2020 formulary - kaiser permanente - community providers
TRANSCRIPT
2020 FormularyKaiser Permanente a TRICARE® Prime Option
To search for a specific medication or condition:
• Press “Ctrl” or “CMD” and “F” on your keyboard at the same time.
• In the search window that pops up, enter the text that you wish to search for and press “Enter”.
• Press enter again to move to the next result.
• You can also find an alphabetic list of medication starting on page 86.
For questions about specific drug costs, call us at 1-877-904-0015.
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies.
All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 1
What is the Kaiser Permanente, a TRICARE®
Prime Option Formulary?
A formulary is a list of drugs determined to
be safe and effective for our members by
our Pharmacy and Therapeutics
committee. Use of the formulary enables
Kaiser Permanente to provide optimal
care to you and your family at
reasonable costs. Kaiser Permanente
continually updates the formulary
throughout the year based on new
medical evidence, considering the
recommendations of appropriate
physician experts. Our physicians and
pharmacists work closely together to
ensure that our formulary meets your
needs.
Does the formulary ever change?
Yes, Kaiser Permanente periodically
updates the formulary based on new
medical evidence, considering the
recommendations of appropriate
physician experts and notifies our doctors,
pharmacists, and other clinicians about
any changes. If a change in the
formulary affects any of your prescriptions,
your doctor or pharmacist will let you
know.
The enclosed formulary is effective as of
November 11, 2020 and represents the most
commonly prescribed medications.
How do I use the Formulary?
There is an easy way to find your drug
within the formulary:
To search for a specific medication or
condition, press the ‘CTRL’ key and the ‘F’
key on your keyboard at the same time.
In the search window that pops up, enter
the text you want to search for and press
‘Enter.’ Press ‘Enter’ again to move to the
next result.
Medical Condition
The drugs on this formulary are grouped
into categories depending on the type of
medical condition that they are used to
treat. For example, drugs used to treat a
heart condition are listed under the
category, “Cardiovascular Drugs.” If you
know what your drug is used for, simply
look for the category name in the list.
Then look under the category name for
your drug.
Alphabetical Listing
If you are not sure what category to look
under, you can look for the drug in the
Index. The Index provides an alphabetical
list of all the drugs included in this
document. Both brand-name drugs and
generic drugs are listed in the Index. Look
in the Index and find your drug. Next to
the drug, you will see the page number
where you can find coverage
information. Go to the page listed in the
Index and find the name of your drug on
the list.
What are generic drugs?
Kaiser Permanente covers both brand-
name drugs and generic drugs.
Generic drugs are produced and sold
under their chemical names after the
patent of the brand name drug expires.
Although the price is lower, the quality
and effectiveness of generic drugs is the
same as brand name drugs. The Federal
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies.
All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 2
Food and Drug Administration (FDA)
requires that generic drugs contain the
same active ingredients in the same
amount as the brand name drug.
Generic drugs are listed in lower-case
italics (e.g., amoxicillin) within the
formulary. Brand-name drugs are
capitalized within the formulary (e.g.,
FLOVENT).
What are Formulary Brand name drugs?
Formulary Brand name drugs are drugs
that are produced and sold under the
original manufacturer’s name.
What are Non-Formulary Brand drugs?
Non-Formulary Brand drugs are drugs that
are not included on the plan's list
of preferred prescription drugs.
Because all drug product strengths and
package sizes of a formulary drug will be
included in your plan’s benefits, just note
the drug cost share coverage amount
will be based on the specific tier of the
formulary, check with your Kaiser
Permanente pharmacist for clarification, if
needed.
How much will I pay for Covered Drugs?
What you pay for covered drugs is
determined by the outpatient prescription
drug benefit outlined in your Evidence of
Coverage. Kaiser Permanente, a TRICARE
Prime Option plan has a three-tier open
formulary benefit.
Open formulary benefits have a generic
cost sharing requirement. This means that
if you choose to fill a brand name drug
when a generic is available, then in
addition to your standard cost share, you
will also pay the difference in cost
between the brand name and generic
drug.
Generics drugs are those covered at the
lowest cost share defined as Tier 1
coverage amount. Formulary brand
drugs are those brands which will be
covered at your formulary brand cost
share defined as Tier 2 coverage amount.
Non-formulary brands drugs are covered
at the non-formulary cost share defined
as Tier 3 coverage amount.
Coverage for prescription drugs is limited
to drugs for which a prescription is
required by law and those that are listed
on the Kaiser Permanente, a TRICARE
Prime Option drug formulary. Certain
diabetic supplies do not require a
prescription but must still be listed in our
formulary in order to be covered under
the benefit.
Each prescription refill is provided on the
same basis as the original prescription.
Cost shares are applied on a per
prescription basis, for up to the lesser of
the dispensing amount listed in the
“Schedule of Benefits” or the standard
prescription amount.
The standard prescription amount for the
following items is:
• Migraine medications ― the smallest
package size commercially available
• Ophthalmic and otic medications ―
the smallest package size
commercially available
Kaiser Permanente, a TRICARE Prime Option Formulary is for medications covered at Kaiser Permanente pharmacies and Network Pharmacies.
All drug product strengths and package sizes of a medication may not be included on the same tier on the formulary. Check with your Kaiser Permanente
pharmacist for clarification, if needed. TRICARE is a registered trademark of the Department of Defense, DHA. All rights reserved.
Kaiser Permanente, a TRICARE Prime Option Formulary 3
• Oral and nasal inhalers ― the smallest
standard package size
Are there any other restrictions on coverage?
Some covered drugs may have
additional requirements or limits on
coverage. These requirements and limits
may include:
• Quantity Limits (QL): For certain drugs,
Kaiser Permanente limits the amount of
the drug that will be covered.
• Age Restriction (Age): For certain drugs,
Kaiser Permanente limits coverage
based on a designated age.
• Prior Authorization (PA): For certain drugs,
Kaiser Permanente requires review and
authorization prior to dispensing. Your
Provider must obtain this review and
authorization. The list of prescription
drugs requiring review and
authorization is subject to periodic
review and modification by our
Pharmacy and Therapeutics
Committee.
• Step Therapy (ST): For certain drugs,
Kaiser Permanente requires the use of
similar, alternative medications prior to
coverage.
You can find out if the drug has any
additional requirements or limits by
looking in the Restrictions Column on the
formulary list.
What if my drug is not on the Formulary?
Because all drug product strengths and
package sizes of a formulary drug may
not be included on the formulary, check
with your Kaiser Permanente pharmacist
for clarification, if needed.
For more information
For more detailed information about your
Kaiser Permanente, a TRICARE Prime
Option prescription drug coverage,
please review your Evidence of Coverage
and other plan materials.
If you have questions about Kaiser
Permanente, please call Member Services
at 1-833-642-5973 or 770-291-4430, Monday
through Friday 7:00 a.m. to 7 p.m. TTY/TDD
users should call 1-800-255-0056.
Or visit kp.org/tricare.
Kaiser Permanente, a TRICARE® Prime Option Formulary
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Antihistamine Drugs
Antihistamine Drugs
ST No 1 carbinoxamine maleate ARBINOXA Generic
No 1 cyproheptadine PERIACTIN Generic
No 1 chlorpheniramine, phenylephrine & pyrilamine
POLY HIST FORTE Generic
No 1 promethazine & phenylephrine PHENERGAN VC Generic
QL No 1 promethazine PHENERGAN Generic
Anti-infective Agents
Anthelmintics
No 2 albendazole ALBENZA Formulary Brand
No 1 ivermectin STROMECTOL Generic
PA, QL No 3 ivermectin (topical) SOOLANTRA Non-Formulary
Brand
ST Yes 1 praziquantel BILTRICIDE Generic
Anti-infectives, Miscellaneous
ST Yes 3 bismuth subcitrate & metronidazole
PYLERA Non-Formulary
Brand
Yes 3 metronidazole, tetracycline & bismuth subsalicylate
HELIDAC Non-Formulary
Brand
Yes 3 benznidazole benznidazole Non-Formulary
Brand
Antibacterials
PA No 3 amikacin liposomal inhalation ARIKAYCE Non-Formulary
Brand
No 1 amoxicillin AMOXIL Generic
No 1 amoxicillin & clavulanate potassium
AUGMENTIN Generic
No 1 amoxicillin & clavulanate potassium extended-release
AUGMENTIN XR Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 ampicillin sodium AMPICILLIN Generic
Yes 1 azithromycin ZITHROMAX Generic
No 1 cefaclor CECLOR Generic
No 1 cefadroxil DURICEF Generic
No 1 cefdinir OMNICEF Generic
ST Yes 1 cefditoren SPECTRACEF Generic
No 3 cefixime SUPRAX Non-Formulary
Brand
No 1 cefixime solution SUPRAX Generic
No 1 cefpodoxime VANTIN Generic
No 1 cefprozil CEFZIL Generic
No 1 cefuroxime axetil CEFTIN Generic
No 1 cephalexin KEFLEX Generic
No 1 ciprofloxacin CIPRO Generic
No 1 clarithromycin BIAXIN Generic
No 1 clarithromycin extended-release BIAXIN XL Generic
No 1 clindamycin hcl CLEOCIN HCL Generic
No 1 clindamycin palmitate CLEOCIN PEDIATRIC Generic
ST Yes 3 delafloxacin BEXDELA Non-Formulary
Brand
No 1 demeclocycline DECLOMYCIN Generic
No 1 dicloxacillin DYNAPEN Generic
Yes 3 doxycycline ORACEA Non-Formulary
Brand
Yes 1 doxycycline hyclate PERIOSTAT Generic
ST Yes 3 doxycycline hyclate DORYX Non-Formulary
Brand
Yes 1 doxycycline monohydrate ADOXA Generic
Yes 1 doxycycline monohydrate MONODOX Generic
No 1 erythromycin & sulfisoxazole E.S.P Generic
No 1 erythromycin base ERYTHROMYCIN Generic
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 erythromycin base delayed-release
ERY-TAB Generic
No 1 erythromycin ethylsuccinate E.E.S. Generic
No 3 erythromycin ethylsuccinate ERYPED Non-Formulary
Brand
No 3 erythromycin sterate ERYTHROCIN Non-Formulary
Brand
ST Yes 3 fidaxomicin DIFICID Non-Formulary
Brand
No 1 gentamicin sulfate GARAMYCIN Generic
Yes 3 lefamulin XENLETA Non-Formulary
Brand
No 1 levofloxacin LEVAQUIN Generic
No 1 linezolid ZYVOX Generic
Yes 1 minocycline DYNACIN Generic
Yes 1 minocycline MINOCIN Generic
Yes 1 minocycline SOLODYN Generic
ST No 1 moxifloxacin AVELOX Generic
No 1 neomycin sulfate MYCIFRADIN Generic
Yes 3 norfloxacin NOROXIN Non-Formulary
Brand
No 1 penicillin v potassium PEN-VK Generic
ST Yes 3 omadacycline NUZYRA Non-Formulary
Brand
ST, QL (200 mg only)
Yes 3 rifaximin XIFAXAN Non-Formulary
Brand
No 1 sulfadiazine SULFADIAZINE Generic
Yes 1 sulfamethoxazole & trimethoprim BACTRIM DS Generic
Yes 1 sulfamethoxazole & trimethoprim SEPTRA Generic
No 1 sulfasalazine AZULFIDINE Generic
ST Yes 3 tedizolid SIVEXTRO Non-Formulary
Brand
ST Yes 3 telithromycin KETEK Non-Formulary
Brand
Yes 1 tetracycline TETRACYCLINE Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 3 tobramycin inhalation powder TOBI PODHALER Non-Formulary
Brand
No 1 tobramycin inhalation solution TOBI Generic
No 1 Vancomycin capsule VANCOCIN Generic
Antifungals
PA, QL Yes 3 efinaconazole JUBLIA Non-Formulary
Brand
QL No 1 fluconazole DIFLUCAN Generic
No 1 flucytosine ANCOBON Generic
No 1 griseofulvin microsize GRIFULVIN V Generic
No 1 griseofulvin ultramicrosize GRIS-PEG Generic
Yes 3 isavuconazonium CRESEMBA Non-Formulary
Brand
No 1 itraconazole SPORANOX Generic
No 1 ketoconazole NIZORAL Generic
No 3 luliconazole LUZU Non-Formulary
Brand
No 1 nystatin MYCOSTATIN Generic
PA No 3 posaconazole NOXAFIL Non-Formulary
Brand
PA Yes 3 tavaborole KERYDIN Non-Formulary
Brand
No 1 terbinafine LAMISIL Generic
No 1 voriconazole tablet VFEND Generic
ST No 3 voriconazole suspension VFEND Non-Formulary
Brand
Antimycobacterials
Yes 1 cycloserine SEROMYCIN Generic
Yes 1 dapsone AVLOSULFON Generic
Yes 1 ethambutol MYAMBUTOL Generic
ST Yes 3 ethionamide TRECATOR Non-Formulary
Brand
Yes 1 isoniazid NYDRAZID Generic
ST Yes 1 pretomanid PRETOMANID Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 pyrazinamide PYRAZINAMIDE Generic
Yes 1 rifabutin MYCOBUTIN Generic
Yes 1 rifampin RIFADIN Generic
Yes 3 rifapentine PRIFTIN Non-Formulary
Brand
Antiprotozoals
ST Yes 3 artemether & lumefantrine COARTEM Non-Formulary
Brand
No 1 atovaquone MEPRON Generic
ST No 1 atovaquone & proguanil MALARONE Generic
ST No 1 chloroquine phosphate ARALEN Generic
Yes 1 hydroxychloroquine sulfate PLAQUENIL Generic
ST No 1 mefloquine LARIAM Generic
No 1 metronidazole FLAGYL Generic
No 3 metronidazole extended-release FLAGYL ER Non-Formulary
Brand
PA Yes 3 miltefosine IMPAVIDO Non-Formulary
Brand
Yes 3 nitazoxanide ALINIA Non-Formulary
Brand
No 1 paromomycin sulfate HUMATIN Generic
ST No 3 pentamidine NEBUPENT Non-Formulary
Brand
No 2 primaquine phosphate PRIMAQUINE Formulary Brand
PA No 3 pyrimethamine DARAPRIM Non-Formulary
Brand
ST No 1 quinine sulfate QUALAQUIN Generic
ST Yes 3 secnidazole SOLOSEC Non-Formulary
Brand
Antiviral
QL Yes 1 abacavir sulfate & lamivudine EPZICOM Generic
QL No 2 abacavir sulfate solution ZIAGEN Formulary Brand
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL Yes 1 abacavir sulfate tablet ZIAGEN Generic
Yes 3 abacavir, dolutegravir & lamivudine
TRIUMEQ Non-Formulary
Brand
QL Yes 1 abacavir, lamivudine & zidovudine
TRIZIVIR Generic
Yes 1 acyclovir ZOVIRAX Generic
QL,ST No 1 adefovir dipivoxil HEPSERA Generic
Yes 3 atazanavir & cobicistat EVOTAZ Non-Formulary
Brand
QL Yes 2 atazanavir sulfate 150 mg REYATAZ Formulary Brand
QL Yes 1 atazanavir sulfate 200 mg, 300 mg
REYATAZ Generic
QL Yes 2 bictegravir & emtricitabine & tenofovir
BIKTARVY Formulary Brand
QL Yes 3 boceprevir VICTRELIS Non-Formulary
Brand
PA Yes 3 daclatasvir DAKLINZA Non-Formulary
Brand
Yes 2 darunavir & cobicistat PREZCOBIX Formulary Brand
QL Yes 2 darunavir ethanolate PREZISTA Formulary Brand
QL Yes 2 darunavir/cobicistat/FTC/tenofovir SYMTUZA Formulary Brand
QL Yes 2 delavirdine mesylate RESCRIPTOR Formulary Brand
QL Yes 1 didanosine VIDEX EC Generic
QL Yes 2 didanosine solution VIDEX Formulary Brand
Yes 2 dolutegravir TIVICAY Formulary Brand
QL Yes 3 dolutegravir & rilpivirine JULUCA Non-Formulary
Brand
QL Yes 2 dolutegravir & lamivudine DOVATO Formulary Brand
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 3 doravirine PIFELTRO Non-Formulary
Brand
QL Yes 3 doravirine, lamivudine, tenofovir DELSTRIGO Non-Formulary
Brand
QL Yes 1 efavirenz 600 mg SUSTIVA Generic
QL Yes 3 efavirenz, emtricitabine & tenofovir
ATRIPLA Non-Formulary
Brand
QL Yes 2 efavirenz 600 mg, lamivudine & tenofvir
SYMFI Formulary Brand
QL Yes 3 efavirenz 400 mg, lamivudine & tenofvir
SYMFI LO Non-Formulary
Brand
PA Yes 3 elbasvir & grazoprevir ZEPATIER Non-Formulary
Brand
QL Yes 3 elvitegravir, cobicistat, emtricitabine, & tenofovir
STRIBILD Non-Formulary
Brand
QL Yes 2 elvitegravir, cobicistat, emtricitabine, & tenofovir
GENVOYA Formulary Brand
QL Yes 2 emtricitabine EMTRIVA Formulary Brand
QL Yes 2 emtricitabine & tenofovir TRUVADA Formulary Brand
QL Yes 2 emtricitabine & tenofovir DESCOVY Formulary Brand
QL Yes 3 emtricitabine, rilpivirine, & tenofovir
COMPLERA Non-Formulary
Brand
QL Yes 2 emtricitabine, rilpivirine, & tenofovir
ODEFSEY Formulary Brand
QL Yes 2 enfuvirtide FUZEON Formulary Brand
QL Yes 1 entecavir BARACLUDE Generic
QL Yes 2 etravirine INTELENCE Formulary Brand
ST Yes 1 famciclovir FAMVIR Generic
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL Yes 2 fosamprenavir calcium LEXIVA Formulary Brand
Yes 1 ganciclovir CYTOVENE Generic
QL, PA Yes 3 glecaprevir & pibrentasvir MAVYRET Non-Formulary
Brand
QL Yes 2 indinavir sulfate CRIXIVAN Formulary Brand
Yes 3 interferon alfacon-1 INFERGEN Non-Formulary
Brand
QL, ST Yes 3 lamivudine EPIVIR HBV Non-Formulary
Brand
QL Yes 1 lamivudine EPIVIR Generic
QL Yes 2 Lamivudine & tenofovir CIMDUO Formulary Brand
QL Yes 1 lamivudine & zidovudine COMBIVIR Generic
ST Yes 3 letermovir PREVYMIS Non-Formulary
Brand
QL, PA No 3 ledipasvir & sofosbuvir HARVONI Non-Formulary
Brand
QL Yes 2 lopinavir & ritonavir KALETRA Formulary Brand
QL Yes 2 maraviroc SELZENTRY Formulary Brand
QL Yes 2 nelfinavir mesylate VIRACEPT Formulary Brand
QL Yes 1 nevirapine solution VIRAMUNE Generic
QL Yes 1 nevirapine tablet VIRAMUNE Generic
PA Yes 3 ombitasvir, paritaprevir & ritonavir TECHNIVIE Non-Formulary
Brand
QL, PA Yes 3 ombitasvir, paritaprevir, ritonavir, & dasabuvir
VIEKIRA Non-Formulary
Brand
QL, PA No 2 sofosbuvir, velpatasvir, voxilaprevir
VOSEVI Formulary Brand
QL Yes 1 oseltamivir phosphate TAMIFLU Generic
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 3 palivizumab SYNAGIS Non-Formulary
Brand
QL Yes 2 peginterferon alfa-2a PEGASYS Formulary Brand
Yes 2 peginterferon-alfa 2b PEG-INTRON Formulary Brand
QL Yes 2 raltegravir ISENTRESS Formulary Brand
QL Yes 2 raltegravir (600mg) ISENTRESS HD Formulary Brand
Yes 1 ribavirin REBETOL Generic
QL Yes 3 rilpivirine EDURANT Non-Formulary
Brand
QL Yes 1 rimantadine FLUMADINE Generic
QL Yes 1 ritonavir NORVIR Generic
QL Yes 2 saquinavir mesylate INVIRASE Formulary Brand
QL, PA Yes 3 simeprevir OLYSIO Non-Formulary
Brand
QL, PA No 3 sofosbuvir SOVALDI Non-Formulary
Brand
QL, PA No 2 sofosbuvir & velpatasvir EPCLUSA Formulary Brand
QL Yes 1 stavudine ZERIT Generic
QL Yes 3 telaprevir INCIVEK Non-Formulary
Brand
ST Yes 3 telbivudine TYZEKA Non-Formulary
Brand
QL Yes 3 tenofovir VIREAD Non-Formulary
Brand
QL Yes 1 tenofovir 300 mg VIREAD Generic
QL, PA Yes 3 tenofovir alafenamide VEMLIDY Non-Formulary
Brand
QL Yes 2 tipranavir APTIVUS Formulary Brand
ST Yes 1 valacyclovir VALTREX Generic
No 1 valganciclovir VALCYTE Generic
QL Yes 2 zanamivir RELENZA Formulary Brand
QL Yes 1 zidovudine RETROVIR Generic
Urinary Antiinfectives
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 3 fosfomycin MONUROL Non-Formulary
Brand
ST No 1 methenamine hippurate HIPREX Generic
No 3
methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and hyoscyamine
URELLE Non-Formulary
Brand
No 2 nitrofurantoin FURADANTIN Formulary Brand
No 1 nitrofurantoin macrocrystal MACRODANTIN Generic
No 1 nitrofurantoin monohydrate MACROBID Generic
Yes 1 trimethoprim PROLOPRIM Generic
Antineoplastic Agents
Antineoplastic Agents
Yes 3 abemaciclib VERZENIO Non-Formulary
Brand
No 2 abiraterone ZYTIGA Formulary Brand
Yes 3 acalabrutinib CALQUENCE Non-Formulary
Brand
QL, PA Yes 2 alpelisib PIQRAY Formulary Brand
No 1 anastrozole ARIMIDEX Generic
QL No 3 avapritinib AYVAKIT Non-Formulary
Brand
Yes 3 axitinib INLYTA Non-Formulary
Brand
No 2 bexarotene TARGRETIN Formulary Brand
No 1 bicalutamide CASODEX Generic
Yes 3 binimetinib MEKTOVI Non-Formulary
Brand
Yes 3 bosutinib BOSULIF Non-Formulary
Brand
Yes 2 busulfan MYLERAN Formulary Brand
Yes 1 capecitabine XELODA Generic
Yes 3 ceritinib ZYKADIA Non-Formulary
Brand
Yes 2 chlorambucil LEUKERAN Formulary Brand
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 2 cobimetinib COTELLIC Formulary Brand
Yes 2 crizotinib XALKORI Formulary Brand
No 1 cyclophosphamide CYTOXAN Generic
Yes 3 dacomitinib VIZIMPRO Non-Formulary
Brand
QL Yes 2 dasatinib SPRYCEL Formulary Brand
QL, PA Yes 3 darolutamide NUBEQA Non-Formulary
Brand
Yes 3 enasidenib IDHIFA Non-Formulary Brand
Yes 3 encorafenib BRAFTOVI Non-Formulary
Brand
PA Yes 3 entrectinib ROZLYTREK Non-Formulary
Brand
Yes 2 enzalutamide XTANDI Formulary Brand
No 2 erlotinib TARCEVA Formulary Brand
Yes 2 estramustine EMCYT Formulary Brand
QL No 2 everolimus AFINITOR Formulary Brand
No 1 exemestane AROMASIN Generic
Yes 3 gilteritinib XOSPATA Non-Formulary
Brand
Yes 3 glasdegib DAURISMO Non-Formulary
Brand
No 1 flutamide EULEXIN Generic
No 1 hydroxyurea HYDREA Generic
No 2 hydroxyurea DROXIA Formulary Brand
QL Yes 2 ibrutinib IMBRUVICA Formulary Brand
QL Yes 3 Ibrutinib 140 mg, 280 mg IMBRUVICA Non-Formulary
Brand
Yes 2 idelalisib ZYDELIG Formulary Brand
No 1 imatinib mesylate GLEEVEC Generic
Yes 3 ivosidenib TIBSOVO Non-Formulary
Brand
Yes 2 ixazomib NINLARO Formulary Brand
Yes 2 lapatinib TYKERB Formulary Brand
PA Yes 3 larotrectinib VITRAKVI Non-Formulary
Brand
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL Yes 2 lenalidomide REVLIMID Formulary Brand
Yes 2 lenvatinib LENVIMA Formulary Brand
No 1 letrozole FEMARA Generic
No 1 leuprolide acetate LUPRON Generic
ST Yes 1 lomustine GLEOSTINE Generic
Yes 3 lorlatinib LORBRENA Non-Formulary
Brand
Yes 3 mechlorethamine VALCHLOR Non-Formulary
Brand
Yes 2 melphalan ALKERAN Formulary Brand
No 1 mercaptopurine PURINETHOL Generic
No 3 methotrexate RASUVO Non-Formulary
Brand
No 3 methotrexate OTREXUP Non-Formulary
Brand
ST No 1 methotrexate sodium RHEUMATREX Generic
No 3 methotrexate sodium TREXALL Non-Formulary
Brand
Yes 2 mitotane LYSODREN Formulary Brand
Yes 2 nilotinib TASIGNA Formulary Brand
ST No 3 nilutamide NILANDRON Non-Formulary
Brand
QL Yes 2 niraparib ZEJULA Formulary Brand
QL Yes 2 palbociclib IBRANCE Formulary Brand
Yes 2 pazopanib VOTRIENT Formulary Brand
No 3 pemigatinib PEMAZYRE Non-Formulary
Brand
QL Yes 2 pomalidomide POMALYST Formulary Brand
Yes 3 ponatinib ICLUSIG Non-Formulary
Brand
Yes 2 procarbazine MATULANE Formulary Brand
Yes 2 regorafenib STIVARGA Formulary Brand
No 3 ripritinib QINLOCK Non-Formulary
Brand
Yes 3 ruxolitinib JAKAFI Non-Formulary
Brand
PA Yes 3 selinexor XPOVIO Non-Formulary
Brand
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Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA No 3 selumetinib KOSELUGO Non-Formulary
Brand
Yes 2 sorafenib tosylate NEXAVAR Formulary Brand
Yes 2 sunitinib malate SUTENT Formulary Brand
Yes 3 talazoparib TALZENNA Non-Formulary
Brand
No 1 tamoxifen citrate NOLVADEX Generic
No 3 tazemetostat TAZVERIK Non-Formulary
Brand
Yes 1 temozolomide TEMODAR Generic
Yes 2 thioguanine TABLOID Formulary Brand
Yes 2 topotecan HYCAMTIN Formulary Brand
ST No 1 toremifene FARESTON Generic
No 1 tretinoin VESANOID Generic
Yes 2 trifluidine/tipiracil LONSURF Formulary Brand
PA No 3 tucatinib TUKYSA Non-Formulary
Brand
PA, QL Yes 3 pexidartinib TURALIO Non-Formulary
Brand
Yes 2 vandetanib CAPRELSA Formulary Brand
Yes 2 vemurafenib ZELBORAF Formulary Brand
Yes 2 vorinostat ZOLINZA Formulary Brand
PA, QL Yes 3 zanubrutinib BRUKINSA Non-Formulary
Brand
Autonomic Drugs
Anticholinergic Agents
Yes 1 atropine sulfate ATROPINE SULFATE Generic
Yes 1 dicyclomine BENTYL Generic
Yes 1 glycopyrrolate ROBINUL Generic
Yes 1 glycopyrrolate ROBINULFORTE Generic
Yes 3 glycopyrrolate inhalation pow SEEBRI NEOHALER Non-Formulary
Brand
ST Yes 3 glycopyrrolate nebulizer soln LONHALA MAGNAIR Non-Formulary
Brand
Yes 1 hyoscyamine sulfate LEVBID Generic
Yes 1 hyoscyamine sulfate LEVSIN Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 17
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 hyoscyamine sulfate SYMAX Generic
Yes 3 hyoscyamine sulfate SYMAX DUOTAB Non-Formulary
Brand
Yes 1 ipratropium bromide ATROVENT Generic
Yes 2 ipratropium bromide ATROVENT HFA Formulary Brand
ST Yes 1 methscopolamine PAMINE Generic
Yes 1 propantheline bromide PRO-BANTHINE Generic
ST Yes 3 revefenacin YUPELRI Non-Formulary
Brand
Yes 3 tiotropium SPIRIVA Non-Formulary
Brand
Yes 2 tiotropium 2.5 mcg SPIRIVA RESPIMAT Formulary Brand
Yes 3 tiotropium 1.25 mcg SPIRIVA RESPIMAT Non-Formulary
Brand
Yes 3 umeclidinium INCRUSE ELLIPTA Non-Formulary
Brand
Smoking Cessation Agents
Yes 1 nicotine gum NICORETTE Generic
QL, ST Yes 3 nicotine inhalation NICOTROL Non-Formulary
Brand
Yes 1 nicotine lozenge NICORETTE Generic
QL, ST Yes 3 nicotine nasal spray NICOTROL Non-Formulary
Brand
Yes 1 nicotine patch NICODERM Generic
ST Yes 3 varenicline CHANTIX Non-Formulary
Brand
Parasympathomimetic (Cholinergic) Agents
Yes 1 bethanechol chloride URECHOLINE Generic
Yes 1 cevimeline hcl EVOXAC Generic
Yes 1 donepezil ARICEPT Generic
Yes 1 donepezil ARICEPT ODT Generic
Yes 1 galantamine hydrobromide RAZADYNE Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 18
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 galantamine hydrobromide ER RAZADYNE ER Generic
Yes 1 neostigmine bromide PROSTIGMIN Generic
ST Yes 1 pilocarpine SALAGEN Generic
Yes 1 pyridostigmine MESTION TIMESPAN Generic
Yes 1 pyridostigmine MESTION Generic
Yes 1 rivastigmine tartrate EXELON Generic
Yes 2 rivastigmine tartrate (solution) EXELON Formulary Brand
Skeletal Muscle Relaxants
Yes 1 baclofen LIORESAL Generic
ST No 1 carisoprodol SOMA Generic
ST No 1 carisoprodol & aspirin SOMA COMPOUND Generic
No 1 chlorzoxazone PARAFON FORTE DSC
Generic
No 1 cyclobenzaprine FLEXERIL Generic
No 3 cyclobenzaprine extended-release
AMRIX Non-Formulary
Brand
No 1 dantrolene sodium DANTRIUM Generic
ST No 1 metaxalone SKELAXIN Generic
No 1 methocarbamol ROBAXIN Generic
No 1 orphenadrine citrate NORFLEX Generic
Yes 1 orphenadrine, aspirin, & caffeine NORGESIC Generic
No 1 tizanidine ZANAFLEX Generic
Sympatholytic (Adrenergic Blocking) Agents
Yes 1 alfuzosin UROXATRAL Generic
No 1 dihydroergotamine mesylate D.H.E.45 Generic
No 2 dihydroergotamine mesylate MIGRANAL Formulary Brand
Yes 1 ergoloid mesylates HYDERGINE Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 19
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 ergotamine & caffeine CAFERGOT Generic
ST No 1 phenoxybenzamine DIBENZYLINE Generic
ST Yes 3 silodosin RAPAFLO Non-Formulary
Brand
Yes 1 tamsulosin hcl FLOMAX Generic
Sympathomimetic (Adrenergic) Agents
Yes 1 albuterol nebulizer solution ACCUNEB Generic
Yes 3 albuterol sulfate PROAIR HFA Non-Formulary
Brand
Yes 3 albuterol sulfate PROVENTIL HFA Non-Formulary
Brand
Yes 2 albuterol sulfate VENTOLIN HFA Formulary Brand
Yes 3 albuterol sulfate & ipratropium COMBIVENT RESPIMAT
Non-Formulary Brand
Yes 1 albuterol sulfate & ipratropium DUONEB Generic
Yes 1 albuterol sulfate tablet VOSPIRE ER Generic
Yes 3 arformoterol BROVANA Non-Formulary
Brand
PA Yes 3 droxidopa NORTHERA Non-Formulary
Brand
No 1 epinephrine ADRENACLICK Generic
PA No 3 epinephrine AUVI-Q Non-Formulary
Brand
No 3 epinephrine EPIPEN Non-Formulary
Brand
No 3 epinephrine EPIPEN JR Non-Formulary
Brand
No 3 epinephrine TWINJECT Non-Formulary
Brand
Yes 3 formoterol fumarate FORADIL Non-Formulary
Brand
ST Yes 1 levalbuterol nebulizer solution XOPENEX NEBULIZER
Generic
ST Yes 1 levalbuterol tartrate XOPENEX HFA Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 20
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 midodrine hcl PROAMATINE Generic
Yes 2 olodaterol STRIVERDI RESPIMAT
Formulary Brand
ST Yes 3 pirbuterol acetate MAXAIR AUTOHALER
Non-Formulary Brand
Yes 1 terbutaline sulfate BRETHINE Generic
Yes 3 umeclidinium & vilanterol ANORO ELLIPTA Non-Formulary
Brand
Blood Formation, Coagulation, and Thrombosis
Coagulants and Anticoagulants
Yes 2 aminocaproic acid AMICAR Formulary Brand
Yes 1 anagrelide AGRYLIN Generic
ST Yes 3 apixaban ELIQUIS Non-Formulary
Brand
Yes 1 aspirin & dipyridamole AGGRENOX Generic
ST Yes 3 betrixaban BEVYXXA Non-Formulary
Brand
Yes 1 cilostazol PLETAL Generic
Yes 1, 3 clopidogrel PLAVIX Generic;
Non-Formulary Brand
QL Yes 2 dabigatran PRADAXA Formulary Brand
ST Yes 3 dalteparin FRAGMIN Non-Formulary
Brand
Yes 1 dipyridamole PERSANTINE Generic
ST Yes 3 edoxaban SAVAYSA Non-Formulary
Brand
No 1 enoxaparin LOVENOX Generic
ST No 1 fondaparinux ARIXTRA Generic
No 1 heparin HEPARIN SODIUM Generic
Yes 1 pentoxifylline TRENTAL Generic
Yes 1 prasugrel EFFIENT Generic
QL, ST Yes 3 rivaroxaban XARELTO Non-Formulary
Brand
Yes 2 ticagrelor BRILINTA Formulary Brand
ST Yes 1 tranexamic acid LYSTEDA Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 21
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 3 vorapaxar ZONTIVITY Non-Formulary
Brand
No 1 warfarin COUMADIN Generic
Hematopoietic Agents
Yes 2 darbepoetin alfa ARANESP Formulary Brand
Yes 2 eltrombopag PROMACTA Formulary Brand
Yes 2 epoetin alfa PROCRIT Formulary Brand
Yes 3 epoetin alfa EPOGEN Non-Formulary
Brand
Yes 3 filgrastim NEUPOGEN Non-Formulary
Brand
Yes 2 filgrastim ZARXIO Formulary Brand
Yes 2 oprelvekin NEUMEGA Formulary Brand
Yes 3 pegfilgrastim NEULASTA Non-Formulary
Brand
Yes 3 pegfilgrastim-jmdb FULPHILA Non-Formulary
Brand
Yes 2 sargramostim LEUKINE Formulary Brand
Cardiovascular Drugs
α-Adrenergic Blocking Agents
Yes 1 doxazosin CARDURA Generic
Yes 1 prazosin MINIPRESS Generic
Yes 1 terazosin HYTRIN Generic
Antilipemic Agents
PA Yes 3 alirocumab PRALUENT Non-Formulary
Brand
Yes 1 atorvastatin LIPITOR Generic
PA Yes 3 bempedoic acid NEXLETOL Non-Formulary
Brand
PA Yes 3 bempedoic acid & ezetimibe NEXLIZET Non-Formulary
Brand
Yes 1 cholestyramine light QUESTRAN LIGHT Generic
Yes 1 cholestyramine QUESTRAN Generic
ST Yes 1 colesevelam WELCHOL Generic
Yes 1 colestipol COLESTID Generic
Yes 3 evolocumab REPATHA Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 22
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA No 3
Yes 1 ezetimibe ZETIA Generic
Yes 3 ezetimibe & simvastatin VYTORIN Non-Formulary
Brand
Yes 1 fenofibrate LOFIBRA TAB Generic
Yes 1 fenofibrate TRICOR Generic
Yes 1 fenofibrate, micronized LOFIBRA CAP Generic
Yes 1 fenofibric acid TRILIPIX Generic
ST Yes 1 fluvastatin extended-release LESCOL XL Generic
ST Yes 1 fluvastatin LESCOL Generic
Yes 1 gemfibrozil LOPID Generic
PA Yes 3 icosapent VASCEPA Non-Formulary
Brand
PA Yes 3 lomitapide JUXTAPID Non-Formulary
Brand
Yes 1 lovastatin MEVACOR Generic
Yes 3 lovastatine extended-release ALTOPREV Non-Formulary
Brand
PA Yes 3 mipomersen sodium KYNAMRO Non-Formulary
Brand
ST Yes 1 niacin NIASPAN Generic
Yes 3 niacin & lovastatin ADVICOR Non-Formulary
Brand
Yes 1 omega-3 acid ethyl esters LOVAZA Generic
Yes 3 omega-3-carboxylic acid EPANOVA Non-Formulary
Brand
ST Yes 3 pitavastatin LIVALO Non-Formulary
Brand
Yes 1 pravastatin PRAVACHOL Generic
Yes 1 rosuvastatin CRESTOR Generic
Yes 1 simvastatin ZOCOR Generic
Calcium Channel Blocking Agents
Yes 1 amlodipine NORVASC Generic
Yes 1 amlodipine & benazepril LOTREL Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 23
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 amlodipine & atorvastatin CADUET Generic
Yes 3 amlodipine & olmesartan AZOR Non-Formulary
Brand
ST Yes 1 amlodipine & telmisartan TWYNSTA Generic
ST Yes 1 amlodipine & valsartan EXFORGE Generic
ST Yes 1 amlodipine, valsartan & hydrochlorothiazide
EXFORGE HCT Generic
Yes 1 amlodipine, olmesartan & hydrochlorothiazide
TRIBENZOR Generic
Yes 1 diltiazem extended-release CARDIZEM CD Generic
Yes 1 diltiazem extended-release TIAZAC Generic
Yes 1 diltiazem extended-release CARTIA XT Generic
Yes 1 diltiazem extended-release CARDIZEM LA Generic
Yes 1 diltiazem CARDIZEM Generic
Yes 1 felodipine PLENDIL Generic
ST Yes 1 isradipine DYNACIRC Generic
Yes 1 nicardipine CARDENE Generic
Yes 1 nifedipine PROCARDIA Generic
Yes 1 nifedipine extended-release ADALAT CC Generic
Yes 1 nifedipine extended-release PROCARDIA XL Generic
Yes 1 nimodipine NIMOTOP Generic
ST Yes 1 nisoldipine SULAR Generic
Yes 1 trandolapril & verapamil TARKA Generic
Yes 1 verapamil sustained-release cap VERELAN Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 24
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 3 verapamil COVERA-HS Non-Formulary
Brand
Yes 1 verapamil extended-release cap VERELAN PM Generic
Yes 1 verapamil sustained-release cap CALAN SR Generic
Yes 1 verapamil sustained-release tab ISOPTIN SR Generic
Cardiac Drugs
Yes 1 amiodarone PACERONE Generic
Yes 1 digoxin LANOXIN Generic
Yes 1 disopyramide NORPACE Generic
Yes 2 disopyramide controlled-release NORPACE CR Formulary Brand
Yes 1 dofetilide TIKOSYN Generic
ST Yes 3 dronedarone MULTAQ Non-Formulary
Brand
Yes 1 flecainide TAMBOCOR Generic
Yes 3 Ivabradine CORLANOR Non-Formulary
Brand
Yes 1 mexiletine MEXITIL Generic
Yes 1 propafenone RYTHMOL Generic
Yes 3 propafenone RYTHMOL SR Non-Formulary
Brand
Yes 1 quinidine gluconate QUINAGLUTE Generic
Yes 1 quinidine QUINIDINE SULFATE Generic
QL Yes 1 ranolazine RANEXA Generic
Yes 3 sacubitril & valsartan ENTRESTO Non-Formulary
Brand
Hypotensive Agents
ST Yes 1 clonidine extended-release KAPVAY Generic
Yes 1 clonidine CATAPRES Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 25
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 clonidine transdermal CATAPRES-TTS Generic
Yes 1 guanfacine TENEX Generic
Yes 1 hydralazine APRESOLINE Generic
Yes 1 methyldopa ALDOMET Generic
Yes 1 methyldopa & hydrochlorothiazide
ALDORIL-25 Generic
Yes 1 minoxidil LONITEN Generic
Yes 3 reserpine SERPASIL Non-Formulary
Brand
Renin-Angiotensin-Aldosterone System Inhibitors
ST Yes 3 aliskiren TEKTURNA Non-Formulary
Brand
ST Yes 3 aliskiren, amlodipine & hydrochlorothiazide
AMTURNIDE Non-Formulary
Brand
Yes 3 aliskiren & amlodipine TEKAMLO Non-Formulary
Brand
ST Yes 3 aliskiren & hydrochlorothiazide TEKTURNA HCT Non-Formulary
Brand
Yes 3 aliskiren & valsartan VALTURNA Non-Formulary
Brand
ST Yes 3 azilsartan EDARBI Non-Formulary
Brand
Yes 1 benazepril LOTENSIN Generic
Yes 1 benazepril & hydrochlorothiazide LOTENSIN HCT Generic
ST Yes 1 candesartan ATACAND Generic
ST Yes 1 candesartan & hydrochlorothiazide
ATACAND HCT Generic
Yes 1 captopril CAPOTEN Generic
Yes 1 captopril & hydrochlorothiazide CAPOZIDE Generic
Yes 1 enalapril VASOTEC Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 26
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 enalapril & hydrochlorothiazide VASERETIC Generic
ST Yes 1 eplerenone INSPRA Generic
ST Yes 3 eprosartan TEVETEN Non-Formulary
Brand
Yes 3 eprosartan & hydrochlorothiazide TEVETEN PLUS Non-Formulary
Brand
ST Yes 1 fosinopril MONOPRIL Generic
ST Yes 1 fosinopril & hydrochlorothiazide MONOPRIL HCT Generic
ST Yes 1 irbesartan AVAPRO Generic
ST Yes 1 irbesartan & hydrochlorothiazide AVALIDE Generic
Yes 1 lisinopril ZESTRIL Generic
Yes 1 lisinopril & hydrochlorothiazide ZESTORETIC Generic
Yes 1 losartan COZAAR Generic
Yes 1 losartan & hydrochlorothiazide HYZAAR Generic
ST Yes 1 moexipril UNIVASC Generic
ST Yes 1 moexipril & hydrochlorothiazide UNIRETIC Generic
ST Yes 1 olmesartan BENICAR Generic
ST Yes 1 olmesartan & hydrochlorothiazide BENICAR HCT Generic
ST Yes 1 perindopril ACEON Generic
ST Yes 1 quinapril hcl ACCUPRIL Generic
ST Yes 1 quinapril & hydrochlorothiazide ACCURETIC Generic
Yes 1 ramipril ALTACE Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 27
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 spironolactone & hydrochlorothiazide
ALDACTAZIDE Generic
Yes 1 spironolactone ALDACTONE Generic
ST Yes 1 telmisartan MICARDIS Generic
ST Yes 1 telmisartan & hydrochlorothiazide MICARDIS HCT Generic
ST Yes 1 trandolapril MAVIK Generic
ST Yes 1 valsartan DIOVAN Generic
ST Yes 1 valsartan & hydrochlorothiazide DIOVAN HCT Generic
Vasodilating Agents
No 2 ambrisentan LETAIRIS Formulary Brand
No 2 bosentan TRACLEER Formulary Brand
Yes 3 isosorbide dinitrate & hydralazine BIDIL Non-Formulary
Brand
Yes 1 isosorbide dinitrate ISORDIL Generic
Yes 1 isosorbide mononitrate IMDUR Generic
Yes 2 macitentan OPSUMIT Formulary Brand
Yes 3 nitroglycerin aerosol NITROMIST Non-Formulary
Brand
Yes 1 nitroglycerin solution NITROLINGUAL Generic
Yes 1 nitroglycerin sublingual NITROSTAT Generic
Yes 2 nitroglycerin topical ointment NITRO-BID Formulary Brand
Yes 1 nitroglycerin transdermal patch NITRO-DUR Generic
Yes 2 nitroglycerin transdermal patch 0.8 mg strength
NITRO-DUR Formulary Brand
ST Yes 3 nitroglycerin (intra-anal) RECTIV Non-Formulary
Brand
Yes 1 papaverine PAVABID Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 28
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 3 riociguat ADEMPAS Non-Formulary
Brand
Yes 1 sildenafil REVATIO Generic
No 3 tadalafil ADCIRCA Non-Formulary
Brand
No 3 treprostinil ORENITRAM Non-Formulary
Brand
No 2 treprostinil REMODULIN Formulary Brand
β-Adrenergic Blocking Agents
Yes 1 acebutolol SECTRAL Generic
Yes 1 atenolol TENORMIN Generic
Yes 1 atenolol & chlorthalidone TENORETIC Generic
ST Yes 1 betaxolol KERLONE Generic
Yes 1 bisoprolol & hydrochlorothiazide ZIAC Generic
Yes 1 bisoprolol ZEBETA Generic
Yes 1 carvedilol COREG Generic
Yes 3 carvedilol phosphate COREG CR Non-Formulary
Brand
Yes 1 labetalol TRANDATE Generic
Yes 1 metoprolol & hydrochlorothiazide LOPRESSOR HCT Generic
Yes 1 metoprolol succinate TOPROL XL Generic
Yes 1 metoprolol tartrate LOPRESSOR Generic
Yes 1 nadolol CORGARD Generic
Yes 1 nadolol & bendroflumethiazide CORZIDE Generic
ST Yes 3 nebivolol BYSTOLIC Non-Formulary
Brand
ST Yes 3 penbutolol LEVATOL Non-Formulary
Brand
ST Yes 1 pindolol VISKEN Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 29
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 propranolol & hydrochlorothiazide INDERIDE Generic
Yes 3 propranolol extended-release INNOPRAN XL Non-Formulary
Brand
Yes 1 propranolol INDERAL Generic
Yes 1 propranolol sustained-release INDERAL LA Generic
Yes 1 sotalol BETAPACE Generic
Yes 1 sotalol BETAPACE AF Generic
Yes 1 timolol BLOCADREN Generic
Central Nervous System Agents
Analgesics and Antipyretics
No 1 acetaminophen & codeine TYLENOL W/ CODEINE
Generic
No 1 acetaminophen, caffeine, & dihydrocodeine
TREZIX Generic
No 1 buprenorphine SUBUTEX Generic
QL No 1 buprenorphine& naloxone tablet SUBOXONE Generic
QL No 3 buprenorphine & naloxone film SUBOXONE Non-Formulary
Brand
QL, ST No 1 buprenorphine transdermal BUTRANS Generic
No 1 butalbital & acetaminophen PHRENILIN Generic
No 3 butalbital & acetaminophen PHRENILIN FORTE Non-Formulary
Brand
No 1 butalbital, acetaminophen, & caffeine
FIORICET Generic
No 1 butalbital, acetaminophen, caffeine, & codeine
FIORICET W/ CODEINE
Generic
No 1 butalbital, aspirin, & caffeine FIORINAL Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 30
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 butalbital, aspirin, caffeine, & codeine
FIORINAL W/ CODEINE
Generic
No 1 butorphanol tartrate STADOL Generic
ST No 1 carisoprodol, aspirin, & codeine SOMA COMPOUND W/ CODEINE
Generic
ST No 1 celecoxib CELEBREX Generic
ST No 1 codeine CODEINE SULF Generic
No 1 diclofenac potassium CATAFLAM Generic
No 1 diclofenac sodium VOLTAREN Generic
No 1 diclofenac sodium PENNSAID Generic
No 1 diclofenac sodium & misoprostol ARTHROTEC Generic
No 1 diclofenac sodium extended release
VOLTAREN XR Generic
ST No 1 diflunisal DIFLUNISAL Generic
No 1 etodolac LODINE Generic
ST No 3 fenoprofen calcium NALFON Non-Formulary
Brand
No 3 fentanyl film ONSOLIS Non-Formulary
Brand
No 3 fentanyl intranasal LAZANDA Non-Formulary
Brand
No 1 fentanyl lozenge ACTIQ Generic
No 3 fentanyl sublingual ABSTRAL Non-Formulary
Brand
No 3 fentanyl tablet FENTORA Non-Formulary
Brand
QL No 1 fentanyl transdermal DURAGESIC Generic
ST No 1 flurbiprofen ANSAID Generic
ST No 3 hydrocodone ZOHYDRO ER Non-Formulary
Brand
No 3 hydrocodone er HYSINGLA ER Non-Formulary
Brand
No 1 hydrocodone & acetaminophen NORCO Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 31
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 hydrocodone & ibuprofen VICOPROFEN Generic
No 3 hydromorphone oral suspension DILAUDID Non-Formulary
Brand
No 1 hydromorphone tablet DILAUDID Generic
ST No 3 hydromorphone tablet EXALGO Non-Formulary
Brand
No 1 ibuprofen MOTRIN Generic
No 1 indomethacin INDOCIN Generic
No 1 ketoprofen KETOPROFEN Generic
QL No 1 ketorolac tablet TORADOL Generic
ST No 1 levorphanol LEVO-DROMORAN Generic
ST No 1 meclofenamate MECLOMEN Generic
QL, ST No 1 mefenamic acid PONSTEL Generic
No 1 meloxicam MOBIC Generic
No 1 meperidine tablet DEMEROL Generic
No 1 methadone DOLOPHINE Generic
No 2 morphine MORPHINE SULFATE
Formulary Brand
No 1 morphine MSIR Generic
No 3 morphine beads AVINZA Non-Formulary
Brand
No 3 morphine extended-release capsule
KADIAN Non-Formulary
Brand
No 1 morphine extended-release tablet MS CONTIN Generic
ST No 3 morphine & naltrexone EMBEDA Non-Formulary
Brand
No 1 nabumetone RELAFEN Generic
Yes 1 nalbuphine NUBAIN Generic
No 1 naproxen NAPROSYN Generic
No 1 naproxen sodium ANAPROX Generic
No 3 naproxen sodium NAPRELAN Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 32
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 opium & belladonna alkaloids B & O SUPPRETTES Generic
Yes 3 opium tincture OPIUM Non-Formulary
Brand
ST No 1 oxaprozin DAYPRO Generic
ST No 1 oxycodone ROXICODONE Generic
No 1 oxycodone & acetaminophen PERCOCET Generic
No 2 oxycodone & acetaminophen ROXICET Formulary Brand
No 3 oxycodone & acetaminophen er XARTEMIS XR Non-Formulary
Brand
No 1 oxycodone & aspirin PERCODAN Generic
QL No 3 oxycodone & ibuprofen COMBUNOX Non-Formulary
Brand
QL, ST No 1 oxycodone controlled-release OXYCONTIN Generic
ST No 1 oxymorphone OPANA Generic
ST No 1 oxymorphone extended-release OPANA ER Generic
No 1 pentazocine & naloxone TALWIN NX Generic
ST No 1 piroxicam FELDENE Generic
Yes 1 salsalate DISALCID Generic
No 1 sulindac CLINORIL Generic
QL, ST Yes 3 tapentadol NUCYNTA Non-Formulary
Brand
No 1 tolmetin sodium TOLECTIN 600 Generic
No 1 tramadol ULTRAM Generic
No 1 tramadol & acetaminophen ULTRACET Generic
ST No 1 tramadol extended-release ULTRAM ER Generic
Anorexigenic Agents and Respiratory and Cerebral Stimulants
ST No 3 amphetamine sulfate EVEKEO Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 33
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST No 3 amphetamine extended-release ADZENYS ER Non-Formulary
Brand
No 1 amphetamine & dextroamphetamine
ADDERALL Generic
No 1 amphetamine & dextroamphetamine extended-release
ADDERALL XR Generic
ST No 3 amphetamine & dextroamphetamine extended-release
MYDAYIS Non-Formulary
Brand
QL, ST
No 1 armodafinil NUVIGIL Generic (ST-Brand only)
QL No 1 dexmethylphenidate FOCALIN Generic
No 1 dexmethylphenidate extended-release
FOCALIN XR Generic
QL No 1 dextroamphetamine sulfate DEXTROSTAT Generic
QL No 1 dextroamphetamine sulfate extended-release
DEXEDRINE Generic
QL, ST Yes 3 lisdexamfetamine VYVANSE Non-Formulary
Brand
ST No 1 methamphetamine DESOXYN Generic
No 1 methylphenidate METHYLIN Generic
No 1 methylphenidate RITALIN Generic
QL No 1 methylphenidate extended-release
METADATE ER Generic
QL No 1 methylphenidate extended-release
CONCERTA Generic
No 1 methylphenidate extended-release
METADATE CD Generic
QL, ST No 1 methylphenidate extended-release
RITALIN LA Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 34
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL No 1 methylphenidate sustained release
RITALIN SR Generic
QL, ST No 3 methylphenidate transdermal patch
DAYTRANA Non-Formulary
Brand
ST No 3 Methylphenidate extended-release disintegrating tablet
COTEMPLA XR-ODT Non-Formulary
Brand
QL No 1 modafinil PROVIGIL Generic
Anticonvulsants
Yes 1 carbamazepine TEGRETOL Generic
Yes 1 carbamazepine extended-release cap
CARBATROL Generic
Yes 3 carbamazepine extended-release cap
EQUETRO Non-Formulary
Brand
Yes 1 carbamazepine extended-release tab
TEGRETOL XR Generic
Yes 3 clobazam ONFI Non-Formulary
Brand
No 1 clonazepam KLONOPIN Generic
No 1 diazepam DIASTAT Generic
No 2 diazepam DIASTAT ACUDIAL Formulary Brand
Yes 1 divalproex sodium DEPAKOTE Generic
Yes 1 divalproex sodium capsule DEPAKOTE SPRINKLE
Generic
Yes 1 divalproex sodium extended release
DEPAKOTE ER Generic
Yes 3 eslicarbazepine APTIOM Non-Formulary
Brand
ST Yes 3 ethontoin PEGANONE Non-Formulary
Brand
Yes 1 ethosuximide ZARONTIN Generic
ST Yes 3 ezogaine POTIGA Non-Formulary
Brand
ST Yes 1 felbamate FELBATOL Generic
No 1 gabapentin NEURONTIN Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 35
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST No 3 gabapentin HORIZANT Non-Formulary
Brand
QL, ST Yes 3 lacosamide VIMPAT Non-Formulary
Brand
Yes 1 lamotrigine LAMICTAL Generic
Yes 1 lamotrigine extended-release LAMICTAL XR Generic
Yes 1 levetiracetam KEPPRA Generic
Yes 1 levetiracetam extended-release KEPPRA XR Generic
Yes 2 methsuximide CELONTIN Formulary Brand
Yes 1 oxcarbazepine TRILEPTAL Generic
Yes 3 perampanel FYCOMPA Non-Formulary
Brand
Yes 1 phenytoin sodium extended-release
DILANTIN Generic
Yes 1 phenytoin sodium extended-release
PHENYTEK Generic
Yes 1 phenytoin suspension DILANTIN Generic
Yes 1 pregabalin LYRICA Generic
Yes 1 primidone MYSOLINE Generic
ST Yes 3 rufinamide BANZEL Non-Formulary
Brand
PA Yes 3 stiripentol DIACOMIT Non-Formulary
Brand
ST Yes 1 tiagabine GABITRIL Generic
Yes 1 topiramate capsule TOPAMAX SPRINKLE Generic
Yes 1 topiramate tablet TOPAMAX Generic
Yes 1 valproate sodium DEPAKENE Generic
Yes 1 valproic acid DEPAKENE Generic
PA No 3 vigabatrin SABRIL Non-Formulary
Brand
Yes 1 zonisamide ZONEGRAN Generic
Antimigraine Agents
ST No 1 almotriptan AXERT Generic
No 1 ergotamine & caffeine MIGERGOT Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 36
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST No 1 eletriptan RELPAX Generic
ST No 1 frovatriptan FROVA Generic
QL, ST No 3 lasmitidan REYVOW Non-Formulary
Brand
No 1 naratriptan AMERGE Generic
QL, ST No 3 rimegepant NURTEC ODT Non-Formulary
Brand
No 1 rizatriptan MAXALT Generic
No 1 rizatriptan orally disintegrating MAXALT MLT Generic
No 1 sumatriptan IMITREX Generic
QL, ST Yes 3 ubrogepant UBRELVY Non-Formulary
Brand
ST No 1 zolmitriptan ZOMIG Generic
No 1 zolmitriptan orally disintegrating ZOMIG ZMT Generic
Antiparkinsonian Agents
Yes 1 amantadine SYMMETREL Generic
ST Yes 3 amantadine ER GOCOVRI Non-Formulary
Brand
ST Yes 3 apomorphine APOKYN Non-Formulary
Brand
Yes 1 benztropine COGENTIN Generic
Yes 1 bromocriptine PARLODEL Generic
ST Yes 3 bromocriptine CYCLOSET Non-Formulary
Brand
Yes 1 cabergoline DOSTINEX Generic
ST Yes 3 carbidopa LODOSYN Non-Formulary
Brand
Yes 1 carbidopa & levodopa SINEMET Generic
Yes 3 carbidopa & levodopa PARCOPA Non-Formulary
Brand
Yes 1 carbidopa & levodopa extended release
SINEMET CR Generic
Yes 2 carbidopa, levodopa, & entacapone
STALEVO Formulary Brand
Yes 1 entacapone COMTAN Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 37
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA Yes 3 levophed (oral inhalation) INBRIJA Non-Formulary
Brand
Yes 1 pramipexole MIRAPEX Generic
Yes 1 pramipexole extended-release MIRAPEX ER Generic
ST Yes 3 rasagiline AZILECT Non-Formulary
Brand
Yes 1 ropinirole REQUIP Generic
ST Yes 1 ropinirole extended-release REQUIP XL Generic
ST Yes 3 rotigotine NEUPRO Non-Formulary
Brand
Yes 1 selegiline ELDEPRYL Generic
ST Yes 3 selegiline ZELAPAR Non-Formulary
Brand
ST Yes 3 selegiline transdermal EMSAM Non-Formulary
Brand
Yes 2 tolcapone TASMAR Formulary Brand
Yes 1 trihexyphenidyl ARTANE Generic
Anxiolytics, Sedatives, and Hypnotics
No 1 alprazolam XANAX Generic
No 1 alprazolam extended-release XANAX XR Generic
No 3 alprazolam orally disintegrating NIRAVAM Non-Formulary
Brand
No 1 buspirone BUSPAR Generic
No 1 chlordiazepoxide LIBRIUM Generic
No 1 clorazepate TRANXENE Generic
No 1 diazepam VALIUM Generic
ST Yes 3 doxepin (sleep) SILENOR Non-Formulary
Brand
No 1 estazolam PROSOM Generic
ST No 1 eszopiclone LUNESTA Generic
No 1 flurazepam DALMANE Generic
No 1 hydroxyzine hcl ATARAX Generic
ST No 1 hydroxyzine pamoate VISTARIL Generic
No 1 lorazepam ATIVAN Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 38
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 meprobamate MILTOWN Generic
No 1 oxazepam SERAX Generic
No 1 phenobarbital PHENOBARBITAL Generic
ST No 1 ramelteon ROZEREM Generic
Yes 3 suvorexant BELSOMRA Non-Formulary
Brand
PA Yes 3 tasimelteon HETLIOZ Non-Formulary
Brand
No 1 temazepam RESTORIL Generic
No 1 triazolam HALCION Generic
No 1 zaleplon SONATA Generic
Yes 3 zolipdem sublingual EDLUAR Non-Formulary
Brand
No 1 zolpidem AMBIEN Generic
No 3 zolpidem extended-release AMBIEN CR Non-Formulary
Brand
No 3 zolpidem oral spray ZOLPIMIST Non-Formulary
Brand
Central Nervous System Agents Miscellaneous
ST Yes 1 acamprosate CAMPRAL Generic
ST Yes 3 atomoxetine STRATTERA Non-Formulary
Brand
PA Yes 3 cannabidiol EPIDIOLEX Non-Formulary
Brand
PA Yes 3 deutetrabenazine AUSTEDO Non-Formulary
Brand
PA Yes 3 dextromethorphan & quinidine NUEDEXTA Non-Formulary
Brand
Yes 1 guanfacine extended-release INTUNIV Generic
ST Yes 3 lofexidine LUCEMYRA Non-Formulary
Brand
No 1 memantine NAMENDA Generic
No 3 memantine er & donepezil NAMZARIC Non-Formulary
Brand
QL, ST Yes 3 milnacipran SAVELLA Non-Formulary
Brand
PA Yes 3 pitolisant WAKIX Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 39
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 riluzole RILUTEK Generic
PA Yes 3 solriamfetol SUNOSI Non-Formulary
Brand
PA Yes 3 sodium oxybate XYREM Non-Formulary
Brand
PA No 3 tetrabenazine XENAZINE Non-Formulary
Brand
PA Yes 3 valbenazine INGREZZA Non-Formulary
Brand
Opioid Antagonists
No 1 naloxone NARCAN Generic
QL No 2 naloxone nasal spray NARCAN Formulary Brand
No 1 naltrexone REVIA Generic
Psychotherapeutic Agents
Yes 1 amitriptyline ELAVIL Generic
Yes 1 amitriptyline & perphenazine TRIAVIL Generic
Yes 1 amoxapine ASENDIN Generic
Yes 1 aripiprazole tablet ABILIFY Generic
ST Yes 3 aripiprazole solution ABILIFY Non-Formulary
Brand
ST Yes 3 aripiprazole ABILIFY DISCMELT Non-Formulary
Brand
ST Yes 3 asenapine SAPHRIS Non-Formulary
Brand
QL, ST Yes 3 brexpiprazole REXULTI Non-Formulary
Brand
Yes 1 bupropion WELLBUTRIN Generic
Yes 1 bupropion extended-release WELLBUTRIN XL Generic
ST Yes 3 bupropion hydrobromide APLENZIN Non-Formulary
Brand
Yes 1 bupropion sustained-release WELLBUTRIN SR Generic
ST Yes 3 bupropion (smoking deterrent) ZYBAN Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 40
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL, ST Yes 3 cariprazine VRAYLAR Non-Formulary
Brand
No 1 chlordiazepoxide & amitriptyline LIMBITROL DS Generic
Yes 1 chlorpromazine THORAZINE Generic
Yes 1 citalopram CELEXA Generic
Yes 1 clomipramine ANAFRANIL Generic
No 1 clozapine CLOZARIL Generic
No 1 clozapine FAZACLO Generic
Yes 1 desipramine NORPRAMIN Generic
ST Yes 1 desvenlafaxine succinate extended release
PRISTIQ Generic
ST Yes 1 desvenlafaxine extended release KHEDEZLA Generic
Yes 1 doxepin SINEQUAN Generic
Yes 1 duloxetine CYMBALTA Generic
Yes 1 escitalopram LEXAPRO Generic
Yes 1 fluoxetine PROZAC Generic
Yes 3 fluoxetine PROZAC WEEKLY Non-Formulary
Brand
Yes 3 fluoxetine SARAFEM Non-Formulary
Brand
Yes 1 fluphenazine PROLIXIN Generic
Yes 1 fluvoxamine LUVOX Generic
Yes 1 haloperidol HALDOL Generic
ST Yes 3 iloperidone FANAPT Non-Formulary
Brand
Yes 1 imipramine TOFRANIL Generic
Yes 1 imipramine pamoate TOFRANIL-PM Generic
ST Yes 3 isocarboxazid MARPLAN Non-Formulary
Brand
QL Yes 3 levomilnacipran FETZIMA Non-Formulary
Brand
Yes 1 lithium carbonate capsule LITHIUM CARBONATE
Generic
Yes 1 lithium carbonate extended release
LITHOBID Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 41
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 lithium citrate CIBALITH-S Generic
ST Yes 1 loxapine LOXITANE Generic
QL, ST Yes 3 lurasidone LATUDA Non-Formulary
Brand
ST Yes 1 maprotiline LUDIOMIL Generic
Yes 1 mirtazapine REMERON Generic
Yes 1 nefazodone SERZONE Generic
Yes 1 nortriptyline PAMELOR Generic
Yes 1 olanzapine ZYPREXA Generic
Yes 1 olanzapine & fluoxetine hcl SYMBYAX Generic
Yes 1 olanzapine orally disintegrating ZYPREXA ZYDIS Generic
ST Yes 1 paliperidone INVEGA Generic
