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Last updated: August 3, 2011 KAISER PERMANENTE HMO FORMULARY Prescription Drug List 2011

KAISER PERMANENTE HMO FORMULARY - Community …providers.kaiserpermanente.org/info_assets/cpp_mas/mid_commercial... · KAISER PERMANENTE HMO FOrMulary ... ANTIHISTAMINE DRUGS

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Page 1: KAISER PERMANENTE HMO FORMULARY - Community …providers.kaiserpermanente.org/info_assets/cpp_mas/mid_commercial... · KAISER PERMANENTE HMO FOrMulary ... ANTIHISTAMINE DRUGS

last updated: august 3, 2011

KAISER PERMANENTE

HMO FOrMulary Prescription Drug List 2011

Page 2: KAISER PERMANENTE HMO FORMULARY - Community …providers.kaiserpermanente.org/info_assets/cpp_mas/mid_commercial... · KAISER PERMANENTE HMO FOrMulary ... ANTIHISTAMINE DRUGS

The following list contains the drugs covered on the Health Plan’s Commercial Drug Formulary. It is approved by the Kaiser Permanente Mid-Atlantic States Pharmacy and Therapeutics Committee.

This formulary applies only to outpatient drugs and self-administered drugs. It does not apply to medications used in inpatient settings or administered in one of the Kaiser Permanente medical centers.

Many members have specific exclusions, copays, or coinsurance amounts that are not reflected in the formulary. Please consult your Evidence of Coverage for additional information regarding your pharmacy benefits, including any specific limitations or exclusions.

Generic, brand name, and non-formulary medications Kaiser Permanente covers generic and brand name drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. In most cases, your doctor will prescribe a generic drug if one is available. Generic drugs generally cost less than brand name drugs.

Brand name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand name drug expires, other pharmaceutical companies may then manufacture and sell the FDA-approved generic version of the drug at lower prices.

Generally, Kaiser Permanente will only approve your request for a non-formulary drug if your prescribing physician considers that drug to be medically necessary. If a non-formulary drug is not medically necessary but you decide nonetheless that you want the non-formulary drug, you will be responsible for paying the full cost share of that medication.

Using the Kaiser Permanente Commercial formulary When you look through the formulary listing, you will see that products available in a generic form are listed by their generic names. Medications that are only available as a brand name product are listed in bold ANd All CAPITAl letters, except where multiple branded products exist.

You can search the formulary by using the index, the “FIND” function in Adobe Reader, or by referencing the therapeutic drug category.

In some cases, a particular drug may be listed in the formulary, but only for certain strengths or in certain dosage forms. For example, some drugs are available in different milligram (mg) strengths (e.g., 5mg, 10mg), but only one strength may be on the formulary. For drugs that are available in more than one dosage form (e.g., tablet, injectable), only one may be on the formulary.

Please remember that this list is subject to change and will be updated from time to time during the year. Any product not found on this list will be considered a non-formulary drug.

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Restrictions on medication coverage Some covered drugs may have additional requirements or limits on coverage, including but not limited to:

• Higher Copay: Some drugs may have a higher cost share. These drugs include, but are not limited to, infertility, growth hormone, and weight management medications.

• Limited Distribution: Some drugs may be subject to limited distribution or restricted access. A drug that is a limited distribution drug may only be available at one or a limited number of pharmacies.

• Oral Chemotherapy Drugs: Drugs that fall under the District of Columbia Oral Chemotherapy Parity Act. Cost shares for these drugs may be different for employer group plans not based in Washington, D.C.

• Quantity Limit: For certain drugs, Kaiser Permanente limits the amount of medication dispensed to a certain quantity per copay.

• Restricted to Benefit: Some drugs are not covered unless your benefits specifically cover such medications. For example, Viagra® and other drugs for sexual dysfunction are not covered unless specifically included under the member’s Evidence of Coverage.

Key: HC = A drug that may have a higher copay.

ld = A drug that may be subject to limited distribution.

oC = A drug included under the District of Columbia Oral Chemotherapy Parity Act.

Ql = A drug that has a quantity limit or is limited to a specific day supply.

Rb = A drug that is restricted to a certain benefit for coverage.

For more information about the Kaiser Permanente Commercial Drug Formulary, you may contact Member Services at 301-468-6000 or 1-800-777-7902 (TTY 301-879-6380). Representatives are available Monday through Friday, 7:30 a.m. until 5:30 p.m.

