kaiser permanente colorado ppo/pos preferred...

Kaiser Permanente Colorado PPO/POS Preferred Product List (October 20, 2015)

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Kaiser Permanente Colorado PPO/POS Preferred Product List

The following is a listing of the drugs on the Kaiser Permanente Southern Colorado PPO & Denver/Boulder PPO/POS preferred product listing. This product listing applies only to outpatient drugs provided to members for self-administration, and does not apply to medications used in inpatient settings or medications administered in a doctor’s office or infusion center. The listing does not provide information regarding the specific coverage, limitations or quotas an individual member may have. Many members have specific exclusions, copays, or coinsurances that are not reflected in the preferred product listing. Kaiser Permanente has many brand and generic medications on the preferred product listing. In most cases, a generic equivalent is used when available. Members will be notified when a generic equivalent is dispensed. If a member requests a brand name when a generic equivalent is routinely used, the member will pay the difference in price between the generic equivalent and the requested brand plus the appropriate copay. Kaiser Permanente may implement programs, such as a therapeutic interchange program, to promote safe and effective drug therapy. In these cases the prescribing provider and member are notified prior to a change occurring.

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

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

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

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


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Quantity Limits or Quotas: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a specific days supply or quantity per copay. For example, Tarceva® is limited to a 30-day supply. In addition, when there is a national shortage of a drug, we may limit the quantity of the drug dispensed per prescription per copayment.

Restricted to Benefit: Some drugs are not covered unless the individual prescription benefit specifically covers such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless the prescription benefit specifically covers them.

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

Restricted to a specific age: Some medications may be restricted to a certain age or age range.

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

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

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

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


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Drug Name Drug Tier Requirements/Limits

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

ALBENZA Brand

BILTRICIDE Brand

ivermectin Generic

MEBENDAZOLE Brand

ANTIBACTERIALS

amoxicillin Generic/Brand †

amoxicillin & pot clavulanate Generic/Brand †

ampicillin Generic/Brand †

azithromycin Generic/Brand †

CAYSTON Brand

cefaclor Generic/Brand †

cefadroxil Generic

cefdinir Generic

cefixime Generic

cefprozil Generic

cefuroxime axetil Generic/Brand †

cephalexin Generic

ciprofloxacin hcl Generic/Brand †

ciprofloxacin-ciprofloxacin hcl Generic

clarithromycin Generic

clindamycin hcl Generic

clindamycin palmitate hydrochloride Generic

dicloxacillin sodium Generic

doxycycline hyclate Generic

E.E.S. 400 Brand

ERYTHROCIN STEARATE Brand

erythromycin base Generic/Brand †

erythromycin-sulfisoxazole Generic

levofloxacin Generic

linezolid Generic/Brand * QL

minocycline hcl Generic

moxifloxacin hcl Generic

NEO-FRADIN Brand

NOROXIN Brand

PCE Brand

penicillin v potassium Generic

SPECTRACEF Brand

SULFADIAZINE Brand

sulfamethoxazole-trimethoprim Generic

sulfasalazine Generic


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SUPRAX Brand

TETRACYCLINE HCL Brand

TOBI Podhaler Brand QL

tobramycin neb Generic QL

vancomycin hcl Generic QL

ZYVOX Brand * QL

ANTIFUNGALS

fluconazole Generic

griseofulvin ultramicrosize Generic

itraconazole Generic/Brand †

ketoconazole Generic

nystatin Generic

nystatin (mouth-throat) Generic

terbinafine hcl Generic

voriconazole Generic

ANTIMYCOBACTERIALS

DAPSONE Brand

ethambutol hcl Generic

isoniazid Generic/Brand †

pyrazinamide Generic

rifabutin Generic

rifampin Generic

ANTIPROTOZOALS

atovaquone Generic

atovaquone-proguanil hcl Generic

chloroquine phosphate Generic

DARAPRIM Brand

hydroxychloroquine sulfate Generic

mefloquine hcl Generic

metronidazole Generic

NEBUPENT Brand

paromomycin sulfate Generic

PRIMAQUINE PHOSPHATE Brand

YODOXIN Brand

ANTIVIRALS

abacavir-lamivudine-zidovudine Generic

abacavir sulfate Generic/Brand †

acyclovir Generic

adefovir dipivoxil Generic QL

APTIVUS Brand

ATRIPLA Brand

BARACLUDE Brand


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CRIXIVAN Brand

didanosine Generic/Brand †

EMTRIVA Brand

entecavir Generic †

EPIVIR HBV Brand

EPZICOM Brand

famciclovir Generic

GANCICLOVIR Brand QL

HARVONI Brand QL

INFERGEN Brand * QL

INTELENCE Brand

INVIRASE Brand

ISENTRESS Brand

KALETRA Brand

lamivudine Generic/Brand †

lamivudine-zidovudine Generic

LEXIVA Brand

nevirapine Generic

NORVIR Brand

PEG-INTRON Brand * QL

PEGASYS Brand * QL

PREZISTA Brand

RELENZA DISKHALER Brand QL

RESCRIPTOR Brand

REYATAZ Brand

ribavirin (hepatitis c) Generic QL

rimantadine hydrochloride Generic

SELZENTRY Brand

SOVALDI Brand QL

stavudine Generic

SUSTIVA Brand

TAMIFLU Brand QL

TRUVADA Brand

TYZEKA Brand QL

valacyclovir hcl Generic

valganciclovir Generic QL

VICTRELIS Brand QL

VIRACEPT Brand

VIRAZOLE Brand QL

VIREAD Brand

zidovudine Generic

URINARY ANTI-INFECTIVES


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methenamine-hyosc-methylene blue-sod phos-phenyl sal Generic

