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last updated: august 3, 2011
KAISER PERMANENTE
HMO FOrMulary Prescription Drug List 2011
The following list contains the drugs covered on the Health Plan’s Commercial Drug Formulary. It is approved by the Kaiser Permanente Mid-Atlantic States Pharmacy and Therapeutics Committee.
This formulary applies only to outpatient drugs and self-administered drugs. It does not apply to medications used in inpatient settings or administered in one of the Kaiser Permanente medical centers.
Many members have specific exclusions, copays, or coinsurance amounts that are not reflected in the formulary. Please consult your Evidence of Coverage for additional information regarding your pharmacy benefits, including any specific limitations or exclusions.
Generic, brand name, and non-formulary medications Kaiser Permanente covers generic and brand name drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. In most cases, your doctor will prescribe a generic drug if one is available. Generic drugs generally cost less than brand name drugs.
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 then manufacture and sell the FDA-approved generic version of the drug at lower prices.
Generally, Kaiser Permanente will only approve your request for a non-formulary drug if your prescribing physician considers that drug to be medically necessary. If a non-formulary drug is not medically necessary but you decide nonetheless that you want the non-formulary drug, you will be responsible for paying the full cost share of that medication.
Using the Kaiser Permanente Commercial formulary When you look through the formulary listing, you will see that products available in a generic form are listed by their generic names. Medications that are only available as a brand name product are listed in bold ANd All CAPITAl letters, except where multiple branded products exist.
You can search the formulary by using the index, the “FIND” function in Adobe Reader, or by referencing the therapeutic drug category.
In some cases, a particular drug may be listed in the formulary, but only for certain strengths or in certain dosage forms. For example, some drugs are available in different milligram (mg) strengths (e.g., 5mg, 10mg), but only one strength may be on the formulary. For drugs that are available in more than one dosage form (e.g., tablet, injectable), only one may be on the formulary.
Please remember that this list is subject to change and will be updated from time to time during the year. Any product not found on this list will be considered a non-formulary drug.
2
Restrictions on medication coverage Some covered drugs may have additional requirements or limits on coverage, including but not limited to:
• Higher Copay: Some drugs may have a higher cost share. These drugs include, but are not limited to, infertility, growth hormone, and weight management medications.
• Limited Distribution: Some drugs may be subject to limited distribution or restricted access. A drug that is a limited distribution drug may only be available at one or a limited number of pharmacies.
• Oral Chemotherapy Drugs: Drugs that fall under the District of Columbia Oral Chemotherapy Parity Act. Cost shares for these drugs may be different for employer group plans not based in Washington, D.C.
• Quantity Limit: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a certain quantity per copay.
• Restricted to Benefit: Some drugs are not covered unless your benefits specifically cover such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless specifically included under the member’s Evidence of Coverage.
Key: HC = A drug that may have a higher copay.
ld = A drug that may be subject to limited distribution.
oC = A drug included under the District of Columbia Oral Chemotherapy Parity Act.
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.