11345_RxFormularyIntro_A_pdf 8/10/11–8/10/13

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

ANTIHISTAMINE DRUGS

Cyproheptadine HCl

Promethazine HCL

ANTI-INFECTIVE AGENTS

Anthelmintics

Mebendazole

YODOXIN

Antibacterials

Amoxicillin

Amoxicillin & Pot Clavulanate

Ampicillin

AVELOX

Azithromycin

Cefaclor

Cefdinir

Cefuroxime Axetil

Cephalexin

Ciprofloxacin

Clarithromycin

Clindamycin

Clindamycin Palmitate HCL

Dicloxacillin Sodium

Doxycycline Hyclate

Doxycycline Monohydrate

ERYPED SUSP

Erythromycin Base

Erythromycin Ethylsuccinate

Erythromycin-Sulfisoxazole

Levofloxacin

Minocycline HCL

Neomycin Sulfate

DRUG NAME REQUIREMENTS AND LIMITS

Penicillin V Potassium

Sulfadiazine

Sulfasalazine

Sulfamethoxazole-Trimethoprim

SUPRAX

Tetracycline HCL

TOBI NEB

VANOCIN

XIFAXAN

ZYVOX

Antifungals

Fluconazole

Griseofulvin Microsize

Griseofulvin Ultramicrosize

Itraconazole

Ketoconazole

Nystatin

Terbinafine

Voriconazole

Antimycobacterials

DAPSONE

Ethambutol HCL

Isoniazid

MYCOBUTIN

Pyrazinamide

Rifabutin

Rifampin

TRECATOR

Antiprotozoals

COARTEM

Chloroquine Phosphate

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

DARAPRIM

Hydroxychloroquine Sulfate

Mefloquine HCL

MEPRON

Metronidazole

NEBUPENT INH

Primaquine Phosphate

Antivirals

Amantadine HCL

APTIVUS

ATRIPLA

BARACLUDE

COMBIVIR

CRIXIVAN

Didanosine

EDURANT

EMTRIVA

EPIVIR

EPZICOM

FUZEON

Ganciclovir

HEPSERA

INTELENCE

INVIRASE

ISENTRESS

KALETRA

LEXIVA

NORVIR

PEGASYS QL

PEG-INTRON QL

PREZISTA

RESCRIPTOR

DRUG NAME REQUIREMENTS AND LIMITS

REYATAZ

Ribavirin

Rimantadine HCL

SELZENTRY

SUSTIVA

TAMIFLU QL

TRIZIVIR

TRUVADA

VALCYTE

VIRACEPT

VIRAMUNE

VIRAMUNE XR

VIREAD

ZIAGEN

Zidovudine

Urinary Anti-Infectives

Methenamine Hippurate

Nitrofurantoin

Nitrofurantoin Monohyd Macro

Nitrofurantoin Macrocrystals

Trimethoprim

ANTINEOPLASTIC AGENTS

Antineoplastic Agents

AFINITOR OC

ALKERAN OC

Anastrozole OC

AROMASIN OC

Bicalutamide OC

CEENU OC

Cyclophosphamide OC

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

EMCYT OC

Etoposide OC

FEMARA OC

Flutamide OC

GLEEVEC OC

HEXALEN OC

HYCAMTIN OC

Hydroxyurea OC

INTRON-A QL

LEUKERAN OC

LUPRON QL

LYSODREN OC

Megestrol Acetate OC

Mercaptopurine OC

Methotrexate Sodium

MYLERAN OC

NEXAVAR OC

Procarbazine HCL OC

SPRYCEL OC

SUTENT OC

TABLOID OC

Tamoxifen Citrate OC

TARCEVA OC

TARGRETIN OC

TASIGNA OC

TEMODAR OC

Tretinoin (Chemotherapy) OC

TYKERB OC

VANDETANIB OC

VOTRIENT OC

XELODA OC

ZYTIGA OC

DRUG NAME REQUIREMENTS AND LIMITS

ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

Barbiturates

Mephobarbital

Phenobarbital

Benzodiazepines

Alprazolam

Chlordiazepoxide HCL

Clonazepam

Clorazepate Dipotassium

Diazepam

Lorazepam

Oxazepam

Temazepam

AUTONOMIC DRUGS

Anticholinergic Agents

ATROVENT HFA

Benztropine Mesylate

Dicyclomine HCL

Hyoscyamine

Ipratropium Bromide (Nasal)

Trihexyphenidyl HCL

SPIRIVA

Autonomic Drugs, Miscellaneous

DIBENZYLINE

Ergoloid Mesylates

Nicotrol Inhaler HC

Parasympathomimetic (Cholinergic) Agents

Bethanechol Chloride

Donepezil HCL

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

Galantamine Hydrobromide

Neostigmine Bromide

Pilocarpine HCL (ORAL)