nitrofurantoin Generic

nitrofurantoin macrocrystal Generic/Brand †

nitrofurantoin monohyd macro Generic

PRIMSOL Brand

trimethoprim Generic

ANTIHISTAMINE DRUGS

ANTIHISTAMINE DRUGS

cyproheptadine hcl Generic

promethazine hcl Generic/Brand *†

ANTINEOPLASTIC AGENTS

ANTINEOPLASTIC AGENTS

AFINITOR Brand QL

ALKERAN Brand

anastrozole Generic

bicalutamide Generic

capecitabine Generic

CEENU Brand

CYCLOPHOSPHAMIDE Brand

ELIGARD Brand *

EMCYT Brand QL

ETOPOSIDE Brand

exemestane Generic

flutamide Generic

GLEEVEC Brand QL

HEXALEN Brand

hydroxyurea Generic

IMBRUVICA Brand QL

INTRON-A Brand * QL

IRESSA Brand QL

letrozole Generic

LEUKERAN Brand

leuprolide acetate Generic/Brand * †

LUPRON DEPOT Brand *

LUPRON DEPOT-PED Brand *

LYSODREN Brand QL

MATULANE Brand QL

megestrol acetate Generic

melphalan hcl Generic *

mercaptopurine Generic

methotrexate sodium Generic/Brand †

MYLERAN Brand


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NEXAVAR Brand QL

NILANDRON Brand

PURIXAN Brand

RHEUMATREX Brand

SPRYCEL Brand QL

SUTENT Brand QL

TABLOID Brand

tamoxifen citrate Generic

TARCEVA Brand QL

TARGRETIN Brand QL

temozolomide Generic QL

tretinoin (chemotherapy) Generic QL

TYKERB Brand QL

VOTRIENT Brand QL

XTANDI Brand QL

ZELBORAF Brand QL

ZOLINZA Brand QL

ZYDELIG Brand QL

ZYTIGA Brand QL

AUTONOMIC DRUGS

ANTICHOLINERGIC AGENTS

ATROVENT HFA Brand

clidinium & chlordiazepoxide Generic

dicyclomine hcl Generic/Brand †

DONNATAL Brand

glycopyrrolate Generic

hyoscyamine sulfate Generic

ipratropium bromide Generic

ipratropium bromide (nasal) Generic

SPIRIVA RESPIMAT Brand

AUTONOMIC DRUGS, MISCELLANEOUS

phenoxybenzamine hcl Generic

tamsulosin hcl Generic

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS

bethanechol chloride Generic

cevimeline hcl Generic

donepezil hydrochloride Generic

galantamine hydrobromide Generic

PROSTIGMIN Brand

pyridostigmine bromide Generic/Brand †

SKELETAL MUSCLE RELAXANTS

baclofen Generic


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carisoprodol Generic

carisoprodol w/ aspirin Generic

cyclobenzaprine hcl Generic

dantrolene sodium Generic

methocarbamol Generic/Brand *†

tizanidine hcl Generic

SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ADRENALIN Brand * QL

ADVAIR DISKUS Brand

albuterol sulfate Generic/Brand †

COMBIVENT Brand

COMBIVENT RESPIMAT Brand

epinephrine hcl Generic *

levalbuterol hcl Generic

METAPROTERENOL SULFATE Brand

midodrine hcl Generic

SEREVENT DISKUS Brand

terbutaline sulfate Generic

XOPENEX HFA Brand

BLOOD FORMATION, COAGULATION, AND THROMBOSIS

ANTITHROMBOTIC AGENTS

anagrelide hcl Generic

cilostazol Generic

clopidogrel bisulfate Generic

EFFIENT Brand

fondaparinux sodium Generic/Brand * QL

FRAGMIN Brand * QL

heparin sod (porcine) in d5w Generic *

heparin sodium (porcine) Generic/Brand *

heparin sodium (porcine) lock flush Generic/Brand *

INNOHEP Brand * QL

LOVENOX Brand * QL

COAGULANTS AND ANTICOAGULANTS

aminocaproic acid Generic/Brand †

BRILINTA Brand

pentoxifylline Generic

warfarin sodium Generic

HEMATOPOIETIC AGENTS

EPOGEN Brand * QL

LEUKINE Brand * QL

NEULASTA Brand * QL

PROCRIT Brand * QL


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CARDIOVASCULAR DRUGS

ALPHA-ADRENERGIC BLOCKING AGENTS

doxazosin mesylate Generic

prazosin hcl Generic

terazosin hcl Generic

ANTILIPEMIC AGENTS

cholestyramine Generic

cholestyramine light Generic

CRESTOR Brand

fenofibrate Generic

fenofibrate micronized Generic

gemfibrozil Generic

lovastatin Generic

NIASPAN Brand

pravastatin sodium Generic

simvastatin Generic

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl Generic

atenolol Generic

atenolol & chlorthalidone Generic

bisoprolol & hydrochlorothiazide Generic

bisoprolol fumarate Generic

BYSTOLIC Brand

carvedilol Generic

COREG CR Brand

labetalol hcl Generic

metoprolol succinate Generic

metoprolol tartrate Generic

nadolol Generic

pindolol Generic

propranolol hcl Generic

sotalol hcl Generic

CALCIUM-CHANNEL BLOCKING AGENTS

amlodipine besylate Generic

amlodipine besylate-benazepril hcl Generic

CARDENE SR Brand

diltiazem hcl Generic

diltiazem hcl coated beads Generic

diltiazem hcl extended release beads Generic

DYNACIRC CR Brand

EXFORGE Brand

EXFORGE HCT Brand


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felodipine Generic

ISRADIPINE Brand

nifedipine Generic

TARKA Brand

verapamil hcl Generic/Brand †

CARDIAC DRUGS

amiodarone hcl Generic

digoxin Generic/Brand †

disopyramide phosphate Generic/Brand †

flecainide acetate Generic

mexiletine hcl Generic

propafenone hcl Generic

quinidine gluconate Generic

quinidine sulfate Generic/Brand †

TIKOSYN Brand

HYPOTENSIVE AGENTS

clonidine hcl Generic

guanfacine hcl Generic

hydralazine hcl Generic

methazolamide Generic

methyldopa Generic

RESERPINE Brand

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS

benazepril & hydrochlorothiazide Generic

benazepril hcl Generic

captopril Generic

CAPTOPRIL/HYDROCHLOROTHIAZIDE Brand

enalapril maleate Generic

fosinopril sodium Generic

fosinopril sodium & hydrochlorothiazide Generic

lisinopril Generic

lisinopril & hydrochlorothiazide Generic

losartan potassium Generic

losartan potassium & hydrochlorothiazide Generic

moexipril hcl Generic

moexipril-hydrochlorothiazide Generic

quinapril hcl Generic

quinapril-hydrochlorothiazide Generic

ramipril Generic

spironolactone Generic

spironolactone & hydrochlorothiazide Generic

valsartan Generic


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valsartan-hydrochlorothiazide Generic

VASODILATING AGENTS

alprostadil Generic * QL, RB

CAVERJECT Brand * QL, RB

CIALIS Brand QL, RB

dipyridamole Generic

isosorbide dinitrate Generic/Brand †

isosorbide mononitrate Generic

LETAIRIS Brand QL, RB

LEVITRA Brand QL, RB

MUSE Brand QL, RB

nitroglycerin Generic/Brand †

sildenafil citrate (pulmonary hypertension) Generic

TRACLEER Brand QL

VIAGRA Brand QL, RB

CENTRAL NERVOUS SYSTEM AGENTS

ANALGESICS AND ANTIPYRETICS

acetaminophen w/ codeine Generic

buprenorphine hcl-naloxone hcl dihydrate Generic/Brand † QL

butalbital-acetaminophen-caffeine Generic

butalbital-acetaminophen-caffeine w/ codeine Generic

butalbital-aspirin-caffeine w/cod Generic

BUTALBITAL/ASPIRIN/CAFFEINE Brand

celecoxib Generic QL

choline & mag salicylate Generic

diclofenac sodium Generic

etodolac Generic

FENOPROFEN CALCIUM Brand

fentanyl Generic QL

fentanyl citrate Generic QL

hydromorphone hcl Generic/Brand † QL

ibuprofen Generic

indomethacin Generic/Brand †

KETOPROFEN (extended release) Brand

ketorolac tromethamine Generic QL

MECLOFENAMATE SODIUM Brand

methadone hcl Generic QL

morphine sulfate Generic/Brand † QL

morphine sulfate (extended release) Generic/Brand † QL

nabumetone Generic

naproxen Generic

naproxen sodium Generic


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oxaprozin Generic

oxycodone hcl Generic/Brand † QL

oxycodone w/ acetaminophen Generic QL

oxycodone-aspirin Generic QL

salsalate Generic

sulindac Generic

tramadol hcl Generic

ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS

amphetamine-dextroamphetamine Generic/Brand † QL

dexmethylphenidate hcl Generic/Brand † QL

dextroamphetamine sulfate Generic QL

methylphenidate hcl Generic/Brand † QL

modafinil Generic QL

ANTICONVULSANTS

carbamazepine Generic

carbamazepine (extended release) Generic

CELONTIN Brand

clonazepam Generic

divalproex sodium Generic

divalproex sodium (extended release) Generic

ethosuximide Generic

felbamate Generic

gabapentin Generic

lamotrigine Generic QL

levetiracetam Generic

lithium carbonate Generic

oxcarbazepine Generic/Brand †

phenytoin Generic/Brand †

phenytoin sodium extended Generic/Brand †

primidone Generic

tiagabine hcl Generic/Brand †

topiramate Generic

valproate sodium Generic

valproic acid Generic

zonisamide Generic

ANTIMIGRAINE AGENTS

CAFERGOT Brand QL

dihydroergotamine mesylate Generic/Brand *† QL

ERGOMAR Brand QL

naratriptan hcl Generic QL

rizatriptan benzoate Generic QL

SUMATRIPTAN Brand QL


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sumatriptan succinate Generic * QL