For more information about the Kaiser Permanente Commercial Drug Formulary, you may contact Member Services at 301-468-6000 or 1-800-777-7902 (TTY 301-879-6380). Representatives are available Monday through Friday, 7:30 a.m. until 5:30 p.m.
11345_RxFormularyIntro_A_pdf 8/10/11–8/10/13
3
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
ANTIHISTAMINE DRUGS
Cyproheptadine HCl
Promethazine HCL
ANTI-INFECTIVE AGENTS
Anthelmintics
Mebendazole
YODOXIN
Antibacterials
Amoxicillin
Amoxicillin & Pot Clavulanate
Ampicillin
AVELOX
Azithromycin
Cefaclor
Cefdinir
Cefuroxime Axetil
Cephalexin
Ciprofloxacin
Clarithromycin
Clindamycin
Clindamycin Palmitate HCL
Dicloxacillin Sodium
Doxycycline Hyclate
Doxycycline Monohydrate
ERYPED SUSP
Erythromycin Base
Erythromycin Ethylsuccinate
Erythromycin-Sulfisoxazole
Levofloxacin
Minocycline HCL
Neomycin Sulfate
DRUG NAME REQUIREMENTS AND LIMITS
Penicillin V Potassium
Sulfadiazine
Sulfasalazine
Sulfamethoxazole-Trimethoprim
SUPRAX
Tetracycline HCL
TOBI NEB
VANOCIN
XIFAXAN
ZYVOX
Antifungals
Fluconazole
Griseofulvin Microsize
Griseofulvin Ultramicrosize
Itraconazole
Ketoconazole
Nystatin
Terbinafine
Voriconazole
Antimycobacterials
DAPSONE
Ethambutol HCL
Isoniazid
MYCOBUTIN
Pyrazinamide
Rifabutin
Rifampin
TRECATOR
Antiprotozoals
COARTEM
Chloroquine Phosphate
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
44
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
DARAPRIM
Hydroxychloroquine Sulfate
Mefloquine HCL
MEPRON
Metronidazole
NEBUPENT INH
Primaquine Phosphate
Antivirals
Amantadine HCL
APTIVUS
ATRIPLA
BARACLUDE
COMBIVIR
CRIXIVAN
Didanosine
EDURANT
EMTRIVA
EPIVIR
EPZICOM
FUZEON
Ganciclovir
HEPSERA
INTELENCE
INVIRASE
ISENTRESS
KALETRA
LEXIVA
NORVIR
PEGASYS QL
PEG-INTRON QL
PREZISTA
RESCRIPTOR
DRUG NAME REQUIREMENTS AND LIMITS
REYATAZ
Ribavirin
Rimantadine HCL
SELZENTRY
SUSTIVA
TAMIFLU QL
TRIZIVIR
TRUVADA
VALCYTE
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIREAD
ZIAGEN
Zidovudine
Urinary Anti-Infectives
Methenamine Hippurate
Nitrofurantoin
Nitrofurantoin Monohyd Macro
Nitrofurantoin Macrocrystals
Trimethoprim
ANTINEOPLASTIC AGENTS
Antineoplastic Agents
AFINITOR OC
ALKERAN OC
Anastrozole OC
AROMASIN OC
Bicalutamide OC
CEENU OC
Cyclophosphamide OC
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
5
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
EMCYT OC
Etoposide OC
FEMARA OC
Flutamide OC
GLEEVEC OC
HEXALEN OC
HYCAMTIN OC
Hydroxyurea OC
INTRON-A QL
LEUKERAN OC
LUPRON QL
LYSODREN OC
Megestrol Acetate OC
Mercaptopurine OC
Methotrexate Sodium
MYLERAN OC
NEXAVAR OC
Procarbazine HCL OC
SPRYCEL OC
SUTENT OC
TABLOID OC
Tamoxifen Citrate OC
TARCEVA OC
TARGRETIN OC
TASIGNA OC
TEMODAR OC
Tretinoin (Chemotherapy) OC
TYKERB OC
VANDETANIB OC
VOTRIENT OC
XELODA OC
ZYTIGA OC
DRUG NAME REQUIREMENTS AND LIMITS
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
Barbiturates
Mephobarbital
Phenobarbital
Benzodiazepines
Alprazolam
Chlordiazepoxide HCL
Clonazepam
Clorazepate Dipotassium
Diazepam
Lorazepam
Oxazepam
Temazepam
AUTONOMIC DRUGS
Anticholinergic Agents
ATROVENT HFA
Benztropine Mesylate
Dicyclomine HCL
Hyoscyamine
Ipratropium Bromide (Nasal)
Trihexyphenidyl HCL
SPIRIVA
Autonomic Drugs, Miscellaneous
DIBENZYLINE
Ergoloid Mesylates
Nicotrol Inhaler HC
Parasympathomimetic (Cholinergic) Agents
Bethanechol Chloride
Donepezil HCL
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
6
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
Galantamine Hydrobromide
Neostigmine Bromide
Pilocarpine HCL (ORAL)
Pyridostigmine Bromide
Skeletal Muscle Relaxants
Baclofen
Cyclobenzaprine HCL
Dantrolene Sodium
Methocarbomol
Sympathomimetic (Adrenergic) Agents
ADVAIR DISKUS
Albuterol Neb
COMBIVENT AER
Epinephrine HCl
EPIPEN
Midodrine HCL
PROAIR HFA
SEREVENT DISKUS AER
Terbutaline Sulfate
BLOOD FORMATION, COAGULATION, AND THROMBOSIS
Coagulants And Anticoagulants