Pyridostigmine Bromide

Skeletal Muscle Relaxants

Baclofen

Cyclobenzaprine HCL

Dantrolene Sodium

Methocarbomol

Sympathomimetic (Adrenergic) Agents

ADVAIR DISKUS

Albuterol Neb

COMBIVENT AER

Epinephrine HCl

EPIPEN

Midodrine HCL

PROAIR HFA

SEREVENT DISKUS AER

Terbutaline Sulfate

BLOOD FORMATION, COAGULATION, AND THROMBOSIS

Coagulants And Anticoagulants

AGGRENOX

Anagrelide HCL

Aminocaproic Acid

Cilostazol

Dipyridamole

EFFIENT

Fondaparinux QL

LOVENOX QL

Pentoxifylline

DRUG NAME REQUIREMENTS AND LIMITS

PLAVIX

Warfarin Sodium

Hematopoietic Agents

NEUPOGEN QL

PROCRIT/EPOGEN QL

PROMACTA

CARDIOVASCULAR DRUGS

Alpha-Adrenergic Blocking Agents

Doxazosin Mesylate

Terazosin HCL

Prazosin HCL

Tamsulosin HCL

Antilipemic Agents

Cholestryramine Light

Fenofibrate 54mg, 160mg

Gemfibrozil

LIPITOR 80mg

Lovastatin

Niacin

Pravastatin Sodium 20mg, 40mg, 80mg

Simvastatin 20mg, 40mg, 80mg

VYTORIN 40/10mg, 80/10mg

Beta-Adrenergic Blocking Agents

Acebutolol HCL

Atenolol/Chlorthalidone

Atenolol HCL

Bisoprolol/ Hydrochlorothiazide

Bisoprolol Fumarate

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

Carvedilol

Labetalol HCL

Metoprolol Succinate

Metoprolol Tartrate

Nadolol

Propranolol HCL

Sotalol HCL

Timolol Maleate

Calcium-Channel Blocking Agents

Amlodipine Besylate

Diltiazem HCL

Nifedipine

Verapamil HCL

Cardiac Drugs

Amiodarone HCL

Digoxin

Disopyramide Phosphate

Flecainide Acetate

Mexiletine HCL

Propafenone HCL

Quinidine Gluconate

QUINIDEX/QUINIDEX ER

TIKOSYN

Hypotensive Agents

Acetazolamide

Clonidine HCL

Guanfacine HCL

Hydralazine HCL

Methazolamide

Methyldopa

Minoxidil

DRUG NAME REQUIREMENTS AND LIMITS

Reserpine

Renin-Angiotensin-Aldosterone System Inhibitors

Captopril

Enalapril Maleate

Lisinopril

Lisinopril/Hydrochlorothiazide

Losartan Potassium

Losartan Potassium/HCTZ

Spironolactone

Spironolactone/ Hydrochlorothiazide

Vasodilating Agents

ADCIRCA

Isosorbide Dinitrate

Isosorbide Mononitrate

Nitroglycerin Patch

Nitroglycerin

NITROSTAT SL

Papaverine HCL

REVATIO

CENTRAL NERVOUS SYSTEM AGENTS

Analgesics and Antipyretics

Acetaminophen/Codeine

Butalbital/Acetaminophen/ Caffeine

Butalbital/Aspirin/Caffeine

Choline/Mag Salicylate

Codeine Phosphate

Codeine Sulfate

Diclofenac Sodium

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

Etodolac

Fentanyl

Hydrocodone/ Acetaminophen

Hydromorphone HCL

Ibuprofen

Indomethacin

Ketoprofen

Mefenamic Acid

Meloxicam

Meperidine HCL

Methadone HCL

Morphine Sulfate

Nabumetone

Naproxen

Oxycodone HCL

Oxycodone/Acetaminophen

SUBOXONE

Salsalate

Sulindac

Tramadol HCL

Anorexigenic Agents and Respiratory and Cerebral Stimulants

ADDERALL XR

Amphetamine/ Detroamphetamine (Mixed)

CONCERTA

Dextroamphetamine Sulfate

METADATE CD

Methylphenidate HCL

Methylphenidate HCL ER

DRUG NAME REQUIREMENTS AND LIMITS

Phentermine HC

Anticonvulsants

BANZEL

Carbamazepine

Carbamazepine ER

Diazepam (Anticonvulsant)

Divalproex Sodium

Ethosuximide

Gabapentin

Lamotrigine

Levetiracetam

Methsuximide

Oxcarbazepine

Phenobarbital

Phenytoin Sodium

Primidone

Topiramate

Valproate Sodium

Valproate Acid

Antimigraine Agents

Belladonna Alkaloids/ Phenobarbital

Ergotamine/Caffeine

Naratriptan HCL QL

Sumatriptan QL

Anxiolytics, Sedatives, and Hypnotics

Buspirone HCL

Hydroxyzine HCL

Hydroxyzine Pamoate

Zolpidem Tartrate QL

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

Central Nervous System Agents, Miscellaneous

Carbidopa/Levodopa, ER

COMTAN

LODOSYN

NAMENDA

Pramipexole Dihydrochloride

RILUTEK

Ropinirole HCL

Selegiline

Opiate Antagonists

Naltrexone HCL

Psychotherapeutic Agents

Amitriptyline HCL

Bupropion HCL, SR, XL

Chlorpromazine HCL

Citalopram HCL

Clomipramine HCL

Clozapine

Desipramine HCL

Doxepine HCL

Fluoxetine HCL

Fluphenazine HCL

Fluvoxamine Maleate

Haloperidol

Imipramine HCL

Lithium Carbonate

Lithium Citrate

DRUG NAME REQUIREMENTS AND LIMITS

Maprotiline HCL

Mirtazapine

Nefazodone HCL

Nortriptyline HCL

ORAP

Paroxetine HCL

Perphenazine

Phenelzine Sulfate

Prochlorperazine Maleate

Protriptyline HCL

Risperidone

SEROQUEL

Sertraline HCL

Thioridazine HCL

Thiothixene

Trazodone HCL

Trifluoperazine HCL

Venlafaxine HCL

ZYPREXA

ELECTROLYTIC, CALORIC, AND WATER BALANCE

Acidifying and Alkalinizing Agents

Potassium & Sodium Acid Phosphates

Potassium Citrate (Alkalinizer)

Sodium Citrate & Citric Acid

Ammonia Detoxicants

Lactulose

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

Diuretics

Amiloride/ Hydrochlorothazide

Amiloride HCL

Bumetanide

Chlorothiazide

Chlorthalidone

Furosemide

Hydrochlorothiazide

Indapamide

Metolazone

Triamterene/ Hydrochlorothiazide

Ion-Removing Agents

RENVELA

Sodium Polystyrene Sulfonate

Replacement Preparations

ELIPHOS

PHOSLO

Potassium Phosphate Dibasic/Monobasic

Potassium Bicarbonate

Potassium Chloride

Potassium Phosphate Monobasic

Uricosuric Agents

Probenecid

ENZYMES

Enzymes

PULMOZYME SOL

VPRIV

DRUG NAME REQUIREMENTS AND LIMITS

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

Antiallergic Agents

Cromolyn Sodium (OP)

Anti-Infectives

Bacitracin (OP)

Bacitracin/Polymyxin B (OP)

Ciprofloxacin (OP)

Erythromycin (OP)

Gentamicin Sulfate (OP)

NATACYN

Neomycin/Bacitracin/ Polymyxin

Neomycin/Polymyxin/ Gramicid

Ofloxacin (OP)

Ofloxacin (OTIC)

Polymyxin B/Trimethoprim

Tobramycin Sulfate (OP)

Trifluridine

ZYMAR

Anti-Inflammatory Agents

Bacitracin/Polymyxin/ Neomycin/HC

CIPRODEX OTIC

COLY-MYCIN S OTIC

DEXASOL OP

Flunisolide

Fluorometholone (OP)

Fluticasone Propionate

Ketorolac Tromethamine

LOTEMAX

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

Neomycin/Polymyxin/ Dexameth

Neomycin/Polymyxin/HC

OCUFEN

PRED-G

Prednisolone Acetate

Prednisolone Sodium Phosphate

Sulfacetamide Sodium/ Prednisolone

Tobramycin/Dexamethasone

EENT Drugs, Miscellaneous

Acetic Acid (OTIC)