zolmitriptan Generic/Brand † QL

ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

alprazolam Generic

buspirone hcl Generic QL

CHLORAL HYDRATE Brand

chlordiazepoxide hcl Generic

clorazepate dipotassium Generic

diazepam Generic *

estazolam Generic

flurazepam hcl Generic

hydroxyzine hcl Generic

hydroxyzine pamoate Generic/Brand †

lorazepam Generic

oxazepam Generic

phenobarbital Generic/Brand †

temazepam Generic

triazolam Generic

zaleplon Generic QL

zolpidem tartrate Generic QL

CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS

amantadine hcl Generic

APOKYN Brand * QL

benztropine mesylate Generic

bromocriptine mesylate Generic

cabergoline Generic

carbidopa-levodopa Generic

carbidopa-levodopa (extended release) Generic

entacapone Generic

pramipexole dihydrochloride Generic

riluzole Generic

ropinirole hydrochloride Generic

SAVELLA Brand QL

selegiline hcl Generic

trihexyphenidyl hcl Generic

OPIATE ANTAGONISTS

naltrexone hcl Generic

PSYCHOTHERAPEUTIC AGENTS

ABILIFY Brand QL

amitriptyline hcl Generic

AMOXAPINE Brand

aripiprazole Generic


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bupropion hcl Generic QL

bupropion hcl (smoking deterrent) Generic

CHLORDIAZEPOXIDE/AMITRIPTYLINE Brand

chlorpromazine hcl Generic

citalopram hydrobromide Generic QL

clomipramine hcl Generic

desipramine hcl Generic

doxepin hcl Generic/Brand †

escitalopram oxalate Generic QL

fluoxetine hcl Generic QL

fluphenazine hcl Generic/Brand †

fluvoxamine maleate Generic

haloperidol Generic

haloperidol lactate Generic

imipramine hcl Generic

imipramine pamoate Generic

lithium carbonate Generic

loxapine succinate Generic

MAPROTILINE HCL Brand

mirtazapine Generic

nefazodone hcl Generic/Brand †

nortriptyline hcl Generic/Brand †

olanzapine Generic QL

olanzapine odt Generic QL

paroxetine hcl Generic/Brand † QL

perphenazine Generic

phenelzine sulfate Generic

prochlorperazine Generic

prochlorperazine maleate Generic

protriptyline hcl Generic

quetiapine fumarate Generic QL

risperidone Generic QL

sertraline hcl Generic

SURMONTIL Brand

thioridazine hcl Generic

thiothixene Generic/Brand †

tranylcypromine sulfate Generic

trazodone hcl Generic

trifluoperazine hcl Generic

venlafaxine hcl Generic/Brand †

ziprasidone hcl Generic QL

DEVICES


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DEVICES

ASSESS FULL RANGE PEAK FLOW METER Brand

NORDIPEN 5 INJECTION DEVICE Brand

DIABETIC SUPPLIES

DIABETIC SUPPLIES

ACCU-CHEK COMPACT PLUS CARE KIT Brand

ACCU-CHEK COMPACT TEST DRUM Brand QL

ACETEST Brand

ADVOCATE DUO/TALKING Brand

AUTOLET PLATFORMS Brand

BD AUTOSHIELD 29G X 3/16" Brand

BD INSULIN SYRINGE LUER-LOK/U-100/1ML Brand

BD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X 1/2" Brand

BD SYRINGE LUER-LOK/1ML Brand

CARTRIDGE IR 1200 Brand

CHEMSTRIP 2 LN STRIPS Brand

CHEMSTRIP UGK Brand

CHEMSTRIP-MICRAL Brand

CLINISTIX Brand

CLINITEST Brand

DUO-CARE CONTROL SOLUTION Brand

FREESTYLE LANCETS Brand

FREESTYLE NAVIGATOR SENSOR KIT Brand

GLUCOLET 2 AUTOMATIC LANCING DEVICE Brand

INSULIN PUMP IR1250 BLUE Brand

NEEDLE-FREE INSULIN SYRINGE A Brand

NOVOPEN 3 PENMATE Brand

PRECISION XTRA Brand

SIDEKICK BLOOD GLUCOSE SYSTEM Brand

ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AND ALKALINIZING AGENTS

POTASSIUM CITRATE Brand

potassium & sodium citrates w/ citric acid Generic

sodium citrate & citric acid Generic/Brand †

AMMONIA DETOXICANTS

lactulose Generic

lactulose (encephalopathy) Generic

DIURETICS

bumetanide Generic

CHLORTHALIDONE Brand

furosemide Generic

SODIUM EDECRIN Brand


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hydrochlorothiazide Generic

indapamide Generic

metolazone Generic

torsemide Generic

triamterene & hydrochlorothiazide Generic

ION-REMOVING AGENTS

RENAGEL Brand

RENVELA Brand

sodium polystyrene sulfonate Generic/Brand †

REPLACEMENT PREPARATIONS

calcium acetate (phosphate binder) Generic

potassium bicarb & chloride Generic

potassium chloride Generic/Brand †

potassium chloride microencapsulated crystals cr Generic

URICOSURIC AGENTS

colchicine Generic

colchicine w/ probenecid Generic

probenecid Generic

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

ANTI-INFECTIVES

BACITRACIN Brand

bacitracin-polymyxin b (ophth) Generic

chlorhexidine gluconate (mouth-throat) Generic

ciprofloxacin hcl (ophth) Generic

erythromycin (ophth) Generic

gatifloxacin (ophth) Generic

gentamicin sulfate (ophth) Generic

neomycin-bacitracinzn-polymyxin Generic

ofloxacin (ophth) Generic

ofloxacin (otic) Generic

polymyxin b-trimethoprim Generic

sulfacetamide sodium (ophth) Generic

tobramycin (ophth) Generic/Brand †

trifluridine Generic

ANTI-INFLAMMATORY AGENTS

bacitracin-poly-neomycin-hc Generic

BLEPHAMIDE (ophthalmic) Brand

BLEPHAMIDE S.O.P. Brand

CIPRO HC Brand

CIPRODEX Brand

COLY-MYCIN S Brand

diclofenac sodium (ophth) Generic


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FLAREX Brand

FLUNISOLIDE (nasal) Brand

fluorometholone (ophth) Generic/Brand †

flurbiprofen sodium Generic

fluticasone propionate (nasal) Generic

FML FORTE Brand

ketorolac tromethamine (ophth) Generic

NASONEX Brand

neomycin-polymy-dexameth Generic

neomycin-polymyxin-hc (otic) Generic

POLY-PRED Brand

PRED-G Brand

prednisolone acetate (ophth) Generic/Brand †

PREDNISOLONE SODIUM PHOSPHATE Brand

sulfacetamide sod-prednisolone Generic/Brand †

tobramycin-dexamethasone Generic/Brand †

ANTIALLERGIC AGENTS

ALAMAST Brand

ALOCRIL Brand QL

ALOMIDE Brand

azelastine hcl Generic

azelastine hcl (ophth) Generic

cromolyn sodium (ophth) Generic

PATANOL Brand QL

ANTIGLAUCOMA AGENTS

acetazolamide Generic/Brand †

AZOPT Brand QL

betaxolol hcl (ophth) Generic/Brand †

BETIMOL Brand

brimonidine tartrate Generic/Brand †

carteolol hcl (ophth) Generic

dorzolamide hcl Generic

dorzolamide hcl-timolol maleate Generic

latanoprost Generic

levobunolol hcl Generic/Brand †

methazolamide Generic

METIPRANOLOL Brand

PHOSPHOLINE IODIDE Brand

pilocarpine hcl Generic

timolol maleate (ophth) Generic

EENT DRUGS, MISCELLANEOUS

acetic acid (otic) Generic


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ACETIC ACID/ALUMINUM ACETATE Brand

hydrocortisone w/acetic acid Generic

LOCAL ANESTHETICS

antipyrine-benzocaine Generic

antipyrine, benzocaine & polycosanol Generic/Brand

lidocaine hcl (mouth-throat) Generic

MYDRIATICS

atropine sulfate (ophthalmic) Generic

dipivefrin hcl Generic

tropicamide Generic

GASTROINTESTINAL DRUGS


APRISO Brand

LIALDA Brand

sulfasalazine Generic

ANTIEMETICS

ANTIVERT Brand

EMEND Brand QL

ondansetron Generic QL

ondansetron hcl Generic QL

ANTIULCER AGENTS AND ACID SUPPRESSANTS

famotidine Generic

misoprostol Generic

omeprazole Generic

pantoprazole sodium Generic

PREVACID SOLUTAB Brand

ranitidine hcl Generic

sucralfate Generic/Brand †

DIGESTANTS

ZENPEP Brand

GI DRUGS, MISCELLANEOUS

diphenoxylate w/ atropine Generic/Brand †

metoclopramide hcl Generic

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate Generic/Brand †

peg 3350-potassium chloride-sod bicarbonate-sod chloride Generic

ursodiol Generic/Brand †

GOLD COMPOUNDS

GOLD COMPOUNDS

RIDAURA Brand

HEAVY METAL ANTAGONISTS

HEAVY METAL ANTAGONISTS

CUPRIMINE Brand


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HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

