15 flucytosine ....................... 15 fludrocortisone acetate .... 29 FLULAVAL

QUADRIVALENT ........ 33

FLUMIST QUADRIVALENT .................................... 33

flunisolide ........................ 37 fluocinolone acetonide..... 24 fluocinolone acetonide body

.................................... 23 fluocinolone acetonide scalp

.................................... 24 fluocinonide ..................... 24 fluocinonide emulsified base

.................................... 24 fluoritab ........................... 27 fluorometholone .............. 35 FLUOROPLEX ................ 24 fluorouracil ...................... 24 FLUOROURACIL ............ 24 fluoxetine hcl ................... 14 fluphenazine decanoate .. 17 fluphenazine hcl .............. 17 FLURA-DROPS .............. 27 flurazepam hcl ................. 38 flurbiprofen ...................... 11 flurbiprofen sodium .......... 35 flutamide ......................... 16 fluticasone propionate ..... 24 fluticasone-salmeterol ..... 37 fluvoxamine maleate ....... 14 FLUZONE HIGH-DOSE

QUADRIVALENT ........ 33 FLUZONE

QUADRIVALENT ........ 33 FML ................................. 35 FML FORTE .................... 35 folic acid .......................... 27 fondaparinux sodium ....... 13 FORTISCARE CONTROL

.................................... 25 fosamprenavir calcium .... 18 fosinopril sodium ............. 20 fosinopril sodium-hctz ..... 20 FREESTYLE TEST ......... 26 furosemide ...................... 20 G gabapentin ...................... 14 galantamine hydrobromide

.................................... 14 galantamine hydrobromide

er ................................. 14 GARDASIL 9 ................... 33 gatifloxacin ...................... 35 gavilyte-c ......................... 28 gavilyte-g......................... 28 gavilyte-n with flavor pack 28 gemfibrozil ....................... 20 generlac .......................... 28

44

gengraf ............................ 33 gentak ............................. 35 gentamicin sulfate ..... 13, 35 GENTEEL LANCING KIT

(BLUE) ........................ 26 GENVOYA ...................... 18 GILENYA ......................... 22 GILOTRIF ........................ 16 glatiramer acetate ............ 22 glatopa ............................ 22 GLEOSTINE .................... 16 glimepiride ....................... 25 glipizide er ....................... 25 glipizide ir ........................ 25 glipizide xl ........................ 25 GLUCAGEN DIAGNOSTIC

.................................... 34 GLUCAGEN HYPOKIT .... 26 GLUCAGON EMERGENCY

KIT ............................... 26 GLUCAGON HCL

(DIAGNOSTIC) ............ 34 glyburide .......................... 25 glycopyrrolate .................. 28 glydo ............................... 12 GOJJI CONTROL ............ 26 GOJJI LANCING

DEVICE/CLEAR CAP .. 26 GOLYTELY ..................... 28 griseofulvin microsize ...... 15 griseofulvin ultramicrosize15 guanfacine hcl ................. 20 guanfacine hcl er ............. 22 H hailey 1.5/30 .................... 31 hailey fe 1.5/30 ................ 31 hailey fe 1/20 ................... 31 halobetasol propionate .... 24 haloperidol ....................... 17 haloperidol decanoate ..... 17 haloperidol lactate ........... 17 HARVONI ........................ 18 HAVRIX ........................... 33 heather ............................ 31 HELIDAC THERAPY ....... 28 HEMLIBRA ...................... 19 heparin sodium (porcine) . 13 heparin sodium (porcine) pf

.................................... 13 HEPLISAV-B ................... 33 HIBERIX .......................... 33 HIZENTRA ...................... 33 homatropaire ................... 36 HUMALOG KWIKPEN ..... 26

HUMALOG U-100 JUNIOR KWIKPEN .................... 26

HUMALOG VIAL ............. 26 HUMIRA .......................... 33 HUMIRA PEDIATRIC

CROHNS START ........ 33 HUMIRA PEN .................. 33 HUMIRA PEN-CD/UC/HS

STARTER ................... 33 HUMIRA PEN-PS/UV/ADOL

HS START .................. 33 HUMULIN 70/30 KWIKPEN

.................................... 26 HUMULIN 70/30 VIAL ..... 26 HUMULIN N KWIKPEN ... 26 HUMULIN N VIAL............ 26 HUMULIN R U-500

KWIKPEN .................... 26 HUMULIN R U-500 VIAL . 26 HUMULIN R VIAL............ 26 hydralazine hcl ................ 20 hydrochlorothiazide ......... 20 hydrocodone-

acetaminophen ............ 11 hydrocodone-homatropine

.................................... 37 hydrocortisone ..... 24, 29, 34 hydrocortisone (perianal) . 34 hydrocortisone ace-

pramoxine ................... 24 hydrocortisone butyrate ... 24 hydrocortisone valerate ... 24 hydromet ......................... 37 hydromorphone hcl .......... 11 hydroxychloroquine sulfate

.................................... 17 hydroxyprogesterone

caproate ...................... 31 hydroxyurea .................... 16 hydroxyzine hcl ............... 19 hydroxyzine pamoate ...... 19 HYPERHEP B S/D .......... 33 HYQVIA .......................... 33 I ibandronate sodium ......... 34 ibu ................................... 11 ibuprofen ......................... 11 icatibant acetate .............. 33 imatinib mesylate............. 16 IMBRUVICA .................... 16 imipramine hcl ................. 14 imiquimod ........................ 24 incassia ........................... 31 indapamide...................... 20 indomethacin ................... 11

indomethacin er............... 11 INFANRIX ....................... 33 INSULIN LISPRO ............ 26 INSULIN LISPRO (1 UNIT