Acetic Acid/Aluminum Acetate

Brimonidine Tartrate

Carbachol (OP)

Dorzolamide

Dorzolamide/Timolol

Latanoprost

Levobunolol HCL

LUMIGAN

Metipranolol

Local Anesthetics

Benzocaine/Antipyrine

Lidocaine HCL

Proparacaine HCL

Tetracaine HCL

Mydriatics

Atropine Sulfate

DRUG NAME REQUIREMENTS AND LIMITS

CYCLOMYDRIL

Homatropine HBR

Tropicamide

Vasoconstrictors

Phenylephrine HCL (OP)

GASTROINTESTINAL DRUGS

Antidiarrhea Agents

Diphenoxylate/Atropine

Antiemetics

EMEND

Ondansetron HCL

Prochlorperazine

TRANSDERM-SCOP

Anti-Inflammatory Agents

ASACOL

CANASA

COLAZAL

PENTASA

ROWASA ENEMA

Antiulcer Agents and Acid Suppressants

Famotidine

Misoprostol

Omeprazole

Pantoprazole

Ranitidine HCL

Sucralfate

Digestants

ZENPEP

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

GI Drugs, Miscellaneous

Metoclopramide HCL

PEG 3350-KCL-Sodium Bicarb-Sodium Chloride-Sodium Sulfate

Urosodiol

Gold Compounds

RIDAURA

HEAVY METAL ANTAGONISTS

Heavy Metal Antagonists

EXJADE

HORMONES AND SYNTHETIC SUBSTITUTES

Adrenals

ASMANEX

Budesonide (Inhalation)

Cortisone Acetate

Dexamethasone

ENTOCORT EC

FLOVENT HFA

Fludrocortisone Acetate

Hydrocortisone

Methlyprednisolone

MILLIPRED

Prednisolone

Prednisolone Sodium Phosphate

Prednisone

QVAR

Androgens

Danocrine

DRUG NAME REQUIREMENTS AND LIMITS

Contraceptives

Desogestrel/Ethinyl Estradiol

Drospirenone/Ethinyl Estradiol

ELLA

Ethynodiol Diacetate/Ethinyl Estradiol

Levonorgestrel/Ethinyl Estradiol

Levonorgestrel/Ethinyl Estradiol (Triphasic)

Norethindrone

Norethindrone/Ethinyl Estradiol

Norethindrone Acetate/ Ethinyl Estradiol

Norethindrone/Ethinyl Estradiol (Triphasic)

PLAN B ONE-STEP

Diabetic Agents

Acarbose

ACTOS

Glipizide

GLUCAGON EMERGENCY KIT

LANTUS

Metformin HCL

Metformin ER

NOVOLIN 70/30

NOVOLIN N

NOVOLIN R

NOVOLOG

NOVOLOG MIX 70/30

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

13

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

Repaglinide

Estrogens and Antiestrogens

CLIMARA

Estradiol

Esterified Estrogens/Methyl Testosterone

EVISTA

PREMARIN VAGINAL CREAM

Gonadotropins

BRAVELLE HC

Chorionic Gonadotropin HC

Clomiphene Citrate HC

FOLLISTIM HC

Ganirelix Acetate HC

GONAL-F HC

REPRONEX HC

IUD

MIRENA

Parathyroid

FORTICAL

Pituitary

Desmopressin Acetate

Progestins

ENDOMETRIUM

Medroxyprogesterone Acetate

Norethindrone Acetate

Somatotropin Agonist and Antagonist

OMNITROPE QL

DRUG NAME REQUIREMENTS AND LIMITS

Thyroid and Antithyroid Agents

Levothyroxine Sodium

Liothyronine Sodium

Methimazole

Propylthiouracil

Thyroid

MISCELLANEOUS THERAPEUTIC AGENTS

Miscellaneous Therapeutic Agents

ACTIMMUNE

Alendronate Sodium

Allopurinol

ANTABUSE

AVONEX QL

Azathioprine

Bromocriptine Mesylate

Colchicine

COPAXONE QL

ELMIRON

ENBREL QL

Etidronate Disodium

EXTAVIA QL

Finasteride

GASTROCROM

GENGRAF

HUMIRA QL

Leflunomide

Leucovorin Calcium

Mycophenolate Mofetil

REBIF QL

REVLIMID OC

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

SANDIMMUNE

SENSIPAR

Sodium Fluoride

Tacrolimus

THALOMID OC

Vitamins

Folic Acid

Iron Complex

Phytonadione

Potassium Aminobenzoate

Pyridoxine HCL

OXYTOCICS

Oxytocics

Methylergonovine Maleate

RESPIRATORY TRACT AGENTS

Anti-Inflammatory Agents

Cromolyn Sodium

DULERA

SINGULAIR

Antitussives

Benzonatate

Guaifenesin/Codeine

Respiratory Agents, Miscellaneous

Acetylcysteine

Sodium Chloride (Inhalant)

DRUG NAME REQUIREMENTS AND LIMITS

SKIN AND MUCOUS MEMBRANE AGENTS

Anti-Infectives (Skin and Mucous Membrane)

Benzoyl Peroxide/ Erythromycin

Ciclopirox Olamine

Clindamycin Phosphate

Clioquinol/Hydrocortisone

Clotrimazole Troche

Erythromycin

Gentamicin Sulfate

Ketoconazole

Malathion

Metronidazole

Mupirocin

Nystatin

Permethrin

Selenium Sulfide

Silver Nitrate/Potassium Nitrate

Silver Sulfadiazine

Anti-Inflammatory Agents (Skin and Mucous Membrane)

APEXICON E

Betamethasone Dipropionate

Betamethasone Valerate

Clobetasol Propionate

Clobetasol Propionate Emollient Base

CORDRAN

Desonide

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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November 2011