Yes 1 paroxetine PAXIL Generic
Yes 3 paroxetine extended-release PAXIL CR Non-Formulary
Brand
Yes 3 paroxetine mesylate PEXEVA Non-Formulary
Brand
Yes 1 perphenazine TRILAFON Generic
Yes 1 phenelzine NARDIL Generic
PA Yes 3 pimavanserin NUPLAZID Non-Formulary
Brand
ST Yes 1 pimozide ORAP Generic
ST Yes 1 protriptyline VIVACTIL Generic
Yes 1 quetiapine SEROQUEL Generic
Yes 1 quetiapine extended-release SEROQUEL XR Generic
Yes 1 risperidone RISPERDAL Generic
Yes 3 risperidone orally disintegrating RISPERDALM-TAB Non-Formulary
Brand
Yes 1 sertraline ZOLOFT Generic
Yes 1 thioridazine MELLARIL Generic
Yes 1 thiothixene NAVANE Generic
Yes 1 tranylcypromine sulfate PARNATE Generic
Yes 1 trazodone DESYREL Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 42
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 3 trazodone extended-release OLEPTRO Non-Formulary
Brand
Yes 1 trifluoperazine STELAZINE Generic
ST Yes 1 trimipramine SURMONTIL Generic
Yes 1 venlafaxine EFFEXOR Generic
Yes 1 venlafaxine extended-release EFFEXOR XR Generic
QL, ST Yes 3 vilazodone VIIBRYD Non-Formulary
Brand
QL, ST Yes 3 vortioxetine TRINTELLIX Non-Formulary
Brand
Yes 1 ziprasidone GEODON Generic
Diabetic Supplies
Diabetic Supplies
QL Yes 2 blood sugar diagnostic ONE TOUCH ULTRA TEST STRIPS
Formulary Brand
QL Yes 2 blood sugar diagnostic ONE TOUCH VERIO TEST STRIPS
Formulary Brand
QL Yes 2 blood sugar diagnostic ACCU-CHEK TEST STRIPS
Formulary Brand
QL Yes 2 blood sugar diagnostic ASCENSIA TEST STRIPS
Formulary Brand
QL Yes 2 blood sugar diagnostic FREESTYLE TEST STRIPS
Formulary Brand
QL Yes 2 blood sugar diagnostic PRODIGY TEST STRIPS
Formulary Brand
QL Yes 2 blood-glucose meter ONE TOUCH ULTRA 2
Formulary Brand
QL Yes 2 blood-glucose meter ONE TOUCH VERIO FLEX
Formulary Brand
QL Yes 2 blood-glucose meter ACCU-CHEK Formulary Brand
QL Yes 2 blood-glucose meter ASCENSIA BREEZE Formulary Brand
QL Yes 2 blood-glucose meter FREESTYLE SYSTEM
Formulary Brand
QL Yes 2 blood-glucose meter ONE TOUCH ULTRA SMART
Formulary Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 43
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL Yes 2 blood-glucose meter ONE TOUCH ULTRAMINI
Formulary Brand
QL Yes 2 blood-glucose meter PRODIGY Formulary Brand
ST Yes 2 Insulin delivery system OMNIPOD DASHTM SYSTEM KIT AND PODs
Formulary Brand
QL Yes 2 syringe with needle,disposable BD INSULIN SYRINGE
Formulary Brand
Electrolytic, Caloric and Water Balance
Acidifying and Alkalinizing Agents
Yes 3 citric acid, sodium citrate, & potassium citrate
CYTRA-3 Non-Formulary
Brand
Yes 1 potassium citrate UROCIT-K Generic
Yes 2 potassium citrate & citric acid POLYCITRA-K Formulary Brand
Yes 3 sodium citrate & citric acid BICITRA Non-Formulary
Brand
Ammonia Detoxicants
ST Yes 3 carglumic acid CARBAGLU Non-Formulary
Brand
PA Yes 3 glycerol phenylbutyrate RAVICTI Non-Formulary
Brand
No 3 sodium phenylbutyrate BUPHENYL Non-Formulary
Brand
Yes 3 lactulose CHRONULAC Non-Formulary
Brand
Yes 1 lactulose ENULOSE Generic
Yes 3 lactulose KRISTALOSE Non-Formulary
Brand
Diuretics
ST Yes 1 amiloride MIDAMOR Generic
Yes 1 amiloride & hydrochlorothiazide MODURETIC Generic
Yes 1 bumetanide BUMEX Generic
ST Yes 1 chlorothiazide DIURIL Generic
Yes 1 chlorthalidone HYGROTON Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 44
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 3 ethacrynic acid EDECRIN Non-Formulary
Brand
Yes 1 furosemide LASIX Generic
Yes 1 hydrochlorothiazide MICROZIDE Generic
Yes 1 indapamide LOZOL Generic
ST Yes 1 methyclothiazide METHYCLOTHIAZIDE Generic
Yes 1 metolazone ZAROXOLYN Generic
PA No 3 tolvaptan JYNARQUE Non-Formulary
Brand
QL No 3 tolvaptan SAMSCA Non-Formulary
Brand
Yes 1 torsemide DEMADEX Generic
ST Yes 3 triamterene DYRENIUM Non-Formulary
Brand
Yes 1 triamterene & hydrochlorothiazide DYAZIDE Generic
Yes 1 triamterene & hydrochlorothiazide MAXZIDE Generic
Ion-Removing Agnets
ST Yes 1 sevelamer carbonate RENVELA Generic
No 1 sodium polystyrene sulfonate SPS Generic
Yes 3 sucroferric oxyhydroxide VELPHORO Non-Formulary
Brand
ST Yes 3 lanthanum carbonate FOSRENOL Non-Formulary
Brand
Yes 3 patiromer VELTASSA Non-Formulary
Brand
Yes 1 sevelamer hcl RENAGEL Generic
ST Yes 3 sodium zirconium cyclosilicate LOKELMA Non-Formulary
Brand
Replacement Products
Yes 2 calcium acetate ELIPHOS Formulary Brand
Yes 1 calcium acetate PHOSLO Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 45
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 2 calcium acetate PHOSLYRA Formulary Brand
Yes 1 potassium bicarbonate & potassium chloride
K-LYTE/CL Generic
Yes 1 potassium chloride K-DUR Generic
Yes 1 potassium chloride K-TAB 10, KLOR-CON 20 MEQ
Generic
Yes 3 potassium chloride powder KLOR-CON 20 MEQ Non-Formulary
Brand
Yes 1 potassium gluconate KAON Generic
Yes 2 potassium phosphate PHOSPHA Formulary Brand
Yes 3 potassium phosphate, monobasic K-PHOS NEUTRAL Non-Formulary
Brand
Yes 2 potassium phosphate, monobasic K-PHOS ORIGINAL Formulary Brand
Uricosuric Agents
Yes 1 colchicine & probenecid COL-BENEMID Generic
Yes 1 probenecid BENEMID Generic
Enzymes
Enzymes
Yes 2 dornase alfa PULMOZYME Formulary Brand
Eye, Ear, Nose and Throat (EENT)
Anti-infectives
Yes 3 azithromycin (ophth) AZASITE Non-Formulary
Brand
No 1 bacitracin & polmyxin B (ophth) POLYSPORIN Generic
No 1 bacitracin (ophth) AK-TRACIN Generic
ST Yes 3 besilfoxacin BESIVANCE Non-Formulary
Brand
No 1 chlorhexidine (mouth-throat) PERIDEX Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 46
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 3 ciprofloxacin (ophth) ointment CILOXAN Non-Formulary
Brand
No 1 ciprofloxacin (ophth) solution CILOXAN Generic
No 1 erythromycin (ophth) ROMYCIN Generic
ST Yes 3 ganciclovir (ophth) ZIRGAN Non-Formulary
Brand
ST No 1 gatifloxacin (ophth) ZYMAXID Generic
No 1 gentamicin (ophth) GENTAK Generic
No 1 levofloxacin (ophth) QUIXIN Generic
No 1 moxifloxacin (ophth) VIGAMOX Generic
Yes 2 natamycin NATACYN Formulary Brand
No 1 neomycin, bacitracin & polymyxin b (ophth)
NEO-POLYCIN Generic
No 1 neomycin, polymycin b & gramicidin (ophth)
NEOSPORIN Generic
No 1 ofloxacin (ophth) OCUFLOX Generic
No 1 ofloxacin (otic) FLOXIN Generic
No 1 polymyxin b & trimethoprim (ophth)
POLYTRIM Generic
No 1 sulfacetamide sodium (ophth) ointment
SULFAC Generic
No 1 sulfacetamide sodium (ophth) solution
BLEPH-10 Generic
No 2 tobramycin sulfate (ophth) ointment
TOBREX Formulary Brand
No 1 tobramycin sulfate (ophth) solution
TOBREX Generic
No 1 trifluridine VIROPTIC Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 47
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Anti-Inflammatory Agents
No 1 bacitracin, neomycin, polymyxin B & hydrocortisone (ophth)
NEO-POLYCIN HC Generic
ST Yes 3 bromfenac (ophth) XIBROM Non-Formulary
Brand
No 2 ciprofloxacin & dexamethasone (ophth)
CIPRODEX Formulary Brand
ST No 3 ciprofloxacin & hydrocortisone (otic)
CIPRO HC Non-Formulary
Brand
QL, ST Yes 3 cyclosporine (ophth) CEQUA Non-Formulary
Brand
QL, ST Yes 3 cyclosporine (ophth) RESTASIS Non-Formulary
Brand
Yes 1 dexamethasone (ophth) solution DECADRON Generic
Yes 2 dexamethasone (ophth) suspension
MAXIDEX Formulary Brand
No 1 diclofenac sodium (ophth) VOLTAREN Generic
ST Yes 3 difluprednate DUREZOL Non-Formulary
Brand
ST Yes 3 fluocinolone acetonide (otic) DERMOTIC Non-Formulary
Brand
Yes 1 fluorometholone (ophth) FML Generic
Yes 3 fluorometholone (ophth) FML FORTE Non-Formulary
Brand
ST Yes 3 fluorometholone (ophth oint) FML OINT Non-Formulary
Brand
Yes 2 fluorometholone acetate FLAREX Formulary Brand
ST No 1 flurbiprofen (ophth) OCUFEN Generic
No 2 gentamicin & prednisolone PRED-G Formulary Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 48
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 hydrocortisone & acetic acid (otic)
ACETASOL HC Generic
No 1 ketorolac (ophth) ACULAR Generic
No 1 ketorolac (ophth) ACULAR LS Generic
QL, ST Yes 3 lifitegrast XIIDRA Non-Formulary
Brand
Yes 3 loteprednol ALREX Non-Formulary
Brand
ST Yes 3 loteprednol LOTEMAX Non-Formulary
Brand
Yes 3 loteprednol & tobramycin ZYLET Non-Formulary
Brand
No 3 neomycin, colistin, hydrocortisone & thonzonium (otic)
CORTISPORIN-TC Non-Formulary
Brand
No 1 neomycin, polymyxin B & dexamethasone (ophth)
MAXITROL Generic
No 3 neomycin, polymyxin B & hydrocortisone (ophth)
CORTISPORIN Non-Formulary
Brand
No 1 neomycin, polymyxin B & hydrocortisone (otic)
CORTISPORIN Generic
ST Yes 3 nepafenac NEVANAC Non-Formulary
Brand
Yes 1 prednisolone acetate (ophth) OMNIPRED Generic
Yes 1 prednisolone acetate (ophth) PRED FORTE Generic
Yes 2 prednisolone acetate (ophth) PRED MILD Formulary Brand
Yes 3 prednisolone sodium phosphate (ophth)
INFLAMASE FORTE Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 49
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 prednisolone sodium phosphate (ophth)
PREDNISOL Generic
ST Yes 3 rimexolone VEXOL Non-Formulary
Brand
No 1 sulfacetamide sodium & prednisolone
BLEPHAMIDE Generic
No 2 tobramycin & dexamethasone ointment
TOBRADEX Formulary Brand
No 1 tobramycin & dexamethasone suspension
TOBRADEX Generic
Antiallergic Agents
ST Yes 3 aflcaftadine LASTACAFT Non-Formulary
Brand
Yes 1 azelastine ASTELIN Generic
Yes 1 azelastine ASTEPRO Generic
Yes 3 azelastine & fluticasone DYMISTA Non-Formulary
Brand
ST Yes 1 azelastine (ophth) OPTIVAR Generic
ST Yes 3 bepotastine BEPREVE Non-Formulary
Brand
Yes 1 cromolyn sodium (ophth) OPTICROM Generic
ST Yes 3 emedastine EMADINE Non-Formulary
Brand
ST Yes 1 epinastine (ophth) ELESTAT Generic
Yes 3 grass pollen allergen extract (5 glass extract)
ORALAIR Non-Formulary
Brand
ST Yes 3 lodoxamide tromethamine ALOMIDE Non-Formulary
Brand
Yes 3 house dust mite allergen extract ODACTRA Non-Formulary
Brand
ST Yes 3 nedocromil sodium (ophth) ALOCRIL Non-Formulary
Brand
ST Yes 3 olopatadine PATADAY Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 50
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 3 olopatadine (nasal) PATANASE Non-Formulary
Brand
ST Yes 1 olopatadine (ophth) PATANOL Generic
Yes 3 short ragweed pollen allergen extract
RAGWITEK Non-Formulary
Brand
Yes 3 timothy grass pollen allergen extract
GRASTEK Non-Formulary
Brand
Antiglaucoma Agents
Yes 1 acetazolamide DIAMOX Generic
Yes 1 acetazolamide DIAMOX SEQUELS Generic
Yes 1 betaxolol hcl BETOPTIC Generic
Yes 2 betaxolol hcl BETOPTIC S Formulary Brand
ST Yes 3 bimatoprost LUMIGAN Non-Formulary
Brand
Yes 1 brimonidine ALPHAGAN Generic
Yes 1 brimonidine tartrate ALPHAGAN P Generic
ST Yes 3 brimonidine & timolol COMBIGAN Non-Formulary
Brand
ST Yes 3 brinzolamide AZOPT Non-Formulary
Brand
Yes 2 carbachol ISOPTO CARBACHOL
Formulary Brand
ST Yes 1 carteolol (ophth) OCUPRESS Generic
Yes 1 dorzolamide TRUSOPT Generic
Yes 1 dorzolamide & timolol COSOPT Generic
Yes 2 ecothiophate PHOSPHOLINE IODIDE
Formulary Brand
Yes 1 latanoprost XALATAN Generic
PA Yes 3 latanoprostene bunod VYZULTA Non-Formulary
Brand
Yes 1 levobunolol BETAGAN Generic
Yes 1 methazolamide NEPTAZANE Generic
Yes 1 metipranolol OPTIPRANOLOL Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 51
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA Yes 3 netarsudil RHOPRESSA Non-Formulary
Brand
Yes 1 pilocarpine ISOPTO CARPINE Generic
Yes 3 pilocarpine gel PILOPINE HS Non-Formulary
Brand
Yes 3 timolol BETIMOL Non-Formulary
Brand
Yes 3 timolol ISTALOL Non-Formulary
Brand
Yes 1 timolol TIMOPTIC Generic
Yes 3 timolol TIMOPTIC-XE Non-Formulary
Brand
ST Yes 3 travoprost TRAVATAN Z Non-Formulary
Brand
Yes 3 unoprostone isopropyl RESCULA Non-Formulary
Brand
EENT Drugs, Miscellaneous
Yes 1 acetic acid VOSOL Generic
Yes 2 apraclonidine IOPIDINE Formulary Brand
ST Yes 3 artificial tear insert LACRISERT Non-Formulary
Brand
PA Yes 3 cenegermin-bkbj OXERVATE Non-Formulary
Brand
Local Anesthetics
Yes 1 antipyrine & benzocaine AURODEX Generic
No 1 lidocaine (mouth-throat) XYLOCAINE VISCOUS
Generic
Yes 1 proparacaine OPTHETIC Generic
Mydriatics
Yes 1 atropine ISOPTO ATROPINE Generic
Yes 2 homatropine ISOPTO HOMATROPINE
Formulary Brand
Yes 2 scopolamine (ophth) ISOPTO HYOSCINE Formulary Brand
Vasoconstrictors
ST Yes 1 tetrahydrozoline TYZINE Generic
Gastrointestinal Drugs
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 52
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Anti-inflammatory Agents
No 1 alosetron LOTRONEX Generic
Yes 1 balsalazide COLAZAL Generic
Yes 3 balsalazide GIAZO Non-Formulary
Brand
PA Yes 3 eluxadoline VIBERZI Non-Formulary
Brand
Yes 2 mesalamine controlled-release PENTASA Formulary Brand
Yes 2 mesalamine suppository CANASA Formulary Brand
Yes 1 mesalamine suspension ROWASA Generic
Yes 2 mesalamine tablet LIALDA Formulary Brand
ST Yes 3 olsalazine DIPENTUM Non-Formulary
Brand
Antidiarrhea Agents
ST Yes 3 difenoxin & atropine MOTOFEN Non-Formulary
Brand
No 1 diphenoxylate & atropine LOMOTIL Generic
Yes 3 paregoric PAREGORIC Non-Formulary
Brand
Antiemetics
No 2 aprepitant EMEND Formulary Brand
ST Yes 3 dolasetron ANZEMET Non-Formulary
Brand
No 1 dronabinol MARINOL Generic
ST No 3 granisetron KYTRIL Non-Formulary
Brand
No 3 granisetron SANCUSO Non-Formulary
Brand
ST Yes 3 nabilone CESAMET Non-Formulary
Brand
Yes 2 netupitant & palonosetron AKYNZEO Formulary Brand
No 1 ondansetron ZOFRAN Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 53
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
No 1 ondansetron (orally disintegrating)
ZOFRAN ODT Generic
QL No 1 prochlorperazine COMPAZINE Generic
Yes 3 rolapitant VARUBI Non-Formulary
Brand
ST Yes 1 scopolamine hydrobromide TRANSDERM-SCOP Generic
ST No 1 trimethobenzamide TIGAN Generic
Antiulcer Agents and Acid Suppressants
No 3 amoxicillin, clarithromycin, & lansoprazole
PREVPAC Non-Formulary
Brand
Yes 1 cimetidine TAGAMET Generic
ST Yes 3 dexlansoprazole DEXILANT Non-Formulary
Brand
ST No 1 esomeprazole NEXIUM Generic
Yes 1 famotidine PEPCID Generic
Yes 1 lansoprazole PREVACID Generic
Yes 1 misoprostol CYTOTEC Generic
ST Yes 1 nizatidine AXID Generic
Yes 1 omeprazole PRILOSEC Generic
Yes 1 pantoprazole PROTONIX Generic
ST Yes 1 rabeprazole ACIPHEX Generic
Yes 1 sucralfate tablets CARAFATE Generic
Yes 3 sucralfate suspension CARAFATE Non-Formulary
Brand
Cathartics and Laxatives
Yes 3 polyethylene glycol-electrolyte solution
HALFLYTELY Non-Formulary
Brand
ST Yes 3 polyethylene glycol-electrolyte solution
MOVIPREP Non-Formulary
Brand
Yes 1 polyethylene glycol-electrolyte solution
COLYTE Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 54
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 polyethylene glycol-electrolyte solution
GOLYTELY Generic
Yes 1 polyethylene glycol-electrolyte solution
GAVILYTE-C Generic
Yes 1 polyethylene glycol-electrolyte solution
NULYTELY Generic
ST Yes 3 sodium phosphates OSMOPREP Non-Formulary
Brand
No 3 sodium phosphates VISICOL Non-Formulary
Brand
ST No 3 sodium picosulfate-mag ox-anhydrous citric acid
PREPOPIK Non-Formulary
Brand
Digestants
Yes 2 pancrelipase (lipase-protease-amylase)
CREON Formulary Brand
Yes 2 pancrelipase (lipase-protease-amylase)
ZENPEP Formulary Brand
Yes 2 pancrelipase (lipase-protease-amylase)
PANCREAZE Formulary Brand
Yes 3 pancrelipase (lipase-protease-amylase)
VIOKACE Non-Formulary
Brand
Yes 3 pancrelipase (lipase-protease-amylase)
PERTZYE Non-Formulary
Brand
GI Drugs, Miscellaneous
Yes 1 clidinium & chlordiazepoxide LIBRAX Generic
QL, ST Yes 3 linaclotide LINZESS Non-Formulary
Brand
ST Yes 3 lubiprostone AMITIZA Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 55
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 3 mepenzolate CANTIL Non-Formulary
Brand
Yes 1 metoclopramide REGLAN Generic
ST Yes 3 methylnaltrexone RELISTOR Non-Formulary
Brand
No 3 phenobarbital and belladonna alkaloids
DONNATAL Non-Formulary
Brand
Yes 3 teduglutide GATTEX Non-Formulary
Brand
Yes 1 ursodiol ACTIGALL Generic
Yes 1 ursodiol URSO Generic
Yes 1 ursodiol URSO FORTE Generic
Gold Compounds
Gold Compounds
Yes 2 auranofin RIDAURA Formulary Brand
Heavy Metal Antagonists
Heavy Metal Antagonists
No 2 deferasirox EXJADE Formulary Brand
Yes 3 deferiprone FERRIPROX Non-Formulary
Brand
No 2 penicillamine CUPRIMINE Formulary Brand
No 2 penicillamine DEPEN Formulary Brand
ST Yes 3 succimer CHEMET Non-Formulary
Brand
ST No 3 trientine SYPRINE Non-Formulary
Brand
Hormones and Synthetic Substitutes
Adrenals
ST No 1 budesonide ENTOCORT EC Generic
No 3 budesonide UCERIS Non-Formulary
Brand
ST Yes 1 cortisone acetate CORTONE ACETATE Generic
Yes 1 dexamethasone DECADRON Generic
Yes 1 fludrocortisone FLORINEF ACETATE Generic
Yes 1 hydrocortisone CORTEF Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 56
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 methylprednisolone MEDROL Generic
Yes 1 prednisolone PRELONE Generic
Yes 1 prednisolone acetate PREDNISOLONE Generic
Yes 1 prednisolone sodium phosphate ORAPRED Generic
Yes 1 prednisolone sodium phosphate ORAPRED ODT Generic
Yes 1 prednisolone sodium phosphate PEDIAPRED Generic
Yes 1 prednisone PREDNISONE Generic
Yes 3 prednisone RAYOS Non-Formulary
Brand
Anabolic Steroid
ST Yes 3 oxymetholone ANADROL-50 Non-Formulary
Brand
Androgens
Yes 1 danazol DANOCRINE Generic
Yes 2 fluoxymesterone ANDROXY Formulary Brand
Yes 2 methyltestosterone ANDROID 10 Formulary Brand
Yes 3 methyltestosterone METHITEST Non-Formulary
Brand
Yes 1 methyltestosterone TESTRED Generic
Yes 1 oxandrolone OXANDRIN Generic
Yes 3 testosterone ANDRODERM Non-Formulary
Brand
Yes 3 testosterone AXIRON Non-Formulary
Brand
ST Yes 1 testosterone ANDROGEL Generic
Yes 1 testosterone TESTIM Generic
Yes 3 testosterone FORTESTA Non-Formulary
Brand
Yes 1 testosterone cypionate DEPO-TESTOSTERONE
Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 57
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Contraceptives
QL Yes 1 desogestrel & ethinyl estradiol APRI Generic
QL Yes 3 desogestrel & ethinyl estradiol DESOGEN Non-Formulary
Brand
QL Yes 3 desogestrel & ethinyl estradiol ORTHO-CEPT Non-Formulary
Brand
QL Yes 1 desogestrel & ethinyl estradiol RECLIPSEN Generic
QL Yes 1 desogestrel & ethinyl estradiol (biphasic)
KARIVA Generic
QL Yes 1 desogestrel & ethinyl estradiol (triphasic)
CYCLESSA Generic
QL Yes 1 desogestrel & ethinyl estradiol (triphasic)
VELIVET Generic
ST Yes 3 drospirenone SLYND Non-Formulary
Brand
QL Yes 1 drospirenone & ethinyl estradiol GIANVI Generic
QL Yes 1 drospirenone & ethinyl estradiol OCELLA Generic
QL Yes 1 drospirenone & ethinyl estradiol YASMIN Generic
QL Yes 1 drospirenone & ethinyl estradiol YAZ Generic
QL Yes 3 drospirenone & ethinyl estradiol w/ folate
BEYAZ Non-Formulary
Brand
QL, ST Yes 3 drospirenone & ethinyl estradiol w/ folate
SAFYRAL Non-Formulary
Brand
No 1 estradiol cypionate DELESTROGEN Generic
No 1 estradiol valerate DEPO-ESTRADIOL Generic
QL, ST Yes 3 estradiol valerate & dienogest NATAZIA Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 58
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL Yes 1 ethynodiol diacetate & ethinyl estradiol
KELNOR Generic
QL Yes 1 ethynodiol diacetate & ethinyl estradiol
ZOVIA Generic
QL Yes 2 etonogestrel & ethinyl estradiol NUVARING Formulary Brand
AGE Yes 1 levonorgestrel PLAN B Generic
QL Yes 1 levonorgestrel & ethinyl estradiol LUTERA Generic
QL Yes 1 levonorgestrel & ethinyl estradiol LESSINA Generic
QL Yes 1 levonorgestrel & ethinyl estradiol PORTIA Generic
QL Yes 3 levonorgestrel & ethinyl estradiol NORDETTE-28 Non-Formulary
Brand
QL Yes 1 levonorgestrel & ethinyl estradiol (91-day)
INTROVALE Generic
QL Yes 3 levonorgestrel & ethinyl estradiol (91-day)
LOSEASONIQUE Non-Formulary
Brand
QL Yes 1 levonorgestrel & ethinyl estradiol (91-day)
SEASONALE Generic
QL Yes 3 levonorgestrel & ethinyl estradiol (91-day)
SEASONIQUE Non-Formulary
Brand
QL Yes 1 levonorgestrel & ethinyl estradiol (continuous)
AMYTHYST Generic
QL Yes 3 levonorgestrel & ethinyl estradiol (continuous)
LYPREL Non-Formulary
Brand
QL Yes 1 levonorgestrel & ethinyl estradiol (triphasic)
TRIVORA Generic
QL Yes 3 norelgestromin & ethinyl estradiol ORTHO EVRA Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 59
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL, ST Yes 1 norelgestromin & ethinyl estradiol XULANE Generic
QL Yes 1 norethindrone CAMILA Generic
QL Yes 1 norethindrone NORA-BE Generic
QL Yes 3 norethindrone NOR-QD Non-Formulary
Brand
QL Yes 1 norethindrone & ethinyl estradiol BALZIVA Generic
QL Yes 3 norethindrone & ethinyl estradiol BREVICON Non-Formulary
Brand
QL Yes 1 norethindrone & ethinyl estradiol JUNEL Generic
QL Yes 1 norethindrone & ethinyl estradiol MICROGESTIN Generic
QL Yes 3 norethindrone & ethinyl estradiol MODICON Non-Formulary
Brand
QL Yes 1 norethindrone & ethinyl estradiol NECON Generic
QL Yes 3 norethindrone & ethinyl estradiol NORINYL 1+35 Non-Formulary
Brand
QL Yes 1 norethindrone & ethinyl estradiol NORTREL 1/35 Generic
QL Yes 1 norethindrone & ethinyl estradiol OVCON-35 Generic
QL Yes 3 norethindrone & ethinyl estradiol OVCON-50 Non-Formulary
Brand
QL Yes 1 norethindrone & ethinyl estradiol (biphasic)
NECON 10/11 Generic
QL Yes 1 norethindrone & ethinyl estradiol (triphasic)
ARANELLE Generic
QL Yes 1 norethindrone & ethinyl estradiol (triphasic)
NORTREL 7/7/7 Generic
QL Yes 3 norethindrone & ethinyl estradiol (triphasic)
ORTHO-NOVUM Non-Formulary
Brand
QL Yes 3 norethindrone & ethinyl estradiol (triphasic)
TRI-NORINYL Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 60
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL Yes 3 norethindrone & ethinyl estradiol w/ ferrous fumarate
ESTROSTEP FE Non-Formulary
Brand
QL, ST Yes 3 norethindrone & ethinyl estradiol w/ ferrous fumarate
FEMCON FE Non-Formulary
Brand
QL Yes 1 norethindrone & ethinyl estradiol w/ ferrous fumarate
GENERESS FE Generic
QL Yes 3 norethindrone & ethinyl estradiol w/ ferrous fumarate
JUNEL FE Non-Formulary
Brand
QL Yes 1 norethindrone & ethinyl estradiol w/ ferrous fumarate
MICROGESTIN FE Generic
QL, ST Yes 3 norethindrone & ethinyl estradiol w/ ferrous fumarate
MINASTRIN 24 FE Non-Formulary
Brand
QL Yes 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate
LOESTRIN 24 FE Non-Formulary
Brand
QL Yes 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate
LOESTRIN FE Non-Formulary
Brand
QL Yes 1 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate
TILIA Generic
QL, ST Yes 3 norethindrone acetate & ethinyl estradiol w/ ferrous fumarate (biphasic)
LO LOESTRIN FE Non-Formulary
Brand
QL Yes 3 norethindrone-mestranol NORINYL 1+50 Non-Formulary
Brand
QL Yes 3 norethindrone-mestranol ORTHO-NOVUM Non-Formulary
Brand
QL Yes 1 norgestimate & ethinyl estradiol CRYSELLE Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 61
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
QL Yes 1 norgestimate & ethinyl estradiol MONONESSA Generic
QL Yes 3 norgestimate & ethinyl estradiol ORTHO-CYCLEN Non-Formulary
Brand
QL Yes 1 norgestimate & ethinyl estradiol SPRINTEC Generic
QL Yes 1 norgestimate & ethinyl estradiol TRINESSA Generic
QL Yes 3 norgestimate & ethinyl estradiol (triphasic)
ORTHO TRI-CYCLEN Non-Formulary
Brand
QL Yes 1 norgestimate & ethinyl estradiol (triphasic)
TRI-LO-SPRINTEC Generic
QL Yes 1 norgestimate & ethinyl estradiol (triphasic)
TRI-SPRINTEC Generic
QL Yes 3 norgestrel & ethinyl estradiol LO/OVRAL-28 Non-Formulary
Brand
QL Yes 1 norgestrel & ethinyl estradiol LOW-OGESTREL Generic
QL Yes 1 norgestrel & ethinyl estradiol OGESTREL Generic
QL, ST Yes 3 segesterone & ethinyl estradiol ANNOVERA Non-Formulary
Brand
Yes 2 ulipristal ELLA Formulary Brand
Diabetic Agents
Yes 1 acarbose PRECOSE Generic
PA Yes 3 albiglutide TANZEUM Non-Formulary
Brand
PA Yes 1 alogliptin NESINA Generic
PA Yes 1 alogliptin & metformin KAZANO Generic
PA Yes 1 alogliptin & pioglitazone OSENI Generic
PA Yes 3 canagliflozin INVOKANA Non-Formulary
Brand
PA Yes 3 canagliflozin & metformin INVOKAMET Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 62
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 1 chlorpropamide CHLORPROPAMIDE Generic
PA Yes 3 dapagliflozin FARXIGA Non-Formulary
Brand
PA Yes 3 dapagliflozin & metformin XIGDUO XR Non-Formulary
Brand
PA Yes 3 dulaglutide TRULICITY Non-Formulary
Brand
PA, QL Yes 2 empagliflozin JARDIANCE 25 MG Formulary Brand
PA Yes 3 empagliflozin & lingaliptin GLYXAMBI Non-Formulary
Brand
PA Yes 3 empagliflozin & metformin SYNJARDY Non-Formulary
Brand
PA Yes 3 ertufliglozin STEGLATRO Non-Formulary
Brand
PA Yes 3 ertugliflozin & metformin SEGLUROMET Non-Formulary
Brand
Yes 3 ertugliflozin & sitagliptin STEGLUJAN
Non-Formulary Brand
PA Yes 3
PA, QL Yes 3 exenatide BYETTA Non-Formulary
Brand
PA,QL Yes 3 exenatide extended-release BYDUREON Non-Formulary
Brand
Yes 1 glimepiride AMARYL Generic
Yes 1 glipizide GLUCOTROL Generic
Yes 1 glipizide & metformin METAGLIP Generic
Yes 1 glipizide extended-release GLUCOTROL XL Generic
No 2 glucagon BAQSIMI Formulary Brand
No 2 glucagon GLUCAGON EMERGENCY KIT
Formulary Brand
No 3 glucagon GLUCAGEN HYPOKIT
Non-Formulary Brand
AGE No 2 glucagon GVOKE Formulary Brand
Yes 1 glyburide DIABETA Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 63
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 glyburide & metformin GLUCOVANCE Generic
Yes 1 glyburide micronized GLYNASE Generic
PA,QL Yes 3 insulin (oral inhalation) AFREZZA Non-Formulary
Brand
ST Yes 3 insulin aspart NOVOLOG Non-Formulary
Brand
ST Yes 3 insulin aspart FIASP Non-Formulary
Brand
ST Yes 3 insulin aspart FIASP FLEXPEN Non-Formulary
Brand
ST Yes 3 insulin aspart protamine & insulin aspart
NOVOLOG MIX 70/30 Non-Formulary
Brand
ST Yes 3 insulin aspart protamine & insulin aspart
NOVOLOG MIX 70/30 FLEXPEN
Non-Formulary Brand
ST Yes 3 insulin degludec TRESIBA Non-Formulary
Brand
Yes 3 insulin degludec/insulin aspart RYZODEG 70/30 Non-Formulary
Brand
PA, QL Yes 3 Insulin degludec/ liraglutide XULTOPHY Non-Formulary
Brand
ST Yes 3 insulin detemir LEVEMIR Non-Formulary
Brand
ST Yes 3 insulin glargine LANTUS Non-Formulary
Brand
ST Yes 3 insulin glargine LANTUS SOLOSTAR Non-Formulary
Brand
ST Yes 3 insulin glargine BASAGLAR Non-Formulary
Brand
PA, QL Yes 3 Insulin glargine/ lixisenatide SOLIQUA Non-Formulary
Brand
ST Yes 3 insulin glulisine APIDRA Non-Formulary
Brand
Yes 3 insulin isophane NOVOLIN N Non-Formulary
Brand
Yes 2 insulin isophane HUMULIN N Formulary Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 64
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 3 insulin isophane HUMULIN N KWIKPEN
Non-Formulary Brand
Yes 3 insulin isophane & regular insulin NOVOLIN 70/30 Non-Formulary
Brand
Yes 3 insulin isophane & regular insulin HUMULIN 50/50 Non-Formulary
Brand
Yes 2 insulin isophane & regular insulin HUMULIN 70/30 Formulary Brand
ST Yes 3 insulin isophane & regular insulin HUMULIN 70/30 KIWKPEN
Non-Formulary Brand
ST Yes 3 insulin lispro HUMALOG Non-Formulary
Brand
ST Yes 3 insulin lispro HUMALOG KWIKPEN Non-Formulary
Brand
ST Yes 3 insulin lispro ADMELOG Non-Formulary
Brand
Yes 3 insulin lispro protamine & insulin lispro
HUMALOG MIX 50/50 Non-Formulary
Brand
ST Yes 3 insulin lispro protamine & insulin lispro
HUMALOG MIX 75/25 Non-Formulary
Brand
ST Yes 3 insulin lispro protamine & insulin lispro
HUMALOG MIX 75/25 KWIKPEN
Non-Formulary Brand
Yes 3 insulin regular NOVOLIN R Non-Formulary
Brand
Yes 2 insulin regular HUMULIN R Formulary Brand
ST Yes 2 insulin regular HUMULIN R U-500 Formulary Brand
ST Yes 3 insulin regular HUMULIN R U-500 KWIKPEN
Non-Formulary Brand
PA Yes 3 linagliptin TRADJENTA Non-Formulary
Brand
PA Yes 3 linagliptin & metformin JENTADUETO Non-Formulary
Brand
PA, QL Yes 3 liraglutide VICTOZA Non-Formulary
Brand
PA, QL Yes 3 lixisenatide ADLYXIN Non-Formulary
Brand
Yes 1 metformin GLUCOPHAGE Generic
PA Yes 1 metformin ER FORTAMET Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 65
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA Yes 1 metformin ER GLUMETZA Generic
Yes 3 metformin RIOMET Non-Formulary
Brand
Yes 1 metformin extended-release GLUCOPHAGE XR Generic
PA Yes 3 mifepristone KORLYM Non-Formulary
Brand
ST Yes 3 miglitol GLYSET Non-Formulary
Brand
ST Yes 1 nateglinide STARLIX Generic
Yes 1 pioglitazone ACTOS Generic
Yes 3 pioglitazone & glimepiride DUETACT Non-Formulary
Brand
Yes 3 pioglitazone & metformin ACTOPLUS MET Non-Formulary
Brand
PA Yes 3 pramlintide acetate SYMLIN Non-Formulary
Brand
ST Yes 1 repaglinide PRANDIN Generic
ST Yes 1 repaglinide & metformin PRANDIMET Generic
ST Yes 3 rosiglitazone AVANDIA Non-Formulary
Brand
ST Yes 3 rosiglitazone & glimepiride AVANDARYL Non-Formulary
Brand
ST Yes 3 rosiglitazone & metformin AVANDAMET Non-Formulary
Brand
PA Yes 3 saxagliptin ONGLYZA Non-Formulary
Brand
PA Yes 3 saxagliptin & metformin extended-release
KOMBIGLYZE XR Non-Formulary
Brand
PA Yes 3 sitagliptin & metformin JANUMET Non-Formulary
Brand
PA Yes 3 sitagliptin & simvastatin JUVISYNC Non-Formulary
Brand
PA Yes 3 sitagliptin phosphate JANUVIA Non-Formulary
Brand
PA, QL Yes 3 semaglutide OZEMPIC Non-Formulary
Brand
ST Yes 1 tolazamide TOLINASE Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 66
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 1 tolbutamide ORINASE Generic
Estrogens and Antiestrogens
Yes 3 conjugated estrogens & bazedoxifene
DUAVEE Non-Formulary
Brand
Yes 3 conjugated estrogens & medroxyprogesterone acetate
PREMPHASE Non-Formulary
Brand
Yes 3 conjugated estrogens & medroxyprogesterone acetate
PREMPRO Non-Formulary
Brand
Yes 3 drospirenone & estradiol ANGELIQ Non-Formulary
Brand
ST Yes 3 esterified estrogens MENEST Non-Formulary
Brand
Yes 1 estradiol ESTRACE TAB Generic
Yes 1 estradiol GYNODIOL Generic
ST Yes 3 estradiol & levonorgestrel CLIMARA PRO Non-Formulary
Brand
Yes 1 estradiol & norethindrone ACTIVELLA Generic
ST Yes 3 estradiol & norethindrone COMBIPATCH Non-Formulary
Brand
Yes 3 estradiol & norgestimate PREFEST Non-Formulary
Brand
Yes 3 estradiol acetate FEMTRACE Non-Formulary
Brand
ST Yes 3 estradiol acetate vaginal tablets FEMRING Non-Formulary
Brand
ST Yes 3 estradiol gel DIVIGEL Non-Formulary
Brand
ST Yes 3 estradiol gel ELESTRIN GEL Non-Formulary
Brand
ST Yes 3 estradiol transdermal ALORA Non-Formulary
Brand
Yes 1 estradiol transdermal CLIMARA DIS Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 67
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 3 estradiol transdermal ESTRADERM Non-Formulary
Brand
ST Yes 3 estradiol transderomal EVAMIST Non-Formulary
Brand
ST Yes 3 estradiol transdermal MENOSTAR Non-Formulary
Brand
Yes 1 estradiol transdermal MINIVELLE Generic
ST Yes 3 estradiol transdermal VIVELLE-DOT Non-Formulary
Brand
Yes 1 estradiol vaginal ESTRACE CREAM Generic
Yes 2 estradiol vaginal ESTRING Formulary Brand
Yes 3 estradiol vaginal VAGIFEM Non-Formulary
Brand
Yes 1 estradiol vaginal YUVAFEM Generic
Yes 1 estradiol vaginal ESTRACE Generic
Yes 1 estrogen, ester/me-testosterone ESTRATEST Generic
ST Yes 3 estrogens, conjugated PREMARIN Non-Formulary
Brand
Yes 3 estrogens, conjugated synthetic a CENESTIN Non-Formulary
Brand
ST Yes 3 estrogens, conjugated synthetic b ENJUVIA Non-Formulary
Brand
ST Yes 2 estrogens, conjugated vaginal PREMARIN CREAM Formulary Brand
Yes 1 estropipate ORTHO-EST Generic
Yes 1 norethindrone acetate & ethinyl estradiol
FEMHRT Generic
Yes 3 ospemifene OSPHENA Non-Formulary
Brand
Yes 1 raloxifene hcl EVISTA Generic
ESTROGEN AND PROGESTIN (COMBINATION PRODUCT)
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 68
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 3 estradiol and progesterone BIJUVA Non-Formulary
Brand
Gonadatropins
Yes 2 nafarelin SYNAREL Formulary Brand
Parathyroid
PA Yes 3 abaloparatide TYMLOS Non-Formulary
Brand
ST Yes 1 calcitonin salmon FORTICAL Generic
ST Yes 1 calcitonin salmon MIACALCIN Generic
PA No 3 teriparatide FORTEO Non-Formulary
Brand
Pitutary
PA Yes 3 corticotropin ACTHAR Non-Formulary
Brand
Yes 1 desmopressin (non-refrigerated) DDAVP Generic
Yes 3 desmopressin acetate STIMATE Non-Formulary
Brand
Progestins
Yes 1 medroxyprogesterone acetate PROVERA Generic
No 1 megestrol acetate MEGACE Generic
Yes 1 norethindrone acetate AYGESTIN Generic
Yes 1 progesterone, micronized PROMETRIUM Generic
Somatotropin Agonists and Antagonists
PA Yes 3 somatropin GENTROPIN Non-Formulary
Brand
PA Yes 3 somatropin HUMATROPE Non-Formulary
Brand
PA Yes 3 somatropin NORDITROPIN Non-Formulary
Brand
PA Yes 3 somatropin NUTROPIN AQ Non-Formulary
Brand
PA Yes 3 somatropin OMNITROPE Non-Formulary
Brand
PA Yes 3 somatropin SAIZEN Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 69
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA Yes 3 somatropin SEROSTIM Non-Formulary
Brand
PA Yes 3 pegvisomant SOMAVERT Non-Formulary
Brand
PA Yes 3 somatropin ZORBTIVE Non-Formulary
Brand
Thyroid and Antihyroid Agent
Yes 1 levothyroxine LEVOTHROID Generic
Yes 1 levothyroxine LEVOXYL Generic
Yes 1 levothyroxine SYNTHROID Generic
Yes 3 levothyroxine TIROSINT Non-Formulary
Brand
Yes 1 levothyroxine UNITHROID Generic
Yes 1 liothyronine CYTOMEL Generic
ST Yes 3 liotrix THYROLAR Non-Formulary
Brand
Yes 1 methimazole TAPAZOLE Generic
Yes 2 potassium iodide & iodine LUGOL’S SOLUTION Formulary Brand
Yes 1 propylthiouracil PROPYLTHIOURACIL Generic
Yes 3 thyroid ARMOUR THYROID Non-Formulary
Brand
Miscellaneous Therapeutic Agents
Miscellanous Therapeutic Agents
Yes 2 abatacept ORENCIA Formulary Brand
Yes 1 acetylcysteine MUCOMYST-10 Generic
PA Yes 3 adalimumab HUMIRA Non-Formulary
Brand
PA Yes 3 adalimumab HUMIRA citrate free Non-Formulary
Brand
Yes 1 alendronate FOSAMAX Generic
Yes 3 alendronate & cholecalciferol FOSAMAX PLUS D Non-Formulary
Brand
Yes 1 allopurinol ZYLOPRIM Generic
PA Yes 3 amifampridine FIRDAPSE Non-Formulary
Brand
Yes 3 anakinra KINERET Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 70
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA Yes 2 apremilast OTEZLA Formulary Brand
Yes 1 azathioprine AZASAN Generic
Yes 1 azathioprine IMURAN Generic
PA Yes 3 baricitnib OLUMIANT Non-Formulary
Brand
Yes 3 bedaquiline SIRTURO Non-Formulary
Brand
ST Yes 3 betaine CYSTADANE POWD Non-Formulary
Brand
PA Yes 3 brodalumab SILIQ Non-Formulary
Brand
PA Yes 3 c-1 esterase inhibitor HAEGARDA Non-Formulary
Brand
PA Yes 3 canakinumab ILARIS Non-Formulary
Brand
PA Yes 3 certolizumab Pegol CIMZIA Non-Formulary
Brand
PA Yes 3 cholic acid CHOLBAM Non-Formulary
Brand
No 2 cinacalcet SENSIPAR Formulary Brand
ST Yes 1 colchicine COLCRYS Generic
Yes 1 cyclosporine SANDIMMUNE Generic
Yes 1 cyclosporine, modified NEORAL Generic
PA Yes 3 cysteamine delayed-release PROCYSBI Non-Formulary
Brand
ST Yes 3 cysteamine immediate-release CYSTAGON Non-Formulary
Brand
No 1 dalfampridine AMPYRA Generic
QL, PA Yes 3 dichlorphenamide KEVEYIS Non-Formulary
Brand
PA Yes 3 daflazacort EMFLAZA Non-Formulary
Brand
PA Yes 1 dimethyl fumarate TECFIDERA Generic
PA Yes 3 dupilumab DUPIXENT Non-Formulary
Brand
Yes 1 disulfiram ANTABUSE Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 71
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 1 dutasteride AVODART Generic
Yes 1 dutasteride & tamsulosin JALYN Generic
PA Yes 3 elagolix ORILISSA Non-Formulary
Brand
PA Yes 3 eliglustat CERDELGA Non-Formulary
Brand
PA Yes 3 emicizumab-kxwh HEMLIBRA Non-Formulary
Brand
PA Yes 3 erenumab-aooe AIMOVIG Non-Formulary
Brand
PA Yes 3 etanercept ENBREL Non-Formulary
Brand
ST Yes 1 etidronate DIDRONEL Generic
No 3 everolimus ZORTRESS Non-Formulary
Brand
ST Yes 3 febuxostat ULORIC Non-Formulary
Brand
PA Yes 3 fingolimod GILENYA Non-Formulary
Brand
PA Yes 3 fostamatinib TAVALISSE Non-Formulary
Brand
PA Yes 3 galcanezumab EMGALITY Non-Formulary
Brand
PA Yes 3 guselkumab TREMFYA Non-Formulary
Brand
PA No 3 glatiramer acetate COPAXONE 20 mg Non-Formulary
Brand
No 1 glatiramer acetate COPAXONE 40 mg Generic
No 1 glatiramer acetate GLATOPA Generic
PA Yes 3 golimumab SIMPONI Non-Formulary
Brand
ST Yes 1 ibandronate BONIVA Generic
PA No 3 icatibant FIRAZYR Non-Formulary
Brand
PA Yes 3 immune globulin HYQVIA Non-Formulary
Brand
PA Yes 3 immune globulin HIZENTRA Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 72
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA Yes 3 inotersen TEGSEDI Non-Formulary
Brand
PA Yes 3 interferon beta-1a AVONEX Non-Formulary
Brand
PA Yes 3 interferon beta-1a PLEGRIDY Non-Formulary
Brand
PA Yes 3 interferon beta-1a REBIF Non-Formulary
Brand
PA Yes 3 interferon beta-1a REBIF REBIDOSE Non-Formulary
Brand
Yes 3 interferon beta-1b BETASERON Non-Formulary
Brand
Yes 2 Interferon beta-1b EXTAVIA Formulary Brand
Yes 2 interferon gamma-1b ACTIMMUNE Formulary Brand
PA Yes 3 ixekizumab TALTZ Non-Formulary Brand
PA Yes 3 lanadelumab TAKHZYRO Non-Formulary
Brand
Yes 3 lanreotide SOMATULINE DEPOT
Non-Formulary Brand
Yes 3 lesinurad ZURAMPIC Non-Formulary
Brand
Yes 1 leflunomide ARAVA Generic
Yes 1 leucovorin LEUCOVORIN Generic
PA Yes 3 l-glutamine ENDARI Non-Formulary
Brand
Yes 2 mesna MESNEX Formulary Brand
No 1
methenamine, sodium biphosphate, phenyl salicylate, methylene blue, and hyoscyamine
URO-MP Generic
Yes 1 methylergonovine maleate METHERGINE Generic
Yes 3 metreleptin MYALEPT Non-Formulary
Brand
Yes 3 mifepristone MIFEPREX Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 73
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA Yes 3 migalastat GALAFOLD Non-Formulary
Brand
PA No 3 miglustat ZAVESCA Non-Formulary
Brand
Yes 1 mycophenolate mofetil CELLCEPT Generic
Yes 1 mycophenolate sodium MYFORTIC Generic
Yes 3 nitisinone ORFADIN Non-Formulary
Brand
No 1 octreotide acetate SANDOSTATIN Generic
PA No 3 ozanimod ZEPOSIA Non-Formulary
Brand
PA Yes 3 parathyroid hormone NATPARA Non-Formulary
Brand
PA Yes 3 pasireotide SIGNIFOR Non-Formulary
Brand
Yes 1 pediatric multivitamins w/ fluoride POLY-VI-FLOR Generic
Yes 1 pediatric multivitamins w/ fluoride & iron
POLY-VI-FLOR W/IRON
Generic
Yes 1 pediatric vitamins a, c, & d, w/ fluoride
TRI-VI-FLOR Generic
Yes 1 pediatric vitamins a, c, & d, w/ fluoride & iron
TRI-VI-FLOR W/IRON Generic
PA Yes 3 pegvaliase PALYNZIQ Non-Formulary
Brand
PA Yes 2 pentosan polysulfate sodium ELMIRON Formulary Brand
PA Yes 3 risankizumab SKYRIZI Non-Formulary
Brand
ST Yes 1 risedronate sodium ACTONEL Generic
Yes 3 risedronate sodium ATELVIA Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 74
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
PA Yes 3 sapropterin dihydrochloride KUVAN Non-Formulary
Brand
PA Yes 3 sarilumab KEVZARA Non-Formulary
Brand
PA Yes 3 secukinumab COSENTYX Non-Formulary
Brand
No 3 sirolimus solution RAPAMUNE Non-Formulary
Brand
Yes 1 sirolimus RAPAMUNE Generic
Yes 3 sodium fluoride FLUORABON BASIC Non-Formulary
Brand
Yes 1 sodium fluoride FLUORITAB Generic
Yes 1 sodium fluoride LURIDE CHEW Generic
Yes 1 sodium fluoride (dental) PREVIDENT Generic
Yes 1 sodium fluoride (dental) PREVIDENT 5000 PLUS
Generic
Yes 1 sodium fluoride drops LURIDE DROPS Generic
Yes 2 stannous fluoride GEL-KAM Formulary Brand
Yes 1 tacrolimus PROGRAF Generic
PA Yes 3 teriflunomide AUBAGIO Non-Formulary
Brand
QL Yes 2 thalidomide THALOMID Formulary Brand
PA Yes 3 tildrakizumab-asmn ILUMYA Non-Formulary
Brand
ST Yes 3 tiludronate SKELID Non-Formulary
Brand
Yes 2 tocilizumab ACTEMRA Formulary Brand
Yes 2 tofacitinib XELJANZ Formulary Brand
PA No 3 upadacitinib RINVOQ Non-Formulary
Brand
PA Yes 3 ustekinumab STELARA Non-Formulary
Brand
PA, QL Yes 3 voxelotor OXBRYTA Non-Formulary
Brand
Respiratory Tract Agents
Antitussives
Yes 1 benzonatate TESSALON PERLES Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 75
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 guaifenesin & codeine CHERATUSSIN AC Generic
No 3 hydrocodone & chlorpheniramine TUSSIONEX Non-Formulary
Brand
No 1 hydrocodone & homatropine HYCODAN Generic
No 1 promethazine & codeine PHENERGAN W/ CODEINE
Generic
No 1 promethazine & dextromethorphan
PROMETHAZINE-DM Generic
No 1 promethazine, phenylephrine & codeine
PHENERGAN VC W/CODEINE
Generic
Yes 3 pseudoephedrine, brompheniramine & codeine
M-END MAX D Non-Formulary
Brand
Anti-Inflammatory Agents
Yes 3 cromolyn sodium GASTROCROM Non-Formulary
Brand
Yes 1 cromolyn sodium INTAL Generic
Yes 1 montelukast SINGULAIR Generic
ST Yes 3 zafirlukast ACCOLATE Non-Formulary
Brand
ST No 1 zileuton ZYFLO CR Generic
ST No 3 zileuton ZYFO Non-Formulary
Brand
Respiratory Agents, Miscellaneous
Yes 3 beclomethasone dipropionate QVAR RediHaler Non-Formulary
Brand
Yes 3 budesonide PULMICORT FLEXHALER
Non-Formulary Brand
Yes 1 budesonide PULMICORT RESPULES
Generic
ST Yes 3 budesonide & formoterol SYMBICORT Non-Formulary
Brand
Yes 2 ciclesonide ALVESCO Formulary Brand
PA Yes 3 Elaxacaftor, tezacaftor & ivacaftor TRIKAFTA Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 76
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 3 fluticasone & salmeterol (100/50 mcg)
WIXELA INHUB Generic
Yes 1 fluticasone & salmeterol (250/50 mcg and 500/50 mcg)
WIXELA INHUB Generic
ST Yes 3 fluticasone & salmeterol ADVAIR HFA Non-Formulary
Brand
ST Yes 3 fluticasone & vilanterol BREO ELLIPTA Non-Formulary
Brand
Yes 3 fluticasone propionate FLOVENT DISKUS AER
Non-Formulary Brand
Yes 3 fluticasone propionate FLOVENT HFA Non-Formulary
Brand
ST Yes 3 fluticasone & umeclidinium & vilanterol
TRELEGY ELLIPTA Non-Formulary
Brand
Yes 3 glycopyrrolate & indacaterol UTIBRON NEOHALER
Non-Formulary Brand
ST Yes 3 indacaterol ARCAPTA NEOHALER
Non-Formulary Brand
PA Yes 3 ivacaftor KALYDECO Non-Formulary
Brand
PA Yes 3 lumacaftor& ivacaftor ORKAMBI Non-Formulary
Brand
ST Yes 3 mometasone & formoterol DULERA Non-Formulary
Brand
Yes 2 mometasone furoate ASMANEX Formulary Brand
PA Yes 3 mepolizumab NUCALA Non-Formulary
Brand
Yes 3 nintedanib OFEV Non-Formulary
Brand
PA Yes 3 omalizumab XOLAIR Non-Formulary
Brand
Yes 3 pirfenidone ESBRIET Non-Formulary
Brand
ST Yes 3 roflumilast DALIRESP Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 77
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 3 salmeterol SEREVENT DISKUS Non-Formulary
Brand
Yes 3 sodium chloride HYPERSAL Non-Formulary
Brand
PA Yes 3 tezacaftor & ivacaftor SYMDEKO Non-Formulary
Brand
Yes 2 tiotropium bromide and olodaterol STIOLTO RESPIMAT Formulary Brand
Skin and Mucous Membrane Agents
Anti-infectives (Skin and Mucous Membranes)
ST Yes 1 acyclovir ZOVIRAX Generic
Yes 3 benzoyl peroxide & erythromycin BENZAMYCIN Non-Formulary
Brand
ST Yes 3 butenafine MENTAX Non-Formulary
Brand
Yes 3 butoconazole nitrate (vaginal) GYNAZOLE-1 Non-Formulary
Brand
No 1 ciclopirox LOPROX Generic
No 1 ciclopirox PENLAC Generic
ST Yes 1 clindamycin & benzoyl peroxide BENZACLIN Generic
Yes 1 clindamycin & benzoyl peroxide DUAC Generic
PA Yes 3 clindamycin & benzoyl peroxide ONEXTON Non-Formulary
Brand
Yes 1 clindamycin phosphate (topical) CLEOCIN T Generic
Yes 1 clindamycin phosphate (topical) CLINDAGEL Generic
Yes 3 clindamycin phosphate (topical) EVOCLIN Non-Formulary
Brand
No 1 clindamycin phosphate (vaginal) CLEOCIN Generic
No 1 clotrimazole MYCELEX Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 78
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST No 1 clotrimazole & betamethasone LOTRISONE Generic
ST Yes 3 crotamiton EURAX Non-Formulary
Brand
No 1 econazole nitrate SPECTAZOLE Generic
Yes 3 erythromycin (acne acid) AKNE-MYCIN Non-Formulary
Brand
Yes 1 erythromycin (acne acid) ERYGEL Generic
No 1 gentamicin sulfate (topical) GARAMYCIN Generic
Yes 3 hexachlorophene PHISOHEX Non-Formulary
Brand
Yes 1 iodoquinol & hydrocortisone VYTONE Generic
No 1 ketoconazole (topical) NIZORAL Generic
No 1 lindane KWELL Generic
ST No 3 mafenide acetate SULFAMYLON Non-Formulary
Brand
No 1 malathion OVIDE Generic
No 1 metronidazole (topical) METROCREAM Generic
No 1 metronidazole (topical) METROGEL Generic
No 1 metronidazole (topical) METROLOTION Generic
No 1 metronidazole (vaginal) METROGEL-VAGINAL
Generic
No 3 miconazole nitrate & zinc oxide VUSION Non-Formulary
Brand
No 1 mupirocin BACTROBAN Generic
No 3 mupirocin calcium BACTROBAN NASAL Non-Formulary
Brand
Yes 3 na sulfacetm/avobenzone/sulfur ROSAC Non-Formulary
Brand
ST No 1 naftifine cream NAFTIN Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 79
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST No 3 Naftifine gel NAFTIN Non-Formulary
Brand
No 1 nystatin (topical) NYSTATIN Generic
ST No 3 oxiconazole nitrate OXISTAT Non-Formulary
Brand
ST Yes 3 penciclovir DENAVIR Non-Formulary
Brand
No 1 permethrin ELIMITE Generic
ST Yes 3 retapamulin ALTABAX Non-Formulary
Brand
No 3 selenium sulfide SELSEB Non-Formulary
Brand
No 3 selenium sulfide SELSUN RX Non-Formulary
Brand
ST Yes 3 sertaconazole nitrate ERTACZO Non-Formulary
Brand
No 1 silver sulfadiazine SILVADENE Generic
Yes 3 spinosad NATROBA Non-Formulary
Brand
ST Yes 3 sulconazole nitrate EXELDERM Non-Formulary
Brand
Yes 1 sulfacetamide sodium (acne) KLARON Generic
Yes 3 sulfacetamide sodium (acne) SEB-PREV Non-Formulary
Brand
Yes 3 sulfanilamide AVC VAGINAL Non-Formulary
Brand
ST No 1 terconazole TERAZOL 7 Generic
ST No 1 terconazole (vaginal) TERAZOL 3 Generic
Anti-inflammatory Agents (Skin and Mucous Membranes)
Yes 1 alclometasone dipropionate ACLOVATE Generic
ST Yes 1 amcinonide CYCLOCORT Generic
ST No 3 bacitracin, polymyxin, neomycin & hydrocortisone
CORTISPORIN Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 80
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 3 benzoyl peroxide & hydrocortisone
VANOXIDE-HC Non-Formulary
Brand
Yes 1 betamethasone dipropionate (topical)
DIPROSONE Generic
Yes 1 betamethasone dipropionate augmented
DIPROLENE Generic
Yes 1 betamethasone valerate LUXIQ Generic
Yes 1 betamethasone valerate VALISONE Generic
ST No 1 calcipotriene & betamethasone TACLONEX Generic
Yes 1 clobetasol propionate CLOBEX Generic
No 1 clobetasol propionate TEMOVATE Generic
Yes 1 clobetasol propionate emollient TEMOVATE E Generic
No 3 clobetasol propionate emulsion OLUX-E Non-Formulary
Brand
ST Yes 1 clocortolone pivalate CLODERM Generic
ST Yes 3 crisaborole EUCRISA Non-Formulary
Brand
QL Yes 1 desonide DESOWEN Generic
ST Yes 1 desoximetasone TOPICORT Generic
ST Yes 1 diflorasone diacetate APEXICON Generic
Yes 3 fluocinolone acetonide CAPEX SHAMPOO Non-Formulary
Brand
Yes 1 fluocinolone acetonide DERMA-SMOOTHE/FS OIL
Generic
Yes 1 fluocinolone acetonide SYNALAR Generic
Yes 1 fluocinonide LIDEX Generic
Yes 3 fluocinonide VANOS Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 81
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 fluocinonide emollient LIDEX-E Generic
ST (Tape Only)
Yes 1, 3 flurandrenolide CORDRAN Generic;
Non-Formulary Brand
ST Yes 1 fluticasone propionate (topical) CUTIVATE Generic
ST Yes 3 halcinonide HALOG Non-Formulary
Brand
Yes 1 halobetasol propionate ULTRAVATE Generic
Yes 1 hydrocortisone (intrarectal) CORTENEMA Generic
Yes 3 hydrocortisone (rectal) ANUSOL-HC Non-Formulary
Brand
Yes 1 hydrocortisone (rectal) PROCTOCORT Generic
Yes 1 hydrocortisone (topical) HYTONE Generic
Yes 1 hydrocortisone acetate & urea CARMOL HC Generic
Yes 3 hydrocortisone acetate (intrarectal)
CORTIFOAM Non-Formulary
Brand
Yes 1 hydrocortisone butyrate LOCOID Generic
Yes 3 hydrocortisone butyrate hydrophilic lipo base
LOCOID LIPOCREAM Non-Formulary
Brand
Yes 3 hydrocortisone probutate PANDEL Non-Formulary
Brand
Yes 1 hydrocortisone valerate WESTCORT Generic
Yes 1 mometasone furoate ELOCON Generic
ST Yes 1 nystatin & triamcinolone MYCOLOG II Generic
ST Yes 1 prednicarbate DERMATOP Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 82
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 triamcinolone acetonide (topical) KENALOG Generic
Antipruritics and Local Anesthetics
ST Yes 3 doxepin (antipuritic) ZONALON Non-Formulary
Brand
Yes 3 hydrocortisone & pramoxine ANALPRAM HC Non-Formulary
Brand
Yes 3 hydrocortisone & pramoxine PRAMOSONE Non-Formulary
Brand
Yes 3 hydrocortisone & pramoxine PRAMOSONE-E Non-Formulary
Brand
Yes 3 hydrocortisone & pramoxine PROCTOFOAM-HC Non-Formulary
Brand
ST Yesline 1 lidocaine LIDODERM Generic
No 1 lidocaine (jelly, topical) XYLOCAINE Generic
No 3 lidocaine & hydrocortisone LIDAMANTLE Non-Formulary
Brand
Yes 1 lidocaine & prilocaine EMLA Generic
ST No 3 lidocaine & tetracaine SYNERA PATCH Non-Formulary
Brand
Yes 1 pramoxine PROCTOFOAM Generic
Astringents
Yes 2 aluminum chloride hexahydrate HYPERCARE Formulary Brand
Keratolytic Agents
No 3 sulfacetamide sodium & sulfur AVAR Non-Formulary
Brand
Yes 1 sulfacetamide sodium & sulfur PLEXION Generic
No 3 sulfacetamide sodium & sulfur PLEXION SCT Non-Formulary
Brand
No 1 sulfacetamide sodium & sulfur ROSULA Generic
Yes 1 urea CARMOL Generic
Keratoplastic Agents
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 83
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 3 anthralin DRITHO-CREME HP Non-Formulary
Brand
Yes 3 anthralin ZITHRANOL-RR Non-Formulary
Brand
Cell Stimulants and Proliferants
QL, AGE Yes 1 tretinoin RETIN-A Generic
QL, AGE Yes 3 tretinoin microspheres RETIN-A MICRO Non-Formulary
Brand
Skin and Mucous Membrane Agents, Miscellaneous
ST No 1 acitretin SORIATANE Generic
QL, AGE, ST
Yes 1 adapalene DIFFERIN Generic
QL, AGE, ST
Yes 3 adapalene & benzoyl peroxide EPIDUO Non-Formulary
Brand
QL, AGE Yes 3 alitretinoin PANRETIN Non-Formulary
Brand
Yes 1 ammonium lactate LAC-HYDRIN Generic
ST Yes 3 azelaic acid FINACEA Non-Formulary
Brand
ST Yes 3 azelaic acid (acne) AZELEX Non-Formulary
Brand
Yes 2 becaplermin REGRANEX Formulary Brand
No 3 bexarotene (topical) TARGRETIN Non-Formulary
Brand
PA, QL Yes 3 brimonidine (topical) MIRVASO Non-Formulary
Brand
Yes 1 calcipotriene DOVONEX Generic
Yes 3 calcipotriene SORILUX Non-Formulary
Brand
Yes 2 calcitriol (topical) VECTICAL Formulary Brand
AGE, ST No 3 clindamycin & tretinoin VELTIN Non-Formulary
Brand
AGE, ST No 3 clindamycin & tretinoin ZIANA Non-Formulary
Brand
Yes 2 collagenase SANTYL Formulary Brand
Yes 3 dapsone (topical) ACZONE Non-Formulary
Brand
ST Yes 3 diclofenac epolamine FLECTOR Non-Formulary
Brand
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 84
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
Yes 1 diclofenac sodium VOLTAREN GEL Generic
Yes 3 diclofenac sodium (actinic keratosis)
SOLARAZE Non-Formulary
Brand
ST Yes 3 doxepin (antipuritic) PRUDOXIN Non-Formulary
Brand
Yes 3 doxycycline (rosacea) ORACEA Non-Formulary
Brand
No 3 fluorouracil (topical) CARAC Non-Formulary
Brand
Yes 1 fluorouracil (topical) EFUDEX Generic
Yes 2 fluorouracil (topical) FLUOROPLEX Formulary Brand
Yes 1 imiquimod ALDARA Generic
Yes 3 imiquimod ZYCLARA Non-Formulary
Brand
PA Yes 3 ingenol mebutate PICATO Non-Formulary
Brand
No 1 isotretinoin ACCUTANE Generic
No 1 isotretinoin CLARAVIS Generic
Yes 3 lactic acid (ammonium lactate) LACTINOL Non-Formulary
Brand
Yes 2 methoxsalen 8-MOP Formulary Brand
Yes 1 methoxsalen, rapid OXSORALEN-ULTRA Generic
Yes 2 pimecrolimus ELIDEL Formulary Brand
Yes 1 podofilox CONDYLOX Generic
ST Yes 3 sinecatechins VEREGEN Non-Formulary
Brand
Yes 1 tacrolimus (topical) PROTOPIC Generic
ST Yes 3 tazarotene FABIOR Non-Formulary
Brand
QL, AGE, ST
Yes 3 tazarotene TAZORAC Non-Formulary
Brand
Smooth Muscle Relaxants
Smooth Muscle Relaxants
Yes 1 darifenacin ENABLEX Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 85
Restrictions Mailable Tier Generic Name Brand Name Coverage Status
ST Yes 3 dyphylline LUFYLLIN Non-Formulary
Brand
ST Yes 3 fesoterodine TOVIAZ Non-Formulary
Brand
ST Yes 3 flavoxate FLAVOXATE Non-Formulary
Brand
ST Yes 3 mirabegron MYRBETRIQ Non-Formulary
Brand
Yes 1 oxybutynin DITROPAN Generic
Yes 1 oxybutynin extended-release DITROPAN XL Generic
Yes 3 oxybutynin transdermal OXYTROL Non-Formulary
Brand
Yes 1 solifenacin VESICARE Generic
Yes 1 theophylline UNIPHYL Generic