AGGRENOX
Anagrelide HCL
Aminocaproic Acid
Cilostazol
Dipyridamole
EFFIENT
Fondaparinux QL
LOVENOX QL
Pentoxifylline
DRUG NAME REQUIREMENTS AND LIMITS
PLAVIX
Warfarin Sodium
Hematopoietic Agents
NEUPOGEN QL
PROCRIT/EPOGEN QL
PROMACTA
CARDIOVASCULAR DRUGS
Alpha-Adrenergic Blocking Agents
Doxazosin Mesylate
Terazosin HCL
Prazosin HCL
Tamsulosin HCL
Antilipemic Agents
Cholestryramine Light
Fenofibrate 54mg, 160mg
Gemfibrozil
LIPITOR 80mg
Lovastatin
Niacin
Pravastatin Sodium 20mg, 40mg, 80mg
Simvastatin 20mg, 40mg, 80mg
VYTORIN 40/10mg, 80/10mg
Beta-Adrenergic Blocking Agents
Acebutolol HCL
Atenolol/Chlorthalidone
Atenolol HCL
Bisoprolol/ Hydrochlorothiazide
Bisoprolol Fumarate
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
7
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
Carvedilol
Labetalol HCL
Metoprolol Succinate
Metoprolol Tartrate
Nadolol
Propranolol HCL
Sotalol HCL
Timolol Maleate
Calcium-Channel Blocking Agents
Amlodipine Besylate
Diltiazem HCL
Nifedipine
Verapamil HCL
Cardiac Drugs
Amiodarone HCL
Digoxin
Disopyramide Phosphate
Flecainide Acetate
Mexiletine HCL
Propafenone HCL
Quinidine Gluconate
QUINIDEX/QUINIDEX ER
TIKOSYN
Hypotensive Agents
Acetazolamide
Clonidine HCL
Guanfacine HCL
Hydralazine HCL
Methazolamide
Methyldopa
Minoxidil
DRUG NAME REQUIREMENTS AND LIMITS
Reserpine
Renin-Angiotensin-Aldosterone System Inhibitors
Captopril
Enalapril Maleate
Lisinopril
Lisinopril/Hydrochlorothiazide
Losartan Potassium
Losartan Potassium/HCTZ
Spironolactone
Spironolactone/ Hydrochlorothiazide
Vasodilating Agents
ADCIRCA
Isosorbide Dinitrate
Isosorbide Mononitrate
Nitroglycerin Patch
Nitroglycerin
NITROSTAT SL
Papaverine HCL
REVATIO
CENTRAL NERVOUS SYSTEM AGENTS
Analgesics and Antipyretics
Acetaminophen/Codeine
Butalbital/Acetaminophen/ Caffeine
Butalbital/Aspirin/Caffeine
Choline/Mag Salicylate
Codeine Phosphate
Codeine Sulfate
Diclofenac Sodium
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
8
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
Etodolac
Fentanyl
Hydrocodone/ Acetaminophen
Hydromorphone HCL
Ibuprofen
Indomethacin
Ketoprofen
Mefenamic Acid
Meloxicam
Meperidine HCL
Methadone HCL
Morphine Sulfate
Nabumetone
Naproxen
Oxycodone HCL
Oxycodone/Acetaminophen
SUBOXONE
Salsalate
Sulindac
Tramadol HCL
Anorexigenic Agents and Respiratory and Cerebral Stimulants
ADDERALL XR
Amphetamine/ Detroamphetamine (Mixed)
CONCERTA
Dextroamphetamine Sulfate
METADATE CD
Methylphenidate HCL
Methylphenidate HCL ER
DRUG NAME REQUIREMENTS AND LIMITS
Phentermine HC
Anticonvulsants
BANZEL
Carbamazepine
Carbamazepine ER
Diazepam (Anticonvulsant)
Divalproex Sodium
Ethosuximide
Gabapentin
Lamotrigine
Levetiracetam
Methsuximide
Oxcarbazepine
Phenobarbital
Phenytoin Sodium
Primidone
Topiramate
Valproate Sodium
Valproate Acid
Antimigraine Agents
Belladonna Alkaloids/ Phenobarbital
Ergotamine/Caffeine
Naratriptan HCL QL
Sumatriptan QL
Anxiolytics, Sedatives, and Hypnotics
Buspirone HCL
Hydroxyzine HCL
Hydroxyzine Pamoate
Zolpidem Tartrate QL
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
9
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
Central Nervous System Agents, Miscellaneous
Carbidopa/Levodopa, ER
COMTAN
LODOSYN
NAMENDA
Pramipexole Dihydrochloride
RILUTEK
Ropinirole HCL
Selegiline
Opiate Antagonists
Naltrexone HCL
Psychotherapeutic Agents
Amitriptyline HCL
Bupropion HCL, SR, XL
Chlorpromazine HCL
Citalopram HCL
Clomipramine HCL
Clozapine
Desipramine HCL
Doxepine HCL
Fluoxetine HCL
Fluphenazine HCL
Fluvoxamine Maleate
Haloperidol
Imipramine HCL
Lithium Carbonate
Lithium Citrate
DRUG NAME REQUIREMENTS AND LIMITS
Maprotiline HCL
Mirtazapine
Nefazodone HCL
Nortriptyline HCL
ORAP
Paroxetine HCL
Perphenazine
Phenelzine Sulfate
Prochlorperazine Maleate
Protriptyline HCL
Risperidone
SEROQUEL
Sertraline HCL
Thioridazine HCL
Thiothixene
Trazodone HCL
Trifluoperazine HCL
Venlafaxine HCL
ZYPREXA