DIAL) ........................... 26 INSULIN PEN NEEDLES 26 INSULIN SYRINGES ...... 26 INTELENCE .................... 18 INTRON A ....................... 18 INVEGA SUSTENNA ...... 17 INVEGA TRINZA ............. 17 INVIRASE ....................... 18 IPOL ................................ 33 ipratropium bromide .. 37, 38 ipratropium-albuterol ....... 38 irbesartan ........................ 21 irbesartan-

hydrochlorothiazide ..... 21 IRESSA ........................... 16 ISENTRESS .................... 18 ISENTRESS HD .............. 18 isibloom ........................... 31 isoniazid .......................... 16 ISOPTO ATROPINE ....... 36 isosorbide dinitrate .......... 21 isosorbide mononitrate .... 21 isosorbide mononitrate er 21 isotretinoin ....................... 24 isradipine......................... 21 itraconazole ..................... 15 J jantoven .......................... 13 JARDIANCE .................... 25 jencycla ........................... 31 juleber ............................. 31 JULUCA .......................... 18 junel 1.5/30 ..................... 31 junel 1/20 ........................ 31 junel fe 1.5/30 ................. 31 junel fe 1/20 .................... 31 K KALETRA........................ 18 kalliga .............................. 31 kelnor 1/35 ...................... 31 kelnor 1/50 ...................... 31 ketoconazole ................... 15 ketorolac tromethamine .. 11,

35 KINRIX ............................ 33 kionex ............................. 27 klor-con ........................... 27 klor-con 10 ...................... 27 klor-con m10 ................... 27 KLOR-CON M15 ............. 27 klor-con m20 ................... 27

45

klor-con sprinkle .............. 27 KRINTAFEL..................... 17 K-TAB.............................. 27 kurvelo............................. 31 L labetalol hcl ..................... 21 LACRISERT .................... 36 lactulose .......................... 28 lactulose encephalopathy 28 lamivudine ....................... 18 lamivudine-zidovudine ..... 18 lamotrigine ....................... 14 LANCETS ........................ 26 lansoprazole .................... 28 LANTUS SOLOSTAR ...... 26 LANTUS U-100 VIAL ....... 27 larin 1.5/30 ...................... 31 larin 1/20 ......................... 31 larin fe 1.5/30................... 31 larin fe 1/20 ..................... 31 larissia ............................. 31 latanoprost ...................... 36 LEDIPASVIR-

SOFOSBUVIR ............. 18 leena ............................... 31 leflunomide ...................... 33 lessina ............................. 31 letrozole ........................... 16 leucovorin calcium ........... 16 LEUKERAN ..................... 16 LEUKINE ......................... 19 leuprolide acetate ............ 30 LEVEMIR U-100

FLEXTOUCH ............... 27 LEVEMIR U-100 VIAL ..... 27 levetiracetam ................... 14 levetiracetam er ............... 14 levobunolol hcl ................. 36 levocarnitine .................... 27 levocarnitine sf ................ 27 levocetirizine

dihydrochloride ............ 37 levofloxacin ..................... 13 levonest ........................... 31 levonorgestrel .................. 31 levonorgestrel-ethinyl estrad

.................................... 31 levonorg-eth estrad triphasic

.................................... 31 levora 0.15/30 (28) .......... 31 levorphanol tartrate.......... 11 levothyroxine sodium ....... 32 LEVULAN KERASTICK ... 24 LEXIVA ............................ 18 LIALDA ............................ 34

lidocaine .......................... 12 lidocaine hcl .................... 12 lidocaine hcl

urethral/mucosal .......... 12 lidocaine viscous hcl ........ 22 lidocaine-prilocaine .......... 12 lillow ................................ 31 linezolid ........................... 13 liothyronine sodium ......... 32 lisinopril ........................... 21 lisinopril-hydrochlorothiazide

.................................... 21 lithium .............................. 19 lithium carbonate ............. 19 lithium carbonate er ......... 19 loperamide hcl ................. 28 lopinavir-ritonavir ............. 18 lorazepam ....................... 19 lorazepam intensol .......... 19 lorcet ............................... 11 lorcet hd .......................... 11 losartan potassium .......... 21 losartan potassium-hctz... 21 lovastatin ......................... 21 LOVENOX ....................... 13 low-ogestrel ..................... 31 loxapine succinate ........... 17 ludent .............................. 27 LUMIGAN ........................ 36 LUPRON DEPOT (1-

MONTH) ...................... 30 LUPRON DEPOT (3-

MONTH) ...................... 30 LUPRON DEPOT (4-

MONTH) INTRAMUSCULAR KIT 30MG .......................... 30

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG .......................... 30

LUPRON DEPOT-PED (1-MONTH) ...................... 30

LUPRON DEPOT-PED (3-MONTH) ...................... 30

lutera ............................... 31 lyza ................................. 31 M MAKENA ......................... 31 maprotiline hcl ................. 14 marlissa ........................... 31 MASK VORTEX .............. 34 MATULANE ..................... 16 MAXICOMFORT SYR 27G

X 1/2 ............................ 27

meclofenamate sodium ... 11 MEDROL......................... 29 medroxyprogesterone

acetate ........................ 31 megestrol acetate ............ 31 MEKINIST ....................... 16 meloxicam ....................... 11 melphalan ....................... 16 memantine hcl ................. 14 MENACTRA .................... 33 MENVEO ........................ 33 MEPHYTON .................... 27 mercaptopurine ............... 16 mesalamine ..................... 34 mesna ............................. 16 MESNEX ......................... 16 MESTINON ..................... 16 metadate er ..................... 22 metaproterenol sulfate..... 38 metformin hcl er .............. 25 metformin hcl ir ............... 25 methadone hcl ................ 11 methadone hcl intensol ... 11 methadose ...................... 11 methazolamide ................ 36 methenamine hippurate ... 13 methergine ...................... 34 methimazole .................... 32 methocarbamol ............... 38 methotrexate ................... 33 methotrexate sodium ....... 33 methotrexate sodium (pf) 33 methoxsalen rapid ........... 24 methyldopa ..................... 21 methylergonovine maleate