ST Yes 1 tolterodine DETROL Generic
ST Yes 1 tolterodine extended-release DETROL LA Generic
Yes 1 trospium SANCTURA Generic
Yes 3 trospium extended-release SANCTURA XR Non-Formulary
Brand
Vitamins
Vitamins
Yes 1 calcitriol ROCALTROL Generic
ST Yes 1 doxercalciferol HECTOROL Generic
Yes 1 ergocalciferol DRISDOL Generic
Yes 1 niacin NIACOR Generic
ST Yes 1 paricalcitol ZEMPLAR Generic
Yes 1 phytonadione MEPHYTON Generic
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 86
8
8-MOP ............................................................................................. 84
A
abacavir sulfate & lamivudine ........................................................ 8
abacavir sulfate solution ................................................................. 8
abacavir sulfate tablet ..................................................................... 9
abacavir, dolutegravir & lamivudine .............................................. 9
abacavir, lamivudine & zidovudine ................................................ 9
abaloparatide .................................................................................. 68
abatacept ........................................................................................ 69
abemaciclib ..................................................................................... 13
ABILIFY ........................................................................................... 39
ABILIFY DISCMELT ...................................................................... 39
abiraterone ...................................................................................... 13
ABSTRAL ........................................................................................ 30
acalabrutinib ................................................................................... 13
acamprosate ................................................................................... 38
acarbose ......................................................................................... 61
ACCOLATE .................................................................................... 75
ACCU-CHEK .................................................................................. 42
ACCU-CHEK TEST STRIPS ........................................................ 42
ACCUNEB ...................................................................................... 19
ACCUPRIL ...................................................................................... 26
ACCURETIC ................................................................................... 26
ACCUTANE .................................................................................... 84
acebutolol ........................................................................................ 28
ACEON ............................................................................................ 26
acetaminophen & codeine ............................................................ 29
acetaminophen, caffeine, & dihydrocodeine .............................. 29
ACETASOL HC .............................................................................. 48
acetazolamide ................................................................................ 50
acetic acid ................................................................................. 48, 51
acetylcysteine ................................................................................. 69
ACIPHEX ........................................................................................ 53
acitretin ............................................................................................ 83
ACLOVATE ..................................................................................... 79
ACTEMRA ...................................................................................... 74
ACTHAR.......................................................................................... 68
ACTIGALL ....................................................................................... 55
ACTIMMUNE .................................................................................. 72
ACTIQ .............................................................................................. 30
ACTIVELLA .................................................................................... 66
ACTONEL ....................................................................................... 73
ACTOPLUS MET ........................................................................... 65
ACTOS ............................................................................................ 65
ACULAR .......................................................................................... 48
ACULAR LS .................................................................................... 48
acyclovir ...................................................................................... 9, 77
ACZONE ......................................................................................... 83
ADALAT CC .................................................................................... 23
adalimumab .................................................................................... 69
adapalene ....................................................................................... 83
adapalene & benzoyl peroxide .................................................... 83
ADCIRCA ........................................................................................ 28
ADDERALL ..................................................................................... 33
ADDERALL XR .............................................................................. 33
adefovir dipivoxil .............................................................................. 9
ADEMPAS ...................................................................................... 28
ADLYXIN......................................................................................... 64
ADMELOG ...................................................................................... 64
ADOXA .............................................................................................. 5
ADRENACLICK ............................................................................. 19
ADVAIR HFA .................................................................................. 76
ADVICOR ....................................................................................... 22
ADZENYS ER ................................................................................ 33
AFINITOR ....................................................................................... 14
aflcaftadine ..................................................................................... 49
AFREZZA ....................................................................................... 63
AGGRENOX ................................................................................... 20
AGRYLIN ........................................................................................ 20
AIMOVIG......................................................................................... 71
AKNE-MYCIN ................................................................................. 78
AK-TRACIN .................................................................................... 45
AKYNZEO ....................................................................................... 52
albendazole ...................................................................................... 4
ALBENZA ......................................................................................... 4
albiglutide ........................................................................................ 61
albuterol nebulizer solution .......................................................... 19
albuterol sulfate.............................................................................. 19
albuterol sulfate & ipratropium ..................................................... 19
albuterol sulfate tablet ................................................................... 19
alclometasone dipropionate ......................................................... 79
ALDACTAZIDE .............................................................................. 27
ALDACTONE ................................................................................. 27
ALDARA .......................................................................................... 84
ALDOMET ...................................................................................... 25
ALDORIL-25 ................................................................................... 25
alendronate ..................................................................................... 69
alendronate & cholecalciferol ....................................................... 69
alfuzosin .......................................................................................... 18
ALINIA ............................................................................................... 8
alirocumab ...................................................................................... 21
aliskiren ........................................................................................... 25
aliskiren & amlodipine ................................................................... 25
aliskiren & hydrochlorothiazide .................................................... 25
aliskiren & valsartan ...................................................................... 25
aliskiren, amlodipine & hydrochlorothiazide ............................... 25
alitretinoin ....................................................................................... 83
ALKERAN ....................................................................................... 15
allopurinol ....................................................................................... 69
almotriptan ...................................................................................... 35
ALOCRIL......................................................................................... 49
alogliptin .......................................................................................... 61
alogliptin & metformin ................................................................... 61
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 87
alogliptin & pioglitazone ................................................................ 61
ALOMIDE ........................................................................................ 49
ALORA ............................................................................................ 66
alosetron ......................................................................................... 52
alpelisib ........................................................................................... 13
ALPHAGAN .................................................................................... 50
ALPHAGAN P................................................................................. 50
alprazolam ...................................................................................... 37
alprazolam extended-release ....................................................... 37
alprazolam orally disintegrating ................................................... 37
ALREX ............................................................................................. 48
ALTABAX ........................................................................................ 79
ALTACE .......................................................................................... 26
ALTOPREV ..................................................................................... 22
aluminum chloride hexahydrate ................................................... 82
ALVESCO ....................................................................................... 75
amantadine ..................................................................................... 36
amantadine ER............................................................................... 36
AMARYL.......................................................................................... 62
AMBIEN ........................................................................................... 38
AMBIEN CR .................................................................................... 38
ambrisentan .................................................................................... 27
amcinonide...................................................................................... 79
AMERGE ......................................................................................... 36
AMICAR .......................................................................................... 20
amifampridine ................................................................................. 69
amikacin liposomal inhalation ........................................................ 4
amiloride .......................................................................................... 43
amiloride & hydrochlorothiazide ................................................... 43
aminocaproic acid .......................................................................... 20
amiodarone ..................................................................................... 24
AMITIZA .......................................................................................... 54
amitriptyline ............................................................................... 39, 40
amitriptyline & perphenazine ........................................................ 39
amlodipine ........................................................................... 22, 23, 25
amlodipine & atorvastatin ............................................................. 23
amlodipine & benazepril ................................................................ 22
amlodipine & olmesartan .............................................................. 23
amlodipine & telmisartan............................................................... 23
amlodipine & valsartan .................................................................. 23
amlodipine, olmesartan & hydrochlorothiazide .......................... 23
amlodipine, valsartan & hydrochlorothiazide ............................. 23
ammonium lactate ................................................................... 83, 84
amoxapine ...................................................................................... 39
amoxicillin................................................................................ 2, 4, 53
amoxicillin & clavulanate potassium .............................................. 4
amoxicillin & clavulanate potassium extended-release .............. 4
amoxicillin, clarithromycin, & lansoprazole ................................. 53
AMOXIL ............................................................................................. 4
amphetamine & dextroamphetamine .......................................... 33
amphetamine & dextroamphetamine extended-release .......... 33
amphetamine extended-release .................................................. 33
amphetamine sulfate ..................................................................... 32
AMPICILLIN ...................................................................................... 5
ampicillin sodium ............................................................................. 5
AMPYRA ......................................................................................... 70
AMRIX ............................................................................................. 18
AMTURNIDE .................................................................................. 25
AMYTHYST .................................................................................... 58
ANADROL-50 ................................................................................. 56
ANAFRANIL ................................................................................... 40
anagrelide ....................................................................................... 20
anakinra .......................................................................................... 69
ANALPRAM HC ............................................................................. 82
ANAPROX ...................................................................................... 31
anastrozole ..................................................................................... 13
ANCOBON ....................................................................................... 7
ANDRODERM................................................................................ 56
ANDROGEL ................................................................................... 56
ANDROID 10 .................................................................................. 56
ANDROXY ...................................................................................... 56
ANGELIQ ........................................................................................ 66
ANNOVERA ................................................................................... 61
ANORO ELLIPTA .......................................................................... 20
ANSAID ........................................................................................... 30
ANTABUSE .................................................................................... 70
anthralin .......................................................................................... 83
antipyrine & benzocaine ............................................................... 51
ANUSOL-HC .................................................................................. 81
ANZEMET ....................................................................................... 52
APEXICON ..................................................................................... 80
APIDRA ........................................................................................... 63
apixaban ......................................................................................... 20
APLENZIN ...................................................................................... 39
APOKYN ......................................................................................... 36
apomorphine .................................................................................. 36
apraclonidine .................................................................................. 51
apremilast ....................................................................................... 70
aprepitant ........................................................................................ 52
APRESOLINE ................................................................................ 25
APRI ................................................................................................ 57
APTIOM .......................................................................................... 34
APTIVUS......................................................................................... 12
ARALEN ............................................................................................ 8
ARANELLE ..................................................................................... 59
ARANESP ....................................................................................... 21
ARAVA ............................................................................................ 72
ARBINOXA ....................................................................................... 4
ARCAPTA NEOHALER ................................................................ 76
arformoterol .................................................................................... 19
ARICEPT ........................................................................................ 17
ARICEPT ODT ............................................................................... 17
ARIKAYCE ....................................................................................... 4
ARIMIDEX ...................................................................................... 13
aripiprazole ..................................................................................... 39
aripiprazole solution ...................................................................... 39
aripiprazole tablet .......................................................................... 39
ARIXTRA ........................................................................................ 20
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 88
armodafinil ...................................................................................... 33
ARMOUR THYROID ..................................................................... 69
AROMASIN ..................................................................................... 14
ARTANE .......................................................................................... 37
artemether & lumefantrine .............................................................. 8
ARTHROTEC ................................................................................. 30
artificial tear insert .......................................................................... 51
ASCENSIA BREEZE ..................................................................... 42
ASCENSIA TEST STRIPS ........................................................... 42
asenapine........................................................................................ 39
ASENDIN ........................................................................................ 39
ASMANEX ...................................................................................... 76
aspirin & dipyridamole ................................................................... 20
ASTELIN ......................................................................................... 49
ASTEPRO ....................................................................................... 49
ATACAND ....................................................................................... 25
ATACAND HCT .............................................................................. 25
ATARAX .......................................................................................... 37
atazanavir & cobicistat .................................................................... 9
atazanavir sulfate 150 mg............................................................... 9
atazanavir sulfate 200 mg, 300 mg ............................................... 9
ATELVIA.......................................................................................... 73
atenolol ............................................................................................ 28
atenolol & chlorthalidone............................................................... 28
ATIVAN ........................................................................................... 37
atomoxetine .................................................................................... 38
atorvastatin ............................................................................... 21, 23
atovaquone ....................................................................................... 8
atovaquone & proguanil .................................................................. 8
ATRIPLA ......................................................................................... 10
atropine ............................................................................... 16, 51, 52
atropine sulfate ............................................................................... 16
ATROPINE SULFATE ................................................................... 16
ATROVENT .................................................................................... 17
ATROVENT HFA ........................................................................... 17
AUBAGIO ........................................................................................ 74
AUGMENTIN .................................................................................... 4
AUGMENTIN XR ............................................................................. 4
auranofin ......................................................................................... 55
AURODEX ...................................................................................... 51
AUSTEDO ....................................................................................... 38
AUVI-Q ............................................................................................ 19
AVALIDE ......................................................................................... 26
AVANDAMET ................................................................................. 65
AVANDARYL .................................................................................. 65
AVANDIA ........................................................................................ 65
avapritinib ........................................................................................ 13
AVAPRO ......................................................................................... 26
AVAR ............................................................................................... 82
AVC VAGINAL ............................................................................... 79
AVELOX ............................................................................................ 6
AVINZA ........................................................................................... 31
AVLOSULFON ................................................................................. 7
AVODART ....................................................................................... 71
AVONEX ......................................................................................... 72
AXERT ............................................................................................ 35
AXID ................................................................................................ 53
AXIRON .......................................................................................... 56
axitinib ............................................................................................. 13
AYGESTIN ..................................................................................... 68
AYVAKIT ......................................................................................... 13
AZASAN .......................................................................................... 70
AZASITE ......................................................................................... 45
azathioprine .................................................................................... 70
azelaic acid ..................................................................................... 83
azelaic acid (acne)......................................................................... 83
azelastine ........................................................................................ 49
azelastine & fluticasone ................................................................ 49
azelastine (ophth) .......................................................................... 49
AZELEX .......................................................................................... 83
AZILECT ......................................................................................... 37
azilsartan......................................................................................... 25
azithromycin ............................................................................... 5, 45
azithromycin (ophth) ...................................................................... 45
AZOPT ............................................................................................ 50
AZOR .............................................................................................. 23
AZULFIDINE .................................................................................... 6
B
B & O SUPPRETTES ................................................................... 32
bacitracin & polmyxin B (ophth) ................................................... 45
bacitracin (ophth) ........................................................................... 45
bacitracin, neomycin, polymyxin B & hydrocortisone (ophth) .. 47
bacitracin, polymyxin, neomycin & hydrocortisone ................... 79
baclofen .......................................................................................... 18
BACTRIM DS ................................................................................... 6
BACTROBAN ................................................................................. 78
BACTROBAN NASAL ................................................................... 78
balsalazide ...................................................................................... 52
BALZIVA ......................................................................................... 59
BANZEL .......................................................................................... 35
BAQSIMI ......................................................................................... 62
BARACLUDE ................................................................................. 10
baricitnib .......................................................................................... 70
BASAGLAR .................................................................................... 63
BD INSULIN SYRINGE ................................................................ 43
becaplermin .................................................................................... 83
beclomethasone dipropionate ...................................................... 75
bedaquiline ..................................................................................... 70
BELSOMRA ................................................................................... 38
bempedoic acid .............................................................................. 21
bempedoic acid & ezetimibe ........................................................ 21
benazepril ................................................................................. 22, 25
benazepril & hydrochlorothiazide ................................................ 25
BENEMID ....................................................................................... 45
BENICAR ........................................................................................ 26
BENICAR HCT ............................................................................... 26
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 89
BENTYL .......................................................................................... 16
BENZACLIN .................................................................................... 77
BENZAMYCIN ................................................................................ 77
benznidazole .................................................................................... 4
benzonatate .................................................................................... 74
benzoyl peroxide & erythromycin ................................................ 77
benzoyl peroxide & hydrocortisone ............................................. 80
benztropine ..................................................................................... 36
bepotastine ..................................................................................... 49
BEPREVE ....................................................................................... 49
besilfoxacin ..................................................................................... 45
BESIVANCE ................................................................................... 45
BETAGAN ....................................................................................... 50
betaine ............................................................................................. 70
betamethasone dipropionate (topical) ......................................... 80
betamethasone dipropionate augmented ................................... 80
betamethasone valerate ............................................................... 80
BETAPACE ..................................................................................... 29
BETAPACE AF............................................................................... 29
BETASERON ................................................................................. 72
betaxolol .................................................................................... 28, 50
betaxolol hcl .................................................................................... 50
bethanechol chloride ..................................................................... 17
BETIMOL ........................................................................................ 51
BETOPTIC ...................................................................................... 50
BETOPTIC S .................................................................................. 50
betrixaban ....................................................................................... 20
BEVYXXA ....................................................................................... 20
bexarotene ................................................................................ 13, 83
bexarotene (topical) ....................................................................... 83
BEXDELA.......................................................................................... 5
BEYAZ ............................................................................................. 57
BIAXIN ............................................................................................... 5
BIAXIN XL ......................................................................................... 5
bicalutamide .................................................................................... 13
BICITRA .......................................................................................... 43
bictegravir & emtricitabine & tenofovir .......................................... 9
BIDIL ................................................................................................ 27
BIJUVA ............................................................................................ 68
BIKTARVY ........................................................................................ 9
BILTRICIDE ...................................................................................... 4
bimatoprost ..................................................................................... 50
binimetinib ....................................................................................... 13
bismuth subcitrate & metronidazole .............................................. 4
bisoprolol ......................................................................................... 28
bisoprolol & hydrochlorothiazide .................................................. 28
BLEPH-10 ....................................................................................... 46
BLEPHAMIDE ................................................................................ 49
BLOCADREN ................................................................................. 29
blood sugar diagnostic .................................................................. 42
blood-glucose meter ................................................................ 42, 43
boceprevir ......................................................................................... 9
BONIVA ........................................................................................... 71
bosentan ......................................................................................... 27
BOSULIF......................................................................................... 13
bosutinib .......................................................................................... 13
BRAFTOVI ...................................................................................... 14
BREO ELLIPTA ............................................................................. 76
BRETHINE ..................................................................................... 20
BREVICON ..................................................................................... 59
brexpiprazole .................................................................................. 39
BRILINTA ........................................................................................ 20
brimonidine ............................................................................... 50, 83
brimonidine & timolol ..................................................................... 50
brimonidine (topical) ...................................................................... 83
brimonidine tartrate ....................................................................... 50
brinzolamide ................................................................................... 50
brodalumab ..................................................................................... 70
bromfenac (ophth) ......................................................................... 47
bromocriptine.................................................................................. 36
BROVANA ...................................................................................... 19
BRUKINSA ..................................................................................... 16
budesonide ............................................................................... 55, 75
budesonide & formoterol .............................................................. 75
bumetanide ..................................................................................... 43
BUMEX ........................................................................................... 43
BUPHENYL .................................................................................... 43
buprenorphine ................................................................................ 29
buprenorphine & naloxone film .................................................... 29
buprenorphine transdermal .......................................................... 29
buprenorphine& naloxone tablet ................................................. 29
bupropion ........................................................................................ 39
bupropion (smoking deterrent)..................................................... 39
bupropion extended-release ........................................................ 39
bupropion hydrobromide ............................................................... 39
bupropion sustained-release ........................................................ 39
BUSPAR ......................................................................................... 37
buspirone ........................................................................................ 37
busulfan .......................................................................................... 13
butalbital & acetaminophen .......................................................... 29
butalbital, acetaminophen, & caffeine ......................................... 29
butalbital, acetaminophen, caffeine, & codeine ......................... 29
butalbital, aspirin, & caffeine ........................................................ 29
butalbital, aspirin, caffeine, & codeine ........................................ 30
butenafine ....................................................................................... 77
butoconazole nitrate (vaginal) ...................................................... 77
butorphanol tartrate ....................................................................... 30
BUTRANS ....................................................................................... 29
BYDUREON ................................................................................... 62
BYETTA .......................................................................................... 62
BYSTOLIC ...................................................................................... 28
C
c-1 esterase inhibitor ..................................................................... 70
cabergoline ..................................................................................... 36
CADUET ......................................................................................... 23
CAFERGOT ................................................................................... 19
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 90
CALAN SR ...................................................................................... 24
calcipotriene .............................................................................. 80, 83
calcipotriene & betamethasone.................................................... 80
calcitonin salmon ........................................................................... 68
calcitriol ..................................................................................... 83, 85
calcitriol (topical) ............................................................................ 83
calcium acetate ........................................................................ 44, 45
CALQUENCE ................................................................................. 13
CAMILA ........................................................................................... 59
CAMPRAL ....................................................................................... 38
canagliflozin .................................................................................... 61
canagliflozin & metformin .............................................................. 61
canakinumab .................................................................................. 70
CANASA.......................................................................................... 52
candesartan .................................................................................... 25
candesartan & hydrochlorothiazide ............................................. 25
cannabidiol ...................................................................................... 38
CANTIL ............................................................................................ 55
capecitabine .................................................................................... 13
CAPEX SHAMPOO ....................................................................... 80
CAPOTEN ....................................................................................... 25
CAPOZIDE ...................................................................................... 25
CAPRELSA ..................................................................................... 16
captopril ........................................................................................... 25
captopril & hydrochlorothiazide .................................................... 25
CARAC ............................................................................................ 84
CARAFATE ..................................................................................... 53
carbachol ......................................................................................... 50
CARBAGLU .................................................................................... 43
carbamazepine ............................................................................... 34
carbamazepine extended-release cap ........................................ 34
carbamazepine extended-release tab ......................................... 34
CARBATROL .................................................................................. 34
carbidopa ........................................................................................ 36
carbidopa & levodopa.................................................................... 36
carbidopa & levodopa extended release .................................... 36
carbidopa, levodopa, & entacapone ............................................ 36
carbinoxamine maleate ................................................................... 4
CARDENE ...................................................................................... 23
CARDIZEM ..................................................................................... 23
CARDIZEM CD .............................................................................. 23
CARDIZEM LA ............................................................................... 23
CARDURA ...................................................................................... 21
carglumic acid................................................................................. 43
cariprazine ...................................................................................... 40
carisoprodol .............................................................................. 18, 30
carisoprodol & aspirin .................................................................... 18
carisoprodol, aspirin, & codeine ................................................... 30
CARMOL ................................................................................... 81, 82
CARMOL HC .................................................................................. 81
carteolol (ophth) ............................................................................. 50
CARTIA XT ..................................................................................... 23
carvedilol ......................................................................................... 28
carvedilol phosphate...................................................................... 28
CASODEX ...................................................................................... 13
CATAFLAM .................................................................................... 30
CATAPRES .............................................................................. 24, 25
CATAPRES-TTS ........................................................................... 25
CECLOR ........................................................................................... 5
cefaclor .............................................................................................. 5
cefadroxil........................................................................................... 5
cefdinir ............................................................................................... 5
cefditoren .......................................................................................... 5
cefixime ............................................................................................. 5
cefixime solution .............................................................................. 5
cefpodoxime ..................................................................................... 5
cefprozil ............................................................................................. 5
CEFTIN ............................................................................................. 5
cefuroxime axetil .............................................................................. 5
CEFZIL .............................................................................................. 5
CELEBREX .................................................................................... 30
celecoxib ......................................................................................... 30
CELEXA .......................................................................................... 40
CELLCEPT ..................................................................................... 73
CELONTIN ..................................................................................... 35
cenegermin-bkbj ............................................................................ 51
CENESTIN ..................................................................................... 67
cephalexin......................................................................................... 5
CEQUA ........................................................................................... 47
CERDELGA .................................................................................... 71
ceritinib ............................................................................................ 13
certolizumab Pegol ........................................................................ 70
CESAMET ...................................................................................... 52
cevimeline hcl ................................................................................. 17
CHANTIX ........................................................................................ 17
CHEMET ......................................................................................... 55
CHERATUSSIN AC....................................................................... 75
chlorambucil ................................................................................... 13
chlordiazepoxide ................................................................ 37, 40, 54
chlordiazepoxide & amitriptyline .................................................. 40
chlorhexidine (mouth-throat) ........................................................ 45
chloroquine phosphate ................................................................... 8
chlorothiazide ................................................................................. 43
chlorpheniramine, phenylephrine & pyrilamine ........................... 4
chlorpromazine .............................................................................. 40
chlorpropamide .............................................................................. 62
CHLORPROPAMIDE .................................................................... 62
chlorthalidone ........................................................................... 28, 43
chlorzoxazone ................................................................................ 18
CHOLBAM ...................................................................................... 70
cholestyramine ............................................................................... 21
cholestyramine light....................................................................... 21
cholic acid ....................................................................................... 70