ELECTROLYTIC, CALORIC, AND WATER BALANCE
Acidifying and Alkalinizing Agents
Potassium & Sodium Acid Phosphates
Potassium Citrate (Alkalinizer)
Sodium Citrate & Citric Acid
Ammonia Detoxicants
Lactulose
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
10
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
Diuretics
Amiloride/ Hydrochlorothazide
Amiloride HCL
Bumetanide
Chlorothiazide
Chlorthalidone
Furosemide
Hydrochlorothiazide
Indapamide
Metolazone
Triamterene/ Hydrochlorothiazide
Ion-Removing Agents
RENVELA
Sodium Polystyrene Sulfonate
Replacement Preparations
ELIPHOS
PHOSLO
Potassium Phosphate Dibasic/Monobasic
Potassium Bicarbonate
Potassium Chloride
Potassium Phosphate Monobasic
Uricosuric Agents
Probenecid
ENZYMES
Enzymes
PULMOZYME SOL
VPRIV
DRUG NAME REQUIREMENTS AND LIMITS
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
Antiallergic Agents
Cromolyn Sodium (OP)
Anti-Infectives
Bacitracin (OP)
Bacitracin/Polymyxin B (OP)
Ciprofloxacin (OP)
Erythromycin (OP)
Gentamicin Sulfate (OP)
NATACYN
Neomycin/Bacitracin/ Polymyxin
Neomycin/Polymyxin/ Gramicid
Ofloxacin (OP)
Ofloxacin (OTIC)
Polymyxin B/Trimethoprim
Tobramycin Sulfate (OP)
Trifluridine
ZYMAR
Anti-Inflammatory Agents
Bacitracin/Polymyxin/ Neomycin/HC
CIPRODEX OTIC
COLY-MYCIN S OTIC
DEXASOL OP
Flunisolide
Fluorometholone (OP)
Fluticasone Propionate
Ketorolac Tromethamine
LOTEMAX
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
11
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
Neomycin/Polymyxin/ Dexameth
Neomycin/Polymyxin/HC
OCUFEN
PRED-G
Prednisolone Acetate
Prednisolone Sodium Phosphate
Sulfacetamide Sodium/ Prednisolone
Tobramycin/Dexamethasone
EENT Drugs, Miscellaneous
Acetic Acid (OTIC)
Acetic Acid/Aluminum Acetate
Brimonidine Tartrate
Carbachol (OP)
Dorzolamide
Dorzolamide/Timolol
Latanoprost
Levobunolol HCL
LUMIGAN
Metipranolol
Local Anesthetics
Benzocaine/Antipyrine
Lidocaine HCL
Proparacaine HCL
Tetracaine HCL
Mydriatics
Atropine Sulfate
DRUG NAME REQUIREMENTS AND LIMITS
CYCLOMYDRIL
Homatropine HBR
Tropicamide
Vasoconstrictors
Phenylephrine HCL (OP)
GASTROINTESTINAL DRUGS
Antidiarrhea Agents
Diphenoxylate/Atropine
Antiemetics
EMEND
Ondansetron HCL
Prochlorperazine
TRANSDERM-SCOP
Anti-Inflammatory Agents
ASACOL
CANASA
COLAZAL
PENTASA
ROWASA ENEMA
Antiulcer Agents and Acid Suppressants
Famotidine
Misoprostol
Omeprazole
Pantoprazole
Ranitidine HCL
Sucralfate
Digestants
ZENPEP
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
12
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
GI Drugs, Miscellaneous
Metoclopramide HCL
PEG 3350-KCL-Sodium Bicarb-Sodium Chloride-Sodium Sulfate
Urosodiol
Gold Compounds
RIDAURA
HEAVY METAL ANTAGONISTS
Heavy Metal Antagonists
EXJADE
HORMONES AND SYNTHETIC SUBSTITUTES
Adrenals
ASMANEX
Budesonide (Inhalation)
Cortisone Acetate
Dexamethasone
ENTOCORT EC
FLOVENT HFA
Fludrocortisone Acetate
Hydrocortisone
Methlyprednisolone
MILLIPRED
Prednisolone
Prednisolone Sodium Phosphate
Prednisone
QVAR
Androgens
Danocrine
DRUG NAME REQUIREMENTS AND LIMITS
Contraceptives
Desogestrel/Ethinyl Estradiol
Drospirenone/Ethinyl Estradiol
ELLA
Ethynodiol Diacetate/Ethinyl Estradiol
Levonorgestrel/Ethinyl Estradiol
Levonorgestrel/Ethinyl Estradiol (Triphasic)
Norethindrone
Norethindrone/Ethinyl Estradiol
Norethindrone Acetate/ Ethinyl Estradiol
Norethindrone/Ethinyl Estradiol (Triphasic)
PLAN B ONE-STEP
Diabetic Agents
Acarbose
ACTOS
Glipizide
GLUCAGON EMERGENCY KIT
LANTUS
Metformin HCL
Metformin ER
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX 70/30
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
13
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
Repaglinide
Estrogens and Antiestrogens
CLIMARA
Estradiol
Esterified Estrogens/Methyl Testosterone
EVISTA
PREMARIN VAGINAL CREAM
Gonadotropins
BRAVELLE HC
Chorionic Gonadotropin HC
Clomiphene Citrate HC
FOLLISTIM HC
Ganirelix Acetate HC