.................................... 35 methylphenidate hcl ........ 22 methylphenidate hcl er .... 22 methylphenidate hcl er (cd)

.................................... 22 methylphenidate hcl er (la)

.................................... 22 methylprednisolone ......... 29 methylprednisolone sodium

succ............................. 29 metoclopramide hcl ......... 15 metolazone ..................... 21 metoprolol succinate er ... 21 metoprolol tartrate ........... 21 metoprolol-

hydrochlorothiazide ..... 21 metronidazole ........... 13, 24 mexiletine hcl .................. 21 MICROCHAMBER .......... 35 microgestin 1.5/30 ........... 31

46

microgestin 1/20 .............. 31 microgestin fe 1.5/30 ....... 31 microgestin fe 1/20 .......... 31 MICROLET NEXT

LANCING DEVICE ...... 26 midazolam hcl ................. 19 midazolam hcl (pf) ........... 19 midodrine hcl ................... 21 MIGERGOT ..................... 16 mili ................................... 31 minitran ........................... 21 minocycline hcl ................ 13 minoxidil .......................... 21 MIRENA (52 MG) ............ 31 mirtazapine ...................... 14 misoprostol ...................... 28 M-M-R II .......................... 33 modafinil .......................... 38 moexipril hcl .................... 21 mometasone furoate ........ 24 mondoxyne nl .................. 13 mono-linyah ..................... 31 montelukast sodium ......... 38 morgidox ......................... 13 morphine sulfate .............. 11 morphine sulfate

(concentrate) ............... 11 morphine sulfate er .......... 11 MOVIPREP ..................... 28 moxifloxacin hcl ......... 13, 35 moxifloxacin hcl (2x day) . 35 mupirocin ......................... 13 mupirocin calcium ............ 13 MYAMBUTOL .................. 16 mycophenolate mofetil ..... 33 mycophenolate sodium .... 33 MYLERAN ....................... 16 myorisan .......................... 24 N NABI-HB .......................... 33 nabumetone .................... 11 nadolol............................. 21 nafrinse ........................... 27 naloxone hcl .................... 12 naltrexone hcl .................. 12 naproxen ......................... 11 naproxen sodium ............. 11 naratriptan hcl .................. 16 NARCAN ......................... 12 NATACYN ....................... 35 nebusal ............................ 37 necon 0.5/35 (28) ............ 31 neomycin sulfate ............. 13 neomycin-polymyxin-

dexameth ..................... 36

neomycin-polymyxin-gramicidin .................... 36

neomycin-polymyxin-hc ... 37 neo-polycin hc ................. 36 NEUPOGEN .................... 19 nevirapine ....................... 18 nevirapine er ................... 18 NEXAVAR ....................... 16 nicardipine hcl ................. 21 NICORETTE ................... 12 nicotine polacrilex ............ 12 nicotine step 1 ................. 12 nicotine step 2 ................. 12 nicotine step 3 ................. 12 nifedipine ......................... 21 nifedipine er ..................... 21 nifedipine er osmotic

release ........................ 21 nimodipine ....................... 21 NITRO-BID ...................... 21 NITRO-DUR .................... 21 nitrofurantoin ................... 13 nitrofurantoin macrocrystal

.................................... 13 nitrofurantoin monohydrate

macrocrystals .............. 13 nitroglycerin ..................... 21 nitro-time ......................... 21 nora-be ............................ 31 norethin ace-eth estrad-fe 31 norethindrone .................. 32 norethindrone acetate ..... 31 norethindrone acet-ethinyl

est ............................... 32 norgestimate-eth estradiol

.................................... 32 norgestimate-ethinyl

estradiol triphasic ........ 32 norlyda ............................ 32 norlyroc ........................... 32 NORPACE CR ................ 21 nortrel 0.5/35 (28) ............ 32 nortrel 1/35 (21) ............... 32 nortrel 1/35 (28) ............... 32 nortrel 7/7/7 ..................... 32 nortriptyline hcl ................ 15 NORVIR .......................... 18 NOVOFINE AUTOCOVER

PEN NEEDLE .............. 27 NOVOFINE PEN NEEDLE

.................................... 27 NOVOFINE PLUS PEN

NEEDLE ...................... 27 NOVOTWIST PEN

NEEDLE ...................... 27

NOZIN NASAL SANITIZER POPSWAB .................. 35

nyamyc ........................... 15 nystatin ........................... 15 nystatin-triamcinolone ..... 15 nystop ............................. 15 O ocella .............................. 32 octreotide acetate ............ 30 ODEFSEY ....................... 18 OFEV .............................. 38 ofloxacin .................... 35, 37 olanzapine ....................... 17 olmesartan medoxomil .... 21 olmesartan medoxomil-hctz

.................................... 21 olopatadine hcl ................ 35 omeprazole ..................... 28 OMNITROPE .................. 30 ondansetron hcl............... 15 ondansetron odt .............. 15 ONETOUCH DELICA