CHRONULAC ................................................................................ 43
CIBALITH-S .................................................................................... 41
ciclesonide ...................................................................................... 75
ciclopirox ......................................................................................... 77
cilostazol ......................................................................................... 20
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 91
CILOXAN ........................................................................................ 46
CIMDUO .......................................................................................... 11
cimetidine ........................................................................................ 53
CIMZIA ............................................................................................ 70
cinacalcet ........................................................................................ 70
CIPRO ......................................................................................... 5, 47
CIPRO HC ...................................................................................... 47
CIPRODEX ..................................................................................... 47
ciprofloxacin .......................................................................... 5, 46, 47
ciprofloxacin & dexamethasone (ophth) ..................................... 47
ciprofloxacin & hydrocortisone (otic) ........................................... 47
ciprofloxacin (ophth) ointment ...................................................... 46
ciprofloxacin (ophth) solution ....................................................... 46
citalopram........................................................................................ 40
citric acid, sodium citrate, & potassium citrate ........................... 43
CLARAVIS ...................................................................................... 84
clarithromycin ............................................................................. 5, 53
clarithromycin extended-release .................................................... 5
CLEOCIN .................................................................................... 5, 77
CLEOCIN HCL ................................................................................. 5
CLEOCIN PEDIATRIC .................................................................... 5
CLEOCIN T ..................................................................................... 77
clidinium & chlordiazepoxide ........................................................ 54
CLIMARA DIS................................................................................. 66
CLIMARA PRO............................................................................... 66
CLINDAGEL ................................................................................... 77
clindamycin & benzoyl peroxide .................................................. 77
clindamycin & tretinoin .................................................................. 83
clindamycin hcl ................................................................................. 5
clindamycin palmitate ...................................................................... 5
clindamycin phosphate (topical) .................................................. 77
clindamycin phosphate (vaginal) ................................................. 77
CLINORIL........................................................................................ 32
clobazam ......................................................................................... 34
clobetasol propionate .................................................................... 80
clobetasol propionate emollient ................................................... 80
clobetasol propionate emulsion ................................................... 80
CLOBEX .......................................................................................... 80
clocortolone pivalate ...................................................................... 80
CLODERM ...................................................................................... 80
clomipramine .................................................................................. 40
clonazepam .................................................................................... 34
clonidine .................................................................................... 24, 25
clonidine extended-release........................................................... 24
clonidine transdermal .................................................................... 25
clopidogrel ....................................................................................... 20
clorazepate ..................................................................................... 37
clotrimazole ............................................................................... 77, 78
clotrimazole & betamethasone ..................................................... 78
clozapine ......................................................................................... 40
CLOZARIL ...................................................................................... 40
COARTEM ........................................................................................ 8
cobimetinib ...................................................................................... 14
codeine ................................................................................ 29, 30, 75
CODEINE SULF ............................................................................ 30
COGENTIN ..................................................................................... 36
COLAZAL ....................................................................................... 52
COL-BENEMID .............................................................................. 45
colchicine .................................................................................. 45, 70
colchicine & probenecid ................................................................ 45
COLCRYS ...................................................................................... 70
colesevelam ................................................................................... 21
COLESTID ...................................................................................... 21
colestipol ......................................................................................... 21
collagenase .................................................................................... 83
COLYTE .......................................................................................... 53
COMBIGAN .................................................................................... 50
COMBIPATCH ............................................................................... 66
COMBIVENT RESPIMAT ............................................................. 19
COMBIVIR ...................................................................................... 11
COMBUNOX .................................................................................. 32
COMPAZINE .................................................................................. 53
COMPLERA ................................................................................... 10
COMTAN ........................................................................................ 36
CONCERTA ................................................................................... 33
CONDYLOX ................................................................................... 84
conjugated estrogens & bazedoxifene ....................................... 66
conjugated estrogens & medroxyprogesterone acetate .......... 66
COPAXONE 20 mg ....................................................................... 71
COPAXONE 40 mg ....................................................................... 71
CORDRAN ..................................................................................... 81
COREG ........................................................................................... 28
COREG CR .................................................................................... 28
CORGARD ..................................................................................... 28
CORLANOR ................................................................................... 24
CORTEF ......................................................................................... 55
CORTENEMA ................................................................................ 81
corticotropin .................................................................................... 68
CORTIFOAM .................................................................................. 81
cortisone acetate ........................................................................... 55
CORTISPORIN ........................................................................ 48, 79
CORTISPORIN-TC ....................................................................... 48
CORTONE ACETATE .................................................................. 55
CORZIDE ........................................................................................ 28
COSENTYX .................................................................................... 74
COSOPT ......................................................................................... 50
COTELLIC ...................................................................................... 14
COTEMPLA XR-ODT ................................................................... 34
COUMADIN .................................................................................... 21
COVERA-HS .................................................................................. 24
COZAAR ......................................................................................... 26
CREON ........................................................................................... 54
CRESEMBA ..................................................................................... 7
CRESTOR ...................................................................................... 22
crisaborole ...................................................................................... 80
CRIXIVAN ....................................................................................... 11
crizotinib .......................................................................................... 14
cromolyn sodium ...................................................................... 49, 75
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 92
cromolyn sodium (ophth) .............................................................. 49
crotamiton ....................................................................................... 78
CRYSELLE ..................................................................................... 60
CUPRIMINE .................................................................................... 55
CUTIVATE ...................................................................................... 81
CYCLESSA ..................................................................................... 57
cyclobenzaprine ............................................................................. 18
cyclobenzaprine extended-release .............................................. 18
CYCLOCORT ................................................................................. 79
cyclophosphamide ......................................................................... 14
cycloserine ........................................................................................ 7
CYCLOSET .................................................................................... 36
cyclosporine .............................................................................. 47, 70
cyclosporine (ophth) ...................................................................... 47
cyclosporine, modified ................................................................... 70
CYMBALTA .................................................................................... 40
cyproheptadine ................................................................................. 4
CYSTADANE POWD .................................................................... 70
CYSTAGON .................................................................................... 70
cysteamine delayed-release ......................................................... 70
cysteamine immediate-release .................................................... 70
CYTOMEL ....................................................................................... 69
CYTOTEC ....................................................................................... 53
CYTOVENE .................................................................................... 11
CYTOXAN ....................................................................................... 14
CYTRA-3 ......................................................................................... 43
D
D.H.E.45 .......................................................................................... 18
dabigatran ....................................................................................... 20
daclatasvir ......................................................................................... 9
dacomitinib ...................................................................................... 14
daflazacort ...................................................................................... 70
DAKLINZA ........................................................................................ 9
dalfampridine .................................................................................. 70
DALIRESP ...................................................................................... 76
DALMANE ....................................................................................... 37
dalteparin ........................................................................................ 20
danazol ............................................................................................ 56
DANOCRINE .................................................................................. 56
DANTRIUM ..................................................................................... 18
dantrolene sodium ......................................................................... 18
dapagliflozin .................................................................................... 62
dapagliflozin & metformin ............................................................. 62
dapsone ....................................................................................... 7, 83
dapsone (topical) ........................................................................... 83
DARAPRIM ....................................................................................... 8
darbepoetin alfa ............................................................................. 21
darifenacin ...................................................................................... 84
darolutamide ................................................................................... 14
darunavir & cobicistat ...................................................................... 9
darunavir ethanolate ........................................................................ 9
darunavir/cobicistat/FTC/tenofovir ................................................. 9
dasatinib .......................................................................................... 14
DAURISMO .................................................................................... 14
DAYPRO ......................................................................................... 32
DAYTRANA .................................................................................... 34
DDAVP ............................................................................................ 68
DECADRON ............................................................................. 47, 55
DECLOMYCIN ................................................................................. 5
deferasirox ...................................................................................... 55
deferiprone ..................................................................................... 55
delafloxacin ....................................................................................... 5
delavirdine mesylate ....................................................................... 9
DELESTROGEN ............................................................................ 57
DELSTRIGO ................................................................................... 10
DEMADEX ...................................................................................... 44
demeclocycline ................................................................................ 5
DEMEROL ...................................................................................... 31
DENAVIR ........................................................................................ 79
DEPAKENE .................................................................................... 35
DEPAKOTE .................................................................................... 34
DEPAKOTE ER ............................................................................. 34
DEPAKOTE SPRINKLE ............................................................... 34
DEPEN ............................................................................................ 55
DEPO-ESTRADIOL....................................................................... 57
DEPO-TESTOSTERONE ............................................................. 56
DERMA-SMOOTHE/FS OIL ........................................................ 80
DERMATOP ................................................................................... 81
DERMOTIC .................................................................................... 47
DESCOVY ...................................................................................... 10
desipramine .................................................................................... 40
desmopressin (non-refrigerated) ................................................. 68
desmopressin acetate ................................................................... 68
DESOGEN ...................................................................................... 57
desogestrel & ethinyl estradiol ..................................................... 57
desogestrel & ethinyl estradiol (biphasic) ................................... 57
desogestrel & ethinyl estradiol (triphasic) .................................. 57
desonide ......................................................................................... 80
DESOWEN ..................................................................................... 80
desoximetasone ............................................................................. 80
DESOXYN ...................................................................................... 33
desvenlafaxine extended release ................................................ 40
desvenlafaxine succinate extended release .............................. 40
DESYREL ....................................................................................... 41
DETROL ......................................................................................... 85
DETROL LA ................................................................................... 85
deutetrabenazine ........................................................................... 38
dexamethasone ........................................................... 47, 48, 49, 55
dexamethasone (ophth) solution ................................................. 47
dexamethasone (ophth) suspension ........................................... 47
DEXEDRINE .................................................................................. 33
DEXILANT ...................................................................................... 53
dexlansoprazole ............................................................................. 53
dexmethylphenidate ...................................................................... 33
dexmethylphenidate extended-release ...................................... 33
dextroamphetamine sulfate .......................................................... 33
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 93
dextroamphetamine sulfate extended-release........................... 33
dextromethorphan & quinidine ..................................................... 38
DEXTROSTAT ............................................................................... 33
DIABETA ......................................................................................... 62
DIACOMIT ...................................................................................... 35
DIAMOX .......................................................................................... 50
DIAMOX SEQUELS ...................................................................... 50
DIASTAT ......................................................................................... 34
DIASTAT ACUDIAL ....................................................................... 34
diazepam ................................................................................... 34, 37
DIBENZYLINE ................................................................................ 19
dichlorphenamide ........................................................................... 70
diclofenac epolamine ..................................................................... 83
diclofenac potassium ..................................................................... 30
diclofenac sodium .............................................................. 30, 47, 84
diclofenac sodium & misoprostol ................................................. 30
diclofenac sodium (actinic keratosis) .......................................... 84
diclofenac sodium (ophth)............................................................. 47
diclofenac sodium extended release ........................................... 30
dicloxacillin ........................................................................................ 5
dicyclomine ..................................................................................... 16
didanosine ......................................................................................... 9
didanosine solution .......................................................................... 9
DIDRONEL ..................................................................................... 71
difenoxin & atropine ....................................................................... 52
DIFFERIN........................................................................................ 83
DIFICID ............................................................................................. 6
diflorasone diacetate ..................................................................... 80
DIFLUCAN ........................................................................................ 7
diflunisal .......................................................................................... 30
DIFLUNISAL ................................................................................... 30
difluprednate ................................................................................... 47
digoxin ............................................................................................. 24
dihydroergotamine mesylate ........................................................ 18
DILANTIN ........................................................................................ 35
DILAUDID ....................................................................................... 31
diltiazem .......................................................................................... 23
diltiazem extended-release ........................................................... 23
dimethyl fumarate .......................................................................... 70
DIOVAN ........................................................................................... 27
DIOVAN HCT ................................................................................. 27
DIPENTUM ..................................................................................... 52
diphenoxylate & atropine .............................................................. 52
DIPROLENE ................................................................................... 80
DIPROSONE .................................................................................. 80
dipyridamole ................................................................................... 20
DISALCID........................................................................................ 32
disopyramide .................................................................................. 24
disopyramide controlled-release .................................................. 24
disulfiram ......................................................................................... 70
DITROPAN ..................................................................................... 85
DITROPAN XL ............................................................................... 85
DIURIL ............................................................................................. 43
divalproex sodium .......................................................................... 34
divalproex sodium capsule ........................................................... 34
divalproex sodium extended release .......................................... 34
DIVIGEL .......................................................................................... 66
dofetilide .......................................................................................... 24
dolasetron ....................................................................................... 52
DOLOPHINE .................................................................................. 31
dolutegravir ....................................................................................... 9
dolutegravir & lamivudine ............................................................... 9
dolutegravir & rilpivirine .................................................................. 9
donepezil................................................................................... 17, 38
DONNATAL .................................................................................... 55
doravirine ........................................................................................ 10
doravirine, lamivudine, tenofovir .................................................. 10
dornase alfa .................................................................................... 45
DORYX ............................................................................................. 5
dorzolamide .................................................................................... 50
dorzolamide & timolol .................................................................... 50
DOSTINEX ..................................................................................... 36
DOVATO ........................................................................................... 9
DOVONEX ...................................................................................... 83
doxazosin ........................................................................................ 21
doxepin .......................................................................... 37, 40, 82, 84
doxepin (antipuritic) ................................................................. 82, 84
doxepin (sleep) .............................................................................. 37
doxercalciferol ................................................................................ 85
doxycycline ................................................................................. 5, 84
doxycycline (rosacea) ................................................................... 84
doxycycline hyclate ......................................................................... 5
doxycycline monohydrate ............................................................... 5
DRISDOL ........................................................................................ 85
DRITHO-CREME HP .................................................................... 83
dronabinol ....................................................................................... 52
dronedarone ................................................................................... 24
drospirenone ............................................................................ 57, 66
drospirenone & estradiol ............................................................... 66
drospirenone & ethinyl estradiol .................................................. 57
drospirenone & ethinyl estradiol w/ folate .................................. 57
DROXIA .......................................................................................... 14
droxidopa ........................................................................................ 19
DUAC .............................................................................................. 77
DUAVEE ......................................................................................... 66
DUETACT ....................................................................................... 65
dulaglutide ...................................................................................... 62
DULERA ......................................................................................... 76
duloxetine ....................................................................................... 40
DUONEB......................................................................................... 19
dupilumab ....................................................................................... 70
DUPIXENT ..................................................................................... 70
DURAGESIC .................................................................................. 30
DUREZOL ....................................................................................... 47
DURICEF .......................................................................................... 5
dutasteride ...................................................................................... 71
dutasteride & tamsulosin .............................................................. 71
DYAZIDE ........................................................................................ 44
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 94
DYMISTA ........................................................................................ 49
DYNACIN .......................................................................................... 6
DYNACIRC ..................................................................................... 23
DYNAPEN ......................................................................................... 5
dyphylline ........................................................................................ 85
DYRENIUM ..................................................................................... 44
E
E.E.S.................................................................................................. 6
E.S.P .................................................................................................. 5
econazole nitrate ............................................................................ 78
ecothiophate ................................................................................... 50
EDARBI ........................................................................................... 25
EDECRIN ........................................................................................ 44
EDLUAR .......................................................................................... 38
edoxaban ........................................................................................ 20
EDURANT ....................................................................................... 12
efavirenz 400 mg, lamivudine & tenofvir ..................................... 10
efavirenz 600 mg ........................................................................... 10
efavirenz 600 mg, lamivudine & tenofvir ..................................... 10
efavirenz, emtricitabine & tenofovir ............................................. 10
EFFEXOR ....................................................................................... 42
EFFEXOR XR................................................................................. 42
EFFIENT ......................................................................................... 20
efinaconazole ................................................................................... 7
EFUDEX .......................................................................................... 84
elagolix ............................................................................................ 71
ELAVIL ............................................................................................ 39
Elaxacaftor, tezacaftor & ivacaftor ............................................... 75
elbasvir & grazoprevir .................................................................... 10
ELDEPRYL ..................................................................................... 37
ELESTAT ........................................................................................ 49
ELESTRIN GEL ............................................................................. 66
eletriptan ......................................................................................... 36
ELIDEL ............................................................................................ 84
eliglustat .......................................................................................... 71
ELIMITE .......................................................................................... 79
ELIPHOS ......................................................................................... 44
ELIQUIS .......................................................................................... 20
ELLA ................................................................................................ 61
ELMIRON ........................................................................................ 73
ELOCON ......................................................................................... 81
eltrombopag .................................................................................... 21
eluxadoline ...................................................................................... 52
elvitegravir, cobicistat, emtricitabine, & tenofovir ...................... 10
EMADINE ........................................................................................ 49
EMBEDA ......................................................................................... 31
EMCYT ............................................................................................ 14
emedastine ..................................................................................... 49
EMEND ........................................................................................... 52
EMFLAZA........................................................................................ 70
EMGALITY ...................................................................................... 71
emicizumab-kxwh .......................................................................... 71
EMLA ............................................................................................... 82
empagliflozin .................................................................................. 62
empagliflozin & lingaliptin ............................................................. 62
empagliflozin & metformin ............................................................ 62
EMSAM ........................................................................................... 37
emtricitabine ............................................................................... 9, 10
emtricitabine & tenofovir ........................................................... 9, 10
emtricitabine, rilpivirine, & tenofovir ............................................ 10
EMTRIVA ........................................................................................ 10
ENABLEX ....................................................................................... 84
enalapril .................................................................................... 25, 26
enalapril & hydrochlorothiazide ................................................... 26
enasidenib ...................................................................................... 14
ENBREL .......................................................................................... 71
encorafenib ..................................................................................... 14
ENDARI........................................................................................... 72
enfuvirtide ....................................................................................... 10
ENJUVIA ......................................................................................... 67
enoxaparin ...................................................................................... 20
entacapone ..................................................................................... 36
entecavir ......................................................................................... 10
ENTOCORT EC ............................................................................. 55
entrectinib ....................................................................................... 14
ENTRESTO .................................................................................... 24
ENULOSE ....................................................................................... 43
enzalutamide .................................................................................. 14
EPANOVA ...................................................................................... 22
EPCLUSA ....................................................................................... 12
EPIDIOLEX ..................................................................................... 38
EPIDUO .......................................................................................... 83
epinastine (ophth) .......................................................................... 49
epinephrine ..................................................................................... 19
EPIPEN ........................................................................................... 19
EPIPEN JR ..................................................................................... 19
EPIVIR ............................................................................................ 11
EPIVIR HBV ................................................................................... 11
eplerenone ...................................................................................... 26
epoetin alfa ..................................................................................... 21
EPOGEN......................................................................................... 21
eprosartan....................................................................................... 26
eprosartan & hydrochlorothiazide................................................ 26
EPZICOM ......................................................................................... 8
EQUETRO ...................................................................................... 34
erenumab-aooe.............................................................................. 71
ergocalciferol .................................................................................. 85
ergoloid mesylates......................................................................... 18
ergotamine & caffeine ............................................................. 19, 35
erlotinib ............................................................................................ 14
ERTACZO ....................................................................................... 79
ertufliglozin ..................................................................................... 62
ertugliflozin & metformin ............................................................... 62
ertugliflozin & sitagliptin ................................................................ 62
ERYGEL ......................................................................................... 78
ERYPED ........................................................................................... 6
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 95
ERY-TAB ........................................................................................... 6
ERYTHROCIN .................................................................................. 6
ERYTHROMYCIN ............................................................................ 5
erythromycin & sulfisoxazole .......................................................... 5
erythromycin (acne acid)............................................................... 78
erythromycin (ophth)...................................................................... 46
erythromycin base ....................................................................... 5, 6
erythromycin base delayed-release .............................................. 6
erythromycin ethylsuccinate ........................................................... 6
erythromycin sterate ........................................................................ 6
ESBRIET ......................................................................................... 76
escitalopram ................................................................................... 40
eslicarbazepine .............................................................................. 34
esomeprazole ................................................................................. 53
estazolam ........................................................................................ 37
esterified estrogens ....................................................................... 66
ESTRACE ................................................................................. 66, 67
ESTRACE CREAM ........................................................................ 67
ESTRACE TAB .............................................................................. 66
ESTRADERM ................................................................................. 67
estradiol ................................................. 57, 58, 59, 60, 61, 66, 67, 68
estradiol & levonorgestrel ............................................................. 66
estradiol & norethindrone .............................................................. 66
estradiol & norgestimate ............................................................... 66
estradiol acetate ............................................................................. 66
estradiol acetate vaginal tablets .................................................. 66
estradiol and progesterone ........................................................... 68
estradiol cypionate ......................................................................... 57
estradiol gel .................................................................................... 66
estradiol transdermal ............................................................... 66, 67
estradiol transderomal ................................................................... 67
estradiol vaginal ............................................................................. 67
estradiol valerate ............................................................................ 57
estradiol valerate & dienogest ...................................................... 57
estramustine ................................................................................... 14
ESTRATEST .................................................................................. 67
ESTRING ........................................................................................ 67
estrogen, ester/me-testosterone .................................................. 67
estrogens, conjugated ................................................................... 67
estrogens, conjugated synthetic a ............................................... 67
estrogens, conjugated synthetic b ............................................... 67
estrogens, conjugated vaginal ..................................................... 67
estropipate ...................................................................................... 67
ESTROSTEP FE ............................................................................ 60
eszopiclone ..................................................................................... 37
etanercept ....................................................................................... 71
ethacrynic acid ............................................................................... 44
ethambutol ........................................................................................ 7
ethionamide ...................................................................................... 7
ethontoin ......................................................................................... 34
ethosuximide .................................................................................. 34
ethynodiol diacetate & ethinyl estradiol ...................................... 58
etidronate ........................................................................................ 71
etodolac ........................................................................................... 30
etonogestrel & ethinyl estradiol ................................................... 58
etravirine ......................................................................................... 10
EUCRISA ........................................................................................ 80
EULEXIN......................................................................................... 14
EURAX ............................................................................................ 78
EVAMIST ........................................................................................ 67
EVEKEO ......................................................................................... 32
everolimus ................................................................................ 14, 71
EVISTA ........................................................................................... 67
EVOCLIN ........................................................................................ 77
evolocumab .................................................................................... 21
EVOTAZ ............................................................................................ 9
EVOXAC ......................................................................................... 17
EXALGO ......................................................................................... 31
EXELDERM .................................................................................... 79
EXELON ......................................................................................... 18
exemestane .................................................................................... 14
exenatide ........................................................................................ 62
exenatide extended-release ......................................................... 62
EXFORGE ...................................................................................... 23
EXFORGE HCT ............................................................................. 23
EXJADE .......................................................................................... 55
EXTAVIA ......................................................................................... 72
ezetimibe......................................................................................... 22
ezetimibe & simvastatin ................................................................ 22
ezogaine ......................................................................................... 34
F
FABIOR ........................................................................................... 84
famciclovir ....................................................................................... 10
famotidine ....................................................................................... 53
FAMVIR........................................................................................... 10
FANAPT .......................................................................................... 40
FARESTON .................................................................................... 16
FARXIGA ........................................................................................ 62
FAZACLO ....................................................................................... 40
febuxostat ....................................................................................... 71
felbamate ........................................................................................ 34
FELBATOL ..................................................................................... 34
FELDENE ....................................................................................... 32
felodipine......................................................................................... 23
FEMARA ......................................................................................... 15
FEMCON FE .................................................................................. 60
FEMHRT ......................................................................................... 67
FEMRING ....................................................................................... 66
FEMTRACE .................................................................................... 66