GONAL-F HC
REPRONEX HC
IUD
MIRENA
Parathyroid
FORTICAL
Pituitary
Desmopressin Acetate
Progestins
ENDOMETRIUM
Medroxyprogesterone Acetate
Norethindrone Acetate
Somatotropin Agonist and Antagonist
OMNITROPE QL
DRUG NAME REQUIREMENTS AND LIMITS
Thyroid and Antithyroid Agents
Levothyroxine Sodium
Liothyronine Sodium
Methimazole
Propylthiouracil
Thyroid
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
ACTIMMUNE
Alendronate Sodium
Allopurinol
ANTABUSE
AVONEX QL
Azathioprine
Bromocriptine Mesylate
Colchicine
COPAXONE QL
ELMIRON
ENBREL QL
Etidronate Disodium
EXTAVIA QL
Finasteride
GASTROCROM
GENGRAF
HUMIRA QL
Leflunomide
Leucovorin Calcium
Mycophenolate Mofetil
REBIF QL
REVLIMID OC
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
14
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
SANDIMMUNE
SENSIPAR
Sodium Fluoride
Tacrolimus
THALOMID OC
Vitamins
Folic Acid
Iron Complex
Phytonadione
Potassium Aminobenzoate
Pyridoxine HCL
OXYTOCICS
Oxytocics
Methylergonovine Maleate
RESPIRATORY TRACT AGENTS
Anti-Inflammatory Agents
Cromolyn Sodium
DULERA
SINGULAIR
Antitussives
Benzonatate
Guaifenesin/Codeine
Respiratory Agents, Miscellaneous
Acetylcysteine
Sodium Chloride (Inhalant)
DRUG NAME REQUIREMENTS AND LIMITS
SKIN AND MUCOUS MEMBRANE AGENTS
Anti-Infectives (Skin and Mucous Membrane)
Benzoyl Peroxide/ Erythromycin
Ciclopirox Olamine
Clindamycin Phosphate
Clioquinol/Hydrocortisone
Clotrimazole Troche
Erythromycin
Gentamicin Sulfate
Ketoconazole
Malathion
Metronidazole
Mupirocin
Nystatin
Permethrin
Selenium Sulfide
Silver Nitrate/Potassium Nitrate
Silver Sulfadiazine
Anti-Inflammatory Agents (Skin and Mucous Membrane)
APEXICON E
Betamethasone Dipropionate
Betamethasone Valerate
Clobetasol Propionate
Clobetasol Propionate Emollient Base
CORDRAN
Desonide
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
15
November 2011
DRUG NAME REQUIREMENTS AND LIMITS
Desoximetasone
Diflorasone Diacetate
Fluocinolone Acetonide
Fluocinonide
Hydrocortisone (Rectal)
Hydrocortisone (Topical)
Hydrocortisone Butyrate
Hydrocortisone Valerate
Mometasone Furoate
Nystatin/Triamcinolone
PROCTOFORM
PROTOPIC
Triamcinolone Acetonide
Cell Stimulants and Proliferants
Tretinion
Skin and Mucous Membrane Agents, Miscellaneous
8-MOP
Acetic Acid Vaginal
Aluminum Chloride
AZELEX
DIFFERIN
EPIDUO
Fluorouracil
Imiquimod
Isotretinoin
Lidocaine HCL
Lidocaine/Prilocaine
Podofilox
Sulfacetamide Sodium/Sulfur
OXSORALEN LOT
OXSORALEN ULTRA
DRUG NAME REQUIREMENTS AND LIMITS
PHISOHEX LIQ
VECTICAL
SMOOTH MUSCLE RELAXANTS
Smooth Muscle Relaxants
Aminophylline
Oxybutynin Chloride
Oxybutynin Chloride Xl
OXYTROL DIS
Theophylline
VASODILATING AGENTS
Miscellaneous Therapeutic Agents
Yohimbine HCL HC, QL
Phosphodiesterase Inhibitors
CAVERJECT HC, RB
CIALIS HC, QL, RB
EDEX HC, RB
LEVITRA HC, QL, RB
MUSE HC, RB
VIAGRA HC, QL, RB
VITAMINS
Vitamins
Calcitriol
Pediatric Multivitamins/ Fluoride
Pediatric Multivitamins/ Fluoride/Iron
Pediatric Multivitamins ACD/ Fluoride
Pediatric Multivitamins ACD/ Fluoride/Iron
Prenatal Vitamins
LEGEND
• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD
dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC
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Index 8-MOP, 16
A
Acarbose, 13 Acebutolol HCL, 7 Acetaminophen/Codeine, 8 Acetazolamide, 8 Acetic Acid/Aluminum Acetate, 12 Acetic Acid (OTIC), 12 Acetic Acid Vaginal, 16 Acetylcysteine, 15 ACTIMMUNE, 14 ACTOS, 13 ADCIRCA, 8 ADDERALL XR, 9 ADVAIR DISKUS, 7 AFINITOR, 5 AGGRENOX, 7 Albuterol Neb, 7 Alendronate Sodium, 14 ALKERAN, 5 Allopurinol, 14 Alprazolam, 6 Aluminum Chloride, 16 Amantadine HCL, 5 Amiloride HCL, 11 Amiloride/Hydrochlorothazide, 11 Aminocaproic Acid, 7 Aminophylline, 16 Amiodarone HCL, 8 Amitriptyline HCL, 10 Amlodipine Besylate, 8 Amoxicillin, 4 Amoxicillin & Pot Clavulanate, 4 Amphetamine/ Detroamphetamine (Mixed), 9 Ampicillin, 4 Anagrelide HCL, 7 Anastrozole, 5
