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Y0043_ N00013102_Final07_C HPMS Approved Formulary File Submission 00020166, Version 17
Kaiser Permanente
2020 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 07/01/20. For more recent information or other questions, please contact the number for your Kaiser Permanente Region listed below, seven days a week, 8 a.m. to 8 p.m., or visit kp.org/seniorrx.
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
HAWAII REGION Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711 MID-ATLANTIC STATES REGION (District of Columbia, Maryland, and Virginia) Kaiser Permanente Medicare Plus (Cost) Basic w/D (AB) and Basic w/D (B) plan
Member Services 1-888-777-5536 TTY 711
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Kaiser Permanente. When it refers to “plan” or “our plan,” it means Kaiser Permanente Senior Advantage or Medicare Plus, depending upon the region in which you are enrolled. This document includes a list of the drugs (formulary) for our plan which is current as of July 1, 2020. For an updated formulary, please visit our website at kp.org/seniorrx or call us. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. The formulary and pharmacy network may change at any time. You will receive notice when necessary.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 1
What is the Kaiser Permanente Formulary? A formulary is a list of covered drugs selected by Kaiser Permanente in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. 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 network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. Can the formulary (drug list) change? Most changes in drug coverage happen on January 1, but Kaiser Permanente may add or remove drugs on the Drug List during the year or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year: New generic drugs We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but
immediately add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.
• If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Kaiser Permanente Formulary?”
Drugs removed from the market If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary or add prior authorization, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.
• If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the
2 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
brand name drug for you. The notice we provide you will include information on how to request an exception. You can find information in the section below entitled “How do I request an exception to the Kaiser Permanente Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. The enclosed formulary is current as of July 1, 2020. To get updated information about the drugs covered by our plan, please call us. Contact information for your Kaiser Permanente Region appears on the front and back cover pages. In the event of a midyear non-maintenance formulary change, we will provide details in the Medicare Part D Explanation of Benefits that we send you or Provision of Notice posted at kp.org/seniorrx. How do I use the formulary? There are two ways to find your drug within the formulary: Medical condition The formulary begins on page 6. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed
under the category, “Cardiovascular Drugs”. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical listing If you are not sure what category to look under, you should look for your drug in the index that begins on page 60. The index provides an alphabetical list of all the drugs included in this document. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. What are generic drugs? 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. Please see your Evidence of Coverage for more information. What are 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 manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices. Please see your Evidence of Coverage for more information.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 3
Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Prior Authorization: Our plan may require you or your network provider to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
Note: If your prescription has more than one refill remaining, you can only get one refill at a time, unless authorized because you will be away from our service area for an extended period of time. For certain drugs, we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive. Also, if there is a shortage in the marketplace, we may fill your prescription for a limited quantity. You can find out if your drug has any additional requirements or limits by looking on the formulary that begins on page 6. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization restriction. You may also ask us to send you a copy. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Kaiser Permanente
formulary?” for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included on this formulary (list of covered drugs), you should first check our Kaiser Permanente 2020 Comprehensive Formulary at kp.org/seniorrx or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region and confirm if your drug is covered. If your Medicare Part D prescription drug is not on our Kaiser Permanente 2020 Comprehensive Formulary, you have two options:
• You can ask your network provider to prescribe a similar drug that is included on our formulary.
• You can ask us to make an exception and cover your drug. See the next section for information about how to request an exception.
How do I request an exception to the Kaiser Permanente Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover a drug even if it may not be on our Kaiser Permanente 2020 Comprehensive Formulary.
• You can ask us to waive coverage
restrictions or limits on your drug. For example, if your drug requires prior authorization, you can ask us to waive the prior authorization requirement for your Part D drug.
4 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your network provider supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your network provider believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. Please note: You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare & Medicaid Services (CMS). You cannot get an exception for drugs that are excluded under Medicare Part D. Please refer to your Evidence of Coverage for more information about requesting exceptions, including the appeals process. What do I do before I can talk to my network provider about changing my drugs or requesting an exception? In some cases, you might be taking Medicare Part D drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited.
For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your network provider to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your network provider to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your Part D drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum of a 30-day supply of medication. After your first 30-day supply, we may cover an additional refill, as medically necessary. After you have used these refills, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. For current members with level of care changes, if you enter into or are discharged from a hospital, skilled nursing facility, or long-term care facility to a different care setting or home, this is what is known as a level of care change. When your level of care changes, you may require an additional fill of your medication. We will generally cover up to a one-month supply of your Part D drugs during this level of care transition period even if the drug is not on our Drug List.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 5
For more information For more detailed information about your Kaiser Permanente prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please call us. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
6 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Kaiser Permanente’s Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the index that begins on page 60. 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 information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below. HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. MO = Mail-order drugs. You may order prescription refills of certain medications through our mail-order service online at kp.org/refill or by phone or mobile app, which may lower your costs for a three-month supply. Please contact us at least 5 days before your refills run out. Generally, you should receive them within 5 days. If not, please contact the mail-order phone number for your Kaiser Permanente Region in the chart below or the phone number on the prescription label for assistance. Not all drugs can be mailed; restrictions and limitations apply. For more information, please visit kp.org/seniorrx or call the appropriate regional phone number below. Region
Mail-Order Contact Numbers (TTY 711)
California
Kaiser Permanente Mail Order Pharmacy Northern CA – 1-888-218-6245 Monday through Friday, 8 a.m. to 8 p.m., Saturday 8 a.m. to 6 p.m., and Sunday 9 a.m. to 6 p.m. Southern CA – 1-866-206-2983 Monday through Friday, 7 a.m. to 7 p.m.
Colorado
Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday, 8 a.m. to 6 p.m.
Hawaii
Kaiser Permanente Mail Order Pharmacy 808-643-7979 (Oahu and neighbor islands) Monday through Friday, 8:00 a.m. to 5 p.m.
Mid-Atlantic States
Kaiser Permanente Mid-Atlantic Automated Refill Center 703-466-4900 or toll-free 1-800-733-6345
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 7
Monday through Friday, 7 a.m. to 6 p.m., Saturday, 8:30 a.m. to 4 p.m.
NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste.
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered.
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 8 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
ANTI-INFECTIVE AGENTS ANTHELMINTICS albendazole tabs NDS ALBENZA TABS NDS emverm chew ivermectin tabs praziquantel tabs MO ANTIBACTERIALS amikacin sulfate soln injection HI amoxicillin caps amoxicillin chew amoxicillin susr amoxicillin tabs amoxicillin-pot clavulanate chew amoxicillin-pot clavulanate er tb12
amoxicillin-pot clavulanate susr amoxicillin-pot clavulanate tabs ampicillin caps ampicillin sodium solr injection 1gm, 125mg HI
ampicillin sodium solr intravenous HI
ampicillin-sulbactam sodium solr injection HI
ampicillin-sulbactam sodium solr intravenous HI
ARIKAYCE SUSP LD,NDS AUGMENTIN SUSR AVYCAZ SOLR INTRAVENOUS HI AZACTAM SOLR INJECTION 1gm, 2gm HI
AZITHROMYCIN PACK MO azithromycin solr intravenous HI azithromycin susr 100mg/5ml, 200mg/5ml MO
azithromycin tabs 250mg, 500mg, 600mg MO
aztreonam solr injection HI BAXDELA SOLR INTRAVENOUS HI
BAXDELA TABS MO BICILLIN C-R 900/300 SUSP
Drug Name Requirements/Limits
BICILLIN C-R SUSP BICILLIN L-A SUSP cefaclor caps cefaclor er tb12 cefaclor susr cefadroxil caps cefadroxil susr cefadroxil tabs cefazolin sodium solr injection 1gm, 10gm, 500mg HI
cefdinir caps cefdinir susr cefepime hcl solr injection 1gm, 2gm HI
cefixime caps cefixime susr cefotetan disodium solr injection 1gm, 2gm HI
cefoxitin sodium solr injection HI cefoxitin sodium solr intravenous 1gm, 2gm HI
cefpodoxime proxetil susr cefpodoxime proxetil tabs cefprozil susr cefprozil tabs ceftazidime solr injection 1gm, 2gm, 6gm HI
CEFTIN SUSR ceftriaxone sodium solr injection 1gm, 2gm, 250mg, 500mg HI
ceftriaxone sodium solr intravenous HI
cefuroxime axetil tabs cefuroxime sodium solr injection 7.5gm, 750mg HI
cefuroxime sodium solr intravenous HI
cephalexin caps cephalexin susr cephalexin tabs ciprofloxacin hcl tabs ciprofloxacin in d5w soln intravenous HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 9
Drug Name Requirements/Limits
ciprofloxacin susr ciprofloxacin-ciproflox hcl er tb24 clarithromycin er tb24 clarithromycin susr clarithromycin tabs cleocin solr clindamycin hcl caps clindamycin palmitate hcl solr clindamycin phosphate in d5w soln intravenous HI
clindamycin phosphate soln injection 300mg/2ml, 600mg/4ml, 900mg/6ml
HI
colistimethate sodium (cba) solr injection HI
CUBICIN SOLR INTRAVENOUS HI DALVANCE SOLR INTRAVENOUS HI
daptomycin solr intravenous 500mg HI
daptomycin solr intravenous 350mg HI
demeclocycline hcl tabs dicloxacillin sodium caps DIFICID TABS NDS DORYX MPC TBEC MO doxy 100 solr intravenous HI doxycycline hyclate caps 50mg, 100mg MO
doxycycline hyclate tabs 20mg, 75mg, 100mg, 150mg MO
doxycycline hyclate tbec 50mg, 75mg, 100mg, 150mg, 200mg MO
doxycycline monohydrate caps 50mg, 75mg, 100mg, 150mg MO
doxycycline monohydrate susr MO doxycycline monohydrate tabs 50mg, 75mg, 100mg, 150mg MO
e.e.s. 400 tabs ertapenem sodium solr injection HI ery-tab tbec erythrocin lactobionate solr intravenous HI
Drug Name Requirements/Limits
erythrocin stearate tabs erythromycin base cpep MO erythromycin base tabs erythromycin base tbec erythromycin ethylsuccinate susr erythromycin ethylsuccinate tabs FETROJA SOLR NDS FIRVANQ SOLR gentamicin in saline soln intravenous HI
gentamicin sulfate soln injection HI imipenem-cilastatin solr intravenous HI
levofloxacin in d5w soln intravenous HI
levofloxacin soln levofloxacin soln intravenous HI levofloxacin tabs linezolid soln intravenous HI linezolid susr NDS linezolid tabs NDS meropenem solr intravenous 1gm, 500mg HI
minocycline hcl caps 50mg, 75mg, 100mg MO
minocycline hcl er tb24 45mg, 55mg, 65mg, 80mg, 90mg, 105mg, 115mg, 135mg
MO
minocycline hcl tabs 50mg, 75mg, 100mg MO
mondoxyne nl caps 75mg, 100mg MO
morgidox caps MO moxifloxacin hcl in nacl soln intravenous HI
moxifloxacin hcl tabs nafcillin sodium solr nafcillin sodium solr injection HI nafcillin sodium solr intravenous HI neomycin sulfate tabs NUZYRA SOLR HI,NDS NUZYRA TABS NDS ofloxacin tabs
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 10 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
ORBACTIV SOLR NDS OXACILLIN SODIUM IN DEXTROSE SOLN INTRAVENOUS
HI
oxacillin sodium solr injection 1gm, 2gm HI
oxacillin sodium solr intravenous HI PENICILLIN G POT IN DEXTROSE SOLN INTRAVENOUS
HI
penicillin g potassium solr injection HI
penicillin g procaine susp penicillin g sodium solr injection HI penicillin v potassium solr penicillin v potassium tabs piperacillin sod-tazobactam so solr intravenous HI
polymyxin b sulfate solr injection HI RECARBRIO SOLR NDS SEYSARA TABS 60mg, 100mg, 150mg NDS
SIVEXTRO SOLR INTRAVENOUS HI
SIVEXTRO TABS NDS soloxide tbec MO streptomycin sulfate solr sulfadiazine tabs sulfamethoxazole-trimethoprim susp MO
sulfamethoxazole-trimethoprim tabs MO
sulfasalazine tabs sulfasalazine tbec SUPRAX CAPS suprax chew suprax susr 100mg/5ml, 200mg/5ml
SUPRAX SUSR 500 MG/5ML SYNERCID SOLR targadox tabs MO tazicef solr injection 1gm, 2gm, 6gm HI
Drug Name Requirements/Limits
TEFLARO SOLR INTRAVENOUS 400mg, 600mg HI
tetracycline hcl caps 250mg, 500mg MO
tigecycline solr intravenous HI tobramycin sulfate soln injection 80mg/2ml, 10mg/ml HI
VABOMERE SOLR INTRAVENOUS HI
VANCOCIN CAPS NDS VANCOCIN HCL CAPS NDS vancomycin hcl caps vancomycin hcl solr vancomycin hcl intravenous 750mg
VANCOMYCIN HCL SOLR INTRAVENOUS 250MG
vancomycin hcl solr intravenous 1gm, 10gm, 500mg HI
VIBRAMYCIN SYRP XENLETA SOLN NDS XENLETA TABS NDS XIFAXAN TABS 200mg, 550mg NDS ZEMDRI SOLN INTRAVENOUS HI ZERBAXA SOLR INTRAVENOUS HI
ZITHROMAX PACK MO ZOSYN SOLN INTRAVENOUS HI ZYVOX SOLN INTRAVENOUS 200mg/100ml, 600mg/300ml HI
ZYVOX SUSR NDS ZYVOX TABS NDS ANTIFUNGALS ABELCET SUSP INTRAVENOUS HI
AMBISOME SUSR INTRAVENOUS HI
amphotericin b solr intravenous HI ANCOBON CAPS 250mg, 500mg NDS
CANCIDAS SOLR INTRAVENOUS 50mg, 70mg HI
caspofungin acetate solr intravenous 50mg, 70mg HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 11
Drug Name Requirements/Limits
CRESEMBA CAPS NDS CRESEMBA SOLR NDS ERAXIS SOLR INTRAVENOUS 50mg, 100mg HI
fluconazole in sodium chloride soln intravenous HI
fluconazole susr fluconazole tabs flucytosine caps 250mg, 500mg NDS griseofulvin microsize susp griseofulvin microsize tabs griseofulvin ultramicrosize tabs itraconazole caps itraconazole soln MO ketoconazole tabs MYCAMINE SOLR INTRAVENOUS 50mg, 100mg HI
NOXAFIL SUSP NDS NOXAFIL TBEC NDS nystatin susp nystatin tabs POSACONAZOLE SUSP NDS posaconazole tbec NDS terbinafine hcl tabs TOLSURA CAPS NDS VFEND SUSR NDS VFEND TABS 50mg, 200mg NDS voriconazole solr intravenous HI voriconazole susr voriconazole tabs ANTIMYCOBACTERIALS CAPASTAT SULFATE SOLR dapsone tabs 25mg, 100mg MO ethambutol hcl tabs 100mg, 400mg MO
isoniazid syrp MO isoniazid tabs 100mg, 300mg MO paser pack MO PRIFTIN TABS MO pyrazinamide tabs MO rifabutin caps MO
Drug Name Requirements/Limits
RIFADIN CAPS MO rifamate caps MO rifampin caps 150mg, 300mg MO rifampin solr intravenous HI RIFATER TABS MO SIRTURO TABS NDS TRECATOR TABS MO ANTIPROTOZOALS ALINIA SUSR ALINIA TABS atovaquone susp NDS atovaquone-proguanil hcl tabs BENZNIDAZOLE TABS 12.5mg, 100mg MO
chloroquine phosphate tabs 250mg, 500mg NDS
COARTEM TABS DARAPRIM TABS hydroxychloroquine sulfate tabs MO,NDS IMPAVIDO CAPS NDS mefloquine hcl tabs MEPRON SUSP NDS metronidazole caps metronidazole in nacl soln intravenous HI
metronidazole tabs NEBUPENT SOLR PA paromomycin sulfate caps pentamidine isethionate inh PA pentamidine isethionate inj primaquine phosphate tabs quinine sulfate caps NDS SOLOSEC PACK tinidazole tabs ANTIVIRALS abacavir sulfate soln abacavir sulfate tabs MO abacavir sulfate-lamivudine tabs MO abacavir-lamivudine-zidovudine tabs MO
acyclovir caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 12 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
acyclovir sodium soln intravenous HI
acyclovir susp MO acyclovir tabs 400mg, 800mg MO adefovir dipivoxil tabs NDS APTIVUS CAPS MO APTIVUS SOLN MO atazanavir sulfate caps 150mg, 200mg, 300mg MO
ATRIPLA TABS MO BARACLUDE SOLN MO BARACLUDE TABS BIKTARVY TABS CIMDUO TABS MO COMBIVIR TABS MO COMPLERA TABS MO CRIXIVAN CAPS 200mg, 400mg MO DAKLINZA TABS 30mg, 60mg, 90mg PA,NDS
DELSTRIGO TABS MO DESCOVY TABS MO didanosine cpdr 200mg, 250mg, 400mg MO
DOVATO TABS MO EDURANT TABS MO efavirenz caps 50mg, 200mg MO efavirenz tabs MO EMTRIVA CAPS MO EMTRIVA SOLN MO entecavir tabs .5mg, 1mg MO EPCLUSA TABS PA,NDS EPIVIR HBV SOLN MO EPIVIR SOLN MO EPIVIR TABS 150mg, 300mg MO EPZICOM TABS MO EVOTAZ TABS MO famciclovir tabs 125mg, 250mg, 500mg MO
fosamprenavir calcium tabs MO FUZEON SOLR NDS GENVOYA TABS MO HARVONI TABS PA,NDS
Drug Name Requirements/Limits
HEPSERA TABS NDS INTELENCE TABS 25mg, 100mg, 200mg MO
INVIRASE CAPS MO INVIRASE TABS MO ISENTRESS CHEW 25mg, 100mg MO
ISENTRESS HD TABS MO ISENTRESS PACK MO ISENTRESS TABS MO JULUCA TABS MO KALETRA TABS MO lamivudine soln MO lamivudine tabs 100mg, 150mg, 300mg MO
lamivudine-zidovudine tabs MO ledipasvir-sofosbuvir tabs PA,NDS LEXIVA SUSP MO LEXIVA TABS MO lopinavir-ritonavir soln MO MAVYRET TABS PA,NDS nevirapine er tb24 100mg, 400mg MO
nevirapine susp MO nevirapine tabs MO NORVIR CAPS MO NORVIR PACK MO NORVIR SOLN MO NORVIR TABS MO ODEFSEY TABS MO OLYSIO CAPS PA,NDS oseltamivir phosphate caps 30mg, 45mg, 75mg MO
oseltamivir phosphate susr MO PEG-INTRON REDIPEN KIT 50mcg/0.5ml, 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml
NDS
PEG-INTRON REDIPEN PAK 4 KIT 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml
NDS
PEG-INTRON REDIPEN PAK 4 KIT NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 13
Drug Name Requirements/Limits
PEGASYS PROCLICK SOLN 135mcg/0.5ml, 180mcg/0.5ml NDS
PEGASYS SOLN 180mcg/0.5ml, 180mcg/ml NDS
PEGINTRON KIT 50mcg/0.5ml, 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml
NDS
PIFELTRO TABS MO PLEGRIDY SOPN NDS PLEGRIDY SOSY NDS PLEGRIDY STARTER PACK SOPN NDS
PLEGRIDY STARTER PACK SOSY NDS
PREVYMIS SOLN 240mg/12ml, 480mg/24ml NDS
PREVYMIS TABS 240mg, 480mg NDS
PREZCOBIX TABS MO PREZISTA SUSP MO PREZISTA TABS 75mg, 150mg, 600mg, 800mg MO
RAPIVAB SOLN NDS REBETOL SOLN MO RELENZA DISKHALER AEPB MO RESCRIPTOR TABS 100mg, 200mg MO
RETROVIR CAPS MO RETROVIR SOLN MO RETROVIR SYRP MO REYATAZ CAPS 150mg, 200mg, 300mg MO
REYATAZ PACK MO ribasphere caps MO ribasphere ribapak (1000 pack) tbpk MO
ribasphere ribapak (1200 pack) tbpk MO
ribasphere tabs MO ribavirin caps MO ribavirin tabs MO rimantadine hcl tabs MO ritonavir tabs MO SELZENTRY SOLN MO
Drug Name Requirements/Limits
SELZENTRY TABS 25mg, 75mg, 150mg, 300mg MO
sofosbuvir-velpatasvir tabs PA,NDS SOVALDI TABS 200mg, 400mg PA,NDS stavudine caps 15mg, 20mg, 30mg, 40mg MO
STRIBILD TABS MO SUSTIVA CAPS 50mg, 200mg MO SUSTIVA TABS MO SYMFI LO TABS MO SYMFI TABS MO SYMTUZA TABS MO SYNAGIS SOLN 50mg/0.5ml, 100mg/ml NDS
tenofovir disoproxil fumarate tabs MO
TIVICAY TABS 10mg, 25mg, 50mg MO
TRIUMEQ TABS MO TRIZIVIR TABS MO TRUVADA TABS 200-300 MG MO TRUVADA TABS MO TYBOST TABS MO valacyclovir hcl tabs 1gm, 500mg MO
VALCYTE TABS NDS valganciclovir hcl solr NDS valganciclovir hcl tabs NDS VEMLIDY TABS VIDEX EC CPDR 125mg, 200mg, 250mg, 400mg MO
VIDEX SOLR 2gm, 4gm MO VIEKIRA PAK TBPK PA,NDS VIEKIRA XR TB24 PA,NDS VIRACEPT TABS 250mg, 625mg MO
VIRAMUNE SUSP MO VIRAMUNE TABS MO VIRAMUNE XR TB24 100mg, 400mg MO
VIREAD POWD MO VIREAD TABS 150mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 14 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
VIREAD TABS 200mg, 250mg, 300mg MO
VOSEVI TABS PA,NDS XOFLUZA (40 MG DOSE) TBPK MO XOFLUZA (80 MG DOSE) TBPK MO ZEPATIER TABS PA,NDS ZERIT CAPS 15mg, 20mg, 30mg, 40mg MO
ZIAGEN SOLN MO ZIAGEN TABS MO zidovudine caps MO zidovudine syrp MO zidovudine tabs MO URINARY ANTI-INFECTIVES methenamine hippurate tabs MONUROL PACK nitrofurantoin macrocrystal caps nitrofurantoin monohyd macro caps
nitrofurantoin susp trimethoprim tabs MO ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate soln carbinoxamine maleate tabs cetirizine hcl soln CLARINEX SYRP CLARINEX-D 12 HOUR TB12 clemastine fumarate tabs cyproheptadine hcl syrp cyproheptadine hcl tabs desloratadine tabs desloratadine tbdp dexchlorpheniramine maleate soln
levocetirizine dihydrochloride soln
levocetirizine dihydrochloride tabs
phenadoz supp promethazine hcl supp promethazine hcl syrp
Drug Name Requirements/Limits
promethazine hcl tabs promethazine-phenylephrine syrp
promethegan supp ryclora soln ryvent tabs SEMPREX-D CAPS ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS abiraterone acetate tabs NDS ABRAXANE SUSR AFINITOR DISPERZ TBSO 2mg, 3mg, 5mg NDS
AFINITOR TABS 2.5mg, 5mg, 7.5mg, 10mg NDS
ALECENSA CAPS NDS ALIMTA SOLR ALIQOPA SOLR NDS ALUNBRIG TABS 30mg, 90mg, 180mg NDS
ALUNBRIG TBPK NDS anastrozole tabs ARRANON SOLN ARZERRA CONC 1000mg/50ml, 100mg/5ml NDS
ASPARLAS SOLN NDS AVASTIN SOLN AYVAKIT TABS 100mg, 200mg, 300mg NDS
BALVERSA TABS 3mg, 4mg, 5mg NDS
BAVENCIO SOLN NDS BCG VACCINE INJ BELEODAQ SOLR NDS BELRAPZO SOLN NDS BENDAMUSTINE HCL SOLN NDS BENDEKA SOLN NDS BESPONSA SOLR NDS bexarotene caps NDS bicalutamide tabs BICNU SOLR BLINCYTO SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 15
Drug Name Requirements/Limits
BORTEZOMIB SOLR BOSULIF TABS 100mg, 400mg, 500mg NDS
BRAFTOVI CAPS 50mg, 75mg NDS BRUKINSA CAPS NDS CABOMETYX TABS 20mg, 40mg, 60mg NDS
CALQUENCE CAPS NDS CAPRELSA TABS 100mg, 300mg LD,NDS
CISPLATIN SOLR NDS COMETRIQ (100 MG DAILY DOSE) KIT LD,NDS
COMETRIQ (140 MG DAILY DOSE) KIT LD,NDS
COMETRIQ (60 MG DAILY DOSE) KIT LD,NDS
COPIKTRA CAPS 15mg, 25mg NDS COTELLIC TABS NDS cyclophosphamide caps 25mg, 50mg PA
CYRAMZA SOLN 100mg/10ml, 500mg/50ml NDS
DARZALEX SOLN 400mg/20ml, 100mg/5ml NDS
DAURISMO TABS 25mg, 100mg NDS DOCETAXEL (NON-ALCOHOL) SOLN 80mg/4ml, 160mg/8ml, 20mg/ml
NDS
DROXIA CAPS ELIGARD KIT ELZONRIS SOLN NDS EMCYT CAPS NDS EMPLICITI SOLR 300mg, 400mg NDS
ENHERTU SOLR NDS ERBITUX SOLN ERIVEDGE CAPS NDS ERLEADA TABS NDS erlotinib hcl tabs 25mg, 100mg, 150mg NDS
ETOPOPHOS SOLR NDS everolimus tabs 2.5mg, 5mg, 7.5mg NDS
Drug Name Requirements/Limits
EVOMELA SOLR NDS exemestane tabs FARESTON TABS NDS FARYDAK CAPS 10mg, 15mg, 20mg LD,NDS
FASLODEX SOLN NDS FIRMAGON (240 MG DOSE) SOLR
FIRMAGON SOLR flutamide caps fulvestrant soln NDS GAZYVA SOLN NDS GILOTRIF TABS 20mg, 30mg, 40mg NDS
GLEEVEC TABS 100mg, 400mg NDS GLEOSTINE CAPS GLEOSTINE CAPS 40mg, 100mg NDS
HERCEPTIN HYLECTA SOLN NDS HERCEPTIN SOLR 150mg, 440mg NDS
HERZUMA SOLR 150mg, 420mg NDS
HEXALEN CAPS NDS hydroxyurea caps IBRANCE CAPS 75mg, 100mg, 125mg NDS
IBRANCE TABS 75mg, 100mg, 125mg NDS
ICLUSIG TABS 15mg, 45mg LD,NDS IDHIFA TABS 50mg, 100mg NDS imatinib mesylate tabs 100mg, 400mg NDS
IMBRUVICA CAPS 70mg, 140mg NDS
IMBRUVICA TABS 140mg, 280mg, 420mg, 560mg NDS
IMFINZI SOLN 500mg/10ml, 120mg/2.4ml NDS
INFUGEM SOLN NDS INLYTA TABS 1mg, 5mg NDS INREBIC CAPS NDS INTRON A SOLN 10mu/ml, 6000000unit/ml NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 16 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
INTRON A SOLR 10mu, 18mu, 50mu NDS
IRESSA TABS NDS IXEMPRA KIT SOLR NDS JAKAFI TABS 5mg, 10mg, 15mg, 20mg, 25mg NDS
KADCYLA SOLR 100mg, 160mg NDS KANJINTI SOLR 150mg, 420mg NDS KEYTRUDA SOLN NDS KEYTRUDA SOLR NDS KISQALI (200 MG DOSE) TBPK NDS KISQALI (400 MG DOSE) TBPK NDS KISQALI (600 MG DOSE) TBPK NDS KISQALI FEMARA (400 MG DOSE) TBPK NDS
KISQALI FEMARA (600 MG DOSE) TBPK NDS
KISQALI FEMARA (200 MG DOSE) TBPK NDS
KOSELUGO CAPS 10mg, 25mg NDS KYPROLIS SOLR 10mg, 30mg, 60mg NDS
LARTRUVO SOLN 190mg/19ml, 500mg/50ml NDS
LENVIMA (10 MG DAILY DOSE) CPPK LD,NDS
LENVIMA (12 MG DAILY DOSE) CPPK LD,NDS
LENVIMA (14 MG DAILY DOSE) CPPK LD,NDS
LENVIMA (18 MG DAILY DOSE) CPPK LD,NDS
LENVIMA (20 MG DAILY DOSE) CPPK LD,NDS
LENVIMA (24 MG DAILY DOSE) CPPK LD,NDS
LENVIMA (4 MG DAILY DOSE) CPPK LD,NDS
LENVIMA (8 MG DAILY DOSE) CPPK LD,NDS
letrozole tabs LEUKERAN TABS NDS leuprolide acetate kit LIBTAYO SOLN NDS
Drug Name Requirements/Limits
LONSURF TABS NDS LORBRENA TABS 25mg, 100mg NDS
LUMOXITI SOLR NDS LUPANETA PACK KIT LUPRON DEPOT (1-MONTH) KIT
LUPRON DEPOT (3-MONTH) KIT
LUPRON DEPOT (4-MONTH) KIT
LUPRON DEPOT (6-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT
LUPRON DEPOT-PED (1-MONTH) KIT 7.5 MG
LUPRON DEPOT-PED (3-MONTH) KIT
LYNPARZA CAPS NDS LYNPARZA TABS 100mg, 150mg NDS
LYSODREN TABS NDS MARQIBO SUSP NDS MATULANE CAPS NDS megestrol acetate susp megestrol acetate tabs MEKINIST TABS .5mg, 2mg NDS MEKTOVI TABS NDS mercaptopurine tabs methotrexate sodium (pf) soln METHOTREXATE SODIUM SOLN
methotrexate tabs PA MUSTARGEN SOLR MVASI SOLN 400mg/16ml, 100mg/4ml NDS
MYLOTARG SOLR NDS NERLYNX TABS NDS NEXAVAR TABS NDS nilutamide tabs NINLARO CAPS 2.3mg, 3mg, 4mg NDS
NUBEQA TABS NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 17
Drug Name Requirements/Limits
ODOMZO CAPS NDS OGIVRI SOLR NDS ONIVYDE INJ NDS ONTRUZANT SOLR 150mg, 420mg NDS
OPDIVO SOLN 100mg/10ml, 240mg/24ml, 40mg/4ml NDS
PADCEV SOLR 20mg, 30mg NDS PEMAZYRE TABS 4.5mg, 9mg, 13.5mg NDS
PERJETA SOLN NDS PIQRAY (200 MG DAILY DOSE) TBPK NDS
PIQRAY (250 MG DAILY DOSE) TBPK NDS
PIQRAY (300 MG DAILY DOSE) TBPK NDS
POLIVY SOLR NDS POMALYST CAPS 1mg, 2mg, 3mg, 4mg NDS
PORTRAZZA SOLN NDS POTELIGEO SOLN NDS PROLEUKIN SOLR NDS PURIXAN SUSP NDS REVLIMID CAPS 2.5mg, 5mg, 10mg, 15mg, 20mg, 25mg NDS
RITUXAN HYCELA SOLN RITUXAN SOLN ROMIDEPSIN SOLN NDS ROZLYTREK CAPS 100mg, 200mg NDS
RUBRACA TABS 200mg, 250mg, 300mg NDS
RUXIENCE SOLN 100mg/10ml, 500mg/50ml NDS
RYDAPT CAPS NDS SARCLISA SOLN 500mg/25ml, 100mg/5ml NDS
SIKLOS TABS NDS SOLTAMOX SOLN SPRYCEL TABS 20mg, 50mg, 70mg, 80mg, 100mg, 140mg NDS
STIVARGA TABS NDS
Drug Name Requirements/Limits
SUTENT CAPS 12.5mg, 25mg, 37.5mg, 50mg NDS
SYLATRON KIT SYLVANT SOLR 100mg, 400mg NDS SYNRIBO SOLR NDS TABLOID TABS TAFINLAR CAPS 50mg, 75mg NDS TAGRISSO TABS 40mg, 80mg NDS TALZENNA CAPS .25mg, 1mg NDS tamoxifen citrate tabs TARCEVA TABS 25mg, 100mg, 150mg NDS
TARGRETIN CAPS NDS TASIGNA CAPS 50mg, 150mg, 200mg NDS
TAZVERIK TABS NDS TECENTRIQ SOLN 840mg/14ml, 1200mg/20ml NDS
TENIPOSIDE SOLN TEPADINA SOLR NDS THALOMID CAPS 50mg, 100mg, 150mg, 200mg NDS
thiotepa solr 15mg, 100mg NDS TIBSOVO TABS NDS toremifene citrate tabs NDS TRAZIMERA SOLR NDS TRELSTAR MIXJECT SUSR tretinoin caps NDS trexall tabs 5mg, 7.5mg, 10mg, 15mg PA
TRISENOX SOLN 10mg/10ml NDS TRISENOX SOLN NDS TRODELVY SOLR NDS TRUXIMA SOLN 100mg/10ml, 500mg/50ml NDS
TUKYSA TABS 50mg, 150mg NDS TURALIO CAPS NDS TYKERB TABS NDS UNITUXIN SOLN NDS VANTAS KIT VELCADE SOLR VENCLEXTA STARTING PACK TBPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 18 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
VENCLEXTA TABS 10mg, 50mg NDS VENCLEXTA TABS NDS VERZENIO TABS 50mg, 100mg, 150mg, 200mg NDS
VITRAKVI CAPS 25mg, 100mg NDS VITRAKVI SOLN NDS VIZIMPRO TABS 15mg, 30mg, 45mg NDS
VOTRIENT TABS NDS VYXEOS SUSR NDS XALKORI CAPS 200mg, 250mg NDS XATMEP SOLN PA,NDS XOSPATA TABS NDS XPOVIO (100 MG ONCE WEEKLY) TBPK NDS
XPOVIO (60 MG ONCE WEEKLY) TBPK NDS
XPOVIO (80 MG ONCE WEEKLY) TBPK NDS
XPOVIO (80 MG TWICE WEEKLY) TBPK NDS
XTANDI CAPS NDS YERVOY SOLN YONDELIS SOLR NDS YONSA TABS NDS ZALTRAP SOLN 100mg/4ml, 200mg/8ml NDS
ZEJULA CAPS NDS ZELBORAF TABS NDS ZIRABEV SOLN 400mg/16ml, 100mg/4ml NDS
ZOLINZA CAPS NDS ZYDELIG TABS 100mg, 150mg NDS ZYKADIA CAPS NDS ZYKADIA TABS NDS ZYTIGA TABS 250mg, 500mg NDS AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA AEPB MO ATROVENT HFA AERS MO BEVESPI AEROSPHERE AERO MO CUVPOSA SOLN MO dicyclomine hcl caps MO
Drug Name Requirements/Limits
dicyclomine hcl soln MO dicyclomine hcl tabs MO DUAKLIR PRESSAIR AEPB NDS glycopyrrolate tabs 1mg, 2mg MO INCRUSE ELLIPTA AEPB MO ipratropium bromide soln .02% PA,MO ipratropium bromide soln .03%, .06% MO
LONHALA MAGNAIR REFILL KIT SOLN NDS
methscopolamine bromide tabs 2.5mg, 5mg MO
propantheline bromide tabs MO SPIRIVA HANDIHALER CAPS MO SPIRIVA RESPIMAT AERS 2.5mcg/act MO
SPIRIVA RESPIMAT AERS MO STIOLTO RESPIMAT AERS MO TUDORZA PRESSAIR AEPB MO YUPELRI SOLN PA,NDS AUTONOMIC DRUGS, MISCELLANEOUS CHANTIX CONTINUING MONTH PAK TABS MO
CHANTIX STARTING MONTH PAK TABS MO
CHANTIX TABS .5mg, 1mg MO NICOTROL INHA MO NICOTROL NS SOLN MO PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS bethanechol chloride tabs 5mg, 10mg, 25mg, 50mg MO
cevimeline hcl caps MO donepezil hcl tabs 5mg, 10mg, 23mg MO
donepezil hcl tbdp 5mg, 10mg MO galantamine hydrobromide er cp24 8mg, 16mg, 24mg MO
galantamine hydrobromide soln MO galantamine hydrobromide tabs 4mg, 8mg, 12mg MO
GUANIDINE HCL TABS MO MESTINON SOLN MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 19
Drug Name Requirements/Limits
pilocarpine hcl tabs 5mg, 7.5mg MO pyridostigmine bromide er tbcr MO pyridostigmine bromide soln MO pyridostigmine bromide tabs 30mg, 60mg MO
REGONOL SOLN rivastigmine pt24 4.6mg/24hr, 9.5mg/24hr, 13.3mg/24hr MO
rivastigmine tartrate caps 1.5mg, 3mg, 4.5mg, 6mg MO
urecholine tabs 5mg, 10mg, 25mg, 50mg MO
SKELETAL MUSCLE RELAXANTS baclofen tabs 5mg, 10mg, 20mg MO carisoprodol tabs 250mg, 350mg PA,NDS carisoprodol-aspirin tabs PA,NDS carisoprodol-aspirin-codeine tabs PA,NDS
chlorzoxazone tabs 375mg, 500mg, 750mg NDS
cyclobenzaprine hcl er cp24 15mg, 30mg PA
cyclobenzaprine hcl tabs 5mg, 7.5mg, 10mg PA
dantrolene sodium caps fexmid tabs PA lorzone tabs 375mg, 750mg NDS metaxall tabs metaxalone tabs methocarbamol tabs orphenadrine citrate er tb12 tizanidine hcl caps tizanidine hcl tabs SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl er tb24 MO D.H.E. 45 SOLN NDS DIBENZYLINE CAPS NDS dihydroergotamine mesylate soln NDS ergoloid mesylates tabs MO phenoxybenzamine hcl caps NDS silodosin caps 4mg, 8mg MO
Drug Name Requirements/Limits
tamsulosin hcl caps MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADVAIR DISKUS AEPB MO ADVAIR HFA AERO MO albuterol sulfate er tb12 4mg, 8mg MO
ALBUTEROL SULFATE HFA AERS 108mcg/act, 108mcg/act MO,NDS
albuterol sulfate nebu .083%, 2.5mg/0.5ml PA,MO
albuterol sulfate nebu .63mg/3ml, 1.25mg/3ml PA,MO
albuterol sulfate syrp MO albuterol sulfate tabs 2mg, 4mg MO ARCAPTA NEOHALER CAPS MO BROVANA NEBU PA,MO,NDS COMBIVENT RESPIMAT AERS MO epinephrine soaj EPIPEN 2-PAK SOAJ EPIPEN JR 2-PAK SOAJ fluticasone-salmeterol aepb MO ipratropium-albuterol soln PA,MO LEVALBUTEROL HCL NEBU 1.25mg/0.5ml, .31mg/3ml, .63mg/3ml, 1.25mg/3ml, .31mg/3ml, .63mg/3ml, 1.25mg/3ml
PA,MO
levalbuterol tartrate aero MO metaproterenol sulfate syrp MO metaproterenol sulfate tabs 10mg, 20mg MO
midodrine hcl tabs 2.5mg, 5mg, 10mg MO
NORTHERA CAPS 100mg, 200mg, 300mg NDS
PERFOROMIST NEBU PA,MO PROAIR RESPICLICK AEPB MO SEREVENT DISKUS AEPB MO STRIVERDI RESPIMAT AERS MO terbutaline sulfate tabs 2.5mg, 5mg MO
VENTOLIN HFA AERS MO,NDS wixela inhub aepb
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 20 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
BLOOD FORMATION, COAGULATION, AND THROMBOSIS BLOOD FORMATION MODIFIERS ADAKVEO SOLN NDS BERINERT KIT INTRAVENOUS HI CINRYZE SOLR INTRAVENOUS HI
FIRAZYR SOLN NDS icatibant acetate soln NDS OXBRYTA TABS NDS RUCONEST SOLR INTRAVENOUS HI
COAGULANTS AND ANTICOAGULANTS AMICAR TABS MO anagrelide hcl caps .5mg, 1mg MO ARIXTRA SOLN 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml NDS
aspirin-dipyridamole er cp12 MO BEVYXXA CAPS 40mg, 80mg MO BRILINTA TABS 60mg, 90mg MO cilostazol tabs 50mg, 100mg MO clopidogrel bisulfate tabs MO ELIQUIS DVT/PE STARTER PACK TABS MO
ELIQUIS TABS 2.5mg, 5mg MO enoxaparin sodium soln 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 120mg/0.8ml, 300mg/3ml, 100mg/ml, 150mg/ml
NDS
fondaparinux sodium soln 2.5mg/0.5ml NDS
fondaparinux sodium soln 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml
NDS
FRAGMIN SOLN 2500unit/0.2ml, 5000unit/0.2ml, 7500unit/0.3ml, 12500unit/0.5ml, 15000unit/0.6ml, 95000unit/3.8ml, 10000unit/ml, 18000unt/0.72ml
NDS
heparin sodium (porcine) soln 1000unit/ml, 5000unit/ml, 10000unit/ml, 20000unit/ml
PA
Drug Name Requirements/Limits
jantoven tabs 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg
MO
LOVENOX SOLN 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 120mg/0.8ml, 300mg/3ml, 100mg/ml, 150mg/ml
NDS
pentoxifylline er tbcr MO PRADAXA CAPS 75mg, 110mg, 150mg MO
prasugrel hcl tabs 5mg, 10mg MO SAVAYSA TABS 15mg, 30mg, 60mg MO
tranexamic acid tabs MO warfarin sodium tabs 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 10mg
MO
XARELTO STARTER PACK TBPK MO
XARELTO TABS 2.5mg, 10mg, 15mg, 20mg MO
ZONTIVITY TABS MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) SOLN 25mcg/ml, 40mcg/ml, 60mcg/ml, 100mcg/ml, 200mcg/ml, 300mcg/ml
PA,NDS
ARANESP (ALBUMIN FREE) SOSY 25mcg/0.42ml, 10mcg/0.4ml, 40mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml
PA,NDS
ARANESP (ALBUMIN FREE) SOSY 60mcg/0.3ml, 150mcg/0.3ml, 200mcg/0.4ml, 100mcg/0.5ml
PA,NDS
CABLIVI KIT NDS DOPTELET TABS NDS EPOGEN SOLN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml, 20000unit/ml
PA,NDS
FULPHILA SOSY NDS GRANIX SOLN 480mcg/1.6ml, 300mcg/ml NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 21
Drug Name Requirements/Limits
GRANIX SOSY 300mcg/0.5ml, 480mcg/0.8ml NDS
LEUKINE SOLR NDS MIRCERA SOSY 30mcg/0.3ml, 50mcg/0.3ml, 75mcg/0.3ml, 100mcg/0.3ml, 150mcg/0.3ml, 200mcg/0.3ml
PA
MULPLETA TABS NDS NEULASTA ONPRO PSKT NDS NEULASTA SOSY NDS NEUPOGEN SOLN 480mcg/1.6ml, 300mcg/ml NDS
NEUPOGEN SOSY 300mcg/0.5ml, 480mcg/0.8ml NDS
NIVESTYM SOLN 480mcg/1.6ml, 300mcg/ml NDS
NIVESTYM SOSY 300mcg/0.5ml, 480mcg/0.8ml NDS
NPLATE SOLR NDS PROCRIT SOLN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml, 20000unit/ml, 40000unit/ml
PA,NDS
PROMACTA PACK 12.5mg, 25mg NDS
PROMACTA TABS 12.5mg, 25mg, 50mg, 75mg NDS
REBLOZYL SOLR 25mg, 75mg NDS RETACRIT SOLN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml, 40000unit/ml
PA,NDS
TAVALISSE TABS 100mg, 150mg NDS
UDENYCA SOSY NDS ZARXIO SOSY 300mcg/0.5ml, 480mcg/0.8ml NDS
ZIEXTENZO SOSY NDS CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA XL TB24 4mg, 8mg MO DEMSER CAPS MO doxazosin mesylate tabs 1mg, 2mg, 4mg, 8mg MO
prazosin hcl caps 1mg, 2mg, 5mg MO
Drug Name Requirements/Limits
terazosin hcl caps 1mg, 2mg, 5mg, 10mg MO
ANTILIPEMIC AGENTS ALTOPREV TB24 20mg, 40mg, 60mg MO
ANTARA CAPS 30mg, 90mg MO atorvastatin calcium tabs 10mg, 20mg, 40mg, 80mg MO
cholestyramine light powd MO cholestyramine pack MO colesevelam hcl pack MO colesevelam hcl tabs MO colestipol hcl pack MO colestipol hcl tabs MO ezetimibe tabs MO ezetimibe-simvastatin tabs MO fenofibrate caps 50mg, 150mg MO fenofibrate micronized caps 43mg, 67mg, 130mg, 134mg, 200mg
MO
fenofibrate tabs 40mg, 48mg, 54mg, 120mg, 145mg, 160mg MO
fenofibric acid cpdr 45mg, 135mg MO
FENOFIBRIC ACID TABS 35mg, 105mg MO
FIBRICOR TABS MO FLOLIPID SUSP 20mg/5ml, 40mg/5ml MO
fluvastatin sodium caps 20mg, 40mg MO
fluvastatin sodium er tb24 MO gemfibrozil tabs MO JUXTAPID CAPS 5mg, 10mg, 20mg, 30mg, 40mg, 60mg PA,LD,NDS
KYNAMRO SOSY PA,LD,NDS LIVALO TABS 1mg, 2mg, 4mg MO lovastatin tabs 10mg, 20mg, 40mg MO
niacin er (antihyperlipidemic) tbcr 500mg, 750mg, 1000mg MO
niacor tabs MO omega-3-acid ethyl esters caps MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 22 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
PRALUENT SOAJ 75mg/ml, 150mg/ml PA,NDS
PRALUENT SOSY 75mg/ml, 150mg/ml PA,NDS
pravastatin sodium tabs 10mg, 20mg, 40mg, 80mg MO
prevalite pack MO questran light powd MO questran pack MO REPATHA PUSHTRONEX SYSTEM SOCT PA,NDS
REPATHA SOSY PA,NDS REPATHA SURECLICK SOAJ PA,NDS rosuvastatin calcium tabs 5mg, 10mg, 20mg, 40mg MO
simvastatin tabs 5mg, 10mg, 20mg, 40mg, 80mg MO
VASCEPA CAPS .5gm, 1gm MO ZYPITAMAG TABS 1mg, 2mg, 4mg MO
BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl caps 200mg, 400mg MO
atenolol tabs 25mg, 50mg, 100mg MO
atenolol-chlorthalidone tabs MO betaxolol hcl tabs 10mg, 20mg MO bisoprolol fumarate tabs 5mg, 10mg MO
bisoprolol-hydrochlorothiazide tabs MO
BYSTOLIC TABS 2.5mg, 5mg, 10mg, 20mg MO
carvedilol phosphate er cp24 10mg, 20mg, 40mg, 80mg MO