fenofibrate ....................................................................................... 22
fenofibrate, micronized ................................................................. 22
fenofibric acid ................................................................................. 22
fenoprofen calcium ........................................................................ 30
fentanyl film .................................................................................... 30
fentanyl intranasal ......................................................................... 30
fentanyl lozenge ............................................................................. 30
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Kaiser Permanente, a TRICARE Prime Option Formulary 96
fentanyl sublingual ......................................................................... 30
fentanyl tablet ................................................................................. 30
fentanyl transdermal ...................................................................... 30
FENTORA ....................................................................................... 30
FERRIPROX ................................................................................... 55
fesoterodine .................................................................................... 85
FETZIMA ......................................................................................... 40
FIASP .............................................................................................. 63
FIASP FLEXPEN ........................................................................... 63
fidaxomicin ........................................................................................ 6
filgrastim .......................................................................................... 21
FINACEA ......................................................................................... 83
fingolimod ........................................................................................ 71
FIORICET ....................................................................................... 29
FIORICET W/ CODEINE .............................................................. 29
FIORINAL.................................................................................. 29, 30
FIORINAL W/ CODEINE............................................................... 30
FIRAZYR ......................................................................................... 71
FIRDAPSE ...................................................................................... 69
FLAGYL ............................................................................................. 8
FLAGYL ER ...................................................................................... 8
FLAREX .......................................................................................... 47
flavoxate .......................................................................................... 85
FLAVOXATE .................................................................................. 85
flecainide ......................................................................................... 24
FLECTOR ....................................................................................... 83
FLEXERIL ....................................................................................... 18
FLOMAX.......................................................................................... 19
FLORINEF ACETATE ................................................................... 55
FLOVENT DISKUS AER............................................................... 76
FLOVENT HFA............................................................................... 76
FLOXIN ........................................................................................... 46
fluconazole ........................................................................................ 7
flucytosine ......................................................................................... 7
fludrocortisone ................................................................................ 55
FLUMADINE ................................................................................... 12
fluocinolone acetonide ............................................................ 47, 80
fluocinolone acetonide (otic) ......................................................... 47
fluocinonide ............................................................................... 80, 81
fluocinonide emollient .................................................................... 81
FLUORABON BASIC .................................................................... 74
FLUORITAB .................................................................................... 74
fluorometholone (ophth oint) ........................................................ 47
fluorometholone (ophth) ................................................................ 47
fluorometholone acetate ............................................................... 47
FLUOROPLEX ............................................................................... 84
fluorouracil (topical) ....................................................................... 84
fluoxetine ................................................................................... 40, 41
fluoxymesterone ............................................................................. 56
fluphenazine ................................................................................... 40
flurandrenolide ................................................................................ 81
flurazepam ...................................................................................... 37
flurbiprofen ................................................................................ 30, 47
flurbiprofen (ophth) ........................................................................ 47
flutamide ......................................................................................... 14
fluticasone & salmeterol................................................................ 76
fluticasone & salmeterol (100/50 mcg) ....................................... 76
fluticasone & salmeterol (250/50 mcg and 500/50 mcg) .......... 76
fluticasone & umeclidinium & vilanterol ...................................... 76
fluticasone & vilanterol .................................................................. 76
fluticasone propionate ............................................................. 76, 81
fluticasone propionate (topical) .................................................... 81
fluvastatin ........................................................................................ 22
fluvastatin extended-release ........................................................ 22
fluvoxamine .................................................................................... 40
FML.................................................................................................. 47
FML FORTE ................................................................................... 47
FML OINT ....................................................................................... 47
FOCALIN ........................................................................................ 33
FOCALIN XR .................................................................................. 33
fondaparinux ................................................................................... 20
FORADIL ........................................................................................ 19
formoterol fumarate ....................................................................... 19
FORTAMET .................................................................................... 64
FORTEO ......................................................................................... 68
FORTESTA .................................................................................... 56
FORTICAL ...................................................................................... 68
FOSAMAX ...................................................................................... 69
FOSAMAX PLUS D ....................................................................... 69
fosamprenavir calcium .................................................................. 11
fosfomycin ....................................................................................... 13
fosinopril .......................................................................................... 26
fosinopril & hydrochlorothiazide................................................... 26
FOSRENOL .................................................................................... 44
fostamatinib .................................................................................... 71
FRAGMIN ....................................................................................... 20
FREESTYLE SYSTEM ................................................................. 42
FREESTYLE TEST STRIPS ........................................................ 42
FROVA ............................................................................................ 36
frovatriptan ...................................................................................... 36
FULPHILA ....................................................................................... 21
FURADANTIN ................................................................................ 13
furosemide ...................................................................................... 44
FUZEON ......................................................................................... 10
FYCOMPA ...................................................................................... 35
G
gabapentin ................................................................................ 34, 35
GABITRIL ....................................................................................... 35
GALAFOLD .................................................................................... 73
galantamine hydrobromide ..................................................... 17, 18
galantamine hydrobromide ER .................................................... 18
galcanezumab ................................................................................ 71
ganciclovir ................................................................................. 11, 46
ganciclovir (ophth) ......................................................................... 46
GARAMYCIN.............................................................................. 6, 78
GASTROCROM ............................................................................. 75
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Kaiser Permanente, a TRICARE Prime Option Formulary 97
gatifloxacin (ophth) ........................................................................ 46
GATTEX .......................................................................................... 55
GAVILYTE-C .................................................................................. 54
GEL-KAM ........................................................................................ 74
gemfibrozil ....................................................................................... 22
GENERESS FE .............................................................................. 60
GENTAK.......................................................................................... 46
gentamicin & prednisolone ........................................................... 47
gentamicin (ophth) ......................................................................... 46
gentamicin sulfate ...................................................................... 6, 78
gentamicin sulfate (topical) ........................................................... 78
GENTROPIN .................................................................................. 68
GENVOYA ...................................................................................... 10
GEODON ........................................................................................ 42
GIANVI ............................................................................................ 57
GIAZO ............................................................................................. 52
GILENYA ......................................................................................... 71
gilteritinib ......................................................................................... 14
glasdegib ......................................................................................... 14
glatiramer acetate .......................................................................... 71
GLATOPA ....................................................................................... 71
glecaprevir & pibrentasvir ............................................................. 11
GLEEVEC ....................................................................................... 14
GLEOSTINE ................................................................................... 15
glimepiride ................................................................................. 62, 65
glipizide ........................................................................................... 62
glipizide & metformin ..................................................................... 62
glipizide extended-release ............................................................ 62
GLUCAGEN HYPOKIT ................................................................. 62
glucagon .......................................................................................... 62
GLUCAGON EMERGENCY KIT ................................................. 62
GLUCOPHAGE ........................................................................ 64, 65
GLUCOPHAGE XR ....................................................................... 65
GLUCOTROL ................................................................................. 62
GLUCOTROL XL ........................................................................... 62
GLUCOVANCE .............................................................................. 63
GLUMETZA .................................................................................... 65
glyburide .................................................................................... 62, 63
glyburide & metformin ................................................................... 63
glyburide micronized...................................................................... 63
glycerol phenylbutyrate ................................................................. 43
glycopyrrolate ........................................................................... 16, 76
glycopyrrolate & indacaterol ......................................................... 76
glycopyrrolate inhalation pow ....................................................... 16
glycopyrrolate nebulizer soln ........................................................ 16
GLYNASE ....................................................................................... 63
GLYSET .......................................................................................... 65
GLYXAMBI ...................................................................................... 62
GOCOVRI ....................................................................................... 36
golimumab ...................................................................................... 71
GOLYTELY ..................................................................................... 54
granisetron ...................................................................................... 52
grass pollen allergen extract (5 glass extract) ........................... 49
GRASTEK ....................................................................................... 50
GRIFULVIN V ................................................................................... 7
griseofulvin microsize ...................................................................... 7
griseofulvin ultramicrosize .............................................................. 7
GRIS-PEG ........................................................................................ 7
guaifenesin & codeine ................................................................... 75
guanfacine ................................................................................ 25, 38
guanfacine extended-release....................................................... 38
guselkumab .................................................................................... 71
GVOKE ........................................................................................... 62
GYNAZOLE-1 ................................................................................ 77
GYNODIOL ..................................................................................... 66
H
HAEGARDA ................................................................................... 70
halcinonide ..................................................................................... 81
HALCION ........................................................................................ 38
HALDOL .......................................................................................... 40
HALFLYTELY ................................................................................. 53
halobetasol propionate ................................................................. 81
HALOG ............................................................................................ 81
haloperidol ...................................................................................... 40
HARVONI ....................................................................................... 11
HECTOROL ................................................................................... 85
HELIDAC .......................................................................................... 4
HEMLIBRA ..................................................................................... 71
heparin ............................................................................................ 20
HEPARIN SODIUM ....................................................................... 20
HEPSERA ......................................................................................... 9
HETLIOZ ......................................................................................... 38
hexachlorophene ........................................................................... 78
HIPREX ........................................................................................... 13
HIZENTRA ...................................................................................... 71
homatropine ............................................................................. 51, 75
HORIZANT ..................................................................................... 35
house dust mite allergen extract ................................................. 49
HUMALOG ..................................................................................... 64
HUMALOG KWIKPEN .................................................................. 64
HUMALOG MIX 50/50 .................................................................. 64
HUMALOG MIX 75/25 .................................................................. 64
HUMALOG MIX 75/25 KWIKPEN ............................................... 64
HUMATIN ......................................................................................... 8
HUMATROPE ................................................................................ 68
HUMIRA .......................................................................................... 69
HUMIRA citrate free ...................................................................... 69
HUMULIN 50/50 ............................................................................ 64
HUMULIN 70/30 ............................................................................ 64
HUMULIN 70/30 KIWKPEN ......................................................... 64
HUMULIN N ............................................................................. 63, 64
HUMULIN N KWIKPEN ................................................................ 64
HUMULIN R ................................................................................... 64
HUMULIN R U-500 ........................................................................ 64
HUMULIN R U-500 KWIKPEN .................................................... 64
HYCAMTIN ..................................................................................... 16
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 98
HYCODAN ...................................................................................... 75
HYDERGINE .................................................................................. 18
hydralazine................................................................................ 25, 27
HYDREA ......................................................................................... 14
hydrochlorothiazide.................................... 25, 26, 27, 28, 29, 43, 44
hydrocodone ....................................................................... 30, 31, 75
hydrocodone & acetaminophen ................................................... 30
hydrocodone & chlorpheniramine ................................................ 75
hydrocodone & homatropine ........................................................ 75
hydrocodone & ibuprofen .............................................................. 31
hydrocodone er .............................................................................. 30
hydrocortisone ...................................... 47, 48, 55, 78, 79, 80, 81, 82
hydrocortisone & acetic acid (otic) .............................................. 48
hydrocortisone & pramoxine ......................................................... 82
hydrocortisone (intrarectal) ........................................................... 81
hydrocortisone (rectal) .................................................................. 81
hydrocortisone (topical) ................................................................. 81
hydrocortisone acetate & urea ..................................................... 81
hydrocortisone acetate (intrarectal) ............................................. 81
hydrocortisone butyrate ................................................................ 81
hydrocortisone butyrate hydrophilic lipo base ............................ 81
hydrocortisone probutate .............................................................. 81
hydrocortisone valerate ................................................................. 81
hydromorphone oral suspension ................................................. 31
hydromorphone tablet ................................................................... 31
hydroxychloroquine sulfate ............................................................. 8
hydroxyurea .................................................................................... 14
hydroxyzine hcl............................................................................... 37
hydroxyzine pamoate .................................................................... 37
HYGROTON ................................................................................... 43
hyoscyamine sulfate ................................................................ 16, 17
HYPERCARE ................................................................................. 82
HYPERSAL ..................................................................................... 77
HYQVIA ........................................................................................... 71
HYSINGLA ER ............................................................................... 30
HYTONE ......................................................................................... 81
HYTRIN ........................................................................................... 21
HYZAAR .......................................................................................... 26
I
ibandronate ..................................................................................... 71
IBRANCE ........................................................................................ 15
ibrutinib ............................................................................................ 14
Ibrutinib 140 mg, 280 mg .............................................................. 14
ibuprofen ................................................................................... 31, 32
icatibant ........................................................................................... 71
ICLUSIG .......................................................................................... 15
icosapent ......................................................................................... 22
idelalisib ........................................................................................... 14
IDHIFA ............................................................................................. 14
ILARIS ............................................................................................. 70
iloperidone ...................................................................................... 40
ILUMYA ........................................................................................... 74
imatinib mesylate ........................................................................... 14
IMBRUVICA ................................................................................... 14
IMDUR ............................................................................................ 27
imipramine ...................................................................................... 40
imipramine pamoate ...................................................................... 40
imiquimod ....................................................................................... 84
IMITREX ......................................................................................... 36
immune globulin ............................................................................. 71
Immune globulin ............................................................................ 71
IMPAVIDO ........................................................................................ 8
IMURAN .......................................................................................... 70
INBRIJA .......................................................................................... 37
INCIVEK .......................................................................................... 12
INCRUSE ELLIPTA ....................................................................... 17
indacaterol ...................................................................................... 76
indapamide ..................................................................................... 44
INDERAL ........................................................................................ 29
INDERAL LA .................................................................................. 29
INDERIDE ....................................................................................... 29
indinavir sulfate .............................................................................. 11
INDOCIN ......................................................................................... 31
indomethacin .................................................................................. 31
INFERGEN ..................................................................................... 11
INFLAMASE FORTE ..................................................................... 48
ingenol mebutate ........................................................................... 84
INGREZZA ..................................................................................... 39
INLYTA ............................................................................................ 13
INNOPRAN XL ............................................................................... 29
inotersen ......................................................................................... 72
Inotersen ......................................................................................... 72
INSPRA ........................................................................................... 26
insulin (oral inhalation) .................................................................. 63
insulin aspart .................................................................................. 63
insulin aspart protamine & insulin aspart ................................... 63
insulin degludec ............................................................................. 63
Insulin degludec/ liraglutide .......................................................... 63
insulin degludec/insulin aspart ..................................................... 63
Insulin delivery system .................................................................. 43
insulin detemir ................................................................................ 63
insulin glargine ............................................................................... 63
Insulin glargine/ lixisenatide ......................................................... 63
insulin glulisine ............................................................................... 63
insulin isophane ....................................................................... 63, 64
insulin isophane & regular insulin ................................................ 64
insulin lispro .................................................................................... 64
insulin lispro protamine & insulin lispro....................................... 64
insulin regular ................................................................................. 64
INTAL .............................................................................................. 75
INTELENCE ................................................................................... 10
interferon alfacon-1 ....................................................................... 11
interferon beta-1a .......................................................................... 72
interferon beta-1b .......................................................................... 72
Interferon beta-1b .......................................................................... 72
interferon gamma-1b ..................................................................... 72
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 99
INTROVALE ................................................................................... 58
INTUNIV .......................................................................................... 38
INVEGA ........................................................................................... 41
INVIRASE ....................................................................................... 12
INVOKAMET .................................................................................. 61
INVOKANA ..................................................................................... 61
iodoquinol & hydrocortisone ......................................................... 78
IOPIDINE ........................................................................................ 51
ipratropium bromide ....................................................................... 17
irbesartan ........................................................................................ 26
irbesartan & hydrochlorothiazide ................................................. 26
isavuconazonium ............................................................................. 7
ISENTRESS ................................................................................... 12
ISENTRESS HD ............................................................................. 12
isocarboxazid .................................................................................. 40
isoniazid ............................................................................................ 7
ISOPTIN SR ................................................................................... 24
ISOPTO ATROPINE...................................................................... 51
ISOPTO CARBACHOL ................................................................. 50
ISOPTO CARPINE ........................................................................ 51
ISOPTO HOMATROPINE ............................................................ 51
ISOPTO HYOSCINE ..................................................................... 51
ISORDIL .......................................................................................... 27
isosorbide dinitrate ......................................................................... 27
isosorbide dinitrate & hydralazine ................................................ 27
isosorbide mononitrate .................................................................. 27
isotretinoin ....................................................................................... 84
isradipine ......................................................................................... 23
ISTALOL.......................................................................................... 51
itraconazole ...................................................................................... 7
Ivabradine ....................................................................................... 24
ivacaftor ..................................................................................... 76, 77
ivermectin .......................................................................................... 4
ivermectin (topical) ........................................................................... 4
ivosidenib ........................................................................................ 14
ixazomib .......................................................................................... 14
ixekizumab ...................................................................................... 72
J
JAKAFI ............................................................................................ 15
JALYN ............................................................................................. 71
JANUMET ....................................................................................... 65
JANUVIA ......................................................................................... 65
JARDIANCE 25 MG ...................................................................... 62
JENTADUETO ............................................................................... 64
JUBLIA .............................................................................................. 7
JULUCA ............................................................................................ 9
JUNEL ....................................................................................... 59, 60
JUNEL FE ....................................................................................... 60
JUVISYNC ...................................................................................... 65
JUXTAPID ....................................................................................... 22
JYNARQUE .................................................................................... 44
K
KADIAN ........................................................................................... 31
KALETRA ....................................................................................... 11
KALYDECO .................................................................................... 76
KAON .............................................................................................. 45
KAPVAY .......................................................................................... 24
KARIVA ........................................................................................... 57
KAZANO ......................................................................................... 61
K-DUR ............................................................................................. 45
KEFLEX ............................................................................................ 5
KELNOR ......................................................................................... 58
KENALOG ...................................................................................... 82
KEPPRA ......................................................................................... 35
KEPPRA XR ................................................................................... 35
KERLONE ....................................................................................... 28
KERYDIN .......................................................................................... 7
KETEK .............................................................................................. 6
ketoconazole .............................................................................. 7, 78
ketoconazole (topical) ................................................................... 78
ketoprofen ....................................................................................... 31
KETOPROFEN .............................................................................. 31
ketorolac (ophth) ............................................................................ 48
ketorolac tablet ............................................................................... 31
KEVEYIS......................................................................................... 70
KEVZARA ....................................................................................... 74
KHEDEZLA ..................................................................................... 40
KINERET ........................................................................................ 69
KLARON ......................................................................................... 79
KLONOPIN ..................................................................................... 34
KLOR-CON 20 MEQ ..................................................................... 45
K-LYTE/CL ..................................................................................... 45
KOMBIGLYZE XR ......................................................................... 65
KORLYM ......................................................................................... 65
KOSELUGO ................................................................................... 16
K-PHOS NEUTRAL ....................................................................... 45
K-PHOS ORIGINAL ...................................................................... 45
KRISTALOSE ................................................................................. 43
K-TAB 10, KLOR-CON 20 MEQ ................................................. 45
KUVAN ............................................................................................ 74
KWELL ............................................................................................ 78
KYNAMRO ..................................................................................... 22
KYTRIL ............................................................................................ 52
L
labetalol ........................................................................................... 28
LAC-HYDRIN ................................................................................. 83
lacosamide ..................................................................................... 35
LACRISERT ................................................................................... 51
lactic acid (ammonium lactate) .................................................... 84
LACTINOL ...................................................................................... 84
lactulose .......................................................................................... 43
LAMICTAL ...................................................................................... 35
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 100
LAMICTAL XR ................................................................................ 35
LAMISIL ............................................................................................. 7
lamivudine ......................................................................... 8, 9, 10, 11
Lamivudine & tenofovir .................................................................. 11
lamivudine & zidovudine ........................................................... 9, 11
lamotrigine ...................................................................................... 35
lamotrigine extended-release ....................................................... 35
lanadelumab ................................................................................... 72
LANOXIN ........................................................................................ 24
lanreotide ........................................................................................ 72
lansoprazole ................................................................................... 53
lanthanum carbonate ..................................................................... 44
LANTUS .......................................................................................... 63
LANTUS SOLOSTAR .................................................................... 63
lapatinib ........................................................................................... 14
LARIAM ............................................................................................. 8
larotrectinib ..................................................................................... 14
LASIX............................................................................................... 44
lasmitidan ........................................................................................ 36
LASTACAFT ................................................................................... 49
latanoprost ...................................................................................... 50
latanoprostene bunod.................................................................... 50
LATUDA .......................................................................................... 41
LAZANDA........................................................................................ 30
ledipasvir & sofosbuvir .................................................................. 11
lefamulin ............................................................................................ 6
leflunomide...................................................................................... 72
lenalidomide .................................................................................... 15
lenvatinib ......................................................................................... 15
LENVIMA ........................................................................................ 15
LESCOL .......................................................................................... 22
LESCOL XL .................................................................................... 22
lesinurad .......................................................................................... 72
LESSINA ......................................................................................... 58
LETAIRIS ........................................................................................ 27
letermovir ........................................................................................ 11
letrozole ........................................................................................... 15
leucovorin ........................................................................................ 72
LEUCOVORIN ................................................................................ 72
LEUKERAN .................................................................................... 13
LEUKINE ......................................................................................... 21
leuprolide acetate ........................................................................... 15
levalbuterol nebulizer solution ...................................................... 19
levalbuterol tartrate ........................................................................ 19
LEVAQUIN ........................................................................................ 6
LEVATOL ........................................................................................ 28
LEVBID ............................................................................................ 16
LEVEMIR ........................................................................................ 63
levetiracetam .................................................................................. 35
levetiracetam extended-release ................................................... 35
levobunolol ...................................................................................... 50
LEVO-DROMORAN ...................................................................... 31
levofloxacin ................................................................................. 6, 46
levofloxacin (ophth)........................................................................ 46
levomilnacipran .............................................................................. 40
levonorgestrel ........................................................................... 58, 66
levonorgestrel & ethinyl estradiol ................................................ 58
levonorgestrel & ethinyl estradiol (91-day) ................................. 58
levonorgestrel & ethinyl estradiol (continuous).......................... 58
levonorgestrel & ethinyl estradiol (triphasic) .............................. 58
levophed (oral inhalation) ............................................................. 37
levorphanol ..................................................................................... 31
LEVOTHROID ................................................................................ 69
levothyroxine .................................................................................. 69
LEVOXYL ....................................................................................... 69
LEVSIN ........................................................................................... 16
LEXAPRO ....................................................................................... 40
LEXIVA ............................................................................................ 11
l-glutamine ...................................................................................... 72
LIALDA ............................................................................................ 52
LIBRAX ........................................................................................... 54
LIBRIUM ......................................................................................... 37
LIDAMANTLE ................................................................................. 82
LIDEX ........................................................................................ 80, 81
LIDEX-E .......................................................................................... 81
lidocaine .................................................................................... 51, 82
lidocaine & hydrocortisone ........................................................... 82
lidocaine & prilocaine .................................................................... 82
lidocaine & tetracaine .................................................................... 82
lidocaine (jelly, topical) .................................................................. 82
lidocaine (mouth-throat) ................................................................ 51
LIDODERM ..................................................................................... 82
lifitegrast .......................................................................................... 48
LIMBITROL DS .............................................................................. 40
linaclotide ........................................................................................ 54
linagliptin ......................................................................................... 64
linagliptin & metformin ................................................................... 64
lindane ............................................................................................. 78
linezolid ............................................................................................. 6
LINZESS ......................................................................................... 54
LIORESAL ...................................................................................... 18
liothyronine ..................................................................................... 69
liotrix ................................................................................................ 69
LIPITOR .......................................................................................... 21
liraglutide................................................................................... 63, 64
lisdexamfetamine ........................................................................... 33
lisinopril ........................................................................................... 26
lisinopril & hydrochlorothiazide .................................................... 26
LITHIUM CARBONATE ................................................................ 40
lithium carbonate capsule ............................................................. 40
lithium carbonate extended release ............................................ 40
lithium citrate .................................................................................. 41
LITHOBID ....................................................................................... 40
LIVALO ............................................................................................ 22
lixisenatide ................................................................................ 63, 64