ANTABUSE, 14 APEXICON E, 15 APTIVUS, 5 AROMASIN, 5 ASACOL, 12 ASMANEX, 13 Atenolol/Chlorthalidone, 7 Atenolol HCL, 7 ATRIPLA, 5 Atropine Sulfate, 12 ATROVENT HFA, 6 AVELOX, 4 AVONEX, 14 Azathioprine, 14 AZELEX, 16 Azithromycin, 4
B
Bacitracin (OP), 11 Bacitracin/Polymyxin B (OP), 11 Bacitracin/Polymyxin/Neomycin/ HC, 11 Baclofen, 7 BANZEL, 9 BARACLUDE, 5 Belladonna Alkaloids/ Phenobarbital, 9 Benzocaine/Antipyrine, 12 Benzonatate, 15 Benzoyl Peroxide/Erythromycin, 15 Benztropine Mesylate, 6 Betamethasone Dipropionate, 15 Betamethasone Valerate, 15 Bethanechol Chloride, 6 Bicalutamide, 5 Bisoprolol Fumarate, 7 Bisoprolol/Hydrochlorothiazide, 7 BRAVELLE, 14
Brimonidine Tartrate, 12 Bromocriptine Mesylate, 14 Budesonide (Inhalation), 13 Bumetanide, 11 Bupropion HCL, SR, XL, 10 Buspirone HCL, 9 Butalbital/Acetaminophen/ Caffeine, 8 Butalbital/Aspirin/Caffeine, 8
C
Calcitriol, 16 CANASA, 12 Captopril, 8 Carbachol (OP), 12 Carbamazepine, 9 Carbamazepine ER, 9 Carbidopa/Levodopa, ER, 10 Carvedilol, 8 CAVERJECT, 16 CEENU, 5 Cefaclor, 4 Cefdinir, 4 Cefuroxime Axetil, 4 Cephalexin, 4 Chlordiazepoxide HCL, 6 Chloroquine Phosphate, 4 Chlorothiazide, 11 Chlorpromazine HCL, 10 Chlorthalidone, 11 Cholestryramine Light, 7 Choline/Mag Salicylate, 8 Chorionic Gonadotropin, 14 CIALIS, 16 Ciclopirox Olamine, 15 Cilostazol, 7 CIPRODEX OTIC, 11 Ciprofloxacin, 4 Ciprofloxacin (OP), 11 Citalopram HCL, 10 Clarithromycin, 4
17
CLIMARA, 14 Clindamycin, 4 Clindamycin Palmitate HCL, 4 Clindamycin Phosphate, 15 Clioquinol/Hydrocortisone, 15 Clobetasol Propionate, 15 Clobetasol Propionate Emollient Base, 15 Clomiphene Citrate, 14 Clomipramine HCL, 10 Clonazepam, 6 Clonidine HCL, 8 Clorazepate Dipotassium, 6 Clotrimazole Troche, 15 Clozapine, 10 COARTEM, 4 Codeine Phosphate, 8 Codeine Sulfate, 8 COLAZAL, 12 Colchicine, 14 COLY-MYCIN S OTIC, 11 COMBIVENT AER, 7 COMBIVIR, 5 COMTAN, 10 CONCERTA, 9 COPAXONE, 14 CORDRAN, 15 Cortisone Acetate, 13 CRIXIVAN, 5 Cromolyn Sodium, 15 Cromolyn Sodium (OP), 11 Cyclobenzaprine HCL, 7 CYCLOMYDRIL, 12 Cyclophosphamide, 5 Cyproheptadine HCl, 4
D
Danocrine, 13 Dantrolene Sodium, 7 DAPSONE, 4 DARAPRIM, 5 Desipramine HCL, 10 Desmopressin Acetate, 14
Desogestrel/Ethinyl Estradiol, 13 Desonide, 15 Desoximetasone, 16 Dexamethasone, 13 DEXASOL OP, 11 Dextroamphetamine Sulfate, 9 Diazepam, 6 Diazepam (Anticonvulsant), 9 Dibenzyline, 6 Diclofenac Sodium, 8 Dicloxacillin Sodium, 4 Dicyclomine HCL, 6 Didanosine, 5 DIFFERIN, 16 Diflorasone Diacetate, 16 Digoxin, 8 Diltiazem HCL, 8 Diphenoxylate/Atropine, 12 Dipyridamole, 7 Disopyramide Phosphate, 8 Divalproex Sodium, 9 Donepezil HCL, 6 Dorzolamide, 12 Dorzolamide/Timolol, 12 Doxazosin Mesylate, 7 Doxepine HCL, 10 Doxycycline Hyclate, 4 Doxycycline Monohydrate, 4 Drospirenone/Ethinyl Estradiol, 13 DULERA, 15
E
ENBREL, 14 ENDOMETRIUM, 14 ENTOCORT EC, 13 EPIDUO, 16 Epinephrine HCl, 7 EPIPEN, 7 EPIVIR, 5 EPZICOM, 5 Ergoloid Mesylates, 6 Ergotamine/Caffeine, 9 ERYPED SUSP, 4 Erythromycin, 15 Erythromycin Base, 4 Erythromycin Ethylsuccinate, 4 Erythromycin (OP), 11 Erythromycin-Sulfisoxazole, 4 Esterified Estrogens/Methyl Testosterone, 14 Estradiol, 14 Ethambutol HCL, 4 Ethosuximide, 9 Ethynodiol Diacetate/Ethinyl Estradiol, 13 Etidronate Disodium, 14 Etodolac, 9 Etoposide, 6 EVISTA, 14 EXJADE, 13 EXTAVIA, 14
F
Famotidine, 12 FEMARA, 6
EDEX, 16 EDURANT, 5 EFFIENT, 7 ELIPHOS, 11 ELLA, 13 ELMIRON, 14 EMCYT, 6 EMEND, 12 EMTRIVA, 5 Enalapril Maleate, 8
Fenofibrate 54mg, 160mg, 7 Fentanyl, 9 Finasteride, 14 Flecainide Acetate, 8 FLOVENT HFA, 13 Fluconazole, 4 Fludrocortisone Acetate, 13 Flunisolide, 11 Fluocinolone Acetonide, 16 Fluocinonide, 16
18
Fluorometholone (OP), 11 Fluorouracil, 16 Fluoxetine HCL, 10 Fluphenazine HCL, 10 Flutamide, 6 Fluticasone Propionate, 11 Fluvoxamine Maleate, 10 Folic Acid, 15 FOLLISTIM, 14 Fondaparinux, 7 FORTICAL, 14 Furosemide, 11 FUZEON, 5