carvedilol tabs 3.125mg, 6.25mg, 12.5mg, 25mg MO
DUTOPROL TB24 MO INNOPRAN XL CP24 80mg, 120mg MO
labetalol hcl tabs 100mg, 200mg, 300mg MO
metoprolol succinate er tb24 25mg, 50mg, 100mg, 200mg MO
Drug Name Requirements/Limits
metoprolol tartrate tabs 25mg, 50mg, 100mg MO
metoprolol tartrate tabs 37.5mg, 75mg MO
metoprolol-hydrochlorothiazide tabs MO
nadolol tabs 20mg, 40mg, 80mg MO nadolol-bendroflumethiazide tabs MO
pindolol tabs 5mg, 10mg MO propranolol hcl er cp24 60mg, 80mg, 120mg, 160mg MO
propranolol hcl soln 20mg/5ml, 40mg/5ml MO
propranolol hcl tabs 10mg, 20mg, 40mg, 60mg, 80mg MO
propranolol-hctz tabs MO sorine tabs 80mg, 120mg, 160mg, 240mg MO
sotalol hcl (af) tabs 80mg, 120mg, 160mg MO
sotalol hcl tabs 80mg, 120mg, 160mg, 240mg MO
SOTYLIZE SOLN MO timolol maleate tabs 5mg, 10mg, 20mg MO
CALCIUM-CHANNEL BLOCKING AGENTS amlodipine besy-benazepril hcl caps MO
amlodipine besylate tabs 2.5mg, 5mg, 10mg MO
amlodipine besylate-valsartan tabs MO
amlodipine-atorvastatin tabs MO amlodipine-olmesartan tabs MO amlodipine-valsartan-hctz tabs MO CARDENE IV SOLN CARDIZEM LA TB24 MO cartia xt cp24 120mg, 180mg, 240mg, 300mg MO
CONSENSI TABS NDS dilt-xr cp24 120mg, 180mg, 240mg MO
diltiazem hcl er beads cp24 360mg, 420mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 23
Drug Name Requirements/Limits
diltiazem hcl er coated beads cp24 120mg, 180mg, 240mg, 300mg
MO
diltiazem hcl er cp12 60mg, 90mg, 120mg MO
diltiazem hcl tabs 30mg, 60mg, 90mg, 120mg MO
felodipine er tb24 2.5mg, 5mg, 10mg MO
isradipine caps 2.5mg, 5mg MO matzim la tb24 180mg, 240mg, 300mg, 360mg, 420mg MO
nicardipine hcl caps 20mg, 30mg MO nifedipine caps 10mg, 20mg MO nifedipine er osmotic release tb24 30mg, 60mg, 90mg MO
nifedipine er tb24 30mg, 60mg, 90mg MO
nimodipine caps MO nisoldipine er tb24 8.5mg, 17mg, 20mg, 25.5mg, 30mg, 34mg, 40mg
MO
NYMALIZE SOLN MO olmesartan-amlodipine-hctz tabs MO taztia xt cp24 120mg, 180mg, 240mg, 300mg, 360mg MO
telmisartan-amlodipine tabs MO tiadylt er cp24 120mg, 180mg, 240mg, 300mg, 360mg, 420mg MO
trandolapril-verapamil hcl er tbcr MO VERAPAMIL HCL ER CP24 120mg, 180mg, 240mg, 100mg, 200mg, 300mg, 360mg
MO
verapamil hcl er tbcr 120mg, 180mg, 240mg MO
verapamil hcl tabs 80mg, 120mg MO verapamil hcl tabs MO VERELAN CP24 MO CARDIAC DRUGS amiodarone hcl tabs 100mg, 200mg, 400mg MO
CORLANOR TABS 5mg, 7.5mg MO digitek tabs .125mg, .25mg MO digox tabs
Drug Name Requirements/Limits
digoxin soln .05mg/ml MO DIGOXIN SOLN MO digoxin tabs 125mcg, 250mcg MO disopyramide phosphate caps 100mg, 150mg MO
dofetilide caps 125mcg, 250mcg, 500mcg MO
flecainide acetate tabs 50mg, 100mg, 150mg MO
LANOXIN PEDIATRIC SOLN LANOXIN TABS MO mexiletine hcl caps 150mg, 200mg, 250mg MO
MULTAQ TABS NORPACE CR CP12 100mg, 150mg MO
pacerone tabs 100mg, 200mg, 400mg MO
propafenone hcl er cp12 225mg, 325mg, 425mg MO
propafenone hcl tabs 150mg, 225mg, 300mg MO
quinidine gluconate er tbcr MO QUINIDINE GLUCONATE SOLN quinidine sulfate tabs 200mg, 300mg MO
ranolazine er tb12 500mg, 1000mg MO
VYNDAMAX CAPS NDS VYNDAQEL CAPS NDS HYPOTENSIVE AGENTS clonidine hcl er tb12 MO clonidine hcl tabs .1mg, .2mg, .3mg MO
clonidine ptwk .1mg/24hr, .2mg/24hr, .3mg/24hr MO
guanfacine hcl tabs 1mg, 2mg MO hydralazine hcl tabs 10mg, 25mg, 50mg, 100mg MO
methyldopa tabs 250mg, 500mg MO methyldopa-hydrochlorothiazide tabs MO
minoxidil tabs 2.5mg, 10mg MO vecamyl tabs NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 24 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ALDACTAZIDE TABS MO aliskiren fumarate tabs 150mg, 300mg MO
benazepril hcl tabs 5mg, 10mg, 20mg, 40mg MO
benazepril-hydrochlorothiazide tabs MO
BYVALSON TABS MO candesartan cilexetil tabs 4mg, 8mg, 16mg, 32mg MO
candesartan cilexetil-hctz tabs MO captopril tabs 12.5mg, 25mg, 50mg, 100mg MO
captopril-hydrochlorothiazide tabs MO
CAROSPIR SUSP MO EDARBI TABS 40mg, 80mg MO EDARBYCLOR TABS MO enalapril maleate tabs 2.5mg, 5mg, 10mg, 20mg MO
enalapril-hydrochlorothiazide tabs MO
ENTRESTO TABS MO eplerenone tabs 25mg, 50mg MO eprosartan mesylate tabs MO fosinopril sodium tabs 10mg, 20mg, 40mg MO
fosinopril sodium-hctz tabs MO irbesartan tabs 75mg, 150mg, 300mg MO
irbesartan-hydrochlorothiazide tabs MO
lisinopril tabs 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg MO
lisinopril-hydrochlorothiazide tabs MO
losartan potassium tabs 25mg, 50mg, 100mg MO
losartan potassium-hctz tabs MO moexipril hcl tabs 7.5mg, 15mg MO olmesartan medoxomil tabs 5mg, 20mg, 40mg MO
Drug Name Requirements/Limits
olmesartan medoxomil-hctz tabs MO perindopril erbumine tabs 2mg, 4mg, 8mg MO
QBRELIS SOLN MO quinapril hcl tabs 5mg, 10mg, 20mg, 40mg MO
quinapril-hydrochlorothiazide tabs MO
ramipril caps 1.25mg, 2.5mg, 5mg, 10mg MO
spironolactone tabs 25mg, 50mg, 100mg MO
spironolactone-hctz tabs MO TEKTURNA HCT TABS MO telmisartan tabs 20mg, 40mg, 80mg MO
telmisartan-hctz tabs MO trandolapril tabs 1mg, 2mg, 4mg MO valsartan tabs 40mg, 80mg, 160mg, 320mg MO
valsartan-hydrochlorothiazide tabs MO
VASODILATING AGENTS ADCIRCA TABS PA alyq tabs PA BIDIL TABS MO dipyridamole tabs 25mg, 50mg, 75mg MO
GONITRO PACK MO ISORDIL TITRADOSE TABS MO isosorbide dinitrate er tbcr MO isosorbide dinitrate tabs 5mg, 10mg, 20mg, 30mg, 40mg MO
isosorbide mononitrate er tb24 30mg, 60mg MO
isosorbide mononitrate er tb24 MO isosorbide mononitrate tabs 10mg, 20mg MO
minitran pt24 .1mg/hr, .2mg/hr, .4mg/hr, .6mg/hr MO
nitro-bid oint MO NITRO-DUR PT24 .3mg/hr, .8mg/hr MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 25
Drug Name Requirements/Limits
nitroglycerin pt24 .1mg/hr, .2mg/hr, .4mg/hr, .6mg/hr MO
nitroglycerin soln MO nitroglycerin subl .3mg, .4mg, .6mg MO
REVATIO SOLN PA,NDS REVATIO SUSR PA REVATIO TABS PA sildenafil citrate soln PA,NDS sildenafil citrate susr PA sildenafil citrate tabs PA,MO tadalafil (pah) tabs 20mg PA tadalafil tabs 2.5mg, 5mg PA CENTRAL NERVOUS SYSTEM AGENTS ALCOHOL DETERRENTS acamprosate calcium tbec MO antabuse tabs 250mg, 500mg MO disulfiram tabs 250mg, 500mg MO ANALGESICS AND ANTIPYRETICS ABSTRAL SUBL 100mcg, 200mcg, 300mcg, 400mcg, 600mcg, 800mcg
PA,NDS
acetaminophen-codeine #3 tabs NDS acetaminophen-codeine soln NDS acetaminophen-codeine tabs NDS ACTIQ LPOP 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg PA,NDS
allzital tabs apap-caff-dihydrocodeine tabs NDS ARYMO ER TBEA NDS ascomp-codeine caps NDS BELBUCA FILM 75mcg, 150mcg, 300mcg, 450mcg, 600mcg, 750mcg, 900mcg
NDS
bupap tabs buprenorphine ptwk 5mcg/hr, 7.5mcg/hr, 10mcg/hr, 15mcg/hr, 20mcg/hr
NDS
butalbital-acetaminophen caps NDS butalbital-acetaminophen tabs butalbital-apap-caff-cod caps NDS butalbital-apap-caffeine caps
Drug Name Requirements/Limits
butalbital-apap-caffeine tabs butalbital-asa-caff-codeine caps NDS butalbital-aspirin-caffeine caps butorphanol tartrate soln NDS BUTRANS PTWK NDS celecoxib caps codeine sulfate tabs 15mg, 30mg, 60mg NDS
DEMEROL SOLN 25mg/0.5ml, 75mg/1.5ml, 100mg/2ml, 75mg/ml
PA,NDS
diclofenac potassium tabs diclofenac sodium er tb24 diclofenac sodium tbec diclofenac-misoprostol tbec diflunisal tabs DUEXIS TABS NDS DURAMORPH SOLN .5mg/ml, 1mg/ml HI,NDS
dvorah tabs NDS EMBEDA CPCR NDS endocet tabs NDS esgic tabs etodolac caps etodolac er tb24 etodolac tabs fenoprofen calcium caps fenoprofen calcium tabs FENTANYL CITRATE (PF) SOLN 1000mcg/20ml, 2500mcg/50ml
NDS
FENTANYL CITRATE (PF) SOLN 100mcg/2ml, 250mcg/5ml NDS
fentanyl citrate lpop 200mcg PA,NDS fentanyl citrate lpop 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg
PA,NDS
fentanyl citrate tabs 100mcg, 200mcg, 400mcg, 600mcg, 800mcg
PA,NDS
fentanyl pt72 12mcg/hr, 25mcg/hr, 37.5mcg/hr, 50mcg/hr, 62.5mcg/hr,
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 26 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
75mcg/hr, 87.5mcg/hr, 100mcg/hr FENTORA TABS 100mcg, 200mcg, 400mcg, 600mcg, 800mcg
PA,NDS
fioricet caps fioricet/codeine caps NDS flurbiprofen tabs GRALISE STARTER MISC GRALISE TABS hydrocodone bitartrate er c12a NDS hydrocodone-acetaminophen soln NDS
hydrocodone-acetaminophen tabs NDS
hydrocodone-ibuprofen tabs NDS hydromorphone hcl er t24a 8mg, 12mg, 16mg, 32mg NDS
hydromorphone hcl liqd NDS hydromorphone hcl pf soln 50mg/5ml, 10mg/ml NDS
HYDROMORPHONE HCL SOLN NDS
hydromorphone hcl tabs 2mg, 4mg, 8mg NDS
ibu tabs ibudone tabs NDS ibuprofen susp ibuprofen tabs ILARIS SOLN NDS indocin supp INDOCIN SUSP indomethacin caps indomethacin er cpcr KADIAN CP24 NDS ketoprofen caps ketoprofen er cp24 ketorolac tromethamine tabs LAZANDA SOLN 100mcg/act, 300mcg/act, 400mcg/act PA,NDS
levorphanol tartrate tabs 2mg NDS levorphanol tartrate tabs NDS lodine tabs
Drug Name Requirements/Limits
lorcet hd tabs NDS lorcet plus tabs NDS lorcet tabs NDS LYRICA CR TB24 82.5mg, 165mg, 330mg MO
meclofenamate sodium caps mefenamic acid caps meloxicam tabs meperidine hcl soln 50mg/5ml, 10mg/ml, 25mg/ml, 50mg/ml, 100mg/ml
PA,NDS
meperidine hcl tabs 50mg, 100mg NDS
methadone hcl soln 5mg/5ml, 10mg/5ml NDS
methadone hcl tabs 5mg, 10mg NDS morphine sulfate (concentrate) soln NDS
MORPHINE SULFATE (PF) SOLN INTRAVENOUS HI
morphine sulfate er beads cp24 30mg, 45mg, 60mg, 75mg, 90mg, 120mg
NDS
morphine sulfate er cp24 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, 80mg, 100mg
NDS
morphine sulfate er tbcr 15mg, 30mg, 60mg, 100mg, 200mg NDS
morphine sulfate soln 10mg/5ml, 20mg/5ml NDS
MORPHINE SULFATE SOLN HI,NDS MORPHINE SULFATE SOLN INJECTION 2mg/ml, 4mg/ml, 10mg/ml
HI
MORPHINE SULFATE SOLN INTRAVENOUS HI
morphine sulfate tabs 15mg, 30mg NDS
MORPHINE SULFATE TABS 15mg, 30mg NDS
nabumetone tabs nalfon tabs nalocet tabs NDS NAPRELAN TB24
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 27
Drug Name Requirements/Limits
naproxen dr tbec naproxen sodium er tb24 naproxen sodium tabs naproxen susp naproxen tabs naproxen-esomeprazole tbec NDS norco tabs NDS NUCYNTA ER TB12 50mg, 100mg, 150mg NDS
NUCYNTA ER TB12 200mg, 250mg NDS
NUCYNTA TABS 50mg, 75mg NDS NUCYNTA TABS NDS oxaprozin tabs OXAYDO TABA NDS oxycodone hcl caps NDS oxycodone hcl conc NDS oxycodone hcl er t12a 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg
NDS
oxycodone hcl soln NDS oxycodone hcl tabs 5mg, 10mg, 15mg, 20mg, 30mg NDS
oxycodone-acetaminophen tabs NDS oxycodone-aspirin tabs NDS oxycodone-ibuprofen tabs NDS OXYCONTIN T12A 10mg, 15mg, 20mg, 30mg, 40mg, 60mg, 80mg
NDS
oxymorphone hcl er tb12 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg, 40mg
NDS
oxymorphone hcl tabs 5mg, 10mg NDS
panlor tabs NDS pentazocine-naloxone hcl tabs NDS percocet tabs NDS phrenilin forte caps piroxicam caps 10mg, 20mg NDS primlev tabs NDS prolate tabs NDS relafen ds tabs NDS
Drug Name Requirements/Limits
ROXYBOND TABA 5mg, 15mg, 30mg NDS
SUBSYS LIQD 100mcg, 200mcg, 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg
PA,NDS
sulindac tabs tencon tabs TIVORBEX CAPS tolmetin sodium caps tolmetin sodium tabs tramadol hcl er (biphasic) tb24 100mg, 200mg, 300mg NDS
tramadol hcl er cp24 100mg, 200mg, 300mg NDS
tramadol hcl er tb24 100mg, 200mg, 300mg NDS
tramadol hcl tabs 50mg, 100mg NDS tramadol-acetaminophen tabs NDS trezix caps NDS tylenol with codeine #3 tabs NDS tylenol with codeine #4 tabs NDS vanatol lq soln vicodin es tabs NDS vicodin hp tabs NDS vicodin tabs NDS VIMOVO TBEC NDS VIVLODEX CAPS XTAMPZA ER C12A 9mg, 13.5mg, 18mg, 27mg, 36mg NDS
zebutal caps ZIPSOR CAPS ZORVOLEX CAPS ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS adderall tabs NDS ADDERALL XR CP24 NDS ADZENYS ER SUER NDS ADZENYS XR-ODT TBED 3.1mg, 6.3mg, 9.4mg, 12.5mg, 15.7mg, 18.8mg
NDS
amphetamine er suer NDS amphetamine sulfate tabs 5mg, 10mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 28 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
amphetamine-dextroamphet er cp24 NDS
amphetamine-dextroamphetamine tabs NDS
APTENSIO XR CP24 10mg, 15mg, 20mg, 30mg, 40mg, 50mg, 60mg
NDS
armodafinil tabs 50mg, 150mg, 200mg, 250mg PA
COTEMPLA XR-ODT TBED 8.6mg, 17.3mg, 25.9mg NDS
DAYTRANA PTCH 10mg/9hr, 15mg/9hr, 20mg/9hr, 30mg/9hr NDS
dexmethylphenidate hcl er cp24 5mg, 10mg, 15mg, 20mg, 25mg, 30mg, 35mg, 40mg
NDS
dexmethylphenidate hcl tabs 2.5mg, 5mg, 10mg NDS
dextroamphetamine sulfate er cp24 5mg, 10mg, 15mg NDS
dextroamphetamine sulfate soln NDS dextroamphetamine sulfate tabs 5mg, 10mg NDS
DYANAVEL XR SUER NDS evekeo tabs 5mg, 10mg NDS metadate er tbcr NDS methamphetamine hcl tabs PA,NDS methylphenidate hcl chew 2.5mg, 5mg, 10mg NDS
methylphenidate hcl er (cd) cpcr 10mg, 20mg, 30mg, 40mg, 50mg, 60mg
NDS
methylphenidate hcl er (la) cp24 10mg, 20mg, 30mg, 40mg, 60mg
NDS
methylphenidate hcl er tb24 18mg, 27mg, 36mg, 54mg NDS
methylphenidate hcl er tbcr 10mg, 18mg, 20mg, 27mg, 36mg, 54mg, 72mg
NDS
methylphenidate hcl soln 5mg/5ml, 10mg/5ml NDS
methylphenidate hcl tabs 5mg, 10mg, 20mg NDS
modafinil tabs 100mg, 200mg PA,NDS
Drug Name Requirements/Limits
MYDAYIS CP24 NDS procentra soln NDS QUILLICHEW ER CHER 20mg, 30mg, 40mg NDS
QUILLIVANT XR SRER NDS relexxii tbcr NDS SUNOSI TABS 75mg, 150mg NDS VYVANSE CAPS 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, 70mg
NDS
VYVANSE CHEW 10mg, 20mg, 30mg, 40mg, 50mg, 60mg NDS
WAKIX TABS 4.45mg, 17.8mg NDS zenzedi tabs 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg
NDS
ANTICONVULSANTS APTIOM TABS 200mg, 400mg, 600mg, 800mg MO
BANZEL SUSP BANZEL TABS 200mg, 400mg NDS BRIVIACT SOLN NDS BRIVIACT TABS 10mg, 25mg, 50mg, 75mg, 100mg NDS
carbamazepine chew MO carbamazepine er cp12 100mg, 200mg, 300mg MO
carbamazepine er tb12 100mg, 200mg, 400mg MO
carbamazepine susp MO carbamazepine tabs MO CELONTIN CAPS MO clobazam susp MO clobazam tabs 10mg, 20mg MO clonazepam tabs .5mg, 1mg, 2mg NDS
clonazepam tbdp .125mg, .25mg, .5mg, 1mg, 2mg NDS
DIACOMIT CAPS 250mg, 500mg NDS
DIACOMIT PACK 250mg, 500mg NDS
DIASTAT ACUDIAL GEL 10mg, 20mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 29
Drug Name Requirements/Limits
DIASTAT PEDIATRIC GEL NDS diazepam gel 2.5mg, 10mg, 20mg NDS
dilantin caps 30mg, 100mg MO dilantin infatabs chew MO divalproex sodium csdr MO divalproex sodium er tb24 250mg, 500mg MO
divalproex sodium tbec 125mg, 250mg, 500mg MO
EPIDIOLEX SOLN NDS epitol tabs MO ethosuximide caps MO ethosuximide soln MO felbamate susp MO felbamate tabs 400mg, 600mg MO FELBATOL SUSP FELBATOL TABS FYCOMPA SUSP NDS FYCOMPA TABS gabapentin caps 100mg, 400mg MO gabapentin soln MO gabapentin tabs 600mg, 800mg MO HORIZANT TBCR 300mg, 600mg MO
LAMICTAL XR KIT MO lamotrigine chew 5mg, 25mg MO lamotrigine er tb24 25mg, 50mg, 100mg, 200mg, 250mg, 300mg MO
lamotrigine starter kit-blue kit MO lamotrigine starter kit-green kit MO lamotrigine starter kit-orange kit MO lamotrigine tabs 25mg, 100mg, 150mg, 200mg MO
lamotrigine tbdp 25mg, 50mg, 100mg, 200mg MO
levetiracetam er tb24 500mg, 750mg MO
levetiracetam soln MO levetiracetam tabs 250mg, 500mg, 750mg, 1000mg MO
magnesium sulfate soln injection 50% HI
Drug Name Requirements/Limits
MAGNESIUM SULFATE SOLN INTRAVENOUS 40gm/1000ml, 4gm/100ml, 20gm/500ml, 2gm/50ml
HI
NAYZILAM SOLN NDS oxcarbazepine susp MO oxcarbazepine tabs 150mg, 300mg, 600mg MO
OXTELLAR XR TB24 150mg, 300mg, 600mg MO
PEGANONE TABS MO phenytek caps 200mg, 300mg MO phenytoin chew MO phenytoin sodium extended caps 100mg, 200mg, 300mg MO
phenytoin susp MO pregabalin caps 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg
MO
pregabalin soln MO primidone tabs 50mg, 250mg MO roweepra tabs 500mg, 750mg, 1000mg MO
roweepra xr tb24 500mg, 750mg MO SABRIL PACK LD,NDS SABRIL TABS LD,NDS SPRITAM TB3D 250mg, 500mg, 750mg, 1000mg NDS
SYMPAZAN FILM 5mg SYMPAZAN FILM 10mg, 20mg tiagabine hcl tabs 2mg, 4mg, 12mg, 16mg MO
topiramate cpsp 15mg, 25mg MO topiramate er cs24 25mg, 50mg, 100mg, 150mg, 200mg MO
topiramate tabs 25mg, 50mg, 100mg, 200mg MO
TROKENDI XR CP24 25mg, 50mg, 100mg, 200mg MO
valproic acid caps MO valproic acid soln MO VALTOCO 10 MG DOSE LIQD NDS VALTOCO 15 MG DOSE LQPK NDS VALTOCO 20 MG DOSE LQPK NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 30 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
VALTOCO 5 MG DOSE LIQD NDS vigabatrin pack LD,NDS vigabatrin tabs NDS vigadrone pack LD,NDS VIMPAT SOLN VIMPAT TABS MO XCOPRI (250 MG DAILY DOSE) TBPK NDS
XCOPRI (350 MG DAILY DOSE) TBPK NDS
XCOPRI TABS 50mg, 100mg, 150mg, 200mg NDS
XCOPRI TBPK NDS zarontin soln MO zonisamide caps 25mg, 50mg, 100mg MO
ANTIMIGRAINE AGENTS almotriptan malate tabs cafergot tabs CAMBIA PACK eletriptan hydrobromide tabs EMGALITY (300 MG DOSE) SOSY NDS
EMGALITY SOAJ EMGALITY SOSY ergotamine-caffeine tabs frovatriptan succinate tabs naratriptan hcl tabs NURTEC TBDP NDS ONZETRA XSAIL EXHP rizatriptan benzoate tabs rizatriptan benzoate tbdp sumatriptan soln sumatriptan succinate refill soct sumatriptan succinate soaj sumatriptan succinate soln sumatriptan succinate sosy sumatriptan succinate tabs TOSYMRA SOLN NDS UBRELVY TABS 50mg, 100mg NDS ZEMBRACE SYMTOUCH SOAJ zolmitriptan tabs
Drug Name Requirements/Limits
zolmitriptan tbdp ZOMIG SOLN ANTIPARKINSONIAN AGENTS amantadine hcl caps MO amantadine hcl syrp MO amantadine hcl tabs MO APOKYN SOCT NDS benztropine mesylate tabs .5mg, 1mg, 2mg MO
bromocriptine mesylate caps MO bromocriptine mesylate tabs MO cabergoline tabs MO carbidopa tabs MO carbidopa-levodopa er tbcr MO carbidopa-levodopa tabs MO carbidopa-levodopa tbdp MO carbidopa-levodopa-entacapone tabs MO
DUOPA SUSP LD EMSAM PT24 6mg/24hr, 9mg/24hr, 12mg/24hr NDS
entacapone tabs MO GOCOVRI CP24 68.5mg, 137mg NDS
INBRIJA CAPS NDS NEUPRO PT24 1mg/24hr, 2mg/24hr, 3mg/24hr, 4mg/24hr, 6mg/24hr, 8mg/24hr
MO
OSMOLEX ER TB24 129mg, 193mg, 258mg MO
pramipexole dihydrochloride er tb24 .375mg, .75mg, 1.5mg, 2.25mg, 3mg, 3.75mg, 4.5mg
MO
pramipexole dihydrochloride tabs .125mg, .25mg, .5mg, .75mg, 1mg, 1.5mg
MO
rasagiline mesylate tabs .5mg, 1mg MO
ropinirole hcl er tb24 2mg, 4mg, 6mg, 8mg, 12mg MO
ropinirole hcl tabs .25mg, .5mg, 1mg, 2mg, 3mg, 4mg, 5mg MO
RYTARY CPCR MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 31
Drug Name Requirements/Limits
selegiline hcl caps MO selegiline hcl tabs MO tolcapone tabs MO trihexyphenidyl hcl soln MO trihexyphenidyl hcl tabs 2mg, 5mg MO
ZELAPAR TBDP MO ANXIOLYTICS, SEDATIVES, AND HYPNOTICS alprazolam er tb24 .5mg, 1mg, 2mg, 3mg NDS
alprazolam intensol conc NDS alprazolam tabs .25mg, .5mg, 1mg, 2mg NDS
alprazolam tbdp .25mg, .5mg, 1mg, 2mg NDS
BELSOMRA TABS buspirone hcl tabs 5mg, 10mg buspirone hcl tabs 7.5mg, 15mg, 30mg
chlordiazepoxide hcl caps 5mg, 10mg, 25mg NDS
clorazepate dipotassium tabs 3.75mg, 7.5mg, 15mg NDS
diazepam conc NDS diazepam soln NDS diazepam tabs 2mg, 5mg, 10mg NDS EDLUAR SUBL 5mg, 10mg NDS estazolam tabs 1mg, 2mg NDS eszopiclone tabs 1mg, 2mg, 3mg NDS flurazepam hcl caps 15mg, 30mg NDS
HETLIOZ CAPS PA,NDS hydroxyzine hcl syrp hydroxyzine hcl tabs hydroxyzine pamoate caps lorazepam conc NDS lorazepam tabs .5mg, 1mg, 2mg NDS meprobamate tabs oxazepam caps 10mg, 15mg, 30mg NDS
PHENOBARBITAL ELIX PHENOBARBITAL TABS
Drug Name Requirements/Limits
ramelteon tabs ROZEREM TABS SILENOR TABS temazepam caps 7.5mg, 15mg, 22.5mg, 30mg NDS
triazolam tabs .125mg, .25mg NDS zaleplon caps 5mg, 10mg NDS zolpidem tartrate er tbcr 6.25mg, 12.5mg NDS
zolpidem tartrate subl 1.75mg, 3.5mg NDS
zolpidem tartrate tabs 5mg, 10mg NDS
CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS atomoxetine hcl caps 10mg, 18mg, 25mg, 40mg, 60mg, 80mg, 100mg
MO
AUSTEDO TABS 6mg, 9mg, 12mg LD,NDS
guanfacine hcl er tb24 1mg, 2mg, 3mg, 4mg MO
INGREZZA CAPS 40mg, 80mg NDS INGREZZA CPPK NDS memantine hcl er cp24 memantine hcl soln MO memantine hcl tabs 5mg, 10mg MO NAMENDA XR TITRATION PACK CP24 MO
NAMZARIC C4PK MO NAMZARIC CP24 MO,NDS NOURIANZ TABS 20mg, 40mg NDS NUEDEXTA CAPS PA,NDS RADICAVA SOLN NDS RILUTEK TABS NDS riluzole tabs MO,NDS SAVELLA TABS 12.5mg, 25mg, 50mg, 100mg MO
SAVELLA TITRATION PACK MISC MO
tetrabenazine tabs 12.5mg, 25mg NDS
TIGLUTIK SUSP NDS XENAZINE TABS 12.5mg, 25mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 32 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
XYREM SOLN LD,NDS MULTIPLE SCLEROSIS AGENTS AMPYRA TB12 NDS AUBAGIO TABS 7mg, 14mg PA,NDS AVONEX KIT NDS AVONEX PEN AJKT NDS AVONEX PREFILLED PSKT NDS BETASERON KIT NDS COPAXONE SOSY 20mg/ml, 40mg/ml NDS
dalfampridine er tb12 NDS EXTAVIA KIT NDS GILENYA CAPS .25mg, .5mg NDS glatiramer acetate sosy 20mg/ml, 40mg/ml NDS
glatopa sosy 20mg/ml, 40mg/ml NDS LEMTRADA SOLN NDS MAYZENT STARTER PACK TBPK NDS
MAYZENT TABS .25mg, 2mg NDS OCREVUS SOLN REBIF REBIDOSE SOAJ 22mcg/0.5ml, 44mcg/0.5ml NDS
REBIF REBIDOSE TITRATION PACK SOAJ NDS
REBIF SOSY 22mcg/0.5ml, 44mcg/0.5ml NDS
REBIF TITRATION PACK SOSY NDS TECFIDERA CPDR 120mg, 240mg NDS
TECFIDERA MISC NDS TYSABRI CONC INTRAVENOUS HI
ZINBRYTA SOSY LD,NDS OPIATE ANTAGONISTS BUNAVAIL FILM NDS buprenorphine hcl subl 2mg, 8mg NDS
buprenorphine hcl-naloxone hcl film NDS
buprenorphine hcl-naloxone hcl subl NDS
LUCEMYRA TABS NDS
Drug Name Requirements/Limits
naloxone hcl soct naloxone hcl soln naloxone hcl sosy naltrexone hcl tabs NARCAN LIQD SUBLOCADE SOSY 100mg/0.5ml, 300mg/1.5ml NDS
VIVITROL SUSR NDS ZUBSOLV SUBL NDS PSYCHOTHERAPEUTIC AGENTS ABILIFY MAINTENA PRSY 300mg, 400mg NDS
ABILIFY MAINTENA SRER 300mg, 400mg NDS
ABILIFY MYCITE TABS 2mg, 5mg, 10mg, 15mg, 20mg, 30mg NDS
amitriptyline hcl tabs 10mg, 25mg, 50mg, 75mg, 100mg, 150mg
MO
amoxapine tabs 25mg, 50mg, 100mg, 150mg MO
APLENZIN TB24 174mg, 348mg, 522mg MO
aripiprazole soln MO aripiprazole tabs 2mg, 5mg, 10mg, 15mg, 20mg, 30mg MO
aripiprazole tbdp 10mg, 15mg MO ARISTADA INITIO PRSY NDS ARISTADA PRSY 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml, 1064mg/3.9ml
NDS
bupropion hcl er (smoking det) tb12 MO
bupropion hcl er (sr) tb12 100mg, 150mg, 200mg MO
bupropion hcl er (xl) tb24 150mg, 300mg, 450mg MO
bupropion hcl tabs 75mg, 100mg MO CAPLYTA CAPS NDS chlordiazepoxide-amitriptyline tabs
chlorpromazine hcl tabs 10mg, 25mg, 50mg, 100mg, 200mg MO
citalopram hydrobromide soln MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 33
Drug Name Requirements/Limits
citalopram hydrobromide tabs 10mg, 20mg, 40mg MO
clomipramine hcl caps 25mg, 50mg, 75mg MO
clozapine tabs 25mg, 50mg, 100mg, 200mg NDS
clozapine tbdp 12.5mg, 25mg, 100mg, 150mg, 200mg NDS
compro supp MO desipramine hcl tabs 10mg, 25mg, 50mg, 75mg, 100mg, 150mg
MO
DESVENLAFAXINE ER TB24 50mg, 100mg MO
desvenlafaxine succinate er tb24 25mg, 50mg, 100mg MO
doxepin hcl caps 10mg, 25mg, 50mg, 75mg, 100mg, 150mg MO
doxepin hcl conc MO doxepin hcl tabs 3mg, 6mg MO DRIZALMA SPRINKLE CSDR duloxetine hcl cpep 20mg, 30mg, 40mg, 60mg MO
EQUETRO CP12 100mg, 200mg, 300mg MO
escitalopram oxalate soln MO escitalopram oxalate tabs 5mg, 10mg, 20mg MO
FANAPT TABS 10mg MO FANAPT TABS 1mg, 2mg, 4mg, 6mg, 8mg, 12mg NDS
FANAPT TITRATION PACK TABS MO
FETZIMA CP24 20mg, 40mg, 80mg, 120mg MO
FETZIMA TITRATION C4PK MO fluoxetine hcl caps 10mg, 20mg, 40mg MO
fluoxetine hcl cpdr MO fluoxetine hcl soln MO fluoxetine hcl tabs 10mg, 20mg, 60mg MO
fluphenazine decanoate soln fluphenazine hcl conc MO
Drug Name Requirements/Limits
fluphenazine hcl elix MO fluphenazine hcl soln fluphenazine hcl tabs 1mg, 2.5mg, 5mg, 10mg MO
fluvoxamine maleate er cp24 100mg, 150mg MO
fluvoxamine maleate tabs 25mg, 50mg, 100mg MO
GEODON SOLR haloperidol decanoate soln haloperidol lactate conc MO haloperidol lactate soln haloperidol tabs .5mg, 1mg, 2mg, 5mg, 10mg, 20mg MO
imipramine hcl tabs 10mg, 25mg, 50mg MO
imipramine pamoate caps 75mg, 100mg, 125mg, 150mg MO
INVEGA SUSTENNA SUSY 39mg/0.25ml NDS
INVEGA SUSTENNA SUSY 78mg/0.5ml, 117mg/0.75ml, 234mg/1.5ml, 156mg/ml
NDS
INVEGA TRINZA SUSY 273mg/0.875ml, 410mg/1.315ml, 546mg/1.75ml, 819mg/2.625ml
NDS
KHEDEZLA TB24 50mg, 100mg MO LATUDA TABS 20mg, 40mg, 60mg, 80mg, 120mg NDS
lithium carbonate caps 150mg, 300mg, 600mg MO
lithium carbonate er tbcr 300mg, 450mg MO
lithium carbonate tabs MO LITHIUM SOLN MO loxapine succinate caps 5mg, 10mg, 25mg, 50mg MO
maprotiline hcl tabs 25mg, 50mg, 75mg MO
MARPLAN TABS MO mirtazapine tabs 7.5mg, 15mg, 30mg, 45mg MO
mirtazapine tbdp 15mg, 30mg, 45mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 34 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
molindone hcl tabs 5mg, 10mg, 25mg MO
nefazodone hcl tabs 50mg, 100mg, 150mg, 200mg, 250mg MO
nortriptyline hcl caps 10mg, 25mg, 50mg, 75mg MO
nortriptyline hcl soln MO NUPLAZID CAPS NDS NUPLAZID TABS 10mg, 17mg NDS olanzapine solr olanzapine tabs 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg MO
olanzapine tbdp 5mg, 10mg, 15mg, 20mg MO
olanzapine-fluoxetine hcl caps MO paliperidone er tb24 1.5mg, 3mg, 6mg, 9mg MO
paroxetine hcl er tb24 12.5mg, 25mg, 37.5mg MO
paroxetine hcl tabs 10mg, 20mg MO paroxetine hcl tabs 30mg, 40mg MO paroxetine mesylate caps MO PAXIL SUSP MO perphenazine tabs 2mg, 4mg, 8mg, 16mg MO
perphenazine-amitriptyline tabs MO PERSERIS PRSY 90mg, 120mg NDS PEXEVA TABS 10mg, 20mg, 30mg, 40mg MO
phenelzine sulfate tabs MO pimozide tabs 1mg, 2mg MO prochlorperazine maleate tabs prochlorperazine supp MO protriptyline hcl tabs 5mg, 10mg MO quetiapine fumarate er tb24 50mg, 150mg, 200mg, 300mg, 400mg
MO
quetiapine fumarate tabs 25mg, 50mg, 100mg, 200mg, 300mg, 400mg
MO
REXULTI TABS .25mg, .5mg, 1mg, 2mg, 3mg, 4mg NDS
RISPERDAL CONSTA SRER 12.5mg, 25mg NDS
Drug Name Requirements/Limits
RISPERDAL CONSTA SRER 37.5mg, 50mg NDS
risperidone soln MO risperidone tabs .25mg, .5mg, 1mg, 2mg, 3mg, 4mg MO
risperidone tbdp .25mg, .5mg, 1mg, 2mg, 3mg, 4mg MO
SAPHRIS SUBL 2.5mg, 5mg, 10mg NDS
SECUADO PT24 3.8mg/24hr, 5.7mg/24hr, 7.6mg/24hr NDS
sertraline hcl conc MO sertraline hcl tabs 25mg, 50mg, 100mg MO
SPRAVATO (56 MG DOSE) SOPK NDS
SPRAVATO (84 MG DOSE) SOPK NDS
thioridazine hcl tabs 10mg, 25mg, 50mg, 100mg MO
thiothixene caps 1mg, 2mg, 5mg, 10mg MO
tofranil tabs 10mg, 25mg, 50mg MO tranylcypromine sulfate tabs MO trazodone hcl tabs 50mg, 100mg, 150mg MO
trazodone hcl tabs MO trifluoperazine hcl tabs 1mg, 2mg, 5mg, 10mg MO
trimipramine maleate caps 25mg, 50mg, 100mg MO
TRINTELLIX TABS 5mg, 10mg, 20mg MO
venlafaxine hcl er cp24 37.5mg, 75mg, 150mg MO
venlafaxine hcl er tb24 37.5mg, 75mg, 150mg, 225mg MO
venlafaxine hcl tabs 25mg, 37.5mg, 50mg, 75mg, 100mg MO
VERSACLOZ SUSP VIIBRYD STARTER PACK KIT MO VIIBRYD TABS 10mg, 20mg, 40mg MO
VRAYLAR CAPS 1.5mg, 3mg, 4.5mg, 6mg NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 35
Drug Name Requirements/Limits
VRAYLAR CPPK NDS ziprasidone hcl caps 20mg, 40mg, 60mg, 80mg MO
ZYPREXA RELPREVV SUSR DIABETIC SUPPLIES DIABETIC SUPPLIES ALCOHOL PREP PADS MO BD INSULIN SYR ULTRAFINE II MISC MO
BD INSULIN SYRINGE MISC MO BD INSULIN SYRINGE U/F MISC MO
BD PEN NEEDLE ORIGINAL U/F MISC MO
CURITY GAUZE PADS MO OMNIPOD STARTER KIT NDS ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS potassium citrate er tbcr 15meq, 540mg, 1080mg MO
SODIUM LACTATE SOLN INTRAVENOUS HI
AMMONIA DETOXICANTS BUPHENYL POWD NDS BUPHENYL TABS NDS CARBAGLU TABS LD constulose soln MO enulose soln MO generlac soln MO kristalose pack 10gm, 20gm MO lactulose pack MO lactulose soln MO LITHOSTAT TABS MO RAVICTI LIQD NDS sodium phenylbutyrate powd NDS sodium phenylbutyrate tabs NDS CALORIC AGENTS AMINOSYN-PF SOLN INTRAVENOUS HI
CLINIMIX E/DEXTROSE (2.75/10) SOLN INTRAVENOUS HI
Drug Name Requirements/Limits
CLINIMIX E/DEXTROSE (2.75/5) SOLN INTRAVENOUS HI
CLINIMIX E/DEXTROSE (4.25/10) SOLN INTRAVENOUS HI
CLINIMIX E/DEXTROSE (4.25/25) SOLN INTRAVENOUS HI
CLINIMIX E/DEXTROSE (4.25/5) SOLN INTRAVENOUS HI
CLINIMIX E/DEXTROSE (5/15) SOLN INTRAVENOUS HI
CLINIMIX E/DEXTROSE (5/20) SOLN INTRAVENOUS HI
CLINIMIX E/DEXTROSE (5/25) SOLN INTRAVENOUS HI
CLINIMIX/DEXTROSE (2.75/5) SOLN INTRAVENOUS HI
CLINIMIX/DEXTROSE (4.25/10) SOLN INTRAVENOUS HI
CLINIMIX/DEXTROSE (4.25/20) SOLN INTRAVENOUS HI
CLINIMIX/DEXTROSE (4.25/5) SOLN INTRAVENOUS HI
CLINIMIX/DEXTROSE (5/15) SOLN INTRAVENOUS HI
CLINIMIX/DEXTROSE (5/20) SOLN INTRAVENOUS HI
CLINIMIX/DEXTROSE (5/25) SOLN INTRAVENOUS HI
clinisol sf soln intravenous HI dextrose soln intravenous 5%, 10% HI
FREAMINE HBC SOLN INTRAVENOUS HI
HEPATAMINE SOLN INTRAVENOUS HI
INTRALIPID EMUL INTRAVENOUS 20gm/100ml HI
INTRALIPID EMUL INTRAVENOUS HI
NEPHRAMINE SOLN INTRAVENOUS HI
NUTRILIPID EMUL INTRAVENOUS HI
plenamine soln intravenous HI premasol soln intravenous HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 36 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
PROCALAMINE SOLN INTRAVENOUS HI
PROSOL SOLN INTRAVENOUS HI TRAVASOL SOLN INTRAVENOUS HI
TROPHAMINE SOLN INTRAVENOUS HI
DIURETICS amiloride hcl tabs MO amiloride-hydrochlorothiazide tabs MO
bumetanide soln bumetanide tabs .5mg, 1mg, 2mg MO
chlorothiazide tabs 250mg, 500mg MO
chlorthalidone tabs 25mg, 50mg MO DIURIL SUSP MO DYRENIUM CAPS 100mg MO DYRENIUM CAPS 50mg EDECRIN TABS NDS ethacrynic acid tabs MO,NDS furosemide soln 8mg/ml, 10mg/ml MO
furosemide soln injection HI furosemide tabs 20mg, 40mg, 80mg MO
hydrochlorothiazide caps MO hydrochlorothiazide tabs 12.5mg, 25mg, 50mg MO
indapamide tabs 1.25mg, 2.5mg MO JYNARQUE TABS 15mg, 30mg NDS JYNARQUE TBPK NDS methyclothiazide tabs MO metolazone tabs 2.5mg, 5mg, 10mg MO
SAMSCA TABS 15mg, 30mg NDS SODIUM EDECRIN SOLR INTRAVENOUS HI
torsemide tabs 5mg, 10mg, 20mg, 100mg MO
triamterene caps 50mg, 100mg MO triamterene-hctz caps MO
Drug Name Requirements/Limits
triamterene-hctz tabs MO ION-REMOVING AGENTS AURYXIA TABS PA,MO,NDS FOSRENOL PACK 750mg, 1000mg NDS
kionex susp MO lanthanum carbonate chew 500mg, 750mg, 1000mg MO
LOKELMA PACK 5gm, 10gm MO sevelamer carbonate pack .8gm, 2.4gm MO
sevelamer carbonate tabs MO sevelamer hcl tabs 400mg, 800mg MO
sodium polystyrene sulfonate powd MO
sodium polystyrene sulfonate susp MO
sps susp MO VELPHORO CHEW NDS VELTASSA PACK 8.4gm, 16.8gm, 25.2gm NDS
REPLACEMENT PREPARATIONS calcium acetate (phos binder) caps MO
calcium acetate (phos binder) tabs MO
DEXTROSE-NACL SOLN INTRAVENOUS HI
DEXTROSE 10%/NACL 0.2% ; DEXTROSE 10%/NACL 0.45% HI
DEXTROSE 5%/NACL 0.225% HI IONOSOL-MB IN D5W SOLN INTRAVENOUS HI
ISOLYTE-P IN D5W SOLN INTRAVENOUS HI
ISOLYTE-S SOLN INTRAVENOUS HI
K-TAB TBCR MO KCL IN DEXTROSE-NACL SOLN INTRAVENOUS HI
KCL IN DEXTROSE-NACL SOLN 40-5-0.9 MEQ HI
KCL IN DEXTROSE-NACL SOLN 20-5-0.33 MEQ HI
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 37
Drug Name Requirements/Limits
KCL-LACTATED RINGERS-D5W SOLN INTRAVENOUS HI
KLOR-CON 10 TBCR MO klor-con m10 tbcr MO klor-con m15 tbcr MO klor-con m20 tbcr MO klor-con pack MO klor-con sprinkle cpcr MO KLOR-CON TBCR MO NORMOSOL-M IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R IN D5W SOLN INTRAVENOUS HI
NORMOSOL-R PH 7.4 SOLN INTRAVENOUS HI
PHOSLYRA SOLN MO PLASMA-LYTE 148 SOLN INTRAVENOUS HI
PLASMA-LYTE A SOLN INTRAVENOUS HI
potassium chloride crys er tbcr 10meq, 20meq MO
potassium chloride er cpcr 8meq, 10meq MO
potassium chloride er tbcr 8meq, 10meq, 20meq MO
POTASSIUM CHLORIDE IN DEXTROSE SOLN INTRAVENOUS
HI
potassium chloride in nacl soln intravenous HI
potassium chloride pack MO potassium chloride soln 10%, 20% MO
POTASSIUM CHLORIDE SOLN INTRAVENOUS 2meq/ml, 10meq/100ml, 20meq/100ml, 40meq/100ml
HI
SODIUM CHLORIDE SOLN INJECTION HI
SODIUM CHLORIDE SOLN INTRAVENOUS .45%, .9%, 3%, .45%, 5%
HI
TPN ELECTROLYTES CONC INTRAVENOUS HI
Drug Name Requirements/Limits
URICOSURIC AGENTS colchicine-probenecid tabs MO probenecid tabs MO ENZYMES ENZYMES ADAGEN SOLN ALDURAZYME SOLN CERDELGA CAPS NDS CEREZYME SOLR NDS CREON CPEP MO ELAPRASE SOLN NDS ELELYSO SOLR NDS ELITEK SOLR FABRAZYME SOLR 5mg, 35mg NDS KANUMA SOLN NDS LUMIZYME SOLR NDS miglustat caps NDS NAGLAZYME SOLN NDS PALYNZIQ SOSY 2.5mg/0.5ml, 10mg/0.5ml, 20mg/ml NDS
PANCREAZE CPEP MO PERTZYE CPEP MO PULMOZYME SOLN PA,NDS REVCOVI SOLN NDS STRENSIQ SOLN 18mg/0.45ml, 28mg/0.7ml, 80mg/0.8ml, 40mg/ml
LD,NDS
SUCRAID SOLN LD VIMIZIM SOLN NDS VIOKACE TABS MO VPRIV SOLR NDS ZAVESCA CAPS LD,NDS ZENPEP CPEP MO EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE SOLN bacitracin oint bacitracin-polymyxin b oint BESIVANCE SUSP bleph-10 soln CETRAXAL SOLN
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 38 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
chlorhexidine gluconate soln CILOXAN OINT ciprofloxacin hcl soln (ophth) CIPROFLOXACIN HCL SOLN (OTIC)
CIPROFLOXACIN-FLUOCINOLONE PF SOLN
erythromycin oint gatifloxacin soln gentak oint gentamicin sulfate soln levofloxacin soln MOXEZA SOLN moxifloxacin hcl soln NATACYN SUSP neomycin-bacitracin zn-polymyx oint
neomycin-polymyxin-gramicidin soln
ofloxacin soln OTOVEL SOLN polymyxin b-trimethoprim soln sulfacetamide sodium oint sulfacetamide sodium soln tobramycin soln TOBREX OINT trifluridine soln ZIRGAN GEL ANTI-INFLAMMATORY AGENTS ACUVAIL SOLN MO ALREX SUSP MO bacitra-neomycin-polymyxin-hc oint MO
BECONASE AQ SUSP MO blephamide s.o.p. oint MO BLEPHAMIDE SUSP MO bromfenac sodium (once-daily) soln MO
BROMSITE SOLN MO CIPRO HC SUSP MO CIPRODEX SUSP MO COLY-MYCIN S SUSP MO
Drug Name Requirements/Limits
dermotic oil MO dexamethasone sodium phosphate soln MO
diclofenac sodium soln MO DUREZOL EMUL MO flac oil MO FLAREX SUSP MO flunisolide soln MO fluocinolone acetonide oil MO fluorometholone susp MO flurbiprofen sodium soln MO fluticasone propionate susp MO FML FORTE SUSP MO FML OINT MO hydrocortisone-acetic acid soln MO ILEVRO SUSP MO INVELTYS SUSP MO ketorolac tromethamine soln .4%, .5% MO
LOTEMAX GEL MO LOTEMAX OINT MO LOTEMAX SUSP MO loteprednol etabonate susp MO MAXIDEX SUSP MO mometasone furoate susp MO neomycin-polymyxin-dexameth oint MO
neomycin-polymyxin-dexameth susp MO
neomycin-polymyxin-hc soln MO neomycin-polymyxin-hc susp MO NEVANAC SUSP MO OMNARIS SUSP MO PRED MILD SUSP MO PRED-G S.O.P. OINT MO PRED-G SUSP MO prednisolone acetate susp MO prednisolone sodium phosphate soln MO
PROLENSA SOLN MO QNASL AERS MO QNASL CHILDRENS AERS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 39
Drug Name Requirements/Limits
RESTASIS EMUL MO sulfacetamide-prednisolone soln MO TOBRADEX OINT MO TOBRADEX ST SUSP MO tobramycin-dexamethasone susp MO
XHANCE EXHU MO XIIDRA SOLN ZETONNA AERS MO ZYLET SUSP MO ANTIALLERGIC AGENTS ALOCRIL SOLN MO ALOMIDE SOLN MO azelastine hcl soln .05%, .1%, .15% MO
azelastine-fluticasone susp MO BEPREVE SOLN MO cromolyn sodium soln MO epinastine hcl soln MO LASTACAFT SOLN MO olopatadine hcl soln .1%, .2%, .6% MO
PAZEO SOLN MO ANTIGLAUCOMA AGENTS acetazolamide er cp12 MO acetazolamide tabs 125mg, 250mg MO
ALPHAGAN P SOLN MO AZOPT SUSP MO betaxolol hcl soln MO BETIMOL SOLN .25%, .5% MO BETOPTIC-S SUSP MO bimatoprost soln MO brimonidine tartrate soln .2%, .15% MO
carteolol hcl soln MO COMBIGAN SOLN MO dorzolamide hcl soln MO dorzolamide hcl-timolol mal pf soln
dorzolamide hcl-timolol mal soln MO latanoprost soln MO
Drug Name Requirements/Limits
levobunolol hcl soln MO LUMIGAN SOLN MO methazolamide tabs 25mg, 50mg MO
PHOSPHOLINE IODIDE SOLR MO pilocarpine hcl soln 1%, 2%, 4% MO SIMBRINZA SUSP MO TIMOLOL MALEATE SOLG .25%, .5% MO
timolol maleate soln .25%, .5% MO TIMOPTIC OCUDOSE SOLN .25%, .5% MO
TIMOPTIC-XE SOLG .25%, .5% MO TRAVATAN Z SOLN MO travoprost (bak free) soln MO VYZULTA SOLN MO XELPROS EMUL MO ZIOPTAN SOLN MO EENT DRUGS, MISCELLANEOUS acetic acid soln MO apraclonidine hcl soln MO ATROPINE SULFATE SOLN MO BEOVU SOLN NDS CYSTARAN SOLN EYLEA SOLN EYLEA SOSY IOPIDINE SOLN MO LACRISERT INST MO LUCENTIS SOLN .3mg/0.05ml, .5mg/0.05ml NDS
LUCENTIS SOSY .3mg/0.05ml, .5mg/0.05ml NDS
OXERVATE SOLN NDS RHOPRESSA SOLN TEPEZZA SOLR NDS LOCAL ANESTHETICS lidocaine viscous hcl soln MO proparacaine hcl soln MO GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS alosetron hcl tabs .5mg, 1mg NDS APRISO CP24 MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 40 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
balsalazide disodium caps MO colazal caps MO DELZICOL CPDR MO DIPENTUM CAPS NDS LIALDA TBEC MO mesalamine cpdr MO mesalamine enem MO mesalamine er cp24 MO mesalamine supp MO mesalamine tbec 1.2gm, 800mg MO PENTASA CPCR 250mg, 500mg MO
ANTIDIARRHEA AGENTS diphenoxylate-atropine liqd diphenoxylate-atropine tabs loperamide hcl caps MO MYTESI TBEC MO XERMELO TABS LD,NDS ANTIEMETICS AKYNZEO CAPS PA ANZEMET TABS 50mg, 100mg PA,NDS aprepitant caps PA,NDS BONJESTA TBCR MO CESAMET CAPS PA doxylamine-pyridoxine tbec MO dronabinol caps 2.5mg, 5mg, 10mg PA
EMEND SUSR PA,NDS granisetron hcl tabs PA meclizine hcl tabs ondansetron hcl soln PA ondansetron hcl tabs 4mg, 8mg, 24mg PA
ondansetron tbdp 4mg, 8mg PA SANCUSO PTCH NDS scopolamine pt72 MO SYNDROS SOLN PA,NDS TRANSDERM-SCOP (1.5 MG) PT72
trimethobenzamide hcl caps PA VARUBI (180 MG DOSE) TBPK PA,NDS
Drug Name Requirements/Limits
ZUPLENZ FILM 4mg, 8mg PA ANTIULCER AGENTS AND ACID SUPPRESSANTS amoxicill-clarithro-lansopraz misc MO
CARAFATE SUSP MO cimetidine hcl soln MO cimetidine tabs 200mg, 300mg, 400mg, 800mg MO
DEXILANT CPDR 30mg, 60mg MO esomeprazole magnesium cpdr 20mg, 40mg MO
esomeprazole magnesium pack 10mg, 20mg, 40mg MO
ESOMEPRAZOLE STRONTIUM CPDR
famotidine susr MO famotidine tabs 20mg, 40mg MO lansoprazole cpdr 15mg, 30mg MO lansoprazole tbdd 15mg, 30mg MO misoprostol tabs 100mcg, 200mcg MO
NEXIUM PACK 2.5mg, 5mg, 10mg, 20mg, 40mg MO
nizatidine caps 150mg, 300mg MO nizatidine soln MO OMECLAMOX-PAK MISC MO omeprazole cpdr 10mg, 20mg, 40mg MO
omeprazole-sodium bicarbonate caps MO
omeprazole-sodium bicarbonate pack MO
pantoprazole sodium tbec 20mg, 40mg MO
pepcid tabs 20mg, 40mg MO PRILOSEC PACK 2.5mg, 10mg MO PROTONIX PACK MO PYLERA CAPS MO,NDS rabeprazole sodium tbec MO sucralfate susp MO sucralfate tabs MO CATHARTICS AND LAXATIVES
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 41
Drug Name Requirements/Limits
gavilyte-c solr MO gavilyte-g solr MO gavilyte-n with flavor pack solr MO GOLYTELY SOLR OSMOPREP TABS MO peg 3350-kcl-na bicarb-nacl solr MO peg 3350/electrolytes solr MO peg-3350/electrolytes solr MO PLENVU SOLR MO SUPREP BOWEL PREP KIT SOLN MO