LO LOESTRIN FE ......................................................................... 60
LO/OVRAL-28 ................................................................................ 61
LOCOID .......................................................................................... 81
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 101
LOCOID LIPOCREAM .................................................................. 81
LODINE ........................................................................................... 30
LODOSYN ...................................................................................... 36
lodoxamide tromethamine ............................................................ 49
LOESTRIN 24 FE .......................................................................... 60
LOESTRIN FE ................................................................................ 60
lofexidine ......................................................................................... 38
LOFIBRA CAP ................................................................................ 22
LOFIBRA TAB ................................................................................ 22
LOKELMA ....................................................................................... 44
lomitapide ........................................................................................ 22
LOMOTIL ........................................................................................ 52
lomustine ......................................................................................... 15
LONHALA MAGNAIR .................................................................... 16
LONITEN ......................................................................................... 25
LONSURF ....................................................................................... 16
LOPID .............................................................................................. 22
lopinavir & ritonavir ........................................................................ 11
LOPRESSOR ................................................................................. 28
LOPRESSOR HCT ........................................................................ 28
LOPROX ......................................................................................... 77
lorazepam ....................................................................................... 37
LORBRENA .................................................................................... 15
lorlatinib ........................................................................................... 15
losartan ............................................................................................ 26
losartan & hydrochlorothiazide ..................................................... 26
LOSEASONIQUE .......................................................................... 58
LOTEMAX ....................................................................................... 48
LOTENSIN ...................................................................................... 25
LOTENSIN HCT ............................................................................. 25
loteprednol ...................................................................................... 48
loteprednol & tobramycin .............................................................. 48
LOTREL .......................................................................................... 22
LOTRISONE ................................................................................... 78
LOTRONEX .................................................................................... 52
lovastatin ......................................................................................... 22
lovastatine extended-release ....................................................... 22
LOVAZA .......................................................................................... 22
LOVENOX ....................................................................................... 20
LOW-OGESTREL .......................................................................... 61
loxapine ........................................................................................... 41
LOXITANE ...................................................................................... 41
LOZOL ............................................................................................. 44
lubiprostone .................................................................................... 54
LUCEMYRA .................................................................................... 38
LUDIOMIL ....................................................................................... 41
LUFYLLIN ....................................................................................... 85
luliconazole ....................................................................................... 7
lumacaftor& ivacaftor ..................................................................... 76
LUMIGAN ........................................................................................ 50
LUNESTA........................................................................................ 37
LUPRON ......................................................................................... 15
lurasidone........................................................................................ 41
LURIDE CHEW .............................................................................. 74
LURIDE DROPS ............................................................................ 74
LUTERA .......................................................................................... 58
LUVOX ............................................................................................ 40
LUXIQ .............................................................................................. 80
LUZU ................................................................................................. 7
LYPREL .......................................................................................... 58
LYRICA ........................................................................................... 35
LYSODREN .................................................................................... 15
LYSTEDA ....................................................................................... 20
M
macitentan ...................................................................................... 27
MACROBID .................................................................................... 13
MACRODANTIN ............................................................................ 13
mafenide acetate ........................................................................... 78
MALARONE ..................................................................................... 8
malathion ........................................................................................ 78
maprotiline ...................................................................................... 41
maraviroc ........................................................................................ 11
MARINOL ....................................................................................... 52
MARPLAN ...................................................................................... 40
MATULANE .................................................................................... 15
MAVIK ............................................................................................. 27
MAVYRET ...................................................................................... 11
MAXAIR AUTOHALER ................................................................. 20
MAXALT .......................................................................................... 36
MAXALT MLT ................................................................................. 36
MAXIDEX ........................................................................................ 47
MAXITROL ..................................................................................... 48
MAXZIDE ........................................................................................ 44
mechlorethamine ........................................................................... 15
meclofenamate .............................................................................. 31
MECLOMEN ................................................................................... 31
MEDROL......................................................................................... 56
medroxyprogesterone acetate ............................................... 66, 68
mefenamic acid .............................................................................. 31
mefloquine ........................................................................................ 8
MEGACE ........................................................................................ 68
megestrol acetate .......................................................................... 68
MEKTOVI ........................................................................................ 13
MELLARIL ...................................................................................... 41
meloxicam ....................................................................................... 31
melphalan ....................................................................................... 15
memantine ...................................................................................... 38
memantine er & donepezil ............................................................ 38
M-END MAX D ............................................................................... 75
MENEST ......................................................................................... 66
MENOSTAR ................................................................................... 67
MENTAX ......................................................................................... 77
mepenzolate ................................................................................... 55
meperidine tablet ........................................................................... 31
MEPHYTON ................................................................................... 85
mepolizumab .................................................................................. 76
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 102
meprobamate ................................................................................. 38
MEPRON .......................................................................................... 8
mercaptopurine .............................................................................. 15
mesalamine controlled-release .................................................... 52
mesalamine suppository ............................................................... 52
mesalamine suspension ............................................................... 52
mesalamine tablet .......................................................................... 52
mesna .............................................................................................. 72
MESNEX ......................................................................................... 72
MESTION ........................................................................................ 18
MESTION TIMESPAN .................................................................. 18
METADATE CD ............................................................................. 33
METADATE ER .............................................................................. 33
METAGLIP ...................................................................................... 62
metaxalone ..................................................................................... 18
metformin ................................................................ 61, 62, 63, 64, 65
metformin ER ............................................................................ 64, 65
metformin extended-release ......................................................... 65
methadone ...................................................................................... 31
methamphetamine ......................................................................... 33
methazolamide ............................................................................... 50
methenamine hippurate ................................................................ 13
methenamine, sodium biphosphate, phenyl salicylate,
methylene blue, and hyoscyamine ................................... 13, 72
METHERGINE ............................................................................... 72
methimazole ................................................................................... 69
METHITEST ................................................................................... 56
methocarbamol............................................................................... 18
methotrexate ................................................................................... 15
methotrexate sodium ..................................................................... 15
methoxsalen ................................................................................... 84
methoxsalen, rapid ........................................................................ 84
methscopolamine ........................................................................... 17
methsuximide ................................................................................. 35
methyclothiazide ............................................................................ 44
METHYCLOTHIAZIDE .................................................................. 44
methyldopa ..................................................................................... 25
methyldopa & hydrochlorothiazide .............................................. 25
methylergonovine maleate ........................................................... 72
METHYLIN ...................................................................................... 33
methylnaltrexone ............................................................................ 55
methylphenidate ....................................................................... 33, 34
methylphenidate extended-release ............................................. 33
Methylphenidate extended-release disintegrating tablet .......... 34
methylphenidate sustained release ............................................. 34
methylphenidate transdermal patch ............................................ 34
methylprednisolone........................................................................ 56
methyltestosterone ........................................................................ 56
metipranolol .................................................................................... 50
metoclopramide .............................................................................. 55
metolazone ..................................................................................... 44
metoprolol & hydrochlorothiazide ................................................ 28
metoprolol succinate...................................................................... 28
metoprolol tartrate .......................................................................... 28
metreleptin ...................................................................................... 72
METROCREAM ............................................................................. 78
METROGEL ................................................................................... 78
METROGEL-VAGINAL ................................................................. 78
METROLOTION ............................................................................ 78
metronidazole ......................................................................... 4, 8, 78
metronidazole (topical) ................................................................. 78
metronidazole (vaginal) ................................................................ 78
metronidazole extended-release ................................................... 8
metronidazole, tetracycline & bismuth subsalicylate .................. 4
MEVACOR ..................................................................................... 22
mexiletine ........................................................................................ 24
MEXITIL .......................................................................................... 24
MIACALCIN .................................................................................... 68
MICARDIS ...................................................................................... 27
MICARDIS HCT ............................................................................. 27
miconazole nitrate & zinc oxide ................................................... 78
MICROGESTIN ........................................................................ 59, 60
MICROGESTIN FE ....................................................................... 60
MICROZIDE ................................................................................... 44
MIDAMOR ...................................................................................... 43
midodrine hcl .................................................................................. 20
MIFEPREX ..................................................................................... 72
mifepristone .............................................................................. 65, 72
migalastat ....................................................................................... 73
MIGERGOT .................................................................................... 35
miglitol ............................................................................................. 65
miglustat .......................................................................................... 73
MIGRANAL ..................................................................................... 18
milnacipran ..................................................................................... 38
miltefosine......................................................................................... 8
MILTOWN ....................................................................................... 38
MINASTRIN 24 FE ........................................................................ 60
MINIPRESS .................................................................................... 21
MINIVELLE ..................................................................................... 67
MINOCIN .......................................................................................... 6
minocycline ....................................................................................... 6
minoxidil .......................................................................................... 25
mipomersen sodium ...................................................................... 22
mirabegron ..................................................................................... 85
MIRAPEX ........................................................................................ 37
MIRAPEX ER ................................................................................. 37
mirtazapine ..................................................................................... 41
MIRVASO ....................................................................................... 83
misoprostol ............................................................................... 30, 53
mitotane .......................................................................................... 15
MOBIC ............................................................................................ 31
modafinil .......................................................................................... 34
MODICON ...................................................................................... 59
MODURETIC.................................................................................. 43
moexipril .......................................................................................... 26
moexipril & hydrochlorothiazide................................................... 26
mometasone & formoterol ............................................................ 76
mometasone furoate ............................................................... 76, 81
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 103
MONODOX ....................................................................................... 5
MONONESSA ................................................................................ 61
MONOPRIL ..................................................................................... 26
MONOPRIL HCT ........................................................................... 26
montelukast .................................................................................... 75
MONUROL ...................................................................................... 13
morphine ......................................................................................... 31
morphine & naltrexone .................................................................. 31
morphine beads ............................................................................. 31
morphine extended-release capsule ........................................... 31
morphine extended-release tablet ............................................... 31
MORPHINE SULFATE .................................................................. 31
MOTOFEN ...................................................................................... 52
MOTRIN .......................................................................................... 31
MOVIPREP ..................................................................................... 53
moxifloxacin ................................................................................ 6, 46
moxifloxacin (ophth) ...................................................................... 46
MS CONTIN .................................................................................... 31
MSIR ................................................................................................ 31
MUCOMYST-10 ............................................................................. 69
MULTAQ ......................................................................................... 24
mupirocin ......................................................................................... 78
mupirocin calcium .......................................................................... 78
MYALEPT ....................................................................................... 72
MYAMBUTOL ................................................................................... 7
MYCELEX ....................................................................................... 77
MYCIFRADIN ................................................................................... 6
MYCOBUTIN .................................................................................... 8
MYCOLOG II .................................................................................. 81
mycophenolate mofetil .................................................................. 73
mycophenolate sodium ................................................................. 73
MYCOSTATIN .................................................................................. 7
MYDAYIS ........................................................................................ 33
MYFORTIC ..................................................................................... 73
MYLERAN ....................................................................................... 13
MYRBETRIQ .................................................................................. 85
MYSOLINE ..................................................................................... 35
N
na sulfacetm/avobenzone/sulfur .................................................. 78
nabilone ........................................................................................... 52
nabumetone .................................................................................... 31
nadolol ............................................................................................. 28
nadolol & bendroflumethiazide ..................................................... 28
nafarelin ........................................................................................... 68
naftifine cream ................................................................................ 78
Naftifine gel ..................................................................................... 79
NAFTIN ..................................................................................... 78, 79
nalbuphine ...................................................................................... 31
NALFON .......................................................................................... 30
naloxone .............................................................................. 29, 32, 39
naloxone nasal spray .................................................................... 39
naltrexone ................................................................................. 31, 39
NAMENDA ...................................................................................... 38
NAMZARIC ..................................................................................... 38
NAPRELAN .................................................................................... 31
NAPROSYN ................................................................................... 31
naproxen ......................................................................................... 31
naproxen sodium ........................................................................... 31
naratriptan....................................................................................... 36
NARCAN ......................................................................................... 39
NARDIL ........................................................................................... 41
NATACYN ....................................................................................... 46
natamycin ....................................................................................... 46
NATAZIA ......................................................................................... 57
nateglinide ...................................................................................... 65
NATPARA ....................................................................................... 73
NATROBA ...................................................................................... 79
NAVANE ......................................................................................... 41
nebivolol .......................................................................................... 28
NEBUPENT ...................................................................................... 8
NECON ........................................................................................... 59
NECON 10/11 ................................................................................ 59
nedocromil sodium (ophth) ........................................................... 49
nefazodone ..................................................................................... 41
nelfinavir mesylate ......................................................................... 11
neomycin sulfate .............................................................................. 6
neomycin, bacitracin & polymyxin b (ophth) .............................. 46
neomycin, colistin, hydrocortisone & thonzonium (otic) ........... 48
neomycin, polymycin b & gramicidin (ophth) ............................. 46
neomycin, polymyxin B & dexamethasone (ophth)................... 48
neomycin, polymyxin B & hydrocortisone (ophth) ............... 47, 48
neomycin, polymyxin B & hydrocortisone (otic) ........................ 48
NEO-POLYCIN ........................................................................ 46, 47
NEO-POLYCIN HC ....................................................................... 47
NEORAL ......................................................................................... 70
NEOSPORIN .................................................................................. 46
neostigmine bromide ..................................................................... 18
nepafenac ....................................................................................... 48
NEPTAZANE .................................................................................. 50
NESINA ........................................................................................... 61
netarsudil ........................................................................................ 51
netupitant & palonosetron ............................................................ 52
NEULASTA ..................................................................................... 21
NEUMEGA ..................................................................................... 21
NEUPOGEN ................................................................................... 21
NEUPRO......................................................................................... 37
NEURONTIN .................................................................................. 34
NEVANAC ...................................................................................... 48
nevirapine solution......................................................................... 11
nevirapine tablet ............................................................................ 11
NEXAVAR ....................................................................................... 16
NEXIUM .......................................................................................... 53
NEXLETOL ..................................................................................... 21
NEXLIZET ....................................................................................... 21
niacin ......................................................................................... 22, 85
niacin & lovastatin .......................................................................... 22
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 104
NIACOR .......................................................................................... 85
NIASPAN ........................................................................................ 22
nicardipine ....................................................................................... 23
NICODERM .................................................................................... 17
NICORETTE ................................................................................... 17
nicotine gum ................................................................................... 17
nicotine inhalation .......................................................................... 17
nicotine lozenge ............................................................................. 17
nicotine nasal spray ....................................................................... 17
nicotine patch ................................................................................. 17
nicotine spray ................................................................................. 17
NICOTROL ..................................................................................... 17
nifedipine ......................................................................................... 23
nifedipine extended-release ......................................................... 23
NILANDRON .................................................................................. 15
nilotinib ............................................................................................ 15
nilutamide ........................................................................................ 15
nimodipine ....................................................................................... 23
NIMOTOP ....................................................................................... 23
NINLARO ........................................................................................ 14
nintedanib........................................................................................ 76
niraparib .......................................................................................... 15
NIRAVAM ........................................................................................ 37
nisoldipine ....................................................................................... 23
nitazoxanide ...................................................................................... 8
nitisinone ......................................................................................... 73
NITRO-BID ...................................................................................... 27
NITRO-DUR .................................................................................... 27
nitrofurantoin ................................................................................... 13
nitrofurantoin macrocrystal ........................................................... 13
nitrofurantoin monohydrate ........................................................... 13
nitroglycerin (intra-anal) ................................................................ 27
nitroglycerin aerosol ...................................................................... 27
nitroglycerin solution ...................................................................... 27
nitroglycerin sublingual .................................................................. 27
nitroglycerin topical ointment ........................................................ 27
nitroglycerin transdermal patch .................................................... 27
nitroglycerin transdermal patch 0.8 mg strength ....................... 27
NITROLINGUAL ............................................................................. 27
NITROMIST .................................................................................... 27
NITROSTAT ................................................................................... 27
nizatidine ......................................................................................... 53
NIZORAL ..................................................................................... 7, 78
NOLVADEX .................................................................................... 16
NORA-BE ........................................................................................ 59
NORCO ........................................................................................... 30
NORDETTE-28 .............................................................................. 58
NORDITROPIN .............................................................................. 68
norelgestromin & ethinyl estradiol ......................................... 58, 59
norethindrone ......................................................... 59, 60, 66, 67, 68
norethindrone & ethinyl estradiol ........................................... 59, 60
norethindrone & ethinyl estradiol (biphasic) ............................... 59
norethindrone & ethinyl estradiol (triphasic) ............................... 59
norethindrone & ethinyl estradiol w/ ferrous fumarate .............. 60
norethindrone acetate ....................................................... 60, 67, 68
norethindrone acetate & ethinyl estradiol ............................. 60, 67
norethindrone acetate & ethinyl estradiol w/ ferrous fumarate 60
norethindrone acetate & ethinyl estradiol w/ ferrous fumarate
(biphasic) ................................................................................... 60
norethindrone-mestranol .............................................................. 60
NORFLEX ....................................................................................... 18
norfloxacin ........................................................................................ 6
NORGESIC .................................................................................... 18
norgestimate & ethinyl estradiol ............................................ 60, 61
norgestimate & ethinyl estradiol (triphasic) ................................ 61
norgestrel & ethinyl estradiol ........................................................ 61
NORINYL 1+35 .............................................................................. 59
NORINYL 1+50 .............................................................................. 60
NOROXIN ......................................................................................... 6
NORPACE ...................................................................................... 24
NORPACE CR ............................................................................... 24
NORPRAMIN ................................................................................. 40
NOR-QD ......................................................................................... 59
NORTHERA ................................................................................... 19
NORTREL 1/35 ............................................................................. 59
NORTREL 7/7/7 ............................................................................. 59
nortriptyline ..................................................................................... 41
NORVASC ...................................................................................... 22
NORVIR .......................................................................................... 12
NOVOLIN 70/30 ............................................................................. 64
NOVOLIN N .................................................................................... 63
NOVOLIN R .................................................................................... 64
NOVOLOG ..................................................................................... 63
NOVOLOG MIX 70/30 .................................................................. 63
NOVOLOG MIX 70/30 FLEXPEN ............................................... 63
NOXAFIL........................................................................................... 7
NUBAIN........................................................................................... 31
NUBEQA ......................................................................................... 14
NUCALA ......................................................................................... 76
NUCYNTA ...................................................................................... 32
NUEDEXTA .................................................................................... 38
NULYTELY ..................................................................................... 54
NUPLAZID ...................................................................................... 41
NURTEC ODT................................................................................ 36
NUTROPIN AQ .............................................................................. 68
NUVARING ..................................................................................... 58
NUVIGIL .......................................................................................... 33
NUZYRA ........................................................................................... 6
NYDRAZID ....................................................................................... 7
nystatin .................................................................................. 7, 79, 81
NYSTATIN ...................................................................................... 79
nystatin & triamcinolone................................................................ 81
nystatin (topical) ............................................................................. 79
O
OCELLA .......................................................................................... 57
octreotide acetate .......................................................................... 73
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 105
OCUFEN ......................................................................................... 47
OCUFLOX ....................................................................................... 46
OCUPRESS .................................................................................... 50
ODACTRA ...................................................................................... 49
ODEFSEY ....................................................................................... 10
OFEV ............................................................................................... 76
ofloxacin (ophth)............................................................................. 46
ofloxacin (otic) ................................................................................ 46
OGESTREL .................................................................................... 61
olanzapine ....................................................................................... 41
olanzapine & fluoxetine hcl ........................................................... 41
olanzapine orally disintegrating.................................................... 41
OLEPTRO ....................................................................................... 42
olmesartan ................................................................................ 23, 26
olmesartan & hydrochlorothiazide ......................................... 23, 26
olodaterol .................................................................................. 20, 77
olopatadine ............................................................................... 49, 50
olopatadine (nasal) ........................................................................ 50
olopatadine (ophth) ........................................................................ 50
olsalazine ........................................................................................ 52
OLUMIANT ..................................................................................... 70
OLUX-E ........................................................................................... 80
OLYSIO ........................................................................................... 12
omadacycline .................................................................................... 6
omalizumab .................................................................................... 76
ombitasvir, paritaprevir & ritonavir ............................................... 11
ombitasvir, paritaprevir, ritonavir, & dasabuvir........................... 11
omega-3 acid ethyl esters............................................................. 22
omega-3-carboxylic acid ............................................................... 22
omeprazole ..................................................................................... 53
OMNICEF.......................................................................................... 5
OMNIPOD DASHTM SYSTEM KIT AND PODs ......................... 43
OMNIPRED .................................................................................... 48
OMNITROPE .................................................................................. 68
ondansetron .............................................................................. 52, 53
ondansetron (orally disintegrating) .............................................. 53
ONE TOUCH ULTRA 2 ................................................................. 42
ONE TOUCH ULTRA SMART ..................................................... 42
ONE TOUCH ULTRA TEST STRIPS ......................................... 42
ONE TOUCH ULTRAMINI ............................................................ 43
ONE TOUCH VERIO FLEX .......................................................... 42
ONE TOUCH VERIO TEST STRIPS .......................................... 42
ONEXTON ...................................................................................... 77
ONFI ................................................................................................ 34
ONGLYZA ....................................................................................... 65
ONSOLIS ........................................................................................ 30
OPANA ............................................................................................ 32
OPANA ER ..................................................................................... 32
OPIUM ............................................................................................. 32
opium & belladonna alkaloids ...................................................... 32
opium tincture ................................................................................. 32
oprelvekin ........................................................................................ 21
OPSUMIT ........................................................................................ 27
OPTHETIC ...................................................................................... 51
OPTICROM .................................................................................... 49
OPTIPRANOLOL ........................................................................... 50
OPTIVAR ........................................................................................ 49
ORACEA ..................................................................................... 5, 84
ORALAIR ........................................................................................ 49
ORAP .............................................................................................. 41
ORAPRED ...................................................................................... 56
ORAPRED ODT ............................................................................ 56
ORENCIA ....................................................................................... 69
ORENITRAM .................................................................................. 28
ORFADIN ........................................................................................ 73
ORILISSA ....................................................................................... 71
ORINASE ........................................................................................ 66
ORKAMBI ....................................................................................... 76
orphenadrine citrate ...................................................................... 18
orphenadrine, aspirin, & caffeine ................................................. 18
ORTHO EVRA ............................................................................... 58
ORTHO TRI-CYCLEN .................................................................. 61
ORTHO-CEPT ............................................................................... 57
ORTHO-CYCLEN .......................................................................... 61
ORTHO-EST .................................................................................. 67
ORTHO-NOVUM ..................................................................... 59, 60
oseltamivir phosphate ................................................................... 11
OSENI ............................................................................................. 61
OSMOPREP ................................................................................... 54
ospemifene ..................................................................................... 67
OSPHENA ...................................................................................... 67
OTEZLA .......................................................................................... 70
OTREXUP ...................................................................................... 15
OVCON-35 ..................................................................................... 59
OVCON-50 ..................................................................................... 59
OVIDE ............................................................................................. 78
OXANDRIN ..................................................................................... 56
oxandrolone .................................................................................... 56
oxaprozin ........................................................................................ 32
oxazepam ....................................................................................... 38
OXBRYTA ....................................................................................... 74
oxcarbazepine ................................................................................ 35
OXERVATE .................................................................................... 51
oxiconazole nitrate......................................................................... 79
OXISTAT......................................................................................... 79
OXSORALEN-ULTRA ................................................................... 84
oxybutynin....................................................................................... 85
oxybutynin extended-release ....................................................... 85
oxybutynin transdermal ................................................................. 85
oxycodone ...................................................................................... 32
oxycodone & acetaminophen....................................................... 32
oxycodone & acetaminophen er .................................................. 32
oxycodone & aspirin ...................................................................... 32
oxycodone & ibuprofen ................................................................. 32
oxycodone controlled-release ...................................................... 32
OXYCONTIN .................................................................................. 32