LANCING DEV ............ 26 ONETOUCH DELICA PLUS

LANCING .................... 26 ONETOUCH ULTRA ....... 26 ONETOUCH VERIO KIT

W/DEVICE .................. 26 opium .............................. 28 OPSUMIT........................ 38 ORACIT .......................... 27 oralone ............................ 22 ORENCIA........................ 33 ORENCIA CLICKJECT ... 33 orphenadrine citrate er .... 38 orsythia ........................... 32 oseltamivir phosphate ..... 18 OTEZLA .......................... 33 oxazepam ....................... 19 oxcarbazepine ................. 14 oxybutynin chloride ......... 29 oxybutynin chloride er ..... 29 oxycodone hcl ................. 11 OXYCODONE HCL ER ... 11 oxycodone-acetaminophen

.................................... 12 oxycodone-aspirin ........... 12 OXYCONTIN ................... 12 P pacerone ......................... 21 PANDA MASK LARGE .... 35 PANDA MASK MEDIUM . 35 PANDA MASK SMALL .... 35 pantoprazole sodium ....... 28 papaverine hcl ................. 21

47

PARAGARD INTRAUTERINE COPPER ..................... 32

paroex ............................. 22 paroxetine hcl .................. 15 PAXIL .............................. 15 PEDIARIX ....................... 33 PEDIATRIC PANDA MASK

.................................... 35 PEDVAX HIB ................... 33 peg 3350-kcl-na bicarb-nacl

.................................... 28 peg-3350/electrolytes ...... 28 PEGASYS ....................... 18 PEGASYS PROCLICK .... 18 PEGINTRON ................... 18 penicillamine.................... 29 penicillin v potassium ....... 13 PENTACEL ..................... 33 PENTASA ....................... 34 PENTOSAN

POLYSULFATE SODIUM .................................... 29

pentoxifylline er ............... 21 perindopril erbumine ........ 21 periogard ......................... 22 permethrin ....................... 17 perphenazine................... 15 perphenazine-amitriptyline

.................................... 15 PERSERIS ...................... 18 phenazo .......................... 29 phenazopyridine hcl ......... 29 phenelzine sulfate ........... 15 phenobarbital................... 14 phenobarbital sodium ...... 14 phenoxybenzamine hcl .... 21 phentolamine mesylate .... 21 phenylephrine hcl ............ 36 phenytoin ......................... 14 phenytoin infatabs ........... 14 phenytoin sodium ............ 14 phenytoin sodium extended

.................................... 14 philith ............................... 32 phospha 250 neutral ........ 27 phosphorous.................... 27 phospho-trin 250 neutral .. 27 phytonadione ................... 27 PICATO ........................... 24 pilocarpine hcl ........... 22, 36 pimecrolimus ................... 24 PIMECROLIMUS ............. 24 pimozide .......................... 18 pindolol ............................ 21

pirmella 1/35 .................... 32 pirmella 7/7/7 ................... 32 piroxicam ......................... 11 PNEUMOVAX 23 ............ 34 pocket spacer .................. 35 podofilox .......................... 24 polycin ............................. 36 polymyxin b-trimethoprim 36 portia-28 .......................... 32 potassium chloride .......... 27 potassium chloride crys er

.................................... 27 potassium chloride er ...... 27 potassium citrate er ......... 27 potassium citrate-citric acid

.................................... 27 PRADAXA ....................... 13 pramipexole dihydrochloride

.................................... 17 PRAMOSONE ................. 24 prasugrel hcl .................... 17 pravastatin sodium .......... 21 praziquantel ..................... 17 prazosin hcl ..................... 21 PRED MILD ..................... 35 PRED-G .......................... 36 PRED-G S.O.P. ............... 36 prednisolone .................... 29 prednisolone acetate ....... 35 prednisolone acetate p-f .. 35 prednisolone sodium

phosphate ................... 29 prednisone ...................... 29 pregabalin ....................... 22 PREMARIN ..................... 32 PREPIDIL ........................ 29 prevalite .......................... 21 preventeza ...................... 32 previfem .......................... 32 PREVNAR 13 .................. 34 PREVYMIS...................... 18 PREZCOBIX ................... 18 PREZISTA....................... 18 PRIFTIN .......................... 16 prilovix ultralite ................ 12 prilovix ultralite plus ......... 12 primaquine phosphate ..... 17 primidone ........................ 14 PRIMSOL ........................ 13 PRO COMFORT SPACER

ADULT ........................ 35 PRO COMFORT SPACER

CHILD ......................... 35 PRO COMFORT SPACER

INFANT ....................... 35

probenecid ...................... 15 procainamide hcl ............. 21 PROCARE

SPACER/ADULT MASK .................................... 35

PROCARE SPACER/CHILD MASK .......................... 35

prochlorperazine ............. 15 prochlorperazine edisylate

.................................... 15 prochlorperazine maleate 15 PROCRIT ........................ 19 PROCTOFOAM HC ........ 34 procto-med hc ................. 34 proctosol hc ..................... 34 proctozone-hc ................. 34 progesterone ................... 32 progesterone micronized . 32 PROGLYCEM ................. 26 promethazine hcl ............. 37 promethazine-dm ............ 37 promethazine-

phenylephrine .............. 37 promethegan ................... 37 propafenone hcl .............. 21 propantheline bromide..... 28 propranolol hcl ................ 21 propranolol hcl er ............ 21 propranolol-hctz .............. 21 propylthiouracil ................ 32 PROQUAD ...................... 34 PROSTIN E2 ................... 29 protriptyline hcl ................ 15 pulmosal ......................... 37 PULMOZYME ................. 38 PYLERA .......................... 28 pyrazinamide ................... 16 pyridostigmine bromide ... 16 pyridostigmine bromide er16 pyrimethamine ................ 17 Q QUADRACEL .................. 34 quetiapine fumarate ........ 18 quetiapine fumarate er .... 18 quinapril hcl ..................... 21 quinapril-

hydrochlorothiazide ..... 21 quinidine gluconate er ..... 21 quinidine sulfate .............. 21 R rabeprazole sodium ......... 28 raloxifene hcl ................... 29 ramipril ............................ 21 rasagiline mesylate ......... 17 RASUVO ......................... 33