ASMANEX 120 METERED DOSES Brand

budesonide Generic QL

budesonide (inhalation) Generic/Brand †

CELESTONE Brand

CORTISONE ACETATE Brand

DEXAMETHASONE Brand

FLOVENT DISKUS Brand

FLOVENT HFA Brand

fludrocortisone acetate Generic

hydrocortisone Generic

methylprednisolone Generic/Brand †

prednisolone Generic

prednisolone sodium phosphate Generic

prednisone Generic/Brand †

QVAR Brand

ANDROGENS

ANDRODERM Brand

ANDROXY Brand QL

danazol Generic

METHITEST Brand

testosterone Generic QL

testosterone cypionate Generic * QL

testosterone enanthate Generic * QL

CONTRACEPTIVES

desogestrel & ethinyl estradiol Generic

desogestrel-ethinyl estradiol (biphasic) Generic

desogestrel-ethinyl estradiol (triphasic) Generic

drospirenone-ethinyl estradiol Generic

ELLA Brand

ethynodiol diacet & ethinyl estradiol Generic/Brand †

levonorgestrel & ethinyl estradiol Generic

levonorgestrel-ethinyl estradiol (91-day) Generic

levonorgestrel-ethinyl estradiol (triphasic) Generic

NECON 1/50-28 Brand

NECON 10/11-28 Brand

norethin acet & ethinyl estradiol-fe Generic

norethindrone & ethinyl estradiol Generic

norethindrone (contraceptive) Generic

norethindrone acet & ethinyl estradiol Generic

norethindrone-ethinyl estradiol (triphasic) Generic


- 20 -


norgestimate-ethinyl estradiol Generic

norgestimate-ethinyl estradiol (triphasic) Generic/Brand †

norgestrel & ethinyl estradiol Generic/Brand †

NUVARING Brand QL

PLAN B Brand

XULANE Brand QL

DIABETIC AGENTS

acarbose Generic

glimepiride Generic

glipizide Generic

glipizide (extended release) Generic

GLUCAGEN Brand *

GLUCAGON EMERGENCY KIT Brand *

glyburide Generic

glyburide-metformin Generic

HUMALOG Brand

HUMALOG MIX 50/50 Brand

HUMULIN N Brand

HUMULIN R Brand

LANTUS Brand

LANTUS SOLOSTAR Brand

LEVEMIR Brand

LEVEMIR FLEXTOUCH Brand

metformin hcl Generic

metformin hcl (extended release) Generic

NOVOLOG Brand

NOVOLOG MIX 70/30 Brand

pioglitazone hcl Generic

tolazamide Generic/Brand †

TOLBUTAMIDE Brand

ESTROGENS AND ANTIESTROGENS

COMBIPATCH Brand

esterified estrogens & methyltestosterone Generic

ESTRACE VAGINAL Brand

estradiol (oral) Generic/Brand †

estradiol (transdermal) Generic/Brand † QL

estropipate Generic/Brand †

FEMHRT LOW DOSE Brand

PREMARIN Brand

PREMPHASE Brand

raloxifene hcl Generic

VAGIFEM Brand


- 21 -


GONADOTROPINS

BRAVELLE Brand * RB

chorionic gonadotropin Generic * RB

clomiphene citrate Generic RB

FOLLISTIM AQ Brand * RB

GONAL-F Brand * RB

MENOPUR Brand * RB

OVIDREL Brand * RB

PARATHYROID

calcitonin (salmon) Generic QL

FORTEO Brand * QL

PITUITARY

ACTHAR HP Brand * QL

desmopressin acetate Generic *

desmopressin acetate refrigerated Generic

desmopressin acetate spray Generic

desmopressin acetate spray refrigerated Generic

PROGESTINS

medroxyprogesterone acetate Generic

norethindrone acetate Generic

progesterone micronized Generic RB

SOMATOTROPIN AGONISTS AND ANTAGONISTS

OMNITROPE Brand * NC, QL

THYROID AND ANTITHYROID AGENTS

levothyroxine sodium Generic

liothyronine sodium Generic

methimazole Generic

propylthiouracil Generic

SSKI Brand

thyroid Generic/Brand †

THYROLAR Brand

MISCELLANEOUS THERAPEUTIC AGENTS

MISCELLANEOUS THERAPEUTIC AGENTS

acetylcysteine Generic

ADCIRCA Brand QL

alendronate sodium Generic/Brand †

allopurinol Generic

azathioprine Generic

cyclosporine modified (for microemulsion) Generic/Brand †

CYSTAGON Brand

disulfiram Generic/Brand †

ELMIRON Brand


- 22 -


ENBREL Brand * QL

ETIDRONATE DISODIUM Brand

finasteride Generic

FIRAZYR Brand * QL

FOSAMAX PLUS D Brand

GLATOPA Generic * QL

HUMIRA Brand * QL

leflunomide Generic

leucovorin calcium Generic/Brand *†

levocarnitine (metabolic modifiers) Generic/Brand †

mycophenolate mofetil Generic

mycophenolate sodium Generic

RAPAMUNE Brand

REBIF Brand * QL

REVLIMID Brand QL

SANDIMMUNE Brand

sirolimus Generic

sodium fluoride Generic/Brand †

sodium fluoride (dental) Generic

tacrolimus Generic

THALOMID Brand QL

OXYTOCICS

OXYTOCICS

ERGOTRATE MALEATE Brand

methylergonovine maleate Generic

RESPIRATORY TRACT AGENTS


cromolyn sodium Generic

montelukast sodium Generic QL

montelukast sodium (granules) Generic QL

STRIVERDI RESPIMAT Brand

zafirlukast Generic

ANTITUSSIVES

benzonatate Generic

guaifenesin-codeine Generic/Brand †

hydrocodone polistirex-chlorpheniramine polistirex Generic QL

hydrocodone w/ homatropine Generic QL

RESPIRATORY AGENTS, MISCELLANEOUS

DULERA Brand

ELIXOPHYLLIN Brand

PULMOZYME Brand QL

sodium chloride (inhalant) Generic


- 23 -


SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)

acyclovir topical Generic

AVC Brand

BACTROBAN NASAL Brand

benzoyl peroxide-erythromycin Generic/Brand †

ciclopirox Generic

ciclopiroxolamine Generic

clindamycin phosphate (topical) Generic

clindamycin phosphate vaginal Generic

clotrimazole Generic

clotrimazole (topical) Generic

clotrimazole w/ betamethasone Generic

erythromycin (acne aid) Generic

EURAX Brand

EXELDERM Brand

GENTAMICIN SULFATE Brand

ketoconazole (topical) Generic

lindane Generic

metronidazole (topical) Generic/Brand †

metronidazole vaginal Generic

MICONAZOLE 3 Brand

mupirocin Generic

NAFTIN Brand

nystatin (topical) Generic

NYSTATIN VAGINAL Brand

permethrin Generic

selenium sulfide Generic

silver sulfadiazine Generic

sulfacetamide sodium (acne) Generic

ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)

