2020 northwest oregon medicaid formulary (list of covered ......no usp class (combination product)...

Last Updated 11/23/2020 ● Effec�ve 12/08/2020

2020 Northwest Oregon Medicaid Formulary (List of Covered Drugs)

Please Read: This document contains information about the drugs we cover when you

participate in a Kaiser Permanente Oregon Medicaid plan.

What is the Kaiser Permanente Northwest Oregon Medicaid Formulary?

A formulary is a list of covered drugs chosen by a group of Kaiser Permanente physicians and

pharmacists known as the Formulary and Therapeutics Committee. This committee meets regularly to

evaluate and select the safest, most effective medications for our members.

What drugs are covered? Our plan will generally cover the drugs listed on our formulary as long as the drug is medically

necessary, the prescription is filled at a Kaiser Permanente or an affiliated pharmacy, and other plan

rules are followed. Over-the-counter (OTC) medications are generally not listed on our formulary;

however, they are covered when prescribed and used to treat conditions funded by Oregon Health

Plan. Mental health drugs are covered directly by Oregon Health Plan, not by Kaiser Permanente.

What drugs are not covered? Drugs not listed on the formulary are not covered unless a Kaiser Permanente or affiliated physician

determines that the drug is medically necessary for you

What is a generic drug? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as

having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than

brand-name drugs.

What is a brand-name drug? Brand-name drugs are manufactured and sold by the pharmaceutical company that originally

researched and developed the drug. When the patent on a brand-name drug expires, other

pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug

with the same active ingredient(s) at lower prices.

Kaiser Permanente Formulary The formulary list that begins on the next page provides information about some of the drugs covered by our plan.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs are listed in lower-case italics (e.g. amoxicillin).

The second column will indicate any requirements or limits for that drug.

DS = A drug that is limited to no more than a 30-day supply per dispense.


PA = A drug that requires specific medical criteria be met and requires approval by the plan prior to being dispensed for benefit.


Drug Name Requirements/Limits

Analgesics

No USP Class (Combination Product)