trilyte solr MO GI DRUGS, MISCELLANEOUS AMITIZA CAPS 8mcg, 24mcg MO CHOLBAM CAPS 50mg, 250mg NDS ENTYVIO SOLR NDS GATTEX KIT NDS LINZESS CAPS 72mcg, 145mcg, 290mcg MO
metoclopramide hcl soln MO metoclopramide hcl tabs 5mg, 10mg MO
metoclopramide hcl tbdp 5mg, 10mg MO
MOVANTIK TABS 12.5mg, 25mg MO
OCALIVA TABS 5mg, 10mg LD,NDS RELISTOR SOLN 8mg/0.4ml, 12mg/0.6ml NDS
RELISTOR TABS NDS SYMPROIC TABS MO TRULANCE TABS ursodiol caps MO ursodiol tabs 250mg, 500mg MO VIBERZI TABS 75mg, 100mg NDS HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET CAPS clovique caps NDS CUPRIMINE CAPS NDS deferasirox tabs 90mg, 180mg, 360mg NDS
Drug Name Requirements/Limits
deferasirox tbso 125mg NDS deferasirox tbso 250mg, 500mg NDS DEPEN TITRATABS TABS EXJADE TBSO 125mg, 250mg, 500mg NDS
FERRIPROX SOLN LD,NDS FERRIPROX TABS 500mg, 1000mg LD,NDS
JADENU SPRINKLE PACK 90mg, 180mg, 360mg NDS
JADENU TABS 90mg, 180mg, 360mg NDS
penicillamine caps NDS penicillamine tabs trientine hcl caps NDS HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS budesonide cpep MO budesonide er tb24 NDS budesonide-formoterol fumarate aero MO
cortisone acetate tabs MO decadron tabs 4mg, 6mg PA,MO deltasone tabs PA,MO DEPO-MEDROL SUSP dexamethasone elix MO dexamethasone intensol conc MO dexamethasone tabs .5mg, .75mg, 1mg, 1.5mg, 2mg, 4mg, 6mg
PA,MO
dexamethasone tbpk MO dexpak 13 day tbpk MO EMFLAZA SUSP LD,NDS EMFLAZA TABS 6mg, 18mg, 30mg, 36mg LD,NDS
ENTOCORT EC CPEP NDS fludrocortisone acetate tabs MO hydrocortisone tabs 5mg, 10mg, 20mg MO
INTRAROSA INST KENALOG SUSP MEDROL TABS MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 42 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
methylprednisolone tabs 4mg, 8mg, 16mg, 32mg MO
methylprednisolone tbpk MO millipred tabs MO prednisolone sodium phosphate soln 5mg/5ml, 10mg/5ml, 20mg/5ml, 25mg/5ml
MO
prednisolone sodium phosphate tbdp 10mg, 15mg, 30mg MO
prednisolone soln MO prednisone intensol conc PA,MO prednisone soln PA,MO prednisone tabs 1mg, 2.5mg, 5mg, 10mg, 20mg, 50mg PA,MO
prednisone tbpk RAYOS TBEC 1mg, 2mg, 5mg PA,MO SOLU-CORTEF SOLR SOLU-MEDROL SOLR taperdex 12-day tbpk taperdex 6-day tbpk MO taperdex 7-day tbpk MO TRELEGY ELLIPTA AEPB MO UCERIS TB24 NDS veripred 20 soln MO ANDROGENS ANADROL-50 TABS MO ANDRODERM PT24 2mg/24hr, 4mg/24hr MO
AVEED SOLN MO danazol caps 50mg, 100mg, 200mg MO
depo-testosterone soln 100mg/ml, 200mg/ml MO
JATENZO CAPS NDS methitest tabs MO methyltestosterone caps MO oxandrolone tabs 2.5mg MO oxandrolone tabs MO,NDS STRIANT MISC MO testosterone cypionate soln 100mg/ml, 200mg/ml MO
testosterone enanthate soln MO
Drug Name Requirements/Limits
testosterone gel 1%, 1.62%, 20.25mg/1.25gm, 25mg/2.5gm, 40.5mg/2.5gm, 50mg/5gm, 10mg/act
MO
testosterone soln MO XYOSTED SOAJ 50mg/0.5ml, 75mg/0.5ml, 100mg/0.5ml MO
CONTRACEPTIVES altavera tabs MO alyacen 1/35 tabs MO amethia lo tabs MO amethia tabs MO apri tabs MO aranelle tabs MO ashlyna tabs MO aubra tabs MO aviane tabs MO balziva tabs MO blisovi 24 fe tabs MO blisovi fe 1.5/30 tabs MO briellyn tabs MO camila tabs MO camrese lo tabs MO caziant tabs MO cryselle-28 tabs MO cyclafem 1/35 tabs MO cyclafem 7/7/7 tabs MO cyred tabs MO deblitane tabs MO delyla tabs MO desogestrel-ethinyl estradiol tabs MO drospiren-eth estrad-levomefol tabs MO
drospirenone-ethinyl estradiol tabs MO
ELLA TABS MO eluryng ring MO emoquette tabs MO enpresse-28 tabs MO enskyce tabs MO errin tabs MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 43
Drug Name Requirements/Limits
estarylla tabs MO ethynodiol diac-eth estradiol tabs MO etonogestrel-ethinyl estradiol ring MO
falmina tabs MO fayosim tabs MO femynor tabs MO gianvi tabs MO hailey 24 fe tabs MO incassia tabs MO introvale tabs MO isibloom tabs MO jasmiel tabs MO JOLIVETTE TABS MO juleber tabs MO junel 1.5/30 tabs MO junel 1/20 tabs MO junel fe 1.5/30 tabs MO junel fe 1/20 tabs MO junel fe 24 tabs MO kaitlib fe chew MO kariva tabs MO kelnor 1/35 tabs MO kelnor 1/50 tabs MO kurvelo tabs MO larin 1.5/30 tabs MO larin 1/20 tabs MO larin fe 1.5/30 tabs MO larin fe 1/20 tabs MO larissia tabs MO LAYOLIS FE CHEW MO leena tabs MO lessina tabs MO levonest tabs MO levonorg-eth estrad triphasic tabs MO
levonorgest-eth est & eth est tabs MO
levonorgest-eth estrad 91-day tabs MO
Drug Name Requirements/Limits
levonorgestrel-ethinyl estrad tabs MO
levora 0.15/30 (28) tabs MO LO LOESTRIN FE TABS MO loestrin 1.5/30 (21) tabs MO loestrin 1/20 (21) tabs MO loestrin fe 1.5/30 tabs MO loestrin fe 1/20 tabs MO loryna tabs MO low-ogestrel tabs MO lutera tabs MO lyza tabs MO marlissa tabs MO melodetta 24 fe chew MO mibelas 24 fe chew MO microgestin 1.5/30 tabs MO microgestin 1/20 tabs MO microgestin fe 1.5/30 tabs MO microgestin fe 1/20 tabs MO mili tabs MO MONONESSA TABS MO NATAZIA TABS MO necon 0.5/35 (28) tabs MO NECON 7/7/7 TABS MO nikki tabs MO nora-be tabs MO norethin ace-eth estrad-fe chew MO norethin ace-eth estrad-fe tabs MO norethin-eth estradiol-fe chew MO norethindrone acet-ethinyl est tabs MO
norethindrone tabs MO norgestim-eth estrad triphasic tabs MO
norgestimate-eth estradiol tabs MO norlyroc tabs MO nortrel 0.5/35 (28) tabs MO nortrel 1/35 (21) tabs MO nortrel 1/35 (28) tabs MO nortrel 7/7/7 tabs MO NUVARING RING MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 44 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
ocella tabs MO ogestrel tabs MO orsythia tabs MO pimtrea tabs MO pirmella 1/35 tabs MO portia-28 tabs MO previfem tabs MO reclipsen tabs MO rivelsa tabs MO setlakin tabs MO sharobel tabs MO sprintec 28 tabs MO sronyx tabs MO syeda tabs MO tarina 24 fe tabs MO tarina fe 1/20 tabs MO tri-estarylla tabs MO tri-legest fe tabs MO tri-lo-estarylla tabs MO tri-lo-sprintec tabs MO tri-mili tabs MO tri-previfem tabs MO tri-sprintec tabs MO tri-vylibra lo tabs MO tri-vylibra tabs MO TRINESSA (28) TABS MO trivora (28) tabs MO tydemy tabs MO velivet tabs MO vienva tabs MO vyfemla tabs MO vylibra tabs MO wymzya fe chew MO xulane ptwk MO zarah tabs MO zovia 1/35e (28) tabs MO DIABETIC AGENTS acarbose tabs 25mg, 50mg, 100mg MO
ADLYXIN SOPN MO
Drug Name Requirements/Limits
ADLYXIN STARTER PACK PNKT MO
ADMELOG SOLN MO ADMELOG SOLOSTAR SOPN MO AFREZZA POWD MO AFREZZA POWD 8 (90) & 12 (90) UNIT NDS
alogliptin benzoate tabs 6.25mg, 12.5mg, 25mg MO
ALOGLIPTIN-METFORMIN HCL TABS MO
alogliptin-pioglitazone tabs MO APIDRA SOLN PA,MO APIDRA SOLOSTAR SOPN MO AVANDIA TABS 2mg, 4mg MO BAQSIMI TWO PACK POWD BASAGLAR KWIKPEN SOPN MO BYDUREON BCISE AUIJ BYDUREON PEN MO BYETTA 10 MCG PEN SOPN MO BYETTA 5 MCG PEN SOPN MO CYCLOSET TABS MO FARXIGA TABS 5mg, 10mg MO FIASP FLEXTOUCH SOPN MO FIASP SOLN MO glimepiride tabs 1mg, 2mg, 4mg MO glipizide er tb24 2.5mg, 5mg, 10mg MO
glipizide tabs 5mg, 10mg MO glipizide-metformin hcl tabs MO GLUCAGEN HYPOKIT SOLR GLUCAGON EMERGENCY KIT glyburide micronized tabs 1.5mg, 3mg, 6mg MO
glyburide tabs 1.25mg, 2.5mg, 5mg MO
glyburide-metformin tabs MO GLYXAMBI TABS MO HUMALOG JUNIOR KWIKPEN SOPN MO
HUMALOG KWIKPEN SOPN 100unit/ml, 200unit/ml MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 45
Drug Name Requirements/Limits
HUMALOG MIX 50/50 KWIKPEN SUPN MO
HUMALOG MIX 50/50 SUSP MO HUMALOG MIX 75/25 KWIKPEN SUPN MO
HUMALOG MIX 75/25 SUSP MO HUMALOG SOCT MO HUMALOG SOLN MO HUMULIN 70/30 KWIKPEN SUPN MO
HUMULIN 70/30 SUSP MO HUMULIN N KWIKPEN SUPN MO HUMULIN N SUSP MO HUMULIN R SOLN PA,MO HUMULIN R U-500 (CONCENTRATED) SOLN MO
HUMULIN R U-500 KWIKPEN SOPN MO
insulin asp prot & asp flexpen supn MO
insulin aspart flexpen sopn MO insulin aspart penfill soct MO insulin aspart prot & aspart susp MO insulin aspart soln PA,MO insulin lispro (1 unit dial) sopn MO insulin lispro soln MO INVOKAMET TABS MO INVOKAMET XR TB24 MO INVOKANA TABS 100mg, 300mg MO
JANUMET TABS MO JANUMET XR TB24 MO JANUVIA TABS 25mg, 50mg, 100mg MO
JARDIANCE TABS 10mg, 25mg MO JENTADUETO TABS MO JENTADUETO XR TB24 MO KAZANO TABS MO KOMBIGLYZE XR TB24 MO KORLYM TABS LD,NDS LANTUS SOLN MO LANTUS SOLOSTAR SOPN MO LEVEMIR FLEXTOUCH SOPN MO
Drug Name Requirements/Limits
LEVEMIR SOLN MO metformin hcl er tb24 500mg, 750mg MO
metformin hcl tabs 500mg, 850mg, 1000mg MO
miglitol tabs 25mg, 50mg, 100mg MO
nateglinide tabs 60mg, 120mg MO NOVOLIN 70/30 SUSP MO NOVOLIN N SUSP MO NOVOLIN R SOLN PA,MO NOVOLOG FLEXPEN SOPN MO NOVOLOG MIX 70/30 FLEXPEN SUPN MO
NOVOLOG MIX 70/30 SUSP MO NOVOLOG PENFILL SOCT MO NOVOLOG SOLN PA,MO ONGLYZA TABS 2.5mg, 5mg MO OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN MO
OZEMPIC (1 MG/DOSE) SOPN MO pioglitazone hcl tabs 15mg, 30mg, 45mg MO
pioglitazone hcl-glimepiride tabs MO pioglitazone hcl-metformin hcl tabs MO
prandin tabs 1mg, 2mg MO PROGLYCEM SUSP MO QTERN TABS MO repaglinide tabs .5mg, 1mg, 2mg MO repaglinide-metformin hcl tabs MO RIOMET SOLN RYBELSUS TABS 3mg, 7mg, 14mg NDS
SEGLUROMET TABS SOLIQUA SOPN MO STEGLATRO TABS 5mg, 15mg MO STEGLUJAN TABS MO SYMLINPEN 120 SOPN MO SYMLINPEN 60 SOPN MO SYNJARDY TABS MO SYNJARDY XR TB24 MO tolazamide tabs 250mg, 500mg MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 46 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
tolbutamide tabs MO TOUJEO MAX SOLOSTAR SOPN MO
TOUJEO SOLOSTAR SOPN MO TRADJENTA TABS MO TRESIBA FLEXTOUCH SOPN 100unit/ml, 200unit/ml MO
TRULICITY SOPN .75mg/0.5ml, 1.5mg/0.5ml MO
VICTOZA SOPN MO XIGDUO XR TB24 MO XULTOPHY SOPN NDS ESTROGENS AND ANTIESTROGENS amabelz tabs MO ANGELIQ TABS MO CLIMARA PRO PTWK MO CLIMARA PTWK 37.5mcg/24hr, .025mg/24hr, .05mg/24hr, .06mg/24hr, .075mg/24hr, .1mg/24hr
MO
COMBIPATCH PTTW MO DELESTROGEN OIL depo-estradiol oil DIVIGEL GEL MO dotti pttw .025mg/24hr, .0375mg/24hr, .05mg/24hr, .075mg/24hr, .1mg/24hr
MO
DUAVEE TABS MO ELESTRIN GEL MO estrace crea MO estrace tabs .5mg, 1mg, 2mg MO estradiol crea MO estradiol pttw .025mg/24hr, .0375mg/24hr, .05mg/24hr, .075mg/24hr, .1mg/24hr
MO
estradiol ptwk 37.5mcg/24hr, .025mg/24hr, .05mg/24hr, .06mg/24hr, .075mg/24hr, .1mg/24hr
MO
estradiol tabs 10mcg, .5mg, 1mg, 2mg MO
estradiol valerate oil estradiol-norethindrone acet tabs MO
Drug Name Requirements/Limits
ESTRING RING MO EVAMIST SOLN MO FEMRING RING .05mg/24hr, .1mg/24hr MO
fyavolv tabs MO IMVEXXY MAINTENANCE PACK INST 4mcg, 10mcg MO
IMVEXXY STARTER PACK INST 4mcg, 10mcg MO
jinteli tabs MO LOPREEZA TABS MO menest tabs .3mg, .625mg, 1.25mg MO
MENOSTAR PTWK MO mimvey lo tabs MO mimvey tabs MO norethindrone-eth estradiol tabs MO OSPHENA TABS MO prefest tabs MO PREMARIN CREA MO PREMARIN SOLR PREMARIN TABS .3mg, .45mg, .625mg, .9mg, 1.25mg MO
PREMPHASE TABS MO PREMPRO TABS MO raloxifene hcl tabs MO yuvafem tabs MO GONADOTROPINS CHORIONIC GONADOTROPIN SOLR PA
NOVAREL SOLR 10000unit PA NOVAREL SOLR PA ORILISSA TABS 150mg, 200mg NDS PREGNYL SOLR PA TRIPTODUR SRER NDS OXYTOCICS MIFEPREX TABS PARATHYROID calcitonin (salmon) soln MO cinacalcet hcl tabs 30mg, 60mg, 90mg PA,NDS
FORTEO SOPN PA,NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 47
Drug Name Requirements/Limits
NATPARA CART 25mcg, 50mcg, 75mcg, 100mcg LD,NDS
SENSIPAR TABS 30mg PA,NDS SENSIPAR TABS 60mg, 90mg PA,NDS TYMLOS SOPN NDS PITUITARY ACTHAR GEL PA,LD,NDS DDAVP RHINAL TUBE SOLN MO DESMOPRESSIN ACE RHINAL TUBE SOLN MO
desmopressin ace spray refrig soln MO
desmopressin acetate tabs .1mg, .2mg MO
NOCDURNA SUBL 27.7mcg, 55.3mcg MO
NOCTIVA EMUL .83mcg/0.1ml, 1.66mcg/0.1ml MO
STIMATE SOLN MO SYNAREL SOLN MO TERIPARATIDE (RECOMBINANT) SOPN NDS
PROGESTINS aygestin tabs MO CRINONE GEL 4%, 8% PA,MO DEPO-PROVERA SUSP 400mg/ml
DEPO-SUBQ PROVERA 104 SUSY
MAKENA SOAJ NDS medroxyprogesterone acetate susp
medroxyprogesterone acetate susy
medroxyprogesterone acetate tabs 2.5mg, 5mg, 10mg MO
megestrol acetate susp MO norethindrone acetate tabs MO progesterone micronized caps 100mg, 200mg MO
SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA SOLR 1mg, 2mg NDS EGRIFTA SV SOLR NDS
Drug Name Requirements/Limits
GENOTROPIN MINIQUICK SOLR .2mg, .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg
PA,NDS
GENOTROPIN SOLR 12mg PA,NDS GENOTROPIN SOLR PA,NDS HUMATROPE SOLR 5mg, 6mg, 12mg, 24mg PA,NDS
INCRELEX SOLN NDS NORDITROPIN FLEXPRO SOLN 5mg/1.5ml, 10mg/1.5ml, 15mg/1.5ml, 30mg/3ml
PA,NDS
NUTROPIN AQ NUSPIN 10 SOLN PA,NDS
NUTROPIN AQ NUSPIN 20 SOLN PA,NDS
NUTROPIN AQ NUSPIN 5 SOLN PA,NDS
octreotide acetate soln OMNITROPE SOLN 5mg/1.5ml, 10mg/1.5ml PA,NDS
OMNITROPE SOLR PA,NDS SAIZEN CLICK.EASY SOLR PA,NDS SAIZEN SOLR 5mg, 8.8mg PA,NDS SAIZENPREP SOLR PA,NDS SANDOSTATIN LAR DEPOT KIT 10mg, 20mg, 30mg NDS
SEROSTIM SOLR 4mg, 5mg, 6mg PA,NDS
SIGNIFOR LAR SRER 10mg, 20mg, 30mg, 40mg, 60mg NDS
SIGNIFOR SOLN .3mg/ml, .6mg/ml, .9mg/ml NDS
SOMATULINE DEPOT SOLN SOMAVERT SOLR 10mg, 15mg, 20mg, 25mg, 30mg LD,NDS
ZOMACTON SOLR 5mg PA,NDS ZOMACTON SOLR PA,NDS ZORBTIVE SOLR PA,NDS THYROID AND ANTITHYROID AGENTS euthyrox tabs 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg
MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 48 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
LEVO-T TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg
MO
levothyroxine sodium tabs 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg
MO
LEVOXYL TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg
MO
liothyronine sodium tabs 5mcg, 25mcg, 50mcg MO
methimazole tabs 5mg, 10mg MO propylthiouracil tabs MO tapazole tabs 5mg, 10mg MO THYROLAR-1 TABS THYROLAR-1/2 TABS THYROLAR-1/4 TABS THYROLAR-2 TABS THYROLAR-3 TABS TIROSINT CAPS 13mcg, 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg
MO
UNITHROID TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 300mcg
MO
MISCELLANEOUS THERAPEUTIC AGENTS 5-ALPHA REDUCTASE INHIBITORS dutasteride caps MO dutasteride-tamsulosin hcl caps MO finasteride tabs MO ANTIDOTES acetylcysteine soln 10%, 20% PA,MO KHAPZORY SOLR 175mg, 300mg NDS
leucovorin calcium tabs 5mg, 10mg, 15mg, 25mg MO
Drug Name Requirements/Limits
VISTOGARD PACK NDS VORAXAZE SOLR NDS ANTIGOUT AGENTS allopurinol tabs 100mg, 300mg MO COLCHICINE CAPS MO colchicine tabs MO febuxostat tabs 40mg, 80mg MO GLOPERBA SOLN NDS MITIGARE CAPS MO ULORIC TABS 40mg, 80mg MO BONE RESORPTION INHIBITORS alendronate sodium soln MO alendronate sodium tabs 5mg, 10mg, 35mg, 70mg MO
alendronate sodium tabs 40mg MO BINOSTO TBEF MO EVENITY SOSY NDS FOSAMAX PLUS D TABS MO ibandronate sodium tabs PA,MO PROLIA SOSY risedronate sodium tabs 5mg, 30mg, 35mg, 150mg MO
risedronate sodium tbec MO XGEVA SOLN NDS DISEASE-MODIFYING ANTIRHEUMATIC AGENTS ACTEMRA ACTPEN SOAJ NDS ACTEMRA SOSY NDS CIMZIA KIT PA,NDS CIMZIA PREFILLED KIT NDS CIMZIA STARTER KIT KIT PA ENBREL MINI SOCT NDS ENBREL SOLR NDS ENBREL SOSY 25mg/0.5ml, 50mg/ml NDS
ENBREL SURECLICK SOAJ NDS HUMIRA PEDIATRIC CROHNS START PSKT NDS
HUMIRA PEN PNKT 40mg/0.4ml, 40mg/0.8ml NDS
HUMIRA PEN-CD/UC/HS STARTER PNKT 40mg/0.8ml, 80mg/0.8ml
NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 49
Drug Name Requirements/Limits
HUMIRA PEN-PS/UV/ADOL HS START PNKT NDS
HUMIRA PSKT 10mg/0.1ml, 10mg/0.2ml, 20mg/0.2ml, 20mg/0.4ml, 40mg/0.4ml, 40mg/0.8ml
NDS
INFLECTRA SOLR INTRAVENOUS HI
KEVZARA SOAJ 150mg/1.14ml, 200mg/1.14ml NDS
KEVZARA SOSY 150mg/1.14ml, 200mg/1.14ml NDS
KINERET SOSY NDS leflunomide tabs 10mg, 20mg MO OLUMIANT TABS 1mg, 2mg NDS ORENCIA CLICKJECT SOAJ NDS ORENCIA SOLR NDS ORENCIA SOSY 50mg/0.4ml, 87.5mg/0.7ml, 125mg/ml NDS
OTEZLA TABS PA,NDS OTEZLA TBPK PA,NDS OTREXUP SOAJ RASUVO SOAJ REMICADE SOLR INTRAVENOUS HI
RENFLEXIS SOLR NDS RINVOQ TB24 NDS SIMPONI ARIA SOLN NDS SIMPONI SOAJ 50mg/0.5ml, 100mg/ml NDS
SIMPONI SOSY 50mg/0.5ml, 100mg/ml NDS
XELJANZ TABS 5mg, 10mg NDS XELJANZ XR TB24 11mg, 22mg NDS IMMUNE SUPPRESSANTS ASTAGRAF XL CP24 .5mg, 1mg PA,MO ASTAGRAF XL CP24 PA azasan tabs 75mg, 100mg PA,MO azathioprine tabs PA,MO BENLYSTA SOAJ BENLYSTA SOLR BENLYSTA SOSY cyclosporine caps 25mg, 100mg PA,MO
Drug Name Requirements/Limits
cyclosporine modified caps 25mg, 50mg, 100mg PA,MO
cyclosporine modified soln PA,MO cyclosporine soln PA,MO ENVARSUS XR TB24 .75mg, 1mg, 4mg PA,MO
everolimus tabs .25mg PA,MO everolimus tabs .5mg, .75mg PA GAMIFANT SOLN 50mg/10ml, 10mg/2ml NDS
gengraf caps 25mg, 50mg, 100mg PA,MO
gengraf soln PA,MO MAVENCLAD (10 TABS) TBPK NDS MAVENCLAD (4 TABS) TBPK NDS MAVENCLAD (5 TABS) TBPK NDS MAVENCLAD (6 TABS) TBPK NDS MAVENCLAD (7 TABS) TBPK NDS MAVENCLAD (8 TABS) TBPK NDS MAVENCLAD (9 TABS) TBPK NDS mycophenolate mofetil caps PA,MO mycophenolate mofetil susr PA,MO mycophenolate mofetil tabs PA,MO mycophenolate sodium tbec 180mg, 360mg PA,MO
NULOJIX SOLR NDS PROGRAF PACK .2mg, 1mg PA,NDS PROGRAF SOLN PA,MO RAPAMUNE SOLN PA SANDIMMUNE CAPS 25mg, 100mg PA,MO
SANDIMMUNE SOLN 50mg/ml PA,MO SANDIMMUNE ORAL SOLN 100mg/ml PA,MO
sirolimus soln PA sirolimus tabs .5mg, 1mg, 2mg PA,MO tacrolimus caps .5mg, 1mg, 5mg PA,MO ZORTRESS TABS .25mg PA,MO ZORTRESS TABS .5mg, .75mg, 1mg PA
MISCELLANEOUS THERAPEUTIC AGENTS ACTIMMUNE SOLN ARCALYST SOLR NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 50 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
BOTOX SOLR 100unit, 200unit PA CARNITOR SOLN PA,MO CARNITOR TABS PA,MO CRYSVITA SOLN 10mg/ml, 20mg/ml, 30mg/ml NDS
CYSTADANE POWD LD,NDS CYSTAGON CAPS 50mg, 150mg LD,NDS
DYSPORT SOLR 300unit, 500unit PA
ELMIRON CAPS MO ENDARI PACK NDS EXONDYS 51 SOLN 500mg/10ml, 100mg/2ml NDS
FIRDAPSE TABS NDS GALAFOLD CAPS NDS GIVLAARI SOLN NDS HAEGARDA SOLR 2000unit, 3000unit NDS
ISTURISA TABS 1mg, 5mg, 10mg NDS
KEVEYIS TABS NDS KUVAN PACK 100mg, 500mg NDS KUVAN TBSO NDS levocarnitine soln PA,MO LEVOCARNITINE TABS PA,MO MESNEX TABS NDS MYALEPT SOLR NDS NITYR TABS 2mg, 5mg, 10mg NDS ODACTRA SUBL ONPATTRO SOLN NDS ORALAIR SUBL MO ORFADIN CAPS 2mg, 5mg, 10mg, 20mg LD,NDS
ORFADIN SUSP LD,NDS PALFORZIA (12 MG DAILY DOSE) CSPK NDS
PALFORZIA (120 MG DAILY DOSE) CSPK NDS
PALFORZIA (160 MG DAILY DOSE) CSPK NDS
PALFORZIA (20 MG DAILY DOSE) CSPK NDS
Drug Name Requirements/Limits
PALFORZIA (200 MG DAILY DOSE) CSPK NDS
PALFORZIA (240 MG DAILY DOSE) CSPK NDS
PALFORZIA (3 MG DAILY DOSE) CSPK NDS
PALFORZIA (300 MG MAINTENANCE) PACK NDS
PALFORZIA (300 MG TITRATION) PACK NDS
PALFORZIA (40 MG DAILY DOSE) CSPK NDS
PALFORZIA (6 MG DAILY DOSE) CSPK NDS
PALFORZIA (80 MG DAILY DOSE) CSPK NDS
PALFORZIA INITIAL ESCALATION CSPK NDS
PROCYSBI CPDR 25mg, 75mg NDS PROCYSBI PACK 75mg, 300mg NDS RIDAURA CAPS MO RIMSO-50 SOLN RUZURGI TABS NDS SODIUM CHLORIDE SOLN MO SODIUM FLUORIDE TABS MO TAKHZYRO SOLN NDS TEGSEDI SOSY NDS THIOLA EC TBEC 100mg, 300mg NDS
THIOLA TABS NDS ULTOMIRIS SOLN NDS VUMERITY (STARTER) CPDR NDS VUMERITY CPDR NDS VYONDYS 53 SOLN NDS XEOMIN SOLR 50unit, 100unit PA XEOMIN SOLR PA,NDS XURIDEN PACK NDS RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS CINQAIR SOLN NDS cromolyn sodium conc MO cromolyn sodium nebu PA,MO DUPIXENT SOSY NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 51
Drug Name Requirements/Limits
FASENRA PEN SOAJ NDS FASENRA SOSY montelukast sodium chew 4mg, 5mg MO
montelukast sodium pack MO montelukast sodium tabs MO NUCALA SOAJ NDS NUCALA SOLR NDS NUCALA SOSY NDS zafirlukast tabs 10mg, 20mg MO zileuton er tb12 NDS ZYFLO CR TB12 NDS ZYFLO TABS MO CYSTIC FIBROSIS BETHKIS NEBU PA CAYSTON SOLR LD,NDS KALYDECO PACK 25mg, 50mg, 75mg PA,NDS
KALYDECO TABS PA,NDS KITABIS PAK NEBU PA ORKAMBI PACK NDS ORKAMBI TABS NDS SYMDEKO TBPK NDS TOBI NEBU PA TOBI PODHALER CAPS tobramycin nebu PA TRIKAFTA TBPK LD,NDS PULMONARY FIBROSIS ESBRIET CAPS PA,NDS ESBRIET TABS 267mg, 801mg PA,NDS OFEV CAPS 100mg, 150mg NDS RESPIRATORY AGENTS, MISCELLANEOUS ALVESCO AERS 80mcg/act, 160mcg/act MO
ARALAST NP SOLR INTRAVENOUS 500mg, 1000mg
HI
ARNUITY ELLIPTA AEPB 50mcg/act, 100mcg/act, 200mcg/act
MO
ASMANEX (120 METERED DOSES) AEPB MO
Drug Name Requirements/Limits
ASMANEX (30 METERED DOSES) AEPB 110mcg/inh MO
ASMANEX (30 METERED DOSES) AEPB MO
ASMANEX (60 METERED DOSES) AEPB MO
ASMANEX HFA AERO 100mcg/act, 200mcg/act MO
budesonide susp .25mg/2ml, .5mg/2ml, 1mg/2ml PA,MO
DALIRESP TABS 250mcg, 500mcg MO
DULERA AERO MO FLOVENT DISKUS AEPB 50mcg/blist, 100mcg/blist, 250mcg/blist
MO
FLOVENT HFA AERO 44mcg/act MO
FLOVENT HFA AERO 110mcg/act, 220mcg/act MO
fluticasone-salmeterol aepb MO GLASSIA SOLN INTRAVENOUS HI
PROLASTIN-C SOLN INTRAVENOUS HI
PROLASTIN-C SOLR INTRAVENOUS HI
PULMICORT FLEXHALER AEPB 90mcg/act, 180mcg/act MO
QVAR REDIHALER AERB XOLAIR SOLR PA,NDS XOLAIR SOSY 75mg/0.5ml, 150mg/ml PA,NDS
ZEMAIRA SOLR INTRAVENOUS HI
VASODILATING AGENTS ADEMPAS TABS .5mg, 1mg, 1.5mg, 2mg, 2.5mg PA,NDS
ambrisentan tabs 5mg, 10mg NDS bosentan tabs 62.5mg, 125mg NDS LETAIRIS TABS 5mg, 10mg NDS OPSUMIT TABS PA,NDS ORENITRAM TBCR .125mg LD,NDS ORENITRAM TBCR .25mg, 1mg, 2.5mg, 5mg LD,NDS
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 52 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
REMODULIN SOLN 20mg/20ml, 50mg/20ml, 100mg/20ml, 200mg/20ml
PA,LD,NDS
TRACLEER TABS 62.5mg, 125mg NDS
TRACLEER TBSO NDS treprostinil soln 20mg/20ml, 50mg/20ml, 100mg/20ml, 200mg/20ml
PA,LD,NDS
TYVASO REFILL SOLN PA,LD TYVASO SOLN PA,LD TYVASO STARTER SOLN PA,LD UPTRAVI TABS 200mcg, 400mcg, 600mcg, 800mcg, 1000mcg, 1200mcg, 1400mcg, 1600mcg
NDS
UPTRAVI TBPK NDS VENTAVIS SOLN 10mcg/ml, 20mcg/ml PA,LD,NDS
SERUMS, TOXOIDS, AND VACCINES SERUMS ASCENIV SOLN NDS BIVIGAM SOLN INTRAVENOUS 10gm/100ml HI
BIVIGAM SOLN INTRAVENOUS HI CUTAQUIG SOLN 1.65gm/10ml, 2gm/12ml, 3.3gm/20ml, 4gm/24ml, 8gm/48ml, 1gm/6ml
PA,NDS
CYTOGAM INJ FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm/100ml, 10gm/100ml, .5gm/10ml, 10gm/200ml, 20gm/200ml, 20gm/400ml, 2.5gm/50ml, 5gm/50ml
HI
GAMASTAN INJ PA GAMASTAN S/D INJ PA GAMMAGARD S/D LESS IGA SOLR INTRAVENOUS 5gm, 10gm
HI
GAMMAGARD SOLN INJECTION HI
GAMMAKED SOLN INJECTION HI GAMMAPLEX SOLN INTRAVENOUS 10gm/200ml HI
Drug Name Requirements/Limits
GAMMAPLEX SOLN INTRAVENOUS 10gm/100ml, 20gm/200ml, 5gm/50ml
HI
GAMUNEX-C SOLN INJECTION 10gm/100ml, 1gm/10ml, 20gm/200ml, 2.5gm/25ml, 5gm/50ml
HI
HYPERRAB S/D SOLN HYQVIA KIT PA,NDS IMOGAM RABIES-HT SOLN NABI-HB SOLN OCTAGAM SOLN INTRAVENOUS 5gm/100ml, 1gm/20ml, 2gm/20ml, 25gm/500ml
HI
OCTAGAM SOLN INTRAVENOUS 5gm/100ml, 1gm/20ml, 2gm/20ml, 25gm/500ml
HI
PANZYGA SOLN INTRAVENOUS 10gm/100ml, 1gm/10ml, 20gm/200ml, 2.5gm/25ml, 30gm/300ml, 5gm/50ml
HI
PRIVIGEN SOLN INTRAVENOUS HI
VARIZIG SOLN XEMBIFY SOLN SUBCUTANEOUS 2gm/10ml, 4gm/20ml, 10gm/50ml, 1gm/5ml
HI
TOXOIDS DIPHTHERIA-TETANUS TOXOIDS DT SUSP
KINRIX SUSP QUADRACEL SUSP TDVAX SUSP TENIVAC INJ VACCINES ACTHIB SOLR ADACEL SUSP BEXSERO SUSY BOOSTRIX SUSP DAPTACEL SUSP
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 53
Drug Name Requirements/Limits
ENGERIX-B SUSP 10mcg/0.5ml, 20mcg/ml PA
GARDASIL 9 SUSP GARDASIL 9 SUSY HAVRIX SUSP HEPLISAV-B SOLN PA HIBERIX SOLR IMOVAX RABIES INJ INFANRIX SUSP IPOL INJ IXIARO SUSP M-M-R II SOLR MENACTRA INJ MENVEO SOLR PEDIARIX SUSP PEDVAX HIB SUSP PROQUAD SUSR RABAVERT SUSR RECOMBIVAX HB SUSP 5mcg/0.5ml, 10mcg/ml, 40mcg/ml
PA
ROTARIX SUSR ROTATEQ SOLN SHINGRIX SUSR TRUMENBA SUSY TWINRIX SUSY TYPHIM VI SOLN VAQTA SUSP VARIVAX INJ VAXCHORA SUSR YF-VAX INJ ZOSTAVAX SUSR
• SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) acyclovir oint AKTIPAK PACK MO AVC VAGINAL CREA BACTROBAN NASAL OINT BENZOYL PEROXIDE GEL NDS
Drug Name Requirements/Limits
benzoyl peroxide-erythromycin gel MO
ciclopirox gel ciclopirox olamine crea ciclopirox olamine susp ciclopirox sham ciclopirox soln CLEOCIN SUPP clindacin-p swab MO clindamycin phos-benzoyl perox gel MO
clindamycin phosphate crea clindamycin phosphate foam MO clindamycin phosphate gel MO clindamycin phosphate lotn MO clindamycin phosphate soln MO clindamycin phosphate swab MO CLINDESSE CREA clotrimazole crea clotrimazole lozg clotrimazole soln clotrimazole-betamethasone crea
clotrimazole-betamethasone lotn DENAVIR CREA econazole nitrate crea ERTACZO CREA ery pads MO erythromycin gel MO erythromycin soln MO EURAX CREA EXELDERM CREA EXELDERM SOLN gentamicin sulfate crea gentamicin sulfate oint gynazole-1 crea ivermectin crea JUBLIA SOLN KERYDIN SOLN ketoconazole crea ketoconazole foam
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 54 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
ketoconazole sham ketodan foam lindane sham LULICONAZOLE CREA LUZU CREA mafenide acetate pack malathion lotn MENTAX CREA metronidazole crea metronidazole gel metronidazole lotn miconazole 3 supp mupirocin calcium crea mupirocin oint naftifine hcl crea NAFTIN GEL NATROBA SUSP nyamyc powd nystatin crea nystatin oint nystatin powd nystop powd ORAVIG TABS ovide lotn oxiconazole nitrate crea OXISTAT LOTN permethrin crea selenium sulfide lotn SILVER SULFADIAZINE CREA SKLICE LOTN SOOLANTRA CREA SSD CREA sulfacetamide sodium (acne) lotn MO SULFAMYLON CREA terconazole crea terconazole supp VANDAZOLE GEL XEPI CREA MO XERESE CREA ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)
Drug Name Requirements/Limits
ala scalp lotn MO ala-cort crea 1%, 2.5% MO alclometasone dipropionate crea MO alclometasone dipropionate oint MO amcinonide crea MO amcinonide lotn MO amcinonide oint MO anusol-hc crea MO apexicon e crea MO BENZOYL PEROXIDE FORTE- HC LOTN NDS
beser lotn MO betamethasone dipropionate aug crea MO
betamethasone dipropionate aug gel MO
betamethasone dipropionate aug lotn MO
betamethasone dipropionate aug oint MO
betamethasone dipropionate crea MO
betamethasone dipropionate lotn MO betamethasone dipropionate oint MO betamethasone valerate crea MO betamethasone valerate foam MO betamethasone valerate lotn MO betamethasone valerate oint MO BRYHALI LOTN MO calcipotriene-betameth diprop oint MO,NDS
calcipotriene-betameth diprop susp NDS
CAPEX SHAM MO clobetasol propionate crea clobetasol propionate e crea MO clobetasol propionate emulsion foam
clobetasol propionate foam MO clobetasol propionate gel MO clobetasol propionate liqd MO clobetasol propionate lotn MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 55
Drug Name Requirements/Limits
clobetasol propionate oint MO clobetasol propionate sham MO clobetasol propionate soln MO CLOBEX SHAM MO CLOBEX SPRAY LIQD MO clocortolone pivalate crea MO clocortolone pivalate pump crea MO clodan sham MO colocort enem MO CORDRAN TAPE MO CORTISPORIN CREA MO CORTISPORIN OINT MO DESONATE GEL MO desonide crea MO desonide lotn MO desonide oint MO desowen lotn MO desoximetasone crea .05%, .25% MO
desoximetasone gel MO desoximetasone liqd MO desoximetasone oint .05%, .25% MO diclofenac epolamine ptch PA,MO diclofenac sodium gel 1%, 3% MO diclofenac sodium soln MO diflorasone diacetate crea MO diflorasone diacetate oint MO DUOBRII LOTN MO ENSTILAR FOAM NDS EUCRISA OINT MO FLECTOR PTCH PA,MO fluocinolone acetonide crea .01%, .025% MO
fluocinolone acetonide oint MO fluocinolone acetonide scalp oil MO fluocinolone acetonide soln MO fluocinonide crea MO fluocinonide emulsified base crea MO
fluocinonide gel MO fluocinonide oint MO
Drug Name Requirements/Limits
fluocinonide soln MO flurandrenolide crea MO flurandrenolide lotn MO flurandrenolide oint MO fluticasone propionate crea MO fluticasone propionate lotn MO fluticasone propionate oint MO halcinonide crea MO halobetasol propionate crea MO HALOBETASOL PROPIONATE FOAM NDS
halobetasol propionate oint MO HALOG CREA MO HALOG OINT MO hydrocortisone butyrate crea MO hydrocortisone butyrate lotn MO hydrocortisone butyrate oint MO hydrocortisone butyrate soln MO hydrocortisone crea 1%, 2.5% MO hydrocortisone enem MO hydrocortisone lotn MO hydrocortisone oint 1%, 2.5% MO hydrocortisone valerate crea MO hydrocortisone valerate oint MO IMPOYZ CREA MO LEXETTE FOAM NDS micort-hc crea MO mometasone furoate crea MO mometasone furoate oint MO mometasone furoate soln MO neo-synalar crea MO nolix crea nolix lotn MO nystatin-triamcinolone crea MO nystatin-triamcinolone oint MO PANDEL CREA MO prednicarbate crea MO prednicarbate oint MO procto-med hc crea MO procto-pak crea MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 56 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
proctosol hc crea MO proctozone-hc crea MO psorcon crea MO TACLONEX OINT NDS TACLONEX SUSP NDS topicort crea .05%, .25% MO topicort gel MO topicort oint MO tovet foam MO triamcinolone acetonide aers MO triamcinolone acetonide crea .025%, .1%, .5% MO
triamcinolone acetonide lotn .025%, .1% MO
triamcinolone acetonide oint .025%, .05%, .1%, .5% MO
triamcinolone acetonide pste MO trianex oint MO triderm crea MO UCERIS FOAM MO ULTRAVATE LOTN NDS ANTIPRURITICS AND LOCAL ANESTHETICS 7T LIDO GEL PA,MO doxepin hcl crea MO glydo prsy MO hydrocortisone ace-pramoxine crea MO
lidocaine hcl soln PA lidocaine hcl urethral/mucosal gel MO
lidocaine oint PA,MO lidocaine ptch PA,MO lidocaine-prilocaine crea PA,MO lidocaine-tetracaine crea PA SYNERA PTCH PA texacort soln MO CELL STIMULANTS AND PROLIFERANTS ALTRENO LOTN PA,MO AVITA CREA PA,MO AVITA GEL PA,MO KEPIVANCE SOLR NDS PANRETIN GEL NDS
Drug Name Requirements/Limits
RETIN-A CREA .025%, .05%, .1% PA,MO
RETIN-A GEL .01%, .025% PA,MO RETIN-A MICRO GEL .04%, .1% PA,MO
RETIN-A MICRO PUMP GEL .04%, .1% PA,MO
RETIN-A MICRO PUMP GEL .08% PA,MO
RETIN-A MICRO PUMP GEL PA,NDS TARGRETIN GEL NDS tretinoin crea .025%, .05%, .1% PA,MO tretinoin gel .01%, .025%, .05% PA,MO tretinoin microsphere gel .04%, .1% PA,MO
tretinoin microsphere pump gel .04%, .1% PA,MO
SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS ABSORICA CAPS 25mg, 35mg NDS ABSORICA LD CAPS 8mg, 16mg, 24mg, 32mg NDS
acitretin caps 10mg, 17.5mg, 25mg NDS
adapalene crea MO adapalene gel .1%, .3% MO adapalene pads MO adapalene soln NDS adapalene-benzoyl peroxide gel MO ammonium lactate crea MO ammonium lactate lotn MO amnesteem caps 10mg, 20mg, 40mg NDS
azelaic acid gel MO AZELEX CREA MO calcipotriene crea MO calcipotriene oint MO calcipotriene soln MO CALCITRIOL OINT MO CARAC CREA claravis caps 10mg, 20mg, 30mg, 40mg NDS
CONDYLOX GEL MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 57
Drug Name Requirements/Limits
COSENTYX (300 MG DOSE) SOSY NDS
COSENTYX SENSOREADY (300 MG) SOAJ NDS
COSENTYX SENSOREADY PEN SOAJ NDS
COSENTYX SOSY NDS dapsone gel 5%, 7.5% MO DIFFERIN CREA MO DIFFERIN LOTN MO DUPIXENT SOSY NDS EPIDUO FORTE GEL MO FABIOR FOAM PA,MO FINACEA FOAM MO fluorouracil crea 5% MO fluorouracil crea .5% fluorouracil soln 2%, 5% MO ILUMYA SOSY PA imiquimod crea MO IMIQUIMOD PUMP CREA MO isotretinoin caps 10mg, 20mg, 30mg, 40mg NDS
methoxsalen rapid caps MO MIRVASO GEL MO myorisan caps 10mg, 20mg, 30mg, 40mg NDS
ORACEA CPDR PICATO GEL .015%, .05% MO pimecrolimus crea MO podofilox soln MO RECTIV OINT MO REGRANEX GEL NDS RYNODERM CREA NDS SANTYL OINT MO SILIQ SOSY NDS SKYRIZI (150 MG DOSE) PSKT SORIATANE CAPS 10mg, 17.5mg, 25mg NDS
SORILUX FOAM MO STELARA SOLN 45mg/0.5ml, 130mg/26ml PA,NDS
STELARA SOSY 45mg/0.5ml, 90mg/ml PA,NDS
Drug Name Requirements/Limits
tacrolimus oint .03%, .1% MO TALTZ SOAJ NDS TALTZ SOSY NDS tazarotene crea PA,MO TAZORAC CREA PA,MO TAZORAC GEL .05%, .1% PA,MO TOLAK CREA TREMFYA SOPN TREMFYA SOSY VALCHLOR GEL NDS VECTICAL OINT MO VEREGEN OINT MO XIMINO CP24 45mg, 90mg, 135mg MO
zenatane caps 10mg, 20mg, 30mg, 40mg NDS
ZYCLARA PUMP CREA MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS darifenacin hydrobromide er tb24 7.5mg, 15mg MO
flavoxate hcl tabs MO GELNIQUE GEL MO GELNIQUE PUMP GEL MO MYRBETRIQ TB24 25mg, 50mg MO oxybutynin chloride er tb24 5mg, 10mg, 15mg MO
oxybutynin chloride syrp MO oxybutynin chloride tabs MO solifenacin succinate tabs 5mg, 10mg MO
theo-24 cp24 100mg, 200mg, 300mg, 400mg MO
theophylline er tb12 100mg, 200mg, 300mg MO
theophylline er tb24 400mg, 600mg MO
theophylline soln MO tolterodine tartrate er cp24 2mg, 4mg MO
tolterodine tartrate tabs MO TOVIAZ TB24 4mg, 8mg MO trospium chloride er cp24 MO
You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 58 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Drug Name Requirements/Limits
trospium chloride tabs MO VITAMINS VITAMINS calcitriol caps .25mcg, .5mcg PA,MO calcitriol soln PA,MO doxercalciferol caps .5mcg, 1mcg, 2.5mcg PA,MO
paricalcitol caps 1mcg, 2mcg, 4mcg PA,MO
RAYALDEE CPCR NDS VP-PNV-DHA CAPS MO
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 59
The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below. HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. MO = Mail-order drugs. You may order prescription refills of certain medications through our mail-order service online at kp.org/refill or by phone or mobile app, which may lower your costs for a three-month supply. Please contact us at least 5 days before your refills run out. Generally, you should receive them within 5 days. If not and you
need an urgent refill, please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 6 or the phone number on the prescription label for assistance. Not all drugs can be mailed; restrictions and limitations apply. For more information, please visit kp.org/seniorrx or call the appropriate regional phone number on page 6. NDS = Non-extended Day Supply drugs that are dispensed up to a 30-day supply to monitor for possible adverse effects and to avoid medication waste.
PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered.
60 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
Index of Drugs
7 7T LIDO GEL ........................................... 56
A abacavir sulfate soln ................................ 11 abacavir sulfate tabs ................................ 11 abacavir sulfate-lamivudine tabs .............. 11 abacavir-lamivudine-zidovudine tabs ....... 11 ABELCET SUSP INTRAVENOUS ........... 10 ABILIFY MAINTENA PRSY 300mg, 400mg
............................................................. 32 ABILIFY MAINTENA SRER 300mg, 400mg
............................................................. 32 ABILIFY MYCITE TABS 2mg, 5mg, 10mg,
15mg, 20mg, 30mg .............................. 32 abiraterone acetate tabs .......................... 14 ABRAXANE SUSR .................................. 14 ABSORICA CAPS 25mg, 35mg ............... 56 ABSORICA LD CAPS 8mg, 16mg, 24mg,
32mg .................................................... 56 ABSTRAL SUBL 100mcg, 200mcg,
300mcg, 400mcg, 600mcg, 800mcg .... 25 acamprosate calcium tbec ....................... 25 acarbose tabs 25mg, 50mg, 100mg ........ 44 acebutolol hcl caps 200mg, 400mg ......... 22 acetaminophen-codeine #3 tabs .............. 25 acetaminophen-codeine soln ................... 25 acetaminophen-codeine tabs ................... 25 acetazolamide er cp12 ............................. 39 acetazolamide tabs 125mg, 250mg ......... 39 acetic acid soln ........................................ 39 acetylcysteine soln 10%, 20% ................. 48 acitretin caps 10mg, 17.5mg, 25mg ......... 56 ACTEMRA ACTPEN SOAJ ..................... 48 ACTEMRA SOSY .................................... 48 ACTHAR GEL .......................................... 47 ACTHIB SOLR ......................................... 52 ACTIMMUNE SOLN ................................ 49 ACTIQ LPOP 400mcg, 600mcg, 800mcg,
1200mcg, 1600mcg ............................. 25 ACUVAIL SOLN ...................................... 38 acyclovir caps .......................................... 11 acyclovir oint ............................................ 53 acyclovir sodium soln intravenous ........... 12
acyclovir susp .......................................... 12 acyclovir tabs 400mg, 800mg ................... 12 ADACEL SUSP ........................................ 52 ADAGEN SOLN ....................................... 37 ADAKVEO SOLN ..................................... 20 adapalene crea ........................................ 56 adapalene gel .1%, .3% .......................... 56 adapalene pads ....................................... 56 adapalene soln ......................................... 56 adapalene-benzoyl peroxide gel .............. 56 ADCIRCA TABS....................................... 24 adderall tabs ............................................ 27 ADDERALL XR CP24 .............................. 27 adefovir dipivoxil tabs ............................... 12 ADEMPAS TABS .5mg, 1mg, 1.5mg, 2mg,
2.5mg ................................................... 51 ADLYXIN SOPN....................................... 44 ADLYXIN STARTER PACK PNKT ........... 44 ADMELOG SOLN .................................... 44 ADMELOG SOLOSTAR SOPN ................ 44 ADVAIR DISKUS AEPB ........................... 19 ADVAIR HFA AERO ................................ 19 ADZENYS ER SUER ............................... 27 ADZENYS XR-ODT TBED 3.1mg, 6.3mg,
9.4mg, 12.5mg, 15.7mg, 18.8mg .......... 27 AFINITOR DISPERZ TBSO 2mg, 3mg, 5mg
............................................................. 14 AFINITOR TABS 2.5mg, 5mg, 7.5mg, 10mg
............................................................. 14 AFREZZA POWD ..................................... 44 AFREZZA POWD 8 (90) & 12 (90) UNIT . 44 AKTIPAK PACK ....................................... 53 AKYNZEO CAPS ..................................... 40 ala scalp lotn ............................................ 54 ala-cort crea 1%, 2.5% ............................. 54 albendazole tabs ........................................ 8 ALBENZA TABS ........................................ 8 albuterol sulfate er tb12 4mg, 8mg ........... 19 ALBUTEROL SULFATE HFA AERS
108mcg/act, 108mcg/act ...................... 19 albuterol sulfate nebu .083%, 2.5mg/0.5ml
............................................................. 19 albuterol sulfate nebu .63mg/3ml,
1.25mg/3ml .......................................... 19 albuterol sulfate syrp ................................ 19 albuterol sulfate tabs 2mg, 4mg ............... 19
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 61
alclometasone dipropionate crea ............. 54 alclometasone dipropionate oint .............. 54 ALCOHOL PREP PADS .......................... 35 ALDACTAZIDE TABS .............................. 24 ALDURAZYME SOLN ............................. 37 ALECENSA CAPS ................................... 14 alendronate sodium soln .......................... 48 alendronate sodium tabs 40mg ................ 48 alendronate sodium tabs 5mg, 10mg,