APEXICON E Brand

betamethasone dipropionate (topical) Generic

betamethasone dipropionate augmented Generic

betamethasone valerate Generic

clobetasol propionate Generic

clobetasol propionate emollient base Generic

CLODERM Brand

CORDRAN Brand

CORTIFOAM Brand

CORTISPORIN Brand

desonide Generic


- 24 -


desoximetasone Generic

diflorasone diacetate Generic/Brand †

EPIFOAM Brand

fluocinolone acetonide Generic

fluocinonide Generic

fluocinonide emulsified base Generic

fluticasone propionate Generic/Brand †

halobetasol propionate Generic

hydrocortisone (intrarectal) Generic

hydrocortisone (rectal) Generic

hydrocortisone (topical) Generic

hydrocortisone valerate Generic

KENALOG Brand

mometasone furoate Generic

nystatin-triamcinolone Generic

triamcinolone acetonide (mouth) Generic

triamcinolone acetonide (topical) Generic/Brand †

ANTIPRURITICS AND LOCAL ANESTHETICS

hydrocortisone acetate (rectal) Generic

hydrocortisone acetate w/ pramoxine Generic/Brand †

lidocaine Generic

lidocaine hcl Generic

phenazopyridine hcl Generic

CELL STIMULANTS AND PROLIFERANTS

tretinoin Generic/Brand † QL

SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS

adapalene Generic/Brand †

aluminum chloride Generic

AMEVIVE Brand * QL

calcipotriene Generic

DRITHO-CREME HP Brand

DRITHO-SCALP Brand

ELIDEL Brand QL

FINACEA Brand

fluorouracil (topical) Generic

imiquimod Generic

isotretinoin Generic/Brand † QL

mupirocin calcium (topical) Generic

OXSORALEN Brand

podofilox Generic/Brand †

REGRANEX Brand QL

tacrolimus (topical) Generic


- 25 -


TARGRETIN Brand QL

TAZORAC Brand QL

VECTICAL Brand

SMOOTH MUSCLE RELAXANTS

GENITOURINARY SMOOTH MUSCLE RELAXANTS

flavoxate hcl Generic

oxybutynin chloride Generic

oxybutynin chloride (extended release) Generic

tolterodine tartrate Generic

tolterodine tartrate (extended release) Generic

trospium chloride Generic

SMOOTH MUSCLE RELAXANTS

AMINOPHYLLINE Brand

theophylline Generic

VITAMINS

VITAMIN B COMPLEX

folic acid Generic

VITAMIN D

calcitriol Generic/Brand †

ergocalciferol Generic

VITAMIN K ACTIVITY

MEPHYTON Brand

VITAMINS

pediatric multivitamins w/fl Generic

pediatric vitamins acd w/ fluoride Generic

PRENATAL VITAMIN WITH DOCUSATE, FERROUS FUMARATE

& FOLIC ACID Brand

PRENATAL VITAMIN WITH DOCUSATE, IRON CARBONYL &

FOLIC ACID Brand

PRENATAL VITAMIN WITH FERROUS FUMARATE & FOLIC

ACID Brand

PRENATAL VITAMIN WITH IRON CARBONYL & FOLIC ACID Brand

PRENATAL VITAMIN WITH MINERALS, IRON & FOLIC ACID Brand

PRENATAL VITAMIN WITH SELENIUM, FERROUS FUMARATE

& FOLIC ACID Brand

PRENATAL VITAMIN WITHOUT VITAMIN A, WITH IRON

CARBONYL, DOCUSATE & FOLIC ACID Brand


- 26 -

INDEX OF DRUGS

Kaiser Permanente Southern Colorado

Commercial PPO Comprehensive Formulary Index

A

abacavir sulfate, 4 abacavir-lamivudine-zidovudine, 4 ABILIFY, 13 acarbose, 20 ACCU-CHEK COMPACT PLUS CARE KIT, 15 ACCU-CHEK COMPACT TEST DRUM, 15 acebutolol hcl, 9 acetaminophen w/ codeine, 11 acetazolamide, 17 ACETEST, 15 acetic acid (otic), 17 ACETIC ACID/ALUMINUM ACETATE, 18 acetylcysteine, 21 ACIDIFYING AND ALKALINIZING AGENTS, 15 ACTHAR HP, 21 acyclovir, 4 acyclovir topical, 23 adapalene, 24 ADCIRCA, 21 adefovir dipivoxil, 4 ADRENALIN, 8 ADRENALS, 19 ADVAIR DISKUS, 8 ADVOCATE DUO/TALKING, 15 AFINITOR, 6 ALAMAST, 17 ALBENZA, 3 albuterol sulfate, 8 alendronate sodium, 21 ALKERAN, 6 allopurinol, 21 ALOCRIL, 17 ALOMIDE, 17 ALPHA-ADRENERGIC BLOCKING AGENTS, 9 alprazolam, 13 alprostadil, 11 aluminum chloride, 24 amantadine hcl, 13 AMEVIVE, 24 aminocaproic acid, 8 AMINOPHYLLINE, 25 amiodarone hcl, 10 amitriptyline hcl, 13 amlodipine besylate, 9

amlodipine besylate-benazepril hcl, 9 AMMONIA DETOXICANTS, 15 AMOXAPINE, 13 amoxicillin, 3 amoxicillin & pot clavulanate, 3 amphetamine-dextroamphetamine, 12 ampicillin, 3 anagrelide hcl, 8 ANALGESICS AND ANTIPYRETICS, 11 anastrozole, 6 ANDRODERM, 19 ANDROGENS, 19 ANDROXY, 19 ANOREXIGENIC AGENTS AND RESPIRATORY AND

CEREBRAL STIMULANTS, 12 ANTHELMINTICS, 3 ANTIALLERGIC AGENTS, 17 ANTIBACTERIALS, 3 ANTICHOLINERGIC AGENTS, 7 ANTICONVULSANTS, 12 ANTIEMETICS, 18 ANTIFUNGALS, 4 ANTIGLAUCOMA AGENTS, 17 ANTIHISTAMINE DRUGS, 6 ANTI-INFECTIVE AGENTS, 3 ANTI-INFECTIVES, 16 ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE), 23 ANTI-INFLAMMATORY AGENTS, 16, 18, 22 ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS

MEMBRANE), 23 ANTILIPEMIC AGENTS, 9 ANTIMIGRAINE AGENTS, 12 ANTIMYCOBACTERIALS, 4 ANTINEOPLASTIC AGENTS, 6 ANTIPROTOZOALS, 4 ANTIPRURITICS AND LOCAL ANESTHETICS, 24 antipyrine, benzocaine & polycosanol, 18 antipyrine-benzocaine, 18 ANTITHROMBOTIC AGENTS, 8 ANTITUSSIVES, 22 ANTIULCER AGENTS AND ACID SUPPRESSANTS, 18 ANTIVERT, 18 ANTIVIRALS, 4 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS, 13 APEXICON E, 23 APOKYN, 13 APRISO, 18


- 27 -

APTIVUS, 4 aripiprazole, 13 ASMANEX 120 METERED DOSES, 19 ASSESS FULL RANGE PEAK FLOW METER, 15 atenolol, 9 atenolol & chlorthalidone, 9 atovaquone-proguanil hcl, 4 ATRIPLA, 4 atropine sulfate (ophthalmic), 18 ATROVENT HFA, 7 AUTOLET PLATFORMS, 15 AUTONOMIC DRUGS, 7 AVC, 23 azathioprine, 21 azelastine hcl, 17 azelastine hcl (ophth), 17 azithromycin, 3 AZOPT, 17

B

BACITRACIN, 16 bacitracin-polymyxin b (ophth), 16 bacitracin-poly-neomycin-hc, 16 baclofen, 7 BACTROBAN NASAL, 23 BARACLUDE, 4 BD AUTOSHIELD 29G X 3/16", 15 BD INSULIN SYRINGE LUER-LOK/U-100/1ML, 15 BD INSULIN SYRINGE MICROFINE IV/U-100/0.3ML/28G X

1/2", 15 BD SYRINGE LUER-LOK/1ML, 15 benazepril & hydrochlorothiazide, 10 benazepril hcl, 10 benzonatate, 22 benzoyl peroxide-erythromycin, 23 benztropine mesylate, 13 BETA-ADRENERGIC BLOCKING AGENTS, 9 betamethasone dipropionate (topical), 23 betamethasone dipropionate augmented, 23 betamethasone valerate, 23 betaxolol hcl (ophth), 17 bethanechol chloride, 7 BETIMOL, 17 bicalutamide, 6 BILTRICIDE, 3 bisoprolol & hydrochlorothiazide, 9 bisoprolol fumarate, 9 BLEPHAMIDE (ophthalmic), 16 BLEPHAMIDE S.O.P., 16 BLOOD FORMATION, COAGULATION, AND THROMBOSIS,

8 BRAVELLE, 21

BRILINTA, 8 brimonidine tartrate, 17 bromocriptine mesylate, 13 budesonide, 19 budesonide (inhalation), 19 bumetanide, 15 buprenorphine hcl-naloxone hcl dihydrate, 11 bupropion hcl, 14 bupropion hcl (smoking deterrent), 14 buspirone hcl, 13 BUTALBITAL/ASPIRIN/CAFFEINE, 11 butalbital-acetaminophen-caffeine, 11 butalbital-acetaminophen-caffeine w/ codeine, 11 butalbital-aspirin-caffeine w/cod, 11 BYSTOLIC, 9

C

cabergoline, 13 CAFERGOT, 12 calcipotriene, 24 calcitonin (salmon), 21 calcitriol, 25 calcium acetate (phosphate binder, 16 CALCIUM-CHANNEL BLOCKING AGENTS, 9 capecitabine, 6 captopril, 10 CAPTOPRIL/HYDROCHLOROTHIAZIDE, 10 carbamazepine, 12 carbamazepine (extended release), 12 carbidopa-levodopa, 13 carbidopa-levodopa (extended release), 13 CARDENE SR, 9 CARDIAC DRUGS, 10 CARDIOVASCULAR DRUGS, 9 carisoprodol, 8 carisoprodol w/ aspirin, 8 carteolol hcl (ophth), 17 CARTRIDGE IR 1200, 15 carvedilol, 9 CAVERJECT, 11 CAYSTON, 3 CEENU, 6 cefaclor, 3 cefadroxil, 3 cefdinir, 3 cefixime, 3 cefprozil, 3 cefuroxime axetil, 3 celecoxib, 11 CELESTONE, 19 CELL STIMULANTS AND PROLIFERANTS, 24 CELONTIN, 12