G
Gabapentin, 9 Galantamine Hydrobromide, 7 Ganciclovir, 5 Ganirelix Acetate, 14 GASTROCROM, 14 Gemfibrozil, 7 GENGRAF, 14 Gentamicin Sulfate, 15 Gentamicin Sulfate (OP), 11 GLEEVEC, 6 Glipizide, 13 GLUCAGON EMERGENCY KIT, 13 GONAL-F, 14 Griseofulvin Microsize, 4 Griseofulvin Ultramicrosize, 4 Guaifenesin/Codeine, 15 Guanfacine HCL, 8
H
Haloperidol, 10 HEPSERA, 5 HEXALEN, 6 Homatropine HBR, 12 HUMIRA, 14 HYCAMTIN, 6 Hydralazine HCL, 8
Hydrochlorothiazide, 11 Hydrocodone/Acetaminophen, 9 Hydrocortisone, 13 Hydrocortisone Butyrate, 16 Hydrocortisone (Rectal), 16 Hydrocortisone (Topical), 16 Hydrocortisone Valerate, 16 Hydromorphone HCL, 9 Hydroxychloroquine Sulfate, 5 Hydroxyurea, 6 Hydroxyzine HCL, 9 Hydroxyzine Pamoate, 9 Hyoscyamine, 6
I
Ibuprofen, 9 Imipramine HCL, 10 Imiquimod, 16 Indapamide, 11 Indomethacin, 9 INTELENCE, 5 INTRON-A, 6 INVIRASE, 5 Ipratropium Bromide (Nasal), 6 Iron Complex, 15 ISENTRESS, 5 Isoniazid, 4 Isosorbide Dinitrate, 8 Isosorbide Mononitrate, 8 Isotretinoin, 16 Itraconazole, 4
K
KALETRA, 5 Ketoconazole, 4 Ketoconazole, 15 Ketoprofen, 9 Ketorolac Tromethamine, 11
L
Labetalol HCL, 8
Lactulose, 10 Lamotrigine, 9 LANTUS, 13 Latanoprost, 12 Leflunomide, 14 Leucovorin Calcium, 14 LEUKERAN, 6 Levetiracetam, 9 LEVITRA, 16 Levobunolol HCL, 12 Levofloxacin, 4 Levonorgestrel/Ethinyl Estradiol, 13 Levonorgestrel/Ethinyl Estradiol (Triphasic), 13 Levothyroxine Sodium, 14 LEXIVA, 5 Lidocaine HCL, 12 Lidocaine HCL, 16 Lidocaine/Prilocaine, 16 Liothyronine Sodium, 14 LIPITOR 80mg, 7 Lisinopril, 8 Lisinopril/Hydrochlorothiazide, 8 Lithium Carbonate, 10 Lithium Citrate, 10 LODOSYN, 10 Lorazepam, 6 Losartan Potassium, 8 Losartan Potassium/HCTZ, 8 LOTEMAX, 11 Lovastatin, 7 LOVENOX, 7 LUMIGAN, 12 LUPRON, 6 LYSODREN, 6
M
Malathion, 15 Maprotiline HCL, 10 Mebendazole, 4 Medroxyprogesterone Acetate, 14
19
Mefenamic Acid, 9 Mefloquine HCL, 5 Megestrol Acetate, 6 Meloxicam, 9 Meperidine HCL, 9 Mephobarbital, 6 MEPRON, 5 Mercaptopurine, 6 METADATE CD, 9 Metformin ER, 13 Metformin HCL, 13 Methadone HCL, 9 Methazolamide, 8 Methenamine Hippurate, 5 Methimazole, 14 Methlyprednisolone, 13 Methocarbomol, 7 Methotrexate Sodium, 6 Methsuximide, 9 Methyldopa, 8 Methylergonovine Maleate, 15 Methylphenidate HCL, 9 Methylphenidate HCL ER, 9 Metipranolol, 12 Metoclopramide HCL, 13 Metolazone, 11 Metoprolol Succinate, 8 Metoprolol Tartrate, 8 Metronidazole, 5 Metronidazole, 15 Mexiletine HCL, 8 Midodrine HCL, 7 MILLIPRED, 13 Minocycline HCL, 4 Minoxidil, 8 MIRENA, 14 Mirtazapine, 10 Misoprostol, 12 Mometasone Furoate, 16 Morphine Sulfate, 9 Mupirocin, 15 MUSE, 16 MYCOBUTIN, 4
Mycophenolate Mofetil, 14 MYLERAN, 6
N
Nabumetone, 9 Nadolol, 8 Naltrexone HCL, 10 NAMENDA, 10 Naproxen, 9 Naratriptan HCL, 9 NATACYN, 11 NEBUPENT INH, 5 Nefazodone HCL, 10 Neomycin/Bacitracin/Polymyxin, 11 Neomycin/Polymyxin/ Dexameth, 12 Neomycin/Polymyxin/Gramicid, 11 Neomycin/Polymyxin/HC, 12 Neomycin Sulfate, 4 Neostigmine Bromide, 7 NEUPOGEN, 7 NEXAVAR, 6 Niacin, 7 Nicotrol Inhaler, 6 Nifedipine, 8 Nitrofurantoin, 5 Nitrofurantoin Macrocrystals, 5 Nitrofurantoin Monohyd Macro, 5 Nitroglycerin, 8 Nitroglycerin Patch, 8 NITROSTAT SL, 8 Norethindrone, 13 Norethindrone Acetate, 14 Norethindrone Acetate/Ethinyl Estradiol, 13 Norethindrone/Ethinyl Estradiol, 13 Norethindrone/Ethinyl Estradiol (Triphasic), 13 Nortriptyline HCL, 10 NORVIR, 5
NOVOLIN 70/30, 13 NOVOLIN N, 13 NOVOLIN R, 13 NOVOLOG, 13 NOVOLOG MIX 70/30, 13 Nystatin, 4 Nystatin, 15 Nystatin/Triamcinolone, 16
O
OCUFEN, 12 Ofloxacin (OP), 11 Ofloxacin (OTIC), 11 Omeprazole, 12 OMNITROPE, 14 Ondansetron HCL, 12 ORAP, 10 Oxazepam, 6 Oxcarbazepine, 9 OXSORALEN LOT, 16 OXSORALEN ULTRA, 16 Oxybutynin Chloride, 16 Oxybutynin Chloride Xl, 16 Oxycodone/Acetaminophen, 9 Oxycodone HCL, 9 OXYTROL DIS, 16
P