acetaminophen-codeine #2 tabs 300-15 mg

acetaminophen-codeine #3 tabs 300-30 mg

acetaminophen-codeine soln 120-12 mg/5ml

hydrocodone-acetaminophen soln 7.5-325 mg/15ml DS

hydrocodone-acetaminophen tabs 10-325 mg DS

hydrocodone-acetaminophen tabs 5-325 mg DS

oxycodone-acetaminophen tabs 5-325 mg DS

Nonsteroidal Anti-Inflammatory Drugs

etodolac caps 300 mg

etodolac tabs 400 mg

ibuprofen tabs 800 mg

indomethacin caps 25 mg

indomethacin caps 50 mg

indomethacin er cpcr 75 mg

ketorolac tromethamine soln 30 mg/ml

meloxicam tabs 15 mg

meloxicam tabs 7.5 mg

nabumetone tabs 500 mg

nabumetone tabs 750 mg

naproxen tabs 250 mg



sulindac tabs 150 mg

sulindac tabs 200 mg

Opioid Analgesics, Long-Acting

fentanyl pt72 100 mcg/hr DS





methadone hcl conc 10 mg/ml DS

methadone hcl tabs 10 mg DS

methadone hcl tabs 5 mg DS

morphine sulfate (concentrate) soln 100 mg/5ml DS

morphine sulfate er tbcr 100 mg DS






morphine sulfate soln 10 mg/5ml DS

MORPHINE SULFATE TABS 15 MG DS

MORPHINE SULFATE TABS 30 MG DS

Opioid Analgesics, Short-Acting

codeine sulfate tabs 30 mg DS

codeine sulfate tabs 60 mg DS

hydromorphone hcl tabs 2 mg DS

hydromorphone hcl tabs 4 mg DS

morphine sulfate supp 10 mg DS



oxycodone hcl soln 5 mg/5 ml DS

oxycodone hcl tabs 5 mg DS

oxycodone hcl tabs 10 mg PA, DS

oxycodone hcl tabs 15 mg PA, DS

tramadol hcl tabs 50 mg

Anesthetics

Local Anesthetics

lidocaine hcl gel 2 %

lidocaine hcl soln 4 %

lidocaine hcl urethral/mucosal prsy 2 %

lidocaine viscous soln 2 %

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-Craving

acamprosate calcium tbec 333 mg

disulfiram tabs 250 mg


buprenorphine hcl-naloxone hcl subl 2-0.5 mg DS

buprenorphine hcl-naloxone hcl subl 8-2 mg DS

Opioid Antagonists

buprenorphine hcl subl 2 mg DS

buprenorphine hcl subl 8 mg DS

naloxone hcl sosy 2 mg/2ml

naltrexone hcl tabs 50 mg

NARCAN LIQD 4 MG/0.1ML

Smoking Cessation Agents

bupropion hcl er (smoking det) tb12 150 mg

CHANTIX STARTING MONTH PAK TABS 0.5 MG X 11 & 1 MG X 42 PA


CHANTIX TABS 0.5 MG PA

CHANTIX TABS 1 MG PA

gnp nicotine polacrilex lozg 2 mg

gnp nicotine polacrilex lozg 4 mg

nicotine kit 21-14-7 mg/24hr

nicotine polacrilex gum 2 mg

nicotine polacrilex gum 4 mg

nicotine pt24 14 mg/24hr



Antibacterials

Aminoglycosides

gentak oint 0.3 %

gentamicin sulfate crea 0.1 %

gentamicin sulfate oint 0.1 %

gentamicin sulfate soln 0.3 %

neomycin sulfate tabs 500 mg

paromomycin sulfate caps 250 mg

TOBI PODHALER CAPS 28 MG

tobramycin nebu 300 mg/5ml

tobramycin soln 0.3 %

Antibacterials, Other

acetic acid soln 2 %

bacitracin oint 500 unit/gm

clindamycin hcl caps 150 mg

clindamycin hcl caps 300 mg

clindamycin palmitate hcl solr 75 mg/5ml

clindamycin phosphate gel 1 %

clindamycin phosphate lotn 1 %

clindamycin phosphate soln 1 %

fosfomycin tromethamine pack 3 gm

linezolid susr 100 mg/5ml

linezolid tabs 600 mg

MACRODANTIN CAPS 25 MG

metronidazole crea 0.75 %

metronidazole gel 0.75 %

metronidazole tabs 250 mg

metronidazole tabs 500 mg

MONUROL PACK 3 GM

mupirocin oint 2 %


nitrofurantoin macrocrystal caps 100 mg

nitrofurantoin macrocrystal caps 50 mg

nitrofurantoin monohyd macro caps 100 mg

trimethoprim tabs 100 mg

vancomycin hcl caps 125 mg

vancomycin hcl caps 250 mg

vancomycin hcl solr 250 mg/5ml

Beta-Lactam, Cephalosporins

cefadroxil caps 500 mg

cefdinir caps 300 mg

cefdinir susr 125 mg/5ml

cefdinir susr 250 mg/5ml

cefixime caps 400 mg

cefpodoxime proxetil susr 100 mg/5ml

cefpodoxime proxetil tabs 200 mg

cefuroxime axetil tabs 250 mg

cefuroxime axetil tabs 500 mg

cephalexin caps 250 mg

cephalexin caps 500 mg

cephalexin susr 125 mg/5ml

cephalexin susr 250 mg/5ml

Beta-Lactam, Other

CAYSTON SOLR 75 MG DS

Beta-Lactam, Penicillins

amoxicillin caps 250 mg

amoxicillin caps 500 mg

amoxicillin susr 125 mg/5ml



amoxicillin-pot clavulanate chew 200-28.5 mg

amoxicillin-pot clavulanate chew 400-57 mg

amoxicillin-pot clavulanate susr 200-28.5 mg/5ml

amoxicillin-pot clavulanate susr 400-57 mg/5ml

amoxicillin-pot clavulanate susr 600-42.9 mg/5ml

amoxicillin-pot clavulanate tabs 500-125 mg

amoxicillin-pot clavulanate tabs 875-125 mg

dicloxacillin sodium caps 250 mg

dicloxacillin sodium caps 500 mg

penicillin v potassium solr 125 mg/5ml

penicillin v potassium solr 250 mg/5ml


penicillin v potassium tabs 250 mg

penicillin v potassium tabs 500 mg

Macrolides

azithromycin susr 100 mg/5ml

azithromycin susr 200 mg/5ml

azithromycin tabs 250 mg

azithromycin tabs 600 mg

clarithromycin tabs 500 mg

ery-tab tbec 250 mg

erythromycin ethylsuccinate susr 400 mg/5ml

erythromycin oint 5 mg/gm

erythromycin soln 2 %

Quinolones

ciprofloxacin hcl soln 0.3 %

ciprofloxacin hcl tabs 250 mg



levofloxacin soln 25 mg/ml

levofloxacin tabs 250 mg



moxifloxacin hcl soln 0.5 %

ofloxacin soln 0.3 %

Sulfonamides

silver sulfadiazine crea 1 %

sulfacetamide sodium soln 10 %

sulfadiazine tabs 500 mg

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml

sulfamethoxazole-trimethoprim tabs 400-80 mg

sulfamethoxazole-trimethoprim tabs 800-160 mg

Tetracyclines

doxycycline hyclate caps 100 mg

doxycycline hyclate caps 50 mg

doxycycline hyclate tabs 20 mg

doxycycline monohydrate tabs 100 mg

doxycycline monohydrate tabs 50 mg

minocycline hcl caps 100 mg

minocycline hcl caps 50 mg

Anticonvulsants

Anticonvulsants, Other


diazepam gel 2.5 mg

diazepam gel 10 mg

diazepam gel 20 mg

levetiracetam er tb24 500 mg

levetiracetam er tb24 750 mg

levetiracetam soln 100 mg/ml

levetiracetam tabs 1000 mg




Calcium Channel Modifying Agents

CELONTIN CAPS 300 MG

ethosuximide caps 250 mg

ethosuximide soln 250 mg/5ml

pregabalin caps 25 mg








pregabalin soln 20 mg/ml

zonisamide caps 100 mg



Gamma-Aminobutyric Acid (GABA) Augmenting Agents

clonazepam tabs 0.5 mg

clonazepam tabs 1 mg

clonazepam tabs 2 mg

divalproex sodium csdr 125 mg

divalproex sodium er tb24 250 mg

divalproex sodium er tb24 500 mg

divalproex sodium tbec 125 mg



gabapentin caps 100 mg



gabapentin tabs 600 mg


gabapentin tabs 800 mg

phenobarbital elix 20 mg/5ml

phenobarbital tabs 16.2 mg




primidone tabs 250 mg

primidone tabs 50 mg

tiagabine hcl tabs 2 mg




valproic acid caps 250 mg

valproic acid soln 250 mg/5ml

Glutamate Reducing Agents

lamotrigine chew 25 mg

lamotrigine chew 5 mg

lamotrigine tabs 100 mg




topiramate cpsp 15 mg

topiramate cpsp 25 mg

topiramate tabs 100 mg




Sodium Channel Agents