- 28 -

CENTRAL NERVOUS SYSTEM AGENTS, 11 CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS,

13 cephalexin, 3 cevimeline hcl, 7 CHEMSTRIP 2 LN STRIPS, 15 CHEMSTRIP UGK, 15 CHEMSTRIP-MICRAL, 15 CHLORAL HYDRATE, 13 chlordiazepoxide hcl, 13 CHLORDIAZEPOXIDE/AMITRIPTYLINE, 14 chlorhexidine gluconate (mouth-throat), 16 chloroquine phosphate, 4 chlorpromazine hcl, 14 CHLORTHALIDONE, 15 cholestyramine, 9 cholestyramine light, 9 choline & mag salicylate, 11 chorionic gonadotropin, 21 CIALIS, 11 ciclopirox, 23 ciclopiroxolamine, 23 cilostazol, 8 CIPRO HC, 16 CIPRODEX, 16 ciprofloxacin hcl, 3 ciprofloxacin hcl (ophth), 16 citalopram hydrobromide, 14 clarithromycin, 3 clidinium & chlordiazepoxide, 7 clindamycin hcl, 3 clindamycin palmitate hydrochloride, 3 clindamycin phosphate (topical), 23 clindamycin phosphate vaginal, 23 CLINISTIX, 15 CLINITEST, 15 clobetasol propionate, 23 clobetasol propionate emollient base, 23 CLODERM, 23 clomiphene citrate, 21 clomipramine hcl, 14 clonazepam, 12 clonidine hcl, 10 clopidogrel bisulfate, 8 clorazepate dipotassium, 13 clotrimazole, 23 clotrimazole (topical), 23 clotrimazole w/ betamethasone, 23 COAGULANTS AND ANTICOAGULANTS, 8 colchicine, 16 colchicine w/ probenecid, 16 COLY-MYCIN S, 16 COMBIPATCH, 20 COMBIVENT, 8

COMBIVENT RESPIMAT, 8 COMTAN, 13 CONTRACEPTIVES, 19 CORDRAN, 23 COREG CR, 9 CORTIFOAM, 23 CORTISONE ACETATE, 19 CORTISPORIN, 23 CRESTOR, 9 CRIXIVAN, 5 cromolyn sodium, 22 cromolyn sodium (ophth), 17 CUPRIMINE, 18 cyclobenzaprine hcl, 8 CYCLOPHOSPHAMIDE, 6 cyclosporine modified (for microemulsion), 21 cyproheptadine hcl, 6 CYSTAGON, 21

D

danazol, 19 dantrolene sodium, 8 DAPSONE, 4 DARAPRIM, 4 desipramine hcl, 14 desmopressin acetate, 21 desmopressin acetate refrigerated, 21 desmopressin acetate spray, 21 desmopressin acetate spray refrigerated, 21 desogestrel & ethinyl estradiol, 19 desogestrel-ethinyl estradiol (biphasic), 19 desogestrel-ethinyl estradiol (triphasic), 19 desonide, 23 desoximetasone, 24 DEVICES, 14 DEXAMETHASONE, 19 dexmethylphenidate hcl, 12 dextroamphetamine sulfate, 12 DIABETIC AGENTS, 20 DIABETIC SUPPLIES, 15 diazepam, 13 diclofenac sodium, 11 diclofenac sodium (ophth), 16 dicloxacillin sodium, 3 dicyclomine hcl, 7 didanosine, 5 diflorasone diacetate, 24 DIGESTANTS, 18 digoxin, 10 dihydroergotamine mesylate, 12 diltiazem hcl, 9 diltiazem hcl coated beads, 9


- 29 -

diltiazem hcl extended release beads, 9 diphenoxylate w/ atropine, 18 dipivefrin hcl, 18 dipyridamole, 11 disopyramide phosphate, 10 disulfiram, 21 DIURETICS, 15 divalproex sodium, 12 divalproex sodium (extended release), 12 donepezil hydrochloride, 7 DONNATAL, 7 dorzolamide hcl, 17 dorzolamide hcl-timolol maleate, 17 doxazosin mesylate, 9 doxepin hcl, 14 doxycycline hyclate, 3 DRITHO-CREME HP, 24 DRITHO-SCALP, 24 drospirenone-ethinyl estradiol, 19 DULERA, 22 DUO-CARE CONTROL SOLUTION, 15 DYNACIRC CR, 9

E

E.E.S. 400, 3 EENT DRUGS, MISCELLANEOUS, 17 EFFIENT, 8 ELECTROLYTIC, CALORIC, AND WATER BALANCE, 15 ELIDEL, 24 ELIGARD, 6 ELIXOPHYLLIN, 22 ELLA, 19 ELMIRON, 21 EMCYT, 6 EMEND, 18 EMTRIVA, 5 enalapril maleate, 10 ENBREL, 22 entacapone, 13 EPIFOAM, 24 epinephrine hcl, 8 EPIVIR HBV, 5 EPOGEN, 8 EPZICOM, 5 ergocalciferol, 25 ERGOMAR, 12 ERGOTRATE MALEATE, 22 ERYTHROCIN STEARATE, 3 erythromycin (acne aid), 23 erythromycin (ophth), 16 erythromycin base, 3 erythromycin-sulfisoxazole, 3

escitalopram oxalate, 14 estazolam, 13 esterified estrogens & methyltestosterone, 20 ESTRACE VAGINAL, 20 estradiol, 20 estradiol (oral), 20 estradiol (transdermal, 20 ESTROGENS AND ANTIESTROGENS, 20 estropipate, 20 ethambutol hcl, 4 ethosuximide, 12 ethynodiol diacet & ethinyl estradiol, 19 ETIDRONATE DISODIUM, 22 etodolac, 11 ETOPOSIDE, 6 EURAX, 23 EXELDERM, 23 exemestane, 6 EXFORGE, 9 EXFORGE HCT, 9 EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS, 16

F

famciclovir, 5 famotidine, 18 felbamate, 12 felodipine, 10 FEMHRT LOW DOSE, 20 fenofibrate, 9 fenofibrate micronized, 9 FENOPROFEN CALCIUM, 11 fentanyl, 11 fentanyl citrate, 11 FINACEA, 24 finasteride, 22 FIRAZYR, 22 FLAREX, 17 flavoxate hcl, 25 flecainide acetate, 10 FLOVENT DISKUS, 19 FLOVENT HFA, 19 fluconazole, 4 fludrocortisone acetate, 19 FLUNISOLIDE, 17 fluocinolone acetonide, 24 fluocinonide, 24 fluocinonide emulsified base, 24 fluorometholone (ophth), 17 fluorouracil (topical), 24 fluoxetine hcl, 14 fluphenazine hcl, 14 flurazepam hcl, 13


- 30 -

flurbiprofen sodium, 17 flutamide, 6 fluticasone propionate, 24 fluticasone propionate (nasal), 17 fluvoxamine maleate, 14 FML FORTE, 17 folic acid, 25 FOLLISTIM AQ, 21 fondaparinux sodium, 8 FORTEO, 21 FOSAMAX PLUS D, 22 fosinopril sodium, 10 fosinopril sodium & hydrochlorothiazide, 10 FRAGMIN, 8 FREESTYLE LANCETS, 15 FREESTYLE NAVIGATOR SENSOR KIT, 15 furosemide, 15

G

gabapentin, 12 galantamine hydrobromide, 7 GANCICLOVIR, 5 GASTROINTESTINAL DRUGS, 18 gatifloxacin (ophth), 16 gemfibrozil, 9 GENITOURINARY SMOOTH MUSCLE RELAXANTS, 25 GENTAMICIN SULFATE, 23 gentamicin sulfate (ophth), 16 GI DRUGS, MISCELLANEOUS, 18 GLATOPA, 22 GLEEVEC, 6 glimepiride, 20 glipizide, 20 glipizide (extended release), 20 GLUCAGEN, 20 GLUCAGON EMERGENCY KIT, 20 GLUCOLET 2 AUTOMATIC LANCING DEVICE, 15 glyburide, 20 glyburide-metformin, 20 glycopyrrolate, 7 GOLD COMPOUNDS, 18 GONADOTROPINS, 21 GONAL-F, 21 griseofulvin ultramicrosize, 4 guaifenesin-codeine, 22 guanfacine hcl, 10