oxymetholone ................................................................................. 56
oxymorphone.................................................................................. 32
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 106
oxymorphone extended-release .................................................. 32
OXYTROL ....................................................................................... 85
ozanimod ......................................................................................... 73
OZEMPIC ........................................................................................ 65
P
PACERONE .................................................................................... 24
palbociclib ....................................................................................... 15
paliperidone .................................................................................... 41
palivizumab ..................................................................................... 12
PALYNZIQ ...................................................................................... 73
PAMELOR ...................................................................................... 41
PAMINE ........................................................................................... 17
PANCREAZE .................................................................................. 54
pancrelipase (lipase-protease-amylase) ..................................... 54
PANDEL .......................................................................................... 81
PANRETIN ...................................................................................... 83
pantoprazole ................................................................................... 53
papaverine ...................................................................................... 27
PARAFON FORTE DSC ............................................................... 18
parathyroid hormone ..................................................................... 73
PARCOPA ...................................................................................... 36
paregoric ......................................................................................... 52
PAREGORIC .................................................................................. 52
paricalcitol ....................................................................................... 85
PARLODEL ..................................................................................... 36
PARNATE ....................................................................................... 41
paromomycin sulfate ....................................................................... 8
paroxetine ....................................................................................... 41
paroxetine extended-release ........................................................ 41
paroxetine mesylate ...................................................................... 41
pasireotide ...................................................................................... 73
PATADAY ....................................................................................... 49
PATANASE ..................................................................................... 50
PATANOL ....................................................................................... 50
patiromer ......................................................................................... 44
PAVABID ......................................................................................... 27
PAXIL............................................................................................... 41
PAXIL CR ........................................................................................ 41
pazopanib........................................................................................ 15
PEDIAPRED ................................................................................... 56
pediatric multivitamins w/ fluoride ................................................ 73
pediatric multivitamins w/ fluoride & iron .................................... 73
pediatric vitamins a, c, & d, w/ fluoride ....................................... 73
pediatric vitamins a, c, & d, w/ fluoride & iron ............................ 73
PEGANONE ................................................................................... 34
PEGASYS ....................................................................................... 12
pegfilgrastim ................................................................................... 21
pegfilgrastim-jmdb ......................................................................... 21
peginterferon alfa-2a ..................................................................... 12
peginterferon-alfa 2b ..................................................................... 12
PEG-INTRON ................................................................................. 12
pegvaliase ....................................................................................... 73
pegvisomant ................................................................................... 69
PEMAZYRE .................................................................................... 15
pemigatinib ..................................................................................... 15
penbutolol ....................................................................................... 28
penciclovir ....................................................................................... 79
penicillamine ................................................................................... 55
penicillin v potassium ...................................................................... 6
PENLAC .......................................................................................... 77
PENNSAID ..................................................................................... 30
pentamidine ...................................................................................... 8
PENTASA ....................................................................................... 52
pentazocine & naloxone ............................................................... 32
pentosan polysulfate sodium ....................................................... 73
pentoxifylline ................................................................................... 20
PEN-VK ............................................................................................. 6
PEPCID ........................................................................................... 53
perampanel ..................................................................................... 35
PERCOCET ................................................................................... 32
PERCODAN ................................................................................... 32
PERIACTIN ...................................................................................... 4
PERIDEX ........................................................................................ 45
perindopril ....................................................................................... 26
PERIOSTAT ..................................................................................... 5
permethrin....................................................................................... 79
perphenazine ........................................................................... 39, 41
PERSANTINE ................................................................................ 20
PERTZYE ....................................................................................... 54
PEXEVA .......................................................................................... 41
pexidartinib ..................................................................................... 16
phenelzine ...................................................................................... 41
PHENERGAN ............................................................................ 4, 75
PHENERGAN VC ...................................................................... 4, 75
PHENERGAN VC W/CODEINE .................................................. 75
PHENERGAN W/ CODEINE ....................................................... 75
phenobarbital ........................................................................... 38, 55
PHENOBARBITAL ........................................................................ 38
phenobarbital and belladonna alkaloids ..................................... 55
phenoxybenzamine ....................................................................... 19
PHENYTEK .................................................................................... 35
phenytoin sodium extended-release ........................................... 35
phenytoin suspension ................................................................... 35
PHISOHEX ..................................................................................... 78
PHOSLO ......................................................................................... 44
PHOSLYRA .................................................................................... 45
PHOSPHA ...................................................................................... 45
PHOSPHOLINE IODIDE .............................................................. 50
PHRENILIN .................................................................................... 29
PHRENILIN FORTE ...................................................................... 29
phytonadione .................................................................................. 85
PICATO ........................................................................................... 84
PIFELTRO ...................................................................................... 10
pilocarpine ................................................................................ 18, 51
pilocarpine gel ................................................................................ 51
PILOPINE HS ................................................................................. 51
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 107
pimavanserin .................................................................................. 41
pimecrolimus .................................................................................. 84
pimozide .......................................................................................... 41
pindolol ............................................................................................ 28
pioglitazone ............................................................................... 61, 65
pioglitazone & glimepiride ............................................................. 65
pioglitazone & metformin .............................................................. 65
PIQRAY ........................................................................................... 13
pirbuterol acetate ........................................................................... 20
pirfenidone ...................................................................................... 76
piroxicam ......................................................................................... 32
pitavastatin ...................................................................................... 22
pitolisant .......................................................................................... 38
PLAN B ............................................................................................ 58
PLAQUENIL ...................................................................................... 8
PLAVIX ............................................................................................ 20
PLEGRIDY ...................................................................................... 72
PLENDIL ......................................................................................... 23
PLETAL ........................................................................................... 20
PLEXION ......................................................................................... 82
PLEXION SCT ................................................................................ 82
podofilox .......................................................................................... 84
POLY HIST FORTE ......................................................................... 4
POLYCITRA-K ............................................................................... 43
polyethylene glycol-electrolyte solution ................................ 53, 54
polymyxin b & trimethoprim (ophth)............................................. 46
POLYSPORIN ................................................................................ 45
POLYTRIM ...................................................................................... 46
POLY-VI-FLOR .............................................................................. 73
POLY-VI-FLOR W/IRON............................................................... 73
pomalidomide ................................................................................. 15
POMALYST .................................................................................... 15
ponatinib .......................................................................................... 15
PONSTEL ....................................................................................... 31
PORTIA ........................................................................................... 58
posaconazole ................................................................................... 7
potassium bicarbonate & potassium chloride ............................ 45
potassium chloride ......................................................................... 45
potassium chloride powder ........................................................... 45
potassium citrate ............................................................................ 43
potassium citrate & citric acid ....................................................... 43
potassium gluconate...................................................................... 45
potassium iodide & iodine ............................................................. 69
potassium phosphate .................................................................... 45
potassium phosphate, monobasic ............................................... 45
POTIGA ........................................................................................... 34
PRADAXA ....................................................................................... 20
PRALUENT ..................................................................................... 21
pramipexole .................................................................................... 37
pramipexole extended-release ..................................................... 37
pramlintide acetate ........................................................................ 65
PRAMOSONE ................................................................................ 82
PRAMOSONE-E ............................................................................ 82
pramoxine ....................................................................................... 82
PRANDIMET .................................................................................. 65
PRANDIN ........................................................................................ 65
prasugrel ......................................................................................... 20
PRAVACHOL ................................................................................. 22
pravastatin ...................................................................................... 22
praziquantel ...................................................................................... 4
prazosin .......................................................................................... 21
PRECOSE ...................................................................................... 61
PRED FORTE ................................................................................ 48
PRED MILD .................................................................................... 48
PRED-G .......................................................................................... 47
prednicarbate ................................................................................. 81
PREDNISOL ................................................................................... 49
prednisolone ................................................................. 47, 48, 49, 56
PREDNISOLONE .......................................................................... 56
prednisolone acetate ............................................................... 48, 56
prednisolone acetate (ophth) ....................................................... 48
prednisolone sodium phosphate ..................................... 48, 49, 56
prednisolone sodium phosphate (ophth) .............................. 48, 49
prednisone ...................................................................................... 56
PREDNISONE ............................................................................... 56
PREFEST ....................................................................................... 66
pregabalin ....................................................................................... 35
PRELONE ....................................................................................... 56
PREMARIN ..................................................................................... 67
PREMARIN CREAM ..................................................................... 67
PREMPHASE ................................................................................. 66
PREMPRO ..................................................................................... 66
PREPOPIK ..................................................................................... 54
pretomanid ........................................................................................ 7
PRETOMANID ................................................................................. 7
PREVACID ..................................................................................... 53
PREVIDENT ................................................................................... 74
PREVIDENT 5000 PLUS ............................................................ 74
PREVPAC ....................................................................................... 53
PREVYMIS ..................................................................................... 11
PREZCOBIX ..................................................................................... 9
PREZISTA ........................................................................................ 9
PRIFTIN ............................................................................................ 8
PRILOSEC ..................................................................................... 53
PRIMAQUINE .................................................................................. 8
primaquine phosphate .................................................................... 8
primidone ........................................................................................ 35
PRISTIQ .......................................................................................... 40
PROAIR HFA ................................................................................. 19
PROAMATINE ............................................................................... 20
PRO-BANTHINE ............................................................................ 17
probenecid ...................................................................................... 45
procarbazine ................................................................................... 15
PROCARDIA .................................................................................. 23
PROCARDIA XL ............................................................................ 23
prochlorperazine ............................................................................ 53
PROCRIT ........................................................................................ 21
PROCTOCORT ............................................................................. 81
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 108
PROCTOFOAM ............................................................................. 82
PROCTOFOAM-HC ...................................................................... 82
PROCYSBI ..................................................................................... 70
PRODIGY.................................................................................. 42, 43
PRODIGY TEST STRIPS ............................................................. 42
progesterone, micronized ............................................................. 68
PROGRAF ...................................................................................... 74
PROLIXIN ....................................................................................... 40
PROLOPRIM .................................................................................. 13
PROMACTA ................................................................................... 21
promethazine .............................................................................. 4, 75
promethazine & codeine ............................................................... 75
promethazine & dextromethorphan ............................................. 75
promethazine & phenylephrine ...................................................... 4
promethazine, phenylephrine & codeine .................................... 75
PROMETHAZINE-DM ................................................................... 75
PROMETRIUM ............................................................................... 68
propafenone .................................................................................... 24
propantheline bromide .................................................................. 17
proparacaine ................................................................................... 51
propranolol ...................................................................................... 29
propranolol & hydrochlorothiazide ............................................... 29
propranolol extended-release ...................................................... 29
propranolol sustained-release ...................................................... 29
propylthiouracil ............................................................................... 69
PROPYLTHIOURACIL .................................................................. 69
PROSOM ........................................................................................ 37
PROSTIGMIN ................................................................................. 18
PROTONIX ..................................................................................... 53
PROTOPIC ..................................................................................... 84
protriptyline ..................................................................................... 41
PROVENTIL HFA .......................................................................... 19
PROVERA ...................................................................................... 68
PROVIGIL ....................................................................................... 34
PROZAC ......................................................................................... 40
PROZAC WEEKLY ........................................................................ 40
PRUDOXIN ..................................................................................... 84
pseudoephedrine, brompheniramine & codeine ........................ 75
PULMICORT FLEXHALER .......................................................... 75
PULMICORT RESPULES ............................................................ 75
PULMOZYME ................................................................................. 45
PURINETHOL ................................................................................ 15
PYLERA ............................................................................................ 4
pyrazinamide .................................................................................... 8
PYRAZINAMIDE .............................................................................. 8
pyridostigmine ................................................................................ 18
pyrimethamine .................................................................................. 8
Q
QINLOCK ........................................................................................ 15
QUALAQUIN .................................................................................... 8
QUESTRAN .................................................................................... 21
QUESTRAN LIGHT ....................................................................... 21
quetiapine ....................................................................................... 41
quetiapine extended-release ........................................................ 41
QUINAGLUTE ................................................................................ 24
quinapril & hydrochlorothiazide ................................................... 26
quinapril hcl .................................................................................... 26
quinidine .................................................................................... 24, 38
quinidine gluconate ....................................................................... 24
QUINIDINE SULFATE .................................................................. 24
quinine sulfate .................................................................................. 8
QUIXIN ............................................................................................ 46
QVAR RediHaler ............................................................................ 75
R
rabeprazole ..................................................................................... 53
RAGWITEK .................................................................................... 50
raloxifene hcl .................................................................................. 67
raltegravir ........................................................................................ 12
raltegravir (600mg) ........................................................................ 12
ramelteon ........................................................................................ 38
ramipril ............................................................................................ 26
RANEXA ......................................................................................... 24
ranolazine ....................................................................................... 24
RAPAFLO ....................................................................................... 19
RAPAMUNE ................................................................................... 74
rasagiline......................................................................................... 37
RASUVO ......................................................................................... 15
RAVICTI .......................................................................................... 43
RAYOS ............................................................................................ 56
RAZADYNE .............................................................................. 17, 18
RAZADYNE ER ............................................................................. 18
REBETOL ....................................................................................... 12
REBIF .............................................................................................. 72
REBIF REBIDOSE ........................................................................ 72
RECLIPSEN ................................................................................... 57
RECTIV ........................................................................................... 27
REGLAN ......................................................................................... 55
regorafenib ..................................................................................... 15
REGRANEX ................................................................................... 83
RELAFEN ....................................................................................... 31
RELENZA ....................................................................................... 12
RELISTOR ...................................................................................... 55
RELPAX .......................................................................................... 36
REMERON ..................................................................................... 41
REMODULIN .................................................................................. 28
RENAGEL ....................................................................................... 44
RENVELA ....................................................................................... 44
repaglinide ...................................................................................... 65
repaglinide & metformin ................................................................ 65
REPATHA ....................................................................................... 21
REQUIP .......................................................................................... 37
REQUIP XL .................................................................................... 37
RESCRIPTOR.................................................................................. 9
RESCULA ....................................................................................... 51
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 109
reserpine ......................................................................................... 25
RESTASIS ...................................................................................... 47
RESTORIL ...................................................................................... 38
retapamulin ..................................................................................... 79
RETIN-A .......................................................................................... 83
RETIN-A MICRO ............................................................................ 83
RETROVIR ..................................................................................... 12
REVATIO ........................................................................................ 28
revefenacin ..................................................................................... 17
REVIA .............................................................................................. 39
REVLIMID ....................................................................................... 15
REXULTI ......................................................................................... 39
REYATAZ.......................................................................................... 9
REYVOW ........................................................................................ 36
RHEUMATREX .............................................................................. 15
RHOPRESSA ................................................................................. 51
ribavirin ............................................................................................ 12
RIDAURA ........................................................................................ 55
rifabutin .............................................................................................. 8
RIFADIN ............................................................................................ 8
rifampin .............................................................................................. 8
rifapentine ......................................................................................... 8
rifaximin ............................................................................................. 6
rilpivirine ................................................................................ 9, 10, 12
RILUTEK ......................................................................................... 39
riluzole ............................................................................................. 39
rimantadine ..................................................................................... 12
rimegepant ...................................................................................... 36
rimexolone ...................................................................................... 49
RINVOQ .......................................................................................... 74
riociguat ........................................................................................... 28
RIOMET .......................................................................................... 65
ripritinib ............................................................................................ 15
risankizumab .................................................................................. 73
risedronate sodium ........................................................................ 73
RISPERDAL ................................................................................... 41
RISPERDALM-TAB ....................................................................... 41
risperidone ...................................................................................... 41
risperidone orally disintegrating ................................................... 41
RITALIN ..................................................................................... 33, 34
RITALIN LA ..................................................................................... 33
RITALIN SR .................................................................................... 34
ritonavir ...................................................................................... 11, 12
rivaroxaban ..................................................................................... 20
rivastigmine tartrate ....................................................................... 18
rivastigmine tartrate (solution) ...................................................... 18
rizatriptan ........................................................................................ 36
rizatriptan orally disintegrating ..................................................... 36
ROBAXIN ........................................................................................ 18
ROBINUL ........................................................................................ 16
ROBINULFORTE ........................................................................... 16
ROCALTROL .................................................................................. 85
roflumilast ........................................................................................ 76
rolapitant ......................................................................................... 53
ROMYCIN ....................................................................................... 46
ropinirole ......................................................................................... 37
ropinirole extended-release .......................................................... 37
ROSAC ........................................................................................... 78
rosiglitazone ................................................................................... 65
rosiglitazone & glimepiride ........................................................... 65
rosiglitazone & metformin ............................................................. 65
ROSULA ......................................................................................... 82
rosuvastatin .................................................................................... 22
rotigotine ......................................................................................... 37
ROWASA ........................................................................................ 52
ROXICET ........................................................................................ 32
ROXICODONE .............................................................................. 32
ROZEREM ...................................................................................... 38
ROZLYTREK .................................................................................. 14
rufinamide ....................................................................................... 35
ruxolitinib ......................................................................................... 15
RYTHMOL ...................................................................................... 24
RYTHMOL SR................................................................................ 24
RYZODEG 70/30 ........................................................................... 63
S
SABRIL ........................................................................................... 35
sacubitril & valsartan ..................................................................... 24
SAFYRAL ....................................................................................... 57
SAIZEN ........................................................................................... 68
SALAGEN ....................................................................................... 18
salmeterol ................................................................................. 76, 77
salsalate .......................................................................................... 32
SAMSCA ......................................................................................... 44
SANCTURA .................................................................................... 85
SANCTURA XR ............................................................................. 85
SANCUSO ...................................................................................... 52
SANDIMMUNE .............................................................................. 70
SANDOSTATIN ............................................................................. 73
SANTYL .......................................................................................... 83
SAPHRIS ........................................................................................ 39
sapropterin dihydrochloride .......................................................... 74
saquinavir mesylate....................................................................... 12
SARAFEM ...................................................................................... 40
sargramostim.................................................................................. 21
sarilumab ........................................................................................ 74
SAVAYSA ....................................................................................... 20
SAVELLA ........................................................................................ 38
saxagliptin ....................................................................................... 65
saxagliptin & metformin extended-release ................................. 65
scopolamine (ophth) ...................................................................... 51
scopolamine hydrobromide .......................................................... 53
SEASONALE.................................................................................. 58
SEASONIQUE ............................................................................... 58
SEB-PREV ..................................................................................... 79
secnidazole ....................................................................................... 8
SECTRAL ....................................................................................... 28
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 110
secukinumab .................................................................................. 74
SEEBRI NEOHALER .................................................................... 16
segesterone & ethinyl estradiol .................................................... 61
SEGLUROMET .............................................................................. 62
selegiline ......................................................................................... 37
selegiline transdermal ................................................................... 37
selenium sulfide ............................................................................. 79
selinexor .......................................................................................... 15
SELSEB .......................................................................................... 79
SELSUN RX ................................................................................... 79
selumetinib ...................................................................................... 16
SELZENTRY .................................................................................. 11
semaglutide .................................................................................... 65
SENSIPAR ...................................................................................... 70
SEPTRA ............................................................................................ 6
SERAX ............................................................................................ 38
SEREVENT DISKUS ..................................................................... 77
SEROMYCIN .................................................................................... 7
SEROQUEL .................................................................................... 41
SEROQUEL XR ............................................................................. 41
SEROSTIM ..................................................................................... 69
SERPASIL ...................................................................................... 25
sertaconazole nitrate ..................................................................... 79
sertraline.......................................................................................... 41
SERZONE ....................................................................................... 41
sevelamer carbonate ..................................................................... 44
sevelamer hcl ................................................................................. 44
short ragweed pollen allergen extract ......................................... 50
SIGNIFOR ....................................................................................... 73
sildenafil .......................................................................................... 28
SILENOR ........................................................................................ 37
SILIQ ................................................................................................ 70
silodosin .......................................................................................... 19
SILVADENE .................................................................................... 79
silver sulfadiazine ........................................................................... 79
simeprevir........................................................................................ 12
SIMPONI ......................................................................................... 71
simvastatin ................................................................................ 22, 65
sinecatechins .................................................................................. 84
SINEMET ........................................................................................ 36
SINEMET CR ................................................................................. 36
SINEQUAN ..................................................................................... 40
SINGULAIR .................................................................................... 75
sirolimus .......................................................................................... 74
sirolimus solution ........................................................................... 74
SIRTURO ........................................................................................ 70
sitagliptin & metformin ................................................................... 65
sitagliptin & simvastatin ................................................................. 65
sitagliptin phosphate ...................................................................... 65
SIVEXTRO ........................................................................................ 6
SKELAXIN ...................................................................................... 18
SKELID ............................................................................................ 74
SKYRIZI .......................................................................................... 73
SLYND ............................................................................................. 57
sodium chloride .............................................................................. 77
sodium citrate & citric acid ............................................................ 43
sodium fluoride ............................................................................... 74
sodium fluoride (dental) ................................................................ 74
sodium fluoride drops .................................................................... 74
sodium oxybate .............................................................................. 39
sodium phenylbutyrate .................................................................. 43
sodium phosphates ....................................................................... 54
sodium picosulfate-mag ox-anhydrous citric acid ..................... 54
sodium polystyrene sulfonate ...................................................... 44
sodium zirconium cyclosilicate..................................................... 44
sofosbuvir ................................................................................. 11, 12
sofosbuvir & velpatasvir ................................................................ 12
sofosbuvir, velpatasvir, voxilaprevir ............................................ 11
SOLARAZE .................................................................................... 84
solifenacin ....................................................................................... 85
SOLIQUA ........................................................................................ 63
SOLODYN ........................................................................................ 6
SOLOSEC ........................................................................................ 8
solriamfetol ..................................................................................... 39
SOMA ........................................................................................ 18, 30
SOMA COMPOUND ............................................................... 18, 30
SOMA COMPOUND W/ CODEINE ............................................ 30
somatropin ................................................................................ 68, 69
SOMATULINE DEPOT ................................................................. 72
SOMAVERT ................................................................................... 69
SONATA ......................................................................................... 38
SOOLANTRA ................................................................................... 4
sorafenib tosylate .......................................................................... 16
SORIATANE ................................................................................... 83
SORILUX ........................................................................................ 83
sotalol .............................................................................................. 29
SOVALDI ........................................................................................ 12
SPECTAZOLE ............................................................................... 78
SPECTRACEF ................................................................................. 5
spinosad .......................................................................................... 79
SPIRIVA .......................................................................................... 17
SPIRIVA RESPIMAT ..................................................................... 17
spironolactone ................................................................................ 27
spironolactone & hydrochlorothiazide ......................................... 27
SPORANOX ..................................................................................... 7
SPRINTEC ..................................................................................... 61
SPRYCEL ....................................................................................... 14
SPS.................................................................................................. 44
STADOL .......................................................................................... 30
STALEVO ....................................................................................... 36
stannous fluoride ........................................................................... 74
STARLIX ......................................................................................... 65
stavudine......................................................................................... 12
STEGLATRO.................................................................................. 62
STEGLUJAN .................................................................................. 62