carbamazepine chew 100 mg

carbamazepine er cp12 100 mg



carbamazepine er tb12 100 mg



carbamazepine susp 100 mg/5ml

carbamazepine tabs 200 mg

dilantin caps 30 mg

oxcarbazepine susp 300 mg/5ml

oxcarbazepine tabs 150 mg




phenytoin chew 50 mg

phenytoin sodium extended caps 100 mg

phenytoin susp 125 mg/5ml

Antidementia Agents

Cholinesterase Inhibitors

donepezil hcl tabs 10 mg

donepezil hcl tabs 5 mg

galantamine hydrobromide er cp24 16 mg



galantamine hydrobromide tabs 12 mg



N-Methyl-D-Aspartate (NMDA) Receptor Antagonists

memantine hcl tabs 10 mg

memantine hcl tabs 5 mg

Antidepressants

Antidepressants, Other

aripiprazole tabs 10 mg






bupropion hcl er (sr) tb12 100 mg



bupropion hcl er (xl) tb24 150 mg

bupropion hcl er (xl) tb24 300 mg

bupropion hcl tabs 100 mg

bupropion hcl tabs 75 mg

mirtazapine tabs 15 mg



trazodone hcl tabs 50 mg



Monoamine Oxidase Inhibitors


phenelzine sulfate tabs 15 mg

tranylcypromine sulfate tabs 10 mg

Serotonin/Norepinephrine Reuptake Inhibitors

citalopram hydrobromide soln 10 mg/5ml

citalopram hydrobromide tabs 10 mg



desvenlafaxine succinate er tb24 25 mg



duloxetine hcl cpep 20 mg



escitalopram oxalate tabs 10 mg



fluoxetine hcl caps 10 mg



fluoxetine hcl soln 20 mg/5ml

fluvoxamine maleate tabs 100 mg



paroxetine hcl tabs 10 mg




sertraline hcl tabs 100 mg



venlafaxine hcl er cp24 150 mg

venlafaxine hcl er cp24 37.5 mg

venlafaxine hcl er cp24 75 mg

venlafaxine hcl tabs 100 mg


venlafaxine hcl tabs 37.5 mg



Tricyclics

amitriptyline hcl tabs 10 mg







desipramine hcl tabs 10 mg






doxepin hcl caps 10 mg



doxepin hcl conc 10 mg/ml

nortriptyline hcl caps 10 mg




protriptyline hcl tabs 10 mg

protriptyline hcl tabs 5 mg

Antiemetics

Antiemetics, Other

chlorpromazine hcl tabs 10 mg





hydroxyzine hcl soln 10 mg/5ml

hydroxyzine hcl soln 50 mg/ml

hydroxyzine hcl tabs 10 mg



hydroxyzine pamoate caps 25 mg

hydroxyzine pamoate caps 50 mg

metoclopramide hcl soln 5 mg/5ml

metoclopramide hcl tabs 10 mg

metoclopramide hcl tabs 5 mg

perphenazine tabs 16 mg





prochlorperazine maleate tabs 10 mg

prochlorperazine maleate tabs 5 mg

prochlorperazine supp 25 mg

promethazine hcl syrp 6.25 mg/5ml

promethazine hcl tabs 25 mg

promethegan supp 12.5 mg

promethegan supp 25 mg

scopolamine pt72 1 mg/3days

Emetogenic Therapy Adjuncts

AKYNZEO CAPS 300-0.5 MG DS

ondansetron hcl tabs 4 mg

ondansetron hcl tabs 8 mg

ondansetron tbdp 4 mg

ondansetron tbdp 8 mg

Antifungals

clotrimazole troc 10 mg

fluconazole tabs 100 mg




FLUCYTOSINE CAPS 250 MG

FLUCYTOSINE CAPS 500 MG

griseofulvin microsize susp 125 mg/5ml

griseofulvin ultramicrosize tabs 125 mg

griseofulvin ultramicrosize tabs 250 mg

ketoconazole crea 2 %

ketoconazole sham 2 %

ketoconazole tabs 200 mg

NATACYN SUSP 5 %

NOXAFIL SUSP 40 MG/ML

nystatin crea 100000 unit/gm

nystatin oint 100000 unit/gm

nystatin susp 100000 unit/ml

nystop powd 100000 unit/gm

posaconazole tbec 100 mg

terbinafine hcl tabs 250 mg

voriconazole tabs 200 mg

voriconazole tabs 50 mg


Antigout Agents

allopurinol tabs 100 mg

allopurinol tabs 300 mg

probenecid tabs 500 mg

colchicine-probenecid tabs 0.5-500 mg

Antimigraine Agents

Ergot Alkaloids

dihydroergotamine mesylate soln 1 mg/ml DS

dihydroergotamine mesylate soln 4 mg/ml


MIGERGOT SUPP 2-100 MG

Serotonin (5-HT) 1B/1D Receptor Agonists

naratriptan hcl tabs 1 mg

naratriptan hcl tabs 2.5 mg

rizatriptan benzoate tabs 10 mg

rizatriptan benzoate tabs 5 mg

rizatriptan benzoate tbdp 10 mg

rizatriptan benzoate tbdp 5 mg

sumatriptan soln 20 mg/act

sumatriptan succinate refill soct 6 mg/0.5ml

sumatriptan succinate soaj 6 mg/0.5ml

sumatriptan succinate soln 6 mg/0.5ml

sumatriptan succinate tabs 100 mg



Antimyasthenic Agents

Parasympathomimetics

pyridostigmine bromide er tbcr 180 mg

pyridostigmine bromide tabs 60 mg

Antimycobacterials

Antimycobacterials, Other

dapsone tabs 100 mg

dapsone tabs 25 mg

rifabutin caps 150 mg

Antituberculars

ethambutol hcl tabs 100 mg

ethambutol hcl tabs 400 mg

isoniazid syrp 50 mg/5ml

isoniazid tabs 100 mg

isoniazid tabs 300 mg


PRETOMANID TABS 200 MG

pyrazinamide tabs 500 mg

rifamate caps 150-300 mg

rifampin caps 150 mg

rifampin caps 300 mg

TRECATOR TABS 250 MG

Antineoplastics

Alkylating Agents

cyclophosphamide caps 25 mg

cyclophosphamide caps 50 mg

GLEOSTINE CAPS 10 MG



HEXALEN CAPS 50 MG DS

LEUKERAN TABS 2 MG

LOMUSTINE CAPS 100 MG

MATULANE CAPS 50 MG DS

melphalan tabs 2 mg

MYLERAN TABS 2 MG

temozolomide caps 100 mg






Antiangiogenic Agents

REVLIMID CAPS 2.5 MG DS

REVLIMID CAPS 5 MG DS





Antiestrogens/Modifiers

tamoxifen citrate tabs 10 mg

tamoxifen citrate tabs 20 mg

Antimetabolites

capecitabine tabs 150 mg DS

capecitabine tabs 500 mg DS

hydroxyurea caps 500 mg

LONSURF TABS 15-6.14 MG DS


LONSURF TABS 20-8.19 MG DS

PURIXAN SUSP 2000 MG/100ML DS

TABLOID TABS 40 MG

Antineoplastics, Other

etoposide caps 50 mg

JAKAFI TABS 10 MG DS




JAKAFI TABS 5 MG DS

leucovorin calcium tabs 25 mg

leucovorin calcium tabs 5 mg

ODOMZO CAPS 200 MG PA, DS

Aromatase Inhibitors, 3rd Generation

anastrozole tabs 1 mg

letrozole tabs 2.5 mg

Enzyme Inhibitors

ALECENSA CAPS 150 MG DS

COPIKTRA CAPS 15 MG PA, DS

COPIKTRA CAPS 25 MG PA, DS

COTELLIC TABS 20 MG DS

IBRANCE TABS 75 MG DS



IRESSA TABS 250 MG DS

LENVIMA 4 MG DAILY DOSE CPPK 4 MG PA, DS

LENVIMA 10 MG DAILY DOSE CPPK 10 MG PA, DS

LENVIMA 12 MG DAILY DOSE CPPK 3 X 4 MG PA, DS

LENVIMA 14 MG DAILY DOSE CPPK 10 & 4 MG PA, DS

LENVIMA 20 MG DAILY DOSE CPPK 10 (2) MG PA, DS

LENVIMA 24 MG DAILY DOSE CPPK 10 (2) & 4 MG PA, DS

LORBRENA TABS 25 MG PA, DS

LORBRENA TABS 100 MG PA, DS

LYNPARZA TABS 100 MG DS

LYNPARZA TABS 150 MG DS

MEKINIST TABS 0.5 MG DS

MEKINIST TABS 2 MG DS

NINLARO CAPS 2.3 MG DS

NINLARO CAPS 3 MG DS

NINLARO CAPS 4 MG DS


ROZLYTREK CAPS 100 MG DS

ROZLYTREK CAPS 200 MG DS

RYDAPT CAPS 25 MG DS

TAFINLAR CAPS 50 MG DS

TAFINLAR CAPS 75 MG DS

TAGRISSO TABS 40 MG DS

TAGRISSO TABS 80 MG DS

VELCADE SOLR 3.5 MG

ZEJULA CAPS 100 MG DS

Molecular Target Inhibitors

AFINITOR TABS 10 MG DS

erlotinib hcl tabs 25 mg DS



everolimus tabs 2.5 mg DS

everolimus tabs 5 mg DS

everolimus tabs 7.5 mg DS

imatinib mesylate tabs 100 mg

imatinib mesylate tabs 400 mg

IMBRUVICA CAPS 140 MG DS

IMBRUVICA TABS 140 MG DS




NEXAVAR TABS 200 MG DS

SPRYCEL TABS 100 MG DS





SUTENT CAPS 12.5 MG DS

SUTENT CAPS 25 MG DS

SUTENT CAPS 50 MG DS