35mg, 70mg ......................................... 48 alfuzosin hcl er tb24 ................................. 19 ALIMTA SOLR ......................................... 14 ALINIA SUSR .......................................... 11 ALINIA TABS ........................................... 11 ALIQOPA SOLR ...................................... 14 aliskiren fumarate tabs 150mg, 300mg .... 24 allopurinol tabs 100mg, 300mg ................ 48 allzital tabs ............................................... 25 almotriptan malate tabs ........................... 30 ALOCRIL SOLN ...................................... 39 alogliptin benzoate tabs 6.25mg, 12.5mg,
25mg .................................................... 44 ALOGLIPTIN-METFORMIN HCL TABS .. 44 alogliptin-pioglitazone tabs ...................... 44 ALOMIDE SOLN ...................................... 39 alosetron hcl tabs .5mg, 1mg ................... 39 ALPHAGAN P SOLN ............................... 39 alprazolam er tb24 .5mg, 1mg, 2mg, 3mg 31 alprazolam intensol conc ......................... 31 alprazolam tabs .25mg, .5mg, 1mg, 2mg . 31 alprazolam tbdp .25mg, .5mg, 1mg, 2mg . 31 ALREX SUSP .......................................... 38 altavera tabs ............................................ 42 ALTOPREV TB24 20mg, 40mg, 60mg .... 21 ALTRENO LOTN ..................................... 56 ALUNBRIG TABS 30mg, 90mg, 180mg .. 14 ALUNBRIG TBPK .................................... 14 ALVESCO AERS 80mcg/act, 160mcg/act 51 alyacen 1/35 tabs .................................... 42 alyq tabs .................................................. 24 amabelz tabs ........................................... 46 amantadine hcl caps ................................ 30 amantadine hcl syrp................................. 30 amantadine hcl tabs................................. 30 AMBISOME SUSR INTRAVENOUS ........ 10 ambrisentan tabs 5mg, 10mg .................. 51 amcinonide crea ...................................... 54 amcinonide lotn ....................................... 54 amcinonide oint ....................................... 54
amethia lo tabs ......................................... 42 amethia tabs ............................................ 42 AMICAR TABS ......................................... 20 amikacin sulfate soln injection .................... 8 amiloride hcl tabs ..................................... 36 amiloride-hydrochlorothiazide tabs ........... 36 AMINOSYN-PF SOLN INTRAVENOUS ... 35 amiodarone hcl tabs 100mg, 200mg,
400mg .................................................. 23 AMITIZA CAPS 8mcg, 24mcg .................. 41 amitriptyline hcl tabs 10mg, 25mg, 50mg,
75mg, 100mg, 150mg........................... 32 amlodipine besy-benazepril hcl caps........ 22 amlodipine besylate tabs 2.5mg, 5mg,
10mg .................................................... 22 amlodipine besylate-valsartan tabs .......... 22 amlodipine-atorvastatin tabs .................... 22 amlodipine-olmesartan tabs ..................... 22 amlodipine-valsartan-hctz tabs ................. 22 ammonium lactate crea ............................ 56 ammonium lactate lotn ............................. 56 amnesteem caps 10mg, 20mg, 40mg ...... 56 amoxapine tabs 25mg, 50mg, 100mg,
150mg .................................................. 32 amoxicill-clarithro-lansopraz misc ............ 40 amoxicillin caps .......................................... 8 amoxicillin chew ......................................... 8 amoxicillin susr ........................................... 8 amoxicillin tabs ........................................... 8 amoxicillin-pot clavulanate chew ................ 8 amoxicillin-pot clavulanate er tb12 ............. 8 amoxicillin-pot clavulanate susr .................. 8 amoxicillin-pot clavulanate tabs .................. 8 amphetamine er suer ............................... 27 amphetamine sulfate tabs 5mg, 10mg ..... 27 amphetamine-dextroamphet er cp24........ 28 amphetamine-dextroamphetamine tabs ... 28 amphotericin b solr intravenous ............... 10 ampicillin caps ............................................ 8 ampicillin sodium solr injection 1gm, 125mg
............................................................... 8 ampicillin sodium solr intravenous .............. 8 ampicillin-sulbactam sodium solr injection .. 8 ampicillin-sulbactam sodium solr
intravenous ............................................. 8 AMPYRA TB12 ........................................ 32 ANADROL-50 TABS ................................ 42 anagrelide hcl caps .5mg, 1mg ................ 20 anastrozole tabs ....................................... 14
62 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
ANCOBON CAPS 250mg, 500mg ........... 10 ANDRODERM PT24 2mg/24hr, 4mg/24hr
............................................................. 42 ANGELIQ TABS ...................................... 46 ANORO ELLIPTA AEPB .......................... 18 antabuse tabs 250mg, 500mg ................. 25 ANTARA CAPS 30mg, 90mg................... 21 anusol-hc crea ......................................... 54 ANZEMET TABS 50mg, 100mg .............. 40 apap-caff-dihydrocodeine tabs ................. 25 apexicon e crea ....................................... 54 APIDRA SOLN ........................................ 44 APIDRA SOLOSTAR SOPN .................... 44 APLENZIN TB24 174mg, 348mg, 522mg 32 APOKYN SOCT ....................................... 30 apraclonidine hcl soln .............................. 39 aprepitant caps ........................................ 40 apri tabs ................................................... 42 APRISO CP24 ......................................... 39 APTENSIO XR CP24 10mg, 15mg, 20mg,
30mg, 40mg, 50mg, 60mg ................... 28 APTIOM TABS 200mg, 400mg, 600mg,
800mg .................................................. 28 APTIVUS CAPS ...................................... 12 APTIVUS SOLN ...................................... 12 ARALAST NP SOLR INTRAVENOUS
500mg, 1000mg ................................... 51 aranelle tabs ............................................ 42 ARANESP (ALBUMIN FREE) SOLN
25mcg/ml, 40mcg/ml, 60mcg/ml, 100mcg/ml, 200mcg/ml, 300mcg/ml ..... 20
ARANESP (ALBUMIN FREE) SOSY 25mcg/0.42ml, 10mcg/0.4ml, 40mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml ............................................................. 20
ARANESP (ALBUMIN FREE) SOSY 60mcg/0.3ml, 150mcg/0.3ml, 200mcg/0.4ml, 100mcg/0.5ml .............. 20
ARCALYST SOLR ................................... 49 ARCAPTA NEOHALER CAPS ................ 19 ARIKAYCE SUSP ...................................... 8 aripiprazole soln ...................................... 32 aripiprazole tabs 2mg, 5mg, 10mg, 15mg,
20mg, 30mg ......................................... 32 aripiprazole tbdp 10mg, 15mg ................. 32 ARISTADA INITIO PRSY ........................ 32 ARISTADA PRSY 441mg/1.6ml,
662mg/2.4ml, 882mg/3.2ml, 1064mg/3.9ml ...................................... 32
ARIXTRA SOLN 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml .......................................... 20
armodafinil tabs 50mg, 150mg, 200mg, 250mg .................................................. 28
ARNUITY ELLIPTA AEPB 50mcg/act, 100mcg/act, 200mcg/act ...................... 51
ARRANON SOLN .................................... 14 ARYMO ER TBEA .................................... 25 ARZERRA CONC 1000mg/50ml,
100mg/5ml ........................................... 14 ASCENIV SOLN....................................... 52 ascomp-codeine caps .............................. 25 ashlyna tabs ............................................. 42 ASMANEX (120 METERED DOSES) AEPB
............................................................. 51 ASMANEX (30 METERED DOSES) AEPB
............................................................. 51 ASMANEX (30 METERED DOSES) AEPB
110mcg/inh ........................................... 51 ASMANEX (60 METERED DOSES) AEPB
............................................................. 51 ASMANEX HFA AERO 100mcg/act,
200mcg/act ........................................... 51 ASPARLAS SOLN ................................... 14 aspirin-dipyridamole er cp12 .................... 20 ASTAGRAF XL CP24 .............................. 49 ASTAGRAF XL CP24 .5mg, 1mg ............. 49 atazanavir sulfate caps 150mg, 200mg,
300mg .................................................. 12 atenolol tabs 25mg, 50mg, 100mg ........... 22 atenolol-chlorthalidone tabs ..................... 22 atomoxetine hcl caps 10mg, 18mg, 25mg,
40mg, 60mg, 80mg, 100mg .................. 31 atorvastatin calcium tabs 10mg, 20mg,
40mg, 80mg ......................................... 21 atovaquone susp ...................................... 11 atovaquone-proguanil hcl tabs ................. 11 ATRIPLA TABS ........................................ 12 ATROPINE SULFATE SOLN ................... 39 ATROVENT HFA AERS ........................... 18 AUBAGIO TABS 7mg, 14mg .................... 32 aubra tabs ................................................ 42 AUGMENTIN SUSR ................................... 8 AURYXIA TABS ....................................... 36 AUSTEDO TABS 6mg, 9mg, 12mg .......... 31 AVANDIA TABS 2mg, 4mg ...................... 44 AVASTIN SOLN ....................................... 14 AVC VAGINAL CREA .............................. 53 AVEED SOLN .......................................... 42
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 63
aviane tabs .............................................. 42 AVITA CREA ........................................... 56 AVITA GEL .............................................. 56 AVONEX KIT ........................................... 32 AVONEX PEN AJKT ................................ 32 AVONEX PREFILLED PSKT ................... 32 AVYCAZ SOLR INTRAVENOUS ............... 8 aygestin tabs ........................................... 47 AYVAKIT TABS 100mg, 200mg, 300mg .. 14 AZACTAM SOLR INJECTION 1gm, 2gm .. 8 azasan tabs 75mg, 100mg ...................... 49 AZASITE SOLN ....................................... 37 azathioprine tabs ..................................... 49 azelaic acid gel ........................................ 56 azelastine hcl soln .05%, .1%, .15% ........ 39 azelastine-fluticasone susp ...................... 39 AZELEX CREA ........................................ 56 AZITHROMYCIN PACK ............................. 8 azithromycin solr intravenous .................... 8 azithromycin susr 100mg/5ml, 200mg/5ml . 8 azithromycin tabs 250mg, 500mg, 600mg . 8 AZOPT SUSP .......................................... 39 aztreonam solr injection ............................. 8
B bacitracin oint .......................................... 37 bacitracin-polymyxin b oint ...................... 37 bacitra-neomycin-polymyxin-hc oint ......... 38 baclofen tabs 5mg, 10mg, 20mg .............. 19 BACTROBAN NASAL OINT .................... 53 balsalazide disodium caps ....................... 40 BALVERSA TABS 3mg, 4mg, 5mg .......... 14 balziva tabs .............................................. 42 BANZEL SUSP ........................................ 28 BANZEL TABS 200mg, 400mg ................ 28 BAQSIMI TWO PACK POWD .................. 44 BARACLUDE SOLN ................................ 12 BARACLUDE TABS ................................ 12 BASAGLAR KWIKPEN SOPN ................. 44 BAVENCIO SOLN ................................... 14 BAXDELA SOLR INTRAVENOUS ............. 8 BAXDELA TABS ........................................ 8 BCG VACCINE INJ.................................. 14 BD INSULIN SYR ULTRAFINE II MISC ... 35 BD INSULIN SYRINGE MISC.................. 35 BD INSULIN SYRINGE U/F MISC ........... 35 BD PEN NEEDLE ORIGINAL U/F MISC . 35 BECONASE AQ SUSP ............................ 38
BELBUCA FILM 75mcg, 150mcg, 300mcg, 450mcg, 600mcg, 750mcg, 900mcg ..... 25
BELEODAQ SOLR ................................... 14 BELRAPZO SOLN ................................... 14 BELSOMRA TABS ................................... 31 benazepril hcl tabs 5mg, 10mg, 20mg,
40mg .................................................... 24 benazepril-hydrochlorothiazide tabs ......... 24 BENDAMUSTINE HCL SOLN .................. 14 BENDEKA SOLN ..................................... 14 BENLYSTA SOAJ .................................... 49 BENLYSTA SOLR .................................... 49 BENLYSTA SOSY ................................... 49 BENZNIDAZOLE TABS 12.5mg, 100mg .. 11 BENZOYL PEROXIDE FORTE- HC LOTN
............................................................. 54 BENZOYL PEROXIDE GEL ..................... 53 benzoyl peroxide-erythromycin gel ........... 53 benztropine mesylate tabs .5mg, 1mg, 2mg
............................................................. 30 BEOVU SOLN .......................................... 39 BEPREVE SOLN ..................................... 39 BERINERT KIT INTRAVENOUS ............. 20 beser lotn ................................................. 54 BESIVANCE SUSP .................................. 37 BESPONSA SOLR ................................... 14 betamethasone dipropionate aug crea ..... 54 betamethasone dipropionate aug gel ....... 54 betamethasone dipropionate aug lotn ...... 54 betamethasone dipropionate aug oint ...... 54 betamethasone dipropionate crea ............ 54 betamethasone dipropionate lotn ............. 54 betamethasone dipropionate oint ............. 54 betamethasone valerate crea ................... 54 betamethasone valerate foam .................. 54 betamethasone valerate lotn .................... 54 betamethasone valerate oint .................... 54 BETASERON KIT .................................... 32 betaxolol hcl soln...................................... 39 betaxolol hcl tabs 10mg, 20mg ................. 22 bethanechol chloride tabs 5mg, 10mg,
25mg, 50mg ......................................... 18 BETHKIS NEBU ....................................... 51 BETIMOL SOLN .25%, .5% ..................... 39 BETOPTIC-S SUSP ................................. 39 BEVESPI AEROSPHERE AERO ............. 18 BEVYXXA CAPS 40mg, 80mg ................. 20 bexarotene caps ...................................... 14 BEXSERO SUSY ..................................... 52
64 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
bicalutamide tabs ..................................... 14 BICILLIN C-R 900/300 SUSP .................... 8 BICILLIN C-R SUSP .................................. 8 BICILLIN L-A SUSP ................................... 8 BICNU SOLR ........................................... 14 BIDIL TABS ............................................. 24 BIKTARVY TABS .................................... 12 bimatoprost soln ...................................... 39 BINOSTO TBEF ...................................... 48 bisoprolol fumarate tabs 5mg, 10mg ........ 22 bisoprolol-hydrochlorothiazide tabs ......... 22 BIVIGAM SOLN INTRAVENOUS ............ 52 BIVIGAM SOLN INTRAVENOUS
10gm/100ml ......................................... 52 bleph-10 soln ........................................... 37 blephamide s.o.p. oint .............................. 38 BLEPHAMIDE SUSP ............................... 38 BLINCYTO SOLR .................................... 14 blisovi 24 fe tabs ...................................... 42 blisovi fe 1.5/30 tabs ................................ 42 BONJESTA TBCR ................................... 40 BOOSTRIX SUSP ................................... 52 BORTEZOMIB SOLR .............................. 15 bosentan tabs 62.5mg, 125mg ................ 51 BOSULIF TABS 100mg, 400mg, 500mg . 15 BOTOX SOLR 100unit, 200unit ............... 50 BRAFTOVI CAPS 50mg, 75mg ............... 15 briellyn tabs ............................................. 42 BRILINTA TABS 60mg, 90mg ................. 20 brimonidine tartrate soln .2%, .15% ......... 39 BRIVIACT SOLN ..................................... 28 BRIVIACT TABS 10mg, 25mg, 50mg,
75mg, 100mg ....................................... 28 bromfenac sodium (once-daily) soln ........ 38 bromocriptine mesylate caps ................... 30 bromocriptine mesylate tabs .................... 30 BROMSITE SOLN ................................... 38 BROVANA NEBU .................................... 19 BRUKINSA CAPS ................................... 15 BRYHALI LOTN ....................................... 54 budesonide cpep ..................................... 41 budesonide er tb24 .................................. 41 budesonide susp .25mg/2ml, .5mg/2ml,
1mg/2ml ............................................... 51 budesonide-formoterol fumarate aero ...... 41 bumetanide soln ...................................... 36 bumetanide tabs .5mg, 1mg, 2mg ........... 36 BUNAVAIL FILM ...................................... 32 bupap tabs ............................................... 25
BUPHENYL POWD .................................. 35 BUPHENYL TABS ................................... 35 buprenorphine hcl subl 2mg, 8mg ............ 32 buprenorphine hcl-naloxone hcl film ......... 32 buprenorphine hcl-naloxone hcl subl ........ 32 buprenorphine ptwk 5mcg/hr, 7.5mcg/hr,
10mcg/hr, 15mcg/hr, 20mcg/hr ............. 25 bupropion hcl er (smoking det) tb12 ......... 32 bupropion hcl er (sr) tb12 100mg, 150mg,
200mg .................................................. 32 bupropion hcl er (xl) tb24 150mg, 300mg,
450mg .................................................. 32 bupropion hcl tabs 75mg, 100mg ............. 32 buspirone hcl tabs 5mg, 10mg ................. 31 buspirone hcl tabs 7.5mg, 15mg, 30mg ... 31 butalbital-acetaminophen caps ................. 25 butalbital-acetaminophen tabs ................. 25 butalbital-apap-caff-cod caps ................... 25 butalbital-apap-caffeine caps ................... 25 butalbital-apap-caffeine tabs .................... 25 butalbital-asa-caff-codeine caps ............... 25 butalbital-aspirin-caffeine caps ................. 25 butorphanol tartrate soln .......................... 25 BUTRANS PTWK ..................................... 25 BYDUREON BCISE AUIJ ........................ 44 BYDUREON PEN .................................... 44 BYETTA 10 MCG PEN SOPN ................. 44 BYETTA 5 MCG PEN SOPN ................... 44 BYSTOLIC TABS 2.5mg, 5mg, 10mg, 20mg
............................................................. 22 BYVALSON TABS ................................... 24
C cabergoline tabs ....................................... 30 CABLIVI KIT ............................................. 20 CABOMETYX TABS 20mg, 40mg, 60mg . 15 cafergot tabs ............................................ 30 calcipotriene crea ..................................... 56 calcipotriene oint ...................................... 56 calcipotriene soln ..................................... 56 calcipotriene-betameth diprop oint ........... 54 calcipotriene-betameth diprop susp.......... 54 calcitonin (salmon) soln ............................ 46 calcitriol caps .25mcg, .5mcg ................... 58 CALCITRIOL OINT .................................. 56 calcitriol soln ............................................ 58 calcium acetate (phos binder) caps .......... 36 calcium acetate (phos binder) tabs .......... 36
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 65
CALQUENCE CAPS ................................ 15 CAMBIA PACK ........................................ 30 camila tabs .............................................. 42 camrese lo tabs ....................................... 42 CANCIDAS SOLR INTRAVENOUS 50mg,
70mg .................................................... 10 candesartan cilexetil tabs 4mg, 8mg, 16mg,
32mg .................................................... 24 candesartan cilexetil-hctz tabs ................. 24 CAPASTAT SULFATE SOLR .................. 11 CAPEX SHAM ......................................... 54 CAPLYTA CAPS ..................................... 32 CAPRELSA TABS 100mg, 300mg .......... 15 captopril tabs 12.5mg, 25mg, 50mg, 100mg
............................................................. 24 captopril-hydrochlorothiazide tabs ........... 24 CARAC CREA ......................................... 56 CARAFATE SUSP ................................... 40 CARBAGLU TABS................................... 35 carbamazepine chew ............................... 28 carbamazepine er cp12 100mg, 200mg,
300mg .................................................. 28 carbamazepine er tb12 100mg, 200mg,
400mg .................................................. 28 carbamazepine susp ................................ 28 carbamazepine tabs ................................ 28 carbidopa tabs ......................................... 30 carbidopa-levodopa er tbcr ...................... 30 carbidopa-levodopa tabs ......................... 30 carbidopa-levodopa tbdp ......................... 30 carbidopa-levodopa-entacapone tabs ...... 30 carbinoxamine maleate soln .................... 14 carbinoxamine maleate tabs .................... 14 CARDENE IV SOLN ................................ 22 CARDIZEM LA TB24 ............................... 22 CARDURA XL TB24 4mg, 8mg ............... 21 carisoprodol tabs 250mg, 350mg ............. 19 carisoprodol-aspirin tabs .......................... 19 carisoprodol-aspirin-codeine tabs ............ 19 CARNITOR SOLN ................................... 50 CARNITOR TABS.................................... 50 CAROSPIR SUSP ................................... 24 carteolol hcl soln ...................................... 39 cartia xt cp24 120mg, 180mg, 240mg,
300mg .................................................. 22 carvedilol phosphate er cp24 10mg, 20mg,
40mg, 80mg ......................................... 22 carvedilol tabs 3.125mg, 6.25mg, 12.5mg,
25mg .................................................... 22
caspofungin acetate solr intravenous 50mg, 70mg .................................................... 10
CAYSTON SOLR ..................................... 51 caziant tabs .............................................. 42 cefaclor caps .............................................. 8 cefaclor er tb12 .......................................... 8 cefaclor susr ............................................... 8 cefadroxil caps ........................................... 8 cefadroxil susr ............................................ 8 cefadroxil tabs ............................................ 8 cefazolin sodium solr injection 1gm, 10gm,
500mg .................................................... 8 cefdinir caps ............................................... 8 cefdinir susr ................................................ 8 cefepime hcl solr injection 1gm, 2gm ......... 8 cefixime caps ............................................. 8 cefixime susr .............................................. 8 cefotetan disodium solr injection 1gm, 2gm 8 cefoxitin sodium solr injection ..................... 8 cefoxitin sodium solr intravenous 1gm, 2gm
............................................................... 8 cefpodoxime proxetil susr .......................... 8 cefpodoxime proxetil tabs .......................... 8 cefprozil susr .............................................. 8 cefprozil tabs .............................................. 8 ceftazidime solr injection 1gm, 2gm, 6gm .. 8 CEFTIN SUSR ........................................... 8 ceftriaxone sodium solr injection 1gm, 2gm,
250mg, 500mg ....................................... 8 ceftriaxone sodium solr intravenous ........... 8 cefuroxime axetil tabs ................................ 8 cefuroxime sodium solr injection 7.5gm,
750mg .................................................... 8 cefuroxime sodium solr intravenous ........... 8 celecoxib caps ......................................... 25 CELONTIN CAPS .................................... 28 cephalexin caps ......................................... 8 cephalexin susr .......................................... 8 cephalexin tabs .......................................... 8 CERDELGA CAPS ................................... 37 CEREZYME SOLR .................................. 37 CESAMET CAPS ..................................... 40 cetirizine hcl soln ...................................... 14 CETRAXAL SOLN ................................... 37 cevimeline hcl caps .................................. 18 CHANTIX CONTINUING MONTH PAK
TABS .................................................... 18 CHANTIX STARTING MONTH PAK TABS
............................................................. 18
66 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
CHANTIX TABS .5mg, 1mg ..................... 18 CHEMET CAPS ....................................... 41 chlordiazepoxide hcl caps 5mg, 10mg,
25mg .................................................... 31 chlordiazepoxide-amitriptyline tabs .......... 32 chlorhexidine gluconate soln.................... 38 chloroquine phosphate tabs 250mg, 500mg
............................................................. 11 chlorothiazide tabs 250mg, 500mg .......... 36 chlorpromazine hcl tabs 10mg, 25mg,
50mg, 100mg, 200mg .......................... 32 chlorthalidone tabs 25mg, 50mg .............. 36 chlorzoxazone tabs 375mg, 500mg, 750mg
............................................................. 19 CHOLBAM CAPS 50mg, 250mg ............. 41 cholestyramine light powd ....................... 21 cholestyramine pack ................................ 21 CHORIONIC GONADOTROPIN SOLR ... 46 ciclopirox gel ............................................ 53 ciclopirox olamine crea ............................ 53 ciclopirox olamine susp ............................ 53 ciclopirox sham ........................................ 53 ciclopirox soln .......................................... 53 cilostazol tabs 50mg, 100mg ................... 20 CILOXAN OINT ....................................... 38 CIMDUO TABS ........................................ 12 cimetidine hcl soln ................................... 40 cimetidine tabs 200mg, 300mg, 400mg,
800mg .................................................. 40 CIMZIA KIT .............................................. 48 CIMZIA PREFILLED KIT ......................... 48 CIMZIA STARTER KIT KIT ...................... 48 cinacalcet hcl tabs 30mg, 60mg, 90mg .... 46 CINQAIR SOLN ....................................... 50 CINRYZE SOLR INTRAVENOUS ........... 20 CIPRO HC SUSP .................................... 38 CIPRODEX SUSP ................................... 38 ciprofloxacin hcl soln (ophth) ................... 38 CIPROFLOXACIN HCL SOLN (OTIC) ..... 38 ciprofloxacin hcl tabs ................................. 8 ciprofloxacin in d5w soln intravenous ........ 8 ciprofloxacin susr ....................................... 9 ciprofloxacin-ciproflox hcl er tb24 ............... 9 CIPROFLOXACIN-FLUOCINOLONE PF
SOLN ................................................... 38 CISPLATIN SOLR ................................... 15 citalopram hydrobromide soln .................. 32 citalopram hydrobromide tabs 10mg, 20mg,
40mg .................................................... 33
claravis caps 10mg, 20mg, 30mg, 40mg .. 56 CLARINEX SYRP .................................... 14 CLARINEX-D 12 HOUR TB12 ................. 14 clarithromycin er tb24 ................................. 9 clarithromycin susr ..................................... 9 clarithromycin tabs ..................................... 9 clemastine fumarate tabs ......................... 14 cleocin solr ................................................. 9 CLEOCIN SUPP ...................................... 53 CLIMARA PRO PTWK ............................. 46 CLIMARA PTWK
37.5mcg/24hr, .025mg/24hr, .05mg/24hr, .06mg/24hr, .075mg/24hr, .1mg/24hr ... 46
clindacin-p swab ...................................... 53 clindamycin hcl caps .................................. 9 clindamycin palmitate hcl solr ..................... 9 clindamycin phos-benzoyl perox gel......... 53 clindamycin phosphate crea ..................... 53 clindamycin phosphate foam .................... 53 clindamycin phosphate gel ....................... 53 clindamycin phosphate in d5w soln
intravenous ............................................. 9 clindamycin phosphate lotn ...................... 53 clindamycin phosphate soln ................. 9, 53 clindamycin phosphate soln injection
300mg/2ml, 600mg/4ml, 900mg/6ml ...... 9 clindamycin phosphate swab ................... 53 CLINDESSE CREA .................................. 53 CLINIMIX E/DEXTROSE (2.75/10) SOLN
INTRAVENOUS ................................... 35 CLINIMIX E/DEXTROSE (2.75/5) SOLN
INTRAVENOUS ................................... 35 CLINIMIX E/DEXTROSE (4.25/10) SOLN
INTRAVENOUS ................................... 35 CLINIMIX E/DEXTROSE (4.25/25) SOLN
INTRAVENOUS ................................... 35 CLINIMIX E/DEXTROSE (4.25/5) SOLN
INTRAVENOUS ................................... 35 CLINIMIX E/DEXTROSE (5/15) SOLN
INTRAVENOUS ................................... 35 CLINIMIX E/DEXTROSE (5/20) SOLN
INTRAVENOUS ................................... 35 CLINIMIX E/DEXTROSE (5/25) SOLN
INTRAVENOUS ................................... 35 CLINIMIX/DEXTROSE (2.75/5) SOLN
INTRAVENOUS ................................... 35 CLINIMIX/DEXTROSE (4.25/10) SOLN
INTRAVENOUS ................................... 35
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 67
CLINIMIX/DEXTROSE (4.25/20) SOLN INTRAVENOUS ................................... 35
CLINIMIX/DEXTROSE (4.25/5) SOLN INTRAVENOUS ................................... 35
CLINIMIX/DEXTROSE (5/15) SOLN INTRAVENOUS ................................... 35
CLINIMIX/DEXTROSE (5/20) SOLN INTRAVENOUS ................................... 35
CLINIMIX/DEXTROSE (5/25) SOLN INTRAVENOUS ................................... 35
clinisol sf soln intravenous ....................... 35 clobazam susp ......................................... 28 clobazam tabs 10mg, 20mg ..................... 28 clobetasol propionate crea ....................... 54 clobetasol propionate e crea .................... 54 clobetasol propionate emulsion foam ...... 54 clobetasol propionate foam ...................... 54 clobetasol propionate gel ......................... 54 clobetasol propionate liqd ........................ 54 clobetasol propionate lotn ........................ 54 clobetasol propionate oint ........................ 55 clobetasol propionate sham ..................... 55 clobetasol propionate soln ....................... 55 CLOBEX SHAM ....................................... 55 CLOBEX SPRAY LIQD ............................ 55 clocortolone pivalate crea ........................ 55 clocortolone pivalate pump crea .............. 55 clodan sham ............................................ 55 clomipramine hcl caps 25mg, 50mg, 75mg
............................................................. 33 clonazepam tabs .5mg, 1mg, 2mg ........... 28 clonazepam tbdp .125mg, .25mg, .5mg,
1mg, 2mg ............................................. 28 clonidine hcl er tb12 ................................. 23 clonidine hcl tabs .1mg, .2mg, .3mg ........ 23 clonidine
ptwk .1mg/24hr, .2mg/24hr, .3mg/24hr 23 clopidogrel bisulfate tabs ......................... 20 clorazepate dipotassium tabs 3.75mg,
7.5mg, 15mg ........................................ 31 clotrimazole crea ..................................... 53 clotrimazole lozg ...................................... 53 clotrimazole soln ...................................... 53 clotrimazole-betamethasone crea ............ 53 clotrimazole-betamethasone lotn ............. 53 clovique caps ........................................... 41 clozapine tabs 25mg, 50mg, 100mg, 200mg
............................................................. 33
clozapine tbdp 12.5mg, 25mg, 100mg, 150mg, 200mg ..................................... 33
COARTEM TABS ..................................... 11 codeine sulfate tabs 15mg, 30mg, 60mg .. 25 colazal caps ............................................. 40 COLCHICINE CAPS ................................ 48 colchicine tabs ......................................... 48 colchicine-probenecid tabs ....................... 37 colesevelam hcl pack ............................... 21 colesevelam hcl tabs ................................ 21 colestipol hcl pack .................................... 21 colestipol hcl tabs ..................................... 21 colistimethate sodium (cba) solr injection ... 9 colocort enem .......................................... 55 COLY-MYCIN S SUSP ............................ 38 COMBIGAN SOLN ................................... 39 COMBIPATCH PTTW .............................. 46 COMBIVENT RESPIMAT AERS .............. 19 COMBIVIR TABS ..................................... 12 COMETRIQ (100 MG DAILY DOSE) KIT . 15 COMETRIQ (140 MG DAILY DOSE) KIT . 15 COMETRIQ (60 MG DAILY DOSE) KIT ... 15 COMPLERA TABS ................................... 12 compro supp ............................................ 33 CONDYLOX GEL ..................................... 56 CONSENSI TABS .................................... 22 constulose soln ........................................ 35 COPAXONE SOSY 20mg/ml, 40mg/ml .... 32 COPIKTRA CAPS 15mg, 25mg ............... 15 CORDRAN TAPE ..................................... 55 CORLANOR TABS 5mg, 7.5mg ............... 23 cortisone acetate tabs .............................. 41 CORTISPORIN CREA ............................. 55 CORTISPORIN OINT ............................... 55 COSENTYX (300 MG DOSE) SOSY ....... 57 COSENTYX SENSOREADY (300 MG)
SOAJ .................................................... 57 COSENTYX SENSOREADY PEN SOAJ . 57 COSENTYX SOSY .................................. 57 COTELLIC TABS ..................................... 15 COTEMPLA XR-ODT TBED 8.6mg,
17.3mg, 25.9mg ................................... 28 CREON CPEP ......................................... 37 CRESEMBA CAPS .................................. 11 CRESEMBA SOLR .................................. 11 CRINONE GEL 4%, 8% .......................... 47 CRIXIVAN CAPS 200mg, 400mg ............. 12 cromolyn sodium conc ............................. 50 cromolyn sodium nebu ............................. 50
68 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
cromolyn sodium soln .............................. 39 cryselle-28 tabs ....................................... 42 CRYSVITA SOLN 10mg/ml, 20mg/ml,
30mg/ml ............................................... 50 CUBICIN SOLR INTRAVENOUS .............. 9 CUPRIMINE CAPS .................................. 41 CURITY GAUZE PADS ........................... 35 CUTAQUIG SOLN 1.65gm/10ml, 2gm/12ml,
3.3gm/20ml, 4gm/24ml, 8gm/48ml, 1gm/6ml ............................................... 52
CUVPOSA SOLN .................................... 18 cyclafem 1/35 tabs ................................... 42 cyclafem 7/7/7 tabs .................................. 42 cyclobenzaprine hcl er cp24 15mg, 30mg 19 cyclobenzaprine hcl tabs 5mg, 7.5mg,
10mg .................................................... 19 cyclophosphamide caps 25mg, 50mg ...... 15 CYCLOSET TABS ................................... 44 cyclosporine caps 25mg, 100mg ............. 49 cyclosporine modified caps 25mg, 50mg,
100mg .................................................. 49 cyclosporine modified soln ....................... 49 cyclosporine soln ..................................... 49 cyproheptadine hcl syrp ........................... 14 cyproheptadine hcl tabs ........................... 14 CYRAMZA SOLN 100mg/10ml,
500mg/50ml ......................................... 15 cyred tabs ................................................ 42 CYSTADANE POWD ............................... 50 CYSTAGON CAPS 50mg, 150mg ........... 50 CYSTARAN SOLN .................................. 39 CYTOGAM INJ ........................................ 52
D D.H.E. 45 SOLN ...................................... 19 DAKLINZA TABS 30mg, 60mg, 90mg ..... 12 dalfampridine er tb12 ............................... 32 DALIRESP TABS 250mcg, 500mcg ........ 51 DALVANCE SOLR INTRAVENOUS .......... 9 danazol caps 50mg, 100mg, 200mg ........ 42 dantrolene sodium caps ........................... 19 dapsone gel 5%, 7.5% ............................ 57 dapsone tabs 25mg, 100mg .................... 11 DAPTACEL SUSP ................................... 52 daptomycin solr intravenous 350mg .......... 9 daptomycin solr intravenous 500mg .......... 9 DARAPRIM TABS ................................... 11
darifenacin hydrobromide er tb24 7.5mg, 15mg .................................................... 57
DARZALEX SOLN 400mg/20ml, 100mg/5ml ............................................................. 15
DAURISMO TABS 25mg, 100mg ............. 15 DAYTRANA PTCH 10mg/9hr, 15mg/9hr,
20mg/9hr, 30mg/9hr ............................. 28 DDAVP RHINAL TUBE SOLN ................. 47 deblitane tabs ........................................... 42 decadron tabs 4mg, 6mg ......................... 41 deferasirox tabs 90mg, 180mg, 360mg .... 41 deferasirox tbso 125mg ............................ 41 deferasirox tbso 250mg, 500mg ............... 41 DELESTROGEN OIL ............................... 46 DELSTRIGO TABS .................................. 12 deltasone tabs .......................................... 41 delyla tabs ................................................ 42 DELZICOL CPDR .................................... 40 demeclocycline hcl tabs ............................. 9 DEMEROL SOLN 25mg/0.5ml, 75mg/1.5ml,