DRUG NAME REQUIREMENTS AND LIMITS

Desoximetasone

Diflorasone Diacetate

Fluocinolone Acetonide

Fluocinonide

Hydrocortisone (Rectal)

Hydrocortisone (Topical)

Hydrocortisone Butyrate

Hydrocortisone Valerate

Mometasone Furoate

Nystatin/Triamcinolone

PROCTOFORM

PROTOPIC

Triamcinolone Acetonide

Cell Stimulants and Proliferants

Tretinion

Skin and Mucous Membrane Agents, Miscellaneous

8-MOP

Acetic Acid Vaginal

Aluminum Chloride

AZELEX

DIFFERIN

EPIDUO

Fluorouracil

Imiquimod

Isotretinoin

Lidocaine HCL

Lidocaine/Prilocaine

Podofilox

Sulfacetamide Sodium/Sulfur

OXSORALEN LOT

OXSORALEN ULTRA

DRUG NAME REQUIREMENTS AND LIMITS

PHISOHEX LIQ

VECTICAL

SMOOTH MUSCLE RELAXANTS

Smooth Muscle Relaxants

Aminophylline

Oxybutynin Chloride

Oxybutynin Chloride Xl

OXYTROL DIS

Theophylline

VASODILATING AGENTS

Miscellaneous Therapeutic Agents

Yohimbine HCL HC, QL

Phosphodiesterase Inhibitors

CAVERJECT HC, RB

CIALIS HC, QL, RB

EDEX HC, RB

LEVITRA HC, QL, RB

MUSE HC, RB

VIAGRA HC, QL, RB

VITAMINS

Vitamins

Calcitriol

Pediatric Multivitamins/ Fluoride

Pediatric Multivitamins/ Fluoride/Iron

Pediatric Multivitamins ACD/ Fluoride

Pediatric Multivitamins ACD/ Fluoride/Iron

Prenatal Vitamins

LEGEND

• Brand-name drugs are in bold type and all capital letters • Restricted Benefit—RB • For drugs not indicated in bold, generic drugs will be • Limited Distribution—LD

dispensed as the formulary agent • Quantity Limits—QL • Higher Copay—HC • Oral Chemo Drugs—OC

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Index 8-MOP, 16

A

Acarbose, 13 Acebutolol HCL, 7 Acetaminophen/Codeine, 8 Acetazolamide, 8 Acetic Acid/Aluminum Acetate, 12 Acetic Acid (OTIC), 12 Acetic Acid Vaginal, 16 Acetylcysteine, 15 ACTIMMUNE, 14 ACTOS, 13 ADCIRCA, 8 ADDERALL XR, 9 ADVAIR DISKUS, 7 AFINITOR, 5 AGGRENOX, 7 Albuterol Neb, 7 Alendronate Sodium, 14 ALKERAN, 5 Allopurinol, 14 Alprazolam, 6 Aluminum Chloride, 16 Amantadine HCL, 5 Amiloride HCL, 11 Amiloride/Hydrochlorothazide, 11 Aminocaproic Acid, 7 Aminophylline, 16 Amiodarone HCL, 8 Amitriptyline HCL, 10 Amlodipine Besylate, 8 Amoxicillin, 4 Amoxicillin & Pot Clavulanate, 4 Amphetamine/ Detroamphetamine (Mixed), 9 Ampicillin, 4 Anagrelide HCL, 7 Anastrozole, 5

ANTABUSE, 14 APEXICON E, 15 APTIVUS, 5 AROMASIN, 5 ASACOL, 12 ASMANEX, 13 Atenolol/Chlorthalidone, 7 Atenolol HCL, 7 ATRIPLA, 5 Atropine Sulfate, 12 ATROVENT HFA, 6 AVELOX, 4 AVONEX, 14 Azathioprine, 14 AZELEX, 16 Azithromycin, 4

B

Bacitracin (OP), 11 Bacitracin/Polymyxin B (OP), 11 Bacitracin/Polymyxin/Neomycin/ HC, 11 Baclofen, 7 BANZEL, 9 BARACLUDE, 5 Belladonna Alkaloids/ Phenobarbital, 9 Benzocaine/Antipyrine, 12 Benzonatate, 15 Benzoyl Peroxide/Erythromycin, 15 Benztropine Mesylate, 6 Betamethasone Dipropionate, 15 Betamethasone Valerate, 15 Bethanechol Chloride, 6 Bicalutamide, 5 Bisoprolol Fumarate, 7 Bisoprolol/Hydrochlorothiazide, 7 BRAVELLE, 14

Brimonidine Tartrate, 12 Bromocriptine Mesylate, 14 Budesonide (Inhalation), 13 Bumetanide, 11 Bupropion HCL, SR, XL, 10 Buspirone HCL, 9 Butalbital/Acetaminophen/ Caffeine, 8 Butalbital/Aspirin/Caffeine, 8

C

Calcitriol, 16 CANASA, 12 Captopril, 8 Carbachol (OP), 12 Carbamazepine, 9 Carbamazepine ER, 9 Carbidopa/Levodopa, ER, 10 Carvedilol, 8 CAVERJECT, 16 CEENU, 5 Cefaclor, 4 Cefdinir, 4 Cefuroxime Axetil, 4 Cephalexin, 4 Chlordiazepoxide HCL, 6 Chloroquine Phosphate, 4 Chlorothiazide, 11 Chlorpromazine HCL, 10 Chlorthalidone, 11 Cholestryramine Light, 7 Choline/Mag Salicylate, 8 Chorionic Gonadotropin, 14 CIALIS, 16 Ciclopirox Olamine, 15 Cilostazol, 7 CIPRODEX OTIC, 11 Ciprofloxacin, 4 Ciprofloxacin (OP), 11 Citalopram HCL, 10 Clarithromycin, 4