48

REBIF.............................. 22 REBIF REBIDOSE .......... 22 REBIF REBIDOSE

TITRATION PACK ....... 22 REBIF TITRATION PACK22 reclipsen .......................... 32 RECOMBIVAX HB........... 34 RECTIV ........................... 21 RELENZA DISKHALER ... 18 relexxii ............................. 22 RELISTOR ...................... 28 RESTASIS ...................... 36 RESTASIS MULTIDOSE . 36 RETIN-A .......................... 24 RETIN-A MICRO GEL 0.04

%, 0.1 % ...................... 24 RETIN-A MICRO PUMP .. 24 REVLIMID ....................... 16 REYATAZ ........................ 18 ribavirin ............................ 18 RIDAURA ........................ 33 rifabutin ........................... 16 rifampin ........................... 16 riluzole ............................. 22 rimantadine hcl ................ 19 RIOMET .......................... 25 risedronate sodium .......... 34 RISPERDAL CONSTA .... 18 risperidone ...................... 18 ritonavir ........................... 19 rivastigmine tartrate ......... 14 rizatriptan benzoate ......... 16 ropinirole hcl .................... 17 rosadan ........................... 24 rosuvastatin calcium ........ 21 ROTARIX ........................ 34 ROTATEQ ....................... 34 roweepra ......................... 14 roweepra xr ..................... 14 RYDAPT .......................... 16 ryvent .............................. 37 S salsalate .......................... 11 SANDOSTATIN LAR

DEPOT ........................ 30 SANTYL .......................... 24 SECONAL ....................... 38 selegiline hcl .................... 17 selenium sulfide ............... 24 SELZENTRY ................... 19 SEREVENT DISKUS ....... 38 sertraline hcl .................... 15 sevelamer carbonate ....... 29 sevelamer hcl .................. 29 sharobel .......................... 32

SHINGRIX ....................... 34 sildenafil citrate ............... 38 silver sulfadiazine ............ 13 simvastatin ...................... 21 sirolimus .......................... 33 SIVEXTRO ...................... 13 SKYLA ............................ 32 sod citrate-citric acid ........ 27 sodium chloride ......... 27, 37 sodium chloride (pf) ......... 27 sodium fluoride ................ 27 sodium polystyrene

sulfonate ...................... 27 sodium sulfacetamide ...... 24 SOFOSBUVIR-

VELPATASVIR ............ 19 solifenacin succinate ....... 29 SOLU-CORTEF .............. 29 sorine .............................. 21 sotalol hcl ........................ 21 sotalol hcl (af) .................. 21 SPIRIVA HANDIHALER .. 38 SPIRIVA RESPIMAT ....... 38 spironolactone ................. 21 spironolactone-hctz ......... 22 sprintec 28....................... 32 SPRYCEL ....................... 16 sps .................................. 27 sronyx ............................. 32 ssd .................................. 13 SSKI ................................ 37 stavudine ......................... 19 STELARA ........................ 33 STIMATE ........................ 30 STIOLTO RESPIMAT ...... 38 STIVARGA ...................... 16 STRIBILD ........................ 19 STRIVERDI RESPIMAT .. 38 subvenite ......................... 14 sucralfate ........................ 28 sulfacetamide sodium ...... 35 sulfacetamide sodium

(acne) .......................... 24 sulfacetamide sodium-sulfur

.................................... 24 sulfacetamide-prednisolone

.................................... 36 sulfacetamide-sulfur in urea

.................................... 24 sulfamethoxazole-

trimethoprim ................ 13 sulfasalazine ................... 34 sulfatrim pediatric ............ 13 sulindac ........................... 11 sumatriptan ..................... 16

sumatriptan succinate ..... 16 sumatriptan succinate refill

.................................... 16 SUPRAX ......................... 13 SURESTEP PRO HIGH

GLUCOSE................... 26 SURESTEP PRO LOW

GLUCOSE................... 26 SURESTEP PRO NORMAL

GLUCOSE................... 26 SURVANTA .................... 37 SUTENT ......................... 16 syeda .............................. 32 SYMFI ............................. 19 SYMFI LO ....................... 19 SYMTUZA ....................... 19 synalar ............................ 25 T TABLOID......................... 16 tacrolimus.................. 25, 33 TAFINLAR ....................... 16 TAGRISSO ..................... 16 TAMIFLU......................... 19 tamoxifen citrate .............. 17 tamsulosin hcl ................. 29 tarina fe 1/20 ................... 32 tarina fe 1/20 eq .............. 32 taron-crystals .................. 27 tazarotene ....................... 25 tazicef ............................. 13 TAZORAC ....................... 25 TDVAX ............................ 34 temazepam ..................... 38 TEMIXYS ........................ 19 temozolomide .................. 17 TENIVAC ........................ 34 tenofovir disoproxil fumarate

.................................... 19 terazosin hcl .................... 29 terbinafine hcl .................. 15 terbutaline sulfate ............ 38 testosterone .................... 29 testosterone cypionate .... 29 TESTOSTERONE

CYPIONATE ............... 29 testosterone enanthate.... 29 TETANUS-DIPHTHERIA

TOXOIDS TD .............. 34 THALOMID ..................... 17 theophylline ..................... 38 theophylline er ................. 38 thiothixene ....................... 18 timolol maleate .......... 22, 36 TIVICAY .......................... 19 TIVICAY PD .................... 19