H

halobetasol propionate, 24 haloperidol, 14 haloperidol lactate, 14

HARVONI, 5 HEAVY METAL ANTAGONISTS, 18 HEMATOPOIETIC AGENTS, 8 heparin sod (porcine) in d5w, 8 heparin sodium (porcine), 8 heparin sodium (porcine) lock flush, 8 HEXALEN, 6 HORMONES AND SYNTHETIC SUBSTITUTES, 19 HUMALOG, 20 HUMALOG MIX 50/50, 20 HUMIRA, 22 HUMULIN N, 20 HUMULIN R, 20 hydralazine hcl, 10 hydrochlorothiazide, 16 hydrocodone polistirex-chlorpheniramine polistirex, 22 hydrocodone w/ homatropine, 22 hydrocortisone, 19 hydrocortisone (intrarectal), 24 hydrocortisone (rectal), 24 hydrocortisone (topical), 24 hydrocortisone acetate (rectal), 24 hydrocortisone acetate w/ pramoxine, 24 hydrocortisone valerate, 24 hydrocortisone w/acetic acid, 18 hydromorphone hcl, 11 hydroxychloroquine sulfate, 4 hydroxyurea, 6 hydroxyzine hcl, 13 hydroxyzine pamoate, 13 hyoscyamine sulfate, 7 HYPOTENSIVE AGENTS, 10

I

ibuprofen, 11 imipramine hcl, 14 imipramine pamoate, 14 imiquimod, 24 indapamide, 16 indomethacin, 11 INFERGEN, 5 INNOHEP, 8 INSULIN PUMP IR1250 BLUE, 15 INTELENCE, 5 INTRON-A, 6 INVIRASE, 5 ION-REMOVING AGENTS, 16 ipratropium bromide, 7 ipratropium bromide (nasal), 7 IRESSA, 6 ISENTRESS, 5 isoniazid, 4


- 31 -

isosorbide dinitrate, 11 isosorbide mononitrate, 11 isotretinoin, 24 ISRADIPINE, 10 itraconazole, 4 ivermectin, 3

K

KALETRA, 5 KENALOG, 24 ketoconazole, 4 ketoconazole (topical), 23 KETOPROFEN ER, 11 ketorolac tromethamine, 11 ketorolac tromethamine (ophth), 17

L

labetalol hcl, 9 lactulose, 15 lactulose (encephalopathy), 15 lamivudine, 5 lamotrigine, 12 LANTUS, 20 LANTUS SOLOSTAR, 20 latanoprost, 17 leflunomide, 22 LETAIRIS, 11 letrozole, 6 leucovorin calcium, 22 LEUKERAN, 6 LEUKINE, 8 leuprolide acetate, 6 levalbuterol hcl, 8 LEVEMIR, 20 LEVEMIR FLEXTOUCH, 20 levetiracetam, 12 LEVITRA, 11 levobunolol hcl, 17 levocarnitine (metabolic modifiers), 22 levofloxacin, 3 levonorgestrel & ethinyl estradiol, 19 levonorgestrel-ethinyl estradiol (91-day), 19 levonorgestrel-ethinyl estradiol (triphasic), 19 levothyroxine sodium, 21 LEXIVA, 5 LIALDA, 18 lidocaine, 24 lidocaine hcl, 24 lidocaine hcl (mouth-throat), 18 lindane, 23 linezolid, 3

liothyronine sodium, 21 lisinopril, 10 lisinopril & hydrochlorothiazide, 10 lithium carbonate, 12, 14 LOCAL ANESTHETICS, 18 lorazepam, 13 losartan potassium, 10 losartan potassium & hydrochlorothiazide, 10 lovastatin, 9 LOVENOX, 8 loxapine succinate, 14 LUPRON DEPOT, 6 LUPRON DEPOT-PED, 6 LYSODREN, 6

M

MAPROTILINE HCL, 14 MATULANE, 6 MEBENDAZOLE, 3 MECLOFENAMATE SODIUM, 11 medroxyprogesterone acetate, 21 mefloquine hcl, 4 megestrol acetate, 6 melphalan hcl, 6 MENOPUR, 21 MEPHYTON, 25 mercaptopurine, 6 METAPROTERENOL SULFATE, 8 metformin hcl, 20 metformin hcl (extended release), 20 methadone hcl, 11 methazolamide, 10, 17 methenamine-hyosc-methylene blue-sod phos-phenyl sal, 6 methimazole, 21 METHITEST, 19 methocarbamol, 8 methotrexate sodium, 6 methyldopa, 10 methylergonovine maleate, 22 methylphenidate hcl, 12 methylprednisolone, 19 METIPRANOLOL, 17 metoclopramide hcl, 18 metolazone, 16 metoprolol succinate, 9 metoprolol tartrate, 9 metronidazole, 4 metronidazole (topical), 23 metronidazole vaginal, 23 mexiletine hcl, 10 MICONAZOLE, 23 midodrine hcl, 8


- 32 -

minocycline hcl, 3 mirtazapine, 14 MISCELLANEOUS THERAPEUTIC AGENTS, 21 misoprostol, 18 modafinil, 12 moexipril hcl, 10 moexipril-hydrochlorothiazide, 10 mometasone furoate, 24 montelukast sodium, 22 montelukast sodium (granules), 22 morphine sulfate, 11 morphine sulfate (extended release), 11 moxifloxacin hcl, 3 mupirocin, 23 mupirocin calcium (topical), 24 MUSE, 11 mycophenolate mofetil, 22 MYDRIATICS, 18 MYLERAN, 6

N

nabumetone, 11 nadolol, 9 NAFTIN, 23 naltrexone hcl, 13 naproxen, 11 naproxen sodium, 11 naratriptan hcl, 12 NASONEX, 17 NEBUPENT, 4 NECON 1/50-28, 19 NECON 10/11-28, 19 NEEDLE-FREE INSULIN SYRINGE A, 15 nefazodone hcl, 14 NEO-FRADIN, 3 neomycin-bacitracinzn-polymyxin, 16 neomycin-polymy-dexameth, 17 neomycin-polymyxin-hc (otic), 17 NEULASTA, 8 nevirapine, 5 NEXAVAR, 7 NIASPAN, 9 nifedipine, 10 NILANDRON, 7 nitrofurantoin, 6 nitrofurantoin macrocrystal, 6 nitrofurantoin monohyd macro, 6 nitroglycerin, 11 NORDIPEN 5 INJECTION DEVICE, 15 norethin acet & ethinyl estradiol-fe, 19 norethindrone & ethinyl estradiol, 19 norethindrone (contraceptive), 19

norethindrone acet & ethinyl estradiol, 19 norethindrone acetate, 21 norethindrone-ethinyl estradiol (triphasic), 19 norgestimate-ethinyl estradiol, 20 norgestimate-ethinyl estradiol (triphasic), 20 norgestrel & ethinyl estradiol, 20 NOROXIN, 3 nortriptyline hcl, 14 NORVIR, 5 NOVOLOG, 20 NOVOLOG MIX 70/30, 20 NOVOPEN 3 PENMATE, 15 NUVARING, 20 nystatin, 4 nystatin (mouth-throat), 4 nystatin (topical), 23 NYSTATIN VAGINAL, 23 nystatin-triamcinolone, 24

O

ofloxacin (ophth), 16 ofloxacin (otic), 16 olanzapine, 14 olanzapine odt, 14 omeprazole, 18 OMNITROPE, 21 ondansetron, 18 ondansetron hcl, 18 OPIATE ANTAGONISTS, 13 OVIDREL, 21 oxaprozin, 12 oxazepam, 13 oxcarbazepine, 12 OXSORALEN, 24 oxybutynin chloride, 25 oxybutynin chloride (extended release), 25 oxycodone hcl, 12 oxycodone w/ acetaminophen, 12 oxycodone-aspirin, 12 OXYTOCICS, 22

P

pantoprazole sodium, 18 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS, 7 PARATHYROID, 21 paromomycin sulfate, 4 paroxetine hcl, 14 PATANOL, 17 PCE, 3 pediatric multivitamins w/fl, 25 pediatric vitamins acd w/ fluoride, 25


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peg 3350-kcl-sod bicarb-sod chloride-sod sulfate, 18 peg 3350-potassium chloride-sod bicarbonate-sod chloride,