100mg/2ml, 75mg/ml ............................ 25 DEMSER CAPS ....................................... 21 DENAVIR CREA ...................................... 53 DEPEN TITRATABS TABS ...................... 41 depo-estradiol oil ...................................... 46 DEPO-MEDROL SUSP ............................ 41 DEPO-PROVERA SUSP 400mg/ml ......... 47 DEPO-SUBQ PROVERA 104 SUSY........ 47 depo-testosterone soln 100mg/ml,
200mg/ml ............................................. 42 dermotic oil ............................................... 38 DESCOVY TABS ..................................... 12 desipramine hcl tabs 10mg, 25mg, 50mg,
75mg, 100mg, 150mg........................... 33 desloratadine tabs .................................... 14 desloratadine tbdp.................................... 14 DESMOPRESSIN ACE RHINAL TUBE
SOLN ................................................... 47 desmopressin ace spray refrig soln .......... 47 desmopressin acetate tabs .1mg, .2mg .... 47 desogestrel-ethinyl estradiol tabs ............. 42 DESONATE GEL ..................................... 55 desonide crea .......................................... 55 desonide lotn ............................................ 55 desonide oint ............................................ 55 desowen lotn ............................................ 55 desoximetasone crea .05%, .25% ............ 55 desoximetasone gel ................................. 55 desoximetasone liqd ................................ 55
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 69
desoximetasone oint .05%, .25% ............. 55 DESVENLAFAXINE ER TB24 50mg,
100mg .................................................. 33 desvenlafaxine succinate er tb24 25mg,
50mg, 100mg ....................................... 33 dexamethasone elix ................................. 41 dexamethasone intensol conc ................. 41 dexamethasone sodium phosphate soln.. 38 dexamethasone tabs .5mg, .75mg, 1mg,
1.5mg, 2mg, 4mg, 6mg ........................ 41 dexamethasone tbpk ............................... 41 dexchlorpheniramine maleate soln .......... 14 DEXILANT CPDR 30mg, 60mg ............... 40 dexmethylphenidate hcl er cp24 5mg,
10mg, 15mg, 20mg, 25mg, 30mg, 35mg, 40mg .................................................... 28
dexmethylphenidate hcl tabs 2.5mg, 5mg, 10mg .................................................... 28
dexpak 13 day tbpk.................................. 41 dextroamphetamine sulfate er cp24 5mg,
10mg, 15mg ......................................... 28 dextroamphetamine sulfate soln .............. 28 dextroamphetamine sulfate tabs 5mg, 10mg
............................................................. 28 DEXTROSE 10%/NACL 0.2% ................. 36 DEXTROSE 5%/NACL 0.225% ............... 36 dextrose soln intravenous 5%, 10% ......... 35 DEXTROSE-NACL SOLN INTRAVENOUS
............................................................. 36 DIACOMIT CAPS 250mg, 500mg ............ 28 DIACOMIT PACK 250mg, 500mg ............ 28 DIASTAT ACUDIAL GEL 10mg, 20mg ... 28 DIASTAT PEDIATRIC GEL ..................... 29 diazepam conc ........................................ 31 diazepam gel 2.5mg, 10mg, 20mg .......... 29 diazepam soln ......................................... 31 diazepam tabs 2mg, 5mg, 10mg .............. 31 DIBENZYLINE CAPS .............................. 19 diclofenac epolamine ptch ....................... 55 diclofenac potassium tabs ....................... 25 diclofenac sodium er tb24 ........................ 25 diclofenac sodium gel 1%, 3% ................ 55 diclofenac sodium soln ...................... 38, 55 diclofenac sodium tbec ............................ 25 diclofenac-misoprostol tbec ..................... 25 dicloxacillin sodium caps ........................... 9 dicyclomine hcl caps ................................ 18 dicyclomine hcl soln ................................. 18 dicyclomine hcl tabs................................. 18
didanosine cpdr 200mg, 250mg, 400mg .. 12 DIFFERIN CREA...................................... 57 DIFFERIN LOTN ...................................... 57 DIFICID TABS ............................................ 9 diflorasone diacetate crea ........................ 55 diflorasone diacetate oint ......................... 55 diflunisal tabs ........................................... 25 digitek tabs .125mg, .25mg ...................... 23 digox tabs ................................................. 23 DIGOXIN SOLN ....................................... 23 digoxin soln .05mg/ml .............................. 23 digoxin tabs 125mcg, 250mcg .................. 23 dihydroergotamine mesylate soln ............. 19 dilantin caps 30mg, 100mg ...................... 29 dilantin infatabs chew ............................... 29 diltiazem hcl er beads cp24 360mg, 420mg
............................................................. 22 diltiazem hcl er coated beads cp24 120mg,
180mg, 240mg, 300mg......................... 23 diltiazem hcl er cp12 60mg, 90mg, 120mg
............................................................. 23 diltiazem hcl tabs 30mg, 60mg, 90mg,
120mg .................................................. 23 dilt-xr cp24 120mg, 180mg, 240mg .......... 22 DIPENTUM CAPS .................................... 40 diphenoxylate-atropine liqd ...................... 40 diphenoxylate-atropine tabs ..................... 40 DIPHTHERIA-TETANUS TOXOIDS DT
SUSP ................................................... 52 dipyridamole tabs 25mg, 50mg, 75mg ..... 24 disopyramide phosphate caps 100mg,
150mg .................................................. 23 disulfiram tabs 250mg, 500mg ................. 25 DIURIL SUSP .......................................... 36 divalproex sodium csdr ............................ 29 divalproex sodium er tb24 250mg, 500mg29 divalproex sodium tbec 125mg, 250mg,
500mg .................................................. 29 DIVIGEL GEL ........................................... 46 DOCETAXEL (NON-ALCOHOL) SOLN
80mg/4ml, 160mg/8ml, 20mg/ml .......... 15 dofetilide caps 125mcg, 250mcg, 500mcg
............................................................. 23 donepezil hcl tabs 5mg, 10mg, 23mg ....... 18 donepezil hcl tbdp 5mg, 10mg ................. 18 DOPTELET TABS .................................... 20 DORYX MPC TBEC ................................... 9 dorzolamide hcl soln ................................ 39 dorzolamide hcl-timolol mal pf soln .......... 39
70 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
dorzolamide hcl-timolol mal soln .............. 39 dotti
pttw .025mg/24hr, .0375mg/24hr, .05mg/24hr, .075mg/24hr, .1mg/24hr .............. 46
DOVATO TABS ....................................... 12 doxazosin mesylate tabs 1mg, 2mg, 4mg,
8mg ...................................................... 21 doxepin hcl caps 10mg, 25mg, 50mg,
75mg, 100mg, 150mg .......................... 33 doxepin hcl conc ...................................... 33 doxepin hcl crea ...................................... 56 doxepin hcl tabs 3mg, 6mg ...................... 33 doxercalciferol caps .5mcg, 1mcg, 2.5mcg
............................................................. 58 doxy 100 solr intravenous .......................... 9 doxycycline hyclate caps 50mg, 100mg..... 9 doxycycline hyclate tabs 20mg, 75mg,
100mg, 150mg ....................................... 9 doxycycline hyclate tbec 50mg, 75mg,
100mg, 150mg, 200mg .......................... 9 doxycycline monohydrate caps 50mg,
75mg, 100mg, 150mg ............................ 9 doxycycline monohydrate susr................... 9 doxycycline monohydrate tabs 50mg,
75mg, 100mg, 150mg ............................ 9 doxylamine-pyridoxine tbec ..................... 40 DRIZALMA SPRINKLE CSDR ................. 33 dronabinol caps 2.5mg, 5mg, 10mg ......... 40 drospiren-eth estrad-levomefol tabs ........ 42 drospirenone-ethinyl estradiol tabs .......... 42 DROXIA CAPS ........................................ 15 DUAKLIR PRESSAIR AEPB.................... 18 DUAVEE TABS ....................................... 46 DUEXIS TABS ......................................... 25 DULERA AERO ....................................... 51 duloxetine hcl cpep 20mg, 30mg, 40mg,
60mg .................................................... 33 DUOBRII LOTN ....................................... 55 DUOPA SUSP ......................................... 30 DUPIXENT SOSY ............................. 50, 57 DURAMORPH SOLN .5mg/ml, 1mg/ml ... 25 DUREZOL EMUL .................................... 38 dutasteride caps ...................................... 48 dutasteride-tamsulosin hcl caps ............... 48 DUTOPROL TB24 ................................... 22 dvorah tabs .............................................. 25 DYANAVEL XR SUER ............................. 28 DYRENIUM CAPS 100mg ....................... 36 DYRENIUM CAPS 50mg ......................... 36
DYSPORT SOLR 300unit, 500unit ........... 50
E e.e.s. 400 tabs ........................................... 9 econazole nitrate crea .............................. 53 EDARBI TABS 40mg, 80mg ..................... 24 EDARBYCLOR TABS .............................. 24 EDECRIN TABS....................................... 36 EDLUAR SUBL 5mg, 10mg ..................... 31 EDURANT TABS ..................................... 12 efavirenz caps 50mg, 200mg ................... 12 efavirenz tabs ........................................... 12 EGRIFTA SOLR 1mg, 2mg ...................... 47 EGRIFTA SV SOLR ................................. 47 ELAPRASE SOLN ................................... 37 ELELYSO SOLR ...................................... 37 ELESTRIN GEL ....................................... 46 eletriptan hydrobromide tabs .................... 30 ELIGARD KIT ........................................... 15 ELIQUIS DVT/PE STARTER PACK TABS
............................................................. 20 ELIQUIS TABS 2.5mg, 5mg ..................... 20 ELITEK SOLR .......................................... 37 ELLA TABS .............................................. 42 ELMIRON CAPS ...................................... 50 eluryng ring .............................................. 42 ELZONRIS SOLN .................................... 15 EMBEDA CPCR ....................................... 25 EMCYT CAPS .......................................... 15 EMEND SUSR ......................................... 40 EMFLAZA SUSP ...................................... 41 EMFLAZA TABS 6mg, 18mg, 30mg, 36mg
............................................................. 41 EMGALITY (300 MG DOSE) SOSY ......... 30 EMGALITY SOAJ..................................... 30 EMGALITY SOSY .................................... 30 emoquette tabs ........................................ 42 EMPLICITI SOLR 300mg, 400mg ............ 15 EMSAM PT24 6mg/24hr, 9mg/24hr,
12mg/24hr ............................................ 30 EMTRIVA CAPS ...................................... 12 EMTRIVA SOLN ...................................... 12 emverm chew ............................................. 8 enalapril maleate tabs 2.5mg, 5mg, 10mg,
20mg .................................................... 24 enalapril-hydrochlorothiazide tabs ............ 24 ENBREL MINI SOCT ............................... 48 ENBREL SOLR ........................................ 48
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 71
ENBREL SOSY 25mg/0.5ml, 50mg/ml .... 48 ENBREL SURECLICK SOAJ ................... 48 ENDARI PACK ........................................ 50 endocet tabs ............................................ 25 ENGERIX-B SUSP 10mcg/0.5ml, 20mcg/ml
............................................................. 53 ENHERTU SOLR .................................... 15 enoxaparin sodium soln 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 120mg/0.8ml, 300mg/3ml, 100mg/ml, 150mg/ml ............................................. 20
enpresse-28 tabs ..................................... 42 enskyce tabs ............................................ 42 ENSTILAR FOAM .................................... 55 entacapone tabs ...................................... 30 entecavir tabs .5mg, 1mg ........................ 12 ENTOCORT EC CPEP ............................ 41 ENTRESTO TABS ................................... 24 ENTYVIO SOLR ...................................... 41 enulose soln ............................................ 35 ENVARSUS XR TB24 .75mg, 1mg, 4mg . 49 EPCLUSA TABS ..................................... 12 EPIDIOLEX SOLN ................................... 29 EPIDUO FORTE GEL .............................. 57 epinastine hcl soln ................................... 39 epinephrine soaj ...................................... 19 EPIPEN 2-PAK SOAJ .............................. 19 EPIPEN JR 2-PAK SOAJ ........................ 19 epitol tabs ................................................ 29 EPIVIR HBV SOLN .................................. 12 EPIVIR SOLN .......................................... 12 EPIVIR TABS 150mg, 300mg .................. 12 eplerenone tabs 25mg, 50mg .................. 24 EPOGEN SOLN 2000unit/ml, 3000unit/ml,
4000unit/ml, 10000unit/ml, 20000unit/ml ............................................................. 20
eprosartan mesylate tabs ........................ 24 EPZICOM TABS ...................................... 12 EQUETRO CP12 100mg, 200mg, 300mg 33 ERAXIS SOLR INTRAVENOUS 50mg,
100mg .................................................. 11 ERBITUX SOLN ...................................... 15 ergoloid mesylates tabs ........................... 19 ergotamine-caffeine tabs ......................... 30 ERIVEDGE CAPS ................................... 15 ERLEADA TABS ..................................... 15 erlotinib hcl tabs 25mg, 100mg, 150mg ... 15 errin tabs ................................................. 42 ERTACZO CREA .................................... 53
ertapenem sodium solr injection ................. 9 ery pads ................................................... 53 ery-tab tbec ................................................ 9 erythrocin lactobionate solr intravenous ..... 9 erythrocin stearate tabs .............................. 9 erythromycin base cpep ............................. 9 erythromycin base tabs .............................. 9 erythromycin base tbec .............................. 9 erythromycin ethylsuccinate susr ............... 9 erythromycin ethylsuccinate tabs ............... 9 erythromycin gel ....................................... 53 erythromycin oint ...................................... 38 erythromycin soln ..................................... 53 ESBRIET CAPS ....................................... 51 ESBRIET TABS 267mg, 801mg ............... 51 escitalopram oxalate soln ......................... 33 escitalopram oxalate tabs 5mg, 10mg,
20mg .................................................... 33 esgic tabs ................................................. 25 esomeprazole magnesium cpdr 20mg,
40mg .................................................... 40 esomeprazole magnesium pack 10mg,
20mg, 40mg ......................................... 40 ESOMEPRAZOLE STRONTIUM CPDR .. 40 estarylla tabs ............................................ 43 estazolam tabs 1mg, 2mg ........................ 31 estrace crea ............................................. 46 estrace tabs .5mg, 1mg, 2mg ................... 46 estradiol crea ........................................... 46 estradiol
pttw .025mg/24hr, .0375mg/24hr, .05mg/24hr, .075mg/24hr, .1mg/24hr .............. 46
estradiol ptwk 37.5mcg/24hr, .025mg/24hr, .05mg/24hr, .06mg/24hr, .075mg/24hr, .1mg/24hr ... 46
estradiol tabs 10mcg, .5mg, 1mg, 2mg .... 46 estradiol valerate oil ................................. 46 estradiol-norethindrone acet tabs ............. 46 ESTRING RING ....................................... 46 eszopiclone tabs 1mg, 2mg, 3mg ............. 31 ethacrynic acid tabs ................................. 36 ethambutol hcl tabs 100mg, 400mg ......... 11 ethosuximide caps ................................... 29 ethosuximide soln .................................... 29 ethynodiol diac-eth estradiol tabs ............. 43 etodolac caps ........................................... 25 etodolac er tb24 ....................................... 25 etodolac tabs ............................................ 25 etonogestrel-ethinyl estradiol ring ............ 43
72 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
ETOPOPHOS SOLR ............................... 15 EUCRISA OINT ....................................... 55 EURAX CREA ......................................... 53 euthyrox tabs 25mcg, 50mcg, 75mcg,
88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg .... 47
EVAMIST SOLN ...................................... 46 evekeo tabs 5mg, 10mg .......................... 28 EVENITY SOSY ...................................... 48 everolimus tabs .25mg ............................. 49 everolimus tabs .5mg, .75mg ................... 49 everolimus tabs 2.5mg, 5mg, 7.5mg ........ 15 EVOMELA SOLR .................................... 15 EVOTAZ TABS ........................................ 12 EXELDERM CREA .................................. 53 EXELDERM SOLN .................................. 53 exemestane tabs ..................................... 15 EXJADE TBSO 125mg, 250mg, 500mg .. 41 EXONDYS 51 SOLN 500mg/10ml,
100mg/2ml ........................................... 50 EXTAVIA KIT ........................................... 32 EYLEA SOLN .......................................... 39 EYLEA SOSY .......................................... 39 ezetimibe tabs ......................................... 21 ezetimibe-simvastatin tabs ...................... 21
F FABIOR FOAM ........................................ 57 FABRAZYME SOLR 5mg, 35mg ............. 37 falmina tabs ............................................. 43 famciclovir tabs 125mg, 250mg, 500mg .. 12 famotidine susr ........................................ 40 famotidine tabs 20mg, 40mg.................... 40 FANAPT TABS 10mg .............................. 33 FANAPT TABS 1mg, 2mg, 4mg, 6mg, 8mg,
12mg .................................................... 33 FANAPT TITRATION PACK TABS .......... 33 FARESTON TABS ................................... 15 FARXIGA TABS 5mg, 10mg .................... 44 FARYDAK CAPS 10mg, 15mg, 20mg ..... 15 FASENRA PEN SOAJ ............................. 51 FASENRA SOSY ..................................... 51 FASLODEX SOLN ................................... 15 fayosim tabs ............................................ 43 febuxostat tabs 40mg, 80mg.................... 48 felbamate susp ........................................ 29 felbamate tabs 400mg, 600mg ................ 29 FELBATOL SUSP ................................... 29
FELBATOL TABS .................................... 29 felodipine er tb24 2.5mg, 5mg, 10mg ....... 23 FEMRING RING .05mg/24hr, .1mg/24hr .. 46 femynor tabs ............................................ 43 fenofibrate caps 50mg, 150mg ................. 21 fenofibrate micronized caps 43mg, 67mg,
130mg, 134mg, 200mg......................... 21 fenofibrate tabs 40mg, 48mg, 54mg,
120mg, 145mg, 160mg......................... 21 fenofibric acid cpdr 45mg, 135mg ............ 21 FENOFIBRIC ACID TABS 35mg, 105mg . 21 fenoprofen calcium caps .......................... 25 fenoprofen calcium tabs ........................... 25 FENTANYL CITRATE (PF) SOLN
1000mcg/20ml, 2500mcg/50ml ............ 25 FENTANYL CITRATE (PF) SOLN
100mcg/2ml, 250mcg/5ml .................... 25 fentanyl citrate lpop 200mcg .................... 25 fentanyl citrate lpop 400mcg, 600mcg,
800mcg, 1200mcg, 1600mcg ............... 25 fentanyl citrate tabs 100mcg, 200mcg,
400mcg, 600mcg, 800mcg ................... 25 fentanyl pt72 12mcg/hr, 25mcg/hr,
37.5mcg/hr, 50mcg/hr, 62.5mcg/hr, 75mcg/hr, 87.5mcg/hr, 100mcg/hr ........ 25
FENTORA TABS 100mcg, 200mcg, 400mcg, 600mcg, 800mcg ................... 26
FERRIPROX SOLN ................................. 41 FERRIPROX TABS 500mg, 1000mg ....... 41 FETROJA SOLR ........................................ 9 FETZIMA CP24 20mg, 40mg, 80mg, 120mg
............................................................. 33 FETZIMA TITRATION C4PK .................... 33 fexmid tabs ............................................... 19 FIASP FLEXTOUCH SOPN ..................... 44 FIASP SOLN ............................................ 44 FIBRICOR TABS...................................... 21 FINACEA FOAM ...................................... 57 finasteride tabs ......................................... 48 fioricet caps .............................................. 26 fioricet/codeine caps ................................ 26 FIRAZYR SOLN ....................................... 20 FIRDAPSE TABS ..................................... 50 FIRMAGON (240 MG DOSE) SOLR ........ 15 FIRMAGON SOLR ................................... 15 FIRVANQ SOLR ........................................ 9 flac oil ....................................................... 38 FLAREX SUSP ........................................ 38 flavoxate hcl tabs ..................................... 57
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 73
FLEBOGAMMA DIF SOLN INTRAVENOUS 5gm/100ml, 10gm/100ml, .5gm/10ml, 10gm/200ml, 20gm/200ml, 20gm/400ml, 2.5gm/50ml, 5gm/50ml ........................ 52
flecainide acetate tabs 50mg, 100mg, 150mg .................................................. 23
FLECTOR PTCH ..................................... 55 FLOLIPID SUSP 20mg/5ml, 40mg/5ml .... 21 FLOVENT DISKUS AEPB 50mcg/blist,
100mcg/blist, 250mcg/blist ................... 51 FLOVENT HFA AERO 110mcg/act,
220mcg/act .......................................... 51 FLOVENT HFA AERO 44mcg/act ........... 51 fluconazole in sodium chloride soln
intravenous .......................................... 11 fluconazole susr ....................................... 11 fluconazole tabs ....................................... 11 flucytosine caps 250mg, 500mg .............. 11 fludrocortisone acetate tabs ..................... 41 flunisolide soln ......................................... 38 fluocinolone acetonide crea .01%, .025% 55 fluocinolone acetonide oil ........................ 38 fluocinolone acetonide oint ...................... 55 fluocinolone acetonide scalp oil ............... 55 fluocinolone acetonide soln ..................... 55 fluocinonide crea ..................................... 55 fluocinonide emulsified base crea ............ 55 fluocinonide gel ........................................ 55 fluocinonide oint ....................................... 55 fluocinonide soln ...................................... 55 fluorometholone susp .............................. 38 fluorouracil crea .5% ................................ 57 fluorouracil crea 5% ................................. 57 fluorouracil soln 2%, 5% .......................... 57 fluoxetine hcl caps 10mg, 20mg, 40mg.... 33 fluoxetine hcl cpdr .................................... 33 fluoxetine hcl soln .................................... 33 fluoxetine hcl tabs 10mg, 20mg, 60mg .... 33 fluphenazine decanoate soln ................... 33 fluphenazine hcl conc .............................. 33 fluphenazine hcl elix ................................ 33 fluphenazine hcl soln ............................... 33 fluphenazine hcl tabs 1mg, 2.5mg, 5mg,
10mg .................................................... 33 flurandrenolide crea ................................. 55 flurandrenolide lotn .................................. 55 flurandrenolide oint .................................. 55 flurazepam hcl caps 15mg, 30mg ............ 31 flurbiprofen sodium soln ........................... 38
flurbiprofen tabs ....................................... 26 flutamide caps .......................................... 15 fluticasone propionate crea ...................... 55 fluticasone propionate lotn ....................... 55 fluticasone propionate oint ....................... 55 fluticasone propionate susp...................... 38 fluticasone-salmeterol aepb ............... 19, 51 fluvastatin sodium caps 20mg, 40mg ....... 21 fluvastatin sodium er tb24 ........................ 21 fluvoxamine maleate er cp24 100mg,
150mg .................................................. 33 fluvoxamine maleate tabs 25mg, 50mg,
100mg .................................................. 33 FML FORTE SUSP .................................. 38 FML OINT ................................................ 38 fondaparinux sodium soln 2.5mg/0.5ml .... 20 fondaparinux sodium soln 5mg/0.4ml,
7.5mg/0.6ml, 10mg/0.8ml ..................... 20 FORTEO SOPN ....................................... 46 FOSAMAX PLUS D TABS ....................... 48 fosamprenavir calcium tabs...................... 12 fosinopril sodium tabs 10mg, 20mg, 40mg
............................................................. 24 fosinopril sodium-hctz tabs ....................... 24 FOSRENOL PACK 750mg, 1000mg ........ 36 FREAMINE HBC SOLN INTRAVENOUS . 35 frovatriptan succinate tabs ....................... 30 FULPHILA SOSY ..................................... 20 fulvestrant soln ......................................... 15 furosemide soln 8mg/ml, 10mg/ml ........... 36 furosemide soln injection .......................... 36 furosemide tabs 20mg, 40mg, 80mg ........ 36 FUZEON SOLR ....................................... 12 fyavolv tabs .............................................. 46 FYCOMPA SUSP..................................... 29 FYCOMPA TABS ..................................... 29
G gabapentin caps 100mg, 400mg .............. 29 gabapentin soln ........................................ 29 gabapentin tabs 600mg, 800mg ............... 29 GALAFOLD CAPS ................................... 50 galantamine hydrobromide er cp24 8mg,
16mg, 24mg ......................................... 18 galantamine hydrobromide soln ............... 18 galantamine hydrobromide tabs 4mg, 8mg,
12mg .................................................... 18 GAMASTAN INJ....................................... 52
74 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
GAMASTAN S/D INJ ............................... 52 GAMIFANT SOLN 50mg/10ml, 10mg/2ml 49 GAMMAGARD S/D LESS IGA SOLR
INTRAVENOUS 5gm, 10gm ................ 52 GAMMAGARD SOLN INJECTION .......... 52 GAMMAKED SOLN INJECTION ............. 52 GAMMAPLEX SOLN INTRAVENOUS
10gm/100ml, 20gm/200ml, 5gm/50ml .. 52 GAMMAPLEX SOLN INTRAVENOUS
10gm/200ml ......................................... 52 GAMUNEX-C SOLN INJECTION
10gm/100ml, 1gm/10ml, 20gm/200ml, 2.5gm/25ml, 5gm/50ml ........................ 52
GARDASIL 9 SUSP ................................. 53 GARDASIL 9 SUSY ................................. 53 gatifloxacin soln ....................................... 38 GATTEX KIT ............................................ 41 gavilyte-c solr ........................................... 41 gavilyte-g solr .......................................... 41 gavilyte-n with flavor pack solr ................. 41 GAZYVA SOLN ....................................... 15 GELNIQUE GEL ...................................... 57 GELNIQUE PUMP GEL ........................... 57 gemfibrozil tabs ....................................... 21 generlac soln ........................................... 35 gengraf caps 25mg, 50mg, 100mg .......... 49 gengraf soln ............................................. 49 GENOTROPIN MINIQUICK
SOLR .2mg, .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg ...... 47
GENOTROPIN SOLR .............................. 47 GENOTROPIN SOLR 12mg .................... 47 gentak oint ............................................... 38 gentamicin in saline soln intravenous ........ 9 gentamicin sulfate crea ............................ 53 gentamicin sulfate oint ............................. 53 gentamicin sulfate soln ........................ 9, 38 gentamicin sulfate soln injection ................ 9 GENVOYA TABS .................................... 12 GEODON SOLR ...................................... 33 gianvi tabs ............................................... 43 GILENYA CAPS .25mg, .5mg.................. 32 GILOTRIF TABS 20mg, 30mg, 40mg ...... 15 GIVLAARI SOLN ..................................... 50 GLASSIA SOLN INTRAVENOUS ............ 51 glatiramer acetate sosy 20mg/ml, 40mg/ml
............................................................. 32 glatopa sosy 20mg/ml, 40mg/ml .............. 32 GLEEVEC TABS 100mg, 400mg ............. 15
GLEOSTINE CAPS .................................. 15 GLEOSTINE CAPS 40mg, 100mg ........... 15 glimepiride tabs 1mg, 2mg, 4mg .............. 44 glipizide er tb24 2.5mg, 5mg, 10mg ......... 44 glipizide tabs 5mg, 10mg ......................... 44 glipizide-metformin hcl tabs ...................... 44 GLOPERBA SOLN ................................... 48 GLUCAGEN HYPOKIT SOLR .................. 44 GLUCAGON EMERGENCY KIT .............. 44 glyburide micronized tabs 1.5mg, 3mg, 6mg
............................................................. 44 glyburide tabs 1.25mg, 2.5mg, 5mg ......... 44 glyburide-metformin tabs .......................... 44 glycopyrrolate tabs 1mg, 2mg .................. 18 glydo prsy ................................................. 56 GLYXAMBI TABS .................................... 44 GOCOVRI CP24 68.5mg, 137mg ............ 30 GOLYTELY SOLR ................................... 41 GONITRO PACK...................................... 24 GRALISE STARTER MISC ...................... 26 GRALISE TABS ....................................... 26 granisetron hcl tabs .................................. 40 GRANIX SOLN 480mcg/1.6ml, 300mcg/ml
............................................................. 20 GRANIX SOSY 300mcg/0.5ml,
480mcg/0.8ml ....................................... 21 griseofulvin microsize susp ...................... 11 griseofulvin microsize tabs ....................... 11 griseofulvin ultramicrosize tabs ................ 11 guanfacine hcl er tb24 1mg, 2mg, 3mg,
4mg ...................................................... 31 guanfacine hcl tabs 1mg, 2mg ................. 23 GUANIDINE HCL TABS ........................... 18 gynazole-1 crea ....................................... 53
H HAEGARDA SOLR 2000unit, 3000unit .... 50 hailey 24 fe tabs ....................................... 43 halcinonide crea ....................................... 55 halobetasol propionate crea ..................... 55 HALOBETASOL PROPIONATE FOAM ... 55 halobetasol propionate oint ...................... 55 HALOG CREA ......................................... 55 HALOG OINT ........................................... 55 haloperidol decanoate soln ...................... 33 haloperidol lactate conc ........................... 33 haloperidol lactate soln ............................ 33
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 75
haloperidol tabs .5mg, 1mg, 2mg, 5mg, 10mg, 20mg ......................................... 33
HARVONI TABS ...................................... 12 HAVRIX SUSP ........................................ 53 heparin sodium (porcine) soln 1000unit/ml,
5000unit/ml, 10000unit/ml, 20000unit/ml ............................................................. 20
HEPATAMINE SOLN INTRAVENOUS .... 35 HEPLISAV-B SOLN ................................. 53 HEPSERA TABS ..................................... 12 HERCEPTIN HYLECTA SOLN ................ 15 HERCEPTIN SOLR 150mg, 440mg ........ 15 HERZUMA SOLR 150mg, 420mg ........... 15 HETLIOZ CAPS ....................................... 31 HEXALEN CAPS ..................................... 15 HIBERIX SOLR ....................................... 53 HORIZANT TBCR 300mg, 600mg ........... 29 HUMALOG JUNIOR KWIKPEN SOPN .... 44 HUMALOG KWIKPEN SOPN 100unit/ml,
200unit/ml ............................................ 44 HUMALOG MIX 50/50 KWIKPEN SUPN . 45 HUMALOG MIX 50/50 SUSP................... 45 HUMALOG MIX 75/25 KWIKPEN SUPN . 45 HUMALOG MIX 75/25 SUSP................... 45 HUMALOG SOCT.................................... 45 HUMALOG SOLN .................................... 45 HUMATROPE SOLR 5mg, 6mg, 12mg,
24mg .................................................... 47 HUMIRA PEDIATRIC CROHNS START
PSKT ................................................... 48 HUMIRA PEN PNKT 40mg/0.4ml,
40mg/0.8ml .......................................... 48 HUMIRA PEN-CD/UC/HS STARTER PNKT
40mg/0.8ml, 80mg/0.8ml...................... 48 HUMIRA PEN-PS/UV/ADOL HS START
PNKT ................................................... 49 HUMIRA PSKT 10mg/0.1ml, 10mg/0.2ml,
20mg/0.2ml, 20mg/0.4ml, 40mg/0.4ml, 40mg/0.8ml .......................................... 49
HUMULIN 70/30 KWIKPEN SUPN .......... 45 HUMULIN 70/30 SUSP ............................ 45 HUMULIN N KWIKPEN SUPN ................ 45 HUMULIN N SUSP .................................. 45 HUMULIN R SOLN .................................. 45 HUMULIN R U-500 (CONCENTRATED)
SOLN ................................................... 45 HUMULIN R U-500 KWIKPEN SOPN...... 45 hydralazine hcl tabs 10mg, 25mg, 50mg,
100mg .................................................. 23
hydrochlorothiazide caps ......................... 36 hydrochlorothiazide tabs 12.5mg, 25mg,
50mg .................................................... 36 hydrocodone bitartrate er c12a ................ 26 hydrocodone-acetaminophen soln ........... 26 hydrocodone-acetaminophen tabs ........... 26 hydrocodone-ibuprofen tabs ..................... 26 hydrocortisone ace-pramoxine crea ......... 56 hydrocortisone butyrate crea .................... 55 hydrocortisone butyrate lotn ..................... 55 hydrocortisone butyrate oint ..................... 55 hydrocortisone butyrate soln .................... 55 hydrocortisone crea 1%, 2.5% ................. 55 hydrocortisone enem ................................ 55 hydrocortisone lotn ................................... 55 hydrocortisone oint 1%, 2.5% ................... 55 hydrocortisone tabs 5mg, 10mg, 20mg .... 41 hydrocortisone valerate crea .................... 55 hydrocortisone valerate oint ..................... 55 hydrocortisone-acetic acid soln ................ 38 hydromorphone hcl er t24a 8mg, 12mg,
16mg, 32mg ......................................... 26 hydromorphone hcl liqd ............................ 26 hydromorphone hcl pf soln 50mg/5ml,
10mg/ml ............................................... 26 HYDROMORPHONE HCL SOLN ............ 26 hydromorphone hcl tabs 2mg, 4mg, 8mg . 26 hydroxychloroquine sulfate tabs ............... 11 hydroxyurea caps ..................................... 15 hydroxyzine hcl syrp ................................. 31 hydroxyzine hcl tabs ................................. 31 hydroxyzine pamoate caps ...................... 31 HYPERRAB S/D SOLN ............................ 52 HYQVIA KIT ............................................. 52
I ibandronate sodium tabs .......................... 48 IBRANCE CAPS 75mg, 100mg, 125mg ... 15 IBRANCE TABS 75mg, 100mg, 125mg ... 15 ibu tabs .................................................... 26 ibudone tabs ............................................ 26 ibuprofen susp ......................................... 26 ibuprofen tabs .......................................... 26 icatibant acetate soln ............................... 20 ICLUSIG TABS 15mg, 45mg .................... 15 IDHIFA TABS 50mg, 100mg .................... 15 ILARIS SOLN ........................................... 26 ILEVRO SUSP ......................................... 38
76 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
ILUMYA SOSY ........................................ 57 imatinib mesylate tabs 100mg, 400mg..... 15 IMBRUVICA CAPS 70mg, 140mg ........... 15 IMBRUVICA TABS 140mg, 280mg, 420mg,
560mg .................................................. 15 IMFINZI SOLN 500mg/10ml, 120mg/2.4ml
............................................................. 15 imipenem-cilastatin solr intravenous .......... 9 imipramine hcl tabs 10mg, 25mg, 50mg .. 33 imipramine pamoate caps 75mg, 100mg,
125mg, 150mg ..................................... 33 imiquimod crea ........................................ 57 IMIQUIMOD PUMP CREA ....................... 57 IMOGAM RABIES-HT SOLN ................... 52 IMOVAX RABIES INJ .............................. 53 IMPAVIDO CAPS .................................... 11 IMPOYZ CREA ........................................ 55 IMVEXXY MAINTENANCE PACK INST
4mcg, 10mcg ....................................... 46 IMVEXXY STARTER PACK INST 4mcg,
10mcg .................................................. 46 INBRIJA CAPS ........................................ 30 incassia tabs ............................................ 43 INCRELEX SOLN .................................... 47 INCRUSE ELLIPTA AEPB ....................... 18 indapamide tabs 1.25mg, 2.5mg .............. 36 indocin supp ............................................ 26 INDOCIN SUSP ....................................... 26 indomethacin caps ................................... 26 indomethacin er cpcr ............................... 26 INFANRIX SUSP ..................................... 53 INFLECTRA SOLR INTRAVENOUS ....... 49 INFUGEM SOLN ..................................... 15 INGREZZA CAPS 40mg, 80mg ............... 31 INGREZZA CPPK .................................... 31 INLYTA TABS 1mg, 5mg ......................... 15 INNOPRAN XL CP24 80mg, 120mg ........ 22 INREBIC CAPS ....................................... 15 insulin asp prot & asp flexpen supn ......... 45 insulin aspart flexpen sopn ...................... 45 insulin aspart penfill soct .......................... 45 insulin aspart prot & aspart susp .............. 45 insulin aspart soln .................................... 45 insulin lispro (1 unit dial) sopn .................. 45 insulin lispro soln ..................................... 45 INTELENCE TABS 25mg, 100mg, 200mg