49

tizanidine hcl.................... 38 TOBRADEX..................... 36 tobramycin ................. 35, 38 tobramycin-dexamethasone

.................................... 36 TOBREX ......................... 35 tolbutamide ...................... 25 tolmetin sodium ............... 11 tolterodine tartrate ........... 29 tolterodine tartrate er ....... 29 topiramate ....................... 14 torsemide ........................ 22 tramadol hcl ir .................. 12 tramadol-acetaminophen . 12 trandolapril ...................... 22 tranexamic acid ............... 19 tranylcypromine sulfate .... 15 travoprost (bak free) ........ 36 trazodone hcl ................... 15 TREMFYA ....................... 33 tretinoin ..................... 17, 25 tretinoin microsphere ....... 25 tretinoin microsphere pump

.................................... 25 tri femynor ....................... 32 triamcinolone acetonide .. 22,

25 triamterene ...................... 22 triamterene-hctz .............. 22 triazolam .......................... 19 tricitrates .......................... 27 triderm ............................. 25 tri-estarylla ....................... 32 trifluoperazine hcl ............ 18 trifluridine ......................... 35 trihexyphenidyl hcl ........... 17 tri-linyah ........................... 32 tri-lo-estarylla ................... 32 tri-lo-marzia ..................... 32 tri-lo-mili ........................... 32 tri-lo-sprintec.................... 32 trilyte ............................... 28 trimethoprim .................... 13 tri-mili............................... 32 tri-previfem ...................... 32 tri-sprintec ....................... 32 TRIUMEQ ........................ 19 trivora (28) ....................... 32 tri-vylibra .......................... 32 tri-vylibra lo ...................... 32 trospium chloride ............. 29 trospium chloride er ......... 29 TRUE METRIX LEVEL 1 . 26 TRUE METRIX LEVEL 2 . 26

TRUE METRIX LEVEL 3 . 26 TRUMENBA .................... 34 TRUVADA ....................... 19 tulana .............................. 32 TYBOST .......................... 19 TYKERB .......................... 17 TYVASO ......................... 38 TYVASO REFILL............. 38 TYVASO STARTER ........ 38 U UNISTRIP CONTROL ..... 26 UPTRAVI ........................ 38 urea ................................. 25 uremez-40 ....................... 25 ursodiol ........................... 28 V valacyclovir hcl ................ 19 valganciclovir hcl ............. 19 valproic acid .................... 14 valsartan ......................... 22 valsartan-

hydrochlorothiazide ..... 22 VALTOCO 10 MG DOSE 14 VALTOCO 15 MG DOSE 14 VALTOCO 20 MG DOSE 14 VALTOCO 5 MG DOSE .. 14 vancomycin hcl ................ 13 vandazole ........................ 13 VAQTA ............................ 34 VARIVAX ........................ 34 VECTICAL....................... 25 velivet .............................. 32 VENCLEXTA ................... 17 VENCLEXTA STARTING

PACK .......................... 17 venlafaxine hcl ................ 15 venlafaxine hcl er ............ 15 VENTAVIS ...................... 38 VENTOLIN HFA .............. 38 verapamil hcl ................... 22 verapamil hcl er ............... 22 vienva .............................. 32 VIGAMOX ....................... 36 VIRACEPT ...................... 19 VIREAD ........................... 19 virt-phos 250 neutral ........ 28 vitamin d (ergocalciferol) . 28 vitamin k1 ........................ 28 VIVAGUARD INO

CONTROL SOLUTION 26 VIVAGUARD LANCING

DEVICE ....................... 26 VIVITROL ........................ 12 voriconazole .................... 15

VOSEVI .......................... 19 VOTRIENT ...................... 17 vyfemla ........................... 32 vylibra ............................. 32 W warfarin sodium ............... 13 wera ................................ 32 WIDE-SEAL DIAPHRAGM

60 ................................ 35 WIDE-SEAL DIAPHRAGM







95 ................................ 35 38 X XARELTO ....................... 13 XARELTO STARTER PACK

.................................... 14 XELJANZ ........................ 33 XELJANZ XR .................. 33 XIIDRA ............................ 36 XTANDI ........................... 17 xulane ............................. 32 Y yuvafem .......................... 32 Z zaleplon .......................... 38 zarah ............................... 32 ZARXIO .......................... 19 ZELBORAF ..................... 17 zenatane ......................... 25 ZENPEP ......................... 28 zenzedi ........................... 22 zidovudine ....................... 19 ziprasidone hcl ................ 18 zolmitriptan ...................... 16 zolpidem tartrate ............. 38 zonisamide ...................... 14 zovia 1/35e (28) .............. 32 zumandimine ................... 32 ZYDELIG......................... 17 ZYPREXA RELPREVV ... 18 ZYTIGA ........................... 17

Appendix A: OVER-THE-COUNTER (OTC) MEDICATION

BENEFIT LIST The medications listed below are covered only for members who have

purchased a special benefit offered through Kaiser Permanente Washington called the Over-the-Counter Pharmacy Benefit.