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CLIMARA, 14 Clindamycin, 4 Clindamycin Palmitate HCL, 4 Clindamycin Phosphate, 15 Clioquinol/Hydrocortisone, 15 Clobetasol Propionate, 15 Clobetasol Propionate Emollient Base, 15 Clomiphene Citrate, 14 Clomipramine HCL, 10 Clonazepam, 6 Clonidine HCL, 8 Clorazepate Dipotassium, 6 Clotrimazole Troche, 15 Clozapine, 10 COARTEM, 4 Codeine Phosphate, 8 Codeine Sulfate, 8 COLAZAL, 12 Colchicine, 14 COLY-MYCIN S OTIC, 11 COMBIVENT AER, 7 COMBIVIR, 5 COMTAN, 10 CONCERTA, 9 COPAXONE, 14 CORDRAN, 15 Cortisone Acetate, 13 CRIXIVAN, 5 Cromolyn Sodium, 15 Cromolyn Sodium (OP), 11 Cyclobenzaprine HCL, 7 CYCLOMYDRIL, 12 Cyclophosphamide, 5 Cyproheptadine HCl, 4

D

Danocrine, 13 Dantrolene Sodium, 7 DAPSONE, 4 DARAPRIM, 5 Desipramine HCL, 10 Desmopressin Acetate, 14

Desogestrel/Ethinyl Estradiol, 13 Desonide, 15 Desoximetasone, 16 Dexamethasone, 13 DEXASOL OP, 11 Dextroamphetamine Sulfate, 9 Diazepam, 6 Diazepam (Anticonvulsant), 9 Dibenzyline, 6 Diclofenac Sodium, 8 Dicloxacillin Sodium, 4 Dicyclomine HCL, 6 Didanosine, 5 DIFFERIN, 16 Diflorasone Diacetate, 16 Digoxin, 8 Diltiazem HCL, 8 Diphenoxylate/Atropine, 12 Dipyridamole, 7 Disopyramide Phosphate, 8 Divalproex Sodium, 9 Donepezil HCL, 6 Dorzolamide, 12 Dorzolamide/Timolol, 12 Doxazosin Mesylate, 7 Doxepine HCL, 10 Doxycycline Hyclate, 4 Doxycycline Monohydrate, 4 Drospirenone/Ethinyl Estradiol, 13 DULERA, 15

E

ENBREL, 14 ENDOMETRIUM, 14 ENTOCORT EC, 13 EPIDUO, 16 Epinephrine HCl, 7 EPIPEN, 7 EPIVIR, 5 EPZICOM, 5 Ergoloid Mesylates, 6 Ergotamine/Caffeine, 9 ERYPED SUSP, 4 Erythromycin, 15 Erythromycin Base, 4 Erythromycin Ethylsuccinate, 4 Erythromycin (OP), 11 Erythromycin-Sulfisoxazole, 4 Esterified Estrogens/Methyl Testosterone, 14 Estradiol, 14 Ethambutol HCL, 4 Ethosuximide, 9 Ethynodiol Diacetate/Ethinyl Estradiol, 13 Etidronate Disodium, 14 Etodolac, 9 Etoposide, 6 EVISTA, 14 EXJADE, 13 EXTAVIA, 14

F

Famotidine, 12 FEMARA, 6

EDEX, 16 EDURANT, 5 EFFIENT, 7 ELIPHOS, 11 ELLA, 13 ELMIRON, 14 EMCYT, 6 EMEND, 12 EMTRIVA, 5 Enalapril Maleate, 8

Fenofibrate 54mg, 160mg, 7 Fentanyl, 9 Finasteride, 14 Flecainide Acetate, 8 FLOVENT HFA, 13 Fluconazole, 4 Fludrocortisone Acetate, 13 Flunisolide, 11 Fluocinolone Acetonide, 16 Fluocinonide, 16

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Fluorometholone (OP), 11 Fluorouracil, 16 Fluoxetine HCL, 10 Fluphenazine HCL, 10 Flutamide, 6 Fluticasone Propionate, 11 Fluvoxamine Maleate, 10 Folic Acid, 15 FOLLISTIM, 14 Fondaparinux, 7 FORTICAL, 14 Furosemide, 11 FUZEON, 5

G

Gabapentin, 9 Galantamine Hydrobromide, 7 Ganciclovir, 5 Ganirelix Acetate, 14 GASTROCROM, 14 Gemfibrozil, 7 GENGRAF, 14 Gentamicin Sulfate, 15 Gentamicin Sulfate (OP), 11 GLEEVEC, 6 Glipizide, 13 GLUCAGON EMERGENCY KIT, 13 GONAL-F, 14 Griseofulvin Microsize, 4 Griseofulvin Ultramicrosize, 4 Guaifenesin/Codeine, 15 Guanfacine HCL, 8

H

Haloperidol, 10 HEPSERA, 5 HEXALEN, 6 Homatropine HBR, 12 HUMIRA, 14 HYCAMTIN, 6 Hydralazine HCL, 8

Hydrochlorothiazide, 11 Hydrocodone/Acetaminophen, 9 Hydrocortisone, 13 Hydrocortisone Butyrate, 16 Hydrocortisone (Rectal), 16 Hydrocortisone (Topical), 16 Hydrocortisone Valerate, 16 Hydromorphone HCL, 9 Hydroxychloroquine Sulfate, 5 Hydroxyurea, 6 Hydroxyzine HCL, 9 Hydroxyzine Pamoate, 9 Hyoscyamine, 6

I

Ibuprofen, 9 Imipramine HCL, 10 Imiquimod, 16 Indapamide, 11 Indomethacin, 9 INTELENCE, 5 INTRON-A, 6 INVIRASE, 5 Ipratropium Bromide (Nasal), 6 Iron Complex, 15 ISENTRESS, 5 Isoniazid, 4 Isosorbide Dinitrate, 8 Isosorbide Mononitrate, 8 Isotretinoin, 16 Itraconazole, 4