TUKYSA TABS 50 MG PA, DS

TUKYSA TABS 150 MG PA, DS

TYKERB TABS 250 MG DS

VOTRIENT TABS 200 MG DS

ZELBORAF TABS 240 MG DS

Monoclonal Antibodies

HERCEPTIN SOLR 440 MG


No USP Class

MESNEX TABS 400 MG DS

XTANDI CAPS 40 MG DS

Retinoids

RETIN-A CREA 0.025 %

RETIN-A CREA 0.05 %

RETIN-A CREA 0.1 %

RETIN-A GEL 0.01 %

RETIN-A GEL 0.025 %

RETIN-A MICRO GEL 0.1 %

tretinoin caps 10 mg DS

Antiparasitics

Anthelmintics

albendazole tabs 200 mg DS

ivermectin tabs 3 mg

praziquantel tabs 600 mg

Antiprotozoals

ALINIA SUSR 100 MG/5ML

atovaquone susp 750 mg/5ml

atovaquone-proguanil hcl tabs 250-100 mg

atovaquone-proguanil hcl tabs 62.5-25 mg

chloroquine phosphate tabs 500 mg PA

COARTEM TABS 20-120 MG

DARAPRIM TABS 25 MG DS

hydroxychloroquine sulfate tabs 200 mg PA

KRINTAFEL TABS 150 MG

mefloquine hcl tabs 250 mg

primaquine phosphate tabs 26.3 mg

YODOXIN TABS 650 MG

Pediculicides/Scabicides

permethrin crea 5 %

Antiparkinson Agents

Anticholinergics

benztropine mesylate tabs 0.5 mg

benztropine mesylate tabs 1 mg

benztropine mesylate tabs 2 mg

trihexyphenidyl hcl tabs 2 mg

trihexyphenidyl hcl tabs 5 mg

Antiparkinson Agents, Other

amantadine hcl caps 100 mg


amantadine hcl syrp 50 mg/5ml

amantadine hcl tabs 100 mg

entacapone tabs 200 mg

Dopamine Agonists

bromocriptine mesylate tabs 2.5 mg

pramipexole dihydrochloride tabs 0.125 mg




pramipexole dihydrochloride tabs 1 mg


ropinirole hcl tabs 0.25 mg

ropinirole hcl tabs 0.5 mg

ropinirole hcl tabs 1 mg





Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

carbidopa-levodopa er tbcr 25-100 mg

carbidopa-levodopa er tbcr 50-200 mg

carbidopa-levodopa tabs 10-100 mg



LODOSYN TABS 25 MG

Monoamine Oxidase B (MAO-B) Inhibitors

selegiline hcl caps 5 mg


carbidopa-levodopa-entacapone tabs 12.5-50-200 mg


carbidopa-levodopa-entacapone tabs 25-100-200 mg



carbidopa-levodopa-entacapone tabs 50-200-200 mg

Antipsychotics

1st Generation/Typical

fluphenazine hcl tabs 1 mg


fluphenazine hcl tabs 2.5 mg



haloperidol lactate conc 2 mg/ml

haloperidol tabs 0.5 mg

haloperidol tabs 1 mg




loxapine succinate caps 10 mg




molindone hcl tabs 25 mg

thiothixene caps 1 mg




trifluoperazine hcl tabs 1 mg




2nd Generation/Atypical

LATUDA TABS 20 MG PA





olanzapine tabs 10 mg


olanzapine tabs 2.5 mg



olanzapine tabs 7.5 mg

quetiapine fumarate er tb24 50 mg




quetiapine fumarate tabs 100 mg







risperidone soln 1 mg/ml

risperidone tabs 0.25 mg

risperidone tabs 0.5 mg

risperidone tabs 1 mg




ziprasidone hcl caps 20 mg




Treatment-Resistant

clozapine tabs 100 mg




Antispasticity Agents

baclofen tabs 10 mg

baclofen tabs 20 mg

dantrolene sodium caps 100 mg



tizanidine hcl tabs 2 mg

tizanidine hcl tabs 4 mg

Antivirals

Anti-Cytomegalovirus (CMV) Agents

PREVYMIS TABS 240 MG DS

PREVYMIS TABS 480 MG DS

valganciclovir hcl solr 50 mg/ml

valganciclovir hcl tabs 450 mg

Antihepatitis Agents

adefovir dipivoxil tabs 10 mg

entecavir tabs 0.5 mg

entecavir tabs 1 mg

EPCLUSA TABS 400-100 MG DS

HARVONI TABS 45-200 MG DS

HARVONI TABS 90-400 MG DS

INTRON A SOLN 10000000 UNIT/ML DS

PEGASYS PROCLICK SOLN 180 MCG/0.5ML DS


PEGASYS SOLN 180 MCG/0.5ML DS

PEGINTRON KIT 50 MCG/0.5ML

PEGINTRON KIT 80 MCG

PEG-INTRON REDIPEN PAK 4 KIT 80 MCG RP

PEG-INTRON REDIPEN KIT 120 MCG/0.5ML

ribavirin caps 200 mg

SOVALDI TABS 400 MG DS

VOSEVI TABS 400-100-100 MG DS

Antiherpetic Agents

acyclovir caps 200 mg

acyclovir susp 200 mg/5ml

acyclovir tabs 400 mg

acyclovir tabs 800 mg

trifluridine soln 1 %

Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors

EDURANT TABS 25 MG

efavirenz caps 50 mg

efavirenz caps 200 mg

efavirenz tabs 600 mg

INTELENCE TABS 100 MG

INTELENCE TABS 200 MG

nevirapine tabs 200 mg

PIFELTRO TABS 100 MG

RESCRIPTOR TABS 100 MG

RESCRIPTOR TABS 200 MG

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors

abacavir sulfate tabs 300 mg

abacavir sulfate-lamivudine tabs 600-300 mg

abacavir-lamivudine-zidovudine tabs 300-150-300 mg

didanosine cpdr 200 mg



EMTRIVA SOLN 10 MG/ML

lamivudine soln 10 mg/ml

lamivudine tabs 100 mg



lamivudine-zidovudine tabs 150-300 mg

tenofovir disoproxil fumarate tabs 300 mg

TRUVADA TABS 200-300 MG


VIREAD POWD 40 MG/GM

VIREAD TABS 150 MG

ZIAGEN SOLN 20 MG/ML

zidovudine caps 100 mg

zidovudine syrp 50 mg/5ml

zidovudine tabs 300 mg

Anti-HIV Agents, Other

FUZEON SOLR 90 MG DS

ISENTRESS CHEW 100 MG

ISENTRESS CHEW 25 MG

ISENTRESS PACK 100 MG

ISENTRESS TABS 400 MG

ISENTRESS HD TABS 600 MG

JULUCA TABS 50-25 MG

SELZENTRY TABS 25 MG




SYMTUZA TABS 800-150-200-10 MG

TIVICAY TABS 50 MG

Anti-HIV Agents, Protease Inhibitors

atazanavir sulfate caps 150 mg



EVOTAZ TABS 300-150 MG

KALETRA TABS 100-25 MG

KALETRA TABS 200-50 MG

lopinavir-ritonavir soln 400-100 mg/5ml

NORVIR SOLN 80 MG/ML

PREZCOBIX TABS 800-150 MG

PREZISTA TABS 150 MG


PREZISTA TABS 75 MG


ritonavir tabs 100 mg

VIRACEPT TABS 250 MG

VIRACEPT TABS 625 MG

Anti-Influenza Agents

oseltamivir phosphate caps 30 mg

oseltamivir phosphate caps 75 mg


oseltamivir phosphate susr 6 mg/ml

RELENZA DISKHALER AEPB 5 MG/BLISTER

rimantadine hcl tabs 100 mg


ATRIPLA TABS 600-200-300 MG

BIKTARVY TABS 50-200-25 MG

COMPLERA TABS 200-25-300 MG PA

DESCOVY TABS 200-25 MG PA

DOVATO TABS 50-300 MG

efavirenz-emtricitab-tenofovir tabs 600-200-300 mg

GENVOYA TABS 150-150-200-10 MG

ODEFSEY TABS 200-25-25 MG

STRIBILD TABS 150-150-200-300 MG PA

SYMFI TABS 600-300-300 MG

TRIUMEQ TABS 600-50-300 MG

Anxiolytics

Anxiolytics, Other

alprazolam tabs 0.25 mg

alprazolam tabs 0.5 mg

alprazolam tabs 1 mg

alprazolam tabs 2 mg

buspirone hcl tabs 5 mg

buspirone hcl tabs 7.5 mg




chlordiazepoxide hcl caps 10 mg



clorazepate dipotassium tabs 15 mg

clorazepate dipotassium tabs 3.75 mg

clorazepate dipotassium tabs 7.5 mg

diazepam intensol conc 5 mg/ml

diazepam tabs 10 mg

diazepam tabs 2 mg

diazepam tabs 5 mg

lorazepam tabs 0.5 mg

lorazepam tabs 1 mg

lorazepam tabs 2 mg

midazolam hcl soln 10 mg/2ml


midazolam hcl syrp 2 mg/ml

oxazepam caps 10 mg

oxazepam caps 15 mg

oxazepam caps 30 mg

Bipolar Agents

Mood Stabilizers

lithium carbonate caps 150 mg



lithium carbonate er tbcr 300 mg

lithium carbonate er tbcr 450 mg

Blood Glucose Regulators

Antidiabetic Agents

acarbose tabs 100 mg

acarbose tabs 50 mg

glimepiride tabs 1 mg



glipizide tabs 5 mg

glipizide tabs 10 mg

glyburide tabs 1.25 mg

glyburide tabs 2.5 mg

glyburide tabs 5 mg

INVOKANA TABS 100 MG PA