STELARA ....................................................................................... 74
STELAZINE .................................................................................... 42
STIMATE ........................................................................................ 68
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 111
STIOLTO RESPIMAT .................................................................... 77
stiripentol ......................................................................................... 35
STIVARGA ...................................................................................... 15
STRATTERA .................................................................................. 38
STRIBILD ........................................................................................ 10
STRIVERDI RESPIMAT ............................................................... 20
STROMECTOL ................................................................................ 4
SUBOXONE ................................................................................... 29
SUBUTEX ....................................................................................... 29
succimer .......................................................................................... 55
sucralfate suspension .................................................................... 53
sucralfate tablets ............................................................................ 53
sucroferric oxyhydroxide ............................................................... 44
SULAR ............................................................................................. 23
sulconazole nitrate ......................................................................... 79
SULFAC .......................................................................................... 46
sulfacetamide sodium & prednisolone ........................................ 49
sulfacetamide sodium & sulfur ..................................................... 82
sulfacetamide sodium (acne) ....................................................... 79
sulfacetamide sodium (ophth) ointment ...................................... 46
sulfacetamide sodium (ophth) solution ....................................... 46
sulfadiazine ................................................................................. 6, 79
SULFADIAZINE ............................................................................... 6
sulfamethoxazole & trimethoprim .................................................. 6
SULFAMYLON ............................................................................... 78
sulfanilamide ................................................................................... 79
sulfasalazine ..................................................................................... 6
sulindac ........................................................................................... 32
sumatriptan ..................................................................................... 36
sunitinib malate .............................................................................. 16
SUNOSI ........................................................................................... 39
SUPRAX............................................................................................ 5
SURMONTIL .................................................................................. 42
SUSTIVA ......................................................................................... 10
SUTENT .......................................................................................... 16
suvorexant ...................................................................................... 38
SYMAX ............................................................................................ 17
SYMAX DUOTAB .......................................................................... 17
SYMBICORT .................................................................................. 75
SYMBYAX ....................................................................................... 41
SYMDEKO ...................................................................................... 77
SYMFI .............................................................................................. 10
SYMFI LO ....................................................................................... 10
SYMLIN ........................................................................................... 65
SYMMETREL ................................................................................. 36
SYMTUZA ......................................................................................... 9
SYNAGIS ........................................................................................ 12
SYNALAR ....................................................................................... 80
SYNAREL ....................................................................................... 68
SYNERA PATCH ........................................................................... 82
SYNJARDY ..................................................................................... 62
SYNTHROID .................................................................................. 69
SYPRINE ........................................................................................ 55
syringe with needle,disposable .................................................... 43
T
TABLOID......................................................................................... 16
TACLONEX .................................................................................... 80
tacrolimus ................................................................................. 74, 84
tacrolimus (topical) ........................................................................ 84
tadalafil ............................................................................................ 28
TAGAMET ...................................................................................... 53
TAKHZYRO .................................................................................... 72
talazoparib ...................................................................................... 16
TALTZ ............................................................................................. 72
TALWIN NX .................................................................................... 32
TALZENNA ..................................................................................... 16
TAMBOCOR ................................................................................... 24
TAMIFLU......................................................................................... 11
tamoxifen citrate ............................................................................ 16
tamsulosin hcl ................................................................................ 19
TANZEUM ...................................................................................... 61
TAPAZOLE ..................................................................................... 69
tapentadol ....................................................................................... 32
TARCEVA ....................................................................................... 14
TARGRETIN ............................................................................. 13, 83
TARKA ............................................................................................ 23
TASIGNA ........................................................................................ 15
tasimelteon ..................................................................................... 38
TASMAR ......................................................................................... 37
tavaborole ......................................................................................... 7
TAVALISSE .................................................................................... 71
tazarotene ....................................................................................... 84
tazemetostat ................................................................................... 16
TAZORAC ....................................................................................... 84
TAZVERIK ...................................................................................... 16
TECFIDERA ................................................................................... 70
TECHNIVIE .................................................................................... 11
tedizolid ............................................................................................. 6
teduglutide ...................................................................................... 55
TEGRETOL .................................................................................... 34
TEGRETOL XR .............................................................................. 34
TEGSEDI ........................................................................................ 72
TEKAMLO ....................................................................................... 25
TEKTURNA .................................................................................... 25
TEKTURNA HCT ........................................................................... 25
telaprevir ......................................................................................... 12
telbivudine....................................................................................... 12
telithromycin ..................................................................................... 6
telmisartan ................................................................................ 23, 27
telmisartan & hydrochlorothiazide ............................................... 27
temazepam ..................................................................................... 38
TEMODAR ...................................................................................... 16
TEMOVATE .................................................................................... 80
TEMOVATE E ................................................................................ 80
temozolomide ................................................................................. 16
TENEX ............................................................................................ 25
tenofovir .......................................................................... 9, 10, 11, 12
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 112
tenofovir 300 mg ............................................................................ 12
tenofovir alafenamide .................................................................... 12
TENORETIC ................................................................................... 28
TENORMIN ..................................................................................... 28
TERAZOL 3 .................................................................................... 79
TERAZOL 7 .................................................................................... 79
terazosin .......................................................................................... 21
terbinafine ......................................................................................... 7
terbutaline sulfate ........................................................................... 20
terconazole ..................................................................................... 79
terconazole (vaginal) ..................................................................... 79
teriflunomide ................................................................................... 74
teriparatide ...................................................................................... 68
TESSALON PERLES .................................................................... 74
TESTIM ........................................................................................... 56
testosterone .............................................................................. 56, 67
testosterone cypionate .................................................................. 56
TESTRED ....................................................................................... 56
tetrabenazine .................................................................................. 39
tetracycline .................................................................................... 4, 6
TETRACYCLINE .............................................................................. 6
tetrahydrozoline .............................................................................. 51
TEVETEN........................................................................................ 26
TEVETEN PLUS ............................................................................ 26
tezacaftor & ivacaftor ............................................................... 75, 77
thalidomide...................................................................................... 74
THALOMID ..................................................................................... 74
theophylline ..................................................................................... 85
thioguanine ..................................................................................... 16
thioridazine...................................................................................... 41
thiothixene ....................................................................................... 41
THORAZINE ................................................................................... 40
thyroid .............................................................................................. 69
THYROLAR .................................................................................... 69
tiagabine .......................................................................................... 35
TIAZAC ............................................................................................ 23
TIBSOVO ........................................................................................ 14
ticagrelor.......................................................................................... 20
TIGAN .............................................................................................. 53
TIKOSYN ........................................................................................ 24
tildrakizumab-asmn........................................................................ 74
TILIA ................................................................................................ 60
tiludronate ....................................................................................... 74
timolol .................................................................................. 29, 50, 51
TIMOPTIC ....................................................................................... 51
TIMOPTIC-XE ................................................................................ 51
timothy grass pollen allergen extract ........................................... 50
tiotropium .................................................................................. 17, 77
tiotropium 1.25 mcg ....................................................................... 17
tiotropium 2.5 mcg ......................................................................... 17
tiotropium bromide and olodaterol ............................................... 77
tipranavir.......................................................................................... 12
TIROSINT ....................................................................................... 69
TIVICAY ............................................................................................ 9
tizanidine ......................................................................................... 18
TOBI .................................................................................................. 7
TOBI PODHALER ........................................................................... 7
TOBRADEX .................................................................................... 49
tobramycin & dexamethasone ointment ..................................... 49
tobramycin & dexamethasone suspension ................................ 49
tobramycin inhalation powder ........................................................ 7
tobramycin inhalation solution ....................................................... 7
tobramycin sulfate (ophth) ointment............................................ 46
tobramycin sulfate (ophth) solution ............................................. 46
TOBREX ......................................................................................... 46
tocilizumab ...................................................................................... 74
tofacitinib ......................................................................................... 74
TOFRANIL ...................................................................................... 40
TOFRANIL-PM ............................................................................... 40
tolazamide ...................................................................................... 65
tolbutamide ..................................................................................... 66
tolcapone ........................................................................................ 37
TOLECTIN 600 .............................................................................. 32
TOLINASE ...................................................................................... 65
tolmetin sodium .............................................................................. 32
tolterodine ....................................................................................... 85
tolterodine extended-release ....................................................... 85
tolvaptan ......................................................................................... 44
TOPAMAX ...................................................................................... 35
TOPAMAX SPRINKLE ................................................................. 35
TOPICORT ..................................................................................... 80
topiramate capsule ........................................................................ 35
topiramate tablet ............................................................................ 35
topotecan ........................................................................................ 16
TOPROL XL ................................................................................... 28
TORADOL ...................................................................................... 31
toremifene ....................................................................................... 16
torsemide ........................................................................................ 44
TOVIAZ ........................................................................................... 85
TRACLEER .................................................................................... 27
TRADJENTA .................................................................................. 64
tramadol .......................................................................................... 32
tramadol & acetaminophen .......................................................... 32
tramadol extended-release .......................................................... 32
TRANDATE .................................................................................... 28
trandolapril ................................................................................ 23, 27
trandolapril & verapamil ................................................................ 23
tranexamic acid .............................................................................. 20
TRANSDERM-SCOP .................................................................... 53
TRANXENE .................................................................................... 37
tranylcypromine sulfate ................................................................. 41
TRAVATAN Z ................................................................................. 51
travoprost ........................................................................................ 51
trazodone .................................................................................. 41, 42
trazodone extended-release ........................................................ 42
TRECATOR ...................................................................................... 7
TRELEGY ELLIPTA ...................................................................... 76
TREMFYA ....................................................................................... 71
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 113
TRENTAL ........................................................................................ 20
treprostinil........................................................................................ 28
TRESIBA ......................................................................................... 63
tretinoin ...................................................................................... 16, 83
tretinoin microspheres ................................................................... 83
TREXALL ........................................................................................ 15
TREZIX ............................................................................................ 29
triamcinolone acetonide (topical) ................................................. 82
triamterene ...................................................................................... 44
triamterene & hydrochlorothiazide ............................................... 44
TRIAVIL ........................................................................................... 39
triazolam .......................................................................................... 38
TRIBENZOR ................................................................................... 23
TRICOR ........................................................................................... 22
trientine ............................................................................................ 55
trifluidine/tipiracil ............................................................................. 16
trifluoperazine ................................................................................. 42
trifluridine ......................................................................................... 46
trihexyphenidyl ............................................................................... 37
TRIKAFTA ....................................................................................... 75
TRILAFON ...................................................................................... 41
TRILEPTAL ..................................................................................... 35
TRILIPIX .......................................................................................... 22
TRI-LO-SPRINTEC........................................................................ 61
trimethobenzamide ........................................................................ 53
trimethoprim .......................................................................... 6, 13, 46
trimipramine .................................................................................... 42
TRINESSA ...................................................................................... 61
TRI-NORINYL................................................................................. 59
TRINTELLIX ................................................................................... 42
TRI-SPRINTEC .............................................................................. 61
TRIUMEQ.......................................................................................... 9
TRI-VI-FLOR .................................................................................. 73
TRI-VI-FLOR W/IRON ................................................................... 73
TRIVORA ........................................................................................ 58
TRIZIVIR ........................................................................................... 9
trospium ........................................................................................... 85
trospium extended-release ........................................................... 85
TRULICITY ..................................................................................... 62
TRUSOPT ....................................................................................... 50
TRUVADA ....................................................................................... 10
tucatinib ........................................................................................... 16
TUKYSA .......................................................................................... 16
TURALIO ......................................................................................... 16
TUSSIONEX ................................................................................... 75
TWINJECT ...................................................................................... 19
TWYNSTA ...................................................................................... 23
TYKERB .......................................................................................... 14
TYLENOL W/ CODEINE ............................................................... 29
TYMLOS.......................................................................................... 68
TYZEKA .......................................................................................... 12
TYZINE ............................................................................................ 51
U
UBRELVY ....................................................................................... 36
ubrogepant ..................................................................................... 36
UCERIS........................................................................................... 55
ulipristal ........................................................................................... 61
ULORIC........................................................................................... 71
ULTRACET ..................................................................................... 32
ULTRAM ......................................................................................... 32
ULTRAM ER ................................................................................... 32
ULTRAVATE .................................................................................. 81
umeclidinium ...................................................................... 17, 20, 76
umeclidinium & vilanterol ........................................................ 20, 76
UNIPHYL ........................................................................................ 85
UNIRETIC ....................................................................................... 26
UNITHROID ................................................................................... 69
UNIVASC ........................................................................................ 26
unoprostone isopropyl ................................................................... 51
upadacitinib .................................................................................... 74
urea............................................................................................ 81, 82
URECHOLINE................................................................................ 17
URELLE .......................................................................................... 13
UROCIT-K ...................................................................................... 43
URO-MP ......................................................................................... 72
UROXATRAL ................................................................................. 18
URSO .............................................................................................. 55
URSO FORTE................................................................................ 55
ursodiol ............................................................................................ 55
ustekinumab ................................................................................... 74
UTIBRON NEOHALER ................................................................. 76
V
VAGIFEM ........................................................................................ 67
valacyclovir ..................................................................................... 12
valbenazine .................................................................................... 39
VALCHLOR .................................................................................... 15
VALCYTE ....................................................................................... 12
valganciclovir .................................................................................. 12
VALISONE ...................................................................................... 80
VALIUM ........................................................................................... 37
valproate sodium ........................................................................... 35
valproic acid ................................................................................... 35
valsartan ....................................................................... 23, 24, 25, 27
valsartan & hydrochlorothiazide ............................................ 23, 27
VALTREX ....................................................................................... 12
VALTURNA .................................................................................... 25
VANCOCIN ....................................................................................... 7
Vancomycin capsule ....................................................................... 7
vandetanib ...................................................................................... 16
VANOS ............................................................................................ 80
VANOXIDE-HC .............................................................................. 80
VANTIN ............................................................................................. 5
varenicline....................................................................................... 17
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 114
VARUBI ........................................................................................... 53
VASCEPA ....................................................................................... 22
VASERETIC ................................................................................... 26
VASOTEC ....................................................................................... 25
VECTICAL ...................................................................................... 83
VELIVET.......................................................................................... 57
VELPHORO .................................................................................... 44
VELTASSA ..................................................................................... 44
VELTIN ............................................................................................ 83
VEMLIDY ........................................................................................ 12
vemurafenib .................................................................................... 16
venlafaxine ...................................................................................... 42
venlafaxine extended-release ...................................................... 42
VENTOLIN HFA ............................................................................. 19
verapamil ................................................................................... 23, 24
verapamil extended-release cap .................................................. 24
verapamil sustained-release cap ........................................... 23, 24
verapamil sustained-release tab .................................................. 24
VEREGEN ...................................................................................... 84
VERELAN ................................................................................. 23, 24
VERELAN PM ................................................................................ 24
VERZENIO ...................................................................................... 13
VESANOID ..................................................................................... 16
VESICARE ...................................................................................... 85
VEXOL ............................................................................................. 49
VFEND .............................................................................................. 7
VIBERZI .......................................................................................... 52
VICOPROFEN ................................................................................ 31
VICTOZA ......................................................................................... 64
VICTRELIS ....................................................................................... 9
VIDEX ................................................................................................ 9
VIDEX EC ......................................................................................... 9
VIEKIRA .......................................................................................... 11
vigabatrin ......................................................................................... 35
VIGAMOX ....................................................................................... 46
VIIBRYD .......................................................................................... 42
vilazodone ....................................................................................... 42
VIMPAT ........................................................................................... 35
VIOKACE ........................................................................................ 54
VIRACEPT ...................................................................................... 11
VIRAMUNE ..................................................................................... 11
VIREAD ........................................................................................... 12
VIROPTIC ....................................................................................... 46
VISICOL .......................................................................................... 54
VISKEN ........................................................................................... 28
VISTARIL ........................................................................................ 37
VITRAKVI ........................................................................................ 14
VIVACTIL ........................................................................................ 41
VIVELLE-DOT ................................................................................ 67
VIZIMPRO ....................................................................................... 14
VOLTAREN ........................................................................ 30, 47, 84
VOLTAREN GEL ........................................................................... 84
VOLTAREN XR .............................................................................. 30
vorapaxar ........................................................................................ 21
voriconazole suspension ................................................................ 7
voriconazole tablet........................................................................... 7
vorinostat ........................................................................................ 16
vortioxetine ..................................................................................... 42
VOSEVI ........................................................................................... 11
VOSOL ............................................................................................ 51
VOSPIRE ER ................................................................................. 19
VOTRIENT ..................................................................................... 15
voxelotor ......................................................................................... 74
VRAYLAR ....................................................................................... 40
VUSION .......................................................................................... 78
VYTONE ......................................................................................... 78
VYTORIN ........................................................................................ 22
VYVANSE ....................................................................................... 33
VYZULTA ........................................................................................ 50
W
WAKIX ............................................................................................. 38
warfarin ........................................................................................... 21
WELCHOL ...................................................................................... 21
WELLBUTRIN ................................................................................ 39
WELLBUTRIN SR ......................................................................... 39
WELLBUTRIN XL .......................................................................... 39
WESTCORT ................................................................................... 81
WIXELA INHUB ............................................................................. 76
X
XALATAN ....................................................................................... 50
XALKORI ........................................................................................ 14
XANAX ............................................................................................ 37
XANAX XR ..................................................................................... 37
XARELTO ....................................................................................... 20
XARTEMIS XR ............................................................................... 32
XELJANZ ........................................................................................ 74
XELODA ......................................................................................... 13
XENAZINE ...................................................................................... 39
XENLETA ......................................................................................... 6
XIBROM .......................................................................................... 47
XIFAXAN........................................................................................... 6
XIGDUO XR ................................................................................... 62
XIIDRA ............................................................................................ 48
XOLAIR ........................................................................................... 76
XOPENEX HFA ............................................................................. 19
XOPENEX NEBULIZER ............................................................... 19
XOSPATA ....................................................................................... 14
XPOVIO .......................................................................................... 15
XTANDI ........................................................................................... 14
XULANE .......................................................................................... 59
XULTOPHY .................................................................................... 63
XYLOCAINE ............................................................................. 51, 82
XYLOCAINE VISCOUS ................................................................ 51
XYREM ........................................................................................... 39
Kaiser Permanente, a TRICARE® Prime Option Formulary
Kaiser Permanente, a TRICARE Prime Option Formulary 115
Y
YASMIN ........................................................................................... 57
YAZ .................................................................................................. 57
YUPELRI ......................................................................................... 17
YUVAFEM ....................................................................................... 67
Z
zafirlukast ........................................................................................ 75
zaleplon ........................................................................................... 38
ZANAFLEX ..................................................................................... 18
zanamivir ......................................................................................... 12
zanubrutinib .................................................................................... 16
ZARONTIN ...................................................................................... 34
ZAROXOLYN ................................................................................. 44
ZARXIO ........................................................................................... 21
ZAVESCA ....................................................................................... 73
ZEBETA .......................................................................................... 28
ZEJULA ........................................................................................... 15
ZELAPAR ........................................................................................ 37
ZELBORAF ..................................................................................... 16
ZEMPLAR ....................................................................................... 85
ZENPEP .......................................................................................... 54
ZEPATIER ...................................................................................... 10
ZEPOSIA ......................................................................................... 73
ZERIT .............................................................................................. 12
ZESTORETIC ................................................................................. 26
ZESTRIL.......................................................................................... 26
ZETIA............................................................................................... 22
ZIAC ................................................................................................. 28
ZIAGEN ......................................................................................... 8, 9
ZIANA .............................................................................................. 83
zidovudine ................................................................................. 11, 12
zileuton ............................................................................................ 75
ziprasidone...................................................................................... 42
ZIRGAN ........................................................................................... 46
ZITHRANOL-RR ............................................................................ 83
ZITHROMAX .................................................................................... 5
ZOCOR ........................................................................................... 22
ZOFRAN ................................................................................... 52, 53
ZOFRAN ODT ................................................................................ 53
ZOHYDRO ER ............................................................................... 30
ZOLINZA ......................................................................................... 16
zolipdem sublingual ....................................................................... 38
zolmitriptan ..................................................................................... 36
zolmitriptan orally disintegrating .................................................. 36
ZOLOFT .......................................................................................... 41
zolpidem .......................................................................................... 38
zolpidem extended-release .......................................................... 38
zolpidem oral spray ....................................................................... 38
ZOLPIMIST ..................................................................................... 38
ZOMIG ............................................................................................ 36
ZOMIG ZMT ................................................................................... 36
ZONALON ...................................................................................... 82
ZONEGRAN ................................................................................... 35
zonisamide ..................................................................................... 35
ZONTIVITY ..................................................................................... 21
ZORBTIVE ...................................................................................... 69
ZORTRESS .................................................................................... 71
ZOVIA .............................................................................................. 58
ZOVIRAX .................................................................................... 9, 77
ZURAMPIC ..................................................................................... 72
ZYBAN ............................................................................................ 39
ZYCLARA ....................................................................................... 84
ZYDELIG......................................................................................... 14
ZYFLO CR ...................................................................................... 75
ZYFO ............................................................................................... 75
ZYKADIA......................................................................................... 13
ZYLET ............................................................................................. 48
ZYLOPRIM ..................................................................................... 69
ZYMAXID ........................................................................................ 46
ZYPREXA ....................................................................................... 41
ZYPREXA ZYDIS .......................................................................... 41
ZYTIGA ........................................................................................... 13
ZYVOX .............................................................................................. 6
60577109_ACA_1557_MarCom_GA_2017_Taglines
Kaiser Permanente, a TRICARE® Prime Option Formulary
NONDISCRIMINATION NOTICE
Kaiser Foundation Health Plan of Georgia, Inc. (Kaiser Health Plan) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also:
• Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and
accessible electronic formats
• Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages
If you need these services, call 1-888-865-5813 (TTY: 711)
If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail at: Member Relations Unit (MRU), Attn: Kaiser Civil Rights Coordinator, Nine Piedmont Center, 3495 Piedmont Road, NE Atlanta, GA 30305-1736. Telephone Number: 1-888-865-5813.
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, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
60577109_ACA_1557_MarCom_GA_2017_Taglines
Kaiser Permanente, a TRICARE® Prime Option Formulary
HELP IN YOUR LANGUAGE
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-888-865-5813 (TTY: 711).
አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-865-5813 (TTY: 711).
.ملحوظة : إذا كنت ت تح دث العر بي ة، فإ ن خدمات ال مساعدة اللغ وي ة تت وافر لك بال مجان (Arabic) ال عربي ة
.)711 :TTY( 1-888-865-5813 م رق ب اتصل
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
1-888-865-5813(TTY:711)。
توج ه: اگر ب ه زبا ن فارس ی گ ف تگو می کنيد، ت س ه ي الت زب ان ی ب صورت رايگا ن بر ای (Farsi) ف ارس ی
. گيريد ب ماس ت (711 :TTY) 1-888-865-5813 با . اشد ب اهمفر می شما
Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-865-5813 (TTY: 711).
Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.
Rufnummer: 1-888-865-5813 (TTY: 711).
ગજુ રુ તુ (Gujarati) સચુ
નુ : જો તમો ગજો
રો તો બો લતો હ , ત નન:શલ્ો ક ભ ષો સહો ય સો વ ઓ
તમ ર મ ટો ઉપલબ્ધ છો . ફ ન કર 1-888-865-5813 (TTY: 711).
Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-888-865-5813 (TTY: 711).
हिन्दी (Hindi) ध्यान दे े : यिद आप ििे िेे दी बोलते िे े े तो आपके ललए मुफ्त मे े भाषा सिेायता िे वाएिेे उपलबेध् िेे े। 1-888-865-5813 (TTY: 711) पर कॉल करे े । 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。1-888-865-5813(TTY: 711)まで、お電話にてご連絡ください。
한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-865-5813 (TTY: 711) 번으로 전화해 주십시오.
60577109_ACA_1557_MarCom_GA_2017_Taglines
Kaiser Permanente, a TRICARE® Prime Option Formulary
Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dé̖ é̖ ’, t’áá jiik’eh, éí ná hóló̖ , koji̖ ’ hódíílnih 1-888-865-5813 (TTY: 711).
Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-865-5813 (TTY: 711).
Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-865-5813 (TTY: 711).
Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-865-5813 (TTY: 711).
Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.
Tumawag sa 1-888-865-5813 (TTY: 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 1-888-865-5813 (TTY: 711).