K

KALETRA, 5 Ketoconazole, 4 Ketoconazole, 15 Ketoprofen, 9 Ketorolac Tromethamine, 11

L

Labetalol HCL, 8

Lactulose, 10 Lamotrigine, 9 LANTUS, 13 Latanoprost, 12 Leflunomide, 14 Leucovorin Calcium, 14 LEUKERAN, 6 Levetiracetam, 9 LEVITRA, 16 Levobunolol HCL, 12 Levofloxacin, 4 Levonorgestrel/Ethinyl Estradiol, 13 Levonorgestrel/Ethinyl Estradiol (Triphasic), 13 Levothyroxine Sodium, 14 LEXIVA, 5 Lidocaine HCL, 12 Lidocaine HCL, 16 Lidocaine/Prilocaine, 16 Liothyronine Sodium, 14 LIPITOR 80mg, 7 Lisinopril, 8 Lisinopril/Hydrochlorothiazide, 8 Lithium Carbonate, 10 Lithium Citrate, 10 LODOSYN, 10 Lorazepam, 6 Losartan Potassium, 8 Losartan Potassium/HCTZ, 8 LOTEMAX, 11 Lovastatin, 7 LOVENOX, 7 LUMIGAN, 12 LUPRON, 6 LYSODREN, 6

M

Malathion, 15 Maprotiline HCL, 10 Mebendazole, 4 Medroxyprogesterone Acetate, 14

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Mefenamic Acid, 9 Mefloquine HCL, 5 Megestrol Acetate, 6 Meloxicam, 9 Meperidine HCL, 9 Mephobarbital, 6 MEPRON, 5 Mercaptopurine, 6 METADATE CD, 9 Metformin ER, 13 Metformin HCL, 13 Methadone HCL, 9 Methazolamide, 8 Methenamine Hippurate, 5 Methimazole, 14 Methlyprednisolone, 13 Methocarbomol, 7 Methotrexate Sodium, 6 Methsuximide, 9 Methyldopa, 8 Methylergonovine Maleate, 15 Methylphenidate HCL, 9 Methylphenidate HCL ER, 9 Metipranolol, 12 Metoclopramide HCL, 13 Metolazone, 11 Metoprolol Succinate, 8 Metoprolol Tartrate, 8 Metronidazole, 5 Metronidazole, 15 Mexiletine HCL, 8 Midodrine HCL, 7 MILLIPRED, 13 Minocycline HCL, 4 Minoxidil, 8 MIRENA, 14 Mirtazapine, 10 Misoprostol, 12 Mometasone Furoate, 16 Morphine Sulfate, 9 Mupirocin, 15 MUSE, 16 MYCOBUTIN, 4

Mycophenolate Mofetil, 14 MYLERAN, 6

N

Nabumetone, 9 Nadolol, 8 Naltrexone HCL, 10 NAMENDA, 10 Naproxen, 9 Naratriptan HCL, 9 NATACYN, 11 NEBUPENT INH, 5 Nefazodone HCL, 10 Neomycin/Bacitracin/Polymyxin, 11 Neomycin/Polymyxin/ Dexameth, 12 Neomycin/Polymyxin/Gramicid, 11 Neomycin/Polymyxin/HC, 12 Neomycin Sulfate, 4 Neostigmine Bromide, 7 NEUPOGEN, 7 NEXAVAR, 6 Niacin, 7 Nicotrol Inhaler, 6 Nifedipine, 8 Nitrofurantoin, 5 Nitrofurantoin Macrocrystals, 5 Nitrofurantoin Monohyd Macro, 5 Nitroglycerin, 8 Nitroglycerin Patch, 8 NITROSTAT SL, 8 Norethindrone, 13 Norethindrone Acetate, 14 Norethindrone Acetate/Ethinyl Estradiol, 13 Norethindrone/Ethinyl Estradiol, 13 Norethindrone/Ethinyl Estradiol (Triphasic), 13 Nortriptyline HCL, 10 NORVIR, 5

NOVOLIN 70/30, 13 NOVOLIN N, 13 NOVOLIN R, 13 NOVOLOG, 13 NOVOLOG MIX 70/30, 13 Nystatin, 4 Nystatin, 15 Nystatin/Triamcinolone, 16

O

OCUFEN, 12 Ofloxacin (OP), 11 Ofloxacin (OTIC), 11 Omeprazole, 12 OMNITROPE, 14 Ondansetron HCL, 12 ORAP, 10 Oxazepam, 6 Oxcarbazepine, 9 OXSORALEN LOT, 16 OXSORALEN ULTRA, 16 Oxybutynin Chloride, 16 Oxybutynin Chloride Xl, 16 Oxycodone/Acetaminophen, 9 Oxycodone HCL, 9 OXYTROL DIS, 16

P

Pantoprazole, 12 Papaverine HCL, 8 Paroxetine HCL, 10 Pediatric Multivitamins ACD/ Fluoride, 16 Pediatric Multivitamins ACD/ Fluoride/Iron, 16 Pediatric Multivitamins/Fluoride, 16 Pediatric Multivitamins/ Fluoride/Iron, 16 PEG 3350-KCL-Sodium Bicarb-Sodium Chloride-Sodium Sulfate, 13 PEGASYS, 5