JARDIANCE TABS 25 MG PA

metformin hcl er tb24 500 mg

metformin hcl er tb24 750 mg

metformin hcl tabs 1000 mg



OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN 2 MG/1.5ML PA

OZEMPIC (1 MG/DOSE) SOPN 2 MG/1.5ML PA

pioglitazone hcl tabs 15 mg



repaglinide tabs 0.5 mg

repaglinide tabs 1 mg

repaglinide tabs 2 mg

tolazamide tabs 250 mg

tolazamide tabs 500 mg


tolbutamide tabs 500 mg

VICTOZA SOPN 18 MG/3ML PA

Glycemic Agents

BAQSIMI ONE PACK POWD 3 MG/DOSE

GLUCAGON EMERGENCY KIT 1 MG

GVOKE PFS SOSY 0.5 MG/0.1ML

Insulins

HUMALOG SOLN 100 UNIT/ML PA

HUMULIN 70/30 SUSP (70-30) 100 UNIT/ML

HUMULIN N SUSP 100 UNIT/ML

HUMULIN R SOLN 100 UNIT/ML

LANTUS SOLN 100 UNIT/ML PA

Blood Products/Modifiers/Volume Expanders

Anticoagulants

enoxaparin sodium soln 100 mg/ml DS

enoxaparin sodium soln 120 mg/0.8ml DS

enoxaparin sodium soln 150 mg/ml DS


enoxaparin sodium soln 300 mg/3ml DS




PRADAXA CAPS 75 MG

PRADAXA CAPS 110 MG

PRADAXA CAPS 150 MG

warfarin sodium tabs 1 mg



warfarin sodium tabs 2.5 mg





warfarin sodium tabs 7.5 mg

XARELTO TABS 2.5 MG PA

XARELTO TABS 10 MG PA



Blood Formation Modifiers

anagrelide hcl caps 0.5 mg


PROCRIT SOLN 2000 UNIT/ML DS






PROMACTA TABS 25 MG PA, DS



VENOFER SOLN 20 MG/ML

ZARXIO SOSY 300 MCG/0.5ML DS

ZARXIO SOSY 480 MCG/0.8ML DS

Coagulants

aminocaproic acid tabs 500 mg

BENEFIX KIT 250 UNIT DS





HEMLIBRA SOLN 30 MG/ML DS

HEMLIBRA SOLN 60 MG/0.4ML DS

HEMLIBRA SOLN 105 MG/0.7ML DS

HEMLIBRA SOLN 150 MG/ML DS

HUMATE-P SOLR 1000-2400 UNIT PA, DS



KOVALTRY SOLR 250 UNIT DS





phytonadione tabs 5 mg

Platelet Modifying Agents

aspirin-dipyridamole er cp 12 25-200 mg

BRILINTA TABS 60 MG PA

BRILINTA TABS 90 MG PA

cilostazol tabs 100 mg

cilostazol tabs 50 mg

clopidogrel bisulfate tabs 75 mg

dipyridamole tabs 25 mg




prasugrel hcl tabs 5 mg

prasugrel hcl tabs 10 mg

Cardiovascular Agents

Alpha-Adrenergic Agonists

clonidine hcl tabs 0.1 mg



guanfacine hcl tabs 1 mg

guanfacine hcl tabs 2 mg

methyldopa tabs 250 mg

methyldopa tabs 500 mg

midodrine hcl tabs 2.5 mg

midodrine hcl tabs 5 mg

midodrine hcl tabs 10 mg

Alpha-Adrenergic Blocking Agents

doxazosin mesylate tabs 1 mg




phenoxybenzamine hcl caps 10 mg

prazosin hcl caps 1 mg



terazosin hcl caps 1 mg




Angiotensin II Receptor Antagonists

losartan potassium tabs 100 mg



valsartan tabs 160 mg




Angiotensin-Converting Enzyme (ACE) Inhibitors

benazepril hcl tabs 10 mg





EPANED SOLR 1 MG/ML

lisinopril tabs 10 mg

lisinopril tabs 2.5 mg





Antiarrhythmics

amiodarone hcl tabs 200 mg

disopyramide phosphate caps 100 mg

disopyramide phosphate caps 150 mg

dofetilide caps 125 mcg



flecainide acetate tabs 100 mg



mexiletine hcl caps 150 mg



NORPACE CR CP12 100 MG

NORPACE CR CP12 150 MG

propafenone hcl tabs 150 mg



quinidine gluconate er tbcr 324 mg

quinidine sulfate tabs 200 mg

Beta-Adrenergic Blocking Agents

acebutolol hcl caps 200 mg

acebutolol hcl caps 400 mg

atenolol tabs 100 mg DS



bisoprolol fumarate tabs 10 mg

bisoprolol fumarate tabs 5 mg

carvedilol tabs 12.5 mg

carvedilol tabs 25 mg




labetalol hcl tabs 100 mg



metoprolol succinate er tb24 25 mg




metoprolol tartrate tabs 100 mg



nadolol tabs 20 mg

nadolol tabs 40 mg

nadolol tabs 80 mg

propranolol hcl soln 20 mg/5ml

propranolol hcl tabs 10 mg





propranolol hcl er cp24 60 mg




sotalol hcl (af) tabs 120 mg



sotalol hcl tabs 120 mg



SOTYLIZE SOLN 5 MG/ML

Calcium Channel Blocking Agents

amlodipine besylate tabs 10 mg

amlodipine besylate tabs 2.5 mg

amlodipine besylate tabs 5 mg

diltiazem hcl tabs 120 mg




dilt-xr cp24 120 mg


dilt-xr cp24 180 mg

dilt-xr cp24 240 mg

KATERZIA SUSP 1 MG/ML PA

nifedipine er osmotic release tb24 30 mg



nifedipine er tb24 90 mg

nimodipine caps 30 mg

verapamil hcl er tbcr 180 mg

verapamil hcl er tbcr 240 mg

verapamil hcl tabs 40 mg



Cardiovascular Agents, Other

DIGOXIN SOLN 0.05 MG/ML

digoxin tabs 125 mcg

digoxin tabs 250 mcg

pentoxifylline er tbcr 400 mg

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide er cp12 500 mg

acetazolamide tabs 125 mg

acetazolamide tabs 250 mg

methazolamide tabs 50 mg

Diuretics, Loop

bumetanide tabs 0.5 mg

bumetanide tabs 1 mg

bumetanide tabs 2 mg

ethacrynic acid tabs 25 mg PA

furosemide soln 10 mg/ml

furosemide tabs 20 mg



torsemide tabs 10 mg



Diuretics, Potassium-Sparing

amiloride hcl tabs 5 mg

CAROSPIR SUSP 25 MG/5ML

spironolactone tabs 100 mg




Diuretics, Thiazide

chlorthalidone tabs 25 mg

chlorthalidone tabs 50 mg

DIURIL SUSP 250 MG/5ML

hydrochlorothiazide tabs 12.5 mg

hydrochlorothiazide tabs 25 mg

hydrochlorothiazide tabs 50 mg

indapamide tabs 1.25 mg

indapamide tabs 2.5 mg

metolazone tabs 2.5 mg

metolazone tabs 5 mg

metolazone tab 10 mg

Dyslipidemics, Fibric Acid Derivatives

fenofibrate tabs 160 mg

fenofibrate tabs 54 mg

gemfibrozil tabs 600 mg

Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium tabs 10 mg




lovastatin tabs 10 mg



pravastatin sodium tabs 10 mg




rosuvastatin calcium tabs 5 mg




simvastatin tabs 10 mg




Dyslipidemics, Other

cholestyramine pack 4 gm

cholestyramine powd 4 gm/dose


colestipol hcl gran 5 gm

colestipol hcl tabs 1 gm

ezetimibe tabs 10 mg

niacin tabs 100 mg

niacin tabs 500 mg

niacin er (antihyperlipidemic) tbcr 500 mg

prevalite powd 4 gm/dose


atenolol-chlorthalidone tabs 100-25 mg

atenolol-chlorthalidone tabs 50-25 mg

bisoprolol-hydrochlorothiazide tabs 10-6.25 mg

bisoprolol-hydrochlorothiazide tabs 2.5-6.25 mg

bisoprolol-hydrochlorothiazide tabs 5-6.25 mg

lisinopril-hydrochlorothiazide tabs 10-12.5 mg

lisinopril-hydrochlorothiazide tabs 20-12.5 mg

lisinopril-hydrochlorothiazide tabs 20-25 mg

losartan potassium-hctz tabs 100-12.5 mg

losartan potassium-hctz tabs 100-25 mg

losartan potassium-hctz tabs 50-12.5 mg

spironolactone-hctz tabs 25-25 mg

triamterene-hctz tabs 37.5-25 mg

triamterene-hctz tabs 75-50 mg

valsartan-hydrochlorothiazide tabs 80-12.5 mg


valsartan-hydrochlorothiazide tabs 160-25 mg


valsartan-hydrochlorothiazide tabs 320-25 mg

Vasodilators, Direct-Acting Arterial

hydralazine hcl tabs 10 mg




Vasodilators, Direct-Acting Arterial/Venous

isosorbide dinitrate er tbcr 40 mg

isosorbide dinitrate tabs 10 mg




isosorbide mononitrate er tb24 120 mg




nitro-bid oint 2 %

nitroglycerin pt24 0.1 mg/hr




nitroglycerin subl 0.3 mg



Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine-dextroamphetamine tabs 5 mg