18 PEGASYS, 5 PEG-INTRON, 5 penicillin v potassium, 3 pentoxifylline, 8 permethrin, 23 perphenazine, 14 phenazopyridine hcl, 24 phenelzine sulfate, 14 phenobarbital, 13 phenoxybenzamine, 7 phenytoin, 12 phenytoin sodium extended, 12 PHOSPHOLINE IODIDE, 17 pilocarpine hcl, 17 pindolol, 9 pioglitazone hcl, 20 PITUITARY, 21 PLAN B, 20 podofilox, 24 polymyxin b-trimethoprim, 16 POLY-PRED, 17 potassium & sodium citrates w/ citric acid, 15 potassium bicarb & chloride, 16 potassium chloride, 16 potassium chloride microencapsulated crystals cr, 16 POTASSIUM CITRATE, 15 pramipexole dihydrochloride, 13 pravastatin sodium, 9 prazosin hcl, 9 PRECISION XTRA, 15 PRED-G, 17 prednisolone, 19 prednisolone acetate (ophth), 17 prednisolone sodium phosphate, 19 PREDNISOLONE SODIUM PHOSPHATE, 17 prednisone, 19 PREMARIN, 20 PREMPHASE, 20 PRENATAL VITAMIN WITH DOCUSATE, FERROUS

FUMARATE & FOLIC ACID, 25 PRENATAL VITAMIN WITH DOCUSATE, IRON CARBONYL &

FOLIC ACID, 25 PRENATAL VITAMIN WITH FERROUS FUMARATE & FOLIC

ACID, 25 PRENATAL VITAMIN WITH IRON CARBONYL & FOLIC ACID,

25 PRENATAL VITAMIN WITH MINERALS, IRON & FOLIC ACID,

25 PRENATAL VITAMIN WITH SELENIUM, FERROUS

FUMARATE & FOLIC ACID, 25

PRENATAL VITAMIN WITHOUT VITAMIN A, WITH IRON CARBONYL, DOCUSATE & FOLIC ACID, 25

PREVACID SOLUTAB, 18 PREZISTA, 5 PRIMAQUINE PHOSPHATE, 4 primidone, 12 PRIMSOL, 6 probenecid, 16 prochlorperazine, 14 prochlorperazine maleate, 14 PROCRIT, 8 progesterone micronized, 21 PROGESTINS, 21 promethazine hcl, 6 propafenone hcl, 10 propranolol hcl, 9 propylthiouracil, 21 PROSTIGMIN, 7 protriptyline hcl, 14 PSYCHOTHERAPEUTIC AGENTS, 13 PULMOZYME, 22 PURIXAN, 7 pyrazinamide, 4 pyridostigmine bromide, 7

Q

quetiapine fumarate, 14 quinapril hcl, 10 quinapril-hydrochlorothiazide, 10 quinidine gluconate, 10 quinidine sulfate, 10 QVAR, 19

R

raloxifene hcl, 20 ramipril, 10 ranitidine hcl, 18 RAPAMUNE, 22 REBIF, 22 REGRANEX, 24 RELENZA DISKHALER, 5 RENAGEL, 16 RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM

INHIBITORS, 10 RENVELA, 16 REPLACEMENT PREPARATIONS, 16 RESCRIPTOR, 5 RESERPINE, 10 RESPIRATORY AGENTS, MISCELLANEOUS, 22 RESPIRATORY TRACT AGENTS, 22 REVLIMID, 22


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REYATAZ, 5 RHEUMATREX, 7 ribavirin (hepatitis c), 5 RIDAURA, 18 rifabutin, 4 rifampin, 4 riluzole, 13 rimantadine hydrochloride, 5 risperidone, 14 rizatriptan benzoate, 12 ropinirole hydrochloride, 13

S

salsalate, 12 SANDIMMUNE, 22 SAVELLA, 13 selegiline hcl, 13 selenium sulfide, 23 SELZENTRY, 5 SEREVENT DISKUS, 8 sertraline hcl, 14 SIDEKICK BLOOD GLUCOSE SYSTEM, 15 sildenafil citrate (pulmonary hypertension), 11 silver sulfadiazine, 23 simvastatin, 9 sirolimus, 22 SKELETAL MUSCLE RELAXANTS, 7 SKIN AND MUCOUS MEMBRANE AGENTS, 23 SKIN AND MUCOUS MEMBRANE AGENTS,

MISCELLANEOUS, 24 SMOOTH MUSCLE RELAXANTS, 25 sodium chloride (inhalant), 22 sodium citrate & citric acid, 15 SODIUM EDECRIN, 15 sodium fluoride, 22 sodium fluoride (dental), 22 sodium polystyrene sulfonate, 16 SOMATOTROPIN AGONISTS AND ANTAGONISTS, 21 sotalol hcl, 9 SOVALDI, 5 SPECTRACEF, 3 SPIRIVA RESPIMAT, 7 spironolactone, 10 spironolactone & hydrochlorothiazide, 10 SPRYCEL, 7 SSKI, 21 stavudine, 5 sucralfate, 18 sulfacetamide sodium (acne), 23 sulfacetamide sodium (ophth), 16 sulfacetamide sod-prednisolone, 17 SULFADIAZINE, 3

sulfamethoxazole-trimethoprim, 3 sulfasalazine, 3, 18 sulindac, 12 SUMATRIPTAN, 12 sumatriptan succinate, 13 SUPRAX, 4 SURMONTIL, 14 SUSTIVA, 5 SUTENT, 7 SYMPATHOMIMETIC (ADRENERGIC) AGENTS, 8

T

TABLOID, 7 tacrolimus, 22 tacrolimus (topical), 24 TAMIFLU, 5 tamoxifen citrate, 7 tamsulosin hcl, 7 TARCEVA, 7 TARGRETIN, 7, 25 TARKA, 10 TAZORAC, 25 temazepam, 13 temozolomide, 7 terazosin hcl, 9 terbinafine hcl, 4 terbutaline sulfate, 8 testosterone, 19 testosterone cypionate, 19 testosterone enanthate, 19 TETRACYCLINE HCL, 4 THALOMID, 22 theophylline, 25 thioridazine hcl, 14 thiothixene, 14 thyroid, 21 THYROID AND ANTITHYROID AGENTS, 21 THYROLAR, 21 THYROLAR-1, 21 tiagabine hcl, 12 TIKOSYN, 10 timolol maleate (ophth), 17 tizanidine hcl, 8 tobramycin, 4 tobramycin (ophth), 16 tobramycin-dexamethasone, 17 tolazamide, 20 TOLBUTAMIDE, 20 tolterodine tartrate, 25 tolterodine tartrate (extended release), 25 topiramate, 12 torsemide, 16


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TRACLEER, 11 tramadol hcl, 12 tranylcypromine sulfate, 14 trazodone hcl, 14 tretinoin, 24 tretinoin (chemotherapy), 7 triamcinolone acetonide (mouth), 24 triamcinolone acetonide (topical), 24 triamterene & hydrochlorothiazide, 16 triazolam, 13 trifluoperazine hcl, 14 trifluridine, 16 trihexyphenidyl hcl, 13 trimethoprim, 6 tropicamide, 18 trospium chloride, 25 TRUVADA, 5 TYKERB, 7 TYZEKA, 5

U

URICOSURIC AGENTS, 16 URINARY ANTI-INFECTIVES, 5 ursodiol, 18

V

VAGIFEM, 20 valacyclovir hcl, 5 valganciclovir, 5 valproate sodium, 12 valproic acid, 12 valsartan-hydrochlorothiazide, 10, 11 vancomycin hcl, 4 VASODILATING AGENTS, 11 VECTICAL, 25 venlafaxine hcl, 14 verapamil hcl, 10 VIAGRA, 11

VICTRELIS, 5 VIRACEPT, 5 VIRAZOLE, 5 VIREAD, 5 VITAMIN B COMPLEX, 25 VITAMIN D, 25 VITAMIN K ACTIVITY, 25 VITAMINS, 25 voriconazole, 4 VOTRIENT, 7

W

warfarin sodium, 8

X

XOPENEX HFA, 8 XTANDI, 7 XULANE, 20

Y

YODOXIN, 4

Z

zafirlukast, 22 zaleplon, 13 ZELBORAF, 7 ZENPEP, 18 zidovudine, 5 ziprasidone hcl, 14 ZOLINZA, 7 zolmitriptan, 13 zolpidem tartrate, 13 zonisamide, 12 ZYDELIG, 7 ZYTIGA, 7 ZYVOX, 4

kaiser permanente colorado ppo/pos preferred...

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