***Typically, if a generic product is available for a drug, the Brand Name product may not be covered.***

Generic Product Name ***Brand Name*** Forms ALLERGY COUGH AND COLD

Antihistamines CHLORPHENIRAMINE CHLOR-TRIMETON® Tab, Liquid CLEMASTINE TAVIST® Tab, Liquid DIPHENHYDRAMINE BENADRYL® Cap, Liquid LORATADINE CLARITIN® Tab, Liquid

Decongestants OXYMETAZOLINE NASAL SPRAY AFRIN® Spray PHENYLEPHRINE NASAL SPRAY NEO-SYNEPHRINE® Spray PSEUDOEPHEDRINE SUDAFED® Tablet

Antihistamine/Decongestant Combinations TRIPROLIDINE/PSEUDOEPHEDRINE ACTIFED® Tablet BROMPHENIRAMINE/PSEUDOEPHEDRINE DIMETAPP® Liquid

Expectorants/Cough Agents GUAIFENESIN ROBITUSSIN® Liquid GUAIFENESIN/DEXTROMETHORPHAN ROBITUSSIN-DM® Liquid DEXTROMETHORPHAN ROBITUSSIN COUGH® Liquid DEXTROMETHORPHAN EXTEND RELEASE DELSYM® Liquid

AUTONOMICS AND CNS Analgesics, Miscellaneous

ACETAMINOPHEN TYLENOL® Tab, Chew, Supp, Liquid

Non-Steroidal Anti-Inflammatories IBUPROFEN MOTRIN®, ADVIL® Tab, Liquid

Salicylates ASPIRIN BAYER®, ASCRIPTIN® Tab, Supp

DERMATOLOGICAL/ TOPICAL AGENTS Acne/Psoriasis, Topical

BENZOYL PEROXIDE 5%, 10% BENZAC® Gel, Wash, Lotion COAL TAR Solution

Anesthetic Agents, Topical BENZOCAINE HURRICAINE® Gel PRAMOXINE ANUSOL® Ointment

Antifungals, Topical

CLOTRIMAZOLE 1% LOTRIMIN® Cream, Solution MICONAZOLE 2% MICATIN®, DESENEX® Cream, Powder

Anti-Infectives, Topical BACITRACIN BACIGUENT® Ointment BACITRACIN, POLYMIXIN B POLYSPORIN® Ointment BACITRACIN, NEOMYCIN, POLYMYXIN B NEOSPORIN® Ointment OATMEAL, COLLOIDAL AVEENO® BATH POWDER Powder

Anti-Itch, Topical CALAMINE CALAMINE Lotion CAMPHOR/ MENTHOL SARNA® Lotion CAPSAICIN ZOSTRIX®, ZOSTRIX-HP® Cream

Anti-Virals, Topical DOCOSANOL 10% ABREVA® Cream

Corticosteroids, Topical, Low Potency HYDROCORTISONE 0.5%, 1% CORTIZONE® Cream, Oint,

Lotion Keratolytics

SALICYLIC ACID 17% DUOFILM® Liquid SALICYLIC ACID 40% MEDIPLAST® Plaster UREA 10%, 20% UREACIN®, CARMOL® 20 Cream, Lotion

Dermatologics, Miscellaneous ALUMINUM ACETATE BUROWS® Liquid AMMONIUM LACTATE 12% AMLACTIN® Cream, Lotion HYDROGEN PEROXIDE HYDROGEN PEROXIDE Liquid VITAMIN A&D A AND D® OINTMENT Ointment WITCH HAZEL TUCKS® Solution, Pads ZINC OXIDE, COD LIVER OIL & LANOLIN DESITIN® Oint, Paste ZINC OXIDE 20% BALMEX® Ointment

Scabicides PERMETHRIN NIX® Rinse PYRETHRINS, PIPERONYL BUTOXIDE RID®, R & C® Shampoo

Skin Protectants LANOLIN, HYDROUS LANOLIN Ointment PETROLATUM, GLYCERIN,BENZYL ALC MOISTUREL® Lotion PETROLATUM, MINERAL OIL/WAX, ETC. AQUAPHOR®, EUCERIN® Ointment

EYE, EAR, NOSE AND THROAT Otics

CARBAMIDE DEBROX® Solution

Nasal Agents CROMOLYN NASALCROM® Spray

Ophthalmics ARTIFICIAL TEARS HYOPTEARS®, PURALUBE® Drops, Ointment CARBOXYMETHYLCELLULOSE CELLUVISC®, REFRESH PLUS® Drops HYDROXYPROPYL METHYLCELLULOSE TEARS NATURALE II® Drops KETOTIFEN FUMARATE 0.025% ZADITOR® Drops NAPHAZOLINE/ PHENIRAMINE OPCON-A® Drops POLYVINYL ALCOHOL, POVIDONE REFRESH® PF Drops SODIUM CHLORIDE 5% MURO®-128 Drops, Ointment

Throat and Mouth Agents

CETYLPYRIDINIUM CL, BENZYL ALCOHOL CEPACOL® Lozenge

GASTROINTESTINAL AGENTS Antacids/Adsorbents

CHARCOAL, ACTIVATED W/O SORBITOL ACTIDOSE Liquid

ALUMINUM/ MAGNESIUM MAALOX® Tablet, Liquid

ALUMINUM/ MAGNESIUM/ SIMETHICONE MINTOX® PLUS, MI-ACID Tablet, Liquid

ALUM/ MAGN/TRISILIS/ALG AC/SOD BICAR GAVISCON®, GENATON Tablet

ALUMINUM HYDROXIDE ALTERNAGEL®, AMPHOGEL® Liquid

MAGNESIUM OXIDE MAG-OX® Tablet

Antidiarrheals BISMUTH SUBSALICYLATE PEPTO BISMOL® Tablet, Liquid LOPERAMIDE IMMODIUM® Tablet, Liquid

Antinauseants DIMENHYDRINATE DRAMAMINE® Tablet, Liquid MECLIZINE BONINE®, ANTIVERT® Tablet