Pantoprazole, 12 Papaverine HCL, 8 Paroxetine HCL, 10 Pediatric Multivitamins ACD/ Fluoride, 16 Pediatric Multivitamins ACD/ Fluoride/Iron, 16 Pediatric Multivitamins/Fluoride, 16 Pediatric Multivitamins/ Fluoride/Iron, 16 PEG 3350-KCL-Sodium Bicarb-Sodium Chloride-Sodium Sulfate, 13 PEGASYS, 5
20
PEG-INTRON, 5 Penicillin V Potassium, 4 PENTASA, 12 Pentoxifylline, 7 Permethrin, 15 Perphenazine, 10 Phenelzine Sulfate, 10 Phenobarbital, 6 Phenobarbital, 9 Phentermine, 9 Phenylephrine HCL (OP), 12 Phenytoin Sodium, 9 PHISOHEX LIQ, 16 PHOSLO, 11 Phytonadione, 15 Pilocarpine HCL (ORAL), 7 PLAN B ONE-STEP, 13 PLAVIX, 7 Podofilox, 16 Polymyxin B/Trimethoprim, 11 Potassium Aminobenzoate, 15 Potassium Bicarbonate, 11 Potassium Chloride, 11 Potassium Citrate (Alkalinizer), 10 Potassium Phosphate Dibasic/ Monobasic, 11 Potassium Phosphate Monobasic, 11 Potassium & Sodium Acid Phosphates, 10 Pramipexole Dihydrochloride, 10 Pravastatin Sodium 20mg, 40mg, 80mg, 7 Prazosin HCL, 7 PRED-G, 12 Prednisolone, 13 Prednisolone Acetate, 12 Prednisolone Sodium Phosphate, 12 Prednisolone Sodium Phosphate, 13 Prednisone, 13
PREMARIN VAGINAL CREAM, 14 Prenatal Vitamins, 16 PREZISTA, 5 Primaquine Phosphate, 5 Primidone, 9 PROAIR HFA, 7 Probenecid, 11 Procarbazine HCL, 6 Prochlorperazine, 12 Prochlorperazine Maleate, 10 PROCRIT/EPOGEN, 7 PROCTOFORM, 16 PROMACTA, 7 Promethazine HCL, 4 Propafenone HCL, 8 Proparacaine HCL, 12 Propranolol HCL, 8 Propylthiouracil, 14 PROTOPIC, 16 Protriptyline HCL, 10 PULMOZYME SOL, 11 Pyrazinamide, 4 Pyridostigmine Bromide, 7 Pyridoxine HCL, 15
Q
QUINIDEX/QUINIDEX ER, 8 Quinidine Gluconate, 8 QVAR, 13
R
Ranitidine HCL, 12 REBIF, 14 RENVELA, 11 Repaglinide, 14 REPRONEX, 14 RESCRIPTOR, 5 Reserpine, 8 REVATIO, 8 REVLIMID, 14 REYATAZ, 5 Ribavirin, 5
RIDAURA, 13 Rifabutin, 4 Rifampin, 4 RILUTEK, 10 Rimantadine HCL, 5 Risperidone, 10 Ropinirole HCL, 10 ROWASA ENEMA, 12
S
Salsalate, 9 SANDIMMUNE, 15 Selegiline, 10 Selenium Sulfide, 15 SELZENTRY, 5 SENSIPAR, 15 SEREVENT DISKUS AER, 7 SEROQUEL, 10 Sertraline HCL, 10 Silver Nitrate/Potassium Nitrate, 15 Silver Sulfadiazine, 15 Simvastatin 20mg, 40mg, 80mg, 7 SINGULAIR, 15 Sodium Chloride (Inhalant), 15 Sodium Citrate & Citric Acid, 10 Sodium Fluoride, 15 Sodium Polystyrene Sulfonate, 11 Sotalol HCL, 8 SPIRIVA, 6 Spironolactone, 8 Spironolactone/ Hydrochlorothiazide, 8 SPRYCEL, 6 SUBOXONE, 9 Sucralfate, 12 Sulfacetamide Sodium/ Prednisolone, 12 Sulfacetamide Sodium/Sulfur, 16 Sulfadiazine, 4
21
4 Sulfamethoxazole-Trimethoprim,
Sulfasalazine, 4 Sulindac, 9 Sumatriptan, 9 SUPRAX, 4 SUSTIVA, 5 SUTENT, 6
T
TABLOID, 6 Tacrolimus, 15 TAMIFLU, 5 Tamoxifen Citrate, 6 Tamsulosin HCL, 7 TARCEVA, 6 TARGRETIN, 6 TASIGNA, 6 Temazepam, 6 TEMODAR, 6 Terazosin HCL, 7 Terbinafine, 4 Terbutaline Sulfate, 7 Tetracaine HCL, 12 Tetracycline HCL, 4 THALOMID, 15 Theophylline, 16 Thioridazine HCL, 10 Thiothixene, 10 Thyroid, 14 TIKOSYN, 8 Timolol Maleate, 8 TOBI NEB, 4
Tobramycin/Dexamethasone, 12 Tobramycin Sulfate (OP), 11 Topiramate, 9 Tramadol HCL, 9 TRANSDERM-SCOP, 12 Trazodone HCL, 10 TRECATOR, 4 Tretinion, 16 Tretinoin (Chemotherapy), 6 Triamcinolone Acetonide, 16 Triamterene/ Hydrochlorothiazide, 11 Trifluoperazine HCL, 10 Trifluridine, 11 Trihexyphenidyl HCL, 6 Trimethoprim, 5 TRIZIVIR, 5 Tropicamide, 12 TRUVADA, 5 TYKERB, 6
U
Urosodiol, 13
V
VALCYTE, 5 Valproate Acid, 9 Valproate Sodium, 9 VANDETANIB, 6 VANOCIN, 4 VECTICAL, 16 Venlafaxine HCL, 10
Verapamil HCL, 8 VIAGRA, 16 VIRACEPT, 5 VIRAMUNE, 5 VIRAMUNE XR, 5 VIREAD, 5 Voriconazole, 4 VOTRIENT, 6 VPRIV, 11 VYTORIN 40/10mg, 80/10mg, 7
W
Warfarin Sodium, 7
X
XELODA, 6 XIFAXAN, 4
Y
YODOXIN, 4 Yohimbine HCL, 16
Z
ZENPEP, 12 ZIAGEN, 5 Zidovudine, 5 Zolpidem Tartrate, 9 ZYMAR, 11 ZYPREXA, 10 ZYTIGA, 6 ZYVOX, 4
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 2101 East Jefferson Street, Rockville, MD 20852 11926_RxFormularyNov_A_pdf 11/1/11–12/3/11
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