amphetamine-dextroamphetamine tabs 7.5 mg


amphetamine-dextroamphetamine tabs 12.5 mg




amphetamine-dextroamphet er cp24 5 mg






dextroamphetamine sulfate er cp24 5 mg PA



dextroamphetamine sulfate tabs 5 mg

dextroamphetamine sulfate tabs 10 mg

Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines

atomoxetine hcl caps 10 mg







dexmethylphenidate hcl er cp24 10 mg









dexmethylphenidate hcl tabs 10 mg

dexmethylphenidate hcl tabs 2.5 mg

dexmethylphenidate hcl tabs 5 mg

guanfacine hcl er tb24 1 mg




methylphenidate hcl er (cd) cpcr 10 mg






methylphenidate hcl er tbcr 10 mg






methylphenidate hcl tabs 10 mg



Central Nervous System Agents, Other

riluzole tabs 50 mg

Ergot Alkaloids

CAFERGOT TABS 1-100 MG

Multiple Sclerosis Agents

AVONEX KIT 30 MCG PA, DS

AVONEX PEN AJKT 30 MCG/0.5ML PA, DS

AVONEX PREFILLED PSKT 30 MCG/0.5ML PA, DS

dalfampridine er tb12 10 mg

EXTAVIA KIT 0.3 MG DS

glatopa sosy 20 mg/ml DS

No USP Class

ketorolac tromethamine soln 60 mg/2ml


Dental and Oral Agents

chlorhexidine gluconate soln 0.12 %

denta 5000 plus crea 1.1 %

pilocarpine hcl tabs 5 mg

PREVIDENT GEL 1.1 %

Dermatological Agents

acitretin caps 10 mg DS

acitretin caps 25 mg DS

adapalene gel 0.1 %

adapalene gel 0.3 %

azelaic acid gel 15 %

AZELEX CREA 20 %

betamethasone dipropionate aug gel 0.05 %

calcipotriene soln 0.005 %

claravis caps 10 mg DS




COSENTYX SENSOREADY PEN SOAJ 150 MG/ML PA, DS

COSENTYX SOSY 150 MG/ML PA, DS

DIFFERIN CREA 0.1 %

DRITHO-CRÈME HP CREA 1 %

DRYSOL SOLN 20 %

fluocinolone acetonide scalp oil 0.01%

fluorouracil crea 5 %

fluorouracil soln 2 %

fluorouracil soln 5 %

hydrocortisone lotn 2.5 %

imiquimod crea 5 %

methoxsalen rapid caps 10 mg

nystatin-triamcinolone crea 100000-0.1 unit/gm-%

nystatin-triamcinolone oint 100000-0.1 unit/gm-%

pimecrolimus crea 1 %

podofilox soln 0.5 %

RECTIV OINT 0.4 %

SANTYL OINT 250 UNIT/GM

selenium sulfide lotn 2.5 %

STELARA SOLN 130 MG/26ML PA

STELARA SOSY 45 MG/0.5ML PA

STELARA SOSY 90 MG/ML PA


sulfacetamide sodium-sulfur emul 10-5 %

tacrolimus oint 0.03 %

tacrolimus oint 0.1 %

tazarotene crea 0.1 %

TAZORAC CREA 0.05 %

TAZORAC GEL 0.05 %

TAZORAC GEL 0.1 %

VECTICAL OINT 3 MCG/GM

XERAC AC SOLN 6.25 %

Enzyme Replacement/Modifiers

CERDELGA CAPS 84 MG DS

ZENPEP CPEP 5000-24000 UNIT






Gastrointestinal Agents

Antispasmodics, Gastrointestinal

dicyclomine hcl caps 10 mg

dicyclomine hcl soln 10 mg/5ml

dicyclomine hcl tabs 20 mg

glycopyrrolate tabs 1 mg

glycopyrrolate tabs 2 mg

Gastrointestinal Agents, Other

diphenoxylate-atropine liqd 2.5-0.025 mg/5ml

diphenoxylate-atropine tabs 2.5-0.025 mg

propantheline bromide tabs 15 mg

READI-CAT 2 SUSP 2 %

ursodiol tabs 250 mg

ursodiol tabs 500 mg

Histamine-2 (H2) Receptor Antagonists

cimetidine hcl soln 300 mg/5ml

famotidine susr 40 mg/5ml

ranitidine hcl tabs 300 mg

Irritable Bowel Syndrome Agents

mesalamine enem 4 gm

salsalate tabs 500 mg

salsalate tabs 750 mg

Laxatives


gavilyte-c solr 240 gm

lactulose soln 10 gm/15ml

Protectants

misoprostol tabs 100 mcg

misoprostol tabs 200 mcg

sucralfate tabs 1 gm

Proton Pump Inhibitors

pantoprazole sodium tbec 20 mg

pantoprazole sodium tbec 40 mg

Genitourinary Agents

Antispasmodics, Urinary

oxybutynin chloride er tb24 10 mg



oxybutynin chloride syrp 5 mg/5ml

oxybutynin chloride tabs 5 mg

solifenacin succinate tabs 5 mg

solifenacin succinate tabs 10 mg

tolterodine tartrate tabs 1 mg

tolterodine tartrate tabs 2 mg

trospium chloride tabs 20 mg

Benign Prostatic Hypertrophy Agents

finasteride tabs 5 mg

tamsulosin hcl caps 0.4 mg

Genitourinary Agents, Other

bethanechol chloride tabs 5 mg



DEPEN TITRATABS TABS 250 MG

ELMIRON CAPS 100 MG

No USP Class

methylergonovine maleate tabs 0.2 mg

Phosphate Binders

calcium acetate (phos binder) caps 667 mg

PHOSLYRA SOLN 667 MG/5ML

sevelamer carbonate pack 0.8 gm

sevelamer carbonate pack 2.4 gm

sevelamer carbonate tabs 800 mg

sevelamer hcl tabs 800 mg

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)


Glucocorticoids/Mineralocorticoids

alclometasone dipropionate crea 0.05 %

alclometasone dipropionate oint 0.05 %

betamethasone dipropionate aug crea 0.05 %

betamethasone dipropionate aug oint 0.05 %

betamethasone dipropionate crea 0.05 %

betamethasone dipropionate lotn 0.05 %

betamethasone dipropionate oint 0.05 %

betamethasone valerate crea 0.1 %

betamethasone valerate lotn 0.1 %

betamethasone valerate oint 0.1 %

budesonide cpep 3 mg

clobetasol propionate e crea 0.05 %

clobetasol propionate lotn 0.05 %

clobetasol propionate oint 0.05 %

clobetasol propionate soln 0.05 %

CLOBEX SHAM 0.05 %

CLOBEX SPRAY LIQD 0.05 %

colocort enem 100 mg/60ml

CORDRAN TAPE 4 MCG/SQCM

desoximetasone crea 0.25 %

dexamethasone elix 0.5 mg/5ml

dexamethasone intensol conc 1 mg/ml

dexamethasone soln 0.5 mg/5ml

dexamethasone tabs 0.5 mg



dexamethasone tabs 4 mg

fludrocortisone acetate tabs 0.1 mg

fluocinolone acetonide crea 0.01 %

fluocinolone acetonide crea 0.025 %

fluocinolone acetonide oint 0.025 %

fluocinolone acetonide soln 0.01 %

fluocinonide gel 0.05 %

fluocinonide oint 0.05 %

fluocinonide soln 0.05 %

hydrocortisone butyr lipo base crea 0.1 %

hydrocortisone crea 2.5 %

hydrocortisone enem 100 mg/60ml

hydrocortisone oint 2.5 %


hydrocortisone tabs 10 mg



mometasone furoate crea 0.1 %

mometasone furoate oint 0.1 %

mometasone furoate soln 0.1 %

prednicarbate crea 0.1 %

prednisolone sodium phosphate soln 15 mg/5ml

prednisone tabs 1 mg


prednisone tabs 2.5 mg




prednisone tbpk 5 mg (21)

SOLU-CORTEF SOLR 100 MG

triamcinolone acetonide aers 0.147 mg/gm

triamcinolone acetonide crea 0.025 %



triamcinolone acetonide oint 0.025 %



triamcinolone acetonide pste 0.1 %

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

desmopressin acetate spray soln 0.01 %

desmopressin acetate tabs 0.1 mg

desmopressin acetate tabs 0.2 mg

chorionic gonadotropin solr 10000 unit

OMNITROPE SOLN 10 MG/1.5ML DS

OMNITROPE SOLN 5 MG/1.5ML DS

OMNITROPE SOLR 5.8 MG DS

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Androgens

danazol caps 100 mg

danazol caps 200 mg

danazol caps 50 mg

DEPO-TESTOSTERONE SOLN 100 MG/ML PA

DEPO-TESTOSTERONE SOLN 200 MG/ML PA

methitest tabs 10 mg


testosterone enanthate soln 200 mg/ml PA

testosterone gel 25 mg/2.5gm (1%) PA

testosterone gel 50 mg/5gm (1%) PA

Estrogens

CLIMARA PTWK 0.025 MG/24HR






depo-estradiol oil 5 mg/ml

estradiol crea 0.1 mg/gm

estradiol tabs 0.5 mg

estradiol tabs 1 mg

estradiol tabs 2 mg

ESTRING RING 2 MG


aranelle tabs 0.5/1/0.5-35 mg-mcg

eluryng ring 0.12-0.015 mg/24hr

est estrogens-methyltest hs tabs 0.625-1.25 mg

est estrogens-methyltest tabs 1.25-2.5 mg

kelnor 1/50 tabs 1-50 mg-mcg

levora 0.15/30 (28) tabs 0.15-30 mg-mcg

microgestin fe 1.5/30 tabs 1.5-30 mg-mcg

microgestin fe 1/20 tabs 1-20 mg-mcg

necon 0.5/35 (28) tabs 0.5-35 mg-mcg

nortrel 1/35 (28) tabs 1-35 mg-mcg

sprintec 28 tabs 0.25-35 mg-mcg

tri-sprintec tabs 0.18/0.215/0.25 mg-35 mcg

trivora (28) tabs

XULANE PTWK 150 35 MCG/24HR

zovia 1/35e (28) tabs 1-35 mg-mcg

Progestins

ELLA TABS 30 MG

hydroxyprogesterone caproate oil 250 mg/ml DS

medroxyprogesterone acetate susp 150 mg/ml

medroxyprogesterone acetate tabs 10 mg

medroxyprogesterone acetate tabs 2.5 mg

medroxyprogesterone acetate tabs 5 mg

megestrol acetate susp 40 mg/ml


megestrol acetate tabs 20 mg

megestrol acetate tabs 40 mg

MIRENA (52 MG) IUD 20 MCG/24HR

NEXPLANON IMPL 68 MG

nora-be tabs 0.35 mg

norethindrone acetate tabs 5 mg

plan b one-step tabs 1.5 mg

progesterone micronized caps 100 mg

progesterone micronized caps 200 mg

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium tabs 100 mcg












liothyronine sodium tabs 25 mcg



Hormonal Agents, Suppressant (Adrenal)