............................................................. 12 INTRALIPID EMUL INTRAVENOUS ....... 35
INTRALIPID EMUL INTRAVENOUS 20gm/100ml.......................................... 35
INTRAROSA INST ................................... 41 INTRON A SOLN 10mu/ml, 6000000unit/ml
............................................................. 15 INTRON A SOLR 10mu, 18mu, 50mu ...... 16 introvale tabs ............................................ 43 INVEGA SUSTENNA SUSY 39mg/0.25ml
............................................................. 33 INVEGA SUSTENNA SUSY 78mg/0.5ml,
117mg/0.75ml, 234mg/1.5ml, 156mg/ml ............................................................. 33
INVEGA TRINZA SUSY 273mg/0.875ml, 410mg/1.315ml, 546mg/1.75ml, 819mg/2.625ml ..................................... 33
INVELTYS SUSP ..................................... 38 INVIRASE CAPS...................................... 12 INVIRASE TABS ...................................... 12 INVOKAMET TABS .................................. 45 INVOKAMET XR TB24 ............................ 45 INVOKANA TABS 100mg, 300mg ........... 45 IONOSOL-MB IN D5W SOLN
INTRAVENOUS ................................... 36 IOPIDINE SOLN....................................... 39 IPOL INJ .................................................. 53 ipratropium bromide soln .02% ................. 18 ipratropium bromide soln .03%, .06% ....... 18 ipratropium-albuterol soln ......................... 19 irbesartan tabs 75mg, 150mg, 300mg ...... 24 irbesartan-hydrochlorothiazide tabs ......... 24 IRESSA TABS ......................................... 16 ISENTRESS CHEW 25mg, 100mg .......... 12 ISENTRESS HD TABS ............................ 12 ISENTRESS PACK .................................. 12 ISENTRESS TABS .................................. 12 isibloom tabs ............................................ 43 ISOLYTE-P IN D5W SOLN INTRAVENOUS
............................................................. 36 ISOLYTE-S SOLN INTRAVENOUS ......... 36 isoniazid syrp ........................................... 11 isoniazid tabs 100mg, 300mg ................... 11 ISORDIL TITRADOSE TABS ................... 24 isosorbide dinitrate er tbcr ........................ 24 isosorbide dinitrate tabs 5mg, 10mg, 20mg,
30mg, 40mg ......................................... 24 isosorbide mononitrate er tb24 ................. 24 isosorbide mononitrate er tb24 30mg, 60mg
............................................................. 24 isosorbide mononitrate tabs 10mg, 20mg 24
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 77
isotretinoin caps 10mg, 20mg, 30mg, 40mg ............................................................. 57
isradipine caps 2.5mg, 5mg ..................... 23 ISTURISA TABS 1mg, 5mg, 10mg .......... 50 itraconazole caps ..................................... 11 itraconazole soln ...................................... 11 ivermectin crea ........................................ 53 ivermectin tabs .......................................... 8 IXEMPRA KIT SOLR ............................... 16 IXIARO SUSP .......................................... 53
J JADENU SPRINKLE PACK 90mg, 180mg,
360mg .................................................. 41 JADENU TABS 90mg, 180mg, 360mg .... 41 JAKAFI TABS 5mg, 10mg, 15mg, 20mg,
25mg .................................................... 16 jantoven tabs 1mg, 2mg, 2.5mg, 3mg, 4mg,
5mg, 6mg, 7.5mg, 10mg ...................... 20 JANUMET TABS ..................................... 45 JANUMET XR TB24 ................................ 45 JANUVIA TABS 25mg, 50mg, 100mg...... 45 JARDIANCE TABS 10mg, 25mg ............. 45 jasmiel tabs .............................................. 43 JATENZO CAPS ..................................... 42 JENTADUETO TABS .............................. 45 JENTADUETO XR TB24 ......................... 45 jinteli tabs................................................. 46 JOLIVETTE TABS ................................... 43 JUBLIA SOLN .......................................... 53 juleber tabs .............................................. 43 JULUCA TABS ........................................ 12 junel 1.5/30 tabs ...................................... 43 junel 1/20 tabs ......................................... 43 junel fe 1.5/30 tabs .................................. 43 junel fe 1/20 tabs ..................................... 43 junel fe 24 tabs ........................................ 43 JUXTAPID CAPS 5mg, 10mg, 20mg, 30mg,
40mg, 60mg ......................................... 21 JYNARQUE TABS 15mg, 30mg .............. 36 JYNARQUE TBPK ................................... 36
K KADCYLA SOLR 100mg, 160mg ............ 16 KADIAN CP24 ......................................... 26 kaitlib fe chew .......................................... 43 KALETRA TABS ...................................... 12 KALYDECO PACK 25mg, 50mg, 75mg ... 51
KALYDECO TABS ................................... 51 KANJINTI SOLR 150mg, 420mg .............. 16 KANUMA SOLN ....................................... 37 kariva tabs ................................................ 43 KAZANO TABS ........................................ 45 KCL IN DEXTROSE-NACL SOLN 20-5-0.33
MEQ ..................................................... 36 KCL IN DEXTROSE-NACL SOLN 40-5-0.9
MEQ ..................................................... 36 KCL IN DEXTROSE-NACL SOLN
INTRAVENOUS ................................... 36 KCL-LACTATED RINGERS-D5W SOLN
INTRAVENOUS ................................... 37 kelnor 1/35 tabs ....................................... 43 kelnor 1/50 tabs ....................................... 43 KENALOG SUSP ..................................... 41 KEPIVANCE SOLR .................................. 56 KERYDIN SOLN ...................................... 53 ketoconazole crea .................................... 53 ketoconazole foam ................................... 53 ketoconazole sham .................................. 54 ketoconazole tabs .................................... 11 ketodan foam ........................................... 54 ketoprofen caps ....................................... 26 ketoprofen er cp24 ................................... 26 ketorolac tromethamine soln .4%, .5% ..... 38 ketorolac tromethamine tabs .................... 26 KEVEYIS TABS ....................................... 50 KEVZARA SOAJ 150mg/1.14ml,
200mg/1.14ml ....................................... 49 KEVZARA SOSY 150mg/1.14ml,
200mg/1.14ml ....................................... 49 KEYTRUDA SOLN ................................... 16 KEYTRUDA SOLR ................................... 16 KHAPZORY SOLR 175mg, 300mg .......... 48 KHEDEZLA TB24 50mg, 100mg .............. 33 KINERET SOSY....................................... 49 KINRIX SUSP .......................................... 52 kionex susp .............................................. 36 KISQALI (200 MG DOSE) TBPK .............. 16 KISQALI (400 MG DOSE) TBPK .............. 16 KISQALI (600 MG DOSE) TBPK .............. 16 KISQALI FEMARA (200 MG DOSE) TBPK
............................................................. 16 KISQALI FEMARA (400 MG DOSE) TBPK
............................................................. 16 KISQALI FEMARA (600 MG DOSE) TBPK
............................................................. 16 KITABIS PAK NEBU ................................ 51
78 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
KLOR-CON 10 TBCR .............................. 37 klor-con m10 tbcr ..................................... 37 klor-con m15 tbcr ..................................... 37 klor-con m20 tbcr ..................................... 37 klor-con pack ........................................... 37 klor-con sprinkle cpcr ............................... 37 KLOR-CON TBCR ................................... 37 KOMBIGLYZE XR TB24 .......................... 45 KORLYM TABS ....................................... 45 KOSELUGO CAPS 10mg, 25mg ............. 16 kristalose pack 10gm, 20gm .................... 35 K-TAB TBCR ........................................... 36 kurvelo tabs ............................................. 43 KUVAN PACK 100mg, 500mg ................. 50 KUVAN TBSO ......................................... 50 KYNAMRO SOSY ................................... 21 KYPROLIS SOLR 10mg, 30mg, 60mg .... 16
L labetalol hcl tabs 100mg, 200mg, 300mg 22 LACRISERT INST ................................... 39 lactulose pack .......................................... 35 lactulose soln ........................................... 35 LAMICTAL XR KIT................................... 29 lamivudine soln ........................................ 12 lamivudine tabs 100mg, 150mg, 300mg .. 12 lamivudine-zidovudine tabs ..................... 12 lamotrigine chew 5mg, 25mg ................... 29 lamotrigine er tb24 25mg, 50mg, 100mg,
200mg, 250mg, 300mg ........................ 29 lamotrigine starter kit-blue kit ................... 29 lamotrigine starter kit-green kit ................. 29 lamotrigine starter kit-orange kit ............... 29 lamotrigine tabs 25mg, 100mg, 150mg,
200mg .................................................. 29 lamotrigine tbdp 25mg, 50mg, 100mg,
200mg .................................................. 29 LANOXIN PEDIATRIC SOLN .................. 23 LANOXIN TABS ...................................... 23 lansoprazole cpdr 15mg, 30mg ................ 40 lansoprazole tbdd 15mg, 30mg ................ 40 lanthanum carbonate chew 500mg, 750mg,
1000mg ................................................ 36 LANTUS SOLN ........................................ 45 LANTUS SOLOSTAR SOPN ................... 45 larin 1.5/30 tabs ....................................... 43 larin 1/20 tabs .......................................... 43 larin fe 1.5/30 tabs ................................... 43
larin fe 1/20 tabs ...................................... 43 larissia tabs .............................................. 43 LARTRUVO SOLN 190mg/19ml,
500mg/50ml.......................................... 16 LASTACAFT SOLN .................................. 39 latanoprost soln ........................................ 39 LATUDA TABS 20mg, 40mg, 60mg, 80mg,
120mg .................................................. 33 LAYOLIS FE CHEW ................................. 43 LAZANDA SOLN 100mcg/act, 300mcg/act,
400mcg/act ........................................... 26 ledipasvir-sofosbuvir tabs ......................... 12 leena tabs ................................................ 43 leflunomide tabs 10mg, 20mg .................. 49 LEMTRADA SOLN ................................... 32 LENVIMA (10 MG DAILY DOSE) CPPK .. 16 LENVIMA (12 MG DAILY DOSE) CPPK .. 16 LENVIMA (14 MG DAILY DOSE) CPPK .. 16 LENVIMA (18 MG DAILY DOSE) CPPK .. 16 LENVIMA (20 MG DAILY DOSE) CPPK .. 16 LENVIMA (24 MG DAILY DOSE) CPPK .. 16 LENVIMA (4 MG DAILY DOSE) CPPK .... 16 LENVIMA (8 MG DAILY DOSE) CPPK .... 16 lessina tabs .............................................. 43 LETAIRIS TABS 5mg, 10mg .................... 51 letrozole tabs ............................................ 16 leucovorin calcium tabs 5mg, 10mg, 15mg,
25mg .................................................... 48 LEUKERAN TABS ................................... 16 LEUKINE SOLR ....................................... 21 leuprolide acetate kit ................................ 16 LEVALBUTEROL HCL NEBU
1.25mg/0.5ml, .31mg/3ml, .63mg/3ml, 1.25mg/3ml, .31mg/3ml, .63mg/3ml, 1.25mg/3ml .......................................... 19
levalbuterol tartrate aero .......................... 19 LEVEMIR FLEXTOUCH SOPN ................ 45 LEVEMIR SOLN....................................... 45 levetiracetam er tb24 500mg, 750mg ....... 29 levetiracetam soln .................................... 29 levetiracetam tabs 250mg, 500mg, 750mg,
1000mg ................................................ 29 levobunolol hcl soln .................................. 39 levocarnitine soln ..................................... 50 LEVOCARNITINE TABS .......................... 50 levocetirizine dihydrochloride soln ............ 14 levocetirizine dihydrochloride tabs ........... 14 levofloxacin in d5w soln intravenous .......... 9 levofloxacin soln ................................... 9, 38
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 79
levofloxacin soln intravenous ..................... 9 levofloxacin tabs ........................................ 9 levonest tabs ........................................... 43 levonorgest-eth est & eth est tabs ........... 43 levonorgest-eth estrad 91-day tabs ......... 43 levonorgestrel-ethinyl estrad tabs ............ 43 levonorg-eth estrad triphasic tabs ............ 43 levora 0.15/30 (28) tabs ........................... 43 levorphanol tartrate tabs .......................... 26 levorphanol tartrate tabs 2mg .................. 26 LEVO-T TABS 25mcg, 50mcg, 75mcg,
88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg ................................................ 48
levothyroxine sodium tabs 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg ................................. 48
LEVOXYL TABS 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg .... 48
LEXETTE FOAM ..................................... 55 LEXIVA SUSP ......................................... 12 LEXIVA TABS .......................................... 12 LIALDA TBEC .......................................... 40 LIBTAYO SOLN ....................................... 16 lidocaine hcl soln ..................................... 56 lidocaine hcl urethral/mucosal gel ............ 56 lidocaine oint ............................................ 56 lidocaine ptch ........................................... 56 lidocaine viscous hcl soln ........................ 39 lidocaine-prilocaine crea .......................... 56 lidocaine-tetracaine crea .......................... 56 lindane sham ........................................... 54 linezolid soln intravenous ........................... 9 linezolid susr .............................................. 9 linezolid tabs .............................................. 9 LINZESS CAPS 72mcg, 145mcg, 290mcg
............................................................. 41 liothyronine sodium tabs 5mcg, 25mcg,
50mcg .................................................. 48 lisinopril tabs 2.5mg, 5mg, 10mg, 20mg,
30mg, 40mg ......................................... 24 lisinopril-hydrochlorothiazide tabs ............ 24 lithium carbonate caps 150mg, 300mg,
600mg .................................................. 33 lithium carbonate er tbcr 300mg, 450mg .. 33 lithium carbonate tabs .............................. 33 LITHIUM SOLN ....................................... 33
LITHOSTAT TABS ................................... 35 LIVALO TABS 1mg, 2mg, 4mg ................ 21 LO LOESTRIN FE TABS ......................... 43 lodine tabs ................................................ 26 loestrin 1.5/30 (21) tabs ........................... 43 loestrin 1/20 (21) tabs .............................. 43 loestrin fe 1.5/30 tabs ............................... 43 loestrin fe 1/20 tabs .................................. 43 LOKELMA PACK 5gm, 10gm ................... 36 LONHALA MAGNAIR REFILL KIT SOLN 18 LONSURF TABS...................................... 16 loperamide hcl caps ................................. 40 lopinavir-ritonavir soln .............................. 12 LOPREEZA TABS .................................... 46 lorazepam conc ........................................ 31 lorazepam tabs .5mg, 1mg, 2mg .............. 31 LORBRENA TABS 25mg, 100mg ............ 16 lorcet hd tabs ........................................... 26 lorcet plus tabs ......................................... 26 lorcet tabs ................................................ 26 loryna tabs ............................................... 43 lorzone tabs 375mg, 750mg ..................... 19 losartan potassium tabs 25mg, 50mg,
100mg .................................................. 24 losartan potassium-hctz tabs .................... 24 LOTEMAX GEL ........................................ 38 LOTEMAX OINT ...................................... 38 LOTEMAX SUSP ..................................... 38 loteprednol etabonate susp ...................... 38 lovastatin tabs 10mg, 20mg, 40mg .......... 21 LOVENOX SOLN 30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml, 120mg/0.8ml, 300mg/3ml, 100mg/ml, 150mg/ml ........ 20
low-ogestrel tabs ...................................... 43 loxapine succinate caps 5mg, 10mg, 25mg,
50mg .................................................... 33 LUCEMYRA TABS ................................... 32 LUCENTIS
SOLN .3mg/0.05ml, .5mg/0.05ml ......... 39 LUCENTIS
SOSY .3mg/0.05ml, .5mg/0.05ml ......... 39 LULICONAZOLE CREA ........................... 54 LUMIGAN SOLN ...................................... 39 LUMIZYME SOLR .................................... 37 LUMOXITI SOLR ..................................... 16 LUPANETA PACK KIT ............................. 16 LUPRON DEPOT (1-MONTH) KIT ........... 16 LUPRON DEPOT (3-MONTH) KIT ........... 16 LUPRON DEPOT (4-MONTH) KIT ........... 16
80 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
LUPRON DEPOT (6-MONTH) KIT .......... 16 LUPRON DEPOT-PED (1-MONTH) KIT .. 16 LUPRON DEPOT-PED (1-MONTH) KIT 7.5
MG ....................................................... 16 LUPRON DEPOT-PED (3-MONTH) KIT .. 16 lutera tabs ................................................ 43 LUZU CREA ............................................ 54 LYNPARZA CAPS ................................... 16 LYNPARZA TABS 100mg, 150mg ........... 16 LYRICA CR TB24 82.5mg, 165mg, 330mg
............................................................. 26 LYSODREN TABS................................... 16 lyza tabs .................................................. 43
M mafenide acetate pack ............................. 54 magnesium sulfate soln injection 50% ..... 29 MAGNESIUM SULFATE SOLN
INTRAVENOUS 40gm/1000ml, 4gm/100ml, 20gm/500ml, 2gm/50ml .... 29
MAKENA SOAJ ....................................... 47 malathion lotn .......................................... 54 maprotiline hcl tabs 25mg, 50mg, 75mg .. 33 marlissa tabs ........................................... 43 MARPLAN TABS ..................................... 33 MARQIBO SUSP ..................................... 16 MATULANE CAPS .................................. 16 matzim la tb24 180mg, 240mg, 300mg,
360mg, 420mg ..................................... 23 MAVENCLAD (10 TABS) TBPK .............. 49 MAVENCLAD (4 TABS) TBPK ................ 49 MAVENCLAD (5 TABS) TBPK ................ 49 MAVENCLAD (6 TABS) TBPK ................ 49 MAVENCLAD (7 TABS) TBPK ................ 49 MAVENCLAD (8 TABS) TBPK ................ 49 MAVENCLAD (9 TABS) TBPK ................ 49 MAVYRET TABS ..................................... 12 MAXIDEX SUSP ...................................... 38 MAYZENT STARTER PACK TBPK ......... 32 MAYZENT TABS .25mg, 2mg ................. 32 meclizine hcl tabs .................................... 40 meclofenamate sodium caps ................... 26 MEDROL TABS ....................................... 41 medroxyprogesterone acetate susp ......... 47 medroxyprogesterone acetate susy ......... 47 medroxyprogesterone acetate tabs 2.5mg,
5mg, 10mg ........................................... 47 mefenamic acid caps ............................... 26
mefloquine hcl tabs .................................. 11 megestrol acetate susp ...................... 16, 47 megestrol acetate tabs ............................. 16 MEKINIST TABS .5mg, 2mg .................... 16 MEKTOVI TABS....................................... 16 melodetta 24 fe chew ............................... 43 meloxicam tabs ........................................ 26 memantine hcl er cp24 ............................. 31 memantine hcl soln .................................. 31 memantine hcl tabs 5mg, 10mg ............... 31 MENACTRA INJ....................................... 53 menest tabs .3mg, .625mg, 1.25mg ......... 46 MENOSTAR PTWK ................................. 46 MENTAX CREA ....................................... 54 MENVEO SOLR ....................................... 53 meperidine hcl soln 50mg/5ml, 10mg/ml,
25mg/ml, 50mg/ml, 100mg/ml .............. 26 meperidine hcl tabs 50mg, 100mg ........... 26 meprobamate tabs ................................... 31 MEPRON SUSP....................................... 11 mercaptopurine tabs ................................ 16 meropenem solr intravenous 1gm, 500mg . 9 mesalamine cpdr ...................................... 40 mesalamine enem .................................... 40 mesalamine er cp24 ................................. 40 mesalamine supp ..................................... 40 mesalamine tbec 1.2gm, 800mg .............. 40 MESNEX TABS ....................................... 50 MESTINON SOLN ................................... 18 metadate er tbcr ....................................... 28 metaproterenol sulfate syrp ...................... 19 metaproterenol sulfate tabs 10mg, 20mg . 19 metaxall tabs ............................................ 19 metaxalone tabs ....................................... 19 metformin hcl er tb24 500mg, 750mg ....... 45 metformin hcl tabs 500mg, 850mg, 1000mg
............................................................. 45 methadone hcl soln 5mg/5ml, 10mg/5ml .. 26 methadone hcl tabs 5mg, 10mg ............... 26 methamphetamine hcl tabs ...................... 28 methazolamide tabs 25mg, 50mg ............ 39 methenamine hippurate tabs .................... 14 methimazole tabs 5mg, 10mg .................. 48 methitest tabs ........................................... 42 methocarbamol tabs ................................. 19 methotrexate sodium (pf) soln .................. 16 METHOTREXATE SODIUM SOLN .......... 16 methotrexate tabs .................................... 16 methoxsalen rapid caps ........................... 57
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 81
methscopolamine bromide tabs 2.5mg, 5mg ............................................................. 18
methyclothiazide tabs .............................. 36 methyldopa tabs 250mg, 500mg .............. 23 methyldopa-hydrochlorothiazide tabs ...... 23 methylphenidate hcl chew 2.5mg, 5mg,
10mg .................................................... 28 methylphenidate hcl er (cd) cpcr 10mg,
20mg, 30mg, 40mg, 50mg, 60mg ........ 28 methylphenidate hcl er (la) cp24 10mg,
20mg, 30mg, 40mg, 60mg ................... 28 methylphenidate hcl er tb24 18mg, 27mg,
36mg, 54mg ......................................... 28 methylphenidate hcl er tbcr 10mg, 18mg,
20mg, 27mg, 36mg, 54mg, 72mg ........ 28 methylphenidate hcl soln 5mg/5ml,
10mg/5ml ............................................. 28 methylphenidate hcl tabs 5mg, 10mg, 20mg
............................................................. 28 methylprednisolone tabs 4mg, 8mg, 16mg,
32mg .................................................... 42 methylprednisolone tbpk .......................... 42 methyltestosterone caps .......................... 42 metoclopramide hcl soln .......................... 41 metoclopramide hcl tabs 5mg, 10mg ....... 41 metoclopramide hcl tbdp 5mg, 10mg ....... 41 metolazone tabs 2.5mg, 5mg, 10mg ........ 36 metoprolol succinate er tb24 25mg, 50mg,
100mg, 200mg ..................................... 22 metoprolol tartrate tabs 25mg, 50mg,
100mg .................................................. 22 metoprolol tartrate tabs 37.5mg, 75mg .... 22 metoprolol-hydrochlorothiazide tabs ........ 22 metronidazole caps.................................. 11 metronidazole crea .................................. 54 metronidazole gel .................................... 54 metronidazole in nacl soln intravenous .... 11 metronidazole lotn ................................... 54 metronidazole tabs .................................. 11 mexiletine hcl caps 150mg, 200mg, 250mg
............................................................. 23 mibelas 24 fe chew .................................. 43 miconazole 3 supp ................................... 54 micort-hc crea .......................................... 55 microgestin 1.5/30 tabs ............................ 43 microgestin 1/20 tabs ............................... 43 microgestin fe 1.5/30 tabs ........................ 43 microgestin fe 1/20 tabs ........................... 43 midodrine hcl tabs 2.5mg, 5mg, 10mg ..... 19
MIFEPREX TABS .................................... 46 miglitol tabs 25mg, 50mg, 100mg ............ 45 miglustat caps .......................................... 37 mili tabs .................................................... 43 millipred tabs ............................................ 42 mimvey lo tabs ......................................... 46 mimvey tabs ............................................. 46 minitran
pt24 .1mg/hr, .2mg/hr, .4mg/hr, .6mg/hr ............................................................. 24
minocycline hcl caps 50mg, 75mg, 100mg . 9 minocycline hcl er tb24 45mg, 55mg, 65mg,
80mg, 90mg, 105mg, 115mg, 135mg ..... 9 minocycline hcl tabs 50mg, 75mg, 100mg . 9 minoxidil tabs 2.5mg, 10mg ...................... 23 MIRCERA SOSY 30mcg/0.3ml,
50mcg/0.3ml, 75mcg/0.3ml, 100mcg/0.3ml, 150mcg/0.3ml, 200mcg/0.3ml ....................................... 21
mirtazapine tabs 7.5mg, 15mg, 30mg, 45mg .................................................... 33
mirtazapine tbdp 15mg, 30mg, 45mg ....... 33 MIRVASO GEL ........................................ 57 misoprostol tabs 100mcg, 200mcg ........... 40 MITIGARE CAPS ..................................... 48 M-M-R II SOLR ........................................ 53 modafinil tabs 100mg, 200mg .................. 28 moexipril hcl tabs 7.5mg, 15mg ................ 24 molindone hcl tabs 5mg, 10mg, 25mg ...... 34 mometasone furoate crea ........................ 55 mometasone furoate oint ......................... 55 mometasone furoate soln ......................... 55 mometasone furoate susp ........................ 38 mondoxyne nl caps 75mg, 100mg ............. 9 MONONESSA TABS ............................... 43 montelukast sodium chew 4mg, 5mg ....... 51 montelukast sodium pack ......................... 51 montelukast sodium tabs ......................... 51 MONUROL PACK .................................... 14 morgidox caps ............................................ 9 morphine sulfate (concentrate) soln ......... 26 MORPHINE SULFATE (PF) SOLN
INTRAVENOUS ................................... 26 morphine sulfate er beads cp24 30mg,
45mg, 60mg, 75mg, 90mg, 120mg ....... 26 morphine sulfate er cp24 10mg, 20mg,
30mg, 40mg, 50mg, 60mg, 80mg, 100mg ............................................................. 26
82 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
morphine sulfate er tbcr 15mg, 30mg, 60mg, 100mg, 200mg .......................... 26
MORPHINE SULFATE SOLN .................. 26 morphine sulfate soln 10mg/5ml, 20mg/5ml
............................................................. 26 MORPHINE SULFATE SOLN INJECTION
2mg/ml, 4mg/ml, 10mg/ml .................... 26 MORPHINE SULFATE SOLN
INTRAVENOUS ................................... 26 morphine sulfate tabs 15mg, 30mg .......... 26 MORPHINE SULFATE TABS 15mg, 30mg
............................................................. 26 MOVANTIK TABS 12.5mg, 25mg ............ 41 MOXEZA SOLN ....................................... 38 moxifloxacin hcl in nacl soln intravenous ... 9 moxifloxacin hcl soln ................................ 38 moxifloxacin hcl tabs .................................. 9 MULPLETA TABS ................................... 21 MULTAQ TABS ....................................... 23 mupirocin calcium crea ............................ 54 mupirocin oint .......................................... 54 MUSTARGEN SOLR ............................... 16 MVASI SOLN 400mg/16ml, 100mg/4ml ... 16 MYALEPT SOLR ..................................... 50 MYCAMINE SOLR INTRAVENOUS 50mg,
100mg .................................................. 11 mycophenolate mofetil caps .................... 49 mycophenolate mofetil susr ..................... 49 mycophenolate mofetil tabs ..................... 49 mycophenolate sodium tbec 180mg, 360mg
............................................................. 49 MYDAYIS CP24 ...................................... 28 MYLOTARG SOLR .................................. 16 myorisan caps 10mg, 20mg, 30mg, 40mg 57 MYRBETRIQ TB24 25mg, 50mg ............. 57 MYTESI TBEC ......................................... 40
N NABI-HB SOLN ....................................... 52 nabumetone tabs ..................................... 26 nadolol tabs 20mg, 40mg, 80mg .............. 22 nadolol-bendroflumethiazide tabs ............ 22 nafcillin sodium solr ................................... 9 nafcillin sodium solr injection ..................... 9 nafcillin sodium solr intravenous ................ 9 naftifine hcl crea ...................................... 54 NAFTIN GEL ........................................... 54 NAGLAZYME SOLN ................................ 37
nalfon tabs ............................................... 26 nalocet tabs .............................................. 26 naloxone hcl soct ..................................... 32 naloxone hcl soln ..................................... 32 naloxone hcl sosy..................................... 32 naltrexone hcl tabs ................................... 32 NAMENDA XR TITRATION PACK CP24 . 31 NAMZARIC C4PK .................................... 31 NAMZARIC CP24 .................................... 31 NAPRELAN TB24 .................................... 26 naproxen dr tbec ...................................... 27 naproxen sodium er tb24 ......................... 27 naproxen sodium tabs .............................. 27 naproxen susp ......................................... 27 naproxen tabs .......................................... 27 naproxen-esomeprazole tbec ................... 27 naratriptan hcl tabs ................................... 30 NARCAN LIQD ........................................ 32 NATACYN SUSP ..................................... 38 NATAZIA TABS ....................................... 43 nateglinide tabs 60mg, 120mg ................. 45 NATPARA CART 25mcg, 50mcg, 75mcg,
100mcg ................................................ 47 NATROBA SUSP ..................................... 54 NAYZILAM SOLN .................................... 29 NEBUPENT SOLR ................................... 11 necon 0.5/35 (28) tabs ............................. 43 NECON 7/7/7 TABS ................................. 43 nefazodone hcl tabs 50mg, 100mg, 150mg,
200mg, 250mg ..................................... 34 neomycin sulfate tabs ................................ 9 neomycin-bacitracin zn-polymyx oint........ 38 neomycin-polymyxin-dexameth oint ......... 38 neomycin-polymyxin-dexameth susp ....... 38 neomycin-polymyxin-gramicidin soln ........ 38 neomycin-polymyxin-hc soln .................... 38 neomycin-polymyxin-hc susp ................... 38 neo-synalar crea ...................................... 55 NEPHRAMINE SOLN INTRAVENOUS .... 35 NERLYNX TABS ...................................... 16 NEULASTA ONPRO PSKT ...................... 21 NEULASTA SOSY ................................... 21 NEUPOGEN SOLN 480mcg/1.6ml,
300mcg/ml ............................................ 21 NEUPOGEN SOSY 300mcg/0.5ml,
480mcg/0.8ml ....................................... 21 NEUPRO PT24 1mg/24hr, 2mg/24hr,
3mg/24hr, 4mg/24hr, 6mg/24hr, 8mg/24hr .............................................. 30
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 83
NEVANAC SUSP .................................... 38 nevirapine er tb24 100mg, 400mg ........... 12 nevirapine susp ....................................... 12 nevirapine tabs ........................................ 12 NEXAVAR TABS ..................................... 16 NEXIUM PACK 2.5mg, 5mg, 10mg, 20mg,
40mg .................................................... 40 niacin er (antihyperlipidemic) tbcr 500mg,
750mg, 1000mg ................................... 21 niacor tabs ............................................... 21 nicardipine hcl caps 20mg, 30mg ............ 23 NICOTROL INHA .................................... 18 NICOTROL NS SOLN ............................. 18 nifedipine caps 10mg, 20mg .................... 23 nifedipine er osmotic release tb24 30mg,
60mg, 90mg ......................................... 23 nifedipine er tb24 30mg, 60mg, 90mg ..... 23 nikki tabs ................................................. 43 nilutamide tabs ........................................ 16 nimodipine caps ....................................... 23 NINLARO CAPS 2.3mg, 3mg, 4mg ......... 16 nisoldipine er tb24 8.5mg, 17mg, 20mg,
25.5mg, 30mg, 34mg, 40mg ................ 23 nitro-bid oint ............................................. 24 NITRO-DUR PT24 .3mg/hr, .8mg/hr ........ 24 nitrofurantoin macrocrystal caps .............. 14 nitrofurantoin monohyd macro caps ......... 14 nitrofurantoin susp ................................... 14 nitroglycerin
pt24 .1mg/hr, .2mg/hr, .4mg/hr, .6mg/hr ............................................................. 25
nitroglycerin soln ...................................... 25 nitroglycerin subl .3mg, .4mg, .6mg ......... 25 NITYR TABS 2mg, 5mg, 10mg ................ 50 NIVESTYM SOLN 480mcg/1.6ml,
300mcg/ml ........................................... 21 NIVESTYM SOSY 300mcg/0.5ml,
480mcg/0.8ml ...................................... 21 nizatidine caps 150mg, 300mg ................ 40 nizatidine soln .......................................... 40 NOCDURNA SUBL 27.7mcg, 55.3mcg ... 47 NOCTIVA EMUL .83mcg/0.1ml,
1.66mcg/0.1ml ..................................... 47 nolix crea ................................................. 55 nolix lotn .................................................. 55 nora-be tabs ............................................ 43 norco tabs ................................................ 27
NORDITROPIN FLEXPRO SOLN 5mg/1.5ml, 10mg/1.5ml, 15mg/1.5ml, 30mg/3ml ............................................. 47
norethin ace-eth estrad-fe chew ............... 43 norethin ace-eth estrad-fe tabs ................ 43 norethindrone acetate tabs ...................... 47 norethindrone acet-ethinyl est tabs .......... 43 norethindrone tabs ................................... 43 norethindrone-eth estradiol tabs ............... 46 norethin-eth estradiol-fe chew .................. 43 norgestimate-eth estradiol tabs ................ 43 norgestim-eth estrad triphasic tabs .......... 43 norlyroc tabs ............................................ 43 NORMOSOL-M IN D5W SOLN
INTRAVENOUS ................................... 37 NORMOSOL-R IN D5W SOLN
INTRAVENOUS ................................... 37 NORMOSOL-R PH 7.4 SOLN
INTRAVENOUS ................................... 37 NORPACE CR CP12 100mg, 150mg ....... 23 NORTHERA CAPS 100mg, 200mg, 300mg
............................................................. 19 nortrel 0.5/35 (28) tabs ............................. 43 nortrel 1/35 (21) tabs ................................ 43 nortrel 1/35 (28) tabs ................................ 43 nortrel 7/7/7 tabs ...................................... 43 nortriptyline hcl caps 10mg, 25mg, 50mg,
75mg .................................................... 34 nortriptyline hcl soln ................................. 34 NORVIR CAPS ........................................ 12 NORVIR PACK ........................................ 12 NORVIR SOLN ........................................ 12 NORVIR TABS ......................................... 12 NOURIANZ TABS 20mg, 40mg ............... 31 NOVAREL SOLR ..................................... 46 NOVAREL SOLR 10000unit..................... 46 NOVOLIN 70/30 SUSP ............................ 45 NOVOLIN N SUSP ................................... 45 NOVOLIN R SOLN ................................... 45 NOVOLOG FLEXPEN SOPN ................... 45 NOVOLOG MIX 70/30 FLEXPEN SUPN .. 45 NOVOLOG MIX 70/30 SUSP ................... 45 NOVOLOG PENFILL SOCT ..................... 45 NOVOLOG SOLN .................................... 45 NOXAFIL SUSP ....................................... 11 NOXAFIL TBEC ....................................... 11 NPLATE SOLR ........................................ 21 NUBEQA TABS ....................................... 16 NUCALA SOAJ ........................................ 51
84 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
NUCALA SOLR ....................................... 51 NUCALA SOSY ....................................... 51 NUCYNTA ER TB12 200mg, 250mg ....... 27 NUCYNTA ER TB12 50mg, 100mg, 150mg