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PEG-INTRON, 5 Penicillin V Potassium, 4 PENTASA, 12 Pentoxifylline, 7 Permethrin, 15 Perphenazine, 10 Phenelzine Sulfate, 10 Phenobarbital, 6 Phenobarbital, 9 Phentermine, 9 Phenylephrine HCL (OP), 12 Phenytoin Sodium, 9 PHISOHEX LIQ, 16 PHOSLO, 11 Phytonadione, 15 Pilocarpine HCL (ORAL), 7 PLAN B ONE-STEP, 13 PLAVIX, 7 Podofilox, 16 Polymyxin B/Trimethoprim, 11 Potassium Aminobenzoate, 15 Potassium Bicarbonate, 11 Potassium Chloride, 11 Potassium Citrate (Alkalinizer), 10 Potassium Phosphate Dibasic/ Monobasic, 11 Potassium Phosphate Monobasic, 11 Potassium & Sodium Acid Phosphates, 10 Pramipexole Dihydrochloride, 10 Pravastatin Sodium 20mg, 40mg, 80mg, 7 Prazosin HCL, 7 PRED-G, 12 Prednisolone, 13 Prednisolone Acetate, 12 Prednisolone Sodium Phosphate, 12 Prednisolone Sodium Phosphate, 13 Prednisone, 13

PREMARIN VAGINAL CREAM, 14 Prenatal Vitamins, 16 PREZISTA, 5 Primaquine Phosphate, 5 Primidone, 9 PROAIR HFA, 7 Probenecid, 11 Procarbazine HCL, 6 Prochlorperazine, 12 Prochlorperazine Maleate, 10 PROCRIT/EPOGEN, 7 PROCTOFORM, 16 PROMACTA, 7 Promethazine HCL, 4 Propafenone HCL, 8 Proparacaine HCL, 12 Propranolol HCL, 8 Propylthiouracil, 14 PROTOPIC, 16 Protriptyline HCL, 10 PULMOZYME SOL, 11 Pyrazinamide, 4 Pyridostigmine Bromide, 7 Pyridoxine HCL, 15

Q

QUINIDEX/QUINIDEX ER, 8 Quinidine Gluconate, 8 QVAR, 13

R

Ranitidine HCL, 12 REBIF, 14 RENVELA, 11 Repaglinide, 14 REPRONEX, 14 RESCRIPTOR, 5 Reserpine, 8 REVATIO, 8 REVLIMID, 14 REYATAZ, 5 Ribavirin, 5

RIDAURA, 13 Rifabutin, 4 Rifampin, 4 RILUTEK, 10 Rimantadine HCL, 5 Risperidone, 10 Ropinirole HCL, 10 ROWASA ENEMA, 12

S

Salsalate, 9 SANDIMMUNE, 15 Selegiline, 10 Selenium Sulfide, 15 SELZENTRY, 5 SENSIPAR, 15 SEREVENT DISKUS AER, 7 SEROQUEL, 10 Sertraline HCL, 10 Silver Nitrate/Potassium Nitrate, 15 Silver Sulfadiazine, 15 Simvastatin 20mg, 40mg, 80mg, 7 SINGULAIR, 15 Sodium Chloride (Inhalant), 15 Sodium Citrate & Citric Acid, 10 Sodium Fluoride, 15 Sodium Polystyrene Sulfonate, 11 Sotalol HCL, 8 SPIRIVA, 6 Spironolactone, 8 Spironolactone/ Hydrochlorothiazide, 8 SPRYCEL, 6 SUBOXONE, 9 Sucralfate, 12 Sulfacetamide Sodium/ Prednisolone, 12 Sulfacetamide Sodium/Sulfur, 16 Sulfadiazine, 4

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4 Sulfamethoxazole-Trimethoprim,

Sulfasalazine, 4 Sulindac, 9 Sumatriptan, 9 SUPRAX, 4 SUSTIVA, 5 SUTENT, 6

T

TABLOID, 6 Tacrolimus, 15 TAMIFLU, 5 Tamoxifen Citrate, 6 Tamsulosin HCL, 7 TARCEVA, 6 TARGRETIN, 6 TASIGNA, 6 Temazepam, 6 TEMODAR, 6 Terazosin HCL, 7 Terbinafine, 4 Terbutaline Sulfate, 7 Tetracaine HCL, 12 Tetracycline HCL, 4 THALOMID, 15 Theophylline, 16 Thioridazine HCL, 10 Thiothixene, 10 Thyroid, 14 TIKOSYN, 8 Timolol Maleate, 8 TOBI NEB, 4

Tobramycin/Dexamethasone, 12 Tobramycin Sulfate (OP), 11 Topiramate, 9 Tramadol HCL, 9 TRANSDERM-SCOP, 12 Trazodone HCL, 10 TRECATOR, 4 Tretinion, 16 Tretinoin (Chemotherapy), 6 Triamcinolone Acetonide, 16 Triamterene/ Hydrochlorothiazide, 11 Trifluoperazine HCL, 10 Trifluridine, 11 Trihexyphenidyl HCL, 6 Trimethoprim, 5 TRIZIVIR, 5 Tropicamide, 12 TRUVADA, 5 TYKERB, 6

U

Urosodiol, 13

V

VALCYTE, 5 Valproate Acid, 9 Valproate Sodium, 9 VANDETANIB, 6 VANOCIN, 4 VECTICAL, 16 Venlafaxine HCL, 10

Verapamil HCL, 8 VIAGRA, 16 VIRACEPT, 5 VIRAMUNE, 5 VIRAMUNE XR, 5 VIREAD, 5 Voriconazole, 4 VOTRIENT, 6 VPRIV, 11 VYTORIN 40/10mg, 80/10mg, 7

W

Warfarin Sodium, 7

X

XELODA, 6 XIFAXAN, 4

Y

YODOXIN, 4 Yohimbine HCL, 16

Z

ZENPEP, 12 ZIAGEN, 5 Zidovudine, 5 Zolpidem Tartrate, 9 ZYMAR, 11 ZYPREXA, 10 ZYTIGA, 6 ZYVOX, 4

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 2101 East Jefferson Street, Rockville, MD 20852 11926_RxFormularyNov_A_pdf 11/1/11–12/3/11

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