LYSODREN TABS 500 MG DS

Hormonal Agents, Suppressant (Pituitary)

cabergoline tabs 0.5 mg

octreotide acetate soln 100 mcg/ml




SYNAREL SOLN 2 MG/ML

Hormonal Agents, Suppressant (Sex Hormones/Modifiers)

Antiandrogens

abiraterone acetate tabs 250 mg DS

bicalutamide tabs 50 mg

flutamide caps 125 mg

ZYTIGA TABS 500 MG DS


Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole tabs 10 mg

methimazole tabs 5 mg

propylthiouracil tabs 50 mg

Immunological Agents

Immune Suppressants

azathioprine tabs 50 mg

everolimus tabs 0.25 mg



gengraf caps 100 mg

gengraf caps 25 mg

HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML PA, DS

HUMIRA PEDIATRIC CROHNS START PSKT 80 MG/0.8ML & 40MG/0.4ML

PA, DS

HUMIRA PEN PNKT 40 MG/0.4ML PA, DS

HUMIRA PEN PNKT 40 MG/0.8ML PA, DS

HUMIRA PSKT 10 MG/0.1ML DS



HUMIRA PSKT 40 MG/0.4ML PA, DS

HUMIRA PSKT 40 MG/0.8ML PA, DS

mercaptopurine tabs 50 mg

methotrexate sodium (pf) soln 50 mg/2ml

methotrexate sodium soln 50 mg/2ml

methotrexate tabs 2.5 mg

mycophenolate mofetil caps 250 mg

mycophenolate mofetil tabs 500 mg

NEORAL SOLN 100 MG/ML

RASUVO SOAJ 10 MG/0.2ML

RASUVO SOAJ 12.5 MG/0.25ML










SANDIMMUNE CAPS 100 MG

SANDIMMUNE CAPS 25 MG

sirolimus tabs 0.5 mg

sirolimus tabs 1 mg

sirolimus tabs 2 mg

sirolimus soln 1 mg/ml

tacrolimus caps 0.5 mg DS

tacrolimus caps 1 mg DS

tacrolimus caps 5 mg DS

XELJANZ TABS 10 MG PA, DS

Immunizing Agents, Passive

GAMMAGARD SOLN 1 GM/10ML

GAMMAGARD SOLN 2.5 GM/25ML





HIZENTRA SOLN 1 GM/5ML DS




HIZENTRA SOSY 1 GM/5ML



VIVOTIF CPDR

Immunomodulators

leflunomide tabs 10 mg

leflunomide tabs 20 mg

OTEZLA TABS 30 MG PA, DS

OTEZLA TBPK 10 & 20 & 30 MG PA, DS

RIDAURA CAPS 3 MG

No USP Class

HAEGARDA SOLR 2000 UNIT DS

HAEGARDA SOLR 3000 UNIT DS

TAKHZYRO SOLN 300 MG/2ML PA, DS

Inflammatory Bowel Disease Agents

Aminosalicylates

ASACOL TBEC 400 MG

balsalazide disodium caps 750 mg

mesalamine-cleanser kit 4 gm


mesalamine supp 1000 mg

mesalamine tbec 1.2 gm

Sulfonamides

sulfasalazine tabs 500 mg

sulfasalazine tbec 500 mg

Metabolic Bone Disease Agents

alendronate sodium tabs 10 mg

alendronate sodium tabs 70 mg

calcitonin (salmon) soln 200 unit/act

calcitriol caps 0.25 mcg

calcitriol caps 0.5 mcg

calcitriol soln 1 mcg/ml

etidronate disodium tabs 200 mg

etidronate disodium tabs 400 mg

MIACALCIN SOLN 200 UNIT/ML

No Designated Placement on USP Model Guidelines V5.0

acetic acid soln 0.25 %

BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 0.3 ML

BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 0.5 ML

BD INSULIN SYRINGE ULTRAFINE MISC 31G X 15/64" 1 ML

BD INSULIN SYRINGE U-500 MISC 31G X 6MM 0.5 ML

bd magni-guide magnifier misc

bd pen needle mini u/f misc 31g x 5 mm

bd safetyglide insulin syringe misc 29g x 1/2" 0.5 ml

CERDELGA CAPS 84 MG DS

fluoridex pste 1.1 %

KETOSTIX STRP

ONETOUCH ULTRA BLUE STRP

PARAGARD INTRAUTERINE COPPER IUD

PRECISION XTRA KETONE STRP

proctozone-hc crea 2.5 %

sodium benzoate powd

WIDE-SEAL DIAPHRAGM 60 DPRH 2 %









Ophthalmic Agents


bacitracin-polymyxin b oint 500-10000 unit/gm

bacitra-neomycin-polymyxin-hc oint 1 %

blephamide s.o.p. oint 10-0.2 %

neomycin-bacitracin zn-polymyx oint 5-400-10000

neomycin-polymyxin-dexameth oint 3.5-10000-0.1

neomycin-polymyxin-dexameth susp 3.5-10000-0.1

polymyxin b-trimethoprim soln 10000-0.1 unit/ml-%

PRED-G SUSP 0.3-1 %

sulfacetamide-prednisolone soln 10-0.23 %

Ophthalmic Agents, Other

ATROPINE SULFATE OINT 1 %

ATROPINE SULFATE SOLN 1 %

cyclopentolate hcl soln 0.5 %

cyclopentolate hcl soln 1 %

cyclopentolate hcl soln 2 %

homatropaire soln 5 %

ISOPTO CARBACHOL SOLN 1.5 %

ISOPTO CARBACHOL SOLN 3 %

tropicamide soln 0.5 %

tropicamide soln 1 %

VISUDYNE SOLR 15 MG

Ophthalmic Anti-Allergy Agents

cromolyn sodium soln 4 %

olopatadine hcl soln 0.1 %

Ophthalmic Antiglaucoma Agents

betaxolol hcl soln 0.5 %

brimonidine tartrate soln 0.2 %

dorzolamide hcl soln 2 %

dorzolamide hcl-timolol mal soln 22.3-6.8 mg/ml

levobunolol hcl soln 0.5 %

phenylephrine hcl soln 2.5 %

PHOSPHOLINE IODIDE SOLR 0.125 %

timolol maleate soln 0.25 %

timolol maleate soln 0.5 %

Ophthalmic Anti-Inflammatories

dexamethasone sodium phosphate soln 0.1 %

diclofenac sodium soln 0.1 %

fluorometholone susp 0.1 %


flurbiprofen sodium soln 0.03 %

FML OINT 0.1 %

PRED MILD SUSP 0.12 %

prednisolone acetate susp 1 %

Ophthalmic Prostaglandin and Prostamide Analogs

latanoprost soln 0.005 %

Otic Agents

acetic acid-aluminum acetate soln 2 %

ciprofloxacin-dexamethasone susp 0.3-0.1 %

neomycin-polymyxin-hc soln 1 %

Respiratory Tract Agents

Antihistamines

azelastine hcl soln 0.1 %

cyproheptadine hcl syrp 2 mg/5ml

cyproheptadine hcl tabs 4 mg

Anti-Inflammatories, Inhaled Corticosteroids

ALVESCO AERS 80 MCG/ACT

ALVESCO AERS 160 MCG/ACT

ASMANEX 120 METERED DOSES AEPB 220 MCG/INH



ASMANEX HFA AERO 100 MCG/ACT

ASMANEX HFA AERO 200 MCG/ACT

FLOVENT HFA AERO 44 MCG/ACT DS

mometasone furoate susp 50 mcg/act

Antileukotrienes

montelukast sodium chew 4 mg

montelukast sodium chew 5 mg

montelukast sodium tabs 10 mg

Bronchodilators, Anticholinergic

ATROVENT HFA AERS 17 MCG/ACT

ipratropium bromide soln 0.02 %



SPIRIVA RESPIMAT AERS 2.5 MCG/ACT

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)