............................................................. 27 NUCYNTA TABS ..................................... 27 NUCYNTA TABS 50mg, 75mg ................ 27 NUEDEXTA CAPS .................................. 31 NULOJIX SOLR ....................................... 49 NUPLAZID CAPS .................................... 34 NUPLAZID TABS 10mg, 17mg ................ 34 NURTEC TBDP ....................................... 30 NUTRILIPID EMUL INTRAVENOUS ....... 35 NUTROPIN AQ NUSPIN 10 SOLN .......... 47 NUTROPIN AQ NUSPIN 20 SOLN .......... 47 NUTROPIN AQ NUSPIN 5 SOLN ............ 47 NUVARING RING .................................... 43 NUZYRA SOLR ......................................... 9 NUZYRA TABS ......................................... 9 nyamyc powd ........................................... 54 NYMALIZE SOLN .................................... 23 nystatin crea ............................................ 54 nystatin oint ............................................. 54 nystatin powd ........................................... 54 nystatin susp ............................................ 11 nystatin tabs ............................................ 11 nystatin-triamcinolone crea ...................... 55 nystatin-triamcinolone oint ....................... 55 nystop powd ............................................ 54
O OCALIVA TABS 5mg, 10mg .................... 41 ocella tabs ............................................... 44 OCREVUS SOLN .................................... 32 OCTAGAM SOLN INTRAVENOUS
5gm/100ml, 1gm/20ml, 2gm/20ml, 25gm/500ml ......................................... 52
octreotide acetate soln ............................. 47 ODACTRA SUBL ..................................... 50 ODEFSEY TABS ..................................... 12 ODOMZO CAPS ...................................... 17 OFEV CAPS 100mg, 150mg ................... 51 ofloxacin soln ........................................... 38 ofloxacin tabs ............................................. 9 ogestrel tabs ............................................ 44 OGIVRI SOLR ......................................... 17 olanzapine solr ........................................ 34
olanzapine tabs 2.5mg, 5mg, 7.5mg, 10mg, 15mg, 20mg ......................................... 34
olanzapine tbdp 5mg, 10mg, 15mg, 20mg ............................................................. 34
olanzapine-fluoxetine hcl caps ................. 34 olmesartan medoxomil tabs 5mg, 20mg,
40mg .................................................... 24 olmesartan medoxomil-hctz tabs .............. 24 olmesartan-amlodipine-hctz tabs ............. 23 olopatadine hcl soln .1%, .2%, .6% .......... 39 OLUMIANT TABS 1mg, 2mg ................... 49 OLYSIO CAPS ......................................... 12 OMECLAMOX-PAK MISC........................ 40 omega-3-acid ethyl esters caps ............... 21 omeprazole cpdr 10mg, 20mg, 40mg ....... 40 omeprazole-sodium bicarbonate caps ...... 40 omeprazole-sodium bicarbonate pack ...... 40 OMNARIS SUSP...................................... 38 OMNIPOD STARTER KIT ........................ 35 OMNITROPE SOLN 5mg/1.5ml,
10mg/1.5ml .......................................... 47 OMNITROPE SOLR ................................. 47 ondansetron hcl soln ................................ 40 ondansetron hcl tabs 4mg, 8mg, 24mg .... 40 ondansetron tbdp 4mg, 8mg .................... 40 ONGLYZA TABS 2.5mg, 5mg .................. 45 ONIVYDE INJ .......................................... 17 ONPATTRO SOLN .................................. 50 ONTRUZANT SOLR 150mg, 420mg........ 17 ONZETRA XSAIL EXHP .......................... 30 OPDIVO SOLN 100mg/10ml, 240mg/24ml,
40mg/4ml ............................................. 17 OPSUMIT TABS ...................................... 51 ORACEA CPDR ....................................... 57 ORALAIR SUBL ....................................... 50 ORAVIG TABS ......................................... 54 ORBACTIV SOLR .................................... 10 ORENCIA CLICKJECT SOAJ .................. 49 ORENCIA SOLR ...................................... 49 ORENCIA SOSY 50mg/0.4ml,
87.5mg/0.7ml, 125mg/ml ...................... 49 ORENITRAM TBCR .125mg .................... 51 ORENITRAM TBCR .25mg, 1mg, 2.5mg,
5mg ...................................................... 51 ORFADIN CAPS 2mg, 5mg, 10mg, 20mg 50 ORFADIN SUSP ...................................... 50 ORILISSA TABS 150mg, 200mg ............. 46 ORKAMBI PACK ...................................... 51 ORKAMBI TABS ...................................... 51
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 85
orphenadrine citrate er tb12 ..................... 19 orsythia tabs ............................................ 44 oseltamivir phosphate caps 30mg, 45mg,
75mg .................................................... 12 oseltamivir phosphate susr ...................... 12 OSMOLEX ER TB24 129mg, 193mg,
258mg .................................................. 30 OSMOPREP TABS.................................. 41 OSPHENA TABS ..................................... 46 OTEZLA TABS ........................................ 49 OTEZLA TBPK ........................................ 49 OTOVEL SOLN ....................................... 38 OTREXUP SOAJ ..................................... 49 ovide lotn ................................................. 54 OXACILLIN SODIUM IN DEXTROSE SOLN
INTRAVENOUS ................................... 10 oxacillin sodium solr injection 1gm, 2gm .. 10 oxacillin sodium solr intravenous ............. 10 oxandrolone tabs ..................................... 42 oxandrolone tabs 2.5mg .......................... 42 oxaprozin tabs ......................................... 27 OXAYDO TABA ....................................... 27 oxazepam caps 10mg, 15mg, 30mg ........ 31 OXBRYTA TABS ..................................... 20 oxcarbazepine susp ................................. 29 oxcarbazepine tabs 150mg, 300mg, 600mg
............................................................. 29 OXERVATE SOLN .................................. 39 oxiconazole nitrate crea ........................... 54 OXISTAT LOTN ....................................... 54 OXTELLAR XR TB24 150mg, 300mg,
600mg .................................................. 29 oxybutynin chloride er tb24 5mg, 10mg,
15mg .................................................... 57 oxybutynin chloride syrp .......................... 57 oxybutynin chloride tabs .......................... 57 oxycodone hcl caps ................................. 27 oxycodone hcl conc ................................. 27 oxycodone hcl er t12a 10mg, 15mg, 20mg,
30mg, 40mg, 60mg, 80mg ................... 27 oxycodone hcl soln .................................. 27 oxycodone hcl tabs 5mg, 10mg, 15mg,
20mg, 30mg ......................................... 27 oxycodone-acetaminophen tabs .............. 27 oxycodone-aspirin tabs ............................ 27 oxycodone-ibuprofen tabs ....................... 27 OXYCONTIN T12A 10mg, 15mg, 20mg,
30mg, 40mg, 60mg, 80mg ................... 27
oxymorphone hcl er tb12 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg, 40mg ......... 27
oxymorphone hcl tabs 5mg, 10mg ........... 27 OZEMPIC (0.25 OR 0.5 MG/DOSE) SOPN
............................................................. 45 OZEMPIC (1 MG/DOSE) SOPN .............. 45
P pacerone tabs 100mg, 200mg, 400mg ..... 23 PADCEV SOLR 20mg, 30mg ................... 17 PALFORZIA (12 MG DAILY DOSE) CSPK
............................................................. 50 PALFORZIA (120 MG DAILY DOSE) CSPK
............................................................. 50 PALFORZIA (160 MG DAILY DOSE) CSPK
............................................................. 50 PALFORZIA (20 MG DAILY DOSE) CSPK
............................................................. 50 PALFORZIA (200 MG DAILY DOSE) CSPK
............................................................. 50 PALFORZIA (240 MG DAILY DOSE) CSPK
............................................................. 50 PALFORZIA (3 MG DAILY DOSE) CSPK 50 PALFORZIA (300 MG MAINTENANCE)
PACK ................................................... 50 PALFORZIA (300 MG TITRATION) PACK
............................................................. 50 PALFORZIA (40 MG DAILY DOSE) CSPK
............................................................. 50 PALFORZIA (6 MG DAILY DOSE) CSPK 50 PALFORZIA (80 MG DAILY DOSE) CSPK
............................................................. 50 PALFORZIA INITIAL ESCALATION CSPK
............................................................. 50 paliperidone er tb24 1.5mg, 3mg, 6mg, 9mg
............................................................. 34 PALYNZIQ SOSY 2.5mg/0.5ml,
10mg/0.5ml, 20mg/ml ........................... 37 PANCREAZE CPEP ................................ 37 PANDEL CREA ........................................ 55 panlor tabs ............................................... 27 PANRETIN GEL ....................................... 56 pantoprazole sodium tbec 20mg, 40mg ... 40 PANZYGA SOLN INTRAVENOUS
10gm/100ml, 1gm/10ml, 20gm/200ml, 2.5gm/25ml, 30gm/300ml, 5gm/50ml ... 52
paricalcitol caps 1mcg, 2mcg, 4mcg......... 58 paromomycin sulfate caps........................ 11
86 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
paroxetine hcl er tb24 12.5mg, 25mg, 37.5mg ................................................. 34
paroxetine hcl tabs 10mg, 20mg .............. 34 paroxetine hcl tabs 30mg, 40mg .............. 34 paroxetine mesylate caps ........................ 34 paser pack ............................................... 11 PAXIL SUSP ............................................ 34 PAZEO SOLN .......................................... 39 PEDIARIX SUSP ..................................... 53 PEDVAX HIB SUSP ................................ 53 peg 3350/electrolytes solr ........................ 41 peg 3350-kcl-na bicarb-nacl solr .............. 41 peg-3350/electrolytes solr ........................ 41 PEGANONE TABS .................................. 29 PEGASYS PROCLICK SOLN
135mcg/0.5ml, 180mcg/0.5ml .............. 13 PEGASYS SOLN 180mcg/0.5ml,
180mcg/ml ........................................... 13 PEGINTRON KIT 50mcg/0.5ml,
80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml ...................................... 13
PEG-INTRON REDIPEN KIT 50mcg/0.5ml, 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml ...................................... 12
PEG-INTRON REDIPEN PAK 4 KIT ........ 12 PEG-INTRON REDIPEN PAK 4 KIT
80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml ...................................... 12
PEMAZYRE TABS 4.5mg, 9mg, 13.5mg . 17 penicillamine caps ................................... 41 penicillamine tabs .................................... 41 PENICILLIN G POT IN DEXTROSE SOLN
INTRAVENOUS ................................... 10 penicillin g potassium solr injection .......... 10 penicillin g procaine susp ......................... 10 penicillin g sodium solr injection ............... 10 penicillin v potassium solr ........................ 10 penicillin v potassium tabs ....................... 10 pentamidine isethionate inh ..................... 11 pentamidine isethionate inj ...................... 11 PENTASA CPCR 250mg, 500mg ............ 40 pentazocine-naloxone hcl tabs ................ 27 pentoxifylline er tbcr ................................. 20 pepcid tabs 20mg, 40mg ......................... 40 percocet tabs ........................................... 27 PERFOROMIST NEBU ........................... 19 perindopril erbumine tabs 2mg, 4mg, 8mg
............................................................. 24 PERJETA SOLN ...................................... 17
permethrin crea ........................................ 54 perphenazine tabs 2mg, 4mg, 8mg, 16mg
............................................................. 34 perphenazine-amitriptyline tabs ............... 34 PERSERIS PRSY 90mg, 120mg ............. 34 PERTZYE CPEP ...................................... 37 PEXEVA TABS 10mg, 20mg, 30mg, 40mg
............................................................. 34 phenadoz supp ........................................ 14 phenelzine sulfate tabs ............................ 34 PHENOBARBITAL ELIX .......................... 31 PHENOBARBITAL TABS ......................... 31 phenoxybenzamine hcl caps .................... 19 phenytek caps 200mg, 300mg ................. 29 phenytoin chew ........................................ 29 phenytoin sodium extended caps 100mg,
200mg, 300mg ..................................... 29 phenytoin susp ......................................... 29 PHOSLYRA SOLN ................................... 37 PHOSPHOLINE IODIDE SOLR ............... 39 phrenilin forte caps ................................... 27 PICATO GEL .015%, .05% ..................... 57 PIFELTRO TABS ..................................... 13 pilocarpine hcl soln 1%, 2%, 4% .............. 39 pilocarpine hcl tabs 5mg, 7.5mg ............... 19 pimecrolimus crea .................................... 57 pimozide tabs 1mg, 2mg .......................... 34 pimtrea tabs ............................................. 44 pindolol tabs 5mg, 10mg .......................... 22 pioglitazone hcl tabs 15mg, 30mg, 45mg . 45 pioglitazone hcl-glimepiride tabs .............. 45 pioglitazone hcl-metformin hcl tabs .......... 45 piperacillin sod-tazobactam so solr
intravenous ........................................... 10 PIQRAY (200 MG DAILY DOSE) TBPK ... 17 PIQRAY (250 MG DAILY DOSE) TBPK ... 17 PIQRAY (300 MG DAILY DOSE) TBPK ... 17 pirmella 1/35 tabs ..................................... 44 piroxicam caps 10mg, 20mg .................... 27 PLASMA-LYTE 148 SOLN INTRAVENOUS
............................................................. 37 PLASMA-LYTE A SOLN INTRAVENOUS 37 PLEGRIDY SOPN .................................... 13 PLEGRIDY SOSY .................................... 13 PLEGRIDY STARTER PACK SOPN ........ 13 PLEGRIDY STARTER PACK SOSY ........ 13 plenamine soln intravenous...................... 35 PLENVU SOLR ........................................ 41 podofilox soln ........................................... 57
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 87
POLIVY SOLR ......................................... 17 polymyxin b sulfate solr injection ............. 10 polymyxin b-trimethoprim soln ................. 38 POMALYST CAPS 1mg, 2mg, 3mg, 4mg 17 portia-28 tabs ........................................... 44 PORTRAZZA SOLN ................................ 17 POSACONAZOLE SUSP ........................ 11 posaconazole tbec ................................... 11 potassium chloride crys er tbcr 10meq,
20meq .................................................. 37 potassium chloride er cpcr 8meq, 10meq 37 potassium chloride er tbcr 8meq, 10meq,
20meq .................................................. 37 POTASSIUM CHLORIDE IN DEXTROSE
SOLN INTRAVENOUS ........................ 37 potassium chloride in nacl soln intravenous
............................................................. 37 potassium chloride pack .......................... 37 potassium chloride soln 10%, 20% .......... 37 POTASSIUM CHLORIDE SOLN
INTRAVENOUS 2meq/ml, 10meq/100ml, 20meq/100ml, 40meq/100ml ................ 37
potassium citrate er tbcr 15meq, 540mg, 1080mg ................................................ 35
POTELIGEO SOLN ................................. 17 PRADAXA CAPS 75mg, 110mg, 150mg . 20 PRALUENT SOAJ 75mg/ml, 150mg/ml ... 22 PRALUENT SOSY 75mg/ml, 150mg/ml .. 22 pramipexole dihydrochloride er
tb24 .375mg, .75mg, 1.5mg, 2.25mg, 3mg, 3.75mg, 4.5mg ............................ 30
pramipexole dihydrochloride tabs .125mg, .25mg, .5mg, .75mg, 1mg, 1.5mg ................................................... 30
prandin tabs 1mg, 2mg ............................ 45 prasugrel hcl tabs 5mg, 10mg.................. 20 pravastatin sodium tabs 10mg, 20mg,
40mg, 80mg ......................................... 22 praziquantel tabs ....................................... 8 prazosin hcl caps 1mg, 2mg, 5mg ........... 21 PRED MILD SUSP .................................. 38 PRED-G S.O.P. OINT .............................. 38 PRED-G SUSP ........................................ 38 prednicarbate crea ................................... 55 prednicarbate oint .................................... 55 prednisolone acetate susp ....................... 38 prednisolone sodium phosphate soln 38, 42
prednisolone sodium phosphate soln 5mg/5ml, 10mg/5ml, 20mg/5ml, 25mg/5ml ............................................. 42
prednisolone sodium phosphate tbdp 10mg, 15mg, 30mg ......................................... 42
prednisolone soln ..................................... 42 prednisone intensol conc ......................... 42 prednisone soln ........................................ 42 prednisone tabs 1mg, 2.5mg, 5mg, 10mg,
20mg, 50mg ......................................... 42 prednisone tbpk ....................................... 42 prefest tabs .............................................. 46 pregabalin caps 25mg, 50mg, 75mg,
100mg, 150mg, 200mg, 225mg, 300mg ............................................................. 29
pregabalin soln ......................................... 29 PREGNYL SOLR ..................................... 46 PREMARIN CREA ................................... 46 PREMARIN SOLR ................................... 46 PREMARIN
TABS .3mg, .45mg, .625mg, .9mg, 1.25mg ................................................. 46
premasol soln intravenous ....................... 35 PREMPHASE TABS ................................ 46 PREMPRO TABS..................................... 46 prevalite pack ........................................... 22 previfem tabs ........................................... 44 PREVYMIS SOLN 240mg/12ml,
480mg/24ml.......................................... 13 PREVYMIS TABS 240mg, 480mg ........... 13 PREZCOBIX TABS .................................. 13 PREZISTA SUSP ..................................... 13 PREZISTA TABS 75mg, 150mg, 600mg,
800mg .................................................. 13 PRIFTIN TABS ......................................... 11 PRILOSEC PACK 2.5mg, 10mg .............. 40 primaquine phosphate tabs ...................... 11 primidone tabs 50mg, 250mg ................... 29 primlev tabs .............................................. 27 PRIVIGEN SOLN INTRAVENOUS .......... 52 PROAIR RESPICLICK AEPB ................... 19 probenecid tabs ....................................... 37 PROCALAMINE SOLN INTRAVENOUS .. 36 procentra soln .......................................... 28 prochlorperazine maleate tabs ................. 34 prochlorperazine supp .............................. 34 PROCRIT SOLN 2000unit/ml, 3000unit/ml,
4000unit/ml, 10000unit/ml, 20000unit/ml, 40000unit/ml ......................................... 21
88 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
procto-med hc crea .................................. 55 procto-pak crea ........................................ 55 proctosol hc crea ..................................... 56 proctozone-hc crea .................................. 56 PROCYSBI CPDR 25mg, 75mg .............. 50 PROCYSBI PACK 75mg, 300mg ............. 50 progesterone micronized caps 100mg,
200mg .................................................. 47 PROGLYCEM SUSP ............................... 45 PROGRAF PACK .2mg, 1mg .................. 49 PROGRAF SOLN .................................... 49 PROLASTIN-C SOLN INTRAVENOUS ... 51 PROLASTIN-C SOLR INTRAVENOUS ... 51 prolate tabs .............................................. 27 PROLENSA SOLN .................................. 38 PROLEUKIN SOLR ................................. 17 PROLIA SOSY ........................................ 48 PROMACTA PACK 12.5mg, 25mg .......... 21 PROMACTA TABS 12.5mg, 25mg, 50mg,
75mg .................................................... 21 promethazine hcl supp ............................. 14 promethazine hcl syrp .............................. 14 promethazine hcl tabs .............................. 14 promethazine-phenylephrine syrp ............ 14 promethegan supp ................................... 14 propafenone hcl er cp12 225mg, 325mg,
425mg .................................................. 23 propafenone hcl tabs 150mg, 225mg,
300mg .................................................. 23 propantheline bromide tabs ..................... 18 proparacaine hcl soln ............................... 39 propranolol hcl er cp24 60mg, 80mg,
120mg, 160mg ..................................... 22 propranolol hcl soln 20mg/5ml, 40mg/5ml 22 propranolol hcl tabs 10mg, 20mg, 40mg,
60mg, 80mg ......................................... 22 propranolol-hctz tabs ............................... 22 propylthiouracil tabs ................................. 48 PROQUAD SUSR.................................... 53 PROSOL SOLN INTRAVENOUS ............ 36 PROTONIX PACK ................................... 40 protriptyline hcl tabs 5mg, 10mg .............. 34 psorcon crea ............................................ 56 PULMICORT FLEXHALER AEPB
90mcg/act, 180mcg/act ........................ 51 PULMOZYME SOLN ............................... 37 PURIXAN SUSP ...................................... 17 PYLERA CAPS ........................................ 40 pyrazinamide tabs ................................... 11
pyridostigmine bromide er tbcr ................. 19 pyridostigmine bromide soln ..................... 19 pyridostigmine bromide tabs 30mg, 60mg 19
Q QBRELIS SOLN ....................................... 24 QNASL AERS .......................................... 38 QNASL CHILDRENS AERS ..................... 38 QTERN TABS .......................................... 45 QUADRACEL SUSP ................................ 52 questran light powd .................................. 22 questran pack .......................................... 22 quetiapine fumarate er tb24 50mg, 150mg,
200mg, 300mg, 400mg......................... 34 quetiapine fumarate tabs 25mg, 50mg,
100mg, 200mg, 300mg, 400mg ............ 34 QUILLICHEW ER CHER 20mg, 30mg,
40mg .................................................... 28 QUILLIVANT XR SRER ........................... 28 quinapril hcl tabs 5mg, 10mg, 20mg, 40mg
............................................................. 24 quinapril-hydrochlorothiazide tabs ............ 24 quinidine gluconate er tbcr ....................... 23 QUINIDINE GLUCONATE SOLN ............. 23 quinidine sulfate tabs 200mg, 300mg ....... 23 quinine sulfate caps ................................. 11 QVAR REDIHALER AERB ....................... 51
R RABAVERT SUSR ................................... 53 rabeprazole sodium tbec .......................... 40 RADICAVA SOLN .................................... 31 raloxifene hcl tabs .................................... 46 ramelteon tabs ......................................... 31 ramipril caps 1.25mg, 2.5mg, 5mg, 10mg 24 ranolazine er tb12 500mg, 1000mg .......... 23 RAPAMUNE SOLN .................................. 49 RAPIVAB SOLN ....................................... 13 rasagiline mesylate tabs .5mg, 1mg ......... 30 RASUVO SOAJ ....................................... 49 RAVICTI LIQD ......................................... 35 RAYALDEE CPCR ................................... 58 RAYOS TBEC 1mg, 2mg, 5mg ................ 42 REBETOL SOLN...................................... 13 REBIF REBIDOSE SOAJ 22mcg/0.5ml,
44mcg/0.5ml ......................................... 32 REBIF REBIDOSE TITRATION PACK
SOAJ .................................................... 32
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 89
REBIF SOSY 22mcg/0.5ml, 44mcg/0.5ml 32 REBIF TITRATION PACK SOSY ............. 32 REBLOZYL SOLR 25mg, 75mg .............. 21 RECARBRIO SOLR ................................. 10 reclipsen tabs .......................................... 44 RECOMBIVAX HB SUSP 5mcg/0.5ml,
10mcg/ml, 40mcg/ml ............................ 53 RECTIV OINT .......................................... 57 REGONOL SOLN .................................... 19 REGRANEX GEL .................................... 57 relafen ds tabs ......................................... 27 RELENZA DISKHALER AEPB ................ 13 relexxii tbcr .............................................. 28 RELISTOR SOLN 8mg/0.4ml, 12mg/0.6ml
............................................................. 41 RELISTOR TABS .................................... 41 REMICADE SOLR INTRAVENOUS ........ 49 REMODULIN SOLN 20mg/20ml,
50mg/20ml, 100mg/20ml, 200mg/20ml 52 RENFLEXIS SOLR .................................. 49 repaglinide tabs .5mg, 1mg, 2mg ............. 45 repaglinide-metformin hcl tabs ................. 45 REPATHA PUSHTRONEX SYSTEM SOCT
............................................................. 22 REPATHA SOSY ..................................... 22 REPATHA SURECLICK SOAJ ................ 22 RESCRIPTOR TABS 100mg, 200mg ...... 13 RESTASIS EMUL .................................... 39 RETACRIT SOLN 2000unit/ml, 3000unit/ml,
4000unit/ml, 10000unit/ml, 40000unit/ml ............................................................. 21
RETIN-A CREA .025%, .05%, .1% .......... 56 RETIN-A GEL .01%, .025% .................... 56 RETIN-A MICRO GEL .04%, .1% ........... 56 RETIN-A MICRO PUMP GEL .................. 56 RETIN-A MICRO PUMP GEL .04%, .1% 56 RETIN-A MICRO PUMP GEL .08% ........ 56 RETROVIR CAPS ................................... 13 RETROVIR SOLN ................................... 13 RETROVIR SYRP ................................... 13 REVATIO SOLN ...................................... 25 REVATIO SUSR ...................................... 25 REVATIO TABS ...................................... 25 REVCOVI SOLN ...................................... 37 REVLIMID CAPS 2.5mg, 5mg, 10mg,
15mg, 20mg, 25mg .............................. 17 REXULTI TABS .25mg, .5mg, 1mg, 2mg,
3mg, 4mg ............................................. 34 REYATAZ CAPS 150mg, 200mg, 300mg 13
REYATAZ PACK ...................................... 13 RHOPRESSA SOLN ................................ 39 ribasphere caps ....................................... 13 ribasphere ribapak (1000 pack) tbpk ........ 13 ribasphere ribapak (1200 pack) tbpk ........ 13 ribasphere tabs ........................................ 13 ribavirin caps ............................................ 13 ribavirin tabs ............................................. 13 RIDAURA CAPS ...................................... 50 rifabutin caps ............................................ 11 RIFADIN CAPS ........................................ 11 rifamate caps ........................................... 11 rifampin caps 150mg, 300mg ................... 11 rifampin solr intravenous .......................... 11 RIFATER TABS ....................................... 11 RILUTEK TABS ....................................... 31 riluzole tabs .............................................. 31 rimantadine hcl tabs ................................. 13 RIMSO-50 SOLN ..................................... 50 RINVOQ TB24 ......................................... 49 RIOMET SOLN ........................................ 45 risedronate sodium tabs 5mg, 30mg, 35mg,
150mg .................................................. 48 risedronate sodium tbec ........................... 48 RISPERDAL CONSTA SRER 12.5mg,
25mg .................................................... 34 RISPERDAL CONSTA SRER 37.5mg,
50mg .................................................... 34 risperidone soln ........................................ 34 risperidone tabs .25mg, .5mg, 1mg, 2mg,
3mg, 4mg ............................................. 34 risperidone tbdp .25mg, .5mg, 1mg, 2mg,
3mg, 4mg ............................................. 34 ritonavir tabs ............................................ 13 RITUXAN HYCELA SOLN ....................... 17 RITUXAN SOLN....................................... 17 rivastigmine pt24 4.6mg/24hr, 9.5mg/24hr,
13.3mg/24hr ......................................... 19 rivastigmine tartrate caps 1.5mg, 3mg,
4.5mg, 6mg .......................................... 19 rivelsa tabs ............................................... 44 rizatriptan benzoate tabs .......................... 30 rizatriptan benzoate tbdp .......................... 30 ROMIDEPSIN SOLN ................................ 17 ropinirole hcl er tb24 2mg, 4mg, 6mg, 8mg,
12mg .................................................... 30 ropinirole hcl tabs .25mg, .5mg, 1mg, 2mg,
3mg, 4mg, 5mg .................................... 30
90 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
rosuvastatin calcium tabs 5mg, 10mg, 20mg, 40mg ......................................... 22
ROTARIX SUSR ...................................... 53 ROTATEQ SOLN .................................... 53 roweepra tabs 500mg, 750mg, 1000mg .. 29 roweepra xr tb24 500mg, 750mg ............. 29 ROXYBOND TABA 5mg, 15mg, 30mg .... 27 ROZEREM TABS .................................... 31 ROZLYTREK CAPS 100mg, 200mg ........ 17 RUBRACA TABS 200mg, 250mg, 300mg 17 RUCONEST SOLR INTRAVENOUS ....... 20 RUXIENCE SOLN 100mg/10ml,
500mg/50ml ......................................... 17 RUZURGI TABS ...................................... 50 RYBELSUS TABS 3mg, 7mg, 14mg ....... 45 ryclora soln .............................................. 14 RYDAPT CAPS ....................................... 17 RYNODERM CREA ................................. 57 RYTARY CPCR ....................................... 30 ryvent tabs ............................................... 14
S SABRIL PACK ......................................... 29 SABRIL TABS ......................................... 29 SAIZEN CLICK.EASY SOLR ................... 47 SAIZEN SOLR 5mg, 8.8mg ..................... 47 SAIZENPREP SOLR ............................... 47 SAMSCA TABS 15mg, 30mg .................. 36 SANCUSO PTCH .................................... 40 SANDIMMUNE CAPS 25mg, 100mg ....... 49 SANDIMMUNE ORAL SOLN 100mg/ml .. 49 SANDIMMUNE SOLN 50mg/ml ............... 49 SANDOSTATIN LAR DEPOT KIT 10mg,
20mg, 30mg ......................................... 47 SANTYL OINT ......................................... 57 SAPHRIS SUBL 2.5mg, 5mg, 10mg ........ 34 SARCLISA SOLN 500mg/25ml, 100mg/5ml
............................................................. 17 SAVAYSA TABS 15mg, 30mg, 60mg ...... 20 SAVELLA TABS 12.5mg, 25mg, 50mg,
100mg .................................................. 31 SAVELLA TITRATION PACK MISC ........ 31 scopolamine pt72 .................................... 40 SECUADO PT24 3.8mg/24hr, 5.7mg/24hr,
7.6mg/24hr ........................................... 34 SEGLUROMET TABS ............................. 45 selegiline hcl caps ................................... 31 selegiline hcl tabs .................................... 31
selenium sulfide lotn ................................. 54 SELZENTRY SOLN ................................. 13 SELZENTRY TABS 25mg, 75mg, 150mg,
300mg .................................................. 13 SEMPREX-D CAPS ................................. 14 SENSIPAR TABS 30mg ........................... 47 SENSIPAR TABS 60mg, 90mg ................ 47 SEREVENT DISKUS AEPB ..................... 19 SEROSTIM SOLR 4mg, 5mg, 6mg .......... 47 sertraline hcl conc .................................... 34 sertraline hcl tabs 25mg, 50mg, 100mg ... 34 setlakin tabs ............................................. 44 sevelamer carbonate pack .8gm, 2.4gm .. 36 sevelamer carbonate tabs ........................ 36 sevelamer hcl tabs 400mg, 800mg .......... 36 SEYSARA TABS 60mg, 100mg, 150mg .. 10 sharobel tabs ........................................... 44 SHINGRIX SUSR ..................................... 53 SIGNIFOR LAR SRER 10mg, 20mg, 30mg,
40mg, 60mg ......................................... 47 SIGNIFOR
SOLN .3mg/ml, .6mg/ml, .9mg/ml ......... 47 SIKLOS TABS .......................................... 17 sildenafil citrate soln ................................. 25 sildenafil citrate susr ................................. 25 sildenafil citrate tabs ................................. 25 SILENOR TABS ....................................... 31 SILIQ SOSY ............................................. 57 silodosin caps 4mg, 8mg .......................... 19 SILVER SULFADIAZINE CREA ............... 54 SIMBRINZA SUSP ................................... 39 SIMPONI ARIA SOLN .............................. 49 SIMPONI SOAJ 50mg/0.5ml, 100mg/ml .. 49 SIMPONI SOSY 50mg/0.5ml, 100mg/ml .. 49 simvastatin tabs 5mg, 10mg, 20mg, 40mg,
80mg .................................................... 22 sirolimus soln ........................................... 49 sirolimus tabs .5mg, 1mg, 2mg ................ 49 SIRTURO TABS....................................... 11 SIVEXTRO SOLR INTRAVENOUS.......... 10 SIVEXTRO TABS..................................... 10 SKLICE LOTN .......................................... 54 SKYRIZI (150 MG DOSE) PSKT .............. 57 SODIUM CHLORIDE SOLN ............... 37, 50 SODIUM CHLORIDE SOLN INJECTION . 37 SODIUM CHLORIDE SOLN
INTRAVENOUS .45%, .9%, 3%, .45%, 5% ........................................................ 37
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 91
SODIUM EDECRIN SOLR INTRAVENOUS ............................................................. 36
SODIUM FLUORIDE TABS ..................... 50 SODIUM LACTATE SOLN INTRAVENOUS
............................................................. 35 sodium phenylbutyrate powd ................... 35 sodium phenylbutyrate tabs ..................... 35 sodium polystyrene sulfonate powd ......... 36 sodium polystyrene sulfonate susp .......... 36 sofosbuvir-velpatasvir tabs ...................... 13 solifenacin succinate tabs 5mg, 10mg ..... 57 SOLIQUA SOPN ..................................... 45 SOLOSEC PACK .................................... 11 soloxide tbec ............................................ 10 SOLTAMOX SOLN .................................. 17 SOLU-CORTEF SOLR ............................ 42 SOLU-MEDROL SOLR ............................ 42 SOMATULINE DEPOT SOLN ................. 47 SOMAVERT SOLR 10mg, 15mg, 20mg,
25mg, 30mg ......................................... 47 SOOLANTRA CREA ................................ 54 SORIATANE CAPS 10mg, 17.5mg, 25mg
............................................................. 57 SORILUX FOAM ..................................... 57 sorine tabs 80mg, 120mg, 160mg, 240mg
............................................................. 22 sotalol hcl (af) tabs 80mg, 120mg, 160mg 22 sotalol hcl tabs 80mg, 120mg, 160mg,
240mg .................................................. 22 SOTYLIZE SOLN .................................... 22 SOVALDI TABS 200mg, 400mg .............. 13 SPIRIVA HANDIHALER CAPS ................ 18 SPIRIVA RESPIMAT AERS..................... 18 SPIRIVA RESPIMAT AERS 2.5mcg/act .. 18 spironolactone tabs 25mg, 50mg, 100mg 24 spironolactone-hctz tabs .......................... 24 SPRAVATO (56 MG DOSE) SOPK ......... 34 SPRAVATO (84 MG DOSE) SOPK ......... 34 sprintec 28 tabs ....................................... 44 SPRITAM TB3D 250mg, 500mg, 750mg,
1000mg ................................................ 29 SPRYCEL TABS 20mg, 50mg, 70mg,
80mg, 100mg, 140mg .......................... 17 sps susp .................................................. 36 sronyx tabs .............................................. 44 SSD CREA .............................................. 54 stavudine caps 15mg, 20mg, 30mg, 40mg
............................................................. 13 STEGLATRO TABS 5mg, 15mg .............. 45
STEGLUJAN TABS .................................. 45 STELARA SOLN 45mg/0.5ml, 130mg/26ml
............................................................. 57 STELARA SOSY 45mg/0.5ml, 90mg/ml ... 57 STIMATE SOLN ....................................... 47 STIOLTO RESPIMAT AERS .................... 18 STIVARGA TABS..................................... 17 STRENSIQ SOLN 18mg/0.45ml,
28mg/0.7ml, 80mg/0.8ml, 40mg/ml ...... 37 streptomycin sulfate solr .......................... 10 STRIANT MISC ........................................ 42 STRIBILD TABS....................................... 13 STRIVERDI RESPIMAT AERS ................ 19 SUBLOCADE SOSY 100mg/0.5ml,
300mg/1.5ml......................................... 32 SUBSYS LIQD 100mcg, 200mcg, 400mcg,
600mcg, 800mcg, 1200mcg, 1600mcg . 27 SUCRAID SOLN ...................................... 37 sucralfate susp ......................................... 40 sucralfate tabs .......................................... 40 sulfacetamide sodium (acne) lotn ............. 54 sulfacetamide sodium oint ........................ 38 sulfacetamide sodium soln ....................... 38 sulfacetamide-prednisolone soln .............. 39 sulfadiazine tabs ...................................... 10 sulfamethoxazole-trimethoprim susp ........ 10 sulfamethoxazole-trimethoprim tabs......... 10 SULFAMYLON CREA .............................. 54 sulfasalazine tabs..................................... 10 sulfasalazine tbec..................................... 10 sulindac tabs ............................................ 27 sumatriptan soln ....................................... 30 sumatriptan succinate refill soct ............... 30 sumatriptan succinate soaj ....................... 30 sumatriptan succinate soln ....................... 30 sumatriptan succinate sosy ...................... 30 sumatriptan succinate tabs ...................... 30 SUNOSI TABS 75mg, 150mg .................. 28 SUPRAX CAPS ....................................... 10 suprax chew ............................................. 10 suprax susr 100mg/5ml, 200mg/5ml ........ 10 SUPRAX SUSR 500 MG/5ML .................. 10 SUPREP BOWEL PREP KIT SOLN......... 41 SUSTIVA CAPS 50mg, 200mg ................ 13 SUSTIVA TABS ....................................... 13 SUTENT CAPS 12.5mg, 25mg, 37.5mg,