Laxatives/Cathartics BISACODYL DULCOLAX® Tablet, Supp DOCUSATE SODIUM COLACE® Tablet, Liquid GLYCERIN GLYCERIN Liquid, Supp MAGNESIUM CITRATE CITRO-MAG® Liquid MILK OF MAGNESIA MILK OF MAGNESIA Liquid MINERAL OIL FLEET® MINERAL OIL Liquid PSYLLIUM METAMUCIL® Powder POLYETHYLENE GLYCOL MIRALAX® Powder SENNA SENOKOT® Tablet, Liquid

Histamine H2 Blockers RANITIDINE ZANTAC® Tablet

Gastrointestinal, Miscellaneous SIMETHICONE MYLICON® Tablet LACTOBACILLUS BACID® Capsule SHARK LIVER OIL, COCOA BUTTER, PHENYLEPHRINE

HEMORRHOIDAL SUPPOSITORIES

Supp

Proton Pump Inhibitors OMEPRAZOLE PRILOSEC OTC Tablet

GENITOURINARY Overactive bladder treatment

OXYBUTYNIN OXYTROL® PATCH Patch

HORMONES Contraceptive

LEVONORGESTROL PLAN B ONE STEP Tablet

LIPID LOWERING AGENTS Non-Prescription Agents

NIACIN NIACIN Tablet NIACIN EXTENDED-RELEASE SLO-NIACIN® Tablet FISH OILS SEA-OMEGA®-50 Capsule

NUTRITIONALS AND SUPPLEMENTS Vitamins/Dietary Supplements

ACETYLCYSTEINE NAC® Capsule

ASCORBIC ACID (VIT C) Tablet CYANOCOBALAMIN (VIT B12) Tablet CHOLECALCIFEROL (VIT D) Tablet FOLIC ACID Tablet NIACINAMIDE (VIT B3) Tablet PRENATAL VITAMINS W/ FOLIC ACID Tablet PYRIDOXINE (VIT B6) Tablet THIAMINE (VIT B1) Tablet VITAMIN A Capsule VITAMIN B COMPLEX Tablet VITAMIN B COMPLEX W/C Tablet VITAMIN E Capsule

Electrolytes, Iron, & Minerals CALCIUM CARBONATE TUMS® Chew tabs, Liquid CALCIUM CITRATE CAL-CITRATE® Tablet CALCIUM CITRATE w/VITAMIN D CITRACAL® Tablet ELECTROLYTE ORAL PEDIALYTE® Liquid FERROUS GLUCONATE FERGON® Tablet FERROUS SULFATE FER-IN-SOL® Tablet, Liquid MAGNESIUM OXIDE URO-MAG® Capsule SODIUM BICARBONATE Tablet ZINC SULFATE ZINCATE® Capsule

VAGINAL PREPARATIONS Vaginal Anti-Infectives

POVIDONE-IODINE BETADINE® Douche

Vaginal Antifungals CLOTRIMAZOLE MYCELEX®-7, GYNE-LOTRIMIN®-

3 Cream, Vag tabs

MICONAZOLE MONISTAT® Cream

Miscellaneous LUBRICATING JELLY K-Y JELLY® JELLY

Kaiser Permanente Nondiscrimination Notice and Language Access Services

KAISER PERMANENTE NONDISCRIMINATION NOTICE

Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (“Kaiser Permanente”) comply with applicable federal civil rights laws and do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or any other basis protected by applicable federal, state, or local law. We also:

Provide free aids and services to people with disabilities to help ensure effective communication, such as:

• Qualified sign language interpreters• Written information in other formats (large print, audio, and accessible electronic formats)• Assistive devices (magnifiers, Pocket Talkers, and other aids)

Provide free language services to people whose primary language is not English, such as:

• Qualified interpreters• Information written in other languages

If you need these services, contact Kaiser Permanente.

If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance. Please call us if you need help submitting a grievance. The Civil Rights Coordinator will be notified of all grievances related to discrimination.

Kaiser Permanente Phone: 206-630-4636 Toll-free: 1-888-901-4636

TTY Washington Relay Service: 1-800-833-6388 or 711 TTY Idaho Relay Service: 1-800-377-3529 or 711

Electronically: kp.org/wa/feedback

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

For Medicare Advantage Plans Only: Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.

© 2018 Kaiser Foundation Health Plan of Washington H5050_XB0001444_56_18 accepted2018-XB-7_ACA_Notice_Taglines

http://www.hhs.gov/ocr/office/file/index.html

LANGUAGE ACCESS SERVICES

English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711).

Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

中文 (Chinese)：注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-901-4636 (TTY: 1-800-833-6388 / 711)。

Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

한국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오.

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).

ភាសាខ្មែរ (Khmer)៖ របយ័ត៖ េ េបើសិនអកនិខ្យមរ, េ សជំនួខ្យផក េ យមិនគិតល គឺចនសំប់បំេ រអក។ ចូរទូ រស័ព 1-888-901-4636 (TTY: 1-800-833-6388 / 711)។日本語 (Japanese): 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-888-901-4636 (TTY: 1-800-833-6388 / 711) まで、お電話にてご連絡ください。

አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711).

Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ।

تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا :ملحوظة في ومعلومات مساعدة على الحصول حق لديكم :(Arabic) العربية: (6388-833-800-1 / 711) .والبكم الصم هاتف رقم 4636-901-888-1 برقم اتصل .بالمجان لك

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ,ແມ່ນມີ ພ້ອມ ໃຫ້ທ່ານ. ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711).

Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711).

Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711).

می فراهم شما برای رايگان بصورت زبانی تسهيالت کنيد، می گفتگو فارسی زبان به اگر :توجه :(Farsi) فارسی.بگيريد تماس (TTY: 1-800-833-6388 / 711) 4636-901-888-1 با .باشد

XB0001444-56-18

20 drug formulary - kaiser permanente...kaiser permanente will only cover fda-approved drugs used...

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