theophylline er tb12 300 mg

theophylline er tb24 400 mg

Bronchodilators, Sympathomimetic

albuterol sulfate hfa aers 108 (90 base) mcg/act


albuterol sulfate nebu (2.5 mg/3ml) 0.083%

albuterol sulfate nebu (5 mg/ml) 0.5%

epinephrine soaj 0.15 mg/0.15ml DS

epinephrine soaj 0.3 mg/0.3ml DS

EPIPEN JR 2-PAK SOAJ 0.15 MG/0.3ML

SEREVENT DISKUS AEPB 50 MCG/DOSE

STRIVERDI RESPIMAT AERS 2.5 MCG/ACT

terbutaline sulfate tabs 2.5 mg

terbutaline sulfate tabs 5 mg

VENTOLIN HFA AERS 108 (90 Base) MCG/ACT

No USP Class

benzonatate caps 100 mg

HYPERSAL NEBU 7 %

PULMOZYME SOLN 1 MG/ML

sodium chloride nebu 0.9 %

sodium chloride nebu 10 %


ADVAIR HFA AERO 45-21 MCG/ACT PA



COMBIVENT RESPIMAT AERS 20-100 MCG/ACT

fluticasone-salmeterol aepb 55-14 mcg/act



hydrocodone-homatropine syrp 5-1.5 mg/5ml DS

ipratropium-albuterol soln 0.5-2.5 (3) mg/3ml

promethazine vc plain syrp 6.25-5 mg/5ml

promethazine vc/codeine syrp 6.25-5-10 mg/5ml

promethazine-codeine syrp 6.25-10 mg/5ml

promethazine-dm syrp 6.25-15 mg/5ml

STIOLTO RESPIMAT AERS 2.5-2.5 MCG/ACT

wixela inhub aepb 100-50 mcg/dose DS



Pulmonary Antihypertensives

LETAIRIS TABS 10 MG PA, DS

LETAIRIS TABS 5 MG PA, DS

TRACLEER TABS 125 MG PA, DS

TRACLEER TABS 62.5 MG PA, DS

VELETRI SOLR 1.5 MG


Respiratory Tract Agents, Other

acetylcysteine soln 10 %

acetylcysteine soln 20 %

cheratussin dac soln 30-10-100 mg/5ml

FASENRA PEN SOAJ 30 MG/ML PA

FASENRA SOSY 30 MG/ML PA

guaifenesin-codeine soln 100-10 mg/5ml

TRIKAFTA TBPK 100-50-75 & 150 MG PA, DS

Skeletal Muscle Relaxants

cyclobenzaprine hcl tabs 10 mg

cyclobenzaprine hcl tabs 5 mg

methocarbamol tabs 500 mg

methocarbamol tabs 750 mg

Sleep Disorder Agents

GABA Receptor Modulators

eszopiclone tabs 1 mg



zolpidem tartrate tabs 10 mg

zolpidem tartrate tabs 5 mg

Sleep Disorders, Other

armodafinil tabs 50 mg




modafinil tabs 100 mg

modafinil tabs 200 mg

temazepam caps 15 mg

temazepam caps 30 mg

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/Mineral Modifiers

deferasirox tabs 90 mg DS

deferasirox tabs 360 mg DS

deferoxamine mesylate solr 500 mg

deferoxamine mesylate solr 2 gm

JADENU TABS 180 MG DS

kionex susp 15 gm/60ml

sodium polystyrene sulfonate powd

sodium polystyrene sulfonate susp 15 gm/60ml

sps susp 15 gm/60ml


SSKI SOLN 1 GM/ML

Electrolyte/Mineral Replacement

citric acid-sodium citrate soln 334-500 mg/5ml

klor-con m20 tbcr 20 meq

K-PHOS TABS 500 MG

K-TAB TBCR 10 MEQ

PHOSPHA 250 NEUTRAL TABS 155-852-130 MG

potassium chloride soln 20 meq/15ml (10%) PA

potassium citrate er tbcr 5 meq (540 mg)



potassium citrate-citric acid soln 1100-334 mg/5ml

sodium fluoride chew 0.55 (0.25 f) mg

sodium fluoride chew 1.1 (0.5 f) mg

sodium fluoride chew 2.2 (1 f) mg

sodium fluoride soln 1.1 (0.5 f) mg/ml

No USP Class

cyanocobalamin soln 1000 mcg/ml

multi-vit/fluoride soln 0.25 mg/ml

multi-vit/fluoride soln 0.5 mg/ml

multi-vit/fluoride/iron soln 0.25-10 mg/ml

multivitamin/fluoride chew 0.25 mg

multivitamin/fluoride chew 1 mg

polyvitamin/fluoride dro 0.5mg/ml

poly-vit drops w/fluoride dro 0.25mg

poly-vitamin/iron/fluoride dro /fl 0.25

tri-vit/fluoride soln 0.25 mg/ml

tri-vit/fluoride soln 0.5 mg/ml

tri-vit/fluoride/iron soln 0.25-10 mg/ml

vitamin d (ergocalciferol) caps 50000 unit


NONDISCRIMINATION NOTICE

Kaiser Foundation Health Plan of the Northwest (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 1-800-813-2000 (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 or phone at: Member Relations, Attention: Kaiser Civil Rights Coordinator, 500 NE Multnomah St. Ste 100, Portland, OR 97232, telephone number: 1-800-813-2000. 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.

____________________________________________________________________

HELP IN YOUR LANGUAGE

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-813-2000 (TTY: 711).

አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-813-2000 (TTY: 711).

-1 اللغویة تتوافر لك بالمجان. اتصل برقم، فإن خدمات المساعدة العربیةإذا كنت تتحدث : ملحوظة (Arabic) العربیة800-813-2000 )TTY :711.(

中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-800-813-2000（TTY：711）。

اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما فراھم می توجھ: (Farsi) فارسی تماس بگیرید. TTY) 1-800-813-2000: 711) باشد. با

Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-813-2000 (TTY: 711).

Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-813-2000 (TTY: 711).

日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-813-2000（TTY: 711）まで、お電話にてご連絡ください。


ែខ�រ (Khmer) �បយ័ត�៖ េប�សិន�អ�កនិ�យ ��ែខ�រ, េស�ជំនួយែផ�ក�� េ�យមិនគិតឈ� �ល គឺ�ច�នសំ�ប់បំេរ �អ�ក។ ចូរ ទូរស័ព� 1-800-813-2000 (TTY: 711)។

한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-813-2000 (TTY: 711) 번으로 전화해 주십시오.

ລາວ (Laotian) ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ້ົາພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫືຼອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-813-2000 (TTY: 711).

Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dé̖é̖’, t’áá jiik’eh, éí ná hóló̖, koji̖’ hódíílnih 1-800-813-2000 (TTY: 711).

Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-813-2000 (TTY: 711).

ਪੰਜਾਬੀ (Punjabi) ਿਧਆਨ ਿਦਓ: ਜੇ ਤਸੁ� ਪੰਜਾਬੀ ਬੋਲਦੇ ਹ,ੋ ਤ� ਭਾਸ਼ਾ ਿਵੱਚ ਸਹਾਇਤਾ ਸਵੇਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-800-813-2000 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।

Română (Romanian) ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-813-2000 (TTY: 711).

Pусский (Russian) ВНИМАНИЕ: если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-813-2000 (TTY: 711).

Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-813-2000 (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 1-800-813-2000 (TTY: 711).

ไทย (Thai) เรยีน: ถา้คณุพูดภาษาไทย คณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ีโทร 1-800-813-2000 (TTY: 711).

Українська (Ukrainian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-813-2000 (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 1-800-813-2000 (TTY: 711).

What drugs are not covered?

2020 northwest oregon medicaid formulary (list of covered ......no usp class (combination product)...

Documents