50mg .................................................... 17 syeda tabs ................................................ 44 SYLATRON KIT ....................................... 17
92 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
SYLVANT SOLR 100mg, 400mg ............. 17 SYMDEKO TBPK .................................... 51 SYMFI LO TABS ..................................... 13 SYMFI TABS ........................................... 13 SYMLINPEN 120 SOPN .......................... 45 SYMLINPEN 60 SOPN ............................ 45 SYMPAZAN FILM 10mg, 20mg ............... 29 SYMPAZAN FILM 5mg ............................ 29 SYMPROIC TABS ................................... 41 SYMTUZA TABS ..................................... 13 SYNAGIS SOLN 50mg/0.5ml, 100mg/ml . 13 SYNAREL SOLN ..................................... 47 SYNDROS SOLN .................................... 40 SYNERA PTCH ....................................... 56 SYNERCID SOLR ................................... 10 SYNJARDY TABS ................................... 45 SYNJARDY XR TB24 .............................. 45 SYNRIBO SOLR ...................................... 17
T TABLOID TABS ....................................... 17 TACLONEX OINT .................................... 56 TACLONEX SUSP................................... 56 tacrolimus caps .5mg, 1mg, 5mg ............. 49 tacrolimus oint .03%, .1% ........................ 57 tadalafil (pah) tabs 20mg ......................... 25 tadalafil tabs 2.5mg, 5mg ......................... 25 TAFINLAR CAPS 50mg, 75mg ................ 17 TAGRISSO TABS 40mg, 80mg ............... 17 TAKHZYRO SOLN .................................. 50 TALTZ SOAJ ........................................... 57 TALTZ SOSY ........................................... 57 TALZENNA CAPS .25mg, 1mg ............... 17 tamoxifen citrate tabs ............................... 17 tamsulosin hcl caps ................................. 19 tapazole tabs 5mg, 10mg ........................ 48 taperdex 12-day tbpk ............................... 42 taperdex 6-day tbpk ................................. 42 taperdex 7-day tbpk ................................. 42 TARCEVA TABS 25mg, 100mg, 150mg .. 17 targadox tabs ........................................... 10 TARGRETIN CAPS ................................. 17 TARGRETIN GEL .................................... 56 tarina 24 fe tabs ....................................... 44 tarina fe 1/20 tabs .................................... 44 TASIGNA CAPS 50mg, 150mg, 200mg ... 17 TAVALISSE TABS 100mg, 150mg .......... 21 tazarotene crea ........................................ 57
tazicef solr injection 1gm, 2gm, 6gm ........ 10 TAZORAC CREA ..................................... 57 TAZORAC GEL .05%, .1% ...................... 57 taztia xt cp24 120mg, 180mg, 240mg,
300mg, 360mg ..................................... 23 TAZVERIK TABS ..................................... 17 TDVAX SUSP .......................................... 52 TECENTRIQ SOLN 840mg/14ml,
1200mg/20ml........................................ 17 TECFIDERA CPDR 120mg, 240mg ......... 32 TECFIDERA MISC ................................... 32 TEFLARO SOLR INTRAVENOUS 400mg,
600mg .................................................. 10 TEGSEDI SOSY ...................................... 50 TEKTURNA HCT TABS ........................... 24 telmisartan tabs 20mg, 40mg, 80mg ........ 24 telmisartan-amlodipine tabs ..................... 23 telmisartan-hctz tabs ................................ 24 temazepam caps 7.5mg, 15mg, 22.5mg,
30mg .................................................... 31 tencon tabs .............................................. 27 TENIPOSIDE SOLN ................................. 17 TENIVAC INJ ........................................... 52 tenofovir disoproxil fumarate tabs ............ 13 TEPADINA SOLR .................................... 17 TEPEZZA SOLR ...................................... 39 terazosin hcl caps 1mg, 2mg, 5mg, 10mg 21 terbinafine hcl tabs ................................... 11 terbutaline sulfate tabs 2.5mg, 5mg ......... 19 terconazole crea ...................................... 54 terconazole supp ...................................... 54 TERIPARATIDE (RECOMBINANT) SOPN
............................................................. 47 testosterone cypionate soln 100mg/ml,
200mg/ml ............................................. 42 testosterone enanthate soln ..................... 42 testosterone gel 1%, 1.62%,
20.25mg/1.25gm, 25mg/2.5gm, 40.5mg/2.5gm, 50mg/5gm, 10mg/act ... 42
testosterone soln ...................................... 42 tetrabenazine tabs 12.5mg, 25mg ............ 31 tetracycline hcl caps 250mg, 500mg ........ 10 texacort soln ............................................. 56 THALOMID CAPS 50mg, 100mg, 150mg,
200mg .................................................. 17 theo-24 cp24 100mg, 200mg, 300mg,
400mg .................................................. 57 theophylline er tb12 100mg, 200mg, 300mg
............................................................. 57
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 93
theophylline er tb24 400mg, 600mg ......... 57 theophylline soln ...................................... 57 THIOLA EC TBEC 100mg, 300mg .......... 50 THIOLA TABS ......................................... 50 thioridazine hcl tabs 10mg, 25mg, 50mg,
100mg .................................................. 34 thiotepa solr 15mg, 100mg ...................... 17 thiothixene caps 1mg, 2mg, 5mg, 10mg .. 34 THYROLAR-1 TABS ................................ 48 THYROLAR-1/2 TABS ............................. 48 THYROLAR-1/4 TABS ............................. 48 THYROLAR-2 TABS ................................ 48 THYROLAR-3 TABS ................................ 48 tiadylt er cp24 120mg, 180mg, 240mg,
300mg, 360mg, 420mg ........................ 23 tiagabine hcl tabs 2mg, 4mg, 12mg, 16mg
............................................................. 29 TIBSOVO TABS ...................................... 17 tigecycline solr intravenous ...................... 10 TIGLUTIK SUSP ...................................... 31 TIMOLOL MALEATE SOLG .25%, .5% ... 39 timolol maleate soln .25%, .5% ................ 39 timolol maleate tabs 5mg, 10mg, 20mg ... 22 TIMOPTIC OCUDOSE SOLN .25%, .5% . 39 TIMOPTIC-XE SOLG .25%, .5% ............. 39 tinidazole tabs .......................................... 11 TIROSINT CAPS 13mcg, 25mcg, 50mcg,
75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg ................................................ 48
TIVICAY TABS 10mg, 25mg, 50mg ......... 13 TIVORBEX CAPS .................................... 27 tizanidine hcl caps ................................... 19 tizanidine hcl tabs .................................... 19 TOBI NEBU ............................................. 51 TOBI PODHALER CAPS ......................... 51 TOBRADEX OINT ................................... 39 TOBRADEX ST SUSP ............................. 39 tobramycin nebu ...................................... 51 tobramycin soln ....................................... 38 tobramycin sulfate soln injection 80mg/2ml,
10mg/ml ............................................... 10 tobramycin-dexamethasone susp ............ 39 TOBREX OINT ........................................ 38 tofranil tabs 10mg, 25mg, 50mg .............. 34 TOLAK CREA .......................................... 57 tolazamide tabs 250mg, 500mg ............... 45 tolbutamide tabs ...................................... 46 tolcapone tabs ......................................... 31
tolmetin sodium caps ............................... 27 tolmetin sodium tabs ................................ 27 TOLSURA CAPS ..................................... 11 tolterodine tartrate er cp24 2mg, 4mg ...... 57 tolterodine tartrate tabs ............................ 57 topicort crea .05%, .25% .......................... 56 topicort gel ............................................... 56 topicort oint .............................................. 56 topiramate cpsp 15mg, 25mg ................... 29 topiramate er cs24 25mg, 50mg, 100mg,
150mg, 200mg ..................................... 29 topiramate tabs 25mg, 50mg, 100mg,
200mg .................................................. 29 toremifene citrate tabs .............................. 17 torsemide tabs 5mg, 10mg, 20mg, 100mg
............................................................. 36 TOSYMRA SOLN..................................... 30 TOUJEO MAX SOLOSTAR SOPN .......... 46 TOUJEO SOLOSTAR SOPN ................... 46 tovet foam ................................................ 56 TOVIAZ TB24 4mg, 8mg .......................... 57 TPN ELECTROLYTES CONC
INTRAVENOUS ................................... 37 TRACLEER TABS 62.5mg, 125mg .......... 52 TRACLEER TBSO ................................... 52 TRADJENTA TABS .................................. 46 tramadol hcl er (biphasic) tb24 100mg,
200mg, 300mg ..................................... 27 tramadol hcl er cp24 100mg, 200mg,
300mg .................................................. 27 tramadol hcl er tb24 100mg, 200mg, 300mg
............................................................. 27 tramadol hcl tabs 50mg, 100mg ............... 27 tramadol-acetaminophen tabs .................. 27 trandolapril tabs 1mg, 2mg, 4mg .............. 24 trandolapril-verapamil hcl er tbcr .............. 23 tranexamic acid tabs ................................ 20 TRANSDERM-SCOP (1.5 MG) PT72 ....... 40 tranylcypromine sulfate tabs ..................... 34 TRAVASOL SOLN INTRAVENOUS......... 36 TRAVATAN Z SOLN ................................ 39 travoprost (bak free) soln ......................... 39 TRAZIMERA SOLR .................................. 17 trazodone hcl tabs .................................... 34 trazodone hcl tabs 50mg, 100mg, 150mg 34 TRECATOR TABS ................................... 11 TRELEGY ELLIPTA AEPB....................... 42 TRELSTAR MIXJECT SUSR ................... 17 TREMFYA SOPN ..................................... 57
94 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
TREMFYA SOSY .................................... 57 treprostinil soln 20mg/20ml, 50mg/20ml,
100mg/20ml, 200mg/20ml .................... 52 TRESIBA FLEXTOUCH SOPN 100unit/ml,
200unit/ml ............................................ 46 tretinoin caps ........................................... 17 tretinoin crea .025%, .05%, .1% ............... 56 tretinoin gel .01%, .025%, .05% .............. 56 tretinoin microsphere gel .04%, .1% ....... 56 tretinoin microsphere pump gel .04%, .1%
............................................................. 56 trexall tabs 5mg, 7.5mg, 10mg, 15mg ...... 17 trezix caps ............................................... 27 triamcinolone acetonide aers ................... 56 triamcinolone acetonide
crea .025%, .1%, .5% .......................... 56 triamcinolone acetonide lotn .025%, .1% . 56 triamcinolone acetonide
oint .025%, .05%, .1%, .5% .................. 56 triamcinolone acetonide pste ................... 56 triamterene caps 50mg, 100mg ............... 36 triamterene-hctz caps .............................. 36 triamterene-hctz tabs ............................... 36 trianex oint ............................................... 56 triazolam tabs .125mg, .25mg.................. 31 triderm crea ............................................. 56 trientine hcl caps ...................................... 41 tri-estarylla tabs ....................................... 44 trifluoperazine hcl tabs 1mg, 2mg, 5mg,
10mg .................................................... 34 trifluridine soln ......................................... 38 trihexyphenidyl hcl soln ............................ 31 trihexyphenidyl hcl tabs 2mg, 5mg ........... 31 TRIKAFTA TBPK ..................................... 51 tri-legest fe tabs ....................................... 44 tri-lo-estarylla tabs ................................... 44 tri-lo-sprintec tabs .................................... 44 trilyte solr ................................................. 41 trimethobenzamide hcl caps .................... 40 trimethoprim tabs ..................................... 14 tri-mili tabs ............................................... 44 trimipramine maleate caps 25mg, 50mg,
100mg .................................................. 34 TRINESSA (28) TABS ............................. 44 TRINTELLIX TABS 5mg, 10mg, 20mg .... 34 tri-previfem tabs ....................................... 44 TRIPTODUR SRER ................................. 46 TRISENOX SOLN ................................... 17 TRISENOX SOLN 10mg/10ml ................. 17
tri-sprintec tabs ........................................ 44 TRIUMEQ TABS ...................................... 13 trivora (28) tabs ........................................ 44 tri-vylibra lo tabs ....................................... 44 tri-vylibra tabs ........................................... 44 TRIZIVIR TABS ........................................ 13 TRODELVY SOLR ................................... 17 TROKENDI XR CP24 25mg, 50mg, 100mg,
200mg .................................................. 29 TROPHAMINE SOLN INTRAVENOUS .... 36 trospium chloride er cp24 ......................... 57 trospium chloride tabs .............................. 58 TRULANCE TABS ................................... 41 TRULICITY SOPN .75mg/0.5ml,
1.5mg/0.5ml.......................................... 46 TRUMENBA SUSY .................................. 53 TRUVADA TABS...................................... 13 TRUVADA TABS 200-300 MG ................. 13 TRUXIMA SOLN 100mg/10ml, 500mg/50ml
............................................................. 17 TUDORZA PRESSAIR AEPB .................. 18 TUKYSA TABS 50mg, 150mg .................. 17 TURALIO CAPS ....................................... 17 TWINRIX SUSY ....................................... 53 TYBOST TABS ........................................ 13 tydemy tabs .............................................. 44 TYKERB TABS ........................................ 17 tylenol with codeine #3 tabs ..................... 27 tylenol with codeine #4 tabs ..................... 27 TYMLOS SOPN ....................................... 47 TYPHIM VI SOLN .................................... 53 TYSABRI CONC INTRAVENOUS ........... 32 TYVASO REFILL SOLN ........................... 52 TYVASO SOLN ........................................ 52 TYVASO STARTER SOLN ...................... 52
U UBRELVY TABS 50mg, 100mg ............... 30 UCERIS FOAM ........................................ 56 UCERIS TB24 .......................................... 42 UDENYCA SOSY..................................... 21 ULORIC TABS 40mg, 80mg .................... 48 ULTOMIRIS SOLN ................................... 50 ULTRAVATE LOTN ................................. 56 UNITHROID TABS 25mcg, 50mcg, 75mcg,
88mcg, 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 300mcg ..... 48
UNITUXIN SOLN ..................................... 17
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 95
UPTRAVI TABS 200mcg, 400mcg, 600mcg, 800mcg, 1000mcg, 1200mcg, 1400mcg, 1600mcg .............................................. 52
UPTRAVI TBPK ....................................... 52 urecholine tabs 5mg, 10mg, 25mg, 50mg 19 ursodiol caps ........................................... 41 ursodiol tabs 250mg, 500mg.................... 41
V VABOMERE SOLR INTRAVENOUS ....... 10 valacyclovir hcl tabs 1gm, 500mg ............ 13 VALCHLOR GEL ..................................... 57 VALCYTE TABS ...................................... 13 valganciclovir hcl solr ............................... 13 valganciclovir hcl tabs .............................. 13 valproic acid caps .................................... 29 valproic acid soln ..................................... 29 valsartan tabs 40mg, 80mg, 160mg, 320mg
............................................................. 24 valsartan-hydrochlorothiazide tabs .......... 24 VALTOCO 10 MG DOSE LIQD ............... 29 VALTOCO 15 MG DOSE LQPK .............. 29 VALTOCO 20 MG DOSE LQPK .............. 29 VALTOCO 5 MG DOSE LIQD ................. 30 vanatol lq soln .......................................... 27 VANCOCIN CAPS ................................... 10 VANCOCIN HCL CAPS ........................... 10 vancomycin hcl caps ................................ 10 vancomycin hcl intravenous 750mg ......... 10 vancomycin hcl solr ................................. 10 vancomycin hcl solr intravenous 1gm,
10gm, 500mg ....................................... 10 VANCOMYCIN HCL SOLR INTRAVENOUS
250MG ................................................. 10 VANDAZOLE GEL ................................... 54 VANTAS KIT ............................................ 17 VAQTA SUSP .......................................... 53 VARIVAX INJ ........................................... 53 VARIZIG SOLN ....................................... 52 VARUBI (180 MG DOSE) TBPK .............. 40 VASCEPA CAPS .5gm, 1gm ................... 22 VAXCHORA SUSR.................................. 53 vecamyl tabs ............................................ 23 VECTICAL OINT ..................................... 57 VELCADE SOLR ..................................... 17 velivet tabs ............................................... 44 VELPHORO CHEW ................................. 36
VELTASSA PACK 8.4gm, 16.8gm, 25.2gm ............................................................. 36
VEMLIDY TABS ....................................... 13 VENCLEXTA STARTING PACK TBPK .... 17 VENCLEXTA TABS ................................. 18 VENCLEXTA TABS 10mg, 50mg ............. 18 venlafaxine hcl er cp24 37.5mg, 75mg,
150mg .................................................. 34 venlafaxine hcl er tb24 37.5mg, 75mg,
150mg, 225mg ..................................... 34 venlafaxine hcl tabs 25mg, 37.5mg, 50mg,
75mg, 100mg ....................................... 34 VENTAVIS SOLN 10mcg/ml, 20mcg/ml ... 52 VENTOLIN HFA AERS ............................ 19 VERAPAMIL HCL ER CP24 120mg,
180mg, 240mg, 100mg, 200mg, 300mg, 360mg .................................................. 23
verapamil hcl er tbcr 120mg, 180mg, 240mg ............................................................. 23
verapamil hcl tabs .................................... 23 verapamil hcl tabs 80mg, 120mg ............. 23 VEREGEN OINT ...................................... 57 VERELAN CP24 ...................................... 23 veripred 20 soln ....................................... 42 VERSACLOZ SUSP ................................. 34 VERZENIO TABS 50mg, 100mg, 150mg,
200mg .................................................. 18 VFEND SUSR .......................................... 11 VFEND TABS 50mg, 200mg .................... 11 VIBERZI TABS 75mg, 100mg .................. 41 VIBRAMYCIN SYRP ................................ 10 vicodin es tabs ......................................... 27 vicodin hp tabs ......................................... 27 vicodin tabs .............................................. 27 VICTOZA SOPN ...................................... 46 VIDEX EC CPDR 125mg, 200mg, 250mg,
400mg .................................................. 13 VIDEX SOLR 2gm, 4gm ........................... 13 VIEKIRA PAK TBPK ................................ 13 VIEKIRA XR TB24 ................................... 13 vienva tabs ............................................... 44 vigabatrin pack ......................................... 30 vigabatrin tabs .......................................... 30 vigadrone pack ......................................... 30 VIIBRYD STARTER PACK KIT ................ 34 VIIBRYD TABS 10mg, 20mg, 40mg ......... 34 VIMIZIM SOLN ......................................... 37 VIMOVO TBEC ........................................ 27 VIMPAT SOLN ......................................... 30
96 • Kaiser Permanente 2020 Defined Standard Comprehensive Formulary
VIMPAT TABS ......................................... 30 VIOKACE TABS ...................................... 37 VIRACEPT TABS 250mg, 625mg ............ 13 VIRAMUNE SUSP ................................... 13 VIRAMUNE TABS ................................... 13 VIRAMUNE XR TB24 100mg, 400mg...... 13 VIREAD POWD ....................................... 13 VIREAD TABS 150mg ............................. 13 VIREAD TABS 200mg, 250mg, 300mg ... 14 VISTOGARD PACK ................................. 48 VITRAKVI CAPS 25mg, 100mg ............... 18 VITRAKVI SOLN ..................................... 18 VIVITROL SUSR ..................................... 32 VIVLODEX CAPS .................................... 27 VIZIMPRO TABS 15mg, 30mg, 45mg ..... 18 VORAXAZE SOLR .................................. 48 voriconazole solr intravenous .................. 11 voriconazole susr ..................................... 11 voriconazole tabs ..................................... 11 VOSEVI TABS ......................................... 14 VOTRIENT TABS .................................... 18 VP-PNV-DHA CAPS ................................ 58 VPRIV SOLR ........................................... 37 VRAYLAR CAPS 1.5mg, 3mg, 4.5mg, 6mg
............................................................. 34 VRAYLAR CPPK ..................................... 35 VUMERITY (STARTER) CPDR ............... 50 VUMERITY CPDR ................................... 50 vyfemla tabs ............................................ 44 vylibra tabs .............................................. 44 VYNDAMAX CAPS .................................. 23 VYNDAQEL CAPS .................................. 23 VYONDYS 53 SOLN ............................... 50 VYVANSE CAPS 10mg, 20mg, 30mg,
40mg, 50mg, 60mg, 70mg ................... 28 VYVANSE CHEW 10mg, 20mg, 30mg,
40mg, 50mg, 60mg .............................. 28 VYXEOS SUSR ....................................... 18 VYZULTA SOLN ...................................... 39
W WAKIX TABS 4.45mg, 17.8mg ................ 28 warfarin sodium tabs 1mg, 2mg, 2.5mg,
3mg, 4mg, 5mg, 6mg, 10mg ................ 20 wixela inhub aepb .................................... 19 wymzya fe chew ...................................... 44
X XALKORI CAPS 200mg, 250mg .............. 18 XARELTO STARTER PACK TBPK .......... 20 XARELTO TABS 2.5mg, 10mg, 15mg,
20mg .................................................... 20 XATMEP SOLN ....................................... 18 XCOPRI (250 MG DAILY DOSE) TBPK ... 30 XCOPRI (350 MG DAILY DOSE) TBPK ... 30 XCOPRI TABS 50mg, 100mg, 150mg,
200mg .................................................. 30 XCOPRI TBPK ......................................... 30 XELJANZ TABS 5mg, 10mg .................... 49 XELJANZ XR TB24 11mg, 22mg ............. 49 XELPROS EMUL ..................................... 39 XEMBIFY SOLN SUBCUTANEOUS
2gm/10ml, 4gm/20ml, 10gm/50ml, 1gm/5ml ............................................... 52
XENAZINE TABS 12.5mg, 25mg ............. 31 XENLETA SOLN ...................................... 10 XENLETA TABS ...................................... 10 XEOMIN SOLR ........................................ 50 XEOMIN SOLR 50unit, 100unit ................ 50 XEPI CREA .............................................. 54 XERESE CREA ....................................... 54 XERMELO TABS ..................................... 40 XGEVA SOLN .......................................... 48 XHANCE EXHU ....................................... 39 XIFAXAN TABS 200mg, 550mg ............... 10 XIGDUO XR TB24 ................................... 46 XIIDRA SOLN .......................................... 39 XIMINO CP24 45mg, 90mg, 135mg ......... 57 XOFLUZA (40 MG DOSE) TBPK ............. 14 XOFLUZA (80 MG DOSE) TBPK ............. 14 XOLAIR SOLR ......................................... 51 XOLAIR SOSY 75mg/0.5ml, 150mg/ml .... 51 XOSPATA TABS ...................................... 18 XPOVIO (100 MG ONCE WEEKLY) TBPK
............................................................. 18 XPOVIO (60 MG ONCE WEEKLY) TBPK 18 XPOVIO (80 MG ONCE WEEKLY) TBPK 18 XPOVIO (80 MG TWICE WEEKLY) TBPK
............................................................. 18 XTAMPZA ER C12A 9mg, 13.5mg, 18mg,
27mg, 36mg ......................................... 27 XTANDI CAPS ......................................... 18 xulane ptwk .............................................. 44 XULTOPHY SOPN ................................... 46 XURIDEN PACK ...................................... 50
Kaiser Permanente 2020 Defined Standard Comprehensive Formulary • 97
XYOSTED SOAJ 50mg/0.5ml, 75mg/0.5ml, 100mg/0.5ml ........................................ 42
XYREM SOLN ......................................... 32
Y YERVOY SOLN ....................................... 18 YF-VAX INJ ............................................. 53 YONDELIS SOLR .................................... 18 YONSA TABS .......................................... 18 YUPELRI SOLN ...................................... 18 yuvafem tabs ........................................... 46
Z zafirlukast tabs 10mg, 20mg .................... 51 zaleplon caps 5mg, 10mg ........................ 31 ZALTRAP SOLN 100mg/4ml, 200mg/8ml 18 zarah tabs ................................................ 44 zarontin soln ............................................ 30 ZARXIO SOSY 300mcg/0.5ml,
480mcg/0.8ml ...................................... 21 ZAVESCA CAPS ..................................... 37 zebutal caps ............................................ 27 ZEJULA CAPS ........................................ 18 ZELAPAR TBDP ...................................... 31 ZELBORAF TABS ................................... 18 ZEMAIRA SOLR INTRAVENOUS ........... 51 ZEMBRACE SYMTOUCH SOAJ ............. 30 ZEMDRI SOLN INTRAVENOUS ............. 10 zenatane caps 10mg, 20mg, 30mg, 40mg
............................................................. 57 ZENPEP CPEP ....................................... 37 zenzedi tabs 2.5mg, 5mg, 7.5mg, 10mg,
15mg, 20mg, 30mg .............................. 28 ZEPATIER TABS ..................................... 14 ZERBAXA SOLR INTRAVENOUS .......... 10 ZERIT CAPS 15mg, 20mg, 30mg, 40mg . 14 ZETONNA AERS ..................................... 39 ZIAGEN SOLN ........................................ 14 ZIAGEN TABS ......................................... 14 zidovudine caps ....................................... 14 zidovudine syrp ........................................ 14 zidovudine tabs ........................................ 14 ZIEXTENZO SOSY.................................. 21
zileuton er tb12 ........................................ 51 ZINBRYTA SOSY .................................... 32 ZIOPTAN SOLN ....................................... 39 ziprasidone hcl caps 20mg, 40mg, 60mg,
80mg .................................................... 35 ZIPSOR CAPS ......................................... 27 ZIRABEV SOLN 400mg/16ml, 100mg/4ml
............................................................. 18 ZIRGAN GEL ........................................... 38 ZITHROMAX PACK ................................. 10 ZOLINZA CAPS ....................................... 18 zolmitriptan tabs ....................................... 30 zolmitriptan tbdp ....................................... 30 zolpidem tartrate er tbcr 6.25mg, 12.5mg . 31 zolpidem tartrate subl 1.75mg, 3.5mg ...... 31 zolpidem tartrate tabs 5mg, 10mg ............ 31 ZOMACTON SOLR .................................. 47 ZOMACTON SOLR 5mg .......................... 47 ZOMIG SOLN .......................................... 30 zonisamide caps 25mg, 50mg, 100mg ..... 30 ZONTIVITY TABS .................................... 20 ZORBTIVE SOLR .................................... 47 ZORTRESS TABS .25mg ........................ 49 ZORTRESS TABS .5mg, .75mg, 1mg ...... 49 ZORVOLEX CAPS ................................... 27 ZOSTAVAX SUSR ................................... 53 ZOSYN SOLN INTRAVENOUS ............... 10 zovia 1/35e (28) tabs ................................ 44 ZUBSOLV SUBL ...................................... 32 ZUPLENZ FILM 4mg, 8mg ....................... 40 ZYCLARA PUMP CREA .......................... 57 ZYDELIG TABS 100mg, 150mg ............... 18 ZYFLO CR TB12 ...................................... 51 ZYFLO TABS ........................................... 51 ZYKADIA CAPS ....................................... 18 ZYKADIA TABS ....................................... 18 ZYLET SUSP ........................................... 39 ZYPITAMAG TABS 1mg, 2mg, 4mg ........ 22 ZYPREXA RELPREVV SUSR ................. 35 ZYTIGA TABS 250mg, 500mg ................. 18 ZYVOX SOLN INTRAVENOUS
200mg/100ml, 600mg/300ml ................ 10 ZYVOX SUSR .......................................... 10 ZYVOX TABS .......................................... 10
60899008
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente 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 Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., seven days a week.
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
60897108 CA
Multi-language Interpreter Services English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-443-0815 (TTY: 711).
Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-443-0815 (TTY: 711).
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Farsi ی م فراھم شمای برا گانیرا بصورتی زبان التیتسھ د،یکنی م گفتگو فارسی زبان بھ اگر: توجھ .دیریبگ تماس (TTY: 711) 0815-443-800-1 با. باشد
Arabic - ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم
).711- ھاتف الصم والبكم:(رقم 1-800-443-0815
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente 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: ♦ ����� 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: ♦ ����� interpreters. ♦ Information written in other languages.
If you need these services, call Member Services at 1-800-476-2167 (TTY 711),8 a.m. to 8 p.m., seven days a week.
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can �� a grievance with our Civil Rights Coordinator by writing to 2500 South Havana, Aurora, CO 80014 or calling Member Services at the number listed above. You can �� a grievance by mail or phone. If you need help ��� a grievance, our Civil Rights Coordinator is available to help you. You can also �� a civil rights complaint with the U.S. Department of Health and Human Services, ��� for Civil Rights electronically through the ��� for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www�����������������.
61102709_CO
Multi-language Interpreter Services
English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-476-2167 (TTY: 711).
Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-476-2167 (TTY: 711).
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 1-800-476-2167 (TTY:711)。
Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-476-2167 (TTY: 711).
Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-476-2167 (TTY: 711).
Korean
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-800-476-2167 (TTY: 711)번으로 전화해 주십시오.
Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-476-2167 (телетайп: 711).
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。1-800-476-2167(TTY:711)まで、お電話にてご連絡ください。
Amharic ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-476-2167 (መስማት ለተሳናቸው: 711).
German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-476-2167 (TTY: 711).
French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-476-2167 (ATS : 711).
Farsi
ی م فراھم شمای برا گانیرا بصورتی زبان التیتسھ د،یکنی م گفتگو فارسی زبان بھ اگر: توجھ . دیریبگ تماس (TTY: 711) 2167-476-800-1 با. باشد
Arabic
ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم ).117- (رقم ھاتف الصم والبكم: 7612-674-008-1
Yoruba AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-800-476-2167 (TTY: 711).
Cushite-Oromo XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-476-2167 (TTY: 711).
Nepali
ध्यान िदनहुोस:् तपाइ�ले नेपाली बोल्नहु�न्छ भने तपाइ�को िनिम्त भाषा सहायता सेवाह� िनःशलु्क �पमा उपलब्ध छ । फोन गनुर्होस ्1-800-476-2167 (िटिटवाइ: 711) ।
KAH2711
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente 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 communicateeffectively 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 Member Services at 1-800-805-2739 (TTY 711), 8 a.m. to 8 p.m., seven days a week.
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to 711 Kapiolani Blvd, Honolulu, HI 96813 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.
H1230_2017MLI accepted
Multi-language Interpreter Services English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-805-2739 (TTY: 711).
Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-805-2739 (TTY: 711).
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 1-800-805-2739 (TTY:711)。
Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-805-2739 (TTY: 711).
Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-805-2739 (TTY: 711).
Korean
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-800-805-2739 (TTY: 711)번으로 전화해 주십시오.
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。1-800-805-2739(TTY:711)まで、お電話にてご連絡ください。
Lao
ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫືຼອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-805-2739 (TTY: 711).
Ilocano PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti 1-800-805-2739 (TTY: 711).
Samoan MO LOU SILAFIA: Afai e te tautala Gagana fa'a Sāmoa, o loo iai auaunaga fesoasoan, e fai fua e leai se totogi, mo oe, Telefoni mai: 1-800-805-2739 (TTY: 711).
Marshallese LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1-800-805-2739 (TTY: 711)
Trukese MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe angei aninisin chiakku, ese kamo. Kori 1-800-805-2739 (TTY: 711).
Hawaiian E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻōlelo hoʻokomo ʻōlelo, loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā 1-800-805-2739 (TTY: 711).
Pohnpeian Ni songen mwohmw ohte, komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie Lokaiahn Pohnpei komw kalangan oh ntingidieng ni lokaiahn Pohnpei. Call 1-800-805-2739 (TTY: 711).
Bisayan ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe, nga walay bayad. Tawag sa 1-800-805-2739 (TTY: 711).
Tongan FAKATOKANGA’I: Kapau ‘oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia. Telefoni mai 1-800-805-2739 (TTY: 711).
Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente 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 Member Services at 1-888-777-5536 (TTY 711), 8 a.m. to 8 p.m., seven days a week.
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to 2101 East Jefferson Street, Rockville, MD 20852 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. 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.
61102310
Multi-language Interpreter Services
English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-777-5536 (TTY: 711).
Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-777-5536 (TTY: 711).
Chinese 1-888-777-5536
TTY 711
Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-777-5536 (TTY: 711).
Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-777-5536 (TTY: 711).
Korean : , .
1-888-777-5536 (TTY: 711) .
Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-777-5536 (телетайп: 711).
Japanese
1-888-777-5536 TTY:711
Thai 1-888-777-5536 (TTY: 711).
Hindi :
1-888-777-5536 (TTY: 711)
Amharic : 1-888-777-5536 ( : 711).
'
Farsi رایگ ان برای شما فراھم می : اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت
باشد. با (TTY: 711) 5536-777-888-1 تماس بگیری Arabic
: إذا كنت تتحدث اذكر اللغة، فإن خدم ملحوظة ت المساعدة اللغویة تتوافر لك بالم ا ن . اتصل برقم جا 5536-777-888-1 (رقم ھاتف الصم والبكم : -711).
German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-777-5536 (TTY: 711).
French ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le 1-888-777-5536 (ATS : 711).
Yoruba AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-888-777-5536 (TTY: 711).
Portuguese ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-777-5536 (TTY: 711).
Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-888-777-5536 (TTY: 711).
Bengali , ,
1-888-777-5536 (TTY: 711)
Urdu خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں
1-888-777-5536 (TTY: 711). French Creole ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-888-777-5536 (TTY: 711).
Gujarati . : , :
1-888-777-5536 (TTY: 711).
329401316 07/2020
This formulary was updated on 07/01/20. For more recent information or other questions, please contact the number for your Kaiser Permanente Region listed below, seven days a week, 8 a.m. to 8 p.m., or visit kp.org/seniorrx.
Kaiser Permanente Regions
CALIFORNIA REGIONS Kaiser Foundation Health Plan, Inc. 393 E. Walnut St. Pasadena, CA 91188-8514 Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) and Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
Member Service Contact Center 1-800-443-0815 TTY 711
COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E. Dakota Ave. Denver, CO 80247 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-476-2167 TTY 711
kp.org/seniorrx Please recycle.
HAWAII REGION Kaiser Foundation Health Plan, Inc. 711 Kapiolani Blvd. Tower Suite 400 Honolulu, HI 96813 Kaiser Permanente Senior Advantage Medicare Medicaid plan (HMO D-SNP)
Member Services 1-800-805-2739 TTY 711
MID-ATLANTIC STATES REGION (District of Columbia, Maryland, and Virginia) Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 2101 East Jefferson St. Rockville, MD 20852 Kaiser Permanente Medicare Plus (Cost) Basic w/D (AB) and Basic w/D (B) plan
Member Services 1-888-777-5536 TTY 711